Search

SummaryThe combination of pegylated liposomal doxorubicin (PLD), bortezomib anddexamethasone has shown efficacy in the treatment of multiple myeloma(MM) patients. Our earlier retrospective study suggested that modification ofthe doses, schedules and route of administration of these drugs appears toreduce toxicity without compromising anti-MM activity. As a result, weevaluated this modified drug combination in the frontline setting in aprospective multicentre phase II trial. Thirty-five previously untreated MMpatients were enrolled. Dexamethasone IV 40 mg, bortezomib 1 mg/m 2 andPLD 5 mg/m 2 were administered on days 1, 4, 8 and 11 of a 4-week cycle.Patients were treated to their maximum response plus two additional cycles.The treatment regimen was discontinued after a maximum of eight cycles.Our modified schedule and dosing regimen achieved a high overall responserate of 86%, while showing a marked decrease in the incidence and severityof peripheral neuropathy, palmar-plantar erythrodysesthesia and myelo-suppression compared to the standard dosing on a 3-week cycle using thesedrugs. This modified regimen of dexamethasone, bortezomib and PLD showsimproved tolerability and safety while maintaining a high response rate whencompared to standard treatment with these agents in the frontline setting.Keywords: multiple myeloma, dexamethasone, bortezomib, pegylated lipo-somal doxorubicin.

F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) has been shown to be useful in the evaluation of many tumors due to its high sensitivity and specificity. However, false-positive interpretations may occur from benign subcutaneous and cutaneous etiologies. At our institution we have encountered FDG-PET scans which demonstrated a variety of cutaneous and subcutaneous lesions including stomas, hernias, rhinophyma, dose infiltrations, physiologic muscle uptake, and tophaceous gout. Additionally, malignant cutaneous and subcutaneous malignant lesions may also demonstrate substantial F-18 FDG uptake on PET scans, including lymphoma, skin metastases, and melanoma. The purpose of this atlas article is to demonstrate and review key features of various cutaneous and subcutaneous lesions, both benign and malignant, which can result in hypermetabolism on FDG-PET or PET-CT scans.

Lymphedema is due to dysfunction in lymphatic transport, and is divided into primary and secondary subtypes. Primary lymphedema is a congenital lymphatic abnormality or dysfunction whereas secondary lymphedema is characterized by pathologic disruption or obstruction of a previously-normal lymphatic system. The stage of lymphedema is determined clinically. Lymphoscintigraphy, however, may be used to assess disease extent, for early detection of disease progression, and can be used to direct therapy. We report a case of a 56-year-old woman with clinically stable lymphedema of 5 years, yet with lymphoscintigraphy findings compatible with disease progression.

Sclerosing hemangioma (SH) is a relatively rare, benign neoplasm of the lung. Although there are relatively characteristic imaging findings, biopsy remains the definitive diagnostic test. We report the radiology and pathology of a patient with a SH, with emphasis on the computed tomographic and (18)F-fluorodeoxyglucose positron emission tomography findings, and review the literature on this unusual tumor.

Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-SD-glucose (18F-FDG PET) has been recognized as a noninvasive imaging modality used in oncology for the initial diagnosis, staging, restaging, and evaluation of response to treatment in numerous malignancies. The use of 18F-FDG

We present the case of a 53-year-old woman after thyroidectomy with metastatic multifocal papillary carcinoma and encapsulated focal Hurthle cell carcinoma. Postoperatively, an I-131 whole-body scan revealed uptake in the low midline anterior neck. She was treated with 151.5 mCi of I-131. The 1-year follow-up I-131 whole-body scan revealed a new pelvic mass with I-131 uptake. Pelvic CT showed bilateral complex ovarian masses. She underwent surgical excision, revealing a right ovarian endometriotic cyst and a left ovarian cystadenofibroma, without thyroid tissue involvement. I-131 uptake in a cystadenofibroma is extremely rare and has been reported only once to our knowledge.

Endogenous subclinical thyrotoxicosis is diagnosed when a patient who is not taking exogenous thyroid hormone has a suppressed level of thyroid-stimulating hormone with normal levels of the free thyroid hormones thyroxine and triiodothyronine and other known causes of a suppressed thyroid-stimulating hormone level have been excluded. Although such a condition is caused by underlying thyroid disease, the specific nature and relative prevalence of these disorders and the utility of nuclear imaging and other studies in their detection remains unclear.The authors performed a retrospective study of 50 patients with endogenous subclinical thyrotoxicosis. The results of the history and physical examination, thyroid nuclear scan, radioactive iodine uptake measurement, and thyroid antibody studies were reviewed. The results of the nuclear imaging and thyroid antibody studies were combined in an attempt to establish an underlying diagnosis for each patient.The thyroid nuclear imaging and antibody studies were used to establish a specific thyroid disorder in most of the patients (n = 39). These disorders included most commonly toxic multinodular goiter, various forms of autoimmune thyroid disease, and solitary toxic adenoma. A specific diagnosis was not determined in 11 patients. Therapy with I-131 radioactive iodine was administered to 14 of these patients, 13 of whom subsequently achieved a normal thyroid-stimulating hormone level.Most patients with endogenous subclinical thyrotoxicosis have underlying thyroid abnormalities that can be determined by nuclear imaging and, in selected cases, thyroid antibody studies.

We report a case of a 61-year-old woman with stage IV non-small cell lung cancer and leptomeningeal carcinomatosis. The patient elected to have intrathecal chemotherapeutic treatment, and underwent surgical placement of an Ommaya reservoir. Before the administration of chemotherapy, In-111

Pulmonary hyalinizing granulomata are rare, noninfectious, fibrosing lesions of the lung, which can mimic metastatic disease radiographically. Their etiology is unknown, but they may be caused by an exaggerated immune response. We report the radiology, long clinical course, and pathology of a patient with pulmonary hyalinizing granuloma who presented with initially asymptomatic pulmonary nodules. Over a 10-year period, the patient developed multiple insidious autoimmune phenomena, including lupus anticoagulant, neuromyotonia, demyelinating sensorimotor polyneuropathy, and eventually, Morvan's syndrome. Such an association has not been previously published to our knowledge.

A 79-year-old female with a history of breast cancer and Hurthle cell carcinoma of the thyroid was found to have a splenic mass on CT, with increased Tc-99m HDP uptake on a bone scan, enhanced on MRI, and was intensely hypermetabolic on F-18 FDG PET. Metastatic thyroid cancer was found in the left iliac bone. No splenic uptake was present on iodine-131 whole body scanning. Biopsy of the splenic mass revealed a hyalinized nodule, resulting from a nongranulomatous response to damage leading to organization of collagenous matrix, fibroblasts, and lymphocytes without evidence of malignancy.

Background. The median survival time for patients with unresectable hepatocellular carcinoma (HCC) is Methods. Nineteen patients with measurable, unresectable, or metastatic HCC were enrolled. All patients were required to have adequate major organ function and performance status. The treatment consisted of weekly epirubicin at a dose of 20 mg/m2 administered i.v. and daily thalidomide at a dose of 200 mg orally given as a 3-weeks-on/1-week-off schedule. Intrapatient dose escalation of thalidomide was allowed every 2 weeks up to 800 mg daily as long as tolerated. Physical examinations, toxicity assessments, and serum chemistry analyses were performed weekly, and tumor measurements were conducted every 8 weeks. Results. All 19 patients enrolled into the study were evaluable for toxicity assessment and 17 patients were evaluable for response assessment. A total of 71 cycles of chemotherapy was administered, with a median of two cycles administered to each patient (range 1–14). No complete or partial responses were observed. Seven patients (41%) had stable disease, with a median duration of 6 months (range 5–14). The median survival time for all 19 patients was 196 days (95% confidence interval 93–302). The treatment was generally well tolerated. Treatment-related toxicities included constipation (grade 3, 5%; grade 2, 37%; grade 1, 21%), fatigue (grade 3, 5%; grade 2, 42%), and sensory neuropathy (grade 2, 5%; grade 1, 32%). Four patients required dose reductions of thalidomide due to treatment-related toxicities, and the median tolerated dose of thalidomide was 200 mg daily. Conclusions. The combination of epirubicin and thalidomide was well tolerated when administered in the schedule used in this study. This regimen has limited activity in HCC, with some patients achieving stable disease and clinical benefit. There is a need for defining more effective systemic therapies for HCC.

A 77-year-old woman with a history of right breast cancer and recently diagnosed B-cell lymphoma was evaluated for developing renal insufficiency with ultrasound and a Tc-99m MAGS renal scan. These studies demonstrated the presence of 3 functioning native kidneys. Supernumerary kidneys are a very rare congenital anomaly, and the use of renal scintigraphy plays an important role in both the diagnosis and the evaluation of renal function in such patients.

Although experience with positron emission tomography (PET) using F-18 FDG for imaging pulmonary carcinoid tumors is limited to date, uptake is usually much lower than expected for lung carcinoma or metastatic adenocarcinoma, or it is not present at all. On a routine chest radiograph, a 74-year-old woman with intraductal breast carcinoma was discovered to have a new right middle lobe nodule. The nodule was intensely hypermetabolic on F-18 FDG PET and was therefore believed to be a metastasis in this nonsmoking patient; however, at wedge resection, the nodule proved to be a primary pulmonary typical carcinoid tumor.

A ureteroinguinal hernia was demonstrated on both a Tc-99m mercaptoacetyltriglycine (MAG3) renal scan and a computed tomographic scan in an 81-year-old man with suspected urinary tract infection and a prior history of transurethral resection of the prostate. Ureteral hernias are relatively rare, although the ureteroinguinal hernia, found in elderly men on the right side, is the most common type. Ureteral hernias may be asymptomatic but can be present in patients with symptoms of obstructive uropathy.

405 ymphedema is the painless progressive accumulation of proteinrich fluid in the interstitial spaces of the skin, resulting from an anatomic or functional obstruction of the lymphatic system [1]. Lymphedema of the lower or upper extremities is typically a chronic condition that has several possible causes and that presents considerable physical as well as psychological difficulties for patients [2]. Patients with lymphedema experience extremity swelling, decreased coordination and mobility, and secondary infections [2]. The disorder typically affects the dermis and spares the deeper compartments [3]. At the initial medical evaluation of patients with suspected extremity lymphedema, it is highly desirable for physicians to define the abnormality; to determine whether the suspected abnormality is, in fact, a lymphatic one (Figs. 1 and 2) before instituting a therapeutic plan; and to establish an objective baseline [3]. The differential diagnosis of suspected extremity lymphedema includes obesity, venous disease, and systemic disease (e.g., hypoalUsing Lymphoscintigraphy to Evaluate Suspected Lymphedema of the Extremities Mariam Moshiri 1 , Douglas S. Katz 1 , Marvin Boris 2 , Elizabeth Yung 1

We report a case of a 70-year-old man with a history of prostatic adenocarcinoma and a 3-month history of right hemiscrotal swelling. The patient underwent a CT scan, scrotal ultrasound, and F-18 FDG-PET scan to evaluate for metastatic prostate cancer. The CT scan demonstrated an ill-defined soft-tissue mass extending along the right gonadal vein. Scrotal ultrasound revealed a heterogeneous right testicular mass. The F-18 FDG-PET scan demonstrated intense hypermetabolic activity along the course of the right gonadal vein extending to the right hemiscrotum. Subsequent right radical orchiectomy and pathologic examination revealed a B-cell lymphoma, infiltrating the testicular parenchyma, spermatic cord, gonadal vessels, and adjacent soft-tissues. Lymphoma or other tumors rarely infiltrate the spermatic cord, and have only very rarely been demonstrated on PET imaging.

Large pelvic varices were demonstrated on both hepatobiliary and gated cardiac imaging in a 66-year-old woman with hepatitis C and alcoholism, cirrhosis, portal hypertension, and hepatic failure, who was admitted with increasing confusion and right upper quadrant pain.

PURPOSE: To assess the use of a Tc-99m erythrocyte-labeled SPECT scan to characterize a giant splenic hemangioma. METHODS: A patient clinically mistaken to have a myelodysplastic disorder underwent a contrast-enhanced CT followed by a Tc-99m erythrocyte-labeled SPECT scan. RESULTS: CT showed a heterogeneous vascular lesion arising in the spleen. Percutaneous biopsy was nondiagnostic. A Tc-99m erythrocyte-labeled SPECT study revealed findings consistent with a giant splenic hemangioma, which was subsequently confirmed at surgery. CONCLUSION: A Tc-99m erythrocyte-labeled SPECT scan may be very useful in confirming the diagnosis of a large or giant splenic hemangioma.