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PURPOSE: To prospectively assess patient response (after 12 months) to magnetic resonance (MR) imaging-guided focused ultrasound surgery in treatment of uterine leiomyomas by using two treatment protocols. MATERIALS AND METHODS: This prospective clinical trial was approved by institutional review boards and was HIPAA compliant. After giving informed consent, patients with symptomatic leiomyomas were consecutively enrolled and treated at one of five U.S. centers by using an original or a modified protocol. Outcomes were assessed with the symptom severity score (SSS) obtained at baseline and 3, 6, and 12 months after treatment. Adverse events (AEs) were recorded. Statistical analysis included Student t test, Fisher exact test, analysis of covariance, Spearman correlation, and logistic regression. RESULTS: One hundred sixty patients had a mean SSS of 62.1 +/- 16.3 (standard deviation) at baseline, which decreased to 35.5 +/- 19.5 at 3 months (P<.001) and to 32.3 +/- 19.8 at 6 months (P<.001) and was 32.7 +/- 21.0 at 12 months (P<.001). Ninety-six patients (mean age, 46.0 years +/- 4.6) were treated with an original protocol, and 64 (mean age, 45.9 years +/- 3.9) were treated with a modified protocol. Patients in the modified group had a significantly greater SSS decrease at 3 months (P=.037) than those in the original group, and 73% of those in the original group and 91% of those in the modified group reported a significant decrease in SSS (of 10 points or greater) at 12 months. No serious AEs were recorded. Fewer AEs were reported in the modified group than in the original group (25% vs 13% reporting no event). Of evaluable patients, fewer in the modified group chose alternative treatment (28%) than in the original group (37%). CONCLUSION: MR imaging-guided focused ultrasound surgery results in symptomatic improvement, sustained to 12 months after treatment. Treatment with a modified protocol results in greater clinical effectiveness and fewer AEs.

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PURPOSE: To determine the diagnostic performance of functional magnetic resonance cholangiography (fMRC) for the evaluation of anatomic and functional biliary disorders. MATERIALS AND METHODS: At 1.5 T, 39 MR examinations with conventional MRC and mangafodipir trisodium-enhanced fMRC were retrospectively reviewed by three observers who recorded anatomic (duct dilation, stricture, filling defects) and functional (cholecystitis, obstruction) abnormalities in three modes: MRC alone, fMRC alone, and MRC and fMRC images together (combined-MRC). Performance was determined by comparing findings with each mode to findings of invasive cholangiography (IC) and surgery. RESULTS: Among 75 biliary segments (correlated with IC), the sensitivity/specificity for diagnosing dilation (N = 41) with MRC was 95%/97%; with fMRC, 90%/100%; with combined-MRC, 100%/97%. For stricture (N = 7), the sensitivity/specificity of MRC was 86%/98%; of fMRC, 43%/100%; of combined-MRC, 86%/100%. For filling defects (N = 9), the sensitivity/specificity of MRC was 91%/98%; of fMRC, 82%/100%; of combined-MRC, 91%/100%. For diagnosing obstruction (N = 9), the sensitivity/specificity of MRC, fMRC, and combined-MRC were 89%/100%, 100%/100%, and 100%/100%, respectively. For surgically proven cholecystitis (N = 13), positive predictive values for diagnosing acute/chronic cholecystitis for MRC were 33%/40%; for fMRC, 100%/50%; for combined-MRC, 100%/50%. CONCLUSION: Although single-shot fast spin echo (SSFSE)-MRC is valuable, the addition of fMRC increased diagnostic performance for functional biliary disorders.

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PURPOSE: To compare the safety and effectiveness of an undiluted direct injection of ferumoxides with those of a diluted slow infusion of ferumoxides during 30 minutes in patients with known liver lesions or in those suspected of having them. MATERIALS AND METHODS: Two hundred thirty-three patients at 16 institutions were randomized to receive either an undiluted direct injection of 0.56 mg of iron per kilogram of body weight of ferumoxides administered during 2 minutes (2 mL/min) or a diluted slow infusion administered during 30 minutes. Safety was assessed with monitoring for adverse events and laboratory tests. For sensitivity, specificity, and accuracy analysis, two independent blinded observers identified and classified lesions as benign or malignant with precontrast images and with pre- and postcontrast images combined. RESULTS: There was no statistically significant difference in adverse events in the group with direct injection compared with those in the group with infusion (21 [18%] of 114 patients vs 19 [17%] of 112 patients, respectively). No serious adverse events were observed. The most common adverse events in the group with direct injection versus the group with infusion were headache (five [4%] of 114 vs three [3%] of 112, respectively) and back pain (five [4%] of 114 vs three [3%] of 112, respectively). Overall, in 68 (62%) of 109 patients with direct injection and 71 (66%) of 108 patients with infusion, additional magnetic resonance (MR) imaging information was obtained after ferumoxides administration (P =.67). Sensitivity, specificity, and accuracy for the diagnosis of malignancy were significantly improved by adding images obtained after ferumoxides administration to the images obtained before contrast agent administration (P <.05 for all comparisons). CONCLUSION: Direct injection of ferumoxides has safety and effectiveness profiles similar to those of slow infusion of the agent. Further findings indicate that the addition of ferumoxides increases the sensitivity and specificity of hepatic MR evaluation when compared with unenhanced MR imaging.

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PURPOSE: To assess whether measuring the pattern of pancreatic enhancement on gadolinium chelate dynamic magnetic resonance imaging (MRI) is helpful for diagnosis of suspected early or mild chronic pancreatitis. MATERIALS AND METHODS: In this retrospective study, 24 patients with suspected early or mild chronic pancreatitis, classified by imaging criteria of equivocal chronic pancreatitis (ultrasound, computed tomography [CT] or ERCP) grading, had dynamic MRI that included unenhanced, arterial dominant, early venous, and late venous phases of contrast enhancement. Twenty patients without pancreatic diseases also had the dynamic sequence as a control group. The signal intensity was measured at the pancreatic head, body, and tail on all phases, and for each, the signal intensity ratio (SIR, the signal intensity in postcontrast divided by that in precontrast) was calculated. Two radiologists independently reviewed the images of the patients with suspected early or mild chronic pancreatitis for pancreatic morphologic abnormalities without knowing the results of signal intensity measurements. RESULTS: On unenhanced images, there was no significant difference of signal intensity between control and pancreatitis groups (P < 0.05). In the pancreatitis group, but not in the control group, the unenhanced signal intensity of the pancreatic head and body were significantly higher than that of the tail (P < 0.05). In the control group, the greatest enhancement (highest SIR) after injection was in the arterial phase (1.89 +/- 0.31), significantly higher than that in the early venous phase (1.68 +/- 0.17, P < 0.01) and in the late venous phase (1.61 +/- 0.15, P < 0.001). The pancreatitis group, however, had an arterial phase SIR (1.65 +/- 0.23) that was significantly lower than its early venous phase SIR (1.75 +/- 0.22, P < 0.05) and lower than the arterial phase SIR of the control group (P < 0.01). The presence of an SIR less than 1.73 in the arterial phase and/or a delayed peak enhancement after contrast agent administration had a sensitivity and specificity of diagnosing early or mild chronic pancreatitis of 92% and 75%, respectively. This sensitivity was significantly higher than the sensitivity of 50% for diagnosis based on morphologic abnormalities (P < 0.05). CONCLUSION: Measuring pancreatic signal intensity on gadolinium chelate dynamic MRI is helpful for diagnosing early or mild chronic pancreatitis, especially before apparent pancreatic morphologic or signal intensity changes are present.

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OBJECTIVE: To study the MR appearance of lymph nodes in relation to activity of chronic active hepatitis C, we correlated the findings on MR imaging with a histologic grading of the activity level. MATERIALS AND METHODS: Fifty patients with chronic active hepatitis C, who had MR imaging examinations and a related histology report from a liver biopsy obtained within 1 month of the MR imaging were chosen from our radiology database and studied retrospectively. All patients were examined over a 4-year period at a single institution to detect cirrhosis or hepatocellular carcinoma. We divided the 50 patients into the mild, moderate, or severe activity groups, according to their histology reports. Two radiologists, unaware of the histologic classifications, individually reviewed the MR images to observe the perihepatic locations, number, size (defined as the sum of the length-by-width products of the largest three nodes), and intensity of the lymph nodes relative to the spleen. The clinical records of the patients were reviewed to check the results of their liver function tests. The lymph node findings on MR imaging were compared with the histologically confirmed activity level of chronic hepatitis C. RESULTS: Forty-four (88.0%) of 50 patients had perihepatic lymph nodes larger than 5 mm on MR images, including 64.2% (9/14) of the patients with mild activity, 96.3% (26/27) of the patients with moderate activity, and 100% (9/9) of the patients with severe activity (p = 0.0034). The average number +/- the standard deviation (SD) of perihepatic lymph nodes was 2.5 +/- 1.8 in patients with mild activity, 5.6 +/- 2.2 in patients with moderate activity, and 8.3 +/- 3.5 in patients with severe activity (p = 0.0001). The average size (+/- SD) of the lymph nodes was 151.0 +/- 104.9 mm(2) in the mild activity group, 366.8 +/- 143.0 mm(2) in the moderate activity group, and 488.2 +/- 244.8 mm(2) in the severe activity group (p = 0.0001). On fat-saturated fast spin-echo T2-weighted MR images, the average number (+/- SD) of hyperintense nodes was 0.17 +/- 0.25 in the mild activity group, 1.7 +/- 0.80 in the moderate activity group, and 2.4 +/- 0.60 nodes in the severe activity group (p = 0.0001). No relationship between histologic activity and results from liver function tests was found. CONCLUSION: MR imaging depicts perihepatic lymph nodes in most patients with chronic hepatitis C. Lymph node number, size, and hyperintensity were related to the activity of chronic hepatitis C, but the results of liver function tests were not.

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PURPOSE: To evaluate single-shot fast spin-echo (SE) magnetic resonance (MR) imaging for depiction of pancreatic cysts in a large number of patients and to analyze cyst prevalence with respect to patient age and sex and other clinical information. MATERIALS AND METHODS: Single-shot fast SE images of the pancreas were obtained in 1,444 patients. The images were reviewed for presence of pancreatic cysts, which were classified as simple and nonsimple types, and cyst diameters were measured. kappa statistic, Fisher exact, McNemar Q, and Pearson product moment correlation tests were performed. RESULTS: Two hundred eighty-three (19.6%) patients had at least one pancreatic cyst. The prevalence of pancreatic cysts increased with age (r = 0.96). The percentages of male and female patients with pancreatic cysts (20.4% vs 18.8%) were not significantly different. Two hundred seventy-one (18.8%) patients had simple cysts, and 147 (10.2%) had nonsimple cysts. Of 283 patients with pancreatic cysts, 158 (55.8%) had only one pancreatic cyst. The number of patients with multiple cysts increased with age after 70 years. Four hundred fifteen (83.8%) cysts were 10 mm in diameter or smaller; 56 (11.3%), 11-20 mm in diameter; and 24 (4.9%), 21 mm in diameter or larger. Sixteen (5.7%) patients with pancreatic cysts had malignant pancreatic tumors, and 75 (26.5%) patients had pancreatitis. CONCLUSION: The prevalence of pancreatic cysts at single-shot fast SE MR imaging-especially cysts with a diameter smaller than 10 mm-is similar to that of pancreatic cysts at autopsy and higher than that of pancreatic cysts at transabdominal ultrasonography. Prevalence is especially high in patients with pancreatitis.

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We present a case of spontaneous rupture of hepatocellular carcinoma (HCC) with poor liver function which was treated by transcatheter arterial embolization (TAE). The patient's bilirubin value was 3.8 mg/dL. The tumor was fed by the right renal capsular artery according to selective arteriography. It was subsequently treated by TAE. With successful TAE, no hepatic failure was related to the treatment. We believe that if tumors are fed only by extrahepatic collateral vessels, TAE may be an effective treatment even in patients with poor liver function.

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