SUVmax-based Parameters of FDG-PET/CT Reliably Predict Pathologic Complete Response After Preoperative Hyperthermo-chemoradiotherapy in Rectal Cancer.

BACKGROUND/AIM: To determine the most reliable predictor for pathologic complete response (pCR) in patients who underwent preoperative chemoradiotherapy and regional hyperthermia (HCRT) for rectal cancer. PATIENTS AND METHODS: Thirty-six patients were enrolled. The local control status of the patients was assessed using 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), magnetic resonance imaging (MRI), and colonoscopy before and after HCRT. The relationships between various parameters of these clinical examinations and pCR were analyzed. RESULTS: Ten (28%) patients achieved pCR. The accuracies of predicting pCR using FDG-PET/CT, MRI, and colonoscopy were 78%, 61%, and 75%, respectively. FDG-PET/CT was the only independent predictive modality for pCR (p=0.021). The maximum standardized uptake value (SUVmax) and SUVmax normalized to liver uptake (SLR) after HCRT showed the highest sensitivity (90%) and the decreasing rate of SUVmax and SLR demonstrated the highest specificity (89%) for pCR. CONCLUSION: SUVmax-based parameters of FDG-PET/CT after HCRT were the most reliable predictors for pCR.

The first thermic treatment predicts following chemoradiation response with concurrent thermal therapy for the treatment of rectal cancer.

The present study aimed to evaluate whether the neoadjuvant chemoradiation response with concurrent thermal therapy for the treatment of rectal cancer can be predicted following the first thermic treatment. Eighty patients with primary rectal adenocarcinoma (≤12 cm from the anal verge) were included in this study. Fifty-four received surgery and pathological response was evaluated. Intensity-modulated radiotherapy was administered conventionally once daily 5 times/week. Neoadjuvant radiotherapy consisted of 50 Gy delivered to the planning target volume in 25 fractions. Concurrent neoadjuvant chemotherapy was delivered in 5-day courses. Capecitabine was administered orally at 1,700 mg/m2/day for 5 days/week. Thermic treatment was performed using the Thermotron-RF 8 and administered once/week for 5 weeks with 50 min irradiation. Patients with a gross tumor volume (GTV) ≤32 cm3 and a radiofrequency (RF) output difference (RO difference) ≥77 Watt/min exhibited pathological complete response (pCR) and CR rates of 50 and 75%, respectively. Those with a GTV ≥80 cm3 and a RO difference ≥77 Watt/min exhibited pCR and CR rates of 42.9 and 42.9%, respectively. The changes in the skin temperature during RF treatment in patients with pCR with a RO difference ≥77 Watt/min increased significantly compared with those of other outcomes, and progressive disease. These data suggest a strategy for predicting which patients will respond best following the first thermic treatment. The results identified that the group of patients with a GTV ≤32 cm3 and a RO difference ≥77 Watt/min (outputable/heatable patients) may respond best.

Chemoradiotherapy and concurrent radiofrequency thermal therapy to treat primary rectal cancer and prediction of treatment responses.

The present study aimed to evaluate a previously reported predictive formula of output-limiting symptoms induced by radiofrequency (RF) to determine the efficacy of this neoadjuvant chemoradiation (NACR) and concurrent RF thermal therapy. The present study included 81 consecutive patients with confirmed diagnoses of rectal adenocarcinoma that was localized in the mid-low rectum (up to 12 cm from the anal verge) who received NACR [intensity-modulated radiotherapy (IMRT), 50 Gy/25 fractions, capecitabine 1,700 mg/m2/day for 5 days/week)] with concurrent thermal therapy (Thermotron-RF8, once a week for 5 weeks with 50 min irradiation). Patients with progressive disease (PD) did not receive RF outputs higher than the predicted value. Some patients who were predicted to receive more output in fact received more than the predicted output. In patients who were predicted to receive moderately higher outputs, 37.5% of the patients experienced pathological complete responses, which was the highest rate, while in those who did not receive more than the predicted output, 66.7% of the patients experienced PD, which was the highest rate in the present study. We speculate that RF thermal therapy may offset the chemoradiation effects in some patients. Adding thermal therapy as a multimodality therapy to NACR potentially affects patients with lower predicted outputs and actual observed outputs slightly higher than the predictive value. Our predictive equation for initial energy output, in which output­limiting symptoms can be used to predict treatment efficacy, consequently, can be used to decide whether to continue this treatment modality.

Radiofrequency thermal treatment with chemoradiotherapy for advanced rectal cancer.

We previously reported that patients with a clinical complete response (CR) following radiofrequency thermal treatment exhibit significantly increased body temperature compared with other groups, whereas patients with a clinical partial response or stable disease depended on the absence or presence of output limiting symptoms. The aim of this study was to evaluate the correlation among treatment response, Hidaka radiofrequency (RF) output classification (HROC: termed by us) and changes in body temperature. From December 2011 to January 2014, 51 consecutive rectal cancer cases were included in this study. All patients underwent 5 RF thermal treatments with concurrent chemoradiation. Patients were classified into three groups based on HROC: with ≤9, 10-16, and ≥17 points, calculated as the sum total points of five treatments. Thirty-three patients received surgery 8 weeks after treatment, and among them, 32 resected specimens were evaluated for histological response. Eighteen patients did not undergo surgery, five because of progressive disease (PD) and 13 refused because of permanent colostomy. We demonstrated that good local control (ypCR + CR + CRPD) was observed in 32.7% of cases in this study. Pathological complete response (ypCR) was observed in 15.7% of the total 51 patients and in 24.2% of the 33 patients who underwent surgery. All ypCR cases had ≥10 points in the HROC, but there were no patients with ypCR among those with ≤9 points in the HROC. Standardization of RF thermal treatment was performed safely, and two types of patients were identified: those without or with increased temperatures, who consequently showed no or some benefit, respectively, for similar RF output thermal treatment. We propose that the HROC is beneficial for evaluating the efficacy of RF thermal treatment with chemoradiation for rectal cancer, and the thermoregulation control mechanism in individual patients may be pivotal in predicting the response to RF thermal treatment.

Output-limiting symptoms induced by radiofrequency hyperthermia. Are they predictable?

BACKGROUND: During radiofrequency (RF) hyperthermia treatment, hot-spot phenomena may occur and prevent treatment continuation if the output is not lowered. We previously reported a significant correlation between the initial energy output at which output-limiting symptoms occurred and patient status. Patients with a complete clinical response had significantly increased temperature, while some patients with partial clinical response and stable disease had increased temperature, depending on the occurrence of output-limiting symptoms. To predict the initial energy output at which output-limiting symptoms occur, we performed multiple regression analysis with the parameters of patients' physical status. MATERIALS AND METHODS: Hyperthermia alone or concomitant with chemotherapy and/or radiotherapy was applied in 62 patients with malignant disease for a total of 310 treatments with a Thermotron RF-8 between December 2011 and April 2014. RESULTS: No output-limiting symptoms were shown in 65.5% of 310 treatments. Pain (29.7%), micturition desire (1.9%), skin discomfort (0.6%), subcutaneous induration (1.6%), cold sensation (0.6%), and nausea (0.3%) were reported in the 310 treatments. A good predictive equation for initial energy output at which output-limiting symptoms occur was determined with two parameters, initial time of an output-limiting symptom onset, and thickness of the fat of the abdominal wall. Multiple regression analysis showed an adjusted R(2 )= 0.99 and variance inflation factor < 2. CONCLUSIONS: We present a good predictive equation for initial energy output at which output-limiting symptoms occur. It is critical to prevent RF hyperthermia-induced output-limiting symptoms and establish new prevention strategies.

A novel strategy of radiofrequency hyperthermia (neothermia) in combination with preoperative chemoradiotherapy for the treatment of advanced rectal cancer: a pilot study.

The safety of weekly regional hyperthermia performed with 8 MHz radiofrequency (RF) capacitive heating equipment has been established in rectal cancer. We aimed to standardize hyperthermia treatment for scientific evaluation and for assessing local tumor response to RF hyperthermia in rectal cancer. Forty-nine patients diagnosed with rectal adenocarcinoma were included in the study. All patients received chemoradiation with intensity-modulated radiation therapy 5 days/week (dose, 50 Gy/25 times) concomitant with 5 days/week for five times of capecitabine (1700 mg/m(2) per day) and once a week for five times of 50 min irradiations by an 8 MHz RF capacitive heating device. Thirty-three patients underwent surgery 8 weeks after treatment. Three patients did not undergo surgery because of progressive disease (PD) and 13 refused. Eight (16.3%) patients had a pathological complete response (ypCR) after surgery. Among patients without surgery, 3 (6.1%) had clinical complete response (CR) and 3 (6.1%) had local CR but distant PD (CRPD). Ninety percent of ypCR + CR patients were shown in 6.21 W min(-1) m(-2) /treatment or higher group of average total accumulated irradiation output with 429°C min(-1) m(-2) or higher group of total accumulated thermal output. However, a patient with CRPD was in the higher total accumulated thermal output group. We propose a new quantitative parameter for the hyperthermia and demonstrated that patients can benefit from mild irradiation with mild temperature. Using these parameters, the exact output, optimal thermal treatment, and contraindications or indications of this modality could be determined in a multi-institutional, future study.

Granular cell tumor of the esophagus with elevated preoperative serum carbohydrate antigen 19-9: a case report.

A 59-year-old Japanese man was admitted to our hospital for treatment of a submucosal tumor of the esophagus detected by upper gastrointestinal endoscopy and computed tomography (CT). Endoscopic examination revealed a submucosal tumor in the esophagus 35 cm from the incisor teeth. Biopsy of the lesions identified granular cell tumor. CT indicated a projecting and slightly enhanced homogenous mass measuring 2.0 × 1.5 cm in the esophagus below the tracheal bifurcation. Serum tumor marker studies revealed elevated carbohydrate antigen (CA) 19-9. Therefore, the tumor was considered to have malignant potential, and surgical resection was performed. The final pathologic diagnosis was a benign granular cell tumor, positive for S-100 protein. The patient was doing well with normal CA 19-9 levels and no recurrence more than 5 years after surgery. To the best of our knowledge, this is the first report of a granular cell tumor with elevated serum CA 19-9.

Torsion of the gallbladder diagnosed by magnetic resonance cholangiopancreatography.

Torsion of the gallbladder is a rare entity that is difficult to diagnose preoperatively, the principal differential diagnosis being cholecystitis. The condition occurs most often in the elderly. Although its etiology is unknown, the presence of a redundant mesentery is a prerequisite for torsion. Computed tomography, ultrasound, and magnetic resonance cholangiopancreatography can provide important diagnostic clues. Torsion of the gallbladder occurs when it twists axially, with subsequent occlusion of bile or blood flow. Therefore, prompt surgical treatment is necessary in order to prevent necrosis and perforation. In the present study, we report a case of torsion of the gallbladder diagnosed by magnetic resonance cholangiopancreatography. This condition was successfully treated by laparoscopic cholecystectomy.

Schwannoma of the stomach with elevated preoperative serum carbohydrate antigen 19-9: report of a case.

We herein report a case of a gastric schwannoma with elevated preoperative serum carbohydrate antigen 19-9 (CA19-9) (155.2 U/ml, normal range 0-36.9 U/ml). A 59-year-old Japanese man was admitted to our hospital for treatment of a submucosal tumor of the stomach detected by barium meal, upper gastrointestinal endoscopy, and computed tomography. Endoscopic examination revealed a 3-cm diameter submucosal tumor in the antrum of the stomach, but biopsy of the lesion was unable to confirm the diagnosis. Positron emission tomography to evaluate the malignant potential showed a high uptake of (18)F-fluorodeoxyglucose in the tumor. Laparoscopy-assisted distal gastrectomy was therefore performed. The histopathological findings of the surgical specimen revealed a benign gastric schwannoma, positive for S-100 protein. The postoperative serum CA19-9 levels gradually decreased and normalized. To the best of our knowledge, this is the first report of a gastric schwannoma with elevated serum CA19-9.

Laparoscopic-assisted partial ileectomy for crohn's disease associated with chronic anemia due to frequent hemorrhage.

Crohn's disease can involve any part of the gastrointestinal tract. Although good conservative treatment is given as soon as possible, most patients with this disease will eventually require surgery. We encountered a case of Crohn's disease associated with anemia which we treated with laparoscopic-assisted ileectomy. The postoperative course was satisfactory. The most important characteristic of Crohn's disease, fat wrapping and extending over the serosal surface toward the antimesenteric border, was observed in the ileum, distinguishing the disease and pinpointing the lesion accurately. This surgical method has an advantage over open surgery in that the recovery time is shorter and incisions are smaller, allowing easier surgery in the future, shortening the patient's hospital stay, and improving the patient's quality of life.

Intraductal papillary mucinous tumor of the pancreas associated with autosomal dominant polycystic kidney disease.

A 43-year-old male with a history of autosomal dominant polycystic kidney disease (ADPKD) was admitted to our center with severe abdominal pain and was diagnosed with acute pancreatitis. CT showed multiple cysts in the liver and both kidneys along with ADPKD and a cystic mass, 4 cm in diameter, in the pancreatic head. The main pancreatic duct was dilated to 1 cm in diameter. The patient was diagnosed with acute pancreatitis due to intraductal papillary mucinous tumor (IPMT), and pancreatoduodenectomy was performed. Histologic examination revealed a multiloculated cystic tumor filled with mucin in the head of the pancreas. Microscopically, the tumor was diagnosed as adenocarcinoma and was found to have invaded the main pancreatic duct. Although, in addition to our case, only seven cases with association between ADPKD and malignant neoplasms have been reported, five of these cases had neoplasms arising from the pancreas. Therefore, we suggest that some genetic interactions may exist between ADPKD and pancreatic carcinogenesis.

Is carbon dioxide as an insufflation agent for double contrast barium enema still worthwhile after a same-day flexible sigmoidoscopy?

PURPOSE: The aim of the study was to evaluate the efficacy of a double-contrast barium enema (DCBE) with CO(2) as a distending gas after a screening flexible sigmoidoscopy for reducing abdominal distension after an examination. PATIENTS AND METHODS: A total of 165 DCBEs for patients with positive faecal occult blood tests were randomly allocated to a CO(2) group (n = 83) and a control group (n = 82) using air. Abdominal radiograph were taken before the DCBE, immediately following it, and 30 minutes later to determine residual bowel gas. The degree of abdominal discomfort was recorded using a scoring system. RESULTS: The patients in the CO(2) group had significantly smaller amounts of residual gas 30 minutes after the DCBE than did the control group, both in the colon (P < 0.02) and in the small intestine (P < 0.001). There was significantly less abdominal distension after the DCBE in the CO(2) group compared to the control group (P < 0.001). The abdominal discomfort score at 30 minutes after CO(2) correlated with the residual gas in the small intestine (r = 0.390,P = 0.003) but not in the colon (r = 0.155, P = 0.15). The quality of the images and the number of polyps detected did not differ between two groups. CONCLUSIONS: We concluded that using CO(2) when administering a DCBE after a screening sigmoidoscopy was useful for relieving abdominal discomfort following the examination; furthermore, it did not impair the diagnostic ability of the DCBE.