A novel functional infrared imaging system coupled with multiparametric computerised analysis for risk assessment of breast cancer.

OBJECTIVE: We evaluated a functional three-dimensional (3D) infrared imaging system (3DIRI) coupled with multiparametric computer analysis for risk assessment of breast cancer. The technique provides objective risk assessment for the presence of a malignant tumour based on automated parameters derived from a clinically known training set. METHODS: Following institutional review board approval, we recruited 434 women for this prospective multicentre trial, including 256 healthy woman undergoing routine screening mammography with BI-RADS-1 results and 178 women with newly diagnosed breast cancer. This was a two-phase study: an initial training and calibration phase, followed by a two-armed blinded evaluation phase (52 healthy and 66 with breast cancer). 3DIRI data sets were acquired using a non-contact, no radiation system. RESULTS: The sensitivity and specificity of functional infrared imaging in providing the correct risk for the presence of breast cancer were 90.9 % and 72.5 %, respectively. The area under the ROC curve was 86 %. Forty-two of the 60 (70 %) cancers in women correctly classified by the system as suspicious were smaller than 20 mm in size. CONCLUSION: The preliminary blinded results of this novel technology show sufficient performance of functional infrared imaging in providing risk assessment for breast cancer to warrant further clinical studies. KEY POINTS: • 3D functional infrared imaging (3DIRI) provides new metabolic signatures from breast lesions. • 3DIRI offers high sensitivity for risk assessment of breast cancer. • It also has reasonable specificity. • This initial experience warrants further evaluation in larger clinical trials.

JOURNAL CLUB: Is screening MRI indicated for women with a personal history of breast cancer? Analysis based on biopsy results.

OBJECTIVE: American College of Radiology and Society of Breast Imaging guidelines call for routine breast MRI screening only for women with the highest risk profiles for development of breast cancer, suggesting that screening of women at lower risk might result in an increased frequency of false-positive biopsy results. The purpose of this study was to test this assumption by comparing MRI-guided biopsy outcomes of lesions detected at MRI screening of women with a personal history of breast cancer with outcomes among women with genetic or familial high risk. MATERIALS AND METHODS: Outcomes of 130 MRI-guided biopsies were analyzed. One group consisted of women with hereditary (genetic or familial) risk, and the other group consisted of women with a personal history of breast cancer. Biopsies were performed with a 9-gauge vacuum-assisted device or surgically after MRI localization. RESULTS: Of 130 MRI-guided biopsies, 20 (15%) yielded malignant histologic findings, 14 (11%) yielded high-risk lesions, and 96 (74%) had benign findings. There was a slightly higher malignancy rate for the personal-risk group (19%) compared with the hereditary-risk group (13.5%). There also was a slightly higher combined rate of malignancy and high-risk lesions (34% vs 22%) with no statistically significant difference (p < 0.25, p < 0.12). Patients in the hereditary-risk group were younger (44 ± 1.2 vs 54 ± 1.7 years; p < 0.001) than those in the personal-risk group. CONCLUSION: Our preliminary data show no difference between the two risk groups with respect to probability of an MRI-guided biopsy result of malignancy, calling into question the proposed assumption. Further prospective studies of the role of MRI screening combined with MRI-guided biopsy when required for patients with previously treated localized breast cancer may be indicated.

Algorithm optimization for multitined radiofrequency ablation: comparative study in ex vivo and in vivo bovine liver.

PURPOSE: To prospectively optimize multistep algorithms for largest available multitined radiofrequency (RF) electrode system in ex vivo and in vivo tissues, to determine best energy parameters to achieve large predictable target sizes of coagulation, and to compare these algorithms with manufacturer's recommended algorithms. MATERIALS AND METHODS: Institutional animal care and use committee approval was obtained for the in vivo portion of this study. Ablation (n = 473) was performed in ex vivo bovine liver; final tine extension was 5-7 cm. Variables in stepped-deployment RF algorithm were interrogated and included initial current ramping to 105 degrees C (1 degrees C/0.5-5.0 sec), the number of sequential tine extensions (2-7 cm), and duration of application (4-12 minutes) for final two to three tine extensions. Optimal parameters to achieve 5-7 cm of coagulation were compared with recommended algorithms. Optimal settings for 5- and 6-cm final tine extensions were confirmed in in vivo perfused bovine liver (n = 14). Multivariate analysis of variance and/or paired t tests were used. RESULTS: Mean RF ablation zones of 5.1 cm +/- 0.2 (standard deviation), 6.3 cm +/- 0.4, and 7 cm +/- 0.3 were achieved with 5-, 6-, and 7-cm final tine extensions in a mean of 19.5 min +/- 0.5, 27.9 min +/- 6, and 37.1 min +/- 2.3, respectively, at optimal settings. With these algorithms, size of ablation at 6- and 7-cm tine extension significantly increased from mean of 5.4 cm +/- 0.4 and 6.1 cm +/- 0.6 (manufacturer's algorithms) (P <.05, both comparisons); two recommended tine extensions were eliminated. In vivo confirmation produced mean diameter in specified time: 5.5 cm +/- 0.4 in 18.5 min +/- 0.5 (5-cm extensions) and 5.7 cm +/- 0.2 in 21.2 min +/- 0.6 (6-cm extensions). CONCLUSION: Large zones of coagulation of 5-7 cm can be created with optimized RF algorithms that help reduce number of tine extensions compared with manufacturer's recommendations. Such algorithms are likely to facilitate the utility of these devices for RF ablation of focal tumors in clinical practice.

Magnetic resonance-guided interventional procedures of the breast: initial experience.

BACKGROUND: Magnetic resonance imaging of the breast has emerged as a valuable imaging tool in addition to conventional imaging modalities. It has high sensitivity for malignant lesions and can detect mammographically, sonographically and clinically occult cancers. "MR only" lesions are best biopsied under MR guidance; however, this may be a challenging task. OBJECTIVES: To evaluate our initial clinical experience with MR-guided core needle breast biopsy and MR-guided needle localization. METHODS: We retrospectively evaluated 81 women with 97 lesions, who were scheduled for guided core needle biopsy or MR-guided needle localization followed by surgery. Lesions were categorized as malignant, high risk, or benign according to the BI-RADS MR classification system. MR findings were compared with final histopathology or with follow-up imaging findings. RESULTS: Fifteen (16%) lesions were malignant (9 invasive ductal carcinoma, 2 invasive lobular carcinoma, 4 ductal carcinoma in situ); 7 (7%) lesions were high risk (4 atypical ductal hyperplasia, 3 radial scars); 75 (77%) lesions were benign, mainly fibrocystic changes. Other benign findings were sclerosing adenosis, pseudoangiomatous stromal hyperplasia, fat necrosis, intraductal papilloma, fibroadenoma, capillary hemangioma, and florid ductal hyperplasia. No major complications were encountered. CONCLUSIONS: MR-guided interventional procedures of the breast are accurate, safe and feasible methods for sampling breast lesions detected only by MR and have become a significant tool in the management of certain patients.

CT colonography: positioning order and intracolonic pressure.

OBJECTIVE: The purpose of this study was to prospectively evaluate the effect of the order of positions on sustained rectal pressure and factors affecting pain perceived by patients during air-insufflated CT colonography. SUBJECTS AND METHODS: Rectal pressure was measured in the supine and prone positions for CT colonography of 379 patients in two groups. One hundred seventy-seven patients underwent imaging supine and then prone, and 202 patients were prone and then supine. Insufflation and patient pain parameters were based on patient self-report and investigator visualization of observable indicators. Colonic distention, residual feces or fluid, and diverticulosis were evaluated with a semiquantitative scoring system. Fisher's exact, Student's t, and chi-square tests as well as multivariate logistic regression analysis were performed. RESULTS: Pressure was higher in the prone than in the supine position in both groups (p < 0.001). The measured pressure in the initial position did not differ between groups (p = 0.88). Pressure increased from 38.3 to 40.07 mm Hg in the second position in the supine-first group and decreased from 38.3 to 32.25 mm Hg in the second position in the prone-first group (p < 0.001). The percentage of patients with pain in the second position was 40% in the supine-first group compared with 18% in the prone-first group (p < 0.003). Distention did not differ between the groups. Pain was associated with increased pressure and diverticulosis (p < 0.001) but not with retained feces or fluid. CONCLUSION: Sustained pressure in the air-insufflated colon was higher in the prone than in the supine position. Imaging in the prone position first results in a significant decrease in pressure in the latter phase and less pain. Pain was associated with pressure and diverticulosis.

Incidence and management of complex fibroadenomas.

OBJECTIVE: Complex fibroadenomas are a fibroadenoma subtype harboring one or more complex features. We sought to evaluate the incidence of complex fibroadenoma on biopsy and to propose decision criteria for managing patients with these breast lesions. MATERIALS AND METHODS: Complex fibroadenomas were diagnosed in 63 of 401 fibroadenomas (15.7%) found at consecutive percutaneous needle or excisional surgical biopsy. We evaluated the clinical and imaging presentations of complex fibroadenomas; compared pathology at core and excisional biopsy; and contrasted age, pathology, and size of complex and simple fibroadenomas using the Student's t test. RESULTS: Patients with complex lesions were 18.5 years older (median age, 47 years; range, 21-69 years) than patients with noncomplex fibroadenomas (median age, 28.5 years; range, 12-86 years) (p < 0.001). Complex fibroadenomas were half the size (average, 1.3 cm; range, 0.5-2.6 cm) of noncomplex fibroadenomas (average, 2.5 cm; range, 0.5-7.5 cm) (p < 0.001). Only one malignancy, an invasive lobular carcinoma, was found in 63 complex fibroadenomas (1.6%). This patient had atypical lobular hyperplasia at core needle biopsy. CONCLUSION: Approximately 16% of fibroadenomas are complex. Complex fibroadenomas are smaller and appear at an older age. At a mean follow-up of 2 years, we found a low incidence of malignancy in complex fibroadenomas. Women with complex fibroadenomas may therefore be managed with a conservative approach, similar to the approach now recommended for women with simple fibroadenomas.

Critical analysis of the performance of double-contrast barium enema for detecting colorectal polyps > or = 6 mm in the era of CT colonography.

OBJECTIVE: The purpose of our study was to perform a meta-analysis comparing the performance of double-contrast barium enema (DCBE) with CT colonography (CTC) for the detection of colorectal polyps > or = 6 mm using endoscopy as the gold standard. MATERIALS AND METHODS: Prospective DCBE and CTC studies were identified. Percentages of polyps and of patients with polyps > or = 10 mm and 6-9 mm were abstracted. The performance of DCBE versus CTC was determined by separately evaluating each technique's performance versus that of endoscopy, and contrasting the techniques. The I-squared statistic and Fisher's exact test were used for heterogeneity, the Cochran-Mantel-Haenszel and the Kruskal-Wallis tests for correlation, and the A(z) test for comparing pooled weighted estimates of performance. RESULTS: Eleven studies of DCBE (5,995 patients, 1,548 polyps) and 30 studies of CTC (6,573 patients, 2,348 polyps) fulfilled inclusion criteria. For polyps > or = 10 mm, a 0.121-per-patient sensitivity difference favored CTC (p < 0.0001; DCBE, 0.702 [95% CI, 0.687-0.715]; CTC, 0.823 [0.809-0.836]). For polyps > or = 10 mm, a 0.031-per-polyp sensitivity difference favored CTC (p < 0.0001; DCBE, 0.715 [0.703-0.726]; CTC, 0.746 [0.735-0.757]). For polyps > or = 10 mm, a specificity difference of 0.104 favored CTC (p = 0.001; DCBE, 0.850 [0.847-0.855]; CTC, 0.954 [0.952-0.955]). DCBE was also significantly less sensitive for 6- to 9-mm polyps (p < 0.001). CONCLUSION: DCBE has statistically lower sensitivity and specificity than CTC for detecting colorectal polyps > or = 6 mm.

Percutaneous image-guided splenic procedures: update on indications, technique, complications, and outcomes.

Percutaneous image-guided splenic procedures are seldom performed due to fear of complications, mainly hemorrhage. Percutaneous splenic invasive procedures are, however, safe, and in most cases, the complication rates are similar to those of other abdominal organs. In most patients, biopsy of a focal splenic lesion establishes the diagnosis. Aspiration and drainage of splenic collections are performed obviating the need for splenectomy. In this review we describe the indications, technique, complications, and outcomes of percutaneous splenic biopsy, aspiration, and drainage.

Computed tomography screening for lung cancer: applicability of an international protocol in a single-institution environment.

BACKGROUND: The purpose of this study was to assess the applicability of an annual low-dose computed tomography (CT) screening program for lung cancer in a single institution in Israel, which has a relatively lower prevalence of lung cancer compared with other Western countries, and to examine stage distribution of detected lung cancers. PATIENTS AND METHODS: A cohort of 842 former and current smokers underwent baseline low-dose CT screening and a total of 942 annual repeat screenings over a period of 68 months. The definition of positive results on baseline and repeat screening and their diagnostic workup were guided by the common International Early Lung Cancer Action Program protocol. Recommendations for biopsy of suspicious nodules were based on nodule size, nodule growth, non-resolution following antibiotic therapy, and positron emission tomography scan. RESULTS: The test result was positive in 102 of the 842 baseline screenings (12%) and in 45 of the 942 annual repeat screenings (5%), and biopsy was recommended in 12 baseline and 2 annual screenings. Twelve of the 14 cancers diagnosed (86%) were stage I tumors. CONCLUSION: Our study indicates that the adoption of a common international protocol is feasible, even in a very different clinical setting, yielding a high proportion of early-stage lung cancers.

Perforation of the colon and rectum--a newly recognized complication of CT colonography.

CT colonography (CTC) and conventional colonoscopy may have similar efficacy for detection of polyps > 6 mm. Perforation of the colon and rectum is a relatively rare, but potentially morbid complication of CTC, especially in symptomatic patients. Older age and underlying concomitant colon pathology increase the risk of perforation. This review describes the incidence, clinical features, and management of colon perforations at CTC, a study that was considered risk-free until recently.

CT pulmonary angiography for the detection of pulmonary embolism: interobserver agreement between on-call radiology residents and specialists (CTPA interobserver agreement).

PURPOSE: The aim of this study was to prospectively determine interobserver agreement between on-call radiology residents and specialists in the interpretation of computed tomographic pulmonary angiography (CTPA). METHODS: CTPA examinations obtained between January 2002 and March 2003 were interpreted by a radiology resident on call and by two radiology specialists. Agreement was assessed using percentage of agreement between interpreters and by the kappa coefficient. Sensitivity of residents' interpretations was calculated by relating them to the interpretation of Specialist 1, which served as the gold standard. RESULTS: Of the 81 CTPA examinations evaluated, there was agreement of 93% and 91% for the diagnosis of pulmonary embolism (PE) and of 97% and 85% for the exclusion of PE with Specialist 1 and 2, respectively. The concordance between residents' interpretations and those of Specialist 1 was very high (kappa=.8), and with those of Specialist 2 was high (kappa=.7). In all cases of agreement between the two specialists, there was complete agreement between the specialists' and the residents' intepretations. CONCLUSIONS: Our study showed good to very good agreement of residents' interpretations with each of the radiology specialists. Therefore, relying on the residents' preliminary interpretations during after-hour calls is reasonable.

A prospective study assessing the efficacy of abdominal computed tomography scan without bowel preparation in diagnosing intestinal wall and luminal lesions in patients presenting to the emergency room with abdominal complaints.

AIM: To evaluate the positive predictive value of abdominal non-prepared computed tomography (CT) for diagnosing intestinal lumen or wall lesions in patients presenting to the emergency room (ER) with abdominal complaints. METHODS: For 1-year we prospectively evaluated all ER patients hospitalized after abdominal CT scan detected either intraluminal or intestinal wall lesions. These patients underwent colonoscopy serving as gold standard. Patients with prior abdominal pathology or CT findings of appendicitis or diverticulitis were excluded. RESULTS: Five hundred and sixty-eight abdominopelvic CT scans were performed in the ER, 96 had positive colonic findings. Sixty-two patients were excluded, 46 because of diverticulitis or appendicitis, 16 because of prior abdominal pathology. Of the remaining 34 patients, 14 did not undergo colonoscopy during hospitalization. Twenty eligible patients were included in the study. The positive predictive value of the CT scans performed in the ER was calculated to be 45% (95% CI 25-67). CONCLUSION: CT findings correlated with colonoscopic findings only in approximately half of the cases. Relying on non-prepared CT scan findings in planning patient management and colonoscopy may lead to unnecessary diagnostic work-ups.

Hepatic lymphoma: an imaging approach with emphasis on image-guided needle biopsy.

BACKGROUND: Involvement of the liver by lymphoma is almost always secondary. A definite diagnosis can be made only after histologic examination. Recently there has been a trend to replace surgical biopsies with percutaneous core-needle biopsies for the diagnosis of lymphoproliferative disorders. OBJECTIVES: To describe our experience with percutaneous image-guided needle biopsies of the liver in 15 cases of primary and secondary hepatic lymphoma. METHODS: Between 1997 and 2002, 15 of all the percutaneous computerized tomography-guided core-needle liver biopsies performed at our institution yielded the diagnosis of lymphoma. We retrospectively reviewed the medical records of these patients. RESULTS: Seven patients had primary hepatic lymphoma (all non-Hodgkin's lymphoma) and eight had secondary (three Hodgkin's disease and five non-Hodgkin's lymphoma). No major complications were caused by the percutaneous biopsies, and all biopsies were diagnostic. The imaging findings were non-specific but were characteristic and similar to previously described series. Imaging demonstrated hypodense lesions by CT, or hypoechoic or anechoic lesions by ultrasound in all but two cases in which hilar lesions resulted in biliary dilatation, both demonstrated by ultrasound. CONCLUSIONS: Review of our primary cases indicated no association with cirrhosis or AIDS in contradistinction to the worldwide experience. There were no significant complications in the 15 patients in the study, and a definite diagnosis of lymphoma was made in all the cases with no need to proceed to surgical biopsy. We highly recommend image-guided core-needle biopsy of the liver as a reliable and useful tool for the diagnosis of hepatic lymphoma.

Effect of breast magnetic resonance imaging on the clinical management of breast cancer.

BACKGROUND: Mammography is the principal breast cancer imaging technique; however, sensitivity is reduced, especially in dense breast tissue. Magnetic resonance imaging is increasingly used in the detection and characterization of breast cancers. The high sensitivity (95-100%) of MRI is consistently observed, and in many situations, MRI is proving superior to classical forms of imaging. Assessment of its impact on management and outcome is vital if MRI is to become standard in the management of breast cancers. OBJECTIVES: To establish the impact of breast MRI on women undergoing testing in our institution. METHODS: We analyzed 82 cases that underwent MRI between January 2001 and April 2003. Analysis appraised the clinical impact of MRI testing in cases where medical summaries were available. RESULTS: Studies were categorized into five indications: a) screening in high risk women (n=7), b) search for primary disease in the presence of disease (n=5), c) monitoring of chemotherapy (n=2), d) postoperative assessment of tumor bed (n=9), and e) diagnostic/characterization of primary or recurrent breast cancer (n=59). Results were defined as negative, positive, or no impact on clinical management. MRI testing had a positive impact in 62 cases, affecting measurable change in 9 cases. Benefit was seen in screening, diagnosis and postoperative cases. In 15 cases, MRI stimulated investigations. CONCLUSION: MRI is a valuable tool in breast imaging and affects management. Further trials are necessary to clearly define the role of MRI and to ascertain whether in cases where beneficial impact on management is noted, there is ultimate impact on outcome.

Multiple myeloma involving the thyroid cartilage: case report.

Multiple myeloma involving the thyroid cartilage is exceedingly rare. We describe a patient with progressive airway obstruction due to diffuse involvement of the thyroid cartilage with multiple myeloma. CT revealed a conglomerate of calcifications of the thyroid cartilage. Additional classic lytic lesions of multiple myeloma were subsequently found in the bones, without associated calcifications. Calcified matrix in multiple myeloma involving the thyroid cartilage should now be included as an additional manifestation of extraosseous multiple myeloma.

Contribution of 11C-choline positron emission tomography/computerized tomography to preoperative staging of advanced transitional cell carcinoma.

PURPOSE: Current imaging modalities for preoperative staging of advanced transitional cell carcinoma of the bladder or upper urinary tract are not sensitive for detection of metastases. This study examines the contribution of 11C-choline positron emission tomography/computerized tomography to preoperative staging of transitional cell carcinoma. MATERIALS AND METHODS: We prospectively evaluated 18 patients with 19 advanced transitional cell carcinomas (17 bladder tumors and 2 upper tract transitional cell carcinomas). All patients had computerized tomography of the chest, abdomen and pelvis negative for metastases. 11C-choline positron emission tomography/computerized tomography was performed on a Discovery ST(R) positron emission tomography/computerized tomography system. Finally 16 patients underwent radical surgery and positron emission tomography/computerized tomography images were compared to histopathological findings. Two patients were not operated on due to the findings on 11C-choline positron emission tomography/computerized tomography. RESULTS: 11C-choline uptake was found in all primary transitional cell carcinomas, with a maximum standardized uptake value of 7.3 +/- 3.2 (mean +/- SD). The series included 3 patients with refractory bladder carcinoma in situ, which was visualized in all 3, with a standardized uptake value of 6.9 +/- 5.6. In 6 patients uptake of 11C-choline in lymph nodes as small as 5 mm was visualized (standardized uptake value 3.8 +/- 1.4). Of these patients 4 underwent surgery and histopathology confirmed malignancy in 3 of 4. No additional patients with positive lymph nodes were found on histopathology. Metastases were visualized in bones with normal architecture on computerized tomography in 4 patients (standardized uptake value 5.2 +/- 1.1) and were confirmed by followup computerized tomography. CONCLUSIONS: In this small series 11C-choline positron emission tomography/computerized tomography was highly sensitive for primary and metastatic transitional cell carcinoma. Carcinoma in situ, lymph node metastases and early bony metastases were visualized. 11C-choline positron emission tomography/computerized tomography is a promising tool for preoperative staging of advanced transitional cell carcinoma.

Phase I/II trial of intravenous NDV-HUJ oncolytic virus in recurrent glioblastoma multiforme.

We undertook a Phase I/II trial in patients with apparent recurrent glioblastoma multiforme (GBM) based on imaging studies to determine the safety and tumor response of repetitive intravenous administration of NDV-HUJ, the oncolytic HUJ strain of Newcastle disease virus. The first part of the study utilized an accelerated intrapatient dose-escalation protocol with one-cycle dosage steps of 0.1, 0.32, 0.93, 5.9, and 11 billion infectious units (BIU) of NDV-HUJ (1 BIU = 1 x 10(9) EID(50) 50% egg infectious dose) followed by three cycles of 55 BIU. Virus was administered by intravenous infusion over 15 min. In the second part, patients received three cycles of 11 BIU. All patients without progressive disease were maintained with two doses of 11 BIU iv weekly. Eleven of the 14 enrolled patients (11-58 years, Karnofsky performance scale 50-90%) received treatment. Toxicity was minimal with Grade I/II constitutional fever being seen in 5 patients. Maximum tolerated dose was not achieved. Anti-NDV hemagglutinin antibodies appeared within 5-29 days. NDV-HUJ was recovered from blood, saliva, and urine samples and one tumor biopsy. One patient achieved a complete response. Intravenous NDV-HUJ is well tolerated. The findings of good tolerability and encouraging responses warrant the continued evaluation of NDV-HUJ in GBM, as well as other cancers.

Facing the new threats of terrorism: radiologists' perspectives based on experience in Israel.

On September 11, 2001, the world changed. The vicious giant of terrorism that was dormant until that date had arisen. After the horrific mass-casualty terror attack on the United States, any and all forms of assault seem possible. Owing to the complexity of injuries encountered in terror attack victims, fast and accurate imaging plays an essential role in triage and identification of abnormalities associated with injuries. The radiologist becomes a crucial part of the first-line team of doctors treating these patients. Knowledge that the best available treatment is given to terror attack victims can enhance the strength and endurance of society against terror. On the basis of the authors' experience with terror events in Israel, the steps involved in imaging of terror attack patients include conventional radiography, focused abdominal sonography in trauma, computed tomography, and angiography, with the judicious use of supplemental imaging.

Doxil-induced regression of pleuro-pulmonary metastases in a patient with malignant meningioma.

Metastatic meningioma is a rare disease, which has no effective chemotherapy. We report on a treatment of this condition with Doxil, a liposomal doxorubicin formulation. A 60-year-old woman with massive pleuro-pulmonary metastases from recurrent cranial meningioma was treated with Doxil (50-37.5 mg/m2) for 18 months with near-complete resolution of metastases and disappearance of pleural fluid. The only significant toxicities observed were stomatitis and hand-foot syndrome, which resolved with dose reduction and increase of dosing intervals. Doxil was cleared very slowly in this patient with a monoexponential half-life of 108 h. The patient remains in near-complete response for 6 months after treatment discontinuation. This is the first report on an effective chemotherapy in a patient with typical metastatic meningioma. The exact mechanism accounting for such an effective drug action is not clear, but may be related to a particularly high microvascular permeability to the liposome carriers in these metastatic lesions.