An experimental model of acute cerebral death: Tc-99m bicisate brain imaging and kinetics.
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Acute Disease↗
Biomedical subjects
M Langer
Publications and source records attributed to M Langer.
MR imaging of the carpal tunnel.
OBJECTIVE: Investigations were conducted regarding changes of carpal tunnel shape during wrist motion and the variations of space for the median nerve as well as the preoperative signs of carpal tunnel syndrome (CTS) and the postoperative restitution. METHODS: Axial MR images (1.0 T) were performed at the level of the distal radioulnar joint, pisiforme bone and hook of hamate level of 20 wrists of patients with clinical symptoms of CTS and further 20 wrists of volunteers. This was conducted with the wrist in neutral position, 45 degrees extension and 45 degrees flexion. T2-weighted signal intensity of the median nerve were measured in 18 patients pre- and postoperatively. RESULTS: The increase of the cross-sectional area of the median nerve at the pisiform level and the flattening of the median nerve at the hook of hamate level as well as the volar bowing of the flexor retinaculum at the pisiform and hook of hamate level were significantly greater in patients with CTS than in those with normal wrists (P < 0.05-0.001). In postoperative follow-up studies the distal flattening of the median nerve recovered in 94%. The signal intensity of the median nerve on T2-weighted images decreased in 67%. CONCLUSIONS: Flexion at the pisiform and hamate level as well as extension at the pisiform level narrows the space available for the median nerve potential leading to compression of the median nerve. MR imaging is accurate and reliable for diagnosis and postoperative follow-up of CTS.
Adult↗
Treatment of bleeding esophageal varices with cyanoacrylate and polidocanol, or polidocanol alone: results of a prospective study in an unselected group of patients with cirrhosis of the liver.
BACKGROUND AND STUDY AIMS: Data concerning the results with emergency and further elective therapy of esophageal varices using polidocanol and cyanoacrylate, or polidecanol alone, in an unselected group of patients with liver cirrhosis have not previously been available. The aim of the present prospective study was to evaluate acute and repeated cyanoacrylate and polidocanol therapy in the emergency and long-term elective management of esophageal varices. METHODS: In accordance with the protocol of the present prospective study, acutely bleeding esophageal varices of grades 1 to 3 were treated endoscopically with polidocanol injection, while grade 4 varices, large solitary varices (over 5 mm) and otherwise uncontrollable cases of variceal bleeding were treated by injection of cyanoacrylate and polidocanol. Over a period of 62 months, 112 patients (65 men, 47 women) with acute bleeding from esophageal varices due to cirrhosis of the liver (69% alcohol-related) underwent a total of 245 treatment sessions in hospital. The average age of the patients was 62.0 +/- 12.3 years (58.1% were 60 or older). Hepatic function corresponded to Child-Pugh class A in 38 patients (33.9%), Child-Pugh class B in 68 patients (60.7%), and Child-Pugh class C in six (4.5%). RESULTS: Sixty-eight patients (60.7%) were treated with polidocanol alone, and 44 (39.3%) with cyanoacrylate and polidocanol. Acute hemostasis was achieved in all cases. In 5.7% of the sclerotherapy procedures, bleeding ulcers were observed, and a pleural effusion was seen in one case. The hospital mortality rate was 24.1%, resulting from the bleeding in 2.7% and due to liver failure in the remaining cases. Recurrent bleeding occurred within 24 hours in four patients (3.6%), and during the later course of the hospital stay in a further 11 patients (9.8%). The mean survival time was 13.7 +/- 17.7 months. Over the entire observation period of 23 +/- 21 months, 67 patients died (59.8%); the cause of death was hemorrhage in 4.5%, the underlying hepatic disease in 65.7%, and non-hepatic causes in 29.8%. Recurrent bleeding occurred in 58 patients (51.7%). The cumulative survival rate in the patients treated with cyanoacrylate and polidocanol was 66 +/- 15% and 26 +/- 32% after one and five years, respectively, and 56 +/- 13% and 33 +/- 19% in those treated with polidocanol alone. CONCLUSIONS: Endoscopic treatment of esophageal varices with cyanoacrylate and polidocanol, or polidocanol alone, is effective in controlling bleeding, and the complication rate is tolerable. The short-term and long-term mortality rates are determined largely by the underlying liver disease.
Adult↗
Cine-MR imaging of the shoulder.
PURPOSE: Shoulder lesions are usually examined with the joint in only one or two positions. We examined the shoulder with the joint in a variety of positions. We also assessed the application of cine-MR to the detection of instability and impingement. MATERIAL AND METHODS: The cine-MR examinations were performed in 30 patients and 15 healthy volunteers. We used an open 0.2 T system and a closed 1.0 T system. Spoiled gradient echo 2D T1-weighted images and turbo spin-echo T1- and T2-weighted images were obtained with a field of view of 180 mm. The examinations were videotaped and evaluated later. RESULTS: Normal variations of the glenohumeral joint were easy to recognize. Sub-luxations and luxations of the humeral head as well as rupture of the labrum were identified. It was also possible to identify the labrum with a signal change after arthroscopic refixation. And we were able to objectively assess distances between the osseous structures during dynamic movement. CONCLUSION: Unlike static MR, cine-MR would appear to be useful in visualizing the capsular ligament complex of the gleno-humeral joint in impingement and instability. It also provides information on dynamic changes and may thus prove to be an important tool for shoulder diagnostics. The method may provide an early diagnosis in the sub-acromial impingement syndrome.
Acromion↗
Prospective evaluation of bone marrow signal changes on magnetic resonance tomography during high-dose chemotherapy and peripheral blood stem cell transplantation in patients with breast cancer.
RATIONALE AND OBJECTIVES: The authors evaluate bone marrow signal changes on magnetic resonance (MR) imaging during high-dose chemotherapy and peripheral blood stem cell transplantation (PBSCT). METHODS: Fourteen patients with breast cancer without bone metastases underwent four sagittal MR imaging studies with T1-weighted, T2-weighted turbo spin-echo and inversion recovery sequences with short inversion time (STIR) of the lumbar spine: (1) during initial staging, (2) prior to high-dose chemotherapy after two cycles of induction chemotherapy, (3) early after PBSCT with a leukocyte exceeding 2000/microL, and (4) 6 to 8 weeks after PBSCT. Signal intensity ratios of averaged lumbar bone marrow to nucleus pulposus were measured and homogeneity was evaluated visually using a semiquantitative score. RESULTS: Compared with the initial finding (1): Signal intensity ratios were altered significantly at (2): T1-weighted: -22% +/- 14, P < 0.001; T2-weighted: -11% +/- 11, P < 0.01; STIR: +33% +/- 31, P < 0.01; Signal intensity ratios were altered significantly at (3): T2-weighted: -23% +/- 12, P < 0.001, STIR: -22% +/- 23, P < 0.01; and Signal intensity ratios were altered significantly at (4): only STIR: -16% +/- 19, P < 0.01. Homogeneity scores decreased at (3) for T1-weighted and STIR sequences (-1.6 +/- 0.5 to -2.0 +/- 0.7, P < 0.01 and -1.0 +/- 0.5 to -1.4 +/- 0.5, P < 0.01, respectively) and at (4) for the latter sequence (-1.0 +/- 0.5 versus -1.4 +/- 0.5, P < 0.01). At (4), T1-weighted images were less homogenous than initially in 3 of 14 (21%) patients. CONCLUSIONS: Magnetic resonance imaging demonstrates significant alterations of bone marrow composition during PBSCT but allows differentiation of benign therapy-related changes from those known in metastatic disease after completion of PBSCT.
Antineoplastic Agents↗
Median nerve compression can be detected by magnetic resonance imaging of the carpal tunnel.
OBJECTIVE: Clinically symptomatic carpal tunnel syndrome is not necessarily accompanied by impaired nerve conduction values. Surgical decompression, however, may immediately lead to complete and lasting relief of symptoms in these patients. Because minimally invasive techniques have reduced perioperative morbidity and vocational impairment related to operative decompression, the decision to decompress symptomatic patients (despite still unimpaired nerve conduction values) might be subject to discussion in the future. New diagnostic tools may be helpful in deciding which therapeutical options to choose. When the wrist is held either in flexion or in extension, the carpal tunnel pressure increases. To investigate the dynamic changes of the carpal tunnel shape during wrist motion, as well as the variations of space for the median nerve and its signal intensity in T2-weighting, magnetic resonance imaging (MRI) was performed on patients and healthy volunteers alike. Restitution and the persistence of pathological findings were assessed pre- and postoperatively. METHODS: MRI (1.0 T) was performed on 20 wrists of patients with clinical symptoms of carpal tunnel syndrome (CTS) and pathological nerve conduction values. Healthy volunteers (20 wrists) were matched according to sex and age. MRI was performed in neutral, 45-degree extension, and 45-degree wrist flexion positions. T2-weighted signal intensity of the median nerve was measured in 18 patients pre- and postoperatively. RESULTS: The cross-sectional area of the carpal tunnel in patients with CTS tends to be smaller than that found in nonsymptomatic volunteers. The cross-sectional area of the carpal tunnel decreases during wrist flexion at the pisiform and hamate level. During wrist extension, the cross-sectional area of the carpal tunnel decreases at the level of the pisiform. During extension, it increases at the level of the hamate. The cross-sectional area of the median nerve showed an increase at the pisiform level (P < 0.05), a flattening of the median nerve at the hamate hook level (P < 0.05), and palmar deviation of the flexor retinaculum at the pisiform and hamate hook level (P < 0.001). This was significantly greater in CTS patients than in individuals with normal wrists. Postoperatively, the distal flattening of the median nerve recovered in 94% of the cases reviewed. Although the signal intensity of the median nerve on T2-weighted images decreased by 67%, the motor latency recovered in only 39% of the cases. CONCLUSION: The carpal tunnel was smaller in CTS patients than in healthy volunteers. During flexion and extension, the space available for the median nerve narrows. This may lead to potential median nerve compression. MRI is accurate and reliable for diagnosis and postoperative follow-up of carpal tunnel syndrome. In cases with obvious clinical symptoms and yet not measurably impaired median nerve conduction values, it may be helpful in making a decision for surgical decompression.
Adult↗
Multiple giant fibroadenomas: clinical presentation and radiologic findings.
We describe the case of a 25-year-old Caucasian woman suffering from unilateral enlargement of the breast. Morphologic evaluation of various imaging modalities including mammography, ultrasound, and magnetic resonance imaging suggested a benign tumor embedded in stromal tissue. The time course of the Gd-DTPA uptake in dynamic magnetic resonance imaging, however, was also compatible with a malignant lesion. Postoperative pathological examination revealed multiple giant fibroadenomas, a rare disease, usually encountered in black female adolescents. Radiologic presentation, differential diagnosis, and morphologic findings are discussed, and a review of the literature is contained herein.
Adult↗
Comparative diagnostic accuracy of magnetic resonance imaging and immunoscintigraphy for detection of bone marrow involvement in patients with malignant lymphoma.
PURPOSE: To compare the diagnostic accuracy of magnetic resonance imaging (MRI) and immunoscintigraphy (IS) for detection of bone marrow infiltration in malignant lymphoma. PATIENTS AND METHODS: In 32 patients with Hodgkin's disease (HD) or non-Hodgkin's lymphoma (NHL), MRI of the axial skeleton and whole-body IS using technetium-99m (99mTc)-labeled monoclonal antibodies were reviewed and compared with iliac crest biopsies. Criterion for marrow infiltration was a positive biopsy or concordant positive results of MRI and IS. RESULTS: In 16 patients (50%), MRI, IS, and iliac crest biopsies were negative for marrow infiltration. Iliac crest biopsy showed infiltration in only four patients (13%). Infiltration was missed in two of 32 patients with IS and in one patient with MRI. In one additional patient, MRI was false-positive because of pelvic hematopoietic hyperplasia. A subset of nine patients (28%) with negative biopsies had bone marrow involvement according to MRI and IS with identical location and pattern of infiltration. In eight of these nine patients, diagnostic imaging indicated marrow involvement only in noncrest marrow. Subsequent biopsy confirmed infiltration in five patients. The clinical course suggested true-positive imaging results in the remaining four patients. Two patients (6%) remained equivocal. Overall concordance of MRI and IS for marrow infiltration was 88% (28 of 32 patients). CONCLUSION: Diagnostic imaging is essential for optimal staging in malignant lymphoma, as blind biopsies appear to have low sensitivity for bone marrow infiltration because of frequent involvement in noncrest marrow. both imaging modalities show a high rate of detection of bone marrow infiltration.
Adolescent↗
Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging.
Several methods for measuring femoral and tibial torsion by CT have been described since 1980. Alternative methods of measurement to CT are needed to avoid irradiating young patients facing derotation osteotomy. In this study, MRI was used to quantify femoral and tibial torsion in normal adult volunteers, firstly with transverse sections analogous to those of CT in order to establish reference values; and secondly, with sections along the axis of the neck of femur to assess the influence of the orientation of the slices on the measured values. The images were acquired using fast T1 weighted gradient echo sequences in 0.2 and 1 T magnets. Average femoral antetorsion (CT-analogous method) was 10.4 degrees (average side difference = 4.6 degrees); average tibial torsion was 41.7 degrees (average side difference = 6.1 degrees). A steeply inclined slice along the axis of the femoral neck gave a mean measurement of the angle of antetorsion that was significantly higher than the mean obtained from either slightly inclined or transverse sections (16.7 degrees vs 12.1 degrees and 11.2 degrees, respectively, p < 0.001). In conclusion, MRI provides an alternative to CT in the measurement of femoral and tibial torsion. MRI enables one to orientate the slice along the axis of the femoral neck, thus obtaining a single cross-section of the entire neck. However, the normal range of measurements will vary according to the plane of image.
Adult↗
Two-center German experience with aortic endografting.
PURPOSE: To report the results of a two-center study of endovascular abdominal aortic aneurysm (AAA) exclusion using a polyester-covered nitinol stent-graft. METHODS: Candidates were evaluated with arteriography and computed tomography. Criteria for endovascular therapy were a proximal aortic neck > 10 mm in length and < 25 mm in diameter, no bilateral internal iliac artery involvement in the aneurysm, no markedly tortuous common iliac arteries (CIAs) or CIAs < 7 mm in diameter, and no superior mesenteric artery occlusive disease. Patients were treated with the Mialhe Stentor and Vanguard stent-grafts in either tube or bifurcated versions. RESULTS: Between August 1994 and November 1996, 149 patients (mean age 67 years, range 49 to 90) were admitted to the study. Overall primary technical success (aneurysm exclusion without endoleak) was 87% (130 patients): 78% (7 patients) for tube grafts and 88% (123 patients) for bifurcated endografts. The rate of local, remote, or systemic complications was 10.8%, with a 30-day mortality rate of 0.7%. During an average 13.5-month follow-up, there were no late deaths. Four of 20 endoleaks sealed spontaneously, 14 were treated with endoluminal techniques, and 2 remain untreated by patient request. Three graft limb thromboses occurred; one was treated surgically, one with lytic therapy, and one was untreated. Secondary patency was 96%. CONCLUSIONS: Endoluminal repair of infrarenal AAAs using straight or bifurcated grafts is a feasible alternative to conventional surgical repair. Longer follow-up and more experience with refined endograft models will elucidate the durability of this endovascular approach to treating AAAs.
Aged↗
[Magnetic resonance tomography in early diagnosis of rheumatoid arthritis].
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Arthritis, Rheumatoid↗
Effects of mistletoe lectin I on human blood cell lines and peripheral blood cells. Cytotoxicity, apoptosis and induction of cytokines.
The effects of mistletoe lectin I (ML I) on the human T-cell leukemia line MOLT-4, the monocytic line THP-1 and on human peripheral blood mononuclear cells (PBMC) were investigated with regard to general cell viability and induction of apoptosis. Using a sensitive serum-free cytotoxicity assay, the time- and concentration-dependent direct toxicity towards MOLT-4 cells was determined with IC50-values ranging from 20-40 pg/ml (300-600 fmol/l). Investigations on the time course of the toxic effect using selected concentrations of ML I revealed distinct response curves for concentrations of high, low and intermediate toxicity, respectively. The ratio of apoptotic to viable MOLT-4 cells was determined after treatment with ML I for 24 h. Apoptosis and cytotoxicity were correlated at low and intermediate concentrations, whereas at long intervals and high concentrations of ML I mostly necrotic effects were observed. The data showed that in the concentration range of low cytotoxicity ML I-induced cell death is quantitatively due to apoptotic processes. The immunomodulatory activity of ML I was investigated in vitro by measuring cytokine release. At concentrations of low cytotoxicity ML I showed immunostimulatory activity on PBMC and THP-1. RT-PCR with THP-1 cells confirmed that cytokine induction by ML I is regulated on the transcriptional level. These findings suggest that in the blood cells investigated both apoptosis and cellular signalling are induced by the same concentration range of ML I.
Apoptosis↗
[Quantitative CT assessment of the proximal femur. Experimental studies on its correlation with breaking load in femoral neck fractures].
PURPOSE: In an experimental study, the correlation between the trabecular bone density of the different regions of the proximal femur and the fracture load in the setting of femoral neck fractures was examined. METHODS: The bone mineral density of 41 random proximal human femora was estimated by single-energy quantitative CT (SE-QCT). The trabecular bone density was measured at the greatest possible extracortical volume at midcapital, midneck and intertrochanteric level and in the 1 cm3 volumes of the centres of these regions in a standardised 10 mm thick slice in the middle of the femoral neck axis (in mg/ml Ca-hydroxyl apatite). The proximal femora were then isolated and mounted on a compression/bending device under two-legged stand conditions and loaded up to the point when a femoral neck fracture occurred. RESULTS: Statistical analysis revealed a linear correlation between the trabecular bone density and the fracture load for the greater regions, with the highest value in the maximal area of the head (coefficient factor r = 0.76). CONCLUSION: According to our data, the measurement of the trabecular bone by SE-QCT at the femoral head is a more confident adjunct than the neck or trochanteric area to predict a femoral neck fracture.
Adult↗
[Neurologic prognosis after cardiocirculatory arrest outside the hospital].
OBJECTIVE: To detect clinical signs and times of evaluation able to identify patients with good neurologic prognosis after out-of-hospital cardiac arrest. EXPERIMENTAL DESIGN: Retrospective study with 6 months-2 years of follow-up. SETTING: General intensive care unit, from 1993 to 1995. PATIENTS: Twenty-three patients aged 18-80 years, admitted with coma after out-of-hospital cardiac arrest, who survived at least 24 hours, without concomitant neurologic disorders. INTERVENTIONS: Neurologic outcome classification in three categories: complete neurologic recovery (A), moderate to severe disability (B), death without regained consciousness (C); A and B groups of patients are considered together as a "good neurologic outcome" group. MEASUREMENTS: Evaluation of some neurological parameters (GCS, motor response to pain, spontaneous motility, cranial nerve reflexes, spontaneous breathing, seizures) 6 hours (t0), 24 hours (t1), 72 hours (t2) and 7 days (t3) after arrest. RESULTS: Patients with good prognosis are identified with 100% sensitivity from the following parameters: at t0 none; at t1 motor response to pain, GCS > 4, absence of seizures; at t2 the former parameters, spontaneous breathing, brain stem reflexes, normal pupils; at t3 all the former parameters and spontaneous motility. Specificity is greater than 50% only for motor response to pain and GCS > 4. CONCLUSIONS: It is mostly impossible to state a neurologic prognosis in the first hours after cardiac arrest. The single predictor with the most reliable prognostic value is motor response to pain which allows, if present, to identify all the patients with a good prognosis as early as 24 hours after arrest.
Adolescent↗
A nonradioactive assay for ribosome-inactivating proteins.
A sensitive nonradioactive method to determine the activity of ribosome-inactivating proteins (RIPs) based on a combined transcription/translation in vitro assay was established. Using this assay we investigated the RIP activities of the heterodimeric toxic plant lectins ricin and mistletoe lectin I (ML-I). The enzymatic activities of the holoproteins were compared to that of the RIP-active chain of ML-I (ML-I A-chain) and recombinant ML-I A-chain expressed in Escherichia coli. The IC50 values determined for the plant toxins showed that the translation-inactivating activity of ML-I (39.8 pM) is about four times higher than that of ricin (176.0 pM). The plant-derived ML-I A-chain is more toxic (3.4 pM) in the cell-free translation system than the respective holoprotein. The recombinant ML-I A-chain was found to be about three times less active (IC50 10.6 pM) than the A-chain from plant. The in vitro assay described here is a convenient method for the fast determination of RIP activity with a 1000-fold lower detection limit than that of commonly used RIP assays.
Animals↗
[Reflux esophagitis--diagnosis and differential diagnosis].
The combination of the two typical symptoms - heartburn and regurgitation - is almost proving gastrooesophageal reflux disease (GORD). Further - atypical - symptoms are dysphagia, odynophagia, pharyngitis, reflux-induced pulmonary symptoms or intermittent chest-pain. Endoscopic signs of GORD are patchy reddening of the mucosa, erosions, ulcers and stricture. Barretts oesophagus is characterized by columnar epithelial metaplasia. Consequence: Typical symptoms of GORD may be treated without further diagnostic procedure whereas in the case of atypical symptoms diagnosis of GORD has to be established by endoscopy.
Barrett Esophagus↗
[Hemosuccus pancreaticus--a rare cause of upper gastrointestinal bleeding. Successful treatment in two cases by radiologic-interventional embolization of the splenic artery].
HISTORY AND CLINICAL FINDINGS: Two patients were admitted to hospital for diagnosis of recurrent upper gastrointestinal bleeding. Both had chronic pancreatitis with alcohol abuse. Their general condition was satisfactory. Physical examination showed no diagnostic abnormalities other than mild epigastric pain on pressure in one patient. INVESTIGATIONS: In case 1 angiography revealed pseudoaneurysm of the splenic artery as a complication of chronic pancreatitis to be the cause of the bleeding. In case 2 sonography demonstrated multiple pancreatic pseudocysts after recurrent pancreatitis. Duplex sonography revealed one of the cyst to be a partly thrombosed pseudoaneurysm of the splenic artery and the source of the bleeding. TREATMENT AND COURSE: In both cases a fistula between splenic artery and pancreatic duct having been shown to be the source of the bleeding, transcatheter embolisation of the splenic artery with platinum coils was successfully undertaken. Both patients remained symptom-free 4 and 10 months later. CONCLUSION: Although haemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding, given certain features in the patient's history and the clinical findings, it should be included in the differential diagnosis.
Aneurysm, False↗
Patterns of disease failure after trimodality therapy of nonsmall cell lung carcinoma pathologic stage IIIA (N2). Analysis of Cancer and Leukemia Group B Protocol 8935.
BACKGROUND: The impact of sequential trimodality therapy on the pattern of first site disease failure in pathologic Stage IIIA (N2) nonsmall cell lung carcinoma (NSCLC) was analyzed. METHODS: Seventy-four eligible patients with histologically documented Stage IIIA (N2) NSCLC underwent sequential trimodality therapy on Cancer and Leukemia Group B (CALGB) Protocol 8935. Treatment consisted of 2 cycles of induction cisplatin at 100 mg/m2 intravenously (i.v.) (Days 1 and 29) and vinblastine at 5 mg/m2 i.v. weekly for 5 weeks followed by surgery. Surgery included a thoracotomy with resection of the primary tumor and hilar lymph nodes and a mediastinal lymph node dissection. Patients with resected disease then received an additional a cycles of cisplatin at 100 mg/m2 i.v. and vinblastine at 5 mg/m2 i.v. biweekly for 2 total of 4 doses followed by consolidative thoracic irradiation. Patients with completely resected disease received 54 Gray (Gy) whereas those with incompletely resected disease received 59.4 Gy at 1.8 Gy/fraction (fx) once a day. Patients with unresectable disease underwent thoracic radiation therapy (TRT) treatments only to 59.4 Gy at 1.8 Gy/fx without any additional chemotherapy. Disease recurrence was determined by clinical, radiographic, or histologic criteria. Pattern of disease failure was identified by site of involvement at first recurrence as indicated by the CALGB Respiratory Follow-Up Form. RESULTS: Sixty-three of the 74 patients completed the induction chemotherapy as planned. Forty-six of the 63 patients underwent resection of disease whereas the remaining 17 were unresectable. Thirty-three of the 46 resected patients completed the entire adjuvant postoperative chemoradiation treatment as planned. Ten of 17 patients with unresectable disease completed postsurgical TRT. At a median follow-up interval of 27 months (range, 4-43), the 3-year overall survival and failure-free survival were 23% and 18%, respectively, for all 74 eligible patients. Overall, disease failure has occurred in 52 (70%) of the 74 eligible patients: local only: 13 (25%); distant only: 16 (31%); and both local and distant: 23 (44%), (P = not significant [NS]). Ten patients progressed during induction chemotherapy: local only: six patients; and both local and distant failure: four patients. Twenty-eight of 46 resected patients recurred: local only: 1 (4%); both local and distant failure: 11 (39%); and distant only: 16 (57%); (P < 0.001). Disease progression occurred in 14 of 17 patients with unresectable disease: local only: 6; both local and distant sites: 8. Among the 52 total patients experiencing disease relapse, isolated or combined local failure occurred commonly among patients during induction chemotherapy (n = 10, [28%]), in those with unresectable disease (n = 14, [39%]), or in those with resected disease (n = 12, [33%]), (P = NS). However, isolated or combined distant failure was more likely to occur among patients with resected disease (n = 27, [69%]) than either during induction chemotherapy (n = 4, [10%]) or in those with unresected disease (n = 8, [21%]), (P < 0.05). Among patients who relapsed, brain metastases occurred in 13 of 52 (25%) patients overall and in 12 of 28 (43%) patients with resected disease. CONCLUSIONS: Overall, disease failure was just as likely to occur in local, distant, or combined sites on CALGB Protocol 8935 using sequential trimodality therapy in the treatment of pathologic Stage IIIA (N2) NSCLC: Isolated or combined local failure occurred commonly during sequential tri-modality therapy whereas isolated or combined distant relapse was prevalent among patients with resected disease. In addition, isolated local failure was rare among patients with resected disease. The pattern of disease failure on CALGB Protocol 8935 reflects the biology of locoregional NSCLC as much as the therapeutic impact of trimodality therapy.
Adenocarcinoma↗