Faculty Bibliography

OBJECTIVE: Transarterial chemoembolization is a widely used therapy for the treatment of hepatocellular carcinoma. A rare adverse event is acute respiratory distress syndrome from pulmonary embolization of Lipiodol, an iodinated oil commonly used during the procedure. The objective of this report is to describe an atypical case of acute respiratory distress syndrome from Lipiodol embolization in a patient who underwent transarterial chemoembolization for hepatocellular carcinoma 9 days prior to presentation, despite having received relatively small amounts of Lipiodol (5.5 mL). Although this diagnosis has classically been based on radiological findings, we established a diagnosis after lipid-laden macrophages were detected in bronchial alveolar lavage fluid. DESIGN: Case report. SETTING: ICU of a major metropolitan academic medical center. PATIENTS: Single case. INTERVENTIONS: Diagnostic interventions included noncontrast CT scan of the chest and cytologic examination of bronchial alveolar lavage fluid with oil red O staining. Therapeutic interventions included mechanical ventilation and methylprednisolone infusions. MEASUREMENTS AND MAIN RESULTS: Noncontrast CT demonstrated nonspecific diffuse ground glass opacification, most prominent within the upper lobes. Mechanical ventilation was begun for hypoxemic respiratory failure. Cytologic examination of bronchial alveolar lavage fluid revealed a high proportion of lipid-laden macrophages, findings consistent with Lipiodol embolism. Despite infusions of methylprednisolone, the patient expired on hospital day 8. CONCLUSIONS: Acute respiratory distress syndrome from Lipiodol embolization following transarterial chemoembolization can occur even with small Lipiodol volumes. Cytologic examination of bronchial alveolar lavage fluid with oil red O staining is a useful diagnostic modality, especially when imaging studies are equivocal.

OBJECTIVE: Refractory status epilepticus (RSE) requires aggressive management with multiple antiepileptic drugs (AEDs) often requiring the initiation of continuous infusions of propofol, midazolam, or pentobarbital to achieve adequate control in addition to intermittent agents. Ketamine has been implicated in several case reports as a successful agent for treating RSE given that it blocks the N-methyl-D-aspartate receptor, which is overexpressed in prolonged status epilepticus. CASE SUMMARY: We describe a previously healthy 27-year-old woman who presented with prolonged RSE requiring the initiation of multiple AEDs, including high-dose propofol and midazolam continuous infusions. As a result of hypotension from propofol and inadequate seizure control with midazolam, the patient was successfully transitioned to a pentobarbital infusion in combination with multiple AEDs. Although the patient achieved control of her RSE, her course was complicated by the development of an anticonvulsant hypersensitivity syndrome (AHS) with transaminitis. Limited with the options of AED that could have been used, it was decided to initiate the patient on a continuous ketamine infusion plus midazolam and slowly wean the patient off pentobarbital as well as to avoid further use of phenytoin and phenobarbital. DISCUSSION: The patient was successfully transitioned off pentobarbital to a ketamine infusion plus midazolam with complete seizure control after several dose escalations. Her AHS and transaminitis resolved on a ketamine infusion for a total of 12 days, and she was successfully discharged from the hospital after 60 days in the ICU. CONCLUSION: This is the first case report to describe a successful transition to a ketamine infusion in a patient with AHS and transaminitis.

Introduction Measles is a highly contagious viral illness with significant mortality. Despite vaccination efforts, measles continues to occur in the United States. Most cases are associated with importation from endemic countries. Respiratory complications of the virus are one of the leading causes of fatalities. We report a case of measles pneumonia in an immunocompetent, unvaccinated adult with no associated importation from abroad. Case Presentation A 38 year old Caucasian female, with no recent travel history, presented with 3 days of fevers, cough, facial rash, and progressive shortness of breath. Her rash spread inferiorly to her trunk and extremities. On examination she was febrile, tachycardic, and hypoxic with a Pa02 of 55mmHg on room air. An erythematous, maculopapular rash was distributed over her face, trunk, and extremities. Her buccal mucosa had 2 mm white lesions, consistent with koplik spots. A chest x-ray showed a right upper lobe infiltrate and increased interstitial markings. She was placed in isolation and a floroquinolone was empirically initiated for a possible bacterial coinfection. Acute measles serologies returned positive, with an IgM level of 11.04 AU. Over the course of 48 hours, her fever defervesced, her oxygen saturation normalized, and her cough and rash resolved. She was discharged with instructions to have her 2 children receive the MMR vaccination immediately. Her children and she had not been vaccinated previously. Discussion Measles was declared eliminated from the United States in the year 2000, but the virus continues to be imported from endemic regions [1]. Our case represents one of 118 reports of measles in the United States between January 1 and May 20, 2011. Of these 118 cases, 105 (89%) were associated with importations from other countries and only 9 developed pneumonia [2]. Uniquely, our patient had no recent travel to, or contact with, individuals from an endemic region. This case, therefore, represents one of the few instances of measles pneumonia in the United States that was not import-associated. Instead, the risk factor in our presentation was the lack of prior vaccination. This absence of immunity resulted in the potentially life threatening complication of pneumonia. Our case underscores the importance of educating reluctant individuals regarding the safety and efficacy of the measles vaccine in preventing a devastating disease

PURPOSE/OBJECTIVE:To report the dosimetric outcome of patients with clinically localized prostate cancer treated with I-125 permanent implantation using an intraoperative real-time conformal planning technique. METHODS AND MATERIALS/METHODS:Five hundred and sixty-two patients with prostate cancer were treated with I-125 permanent interstitial implantation using a transrectal ultrasound-guided approach. Real-time intraoperative treatment planning software that incorporates inverse planning optimization was used. Dose-volume constraints for this inverse-planning system included: prostate V100 >or=95%, maximal urethral dose <or=120%, and average rectal dose <80% of the prescription dose. Day zero computed tomography scans were acquired for post-implantation dosimetric evaluation. RESULTS:The median V100 and D90 to the prostate target were 96% and 166 Gy, respectively. In 91% of cases a D90 of >or=140 Gy was achieved. In these patients, the V100 and D90 values did not have a significant influence on PSA relapse-free survival outcomes. The median maximum rectal dose and urethral doses were 104 Gy (72% of the prescription dose) and 187 Gy (130% of the prescription dose). The average and maximum rectal doses exceeding 100% of the prescription dose were less than 1% and 10% of patients, respectively. Average and maximum urethral doses exceeding 150% of the prescription dose were noted in 3% and 24% of patients, respectively. Average and maximum urethral doses exceeded 120% of the prescription dose in 21% and 58% of patients, respectively. Among patients where >or=2.5 cm(3) of the rectum was exposed to the prescription dose, the incidence of late grade 2 toxicity rectal toxicity was 9% compared to 4% for smaller volumes of the rectum exposed to similar doses (p=0.003). No dosimetric parameter in these patients with tight dose confines for the urethra influenced acute or late urinary toxicity. CONCLUSION/CONCLUSIONS:Real-time intraoperative planning was associated with a 90% consistency of achieving the planned intraoperative dose constraints for target coverage and maintaining planned urethral and rectal constraints in a high percentage of implants. Rectal volumes of >or=2.5 cm(3) exposed to the prescription doses were associated with an increased incidence of grade 2 rectal bleeding. Further enhancements in imaging guidance for optimal seed deposition are needed to guarantee optimal dose distribution for all patients. Whether such improvements lead to further reduction in acute and late morbidities associated with therapy requires further study.

PURPOSE/OBJECTIVE:To report the 5-year tumor control and toxicity outcomes for patients with localized prostate treated with I-125 permanent implantation using an intraoperative real-time conformal planning technique. METHODS AND MATERIALS/METHODS:Between January 1998 and June 2002, 367 patients with prostate cancer were treated with I-125 permanent interstitial implantation using a transrectal ultrasound-guided approach. Real-time intraoperative treatment planning which incorporated inverse planning optimization was used. The median follow-up time was 63 months. RESULTS:The median V100 and D90 were 96% and 173 Gy, respectively. In 96% of cases a D90 of >140 Gy was achieved. The median urethral and rectal doses were 100% and 33% of the prescription doses, respectively. The 5-year PSA relapse-free survival outcomes for favorable and intermediate risk patients according to the ASTRO definition were 96% and 89%, respectively. In these patients no dosimetric parameter was identified which influenced the biochemical outcome. Of 38% who developed acute Grade 2 urinary symptoms, 63% had resolution of their symptoms within a median time of 6 months. The incidence of late rectal and urinary Grade 3 or higher toxicities were 1% and 4%, respectively. Seven percent (n = 27) developed late rectal bleeding (Grade 2) and 19% experienced late Grade 2 urinary symptoms. CONCLUSION/CONCLUSIONS:Real-time intraoperative planning consistently achieved optimal coverage of the prostate with the prescription dose with concomitant low doses delivered to the urethra and rectum. Biochemical control outcomes were excellent at 5 years and late toxicity was unusual. These data demonstrate that real-time planning methods can consistently and reliably deliver the intended dose distribution to achieve an optimal therapeutic ratio between the target and normal tissue structures.