Phase I study of weekly oxaliplatin plus irinotecan in previously treated patients with metastatic colorectal cancer.

BACKGROUND: In vitro synergy between Oxal (oxaliplatin) and CPT-11 (irinotecan) has been reported. Oxaliplatin exerts its antineoplastic activity through the formation of platinum-DNA adducts. Resistance to oxaliplatin is through repair of these adducts, which is inhibited by irinotecan. PATIENTS AND METHODS: Oxaliplatin and irinotecan were administered weekly for 4 weeks followed by a 2-week rest period. The dose of oxaliplatin was escalated first, starting at 30 mg/m(2). Once a dose of 60 mg/m(2) was attained, the weekly dose of irinotecan was escalated, from 40 mg/m(2) to 85 mg/m(2). A total of 49 previously treated patients with metastatic colorectal cancer were entered in order to establish the maximum tolerated dose. Pharmacokinetics of oxaliplatin and irinotecan were analyzed. RESULTS: Forty-nine patients were evaluable for toxicity. The recommended phase II doses for this combination are oxaliplatin 60 mg/m(2) and irinotecan 50 mg/m(2), weekly x 4 q 6 weeks. Diarrhea was the most common dose-limiting toxicity. No pharmacological interactions were noted between oxaliplatin and irinotecan. Twelve of the 47 evaluable patients (26%) achieved a partial response. CONCLUSION: Weekly combination of oxaliplatin and irinotecan appears to be a well tolerated and active regimen in patients previously treated for metastatic colorectal cancer. Further investigations of this regimen are warranted.

Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT.

OBJECTIVE: We determined the pattern of spread of metastatic lobular carcinoma in the chest, abdomen, and pelvis on CT. MATERIALS AND METHODS: We identified 57 women (age range, 30-79 years; mean age, 57 years) with metastatic lobular carcinoma of the breast who underwent CT of the chest, abdomen, or pelvis between 1995 and 1998. Then two experienced oncology radiologists retrospectively reviewed 78 CT examinations of those patients to identify sites of metastatic disease and to identify complications caused by metastases. RESULTS: Metastases were identified in bone in 46 patients (81%), lymph nodes in 27 patients (47%), lung in 19 patients (33%), liver in 18 patients (32%), peritoneum in 17 patients (30%), colon in 15 patients (26%), pleura in 13 patients (23%), adnexa in 12 patients (21%), stomach in nine patients (16%), retroperitoneum in nine patients (16%), and small bowel in six patients (11%). Eighteen patients (32%) had gastrointestinal tract involvement that manifested as bowel wall thickening. Hydronephrosis was present in six patients (11%). CONCLUSION: Although lobular carcinoma metastasized to common metastatic sites of infiltrating ductal carcinoma, lobular carcinoma frequently metastasized to unusual sites, including the gastrointestinal tract, peritoneum, and adnexa. Gastrointestinal tract involvement was as frequent as liver involvement, appearing as bowel wall thickening on CT. Hydronephrosis was a complication of metastatic lobular carcinoma.

CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria.

OBJECTIVE: Patients with nonseminomatous germ cell cancer of the testis with no evidence of metastatic disease after orchiectomy may be managed with either retroperitoneal lymph node dissection or surveillance. The present retrospective study was undertaken to determine the accuracy of CT for revealing retroperitoneal lymph node metastases in patients with newly diagnosed clinical stage 1 testicular nonseminomatous germ cell cancer of the testis when smaller size criteria (smaller than 10 mm) are applied and to test the hypothesis that CT-revealed anterior retroperitoneal lymph nodes are more likely to correlate with metastases than are posterior lymph nodes. MATERIALS AND METHODS: Abdominal CT scans obtained before surgery in 70 patients were reviewed by three observers who were unaware of the results of retroperitoneal lymphadenectomy. The sizes and sites of all lymph nodes measuring larger than or equal to 4 mm were recorded. Each CT scan was judged as positive or negative for retroperitoneal metastasis on the basis of the size of the largest measured lymph node at the expected metastatic site. Diameters of 4, 6, 8, and 10 mm were successively applied to each case as the criteria for a positive scan. RESULTS: Using a criterion of 10 mm or larger for metastases, we calculated a sensitivity of 37% and a specificity of 100%; with a 4-mm criterion, the sensitivity was 93% and the specificity was 58%. Receiver operating characteristic curves comparing the accuracy of CT for revealing similar-sized lymph nodes located anterior or posterior to a line bisecting the aorta differed significantly (p = .04) when the same criteria were applied to lymph nodes in both regions. CONCLUSION: False-negative rates were decreased from 63% using a size criterion of 10 mm to as low as 7% using a size criterion of 4 mm, with a corresponding decrease in specificity. Lymph nodes measuring larger than or equal to 4 mm, especially those located anterior to the mid portion of the aorta, should raise a suspicion of metastases.

Hepatic lobar atrophy: association with ipsilateral portal vein obstruction.

OBJECTIVE: This study was performed to evaluate the association between hepatic lobar atrophy, bile duct obstruction, and portal vein obstruction. MATERIALS AND METHODS: Thirty cases of hepatic lobar atrophy identified on angiography with CT during arterial portography from August 1992 to March 1995 were retrospectively reviewed by two independent observers. Cases were evaluated for vascular patency and bile duct obstruction. Malignant diagnoses were present in 28 of 30 patients. RESULTS: Twenty-two patients (73%) had atrophy in the left lobe and eight patients (27%) had right lobar atrophy. Portal vein obstruction was unilateral and confined to the atrophic lobe in 26 patients (87%). In contrast, bile duct obstruction was bilateral in 23 patients (77%) and in only four patients (13%) was it isolated to the atrophic lobe. The correlation between atrophy and portal vein obstruction was significant, with 90% sensitivity, 97% specificity, and 96% positive predictive value (p < .00001). For the correlation between atrophy and biliary obstruction, the sensitivity of angiography with CT during arterial portography was 90%, specificity was 23%, and positive predictive value was 54% (p = .17). CONCLUSION: Hepatic lobar atrophy usually occurs in the setting of combined biliary and portal vein obstruction. A significant correlation exists between hepatic lobar atrophy and ipsilateral portal vein obstruction.

Massive hemothorax due to intrathoracic extramedullary hematopoiesis in a patient with thalassemia intermedia.

We report the case of a 49-year-old woman with thalassemia intermedia who developed a massive hemothorax due to hemorrhage from a large intrathoracic, paraspinal hematopoietic mass. Thoracotomy was required for initial control of bleeding. Postoperatively she received a total of 1,500 rads to the mass and has not had recurrence of the hemothorax. This complication of extramedullary hematopoiesis has not been previously reported, to our knowledge.

Ileal leiomyosarcoma and leiomyoma. False-positive scintiscans for Meckel's diverticulum.

Two cases of ileal leiomyomatous neoplasms with positive scintigraphic findings for Meckel's diverticulum are presented. The precise mechanism for the abnormal concentration of the Tc-99m pertechnetate is uncertain. Illustrations of the collating barium and computerized tomographic studies are included and the scanning technique utilized is reviewed.

Venous air embolization as a complication of pressure injection of contrast media: CT findings.

Pressurized contrast medium infusion for CT carries a risk of potentially fatal air embolization if improperly or carelessly administered. Two cases of intracardiac air embolization and three cases of subclavian venous air due to faulty contrast medium administration have been seen by the authors during a 2 year period.

Solid and papillary epithelial pancreatic neoplasm: an unusual tumor.

Solid and papillary epithelial neoplasms of the pancreas are uncommon. These grow to a large size, are often palpable, and occur most often in young black women. The tumors have a characteristic histologic appearance and a low malignant potential. Heavy tumor calcification is an unusual finding. Two cases with radiologic-pathologic correlation are presented herein.

Hyperphosphatasemia in an adult. Clinical, roentgenographic, and histomorphometric findings and comparison to classical Paget's disease.

A 54-year-old man with short stature, diffuse skeletal abnormalities, and elevated alkaline phosphatase was evaluated by bone biopsy with undecalcified sections and morphometry analysis. Microscopically the bone changes were identical to those of classic Paget's disease. Histomorphometric analysis of bone demonstrated a high remodeling activity with increased mineralization rate similar to Paget's disease. However, the early age at onset and severity suggest that this man suffers from hyperphosphatasemia, a different and distinct condition.

Hypothalamic-pituitary-adrenal (HPA) function in adrenocortical steroid treated minimal change nephrotic syndrome.

Seventeen children aged 1.5 to 15.6 years with minimal change nephrotic syndrome (MCNS) had hypothalamic-pituitary-adrenal (HPA) tests performed. The study consisted of baseline cortisol levels (8 a.m. and 4 p.m.), 6-hour ACTH stimulation tests and metyrapone tests. Ten patients were frequent relapsers (4 or more relapses per year) and 7 patients were infrequent relapsers (less than 4 relapses per year). All relapses were treated with daily prednisone 60 mg/m2 until the urine was protein-free for 3 days followed by prednisone 40 mg/m2 every other day for 28 days. All were tested no sooner than 1 week after alternate-day prednisone therapy was discontinued. The morning and afternoon cortisol levels of all frequent relapsers were abnormally low. The average a.m. and p.m. cortisol levels in the frequent relapsers were 2.6 +/- 0.08 and 1.4 +/- 0.4 microgram/dl respectively (normal a.m. value 10-20 microgram/dl, p.m. 50% a.m. value). In the frequent relapsers 9 out of 10 had a normal 6-hour ACTH test and 8 out of 9 had a normal response to metyrapone. In all infrequent relapsers the morning and afternoon cortisols were normal (mean a.m. 12.9 +/- 1.4 and p.m. 6.8 +/- 0.8 microgram/dl). Also, all infrequent relapsers had normal responses to ACTH and metyrapone. It is concluded that low baseline plasma cortisol levels are predictably present in frequent relapsers treated with prednisone.