Beatrice Madrazo

Low-dose-rate brachytherapy as the sole radiation modality in the management of patients with early-stage breast cancer treated with breast-conserving therapy: Preliminary results of a pilot trial

PURPOSEnWe present the preliminary findings of our in-house protocol treating the tumor bed alone after lumpectomy with low-dose-rate (LDR) interstitial brachytherapy in selected patients with early-stage breast cancer treated with breast-conserving therapy (BCT).nnnMETHODS AND MATERIALSnSince March 1, 1993, 60 women with early-stage breast cancer were entered into a protocol of tumor bed irradiation only using an interstitial LDR implant with iodine-125. Patients were eligible if the tumor was < or = 3 cm, margins were > or = 2 mm, there was no extensive intraductal component, the axilla was surgically staged, and a postoperative mammogram was performed. Implants were placed using a standardized template either at the time of reexcision or shortly after lumpectomy. A total of 50 Gy was delivered at 0.52 Gy/h over a period of 96 h to the lumpectomy bed plus a 2-cm margin. Perioperative complications, cosmetic outcome, and local control were assessed.nnnRESULTSnThe median follow-up for all patients is 20 months. Three patients experienced minimal perioperative pain that required temporary nonnarcotic analgesics. There have been four postoperative infections which resolved with oral antibiotics. No significant skin reactions related to the implant were noted and no patient experienced impaired would healing. Early cosmetic results reveal minimal changes consisting of transient hyperpigmentation of the skin at the puncture sites and temporary induration in the tumor bed. Good to excellent cosmetic results were noted in all 19 patients followed up a minimum of 24 months posttherapy. To date, 51 women have obtained 6-12-month follow-up mammograms and no recurrences have been noted. All patients currently have no physical signs of recurrence, and no patient has failed regionally or distantly.nnnCONCLUSIONnTreatment of the tumor bed alone with LDR interstitial brachytherapy appears to be well tolerated, and early results are promising. Long-term follow-up of these patients is necessary to establish the equivalence of this treatment approach compared to standard BCT, however.

CT features of renal infarction

PURPOSEnTo demonstrate the different patterns of renal infarction to avoid pitfalls. To present flip-flop enhancement pattern in renal infarction.nnnMATERIALS AND METHODSnRetrospective review of a total of 41 renal infarction in 37 patients were done. These patients underwent initial CT and the diagnosis of renal infarction was confirmed with either follow up CT or at surgery.nnnRESULTSnTwenty-three patients had wedge-shaped focal infarcts, nine patients had global and five patients had multifocal infarcts of the kidneys. Cortical rim sign was seen predominantly with global infarcts. In five patients, a flip-flop enhancement pattern was observed. In two patients, planned renal biopsies due to tumefactive renal lesions were cancelled because of flip-flop enhancement pattern on follow up CTs.nnnCONCLUSIONnAlthough most of our cases were straightforward for the diagnosis of renal infarction, cases with tumefactive lesions and global infarctions without the well-known cortical rim sign were particularly challenging. We describe a new sign, flip-flop enhancement pattern, which we believe solidified the diagnosis of renal infarction in five of our cases. The authors recommend further investigations for association of flip-flop enhancement and renal infarction.

Hepatic focal nodular hyperplasia: CT and sonographic spectrum

Fifteen patients with pathologically proven focal nodular hyperplasia (FNH) of the liver had abdominal computed tomography (CT) (15) and ultrasound (11). In seven patients, the lesions were incidentally found during gallbladder or renal examination, whereas the other eight had a primary neoplasm and the liver was studied for possible metastasis. In 11 unenhanced CT scans, the ratio of isodense to hypodense lesions was 8 to 3. In 15 contrasten-hanced CT scans, seven were isodense, six were hypodense, and in two, the lesion enhanced (hyperdense). In seven patients a hypodense lesion on unenhanced CT became isodense with contrast injection. Delayed images in three showed the lesions appearing as hypodense in two and displaying a rim of enhancement in one. In one case, unenhanced CT was normal and only enhanced CT showed an area of homogeneous increased density. Ultrasound was done in 11 patients, the lesion was hypoechoic to the liver in five, echogenic in four, and isoechoic in two. Findings of central scar were seen on CT and ultrasound in three cases. Pathologic diagnosis was available in all cases, seven by needle aspiration and eight by surgical resection. In our experience, FNH has many CT and sonographic features that can mimic hemangioma or metastasis. While the presence of a central scar increases the specificity, in a cancer patient, the findings should be interpreted with caution and needle aspiration should be obtained.

The use of ultrasonography in the localization of the lumpectomy cavity for interstitial brachytherapy of the breast

PURPOSEnTo determine the value of breast ultrasonography (US) in defining the lumpectomy cavity for patients treated with interstitial brachytherapy.nnnMETHODS AND MATERIALSnIn March 1993, a protocol of low dose rate (LDR) interstitial brachytherapy as the sole radiation modality in selected patients with early breast cancer was initiated at William Beaumont Hospital. To date, 60 patients have been entered in this protocol, and 38 have undergone US assisted placement of interstitial brachytherapy needles. The lumpectomy cavity was outlined in all dimensions and corresponding skin marks were placed for reference at time of implantation. These US dimensions were compared to the physicians clinical estimate of the location of the lumpectomy cavity, the patients presurgical mammogram, and the position of the surgical scar. In the intraoperative setting, the dimensions of the lumpectomy cavity were also obtained and the placement of the deep plane of interstitial needles was verified by US.nnnRESULTSnThe full extent of the lumpectomy cavity was underestimated by clinical examination (physical exam, operative report, mammographic information and location of the surgical scar) in 33 of 38 patients (87%). The depth to the chest wall was also incorrectly estimated in 34 (90%) patients when compared to US examination. Intraoperatively, US was performed in nine patients and was useful in verifying the accurate placement of the deepest plane of interstitial brachytherapy needles. In 7 of 9 patients (75%), clinical placement of needles did not ensure adequate coverage of the posterior extent of the lumpectomy cavity as visualized by intraoperative US.nnnCONCLUSIONSnIn breast cancer patients considered for interstitial brachytherapy, US appears to be a more accurate means of identifying the full extent of the lumpectomy cavity when compared to clinical estimates. In addition, US allows real-time verification of needle placement in the intraoperative setting.

Clinical and imaging features of rhabdoid tumor of the kidney

Rhabdoid tumor of the kidney (RTK) is a rare, highly malignant neoplasm of childhood. The clinical profile of this neoplasm differs from that of Wilms’ tumor. We present two cases of RTK. In both our cases, large bulky masses with poorly defined margins and calcifications were demonstrated. The clinical and imaging findings are compared with other childhood renal neoplasms.