Portal vein thrombosis and arterioportal shunts : effects on tumor response after chemoembolization of hepatocellular carcinoma

AIM: To evaluate the effect of portal vein thrombosis and arterioportal shunts on local tumor response in advanced cases of unresectable hepatocellular carcinoma treated by transarterial chemoembolization. METHODS: A retrospective study included 39 patients (mean age: 66.4 years, range: 45-79 years, SD: 7) with unresectable hepatocellular carcinoma (HCC) who were treated with repetitive transarterial chemoembolization (TACE) in the period between March 2006 and October 2009. The effect of portal vein thrombosis (PVT) (in 19 out of 39 patients), the presence of arterioportal shunt (APS) (in 7 out of 39), the underlying liver pathology, Child-Pugh score, initial tumor volume, number of tumors and tumor margin definition on imaging were correlated with the local tumor response after TACE. The initial and end therapy local tumor responses were evaluated according to the response evaluation criteria in solid tumors (RECIST) and magnetic resonance imaging volumetric measurements. RESULTS: The treatment protocols were well tolerated by all patients with no major complications. Local tumor response for all patients according to RECIST criteria were partial response in one patient (2.6%), stable disease in 34 patients (87.1%), and progressive disease in 4 patients (10.2%). The MR volumetric measurements showed that the PVT, APS, underlying liver pathology and tumor margin definition were statistically significant prognostic factors for the local tumor response (P = 0.018, P = 0.008, P = 0.034 and P = 0.001, respectively). The overall 6-, 12- and 18-mo survival rates from the initial TACE were 79.5%, 37.5% and 21%, respectively. CONCLUSION: TACE may be exploited safely for palliative tumor control in patients with advanced unresectable HCC; however, tumor response is significantly affected by the presence or absence of PVT and APS

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Diagnostic value of combined versus individual MRI parameters in distinguishing adenomatous from non-adenomatous adrenal lesions in cancer patients

Purpose: Our aim was to evaluate the diagnostic value of MRI using different parameters in differentiation of adenomas versus non-adenomas adrenal lesions. Materials and methods: Forty-five patients with 48 adrenal masses (28 lipid rich adenomas, 3 lipid poor adenomas, 15 metastases and 2 lymphoma) were retrospectively evaluated with MRI. The mean diameter of adrenal mass, T2WI signal, signal drop on chemical shift imaging (CSI) and enhancement pattern were assessed separately and in various combinations. Accuracies, sensitivities, specificities, PPV, NPV and P values by Chi-square test were calculated for individual and combined parameters. Results: Signal drop on CSI and enhancement pattern were the most statistically significant diagnostic discriminators of adenomatous and non-adenomatous lesions with accuracies, specificities and sensitivities of 93.8%, 90.3%, 100% and 91.7%, 93.5%, 88.2%, respectively (P-value <0.0001). The best performance of a combination of parameters was obtained after exclusion of the size, with an accuracy of 89.6% (P-value <0.0001). Conclusion: The most specific predictors for adrenal mass characterization were CSI signal drop and Gd-DTPA enhancement characteristics. Combining the MR parameters did not prove superior to those two individual parameters, however it yielded a valuable diagnostic protocol for distinguishing the adrenal masses, considering that size criterion should not be used as an individual discriminator

Brain MR imaging abnormalities in pediatric patients after allogeneic bone marrow transplantation

Objective: Our aim was to analyze brain MRI findings in pediatric patients who developed neurologic complications after allogeneic bone marrow transplantation. Materials and methods: This prospective study included 33 consecutive patients (age range from 3 to 18 years, mean 11.8 ± 5.1 years). They were referred to the MRI unit because of the neurological symptoms in the post transplant period. The underlying disorders included: non malignant hematological disorders (n = 20, 60.6%) and hematological malignancies (n = 13, 39.4%). Onset of the presentation of the complication in relation to the chronology of the transplant was identified in each patient (phase1: from days 0 to 30, phase 2: from days 30 to 100, and late phase after day 100). Results: According to the MRI findings 6 patients (18.2%) showed normal examinations. Twenty-seven patients (81.8%) with positive MRI findings, are grouped into 7 main categories: posterior reversible encephalopathy syndrome (n = 16, 48.48%), intracranial hemorrhage (n = 2, 6.06%), cerebral venous sinus thrombosis (n = 1, 3.03%), CNS infection (n = 2, 6.06%), leukoencephalopathy (n = 5, 15.15%), mild atrophy (n = 11, 33.33%), CNS relapse (n = 1, 3.03%), with 9 patients having more than one diagnosis. Ten cases of PRES and 1 case of sinus thrombosis were detected in phase 1. Two cases of PRES and 2 cases of intracranial hemorrhage were detected in phase 2. Four cases of leukoencephalopathy, 4 cases of PRES, 2 cases of CNS infection, and 1 case of CNS relapse were detected in phase 3. Conclusion: CNS complications after allogenic BMT in pediatric patients could cause a significant clinical problem. MRI can provide early diagnosis and follow-up to monitor treatment changes. Knowing the onset of the presentation of the complication in relation to the chronology of the transplant is important as it provides significant guidance on which causes to consider

Diffusion-weighted MRI in adrenal lesions: A warranted adju

Purpose: We assessed the value of adding Diffusion-weighted (DW) sequences to conventional MR in the diagnostic adrenal algorithm, particularly in patients with indeterminate adrenal mass. We compared the predictive capabilities of apparent diffusion coefficient values (ADC), lesion size and signal drop on chemical shift MRI (CS MRI) for differentiating benign and malignant lesions. Materials and methods: Fifty-five patients with 59 adrenal lesions were evaluated. Lesion size, signal loss on CSMRI and ADCs were assessed. Sensitivity, specificity and accuracy were calculated for each parameter. We compared the predictive capability of ADC, CS signal drop, and lesion size for malignancy with receiver operating characteristic (ROC) curves. Results: Considering all lesion subtypes, ADC values showed overlap. Benign and malignant masses had statistically different mean ADCs, with greater mean ADC values in benign lesions (1.78 ± 0.5 versus 0.97 × 10−3 mm2/s ± 0.3). ADC had the lowest accuracy (71.2%) but highest specificity (100%). Lack of signal drop had the greatest sensitivity (100%); lesion size was the most accurate (88.1%). On ROC curves, ADC had the lowest prediction for malignancy. Conclusion: Lesion size and signal drop were stronger predictors of adrenal malignancy than ADC. ADC shows poor significance in individual cases due to overlapping values

Diagnostic value of combined static-excretory MR Urography in children with hydroneph

The aim of this study was to determine the feasibility, accuracy and diagnostic potential of combined static-excretory MR Urography in children with sonographically detected hydronephrosis. We prospectively evaluated 28 children (11 girls and 17 boys), mean age 8.3 years (range 2 months–16 years). Static-excretory MR Urography was performed in all cases. The results of MR Urography were compared with the results of other imaging modalities, cystoscopy and surgery. In 28 children, 61 renal units were evaluated by MR Urography (the renal unit is the kidney and its draining ureter). The final diagnoses included: normal renal units (n = 23); uretropelvic junction obstruction (n = 14); megaureter (n = 8); midureteric stricture (n = 1), complicated duplicated systems (n = 5), post ESWL non-obstructive dilation (n = 2), extrarenal pelvis (n = 4), dysplastic kidney (n = 4). Complex pathology and more than one disease entity in were found in 7 children. The MRI diagnosis correlated with the final diagnosis in 57 units, with diagnostic accuracy 93.4%. In conclusions static and excretory MRU give both morphological and functional information in a single examination without exposure to ionizing radiation and iodinated contrast agent. It is a valuable imaging technique for children with upper urinary tract dilatation; especially in cases of complex congenital pathologies and severely hydronephrotic kidney

Usefulness of diffusion-weighted magnetic resonance imaging for the characterization of benign and malignant renal lesions

Purpose: Our aim was to evaluate the diagnostic potential of diffusion-weighted magnetic resonance imaging (DW-MRI) and quantitative assessment of apparent diffusion coefficient (ADC) value for the characterization of renal lesions and differentiation into benign and malignant. Patients and methods: A total of 87 consecutive patients with 107 renal lesions were enrolled in this prospective study. MRI examinations including DWI with b factors of 0, 600 and 800 s/mm2 were performed at 1.5 T MRI unit. The mean ADC values of normal renal parenchyma, solid and cystic lesions were calculated. Results: There was statistical significance difference between ADC value of normal renal parenchyma with that of benign (n = 60, 56%) and malignant (n = 47, 44%) renal lesions (P value < 0.0001). ADC values differed significantly between solid (n = 74, 69.2%) and cystic lesions (n = 33, 30.8%) (P value < 0.0001). There was significant difference between ADC values of all benign (n = 60, 56%) and malignant renal lesions (n = 47, 44%) (P value < 0.0001) but not between benign solid (n = 27, 36.5%) and malignant solid renal lesions (n = 47, 63.5%) (P value = 0.784). Conclusion: There is overlap between the ADC values of benign and malignant lesions. The use of ADC value alone may lead to inaccurate assessment of renal lesions. Thus, DW-MRI should be interpreted in conjunction with conventional MRI sequences to allow for better characterization of renal lesions

Diffusion-weighted MR imaging and ADC measurement in normal prostate, benign prostatic hyperplasia and prostate carcinoma

Purpose: Our aim was to investigate the diffusion-weighted Imaging (DWI) appearance and apparent diffusion coefficient (ADC) values of normal prostatic gland, prostate carcinoma (PCa) and benign prostate hyperplasia (BPH) and to determine the utility of DWI in their characterization. Materials and methods: During a period of 16 months, 40 consecutive patients, with elevated PSA level and 12 healthy volunteers with no clinical symptoms or history of prostate disease were prospectively evaluated with DWI of the prostate. MRI was performed using a 1.5T MR scanner equipped with a pelvic phased array coil. For anatomical imaging, T2W FSE in the three orthogonal planes, and T1WI in axial plane were obtained. DWI with b values of 0, 300, 500 and 800 s/mm2 were performed in axial plane. The results were confirmed by TRUS-guided biopsy or prostatectomy. Results: Patients ranged in age from 45 to 85 years (mean 66.6 ± 7.9 year). Twenty patients were confirmed to have BPH, whereas 20 patients had PCa. The mean and SD of ADC values for the peripheral zone (PZ), central gland (CG), BPH nodules and PCa were 1.839 ± 0.233, 1.469 ± 0.239, 1.359 ± 0.201 and 0.87 ± 0.13 respectively. The mean ADC value of PCa was significantly lower than that of CG, PZ, and BPH nodule, with p value <0.05. Conclusion: DW MR imaging characteristics and ADC values can differentiate PCa and BPH. DWI with ADC may be used as a complementary method to conventional MRI in diagnosis of PCa and BPH

Correlation of diffusion tensor imaging findings and episodic memory impairment in temporal lobe epilepsy

Purpose: Our aim was to evaluate the utility of diffusion tensor imaging (DTI) in exploration of white matter tracts microstructure changes and clarify their relation to episodic memory in temporal lobe epilepsy (TLE). Materials and methods: DTI was performed on 30 (18 left, 12 right) TLE patients and 20 healthy controls. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were calculated for six fiber tracts; the parahippocampal cingulum (PHC), superior longitudinal fasciculus (SLF), inferior longitudinal fasciculus (ILF), fornix (FORX), uncinate fasciculus (UF) and corpus callosum (CC). Assessment for episodic memory (visual and verbal) was performed at least 48 h after the last seizure. Results: All TLE patients had episodic memory impairment. Left TLE patients demonstrated more verbal memory affection, whereas right TLE patients demonstrated more visual memory affection (p < 0.05). Abnormal DTI parameters (decreased FA and increased ADC) were detected in most of the white matter tracts (p < 0.001) compared to control group. In left TLE patients, there was significant correlation between DTI parameters of left (PHC, SLF, UF, FORX) and verbal memory. Whereas, in right TLE patient, we found significant correlation between DTI parameters of right ILF and visual memory. Conclusions: TLE patients had multiple micro-structural white matter tracts abnormalities and episodic memory impairment. Both are structurally and functionally related