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.

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.

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.

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.

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.

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.

Additional extrarenal abnormalities seen in Tc-99m DTPA renal flow study.

During 99mTc-DTPA renal flow studies, extrarenal abnormalities have been found to include aortic abnormalities (aneurysm, ectasia, thrombosis, and abruptly decreased flow), splenic abnormalities (enlarged, small, or absent spleen), hepatic arterialization, and very slow circulation. In addition to the above abnormal findings, we add three more extrarenal pathologies that may be concomitantly found with renal flow study: pleural effusion(s), malignancy of the abdomen, and anemia and/or skeletal metastases.

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.

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.

Extensive gastric varices demonstrated by technetium-99m red blood cell scintigraphy.

An alcohol abuse patient complicated by chronic pancreatitis had splenic vein thrombosis leading to gastric varices and underwent abdominal Tc-99m red blood cell scintigraphy. First pass study, sequential images up to 1 hour, and a 2.5 hour image showed abnormal radioactivity in the left side of the abdomen and midabdomen. In 24 hour images, the high level of activity in the left side persisted; in addition, there was accumulation of radioactivity in the cecum, ascending, transverse colon, the splenic flexure, and descending colon. A splenectomy was performed and during the surgical procedure, a large dilated vein in the greater omentum was noted. It is reemphasized that delayed imaging up to 24 hours is important when the results of earlier images are equivocal or negative.

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.

I-123 HIPDM planar brain images demonstrating crossed cerebellar diaschisis.

I-123 HIPDM or IMP brain planar images, as well as SPECT images, have been useful in the detection of large lesion(s) of the cerebral cortex. Planar imaging may be useful not only for cerebral lesions, but also for a cerebellar abnormality and in certain clinical situations, such as phobia to a gantry or being too heavy for the imaging table, when SPECT imaging cannot be performed. The authors concur that a large cerebral lesion can be detected by planar images; in addition, cerebellar lesions, such as the presence of crossed cerebellar diaschisis (CCD), may be detectable by planar imaging using I-123 HIPDM. This article presents a patient with a large cerebral infarct detected by planar imaging whose CCD has been demonstrated by planar images.

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.

I-123 hydroxyiodobenzyl propanediamine (HIPDM) cerebral blood flow imaging demonstrating transtentorial diaschisis.

To assess the clinical significance of transtentorial diaschisis (TTD) as demonstrated by I-123 HIPDM brain imaging, SPECT and/or planar images of 35 patients with stroke, 26 patients with Alzheimer's disease (AD), 2 patients with Creutzfeldt-Jakob disease (CJD), and 1 patient with a schizoaffective disorder were analyzed. TTD was observed in 21 of the 35 patients with strokes. In 13 stroke patients, TTD was associated with large infarcts in the middle cerebral artery (MCA) territory; in the remaining 8 stroke patients, TTD was associated with internal capsule and/or basal ganglia infarcts. TTD was not associated with small occipital or parietal infarcts. Despite cortical perfusion decrements, TTD was not seen in the AD patients, the CJD patients, or the patient with schizoaffective disorder. It is concluded that 1) TTD frequently occurs following cerebral infarct of the MCA territory (60% of the patients in this sample); 2) absence of TTD in the presence of a large cerebral perfusion abnormality may represent neuronal dysfunction of the cerebral cortex; and 3) the presence of TTD without a significant cortical perfusion abnormality may indicate basal ganglia and/or internal capsule infarct.