Cynthia L. David

Fluconazole therapy for chronic disseminated candidiasis in patients with leukemia and prior amphotericin B therapy

OBJECTIVE To study the efficacy of fluconazole against chronic disseminated candidiasis (hepatosplenic candidiasis) in patients with leukemia in whom amphotericin B treatment had failed. DESIGN Retrospective analysis of patients with chronic disseminated candidiasis treated with fluconazole on a compassionate investigational new drug protocol. SETTING Multi-institutional. PATIENTS AND METHODS Twenty consecutive patients received 100 to 400 mg of fluconazole per day for a median of 30 weeks. All had either failed to respond to treatment with more than 2 g of amphotericin B or had serious amphotericin B-related toxicities. RESULTS Fourteen of 16 evaluable patients (88%) responded. Responses were observed in seven of nine patients in whom adequate doses of amphotericin B had failed and in all seven patients who had amphotericin B-related toxicities. In 12 patients, cytotoxic chemotherapy was continued without flare of the infection. Fluconazole was well tolerated with rare side effects. Aspergillus superinfection developed in three patients and contributed to the death of two of them. CONCLUSION Fluconazole is a safe and effective agent with significant activity against chronic disseminated candidiasis.

Vascular involvement in pancreatic adenocarcinoma:reassessment by thin-section CT

Abstract. We defined computed tomographic (CT) criteria of vascular involvement by pancreatic carcinoma and used these criteria to assess vascular involvement in 56 patients with pancreatic adenocarcinoma. CT of the pancreas was performed at 1.5-mm section thickness and 5-mm section intervals during a bolus phase of intravenous contrast enhancement. The type of vascular involvement was correlated with surgical and pathologic findings. When there was fat-plane (type A) or normal pancreatic parenchyma (type B) separating the tumor from adjacent vessels, the tumor could be resected without venous resection in 21 of 22 patients (95%). When the tumor was inseparable from the vessels but the points of contact formed a convexity against the vessel (type C), CT was not reliable in predicting whether or not the tumor was fixed against the vessel. When the tumor was partially encircling (type D) the vessel, the tumor was fixed against the vessels in most cases. The resectable rate was 47%, but resection would also require venous resection. When the tumor was completely encircling (type E) or occluding (type F<+>) the vessel, all tumors were not resectable with a negative margin. Thin-section CT with bolus intravenous contrast enhancement improved the ability to assess vascular involvement in pancreatic adenocarcinoma.

Increased incidence of hypersensitivity to iodine-containing radiographic contrast media after interleukin-2 administration

Eight of 28 (28%) cancer patients with liver metastases treated by either splenic (four) or hepatic (four) arterial infusion of recombinant interleukin‐2 (rIL‐2) developed hypersensitivity reactions to iodine‐containing radiographic contrast media. These reactions consisted of fever, chills, malaise, nausea and vomiting, skin rash, diarrhea, and occasionally, hypotension. Reactions usually occurred 1 month after the initial arteriographic procedure and rIL‐2 infusion, with 1‐hour to 4‐hour intervals between procedure and reexposure of the patient to the iodine‐containing contrast medium (used in conjunction with computerized tomography or repeated arteriography for subsequent courses of rIL‐2 infusions) and the onset of symptoms. Prompt administration of corticosteroids during the reaction and premedication of patients who were known to have had a reaction in the past were very effective in stopping reactions or preventing them from reoccurring. The high incidence (28%) of hypersensitivity reactions, the temporal relationship (4 hours) between the arteriographic procedure (utilizing iodine‐containing contrast medium) and the initial infusion of rIL‐2 (while some of the contrast medium was still present), and the absence of such hypersensitivity reactions among patients receiving systemic (intravenous) rIL‐2 (not requiring the use of concomitant iodine‐containing contrast medium) provide additional evidence that in the presence of a potentially immunogenic moiety, rIL‐2, a potent stimulant of the human immune system, can produce an initial sensitization followed by subsequent anamnestic reaction upon reexposure of the patient to the immunogen (even without the additional rIL‐2).

Detection of hepatic metastases in breast cancer: the role of nonenhanced and enhanced CT scanning.

Nonenhanced and enhanced CT was compared in 88 patients with breast cancer and hepatic metastasis. Twenty-five patients had bolus, sequential dynamic CT, and 63 patients were scanned more slowly after a bolus or during drip infusion. Metastatic lesions were more conspicuous on nonenhanced CT and became isodense or nearly isodense after contrast medium administration in 28% of the patients scanned dynamically and in 29% of those scanned more slowly. Although breast cancer has not generally been considered a common origin of hypervascular metastases, we recommend that it be treated as such and that both enhanced and nonenhanced CT of the liver be obtained when patients are screened for metastasis.

Primary renal carcinoid : computed tomography, ultrasound, and angiographic findings

We present a rare case of primary renal carcinoid tumor that metastasized to the liver and kidneys. The tumor and the metastases were hypovascular angiographically, did not enhance on CT, and were hyperechoic with a hypoechoic halo on ultrasound. A similar pattern has been seen in a few cases previously reported in the literature.

Importance of dynamic assessment of the soft tissues in the sonographic diagnosis of echogenic superficial abscesses.

Superficial abscesses evaluated by ultrasonography may occasionally be isoechoic relative to the surrounding inflamed tissues and without mass effect, preventing diagnosis by morphologic criteria alone. We present a simple and effective method to detect such abscesses. In three cases, gentle repetitive pressure of the inflamed tissue revealed the liquefied nature of abscesses that otherwise would have been overlooked.

The long-term effects of internal mammary chain irradiation and its role in the vascular supply of the pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction

With an increase in breast-sparing surgery and adjuvant radiotherapy, there has been a concomitant increase in the complexity of breast reconstruction. The effects of radiotherapy on the Internal mammary artery were evaluated with respect to flap viability for conventional transverse rectus abdominis musculocutaneous breast reconstruction using the irradiated rectus muscle. Twenty-eight women who received postoperative irradiation for breast cancer were studied. All women had unilateral irradiation, and evaluation of the internal mammary arteries was performed at least 1 year after the completion of radiotherapy to allow for fibrosis and long-term vascular changes. Examination of the internal mammary artery (upper and lower chains) was performed using color Doppler sonography to assess vessel diameter, peak systolic velocity, and blood flow. The nonirradiated side was compared to the radiated internal mammary artery as an internal control. Based on the details of prior radiotherapy, the 28 women were designated into two groups. Group I included 14 women with radiation portals that specifically treated the internal mammary chain; the average dose to the internal mammary chain was 47.44 Gy. Group II comprised 14 patients that received tangential portals that did not directly target the internal mammary chain region; the average radiation dose was 48.21 Gy to the chest wall. No statistical difference was observed in group I between the irradiated and nonirradiated side for vessel diameter (p = .8631) or peak systolic velocity (p = .2646). However, an increase in blood flow on the irradiated side was significant (p = .0321). In evaluating group II alone in addition to the study population (28 patients), we failed to identify significant differences in these parameters. In conclusion, radiation portals that specifically target the internal mammary chain region may affect blood flow but did not have a statistical effect on vessel diameter and peak systolic velocity. Tangential radiation portals, which may or may not include the internal mammary chain region, appear to have little effect on the internal mammary artery. From these indirect measurements of internal mammary chain patency, prior radiotherapy may not preclude the use of the ipsilateral muscle as a possible vascular source for pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction.

Design and analysis of trials of salvage therapy in acute myelogenous leukemia

Abstract Results obtained with a given regimen in relapsed or refractory acute myelogenous leukemia (AML) are variable. This often reflects variability in patient selection. We have developed a system to account for such variability that stratifies patients with refractory or relapsed AML into four groups: group 1, first complete response (CR) duration ≥ 2 years and receiving first salvage treatment (S1); group 2, first CR duration 1–2 years and receiving S1; group 3, first CR duration 0–1 years and receiving S1; and group 4, first CR duration 0–1 years and receiving S2, S3, or S4 after failing S1. CR rates achieved in the four groups are 73%, 47%, 14%, and 0, respectively. This system is useful for comparing results obtained with different therapies and for assigning patients to treatment. At our institution, patients in group 4 are enrolled in phase I studies, and phase I1/2 – II studies are carried out separately in patients in groups 2, 3, and 4. A phase I1/2 study refers to one in which the intent is to select for phase II therapies emerging from phase I trial results. The design is Bayesian, and although false-negative rates are relatively high, they are lower than those obtained if a drug for phase II testing is arbitrarily selected.

Use of thin-section, multidetector row helical CT images for coronal oblique reformations for optimal visualization of structures in the hepatoduodenal ligament.

Abstract Multidetector row computed tomography (CT) can acquire abdominal images of unprecedented thinness in a single breath-hold. This study investigated whether acquiring source axial images at 1.25 mm as opposed to 2.5 mm would result in a perceptible difference in image quality for coronal oblique reformations. Similarly, the hypothesis that a slice pitch of 3:1 would be superior to 6:1 was evaluated. Twenty-nine CT studies were retrospectively evaluated. The images were divided into four groups: 1.25-mm axial images, pitch 3:1; 2.5-mm axial images, pitch 3:1; 1.25-mm axial images, pitch 6:1; and 2.5-mm axial images, pitch 6:1. Three radiologists evaluated by consensus the coronal oblique reformations for overall image quality and image quality of structures in the hepatoduodenal ligament and of nodal groups. Use of 1.25-mm rather than of 2.5-mm source axial images resulted in statistically significant better scores for overall image quality and visualization of the hepatic artery, portal vein, pancreatic duct, and nodal groups. However, a pitch of 3:1 rather than of 6:1 did not result in significant differences in ratings of image quality. Use of 1.25-mm rather than of 2.5-mm source axial images improves image quality when creating coronal oblique reformations for abdominal anatomy.

Macroglobulinaemic lymphoma presenting with perirenal masses

Perirenal masses are an uncommon manifestation of lymphoma. They are almost always associated with lymphoma elsewhere and usually represent direct spread from retroperitoneal lymph nodes (Jafri et al, 1982; Heiken et al, 1986). Renal or perirenal lymphoma may present as an abdominal mass, hydronephrosis, impairment of renal function, or as an incidental finding (Jafri et al, 1982; Horii et al, 1983; Heiken et al, 1986). We describe an unusual case of macroglobulinaemic lymphoma in a patient who presented with perirenal masses, correlating the findings on ultrasound, computed tomography (CT) and magnetic resonance (MR).