Publications by authors named "Hyung Jin Won"

87 Publications

Abbreviated magnetic resonance imaging vs ultrasound for surveillance of hepatocellular carcinoma in high-risk patients.

Liver Int 2021 Nov 24. Epub 2021 Nov 24.

Liver Cancer Center, Asan Medical Center, Seoul, Republic of Korea.

Background & Aims: We aimed to compare the performance of gadoxetic acid-enhanced abbreviated MRI (AMRI)-based surveillance and ultrasound-only surveillance in high-risk patients for hepatocellular carcinoma (HCC).

Methods: Prospectively recruited high-risk patients (>5% annual risk of HCC) who underwent one to three rounds of complete gadoxetic acid-enhanced MRI (CMRI) and ultrasound at 6-months intervals were retrospectively analysed. AMRI consisted of diffusion-weighted, T2-weighted, and hepatobiliary phase imaging. The sensitivity, specificity, and accuracy of CMRI followed by AMRI (CAA), AMRI-only (AAA), and ultrasound-only (US) were compared using generalized estimating equations. Image quality was assessed.

Results: In 382 patients, HCC was diagnosed in 43 (11.3%), including 42 with early-stage HCCs. The sensitivities of CAA (90.7%, 39/43) and AAA (86.0%, 37/43) were higher than US (27.9% [12/43]; P < 0.001), whereas the sensitivities of the two MRI approaches did not significantly differ (P = 0.56). The specificity of CAA (97.1%, 983/1012) was higher than AAA (95.6% [967/1012]; P = 0.01) and not significantly different from US (96.3% [975/1012]; P = 0.59). The CAA approach had the best accuracy of 96.9% (1022/1055), higher than the AAA approach (95.2% [1004/1055]; P = 0.01) and the US approach (93.6% [987/1055]; P = 0.01). Image quality was inadequate in 33.7% (356/1055) of US examinations but in only 10.0% (105/1055) of the AAA and 11.1% (117/1055) of the CAA approach.

Conclusions: In high-risk patients, AMRI-based surveillance approaches had higher sensitivities than ultrasound-only surveillance for early-stage HCC. A sequential MRI approach of CMRI followed by AMRIs showed superior accuracy than the AMRI-only or ultrasound-only approach.
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http://dx.doi.org/10.1111/liv.15110DOI Listing
November 2021

Thermal ablation in the treatment of intrahepatic cholangiocarcinoma: a systematic review and meta-analysis.

Eur Radiol 2021 Aug 4. Epub 2021 Aug 4.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.

Objective: To summarize the efficacy and safety of thermal ablation for the treatment of intrahepatic cholangiocarcinoma (ICC).

Methods: MEDLINE, EMBASE, Cochran Library, and Web of Science databases were searched for studies reporting outcomes in patients with ICC treated with thermal ablation. Meta-analyses of cumulative overall survival (OS) and recurrence-free survival (RFS), Kaplan-Meier survival rates according to time to local tumor progression (TTLTP), technical efficacy, and incidence of complications were analyzed. Pooled hazard ratios of common variables were calculated to explore factors associated with OS.

Results: Twenty observational studies comprising 917 patients were reviewed (primary ICC [n = 502]; post-surgical recurrent ICC [n = 355]; information not available [n = 60]). The pooled proportion of technical efficacy was 91.9% (95% CI, 87.3-94.9%). The pooled 1-, 3-, and 5-year OS rates were 82.4% (95% CI, 75.1-88.9%), 42.1% (95% CI, 36.0-48.4%), and 28.5% (95% CI, 21.2-36.2%). Primary tumors showed higher 3-year OS rates than recurrent ones, with borderline significance (p = 0.072). The pooled 1- and 3-year RFS rates were 40.0% (95% CI, 33.6-46.4%) and 19.2% (95% CI, 8.4-32.7%). The pooled 1-, 3-, and 5-year TTLTP rates were 79.3% (95% CI, 65.1-90.9%), 59.5% (95% CI, 49.1-69.4%), and 58.2% (95% CI, 44.9-70.9%). The pooled incidence of major complications was 5.7% (95% CI, 4.1-7.8%). Tumor size (> 3 cm), multiple tumors, and age (> 65 years) were factors associated with shorter OS.

Conclusion: Thermal ablation is a successful alternative with a good safety profile, especially for a single ICC smaller than 3 cm.

Key Points: • The pooled 1-, 3-, and 5-year OS rates following thermal ablation for the treatment of intrahepatic cholangiocarcinoma were 82.4%, 42.1%, and 28.5%. • The pooled incidence of major complications was 5.7%. • A tumor size > 3 cm (HR: 2.12, p = 0.006), multiple tumors (HR: 1.67, p = 0.004), and age > 65 years (HR: 1.67, p = 0.006) were factors associated with shorter OS.
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http://dx.doi.org/10.1007/s00330-021-08216-xDOI Listing
August 2021

Percutaneous Radiofrequency Ablation for Recurrent Intrahepatic Cholangiocarcinoma After Curative Resection: Multivariable Analysis of Factors Predicting Survival Outcomes.

AJR Am J Roentgenol 2021 08 2;217(2):426-432. Epub 2021 Jun 2.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea.

The purpose of this study was to evaluate the factors associated with local tumor progression (LTP) and overall survival (OS) in patients who have undergone percutaneous radiofrequency ablation (RFA) for recurrent intrahepatic cholangiocarcinoma (iCCA) after curative resection. Data from 40 patients (mean age, 56.3 years) with 64 recurrent iCCAs (median diameter, 1.5 cm) who underwent percutaneous RFA between 1999 and 2019 were retrospectively analyzed. Patients were included if they had three or fewer metastases, a maximum tumor diameter of 5 cm or less, and disease confined to the liver. Technical success was achieved in all patients, with no procedure-related mortality. During follow-up, local progression of treated lesions was observed in 31.3% of tumors. The median OS and 5-year survival rate from initial RFA were 26.6 months and 18.3%, respectively. Multivariable analysis showed that a larger tumor diameter (> 2 cm, = .004) was significantly associated with reduced LTP-free survival and that both a larger tumor diameter and less than 1 year from surgery to recurrence ( = .005 and .006, respectively) were statistically significant predictors of reduced OS after RFA. Percutaneous RFA may offer a well-tolerated and successful approach to local tumor control in patients with recurrent iCCA after curative surgery. Patients with a small-diameter tumor (≤ 2 cm) and late hepatic recurrence (≥ 1 year after curative resection) benefited most from RFA treatment.
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http://dx.doi.org/10.2214/AJR.20.23461DOI Listing
August 2021

Combined computed tomography and magnetic resonance imaging improves diagnosis of hepatocellular carcinoma ≤ 3.0 cm.

Hepatol Int 2021 Jun 6;15(3):676-684. Epub 2021 May 6.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.

Background/purpose: Imaging diagnosis of hepatocellular carcinoma (HCC) is important, but the diagnostic performance of combined computed tomography (CT) and magnetic resonance imaging (MRI) using the Liver Imaging Reporting and Data System (LI-RADS) v2018 is not fully understood. We evaluated the clinical usefulness of combined CT and MRI for diagnosing HCC ≤ 3.0 cm using LI-RADS.

Methods: In 222 patients at risk of HCC who underwent both contrast-enhanced dynamic CT and gadoxetate disodium-enhanced MRI in 2017, 291 hepatic nodules ≤ 3.0 cm were retrospectively analyzed. Two radiologists performed image analysis and assigned a LI-RADS category to each nodule. The diagnostic performance for HCC was evaluated for CT, ordinary-MRI (washout confined to portal venous-phase), and modified-MRI (washout extended to hepatobiliary phase), and sensitivity and specificity were calculated for each modality. Generalized estimating equations were used to compare the diagnostic performance for HCC between combined CT and ordinary-MRI, combined CT and modified-MRI, and CT or MRI alone. p < 0.0062 (0.05/8) was considered statistically significant following Bonferroni correction for multiple comparisons.

Results: In 291 nodules, the sensitivity and specificity of CT, ordinary-MRI, and modified-MRI were 70.2% and 92.8%, 72.6% and 96.4%, and 84.6% and 88.0%, respectively. Compared with CT or MRI alone, both combined CT and ordinary-MRI (sensitivity, 83.7%; specificity, 95.2%) and combined CT and modified-MRI (sensitivity, 88.9%; specificity, 89.2%) showed significantly higher sensitivity (p ≤ 0.006), without a significant decrease in specificity (p ≥ 0.314).

Conclusions: Compared with CT or MRI alone, combined CT and MRI can increase sensitivity for diagnosing HCC ≤ 3.0 cm, without a significant decrease in specificity.
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http://dx.doi.org/10.1007/s12072-021-10190-xDOI Listing
June 2021

Value of discrepancy of the central scar-like structure between dynamic CT and gadoxetate disodium-enhanced MRI in differentiation of focal nodular hyperplasia and hepatocellular adenoma.

Eur J Radiol 2021 Jun 22;139:109730. Epub 2021 Apr 22.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.

Purpose: To identify the value of discrepancies in the central scar (CS)-like structure between dynamic CT and gadoxetate disodium-enhanced MRI for differentiating FNH from HCA.

Methods: This retrospective study included 113 patients with pathologically-diagnosed FNH (n = 80) or HCA (n = 37). CS-like structures were evaluated on arterial phase (AP) CT and hepatobiliary phase (HBP) MRI. Presence of the CS-like structure, its discrepancy in visibility or size between AP CT and HBP MRI and between AP and HBP MRI, and features of non-scarred tumor portion were evaluated by two radiologists. Inter-observer agreement was evaluated by intraclass correlation coefficients (ICCs) and weighted kappa. Univariable and multivariable logistic regression and ROC analysis were performed to explore features differentiating FNH from HCA.

Results: Inter-observer agreement was moderate-to-excellent (ICCs≥0.74, kappa≥0.65). On univariable analysis, presence of CS-like structures (P < 0.001), discrepancy of the CS-like structures between AP CT and HBP MRI (73.8 % in FNH; 16.2 % in HCA, P < 0.001) and between AP and HBP MRI (70.0 % in FNH; 16.2 % in HCA, P < 0.001), and the features of non-scarred tumor portion (P ≤ 0.011) were significantly different between FNH and HCA. On multivariable analysis, the discrepancy of CS-like structures between AP CT and HBP MRI, and the absence of low SI of the non-scarred tumor portion on HBP MRI, were suggestive of FNH (P = 0.036 and P < 0.001, respectively; area under the ROC curve, 0.96 [95 % CI, 0.93-0.99]).

Conclusion: Evaluation of discrepancy in the visibility or size of CS-like structures between dynamic CT and gadoxetate disodium-enhanced MRI may facilitate the differentiation of FNH from HCA.
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http://dx.doi.org/10.1016/j.ejrad.2021.109730DOI Listing
June 2021

Enhanced production of clavulanic acid by improving glycerol utilization using reporter-guided mutagenesis of an industrial Streptomyces clavuligerus strain.

J Ind Microbiol Biotechnol 2021 Jun;48(3-4)

Natural Products Research Institute, College of Pharmacy, Seoul National University, Seoul 08826, Republic of Korea.

Clavulanic acid (CA) produced by Streptomyces clavuligerus is a clinically important β-lactamase inhibitor. It is known that glycerol utilization can significantly improve cell growth and CA production of S. clavuligerus. We found that the industrial CA-producing S. clavuligerus strain OR generated by random mutagenesis consumes less glycerol than the wild-type strain; we then developed a mutant strain in which the glycerol utilization operon is overexpressed, as compared to the parent OR strain, through iterative random mutagenesis and reporter-guided selection. The CA production of the resulting S. clavuligerus ORUN strain was increased by approximately 31.3% (5.21 ± 0.26 g/l) in a flask culture and 17.4% (6.11 ± 0.36 g/l) in a fermenter culture, as compared to that of the starting OR strain. These results confirmed the important role of glycerol utilization in CA production and demonstrated that reporter-guided mutant selection is an efficient method for further improvement of randomly mutagenized industrial strains.
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http://dx.doi.org/10.1093/jimb/kuab004DOI Listing
June 2021

Classification of the interosseous tarsometatarsal ligaments of the foot.

Foot Ankle Surg 2021 Feb 4. Epub 2021 Feb 4.

Department of Anatomy, Sungkyunkwan University School of Medicine, Jangan-gu, Suwon, Gyeonggi-do 440-746, Republic of Korea. Electronic address:

Background: The aim of this study was to clarify the anatomical features of the interosseous tarsometatarsal ligaments of foot and to classify their types based on the combinations of their ligamentous components.

Methods: Fifty feet from 27 adult Korean cadavers were dissected.

Results: The interosseous tarsometatarsal ligaments were observed in the first, second, and third cuneometatarsal joint spaces. The interosseous tarsometatarsal ligament of the first cuneometatarsal space consistently connected the medial cuneiform and the second metatarsal, and was accompanied by one or two accessory ligaments above (34%) and/or below (6%) the Lisfranc ligament. The interosseous tarsometatarsal ligaments of the second and third cuneometatarsal joint spaces comprised seven and five components, and were classified into five and three types depending on the number and combination of the components, respectively.

Conclusions: These results are expected to advance the current knowledge on the tarsometatarsal joint and provide helpful information for more accurate and successful diagnosis and treatment of lesions at this joint.
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http://dx.doi.org/10.1016/j.fas.2021.01.010DOI Listing
February 2021

Accuracy of contrast-enhanced ultrasound liver imaging reporting and data system: a systematic review and meta-analysis.

Hepatol Int 2020 Dec 10;14(6):1104-1113. Epub 2020 Nov 10.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.

Background And Aim: After the introduction of the contrast-enhanced ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS), several studies have reported on its performance, but the reported data vary considerably. Therefore, we performed a systematic review and meta-analysis to determine the diagnostic performance of CEUS LI-RADS in patients at risk for hepatocellular carcinoma (HCC) and investigate the causes of study heterogeneity.

Methods: Original studies published until May 30, 2020, investigating the diagnostic performance of CEUS LI-RADS were identified in the MEDLINE, EMBASE, and Cochrane library databases. Study quality was assessed using the QUADAS-2 tool. Meta-analytic summary sensitivity and specificity for the diagnosis of HCC were calculated using a bivariate random-effects model. Meta-regression analysis was performed to explore the causes of study heterogeneity.

Results: Of the 105 articles screened, eight studies were finally analyzed (5428 hepatic observations). The summary sensitivity and specificity of CEUS LI-RADS category 5 (LR-5) for diagnosing HCC were 73% [95% confidence interval (CI) 65-79%; I = 93%] and 95% (95% CI 91-97%; I = 89%), respectively. Substantial study heterogeneity was noted in both sensitivity and specificity. Study heterogeneity was significantly associated with the proportion of cases of HCC and the type of reference standard (p ≤ 0.05).

Conclusion: CEUS LI-RADS had high pooled specificity for diagnosing HCC but suboptimal pooled sensitivity. Substantial study heterogeneity was found, which was significantly associated with the proportion of cases of HCC and the type of reference standard.
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http://dx.doi.org/10.1007/s12072-020-10102-5DOI Listing
December 2020

US LI-RADS visualization score: diagnostic outcome of ultrasound-guided focal hepatic lesion biopsy in patients at risk for hepatocellular carcinoma.

Ultrasonography 2021 Jan 9;40(1):167-175. Epub 2020 May 9.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Purpose: This study investigated the diagnostic outcome of ultrasound (US)-guided focal hepatic lesion biopsy in patients at risk for hepatocellular carcinoma (HCC) and evaluated the US visualization score as a risk factor for non-diagnostic results.

Methods: We retrospectively evaluated 208 focal hepatic lesions in 208 patients who underwent US-guided biopsy in 2016. Using the US Liver Imaging Reporting and Data System version 2017, each exam was assigned a US visualization score (A, B, or C). Final diagnoses were made using pathology reports, and biopsy results were categorized as diagnostic or non-diagnostic. Univariable and multivariable analyses were performed to determine risk factors for non-diagnostic results, including US visualization score and other clinical covariates.

Results: Of the 208 lesions, 85.1% were diagnostic and 14.9% were non-diagnostic. The rates of non-diagnostic results were 8.9%, 25.5%, and 57.1% for scores of A, B, and C, respectively. In the univariable analysis, scores of B or C were associated with a significantly higher rate of nondiagnostic results than scores of A (58.1% vs. 24.9%, P<0.001). In the multivariable analysis, US visualization score of B or C (adjusted odds ratio [aOR], 2.7; P=0.027), high-risk needle pathway usage (aOR, 5.7; P=0.001), and lesion size ≤2.0 cm (aOR, 2.7; P=0.024) were independent risk factors for non-diagnostic results.

Conclusion: US-guided biopsy had a high diagnostic yield for focal hepatic lesions in patients at risk for HCC. US visualization score of B or C, lesion size ≤2.0 cm, and high-risk needle pathway usage were independent risk factors for non-diagnostic results.
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http://dx.doi.org/10.14366/usg.19066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758094PMC
January 2021

Anatomic variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus.

Clin Anat 2021 May 30;34(4):590-595. Epub 2020 Jun 30.

Department of Anatomy, School of Medicine, Kangwon National University, Chuncheon, South Korea.

Introduction: This study investigated morphological variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus based on the existence of the intrathoracic nerves and the rami communicantes.

Materials And Methods: Fifty thoracic sympathetic trunks from 26 Korean adult cadavers were used.

Results: The first intrathoracic nerve connecting the first and second thoracic nerves was observed on 36 sides (72%), and the second intrathoracic nerve connecting the second and third thoracic nerves was found on three sides (6%). There were either one (62%) or two (10%) first intrathoracic nerves, and only one second intrathoracic nerve (6%). The neural connections of the second and third thoracic sympathetic ganglia to the first thoracic nerve were classified into three types based on the existence of the intrathoracic nerves: Type I (68%) had only the first intrathoracic nerve, Type II (26%) had no intrathoracic nerve, and Type III (6%) had both the first and second intrathoracic nerves. Types I, II, and III were further subdivided into 10, 6, and 3 types, respectively, according to the types of the rami communicantes arising from the second and third thoracic sympathetic ganglia.

Conclusions: Improved knowledge of the variations in intrathoracic nerves and upper thoracic sympathetic ganglia will be helpful to thoracic surgeons when they are disrupting the sympathetic supply to the hand for treating palmar hyperhidrosis, and contribute to successful diagnoses and treatments.
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http://dx.doi.org/10.1002/ca.23619DOI Listing
May 2021

Comparison of the diagnostic performance of imaging criteria for HCCs ≤ 3.0 cm on gadoxetate disodium-enhanced MRI.

Hepatol Int 2020 Jul 20;14(4):534-543. Epub 2020 Apr 20.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.

Background And Purpose: Imaging-based diagnostic systems play important roles in hepatocellular carcinoma (HCC). We aimed to compare the diagnostic performance of recently updated imaging criteria for HCCs ≤ 3.0 cm on gadoxetate disodium-enhanced magnetic resonance imaging (MRI).

Methods: 493 nodules (399 HCCs, 24 other malignancies, 70 benign) 1.0-3.0 cm from 400 patients, including 322 male (mean age 59.3 ± 9.4 years) and 78 female (mean age 61.2 ± 9.0 years), at risk for HCC who underwent gadoxetate disodium-enhanced MRI between July 2015 and December 2016 were retrospectively evaluated. Final diagnosis was determined histopathologically or clinically. The sensitivity and specificity in diagnosing HCC of the latest versions of four imaging criteria [Liver Imaging Reporting and Data System (LI-RADS), European Association for the Study of the Liver (EASL), Asian Pacific Association for the Study of the Liver (APASL), Korean Liver Cancer Association-National Cancer Center (KLCA-NCC)] were compared using generalized estimating equations.

Results: In 331 only pathologically diagnosed nodules, the sensitivities of both the APASL (86.8%) and KLCA-NCC criteria (85.4%) were significantly higher than the sensitivities of the EASL (71.8%) and LR-5 (71.1%) criteria (p < 0.001 for each pairwise comparison). However, the specificity of LR-5 was significantly higher than that of APASL (92.2% vs. 70.6%, respectively; p = 0.011) but did not differ significantly from the specificities of EASL (84.3%; p = 0.634) and KLCA-NCC (78.4%; p = 0.107).

Conclusion: Of the four international imaging criteria, LI-RADS and EASL showed high specificity but suboptimal sensitivity for diagnosing HCCs ≤ 3 cm. However, APASL and KLCA-NCC had a higher sensitivity but a lower specificity than LI-RADS and EASL.
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http://dx.doi.org/10.1007/s12072-020-10040-2DOI Listing
July 2020

Liver imaging reporting and data system category M: A systematic review and meta-analysis.

Liver Int 2020 06 15;40(6):1477-1487. Epub 2020 Mar 15.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background And Aims: The Liver Imaging Reporting and Data System (LI-RADS) category M (LR-M) was introduced to preserve the high specificity of LI-RADS algorithm for diagnosing hepatocellular carcinoma (HCC). We aimed to systematically determine the probability of the LR-M for HCC and non-HCC malignancy, and to determine the sources of heterogeneity between reported results.

Methods: Original studies reporting the probability of LR-M for HCC and non-HCC malignancy on magnetic resonance imaging (MRI) were identified in MEDLINE and EMBASE. The meta-analytic pooled percentages of HCC and non-HCC in LR-M were calculated. Meta-regression analysis was performed to explore study heterogeneity. The meta-analytic frequency of each LR-M imaging feature was determined.

Results: We found 10 studies reporting the diagnostic performance of LR-M (1819 lesions in 1631 patients), and six reporting the frequency of LR-M imaging features. The pooled percentages of HCC and non-HCC malignancy for LR-M were 28.2% (95% confidence interval [CI], 23.8%-33.1%; I  = 83%) and 69.6% (95% CI, 64.6%-74.1%; I  = 83%) respectively. The study type and MRI scanner field strength were significantly associated with study heterogeneity (P ≤ .04). Of the seven imaging features, rim arterial phase hyperenhancement showed the highest frequency in both non-HCC (48.9%; 95% CI, 43.0%-54.8%) and HCC groups (9.8%; 95% CI, 6.9%-13.6%).

Conclusions: The LR-M category most commonly included non-HCC malignancy but also included 28.2% of HCC. Substantial study heterogeneity was noted, and it was significantly associated with study type and MRI scanner field strength. In addition, the frequency of LR-M imaging features was variable.
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http://dx.doi.org/10.1111/liv.14420DOI Listing
June 2020

Percutaneous Radiofrequency Ablation for Metachronous Hepatic Metastases after Curative Resection of Pancreatic Adenocarcinoma.

Korean J Radiol 2020 03;21(3):316-324

Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: To retrospectively evaluate the safety and efficacy of percutaneous radiofrequency ablation (RFA) in patients with metachronous hepatic metastases arising from pancreatic adenocarcinoma who had previously received curative surgery.

Materials And Methods: Between 2002 and 2017, percutaneous RFA was performed on 94 metachronous hepatic metastases (median diameter, 1.5 cm) arising from pancreatic cancer in 60 patients (mean age, 60.5 years). Patients were included if they had fewer than five metastases, a maximum tumor diameter of ≤ 5 cm, and disease confined to the liver or stable extrahepatic disease. For comparisons during the same period, we included 66 patients who received chemotherapy only and met the same eligibility criteria described.

Results: Technical success was achieved in all hepatic metastasis without any procedure-related mortality. During follow-up, local tumor progression of treated lesions was observed in 38.3% of the tumors. Overall median survival and 3-year survival rates were 12 months and 0%, respectively from initial RFA, and 14.7 months and 2.1%, respectively from the first diagnosis of liver metastasis. Multivariate analysis showed that a large tumor diameter of > 1.5 cm, a late TNM stage (≥ IIB) before curative surgery, a time from surgery to recurrence of < 1 year, and the presence of extrahepatic metastasis, were all prognostic of reduced overall survival after RFA. Median overall (12 months vs. 9.1 months, = 0.094) and progression-free survival (5 months vs. 3.3 months, = 0.068) were higher in the RFA group than in the chemotherapy group with borderline statistical difference.

Conclusion: RFA is safe and may offer successful local tumor control in patients with metachronous hepatic metastases arising from pancreatic adenocarcinoma. Patients with a small diameter tumor, early TNM stage before curative surgery, late hepatic recurrence, and liver-only metastasis benefit most from RFA treatment. RFA provided better survival outcomes than chemotherapy for this specific group with borderline statistical difference.
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http://dx.doi.org/10.3348/kjr.2019.0647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039725PMC
March 2020

Ancillary features in the Liver Imaging Reporting and Data System: how to improve diagnosis of hepatocellular carcinoma ≤ 3 cm on magnetic resonance imaging.

Eur Radiol 2020 May 4;30(5):2881-2889. Epub 2020 Feb 4.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.

Objectives: To determine the strength of association with hepatocellular carcinoma (HCC) of each ancillary feature (AF) in LI-RADS version 2018, and to develop an appropriate strategy for applying AFs to improve the diagnosis of HCC ≤ 3 cm on gadoxetate-enhanced MRI.

Methods: A total of 385 nodules (283 HCCs, 18 non-HCC malignancies, 84 benign nodules) of ≤ 3 cm in 266 patients at risk for HCC who underwent gadoxetate-enhanced MRI in 2016 were retrospectively evaluated. Two radiologists independently evaluated the presence/absence of AFs, and assigned a LI-RADS category to each nodule. Diagnostic odds ratio (DOR) of each AF was assessed. To improve the diagnostic performance for HCC, various criteria were developed based on the number of AFs favoring malignancy in general or HCC in particular. Generalized estimating equation models were used to compare the diagnostic performance of each criterion with that of the major features (MFs) only.

Result: All AFs favoring HCC in particular and malignancy in general were more common in the HCC group than in the non-HCC group. Of these AFs, hepatobiliary-phase hypointensity had the strongest association with HCC (DOR, 21.82; 95% confidence interval, 5.59-85.20). When we applied AFs in addition to MFs, the new criterion (with a number of AFs ≥ 4) had significantly higher sensitivity (80.6% vs. 70.0%; p < 0.001) than MFs only, without significant lower specificity (85.3% vs. 90.2%; p = 0.060).

Conclusions: The AFs varied in the strengths of association with HCC. More strict application of AFs (AFs ≥ 4) in LR-3 may improve the diagnostic performance for probable HCC ≤ 3 cm.

Key Points: • The ancillary features (AFs) in the Liver Imaging Reporting and Data System version 2018 showed variable frequencies of occurrence and strengths of association with hepatocellular carcinoma (HCC). • Of the various AFs, hepatobiliary-phase hypointensity had the highest frequency and strongest association with HCC on gadoxetate disodium-enhanced MRI. • When applying AFs in addition to major features, a criterion of four or more AFs significantly increased the sensitivity for diagnosing HCC, without a significantly decreased specificity, especially in LR-3 observations.
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http://dx.doi.org/10.1007/s00330-019-06645-3DOI Listing
May 2020

Non-enhanced magnetic resonance imaging as a surveillance tool for hepatocellular carcinoma: Comparison with ultrasound.

J Hepatol 2020 04 10;72(4):718-724. Epub 2019 Dec 10.

Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background & Aims: Recently revised international guidelines for hepatocellular carcinoma (HCC) suggest that patients with inadequate ultrasonography be assessed by alternative imaging modalities. Non-enhanced MRI has potential as a surveillance tool based on the short scan times required and the absence of contrast agent-associated risks. This study compared the performance of non-enhanced MRI and ultrasonography for HCC surveillance in high-risk patients.

Methods: We included 382 high-risk patients in a prospective cohort who underwent 1 to 3 rounds of paired gadoxetic acid-enhanced MRI and ultrasonography. Non-enhanced MRI, consisting of diffusion-weighted imaging (DWI) and T2-weighted imaging, was simulated and retrospectively analyzed, with results considered positive when lesion(s) ≥1 cm showed diffusion restriction or mild-moderate T2 hyperintensity. Ultrasonography results were retrieved from patient records. HCC was diagnosed histologically and/or radiologically. Sensitivity, positive predictive value (PPV), specificity, and negative predictive value (NPV) were evaluated using generalized estimating equations.

Results: Forty-eight HCCs were diagnosed in 43 patients. Per-lesion and per-exam sensitivities of non-enhanced MRI were 77.1% and 79.1%, respectively, which were higher than those achieved with ultrasonography (25.0% and 27.9%, respectively, p <0.001). Specificities of non-enhanced MRI (97.9%) and ultrasonography (94.5%) differed significantly (p <0.001). NPV was higher for non-enhanced MRI (99.1%) than ultrasonography (96.9%). Per-lesion and per-exam PPVs were higher for non-enhanced MRI (56.9% and 61.8%, respectively) than for ultrasonography (16.7% and 17.7%, respectively). The estimated scan time of non-enhanced MRI was <6 min.

Conclusion: Based on its good performance, short scan times, and the lack of contrast agent-associated risks, non-enhanced MRI is a promising option for HCC surveillance in high-risk patients.

Lay Summary: Recently revised international guidelines for hepatocellular carcinoma (HCC) suggest that selected patients with inadequate surveillance on ultrasonography be assessed by alternative imaging modalities such as computed tomography or magnetic resonance imaging (MRI). Herein, we show that MRI without contrast agents performed significantly better than ultrasonography for HCC surveillance in high-risk patients. Given this good performance, as well as short scan times and the lack of contrast agent-associated risks, non-enhanced MRI is a promising option for HCC surveillance in high-risk patients.
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http://dx.doi.org/10.1016/j.jhep.2019.12.001DOI Listing
April 2020

Meta-analysis of the accuracy of Liver Imaging Reporting and Data System category 4 or 5 for diagnosing hepatocellular carcinoma.

Gut 2019 09 12;68(9):1719-1721. Epub 2019 Jul 12.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.

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http://dx.doi.org/10.1136/gutjnl-2019-318555DOI Listing
September 2019

Validation of US Liver Imaging Reporting and Data System Version 2017 in Patients at High Risk for Hepatocellular Carcinoma.

Radiology 2019 08 18;292(2):390-397. Epub 2019 Jun 18.

From the Department of Radiology and Research Institute of Radiology (J.H.S., S.H.C., S.Y.K., J.H.B., H.J.W., S.J.L.), and Department of Gastroenterology (Y.S.L.), University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea; Department of Radiology, National Cancer Center, Goyang, South Korea (H.Y.J.).

Background The 2017 version of the Liver Imaging Reporting and Data System (LI-RADS) recently included standardized interpretation, reporting, and management guidelines for US (US LI-RADS); however, this system has not yet been validated. Purpose To evaluate the diagnostic performance of US LI-RADS version 2017 for detecting hepatocellular carcinoma (HCC) in participants at high risk and to determine the clinical factors associated with a poor visualization score. Materials and Methods This study included 407 prospectively recruited participants (mean age, 56 years; age range, 28-76 years) with cirrhosis at high risk for HCC who underwent US surveillance from November 2011 to August 2012. Two radiologists retrospectively analyzed US images, assigning a LI-RADS category (US-1 = negative, US-2 = subthreshold, US-3 = positive) and a visualization score (A = no or minimal limitations, B = moderate limitations, C = severe limitations). The sensitivity and specificity for diagnosing HCC were calculated on a per-patient and per-lesion basis, using pathologic results and typical CT or MRI as reference standards. The risk factors for a poor visualization score were determined by using univariable and multivariable analyses. Results Of 429 lesions in 407 participants, there were 32 HCCs in 28 participants. In the per-lesion analysis, the specificity for US-3 was 366 of 397 (92%; 95% confidence interval [CI]: 89%, 95%) and the sensitivity was 11 of 32 (34%; 95% CI: 20%, 52%). In the per-patient analysis, the specificity for US-3 was 352 of 379 (93%; 95% CI: 90%, 95%) and the sensitivity was 11 of 28 (39%; 95% CI: 24%, 58%). Visualization score C (114 of 407 [28%] participants) had the highest false-negative rate (six of seven [86%] participants). High body weight (adjusted odds ratio [OR], 2.1 [95% CI: 1.2, 3.6]; = .01), Child-Pugh class B disease (OR, 2.9 [95% CI: 1.7, 4.9]; < .001), and moderate to severe fatty liver (OR, 1.7 [95% CI: 1.0, 2.8]; = .047) were associated with a poor visualization score of C. Conclusion The US-3 category demonstrated high specificity but low sensitivity for diagnosing hepatocellular carcinoma. The visualization score C had a higher false-negative rate than scores A or B, and patients with high body weight, Child-Pugh class B disease, and moderate to severe fatty liver may present limitations for US surveillance. © RSNA, 2019 See also the editorial by Milot in this issue.
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http://dx.doi.org/10.1148/radiol.2019190035DOI Listing
August 2019

Arterial subtraction images of gadoxetate-enhanced MRI improve diagnosis of early-stage hepatocellular carcinoma.

J Hepatol 2019 09 18;71(3):534-542. Epub 2019 May 18.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 05505, Republic of Korea.

Background & Aims: Although gadoxetate disodium-enhanced magnetic resonance imaging (MRI) shows higher sensitivity for diagnosing hepatocellular carcinoma (HCC), its arterial-phase images may be unsatisfactory because of weak arterial enhancement. We investigated the clinical effectiveness of arterial subtraction images from gadoxetate disodium-enhanced MRI for diagnosing early-stage HCC using the Liver Imaging Reporting and Data System (LI-RADS) v2018.

Methods: In 258 patients at risk of HCC who underwent gadoxetate disodium-enhanced MRI in 2016, a total of 372 hepatic nodules (273 HCCs, 18 other malignancies, and 81 benign nodules) of 3.0 cm or smaller were retrospectively analyzed. Final diagnosis was assessed histopathologically or clinically (marginal recurrence after treatment or change in lesion size on follow-up imaging). The detection rate for arterial hyperenhancement was compared between ordinary arterial-phase and arterial subtraction images, and the benefit of arterial subtraction images in diagnosing HCC using LI-RADS was assessed.

Results: Arterial subtraction images had a significantly higher detection rate for arterial hyperenhancement than ordinary arterial-phase images, both for all hepatic nodules (72.3% vs. 62.4%, p <0.001) and HCCs (91.9% vs. 80.6%, p <0.001). Compared with ordinary arterial-phase images, arterial subtraction images significantly increased the sensitivity of LI-RADS category 5 for diagnosis of HCC (64.1% [173/270] vs. 55.9% [151/270], p <0.001), without significantly decreasing specificity (92.9% [91/98] vs. 94.9% [93/98], p = 0.155). For histopathologically confirmed lesions, arterial subtraction images significantly increased sensitivity to 68.8% (128/186) from the 61.3% (114/186) of ordinary arterial-phase images (p <0.001), with a minimal decrease in specificity to 84.8% (39/46) from 89.1% (41/46) (p = 0.151).

Conclusions: Arterial subtraction images of gadoxetate disodium-enhanced MRI can significantly improve the sensitivity of early-stage HCC diagnosis using LI-RADS, without a significant decrease in specificity.

Lay Summary: Gadoxetate disodium-enhanced magnetic resonance imaging is an imaging technique with a high sensitivity for the diagnosis of hepatocellular carcinoma. However, arterial-phase images may be unsatisfactory because of weak arterial enhancement. We found that using arterial subtraction images led to clinically meaningful improvements in the diagnosis of early-stage hepatocellular carcinoma.
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http://dx.doi.org/10.1016/j.jhep.2019.05.005DOI Listing
September 2019

Variations of the plantar tarsometatarsal ligaments.

Clin Anat 2019 Jul 1;32(5):699-705. Epub 2019 Apr 1.

Department of Anatomy, Sungkyunkwan University School of Medicine, Suwon, Gyeonggi-do, Korea.

This study investigated the morphological variations of the plantar tarsometatarsal ligaments of the foot by classifying them based on their ligamentous components. Fifty embalmed feet from 27 adult Korean cadavers were used. The plantar tarsometatarsal ligaments comprised nine components (medial cuneiform-first metatarsal, pCn1-M1; medial cuneiform-second metatarsal, pCn1-M2; medial cuneiform-second and third metatarsals, pCn1-M2,3; median cuneiform-second metatarsal, pCn2-M2; lateral cuneiform-third metatarsal, pCn3-M3; lateral cuneiform-fourth metatarsal, pCn3-M4; lateral cuneiform-third and fourth metatarsals, pCn3-M3,4; cuboid-fourth metatarsal, pCb-M4; and cuboid-fifth metatarsal, pCb-M5). pCn1-M2 was newly observed in the present study. The number of the bands composing the ligament was one in the pCn1-M2, pCn2-M2, pCn3-M3, and pCn3-M4 components, and one or two in the pCn1-M1, pCn1-M2,3, pCn3-M3,4, pCb-M4, and pCb-M5 components. The plantar tarsometatarsal ligaments were classified into five types based on the combination of their components. The pCn1-M1, pCn1-M2,3, and pCn2-M2 components were consistently observed in types I-IV (88%), along with pCn3-M3,4 in type I, pCn3-M4 and pCb-M5 in type II, and pCn3-M3 in type IV. In type V (12%), the pCn1-M1 and pCb-M5 components were consistently present. Improved comprehension of the variations in plantar tarsometatarsal ligament anatomy is expected to help diagnose diverse injuries to this region, better understand the structural pathomechanism of the injuries, and contribute to successful treatment. Clin. Anat. 32:699-705, 2019. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23376DOI Listing
July 2019

Morphologic variations of the dorsal tarsometatarsal ligaments of the foot.

Clin Anat 2019 Mar 14;32(2):212-217. Epub 2018 Oct 14.

Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

This study investigated the anatomical features of the dorsal tarsometatarsal ligaments of the foot for the purpose of analyzing the ligamentous components and classifying their types. Fifty embalmed cadaveric feet from 27 adult cadavers were dissected in this study. The dorsal tarsometatarsal ligaments comprised nine components (first cuneiform-first metatarsal, dCn1-M1; first cuneiform-second metatarsal, dCn1-M2; second cuneiform-second metatarsal, dCn2-M2; third cuneiform-second metatarsal, dCn3-M2; third cuneiform-third metatarsal, dCn3-M3; third cuneiform-fourth metatarsal, dCn3-M4; cuboid-third metatarsal, dCb-M3; cuboid-fourth metatarsal, dCb-M4; cuboid-fifth metatarsal, dCb-M5). The dCn3-M4 and dCb-M3 had not been previously reported. The dCn1-M1, dCn1-M2, dCn3-M2, dCn3-M4, and dCb-M3 had only one band, the dCn2-M2 had two bands, and the others had one or two bands. The ligaments originating from Cb attached simultaneously to M3 and M4 (4/50), M4 and M5 (7/50), or M3 and M5 (5/50), which were Y-shaped (dCb-M3, 4 and dCb-M3, 5), or V-shaped (dCb-M4, 5). The dorsal tarsometatarsal ligaments were classified into four types according to the presence of each component. In Type I (52%), Type II (36%), Type III (10%), and Type IV (2%), all components were observed except for one, two, three, and four components, respectively. The dimensions of each component were measured, and as a result the dCn1-M1 was found to be the widest and longest of the dorsal ligaments while the dCn1-M2 was found to be the thickest. The dorsal tarsometatarsal ligaments comprised nine components and were classified into four types. Clin. Anat. 32:212-217, 2019. © 2018 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23282DOI Listing
March 2019

Topographical study of the trapezius muscle, greater occipital nerve, and occipital artery for facilitating blockade of the greater occipital nerve.

PLoS One 2018 15;13(8):e0202448. Epub 2018 Aug 15.

Department of Anatomy, Wonkwang University College of Medicine, Iksan, Korea.

The aim of this study was to clarify the topographical relationships between the greater occipital nerve and the trapezius muscle and between the greater occipital nerve and the occipital artery in the occiput in order to increase the success rate of greater occipital nerve blockade. Fifty-six halved heads of 28 cadavers were used in this study. The piercing points and the courses of the greater occipital nerve and occipital artery were analyzed by dividing a line connecting between the external occipital protuberance and mastoid process into three equal parts. A circle with a radius of 2 cm drawn at the medial trisection point of this line was divided into four equal sectors. The greater occipital nerve simply passed the lateral border of the trapezius muscle and then pierced the fascia connecting the cranial attachment of the trapezius muscle with the sternocleidomastoid muscle in 62.5% of the specimens, whereas it pierced the muscle itself in the other 37.5%. The greater occipital nerve and occipital artery pierced the fascia within the 2-cm-radius circle in 85.7% and 98.2% of the specimens, respectively. The piercing points of the greater occipital nerve and occipital artery were observed most frequently in the inferomedial (42.9%) and inferolateral (37.5%) sectors of the circle, respectively. The greater occipital nerve and occipital artery pierced the same sector of the circle and accompanied each other in 51.8% of the specimens. These results are expected to improve the understanding of the topographical relationships between the greater occipital nerve and trapezius muscle and between the greater occipital nerve and occipital artery in the occiput, and thus provide helpful information for the management of occipital neuralgia.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202448PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6093687PMC
February 2019

Topographical study of the connections of the rami communicantes from the first to the fifth thoracic sympathetic ganglia.

Clin Anat 2018 Nov 15;31(8):1151-1157. Epub 2018 Nov 15.

Department of Anatomy, Wonkwang University College of Medicine, Iksan, Korea.

This study investigated the morphological variations and histological patterns of the rami communicantes (RCs) arising from the first to the fifth thoracic sympathetic ganglia, and considered the clinical significance of these variations. Fifty upper thoracic portions from 26 adult Korean cadavers were used in this study. There were 731 RCs arising from the first to the fifth thoracic sympathetic ganglia. They were classified into three types depending on the connection between the sympathetic ganglion and the intercostal nerves: in type I, the RCs connected the ganglion to the corresponding intercostal nerve, and in types II and III, respectively, they connected it to the nerve one level above or below the corresponding intercostal nerve. Some RCs of types I and II could not be observed without additional preliminary surgical procedures. Diverse combinations of RC types arose from the first to the fifth thoracic sympathetic ganglia, combinations of types I and III being the most common (70%) in the first sympathetic ganglion and those comprising only type I being most frequent in the other ganglia. The RCs could not be identified by the naked eye in either fresh or fixed cadavers, so they were confirmed on the basis of their histological appearance. These results are expected to improve knowledge of morphological variations of the RCs in the upper five thoracic sympathetic ganglia, and to provide helpful information for clinical management in this region. Clin. Anat. 31:1151-1157, 2018. © 2018 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23218DOI Listing
November 2018

Liver Imaging Reporting and Data System: Patient Outcomes for Category 4 and 5 Nodules.

Radiology 2018 05 19;287(2):515-524. Epub 2018 Feb 19.

From the Department of Radiology and Research Institute of Radiology (S.H.C., J.H.B., S.J.L., S.Y.K., H.J.W., Y.M.S., P.N.K.) and Department of Gastroenterology (Y.S.L.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.

Purpose To determine the outcomes after initial therapy in patients with chronic liver disease and retrospectively assigned Liver Imaging Reporting and Data System (LI-RADS; version 2014) category 4 (LR-4) and 5 (LR-5) nodules at gadoxetate disodium-enhanced MR imaging. Materials and Methods In this retrospective study, 260 patients with a single LR-4 (n = 132) or LR-5 (n = 128) nodule who were assigned a LI-RADS category were included. Patients were identified between January 2012 and December 2012, and were initially treated by resection, liver transplant, radiofrequency ablation (RFA), or transcatheter arterial chemoembolization (TACE) according to the Barcelona Clinic Liver Cancer staging system. Follow-up continued until August 31, 2016. The incidences of local tumor recurrence (ILRs) and distant tumor recurrence (IDRs) and recurrence-free survival (RFS) were compared between the LR-4 and LR-5 patients. For each category, ILRs, IDRs, and RFS were compared across the four treatments. Results LR-5 patients were more frequently treated by surgical resection than LR-4 patients (72.7% [93 of 128] vs 41.7% [55 of 132], respectively; P < .001), but less frequently treated by RFA (19.5% [25 of 128] vs 30.3% [40 of 132], respectively; P = .047) and TACE (6.3% [eight of 128] vs 22.0% [29 of 132], respectively; P < .001). ILRs and IDRs were not significantly different between LR-4 and LR-5 patients according to the type of treatment (0%-48.3% [14 of 29] vs 0%-25.0% [two of eight], P $ .423; 0%-55.2% [16 of 29] vs 0%-37.5% [three of eight], P $ .447, respectively). There was no difference in RFS between the two categories (36.3 months vs 41.7 months, respectively; P = .084). Liver transplant showed no local or distant tumor recurrence in either category. Resection showed higher RFS and lower ILR and IDR than RFA and TACE in both LR-4 and LR-5 patients. Conclusion Patients with LR-4 nodules had ILRs and IDRs similar to patients with LR-5 nodules when stratified by treatment type. RFS was also similar between patients with LR-4 and LR-5 nodules. Among the four initial treatments, liver transplant and resection showed better local tumor control, with longer RFS than RFA or TACE. RSNA, 2018 Online supplemental material is available for this article.
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http://dx.doi.org/10.1148/radiol.2018170748DOI Listing
May 2018

Utility and Safety of Repeated Ultrasound-Guided Core Needle Biopsy of Focal Liver Masses.

J Ultrasound Med 2018 Feb 29;37(2):447-452. Epub 2017 Aug 29.

Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objectives: To evaluate the accuracy and safety of repeated ultrasound-guided core needle biopsy (CNB) for hepatic focal lesions and to assess the predictive factors for success of repeated CNB.

Methods: For 5 years, 3085 CNBs were performed for focal hepatic lesions using an automated biopsy gun with an 18-gauge needle. Seventy-eight patients underwent repeated CNB because of pathologically inconclusive or unexpected results. Twelve patients were excluded because of unavailable additional tissue or follow-up imaging by radiofrequency ablation (n = 5), repeated CNB greater than than 3 months after the first CNB (n = 5), and insufficient follow-up time (n = 2). Sixty-six patients were finally enrolled after the exclusion criteria were applied. We retrospectively evaluated tumor necrosis, tumor size, number of passes, lesion site, depth, tumor conspicuity, and complications. Continuous data and the total scores of the grading system were analyzed by the Student t test, and categorical data and each category were analyzed by the Fisher exact test.

Results: The repeated CNB rate was 2.5% (78 of 3085). The diagnostic accuracy of the repeated biopsies was 83.3% (55 of 66). Comparing the diagnostic group with the nondiagnostic group, no variable (ie, size, depth, necrosis, lesion site [segment], and number of passes) had a statistically significant difference. Tumor conspicuity was a significant factor for predicting successful repeated biopsy (P < .001). The cumulative complication rate was 10.6% (7 of 66), with only minor complications.

Conclusions: Repeated CNB is an accurate and safe procedure for obtaining a histologic diagnosis of hepatic focal lesions if the initial biopsy fails. High tumor conspicuity showed a significant correlation with successful repeated CNB.
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http://dx.doi.org/10.1002/jum.14358DOI Listing
February 2018

Efficacy and Safety of Radiofrequency Ablation for Focal Hepatic Lesions Adjacent to Gallbladder: Reconfiguration of the Ablation Zone through Probe Relocation and Ablation Time Reduction.

J Vasc Interv Radiol 2017 Oct 23;28(10):1395-1399. Epub 2017 Jul 23.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.

Purpose: To evaluate the safety and efficacy of radiofrequency (RF) ablation for treatment of focal hepatic lesions adjacent to the gallbladder with electrode relocation and ablation time reduction.

Materials And Methods: Thirty-nine patients who underwent RF ablation for focal hepatic lesions adjacent to the gallbladder (≤ 10 mm) were evaluated retrospectively from January 2011 to December 2014 (30 men and 9 women; age range, 51-85 y; mean age, 65 y). Of 36 patients with hepatocellular carcinoma, 3 had a second treatment for recurrence (mean tumor size, 15 mm ± 6). Patients were divided into 2 subgroups based on lesion distance from the gallbladder: nonabutting (> 5 mm; n = 19) and abutting (≤ 5 mm; n = 20). Electrodes were inserted parallel to the gallbladder through the center of a tumor in the nonabutting group and through the center of the expected ablation zone between a 5-mm safety zone on the liver side and the gallbladder in the abutting group. Ablation time was decreased in proportion to the transverse diameter of the expected ablation zone.

Results: Technical success and technical effectiveness rates were 89.7% and 97.4%, respectively, with no significant differences between groups (P = 1.00). Local tumor progression was observed in 3 patients (1 in the nonabutting group and 2 in the abutting group; P = 1.00). There were no major complications. The gallbladder was thickened in 10 patients, with no significant difference between groups (P = .72). Biloma occurred in 1 patient in the nonabutting group.

Conclusions: RF ablation with electrode relocation and reduction of ablation time can be a safe and effective treatment for focal hepatic lesions adjacent to the gallbladder.
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http://dx.doi.org/10.1016/j.jvir.2017.06.004DOI Listing
October 2017

Efficacy and safety of ultrasound-guided implantation of fiducial markers in the liver for stereotactic body radiation therapy.

PLoS One 2017 21;12(6):e0179676. Epub 2017 Jun 21.

Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-Gu, Seoul, KOREA.

Objective: Stereotactic body radiation therapy (SBRT) for the treatment of a malignancy in the liver requires the perilesional implantation of fiducial markers for lesion detection. The purpose of this study is to evaluate the efficacy and safety of ultrasound (US) -guided marker implantation for SBRT.

Methods: We retrospectively reviewed 299, US-guided, intrahepatic fiducial markers implanted in 101 patients between November 2013 and September 2014. SBRT-planning CT images were analyzed to determine the technical success of the implantation, the mean distance between the tumor margin and the marker, with the ideal location of fiducials defined as the distance between a marker and a tumor less than 3 cm and the distance between markers greater than 2 cm according to the tumor conspicuity seen on gray-scale US and the artifact obscuring tumor margins. We also evaluated procedure-related major and minor complications.

Results: Technical success was achieved in 291 (97.3%) fiducial marker implantations. The mean distance between the tumor and the marker was 3.1 cm (S.D., 2.1 cm; range, 0-9.5 cm). Of 101 patients, 72 lesions (71.3%, 2.2 ± 1.0 cm; range, 0-3.0 cm) had fiducial markers located in an ideal location. The ideal location of fiducials was more common in visible lesions than in poorly conspicuous lesions (90.2% vs. 52.0%, P < 0.001). Seventeen markers (5.8%) developed beam-hardening artifacts obscuring the tumor margins. There were no major complications, although 12 patients (11.9%) developed minor complications.

Conclusions: US-guided implantation of fiducial markers in the liver is an effective and safe procedure with only rare complications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0179676PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5479553PMC
September 2017

Improved recovery and biological activities of an engineered polyene NPP analogue in Pseudonocardia autotrophica.

J Ind Microbiol Biotechnol 2017 Sep 29;44(9):1293-1299. Epub 2017 May 29.

Department of Biological Engineering, Inha University, Incheon, 22212, Korea.

NPP A1 produced by Pseudonocardia autotrophica is a unique disaccharide-containing polyene macrolide. NPP A1 was reported to have higher water solubility and lower hemolytic toxicity than nystatin A1 while retaining its antifungal activity. An engineered NPP A1 analogue, NPP A2, was generated by inactivation of the nppL gene, encoding a P450 monooxygenase in P. autotrophica. The resulting compound exhibited the corresponding chemical structure of NPP A1 but lacked a C10 hydroxyl group. In this study, newly developed crystallization recovery methods for NPP A2 purification, followed by an evaluation of in vitro antifungal activity and hemolytic activity, were performed. The crystallization methods were designed to eliminate the undesired viscous impurities encountered during the NPP A2 purification process, resulting in improved purity from 5.3 to 83.5% w/w. NPP A2 isolated from the improved purification process also exhibited two times higher antifungal activity and 1.8 times higher hemolytic toxicity than those of NPP A1. These results suggest that the minor structural modification of disaccharide-containing polyene macrolides, such as removing a C10 hydroxyl group, might require an alternative recovery process, such as crystallization, to confirm its improved biological activity.
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http://dx.doi.org/10.1007/s10295-017-1954-8DOI Listing
September 2017

Validation of a CT-guided intervention robot for biopsy and radiofrequency ablation: experimental study with an abdominal phantom.

Diagn Interv Radiol 2017 May-Jun;23(3):233-237

Departments of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Purpose: We aimed to evaluate the accuracy of a needle-placement robot for biopsy and radiofrequency ablation on an abdominal phantom.

Methods: A master-slave robotic system has been developed that includes a needle-path planning system and a needle-inserting robot arm with computed tomography (CT) and CT fluoroscopy guidance. For evaluation of its accuracy in needle placement, a commercially available abdominal phantom (Model 057A; CIRS Inc.) was used. The liver part of the phantom contains multiple spherical simulated tumors of three different size spheres. Various needle insertion trials were performed in the transverse plane and caudocranial plane two nodule sizes (10 mm and 20 mm in diameter) to test the reliability of this robot. To assess accuracy, a CT scan was performed after each trial with the needle in situ.

Results: The overall error was 2 mm (0-2.6 mm), which was calculated as the distance from the planned trajectory before insertion to the actual needle trajectory after insertion. The standard deviations of the insertions on two nodules (10 mm and 20 mm in diameter) were 0.5 mm and 0.2 mm, respectively.

Conclusion: The CT-compatible needle placement robot for biopsy and radiofrequency ablation shows relatively acceptable accuracy and could be used for radiofrequency ablation of nodules ≥10 mm under CT fluoroscopy guidance.
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http://dx.doi.org/10.5152/dir.2017.16422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411006PMC
January 2018

Value of contrast-enhanced sonography of small hepatocellular carcinoma with sonazoid prior to radiofrequency ablation.

J Clin Ultrasound 2017 Sep 8;45(7):383-390. Epub 2017 Mar 8.

Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.

Background: We aimed to determine the value of contrast-enhanced sonography (CEUS) with Sonazoid prior to percutaneous radiofrequency ablation (RFA) of small (<3 cm) hepatocellular carcinoma (HCC).

Methods: This prospective study was approved by our institutional review board and informed consent was obtained. The following criteria were used for study enrollment: (1) cirrhotic patients with HCCs found by contrast-enhanced CT or Gd-EOB-DTPA-enhanced MRI; (2) a single HCC <3 cm in longest diameter or multinodular HCCs (<3) with each tumor <3 cm in longest diameter; and (3) indeterminate identification of the index tumor from the surrounding cirrhosis-related pseudolesions on conventional US. Percutaneous RFA was performed under the guidance of CEUS with Sonazoid. The value of CEUS in index tumor detection and targeting was compared with that of concurrently performed conventional US.

Results: A total of 38 patients with 43 HCCs (mean size, 1.6 cm; range, 0.5-2.9 cm) were enrolled. The vascular phase of Sonazoid-enhanced ultrasonography showed good tumor enhancement in 30/43 HCCs (70%). The Kupffer phase increased lesion conspicuity and operator's diagnostic confidence in 29 patients with 31 HCCs (31/43, 72%) compared with conventional US.

Conclusions: CEUS with Sonazoid is useful for detection and targeting of small HCC prior to RFA. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:383-390, 2017.
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http://dx.doi.org/10.1002/jcu.22469DOI Listing
September 2017

Changes in echogenicity of hepatic hemangiomas during the valsalva maneuver.

J Clin Ultrasound 2017 Jul 10;45(6):328-331. Epub 2017 Feb 10.

Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, Korea.

Background: We aimed to evaluate changes in echogenicity of hepatic hemangiomas during the Valsalva maneuver.

Methods: We examined 16 liver hemangiomas in 12 patients with a mean diameter of 1.5 cm (range, 0.7-2.2 cm), which showed variations in echogenicity during the Valsalva maneuver. Two radiologists reviewed the sonographic (US) images of the hemangiomas at three different times: prior to the Valsalva maneuver, during the Valsalva maneuver, and on follow-up US examinations.

Results: Prior to Valsalva maneuver, the 16 hemangiomas appeared as hypoechoic nodules with an echogenic rim (n = 7), homogeneously echogenic nodules (n = 5), one hypoechoic nodule with sound-through enhancement, one heterogeneous nodule with a hyperechoic rim, one heterogeneous nodule, and one echogenic nodule with a hyperechoic rim. During the Valsalva maneuver, increased echogenicity was observed in 11 cases, as a diffuse increase in 5 cases, and as a partial increase in 6. Prior to the Valsalva maneuver, 9 of 16 hemangiomas exhibited an echogenic rim. During the maneuver, all the rims were accentuated, and an additional five hemangiomas exhibited an echogenic rim. Throughout follow-up, 12 of 15 hemangiomas underwent some echogenicity change.

Conclusions: Use of the Valsalva maneuver during US examination of the liver can increase the echogenicity of hepatic hemangiomas and accentuate the echogenic rim, which could enhance the operator's confidence in the diagnosis of hemangioma. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:328-331, 2017.
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http://dx.doi.org/10.1002/jcu.22456DOI Listing
July 2017
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