Prediction of cognitive decline in normal elderly subjects with 2-[(18)F]fluoro-2-deoxy-D-glucose/poitron-emission tomography (FDG/PET)

Neuropathology studies show that patients with mild cognitive impairment (MCI) and Alzheimer's disease typically have lesions of the entorhinal cortex (EC), hippocampus (Hip), and temporal neocortex. Related observations with in vivo imaging have enabled the prediction of dementia from MCI. Although individuals with normal cognition may have focal EC lesions, this anatomy has not been studied as a predictor of cognitive decline and brain change. The objective of this MRI-guided 2-[(18)F]fluoro-2-deoxy-d-glucose/positron-emission tomography (FDG/PET) study was to examine the hypothesis that among normal elderly subjects, EC METglu reductions predict decline and the involvement of the Hip and neocortex. In a 3-year longitudinal study of 48 healthy normal elderly, 12 individuals (mean age 72) demonstrated cognitive decline (11 to MCI and 1 to Alzheimer's disease). Nondeclining controls were matched on apolipoprotein E genotype, age, education, and gender. At baseline, metabolic reductions in the EC accurately predicted the conversion from normal to MCI. Among those who declined, the baseline EC predicted longitudinal memory and temporal neocortex metabolic reductions. At follow-up, those who declined showed memory impairment and hypometabolism in temporal lobe neocortex and Hip. Among those subjects who declined, apolipoprotein E E4 carriers showed marked longitudinal temporal neocortex reductions. In summary, these data suggest that an EC stage of brain involvement can be detected in normal elderly that predicts future cognitive and brain metabolism reductions. Progressive E4-related hypometabolism may underlie the known increased susceptibility for dementia. Further study is required to estimate individual risks and to determine the physiologic basis for METglu changes detected while cognition is normal.

Hippocampal formation glucose metabolism and volume losses in MCI and AD

We used MRI volume sampling with coregistered and atrophy corrected FDG-PET scans to test three hypotheses: 1) hippocampal formation measures are superior to temporal neocortical measures in the discrimination of normal (NL) and mild cognitive impairment (MCI); 2) neocortical measures are most useful in the separation of Alzheimer disease (AD) from NL or MCI; 3) measures of PET glucose metabolism (MRglu) have greater diagnostic sensitivity than MRI volume. Three groups of age, education, and gender matched NL, MCI, and AD subjects were studied. The results supported the hypotheses: 1) entorhinal cortex MRglu and hippocampal volume were most accurate in classifying NL and MCI; 2) both imaging modalities identified the temporal neocortex as best separating MCI and AD, whereas widespread changes accurately classified NL and AD; 3) In most between group comparisons regional MRglu measures were diagnostically superior to volume measures. These cross-sectional data show that in MCI hippocampal formation changes exist without significant neocortical changes. Neocortical changes best characterize AD. In both MCI and AD, metabolism reductions exceed volume losses.

Primary structure of dystrophin-related protein

Dystrophin-related protein (DRP or 'utrophin') is localized in normal adult muscle primarily at the neuromuscular junction. In the absence of dystrophin in Duchenne muscular dystrophy (DMD) patients, DRP is also present in the sarcolemma. DRP is expressed in fetal and regenerating muscle and may play a similar role to dystrophin in early development, although it remains to be determined whether DRP can functionally replace dystrophin in adult tissue. Previously we described a 3.5-kilobase complementary DNA clone that exhibits 80 per cent homology to the C-terminal domain of dystrophin. This sequence identifies a 13-kilobase transcript that maps to human chromosome 6 (refs 2, 11). Antibodies raised against the gene product identify a polypeptide with a relative molecular mass of about 400K in all tissues examined. To investigate the relationship between DRP and dystrophin in more detail, we have cloned and sequenced the whole DRP cDNA. Homology between DRP and dystrophin extends over their entire length, suggesting that they derive from a common ancestral gene. Comparative analysis of primary sequences highlights regions of functional importance, including those that may mediate the localization of DRP and dystrophin in the muscle cell.

A randomized trial of hepatic arterial chemoembolization in patients with unresectable hepatocellular carcinoma

A randomized trial of hepatic arterial chemoembolization was conducted in 42 patients with unresectable hepatocellular carcinoma. These patients represented 41% of patients with hepatocellular carcinoma seen during the inclusion period. In the remaining 59%, 9% had resectable tumours and 50% had unresectable tumours with contraindication for chemoembolization. Patients received either repeated chemoembolization with gelfoam powder and doxorubicin (group 1) or symptomatic treatment (group 2). There was no difference in age, prevalence of cirrhosis or staging according to Okuda between the two groups of patients. A complete tumour response (assessed by arteriography, ultrasonography and serum alphafetoprotein) was observed in four patients, and a partial response in three other patients from group 1. Actuarial survival rates were 33 and 24% in group 1 and 52 and 31% in group 2 at 6 and 12 months, respectively (differences were not significant--logrank test). With the treatment used in our study, chemoembolization did not prolong the survival time of patients with unresectable hepatocellular carcinoma. There were, however, some complete or partial responses. The high spontaneous 1-year survival rate of untreated patients was probably due to the exclusion of the most severely ill patients. Our results do not support the use of this method of chemoembolization in the treatment of hepatocellular carcinoma.

Treatment of unresectable hepatocellular carcinoma with lipiodol chemoembolization: a multicenter randomized trial. Groupe CHC

BACKGROUND/AIMS

Lipiodol chemoembolization is a widely used method of treatment in patients with unresectable hepatocellular carcinoma, but its efficacy is still debated. The aim of our study was to assess the efficacy of lipiodol chemoembolization in patients with unresectable hepatocellular carcinoma.

METHODS

Seventy-three patients with unresectable hepatocellular carcinoma, but without severe liver disease or portal vein occlusion, were randomly assigned to receive either repeated lipiodol chemoembolization (lipiodol, cisplatin (2 mg/kg), lecithin, and gelatin sponge injected into the hepatic artery) plus tamoxifen (40 mg) or tamoxifen alone. The main end-point was survival.

RESULTS

The 37 patients in the lipiodol chemoembolization group received 104 courses (median 3 per patient). By 1 September 1996, 58 patients had died: 30 in the lipiodol chemoembolization group and 28 in the tamoxifen group. There was no difference in survival between the two groups (p=0.77). The relative risk of death in the lipiodol chemoembolization plus tamoxifen group as compared to the tamoxifen group was 0.92 (95% confidence interval 0.55 to 1.56). At 1 year, survival was 51% and 55%, respectively. An objective tumoral response was more frequently observed in the lipiodol chemoembolization group than in the tamoxifen group (24 versus 5.5%, respectively, p=0.046). Lipiodol chemoembolization caused two deaths and induced signs of liver failure in 51% of the patients assigned to this treatment.

CONCLUSION

In our randomized study, lipiodol chemoembolization did not improve the survival of patients with unresectable hepatocellular carcinoma treated with tamoxifen.

Radiofrequency ablation of 100 hepatic metastases with a mean follow-up of more than 1 year

OBJECTIVE

The objective of our study was to evaluate the efficacy and safety of radiofrequency ablation of hepatic metastases performed either percutaneously for treatment of hepatic metastases in patients deemed ineligible for surgery or intraoperatively during partial hepatectomy to destroy unresectable metastases.

SUBJECTS AND METHODS

Sixty-eight patients with 121 hepatic metastases (<5 metastases per patient) that were mainly colorectal in origin underwent 76 sessions of radiofrequency ablation with cooled-needle electrodes under sonographic guidance. Twenty-one patients with 33 metastases of 5-20 mm in diameter (mean +/- SD,13 +/- 7 mm) underwent intraoperative radiofrequency ablation. Forty-seven patients with 88 metastases of 10 to 42 mm in diameter (mean +/- SD, 26 +/- 9 mm) were treated with percutaneous radiofrequency ablation. Procedure efficacy was evaluated with dynamic enhanced CT and MR imaging performed 2, 4, and 6 months after treatment and then every 3 months.

RESULTS

Radiofrequency ablation allowed eradication of 91% of the 100 treated metastases that were followed up for 4-23 months (mean, 13.7 months). Tumor control was equivalent for percutaneous radiofrequency ablation (90%) and for intraoperative radiofrequency ablation (94%). Failure to achieve tumor control occurred mostly with the largest tumor nodules. One bilioperitoneum and two abscesses were the major complications encountered after treatment of 121 metastases with a follow-up of more than 2 months.

CONCLUSION

Radiofrequency ablation appears to be a promising therapeutic modality capable of extending the possibilities of partial hepatectomy and of efficiently treating small metastases percutaneously.

What is the best similarity measure for motion correction in fMRI time series?

It has been shown that the difference of squares cost function used by standard realignment packages (SPM and AIR) can lead to the detection of spurious activations, because the motion parameter estimations are biased by the activated areas. Therefore, this paper describes several experiments aiming at selecting a better similarity measure to drive functional magnetic resonance image registration. The behaviors of the Geman-McClure (GM) estimator, of the correlation ratio, and of the mutual information (MI) relative to activated areas are studied using simulated time series and actual data stemming from a 3T magnet. It is shown that these methods are more robust than the usual difference of squares measure. The results suggest also that the measures built from robust metrics like the GM estimator may be the best choice, while MI is also an interesting solution. Some more work, however, is required to compare the various robust metrics proposed in the literature.

Physical mapping across the fragile X: hypermethylation and clinical expression of the fragile X syndrome

The most common genetic cause of mental retardation after Down's syndrome, the fragile X syndrome, is associated with the occurrence of a fragile site at Xq27.3. This X-linked disease is intriguing because transmission can occur through phenotypically normal males. Theories to explain this unusual phenomenon include genomic rearrangements and methylation changes associated with a local block of reactivation of the X chromosome. Using microdissected markers close to the fragile site, we have been able to test these hypotheses. We present evidence for the association of methylation with the expression of the disease. However, there is no simple relationship between the degree of methylation and either the level of expression of the fragile site or the severity of the clinical phenotype.

During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma

BACKGROUND

The relative growth rates of human liver metastases are not known. The aim of this study was to determine in humans the growth rate of liver parenchyma during regeneration and the growth rate of liver metastases during the same process.

METHODS

Among 556 patients hepatectomized for a malignant lesion, 48 underwent preoperative selective right portal vein embolization to induce hypertrophy of the left lobe. Five cases were selected because a liver metastasis was present inside the regenerating left lobe. The volumes of the liver metastasis and left lobe were measured with a three-dimensional technique on pre-embolization and postembolization computed tomography (CT) or CT arterial portography. The median interval between the two measurements was 34 (range 28-40) days.

RESULTS

An increase occurred in the volume of the liver metastasis and the left lobe in the four patients with functionally intact liver parenchyma, but not in the patient with an impaired parenchyma. The volumetric increase of the normal liver varied from 59 to 127 per cent, compared with 60 to 970 per cent for the liver metastases. The ratio between the growth rate of the left lobe and the liver metastasis varied from 1.0 to 15.6. The growth rates of two metastases in the left lobe of a single patient were different.

CONCLUSION

In functionally intact liver parenchyma, during hepatic regeneration or hypertrophy, the growth rate of metastases is more rapid that that of the liver parenchyma. However, a wide variation in growth rate is observed between patients and between metastases.

Ecstasy use in Australia: patterns of use and associated harm

This study explored patterns of ecstasy use and associated harm through the administration of a structured interview schedule to 329 ecstasy users, recruited from three Australian cities. A broad range of ecstasy users were interviewed, but on the whole, the sample was young, relatively well educated and most were employed or students. Patterns of use were varied, although extensive polydrug use was the norm. High rates of intravenous drug use were recorded, which may relate to an over-representation of chaotic intravenous polydrug users. Subjects had experienced an average of eight physical and four psychological side-effects, which they attributed to their ecstasy use in the preceding 6 months. Approximately 40% of the sample also reported financial, relationship and occupational problems. Young, female, polydrug users and those who binged on ecstasy for 48 h or more appeared most at risk of experiencing harm that they related to their ecstasy use. One-fifth of the sample had received treatment for an ecstasy-related problem, most often from a GP or natural therapist, and 7% were currently in treatment. One quarter wanted to reduce their use because of financial, relationship and psychological problems. A total of 15% wanted formal treatment for an ecstasy-related problem and 85% requested more information. These results have implications for the development of policies to respond to drug use among this population.

Preoperative portal vein embolization for extension of hepatectomy indications

To render hepatectomy feasible in patients with an initially deficient volume of the future remnant liver (FRL), we redistributed portal blood flow rich in hepatotrophic substances toward the FRL. Redistribution was achieved with preoperative portal vein embolization (POPE) feeding the future resected liver. POPE was performed in 31 patients, under fluoroscopic guidance, via a percutaneous access. POPE was well tolerated and surgery was practicable in 24 patients without severe postoperative liver failure. Seven operations were cancelled, but only one due to insufficient hypertrophy of the FRL. FRL volume values were 90 to 560 mL (mean 260 mL) before POPE and 160-783 mL (mean 443 mL) after POPE, which represents a median increase of 79% +/- 50%. Hypertrophy of the FRL was 90% +/- 52% after 30 days with cyanoacrylate, 53% +/- 6% after 43 days with Gelfoam, and 44% +/- 30% after 35 days with coils. Slight shrinkage was obtained in the volume of the embolized liver, for which resection was planned. Overall survival was 2-62 months (mean 26 months), disease-free survival was 0-60 months (mean 19 months), and 7 patients are disease-free and alive 14 to 60 months (mean 43 months) after surgery. Although exclusively applicable in a limited subset of patients, POPE widens the possibilities of curative hepatectomies, because it induces sound hypertrophy of unembolized liver segments. Cyanoacrylate seems to ensure better and faster hypertrophy.

Hepatic arterial chemoembolization in patients with liver metastases of endocrine tumors. A prospective phase II study in 24 patients

BACKGROUND

Liver metastases of endocrine tumors are of major prognostic significance. The various therapeutic approaches have given disappointing results; however, locoregional treatment has allowed transient control of hepatic tumor growth.

METHODS

Twenty-four patients with liver metastases of endocrine tumors (mainly carcinoid tumors [n = 18] and gastrinomas [n = 5]) were included in a Phase II study of hepatic arterial chemoembolization (CE). Metastases were bilateral in all patients and invaded more than 50% of the liver in 12. They were synchronous of the primary tumor in 62.5% of the patients. Seventeen patients had not responded to previous intravenous chemotherapy. CE courses were performed every 3 months using an emulsion of 10 ml of iodized oil and doxorubicin 50 mg/m2 injected into tumor vessels, followed by CE arterial occlusion with gelatin sponge particles. Seventy-one CE courses were performed in 23 patients; there was one technical failure.

RESULTS

Among patients with carcinoid tumors, disappearance of diarrhea and/or flushing was observed in 8 of 11. Serotonin and/or its metabolite 5-hydroxyindoleacetic acid levels decreased by more than 50% in 57% of the patients. The size of liver metastases decreased by at least 50% in 6 of 18 patients, i.e., in 33% (range, 12-54%). Two had complete responses. The median duration of the responses was 14 months (range, 6-40). Among patients with noncarcinoid tumors, minor response or stabilization occurred in three of five patients. Major side effects were bleeding peptic ulcer (one patient) and oligoanuric renal failure (one patient). Abdominal pain, fever, and increases in hepatic enzyme levels were common and transient.

CONCLUSIONS

These results suggest that CE is effective in patients with liver metastases of endocrine tumors, mainly in carcinoids. In the latter, CE allows control of the carcinoid syndrome and regression or stabilization of the liver tumors in 80% of patients.

Primary treatment of hepatocellular carcinoma by arterial chemoembolization

Two hundred and ninety-one patients with hepatocellular carcinoma were treated by chemoembolization (CE), using ethiodized oil, doxorubicin, and a gelatin sponge. Patients with thrombosis of either the portal vein or a main branch were excluded. The mortality rate in the first 2 months after treatment was 7% in noncirrhotic patients, 2.8% in patients with class A cirrhosis, 8% in patients with class B cirrhosis, and 37% in patients with class C cirrhosis. The tumor diameter remained the same in 55.3% of patients, was reduced by up to 50% in 20% of the patients, was reduced by more than 50% in 7.3% of the patients, and almost completely disappeared in 1.8% of the patients. The diameter of the tumor increased in 15.6% of patients. Forty-three patients underwent a resection or transplantation after chemoembolization. Histologic examination of the specimens revealed significant necrosis of the tumor. The long-term survival rate at 2 years was 49% for class A cirrhotics, 29% for class B cirrhotics, and 9% for class C cirrhotics. Complications included cholecystitis (10%), vasculitis (14%), renal decompensation (13%), an increase in ascites (14%), and jaundice (12%). Chemoembolization is an effective and safe initial treatment for hepatocellular carcinoma. It is effective in producing tumor necrosis and reducing the size of the tumor. Improvement in survival was noted when patients who underwent chemoembolization were compared with an historical series of untreated patients, and resection and transplantation are kept as options.

Percutaneous radiofrequency ablation of hepatic tumors during temporary venous occlusion

OBJECTIVE

We evaluated the feasibility, tolerance, and efficacy of percutaneous hepatic vein or segmental portal branch balloon occlusion during radiofrequency ablation of hepatic malignancies.

SUBJECTS AND METHODS

Ten tumors were treated by percutaneous radiofrequency ablation during balloon occlusion of a hepatic vein (n = 8) or a segmental portal branch (n = 2). Venous occlusion was undertaken because the tumor was in contact with a hepatic vein (n = 3) or a portal branch (n = 1); because the tumor exceeded 35 mm in width (mean, 44 mm), which was considered the maximum size amenable to ablation in a single session (n = 2); or because of both large size and contact with a hepatic vein (n = 3) or a portal branch (n = 1).

RESULTS

Vascular occlusion was always technically possible. Radiofrequency was delivered to one to three locations (mean, 1.9 locations) with a cluster electrode. The largest axis of radiofrequency-induced lesions after ablation with the cluster needle-between 42 and 51 mm (mean, 49 mm)-was always larger than the targeted tumor. These sizes were statistically larger than in a matched control group of patients who underwent radiofrequency ablation without vascular occlusion (p < 0.0003). After a mean follow-up of 12.6 months, CT and MR imaging revealed complete destruction of nine tumors after a single radiofrequency ablation treatment; one tumor required three treatments to achieve ablation. Five patients are tumor-free 12-18 months (mean, 14.4 months) after the first radiofrequency ablation treatment, and five developed new liver metastases.

CONCLUSION

Temporary hepatic vein or portal branch occlusion during radiofrequency ablation can safely facilitate the treatment of large tumors or tumors in contact with the walls of large vessels.

Effect of growth hormone treatment on adult height of children with idiopathic short stature. Genentech Collaborative Group

BACKGROUND

Short-term administration of growth hormone to children with idiopathic short stature results in increases in growth rate and standard-deviation scores for height. However, the effect of long-term growth hormone therapy on adult height in these children is unknown.

METHODS

We studied 121 children with idiopathic short stature, all of whom had an initial height below the third percentile, low growth rates, and maximal stimulated serum concentrations of growth hormone of at least 10 microg per liter. The children were treated with growth hormone (0.3 mg per kilogram of body weight per week) for 2 to 10 years. Eighty of these children have reached adult height, with a bone age of at least 16 years in the boys and at least 14 years in the girls, and pubertal stage 4 or 5. The difference between the predicted adult height before treatment and achieved adult height was compared with the corresponding difference in three untreated normal or short-statured control groups.

RESULTS

In the 80 children who have reached adult height, growth hormone treatment increased the mean standard-deviation score for height (number of standard deviations from the mean height for chronologic age) from -2.7 to -1.4. The mean (+/-SD) difference between predicted adult height before treatment and achieved adult height was +5.0+/-5.1 cm for boys and +5.9+/-5.2 cm for girls. The difference between predicted and achieved adult height among treated boys was 9.2 cm greater than the corresponding difference among untreated boys with initial standard-deviation scores of less than -2, and the difference among treated girls was 5.7 cm greater than the difference among untreated girls.

CONCLUSION

Long-term administration of growth hormone to children with idiopathic short stature can increase adult height to a level above the predicted adult height and above the adult height of untreated historical control children.

Radiofrequency liver ablation: experimental comparative study of water-cooled versus expandable systems

OBJECTIVE

We evaluate the uniformity and reproducibility of thermal lesion ablation and quantify the volume of tissue destruction and hemorrhage induced with two different commercially available radiofrequency ablation devices.

MATERIALS AND METHODS

A four-array anchor expandable needle electrode and a triple-cluster cooled-tip needle electrode were used to induce lesions in three explanted calf livers and in vivo in eight swine livers. The sizes of the radiofrequency-induced lesions were macroscopically evaluated by measuring two perpendicular dimensions immediately after the experiment. Bleeding was evaluated by weighing gauze swabs used to dry the hemorrhage caused by electrode insertions.

RESULTS

In explanted liver, the mean diameter of the radiofrequency-induced lesion was 5.3 +/- 0.7 cm for the cooled-tip needle and 3.7 +/- 0.4 cm for the expandable needle (p = 0.042), which correspond to approximate volumes of 65.35 +/- 26.22 cm(3) and 26.67 +/- 9.59 cm(3), respectively (p < 0.002). In vivo, the mean diameter was 3.7 +/- 0.4 cm for the cooled-tip needle and 3 +/- 0.4 cm for the expandable needle (p < 0.0001), which correspond to approximate volumes of 24.18 +/- 7.56 cm(3) and 11.16 +/- 3.65 cm(3), respectively (p < 0.0001). Blood loss attained a median value of 3.5 g for the cooled-tip needle and 2.6 g for the expandable needle; this difference was not statistically significant (p = 0.06).

CONCLUSION

The cooled-tip needle induced significantly larger lesions than the expandable needle, but the lesions produced by the expandable needle are more reproducible, uniform, and spheric. The larger size of the lesions produced by the cooled-tip needle may be attributed to the higher maximum power used by the generator and the higher energy deposition, which is due to the cooling of the needle electrode.

Portal vein embolization: utility for inducing left hepatic lobe hypertrophy before surgery

Right portal vein embolization (PVE) was performed in patients in need of wide hepatectomy to induce preoperative hypertrophy of the future remnant liver (FRL), which would have been insufficient for safe resection. PVE was achieved with cyanoacrylate or gelatin sponges by using a percutaneous subxiphoid approach in 10 patients with tumors in noncirrhotic liver. Surgery was performed in nine patients 17-48 days (mean, 34 days) after PVE. Computed tomographic liver volumetric studies were performed before embolization and before surgery. Clinical and biologic tolerance of PVE was excellent except in one case. Histopathologic studies showed occlusion of portal veins with minimal parenchymal ischemia in eight of nine patients. The FRL volume increased by 64%, which represented 31% of the preresection volume of the liver. Better hypertrophy was seen after cyanoacrylate embolization. The authors conclude that PVE is safe and well tolerated and induces marked hypertrophy of the unembolized parenchyma in noncirrhotic patients. This hypertrophy allows hepatectomy to be performed under safe conditions when the FRL volume is initially insufficient.

Gianturco expandable metallic biliary stents: results of a European clinical trial

Eleven patients with benign strictures (after choledochojejunostomy, n = 10; chronic pancreatitis, n = 1) and 16 with malignant biliary strictures (cancer of the pancreas, n = 7; cholangiocarcinoma, n = 5) were treated with a self-expanding metallic biliary stent. The patients with benign disease had failed treatment with surgical reconstruction and transhepatic balloon dilation. All patients had immediate relief of jaundice and cholangitis. In a follow-up period of 6-21 months, nine of the 11 patients with benign disease had no difficulties with infection, pruritus, or recurrent jaundice. In patients with malignant strictures, the stent produced relief of biliary obstruction unless recurrent tumor invaded the bile ducts. With careful patient selection, this stent appears to be useful in the management of biliary obstruction, particularly in benign disease.

Pancreatic venous sampling and arteriography in localizing insulinomas and gastrinomas: procedure and results in 55 cases

A comparative study of arteriography and pancreatic venous sampling (PVS) was performed in 55 patients. Twenty-seven patients with Zollinger-Ellison syndrome, 24 with insulinomas, and 4 control subjects underwent arteriography and PVS (for pancreatic hormonal radioimmunoassays) in an attempt to localize a suspected endocrine tumor. Accurate tumor localization was achieved by arteriography in 13% of the cases of gastrinoma and 29% of the cases of insulinoma. Although arteriographic signs could be described retrospectively in 62% of insulinomas, erroneous localization was relatively frequent. In contrast, localization by PVS was successful in 36 out of the 38 patients who underwent surgery; false-negative results were obtained in two patients, but in no case did PVS result in false localization. In 27% of insulinomas and 43% of gastrinomas, gross examination during surgery was negative but microscopic tumors were identified.

Rigid registration of 3-D ultrasound with MR images: a new approach combining intensity and gradient information

We present a new image-based technique to rigidly register intraoperative three-dimensional ultrasound (US) with preoperative magnetic resonance (MR) images. Automatic registration is achieved by maximization of a similarity measure which generalizes the correlation ratio, and whose novelty is to incorporate multivariate information from the MR data (intensity and gradient). In addition, the similarity measure is built upon a robust intensity-based distance measure, which makes it possible to handle a variety of US artifacts. A cross-validation study has been carried out using a number of phantom and clinical data. This indicates that the method is quite robust and that the worst registration errors are of the order of the MR image resolution.

Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive cancer patients

PURPOSE

To evaluate the feasibility, complications, adequacy of feeding support, and tolerability of fluoroscopically guided gastrostomy in cancer patients.

MATERIALS AND METHODS

Five hundred cancer patients were referred for fluoroscopically guided gastrostomy, among whom percutaneous endoscopic gastrostomy was contraindicated or had been unsuccessful in approximately one-fourth. Five hundred eight fluoroscopically guided gastrostomies with T-fastener gastropexy were performed in 496 patients. The procedure was unsuccessful in four patients, and 12 patients needed a second gastrostomy.

RESULTS

Fluoroscopically guided gastrostomy was feasible in 99% of patients. During the first 30 postprocedure days, there were seven major complications (1.4%): cardiac failure (n = 1), hemorrhage (n = 1), and peritonitis (n = 5); one patient died of peritonitis. No major complications occurred after the 30th postprocedure day. There were 27 minor complications (5.4%) during the first 30 postprocedure days and 88 (17.6%) thereafter. Long-term minor complications mainly involved the disturbances and nearly always resolved once the tube was exchanged. Such exchanges were easily performed under fluoroscopic guidance except in two patients, who required repeat fluoroscopically guided gastrostomy.

CONCLUSION

Fluoroscopically guided gastrostomy is highly feasible and safe and provides adequate feeding support, even when percutaneous endoscopic gastrostomy is impossible. Long-term complications, which are mainly tube disturbances, are easily treated.

Transcatheter chemoembolization of progressive carcinoid liver metastasis

PURPOSE

The authors report their experience treating progressive liver metastases from carcinoid tumor with doxorubicin, iodized oil, and gelatin sponge embolization.

MATERIALS AND METHODS

Of 23 patients, 18 had carcinoid syndrome and 19 had elevated urinary 5-hydroxyindoleacetic acid (5-HIAA) levels. Relief of symptoms, changes in 5-HIAA levels, and changes in tumor size could be evaluated in 10, 11, and 17 patients, respectively.

RESULTS

Symptomatic response was complete (average duration, 29 months) in 70% and partial in 30% of evaluated patients. Biologic response was complete (average duration, 21 months) in 73%, partial in 18%, and minor in 9% of evaluated patients. Morphologic response was complete in 11%, partial in 24%, and minor in 24% of evaluated patients. Survival after diagnosis of primary tumor, diagnosis of hepatic metastases, and first chemoembolization was 81, 47, and 24 months, respectively. Eight patients were alive at the end of the study. No mortality was related to chemoembolization.

CONCLUSION

Chemoembolization is safe and effective for palliation of carcinoid liver metastases.

Percutaneous radiofrequency thermoablation as an alternative to surgery for treatment of liver tumour recurrence after hepatectomy

BACKGROUND

Radiofrequency (RF) current, converted into heat through ion agitation and friction, can destroy liver tumours by means of coagulation necrosis. This study assessed whether percutaneous RF ablation is a useful and safe technique for the treatment of liver tumour recurrence after hepatectomy.

METHODS

Forty-seven patients presenting with local recurrence after hepatectomy for malignant tumours (29 with colorectal secondaries) were treated with percutaneous RF ablation instead of repeat hepatectomy. RF thermal ablation was performed under image guidance for 12-15 min. This group represented 63 per cent of 75 patients treated with curative intent for liver recurrence in the same time interval. The other 28 patients underwent repeat hepatectomy.

RESULTS

The mean(s.d.) number of liver metastases destroyed was 1.4(0.7) (range 1-3) and their diameter was 21(8) (range 9-35) mm. Twenty-six patients presented with liver recurrence at least once but up to three times after the initial RF application. Incomplete local RF treatment was observed in six of 47 patients. Fifteen patients developed extrahepatic recurrence. The mean(s.d.) interval between RF ablation and the last follow-up visit was 14.4(10.1) (range 5.5-40) months. One death and three major complications occurred. Survival rates at 1 and 2 years were 88 and 55 per cent respectively. A retrospective study of the authors' database over two similar consecutive periods showed that RF ablation increased the percentage of curative local treatments for liver recurrence after hepatectomy from 17 to 26 per cent and decreased the proportion of repeat hepatectomies from 100 to to 39 per cent.

CONCLUSION

Percutaneous RF treatment increases the number of patients eligible for curative treatment. It should be preferred to repeat hepatectomy when feasible and safe because it is less invasive. Repeat hepatectomy is indicated only when percutaneous RF ablation is contraindicated or fails.

Detection of liver metastases from colorectal cancer: comparison of intraoperative US and CT during arterial portography

A prospective study was performed to compare the sensitivities of intraoperative ultrasound (US) and computed tomography during arterial portography (CTAP) in the depiction of hepatic metastases from colorectal cancer. Twenty-five patients with hepatic metastases from colorectal cancer were evaluated. All patients underwent partial hepatectomy, and 56 metastases were pathologically proved. Preoperatively, CTAP depicted 51 of the 56 metastases (91%). Intraoperative US depicted 54 of the 56 metastases (96%). Intraoperative US depicted three metastases (5%) that were not depicted with CTAP and two that were missed with palpation (3%). Furthermore, intraoperative US did not demonstrate any false-positive lesions. There was no statistically significant difference in sensitivity between the two techniques. The authors concluded that intraoperative US does not enable detection of more liver metastases from colorectal cancer when CTAP is considered as the preoperative standard of reference. Nevertheless, the results of the study suggest that intraoperative US and CTAP are complementary techniques, and the preoperative use of CTAP for determining the feasibility of hepatic resection cannot prevent the use of intraoperative US.