Radiological features of extraskeletal Ewing sarcoma

The radiological features of extraskeletal Ewing sarcoma were reviewed in 22 patients whose average age was 22 years. Tumours were located in the extremities (11 patients), abdomen or pelvis (six patients) and the chest (five patients). The tumours ranged in size from 2 cm to 20 cm, were mainly well circumscribed and showed no evidence of calcification prior to treatment. Most tumours (13 out of 14) were of low attenuation or contained areas of lower attenuation than muscle on computed tomographic examination, and in six out of seven patients studied by ultrasound the tumours were hypoechoic or partly anechoic. No distinctive post-contrast medium enhancement pattern on CT examination (11 patients) or angiographic features (three patients) were evident. Tumour haemorrhage was a frequent microscopic finding and changes consistent with this were present in one patient on magnetic resonance imaging examination. Distant metastases or local recurrence developed in 13 patients with lung being the most frequent metastatic site (eight patients). Although its radiological features are non-specific, extraskeletal Ewing sarcoma should be included in the differential diagnosis of noncalcified soft-tissue tumours especially in a young age group and where located in an extremity or paravertebral region of the chest.

Hepatic artery infusion and chemoembolization in the management of liver metastases

Hepatic metastases rather than the primary neoplasm usually dictate the course of the disease and patient's survival. For unresectable disease, intraarterial infusion of chemotherapy, embolization, and chemoembolization are viable alternatives. Intraarterial therapy for hepatic metastases is based on the dual blood supply of the normal liver (portal vein, 75%, and hepatic artery, 25%) and that of the tumors (hepatic artery, 90%). Intraarterial infusion delivers a higher concentration of chemotherapy, whereas chemoembolization adds ischemia and increased contact time with the tumor. Selective vascular occlusion for infusion, redistribution of the blood supply and pulsatile flow enhance the delivery of therapeutic agents to the liver.

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).

Osteosarcoma: MR imaging after preoperative chemotherapy

The authors reviewed 76 magnetic resonance (MR) images of 38 patients with osteosarcoma treated with preoperative chemotherapy (intraarterial cisplatin with or without systemic chemotherapy). Histologic maps of the surgical tumor specimens in 33 cases were correlated with either late-chemotherapy or postchemotherapy MR images. There were four MR patterns--dark, mottled or speckled, homogeneous, and cystic--that corresponded to different amounts of tumor matrix, granulation tissue, hemosiderin deposits, fluid-filled cysts, and residual viable tumor. Nested foci of residual viable tumor could not be specifically identified, although tumor progression or skip metastases were accurately depicted in four patients. Other findings included (a) peritumoral edema in the soft tissues and intramedullary space that shrank with chemotherapy, (b) chemotherapy effect in the surrounding soft tissues, (c) a dark rim around the extramedullary component of the tumors corresponding to a collagenous capsule continuous with the periosteum, (d) development of metaphyseal hemorrhages and bone marrow infarcts, and (e) intramedullary vascular channels.

Splenic versus hepatic artery infusion of interleukin-2 in patients with liver metastases

In an attempt to improve the therapeutic index of recombinant interleukin-2 (rIL-2) by generating or activating lymphokine-activated killer (LAK) cells and tumor-infiltrating lymphocytes (TIL) regionally and/or in situ, we randomly assigned 28 patients with liver metastases to receive rIL-2 by continuous infusion for 5 days via either the splenic artery or the hepatic artery. Clinically significant and lasting tumor regression was observed only in two of 28 patients (7%), one in each of the two treatment arms. The maximum-tolerated daily dosage of rIL-2 was 3 x 10(6) U/m2; beyond this dosage, toxicity was excessive. Peripheral LAK cell activity measured in vitro and clinical tumor regression did not correlate. This observation, coupled with the equal distribution of regressions between the two treatment arms, raises the possibility that tumor regression, rare though it may be in response to rIL-2 administration, is largely mediated by TIL activation and not by LAK cell generation.

Sonographic findings of adrenal cortical carcinomas in children

Fourteen children with adrenal cortical carcinoma were evaluated by ultrasonography. The neoplasms, 2.5 cm-19 cm in maximum diameter, were all well circumscribed. The four smaller lesions were either homogeneously hypoechoic (2 patients) or generally hyperechoic (2 patients). In the 10 patients with larger tumors, a complex predominantly echogenic pattern was demonstrated, eight of which contained radiating linear echoes, the "scar sign". This finding, although not specific, when present in a large adrenal mass, is suggestive of a cortical carcinoma. Associated findings of vascular invasion or retroperitoneal adenopathy supported the diagnosis of a malignant adrenal neoplasm in 3 patients.

Sonographic features of benign intraperitoneal lipomatous tumors in children--report of 4 cases

Four children with benign intraperitoneal lipomatous tumors (mesenteric lipoma, mesenteric lipoblastoma, omental lipoblastoma and mesenteric mesenchymoma) are reported. The ultrasonographic findings of these unusual pediatric masses are described and correlated with their conventional radiologic and pathologic appearance. The pre-operative diagnosis of these entities can be suggested by these features.

Systemic and regional therapy of advanced islet cell tumors

Asymptomatic patients with islet cell tumors should be observed every 3 to 6 months. Once symptomatic, many therapeutic choices exist. First choice would be symptomatic management resulting in minimum side effects. More aggressive approaches include systemic therapy with cytotoxic or biologic agents. Vascular occlusion provides useful palliation of liver metastases.

Small cell osteosarcoma. A clinicopathologic study of 27 cases

We report a study of 27 patients with small cell osteosarcoma (SCO), 17 from the M. D. Anderson Cancer Center (MDAH) and ten from the Pediatric Oncology Group (POG). There were 12 male patients and 15 female patients; 19 were white, five were black, and three were Hispanic. They ranged from 6 to 28 years of age with a median of 14 years. Histologically there were three patterns: Ewing's-like, lymphoma-like, and spindle cell. All cases showed osteoid formation and a few had chondroid areas. There was cytoplasmic glycogen in ten cases. Initial treatment for MDAH patients included intraarterial infusion of cisplatin in ten, amputation in four, partial mandibulectomies in two, and biopsy with local radiotherapy and systemic chemotherapy in one. All POG patients had resection or amputation followed by adjuvant chemotherapy. Twelve patients are alive, of whom nine have had significant follow-ups for 25 to 90 months. Fourteen patients are dead of lung, spine, and brain metastases from 1 to 23 months after initial diagnosis. One patient is alive with lung relapse at 4 months. In summary, SCO is a high-grade variant of osteosarcoma, with an incidence of up to 4% of all osteosarcomas, that affects patients of the same age group and has the same anatomic location as conventional osteosarcoma. Currently, SCO appears to have a prognosis that is the same as or slightly worse than that of conventional osteosarcoma. Furthermore, although intraarterial infusion is effective for the primary tumors in the bone, distant metastases are difficult to control.

MR imaging of liposarcomas: correlation of MR features and histology

The magnetic resonance (MR) imaging features of liposarcoma were correlated with histology in 15 patients. The MR findings for liposarcoma were not specific. The six myxoid liposarcomas and two atypical lipomatous tumors, however, had distinctive MR features, i.e., nodular masses of slightly heterogeneous intermediate to high signal intensity (SI), intermingled with high SI septa on T1-weighted images. The T2-weighted images demonstrated the relative reversal of these regional SI characteristics. Additionally, MR correctly identified the presence of fat in all eight cases in which it was pathologically present. The fat in two atypical lipomatous tumors was inseparable on MR from the subcutaneous fat. Magnetic resonance appears useful for preoperative staging and follow-up studies of liposarcomas. It may be helpful in identifying patients with myxoid liposarcoma and atypical lipomatous tumors who have longer survival times.

The clinical and radiologic manifestations of hemangiopericytoma

The clinical and radiologic findings in nine patients with hemangiopericytoma were reviewed. There were eight women and one man with a mean age of 46 years. Seven of the neoplasms, including two locally recurrent tumors, were in the pelvis and two were in the thigh. Conventional radiographs were available for all patients. Five patients were evaluated by sonography, four by CT, three by angiography, and two by MR imaging. There was evidence of compression of adjacent viscera by six of the seven pelvic tumors with associated hydronephrosis in one patient. One thigh lesion had focal areas of speckled calcification. All five neoplasms evaluated by sonography showed a well-circumscribed hypoechoic lesion and three had significant sound through-transmission. Hypervascularity was documented by contrast-enhanced CT or angiography in each of three patients in whom these procedures were performed. Surgical resection of the pelvic neoplasms was complicated by marked hemorrhage. Hemangiopericytoma should be considered in the differential diagnosis of well-circumscribed hypervascular tumors in a middle-aged patient.

The radiologic manifestations of alveolar soft-part sarcoma

Alveolar soft-part sarcoma is a rare soft-tissue tumor of unknown cellular origin that is characterized histologically by its organized "pseudoalveolar" pattern. The radiologic findings in 11 patients with this neoplasm were reviewed. The six men and five women were 16-48 years old (mean, 27 years). Nine patients had untreated primary tumors (thigh, four; forearm, two; and buttock, rectus abdominis muscle, and infratemporal fossa, one each) and two had locally recurrent masses (one each in the retroperitoneum and retrocrural space). All patients were evaluated by conventional radiography, two by sonography, eight by CT, five by angiography, and three by MR. Conventional radiographs showed the soft-tissue mass in only four patients; four lesions caused destruction of adjacent bone and two had soft-tissue calcification. Unenhanced CT showed low-attenuation lesions in four of five patients. The lesions were hypervascular on contrast-enhanced CT or angiography in each of nine patients studied. Prominent draining veins were shown by CT or angiography in five patients. Three lesions had a prolonged capillary stain on angiography. Alveolar soft-part sarcoma should be considered in the differential diagnosis of a hypervascular soft-tissue mass, particularly in the thigh of a young adult.

Percutaneous drainage and feeding gastrostomies in 100 patients

Percutaneous gastrostomy was performed in 100 cancer patients. In 67 patients with bowel obstruction, the procedure was performed for gastric drainage with 24-28-F Malecot catheters inserted in one sitting. The remaining 33 patients had supragastric obstructions or fistulas and required 10-14-F pigtail catheters for feeding purposes. Average postgastrostomy hospitalization was 3.6 days. Drainage gastrostomies were ready for use immediately after the procedure, whereas use of feeding gastrostomies started on average within 2 days of tube insertion. There were no major complications or deaths related to the procedure. Percutaneous gastrostomy is a simple and safe procedure even when large-caliber catheters are used, and it does not require gastric fixation to the abdominal wall to prevent spillage into the peritoneum.

Malignant cardiac fibrous histiocytomas and angiosarcomas: MR features

Primary tumors of the heart are rare, and one-third of them are malignant. The magnetic resonance (MR) features, their specificity, and significance in two patients with malignant fibrous histiocytoma and three patients with angiosarcoma are presented and the literature briefly reviewed. Malignant fibrous histiocytoma occurred in the left atrium and demonstrated slightly heterogeneous intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The angiosarcomas involving primarily the right heart were more varied in MR appearance with heterogeneous signals. The extensive angiosarcomas almost circumferentially involving the epicardium and pericardium showed the "cauliflower" appearance with focal areas of increased signal intensity probably related to thrombosis or hemorrhage. Magnetic resonance provided detailed anatomic information and characterization of malignant cardiac tumors.

Randomized comparison of viral oncolysate plus radiation and radiation alone in uterine cervix carcinoma

A randomized, controlled study was performed in patients with high-risk, untreated squamous cell carcinoma of the uterine cervix to evaluate the adjunctive use of viral oncolysate (VO) prepared from the SW756 cell line. Seventy-five patients were stratified by tumor volume and randomized to receive radiation therapy (RT) alone or RT plus intradermal immunization with VO. Fifty-one (68%) patients relapsed with a median survival (MS) of 29.1 months and a median progression-free interval (MPFI) of 18.0 months. No differences in MS or median PFI were observed by treatment arm or site of relapse, although a trend toward improved MS and median PFI in patients with small-volume primary lesions was suggested. Serum surface-binding antibody activity (greater than or equal to 1:8) to the SW756 cell line was detected in 14 of 41 unselected patients prior to therapy. Virus hemagglutination inhibitory activity (greater than or equal to 1:8) was detected in 37 of 41 patients before treatment. four-fold increases in titer were observed to the SW756 cell line in 83% and to influenza in 74% of patients tested after immunization. Preirradiation measurements of phytohemagglutinin-induced blastogenesis by the relative proliferation index (RPI) method in 39 patients revealed RPI values less than 0.58 in nine patients, eight of whom relapsed. At 3-6 months after the initiation of irradiation, 32 of 39 patients had values less than 0.58. Patients in the RT group with values less than 0.58 had significantly more relapses than those who received RT plus VO.

Variable patterns of technetium-99m MAA perfusion in the therapeutically embolized liver

Hepatic perfusion studies using 99mTc macroaggregate albumin (MAA) particles have been utilized to document arterial catheter position and flow distribution in patients who are to undergo hepatic arterial chemotherapy infusion (HAI). We have recently been treating nonresectable hepatic neoplasms with transcatheter hepatic arterial chemoembolization (HAE) followed by HAI. The MAA perfusion studies in these patients show variable patterns. For this reason, we have reviewed our recent experience with 15 patients who underwent 21 HAEs and HAIs. The arteriograms and the MAA perfusion studies were reviewed and correlated. Early (within 4 hr of embolization) perfusion studies revealed flow reversal, or MAA reflux into an undesirable location in 11 cases. Two selected follow-up scans in 24 hr revealed restoration of flow to the embolized lobe, confirming the proper position of the catheter for HAI. Knowledge of both the hepatic arterial anatomy, and of the specific embolization procedure will allow accurate interpretation of the MAA perfusion study. Initial flow reversal, or MAA reflux, should not be interpretated as a malpositioned catheter, but prompt reevaluation after a period of 24 hr to document restoration of antegrade flow is suggested.

Hepatic arterial infusion of human recombinant tumor necrosis factor-alpha. An experimental study in dogs

Local and systemic toxicities associated with hepatic arterial infusion of human recombinant tumor necrosis factor (rTNF) were studied in healthy adult mongrel dogs. The animals received saline containing human serum albumin with or without rTNF (0.02, 0.2, or 2.0 mg/m2). Arteriograms were made, and blood samples were collected for hematologic and biochemical analyses at regular intervals. The dogs were killed at 1, 3, and 7 days postinfusion and complete necropsies were performed. Specimens were obtained from various tissues for histopathologic evaluation. Results indicated that all but the highest dose of rTNF were well tolerated. Severe histopathologic changes were found in the liver, spleen, and kidneys of the animals receiving 2.0 mg/m2 rTNF. In addition, focal tubular degeneration was found in one dog administered 0.2 mg/m2 rTNF. These data suggest that the upper dose limit for hepatic arterial infusion of rTNF is between 0.2 and 2.0 mg/m2 and that renal function should be closely monitored after infusion.

Gastrointestinal and pancreatic endocrine tumours

The radiological diagnosis and interventional management of neuroendocrine tumours of the gastrointestinal tract and pancreas are challenging, demanding the complete gamut of available resources. Carcinoid tumours are most commonly found in the appendix and small bowel. Barium studies usually disclose a small solitary mucosal or submucosal mass in the distal ileum at times associated with smooth muscle hypertrophy and thickening of the mucosal folds. Intussusception and bowel obstruction may be the presenting finding. Mesenteric involvement may evoke a desmoplastic reaction with rigidity, fixation, angulation and tethering of small bowel loops. Angiography may demonstrate a hypervascular primary neoplasm but more frequently reveals vascular encasement and distortion from the mesenteric desmoplastic reaction. Pancreatic islet cell tumour is best defined radiologically by angiography and computed tomography as a well circumscribed hypervascular mass which enhances with contrast material. Portal venous sampling is of considerable assistance in localizing insulinoma. Metastases from neuroendocrine tumours to lymph nodes and to the liver are usually hypervascular. In the evaluation of the liver by CT scanning prior to contrast as well as dynamic scanning during the bolus intravenous injection of contrast material are necessary. At times the precontrast scan is more revealing. Computed tomography with the catheter in the superior mesenteric artery followed by selective hepatic arteriography is the most accurate combination for the detection of hepatic metastases. Interventional radiological management by sequential hepatic arterial embolization is the treatment of choice for multiple hepatic metastases from neuroendocrine tumours. Thus far, the maximum number of embolic episodes in a single patient has been 13. The carcinoid syndrome has been controlled in 87% while 79% of islet cell tumour hepatic metastases have responded. Contraindications to HAE includes a combination of all of the following: (i) replacement of more than 50% of the liver by tumour, (ii) serum lactic dehydrogenase above 425 mU/ml, (iii) serum glutamic oxaloacetic transaminase above 100 mU/ml, and (iv) bilirubin above 2 mg/dl. In the face of occlusion of the portal vein by intravascular neoplasm, HAE is contraindicated only if portal flow through collateral vein is away from the liver.

Magnetic resonance imaging of malignant fibrous histiocytoma

The magnetic resonance imaging (MRI) changes in 39 patients with malignant fibrous histiocytoma (MFH) were reviewed retrospectively. Twenty-one sarcomas were in the lower extremity, five each in the upper extremity and trunk, two each in the neck and heart, and one each in the maxillary sinus, sella turcica, tongue, and spermatic cord. The examinations were performed with spin-echo sequences on a 1.5 Tesla Signa Scanner (GE, Milwaukee WI). Twenty-two tumors exhibited intermediate signal intensity on T1-weighted images and 23 were of high signal intensity on T2-weighted images. There was no significant differences in signal intensity of 12 preoperative and 13 recurrent neoplasms. Twelve of 13 patients were correctly diagnosed as having postoperative changes. The MR sensitivity and specificity for detecting a neoplasm were 96% and 83% respectively, but the signal changes were nonspecific for MFH. When compared to CT in 14 patients, MR better defined the extent of the MFH, its relationship to surrounding tissues and vessels, and best differentiated residual or recurrent disease from postoperative changes when examined at least 3 months after surgery.

A new device for transcatheter closure of the patent ductus arteriosus. A feasibility study in dogs

A new device for transcatheter closure of the patent ductus arteriosus was developed and initially evaluated in the vasculature of adult mongrel dogs. The device consists of a nylon sack that can be made in various sizes and shapes. A small flexible crossbar attached to the distal end maintains the position of the sack while it is filled with a segment of modified guide wire. The device is delivered coaxially through a 10-Fr Teflon catheter and is easily repositioned or retrieved before release. The expansile force of the sack against the vessel wall can be varied, and its stability is easily checked prior to detachment. The device produced immediate and permanent vascular occlusion without inflammation or erosion. Over time, the entire unit became incorporated into the vessel wall by neointimal encasement. Nylon sacks offer a simple, unique method of closing virtually any ductus arteriosus without general anesthesia and major surgery.

Osteosarcoma: angiographic assessment of response to preoperative chemotherapy

Adjuvant chemotherapy prolongs the survival of patients with high-grade osteosarcoma. Preoperative chemotherapy allows identification of effective agents for adjuvant chemotherapy based on response of the primary tumor. Preoperative determination of tumor response has therapeutic implications, and angiography offers a less subjective means of assessing it than do conventional radiography or computed tomography. Changes in tumor vascularity, as seen angiographically, after two courses and at the time of the last of several courses of preoperative chemotherapy were correlated with histologic tumor necrosis of resected specimens in 81 patients. Angiographically, 40% of the histologic responders and 91% of the nonresponders were identified after two courses of preoperative chemotherapy. After a median of four courses of chemotherapy, 91% of the responders but only 50% of the nonresponders were identified angiographically. Angiographic assessment of tumor vascularity, although not of absolute value, offers a useful guideline for determining the preoperative chemotherapy strategy.

Percutaneously placed endovascular grafts for aortic aneurysms: feasibility study

This limited study addressed the feasibility of treating aneurysms with a new transcatheter endoprosthesis. Aortic aneurysms were experimentally created in six dogs and subsequently bridged with nylon-covered, self-expanding metallic stents. The dogs were followed up for as long as 7 months (median, 22 weeks). In each dog, the graft effectively reconstituted the aortic lumen, excluding the aneurysm. One dog exhibited minimal (less than 1-mm) residual dilatation at the site of the aneurysm 7 months after graft placement. The nylon material acted as a support and template for neointimal encasement, enabling the formation of a new vascular lumen. It also remained porous at the origin of aortic side branches, preserving the visceral blood supply. One of the endovascular grafts failed to expand completely at its distal end, which promoted thrombus formation within the graft and resulted in the occlusion of both renal arteries. The dog was found comatose 48 hours after graft placement and was killed at that time.

Chemotherapy and embolization via the inferior epigastric artery for the treatment of primary and metastatic cancer

We evaluated the results of arterial chemotherapy and embolization via the inferior epigastric artery and its branches in 10 patients with a variety of primary and metastatic neoplasms supplied by that vessel. A total of 15 infusions and five occlusions were performed. There were no complications related to arteriography, indwelling catheters, or arterial occlusion. The effects on tumor bulk ranged from complete necrosis in one patient to partial necrosis in three patients. Surgical resection was facilitated in four of six patients. Local recurrence of tumor occurred in two of these patients. Three of four patients with intractable pain had effective relief. Our experience suggests that transarterial therapy of tumors supplied by the inferior epigastric artery or its branches is a safe procedure and may be useful in tumor management.