E. K. Fishman

Iodine 131 antiferritin, a new treatment modality in hepatoma: a Radiation Therapy Oncology Group study.

One hundred five patients with hepatoma were treated with iodine 131 antiferritin in three sequential protocols in phase 1-2 trials. Therapy began in all trials with external beam irradiation and chemotherapy. The dosimetric results with 131I antiferritin indicated that 30 mCi (8 to 10 mCi/mg immunoglobulin G [IgG]) was sufficient to saturate the tumor. Tumor-effective half-life of the radioactive antibody was 3 to 5 days and was dependent on the species of animal from which the antibody was derived. This led to a 30 mCi on day 0 and 20 mCi on day 5 treatment schedule. Toxicity was predominantly thrombocytopenia. Due to clinical remission, cyclic therapy was next developed with antibodies from different species of animals. Rabbit, pig, monkey, and bovine antibodies were determined to produce the longest tumor-effective half-life and therefore the highest dose of radiation. Integration of 15 mg doxorubicin and 500 mg 5-fluorouracil (5-FU) with 131I antiferritin was accomplished next. Remission to external beam radiation was evaluated by computed tomography (CT) scan tumor volume computations that indicated that 22% of the patients had a partial remission (PR) from initial presentation to 1 month following external irradiation and chemotherapy. From the time of radioactive antibody administration, 48% of the patients (7% complete response [CR] and 41% PR) achieved remission to 131I antiferritin. Of 79 patients evaluated by CT scan tumor volumetrics 50% of the patients (7% CR and 43% PR) remitted to the entire treatment regimen. Patients not previously treated and without metastasis who were alpha fetoprotein positive (AFP+) had a 5-month median survival compared with AFP- median survival of 10 1/2 months. There were four CRs with one being 3 years and 6 months. The longest PR was 5 years and 8 months. These studies have demonstrated the toxicity and therapeutic activity of 131I antiferritin and the emerging role of radiolabelled antibody in cancer therapy.

The anatomy of the pelvis in the exstrophy complex

We compared computerized tomography scans of the pelvis of twenty-four patients who had exstrophy of the bladder with scans of age-matched controls in order to analyze the pelvic deformity that accompanies the variably severe manifestations of this condition. The patients who had classic exstrophy of the bladder were found to have a mean of 12 degrees of external rotation of the posterior aspect of the pelvis on each side, retroversion of the acetabula, a mean additional 18 degrees of external rotation and 30 per cent shortening of the pubic rami, and progressive diastasis of the symphysis pubis. The foot-progression angle demonstrated 20 to 30 degrees of external rotation beyond the normal limits seen in early childhood, but this improved with age. The patients who had exstrophy of the cloaca and the bladder not only had all of these pelvic deformities to a greater degree but also had asymmetry of measured parameters between the right and left sides of the pelvis, malformation of the sacro-iliac joints, and occasional dislocation of the hip. An understanding of the pelvic anatomy that accompanies exstrophy is essential when corrective approaches are planned. Such an understanding will improve the rate of success of both closure of the bladder and control of urinary continence postoperatively.

194 Hepatocellular cancers treated by radiation and chemotherapy combinations: toxicity and response: A radiation therapy oncology group study☆

Hepatocellular carcinoma is known to have a doubling time of approximately 41 days. This rapid cell division suggested that hyperfractionated radiation and chemotherapy might add an advantage in gaining remission of this malignancy. One hundred and thirty-five patients (70% with metastasis and/or previous treatment) were prospectively treated with single daily fractions to the liver (3.0 Gy external beam radiation, total dose 21.0 Gy), and chemotherapy for hepatocellular carcinoma. The low dose chemotherapy used in conjunction with the radiation was 2 hr before treatment on days 1, 3, 5, and 7 and consisted of Adriamycin, 15 mg IV and 5-FU, 500 mg IV. These patients were compared to a second group of 59 patients (80% with metastases and/or previous treatment) treated using the same chemotherapy regimen but using hyperfractionated whole liver external beam irradiation (1.2 Gy twice daily, 4 hr between treatments, 5 days per week to 24.0 Gy, 10 MV photons). Response was determined by CT scan tumor volumetric analysis. The response rate for the single daily fraction patient group was 22% and for the new hyperfractionated group, 18% (p = 0.68). Toxicity was evaluated by RTOG criteria. The grade 4 hematologic toxicity noted in the daily fraction patient group was 6%. Among 59 patients treated with the hyperfractionated liver irradiation, 2% experienced grade 4 hematologic toxicity. Esophagitis occurred in 1% of patients in the standard fractionation group and 19% in the hyperfractionated group (p = 0.0001). Grade 1-4 thrombocytopenia occurred in 49% of patients in the conventional group and 68% in the hyperfractionated group (p = 0.03). Normal liver volume changes with treatment were measured with CT scan tumor volumetric analysis. The hyperfractionated group experienced a median of 11 cc increase in liver volume and the conventional group a 46 cc decrease, but the difference was not significant. Hyperfractionated radiation did not demonstrate a significant benefit over standard daily radiation, but acute toxicity appeared to be higher.

Imaging of neuroendocrine tumors: accuracy of helical CT versus SRS

Background: We retrospectively compared the accuracy of somatostatin receptor scintigraphy (SRS) with that of helical computed tomography (CT) in the detection and localization of primary and metastatic neuroendocrine tumors.Methods: A medical record search identified 27 patients with known or clinically suspected neuroendocrine tumors who underwent helical CT and SRS within 3 months of one another at our institution. CT images were evaluated retrospectively by two blinded radiologists who used consensus reading. Images were evaluated for the presence or absence of primary tumor and hepatic and extrahepatic metastases. CT results were compared with the SRS report as interpreted by the nuclear medicine physicians. The results of the surgical, clinical follow-up, and pathologic findings were considered as the gold standard. Sensitivity, specificity, and accuracy were calculated for both imaging techniques. In addition, McNemar analysis was performed to determine statistically significant differences between CT and SRS.Results: Helical CT was more sensitive than SRS in the detection of extrahepatic metastases, and the difference between the two imaging modalities was statistically significant (p = 0.0312) as determined by the McNemar chi-square test. However, the difference between CT and SRS in detecting primary neuroendocrine tumors, hepatic metastasis, and combined hepatic and extrahepatic metastasis was not statistically significant (p = 0.625, 1.000, and 1.000, respectively).Conclusion: Helical CT and SRS have similar sensitivity, specificity, and accuracy in detecting primary neuroendocrine tumor and hepatic metastasis. However, helical CT appears to be more sensitive in detecting extrahepatic metastasis from primary neuroendocrine tumors.

PET-CT detection of abdominal recurrence of ovarian cancer:radiologic–surgical correlation

Abstract The diagnosis of recurrent ovarian cancer can be difficult on cross-sectional imaging, and variable sensitivities and specificities have been reported for positron emission tomography (PET). Combined functional and anatomic imaging with PET plus computed tomography (CT) potentially allows for improved detection of tumor masses. We investigated the sensitivity, specificity, and accuracy of PET-CT for the diagnosis of recurrent ovarian cancer. Sixteen women with previously treated ovarian cancer underwent imaging on a combined PET-CT scanner followed by surgery to assess for possible recurrent disease. The fused PET-CT images were retrospectively reviewed for recurrent disease, and the results of PET-CT were compared with the operative notes. Eleven of the 16 patients had recurrent disease at surgery. The sensitivity, specificity, and accuracy of PET-CT for disease detection on a per-patient basis were 72.7%, 40%, and 62.5%, respectively. For cases of malignant adenopathy (n = 7), 100% were detected on PET-CT. For peritoneal lesions no larger than 1 cm (n = 23), 13% were detected on PET-CT. For peritoneal lesions larger than 1 cm (n = 8), 50% were detected on PET-CT. The sensitivity of PET-CT for recurrent ovarian cancer is moderate in patients with low volume disease. A trial involving a larger number of patients with a spectrum of disease volumes is necessary to determine the impact of PET-CT in clinical practice.

Incremental value of CT in PET/CT of patients with colorectal carcinoma

Background: We assessed the contribution of dedicated computed tomographic (CT) interpretation to the accuracy of positron emission tomography (PET) plus CT in imaging patients with suspected primary or metastatic colorectal carcinoma.Methods: One hundred PET/CT scans in 90 consecutive patients were evaluated retrospectively. Imaging was performed on a GE Discovery LS PET/CT scanner. PET images were obtained from the skull base through the midthigh after intravenous administration of 15 to 20 mCi of [18F] fluorine-18-fluoro-2-deoxyglucose. Noncontrast axial CT images were obtained at the same anatomic locations, with 140 kV, 80 mA, 0.8 s/CT rotation, a pitch of 6, and a table speed of 22.5 mm/s. The CT component of the PET/CT study was reviewed independently by consensus of two blinded readers. Scans were evaluated for the presence of primary disease, local recurrence, and distant metastases. Results were compared with the PET/CT report. The gold standard was clinical and imaging follow-up for at least 6 months, surgery, or biopsy.Results: The study included 40 males and 50 females, with a mean age of 63 years (range, 31–92 years). The indications for the examination were to evaluate for recurrence of colorectal cancer in 83 cases, determine disease spread in 15 cases, and evaluate for possible primary malignancy in two cases with rising carcinoembryonic antigen. Sensitivity, specificity, and accuracy of the PET/CT report and of the combined PET/CT with dedicated CT interpretation were 0.914, 0.633, and 0.830 and 0.986, 1.000, and 0.980, respectively. The difference between PET/CT and the combined PET/CT with dedicated CT interpretation with respect to accuracy was statistically significant (p < 0.05).Conclusion: The CT portion of PET/CT provides valuable anatomic and pathologic information to the functional information provided by PET and helps improve the overall accuracy of the combined study.

Conversion by new treatment modalities of nonresectable to resectable hepatocellular cancer.

Eleven patients with hepatocellular cancer had nonresectable lesions, ten as determined by laparotomy and one by computed tomographic (CT) evidence of inferior vena caval invasion. These patients were treated with a variety of new modalities, particularly radiolabeled antiferritin antibodies. Following treatment, seven of the 11 patients were considered to have converted their lesions to possible resectability. Six patients had complete resections, and one patient was partially resected. All patients had the common features of either nodular massive or nodular multifocal hepatocellular cancer. Relative to the patients initial status, the quality of life remains high, and a new approach in the treatment of the nodular form of nonresectable hepatoma has been demonstrated. The present rate of such conversion to resectability is unknown. However, with further advances in radiolabeled antibody therapy, these results offer a new opportunity in the management of hepatocellular cancer.

Serous cystic neoplasm involving the pancreas and liver : an unusual clinical entity

Abstract Serous cystic neoplasm of the pancreas is typically considered to represent a benign pancreatic neoplasm. We present a case where the tumor displayed unusually aggressive behavior with metastatic disease to the liver and pancreatic bed. Although serous cystic neoplasms should be considered a benign lesion and will be cured in most cases by surgical excision, the radiologist should be aware that on occasion they can exhibit aggressive behavior.

MDCT angiography of living laparoscopic renal donors.

Laparoscopic donor nephrectomy has become the accepted method of harvesting the kidney at many institutions because of multiple advantages over open donor nephrectomy. Spiral computed tomographic (CT) angiography provides accurate information of renal vascular anatomy and has become an accepted method of preoperative evaluation of potential laparoscopic renal donors. More recently, multidetector CT (MDCT) provides more detailed datasets compared with single-detector spiral CT and has been used for preoperative evaluation of laparoscopic donor nephrectomy to provide accurate anatomic information. MDCT (especially 16- and 64-slice MDCT) angiography has advantages over single-detector helical CT due to rapid scan time that allows coverage of a large volume of interest with higher spatial and temporal resolutions. In this article, we review the current status of MDCT angiography in the evaluation of laparoscopic renal donors and potential advantages of using this technology.

Fluid–fluid levels within focal hepatic lesions: imaging appearance and etiology

Abstract.Purpose: To report our experience with fluid–fluid levels within focal hepatic lesions and determine if this finding indicates a specific diagnosis. Materials and methods: We reviewed our experience with eight patients with focal hepatic lesions that showed fluid–fluid level on cross-sectional imaging. Seven CT scans, four MR examinations, and four sonograms were reviewed. The hepatic lesions included metastases (four patients), biliary cystadenoma (two patients), cavernous hemangioma (one patient), and hematoma (one patient). A histologic diagnosis was made in all cases. Results: Fluid–fluid levels were found in both malignant and benign focal hepatic lesions. Fluid–fluid levels were seen on six CT scans, four MR examinations and on none of the four sonograms. Radiologic–pathologic correlation showed that fluid–fluid levels corresponded to internal hemorrhage in all but one case. In the case of cavernous hemangioma, a fluid–fluid level was found to correspond to a sedimentation effect within a large vascular space. Conclusion: Fluid–fluid levels in focal hepatic lesions do not indicate a specific diagnosis but can be seen in both malignant and benign conditions affecting the liver.