John F. Bruzzi

Pleural Effusion in Patients With Chronic Myelogenous Leukemia Treated With Dasatinib After Imatinib Failure

PURPOSE We investigated the risk factors and management of pleural effusion associated with dasatinib therapy for chronic myelogenous leukemia (CML) after failure of imatinib. PATIENTS AND METHODS We analyzed 138 patients with CML treated with dasatinib from November 2003 to January 2006 in one phase I (n = 50) and four phase II (n = 88) studies for the development of pleural effusion. RESULTS Pleural effusion occurred in 48 patients (35%; grade 3/4 in 23 [17%]), including 29% of those treated in chronic phase (CP), 50% in accelerated phase (AP), and 33% in blast phase (BP). By multivariate analysis, history of cardiac disease, hypertension, and use of a twice-daily schedule (v once daily) were identified as factors associated with development of pleural effusions. Effusions were exudative in 78% of the assessable cases. In some patients, effusions were associated with reversible increments of right ventricular systolic pressure. Management included transient dasatinib interruption in 83%, diuretics in 71%, pulse steroids in 27%, and thoracentesis in 19% of patients. CONCLUSION Pleural effusions occur during dasatinib therapy, particularly among patients in AP or BP. A twice-daily schedule may result in a higher incidence of pleural effusion. Close monitoring and timely intervention may allow patients to continue therapy and achieve the desired clinical benefit.

Endobronchial Ultrasound Guided Transbronchial Needle Aspiration in the Diagnosis of Lymphoma.

Background: The diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of lymphoma in patients with mediastinal lymphadenopathy is not well defined. Methods: A retrospective review was performed of all patients with mediastinal lymphadenopathy referred for EBUS-TBNA between August 2005 and December 2006 in whom lymphoma was suspected based on prior history or clinical presentation. Mediastinal biopsy specimens were taken using a linear array ultrasonic bronchoscope (Olympus XBF-UC 160F) and a 22-gauge cytology needle (NA-202C Olympus) with on-site cytopathological support. The EBUS-TBNA result was compared with a reference standard of pathological tissue diagnosis or a composite of ⩾6 months of clinical follow-up with radiographic imaging. Results: Of 236 patients who underwent EBUS-TBNA, 25 were eligible for inclusion. Indications for EBUS-TBNA were suspected mediastinal recurrence of lymphoma (n = 13) and mediastinal lymphadenopathy of unknown cause (n = 12). Adequate lymph node sampling was accomplished in 24/25 patients (96%); there were no complications. EBUS-TBNA identified lymphoma in 10 patients and benign disease in 14 patients. There was one false negative EBUS-TBNA for lymphoma (lymphoma prevalence 11/25 (44%)). Follow-up over a median of 10.5 months (range 1–19) confirmed stable or regressive lymphadenopathy in all 14 patients without a lymphoma diagnosis, consistent with a benign diagnosis. Overall, EBUS-TBNA had a sensitivity of 90.9%, specificity of 100%, positive predictive value of 100% and negative predictive value of 92.9% for the diagnosis of lymphoma. Conclusions: EBUS-TBNA is an accurate, safe and useful tool in the investigation of suspected lymphoma with isolated mediastinal adenopathy, and may diminish the need for more invasive procedures such as mediastinoscopy.

Detection of interval distant metastases: clinical utility of integrated CT-PET imaging in patients with esophageal carcinoma after neoadjuvant therapy.

The objective of the study was to determine the utility of integrated computed tomography / positron emission tomography (CT‐PET) imaging for detecting interval distant metastases and assessing therapeutic response in patients with locally advanced, potentially resectable esophageal carcinoma after neoadjuvant therapy.

Clinical utility of PET/CT in lymphoma

OBJECTIVE The purpose of this review is to assist interpreting radiologists in becoming familiar with the role of PET/CT in baseline staging and therapeutic response assessment in the management of lymphoma, in becoming aware of imaging pitfalls, and in understanding the natural behavior of lymphoma and the therapeutic options. CONCLUSION Therapeutic strategies for the management of lymphoma are constantly being refined to improve long-term survival with the lowest risk of toxicity to the patient. PET/CT is accurate for baseline staging and yields important prognostic information for determining the most appropriate initial treatment. Used for evaluation of treatment response, PET/CT can depict residual viable malignant lesions with greater accuracy than can other imaging techniques. The findings thereby influence decisions about the need for additional or alternative treatment.

Preoperative Chemo-Radiation-Induced Ulceration in Patients with Esophageal Cancer: A Confounding Factor in Tumor Response Assessment in Integrated Computed Tomographic-Positron Emission Tomographic Imaging

Hypothesis: Positron emission tomography can be useful in predicting response of esophageal cancer after preoperative chemo-radiation therapy (CRT). We evaluated the use of integrated computed tomography (CT)-PET among patients with esophageal cancer being considered for resection after CRT. Methods: Three reviewers blinded to clinical and pathologic staging retrospectively reviewed the CT-PET scans of patients with esophageal cancer after preoperative CRT who underwent esophagectomy. [18F]-fluoro-2-deoxy-D-glucose uptake for residual malignancy was determined by visual analysis and semi-quantitatively when standardized uptake value (SUV) was ≥4. Results: Forty-two patients underwent esophageal resection. Using visual analysis, CT-PET had a sensitivity of 47% and specificity of 58% in detecting residual malignancy. Using semi-quantitative analysis, 19 patients had a SUV ≥4 in the region of the primary esophageal tumor and were interpreted as having residual malignancy (sensitivity 43%, specificity 50%). Of these 19, six had complete pathologic response to CRT. These false-positive results, due to therapy-induced ulceration detected at endoscopy, limit the use of CT-PET alone in detecting residual malignancy. Similarly, sensitivity (25%) and specificity (73%) of endoscopy/biopsy in detecting residual malignancy were poor. However, the accuracy of CT-PET in detecting residual malignancy was improved when combined with endoscopic findings. In the absence of ulceration at endoscopy, 8 of 8 patients with SUV ≥4 after chemo-radiation had residual malignancy at surgery. Conclusions: CRT-induced ulceration results in false-positive results on CT-PET and precludes accurate detection of residual esophageal tumor. However, CT-PET in combination with endoscopy is useful in identifying patients with a high risk of residual tumor post-CRT.

PET/CT imaging of lung cancer.

Fluoro-deoxyglucose positron emission tomography (PET) imaging has a diagnostic and prognostic value in the initial staging, restaging, and surveillance of non–small-cell lung cancer (NSCLC). When used in conjunction with conventional radiologic imaging, PET imaging has been shown to result in significant changes in clinical management of NSCLC. Specifically, baseline PET imaging can improve initial staging and guide surgical and radiotherapy planning, whereas repeat PET imaging after the initiation of chemoradiotherapy can predict tumor response and help tailor therapy. After the end of definitive treatment, PET has greater diagnostic accuracy than other imaging modalities for the detection of tumor recurrence. The recent development of fused PET/CT imaging has improved the radiologic evaluation of NSCLC patients by combining metabolic and anatomic imaging; however, this has resulted in more complexity in the image interpretation. It is important for the interpreting physician to understand the role PET/CT plays in the staging, assessment of treatment, and follow-up after therapy in the multidisciplinary management of patients with NSCLC.

Imaging of non-small cell lung cancer of the superior sulcus: part 2: initial staging and assessment of resectability and therapeutic response.

Imaging plays a crucial role in the diagnosis and staging of superior sulcus tumors, assessment of their resectability, determination of the optimal approach to disease management, and evaluation of the response to therapy. Computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET)/CT contribute important and complementary information. Whereas CT is optimal for depicting bone erosion and for staging of intrathoracic disease, MR imaging is superior for evaluating tumor extension to the intervertebral neural foramina, the spinal cord, and the brachial plexus, primarily because of the higher contrast resolution and multiplanar capability available with MR imaging technology. Use of PET/CT enables the detection of unsuspected nodal and distant metastases. However, imaging has only limited usefulness for evaluating the response of a tumor to induction therapy and detecting local recurrence, and surgical biopsy often is necessary to verify the results of therapy.

Sonography of Pediatric Small-Bowel Intussusception: Differentiating Surgical from Nonsurgical Cases

OBJECTIVE The purpose of this study was to determine whether there are clinical or sonographic findings that can be used to differentiate benign self-limited small-bowel intussusception from pathologic small-bowel intussusception that necessitates surgical intervention. MATERIALS AND METHODS A retrospective search was performed of abdominal sonograms obtained at two institutions between January 1996 and June 2005. Sonographic findings were correlated with medical and surgical records. RESULTS A total of 35 cases of isolated small-bowel intussusception were found. Thirteen (37%) of these cases necessitated surgical intervention, and 22 (63%) of the cases were benign and self-limiting. Patients with self-limiting intussusception were younger than patients with intussusception necessitating surgical intervention (mean, 4.2 vs 7.5 years; p = 0.0327). Abdominal sonograms depicted ascites and small-bowel obstruction significantly more frequently in patients with small-bowel intussusception necessitating surgery (n = 7 [54%] for each finding) than in patients with self-limiting intussusception (n = 2 [9%], n = 0) (p = 0.006 and p = 0.0003, respectively). At sonography, patients who later underwent surgical intervention had small-bowel intussusception of significantly greater length (mean, 7.3 cm) than those treated conservatively (mean length, 1.9 cm) (p < 0.0001). Intussusception length greater than 3.5 cm was considered a sensitive and specific independent predictor of the need for surgery (sensitivity, 93%; specificity, 100%). CONCLUSION When small-bowel intussusception is detected in infants and children undergoing abdominal sonography, intussusception length greater than 3.5 cm is a strong independent predictor of the need for surgical intervention.

Incidental Findings on Integrated PET/CT That Do Not Accumulate 18F-FDG

OBJECTIVE The purpose of this study was to report the prevalence of abnormalities that do not show increased 18F-FDG uptake on the CT component of integrated PET/CT in patients with non-small cell lung cancer. MATERIALS AND METHODS Images from all PET/CT studies performed consecutively between April and October 2003 on patients with non-small cell lung cancer were retrospectively reviewed. All abnormalities present on the CT component of the PET/CT scans that did not show abnormally increased 18F-FDG uptake were documented. RESULTS Three hundred twenty-one patients with non-small cell lung cancer (179 men, 142 women; mean age, 67 years; age range, 38-91 years) underwent initial staging (198/321 [62%]) or restaging (123/321 [38%]) PET/CT imaging during the study period. In 263 (82%) of the patients, CT showed 1,231 abnormalities that were not 18F-FDG avid. The abnormalities were located in the thorax (n = 650), abdomen and pelvis (n = 444), head and neck (n = 69), and bony skeleton (n = 68). In total, 298 (24%) of the abnormalities that were not 18F-FDG avid were located outside the range of a standard thoracic CT scan. The clinical importance of these abnormalities was classified as major (n = 48 [4%]), moderate (n = 465 [38%]), or minor (n = 718 [58%]). Four (1%) of the patients had findings of major clinical importance that did not show increased 18F-FDG uptake and were previously unsuspected. CONCLUSION Among patients with non-small cell lung cancer undergoing PET/CT, there is a high prevalence of CT abnormalities that do not show correlative 18F-FDG avidity but that may be clinically important.

Imaging of non-small cell lung cancer of the superior sulcus: Part 1: Anatomy, Clinical Manifestations, and Management

Non-small cell carcinomas of the superior pulmonary sulcus represent 3% of all lung cancers and are associated in most cases with a poor clinical outcome. Multimodality therapy with irradiation, chemotherapy, and surgery offers the best possibility for long-term survival and cure in most cases. For patients with pulmonary sulcus tumors that are not surgically resectable, chemoradiotherapy may help prolong survival and provide long-term pain relief. To accurately determine tumor resectability and to help optimize the planning and delivery of therapy, radiologists need a detailed knowledge of the clinical and imaging manifestations of disease in the individual patient and an awareness of the therapeutic options available. Accurate three-dimensional imaging and image interpretation are essential for mapping of the primary tumor before irradiation or surgical resection. Familiarity with the complex anatomy of the superior pulmonary sulcus is particularly crucial for determining the local-regional extension of a tumor and the most appropriate surgical approach.