Analysis of fistula formation of T4 esophageal cancer patients treated by chemoradiotherapy.

BACKGROUND AND AIM: Fistula is one of the known complications of T4 esophageal cancer (T4-EC). The standard treatment for T4-EC is chemoradiotherapy, but detailed data about fistula resulting from chemoradiotherapy in this condition are limited. In particular, radiographic findings of T4-EC with fistula have not been reported. This study assessed the risk factors of fistula based on clinical information on patients with chemoradiotherapy for T4-EC. METHODS: We retrospectively reviewed the clinical data of 59 T4-EC patients who had squamous cell carcinoma without any fistula before receiving definitive or palliative chemoradiotherapy. RESULTS: A fistula was observed in 18 patients (31%) throughout their clinical course. The overall survival in the fistula group was significantly shorter than that in the non-fistula group (259 vs. 346 days; p = 0.0341). The axial tumor size on computed tomography (CT) was confirmed as an independent risk factor for esophageal fistula in multivariate analysis of stepwise methods [OR 1.226; 95% CI 1.109-1.411; p < 0.0001]. Twelve out of 14 patients with an axial tumor size of 50 mm or greater had developed a fistula. CONCLUSIONS: A large tumor size on the axial plane on CT is a risk factor for fistula formation.

Analysis of the posterior ramus of the lumbar spinal nerve: the structure of the posterior ramus of the spinal nerve.

BACKGROUND: Knowledge of neural anatomy is fundamental for safe, efficacious use of regional anesthesia. Spinal column procedures, such as a facet joint block, require an accurate understanding of neural pathways relative to anatomic structure. Since Bogduk's report it has been known that human lumbar posterior ramus of the spinal nerve (PRSN) comprises three, equally sized primary branches. However, inconsistencies and controversy remain over the exact locations and pathways of the peripheral portions of the PRSN branches. In this study, the authors investigated the detailed anatomy of the human PRSN. METHODS: The authors performed ventral dissection in seven cadavers to determine the layout of the PRSN between T10 and L4 spinal segments. They captured three-dimensional images with a laser scanner. For fine detail analysis, specimens from another cadaver were subjected to a modified Spalteholz technique to render all nonnerve tissue transparent. Computer graphics were used to create a three-dimensional structural model. RESULTS: All three PRSN branches emanated from an ipsilateral origin and passed posterior to the transverse process. The medial PRSN branch consistently passed between the mammillary and accessory processes under the mammilloaccessory ligament. The intermediate branch passed between the longissimus and iliocostalis muscles and extended to the skin. The lateral branch traveled far lateral from the origin. CONCLUSIONS: The authors created a 3D model of the PRSN in the lumbar segment, which may be useful for planning surgical approaches to dorsal areas of the vertebral column. In addition, this knowledge may improve the accuracy of procedures involving the spinal column, particularly radiofrequency neurolysis of the facet joint.

Internal hernia through the foramen of Winslow: the "narrowed portal vein" sign on abdominal CT.

We report a case of ileal internal hernia through the foramen of Winslow into the lesser sac. Preoperative computed tomography (CT) demonstrated that the herniated ileum, which showed a closed-loop obstruction, was located behind the portal vein, and the vein was subsequently compressed and narrowed by the herniated ileum. We found that similar cases in the literature of Winslow's foramen hernias that caused portal vein compression; however, portal vein narrowing has not been described as a characteristic CT finding. The narrowed portal vein sign could be useful in diagnosing the hernia through the foramen of Winslow.

Pyothorax-associated lymphoma: imaging findings.

OBJECTIVE: The purpose of this study was to evaluate the radiologic features of pyothorax-associated lymphoma on CT scans and chest radiographs. MATERIALS AND METHODS: Radiographs and CT scans of 21 patients with biopsy-proven pyothorax-associated lymphoma (17 men, four women; median age, 71 years; range 52-77 years) were retrospectively identified. Two readers in consensus analyzed the morphologic imaging features of pyothorax-associated lymphoma and determined their relation to the preexisting chronic empyema cavity. In 13 cases, gallium scans were available and were reviewed. RESULTS: Sixteen patients had a history of artificial pneumothorax therapy for tuberculosis. Pyothorax-associated lymphoma was visualized mainly (71.4% of cases) as extrapulmonary pleural masses on chest radiographs. The CT features included a lenticular (60%) or crescentic (20%) soft-tissue mass located eccentrically at the margin of a coexistent empyema cavity, which was present in all cases. Masses of pyothorax-associated lymphoma were commonly located in the lateral costal pleura (50%) or at the costophrenic angle (30%). The tumor matrix often appeared heterogeneous and contained areas of necrosis (60%). Direct invasion of the chest wall, ribs, lung parenchyma, and abdomen was found in 75%, 50%, 25%, and 25% of patients. Gallium scans, when available, showed marked uptake in 10 of 13 patients (76.9%). CONCLUSION: In patients who have undergone artificial pneumothorax therapy for tuberculosis more than 20 years in the past, a pleural soft-tissue mass adjacent to the margin of a coexistent empyema cavity suggests the presence of pyothorax-associated lymphoma. Knowledge of the typical radiologic findings and locations of pyothorax-associated lymphoma help in the diagnosis of this rare pathologic entity.

Tumor staging of advanced esophageal cancer: combination of double-contrast esophagography and contrast-enhanced CT.

OBJECTIVE: The objective of this study was to compare the diagnostic accuracy of tumor staging in patients with advanced esophageal cancer based on contrast-enhanced CT findings alone with that based on a combination of CT and double-contrast esophagography and to evaluate the relevance of tumor stage to survival rate. MATERIALS AND METHODS: In 94 patients who underwent surgery as the primary treatment for esophageal cancer and had a diagnosis of postoperative T stage 3 (pT3) or pT4 disease based on pathologic examination, T stage was evaluated using CT alone and using a combination of CT and double-contrast esophagography. The diagnostic criterion for T4 disease using CT alone was tumor strongly displacing or deforming adjacent organs. The diagnostic criterion for T4 disease using the combined method was tumor displacing or deforming adjacent organs in the direction that corresponded to the direction of the location of the tumor or the deepest ulcer as diagnosed by barium esophagography. Concordance of T staging based on imaging with postoperative T staging based on pathology results, the gold standard, and survival rate were assessed for CT alone and for the combined method. RESULTS: The concordance rate with postoperative T staging pathology results was 78% for CT alone and 84% for CT and double-contrast esophagography combined, with a significant difference between the two diagnostic methods. For patients with a diagnosis of T3 and those with a diagnosis of T4 using CT alone, the 3-year survival rate was 42% and 26%, respectively, with no significant difference between the two. For patients with a diagnosis of T3 and those with a diagnosis of T4 using the combined method, the 3-year survival rate was 42% and 21%, respectively, with a significant difference between the two. CONCLUSION: The diagnostic performance of contrast-enhanced CT and double-contrast esophagography combined in staging advanced esophageal tumors is better than that of CT alone and thus has potential for estimating prognosis.

Factors associated with pericolic fat stranding of colon cancer on computed tomography colonography.

BACKGROUND: Pericolic fat stranding on computed tomography (CT) scans has been an important feature for staging colon cancer. However, the factors associated with pericolic fat stranding have not been elucidated to date. PURPOSE: To determine factors associated with pericolic fat stranding of colon cancer on CT colonography (CTC). MATERIAL AND METHODS: Overall, 150 patients with 155 colon cancer lesions were retrospectively assessed by two radiologists for pericolic fat stranding on CTC. Circumferential proportion of the tumor (CPtumor; <50%, 50-75%, and ≥75%), longitudinal length, depth of invasion (≤T2, T3, T4), lymph node and distant metastasis, and lymphovascular invasion were recorded. Univariate and multivariate logistic regression analyses were performed between pericolic fat stranding and each factor. Multi-group comparisons were performed for the CPtumor and depth of invasion. RESULTS: Pericolic fat stranding was identified in 57 lesions (36.8%). Univariate analysis revealed significant associations of pericolic fat stranding with all factors (P < 0.027), except for lymph node metastasis (P = 0.087). Multi-group comparisons revealed that pericolic fat stranding was more frequent with increasing CPtumor (P < 0.001); however, no significant differences were observed beyond subserosal infiltration (P = 0.225). Logistic regression analysis revealed the CPtumor (<75% vs. ≥75%; P = 0.008, <50% vs. 50-75%; P = 0.047) and longitudinal length (P = 0.001) as explainable variables. CONCLUSION: Pericolic fat stranding identified on CT images of colon cancer is demonstrated more frequently with increasing circumferential proportion of the tumor and longitudinal length.

Early morphological change for predicting outcome in metastatic colorectal cancer after regorafenib.

BACKGROUND AND OBJECTIVE: It is unclear whether early morphological change (EMC) is a predictive marker for regorafenib in metastatic colorectal cancer (mCRC). Therefore, the present study investigated whether EMC can predict the outcome of mCRC patients receiving regorafenib. RESULTS: This study evaluated 68 patients. Among 52 patients with lung metastasis, 16 (31%) had cavity formation (CF). The median progression-free survival (PFS) and overall survival (OS) in patients with/without CF were 4.2/2.4 months (p<0.01) and 9.2/6.5 months (p=0.09), respectively. Among 45 patients with liver metastasis, 14 (31%) had active morphological response (MR). The median PFS and OS in patients with/without active MR were 5.3/2.4 months (p<0.01) and 13.6/6.9 months (p=0.02), respectively. Overall, 25 patients (37%) had EMC. The median PFS and OS in patients with/without EMC were 5.3/2.1 months (p<0.01) and 13.3/6.1 months (p<0.01), respectively. MATERIALS AND METHODS: This retrospective study included mCRC patients with lung and/or liver metastases receiving regorafenib. CF in lung metastasis and MR in liver metastasis were evaluated at the first post-treatment computed tomography scan. EMC was determined as CF and/or active MR. We compared PFS and OS between patients with and those without EMC. CONCLUSIONS: EMC could be a useful predictive marker for regorafenib in mCRC.

The imaging features of protruding esophageal lesions.

Except for squamous cell carcinoma and adenocarcinoma, lesions that protrude into the esophagus are rare, and include benign and malignant tumors. The imaging findings of these lesions on esophagography, computed tomography (CT), and magnetic resonance imaging (MRI) are often non-specific. However, some of them reveal characteristic imaging findings. In addition, esophagography, CT, and MRI are useful to evaluate location, extent, invasion, vascularity, lymphadenopathy, and metastasis. Knowledge of the imaging features of protruding esophageal lesions helps to narrow the differential diagnosis. We describe the main features of esophageal protruding lesions.

Three cases of retroesophageal right subclavian artery.

We have experienced three cases of retroesophageal right subclavian artery. Two cases were cadavers, and one case was a live human. In the two cadavers of a 68-year-old and a 76-year-old, respectively Japanese and European males, the right subclavian artery originated from the aorta after the aorta branched the right carotid artery, the left carotid artery and the left subclavian artery. The right carotid artery immerged solely from the aorta. Where the right subclavian artery originated from the aorta, the artery took a dorsal direction. It passed between the esophagus and the vertebral column. The esophagus was compressed from the dorsal side by the right subclavian artery. The structural anomaly of the right subclavian artery accompanied the cephalad recurrence of the branch from the right vagal nerve toward the larynx. In the live human case, we obtained CT views. The patient was a 41-year-old Japanese, who complained of dysphagia lusoria. We found that the right subclavian artery was anomalous and originated from the aorta as the last cardinal branch in the thorax.

The role of computed tomography in the selection of breast cancer treatment.

Contrast-enhanced computed tomography (CE-CT) is one of the most sensitive imaging modalities. CE-CT plays a role in the following: (1) to determine the extent of breast cancer to select the appropriate breast conserving treatment (BCT). The sensitivity and specificity for the detection of extensive intraductal component (EIC) by CE-CT were 82-88% and 75-89%, respectively. The pathological extent of tumors significantly correlated with the extension revealed by CE-CT; (2) to determine the extent of resection following neoadjuvant chemotherapy, which is difficult to assess by other modalities; (3) to diagnose axillary lymph node metastasis. The sensitivity and specificity are 79-90% and 70-89%, respectively; (4) to identify occult breast cancer with axillary metastasis and to diagnose local recurrence after BCT.

Clinicopathological features of tumors as predictors of the efficacy of primary neoadjuvant chemotherapy for operable breast cancer.

BACKGROUND: Neoadjuvant chemotherapy (NC) is standard therapy for patients with locally advanced breast cancer and is increasingly used for early-stage operable disease. Clinical and pathological responses are important prognostic parameters for NC, which aims to achieve a pathological complete response or tumor reduction to reduce the volume of subsequent breast resection. Clinicopathological markers that predict patient response to NC are needed to individualize treatment. METHODS: From 1998 to 2006, 368 patients with primary breast cancer underwent curative surgical treatment after NC (anthracycline and/or taxane without trastuzumab). We retrospectively evaluated the clinicopathological features and classification of the tumors using computed tomography (CT) before NC and analyzed the correlation with the pathological complete response (pCR) and reduction of tumor size after treatment. RESULTS: The overall response and pCR rates in these patients were 86% and 17%, respectively. In multivariate analysis, classification as a scirrhous-type tumor was an independent predictor of reduced likelihood of pCR (p=0.0115; odds ratio 0.21). For tumor reduction, histological grade 3 (p=0.0002; odds ratio 3.3) and localized tumors identified by using CT imaging (p=0.0126; odds ratio 2.4) were independent predictors in multivariate analysis. CONCLUSIONS: In this study, NC often did not result in pCR for breast cancers classified as scirrhous. Furthermore, tumor type classification using CT imaging and histological grading was effective to predict tumor reduction in response to NC that included an anthracycline and/or a taxane.

Evaluation of axillary status in patients with breast cancer using thin-section CT.

BACKGROUND: In recent years, the surgical management of patients with breast cancer has shifted to a locoregional approach, and evaluating the patient's axillary lymph node status is of the greatest importance in determining the appropriate treatment strategy. We evaluated on the efficacy of preoperative axillary staging using contrast-enhanced computed tomography (CE-CT). METHODS: Between 2000 and 2003, 235 patients with operable breast cancer who underwent CE-CT before surgery and 137 patients who received neoadjuvant chemotherapy (NAC) and underwent CE-CT before NAC and surgery were enrolled in this study. The axillary status was evaluated based on three criteria (short-axis diameter, shape, and enhancement type), and the diagnosis was correlated with the histopathological results. RESULTS: In patients who did not receive NAC, the size criterion of a short-axis diameter of more than 5 mm provided a sensitivity of 78%, a specificity of 75%, and an accuracy of 76% in predicting node-positive status. According to the size criterion of a short-axis diameter of more than 5 mm and the shape criterion of the absence of intranodal fat density, the specificity and accuracy were 90% and 81%, respectively, and according to the enhancement type criterion of early enhancement, the corresponding values were 89% and 78%. Evaluation was more difficult in patients who received NAC and the sensitivity of the size-based criterion in the patients who received NAC was lower than in those who did not. CONCLUSION: These findings suggest that CE-CT based on size criteria is useful for evaluating the preoperative axillary status of breast cancer patients, but that evaluation is more difficult and the sensitivity is reduced in patients who have received NAC.

Efficacy and safety profile of imatinib mesylate (ST1571) in Japanese patients with advanced gastrointestinal stromal tumors: a phase II study (STI571B1202).

BACKGROUND: Imatinib mesylate, an inhibitor of KIT, ABL protein, and platelet-derived growth factor receptor alpha (PDGFRalpha) tyrosine kinase, has recently been found to have a dramatic antitumor effect on gastrointestinal stromal tumor (GIST). The aim of this study was to assess the efficacy and safety of imatinib mesylate in Japanese patients with advanced GIST. METHODS: Patients with measurable lesions were enrolled between April 1, 2002, and September 20, 2002, using a design based on previous phase II studies in the United States and the European Union. The diagnosis of GIST was proven histologically with positive immunostaining for KIT (CD117). Imatinib mesylate was administered at a dose of either 400 mg or 600 mg once a day. Pharmacokinetic parameters and mutation analysis of c-kit were also assessed in a subgroup of patients. RESULTS: A total of 74 patients (28 receiving imatinib mesylate at 400 mg/day; 46 receiving 600 mg/day); median age, 56.0 years, were enrolled. No patient had a complete response, 51 patients (69%) had a partial response, and 19 patients (26%) had stable disease. The median progression-free survival time was 96 weeks. The estimated 3-year overall survival (Kaplan-Meier) rate for all patients was 73.6%. The most frequent adverse effects related to the drug were nausea (78%), diarrhea (70%), dermatitis (62%), facial edema (61%), edema of the lower limbs (58%), vomiting (54%), and eyelid edema (51%). Most of the adverse effects were mild and manageable. CONCLUSION: Imatinib mesylate is generally safe and has significant activity in the treatment of advanced GIST in Japanese patients.

Thin-section MRI with a phased-array coil for preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer.

OBJECTIVE: The aim of our study was to assess the accuracy of thin-section MRI performed with a phased-array coil as a technique for the preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer. CONCLUSION: Thin-section MRI with a phased-array coil is accurate and reliable for preoperative evaluation of pelvic anatomy and depth of transmural tumor invasion. Thus, it may be helpful in the selection of the appropriate treatment for patients with rectal cancer.

Vascular virtual endoluminal visualization of invasive colorectal cancer on MDCT colonography.

OBJECTIVE: The purpose of this study was to assess the utility of vascular views for visualization of invasive colorectal cancers on contrast-enhanced MDCT colonography. CONCLUSION: By means of Hounsfield-transparency settings, we obtained virtual endoluminal images that show vascular structures and delineate invasive cancers of the colorectal wall, and we call these images "vascular views." Using this technique for contrast-enhanced MDCT colonography, we found that the increase in flow and pooling of blood related to angiogenesis of cancerous lesions is easy to identify and that this finding is useful in the detection of invasive colorectal cancers.

Diagnosis of complete response to neoadjuvant chemotherapy using diagnostic imaging in primary breast cancer patients.

Advances in the therapeutic agents used for neoadjuvant chemotherapy (NAC) have recently achieved higher response rates and induced a greater number of pathologic complete responses (pCR) than ever before. The aim of this study is the diagnosis of pCR after NAC by diagnostic imaging of clinical complete response (cCR) patients. This study included 35 breast cancer patients who demonstrated cCR after receiving NAC with a combination of anthracycline and taxane from May 1998 to August 2003. Surgical treatment included breast-conserving therapy followed by radiotherapy or mastectomy. The identity of post-NAC lesions as either a complete response (CR) or partial response (PR) were made by mammography, ultrasonography, and contrast-enhanced computed tomography (CT). Among the 35 patients, 11 achieved pCR, including the disappearance of both invasive and intraductal components. Of the patients achieving pCR, eight were defined as CR and three were determined to be PR by CT. There was a significant relationship between the pCR and the determination of CR by CT. The determination of CR by ultrasonography was indicative of the disappearance of pathologic invasive components. While mammography appeared to reflect the observed histologic results, we did not observe any statistical differences. A subset of cases exhibited discrepancies between the imaging and pathologic results, likely due to the replacement of destroyed tumor cells by fibrosis and granulomatous tissue. The evaluation of CR by CT was significantly indicative of pCR. The positive predictive value, however, was not large enough to avoid surgical treatment. Further studies will be needed to establish a diagnosis of pCR.

Pathways of anesthetic from the thoracic paravertebral region to the celiac ganglion.

Communication between the lower thoracic paravertebral region and the celiac ganglion through the retrocrural space was investigated. After dye was injected into the endothoracic fascia in the lower thoracic paravertebral region at the T11 level, its spread to the celiac ganglion was examined in fifteen cadavers. The dye reached the celiac ganglion in nine cadavers (60%) by passing through the retrocrural space, along the greater and lesser splanchnic nerves and through the split in the crus of the diaphragm through which the splanchnic nerves traveled. In the remaining six cadavers, dye spread toward the ganglion along the crus of the diaphragm. In three living subjects the spread of a radio-opaque dye injected in the same manner was studied using 3D-computed tomography. This study confirmed that the radio-opaque dye traveled toward the celiac ganglion along the crus of the diaphragm. From our results we suggest that a fluid communication may exist between the lower thoracic paravertebral region and the celiac ganglion in cadavers and in living humans and that clinicians should be aware of this possible route of spread when administering lower thoracic paravertebral anesthesia.

Accuracy in estimating tumor extension according to mammographic subtypes in patients with ductal carcinoma in situ.

BACKGROUND: The association between subtypes of mammographic findings and histopathological tumor extension in patients with ductal carcinoma in situ has remained unclear. The purpose of this study was to investigate the relationship between tumor extension on mammography, by stratifying four subtypes, and histopathological tumor size in patients with ductal carcinoma in situ. METHODS: This study was performed on 109 breasts with ductal carcinoma in situ. They were treated by mastectomy at our Hospital between January 1990 and December 1999. Findings on mammography were categorized as microcalcification type, spiculated type, circumscribed type or fibrocystic-change type. The microcalcification type consisted of breasts with malignant microcalcifications, regardless of the presence or absence of tumor shadow. We analyzed the relationship between tumor size on mammography in each category and histopathological tumor size. In the breasts with palpable tumors, we compared palpated tumor size and histopathological tumor size according to the mammographic subtypes. RESULTS: There was no statistical difference between mammographic tumor size and histopathological tumor size for each mammographic subtype (microcalcification type, P = 0.60; spiculated type, P = 0.72; circumscribed type, P = 0.055). The size of the ductal carcinoma in situ in microcalcification and spiculated type was estimated approximately by mammography. However, mammography tended to overestimate the circumscribed type. In the cases of palpable tumor, we statistically underestimated the size of ductal carcinoma in situ by palpation in microcalcification and fibrocystic-change type (microcalcification type, P = 0.0001; fibrocystic-change type, P = 0.040). CONCLUSION: Mammographic categorization is useful for surgical planning of ductal carcinoma in situ, particularly when considering breast-conserving surgery.

Invasive ductal carcinoma associated with tubular adenoma of the breast.

We report an extremely rare case of the colocalization of a tubular adenoma and an invasive ductal carcinoma occurring in a 55-year-old woman. Following radiographical evaluation, fine-needle aspiration cytology of the left breast tumor was undertaken. Because cytological examination revealed malignancy, a partial mastectomy was performed. Histologically, the tumor (measuring 1.7 x 1.3 cm) comprised two distinct parts: tubular adenoma and invasive ductal carcinoma. The invasive ductal carcinoma showed a solid pattern, high nuclear and structural atypia and frequent mitotic figures, while the tubular adenoma consisted of a proliferation of small ducts lined by single layers of epithelial and myoepithelial cells with bland nuclei and inconspicuous nucleoli. The histological boundary was clearly defined between the tubular adenoma and the invasive ductal carcinoma, and between the tubular adenoma and the surrounding breast tissue. The current case might be a collision between separate tubular adenoma and invasive ductal carcinoma, but the malignant transformation of a tubular adenoma cannot be ruled out. Both the long-term observation of this case and analysis of more cases may enable us to determine the histological characteristics and clinical significance of invasive ductal carcinoma associated with tubular adenoma.