Early Radiation-Induced Sarcoma in an Adolescent Treated for Relapsed Hodgkin Lymphoma with Nivolumab.

Radiation-induced sarcoma (RIS) has been reported as a late secondary malignancy following radiotherapy for various types of cancer with a median latency of 10 years. We describe an early RIS that developed in an adolescent within three years of treatment (including PD-L1 check-point inhibitor Nivolumab) of a relapsed classic Hodgkin lymphoma (HL) and was diagnosed post-mortem. The patient died of the progressive RIS that was misleadingly assumed to be a resistant HL based on the positive PET/CT scan. Repetitive tumor biopsies are warranted in cases of aggressive and multi-drug resistant HL to validate imaging findings, ensure correct diagnosis and avoid overtreatment.

Impact of the 2014 International Society of Urological Pathology Grading System on Concept of High-Risk Prostate Cancer: Comparison of Long-Term Oncological Outcomes in Patients Undergoing Radical Prostatectomy.

Objective: To investigate the relationship between the new International Society of Urological Pathology (ISUP) grading system, biochemical recurrence (BCR), clinical progression (CP) and cancer related death (CRD) after open radical prostatectomy (RP) and determine whether the 2014 ISUP grading system influences the concept of high-risk prostate cancer (HRPCa). Patients and Methods: A total of 1,754 men who underwent RP from 2005 to 2017 were identified from a database at a single tertiary institution. Histopathology reports were reassessed according to the 2014 ISUP grading system. All preoperative, pathological, and clinical follow-up data were obtained. Univariable and multivariable Cox regression, Kaplan-Meier and log-rank analyses were performed. Results: At a median (quartiles) follow-up of 83 (48-123) months, 446 men (25.4%) had BCR, 77 (4.4%) had CP and 39 (2.2%) died from cancer. Grade groups 1, 2, 3, 4, and 5 were detected in 404 (23%), 931 (53.1%), 200 (11.4%), 93 (5.3%), and 126 (7.2%), respectively. 10-year biochemical progression free survival difference between Grade group 3 and 4 was minor but significant (log-rank p = 0.045). There was no difference between Grade groups 3 and 4 comparing 10-year clinical progression free and 10-year cancer specific survival: p = 0.82 and p = 0.39, respectively. Group 5 had the worst survival rates in comparison with other groups (from p < 0.005 to p < 0.0001) in all survival analyses. Pathological stage (hazard ratio (HR) 2.6, p < 0.001), positive surgical margins (HR 2.2, p < 0.0001) and Grade group (HR 10.4, p < 0.0001) were independent predictors for BCR. Stage and Grade group were detected as independent predictors for CP-HR 6.0, p < 0.0001 and HR 35.6, p < 0.0001, respectively. Only Grade group 5 (HR 12.9, p = 0.001) and pT3b (HR 5.9, p = 0.001) independently predicted CRD. Conclusions: The new ISUP 2014 grading system is the most significant independent predictor for BCR, CP, and CRD. Grade group 3 and 4 had similar long-term disease progression survival rates and could potentially be stratified in the same risk group. High-risk cancer associated only with group 5.

Use of 18F-FDG PET/CT Imaging for Radiotherapy Target Volume Delineation after Induction Chemotherapy and for Prognosis of Locally Advanced Squamous Cell Carcinoma of the Head and Neck.

Background and objectives: Induction chemotherapy (ICT) before definitive chemoradiation (CRT) gives high response rates in locally advanced squamous cell carcinoma of the head and neck (LA-SCCHN). However, pre-ICT gross tumor volume (GTV) for radiotherapy (RT) planning is still recommended. As 18F-FDG PET/CT has an advantage of biological tumor information comparing to standard imaging methods, we aimed to evaluate the feasibility of 18F-FDG PET/CT-based post-ICT GTV delineation for RT planning in LA-SCCHN and to assess the prognostic value of PET parameters: maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG). Methods: 47 LA-SCCHN patients were treated with 3 cycles of ICT (docetaxel, cisplatin, and 5-fluorouracil) followed by CRT (70 Gy in 35 fractions with weekly cisplatin). Pre- and post-ICT PET/CT examinations were acquired. Planning CT was co-registered with post-ICT PET/CT and RT target volumes were contoured according to post-ICT PET. Post-ICT percentage decrease of SUVmax, MTV and TLG in primary tumor and metastatic regional lymphnodes (LN) was counted. Loco-regional failure patterns, 3-year progression free (PFS) and overall survival (OS) were evaluated. Results: 3-year PFS and OS rates for study population were 67% and 61% respectively. 31.9% of patients progressed loco-regionally. All progress was localized in high-to-intermediate dose (60⁻70 Gy) RT volumes and none in low dose (50 Gy) volumes. Decrease of SUVmax ≥ 74% (p = 0.04), MTV ≥ 68% (p = 0.03), TLG ≥ 76% (p = 0.03) in primary tumor, and LN TLG decrease ≥ 74% (p = 0.03) were associated with PFS. Decrease of primary tumor SUVmax ≥ 74% (p = 0.04), MTV ≥ 69% (p = 0.03), TLG ≥ 74% (p = 0.02) and LN TLG ≥ 73% (p = 0.02) were prognostic factors for OS. Conclusions: According to our results, 18F-FDG PET/CT-based post-ICT GTV delineation is feasible strategy without negative impacts on loco-regional control and survival. Percentage decrease of metabolic PET parameters SUVmax, MTV and TLG has a prognostic value in LA-SCCHN.

Prognostic value of myocardial perfusion abnormalities for long-term prognosis in patients after coronary artery bypass grafting.

AIMS: The objective was to evaluate the prognostic value of exercise myocardial perfusion scintigraphy (MPS) in patients who underwent coronary artery bypass grafting (CABG). SUBJECTS AND METHODS: A retrospective, one-center study of 361 patients with multivessel coronary artery disease was carried out. All the patients underwent MPS after CABG due to worsened health status. MPS was performed at 4.5 years standard deviation (SD: 0.2), based on symptoms. MPS was carried out using Tc-99m methoxy isobutyl isonitrile and following a 1-day protocol (stress-rest). The end points were analyzed at 6.5 years (SD: 3.3) after MPS, on the average. STATISTICAL ANALYSIS USED: SPSS software for Windows, version 13.0. The t-test or the χ(2)-test was used. Survival times were calculated. A multivariate Cox proportional hazards model was developed. RESULTS: During the follow-up, death occurred in 54 patients, and 37 patients experienced major adverse cardiovascular events (MACE). In the multivariate analysis, advanced age hazard ratio (HR: 1.45; 95% confidence interval [CI]: 1.4-2.02; P = 0.027), previous myocardial infarction (HR: 3.17; 95% CI: 1.22-8.2; P = 0.018), left ventricular ejection fraction of <40% (HR: 2.16; 95% CI: 1.2-3.89; P = 0.01), and the summed stress score (SSS) of ≥4 (HR: 1.87; 95% CI: 1.02-3.41; P = 0.04) were independent predictors of all-cause death. The summed difference score (SDS) was the only independent predictor of MACE (HR: 1.26; 95% CI: 1.06-1.48; P = 0.034). CONCLUSIONS: The parameters of MPS were found to have prognostic value in the long-term period after CABG. Advanced age, previous myocardial infarction, decreased left ventricular ejection fraction, and the abnormal SSS were associated with an increased risk of all-cause death. The SDS was found to be the only significant risk factor for MACE.

Rare refractory Kawasaki disease in an adolescent boy with cardiac and diffuse coronary artery involvement.

Kawasaki disease is an acute multisystemic vasculitis occurring predominantly in infants and young children and rarely in adolescents and adults. At elderly age, Kawasaki disease may remain unrecognized with a subsequent delay in appropriate therapy and an increased risk of coronary artery aneurysms. We report a case of intravenous immunoglobulin- and aspirin-resistant Kawasaki disease and severe cardiovascular damage in an adolescent boy. The article discusses major issues associated with the management of refractory Kawasaki disease.

Perioperative single photon emission computed tomography in predicting survival of malignant glioma patients.

Single photon emission computed tomography (SPECT) is widely used in the evaluation of glioma patients and has been demonstrated to correlate with glioma malignancy and proliferation indexes. The aim of this study was to evaluate the association between perioperative technetium-99m-methoxyisobutylisonitrile ((99m)Tc-MIBI) uptake on SPECT scans and survival of malignant glioma patients. A total of 17 patients (11 males and 6 women; mean age, 62.2±8.4 years) with histologically confirmed malignant gliomas (16 glioblastoma multiforme and 1 gliosarcoma) underwent (99m)Tc-MIBI SPECT scans 2.8±1.9 days before surgery and 9.8±1.5 days after surgery. The total intensity index (TII) that corresponds to the area and intensity of tracer uptake was calculated before and after surgery. In addition, the change of TII before versus after surgery (Δ TII) was calculated. The overall survival (OS) was defined as the period between the date of surgery and the date of death. The median overall survival time was 12.4 months, ranging from 1.4 to 88 months; there were nine (45%) 12-month survivors. In univariate analyses using a log-rank test, worse OS was significantly associated with higher preoperative TII (≥12), higher postoperative TII (≥6), lower Δ TII (<50%) and higher number of neurological symptoms prior to surgery (≥4). In multivariate analyses, higher postoperative TII, a greater number of neurological symptoms and female gender were found to be factors with independent prognostic value of OS. Patients who survived more than 12 months following surgery had a significantly lower postoperative TII, higher Δ TII and greater rate of gross total resection compared to patients who survived less than 12 months following surgery. Higher peri-operative tracer uptake and lower decrease of tracer uptake following surgery (suggesting less radical resection) were associated with worse OS of malignant glioma patients. Our results suggest that SPECT may be used to predict survival of malignant glioma patients; however, further studies using larger samples are required.

Introduction of novel semiquantitative evaluation of (99m)Tc-MIBI SPECT before and after treatment of glioma.

BACKGROUND AND OBJECTIVE. There is a need for objective semiquantitative indexes for the evaluation of results of single-photon emission tomography (SPECT) in patients with brain glioma. The aim of this study was to validate the total size index (TSI) and total intensity index (TII) based on technetium-99m-methoxyisobutylisonitrile ((99m)Tc-MIBI) SPECT scans to discriminate the patients with high-grade glioma versus low-grade glioma and to evaluate the changes of viable glioma tissue by the means of TSI and TII after surgery and after radiation treatment. MATERIAL AND METHODS. Thirty-two patients (mean age, 55 years [SD, 18]; 20 men) underwent a (99m)Tc-MIBI-SPECT scan before surgery. Of these patients, 27 underwent a postoperative (99m)Tc-MIBI-SPECT scan and 7 patients with grade IV glioma underwent a third (99m)Tc-MIBI-SPECT scan after radiation treatment. TII that corresponds to the area and intensity of tracer uptake and TSI that corresponds to the area of tracer uptake were calculated before surgery, after surgery, and after radiation treatment. RESULTS. The TII and TSI were found to be valid in discriminating the patients with high-grade versus low-grade glioma with optimal cutoff values of 3.0 and 2.5, respectively. Glioma grade correlated with the preoperative TSI score (r=0.76, P<0.001) and preoperative TII score (r=0.64, P<0.001). There was a significant decrease in the TII and TSI after surgery in patients with grade IV glioma. After radiation treatment, there was a significant increase in the TII in patients with grade IV glioma. CONCLUSIONS. TSI and TII were found to be reliable in discriminating the patients with high-grade versus low-grade glioma and allowed for the semiquantitative evaluation of change in viable glioma tissue after surgery and after radiation treatment in patients with grade IV glioma.

Comparative diagnostic value of contrast-enhanced ultrasonography, computed tomography, and magnetic resonance imaging in diagnosis of hepatic hemangiomas.

AIM: To compare the value of intravenous contrast-enhanced ultrasonography (US), intravenous contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis of hepatic hemangiomas. MATERIAL AND METHODS: The study enrolled 48 patients, aged between 20 and 79 years (35 [72.9%] women, 13 [27.1%] men; mean age, 53.5+/-12.855 years), who were examined and treated in the Departments of Gastroenterology, Surgery, and Oncology, Hospital of Kaunas University of Medicine, in the year 2007. All patients underwent intravenous contrast-enhanced US, intravenous contrast-enhanced CT, and MRI and were diagnosed with hepatic hemangioma according to the findings of these examinations. RESULTS: The size of hemangiomas was < or =2.0 cm in 20 cases (41.7%) and >2.0 cm in 28 (58.3%). No association between hepatic hemangioma and patient's age was found (chi(2)=0.547, df=2, P=0.761). Nearly one-third of hemangiomas were located in the segment IV of the left hepatic lobe. There were a few complicated hemangiomas in the study sample: 2 with calcification and 1 with necrosis. The sensitivity of CT in the diagnosis of hepatic hemangioma was 76.92%; specificity, 33.3%; positive prognostic value, 83.3%; and negative prognostic value, 25.0%. The sensitivity of intravenous contrast-enhanced US in the diagnosis of hepatic hemangioma was 77.8%; specificity, 100%; positive prognostic value, 100%; and negative prognostic value, 23.1%. CONCLUSIONS: Intravenous contrast-enhanced US is more specific than intravenous contrast-enhanced CT in the diagnosis of hepatic hemangioma (P=0.0005) and has a higher positive prognostic value (P=0.001).

[Data of coronary angiography and normal stress myocardial perfusion scintigraphy]. / Normali kruvio miokardo perfuzija ir vainikiniu arteriju bukle.

OBJECTIVE: To determine informativity of clinical variables in predicting significant coronary artery disease in patients with chest pain and normal stress myocardial perfusion scintigraphy. MATERIAL AND METHODS: This study was a retrospective analysis of data of coronary angiography performed in 84 patients with chest pain and normal stress myocardial perfusion scintigraphy during 2000-2007. Single-photon emission computed tomography was performed following a one-day protocol (stress-rest). A 5-point (0-4) scoring system in a 20-segment model was used for interpretation of results. Myocardial perfusion was considered normal if the sum of stress scores was 0 to 3. RESULTS: High pretest probability and informative exercise-terminating criteria were documented in 25% and 45.2% of patients, respectively. Significant coronary artery disease (stenosis ≥ 75%) was determined in 26 (31%) patients with normal myocardial perfusion scintigraphy: 15 (17.9%) patients had coronary artery disease of a single vessel, 5 (6%) of two vessels, and 6 (7.1%) of three vessels. Univariate logistic regression analysis showed that patients with typical angina and high pretest probability were more likely to have significant stenosis of one to three arteries (odds ratios, 3.8; P=0.008 and 3.43; P=0.023, respectively). Three-vessel disease was more often documented in patients with typical angina (odds ratio, 11.2; P=0.009), high pretest probability (odds ratio, 7.93; P=0.018), and signs of ischemia during exercise test (odds ratio, 6.4; P=0.037). CONCLUSION: Patients with typical angina, high pretest probability, and signs of ischemia during exercise test have an increased probability of having significant coronary artery disease despite normal stress myocardial perfusion scintigraphy; therefore, this group of patients should undergo coronary angiography.

[Comparison of serum prostate specific antigen levels and bone scintigraphy in patients with prostate carcinoma]. / Serganciuju prostatos veziu kaulu scintigrafijos ir prostatos specifinio antigeno duomenu palyginimas.

The aim of this study was to analyze the levels of serum prostate specific antigen in patients with and without bone metastases detected by means of bone scintigraphy and to determine the highest prostate specific antigen level in patients without bone metastases. The 50 patients consecutively diagnosed of prostate cancer between 1999 and 2001 in our institution made up the study population. Prostate specific antigen plasmatic levels were determined and bone scintigraphy was performed (whole body study after 99mTc-methyl-diphosphonate administration) in all the patients. In patients with positive bone scans (n=23), the mean prostate specific antigen level was 71.4+/-35.2 ng/ml and was significantly (p<0.00005) higher than in 14 patients with negative bone scans (mean prostate specific antigen level was 10.1+/-10.5 ng/ml). Suspicious lesions were found in 13 patients and their mean prostate specific antigen level was 8.5+/-7.7 ng/ml. Regarding prostate specific antigen levels, no statistically significant differences were found between patients with suspicious lessons and normal bone scans. The highest determined prostate specific antigen level in patients without bone metastases was 18 ng/ml. The bone scintigraphy should be performed in all patients with prostate specific antigen level above 18 ng/ml, but it is of limited value in patients with prostate specific antigen level below 18 ng/ml.

[Scintigraphy of lymphomatous masses using 99mTc-MIBI]. / Limfominiu masiu scintigrafija naudojant 99m Tc-MIBI.

Tc 99m sestamibi imaging is used in nuclear oncology, cardiology, but its role in detecting lymphomas has not been widely investigated. During 1998-2001 at the Department of Nuclear medicine, Kaunas University Hospital 68 patients with lymphomas (50 patients with Hodgkins disease (HD), 18 with non-Hodgkins (NHL)) underwent Tc 99m MIBI whole-body imaging. Of the 47 lymphoma lesions showed abnormal MIBI uptake. The accuracy of MIBI scintigraphy in patients with Hodgkins disease was lower (78%) compared to that of patients with non-Hodgkins lymphomas (94%). However, this difference was not related to tumor type, but to lesion size. Tumor size was significantly (p = 0.01) higher in lesions NHL with increased MIBI uptake (3.9 +/- 2.5 cm) compared with those with no uptake (1.5 +/- 0.5 cm).

[Evaluation of lung perfusion scintigraphy without ventilation scintigraphy in the diagnosis of pulmonary thromboembolism]. / Perfuziniu plauciu scintigramu vertinimas be ventiliacines scintigrafijos esant plauciu arterijos tromboembolijai.

The role of perfusion lung scintigraphy in the diagnosis of pulmonary embolism (PE) is reviewed. During the study 227 perfusion lung scans were obtained. The scans were grouped according to the PIOPED criteria into 5 groups: normal scans, very low, low, intermediate and high PE probability. The perfusion scans were analyzed according to the original PIOPED criteria, without ventilation scans. Evidence is provided that a normal perfusion scan excludes pulmonary embolism, and that a high probability lung scan, defined as a segmental perfusion defect with locally normal chest X-ray or findings in X-ray are smaller, sufficiently confirms the presence of pulmonary embolism in the majority of these patients (92.2%).