Unresectable hepatocellular carcinoma treated with radiotherapy and/or chemoembolization

The purpose of our study was to evaluate the outcome, patterns of failure, and toxicity for patients with unresectable hepatocellular carcinoma (HCC) treated with radiotherapy, transcatheter arterial chemoembolization (TACE), or combined TACE and radiotherapy. Forty-two patients with unresectable HCC were treated with combined radiotherapy and TACE (TACE+RT group, 17 patients), radiotherapy alone (RT group, 9 patients), or with TACE alone (TACE group, 16 patients). Mean dose of radiation was 46.9 +/- 5.8 Gy in a daily fraction of 1.8 to 2 Gy, directed only to the cancer-involved areas of the liver. TACE was performed with a combination of Lipiodol, doxorubicin, cisplatin, and mitomycin C, followed by Gelfoam or Ivalon embolization. Tumor size was smaller in the TACE group (mean: 5.4 cm) compared with the TACE+RT group (8.6 cm) and the RT group (13.1 cm) (P = 0.0003). The median follow-up was 24 months in the TACE+RT group, 28 months in the RT group, and 23 months in the TACE group. Survival was significantly worse for patients treated with radiotherapy alone due to the selection bias of patients with more advanced disease and compromised condition in this group. In contrast, the TACE+RT and TACE groups had comparable survival (two-year rates: TACE+RT 58%, TACE 56%, P = 0.69). The local control rate for the treated tumors was similar in the TACE+RT and TACE groups (P = 0.11). The intrahepatic recurrence outside the treated tumors was common and similar between these two groups (P = 0.48). The extrahepatic progression-free survival was significantly shorter for patients in the TACE+RT group than in the TACE group (two-year rates: TACE+RT 36%, TACE 100%, P = 0.002). Seven patients died from complications of treatment. Local radiotherapy may be added to treat patients with unresectable HCC, and the control of progression of the treated tumors was promising even in patients with large hepatic tumors. Survival of patients with combined TACE and radiotherapy was similar to that with TACE as the only treatment, while a significant portion of the patients treated with radiotherapy developed extrahepatic metastasis.

Local radiotherapy with or without transcatheter arterial chemoembolization for patients with unresectable hepatocellular carcinoma

PURPOSE

To evaluate the treatment outcome, patterns of failure, and prognostic factors for patients with unresectable hepatocellular carcinoma (HCC) treated with local radiotherapy alone or as an adjunct to transcatheter arterial chemoembolization (TACE).

METHODS AND MATERIALS

From March 1994 to December 1997, 25 patients with unresectable HCC underwent local radiotherapy to a portion of the liver. Twenty-three patients were classified as having cirrhosis in Child-Pugh class A and 2 in class B. Mean diameter of the treated hepatic tumor was 10.3 cm. Mean dose of radiation was 46.9 +/- 5.9 Gy in a daily fraction of 1.8-2 Gy. Sixteen patients were also treated with Lipiodol and chemotherapeutic agents mixed with Ivalon or Gelfoam particles for chemoembolization, either before and/or after radiotherapy. Percutaneous ethanol injection therapy (PEIT) was given to one patient. All patients were monitored for treatment-related toxicity and for survival and patterns of failure.

RESULTS

In a median follow-up period of 23 months, 11 patients were alive and 14 dead. The median survival duration from treatment was 19.2 months with a 2-year survival of 41%. Only 3 of 25 patients had local progression of the treated hepatic tumor. The recurrences were seen within the liver or extrahepatic. The 2-year local, regional, and extrahepatic progression-free survival rates were 78%, 46%, and 39%, respectively. The local control ranked the highest. Patients with Okuda Stage I disease had significantly longer survival than those with Stage II and III (p = 0.02). Patients with T4 disease (p = 0.02) or treated with radiotherapy alone (p = 0.003) had significantly shorter survival. T4 disease (p = 0.03) and pretreatment alpha-fetoprotein level of more than 200 ng/ml (p = 0. 03) were associated with significantly worse regional progression-free survival. A significant difference was observed in both regional progression-free survival (p = 0.0001) and extrahepatic progression-free survival (p = 0.005) between patients with and without portal vein thrombosis before treatment. The presence of satellite nodules had a significantly worse impact on regional progression-free survival (p = 0.04) and extrahepatic progression-free survival (p = 0.03). Patients with hepatic tumor more than 6 cm in diameter or portal vein thrombosis tended to have shorter survival. Radiation-induced liver disease (RILD) and gastrointestinal bleeding were the most common treatment-related toxicities.

CONCLUSION

Radiotherapy is effective in the treatment of patients with unresectable HCC. Its effect appeared to be more prominent within the site to which radiation was given. The combination of TACE and radiation was associated with better control of HCC than radiation given alone, probably due to the selection of patients with favorable prognosis for the combined treatment. A dose-volume model should be established in the next phase of research in the treatment of unresectable HCC.

Cerebral perfusion SPECT in transient ischemic attack

PURPOSE

The purpose of our study is to evaluate the efficacy of cerebral perfusion single photon emission computerized tomography (SPECT) in patients with transient ischemic attack (TIA).

METHODS

Thirty-seven patients with TIA were collected for study. All patients had transient focal neurological symptoms or signs with complete recovery within 24 h after onset. The patients underwent cerebral perfusion SPECT between 6 h and 11 days after onset, with 10 cases performed within 24 h (group A), nine cases performed between 1 and 3 days (group B), 11 cases performed between 3 and 5 days (group C), and seven cases performed after more than 5 days (group D). A semi-quantitative method was used for analyzing the SPECT data, and the difference ratios between lesion side and contralateral normal side were calculated on each pair of regions of interest.

RESULTS

In total, 78.4% (29/37) of patients had reduced perfusion in the cerebral cortical regions or deep nuclei, and the regions with reduced perfusion corresponded with clinical presentations of the patients. The abnormal rate with reduced perfusion was 90.0% in group A, 77.8% in group B, 72.7% in group C and 71.4% in group D. Cross cerebellar diaschisis (CCD) was present in seven patients, and all of the primary cerebral perfusion defects of these patients were located at the territory of left or right middle cerebral artery.

CONCLUSION

Cerebral perfusion SPECT is a potential tool to detect cerebral perfusion defects and CCD in patients with TIA. Although the perfusion defect may persist more than 5 days after onset, we suggest cerebral perfusion SPECT should be performed as soon as possible.

Central representation of phantom limb phenomenon in amputees studied with single photon emission computerized tomography

To explore the possible mechanisms of phantom limb discomfort after amputation, three amputees with phantom limb pain were studied. This study examined the change of regional cerebral blood flow using technetium-99m hexamethylpropyleneamine oxime-single photon emission computerized tomography, which was arranged at the time of severe phantom limb discomfort and after the discomfort subsided or was completely relieved. Nine representative transverse slices parallel to the orbitomeatal line were selected for quantification. The cortical ribbon (2-cm thickness) was equally subdivided into 12 symmetrical pairs of sector regions of interest in each slice. The irregularly shaped regions of interest were drawn manually around the right thalamus and basal ganglion and then mirrored to the left thalamus and basal ganglion. The contralateral to ipsilateral ratio of regional cerebral blood flow for each area was calculated. The intensity of phantom limb pain was evaluated on a 0 to 10 visual analog scale. In Cases 1 and 2, the contralateral to ipsilateral regional cerebral blood flow ratios of multiple areas of the frontal, temporal, or parietal lobes were increased at the time of more severe phantom limb pain, and the ratios were normalized or even decreased when the phantom limb pain subsided. In Case 3, increased contralateral to ipsilateral regional cerebral blood flow ratios were also found over the frontal, temporal, and parietal lobe. However, most of the increased regional cerebral blood flow ratios of regions of interest in the first study persisted in the follow-up study. Also, the regional cerebral blood flow ratios of greater number of regions of interest of the same gyrus and new gyrus were increased. There was no significant right-left difference of regional cerebral blood flow over bilateral thalami and basal ganglia in all three cases. The results suggested that phantom limb pain might be associated with cortical activation involving the frontal, temporal, or parietal cortex, and it may imply the possibility of the existence of an ascending polysynaptic pathway that conveys the uncomfortable phantom limb sensation to the cerebral cortex. These findings may also indicate that reorganization of the cortical blood flow occurs in amputees. However, it is still difficult to conclude that the changes in regional cerebral blood flow were attributable directly to pain. With no comparison group of amputees and because of the small number of cases, it is hard to generalize about cerebrocortical involvement in phantom pain, and it is possible that the findings represent a normal phenomenon seen after 'amputation. Another possibility is that the findings represent increased arousal caused by pain rather than an intrinsic pain pathway. Further study is worthwhile.

Quantitative cerebral perfusion SPECT in systemic lupus erythematosus with severe central nervous involvement--before and after methylprednisolone pulse therapy

Severe cerebral involvement may occur in patients with systemic lupus erythematosus. Methylprednisolone pulse therapy is a management choice for those with severe cerebral involvement. However, its effectiveness is uncertain. This article describes Tc-99m HMPAO cerebral perfusion single-photon emission computerized tomography to document the restoration of cerebral perfusion after methylprednisolone pulse therapy in a case of systemic lupus erythromatosus with severe cerebral manifestations.

False-positive whole-body iodine-131 scan due to intrahepatic duct dilatation

Focal retention of radioactivity in the liver on whole-body 131I scan was interpreted as a metastatic lesion in a patient with well-differentiated thyroid cancer. Intrahepatic duct dilatation, usually resulting from biliary tract obstruction by bile stone, is a common disorder and may cause bile stasis. A patient with papillary thyroid cancer and a previous history of biliary tract stones had focal retention of radioactivity in the liver on whole-body 131I scan. Abdominal CT, endoscopic retrograde cholagiopancreatography, radionuclide cholangiography and sequential 131I scans demonstrated that this focal retention of radioactivity was caused by intrahepatic duct dilatation. Focal retention of radioactivity is visualized on delayed images but not on early images. The radioactivity initially increases and then decreases on following days.

99Tcm-MDP scintigraphy in high-voltage electrical burn patients

In high-voltage electrical burn injuries (> 1000 V), it is difficult to identify the site and extent of non-viable deep tissue damage for debridement to avoid further tissue injury from wound infection and the risk of sepsis. This prospective study was designed to evaluate the usefulness of 99Tcm-methylene di-phosphonate (99Tcm-MDP) scintigraphy in detecting the extent of tissue injury and determining the level of amputation required for electrical burn patients. Over a 5 year period, 33 high-voltage electrical burn patients were studied. Blood flow and blood pool studies revealed absent perfusion in 37 limbs, all of which eventually were amputated. In addition to a routine three-phase bone scan, images were obtained at 30-60 min (early images) to evaluate whether soft tissue injury could be detected better at that time. For comparison of the detection rate from the early images and bone (delayed) images, 164 corresponding spot views of both images were reviewed. Eighty-three and 125 tissue necrotic lesions were demonstrated by the early images and bone images respectively. All of the 83 lesions found by the early images were more clearly identified by the bone images. All but one of the 125 lesions underwent surgical debridement or amputation. We concluded that the blood flow and blood pool images correlated well with the level of amputation required. The site and extent of tissue necrotic lesions can be clearly identified on 99Tcm-MDP bone scans. Because the early images were less sensitive in detecting tissue necrosis, we suggest that early imaging is not necessary.

Serial single photon emission computed tomography imaging in patients with cerebral lupus during acute exacerbation and after treatment

Single photon emission computed tomography (SPECT) with [99mTc] HMPAO was performed sequentially every week in 4 patients with systemic lupus erythematosus (SLE), from the acute phase of neurologic involvement until normal cerebral blood flow (CBF) was detected by the scan. SPECT accurately reflects central nervous system (CNS) abnormalities in patients with SLE and correlates with subsequent improvement. Correlated with the patients' rapid clinical improvement, the brain SPECT blood flow scan demonstrated homogeneous distribution in 1 to 9 weeks. In these four patients, the defect in CBF could be reversed by optimal treatment. Brain SPECT blood flow scan may be used as a biologic marker of pathologic activity in the brain of patients with SLE.

Cerebral sparganosis: increased uptake of technetium-99m-HMPAO

Cerebral sparganosis is an extremely rare intracranial parasitic infectious disease. We report findings of 99mTc-HMPAO cerebral perfusion SPECT in a case with cerebral sparganosis. SPECT revealed an irregularly shaped area with markedly increased 99mTc-HMPAO uptake in the parasitic infectious region of the cerebrum. Both white and gray matter was involved, the white matter involved predominantly. Decreased perfusion to the right cerebellum, suggesting cross cerebellar diaschisis, was also demonstrated. This article illustrates that cerebral sparganosis is one of the causes of increased 99mTc-HMPAO uptake in the cerebrum and should be considered clinically if present.

Diuretic renography findings in enterovesical fistula

A 73-year-old male presented with a 2 week history of gross haematuria and faecal material in the urine. Bone scan for cancer work-up showed 99T(cm)-MDP radioactivity accumulation in the transverse and descending colon. A 99T(cm)-DTPA diuretic renogram was arranged to study renal function and to determine the location of the enterovesical fistula. Diuretic renography demonstrated extraurinary tract radioactivity in the sigmoid colon in the early images, extending to the descending and transverse colon in the subsequent dynamic images. A sigmoid colon adenocarcinoma with bladder wall invasion and fistula formation was confirmed at surgical operation. The impressive dynamic diuretic renography study in this patient was helpful in determining the location of the fistula and in planning surgical management.

The clinical significance of gall-bladder non-visualization in cholescintigraphy of patients with choledochal cysts

Intravenous radionuclide cholescintigraphy (IVRC) provides a very specific picture for choledochal cysts. However, the clinical significance of the non-visualization of the gall-bladder (GB) activity in these cases is unclear. In this study, we reviewed 27 patients with choledochal cysts who underwent IVRC within 7 days prior to operation and correlated the GB findings on IVRC with the histopathological results. In 18 of the 27 patients (66.7%), there was non-visualization of the GB at 4 h post injection. Among these, two had histopathological features of acute cholecystitis (AC), 11 had chronic cholecystitis (CC), and five had normal GBs. In the other nine patients with visualization of the GB, there were five cases of CC and four normal GBs. If we apply the finding of non-visualization of the GB at 4 h post injection as the criterion for the diagnosis of AC, the diagnostic accuracy was only 40.7% (11/27). We concluded that: (1) GB disease (AC and CC) was common (66.7%: 7.4% and 59.3% respectively) in choledochal cyst patients. (2) Non-visualization of the GB on IVRC did not necessarily indicate AC in choledochal cyst cases, and the diagnostic accuracy was low. (3) GB disease is not the only cause of GB non-visualization on IVRC. A huge choledochal cyst causing a mass or reservoir effect may be a cause of GB compression and result in non-visualization of the GB.

Immobilization of prostaglandin synthetase by hydrophobic adsorption

In this article, the immobilization of prostaglandin synthetase on n-alkyl or aryl amino-agar beads by hydrophobic adsorption is reported. The effects of different hydrophobic groups in the agar beads, pH of buffer, concentration of salts on the adsorption of prostaglandin synthetase, and the properties of immobilized prostaglandin synthetase were also studied. The results showed that 20-35 mg of microsome containing PG synthetase (protein content 8-15 mg) could be adsorbed on each gram of n-dodecylamino-agar beads after suction drying the gel in the buffer of pH 5.5 (containing 0.5 mol/L KCl), 0.1 mol/L citric-phosphate at 4 degrees C. The remaining immobilized enzyme activity was over 80%. The optimum pH of immobilized PG synthetase is 8.0, similar to that of the native enzymes. The thermostability of immobilized PG synthetase in the buffer containing 0.5 mol/L KCl was increased. Immobilized PG synthetase was used as a catalyst of synthesis of prostaglandin E1. The preservation of activity after 10 working cycles was 86.2%.

Accumulation of Ga-67 citrate in a tuberculous splenic abscess. Report of a rare case

A case of 65-year-old man with tuberculous splenic abscess is presented. The Ga-67 citrate scan revealed three focal areas of increased uptake in the left upper quadrant of the abdomen. The combined Tc-99m SC/Ga-67 scans revealed that these Ga-67 avid lesions localized in the splenic photon-deficit areas found in the Tc-99m SC scan. This case demonstrated the usefulness of Ga-67 imaging in a survey of fever of unknown origin in unsuspected tuberculous splenic abscess.

Serial regional blood flow and visual evoked responses in transient cortical blindness

Normal regional blood flow was documented by Single Photon Emission Computed Tomograms 5 and 20 hours before the full recovery of cortical blindness in two patients, lending itself to the possibility of being a prognostic factor. Rubbing of the posterior cerebral arteries against the tentorial edges during trauma instead of traction was believed to cause blindness in one patient and embolization due to hammering bone grafts home during cervical spinal fusion, in the other. Pattern reversal visual evoked responses (PRVERs) were absent during blindness; upon recovery P 100 with full amplitude and normal latency appeared despite the presence of tunnel vision. These are consistent with the fact that the central 8-10 degrees of visual field represented in the posterior occipital poles being the main sources of P 100 in association with the x-cells in the centre of the retina.

[Using 131I-MIBG and 99mTc-MDP bone scan for localization of rare extra-adrenal pheochromocytomas: report of 2 cases]

It is difficult, but important, to diagnose extra-adrenal pheochromocytomas before surgery. Failure to recognize the existence and nature of an extra-adrenal pheochromocytoma can cause life-threatening problems even in a minor surgical operation. We present two rare cases of extra-adrenal pheochromocytomas which were detected by 131I-MIBG scintigraphy. One of them was intrapericardial, and the other was a vesical pheochromocytoma. We used a combined 99mTc-MDP bone scan and 131I-MIBG scintigraphy to locate the pheochromocytomas. Both cases of extra-adrenal pheochromocytoma were correctly diagnosed preoperatively and successfully resected in the subsequent operations.