Serum CA19-9 is a significant predictor among preoperative parameters for early recurrence after resection of pancreatic adenocarcinoma.

OBJECTIVE: To evaluate the preoperative factors predictive of postoperative early recurrence in patients with resected pancreatic cancer focusing on the serum CA19-9 value. METHODS: One hundred fifty-four patients undergoing surgical resection for pancreatic cancer were enrolled in this study. Univariate and multivariate analyses were performed to determine the predictors of early recurrence which was defined as relapse within 6 months after surgery. RESULTS: On ROC curve analysis, the cutoff value of CA19-9 was determined to be 100 U/ml. Of 73 patients with CA19-9 value ≥ 100 U/ml, 39 (53 %) had early recurrence. In contrast, only 9 of 81 patients (11 %) with CA19-9 value < 100 U/ml developed a recurrence at an early period (p < 0.001). Multivariate analysis revealed that CA19-9 value ≥ 100 U/ml (odds ratio, 11.2) were significant predictors of early recurrence. The overall 3- and 5-year survival rates and median survival times were 47.3 %, 40.1 %, and 31 months in patients with CA19-9 value < 100 U/ml and 21.2 %, 9.4 %, and 16 months in patients with CA19-9 value ≥ 100 U/ml (p < 0.001). CONCLUSIONS: A preoperative CA19-9 value ≥ 100 U/ml was a significant predictor of early recurrence and a poor prognosis after resection for pancreatic adenocarcinoma.

Content-based image-retrieval system in chest computed tomography for a solitary pulmonary nodule: method and preliminary experiments.

PURPOSE: The aim of this study was to develop a new diagnostic support system using content-based image-retrieval technology. In this article, we describe the mechanism and preliminary evaluation of this system for use with CT images of solitary pulmonary nodules. MATERIALS AND METHODS: With the approval of the institutional review board of Shizuoka Cancer Center, we built a database that included CT images of 461 solitary pulmonary nodules. With this database, we developed a system that automatically extracts the pulmonary nodule when the nodule area is clicked, retrieves previous cases based on an image analysis of the extracted lesion, and generates reports of the pulmonary nodule semi-automatically. We compared the percentage of correct diagnoses with and without the system using 30 solitary pulmonary nodules, which were not included in the database, with one radiologist and two residents. As a per-user evaluation, the number of clicks required to extract the nodule region and the extracted regions was compared, and presented candidate cases were evaluated. As an evaluation of the retrieval results, the presented candidate cases were evaluated by comparing the number of diagnostic matches (benign/malignant) between the queries and four presented cases. Additionally, to evaluate the validity of the retrieval technology, the radiologist selected the most similar cases presented by the system and evaluated the visual similarity on a five-point scale. RESULTS: With this system, the percentage of correct diagnoses for the radiologist improved from 80 to 93%. For the two residents, the diagnostic accuracy improved from 66.7 to 80% and from 76.7 to 90%, respectively. The evaluation of the number of clicks required indicated that for 19 cases with the radiologist and 12 and 11 cases with the two residents, respectively, only one click was required to extract the region. When the extracted regions were compared between the radiologist and the residents, 22 and 19 cases had a Dice's Coefficient of 0.85 or higher, respectively. For the radiologist, the number of cases that matched the diagnosis (benign/malignant) averaged 3.7 ± 0.5 among 23 malignant cases and 1.7 ± 1.4 among 7 benign cases, while for the residents, these values were 3.6 ± 0.5 and 1.1 ± 0.9, and 3.4 ± 0.8 and 1.1 ± 1.3, respectively. With regard to visual evaluations by the radiologist, there were 15 similar cases and 11 somewhat similar cases. CONCLUSION: These results suggest that, despite some differences in the search results among the users, this system has been confirmed that it can improve the accuracy of diagnosis as it displays similar cases at high probability. In addition, with the use of this system, past cases and their reports can be effectively referred to. Therefore, this diagnostic-assistant system has the potential to improve the efficiency of the CT image-reading workflow.

Usefulness of positron emission tomography in the evaluation of distribution and activity of systemic lesions associated with autoimmune pancreatitis.

BACKGROUND/AIMS: Autoimmune pancreatitis (AIP) is an IgG4-related systemic disease often accompanied with a variety of lesions outside of the pancreas and is treated with steroid therapy. The aim of this study is to analyze the usefulness of positron emission tomography with (18)F-fluorodeoxyglucose (FDG-PET) in the evaluation of distribution and activity of systemic lesions of AIP during steroid therapy. METHODS: Eleven cases of AIP had their FDG-PET images evaluated before and 3 months after steroid therapy and another 2 cases only before therapy. AIP activity was determined by the level of serum markers, IgG and IgG4, and compared with findings of PET. RESULTS: In all 13 cases of AIP, a moderate to intense level of FDG accumulation was recognized in the pancreatic lesion before steroid therapy. Of 13 patients, 11 (84.6%) showed FDG accumulation in the multiple organs, such as mediastinal and other lymph nodes, salivary gland, biliary tract, prostate, and aortic wall. In 11 patients who underwent PET before and after steroid therapy, FDG accumulation was diminished in almost all systemic lesions, with a mean of maximum standardized uptake value (SUV(max)) in the pancreatic lesion from 5.12 to 2.69. Similar to the SUV level, serum IgG and IgG4 were decreased in most of the cases after steroid therapy. CONCLUSIONS: FDG-PET is an effective modality to evaluate the response of steroid therapy and the distribution and activity of various systemic lesions of AIP.

Prognostic importance of standardized uptake value on F-18 fluorodeoxyglucose-positron emission tomography in biliary tract carcinoma.

BACKGROUND AND OBJECTIVES: F-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) has been used for diagnosis and staging of malignant diseases. However, the prognostic significance of FDG uptake on PET had not been sufficiently evaluated in patients with biliary carcinoma. METHODS: We performed a retrospective review of patients with biliary carcinoma imaged by FDG-PET to determine whether high uptake of FDG predicted overall survival independently of clinicopathological characteristics. Sixty-nine patients with biliary carcinoma underwent FDG-PET before cancer treatment. The maximum standard uptake value (maxSUV) was calculated as an index of FDG uptake. RESULTS: A receiver operating characteristic curve demonstrated a maxSUV of 6.3 to be the optimal cutoff point. The 3-year survival rate of patients with a maxSUV of 6.3 or less was 74.3%, whereas it was 44.1% for those with values greater than 6.3. Univariate analysis showed that the maxSUV was one of the significant prognostic factors for overall survival (P = 0.0119), whereas multivariate analysis showed that the independent predictors of survival were pN, pM, and pTNM staging. CONCLUSIONS: SUV analysis of FDG-PET was useful to predict the prognosis of biliary carcinoma. This information may assist in the guiding of treatment strategies before postoperative pathological assessment.

Small-cell carcinoma in the common bile duct treated with multidisciplinary management.

Small-cell carcinoma occasionally occurs in the gastrointestinal tract, with rare reports of it in the biliary system. When it does occur in the biliary system, it is mainly within the gallbladder, and those arising in the extrahepatic bile duct are extremely rare with only seven reported cases to date. A 62-year-old man with this unusual condition is documented. The patient was preoperatively diagnosed as having small-cell carcinoma on the basis of a biopsy specimen and was treated with multidisciplinary management, which consisted of preoperative chemotherapy, a curative resection, adjuvant chemotherapy, and radiation therapy. The patient died 23 months after the initial diagnosis (20 months after surgery). To the best of our knowledge, the survival time of this case was the longest among reported cases, and multidisciplinary management might contribute to a prolonged survival.

Hepatocellular adenoma in a male with familial adenomatous polyposis coli.

Hepatocellular adenoma (HA) is a benign liver tumor most frequently occurring in young women using oral contraceptives. We report a rare case of HA in a 27-year-old male patient with familial adenomatous polyposis (FAP). The patient underwent a total colectomy and ileo-rectal anastomosis for FAP in 2003. A preoperative computed tomography scan of the abdomen disclosed a tumor in the left-lobe of the liver, 5.8 cm in diameter. Pathologic examination of a needle biopsy disclosed HA, but he had never used anabolic steroids or other known inducers of HA. The size of the liver mass gradually increased to 8.5 cm during a follow-up period of 38 months, and a left hepatectomy was performed in 2006. Pathology of the resected specimen confirmed the diagnosis of HA. Although FAP is known to be complicated with neoplasia in various extracolonic organs, only five reported cases of HA have developed in patients with FAP, including this case. This is the first report of HA to develop in a male FAP patient.

A case of pancreatic carcinoma with suspected autoimmune pancreatitis.

We present a case of pancreatic carcinoma with strongly suspected coexisting autoimmune pancreatitis (AIP). The patient presented with a chief complaint of icterus and weight loss, and was referred to our institution after a pancreatic lesion was found. Blood test showed elevation of serum bilirubin, hepato-biliary enzyme, glucose and tumor markers, and also high levels of serum IgG4 (344 mg/dl, normal 4.8-105 mg/dl) and anti-DNA antibody (14 IU/ml, normal <6.0 IU/ml). Ultrasonography demonstrated an enlarged pancreas with smooth borders and low internal echo density. Enhanced computed tomography (CT) showed a sausage-shaped pancreas without definitive metastasis to the surrounding lymph nodes and liver. Imaging of the pancreatic duct, including endoscopic retrograde pancreatography (ERP) and magnetic resonance cholangiopancreatography (MRCP), showed stenosis of the main pancreatic duct at the pancreatic head as well as a long segment of narrowing at the body and no dilatation at the tail. Tissues from these stenotic sites and open biopsy from pancreatic body showed infiltrating adenocarcinoma and dense fibrosis. To date, only a small number of reports have described pancreatic carcinoma accompanied with AIP. It is important to confirm diagnosis with histology in cases of suspicious autoimmune pancreatitis, even when the clinical images are compatible with AIP.

Is PET-CT suitable for predicting lymph node status for gastric cancer?

BACKGROUND/AIMS: To verify the value of PET-CT for predicting lymph node status of gastric cancer preoperatively. METHODOLOGY: 78 gastric cancer patients accepted PET-CT preoperatively, the results of lymph node status were compared with the postoperative pathology. CT was used as control. RESULTS: The accuracy of PET-CT and CT in N category was 55.1% vs. 54.4%, respectively. The sensitivity, specificity, accuracy, positive predicting value (PPV), and negative predicting value (NPV) of PET-CT in predicting position of positive lymph node were 31.0%, 97.2%, 61.5%, 92.9%, and 54.7%, respectively. While for CT, were 60.5%, 83.3%, 70.6%, 82.1%, and 62.5%, respectively. For tier 1 lymph node metastasis, the sensitivity, specificity, accuracy, PPV, and NPV of PET-CT were 31.6%, 95.0%, 64.1%, 85.7%, and 59.4%, respectively. While for CT, were 60.0%, 78.8%, 69.1%, 75.0%, and 65.0%, respectively. The sensitivity of CT was significantly better (p = 0.031). For tier 2 or tier 3 lymph node metastasis, the sensitivity, specificity, accuracy, PPV, and NPV of PET-CT were 12.0%, 98.1%, 70.5%, 75.0%, and 70.3%, respectively. While for CT, were 22.7%, 93.5%, 70.6%, 62.5%, and 71.7%, respectively, without significance. CONCLUSIONS: PET-CT is not sensitive enough to predict the regional lymph node status of gastric cancer preoperatively.

Preoperative staging of biliary carcinoma using 18F-fluorodeoxyglucose PET: prospective comparison with PET+CT, MDCT and histopathology.

The aim of this study was to evaluate the value of positron emission tomography with (18)F-labeled fluorodeoxyglucose (FDG-PET) as a preoperative diagnostic investigation in patients with biliary carcinoma. Seventy-two patients with potentially resectable biliary carcinoma underwent preoperative multidetector-row computed tomography (MDCT) and FDG-PET. Both diagnoses were compared with subsequent histopathology and follow-up results. In 64 lesions with biliary carcinoma, 57 (89%) revealed an intense focal accumulation on FDG-PET and were interpreted as malignant. On the other hand, eight benign lesions did not show any specific accumulation. Detection rate of FDG-PET in the nodular type of the tumour (96% or 27/28) was superior to that of the infiltrating type (74% or 17/23) (p = 0.037). For the evaluation of lymph node metastasis, the overall accuracy was 69% (35/51) in both FDG-PET and MDCT: FDG-PET had a lower sensitivity (33% vs. 57%) and a higher specificity (97% vs. 79%) than MDCT, although the values were not significantly different. FDG-PET revealed all six lesions of distant metastases in six patients including two lesions missed by MDCT. FDG-PET has high detectability of biliary malignancies. Like MDCT, FDG-PET offers only modest accuracy for regional lymph node staging, but it may reveal distant metastases missed by MDCT.

Treatment decision making in pancreatic adenocarcinoma: multidisciplinary team discussion with multidetector-row computed tomography.

HYPOTHESIS: Multidetector-row computed tomography reduces the frequency of use of other imaging methods in patients with pancreatic carcinoma. DESIGN: Validation cohort study. SETTING: Tertiary care public hospital. PATIENTS: Two hundred thirteen patients with pancreatic carcinoma. MAIN OUTCOME MEASURE: Multidetector-row computed tomography was initially performed in patients with newly diagnosed pancreatic carcinoma. RESULTS: Of the 213 pancreatic carcinomas, 79 (37%) were classified as probably resectable, 127 (60%) as certainly unresectable, and 7 (3%) as probably unresectable. Of 79 tumors classified as probably resectable, 68 (86%) were found to be resectable, 7 tumors considered as probably unresectable were unresectable, and the remaining 127 tumors were treated nonsurgically. Magnetic resonance imaging was recommended in 92 patients (43%), angiography in 1 patient (0.5%), and both endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in 15 patients (7%). CONCLUSIONS: Multidetector-row computed tomography provides reliable information for staging pancreatic carcinoma. Multidisciplinary team discussion along with use of this noninvasive technique simplifies the diagnostic strategy for pancreatic carcinoma and decreases the need for invasive staging methods.

Autoimmune pancreatitis accompanied by cholecystitis, periaortitis and pseudotumors of the liver.

A variety of extrapancreatic lesions have been associated with autoimmune pancreatitis (AIP), and these lesions can be difficult to diagnose. We report a patient referred to Shizuoka Cancer Center with the diagnosis of a possible biliary carcinoma with liver metastasis who was shown to have AIP accompanied by pseudotumors of liver. Clinical imaging revealed diffuse enlargement of the head of the pancreas with irregular narrowing of the main pancreatic duct and inferior common bile duct, multiple liver masses, mediastinal lymphadenopathy, and thickening of the wall of the gallbladder and abdominal aorta. Cytology and biopsy from the pancreaticobiliary tract was negative for malignancy. Serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9) levels were in the normal range, but soluble interleukin 2 receptor (sIL2R), IgG4 and antinuclear antibody were abnormally high (sIL2R: 2,550 U/ml; IgG4: 764 mg/dl). Corticosteroid therapy was effective and these abnormal findings all improved. This case demonstrates the clinical importance of AIP accompanied by other systemic disorders in the differential diagnosis of patients with a pancreatic mass lesion.

Breast carcinomas with strong high-signal intensity on T2-weighted MR images: pathological characteristics and differential diagnosis.

PURPOSE: To investigate the histopathological characteristics of breast carcinomas with strong high-signal intensity (SHi) on T2-weighted (T2W) MR images (T2-SHi), and discuss the differential diagnosis between T2-SHi breast carcinomas and T2-SHi fibroadenomas. MATERIALS AND METHODS: Thirty of 480 breast carcinomas examined by MRI were defined as tumors with T2-SHi (defined as homogeneous higher signal intensity (SI) compared to surrounding normal breast tissue on fat-suppressed T2W imaging (T2WI). They included eight mucinous and 22 nonmucinous carcinomas. The histopathological characteristics of T2-SHi breast carcinomas, their signal-to-noise ratios (SNRs) on T2WI, contrast-enhancement patterns, and morphology were compared with those of 22 non-T2-SHi breast carcinomas and 19 T2-SHi fibroadenomas. RESULTS: In nonmucinous carcinomas T2-SHi was attributable to a mixture of background matrix, a higher proportion of cells than stroma, abundant cytoplasm, edematous stroma, and hemorrhage. The significantly high SNR (mean = 75) and enhancing internal septations seen in mucinous carcinomas, and the washout phenomenon, irregular border, absence of internal septation, and rim enhancement seen in nonmucinous carcinomas provide useful information for differentiating these tumors from T2-SHi fibroadenomas. CONCLUSION: A mixture of several histopathological characteristics was associated with T2-SHi breast carcinomas. The combined information from T2WI and contrast-enhanced (CE) imaging may help distinguish T2-SHi breast carcinomas from T2-SHi fibroadenomas.

The diagnostic value of PET-CT for peritoneal dissemination of abdominal malignancies.

AIM: To evaluate the diagnostic value of PET-CT for predicting peritoneal metastasis of abdominal malignancies. METHODS: One hundred fifty four (154) cases of malignant tumor, including 141 cases of gastric cancer, 9 cases of colon cancer, 2 cases of ovary cancer, and 2 cases of pseudomyxoma, had accepted PET CT from Nov. 2002 to Jan. 2006. One hundred twenty three (123) had also accepted high speed spiral CT (HSSCT) as control. The results were compared with peritoneal lavage, pathological examination and clinical manifestation. RESULTS: The accuracy of PET-CT for peritoneal metastasis was 87.7%, with sensitivity 72.7%, specificity 93.6%, PPV 82.1% and NPV 89.6%. HSSCT showed an accuracy of 79.7%, sensitivity 47.4%, specificity 94.1%, PPV 78.3%, and NPV 80.0%. PET-CT had significantly better sensitivity than HSSCT (p < 0.05). For gastric cancer patients alone, PET CT had an accuracy of 87.9%, sensitivity 74.4%, specificity 93.1%, PPV 80.6% and NPV 90.5%, significantly better than HSSCT's 78.1, 39.4, 93.8, 72.2, and 79.2% (p < 0.01), respectively. In case of Cy1P0, PET-CT showed a seemingly better sensitivity of 53.3% vs. 13.3% of HSSCT, although not statistically significant because of the number of observations (p = 0.053). And in P1 cases, PET-CT and HSSCT manifested sensitivity of 84.2% vs 63.2%, respectively, without significance (p = 0.141). CONCLUSION: PET-CT is useful in predicting peritoneal metastasis of malignancies.

Primary liver cancer with bidirectional differentiation into hepatocytes and biliary epithelium.

A 70-year old Japanese man with hepatitis B infection developed a 4.8-cm liver tumor in the right lobe. Computed tomographic findings suggested hepatocellular carcinoma or combined hepatocellular and cholangiocarcinoma. After right hepatectomy, the cut surface of the resected specimen showed a whitish tumor with indistinct borders. Microscopically, the tumor consisted of pleomorphic, eosinophilic cells forming thickened trabeculae, suggesting hepatocellular carcinoma, and also tumor cells forming glandular structures, suggesting adenocarcinoma. Cells comprising both the trabeculae and the glands were immunoreactive for cytokeratin (CK) 19. In some gland-forming cells, varying immunoreactivity for CK7 and carcinoembryonic antigen (CEA) was observed. In the cytoplasm of cells in the thickened trabeculae, hepatocyte paraffin (HepPar) 1 and alpha-fetoprotein (AFP) were focally reactive. Some of these tumor cells were also reactive for CK19. Accordingly, we concluded that this tumor was a combined hepatocellular and cholangiocarcinoma whose cells had undergone divergent differentiation into hepatocytes and biliary epithelium. Because the tumor expressed markers of both phenotypes, it may have originated from cells intermediate between hepatocytes and biliary epithelium. A few reported cases have shown similar histologic features.

Unusual late pulmonary complication in a child after umbilical cord blood transplantation: high-resolution CT-pathologic correlation.

We encountered a late pulmonary complication after umbilical cord blood transplantation (UCBT) that has not been previously reported. High-resolution CT (HRCT) findings of this disease were compared with the pathology. HRCT obtained on inspiration showed dilated thick-walled bronchioli, and innumerable centrilobular linear and branching structures in the bilateral middle and lower lobes. Neither mosaic perfusion nor air-trapping was seen in HRCT on inspiration and expiration. These HRCT findings were atypical compared with those of former bronchiolitis obliterans (BO) after bone marrow transplant (BMT). Pathologic specimens obtained by open lung biopsy showed thickening of the wall from the distal bronchioli to the alveolar ducts due to submucosal and intraepithelial infiltration of lymphocytes, histiocytes and foamy macrophages, which was not accompanied by organizing changes. These changes resemble lymphocytic bronchiolitis in lung transplant recipients, which was well correlated with HRCT findings. We think that our case was a new late pulmonary complication after UCBT.

Comparison of FDG PET and SPECT for detection of bone metastases in breast cancer.

OBJECTIVE: The purpose of our study was to evaluate the efficacy of FDG PET and bone SPECT for diagnosing bone metastases in breast cancer. SUBJECTS AND METHODS: The study was a prospective series of 15 patients with breast cancer who underwent both PET and bone scanning with SPECT. Comparison was performed on a lesion-by-lesion analysis. MDCT, MRI, and the patient's clinical course were used as references. RESULTS: In the lesion-by-lesion analysis (n = 900), the sensitivity for diagnosing bone metastases was 85% for SPECT and 17% for PET, specificity was 99% for SPECT and 100% for PET, and accuracy was 96% for SPECT and 85% for PET. In the statistical analysis, bone SPECT was significantly superior to FDG PET for its sensitivity (p < 0.0001) and accuracy (p < 0.0001). No statistically significant difference was seen with regard to specificity. When classifying the bone metastases as osteoblastic or osteolytic, bone scanning classified 92% of metastases as osteoblastic and 35% of metastases as osteolytic, whereas PET classified 6% of metastases as osteoblastic and 90% of metastases as osteolytic. CONCLUSION: Bone SPECT is superior to FDG PET in detecting bone metastases in breast cancer. The sensitivity of osteoblastic lesions is limited with FDG PET. Surveillance of metastatic spread to the skeleton in breast cancer patients based on FDG PET alone is not possible.

Picture archiving and communication system introduced to a new Japanese cancer center hospital.

Picture archiving and communication systems (PACS) have been widely introduced as a credible alternative to the traditional film-based radiological service. Shizuoka Cancer Center Hospital (SCCH) introduced PACS and hospital information systems as an alternative to the film- and traditional paper-based hospital system at the opening of the hospital. Using PACS, whole images and their reports can be available at any nearby terminal. Users can select the display format for monitor viewing on the bases of individual preference and navigate through cases by buttons and rollerballs on the mouse with easy handling and quick response. Most clinicians in SCCH evaluated such medical circumstances well. Filmless image management systems will become popular in all hospitals in the near feature. All staff in each hospital should investigate the merits and demerits of this system and how to introduce it effectively.