Comparison of preoperative whole-body positron emission tomography with MDCT in patients with primary colorectal cancer

OBJECTIVE

Preoperative use of emission tomography with(18)F-fluorodeoxyglucose (FDG-PET) in patients with primary colorectal cancer remains controversial. This study evaluated the additional value of FDG-PET in comparison with routine multidetector row computed tomography (MDCT) in patients with primary colorectal cancer.

METHOD

Retrospective analysis was performed in 65 patients with colorectal cancer who underwent whole-body FDG-PET. Results of FDG-PET were compared with routine preoperative evaluation by MDCT regarding detection of primary tumour, lymph node involvement and distant metastases. All images were evaluated before surgery.

RESULTS

Tumour detection rate was 100% (63/63) for MDCT and 98% (62/63) for FDG-PET. Lymph node involvement was pathologically confirmed in 35 patients. MDCT and FDG-PET displayed sensitivities of 89% (31/35; 95% CI: 73-97%) and 43% (15/35; 95% CI: 26-61%) and specificities of 52% (11/21; 95% CI: 30-74%) and 95% (20/21; 95% CI: 76-100%), respectively. Liver metastases were present in 22 patients. MDCT and FDG-PET showed accuracies of 98% (64/65; 95% CI: 92-100%) and 97% (63/65; 95% CI: 89-100%), respectively. FDG-PET detected additional extrahepatic metastatic lesions and affected treatment plan compared with MDCT in 10 patients.

CONCLUSION

Preoperative FDG-PET is not superior to MDCT for detection of primary tumour, lymph node involvement or liver metastases, but may have potential clinical value in patients with advanced colorectal cancer by detecting extrahepatic distant metastases.

A phase II trial of the novel serotonin type 3 receptor antagonist ramosetron in Japanese male and female patients with diarrhea-predominant irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder. Serotonin type 3 (5-HT3) receptor antagonist alosetron hydrochloride is indicated for women with chronic, severe diarrhea-predominant IBS who have not responded adequately to conventional therapy. However, whether or not the therapeutic efficacy of 5-HT3 receptor antagonists has gender difference is uncertain.

METHODS

A double-blind, placebo-controlled, parallel-group, comparative study was conducted to evaluate the effect of novel 5-HT3 receptor antagonist, ramosetron hydrochloride, in male and female patients with diarrhea-predominant IBS. 418 subjects were randomized (109 subjects: placebo, 105 subjects: 1 microg, 103 subjects: 5 microg, and 101 subjects: 10 microg) and administered the study drug once daily.

RESULTS

The monthly responder rates of 'Patient-reported global assessment of relief of irritable bowel syndrome symptoms' in the 5- and 10-microg ramosetron hydrochloride-administered groups were higher than the placebo group (26.92, 42.57, and 43.01% for placebo, 5 and 10 microg). Moreover, the difference of the responder rate in comparison with the placebo group was similar in males and females. As for safety, there was tolerability at doses up to 10 microg.

CONCLUSION

Ramosetron is an effective and well-tolerated treatment not only for female IBS patients but also for male patients.

Regional difference in the healing process of colitis induced by 2,4,6-trinitrobenzene sulfonic acid in rats

We recently reported an improved method to induce colitis by 2,4,6-trinitrobenzene sulfonic acid. This method enabled us to induce colitis at appropriate regions. This study aimed to investigate the regional differences on the healing process of colitis in rats. Colitis was induced at the proximal, middle or distal colon. On Day 10, the size of colitis was large in the order of the middle, distal and proximal colon. Colitis of the proximal colon healed more rapidly than that of the middle colon. Prostaglandin E(2) generation in the normal colonic mucosa was measured. Prostaglandin E(2) generation correlated with sizes of colitis among three regions. It was found that there was the regional difference on the healing process of the colitis and prostaglandin E(2) generation may show the different protective integrity of the colonic mucosa from the fact that higher prostaglandin E(2) generation showed larger colitis size.

Cervical oesophageal stent placement via a retrograde transgastric route

During attempted oesophageal stent placement in a patient with cervical oesophageal cancer in whom swallowing of even saliva was impossible, transoral access to the cervical oesophagus was unsuccessful. Under ultrasound and fluoroscopy guidance, percutaneous gastric puncture was performed, and using an angiographic catheter and guidewire, access to the oesophagus by a retrograde transgastric route was successfully achieved. The obstructed segment of the oesophagus was traversed. It was then possible to pull the guidewire through the mouth and place an oesophageal stent via an antegrade approach.

Mediastinal abscess successfully treated by percutaneous drainage using a unified CT and fluoroscopy system

We report two patients with mediastinal abscess developing after surgery for oesophageal cancer who were treated by percutaneous drainage using a unified CT and angiography system, which allows both CT and fluoroscopy to be conducted with the patient on the same bed. Fine needle puncture is performed under CT guidance and this needle is used as a tandem for insertion of the drainage needle under fluoroscopic guidance, making safe puncture possible whilst confirming the position of the needle tip. Moreover, contrast medium can be injected from the drainage tube, allowing the extent of the abscess cavity to be determined by fluoroscopy and CT, thereby making accurate drainage possible.

Severe obstruction of the superior vena cava caused by tumor invasion. Recanalization using a PTFE-covered Z stent

Bare stents are commonly used for the treatment of malignant vena cava stenoses. However, the therapeutic effect of treatment using bare stents for cases with intraluminal tumor invasion is not satisfactory. We report a case with severe obstruction of the superior vena cava caused by tumor invasion of mediastinal lymph node metastases from colon cancer, which was successfully treated by the recanalization of superior vena cava using a polytetrafluoroethylene-covered Z stent. The covered stent could not be fully expanded at first, and re-obstruction developed at the stented site due to thrombus formation soon after stenting. So, the additional balloon dilatation made the stent expend fully on another day of stenting. After the balloon dilatation blood flow improved immediately and the clinical symptoms associated with the superior vena cava obstruction resolved. Thereafter no symptomatic recurrence has been observed in 12 months of follow-up period.

Distal migration of duodenal tumors: simple prolapse or intussusception?

BACKGROUND

To define radiographically simple prolapse or intussusception in cases of distal migration of duodenal tumors.

METHODS

In one pyloric and four duodenal tumors showing distal migration, the findings of gastrointestinal contrast examinations were retrospectively evaluated in relation to CT and operative findings.

RESULTS

All lesions were intraluminal growing and well demarcated, and they included two carcinoids, a papillary adenoma, a Brunner's gland adenoma, and a hyperplastic polyp. All lesions were accompanied by long mucosal stalks, and, in three, folding deformity of the proximal jejunum was observed. CT showed no target signs except for one with gastroduodenal intussusception. Intussusception was not verified surgically in any cases.

CONCLUSION

Distal migration of duodenal tumors can occur as the result of mucosal elongation and slipping. Duodenojejunal intussusception is not necessarily associated with that phenomenon.

Patients with constipation-predominant irritable bowel syndrome (IBS) may have elevated serotonin concentrations in colonic mucosa as compared with diarrhea-predominant patients and subjects with normal bowel habits

BACKGROUND

Serotonin (5-HT) may play an important role in the regulation of colonic motility in humans. However, it is not known whether alterations in the colonic 5-HT system are involved in the pathophysiology of irritable bowel syndrome (IBS).

METHODS

Colonic mucosal specimens ranging from the ascending colon to the rectum were obtained from patients with diarrhea- or constipation-predominant IBS (n = 7 and n = 8, respectively) and from subjects with normal bowel habits (n = 7) by endoscopic biopsy in order to determine whether patients with different clinical manifestations of IBS have different mucosal disposition of 5-HT. The tissue concentrations of 5-HT and its major metabolite, 5-hydroxyindoleacetic acid, were determined by reversed-phase high-performance liquid chromatography with fluorescence detection.

RESULTS

In all study groups, the mean mucosal 5-HT concentrations obtained from the rectum were significantly (p < 0.05) higher than those obtained from more cephalic regions of the colon. In addition, the overall mean mucosal 5-HT concentrations obtained from patients with constipation-predominant IBS were significantly (p < 0.05) higher than those obtained from the control subjects and patients with diarrhea-predominant IBS. No significant differences were observed in 5-hydroxyindoleacetic acid concentrations among the three groups.

CONCLUSIONS

The mucosal 5-HT concentrations in the colon showed an ascending cephalocaudal gradient in all study groups. Although the mucosal 5-HT concentrations were elevated in patients with constipation-predominant IBS as compared with those with diarrhea-predominant IBS and the control subjects, further studies are necessary to determine whether the elevated mucosal 5-HT is a cause or a result of abnormal colonic motility.

Right gastric artery embolization to prevent acute gastric mucosal lesions in patients undergoing repeat hepatic arterial infusion chemotherapy

PURPOSE

The purpose of the study was to investigate the technical outcome and clinical effect of right gastric artery (RGA) embolization to prevent acute gastric mucosal lesions caused by influx of anticancer agents into the RGA in patients undergoing repeat hepatic arterial infusion chemotherapy (HAIC).

MATERIALS AND METHODS

In 217 patients with malignant hepatic tumors, we attempted RGA embolization with use of metallic coils and/or a mixture of n-butyl cyanoacrylate (n-BCA) and iodized oil, along with the embolization of the gastroduodenal artery. After this procedure, an infusion catheter was placed radiologically and HAIC was performed. We then evaluated the technical outcome and clinical effect of RGA embolization.

RESULTS

RGA embolization was technically successful in 201 of 217 patients (93%). Major complications--nausea, epigastric pain, and fever--were noted in 12%, 4%, and 2% of successful cases, respectively, and were treated conservatively. Recanalization occurred in 4% (nine of 201) of the patients. Eventually, sufficient RGA embolization was achieved in 192 patients. The incidence of acute gastric mucosal lesions confirmed endoscopically was only 3% (five of 192) in patients with sufficient RGA embolization, whereas it was 36% (nine of 25) in patients without sufficient RGA embolization, with a significant difference (P <.01).

CONCLUSION

RGA embolization is a highly feasible procedure that can reduce the incidence of acute gastric mucosal lesions associated with HAIC.

Safety and efficacy of granulocyte and monocyte adsorption apheresis in patients with active ulcerative colitis: a multicenter study

Active ulcerative colitis (UC) is characterized by activation and infiltration of granulocytes and monocytes/macrophages into the colonic mucosa. The infiltrated leukocytes can cause mucosal damage by releasing degradative proteases, reactive oxygen derivatives, and proinflammatory cytokines. The aim of this trial (conducted in 14 specialist centers) was to assess safety and efficacy of granulocyte and monocyte adsorption apheresis in patients with active UC most of whom were refractory to conventional drug therapy. We used a new adsorptive type extracorporeal column (G-1 Adacolumn) filled with cellulose acetate beads (carriers) of 2 mm in diameter, which selectively adsorb granulocytes and monocytes/macrophages. Patients (n = 53) received five apheresis sessions, each of 60 minutes duration, flow rate 30 ml per minute for 5 consecutive weeks in combination with 24.4 +/- 3.60 mg prednisolone (mean +/- SE per patient per day, baseline dose). During 60 minutes apheresis, 26% of granulocytes, 19.5% of monocytes and 2% of lymphocytes adsorbed to the carriers. At week 7, 58.5% of patients had remission or improved, the dose of prednisolone was reduced to 14.2 +/- 2.25 mg (n = 37). The apheresis treatment was fairly safe, only eight non-severe side effects (in 5 patients) were reported. Based on our results, we believe that in patients with active severe UC, patients who are refractory to conventional drugs, granulocyte and monocyte adsorption apheresis is a useful adjunct to conventional therapy. This procedure should have the potential to allow tapering the dose of corticosteroids, shorten the time to remission and delay relapse.

Efficacy of treatment with chimeric monoclonal antibody (Infliximab) to tumor necrosis factor-alpha for Crohn's disease in Japan: evaluation by rapid turnover proteins, and radiologic and endoscopic findings

BACKGROUND

Several studies have reported that the chimeric monoclonal antibody to tumor necrosis factor (TNF)-alpha (Infliximab) is extremely valuable in the treatment of Crohn's disease. The aim of this study was to clarify the efficacy of this treatment in Japanese patients with Crohn's disease.

METHODS

A 12-week multicenter, open trial of Infliximab was carried out and involved 25 patients with moderate to severe Crohn's disease who were resistant to conventional treatment. Patients received a single 2-h intravenous infusion of Infliximab at a dose of 1, 3, 5 or 10 mg/kg bodyweight. Clinical evaluation of this treatment response was defined as a reduction in the index of the inflammatory bowel disease (IOIBD) and of the Crohn's disease activity index scores (CDAI), and in serum levels of C-reactive protein (CRP) at 2, 4, 8 and 12 weeks, and as an increase in serum levels of rapid turnover proteins as well as improvement of radiologic and endoscopic findings at 4 weeks.

RESULTS

The IOIBD score was reduced after 4 weeks in 66.7% of the group receiving 1 mg/kg Infliximab, 71.4% in the group receiving 3 mg/kg, 80.0% in the group receiving 5 mg/kg, and 85.7% in the group receiving 10 mg/kg. Improvement was better maintained over 12 weeks in the 5 and 10 mg/kg groups compared with the 1 and 3 mg/kg groups. Similar results were obtained for the CDAI scores. Serum levels of rapid turnover proteins significantly increased to within the normal ranges after infusion in all groups. Seven of the 11 (63.6%) patients evaluated showed improvement of radiologic and endoscopic findings.

CONCLUSIONS

A single infusion of Infliximab was effective for the treatment of Japanese patients with Crohn's disease. Serum rapid turnover proteins reflected the clinical response to antibody for TNF-alpha well.

Case report: Hepatic arterial occlusion following infusion catheter placement: recanalization using the Palmaz stent

We report two cases in which hepatic arterial occlusion developed soon after percutaneous catheter placement for hepatic arterial infusion chemotherapy in malignant hepatic neoplasms. A replaced hepatic artery and a proper hepatic artery, respectively, became occluded in these cases. In both, because the tip of a side-holed catheter for arterial infusion was fixed in place, we performed recanalization without removing the indwelling catheter. Despite the presence of the catheter, a stent could be inserted into the occluded portion of the hepatic artery. Recanalization of the hepatic artery was achieved with stent placement, and continuation of hepatic arterial infusion became possible.

Effectiveness of endoscopic biliary drainage for unresectable hepatocellular carcinoma associated with obstructive jaundice

Endoscopic biliary drainage (EBD) for unresectable hepatocellular carcinoma (HCC) associated with obstructive jaundice remains controversial because of the short survival of these patients. To evaluate the effectiveness of this procedure, we retrospectively studied 18 patients who had unresectable HCC with obstructive jaundice and underwent EBD with polyethylene stents, over a 10-year period. Nine patients with tumor thrombus involving the first branches of the portal vein or portal trunk (Vp3) formed group A and the other 9 (Vp0-Vp2) formed group B. The serum albumin level and serum total bililubin level differed significantly between the two groups (P < 0.05 and P < 0.005. Student's t-test), but prothrombin time did not. The obstructive jaundice was mainly caused by direct tumor invasion in 6 patients from group A and 3 from group B, by blood clots and/or tumor fragments in 2 patients from group A and 3 from group B, by the tumor protruding into the common hepatic duct in 2 patients from group B. and by tumor compression of the common bile duct in 1 patient from each group. Drainage was successful in 4 patients (44%) from group A and in all 9 patients (100%) from group B. Among the 5 patients with unsuccessful drainage in group A, 4 had obstruction of both the left and right hepatic ducts and 3 had multiple tumors in both lobes. The mean survival time (mean +/- SD) after EBD was 47 +/- 44 days in group A and 181 +/- 70 days in group B. In group A. the average survival time was only 85 days in the 4 patients with successful drainage. However, an improvement in the quality of life after EBD was observed in one-third of the Vp3 patients and in all of the Vp0-Vp2 patients. In summary, satisfactory palliation is possible with successful EBD, but this is difficult in most patients with Vp3 portal thrombus, direct tumor invasion involving both hepatic ducts, and multiple tumors in both lobes. It is important to determine the site, extent, and nature of the obstruction, as well as liver function and the presence of portal thrombus, before performing EBD.

Pre-operative detection of malignant hepatic tumours: value of combined helical CT during arterial portography and biphasic CT during hepatic arteriography

AIMS

The purpose of our study was to evaluate the observer performance with combined helical CT during arterial portography (CTAP) and biphasic CT hepatic arteriography (CTHA) in the pre-operative detection of malignant hepatic tumours.

METHODS

Computed tomography images obtained in 41 patients with suspected hepatic tumours were retrospectively reviewed. In a blind fashion, three off-site, independent radiologists reviewed CTAP and early-phase CTHA combined for the first review, then late-phase CTHA was added for the second review. Statistical analysis was conducted on lesion-by-lesion and segment-by-segment bases; a total of 328 liver segments including 65 segments with 74 malignant hepatic tumours ranging in size from 5 to 100 mm (mean, 21.4 mm) were analysed.

RESULTS

Sensitivity for detection of liver segments harbouring tumours of CTAP and biphasic CTHA combined (82%) was identical to that of CTAP and early-phase CTHA combined (82%). Specificity of CTAP and biphasic CTHA combined (93%) was greater than that of CTAP and early-phase CTHA combined (90%, P < 0.005). The mean confidence level for the 74 tumours significantly increased by adding late-phase CTHA (P < 0.0005). The mean confidence level for 100-142 benign perfusion abnormalities detected with CTAP and early-phase CTHA combined significantly decreased by adding late-phase CTHA (P < 0.0005).

CONCLUSION

By combining late-phase CTHA with CTAP and early-phase CTHA information, the specificity for the detection of malignant hepatic tumours rises significantly, allowing more accurate preoperative tumour detection.

Biopsy of lung nodules with use of I-I device under intermittent CT fluoroscopic guidance: preliminary clinical study

PURPOSE

To investigate the efficacy of computed tomography (CT) fluoroscopy and a new needle holder (the I-I device) in lung nodule biopsy.

MATERIALS AND METHODS

The I-I device is made of acrylate resin and was used to keep the entire needle in the tomographic plane. This study consisted of biopsies of 79 lung nodules in 77 patients. The final diagnoses were malignant in 54 patients, benign in 23, and unconfirmed in two. The biopsy procedure time from the beginning of the CT fluoroscopy procedure to the removal of the needle was measured for 24 needle passes. The radiation dose on the physician's hand was measured in five cases with use of a thermoluminescence ring.

RESULTS

Fifty-one malignant and 20 benign lesions were correctly diagnosed with histologic specimens (90%). In 58 of 77 patients (75%), the biopsy procedures were completed within a single breath-hold. Pneumothorax occurred in 20 of 77 patients (26%) and chest tube insertion was required in five. The incidence of pneumothorax was significantly lower in patients who held their breath during biopsy procedures compared with those who did not (P < .0001; chi2 test). The biopsy procedure time ranged from 15 to 39 seconds (mean: 28.2 sec). The mean radiation dose on the physician's hand was 2 mSv/case.

CONCLUSION

The diagnostic accuracy of biopsy with use of the I-I device under CT fluoroscopic guidance is comparable with that of the conventional method; however, a combination of CT fluoroscopy and the I-I device enables rapid biopsy procedures.

Nitric oxide donating compounds inhibit HCl-induced gastric mucosal lesions mainly via prostaglandin

Prostaglandin (PG) and nitric oxide (NO) have been known to inhibit the lesion formation induced by necrotic agents. However, no clear correlation between PG and NO has been shown in the gastroprotective action against necrotic agent-induced gastric mucosal lesions in rats. Thus, the present study was performed to clarify this correlation. Gastric mucosal lesions were induced by the oral administration of 0.6 M HCl in rats. 16,16-Dimethyl PGE2 (0.3-3 microg/kg, p.o.; dim-PGE2), sodium nitrite (0.3 and 1 mg/kg, s.c.) and sodium nitroprusside (30 and 100 microg/kg, i.v.; SNP) dose-dependently inhibited the lesion formation. Orally administered sodium nitrite or SNP (3 mg/kg) also significantly inhibited the lesion formation. The gastroprotective action by dim-PGE2 was not affected by the pre-treatment with N(G)-nitro-L-arginine methylester (10 mg/kg, i.v.). The gastroprotective effect by sodium nitrite or SNP was markedly attenuated by the pre-treatment with indomethacin (10 mg/kg, s.c.). These findings suggest that NO donating compounds inhibit the HCl-induced mucosal lesions mainly through prostaglandin, but dim-PGE2 directly inhibits the lesions without involvement of NO in rats.

[Hepatic arterial infusion chemotherapy for liver metastases from colorectal cancer]

After randomized studies of hepatic arterial infusion chemotherapy (HAIC) versus systemic chemotherapy for liver metastases from colorectal cancer in the 1980s, the role of HAIC has been unclear and there is still no evidence to support it as the treatment of choice. The high local control, the differences in techniques between Japan and Western countries, the difficulty of detecting pre-treatment extra-hepatic metastases and the fact that HAIC does not control extra-hepatic lesions are the most important points in considering clinical trials of HAIC. Clinical studies on the combination of HAIC using 5-FU and systemic chemotherapy using CPT-11, and then randomized trial of systemic chemotherapy with/without HAIC is required in Japan to reveal the role of HAIC in the management of liver metastases from colorectal cancer. We should understand the importance of our role in this field.

Massive intrathoracic haemorrhage after CT-guided lung biopsy

CT-guided lung biopsy is now widely performed for tumorous lesions in the lung, and both its usefulness in this context and the associated complications have been well described in the literature. Although severe complications are rare, we describe a case in which massive intrathoracic haemorrhage developed after lung biopsy and necessitated emergency operation for control. Intraoperative findings suggested that the source of the haemorrhage was a fibrous, cord-like substance present at the site of adhesion associated with old tuberculosis. We attributed this haemorrhage to a pneumothorax, which developed after lung biopsy and caused the new vessels penetrating the centre of the fibrous, cord-like substance to stretch and rupture. Numerous cases have been reported of spontaneous haemopneumothorax precipitated by spontaneous pneumothorax and resulting from the rupture of such vessels.

Increased hepatic arterial blood flow after decreased portal supply to the liver parenchyma owing to intrahepatic portosystemic venous shunt: angiographic demonstration using helical CT

This study was conducted to investigate the haemodynamics of the liver parenchyma in the presence of intrahepatic portosystemic venous shunt. 3 patients with intrahepatic portosystemic venous shunts and 24 patients with normal intrahepatic haemodynamics underwent both CT arterial portography and CT during hepatic arteriography. Angiographic findings with helical CT were compared, and CT attenuated values were measured in both groups. The liver parenchyma on CT arterial portography had lower attenuation than on CT during hepatic arteriography in all patients with intrahepatic portosystemic venous shunts. Overall average CT attenuation was 92.2 +/- 7.7 Hounsfield units (HU) on CT arterial portography and 149.9 +/- 8.5 HU after CT during hepatic arteriography, with the opposite findings in all patients without intrahepatic portosystemic venous shunt: CT attenuation 142.0 +/- 25.7 HU on CT arterial portography and 100.7 +/- 16.4 HU after CT during hepatic arteriography. In conclusion, the portal venous supply to the liver parenchyma decreased due to intrahepatic portosystemic venous shunts, with a compensatory increase in hepatic arterial blood supply.

The aetiology of non-tumorous enhancement in the hepatic hilum shown on CT hepatic arteriography

The causes of non-tumorous abnormalities in the hepatic hilum seen on CT hepatic arteriography were investigated. 13 patients with non-tumorous defects of portal perfusion in the hepatic hilum on CT arterial portography underwent both CT hepatic arteriography from the common hepatic artery and CT obtained during proper hepatic arteriography. The findings of non-tumorous portal defects on these two angiographic studies using helical CT were compared. In the 13 patients, 14 non-tumorous defects of portal perfusion in the hepatic hilum on CT arterial portography were detected as enhanced areas in 10 regions (dorsum of segment IV, 7/10; dorsum of the lateral segment, 3/4) on CT hepatic arteriography via the common hepatic artery, but none were enhanced on CT obtained during proper hepatic arteriography. In conclusion, the main cause of non-tumorous enhancement in the hepatic hilum seen on CT hepatic arteriography is non-portal direct inflow via the parabiliary venous system.