Post-radiation sarcomas: a review of the clinical and imaging features in 63 cases

AIMS

The development of sarcomas is a recognized complication of radiation therapy. We set out to retrospectively review the clinical and therapeutic demographics, as well as the cross-sectional imaging findings in patients with post-radiation sarcomas.

MATERIALS AND METHODS

Sixty-three patients with post-radiation sarcomas were identified at a single institution. Computed tomography and/or magnetic resonance imaging was available for all patients. The medical records were reviewed for the primary diagnoses, the radiation history, and the latency period to the development of the sarcoma.

RESULTS

There were 43 women and 20 men with a mean age of 52.8 years. The mean radiation dose delivered was 50.1 Gy, with a mean latency period for the development of the sarcoma of 15.5 years. The most common primary diagnoses were breast cancer, lymphoma and head and neck cancer. The most common sarcoma histopathologies were osteosarcoma and malignant fibrous histiocytoma. The most common imaging findings were a soft tissue mass and bone destruction.

CONCLUSIONS

Post-radiation sarcomas, while uncommon, are not rare. The imaging findings are not pathognomonic, but an appreciation of the expected latency period may help to suggest the diagnosis. Sheppard, D. G. and Libshitz, H. I. (2001). Clinical Radiology56, 22-29.

Mycobacterium kansasii infections in patients with cancer

Mycobacterium kansasii was isolated from 25 patients with cancer who were cared for at the University of Texas M. D. Anderson Cancer Center (Houston) from January 1987 through December 1996. Two patients (8%) had disseminated disease, and 23 (92%) had pleuropulmonary isolates only. Signs and symptoms of mycobacterial infection at the time of diagnosis were often minimal or absent despite substantial radiographically evident involvement. The infections responded well to rifampin-based antimycobacterial regimens. M. kansasii is an infrequent but serious cause of pulmonary and, occasionally, disseminated disease in patients with cancer.

Radiographic appearance of the chest following therapy for Hodgkin disease

This study was carried out to define the post-treatment appearance of the chest radiographs in 44 consecutive patients with Hodgkin disease who received mantle irradiation with or without chemotherapy and to determine how the incidence and severity of post-treatment abnormalities relate to the radiation parameters and chemotherapeutic regimens. Radiographs of the chest in 44 patients, computed tomograms of the chest in 31 patients and of the abdomen of 35 patients were reviewed, prior to and following treatment, for mediastinal contours, pericardial status, cardiac size and pulmonary fibrosis. All patients were followed for a minimum of 1 year and 27 were followed for more than 5 years. Stable post-treatment imaging studies were correlated with the initial extent of disease, radiation parameters, and chemotherapeutic regimens. Stable post-treatment findings were categorised as follows: the chest radiograph was normal or showed subtle vascular reorientation; moderate paramediastinal fibrosis was present; severe pulmonary fibrosis had occurred with narrowing of the cardiomediastinal silhouette in some patients. In general, the severity of the fibrosis was dependent on (1) the size of the radiation fields and on whether or not the coverage of the hila included a 1- to 2-cm margin; (2) the amounts of chemotherapy and particularly bleomycin containing regimens and (3) individual susceptibility of normal tissue irradiation. Therapy for Hodgkin disease is not necessarily associated with radiographic sequelae regardless of the initial status of the mediastinum or the treatment. However, the post-treatment appearance of the chest radiographs in this study was related strongly to (1) the initial extent of disease and particularly the status of the hila, both of which influenced the amounts of lung parenchyma that were included in the treatment fields; (2) the use of bleomycin in chemotherapy regimens and (3) individual normal tissue radiosensitivity.

Mycobacterium kansasii infections in patients with cancer

Mycobacterium kansasii was isolated from 25 patients with cancer who were cared for at the University of Texas M. D. Anderson Cancer Center (Houston) from January 1987 through December 1996. Two patients (8%) had disseminated disease, and 23 (92%) had pleuropulmonary isolates only. Signs and symptoms of mycobacterial infection at the time of diagnosis were often minimal or absent despite substantial radiographically evident involvement. The infections responded well to rifampin-based antimycobacterial regimens. M. kansasii is an infrequent but serious cause of pulmonary and, occasionally, disseminated disease in patients with cancer.

Malignant pleural mesothelioma: the spectrum of manifestations on CT in 70 cases

AIM

The aim of this pictorial review is to illustrate the spectrum of manifestations on computed tomography (CT) of malignant pleural mesothelioma. Malignant pleural mesothelioma is the most common primary neoplasm of the pleura, but nevertheless is a rare tumour. It has a strong association with previous occupational exposure to asbestos and has a bleak prognosis.

MATERIALS AND METHODS

The pre-treatment CT findings of 70 patients at our institution, and the subsequent findings of the 35 patients who had follow-up CT, have been reviewed by three observers by consensus. 16 patients had surgical resections.

RESULTS

The most common pre-treatment findings were pleural thickening (94%) and pleural effusions (76%). Both contraction (27%) and enlargement (10%) of the ipsilateral hemithorax were identified. Extension of disease to the chest wall, mediastinum, thoracic lymph nodes, and below the diaphragm were identified. Concurrent bilateral pleural calcification and plaques indicative of previous asbestos exposure were identified in 16% of patients. CT failed to identify chest wall and mediastinal invasion in a number of patients who underwent surgical resections.

CONCLUSION

CT plays an important role in the diagnosis, assessment, and evaluation of treatment response of this tumour, although it has some limitations in specific areas in evaluating patients for surgical resection.

Filling in of radiation therapy-induced bronchiectatic change: a reliable sign of locally recurrent lung cancer

PURPOSE

To determine if filling in of radiation therapy-induced bronchiectatic change is a reliable computed tomographic (CT) sign of locally recurrent lung cancer.

MATERIALS AND METHODS

The study included 28 patients who were free of disease and had stable radiation therapy-induced consolidation in ectatic bronchi at least 9 months after completion of radiation therapy for non-small cell lung cancer. Serial CT scans were retrospectively reviewed for evidence of local recurrence.

RESULTS

Filling in of previously patent ectatic bronchi occurred in the 20 patients with recurrent disease. Filling in was the first sign of recurrence in six patients (30%), was seen concurrently with other evidence of local recurrence in 11 (55%), and was seen after the occurrence of other signs in three (15%). Eight patients with stable radiation-induced fibrosis and patent bronchi remained disease free.

CONCLUSION

Filling in of radiation therapy-induced bronchiectatic change is a reliable CT sign of locally recurrent lung cancer.

Presenting symptoms in patients referred to a multidisciplinary clinic for bone metastases

Symptom control is the goal of palliative irradiation. Approximately 1 month is required before symptomatic relief is accomplished with radiotherapy. However, many patients with cancer-related pain do not receive adequate analgesics, and opioids are often not prescribed until patients fail to respond to palliative irradiation. The presenting symptoms of 108 patients who were referred to a multidisciplinary clinic for bone metastases were evaluated with the Wisconsin Brief Pain Inventory (BPI). This validated instrument evaluates the severity of pain using a 0-10 scale; 10 represents the worst pain imaginable. The population comprised 65 men (60%) and 43 women whose ages ranged from 33 years to 81 years; median age was 55 years, and 69% of patients were less than 65 years of age. Despite the presence of metastatic disease, 21% of patients were working full-time outside the home, and 6% were employed part-time outside the home; 13% were homemakers. Only 17 patients (16%) were unemployed. The time since diagnosis ranged from 2 weeks to 23 years; the median time since diagnosis was 22 months, and 30% of patients had been diagnosed with the past 6 months. Pain was a presenting symptom in 74% (N = 80) of patients at diagnosis. At its worst, the pain was rated as severe (levels 7-10) by 78% and intolerable (level 10) in 22% of the patients in the 24 hr prior to the clinic appointment. On average, the pain was rated moderate to severe (levels 4-10) in 79% and severe in 23% of patients. Only 45% of patients experienced good relief from the prescribed analgesics, and 23% of patients indicated that the prescribed analgesics were ineffective. This survey demonstrates that bone metastases incur significant pain that is often undertreated with analgesics before antineoplastic therapy is administered.

Rounded atelectasis and mesothelioma

OBJECTIVE

The purpose of this article is to report the coexistence of rounded atelectasis with malignant pleural mesothelioma as revealed by radiography and CT.

CONCLUSION

Our five cases show the coexistence of rounded atelectasis and malignant mesothelioma. If rounded atelectasis is associated with a pleural effusion, a pleural mass with or without chest-wall invasion, or thickened pleura not adjacent to the rounded atelectasis, malignant mesothelioma should be strongly considered.

Hodgkin disease and non-Hodgkin lymphoma: plain chest radiographs and chest computed tomography of thoracic involvement in previously untreated patients

PURPOSE

To provide further information about the presentation of thoracic involvement in Hodgkin disease and non-Hodgkin lymphoma and to compare chest radiography with chest CT findings.

MATERIALS AND METHODS

We reviewed the chest radiographs and the CT images of 100 Hodgkin and 100 non-Hodgkin patients, all of them untreated. Our data were compared with those of literature series: the latest study comparing the different patterns of Hodgkin and non-Hodgkin disease appeared in 1976 and it compared chest radiography with conventional tomography, not with CT.

RESULTS

Intrathoracic involvement (75% vs 48%) and adenopathy (74% vs 28%) were more frequent in Hodgkin than in non-Hodgkin lymphoma. Ninety-nine per cent of the patients with intrathoracic involvement (74/75) had nodal disease. Paratracheal/prevascular nodes were most frequently involved, namely in 72/74 Hodgkin (97%) and in 27/28 non-Hodgkin patients (96%). The lung parenchyma was more often involved in non-Hodgkin (24%) than in Hodgkin (8%) patients; it was associated with mediastinal/hilar adenopathy in all Hodgkin and in 10/24 (42%) non-Hodgkin cases. Parenchymal involvement was demonstrated with chest radiography in 7/8 Hodgkin (88%) and in 13/24 non-Hodgkin patients (54%). Chest radiography showed paratracheal/prevascular adenopathy more often in Hodgkin (54/72, 75%) than in non-Hodgkin (15/27, 56%) cases. Subcarinal and internal mammary adenopathy was poorly depicted with plain films, while hilar adenopathy was generally identified with both CT and chest radiography. Chest radiography usually missed posterior mediastinal and anterior diaphragmatic adenopathy.

CONCLUSIONS

The differences in the presentation of Hodgkin vs non-Hodgkin disease are not sufficiently distinctive to permit radiographic differentiation of the two conditions, but some patterns are helpful. Recognizing the frequency of thoracic involvement and that of the additional CT findings in Hodgkin and non-Hodgkin patients makes a sound basis for lymphoma imaging.

Tuberculosis in cancer patients: an update

The demographics of tuberculosis (TB) and the therapy of malignancies have significantly changed since the last comprehensive review of TB in cancer patients. Fifty-six patients with both TB and malignancy were identified from January 1989 through December 1994 in a population of 61,931 newly registered cancer patients. The frequency of TB in cancer patients was 90 per 100,000. TB was more frequent in foreign-born patients (p < 0.001) and in racial and ethnic minorities (p < 0.001) than in non-Hispanic whites. TB developed during therapy in 48%. TB was discovered synchronously with the malignancy in 30% and in 21% occurred > or = 18 months after therapy. Pulmonary TB occurred in 50 (89%) patients and extrapulmonary TB in nine (16%) (three had both). Chest radiographic findings did not suggest TB in 20%. TB was less frequent in lung cancer (p < 0.001), head and neck cancer (p = 0.002), and solid hematologic malignancies (p < 0.001) than it had been historically, but the frequency was unchanged in acute leukemia patients (p = 0.46). TB in cancer patients occurs at a nine times greater than in the general population. It is now most frequent in leukemia patients.

Radiation change in normal organs: an overview of body imaging

Radiotherapy causes changes in a treated malignancy and the surrounding normal tissue which must be included in the radiation fields. Awareness of the expected appearance of these changes frequently permits differentiation of them from superimposed infection, recurrent malignancy, radiation-induced tumors, and the other true complications of radiation therapy. Radiotherapy changes are a function of the tissue volume treated, field shape, total dose and how it was delivered, time from completion of therapy, and the possible effect of other therapies. Timing of radiation changes varies in the different organs. Acute radiation pneumonitis is generally seen approximately 2 months after completion of radiotherapy, but radiation pericarditis not until 6-9 months after therapy. Radiation-induced sarcomas do not develop on average until 10-15 years after radiation therapy. An overview of expected findings and complications in the lungs, heart, gastrointestinal tract, genitourinary tract, and bones is presented.

MR prediction of benign and malignant vertebral compression fractures

We reviewed spinal MR images of 58 patients with 98 compressed vertebrae. Benign (47 vertebrae) or malignant (51 vertebrae) etiology was established by biopsy or radiologic follow-up. Compressed vertebrae were analyzed for presence and characteristics of signal abnormality, altered vertebral contour, Schmorl's nodes, pedicular involvement, and contrast uptake. Statistical analysis was performed. Diffuse and homogeneous decrease in signal intensity on T1-weighted images, convex vertebral contour, involvement of the pedicles, and a lumbar location were more frequently observed in malignant fractures (P < .01). A thoracic location, lack of signal change, or a band-like abnormality and absence of pedicular involvement or contour abnormality characterized benign fractures (P < .01). Schmorl's nodes and enhancement did not help establish a diagnosis. When a constellation of MR criteria are applied, the accuracy of the diagnosis of malignant and benign vertebral compression fractures may reach 94%.

Axillary lymph node metastases of bronchogenic carcinoma

BACKGROUND

Metastasis of bronchogenic carcinoma to axillary lymph nodes is rare. The pathways and possible significance of axillary lymph node metastasis from bronchogenic carcinoma were investigated.

METHODS

Seventeen patients with probable axillary lymph node metastases from bronchogenic carcinoma were identified by computed tomography. There were 15 nonsmall cell lung cancers and 2 small cell lung cancers. Axillary lymph node metastasis was proven by biopsy in six cases. Metastases were presumed because of an increase in the size of axillary lymph nodes compared with prior studies in six patients and enlarged axillary lymph nodes associated with biopsy-proven ipsilateral supraclavicular lymph node metastasis in five patients.

RESULTS

Four of 10 right-sided lung cancers had ipsilateral and six had contralateral axillary lymph node metastases. Six of seven left-sided cancers had ipsilateral and one had contralateral axillary lymph node metastases. Patients with ipsilateral lymph node disease had chest wall involvement and/or supraclavicular and mediastinal lymph node metastases. All seven patients with contralateral axillary lymph node metastases had supraclavicular and/or mediastinal lymph node metastases.

CONCLUSION

Bronchogenic carcinoma may involve ipsilateral axillary lymph nodes via either chest wall invasion or retrograde spread from supraclavicular lymph nodes. Contralateral axillary lymph node involvement requires involvement of contralateral mediastinal and supraclavicular lymph nodes with retrograde spread to the axillary lymph nodes.

Axillary lymph node metastases of bronchogenic carcinoma

BACKGROUND

Metastasis of bronchogenic carcinoma to axillary lymph nodes is rare. The pathways and possible significance of axillary lymph node metastasis from bronchogenic carcinoma were investigated.

METHODS

Seventeen patients with probable axillary lymph node metastases from bronchogenic carcinoma were identified by computed tomography. There were 15 nonsmall cell lung cancers and 2 small cell lung cancers. Axillary lymph node metastasis was proven by biopsy in six cases. Metastases were presumed because of an increase in the size of axillary lymph nodes compared with prior studies in six patients and enlarged axillary lymph nodes associated with biopsy-proven ipsilateral supraclavicular lymph node metastasis in five patients.

RESULTS

Four of 10 right-sided lung cancers had ipsilateral and six had contralateral axillary lymph node metastases. Six of seven left-sided cancers had ipsilateral and one had contralateral axillary lymph node metastases. Patients with ipsilateral lymph node disease had chest wall involvement and/or supraclavicular and mediastinal lymph node metastases. All seven patients with contralateral axillary lymph node metastases had supraclavicular and/or mediastinal lymph node metastases.

CONCLUSION

Bronchogenic carcinoma may involve ipsilateral axillary lymph nodes via either chest wall invasion or retrograde spread from supraclavicular lymph nodes. Contralateral axillary lymph node involvement requires involvement of contralateral mediastinal and supraclavicular lymph nodes with retrograde spread to the axillary lymph nodes.

Malignant pleural mesothelioma after radiation therapy for breast cancer. A report of two additional patients

BACKGROUND

Malignant pleural mesotheliomas (MPMs) are rare tumors that usually have a fatal outcome. The association of these tumors with asbestos exposure is well established. Induction of malignant mesothelioma by nonasbestos-related causes also has been reported in the literature, although the number of documented cases is extremely small. Two additional patients with malignant pleural mesothelioma many years after radiotherapy for breast cancer are reported.

METHODS

The observations as reported in the literature on the involvement of radiation in the development of MPMs are reviewed and compared with the authors' clinical experience. In a retrospective random review, 1000 patients who received thoracic irradiation at M. D. Anderson Cancer Center were studied for histologic and radiographic evidence of MPM. The selection criteria included the development of a unilateral pleural effusion years after successful treatment with thoracic irradiation for a proven malignancy. Patients with a history compatible with asbestos exposure were excluded from the review.

RESULTS

There have been only three previous cases of documented MPM associated with thoracic irradiation reported in the English literature. A review of the experience at our institution has demonstrated three patients with radiation-induced MPM. One patient has been reported elsewhere. Details of the other two patients are discussed in this paper.

CONCLUSIONS

Nonasbestos-related causes of MPMs are rare. The additional two patients lend added support to the association between thoracic irradiation and the development of MPM. The development of a unilateral pleural effusion occurring years after successful treatment of a proven malignancy with thoracic irradiation should alert the clinician to the possibility of MPM.

Radiographic demonstration of intercostal lymphatics and lymph nodes

The anatomy of the posterior intercostal lymphatics and lymph nodes is reviewed. These lymph nodes are occasionally visualized by bipedal conventional lymphography. Opacified and/or enlarged posterior intercostal lymph nodes may also be identified with computed tomography of the chest. Familiarity with the lymphatic drainage patterns of the intercostal spaces and recognition of abnormal intercostal lymph nodes may provide additional information regarding disease status in patients with inflammatory or malignant disease of the thorax.

Cascade of metastatic colorectal carcinoma from the liver to the anterior diaphragmatic lymph nodes

RATIONALE AND OBJECTIVES

Metastases of colon carcinoma from the liver to porta hepatis and celiac axis lymph nodes constitute a contraindication to hepatic metastatic resection. Our objective was to determine the frequency of anterior diaphragmatic lymph node (ADLN) enlargement, another efferent pathway of hepatic lymphatic drainage, in patients with colon carcinoma.

METHODS

Abdominal computed tomography scans from 50 patients with colon carcinoma in whom hepatic metastases were either present (n = 25) or absent (n = 25) were reviewed. ADLNs greater than or equal to 5 mm were considered enlarged.

RESULTS

Thirteen of 25 patients with hepatic metastases had ADLNs greater than or equal to 5 mm; three of 25 patients without hepatic metastases had ADLNs greater than or equal to 5 mm. The difference was statistically significant (p = .002).

CONCLUSION

Metastases of colon carcinoma from the liver to the ADLNs probably are not rare. ADLN involvement would obviate hepatic resection. The ADLNs should be assessed preoperatively in surgical candidates with hepatic metastases of colon carcinoma.

Papillary thyroid cancer with pulmonary metastases beginning in childhood: clinical course over three decades

We present a case of childhood papillary thyroid cancer with persistent but stable pulmonary metastases for over three decades in order to highlight the natural history and clinical features of this unusual disease entity. A nine-year-old girl had thyroidectomy and cervical lymph node dissection followed by neck irradiation for invasive papillary thyroid cancer. Diffuse pulmonary metastases were present at the time of diagnosis and were treated with radioactive iodine 10 and 30 years later; both the chest radiographs and the patient remained stable throughout. This case illustrates the potential indolence of thyroid cancer when it presents during childhood.

Prognostic significance of magnetic resonance imaging in patients with asymptomatic multiple myeloma

PURPOSE

To assess the prognostic significance of magnetic resonance (MR) imaging in patients with newly diagnosed asymptomatic multiple myeloma.

PATIENTS AND METHODS

Thirty-eight consecutive patients with asymptomatic myeloma of low tumor mass and negative skeletal surveys underwent MR imaging of the thoracic and lumbosacral spine. The presence and patterns of marrow involvement were correlated with standard laboratory parameters and time to disease progression.

RESULTS

Nineteen patients (50%) had evidence of marrow involvement at spinal MR imaging. MR patterns of marrow involvement were classified as diffuse (five patients), variegated (nine), and focal (five). Patients with abnormal MR imaging studies required therapy after a median of 16 months, versus 43 months for those with normal MR studies (P < .01).

CONCLUSION

Abnormal marrow patterns were present in half of patients with asymptomatic myeloma. An abnormal MR study of the spine identified asymptomatic patients who were likely to require treatment earlier than those with a normal MR study. A normal MR pattern provided additional justification to defer institution of chemotherapy. However, MR imaging remains an investigational tool to stage patients with multiple myeloma until more data are accumulated.

Multiple myeloma: MR patterns of response to treatment

PURPOSE

To assess changes in the magnetic resonance (MR) appearance of the spine in patients with multiple myeloma who responded to chemotherapy.

MATERIALS AND METHODS

Twenty patients with multiple myeloma underwent MR imaging of the spine before and after chemotherapy. Sagittal T1-weighted images were obtained before and after administration of contrast material. MR patterns of marrow involvement before treatment were classified as focal, diffuse, or variegated. The changes seen on MR images after treatment were analyzed and correlated with the clinical response as defined with standard criteria.

RESULTS

Patterns of complete response included resolution of marrow abnormality or persistent abnormality without enhancement or with peripheral rim enhancement. Conversion of a diffuse to a variegated or focal pattern and a decrease in the amount of marrow abnormality with persistent enhancement were observed in patients who showed a partial response. Ten patients sustained new or progressive compression fractures after successful therapy.

CONCLUSION

Recognition of spinal MR patterns of response to treatment supported the occurrence of remission in patients with multiple myeloma. MR findings may help clarify response to therapy in patients with equivocal clinical changes or nonsecretory myeloma.

Acute airway obstruction and necrotizing tracheobronchitis from invasive mycosis

Necrotizing tracheobronchitis and acute airway obstruction from invasive mycosis developed in a patient who had undergone bone marrow transplantation. The infectious process obstructed the airway and disintegrated the walls of the right mainstem bronchus and pulmonary artery. The airway was cleared using rigid bronchoscopy to extract the detritus. The patient died of hemorrhage after rupture of the pulmonary artery through the right mainstem bronchus.

Extraosseous multiple myeloma: imaging features

Multiple myeloma is a disseminated malignant neoplasm usually derived from a single clone of plasma cells. Patients with myeloma have diverse signs such as anemia, hypercalcemia, uremia, pathologic fractures, and recurrent infections. Extraosseous manifestations are found in less than 5% of patients with multiple myeloma. They can arise in any tissue, and their presence has been associated with more aggressive disease. The purpose of this essay is to illustrate the imaging findings of extraosseous myeloma and heighten awareness of this unusual manifestation of multiple myeloma.

Waldenström macroglobulinemia: MR imaging of the spine and CT of the abdomen and pelvis

Twenty-three consecutive patients with Waldenström macroglobulinemia were studied with magnetic resonance (MR) imaging of the spine and computed tomography (CT) of the abdomen and pelvis. MR imaging studies included sagittal T1-weighted and gradient-recalled-echo sequences performed with and without contrast material enhancement. Marrow involvement was identified with MR imaging in 21 of 23 (91%) patients. Diffuse involvement was noted in 13 patients (56%), and a variegated pattern in eight (35%). CT demonstrated enlarged nodes in 10 of 23 (43%) patients. Correlation of MR imaging patterns and presence of adenopathy at CT with standard laboratory values for Waldenström macroglobulinemia revealed an association of the diffuse MR imaging pattern of marrow involvement and the presence of enlarged nodes at CT with more advanced disease. MR imaging of the spine and CT are reliable means of evaluation of disease status in Waldenström macroglobulinemia. They may be employed as additional means in the staging of Waldenström macroglobulinemia and may be helpful in the follow-up of patients with this rare hematologic malignancy.

Magnetic resonance imaging in the staging of solitary plasmacytoma of bone

PURPOSE

To assess prospectively the role of magnetic resonance (MR) imaging in the staging of patients with a solitary bone plasmacytoma (SBP).

PATIENTS AND METHODS

Twelve consecutive patients with an apparent SBP underwent MR imaging of both the primary tumor and the thoracic and lumbosacral spine to seek additional foci of marrow involvement that might have been undetected by standard skeletal survey. All patients received megavoltage irradiation (total dose, 40 Gy) to the primary lesion.

RESULTS

MR imaging of the thoracic and lumbosacral spine showed additional foci of marrow replacement in four of 12 patients, with signal characteristics identical to those of the primary tumor. In all four patients, the abnormal protein persisted at greater than 50% of the pretreatment value following radiation treatment. In contrast, the myeloma protein disappeared or was reduced by greater than 50% in five of the six patients with secretory disease and without additional marrow abnormalities. One of four patients progressed to multiple myeloma 10 months after diagnosis with new lesions on conventional radiographs in the same areas as detected previously by MR imaging.

CONCLUSION

Four of 12 patients considered to have a SBP by standard criteria may have been understaged, because MR imaging showed additional marrow abnormalities consistent with myeloma. MR imaging of the spine may contribute to the initial staging of SBP, especially since some patients may be cured with radiotherapy.

Treatment of primary neoplasms of the trachea. The role of radiation therapy

BACKGROUND

Primary tracheal tumors are a rare malignancy. Before 1960, most patients had a biopsy, followed by external orthovoltage irradiation or radon seed implantation. Advances in surgery and in radiation therapy during the past three decades have allowed more patients to undergo definitive treatment.

METHODS

Between 1957 and 1988, 22 patients with primary tracheal malignancy were treated with curative intent at The University of Texas M.D. Anderson Cancer Center. Five patients underwent primary surgical resection (Group 1), 5 patients had surgical resection and adjuvant irradiation (Group 2), and 12 patients had primary irradiation (Group 3).

RESULTS

Median survival times were 26 months for all patients; 16 months for Group 1; 61 months for Group 2; and 26 months for Group 3. Local control was attained in 1 of 5 patients in Group 1, 4 of 5 patients in Group 2, and 4 of 12 patients in Group 3. Among those treated with primary radiation therapy, local control was attained by three of four patients who received 60 Gy or higher and one of eight patients who received less than 60 Gy. Results of chi-square test (P = 0.03) were statistically significant. Severe complications, including treatment-related deaths, occurred in 2 of 5 patients in Group 1, 2 of 5 patients in Group 2, and 3 of 12 patients in Group 3.

CONCLUSION

Radiation therapy has a role in the treatment of patients with tracheal malignancy, either as postoperative adjuvant therapy or as sole therapy for those who refuse surgery or have medically inoperable disease. Alternative methods for increasing the local administration of radiation therapy, such as endotracheal brachytherapy, should be investigated for improvement in local control.

Multiple myeloma: spinal MR imaging in patients with untreated newly diagnosed disease

Spinal magnetic resonance (MR) imaging was performed in 29 patients with newly diagnosed, untreated multiple myeloma. Nineteen (66%) patients were asymptomatic. Sagittal pre- and postcontrast T1-weighted spin-echo images and gradient-recalled-echo images of the thoracic and lumbosacral spine were obtained. Marrow involvement was identified in 20 (69%) patients. There were three MR patterns: focal lesions in nine patients (31%), diffuse involvement in seven (24%), and an inhomogeneous pattern of tiny lesions on a background of normal marrow in four (14%). A statistically significant correlation between MR imaging patterns of marrow involvement and serum hemoglobin values (one-way, P = .0899; Kruskal-Wallis, P = .0620) and between MR imaging patterns and percentage of marrow plasmacytosis (Kruskal-Wallis, P = .0314) was noted, with patterns of diffuse and focal marrow involvement associated with more abnormal values. Spinal MR imaging in patients with early myeloma may reveal marrow involvement in both symptomatic and asymptomatic patients. Some correlation was found between MR imaging patterns and laboratory indexes of disease.

Mediastinal metastases of infradiaphragmatic malignancies

Mediastinal lymph node metastases from infradiaphragmatic malignancies are reported to be a rare occurrence. The results of previous studies have been based on the evaluation of chest radiographs. In this study we retrospectively reviewed the chest and abdominal computed tomography examinations of 50 such patients. Of these, 25 had renal cell carcinoma and the remainder, other genitourinary or gastrointestinal carcinomas. The major nodal groups involved in the mediastinum were the right paratracheal in 41 cases, subcarinal in 31, paraesophageal in 26, and aortopulmonary in 25. Hilar nodes were involved in 21 cases. In the abdomen, para-aortic and or retrocrural adenopathy was present in 29 cases. Of 21 patients with pulmonary metastases, only 12 cases were associated with ipsilateral hilar lymphadenopathy. Supraclavicular lymphadenopathy occurred in only 8 patients. These results suggest that spread of infradiaphragmatic malignancies to the mediastinum occurs primarily by extension from the retrocrural and para-aortic nodes into the thoracic duct and then by antegrade flow in the thoracic duct and its collaterals, with retrograde flow from these channels to the mediastinal nodes.

Multiple myeloma: appearance at MR imaging

Magnetic resonance (MR) imaging examinations of the lumbar spine and clinical and laboratory findings in 32 patients with multiple myeloma were reviewed. On T1-weighted images, signal intensity (SI) of the vertebrae approximated that of muscle in 14 cases and was intermediate (between the SIs of muscle and fat) in 18. Definite foci of decreased SI were seen in eight cases (25%), and foci of increased SI, representing fatty infiltration, were seen in 12 (38%). On T2-weighted images, SI approximated that of muscle in 17 cases and was intermediate in 15. Definite foci of increased SI were seen in 17 (53%). Of 38 vertebral compression fractures (including 18 in nine additional patients), foci of abnormal SI consistent with tumor on either T1- or T2-weighted images were seen in 19 cases (50%). There was no correlation between MR imaging findings and laboratory or bone marrow findings. Foci of presumed tumor were better or exclusively shown on T2-weighted images in 11 of 17 patients (65%) with identifiable focal disease. Other suggestions of multiple myeloma on T1-weighted images may be the absence of fatty replacement or a generalized decrease in SI.

Edatrexate improves the antitumor effects of cyclophosphamide and cisplatin against non-small cell lung cancer

The authors treated 32 patients with Stage IIIB or IV non-small cell lung cancer (NSCLC) with an outpatient regimen of edatrexate (10-ethyl-10-deaza-aminopterin) (10-EdAM) on days 1 and 8, cyclophosphamide on day 1, and cisplatin on day 1, repeated every 3 weeks with dose modification. The 22 men and 10 women (median age, 57 years of age) had no prior chemotherapy and a Zubrod performance status less than or equal to 2. A schedule with initial doses of 80 mg/m2, 800 mg/m2, and 80 mg/m2, respectively, yielded a 47% major response rate with two complete responses (95% confidence interval [CI], 25% to 70%), but it also yielded significant stomatitis and myelosuppression. A schedule with reduced starting doses (70 mg/m2, 700 mg/m2, and 70 mg/m2) was better tolerated, but dropped the major response rate to 27% with no complete responses (95% CI, 11% to 52%). Median survival time was 39 weeks for all 30 evaluable patients without a significant difference between the treatment groups (which were comparable in patient characteristics). Major response, however, was associated with longer survival time than minor response or no change (P = 0.024) or progressive disease (P = 0.001) (median survival times, 55, 39, and 27 weeks, respectively). When the doses delivered were compared, patients treated with the reduced dose schedule received less mean 10-EdAM per course (P = 0.01), although the doses of cyclophosphamide and cisplatin were comparable to the original dose schedule for the second course and thereafter. These results suggest that this three-drug regimen may have synergistic antitumor effects, with a steep dose-response relationship, particularly with 10-EdAM. With amelioration of the dose-limiting stomatitis of 10-EdAM, it seems possible to maximize the antitumor effects of this regimen.

Mammographic and CT findings after breast reconstruction with a rectus abdominis musculocutaneous flap

This essay illustrates the radiologic appearance of the reconstructed breast and the abdominal wall after breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The findings are based on a retrospective study of 42 mammograms, 17 abdominal CT scans, and two CT scans each of the chest and pelvis of patients who underwent this procedure.

Radiation-induced malignant pleural mesothelioma

Malignant pleural mesothelioma is a rare and usually fatal disease. Its association with asbestosis is well recognized. The authors report a case of malignant pleural mesothelioma that developed 30 years after the patient underwent radiotherapy for breast cancer. This appears to be the first such case reported in the radiology literature.

Malignant pleural mesothelioma: CT manifestations in 50 cases

Malignant pleural mesothelioma, a rare and usually fatal neoplasm that is associated with asbestos exposure, is being encountered with increasing frequency. Pretreatment CT findings from 50 patients with malignant pleural mesothelioma are illustrated. Pleural thickening was found in 46 (92%) of the 50 patients, thickening of the pleural surfaces of the interlobar fissures in 43 (86%), pleural calcifications in 10 (20%), and pleural effusions in 37 (74%). The volume of the involved hemithorax varied appreciably. Contractions of the involved hemithorax was noted in 21 (42%) of 50 patients and contralateral mediastinal shift in seven (14%). Disease beyond the parietal pleura was found in the chest wall (nine patients), mediastinum, lymph nodes, and diaphragm.

Primary malignant tumors of the trachea. A radiologic and clinical study

Fifty-four cases (55 foci) of primary tracheal malignancies were reviewed retrospectively. Radiologic material was available in 32 cases (33 tracheal foci). The most frequent primary malignant tumor of the trachea was squamous cell carcinoma (54.5%), followed by adenoid cystic carcinoma (18%) and adenocarcinoma (9%). The radiologic appearance of the tumors could be divided into intraluminal, wall-thickening, and exophytic forms. Wall-thickening and exophytic forms in this study accounted for 62% of the tumors. This indicates that malignant tumors of the trachea tend to extraluminal invasion. Tomography and computed tomography are the most helpful methods of radiologic examination for tracheal tumors. Bronchoscopy and radiologic examination are complementary procedures. The chief advantage of imaging is the demonstration of tracheal wall thickening and extraluminal changes. Hemoptysis, dyspnea, and cough were the most common symptoms. Four cases (7%) in our series presented as thyroid tumors due to direct extension into the thyroid gland. Fifteen of the 54 cases (28%) were associated with other carcinomas of the head and neck and the lung.

Phase II study of 10-ethyl-10-deaza-aminopterin (10-EdAM; CGP 30 694) for stage IIIB or IV non-small cell lung cancer

Thirty-one patients with stage IIIB or IV non-small cell lung cancer (NSCLC) were treated with intravenous 10-EdAM on a weekly basis. The starting dose was 80 mg/m2, with subsequent doses adjusted depending on evidence of toxicity. There were 20 men and 11 women with a median age of 58 years (range, 33-75). Response was evaluated in 30 patients, 5 with evaluable but not measurable tumors and 25 with measurable indicator lesions. There were no complete remissions; 3 patients achieved partial remission. Nine patients had a minor response, 6 showed no change, and 12 had progressive disease. Median survival for all 31 patients was 43 weeks (range, 12-65+). During the first 3-week period, the 10-EdAM dose was reduced or withheld in 19 patients (because of stomatitis in 12, SGPT elevation in 3, skin rash in 2, and granulocytopenia in 2), escalated in 11 patients, and unchanged in 1 patient. A mean of 34-88 mg/m2 of 10-EdAM (median, 50) was given per week during the first 5-week period. Myelotoxicity was infrequent and there was no significant nephrotoxicity. Considering the modest side effects of this treatment and the conservative dose-modification schedule which mandated substantial dose reductions, we conclude that 10-EdAM is a promising antitumor agent for NSCLC.

Thoracic lymphoma

Mediastinal adenopathy is a common manifestation of HD in a usually predictable pattern involving anterior and middle mediastinal nodes with or without disease in the hili. Hilar adenopathy is uncommon without detectable mediastinal disease and the lung is virtually never involved alone. In NHL the pattern of disease is more unpredictable. Lung manifestations include direct extension from involved nodes, nodules with or without cavitation, atelectasis secondary to endobronchial or nodal obstruction and rarely an interstitial pattern. Pleural effusions are not uncommon, but solid pleural masses are less frequent. Invasion of the pericardium is not often seen, although masses are commonly seen along the pericardium. Invasion of the chest wall occurs particularly with involvement of internal mammary nodes. Occasionally, posterior nodes will invade the adjacent vertebrae and spinal canal. The chest wall may be invaded by enlarged axillary nodes. Isolated chest wall soft-tissue masses are not common and are usually a manifestation of NHL, especially large cell lymphoma. Although the chest radiograph should detect most intrathoracic disease. CT has been found a necessary adjunct in patients with HD for accurate staging and therapy, especially if radiotherapy is planned. CT has been found helpful in NHL for staging, especially for the pleura and chest wall. MR imaging has not been found to contribute additional useful information except in selected cases.

Detection of hepatic metastases in breast cancer: the role of nonenhanced and enhanced CT scanning

Nonenhanced and enhanced CT was compared in 88 patients with breast cancer and hepatic metastasis. Twenty-five patients had bolus, sequential dynamic CT, and 63 patients were scanned more slowly after a bolus or during drip infusion. Metastatic lesions were more conspicuous on nonenhanced CT and became isodense or nearly isodense after contrast medium administration in 28% of the patients scanned dynamically and in 29% of those scanned more slowly. Although breast cancer has not generally been considered a common origin of hypervascular metastases, we recommend that it be treated as such and that both enhanced and nonenhanced CT of the liver be obtained when patients are screened for metastasis.