Multiple Breath-hold Volumetric Modulated Arc Therapy Under Fluoroscopic Image Guidance with an Implanted Fiducial Marker: An Advanced Technique.

An advanced technique for multiple breath-hold volumetric modulated arc therapy (VMAT) has been proposed under fluoroscopic image guidance with a fiducial marker implanted close to a tumor. The marker coordinates on a digitally reconstructed radiography image at a gantry start angle, under a planned breath-hold condition, were transferred to the fluoroscopic image window. Then, a reference lateral line passing through the planned breath-hold marker position was drawn on the fluoroscopic image. Additional lateral lines were further added on both sides of the reference line with a distance of 3 mm as a tolerance limit for the breath-hold beam delivery. Subsequently, the patient was asked to breathe in slowly under fluoroscopy. Immediately after the marker position on the fluoroscopic image moved inside the tolerance range, the patient was asked to hold the breath and the VMAT beam was delivered. During the beam delivery, the breath-hold status was continuously monitored by checking if the deviation of the marker position exceeded the tolerance limit. As long as the marker stayed within the tolerance range, a segmented VMAT delivery continued for a preset period of 15 to 30 seconds depending on the breath-hold capability of each patient. As soon as each segmented delivery was completed, the beam interrupt button was pushed; subsequently, the patient was asked for free breathing. This procedure was repeated until all the segmented VMAT beams were delivered. A lung tumor case is reported here as an initial study. The proposed technique may be clinically advantageous for treating respiratory moving tumors including lung tumor, liver cancer, and other abdominal cancers.

Radiofrequency Ablation Combined with Hepatic Arterial Chemoembolization Using Degradable Starch Microsphere Mixed with Mitomycin C for the Treatment of Liver Metastasis from Colorectal Cancer: A Prospective Multicenter Study.

PURPOSE: This phase II prospective study investigates possible benefits of radiofrequency ablation (RFA) combined with hepatic arterial chemoembolization using degradable starch microsphere (DSM) mixed with mitomycin C (MMC) in non-surgical candidates with colorectal liver metastases. MATERIALS AND METHODS: This study, approved by the respective institutional review board, included non-surgical candidates with 3 or fewer liver tumors of 3 cm or smaller, or a single lesion 5 cm or smaller. Percutaneous RFA was performed immediately after chemoembolization using DSM-MMC. Primary and secondary endpoints were the local tumor control rate, safety, and 2-year recurrence-free and overall survival rates. RESULTS: This study examined 25 patients (22 males, 3 females) with 38 tumors of mean maximum diameter of 2.2 ± 0.9 cm (standard deviation) (range 1.0-4.2 cm). Their mean age was 70.2 ± 8.2 years (range 55-82 years). Local tumor progression developed in 3 tumors (7.9%, 3/38) of 3 patients (12%, 3/25) during the mean follow-up of 34.9 ± 9.2 months (range 18.3-50.1 months). The 2-year local tumor control rates were 92.0% [95% confidence interval (CI), 81.4-100%] on a patient basis and 94.6% (95% CI, 87.3-100%) on a tumor basis. The respective 2-year overall and recurrence-free survival rates were 88.0% (95% CI, 75.3-98.5%) and 63.3% (95% CI, 44.2-82.5%), with median survival time of 48.4 months. Fever was the only adverse event requiring treatments in 2 patients (8%). CONCLUSIONS: This combination therapy is safe, exhibiting strong anticancer effects on colorectal liver metastasis, which might contribute to patient survival.

Multicystic biliary hamartoma: a hitherto undescribed lesion.

In this report, we presented 3 cases of unusual hamartomatous nodules of the liver. These nodules were located around hepatic capsule of the left hepatic lobe and characteristically protruded from the liver. Histologically, these nodular lesions consisted of ductal structures, periductal glands, and fibrous connective tissues containing blood vessels. Smooth muscle bundles focally surrounded ductal structures. Bile-like materials were observed within some ducts. Two cases were associated with xanthogranulomatous inflammation around bile-like materials, and this inflammatory process extended from ductal lumens to periductal connective tissues. In contrast, the remaining case, which was not associated with inflammation, showed a honeycomb appearance. Ductal epithelium and periductal glands resembled biliary epithelium and peribiliary glands, respectively, and they also expressed biliary-type cytokeratins such as cytokeratins 7 and 19. These nodules shared pathologic characteristics of ciliated hepatic foregut cysts, such as their location (around the falciform ligament) and periductal smooth muscle bundles, but did not fulfill the diagnostic criteria (no ciliated cells and multilocular lesions). These hamartomatous nodules of the liver did not fit into any of the described categories of hepatic nodular lesions. At present, we speculate that these lesions might be related to developmental abnormalities of the biliary tract or embryonal foregut.

Thickening of multiple cranial nerves in a patient with extranodal peripheral T-cell lymphoma.

A 57-year-old male became aware of a subcutaneous tumor in March 2001. Histopathological examination showed peripheral T-cell lymphoma. He achieved complete remission after chemotherapy. Later the lymphoma relapsed in the subcutaneous lesion and chemotherapy was performed again. In April 2003, he developed diplopia, dysarthria, and dysphagia. Abnormal lymphoid cells were found in the cerebrospinal fluid. An immunophenotypical study disclosed that CD2, CD3, CD5, and CD8 were positive. Rearrangement of TCR was detected by Southern blotting. Cranial magnetic resonance imaging did not detect any intraparenchymal lesions, but thickening of multiple cranial nerves was detected. These nerves were homogeneously enhanced by gadolinium-DTPA. After intrathecal chemotherapy, atypical cells disappeared from the cerebrospinal fluid and thickening of the cranial nerves was resolved. Finally, lymphoma spread to the bone marrow, and the patient died in July 2003.

Role of brain perfusion single-photon emission tomography in traumatic head injury.

This investigation examined the role of brain perfusion single-photon emission tomography (SPET) in traumatic head injury in 35 patients. The results were compared with those of X-ray computerized tomography (CT) and magnetic resonance imaging (MRI). CT and MRI detected brain contusions in seven patients, subarachnoid haemorrhage in one patient and both in nine patients. In 16 of the 17 subjects (94%), SPET with technetium-99m-hexamethylpropyleneamine oxime (Tc-HMPAO) revealed CT/MRI-negative abnormalities, such as hypoperfusion in the contre-coup region, frontal hypoperfusion related to personality change and cerebellar hypoperfusion associated with vertigo. In two patients presenting with diffuse axonal injury in the brainstem, hypoperfusion in the frontal cortex on the affected side was observed on SPET. SPET demonstrated hypoperfusion in the adjacent cortex, with no abnormality on either CT or MRI, in six of seven patients exhibiting acute epidural haematoma. SPET failed to provide additional information in two of five patients with acute subdural haematoma and in one of two patients displaying chronic subdural haematoma. In four of nine patients with post-traumatic amnesia, SPET detected hypoperfusion in the temporal lobe, with no abnormality on either CT or MRI. In five of eight patients with vertigo, SPET detected hypoperfusion in the morphologically normal cerebellum. In seven cases involving personality change, frontal hypoperfusion was observed in four; moreover, a markedly non-homogeneous pattern was evident in the remaining three. Overall, SPET afforded additional information in 26 patients (74%). CT possesses an advantage with respect to the detection of haemorrhagic lesions. MRI provides more precise information regarding contusions and axonal injury. Frequently, SPET may be the only examination to reveal perfusion abnormalities which are related to symptoms in the absence of other objective findings, such as post-traumatic amnesia, vertigo or personality change.

Thallium-201 brain SPECT to diagnose aggressiveness of meningiomas.

This investigation was conducted to determine the ability of 201Tl brain SPECT with respect to preoperative prediction of lesional aggressiveness of meningioma. Fifty-nine lesions in 42 patients were examined. Early (15 min) and late (3 h) SPECT were obtained. Early uptake ratio (ER; lesion to normal brain average count ratio), late uptake ratio (LR) and the ratio of LR to ER (L/E ratio) were calculated. Twenty-three lesions exhibited malignant features based on histologic or clinical course such as recurrence or skull invasion. Both ER and LR of malignant meningiomas were significantly higher than those in thirty-six benign lesions. Benign lesions were classified into two groups for further analysis: meningotheliomatous type, which is the most common histology, and benign lesions other than the meningotheliomatous (other benign) type. ER in other benign type was lower than the meningotheliomatous and the malignant type. LR afforded differentiation of the malignant type from the two benign types. These two benign types could be distinguished on the basis of the L/E ratio. These results indicate that high pre-operative ER and LR values in patients with meningioma are indicators of the aggressiveness of lesions, i.e., malignant meningioma, recurrence or skull invasion.

Differential diagnosis in patients with ring-like thallium-201 uptake in brain SPECT.

UNLABELLED: This study was performed to investigate lesions with ring-like thallium-201 (201Tl) uptake and to determine whether SPECT provides any information in differential diagnosis. METHODS: A total of 244 201Tl SPECT images were reviewed. In each study, early (15 min postinjection) and late (3 hr) brain SPECT images were obtained with 111 MBq of 201Tl. The early uptake ratio (ER; lesion to normal brain average count ratio) and the late uptake ratio (LR) and the L/E ratio (ratio of LR to ER) were calculated. RESULTS: Ring-like uptake was observed in pre-therapeutic 26 SPECT images, including ten glioblastoma multiformes (ER, 3.45 +/- 0.64; LR, 2.74 +/- 0.54; L/E ratio 0.80 +/- 0.13), five meningiomas (6.48 +/- 2.34; 4.41 +/- 1.41; 0.72 +/- 0.19), four metastatic lung cancers (3.47 +/- 1.23; 2.40 +/- 0.98; 0.70 +/- 0.14), four brain abscesses (2.48 +/- 1.06; 1.59 +/- 0.30; 0.78 +/- 0.15), one invasive lesion of squamous cell carcinoma from the ethmoid sinus (1.54; 1.52; 0.99), one medulloblastoma (3.53; 3.52; 1.00) and one hematoma (3.32; 2.36; 0.71). The ER of meningioma was significantly higher than those of glioblastoma multiforme (p < 0.0005), metastatic lung cancer (p < 0.005) and brain abscess (p < 0.0005). There were no significant differences among these three entities. The LR of meningioma was significantly higher than those of glioblastoma multiforme (p < 0.005), metastatic lung cancer (p < 0.005) and brain abscess (p < 0.0001). The LR of brain abscess was significantly lower than that of glioblastoma multiforme (p < 0.05). The L/E ratio could not differentiate these four entities. CONCLUSION: High ER and high LR in a lesion with ring-like uptake is likely an indicator of meningioma. The LR of brain abscess was significantly lower than that of glioblastoma multiforme, but 201T1 SPECT has still difficulty in differentiating abscess from brain tumor.

Thyroid calcifications: sonographic patterns and incidence of cancer.

We investigated the incidence of cancer in surgically resected 151 thyroid nodules in 101 patients according to their calcification patterns on preoperative ultrasonography (US). Calcification was detected in 57 (38%) nodules, 31 (54%) of which was histologically diagnosed as cancer. According to the calcification types, 9 of 11 nodules with microcalcifications, 15 of 29 nodules with intranodular coarse calcification, 6 of 14 nodules with peripheral calcification and 1 of 3 calcified spots without surrounding tumor were diagnosed as cancer.

Diagnostic accuracy of fat-saturated T2-weighted magnetic resonance imaging in the diagnosis of perforation of the articular disc of the temporomandibular joint.

The accuracy of diagnosing a perforation of the articular disc of the temporomandibular joint (TMJ) is poor with conventional magnetic resonance imaging (MRI). We recently reported that a high signal-intensity area is usually found on fat-saturated T2-weighted MRI in the joint space between the articular disc and cartilage surface in joints in which the disc is displaced. A discrete image with an area of high signal-intensity in the middle of the articular disc may indicate perforation or rupture. The purpose of this study was to compare the accuracy of diagnosis of a perforated articular disc by fat-saturated T2-weighted MRI with that of arthroscopy. We studied 50 joints in 50 patients with closed lock of the TMJ who were examined with MRI and then by arthroscopy using an ultra-thin arthroscope. The agreement between the two methods of diagnosis was assessed using the κ coefficient. Evidence of perforation of the disc on MRI and arthroscopically was found in the same 7 joints; there was complete concordance (κ=1.00, p<0.001). The accuracy of diagnosis of perforation of a disc by fat-saturated MRI was therefore the same as that by arthroscopy using an ultra-thin arthroscope.

Hyperintensity signal in the joint space of the temporomandibular joint on fat-saturated T2-weighted magnetic resonance imaging.

Our aim was to investigate the incidence of a hyperintense signal in the joint space of the temporomandibular joint (TMJ) on fat-saturated T2-weighted magnetic resonance images (MRIs). We studied 112 patients (224 joints) with disorders of the TMJ who were examined by T2-weighted MRI, and recorded the association between displacement of the disc and the hyperintense signal using the κ coefficient. A hyperintense signal was found in 4 of 91 joints (4%) when the disc was in the normal position, in all 19 joints with anterior disc displacement with reduction, and in 108 of the 114 joints (95%) with anterior disc displacement without reduction. There was a significant correlation between displacement of the disc and the hyperintense signal (p<0.001). The κ coefficient was 0.91. Such a signal in the joint space of the TMJ on fat-saturated T2-weighted MRI may indicate the presence of synovial fluid in the joint space with displacement of the disc.