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Purpose: The aim of this study is to analyze the technical and clinical success rates and safety of transarterial fiducial marker placement for image-guided proton therapy for malignant liver tumors., Methods and Materials: Fifty-five patients underwent this procedure as an interventional treatment. Five patients had 2 tumors, and 4 tumors required 2 markers each, so the total number of procedures was 64. The 60 tumors consisted of 46 hepatocellular carcinomas and 14 liver metastases. Five-mm-long straight microcoils of 0.018 inches in diameter were used as fiducial markers and placed in appropriate positions for each tumor. We assessed the technical and clinical success rates of transarterial fiducial marker placement, as well as the complications associated with it. Technical success was defined as the successful delivery and placement of the fiducial coil, and clinical success was defined as the completion of proton therapy., Results: All 64 fiducial coils were successfully installed, so the technical success rate was 100 % (64/64). Fifty-four patients underwent proton therapy without coil migration. In one patient, proton therapy was not performed because of obstructive jaundice due to bile duct invasion by hepatocellular carcinoma. Thus, the clinical success rate was 98 % (54/55). Slight bleeding was observed in one case, but it was stopped immediately and then observed. None of the patients developed hepatic infarctions due to fiducial marker migration., Conclusion: Transarterial fiducial marker placement appears to be a useful and safe procedure for proton therapy for malignant liver tumors.

Background: Organizing pneumonia (OP), so called bronchiolitis obliterans organizing pneumonia after postoperative irradiation for breast cancer has been often reported. There is little information about OP after other radiation modalities. This cohort study investigated the clinical features and risk factors of OP after stereotactic ablative radiotherapy of the lung (SABR)., Methods: Patients undergoing SABR between 2004 and 2010 in two institutions were investigated. Blood test and chest computed tomography were performed at intervals of 1 to 3 months after SABR. The criteria for diagnosing OP were: 1) mixture of patchy and ground-glass opacity, 2) general and/or respiratory symptoms lasting for at least 2 weeks, 3) radiographic lesion in the lung volume receiving < 0.5 Gy, and 4) no evidence of a specific cause., Results: Among 189 patients (164 with stage I lung cancer and 25 with single lung metastasis) analyzed, nine developed OP. The incidence at 2 years was 5.2% (95% confidence interval; 2.6-9.3%). Dyspnea were observed in all patients. Four had fever. These symptoms and pulmonary infiltration rapidly improved after corticosteroid therapy. Eight patients had presented with symptomatic radiation pneumonitis (RP) around the tumor 2 to 7 months before OP. The prior RP history was strongly associated with OP (hazard ratio 61.7; p = 0.0028) in multivariate analysis., Conclusions: This is the first report on OP after SABR. The incidence appeared to be relatively high. The symptoms were sometimes severe, but corticosteroid therapy was effective. When patients after SABR present with unusual pneumonia, OP should be considered as a differential diagnosis, especially in patients with prior symptomatic RP.

Background: Radiation proctitis after intensity-modulated radiation therapy (IMRT) differs from that seen after pelvic irradiation in that this adverse event is a result of high-dose radiation to a very small area in the rectum. We evaluated the results of treatment for hemorrhagic proctitis after IMRT for prostate cancer., Methods: Between November 2004 and February 2010, 403 patients with prostate cancer were treated with IMRT at 2 institutions. Among these patients, 64 patients who developed late rectal bleeding were evaluated. Forty patients had received IMRT using a linear accelerator and 24 by tomotherapy. Their median age was 72 years. Each patient was assessed clinically and/or endoscopically. Depending on the severity, steroid suppositories or enemas were administered up to twice daily and Argon plasma coagulation (APC) was performed up to 3 times. Response to treatment was evaluated using the Rectal Bleeding Score (RBS), which is the sum of Frequency Score (graded from 1 to 3 by frequency of bleeding) and Amount Score (graded from 1 to 3 by amount of bleeding). Stoppage of bleeding over 3 months was scored as RBS 1., Results: The median follow-up period for treatment of rectal bleeding was 35 months (range, 12-69 months). Grade of bleeding was 1 in 31 patients, 2 in 26, and 3 in 7. Nineteen of 45 patients (42%) observed without treatment showed improvement and bleeding stopped in 17 (38%), although mean RBS did not change significantly. Eighteen of 29 patients (62%) treated with steroid suppositories or enemas showed improvement (mean RBS, from 4.1 ± 1.0 to 3.0 ± 1.8, p = 0.003) and bleeding stopped in 9 (31%). One patient treated with steroid enema 0.5-2 times a day for 12 months developed septic shock and died of multiple organ failure. All 12 patients treated with APC showed improvement (mean RBS, 4.7 ± 1.2 to 2.3 ± 1.4, p < 0.001) and bleeding stopped in 5 (42%)., Conclusions: After adequate periods of observation, steroid suppositories/enemas are expected to be effective. However, short duration of administration with appropriate dosage should be appropriate. Even when patients have no response to pharmacotherapy, APC is effective.

Introduction: Principles of echo shifting with a train of observations (PRESTO) sequence has long echo time which emphasizes the effect of T2* relaxation time and contribute to its high sensitivity to the susceptibility change. The aim of our study was to evaluate the ability of 3D-PRESTO sequence in detecting putaminal hypointensity in patients with parkinsonian variant of multiple system atrophy (MSA-P) and in discriminating between MSA-P and Parkinson's disease (PD)., Methods: The signal intensity of the putamen and localization of abnormality were evaluated on 3D-PRESTO, T2*-weighted (T2*W), and T2-weighted (T2W) sequences in ten patients with MSA-P, 14 with PD, and ten controls. The putaminal signal intensity was assessed in all sequences and graded relative to the palladium. Atrophy of the putamen and posterolateral hyperintensity rim on T2W sequence were also evaluated in MSA-P patients., Results: Putaminal hypointensity was more often seen in MSA-P than PD and controls on 3D-PRESTO sequence (p = 0.002) as well as on T2*W sequence (p = 0.003). 3D-PRESTO sequence could reveal lower intensity better than T2*W sequence in four of ten MSA-P cases. Hemi- or bilateral putaminal hypointensity, atrophy, and posterolateral hyperintensity rim were recognized in 90%, 70%, and 70% of ten MSA-P cases, respectively. Three cases revealed hypointensity on 3D-PRESTO sequence without posterolateral hyperintensity rim. Putaminal signal changes occurred in the posterolateral part with a striking lateral to medial gradient in all nine cases with putaminal hypointensity (nine out of nine, 100%)., Conclusions: 3D-PRESTO sequence appears to be useful for depicting putaminal hypointensity in MSA-P patients and in differentiating MSA-P from PD.

To ascertain whether meloxicam used in a clinical setting as a non-steroidal anti-inflammatory drug (NSAID) warrants preclinical in vivo evaluation as an anticancer agent, we investigated its antitumor effects alone and in combination with radiation and/or 5-fluorouracil (5-FU) in cultured cells. Seven cell lines were examined for cyclooxygenase-2 (COX-2) protein expression by immunoblot analysis, and the HeLaS3, SCCVII and EMT6 cell lines were selected, expressing relatively high, intermediate, and relatively low COX-2 levels, respectively. Antitumor effects were examined using a colony assay. Among the three cell lines, the effect of meloxicam alone was strongest in SCCVII cells. With 24 h of drug exposure, meloxicam at concentrations of 250 and 1250 µM had a definite antitumor effect, dependent on the drug exposure time. The effect of meloxicam in combination with radiation and/or 5-FU was also investigated in the SCCVII cells. At a meloxicam concentration of 250 µM, the antitumor effect in combination with radiation or 5-FU was increased compared to the effect of radiation or 5-FU alone; however, the combined effect appeared to be additive. At lower concentrations, meloxicam had no radiosensitizing effect, nor did it enhance the effect of 5-FU. A meloxicam concentration of 250 µM is considerably higher than concentrations obtained in humans taking meloxicam as an NSAID. In conclusion, the antitumor effect of meloxicam was not correlated with the level of COX-2 protein expression. The effect of meloxicam in combination with radiation and/or 5-FU appeared to be additive. To evaluate the possibility of using meloxicam as an anticancer agent, in vivo investigations at clinically relevant drug dose levels are required.

A case of acute necrotizing pancreatitis due to Mycoplasma pneumoniae infection was treated in an 8-year-old girl. She experienced acute pancreatitis during treatment for M. pneumoniae. Contrast-enhanced computed tomographic scan revealed necrotizing pancreatitis. The computed tomographic severity index was 8 points (grade E). A protease inhibitor, ulinastatin, was provided via intravenous infusion but was ineffective. Continuous regional arterial infusion therapy was provided with gabexate mesilate (FOY-007, a protease inhibitor) and meropenem trihydrate, and the pancreatitis improved. This case suggests that infusion therapy is safe and useful in treating necrotizing pancreatitis in children.

An aneurysm of the middle-colic artery, associated with segmental arterial mediolysis (SAM), is a rare condition. This report describes a case of a middle-colic artery aneurysm that was associated with SAM. A 57-year-old man was admitted to our hospital because of severe abdominal pain. A rupture of a middle-colic artery aneurysm was diagnosed by computed tomography, and angiography showed that it may have been associated with SAM. The ruptured aneurysm was successfully treated with transcatheter arterial embolization. Transcatheter arterial embolization might be one of the best treatments for such a complicated aneurysm occurring in a visceral artery.

Purpose: To report outcomes of transcatheter arterial embolization for segmental arterial mediolysis (SAM), a vascular disorder characterized by angiographically documented fusiform aneurysms separated by areas of normal appearing vessel in the celiac or mesenteric arteries., Case Reports: Four patients (3 men; median age 70 years, range 57-77) had a presumptive diagnosis of SAM; the possibility of vasculitis was ruled out based on clinical and laboratory findings. Three patients were symptomatic, with aneurysm rupture; the fourth patient was diagnosed incidentally. Coil embolization was used in 3 cases and N-butyl cyanoacrylate in the other. There was no re-rupture. One patient developed a focal dissection of the superior mesenteric artery 9 months after middle colic artery embolization. Another patient died of perforation of the lower gastrointestinal tract 3 months after treatment, but the cause was unknown; mesenteric ischemia from embolization and arteriopathy could not be ruled out., Conclusion: Transcatheter embolization is useful for SAM. However, it is likely that the morphology associated with SAM transforms rapidly, so patients undergoing mesenteric artery embolization should be monitored at short intervals.

Purpose: In vivo effects of intermittent irradiation are influenced by recovery from sublethal damage (SLDR) and reoxygenation, so contribution of the two factors were investigated using murine tumors., Methods and Materials: 1-cm-diameter SCCVII tumors growing in the legs of C3H/HeN mice were used. First, effects of 5 fractions of 6 Gy given at intervals of 2.5-15 min were compared using an in vivo-in vitro assay, by clamping the tumor-bearing legs to exclude the influence of reoxygenation. In the second and third experiments, changes in the hypoxic fraction at 0-15 min after 13 or 5 Gy were assessed by a paired cell survival method. Fourth, effects of 5 fractions of 5 Gy given at intervals of 3-10 min under conditions of limited reoxygenation were compared using a growth delay assay., Results: Cell survival from clamped tumors tended to increase with elongation of the intervals, but not significantly. The hypoxic fraction tended to decrease at 5-15 min from the level immediately after irradiation. Effects on tumor growth tended to decrease with elongation of the intervals., Conclusions: Reoxygenation occurring within 5-15 min appeared to compensate for SLDR in SCCVII tumors. When reoxygenation was limited, the decrease of radiation effect occurred due to SLDR.

Introduction: We evaluated the results of postoperative mediastinal radiotherapy (MRT) for invasive thymoma and low-dose entire hemithorax radiotherapy (EHRT) for pleural dissemination., Methods: Sixty patients were treated with a nearly uniform policy. Generally, we administered 30 to 40 Gy MRT after surgery at 2 Gy daily fractions for Masaoka stage II tumors or suspected residual diseases, and 50 to 55 Gy MRT for stage III tumors and for highly-suspected or macroscopic residual diseases. Since 1992, we have administered EHRT in patients with pleural dissemination, with 11.2 Gy in 7 fractions or 15 to 16 Gy in 10 fractions after removal of disseminated lesions in addition to MRT. We treated 52 patients with MRT alone and 8 with EHRT and MRT. In addition, we gave EHRT to four patients who developed pleural dissemination later., Results: For all 60 patients, the overall and cause-specific survival and local and pleural-dissemination control rates at 5 years were 79, 87, 86, and 69%, respectively. Both Masaoka stage and tumor resectability were associated with prognosis. In stage IVa patients, pleural dissemination control rate was 71% at 3 years after EHRT, whereas it was 49% in patients receiving MRT alone (p = 0.38). Grade 2 or higher radiation pneumonitis was observed in only 3 of 52 patients (5.8%) undergoing MRT initially. In 12 patients who underwent EHRT, 3 patients (25%) experienced grade 2 or 4 pneumonitis., Conclusions: Postoperative MRT appeared to prevent local recurrence with acceptable toxicity. EHRT is generally safe and may contribute to control of pleural dissemination.

Purpose: We analyzed the therapeutic results and prognostic factors of 46 primary central nervous system lymphoma (PCNSL) patients who were treated at twelve institutions in the Tokai district of Japan between 1995 and 1999. We compared the results with those of a Japanese nationwide survey performed in the past., Materials and Methods: We sent each institution a questionnaire about the state of patients' disease, pathological type, method and doses of radiotherapy, regimen and intensity of chemotherapy, and patients' prognoses. The range of patients' ages was 33 to 93 years (median, 61 years). Thirty-one were men and 15 were women. The most prevalent histology was diffuse large B cell type (33 patients). We used the Kaplan-Meier method to calculate the survival rate and Cox's proportional hazards model to analyze the prognostic factors., Results: The five-year cumulative survival rate was 25%, and the median survival time was 22.7 months. The five-year disease-free survival rate was 23%. In monovariate analysis, patients who were both younger than 60 years old and had a WHO performance status (PS) score equal to or less than 2 showed a better survival rate. Furthermore, the patients receiving systemic chemotherapy showed a significantly better local control rate. In addition, patients who received systemic chemotherapy achieved a higher complete remission rate than those not receiving it. However, no factors that significantly influenced survival rate were identified in multivariate analysis., Conclusion: We demonstrated that the therapeutic outcome of PCNSL patients has recently improved. In particular, patients with good PS showed better local control than those with poor PS. However, we could not identify any significant prognostic factors in PCNSL patients.

Objective: To compare histological findings of FDG-PET false-positive and true-negative hilar and mediastinal lymph nodes., Methods: Sixty-seven lymphnode areas in 11 patients who were diagnosed to have N3 lymph nodes by FDG-PET and underwent surgery were histologically examined, and the histopathological findings in false-positive and true-negative lymph nodes were compared. Lymph nodes with higher accumulation of FDG than the surrounding mediastinum level were judged as positive. On histological sections, proportions of macrophages and lymphocytes, amount of coal dust deposit, presence of silicotic nodules, long- and short-axes of the largest node, and volume of macrophages and lymphocytes were evaluated. Correlations between the above-mentioned factors and FDG accumulation were evaluated., Results: FDG uptake was not correlated with the proportion of macrophages and lymphocytes, coal dust amounts, or the presence of silicotic nodules. The long- and short-axes of the largest node in the false-positive areas were significantly longer than those in the true-negative areas (p = 0.01, and 0.001, respectively). Volumes of lymph nodes (mean +/- SD: 150 +/- 190 mm3) and macrophages (78 +/- 71 mm3) in false-positive areas were markedly larger than those in true-negative areas (68 +/- 87 mm3, p = 0.0009 and 34 +/- 54 mm3, p = 0.0001, respectively). The volume of lymphocytes was also larger in false-positive areas but less markedly., Conclusion: Our study suggested that false-positive results of FDG-PET in hilar and mediastinal lymph nodes were closely related to the size of lymph node and the volume of macrophages.

Purpose: To evaluate the radiographic findings of aberrant right subclavian artery (ARSCA) initially depicted on CT., Methods: Twenty-five cases incidentally diagnosed during CT between June 1993 and May 2001, were examined. They included 13 men and 12 women aged from 29 to 84 years old (mean, 63 years). Three findings were evaluated on posteroanterior radiographs: 1) oblique edge, 2) vessel through the trachea, and 3) mass effect. On lateral radiographs, the following findings were evaluated: 1) posterior tracheal imprint, 2) retrotracheal opacity, and 3) aortic arch obscuration., Results: On the posteroanterior radiographs, oblique edge, vessel through the trachea, and mass effect were observed in 32% (8/25), 44% (11/25), and 20% (5/25) of cases, respectively. On the lateral radiographs, posterior tracheal imprint, retrotracheal opacity, and aortic arch obscuration were observed in 95% (18/19), 58% (11/19), and 37% (7/19), respectively. On posteroanterior radiographs, normal cases were most frequent (40%). In contrast, lateral radiographs demonstrated at least one abnormality in all cases. As a variation of posterior tracheal imprint, the long-segment type of compression was observed in 32%., Conclusions: We consider detailed interpretation of the posterior tracheal edge on lateral radiographs to be important in diagnosing cases of mild ARSCA.

We report a case of focal fibrosis that appeared as localized ground glass attenuation (GGA) on thin-section computed tomography (TSCT). The TSCT and MRI findings correlated well with the pathological results, corresponding to fibrous thickening of the alveolar septa with mild chronic inflammation.

In this report we describe the pathological and radiological findings in a patient with primary ureteral MALT lymphoma. We suggest that it is useful for the differential diagnosis of ureter masses that some MALT lymphomas may show a low signal intensity on T2-weighted MR images.