Superselective intra-arterial infusion chemotherapy for stage III/IV squamous cell carcinomas of the oral cavity: midterm results.

PURPOSE: We performed superselective intra-arterial infusion chemotherapy (SIC) according to a protocol in which drug distribution is evaluated by the use of interventional radiology (IVR)-computed tomography (CT) system, and the chemotherapy is combined with medium-dose conformal radiation therapy (CRT). We analyzed retrospectively the factors that affect the midterm survival ratio, including local response, for stage III and IV squamous cell carcinomas of the oral cavity. MATERIALS AND METHODS: Forty consecutive patients with stage III and IV squamous cell carcinomas of the oral cavity and who had undergone both SIC and CRT were enrolled. A microcatheter was placed in the appropriate feeding artery of the tumor and cisplatin (50mg/body) was infused twice. CRT was administered with a dual-energy (4 and 10 MV) linear accelerator. The total and daily doses delivered were 30 and 2.0 Gy, respectively. Histopathologic effects were classified into five grades: grade 0 or 1 was defined as a poor response, and grade II or higher as a good response. Age, sex, stage, local response to treatment, mode of invasion and lymph node metastasis were analyzed, and differences in the midterm survival ratio were assessed. RESULTS: The 3-year survival ratio of the 40 cases was 67%. A good local response (III or IV) was achieved in 75% of the cases. The survival ratio of the good local response group was significantly better than that of the poor response group (p=0.04). Mode of invasion (p=0.03) and lymph node metastasis (p=0.01) were also predictive of survival. In the multivariable analysis of survival, however, no variables including good local response (p=0.12), were predictive. CONCLUSION: Our new protocol improved local response, but it did not contribute to the survival ratio.

Superselective arterial infusion chemotherapy for squamous cell carcinomas of the oral cavity: histopathologic effects on metastatic neck lymph nodes.

We have performed superselective intra-arterial infusion chemotherapy (SIC) on carcinomas of the oral cavity according to a protocol in which the distribution of the drug was evaluated by the use of a combined CT and angiography system, and the chemotherapy was combined with medium-dose conformal radiation therapy (CRT). The purpose of this study was to evaluate the pathological effect of this treatment on the metastatic neck lymph nodes (LNs). Twenty consecutive patients who had metastatic neck LNs from squamous cell carcinomas of the mouth and who underwent both SIC and CRT were included in this study, in which a total of 22 LNs were evaluated. A microcatheter was placed in the appropriate feeding artery of the tumor, such as the internal maxillary artery, facial artery, lingual artery and external carotid artery (ECA), and cisplatin (50 mg/body) was infused twice through a microcatheter. The CRT was administered with a dual-energy (4 and 10 MV) linear accelerator. The total and daily doses delivered were 30 and 2.0 Gy, respectively. Intra-arterial infusion to the LNs was divided into two groups: superselective infusion (mainly to the submandibular LNs via the facial artery, n = 10) and nonsuperselective infusion via the ECA (n = 12). The distribution of cisplatin into the LNs was confirmed by slow-infusion CT. Histopathologic effects on the LNs were evaluated on the specimens obtained during the operation and classified into five grades (0: no or minimal response: I: disappearance of less than three quarters of the tumor cells: II: disappearance of more than three quarters of the tumor cells: III: disappearance of viable tumor cells with a small amount of residual nonviable tumor cells: IV: complete disappearance of all viable and nonviable tumor cells). Grade 0 or 1 was defined as poor response and Grade II or more as good response. Twenty-three LNs from nine patients without CRT and SIC were served as control. In the superselective infusion group, all 10 LNs showed good response (response rate, 100%: grade II = 4, grade III = 3, grade IV = 3). In the non-superselective group, however, 6 of 12 LNs showed poor response (response rate, 50%: grade 0 = 2, grade I = 4, grade II = 2, grade III = 2, grade IV = 2). All 23 control LNs with no treatment showed grade 0 response. Superselective infusion seems necessary to obtain good histopathologic effects on the metastatic LNs. SIC combined with CRT can be applied to the metastatic LNs.

Diffusion-weighted imaging of metastatic brain tumors: comparison with histologic type and tumor cellularity.

BACKGROUND AND PURPOSE: On diffusion-weighted imaging (DWI), metastatic tumors of the brain may exhibit different signal intensities (SI) depending on their histology and cellularity. The purpose of our study was to verify the hypotheses (1) that SI on DWI predict the histology of metastases and (2) that apparent diffusion coefficient (ADC) values reflect tumor cellularity. MATERIALS AND METHODS: We assessed conventional MR images, DWI, and ADC maps of 26 metastatic brain lesions from 26 patients, 13 of whom underwent surgery after the MR examination. Two radiologists performed qualitative assessment by consensus of the SI on DWI in areas corresponding to their enhancing portions. We measured the contrast-to-noise ratio (CNR) on T2-weighted images and normalized ADC (nADC) values, and compared them with tumor cellularity. RESULTS: The mean SI on DWI and the CNR on T2-weighted images were significantly lower in well differentiated than in poorly differentiated adenocarcinomas and lesions other than adenocarcinoma. The mean nADC value was significantly higher in well differentiated than poorly differentiated adenocarcinomas and lesions other than adenocarcinoma. All 3 small-cell carcinomas and 1 large-cell neuroendocrine carcinoma exhibited high SI on DWI. The nADC value showed a significant inverse correlation with tumor cellularity. There was no significant correlation between the CNR and tumor cellularity. CONCLUSION: The SI on DWI may predict the histology of metastases; well differentiated adenocarcinomas tended to be hypointense, and small- and large-cell neuroendocrine carcinomas showed hyperintensity. Their ADC values reflect tumor cellularity.

Evaluation of drainage patterns of the major anastomotic veins on the lateral surface of the cerebrum using three-dimensional contrast-enhanced MP-RAGE sequence.

BACKGROUND AND PURPOSE: Three-dimensional (3D) contrast-enhanced magnetization-prepared rapid gradient-echo (MP-RAGE) sequence has been reported useful for evaluation of the intracranial venous structures. The purpose of this study is to assess the patterns of the major anastomotic veins on the lateral surface of the cerebrum using MP-RAGE sequence. METHODS: MP-RAGE images in consecutive 100 patients (200 sides) were reviewed by two neuroradiologists in consensus to evaluate drainage patterns of the superficial middle cerebral vein (SMCV), the vein of Labbe, and the Trolard vein. RESULTS: MP-RAGE images clearly depicted the major anastomotic veins and their draining vessel. The dominant vein was the Trolard vein in 12%, the vein of Labbe in 36%, SMCV in 38%, and all three veins in 14%. The vein of Labbe was entered the transverse sinus in 80% and superior petrosal sinus in 4%. Undeveloped type of the vein of Labbe was seen in 16%. The SMCVs were entered the sphenoparietal sinus in 57%, the cavernous sinus in 19%, and the emissary vein in 5%. Basal type of the SMCVs was seen in 3% and undeveloped type in 16%. It was difficult to differentiate the Trolard vein from other cortical veins, if it was not dominant. In the most cases with the dominant Trolard vein, it located at the level of the post central vein. CONCLUSION: With MP-RAGE sequence, it is easy to identify the variation of the major anastomotic veins. Such information may be helpful to reduce the risk of damage on these important veins at surgery.

MR imaging of Tornwaldt's cysts.

OBJECTIVE: The purpose of this study was to assess the characteristics of Tornwaldt's cysts as revealed by routine MR studies. MATERIALS AND METHODS: We retrospectively reviewed MR images of the brain in 1208 consecutive subjects who ranged in age from 3 weeks to 93 years (mean, 57.1 years). The signal intensity, shape, and size of Tornwaldt's cysts were assessed. Patients with Tornwaldt's cysts were then questioned about the presence of persistent nasal discharge, occipital headaches, and halitosis and an unpleasant taste in the mouth and about a history of adenoidectomy. RESULTS: Tornwaldt's cysts were found in 23 patients (1.9%) who ranged in age from 39 to 78 years (mean, 57.3 years). Of the 23 Tornwaldt's cysts, all were isointense to CSF on T2-weighted images and hyperintense to gray matter on the fluid-attenuated inversion-recovery images. The cysts showed high signal intensity compared with muscle on T1-weighted images. Nineteen cysts were round and four were oval. The mean size of the lesions was 6.0 mm in the major axis and 5.5 mm in the minor axis. Two patients with Tornwaldt's cysts had persistent nasal discharge and occipital headaches, and another patient had occipital headaches alone. None of the patients had undergone an adenoidectomy. CONCLUSION: Lesions consistent with Tornwaldt's cysts were found in 1.9% of the routine MR studies of the brain. The cysts had high signal intensity on T1-weighted, T2-weighted, and fluid-attenuated inversion-recovery images.

Current concepts of instep island flap.

The durability of the instep island flap and the sequelae of the flap donor site were assessed. The average follow-up period for 13 patients was 3 years and 8 months. Flaps provided permanent durable reconstruction of the heel, if there was no scar in the flap preoperatively. Flaps with scar or free skin graft showed hyperkeratosis or fissure of the flap after transfer to the heel. Accordingly, conservative treatment, special shoes, or other surgical procedures should be considered for these patients. All flaps that were transferred as sensory flaps preserved light-touch cutaneous sensitivity and static 2-point discrimination within a measurable range. The sequelae due to the flap elevation were tenderness in the bifurcation of superficial branches from the common digital nerves and sensory disturbance of the forefoot. Indications and surgical techniques are discussed.