Computed tomography-guided coil injection and thoracoscopic pulmonary resection under roentgenographic fluoroscopy.

To remove a small, chest roentgenogram-negative, computed tomogram-positive nodule, we developed a novel technique of thoracoscopic pulmonary resection. This technique consists of the computed tomography-guided coil injection of a metallic coil and subsequent thoracoscopic resection under roentgenographic fluoroscopy. During the thoracoscopic resection, the fluoroscopic image was a valuable aid in determining the location of the nodule and in ensuring that the stapler was applied with a sufficient distance from the coil. Because this technique helps to determine the exact location of the nodule regardless of its depth from the pleural surface, even a minithoracotomy for direct palpation can be avoided.

Case report: hepatocellular carcinoma diagnosed radiologically, treated by transcatheter arterial embolization and limited-field radiotherapy.

Even though the resection rate for hepatocellular carcinoma (HCC) has risen recently, many patients cannot be treated surgically because of the advanced stage of the tumour and/or coexisting cirrhosis. An alternative therapeutic approach for some of these patients is transcatheter arterial embolization (TAE) which has become very common in Japan. However, it is not a curative measure, and an additional therapy is required to eradicate the residual disease. In this communication, we report a case in which a patient with HCC has been successfully treated by TAE followed by limited-field radiotherapy. The results suggest that this is a very promising therapeutic approach for HCC and that the potential of limited-field radiotherapy for HCC with or without TAE also needs to be explored.

Japanese experience of telemedicine in oncology.

We started telemedicine projects from 1990 with a telepathology system within Tsukiji Campus of National Cancer Center. In 1994, we connected Tsukiji Campus and Kashiwa Campus by 6 Mbps optical fiber leased line using IP protocol for data transmission, for teleconference, telepathology, and teleradiology projects. We also started connection of regional cancer centers and are now forming a cancer center network of 14 cancer centers. We are at present organizing 130 teleconferences per year with an attendance of more than 16000 people as summary. We have also used a high-resolution image transferring system, such as SHD (2000 pixelsx2000 pixels resolution) system on one side, and an economical telemedicine system using JAVA and a WWW browser (NCC_image) on the other side. We think that providing information is another field of telemedicine. We began the experimental gopher and WWW service in 1993. We are now providing official up-to-date cancer information for patients and healthcare professionals. We are getting more than 400000 hits per month. We are also providing a teleconference video session which is held every week on the Internet using a Real Video system with synchronized slide presentation on the WWW browser. We are also organizing a Cancer Image Reference Database System including DICOM images with viewer software. This paper is a summary of the telemedicine projects performed at the National Cancer Center.

The clinical advantages of editable real-time volume rendering in a medical virtual environment: VolMed.

Segmentation for a medical virtual environment is a process of image diagnosis. It should be performed by clinical doctors, otherwise the data may be meaningless for using clinical purposes. At the National Cancer Center, in Japan, we have recently developed interactive, editable real-time volume rendering software (VolMed), based on Volren-6 software, with the ability to interactively edit the 3D images of a patient's virtual cancer and virtual organs, in a virtual environment. Doctors can see proposed solutions to clinical problems as 3D images, using real-time volume rendering. We conclude that interactive editing is very important for clinical use, and also decreases the time required to create the virtual cancer images used for surgical simulation, pre-surgical planning and 3D invasion diagnoses.

Virtual reality support system in palliative medicine.

We have been examining the potential value of a VR system for the palliative care of cancer. We recently developed palliative care system which consists of a 100-inch-wide screen, HMD (Head-mounted display) and 8-mm video or a PC. Our goal is to use VR techniques to help alleviate a patient's stress and concern regarding their cancer during hospitalization. We can use this system to present (1) personal video movies, (2) video letters from friends and family, (3) personal video instruction about medical examinations, and (4) interactive information about their cancer using a PC-based VR system. Our preliminary results indicate that interesting VR presentations are useful for reducing stress.

Virtual reality enhanced surgical conference system.

We present our ongoing work on an enhanced surgical conference system with a technology of virtual reality (VR). We reported on a surgical simulation support system by using a technology of virtual reality last year. In the present time, while using our VR simulation system, we realized that many surgeons and nurses needed to see both a solid real image and a virtual image of the surgical operation at the same time. According to this reason we added a solid video system to our previous VR simulation system. The new system can display both real and virtual images on 100 inch wide screen and a console monitor of Onyx computer. The doctors can see both images with shutter glasses on the screen or console. We can now simulate various cancer surgery while watching the real solid surgical picture. We expect our enhanced surgical conference system to be beneficial for surgeons and nurses with limited experience to familiarize surgical procedures. The system could be also employed in planning a surgical procedure and educating medical staffs. Here we discuss about the aim of the system, current implementation, its limitations and its future directions.

Stereoscopic visualization system for clinical angiography.

Four dimensional visualization (FDV) project for clinical angiography has started at National Cancer-Center since 1995 in cooperation with medical virtual reality projects in our center. All stereo pair of x-ray angiographic images, both digital images and film based conventional x-ray images, are available in this system. FDV system software was developed on a Silicon Graphics platform. Every stereo pair angiographic images can be viewed stereoscopically using a stereoscopic visualization interface. Series of image data sets provide three dimensional blood flow dynamics that is very useful to diagnose vascular encasement by the tumor and to determine vessel of purpose which locates in front or in back from superimposed angiographic images. FDV system is expected to improve the accuracy and efficiency of diagnostic radiology and interventional radiology (IVR) procedures. In future, angiography system will equipped with a stereoscopic visualization interface that will provide a more flexible and more effective guidance tool for diagnostic radiology, especially for IVR that requires image-guided procedure.

Virtual cancer image data warehouse.

We previously developed a system with which we have created more than 100 virtual cancer images from CT or MR data of individual patients with cancer (Cancer Edutainment Virtual Reality Theater: CEVRT). These images can be used to help explain procedures, findings, etc. to the patient, to obtain informed consent, to simulate surgery, and to estimate cancer invasion to surrounding organs. We recently developed a web-based object-oriented database both to access these cancer images and to register medical images at international research sites via the Internet. In this report, we introduce an international medical VR data warehouse created using an object-oriented database.

[Cancer therapy and processing information].

The National Cancer Center Japan started to provide free, computer-based cancer information, through a service called the National Cancer Center--Cancer Information Service (NCC-CIS), to patients and their families, physicians and other health professionals via fax (telephone) and the Internet in 1996. NCC-CIS in Japanese is modeled on the Physician Data Query service produced by the National Cancer Institute in the United States and is produced from an independent standpoint adopted to the medical and social environment in Japan. NCC-CIS provides up-to-date cancer treatment information (staging, prognosis and state-of-the-art treatment by stage of disease), supportive care for each type of cancer, an image reference database, and a directory of organizations and lecture meeting reports in Japan in order to facilitate better understanding of cancer among people and support the decision-making process for physicians in order to achieve a reduction in cancer deaths.

Detection of hepatocellular carcinoma: comparison of CT during arterial portography with CT after intraarterial injection of iodized oil.

Fourteen patients with hepatocellular carcinoma (HCC) were examined with computed tomography (CT) during arterial portography (CTAP) and with CT after intraarterial injection of iodized oil. The detectability of main lesions and associated daughter nodules or intrahepatic metastases was assessed. Hepatic resection was subsequently performed in all 14 patients. The results of the imaging studies were compared with the surgical and pathologic findings by means of a lesion-by-lesion analysis. A total of 34 masses were identified in the resected specimens: 18 main tumor masses and 16 intrahepatic metastases. For CTAP, the detection rate of main tumors was 94%; for iodized-oil CT, 82%. However, the daughter-nodule detection rates for both techniques were poor-only 38% detected for CTAP and 50% for iodized-oil CT. Although these two techniques remain important preoperative imaging methods in patients with HCC, the results of this study suggest that small daughter nodules (less than 5 mm in diameter) may go undetected with both techniques.

Alveolar architecture of clear cell renal carcinomas (< or = 5.0 cm) show high attenuation on dynamic CT scanning.

BACKGROUND: To establish the correlation between tumor appearance on CT and tumor histology in renal cell carcinomas. METHODS: The density and attenuation patterns of 96 renal cell carcinomas, each < or = 5 cm in greatest diameter, were studied by non-enhanced CT and early and late after bolus injection of contrast medium using dynamic CT. The density and attenuation patterns and pathological maps of each tumor were individually correlated. RESULTS: High attenuated areas were present in 72 of the 96 tumors on early enhanced dynamic CT scanning. All 72 high attenuated areas were of the clear cell renal cell carcinoma and had alveolar architecture. The remaining 24 tumors that did not demonstrate high attenuated foci on early enhanced scanning included three clear cell, nine granular cell, six papillary, five chromophobe and one collecting duct type. With respect to tumor architecture, all clear cell tumors of alveolar architecture demonstrated high attenuation on early enhanced scanning. CONCLUSION: Clear cell renal cell carcinomas of alveolar architecture show high attenuation on early enhanced dynamic CT scanning. A larger number of patients are indispensable to obtaining clear results. However, these findings seem to be an important clue to the diagnosis of renal cell carcinomas as having an alveolar structure.

Helical computed tomography scanning of the thorax and abdomen.

We applied helical CT to examinations of the abdomen and thorax. Scanning was performed continuously while the couchtop of the CT scanner was shifted at a constant speed. The entire lung field could be scanned during a single holding of the breath when the couchtop speed was 20 mm/s. Tumors as small as 3 mm were detected. The diagnostic detectability and accuracy of helical CT were far superior to those of conventional chest radiography. During abdominal examination, the target organ could be scanned at any specified phase (preferably arterial) during the injection of contrast medium. We detected very small hepatic tumors which could not be detected by conventional CT. Helical CT produced continuous data, which was reconstructed to display three-dimensional images. Helical CT could be used in mass screening for the detection of early lung cancer and in computer-aided diagnosis.

Findings in primary hepatic carcinoid tumor: US, CT, MRI, and angiography.

Two asymptomatic patients with surgically proven solitary primary hepatic carcinoid tumors are reported. Ultrasonography showed hyperechoic masses containing multiple small cystic areas in both cases. On unenhanced CT, one tumor was of low density and one was isodense with multiple low density foci. One tumor showed marked retention of contrast medium on post-angiographic CT. Magnetic resonance imaging revealed low intensity masses on T1-weighted images and high intensity tumors with multiple areas of higher intensity on T2-weighted imaging. The small low density areas in these masses corresponded histopathologically to multiple vascular lakes. Late enhancement of the mass was presumed to correspond with proliferative fibrous tissue within the mass.

Radiological study of idiopathic Budd-Chiari syndrome complicated by hepatocellular carcinoma. A report of four cases.

During an 11-yr period (1979-1989), we have experienced five patients with idiopathic Budd-Chiari syndrome (BCS), four (80%) of whom had associated hepatocellular carcinoma (HCC). In contrast, the incidence of BCS complicated by HCC was 0.7% of a total of 556 patients who underwent surgery for HCC or were autopsied. Hepatitis B virus-related antigen or antibody was positive in one patient each. Four of our five patients were asymptomatic and were initially diagnosed by ultrasonography (n = 3) or computed tomography (n = 1). The hepatic parenchyma histopathological findings were cirrhosis and fibrosis in one each. Infection of hepatitis B virus rather than BCS was speculated as a causative factor for HCC in two patients. Membranous obstruction with spotty calcification, intrahepatic bizarre communicating vessels, and the dilated anterior longitudinal veins in spinal canal were recognized in three patients. Three patients had two HCCs which were similar in size and arose from the right and left hepatic lobe, separately, suggesting multicentricity of HCC. Both percutaneous transluminal angioplasty with Gruntzig balloon catheters for the obstruction of the inferior vena cava and hepatic arterial embolization for HCC(s) were performed in three patients. These patients survived 29.3 months on average after the diagnosis of BCS complicated by HCC(s). The opened IVC was confirmed to be patent on an average of 26.3 months after the first angioplasty.

[Clinical application of helical scanning CT of upper abdomen].

The helical scanning CT unit, in which an X-ray tube continuously rotates at the rate of one revolution per second with constant movement of the table on which the patient is placed, was clinically tested in scanning of upper abdomen. Quality of the images obtained was equal to that of conventional CT. The images were particularly good at an X-ray beam width of 5 mm and table movement of 5 mm/sec with scan parameters of 120 kvp, 200 mA. Because of limitation of the X-ray tube capacity. X-ray beam width of 5 mm and table movement of 10 mm/sec with scan parameters of 120 kvp, 150 m, would be the most appropriate clinically. Application of the helical scanning CT will result in examination times shorter than in the case of conventional high-resolution CT and be obtained images at early vascular enhancement phase through the whole scanning area, so that it can be expected to be extremely useful in clinical diagnosis involving upper abdomen.

Telecytology in Hokkaido Island, Japan: results of primary telecytodiagnosis of routine cases.

In 1997, an Internet-based static image telepathology system was built at Sapporo National Hospital, Japan. We can exchange high-resolution microscopical images through a file transfer protocol server and discuss cytological findings and diagnosis on an electronic mailing list. We applied the system to primary telecytodiagnosis. From May 1997 to April 1999 we have made diagnoses of 614 daily cases only by looking at the video monitor images transmitted from the cytotechnologist of Wakkanai Municipal Hospital 300 km distant from Sapporo. The concordance between telecytodiagnosis and glass slide diagnosis was 88.6%. Kappa statistics for cervical smears was 0.919 and that for specimens other than uterine cervix was 0.810. The accuracy of telecytodiagnosis was 91.4%, and was not substantially different from that of the conventional mail-based cytology in a previous year. We had five cases with a severely inappropriate diagnosis in telecytology, all of which however were quickly corrected by follow-up histological or cytological specimens. With the use of an electronic mailing list the participants had quick and sufficient discussions. We conclude that telecytology is very useful for primary cytodiagnosis in regional medicine and that it may raise the accuracy of cytodiagnosis in future, if we make consistent efforts to reflect the benefits of telecytology in daily practices. This is the first report of clinical results of telecytology from Japan.

Early hepatocellular carcinoma: appearance at CT during arterial portography and CT arteriography with pathologic correlation.

PURPOSE: To use computed tomography (CT) during arterial portography (CTAP) and CT arteriography to compare the hemodynamic properties of early hepatocellular carcinoma (HCC) with those of small HCC. MATERIALS AND METHODS: Forty-four early HCCs (mean diameter, 1.5 cm) in 37 patients (26 men and 11 women aged 52-74 years; mean age, 59.2 years) were studied. CTAP was performed on 35 early HCCs, CT arteriography on 20, and both studies on 11. CTAP, CT arteriography, or both were performed on 90 small HCCs (mean diameter, 2.0 cm) in 57 patients (44 men and 13 women aged 48-71 years; mean age, 61 years). The findings for small HCC were compared with those for early HCC. RESULTS: CTAP depicted 23 early HCCs as hypoattenuating masses and 12 as isoattenuating. CT arteriography depicted 11 early HCCs as hypoattenuating masses, six as isoattenuating, and three as hyperattenuating. CTAP depicted 85 of 88 small HCCs as hypoattenuating masses and three as isoattenuating. CT arteriography depicted 13 of 14 small HCCs as hyperattenuating masses. CONCLUSION: CTAP, the standard of reference for the detection of small HCC, is not sensitive enough for the detection of early HCC.

Combined hepatocellular carcinoma and cholangiocarcinoma: clinical features and computed tomographic findings.

Clinicoradiological features were studied in 20 patients with 22 mass lesions of combined hepatocellular carcinoma and cholangiocarcinomas and findings of computed tomography in 12 of these patients with 14 hepatocellular carcinoma-cholangiocarcinomas. Five of these patients also had single overt hepatocellular carcinomas. The incidence of hepatocellular carcinoma-cholangiocarcinoma was 3.3% among the patients with primary liver cancer treated in our hospital. HBsAg was present in 25%, and increased levels of serum alpha-fetoprotein (> 200 ng/ml) and carcinoembryonic antigen (> 5 ng/ml) were found in 25% and in 47%, respectively. Associated cirrhosis was present in 60%. Analysis of 14 hepatocellular carcinoma-cholangiocarcinomas in 12 patients in whom the enhancement pattern on dynamic computed tomography and pathological findings could be studied and compared suggested three tumor types. Nine lesions (type A) were demonstrated only as areas with high-density peripheries in the early phase of enhancement that evolved into a pattern of peripheral low density and central high density in the late phase. Four masses (type B) were shown as hyperdense tumors (early phase) that changed to low density in the late phase. One mass (type C) was seen as a low-density lesion that did not change. Histopathologically, type A comprised hepatocellular carcinoma-predominant components in the peripheral area, cholangiocarcinoma-predominant components with abundant fibrous stroma in the central area and a tissue transitional between the two in the midzone. By contrast, two of four type B masses comprised hepatocellular carcinoma with scattered cholangiocarcinoma components throughout the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)