Masakuni Sakaguchi

Radiological assessment following thermoradiation therapy for primary pleural synovial sarcoma: case report

Primary pleural synovial sarcoma is a rare disease with poor outcomes. Although hyperthermia therapy as part of a combined treatment regimen can offer improved local tumor control, only two reports of hyperthermia therapy for synovial sarcoma have appeared in the literature, and these sarcomas were not of pleuropulmonary origin. This report of an advanced inoperable primary pleural synovial sarcoma is the first to address the use of hyperthermia therapy in combination with chemoradiotherapy for this disease, together with radiological assessment following that therapy. Computed tomography performed after thermoradiation showed a decrease in tumor size and a characteristic unenhanced low-density area in the tumor suggesting that tumor necrosis resulted from the therapy. These image findings were helpful in assessing the tumor response to thermoradiation. We believe that hyperthermia therapy combined with chemoradiotherapy should be regarded as an option for advanced primary pleural synovial sarcoma. This would give computed tomography important role in evaluating this approach.

Solitary pulmonary metastasis from prostate cancer with neuroendocrine differentiation: a case report and review of relevant cases from the literature

BackgroundSolitary lung metastasis from prostate cancer is rare. There are few reports of such cases with neuroendocrine differentiation.Case presentationA 50-year-old man presented to our hospital with a chief complaint of dysuria. Histological examination revealed prostate cancer, which was classified as cT4 N0 M0, stage IV adenocarcinoma. Since the patient was at high risk, endocrine and radiation therapies were started. One year after starting radiation therapy, the patient developed bloody sputum. Chest radiography revealed a nodular shadow in his left lung (S5). Although 18-fluoro-2-deoxyglucose positron emission tomography revealed abnormal accumulation in the lesion, the cytological diagnosis was class IIIa, which did not yield a definitive diagnosis. Given that prostate specific antigen (PSA) was not elevated, a primary lung tumor was suspected, and thoracoscopic segmental resection of the lung was performed with lymph node dissection. The final pathological diagnosis was solitary lung metastasis from prostate cancer with neuroendocrine differentiation and mediastinal lymph node metastasis. The specimen showed a mixed pattern of conventional prostatic and neuroendocrine carcinomas.ConclusionWe herein report a case with neuroendocrine differentiation (NED), along with a review of the relevant literature, including histopathological findings. According to previous case reports, some patients with solitary lung metastasis from prostate cancer achieved relatively good long-term survival. We consider establishing the correct diagnosis and implementing an appropriate treatment plan to be essential in prostate cancer patients with oligometastases that have the potential to be neuroendocrine (NE) tumors.

Myelosuppression toxicity of palliative splenic irradiation in myelofibrosis and malignant lymphoma

Abstract Objectives Distinctive splenomegaly resulting from extramedullary hematopoiesis and infiltration of neoplastic cells is observed in some patients with myelofibrosis (MF) or malignant lymphoma. Palliative splenic irradiation is known to be effective for such patients and is widely performed. However, little is known about the biological mechanism of palliative splenic irradiation. Various reports have focused on irradiation doses, in terms of efficacy and safety. We examined the toxicity of myelosuppression and the timing of the platelet, white blood cell, and red blood cell count nadirs within 3 months after the start of irradiation in a total of eight patients with MF or malignant lymphoma, all of whom underwent palliative splenic irradiation at our hospital between 2004 and 2013. Methods Five patients with idiopathic MF and three patients with non-Hodgkins lymphoma (NHL) treated with splenic irradiation between 2004 and 2013. Of the three patients with NHL, two had diffuse large B-cell lymphoma and one had mantle cell lymphoma. There were four male and four female patients, with median age of 61 years (range, 51–73). Patients with MF received irradiation at 20–100 cGy per fraction dose; four patients received irradiation five times a week and one patient received irradiation three times a week. In three of these patients, the irradiation dose was gradually increased while observing for hematotoxicity. Patients with NHL received irradiation at a fraction dose of 150–200 cGy, and all received irradiation five times a week. Irradiation was terminated when we judged symptoms to be alleviated, splenomegaly reduced, or efficacy to be poor. With regard to the total irradiation dose, 175, 320, 400, 600, and 640 cGy were given to one MF patient each, and 1050 and 3000 cGy were given to one and two NHL patients, respectively. Results Symptoms diminished or disappeared in five of the six symptomatic patients (83%). A reduction in the size of the spleen was confirmed in five of six patients (83%) with splenomegaly. For MF, the platelet count nadir was observed at week 3 in two patients, week 5 in two, and week 6 in one patient. For NHL, it was observed at week 1 in one patient, week 4 in one, and week 9 in one patient. For MF, the white blood cell count nadir was observed in at week 2 in one patient, week 3 in two, and week 5 in two patients. For NHL, it was observed at week 1 in one patient and week 4 in two patients. For MF, the red blood cell count nadir was observed at week 1 in two patients, week 3 in one, week 7 in one, and week 8 in one patient. For NHL patients, it was observed at week 1 in one patient, week 4 in one, and week 9 in one patient. Discussion There was a trend for the nadir to be steeper in patients with MF than in those with NHL. With regard to the total dose, symptoms diminished at the minimum dose of 175 cGy in MF patients, whereas the maximum dose of 3000 cGy was not effective in NHL patients. These observations suggest that a splenic lesion in NHL patients may be the primary site of neoplastic cell infiltration and that extramedullary hematopoiesis may not necessarily occur in the spleen. Conclusion Although palliative irradiation of splenic lesions in patients with MF or NHL is safe and effective, optimal irradiation doses may differ for MF and NHL. More cases need to be accumulated to elucidate these differences.

Data Management Solution for Large-Volume Computed Tomography in an Existing Picture Archiving and Communication System (PACS)

Multidetector row computed tomography (MDCT) creates massive amounts of data, which can overload a picture archiving and communication system (PACS). To solve this problem, we designed a new data storage and image interpretation system in an existing PACS. Two MDCT image datasets, a thick- and a thin-section dataset, and a single-detector CT thick-section dataset were reconstructed. The thin-section dataset was archived in existing PACS disk space reserved for temporary storage, and the system overwrote the source data to preserve available disk space. The thick-section datasets were archived permanently. Multiplanar reformation (MPR) images were reconstructed from the stored thin-section datasets on the PACS workstation. In regular interpretations by eight radiologists during the same week, the volume of images and the times taken for interpretation of thick-section images with (246 CT examinations) or without (170 CT examinations) thin-section images were recorded, and the diagnostic usefulness of the thin-section images was evaluated. Thin-section datasets and MPR images were used in 79% and 18% of cases, respectively. The radiologists’ assessments of this system were useful, though the volume of images and times taken to archive, retrieve, and interpret thick-section images together with thin-section images were significantly greater than the times taken without thin-section images. The limitations were compensated for by the usefulness of thin-section images. This data storage and image interpretation system improves the storage and availability of the thin-section datasets of MDCT and can prevent overloading problems in an existing PACS for the moment.

Isolated Tuberculous Liver Abscess Invading the Abdominal Wall : Report of a Case

Isolated tuberculous liver parenchymal and subcapsular abscesses are unusual,^but an abdominal wall abscess secondary to a tubercular liver abscess is extremely rare. To our knowledge, there is only one reported case of an abdominal wall abscess occurring secondary to a subcapsular liver abscess. We report the first documented case of direct invasion of the abdominal wall from an isolated tuberculous liver parenchymal abscess, diagnosed by imaging, surgical, and pathological findings. Although ultrasonography and computed tomography showed nonspecific hypoechoic and hypodense findings with peripheral contrast enhancement, T2-weighted magnetic resonance imaging (MRI) revealed a heterogeneous mass with characteristic hypointensity, suggesting the presence of free radicals produced by macrophages during active phagocytosis in tuberculosis. Although our case is extremely unusual, when hypointensity on T2-weighted MRI is seen, the possibility of tuberculosis should be considered and the results of polymerase chain reaction, culture, and histopathological diagnosis must be taken into account to avoid needless invasive surgery.

Inguinal bladder hernia: multi-planar reformation and 3-D reconstruction computed tomography images useful for diagnosis.

We present a case of inguinal bladder hernia that was preoperatively diagnosed with the aid of multi-planar reformation (MPR) and 3-D reconstruction computed tomography (CT) (Figs 1,2) and confirmed with surgery. While CT is a useful tool, reported CT findings are not consistently observed. To make the diagnosis with certainty, an oblique sagittal MPR CT image which is reconstructed along the inguinal canal by volume data (1 mm slice thickness) was completed and shows clear visualization of the continuity from the bladder to the hernia (arrow). 3-D reconstruction CT imaging by volume rendering shows the herniated bladder situated lateral to the inferior epigastric artery (arrow). This is useful in demonstrating its exact location and its relationship with the surrounding structures such as the inferior epigastric vessels, as shown in our case.

A Computer-Assisted System for Diagnostic Workstations: Automated Bone Labeling for CT Images

Although accurate information on thoracolumbar bone structure is essential when computed tomography (CT) images are examined, there is no automated method of labeling all the vertebrae and ribs on a CT scan. We are developing a computer-aided diagnosis system that labels ribs and thoracolumbar vertebrae automatically and have evaluated its accuracy. A candidate bone was extracted from the CT image volume data by pixel thresholding and connectivity analysis. All non-bony anatomical structures were removed using a linear discriminate of distribution of CT values and anatomical characteristics. The vertebrae were separated from the ribs on the basis of their distances from the centers of the vertebral bodies. Finally, the thoracic cage and lumbar vertebrae were extracted, and each vertebra was labeled with its own anatomical number by histogram analysis along the craniocaudal midline. The ribs were labeled in a similar manner, based on location data. Twenty-three cases were used for accuracy comparison between our method and the radiologist’s. The automated labeling of the thoracolumbar vertebrae was concordant with the judgments of the radiologist in all cases, and all but the first and second ribs were labeled correctly. These two ribs were frequently misidentified, presumably because of pericostal anatomical clutter or high densities of contrast material in the injected veins. We are confident that this system can contribute usefully as part of a picture archiving and communication system workstation, though further technical improvement is required for identification of the upper ribs.

Radiation therapy for primary breast lymphoma in male gynecomastia: a rare case report and review of the literature

Primary breast lymphoma is a rare type of non-Hodgkin lymphoma and usually affects women, although a few cases have been reported in men. Chemotherapy and radiation therapy, or a combination of both, are frequently administered for treatment of primary breast lymphoma, as local control by surgical resection is poor. No standard therapy has been established, and the optimal radiation dose and irradiation field for male patients are unknown. The present report describes a 75-year-old man with bilateral cirrhosis-induced gynecomastia who was diagnosed with primary breast lymphoma; specifically, diffuse large B-cell lymphoma. Because of his hepatic dysfunction, he was treated with radiation therapy alone. Radiation therapy was followed by eight cycles of rituximab monotherapy. Clinical response was good, with no signs of relapse. Clinicians may benefit from knowledge regarding effective treatment of primary breast lymphoma in male patients, which has been rarely reported owing to the low incidence of this condition. The outcome in the present case may help to establish effective treatment guidelines in similar cases.

Successful Pregnancy and Delivery After Radiation With Ovarian Shielding for Acute Lymphocytic Leukemia Before Menarche.

Total body irradiation is performed as a preconditioning regimen to inhibit graft-versus-host disease after bone marrow transplantation and to eradicate remaining tumor cells. However, these regimens result in delayed secondary sex characteristics and failure of ovarian function recovery, leading to amenorrhea and infertility. Herein, we report a case of an 11-year-old girl diagnosed with acute lymphocytic leukemia who received induction chemotherapy and prophylactic cranial irradiation. For bone marrow transplantation, she received total body irradiation of 12 Gy with uterine and ovarian shielding at 13 years of age. The patient remained in remission and menarche began at 14 years of age. At 23, she became pregnant and delivered a baby naturally with no abnormalities.

Significance of stereotactic body radiotherapy in older patients with early stage non-small cell lung cancer

OBJECTIVES Our aim was to investigate long-term treatment outcomes in older patients with early stage non-small cell lung cancer (NSCLC) and the presence or absence of therapeutic benefits, using the G8 screening tool. METHODS We retrospectively studied 43 older patients (median age 78 years, range 65-89 years) with stage I lung tumors (T1 and T2 tumors in 34 and 9 patients, respectively), who underwent stereotactic body radiotherapy (SBRT). This study assessed outcomes in a cohort of patients who received geriatric assessments, performed between 2004 and 2011, before the start of their SBRT regimen. Any questions asked to patients before undergoing treatment were applied to the G8 screening tool. RESULTS G8 scores ranged from 8 to 16 (median, 12) in all patients (n = 43), while G8 scores in the T1 and T2 groups ranged from 9 to 16 (median, 13) and 8 to 15 (median, 12), respectively. In patients with G8 scores ≤12, the 2-year and 5-year survival rates were 56.1% and 28% respectively, while the rates were 94.1% and 68.4%, respectively, in patients with G8 scores ≥13 (P = 0.0014). During long-term follow-up, 25.9% of the patients (n = 43) died of the primary disease, NSCLC, and 34.9% of patients died of other diseases or other types of cancer. CONCLUSION SBRT may be effective, even in older adults. Regardless of age, SBRT improved the long-term survival of patients only with G8 scores ≥13. The G8 screening tool may aid in determining whether older patients with comorbidities would benefit from SBRT.