Single-Fraction Palliative High-Dose-Rate Brachytherapy for Symptom Management in a 97-Year-Old Patient With Dementia.

Background: Delivering cancer treatment to elderly patients with dementia is often challenging. We describe performing palliative surface mold brachytherapy (SMBT) in an elderly patient with advanced dementia for pain control using music therapy to assist with agitation. Case Description: The patient was a 97-year-old Japanese woman with advanced dementia. Exudate was observed from her tumor, and she complained of Grade 2 severity pain using Support team assessment schedule (STAS), especially when undergoing would dressings. Given her advanced dementia, she was not considered a candidate for radical surgery or external beam radiotherapy. We instead treated her with high-dose-rate (HDR) SMBT. Due to her advanced dementia associated with agitation, she could not maintain her position. She was able to remain calm while listening to traditional Japanese enka music, which enables our team to complete her radiation without using anesthetics or sedating analgesics. Her localized pain severity decreased ≤21 days and the exudate fluid disappeared ≤63 days after HDR-SMBT. Her tumor was locally controlled until her death from intercurrent disease 1 year after HDR-SMBT. Discussion: Single fraction palliative HDR-SMBT was useful for successful treatment of skin cancer in an elderly patient. Traditional Japanese music helped reduce her agitation to complete HDR-SMBT. For elderly patients with agitation associated with dementia, we should consider using music and music therapy to facilitate radiation therapy.

The radiologic (CT/MRI)-pathological correlations of the salivary duct carcinoma (SDC) with hyaline degeneration and peripheral nerve invasion.

OBJECTIVES: Salivary duct carcinoma is an aggressive tumour commonly showing local invasion and/or nerve palsy. However, their CT/MRI findings, especially, regarding T2WI, and the diffusion-weighted-image (DWI), were not well known. In this study, we correlated the CT/MRI appearance and the pathological findings containing the nerve invasion cases such as a facial nerve. METHODS: We reviewed 14 cases of SDC (parotid = 11, submandibular = 2, minor salivary gland = 1) pathologically proven peripheral nerve involvement. Their CT findings of all patient including dynamic contrast-enhancement study､MRI (n = 9) and DWI (n = 6) were also analyzed with histopathological correlation. RESULTS: On contrast-enhanced CT, the solid component was moderately enhanced. On MRI, T2WI central low signal core (n = 6) with peripheral high intensity rim (n = 5) was frequently observed except heterogeneous low and high (n = 1), diffuse low (n = 1), and high (n = 1) signal cases. The hyaline degenerative area located in the tumour core was poorly enhanced. Eleven tumours had an ill-defined margin, reflecting invasive tumour growth. On DWI, they showed high signal [the central low and peripherally high (n = 4), and diffuse (n = 1), heterogeneously high signal (n = 1)]. The mean ADC value was 1.148 ~ 0.961 x 10-3 mm2/s. With pathological correlation, the central low signal area on T2WI reflected hyaline degeneration. The sites of gross nerve involvement were revealed as tubular or branching structures on CE-CT (n = 3), and MRI (n = 1). CONCLUSIONS: (1) We frequently observed a central low signal area on T2WI/DWI in SDC. With histopathological correlation, it corresponded to the central hyaline degeneration with the peripheral viable tumour. 2) The gross nerve involvement might be detected as a strongly enhancement structure.

Effectiveness and safety of lower dose sulfamethoxazole/trimethoprim therapy for Pneumocystis jirovecii pneumonia in patients with systemic rheumatic diseases: A retrospective multicenter study.

OBJECTIVES: To evaluate the effectiveness and safety of lower-dose sulfamethoxazole/trimethoprim therapy (SMX/TMP) for Pneumocystis jirovecii pneumonia (PCP) in patients with systemic rheumatic diseases. METHODS: In this multicenter retrospective study, we compared effectiveness and safety of SMX/TMP for the treatment of PCP among patients divided into three groups according to the initial dosage of SMX/TMP: the low, ≤10 mg/kg/day; the intermediate, 10-15 mg/kg/day; and the high and conventional, 15-20 mg/kg/day for TMP dose. RESULTS: Eighty-one patients, including 22, 30, and 29 patients in the low-, the intermediate- and the high-dose group could be analyzed and the 30-day survival rate were 100%, 93.3%, and 96.7%, respectively (P = 0.28). There were significant dose-dependent increasing trends of severe adverse drug reactions (ADRs) for SMX/TMP that were graded as ≥3 according to the Common Terminology Criteria for Adverse Events. When stratified by presence of severe hypoxemia defined by alveolar-arterial O2 gradient ≥45 mmHg, the 30-day survival and treatment modification rate were similar among the three groups, but frequency of severe ADRs were significantly decreased in the low-dose group. The low-dose group was independently and negatively associated with treatment modification within 14 days and severe ADRs. CONCLUSIONS: Lower dose SMX/TMP therapy with ≤10 mg/kg/day for TMP was as effective as higher dose therapy for the treatment of PCP and associated with lower rates of treatment modification and severe ADRs in patients with systemic rheumatic diseases.

[Pulmonary Carcinosarcoma Presenting Hemothorax Caused by Pleural Invasion;Report of a Case].

A 71-year-old man presented with hemothorax with cough, sputa and worsening dyspnea. On chest X-ray and computed tomography(CT), a huge tumor in the right upper lobe with hematoma and small amount of gas suggesting hemopneumothorax was revealed. No apparent lymphadenopathy nor intrapulmonary metastases were observed. The tumor showed a little enhancement on the contrastenhanced CT. Then the resction of the tumor was performed, and the pathological evaluation revealed a carcionosarcoma (adenocarcinoma+osteosarcoma) pT3N0 (stage II B) G4 pl2. Sarcomatoid carcinoma such as carcinosarcoma should be considered as a possible cause of hemothorax in making a diagnosis of hemorrhagic hypovascular huge lung tumor.

Correction: Normal Lung Quantification in Usual Interstitial Pneumonia Pattern: The Impact of Threshold-based Volumetric CT Analysis for the Staging of Idiopathic Pulmonary Fibrosis.

[This corrects the article DOI: 10.1371/journal.pone.0152505.].

The anatomical classification of AICA/PICA branching and configurations in the cerebellopontine angle area on 3D-drive thin slice T2WI MRI.

BACKGROUND: With the technical advance of magnetic resonance imaging (MRI), we have been able to observe not only the small cranial nerves arising from the brain stem but also the branches of vertebrobasilar artery in the cerebellopontine angle (CPA) cistern. PURPOSE: The purpose was to demonstrate the courses and configurations of the anterior inferior cerebellar artery (AICA) or posterior inferior cerebellar artery (PICA) branch including the internal auditory artery in the CPA cistern and evaluate the relationship between the facial-vestibulocochlear (VIIth-VIIIth) nerves and AICA/PICA on high-resolution, thin-slice, three-dimensional T2-weighted MRI using driven equilibrium pulse. MATERIAL AND METHODS: Thirty-three men and 27 women aged 8-85 years old with sensory hearing loss or vertigo, and/or tinnitus were evaluated by thin-slice (0.75 mm) T2-weighted MRI. Five subjects (3 men, 2 women) without any auditory symptoms were also examined. RESULTS: Thin-slice T2WI drive MRI revealed several variations of the AICA/PICA coursing, such as a loop formation (n=30, 48 sides) or the IAC extension (n=19, 30 sides). Contact with the vestibulocochlear nerve was seen in 31.7% subjects (n=19, 27 sides). The AICA/PICA branching and shape patterns relative to the CPA and IAC were classified into four major types: type 1A, nonloop AICA/PICA in the CPA cistern; type 1 B, nonloop AICA/PICA (internal auditory artery) entering the IAC; type 2A, loop-type AICA/PICA in the CPA cistern; and type 2B, loop-type AICA/PICA entering the IAC. CONCLUSION: There was statistically significant association between types 1A and 2A (P<.01) regarding the existence of any auditory 3 symptoms. The results of our study suggest that this classification is simple and very useful for the elucidation of the mechanism of auditory symptoms and deciding the therapeutic strategies.

T2WI MRI and MRI-MDCT correlations of the osteoporotic vertebral compressive fractures.

PURPOSE: The purpose of this study was to present the various vertebral bone signal and configuration patterns on T2WI MRI in osteoporotic benign fractures. The appearances were also assessed with thin slice MPR CT images. MATERIALS AND METHODS: 66 patients (43 women, 23 men; age range, 34-97 years; mean age, 76 years) with 100 vertebral compression fractures due to osteoporosis were included in our study. All cases are acute or subacute phase fractures which occurred within 1 month. Multiple fractures were observed in 29 patients, in 8 cases multiple concurrent fractures were proved by past radiograph or MRI. Three planes of T2WI (sagittal, coronal, axial) section images were correlated with the corresponding MDCT images. RESULTS: In our retrospective study, various signals and forms of vertebral body fractures were observed. The fracture zone (line) was classified 3 signal intensity patterns. (high; n = 24, low to intermediate; n = 16, low intensity; n = 38) on T2WI. The signal of the peri(para) fractured area were high (n = 6), intermediate to low (n = 41), low (n = 53)intensity. With CT correlative study, high, low to intermediate area were considered to be corresponded to the bone marrow edema, fibrous reparative tissue with/without the bony callus formation. The localization were as follows: sub-end plate band like lesion in 53, central in 16, anterior in 13, sub-endplate+anterior in 10, and complete (diffuse) in 8. In 10 cases, adjacent Schmorl's nodules were observed. CONCLUSION: The various vertebral body signal patterns were observed in osteoporotic compressive fracture on T2WI. By MRI-CT correlations, high signal and low signal area on T2WI corresponded to the bone marrow edema, and the fibrous tissue or callus formation respectively.

Small cell lung carcinoma: Eight types of extension and spread on computed tomography.

OBJECTIVE: The aim of this study was to classify the types of tumor extension and spread of small cell lung carcinoma (SCLC) and to recognize the unusual types of spread pattern of SCLC on computed tomography (CT) including multidetector row CT (MDCT) using contrast-enhanced material. MATERIALS AND METHODS: Sixty-eight cases (53 men and 15 women aged 54-83 years old) of pathologically proven SCLC were examined mainly by contrast-enhanced CT scan. In surgically treated 7 cases, CT-pathologic correlations were performed. RESULTS: Eight types of extension and spread were recognized by the examinations of chest CT. The type of central mass + mediastinal extension (n = 20 [29.4%]) was the most common manifestation. The types of central perihilar mass (n = 12 [17.6%]), peripheral mass + mediastinal extension (n = 14 [20.6%]), and peripheral mass (n = 7 [10.3%]) were frequently observed. The primary site of SCLC was in peripheral lung tissue in 21 of 68 cases (30.9%) in this study. Unusual CT manifestations, such as the types of lymphangitic spread (n = 6 [8.8%]), pleural dissemination (n = 4 [5.9%]), lobar replacement (n = 3 [4.4%]), pneumonialike air-space infiltrative spread (n = 2 [2.9%]) were recognized in our study. Stenosis of trachea and main bronchus caused by peribronchial extension were commonly noted. In the advanced cases with mediastinal extension, we observed the extension of SCLC to superior vena cava (n = 22), main pulmonary artery (n = 18), pulmonary vein (n = 11), and thoracic aortic wall (n = 7). Peri-and intracardial invasions were also observed in 9 cases. CONCLUSIONS: Computed tomography including MDCT analysis revealed 8 types of extension and spread of SCLC including unusual forms in 68 SCLC cases. Peribronchial extension and great vessel wall involvement, such as superior vena cava, main pulmonary artery, and peri-/intra-cardial extension, were commonly observed in advanced stage.