Stereotactic Radiosurgery for Metastatic Brain Tumor / 이화의대지

Brain metastases are a leading cause of morbidity and mortality for patients with systemic cancer and are among the most common intracranial tumors in adults. Its incidence increases as cancer therapies improve, and patients live longer, providing new challenges to the multidisciplinary teams that manage these patients. The contemporary neurosurgical treatment of intracranial metastases has become gradually more complex as the available therapeutic options increase. For the past 50 years, wholebrain radiotherapy and systemic corticosteroids have been considered as the standard of care for patients with brain metastases. However, in recent years, stereotactic radiosurgery is spotlighted as an alternative therapeutic modality for these patients because of its relatively short, convenient, and non-invasive treatment course. Stereotactic radiosurgery is a radiation therapy technique in which multiple focused radiation beams intersect over a target, which results in the delivery of highly conformal, high-dose of radiation to the target and minimal radiation to surrounding normal parenchyma. The purpose of this review is to provide an overview of stereotactic radiosurgery as a treatment modality for patients with brain metastases.

Clinical Features and Treatment Outcomes of Acute Multiple Thoracic and Lumbar Spinal Fractures: A Comparison of Continuous and Noncontinuous Fractures

OBJECTIVE: The treatment of multiple thoracolumbar spine fractures according to fracture continuity has rarely been reported. Herein we evaluate the clinical features and outcomes of multiple thoracolumbar fractures depending on continuous or noncontinuous status.METHODS: From January 2010 to January 2016, 48 patients with acute thoracic and lumbar multiple fractures who underwent posterior fusion surgery were evaluated. Patients were divided into two groups (group A : continuous; group B : noncontinuous). We investigated the causes of the injuries, the locations of the injuries, the range of fusion levels, and the functional outcomes based on the patients’ general characteristics.RESULTS: A total of 48 patients were enrolled (group A : 25 patients; group B : 23 patients). Both groups had similar pre-surgical clinical and radiologic features. The fusion level included three segments (group A : 4; group B : 5) or four segments (group A : 19; group B : 5). Group B required more instrumented segments than did group A. Group A scored 23.5 and group B scored 33.4 on the Korean Oswestry Disability Index (KODI) at the time of last follow-up. In both groups, longer fusion was associated with worse KODI score.CONCLUSION: In this study, due to the assumption of similar initial clinical and radiologic features in both group, the mechanism of multiple fractures is presumed to be the same between continuous and noncontinuous fractures. The noncontinuous fracture group had worse KODI scores in long-term follow-up, thought to be due to long fusion level. Therefore, we recommend minimizing the number of segments that are fused in multiple thoracolumbar and lumbar fractures when decompression is not necessary.

Clinical Features and Treatment Outcomes of Acute Multiple Thoracic and Lumbar Spinal Fractures: A Comparison of Continuous and Noncontinuous Fractures

OBJECTIVE: The treatment of multiple thoracolumbar spine fractures according to fracture continuity has rarely been reported. Herein we evaluate the clinical features and outcomes of multiple thoracolumbar fractures depending on continuous or noncontinuous status. METHODS: From January 2010 to January 2016, 48 patients with acute thoracic and lumbar multiple fractures who underwent posterior fusion surgery were evaluated. Patients were divided into two groups (group A : continuous; group B : noncontinuous). We investigated the causes of the injuries, the locations of the injuries, the range of fusion levels, and the functional outcomes based on the patients’ general characteristics. RESULTS: A total of 48 patients were enrolled (group A : 25 patients; group B : 23 patients). Both groups had similar pre-surgical clinical and radiologic features. The fusion level included three segments (group A : 4; group B : 5) or four segments (group A : 19; group B : 5). Group B required more instrumented segments than did group A. Group A scored 23.5 and group B scored 33.4 on the Korean Oswestry Disability Index (KODI) at the time of last follow-up. In both groups, longer fusion was associated with worse KODI score. CONCLUSION: In this study, due to the assumption of similar initial clinical and radiologic features in both group, the mechanism of multiple fractures is presumed to be the same between continuous and noncontinuous fractures. The noncontinuous fracture group had worse KODI scores in long-term follow-up, thought to be due to long fusion level. Therefore, we recommend minimizing the number of segments that are fused in multiple thoracolumbar and lumbar fractures when decompression is not necessary.

Syntenin increases the invasiveness of small cell lung cancer cells by activating p38, AKT, focal adhesion kinase and SP1

Syntenin is a PDZ domain-containing adaptor protein that has been recently shown to regulate migration and invasion in several tumors. Small cell lung cancer (SCLC) is notorious for its invasiveness and strong potential for metastasis. We therefore studied the influence of syntenin on the invasiveness of SCLC. Immunohistochemistry in tumor tissues showed that syntenin was more frequently expressed in small cell carcinomas than other neuroendocrine tumors, such as carcinoids and neuroblastomas, suggesting that syntenin expression may be related to more aggressive forms of neuroendocrine tumors. In SCLC patients, syntenin overexpression in tumor cells was significantly associated with more extensive and advanced disease at the time of diagnosis (P=0.029). Overexpression of syntenin in SCLC cells that were intrinsically syntenin-low increased the invasiveness of cells and led to the induction of extracellular matrix (ECM)-degrading membrane type 1-matrix metalloproteinase (MT1-MMP) and matrix metalloproteinase 2 (MMP2). In contrast, suppression of syntenin in syntenin-high cells was associated with the downregulation of MT1-MMP. Contrary to the results of previous studies using malignant melanomas and breast carcinomas, signaling cascades were shown to be further transduced through p38 MAPK and PI3K/AKT, with activation of SP1 rather than NF-kappaB, under circumstances not involving ECM interaction. In addition, the upstream molecule focal adhesion kinase was induced by syntenin activation, in spite of the absence of ECM interaction. These results suggest that syntenin might contribute to the invasiveness of SCLC and could be utilized as a new therapeutic target for controlling invasion and metastasis in SCLC.

Solitary Primary Leptomeningeal Glioma: Case Report

We report a case of solitary primary leptomeningeal glioma. The mass was totally removed under awake surgery. Intraoperatively, no parenchymal involvement was noted. Histopathological study revealed a predominant anaplastic oligodendroglioma component and a focal anaplastic astrocytoma component, which was consistent with an anaplastic oligoastrocytoma. Adjuvant tomotherapy was followed and the tumor has not recurred until 12 months after surgery. A focal type of primary leptomeningeal glioma is extremely rare. We report a rare case of solitary primary leptomeningeal anaplastic oligoastrocytoma.

Post-traumatic Arterial Priapism: Doppler Ultrasonographic Findings and Therapeutic Embolization

Two cases of post-traumatic arterial priapism diagnosed with duplex and color Doppler ultrasonography showed pseudoaneurysm and increased peak systolic and diastolic velocity of the inflowing cavernosal artery(low resistance index). An autologous blood clot successfully controlled tumescence and was comfortable and secure in preventing necrosis and impotence.

Large Impacted Intrahepatic Bile Duct Stones: Usefulness of Ultrasonic Lithotripsy

PURPOSE: To determine the usefulness of ultrasonic lithotripsy for the fragmentation of large impacted intrahepatic duct(IHD) stones. MATERIALS AND METHODS: Large impacted stones in five patients were fragmented with a 12.5F rigid ureterorenoscope and a 5.5F rigid ultrasonic oscillating burr via T-tube tract. Two to three dayslater, the fragmented stones were extracted via T-tube tract with basket. RESULTS: Disintegration was complete in three patients and partial in two. The fragmented stones were completely removed in four patients and partially in one. due to that patient's refusal. CONCLUSION: Insertion of a rigid endoscope and ultrasound drill into theorifice of the IHD can be performed without problem. Ultrasonic lithotripsy is an effective technique for the fragmentation of large impacted intrahepatic stones located in the or ifice of the IHD.

The Internationalization of the Korean Radiological Society

Toward the beginning of the twenty-first century, the world experiences the dramatic changes in politics, economics and culture, and it is evident that the Korean medical field will not be able to survive provided it doesn't prepare ourselves to adapt to those changes. The Korean Medical Society held a forum for the active operation of the medical society, inviting several leading affiliated societies, to meet the needs of the times. This review describes the summary of the presentation that the authors made on behalf of the Korean Radiological Society in the forum, including the organization, current status of academic activity, current status of international communication, and problems encountered in the internationalization of the Korean Radiological Society.

Airway Responses to Bronchoprovocation Using High-Resolution Computed Tomography in Patients with Bronchial Asthma / 결핵

BACKGROUND: Bronchial hyperresponsiveness and abnormal response such as a loss of distensi- bility are pathophysiologic characteristics if bronchial asthma. The only means of direct in vivo measurement of airway size had been a tantalium bronchography, until high-resolution computed tomography(HRCT) enabled to measure noninvasively two dimensional airway area more accurately and reliably. METHOD: To investigate airway area responses to bronchial provocation with methacholine and evaluate the major sites of bronchial constriction in patients with bronchial asthma. We examined HRCT scans in five patients with bronchial asthma who had significant bronchoconstriction(20% or more decrease in FEV1) using CT scanner(5,000T CT, Shimadzu Co, Japan) before and in 3~5 min. after methacholine inhalation. Airways which were matched by parenchymal anatomic landmarks in each patient before and after methacholine inhalation were measured using film scanner(TZ-3X scanner; Truvel Co. Chatsworth CA, USA) and a semiautomated region growing method. RESULTS: 1) We identified 9 to 12 airways in each patient which were matched by parenchymal anatomic landmarks before and after methacholine inhalation. 2) Airway responses to methacholine are quite different even in a patient. 3) The constriction of small airways(average diameter 2 mm; area >3.14 mm2), 53.8% (4.4;SEM, n=10), but not significantly different(p>0.05). 4) There was no significant difference in the degree of constriction between upper(44.3% +5.8; mean + SEM, n=30) and lower lung regions(56.7% +4.5, n=23). CONCLUSIONS: Thus airway responses to methacholine bronchoprovocation is quite variable in a patient with bronchial asthma and has no typical pattern in patients with bronchial asthma.

Chemical Dissolution of Intrahepatic Stones in Vitro

PURPOSE: The in vitro dissolution of intrahepatic stones was evaluated using the various solvent mixtures. MATERIALS AND METHODS: Sixty four intrahepatic stones from 16 patients were used. Four kinds of solvent mixtures(No. 1 = basic buffer + EDTA, No. 2=1 + Sulfobetain-12, No. 3=2 + N-acetylcysteine, No. 4=3 + urea) were used. Dissolution rates were determined by measuring the weight loss of stones after 6, 12, 24, 48 hours incubation periods, respectively. RESULTS: The highest dissolution rates in dissolving intrahepatic stones were achieved with No. 4 solvent mixture(1% W/V EDTA/80mM, Sulfobetain-12/1 M, urea, pH 9.5). CONCLUSION: lntrahepatic stones could be largely dissolved up to about 70% of their initial weight after 48 hours incubation period in vitro.

Percutaneous Removal of the Retained Biliary Stones: Evaluation of the Results on of Impatient-basis Management

PURPOSE: All procedures for the removal of retained intrahepatic stones were performed on inpatient basis. We evaluated the advantage of the procedures performed on inpatient basis compared with outpatient basis in terms of the success rate, causes of failure and the complication. MATERIALS AND METHODS: Percutaneous removal of retained intrahepatic stones was performed in 58 patients through a T-tube tract on inpatient basis from April 1990 to December 4992. Stones were exclusively intrahepatic in 28 patients, whereas 30 patients had combined stones in common bile duct. Preshaped catheters, baskets, and balloon catheters were used to remove the stones and dilate the strictures of the ducts. Extracorporeal shock wave lithotripsy and choledochoscopy with electrohydraulic lithotripsy were used to crush the impacted stones. RESULTS: The stones were completely removed in 34 (58.6%) of 58 patients and most of the stones were removed in 17 patients (29.3%). The overall success rate was 87.9%. The complications (cholangitis in 13% and pancreatitis in 0.8% per session) were found and successfully managed by appropriate care. CONCLUSION: Better success rate could be achieved by more aggressive appraoch on inpatient basis when compared with previous reports on outpatient basis. We suggest that the procedures should be performed on inpatient basis especially in a case with severe strictures or impacted stones.

Gallstone Dissolution with Methyl Tertiary Butyl Ether: An Experimental Study on Selection of Gallstone by Plain Radiography and Ultrasonography

PURPOSE: The purpose of this study was to determine whether in vitro plain radiography and ultrasonography(US) could predict the outcome of gallstone dissolution with methyl tert-butyl ether(MTBE). METHODS AND MATERIALS: The plain radiography and ultrasonography of 75 gallstones removed at surgery from 75 patients were obtained. The plaih radiographic findings were grouped by their calcification pattern as group l:lucent, group 2:central, group 3:diffuse and group 4: laminated. The ultrasonographic findings were grouped by their echo pattern as group 1 :arc shaped, clearly defined surface echo followed by distinct acoustic shadow, group 2:strong surface echo with gradually attenuating, meniscus shaped inner echo, group 3:strong surface echo with fill-in pattern of internal echo, group 4:strong surface echo with irregular inner echo and group 5:entirely discerning circumsference, homogeneous internal echotexture. After imaging, the gallstones underwent MTBE dissolution for 6 hours. The residual weight of each stone was measured every 2 hours. The correlation between imaging findings and dissolution rate was retrospectively analysed. RESULTS: The radiolucent and central calcification stones were dissolved rapidly as compared with the diffuse and laminated calcification stones(p<.05). There was no statistically significant difference among the groups based on ultrasonographic findings alone. However, after exclusion of the certain calcification groups that were resistent to dissolution-diffuse or laminated calcification stones-all US groups except one that shows wholly circumscribed margin and homogeneous fill-in pattern of internal echo dissolved well to average 20% or less of the original weight(p<.05). CONCLUSION: MTBE dissolution can be tried in stones that meet both ultrasonographic (not a stone with homogeneous fill-in pattern of internal echo) and plain radiographic (radiolucent or cental calcification stone) criteria.

CT Findings of Focal Organizing Pneumonia: Correlation with Pathologic Findings

PURPOSE: To evaluate the CT findings of focal organizing pneumonia and to correlate them with pathologic findings to help differentiating from lung cancer. MATERIALS AND METHODS: We evaluated radiologic and pathologic findings of five patients with solitary pulmonary nodule which were confirmed as focal organizing pneumonia pathologically. RESULTS: On CT scan, focal organizing pneumonia had irregular margin contacting the pleura in all five cases. The shape of the nodules were spherical to wedge or elliptical and the size from 3.5cm to 5.5cm (average 4.2cm) in largest diameter. On postcontrast CT scan, all nodules showed enhancement and four cases showed central low density components. Two nodules contained air within the nodule. In four cases, pleural changes such as effusion and/or focal thickening were noted. No lymphadenopathy was found in all cases. Pathologically, the enhancing portion on CT showed findings of organizing pneumonia such as granulation tissue with fibroblast proliferation in alveolar space and interstitial thickening. The central low density areas on CT were due to ischemic necrosis, abscess and exudate, transudate and infiltration of foamy histiocyte. CONCLUSION: The possibility of focal organizing pneumonia should be considered when peripherally located solitary pulmonary nodule had enhancing component with no combined lymphadenopathy on CT scan.

Changes of Brachial Arterial Doppler Waveform during Immersion of the Hand of Young Men in Ice-cold Water

PURPOSE: To evaluate the changes of brachial arterial Doppler waveform during immersion of the hand of young men in ice-cold water. MATERIALS AND METHODS: Doppler waveforms of brachial arteries in 11 young male patients were recorded before and during immersion of ipsilateral hand in ice-cold water(4--5 degree C). The procedure was repeated on separate days. Patterns of waveform during immersion were compared with the changes of pulsatility index. RESULTS: Four men showed high impedance waveforms, and 5 men showed low impedance waveforms during immersion both at the first and at the second study. Two men, however, showed high impedance waveforms at the first study and low impedance waveforms at the second study. The pulsatility index rose and fell in high and low impedance waveforms, respectively. CONCLUSION: The changes of brachial arterial Doppler waveforms could be classified into high and low impedance patterns, probably reflecting the acute changes in downstream impedance during immersion of hand in ice-cold water.

Effect of Transcatheter Arterial Embolization according to Angiographic Findings in Hepatocellular Carcinoma

PURPOSE: The purpose of this study is to assess the effect of Transcatheter Arterial Embolization(TAE) according to anglographic findings in hepatocellular carcinoma. MATERIALS AND METHOD: We retrospectively reviewed 50 cases who received TAE for unresectable hepatocellular carcinoma. We analyzed the anglographic findings which were correlated with the effect of TAE. The common anglographic findings of the hepatocellular carcinoma were tumor staining, neovascularity and enlargement of feeding artery. These anglographic findings were classified into grade 0, +1, +2. Effect of TAE were classified into five patterns;good response, partial response, minimal response, no response and more aggravation. RESULT:In grading of tumor staining, among 50 cases, the grade 0, +1, +2 were seen in 1 case(2%), 14 cases(28%), 35 cases(70%) each. In grading of enlargement of feeding artery, the grade 0, +1, +2 were seen in 7 cases(14%), 19 cases(38%), 24 cases(48%) each. In grading of neovascularity, the grade 0, +1, +2 were seen in 6 cases(12%), 15 cases(30%), 29 cases(58%) each. This study showed that the higher grade of anglographic finding, the better effect of TAE. A statistically significant differance was found (p<0.005). But the TAE was not effective in some cases (the maximum diameter of mass is over 10cm, portal vein thrombosis or ateriovenous shunt) in spite of high grade. CONCLUSION: We believe that these angiogr. aphic findings (tumor staining, enlargement of feeding artery, neovascularity) are one of important indices for anticipating the effect of TAE in patients with unresectable hepatocellular carcinoma.

Chronic Recurrent Hemoptysis: Effectiveness of Bronchial Artery Embolization in 25 Patients

PURPOSE: Bronchial artery embolization has been effective in the treatment of massive hemoptysis. The purpose of this study was to report the effectiveness of bronchial artery embolization in patients with chronic recurrent hemoptysis intractable to medical treatment. MATERIALS AND METHODS: This study included 25 patients who were admitted for treatment of chronic recurrent hemoptysis with bronchial artery embolization. Chronic recurrent hemoptysis was defined as condition intractable to medical treatment persistently and occuring over two times per two months. The target vessels for embolization were selected in consideration of the results of aortography as well as the finding of chest radiography and bronchoscopy. After selective arteriography for embolization by using 5-French Simmons catheter, embolic agents(mainly polyvinyl alcohol(PVA) and additionally gelfoam and coils) were released through the catheter. The results of the embolization were assessed with the review of medical records. RESULT: The causes of the hemoptysis were pulmonary tuberculosis(n=12,48%), bronchiectasis(n=6,24%), aspergilloma(n=3,12%), chronic obstructive pulmonary disease(n=2,8%), chronic bronchitis(n=I,4%) and lung abscess(n=1,4%). Selective embolization was carried out in 49 sites(42 in bronchial artery and 7 in nonbronchial systemic collaterals). Early success rate within 2 months was 96%. After long-term follow up study (6-30 months, average 15 months), complete remission was 72%, partial remission 12% and recurrence 12% respectively. During and after embolization, major complications such as spinal cord injury or bronchial wall necrosis was not found. Minor complications were chest pain, shoulder pain and chilling sense, which were relieved spontaneously within a few days. CONCLUSION: High success rate and relatively low recurrence with no significant complication were achieved with bronchial artery embolization in the patients complaining of chronic recurrent hemoptysis.

Doppler Sonographic Evaluation of Ophthalmic Arterial Flow Pattern in Hypertensive Patients

PURPOSE: To compare the Doppler velocity waveform pattern of ophthalmic artery of hypertensive patients with that of normotensive subjects. MATERIALS AND METHODS: Doppler velocity waveform was obtained from ophthalmic artery in 45 hypertensive patients and 60 normotensive subjects. Both hypertensives and normotensive subjects were classified according to age into those younger than and those older than 45 years. Doppler indices[pulsatility index(PI), resistance index(RI), the first systolic peak/the second systolic peak(S1/S2), the first sytolic peak/diastolic peak (S1/D)] measured in hypertensive patients were compared with normotensive subjects. RESULTS: Among the various doppler indices, only S1/S2 showed significant difference(p < 0.05) between the hypertensive patients and normotensive subjects younger than 45 years. Doppler velocity waveform of hypertensive patients older than 45 years showed no significant difference from that of normotensive subjects with corresponding age. CONCLUSION: Doppler velocity waveform of ophthalmic artery in hyopertensive patients younger than 45 years shows pattern with S2 higher than that of normotensive subjects. High S2 component(reflective-wave) may represent increased vascular impedance ~ue to vasococonstriction of retinal arterioles in hypertensve patients.

Assessment of Pulmonary Airway Reactivity using High-Resolution CT after Administration of Bronchodilator in Patients with Bronchial Asthma

PURPOSE:The purpose of this study is to assess the pulmonary airway reactivity in asthmatic patients directly and noninvasively by using high-resolution CT(HRCT). MATERIALS AND METHODS: 130 bronchial luminal areas were measured by HRCT in 16 asthmatic patients before and after inhalation of bronchodilator (Salbutamol sulfate). The change of bronchial luminal area on HRCT was analyzed and correlated with the change of forced expiratory volume in 1 second(FEV1) on pulmonary function test in each patient. RESULTS: The mean percentage of increase in luminal areas of the 130 bronchi after bronchodilator inhalation was 95.4 +/- 103.3%. The group with the smallest luminal areas (lesser than 1.35mm2) was more sensitively increased in area than the group with the largest areas (equal or larger than 3.72 mm2) ;183.5% versus 63.5%. The mean percentage of increase in FEV1 was 21.7% and there was no statistically significant correlation between the increased degrees of luminal areas and that of FEV1(r=-0.04). CONCLUSION:We can measure the bronchial luminal area directly and noninvasively with HRCT and can also estimate the degree of airway reactivity in asthmatic patient by measuring of the changes of bronchial luminal areas after administration of bronchodilator.

Change in Pancreatic Size after Gastric Resection: CT Evaluation

PURPOSE:The purpose of this study is to evaluate the change of pancreatic size after gastric resection in patients with gastric malignancy. MATERIALS AND METHODS: We compared the pancreatic sizes on pre- and post-operative abdominal CT scans in 50 patients whose stomach had been resected due to malignancy. The mean interval was 20.3 months (range, 5-81 months). The types of the operation were total gastrectomy with esophagojejunostomy and jejunojejunostomy (n=7), and subtotal gastrectomy with gastrojejunostomy (Billroth II) (n=43). Pancreatic thickness was measured perpendicular to the pancreatic long axis at head, body and tail. RESULT: There was a significant reduction of pancreatic size on postoperative CT scan. The reduction rate was 5.9% in the head (p<0.001), 7.1% in the body (p<0.001) and 14.4% in the tail (p<0.001). CONCLUSION:Significant reduction of pancreatic size was observed after gastric resection due to gastric rnalignancy, especially in tail.

Gallbladder contractability before and after extracorporeal shock- wave lithotripsy

No abstract available.