Posterior Reversible Encephalopathy Syndrome after Lenvatinib Therapy in a Patient with Anaplastic Thyroid Carcinoma

Posterior reversible encephalopathy syndrome (PRES) is a rare reversible neurological syndrome that causes subcortical vasogenic brain edema and which is associated with the use of target-specific agents. Lenvatinib is a target-specific agent that was recently approved for inoperable thyroid cancer. We herein describe the case of a 66-year-old woman with anaplastic thyroid cancer (ATC) who was treated with lenvatinib and who subsequently developed PRES. The clinical and radiological findings improved after suspending therapy for 1 week, and there was no recurrence with intermittent lower-dose lenvatinib treatment. Lenvatinib may prolong survival in patients with ATC and can be administered intermittently, even after PRES onset.

The Use of External-beam Radiotherapy for Muscle-invasive Bladder Cancer in Elderly or Medically-fragile Patients

AIM

To evaluate the clinical results of external-beam radiotherapy (EBRT) for muscle-invasive bladder cancer (MIBC) in elderly or medically-fragile patients.

PATIENTS AND METHODS

Twenty-five consecutive patients with MIBC (cT2-4N0-1M0) receiving EBRT were retrospectively analyzed. Their median age was 82 years. Radiotherapy median dose was 60 Gy administered in 30 fractions.

RESULTS

Median follow-up period was 14.7 months. Median overall survival (OS) and progression-free survival (PFS) were 14.7 months and 7.8 months, respectively. The OS, cause-specific survival (CSS), and PFS rates at 1-year were 56.0%, 68.5%, and 40.0%, respectively. The local progression-free rates (LPFR) at 6 months and 1 year were 89.3% and 59.5%, respectively. Performance status 3 was a significantly unfavorable factor for OS, CSS, and progression-free survival; clinical N stage was a significantly unfavorable factor for progression-free survival; and lower irradiation dose (≤50.4 Gy) was a significantly unfavorable factor for LPFR.

CONCLUSION

EBRT for elderly or medically-fragile patients is feasible, and achieves acceptable local progression-free status.

Two adult cases of extralobar pulmonary sequestration: A non-complicated case and a necrotic case with torsion

Background

This case report describes two cases of extralobar pulmonary sequestration in adults with and without torsion/necrosis.

Case Reports

Non-complicated extralobar pulmonary sequestration was found incidentally in a 50-year-old asymptomatic woman (Case 1), diagnosed with the presence of a branching structure in a mass lesion and blood supply from the right inferior phrenic artery. Another case of a 38-year-old woman presented with a sudden onset of back pain caused by extralobar pulmonary sequestration with torsion/necrosis (Case 2). A 4-cm fusiform mass in the paravertebral region showed enhancement in the peripheral rim only, and no feeding artery. These were the same as it had been reported typical findings in extralobar pulmonary sequestration with necrosis. On magnetic resonance imaging, the masses in both cases showed inhomogeneous low signal and branching high signal on T2-weighted images. That was characteristic for a stroma without dilated alveoli as a solid part and dilated alveoli as fluid regions.

Conclusions

By comparing those two cases, we came to a conclusion that only T2-weighted imaging reflects the native structure, even after infarction. Although differentiation from a cystic tumor with hemorrhage or infection can be problematic, inhomogeneous low signal and branching high signal on T2-weighted images may help us distinguish extralobar pulmonary sequestration from other cystic lesions.

Difficulties in the diagnosis of appendicitis: review of CT and US images

To determine the reasons for missing a distended appendix, we discuss cases of acute appendicitis in which either or both computed tomography (CT) and/or ultrasonography (US) initially failed to detect distended appendix. In some cases, distended appendices that were undetected on US were easily detected by CT, and vice versa. Failure to detect a distended appendix does not always eliminate the possibility of acute appendicitis.

Imaging by multiple modalities of patients with a carotidynia syndrome

The purpose of this article is to familiarize readers with the clinical syndrome of carotidynia. In the past, the International Headache Society (IHS) described idiopathic carotidynia as a diagnostic entity consisting of a self-limiting neck pain syndrome and tenderness over the carotid bifurcation without structural abnormality and then recently removed it from its classification. Although the clinical criteria of carotidynia in the former classification of the IHS included the absence of structural abnormality, several publications have demonstrated associated radiological findings and have described the usefulness of radiological investigations in diagnosing this syndrome. In this paper, we report four additional cases with a carotidynia clinical syndrome (according to the former classification) and the presence of abnormal soft tissue infiltration surrounding the symptomatic carotid artery as demonstrated by multiple imaging modalities, without any other underlying cause for the carotid pain syndrome. Our findings support the hypothesis that carotidynia could be a distinct disease entity, possibly caused by inflammation.

Transcatheter arterial embolization for bleeding from bile duct tumor thrombi of hepatocellular carcinoma

BACKGROUND/AIMS

Advanced hepatocellular carcinoma usually invades the portal vein, forming tumor thrombi. Invasion of the bile duct, i.e., intrabile tumor growth or bile duct tumor thrombi is rare. Patients with bile duct tumor thrombi present with obstructive jaundice, abdominal pain or hemobilia. Hemobilia due to bile duct tumor thrombi is sometimes massive and fatal. The purpose of our study was to evaluate the effectiveness of transcatheter arterial embolization for hemobilia caused by bile duct tumor thrombi of hepatocellular carcinoma.

METHODOLOGY

Between 1993 January and 2000 December, transcatheter arterial embolization was performed in 4 patients with hemobilia and gastrointestinal bleeding from bile duct tumor thrombi of hepatocellular carcinoma.

RESULTS

In all 4 patients, transcatheter arterial embolization was successfully performed and resulted in cessation of bleeding. One patient had recurrent hemobilia, which was controlled by another transcatheter arterial embolization. Three patients were discharged from hospital after transcatheter arterial embolization. Patients died of hepatic failure or multiple tumors 5 to 7 months after the onset of hemobilia, although hemobilia had been fully controlled.

CONCLUSIONS

Transcatheter arterial embolization seemed to be effective for the control of massive hemobilia caused by bile duct tumor thrombi associated with hepatocellular carcinoma.

Purulent meningitis with unusual diffusion-weighted MRI findings

We describe unusual findings obtained by diffusion-weighted magnetic resonance imaging (MRI) in a patient with acute purulent meningitis caused by penicillin-resistant Streptococcus pneumoniae. Along cerebral convexities and the Sylvian fissure, multiple small intense lesions showed high signal intensity in these sequences. This may be the first report of diffusion-weighted in purulent meningitis.

Transcatheter microcoil embolotherapy for ruptured pseudoaneurysm following pancreatic and biliary surgery

PURPOSE

To evaluate the outcome of transcatheter microcoil embolotherapy for bleeding pseudoaneurysms complicating major pancreatic and biliary surgery.

MATERIALS AND METHODS

Over an 8-year period, 8 patients were encountered who developed massive bleeding from pseudoaneurysms 15-64 days (mean 31 days) following major pancreatic and biliary surgery. Urgent transcatheter microcoil embolotherapy was performed in all 8 patients.

RESULTS

Transcatheter embolotherapy was successful in 7 of 8 patients (88%) but failed in one due to development of disseminated intravascular coagulation. One patient developed recurrent bleeding 36 days after the first embolotherapy from a newly developed pseudoaneurysm, which was again treated successfully with embolization. Two patients subsequently underwent additional surgery for residual pathology. Three of the 7 patients with successful embolotherapy were alive at 10-96 months, 4 patients died of associated malignancies 4-20 months after embolotherapy.

CONCLUSION

Transcatheter microcoil embolotherapy is effective for bleeding pseudoaneurysms complicating pancreatic and biliary surgery, and should be considered the first treatment of choice.

[Intraarterial chemotherapy combined with radiation therapy for advanced cancer of the uterine cervix]

The results of intraarterial chemotherapy (IACT) combined with definitive radiation therapy for 23 advanced and bulky carcinomas of uterine cervix are reported. IA-CT with cisplatin 50 mg and doxorubicin 30 mg was administered by one shot method in bilateral internal iliac arteries. The protocol consisted of one to three treatment session every 3 weeks. Nine of eleven patients with clinical stage III achieved a complete local response (82%), and the 3- and 5-year survival in these cases were 72% and 72%, respectively. These results were superior to the response (58%), 3- and 5-year survivals (68%, 58%) obtained in 19 patients treated mainly with radiation therapy alone. The side effect of grade 2 and 3 for the intestine, such as ileus and hemorrhagic colitis, was noted in 3 patients (15%). In addition, 3 of 8 patients with radical surgery and postoperative radiation therapy after IA-CT developed insufficient fracture of pelvic bone. These complications accompanied by IA-CT combined with radiation therapy and/or surgery increased slightly, compared with that by the previous therapy without IA-CT, but were not critical. The results suggest that IA-CT following radiation therapy is effective to improve the prognosis of patients with Stage III cervical cancer.

Uterine deformity caused by surgery during pregnancy

OBJECTIVE

The purpose of our study was to determine the cause of a unique deformity of the uterus, in which the cervix is elongated and appears fixed to the anterior abdominal wall.

MATERIALS AND METHODS

Imaging from 2,558 consecutive MR studies of the pelvis of women were retrospectively reviewed for the simultaneous presence of elongation of the uterine cervix, angulation of the uterine isthmus just beneath the anterior abdominal wall, and vertical orientation of the long axis of the uterine corpus.

RESULTS

Fourteen cases exhibited the uterine deformity; 13 of these cases had histories of cesarean section (CS) performed from 9 to 33 years (mean 18.2 years) previous to MRI. Among them, six patients had a history of multiple CS. The remaining case had a history of enucleation at 13 weeks' gestation of uterine leiomyoma, located at the anterior wall of the lower uterine segment. Thirteen patients had not become pregnant after the last CS (no. = 12) or the myomectomy (no. = 1).

CONCLUSION

This unique uterine deformity strongly indicates a history of incision in the lower uterine segment especially at late gestational age. Since all but one patient with this deformity did not become pregnant after the last surgery, this deformity may be one reason for infertility after CS.

Intravenous leiomyomatosis of uterus: MR appearance

We report a case with intravenous leiomyomatosis of uterus that showed characteristic appearances on MR. Magnetic resonance demonstrated a tangle of distended and folded tubular structures, well enhanced by Gd-diethylenetriamine pentaacetic acid. It was confirmed by surgery that these tubular structures reflected the vessels markedly dilated by intravascular tumor.

Gallbladder carcinoma: evaluation with MR imaging

Magnetic resonance (MR) images of 19 patients with histologically proved gallbladder carcinoma were retrospectively reviewed to determine the appearance of the primary tumor, and to assess the ability of MR imaging to demonstrate the various modes of tumor spread beyond the gallbladder. The primary tumor, as well as tumor spread beyond the gallbladder, was hyperintense on T2-weighted images and hypointense on T1-weighted images when compared with the liver parenchyma. Liver invasion and metastasis could be depicted by MR imaging with both sequences, unless the tumors were small or the extent of invasion was minimal. Duodenal invasion was difficult to evaluate because of motion artifacts, paucity of fat, and partial volume effects. T1-weighted images readily demonstrated extension of the tumor to the hepatoduodenal ligament and para-aortic region with good contrast between tumor and surrounding tissue. The extent of tumor extension to the blood vessels was also easily evaluated because of flow void in the vasculature. MR imaging can help determine the extent of gallbladder carcinoma and can contribute to the staging of this disease.

Gamna-Gandy bodies of the spleen: evaluation with MR imaging

The authors retrospectively evaluated magnetic resonance (MR) images obtained in 64 patients with portal hypertension. Multiple low-intensity nodules were noted within the spleen in eight patients. In all eight cases, these nodules were most apparent on images obtained with the GRASS (gradient-recalled acquisition in the steady state) technique, which is known to be more sensitive to heterogeneity of the magnetic susceptibility, usually caused by hemosiderin deposition. In one of these cases, ultrasonography demonstrated diffuse hyperechoic spots that had been reported to represent Gamna-Gandy bodies of the spleen (ie, organized hemorrhage caused by portal hypertension). Although there was no pathologic proof in their series, the authors believe these low-intensity nodules seen on MR images may represent the hemosiderin deposits of Gamna-Gandy bodies.

Enlarged uterus: differentiation between adenomyosis and leiomyoma with MR imaging

The potential of magnetic resonance (MR) imaging in differentiation of adenomyosis from leiomyoma was evaluated in 93 patients who had a palpable enlarged uterus that was suspect for leiomyoma or adenomyosis. In all cases, MR images were correlated with surgical/pathologic findings. Pathologic findings showed that 71 enlarged uteri were due to leiomyoma, including one leiomyosarcoma, and 16 were due to adenomyosis. The other six patients were shown to have an enlarged uterus attributable to simultaneous involvement of both lesions. On T2-weighted images, adenomyosis appeared as an ill-defined, relatively homogeneous low-signal-intensity area embedded with sparse high-intensity spots. In contrast, leiomyomas were well-circumscribed masses with a spectrum of signal intensity. The cause of uterine enlargement was correctly diagnosed with MR images in 92 of the 93 cases. It is concluded that MR imaging is highly accurate in helping to distinguish between adenomyosis and leiomyoma in cases of enlarged uterus.

Carcinoma of the cervix: staging with MR imaging

Demonstration and staging of carcinoma of the cervix with magnetic resonance (MR) imaging was evaluated prospectively in 67 patients with histologically proven lesions. Findings were correlated with surgical/pathologic results obtained within 2 weeks. MR imaging had an accuracy of 95% in demonstrating invasive disease (stage IB or higher). It was capable of depicting the location and extent of tumor invasion of cervical stroma and helped detect tumor beneath relatively normal epithelium or within the endocervical canal that had not been detected by means of colposcopic biopsy. The overall accuracy of MR imaging in staging carcinoma of the cervix was 76%, and in demonstrating parametrial status, the overall accuracy was 89%. In 39 patients with proven invasive disease, the accuracy in demonstrating parametrial status was 82%. In 13 of these 39 patients the low-signal-intensity stromal ring of the cervix on MR images was completely preserved and there were no false-positive results. MR imaging is a highly promising method for directly demonstrating and staging carcinoma of the cervix and seems to be capable of providing answers to crucial questions regarding mode of therapy.

[Magnetic resonance imaging of the thorax]

We examined thirty-five patients with various chest diseases with cardiac gated Magnetic Resonance Imaging (MRI) at 1.5 tesla. Major advantages of MRI of the thorax are its abilities to display sagittal and coronal planes and to disclose vessels clearly without contrast media. We conclude MRI is useful in evaluating, 1) masses at the lung apex or base, 2) chest wall invasion, 3) hilar and mediastinal lymphadenopathy, 4) aortic aneurysm, and 5) bronchogenic cyst.

Spinal arteriovenous malformation: MR imaging

Ten patients with spinal arteriovenous malformations (AVMs) were examined with high-field-strength (1.5-T) magnetic resonance (MR) imaging and a surface coil (eight patients) or head coil (two patients). Four AVMs were intramedullary, and six were extramedullary. There was one case of Foix-Alajouanine disease (subacute necrotizing myelitis; thrombosed AVM). Three important pathologic findings--myelomalacia, total thrombosis, and wall thickening of the draining vein--were clearly demonstrated at MR imaging and confirmed at autopsy. A flow-sensitive sequence was valuable in the depiction of one intramedullary AVM as hyperintense, the postoperative evaluation of AVM, and the differentiation of nidus from old intramedullary hematoma. In other AVMs, cord edema, periradicular hematoma, and reversible changes of cord scalloping after surgery were demonstrated. MR imaging demonstrated various pathologic changes of the spinal cord that could not be detected with any other imaging method.

Thyroid masses: MR imaging and pathologic correlation

The authors explored the capability of high-field-strength surface coil magnetic resonance (MR) imaging in disclosing the gross pathologic characteristics of thyroid masses (especially pseudocapsular and hemorrhagic degeneration). Twenty-four patients were examined, including 12 with papillary carcinoma, eight with adenoma, and four with adenomatous goiter. All patients underwent surgery within 2 days after MR imaging. Specimens were cut and correlated directly with MR images. The appearance of the pseudocapsule was classified into four types: A, intact and even thickness around the tumor; B, only partially present or even absent; C, intact but with uneven thickness; D, partially destroyed by tumor. MR imaging findings corresponded precisely with those of gross pathologic examination in all cases but four of adenoma. Type A pseudocapsules were found only in adenoma and type D only in papillary carcinoma. Although the number of cases in the series was limited, the authors conclude that MR images reflect gross pathologic findings well and that some characteristic findings are suggestive of benign or malignant disease.

Transcriptional regulation of myeloperoxidase gene expression in myeloid leukemia HL-60 cells during differentiation into granulocytes and macrophages

Myeloperoxidase gene transcription in isolated nuclei from HL-60 cells induced to differentiate into granulocytes by dimethyl sulfoxide or into macrophages by 12-O-tetradecanoylphorbol-13-acetate was studied by dot-blot hybridization of a myeloperoxidase cDNA to the 32P-labeled nuclear transcripts. Myeloperoxidase gene transcription, like that of c-myc gene transcription, was reduced to a low level within 12 h after the inductions of these differentiations. In contrast, transcription of the actin gene remained constant. These results indicate that decrease in myeloperoxidase synthesis in HL-60 cells during differentiation is regulated at a transcriptional level.

Transection of the pituitary stalk: development of an ectopic posterior lobe assessed with MR imaging

Magnetic resonance (MR) imaging was performed in ten patients with pituitary stalk transection who had idiopathic pituitary dwarfism. Contiguous sagittal T1-weighted images were obtained in all cases, and, in some, axial or coronal images were taken for further evaluation. On MR images, normal anterior and posterior lobes of the pituitary gland can be clearly differentiated because the posterior lobe has a characteristic high intensity on T1-weighted images. In the ten patients, the high-intensity posterior lobe was not seen, but a similar high signal intensity was observed at the proximal stump in seven patients. This high-intensity area is the newly formed ectopic posterior lobe, which secretes antidiuretic hormone just as the posterior lobe would. When the ectopic lobe completely compensates for the impaired posterior lobe, endocrinologic data indicate normal posterior lobe function. However, MR imaging can reveal the transection of the pituitary stalk and formation of the ectopic lobe.

Moyamoya disease: MR imaging

Eleven patients with moyamoya disease were studied with magnetic resonance (MR) imaging performed with a high-field-strength (1.5-T) superconducting magnet. In all cases a fundamental pathologic change of moyamoya disease--occlusion or stenosis of the terminal portion of the internal carotid artery and the proximal portion of anterior and middle cerebral arteries--was clearly demonstrated. The characteristic collateral network from the suprasellar cistern to the basal ganglia, which corresponds to the "moyamoya vessels" on angiograms, was seen in several patients. Various ischemic changes, including infarction, brain atrophy, and ventricular dilatation, were also well demonstrated. MR imaging plays an important role in the diagnosis of moyamoya disease.

Hepatocellular carcinoma: MR imaging

Sixty patients with hepatocellular carcinoma (HCC) were studied with computed tomography (CT) and magnetic resonance (MR) imaging at 1.5 T. MR imaging was equivalent to CT in detection of HCC. MR imaging was superior to CT in demonstrating the details of tumors, especially pseudocapsules. In 58 cases, main tumors were detected with MR imaging. On spin-echo (SE) 600/25 (repetition time msec/echo time msec) sequences, tumors were hyperintense in 18 cases, isointense in ten, and hypointense in 30. On SE 2,000/60 sequences, all but two tumors had high signal intensity. Pseudocapsules, intratumoral septa, daughter nodules, and tumor thrombi, which are important characteristics of HCC, were demonstrated in 22, three, six, and six cases, respectively, on MR imaging. MR imaging is useful for characterizing the internal architecture of HCC.

Direct radiographic magnification with computed radiography

Computed radiography was combined with a 0.1-mm microfocus radiographic tube to obtain radiographic magnification of a x3 to x5. Gray-scale image processing compensated for the loss of radiographic contrast associated with the high-kilovoltage, short-exposure technique. The high-pass spatial frequency filtering capability of the computed radiography resulted in enhanced edges and increased displayed latitude. The improved image quality obtained by magnification computed radiography allowed delineation of subtle abnormalities and small anatomic structures not apparent on conventional screen-film contact or magnification radiographs.