High-dose intra-arterial cisplatin boost with hyperfractionated radiation therapy for advanced squamous cell carcinoma of the head and neck.

PURPOSE: To evaluate the tolerance and efficacy of intra-arterial (IA) cisplatin boost with hyperfractionated radiation therapy (HFX-RT) in patients with advanced squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS: Forty-two patients with locally advanced primary SCCHN were treated on consecutive phase I/II studies of HFX-RT (receiving a total of 76.8 to 81.6 Gy, given at 1.2 Gy bid) and IA cisplatin (150 mg/m(2) received at the start of and during RT boost treatment). RESULTS: Acute grade 3 to 4 toxicities were as follows: grade 4 and grade 3 mucosal toxicity occurred in three (7%) and 31 patients (69%), respectively, and grade 3 hematologic, infectious, and skin events occurred in one patient each. Eight of 24 patients (33%) were unable to receive a second planned dose of IA cisplatin because of general anxiety (n = 5), nausea and/or emesis (n = 2), or asymptomatic occlusion of an external carotid artery (n = 1). Thirty-seven patients (88%) experienced complete response (CR) at primary site. Twenty-nine (85%) of 34 patients presenting with nodal disease experienced CR. The actuarial 2-year rates of locoregional control and disease-specific and overall survival are 73%, 63%, and 57%, respectively, with a median active follow-up of 30 months. CONCLUSION: In this highly unfavorable subset of patients, these results seem superior to previously reported chemoradiation regimens in more favorable patients. Use of a second dose of IA cisplatin boost was associated with increased toxicity without obvious therapeutic gain. This novel strategy allows for an incremental increase in the treatment intensity of the HFX-RT regimen recently established as superior to once-a-day RT.

Spontaneous subcapsular and intrarenal hematoma demonstrated by various diagnostic modalities and monitored by ultrasonography until complete resolution.

A patient with acute right abdominal pain and nausea underwent various diagnostic imaging studies, including ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), technetium-99m DTPA renal study, and contrast arteriogram. The 99mTc renal study showed a linear photopenic area along the lateral cortical aspect of the right kidney and a focal cortical defect in the left kidney. These lesions corresponded to the findings of US, CT, MRI, and contrast angiography. Because of a suspected malignant mass, a CT-guided aspiration biopsy of the right kidney was performed that resulted in bloody fluid without malignant cells. The patient's condition was diagnosed as intrarenal and subcapsular renal hematoma. The patient was treated conservatively and followed up with CT and US studies. Sequential CT and US demonstrated gradual reduction of the size of the hematoma, and complete resolution was confirmed by US 1.5 years later. As long as underlying pathology can be ruled out, conservative management of spontaneous renal subcapsular hematoma is recommended.

High-dose intra-arterial cisplatin and concurrent hyperfractionated radiation therapy in patients with locally advanced primary squamous cell carcinoma of the head and neck: report of a phase II study.

BACKGROUND: This phase II study evaluates the tolerability and efficacy of concurrent hyperfractionated radiation therapy (HFX-RT) and high-dose intra-arterial (IA) cisplatin in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). METHODS: Between December 1995 and November 1997, 20 patients with locally advanced T4/T3 SCCHN were treated with HFX-RT (76.8-79.2 Gy at 1.2 Gy bid over 6-7 weeks) and high-dose IA cisplatin (150 mg/m(2) given at the start of RT boost treatment [start of week 6]). Seventeen patients (85%) had T4 disease, and 14 (70%) had N2/ N3 disease. RESULTS: Grade 3-5 acute toxicity was limited to one grade 4 (5%) and 14 grade 3 (70%) mucosal events. No grade 3/4 hematologic toxicity was observed. Median weight loss during therapy was 9% (range, 2%-16%). Eighteen patients had complete response (90%) at the primary site; 14 were confirmed pathologically. Among 17 patients with positive neck disease, 16 (94%) achieved complete response in the neck, including 12 of 13 patients with N2/N3 disease who underwent planned neck dissection. Active follow-up ranges from 12 to 32 months (median, 20 months) with 11 patients alive without disease, 5 dead of disease, and 4 dead of intercurrent disease. Eighteen patients (90%) remained disease free at the primary site, and the locoregional control rate is 80%. CONCLUSIONS: High-dose IA cisplatin and concurrent HFX-RT as used in this study is feasible and warrants further investigation. The high complete response rate and low grade 4 toxicity in this highly unfavorable subset of patients appears better than previously reported chemoradiation regimens for more favorable patients.

Demonstration of Achilles tendon rupture by three phase bone scintigraphy and MRI.

A man with complaint of soreness in the right medial ankle underwent three-phase bone scintigraphy; the results of the study suggested chronic active osteomyelitis or cellulitis, he was on antibiotics and was not experiencing any improvement. MR imaging confirmed Achilles tendon rupture. This case illustrates that a positive three-phase study is non-specific disease entity.

Myositis ossificans demonstrated by positive gallium-67 and technetium-99m-HMDP bone imaging but negative technetium-99m-MIBI imaging.

Gallium-67-citrate and 99mTc-diphosphate bone imaging agents are localized in myositis ossificans, a tumor-like benign soft-tissue mass that makes it impossible to differentiate between malignant tumor and the infection/inflammatory process. We present such a myositis ossificans patient whose bone and 67Ga-citrate imagings showed increased uptake in the left thigh and two foci of the right gluteal region leading to inconclusive results. Technetium-99m-MIBI imaging showed the absence of substantial uptake in these regions. ACT scan confirmed myositis ossificans. The lack of 99mTc-MIBI uptake in myositis ossificans means that 99mTc-MIBI imaging may be useful in the differential diagnosis.

Persistent lung uptake in the redistribution phase of Tl-201 chloride myocardial SPECTs--a sign of severe pulmonary edema: a case report.

Assessment of thallium (Tl)-201 chloride myocardial stress and rest single photon emission computed tomography (SPECT) includes left ventricular defects, left ventricular dilation, and pulmonary uptake. Lung uptake is associated with severe coronary artery disease or reflects transient left ventricular dysfunction and provides poor long-term prognosis. On redistribution imaging, lung activity should be absent or decreased relative to the myocardial activity. A patient with persistent Tl-201 uptake upon redistribution imaging due to lung edema secondary to congestive heart failure is reported. One should be aware that pulmonary edema/congestive heart failure can cause an increase in pulmonary uptake which persists in redistribution imaging.

Massive pulmonary embolism without symptoms demonstrated by radionuclide imaging with thromboemboli in both main pulmonary arteries.

Massive pulmonary embolism is defined as an anatomic obstruction of 50% or more of the pulmonary artery. A reduction of at least 50% of the cross-sectional area of the pulmonary artery causes significant hemodynamic instability and marked hypoxia exhibiting syncope, apprehension, hypotension, diaphoresis, chest pain, altered mental status, and shortness of breath. A patient, who had no definite clinical signs and symptoms, was demonstrated to have massive pulmonary embolism by extensive mismatched ventilation-perfusion defects scintigraphically and confirmed as thromboemboli in the main pulmonary arteries on a standard CT of the thorax. The lack of clinical manifestations of massive pulmonary embolism might be related to the insidious onset and progressive formation of thromboembolism. The patient gradually adapted to and/or compensated for hemodynamic changes.

A mural thrombus of an infrarenal aortic aneurysm demonstrated as photon deficiency in a radionuclide study.

Radionuclide angiogram (RNA) and aortogram may underestimate external aneurysmal diameter. Photon deficient areas are not uncommon along the abdominal aortic aneurysm (AAA) on RNA. To determine whether or not photon deficient areas along the aneurysm could represent a large thrombus, we studied radionuclide aortic angiography in thirty-eight patients during a preoperative cardiac gated study. All the patients (men, ages from 60 to 78) had CT, US, and/or aortogram for comparison. The presence of a thrombus was determined by CT, US, and/or surgical findings. Twelve of 38 (32%) patients' RNA and blood pool images showed photon deficient areas along the aneurysmal walls having a large concentric or eccentric thrombus of the AAA. A large photon deficient area could be detected along the narrowing calibre of the aorta lumen. This finding results from a large mural thrombus being interposed between the left or right bowel/mesentery activity and the activity of the aneurysms functioning patent lumen. We concluded that a photon deficient area along an inferorenal aortic aneurysm may indicate a large thrombus of either eccentric or concentric type within an AAA.

Medullary thyroid carcinoma imaged by Tc-99m MIBI SPECT and Tl-201 chloride/Tc-99m pertechnetate subtraction SPECT.

A 61-year-old man with medullary thyroid carcinoma and local invasion of the left lobe of the thyroid had Tc-99m MIBI SPECT and Tl-201 chloride/Tc-99m pertechnetate subtraction SPECT after left lobectomy of the thyroid, using a triple-headed gamma camera. Tl-201 chloride/Tc-99m pertechnetate subtraction demonstrated a large mass with high Tl-201 uptake in the left neck. Although there was intense uptake in the tumor in the left thyroid bed on Tc-99m MIBI neck SPECT, there was also uptake in both salivary glands and the right lobe of the thyroid gland. Thus, uptake in the right lobe of the thyroid gland and the salivary glands might not be differentiated from tumor invasion or metastasis from medullary cell carcinoma. Compared with MIBI SPECT, Tl-201 chloride/Tc-99m pertechnetate subtraction SPECT shows more apparent delineation of tumor uptake and may be a preferable technique.

Tc-99m MAA lung perfusion scintigraphy performed before and after pulmonary embolectomy for saddle-type pulmonary embolism.

A 58-year-old man had shortness of breath, hypotension, and decreased partial pressure of oxygen (PO2) on the eighteenth day after undergoing craniotomy for a meningioma. Tc-99m MAA pulmonary perfusion scintigraphy showed little perfusion to the right lung and left lower lung and multiple perfusion defects in the left upper lung. Although the results of concurrent chest radiography were negative for pulmonary infiltrates, pulmonary angiography demonstrated a saddle-type embolism. The patient underwent emergency pulmonary artery embolectomy to remove blood clots and organized thromboemboli from the main pulmonary artery and the right and left pulmonary arteries. The patient's postoperative course was uneventful, and a second Tc-99m MAA lung perfusion scan demonstrated marked improvement in lung perfusion.

Extracardiac 'hot' and 'cold' areas on thallium-201 myocardial SPECT imaging.

A 72-year-old man underwent Persantine 201Tl myocardial SPECT imaging that showed a transient area of extracardiac radiotracer accumulation inferior to the inferior wall of the left cardiac ventricle, and a persistent, rounded, cold area in the liver. CT of the abdomen confirmed a cystic lesion in the liver corresponding to the cold area, and the transient extracardiac tracer accumulation area corresponded to a large aneurysm of the distal descending thoracic aorta. An extracardiac abnormal area of 201Tl localization, 'hot' or 'cold', should be included for scan interpretation to depict thoracic and/or upper abdominal lesions(s).

Bile leak from gallbladder perforation mimicking bowel activity and a false-negative result in a morphine-augmented cholescintigraphy.

Cholescintigraphy of a patient with bile leak demonstrated intra-abdominal activity that mimicked normal bowel activity. Because the gallbladder was not visualized, morphine was injected intravenously. Gallbladder activity after morphine injection was misleading in the finding of chronic cholecystitis. Concurrent abdominal sonography and computerized tomography revealed a thickened gallbladder wall with a gallstone and pericholecystic fluid collection. Exploratory laparotomy confirmed acute and chronic cholecystitis, cholelithiasis, choledocholithiasis, and a pericholecystic abscess. The false-negative conclusion for acute cholecystitis in the patient's morphine-augmented cholescintigraphy resulted from an acceleration of bile leakage due to pre-existing gallbladder perforation.

Urinary extravasation from the kidney of recurrent renal cell carcinoma.

A man presented with recurrent renal cell carcinoma, complicated with acute pyelonephritis, 3 months status post partial nephrectomy. He underwent cystourethroscopy and a bilateral retrograde pyelogram, then was referred for a Tc-99m DTPA renal study; the images showed an initial photon-deficient area of the right kidney being gradually filled-in by radiotracer with further extension laterally, indicating urinary extravasation. 16 days later this area was aspirated, yielding 5 ml of yellowish fluid with clots consistent with necrotic tumor and pus.

Nuclear changes in cytologic specimens obtained by CT-guided fine needle aspiration biopsies.

A light and electron microscopic study was conducted to investigate nuclear changes observed in specimens obtained from various sites by computed tomographic (CT)-guided fine needle aspiration (FNA) biopsy. These changes, which consisted of a disappearance of the nuclear chromatin and a disruption of the nuclear membrane, were found in 70% of 10 FNA specimens obtained with CT guidance, in 26% of 15 specimens obtained with fluoroscopic guidance and in 0% of 10 specimens obtained without x-ray imaging techniques. Although the number of cases studied was small and the mechanisms responsible for these changes are not clear, cytopathologists should be aware of alterations in evaluating FNA specimens obtained with the guidance of x-ray imaging techniques.