Transpulmonary chemoembolization (TPCE) as a treatment for unresectable lung metastases

To evaluate tumor response after treating unresectable lung metastases with transpulmonary chemoembolization (TPCE) in palliative intention. From 2001 to 2005, 52 patients (mean: 59.8 years; 32 males/20 females) suffering from 106 unresectable lung metastases (mean:6 metastases/patient; range,1–21) were treated with 2–10 TPCE-sessions (mean: 3.3 sessions/patient). Metastases originated from primaries, including colorectal carcinoma (n = 20), breast cancer (n = 6), renal cellular carcinoma (n = 5), thyroid cancer (n = 4), cholangiocellular carcinoma (n = 2), leiomyosarcoma (n = 2), and others (n = 13). Tumor-feeding pulmonary arteries were selectively probed after puncturing the femoral vein, and administering 10 ml lipiodol, mitomycin C, and microspheres (Spherex) each via balloon catheter over pulmonary approach. During therapy, follow-up was accomplished at 4-week intervals using unenhanced and contrast-enhanced CT. After sequential therapy, follow-up was performed every 3 months for a period of 6 months up to 2.25 years. All patients tolerated the treatments well without major side effects or complications. In 24% (n = 13) moderate to high lipiodol uptake was found, while 75% (n = 39) of the tumors showed a low uptake. According to the RECIST criteria, “partial response” was achieved in 16 cases, “stable disease” in 11 cases, and “progressive disease” in 25 cases [mean survival: 17 months/median: 21.1 months (Kaplan-Meyer)]. According to these findings, TPCE is a well-tolerated procedure for palliative treatment of unresectable lung metastases.     

A Nomogram for Predicting the Likelihood of Additional Nodal Metastases in Breast Cancer Patients With a Positive Sentinel Node Biopsy

Background:The standard of care for breast cancer patients with sentinel lymph node (SLN) metastases includes complete axillary lymph node dissection (ALND). However, many question the need for complete ALND in every patient with detectable SLN metastases, particularly those perceived to have a low risk of non-SLN metastases. Accurate estimates of the likelihood of additional disease in the axilla could assist greatly in decision-making regarding further treatment.Methods:Pathological features of the primary tumor and SLN metastases of 702 patients who underwent complete ALND were assessed with multivariable logistic regression to predict the presence of additional disease in the non-SLNs of these patients. A nomogram was created using pathological size, tumor type and nuclear grade, lymphovascular invasion, multifocality, and estrogen-receptor status of the primary tumor; method of detection of SLN metastases; number of positive SLNs; and number of negative SLNs. The model was subsequently applied prospectively to 373 patients.Results:The nomogram for the retrospective population was accurate and discriminating, with an area under the receiver operating characteristic (ROC) curve of 0.76. When applied to the prospective group, the model accurately predicted likelihood of non-SLN disease (ROC, 0.77).Conclusions:We have developed a user-friendly nomogram that uses information commonly available to the surgeon to easily and accurately calculate the likelihood of having additional, non-SLN metastases for an individual patient.Drs. Manasseh and Bevilacqua contributed equally to the work.Dr. Bevilacqua is currently affiliated with Hospital Sírio Libanes, Instituto Brasileiro de Controle do Câncer, and Disciplina de Cirurgia Geral, Departamento de Cirurgia, Faculdade de Medicina da Univerdidade de Sao Paulo. São Paulo, Brazil; Dr. Boolbol is currently affiliated with Beth Israel Medical Center, New York, New York.     

~(89)SrCl_2在前列腺癌骨转移治疗中的应用

目的　观察89SrCl2 在前列腺癌骨转移中的治疗效果。　方法　前列腺癌骨转移患者38例。89SrCl2 治疗组 (2 5例 )采用去势术加缓退瘤加89SrCl2 ,对照组 (13例 )采用去势术加缓退瘤治疗 ,分别于治疗前和治疗后 3、6个月测定血清PSA ,骨扫描 ,观察骨痛缓解情况。　结果　89SrCl2 治疗组有效率 92 % (2 3/ 2 5 ) ,对照组 31% (4/ 13) ,差异有显著性意义 (P <0 .0 5 )。　结论　89SrCl2 治疗前列腺癌骨转移疼痛效果明显 ,副作用小 ,且对前列腺癌骨转移灶有治疗作用。     

Intraoperative ultrasound for the colorectal surgeon: current trends and barriers

Up to two thirds of patients diagnosed with colorectal cancer (CRC) develop colorectal liver metastases (CRLMs) and one quarter of patients present with synchronous metastases. Early detection of CRLM widens the scope of potential treatment. Surgery for CRLM offers the best chance of a cure. Current preoperative staging of CRC relies on computerized tomography and magnetic resonance imaging. Intraoperative ultrasound (IOUS) scans and contrast‐enhanced IOUS (CE‐IOUS) have been demonstrated to detect additional metastases not seen on routine preoperative imaging. IOUS is not widely used by colorectal surgeons during primary resection for CRC. Confident use of IOUS/CE‐IOUS during primary resection of CRC may improve decision‐making by providing the most sensitive form of liver staging even when compared with magnetic resonance imaging. This may be particularly important in the era of laparoscopic resections, where the colorectal surgeon loses the opportunity to palpate the liver. There are several implied barriers to the routine use of IOUS/CE‐IOUS by colorectal surgeons. These include time pressure, familiarity with techniques, a perceived learning curve, cost implications and limitation of the modality due to operator variations. Inclusion of IOUS in the training of colorectal surgeons and further investigation of potential benefits of IOUS/CE‐IOUS could potentially reduce these barriers, enabling usage during primary resection for CRC to become more widespread.     

脊柱不典型单发转移性恶性黑色素瘤的MRI表现:与脊柱血管瘤鉴别

目的探讨MRI对脊柱不典型单发转移性恶性黑色素瘤与血管瘤的鉴别诊断价值。方法回顾性分析13例脊柱不典型单发转移性黑色素瘤患者及40例脊柱单发血管瘤患者。对所有患者均行1.5T MR扫描,采用T1W、T2W、脂肪抑制T2W序列和增强扫描。观察病灶的信号特征,平扫分为低、等、高信号,增强扫描分为低、等、稍高及明显强化。测量病灶的最长径,然后取平均值。结果脊柱单发转移性黑色素瘤T1WI低、等及高信号比例分别为76.92%(10/13)、15.38%(2/13)及7.69%(1/13),T2WI低、等及高信号比例分别为61.54%(8/13),30.77%(4/13)及7.69%(1/13);92.31%(12/13)的脊柱单发转移性恶性黑色素瘤增强扫描表现为明显强化。与脊柱血管瘤比较,转移性黑色素瘤长径大于血管瘤(P0.001)。脊柱血管瘤和不典型转移性黑色素瘤之间T1WI与T2WI信号特征、增强扫描强化特征差异均有统计学意义(P均0.05)。结论MRI对鉴别脊柱单发不典型转移性黑色素瘤与血管瘤有一定的临床应用价值。     

脊柱转移瘤减压手术的研究进展

脊柱是恶性肿瘤骨转移最常发生的部位,其中约10%的脊柱转移瘤患者会出现硬膜外脊髓压迫。姑息性放疗和单纯椎板切除减压术曾是转移性脊髓压迫的主要治疗方式,而前者对放疗不敏感肿瘤无效且疗效具有延后性,后者还常常损害脊柱稳定性。随着近年来手术技术和内固定器械的不断改进,脊柱转移瘤的治疗模式也发生了很大改变。减压手术经历了开放性手术减压、分离手术减压、微创手术减压和激光间质热消融减压等手术方案。但无论采取何种手术方案,都应根据患者的具体情况精确评估,尽量减少手术风险,以确保后续放疗的顺利开展。本文就脊柱转移瘤减压手术的研究进展作一综述。     

双部位CT引导下穿刺活检肺及其他部位共存病变

目的探讨同时对肺及其他部位共存病变行双部位CT引导下穿刺活检的临床意义。方法回顾性分析134例接受双部位CT引导下穿刺活检的临床疑似恶性肿瘤患者资料。依活检部位组合类型分为肺-肺、肺-淋巴结样结构、肺-骨、肺-远隔软组织4组。分析4组及肺内不同病变部位双部位活检病理的良恶性分布特点。结果肺-肺、肺-淋巴结样结构、肺-骨、肺-远隔软组织4组中,双部位均为恶性的比率分别为44.59%(33/74)、82.35%(14/17)、78.79%(26/33)、70.00%(7/10);肺内不同部位病变的良恶性分布差异无统计学意义(χ~2=2.22,P=0.70)。结论对于肺及其他部位同时怀疑恶性病变的患者,CT引导下双部位穿刺活检在明确病变性质、指导临床决策等方面具有重要价值。     

18F-氟化钠P ET/CT诊断肿瘤骨转移应用进展

18F-氟化钠（18F-NaF）作为骨扫描示踪剂已有50多年的历史,期间由于正电子探测器的缺乏等因素被99Tcm-MDP替代。随着PET/CT的发展,将18F-NaF作为PET/CT示踪剂的研究逐渐增多。18F-NaF本身的药物特性以及PET/CT相对于SPECT/CT的优势,使得18F-NaF PET/CT诊断恶性肿瘤骨转移的灵敏度、特异度优于99Tcm-MDP骨扫描。与99Tcm-MDP骨显像、18F-FDG PET/CT和MRI相比,18F-NaF PET/CT在诊断恶性肿瘤骨转移时具有更高的灵敏度,并且对于不同肿瘤的骨转移有不同的诊断价值。18F-NaF联合18F-FDG PET/CT扫描被证明具有一定的应用价值。18F-NaF PET/CT是诊断恶性肿瘤骨转移的安全、有效、简便、无创的方法。     

Resection of liver metastases from colorectal cancer: does preoperative chemotherapy affect the accuracy of PET in preoperative planning?

Background: Preoperative scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of preoperative chemotherapy, which has marked biochemical and physical effects on the liver. Integrated fluoro‐deoxyglucose positron emission tomography and computed tomography (FDG‐PET/CT) has applications for detecting extrahepatic disease. The aim of the present study was to investigate FDG‐PET/CT as a preoperative planning tool for detecting liver lesions in patients with and without preoperative chemotherapy. Methods: Patients who had resection of hepatic colorectal metastases between January 2004 and June 2006 were included. Patients were divided into those who received preoperative chemotherapy and those who did not. Malignant hepatic lesions found on each scan were compared with those found on histopathology, intraoperative examination and/or intraoperative ultrasound. Accurate scans (scan lesions corresponded to true lesions), false positives (scan lesions detected at least one non‐lesion) and false negatives (scan lesions missed at least one true lesions) were recorded. Results were also compared on a per lesion basis. Results: A total of 21 patients had preoperative FDG‐PET/CT scans with preoperative chemotherapy and 53 without. Accurate tests were six (29%) for the chemotherapy group versus 28 (53%) for the non‐chemotherapy group (P= 0.06). Notably, there were 11 (52%) underestimations in the chemotherapy group versus 18 (34%) in the non‐chemotherapy group. A total of 1.7 lesions were missed per patient in the chemotherapy group versus 0.7 in those who did not receive chemotherapy. Conclusion: Preoperative assessment with FDG‐PET/CT is not useful for hepatic colorectal metastases, particularly when preoperative chemotherapy is used, with a trend towards underestimation of lesions.     

Video-assisted thoracic surgery (VATS) for resection of metastatic adenocarcinoma as an acceptable alternative

Background  Adenocarcinomas commonly metastasize to the lungs and can be resected using open thoracotomy or video-assisted thoracic surgery (VATS). This study reviews metastatic resections in primary adenocarcinoma patients, using both thoracotomy and VATS. We aim to compare long-term prognoses to test the efficacy and viability of VATS. Methods  A retrospective review of primary adenocarcinoma patients who underwent resection of pulmonary metastases from 1990 to 2006 was carried out. Information was obtained by chart review. Endpoints analyzed were disease-free interval (DFI), survival time, and recurrence-free survival (RFS). Results  In a total of 42 (16 male, 26 female; median age 58.5 years) primary adenocarcinoma patients, 21 patients underwent first pulmonary metastatic resection using VATS (7 male, 14 female; median age 57 years) and 21 using thoracotomy (9 male, 12 female; median age 59 years). Primary adenocarcinomas were mainly 27 colorectal (64%) and 11 breast (26%). Two VATS (10%) and three open patients (14%) had local recurrences of the original cancer. Median postoperative follow was 13.3 months [interquartile range (IQR) 4.5–32.8 months] for VATS and 36.9 months (IQR 19.3–48.6 months) after thoracotomy. Median DFI–1 was 22.3 months (IQR 13.5–40.6 months) for VATS patients and 35.6 months (IQR 26.7–61.3 months) for open patients. Second thoracic occurrences were noted in six VATS patients (median DFI–2 9.2 months), and in seven open patients (median DFI-2 21.5 months). Third thoracic occurrences were noted in one VATS patient (DFI-3 18.7 months) and in one thoracotomy patient (DFI-3 21.8 months). Odds ratio of recurrence showed 12.5% less chance of developing recurrence in VATS patients. Five-year RFS was 53% in VATS and 57% in thoracotomy patients. Conclusions  VATS has become a viable alternative to open thoracotomy for resection of pulmonary metastases. In cases of primary adenocarcinoma, VATS showed no increase in number of thoracic recurrences, and comparable RFS. Short-term follow-up is encouraging; long-term follow-up will be needed to confirm these results.