[A case report of preoperative intra-arterial infusion chemotherapy for pancreatic head carcinoma]

Intra-arterial infusion chemotherapy was given preoperatively to one patient with pancreatic head adenocarcinoma, in order to prevent local failure after surgery. Under an angiographic procedure, a catheter was placed in the gastroduodenal artery after embolizing the right gastric artery and gastroepiploic artery. Before surgery, 5-fluorouracil (250 mg/day) had been continuously infused for 2 weeks and bolus infusion of methotrexate (25 mg) with 5 micrograms of angiotensin-II had been performed every 3 days. As a results, the maximum diameter of the pancreatic tumor decreased from 3 cm to 2 cm on the CT-Scan. An extended pancreatoduodenectomy with portal vein reconstruction was performed. In histologic study, degenerative tumor cells were shown not only in the primary tumor but also in the extrapancreatic perineural invasion.

[An adult case of mediastinal lymphangioma]

Mediastinal lymphangioma is rare (less than 1%) and is usually not discovered until adulthood because of its asymptomatic nature and deeply seated location. We experienced an adult case of mediastinal lymphangioma. CT and MRI showed a non-invasive multilocular cystic mass spreading in the potential space of the mediastinum including the precardiovascular region and central region. To determine the extent of the tumor, the concept of the potential space of the mediastinum was useful in making the differential diagnosis of cystic mediastinal tumor.

Reducing misregistration of mask image in hepatic DSA

When performing hepatic digital subtraction angiography, misregistration of the mask image can cause artifacts that obscure pathology. For this article, researchers analyzed the breath expiration times of 59 patients and found that expiration times ranged from 1.8 seconds to 6 seconds. Thirty DSA series were obtained taking into account the patient's breath expiration time, and 35 series were obtained without taking the expiration time into consideration. Artifacts were detected in 20% of the DSA series where expiration time was taken into consideration and in 42.9% of series where it was not (p < 0.05). The research showed that misregistration of the mask image during hepatic DSA can be reduced by starting the exposure at the end of breath expiration.

Paradoxic uptake of Gd-EOB-DTPA by hepatocellular carcinoma in mice: quantitative image analysis

To determine whether paradoxic uptake of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) occurs only with highly differentiated hepatocellular carcinomas, quantitative image analysis was performed in 37 mice with 133 hepatocellular carcinomas. The results of lesion/ liver signal intensity measurement and relative enhancement calculation indicate that paradoxic positive enhancement occurs independently of cellular differentiation.

Types of diaphragmatic motion during hepatic angiography

To determine the types and causes of diaphragmatic motion during hepatic angiography, the authors used transarterial cut-film portography (TAP) to study movement of the diaphragm during breath-holding. Thirty-three TAP sequences were studied, and the patients' diaphragmatic motions were classified into four categories according to the distance their diaphragms moved. Results showed that the diaphragm was stationary in 33% of the TAP studies, while perpetual motion occurred in 15% of the studies, early-phase motion occurred in 12% and late-phase motion occurred in 40%. Ten sequences showed diaphragmatic motion of more than 10 mm, with eight sequences showing caudal motion and two showing cranial motion. This article discusses the cause of diaphragmatic motion during breath-holding for hepatic angiography and presents suggestions to reduce motion artifacts during the exam.

A computerized analysis system in chest radiography: evaluation of interstitial lung abnormalities

We evaluated the usefulness of a computerized analysis system in the detection of interstitial lung abnormalities in digitized chest radiography. This system uses the processes of four-directional Laplacian-Gaussian filtering, linear opacity judgment, and linear opacity subtraction. For qualitative analysis, we employed a combined radiographic index, which was calculated from two normalized radiographic indices obtained by linear opacity judgment and subtraction of linear opacities. We selected 50 regions of interest (ROIs) in patients with mild interstitial lung abnormalities, 50 ROIs in patients with severe interstitial lung abnormalities, and 50 ROIs in individuals with normal lung parenchyma. High-resolution computed radiography (HRCT) findings were used as the standard of reference for this study. These ROIs were processed by our computerized analysis system, and radiographic indices were obtained from each ROI. The area under the receiver operating characteristic curve (Az) was used as the measure of performance. The combined radiographic index provided better results in the mild interstitial lung abnormality group (Az = 0.94 +/- 0.02), but it also yielded good results in the severe interstitial lung abnormality group (Az = 0.98 +/- 0.01). These results indicate that this system of combining radiographic indices has improved the detection performance over that with our previous system.

Prospective and randomized trial of lipiodol-transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: a comparison of epirubicin and doxorubicin (second cooperative study). The Cooperative Study Group for Liver Cancer Treatment of Japan

A randomized, controlled clinical trial was conducted to compare the use of epirubicin (EPI) and doxorubicin (DOX) in Lipiodol (Laboratoire Guerbet, Roissy-Charles-de-Gaulle Cedex, France)-transcatheter arterial chemoembolization as a treatment of hepatocellular carcinoma. One hundred ninety-two hospitals participated, and 415 patients were enrolled in the study during the period between October 1989 and December 1990. The patients were randomly allocated to group A (EPI) or group B (DOX) by a centralized telephone registration. The actual doses of EPI and DOX were 72 mg/body and 48 mg/body, respectively. The 1-, 2-, and 3-year survival rates were, respectively, 69%, 44%, and 33% for group A and 73%, 54%, and 37% for group B. There were no statistically significant differences (P = .2296, log-rank test). When each group of patients was classified retrospectively into high-risk and low-risk subgroups based on the severity index calculated by the Cox regression model from the significant prognostic factors (the pretreatment tumor size, the pretreatment serum alpha-fetoprotein level, tumor encroachment, and Child's classification), the survival curve of the low-risk DOX subgroup was significantly superior to that of the low-risk EPI subgroup (P = .0182). However, there was no significant difference between the high-risk subgroups (P = .4606). The change in the serum alpha-fetoprotein level, the extent of Lipiodol accumulation in the tumor, and the extent of tumor reduction after the treatment did not show any significant differences between the groups. The white blood cell count in group B showed a tendency to decrease slightly more than in group A at 3 weeks after Lipiodol-transcatheter arterial chemoembolization. In conclusion, there was no statistically significant difference between the survival curves of the EPI and DOX groups in Lipiodol-transcatheter arterial embolization treatment of hepatocellular carcinoma.

MR imaging evaluation of renal cell carcinoma

BACKGROUND

This study examines the minimally required imaging protocol needed for detection and staging of renal cell carcinoma (RCC).

METHODS

In 81 patients (21 women, 60 men; mean age = 62 years) with 85 RCCs, T1-weighted (T1WI), contrast-enhanced T1-weighted (Gd-T1WI), T2-weighted (T2WI), and gradient recalled echo-fast low flip angle shot (GRE/FLASH) images were evaluated alone and in combination. Surgical-pathological findings were available in all patients and were considered the standard of reference.

RESULTS

Tumor detection for lesions smaller than 3 cm was better on Gd-T1WI than on any other sequence, but only the comparison with noncontrast T1WI and GRE/FLASH was statistically significant (detection: T1WI = 33%, Gd-TIWI = 80%, T2WI = 60%, GRE = 47%). The respective accuracies of T1WI, Gd-T1WI, T2WI, and GRE/FLASH images were 81%, 78%, 71%, and 62% for evaluating local tumor extension; 90%, 88%, 89%, and 85% for lymphadenopathy; and 89%, 81%, 91%, and 95% for renal vein thrombus. The combination of T1WI and GRE sequences rendered the highest overall staging accuracy.

CONCLUSION

For tumor detection, contrast-enhanced T1WI is necessary for lesions smaller than 3 cm. For tumor staging, although the addition of GRE results in significant improvement in the evaluation of venous thrombus, any combination of two sequences will result in similar accuracy, and the use of multiple sequences is not necessary.

Using compensating filters to reduce radiation dose

The study described in this article explores the role of compensating filters in reducing radiation exposure. Radiation exposure levels with and without filters were compared in skull radiographs, hepatic angiographs and one-shot full-length lower extremity radiographs. Absorbed doses were measured with and without a skull filter in a phantom at a depth of 5 cm. Results showed that filters reduced exposure by 29% in skull radiographs, 47% in hepatic angiographs and 80% in one-shot full-length lower extremity radiographs. Absorbed doses were reduced by more than 26% in the skull phantom in the filtered area. To reduce patient dose, the filters were positioned between the x-ray tube and the patient.

MR of xanthogranuloma of the choroid plexus

We present a case of a xanthogranuloma of the lateral ventricle choroid plexus in association with focal areas of abnormal T2 signal in the tegmentum of the pons as well as within the middle cerebellar peduncles. The characteristic MR appearance of this rare entity is described along with a pathologic basis suggesting an association with posterior fossa lesions.

Contrast enhancement with Gd-EOB-DTPA in MR imaging of hepatocellular carcinoma in mice: a comparison with superparamagnetic iron oxide

The purpose of this study was to evaluate the ability of the new liver-specific magnetic resonance contrast agent gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid (Gd-EOB-DTPA) to detect hepatocellular carcinoma (HCC). Seventeen mice with 66 chemically induced HCCs underwent magnetic resonance imaging with both Gd-EOB-DTPA (30 mumol/kg) and superparamagnetic iron oxide (SPIO; 10 mumol/kg). After enhancement, lesion-to-liver contrast-to-noise ratios (CNRs) of 47 detected HCCs increased negatively from 3.7 +/- 10.7 (mean +/- SD) to -55.1 +/- 25.8 with Gd-EOB-DTPA (P < .001) and increased positively from 10.4 +/- 10.4 to 26.1 +/- 16.3 with SPIO (P < .001). The improvement of CNR after administration of SPIO was less in smaller lesions (< 4 mm), whereas that after administration of Gd-EOB-DTPA was independent of lesion size. However, Gd-EOB-DTPA positively enhanced four HCCs (8.5%), both highly differentiated (grade 1) and moderately differentiated (grade 2). Gd-EOB-DTPA allows the conspicuous detection of small HCCs; however, moderately differentiated HCCs occasionally may be positively enhanced.

Clinical features of small hepatocellular carcinomas as assessed by histologic grades

BACKGROUND

Ninety-seven patients with small hepatocellular carcinomas (HCCs) measuring 3 cm or less in size and three patients with adenomatous hyperplasia who underwent radical hepatic resection were examined in this study.

METHODS

The lesions were classified into four groups according to the following histologic grading criteria: group A, adenomatous hyperplasia (n = 3); group B, early HCC (n = 6); group C, well-differentiated HCC (wHCC) (n = 32); and group D, moderately or poorly differentiated HCC (n = 59). The involvement factors that seemed to be important or to characterize the progression of HCC and the survival rates were compared among the four histologic groups.

RESULTS

The frequency of patients with tumors larger than 2.0 cm in size and that of patients with 200 or more ng/ml serum alpha-fetoprotein increased with the progression of histologic malignancy. Tumor staining on the angiogram, capsular formation, and extranodular invasion were never seen in groups A and B, but they began to appear in group C and increased remarkably in group D. The 5-year survival rates of the patients in groups B, C, and D were 100%, 60%, and 27%, respectively, and statistically significant differences were seen among them. In comparative evaluation of the group C patients the lesions that showed no tumor staining had no capsule, and those that had no capsule had no extranodular invasion. The 5-year survival rate of patients with wHCC without extranodular invasion (81%) was significantly higher than that of patients with extranodular invasion (35%) (p < 0.05).

CONCLUSIONS

It may be recommended to provide the category of wHCC without extranodular invasion for pathologic classification of clinically early HCC (i.e., HCC of high curability).

[Usefulness of spiral CT in the detection of hypovascular, well-differentiated hepatocellular carcinoma]

Whole liver scanning during artery-dominant phase using spiral CT was performed in 14 patients with 17 histologically proven well-differentiated HCCs, which were not depicted by hepatic digital subtraction angiography but by CT during arterial portography. The density of HCC relative to the liver was evaluated with conventional precontrast CT, spiral CT, and following conventional CT during the equilibrium phase. Comparison between spiral CT and magnetic resonance (MR) imaging of dynamic contrast studies was also investigated. Four tumors of 17 HCCs (24%) were shown as a high-density area by the artery-dominant phase using spiral CT. Consequently, the total sensitivity of these three kinds of CT techniques was elevated to 82%. The sensitivity of dynamic MR imaging was slightly greater than that of spiral CT. However, spiral CT sometimes made the diagnosis more conspicuous by it's good spatial resolution. Our results indicate that spiral CT has a potential benefit in the detection of hypovascular well-differentiated HCC, and MR imaging and spiral CT may be complement each other.

[Double lumen--coaxial catheter system for combined CT during arterial portography and CT hepatic angiography]

The high sensitivity of CT during arterial portography (CTAP) for hepatic lesions is accompanied with a lack of specificity for diagnosis. Combined CTAP and CT hepatic angiograpy (CTHA) had been proved to improves lesion detection and heightens confidence in interpreting perfusion abnormalities. We describe a new double lumen - coaxial catheter system for performing combined CTAP and CTHA without the need for repeated transfer of the patient or bilateral arterial punctures. This technique was employed in eight patients with liver neoplasms. In all eight patients, CTAP and CTA images were obtained successfully. We concluded that this method was useful for the evaluation of liver tumors.

G10BP, an E1A-inducible negative regulator of Sp1, represses transcription of the rat fibronectin gene

Downregulation of the fibronectin (FN) gene in a rat 3Y1 derivative cell line, XhoC, transformed by the adenovirus E1A and E1B genes seems to be caused by the induction of a negative regulator, G10BP, which binds to three G-rich sequences in the promoter (T. Nakamura, T. Nakajima, S. Tsunoda, S. Nakada, K. Oda, H. Tsurui, and A. Wada, J. Virol. 66:6436-6450, 1992). These are the G10 stretch and two GC boxes consisting of the G10 stretch with one internal C residue insertion. The recognition sequences of G10BP and Sp1 (GGGCGG) overlap in these GC boxes. To analyze the mechanism of the downregulation, G10BP was purified by DNA affinity chromatography, and its molecular mass was estimated to be about 30 kDa. The promoter was modified by substituting the sequence GGGG with ATCC or CTTA in these G-rich sequences, leaving the Sp1 motif intact, and by replacing the Sp1 motif by the T stretch. Transcription of FN promoter-chloramphenicol acetyltransferase fusion genes carrying the base substitution in one or more of these G-rich sequences both in vivo and in vitro revealed that the base substitution in any G-rich sequence results in reduction of promoter activity, although the downstream GC box (GCd) plays a primary role. The addition of G10BP severely inhibited the activities of the FN promoters carrying the wild-type GCd in vitro, while the promoters carrying the mutant GCd were unaffected. The binding affinity of G10BP and Sp1 to each of the G-rich sequences, analyzed by gel shift assays, indicated that G10BP binds strongly to the GCd, moderately to the G10 stretch, and weakly to GCu, while Sp1 binds strongly to GCu, moderately to GCd, and weakly to the G10 stretch. Sp1 binding to GCd and the G10 stretch was inhibited by G10BP, while binding to GCu was unaffected. These results indicate that FN gene transcription is inhibited in XhoC cells primarily by exclusion of Sp1 binding to GCd by G10BP and that G10BP is a new class of Sp1 negative regulator.

Comparative safety and efficacy of two immune globulin products in Kawasaki disease

OBJECTIVE

To compare the safety and efficacy of various intravenously administered immune globulin (IVGG) products in patients with Kawasaki disease.

METHODS

We performed a retrospective matched-pair study of 45 pairs of patients, matched by age, gender, hospital, and illness day when IVGG therapy was initiated. All patients received aspirin, 80 to 100 mg/kg per day; one of each pair received Venoglobulin, 2 gm/kg (product A), and the other received Iveegam, 2 gm/kg (product B). Safety was assessed during and after IVGG infusion by recording rigors, pruritus, hypotension, urticaria, and nausea. Treatment efficacy was evaluated by posttreatment height and duration of fever, and subsequent echocardiographic changes.

RESULTS

Untoward reactions during infusions occurred more often with product A (25%) than with product B (2%) (p < 0.025); most reactions were rigors (18% vs 2%) (p < 0.05). Therapy was completed in all patients. Height of fever and proportion of patients febrile each day after product A or B did not differ significantly. No differences were found in the frequency of coronary artery abnormalities 1 year after illness.

CONCLUSIONS

No significant differences in efficacy appeared between the two IVGG products, but they differed significantly in non-life-threatening adverse reactions, especially infusion-related rigors. Other IVGG products should be evaluated in a similar fashion.

Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer

The accuracy of endoscopic ultrasonography (EUS) for diagnosis of pancreatic cancers was evaluated in consecutive 232 patients with possible pancreatic cancer, and that for assessment of their locoregional spread was evaluated in 28 patients with pancreatic cancer subjected to pancreatectomy, in comparison with the accuracies of transabdominal ultrasonography (US) and computed tomography (CT). EUS was found to be significantly more accurate than US or CT and was especially useful for detecting small pancreatic cancers of less than 2 cm in diameter. With EUS, pancreatic cancers could be detected as a hypoechoic mass with a relatively unclear margin and irregular internal echoes. EUS was also more sensitive than CT and US for detecting venous and gastric invasions: it was more useful for detecting direct invasion of pancreatic cancers when the tumors were less than 3 cm in diameter. These findings indicate that EUS is an accurate method for diagnosis of pancreatic cancer and assessment of their locoregional spread and is particularly useful for detecting small tumors.

Hepatocellular carcinoma: efficacy of transcatheter oily chemoembolization in relation to macroscopic and microscopic patterns of tumor growth among 100 patients with partial hepatectomy

PURPOSE

To evaluate the efficacy of transcatheter oily chemoembolization (TOCE) for hepatocellular carcinoma (HCC) on the basis of microscopic and macroscopic findings postembolization.

METHODS

HCCs ranging in size from 0.5 to 13 cm (mean 3.6 cm) were obtained from partial hepatectomies of 100 consecutive patients who had undergone TOCE between 20 and 246 days (mean 59.5 days) prior to surgery. The efficacy of TOCE was assessed on the basis of the necrotic to live cell ratio of the tumors. The microscopic pattern of tumor growth was grouped into expanding type (complete capsule formation) and replacing type (incomplete or no capsule). There were five types of macroscopic groupings: single nodule, single nodule with extranodular growth (SNE), contiguous and noncontiguous multinodular, and massive growth type.

RESULTS

Among 79 cases with the expanding type, 29 (37%) had 100% HCC necrosis, but none with 100% necrosis were in the replacing type. By macroscopic grouping, the efficacy of TOCE decreased from the single nodule type (50% of patients had 100% necrosis) to the SNE type (21%), and the other types (9%).

CONCLUSION

TOCE appears to be most efficacious for HCC with the expanding growth pattern and HCC forming single nodules. Poor results are to be expected in HCC of replacing growth type and multinodular or massive growth types.

Dye-injection method for placement of an infusion catheter in regional hepatic chemotherapy

PURPOSE

To evaluate the usefulness of a dye-injection method in the placement of an infusion catheter and port via proximal branches of the axillary artery for hepatic infusion chemotherapy.

MATERIALS AND METHODS

Sixteen patients with surgically unresectable hepatic cancer underwent transfemoral hepatic arteriography. Then a 3-F coaxial catheter was inserted into a proximal branch of the left axillary artery. Dye injected through the coaxial catheter during the surgical procedure improved the visualization of the target branch. The coaxial catheter was also used as a guide for retrograde insertion through the target branch of an infusion catheter into the descending aorta.

RESULTS

In 13 of 16 patients (81%), catheterization was successful without exposure of the axillary artery. In these patients, the acromial-deltoid branch of the thoracoacromial artery was chosen as the target.

CONCLUSION

Injection of dye simplifies the surgical procedure for placement of a hepatic infusion catheter via proximal branches of the axillary artery. The depth and extent of incisions, as well as the risk of nerve injury, are reduced.

Developing a new picture archiving and communication system for the new Osaka University Hospital

Osaka University Hospital moved into a new hospital building on the suburban Suita campus in October 1993. A newly developed hospital information system, a new radiologic information system and phase I of a completely new Picture Archiving and Communication System (PACS) also began operating. Work began in 1986 on this PACS. The PACS effort has been guided by one working group and two committees during the last 7 years. A survey of the previous diagnostic and image delivery system was performed as part of the preamble to designing an optimal PACS. Extensive analysis and measurement of pre-existing operational conditions was undertaken. These studies and technical research projects are described in a companion paper in this issue. The phase I hardware installation and initial testing were completed in March 1994. Subsequent phases will build incrementally until the completely new, hospital-wide PACS is realized.

Initial data-element selection for the evaluation of picture archiving and communication system performance

The completely new, hospital-wide picture archiving and communication system (PACS) now being implemented at Osaka University Hospital is described elsewhere in this issue. This paper lists the many studies of the department and hospital that were performed before the PACS for the purpose of identifying data elements for use in evaluating a PACS system. A second purpose of the initial data-element collection was to assist in the overall Osaka University PACS design. Selected studies from this work are presented here.

A comparison of conventional screen-film radiography and hard copy of computed radiography in full and two-thirds sizes in detection of interstitial lung disease

This study examined whether hard-copy radiographs produced from computed radiography (CR) images show the subtle interstitial pulmonary disease equally well to conventional screen-film radiographs, because a digital radiography should be chosen for introduction of the digital picture archiving and communication system (PACS) for the new Osaka University Hospital. Eleven radiologists examined 20 abnormal and 20 control chest radiographs presented in each of three groups: conventional screen-film radiographs and two sizes of hard-copy radiographs made from CR images. This study of digital image quality of chest examinations found that some findings on conventional screen-film radiography images are not reproduced by current CR (2,000 x 2,000 x 10 bits in matrix), especially when the experienced radiologists were observed. This finding suggested improvements are needed in CR before CR of chest should fully replace conventional screen-film radiography.