The Diagnostic Accuracy of MRI in Rectal Mucinous Carcinoma

ope

Radionuclide Therapy of Skin Cancers and Bowen's Disease Using a Specially Designed Skin Patch

Skin cancer is the most common malignancy in humans. Therapeutic modalities for skin cancer are local destruction, radiotherapy and surgery. External radiation therapy leads to good results, however, generally 5-6 wk of treatment is needed to deliver optimal radiation dose to tumors. In this study, a beta-emitting radionuclide, 166Ho, impregnated in a specially designed patch, was used on superficial skin cancers and Bowen's disease for local irradiation. METHODS: Ten mice with chemically induced skin tumors were studied. Five-millimeter size patches containing 22.2-72.15 MBq (0.6-1.95 mCi) 166Ho were applied to the tumor surface for 1-2 hr. In a human trial, patients with squamous-cell carcinoma (n = 3), basal cell carcinoma (n = 1) and Bowen's disease (n = 1) were treated with patches containing 273.8-999 MBq (7.4-27 mCi) of 166Ho for 30 min to 1 hr. Pathologic examination was performed 4-7 wk after treatment in an animal model. Skin biopsy was performed 8 wk post-treatment in four patients. RESULTS: Tumor destruction was seen 1 wk post-treatment, however, radiation dermatitis or ulceration developed at the site of radionuclide application. Those reactions healed gradually with fibrosis or epithelialization, which was confirmed pathologically. No significant adverse reaction to radiation except subcutaneous fibrosis was found. CONCLUSION: Superficial skin tumors could be successfully treated by topical application of beta-emitting radionuclides.ope

Two cases of Vessel invasion of Hepatocellular carcinoma

Despite growing information on the clinical behavior of hepatocellular carcinoma(HCC), the histologic features associated with survival are not well characterized. Several different staging systems are suggested for use in predicting the prognosis of HCC. American Joint Committee on Cancer/International Union Against Cancer Staging System (AJCC/UICC) 6th edition divided T stages according to vessel invasion, T1 without microvessel invasion, T2 showing microvessel invasion and T3 showing major vessel invasion. The vessel invasion is generally considered a poor prognostic factor for HCC. Our report of the two patients with HCC run along similar terms. The patient diagnosed HCC with microvessel invasion underwent left lateral sectionectomy. Although the presence of microvessel invasion was found, this patient has survived without any recurrence for over 5 years now. The other patient underwent S8 segmentectomy and lived 10 years disease-free. After 10 years, although an intrahepatic recurred HCC successfully treated with local therapy, the recurred and newly developed multiple lesions were found again leading to a decision to perform operation. The HCC invaded into the portal vein and constituted portal vein thrombosis. The patient expired after 3 months postoperatively due to intrahepatic dissemination of the tumor. Therefore the impact of the vascular invasion on long-term survivors remains to be determined.ope

Long-term Clinical Outcome of Phase IIb Clinical Trial of Percutaneous Injection with Holmium-166/Chitosan Complex (Milican) for the Treatment of Small Hepatocellular Carcinoma

PURPOSE: The purpose of this study was to evaluate the long-term tumor response after phase IIb clinical study and the safety of percutaneous holmium-166 ((166)Ho)/chitosan complex injection (PHI) therapy for small hepatocellular carcinoma as a local ablative treatment. (166)Ho is a radioactive isotope derived from natural holmium-165. We developed a (166)Ho/chitosan complex (Milican, Dong Wha Pharmaceutical Co., Seoul, Korea) using chitosan as a vehicle to retain the radioactive material within the tumor. EXPERIMENTAL DESIGN: Forty patients with single hepatocellular carcinoma < 3 cm in maximal diameter were enrolled in this study. The patients either had refused surgery or were poor surgical candidates and were treated with only single session of PHI. RESULTS: Two months after PHI, complete tumor necrosis was achieved in 31 of 40 patients (77.5%) with hepatocellular carcinoma lesions < 3 cm and in 11 of 12 patients (91.7%) with hepatocellular carcinoma < 2 cm. Tumors recurred in 28 patients during the long-term follow-up period, of which 24 recurred at another intrahepatic site. The 1-year and 2-year cumulative local recurrence rates were 18.5% and 34.9%, respectively. The survival rates at 1, 2, and 3 years were 87.2%, 71.8%, and 65.3%, respectively. Transient bone marrow depression was serious adverse event requiring hospitalization in two patients. CONCLUSIONS: PHI was found to be a safe and novel local ablative procedure for the treatment of small hepatocellular carcinoma and could be used as a bridge to transplantation. A phase III randomized active control trial is clearly warranted among a larger study population.ope

Long-term therapeutic effects of partial splenic embolization on secondary hypersplenism

Background: Liver cirrhosis causes secondary hypersplenism and thrombocytopenia is clinically troublesome. Splenectomy (SPL) was thought to be the curative management for correcting thrombocytopenia. However, decompensated liver function prevents any surgical approach due to high morbidity and mortality. Hence, partial splenic embolization (PSE) has been introduced, which is a less invasive procedure. The purpose of this study was to assess the long-term therapeutic effects of PSE and to compare them with those of SPL. Methods: This study was performed retrospectively in patients who underwent PSE or SPL from Jan. 1999 to Dec. 2003. The patients either had symptoms of bleeding or they needed to correct their thrombocytopenia for further treatment of associated diseases. The therapeutic effects were evaluated, and the complications were assessed. Results: Forty and 35 patients were enrolled in the PSE and SPL groups, respectively. WBC, platelet and hemoglobin counts were all significantly increased at the 2 year follow-up in both groups. Child-Pugh score significantly decreased in the PSE group from 6.5 before treatment to 5.5 after treatment (p=0.004). Minor complications were easily controlled with supportive care, and major complications very rarely occurred in both groups. Conclusions: PSE and SPL both proved to be effective measures with few serious complications for treating pancytopenia in patients with liver cirrhosis. Considering the improved liver function (the prothrombin time) and the Child-Pugh score after PSE, it may be more reasonable to initially recommend PSE for the patients with liver cirrhosis and secondary hypersplenism.ope

Risk factors of acute hepatic failure associated with transcatheter arterial chemoembolization for hepatocellular carcinoma

Background : Transcatheter Arterial Chemoembolization (TACE) has been the most widely used treatment for advanced hepatocellular carcinoma (HCC) in Korea. However a number of complications associated with TACE have been reported in many studies. Acute hepatic failure is one of the most serious complications of TACE, because of its grave prognosis. The aim of this study was to investigate the risk factors associated with acute hepatic failure after TACE. Methods : A total of 263 TACE procedures performed in 163 patients with HCC were included in this study. We reviewed retrospectively the complications that occurred after TACE and analysed the risk factors associated with acute hepatic failure after TACE. Results : Complications included post-embolization syndrome (187 cases), temporary hepatic insufficiency (90 cases), acute hepatic failure (13 cases), hepatic arterial injury (9 cases), intrahepatic biloma (4 cases), liver infarction (2 cases), liver abscess (2 cases), tumor rupture (1 cases), gastrointestinal bleeding (14 cases), septicemia (3 cases), gall bladder infarction (2 cases), thrombocytopenia (2 cases), gastric perforation (1 cases), pneumonia (1 cases), urticaria (1 cases), sensorineural hearing loss (1 cases), femoral artery aneurysm (1 cases). According to univariate analysis, risk factors associated with acute hapatic failure after TACE were serum bilirubin and albumin, prothrombin time, dose of adriamycin, pre-TACE Child-Pugh class, tumor size, diffuse tumor type, portal vein thrombosis and TNM stage. Multivariate analysis revealed that serum bilirubin {odd ratio=3.86 (95% CI: 1.59-9.32)}, and diffuse tumor type {odd ratio=5.29 (95% CI: 1.46-23.86)} were statistically significant risk factors. Conclusions : It is recommended that above mentioned risk factors should be considered carefully before TACE to prevent the occurrence of acute hepatic failure after TACE in HCC patients.ope

A Pilot Study of Trans-Arterial Injection of 166Holmium-Chitosan Complex for Treatment of Small Hepatocellular Carcinoma

Percutaneous approaches, such as percutaneous ethanol injection and radiofrequency ablation, have been most widely used for hepatocellular carcinoma patients who were not eligible for surgery. New technologies to improve the efficacy are currently needed. 166Holmium is a neutron activated radionuclide, and has several beneficial radiophysical characteristics for internal radiation therapy. 166Holmium-Chitosan complex, in which chitosan is chelated with 166Holmium, was developed as a radiopharmaceutical for cancer therapy. We have conducted a pilot study to evaluate the clinical efficacy of transarterial administration of 166Holmium-Chitosan complex in patients with a single and small (< 3 cm) hepatocellular carcinoma. 166Holmium-Chitosan complex, at a dose of 20 mCi per cm of tumor mass-diameter, was administered through the artery that directly fed the tumor. Twelve patients were treated with a median follow-up duration of 26 (range: 12-61) months. The tumor diameter ranged between 1.5 and 2.5 cm. Ten patients (83%) had complete response and two (17%) had partial response. The median complete response duration was not reached. The median AFP level declined from 83.8 to 8.3 ng/mL within 2 months after treatment. No grade III/IV toxicity was observed. Grade I and II toxicities were observed in four patients (2 abdominal pain, 1 fever, and 1 AST/ALT elevation). No toxic death occurred. This preliminary study shows a promising and durable complete response rate with an acceptable safety profile. Further studies with greater accrual of patients are warranted.ope

Radiological observation of external carotid artery in Korea

의학과/석사[한글] 경 두부 병변의 진단방법으로 외경동맥 조영촬영은 임상적으로 중요한 이용가치를 가지고 있다. 특히 경 두부의 종양의 조기진단 치료의 적절을 기하는데 큰 역할을 하게 된다. 이를 위하여는 먼저 외경동맥의 정상분포 상태가 정확히 파악되야 할 것이다. 저자는 총경동맥 천자술로 내 외경동맥이 동시 조영된 106예를 선택하여 외경동맥과 주 분지의 기시와 형상변형, 전시율 및 외경동맥 기시부로부터 주 분지의 기시부까지 거리를 계측하여 다음과 같은 결과를 얻었다. 1. 외경동맥의 기시분는 제3 및 제4 경추사이가 가장 많아 52.8%의 비율이고 주행상은 연령에 따라 상당한 변화를 보이고 있었다. 2. 상갑상선동맥은 외경동맥으로부터 기시하는 경우가 49.5%로 가장 많았다. 3. 상갑상선동맥, 설동맥 및 안면동맥은 외경동맥 기시부로부터 공히 1cm 이상 2cm 미만 거리의 외경동맥에서 기시하나 서로 다른 부위로부터 기시하는 경우가 78.3%로 가장 높은 빈도를 보였다. 4. 상행인두동맥은 59.8%에서 전시되었고 외경동맥과 후두동맥으로부터 기시하는 경우가 가장 많았다. 5. 안면횡동맥은 72.1%에서 전시되었고 외경동맥과 천측두동맥으로부터 기시하는 경우가 가장 많았다. 6. 상악동맥은 외경동맥 기시로부터 5cm 이상 7cm 미만 거리의 외경동맥 종지가 되는 경우가 69%로 가장 많고 주행상은 대부분 수평으로 놓은 "S"상을 하고 있었다. 7. 부중경뇌막동맥은 18%에서 전시되었다. 8. 후이개동맥과 천측두동맥의 두개부 전시율은 각각 69.5% 및 72.1%로 나타났다. 9. 중경뇌막동맥은 상악동맥 기시부로부터 0.5cm 이상 1cm 미만 거리의 상악동맥으로부터 기시하는 경우가 57.6%로 가장 많고 두개부 전시율은 29.5%정도에 불과하였다. [영문] The external carotid arteriogram is useful in the diagnosis of head and neck disease, however, clinically has not been widely used in contrast with the internal carotid anteriogram of intracranial lesion. It is due to the shape of branches of external carotid artery being variable according to underlying mechanical factors in the normal condition and is the diagnosis of head and neck lesion has been established easily by other clinical methods. Recently the external carotid arteriogram is valuable for the detection, location and extension of the head and neck lesion, especially in case of early and small malignant lesion. For these reasons the normal distribution and variation of branches of external carotid artery should be analysed to fulfill these purposes. In this study the selected external carotid arteriogram of 106 cases which had been performed by puncture of common carotid artery, was conjoined. Therefore, the purpose of this study is an analysis of shape and origination of the main branches of external carotid artery, visualization rate of the branches of external carotid artery and direct distance measurement from the root of external carotid artery to the main branches by common carotid artery injection. The results were as follows: 1. The bifurcation level of common artery is C^^3 - C^^4 in 52.8%, C^^2 - C^^3 in 34.9% and C^^4 - C^^5 in 10.4%(range: C^^2 - C^^6). 2. The shape of external carotid artery is variable and frequently appears straight and curved in the young adult before 4th decade, whereas appears waved and arch in the older age group. This fact suggest the arteriosclerotic changes of blood vessel by aging process. 3. The superior thyroidal artery arises from the external carotid artery in 49.5% and from the common carotid artery in 23.8%. 4. The variable originations of superior thyroidal, lingual and facial artery are the normal origination in 78.3%, the lingofacial common trunk in 16.1%, the thyroilingual common trunk in 3.7% and the thyrolingofacial common trunk in 1.9%. 5. The ascending pharyngeal artery arises from the external carotid artery in 24.6%, from the occipital artery in 23.5%, from the root of occipital artery in 9.8%, and from the internal carotid artery in 1.9%. 6. The transverse facial artery arises from the external carotid artery in 27.9%, from the superficial temporal artery in 21.2%, and from the maxillray artery in 10.5%. 7. The roentgen-anatomical shape of maxillary artery is divided by three part; 1st part of mandibular, 2nd part of pterygoid and 3rd part of spheno-maxillary. The most frequent shape of each part of maxillary artery is convex in 78.4% of mandibular, oblique straight in 45.8% and oblique convex in 35.2% of pterygoid and ill-defined variable shapes of sphenomaxillary. 8. The visualization of main branches of external carotid arteriogram by the common carotid artery injection is in 69.5% of posterior auricular, 70.5% of the cranial part of superficial temporal, 29.5% of the cranial part of middle meningeal and 72.1% of transverse facial artery. 9. The accessory middle meningeal artery observed in 18% of total 105 cases. 10. The distance from the root of external carotid artery to the origination of main branches is 1) in the range of 5-6cm in 33%, 6-7cm in 26% of the maxillary artery, 2) in the range of 1-2cm in 47.2% and 2-3cm in 25.2% of the occipital artery. 3) in the range of 1-2cm in 54% and 2-3cm in 30.6% of the facial artery and 4) in the range of 1-2cm in 55.6% and 0-1cm in 24.7% of the lingual artery in order frequency. (range; 0-7cm). 11. The origination of middle meningeal artery is in the range of 0.5-1cm in 57.6% from the root of maxillary artery in the most frequency and arises from the root of maxillary artery in 10.2%.restrictio

Virtual Colonscopy with Electron Beam CT ; Correlation with Barium Enema, Colonoscopy and Pathology

Purpose : To perform virtual colonoscopy using electron beam tomography(EBT) in patients in whom a colonic mass was present, and to compare the results with those obtained using barium enema, colonoscopy and gross pathologic specimens. Materials and Methods : Ten patients in whom colonic masses were diagnosed by either barium enema or colonoscopy were involved in this study. There were nine cases of adenocarcinoma and one of tubulovillous adenoma. Using EBT preoperative abdominopelvic CT scans were performed. Axial scans were then three-dimensionally reconstructed to produce virtual colonoscopic images and were compared with barium enema, colonoscopy and gross pathologic specimens. Virtual colonoscopic images of the masses were classified as either 1) polypoid, 2) sessile, 3) fungating, or 4) annular constrictive. We also determined whether ulcers were present within the lesions and whether there was obstruction. Results : After virtual colonoscopy, two lesions were classified as polypoid, one as sessile, five as fungating and two as annular constrictive. Virtual colonoscopic images showed good correlation with the findings of barium enema, colonoscopy and gross pathologic specimens. Three of six ulcerative lesions were observed on colonoscopy; in seven adenocarcinomas with partial or total luminal obstruction, virtual colonoscopy visualized the colon beyond the obstructed sites. In one case, barium contrast failed to pass through the obstructed portion and in six cases, the colonoscope similarly failed. Conclusion : Virtual colonoscopies correlated well with barium enema, colonoscopy and gross patholoic specimens. They provide three dimensional images of colonic masses and are helpful for the evaluation of obstructive lesions.ope

Experimental and Clinical Studies on the Intraarterial Injection of Holmium-166 Chitosan Complex in the Treatment of Hepatocellular Carcinoma

PURPOSE: The purposes of this study were to evaluate the biodistribution and effect of Ho-166 radionuclide by intra-arterial injection of the Ho-166 chitosan complex in dogs and to assess the clinical efficacy and side effects of this complex in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: In an experimental study, 20 mCi of Ho-166 chitosan complex was injected into the left hepatic artery of six adult dogs. The distribution of radioactivity in each organ was calculated using a gamma camera scan at regular intervals. A beta ray radioactivity count (cpm) of blood and urine was performed periodically, and hematologic and hepatic function were regularly assessed. At 4, 8 and 12 weeks after intra-arterial injection, bone marrow and liver were pathologically evaluated. Twenty-five patients with a single, nodular HCC mass 3 -9 cm in diameter were treated by intra-arterial injection of Ho-166 chitosan complex, and immediately after the procedure a gamma camera scan was obtained. A beta ray radioactivity count(cpm) of blood was performed periodically, hematologic and hepatic function were regularly evaluated, and CT scans and angiograms were obtained 3 months after the procedure. On the basis of the CT and angiographic findings, the treatment effects were classified as complete (CR), partial (PR) or non-response(NR). RESULTS: In the animal study, blood radioactivity peaked immediately after injection and then declined rapidly. Urinary excretion was 0.17%. The proportion of radioactivity in each organ per whole body was 25% in the left lobe of the liver, 7% in the right lobe, 3% in the lung, 1.4 -3% in the bladder, and 2% in bone. WBC and platelet counts declined maximally at 3 -4 weeks and recovered at 12 weeks. The cellularity of bone marrow was 25% at 4 weeks and 55% at 12 weeks, findings which correlated well with the observed hematologic changes. In the clinical study of 25 HCC patients, CR was achieved in 17 (68%) cases, PR in 5 (20%) and NR in 3 (12%). At gamma camera imaging immediately after treatment, tumor radioactivity was localized in 76% of cases. In six cases (24%) WBC and platelet counts decreased 50% or more compared with their pretreatment level. In 67 -75% of cases, SGOT and SGPT were, within 1 -3 days, 2 -3 times higher than their pre-treatment level, and recovered at post 4 weeks. CONCLUSION: Ho-166 chitosan complex administrated intra-arterially localized the target organ with minimal side effects, and we therefore suggest that it may be used in the treatment of nodular and hypervascular HCC. Further study of its dosimetry and possible hematologic side reactions is needed, however.ope