Malignant pheochromocytoma with multiple hepatic metastases treated by chemotherapy and transcatheter arterial embolization

A 62-year-old Japanese male developed multiple hepatic metastases two years after resection of pheochromocytoma of the right adrenal gland. Transcatheter arterial embolization (TAE) was performed for the purpose of the treatment of hepatic metastases resistant to 27 cycles of combined chemotherapy consisting of cyclophosphamide, vincristine, and dacarbazine. After TAE, the hepatic metastatic lesions decreased in size and hypertension passed its crisis. The present case suggests the utility of TAE for multiple hepatic metastases under careful blood pressure monitoring.

Clinical efficacy and indication of acetazolamide treatment on sleep apnea syndrome

The efficacy and indication of acetazolamide treatment on patients with sleep apnea syndrome (SAS) were discussed from assessing the changes of polysomnographic findings with the treatment in 75 SAS patients. For the patients as a whole, respiratory disorder variables improved significantly during the treatment. However, the number of acetazolamide treatment responders who showed a decrease of apnea hypopnea index (AHI) to 50% or less of the pretreatment value numbered only 34 (45.3%). The lower values of body mass index and AHI in the responder group indicated that monotherapy with acetazolamide is the treatment choice only for mild SAS cases without obesity. However, combined treatment with acetazolamide and uvulopalatopharyngoplasty was thought to be beneficial for severe cases.

Aortoiliac and lower extremity arteries: comparison of three-dimensional dynamic contrast-enhanced subtraction MR angiography and conventional angiography

PURPOSE

To determine the clinical feasibility of three-dimensional dynamic contrast agent-enhanced subtraction magnetic resonance (MR) angiography in patients with symptoms of lower extremity ischemia.

MATERIALS AND METHODS

Twenty-three patients suspected of having lower extremity ischemia underwent three-dimensional dynamic contrast-enhanced subtraction MR angiography of the aortoiliac arteries and arteries of the lower extremity. As the reference standard, conventional angiography was also performed. For data analysis, the arterial system was divided into 10 segments. Each segment was classified as normal, mildly stenosed, moderately stenosed, severely stenosed, or occluded.

RESULTS

At conventional angiography, 83 stenosed segments (14 mildly stenosed, 16 moderately stenosed, 14 severely stenosed, and 39 occluded) were identified in a total of 423 segments. For the segments with more than mild stenosis, MR angiography was 97.1% sensitive and 99.2% specific.

CONCLUSION

Three-dimensional dynamic contrast-enhanced subtraction MR angiography has high sensitivity and specificity. This technique is a noninvasive alternative to conventional angiography for screening patients suspected of having lower extremity ischemia.

Refractory hepatic hydrothorax treated with transjugular intrahepatic portosystemic shunt

A 66-year-old cirrhotic woman was referred to our hospital for evaluation of refractory pleural effusion and dyspnea. Massive right sided-pleural effusion but no ascites was detected. She had been treated with diuretics and albumin, repeated thoracenteses, and pleural drainage with an intercostal catheter, all of which had failed to relieve her symptoms. The diagnosis of hepatic hydrothorax without ascites was made by injection of technetium-99m-sulfur colloid into the peritoneal cavity. A transjugular intrahepatic portosystemic shunt was placed and successfully reduced the pleural effusion, resulting in complete relief of her symptoms. The patient has been free of symptoms for 18 months after the procedure.

Arterial dynamic appearance of common bile duct carcinoma by helical CT on angiography (angio-HCT): four operated cases

We present four cases of common bile duct carcinoma in which both angiographic helical CT (angio-HCT) and pancreatoduodenectomy were done in the 3 years since 1995. Angio-HCT was performed with direct infusion of the contrast medium through the gastroduodenal artery inserted on angiography. Angio-HCT displayed the tumors as lower density areas in contrast to the strong enhancement of the circumferential nontumorous areas, including the pancreas and duodenum.

Infected abdominal aortic aneurysm: early CT findings

We describe computed tomographic (CT) findings at the early stage of infected abdominal aortic aneurysm in three patients. Periaortic mass and increased fat density were the characteristic findings of early aortic infection on CT. Similar findings caused by other diseases may be difficult to differentiate by imaging alone, but these findings should be used to trigger close follow-up for patients with suspected infected abdominal aortic aneurysm.

Abscopal regression of hepatocellular carcinoma after radiotherapy for bone metastasis

Spontaneous regression of hepatocellular carcinoma is a rare phenomenon. Abscopal regression of tumours resulting from the effect of irradiation of a tissue on a remote non-irradiated tissue is also rare. The case of a 76 year old Japanese man with hepatocellular carcinoma that regressed after radiotherapy for thoracic vertebral bone metastasis is described. Serum levels of tumour necrosis factor-alpha increased after radiotherapy. The findings suggests that such abscopal related regression may be associated with host immune response, involving cytokines such as tumour necrosis factor-alpha.

[Relationship between aging and morphological bone changes of the condyle in temporomandibular disorders]

In order to clarify the clinical significance of morphological bone changes of the mandibular condyle in temporomandibular disorders, the relationship between radiographic bone changes and aging was clinically studied. The subjects of the study were 1,120 patients (812 females and 308 males). The average age was 33 years +/- 15 years (from 10 to 81 years of age). The 1,120 patients were divided into six age brackets (10 to 19 years, 20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 81 years). According to radiograms taken by lateral oblique transcranial projection, orbitcondyle projection and orthopantomography, the morphological bone changes were classified into seven groups, erosion, osteophyte, eburnation, flattening, deformity, concavity and sclerosis. The results were as follows: 1. The incidence of the patients with radiographic bone changes of the mandibular condyle increased with aging and showed significantly different age distribution from that without bone changes (Mann-Whitney U test: p < 0.01). 2. The incidence of erosion did not increase with aging and showed significantly different age distribution from osteophyte or eburnation (Mann-Whitney U test: p < 0.01, 0.05). The incidence of flattening also did not increase with aging and showed significantly different age distribution from osteophyte, eburnation or deformity (Mann-Whitney U test: p < 0.01, 0.05, 0.05).

CT of neural plexus invasion in common bile duct carcinoma

PURPOSE

Our purpose was to analyze the CT findings of neural plexus invasion in common bile duct carcinoma.

METHOD

We studied 16 patients with common bile duct carcinoma who underwent surgery. Of these, neural invasion was seen in 10 patients. CT findings were retrospectively reviewed and correlated with the surgical and pathological findings.

RESULTS

Irregular masses adjacent to the medial aspect of the uncinate process were observed in 4 of 14 patients with distal common bile duct carcinoma. These lesions extended medially and showed contiguity with the superior mesenteric artery and/or celiac axis, corresponding to neural plexus invasion with desmoplastic change. Increased attenuation of the fat between the common bile duct and the proper hepatic artery was seen in two of two patients with proximal common bile duct carcinoma, associated with neural plexus invasion in the hepatoduodenal ligament.

CONCLUSION

The location and spread of neural plexus invasion in common bile duct carcinoma are characteristic and can be diagnosed by CT.

Axin, a negative regulator of the wnt signaling pathway, directly interacts with adenomatous polyposis coli and regulates the stabilization of beta-catenin

The regulators of G protein signaling (RGS) domain of Axin, a negative regulator of the Wnt signaling pathway, made a complex with full-length adenomatous polyposis coli (APC) in COS, 293, and L cells but not with truncated APC in SW480 or DLD-1 cells. The RGS domain directly interacted with the region containing the 20-amino acid repeats but not with that containing the 15-amino acid repeats of APC, although both regions are known to bind to beta-catenin. In the region containing seven 20-amino acid repeats, the region containing the latter five repeats bound to the RGS domain of Axin. Axin and beta-catenin simultaneously interacted with APC. Furthermore, Axin stimulated the degradation of beta-catenin in COS cells. Taken together with our recent observations that Axin directly interacts with glycogen synthase kinase-3beta (GSK-3beta) and beta-catenin and that it promotes GSK-3beta-dependent phosphorylation of beta-catenin, these results suggest that Axin, APC, GSK-3beta, and beta-catenin make a tetrameric complex, resulting in the regulation of the stabilization of beta-catenin.

Complications associated with transcatheter arterial embolization for hepatic tumors

Transcatheter arterial embolization (TAE) is widely used in the treatment of hepatic tumors. A total of 2,300 TAE procedures were performed with a 2-15-mL injection of a mixture or suspension of anticancer drugs and iodized oil, followed by administration of gelatin sponge particles. One or two chemotherapeutic drugs, including doxorubicin hydrochloride (10-30 mg), epirubicin hydrochloride (10-30 mg), mitomycin C (10-20 mg), and cisplatin (25-100 mg), were used for each procedure. Complications were encountered in 4.4% of cases (n = 102) and were related to the use of chemoembolic agents or the manipulation of a catheter or guide wire. These complications included acute hepatic failure (n = 6), liver infarction (n = 4) or abscess (n = 5), intrahepatic biloma (n = 20), multiple intrahepatic aneurysms (n = 6), cholecystitis (n = 7), splenic infarction (n = 2), gastrointestinal mucosal lesions (n = 5), pulmonary embolism or infarction (n = 4), tumor rupture (n = 1), variceal bleeding (n = 3), and iatrogenic dissection (n = 35) or perforation (n = 4) of the celiac artery and its branches. Knowledge of these complications is important for correct diagnosis and appropriate management.

Changes in cyclin B during oocyte maturation and early embryonic cell cycle in the newt, Cynops pyrrhogaster: requirement of germinal vesicle for MPF activation

When full-grown oocytes of the newt Cynops pyrrhogaster were treated with progesterone in O-R2 solution containing antibiotics, approximately 85% of the oocytes completed meiosis synchronously. Maturation-promoting factor (MPF) activity appeared just before germinal vesicle breakdown (GVBD) and the oocytes maintained high MPF activity throughout metaphase I and metaphase II of meiosis. A slight decrease of MPF activity was observed at the first polar body emission. The distribution of cyclin B1 was investigated with anti-cyclin B1 antibody. No cyclin B1 was found in the oocytes before progesterone treatment. Cyclin B1 appeared in the cortex of animal hemispheres, especially around and inside germinal vesicle just before GVBD. A large amount of cyclin B1 accumulated at metaphase I, approximately half disappeared at the first polar body emission, and then cyclin B1 accumulated again at metaphase II. An inactive form of cdc2 kinase was observed in both the germinal vesicles and the oocyte cytoplasm, while an active form appeared at the M phase. No MPF was observed in the oocytes from which the germinal vesicle had been removed. A cdk7-like molecule was localized in the germinal vesicle, but not in oocyte cytoplasm, indicating that inactive cdc2 kinase associated with cyclin B1 derived from cytoplasm is activated by phosphorylation in the germinal vesicle. The changes in the amount of cyclin B1 were synchronous with the first cell cycle after fertilization. Cyclin B1 was primarily localized in the cortex of the animal hemisphere. A shift in band mobility upon electrophoresis of cyclin B1 was observed from samples taken during the cell cycle; this shift was probably due to the protein's phosphorylation state.

Takayasu arteritis: MR manifestations and diagnosis of acute and chronic phase

Diagnosis of Takayasu arteritis is difficult because the clinical features are similar to those of other diseases. In the late occlusive or pulseless phase Takayasu arteritis, angiography usually demonstrates luminal changes such as such as stenosis, occlusion, or aneurysmal dilatation of the aorta and pulmonary artery and of their branches. However, absence of such luminal changes does not exclude the possibility of early or systemic phase Takayasu arteritis. Cross-sectional scanning such as CT scan and MRI plays an important role in demonstrating arterial wall changes in the early diagnosis of Takayasu arteritis. Improvement in the clinical findings and subsidence of the active inflammatory process can be expected with early steroid treatment. The common and uncommon MR appearances of the late occlusive phase and the recently described radiographic features of the early systemic phase are illustrated.

Fate of intramural hematoma of the aorta: CT evaluation

PURPOSE

Our goal was to investigate the fate of intramural hematoma of the aorta.

METHOD

In 32 patients with intramural hematoma of the aorta, we reviewed CT (n = 32) and MR (n = 22) findings. The diagnosis was established by CT, and regular follow-up studies were performed.

RESULTS

All intramural hematomas decreased in size. Ulcer-like projections (ULPs) were identified at the initial study in 6 patients and during the follow-up period in 14 patients. The ULPs progressed to saccular aneurysm in 12 patients (mean 47.0 days), while fusiform aneurysm developed in 6 patients (mean 347.7 days) without ULP. In two patients, the affected aorta progressed to overt aortic dissection.

CONCLUSION

Intramural hematoma itself usually decreases in size. However, the affected aorta can progress to aneurysm or overt aortic dissection. Development of saccular aneurysm from ULPs can be considered an early complication. In cases without ULP, fusiform aneurysm may develop as a late complication. All intramural hematomas need to be followed since it seems to be difficult to predict the exact fate of intramural hematoma from the initial imaging findings.

Combined intraarterial chemotherapy and radiotherapy in the treatment of bladder carcinoma

BACKGROUND

The combination of radiotherapy and cisplatin-based chemotherapy has proved to be an effective treatment for bladder carcinoma in many clinical studies. Intra-arterial approaches to chemotherapy have been developed to reduce systemic toxicities and improve response rates. This study was designed to determine the effectiveness of intra-arterial chemotherapy with cisplatin and doxorubicin combined with radiotherapy in the treatment of patients with invasive bladder carcinoma. The objectives were to evaluate the response rate, bladder preservation rate, toxicity, and survival rate.

METHODS

Thirty-five patients with muscle-invasive bladder carcinoma at clinical stage T2-T4N0M0 were each treated with 2courses of intra-arterial cisplatin and doxorubicin at 3-week intervals, whereas radiotherapy was administered for 4 weeks (2 gray [Gy] given a total of 20 times, at 5 fractions per week). Patients with complete responses were given an additional course of chemotherapy (intra-arterial cisplatin and doxorubicin) and irradiation (20 Gy), and patients with residual tumor after the initial chemoradiotherapy underwent cystectomy.

RESULTS

A clinical complete response was observed in 26 patients (74%; 95% confidence interval, 59-89%), and an incomplete response was observed in 9 (26%; 95% confidence interval, 11-41%). The bladder was preserved in all patients with a complete response, and it was tumor free in 19 of them (54% of all patients). The actuarial survival rate was 76.6% at 5 years. After a median follow-up interval of 45 months, 28 patients (80%) were alive and 7 (20%) had died due to disease progression. The regimen was well tolerated, with no severe systemic or local toxicities.

CONCLUSIONS

The high rates of response, survival, and bladder preservation observed indicate that this combined intra-arterial chemotherapy and radiotherapy regimen would be useful in the management of invasive bladder carcinoma. This was a small Phase II trial; the results are preliminary, and the utility of this treatment modality in patient management remains to be proven.

[Stanford type A aortic dissection with closed false lumen: analysis of prognostic factors at initial CT or MRI]

Nineteen patients with Stanford type A acute aortic dissection with closed false lumen were reviewed. In the follow-up examinations, ulcerlike projection (ULP) in the ascending aorta (AA) or aortic arch (AR) was identified in 8 of 19 patients. In 5 of these 8 patients, acute cardiac tamponade occurred and 3 of them died. In the other 11 patients, there was no mortality, and only one patient underwent elective surgery. The appearance of ULP in the AA/AR is considered an indication for urgent surgery because it is regarded as a precursor of lethal complications such as cardiac tamponade. The purpose of this study was to investigate predictors of the appearance of ULP in the AA/AR with early imagings (CT or MRI) before the appearance of ULP. The patients were divided into two groups: patients with ULP in the AA/AR (8 patients) and others (11 patients). Initial CT or MRI findings of the thoracic aorta were retrospectively statistically analyzed in each group. Three predictive factors were statistically significant for the appearance of ULP in the AA/AR (diameter of the AA > or = 5 cm, thickness of the false lumen of the AA > or = 1 cm, thickness of the false lumen of the AA > or = that of the descending aorta). Close attention should be paid, if any of these 3 factors is observed at initial CT or MRI.

[Observations on structure of bone in human mandibular condyles with osteophyte formation]

The purpose of this study was to investigate the functional characteristics of human mandibular condyles from a morphological viewpoint. The structure of bone in the human mandibular condyles with osteophyte formation was observed macroscopically and microscopically and compared with that in the condyles which seemed to be normal. The following observations were made: 1. Generally, it was observed that remodeling seemed to occur frequently in compact bone in the joint surface area of the mandibular condyle. 2. As the distribution of lamellar bone, nonlamellar, and bundle bone in the joint surface area changes, the compact bone seems to shift down and protrude forward. In larger osteophytes, trabeculae of cancellous bone-like structure are observed. However, the basic structure of compact bone, including haversian system and the interlamellae structure remains within the trabecullae. Therefore, observation revealed histologically that this is a compact bone. The macroscopical appearance of cancellous bone-like structure seems to be a result of functional demand. 4. It was concluded that the mandibular condyles accommodate the functional loads, and adoptational changes occur constantly in a stable manner.

Takayasu arteritis: protean radiologic manifestations and diagnosis

Diagnosis of Takayasu arteritis is difficult because the clinical features are similar to those of other diseases. In early-phase Takayasu arteritis, computed tomography (CT) and magnetic resonance (MR) imaging show thickening of the aortic wall. Late-phase Takayasu arteritis has been classified into four types: classic pulseless disease (type I), a mixed type (type II), the atypical coarctation type (type III), and the dilated type (type IV). In late-phase Takayasu arteritis, angiography usually demonstrates luminal changes such as stenosis, occlusion, or aneurysmal dilatation of the aorta and pulmonary artery and their branches. However, absence of such luminal changes does not exclude the possibility of early-phase Takayasu arteritis. Improvement in the clinical findings and subsidence of the active inflammatory process can be expected with early steroid treatment. Familiarity with the varied chest radiographic, angiographic, CT, and MR imaging features of Takayasu arteritis will permit earlier diagnosis and treatment.

Transarterial infusion of cisplatin and doxorubicin in bladder cancer

Forty-five patients (median age 63 years) with muscle invasive bladder cancer were treated with transcatheter intraarterial infusion (TAI) of cisplatin (CDDP) and doxorubicin. They received a total of 114 courses (median 3 courses per patient) of TAI. Complete response was obtained in 20 patients (44%), partial response in 17 (38%), stable disease in 6(13%), and progression of disease in 2 patients (5%). The overall response rate was 82% at a median follow-up of 36 months. The actuarial survival of the patient population was 72% at 5 years; 36 patients were alive and 9 had died of cancer progression. The treatment was generally extremely well tolerated without major complications. The current study also revealed the fact that papillary carcinomas were more sensitive to this therapy than were non-papillary tumors. Overall, response rate and local control were significantly higher in low-grade than in high-grade tumors. The observed high complete response and good survival rate suggest that intraarterial CDDP and doxorubicin might be highly effective for localized invasive bladder cancer.

Coronary angiographic finding of thrombus in the left atrial appendage

PURPOSE

The value of coronary angiography in the diagnosis of thrombus in the left atrial appendage (LAA) was retrospectively analyzed.

MATERIAL AND METHODS

The study covers 34 patients in whom coronary angiography showed coronary neovascularity in LAA with coronary artery-left atrial fistula indicating LAA thrombus. All 34 patients underwent transthoracic echocardiography within one week of coronary angiography. Open-heart surgery was undertaken 2-31 months after angiography in 28 patients.

RESULTS

Coronary neovascularity and coronary artery-left atrial fistula arose from the left circumflex artery in 28 patients, and from the left circumflex artery and the right coronary artery in the remaining 6 patients. By echocardiography, LAA thrombus was detected in only one of the 34 patients. In 18 of the 28 patients who underwent open-heart surgery, LAA thrombus was found at surgery to have resolved.

CONCLUSION

Coronary angiography is useful in the diagnosis of LAA thrombus, and coronary neovascularity and fistula formation may indicate that the thrombus can spontaneously resolve.