Proton and Carbon Ion Radiotherapy for Operable Early-Stage Lung Cancer: 3-Year Results of a Prospective Nationwide Registry

PURPOSE/OBJECTIVE(S)

The purpose of this analysis was to report subset analysis as to progression-free survival (PFS) and overall survival (OS) of particle-beam radiation therapy for operable early-stage lung cancer.

MATERIALS/METHODS

Patients of early-stage lung cancer (T1-T2aN0) who were eligible for radical surgery but did not wish to undergo surgery were treated by proton-ion (PT) or carbon-ion (CT) radiation therapy and enrolled in Japanese prospective registry. In this analysis, PFS and OS by clinical stage, tumor location, pathological confirmation and particle-ion type were evaluated.

RESULTS

A total of 274 patients were enrolled and included in efficacy and safety analyses. Most tumors were adenocarcinoma (44%), and 105 (38%) were not histologically confirmed and diagnosed clinically. 250 (91%) of 274 patients had tumors that were peripherally situated. 138 (50%) and 136 (50%) patients were treated by PT and CT, respectively. The median follow-up time for all censored patients was 42.8 months (IQR 36.7 - 49.0). No grade 3 or severe treatment-related toxicity was observed. 3-year PFS was 81% (95% CI;76-86) and OS was 93% (95% CI;89-96), respectively. As to particle-ion type, 3-year PFS were 79.0% and 81.9% in PT and CT (p = 0.19), and 3-year OS were 93.9% and 91.1% in PT and CT (P = 0.72), respectively. For PFS, pathological confirmation, clinical stage was significant factors but there were no significant differences by tumor location or particle-ion type; for OS, clinical stage was significant factor but there was no significant difference on pathological confirmation, tumor location or particle-ion type (Table1). Table 1. 3-year PFS and OS CONCLUSION: Particle therapy for operable early-stage lung cancer resulted in excellent 3-year OS and PFS on each subset.

Usefulness of Pseudocontinuous Arterial Spin-Labeling for the Assessment of Patients with Head and Neck Squamous Cell Carcinoma by Measuring Tumor Blood Flow in the Pretreatment and Early Treatment Period

BACKGROUND AND PURPOSE

For the assessment of the treatment response in non-surgical treatment, tumor blood flow provides the functional information of the tumor which is different from the morphological information such as tumor volume. The purpose of this study was to evaluate the diagnostic value of tumor blood flow values obtained by pseudocontinuous arterial spin-labeling in patients with head and neck squamous cell carcinoma.

MATERIALS AND METHODS

Forty-one patients with head and neck squamous cell carcinoma were evaluated by using pseudocontinuous arterial spin-labeling. Quantitative tumor blood flow was calculated at the pretreatment and the early treatment periods in all the patients, and the percentage change of tumor blood flow between the two was calculated. At the early treatment period, based on their tumor volume reduction rate, we divided the patients into stable disease and partial response groups for a subgroup analysis. The local control or failure was confirmed either by histopathology or by radiologic evaluation within the follow-up.

RESULTS

Pretreatment tumor blood flow in patients in the failure group was significantly lower than that in patients in the local control group. In the subgroup analysis of patients with stable disease, the percentage change of tumor blood flow was significantly larger (due to the tumor blood flow increase from pretreatment value) in the local control group than in the failure group. In addition, in patients with a partial response, the percentage change of tumor blood flow was significantly smaller (due to the tumor blood flow decrease from the pretreatment value) in the local control group than in the failure group. The accuracy for determination of the local control group or the failure group in pretreatment tumor blood flow was 0.83 and that in the combination use of the percentage change of tumor blood flow and tumor volume in the early treatment period was 0.93.

CONCLUSIONS

Tumor blood flow obtained by pseudocontinuous arterial spin-labeling can be useful for the determination of local control. The combined use of the percentage change of tumor blood flow and tumor volume had particularly high diagnostic accuracy.

Novel approach to analysis of in vitro tumor angiogenesis with a variable-pressure scanning electron microscope: suppression by matrix metalloproteinase inhibitor SI-27

Degradation of basement membrane by metalloproteinases (MMP) is a critical step in tumor angiogenesis. To evaluate in vitro angiogenesis, several models have been employed, including bovine cornea, fenestrated rat brain, Matrigel, and others. These models did not provide quantitative analysis of capillary formation. The current study aimed for a novel approach to in vitro assay of angiogenesis with a "wet scanning electron microscope (SEM)" to investigate suppression of tumor angiogenesis by the MMP inhibitor, SI-27. The effects of noncytotoxic concentrations of SI-27 (1-100 microM) were determined on nonmitogenic vascular endothelial growth factor (VEGF) (10 ng/ml)-mediated cell motility and in vitro angiogenesis of human umbilical vein endothelial cells (HUVECs). Activities of MMP and tissue inhibitor of metalloproteinase (TIMP) were determined by enzyme-linked immunosorbent assay (ELISA). Subsequently, the inhibitory effect of SI-27 was examined on in vitro angiogenesis stimulated by supernatants of human glioma cell lines (U87MG, U251MG, or U373MG). In vitro angiogenesis was quantitatively analyzed with a variable-pressure SEM. Cell motility and in vitro angiogenesis by HUVECs were significantly increased by VEGF along with elevated MMP-1 and -2 activity, whereas SI-27 significantly suppressed VEGF-mediated in vitro angiogenesis and inactivated both MMP-1 and MMP-2, but not inhibited cell motility. The angiogenesis promoted by glioma supernatants showed a significant reduction in the presence of SI-27. SI-27, a novel MMP inhibitor, inhibited tumor angiogenesis in vitro. It can be anticipated to prevent tumor growth through its angiosuppressive effect. Quantitative analysis with a variable-pressure SEM is a novel approach to in vitro angiogenesis assay.

Signalling pathway mediated by CXCR7, an alternative chemokine receptor for stromal-cell derived factor-1α, in AtT20 mouse adrenocorticotrophic hormone-secreting pituitary adenoma cells

Stromal cell-derived factor (SDF)-1 and its receptor, CXCR4, have been identified in both neurones and glia of many brain areas. Previous studies have mainly focused on the role of SDF-1 and CXCR4 in modulating the hypothalamic-pituitary axis and their possible involvement in the development of pituitary adenomas. An alternative SDF-1 receptor, CXCR7, has recently been identified, but it has not been studied in the context of pituitary adenomas. The present study aimed to investigate the distribution and function of CXCR7 in pituitary adenomas. The expression of CXCR7, normalised to β-actin, was assessed by tissue microarray analysis of 62 adenomas, including 23 growth hormone (GH)-producing adenomas, 22 nonfunctioning adenomas, seven prolactin (PRL)-producing adenomas, six adrenocorticotrophic hormone-producing adenomas and four thyroid-stimulating hormone-producing adenomas. In vitro functional studies used RNA interference (RNAi) and cDNA microarray analysis to evaluate the CXCR7 signalling pathway in AtT-20 mouse pituitary adenoma cells treated with recombinant mouse SDF-1α and transfected with RNAi against Cxcr7 or control RNAi. In tissue microarray analysis, prominent expression of CXCR7 was observed in GH-producing adenomas and PRL-producing adenomas, and in macroadenomas (P < 0.05). Intracellular signalling via CXCR7 up-regulated Bub1, Cdc29 and Ccnb1, and down-regulated Asns, Gpt, Pycr1, Cars and Dars. The present study demonstrates that the SDF-1α ⁄ CXCR7 signalling pathway regulates genes involved in cell cycle control, amino acid metabolism and ligase activity, which comprise targets that are distinct from those of CXCR4.

Effectiveness of endoscopic surgery training for medical students using a virtual reality simulator versus a box trainer: a randomized controlled trial

BACKGROUND

The first step toward increasing the level of patient safety in endoscopic surgery is for all endoscopic surgeons to acquire fundamental skills, including psychomotor skills, in the preoperation stage of training. The current study aimed to evaluate the effectiveness of virtual reality (VR) simulator training and box training for training the fundamental skills of endoscopic surgery.

METHODS

For this study, 35 medical students at Kyushu University were divided into three groups: simulator (SIM) group (n = 20), box trainer (BOX) group (n = 20), and control group (n = 15). None of the students had any experience assisting with endoscopic surgery or any previous training for endoscopic surgery. The students in the SIM group underwent training using a VR simulator, the Procedicus MIST, 2 h per day for 2 days. The students in the BOX group underwent training using a box trainer 2 h per day for 2 days. The students in the control group watched an educational video for 30 min. The endoscopic surgical skills of all the students were evaluated before and after training with a task of suturing and knot tying using a box trainer.

RESULTS

Although no significant differences were found between the three groups in the total time taken to complete the evaluation task before training, there were significant improvements in the SIM and BOX groups after training compared with the control group. Box training increased errors during the task, but simulator training did not.

CONCLUSION

The findings showed that box training and VR training have different outcomes. The authors expect that the best curriculum for their training center would involve a combination that uses the merits of both methods.

Decompression surgery and intraoperative radiation therapy (IORT) for metastatic spinal tumors

20515

Background: Metastatic spinal tumors often cause spinal cord compression and jeopardize the quality of life of the patients much. To decrease the local symptomatic recurrence rate, we have been adding IORT to decompression surgery. Methods: For those patients whose life expectancy was more than 6 months were eligible for this treatment. Posterior decompression by laminectomy of the involved vertebrae was performed. Following decompression, the patient was irradiated the lesions intraoperatively with electrons generated from Microtron by shielding the spinal cord with lead plate. The central aspects of the vertebrae were irradiated by scattered electrons detouring from the edge of the lead shield up to 40% of the administered dose. Following IORT, posterior instrumentation was performed. External beam radiotherapy might be added pre- and/or postoperatively when considered necessary. Results: 108 patients were treated between 1992–2005. There were 58 males and 50 females. Age ranged from 26 to 85 with a median of 62.5. By primary sites, 26 breast, 24 kidney, 18 colorectum, 17 lung 12 prostate and 11 thyroid cases were included. Irradiated spines were cervical in 6, thoracic in 76, and lumbar/sacral in 27. Overall median follow-up period was 12.7months. Median IORT dose was 20Gy (range 15–26Gy) and median electron energy was 16MeV (range 11–22MeV). There were 37 cases with preoperative RT and 41 cases with postoperative RT. Overall median survival time was 14.5months (breast 15.3, kidney 22.6, colorectum 5.7, lung 6.2, prostate 31.6, thyroid 60.6months). Neurological response rate was 73.1%. Ambulatory rates were 87.0% for success and 80.6% for rescue by Klimo's definition(2005). There were only 8 symptomatic relapses (7%). As for major complications, only one myelopathy has been observed. Conclusions: Decompression surgery and IORT for metastatic spinal tumors with impending spinal cord compression was a promising treatment modality with excellent local control and neurological response rate and with minimal toxicity especially for those patients with long-term prognosis.

No significant financial relationships to disclose.

Development and assessment of morphologic criteria for diagnosing gastric cancer using confocal endomicroscopy: an ex vivo and in vivo study

BACKGROUND AND STUDY AIMS

The Confocal Endomicroscopy System (Optiscan Pty Ltd. and Pentax Corp.) is a newly developed imaging tool that uses laser light and optical technology to visualize living tissue at the cellular level. Digital images of cells magnified 1000-fold appear in real time on a computer screen, which enables immediate detection of changes in cellular structure without the need for a biopsy. The aim of this study was to assess the features of the cellular architecture of cancerous tissue that can be used in the differential diagnosis of cancerous tissue and normal mucosa using this system's image-processing software.

PATIENTS AND METHODS

A total of 27 gastric cancers were examined ex vivo using confocal endomicroscopy. A fluorescent contrast agent, acriflavine, was applied topically to normal and to cancerous mucosa. In vivo imaging of the gastric mucosa after intravenous injection of fluorescein sodium was also performed in nine patients with gastritis or gastric cancer.

RESULTS

The nuclear area in the ex vivo specimens was calculated using Scion Image software. The mean nuclear area of cancer cells was found to be significantly larger than that of normal cells in 18/27 gastric cancers (67 %). The mean nuclear area of the cancers tended to be larger than that of normal mucosa, especially in cases of differentiated adenocarcinoma. In more than half the cases, it was possible to diagnose malignancy automatically using confocal endomicroscopy and image-processing software without the need for biopsy and pathological examination. In vivo imaging of cancerous lesions showed irregularity in cellularity and vascularity.

CONCLUSION

The ability of this imaging device to differentiate between normal tissue and cancerous tissues gives it potential value as a new screening tool for early detection of malignancy.

A case of pleomorphic xanthoastrocytoma presenting with massive tumoral hemorrhage

Pleomorphic xanthoastrocytoma has been generally conceived to be in a benign nature, showing a relatively favorable prognosis. Apoplectic attack attributable by massive hemorrhage in this distinct form of the supratentorial glioma is an exceedingly rare event. A 61-year-old female presented with a sudden onset of generalized tonic--clonic convulsion. CT and MRI disclosed the presence of a tumor composing of massive intra-tumoral hemorrhage filling the cyst associated with mural nodule in the left frontotemporal lobe. At surgery, the subpial mass involving hematoma was well marginated and slightly adherent to the dura mater. It could be removed totally and proved to be a pleomorphic xanthoastrocytoma. The unusual hemorrhagic presentation of this typically benign entity is extremely rare and is thought to be intra-tumoral bleeding in this case, since subarachnoid hemorrhage was absent.

Induction of apoptosis by estramustine phosphate mediated by phosphorylation of bcl-2

Estramustine phosphate (EMP) is an anti-microtubule agent that induces apoptosis of glioma cells. We investigated whether EMP caused apoptosis through the alkylating effect of its nitrogen mustard component or by phosphorylation of bcl-2 like other anti-microtubule agents in normal human astrocyte and human malignant glioma cell lines. Apoptosis was seen in glioma cells treated either with nitrogen mustard or EMP and expression of bcl-2 mRNA was not changed by exposure to the drug. An immunoprecipitation study only found phosphorylation bcl-2 in glioma cells exposed to EMP and not in cells exposed to nitrogen mustard. These results indicate that induction of apoptosis in glioma cells by EMP is mediated by phosphorylation of bcl-2.

Suppression of matrix metalloproteinase-2 and -9 mediated invasiveness by a novel matrix metalloproteinase inhibitor, BE16627B

Cell invasion is a nature of malignant gliomas, demeriting to many efforts of the treatment. Matrix metalloproteinase (MMP) is acknowledged as a key factor in this complicated process. The aim of this study was to investigate whether inhibition of MMP activity in malignant glioma cells could be achieved by a novel agent, BE16627B (BE). Malignant glioma cell lines, U87MG, U251MG, and U373MG, were employed to evaluate inhibitory effect on zymogram, type IV collagenolysis assay, and haptoinvasion assay for 24 h exposure of BE, following preliminar

Evaluation of hepatocellular carcinoma after treatment with transcatheter arterial chemoembolization: comparison of Lipiodol-CT, power Doppler sonography, and dynamic MRI

BACKGROUND

The purpose of this study was to compare the ability of Lipiodol-computed tomography (CT), power Doppler (PD) sonography, and dynamic magnetic resonance imaging (MRI) in evaluating the therapeutic effect of transcatheter arterial chemoembolization (TACE) on hepatocellular carcinoma (HCC).

METHODS

TACE was performed by injecting an emulsion consisting of Lipiodol and a chemotherapeutic drug, followed by gelatin sponge particles, into 54 patients with 84 HCC lesions. Five to 7 days later, Lipiodol-CT, PD sonography, and dynamic MRI were performed. Findings from the three modalities were correlated with relapse within 1 year after TACE.

RESULTS

All lesions with blood flow on PD sonography or intratumoral enhancement on dynamic MRI relapsed regardless of the findings with Lipiodol-CT. None of the negatively enhanced lesions on dynamic MRI relapsed regardless of the Lipiodol-CT findings. However, the readers could not evaluate the contrast uptake in 14 lesions that were already hyperintense on the precontrast images. These cases were considered unsuitable for qualitative assessment and reduced the applicability of MRI to 83% of the examined lesions (70 of 84). Although PD sonography perfectly predicted relapse in superficial (0-5 cm from abdominal surface) lesions of the right hepatic lobe, blood flow in deep (>5 cm) or left lobe lesions was undetectable regardless of the occurrence of relapse. As a result, Lipiodol-CT displayed 76.0% sensitivity, 67.6% specificity, and 72.6% accuracy. The sensitivity, specificity, and accuracy of PD sonography were 34.0%, 100%, and 60.7%, respectively. In the 70 lesions in which evaluation was possible, dynamic MRI achieved 100% sensitivity, 100% specificity, and 100% accuracy.

CONCLUSION

Of the three modalities, dynamic MRI was the best for evaluating the efficacy of TACE in the treatment of HCC. We also found that superficial lesions of the right lobe are good candidates for PD sonography. However, high signals on precontrast MR images, motion artifacts, and ultrasonic attenuation remain key limitations.

Chronological analysis of physiological T2* signal change in the cerebrum during breath holding

The purpose of this study was to examine which physiological factors affect cerebral T2* signal intensity (SI) during breath holding (BH) (apnea after inspiration and breathing after expiration) in normal volunteers. We examined SI changes caused by anoxic gas inhalation, by respiratory movements, and by BH. High-speed echo planar images (EPI) showed changes in SI that could be divided into five phases. Reports indicate that SI changes induced by BH are due to the effects on the magnetic susceptibility of deoxygenated hemoglobin (deoxyhemoglobin (dHb)) and to hypercapnia, but these reports could not fully explain the observed five phases. In addition to deoxyhemoglobin susceptibility and hypercapnia, we found that respiratory movements play a third critical role in modifying SI by affecting blood flow into the region of interest (ROI), as judged from right carotid artery flow. Consequently, we propose that the physiological SI changes induced by BH are derived from blood oxygenation, hypercapnia, and respiratory movements.

The bleb formation of the extracellular pseudopodia; early evidence of microtubule depolymerization by estramustine phosphate in glioma cell; in vitro study

Estramustine phosphate (EMP) is an anti-microtubule agent that depolymerizes microtubules and also causes apoptosis of glioma cells. Both of these pharmacological actions have been previously studied within the same cytotoxic range of EMP concentrations. The purpose of this study was to investigate which of these two phenomena occurred before the other. A preliminary MTT assay was done to distinguish non-cytotoxic (0.005-0.1 microM) and cytotoxic (0.5-10 microM) of EMP for BT4C cells. To investigate apoptotic changes, transmission electron microscopy (TEM), DNA laddering, and in situ endo-labeling (TUNEL) method were employed. A chemotaxis assay was used to assess cell motility. Scanning electron microscopy and TEM immunocytochemistry with an anti-beta tubulin antibody were applied to detect morphological changes of the microtubules. Suppression of cell motility by cytotoxic doses of EMP (0.5-10 microM) group was attributed by the cyto-reductive effect, relating to apoptosis. At 0.01-0.1 microM (non-cytotoxic doses), EMP did not indue apoptosis. At these concentrations, TEM and immunohistochemistry revealed the formation of blebs on the tip of the pseudopodia that contained abnormally depolymerized microtubules, a finding that was not observed at a low temperature or during cell migration. Cell chemotaxis was significantly inhibited by cytostatic EMP doses (0.05 and 0.1 microM). Bleb formation of the pseudopodia might be evidence of the abnormal disassembly of microtubules by cytostatic EMP concentrations, prior to the induction of apoptosis. In glioma cells EMP probably initiates apoptosis by causing the depolymerization of microtubules. Inhibition of cell motility by cytostatic doses of EMP could be beneficial to support other therapies.

Suppression of cell invasion on human malignant glioma cell lines by a novel matrix-metalloproteinase inhibitor SI-27: in vitro study

Matrix metalloproteinase (MMP) has come to be highlighted by its close relation to the cell invasion of gliomas. Suppression of MMP activity in malignant glioma cells would be meriting to local delivery of genes or chemotherapeutic agents. In this study, we employed a novel MMP inhibitor, SI-27 to investigate inhibition of cell invasiveness in human malignant glioma cell lines, U87MG, U251MG, and U373MG. We evaluated with zymogram, reverse zymogram, and cell invasion assay after exposure of SI-27 for 24 h followed by preliminary MTT assay to find non-cytotoxic dose range, 5, 10, 50, 100 microg/ml compared with non-treatment group as the control. Common to three glioma cell lines, zymogram disclosed that expressions of MMP-2 and -9 were suppressed in a dose-dependent fashion, meanwhile those of tissue inhibitor of MMP (TIMMP) in reverse zymogram were not. The numbers of invading cells through Boyden chamber were significantly reduced in a dose-dependent manner, while those with 5 microg/ml were not diminished common to those three lines. In conclusion, dose concentration ranging 10-100 microg/ml of SI-27 inhibited MMP-2 and -9 mediated cell invasiveness in malignant glioma cell lines. This is the first report for chemotherapeutic effect of SI-27 on glioma cells.

Drug-induced apoptosis by anti-microtubule agent, estramustine phosphate on human malignant glioma cell line, U87MG; in vitro study

The drug effect of estramustine phosphate (EMP), an anti-microtubule agent on human glioma cells has been studied with the focus being mainly its cytotoxity or its targeting of organelles. However, the pharmacological knowledge of estramustine with respect to its cytotoxity and mechanism is limited. To acquire such knowledge, the present study investigates the ability of EMP to induce apoptosis in a human malignant glioma cell line. Transmission electron microscope (TEM) images were examined to monitor periodic changes. Agarose gel electrophoresis was also examined. Cellular DNA fragmentation ELISA was performed to investigate the DNA fragmentation rates and an MTT assay was studied to evaluate the ID50. A TEM study revealed condensing and fragmentation of the chromatin. Laddering of the bands was observed in all EMP exposure groups in agarose gel electrophoresis. DNA fragmentation in all EMP groups began at 0.5 h following an exposure with EMP and increased in a dose- and time-dependent manner as revealed by DNA ELISA fragmentation. ID50 at 24 h was 5.0 microM according to the MTT assay, a value close to 4.8 microM of ID50 was revealed by the DNA fragmentation assay. None of the above mentioned changes was observed in the control group. These results indicated that EMP caused a drug-induced apoptosis in the human malignant glioma cell line, U87MG.

Intracranial malignant meningioma with abdominal metastases associated with hypoglycemic shock: a case report

A thirty-year-old male with an intracranial malignant meningioma, first diagnosed 9 years ago, with three recurrences was admitted with a hypoglycemic shock. The blood glucose level was 17 mg/dl, requiring treatment with high doses of intravenous and oral dextrose for improvement. A large metastatic tumor in the liver was noted. All hormones and peptides influencing blood glucose levels were in their normal levels. Chemo-embolization and injection of anti-cancer drugs was employed in the management of the metastatic tumor. Positron emission tomography was performed to measure the glucose metabolism of the abdominal tumor and it indicated that glucose consumption within the tumor was much elevated than the surrounding abdominal organs. Hypoglycemia secondary to primary hepatoma or islet-cell cancer has been frequently described, but a complication of metastatic meningioma is an exceedingly rare event. Elevated glucose consumption within the tumor might be addressed as one of the reasons for hypoglycemia, not due to the elevated serum levels of insulin or IGF, but due to the closely related blood glucose level.

Evaluation of the intratumoral vasculature of hepatocellular carcinoma by power doppler sonography: advantages and disadvantages versus conventional color doppler sonography

BACKGROUND

To determine whether a difference exists in the relative ability of power Doppler sonography and conventional color Doppler sonography to detect the intratumoral vasculature of hepatocellular carcinoma based on lesion size and location.

METHODS

Sixty patients with 88 hepatocellular carcinoma lesions that showed tumor staining on angiography and were enhanced on dynamic computed tomography were evaluated. Power Doppler sonography and color Doppler sonography were used to detect the intratumoral vasculature, and their sensitivity to blood flow was evaluated.

RESULTS

Power Doppler sonography showed a superior detection rate for lesions smaller than 2 cm and located 4-8 cm from the abdominal surface in the right hepatic lobe as compared with color Doppler sonography (p < 0.01). Neither power Doppler sonography nor color Doppler sonography depicted the intratumoral vasculature of lesions located more than 8 cm from the abdominal surface (n = 14). Both color Doppler imagings exhibited a low detection rate for lesions in the left hepatic lobe (n = 31, p < 0.01).

CONCLUSIONS

Power Doppler sonography should be applied in the evaluation of small or intermediate depth lesions because it is more sensitive to these lesions than color Doppler sonography, but it is not useful for left lobe and deep lesions.

[Preliminary study of calculating cerebral arterial blood oxygen saturation using MRI]

To assess whether cerebral arterial blood oxygen saturation (SaO2) can be calculated by EPI, we examined the relationship between peripheral SaO2 and T2+ signal intensity (SI) changes in the brain in three normal subjects, using 1.5 Tesla MRI. To decrease SaO2, hypoxia was induced by 100% helium-gas inhalation (60 sec). SI declined as SaO2 decreased during helium inhalation, while rapid recovery of SI to the baseline was noted with recovery from hypoxia. The differential effective transverse relaxation rate was closely correlated with SaO2 (r > 0.94). Consequently, using MRI, we were able to calculate arterial SaO2.

Scintigraphic prediction of resistance to radiation and chemotherapy in patients with lung carcinoma: technetium 99m-tetrofosmin and thallium-201 dual single photon emission computed tomography study

BACKGROUND

Various prognostic markers for lung carcinoma have been proposed, but to the authors' knowledge none is noninvasive and convenient for clinical use. The current study examined the utility of several radiotracers for the prediction of multidrug resistance (MDR) and radioresistance in patients with lung carcinoma.

METHODS

Thirty patients with untreated lung carcinoma underwent a dual isotope single photon emission computed tomography (SPECT) scan at 10 minutes and 120 minutes after the injection of technetium-99m ((99m)Tc)-tetrofosmin ((99m)Tc-TF) (370 megabecquerels [MBq]) and thallium-201 ((201)TlCl) (111 MBq). Retention of each tracer was evaluated semiquantitatively. Using radiation and chemotherapy (cisplatin plus etoposide), the patients either were treated sequentially (n = 12) or concurrently (n = 18). The relation between therapeutic response and retention of each tracer was analyzed. The detectability of radioresistance was examined.

RESULTS

In patients treated with sequential therapy, the response to radiation was predicted by (99m)Tc-TF retention, whereas (201)Tl retention was found not to be predictive. Regardless of whether the sequential or concurrent protocol was applied, 14 of 18 tumors with high (99m)Tc-TF retention (>/= 15%) exhibited a favorable response to chemoradiotherapy whereas all 12 tumors with low (99m)Tc-TF retention (</= 15%) did not respond to the therapy. In contrast, (201)Tl retention was not found to be a predictive factor.

CONCLUSIONS

The employed SPECT method is a useful tool for the in vivo prediction of radioresistance, P-glycoprotein (P-gp), and non-P-gp MDR in lung carcinoma. Low (99m)Tc-TF retention serves as a strong predictor of therapeutic resistance. High (99m)Tc-TF retention implies a favorable response. (201)Tl did not appear to be a predictive factor but is required for localization of the lesion on SPECT imaging.

Changes in the findings of dynamic MRI by preoperative CAF chemotherapy for patients with breast cancer of stage II and III: pathologic correlation

Preoperative neoadjuvant chemotherapy is essential for treatment of patients with breast cancer who have a large tumor mass and/or regional lymph node involvement, in terms of both tumor shrinkage and further improvement of the survival rate. In order to safely perform breast-conservation treatment for these patients, a detailed diagnostic procedure for precisely evaluating the therapeutic response is needed. Dynamic magnetic resonance imaging (MRI) is thought to be important in the evaluation of responses to neoadjuvant therapy in patients with considerably large tumors, however, few studies have detailed the changes, as depicted by dynamic MRI, that can be expected with neo-adjuvant chemotherapy. The purpose of this study was to document the changes that occur in response to neoadjuvant chemotherapy and to correlate them with the pathological findings observed in the surgical specimen. The study was performed at Kochi Medical School Hospital from 1995 to 1998. The series consisted of 31 patients with stage II and III breast cancer. Prior to and after 1-5 courses of neoadjuvant chemotherapy, dynamic MRI examinations were performed. Eight of the time-intensity curves for the 10 grade 1a tumors flattened during neoadjuvant chemotherapy, while two remained the same. Six of the curves flattened for the 14 grade 1b tumors, 7 remained the same, and one spiked. And for the seven grade 2 tumors, two of the curves flattened and five remained the same (p=0.0340). In the five grade 1 tumors, the mean after/before normalized peak signal intensity ratio was 0.42+/-0.22. In the 18 grade 2 and 8 grade 3 tumors, the mean normalized signal intensity ratios were 0.59+/-0.28, 0.88+/-0.10, respectively (p<0.05). In the 15 tumors that showed shrinkage of the linear enhancement during neo-adjuvant chemotherapy, 10 had no remarkable intraductal spreading and 9 had a negative surgical margin. In the 16 tumors that had no shrinkage of the linear enhancement during chemotherapy, 13 had remarkable intraductal spreading and 12 had a positive surgical margin (p<0.05). It is concluded that dynamic MRI is a valuable tool for determining tumor response and predicting a positive surgical margin. Breast-conservation treatment can be performed for these patients by meticulous assessment using such detailed diagnostic procedures after local tumor control by combined chemotherapy with high dose-intensity.

Cavernous hemangioma of the skull in a neonate

Cavernous hemangiomas rarely occur in the calvarium and most commonly present in middle-age. Although a congenital vascular disorder can theoretically cause a diploic lesion in any age group, a calvarial cavernous hemangioma has not been reported in newborn. A 4-month-old male infant presented with a large left parietal mass that had been present since birth. Total resection was performed. Pathological examination revealed a cavernous hemangioma developing within the diploic space adjacent to prior hemorrhages. Surgery was performed in this case because of the size and persistence of the lesion. Removal of tumors of a benign nature from the calvarium can be done safely. Cavernous hemangioma of the skull in a neonate should be considered as one of the differential diagnoses in the case of suspected ossified cephalohematoma.

Extraosseous metastases of hepatocellular carcinoma detection and therapeutic assessment with Tc-99m PMT SPECT

Owing to recent advances in imaging technology and radiologic intervention, survival rates in patients with hepatocellular carcinoma have improved markedly. However, such prolonged survival has resulted in an increase in extrahepatic metastases. Tc-99m (Sn)-N-pyridoxyl-5-methyltryptophan (Tc-99m PMT), developed for hepatobiliary scintigraphy, has been used to visualize extrahepatic metastases, with most related reports limited to osseous metastases. The authors report two cases of hepatocellular cancer presenting as a hypopharyngeal metastasis and intraperitoneal dissemination along the tract of a fine-needle biopsy. Lesions undetectable on planar imaging could be visualized by Tc-99m PMT SPECT.

Relationship between ATP synthesis and 201Tl uptake in transformed and non-transformed cell lines

201Tl tumour imaging is an established procedure, but little is known about its biological significance in transformed and non-transformed cells. In investigating the relationship between 201Tl uptake and intracellular ATP, we wished to determine whether the observed difference in delayed uptake is attributable to re-uptake via Na-K ATPase by using transformed (HeLa) and non-transformed (human fibroblast: hFB) cell lines. In each cell line, ATP was measured using the Luciferin-Luciferase method (LLM). The change in 201Tl uptake was assessed under conditions of mitochondrial suppression. Additionally, we assessed whether glycolysis is involved in 201Tl uptake under conditions of mitochondrial suppression and anaerobic incubation. Re-uptake via Na-K ATPase (HeLa vs hFB: 37.3 vs 24.2%) showed a clear difference in delayed uptake between HeLa and hFB. With HeLa, 201Tl uptake decreased biphasically with a reduction in ATP levels, whereas with hFB a linear correlation was evident. Despite the suppression of mitochondrial potential, a 5% glucose loading accelerated glycolysis with HeLa, and increased ATP (10.0 +/- 4.0%) and 201Tl uptake (16.2 +/- 3.0%). Conversely, neither ATP nor 201Tl uptake increased with hFB. Our results provide evidence that 201Tl uptake in transformed cells is related to enhanced glycolysis as well as mitochondrial ATP synthesis.

Dual-isotope SPECT diagnosis of a skull-base metastasis causing isolated unilateral hypoglossal nerve palsy

We describe a 48-year-old female with an isolated unilateral hypoglossal nerve palsy caused by a skull base metastasis from breast cancer. The patient had a medical history of conservative breast therapy for breast cancer. Although the cause of such a neurological deficit includes various pathologies, the reports focusing on metastatic tumor have been limited in number. Radiologic investigation showed a mass involving both the right hypoglossal canal and the clival edge. Swelling of the hypoglossal nerve was observed in views including its canal. Three-dimensional CT images demonstrated the tumor protruding from the enlarged external orifice of the hypoglossal canal. In the present report we mentioned a nuclear medicine procedure to visualize and characterize the small, abnormal tissue in the skull base. Dual-isotope SPECT confirmed an abnormal uptake of 99mTc-HMDP around the hypoglossal canal and a 201Tl-positive elongated lesion running along the hypoglossal nerve.

Dual isotope SPECT in malignant Jacod's syndrome

A case is presented of metastatic tumor causing Jacod's syndrome: total ophthalmoplegia, blindness, and trigeminal neuralgia. Abnormal soft tissue invading the orbital apex, anterior clinoid process, and cavernous sinus was difficult to assess by CT and MRI, but dual-isotope SPECT including Tc-99m HMDP bone imaging and Tl-201 tumor imaging strongly suggested that the cause of this rare syndrome was a small metastatic tumor. Although the therapeutic effect was also difficult to assess by anatomic imaging alone, dual-isotope SPECT after radiation therapy showed a decline of tumor viability.

Malignant fibrous histiocytoma in the parietal bone

Malignant fibrous histiocytomas (MFHs) are mesenchymal tumors, usually arising in soft tissue of the extremities and are remarkably resistant to radiation and chemotherapy. A 45-year-old female presented with a rare case of MFH originating in the cranial bone manifesting as a lump in the left parietal region with no neurological abnormality. Neuroimaging revealed the presence of an osteolytic tumor in the left parietal bone invading into muscle and subdural region, penetrating through the dura. Selective external carotid angiography disclosed a marked tumor stain. Examination of the whole body excluded neoplastic disease elsewhere. The patient was treated by surgical excision, radiation, and two courses of multi-drug chemotherapy using cyclophosphamide, doxorubicin, vincristine, and prednisolone. Since there is no established treatment against this malignancy, a longer follow-up is necessary to determine whether cure has been achieved.

Dynamic MR appearance of adenoid cystic carcinoma of the breast in a 67-year-old female

We describe an adenoid cystic carcinoma on the right breast of a 67-year-old woman. Dynamic magnetic resonance (MR) imaging demonstrated a well-circumscribed round lesion with rapid and marked enhancement on T1-weighted images, without washout of the contrast agent. The enhanced area extended gradually from the margin to the center of the tumor, showing very late enhancement of the tumor center. The findings suggested a tumor with rich stromal component, including adenoid cystic carcinoma of a special type of breast cancer. Histological examination of a lumpectomy disclosed a well-circumscribed tumor consisting of ovoid, trabecular, and irregularly shaped 'nests' of tumor cells, with a focally cribriform pattern. The examination confirmed the diagnosis of adenoid cystic carcinoma of the breast.

Suppression of matrix metalloproteinase-2-mediated cell invasion in U87MG, human glioma cells by anti-microtubule agent: in vitro study

Because microtubules are important components of cell motility and intracellular transport, it is reasonable to propose that the depolymerizing effect of an antimicrotubule agent, estramustine, on glioma microtubules would modulate cell invasiveness. To determine whether matrix metalloproteinases, key factors in cell invasion, are affected by exposure to estramustine, a cell proliferation assay, a zymogram, a collagenolysis assay and a haptoinvasion assay were used in this study. The zymogram revealed that an activated (62 kDa) form of matrix metalloproteinase-2 diminished with increasing estramustine concentrations. The collagenolysis assay demonstrated approximately 2.5- to 21-fold lower rates of enzymatic activity suppressed by estramustine in a dose-dependent manner at estramustine concentrations of 1, 5, and 10 microM, compared with the control group. On the haptoinvasion assay, no statistically significant difference was seen in the 0.5 microM estramustine group, whereas 1-10 microM estramustine groups revealed significant suppression of invasion from 6 to 24 h in a dose-dependent manner. The results suggest that estramustine suppresses the invasion of U87MG cells in vitro using the decreasing available matrix metalloproteinase-2, an effect caused by the disassembly of microtubules. Suppression of the infiltrative capacity of malignant glioma cells could be of significant value in the treatment of this disease.

Subcellular distribution of thallium: morphological and quantitative study in rat myocardium

The purpose of this study is to determine the subcellular distribution of thallium (SDTl) by electron microscopy and a newly designed fixation method that makes insoluble grains of Tl visible.

METHODS

To obtain the high dose necessary for electron microscopic visualization, we employed TlCl instead of 201TlCl. EM was performed in fixed rat myocardium resected at 20 min (early phase) and 3 hr (delay phase) after intravenous injection of TlCl. To fix Tl in the cell, we used orthovanadate in our fixative. Atomic absorption spectroscopy (AAS) of Tl and quantification of subcellular distribution of 201Tl (SD201Tl) were studied to prove the propriety of our fixation.

RESULTS

AAS detected Tl in the Tl-loaded specimen but not in the control, indicating that Tl was the origin of the grains observed in the former. In the early phase, numerous grains were observed in mitochondria, sarcoplasmic reticulum (SR), myofibrils, and nuclei, but no such grains were visible in controls. In the delay phase, grains were retained in mitochondria, SR and nuclei, but not in myofibrils. Electron microscopic SDTl(%) correlated with SD201Tl(%) calculated from isolated fractions.

CONCLUSION

In both the early and delay phases, mitochondria are the major site of Tl and 201Tl uptake.

Dynamic MR appearance of benign phyllodes tumor of the breast in a 20-year-old woman

We describe a 20-year-old woman with benign phyllodes tumor of the left breast. Dynamic MRI demonstrated a multi-lobulated lesion rapidly and markedly enhanced on dynamic studies of contrast-enhanced T1-weighted imaging without washout. Histological examination of an excisional biopsy specimen obtained under local anesthesia disclosed a well-circumscribed multi-lobulated lesion, confirming the diagnosis of benign phyllodes tumor of the breast.

Thyroid storm precipitated by trauma

A 21-year-old woman presented to the emergency department complaining of head, neck, and abdominal pain after being assaulted. She denied a previous history or significant symptoms of hyperthyroidism. The physical examination was remarkable for lethargy, low-grade fever, tachycardia, facial abrasions, swelling of the anterior neck, and a tremor. A diagnosis of thyroid storm was made. An extensive work up excluded other causes of the patient's tachycardia, altered mental status, and neck swelling. A review of the clinical features and management of thyroid storm is presented. Relatively minor trauma can be a precipitating event for thyroid storm.

Targeting microtubule-associated proteins in glioblastoma: a new strategy for selective therapy

BACKGROUND

This report presents a summary of preclinical data concerning the use of estramustine, an antimicrotubule agent against human glioblastoma cells. The strategy for the investigation of estramustine is predicated on the unique affinity of this agent for microtubule-associated proteins (MAPs).

METHODS

A series of laboratory investigations were used to demonstrate antiproliferative effects (MTT assay, colony forming assay, thymidine incorporation), cell cycle synchronization (flow cytometry), intracellular localization of binding sites (immunocytochemistry, electron microscopy), and activity in subcutaneous xenografts of human glioblastoma.

RESULTS

Estramustine has potent in vitro activity against human glioblastoma cells and can enhance the cytotoxic effects of ionizing radiation. Estramustine-binding protein was abundantly expressed in glioblastoma cells and may contribute to the selective effects of estramustine on neoplastic cells. This agent has activity against subcutaneous xenografts of human glioblastoma. Synthesized novel estrogen carbamates also can inhibit proliferation of glioblastoma cells.

CONCLUSIONS

Cytoskeletal elements (MAPs) of glioblastoma cells may provide a useful target for therapy with agents like estramustine because of the potent antimitotic effects of this agent and its affinity to a protein that is expressed in glioma cells. These observations have stimulated a search for other estrone carbamates with antimitotic activity that exceeds more conventional antimicrotubule agents.

Estramustine in malignant glioma

Estramustine, a carbamate ester combining 17 beta-estradiol and nornitrogen mustard, has primarily been employed in the treatment of advanced prostatic carcinoma. However, a significant amount of preclinical investigation has been directed toward estramustine's activity against human malignant glioma. These studies have demonstrated that estramustine has potent antiproliferative effects against malignant glioma both in vitro and in vivo. Similar antimitotic effects also have been demonstrated for other carbamate esters. Estramustine does not impair proliferation of nonneoplastic astrocytes at concentrations that inhibit glioma cells. Although the reasons for this selective activity remain to be determined, it has been shown that malignant gliomas expresses an estramustine-specific binding site, estramustine-binding protein, more than brain tissue. In the clinical situation, an uptake and accumulation of estramustine in human glioma tissue have been demonstrated. Estramustine has been shown to enhance the cytotoxic effects of irradiation in relatively radioresistant glioma cells both in cell culture and in a rat glioma model. Estramustine has been regarded as mainly an anti-mitotic drug but recently other effects such as inhibition of DNA synthesis, induction of apoptosis, and membrane alterations have been shown. This report summarizes the preclinical observations concerning the effects of estramustine and related compounds on human malignant gliomas. These findings form the basis for proposing further laboratory and clinical investigation regarding estramustine and human malignant gliomas.

In vitro inhibition of cell proliferation, viability, and invasiveness in U87MG human glioblastoma cells by estramustine phosphate

OBJECTIVE

Several determinants of cell motility are highly dependent on the cytoskeleton, in particular, microtubules. To our knowledge, there have been no previous reports regarding the anti-invasive ability by an antimicro-tubule agent, estramustine phosphate (EMP), on glioblastoma cell lines. We investigated the modulated cell proliferation and invasiveness by EMP in vitro.

METHODS

We determined the relative survival rate by cell proliferation assay and the percent survival fraction by monotetrazolium assay. Furthermore, an invasion index was used to quantify the migrating and invasive potential of the human glioblastoma cell line, U87MG, in Boiden's chamber with reconstituted basement membrane (Matrigel; Collaborative Research, Lexington, MA).

RESULTS

We found that 0.5 mumol/L EMP had no effect in any of the assays. Concentrations of 1, 5, and 10 mumol/L demonstrated a concentration- and time-dependent depression in all of the assays. A range of drug concentration of EMP, 1 to 10 mumol/L, in which cell invasiveness was successfully inhibited, was comparable with antiproliferative capacity.

CONCLUSION

The data add to the findings that EMP not only offers selective antiproliferative activity against glioblastoma but also reduces invasiveness, consistent with its main mechanism of action. Such findings form the basis for the development of agents that use non-DNA targets for the treatment of glioblastomas and may improve control over tumor proliferation and invasion.

Spontaneous intraventricular hemorrhage caused by lateral ventricular meningioma--case report

A 39-year-old female presented with acute intraventricular hemorrhage manifesting as sudden onset of headache associated with gradually progressing somnolence and left oculomotor nerve paresis. Intraventricular hemorrhage occurred from a meningioma of the lateral ventricle. Computed tomography and magnetic resonance (MR) imaging revealed intraventricular hemorrhage and a mass in the right trigone. The tumor was totally removed. Her postoperative course was uneventful except for left homonymous hemianopia. The histological diagnosis was fibroblastic meningioma. The MR imaging was highly suggestive of hemorrhage from the tumor periphery.

A prospective evaluation of the safety and efficacy of methohexital in the emergency department

A prospective observational study in an inner-city teaching hospital was conducted to evaluate the safety and efficacy of intravenous methohexital (MTX) in the emergency department (ED). Pulse oximetry, vital signs and Glasgow Coma Scale (GCS) scores were recorded serially for 30 minutes after the administration of MTX to 76 adult patients. Likert scales of 1 to 5 were used to record the physician's assessment of the adequacy of sedation and the patient's assessments of recall and pain of the procedure. Patients received an average of 88 +/- 21 mg of MTX for a variety of indications (orthopedic procedures, 78%; sedation for other procedures, 14%; intubation, 5%; and psychiatric interview, 3%). No patient had clinically significant changes in heart rate or blood pressure. Eight (10.5%) had apnea, although only one patient had oxygen saturations of less than 90%. Each episode was brief and easily managed with bag-valve-mask ventilation. Risk factors for apnea included a history of alcoholism (P = .0003) and recent recreational narcotic use (P = .0139). Patients were maximally sedated in an average of 37 +/- 42 seconds. In the subset of initially alert patients, GCS scores decreased from 15 at baseline to 5.9 +/- 4.5. The physician's assessment of the adequacy of sedation was excellent (4.7 +/- 0.7). Patients reported little recall (1.3 +/- 0.9) or pain (1.3 +/- 0.8). It was concluded that MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.