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Gallbladder paraganglioma (GP) is a rare tumor, with only 12 cases reported in the literature to date. Due to its rarity, clinical information of GP is insufficient. We present a case of GP in a 48-year-old female along with a literature review of all GP cases described to date. A 48-year-old female presented with intermittent right upper abdominal pain. Preoperative imaging revealed a hematoma in the gallbladder lumen without any definite etiology. Laparoscopic cholecystectomy was performed. Gross examination of the gallbladder revealed multiple small stones and a large hematoma as well as a 1.6-cm-sized polypoid mass at the gallbladder fundus. Microscopic study of the polypoid mass showed a zellballen appearance. Immunohistochemical analysis revealed that the mass was positive for synaptophysin, CD56, and chromogranin, suggesting GP. GP is difficult to diagnose because of non-specific clinical findings. Almost all GP cases are diagnosed based on histologic findings after cholecystectomy. Simple cholecystectomy was performed as a treatment in all reported cases of GP, including our case. There was no postoperative tumor recurrence or metastasis after surgery.

Backgrounds/Aims A stapler is widely used in various surgeries, and there have been recent attempts to use it for performing duodenojejunostomy and gastrojejunostomy during pancreaticoduodenectomy. This study aimed to compare the postoperative results of handsewn gastrojejunostomy (HGJ) and stapled gastrojejunstomy (SGJ) limited to pylorus-resecting pancreaticoduodenectomy (PrPD) performed by a single surgeon. Methods This retrospective study was conducted between January 2014 and March 2020, and included 131 patients who underwent PrPD performed by a single surgeon. Of the total subjects, 90 were in the HGJ group and 41 in the SGJ group. Results The mean time of surgery was significantly shorter in the stapled group than in the handsewn group (450.4±75.4 min vs. 397.1±66.5 min, p

Background/objective: A high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. Methods: This retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. Results: The overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p

Background: Treatment outcomes of laparoscopic liver resection (LLR) and percutaneous radiofrequency ablation (p-RFA) for small single hepatocellular carcinomas (HCCs) have not yet been fully compared. The aim of this study was to compare LLR and p-RFA as first-line treatment options in patients with single nodular HCCs ≤3 cm. Methods: From January 2014 to December 2016, a total of 566 patients with single nodular HCC ≤3 cm treated by either LLR (n = 251) or p-RFA (n = 315) were included. The recurrence-free survival (RFS) and cumulative incidence of local tumor progression (LTP) were estimated using Kaplan-Meier methods and compared using the log-rank test. Treatment outcome of 2 treatment modalities was compared in the subgroup of patients according to the tumor location. Results: There were no significant differences in overall survival between LLR and p-RFA (p = 0.160); however, 3-year RFS was demonstrated to be significantly higher after LLR (74.4%) than after p-RFA (66.0%) (p = 0.013), owing to its significantly lower cumulative incidence of LTP (2.1% at 3 years after LLR vs. 10.0% after p-RFA, p < 0.001). The complication rate of p-RFA was significantly lower than that of LLR (5.1 vs. 10.0%, p = 0.026). LLR also provided significantly better local tumor control than p-RFA for subscapular tumors (3-year LTP rates: 1.9 vs. 8.8%, p = 0.012), perivascular tumors (3-year LTP rates: 0.0 vs. 17.2%, p = 0.007), and tumors located in anteroinfero-lateral liver portions (3-year LTP rates: 0.0 vs. 10.7%, p < 0.001). However, there were no significant differences in LTP rates between LLR and p-RFA for non-subcapsular and non-perivascular tumors (p = 0.482) and for tumors in postero-superior liver portions (p = 0.380). Conclusions: LLR can provide significantly better local tumor control than p-RFA for small single HCCs in subcapsular, perivascular, and anteroinferolateral liver portions and thus may be the preferred treatment option for these tumors.

Multidetector computed tomographic urography (MDCTU) is not yet sufficient to be used in the clinical staging of upper tract urothelial carcinoma (UTUC). This study aimed to compare the diagnostic accuracy of MDCTU T stage classification and pathologic T staging for UTUC. We retrospectively evaluated 125 patients with UTUC who underwent preoperative MDCTU. A single radiologist classified the MDCTU pattern of the tumors as either low or advanced T stage for localized or locally advanced tumors, respectively. The diagnostic values of MDCTU for locally advanced tumors and the kappa agreement between MDCTU and pathologic T stage were investigated. Among 85 pathologic low T stage (Ta–T2) tumors, 71 low T stage tumors were correctly detected by MDCTU, while 30 out of 40 advanced T stage (T3–T4) tumors were correctly diagnosed by MDCTU. MDCTU led to under-staging in 8% (10/125) tumors and over-staging in 11.2% (14/125) tumors. Therefore, the overall accuracy of MDCTU in the diagnosis of low and advanced T stage tumors was 80.8% (101/125 patients). The sensitivity for advanced T stage tumors was 75% (30/40), the specificity was 83.5% (71/85), and the positive and negative predictive values were 68.1% (30/44) and 87.6% (71/81), respectively. The kappa agreement value between the MDCTU T stage and pathologic T stage was 0.57 (95% confidence interval (CI) 0.42–0.72), which was statistically significant (P = 0.001). MDCTU T stage classification may be relatively accurate for the detection and staging of UTUC correspondence with a pathologic stage.

BACKGROUND Liver fibrosis is characterized by the excessive accumulation of extracellular matrix proteins. Electrical conductivity imaging at low frequency can provide novel contrast because the contrast mechanisms originate from the changes in the concentration and mobility of ions in the extracellular space. PURPOSE To evaluate the feasibility of an MR-based electrical conductivity imaging that can detect the changes in a tissue condition associated with the progression of liver fibrosis. STUDY TYPE Prospective phantom and animal study. ANIMAL MODEL Fibrosis was induced by weekly intraperitoneal injection of dimethylnitrosamine (DMN) in 45 male Sprague-Dawley rats. FIELD STRENGTH/SEQUENCE 3T MRI with a multispin-echo pulse sequence. ASSESSMENT The percentage change of conductivity (Δσ, %) in the same region-of-interest (ROI) was calculated from the DMN-treated rats based on the values of the normal control rats. The percentage change was also calculated between the ROIs in each DMN-treated group. STATISTICAL TESTS One-way analysis of variance (ANOVA) and a two-sample t-test were performed. RESULTS Liver tissues in normal control rats showed a uniform conductivity distribution of 56.6 ± 4.4 (mS/m). In rats more than 5 weeks after induction, the fibrous region showed an increased conductivity of ≥12% compared to that of the corresponding normal control rats. From regional comparisons in the same liver, the fibrous region showed an increased conductivity of ≥11% compared to the opposite, less induced region of rats more than 5 weeks after induction. Liver samples from the fibrous region represent tissue damages such as diffuse centrilobular congestion with marked dilatation of central veins from the histological findings. Immunohistochemistry revealed significant levels of attenuated fibrosis and increased inflammatory response. DATA CONCLUSION The increased conductivity in the fibrous region is related to the changes of the extracellular space. The correlation between the collagen deposition and conductivity changes is essential for future clinical studies. Level of Evidence 2 Technical Efficacy Stage 2 J. MAGN. RESON. IMAGING 2021;53:554-563.

Backgrounds/Aims The purpose of this study is to demonstrate that laparoscopic distal pancreatectomy in benign disease is is safer and more favorable to patients than open distal pancreatectomy. Methods We retrospectively reviewed data of 150 patients who underwent laparoscopic (n=69) or open (=81) distal pancreatectomy at a double institutes from 2008 to 2018. We reviewed each patient's history for age, sex, pathologic diagnosis. Specific outcomes that were included hospital stay, operative time (in minutes), operative blood loss (in milliliters), 30-daymajormorbidity and mortality (Clavian-Dindo classification), pancreatic leak rate (grade of leak A, B, or C), pancreatic hemorrhage. Results From 2008 to 2018, there were 150 patients underwent distal pancreatectomy with or without splenectomy for benign pancreatic disease. 81 patients underwent open and 69 patients underwent laparoscopic distal pancreatectomy (LDP) Intra-operative estimated blood loss was significantly lower in the LDP group than in the OPD group (200 vs. 400 ml p

Background Electrical conductivity-based magnetic resonance (MR) imaging may provide unique information on tissue condition because its contrast originates from the concentration and mobility of ions in the cellular space. We imaged the conductivity of normal canine prostate in vivo and evaluated tissue contrast in terms of both the conductivity distribution and anatomical significance. Methods Five healthy laboratory beagles were used. After clipping the pelvis hair, we attached electrodes and placed each dog inside the bore of an MRI scanner. During MR scanning, we injected imaging currents into two mutually orthogonal directions between two pairs of electrodes. A multi spin echo pulse sequence was used to obtain the MR magnitude and magnetic flux density images. The projected current density algorithm was used to reconstruct the conductivity image. Results Conductivity images showed unique contrast depending on the prostatic tissues. From the conductivity distribution, conductivity was highest in the center area and lower in the order of the middle and outer areas of prostatic tissues. The middle and outer areas were, respectively, 11.2 and 25.5% lower than the center area. Considering anatomical significance, conductivity was highest in the central zone and lower in the order of the transitional and peripheral zones in all prostates. The transitional and peripheral zones were, respectively, 7.5 and 17.8% lower than the central zone. Conclusions Current conductivity-based MR imaging can differentiate prostatic tissues without using any contrast media or additional MR scans. The electrical conductivity images with unique contrast to tissue condition can provide a prior information on tissues in situ to be used for human imaging.

The molecular profile of cholangiocarcinoma (CC) remains elusive. The prognostic value of isocitrate dehydrogenase (IDH) mutations in CC is controversial, and there have been few relevant studies in Asian populations. In the present study, we investigated the frequency and prognostic significance of IDH mutations in Korean patients with CC. CC specimens were collected from patients who underwent surgical liver resection between 2004 and 2019. Clinical and pathological data were retrospectively reviewed from medical records. Mutational IDH profiling was performed by peptide nucleic acid-mediated PCR clamping in 206 surgical specimens; IDH-mutant samples were confirmed by next-generation sequencing (NGS). Of the 195 patients with CC, six (3.13%) were found to exhibit IDH1 (n = 5) or IDH2 (n = 1) mutations. Among patients with IDH1 mutations, four had R132C (c.394C>T) and one had R132G (c.394C>G) mutations. One patient had R172W (c.514A>T) mutations in IDH2. All IDH-mutant samples were of intrahepatic origin, and patients with IDH mutations had physiological to low serum levels of carbohydrate antigen 19-9 (CA19-9). No association between IDH mutation status and long-term survival outcomes was observed. The frequency of IDH mutations was considerably lower than the 10–20% reported in previous studies. The frequency and pattern of IDH mutations in CC are likely to vary among patients with different ethnicities. These findings suggest that characterization of the oncogenic mutation profile in different populations is of high clinical importance.

To retrospectively investigate incidence, clinical outcome, and risk factors of iatrogenic pleural effusion in patients with hepatic tumors undergoing radiofrequency (RF) ablation using artificial ascites (AA).Patients (N = 163) who underwent RF ablation using AA were classified into pleural effusion and non-pleural effusion groups according to the presence of pleural effusion on immediate follow-up CT and chest radiograph after RF ablation. The pleural effusion group included asymptomatic and symptomatic subgroups. The incidence and subsequent clinical outcomes of patients developing pleural effusion after RF ablation were evaluated.Overall, 96 patients (58.9%) developed pleural effusion, which resolved in 4.4 d ± 3.1. Hospital length of stay in the pleural effusion group was longer than the non-pleural effusion group (6.5 d ± 2.6 vs 5.7 d ± 2.8, P.01). The pleural effusion group had longer AA infusion time (P = .01), larger infused AA volume (P.01), and longer ablation time (P.01) than the non-pleural effusion group. Eighteen patients (18.8%) developed symptomatic pleural effusion and had a larger infused AA volume than asymptomatic patients with pleural effusion (P.01). Pleural effusion duration and hospital length stay were also longer in the symptomatic pleural effusion subgroup than in the asymptomatic subgroup (P.01). Infused AA volume was the only independent prognostic factor of pleural effusion duration in multivariate analysis (P = .038).Pleural effusion frequently occurs after RF ablation using AA. Although generally considered negligible, pleural effusion could be a clinical problem and prolong hospitalization. Therefore, operators should be careful not to infuse too much AA when performing RF ablation.

Backgrounds/Aims The albumin-bilirubin (ALBI) score has been validated as a predictor of disease-free survival and overall survival in hepatocellular carcinoma (HCC). The purpose of this study was to assess the ALBI score as a risk factor for early recurrence (ER) after curative liver resection in HCC. Methods Patients who underwent liver resection with curative intent for HCC without previous treatment between January 2004 and December 2014 were included in this retrospective study. The utility of the ALBI score in predicting ER and late recurrence (LR) was evaluated. Results A total of 465 HCC patients were enrolled; multivariate analysis identified ALBI grade ≥2 (p=0.003) as a risk factor for ER, in addition to hepatitis B virus surface antigen (HBsAg)-positive status (p9 (p=0.046), HBsAg positive status (p=0.004), tumor size ≥3.5 cm (p

// Jun Eul Hwang 1,4,* , Myung Seo Ki 1,4,* , Karham Kim 1,4 , Sung-Hoon Jung 1,4 , Hyun-Jeong Shim 1,4 , Woo-Kyun Bae 1,4 , Eu-Chang Hwang 2,4 , Young Hoe Hur 3,4 , Oh Jeong 3,4 , Seong Yeob Ryu 3,4 , Young Kyu Park 3,4 , Sang-Hee Cho 1,4 , Ju-Seog Lee 5 and Ik-Joo Chung 1,4 1 Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Jeonnam, Korea 2 Department of Urology, Chonnam National University Hwasun Hospital, Jeonnam, Korea 3 Department of General Surgery, Chonnam National University Hwasun Hospital, Jeonnam, Korea 4 Chonnam National University Hwasun Hospital, Jeonnam, Korea 5 Department of Systems Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA * These authors have contributed equally to this work as first co-authors Correspondence to: Ik-Joo Chung, email: // Keywords : gastric cancer, gastrectomy, prognosis, platinum, adjuvant chemotherapy Received : December 22, 2016 Accepted : March 01, 2017 Published : March 16, 2017 Abstract Adjuvant chemotherapy using TS-1 or capecitabine plus oxaliplatin improves survival outcomes after radical gastrectomy, with both regimens showing similar efficacies. A total of 494 patients with stage II‒III gastric cancer who underwent curative D2 gastrectomy and received adjuvant chemotherapy from April 2004 to June 2014 were included in this study. 219 patients received TS-1, and 275 received platinum-based chemotherapy. The disease-free survival associated with adjuvant chemotherapy with TS-1 was compared with that associated with fluoropyrimidine plus platinum chemotherapy to identify the subgroups that would benefit most from platinum-based chemotherapy. The platinum group consisted of younger individuals, more males and more stage III patients compared with the TS-1 group. To reduce selection bias and its effects on treatment results, we performed a propensity score-matched analysis. The matched cohort consisted of 219 TS-1 and 219 platinum treatment patients, respectively. In the matched cohort, the chemotherapeutic regimen did not affect disease-free survival according to stage (stage II: platinum vs. TS-1, P = 0.348; stage III: P = 0.132). According to the subgroup analysis, platinum-based chemotherapy resulted in an improved 3-year disease-free survival compared with TS-1 treatment (66.8% vs. 57.8%, P = 0.015) for patients with high-risk features (any two or more of pT4, pN3, and lymphovascular invasion positivity). Our results suggest that TS-1 alone is acceptable for patients without high-risk features, while platinum-based adjuvant chemotherapy should be administered to patients with high-risk features in D2-resected gastric cancer.

Gastric infarction is a rare complication of acute pancreatitis. The proposed mechanism underlying this condition is a marked reduction of blood supply due to thrombotic occlusion of the vascular system. A review of the medical literature published thus far identified three reported cases of gastric infarction caused by acute pancreatitis. We report an additional case of gastric and splenic infarctions caused by acute pancreatitis in a 63-year-old woman. Laboratory investigation revealed increases of serum amylase, serum lipase, serum lactate dehydrogenase, blood urea nitrogen, blood creatinine, and blood C-reactive protein levels, as well as increases in the white blood cell count, indicating acute severe pancreatitis. Abdominal computed tomography revealed acute necrotic collection in the peripancreatic area, and gastric and splenic infarctions associated with multiple thromboses of the short gastric and splenic arteries. She received a total gastrectomy with a Roux-en-Y esophagojejunostomy and a splenectomy. At the follow-up examination, no symptoms were noted. This article is protected by copyright. All rights reserved.

Purpose To retrospectively compare long-term outcomes of conventional chemoembolization plus radiofrequency (RF) ablation vs those of surgical resection in patients with a single 3–5-cm hepatocellular carcinoma (HCC). Materials and Methods From January 2008 to December 2017, 139 of 623 patients who underwent surgical resection and 60 of 186 patients who underwent chemoembolization/RF ablation in a single center were compared with respect to local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS), overall survival (OS), major complications, and hospital stay before and after propensity-score matching. Results Mean follow-up periods were similar in the chemoembolization/RF ablation and surgical resection groups (41.9 mo vs 48.4 mo). Three (5%) and 17 (28.3%) patients in the chemoembolization/RF ablation group and 12 (8.6%) and 57 (41.0%) patients in the surgical resection group showed LTP and IDR (P = .366 and P =.114, respectively). At 1, 3, and 5 years, respective DFS rates were 88.1%, 65.3%, and 49.0% for chemoembolization/RF ablation and 84.2%, 58.2%, and 46.5% for surgical resection (P = .294). Moreover, respective OS rates were 95.0%, 73.5%, and 54.0% for chemoembolization/RF ablation and 97.1%, 87.4%, and 75.0% for surgical resection (P = .055). After matching (n = 52), therapeutic outcomes remained similar (P = .370, P = .110, P = .230, and P = .760, respectively). Surgical resection was associated with higher complication rates (P = .015) and longer hospital stays (8.4 d ± 3.7 vs 16.9 d ± 7.0; P Conclusions Conventional chemoembolization combined with RF ablation may be feasible for single 3–5-cm HCCs, with comparable therapeutic outcomes vs surgical resection and shorter hospital stays.

To define and correlate multidetector CT (MDCT) findings of pancreatic fistula after pancreaticoduodenectomy with surgical grading based on the 2016 Revised International Study Group of Pancreatic Fistula (ISGPF) classification. Between May 2011 and December 2016, 235 patients with periampullary tumor underwent pancreaticoduodenectomy and postoperative MDCT. Patients were classified into three groups (clinically no pancreatic fistula (cNo-PF), grade B, and grade C) according to the ISGPF classification. MDCT images were retrospectively evaluated by two radiologists in consensus for the presence of pancreaticojejunostomy (PJ) dehiscence, PJ dehiscence diameter, PJ defect, acute necrotic collection (ANC), peripancreatic fluid collection, and imaging findings of complications. Categorical MDCT findings were compared among the three groups using Pearson’s chi-square test, and PJ dehiscence diameter was compared using the Kruskal–Wallis test. There was no significant difference in patient demographics among the groups (cNo-PF = 133, grade B = 68, and grade C = 34), but the MDCT findings were significantly different regarding the presence of PJ dehiscence (p

PURPOSE To evaluate the effects of the degree of ethiodized oil accumulation achieved by transarterial chemoembolization followed by radiofrequency (RF) ablation on the treatment efficacy for a single intermediate-sized hepatocellular carcinoma (HCC). MATERIALS AND METHODS A total of 153 consecutive patients who underwent chemoembolization and RF ablation for a single intermediate-sized HCC (2-5 cm) were included. On the basis of the degree of ethiodized oil accumulation in HCC on cone-beam CT images, patients who underwent chemoembolization and RF ablation were classified into 2 groups: compact accumulation (≥ 75%) and noncompact accumulation (< 75%). The rates of cumulative local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were compared between groups. RESULTS Of the 153 patients, 89 were classified into the compact ethiodized oil accumulation group and 64 in the noncompact ethiodized oil accumulation group. There were no significant differences in patient demographic or HCC characteristics between groups except for the incidence of liver cirrhosis (P = .038) and the tumor margin morphology (P = .008). The cumulative LTP rate was significantly lower in the compact accumulation group than in the noncompact accumulation group (P = .013). There were no significant differences in the incidences of complications, DFS rates (P = .055), or OS rates (P = .184). CONCLUSIONS The degree of ethiodized oil accumulation does not play a role in decreasing the OS or DFS rate after chemoembolization and RF ablation for intermediate-sized HCC; however, it may contribute to reducing the rate of LTP.

Previous studies have suggested that stearoyl lysophosphatidlycholine (LPC) protects against lethal experimental sepsis by inhibiting lipopolysaccharide (LPS)-induced extracellular release of high-mobility group box 1 (HMGB1). However, limited information exists on the mechanism by which stearoyl-LPC suppresses the extracellular release of HMGB1 in monocyte/macrophages stimulated with LPS. In this study, we found that stearoyl-LPC increased the phosphorylation of AMP-activated protein kinase (AMPK) in macrophages. Exposure of LPS-stimulated macrophages to stearoyl-LPC decreased the extracellular release of HMGB1 in peritoneal macrophages, which were inhibited by the AMPK inhibitor, compound C. In addition, stearoyl-LPC-mediated suppression of HMGB1 release was abolished by siRNA-mediated knock-down of AMPKα1. Stearoyl-LPC increased the phosphorylation of acetyl-CoA carboxylase (ACC), a downstream target of activated AMPK, in mice lungs and decreased HMGB1 levels in bronchoalveolar lavage fluids in mice administered LPS. These results reveal a novel mechanism by which stearoyl-LPC regulates LPS-mediated cellular translocation of HMGB1.

ObjectivesThe actual future liver remnant (aFLR) is calculated as the ratio of remnant liver volume (RLV) to total functional liver volume (TFLV). The standardized future liver remnant (sFLR) is calculated as the ratio of RLV to standard liver volume (SLV). The aims of this study were to compare the aFLR with the sFLR and to determine criteria for safe hepatectomy using computed tomography volumetry and indocyanine green retention rate at 15 min (ICG R15).MethodsMedical records and volumetric measurements were obtained retrospectively for 81 patients who underwent right hemi‐hepatectomy for malignant hepatic tumours from January 2010 to November 2013. The sFLR was compared with the aFLR, and a ratio of sFLR to ICG R15 as a predictor of postoperative hepatic function was established.ResultsIn patients without cirrhosis, the sFLR showed a stronger correlation with the total serum bilirubin level than the aFLR (R2 = 0.499 versus R2 = 0.239). Post‐hepatectomy liver failure developed only in the group with an sFLR of 1.9 showed 66.7% sensitivity and 100% specificity.ConclusionsRegardless of ICG R15, an sFLR of ≥25% in patients without cirrhosis, and an sFLR of ≥25% with an sFLR : ICG R15 ratio of >1.9 in patients with cirrhosis indicate acceptable levels of safety in major hepatectomy.

// Ho Song Yu 1,* , Jun Eul Hwang 3,* , Ho Seok Chung 1 , Yang Hyun Cho 1 , Myung Soo Kim 1 , Eu Chang Hwang 1 , Kyung Jin Oh 1 , Sun-Ouck Kim 1 , Seung Il Jung 1 , Taek Won Kang 1 , Dong Deuk Kwon 1 , Kwangsung Park 1 , Soo Bang Ryu 1,2 , Sung-Hoon Jung 3 , Young Hoe Hur 4 , Joon Hwa Noh 5 , Myung Ki Kim 6 , Ill Young Seo 7 , Chul-Sung Kim 8 , Sung Gu Kang 9 , Seok Ho Kang 9 and Jun Cheon 9 1 Department of Urology, Chonnam National University Medical School, Gwangju, Korea 2 Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea 3 Department of Hemato-Oncology, Chonnam National University Medical School, Gwangju, Korea 4 Department of General Surgery, Chonnam National University Medical School, Gwangju, Korea 5 Department of Urology, Kwangju Christian Hospital, Gwangju, Korea 6 Department of Urology, Chonbuk National University Medical School, Jeonju, Korea 7 Department of Urology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea 8 Department of Urology, Chosun University School of Medicine, Gwangju, Korea 9 Department of Urology, Korea University College of Medicine, Seoul, Korea * These authors have contributed equally to this work as first co-authors Correspondence to: Eu Chang Hwang, email: // Keywords : renal insufficiency, chronic, carcinoma, transitional cell, prognosis Received : January 02, 2017 Accepted : March 06, 2017 Published : March 15, 2017 Abstract Purpose: The aim of this study was to determine the effect of preoperative chronic kidney disease (CKD) on the prognosis of patients with upper urinary tract urothelial carcinoma (UTUC) who had undergone radical nephroureterectomy (RNU). Results: The median follow-up period was 31.1 months (interquartile range: 16.2-55.7 months). Among the study patients, 224 patients in the non-CKD group were selected via propensity score matching. The median recurrence-free, cancer-specific, and overall survival were significantly shorter for patients with preoperative CKD than for non-CKD patients ( p = 0.001, p = 0.001, and p = 0.001, respectively). According to multivariable Cox regression analysis, preoperative CKD was related to worse recurrence-free (hazard ratio [HR]: 1.81, 95% confidence interval [CI]: 1.15-2.86, p = 0.011), cancer-specific (HR: 2.44, 95% CI: 1.44-4.14, p = 0.001), and overall survival (HR: 1.66, 95% CI: 1.15-2.40, p = 0.007). Methods: A total of 566 patients who underwent RNU at 6 institutions from 2004 to 2014 were retrospectively reviewed. Of these patients, 342 had an estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m 2 (non-CKD group) and 224 patients had an eGFR

Purpose: The aim of this study was to compare the therapeutic effects of radiofrequency ablation (RFA) and hepatic resection (HR) with regards to procedural morbidity, mortality, overall survival (OS) and disease-free survival (DFS) rates in hepatocellular carcinoma (HCC) patients. Methods: Retrospective studies were performed based on the medical records of 129 patients who underwent curative HR, and 57 who patients received RFA for HCC, between 2005 and 2009. The inclusion criteria of HCC were the presence of three or fewer nodules 3 cm or less in diameter or a single nodule of 5 cm or less. Results: The 1-, 3- and 5-year OS rates in the HR group were 91.3%, 78.8%, and 64.9%, compared to 94.4%, 74.0%, and 74.0% in the RFA group, with no significant difference between the two groups (P = 0.725). The estimated 1- and 3-year DFS rates were 70.0% and 53.0% in the HR group and 65.2% and 24.7% in the RFA group, respectively. The DFS rates of HR group were significantly higher than RFA group (P = 0.015). Multivariate analysis identified that recurrence (P = 0.036) and portal hypertension (P = 0.036) were associated with OS and that portal hypertension (P = 0.048) and increased serum a-FP (P = 0.008) were the factors significantly associated with DFS. Conclusion: HCC within Milan criteria should consider hepatectomy as the primary treatment if the patient"s liver function and general conditions are good enough to undergo surgical operation. But in that RFA revealed similar overall survival to HR, RFA can be an alternative therapy for patients who are eligible for surgical resection.

Radiologists can narrow the list of differential diagnoses for splenic lesions by understanding characteristic imaging findings, including the nature and degree of lesion contrast enhancement

Rationale:Intrahepatic adrenocortical adenoma (IAA) arising from adrenohepatic fusion (AHF) is rare and its imaging findings are not well established. Moreover, it is easily misdiagnosed as malignant hepatic tumor in patients at risk of malignancy. Its key finding is the connection between t

Hepatic abscesses are known to present with various imaging findings according to the degree of maturation and internal contents.1 Hepatic abscess rarely mimics hepatic neoplasm such as HCC. As evidenced by our case, if there are no clinical and laboratory findings suggestive of hepatic abscess, hepatic abscess that presents with imaging findings, such as early arterial enhancement and delayed washout, mosaic pattern of enhancement, and well-defined tumoral capsule with delayed enhancement could be hardly differentiated from HCC.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is a rare benign vascular mass, with fewer than 100 cases documented. It is generally recognized as a vascular lesion that develops in the red pulp of the spleen; however, its pathogenesis is not clearly defined. We report a case of SANT of the spleen, which presents evidence to support the hypothesis that this disease entity is associated with IgG4-associated disease. Microscopically, the tumor was composed of multiple vascular structures separated by fibrous connective tissue and immunohistochemical examination revealed positive staining for CD31, CD34, factor VIII, and IgG4. Further research based on large number of cases is warranted to clarify the pathogenesis of this tumor.

Portal vein thrombosis (PVT) is commonly associated with liver cirrhosis, irrespective of the presence of hepatocellular carcinoma (HCC). Given that malignant PVT is a poor prognostic factor in patients with HCC, it is important to differentiate malignant PVT from benign PVT. Because malignant PVT has been reported to be contiguous with parenchymal HCC, in most cases, the presence of PVT alone indicates a benign entity. We report the case of a patient with rapid progression of malignant PVT mimicking benign PVT but without definite parenchymal HCC on imaging modalities.

Background The platelet–lymphocyte ratio (PLR) and neutrophil–lymphocyte ratio (NLR) have been reported as prognostic factors in various cancers, but their roles in metastatic renal cell cancer (mRCC) remain unclear. We investigated the significance of PLR and NLR, along with that of established prognostic factors, in mRCC patients receiving first-line tyrosine kinase inhibitors (TKI). Methods Data obtained from 63 mRCC patients who received first-line TKI between 2007 and 2013 were evaluated retrospectively. The association of PLR, NLR, and established prognostic factors with progression-free survival (PFS) and overall survival (OS) was analyzed using the Kaplan–Meier method. The influence of independent prognostic factors on survival was determined using multivariable Cox regression analysis. Results High NLR (>3.6) and PLR (>150) were related to shorter PFS (p = 0.001) and OS (p = 0.001). The presence of brain metastases [hazard ratio (HR) 4.94, 95% CI 1.75–13.9; p = 0.002] and high PLR (>150, HR 13.1, 95% CI 5.14–33.2; p = 0.001) were independently associated with PFS, and Eastern Cooperative Oncology Group Performance status ≥2 (HR 3.60, 95% CI 1.39–9.31; p = 0.008), lymph node metastasis (HR 2.76, 95% CI 1.11–6.86; p = 0.029), brain metastasis (HR 9.39, 95% CI 2.74–32.1; p = 0.001), and high PLR (>150, HR 16.1, 95% CI 4.41–58.4; p = 0.001) with OS. Conclusions High PLR was associated with shorter survival of mRCC patients receiving first-line TKI. The PLR may be an effective independent prognostic factor in this setting.

Splenic vein thrombosis is a relatively common finding in pancreatitis. Gastric variceal bleeding is a life-threatening complication of splenic vein thrombosis, resulting from increased blood flow to short gastric vein. Traditionally, splenectomy is considered the treatment of choice. However, surgery in necrotizing pancreatitis is dangerous, because of severe inflammation, adhesion, and bleeding tendency. In the Warshaw operation, gastric variceal bleeding is rare, even though splenic vein is resected. Because the splenic artery is also resected, blood flow to short gastric vein is not increased problematically. Herein, we report a case of gastric variceal bleeding secondary to splenic vein thrombosis complicated by necrotizing pancreatitis successfully treated with splenic artery embolization. Splenic artery embolization could be the best treatment option for gastric variceal bleeding when splenectomy is difficult such as in case associated with severe acute pancreatitis or associated with severe adhesion or in patients with high operation risk.

Adenocarcinoma is the predominant histological type of carcinoma of the gallbladder, accounting for more than 80% of all gallbladder carcinomas. In contrast, carcinosarcoma of the gallbladder is an extremely atypical subset of gallbladder malignancies. It is characterized by the presence of both epithelial and mesenchymal components. Currently, fewer than 100 cases have been reported in the English literature. Therefore, knowledge and experience regarding this disease are limited. Recently, we experienced two cases of gallbladder carcinosarcoma, which were diagnosed as gallbladder carcinoma based on the preoperative clinical and radiological examinations. Cholecystectomies were performed in both cases, and the malignant tumor cells included carcinomatous and sarcomatous components histologically. The final pathological diagnoses were carcinosarcoma of the gallbladder. We herein report these two cases of gallbladder carcinosarcoma and review the previous pertinent literature.

Primary extragastrointestinal stromal tumors (EGISTs) arising in the pancreas are extremely rare, with only ten cases documented to our knowledge. We report a further case of EGIST of the pancreas. The patient was a 55-year-old man who presented with postprandial abdominal discomfort. Abdominal computed tomography and magnetic resonance imaging showed a lobulated heterogenous enhancing mass, 11 cm in diameter, in the abdominal cavity. No regional lymphadenopathy, ascites, or metastasis was seen radiologically. There was no obvious lesion in the stomach or small intestine. The initial diagnosis was a solid pseudopapillary tumor or serous cystic neoplasm. The patient underwent distal pancreatectomy with splenectomy. Microscopically, the tumor consisted of spindle cells arranged in short fascicles. Mitotic figures were seen in 7/50 high-power fields. Immunohistochemical examination revealed strongly positive staining for CD117. Based on these findings, the final pathologic diagnosis was a primary EGIST of the pancreas. This case consolidates the possibility that this rare tumor can involve the pancreas as a primary site and should be included in the differential diagnosis of cystic lesions in this site.

Background Undifferentiated embryonal sarcoma (UES) of the liver is a rare, highly malignant neoplasm with a poor prognosis occurring almost exclusively in late childhood (6–10 years of age). Only a few cases have been reported in adults, accounting for less than 1% of all primary liver neoplasms. Methods A 47-year-old woman presented with a palpable mass in the left upper abdomen. Magnetic resonance imaging revealed a 12×10 cm cystic mass with hemorrhage in the left lateral segment of the liver. The initial impression was a hemorrhagic cystic tumor of the liver. The patient underwent a left lateral sectionectomy of the liver. Histopathology and immunohistochemistry helped make a diagnosis of UES. Results The patient recovered uneventfully and received systemic chemotherapy. Radiologie examination for follow-up revealed a metastatic lesion in the lumbar spine (L5). She was subjected to radiotherapy at the lumbar spine. She survived 48 months. Conclusions Although hepatic cyst as UES of the liver is diffcult to diagnose because of its rarity in adults and lack of specifc findings, it should be considered in a differential diagnosis.

Primary sarcomas of the pancreas are extremely rare, accounting for 0.1% of malignant pancreatic (non-islet) neoplasms. Pancreatic leiomyosarcoma is a highly aggressive malignancy that spreads in a similar manner to gastric leiomyosarcoma, i.e., by adjacent organ invasion, hematogenous spread, and lymph node metastasis. These tumors are large at the time of diagnosis and are usually found at an advanced stage. We report a case of a 70-year-old female with intermittent right upper quadrant abdominal discomfort. Radiological, histopathological, and immunohistochemical studies revealed the tumor to be a primary leiomyosarcoma of the pancreas. Herein, we describe a patient with a primary leiomyosarcoma of the pancreas who presented with clinical and radiological findings indicative of a mass in the pancreatic head.

Lymphangiomas are rare congenital benign tumors arising from the lymphatic system, and are mostly encountered in the neck and axillary regions of pediatric patients (95%). Lymphangioma of the pancreas is extremely rare accounting for less than 1% of these tumors. We report here on a case of pancreatic cystic lymphangioma. A 54-year-old woman presented with intermittent postprandial abdominal discomfort and radiating back pain. Abdominal computed tomography scan revealed 8 × 6.5 cm hypodense cystic mass arising from the tail of the pancreas without septa or solid component. The initial impression was a pancreatic pseudocyst. The patient underwent distal pancreatectomy with splenectomy. The histopathologic and immunohistochemical study helped make the diagnosis of a pancreatic cystic lymphangioma. Herein, we report a case of pancreatic cystic lymphangioma mimicking pancreatic pseudocyst and review the relevant medical literature.

To compare therapeutic outcomes of radiofrequency (RF) ablation combined with transcatheter arterial chemoembolization vs surgical resection (SR) for single 2-3 cm hepatocellular carcinoma (HCC).Seventy patients underwent combined chemoembolization/RF ablation therapy and 84 underwent SR. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS), and overall survival (OS) rates, as well as major complications and duration of hospital stay, were compared between groups before and after propensity-score matching.LTP and IDR had developed in 9 (12.9%) and 24 (34.3%) patients in the combined treatment group and in 7 (8.3%) and 24 (28.6%) patients in the SR group (P = .262 and P = .252, respectively). The 1-, 3-, 4-, and 5-year DFS rates were similar between groups (82.6%, 53.2%, 53.2%, and 37.6%, respectively, vs 84.5%, 63.6%, 59.2%, and 52.1%, respectively; P = .278), and 1-, 3-, 4-, and 5-year OS rates were also comparable (94.2%, 81.2%, 74.1%, and 59.4%, respectively, vs 95.2%, 86.3%, 84.0%, and 80.3%, respectively; P = .081). After matching (n = 98), LTP, IDR, DFS, and OS rates were still similar (P = .725, P = .826, P = .484, and P = .578, respectively). Major complication rate was not significantly different (2.9% vs. 6.0%; P = .596); however, after matching, major complication rate was higher in SR group (2.0% vs. 6.1%; P.001). Hospital stays were significantly longer in the SR group (16.6 ± 6.7 d vs 8.5 ± 4.1 d; P.001).Before and after matching, there were no significant differences in long-term therapeutic outcomes between combined chemoembolization/RF ablation and SR groups. Therefore, combined chemoembolization/RF ablation therapy may be an alternative treatment for single 2-3 cm HCCs.

The purpose of this study was to elucidate the prognostic factors for distal cholangiocarcinoma after curative resection, and to assess the significance of perineural invasion (PNI) and lymphovascular invasion (LVI) as prognostic factors.A retrospective analysis of 91 patients who underwent radical surgery for distal cholangiocarcinoma between March 2004 and October 2011 was performed. We analyzed the survival rate and prognostic factors affecting the survival.The overall 1-, 3- and 5-year survival rates were 84.1, 49.7 and 38.9 %, respectively. In the univariate analysis, the prognostic factors influencing the survival were the histological differentiation, lymph node (LN) involvement and TNM stage. In the multivariate analysis, LN metastasis was the only independent prognostic factor. Although patients with PNI tended to show poorer survival, it was not a statistically significant factor (3- and 5-year OS; 62.0 and 54.6 % vs. 42.8 and 30.9 %, P = 0.166). In the patients with a total lymph node count (TLNC) of 11 or less, PNI was a significant prognostic factor; however, it was not a significant factor in the patients with a TLNC over 11. Overall, the LVI had no influence on the patient survival.LN metastasis was the only significant prognostic factor after the curative resection of distal cholangiocarcinoma. In cases where adequate dissection was performed, it appeared that the PNI and LVI had no influence on the survival.

Hepatoid adenocarcinoma is a special type of extrahepatic adenocarcinoma that mimics hepatocellular carcinoma morphologically. The stomach is one of the most common sites of hepatoid adenocarcinoma. Hepatoid adenocarcinoma is characterized histologically by hepatoid differentiation and production of large amounts of AFP. It is not easy to differentiate hepatic metastases from hepatoid adenocarcinoma and hepatocellular carcinoma when hepatic tumor is incidentally detected. Furthermore, imaging findings of hepatoid adenocarcinoma are rarely described. Therefore, we report a case of hepatic metastases from hepatoid adenocarcinoma of stomach mimicking hepatocellular carcinoma with image findings and a review of the literature.

Backgrounds/Aims: Despite hepatolithiasis being a risk factor for biliary neoplasm including cholangiocarcinoma, the incidence of underlying biliary neoplasm is unknown in patients with preoperative benign hepatolithiasis. The aim of this study was to evaluate the incidence of underlying biliary neoplasm in patients who underwent major hepatectomy for preoperative benign hepatolithiasis. Methods: Between March 2005 and December 2015, 73 patients who underwent major hepatectomy for preoperative benign hepatolithiasis were enrolled in this study. The incidence and pathological differentiation of concomitant biliary neoplasm were retrospectively determined by review of medical records. Postoperative complications after major hepatectomy were evaluated. Results: Concomitant biliary neoplasm was pathologically confirmed in 20 patients (27.4%). Biliary intraepithelial neoplasia (BIN) was detected in 12 patients (16.4%), and 1 patient (1.4%) had intraductal papillary mucinous neoplasm (IPMN), as the premalignant lesion. Cholangiocarcinoma was pathologically confirmed in 7 patients (9.6%). Preoperative imaging of the 73 patients revealed biliary stricture at the first branch of bile duct in 31 patients (42.5%), and at the second branch of bile duct in 39 patients (53.4%). Postoperative complications developed in 14 patients (19.1%). Almost all patients recovered from complications, including intra-abdominal abscess (9.6%), bile leakage (4.1%), pleural effusion (2.7%), and wound infection (1.4%). Only 1 patient (1.4%) died from aspiration pneumonia. Conclusions: The incidence of underlying biliary neoplasm was not negligible in the patients with hepatolithiasis, despite meticulous preoperative evaluations.

Objective To compare the effectiveness of radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) with surgical resection in patients with a single hepatocellular carcinoma (HCC) ranging from 2 to 5 cm. Materials and Methods The study participants were enrolled over a period of 29 months and were comprised of 37 patients in a combined therapy group and 47 patients in a surgical resection group. RFA was performed the day after TACE, and surgical resection was performed by open laparotomy. The two groups were compared with respect to the length of hospital stay, rates of major complication, and rates of recurrence-free and overall survival. Results Major complications occurred more frequently in the surgical resection group (14.9%) than in the combined therapy group (2.7%). However, there was no statistical significance (p = 0.059). The rates of recurrence-free survival at 1, 2, 3 and 4 years were similar between the combined therapy group (89.2%, 75.2%, 69.4% and 69.4%, respectively) and the surgical resection group (81.8%, 68.5%, 68.5% and 65%, respectively) (p = 0.7962, log-rank test). The overall survival rates at 1, 2, 3 and 4 years were also similar between groups (97.3%, 86.5%, 78.4% and 78.4%, respectively, in the combined therapy group, and 95.7%, 89.4%, 84.3% and 80.3%, respectively, in the surgical resection group) (p = 0.6321, log-rank test). Conclusion When compared with surgical resection for the treatment of a single HCC ranging from 2 to 5 cm, RFA combined with TACE shows similar results in terms of recurrence-free and overall survival rates.

OBJECTIVE The purpose of this study was to prospectively compare pre-operative computed tomography (CT) perfusion parameters with tumor grade from colorectal adenocarcinoma (CRC) and to correlate pre-operative CT perfusion parameters with microvessel density (MVD) to evaluate angiogenesis in CRC. MATERIALS AND METHODS Pre-operative perfusion CTs were performed with a 64-channel multidetector row CT in 27 patients (17 women and 10 men; age range 32-82 years) who were diagnosed with CRC involving the sigmoid and rectum between August 2006 and November 2007. All patients underwent surgery without pre-operative chemotherapy or radiation therapy. Dynamic perfusion CTs were performed for 65 seconds after intravenous injection of contrast medium (100 mL, 300 mg of iodine per mL, 5 mL/sec). Before surgery, blood flow (BF), blood volume, mean transit time (MTT), and permeability-surface area product were measured in the tumor. After surgery, one gastrointestinal pathologist evaluated tumor grade and performed immunohistochemical staining using CD 34 to determine MVD in each tumor. The Kruskal-Wallis test was used to compare CT perfusion parameters with tumor grade, and Pearson's correlation analysis was used to correlate CT perfusion parameters with MVD. RESULTS In 27 patients with CRC, tumor grading was as follows: well differentiated (n = 8); moderately differentiated (n = 15); and poorly differentiated (n = 4). BF was higher in moderately differentiated CRC than well differentiated and poorly differentiated CRCs (p = 0.14). MTT was shorter in moderately differentiated than well differentiated and poorly differentiated CRCs (p = 0.039). The MVD was greater in poorly differentiated than well differentiated and moderately differentiated CRCs (p = 0.034). There was no significant correlation between other perfusion parameters and tumor grade. There was no significant correlation between CT perfusion parameters and MVD. CONCLUSION BF and MTT measurement by perfusion CT is effective in predicting moderately differentiated CRCs. However, perfusion CT is limited in distinguishing well differentiated and poorly differentiated CRCs. Pre-operative perfusion CT does not reflect the MVD of CRCs.

Purpose: To analyze the outcomes of laparoscopic liver resection compared with open liver resection in patients with hepatocellular carcinoma (HCC). Methods: Between July 2005 and December 2009, 26 consecutive patients with HCC underwent a pure laparoscopic liver resection, and data from this group (laparoscopic liver resection group, L-group) were compared with a retrospective control group of 29 patients who underwent open liver resection for HCC (open liver resection group, O-group) during the same period. The two groups were matched in terms of demographic data, tumor size, degree of liver cirrhosis, American Society of Anesthesiology score, type of resection, and tumor location. Results: Median operation time and the amount of intraoperative packed red blood cell transfusion in the L-group were 147.5 minutes and 0.35 units, respectively. The L-group revealed a shorter operation time (147.5 vs. 220.0 minutes, P = 0.031) than the O-group. No difference in perioperative morbidity or mortality rates was observed (3.8, 0 vs. 24.1%, 0%; P = 0.054, non-specific, respectively); the L-group was associated with a shorter hospital stay than the O-group (11.08 vs. 16.07 days, P = 0.034). After a mean follow-up of 23.9 months (range, 0.7 to 59.4 months), the 1-year disease-free survival rate was 84.6% in the L-group and 82.8% in the O-group (P = 0.673). Conclusion: Laparoscopic liver resection for HCC is feasible and safe in selected patients and can produce good surgical results with a shorter postoperative hospital stay and similar outcomes in terms of perioperative morbidity, mortality, and disease-free survival than open resection.

Ultrasound-guided percutaneous radiofrequency (RF) ablation has become one of the most promising local cancer therapies for both resectable and nonresectable hepatic tumors. Although RF ablation is a safe and effective technique for the treatment of liver tumors, the outcome of treatment can be closely related to the location and shape of the tumors. There may be difficulties with RF ablation of tumors that are adjacent to large vessels or extrahepatic heat-vulnerable organs and tumors in the caudate lobe, possibly resulting in major complications or treatment failure. Thus, a number of strategies have been developed to overcome these challenges, which include artificial ascites, needle track ablation, fusion imaging guidance, parallel targeting, bypass targeting, etc. Operators need to use the right strategy in the right situation to avoid the possibility of complications and incomplete thermal tissue destruction; with the right strategy, RF ablation can be performed successfully, even for hepatic tumors in high-risk locations. This article offers technical strategies that can be used to effectively perform RF ablation as well as to minimize possible complications related to the procedure with representative cases and schematic illustrations.

s / Pancreatology 13 (2013) S1–S80 S74 Background/aim: During a PD it is important to fully understand the arcade of blood vessels in the head of the pancreas before the surgery to reduce intraoperative bleeding. In most of our patients, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, forms a short common trunkwith thefirst jejunal artery (FJA). There are twoways to locate the IPDA: tomeasure the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA or to measure the distance between the origin of the middle colic artery (MCA) and that of the FJA. In this study, we measured both distances using 3D models of arteries constructed with MD-CT and discussed which distance can be more easily measured to help determine the location of the IPDA. Methods: One-hundred-forty patients underwent 64-MD-CT to acquire early and late arterial phase images. The distance between the SMA origin and the FJA origin and the distance between the MCA origin and the FJA origin were measured. Results: In patients whose IPDA formed a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from theMCAorigin towards the center. The distance between the SMAorigin and the IPDAwas significantly longer. Therefore, locating the MCA origin during PD helped determine the location of the IPDA. Thus, locating the SMA origin was helped determine the location of the IPDA during PD in these patients. Conclusions: Considering that the distance between the IPDA origin and the MCA origin was short, it was demonstrated that it is effective to locate the MCA origin to determine the location of the PIPDA.