Patterns of care study of radiation therapy for cervix cancer in Japan: the influence of the stratification of institution on the process.

BACKGROUND: To improve the quality of radiation oncology in Japan, Patterns of Care Study (PCS), a widely known quality assurance (QA) program in the USA, was introduced. The feasibility was tested by collecting nationwide data by extramural audit for cervix cancer. METHODS: From July 1996 through February 1997, PCS audits were performed for 29 institutions nationwide. On the basis of the facility survey by Tsunemoto, 13 institutions were classified as A1 (university hospital/cancer center), 10 as B1 (other institutions treating >120 patients/year) and six as B2 (other institutions treating <120 patients/year). Medical charts for the patients treated for cervix cancer between 1992 and 1994 were reviewed based on the data format of the US PCS. The total number of patients surveyed was 432. RESULTS: Simulation was used for >90% of the patients in both A1 and B1-2 institutions. However, in B1-2, planning for 5% of the patients was performed with only a clinical set-up (p = 0.0287). A daily fraction with a size of 200 cGy was given to >65% of patients in A1 and to <47% in B1-2. On the other hand, >50% of those in B1-2 were treated with daily fractions of 180 cGy and less compared with 25% in A1 institutions (p < 0.0001). Brachytherapy was utilized more frequently for patients in Stages II (p = 0.0365), III (p = 0.0015) and IV (p = 0.0483) in A1 than in B1-2. As for external beam equipment, linear accelerators with 10 MV or more were used for 83% of the patients in A1. However, in B1-2 institutions, machines with lower energy were used for 38% of the patients (p < 0.0001). The median number of full-time-equivalent (FTE) radiation oncologists was 2.7 in A1, 0.65 in B1 and 0.2 in B2. CONCLUSIONS: Institutional stratification, including equipment and personnel, was found to affect significantly the patterns of care for cervix cancer. Therefore, to improve the quality of radiation therapy nationwide, improvements in equipment and in supply of FTE personnel are extremely important. PCS was found to have great potential for a practical evaluation of how much improvement will be required in Japan.

Magnetic resonance imaging of neurohypophyseal germinomas.

The authors reviewed magnetic resonance (MR) images in seven cases of germinoma in the hypothalamoneurohypophyseal axis (HNA). The intrasellar portions were clearly identified in six germinomas. Two small germinomas of these six were located only in the neurohypophysis. The major parts of the four large germinomas were located below the optic chiasm, and the large intrasellar portions were demonstrated. The remaining one small germinoma was localized from the pituitary stalk to the third ventricular floor. These findings strongly suggest that the primary site of germinomas in the HNA is the neurohypophysis. In the four large germinomas, the tumor shape was similar to that of pituitary adenoma. The authors believe that age (limited to first three decades), symptoms (diabetes insipidus), MR findings (absence of normal hyperintense signal of the posterior pituitary on T1-weighted (T1WI) images, and homogeneous hypointensity to the pons on T1WI images/isointensity on T2-weighted images are important in differential diagnosis.

Computed tomography and angiogram of primary hepatic rhabdomyosarcoma: report of two adult cases.

Two adult cases of primary hepatic rhabdomyosarcoma, one of which was associated with hepatocellular carcinoma and had double malignant tumors, are described with emphasis on the radiologic features. On precontrast computed tomography, the lesion appeared as a well-defined hypodense mass like an abscess, while linear mottled enhancement was observed on the postcontrast scan. Angiography revealed displacement of the hepatic arteries and portal veins, irregular neovascularity in the peripheral portion, and scant tumor stain without dilatation of the feeding artery. Review of the literature revealed only 10 previous reports.

Development and aging of brain midline structures: assessment with MR imaging.

The development and aging of four brain midline structures--the pituitary gland, pons, cerebellar vermis, and corpus callosum--were studied. The dimensions and area of these structures were measured by means of midsagittal magnetic resonance imaging. The study group consisted of 94 patients newborn to 15 years old and 49 patients and seven volunteers 16-60 years old. Except for growth spurts in the 1st year and in the 10-15-year age range, the pituitary gland showed linear growth. The pons, cerebellar vermis, and corpus callosum all showed exponential growth. The cerebellar vermis showed the sharpest 1st-year growth spurt, followed by the corpus callosum and the pons. The pituitary gland showed a decrease in size in the 51-60-year age range. The corpus callosum also showed a tendency to diminish in size but to a lesser degree. There were no statistically significant declines in the size of either the pons or the cerebellar vermis in the 51-60-year age range.

Mycotic aneurysm.

Mycotic aneurysms must be diagnosed rapidly because of the high mortality, associated with them. X-ray computed tomography (X-CT) is a noninvasive modality. Intravenous digital subtraction angiography (IVDSA) is also much less invasive and less dangerous than arteriography, especially in mycotic aneurysms, whose wall is thin. We describe two patients with mycotic aneurysms diagnosed by X-CT and IVDSA.

Perinephric xanthogranulomatous pyelonephritis simulating a renal or retroperitoneal tumor on X-ray CT and angiography.

A case of perinephric xanthogranulomatous pyelonephritis is presented. Ultrasonography and X-ray computed tomography (X-CT) showed a mass on the posterior aspect of the right kidney, causing us to suspect right renal cell carcinoma. Pyelography showed a deformity of the right renal calyces. From angiographic results, we considered the possibility of hypovascular renal cell carcinoma, subcapsular tumor, or retroperitoneal tumor. The mass was diagnosed pathologically as perinephric xanthogranulomatous pyelonephritis.

Comparison of image quality and portal vein visualization in IADSP using iopamidol, 76% urografin, and 38% urografin.

The image quality of intra-arterial digital subtraction portography (IADSP) was studied in 50 randomly assigned patients using one of three contrast agents: iopamidol, (IOP, 20 cases), 76% Na-meglumine diatrizoate (76% UG, 20 cases), and 38% Na-meglumine diatrizoate (38% UG, 10 cases). Sharpness and contrast of images, and portal vein visualization were evaluated in these groups. IOP provided better image quality and portal vein visualization than 76% UG. There was no significant difference between them in terms of side effects, such as contrast medium-induced pain and feeling of warmth, or changes in physiological parameters like blood pressure and heart rate. When a low osmolar contrast agent like IOP passes through the mesentery capillary bed, the eflux of the contrast agent into the interstitial space and the influx of water into the capillary may be less, resulting in less dilution of the contrast agent in the superior mesenteric vein. This might explain the better image quality and portal vein visualization of IOP.

Clinical application of the 10-MHz electronic linear array scanner.

A 10-MHz electronic linear array real-time scanner was developed. The axial resolution was 0.26 mm at the -20dB ring down point. The display field was 6.0 cm in width. Excellent high-resolution sonograms of the thyroid, breast and other diseases were obtained using this scanner.

A new imaging agent for medullary carcinoma of the thyroid.

Thyroid scintigraphy, using 99mTc(V) dimercaptosuccinic acid, was performed in four patients with pathologically confirmed medullary thyroid carcinoma and elevated serum calcitonin values. Significant uptake of the tracer was found in the clinically palpable cervical tumor masses, metastatic sites, and residual tumor. This finding, probably specific for medullary thyroid carcinoma, could be of great use in the diagnosis and the surgical follow-up.

A quantitative assessment of scintigraphy of the legs using 201Tl.

201Tl perfusion scintigraphy of the legs was evaluated to define intermittent claudication quantitatively, based on Sapirstein's indicator fractionation principle. After intravenous injection of 201Tl with or without exercise, the distribution of the radiotracer throughout the body was obtained using the whole blood scanner. Regional blood flow of cardiac output for three segments of the leg was estimated as a regional fractional uptake (rFU) distributed in these segments compared with the whole body distribution. The validity of the principle was confirmed by a comparative study with 99mTc-MAA (r = 0.979). Normal rFUs (%) for each section at rest and after stress, respectively, were 5.49 +/- 0.69 and 19.40 +/- 2.04 (whole leg); 3.57 +/- 0.49 and 12.26 +/- 1.91 (thigh); 1.59 +/- 0.34 and 6.58 +/- 0.61 (calf). The rates of rFU change from the state of rest to stress (delta rFU) in normals were 3.41 +/- 0.45 (whole leg), 3.44 +/- 0.61 (thigh), and 4.30 +/- 1.03 (calf). Although rFU was within normal limits in patients with arteriosclerosis obliterans (ASO) and thromboangitis obliterans (TAO), delta rFU of the whole leg was significantly decreased from the normal value of 3.41 +/- 0.45 to 1.95 +/- 0.40 for ASO (P less than 0.001) and 1.82 +/- 0.47 for TAO (P less than 0.001). A defect or decreased activity on the stress scintigraph was well correlated with the angiographic findings.

Clinical evaluation of 99mTc-pyrophosphate myocardial emission computed tomography: comparison with planar imaging.

To depict the three-dimensional distribution of 99mTc-pyrophosphate in the heart, emission computed tomography (ECT) was performed, following the conventional planar imaging, in 32 cases with suspected acute myocardial infarction (AMI). There were 23 cases with evidence of AMI, 7 with unstable angina (UA), and 2 with dilated cardiomyopathy (DCM). While the planar images showed discrete cardiac activity in only 11 of the 23 cases (48%) with AMI, the ECT images delineated focal myocardial uptake clearly in 20 of them (87%). On the other hand, the ECT images revealed cardiac blood-pool activity without significant myocardial uptake in all cases with UA and DCM in which the planar images showed diffuse activity. Thus, the ECT imaging of 99mTc-pyrophosphate seems to be a valuable technique for assessing the presence and localization of myocardial necrosis, especially in cases showing diffuse cardiac activity in the planar imaging.

A femocerebral catheter for middle-aged patients of relatively small stature.

The authors describe a catheter for multi-artery studies in middle aged patients of relatively small stature. Experience in more than a thousand cases proved its special usefulness in selecting the left common carotid artery with tortuous aortic arch.

[Detection of cancer by radionuclide imaging].

Tumor imaging by radiopharmaceuticals classified into two modalities; The one is a negative imaging, whereby a tumor is depicted as a non-functional cold spot. The other is a positive imaging on the use of tumor seeking agents. The detectability of the tumor as a cold spot has enhanced by introducing the emission computed tomography. A variety of effort to develop specific tumor seeking agents are in progress, by radio-labeling tumor specific antigen and its abnormal metabolic conditions using cyclotron produced radioactive metabolites as well as radiometal compounds.