Computed Tomographic Percutaneous Transsplenic Portography

The diagnosis of liver tumors should be utilized for determination of not only the number of lesions, but also their size, segmental location and extent, and the relationship of the mass or masses to the hepatic vasculature. CT during arterial portography (CTAP) is the most sensitive imaging modality for precise diagnosis of hepatocellular carcinoma (1–3, 5). CTAP is thus widely used as a diagnostic imaging technique, particularly for the detection of small hepatocellular carcinomas (4, 6, 8).

Conventional splenic portography has been carried out for many years using a wide diameter needle, a large amount of contrast medium and a film-screen system (7). Since the development of arterial portography, fewer splenoportograms have been performed due to the high incidence of bleeding and other complications (7). In this study a 0.6-mm (23 gauge) thin needle was used for splenic puncture and CT was used as a detector instead of a film-screen system. With this technique CT during percutaneous transsplenic portography may be performed on an outpatient basis.

Application of Expandable Metallic Stents to the Venous System

Expandable metallic stents were successfully introduced in 12 patients; 6 with superior vena cava (SVC) obstruction due to tumor invasion or lymph node metastases, 3 with inferior vena cava (IVC) obstruction or stenosis due to lymph node metastases or hepatic tumor, one with common iliac vein (CIV) obstruction due to lymph node metastases, one with idiopathic obstruction of the hepatic IVC and Budd-Chiari syndrome, and one with CIV obstruction following a dialysis shunt. The length of the lesions was between 2 and 15 cm. Multiple (2–7) stents in tandem were inserted percutaneously from a femoral venous approach through a 12 to 16 F (4.0–5.3 mm) Teflon sheath. Postoperatively, all 12 patients became free from symptoms such as SVC syndrome or IVC syndrome. In 11 patients, the symptoms did not recur during the follow-up periods of 1 to 21 months.

Endotracheal Expandable Metallic Stent Placement in Dogs

Various types of Gianturco zig-zag wire stent were implanted into the tracheas of 4 dogs to define the suitable characteristics of the endotracheal wire stent in these animals. The stents were constructed of 0.45, 0.40, and 0.33 mm stainless steel wire. The diameter of the fully expanded stents was 3 cm and their lengths were 2, 3, and 4 cm. The 2 cm stent constructed of 0.33 mm wire showed minimum pathologic changes of the trachea of the dog compared to the other stents, and at the same time had a complete covering of ciliated columnar epithelium over the stent surface.

Clinical Experience of 123I-IMP Scintigraphy in Detecting Vertebral Bone Metastases of Hepatocellular Carcinoma

Although bone scintigraphy with 99mTc-MDP is a sensitive diagnostic method to detect bone metastasis, it is not specific for malignancy. A radioactive substance which accumulates specifically into metastatic lesions should be of value. 123I-IMP and bone scintigraphy with 99mTc-MDP were consecutively performed in patients with vertebral bone metastases from hepatocellular carcinoma and lumbar spondylosis deformans in a 7-day interval or shorter. The intensity of uptake was compared. Eighteen of the 20 metastatic lesions (90%) were classified as increased uptake areas in 123I-IMP scintigraphy. MDP-scintigraphy disclosed 16 metastatic lesions (80%), 9 as “hot” lesions (56%) and 7 as “cold” lesions (44%). 123I-IMP scintigraphy was negative in all 12 lesions of lumbar spondylosis deformans. Compared to MDP-scintigraphy, 123I-IMP scintigraphy was more sensitive in detecting vertebral bone metastases of hepatocellular carcinoma with smaller rates of false-positive and false-negative findings.

Intraarterial Occlusion by Radiofrequency

Arterial occlusion using radiofrequency energy was performed. The length of the noninsulated part of the guidewire was 10 mm and the duration of radiofrequency supply was 20 s. Animal experiments were carried out in 17 canine arteries; 4 out of 6 arteries less than 2.3 mm in diameter were completely occluded during the 20 s radiofrequency supply. A clinical application was also successfully performed without any complications. Arterial occlusion with radiofrequency can be applied to vessels less than about 2 mm in diameter.

A new liquid embolic material for liver tumors: An animal experimental study using Onyx

Purpose: To evaluate the feasibility of a new liquid embolic material, Onyx, for treating liver tumors.

Material and Methods: Onyx is a mixture of 6% (w/v) ethylene-vinyl-alcohol copolymer dissolved in anhydrous dimethyl sulfoxide (DMSO) with 28% (w/v) tantalum powder. In addition to 6% Onyx, we also tried 4%, 2% and 1% solutions, prepared by adjusting the amount of DMSO. We used 15 white rabbits with liver tumors created by percutaneous injection of VX2 tumor cells. In 4 groups with 3 rabbits in each, the liver arteries were embolized with 6%, 4%, 2% and 1% Onyx, respectively, and in 3 rabbits DMSO alone was injected. The injections were performed just proximal to the bifurcation of the proper hepatic artery, followed by celiac arteriography. Post mortem, the livers were examined by soft-tissue radiography, and liver-tissue section microscopy.

Results: The maximum number of arterial branching points passed by embolic material in either the right or left hepatic arteries was 11, 15 and 16, for 6%, 4% and 2% Onyx, respectively, but was non-measurable for 1% Onyx. Minimum diameters of arteries reached by 6%, 4%, 2% and 1% Onyx in tumorous areas were 40 μm, 35 μm, 20 μm and 10 μm, respectively, and in non-tumorous areas 35 μm, 5 μm, 5 μm and 5 μm, respectively.

Conclusion: This study suggests that Onyx may be feasible for treatment of hepatic tumors.

Treatment of Tuberculous Bronchial Stenosis with Expandable Metallic Stents

Gianturco expandable metallic stents were placed in 5 patients with dyspnea on exercise due to tuberculous bronchial stenosis. The stents were placed after dilatation with a 10-mm diameter high pressure balloon catheter. In all 5 patients, obstructive changes disappeared following the procedure, and dyspnea on exercise improved markedly. No complications related to the procedure were encountered. At follow-up during a period of up to 38 months, 2 patients showed bronchial restenosis at 11 and 17 months, respectively, after stent placement. Restenosis by granulomatous tissue was successfully treated by laser ablation. One patient showed slight one-day hemoptysis 26 months after stent placement.

REPEATED INTRANODAL LYMPHANGIOGRAPHY FOR THE TREATMENT OF LYMPHATIC LEAKAGE

Treatment of patients with chylous or non-chylous lymphatic leakage can be difficult. An approach using therapeutic lymphangiography can reduce the lymphatic leakage, but it seldom stops the leakage immediately and subsequent conservative treatment is necessary. We report three cases in which intranodal lymphangiography was performed multiple times to inhibit lymphatic leakage. In each case, the lymph node was punctured under ultrasound guidance using a 23-gauge needle and lipiodol was injected manually at a rate of 1 ml/3 min. The procedure was repeated twice in two cases of gastrointestinal carcinoma and four times in one case of lymphoma. In all three cases, the postoperative lymphatic leakage stopped after the repeated intranodal lymphangiography.

Down-regulated expression of monocyte/macrophage major histocompatibility complex receptors in human and mouse monocytes by expression of their ligands

Mouse monocyte/macrophage major histocompatibility complex (MHC) receptor 1 (MMR1; or MMR2) specific for H-2D(d) (or H-2K(d) ) molecules is expressed on monocytes from non-H-2D(d) (or non-H-2K(d) ), but not those from H-2D(d) (or H-2K(d) ), inbred mice. The MMR1 and/or MMR2 is essential for the rejection of H-2D(d) - and/or H-2K(d) -transgenic mouse skin onto C57BL/6 (H-2D(b) K(b) ) mice. Recently, we found that human leucocyte antigen (HLA)-B44 was the sole ligand of human MMR1 using microbeads that had been conjugated with 80 types of HLA class I molecules covering 94·2% (or 99·4%) and 92·4% (or 96·2%) of HLA-A and B molecules of Native Americans (or Japanese), respectively. In the present study, we also explored the ligand specificity of human MMR2 using microbeads. Microbeads coated with HLA-A32, HLA-B13 or HLA-B62 antigens bound specifically to human embryonic kidney (HEK)293T or EL-4 cells expressing human MMR2 and to the solubilized MMR2-green fluorescent protein (GFP) fusion protein; and MMR2(+) monocytes from a volunteer bound HLA-B62 molecules with a Kd of 8·7 × 10(-9)  M, implying a three times down-regulation of MMR2 expression by the ligand expression. H-2K(d) (or H-2D(d) ) transgene into C57BL/6 mice down-regulated not only MMR2 (or MMR1) but also MMR1 (or MMR2) expression, leading to further down-regulation of MMR expression. In fact, monocytes from two (i.e. MMR1(+) /MMR2(+) and MMR1(-) /MMR2(-) ) volunteers bound seven to nine types of microbeads among 80, indicating ≤ 10 types of MMR expression on monocytes. The physiological role of constitutive MMRs on monocytes possibly towards allogeneic (e.g. fetal) cells in the blood appears to be distinct from that of inducible MMRs on macrophages toward allografts in tissue.

Predictive factors for pericardial effusion identified by heart dose-volume histogram analysis in oesophageal cancer patients treated with chemoradiotherapy

OBJECTIVE

To identify predictive factors for the development of pericardial effusion (PCE) in patients with oesophageal cancer treated with chemotherapy and radiotherapy (RT).

METHODS

From March 2006 to November 2012, patients with oesophageal cancer treated with chemoradiotherapy (CRT) using the following criteria were evaluated: radiation dose >50 Gy; heart included in the radiation field; dose-volume histogram (DVH) data available for analysis; no previous thoracic surgery; and no PCE before treatment. The diagnosis of PCE was independently determined by two radiologists. Clinical factors, the percentage of heart volume receiving >5-60 Gy in increments of 5 Gy (V5-60, respectively), maximum heart dose and mean heart dose were analysed.

RESULTS

A total of 143 patients with oesophageal cancer were reviewed retrospectively. The median follow-up by CT was 15 months (range, 2.1-72.6 months) after RT. PCE developed in 55 patients (38.5%) after RT, and the median time to develop PCE was 3.5 months (range, 0.2-9.9 months). On univariate analysis, DVH parameters except for V60 were significantly associated with the development of PCE (p < 0.001). No clinical factor was significantly related to the development of PCE. Recursive partitioning analysis including all DVH parameters as variables showed a V10 cut-off value of 72.8% to be the most influential factor.

CONCLUSION

The present results showed that DVH parameters are strong independent predictive factors for the development of PCE in patients with oesophageal cancer treated with CRT.

ADVANCES IN KNOWLEDGE

A heart dosage was associated with the development of PCE with radiation and without prophylactic nodal irradiation.

CO2 microbubble contrast enhancement in x-ray angiography

AIM

To demonstrate that carbon dioxide (CO2) microbubble contrast enhancement depicts blood vessels when used for x-ray examinations.

MATERIALS AND METHODS

Microbubbles were generated by cavitation of physiological saline to which CO2 gas had been added using an ejector-type microbubble generator. The input pressure values for CO2 gas and physiological saline that produced a large quantity of CO2 microbubbles were obtained in a phantom. In an animal study, angiography was performed in three swine using three types of contrast: CO2 microbubbles, conventional CO2 gas, and iodinated contrast medium. For CO2 microbubble contrast enhancement, physiological saline, and CO2 gas were supplied at the input pressures calculated in the phantom experiment. Regions of interest were set in the abdominal aorta, external iliac arteries, and background. The difference in digital values between each artery and the background was calculated.

RESULTS

The input pressures obtained in the phantom experiment were 0.16 MPa for physiological saline and 0.5 MPa for CO2 gas, with physiological saline input volume being 8.1 ml/s. Three interventional radiologists all evaluated the depictions of all arteries as "present" in the CO2 microbubble contrast enhancement, conventional CO2 contrast enhancement, and iodinated contrast enhancement performed in three swine. Digital values for all vessels with microbubble CO2 contrast enhancement were higher than background values.

CONCLUSIONS

In x-ray angiography, blood vessels can be depicted by CO2 microbubble contrast enhancement, in which a large quantity of CO2 microbubbles is generated within blood vessels.

Rapid cytologic diagnosis of choroidal malignant melanoma by vitreous smear

The eye is an uncommon subject of cytopathological examination. However, cytopathologic examination may be required for definitive diagnosis in some cases, as malignant tumors of the eye may sometimes be difficult to distinguish clinically from benign disorders. We report a case of malignant melanoma (MM) of the choroid, in which vitrectomy was performed for the initial clinical diagnosis of vitreous hemorrhage. As the dense vitreous hemorrhage was gradually cleared during the vitrectomy, a choroidal mass was discovered and the vitreous fluid was procured for rapid cytologic diagnosis. We used a modified Shorr's stain that can be completed within several minutes. With this method, highly atypical, pleomorphic cancer cells, occasionally associated with melanin pigment granules, were demonstrated. These cytologic findings indicated a diagnosis of MM arising from the choroid. Histologic examination of the enucleated eye confirmed MM of epithelioid type. The advantage and indication of the rapid cytologic diagnosis is discussed.

Endoscopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric stenosis

BACKGROUND AND STUDY AIMS

Pyloric stenosis is currently managed using open or laparoscopic pyloromyotomy. However, with recent improvements in flexible endoscopic instrumentation and techniques, totally peroral endoscopic approaches could reduce the invasiveness of myotomic procedures. The aim of the study was to establish the feasibility and efficacy of endoscopic submucosal pyloromyotomy in a porcine model.

METHODS

Four pigs were included in a preliminary study and a 2-week survival study was performed in another four pigs. An esophagogastroduodenoscope was inserted perorally into the stomach. Saline solution was injected into the submucosal space proximal to the pylorus. The gastric mucosa was incised and a 5-cm submucosal tunnel was created. After exposure of the muscular layer in a submucosal tunnel, myotomy of the circular muscle layer was performed until the longitudinal muscular layer was reached. Once myotomy was completed, endoscopic clips were used to re-approximate the mucosal incision.

RESULTS

Submucosal dissection, identification of the circular muscular layer, and pyloromyotomy were achieved in all animals. Acute complications such as bleeding and perforation were not observed in any cases. Median pyloric resting pressure was reduced from 16.5 mmHg to 6.1 mmHg immediately after myotomy and 8.4 mmHg at 14 days after myotomy.

CONCLUSION

Peroral endoscopic submucosal pyloromyotomy appears to be technically feasible and effective. Potential clinical applications, such as for infantile hypertrophic pyloric stenosis or delayed gastric emptying after esophagectomy, could be considered after confirmation of safety in additional survival studies.

The Endoscopic Surgical Skill Qualification System for gastric surgery in Japan

INTRODUCTION

Laparoscopic surgery has been increasing in popularity in recent years. In 2004, the Japan Society for Endoscopic Surgery developed its Endoscopic Surgical Skill Qualification System (ESSQS) to assess surgeons.

METHODS

To earn the ESSQS accreditation, applicants must submit an unedited operative video in which they perform either a distal gastrectomy or pylorus-preserving gastrectomy with lymph node dissection for gastric cancer. The videos are assessed by two separate judges based on detailed criteria for common and procedure-specific technical-grade slips. Common criteria from all fields of gastrointestinal and general surgery are used to evaluate the basic laparoscopic surgical skills and autonomy of the operator. The target organ determines the procedure-specific criteria are set to assess whether or not adequate oncological clearance has been achieved.

RESULTS

Between 2004 and 2009, 154 (44.6%) out of 345 applicant surgeons assessed under the ESSQS for gastric surgery have been accredited. Interrater agreement was acceptable and ranged between 0.21 and 0.59.

CONCLUSION

The ESSQS system may facilitate improvement in surgical technique and the standardization of laparoscopic surgery in Japan.

Safe anastomosis in laparoscopic low anterior resection for rectal cancer

INTRODUCTION

In laparoscopic rectal surgery, there are some limitations on a surgeon's ability to maneuver, especially in transection of the lower rectum. To achieve minimally invasive surgery, safe anastomosis, including proper rectal transaction, is necessary.

METHODS

To overcome the difficulty in lower rectal resection, we followed a series of steps. First, we completely mobilized the rectum to the pelvic bottom, just above the anal canal, making the lower rectum mobile and allowing for an easy rectal transection. To secure the transaction, the mesorectum around the transection must be properly divided. We recommend placing the lower right quadrant port as caudal as possible to properly staple the rectum. We found a 60 mm compression-type stapler most suitable for rectal transection. To wash and flatten the rectum, a detachable intestinal clip is quite useful because of its flexibility. Finally, in addition to conventional abdominal drains around the anastomotic site, we employed transanal tube to actively decompress rectal pressure inside the anastomotic site.

RESULTS

Between August 2009 and July 2010, 101 patients underwent laparoscopic low anterior resection using this technique. Most patients, 98.0% (99/101), underwent lower rectum transection using a single-fire cartridge. The anastomotic leakage rate was only 1.0% (1/101) in total and 1.3% (1/78), when not including patients with diverting stoma.

CONCLUSION

We have to follow up with more patients to conclude whether our technique is effective in the long term. However, this step-by-step technique could lead to safe anastomosis in laparoscopic low anterior resection for rectal cancer.

Impact of single-port cholecystectomy on postoperative pain

BACKGROUND

This study compared postoperative pain following four-port laparoscopic cholecystectomy (LC) and single-port cholecystectomy (SPC).

METHOD

This prospective, quasi-randomized, single-centre trial focusing on postoperative pain included 49 patients undergoing elective surgery with either a conventional LC, or SPC using a surgical glove port. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use as primary outcome measures. Total duration of operation, length of hospital stay, blood test results on the day after surgery and total port cost were secondary outcome measures.

RESULTS

Twenty-five LCs and 24 SPCs were undertaken. The VAS score on day 1 after surgery was significantly less in the SPC group than in the LC group: median (range) 24 (12-38) versus 45 (33-57) mm (P = 0·002). Significantly fewer patients in the SPC group required analgesia (9 of 24 versus 19 of 25 in the LC group; P = 0·007). There were no significant differences in total duration of operation, length of hospital stay, and blood test results on the day after surgery.

CONCLUSION

Single-port surgery using a surgical glove port reduces postoperative pain compared with conventional LC.

Feasibility study of adjuvant chemotherapy with S-1 plus cisplatin for gastric cancer

PURPOSE

To evaluate the feasibility of S-1 plus cisplatin as adjuvant chemotherapy for stage III gastric cancer after curative resection.

METHODS

Japanese patients with stage III gastric cancer who underwent gastrectomy with D2 lymph node resection were enrolled. Treatment consisted of 3 cycles of S-1 (80 mg/m(2)/day, b.i.d.) for 21 days followed by a 14-day rest, and cisplatin (60 mg/m(2) iv) on day 8. After that, S-1 monotherapy was given on days 1-28 every 6 weeks until 1-year postsurgery. After protocol amendment, the first chemotherapy cycle consisted of S-1 monotherapy; cisplatin was added to cycles 2, 3, and 4, followed by S-1 monotherapy up to 1-year postsurgery. The primary endpoint was the completion rate of three cycles of S-1 plus cisplatin.

RESULTS

A total of 63 enrolled patients have been evaluated. Grade 3/4 toxicities included neutropenia (40%), anorexia (28%), and febrile neutropenia (4%) before protocol amendment (n = 25), and neutropenia (37%), anorexia (8%), and febrile neutropenia (3%) after amendment implementation (n = 38). Excluding ineligible cases, treatment completion rates were 57% (12/21) before and 81% (30/37) after the protocol amendment.

CONCLUSIONS

The amended S-1 plus cisplatin is more feasible than the original protocol because of early dose reduction of S-1 prior to cisplatin addition and greater recovery time from surgery prior to cisplatin. This treatment should be considered as a feasible experimental arm for the next postoperative adjuvant phase III trial.

Tau Expression and Efficacy of Paclitaxel Treatment in Metastatic Breast Cancer

Purpose: Paclitaxel is widely used for the treatment of patients with metastatic breast cancer (MBC), such as in anthracycline-based combinations as a first-line chemotherapy. Although several mechanisms of paclitaxel resistance have been demonstrated, useful markers of paclitaxel resistance have not been available in clinical practice. A recent study revealed that low tau expression in cases of early breast cancer can predict susceptibility to paclitaxel administration in neoadjuvant therapy.Methods: In this study, the clinical significance of tau expression in MBC cases was established by identifying candidates with paclitaxel administration. Tissue specimens obtained from 35 patients who had received neither chemotherapy nor radiotherapy before surgery were examined. Status of tau expression was determined by immunohistochemistry.Results: Based on a previously reported classification scheme, 15 cases were classified as tau-negative (0, 1+) and 20 cases were classified as tau-positive (2+, 3+).Nine (60%) of 15 cases with tau-negative expression showed favorable response. Conversely, 17 (85%) of 20 cases with tau-positive expression showed progressive or stable disease after paclitaxel administration.Table 1 Relationship between tau expression and response to paclitaxel  nNumber of responses (%)PTaunegative159 (60%)  positive203 (15%)0.01 Time to disease progression in tau-negative and tau-positive groups was 9.4 ± 6.6 months and 6.0 ± 3.7 months, respectively. Although no significant differences were apparent, this period tended to be longer in the tau-negative group.Discussion: Patients with tau-positive expression may derive less benefit than tau-negative from paclitaxel therapy in MBC. This suggests that tau expression could be used at diagnosis to select patients for whom paclitaxel treatment is likely to be of most benefit. However, this study has some clear limitations in terms of the modest sample size and the heterogeneity of eligible patients (e.g., different numbers and regimens for adjuvant and MBC chemotherapy). Many more cases must be examined before tau expression can be applied to practical clinical treatment.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1138.

Endoscopic submucosal dissection allows less-invasive curative resection for gastric tube cancer after esophagectomy - a case series

Detection of early gastric tube cancers (GTCs) has increased with more detailed surveillance endoscopy using indigo carmine dye following esophagectomy. This retrospective study clarified the clinicopathological features and application of endoscopic submucosal dissection (ESD) for GTCs. Data collected for eight GTCs treated by ESD included clinical and pathological features and outcomes following ESD. Overall, eight GTCs were identified in seven (6.3 %) of 112 patients who underwent esophagectomy and gastric tube reconstruction. Almost all lesions were macroscopically type 0-IIa with mucosal to submucosal invasion, and seven GTCs were successfully resected en bloc by ESD. Submucosal invasion to > 500 microm was observed in one case with associated delayed perforation that was treated conservatively. No local recurrences of GTCs were observed. Detailed surveillance endoscopy using indigo carmine dye appears useful for diagnosing early-stage GTC. Furthermore ESD represents a feasible alternative to conventional endoscopic mucosal resection as a minimally invasive therapy for early-stage GTC.

Composite material stent comprising metallic wire and polylactic acid fibers, and its mechanical strength and retrievability

BACKGROUND

Although metallic stents are characterized by strong expanse of force, thin walls, and easy stent deployment, their removal from the body is usually difficult or impossible due to the difficulty of unraveling their mesh structure. A stent built of a composite material comprising a metallic wire and a polylactic acid (PLA) fiber, in which the metallic wire component could be unraveled after PLA fiber degradation in the body, should allow easy stent removal.

PURPOSE

To evaluate the mechanical strength and retrievability of a composite material stent comprising a metallic wire and a PLA fiber.

MATERIAL AND METHODS

We produced a composite material stent comprising a metallic wire and a biodegradable fiber (hybrid stent). As the metallic wire is not cross-linked with itself, but with the PLA fibers only, the hybrid stent can be easily unraveled after PLA fiber degradation. This stent was built with a 0.2-mm stainless-steel wire and a 0.23-mm PLA fiber knitted in the same textile as an Ultraflex stent. For comparison, an identical stent was built using PLA fiber only (PLA stent). The mechanical strength of these stents was tested by the radial expansive force response against circumferential shrinkage stress load. Change in radial force due to PLA fiber degradation was estimated by adding an artificial PLA degeneration process, by immersing each stent in a water bath at 80 degrees C for 48 hours. Retrievability of the hybrid stent after PLA degeneration was examined by hooking and pulling out the residual stainless-steel wire from a silicon tube.

RESULTS

The hybrid stent exhibited a linear response in radial expansive force within the range of 15% diameter reduction. The PLA stent did not exhibit linear response at over 15% diameter reduction. Decrease of radial expansive force after PLA degradation was within 5% of the original force in the hybrid stent, but the PLA stent did not create effective radial expansive force. Hybrid stents, even after PLA degradation, exhibited a linear response in radial expansive force, within the range of 15% diameter reduction. The metallic component of the heat-processed hybrid stent was easily unraveled by pulling out the wire.

CONCLUSION

The hybrid stent comprising a stainless-steel wire and a PLA fiber appears to provide effective radial expansive force and retrievability.

Ancillary N.O.T.E.S. procedures for early stage gastric cancer

The potential for performing truly scarless, safe surgery that at the same time may be less morbid is tempting both patients and physicians alike to seriously consider Natural Orifice Transluminal Endoscopy Surgery (NOTES) for a range of clinical applications. Given the move towards gastric-preservation by minimally invasive techniques for definitive management of early gastric cancer, this radical approach may find a niche within future clinical care paradigms for early stage malignant lesions of the stomach. Indeed already selected T1,N0 adenocarcinoma is being treated and even cured by advanced endoscopic techniques such as Endoscopic Submucosal Dissection. NOTES may initially therefore find a role in furthering the application of such endeavour by ensuring oncological providence in the treatment of those T1 lesions with higher risk of lymphatic metastases that currently are advised to lie outwith the scope of pure endoscopic resection (for reasons of oncological propriety rather than technical capacity). One such means NOTES could supplement ESD is by providing for direct sampling of sentinel nodes from the perigastric lymph basins. Subsequently perhaps a NOTES technique may develop capable of performing localized, full-thickness gastric wedge or sleeve resection for T2,N0 adenocarcinoma (and indeed perhaps other pathologies such as small gastrointestinal stromal tumors). This review examines how advancing technology along with progressive surgical thinking and innovation could lead to NOTES becoming absorbed into clinical care pathways for early gastric malignancy.

Transcatheter coil embolization for steal syndrome in patients with hemodialysis access

BACKGROUND

Drainage of large amounts of shunt blood into deep veins via collaterals reduces resistance to venous outflow and decreases blood flow to the artery distal to the arterial anastomotic site, potentially resulting in steal syndrome.

PURPOSE

To evaluate the effectiveness of transcatheter coil embolization for collateral veins of hemodialysis access in the treatment of steal syndrome.

MATERIALS AND METHODS

Five hemodialysis patients (four male, one female; mean age 58.8 years, range 40-71 years) with symptomatic steal syndrome were treated. Steal syndrome was diagnosed based on decreased or absent distal pulse, coolness, pain, abnormal skin color, ischemic ulceration of digits, numbness, sensory impairment, or motor impairment. Coil embolization was performed to block collaterals communicating with deep veins, with conscious sedation and local anesthesia. Fistulography was performed before, immediately after, and 1 month after embolization. Ultrasonography was performed 2 days after embolization. Symptoms and signs were assessed 2 days after embolization. Clinical findings related to steal syndrome and access failure were observed at each hemodialysis.

RESULTS

Blood flow in the collaterals was successfully blocked by coil embolization in all patients. Distal pulse, coolness, pain, and skin color improved in all patients. Numbness, sensory impairment, and motor impairment were unimproved in two patients. In all patients, hemodialysis following embolization was performed normally. The mean observation period after embolization was 33 months (range 9-75 months).

CONCLUSION

Coil embolization of collaterals that drain shunt blood into deep veins is effective for steal syndrome for hemodialysis access originating in the brachial artery.

Evaluation of combined docetaxel and nedaplatin chemotherapy for recurrent esophageal cancer compared with conventional chemotherapy using cisplatin and 5-fluorouracil: a retrospective study

This retrospective study evaluated the safety and efficacy of combination chemotherapy using docetaxel and nedaplatin in an outpatient setting compared with those of chemotherapy using cisplatin (CDDP) and 5-Fu under hospitalization. Subjects comprised 21 patients who had been diagnosed with recurrent esophageal squamous cell carcinoma (ESCC), with 10 patients receiving combination chemotherapy comprising CDDP and 5-fluorouracil (5-Fu) under hospitalization (FP group; n = 10), and 11 patients receiving combination chemotherapy comprising docetaxel and nedaplatin in an outpatient setting (Doc/Ned group; n = 11). In the Doc/Ned group, patients received 30 mg/m(2) of docetaxel over a 1-h infusion on day 1, followed by 40 mg/m(2) of nedaplatin over a 2-h infusion on day 1 in an outpatient setting. In the Doc/Ned group, complete response was observed in two patients (18.1%), one with liver metastasis and one with abdominal lymph node metastasis, and two (18.1%) achieved partial response. In contrast, no complete responses were obtained in the FP group, and partial response was observed in only one patient (10.0%) with local recurrence. Response rates were thus 36.3% for the Doc/Ned group and 10.0% for the FP group. With a median follow-up of 234 days in the Doc/Ned group and 279 days in the FP group, median survival time (MST) was 234 days in the Doc/Ned group and 378 days in the FP group. No significant differences in MST were identified between groups. Thus regimen based on docetaxel and nedaplatin allows administration on an outpatient basis and appears feasible for recurrent ESCC as a second-line chemotherapy.

Improvement in respiratory function by percutaneous vertebroplasty

BACKGROUND

Percutaneous vertebroplasty (PVP) improves back pain and corrects spinal misalignment to some extent, and thus may improve respiratory function.

PURPOSE

To retrospectively investigate changes in respiratory function after PVP.

MATERIAL AND METHODS

41 patients (mean age 72.0 years, range 59-86 years; 39 women, two men) who had undergone PVP for vertebral compression fractures (37 thoracic vertebral bodies [Th6-Th12] and 50 lumbar vertebral bodies [L1-L5]) caused by osteoporosis visited our hospital for follow-up consultation between January and June 2005. At this follow-up consultation, respiratory function testing, including percent forced vital capacity (FVC%) and percent forced expiratory volume in 1 s (FEV(1)%), was performed. We retrospectively compared these values with those taken before PVP using a Wilcoxon signed-rank test.

RESULTS

FVC% was 85.2+/-30.3% before PVP and 91.5+/-16.8% at follow-up (mean 10 months after PVP), which represented a significant difference (P<0.003). No significant difference in FEV(1)% was detected. Regarding the number of treatment levels, that is, single vertebroplasty versus multiple vertebroplasty, no significant difference in improvement of FVC% was confirmed (P=0.1). FVC% was abnormally low (<or=79%) before PVP in 16 patients and improved to within normal range postoperatively in six of these patients (38%).

CONCLUSION

PVP improves preoperatively decreased lung function, but this improvement takes time.

Diffusion-weighted imaging for predicting new compression fractures following percutaneous vertebroplasty

BACKGROUND

Percutaneous vertebroplasty (PVP) is a technique that structurally stabilizes a fractured vertebral body. However, some patients return to the hospital due to recurrent back pain following PVP, and such pain is sometimes caused by new compression fractures.

PURPOSE

To investigate whether the apparent diffusion coefficient (ADC) of adjacent vertebral bodies as assessed by diffusion-weighted imaging before PVP could predict the onset of new compression fractures following PVP.

MATERIAL AND METHODS

25 patients with osteoporotic compression fractures who underwent PVP were enrolled in this study. ADC was measured for 49 vertebral bodies immediately above and below each vertebral body injected with bone cement before and after PVP. By measuring ADC for each adjacent vertebral body, ADC was compared between vertebral bodies with a new compression fracture within 1 month and those without new compression fractures. In addition, the mean ADC of adjacent vertebral bodies per patient was calculated.

RESULTS

Mean preoperative ADC for the six adjacent vertebral bodies with new compression fractures was 0.55 x 10(-3) mm(2)/s (range 0.36-1.01 x 10(-3) mm(2)/s), and for the 43 adjacent vertebral bodies without new compression fractures 0.20 x 10(-3) mm(2)/s (range 0-0.98 x 10(-3) mm(2)/s) (P < 0.001). Mean preoperative ADC for the six patients with new compression fractures was 0.55 x 10(-3) mm(2)/s (range 0.21-1.01 x 10(-3) mm(2)/s), and that for the 19 patients without new compression fractures 0.17 x 10(-3) mm(2)/s (range 0.01-0.43 x 10(-3) mm(2)/s) (P < 0.001).

CONCLUSION

The ADC of adjacent vertebral bodies as assessed by diffusion-weighted imaging before PVP might be one of the predictors for new compression fractures following PVP.

Diffusion-weighed MR imaging of pancreatic carcinoma

PURPOSE

The aim of this study was to demonstrate the feasibility of body diffusion-weighted (DW) MR imaging in the evaluation of a pancreatic carcinoma.

MATERIAL AND METHODS

In nine normal volunteers and in eight patients with pancreatic carcinoma, DW images were obtained on the axial plane scanning with a multisection spin-echo-type single-shot echo planar sequence with a body coil. Moreover, we measured the apparent diffusion coefficient (ADC) value in a circular region of interest (ROI) within the normal pancreas, pancreatic carcinoma, and tumor-associated chronic pancreatitis.

RESULTS

On the DW images, all eight carcinomas were clearly shown as high signal intensity relative to the surrounding tissue. The ADC value (x10(-3) mm(2)/s) in the carcinoma was 1.44 +/- 0.20, which was significantly lower compared to that of normal pancreas (1.90 +/- 0.06) and tumor-associated chronic pancreatitis (2.31 +/- 0.18).

CONCLUSION

Diffusion-weighted (DW) images can be helpful in detecting the pancreatic carcinoma and accessing the extent of the tumor.

Lower limb ischaemia caused by fractured osteochondroma of the femur

Osteochondroma is the most common benign bone tumour and can arise in any bone. They frequently develop around the knee in the distal femur and the proximal tibia. These are usually asymptomatic, but can occasionally impinge on the surrounding vessels and cause various clinical manifestations. We have encountered a patient with multiple hereditary exostoses, in whom the osteochondroma located in the distal portion of the femur fractured as a result of an injury from a traffic accident. The migrated osteochondroma compressed the femoral artery and led to an acute onset of lower extremity ischaemia. Although trauma or vigorous exercise can cause vascular complications caused by osteochondroma, vascular insufficiency due to fracture of osteochondroma after a traumatic injury is extremely rare.

Graft selection algorithm based on congestion volume for adult living donor liver transplantation

A major concern in adult-to-adult living donor liver transplantation is the selection of graft type; that is, is it is better to use the right lobe with or without the middle hepatic vein (MHV)? This choice has a considerable impact on donor safety, vascular reconstruction and graft function in the recipient. To facilitate making an appropriate choice, on the basis of a preliminary study (n = 17), we herein propose a graft selection algorithm using three parameters: graft-to-recipient body weight ratio (GRWR), percentage remnant liver volume (%RLV) and estimated congestion ratio (ECR). The algorithm was evaluated with 50 consecutive cases with respect to postoperative liver function of donors and recipients and survival of recipients. Postoperative recovery was comparable between the two groups (p = NS). The overall cumulative 18-month survival rate was 86.7% for the 'with MHV graft group', and 76.1% for the gwithout MHV graft grouph (p = NS). For 41 cases (82%), graft types were chosen according to the algorithm, whereas the remaining 9 cases (18%) needed detailed discussion of donor, recipient and operative factors. In conclusion, we constructed a graft selection algorithm based on congestion volume, which will contribute to objective graft-type selection in adult-to-adult LDLT.

Phase I/II study of percutaneous vertebroplasty (PVP) for painful malignant vertebral compression fracture(PMVCF): JIVROSG- 0202

9118

Backgrounds: This multi-center prospective study was conducted to evaluate the safety and efficacy of PVP, a new treatment modality for PMVCF, using techniques of interventional radiology. Methods: Enrolled patients (pts) had PMVCF by primary or metastatic tumor; restricted activities by PMVCF; tumor not exposed into spinal canal; adequate hematologic, hepatic, renal and cardiac functions; 0–3 ECOG performance status (PS); estimated prognosis over 4 weeks; and written consent. In phase I, 9 pts were enrolled; in phase II, 24 pts. Safety and efficacy were evaluated by NCI-CTC Ver. 2 and Visual Analogue Scale (VAS) at week 1 after PVP, respectively. By VAS score decreases, efficacy was classified into significantly effective (SE: =5 or reached 0–2), moderately effective (ME: 2–4), or not effective (NE: <2 or increase). Response rate was the ratio of pts with SE or ME in total pts. PVP was performed by insertion of 14–16 G bone biopsy needle into fractured vertebral body (FVB) using fluoroscopy or CT guidance, injection of bone cement (BC) under real time imaging observation, and discontinuation of BC injection at its distribution to adequate area of FVB or into extra bone space. Results: Procedures were completed in all 33 patients with 42 PMVCF. PS of pts was 0 in 1, 1 in 7, 2 in 12 and 3 in 13. In 30 days after PVP, 2 patients died of primary disease progression, but no major adverse reaction (>Grade 2) was observed. Response rate was 73% (56–85% in 95% CI) (61% (n=20) with SE; 12% (n=4) with ME; 27% (n=9) with NE), and increased to 83% at week 4. Median to PVP effect was 1 day (mean: 2.4). Median pain controlled survival was 73 days. Conclusion: For PMVCF, PVP is a safe and effective treatment modality with immediate responses. A phase III trial comparing PVP and standard radiation therapy is planned to evaluate PVP as the front line treatment.

No significant financial relationships to disclose.

Stage migration caused by D2 dissection with para-aortic lymphadenectomy for gastric cancer from the results of a prospective randomized controlled trial

BACKGROUND

Extended lymphadenectomy (D2) provides accurate nodal staging of gastric cancer. The aim of this study was to clarify the degree of stage migration seen with D2 combined with para-aortic lymph node dissection for gastric cancer invading the subserosa, the serosa and adjacent structures (T2ss-4) in patients considered not to have distant metastases (M0).

METHODS

Between July 1995 and April 2001, 523 patients were recruited and randomized in a prospective phase III trial comparing D2 with D2 and para-aortic nodal dissection for T2ss-4 gastric cancer without macroscopic para-aortic nodal metastases. Stage migration was evaluated by Japanese Gastric Cancer Association staging in 260 patients who underwent D2 with para-aortic dissection by analysing pathological information from the dissected lymph nodes.

RESULTS

Node (N)-stage migration was observed in 1 per cent (1 of 82) of patients with N1 disease, 20 per cent (12 of 59) with N2, 43 per cent (10 of 23) with N3 and 8.8 per cent (23 of 260) of all patients. Final stage migration occurred in 9 per cent (5 of 58) of patients with stage IIIa, 19 per cent (8 of 42) with stage IIIb, 56 per cent (9 of 16) with stage IVa and 8.5 per cent (22 of 260) of all patients. Metastasis to N4 nodes was found in 4 per cent (four of 95) of tumours invading the subserosa and 17.4 per cent (19 of 109) of tumours penetrating the serosa. The overall incidence of N4 involvement was 8.8 per cent (23 of 260).

CONCLUSION

Extended para-aortic lymphadenectomy for gastric cancer provides accurate nodal staging and results in stage migration, which may improve stage-specific survival regardless of overall survival benefit.

Percutaneous transluminal cutting-balloon angioplasty for hemodialysis access stenoses resistant to conventional balloon angioplasty

PURPOSE

To examine the value of cutting-balloon percutaneous transluminal angioplasty (PTA) for hemodialysis access with residual stenosis after conventional balloon PTA.

MATERIAL AND METHODS

Angioplasty with conventional balloons was performed on 48 hemodialysis access stenoses in 28 patients. If the balloon waist still remained at the rated burst pressure, the balloon was reinflated up to three times. Fifteen of 48 stenoses had residual stenoses of more than 30% after conventional balloon PTA. In these 15 stenoses, additional cutting-balloon PTA was performed.

RESULTS

The mean residual percent diameter stenoses before and after conventional balloon PTA were 77.6+/-3.4% and 48.6+/-8.5%, respectively. Additional cutting-balloon PTA decreased the mean residual percent diameter to 27.9+/-10.0%, and the cutting balloon was completely inflated without complication. In 12 patients, the 6-month primary patency rate (+/-SE) was 90.0% (9.5), and the 1-year primary patency rate (+/-SE) was 25.0% (14.8).

CONCLUSION

Additional cutting-balloon PTA was found useful for reducing residual stenosis.