Todd R. Hazelton

Feasibility and Efficacy of Molecular Analysis-Directed Individualized Therapy in Advanced Non–Small-Cell Lung Cancer

PURPOSE The treatment of patients with advanced non-small-cell lung cancer (NSCLC) is based on clinical trials experience. Molecular characteristics that impact metabolism and efficacy of chemotherapeutic agents are not used for decision making. Ribonucleotide reductase subunit 1 (RRM1) is crucial for nucleotide metabolism, and it is the dominant molecular determinant of gemcitabine efficacy. Excision repair cross-complementing group 1 gene (ERCC1), a component of the nucleotide excision repair complex, is important for platinum-induced DNA adduct repair. We hypothesized that selection of double-agent chemotherapy based on tumoral RRM1 and ERCC1 expression would be feasible and beneficial for patients with advanced NSCLC. PATIENTS AND METHODS We conducted a prospective phase II clinical trial in patients with advanced NSCLC. Patients were required to have a dedicated tumor biopsy for determination of RRM1 and ERCC1 gene expression by real-time quantitative reverse transcriptase polymerase chain reaction. Double-agent chemotherapy consisting of carboplatin, gemcitabine, docetaxel, and vinorelbine was selected based on gene expression. Disease response and patient survival were monitored. RESULTS Eighty-five patients were registered, 75 had the required biopsy without significant complications, 60 fulfilled all eligibility criteria, and gene expression analysis was not feasible in five patients. RRM1 expression ranged from 0 to 1,637, ERCC1 expression ranged from 1 to 8,103, and their expression was correlated (Spearmans rho = 0.46; P < .01). Disease response was 44%. Overall survival was 59% and progression-free survival was 14% at 12 months, with a median of 13.3 and 6.6 months, respectively. CONCLUSION Therapeutic decision making based on RRM1 and ERCC1 gene expression for patients with advanced NSCLC is feasible and promising for improvement in patient outcome

ACR-STR practice parameter for the performance and reporting of lung cancer screening thoracic computed tomography (CT): 2014 (Resolution 4)

Author(s): Kazerooni, Ella A; Austin, John HM; Black, William C; Dyer, Debra S; Hazelton, Todd R; Leung, Ann N; McNitt-Gray, Michael F; Munden, Reginald F; Pipavath, Sudhakar; American College of Radiology; Society of Thoracic Radiology | Abstract: The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists,and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance thescience of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encouragecontinuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields.The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to helpadvance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters andtechnical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensusprocess in which it has been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safeand effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document.Reproduction or modification of the published practice parameter and technical standard by those entities not providing these services is notauthorized.?

Aspiration-related lung diseases.

Aspiration is a common but underrecognized clinicopathologic entity, with varied radiographic manifestations. Aspiration represents a spectrum of diseases, including diffuse aspiration bronchiolitis, aspiration pneumonitis, airway obstruction by foreign body, exogenous lipoid pneumonia, interstitial fibrosis, and aspiration pneumonia with or without lung abscess formation. Many patients who aspirate do not present with disease, suggesting that pathophysiology is related to a variety of factors, including decreased levels of consciousness, dysphagia, impaired mucociliary clearance, composition of aspirate, and impaired host defenses. In this pictorial essay, we will review the different types of aspiration lung diseases, focusing on their imaging features and differential diagnosis.

Composite and classified color display in MR imaging of the female pelvis

Because of its superior soft-tissue-imaging capabilities, MRI has proved to be an excellent modality for visualizing the contents of the female pelvis. In an effort to potentially improve gynecological MRI studies, we have applied color composite techniques to sets of spin-echo and gradient-echo gray-tone MR images obtained from various individuals. For composite generation, based on tissue region of interest calculated mean pixel intensity values, various colors were applied to spatially aligned images using a DEC MicroVAX II computer with interactive digital language (IDL) so that tissue contrast patterns could be optimized in the final image. The IDL procedures, which are similar to those used in NASAs LANDSAT image processing system, allowed the generation of single composite images displaying the combined information present in a series of spatially aligned images acquired using different pulse sequences. With our composite generation techniques, it was possible to generate seminatural-appearing color images of the female pelvis that possessed enhanced conspicuity of specific tissues and fluids. For comparison with color composites, classified images were also generated based on computer recognition and statistical separation of distinct tissue intensity patterns in an image set using the maximum likelihood processing algorithm.

PC-based multiparameter full-color display for tissue segmentation in MRI of adnexal masses.

Objective Our purpose was to apply full-color composite generation methods to multiparameter MRI to assess the ability of the technique to quantitatively segment clinically important anatomic and pathologic tissues. Materials and Methods: With use of a personal computer with a 386 micro processor and full-color (24 bit) graphics display capabilities, custom and commercially available image-processing softwares were applied to spatially aligned multiparameter SE MR image sets obtained from six patients under going diagnostic work-up for suspected adnexal or pelvic masses to generate intensity-based color composites. To quantitatively assess the ability of this technique to differentially segment anatomically and pathologically confirmed tissue types into unique color regions within the full-color spectrum, color image analysis was performed on the multiparameter color composites within each patient case, and the results were compared using 95% confidence intervals. Results: Based on the results of pathologic correlation and color image analysis, the generation of full-color composites represents a feasible technique for compressing the diverse tissue contrast data present in multiparameter MR images of adnexal masses. Conclusion: With this technique, it is possible to generate composites that simultaneously display uniquely color-coded anatomic and pathologic tissue information within the context of partially natural-appearing images.

Gerbode ventricular septal defect diagnosed using cardiac CTA imaging.

This report describes the ability of computed tomography angiography (CTA) imaging of the heart to visualize an acquired shunt between the left ventricular outflow tract (LVOT) and the right atrium (RA) (Gerbode defect). Previously, transesophageal echocardiography (TEE) has been the mainstay of diagnosis. To the best of our knowledge, the use of cardiac CTA imaging to visualize and diagnose this disorder has not been previously reported. Cardiac CTA allows for more detailed visualization of cardiac anatomy and can supplement or supplant TEE as the diagnostic test of choice for evaluation of patients with this rare defect.

External beam irradiation of myocardial carcinoid metastases: a case report

The heart is an exceedingly rare site of metastatic involvement in carcinoid tumors. Only nineteen cases have been described in the literature over the past 30 years. We report here on a patient who presented with progressive carcinoid syndrome despite surgical resection of her liver metastases. She was found to have cardiac metastases on inidium-111-pentetreotide scintigraphy and subsequently underwent external beam radiation to the heart resulting in symptomatic palliation of her syndrome and objective radiographic response. To our knowledge, this is the first reported case of metastatic cardiac carcinoid treated with external beam irradiation.

To breathe or not to breathe: a review of artificial airway placement and related complications.

Artificial airway devices are commonly used to provide adequate ventilation and/or oxygenation in multiple clinical settings, both emergent and nonemergent. These frequently used devices include laryngeal mask airway, esophageal–tracheal combitube, endotracheal tube, and tracheostomy tube and are associated with various acute and late complications. Clinically, this may vary from mild discomfort to a potentially life-threatening situation. Radiologically, these devices and their acute and late complications have characteristic imaging findings which can be detected primarily on radiographs and computed tomography. We review appropriate positioning of these artificial airway devices and illustrate associated complications including inadequate positioning of the endotracheal tube, pulmonary aspiration, tracheal laceration or perforation, paranasal sinusitis, vocal cord paralysis, post-intubation tracheal stenosis, cuff overinflation with vascular compression, and others. Radiologists must recognize and understand the potential complications of intubation to promptly guide management and avoid long-term or even deadly consequences.

Reversed Halo Sign on CT as a Presentation of Lymphocytic Interstitial Pneumonia

A 52 year-old African American female with a past medical history of symptomatic uterine fibroids and increasing abdominal circumference underwent abdominal computed tomography (CT) as part of her workup. Because of an abnormality in the left lower lobe, CT of the chest was subsequently performed and showed a focal region of discontinuous crescentic consolidation with central ground glass opacification in the right lower lobe, suggestive of the reversed halo sign. The patient underwent percutaneous CT-guided core biopsy of the lesion, which demonstrated lymphocytic interstitial pneumonia, a benign lymphoproliferative disease characterized histologically by small lymphocytes and plasma cells. This case report describes the first histologically confirmed presentation of lymphocytic interstitial pneumonia with the reversed halo sign on CT.

Delayed levorotation of the heart in traumatic pericardial rupture

Traumatic pericardial rupture, with complicating cardiac herniation, is an extremely uncommon condition with a high mortality rate. We are reporting our experience with a case of blunt trauma to the chest, secondary to high-impact motor vehicle collision. The preoperative diagnosis of ascending aortic transection was made on subsequent imaging studies for which surgical repair was elected. Upon thoracotomy, a posterior pericardial tear was found to be associated with laterally displaced cardiac axis. Delayed levorotation of the cardiac axis in traumatic pericardial rupture is an uncommon finding and needs to be recognized in a timely manner.