Alan P. Mautz

Staging chest computed tomography and positron emission tomography in patients with pancreatic adenocarcinoma: utility or futility?

OBJECTIVES This study was conducted to determine if routine staging chest computed tomography (CT) or positron emission tomography (PET) scanning alters the clinical management of patients with newly diagnosed pancreatic adenocarcinoma. METHODS All new pancreas cancers seen in medical oncology, radiation oncology and surgery from 1 June 2008 to 20 June 2010 were retrospectively reviewed. Patients with metastatic disease on chest CT or PET, that had been unsuspected on initial imaging, were identified. RESULTS Pancreatic adenocarcinoma was present in 247 consecutive patients. Abdominal CT demonstrated metastases in 108 (44%) and localized disease in 139 (56%) patients. Chest CT and PET were not performed in 15 (11%) of these 139 patients. In the remaining 124 patients, CT imaging suggested resectable disease in 46, borderline resectable disease in 52 and locally advanced disease in 26 patients. Chest CT demonstrated an unsuspected lymphoma in one patient with borderline resectable disease and PET identified extrapancreatic disease in two patients with locally advanced disease. Chest CT and PET added no information in 121 (98%) of the 124 patients. CONCLUSIONS The addition of chest CT and PET to high-quality abdominal CT is of little clinical utility; additional sites of metastasis are rarely found. As the quality of abdominal imaging declines, the yield from other imaging modalities will increase. Dedicated pancreas-specific abdominal CT remains the cornerstone of initial staging in suspected or biopsy-proven pancreatic cancer.

Fabella fracture with CT imaging: a case report

Fracture of the fabella is rare, may be easily overlooked, and can be a clinically important cause of posterolateral knee pain following traumatic injury or total knee arthroplasty. To date, nine case reports of fabella fracture with radiographic documentation have been reported in the literature. This report documents a 55-year-old male pedestrian who was struck by an automobile and presented with radiographs demonstrating depressed lateral tibial plateau and proximal fibula fractures. Computed tomography (CT) was performed for surgical planning and demonstrated the additional finding of a radiographically occult nondisplaced fabella fracture. To the best of our knowledge, this is the first case in which CT documentation of a fabella fracture is reported. Fracture of the fabella is a rare but important clinical entity which may be overlooked clinically and radiographically. Clinical information can provide a high index of suspicion, and when coupled with radiographic and CT findings, may lead to the correct diagnosis. CT imaging of the knee may confirm a suspected fabella fracture or may help detect a radiographically occult fracture.

Tumor Increase on MRI after Neoadjuvant Treatment is Associated withGreater Pathologic Necrosis and Poor Survival in Patients with Soft TissueSarcoma

Purpose: MRI is often used to evaluate sarcoma response to neoadjuvant treatment, however its role to predict for pathologic response and survival is unclear. Methods and materials: From 2003-2010, 116 patients with STS were treated with neoadjuvant therapy (NAT). 62 patients who had an MRI before and after radiotherapy were analyzed. Radiographic change was correlated with survival and necrosis and fibrosis on pathology. ROC curve analysis was used to assess change in volume that best predicted for pathological necrosis. Results: Median follow-up was 33 months. There was median tumor volume decrease of 15.08 cm3 after treatment. Increase in tumor size and volume was associated with greater necrosis (p<0.03, p=0.001, respectively) and less fibrosis (p<0.001) on pathology. High-grade tumors had more necrosis (p<0.001) and comprised the majority of patients with tumor increases following NAT (88%). Tumor increase of at least 66% predicted for ≥ 70% necrosis with 94% specificity. The 3-year OS was 65% vs. 93% in patients with a decrease in size and volume (p=0.004). In tumors with ≥ 70% necrosis, the 3-year OS was 38% vs. 91% if necrosis was <70% (p<0.001). Conclusions: MR-based tumor increase following NAT was associated with greater % necrosis and less fibrosis on pathology. This tumor increase was more likely high-grade and associated with worse survival.

AIRP Best Cases in Radiologic-Pathologic Correlation: Intraosseous Lipoma

History A 32-year-old woman with a previous diagnosis of human immunodeficiency virus infection presented to her primary care provider in 2010 with a progressively enlarging mass in her proximal right forearm. The patient reported a limited range of motion with decreased extension and, to a lesser extent, decreased flexion because of physical obstruction created by the mass. She denied experiencing pain associated with the mass. The patient reported that the area had been injured when she was assaulted with a board several years before. There was no other pertinent medical history.