Mana Yoshimura

Evaluation of chest wall invasion by lung cancer using respiratory dynamic MRI

Conventional CT or MRI has low accuracy in assessing chest wall invasion in patients with peripheral lung cancer. For preoperative evaluation of chest wall invasion by peripheral lung cancer, respiratory dynamic (RD) MRI was carried out in 98 patients in whom conventional CT scan showed that the tumour was abutting the pleural surface, but there was no evidence of definite tumour invasion. We used 1.5‐T MR equipment. RD MR images were acquired by snapshot fast field echo sequence (repetition time = 8, echo time = 3, flip angle = 100) and 25 consecutive images were taken while the patient took deep breaths. These images were evaluated in cine mode to assess tumour movement along the chest wall. Sixty‐one patients underwent surgical resection of the tumour and RD MR findings were compared with those in pathological specimens. RD MR showed free tumour movement along the chest wall in 34 patients. At pathological examination, the RD MR findings were proved correct in all patients. Pathologically, 20 patients had chest wall invasion and their RD MR was positive (sensitivity 100%). There were seven false‐positive results among the 41 patients without chest wall invasion (specificity 82.9%). RD MR may improve the accuracy of conventional CT scan or MRI in the prediction of chest wall invasion of lung cancer, especially in patients in whom the results of conventional CT scan or MRI appear equivocal in the presence of a peripheral mass abutting the chest wall surface without obvious chest wall invasion.

Clinical Experience with Autofluorescence Imaging System in Patients with Lung Cancers and Precancerous Lesions

Background: It is important to detect preinvasive bronchial lesions before they become invasive cancer, because detection of early cancer is expected to lead to a cure. Autofluorescence bronchoscopy is a useful device in the detection of preinvasive and cancerous lesions. Recently, a new autofluorescence bronchoscopic system, autofluorescence imaging (AFI) system, has been developed. Objectives: We evaluated the efficacy of AFI in the diagnosis of precancerous and cancerous lesions. Methods: A total of 31 patients underwent both conventional white-light bronchoscopy (WLB) and AFI from January 2002 to September 2004. We evaluated autofluorescence findings using a four-point scale: AFI-I, II, III, and B. The findings in WLB were evaluated on a three-point scale: WLB-I, II, and III. Abnormal areas by WLB and AFI were biopsied for histopathological examinations. Results: A total of 64 lesions were evaluated. When the AFI-III finding was regarded as positive in AFI and WLB-III as positive in WLB, sensitivity for severe dysplasia or worse was 94.7% with AFI and 73.7% with WLB, respectively. Conclusions: AFI is an effective system for the detection of precancerous and cancerous lesions.

Enhanced diagnostic accuracy for quantitative bone scan using an artificial neural network system: a Japanese multi-center database project

BackgroundArtificial neural network (ANN)-based bone scan index (BSI), a marker of the amount of bone metastasis, has been shown to enhance diagnostic accuracy and reproducibility but is potentially affected by training databases. The aims of this study were to revise the software using a large number of Japanese databases and to validate its diagnostic accuracy compared with the original Swedish training database.MethodsThe BSI was calculated with EXINIbone (EB; EXINI Diagnostics) using the Swedish training database (n = 789). The software using Japanese training databases from a single institution (BONENAVI version 1, BN1, n = 904) and the revised version from nine institutions (version 2, BN2, n = 1,532) were compared. The diagnostic accuracy was validated with another 503 multi-center bone scans including patients with prostate (n = 207), breast (n = 166), and other cancer types. The ANN value (probability of abnormality) and BSI were calculated. Receiver operating characteristic (ROC) and net reclassification improvement (NRI) analyses were performed.ResultsThe ROC analysis based on the ANN value showed significant improvement from EB to BN1 and BN2. In men (n = 296), the area under the curve (AUC) was 0.877 for EB, 0.912 for BN1 (p = not significant (ns) vs. EB) and 0.934 for BN2 (p = 0.007 vs. EB). In women (n = 207), the AUC was 0.831 for EB, 0.910 for BN1 (p = 0.016 vs. EB), and 0.932 for BN2 (p < 0.0001 vs. EB). The optimum sensitivity and specificity based on BN2 was 90% and 84% for men and 93% and 85% for women. In patients with prostate cancer, the AUC was equally high with EB, BN1, and BN2 (0.939, 0.949, and 0.957, p = ns). In patients with breast cancer, the AUC was improved from EB (0.847) to BN1 (0.910, p = ns) and BN2 (0.924, p = 0.039). The NRI using ANN between EB and BN1 was 17.7% (p = 0.0042), and that between EB and BN2 was 29.6% (p < 0.0001). With respect to BSI, the NRI analysis showed downward reclassification with total NRI of 31.9% ( p < 0.0001).ConclusionIn the software for calculating BSI, the multi-institutional database significantly improved identification of bone metastasis compared with the original database, indicating the importance of a sufficient number of training databases including various types of cancers.

High-Dose-Rate Brachytherapy for Small-Sized Peripherally Located Lung Cancer

Background:The demand for minimally invasive therapies is increasing in the treatment of small peripheral non-small cell lung cancer (NSCLC).Patients and Methods:Twelve patients with T1-2 N0 M0 peripheral NSCLC were treated by high-dose-rate brachytherapy with 192Ir radioactive source.Results:A 192Ir source was introduced into the tumors percutaneously in five patients (percutaneous brachytherapy) or transbronchially in seven patients (transbronchial brachytherapy). Whereas irradiation was performed with a single fraction of 20 Gy in percutaneous brachytherapy, it was hypofractionated from 5 × 5 Gy to 2 × 12.5 Gy in transbronchial brachytherapy. Complications were generally mild in all patients, although focal radiation pneumonitis was observed in most patients. Primary recurrence occurred in three patients, including one with a T2 tumor and one treated by brachytherapy as a salvage treatment for recurrence after conformal radiotherapy. When brachytherapy is evaluated as a primary treatment for T1 N0 M0 NSCLC, local control rate is 88.9% and estimated 5-year survival rate is between 60% and 70%.Conclusion:Brachytherapy has a potential to be a method to treat peripheral T1 N0 M0 NSCLC.Hintergrund:Das Erfordernis minimalinvasiver Eingriffe in der Behandlung kleiner, peripherer, nichtkleinzelliger Bronchialkarzinome (NSCLC) nimmt zu.Patienten und Methodik:Zwölf Patienten mit peripherem NSCLC der Stadien T1-2 N0 M0 erhielten eine High-Dose-Rate-Brachytherapie mit radioaktiver 192Ir-Quelle.Ergebnisse:Die 192Ir-Quelle wurde bei fünf Patienten über einen perkutanen Zugang (perkutane Brachytherapie) und bei sieben Patienten über einen bronchialen Zugang (transbronchiale Brachytherapie) eingeführt. Bei der perkutanen Brachytherapie wurde die Bestrahlung mit einer Einzeitdosis von 20 Gy durchgeführt, bei der transbronchialen Brachytherapie hypofraktioniert mit 5 × 5 Gy bis 2 × 12,5 Gy. Komplikationen waren im Allgemeinen geringgradig ausgeprägt, allerdings wurde bei den meisten Patienten eine fokale Strahlenpneumopathie beobachtet. Bei drei Patienten trat ein Lokalrezidiv auf (zwei Patienten mit T2-Tumor und ein Patient mit Brachytherapie als Salvage-Behandlung wegen eines Rezidivs nach konventioneller Strahlentherapie). Für die Brachytherapie in der Primarbehandlung von NSCLC des Stadiums T1 N0 M0 beträgt die lokale Kontrollrate 88,9%, und die geschätzte 5-Jahre-Überlebensrate liegt bei 60–70%.Schlussfolgerung:Die Brachytherapie ist eine effektive Behandlungsmethode bei peripherem NSCLC des Stadiums T1 N0 M0.

Improved Diagnostic Efficacy by Rapid Cytology Test in Fluoroscopy-Guided Bronchoscopy

Background: Fluoroscopy-guided bronchoscopy is a safe and routine method used to obtain a histologic or cytologic specimen of peripheral lung nodules, but it has low sensitivity in diagnosing malignant tumors. Although feedback from rapid cytology tests are expected to improve diagnostic rates, the value of the routine use of rapid cytology tests has not been established. Materials and Methods: We prospectively studied 657 patients with suspected peripheral malignant lung lesions on chest computed tomography who underwent fluoroscopy-guided bronchoscopy between January 2002 and December 2004. Rapid on-site cytopathologic examinations (ROSE) were performed during bronchoscopic examinations. The additional approach to the lesions was performed immediately after conventional bronchoscopic examinations when ROSE was not considered diagnostic. Results: There were 528 patients diagnosed as having malignant lesions. In 477 of these patients (90.3%), final malignant diagnosis was established by the initial bronchoscopy. Among these, 84 patients (15.9%) were diagnosed only with the additional feedback from ROSE. Of 240 peripheral lesions ≤2 cm, 174 were found to be malignant. Without ROSE, 110 (63.2%) of peripheral malignant lesions were diagnosed by bronchoscopy. The integration of ROSE enabled us to diagnose an additional 40 patients (23.0%) by bronchoscopy. ROSE improved diagnostic yield independent of the site and histology of the lesions and experience of the operators. Conclusion: ROSE increased the diagnostic yield of bronchoscopy from 74.4% to 90.3% and therefore is an effective reinforcement in bronchoscopic diagnosis of peripheral pulmonary malignancies. The use of ROSE in routine bronchoscopy should be encouraged.

Gallium-67 accumulation to the tumor thrombus in anaplastic thyroid cancer

A sixty-five-year-old woman was hospitalized for examination of swelling in the left arm. Gallium-67 scintigraphy showed the same radioactivity in the left lobe of the thyroid gland and the junction of the internal jugular vein and the subclavian vein. Operation then proved obstruction of the left internal jugular vein and subclavian vein due to tumor thrombus accompanied by anaplastic thyroid cancer. Gallium-67 scintigraphy was extremely useful in grasping the extent and feature of the tumor.

Multiplanar reconstruction MR image of primary adenoid cystic carcinoma of the central airway: MPR of central airway adenoid cystic carcinoma

Multiplanar reconstruction (MPR) is a method that allows free selection of computerized reconstruction images. We reviewed a total of six MPR magnetic resonance (MR) examinations in five cases of adenoid cystic carcinoma of the central airway, which is a rare low-grade malignant tumor. MPR MR provides images either longitudinally or at right angles to the longitudinal axis of the trachea and main bronchi, so it was useful to diagnose tumor extent along airways more precisely and to evaluate therapeutic effects. MPR MR may help in planning therapeutic strategy and in posttherapeutic follow-up.

High-resolution computed tomographic findings of small peripherally located squamous cell carcinoma.

With the spread of high-resolution computed tomography (HRCT) screening for lung cancer, we are increasingly faced with the need to determine whether certain small lesions are benign or malignant. The features of small adenocarcinomas have been clarified but not those of squamous cell carcinoma. The objective of our study was therefore to clarify the HRCT findings of peripherally located squamous cell carcinomas less than 2 cm in maximum dimension. Subjects consisted of 27 consecutive pathologically proven cases of peripherally located squamous cell carcinoma that were less than 2 cm in maximum dimension. HRCT findings of all 27 cases were analyzed retrospectively and independently by three radiologists who were unaware of the pathological diagnosis, and decisions were reached by consensus with special attention to 10 review points. Internal characteristic features included calcification, cavity formation, and air bronchogram. Tumor margin features included spiculation, notching, irregularity, and ground-glass opacity. Surrounding structural features consisted of pleural indentation, pulmonary emphysema, and satellite lesions. The presence of irregularity (70.4%), surrounding pulmonary emphysema (70.4%), and pleural indentation (51.9%) was observed frequently. No mass was accompanied by calcification. HRCT images of peripherally located squamous cell carcinoma suggested that the demonstration of irregularity, surrounding pulmonary emphysema, pleural indentation, and absence of calcification may contribute to the accurate CT diagnosis of small peripheral squamous cell carcinoma.

New semiquantitative assessment of123I-FP-CIT by an anatomical standardization method

We evaluated a new semiquantitative procedure to more easily and objectively estimate the striatal uptake of123I-FP-CIT in patients with Parkinsonian syndrome (PS) and essential tremor (ET), using an anatomical standardization method, the Neurostat.MethodsEleven patients with PS and 8 with ET were examined by clinical assessment and123I-FP-CIT SPECT imaging. The modified Hoehn and Yahr Staging Scale and Unified Parkinson’s Disease Rating Scale (UPDRS) were used to assess the stage and severity of the disease. The co-registered MR and SPECT images were created with fusion software included in Neurostat. On the cross section, which shows the largest area of striate, irregular shaped regions of interest corresponding to the striate and occipital cortex were drawn. Then the ratio of specific striatal uptake to non-specific occipital cortex, V3″(F), was calculated. Another calculation was done by VOIClassic, which is a software included in Neurostat to estimate the counts per voxel of anatomically defined regions such as caudate nucleus, putamen, occipital cortex, and total cortex. Using these count data, the ratio of specific striatal uptake to non-specific occipital cortex, V3″(OC), and total cortex, V3″(TC), was calculated.ResultsA fair linear correlation was observed between V3″(OC) and V3″(F) (y = 1.53x + 1.40; r = 0.756; p < 0.01), as well as between V3″(TC) and V3″(F) (y = 1.24x + 1.43; r = 0.713; p < 0.01). Both V3″(OC) and V3″(TC) yielded similar tendencies. Concerning discrimination between ET and PS, there was a significant difference between the mean V3″ of PS and ET (p < 0.01). Concerning the correlation between V3″ value and the severity of PS, the UPDRS motor score significantly correlated with the V3″(F) value (rs= -0.816). However, V3″(OC) and V3″(TC) correlated less with UPDRS (rs = -0.667 and -0.645, respectively).ConclusionsSemiquantitative parameters, V3″(OC) and V3″(TC), calculated by VOIClassic including the Neurostat system are useful and easily calculable parameters as well as V3″(F) for the differential diagnosis of PS from ET.

89Sr Imaging With Bremsstrahlung in Patients With Metastatic Breast Cancer

Purpose In this study, we investigated the clinical and laboratory factors that may enhance 89Sr uptake to strengthen its tumoricidal effect. Methods We enrolled 21 patients with multiple bone metastases (n = 23) from breast cancer and classified them into 2 groups according to their zoledronic acid (ZOL) treatment history. 89Sr imaging with bremsstrahlung was performed 2 to 6 weeks after administration and 89Sr index was measured using combined imaging with bone scintigraphy. We compared the 89Sr index with the levels of alkaline phosphatase, bone-specific alkaline phosphatase, serum cross-linked N-telopeptides, carboxy-terminal telopeptide of type 1 collagen, C-reactive protein, calcium, and hemoglobin on administration and evaluated the differences among the groups. Results The 89Sr index ranged from 0.01 to 2.0 and was significantly correlated with C-reactive protein and alkaline phosphatase and moderately correlated with carboxy-terminal telopeptide of type 1 collagen, serum cross-linked N-telopeptides, and bone-specific alkaline phosphatase. The 89Sr index was not significantly correlated with calcium or hemoglobin. The group with less than 1 year of ZOL treatment demonstrated a mean (SD) 89Sr index of 1.11 (0.59), and the group with 1 or more years of ZOL treatment showed a mean 89Sr index of 0.36 (0.26). The Wilcoxon signed-rank test demonstrated a significant difference between the 2 groups (P < 0.001). Conclusions 89Sr accumulation seemed to be associated with bone turnover, in particular bone resorption, and vascularization due to inflammation or tumor growth. Long-term ZOL treatment may reduce bone resorption and vascularization. To enhance the tumoricidal effect and palliation of bone pain by 89Sr, combined therapy must be established.