Growth rate of pancreatic adenocarcinoma: initial clinical experience

A better understanding of the growth rate of pancreatic carcinoma is important in determining its natural course and in evaluating the effects of treatment or prognosis. The authors studied the growth rate of pancreatic carcinoma and the relation between its tumor volume doubling time (TVDT) and host survival. Nine patients with pancreatic carcinoma who underwent serial examinations by helical computed tomography but no anticancer treatment during the observation period were included. The TVDTs were calculated by measuring the tumor size on the helical computed tomograms. The mean TVDT of the nine primary lesions of pancreatic carcinoma was 159 +/- 67 days (median, 144 days), and the range was 64 to 255 days. The correlation between TVDT and survival time was positive and significant (r = 0.793, p = 0.011). This preliminary study suggests that examination of TVDT may be useful in the clinical evaluation of prognosis for patients with pancreatic carcinoma in certain situations.

Is CT during arterial portography useful for the preoperative evaluation of liver metastases from pancreatic carcinoma?

We evaluated computed tomography during arterial portography (CTAP) for the preoperative evaluation of liver metastases from pancreatic carcinoma. Thirty-one patients with invasive ductal carcinoma of the pancreas underwent CTAP for evaluation of liver metastasis. Diagnostic accuracy of CTAP was compared with that of intravenous contrast-enhanced CT (IVCT). In this series, both CTAP and IVCT showed the same diagnostic accuracy for the patients. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of both CT examinations for detecting liver metastases were 60% (three of five), 100% (26 of 26), 100% (three of three), 93% (26 of 28), and 94% (29 of 31), respectively. CTAP did not confer any advantage over IVCT for the preoperative evaluation of liver metastases from pancreatic carcinoma.

Targeted transarterial oily chemoembolization for small foci of hepatocellular carcinoma using a unified helical CT and angiography system: analysis of factors affecting local recurrence and survival rates

OBJECTIVE

We assessed the local recurrence rate after a single targeted transarterial oily chemoembolization for small hepatocellular carcinoma with the unified helical CT and angiography system and analyzed the factors affecting the local recurrence rate and survival rate with Cox proportional hazards model.

MATERIALS AND METHODS

For 54 consecutive patients with 71 small hepatocellular carcinomas (< or = 5 cm) with no more than two associated lesions, targeted oily chemoembolization was performed with an emulsion of doxorubicin hydrochloride mixed with iodized oil or a suspension of zinostatin stimalamer followed by gelatin sponge particles. When local recurrence or a new lesion appeared, follow-up targeted oily chemoembolization was performed.

RESULTS

For 52 of 71 lesions, the catheterization to a subsegmental or more distal feeding artery could be performed. Local recurrence was recognized in 33.2% at 1 year and 37.8% at 2 and 3 years. The significant factors that affected local recurrence were tumor size (p = 0.005) and degree of deposition of iodized oil within the lesion (p = 0.049). The survival rates at 1, 2, and 3 years were 93.3%, 77.1%, and 77.1%, respectively. The significant factors affecting survival rate were tumor thrombus in large vessels (p = 0.0001), appearing after the first chemoembolization, and maximum tumor size (p = 0.022).

CONCLUSION

Single targeted transarterial oily chemoembolization with the unified helical CT and angiography system had a low local recurrence rate for small hepatocellular carcinoma, and follow-up embolization resulted in a good survival rate. Tumor size along with degree of intratumoral iodized oil deposition and tumor thrombus along with maximum tumor size were significant factors affecting local recurrence and survival rate, respectively.

Histamine H(1) receptors in patients with Alzheimer's disease assessed by positron emission tomography

Cerebral histamine H(1) receptor binding was measured in vivo in 11 normal subjects (six young and five old) and 10 patients with Alzheimer's disease by positron emission tomography and [11C]doxepin, a radioligand for H(1) receptors. The parametric images describing the tracer kinetics were generated by either compartmental or graphical analysis, and were examined statistically on region-of-interest and voxel-by-voxel bases. The binding potential of H(1) receptors showed a significant decrease particularly in the frontal and temporal areas of the Alzheimer's disease brain compared to the old, normal subjects. In addition, the receptor binding correlated closely to the severity of Alzheimer's disease assessed by the Mini-Mental State Examination score within several brain areas. The ratio of K1 values between the brain areas and the cerebellum was used as a relative measure of regional cerebral blood flow which decreased in the frontal and temporal areas of the Alzheimer's disease brain. However, the difference in the binding potential (total concentration of receptor/equilibrium dissociation constant) between the Alzheimer's disease patients and the old, normal subjects was greater than that in the cerebral blood flow, and the rate of decrease in the binding potential with the progression of Alzheimer's disease was greater than the rate of decrease in the cerebral blood flow. This study reveals the predominant disruption of the histaminergic neurotransmission in the neurodegenerative processes of Alzheimer's disease. This study suggests that the decline of the histamine receptor binding might play a substantial role in the cognitive deficits of Alzheimer's disease patients.

Angiographic assessment of the right hepatic artery for encasement by hilar cholangiocarcinoma: comparison between antero-posterior and right anterior oblique projections

PURPOSE

To evaluate the usefulness of right anterior oblique (RAO) arteriography for evaluating encasement of the right hepatic artery (RHA) by hilar cholangiocarcinoma.

METHODS

Celiac arteriography was performed in both the antero-posterior (AP) and RAO projection in ten patients with cholangiocarcinoma. The lengths of the arteries between the bifurcation of the anterior and posterior branch of the liver and the following points were measured: (a) the bifurcation of the left and right hepatic artery (AP-LR), (b) the bifurcation of the proper hepatic artery and the gastroduodenal artery (AP-PG). Additionally, image quality in investigating the invasion of the RHA was evaluated.

RESULTS

On the AP images, the average lengths of AP-LR and AP-PG were 24.5 +/- 5.1 mm and 30.0 +/- 4.9 mm, respectively. On RAO images, the lengths were 28.2 +/- 4.6 mm and 32.7 +/- 4.8 mm, respectively. Every length was different between the two projections (p < 0.01). In 6 of 10 patients with hilar cholangiocarcinoma, images in RAO projections were superior to AP images for evaluation of encasement.

CONCLUSION

We conclude that angiography obtained in the RAO projection yields images that are superior to those obtained in the conventional AP projection for assessment of RHA encasement.

Selective intraarterial contrast-enhanced CT of pancreaticoduodenal tumors: early clinical experience in evaluating blood supply and detectability

OBJECTIVE

The purpose of this study was to compare CT with selective intraarterial contrast enhancement with IV contrast-enhanced CT for diagnostic usefulness in the detection of tumors in the pancreaticoduodenal region.

SUBJECTS AND METHODS

intraarterial contrast enhanced CT was performed in 36 patients with tumors of the pancreaticoduodenal region. Feeding arteries of the tumors and distribution of hyperattenuating areas on intraarterial contrast-enhanced CT were analyzed with various routes of contrast material injections. The intraarterial contrast-enhanced CT scans were compared with the IV contrast-enhanced CT scans.

RESULTS

In all 29 patients with standard vascular anatomy, the right cephalic portion of the pancreatic head was enhanced on CT during common hepatic or gastroduodenal arteriography and the left caudal portion was enhanced on CT during superior mesenteric arteriography. The enhanced areas were complementary to each other in the whole pancreatic head, including the tumor. Tumor conspicuity from the surrounding pancreatic tissue on intraarterial contrast-enhanced CT was not superior to that on IV contrast-enhanced CT in all but four patients with cystic tumors. After intraarterial contrast-enhanced CT, three patients with tumors less invasive than pancreatic ductal carcinoma underwent local resection of their lesions.

CONCLUSION

Intraarterial contrast-enhanced CT for pancreaticoduodenal tumors has potential technical problems and is not valuable in improving the detectability of tumors other than cystic lesions because the enhancement of the wall and septa of the tumor is emphasized. However, the feeding artery of the tumor and its surrounding tissue were clearly depicted.

Hilar cholangiocarcinoma evaluated by three-dimensional CT cholangiography and rotating cine cholangiography

BACKGROUND/AIMS

To evaluate the usefulness of three-dimensional cholangiography and rotating cine cholangiography in depicting the anatomy of the hilar bile duct and tumor extension, and in planning surgical procedures for hilar cholangiocarcinomas.

METHODOLOGY

Five patients with hilar cholangiocarcinoma and obstructive jaundice who underwent percutaneous transhepatic biliary drainage followed by resection were serially examined by cine cholangiography and three-dimensional cholangiography which were reconstructed from a helical computed tomography scan. Tumor extension to the bile ducts was prospectively diagnosed and the resection margin was planned using both cine and three-dimensional cholangiograms. The histological evaluation of the resected specimens were compared with preoperative findings of cholangiograms.

RESULTS

The three-dimensional cholangiograms from vertical projection demonstrated the bile duct anatomy with excellent image quality. To assess tumor invasion to the intrahepatic bile ducts, cine cholangiograms from lateral and oblique projections were necessary. Selection of the surgical procedure was influenced by preoperative evaluations of the lesion on both three-dimensional and cine cholangiograms. Histologically, the resected margin was free from tumor in all cases.

CONCLUSIONS

Three-dimensional and cine cholangiography allowed accurate assessment of the biliary system in patients with hilar cholangiocarcinoma, which was helpful for planning the surgical procedure.

Evaluation of the therapeutic effect of transcatheter arterial embolization for hepatocellular carcinoma

Transcatheter arterial embolization (TAE) has been widely performed for patients with hepatocellular carcinoma (HCC). However, the method of evaluating the therapeutic effect of TAE has not been established. We examined the rate of necrotic area to whole tumor (TN) by CT, the tumor regression rate (TR) and the reduction rate in serum alpha-fetoprotein (AFP) levels in patients with HCC who received hepatic resection within 3 months after TAE. In the evaluation of TN, the lipiodol accumulation in tumor was regarded as being necrotic. Rates of necrotic area, which were also examined pathologically (PN) in resected tumors, were compared with TN, TR and AFP reduction rates, respectively. Eighty-eight patients were enrolled in this study, and there was a significant positive correlation between TN and PN (r = 0.80, p < 0.001). Although TR significantly correlated to PN (p = 0.001), the correlation coefficient between them was low (r = 0.34). The correlation coefficients between AFP reduction rate and PN was 0.76 (p < 0.001) in 26 patients (30%) with an AFP level >/=200 ng/ml before TAE. The evaluation method using lipiodol accumulation in CT is the most useful for assessing the therapeutic effect of TAE, particularly when a sufficiently long interval exists between TAE and the evaluation, because of the highest correlation coefficient between TN and PN, and the availability of TN for all patients. The reduction rate in serum AFP levels was also useful in patients with AFP levels >200 ng/ml before treatment.

A new, convenient method for the preparation of 4-[18F]fluorobenzyl halides

A convenient method suitable for automated preparation of 4-[18F]fluorobenzyl halides from no-carrier-added [18F]fluoride has been developed. 4-[18F]Fluorobenzaldehyde, synthesized from [18F]fluoride by aromatic nucleophilic substitution on 4-trimethylammoniumbenzaldehyde triflate, was first retained on a C18 cartridge and there efficiently reduced to 4-[18F]fluorobenzyl alcohol simply by flowing an aqueous solution of NaBH4. The conversion of 4-[18F]fluorobenzyl alcohol to 4-[18F]fluorobenzyl halide was investigated using PBr3, PI3, P2I4, Ph3PBr2 and Ph3PI2 in CH2Cl2. 4-[18F]Fluorobenzyl halides were purified by passing through a disposable silica cartridge. The conversion rapidly proceeded in radiochemical yields of nearly 90% at 40 degrees C with P2I4 and almost quantitatively at room temperature with Ph3PBr2. With this last reagent 4-[18F]fluorobenzyl bromide was obtained in overall radiochemical yields of 50-60% within 30 min from EOB.

Blood supply to the pancreatic head, bile duct, and duodenum: evaluation by computed tomography during arteriography

HYPOTHESIS

Blood supply to the peripancreatic region is derived from the celiac and superior mesenteric arteries, complementary to each other.

DESIGN

Cohort analytic study.

SETTING

Tertiary care public hospital.

PATIENTS AND METHODS

Computed tomography (CT) during superior mesenteric artery arteriography (SMAA-CT) and during celiac artery arteriography (CEAA-CT), in which a catheter tip was inserted into the common hepatic or gastroduodenal artery, was performed in 25 patients.

MAIN OUTCOME MEASURE

Distribution and correlation of these areas of marked enhancement on SMAA-CT and CEAA-CT were analyzed.

RESULTS

The right cephalic part of the pancreatic head that is derived from the dorsal bud was enhanced on CEAA-CT, and the left caudal part of the pancreatic head that is derived from the ventral bud was enhanced on SMAA-CT. Blood supply to the intrapancreatic bile duct, including the ampulla of Vater, is derived from the CEA. The boundary between the areas of the duodenum supplied from the CEA and SMA was in the second or third portion.

CONCLUSION

The pancreatic head can be separated into 2 segments by the arterial supply, and each segment may be removed separately.

Haemodynamic changes in non-alcoholic (viral) liver cirrhosis studied by computed tomography (CT) arterial portography and CT arteriography

AIMS

To evaluate haemodynamic and vascular changes in non-alcoholic (viral) cirrhosis on conventional computed tomography (CT), CT arteriography (CTA) and CT arterial portography (CTAP), and to determine the cause of the observed reticular stain on angiography.

METHODS

Using surgically resected liver specimens from 31 patients with viral hepatitis associated hepatocellular carcinoma, images of conventional CT, CTA, CTAP and the sinusoidal phase of hepatic arteriography were retrospectively analysed and compared with pathology of the non-cancerous portion of the liver.

RESULTS

Computed tomography arteriography showed inhomogeneous enhancement (diffuse, low-density nodules) in a total of 16 samples (52%); in eight of 10 (80%) cirrhotic livers, three of six (50%) precirrhotic livers, five of 12 (42%) livers with chronic active hepatitis and none of three with no active liver disease. The frequency of inhomogeneous enhancement became significantly higher with increasing severity of parenchymal damage (P < 0.05). In contrast, conventional CT and CTAP showed homogeneous enhancement in all 31 (100%) patients. There was no correlation between inhomogeneous enhancement on CTA and reticular staining on sinusoidal-phase hepatic angiograms. Inhomogeneous enhancement was frequently seen in patients with hepatitis B surface antigen and/or anti-hepatitis C virus antibody compared with those without them (P < 0.05).

CONCLUSION

The CTA was much more sensitive in detecting haemodynamic changes in the cirrhotic liver than CTAP, conventional CT and sinusoidal-phased hepatic angiography. Further study is required to clarify the mechanism of inhomogeneous enhancement on CTA and homogeneous enhancement on CTAP seen in cirrhosis.

Comparison of the distribution of fluorine-18 fluoromisonidazole, deoxyglucose and methionine in tumour tissue

To evaluate the tumour imaging potential of fluorine-18 fluoromisonidazole (FMISO), we studied FMISO uptake in an experimental tumour model and examined the correlation between intratumoral distributions of FMISO, 14C-2-deoxyglucose (2DG) and 14C-methionine (Met). The study was performed using control rats with the AH109A tumour and rats with the same tumour under local hypoxia. Tumour uptake of FMISO was constant between 30 min and 2 h after injection, and the tumour to muscle ratio was 2 from 2 to 4 h. A tumour study with FMISO was scheduled at 2 h. Double-tracer autoradiography of the tumour demonstrated that in the areas of high FMISO uptake, there was low uptake of Met, while areas of low FMISO uptake showed high Met uptake. FMISO showed high grain density in the rim of the tumour surrounding the necrotic area. 2DG showed a more uniform distribution over the entire section of viable cells. The mean uptake of FMISO by hypoxic, radioresistant tumours was significantly higher than that by the control tumours (P<0.05), while both 2DG and Met uptake by the control tumours was higher than uptake by hypoxic tumours. When individual tumours were examined, the uptake of FMISO was inversely correlated with that of Met (r = -0.507, P<0.02), while 2DG showed almost uniform uptake with no significant correlation to FMISO. In conclusion, hypoxic and radioresistant tumours could be identified by increased FMISO uptake in our model, consistent with findings reported by others. We found a large overlap in the distribution of FMISO and 2DG within the tumour, but only a small overlap in the distribution of FMISO and Met. A combination of FMISO and other tracers in positron emission tomography or single-photon emission tomography studies might be more helpful than single-tracer studies in predicting the response of tumour tissues to radiotherapy.

FDG PET evaluation of residual masses and regrowth of abdominal lymph node metastases from colon cancer compared with CT during chemotherapy

Fluorine-18-2-deoxy-2-fluoro-D-glucose (F-18 FDG) PET may be more suitable for follow-up after cancer treatment than other morphologic approaches, because it reflects tumor viability. A patient with abdominal lymph node metastases from colon cancer was followed by CT and F-18 FDG PET during chemotherapy. F-18 FDG PET tumor images changed in accordance with the clinical progress, whereas CT findings were relatively unchanged. This case clearly shows the utility of F-18 FDG PET for follow-up during cancer chemotherapy.

Transarterial chemotherapy with zinostatin stimalamer for hepatocellular carcinoma

Zinostatin stimalamer (SMANCS) is a lipophilic intra-arterial chemotherapeutic agent for hepatocellular carcinoma (HCC). Thirty HCC patients underwent transcatheter arterial injection of 4 mg SMANCS-lipiodol emulsion. Their responses were evaluated by computed tomography 1 month after treatment. Complete response (CR) was defined as disappearance or 100% necrosis of all tumors. Partial response (PR) was defined as > or = 50% reduction and/or > or = 50% necrosis. We regarded the lipiodol accumulation in tumors as being necrotic. CR and PR were observed in 8 patients (27%) and 4 patients (13%), respectively, and the overall response rate (CR + PR/all patients) was 40% (12/30). Of 12 patients whose serum alpha-fetoprotein levels had been more than 200 ng/ml before treatment, 5 patients (42%) showed more than 50% reduction in this level within 1 month after treatment. Toxicity was quite acceptable, although grade 4 toxicity (WHO) was observed as liver dysfunction in 1 patient. Transarterial chemotherapy with SMANCS, which is well tolerated, appears to have moderate antitumor effect in patients with HCC.

Small polypoid lesions of the gallbladder: differential diagnosis and surgical indications by helical computed tomography

OBJECTIVES

To demonstrate the helical computed tomographic (CT) features of small polypoid lesions of the gallbladder and to establish a clinical strategy based on CT findings for the treatment of such lesions.

DESIGN

Validation cohort study.

SETTING

Tertiary care public hospital.

PATIENTS

Thirty-one patients with polypoid lesions of the gallbladder (< or = 3 cm) underwent CT followed by resection.

MAIN OUTCOME MEASURE

The detectability of the lesions on both unenhanced and enhanced CT and the configuration of the lesions on enhanced CT were prospectively evaluated in comparison with the histopathological findings.

RESULTS

Unenhanced CT detected 14 (45%) of the 31 lesions, whereas enhanced CT detected all of the lesions. The detection rates of the neoplastic lesions (adenoma, adenocarcinoma, and metastatic tumor) and cholesterol polyps were 81% (13/16) and 7% (1/15), respectively (P<.001). Among the 20 lesions demonstrated as pedunculated, 6 (30%) were neoplastic, whereas 10 (91%) of the 11 lesions demonstrated as sessile were neoplastic (P<.001). When a lesion was demonstrated on unenhanced CT or its shape was sessile on enhanced CT, the case was diagnosed as a neoplastic lesion. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the CT diagnosis of the neoplastic lesions were 88% (14/16), 87% (13/15), 88% (14/16), 87% (13/15), and 87% (27/31), respectively.

CONCLUSION

Computed tomography can differentiate neoplastic and nonneoplastic small polypoid lesions of the gallbladder and reliably identify the presence of neoplastic lesions that should be resected.

Biotransformation of digitoxigenin by cultured Strophanthus hybrid cells

Hybrid cells between Strophanthus gratus and S. amboensis were obtained by electrofusion and confirmed to be hybrids through isozyme and RFLP analyses. Because a new and hybrid compound, 17 beta H-periplogenin beta-D-glucoside, was isolated as a biotransformation product of digitoxigenin by the hybrid cells, isomerization of 17 beta-lactone ring on S. gratus and glucosylation on S. amboensis were demonstrated simultaneously as the biotransformation abilities in the hybrid cells. Moreover, the productivity of the hybrid compound was increased by raising the sucrose concentration.

Helical computed tomography in the diagnosis of portal vein invasion by pancreatic head carcinoma: usefulness for selecting surgical procedures and predicting the outcome

OBJECTIVE

To evaluate the use of helical computed tomography (CT) in diagnosing portal vein (PV) invasion by pancreatic head carcinoma and its usefulness in predicting outcome.

DESIGN

Validation cohort study.

SETTING

Tertiary care public hospital.

PATIENTS

Twenty-seven patients with carcinoma involving the pancreatic head were preoperatively studied with helical CT. All patients underwent resection.

MAIN OUTCOME MEASURE

By quantifying the contact between the tumor and PV on helical CT, the relationship between them was classified into 1 of 4 types: type 1, visible fat layer between PV and the tumor; type 2, with the total PV circumference defined as 360 degrees, contact between the tumor and PV was considered to be 90 degrees or less; type 3, contact ranged between 91 degrees and 180 degrees; and type 4, contact greater than 180 degrees. Helical CT results were compared with intraoperative observation, histological findings of the resected specimen, and postoperative course.

RESULTS

When helical CT showed type 3 or 4, the case was diagnosed as positive for PV invasion. Sensitivity, specificity, and overall accuracy were 83%, 100%, and 89% when compared with the intraoperative assessment, and 92%, 79%, and 85% with the histological assessment, respectively. One- and 2-year survival rates were 86% and 69% for type 1, 100% and 75% for type 2, and 33% and 12% for type 3, respectively. The survival rates of patients with types 1 and 2 were significantly higher than that of those with type 3 (P<.05). All 3 patients with type 4 died within 9 months.

CONCLUSIONS

Helical CT facilitates detection of PV invasion by pancreatic head carcinoma. The extent of PV involvement reflected the outcome after pancreatectomy.

Pheochromocytoma growing exophytically from the right adrenal gland and invaginating into the liver

A 5-cm pheochromocytoma located in segment 7 of the liver was found incidentally in a 45-year-old man with mild diabetes mellitus and hypertension, and resected. The tumor was demonstrated by computed tomography and magnetic resonance imaging to have completely invaginated itself into the liver and to be receiving blood from a dilated right hepatic artery alone. Surgery revealed the hepatic mass to be tightly adherent to the right adrenal gland. The histopathologic diagnosis was pheochromocytoma growing exophytically from the right adrenal gland. There was no association with multiple endocrine neoplasia type 1 and type 2. A postoperative 131I metaiodobenzylguanidine scan revealed no accumulation, and the patient is currently doing well without recurrence or hypertension one year after the operation. A pheochromocytoma deeply invaginating into the liver should be considered in the differential diagnosis of primary hypervascular hepatic tumors.

Hepatic tumor invasion of bile ducts: wedge-shaped sign on MR images

PURPOSE

To clarify the diagnostic importance of wedge-shaped areas of increased signal intensity that surround liver tumors on T1-weighted magnetic resonance (MR) images.

MATERIALS AND METHODS

In five patients with hepatic tumors, T1-weighted MR images that demonstrated wedge-shaped areas of increased signal intensity in the liver were reviewed; findings were compared with those at surgical and histologic examinations.

RESULTS

MR images showed localized intrahepatic bile duct dilatation lateral (three patients) and medial (two patients) to liver tumors within the wedge-shaped areas. At histopathologic examination, intraductal tumor growth was seen in local bile ducts in the same areas in five patients, and lipofuscin deposits were seen in the cytoplasm of atrophic hepatocytes in three patients.

CONCLUSION

On T1-weighted images, wedge-shaped areas of increased signal intensity associated with liver tumors indicate intraductal tumor extension in intrahepatic bile ducts. T1 shortening is possibly caused by lipofuscin deposits in atrophic hepatocytes.

[Three-dimensional positron emission tomography imaging system and its application for medical use]

Current positron emission tomography is capable for three dimensional data acquisition and reconstruction (3D PET). The main advantage of 3D PET is its detectability for lower tracer concentrations. The images by a 3D PET have better signal to noise ratios compared to those by conventional 2D PET. This point is especially important for the studies of distributions of ligands for neuroreceptors such as F-18 FDOPA and C-11 YM-01951, since these ligands show low accumulation in brain. Reduction of scanning time is useful as well for patients are permitting extended scanning periods