Deep Learning Nomogram for the Identification of Deep Stromal Invasion in Patients With Early-Stage Cervical Adenocarcinoma and Adenosquamous Carcinoma: A Multicenter Study

BACKGROUND

Deep stromal invasion (DSI) is one of the predominant risk factors that determined the types of radical hysterectomy (RH). Thus, the accurate assessment of DSI in cervical adenocarcinoma (AC)/adenosquamous carcinoma (ASC) can facilitate optimal therapy decision.

PURPOSE

To develop a nomogram to identify DSI in cervical AC/ASC.

STUDY TYPE

Retrospective.

POPULATION

Six hundred and fifty patients (mean age of 48.2 years) were collected from center 1 (primary cohort, 536), centers 2 and 3 (external validation cohorts 1 and 2, 62 and 52).

FIELD STRENGTH/SEQUENCE

5-T, T2-weighted imaging (T2WI, SE/FSE), diffusion-weighted imaging (DWI, EPI), and contrast-enhanced T1-weighted imaging (CE-T1WI, VIBE/LAVA).

ASSESSMENT

The DSI was defined as the outer 1/3 stromal invasion on pathology. The region of interest (ROI) contained the tumor and 3 mm peritumoral area. The ROIs of T2WI, DWI, and CE-T1WI were separately imported into Resnet18 to calculate the DL scores (TDS, DDS, and CDS). The clinical characteristics were retrieved from medical records or MRI data assessment. The clinical model and nomogram were constructed by integrating clinical independent risk factors only and further combining DL scores based on primary cohort and were validated in two external validation cohorts.

STATISTICAL TESTS

Student's t-test, Mann-Whitney U test, or Chi-squared test were used to compare differences in continuous or categorical variables between DSI-positive and DSI-negative groups. DeLong test was used to compare AU-ROC values of DL scores, clinical model, and nomogram.

RESULTS

The nomogram integrating menopause, disruption of cervical stromal ring (DCSRMR), DDS, and TDS achieved AU-ROCs of 0.933, 0.807, and 0.817 in evaluating DSI in primary and external validation cohorts. The nomogram had superior diagnostic ability to clinical model and DL scores in primary cohort (all P < 0.0125 [0.05/4]) and CDS (P = 0.009) in external validation cohort 2.

DATA CONCLUSION

The nomogram achieved good performance for evaluating DSI in cervical AC/ASC.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Primary Adenosquamous Carcinoma of the Prostate With Multiple Heterogenic Metastases Demonstrated on 68 Ga-PSMA and 18 F-FDG PET/CT Imaging

ABSTRACT

A 54-year-old man presented with a 2-month history of urination disturbances. Serum prostate-specific antigen level was 4.96 ng/mL, and a possibility of benign prostate hyperplasia was raised by outside medical CT. Histopathology revealed adenosquamous carcinoma. Staging workup showed large areas of high PSMA uptake and focal intense hypermetabolism in the prostate, multiple lymphatics, bone, and pulmonary heterogenic metastases on 68 Ga-PSMA and 18 F-FDG PET/CT imaging.

Intratumoral and peritumoral MRI radiomics nomogram for predicting parametrial invasion in patients with early-stage cervical adenocarcinoma and adenosquamous carcinoma

OBJECTIVE

To develop a comprehensive nomogram based on MRI intra- and peritumoral radiomics signatures and independent risk factors for predicting parametrial invasion (PMI) in patients with early-stage cervical adenocarcinoma (AC) and adenosquamous carcinoma (ASC).

METHODS

A total of 460 patients with IB to IIB cervical AC and ASC who underwent preoperative MRI examination and radical trachelectomy/hysterectomy were retrospectively enrolled and divided into primary, internal validation, and external validation cohorts. The original (Ori) and wavelet (Wav)-transform features were extracted from the volumetric region of interest of the tumour (ROI-T) and 3mm- and 5mm-peritumoral rings (ROI-3 and ROI-5), respectively. Then the Ori and Ori-Wav feature-based radiomics signatures from the tumour (RST) and 3 mm- and 5 mm-peritumoral regions (RS3 and RS5) were independently built and their diagnostic performances were compared to select the optimal ones. Finally, the nomogram was developed by integrating optimal intra- and peritumoral signatures and clinical independent risk factors based on multivariable logistic regression analysis.

RESULTS

FIGO stage, disruption of the cervical stromal ring on MRI (DCSRMR), parametrial invasion on MRI (PMIMR), and serum CA-125 were identified as independent risk factors. The nomogram constructed by integrating independent risk factors, Ori-Wav feature-based RST, and RS5 yielded AUCs of 0.874 (0.810-0.922), 0.885 (0.834-0.924), and 0.966 (0.887-0.995) for predicting PMI in the primary, internal and external validation cohorts, respectively. Furthermore, the nomogram was superior to radiomics signatures and clinical model for predicting PMI in three cohorts.

CONCLUSION

The nomogram can preoperatively, accurately, and noninvasively predict PMI in patients with early-stage cervical AC and ASC.

CLINICAL RELEVANCE STATEMENT

The nomogram can preoperatively, accurately, and noninvasively predict PMI and facilitate precise treatment decisions regarding chemoradiotherapy or radical hysterectomy in patients with early-stage cervical AC and ASC.

KEY POINTS

The accurate preoperative prediction of PMI in early-stage cervical AC and ASC can facilitate precise treatment decisions regarding chemoradiotherapy or radical hysterectomy. The nomogram integrating independent risk factors, Ori-Wav feature-based RST, and RS5 can preoperatively, accurately, and noninvasively predict PMI in early-stage cervical AC and ASC. The nomogram was superior to radiomics signatures and clinical model for predicting PMI in early-stage cervical AC and ASC.

Adenosquamous carcinoma of the liver: The challenge of diagnosis

Adenosquamous carcinoma of the liver is extremely rare. We report a case of adenosquamous carcinoma in the intrahepatic bile duct of a 56-year-old woman who complained of persistent abdominal pain, shivering and hyperthermia. Computed tomography demonstrated a solid-cystic neoplasm in segment 5/6/8 of the liver with a gradual enhancement pattern in the solid area. However, postoperative pathological examination showed adenosquamous carcinoma of intrahepatic bile duct.

Adenosquamous carcinoma lung radiologically mimicking pneumonia: A potentially disastrous diagnostic challenge in an unusual malignancy

Lung cancer is among the most frequently diagnosed cancers and the world's leading cause of cancer-related death. Radiology remains the mainstay for timely diagnosis; however, atypical radiologic patterns are known, and these may be misdiagnosed as infectious or inflammatory pathology, particularly in the absence of smoking history. We report herein an account of an older male nonsmoker who presented radiologically with bilateral diffuse pulmonary infiltrates, simulating pneumonia, but was eventually diagnosed with adenosquamous lung carcinoma. The delay in diagnosis and subsequent unfortunate rapid deterioration of our patient serves as a reminder for clinicians to consider lung cancer in patients with clinical/radiologic findings suggestive of pneumonia, especially in nonsmokers or cases refractory to antibiotic therapy.

Application of Unenhanced Computed Tomography Texture Analysis to Differentiate Pancreatic Adenosquamous Carcinoma from Pancreatic Ductal Adenocarcinoma

OBJECTIVE

The objective of this study was to investigate the application of unenhanced computed tomography (CT) texture analysis in differentiating pancreatic adenosquamous carcinoma (PASC) from pancreatic ductal adenocarcinoma (PDAC).

METHODS

Preoperative CT images of 112 patients (31 with PASC, 81 with PDAC) were retrospectively reviewed. A total of 396 texture parameters were extracted from AnalysisKit software for further texture analysis. Texture features were selected for the differentiation of PASC and PDAC by the Mann-Whitney U test, univariate logistic regression analysis, and the minimum redundancy maximum relevance algorithm. Furthermore, receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of the texture feature-based model by the random forest (RF) method. Finally, the robustness and reproducibility of the predictive model were assessed by the 10-times leave-group-out cross-validation (LGOCV) method.

RESULTS

In the present study, 10 texture features to differentiate PASC from PDAC were eventually retained for RF model construction after feature selection. The predictive model had a good classification performance in differentiating PASC from PDAC, with the following characteristics: sensitivity, 95.7%; specificity, 92.5%; accuracy, 94.3%; positive predictive value (PPV), 94.3%; negative predictive value (NPV), 94.3%; and area under the ROC curve (AUC), 0.98. Moreover, the predictive model was proved to be robust and reproducible using the 10-times LGOCV algorithm (sensitivity, 90.0%; specificity, 71.3%; accuracy, 76.8%; PPV, 59.0%; NPV, 95.2%; and AUC, 0.80).

CONCLUSION

The unenhanced CT texture analysis has great potential for differentiating PASC from PDAC.

Primary Adenosquamous Carcinoma of the Liver on FDG PET/CT

ABSTRACT

Primary adenosquamous carcinoma (ASC) of the liver is a rare subtype of intrahepatic cholangiocarcinoma. Hepatic ASC consists of both adenocarcinoma and squamous cell carcinoma components. Because hepatic ASC is extremely rare, only a few cases describing the imaging findings of hepatic ASC were reported before. Herein, we present FDG PET/CT findings of hepatic ASC in a 78-year-old woman who was admitted to hospital with a 4-week history of right upper quadrant pain.

[The Postoperative Recurrence of Adenosquamous Cell Carcinoma of the Lung as a Polypoid Mass in the Tracheal Lumen;Report of a Case]

The case is 77 years old, female. She was referred to a local doctor with a chief complaint of cough and wheezing and was treated as asthma. However, symptoms did not improve and she was referred to our hospital. She had a history of right upper lobectomy for lung cancer about 2 years before, with the pathological diagnosis of adenosquamous cell carcinoma, pT1aN0M0, stage I A. Chest computed tomography (CT) scan showed a pedunculated polypoid mass almost occupying the lumen in the trachea immediately above the tracheal bifurcation, and the emergency bronchoscopic resection using a high-frequency snare under general anesthesia was performed. Postoperatively, 50 Gray of radiotherapy was added.

18F-FDG PET/CT in lung adenosquamous carcinoma and its correlation with clinicopathological features and prognosis

OBJECTIVE

Lung adenosquamous carcinoma (ASC) is a rare histological subtype of non-small cell lung cancer (NSCLC). Due to its rarity, the studies about ¹⁸F-FDG PET/CT in this kind of pulmonary tumor were quite limited. Thus, this study investigated ¹⁸F-FDG PET/CT findings in ASC and its correlation with clinicopathological features and clinical outcomes.

METHODS

Preoperative ¹⁸F-FDG PET/CT findings and parameters of maximum standard uptake value (SUV_max), metabolic tumor volume and total lesion glycolysis of primary lesion (MTV-P, TLG-P), combination of primary lesion and metastases (MTV-C, TLG-C), and clinicopathological features were retrospectively investigated in patients with ASC. Moreover, progression-free survival (PFS) was also analyzed.

RESULTS

All 41 patients (25 men; 16 women; age: 60 ± 7 years) had single ASC with the mean diameter of 33 ± 14 mm. Six lesions were located centrally and 35 peripherally. Serum tumor markers were abnormally increased sporadically. Twenty-two cases were at TNM stage I, 9 at II, and 10 at III. The primary tumors were FDG-avid in all cases, with the average SUV_max of 11.5 ± 6.0. SUV_max was significantly associated with tumor location, size, and TNM stage (P < 0.05). Forty-one lesions were subgrouped into 23 AC-predominant and 18 SCC-predominant lesions, and significant differences were observed for age, tumor size, and SUV_max in two groups (P < 0.05). The median PFS of 41 cases was 19 months, and 12-month and 24-month PFS rates were 72.1% and 36.1%, respectively. SUV_max, MTV-P, and TLG-C were significantly associated with PFS (P < 0.05).

CONCLUSIONS

ASC of the lung displayed high SUV_max on ¹⁸F-FDG PET/CT, which was associated with tumor location, size, TNM stage, and predominant histologic component. Moreover, metabolic parameters of ¹⁸F-FDG PET/CT were independent prognostic factors of this rare lung malignancy.

CT and MR imaging features of pancreatic adenosquamous carcinoma and their correlation with prognosis

PURPOSE

To retrospectively investigate the computed tomography (CT) and magnetic resonance (MR) imaging features of pancreatic adenosquamous carcinoma (PASC) and the association between imaging findings and prognosis.

MATERIALS AND METHODS

CT, MR images of 26 patients with PASC were analyzed. Clinical symptoms, tumor markers, and patients' survival were recorded. Tumor attenuation, enhancement pattern and degree, vessel involvement, adjacent tissue invasion and metastasis were evaluated. The association between imaging features and overall survival (OS) were also assessed using Cox proportional hazards ratio model.

RESULTS

Fourteen masses were found in the head of the pancreas and 12 in the body/tail. The mean tumor size was 4.47 ± 1.76 cm. PASC usually showed ill-defined (96.2%), lobulated (76.9%) and predominantly solid mass (92.3%). Ring enhancement in the peripheral area of the tumor was commonly seen (76.9%). Vessel invasion was seen in 17 cases (65.4%), encasement of adjacent arteries in 7 cases (26.9%), upstream main pancreatic duct (MPD) dilatation in 16 cases (61.5%) and double duct sign in 9 cases (34.6%). Multivariate Cox proportional hazards model demonstrated that patients with vessel invasion may predict a poor prognosis (p = 0.037).

CONCLUSION

PASC tends to be an ill-defined solid mass with peripheral ring enhancement, and relatively poor enhancement in the central area. PASC may also show vessel invasion, vessel encasement and upstream MPD dilatation. Vessel invasion may indicate a poor prognosis.

110 Patients with adenosquamous carcinomas of the pancreas (PASC): imaging differentiation of small (≤ 3 cm) versus large (> 3 cm) tumors

OBJECTIVE

This study examined radiological imaging features of small (≤ 3 cm) and large (> 3 cm) adenosquamous carcinomas of the pancreas (PASC) lesions to better understand the morphology of these lesions.

METHODS

Images from 110 patients with pathologically proven PASC (80 males and 30 females, mean age: 62.6 years) were retrospectively reviewed. Two radiologists analyzed images and reached a consensus regarding the following features: location, shape, margins, presence of solid and necrotic components, rim enhancement, density/intensity during the portal venous phase, invasion of surrounding organs, vascular invasion, venous tumor thrombus formation, and enlarged lymph nodes. Differences in the imaging features between the two groups were evaluated with the Chi-square test or Fisher's exact test.

RESULTS

There were 41 small PASC lesions (mean age: 60.59 years) and 69 large PASC lesions (63.74 years). Statistical analysis demonstrated significant differences in the location, shape, adjacent organ and vessel invasion, and venous tumor thrombus formation (P < 0.05). Small PASC lesions were more frequently detected in the pancreatic head and had an ovoid shape. There was no significant difference in the presence of solid and necrotic components (P = 0.090), including approximately 3/4 of the lesions with necrosis and 1/4 purely solid lesions, enlarged lymph nodes (P = 0.068) and other features.

CONCLUSION

Regardless of the tumor size, 75% of PASC lesions present with central necrosis while 25% are purely solid. Small PASC lesions can be associated with lymph node metastasis at a relatively early stage. Large PASC lesions are likely to invade adjacent tissues and be associated with venous tumor thrombus formation.

[A Resected Case of Adenosquamous Carcinoma of Pancreas That Relapsed in Remnant Pancreas]

A 70's man underwent subtotal stomach preserving pancreatoduodenectomy(SSPPD)for pancreatic head cancer. The pathological diagnosis was adenosquamous carcinoma(ASC)of the pancreas. Two months after surgery, a recurrent tumor in the remnant pancreas was confirmed with a CT scan and suspected to be ASC by endoscopic ultrasound-guided fine needle aspiration(EUS-FNA). As the recurrent lesion was limited in the pancreas, total remnant pancreatectomy(TP)was performed 4 months after SSPPD. The final pathological diagnosis was ASC. Two months after TP, liver and para-aortic lymph node metastases were revealed. The patient has been alive for 14 months after SSPPD with chemotherapy. Because of its rarity, it is difficult to implement treatment plans for recurrent ASC in the remnant pancreas.

Primary adenosquamous cell carcinoma of the pancreas: the use of endoscopic ultrasound guided - fine needle aspiration to establish a definitive cytologic diagnosis

Pancreatic cancer is the second most common malignancy of the gastrointestinal tract in the US, and adenocarcinoma has been identified as the most common type of pancreatic cancer. Different types of pancreatic cancers have been classified: adenocarcinoma, ductal adenosquamous carcinoma, solid pseudopapillary tumors, endocrine neoplasms, acinar cell carcinoma, squamous cell carcinoma, cystic tumors, primary lymphoma of the pancreas, and metastatic lesions of the pancreas. Adenosquamous carcinoma is extremely rare, behave in a very aggressive way and is responsible for the 1 to 4% of the pancreatic exocrine neoplastic lesions. We describe the case of an 82-years-old African American female, presenting to our institution with quantifiable weight loss (12 kg in 3 months), jaundice and abdominal pain. On admission, laboratory tests were obtained: total bilirubin: 11.07 mg/dl with a direct fraction of 10.32 mg/dl. Cross-sectional abdominal CT scan with contrast, showed a lesion localized in the pancreatic head (hypodense on T1, measuring 3.5 x 3.5 x 2.5 cm), with vascular invasion of the portal vein. EUS showed a solid, hypoechoic, not well-defined lesion (measuring 3.98 x 3.80 cm), localized between the head and neck of the pancreas. EUS-FNA was performed with a 22G needle using the fanning technique. The cytological specimens demonstrated components of both squamous carcinoma and adenocarcinoma. The patient underwent ERCP procedure, and biliary drainage was performed with an entirely covered metallic stent placement. After a month from the procedures, the patient died due to the severity of the disease. Endoscopic ultrasound has proven to be the best method to diagnose solid pancreatic lesions, including rare and aggressive type of tumors like primary adenosquamous cell carcinoma that we described in this very interesting case report.

Penile metastases from primary lung cancer: Case report and literature review

BACKGROUND

Metastasis to the penis from primary lung cancer is quite rare. To improve the understanding, we present a case diagnosed as penile metastasis from primary lung cancer and review the literature.

METHODS

One case report and retrospectively analysis penile cancer patient secondary from primary lung cancer.

RESULTS

The patient complained of perineal pain and burning on urination for about 2 months. On physical examination, painful nodular masses at the base of left side of the corpora cavernosa were found. 18F-fluorodeoxyglucose positron emission tomography/CT (PET/CT) scan showed that maximum standardized uptake value (SUVmax) in left side corpora cavernosa and right hilar increased to 12.0 and 13.5 respectively. On flexible bronchoscopy checking, stenosis of the opening of apical segmental and posterior segmental bronchi of right upper lobe was found. The lateral segmental bronchi of left lower lobe was obstructed by a neoplasm. The pathological result was primary pulmonary adenosquamous carcinoma (ASC). Two months later, total penectomy was performed. The pathological result was penile ASC derived from pulmonary. On reviewing the literature, there are 39 cases reported. The patient we present is the 40 one. The average age at diagnosis was (60.5 ± 10.7) years old. The most common symptom was mass, followed by priapism, pain. The overall survival time was (4.5 ± 3.9) months.

CONCLUSIONS

The penis may be a site of metastasis from lung cancer, especially for old patient. Metastasis to the penis usually indicates that the primary lung cancer is at an advanced stage and the prognosis is very poor.

Leptomeningeal metastasis of poorly differentiated uterine cervical adenosquamous carcinoma following reirradiation to metastatic vertebrae: A case report

RATIONALE

Leptomeningeal metastasis from cervical adenosquamous carcinoma is extremely rare especially after radiotherapy for vertebral metastasis.

PATIENT CONCERNS

A 52-year-old woman with International Federation of Gynecology and Obstetrics (FIGO) stage IIB adenosquamous carcinoma of cervix presented with bilateral lower limbs weakening after 2 courses radiotherapy to thoracic vertebral metastases.

DIAGNOSES

Initial spine magnetic resonance imaging (MRI) showed no obvious nerve compression, and radiation myelopathy was suspected by the clinician. Progressive multifocal neurological signs developed one month after completion of spine re-irradiation. She was diagnosed with leptomeningeal metastasis by MRI and cerebrospinal fluid (CSF) study.

INTERVENTIONS

She received whole brain irradiation with a dose of 30 Gy in 10 fractions. Systemic chemotherapy with cisplatin (50 mg/m) and topotecan (0.75 mg/m) was administered sequentially.

OUTCOMES

She died with progressive disease two months after the diagnosis of leptomeningeal metastases.

LESSONS

Poorly differentiated advanced-stage cervical adenosquamous carcinoma is an aggressive neoplasm with a worse outcome. Leptomeningeal metastasis should be included in the differential diagnosis for patients with multifocal craniospinal neurological signs. A combination of detailed neurological examinations, MRI and CSF study allowed us to establish a correct diagnosis of leptomeningeal metastasis and initiate treatment in a timely manner.

Adenosquamous carcinoma of pancreas: CT and MR imaging features in eight patients, with pathologic correlations and comparison with adenocarcinoma of pancreas

PURPOSE

To reveal the CT and MR imaging features of adenosquamous carcinoma of pancreas (ASqC) in eight patients.

METHODS

This study was approved by our institutional review board. Eight patients with ASqC were included in this study. Radiologic and pathologic findings were reviewed in each lesion. Additionally, radiologic imaging findings were compared between ASqC and controlled adenocarcinoma groups.

RESULTS

Significant differences between ASqC and adenocarcinoma groups were noted in lesion shape, enhancement pattern on dynamic CT images, the presence or absence of necrosis, and tumor thrombus in the portal vein (PV) system. Compared with adenocarcinoma, ASqC tended to be round-lobulated shape (100% vs. 57.6%), have necrotic portions (100% vs. 39.4%), and have tumor thrombus in the PV system (37.5% vs. 6.1%). Extensive central necrosis was found in six (75%) of ASqC lesions. More lesions in ASqC group (62.5% vs. 12.1%) showed the highest absolute attenuation on pancreatic arterial phase (PAP) or portal venous phase (PVP) images, although the average attenuation values of all ASqC lesions on PAP, PVP, and delayed phase images were almost the same. Five (83.3%) of six resected lesions appeared as nodular type macroscopically. Microscopically, all lesions did not show infiltrating growth pattern, but showed an intermediate growth pattern, and were surrounded incompletely by fibrous tissue.

CONCLUSIONS

ASqC tended to be a round-lobulated lesion with extensive central necrosis. Additionally, tumor thrombus in the PV system was often present. These CT and MR imaging features could be a useful clue for diagnosing ASqC.

[Positron emission tomography/computed tomography for lung cancer staging]

BACKGROUND

PET/CT (Positron Emission Tomography/Computed Tomography) is widely used in nodal and metastatic staging of lung cancer patients.

AIM

To analyze PET/CT detection of metastatic disease in patients with lung cancer.

MATERIAL AND METHODS

We reviewed retrospectively F18Fluorodeoxyglucose PET/CT scans performed between December 2008 and December 2013. We selected 143 patients aged 30 to 92 years (63% males) with confirmed lung cancer referred for staging, with no previous treatment. We reviewed whole body PET/CT and brain magnetic resonance images. SUVmax (Standardized Uptake Value maximum) of primary pulmonary lesion, hilar/mediastinal nodes, and distant metastases were calculated.

RESULTS

Histological types encountered were adenocarcinoma in 55%, squamous-cell in 15%, small-cell in 8%, large-cell in 6% and adeno-squamous in 2%. In 22 cases (15%) histology was not available. Nodal involvement was observed in 60% of patients (44% hilar and 48% mediastinal). Skip metastases (mediastinal involvement without hilum involvement) were encountered in 17% of cases, and were significantly more common among high uptake lung tumors (p < 0.01). Best SUVmax cut-off for node involvement was 4.4 for hilum and 4.0 for mediastinum (sensibility: 86.4%, specificity: 99.8%). Sixty six patients (46.2%) showed distant metastases on PET/CT. The most common metastases were osseous in 22%, adrenal in 16%, hepatic in14%, pulmonary in 14% and cerebral in 12%. PET/CT detected a second unexpected synchronic cancer in eight patients (6%).

CONCLUSIONS

PET/CT is accurate for nodal staging using an uptake index as SUVmax. Distant metastases are common, especially in bone, adrenal glands and liver.

Contrast-enhanced multiphasic CT and MRI findings of adenosquamous carcinoma of the pancreas

OBJECTIVE

The objective was to retrospectively study computed tomography (CT) and magnetic resonance imaging (MRI) findings of adenosquamous carcinoma of the pancreas (PASC).

MATERIALS AND METHODS

Twelve patients (six women and six men; mean age, 61.3 years; range, 47-78 years) who presented with PASC as documented by pathologic examination underwent CT (n=10) or both CT and MRI (n=2) examination. Two radiologists evaluated the images and determined the location, size, margin, internal attenuation or signal intensity, contrast enhancement, and pattern for each tumor. Additionally, the presence of poorly enhanced areas, upstream main pancreatic duct (MPD) dilatation, pancreatic atrophy, and peripancreatic tissue metastasis were evaluated. Images were cross-referenced to surgical and pathologic findings.

RESULTS

Masses were distributed throughout the pancreas (head, n=6; body, n=1; and tail, n=5). The tumor size ranged from 2.4 to 5.5 cm with an average size of 3.7 cm. Eight (66.7%) masses were ill defined, and seven (58.3%) were partially exophytic. Twelve (100%) masses showed heterogeneous and poorly enhanced areas. The lesions showed weak (n=5), moderate (n=5), or intense (n=2) progressive enhancement. The diameter of MPD in six patients ranged from 3.0 to 5.0 mm with an average of 3.7 mm. Pancreatic atrophy was not found. In 10 patients (83.3%), masses invaded the peripancreatic tissues. Two patients had metastatic liver disease at presentation.

CONCLUSION

PASC typically presented as an ill-defined, hypovascular mass with a poorly enhanced area, exophytic tendency, and peripancreatic tissue invasion. Lack of pancreatic atrophy and mild MPD dilatation were also distinct from common duct pancreatic adenocarcinoma.

Atypical localization of lung cancer located in lobus v. azygos

Lobus v. azygos (lobe of the azygos vein, azygos lobe) is an accessory lobe of the right upper lobe of the lung that corresponds to the anatomical variety. The presence of expansive lesions in it represents unusual radiographic findings. This paper presents the case of a patient with an extensive expansion process in azygos lobe, radiologically diagnosed by standard radiography (X-ray) and Multislice Computed Tomography Scan (MSCT). The process was subsequently treated surgically and confirmed histologically as a non-small-cell lung adenocarcinoma.

Apparent diffusion coefficients in GEC ESTRO target volumes for image guided adaptive brachytherapy of locally advanced cervical cancer

BACKGROUND AND PURPOSE

T2 weighted MRI is recommended for image guided adaptive brachytherapy (IGABT) in cervical cancer. Diffusion weighted imaging (DWI) and the derived apparent diffusion coefficient (ADC) may add additional biological information on tumour cell density. The purpose of this study was to evaluate the distribution of the ADC within target volumes as recommended by GEC-ESTRO: Gross Tumour Volume at BT (GTV(BT)), High-Risk Clinical Tumour Volume (HR-CTV) and Intermediate-Risk Clinical Target Volume (IR-CTV) and to evaluate the change of diffusion between fractions of IGABT.

MATERIAL AND METHODS

Fifteen patients with locally advanced cervical cancer were examined by MRI before their first (BT1) and second (BT2) fraction of IGABT, resulting in a total of 30 MR examinations including both T2 weighted and DWI sequences. The Apparent Diffusion Coefficient (ADC) was calculated by use of three levels of b-values (0, 600, 1000 s/mm(2)). ADC maps were constructed and fused with the GEC ESTRO target contours. The mean ADC value within each target volume was calculated. Furthermore, volumes of low diffusion (ADC(low)) were defined based on an ADC threshold of 1.2 × 10(-3) mm(2)/s, and overlap with target volumes was evaluated. Change of ADC level in target volumes and change of ADC(low) volume from BT1 to BT2 was also evaluated.

RESULTS

The mean ADC was significantly lower in GTV(BT) than in HR-CTV (p<0.001) which again was significantly lower than in IR-CTV (p<0.001). There was no significant change of the ADC(low) volume or ADC level within each target structure between BT1 and BT2 (p=0.242). All three GEC-ESTRO volumes contained volumes with low diffusion. The GTV(BT) contained 37.2% volume of low diffusion, HR-CTV 20.3% and IR-CTV 10.8%.

CONCLUSION

With DWI we were able to find a significant difference in ADC-values for the three different GEC ESTRO targets. This supports the assumption that the target volumes used for dose prescription in IGABT contain tissues with different characteristics, with the tumour (GTV(BT)) being the volume with the lowest diffusion. No significant changes were found from BT1 to BT2 indicating that changes of ADC level and volumes are stable at the time of BT. Further studies are needed to evaluate the role of DWI in target contouring and dose prescription for IGABT.

[A case of gastric adenosquamous carcinoma successfully treated with second-line chemotherapy (CPT-11 and CDDP)]

Gastric adenosquamous carcinoma is known as an infrequent histological cancer with a poor prognosis. A 69-year-old man was revealed to have gastric squamous carcinoma on the gastric body remote from esophagus (cT4 cN3, cStage IV). A curative operation was impossible so he was treated with systemic chemotherapy using S-1+docetaxel. After 1 course, we changed to second-line chemotherapy combining CPT-11+CDDP because of heterochronic multiple hepatic metastases. PET-CT and CT findings after 5 courses of second-line therapy showed reduced primary tumor and metastatic lesions. The curative operation was performed based on the effective response with downstaging. The final histological diagnosis showed gastric adenosquamous carcinoma. The adjuvant chemotherapy of CPT-11 was continued without relapse for almost 2 years.

Radical hysterectomy for FIGO stage IIB cervical cancer: clinicopathological characteristics and prognostic evaluation

OBJECTIVE

To clarify the clinicopathological features and prognostic factors of patients with FIGO stage IIB cervical cancer who were treated with radical hysterectomy.

METHODS

One hundred thirty-nine FIGO stage IIB patients with squamous or adenosquamous cell carcinoma (median age, 51 years) who were treated with primary radical hysterectomy were examined retrospectively. Sixty-six FIGO stage IIB patients who were treated with primary radiotherapy (median age, 70 years) were included for comparison of survival.

RESULTS

Fifty percent (70/139) of the patients had pathological parametrial involvement. Among them, the positive rate of pelvic lymph nodes was 71% (50/70). Ninety-nine percent (138/139) of the tumors were completely removed, and the pelvic control rate was 88%. Major complications requiring surgery were found in 2.9% (4/139). Significant differences in survival were found among patients in subgroups according to pathological parametrial involvement, pelvic lymph node status, tumor size, lymph-vascular space invasion, and depth of myometrial invasion (log-rank test, P<0.05). Of these, the Cox proportional-hazard model revealed that parametrial involvement (P=0.001, 95% CI 1.992-6.297) and lymph node metastasis (P=0.042, 95% CI 1.023-3.298) were independent prognostic factors. The 5-year survival rate and relapse-free survival at 36 months were 69% and 72% among the radical hysterectomy group, and 69% and 75% among the radiotherapy group. The Cox model adjusted for age showed no significant differences in survival and relapse-free survival between these two groups.

CONCLUSION

Pathological parametrial involvement and positive nodes were prognostic factors for surgically treated patients with FIGO stage IIB cervical cancer.

[A case of non-Hodgkin's lymphoma after chemotherapy for cancer of unknown origin]

We present a case of non-Hodgkin's lymphoma after chemotherapy for a cancer of unknown origin. A 68-year-old man was hospitalized for hoarseness. Computed tomography(CT)scans showed a swelling of the superior mediastinal lymph node and a tumor of the right lobe of thyroid gland. Resection of the superior mediastinal lymph node and right hemithyroidectomy were performed. Pathological findings of the lymph node showed adenosquamous cell carcinoma, but no malignant lesion was found in the thyroid gland. Post-operative systemic survey failed to identify the origin of the adenosquamous cell carcinoma. Six courses of chemotherapy consisting of carboplatin and docetaxel were carried out. Seven months later, CT and positron emission tomography revealed swelling of the mediastinal lymph nodes and a tumor in the left abdominal tumor. An open biopsy of the abdominal tumor demonstrated non-Hodgkin's lymphoma, mature B cell type, follicular lymphoma, grade 1. Radiotherapy was done for the malignant lymphoma, and radiochemotherapy for the mediastinal lymph nodes. Seven months later, the patient died of systemic metastases of the adenosquamous cell carcinoma.

[Congenital diaphragmatic adult hernia. Case report]

BACKGROUND

Bochdalek's hernia is a congenital defect of the posterolateral region of the diaphragm, usually on the left side. It appears frequently in infants and is rare in adults. Diagnosis is incidental or when it becomes symptomatic. Our objective was to offer the general surgeon a differential diagnosis for presence of noncardiac thoracic pain in the adult.

CLINICAL CASE

We present the case of a 78-year-old female with cardiorespiratory and digestive symptoms of slight intensity and managed for many years as hypertensive cardiopathy and dyspeptic syndrome until she was admitted to our service with severe epigastric pain. Postero-anterior x-ray of the thorax demonstrated the presence of the stomach in the thoracic cavity. This was confirmed by barium esophagogram, upper gastrointestinal endoscopy and abdominal CT scan where porcelain gallbladder was also detected. The patient underwent abdominal surgery where a large diaphragmatic hernia was found with the complete stomach and small bowel inside. Primary repair of the diaphragm and cholecystectomy were performed, confirming gallbladder cancer.

DISCUSSION

It is frequent that thoracic pain in patients of advanced age is interpreted as cardiac and/or digestive pathology and that more diagnostic investigation is not pursued due to patient age and invasive nature of the studies. Therefore, patients are treated according to their symptoms. It is important that the surgeon establishes an etiological diagnosis in order to offer appropriate treatment.

CONCLUSIONS

Congenital diaphragmatic hernia in the adult is rarely suspected in the differential diagnosis of noncardiac thoracic pain. The surgeon must keep this in mind, especially in patients of advanced age, even when cardiac and/or gastrointestinal diagnosis is confirmed.

Imaging findings in primary adenosquamous carcinoma of the liver: a case report

Adenosquamous cell carcinoma is characterized by both squamous and glandular components, and is a rare disease of the liver that is the subject of few reports in the literature. We present a case in which the imaging findings on CT, MRI, and hepatic arteriography, as well as pathological correlation of the tumor and the clinical history, aided in including this entity in the differential diagnosis.

[Clinical analysis of primary lung cancer with a thin-walled cavity to explain the mechanism of thin-walled cavity formation]

We report 8 rare cases of primary lung cancer which showed a thin-walled cavity on chest X-ray and CT. We analyzed 8 cases (7 men, 1 woman) of primary lung cancer with thin-walled cavities admitted to our hospital between 1995 and 2006. The subjects were aged between 45 and 84 years of age (median: 72 years old). The reason for detection was treatment for tuberculosis in 1 case, ileus owing to metastasis to the small intestine in 1 case and tension pnumathorax 1 case, while 5 cases had abnormal chest x-ray film shadows without symptoms. Histologically, there were 5 cases of adenocarcinoma, 2 of squamous cell carcinoma, and 1 of adenosquamous cell carcinoma. Though various reports on the mechanism of the development of thin-walled cavity formation have been made, we suggest that it mainly develops by a check-valve mechanism, based on evaluation of the clinical course.

Lung cancer detection with low-dose spiral computed tomography in chronic obstructive pulmonary disease patients

PURPOSE

To determine whether low-dose spiral computed tomography (LDCT) can improve the lung cancer detection rate in chronic obstructive pulmonary disease (COPD) subjects.

MATERIAL AND METHODS

From October 1999 to December 2003, 374 COPD patients underwent LDCT for lung carcinoma screening. All subjects with an abnormal baseline CT scan were followed with serial CT scans as part of our protocol. Follow-up was continued until the demonstration of no change over a minimum of 24 months, or resolution. Sputum samples were also obtained for cytological analysis.

RESULTS

On the baseline spiral CT scan, 132 of 374 patients (35.2%) had at least one non-calcified nodule that required periodic follow-up with CT scans. The median follow-up time was 21 months (range 2-48 months). Of the 374 COPD subjects, nine patients with primary lung cancer (2.4%) were detected: six were squamous cell carcinomas, two were small-cell lung carcinomas (SCLC), and one was adenosquamous carcinoma. Three of the nine tumors were in stage IA, two in stage IIB, two in stage IIIA, and two were limited SCLC. Potentially curative pulmonary resection was performed in four patients, pulmonary lobectomy in three, and wedge excision in one. One subject with stage IA squamous cell carcinoma received radiotherapy, as pulmonary function was severely impaired. In addition, four patients underwent removal of benign lesions. Sputum was collected in 205 (54.8%) of 374 patients. There were 154 (75 %) metaplasia, 14 (6%) moderate dysplasia, and one (0.4%) malignant case.

CONCLUSION

LDCT increases early lung carcinoma detection rate in COPD patients, but pulmonary function impairment may reduce its benefit.

[A case of primary adenosquamous carcinoma of the liver with formation of colonic fistula]

Primary adenosquamous carcinoma of the liver is generally considered as an extremely rare subtype of cholangiocarcinoma. It has been reported mostly in a form of case studies. As far as we know, there was only one case report on tumor related with biliary fistula. Recently, we experienced a case of primary adenosquamous carcinoma of liver with a formation of tumor-colonic fistula. A 54-year-old man was transferred to our hospital due to liver mass detected by abdominal ultrasonogram. Dynamic computed tomogram of liver showed a large irregular hypodense mass without rim enhancement in right lobe of liver and also suggested a fistula formation between the tumor and hepatic flexure of right colon. Colonoscopic examination showed a large colonic wall defect in hepatic flexure and a friable, nodular mucosa around the defected colonic wall. Extended right lobectomy and right hemicolectomy were done. Microscopically, the tumor was composed of squamous cell carcinoma mainly with foci of the adenocarcinoma component.

Sentinel node identification in cervical cancer patients undergoing transperitoneal radical hysterectomy: a study of 100 cases

We investigated the feasibility of sentinel lymph node (SN) identification using radioisotopic lymphatic mapping with technetium-99m-labeled nanocolloid and blue-dye injection in 100 patients with early cervical cancer (FIGO stage IB1 in 58, IB2 in 18, and IIA in 24) undergoing radical hysterectomy with pelvic lymphadenectomy. At least one SN was found in 84% on one side and in 66% on both sides. The sentinel detection rates according to the stages were as follows: 96.6% in IB1, 66.7% in IB2, and 62.5% in IIA with at least one SN on one side, and 86.2% in IB1, 38.9% in IB2, and 37.5% in IIA with at least one SN on both sides. Successful identification of at least one SN was less likely in patients with tumors >2 cm (54% of SN) compared with those with tumors </=2 cm (96% of SN). In 15/22 patients, the SNs were the only lymph nodes that were tumor positive. The false-negative rate for the SN procedure was 3% (3/100). In all false-negative SNs, the primary cervical tumor was above 2 cm and there was an isthmus infiltration. SN detection had 86.4% sensitivity (19/22), 100% specificity (66/66), and 95.5% negative predictive value (63/68). The sentinel node detection rate is relatively high and depends on the tumor size and FIGO stage.

Beam angle optimization and reduction for intensity-modulated radiation therapy of non–small-cell lung cancers

PURPOSE

To optimize beam angles and reduce the number of beams used for intensity-modulated radiation therapy (IMRT) of non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

An exhaustive search scheme was used to perform beam angle optimization (BAO) for IMRT of NSCLC. This approach involved intercomparison of all possible beam angle combinations and selection of the best angles based on the scores or costs of the objective functions used in the treatment plan optimization. Ten Stage III NSCLC cases were selected to evaluate the BAO algorithm and dosimetry benefits of IMRT-BAO. IMRT plans using five or seven coplanar beams were optimized and compared with those using nine equal-spaced beams. Results of BAO were also compared between plans using different numbers of beams with or without fluence modulation.

RESULTS

Each anatomic structure, e.g., tumor or lung, had its own preferred beam angles. Thus, BAO required appropriate balance of competing objective functions. Plans using fewer angles (five or seven beams) could achieve plan quality similar to those using nine equal-spaced beams, however with reduced monitor units and field segments. The number of beams used for the treatment (five vs. seven) and the fluence modulation (open or IMRT beams) did not have a significant impact on the results of the BAO.

CONCLUSIONS

Use of fewer beams (e.g., five) for lung IMRT could result in acceptable plan quality but improved treatment efficiency. A multiresolution search scheme could be developed for BAO using fewer and nonmodulated beams to reduce the computation cost of BAO.

FDG-PET imaging for the assessment of physiologic volume response during radiotherapy in cervix cancer

PURPOSE

To evaluate the physiologic tumor volume response during treatment in cervical cancer using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET).

PATIENTS AND METHODS

This was a prospective study of 32 patients. Physiologic tumor volume in cubic centimeters was determined from the FDG-PET images using the 40% threshold method.

RESULTS

The mean pretreatment tumor volume was 102 cm3. The mean volume by clinical Stages I, II, and III were 54, 79, and 176 cm3, respectively. After 19.8 Gy external irradiation to the pelvis, the reduction in tumor volume was 29% (72 cm3). An additional 13 Gy from high-dose-rate (HDR) brachytherapy reduced the mean volume to 15.4 cm3, and this was subsequently reduced to 8.6 cm3 with 13 Gy additional HDR brachytherapy (26 Gy, HDR). Four patients had physiologic FDG uptake in the cervix at 3 months after the completion of therapy. The mean time to the 50% reduction in physiologic tumor volume was 19.9 days and after combined external irradiation and HDR to 24.9 Gy.

CONCLUSION

These results indicate that physiologic tumor volume determination by FDG-PET is feasible and that a 50% physiologic tumor volume reduction occurs within 20 days of starting therapy.

Dose escalation study of carbon ion radiotherapy for locally advanced carcinoma of the uterine cervix

PURPOSE

To evaluate the toxicity and efficacy of carbon ion radiotherapy (CIRT) for locally advanced cervical cancer by two phase I/II clinical trials.

METHODS AND MATERIALS

Between June 1995 and January 2000, 44 patients were treated with CIRT. Thirty patients had Stage IIIB disease, and 14 patients had Stage IVA disease. Median tumor size was 6.5 cm (range, 4.2-11.0 cm). The treatment consisted of 16 fractions of whole pelvic irradiation and 8 fractions of local boost. In the first study, the total dose ranged from 52.8 to 72.0 gray equivalents (GyE) (2.2-3.0 GyE per fraction). In the second study, the whole pelvic dose was fixed at 44.8 GyE, and an additional 24.0 or 28.0 GyE was given to the cervical tumor (total dose, 68.8 or 72.8 GyE).

RESULTS

No patient developed severe acute toxicity. In contrast, 8 patients developed major late gastrointestinal complications. The doses resulting in major complications were > or =60 GyE. All patients with major complications were surgically salvaged. The 5-year local control rate for patients in the first and second studies was 45% and 79%, respectively. When treated with > or =62.4 GyE, the local control was favorable even for the patients with stage IVA disease (69%) or for those with tumors > or =6.0 cm (64%).

CONCLUSIONS

In CIRT for advanced cervical cancer, the dose to the intestines should be limited to <60 GyE to avoid major complications. Although the number of patients in this study was small, the results support continued investigation to confirm therapeutic efficacy.

FDG-PET in carcinoma of the uterine cervix with endometrial extension

BACKGROUND

The authors wished to determine whether pretreatment pathologic evidence of endometrial invasion correlated with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) findings and outcomes in patients with carcinoma of the uterine cervix.

METHODS

Pretreatment whole body FDG-PET was performed in 58 patients with cervical carcinoma who also underwent pathologic evaluation of the endometrium by biopsy or dilation and curettage. FDG-PET lymph node status, disease free survival, and overall survival were evaluated.

RESULTS

Thirty seven (64%) patients had pathologic evidence of endometrial invasion. Pelvic lymph node metastases were three times more frequent in patients with evidence of endometrial invasion compared with those without endometrial invasion (70% vs. 23%, P < 0.001). Patients with endometrial invasion also had a significantly increased risk of paraaortic and supraclavicular lymph node metastases at presentation (30% vs. 0% P = 0.006). Endometrial invasion was associated with a decreased 2-year disease-free survival (78% vs. 58%, P = 0.046) and overall survival (92% vs. 65%, P = 0.047).

CONCLUSIONS

Endometrial extension in cervical cancer correlated strongly with risk of FDG-PET detected lymph node metastases in this study's population and was associated with a poor prognosis.

Recurrencia ovárica y paraaórtica de un carcinoma de cuello uterino detectada mediante PET/TC

We present the case of a 34-year-old woman diagnosed of an adenosquamous carcinoma of the uterine cervix, stage IIB of the FIGO classification (International Federation of Gynecology and Obstetrics), treated with quimiotherapy, radiotheraphy and brachytheraphy with posterior hysterectomy. A recurrence of the disease was suspected due to the progressive rise of CEA levels. A PET/CT revealed abnormal foci in both ovaries, that had been transposed to avoid lesions due to radiation, and in a left para-aortic adenopathy. The diagnosis of recurrence in these sites was confirmed by biopsy. PET with FDG (F18-fluorodeoxyglucose) is useful in the staging of primary tumour and in the detection of recurrence in uterine cervical carcinoma, with better sensitivity and specificity than CT and MRI. PET/CT improves anatomic resolution and helps to resolve the origin of unclear foci like in the case presented in which ovaries were not in their normal situation due to transposition.

Role of Imaging in Pretreatment Evaluation of Early Invasive Cervical Cancer: Results of the Intergroup Study American College of Radiology Imaging Network 6651–Gynecologic Oncology Group 183

Purpose

To compare magnetic resonance imaging (MRI) and computed tomography (CT) with each other and to International Federation of Gynecology and Obstetrics (FIGO) clinical staging in the pretreatment evaluation of early invasive cervical cancer, using surgicopathologic findings as the reference standard.

Patients and Methods

This prospective multicenter clinical study was conducted by the American College of Radiology Imaging Network and the Gynecologic Oncology Group from March 2000 to November 2002; 25 United States health centers enrolled 208 consecutive patients with biopsy-confirmed cervical cancer of FIGO stage ≥ IB who were scheduled for surgery based on clinical assessment. Patients underwent FIGO clinical staging, helical CT, and MRI. Surgicopathologic findings constituted the reference standard for statistical analysis.

Results

Complete data were available for 172 patients; surgicopathologic findings were consistent with FIGO stages IA to IIA in 76% and stage ≥ IIB in 21%. For the detection of advanced stage (≥ IIB), sensitivity was poor for FIGO clinical staging (29%), CT (42%), and MRI (53%); specificity was 99% for FIGO clinical staging, 82% for CT, and 74% for MRI; and negative predictive value was 84% for FIGO clinical staging, 84% for CT, and 85% for MRI. MRI (area under the receiver operating characteristic curve [AUC], 0.88) was significantly better than CT (AUC, 0.73) for detecting cervical tumors (P = .014). For 85% of patients, FIGO clinical staging forms were submitted after MRI and/or CT was performed.

Conclusion

CT and MRI performed similarly; both had lower staging accuracy than in prior single-institution studies. Accuracy of FIGO clinical staging was higher than previously reported. The temporal data suggest that FIGO clinical staging was influenced by CT and MRI findings.

Whole-body [18F]fluoro-2-deoxyglucose positron emission tomography scan staging prior to planned radical hysterectomy and pelvic lymphadenectomy

The aim of the study was to determine the effectiveness of whole-body [18F]fluoro-2-deoxyglucose positron emission tomography (FDG PET) imaging in properly selecting candidates for radical hysterectomy who are at low risk for subsequent chemoradiation. Retrospective study of 14 women undergoing planned radical hysterectomy and pelvic lymphadenectomy with clinically localized cervical cancer and either negative or inconclusive metastatic nodal disease by PET scan was performed. Pelvic lymph nodes were clearly negative by FDG PET scan in 12 of the 14 women. Two women had focal FDG uptake suspicious, although not definitive, for nodal metastasis, and pelvic nodes were positive at surgery in both. Computed tomography (CT) scan failed to detect nodal disease in either woman. Neither PET nor CT was effective at detecting parametrial disease, and both also failed to detect the primary tumor in some cases. Women with FDG PET scans that are clearly negative for nodal disease are good candidates for radical hysterectomy and are at low risk for subsequent chemoradiation.

Weekly versus three-weekly cisplatin as an adjunct to radiation therapy in high-risk stage I-IIA cervical cancer after surgery: a randomized comparison of treatment compliance

OBJECTIVES

To compare weekly and three-weekly cisplatin as an adjunct to radiation therapy in high-risk early-stage cervical cancer after surgery with regard to treatment compliance.

MATERIAL AND METHOD

From June 1st, 2003 to February 29th, 2004, the authors performed a randomized trial of radiotherapy in combination with two concurrent chemotherapy regimens - weekly or three-weekly cisplatin--in patients with high-risk cervical cancer FIGO stage I-IIA after surgery. Women with primary invasive squamous-cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the cervix were enrolled. The patients also had to have an absolute neutrophil count of at least 1,500 cells per cubic millimeter, a platelet count of at least 75,000 cells per cubic millimeter, a creatinine clearance higher than 40 milliliter per minute, and adequate hepatic function. All patients received external-beam radiotherapy according to a strict protocol. Patients were randomly assigned to receive one of two chemotherapy regimens: 75 mg per square meter of cisplatin on days 1, 22, 43 and 64 or every three weeks for 4 cycles (group 1) or 40 mg per square meter of cisplatin per week for six cycles (group 2).

RESULTS

The analysis included 40 women. The first group that received three-weekly cisplatin had a higher rate of incomplete and delayed treatments than the second group that received weekly cisplatin (p < 0.001 and p = 0.0236 respectively). The relative risks of delayed courses were 2.06 (95 percent confidence interval, 1.15 to 3.68) for group 1, compared with group 2. The toxicity-related incomplete treatments rate and G-CSF doses used were significantly higher in group 1 than in group 2.

CONCLUSION

Concurrent chemoradiation with weekly cisplatin regimen has more complete treatment rate and less delayed courses than that with three- weekly cisplatin among women with high-risk cervical cancer after surgery.

Adenosquamous carcinoma arising within a retrorectal tailgut cyst: Report of a case

Retrorectal, developmental tail gut cysts, include dermoid cysts, rectal duplication cysts and retrorectal cyst-hama-rtomas. Retrorectal cyst-hamartomas (RCH) are derived from remnants of the tail gut, the most caudal part of the embryonic hind gut, which normally involutes by the 8th wk of embryonic development (3-8 mm stage). They have specific radiological and histopathological features that distinguish them from other similar formations (dermoid cysts, enteric duplication cysts and teratomas). We report a patient with adenosquamous carcinoma arising within RCH, who underwent complete resection of the cyst through anterior laparotomy, and reached complete (recurrence-free for 14 mo, so far) functional recovery. The cyst was incidentally discovered during hysterectomy 12 years ago. Diagnostic, therapeutic and histopathological aspects of this rare case are discussed. The mentioned period between diagnosis and surgical treatment suggests that RCH, given enough time, can develop malignant degeneration, and should be resected at the time of diagnosis.

Evaluation of contrast-enhanced helical hydro-CT in staging gastric cancer

AIM: To discuss the helical computed tomography (CT) characteristics of gastric cancer and evaluate the diagnostic value of contrast-enhanced helical hydro-CT (HHCT) in staging gastric cancer.

METHODS: A total of 50 patients with gastric cancer were included in this study. The CT findings in them were retros-pectively analyzed and correlated with pathologic findings at surgery. All patients were preoperatively imaged by plain and contrast-enhanced helical CT after orally ingesting 1 000-1 500 mL water. Peristalsis was minimized by intra-venous administration of spasmolytics.

RESULTS: The foci of gastric cancer became more prominent in all the 50 patients and showed strong enhancement in contrast-enhanced HHCT. The tumor was located at the gastric cardia in 14 cases, at the gastric fundus in 3 cases, at the gastric body in 8 cases, at the gastric antrum in 4 cases, at the gastric fundus and the body in 8 cases, at the gastric body and antrum in 11 cases, and at three segments of the stomach in 2 cases. The CT features of gastric cancer were focal or diffuse mural thickening, soft tissue mass, cancerous ulcer, stenosis of stomach, infiltration to adjacent tissues, lymph node and distant metastases. Strong contrast enhancement of the gastric wall was closely related to gastric cancer. The accuracy rate of contrast-enhanced HHCT in staging gastric cancer was 86% (43/50). The detection rate of lymph node metastases by CT was 60% (12/20).

CONCLUSION: Contrast-enhanced HHCT is a reliable method to diagnose and stage gastric cancer.

Squamous and adenosquamous cell carcinomas of the gallbladder

Squamous and adenosquamous cell carcinomas (ASC and SCC) are rare subtypes of gallbladder cancer, traditionally considered more aggressive and with a poorer prognosis than adenocarcinoma. We report about two patients affected by an advanced squamous cell carcinoma of the gallbladder. Both had a large tumour in the gallbladder fossa region with infiltration of the liver. Surgical resection was radical in one, but palliative in the other. pTNM was T3 N0 M0, G3, R0 in the former and T3 N0 M0, G2 R1 in the latter. Patients died for local recurrence after 12 and 5 months, respectively. Natural history, clinical findings, prognosis and outcome of this rare gallbladder tumour are discussed on the basis of a review of the English literature. In conclusion, an aggressive and radical surgical treatment of advanced squamous and adenosquamous cell gallbladder carcinomas seems to be indicated for their low proclivity to distant spreading.

Adenosquamous carcinoma of the lung: CT—pathological correlation

AIM

To correlate CT morphological features and histopathological findings of adenosquamous carcinoma of the lung.

MATERIALS AND METHODS

In all, 29 patients underwent contrast-enhanced CT of an adenosquamous carcinoma of the lung, followed by resection of the cancer. Correlations between CT morphological and histopathological features were evaluated, including location, characteristics of margins, attenuation and the presence of necrosis.

RESULTS

The tumour was peripheral in 21 (72%) and central in 8 (28%) cases. The tumours varied in size from 1.1cm to 11.0cm (mean 3.8cm); 20 (69%) appeared as heterogeneous masses and 9 (31%) as homogeneous masses. The most common CT features were lobulation in 27 (93%), pleural tail in 22 (76%), spiculation in 17 (59%), necrosis in 15 (52%) and vessel convergence in 13 (45%). Among the 21 peripheral tumours, 14 (67%) showed intratumoural necrosis and 17 (81%) were heterogeneous. Among the 8 central tumours, only 1 (12.5%) showed intratumoural necrosis and 5 (62.5%) were homogeneous. These CT features corresponded mainly to solid tumour growth, which was composed of both squamous cell carcinomatous and adenocarcinomatous tissue.

CONCLUSION

Adenosquamous carcinoma of the lung is shown to be characteristically a solid, lobulated nodule or mass, more commonly peripheral than central. After intravenous injection of positive contrast medium, CT shows that the peripheral lesions are usually of heterogeneous soft-tissue attenuation.

Remote intrapulmonary spread of recurrent respiratory papillomatosis with malignant transformation

Recurrent respiratory papillomatosis is the most common neoplasm of the larynx in childhood. Extension into lung parenchyma occurs in less than 1% of patients and has a low risk of malignant transformation. Treatment options for intrapulmonary spread have shown limited success. We describe a case of recurrent respiratory papillomatosis with extensive parenchymal involvement and adenosquamous carcinoma in a 14-year-old girl.

Endometrial cancer in polyps: a clinical study of 27 cases

PURPOSE OF INVESTIGATION

To review risk factors, clinical presentation, diagnostic methods, and histopathologic findings in 27 cases of endometrial cancer in polyps.

METHODS

A descriptive, retrospective study of 204 consecutive patients with endometrial carcinoma who were diagnosed at our institution between June 1998 to June 2001. Endometrial cancer arising in polyps occurred in 27 patients (13.2%) and accounted for 1.8% of 1492 endometrial polyps diagnosed during this period.

RESULTS

Patients had a mean age of 62 years. All except one woman were postmenopausal. Three breast cancer patients were currently given tamoxifen. Metrorrhagia was the presenting symptom in 74% of cases, although 22% of patients were asymptomatic at the time of diagnosis. Ultrasonography performed in 22 patients showed images compatible with an endometrial polyp in 50% of cases, myoma in 5%, and inconclusive findings in 45%. The median endometrial thickness was 11 mm (range 4-33 mm). Diagnosis was made by aspiration-biopsy in 13 patients and by hysteroscopic endometrial sampling in 13 (in one patient endometrial carcinoma was incidentally found in the surgical specimen). All patients were in FIGO Stage IA. Endometrioid carcinoma was found in 81.5% of cases. Retroperitoneal metastases were not found in 25 patients undergoing pelvic lymphadenectomy, nor neoplastic growth in the specimens of six polypeptomies performed during hysteroscopy. All patients are free of relapse after a mean follow-up of 30 months.

CONCLUSIONS

Postmenopausal women with endometrial polyps diagnosed by ultrasonography should undergo directed biopsies under hysteroscopic vision. The present series confirms the good prognosis of endometrial cancer in polyps.

Case report: adenosquamous carcinoma of the liver successfully treated with repeated transcatheter arterial infusion chemotherapy (TACE) with degradable starch microspheres

This report describes a 58-year-old female with adenosquamous carcinoma (ASC) of the liver presenting with right lower abdominal pain. In most ASC of the liver, surgery is the first choice of treatment. However, surgery often seems to be ineffective because of the aggressive behaviour of this disease. At surgical laparotomy in the present case, there was a large tumour occupying the entire right lobe of the liver and invading the diaphragm. Thus, partial hepatectomy was performed. For the residual tumour, we performed repeated transcatheter arterial infusion chemotherapy with degradable starch microspheres (DSM). After four sessions of transcatheter arterial infusion chemotherapy, tumour size decreased remarkably and tumour markers had also decreased. Despite the poor prognosis, the patient remains alive and well 12 months after laparotomy. It is suggested that minimally invasive transcatheter infusion chemotherapy with DSM can be an effective treatment preserving a high quality of life.

Effect of endoscopic ultrasonography on the management of 100 consecutive patients with oesophageal and junctional carcinoma

BACKGROUND

Endoscopic ultrasonography (EUS) offers very accurate tumour and node staging information for oesophagogastric cancer. The aim was to determine whether the addition of EUS directly influenced the definitive management plan for individual patients.

METHODS

Personal and staging information from 100 consecutive patients with carcinoma of the oesophagus or oesophagogastric junction were summarized and blinded. Three consultant oesophagogastric surgeons independently made a management decision for each patient, in the presence and absence of the EUS data. All scored their perceived value of the EUS staging data for each patient.

RESULTS

EUS was deemed useful in 63-87 per cent of patients and its addition resulted in an increased number of concordant management plans (from 53 to 62 per cent), and increased agreement between surgeons. The greatest change in concordant management was an increased referral of patients for non-surgical palliation.

CONCLUSION

The addition of EUS to the staging of patients with oesophageal and oesophagogastric junction cancer significantly altered the management strategy for some of these patients.

FDG-PET lymph node staging and survival of patients with FIGO stage IIIb cervical carcinoma

PURPOSE

To evaluate the outcome of patients with International Federation of Gynecology and Obstetrics (FIGO) clinical Stage IIIb cervical carcinoma as a function of site of initial regional lymph node metastasis as detected by 2[18F]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET).

METHODS AND MATERIALS

Forty-seven patients with FIGO Stage IIIb cervical cancer were evaluated before therapy with whole-body FDG-PET. Most patients were treated with external beam irradiation, intracavitary brachytherapy, and weekly cisplatin for six cycles. Overall and cause-specific survival rates were calculated by the Kaplan-Meier method.

RESULTS

The pretreatment whole-body FDG-PET demonstrated that all patients had FDG uptake in the cervix. Of 47 patients, 13 (28%) had no evidence of lymph node metastasis, 20 (43%) had metastasis to pelvic lymph nodes only, 7 (15%) had pelvic and para-aortic lymph node metastases, and 7 (15%) had metastases to pelvic, para-aortic, and supraclavicular lymph nodes. The 3-year estimate of cause-specific survival was 73% for those with no lymph node metastasis, 58% for those with only pelvic lymph node metastasis, 29% for those with pelvic and para-aortic lymph node metastases, and 0% for those with pelvic, para-aortic, and supraclavicular lymph node metastasis (p = 0.0005).

CONCLUSION

The cause-specific survival for patients with FIGO Stage IIIb carcinoma is highly dependent on the extent of lymph node metastasis as demonstrated by whole-body FDG-PET.

Posttherapy surveillance monitoring of cervical cancer by FDG-PET

PURPOSE

To evaluate the effect of irradiation and chemotherapy for carcinoma of the uterine cervix on posttreatment tumor uptake of the glucose analog (18)F-fluorodeoxyglucose (FDG) imaged by positron emission tomography (PET) and to assess the utility of FDG-PET for surveillance monitoring.

MATERIALS AND METHODS

This was a retrospective review of 76 patients with a new diagnosis of carcinoma of the uterine cervix who underwent pre- and posttreatment whole-body FDG-PET. Posttreatment FDG-PET was performed 2.4-10.4 months (median 4.2) after irradiation completion.

RESULTS

After treatment, persistent abnormal FDG uptake in the cervix was found in 18% (14 of 76), in the pelvic lymph nodes in 16% (9 of 55), in the paraaortic lymph nodes in 45% (5 of 11), and in the supraclavicular lymph nodes in 75% (3 of 4). Eleven patients developed new sites of increased FDG uptake. In relation to the findings on posttreatment PET, the 2-year progression-free survival rate was 86% for patients with no abnormal FDG uptake at any site and 40% for those with persistent abnormal uptake; there were no survivors at 2 years among patients who developed new sites of abnormal FDG uptake (p <0.0001). A multivariate analysis of prognostic factors demonstrated that any posttreatment abnormal FDG uptake (persistent or new) was the most significant prognostic factor (p <0.0001) for death from cervical carcinoma.

CONCLUSIONS

FDG-PET is a valuable tool to evaluate the response of primary cervical carcinoma and lymph node metastasis to treatment and for the surveillance of patients after initial therapy.

Spontaneous regression of a metastatic liver tumor: report of a case

A 60-year-old man, who suffered from advanced rectal cancer accompanied with liver metastasis, underwent an abdominoperineal resection and a partial hepatectomy. He remained well until 4 months after surgery when he developed a biopsy-proven recurrent intrapelvic mass and multiple liver tumors. At 6 months after surgery, the metastatic liver tumors grew larger and almost completely occupied both lobes of the liver. However, 9 months after surgery, the liver tumors regressed remarkably and his clinical condition improved without any specific treatment for cancer. Although he died of cancerous peritonitis 18 months after surgery, the autopsy findings did not indicate any apparent regrowth of the liver tumors. To date, only one case report of a spontaneous regression of a metastatic liver tumor from colorectal cancer has been published in the English literature. We herein describe this rare case and discuss some of the reasons potentially responsible for the regression.