Dwarkasing, R.S.

Increased alpha-fetoprotein serum level is predictive for survival and recurrence of hepatocellular carcinoma in non-cirrhotic livers (Article)

2013-04-01T00:00:00Z

Background: Hepatocellular carcinoma (HCC) may be diagnosed in the absence of cirrhosis. However, little is known about prognostic factors for the survival of HCC patients with a non-cirrhotic liver in the absence of well-established risk factors. Method: Survival rates and risk factors for survival and recurrence were analysed in all patients diagnosed between 2000 and 2010 with HCC in a non-cirrhotic liver and in the absence of well-established risk factors. Results: Ninety-four patients were analysed. Treatment with curative intent consisted of surgical resection in 43 patients (46%) and radiofrequency ablation in 4 patients (4%). In patients treated with curative intent and alive 30 days after treatment (n = 40), 1-and 5-year overall survival rates were 95 and 51%, respectively. Patients with a high preoperative α-fetoprotein (AFP) serum level, the presence of microvascular invasion in the resected specimen, a complicated postoperative course and a major resection, due to a greater tumour volume, had a significantly worse outcome and a higher recurrence rate. In multivariate analysis, a high AFP serum level at presentation was significantly associated with recurrence and a worse survival. Conclusion: HCC presenting in a non-cirrhotic liver in the absence of well-established risk factors has a poor prognosis. Increased AFP serum levels are significantly associated with clinical outcome.

Hepatocellular adenoma as a risk factor for hepatocellular carcinoma in a non-cirrhotic liver: A plea against (Article)

2012-11-01T00:00:00Z

The CARTS study: Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (Article)

2011-12-16T00:00:00Z

Background: The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer. Methods/Design. Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response. Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol. Discussion. The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051).

Hepatocellular adenomas: Correlation of MR imaging findings with pathologic subtype classification (Article)

2011-10-01T00:00:00Z

Purpose: To investigate the correlation between magnetic resonance (MR) imaging findings and pathologic subtype classification of hepatocellular adenoma (HCA). Materials and Methods: This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. MR imaging studies of 61 lesions (48 patients; median age, 36 years) were available and were independently reviewed by two radiologists. Consensus readings on all morphologic and signal-intensity imaging features were obtained. Previously, these lesions had been classified on the basis of pathologic findings and immunohistochemical analysis. Fisher exact and χ2tests were performed to compare the results between the different subtypes. A Bonferroni correction was applied to correct for multiple testing (α < .0033). Results: MR imaging signs of diffuse intratumoral fat deposition were present in seven (78%) of nine liver-fatty acid binding protein (L-FABP)-negative HCAs compared with five (17%) of 29 inflammatory HCAs (P = .001). Steatosis within the nontumoral liver was present in 11 (38%) of 29 inflammatory HCAs compared with none of the L-FABP-negative HCAs (P = .038). A characteristic atoll sign was only seen in the inflammatory group (P = .027). Presence of a typical vaguely defined type of scar was seen in five (71%) of seven β-catenin-positive HCAs (P = .003). No specific MR imaging features were identified for the unclassified cases. Conclusion: L-FABP-negative, inflammatory, and β-catenin-positive HCAs were related to MR imaging signs of diffuse intratumoral fat deposition, an atoll sign, and a typical vaguely defi ned scar, respectively. Since β-catenin-positive HCAs are considered premalignant, closer follow-up with MR imaging or resection may be preferred.

MRI evaluation of urethral diverticula and differential diagnosis in symptomatic women (Article)

2011-09-01T00:00:00Z

OBJECTIVE. The purpose of this study was to evaluate the role of MRI in the diagnosis and differential diagnosis of urethral diverticula in symptomatic women. MATERIALS AND METHODS. Women referred for MRI at a single institution because of suspicion of urethral diverticula were included. All MRI examinations were independently evaluated by two radiologists and compared with patients' follow-up data. Sensitivity and specificity of MRI for urethral diverticula were calculated using surgery and clinical confirmation as the reference standards. Image quality of the urethra and periurethral region performed with the endoluminal coil was compared with the pelvic phased-array coil. RESULTS. From a study group of 60 patients (mean age, 44 years), 20 patients (33%) had urethral diverticula and 28 (47%) had an alternative diagnosis, of which 13 (46%) were visualized with MRI. In the remaining 12 patients (20%) no abnormalities were found. For urethral diverticula, MRI had both sensitivity and specificity of 100%. Twenty patients had a total of 27 diverticula; these were mostly locally round (n = 12) with sharp margins (n = 25) and high (n = 19) homogeneous (n = 16) signal intensity on T2- weighted sequences. The ostium of urethral diverticula was identified in 23 diverticula (85%) by both readers. Agreement was 93% with κ = 0.72. Endoluminal coil placement in the vagina showed the best image quality of the urethra and periurethral region. CONCLUSION. Dedicated MRI is an excellent imaging modality for urethral diverticula; furthermore, MRI will show the alternative diagnosis in almost one half of the remaining patients.

Hepatic steatosis assessment with CT or MRI in patients with colorectal liver metastases after neoadjuvant chemotherapy (Article)

2011-07-01T00:00:00Z

Purpose: Preoperative radiological assessment of hepatic steatosis is recommended in patients undergoing a liver resection, but few studies investigated the diagnostic accuracy after neoadjuvant chemotherapy. The aim of this study was to compare diagnostic accuracy of preoperative CT or MRI measurements of steatosis in patients with colorectal liver metastases after induction chemotherapy. Methods: MRI measurements (relative signal intensity decrease; RSID), N = 36, and CT scan measurements (Hounsfield units; HU), N = 32, were compared with histological steatosis assessment. Diagnostic accuracy was determined for detecting any (>5%) or marked macrovesicular steatosis (>33%). Results: MRI showed the highest correlation with histology (r = 0.82, P < 0.001), compared to CT measurements (r = -0.65, P < 0.001). Based on linear regression analysis, radiological cut-off values for 5% and 33% macrovesicular steatosis, corresponded to 0.7% and 19.2% RSID in the MRI-group, and 60.4 and 54.2 HU in the CT-group, respectively. Sensitivity and specificity for the detection of any and marked macrovesicular steatosis using MRI was 87% and 69%, and 78% and 100%, respectively, and for CT, 83% and 64%, and 70% and 87%, respectively. Conclusion: In patients treated with neoadjuvant chemotherapy MRI measurements of steatosis showed the highest correlation coefficient and the best diagnostic accuracy, as compared to CT measurements.

Validation of a liver adenoma classification system in a tertiary referral centre: Implications for clinical practice (Article)

2011-07-01T00:00:00Z

Background & Aims: A molecular and pathological classification system for hepatocellular adenomas (HCA) was recently introduced and four major subgroups were identified. We aimed to validate this adenoma classification system and to determine the clinical relevance of the subtypes for surgical management. Methods: Paraffin fixed liver tissue slides and resection specimens of patients radiologically diagnosed as HCA were retrieved from the department of pathology. Immunostainings included liver-fatty acid binding protein (L-FABP), serum amyloid A (SAA), C-reactive protein (CRP), glutamine synthetase (GS) and β-catenin. Results: From 2000 to 2010, 58 cases (71 lesions) were surgically resected. Fourteen lesions were diagnosed as focal nodular hyperplasia with a characteristic map-like staining pattern of GS. Inflammatory HCA expressing CRP and SAA was documented in 36 of 57 adenomas (63%). Three of these inflammatory adenomas were also β-catenin positive as well as GS positive and only one was CRP and SAA and GS positive. We identified eleven L-FABP-negative HCA (19%) and four β-catenin positive HCA (7%), without expression of CRP and SAA and with normal L-FABP staining, one of which was also GS positive. Six HCA were unclassifiable (11%). In three patients multiple adenomas of different subtypes were found. Conclusions: Morphology and additional immunohistochemical markers can discriminate between different types of HCA in >90% of cases and this classification, including the identification of β-catenin positive adenomas may have important implications in the decision for surveillance or treatment. Interpretation of nuclear staining for β-catenin can be difficult due to uneven staining distribution or focal nuclear staining and additional molecular biology may be required.

Is the outcome of transanal advancement flap repair affected by the complexity of high transsphincteric fistulas? (Article)

2011-07-01T00:00:00Z

Background: Transanal advancement flap repair for the treatment of high transsphincteric fistulas fails in 1 of every 3 patients. Until now no definite risk factors for failure have been identified. The question is whether the more complex fistulas, such as those with horseshoe extensions and associated abscesses, have a less favorable outcome. Objective: Aim of the present study was to indentify whether more complex fistulas have a less favorable outcome. Design: This study is a retrospective case series review. Patients: Between 1995 and 2007 a series of 162 patients underwent endoanal MR imaging before transanal advancement flap repair. Two investigators, without prior knowledge of the surgical findings, reviewed all MR images. Results: Lateral fistulas were identified in 5 patients. Because of the small number, these patients were excluded from further analysis. Posterior fistulas were identified in 119 patients (76%). These fistulas had 3 types of extensions: a direct course (36%), a classic horseshoe extension (23%), or an intersphincteric horseshoe extension (41%). The corresponding healing rates were 37%, 81%, and 73%. Anterior fistulas were observed in 23% of the patients. These fistulas had 2 types of extensions: a direct course (61%) or a classic horseshoe extension (39%). The corresponding healing rates were 60% and 52%. The healing rate of fistulas with a direct course was significantly lower than the healing rate of fistulas with a classic or intersphincteric horseshoe extension. Associated abscesses were found in 47% of the posterior fistulas and 5% of the anterior fistulas. Once adequately drained, these abscesses did not affect the outcome of transanal advancement flap repair. Conclusion: The complexity of high transsphincteric fistulas does not affect the outcome of transanal advancement flap repair.

Evaluation of a standardized CT colonography training program for novice readers (Article)

2011-02-01T00:00:00Z

Purpose: To determine how many computed tomographic (CT) colonography training studies have to be evaluated by novice readers to obtain an adequate level of competence in polyp detection. Materials and Methods: The study was approved by the Institutional Review Board. Informed consent was obtained from all participants. Six physicians (one radiologist, three radiology residents, two researchers) and three technicians completed a CT colonography training program. Two hundred CT colonographic examinations with colonoscopic verification were selected from a research database, with 100 CT colonographic examinations with at least one polyp 6 mm or larger. After a lecture session and short individual hands-on training, CT colonography training was done individually with immediate feedback of colonoscopy outcome. Per-polyp sensitivity was calculated for four sets of 50 CT colonographic examinations for lesions 6 mm or larger. By using logistic regression analyses, the number of CT colonographic examinations to reach 90% sensitivity for lesions 6 mm or larger was estimated. Reading times were registered. Results: The average per-polyp sensitivity for lesions 6 mm or larger was 76% (207 of 270) in the first set of 50 CT colonographic examinations, 77% (262 of 342) in the second (P = .96 vs first set), 80% (310 of 387) in the third(P = .67 vs first set), and 91% (261 of 288) in the fourth(P = .018). The estimated number of CT colonographic examinations for a sufficient sensitivity was 164. Six of nine readers reached this level of competence within 175 CT colonographic examinations. Reading times decreased significantly from the first to the second set of 50 CT colonographic examinations for six readers. Conclusion: Novice CT colonography readers obtained sensitivity equal to that of experienced readers after practicing on average 164 CT colonographic studies.

Comparison of Macroscopic Pathology Measurements with Magnetic Resonance Imaging and Assessment of Microscopic Pathology Extension for Colorectal Liver Metastases (Article)

2010-12-23T00:00:00Z

Purpose: To compare pathology macroscopic tumor dimensions with magnetic resonance imaging (MRI) measurements and to establish the microscopic tumor extension of colorectal liver metastases. Methods and Materials: In a prospective pilot study we included patients with colorectal liver metastases planned for surgery and eligible for MRI. A liver MRI was performed within 48 hours before surgery. Directly after surgery, an MRI of the specimen was acquired to measure the degree of tumor shrinkage. The specimen was fixed in formalin for 48 hours, and another MRI was performed to assess the specimen/tumor shrinkage. All MRI sequences were imported into our radiotherapy treatment planning system, where the tumor and the specimen were delineated. For the macroscopic pathology analyses, photographs of the sliced specimens were used to delineate and reconstruct the tumor and the specimen volumes. Microscopic pathology analyses were conducted to assess the infiltration depth of tumor cell nests. Results: Between February 2009 and January 2010 we included 13 patients for analysis with 21 colorectal liver metastases. Specimen and tumor shrinkage after resection and fixation was negligible. The best tumor volume correlations between MRI and pathology were found for T1-weighted (w) echo gradient sequence (rs= 0.99, slope = 1.06), and the T2-w fast spin echo (FSE) single-shot sequence (rs= 0.99, slope = 1.08), followed by the T2-w FSE fat saturation sequence (rs= 0.99, slope = 1.23), and the T1-w gadolinium-enhanced sequence (rs= 0.98, slope = 1.24). We observed 39 tumor cell nests beyond the tumor border in 12 metastases. Microscopic extension was found between 0.2 and 10 mm from the main tumor, with 90% of the cases within 6 mm. Conclusions: MRI tumor dimensions showed a good agreement with the macroscopic pathology suggesting that MRI can be used for accurate tumor delineation. However, microscopic extensions found beyond the tumor border indicate that caution is needed in selecting appropriate tumor margins.

Severe group A streptococcal toxic shock syndrome presenting as primary peritonitis: A case report and brief review of the literature (Article)

2010-09-01T00:00:00Z

Streptococcal toxic shock syndrome (STSS) can be defined as a septic shock syndrome resulting from infection with toxin-producing group A streptococci (GAS). STSS can sporadically present as primary peritonitis in previously healthy persons. Signs of STSS are non-specific and patients generally present with flu-like symptoms and can develop a life-threatening toxic shock syndrome in just a few hours. Diagnosis is mainly by a combination of physical examination, laboratory/culture results, and exclusion of surgical causes by means of imaging modalities and/or surgical exploration. GAS remain penicillin-sensitive and most are clindamycin-sensitive. Prompt supportive treatment, possibly together with high-dose intravenous immunoglobulins, is crucial.

Kidney and urinary tract imaging: Triple-bolus multidetector CT urography as a one-stop shop-protocol design, opacification, and image quality analysis (Article)

2010-07-01T00:00:00Z

Diagnosis and treatment of hepatocellular adenoma in the Netherlands: Similarities and differences (Article)

2010-04-01T00:00:00Z

Background: The diagnosis of hepatocellular adenoma (HA) has a great impact on the lives of young women and may pose clinical dilemmas to the clinician since there are no standardized protocols to follow. We aimed to establish expert opinions on diagnosis and treatment of HA by collecting data from a nationwide questionnaire in the Netherlands. Methods: A questionnaire was sent to 20 Dutch hospitals known to offer hepatologic and surgical experience on liver tumours. Results: 17 hospitals (85%) responded to the questionnaire. Annually, a median of 52 patients presented with a solid liver tumour. In 15 (88%) hospitals, hepatic adenomas were diagnosed with contrast-enhanced, multiphase spiral CT or MRI. In 2 (12%) hospitals, histology was required as part of a management protocol. Surveillance after withdrawal of oral contraceptives was the initial policy in all clinics. MRI, CT or ultrasound was used for follow-up. Criteria for surgical resection were a tumour size >5 cm and abdominal complaints. In 5 (29%) hospitals, patients were dismissed from follow-up after surgery. In complex cases (e.g. large, multiple or centrally localized lesions, a wish for pregnancy), the treatment policy was highly variable. Pregnancy was not discouraged in 15 hospitals, but in 11 (65%) of these, strictly defined conditions were noted: frequent follow-up, peripheral tumour localization that makes surgery easier if necessary, stable tumour size, and a good informed consent. Conclusion: The management of HAs in the Netherlands is rather uniform, except in complex cases in which multiple factors may influence policy. Copyright

Abdominosacral resection for locally advanced and recurrent rectal cancer (Article)

2009-11-01T00:00:00Z

Background: The results of resection of locally advanced and recurrent rectal cancers, including sacral resection, were analysed critically. Methods: Between 1987 and 2007, 353 patients with locally advanced or recurrent rectal cancer, all treated in a tertiary referral centre, were identified from a prospective database. Twenty-five patients (eight primary and 17 recurrent tumours) underwent en bloc sacral resection. Results: A mid-sacral resection was carried out in 12 patients (level S3) and a low sacral resection in 13 (level S4/S5). Nineteen patients had an R0, four an R1 and two an R2 resection. There was no postoperative mortality. Median follow-up was 32 months. Incomplete resection had an independent negative influence on local control (5-year local recurrence rate 42 versus 0 per cent in those with and without incomplete resection; P < 0.001). The 5-year overall survival rate was 30 per cent. Five patients with recurrent tumour had pathological invasion into the sacral bone and none survived beyond 1 year. Conclusion: Abdominosacral resection can be performed in patients with locally advanced and recurrent rectal cancer. Patients who cannot undergo a complete resection or have clear evidence of cortical invasion have a poor prognosis. Copyright

MR imaging of hepatocellular carcinoma: Relationship between lesion size and imaging findings, including signal intensity and dynamic enhancement patterns (Article)

2007-12-01T00:00:00Z

Purpose: To assess the relationship between lesion size and MR imaging findings of pathologically-proven hepatocellular carcinoma (HCC). Materials and Methods: In a retrospective, single-center study, 37 consecutive patients were identified between 1999 and 2005 that underwent preoperative MRI and surgical resection of HCC. A total of 47 lesions (mean size = 6.85 cm, range = 1-25 cm) were assessed for signal intensity (SI), enhancement patterns, and secondary morphologic features. Interobserver rating, percentage enhancement, and contrast-to-noise-ratio (CNR) were determined. Lesions were assessed for combinations of typical MRI features. Regression analysis was used to assess relations between MRI findings and tumor size. Results: On fat-suppressed T2-weighted (T2w) fast-spinecho, smaller lesions had lower SI compared to larger lesions (P < 0.05). In the arterial phase, smaller lesions showed significantly higher percentage enhancement compared to larger lesions (P < 0.05). In the delayed phase, smaller lesions showed less pronounced washout (P < 0.05). Heterogeneity of the lesions, including fatty infiltration, internal nodules, or mosaic pattern, was observed significantly more frequently in larger lesions (P < 0.001). The classic combination of high T2w signal, strong arterial enhancement, and delayed phase washout was present in 23 of 44 lesions (52%). Conclusion: Smaller HCC often showed lower SI on T2w, more intense arterial enhancement, and less pronounced delayed washout compared to larger HCC.

Successful endoscopic treatment of chronic groin pain in athletes (Article)

2007-02-01T00:00:00Z

Background: Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. Methods: From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 ± 4.5 years; range, 17-36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. Results: Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. Conclusions: A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.