Chikazumi Kuroda

Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein.

This retrospective study attempted to determine the indications for extended pancreatectomy for locally advanced carcinoma of the pancreas, in terms of postoperative prognosis. An extended pancreatectomy with portal vein or superior mesenteric vein (PV/ SMV) resection and regional lymphadenectomy was performed in 35 of 50 consecutive cancers that extended into the retroperitoneal spaces and involved the PV or SMV. Among the many background factors in the 35 resected specimens, the degree of PV/SMV invasion by the cancer was most closely associated with prognosis, despite resection of all involved PV/SMV. This factor generally correlated with the preoperative findings on the portal phase of superior mesenteric arteriograph. In 17 selected patients in whom PV/SMV invasion had been angiographically both semicircular or less and 1.2 cm (1.4 cm on the film) or less in length, the 3-year survival rate was 59%. This survival rate was significantly higher than the 29% 3-year survival rate in all 35 patients (p < 0.05). Conversely, among the 18 patients in whom invasion was angiographically either beyond semicircular or more than 1.2 cm (1.4 cm on the film) in length, there were no 1.5-year survivors, and this result was even worse than that of 15 nonresectable cases. Based on postoperative survival, the degrees of PV/SMV invasion on preoperative angiography (narrowing pattern and length) are good indicators for aggressive pancreatectomy for locally advanced pancreatic cancer.

Transcatheter chemo‐embolization effective for treating hepatocellular carcinoma. A histopathologic study

A histopathologic study was done on livers from 14 patients who underwent surgery for hepatocellular carcinoma and who had been pretreated by a combination of intra‐arterial embolization of Gelfoam (Upjohn) plus intra‐arterial chemotherapy. This technique was effective as the excess vascularity of the tumor and the tumor bulk were reduced and resection was readily facilitated. For solitary tumors of less than 4 cm in diameter, this approach was particularly effective. As this combined treatment almost invariably leads to liquefaction and necrosis of the tumor, the likelihood of metastases is diminished.

Prospective and randomized clinical trial for the treatment of hepatocellular carcinoma — a comparison of lipiodol-transcatheter arterial embolization with and without Adriamycin (first cooperative study)

SummaryA randomized, controlled clinical trial comparing the use of lipiodol-transcatheter arterial embolization (L-TAE) in the presence versus the absence of Adriamycin (ADR) for the treatment of hepatocellular carcinoma was conducted from August 1988 through September 1989. In all, 125 Japanese hospitals participated in this study and 289 patients were entered in the trial. The patients were randomly allocated into group A (L-TAE) or group B (L-TAE+ADR) by telephone registration. There was no significant difference in background factors between group A and group B. Additional treatment, including repeated TAE or hepatic resection, was given to 189 patients. Among the four endpoints analyzed, the rate of tumor reduction and lipiodol accumulation in the tumor did not significantly differ between the two groups. The 3-year survival values for groups A and B were 33.6% and 34.9%, respectively; the difference was not significant. The serum alpha-fetoprotein level, however, decreased to a significantly greater extent in the group that received ADR than in the group that did not (P<0.05). This result suggests that ADR has some favorable additional effect in L-TAE for the treatment of hepatocellular carcinoma.

Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer

The accuracy of endoscopic ultrasonography (EUS) for diagnosis of pancreatic cancers was evaluated in consecutive 232 patients with possible pancreatic cancer, and that for assessment of their locoregional spread was evaluated in 28 patients with pancreatic cancer subjected to pancreatectomy, in comparison with the accuracies of transabdominal ultrasonography (US) and computed tomography (CT). EUS was found to be significantly more accurate than US or CT and was especially useful for detecting small pancreatic cancers of less than 2 cm in diameter. With EUS, pancreatic cancers could be detected as a hypoechoic mass with a relatively unclear margin and irregular internal echoes. EUS was also more sensitive than CT and US for detecting venous and gastric invasions: it was more useful for detecting direct invasion of pancreatic cancers when the tumors were less than 3 cm in diameter. These findings indicate that EUS is an accurate method for diagnosis of pancreatic cancer and assessment of their locoregional spread and is particularly useful for detecting small tumors.

Limitation of transcatheter arterial chemoembolization using iodized oil for small hepatocellular carcinoma. A study in resected cases

The radiologic and histologic findings are presented of the resection of 14 small hepatocellular carcinomas (HCC), less than 2 cm in maximum diameter, after transcatheter arterial chemoembolization (TCE) using iodized oil. The effect of TCE on small HCC depended on the morphologic type of the tumors. When no extracapsular invasion of tumor cells occurred, TCE was extremely effective against encapsulated tumors. However, in nine of the 14 resected specimens, viable tumor cells remained in or around the tumor. The authors suggest that small HCC are not always curable with TCE alone and that a multi‐disciplinary approach is necessary for patients with small HCC.

Fractal analysis of small peripheral pulmonary nodules in thin-section CT: evaluation of the lung-nodule interfaces.

Objectives To analyze the lung-nodule interfaces on small peripheral pulmonary nodules (<2 cm) in thin-section CT (HRCT) images with fractal analysis. Methods Thin-section CT images from 70 patients with bronchogenic carcinomas (61 adenocarcinomas and 9 squamous cell carcinomas) and 47 patients with benign pulmonary nodules (23 hamartomas, 13 organizing pneumonias, and 11 tuberculomas) were used. For calculation of fractal dimensions (FDs), the authors used a box-counting method for binary- and gray-scale images of nodules. FD(two-dimensional [2D]) was an FD obtained from the binary image, and FD(three-dimensional [3D]) was an FD obtained from the gray-scale image. Results The FD(2D)s of hamartomas were smaller than those of other nodules (P < 0.05). The FD(3D)s obtained from the gray-scale images of organizing pneumonias and tuberculomas were greater than those of bronchogenic carcinomas (P < 0.0001) and hamartomas (P < 0.0001). In bronchogenic carcinomas, FD(3D)s of adenocarcinomas were greater than those of squamous cell carcinomas (P < 0.05). Conclusions Fractal dimensions reflect the characteristics of the lung-nodule interfaces of small peripheral pulmonary nodules. The FD(2D)s revealed the irregularities of the contours. On the other hand, FD(3D)s revealed the complexities of the heterogeneous textures. With use of FD(2D) and FD(3D), it may be possible to distinguish bronchogenic carcinomas from benign pulmonary nodules. Moreover, FD(3D) may make it possible to distinguish between adenocarcinomas and squamous cell carcinomas.

Fractal analysis of internal and peripheral textures of small peripheral bronchogenic carcinomas in Thin-section computed tomography: Comparison of bronchioloalveolar cell carcinomas with nonbronchioloalveolar cell carcinomas

Purpose To analyze the internal and peripheral textures of small peripheral bronchogenic carcinomas (<2 cm) in thin-section computed tomography (HRCT) images with fractal analysis. Method Thin-section computed tomography images from 70 patients with bronchogenic carcinomas (61 adenocarcinomas and 9 squamous cell carcinomas) were used. Regions of interest (ROIs) with a matrix size of 32 × 32 (0.326 mm per pixel) were selected manually on the lung-nodule interfaces and within the nodules on HRCT images. Three-dimensional density surfaces based on CT values of ROIs were characterized by fractal dimensions (FDs). Results When all the bronchogenic carcinomas were divided into bronchioloalveolar cell carcinomas (BACs) and other bronchogenic carcinomas (nonBACs), there were significant differences between BACs and nonBACs in the FDs obtained from the internal textures (mean: 2.38 ± 0.05 versus 2.19 ± 0.05;P < 0.0001) and in the FDs obtained from the peripheral textures (mean: 2.16 ± 0.01 versus 2.06 ± 0.01;P < 0.0001). Conclusion The textures of BACs that reveal ground-glass opacities are more complicated than those of nonBACs. The FDs can differentiate between small localized BACs, which have a good prognosis, and nonBACs, which have a poor prognosis. Fractal analysis is promising for characterization of small peripheral pulmonary bronchogenic carcinomas based on radiographic features of HRCT images.

Clinical features of small hepatocellular carcinomas as assessed by histologic grades

BACKGROUND Ninety-seven patients with small hepatocellular carcinomas (HCCs) measuring 3 cm or less in size and three patients with adenomatous hyperplasia who underwent radical hepatic resection were examined in this study. METHODS The lesions were classified into four groups according to the following histologic grading criteria: group A, adenomatous hyperplasia (n = 3); group B, early HCC (n = 6); group C, well-differentiated HCC (wHCC) (n = 32); and group D, moderately or poorly differentiated HCC (n = 59). The involvement factors that seemed to be important or to characterize the progression of HCC and the survival rates were compared among the four histologic groups. RESULTS The frequency of patients with tumors larger than 2.0 cm in size and that of patients with 200 or more ng/ml serum alpha-fetoprotein increased with the progression of histologic malignancy. Tumor staining on the angiogram, capsular formation, and extranodular invasion were never seen in groups A and B, but they began to appear in group C and increased remarkably in group D. The 5-year survival rates of the patients in groups B, C, and D were 100%, 60%, and 27%, respectively, and statistically significant differences were seen among them. In comparative evaluation of the group C patients the lesions that showed no tumor staining had no capsule, and those that had no capsule had no extranodular invasion. The 5-year survival rate of patients with wHCC without extranodular invasion (81%) was significantly higher than that of patients with extranodular invasion (35%) (p < 0.05). CONCLUSIONS It may be recommended to provide the category of wHCC without extranodular invasion for pathologic classification of clinically early HCC (i.e., HCC of high curability).

Effect of transcatheter arterial embolization on the boundary architecture of hepatocellular carcinoma

Daughter nodules and intrahepatic metastases are resistant to conventional transcatheter arterial embolization therapy. To clarify the mechanism of this resistance, the boundaries of hepatocellular carcinomas and their relationship to the blood supply were studied. The boundaries of the hepatocellular carcinomas studied were classified as one of five types: encapsulated, granulation, stromal, replacing, or sinusoidal. The granulation and stromal types had a capsule‐like structure, but lacked the hyalinization which is the hallmark of a true tumor capsule. The granulation and stromal types could also be differentiated from the encapsulated types because of their different blood supplies and the differing effects of transcatheter arterial embolization. When barium sulfate was infused into the portal vein, it did not enter into encapsulated tumors, but it entered granulation and stromal type tumors. Small nodules such as daughter nodules and intrahepatic metastases do not have capsules, and so have a blood supply that makes them resistant to conventional transcatheter arterial ebolization therapy.

Differentiation between hepatoma and hemangioma with inversion recovery snapshot FLASH MRI and Gd-DTPA

Thirty-eight patients with focal liver tumors (20 hepatomas, 18 hemangiomas) were studied by dynamic sequential inversion recovery (IR) snapshot fast low angle shot (FLASH) MR imaging with Gd-DTPA. Immediately after 0.05 mmol/kg Gd-DTPA was administered intravenously for 2-3 s followed by flushing with normal saline for 4-5 s, 10 images were obtained in the first 20 s (time zero is the end of flush, early phase). Then, one image every 30 s from 1 to 3 min (late phase) and images at 5 min and 7 min (delayed phase) were obtained serially. Hepatomas showed total enhancement in 18 of 20 patients in the early phase, and isointense or low intensity enhancement with respect to the surrounding liver parenchyma in 18 patients in the late to delayed phases. Hemangiomas showed peripheral enhancement in 14 patients in the early phase, but did not show total enhancement (except for two hemangiomas less than 3 cm in size) in the early phase, and showed high intensity enhancement in 15 patients in the late phase. Ninety percent of hepatomas and 82% of hemangiomas showed their characteristic enhancement patterns in the early to delayed phases. We conclude that dynamic sequential IR snapshot FLASH MR images enhanced with Gd-DTPA can facilitate differentiation between hepatomas and hemangiomas.