Significance of smoking history and FDG uptake for pathological N2 staging in clinical N2-negative non-small-cell lung cancer.

BACKGROUND: This study was conducted to evaluate whether smoking history and the standardized uptake value (SUV) of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) uptake are associated with unexpected pathological N2 status (pN2) in non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: We analyzed the data of 220 patients who underwent surgical resection with clinical N2-negative status on computed tomography (CT) and positron emission tomography (PET)-CT. The maximum SUV of primary tumor was chosen for logistic analysis. RESULTS: Seventy-two patients (33%) had never smoked. The SUV ranged from 1.0 to 29.0 (median 9.1). In univariate analysis, adenocarcinomas (P = 0.019), female gender (P = 0.010), N1 on CT (P = 0.025), and N1 PET-CT (P = 0.001) were associated with a high probability of pN2. The proportion of pN2 in never smokers was higher than in ever smokers (26% versus 10% respectively; P = 0.002). The SUV remained on a multivariate logistic model (odds ratio 1.1; 95% confidence interval 1.0-1.2; P = 0.010) and it had a better predictive value in never smokers than in ever smokers (P = 0.017). CONCLUSIONS: This study indicates an association between smoking history and pN2 in clinically negative N2 NSCLC. The different roles of FDG uptake were also suggested based on smoking history.

An experimental study of embolic effect according to infusion rate and concentration of suspension in transarterial particulate embolization.

RATIONALE AND OBJECTIVES: The authors evaluate the embolic effect according to infusion rate and concentration of particulate suspension, focusing on arterial occlusion level. METHODS: The renal arteries of 14 rabbits were embolized with 150 to 250 microns polyvinyl alcohol (PVA) particles, divided into four groups according to two different infusion rates (1 mg/second and 0.1 mg/second) and two different concentrations of suspension (10 mg/mL and 2.5 mg/mL). Arteriograms obtained immediately and a week after embolization were assessed for occlusion level. For the nephrograms obtained a week after embolization, the opacifying areas were graded from 0 to 4. Median coronal sections of each kidney specimen were investigated for the presence of peripheral infarct grossly and for the presence of PVA particles in the small artery microscopically. RESULTS: Arteriograms showed various occlusion levels. Using a 0 to 4 grading system, the opacifying area of the nephrogram obtained 1 week after embolization was noted to be smaller in the low infusion rate group (P < 0.05). In gross and microscopic pathologic examination, the number of cases with peripheral infarct or PVA particles in the small artery (< 300 microns) was greater in the group with the low infusion rate and low concentration (P < 0.05). CONCLUSIONS: In transarterial particulate embolization, slower infusion of more diluted suspension provides for a more distal arterial occlusion.

Postoperative adjuvant therapy for stage II non-small-cell lung cancer.

BACKGROUND: Stage II non-small-cell lung cancer is regarded as one of the early lung cancers. Although resection, including the mediastinal lymph nodes, is currently regarded as the standard treatment, the survival rate of this disease is not encouraging. It is well known that the most common causes of death are locoregional recurrences or distant metastases, or both. However, the best adjuvant treatment to improve survival is as controversial an issue as ever. METHODS: This study was designed as a randomized, blinded, two-armed study with operation and adjuvant radiotherapy in one arm, versus operation and adjuvant mitomycin C (10 mg/m2), vinblastine (6 mg/m2), and cisplatin (100 mg/m2) (MVP) chemotherapy in the other arm. We assigned 57 resected patients with pathologic proven stage II non-small cell lung cancer to the groups according to our eligibility criteria. RESULTS: The most common pattern of recurrence was distant metastases, and nearly all the recurrences (17 of 18 patients) in both groups were found within 2 years after operation. The rates of the locoregional and distant metastases were 3.6% and 46.4% in the adjuvant radiotherapy group and 6.9% and 10.3% in the adjuvant chemotherapy group (p = 0.018). The 5-year disease-free survival rates were 52.0% in the adjuvant radiotherapy group and 74.0% in the adjuvant chemotherapy group (p = 0.16, log-rank test). The 2-year, 5-year, and 6-year survival portions were 60.3%, 56.5%, and 28.3% in the adjuvant radiotherapy group, and 82.8%, 70.1%, and 60.1% in the adjuvant chemotherapy group (p = 0.01, p = 0.17, and p = 0.03, Z-test). The difference of the actuarial survival between these two groups was somewhat significant (p = 0.09, log-rank test). CONCLUSIONS: Our results suggest that the addition of adjuvant MVP chemotherapy may reduce the distant metastasis rates and prolong the survival of the surgically resected stage II non-small-cell lung cancer patients.

Sonographic findings of the neopharynx after total laryngectomy: comparison with CT.

BACKGROUND AND PURPOSE: To our knowledge, sonographic findings in the neopharynx have not been well characterized. We describe our results and assess the role of sonography versus CT in patients who have undergone total laryngectomy. METHODS: We examined 25 patients (24 men and one woman; 44-78 years old) who had had a total laryngectomy. Sonography (with a 10-MHz transducer) and contrast-enhanced CT were performed in all patients. We evaluated the normal shape of the neopharynx and assessed the accuracy of sonography versus CT in detecting tumor recurrence in the neck. RESULTS: The neopharynx appears as a round or ovoid structure on imaging studies. On sonograms, the neopharyngeal wall has five layers of alternating echogenicity: an innermost hyperechoic layer of superficial mucosa, an inner hypoechoic layer of deep mucosa, a middle hyperechoic layer of submucosa, an outer hypoechoic layer of muscle, and an outermost hyperechoic layer of adventitia. On CT scans, the neopharynx appears as a three-layered structure, with an inner hyperdense layer of mucosa, a middle hypodense layer of submucosa, and an outer isodense layer of pharyngeal constrictor muscles. Nine pathologically proved recurrences were found: three local recurrences, one local recurrence with lymph node metastasis, and five cases of lymph node metastasis only. One instance of false-negative lymph node metastasis was seen at sonography and one case of false-positive local recurrence was seen at CT. CONCLUSION: The neopharynx has a unique sonographic appearance, and this imaging technique is useful for detecting local tumor recurrence in the neopharynx in patients who have had a total laryngectomy.

Rhabdomyosarcoma of the head and neck in adults: MR and CT findings.

PURPOSE: To evaluate imaging findings of rhabdomyosarcoma of the head and neck in adults. METHODS: We examined 11 patients (seven men and four women; 17 to 73 years old) with pathologically proved rhabdomyosarcoma of the head and neck. The tumors originated in the paranasal sinuses (n = 6), cheek (n = 3), nasal cavity (n = 1), and infratemporal fossa (n = 1). Eight of the rhabdomyosarcomas were of the embryonal type, two were pleomorphic, and one was alveolar. Necrosis was seen in four patients, but calcification or intratumoral hemorrhage was not found. Two tumors had nodal extension. Contrast-enhanced CT was performed in 10 patients, and two patients had contrast-enhanced MR imaging. RESULTS: On CT scans, the masses enhanced to the same degree as adjacent muscle. The masses showed a homogeneous pattern in six cases and a heterogeneous pattern in four cases. The tumor margins were poorly defined in eight cases. On MR images, the masses were homogeneously isointense with muscle on T1-weighted studies and were hyperintense relative to muscle on T2-weighted studies. On both CT and MR images, 10 of 11 cases showed poorly defined, homogeneous masses destroying adjacent bony structures. CONCLUSIONS: MR imaging seems to be better than CT for initial and follow-up examination of patients with rhabdomyosarcoma because of its multiplanar capability and because it more precisely defines the extent of tumor.

Postpneumonectomy empyema. CT findings in six patients.

Chest radiographs and CT scans, obtained in six patients with proven postpneumonectomy empyema, were retrospectively reviewed by comparing the radiologic image obtained at present with that obtained before symptom onset. Convexity or straightening of the concave mediastinal margin of the postpneumonectomy space was identified on CT scans in all of six patients (100%), while contralateral mediastinal shift was noted on both radiographs and CT scans in four patients (67%). Multiple air-fluid levels appeared equally on radiographs and CT scans in three patients (50%). CT depicted increased thickening of the parietal pleura (n=5, 83%) and the extrapleural tissues (n=3, 50%) and empyema necessitans (n=2, 33%), which were not apparent on radiographs. Postpneumonectomy empyema is characterized on CT scans by reversal of the normal concavity of the mediastinal margin with increased thickening of the residual parietal pleura. CT is superior to radiography in assessing the manifestations of postpneumonectomy empyema.

Metallic stents in malignant biliary obstruction: prospective long-term clinical results.

OBJECTIVE: The purpose of this prospective study was to evaluate the long-term clinical efficacy of metallic stents when used as the initial palliative treatment of patients with inoperable malignant biliary obstruction. SUBJECTS AND METHODS: From August 1991 through May 1995, 100 consecutive patients with malignant biliary obstruction were treated with percutaneous placement of metallic stents. The causes of obstruction were bile duct carcinoma (n = 50), pancreatic carcinoma (n = 17), gallbladder carcinoma (n = 6), hepatocellular carcinoma (n = 2), and metastatic lymphadenopathy in the hepatoduodenal ligament (n = 25). We used 123 stents: 64 Gianturco Z stents, 39 Hanaro spiral stents, 16 Wallstents, two tantalum Strecker stents, one Endocoil stent, and one Memotherm nitinol stent. Every 3 months we followed up all patients except those who died. The average length of follow-up was 220 days (range, 4-1125 days). Patient survival and stent patency rates were estimated by life-table analysis. RESULTS: The median length of survival for the entire patient group was 246 days: 25-week and 50-week survival rates were 62% and 25%, respectively. We found no statistically significant difference in the median length of survival between patients with hilar obstruction (256 days) and patients with common bile duct (CBD) obstruction (227 days). Patients with bile duct carcinoma had longer median survival (269 days) than did patients with other conditions (197 days). The overall median length of patency for all stents was 360 days; the 25-week and 50-week patency rates were 81% and 53%, respectively. The stent patency rate at the median length of survival was 71%. The median length of stent patency in patients with hilar obstruction (617 days) was nearly double that of patients with CBD obstruction (324 days). However, the median length of stent patency in patients with bile duct carcinoma showed no statistically significant difference from the median length in patients with other disease. Four patients (4%) died within 1 month after stent placement. Twenty-one patients (21%) developed recurrent jaundice or cholangitis. In order of frequency, the causes of recurrent jaundice were tumor overgrowth, incrustation of bile sludge, duodenal obstruction due to tumor invasion, stent impaction into the bile duct wall, stent malposition, and tumor ingrowth. CONCLUSION: Metallic stents showed a favorable patency rate with regard to patient survival. In patients with hilar obstruction, the clinical efficacy of metallic stents was superior to that in patients with CBD obstruction. We believe that placement of metallic stents is the procedure of choice for palliation of malignant biliary obstruction.

Device for occlusion of rectovaginal fistula: clinical trials.

PURPOSE: To evaluate a device designed for occlusion of rectovaginal fistula in patients with acquired rectovaginal fistula. MATERIALS AND METHODS: The device consisted of a disk portion, an anchoring portion, and a shaft that connected each portion. The device was framed with a nitinol wire. The disk portion was framed in a four-leaf clover configuration, and the anchoring portion had two ellipsoid arms. The disk and anchoring portions were mounted with a nylon patch and coated with silicone. The device was designed for transrectal insertion and was placed in seven women with rectovaginal fistula caused by pelvic irradiation or pelvic surgery. RESULTS: All devices were placed successfully, and all fistulas were completely occluded after placement of the device. No procedural complications were encountered. The follow-up period was 1-26 months. One patient died of distant metastasis 5 months after placement of the device. None of the patients reported leakage from the rectovaginal fistula during the follow-up period. CONCLUSION: The occlusion device may be promising and beneficial for use in occlusion of rectovaginal fistula that results from pelvic irradiation or pelvic surgery.

Obliteration of the pulmonary vein in lung cancer: significance in assessing local extent with CT.

PURPOSE: The purpose of this study was to evaluate the significance of obliteration of the pulmonary vein in assessing local extent of lung cancer with CT, particularly in regard to intrapericardial extension of tumor through the vein. METHOD: Preoperative CT scans of 325 patients, who underwent thoracotomy for primary lung cancer, were reviewed. Among them, CT scans of 19 patients showed obliteration of the pulmonary vein up to its entrance into the left atrium, without filling defect in the left atrium. Surgical records of these patients were then reviewed to investigate the extent of tumor growth through the pulmonary vein, with particular emphasis on intrapericardial extension. RESULTS: The surgical records revealed extension of tumor through the pulmonary vein beyond the pericardial reflection in 14 or 19 patients. In 10 patients showing obliteration of either the left of the right superior pulmonary vein, all tumors extended beyond the pericardial reflection (100%). Intrapericardial extension occurred in four of nine patients showing obliteration of either the left or the right inferior pulmonary vein (44%). The difference was statistically significant (p < 0.05). CONCLUSION: When assessing local extent of lung cancer with CT, obliteration of the superior pulmonary vein is a highly suggestive finding for intrapericardial extension of tumor through the pulmonary vein. On the contrary, obliteration of the inferior pulmonary vein is believed to be a less reliable finding for intrapericardial extension of lung cancer.