Can pretreatment CT perfusion predict response of advanced squamous cell carcinoma of the upper aerodigestive tract treated with induction chemotherapy?

BACKGROUND AND PURPOSE

Treatment of advanced stage squamous cell carcinoma of the upper aerodigestive tract with nonsurgical organ preservation protocols demonstrates improved cure rates with fewer comorbidities compared with surgery and radiation. The purpose of this study was to prospectively assess whether pretreatment evaluation of the primary site with quantitative CT perfusion measurements predicted response to induction chemotherapy and to create a prediction model to predict the response to induction chemotherapy in future patients.

METHODS

Seventeen patients who were enrolled in a prospective trial assessing surgical intervention versus a nonsurgical protocol underwent a pretreatment CT perfusion followed by direct laryngoscopy. After induction chemotherapy, tumor response was determined by the surgeon's estimate of tumor volume. The CT perfusion parameters were correlated with the clinical response using a Wilcoxon rank-sum analysis. A logistic regression model was used to create a prediction based on the most significant CT perfusion parameter.

RESULTS

Elevated values of blood volume (P = .004) and blood flow (P = .03) were significantly correlated with >50% reduction in tumor volume after chemotherapy. A prediction model based on tumor blood volume demonstrated 91.7% sensitivity and 80.0% specificity, with an area under the receiver operating characteristic curve of 0.95.

CONCLUSION

Our preliminary data imply that tumors with elevated blood volume and blood flow were statistically associated with response to induction chemotherapy. These results suggest that pretreatment CT perfusion may be able to identify patients who will successfully respond to induction chemotherapy, which could potentially eliminate this step for subsequent patients when deciding on the appropriate treatment regimen.

Transarterial embolization of a cervical dural arteriovenous fistula. Presenting with subarachnoid hemorrhage

SUMMARY

We describe a case of a 75-year-old man who presented with acute onset of headache and subarachnoid hemorrhage and initial cerebral angiography was deemed "negative". In retrospect, a faint contrast collection was present adjacent to the right vertebral artery at the C1 level suspicious for a small dural arteriovenous fistula (dAVF). Follow-up angiography with selective microcatheter injections of the right vertebral artery and C1 radicular artery confirmed a complex dAVF with characteristically specific venous drainage patterns associated with a subarachnoid hemorrhage presentation. Subsequently, the cervical dAVF was treated with superselective glue embolization resulting in complete occlusion. Cervical dAVFs are extremely rare vascular causes of subarachnoid hemorrhage. Both diagnostic angiography and endovascular treatment of these lesions can be challenging, especially in an emergent setting, requiring selective evaluation of bilateral vertebral arteries and careful attention to their cervical segments. Although only a single prior case of a cervical dAVF presenting with subarachnoid hemorrhage has been successfully treated with embolization, modern selective transarterial techniques may allow easier detection and treatment of subtle pathologic arteriovenous connections.

Correlation between initial and early follow-up CT perfusion parameters with endoscopic tumor response in patients with advanced squamous cell carcinomas of the oropharynx treated with organ-preservation therapy

BACKGROUND AND PURPOSE

Current organ-preservation regimens for upper aerodigestive tract squamous cell carcinoma (SCCA) require endoscopic procedures under general anesthesia to evaluate the tumor response. The purpose of our study was to determine whether CT perfusion (CTP) parameters correlate with response to induction chemotherapy as assessed by endoscopy under general anesthesia.

METHODS

Nine patients with advanced (stage 3 or 4) SCCA of the oropharynx were enrolled in a nested phase 2 prospective trial in which induction chemotherapy was used to assess the tumor response. Patients underwent direct laryngoscopy and CTP before and 3 weeks after one cycle of induction chemotherapy. The outcome variables were the surgeon's estimate of tumor volume during endoscopy with biopsy under anesthesia and CTP parameters (capillary permeability (CP), blood volume (BV), blood flow (BF), and mean transit time (MTT)). Wilcoxon rank sum analysis was used to correlate the baseline values of BF and BV with response to induction chemotherapy. Comparison of agreement between the reduction in tumor volume and change in CTP parameters was performed by using kappa estimates.

RESULTS

Seven of 9 patients demonstrated > or =50% tumor volume reduction, representing positive response to induction chemotherapy. In the responder group, the following changes in mean pre- and postinduction chemotherapy values were noted: mean BF, 114.2 mL/100 g /min (preinduction) to 45.1 mL/100 g/min (postinduction); mean BV, 5.11 mL/100 g to 3.1 mL/100 g; mean CP, 25.6 mL/100 g /min (preinduction) to 18.3 mL/100 g / min (postinduction); mean MTT, 4.9 seconds (preinduction) to 8.0 seconds (postinduction). In the nonresponder group, the following changes were noted: mean BF, 56.9 mL/100 g/min to 75.9 mL/100 g/min; mean, BV 2.7 mL/100 g to 4.71 mL/100 g; mean CP, 24.1 mL/100 g/min to 23.7 mL/100 g/min; mean MTT, 4.3 seconds to 5.34 seconds. Higher baseline (pretherapy) values of BV showed significant correlation with endoscopic tumor response (P < .05). Reduction in the BV (by >/=20%) on follow-up studies also showed substantial agreement with clinical response as assessed with endoscopy (kappa = 0.73). The agreement between decreased BF, decreased CP, and increased MTT and clinical response was fair (kappa = 0.37).

CONCLUSION

These preliminary results show that deconvolution-based CTP technique offers potential for noninvasive monitoring of response to induction chemotherapy in patients with oropharyngeal cancers. Percentage reduction of BV is significantly correlated to endoscopic response to induction chemotherapy, though we acknowledge that the data correspond to short-term outcomes and long-term durability of response cannot be established. Nevertheless, validation of the use of deconvolution CTP parameters as predictors of tumor response may permit replacement of an invasive diagnostic procedure conducted under anesthesia currently used to assess response with noninvasive perfusion CT imaging.

Obstructed labour - a preventable entity

We present a clinical study of 204 cases of obstructed labour admitted over a period of 5 years between 1991-92 and 1996-97 in a rural institute in central India. They constituted 1.9% of births. Seventy-one per cent of the cases were from the rural area (similar to the overall patient population in this hospital), 31.4% women were primigravidae. Of the subjects, 64.7% were between 20 and 29 years. Malpresentation was the cause in 53.2%, followed by cephalopelvic disproportion, in 41.1%. Intraoperative incomplete rupture was detected in 5.9% cases. The commonest maternal morbidity was intraoperative extension of uterine incision at the time of caesarean section, mostly lateral (14.0%). Of the women, 12.5% had intrapartum or postpartum sepsis. The perinatal mortality was 160/1000. There was no maternal mortality. Timely diagnosis of malpresentation, pelvic contraction and use of a partogram at all levels could have prevented obstructed labour. In these unfortunate situations, judicious selection of subjects for caesarean section is appropriate, avoiding heroic vaginal procedures even with a dead baby. Infection devitalises tissues and attempts at vaginal delivery may be dangerous.

Skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder: clinicoradiological features

AIM

To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder.

MATERIALS AND METHODS

A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records.

RESULTS

Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27-70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of low-density enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6-12 months).

CONCLUSION

Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal.

Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: a prospective study

BACKGROUND

This prospective study evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) for the treatment of symptomatic cavernous hemangiomas of the liver. The technique, its complications, and effectiveness also were analyzed.

METHODS

Eight patients (five male, three female; mean age +/- SD = 47.75 +/- 8.59 years) with symptomatic cavernous hemangiomas of the liver were treated by TAE with polyvinyl alcohol particles or gelfoam and steel coils (single session) followed by supportive treatment. Tumor characterization (including the extent and number of lesions) was done on triple-phase helical computed tomography or gadolinium-enhanced dynamic magnetic resonance imaging.

RESULTS

The lesions were located in the right lobe in five patients, left lobe in one, and both lobes in two. The largest diameter of the lesions was 6-18 cm (9.28 +/- 5.13 cm). The treatment response was assessed on follow-up ultrasound and color Doppler and/or contrast-enhanced helical computed tomography. There were no treatment-related deaths and morbidity was minimal. Embolization was the only method of treatment in seven patients; however, one patient had surgery after TAE because the symptoms were only partly relieved. Indications for embolization were abdominal pain (eight patients), rapid tumor enlargement (four of eight), and recurrent jaundice (one of eight). Symptomatic improvement was documented in all patients after embolization. Symptoms did not worsen in any patient. The mean size of the tumor did not show any statistically significant change on follow-up radiologic examinations. However, in one patient, the tumor significantly regressed in size after embolization.

CONCLUSION

TAE of hepatic cavernous hemangioma is a useful procedure in the therapy of symptomatic hemangiomas.

Gastrointestinal hemorrhage in hepatocellular carcinoma: management with transheptic arterioembolization

Gastrointestinal hemorrhage in patients with hepatocellular carcinoma is common and a major contributor to mortality. These patients tend to have a very poor prognosis. This report describes five such cases in which gastrointestinal bleeding was one of the presenting problems and required urgent management. The causes of massive intermittent gastrointestinal bleeding were variceal (two cases), direct invasion of the duodenum (one case), transverse colon (one case), and stomach (one case). All five patients were inoperable because of locally advanced disease, poor general condition, or comorbid disorders and were managed with angioembolization. After transcatheter embolization, the bleeding stopped completely in two patients and was reduced significantly in the remaining three. We report the role of transhepatic arterioembolization in the management of gastrointestinal bleed in such patients, and we recommend its use more often in similar situations.

Proptosis with orbital soft tissue and bone changes and unilateral papilloedema: unusual presentation of POEMS syndrome

POEMS syndrome is a rare manifestation comprising of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes. Orbital involvement in this syndrome is rare and manifestation with proptosis, even rarer. The imaging features in Poems syndrome and rarity of various features in our case are being highlighted here.

Medical complications due to mothball abuse

Inhalant abuse is a major public health problem that has been associated with numerous acute and chronic medical problems. Inhalants are defined as volatile organic substances and are found in common household and commercial products that are easily accessible, inexpensive, and legally obtained. We discuss a rare case of mothball abuse predominantly by inhalation. The patient had acute peripheral neuropathy and chronic renal failure, both of which were concluded to be casually related to mothball abuse. We briefly review the abuse potential and medical complications of naphthalene and paradichlorobenzene, the compounds in mothballs. Our case illustrates that common household products not usually identified as recreational drugs can be abused; furthermore, linking specific medical problems with particular inhalants can be difficult because of confounding variables.

Sonographic diagnosis of a ruptured primary hydatid cyst of the gallbladder

We report an unusual case of a ruptured primary hydatid cyst of the gallbladder. The sonographic appearance-a distended gallbladder containing an intraluminal mass with undulating membranes in the neck and body-led to the diagnosis of this extremely rare condition.

Splenic tuberculosis: an unusual sonographic presentation

Tuberculosis (TB) of the spleen is rare, especially in the immunocompetent. Recently there has been an increase in the incidence of splenic TB, primarily attributable to the raging HIV epidemic. Almost all cases of splenic TB present as multiple hypoechoic foci (< 2 cm) on ultrasonography. We present a case of a large solitary splenic tuberculoma in a middle-aged, non-immunosuppressed female, an employee at the local TB hospital. To the best of our knowledge, only two such cases have been described on ultrasound before. We suggest that, regardless of immune status, splenic TB should be considered as a diagnostic possibility when dealing with the solitary nodules of the spleen, especially when there is a history of exposure to or evidence of tuberculous foci elsewhere in the body.

Eating disorders in British Asians

OBJECTIVE

There has been a clinical impression that British Asians present with eating disorders less commonly than expected. The study examines the numbers and characteristics of Asians presenting to the Leicestershire Eating Disorders Service with a catchment area which includes a substantial proportion of people with a background in the Indian subcontinent.

METHOD

Case note review and comparison of rates of presentation of people with and without such a background.

RESULTS

Twenty-one eating-disordered Asians were seen in 10 years. Their clinical characteristics resembled the rest of the referrals. However, the rate of presentation of people from the Asian population was about one fourth of that of the white population.

DISCUSSION

Asian women with eating disorders were referred less often. This might be because of a lower prevalence in this population. However, it seems likely there are variable and sometimes high threshold filters to secondary care for such women.

Surgical treatment of persistent truncus arteriosus in the first year of life

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