Safety trial of high-intensity focused ultrasound therapy for pancreatic cancer

AIM:To evaluate the safety and clinical application of high-intensity focused ultrasound(HIFU)therapy for unresectable pancreatic cancer(PC).METHODS:Thirty PC patients(16 cases in stage III and 14 cases in stage IV)with visualized pancreatic tumors were admitted for HIFU therapy as an optional local therapy in addition to systemic chemotherapy or chemoradiotherapy.Informed consent was obtained.This study began at the end of 2008 and was approved by the ethics committee of our hospital[Institutional Review Board(IRB):890].The HIFU device used was the FEP-BY02(Yuande Bio-Medical Engineering,Beijing,China).RESULTS:The mean tumor size after HIFU therapy changed to 30.9±1.7 mm from 31.7±1.7 mm at pre-therapy.There were no significant changes in tumor size,mean number of treatment sessions(2.7±0.1 mm),or mean total treatment time(2.4±0.1 h).The rate of symptom relief effect was 66.7%.The effectiveness of primary lesion treatment was as follows:complete response,0;partial response,4;stable disease,22;progressive disease,4.Treatment after HIFU therapy included 2 operations,24 chemotherapy treatments,and 4 best supportive care treatments.Adverse events occurred in 10%of cases,namely pseudocyst formation in 2 cases and mild pancreatitis development in 1.However,no severe adverse events occurred in this study.CONCLUSION:We suggest that HIFU therapy is safe and has the potential to be a new method of combination therapy for PC.

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Endoscopic ultrasonography (EUS)-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). In the present study,we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCP. We performed the procedure in 2 papilla of Vater,including one resectable case,and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope,a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation,or papillary balloon dilator,a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 (75%) of 4 cases,an indwelling plastic stent was placed,and in one case in which the stent could not be advanced into the bile duct,a naso-biliary drainage tube was placed instead. In all cases,the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case,pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory,EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.

Prognosis of cancer with branch duct type IPMN of the pancreas

AIM:To examine the coexistence of metachronous and synchronous cancer in branch duct intraductal papillary mucinous neoplasms of the pancreas (IPMN).METHODS: We reviewed the records of 145 patients with branch duct IPMN between January 1991 and April 2008 and assessed the relationship between IPMN and intraor extra-pancreatic carcinoma and the outcome of IPMN.RESULTS: The mean observation period was 55.9 ± 45.3 mo. Among the 145 patients, the frequency of extra-pancreatic cancer was 29.0%. The frequency of gastric cancer, colon cancer, breast cancer, and pan-creatic cancer were 25.5%, 15.7%, 13.7%, and 9.8%, respectively. Twenty (13.8%) of the patients died. The cause of death was extra-pancreatic carcinoma in 40%,pancreatic cancer in 25%, IPMN per se in 20%, and benign disease in 15% of the patients.CONCLUSION: The prognosis for IPMN depends not on the IPMN per se, but on the presence of intraor extra-pancreatic cancer.

Usefulness of contrast-enhanced ultrasonography in determining treatment efficacy and outcome after pancreatic cancer chemotherapy

AIM:To investigate if contrast-enhanced ultrasonography(CE-US) is useful for determining treatment efficacy and outcome in the early stages of pancreatic cancer chemotherapy by assessing changes in intratumor hemodynamics using CE-US with a contrast agent.METHODS:The subjects were 34 patients with unresectable advanced pancreatic cancer treated by chemotherapy.CE-US was assessed after every treatment(course) completion under the same conditions,and patients were divided into two groups according to the intratumor enhancement pattern:Vascular rich(R) group and vascular poor(P) group.RESULTS:After the second course of treatment,R group in intratumor hemodynamics had 18 patients,and P group had 16 patients.The reduction rates of serum CA19-9 level after chemotherapy which decreased to half or less of the baseline level were 2/15(0.1%) in P group,but 11/16(69%) in R group(P = 0.006).When the mean number of courses of chemotherapy and outcome were compared,P group had a mean number of courses of 4.9(R group,10.2) and mean survival time(MST) of 246 d(R group,402 d),showing that outcome was significantly better in R group(P=0.006).CONCLUSION:CE-US revealed that the change in intratumor blood flow correlated with both serum CA19-9 level and outcome.Patients with serum CA19-9 that decreased to less than half the baseline level,and patients with an abundant intratumor blood flow,had a significantly better outcome.Thus,CE-US is potentially useful for evaluating treatment efficacy and outcome in the early stages of pancreatic cancer chemotherapy.

Real-time virtual sonography visualization and its clinical application in biliopancreatic disease

AIM:To evaluate the usefulness of real-time virtual sonography(RVS)in biliary and pancreatic diseases.METHODS:This study included 15 patients with biliary and pancreatic diseases.RVS can be used to observe an ultrasound image in real time by merging the ultrasound image with a multiplanar reconstruction computed tomography(CT)image,using pre-scanned CT volume data.The ultrasound used was EUB-8500with a convex probe EUP-C514.The RVS images were evaluated based on 3 levels,namely,excellent,good and poor,by the displacement in position.RESULTS:By combining the objectivity of CT with free scanning using RVS,it was possible to easily interpret the relationship between lesions and the surrounding organs as well as the position of vascular structures.The resulting evaluation levels of the RVS images were12 excellent(pancreatic cancer,bile duct cancer,cholecystolithiasis and cholangiocellular carcinoma)and 3 good(pancreatic cancer and gallbladder cancer).Compared with conventional B-mode ultrasonography and CT,RVS images achieved a rate of 80%superior visualization and 20%better visualization.CONCLUSION:RVS has potential usefulness in objective visualization and diagnosis in the field of biliary and pancreatic diseases.

Endoscopic removal and trimming of distal self-expandable metallic biliary stents

AIM:To evaluate the efficacy and safety of endoscopic removal and trimming of self-expandable metallic stents(SEMS).METHODS:All SEMS had been placed for distal biliary strictures.Twenty-seven endoscopic procedures were performed in 19 patients in whom SEMS(one uncovered and 18 covered) removal had been attempted,and 8 patients in whom stent trimming using argon plasma coagulation(APC) had been attempted at Tokyo Medical University Hospital.The APC settings were:voltage 60-80 W and gas flow at 1.5 L/min.RESULTS:The mean stent indwelling period for all patients in whom stent removal had been attempted was 113.7 ± 77.6 d(range,8-280 d).Of the 19 patients in whom removal of the SEMS had been attempted,the procedure was successful in 14(73.7%) without procedure-related adverse events.The indwelling period in the stent removable group was shorter than that in the unremovable group(94.9 ± 71.5 d vs 166.2 ± 76.2 d,P = 0.08).Stent trimming was successful for all patients with one minor adverse event consisting of self-limited hemorrhage.Trimming time ranged from 11 to 16 min.CONCLUSION:Although further investigations on larger numbers of cases are necessary to accumulate evidence,the present data suggested that stent removal and stent trimming is feasible and effective for stent-related complications.

Transpapillary incision of refractory circumscript pancreatic duct stricture using wire-guided snare forceps

Endoscopic therapy of pancreatic duct(PD)strictures using balloon dilation and pancreatic duct stent(PS) placement has been reported to improve the severity of abdominal pain in selected patients with chronic pancreatitis(CP).However,some strictures are refractory and require frequent PS exchange to control symptoms.We describe two cases of successful endoscopic PD incision for difficult PD stricture using a wireguided snare.The snare is partially opened within the strictured pancreatic duct while applying current,thus incising the duct.Although both cases were successful without complications we do not advocate that this method be used routinely because of the potential for severe complications,e.g.bleeding,ductal perforation or pancreatic parenchymal damage.In order to prevent these complications,we developed a wire-guided technique under fluoroscopic control.We think this procedure may be useful in patients with short,straight PD strictures.Although further study is required,this approach may have potential for selected patients with refractory PD strictures due to CP.

Transnasal endoscopic biliary drainage as a rescue management for the treatment of acute cholangitis

Endoscopic biliary drainage has been established to provide effective treatment for acute obstructive jaundice and cholangitis. A recently developed ultrathin transnasal videoendoscope (TNE) is minimally invasive even for critically ill patients and can be performed without conscious sedation. Transnasal endoscopic biliary drainage (TNE-BD) is performed using a frontviewing TNE with approximately 5 mm outer diameter and 2 mm working channel diameter. Finally, 5F nasobiliary tube or plastic stent are placed. Technical success rates are approximately 100% and 70% for postendoscopic sphincterotomy or placement of self-expandable metallic stent, and intact papilla, respectively. There are no serious complications. In conclusion, although further cases should be accumulated, TNEBD and in particular, one-step naso-biliary drainage using TNE may be a useful and novel technique for the treatment of acute cholangitis.

Dosimetric Comparison between Bone and Target Matching Considering Interfractional Prostate Motion in Volumetric Modulated Arc Therapy

Adequate matching methods are critical for accurate volumetric-modulated arc therapy (VMAT). We investigated the dosimetric differences in the target and organs at risk (OARs) between bone matching and target matching in patients with prostate cancer treated with VMAT. The relationship between the dosimetric differences and interfractional motion of the prostate was also evaluated. Forty patients with prostate cancer classified as intermediate risk were enrolled in a study to assess the differences in dosimetry between two matching methods. These patients were treated with VMAT and prescribed dose was 78 Gy. The dose distribution was calculated using cone-beam computed tomography (CBCT) for this study. We selected clinical target volume (CTV) as the target, and the rectum and bladder as the OARs. The Dmean, D98, D95, and D2 to the target and V10-V70 to the OARs were calculated as different dose from target matching value minus bone matching value. Multiple regression analysis was used to evaluate the effect of interfractional motion of the prostate on the differences in dose. The CTV D95 values differed by -0.22 ± 1.01 Gy (mean ± standard deviation). Rectum and bladder V70 values differed by 4.6% ± 7.2% and -2.6% ± 7.2%, respectively. There was a correlation between interfractional motion of the prostate and the dose differences to OARs (R2 = 0.73 - 0.94). The dose differences to OARs also varied depending on the direction of the prostate’s motion. We found that bone matching resulted in an increased rectal dose and high risk of decreasing dose to the CTV.

Usefulness of a Newly-Developed Device, the Power Tree^(■), for Body Massage: Evidence from a Medical Evaluation

We investigated the effectiveness and usefulness of a novel tool: the Power Tree?, for body massage in 10 healthy female volunteers (age range, 24 - 55 years;mean age, 40.5 years) by evaluating several dermatological and psychological parameters, such as the amount of dermal collagen, the skin temperature, the level of salivary amylase and the scores on the State-Trait Anxiety Index (STAI). After 60-minute Power Tree?-mediated body massage, both the dermal collagen score determined from the DermaLab? images and skin temperature measured by infrared thermography were found to have increased significantly in several body sites compared to those before the treatment (p < 0.01 and p < 0.001, respectively). Although the level of stress estimated by the amount of amylase in the saliva was not significantly different pre- and post-procedure (p = 0.3), the treatment significantly reduced both the state anxiety (SA) and trait anxiety (TA) scores on the STAI (p < 0.001 for the SA, p < 0.01 for the TA). The treatment with this device was smoothly performed without any burden on the therapists during the present study. These data suggest that the newly-developed device is a powerful and useful tool for reflexology when used for full body massage therapy, and massage therapy using this device may produce beneficial, physiological effects as well as psychosocial improvements.