Simple visualization of the corticospinal pathway using tractography: one-ROI and two-ROI methods

Diffusion tensor imaging (DTI), a magnetic resonance (MR) technique to analyze diffusion anisotropy of the brain, is able to demonstrate subtle white matter anatomy. Tractography is expected to be a unique, non-invasive tool to provide more pertinent insights into brain structure and orientation not accessible by conventional MRI. In this report, preliminary experiences of visualization of the corticospinal tract using tractography are described. DTI of the brain was performed in 5 normal volunteers using single-shot echo-planar imaging, then tractography was generated by our original software. We determined that the two-region-of-interest (ROI) method is superior to the one-ROI method.     

MR imaging of ischemic penumbra

Cerebral ischemic stroke is one of the most fatal diseases despite current advances in medical science. Recent demonstration of efficacy using intravenous and intra-arterial thrombolysis demands therapeutic intervention tailored to the physiologic state of the individual tissue and stratification of patients according to the potential risks for therapies. In such an era, the role of the neuroimaging becomes increasingly important to evaluate the extent and location of tissues at risk of infarction (ischemic penumbra), to distinguish it from unsalvageable infarcted tissues or doomed hemorrhagic parenchyma. In this review, we present briefly the current role and limitation of computed tomography and conventional magnetic resonance imaging (MRI). We also present the possible applications of advanced MR techniques, such as diffusion and perfusion imaging, concentrating on the delineation or detection of ischemic penumbra.     

Torsion of the middle lobe after right upper lobectomy of the lung; report of a case and the review of the Japanese literatures

We report a case of torsion of the residual right middle lobe of the lung, following right upper lobectomy for lung cancer. A 71-year-old man who had medical treatment for emphysema was admitted with a lung tumor on chest computed tomography. The tumor was diagnosed as pulmonary adenocarcinoma by transbronchial biopsy. Right upper lobectomy with mediastinal lymph node dissection, and partial resection of the right lower lobe were performed. On the following day, chest X-ray showed an opacification in the right upper lung field, which gradually increased. Bronchoscopic examination revealed a stenotic middle lobe bronchus. Torsion of the middle lobe was suspected, and rethoracotomy was performed on the second postoperative day. The middle lobe was torsed 90-degree counterclockwise around its bronchovascular pedicle. A middle lobectomy was performed secondary to severe congestion. The patient was discharged in good condition on the 11th postoperative day. In reviewing the literatures including this case, 13 of 16 torsions occurred after right upper lobectomy of the lung. Thirteen patients had rethoracotomy, 10 of them underwent resection of the rotated lung. Simple detorsion was carried out in 3 patients, and 1 of them developed cerebral infarction. Lung torsion was reported to be potentially life-threatening. Therefore, fixation of a remaining lobe should be performed. Exploratory thoracotomy should be performed without delay, if lung torsion is suspected.     

The stratification of surgically treated T4 (stage IIIb) primary lung cancers; analysis of cases with intrapulmonary metastases in the same lobe as the primary tumors (pm 1) and invading adjacent organs

OBJECTIVE: The purpose of this article was to investigate the validity of T4 classification of primary non-small cell lung cancer. METHODS: We retrospectively reviewed the clinical outcome of cases with pm 1 (n = 65) and T4 tumors invading adjacent organs (n = 36). RESULTS: When the pm 1 tumors were excised completely (n = 57), the prognosis of these cases was affected by the pN factor (5-year survival rate: pN 0-1; 70.1%, pN 2-3; 7.7%, p = 0.0002) and comparable to that of T2 diseases (pN 0-1 cases: p = 0.7315). The patients who underwent complete resection for their pm 1 tumors had a significantly better prognosis than cases with disseminations or malignant pleural effusions which had the same T4 classification (p < 0.0001). The prognosis of the patients who underwent complete resection for the tumors invading adjacent organs (classified under T4) was similar to that of T3 diseases (pN 0-1 cases: p = 0.7116). CONCLUSIONS: Patients whose lung cancer is classified as T4 comprise 2 subgroups; those whose tumors can be completely resected, and those in whom complete resection is impractical. There is a significant difference in the management and the prognosis between these 2 groups although they share the same T4 classification.     

Assessment of left ventricular diastolic function by gated single-photon emission tomography: comparison with Doppler echocardiography

Gated single-photon emission tomography (SPET) is not yet an established procedure for the evaluation of left ventricular (LV) diastolic function. This study examined diastolic function derived from gated SPET in comparison with an established diagnostic tool, Doppler echocardiography. We examined 37 consecutive patients with normal sinus rhythm who underwent gated technetium-99m tetrofosmin SPET. A gated SPET program was used with a temporal resolution of 32 frames per R-R interval. We obtained the Doppler transmitral flow velocity waveform immediately before gated SPET image acquisition. Patients who showed a ratio of peak early transmitral flow velocity to atrial flow velocity (E/A) of >1 or whose R-R intervals differed by >5% between Doppler echocardiography and gated SPET were excluded from this investigation. We compared diastolic indices and presumed corresponding intervals in diastole using the two methods. The peak filling rate (PFR) derived from gated SPET correlated with the Doppler peak velocity of the early transmitral flow (E) wave (r=0.65) and deceleration of the E wave (r=0.71). The time to PFR and percent atrial contribution to LV filling from gated SPET correlated excellently with the Doppler LV isovolumic relaxation time (r=0.93) and the E/A ratio (r=–0.85), respectively. There was a significant linear correlation in all the intervals from the R wave to the presumed corresponding diastolic points. The point of PFR in gated SPET and the peak of the E wave in Doppler echocardiography generally coincided. The onset of filling in gated SPET tended to be closer to the second heart sound than the start of the E wave in Doppler echocardiography. We conclude that gated SPET permits the assessment of not only myocardial perfusion and LV systolic function but also diastolic function, although there may be some errors in detection of the precise beginning of LV filling.     

Living-related liver transplantation for Alagille syndrome

Alagille syndrome (AGS) is an autosomal dominant genetic disorder characterized by chronic cholestasis, congenital heart disease, peculiar facies, butterfly-like vertebrae, and posterior embryotoxon. Liver dysfunction is the common presentation of AGS, and liver transplantation may be indicated. This study examines the outcome of living-related liver transplantation (LRLT) for AGS. Twenty patients with AGS (median age 5.0 years, range 0.6-12.9) underwent LRLT at Kyoto University Hospital between June 1990 and February 2002. Five potential donors were excluded because of paucity of intrahepatic bile ducts diagnosed by preoperative liver biopsy and one because of a hepatic vascular anomaly. The overall 5-year patient survival was 80.4%. Three patients died as the result of the following: complications related to surgery, heart failure caused by progressive pulmonary artery stenosis, and a graft with unsuspected bile duct paucity. Liver dysfunction was improved in all successful cases, and catch-up growth occurred in 90% of patients. LRLT is an efficacious treatment modality for AGS if donors are selected by cautious evaluation to rule out unsuspected bile duct paucity.     

Patterns of care study in Japan: analysis of patients subjected to mastectomy followed by radiotherapy

BACKGROUND: Two prospective studies reported in 1997 demonstrated that postoperative radiotherapy after mastectomy was not only associated with a higher loco-regional control rate but also with a higher overall survival rate. The purpose of this study is to clarify the processes of care for patients undergoing mastectomy and postoperative radiotherapy in Japan. METHODS: A national survey carried out in 1998-2000, involving 79 Japanese institutions by two-stage cluster sampling of institutions and patients, disclosed that 1124 patients with breast cancer had been treated between 1995 and 1997. Mastectomy followed by radiotherapy was performed on 258 patients. RESULTS: The compliance rates for pre-treatment evaluation, including history, physical examination and mammography, averaged approximately 50% (24-81%). The chest wall was irradiated in only 19% of the patients and regional node irradiation was carried out for 70-86%. Radiation treatment planning with the aid of computed tomography was done in only 29% of patients (university hospitals or cancer centers, 39%; other hospitals, 17%; P = 0.001). Hormonal therapy was administered to 56% of the patients who showed no endocrine responsiveness. Non-intensive chemotherapy, which did not include the use of anthracycline or taxol, was used in 55% of the patients who received chemotherapy. CONCLUSIONS: There is room for improvement regarding some aspects of radiotherapy and adjuvant systemic therapies. Especially in the field of radiotherapy, significant differences were found among the treatment techniques employed in various institutions.     

The limited efficacy of methotrexate, actinomycin D and cisplatin (MAP) for patients with advanced testicular cancer

BACKGROUND: Combination chemotherapy of methotrexate, actinomycin D and cisplatin (MAP) is reported to be effective against gestational choriocarcinoma. METHODS: Eight patients with metastatic testicular cancer who had elevated beta-hCG were treated with MAP. They included three refractory cases and two relapsed cases. An additional three patients received MAP as part of the induction therapy. The MAP therapy consisted of methotrexate (10 mg/m2) on days 1-5, actinomycin D (0.01 mg/kg) on days 1-5 and cisplatin (70 mg/m2) on day 1. RESULTS: In all three refractory patients, MAP failed to achieve tumor marker normalization. However, the elevated tumor markers normalized after MAP in the two cases of relapse. Of these two, one patient relapsed again 7 months after MAP and was subsequently salvaged with high-dose chemotherapy. The other patient relapsed and died of the disease 30 months after receiving MAP. Of the three patients who received MAP as part of the induction chemotherapy, one with pure choriocarcinoma achieved tumor marker normalization after MAP and is still alive without disease progression. In the other two patients, MAP failed to achieve marker normalization and the patients received high-dose chemotherapy. The toxicities were mainly bone marrow suppression and mucositis, which were almost acceptable. CONCLUSIONS: The results demonstrated the limited efficacy of MAP as salvage therapy. In addition, the efficacy of MAP as part of induction chemotherapy was negligible. However, there might be some role for MAP as a salvage therapy for patients with pure choriocarcinoma.