Telecytology in Hokkaido Island, Japan: results of primary telecytodiagnosis of routine cases.

In 1997, an Internet-based static image telepathology system was built at Sapporo National Hospital, Japan. We can exchange high-resolution microscopical images through a file transfer protocol server and discuss cytological findings and diagnosis on an electronic mailing list. We applied the system to primary telecytodiagnosis. From May 1997 to April 1999 we have made diagnoses of 614 daily cases only by looking at the video monitor images transmitted from the cytotechnologist of Wakkanai Municipal Hospital 300 km distant from Sapporo. The concordance between telecytodiagnosis and glass slide diagnosis was 88.6%. Kappa statistics for cervical smears was 0.919 and that for specimens other than uterine cervix was 0.810. The accuracy of telecytodiagnosis was 91.4%, and was not substantially different from that of the conventional mail-based cytology in a previous year. We had five cases with a severely inappropriate diagnosis in telecytology, all of which however were quickly corrected by follow-up histological or cytological specimens. With the use of an electronic mailing list the participants had quick and sufficient discussions. We conclude that telecytology is very useful for primary cytodiagnosis in regional medicine and that it may raise the accuracy of cytodiagnosis in future, if we make consistent efforts to reflect the benefits of telecytology in daily practices. This is the first report of clinical results of telecytology from Japan.

Japanese experience of telemedicine in oncology.

We started telemedicine projects from 1990 with a telepathology system within Tsukiji Campus of National Cancer Center. In 1994, we connected Tsukiji Campus and Kashiwa Campus by 6 Mbps optical fiber leased line using IP protocol for data transmission, for teleconference, telepathology, and teleradiology projects. We also started connection of regional cancer centers and are now forming a cancer center network of 14 cancer centers. We are at present organizing 130 teleconferences per year with an attendance of more than 16000 people as summary. We have also used a high-resolution image transferring system, such as SHD (2000 pixelsx2000 pixels resolution) system on one side, and an economical telemedicine system using JAVA and a WWW browser (NCC_image) on the other side. We think that providing information is another field of telemedicine. We began the experimental gopher and WWW service in 1993. We are now providing official up-to-date cancer information for patients and healthcare professionals. We are getting more than 400000 hits per month. We are also providing a teleconference video session which is held every week on the Internet using a Real Video system with synchronized slide presentation on the WWW browser. We are also organizing a Cancer Image Reference Database System including DICOM images with viewer software. This paper is a summary of the telemedicine projects performed at the National Cancer Center.

[Cancer therapy and processing information].

The National Cancer Center Japan started to provide free, computer-based cancer information, through a service called the National Cancer Center--Cancer Information Service (NCC-CIS), to patients and their families, physicians and other health professionals via fax (telephone) and the Internet in 1996. NCC-CIS in Japanese is modeled on the Physician Data Query service produced by the National Cancer Institute in the United States and is produced from an independent standpoint adopted to the medical and social environment in Japan. NCC-CIS provides up-to-date cancer treatment information (staging, prognosis and state-of-the-art treatment by stage of disease), supportive care for each type of cancer, an image reference database, and a directory of organizations and lecture meeting reports in Japan in order to facilitate better understanding of cancer among people and support the decision-making process for physicians in order to achieve a reduction in cancer deaths.

Alveolar architecture of clear cell renal carcinomas (< or = 5.0 cm) show high attenuation on dynamic CT scanning.

BACKGROUND: To establish the correlation between tumor appearance on CT and tumor histology in renal cell carcinomas. METHODS: The density and attenuation patterns of 96 renal cell carcinomas, each < or = 5 cm in greatest diameter, were studied by non-enhanced CT and early and late after bolus injection of contrast medium using dynamic CT. The density and attenuation patterns and pathological maps of each tumor were individually correlated. RESULTS: High attenuated areas were present in 72 of the 96 tumors on early enhanced dynamic CT scanning. All 72 high attenuated areas were of the clear cell renal cell carcinoma and had alveolar architecture. The remaining 24 tumors that did not demonstrate high attenuated foci on early enhanced scanning included three clear cell, nine granular cell, six papillary, five chromophobe and one collecting duct type. With respect to tumor architecture, all clear cell tumors of alveolar architecture demonstrated high attenuation on early enhanced scanning. CONCLUSION: Clear cell renal cell carcinomas of alveolar architecture show high attenuation on early enhanced dynamic CT scanning. A larger number of patients are indispensable to obtaining clear results. However, these findings seem to be an important clue to the diagnosis of renal cell carcinomas as having an alveolar structure.

The clinical advantages of editable real-time volume rendering in a medical virtual environment: VolMed.

Segmentation for a medical virtual environment is a process of image diagnosis. It should be performed by clinical doctors, otherwise the data may be meaningless for using clinical purposes. At the National Cancer Center, in Japan, we have recently developed interactive, editable real-time volume rendering software (VolMed), based on Volren-6 software, with the ability to interactively edit the 3D images of a patient's virtual cancer and virtual organs, in a virtual environment. Doctors can see proposed solutions to clinical problems as 3D images, using real-time volume rendering. We conclude that interactive editing is very important for clinical use, and also decreases the time required to create the virtual cancer images used for surgical simulation, pre-surgical planning and 3D invasion diagnoses.

Virtual cancer image data warehouse.

We previously developed a system with which we have created more than 100 virtual cancer images from CT or MR data of individual patients with cancer (Cancer Edutainment Virtual Reality Theater: CEVRT). These images can be used to help explain procedures, findings, etc. to the patient, to obtain informed consent, to simulate surgery, and to estimate cancer invasion to surrounding organs. We recently developed a web-based object-oriented database both to access these cancer images and to register medical images at international research sites via the Internet. In this report, we introduce an international medical VR data warehouse created using an object-oriented database.

Virtual reality support system in palliative medicine.

We have been examining the potential value of a VR system for the palliative care of cancer. We recently developed palliative care system which consists of a 100-inch-wide screen, HMD (Head-mounted display) and 8-mm video or a PC. Our goal is to use VR techniques to help alleviate a patient's stress and concern regarding their cancer during hospitalization. We can use this system to present (1) personal video movies, (2) video letters from friends and family, (3) personal video instruction about medical examinations, and (4) interactive information about their cancer using a PC-based VR system. Our preliminary results indicate that interesting VR presentations are useful for reducing stress.

Virtual reality enhanced surgical conference system.

We present our ongoing work on an enhanced surgical conference system with a technology of virtual reality (VR). We reported on a surgical simulation support system by using a technology of virtual reality last year. In the present time, while using our VR simulation system, we realized that many surgeons and nurses needed to see both a solid real image and a virtual image of the surgical operation at the same time. According to this reason we added a solid video system to our previous VR simulation system. The new system can display both real and virtual images on 100 inch wide screen and a console monitor of Onyx computer. The doctors can see both images with shutter glasses on the screen or console. We can now simulate various cancer surgery while watching the real solid surgical picture. We expect our enhanced surgical conference system to be beneficial for surgeons and nurses with limited experience to familiarize surgical procedures. The system could be also employed in planning a surgical procedure and educating medical staffs. Here we discuss about the aim of the system, current implementation, its limitations and its future directions.

Stereoscopic visualization system for clinical angiography.

Four dimensional visualization (FDV) project for clinical angiography has started at National Cancer-Center since 1995 in cooperation with medical virtual reality projects in our center. All stereo pair of x-ray angiographic images, both digital images and film based conventional x-ray images, are available in this system. FDV system software was developed on a Silicon Graphics platform. Every stereo pair angiographic images can be viewed stereoscopically using a stereoscopic visualization interface. Series of image data sets provide three dimensional blood flow dynamics that is very useful to diagnose vascular encasement by the tumor and to determine vessel of purpose which locates in front or in back from superimposed angiographic images. FDV system is expected to improve the accuracy and efficiency of diagnostic radiology and interventional radiology (IVR) procedures. In future, angiography system will equipped with a stereoscopic visualization interface that will provide a more flexible and more effective guidance tool for diagnostic radiology, especially for IVR that requires image-guided procedure.

CT diagnosis of early hepatocellular carcinoma: sensitivity, findings, and CT-pathologic correlation.

OBJECTIVE: The purpose of this study was to determine the sensitivity of CT in detecting early hepatocellular carcinoma and to evaluate its CT appearance. An early hepatocellular carcinoma is a nodular lesion with no fibrous capsule composed of well-differentiated tumor histologically. It differs from a small hepatocellular carcinoma, which is an overt tumor that is moderately to poorly differentiated and has a fibrous capsule. Size is not a criterion for distinguishing between early and small hepatocellular carcinomas. MATERIALS AND METHODS: Thirty-one patients with 39 histopathologically proved early hepatocellular carcinomas (mean diameter, 1.7 cm) found by sonography, MR imaging, and/or intraoperative sonography were included in a retrospective study. We reviewed unenhanced CT scans of the entire liver in 30 patients (37 lesions) and early and late (35 sec and 5 min after the beginning of injection of contrast material) contrast-enhanced CT scans of the entire liver in all 31 patients (table incremental CT in 21; helical CT in 10; 39 lesions). Eighteen histologically proved small hepatocellular carcinomas (< or = 3 cm; mean diameter, 2.3 cm), present in the same patients, served for comparison. Histopathologically, nine patients had chronic hepatitis, and 22 had cirrhosis. RESULTS: The overall sensitivity of CT in detecting early hepatocellular carcinoma was 56%. These tumors were usually isodense with respect to surrounding liver on unenhanced, early enhanced, and late enhanced CT scans (iso-iso-iso). This pattern was seen in 17 (46%) of 37 lesions; thus, these 17 histologically proved early hepatocellular carcinomas were not detected with CT. An iso-iso-low density pattern was recognized in eight (22%), a low-low-low pattern in seven (19%), and several different patterns in five (13%) of the 37 lesions. Only two (5%) of 39 early hepatocellular carcinomas had a high-density appearance on early enhanced CT scans. In comparison, the most common pattern of small overt hepatocellular carcinomas on CT scans was low-high-low, seen in 17 lesions (94%) detected with CT. When the density of lesions on unenhanced CT scans was compared with the histopathologic appearance of the masses, low-density lesions showed mild to moderate fatty change and isodense lesions showed no or minimal fatty change (p = .006). CONCLUSION: The sensitivity of CT in detecting early hepatocellular carcinoma is poor (56%). However, the diagnosis of early hepatocellular carcinoma should be considered if CT scans show a small lesion with an iso-low or low-low density enhancement pattern on early and late contrast-enhanced CT scans, respectively, in patients with chronic liver disease.

CT of lymphoepithelial cysts of the pancreas.

OBJECTIVE: To clarify imaging and clinicopathologic features of lymphoepithelial cysts (LEC), a benign lesion of the pancreas. MATERIALS AND METHODS: Two male patients with LECs that were found incidentally and proven surgically were reviewed. RESULTS: Sonography revealed a hypoechoic mass in both cases, one of which had septation and an intracystic isoechoic component within it. The mass was shown as low attenuation on unenhanced CT, and the intracystic solid component was not enhanced by dynamic CT or computed tomographic arteriography. One lesion had calcifications around the mass. Magnetic resonance imaging showed hyper- in hypointensity on T1-weighted imaging and hypo- in hyper- on T2-weighted imaging in one case. Both lesions were located on the surface of the head of the pancreas, and the main pancreatic ducts appeared normal on endoscopic retrograde pancreatography. Both patients were asymptomatic. CONCLUSION: These imaging and clinical findings suggest LEC, which should be considered when one encounters cystic lesions of the pancreas.

Early hepatocellular carcinoma: appearance at CT during arterial portography and CT arteriography with pathologic correlation.

PURPOSE: To use computed tomography (CT) during arterial portography (CTAP) and CT arteriography to compare the hemodynamic properties of early hepatocellular carcinoma (HCC) with those of small HCC. MATERIALS AND METHODS: Forty-four early HCCs (mean diameter, 1.5 cm) in 37 patients (26 men and 11 women aged 52-74 years; mean age, 59.2 years) were studied. CTAP was performed on 35 early HCCs, CT arteriography on 20, and both studies on 11. CTAP, CT arteriography, or both were performed on 90 small HCCs (mean diameter, 2.0 cm) in 57 patients (44 men and 13 women aged 48-71 years; mean age, 61 years). The findings for small HCC were compared with those for early HCC. RESULTS: CTAP depicted 23 early HCCs as hypoattenuating masses and 12 as isoattenuating. CT arteriography depicted 11 early HCCs as hypoattenuating masses, six as isoattenuating, and three as hyperattenuating. CTAP depicted 85 of 88 small HCCs as hypoattenuating masses and three as isoattenuating. CT arteriography depicted 13 of 14 small HCCs as hyperattenuating masses. CONCLUSION: CTAP, the standard of reference for the detection of small HCC, is not sensitive enough for the detection of early HCC.

Computed tomography-guided coil injection and thoracoscopic pulmonary resection under roentgenographic fluoroscopy.

To remove a small, chest roentgenogram-negative, computed tomogram-positive nodule, we developed a novel technique of thoracoscopic pulmonary resection. This technique consists of the computed tomography-guided coil injection of a metallic coil and subsequent thoracoscopic resection under roentgenographic fluoroscopy. During the thoracoscopic resection, the fluoroscopic image was a valuable aid in determining the location of the nodule and in ensuring that the stapler was applied with a sufficient distance from the coil. Because this technique helps to determine the exact location of the nodule regardless of its depth from the pleural surface, even a minithoracotomy for direct palpation can be avoided.

Early advanced hepatocellular carcinoma: evaluation of CT and MR appearance with pathologic correlation.

PURPOSE: To determine the computed tomographic (CT) and magnetic resonance (MR) imaging appearances of early advanced hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-seven surgically resected cases of early advanced HCC were studied with CT, CT during arterial portography, CT arteriography, and MR imaging. RESULTS: The sensitivity of standard CT (unenhanced, early, and late CT combined) for the detection of early advanced HCC was 81%, while that of standard MR imaging (T1- and T2-weighted MR imaging combined) was 83%. A nodule-in-nodule appearance was identified in approximately one-third to one-half of cases. Signal behavior of early and advanced components of early advanced HCC followed the expected behaviors of isolated early HCC and isolated advanced HCC, respectively. Tumor size was accurately estimated with standard CT and standard MR imaging. CONCLUSION: More research must be performed to ascertain whether any relationship exists between the different types of HCC and the clinical outcome.

Case report: hepatocellular carcinoma diagnosed radiologically, treated by transcatheter arterial embolization and limited-field radiotherapy.

Even though the resection rate for hepatocellular carcinoma (HCC) has risen recently, many patients cannot be treated surgically because of the advanced stage of the tumour and/or coexisting cirrhosis. An alternative therapeutic approach for some of these patients is transcatheter arterial embolization (TAE) which has become very common in Japan. However, it is not a curative measure, and an additional therapy is required to eradicate the residual disease. In this communication, we report a case in which a patient with HCC has been successfully treated by TAE followed by limited-field radiotherapy. The results suggest that this is a very promising therapeutic approach for HCC and that the potential of limited-field radiotherapy for HCC with or without TAE also needs to be explored.

Accuracy of computed tomography in determining pancreatic cancer tumor size.

We compared tumor sizes determined by computed tomography (CT) with those of the resected specimens in 26 patients with pancreatic cancer in order to clarify whether or not the size of a pancreatic tumor can be accurately determined by CT. From the precontrast, postcontrast and arterial dominant phases of dynamic CT, the arterial dominant phase was found to yield the highest correlation between CT measured tumor size and that of the resected specimens (P < 0.01). The correlation coefficient was, however, not high (r = 0.67). CT alone may therefore be insufficient to determine tumor size in pancreatic cancer accurately.

Radiological study of idiopathic Budd-Chiari syndrome complicated by hepatocellular carcinoma. A report of four cases.

During an 11-yr period (1979-1989), we have experienced five patients with idiopathic Budd-Chiari syndrome (BCS), four (80%) of whom had associated hepatocellular carcinoma (HCC). In contrast, the incidence of BCS complicated by HCC was 0.7% of a total of 556 patients who underwent surgery for HCC or were autopsied. Hepatitis B virus-related antigen or antibody was positive in one patient each. Four of our five patients were asymptomatic and were initially diagnosed by ultrasonography (n = 3) or computed tomography (n = 1). The hepatic parenchyma histopathological findings were cirrhosis and fibrosis in one each. Infection of hepatitis B virus rather than BCS was speculated as a causative factor for HCC in two patients. Membranous obstruction with spotty calcification, intrahepatic bizarre communicating vessels, and the dilated anterior longitudinal veins in spinal canal were recognized in three patients. Three patients had two HCCs which were similar in size and arose from the right and left hepatic lobe, separately, suggesting multicentricity of HCC. Both percutaneous transluminal angioplasty with Gruntzig balloon catheters for the obstruction of the inferior vena cava and hepatic arterial embolization for HCC(s) were performed in three patients. These patients survived 29.3 months on average after the diagnosis of BCS complicated by HCC(s). The opened IVC was confirmed to be patent on an average of 26.3 months after the first angioplasty.

Combined hepatocellular carcinoma and cholangiocarcinoma: clinical features and computed tomographic findings.

Clinicoradiological features were studied in 20 patients with 22 mass lesions of combined hepatocellular carcinoma and cholangiocarcinomas and findings of computed tomography in 12 of these patients with 14 hepatocellular carcinoma-cholangiocarcinomas. Five of these patients also had single overt hepatocellular carcinomas. The incidence of hepatocellular carcinoma-cholangiocarcinoma was 3.3% among the patients with primary liver cancer treated in our hospital. HBsAg was present in 25%, and increased levels of serum alpha-fetoprotein (> 200 ng/ml) and carcinoembryonic antigen (> 5 ng/ml) were found in 25% and in 47%, respectively. Associated cirrhosis was present in 60%. Analysis of 14 hepatocellular carcinoma-cholangiocarcinomas in 12 patients in whom the enhancement pattern on dynamic computed tomography and pathological findings could be studied and compared suggested three tumor types. Nine lesions (type A) were demonstrated only as areas with high-density peripheries in the early phase of enhancement that evolved into a pattern of peripheral low density and central high density in the late phase. Four masses (type B) were shown as hyperdense tumors (early phase) that changed to low density in the late phase. One mass (type C) was seen as a low-density lesion that did not change. Histopathologically, type A comprised hepatocellular carcinoma-predominant components in the peripheral area, cholangiocarcinoma-predominant components with abundant fibrous stroma in the central area and a tissue transitional between the two in the midzone. By contrast, two of four type B masses comprised hepatocellular carcinoma with scattered cholangiocarcinoma components throughout the tumor.(ABSTRACT TRUNCATED AT 250 WORDS)