Hodgkin's disease stage I and II with exclusive subdiaphragmatic presentation. The experience of the Departments of Radiation Oncology and Hematology, University "La Sapienza" of Rome.

During the period 1978 to 1994, 1054 patients with Hodgkins's disease were evaluated and treated at the Departments of Radiation Oncology and Hematology, University "La Sapienza", Rome. A total of 549 patients presented with clinical or pathological stage I and II; 37 of these had Hodgkin's disease below the diaphragm (BDHD), and 512 above the diaphragm (ADHD). A comparison of patients with BDHD versus those with ADHD showed that the first group had a higher male to female ratio. A comparison of cases with stage II BDHD versus those with stage II ADHD showed that patients with BDHD were older (48 years vs 28 years), had different histologic features and a higher incidence of systematic symptoms (67% vs 33%). Stage II BDHD patients had a worse prognosis; in fact, there were significant differences in the overall survival and relapse-free-survival rates for cases with stage II BDHD versus those with stage II ADHD (overall survival, 46% vs 80%, P<0.001; relapse-free survival, 44% vs 69%, P<0.005). Stage was found to be the most important prognostic factor for BDHD cases without systematic symptoms treated with radiation therapy alone. The type of infradiaphragmatic presentation (intra-abdominal vs peripheral disease) did not influence outcome, probably due to the more aggressive therapy received by the intra-abdominal group. Treatment recommendations for BDHD cases should be tailored to the stage and the presence or absence of intra-abdominal localization. For patients with stage IA extended fields, irradiation (inverted Y) is sufficient. However, combined modality therapy should be the treatment of choice for stage II cases, particularly in the presence of intra-abdominal disease. Patients with systematic symptoms also require combined modalities.

Cardiac magnetic resonance imaging: diagnostic value and utility in the follow-up of patients with acute myocarditis mimicking myocardial infarction.

PURPOSE: The aim of our study was to evaluate the efficacy of magnetic resonance imaging (MRI) in the differential diagnosis between active myocarditis and myocardial infarction in patients with clinical symptoms mimicking acute myocardial infarction. MATERIALS AND METHODS: Between 1 January 2006 and 30 June 2007, 23 consecutive patients (21 men and 2 women) presenting with electrocardiographic abnormalities mimicking acute myocardial infarction and a clinical suspicion of acute myocarditis (fever, chest pain and elevated troponin levels) underwent contrast-enhanced cardiac MRI within a week of admission. All patients also underwent coronary angiography, which demonstrated the absence of significant coronary artery lesions. The mean follow-up period was 2+/-4 months. RESULTS: Cardiac MRI with injection of contrast material showed late subepicardial and intramyocardial enhancement in all patients. Subendocardial late enhancement, a typical pattern of myocardial infarction, was never seen. In addition, in agreement with the literature, there was prevalent involvement of the lateral segments of the left ventricular wall. CONCLUSIONS: Cardiac MRI could be a valuable tool for the early diagnosis of acute myocarditis, as it can demonstrate specific patterns that help rule out acute myocardial infarction.

[Towards the standardization of sentinel lymph node analysis in women with breast cancer]. / Verso una standardizzazione dell'analisi del linfonodo sentinella in donne con cancro della mammella.

Sentinel lymph node biopsy allows enhanced pathology through serial sections and immunohistochemical analysis of the retrieved node, with detection of micrometastases and isolated tumor cells not otherwise recognized. We present our experience with a simple, effective, pathology protocol requiring six couples of sections at three different sentinel lymph node levels. Additional micrometastases or ITC were diagnosed in 51/416 patients (14.6%).

Comparison between transrectal ultrasonography and computed tomography with rectal inflation of gas in preoperative staging of lower rectal cancer.

Computed tomography with rectal air insufflation was compared with transrectal ultrasonography (TRUS) in 63 patients. The CT protocol involved pre- and postcontrast scans with 5 mm slice thickness following air insufflation in IV antiperistaltic agent. Of the patients, 79 % were scanned in the prone position. Results of the preoperative examinations were compared with the histological findings. The CT examination had an accuracy rate of 74 %, predicting perirectal spread with a sensitivity of 83 % and a specificity of 62 %, whereas the corresponding figures for TRUS were 83, 91 and 67 %. The accuracy, sensitivity and specificity of CT and TRUS for nodal involvement were 57, 56, 57, 66, 68 and 64 %-respectively. These findings confirm that TRUS is more accurate than CT in local tumour (T) staging and in detecting nodal (N) spread. However, the appropriate CT technique shows spread of tumour outside the rectal wall and locoregional lymph nodes with reasonable accuracy. Lymphatic spread correlated with nodal size. TRUS and CT correctly staged only 57 and 43 %, respectively, of cases with nodal metastases with maximum diameter of 5 mm. TRUS sometimes overstaged perirectal growth of tumour in 7 patients, due to inflammation (5 patients) or incorrect positioning of the balloon in relation to the tumour surface (2 patients).

[Assessment of residual mediastinal tumor in patients with Hodgkin's lymphoma using computed tomography, magnetic resonance and 67Ga scintigraphy]. / Valutazione del residuo mediastinico nei pazienti affetti da linfoma di Hodgkin con Tomografia Computerizzata, Risonanza Magnetica e oncoscintigrafia con 67Ga.

594 patients with Hodgkin's disease were treated from 1983 to 1993 at the Department of Radiotherapy and Institute of Hematology, "La Sapienza" University, Rome, Italy. 385 patients presented mediastinal involvement; CT and/or chest radiography showed residual mediastinal masses in 96 of them (25%). In this study we included only the patients treated after 1986; they were examined with MRI of the chest (24 patients) and 67Gallium scintigraphy of the mediastinum (44 patients) with or without SPECT, combined with high-dose 67Ga in some cases. Eighteen patients underwent both MRI and 67Gallium scintigraphy. MR accuracy, sensitivity and specificity were respectively 75%, 86% and 86%; gallium scintigraphy had 86%, 77% and 93%. These data were confirmed by the results fo the subgroup of 18 patients submitted to both exams; MRI had higher sensitivity (80% vs. 75%) and lower specificity and accuracy (83% vs. 80% and 72% vs. 67, respectively) than 67Gallium scintigraphy. The predictive value of MR-scintigraphy agreement is high: indeed, no false negatives or false positives were observed when MR and scintigraphy results were in agreement.

[Comparison of computerized tomography and magnetic resonance in staging of T and N parameters in head and neck neoplasms]. / Stadiazione dei parametri "T" e "N" dei tumori della testa e del collo con tomografia computerizzata e risonanza magnetica a confronto.

January 1990, through January 1994, eighty untreated patients with head and neck cancer were consecutively submitted to CT and MRI of the head and neck before surgery. CT and MR findings were then compared to operative histologic findings. Forty-eight of 52 T4 cases at CT were confirmed at surgery (89%), 7 of 13 T3 cases at CT were also confirmed (54%), as well as 8 of 15 T2 cases (53%). CT understaged 13 cases (6 T3 and 7 T2), which surgery staged as T4, CT overstaged 4 cases as T4, which were 2 pT2 and 2 pT3 at histology. All the 54 cases MRI staged as T4 were confirmed at surgery (100%), 3 of 12 MRI staged as T3 were pT4 at surgery (25%) and, finally, 4 of 14 cases MRI staged as T2 were pT4 at histology (28%). Only one case staged as pT4 at surgery and CT had been staged as T3 by MRI because the latter method had failed to depict hyoid involvement. On the other hand, in 6 cases MRI correctly modified CT staging. Overall CT accuracy was 79% and MR accuracy 91%. CT sensitivity was 70% versus 75% with MRI, specificity was 80% versus 78%, respectively, and overall accuracy 75% versus 76%. Only in two patients MRI correctly modified CT staging (N1 at surgery). Our results confirm various advantages of MRI over CT in the assessment of tumor mass ("T" parameter), mainly in T2 and T3 cases, because MRI yields higher soft tissue contrast resolution and has multiplanar capabilities. CT was superior to MRI only in the assessment of bone involvement. This study also confirmed similar CT and MR capabilities in detecting lymph node tumor spread. Finally, MRI did not allow earlier detection of micrometastases than CT.

[Computerized tomography and magnetic resonance in radical and reconstructive surgery using pedunculated and revascularized flaps in advanced-stage tumors of the head and neck. Analysis of recurrences. II]. / Tomografia Computerizzata e Risonanza Magnetica nella chirurgia radicale e ricostruttiva con lembi peduncolati e rivascolarizzati nei tumori negli stadi avanzati del capo e del collo. Analisi delle recidive (II parte).

January, 1992, to October, 1995, sixty-four patients with advanced head and neck carcinoma were submitted to reconstructive surgery using pedunculated myocutaneous or revascularized flaps and then to CT and MRI. Myocutaneous flaps were used in 26 cases--12 tubular and 14 linear flaps--and revascularized flaps in 38--14 latissimus dorsi flaps, 12 temporal flaps, 7 jejunal flaps and 5 radial flaps. Twenty-six of 64 cases (41%) relapsed: MRI correctly depicted the recurrence in 24 cases and CT in 19, with 2 false positives and 2 false negatives at MRI and 6 false positives and 7 false negatives at CT. The sensitivity, specificity, accuracy, positive and negative predictive value of CT were 84%, 78%, 73%, 76% and 82%, respectively, while the corresponding MR rates were 95%, 94%, 92%, 92% and 95%. MRI was more accurate than CT in demonstrating postoperative and postirradiation changes (92% for MRI versus 73% for CT) thanks to its higher sensitivity in depicting tumor tissue on T2-weighted and post-Gd-DTPA images. CT is very useful in the early postoperative period, to follow-up poorly collaborative patients, because its acquisition time is short; MRI should be performed when CT findings are questionable and the revascularized flap is used to repair a large defect at the skull base.

Acute nonlymphocytic leukemia: onset after treatment for Hodgkin's disease.

This study was undertaken to examine the influence of various factors on the occurrence of acute nonlymphocytic leukemia (ANLL) in a group of longterm survivors of Hodgkin's disease (HD). From 1972 to 1992, 1045 patients with HD were assessed and treated at the Department of Radiation Oncology, the Institute of Radiology, and the Department of Human Biopathology, Hematology Section, University of Rome "La Sapienza". The average follow-up was 72 months. For a more accurate calculation of the risk of ANLL occurrence, the patients were first divided into three subgroups according to initial treatment and then according to the total treatment they had received. Moreover, to establish the probable connection between leukemia and splenic treatment the patients were also divided into three subgroups (splenectomy, splenic irradiation, and no splenectomy/no splenic irradiation). Sixteen cases of ANLL were recorded, giving an overall risk of 0.2% at 5 years and 3.4% at 20 years. In 12 patients overt leukemia was preceded by a myelodys-plastic syndrome. Five cases had evaluable chromosome analysis. Clonal chromosome abnormalities were demonstrated in two patients, whereas three patients showed an apparently normal karyotype. Bone marrow agar cultures were analyzed in two patients and were abnormal in both cases. In the radiotherapy (RT) group, the cumulative risk was 0.4% at 10 years and 3.2% at 15 and 20 years: in the chemotherapy (CT) group it was 1.2% at 10, 15, and 20 years; in the combined group it was 3.7% at 10 years and 4.9% at 15 and 20 years. In the multivariate analysis, MOPP treatment with or without RT is a statistically significant variable for ANLL occurrence (p = 0.009). This study demonstrates that splenic treatment does not lead to ANLL. Treatment with MOPP alone and with MOPP plus RT can increase the risk of ANLL.

[Anatomic changes after radical surgery and reconstruction with pedunculated or revascularized flaps in advanced head and neck tumors: computerized tomography and magnetic resonance findings]. / Modificazioni anatomiche dopo chirurgia radicale e ricostruzione con lembi peduncolati o rivascolarizzati nei tumori cervico-facciali negli stadi avanzati: aspetti con Tomografia Computerizzata e Risonanza Magnetica.

January, 1992, to October, 1995, sixty-four patients with advanced head and neck cancer underwent head and neck reconstructive surgery using myocutaneous or revascularized flaps; in the same period, all patients were consecutively examined with CT and MRI. Myocutaneous flaps wer used in 26 patients: 12 flaps were tubular and 14 linear. Revascularized flaps were used in 38 patients: to repair a large defect in 26 patients (14 latissimus dorsi flaps and 12 temporal muscle flaps) and to repair an oral damage in 12 patients (5 revascularized radial and 7 jejunal flaps). CT and MR images of myocutaneous flaps showed the flaps as fatty areas, repairing large surgical defects, hypodense at CT and hyperintense at MRI, with no post-contrast enhancement. The postoperative scar around the flap exhibited soft-tissue density with slight post-contrast enhancement at CT and slightly hypodense on T2-weighted MR images. Post-contrast CT and MRI showed slight scar enhancement with no signal changes in the fatty component. The appearance of revascularized flaps at CT and MRI depends on the characteristics of the structure used to repair the surgical defect: jejunal and radial flaps appeared as mostly fatty thickened layers with both imaging methods. Temporal and latissimus dorsi flaps are made basically of muscular tissue, fatty tissue and occasionally skin (used to repair a mucosal defect): consequently, CT showed a structure with mostly parenchymal density in all cases and MRI depicted intermediate signal intensity. MRI was useful to detect 12 revascularized jejunal or radial flaps thanks to its higher contrast resolution and multiplanar capabilities showing even such thin structures as these flaps. Moreover, MRI permitted to study skull base reconstruction with revascularized (latissimus dorsi) flaps in 5 of our patients.

[Role of computerized tomography following transrectal air insufflation and hypotonization and transrectal ultrasonography in the staging of rectal tumors]. / Ruolo della Tomografia Computerizzata eseguita dopo insufflazione di aria per via transrettale e ipotonizzazione e dell'ecotomografia transrettale nella stadiazione locale del tumore del retto.

Computed Tomography (CT) with rectal air inflation was compared with transrectal ultrasound (TRUS) in the preoperative staging of lower rectal cancer in 126 patients. Precontrast and postcontrast CT scans were performed with 5 mm thick slices; the rectum was previously inflated with air and antiperistaltic agents were administered. Preoperative results were compared with histologic findings. The accuracy, sensitivity and specificity of CT in predicting perirectal spread were 76%, 62% and 83%, whereas the corresponding figures for TRUS were 84%, 69% and 92%. The accuracy, sensitivity and specificity of CT and TRUS for nodal involvement were 58%, 60%, 57% and 72%, 68% and 66%, respectively. These results show that TRUS predicts perirectal spread and detects nodal metastases better than CT. However CT, when performed appropriately, shows tumor spread into perirectal fat and locoregional lymph nodes with high accuracy. Lymphatic involvement is strictly correlated with tumor size: TRUS and CT correctly staged only 57% and 43%, respectively, of the cases with nodal metastases and max. diameter of 5 mm. TRUS sometimes overstaged perirectal tumor growth (13 patients in our series) due to perirectal inflammation (9 cases) or artifacts caused by the presence of air bubbles between the probe and the tumor surface (4 patients). TRUS is a very useful tool for detecting tumor distance from the anal opening; in our series, the distance was incorrectly calculated only in one case (3 cm with TRUS versus 4 cm at surgery).

[Hodgkin's disease in stages I and IIA. Analysis of results in a group of patients with a follow-up of at least 10 years treated at the onset of the disease with radiotherapy alone]. / Morbo di Hodgkin negli stadi I e IIA. Analisi dei risultati in un gruppo di pazienti con follow-up minimo di 10 anni trattati all'esordio con radioterapia esclusiva.

January, 1972, through December, 1982, ninety-four patients with Hodgkin's disease in stages I and IIA were treated in the Dept. of Radiation Oncology of the University "La Sapienza", Rome. All patients had a minimum follow-up of 10 years. After careful clinical and surgical examinations comprehensive of laparosplenectomy, all patients were submitted to extended field radiation treatment. Ninety-one of 94 patients (97%) obtained complete remission. Overall survival at 10 years was 91% and independent of stage (94% in stage I and 87% in stage II), while relapse-free survival at 10 years did depend on stage (83% in stage I and 49% in stage II); the difference was statistically significant (p < 0.01). Thirty-one of 94 patients relapsed, but fortunately 94% of them obtained a second complete remission after salvage chemotherapy. Our experience confirms the low tumorigenic potential of exclusive radiation therapy; only one of 4 secondary neoplasms (acute non-lymphatic leukemia) observed in this series had been treated with radiotherapy. The results of this study confirm the efficacy of exclusive irradiation in stage I patients, while treatment approach remains debated in stage II patients. The combination of short-time chemotherapy with curative irradiation is probably the best option to reduce both the incidence of recurrences and treatment-induced complications.

Long-term results of treatment of childhood and adolescent Hodgkin's disease in 73 patients: the experience of the Departments of Radiology and Hematology of the University of Rome "La Sapienza".

PURPOSE: Various experiences show no substantial differences between children and adults in the treatment of Hodgkin's disease. In consideration of some peculiar characteristics of these cases which might influence the therapeutical choice, particularly regarding long-term survival and therapeutical complications, we report the results of a series of 73 children and adolescents with Hodgkin's disease treated at the University of Rome "La Sapienza". METHODS: Between 1976 and 1983, 73 untreated pediatric cases of stage I-IV Hodgkin's disease were treated with radiotherapy, alone or associated with chemotherapy, using high doses and extended fields. RESULTS: Fifty-six patients (77%) were in continuous complete remission in April 1995 and seventeen (23%) had died. CONCLUSIONS: The authors confirm the excellent results in the treatment of pediatric Hodgkin's disease, both in terms of overall and relapse free survival, in spite of a high incidence of complications caused by the aggressive treatment used in this series. Therefore the majority of authors suggest combined alternating low-dose radiation administered with small portals and short-term chemotherapy. These procedures provide optimal results together with a significant reduction of complications. Consequently, it is very important to evaluate all patient characteristics accurately in order to tailor optimal treatment and select cases with risk factors which might be undertreated and therefore undergo a higher risk of recurrence.