Thoracic Complications of Precision Cancer Therapies: A Practical Guide for Radiologists in the New Era of Cancer Care.

Recent advances in understanding the molecular mechanisms of cancer have opened a new era of precision medicine for cancer treatment. Precision cancer therapies target specific molecules that are responsible for cancer development and progression, and they achieve marked treatment benefits in specific cohorts of patients. However, these therapies are also associated with a variety of complications that are often unique to specific groups of anticancer agents. The rapidly increasing use of immune checkpoint inhibitors in the treatment of various advanced malignancies has brought new challenges in diagnosing and monitoring a unique set of toxic effects termed immune-related adverse events. Familiarity with cutting-edge cancer treatment approaches and awareness of the emerging complications from novel therapies are essential for radiologists, who play a key role in the care of patients with cancer. This article provides a comprehensive review of the thoracic complications of precision cancer therapies, describes their imaging features and clinical characteristics, and discusses the role of radiologists in the diagnosis and monitoring of these entities. The authors also address the molecular mechanisms of anticancer agents that relate to thoracic complications and emphasize emerging challenges in novel cancer therapies. This article is designed to serve as a practical reference guide for day-to-day practice for radiologists in the era of precision cancer medicine. ©RSNA, 2017.

Huge extrapleural hematoma in an anticoagulated patient.

We report an unusual case of huge extrapleural hematoma in an anticoagulated patient with no apparent traumatic episode. An extrapleural hematoma (EH) was successfully treated by video-assisted thoracic surgery (VATS). If an EH is large enough to cause ventilatory or circulatory disturbances, VATS may be the first option for the management of EH. Otherwise limited thoracotomy should be considered.

Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants.

OBJECTIVE: To assess the occurrence of muscle rigidity after fentanyl administration in premature and term neonates. DESIGN: Prospective case series, observational study. SETTING: A university hospital neonatal intensive care unit. PATIENTS: 8/89 preterm and term infants (25-40 wks gestational age) who received fentanyl for perioperative analgesia and sedation or intensive care procedures. INTERVENTIONS: Mechanical or bag mask ventilation and antagonization with naloxone. MEASUREMENTS AND MAIN RESULTS: We observed chest wall rigidity in 8 patients after low dosage of fentanyl (3-5 microg/kg body weight). All patients presented with respiratory distress, hypercapnia, and hypoxemia leading to bradycardia. In two patients, laryngospasm was noted and associated with muscle rigidity, thus making intubation impossible. Naloxone (20-40 microg/kg body weight) reversed the laryngospasm and muscle rigidity immediately, allowing restitution within 1 min. In our patient population, we found fentanyl-induced chest wall rigidity in 4% of neonates after fentanyl administration. CONCLUSION: Even low doses of fentanyl can lead to thoracic rigidity in neonates. Additionally, we observed laryngospasm in two patients and speculate that it might be a variant of muscle rigidity.

Massive subfascial hematoma after alteplase therapy for acute myocardial infarction.

The authors report a case of a patient who received alteplase for acute myocardial infarction and developed spontaneous subfascial hematoma without any evidence of direct trauma. Subfascial hematoma remains a rare and self-limited complication of thrombolytic therapy. The development of cutaneous ecchymosis associated with a sudden fall in hemoglobin after the administration of alteplase should strongly suggest the possibility of diffuse subfascial hematoma. Physicians should be aware of the possible association between the use of alteplase and the development of subfascial hemorrhage.

[Destructive paraffinoma of the breast and thoracic wall caused by paraffin injection for mammary increase. Apropos of 3 cases with review of the literature]. / Paraffinomes destructifs des seins et de la paroi thoracique dus à l'injection de paraffine pour augmentation mammaire. A propos de trois cas et revue de la littérature.

The injection of a high viscosity fluids into the tissues for cosmetic body contouring has been practised in the last four decades in the East and South-East of Asia. The injection of liquid paraffin for mammary augmentation was widely practised by surgeons, physician and even non medical people. Unfortunately, most of these cases ended by having different varieties of paraffinoma as a complication of a foreign body reaction. We report three cases of a destructive form of these paraffinomas ulcerating into both breasts and the anterior chest wall. One case was treated by bilateral mastectomy, radical excision of the anterior chest wall soft tissue and reconstruction by a vertical Rectus Abdominus Myocutaneous Flap. The second case had bilateral mastectomy and followed up for facial paraffinomas. The third case was just followed for up regular wound care as surgery was not indicated due to advanced age, poor general condition and the family request.

[Internal bleeding in patients on oral anticoagulants]. / Die innere Blutung beim oral antikoagulierten Patienten.

Five selected case reports of patients suffering from rather unusual bleeding complications during oral anticoagulant therapy are presented. The reported frequency of bleeding during oral anticoagulation varies greatly. An unacceptably high incidence of hemorrhages has been reported in North American studies of the early 1980ies. The therapeutic target INR of 2.5-4.9 in these series is comparable to that in European studies where bleeding occurred much less frequently. We suggest that the insensitive thromboplastin reagents used in North America are unsuited to guide coumarin dosage, because too many prothrombin time values were outside the INR target range. In contrast, most prothrombin time values in European studies where a sensitive thromboplastin reagent was used, were within the target range. A recent prospective investigation by 25 Swiss practitioners showed an acceptably low bleeding complication rate (2.1 hemorrhagic complications severe enough to necessitate hospitalization per 100 patient years). Observation of contraindications, regular control of the prothrombin time using a sensitive and correctly calibrated thromboplastin, participation of practitioners and hospital laboratories at quality control exercises and consideration of drug interferences with coumarins help to reduce the incidence of hemorrhagic side effects. In case of either a PT value outside the target range or manifest bleeding, the necessary measures have to be tailored to the individual situation considering the Quick value as well as the severity and localization of hemorrhage.

A double-blind group comparative trial of nedocromil sodium and placebo in the management of bronchial asthma.

A 3-month double-blind group comparative trial of nedocromil sodium (4 mg twice daily) and placebo was carried out in 30 adult asthmatic patients maintained on bronchodilator therapy. Fifteen patients received each treatment. Subjective (asthma symptoms and severity) and objective (lung function and use of concomitant medication) variables were measured to monitor the response to trial treatments. Significant differences in favour of nedocromil sodium for night-time asthma, daytime asthma, cough, daytime bronchodilator use and clinic assessment of forced expiratory volume during the first second of expiration were observed by week 4 of the trial. The diurnal variation in peak expiratory flow rate was reduced in the nedocromil sodium treated patients. There were no serious adverse reactions and no treatment related changes in haematological findings, blood biochemistry or urinalysis.

Therapeutic neuromuscular paralysis in neonates: characteristic radiographic features.

Neonates with respiratory distress requiring mechanical ventilation may be treated with muscular paralysis to improve oxygenation. This results in characteristic radiographic features that relate in part to the specific drug used. The radiographic signs are: bell-shaped chest, decreased bowel gas, and soft-tissue edema. When all three findings are present, the use of neuromuscular blockade can be suggested from the radiographs alone without the aid of clinical history. Radiographs of 57 infants treated with muscular paralysis and mechanical ventilation were compared to 20 infants treated with mechanical ventilation alone. In paralyzed patients, a characteristic bell-shaped chest was seen in 24 of 57 and decreased bowel gas in 46 of 52. Soft-tissue edema was seen in patients treated with metocurine, and the incidence increased with duration of therapy (18 of 25 treated for 5 or more days); it was not radiographically detected in patients treated with d-tubocurarine (0 of 13). Bell-shaped chest, decreased bowel gas, and soft-tissue edema occurred one, three, and one times, respectively, in 20 nonparalyzed control infants, and each time the findings carried significantly different clinical implications. All cases were reviewed to determine if pulmonary edema can result from mobilization of soft-tissue edema fluid after cessation of neuromuscular paralysis, and this was found not to occur.