Observation of rat hind limb skeletal muscle during arterial occlusion and reperfusion by 31P MRS and 1H MRI

31P NMR spectra and 1H MR T1- and T2-weighted spin-echo images were concurrently observed in rat hind limb during arterial occlusion and following reperfusion. With arterial occlusion, phosphocreatine level decreased and inorganic phosphate (Pi) level increased in 31P NMR spectra. Intracellular pH's dropped as a function of time. Beta-ATP started to decrease in three hours. In six hours after the occlusion, any peaks other than Pi were scarcely detected. The signal intensities in the 1H MR images increased homogeneously in both T1- and T2-weighted conditions, but the changes were more profound with T2-weighted images. After the release of the arterial occlusion, the 31P NMR spectra recovered to the preischemic state in several hours. The 1H MR images during reperfusion showed characteristic heterogenous pattern. The signal intensities in the anterior tibial muscle and the gastrocnemius muscle remained high in T1-weighted condition and the intensities further increased in T2-weighted condition, while those in other parts returned to the preischemic level. These changes were found to be irreversible even 12 hr after the release. The high signal intensities suggested the increase of water in the extracellular compartment induced by so-called reperfusion injury. Multinuclear analysis using in vivo NMR was valuable to consecutively detect time-dependent and location-specific response in skeletal muscle during ischemia and reperfusion.

[Ca++ antagonist and acute brain ischemia: effects of nilvadipine and nicardipine on middle cerebral artery occlusion in rats]

Effects of calcium antagonists, Nicardipine and Nilvadipine, on neurologic deficits and size of infarct were studied in the rat middle cerebral artery (MCA) occlusion model. Each drug was administered immediately after induction of ischemia, and neurologic grade was evaluated 1 to 24 hours after MCA occlusion. At 24 hours post-occlusion, size of the infarct was compared with that of the control group. In addition, evolution of cerebral infarction was studied at 6 hours and 12 hours post-occlusion by magnetic resonance imaging (MRI). In the Nilvadipine-treated group, neurologic deficits improved more rapidly and the size of infarct was significantly smaller than in the Nicardipine-treated group. MRI showed a progressive extension of cortical infarct in the untreated rat, whereas the infarct size remained unchanged in the Nilvadipine-treated rat. These results suggest the potential therapeutic usefulness of calcium antagonist for acute cerebral ischemia.

Comparisons of interval breast cancers with other breast cancers detected through mass screening and in outpatient clinics in Japan

In a nation-wide collaborative study on mass screening for breast cancer, we collected 152 cases of interval breast cancer diagnosed at 35 hospitals or clinics distributed throughout Japan. The definition of interval breast cancer used in the present study is "breast cancer cases which were diagnosed as having 'no malignant findings' in a previous screening for breast cancer but subsequently diagnosed as 'breast cancer' at a hospital or medical clinic within two years of the previous screening." The clinical stages and prognoses of these interval cancer were analyzed and compared with those of other breast cancers detected through mass screening and in outpatient clinics. In the clinical staging of interval breast cancer, Tis (non infiltrating cancer) accounted for only 2.1%, compared to 8.0% in cases detected through mass screening. At stage I 43.4% were interval breast cancers compared to 32.9% breast cancers detected through mass screening and 25.4% diagnosed in outpatient clinics. The stage differences between interval breast cancers and breast cancers detected through mass screening were not statistically significant. Five-year survival rates were 85.6% for interval breast cancers, 91.7% for breast cancers detected through mass screening and 84.7% for breast cancers diagnosed in outpatient clinics. Ten-year survival rates were 75.9, 80.5 and 78.1%, respectively, suggesting the interval breast cancer cases to show a similar prognosis to that of breast cancer cases diagnosed in outpatient clinics. The differences in five- and 10-year survival rates among the three groups were not statistically significant. From the present study we were not able to confirm the general belief of interval cancer being more aggressive in nature and showing a poorer prognosis than cancer detected through periodic screening. The reasons for this are discussed.

[Progress of imaging diagnosis for the cancer therapy--breast cancer]

As two main modalities for the breast cancer, ultrasonography (US) and mammography (MMG) were discussed about the efficacy and limitation of qualitative diagnosis. The accuracy rate of US and MMG for the breast cancer were 90.0% and 92.7% at the Aichi Cancer Center Hospital during these 2 years (1986-1988). The number of patients with the breast cancer is increasing recently in Japan. This cancer, however, is one of the curable cancer at the early stage. Therefore, it is very important thing to detect a small malignant mass less than 1cm in a diameter by using these modalities. In addition, the establishment of the mass screening system for breast cancer is desired. In order to make a precise diagnosis, it is necessary to add some devices on the ordinary modalities. For examples, mechanical improvement of the Moribuden tube with 0.1mm focus, operation of ductgraphy and cystography by double contrast method in MMG and application of 10MHz transducer in US. Furthermore, needle biopsy under US or X-ray is expected positively to make a fast diagnosis. On the other hand, DMR (Digital Mammo-Radiography) system has a bright prospect for the mass screening of the breast cancer in the respect of efficacy, cost and radiation hazard. DMR system has many advantages as follows, 1. The system is capable of bringing out clearly very minor differences of contrast. 2. Tumor shadows can be easily displayed. 3. The lateral projection only is sufficient (allowing examination of the chest wall also). 4. The X-ray dose is small: 0.03-0.05mSv. 5. The equipment is inexpensive to use. 6. Patient positioning is simple, and examinations take little time. 7. Long operator training programs are unnecessary. 8. The system uses digital signals, and so automatic diagnosis is possible. 9. Theoretically, at least, tumors as small as 0.2 mm in diameter can be detected.

[Requirements for the randomized trial of i.a. vs. i.v. administration to reveal the impact of hepatic arterial infusion on survival in the treatment of liver metastases]

In spite of its high response rate, the impact of hepatic arterial infusion (HAI) chemotherapy on survival is still uncertain in the treatment of liver metastases. There were no significant differences in survival between i.a. and i.v. in western randomized trials for liver metastases from colorectal cancer in the 1980s. The requirements for randomized trials between i.v. and i.a. administration for liver metastases to reveal the impact of HAI on survival are as follows. 1) Investigators have standardized the technical level for HAI. 2) The natural history of the disease is not so long for continuing HAI over living period. 3) The cases have no extra-hepatic lesions. 4) The number of patients suffices for the evaluation. Therefore, the patients with liver metastases from gastric cancer and without extra-hepatic lesions are better materials for the randomized trial of i.a. vs i.v. in Japan, and the multiinstitutional trial with standard technical level is recommended.

[Diagnostic imaging for breast cancer]

With the westernization of the Japanese diet and way of life, the mortality due to breast cancer continues gradually to increase. This disease, however, is a type of cancer that can be well controlled by primary preventive measures and early detection. Numerous techniques of diagnostic imaging for breast cancer have been established, but the most common are mammography and ultrasonography. For X-ray mammography, a low tube voltage is necessary so that small differences in X-ray absorption by the various tissues within the breast may be detected, but when the surface dose is increased, it is a source of anxiety because of the possible development of secondary carcinoma. Ultrasonography of the breast, however, is free from the dangers of radiation exposure, and may be conducted in conjunction with palpation, thus representing a highly reliable approach. The diagnostic reliability of mammography and ultrasonography was investigated in 251 cases in which breast cancer was confirmed by these methods in a total of 752 outpatients who visited the Department of Breast Surgery of the Aichi Cancer Center Hospital in Nagoya, Japan. As a diagnostic procedure for breast cancer, mammography was shown to have a sensitivity of 89.2%, a specificity of 92.6%, and an accuracy rate of 91.5%, the respective values for the ultrasound technique being 84.9%, 88.9%, and 87.5%. These results are superior even to those of surgeons with 30 years of experience specializing in the breast (86.9%, 85.3%, and 85.8%), especially when tumors cannot be palpated.(ABSTRACT TRUNCATED AT 250 WORDS)

[A 5-FU, ADR, MMC combined hepatic arterial infusion therapy in non-resectable liver metastases from colon and gastric cancer]

Fifty-seven patients with non-resectable liver metastases (31 from colon cancer, 26 from gastric cancer) received 5-FU, ADR, MMC combined hepatic arterial infusion therapy. (FAMia: 5-FU 334 mg/m2 qw, ADR 20 mg/m2 q4w, MMC 2.7 mg/m2 q2w; in colon cancer, 5-FU 167 mg/m2/day continuously for 3 months and then 334 mg/m2 qw). Myelo-suppression, hepatic arterial occlusion, gastroduodenal toxicity and elevation of biliary enzyme were observed at 29%, 39%, 32% and 13% in colon cancer, respectively, and at 35%, 8%, 0% and 0% in gastric cancer, respectively. Response rates evaluated by CT-scan were 63% (1 CR + 18 PR/30) in colon cancer and 79% (4 CR + 15 PR/24) in gastric cancer. Overall median survival was 352 days in colon cancer and 449 days in gastric cancer. Concerning background factors, the response rate in the well-differentiated type of colon cancer was significantly higher than in the moderately differentiated type, and significantly low in poorly differentiated medullary type gastric cancer. The existence of extra-hepatic lesions was the most important factor in survival in both cancers. [colon cancer: (-) 740 days vs (+) 267 days; gastric cancer: (-) 517 days vs (+) 245 days]. In conclusion, this therapy yields favorable direct effects on liver metastases from colon and gastric cancer without major side-effects and complications, but effective therapy of extrahepatic lesions is required for longer survival. Now, to release colon cancer patients from restrictions of continuous infusion pumps, a phase I study of weekly high dose 5-FU HAI therapy is under way.

[On the assessment of the diagnostic accuracy of imaging diagnosis by ROC and BVC analyses--in reference to X-ray CT and ultrasound examination of liver disease]

To achieve an effective assessment of diagnostic accuracies of currently used imaging methods on liver diseases, X-ray CT (CT) and realtime ultrasound (US), ROC analysis and a new analysis method, "the bias to variance characteristics (BVC)" were applied in parallel. The survey has been carried out to assess an image interpretation accuracy on cases with established diagnosis collected on the multi-institutional basis. The images, CT and US of liver diseases including localized and diffuse lesions were selected for image reading sessions and the interpretative difficulties were geared to an appropriate grade so that it does fit to the basic requirement of ROC analysis. Consequently, 91 cases were selected from a total of 258 cases which were collected from 16 institutions. Two image reading sessions were scheduled and a total of 28 radiologists and sonologists undertook the first session. The final analysis covered 8 radiologists for CT and 9 sonologists who carried out both sessions. The image interpretation results were fed to the computer and analyses were made accordingly. Analysis of the first image reading session gave true positive ratios (TPR) of CT and US as 92.5% and 97.4%, and true negative ratios (TNR) of 50.5% and 46.8%, respectively. The second reading session, in which both CT and US images were interpreted simultaneously, gave the similar values of TPRs, 96-97% and TNRs, 44-47%. The ROC analysis of existence of liver mass and diagnosis of malignancy resulted in the higher values in US compared to CT in the first separate reading, however, the 2nd session gave almost identical values in each modality. The diagnostic accuracy for the benign tumors, mostly consisted of hemangioma, CT reading gave higher accuracy rates compared to the US. The entirely new interpretations scheme, arbitrarily named as BVC was carried ou on matrix data obtained in the same experiment. The scatterograms plotted according to the BV values, the mean and the standard deviation inherent to individual cases have demonstrated marked variations among individual cases most likely reflecting the interpretative difficulty of respective images, thus indicating the method to be well in adjunct to the ROC analysis.

[Non vascular interventional radiology--general]

Since last about 20 years, invasive diagnostic procedures have gradually changed the conception to interventional radiology (IVR). Non vascular IVR has been developing steadily by suitable instruments and excellent techniques as well as vascular IVR. The fields of non-vascular IVR is becoming wider and wider in various regions in the body. Non-vascular IVR contains many kinds of drainage and forming inner fistula in the biliary and urinary tracts, for example, occlusive jaundice or hydronephrosis. Drainage for abscess in the thoracic or abdominal cavity is a good indication except peri-pancreatic abscess. In addition, IVR means time saving and cost saving in the aspiration biopsy for malignant neoplasms this is fast decision for reasonable therapies. In the earlier period, aspiration biopsy was considered as dangerous method because of bleeding and dissemination of malignant seeds along the route of aspiration needles. By using fluoroscopic image amplifier and ultrasonic unit, non-vascular IVR has many indications that radiologist's specialty demonstrated. Therefore, radiologist should have heavy responsibility based on understanding of right knowledge and good management for non-vascular IVR.

Roentgenologic appearance of a thorotrast-induced small cholangiocarcinoma in a case of thorotrastosis. An autopsy case of massive gastrointestinal bleeding of esophageal varices

A small cholangiocarcinoma was detected at autopsy in a patient with thorotrastosis who died from the rupture of esophageal varices at the esophagogastric junction. Prior to the advent of recent diagnostic imaging technique, a correct antemortem diagnosis could only be obtained from tumor markers. However, the tendency for the opacity of the liver to decrease slowly with time and develop uneven trabeculation suggests that small tumors may be difficult to detect against such a non-homogeneous background.

[5-FU/ADR/MMC combined hepatic infusion in liver metastases from gastric cancer]

Twenty patients with liver metastases from gastric cancer judged non-resectable and the factors limiting their survival were treated with 5-fluorouracil (5-FU), adriamycin (ADR) and mitomycin C (MMC) combined hepatic arterial infusion chemotherapy. The catheter was placed into the hepatic artery, via the left subclavian artery in every case, and 5-FU 334 mg/m2 qw, ADR 20 mg/m2 q4w, MMC 2.7 mg/m2 q2w was administered bolusly. Myelo-suppression (WBC less than 2,000 or platelet less than 50,000) occurred in 25% of the patients, but this therapy was tolerable in all patients without major complication. The response rate in evaluable cases by CT-scan was 76.5% (4CR + 9PR/17), and 50% survival was 407 days. A significant correlation between the existence of extra-hepatic lesions and 50% survival (extra-hepatic lesions (-): 196 days vs (+): 464 days) was noted. The comparison between responder and non-responder in terms of 50% survival and the cause of death showed the importance of control of liver metastases for improved survival.

[Digital mammo-radiography (DMR) in mass screening for breast cancer]

There are still many problems to be overcome in the development of mammographic apparatus suitable for mass screening purposes, but a certain number of these have been solved in the system discussed in the present paper. The equipment employs the technique of displaying I.I. images on a monitor by means of an image processor. This possesses the advantages of both film mammography and xeromammography, and the X-ray dose involved is small. The following advantages over film mammography are offered: The system is capable of clearly bringing out very minor differences of contrast. Tumor shadows can be easily displayed. The X-ray dose is small: 0.03-0.05 R. The equipment is inexpensive to use. Patient positioning is simple, and examinations take little time. Long operator training programs are unnecessary. The system uses digital signals, and so automatic diagnosis is possible. Theoretically, at least, tumors as small as 0.2 mm in diameter can be detected. The future goal is discovering unpalpable breast cancers. DMR is useful because of low dose, low cost and high safety. In our study as screening for breast cancer, DMR system shows high sensitivity (87.1%), specificity (78.7%) in 391 cases of out patients.

[Changes in CT findings in patients with liver metastases of breast cancer during effective intra-arterial infusion]

A study was done of the changes occurring in the CT findings of 12 cases in which liver metastases were found after radical mastectomy for breast cancer, as a result of intermittent low-dose hepatic arterial infusion chemotherapy using a reservoir, achieving PR. In four cases (33.3%) only shrinkage of the metastatic lesions was seen; in 3 others (25.0%), this was accompanied by irregularities in the margins of the liver surface; in the other 5 (41.7%), a high proportion of total, widespread compensatory deformity of the liver was observed. A tendency was noted for these changes to be more pronounced in cases in which the metastatic lesions occupied a large proportion of the liver. Hepatic degeneration appeared with a high frequency in cases where liver metastasis followed breast cancer, and it is considered that considerable care is necessary in evaluating the efficacy of treatment.

Increased risk of death in thorotrast-exposed patients during the late follow-up period

To evaluate the effects of continuous low-level ionizing radiation on humans, the follow-up data (1980-85) on Japanese thorotrast-exposed patients were analyzed. The patients were 241 war-wounded military personnel registered with and cared for by the Ministry of Health and Welfare since 1979. During this period, a total of 1144 person-years, 94 patients died. Compared with the expected number of deaths calculated from age- and cause-specific death rates in Japan during the same period, the thorotrast-exposed patients were at three times greater risk of death from all causes (P less than 0.001), had 47 times the risk of liver cancer (P less than 0.001), 12 times the risk of leukemia (P less than 0.05), and 20 times the risk of liver cirrhosis (P less than 0.001). Age at time of thorotrast injection, drinking and smoking habits had little effect on these statistics. Analyses of 30 autopsied patients with liver cancer showed statistically significantly increases in hemangiosarcoma and cholangiocarcinoma. The thorotrast-exposed patients' estimated risk of liver cancer by histological type was 21 times that of the general population for hepatocellular carcinoma, 303 times that for cholangiocarcinoma and 3129 times that for hemangiosarcoma.

[The effect and CT imaging of FAM hepatic infusion chemotherapy in patients with liver metastasis from colorectal carcinoma]

A study of FAM (5-FU, ADM, MMC) hepatic infusion chemotherapy via the left subclavian artery was performed in 40 patients with liver metastasis from colorectal carcinoma. The response rate was 61.1% (1 CR and 21 PR among 36 evaluable cases), and the 50% survival period was 11.6 months. CT imaging in the 22 responders was discussed. The CT scan images showed no remarkable changes except for tumor size in 10 cases (45.5%), a decrease of marginal density in 4 cases (18.2%), an increase of calcification in 2 cases (9.1%), dimpling sign in 3 cases (13.6%) and fatty liver degeneration and abscess formation in the hepatic duct in 1 case (4.5%). These findings on CT scan were important for evaluating the effects and side effects in patients receiving hepatic infusion chemotherapy, and provided useful information for follow-up.

[A study of hepatic arterial occlusion by infusion chemotherapy via the left subclavian artery]

Hepatic arterial infusion chemotherapy via the left subclavian artery was performed in 112 patients with primary or metastatic liver tumors, and those cases showing hepatic arterial occlusion were discussed. Hepatic arterial occlusion occurred in 22.3% of cases, and the rates of occurrence in males and females showed no significant difference. Therefore, when the catheter was placed and replaced in the RHA or LHA, the occurrences of arterial occlusion seemed to be relatively high, i.e., 45.5% and 50.0%. The diameter of the hepatic artery, which was measured in 25 patients with hepatic arterial occlusion (occlusion group) and 17 patients in a control group (catheter placed in position for over 150 days) on angiographs was 5.2 +/- 1.42 mm (mean +/- S.D) in the occlusion group and 6.1 +/- 1.77 mm in the control group, but the difference was not significant (p less than 0.05). Clinical symptoms and flow scintigraphy were useful for the diagnosis of hepatic arterial occlusion. However, recently, a frequent check of drug delivery has been necessary.

[Preliminary results of a phase II study of 5-FU, adriamycin, and mitomycin C (FAM) in combined hepatic infusion in patients with non-resectable metastatic liver cancer]

Sixty-eight patients in which non-resectable liver metastases were the predicted limiting factor of their survival were treated with 5-FU, ADM, MMC combined hepatic infusion chemotherapy using the following regimen: 5-FU 334 mg/m2/w shot, ADM 20 mg/m2/4 shot, MMC 2.7 mg/m2/2w shot. In the case of colorectal cancer, 5-FU 167 mg/m2/day continuously for over 3 months, then 334 mg/m2/w shot was used. In every case, the catheter was placed into the hepatic artery via the left subclavian artery and an implantable portal system was used for shot infusion and a portable pump for continuous infusion. The results were as follows: Except for one drop-out case, 67 patients were able to receive this therapy. Bone marrow suppression occurred in 32.8% of patients, gastroduodenal trouble in 31.3%, and hepatic arterial occlusion in 19.4%. Response rates and 50% survival times were 65.6%, 324 days for colorectal cancer, 80.0%, 393 days for breast cancer, and 87.5%, 342 days for gastric cancer. These are preliminary results. However, we conclude that it is appropriate to go on with this study, although discussion of this regimen involving more cases is required.