Dong-Ling You

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.

Sex-associated differences in non-small cell lung cancer in the new era: is gender an independent prognostic factor?

BACKGROUND Women with non-small cell lung cancer (NSCLC) appear to have better survival. This study aimed to evaluate sex differences in NSCLC in recent years. The true effect of gender on the overall survival was analyzed taking other prognostic factors into account. METHODS A cohort of consecutive NSCLC patients was prospectively enrolled from January 2002 to December 2005, and followed-up until December 2006. They were clinically and pathologically staged and underwent homogenous treatment algorithms. Demographics, histology, and disease stage between sexes were compared. The clinical prognostic factors to be analyzed in addition to gender included stage, age, smoking history and histology. The overall survival of females and males within relevant subgroups defined by smoking history and histology was also compared. RESULTS Of the 738 patients, 695 were analyzed with a definite stage (94.2%; 315 females and 380 males), which was similar in both sexes. Females were younger (median age: 59.5 years vs. 65.0 years; P<0.001) and more likely to have adenocarcinoma (81% vs. 60.5%; P<0.001). Patients with earlier stage, younger patients, never-smokers and females had better overall survival in univariate analyses and no significant survival difference was noted between adenocarcinoma and squamous cell carcinoma. Multivariate analyses demonstrated age, smoking history and gender to have a hazard ratio 1.46 (95% confidence interval, CI 1.21-1.76; P<0.001), 1.27 (95% CI 0.97-1.65; P=0.082), and 1.18 (95% CI 0.90-1.55; P=0.226), respectively. Subgroup analyses revealed the survival of never-smoker males with adenocarcinoma was similar to that of females. CONCLUSIONS There are sex-related differences in the clinico-pathologic characteristics and survival of NSCLC patients. The survival advantages of females could be attributed to the younger age and lower smoking prevalence. Never-smokers with adenocarcinoma should be given special attention regardless of sex as they imply better survival with different treatment outcomes.

Characteristics of integrated 18F-FDG PET/CT in Pulmonary Cryptococcosis.

Background: Pulmonary cryptococcosis is an uncommon cause of pulmonary nodules found by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scans. It is rarely reported but may mislead interpretation. Purpose: To describe the 18F-FDG PET/CT findings of pulmonary cryptococcosis. Material and Methods: The 18F-FDG PET/CT images of seven patients with pulmonary cryptococcosis were evaluated. Results: The 18F-FDG PET/CT exams showed single or multiple nodular lesions. The standardized uptake values (SUV) in early images varied significantly for the seven patients (ranging from 2.2 to 11.6). Delayed SUVs showed significant increases in four patients. Conclusion: Pulmonary cryptococcosis mimics primary or metastatic lung cancer on 18F-FDG PET/CT scan. Tissue confirmation should be considered for any suspicious pulmonary nodules found on 18F-FDG PET/CT scan with an SUV score higher than 2.5, in order to avoid overdiagnosis or overstaging.

Transbronchial needle aspiration accurately diagnoses subcentimetre mediastinal and hilar lymph nodes detected by integrated positron emission tomography and computed tomography

Objective and background:  Integrated PET and CT (PET/CT) is accurate in detecting hilar‐mediastinal metastases. However, it has a moderate positive predictive value, necessitating pathological verification, especially in situations in which the result would make a difference to treatment. This study aimed to evaluate the performance of transbronchial needle aspiration (TBNA) for hilar‐mediastinal lesions suspicious on PET/CT.

FDG PET-CT in Patients with Recurrent Thyroid Cancer with Elevated Serum Thyroglobulin but Negative Iodine-131 Whole Body Scan

Background: The aim of this study is to evaluate the clinical role of 18F-FDG (FDG) PET-CT in detecting recurrent or metastatic lesions in patients with well-differentiated thyroid cancer who have elevated serum thyroglobulin level but negative 131I whole body scan. Methods: A retrospective study was performed in 23 patients with recurrent well-differentiated thyroid cancer who underwent FDG PET-CT in our institute from August 2003 to November 2006. All of these patients had received total thyroidectomy and 131I treatment, and subsequently presented with elevated serum thyroglobulin but negative 131I whole body scan. Among these 23 patients, 8 patients performed FDG PET-CT during high thyroid stimulating hormone (TSH) level and 15 patients performed FDG PET-CT during low TSH level. In all patients, results of FDG PET-CT were correlated with conventional images, histopathological findings and clinical follow-up. Results: FDG PET-CT showed positive findings in 17 of 23 patients, giving a sensitivity of 74%. There were altogether 25 metastatic lesions being detected in these 17 patients, which comprised of 14 neck lesions, 3 mediastinal lesions, 4 lung lesions, 3 bone lesions and 1 soft tissue lesion. FDG PET-CT led to a change in management in 8 patients, in whom 6 patients received surgery, 1 patient received radiation therapy of bone metastasis and the remaining patient received alcohol injection of metastatic neck lymph node. In 6 patients with negative finding on FDG PET-CT, 3 patients developed neck recurrence within 12 months after PET study. In our study, the sensitivity of FDG PET-CT was not improved by high serum TSH level. Conclusion: FDG PET-CT is a reliable method for detecting recurrence in patients with well-differentiated thyroid cancer with elevated serum thyroglobulin and negative 131I whole body scan.

Underperformance of gallium-67 scan is greater in relapse than in initial staging, compared with FDG PET.

Purpose: The purpose of this study is to evaluate the performance of gallium-67 scan (GS) and F-18 fluorodeoxyglucose (FDG) PET scan in lymphoma staging and recurrence detection by comparing the 2 imaging studies in the same patient. Materials and Methods: A total of 42 patients from the period between July 2002 and May 2006 were included in this study. Of the 42 patients, 6 had Hodgkin disease and 36 had non-Hodgkin lymphomas. All of them underwent one or more FDG PET scans and also underwent corresponding GS performed within 7 days of FDG PET, for staging or detection of lymphoma recurrence. Among the non-Hodgkin lymphoma cases, 18 were diffuse large B-cell lymphoma, 10 were follicular center cell lymphoma, and 8 were of other types. Of the total 46 pairs of imaging performed in these 42 patients, 27 were for staging, and 19 for restaging after recurrence. Results: In all these studies, FDG PET detected 230 lesion sites, whereas GS detected 85 lesion sites. All of the lesions detected by GS were noted on FDG PET, whereas GS detected only 37.0% of the lesions detected by FDG PET. Among the 27 studies for staging, FDG PET detected 120 lesions, whereas GS detected 68 lesions (56.7%). In the 19 images taken for relapse, FDG PET detected 110 lesions, whereas GS detected only 17 (15.5%). Conclusions: FDG PET is superior to GS in staging and detecting all types of lymphoma. The difference is notably more significant in recurrence detection.

The Significance of Tc-99m SPECT and MRI Findings in the Diagnosis of Skull Base Invasion in Nasopharyngeal Carcinoma

Purpose: To evaluate the role of Tc-99m SPECT in the diagnosis of skull base invasion in nasopharyngeal carcinoma (NPC) and to compare its findings to magnetic resonance imaging (MRI). Materials and Methods: We retrospectively analyzed 179 newly diagnosed NPC patients treated between August 1, 1997 and December 31, 2000 in our institute. All patients were examined with both MRI and Tc-99m SPECT of the skull base prior to treatment. Bone involvement was suspected on MRI when there was a defect in cortical intactness or an abnormality or asymmetry in the signal intensity of the marrow. Malignancy in the skull base was suspected on SPECT when there was an abnormal focal area of increased uptake or left-to-right asymmetry in the skull bone radioactivity. Patients were staged according to the 1997 AJCC classification of NPC based on physical exam and MRI findings. Primary tumor control rates for patients stratified by T stage and MRI or SPECT results were analyzed using the Kaplan-Meier method and the log rank test. Results: Out of 179 patients, a total of 92 (51.4%) had an abnormal SPECT (positive or questionable for malignancy) in the skull base (T1: 10, T2: 14, T3: 24, and T4: 44), while 78 (43.6%) demonstrated skull base malignancy on MRI (T3: 30 and T4: 48). The 3-year primary tumor control rate of the 92 patients with an abnormal SPECT was 87.1%, versus 98.2% for the patients with a normal SPECT in the skull base (p=0.11). Twenty-three patients in stages T1-T2 had an abnormal SPECT but a normal MRI in the skull base, and their 3-year primary tumor control rate was 100%. Conclusions: An abnormal SPECT in the skull base without corresponding MRI findings is not a poor prognostic factor by itself and patients are not at an increased risk for primary tumor recurrence. However, SPECT appears to be more sensitive than MRI, although specificity is low, and it can be a helpful adjunct to MRI in the pretreatment evaluation of NPC.

Radionuclide Hepatobiliary Imaging in Evaluation of Reserved Hepatic Function in Patients with Hepatocelluar Carcinoma before Transcatheter Arterial Embolization

Background: Hepatocellular carcinoma(HCC)is a common cancer in Asia. Transcatheter arterial embolization(TAE)is the most common modality to treat unresectable HCC but is contraindicated inpatients with insufficient hepatic reserve. The purpose of this study is to use radionuclide hepatobiliary imaging (RHI)to evaluate the reserved hepatic function inpatients with HCC before TAE. Methods: Eighty-two patients(male: female=63:19;age range:23～72 y/o,mean:49.6 y/o)with HCC were included in this study. All of the patients underwent conventional hepatic function tests(HFT),and indocyanine green(ICG)test. RHI was done within 2 days after HFT and ICG test. RHI was performed dynamically after bolus injection of 6 mCi of 99mTc-diisopropyl iminodiacetate (DISIDA)with 60 sec per frame for 60 min. Hepatic extraction fraction(HEF),excretion half-time(T(subscript 1/2))and peak-time of uptake(PTU)were calculated. The correlations between HEF,T(subscript 1/2),PTU and HFT, ICGtest were studied. Results: There was significant correlation between HEF and Bil, AST,ALT, albumin, Alk-P,PT and ICG test(P＜0.05).There was significant correlation between PTU and Bil, Alk-P and ICG test(P＜0.05).There was also significant correlation between T(subscript 1/2)and Bil, Alk-Pand ICG test(P＜0.05).Discrepancies between HFT and ICG test occurred in 8 patients; however, the values of HEF in these 8 patients correlate well with HFT. Conclusion: RHI could be used as a final arbitration when discrepancy between traditional HFT occurs. HEF could be a single indicator for reserved hepatic function.