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ORIGINAL ARTICLE, Background: The relationship of thymidine phosphorylase (TP) expression and patient outcomes has been investigated in various cancers. This study investigated the association of TP expression, serum TP, and platelet counts in patients with gastric cancer. Methods: A series of 77 patients with gastric adenocarcinoma were enrolled in the study. Pretreatment serum TP was determined by enzyme-linked immunosorbent assay and the patient characteristics, including platelet count, gender, age, tumor stage and histological grade, and immunoreactivity of surgically resected tissue specimens, were recorded. Results: The serum TP level was significantly higher in poorly differentiated and signet ring cell adenocarcinomas than in more differentiated types. TP expression was observed within well- and moderately differentiated adenocarcinoma cancer cells, but was significantly weaker in poorly differentiated adenocarcinomas and signet ring cell carcinomas. There were no significant differences in the survival of patients with different histological types and serum TP levels. Although the differences were not statistically significant, high TP expression and high platelet counts were poor prognostic factors. TP expression was not correlated with serum TP levels, but was slightly correlated with the platelet count. Conclusions: TP expression in gastric cancer tissue was slightly related to the platelet count rather than to the serum TP concentration. Therefore, a larger number of patients should be evaluated to assess the relationship between platelet count and capecitabine treatment response in gastric cancer patients.

AIM To assess the usefulness of intra-arterial contrast-enhanced ultrasonography (IAUS) during transarterial chemoembolization (TACE) with drug-eluting beads (DEB) for hepatocellular carcinoma (HCC). METHODS Thirty two patients with 39 HCC underwent DEB-TACE guided with IAUS, and examined by contrast-enhanced ultrasonography (CEUS) or dynamic CT after DEB-TACE were enrolled in this study. CEUS findings before DEB-TACE and IAUS findings were compared. Treatments judged to be complete and incomplete for lesions were appropriate and insufficient, respectively. Findings on CEUS and/or dynamic CT performed 1, 3 and 6 mo after DEB-TACE were evaluated using mRECIST (CR/PR/SD/PD). RESULTS The treatments were complete and incomplete in 26 and 13 lesions, respectively. On imaging evaluation using CEUS and/or dynamic CT one month after treatment, 25 and 1 lesions were judged to be CR and PR, respectively, and at 6 mo after treatment, the results were CR, PR, SD and PD for 24, 1, 0 and 1 of these lesions, respectively, in the 26 completely treated lesions. Of the 13 lesions in which treatment was incomplete, the results on imaging at one month after treatment were CR, PR, SD and PD for 0, 6, 4 and 3 lesions, respectively. The overall CR rate at 6 mo after treatment was 61.5% (24/39). CONCLUSION A combination of DEB-TACE with IAUS can improve the therapeutic effects in patients with HCC.

Purpose To compare contrast-enhanced ultrasonography (CEUS) using Sonazoid with Gd-EOB-DTPA-enhanced MRI (EOB-MRI) in the diagnosis of liver metastases in patients with colorectal cancer. Methods A total of 69 patients diagnosed with or suspected of having liver metastasis were enrolled. These hepatic lesions were diagnosed by histopathological examination after surgical resection or based on follow-up using various imaging modalities. The diagnostic accuracies of CEUS and EOB-MRI were compared. Results One hundred thirty-three lesions were detected. Of these lesions, 109 were diagnosed as liver metastases. Of the 133 lesions, 90.2% were detected on CEUS, and 98.5% on EOB-MRI. One hundred nine lesions were diagnosed as liver metastasis. The areas under the receiver operating characteristic curve for diagnosis were 0.906 and 0.851 on CEUS and EOB-MRI, respectively (p = 0.41). Sensitivity, specificity, positive predictive value (PPV), negative predictive value, and overall accuracy were 90.8%, 84.5%, 97.1%, 67.1%, and 90.2%, respectively, for CEUS, and 95.4%, 70.8%, 93.7%, 77.3%, and 91%, respectively, for EOB-MRI. Conclusions CEUS has a higher specificity and PPV for the diagnosis of liver metastasis than EOB-MRI. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:138–144, 2017

The CyberKnife® is expected to be a novel local treatment for hepatocellular carcinoma (HCC), however, a long-term follow-up using dynamic computed tomography and magnetic resonance imaging is required to determine the effect of treatment in a number of the affected patients. Therefore, there is a requirement to evaluate procedures for early determination of the effect of CyberKnife treatment. The present study aimed to evaluate the changes in the hemodynamics of the tumors and the hepatic parenchyma surrounding the tumor prior to and following CyberKnife treatment for HCC. A total of 4 HCC patients were enrolled in this study. These patients underwent CyberKnife treatment and were evaluated by image analysis prior to and following treatment using contrast-enhanced ultrasonography (CEUS) with Sonazoid. CEUS was performed prior to treatment, at 2 and 4 weeks post-treatment, and every 4 weeks thereafter for as long as possible. The dynamics of the enhancement of the tumor and the hepatic parenchyma surrounding the tumor in the vascular phase, and the presence or absence of a hypoechoic area in the hepatic parenchyma surrounding the tumor in the post-vascular phase were assessed. Results showed that: i) In the patient with earlier changes, hemodynamic changes were evident in the tumor at 4 weeks and in the hepatic parenchyma surrounding the tumor at 2 weeks post-treatment, respectively; ii) the tumor showed hypoenhancement in all patients; and iii) with regard to findings in the hepatic parenchyma surrounding the tumor, strong hyperenhancement appeared in the vascular phase initially, followed by a hypoechoic area in the post-vascular phase. Evaluation of the hemodynamics of tumors and hepatic parenchyma surrounding the tumor using CEUS with Sonazoid may be therapeutically applicable, as it is less invasive than dynamic computed tomography (CT) and provides an early evaluation of the effectiveness of CyberKnife treatment.

Primary hepatic marginal zone B-cell malignant lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is extremely rare. We present a case in which a lesion was diagnosed as 2 contiguous tumors (MALT lymphoma and hemangioma) using contrast-enhanced ultrasonography (US) with sonazoid. There has been no previous case of contiguous hepatic MALT lymphoma and hemangioma. The present case was a female with no medical history. We detected a snowman-like appearance, which was a tumor of 15 mm in diameter with hypo- and hyper-echogenicities in the lateral and medial parts, respectively, in the Couinaud's segment (S6) of the liver on US. The tumor appeared as a single lesion with a low-density area in the unenhanced phase and prolonged enhancement in the equilibrium phases on dynamic CT. On MRI, the whole lesion showed a low-intensity signal on T1-weighted imaging, but isointensity in the lateral part and high intensity in the medial part were seen on T2-weighted imaging. On contrast-enhanced US, the lateral hypoechoic region was homogenously hyperenhanced in the early vascular phase, and the contrast medium was washed out after about 30 s; in contrast, the medial hyperechoic region was gradually stained from the margin toward the central region. The tumor showed a defect in both hypo- and hyperechoic regions in the postvascular phase. Hemangioma was suspected for the medial part based on the typical image findings, but the lateral part was not given a diagnosis. Thus, surgical resection was performed. The medial part was a hemangioma, and the lateral part was a MALT lymphoma by histopathological findings.

Sclerosing angiomatoid nodular transformation (SANT) is a recently recognized benign vascular lesion of the spleen. Detection of SANT as an incidentaloma has increased due to improvements in imaging techniques. However, a definitive diagnosis of SANT on CT or MRI remains difficult. We report the use of contrast-enhanced ultrasonography with Sonazoid in a case of SANT in a 50-year-old woman, with gross and microscopic pathologic correlations.

Purpose To determine the usefulness of arrival time parametric imaging (AtPI) using contrast-enhanced ultrasonography (CEUS) with Sonazoid in evaluating early response to sorafenib for hepatocellular carcinoma (HCC). Methods Twenty-one advanced HCC patients with low α-fetoprotein (AFP) levels (≤35 ng/ml) who received sorafenib for at least 4 weeks were enrolled in this study. CEUS was performed before and 2 weeks after treatment, and the images of the target lesion in the arterial phase were analyzed by AtPI. In the color mapping images obtained by AtPI, the mean arrival time of the contrast agent in the target lesion from the reference point (mean time: MT) was calculated. In each patient, differences between MT before and MT 2 weeks after treatment were compared. MT (+) and MT (−) groups were defined as difference of 0 s or greater and less than 0 s, respectively. Overall survival was evaluated between the two groups. Results In the MT (+) (11 patients) and MT (−) (10 patients) groups, the median survival time was 792 and 403 days, respectively, which was statistically significant. Conclusions The results suggested that AtPI was useful for evaluating early response to sorafenib for advanced HCC with low AFP level.

We examined plasma biomarkers as predictive factors for advanced hepatocellular carcinoma(ad-HCC)patients treated with sorafenib. We analyzed a-fetoprotein(AFP), AFP-L3, des-g-carboxy prothrombin(DCP), neutrophil-to-lymphocyte ratio(NLR), platelet-to-lymphocyte ratio(PLR), and vascular endothelial growth factor(VEGF)before sorafenib therapy, and changes in AFP-L3, NLR, PLR, and VEGF 1 month after sorafenib therapy in 16 patients. High AFP-L3(hazard ratio: 1.058, 95%CI: 1.019-1.098, p=0.003)and high NLR(hazard ratio: 1.475, 95%CI: 1.045-2.082, p=0.027)were significantly associated with poor prognosis in ad-HCC patients treated with sorafenib. There were no significant differences in changes in AFP-L3, NLR, PLR, and VEGF 1 month after sorafenib therapy. We suggest that AFP-L3 and NLR levels before sorafenib therapy in patients with ad-HCC are an important predictive factor for the therapeutic effect of sorafenib and patient survival.

We aimed to determine the usefulness of arrival time parametric imaging (AtPI) using contrast-enhanced ultrasonography (CEUS)with Sonazoid in the evaluation of early response to sorafenib for hepatocellular carcinoma (HCC). Thirteen ad- vanced HCC patients with low a / -fetoprotein (AFP) level (≤35 ng/mL) who received sorafenib for at least 4 weeks were enrolled in this study. CEUS was performed before and after treatment (2 weeks), and the images of the target lesion in the arterial phase were analyzed by AtPI. In the color mapping images obtained by AtPI, the mean arrival time of the contrast agent in the target lesion from the starting point (mean time: MT) was calculated. In each patient, differences between MT before and MT 2 weeks after treatment were compared. MT (+) and MT(-) groups were designated as such if the difference was 0 or greater(blood flow velocity of the lesion was reduced)and less than 0 sec(blood flow velocity of the lesion was increased), respectively. The overall survival was evaluated between the 2 groups. In the MT (+) group (7 patients) and MT (-) group (6 patients), the median survival times were 307 and 208 days, respectively, which was statistically significant. We suggest AtPI is useful for evaluating early response to sorafenib in advanced HCC patients with low AFP level.

Purpose To compare contrast‐enhanced ultrasonography (CEUS) using Sonazoid with Gd‐EOB‐DTPA‐enhanced MRI (EOB‐MRI) in the diagnosis of liver metastases in patients with colorectal cancer. Methods A total of 69 patients diagnosed with or suspected of having liver metastasis were enrolled. These hepatic lesions were diagnosed by histopathological examination after surgical resection or based on follow‐up using various imaging modalities. The diagnostic accuracies of CEUS and EOB‐MRI were compared. Results One hundred thirty‐three lesions were detected. Of these lesions, 109 were diagnosed as liver metastases. Of the 133 lesions, 90.2% were detected on CEUS, and 98.5% on EOB‐MRI. One hundred nine lesions were diagnosed as liver metastasis. The areas under the receiver operating characteristic curve for diagnosis were 0.906 and 0.851 on CEUS and EOB‐MRI, respectively (p = 0.41). Sensitivity, specificity, positive predictive value (PPV), negative predictive value, and overall accuracy were 90.8%, 84.5%, 97.1%, 67.1%, and 90.2%, respectively, for CEUS, and 95.4%, 70.8%, 93.7%, 77.3%, and 91%, respectively, for EOB‐MRI. Conclusions CEUS has a higher specificity and PPV for the diagnosis of liver metastasis than EOB‐MRI. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:138–144, 2017

The bile duct of Luschka (BDL) is an anatomic anomaly that is an important cause of bile leakage after bile duct surgery. We report a case of bile duct carcinoma with dilated BDL that was diagnosed by ultrasonography (US). An 83-year-old man presented with an obstructive jaundice. US on admission revealed the presence of a solid hypoechoic mass in the bile duct at the hepatic duct confluence and a branch of the bile duct, about 2-4 mm in diameter, distinct from the dilated right anterior hepatic duct slightly upstream of the tumor. This branch had a spiral structure, extended along the gallbladder bed on the surface of segment 5 (S5) of the liver, and emanated small branches that entered the hepatic parenchyma. There has been no previous report of delineation of BDL by preoperative US.

Heterotopic pancreas (HP) is typically an asymptomatic malformation that can present anywhere along the gastrointestinal tract. It is often detected incidentally on surgery for other diseases or autopsy. We encountered 2 patients with jejunal HP incidentally detected by computed tomography (CT) performed for close evaluation of other diseases. In a 57-year-old woman diagnosed with reactive lymphoid hyperplasia on the dorsal portion of the pancreas head, CT detected a 15 mm oval-shaped submucosal lesion at the jejunum. In an 87-year-old woman diagnosed with type 2 adenocarcinoma occupying the sigmoid colon, CT detected a round-shaped submucosal tumor 15 mm in diameter in the jejunum. Both cases were histologically diagnosed as type 1 HP according to the classification by Heinrich. Contrast-enhanced CT revealed that the CT analyses of HP and pancreatic parenchyma were nearly identical in the arterial phase, but in the equilibrium phase, contrast enhancement persisted longer in HP than in the pancreatic parenchyma. There has been no report of asymptomatic jejunal HP preoperatively diagnosed by CT. These cases are presented with a review of the literature, particularly focusing on CT findings.

We carried out contrast-enhanced ultrasonography using Sonazoid for a patient who had portal thrombosis due to choledocholith and cholangitis, and the video images were analyzed by an offline procedure using arrival-time parametric imaging. Colors were changed with the time course from red to orange, yellow, green, light blue, and blue, with the time the contrast agent reached the right hepatic artery as the starting point. The central part of the liver was primarily colored blue, and the peripheral part primarily yellowish-green. In other words, we confirmed the central and peripheral zonal differentiation observed in the arterial phase of dynamic computed tomography by color mapping image of arrival-time parametric imaging. Particularly, real-time changes in the hemodynamics of the hepatic parenchyma could be captured by color mapping image using arrival-time parametric imaging.

There have been case reports of small intestinal gastrointestinal stromal tumors (GISTs) complicated with arteriovenous malformation (AVM) and angiodysplasia and exhibiting intense tumor staining. Herein we report a GIST of the small intestine that showed tumor staining and early venous return on imaging studies, and so the patient was suspected to have AVM. A 62-year-old male presented with intermittent pain in the left abdominal region. Contrast-enhanced computed tomography revealed a 15-mm-long spindle-shaped mass showing intense tumor staining and early venous return through the jejunal vein. In the arterial phase, the attenuation value of the tumor was 250 Hounsfield units. Color Doppler ultrasonography simultaneously delineated vessels extending from the serosal side and turbulent signals showing a mosaic pattern in the tumor. On angiography, intense staining was observed in the peripheral part of the second branch of the jejunal artery. Although these findings suggested AVM, the tumor was diagnosed as a GIST based on pathological examination of the resected specimens. In this case, no AVM or change in vascular density was noted despite the careful examination of pathological specimens, and the cause of the tumor staining remained unknown.

The number of amino acid (AA) mutations in the interferon sensitivity determining region (ISDR) of NS5A is reported to affect the response to interferon (IFN) therapy in patients with chronic hepatitis C (CHC). The aim of this study was to clarify whether host immunity is influenced by the number of AA mutations in the ISDR. Subjects included 44 patients with CHC infected with genotype 1b and high viral load. The number of AA mutations in the ISDR was retrospectively determined using stored serum samples taken immediately before starting therapy. All patients received IFN-alpha 2b or pegylated-IFN (PEG-IFN)-alpha 2b and ribavirin. When serum hepatitis C virus-ribonucleic acid (HCV-RNA) was negative at 4 or 12 weeks after starting therapy, the patient was defined as having rapid viral response (RVR) or early viral response (EVR), respectively. CD4+ T cell (Th1 or Th2) in peripheral blood (PB) before and until day 56 of treatment was analyzed. Rates of RVR and EVR were 0 (0/21) and 14% (3/21), respectively, in patients with one or fewer AA mutations in the ISDR (ISDR0-1), and 30 (7/23), and 74% (17/23), respectively, with two or more AA mutations in the ISDR (ISDR > 2). Although the percentage of PB Th1 cells did not differ between the two groups during the study period, the percentage of PB Th2 cells was significantly lower in the ISDR0-1 group than in the ISDR > 2 group at baseline and on days 3, 7, 14, and 28 of treatment. The number of AA mutations in the ISDR influenced PB Th2 cells before and until day 28, and was associated with higher RVR and EVR rates.

65歳，男性．前日ゴルフのラウンド中に上腹部痛が出現し入院となった．腹部超音波検査（US）にてintimal flapの描出は認めなかったが上腸間膜動脈（SMA）近位部の軽度拡張とカラードプラ法にて背側の順行性シグナルと反転するように腹側の逆行性シグナルを確認した．腹部multi-detector-row computed tomography（MDCT）でSMA根部の解離と限局性空腸壁肥厚を認めたため虚血性空腸を合併した孤立性上腸間膜動脈解離（ISMAD）と診断し抗凝固剤を開始した．SMA解離部及び虚血空腸についてUSとMDCTにて血流動態を追跡観察した．SMA解離は根部より約2 cm末梢側まで真腔・偽腔ともに血流を有していたが，偽腔拡張による真腔の狭小化をUSにて経時的に確認した．一方，MDCTや造影超音波（CEUS）で染影が低下していた空腸壁肥厚部の一部は，第19病日のCEUSにて血流の改善を認めた．その後，腹痛はなく第26病日より食事を開始したが，第38病日に食後の左側腹部痛が出現した．小腸造影で空腸に狭窄部位を認めたため，第59病日に開腹術を施行した．Treitz靭帯から20 cm肛門側の部位から約30 cmの範囲で空腸の狭窄を認めたため切除した．病理組織学的検査にて虚血に伴う遅延性狭窄と診断した．本症例では，保存的治療中のSMAの解離状態や腸管viabilityの判定にUSはきわめて有用であった．

22歳，男性．左下腹部痛にて入院となった．血液検査にてWBC 11,900/μl，CRP 0.3 mg/dlと軽度炎症反応を認めた．腹部超音波検査（US）にて圧痛部に一致するS状結腸前壁に比較的境界明瞭なリング状低エコー帯を有する18×13 mm大の卵円形高エコー腫瘤を認めた．また，厚みをもった腹壁直下脂肪層と周囲脂肪層を隔てるように，そのリング状低エコー帯と連続する線状低エコーが描出された．S状結腸壁は腫瘤と接する部のみ軽度肥厚していた．カラードプラ法では高エコー腫瘤や周囲脂肪層などに明らかな血流シグナルは描出されなかった．USとCTの対比においてCTで認められる卵円形腫瘤の中心にある索状高吸収域はUS上では判別出来なかったが，腫瘤全体は脂肪塊であることが判明した．この脂肪性腫瘤を取り囲むリング状低エコー帯はCT上高吸収域として描出され肥厚した漿膜であった．また，US上認めた線状低エコーは壁側腹膜を，肥厚した周囲脂肪層は炎症性浮腫を呈した腸間膜脂肪織であった．Sonazoid®を使用した造影超音波では，高エコー腫瘤部には造影剤の流入は認めなかったものの，腫瘤低エコー帯や周囲脂肪織の染影が明らかとなった．以上よりS状結腸の原発性（血行障害性）腹膜垂炎と診断した．自験例では，USとCTのほぼ同一断面で腹膜垂炎病変部を比較検討すると共に，ドプラ法や造影超音波検査により血流動態を観察することが出来た．

To clarify the usefulness of parametric imaging using contrast-enhanced ultrasound (CE-US) with Sonazoid by comparing parametric images of hepatocellular carcinoma (HCC) with histopathological findings. Two patients with HCCs underwent CE-US with Sonazoid before surgical resection. A single focus point was set at the lower margin of the tumor, and a bolus intravenous injection of Sonazoid (0.5 ml) was administered. Images of the ideal scanning plane were displayed in real-time mode for the early vascular phase. We analyzed these images using prototype PC software. The software watches, pixel by pixel, the increase in the intensity due to the inflow of the microbubbles, and displays colors if the intensity becomes larger than a certain threshold. Parametric images were compared with histopathological findings. The level of blood flow in the tumor could be visually evaluated using a single image by expressing the detailed hemodynamics of the tumor in terms of differences in color using a time axis appropriate for each case. Parametric imaging is a very useful way of facilitating straightforward visualization of the level of blood flow within HCC and the distribution of histopathological findings in single static images.

We compared the benefits of sorafenib with that of hepatic arterial infusion chemotherapy (HAIC) for advanced hepatocellular carcinoma (ad-HCC) refractory to transcatheter arterial chemoembolization (TACE). We evaluated the patient characteristics, the median survival time (MST), and the prognostic factors in 17 patients in the sorafenib group and in 26 patients in the HAIC group. No significant difference was observed in the patient characteristics between the groups. The MST in the sorafenib group and HAIC group was 483 days and 284 days, respectively. A significantly longer survival time was noted in the sorafenib group (p=0.033). The prognostic factors were sorafenib therapy in all 43 patients(hazard ratio: 3.32 [95% CI: 1.36-8.10], p=0.008) and the longer treatment period of sorafenib in the sorafenib group(hazard ratio: 0.99 [95% CI: 0.984- 0.999], p=0.009). When compared with HAIC, sorafenib showed favorable treatment results in patients with ad-HCC refractory to TACE.

This prospective non-randomized controlled trial aimed to compare the efficacy of sorafenib vs hepatic arterial infusion chemotherapy (HAIC) for advanced hepatocellular carcinoma.Forty-seven patients treated with sorafenib (sorafenib group) and 77 patients treated with HAIC (HAIC group) were investigated retrospectively using propensity score matching (PSM) to minimize selection bias. The cumulative survival rate was investigated before and after PSM in each of the sorafenib and HAIC groups. The cumulative survival rate was compared between the sorafenib and HAIC groups, and among the TNM stage by the Liver Cancer Study Group of Japan (LCSGJ TNM stage).No significant difference was noted in overall survival (OS) between the sorafenib and HAIC groups regardless of before or after PSM. On comparison of the cumulative survival rate between the groups by the same LCSGJ TNM stage, significant prolongation of OS was noted in stage IVB only in the sorafenib group (p = 0.032) after PSM.It may be better to actively introduce sorafenib for stage IVB, i.e., patients with extrahepatic metastasis.

To compare therapeutic outcomes and adverse events in initial solitary hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA) and CyberKnife(®).Seventy three consecutive patients with initial solitary HCC treated with RFA (38 patients; RFA group) and CyberKnife(®) (35 patients; CK group) were enrolled in this study. Background factors were compared between the two groups. Local and intrahepatic distant recurrence control, and cumulative survival rates were compared between the two groups. These were determined using the Kaplan-Meier method, and the significance of differences was analyzed by log-rank test. The presence of more grade 3 on CTCAE ver. 4.0 early and late adverse events was investigated.In background factors, age was significantly higher (P = 0.005) and the tumor diameter was significantly larger (P = 0.001) in the CK group. The 1-year local recurrence control rates were 97.4% and 97.1% in the RFA and CK groups, respectively (P = 0.71); the 1-year intrahepatic distant recurrence control rates were 85.6% and 86.1%, respectively (P = 0.91); and the 1-year cumulative survival rates were 100% and 95.2%, respectively (P = 0.075), showing no significant difference in any rate between the two groups. There were no late adverse event in the RFA group, but 11.4% in the CK group had late adverse events. In the CK group, the Child-Pugh score at 12 mo after treatment was significantly higher than that in the RFA group (P = 0.003) and significantly higher than the score before treatment (P = 0.034).The occurrence of adverse events is a concern, but CyberKnife(®) treatment is likely to become an important option for local treatment of early HCC.

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-associated mortality worldwide. No effective treatment has been established for unresectable advanced HCC, and the prognosis is poor. Sorafenib is an oral multi-targeted tyrosine kinase inhibitor for unresectable advanced HCC that significantly improves progression-free and overall survival. However, in the two large phase III clinical trials (the SHARP and Asia-Pacific trials), no cases of complete response (CR) were reported. The present study reports the case of a 68-year-old male with hepatitis C virus-related cirrhosis and multiple recurrent HCCs, with a tumor thrombus of the third portal vein following resection. The patient received 400 mg once daily (half the standard dose) of sorafenib for two years and achieved a CR. At the most recent follow-up examination at one year after the cessation of treatment, the patient was observed to be in remission without clinical or imaging evidence of disease recurrence.

Objective: To report a rare case of right hepatic artery pseudoaneurysm complicating acute pancreatitis based upon imaging findings obtained before and after the development of pseudoaneurysm. Clinical Presentation and Intervention: A 32-year-old male with a history of acute pancreatitis 1 year prior was readmitted for acute pancreatitis. Computed tomography (CT) and angiography after admission revealed pseudoaneurysm of the right hepatic artery. Transcatheter arterial embolization with coils was used to successfully treat the pseudoaneurysm. A CT and angiography 1 year earlier did not reveal any pseudoaneurysm. Conclusion: This patient with a rare right hepatic artery pseudoaneurysm complicating acute pancreatitis was successfully treated with coil embolization.

The present study aimed to determine the usefulness of contrast-enhanced ultrasonography (CEUS) with Sonazoid in evaluating the therapeutic response to sorafenib for hepatocellular carcinoma (HCC). In total, 26 patients with advanced HCC who received sorafenib and were followed up by CEUS were enrolled in the present study. CEUS was performed prior to and within 2-4 weeks of treatment, and the images of the target lesion in the post-vascular phase with a re-injection method were analyzed. The presence (+) or absence (-) of intratumoral necrosis and the intratumoral vascular architecture on micro-flow imaging (MFI) were compared prior to and subsequent to treatment. Target lesions that exhibited non-enhancement after re-injection were considered to indicate intratumoral necrosis. The intratumoral vascular architecture was classified into three groups, as follows: Vd, the intratumoral vessels visually narrowed or decreased; Vnc, the vessels remained unchanged; and Vi, the vessels were thickened or increased. Survival curves were estimated using the Kaplan-Meier method and compared using the log rank test between the intratumoral necrosis (+) and (-) groups, and among the Vd, Vnc and Vi groups. P

A 68-year-old Japanese woman was admitted to our hospital in September 1995, because of a mass detected by ultrasonography during a follow-up examination for chronic hepatitis B. Hepatocellular carcinoma (HCC) in the right liver lobe was diagnosed based on imaging studies and elevated alpha-fetoprotein (AFP). Percutaneous ethanol injection therapy (PEIT) was performed. PEIT was repeated in November 1998, because the tumor had enlarged and serum AFP was re-elevated. Follow-up ultrasonography (US) demonstrated low echoic mass in the left liver lobe in August 1999; serum AFP was normal, but serum carbohydrate antigen 19-9 (CA19-9) was elevated to 420 U/ml. In October 1999, radiofrequency interstitial tissue ablation (RITAR) was performed after tumor biopsy. Pathological findings revealed adenocarcinoma and pathological diagnosis was made as intrahepatic Cholangiocellular carcinoma (ICC). Three weeks later, her serum CA19-9 was remarkably decreased (180 U/ml). The patient has been well for 5 months. Her latest AFP and CA19-9 in the serum were 2 ng/ml and 89 U/ml, respectively. The incidence of double cancer in the liver is rare. This is also the first case report to discuss ICC treated with RITA®.(Internal Medicine 40: 624-630, 2001)

The identification of bleeding sites of ruptured hepatocellular carcinoma (HCC) is important for immediate treatment. We experienced a case of ruptured HCC readily treated with transarterial embolization (TAE) after identification of the bleeding site using contrast-enhanced ultrasonography (CEUS) with Sonazoid. We report the case of a 61-year-old male with multiple HCCs caused by alcohol-related cirrhosis, who was admitted for rapid development of abdominal fullness. The diagnosis was established by hemorrhagic ascites by abdominal paracentesis. No clear extravasation was found on contrast-enhanced computed tomography. CEUS using the re-injection method in the post-vascular phase showed active bleeding from a lesion close to the S5 gallbladder bed. Abdominal angiography was urgently performed. Based on CEUS findings, selective cannulation of the cystic artery was performed. Cystic angiography findings with carbon dioxide showed extravasation. He was treated by TAE. Our case had multiple HCCs, but CEUS was useful for the identification of bleeding sites.

The short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) to treat gastric varices were evaluated by using computed tomography (CT) and gastroscopy (GF). The subjects were 77 patients who underwent BRTO to treat gastric varices. The short-term effects of BRTO were investigated with regard to ascites, pleural effusion, venous thrombus, and esophageal varices by comparing the findings of CT and GF performed within one month before and after BRTO. The mean duration of followup was 960.1 days. Ascites and pleural effusion were exacerbated after BRTO in 26 (33.8%) and 31 (40.3%), respectively. A significant difference in ascites exacerbation was noted in patients with hypoalbuminemia and a high Child-Pugh score, and a significant difference in exacerbation of pleural effusion was noted in patients with hypoalbuminemia. Venous thrombus was noted in 7 patients (9.1%). Esophageal varices were exacerbated in 14 (21.2%) of the 66 patients. The 2-year survival rate was 720 days, and significant differences were noted in the Child-Pugh classification and the concomitance of hepatocellular carcinoma (HCC) on multivariate analysis of prognosis-related factors. Conclusion. The frequencies of exacerbation of ascites, pleural effusion, and esophageal varices after BRTO were high but these may not be related to survival.

Intrahepatic bile duct adenoma (BDA) is a relatively rare benign tumor. Most cases are incidentally discovered during surgery or autopsy. We report here the co-existence of renal cell carcinoma and BDA mimicking metastasis in a 30-year-old female. An isoechoic nodule with a hypoechoic rim sized 10 × 9 mm was observed by ultrasonography in S2 of the liver. On contrast-enhanced ultrasonography (CEUS), the mass was enhanced in the early vascular phase and a defect with a clear border appeared in the post-vascular phase. We present the ultrasonography findings of BDA, including those yielded by CEUS using Sonazoid, along with the gross and microscopic pathological correlation.

A 60-year-old man with liver cirrhosis caused by hepatitis C, who was receiving warfarin anticoagulation following acute myocardial infarction, was diagnosed with advanced hepatocellular carcinoma and multiple lung metastases, and began treatment with sorafenib 200 mg daily. From the treatment's start to 14 and 63 days later, sorafenib was increased to 400 mg and 600 mg, respectively. After increasing the quantity to 600 mg, he had an increase in PT-INR values and experienced a lower-extremity hemorrhage. For the patient with liver cirrhosis, who is receiving warfarin, PT-INR values might be elevated during the early period of sorafenib treatment dosage as for the increase in quantity. Therefore, when increasing dosage, a frequent measurement of PT-INR and a careful follow-up for PT-INR is necessary.

Background/aims Comparison of Parametric Imaging (PI) using Sonazoid-enhanced ultrasonography (US) and microflow imaging (MFI) to determine the possibility of hepatic hemangioma diagnosis using PI. Methodology Twenty-two hepatic hemangioma nodules (mean±SD diameter: 31.6±19.1mm) undergoing Sonazoid-enhanced US between February 2008 and March 2009. After Sonazoid-enhanced US, COMMUNE ultrasonographic image analysis software was used for analysis of tumor imaging dynamics in the vascular phase using PI and MFI. In PI, 0s was set as the time contrast agent reached the tumor. Imaging within the tumor after 0s was color-coded according to time, and the images were displayed in color. In MFI, 0s was set as the time contrast agent reached the tumor. The path of microbubbles as it flowed through blood vessels was superimposed on the original B-mode images. Three trained physicians used these methods to analyze tumor imaging dynamics. Results All physicians concluded all cases were hepatic hemangioma regardless of method used. However, compared to MFI, PI allowed determination of more detailed blood flow dynamics in high-flow hepatic hemangioma, where blood flow speed was faster than in normal hepatic hemangioma. Conclusions It is possible to diagnose hepatic hemangioma using PI using sonazoid-enhanced US.

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

To determine the incidence and risk factors associated with tumor seeding after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC), 781 lesions from 352 patients who had undergone ultrasound (US)-guided RFA at our hospital between April 1999 and December 2005 were examined. Of these patients, 6 presented HCC lesions (6 lesions in total) and tumor seeding (7 seedings in total), which were analyzed. RFA using RITA 500 PA, the Cool-tip RFA System or the RTC 2000 System was performed. RFA sessions were repeated until complete necrosis was confirmed by imaging. Subsequently, follow-up was performed every 3-4 months by means of computed tomography (CT) and US scans. The 6 patients were retrospectively analyzed for patient characteristics, CT and histopathological findings, RFA method and complications, and clinical and imaging progress and outcome. Of the 6 lesions, 2 were in a subcapsular location at S7. Mean tumor diameter was 23.3±9 mm. Tumor biopsies indicated that 1 of the 6 lesions was well-differentiated, 4 were moderately-differentiated, and 1 was undifferentiated. The RITA 500 PA was used in 2 cases, and the Cool-tip RFA System in 4. Seeding was identified 14.6±13 months after RFA. Four of the cases with seeding were located on the abdominal wall, 2 on the thoracic wall and 1 in the Douglas pouch. Four of the patients underwent surgical resection, 1 radiation, and 1 conservative treatment for seeding. Five of the 6 patients died 12.6±9 months after seeding was detected, with the exception having undergone surgical treatment. The seeding risks identified in this study include treatment of subcapsular lesions and patient treatment over multiple sessions. The selection of the proper RFA system to avoid multiple sessions and the use of ablation technique are important for the prevention of seeding. Additionally, long-term follow-up after RFA by extensive imaging of the pelvic cavity and the thoracoabdominal wall is needed.

The incidence of local recurrence of hypervascular hepatocellular carcinoma (HCC) (15 mm or less) was compared retrospectively between a group treated with radiofrequency ablation (RFA) using cool-tip (Radionics, USA) 10-mm electrodes and a group treated with percutaneous ethanol injection (PEI).There were 23 patients who were treated for a total of 25 tumors during a 3-year period at our hospital. Ten of the tumors (11.1 +/- 2.7mm) were treated with RFA using cool-tip 10-mm electrodes and 15 tumors (10.6 +/- 2.7 mm) were treated with PEI. After treatment, progression was evaluated in enhanced CT scans every 3-6 months to confirm presence or absence of local recurrence.The number of recurrences, mean observation period, and mean recurrence period in the RFA group were 2 (20%), 6.6 months, and 6 months. The number of recurrences, mean observation period, and mean recurrence period in the PEI group were 2 (13.3%), 19.1 months, and 18 months. The period between treatment and recurrence tended to be longer in the PEI group than in the RFA group to be significant p0.05.The results suggest that PEI treatment is more effective in local treatment of hypervascular HCC with tumor diameters of 15 mm or less.

Purpose. To evaluate the effectiveness of contrast-enhanced ultrasonography (CEUS) using Sonazoid for the diagnosis of the local recurrence after treatment for hepatocellular carcinoma (HCC) by comparing it with dynamic CT. Methods. Seventy-one patients with 87 HCC lesions (mean ± SD; 19.5 ± 9.6 mm) underwent CEUS using Sonazoid and dynamic CT after radiofrequency ablation (n = 55), transcatheter arterial chemoembolization (n = 22), or radiofrequency ablation combined with transcatheter arterial chemoembolization (n = 10). Two hepatologists (observer 1; 10 years of experience, and 2; 20 years of experience) reviewed the CEUS and dynamic CT images independently and evaluated presence or absence of the local recurrence. Diagnostic performance for the local recurrence was assessed using receiver operating characteristic curve analysis. Results. The Az value for dynamic CT was significantly lower in observer 1 than 2 (p < 0.05). The sensitivity of CEUS was 79% in observer 1 and 83.9% in observer 2, and that of dynamic CT was 83.9% and 90.3%, respectively. The specificity of CEUS was 96%, and that of dynamic CT was 92%, in both observers. Conclusion. This study suggests that CEUS using Sonazoid is less affected by the observer's experience and is more accurate in the diagnosis of local recurrence after treatment for HCC than dynamic CT. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound, 2010

Rapid aggressive tumor progression of hepatocellular carcinoma is one of the major complications after radiofrequency ablation. We statistically analyzed hepatocellular carcinoma patients with rapid aggressive tumor progression after radiofrequency ablation regarding patient characteristics, computed tomography findings, radiofrequency ablation methods, and the course of clinical and imaging changes and outcomes.We defined the tumor not detected by previous CT and US rapidly increased more than double in compared with the ablated area as rapid aggressive tumor progression. Ten hundred seventy three lesions of 538 patients underwent ultrasound-guided radiofrequency ablation in our hospital between April 1999 and March 2008. Of these patients, the risk factors for rapid aggressive tumor progression of 7 with 7 lesions were analyzed.The rate of rapid aggressive tumor progression was 0.65%. Subcapsular lesions, a pretreatment Protein Induced by Vitamin K Absence-II levelor = 40mAU/ml, and initial treatment for hepatocellular carcinoma were significantly identified as risk factors.There is possibility that portal vein invasion by hepatocellular carcinoma is an important factor involved in rapid aggressive tumor progression after radiofrequency ablation from the results of this study. In our opinion, these hepatocellular carcinomas need to be sufficiently ablated.

Whether a cool-tip 10mm electrode is useful for radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) has not been established. Accordingly, the present study goal was to determine this electrode is indicated for RFA of HCC.This study was conducted with 30 HCC patients who were treated with a cool-tip 10-mm electrode over a period of about 3 years. Ten had hypervascular HCC nodules and 20 had hypovascular HCC nodules; mean tumor diameter was 10.5 +/- 1.8mm. Patients underwent follow-up CT scans every 3 to 6 months to detect local progression.Of the 30 lesions, 4 (13.3%) showed local progression. Enhanced CT imaging of the four cases with local progression revealed that two had hypervascular HCC. The remaining two cases had hypovascular HCC.The present study results suggest that, RFA with a cool-tip 10-mm electrode is indicated in cases of hypovascular HCC nodules if the lesion diameter is no more than 10mm. In addition, in order to avoid skin burns, only lesions at a depth of at least 16mm below the liver surface are suitable for this treatment. Because of its lesser invasiveness, the cool-tip 10-mm electrode appears to be more useful than other, more powerful, devices in patients with hepatic carcinoma.

A 62-year-old man was admitted to our hospital complaining of sore throat and epigastralgia. Laboratory tests revealed leukocytosis and an elevated CRP level. CT showed a low density area in the right hypopharynx, wall thickening of the esophageal and gastric wall with an intramural low density area. Phlegmonous esophagogastritis associated with hypopharyngeal abscess was diagnosed. The infection was extension and his condition was serious because of his accompanying poorly controlled diabetes. He was successfully treated by antibiotics and drainage of the hypopharyngeal abscess. CT was useful for early diagnosis, confirmation of the extent of inflammation and follow-up.

Objective: To clarify the validity of the evaluation of the hemodynamics of hepatic lesions ≤20 mm in diameter using contrast-enhanced ultrasonography (CE-US) with Sonazoid. Methods: Sixty-two hepatic lesions in 55 patients with chronic hepatitis or cirrhosis due to hepatitis C virus were studied. We evaluated by quantitative analysis the time intensity curve (TIC) on hepatic lesion and parenchyma in the early vascular phase and Kupffer imaging in the post-vascular phase. Results: TIC patterns were classified into those with a maximum slope (Max slope) steeper in the hepatic lesion than in the parenchyma (Pattern I), those with a Max slope similar in the hepatic lesion and parenchyma (Pattern II), and those with a Max slope gentler in the hepatic lesion than in the parenchyma (Pattern III). The blood flow was considered to be higher, the blood flow velocity to be faster, and the contrast agent to reach the lesion more rapidly in Pattern I lesions than in the hepatic parenchyma. Pattern III lesions showed that the velocity of arterial blood influx was slow. Conclusion: Our study suggested the possibility that the TIC allows a detailed evaluation of the hemodynamics of hepatic lesions.

Radiofrequency ablation (RFA) is a new local therapy for hepatocellular carcinoma (HCC). In this study, we investigated the risk factors associated with local recurrence of HCC after single-session RFA with a single electrode insertion. From April 2003 to December 2007, we treated 138 HCC lesions by single-session RFA with a single electrode insertion using the Cool-tip RFA, RTC 2000 and RTC 3000 Systems. Risk factors for the local recurrence of these lesions and complications after RFA were analyzed. The mean size of the 138 lesions was 16.9±5.4 mm in diameter (range 7-33 mm). Local recurrence rates were 6.6 and 22.0% at 1 and 2 years, respectively, during the mean follow-up period of 16.4 months. Univariate analysis showed that tumor diameter (≥20 mm), tumor location, pre-treatment AFP-L3 fraction level and ablation pattern were significant variables. Multivariate analysis of these four variables identified only the tumor diameter as an independent risk factor for local recurrence. Complications occurred in 2.2% of the lesions (3/138). Single-session RFA is an effective treatment for HCC in that it reduces serious complications. This study demonstrated that a tumor size ≥20 mm influenced the local recurrence of single-session RFA with a single electrode insertion.