Rheun-Chuan Lee

How Accurate is Magnetic Resonance Imaging in Restaging Rectal Cancer in Patients Receiving Preoperative Combined Chemoradiotherapy

PURPOSEPreoperative combined chemoradiotherapy is currently the main neoadjuvant therapy used to treat locally advanced middle and low rectal adenocarcinoma. A restaging work-up with magnetic resonance imaging was hoped to provide information about the effects related to combined chemoradiotherapy. The goal was to evaluate the correlation between pathologically verified tumor stages and clinical stages predicted by magnetic resonance imaging after combined chemoradiotherapy.METHODSBetween August 2000 and June 2003, 50 patients with biopsy-proven middle and lower rectal adenocarcinoma, with initial stage T3–T4 or N+, M0, were recruited in this series. Pelvic magnetic resonance imaging was used to stage the tumor before and after combined chemoradiotherapy. A protocol of the standard external radiation dose and oral combined uracil and 5-fluorouracil plus leucovorin was used. The results of magnetic resonance imaging restaging after combined chemoradiotherapy were correlated with the pathologic staging.RESULTSThe overall predictive accuracy in T stage was 52 percent, whereas overstaging and understaging occurred in 38 percent and 10 percent of patients, respectively. Most of the inaccurate T staging was a result of the overstaging of superficial tumors (T0–T2). In N stage, accurate staging was noted in 68 percent of all patients, whereas 24 percent were overstaged and 8 percent were understaged.CONCLUSIONIn restaging irradiated tumors, magnetic resonance imaging had the accuracy of 52 percent in T stage and 68 percent in N stage. Poor agreement between post–combined chemoradiotherapy magnetic resonance imaging and pathologic staging was observed in both T (k = 0.017) and N (k = 0.031) stages. Most of the inaccuracy in both T and N stages was caused by overstaging. The problem with magnetic resonance imaging was believed to be that it could not completely differentiate fibrosis from viable residual tumors.

Concurrent chemoradiotherapy treatment of locally advanced pancreatic cancer: Gemcitabine versus 5-fluorouracil, a randomized controlled study

PURPOSE To determine the efficacy and tolerability of gemcitabine (GEM)-concurrent chemoradiotherapy (CCRT) vs. 5-fluorouracil (5-FU) CCRT for locally advanced pancreatic cancer. METHODS AND MATERIALS Thirty-four patients with locally advanced pancreatic cancer were studied. Eighteen patients were randomized to receive GEM CCRT (600 mg/m(2)/wk for 6 weeks) and 16 patients to receive bolus 5-FU CCRT (500 mg/m(2)/d for 3 days repeated every 2 weeks for 6 weeks). All patients were to receive 3D-CRT 50.4-61.2 Gy at 1.8-Gy/d fractions and GEM (1000 mg/m(2) weekly for 3 weeks repeated every 4 weeks) after RT. RESULTS The median survival and median time to progression were 14.5 months and 7.1 months for the GEM CCRT group and 6.7 months and 2.7 months for the 5-FU CCRT group (p = 0.027 and p = 0.019, respectively). The quality-adjusted life month survival time was 11.2 +/- 0.5 months for GEM CCRT and 6.0 +/- 0.3 months for 5-FU CCRT patients (p <0.001). The response rate was 50% (four complete responses and five partial responses) for GEM CCRT and 13% (two partial responses) for 5-FU CCRT (p = 0.005). Pain control was 39% for GEM CCRT and 6% for 5-FU CCRT (p = 0.043). Grade 3-4 neutropenia (34% vs. 19%), thrombocytopenia (0% vs. 7%), nausea (33% vs. 31%), vomiting (17% vs. 19%), hospitalization days per month of survival (7.4 +/- 1.7 days vs. 8.0 +/- 1.3 days), and full dose of RT received (78% vs. 75%) were not significantly different between the GEM CCRT and 5-FU CCRT patients. CONCLUSION GEM CCRT appears more effective than 5-FU CCRT for locally advanced pancreatic cancer and has comparable tolerability.

Diffusion-weighted single-shot echo-planar imaging with parallel technique in assessment of endometrial cancer.

OBJECTIVE The purposes of this study were to determine the feasibility of diffusion-weighted imaging (DWI) with a single-shot echo-planar sequence and parallel technique for depicting endometrial cancer and to examine the role of this technique in preoperative assessment. SUBJECTS AND METHODS A total of 31 patients were recruited for MRI evaluation of suspicious endometrial lesions found on transvaginal sonography. Twenty-four of the patients were proved to have endometrial cancer (patient group), and seven to have benign diseases (control group). The MRI examinations included diffusion-weighted single-shot echoplanar sequences and contrast-enhanced T1-weighted 3D fat-suppressed spoiled gradient-echo sequences. The apparent diffusion coefficient of endometrial cancer in the patient group and of normal endometrium in the control group were measured on the apparent diffusion coefficient map of each diffusion-weighted image and compared for the two groups. In the patient group, myometrial invasion was evaluated with the two sequences. The diagnostic accuracy rates of each pulse sequence were compared. RESULTS The mean apparent diffusion coefficient of endometrial cancer was 0.864 x 10(-3) mm2/s and that of benign endometrial lesions was 1.277 x 10(-3) mm2/s. The difference between the two groups was significant (p = 0.0058). The diagnostic accuracy for myometrial invasion was 61.9% for DWI and 71.4% for gadolinium-enhanced T1-weighted 3D fat-suppressed spoiled gradient-recalled echo images. In five cases, DWI provided information about tumor extent and depicted the tumor focus, findings that changed preoperative staging. CONCLUSION DWI performed with parallel imaging technique has potential as a method for differentiating benign from malignant endometrial lesions. It also provides valuable information for preoperative evaluation and should be considered part of routine preoperative MRI evaluation for endometrial cancer.

Performance status in patients with hepatocellular carcinoma: Determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system

Performance status is included in the Barcelona Clinic Liver Cancer (BCLC) system for hepatocellular carcinoma (HCC). Few studies specifically evaluated the role of performance status in patients with HCC. This study investigated its distribution, determinants, and prognostic impact, aiming to improve the performance of the BCLC system. A total of 2,381 HCC patients were enrolled. Performance status was determined according to the Eastern Cooperative Oncology Group scale. The prognostic ability of the original and three modified BCLC systems in HCC patients was compared by the Akaike information criterion (AIC). There were 60, 17, 11, 8, and 4% of patients who were classified as performance status 0, 1, 2, 3, and 4, respectively. A worse performance status significantly correlated with age, alcoholism, hypoalbuminemia, hyperbilirubinemia, renal insufficiency, hyponatremia, and prothrombin time prolongation (all P < 0.001). Larger tumor burden, poorer residual liver function, more frequent vascular invasion, and diabetes mellitus were also observed in patients with worse performance status (all P < 0.001). Patients with poorer performance status more often received best supportive care (P < 0.001). In the Cox proportional hazards model, performance status was an independent prognostic predictor and the long‐term survival tended to be worse in patients with progressively poor performance status (all P < 0.05). Reassigning patients with performance status 0 or 1 to stage B provided the lowest AIC among the four BCLC‐based staging systems.

Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy.

Objectives: Pancreatic exocrine insufficiency has been reported to be more common in pancreaticogastrostomy (PG) than in pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). This study aimed to evaluate the long-term outcome after PD between these 2 groups. Methods: We evaluated the long-term functional status of 42 surviving patients diagnosed with periampullary lesions who underwent PJ or PG after PD and followed up for more than 1 year. Among these, 23 patients underwent PJ and 19 patients underwent PG. To compare the 2 groups, we analyzed the (1) pancreatic exocrine insufficiency by questioning the presence or absence of steatorrhea, (2) pancreatic endocrine function by measuring glycohemoglobin A1c, fasting blood glucose, and history of new-onset diabetes, (3) nutritional status by measuring serum total protein, albumin, cholesterol, and triglyceride, (4) gastric emptying time, (5) panendoscopic findings, (6) changes of pancreatic duct diameter by computed tomography, and (7) relaparotomy rate. Results: The mean follow-up time for PG and PJ were 37 ± 23 and 103 ± 52 months, respectively (P < 0.05). A total of 52.4% patients developed pancreatic exocrine insufficiency, and 11.9% had new-onset diabetes. There was no significant difference between PJ and PG groups. A significantly improved postoperative nutritional state regarding serum total protein and albumin were noticed in both groups. There was no significant difference in terms of gastric emptying time, positive panendoscopic findings, and changes in pancreatic duct diameter. The pancreatic remnant-related relaparotomy rate was higher in the PJ group as compared with the PG group (17.4% vs 0%; P = 0.056). Conclusions: There is no significant difference in pancreatic exocrine or endocrine insufficiency, gastric emptying time, and positive panendoscopic findings between PJ and PG. Pancreaticojejunostomy was associated with a higher pancreatic remnant-related relaparotomy rate; however, because of a shorter follow-up in the PG group, a continuous long-term follow-up is still needed.

Comparison of radiofrequency ablation and transarterial chemoembolization for hepatocellular carcinoma within the Milan criteria: a propensity score analysis.

Radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) are used to treat hepatocellular carcinoma (HCC). This study was designed to compare the long‐term survival of HCC patients within the Milan criteria who underwent RFA or TACE. In all, 315 RFA patients and 215 TACE patients with HCC within the Milan criteria were analyzed. Propensity scores were generated to select matched patients. For the propensity model, 101 patients were selected from each arm of the study. Independent prognostic predictors were determined with the Cox proportional hazards model. The long‐term survival was significantly better for the RFA group in the univariate survival analysis (P = 0.048). In the Cox model, the following were identified as independent predictors of poor prognosis (TACE was not): age > 69 years (P = 0.026), serum α‐fetoprotein level > 20 ng/mL (P = 0.003), ascites (P < 0.001), Eastern Cooperative Oncology Group performance status ≥ 1 (P = 0.004), total tumor volume (TTV) > 8.2 cm3 (P = 0.020), and vascular invasion (P = 0.023). With similar baseline patient characteristics generated in the propensity score model, there was no significant difference in the long‐term survival rates of the 2 groups of patients. A subgroup analysis showed that among patients with a TTV < 11 cm3, the RFA group had significantly better long‐term survival than the TACE group (P = 0.032). In conclusion, TACE and RFA lead to comparable long‐term survival rates for HCC patients within the Milan criteria. Patients with a smaller TTV (<11 cm3) are likely to benefit more from RFA treatment. Further studies are needed to compare RFA and TACE in patients with early‐stage cancers. Liver Transpl 17:556–566, 2011.

Concurrent chemoradiation is effective in the treatment of alpha-fetoprotein-producing acinar cell carcinoma of the pancreas: report of a case.

Alpha-fetoprotein (AFP), a serum glycoprotein, is produced mainly in the fetal liver, yolk sac, and fetal gastrointestinal tract (1), and is usually not detected in the sera of healthy adults. However, when a hepatocellular carcinoma (HCC) or embryonal cell carcinoma exists, the serum AFP level frequently increases. It is regarded as a sensitive tumor marker for diagnosis and recurrence. In addition to HCC and embryonal cell carcinoma, AFP elevation is rarely seen in other malignancies, including cancers of the gastrointestinal tract (2–4), lungs (5), or kidneys (6). Pancreatic carcinomas with elevated serum levels of AFP have been occasionally reported, with an incidence between 6%–24% (2,7), which were usually associated with liver metastasis. Acinar cell carcinoma (ACC) of the pancreas is a rare type of pancreatic carcinoma, which comprises only approximately 1% of all nonendocrine tumors of the pancreas (8). Among all ACCs, AFP-producing ACC has been rarely reported (9,10), with an incidence of only 4.5–6% of all ACCs (8,11). Surgical resection remains the best treatment for resectable ACC of pancreas under feasible conditions. For locally advanced tumors, concurrent chemoradiotherapy also may be effective. We present a case of AFP-producing ACC of the pancreas mimicking HCC, and we detail its radiologic and immunohistochemical features. Successful palliative treatment with concurrent chemoradiotherapy is also discussed.

Tuberculosis of the prostate : MR appearance

Tuberculosis of the prostate is uncommon. Here we present a case of tuberculosis of the prostate with its MR findings.: Tuberculosis of genitourinary tract is common in Taiwan. We present two cases of tuberculosis of the prostate with their CT findings.

Liver failure after transarterial chemoembolization for patients with hepatocellular carcinoma and ascites: incidence, risk factors, and prognostic prediction.

Background Transarterial chemoembolization (TACE) is widely used in patients with hepatocellular carcinoma (HCC). Post-TACE liver failure may occur, especially in patients with poor hepatic reserve. Ascites is often present in patients with HCC with coexisting cirrhosis. This study investigated the incidence, risk factors, and prognostic predictors in patients with HCC and ascites receiving TACE. Methods A total of 614 patients with HCC were enrolled and analyzed. Liver failure was defined as an increase of serum bilirubin level (≥2.0 mg/dL), increasing or newly developed ascites, or hepatic encephalopathy within 2 weeks of TACE. Results Ascitesthat were present in 100 (16.2%) patients at study entry, independently predicted a poor prognosis in the Cox proportional hazard model [relative risk (RR)=1.75, P=0.004]. Post-TACE liver failure occurred in 17 (17.3%) of 98 patients with HCC who had ascites and long-term follow-up. Child-Turcotte-Pugh class B (odds ratio=10.1, P=0.038) and post-TACE gastrointestinal bleeding (odds ratio=10.86, P=0.006) were independent risk factors associated with liver failure in the multivariate analysis. Of the 17 patients with post-TACE liver failure, 16 (94%) died within the first year of treatment. Liver failure (RR: 2.13, P=0.029), serum &agr;-fetoprotein level >51 ng/mL (RR=2.0, P=0.013) and poor performance status (RR: 2.17, P=0.003) independently predicted a poor prognosis in patients with ascites receiving TACE. Conclusions Preexisting ascites increases the mortality in patients with HCC receiving TACE. In patients with HCC and ascites, Child-Turcotte-Pugh class B and gastrointestinal bleeding are associated with liver failure after TACE. Post-TACE liver failure is a common event and predicts a decreased survival in patients with HCC and ascites.

Efficacy and Factors Affecting Outcome of Gemcitabine Concurrent Chemoradiotherapy in Patients With Locally Advanced Pancreatic Cancer

PURPOSE To evaluate the efficacy and prognostic factors of gemcitabine (GEM) concurrent chemoradiotherapy (CCRT) in patients with locally advanced pancreatic cancer. METHODS AND MATERIALS Between January 2002 and December 2005, 55 patients with locally advanced pancreatic cancer treated with GEM (400 mg/m(2)/wk) concurrently with radiotherapy (median dose, 50.4 Gy; range, 26-61.2) at Taipei Veterans General Hospital were enrolled. GEM (1,000 mg/m(2)) was continued after CCRT as maintenance therapy once weekly for 3 weeks and repeated every 4 weeks. The response, survival, toxicity, and prognostic factors were evaluated. RESULTS With a median follow-up of 10.8 months, the 1- and 2-year survival rate was 52% and 19%, respectively. The median overall survival (OS) and median time to progression (TTP) was 12.4 and 5.9 months, respectively. The response rate was 42% (2 complete responses and 21 partial responses). The major Grade 3-4 toxicities were neutropenia (22%) and anorexia (19%). The median OS and TTP was 15.8 and 9.5 months in the GEM CCRT responders compared with 7.5 and 3.5 months in the nonresponders, respectively (both p < 0.001). The responders had a better Karnofsky performance status (KPS) (86 +/- 2 vs. 77 +/- 2, p = 0.002) and had received a greater GEM dose intensity (347 +/- 13 mg/m(2)/wk vs. 296 +/- 15 mg/m(2)/wk, p = 0.02) than the nonresponders. KPS and serum carbohydrate antigen 19-9 were the most significant prognostic factors of OS and TTP. CONCLUSION The results of our study have shown that GEM CCRT is effective and tolerable for patients with locally advanced pancreatic cancer. The KPS and GEM dose correlated with response. Also, the KPS and CA 19-9 level were the most important factors affecting OS and TTP.