We report two cases of recurrent extramarnmary Pagets disease after wide local excision. Both cases involved the scrotum and the penoserotal junction, respectively. On histopathological examination, we could observed many Paget cells confined to the epidermis and the hair follicle, but not invading the underlying dermis in both cases. There was no evidence of internal malignancy. Both cases were treated with wide local reexcision.
Dermis ; Epidermis ; Hair Follicle ; Paget Disease, Extramammary* ; Scrotum

The present study examined cortical cerebral microinfarcts (CMIs) on a 3T magnetic resonance imaging and investigated the impact of CMIs on the comprehensive functional outcomes during the post-stroke rehabilitation period. Patients with acute phase of firstever ischemic stroke were retrospectively recruited (n = 62) and divided into 2 groups with and without CMIs. Clinical parameters including age, sex, stroke lesion laterality, location, the National Institutes of Health Stroke Scale score, as well as history of hypertension, dyslipidemia, diabetes mellitus, and smoking were obtained. Functional outcomes were assessed twice at baseline and one month later with the Korean version of the MiniMental State Examination, the Berg balance scale (BBS), and the functional independence measure. Partial correlation and multiple linear regression analyses were used to examine the relationship between the presence of CMIs and the change in functional outcomes. At least one CMI was reported in 27 patients, who were older (p = 0.043). The presence of CMIs was significantly associated with functional impairment in all 3 functional outcomes, after controlling for confounding factors (p < 0.05). CMIs might contribute to poor functional outcomes during the post-stroke rehabilitation period. These results suggest that CMIs should be considered when establishing rehabilitation treatment strategies or making a prognosis.

Hepatocellular carcinoma (HCC) can be diagnosed based on characteristic findings of arterial-phase enhancement and portal/delayed "washout" in cirrhotic patients. Several countries and major academic societies have proposed varying specific diagnostic criteria for HCC, largely reflecting the variable HCC prevalence in different regions and ethnic groups, as well as different practice patterns. In 2014, a new version of Korean practice guidelines for management of HCC was released by the Korean Liver Cancer Study Group (KLCSG) and the National Cancer Center (NCC). According to the KLCSG-NCC Korea practice guidelines, if the typical hallmark of HCC (i.e., hypervascularity in the arterial phase with washout in the portal or 3 min-delayed phases) is identified in a nodule > or = 1 cm in diameter on either dynamic CT, dynamic MRI, or MRI using hepatocyte-specific contrast agent in high-risk groups, a diagnosis of HCC is established. In addition, the KLCSG-NCC Korea practice guidelines provide criteria to diagnose HCC for subcentimeter hepatic nodules according to imaging findings and tumor marker, which has not been addressed in other guidelines such as Association for the Study of Liver Diseases and European Association for the Study of the Liver. In this review, we briefly review the new HCC diagnostic criteria endorsed by the 2014 KLCSG-NCC Korea practice guidelines, in comparison with other recent guidelines; we furthermore address several remaining issues in noninvasive diagnosis of HCC, including prerequisite of sonographic demonstration of nodules, discrepancy between transitional phase and delayed phase, and implementation of ancillary features for HCC diagnosis.
Aged ; Aged, 80 and over ; Carcinoma, Hepatocellular/*diagnosis/pathology ; Contrast Media ; Female ; Hepatitis B, Chronic/complications ; Hepatitis C, Chronic/complications ; Humans ; Liver/*pathology ; Liver Neoplasms/*diagnosis/pathology ; Magnetic Resonance Imaging/*methods ; Male ; Middle Aged ; Practice Guidelines as Topic ; Republic of Korea ; Young Adult

The original article contained incorrect figure captions.

Hepatocellular carcinoma (HCC) can be noninvasively diagnosed on the basis of its characteristic imaging findings of arterial phase enhancement and portal/delayed “washout” on computed tomography (CT) and magnetic resonance imaging (MRI) in cirrhotic patients. However, different specific diagnostic criteria have been proposed by several countries and major academic societies. In 2018, major guideline updates were proposed by the Association for the Study of Liver Diseases, European Association for the Study of the Liver (EASL), Korean Liver Cancer Association and National Cancer Center (KLCA-NCC) of Korea. In addition to dynamic CT and MRI using extracellular contrast media, these new guidelines now include magnetic resonance imaging (MRI) using hepatobiliary contrast media as the first-line diagnostic test, while the KLCA-NCC and EASL guidelines also include contrast-enhanced ultrasound (CEUS) as the second-line diagnostic test. Therefore, hepatobiliary MR contrast media and CEUS will be increasingly used for the noninvasive diagnosis and staging of HCC. In this review, we discuss the emerging role of hepatobiliary phase MRI and CEUS for the diagnosis of HCC and also review the changes in the HCC diagnostic criteria in major guidelines, including the KLCA-NCC practice guidelines version 2018. In addition, we aimed to pay particular attention to some remaining issues in the noninvasive diagnosis of HCC.
Carcinoma, Hepatocellular ; Contrast Media ; Diagnosis ; Diagnostic Tests, Routine ; Humans ; Korea ; Liver ; Liver Diseases ; Liver Neoplasms ; Magnetic Resonance Imaging ; Ultrasonography

PURPOSE: The purpose of this study was to retrospectively compare the technical success and reliability of the measurements made using two 2-dimensional (2D) shear wave elastography (SWE) systems using the comb-push technique from the same manufacturer and to assess the intersystem reproducibility of the resultant liver stiffness (LS) measurements. METHODS: Ninety-four patients with suspected chronic liver diseases were included in this retrospective study. LS measurements were obtained using two 2D-SWE systems (LOGIQ E9 and LOGIQ S8) from the same manufacturer, with transient elastography (TE) serving as the reference standard, on the same day. The technical success rates and reliability of the measurements of the two 2D-SWE systems were compared. LS values measured using the two 2D-SWE systems and TE were correlated using Spearman correlation coefficients and 95% Bland-Altman limits of agreement. Thereafter, Bland-Altman limits of agreement and intraclass correlation coefficients (ICCs) were used to analyze the intersystem reproducibility of LS measurements. RESULTS: The two 2D-SWE systems showed similar technical success rates (98.9% for both) and reliability of LS measurements (92.3% for the LOGIQ E9, 91.2% for the LOGIQ S8; P=0.185). Despite the excellent correlation (ICC=0.92), the mean LS measurements obtained by the two 2D-SWE systems were significantly different (LOGIQ E9, 6.57±2.33 kPa; LOGIQ S8, 6.90±6.64 kPa; P=0.018). CONCLUSION: Significant intersystem variability was observed in the LS measurements made using the two 2D-SWE systems. Therefore, even 2D-SWE systems from the same manufacturer should not be used interchangeably in longitudinal follow-up.
Elasticity Imaging Techniques ; Follow-Up Studies ; Humans ; Liver Cirrhosis ; Liver Diseases ; Liver ; Reproducibility of Results ; Retrospective Studies ; Ultrasonography

PURPOSE: The purpose of this study was to compare the technical success rate and reliability of measurements made using three shear wave elastography (SWE) techniques and to assess the inter-platform reproducibility of the resultant liver stiffness measurements. METHODS: This prospective study included 54 patients with liver disease. Liver stiffness (LS) measurements were obtained using 2-point SWE techniques (Virtual Touch Quantification and S-Shearwave) and 2-dimensional (2D) SWE, with transient elastography (TE) serving as the reference standard. The technical success rates and measurement reliability of the three techniques were compared. LS values measured using the three SWE techniques and TE were compared using Spearman correlation coefficients and 95% Bland-Altman limits of agreement. Intra-class correlation coefficients (ICC) were used to analyze the inter-platform reproducibility of LS measurements. RESULTS: The three SWE techniques and TE showed similar technical success rates (P=0.682) but demonstrated significant differences in the reliability of LS measurements (P=0.006) and mean LS measurements (P<0.001). Despite strong correlations (r=0.73-0.94) between SWE systems, various degrees of inter-platform reproducibility (ICC, 0.58-0.92) were observed for the three SWE techniques. The best agreement was observed between S-Shearwave and TE (ICC, 0.92), and the worst agreement was observed between 2D-SWE and TE (ICC, 0.58). In the Bland-Altman analysis, a tendency toward lower LS values with the three SWE techniques than with TE in patients with F3 and F4 disease was observed. CONCLUSION: Significant inter-system variability was observed in LS measurements made using the three SWE techniques. Therefore, LS values measured using different SWE techniques should not be used interchangeably for longitudinal follow-up.
Elasticity Imaging Techniques ; Follow-Up Studies ; Humans ; Liver Cirrhosis ; Liver Diseases ; Liver ; Prospective Studies

Retroperitoneal hemorrhage is a potentially lethal complication in patients on anticoagulant therapy and can be caused by ovarian artery bleeding, regardless of the patients’ age and obstetric history. This case illustrates the clinical presentation of ovarian artery bleeding in a postmenopausal female on anticoagulant therapy, the diagnostic utility of transcatheter angiography, and successful embolization.

Purpose: The purpose of this study was to prospectively investigate the intra- and interobserver repeatability of a new 2-dimensional (2D) shear wave elastography (SWE) technique (S-Shearwave Imaging) for assessing liver fibrosis in chronic liver disease patients, and to compare liver stiffness measurements (LSMs) made using 2D-SWE with those made using point SWE (pSWE). Methods: This prospective study received institutional review board approval and informed consent was obtained from all patients. Fifty-three chronic liver disease patients were randomly allocated to group 1 (for intra-observer repeatability [n=33]) or group 2 (for inter-observer repeatability [n=20]). In group 1, two 2D-SWE sessions and one pSWE sessions were performed by one radiologist. In group 2, one 2D-SWE session and one pSWE session were performed by the aforementioned radiologist, and a second 2D-SWE session was performed by another radiologist. The intraclass correlation coefficient (ICC) was used to assess intra- and interobserver reliability. LSMs obtained using 2D-SWE and pSWE were compared and correlated using the paired t test and Pearson correlation coefficient, respectively. Results: LSMs made using 2D-SWE demonstrated excellent intra- and inter-observer repeatability (ICC, 0.997 [95% confidence interval, 0.994 to 0.999]) and 0.995 [0.988 to 0.998], respectively). LSMs made using 2D-SWE were significantly different from those made using pSWE (2.1±0.6 m/sec vs. 1.9±0.6 m/sec, P<0.001), although a significant correlation existed between the 2D-SWE and pSWE LSMs (rho=0.836, P<0.001). Conclusion S-Shearwave Imaging demonstrated excellent intra- and inter-observer repeatability, and a strong correlation with pSWE measurements of liver stiffness. However, because of the significant difference between LSMs obtained using 2D-SWE and pSWE, these methods should not be used interchangeably.

Hepatocellular carcinoma (HCC) is a unique cancer entity that can be noninvasively diagnosed using imaging modalities without pathologic confirmation. In 2018, several major guidelines for HCC were updated to include hepatobiliary contrast agent magnetic resonance imaging (HBA-MRI) and contrast-enhanced ultrasound (CEUS) as major imaging modalities for HCC diagnosis. HBA-MRI enables the achievement of high sensitivity in HCC detection using the hepatobiliary phase (HBP). CEUS is another imaging modality with real-time imaging capability, and it is reported to be useful as a second-line modality to increase sensitivity without losing specificity for HCC diagnosis. However, until now, there is an unsolved discrepancy among guidelines on whether to accept “HBP hypointensity” as a definite diagnostic criterion for HCC or include CEUS in the diagnostic algorithm for HCC diagnosis. Furthermore, there is variability in terminology and inconsistencies in the definition of imaging findings among guidelines; therefore, there is an unmet need for the development of a standardized lexicon. In this article, we review the performance and limitations of HBA-MRI and CEUS after guideline updates in 2018 and briefly introduce some future aspects of imaging-based HCC diagnosis.