Ryan James Bair

Clinical Outcomes for Gastric Cancer following Adjuvant Chemoradiation Utilizing Intensity Modulated versus Three-Dimensional Conformal Radiotherapy

Purpose/Objective(s) To determine if intensity modulated radiation therapy (IMRT) in the post-operative setting for gastric cancer was associated with reduced toxicity compared to 3D conformal radiation therapy (3DCRT). Materials/Methods This retrospective study includes 24 patients with stage IB-IIIB gastric cancer consecutively treated from 2001–2010. All underwent surgery followed by adjuvant chemoradiation. Concurrent chemotherapy consisted of 5-FU/leucovorin (n = 21), epirubicin/cisplatin/5FU (n = 1), or none (n = 2). IMRT was utilized in 12 patients and 3DCRT in 12 patients. For both groups, the target volume included the tumor bed, anastomosis, gastric stump, and regional lymphatics. Results Median follow-up for the entire cohort was 19 months (range 0.4–8.5 years), and 49 months (0.5–8.5 years) in surviving patients. The 3DCRT group received a median dose of 45 Gy, and the IMRT group received a median dose of 50.4 Gy (p = 0.0004). For the entire cohort, 3-year overall survival (OS) was 40% and 3-year disease free survival (DFS) was 41%. OS and DFS did not differ significantly between the groups. Acute toxicity was similar. Between 3DCRT and IMRT groups, during radiotherapy, median weight lost (3.2 vs. 3.3 kg, respectively; p = 0.47) and median percent weight loss were similar (5.0% vs. 4.3%, respectively; p = 0.43). Acute grade 2 toxicity was experienced by 8 patients receiving 3DCRT and 11 receiving IMRT (p = 0.32); acute grade 3 toxicity occurred in 1 patient receiving 3DCRT and none receiving IMRT (p = 1.0). No patients in either cohort experienced late grade 3 toxicity, including renal or gastrointestinal toxicity. At last follow up, the median increase in creatinine was 0.1 mg/dL in the IMRT group and 0.1 mg/dL in the 3DCRT group (p = 0.78). Conclusion This study demonstrates that adjuvant chemoradiation for gastric cancer with IMRT to 50.4 Gy was well-tolerated and compared similarly in toxicity with 3DCRT to 45 Gy.

Longitudinal study of acute haematologic toxicity in cervical cancer patients treated with chemoradiotherapy.

Acute hematologic toxicity (HT) limits optimal delivery of concurrent chemoradiotherapy (CRT) for patients with pelvic malignancies. We tested the hypothesis that pelvic bone marrow (PBM) dose‐volume metrics were associated with weekly reductions in peripheral blood cell counts in cervical cancer patients undergoing CRT.

Demystifying NUT Midline Carcinoma: Radiologic and Pathologic Correlations of an Aggressive Malignancy

OBJECTIVE NUT midline carcinoma is a rare poorly differentiated aggressive subtype of squamous cell carcinoma. To date, fewer than 100 total cases have been reported. CONCLUSION Given the rarity of this disease process and lack of pathognomonic imaging findings, a definitive diagnosis based solely on imaging findings alone is untenable. Select cases are used to emphasize the particularly infiltrative and aggressive nature of NUT midline carcinoma, which shows a complete disregard for normal tissue boundaries and rapid progression during brief intervals.

Giant left atrium in rheumatic heart disease: the classic signs of left atrial enlargement.

*Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, †Department of Medicine, Stanford University Hospital andClinics, Stanford University School of Medicine, Stanford, California, and ‡Department of Radiation andCellular Oncology, University of Chicago Medical Center, Pritzker School of Medicine, Chicago, Illinois Reprint Address: Jeffrey F. B. Chick, MD, Department of Radiology, Brigham andWomen’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115

Complex iatrogenic esophageal injuries: an imaging spectrum.

AJR:204, February 2015 Disease Epidemiology Esophageal injuries are classified into two broad subcategories: iatrogenic and noniatrogenic. Iatrogenic injuries represent more than half of all cases and have been reported to represent as many as 59% of cases, with endoscopic injury being the most common cause [1]. Although the relative incidence of esophageal injury during endoscopy is low (< 0.04%), because of its overall prevalence, it represents the most common cause of iatrogenic esophageal injury [2]. Noniatrogenic esophageal injuries are most commonly spontaneous perforations occurring after foreign body ingestion (15% of cases), food impaction or vomiting (12% of cases), and trauma (9% of cases) [1]. The average mortality rate is 19% for iatrogenic esophageal injury, compared with 36% for noniatrogenic causes. This difference in mortality results from the subacute nature of many noniatrogenic injuries leading to a delay in diagnosis and treatment [3].

Traffic Jam in the Duodenum: Imaging and Pathogenesis of Bouveret Syndrome

A 90-year-old woman with a history of cholelithiasis and chronic cholecystitis presented to the hospital with nausea, bilious vomiting, and anorexia for 3 days. The patient denied fevers, chills, hematemesis, hematochezia, or melena. Physical examination was notable for an uncomfortable woman with epigastric tenderness. An abdominal radiograph was obtained and demonstrated pneumobilia and an enlarged gastric bubble (Figure 1). Subsequent computed tomography with intravenous contrast material was obtained and demonstrated a gallstone in the proximal duodenum causing gastric distention, consistent with Bouveret syndrome (Figure 2). The patient underwent endoscopic-guided lithotripsy with resolution of symptoms.

The Lady Windermere Syndrome

A 78-year-old woman with bronchiectasis, numerous prior admissions for bacterial pneumonia, and mitral valve prolapse presented to this hospital with fever and cough for 6 days. The patient reported developing a nagging, persistent cough described as ‘‘inhaling cake crumbs,’’ without sputum production 6 days prior. Concomitantly, the patient experienced low-grade temperatures ranging from 37.8–38.6 C. On presentation to this hospital, the patient reported worsening ‘‘coughing attacks,’’ complicated by diffuse myalgias and generalized weakness. The patient, however, denied recent illnesses or travel. Physical examination was notable for a temperature of 38.9 C, respirations of 29 breaths per minute, an oxygen saturation of 90 % while breathing ambient air, and diffuse wheezing and rhonchi throughout all the lung fields. A chest radiograph showed widespread bronchiectasis bilaterally, but no consolidative opacities, pleural effusions, pulmonary edema, or pneumothoraces (Fig. 1). Computed tomography of the chest without intravenous contrast material demonstrated moderate bilateral bronchiectasis as well as tree-in-bud nodularity throughout the right, middle and lingular segments, suggestive of mycobacterium avium–intracellulare infection (Fig. 2). Two separate sputum samples were obtained, and were subsequently positive for mycobacterium avium–intracellulare. Human immunodeficiency virus testing was negative. The patient was initially prescribed ceftazidime and levofloxacin with transition to clarithromycin, rifampin, and ethambutol for 1 year, with complete resolution of her symptoms. Repeated computed tomography of the chest without intravenous contrast material completed 6 months later demonstrated persistent, moderate bilateral bronchiectasis with near complete resolution of the previously seen tree-in-bud nodularity, suggestive of resolving mycobacterium avium–intracellulare infection (Fig. 3).

Pulmonary cement emboli after kyphoplasty

CaseA 37-year-old woman with estrogen/progesterone receptorpositive breast cancer with metastases to the lungs, liver,and lumbar spine, being treated with vinorelbine, initiallypresented to this hospital with severe lower back pain. Atthe time of presentation, multiplanar magnetic resonanceimaging of the spine after the administration of intravenousgadolinium demonstrated anterior wedge compressiondeformities of the L1 and L2 vertebral bodies (Fig. 1). Thepatient underwent bilateral transpedicular kyphoplasty,without evidence of cement extravasation (Fig. 2). Onemonth later, after an uneventful recovery, the patientreturned to this hospital with pleuritic chest pain, shortnessof breath, and generalized weakness for 4 days. On phys-ical examination, the patient was tachycardic with a heartrate of 115 beats per min, with diffuse chest wall tender-ness and diminished breath sounds at the bilateral lungbases. Laboratory testing demonstrated an elevatedD-dimer of 1,700 ng/mL (normal reference range less than250 ng/mL). A portable chest radiograph demonstrated apossible serpiginous linear density within the left lung,without evidence of pneumonia, pleural effusions, orpneumothorax (Fig. 3). Given the patient’s pleuritic chestpain, shortness of breath, and tachycardia, history of met-astatic disease, and elevated D-dimer, computed tomogra-phy of the chest with pulmonary angiography protocol wascompleted to evaluate for pulmonary emboli. Analysis ofthe study demonstrated numerous linear hyperdensitiesthroughout the arterial tree, consistent with pulmonarycement emboli from the prior kyphoplasty as well asmultiple hypodense filling defects representing associatedthrombi (Fig. 4). The patient was admitted to the MedicalOncology Service, where she was started on enoxaparin,and eventually discharged with plans to continue vinorel-bine treatments. On return clinic visits 1 month later, thepatient reported complete resolution of chest pain, short-ness of breath, and weakness, with mild improvement inback pain.DiscussionVertebral body compression fractures are common,occurring at a rate of 500 per 100,000 in patients aged50–54 and 2,960 per 100,000 in patients older than 85, andprompting numerous emergency department visits per year[1]. Initial treatment consists of conservative measuresincluding analgesia, bed rest, and bracing. Further man-agement of intractable pain from vertebral compressionfractures may be undertaken with vertebroplasty and kyp-hoplasty, although these procedures remain somewhatcontroversial. Vertebroplasty and kyphoplasty are associ-ated with a variety of complications including infection,

Intestinal malrotation and acute left-sided appendicitis.

*Department of Radiology, †Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, and ‡Department of Radiation Oncology, University of Chicago Medical Center, Pritzker School of Medicine, Chicago, Illinois Reprint Address: Jeffrey F. B. Chick, MD, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, 75 Francis Street, Boston, MA 02115

The many faces of Behçet's disease.

A 23-year-old man with fevers, night sweats, lymphadenopathy, worsening vision, and aphthous ulcers was diagnosed with Behçets disease. Multiple diagnostic imaging modalities were used to identify various multisystem complications associated with Behçets disease including vascular thomboses, mediastinal fibrosis, chylothoraces, chylopericardium and coronary artery aneurysms.