Imaging diagnosis of genitourinary tract tumors

Recent advance of imaging technique have brought great advantages for management of genitourinary tract tumors. We described few examples of changes in this field from our experience. Many asymptomatic masses are discovered in the kidney and adrenal gland associated with wide clinical application of CT and US. In the kidney, the greater part of incidental masses are renal cell carcinomas (RCC) and the rate of such cases has been increasing. When small RCC is diagnosed without any clinical symptoms, better survival would be expected. Many adrenal incidental mass are also discovered by routine use of CT for abdominal workup. Since greater part of these masses are benign nonfunctioning adenomas, correct diagnosis should be made in order to avoid inappropriate surgery. Rapid development of MR also resulted in some changes in the diagnosis of urinary tract tumors. However, MR cannot be used as a screening method. For staging of RCC, intravascular or adjacent organ invasion was well determined with MR compared with CT. Differentiation of adrenal carcinomas from nonfunctioning adenomas is suggested by the difference of signal intensity on T2 weighted images. Fast spin echo scan with GD-DTPA enhancement is new MRI technique separating bladder mucosal layer from muscle layer as hyper-intensity area. Using this method, diagnostic accuracy of deep muscle invasion for bladder tumor would be improved.     

Differential diagnosis of the early cancer: imaging diagnosis "CT"

Computed tomography (CT) makes a significant contribution to the care of the patient with cancer, and is still expanding its usage in the diagnosis of the tumor. CT is considered to be an essential tool for the cancer of the pharynx and larynx, lung, liver, biliary tract, pancreas, kidney, adrenal gland, and ovary. We briefly describe the CT anatomy and oncologic pathology in these regions.     

A 66-year-old woman with newly diagnosed oligometastatic non-small cell lung cancer

A 66-year-old woman presented with newly diagnosed stage IV non-small cell lung cancer (NSCLC) and a large adrenal metastasis. She initially had flu-like symptoms and dyspnea and was found to have a right upper lobe (RUL) lung nodule. Chest CT showed a 1.4-cm spiculated RUL lung nodule, peripheral right lung nodule, right perihilar mass, and 10.9-cm left adrenal mass. PET/CT showed enhancement of the RUL nodule, hilar mass, and left adrenal mass. She presented for evaluation of treatment options. This case was thought to represent an instance of oligometastatic stage IV NSCLC. Literature suggests that a select patient population with otherwise resectable disease may benefit from surgical resection of a lung primary and the isolated metastasis with improved survival. This seems to be most effective in patients who have undergone a complete staging evaluation with PET scan; CT of the chest, abdomen, and pelvis; and a brain MRI revealing T1-2, N0-1, M-oligo disease. This radical approach should be reserved for patients with potentially curative disease based on the staging evaluation and who are otherwise good surgical candidates.     

Evaluation of chest wall invasion by lung cancer using respiratory dynamic MRI

Conventional CT or MRI has low accuracy in assessing chest wall invasion in patients with peripheral lung cancer. For preoperative evaluation of chest wall invasion by peripheral lung cancer, respiratory dynamic (RD) MRI was carried out in 98 patients in whom conventional CT scan showed that the tumour was abutting the pleural surface, but there was no evidence of definite tumour invasion. We used 1.5-T MR equipment. RD MR images were acquired by snapshot fast field echo sequence (repetition time = 8, echo time = 3, flip angle = 100) and 25 consecutive images were taken while the patient took deep breaths. These images were evaluated in cine mode to assess tumour movement along the chest wall. Sixty-one patients underwent surgical resection of the tumour and RD MR findings were compared with those in pathological specimens. RD MR showed free tumour movement along the chest wall in 34 patients. At pathological examination, the RD MR findings were proved correct in all patients. Pathologically, 20 patients had chest wall invasion and their RD MR was positive (sensitivity 100%). There were seven false-positive results among the 41 patients without chest wall invasion (specificity 82.9%). RD MR may improve the accuracy of conventional CT scan or MRI in the prediction of chest wall invasion of lung cancer, especially in patients in whom the results of conventional CT scan or MRI appear equivocal in the presence of a peripheral mass abutting the chest wall surface without obvious chest wall invasion.     

血清CA125临床意义的回顾性分析

目的:评价血清CA125在恶性肿瘤诊断中的价值。方法:回顾性分析2775例不同疾病患者的血清CA125结果(临界值35U/ml)。结果:胆囊癌、胰腺癌、卵巢癌、肺癌和肝癌患者的血清CA125阳性率较其它肿瘤患者高(P<0.05)。在一些严重的非肿瘤疾病如器官衰竭、肝硬化、肺结核等也有较高的阳性率。患同样的疾病,有腹水的患者血清CA125水平较没有腹水者高(P<0.05)。结论:血清CA125水平对于胆囊癌胰腺癌、卵巢癌、肺癌和肝癌等恶性肿瘤的辅助诊断有一定的临床应用价值,但应注意与肝硬化,肺结核等非肿瘤疾病的鉴别诊断。     

Current applications of imaging procedures in the patient with lung cancer

The primary role of imaging procedures in the patient with lung cancer should be focused on staging and follow-up challenges. The role of imaging procedures in the detection of the patient at risk for primary lung cancer remains limited and cannot be recommended at present. There is no significant difference between the yield of CT and MR in this patient group, with the possible exception of a more specific role for MR when questions are raised concerning hilar lymph node involvement and mediastinal compartmental invasion. The main role of cross-sectional imaging techniques should be in the avoidance of unnecessary surgical procedures, identifying the unresectable patient prior to exploratory thoracotomy. It should be emphasized that all radiographic abnormalities are non-specific and must be histologically verified before presuming that an abnormal lymph node or large adrenal gland contains metastatic lung cancer.     

肾上腺神经鞘瘤的诊断及临床特点并文献复习（附8例报告）

背景与目的：肾上腺神经鞘瘤非常少见,多为良性,缺乏特异性的临床及影像学表现。该研究通过对肾上腺神经鞘瘤的CT和MRI表现与病理对照分析,提高对肾上腺神经鞘瘤的诊断水平。方法：回顾性分析经病理证实的8例肾上腺神经鞘瘤患者的CT和MRI影像特征,其中4例患者仅行CT扫描,3例患者仅行MR扫描,1例患者行CT和MR扫描。并将影像学诊断结果与病理诊断结果进行对比分析。结果：5例肿瘤位于左侧肾上腺,3例位于右侧肾上腺;所有患者均未出现内分泌症状。所有8例肿瘤表现为边界清楚的类圆形、分叶状肿块,2例肿瘤见钙化,5例肿瘤伴囊变,2例肿瘤伴出血;7例肿瘤CT或MRI的强化表现为中度不均匀、延迟强化,并可见强化的包膜,4例肿瘤增强可见兔尾征。结论：肾上腺神经鞘瘤的影像及病理有一定的特征性,完整包膜、囊变、兔尾征、钙化及渐进强化等影像征象有助于提高肾上腺神经鞘瘤的诊断准确率。     

Clinical utility of PET-FDG imaging in differentiation of benign from malignant adrenal masses in lung cancer

This study was designed to evaluate the sensitivity, specificity, and predictive accuracy of PET-FDG imaging in detecting metastatic disease involvement of adrenal glands in patients with lung cancer. We wanted to compare efficacy of positron emission tomography (PET)-fluorodeoxyglucose (FDG) imaging to computed tomography (CT) scanning in differentiating benign from malignant involvement of adrenal glands in patients with lung cancer. Thirty patients with biopsy-proven lung cancer and abnormal findings on PET and/or CT scanning were studied for presence of adrenal abnormality suggestive of metastatic disease involvement (n = 26) or benign adrenal enlargement (n = 4). The results of PET and CT scanning were compared to histological findings and/or clinical follow-up for at least 1 year for presence or absence of adrenal metastases. PET-FDG imaging correctly detected the presence of metastatic involvement in 17 of 18 patients and excluded metastatic involvement in 11 of 12 patients for sensitivity, specificity, and accuracy of 94.4%, 91.6%, and 93.3%, respectively. CT scanning showed enlarged adrenals without metastases in 8 of 30 patients and normal-sized adrenals in the presence of metastases in 5 of 30 patients. There was a false-positive PET finding in 1 patient and a false-negative PET finding in another patient. PET-FDG imaging is a highly sensitive, specific, and accurate test to differentiate benign from malignant involvement of adrenal glands in patients with lung cancer and often ambiguous findings on CT scanning.     

Dysgenetic hypoplastic kidney simulating metastatic lung carcinoma

We describe a 57-year-old male with prior history of an absent right kidney and kidney transplant who was found to have lung cancer. Integrated positron emission tomography (PET) and computerized tomography (CT) scan was done for staging and showed uptake in the right upper lung primary and right renal fossae region which was suggestive of metastatic disease. An excisional biopsy of the right renal fossae mass showed that it was a hypoplastic kidney simulating a metastatic focus on PET scan. The patient eventually underwent a left upper lobectomy with a final pathological stage of T2N0M0. Positive PET scan areas should be biopsied to confirm the presence of metastatic disease before excluding patients from surgical treatment.     

Modulation of A N-nitrosobis(2-hydroxypropyl)amine-induced carcinogenesis by clofibrate in hamsters

The effects of clofibrate treatment on N-nitrosobis(2-hydroxy-propyl)amine(BHP) induced liver, gall bladder, pancreas, lung and kidneycarcinogenesis in hamsters were studied. Animals were givenBHP as an initiator at a dose of 500 mg/kg body weight subcutaneouslyonce a week for 5 weeks followed by diet containing 0.25 or0.5% clofibrate for 30 weeks. Both doses of clofibrate promotedhepatocarcino-genesis as judged from the associated multiplicityof liver lesions including hyperplastic nodules and hepatocellularcarcinomas. -Glutamyltranspeptidase (-GTP) activity was notexpressed in those lesions in the liver of hamsters given BHPfollowed by a basal diet or diets containing clofibrate. Clofibrateat a dose of 0.5% in the diet, in contrast, inhibited the developmentof pancreatic adenocarcinomas and lung neoplasms, includingadenomas and adenocarcinomas, without affecting carcinogenesisin the gall bladder and kidney. These results clearly indicatedifferectial modification potential of clofibrate for BHP-inducedliver, pancreas and lung carcinogenesis in Syrian hamsters.     

A case of unresectable advanced gall bladder cancer successfully treated by hepatic arterial chemotherapy with reservoir (HACR) using CDDP and 5-FU

A 64-year-old female was admitted for treatment of a huge tumor (10 cm in diameter) in segment S4-S5 of the liver. The lymph node (2 cm in diameter) was located posterior to the pancreas head. The patient was diagnosed with an unresectable advanced gall bladder cancer with direct invasion of the liver bed and lymph node metastasis. At first, hepatic arterial infusion of CDDP, MMC and ADM through the hepatic artery was performed. Then, hepatic arterial chemotherapy with reservoir (HACR) using CDDP and 5-FU (CDDP 20 mg/body/day, 5-FU 750 mg/body/day) was started. As a result, the primary tumor and enlarged lymph node almost disappeared in two years. Mild bone marrow suppression, nausea and vomiting were encountered, but no severe side effects were noted. We conclude that this strategy is effective for unresectable advanced cancer of the gall bladder with lymph node metastasis.     

Hospital procedure volume and survival of cancer patients in Osaka, Japan: a population-based study with latest cases

BACKGROUND: Recent studies reported that hospital procedure volume (i.e. volume of patients per hospital receiving a particular treatment)was directly proportional to cancer survival; however the degree of association might be different according to the primary tumor site, extent of disease and year of diagnosis. We performed a systematical examination of survivals by hospital procedure volume according to the primary site with inclusion of latest cases in Osaka, Japan. METHODS: Individual data on reported cancer cases with active follow-up information and diagnosis between 1994 and 1998 were retrieved from Osaka Cancer Registry's database. The analysed primary sites included oesophagus, stomach, large bowel, liver, gall bladder, pancreas, lung, breast, uterus, ovary, prostate, bladder and lymphoma. Hospitals were ranked as high-, medium-, low- and very low-volume hospitals for every primary site by dividing the number of cancer patients who received treatment in hospitals into four quartiles. RESULTS: The primary sites could be classified into three categories based on the association between hospital procedure volume and cancer survival: In type 1, a better survival was associated with a higher procedure volume as for oesophagus, liver, lung, ovary, prostate, or lymphoma; in type 2, a better survival was associated with a higher procedure volume but there was no significant difference in survival between high- and medium-volume hospitals as for uterus; and in type 3, there was no significant difference in survival among high-, medium- and low-volume hospitals as for stomach, large bowel, gall bladder, pancreas, breast, or bladder sites. CONCLUSIONS: A higher procedure volume was generally associated with a better survival; however, this association could be classified into three types according to the primary site.     

Evaluation of gall bladder carcinoma with dynamic magnetic resonance imaging and magnetic resonance cholangiopancreatography

The objective of this study is to evaluate the efficacy of dynamic MRI with magnetic resonance cholangiopancreatography (MRCP) in the preoperative assessment of gall bladder carcinoma. Magnetic resonance imaging and MRCP were carried out in 15 patients with gall bladder carcinoma before surgery and the imaging findings correlated with surgical and pathological findings. Gall bladder carcinoma manifested as focal or diffuse wall thickening in 73% (11/15) and as a mass replacing the gall bladder in 27% (4/15). All tumours showed enhancement in the early phase, which persisted into the delayed phase. The sensitivity and specificity of MRI with MRCP in detecting hepatic invasion, lymph node metastasis and bile duct invasion was 87.5 and 86%, 60 and 90%, and 80 and 100%, respectively. Magnetic resonance imaging correctly diagnosed duodenal invasion in only 50% and in none of the two patients with peritoneal metastasis. In conclusion, dynamic MRI with MRCP is an accurate and a reliable method of showing gall bladder carcinoma and in assessing its local and regional extent as part of preoperative assessment.     

Organ defects due to cancer treatment in infancy and childhood

In infancy and childhood, as in adults, organ defect is the most direct adverse effect of cancer treatment. Anatomical defects due to surgical treatment and functional defects due to radiotherapy are the two main types. In this paper, the relationship between the radicality of surgical treatment and preservation of organ form and function are discussed with regard to the thyroid, chest wall, lung, stomach, intestine, liver, pancreas, kidney and intra-pelvic organs. The more radical the treatment, the less preservation of organ form and function. The role of surgery has been changing in accordance with the development of chemotherapeutic drugs and drug combination, and must always be reevaluated in accordance with any progress made in other treatment modalities. Some typical cases from a series of patients we have treated were presented. A neonatal case of broad right chest wall defect due to surgical removal of chondroblastoma was presented, showing our new method of chest wall reconstruction. A case of bilateral Wilms' tumor was presented, which was treated using bench surgery to prevent total removal of kidney tissue. A case of huge and infiltrative intra-pelvic rhabdomyosarcoma was also described, which was treated by tumor extirpation and 2/3 partial resection of the urinary bladder, in combination with chemotherapy and radiotherapy.     

Bilateral adrenal leiomyosarcoma treated with multiple local therapies

A 62-year-old woman presented with right flank pain, and computed tomography (CT) showed bilateral adrenal tumors (right, 8 cm; left, 4 cm). There were no abnormal findings on physical examination, and adrenal hormone levels in serum and urine were within normal limits. Radiological studies showed a right adrenal tumor with intratumoral hemorrhage, a cystic tumor in the left adrenal gland, and no sign of distant metastasis. Because laboratory tests showed normal levels of adrenal hormones, we considered the tumors to be nonfunctioning adrenal tumors. The right adrenal tumor was surgically removed because it was thought to be malignant, and histological examination revealed that it was a leiomyosarcoma. Postoperative CT showed a pleural metastasis in the right chest wall. The patient received combination chemotherapy with cyclophosphamide, vincristine, adriamycin, and dacarbazine. The metastasis was also treated with radiofrequency ablation (RFA). Because the left adrenal tumor grew rapidly despite two courses of the chemotherapy, it too was surgically removed. After the operation, metastasis in the right iliac bone was treated with RFA and radiotherapy. Positron emission tomography detected bilateral femoral metastases, and these were treated with radiotherapy in combination with a low dose of cisplatin. A liver metastasis and a small metastasis in the left kidney were treated with RFA and a metastasis in the pancreatic tail was removed surgically. Sixteen months after the right adrenalectomy, the patient died due to systemic spread of the disease. Multiple local treatments including RFA, radiotherapy, and resection were effective for the local control of metastatic lesions of adrenal leiomyosarcoma.     

Abdominal organ motion measured using 4D CT

PURPOSE: To measure respiration-induced abdominal organ motion using four-dimensional computed tomography (4D CT) scanning and to examine the organ paths. METHODS AND MATERIALS: During 4D CT scanning, consecutive CT images are acquired of the patient at each couch position. Simultaneously, the patient's respiratory pattern is recorded using an external marker block taped to the patient's abdomen. This pattern is used to retrospectively organize the CT images into multiple three-dimensional images, each representing one breathing phase. These images are analyzed to measure organ motion between each phase. The displacement from end expiration is compared to a displacement limit that represents acceptable dosimetric results (5 mm). RESULTS: The organs measured in 13 patients were the liver, spleen, and left and right kidneys. Their average superior to inferior absolute displacements were 1.3 cm for the liver, 1.3 cm for the spleen, 1.1 cm for the left kidney, and 1.3 cm for the right kidney. Although the organ paths varied among patients, 5 mm of superior to inferior displacement from end expiration resulted in less than 5 mm of displacement in the other directions for 41 of 43 organs measured. CONCLUSIONS: Four-dimensional CT scanning can accurately measure abdominal organ motion throughout respiration. This information may result in greater organ sparing and planning target volume coverage.     

人葡萄膜黑色素瘤小鼠肝内种植模型生长行为研究

目的：采用肝内注射人眼葡萄膜恶性黑色素瘤株（MuM2B细胞）方法制备该肿瘤的小鼠肝内种植模型,研究肿瘤在其体内的生物学行为。方法：选用BALB／C-nu裸鼠,将5×10^4个MUM2B细胞注入裸鼠肝脏包膜下。连续观察6周,每周随机处死3只裸鼠以观察成瘤率及侵袭率。采集裸鼠的荷瘤肝脏、心脏、脾脏、肺脏、肾脏、胃和肠等组织器官,常规石蜡切片,HE染色后镜检肿瘤在肝脏内的生长行为及其向其他脏器侵袭和转移的情况。结果：该模型的成瘤率可达83．3％。接种后的前4周,肿瘤在肝脏内浸润性生长,未侵犯周围脏器;接种后第5周,肿瘤开始侵袭肾脏、脾脏、胃和十二指肠的包膜,并可突破胃及肠道的包膜,在其浆膜层中侵袭生长;接种后第6周,肿瘤对肾脏、脾脏、十二指肠和胃的侵袭加剧。肿瘤细胞可侵入裸鼠十二指肠的肌层内生长,亦可侵入裸鼠胃肌层及胃黏膜下层,甚至向胃黏膜肌层内侵袭生长;接种后第6周,肿瘤开始向裸鼠肺脏转移,所有受检裸鼠的肺门组织及肺实质内均可查见转移性瘤灶,转移率达100％;除肺脏外,其余脏器内均未查见转移性瘤灶,提示肺脏是该肝内种植瘤的主要转移靶器官。此外,荷瘤2周后,裸鼠脾脏红髓增生明显,髓内可见大量巨核细胞及髓系来源的粒细胞,呈现白血病样反应;荷瘤4周后,脾脏内星空样现象明显,巨噬细胞活跃,提示裸鼠脾脏组织学改变与荷瘤生长状态密切相关。结论：裸鼠肝内注射MUM2B细胞能够建立起稳定的人葡萄膜黑色素瘤小鼠肝内种植模型。种植的肿瘤细胞在裸鼠肝脏内呈浸润性生长,侵袭包括胃、十二指肠、脾脏及肾脏在内的多个器官,并可远端转移至肺脏。     

Primary carcinoma of the gallbladder

Seventy-four patients with primary carcinoma of the gallbladder, diagnosed over 18 years from 1969 to 1987, were studied retrospectively. The most common presenting complaint was abdominal pain, followed by jaundice and weight loss. Surgery was performed in 61 patients and of these patients, only two had accurate preoperative diagnosis which was made by ultrasonography. Twelve of the 13 patients who were treated medically had the disease diagnosed at autopsy. One of the 13 patients had the diagnosis of gallbladder cancer by the findings of ultrasonography and abdominal computed tomography (CT) scanning. The resectability of the surgically managed group was 36.1%, and the majority of patients with advanced tumors (82.2%) were deemed unresectable. The most common histologic type was adenocarcinoma. Liver was the organ most commonly invaded (76.5%) by direct extension and/or metastases, followed by regional lymph nodes (52.9%). The overall 5-year survival rate was 5.4%. A high index of suspicion of the disease, intraoperative examination of gallbladder specimen, and earlier, more aggressive surgical treatment may improve patient survival.     

A resected case of non-invasive type of intraductal papillary mucinous carcinoma penetrating to the duodenum

A 74-year-old man was admitted to a nearby clinic complaining of high fever. Abdominal CT showed a 10 mm diameter cystic mass in the head of pancreas and dilation of the pancreatic duct. Endoscopy revealed a fistula filled with mucin in the posterior wall of the duodenum. The patient was referred to our institution for a surgical resection. Endoscopic ultrasonography revealed dilation of the pancreatic duct and also mural nodules in the pancreatic duct, ERP demonstrated a fistula from the pancreatic duct to the duodenum. Biopsied specimen from the papillary nodule in the pancreatic duct showed adenoma. We performed pancreaticoduodenectomy for main-duct IPMN penetrating to the duodenum. Pathological findings showed a non-invasive type of IPMC. Furthermore, a cancer invasion to the duodenum was not detected. These findings suggest that the increased pressure within the pancreatic duct caused a fistula to the duodenum.     

肾上腺转移癌21例临床分析

背景与目的:近年来肾上腺转移癌的发生率在临床上呈逐年上升趋势,但早期诊断、鉴别诊断有时仍比较困难。肾上腺转移癌是否需要手术切除、何时切除及怎样切除仍然存有争议。本研究旨在探讨肾上腺转移癌手术指征及腹腔镜下肾上腺切除的价值。方法:回顾性分析中山大学附属第一医院1997年3月至2004年3月收治的21例肾上腺转移癌的临床资料及复习有关肾上腺转移癌诊断与治疗方面的文献。结果:本组患者经B超和CT检查,对肾上腺肿物的诊断率分别为70.0%(7/10)与84.6%(11/13)。10例行肾上腺转移癌手术切除,其中4例患者于术后1个月至5年间行腹腔镜肾上腺转移癌切除,切缘均无癌细胞。患者生存1～67个月,中位生存时间18个月,其中1例患者行肾上腺转移癌切除术后67个月仍生存,2例失访。未手术组共11例,生存5～28个月,中位生存时间13个月,1例失访。两组生存率的差异无统计学意义(P=0.346)。结论:B超及CT是诊断肾上腺转移癌的重要检查方法。对转移癌局限在肾上腺包膜内、无局部淋巴结肿大、肾上腺外无转移的应尽可能的行手术治疗。而腹腔镜下肾上腺切除也是安全的、有效的。