RESUMEN
Elderly patients with ovarian cancer are an increasing population and many of them are frailty with an increased risk of postoperative complications, chemotherapy intolerance and mortality. Metronomic chemotherapy is the chronic administration of low, equally spaced, doses of antineoplastic drugs with therapeutic efficacy and low toxicity. Oral metronomic cyclophosphamide has gained increasing interest in recent years in the treatment of patients with recurrent ovarian cancer. We report the case of a 87-year-old and -frailty woman with advanced ovarian cancer, not eligible for surgery or standard first-line intravenous chemotherapy. The patient has received oral metronomic cyclophosphamide with a long-lasting clinical response and improved performance status. Oral metronomic cyclophosphamide is a promising treatment for elderly and frailty advanced ovarian cancer patients and should be further investigated.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Ciclofosfamida/uso terapéutico , Neoplasias Ováricas/tratamiento farmacológico , Administración Oral , Anciano de 80 o más Años , Femenino , Fragilidad , HumanosRESUMEN
OBJECTIVE: The main objective is to develop a model based on computed tomographic features to predict surgical outcome and establish cut-offs to rationalize clinical management in advanced epithelial ovarian carcinoma. The secondary purpose is to identify parameters that should be reported by radiologists to allow a correct pre-operative evaluation. METHODS: This study evaluated the association between 17 radiologic parameters and surgical outcome through the review of 61 computed tomographic scans. Each parameter received a score according to the strength of statistical association and points were added to obtain a predictive index value. The absence of residual tumor was considered an optimal result. Receiver operating characteristic curves were applied to assess the ability to predict surgical outcome. The score was applied to the study population to verify if the therapeutic approach had been congruent with the predicted results and to define adequate cut-offs. RESULTS: Analysis with a receiver operating characteristic curve demonstrated a statistical association with surgical outcome (area under curve=0.949). The clinical approach agreed with the predicted outcome. Patients with lower scores received primary debulking surgery (mean predictive index value 2.4) whereas those with higher scores (mean 14.1) were given neoadjuvant chemotherapy. Further surgical investigation (laparoscopy) was performed in patients with higher predictive index value variability (0-17.5). Different cut-offs were analysed to define the model applicability. The results show that surgery is appropriate for patients with a predictive index value <6 (failure rate 11.5%) while a predictive index value >8 should address to neoadjuvant chemotherapy (0% of inappropriately unexplored patients). In addition, patients with a predictive index value between 6 and 8 could benefit from diagnostic exploration with a good success rate (71.4%). CONCLUSIONS: The model correctly discerns patients who can benefit from surgery (predictive index value <6) from those who should undergo neoadjuvant chemotherapy (>8) and establishes a range (6-8) where surgical investigations may be helpful. This score is a flexible tool where cut-offs can be changed according to the desire to be surgically more aggressive or more conservative.
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Carcinoma Epitelial de Ovario/diagnóstico por imagen , Carcinoma Epitelial de Ovario/cirugía , Neoplasias Ováricas/diagnóstico por imagen , Neoplasias Ováricas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Quimioterapia Adyuvante , Procedimientos Quirúrgicos de Citorreducción , Femenino , Humanos , Persona de Mediana Edad , Modelos Estadísticos , Terapia Neoadyuvante , Estadificación de Neoplasias , Valor Predictivo de las Pruebas , Cuidados Preoperatorios , Curva ROC , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
AIM: Our study aimed to investigate the role of qualitative and quantitative whole body MRI with DWI for assessment of bone marrow involvement (BMI) in newly diagnosed lymphoma using FDG PET-CT and bone marrow biopsy (BMB) as reference standard. MATERIALS AND METHODS: We retrospectively evaluated 56 patients with newly diagnosed lymphoma (21 Hodgkin's lymphoma and 35 non-Hodgkin's lymphoma) who underwent random unilateral BMB, FDG PET-CT and Wb-MRI-DWI for initial staging. In a patient-based analysis, results of Wb-MRI-DWI were compared with FDG PET-CT and BMB. For quantitative analysis, mean ADC values of posterior iliac crest were correlated with BMI and bone marrow cellularity. RESULTS: WB-MR-DWI obtained excellent concordance with FDG PET-CT both in HL (k = 1.000; 95% CI 1.000-1.000) and in DLBCL (k = 1.000; 95% CI 1.000-1.000). In other NHL, WB-MRI-DWI obtained a good correlation with BMB (k = 0.611; 95% CI 0.295-0.927) while FDG PET-CT had poor concordance (k = 0.067; 95% CI 0.372-0.505). WB-MR-DWI has no false negative errors but 4 false positive results consisting in focal lesions consensually reported by FDG PET-CT and resolved after therapy. No significant correlation between ADC mean value and BMI was found (p = 0.0586). CONCLUSION: Our data suggest that Wb-MRI-DWI is a valid technique for BMI assessment in lymphoma patients, thanks to its excellent concordance with FDG PET-CT and good concordance with BMB (superior than FDG PET-CT). If further investigations will confirm our results on larger patient groups, it could become a useful tool in the clinical workup.
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Médula Ósea/diagnóstico por imagen , Médula Ósea/patología , Imagen de Difusión por Resonancia Magnética/métodos , Linfoma/diagnóstico por imagen , Linfoma/patología , Tomografía Computarizada por Tomografía de Emisión de Positrones , Imagen de Cuerpo Entero , Adolescente , Adulto , Anciano , Biopsia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
OBJECTIVES: To compare the diagnostic accuracy and sensitivity of Gd-EOB-DTPA MRI and diffusion-weighted (DWI) imaging alone and in combination for detecting colorectal liver metastases in patients who had undergone preoperative chemotherapy. METHODS: Thirty-two consecutive patients with a total of 166 liver lesions were retrospectively enrolled. Of the lesions, 144 (86.8 %) were metastatic at pathology. Three image sets (1, Gd-EOB-DTPA; 2, DWI; 3, combined Gd-EOB-DTPA and DWI) were independently reviewed by two observers. Statistical analysis was performed on a per-lesion basis. RESULTS: Evaluation of image set 1 correctly identified 127/166 lesions (accuracy 76.5 %; 95 % CI 69.3-82.7) and 106/144 metastases (sensitivity 73.6 %, 95 % CI 65.6-80.6). Evaluation of image set 2 correctly identified 108/166 (accuracy 65.1 %, 95 % CI 57.3-72.3) and 87/144 metastases (sensitivity of 60.4 %, 95 % CI 51.9-68.5). Evaluation of image set 3 correctly identified 148/166 (accuracy 89.2 %, 95 % CI 83.4-93.4) and 131/144 metastases (sensitivity 91 %, 95 % CI 85.1-95.1). Differences were statistically significant (P < 0.001). Notably, similar results were obtained analysing only small lesions (<1 cm). CONCLUSIONS: The combination of DWI with Gd-EOB-DTPA-enhanced MRI imaging significantly increases the diagnostic accuracy and sensitivity in patients with colorectal liver metastases treated with preoperative chemotherapy, and it is particularly effective in the detection of small lesions.
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Carcinoma/patología , Carcinoma/secundario , Neoplasias Colorrectales/patología , Gadolinio DTPA , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/secundario , Imagen por Resonancia Magnética/métodos , Anciano , Antineoplásicos/uso terapéutico , Carcinoma/tratamiento farmacológico , Neoplasias Colorrectales/tratamiento farmacológico , Medios de Contraste , Quimioterapia , Femenino , Humanos , Neoplasias Hepáticas/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Cuidados Preoperatorios , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
Open partial horizontal laryngectomies (OPHLs) represent a valuable therapeutic option for tumors of the intermediate T-category and, in selected cases, for locally advanced tumors with low-volume extra-laryngeal extension. The eligibility of patients treated with this type of surgery has increased with the introduction of the modular approach to OPHL planning. This strategy follows the introduction of the classification proposed by the European Laryngological Society, based on the extent of horizontal resection. Optimization of the selection is the result of a meticulous work-up process involving close cooperation between experienced surgeons and radiologists, followed by final quality control by pathologists. Computed tomography and magnetic resonance imaging are study methods whose pearls and pitfalls are well known, especially when performed at a high level of expertise. In this paper, based on the experience of two high-volume centers, a checklist of 20 questions addressed by the surgeon to the radiologist before planning an OPHL was proposed. Considerations regarding case selection are reported for each of the questioned parameters. A very simple question-and-answer process is easy to understand and mainly addressed by less experienced colleagues who wish to increase their knowledge and skills in performing this type of surgery.
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To evaluate diagnostic performance of endorectal magnetic resonance (eMR) for diagnosing local recurrence of prostate cancer (PC) in patients with previous radical prostatectomy (RP) and to assess whether contrast-enhanced (CE)-eMR improved diagnostic accuracy in comparison to unenhanced study. Unenhanced eMR data of 72 male patients (mean of total PSA: 1.23 +/- 1.3 ng/ml) with previous RP were interpreted retrospectively and classified either as normal or suspicious for local recurrence. All eMR examinations were re-evaluated also on CE-eMR 4 months after the first reading. Images were acquired on a 1.5-T system. These data were compared to the standard of reference for local recurrence: prostatectomy bed biopsy results; choline positron emission tomography results; PSA reduction or increase after pelvic radiotherapy; PSA modification during active surveillance. Sensitivity, specificity, predictive positive value, negative predictive value and accuracy were 61.4%, 82.1%, 84.4%, 57.5% and 69.4% for unenhanced eMR and 84.1%, 89.3%, 92.5%, 78.1% and 86.1% for CE-eMR. A statistically significant difference was found between accuracy and sensitivity of the two evaluations (chi(2) = 5.33; p = 0.02 and chi(2) = 9.00; p = 0.0027). EMR had great accuracy for visualizing local recurrence of PC after RP. CE-eMR improved diagnostic performance in comparison with T2-weighted imaging alone.
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Medios de Contraste/farmacología , Imagen por Resonancia Magnética/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Anciano , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Próstata/patología , Antígeno Prostático Específico/biosíntesis , Recurrencia , Valores de Referencia , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
Background: The aim of this retrospective study was to identify different radiological features in intermediateâ»advanced laryngeal cancer (LC) associated with arytenoid fixation, in order to differentiate cases still safely amenable to conservative treatment by partial laryngectomy or chemoradiotherapy. Methods: 29 consecutive patients who underwent open partial horizontal laryngectomies (OPHLs), induction chemotherapy followed by radiotherapy in the case of >50% response (IC + RT) or total laryngectomy were classified as: pattern I (supraglottic LC fixing the arytenoid due to weight effect), pattern II (glottic LC involving the posterior paraglottic space and spreading toward the crico-arytenoid joint and infraglottic extension <10 mm), pattern III (glottic-infraglottic LC involving the crico-arytenoid joint and infraglottic extension >10 mm) and pattern IV (transglottic and infraglottic LC with massive crico-arytenoid unit involvement, reaching the hypopharyngeal submucosa). All glottic cancers treated with surgery were studied by a cross sectional approach. Results: A substantial agreement between the work-up and the pathology results has been obtained in each of the subcategories. Three-year disease-free survivals, local control and freedom from laryngectomy were significantly better in pattern II compared to pattern IIIâ»IV. Conclusions: LC showing fixed arytenoid due to weight effect or posterior paraglottic space involvement with infraglottic extension <10 mm assessed at the true vocal cord midline are still safely manageable by OPHL or IC + RT.
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OBJECTIVE: To assess the role of magnetic resonance imaging (MRI) for evaluating changes in the prostate after transrectal high-intensity focused ultrasound (HIFU) for treating prostate cancer, correlating the findings with histology to assess its possible role in predicting the outcome, evaluating residual cancer or local recurrence of disease. PATIENTS AND METHODS: Ten patients with prostate cancer were assessed with MR and MR spectroscopy (MRS) before and at 1, 4 and 12 months after HIFU, assessing the glandular volume and MRI and MRS data after HIFU. These data were correlated with the prostate-specific antigen (PSA) levels at each examination (suspicious for residual cancer if >0.5 ng/mL) and with histological findings of prostate biopsy sampling at 6-8 months (random or targeted at suspicious MR areas). RESULTS: Variations in volume during the follow-up were not associated with treatment outcome. MRI was suspicious for residual cancer in one patient at 1 month and in another two at 4 months; in all three patients (one with a PSA level of <0.5 ng/mL) targeted biopsies were positive for cancer. MRI was negative in seven patients; in six of these (one with a PSA level of >0.5 ng/mL) random biopsies were negative, and in one the random biopsies were positive for residual cancer. At 4 months there was a statistically significant difference (P = 0.015) between patients responsive to treatment and those with persistent disease, by combining negative MRI with a PSA level of <0.5 ng/mL; MRS data were suitable for analysis only in three patients with partial necrosis. CONCLUSION: Our preliminary data support the role of MRI in association with PSA levels as a useful and accurate tool in the follow-up of patients treated with HIFU for prostate cancer. However, considering the economic issue, it should not be used routinely and should be limited to detecting residual cancer (in patients with a PSA level of >0.5 ng/mL) with the main purpose of improving the detection rate of transrectal ultrasonography (TRUS)-guided prostate biopsy. MRS data had no additional value over MRI. Further evaluation is needed to compare the use of contrast media and other techniques (e.g. colour Doppler TRUS) in detecting residual or local recurrent cancer.
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Imagen por Resonancia Magnética/normas , Espectroscopía de Resonancia Magnética/normas , Neoplasias de la Próstata/patología , Ultrasonido Enfocado Transrectal de Alta Intensidad/métodos , Anciano , Anciano de 80 o más Años , Biopsia/métodos , Humanos , Imagen por Resonancia Magnética/economía , Espectroscopía de Resonancia Magnética/economía , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Neoplasia Residual , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/terapiaRESUMEN
AIMS AND BACKGROUND: To determine retrospectively the role of endorectal magnetic resonance in the staging of prostate cancer. The aim of the study was to assess whether it is possible to identify a group of patients with prostate cancer, chosen for certain prognostic factors, eligible for radiotherapy that could take advantage of endorectal magnetic resonance in staging and therapy management. METHODS: Between January 2002 and December 2005, 143 patients with biopsy proven prostate cancer underwent endorectal magnetic resonance. All patients were initially evaluated considering the following prognostic factors: serum prostate-specific antigen at diagnosis, Gleason score, histological grade, involvement of the seminal vesicle and extracapsular extension using the Roach III and ECE equations. The findings were then compared to the results of endorectal magnetic resonance. RESULTS: The relationship between the variable post-endorectal magnetic resonance stage modification and Gleason score was statistically significant (P = 0.02847). In addition, our study showed a statistically significant correlation between the risk of seminal vesicle involvement according to the Roach III formula and post-endorectal magnetic resonance stage modification (P = 0.01305). Conversely, statistical analysis showed no significant correlation between post-endorectal magnetic resonance stage modification and prostate-specific antigen values (P = 0.83440) or between post-endorectal magnetic resonance stage modification and the risk of extracapsular extension according to the extracapsular extension formula (P = 0.42748). CONCLUSIONS: Our data suggest that endorectal magnetic resonance could be used for staging of the subgroup of patients at high risk of seminal vesicle involvement (> 15%). Although we found a statistical correlation between Gleason score and post-endorectal magnetic resonance stage modification, statistical analysis showed no correlation between any of the subgroups. Therefore, it is not possible at the moment to identify a subgroup of patients by Gleason score that may benefit from endorectal magnetic resonance. In our opinion, extracapsular extension values were not useful to select patients for endorectal magnetic resonance.
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Imagen por Resonancia Magnética/métodos , Nomogramas , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/radioterapia , Anciano , Anciano de 80 o más Años , Terapia Combinada , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Prostatectomía , Neoplasias de la Próstata/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: The purpose of this retrospective study was to identify subcategories in cT3 to cT4a supraglottic/glottic cancers, describing their different spreading patterns, and local and locoregional recurrence modes. METHODS: Four hundred eighty-nine patients who underwent open partial horizontal laryngectomies (OPHLs) were retrospectively classified as: subcategory I (anterior pT3 with normal arytenoid mobility); subcategory II (posterior pT3 with impaired/absent mobility); subcategory III (anterior pT4 with normal mobility); and subcategory IV (posterior pT4 with impaired/absent mobility). RESULTS: Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional, local control, freedom from laryngectomy, and laryngectomy-free survival were significantly better in anterior tumors (subcategories I and III) when compared with the corresponding posterior ones (subcategories II and IV). CONCLUSION: Anterior cT3 tumors are manageable by OPHL, and this approach could also be proposed in the treatment of early anterior cT4aN0. Despite promising results, OPHLs should be considered under investigation in posterior cT3 tumors due to clinical and biological behavior similar to cT4a tumors.
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Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Neoplasias Laríngeas/patología , Neoplasias Laríngeas/cirugía , Laringectomía , Recurrencia Local de Neoplasia/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/mortalidad , Supervivencia sin Enfermedad , Femenino , Humanos , Neoplasias Laríngeas/mortalidad , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
The diagnosis and management of patients with obscure gastrointestinal bleeding are often long and challenging processes. Over the last 10 years the introduction in clinical practice of new diagnostic and therapeutic procedures (i.e. Capsule Endoscopy, Computed Tomographic Enterography, Magnetic Resonance Enterography, and Device Assisted Enteroscopy) has revolutionized the diagnostic/therapeutic work-up of these patients. Based on evidence published in the last 10 years, international scientific societies have proposed new practice guidelines for the management of obscure gastrointestinal bleeding, which include these techniques. However, although these algorithms (the most recent ones are endorsed by the American Society for Gastrointestinal Endoscopy - ASGE) allow the management of the large majority of patients, some issues still remain unsolved. The present paper reports the results of the discussion, based on the literature published up to September 2011, among a panel of experts and gastroenterologists, working with Capsule Endoscopy and with Device Assisted Enteroscopy, attending the 6th annual meeting of the Italian Club for Capsule Endoscopy and Enteroscopy. Eight unresolved issues were selected: each of them is presented as a "Burning question" and the "Answer" is the strategy proposed to manage it, according to both the available evidence and the discussion among participants.