Immunological assessment of cryotherapy in breast cancer patients.

BACKGROUND: In murine studies, cryotherapy has induced antitumor immune responses associated with the rejection of tumors. However, the effects of freezing-induced immunomodulation in breast cancer (BC) patients remain unclear. MATERIALS AND METHODS: Ten BC patients were prospectively divided into two groups: 1) cryotherapy followed by surgical excision and 2) surgical excision-alone. The cytokine profiles of plasma and peripheral blood mononuclear cells (PBMCs) were analyzed using flow cytometry following in vitro stimulation with the 30-mer MUC1 peptide. RESULTS: No differences in the percentages of interferon-γ (IFN-γ)-producing cluster of differentiation (CD)4(+) or CD8(+) T cells and the plasma levels of IFN-γ, interleukin-1ß (IL-1ß), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, tumor necrosis factor-α (TNF-α) and TNF-ß were observed between these 2 groups, and PBMCs were not significantly altered. CONCLUSION: Alternations to the type 1 and 2 helper cytokine profiles were not detected in vitro in BC patients treated with cryotherapy-alone.

External beam radiotherapy for angiographically diagnosed arteriovenous malformation involving the entire pancreas.

Ultrasonography of a 66-year-old man with abdominal discomfort detected an abnormality of the pancreas. Multiphase contrast-enhanced computed tomography (CT) and angiography revealed arteriovenous malformation (AVM) involving the entire pancreas. The large number of dilated and tortuous feeding arteries contraindicated surgical resection or transcatheter embolization. Hemorrhage into the main pancreatic duct occurred 1 month after diagnosis. The patient underwent external radiotherapy with a total dose of 44 Gy following a conventional fractionation schedule of 2 Gy daily for 22 days administered 5 days per week. Contrast-enhanced CT after treatment confirmed disappearance of feeding vessels and nidi with no complication. Evidence of recurrence was not detected on contrast-enhanced CT 6 months after irradiation.

Diffusion-weighted imaging with relative signal intensity statistical thresholding for delineating prostate cancer tumors.

PURPOSE: We assessed the utility of diffusion-weighted imaging (DWI) with relative signal intensity (rSI) statistical thresholding for delineating prostate cancer tumors. MATERIALS AND METHODS: Seventeen patients with prostate cancer underwent DWI before total prostatectomy. We measured standard deviation (SD) of the signal intensity (SI) of the lesser pelvic space at DWI, created rSI maps, displaying signal intensities with SDs of only > +3, > +3.5, > +4, or > +5, and assessed correlation between the proportion of cancerous area on the 4 different rSI maps and that on pathological slices. RESULTS: We could detect prostate cancer on rSI maps for all cases with SD > +3, but not 2 cases with SD > +3.5, five with SD > +4, and eight with SD > +5. The correlation coefficients (R) between the proportion of cancerous area on pathological examination and rSI maps were 0.7464 for SD > +3 (P = 0.0006); 0.6469 for SD > +3.5 (P = 0.0050); 0.6459 for SD > +4 (P = 0.0051), and 0.4540 for SD > +5 (P = 0.0671). CONCLUSION: DWI-based rSI mapping may be used to delineate the extent of prostate cancer. We achieved best correlation between ratio of cancerous area of the lesser pelvic space on pathological examination and on rSI map using a threshold with SD > +3 of the SI.

Pulmonary vein analysis using three-dimensional computed tomography angiography for thoracic surgery.

OBJECTIVE: Little information is available regarding the variations in pulmonary vein anatomy for the purpose of thoracic or video-assisted thoracoscopic surgery (VATS). To learn about the types and frequency of pulmonary vein variations for VATS, we reviewed a "tailor-made virtual lung" of patients that was constructed using three-dimensional multidetector computed tomography (3D-MDCT) angiography. METHODS: We reviewed routine 64-row 3D-MDCT pulmonary angiography of 140 patients before surgery between June 2006 and February 2009. RESULTS: We observed that most patients had the expected anatomy (98%) on the left side and on the right side (86%). On the right side, 10% of patients had three branches, and 4% patients had four or five branches. Independent drainage of the middle lobe vein directly into the left atrium was observed in 8% patients. Common ostia were observed on the left side in 33% and on the right side in 13% of the patients. The right inferior pulmonary veins branched immediately in 23% of the patients. Right isolated superior posterior branches were observed occasionally (2%). CONCLUSIONS: We observed common ostia more frequently on the left side than on the right. The middle lobe variations were frequent, and the right inferior pulmonary vein often divided at the root. Preoperative 3D-MDCT presented correct pulmonary vein anatomy of the patients.

Modified echo peak correction for radial acquisition regime (RADAR).

PURPOSE: Because radial sampling imposes many limitations on magnetic resonance (MR) imaging hardware, such as on the accuracy of the gradient magnetic field or the homogeneity of B(0), some correction of the echo signal is usually needed before image reconstruction. In our previous study, we developed an echo-peak-shift correction (EPSC) algorithm not easily affected by hardware performance. However, some artifacts remained in lung imaging, where tissue is almost absent, or in cardiac imaging, which is affected by blood flow. In this study, we modified the EPSC algorithm to improve the image quality of the radial aquisition regime (RADAR) and expand its application sequences. METHODS: We assumed the artifacts were mainly caused by errors in the phase map for EPSC and used a phantom on a 1.5-tesla (T) MR scanner to investigate whether to modify the EPSC algorithm. To evaluate the effectiveness of EPSC, we compared results from T(1)- and T(2)-weighted images of a volunteer's lung region using the current and modified EPSC. We then applied the modified EPSC to RADAR spin echo (SE) and RADAR balanced steady-state acquisition with rewound gradient echo (BASG) sequence. RESULTS: The modified EPSC reduced phase discontinuity in the reference data used for EPSC and improved visualization of blood vessels in the lungs. Motion and blood flow caused no visible artifacts in the resulting images in either RADAR SE or RADAR BASG sequence. CONCLUSION: Use of the modified EPSC eliminated artifacts caused by signal loss in the reference data for EPSC. In addition, the modified EPSC was applied to RADAR SE and RADAR BASG sequences.

Importance of preoperative imaging with 64-row three-dimensional multidetector computed tomography for safer video-assisted thoracic surgery in lung cancer.

PURPOSE: Video-assisted thoracic surgery (VATS) has recently been adopted for complicated anatomical lung resections. During these thoracoscopic procedures, surgeons view the operative field on a two-dimensional (2-D) video monitor and cannot palpate the organ directly, thus frequently encountering anatomical difficulties. This study aimed to estimate the usefulness of preoperative three-dimensional (3-D) imaging of thoracic organs. METHODS: We compared the preoperative 64-row three-dimensional multidetector computed tomography (3DMDCT) findings of lung cancer-affected thoracic organs to the operative findings. RESULTS: In comparison to the operative findings, the branches of pulmonary arteries, veins, and bronchi were well defined in the 3D-MDCT images of 27 patients. CONCLUSION: 3D-MDCT imaging is useful for preoperatively understanding the individual thoracic anatomy in lung cancer surgery. This modality can therefore contribute to safer anatomical pulmonary operations, especially in VATS.

Preoperative evaluation of a tracheal bronchus by three-dimensional 64-row multidetector-row computed tomography (MDCT) bronchography and angiography: report of a case.

We performed successful surgery for lung cancer after confirming the anatomical abnormality of a tracheal bronchus by three-dimensional multidetector-row computed tomography (3D-MDCT) bronchography and angiography. Tracheal bronchus is unusual, and right upper lobectomy for lung cancer would rarely be performed in a patient with a tracheal bronchus. Most clinicians are unfamiliar with the anatomy of a right upper lobe that includes a tracheal bronchus. Preoperative 3D imaging of the tracheal bronchus and its related vessels familiarized us with the anatomy of this patient before the operation. Thus, we recommend preoperative 3DMDCT bronchography and angiography, especially for patients with a possible bronchial anomaly.

Anomalous pulmonary vein detected using three-dimensional computed tomography in a patient with lung cancer undergoing thoracoscopic lobectomy.

Few clinicians are familiar with the anatomy of anomalous pulmonary veins, and studies reporting patients who required right lower lobectomy for lung cancer and who had anomalies of the middle and lower pulmonary veins are even rarer. This report describes the case of a lung cancer patient who had an anomalous lateral part of the middle lobe vein (V4) draining into the right inferior pulmonary vein, which was confirmed by three-dimensional 64-row multidetector computed axial tomography (3D-MDCT) angiography. She was then successfully treated with video-assisted thoracic surgery. The preoperative 3D imaging of the pulmonary vein and artery allowed us to comprehend fully the patient's vascular anatomy before the operation. Thus, we recommend preoperative 3D-MDCT angiography for patients with lung cancer undergoing thoracic surgery, especially video-assisted thoracic surgery.

[Radiation therapy for bone metastasis from renal cell carcinoma with emphasis on local control].

If bone metastasis of renal cell carcinoma is neglected, pain, paralysis, and pathologic fracture develope; consequently, the patient's quality of life is significantly lowered. We investigated the local effect of the radiation therapy to the patients with metastasis. The investigation targeted 22 cases (27 parts) of renal cell carcinoma with bone metastasis that were treated with radiation therapy in our hospital during the last 6 years. We analyzed cell type, presence or absence of organ metastasis, irradiated site, therapeutic dose, treatment period, and combination therapy. The object was classified into 2 groups by metastatic site: the group with metastasis in the vertebra, and the group of metastasis in the pelvis or long bones. We examined re-calcification rate, length of time to recalcification emergence, pain relief and duration of effect as therapeutic effects. The irradiated site was vertebra in 14, pelvis in 7, and long bone in 6 patients. The therapeutic dose was 15 to 50 Gy, and the average was 35.7 Gy. No difference was found in the re-calcification rate and length of time to recalcification according to the metastatic site. The pain relief effect was significant in the pelvis and long bone group compared to the vertebra group. The effect lasted longer when the radiation dose was 35 Gy or more, compared with a lower dose. The radiation therapy for renal cell carcinoma with bone metastasis was effective to relieve pain and improve the patients' quality of life. The results showed that early detection and recognition of bone metastasis provide local control.

Percutaneous MR-guided cryoablation for malignancies, with a focus on renal cell carcinoma.

Cryosurgery is the oldest thermal ablation method, and was first performed in the mid-nineteenth century. Since the development of cryosurgical systems capable of delivering liquid nitrogen, organs in various regions have been treated with cryosurgery. However, the lack of an adequate monitoring modality during the freezing process did not allow the precise and complete destruction of lesions deep inside the parenchyma. This led to local recurrences caused by unsatisfactory results of treatment. Recently, a magnetic resonance (MR)-compatible argon-based cryoablation system has been developed, and a combination of this cryoablation system and MR imaging has been shown to be an effective method for treating malignant tumors. In this article, we describe our clinical experience of percutaneous MR-guided cryoablation for malignancies, focusing on renal cell carcinoma.

Percutaneous cryoablation of renal cell carcinoma guided by horizontal open magnetic resonance imaging.

BACKGROUND: Cryoablation is a treatment option for some patients with small exophytic lesions of the kidney. The purpose of this study is to determine the feasibility, safety, and intermediate-term treatment outcome of percutaneous cryoablation of renal cell carcinoma guided by horizontal open magnetic resonance imaging (MRI). METHODS: We prospectively used cryoablation to treat 13 patients with radiographically confirmed enhancing small, solid renal tumors (< or =4.8 cm). An argon gas-based cryoablation system was used. One to four cryoprobes with 2 or 3-mm diameters were placed percutaneously into the tumor under local anaesthesia and MRI guidance. Ice ball dimensions were monitored by 2-D MR images. Double freeze-thaw cycles were conducted throughout the procedure. After successful cryoablation, patients were followed on a regular basis to evaluate the treatment's clinical outcome. RESULTS: Median follow up from time of procedure is 35 months (range, 28-42). In all cases the entire procedure was accomplished without significant morbidity or complications. A mild retroperitoneal hematoma, which subsided spontaneously, was noted in one patient. Follow-up dynamic computed tomography (CT) at 3 months after operation confirmed the absence of enhancement in resolved tumor masses for 11 of 13 cases. None of these 11 patients had clinical evidence of recurrent disease at last follow up. The remaining two patients had lesions with some enhanced areas. Subsequent partial nephrectomy histologically confirmed the presence of vital tumor in, respectively, the center and the periphery of the residual masses. One of these patients developed multiple lung and ipsilateral adrenal metastases 13 months after surgical resection. CONCLUSIONS: Percutaneous cryoablation of small renal cell carcinomas under horizontal open MRI guidance appears to be safe and feasible. An intermediate-term follow up continues to demonstrate efficacy in most patients; however, a few patients experience incomplete ablation with risk of treatment failure. The ideal candidates for this procedure still need to be determined in longer follow up with diligent observation.

[Minimally invasive therapy under image guidance--emphasizing MRI-guided cryotherapy].

Cryotherapy may provide a method for the focal destruction of cancerous tissue while preserving most of the surrounding normal tissue. The mechanisms of tissue injury in cryotherapy are 1) intracellular ice formation, 2) dehydration of cells, and 3) stagnation of microcirculation. MR images were superior to CT and ultrasound in monitoring interstitial cryotherapy, because the very short T2 relaxation time of ice affords excellent contrast between the ice and surrounding tissue, allowing an accurate depiction of the entire extent of the iceball. MR imaging demonstrates the iceball as sharply marginated regions of signal loss that expanded and engulfed the renal and hepatic masses with clear contrast between the iceball and surrounding tissue. Recently, a fast Joule-Thomson cryocycling device for MR-compatible cryotherapy application was developed and clinical trials under MRI-guided monitoring were performed in several sites of the body. In our series, cryotherapy was performed in 14 cases of renal tumor and 4 cases of hepatic malignancy under the guidance of a horizontal open MR system. Fourteen of the 18 cases were discharged a day after cryotherapy. One of the residual tumors at the margin of a renal cancer required re-cryoablation. All cryoablated tumors resolved and there were no serious complications and no clinically significant changes-during the follow-up study.

MR-guided transvaginal cryotherapy of uterine fibroids with a horizontal open MRI system: initial experience.

PURPOSE: We evaluated the feasibility of MR-guided transvaginal cryotherapy for treating intramural, submucosal, and sub-serosal uterine fibroids with a horizontal open MRI system. MATERIALS AND METHODS: Using an MR-compatible cryotherapy system and a horizontal magnetic open-configuration MR scanner, we performed transvaginal cryotherapies using a Cusco speculum on eight uterine fibroids whose longest diameter ranged from 2.9 to 10.0 cm. We assessed the ratio of pre-treatment to post-treatment volume of the uterine fibroids as well as the patients' symptoms (anemia, abdominal pain, dysfunctional uterine bleeding, etc.). RESULTS: All procedures were carried out safely and accurately without any complications that required surgical treatment. MRI enabled clear visualization of the cryoneedle and freezing area as band-like and ellipsoid-like signal losses, respectively. The mean ratio of reduction in uterine fibroid volume was 31.0% at 9-12 months (0-75.0%). Symptoms caused by uterine fibroids improved in seven cases. CONCLUSION: This is the first report on a transvaginal approach to cryotherapy for uterine fibroids. MR-guided transvaginal cryotherapy appears to be feasible and promising as a minimally invasive therapy for symptomatic uterine fibroids.

[Evaluation of enhancement patterns using three-dimensional dynamic contrast-enhanced MR imaging in 209 cases of breast cancer].

PURPOSE: To evaluate contrast-enhanced patterns using three-dimensional (3D) dynamic MR imaging in 209 cases of breast cancer. MATERIALS AND METHODS: Three-dimensional dynamic imaging of the breast (1.5-T scanner) was performed in 755 cases. Of 227 breast carcinomas, 209 cases that were histologically confirmed were enrolled in this study. The histological diagnoses included ductal carcinoma in situ (DCIS) (n=12), invasive ductal carcinoma (n=176), mucinous carcinoma (n=10), medullary carcinoma (n=4), invasive lobular carcinoma (n=6), and other (n=1). Tumor size was a mean 24.6 mm in diameter (range, 7-110 mm), including 110 cases of small breast carcinomas (< or = 2 cm). The contrast-enhancement pattern was analyzed from the early phase of 3D-MRI and the post-contrast T1-weighted SE image acquired before the delayed phase of 3D-MRI. The type of peripheral enhancement (PE) was evaluated on the early and delayed phases of 3D-MRI. These enhancement patterns were also compared with the histological findings of small breast carcinomas. RESULTS: The sensitivity of the 209 cases of breast carcinoma was 99% (207/209) on 3D dynamic MRI. Two hundred six cases (98.6%), including all DCIS, showed strong enhancement on the early phase of 3D MRI. An increased washout pattern showing signal intensity lower than that of fat on post-contrast T1-weighted imaging was noted in 201 cases (96.1%), of which 179 cases (85.6%) showed washout patterns. PE was identified in 63 cases (30.4%) and in 35 of 110 cases of small breast carcinoma (31.8%). Delayed PE following central washout was noted in 65% of 63 cases and 71.4% of 35 cases of small breast carcinoma. Delayed PE was well correlated with marginal fibrosis. CONCLUSION: Three-dimensional dynamic MRI of the breast was highly sensitive for breast carcinoma. Delayed PE following central washout was considered a specific finding of breast carcinoma. It is important to understand the enhancement patterns of 3D dynamic MRI for excellent specificity of breast carcinomas.

MR-guided percutaneous cryotherapy of malignant liver tumor under horizontal-magnetic open system: initial experience.

BACKGROUND/PURPOSE: We describe the feasibility and accuracy of magnetic resonance (MR)-guided cryotherapy for malignant liver tumor, using a horizontal-magnetic open system. METHODS: Using an MR-compatible cryotherapy system and horizontal-magnetic open-configuration MR scanner, we performed percutaneous cryotherapy for four malignant liver tumors. RESULTS: All procedures were carried out safely and accurately without any serious complication. Residual tumor was observed in one patient with metastatic liver tumor located directly under the diaphragm. CONCLUSIONS: MR-guided cryotherapy appears to be ideal and desirable as a minimally invasive therapy for liver tumor.

Correlation of urine type I collagen-cross-linked N telopeptide levels with bone scintigraphic results in prostate cancer patients.

The diagnostic potential of a new bone resorption marker, type I collagen-cross-linked N telopeptide (NTx), for bone metastasis of prostate cancer was evaluated. Ninty-one prostate cancer patients underwent bone scintigraphy, and urine NTx/creatinine (NTx/Cr) was measured. Urine NTx/Cr levels were compared with bone scintigraphic results. Urine NTx/Cr levels in the bone metastasis-positive group (n = 47) were 92.9 +/- 105.1 nmol/L of bone collagen, which is equivalent to per millimole of urinary creatinine (nmol/L BCE/mmol/L Cr), significantly higher than the level of the bone metastasis-negative group (n = 44) (59.0 +/- 41.6 nmol/L BCE/mmol/L Cr). When patients were classified by the extent of disease grade (EOD grade) nomenclature, the urine NTx/Cr level of the EOD (4+) group was 209.5 +/- 186.5 nmol/L BCE/mmol/L Cr. This level was significantly higher than those of the EOD (-) group (59.0 +/- 41.6 nmol/L BCE/mmol/L Cr), EOD (1+) group (59.0 +/- 47.8 nmol/L BCE/mmol/L Cr), and EOD (2+) group (81.1 +/- 41.3 nmol/L BCE/mmol/L Cr). However, no significant difference was observed between the EOD (-) and EOD (1+) groups. The mean change in urine NTx/Cr level 3 to 17 months after the first bone scintigraphy and urine NTx/Cr examination in the bone metastasis-progression group (n = 8) was 11.0 +/- 31.2 nmol/L BCE/mmol/L Cr, significantly higher than that in the bone metastasis-regression group (n = 15) (-26.8 +/- 40.7 nmol/L BCE/mmol/L Cr). In conclusion, urine NTx /Cr can be measured noninvasively and reflects the state of bone metastasis. However, the sensitivity of urine NTx/Cr is not as high as that of bone scintigraphy. Therefore, it may provide an auxiliary diagnostic index for bone scintigraphy.

Wireless local area networking for linking a PC reporting system and PACS: clinical feasibility in emergency reporting.

Although local area networks (LANs) are commonplace in hospital-based radiology departments today, wireless LANs are still relatively unknown and untried. A linked wireless reporting system was developed to improve work throughput and efficiency. It allows radiologists, physicians, and technologists to review current radiology reports and images and instantly compare them with reports and images from previous examinations. This reporting system also facilitates creation of teaching files quickly, easily, and accurately. It consists of a Digital Imaging and Communications in Medicine 3.0-based picture archiving and communication system (PACS), a diagnostic report server, and portable laptop computers. The PACS interfaces with magnetic resonance imagers, computed tomographic scanners, and computed radiography equipment. The same kind of functionality is achievable with a wireless LAN as with a wired LAN, with comparable bandwidth but with less cabling infrastructure required. This wireless system is presently incorporated into the operations of the emergency and radiology departments, with future plans calling for applications in operating rooms, outpatient departments, all hospital wards, and intensive care units. No major problems have been encountered with the system, which is in constant use and appears to be quite successful.

A new image navigation system for MR-guided cryosurgery.

PURPOSE: To evaluate the feasibility of Interactive Scan Control (ISC), a new MR image navigation system, during percutaneous puncture in cryosurgery. MATERIALS AND METHODS: With the ISC system in place, percutaneous MR-guided cryosurgery was performed in 26 cases, with the ISC system being used in 11 cases (five renal tumors, three uterine fibroids and three metastatic liver tumors). The ISC system comprised infrared cameras and an MR-compatible optical tracking tool that was directly connected to a cryoprobe. Tumor sizes ranged from 1.2 cm (metastatic liver tumor) to 9.0 cm (uterine fibroid), for a mean size of 3.9 cm. With ISC, one to three cryoprobes with a diameter of 2 mm or 3 mm were advanced into the tumors with the guidance of an MR fluoroscopic image. Two freeze-thaw cycles were used for cryosurgery. During the cryosurgery, the formation of iceballs was monitored on MR images. Follow-up dynamic CT or MRI as well as physical examinations were conducted after two weeks and six weeks. RESULTS: Placement of probes was successfully performed under the control of the ISC system. During cryosurgery, engulfment of the tumors by iceballs was carefully monitored by MRI. Necrosis of the cryoablated area was confirmed in all renal tumors by follow-up dynamic CT. The size regression of the uterine fibroids was observed through follow-up MRI. Two of the three cases of metastatic liver tumor were ablated completely. Additional therapy for a residual tumor was performed on one patient with a metastatic liver tumor. A small amount of pneumothorax was the only complication found in a patient with a metastatic liver tumor. CONCLUSION: MR-guided cryosurgery with this new navigation system was feasible with low morbidity and allowed for safe and accurate puncture with a cryoprobe.