New simplified lymphoscintigraphic technique in patients with breast cancer.

To achieve the visualization of regional lymph nodes using lymphoscintigraphy, 100 preoperative patients with breast cancer were studied, with [99mTc]rhenium colloid having been injected into the periosteum of their ribs. In order to identify the exact location of the visualized nodes, the obtained lymphoscintigram was superimposed onto the patient's chest roentgenogram. The visibility of the internal mammary region was 91% on the affected side, and 93% on the healthy side, whereas the visibility of the axillary region was 85% and 86%, respectively. The injection resulted in simultaneous visualization of both the internal mammary and the axillary nodes: in our series, it meant the visualization of 82 patients (82%) on the affected side and 83 patients (83%) on the healthy side. Our technique appears to be a rather efficient method for imaging the regional lymph nodes in breast cancer patients.

Thallium-201 scintigraphy to assess effect of chemotherapy in osteosarcoma.

UNLABELLED: Imaging results in patients with high-grade osteosarcoma of the extremities were reviewed to determine whether scintigraphic appearance correlated with histologic response to preoperative chemotherapy. METHODS: Histologically, the percent tumor necrosis in specimens from 30 patients were classified into three grades: grade 1 = necrosis less than 60%, grade 2 = 60%-89% necrosis and grade 3 = diffuse necrosis greater than 90% based upon whole transverse sections. Scintigraphically, we analyzed 201TI uptake before and after preoperative chemotherapy. The changes in the tumor-to-background ratio were defined by an alteration ratio. RESULTS: Of the 11 patients with a grade 1 response, the ratio showed -67.1% +/- 45.4% (mean +/- s.d.). Of the 9 patients with a grade 2 response, the ratio showed 37.9% +/- 29.9% of the 10 patients with a grade 3 response the ratio showed 105.5% +/- 12.4%. The ratios correlated well with the histologic grades (p < 0.0001; analysis of variance). CONCLUSION: Thallium-201 scintigraphy accurately assesses the effect of chemotherapy on osteosarcoma.

Serious chemical sclerosing cholangitis associated with hepatic arterial 5FU and MMC chemotherapy.

A case of iatrogenic sclerosing cholangitis secondary to hepatic intra-arterial 5-fluorouracil (5FU) and Mitomycin C (MMC) chemotherapy is described. When any unexplained elevation of liver function results in alkaline phosphatase and bilirubin level, chemotherapy should be discontinued, and further examination carried out using ultrasonography, transhepatic cholangiography and endoscopic retrograde cholangio-pancreatography (ERCP). Although percutaneous transhepatic biliary drainage has been effective in some cases, in our case, the clinical course was irreversible and the patient died of hepatic failure and gastrointestinal bleeding. When clinical signs of hepatic dysfunction occur in the absence of tumor progression, iatrogenic sclerosing cholangitis must be suspected.

Pharyngoesophageal reconstruction using a fabricated forearm free flap.

A new microsurgical alternative in reconstruction of the pharynx and cervical esophagus is reported. A trapezoidal forearm flap is fabricated into an inverted skin tube and placed in the pharyngoesophageal defect. Although microvascular anastomoses are required to revascularize the transferred forearm flap, the long and large nutrient vessels of the flap make anastomoses easy and reliable. None of our 12 patients demonstrated any necrosis of the transferred flap. This one-stage, less invasive operation for pharyngoesophageal reconstruction greatly benefits older persons, who are the more likely to be involved with pharyngoesophageal carcinomas.

On clinical usefulness of Tl-201 scintigraphy for the management of malignant soft tissue tumors.

The purpose of this study was to investigate Tl-201 as a tumor scanning agent in patients with malignant soft tissue sarcomas and to establish the sensitivity of this type of scintigraphy concerning local recurrences or metastases that may remain clinically suspected. Seventy-eight patients with malignant soft tissue sarcomas and 22 with benign soft tissue tumors were studied. Of these 78 malignant soft tissue sarcomas patients, the sensitivity of Tl-201 (81.2%) was higher than that of Ga-67 (68.8%). Thirty-three out of 78 patients received a total of 95 consecutive scintigraphic follow-up examinations. Therapeutic effects was assessed by comparing the results of Tl-201 examinations with the clinical findings. Of these 33 patients, the therapeutic effects observed were as follows: complete remission 1, partial remission 8, progress of disease 1, and no remarkable change 23. Tl-201 scintigraphy has proved itself very useful not only in clinically detecting the malignant soft tissue sarcomas and in assessing therapeutic effects on these diseases, but also in assessing the follow-up patients with malignant soft tissue sarcomas.

Lymphoscintigraphy of head-and-neck cancer.

To achieve the visualization of regional lymph nodes by lymphoscintigraphy, 21 patients with head-and-neck cancer were studied with the aid of 99mTc-labeled rhenium sulfur colloid (99mTc Re). Four injection sites were selected; the injections were given into the subcutaneous tissue of the parietal area of 11 patients, into the submucosa of the retromolar area of 6 patients, into the subcutaneous tissue of the postauricular area of 2 patients, and into the thyroid glands of 2 patients. Lymphoscintigraphy was done three hours after the injection. The cervical regions were visible in 85.7% of the patients on the affected side and in 90.5% on the healthy side. The visualization comprised the following regions: submental, submandibular, deep cervical, accessory, and supraclavicular regions. In total, 102 nodes were visualized on the affected side (average 4.8 per patient) and 110 nodes in the healthy side (average 5.5). Histologically, 15 of 21 patients had lymph nodes metastases and 6 did not. Of these 21 patients, 66.7% (14/21) had confirmed lymph node metastases in the visualized regions. This technique appears to be a relatively easy and efficient method of imaging the regional lymph nodes in head-and-neck cancer both before treatment and after neck surgery.

Comparison of Tc-99m pertechnetate with Tl-201 and Ga-67 scintigraphy of malignant soft-tissue tumors.

Tc-99m pertechnetate scintigraphy was compared with Tl-201 chloride and Ga-67 citrate to evaluate the avidity of Tc-99m pertechtate for malignant soft-tissue tumors. Twenty-three patients with malignant soft-tissue tumors underwent scintigraphic studies. All 23 received Tc-99m and Tl-201, whereas 14 also were injected with Ga-67. In 21 (91%) of the 23 patients, Tc-99m accumulated extensively in the tumors. Tl-201 accumulated in 12 (52%) of the 23 tumors. Ga-67 accumulated in only 5 (36%) of the 14 tumors. The avidity of Tc-99m for myxoid tumors was markedly different from the other two agents. Tc-99m accumulated in all eight myxoid tumors, while neither Tl-201 or Ga-67 showed marked accumulation except for one patient with increased accumulation of Tl-201. This study shows that Tc-99m pertechnetate has the potential to localize malignant soft-tissue tumors and may be useful in the evaluation of these tumors.

[Clinical usefulness of thallium-201 chloride in the diagnosis of tumor (II)--An evaluation in bone, soft tissue and mediastinal tumors].

The clinical usefulness of scintigraphy with thallium-201 (201Tl) chloride injection was evaluated in 79 patients with suspected bone, soft tissue or mediastinal tumors. No abnormal changes of subjective or objective signs and clinical test values were observed post injection. It is considered that 201Tl chloride is a safe radiopharmaceutical. In comparison with benign tumors, malignant tumors showed longer retention or more increased uptake of the 201Tl in the lesions on delayed images. The results suggested that the evaluation of changes of 201Tl uptake might be useful to some extent to differentiate malignant tumor from benign tumor. It is considered that 201Tl scintigraphy is useful for evaluating the location and extent of tumor and differentiating malignant from benign tumor.

[Diagnosis and treatment of metastatic bone cancer of the extremities].

Eight hundred and thirty-six patients with metastatic cancer in the bone excluding autopsy findings, occurring between January, 1976 and December, 1985 were reviewed. The most frequent site of primary focus was the breast (33.2%), followed by lung (24.6%). Three hundred and forty-two patients (40.9%) were male and 494 (59.1%) female. Diagnosis of bone metastasis was based on abnormal accumulation in the bone scintigram and abnormal findings in the bone X-ray at the same site. Out of 836 patients, 285 had metastatic skeletal lesion including extremities and 43 had a solitary lesion of the extremity. The most frequent site of bone metastases in the extremity was proximal femur and involvement of the femur was 65.2% and that of humerus was 25.6%. The majority of the patients were treated by irradiation (24.9%), irradiation with chemotherapy and/or hormone therapy (21.1%), chemotherapy (18.6%) and chemotherapy with hormone therapy (17.2%), on the other hand, only 25(8.8%) of 285 patients were treated by surgical procedures. Cumulative survival rate after diagnosis of bone metastasis varied with site of primary focus and 5 year survival rate of all cases was 6.1%. Clinical courses after skeletal metastasis were separated into two types, and one type was breast type which was slow and other type was lung type which was rapid. The most important factor for the prognosis of the patients with bone metastasis is thought to be the primary site of origin.

Clinical evaluation of thyroxine-binding globulin (TBG) as a marker of liver tumors.

This investigation was undertaken to evaluate thyroxine-binding globulin (TBG) as a marker of liver tumors, in conjunction with the liver scintigram. Of 30 patients with primary hepatocellular carcinoma (PHC), 22 (73.3%) showed significantly higher TBG concentrations. Eight patients (26.7%) showed normal TBG concentrations. In the case of 27 out of 30 patients with definite liver tumors, defects were apparent on the scintigrams. But seven of them had normal TBG concentrations in spite of the defects on the scintigrams. Out of 33 postoperative patients with liver metastasis, 28 (84.8%) had a raised TBG concentration. Only five (15.2%) had a normal TBG level. In 31 patients (93.9%) out of 33 with liver metastasis, a definite diagnosis was made on the basis of the liver scintigram. In 28 (90.3%) of these 31 people, the TBG concentration was higher than normal. Among 63 patients with liver tumors, both primary and metastatic, the test sensitivity for liver tumors was 92.1% (58/63) based on the accuracy of the liver scintigram. It was 79.4% (50/63) based on the TBG measurement. Why TBG increases to such an extent in spite of the euthyroid state remains unexplained. But it may be concluded that elevated TBG with positive liver scintigram furnishes a sensitive, fairly reliable, nonspecific tumor marker to determine liver tumors, especially in the case of liver metastasis.

[99mTc pertechnetate scintigraphy for malignant soft-tissue tumors].

The purpose of this study was to investigate the accumulation of technetium-99m pertechnetate (99mTc) in malignant soft-tissue tumors. Twenty-one patients with malignant soft-tissue tumors were subjected to 99mTc scintigraphic studies. In 19 of 21 patients (90%), 99mTc accumulated extensively in the tumors. 99mTc accumulation was especially thorough in all cases of MFH and liposarcoma. Therefore, 99mTc is useful for the local evaluation of malignant soft-tissue tumors.

99mTc-PI as safe and easy scintigraphy after hepatectomy.

Hepatobiliary scintigraphy with 99mTc-PI was performed on 16 patients after various types of hepatectomy for either primary or secondary liver tumor. 99mTc-PI scintigraphy was found very useful, especially in regard to clinical evaluation of indistinct low-uptake areas observed on a 99mTc colloid liver scintigram in the regenerating liver after hepatectomy. Both tests were conducted successively within a couple of weeks. Colloid scintigrams after hepatectomy were divided into two groups according to the sites of indistinct low-uptake areas; one showed them near the resected margin of the regenerating liver (Type I), and the other showed them in both marginal and intrahepatic. regions (Type II). Of these 16 patients, 8 showed Type I and 7 showed Type II. The remaining one was excluded for postsurgical complications. By comparing the colloid scintigram with the 99mTc-PI scintigram, in all the cases of Type I indistinct low-uptake areas were found to be the hilum with a shifted common bile duct. On the other hand, in 2 cases of Type II indistinct low-uptake areas were caused by the hilum accompanied by the dilated bile ducts. In the remaining 5, indistinct low-uptake areas were not identified as bile ducts but were confirmed to be a recurrence of the tumor.

Clinical significance of abnormal accumulations found in the vertebrae on the bone scintigram of cancer patients.

From January 1975 to December 1976, 180 cancer patients were found to have abnormal accumulations in the vertebrae on their bone scintigrams. These patients were carefully surveyed through their clinical records for more than two years follow-up, x-ray pictures, and autopsy findings; and finally 115 patients were selected for this study. Abnormal accumulations were classified into two categories; significantly positive and equivocal. Among thses 115 patients, significant accumulations were found in 85, and equivocal in 17. The remaining 13 showed both significant and equivocal accumulations. In 81 out of 98 (85 + 13) patients, the significant accumulations were due to metastases; and in 15 out of 30 (17 + 13) patients, the equivocal accumulation only are taken into consideration, the true positive cases are only 3 of the 17. The major factor for false positive was degenerative changes of the vertebrae in either group of significant or equivocal accumulations. Although it is difficult to differentiate benign changes of the vertebrae from the metastases on the bases of scintigram findings only, a cushion-like pattern in disc degeneration as well as in colapse of the vertebral body, a vague concentration with indistinct margin in spondlyosis deformans, and symmetrical accumulations in the intervertebral joints due to sclerotic changes are helpful in evaluating the bone scintigram of cancer patients, together with the site of abnormal accumulation and the age of the patient.

Thyroxine-binding globulin as a marker of liver tumors.

This investigation was undertaken to evaluate the level of thyroxine-binding globulin (TBG) as a marker of liver tumors. TBG examination was performed on 42 patients with primary hepatocellular carcinoma (PHC) and 50 postoperative patients with metastases to the liver. alpha-Fetoprotein (AFP) and carcinoembryonic antigen (CEA) concentrations were determined at the same time. AFP was positive in 90.5% of the patients with PHC, and TBG was higher than normal in 69% of patients with PHC. In the 50 patients with liver metastasis, the TBG was higher than normal in 72%, and CEA was also increased in 64%. CEA was negative in 18 of 50 patients with liver metastasis. On the other hand, of the 18 CEA-negative patients, 14 (77.8%) had a higher than normal TBG concentration. This was a significant, but not specific, increase. Therefore, elevated TBG levels are a sensitive, although nonspecific, tumor marker to determine the presence of liver tumors, especially in cases of metastasis to the liver.