Hiroya Saito

Intraluminal low-dose-rate 192Ir brachytherapy combined with external beam radiotherapy and biliary stenting for unresectable extrahepatic bile duct carcinoma

PURPOSE To evaluate the results of combined-modality therapy, including external beam radiotherapy, intraluminal (192)Ir, and biliary stenting for extrahepatic bile duct carcinoma. MATERIALS AND METHODS Between 1988 and 1998, 93 patients with unresectable extrahepatic bile duct carcinoma underwent definitive radiotherapy. The dose of external beam radiotherapy was 50 Gy in 25 fractions. Low-dose-rate (192)Ir was delivered at a dose of 27-50 Gy (mean 39.2) at 0.5 cm from the source. An expandable metallic endoprosthesis was used to establish an internal bile passage. RESULTS The median survival was 12 months, with a 1-, 3-, and 5-year actuarial survival rate of 50%, 10%, and 4%, respectively. Tumor length, hepatic invasion, and distant metastasis significantly affected survival. Ninety-six percent of patients could successfully remove external drainage catheters. The actuarial biliary patency rate for these patients at 1, 3, and 5 years was 52%, 29%, and 18%, respectively. Tumor length, tumor diameter and T stage were significantly associated with the patency rate. Mild-to-severe gastroduodenal complications were observed in 32 patients and were significantly associated with the active length of (192)Ir and linear source activity. Eight patients had treatment-related biliary fistula. CONCLUSIONS Our combined-modality therapy provided reasonable local control and improved the quality of life of patients with extrahepatic bile duct carcinoma. Because none of the treatment characteristics had any impact on survival or biliary patency, lower dose levels and/or a localized target volume are recommended to minimize morbidity.

Temporary use of an accuflex stent for unextractable common bile duct stones

Endoscopic management has become the main therapeutic approach for the extraction of common bile duct (CBD) stones, and successful removal can be achieved in 80–90% patients using conventional balloon and basket techniques. However, if it is difficult to completely fragment a stone, or to clear the CBD, which may occur for a variety of reasons, the therapeutic problem will remain. When bile duct stones can not be removed, a viable management option is to place a biliary stent to ensure drainage. However, recent studies of long‐term biliary stenting, with a plastic stent, showed a relatively high rate of morbidity and mortality. We report an alternative, unique treatment for unextractable common bile duct stones, using the temporal placement of an expandable metallic stent (EMS) to facilitate passage of fragments through the papilla.

C ASE R EPORT: Mucinous cholangiocarcinoma featuring a multicystic appearance and periportal collar in imaging

A case of mucinous cholangiocarcinoma (CC), a rare histological type of CC, featuring unusual images is reported. The patient was hospitalized because of acute development of jaundice and fever. Computed tomography demonstrated multiple cystic lesions in the liver and a band‐like low density area parallel to the intrahepatic portal vein, a so‐called ‘periportal collar’. Endoscopic cholangiography revealed a stricture of the hepatic duct with slight upstream dilatation. Cytology of the bile juice and fine‐needle aspiration of the cystic lesion in the liver disclosed mucinous carcinoma. The patient died of multiorgan failure 3 weeks after admission. The autopsied liver showed that multiple mucus lakes were lined with adenocarcinoma cells and signet ring cells were floating in the mucus lakes. The cancer cells had spread along the portal tract and invaded into the hepatic parenchyma.

Tumors of the Liver and Biliary Tract

Hepatoma or hepatocellular carcinoma (HCC), a tumor arising from hepatocytes, is one of the most common tumors worldwide, with approximately one million new cases diagnosed/year. Five-year survival ranges from 70% for stage I to <20% for stage III. HCC is often associated with cirrhosis and chronic hepatitis. The tumor is staged using the AJCC TNM classification, which considers tumor size, vascular invasion, lymph node status, and metastatic disease. The tumor is usually advanced at the time of diagnosis. CT and MRI are usually used for staging used for this purpose. Several reports indicated low sensitivity of [18F]FDG for detecting HCC due to a relatively low [18F]FDG uptake within the tumor, due to the presence of glucose-6-phosphatase (G-6-Pase), an enzyme present in normal liver, which converts [18F]FDG-6-P to [18F]FDG, allowing the tracer to diffuse out of tumor cells. [18F]FDG-PET has clinical value for identifying distant metastases and identifying poorly differentiated HCC in patients with multiple lesions, since these lesions show higher [18F]FDG uptake.

Factors associated with tumor response and survival in radiosurgery for brain metastasis

BackgroundWe reviewed our experience with radiosurgery for brain metastasis and focused on factors associated with tumor response and survival.MethodsOur study consists of 19 patients with 25 brain metastases who underwent linear accelerator radiosurgery. There was evidence of extra-central nervous system (CNS) tumors in 15 patients. The maximum diameter of the tumors ranged from 3 to 40 mm with a mean of 20 mm. Tumor doses at the isocenter varied from 16 to 25 Gy with a mean of 21 Gy. Eighteen lesions were treated by radiosurgery alone and 7 lesions received combined radiosurgery with fractionated radiotherapy. Of the 11 patients who experienced CNS failure either in or out of the radiosurgery field, 6 patients had salvage radiotherapy.ResultsMedian survival was 7 months, and the 1-year actuarial survival rate was 40%. Death was due to extra-CNS tumor manifestations in 11 patients. In 3 patients, CNS failure was the cause of death. One died of local progression, and the other 2 died of newly developed metastases. Poor Karnofsky performance scores and the presence of extra-CNS tumors significantly affected 1-year survival in univariate analysis (P<0.05). Local tumor control was achieved in 80% of the lesions. The 1-year actuarial tumor control rate was 51%. Newly developed brain metastases were observed in 7 patients. The tumor diameter was mostly associated with tumor response in multiple regression analysis (P=0.0031).ConclusionWe concluded that radiosurgery is effective in controlling small brain metastasis. Survival benefit is expected for those with good performance status and adequately controlled extra-CNS disease.

Tc-99m HMPAO uptake in renal cell carcinoma metastases

A 77-year-old man with renal cell carcinoma underwent Tc-99m HMPAO scintigraphy to evaluate a brain mass seen on CT scan after radiation therapy. Tc-99m HMPAO SPECT imaging showed intense accumulation in the nasal cavity and in the parietal bone. These lesions were well seen on CT with contrast enhancement and were thought to be suggestive of hypervascularity. They were in fact hypervascular. The tumor in the nasal cavity had been histologically proven to be a metastasis from a renal cell carcinoma.

Combined chemotherapy with twice-daily radiation therapy for inoperable squamous cell carcinoma of the thoracic esophagus

BackgroundA study with chemotherapy and twice-a-day radiotherapy in patients with esophageal carcinoma was performed to evaluate toxicity and efficacy.MethodsThirty-seven patients with squamous cell carcinoma of the thoracic esophagus (1, stage IIB; 19, stage III; 17, stage IV) were enrolled. The chemotherapy regimen consisted of 3 cycles with cisplatin (70 mg/m2 on day 1) and 96-hour continuous infusion 5-fluorouracil (700 mg/m2 per day on days 1 to 4). Second and third cycles were initiated on day 22 and day 92, respectively. Radiotherapy was administered twice daily with concomitant boost technique over days 43 to 75, up to a total dose of 60 Gy. Daily fractions were 2.0 Gy for large fields and 1.0 Gy for small fields at 4- to 6-hour intervals.ResultsTwenty-nine patients (78%) received the full treatment. Of the 36 patients who started radiotherapy, 94% were able to complete the full course. Grade 3+toxicities observed were leukopenia 5%, anemia 14%, thrombocytopenia 5%, vomiting 14%, esophagitis 5%, pulmonary toxicity 5%, cardiac toxicity 3%, hepatic dysfunction 3%, and nephrotoxicity 3%. Of the 36 patients who started radiotherapy, 8 (22%) showed complete response, and 16 (44%) had partial response. The median survival time was 9 months, with a 1-year actuarial survival rate of 33%. Death was due to local-regional tumor manifestations in 18 patients.ConclusionThe preliminary analysis showed that this treatment scheme was well tolerated with acceptable toxicity, but local-regional failure remains the principal cause of death. New treatment schemes such as concurrent use of chemotherapy with radiation warrant further investigation.