Pediatric Hodgkin Lymphoma: Predictive value of interim 18F-FDG PET/CT in therapy response assessment.

We investigated the prognostic value of interim F-FDG PET/CT (PET-2) in pediatric Hodgkin lymphoma (pHL), evaluating both visual and semiquantitative analysis.Thirty pHL patients (age ≤16) underwent serial F-FDG PET/CT: at baseline (PET-0), after 2 cycles of chemotherapy (PET-2) and at the end of first-line chemotherapy (PET-T). PET response assessment was carried out visually according to the Deauville Score (DS), as well as semiquantitatively by using the semiquantitative parameters reduction from PET-0 to PET-2 (ΔΣSUVmax0-2, ΔΣSUVmean0-2). Final clinical response assessment (outcome) at the end of first-line chemotherapy was the criterion standard, considering patients as responders (R) or nonresponders (NR). Disease status was followed identifying patients with absence or relapsed/progression disease (mean follow-up: 24 months, range 3-78).Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of visual and semiquantitative assessment were calculated; furthermore, Fisher exact test was performed to evaluate the association between both visual and semiquantitative assessment and outcome at the end of the first-line chemotherapy. The prognostic capability of PET-2 semiquantitative parameters was calculated by ROC analysis and expressed as area under curve (AUC). Finally, progression-free survival (PFS) was analyzed according to PET-2 results based on the 5-point scale and semiquantitative criteria, using the Kaplan-Meier method.Based on the outcome at the end of first-line chemotherapy, 5 of 30 patients were NR, the remnant 25 of 30 were R. Sensitivity, specificity, PPV, NPV, and accuracy of visual analysis were 60%,72%,30%,90%,70%; conversely, sensitivity, specificity, PPV, NPV, and accuracy of semiquantitative assessment were 80%, 92%, 66.7%, 95.8%, 90%. The highest AUC resulted for ΔΣSUVmax0-2 (0.836; cut-off <12.5; sensitivity 80%; specificity 91%). The association between ΔΣSUVmax0-2 and outcome at the end of first-line chemotherapy resulted to have a strong statistical significance (P = 0.0026). Both methods demonstrated to influence PFS, even if the semiquantitative assessment allowed a more accurate identification of patients with a high risk of treatment failure (P = 0.005).Our preliminary results showed that PET-2 visual assessment, by using Deauville criteria, can be improved by using the semiquantitative analysis. The SUV max reduction (ΔΣSUVmax0-2) evaluation might provide a support for the interpretation of intermediate scores, predicting with good confidence those patients who will have a poor outcome and require alternative therapies.

Homeopathic mistletoe adverse reaction mimics nodal involvement in 18F-FDG PET/CT performed for evaluation of response to chemotherapy in lymphoma.

Some patients use complementary medicine. We present a patient with Hodgkin's lymphoma, scanned with 18F-FDG PET/CT for evaluation of response after chemotherapy, who was self-administering mistletoe as a homeopathic medicine product. The careful review of the images of the entire scan and patient collaboration in anamnesis were crucial to avoid a false positive result. A review of the published scientific data on the effects of mistletoe is also presented.

Positron Emission Tomography Scanning in the Management of Hodgkin Lymphoma Patients: A Single-Institution Experience.

BACKGROUND: Positron emission tomography (PET-CT) has become a valuable implement in the management of Hodgkin lymphoma (HL). However, since PET-CT is a relatively new imaging method, its capabilities have not been fully explored. OBJECTIVES: The aim of the study was to evaluate the role of PET-CT at different points in HL management. MATERIAL AND METHODS: The medical documentation of 47 HL patients treated at the Comprehensive Cancer Center in Bialystok, Poland, was analyzed retrospectively. The study group consisted of 15 men and 32 women, aged 18-59 years, in HL clinical stages II-IV, treated either with chemotherapy or sequential chemoradiotherapy. RESULTS: In 65.2% of the patients who underwent post-chemotherapy PET-CT scanning before their qualification for adjuvant radiotherapy (RT), PET-CT was decisive in qualifying them for RT, by establishing whether or not metabolic partial remission (PR) had occurred. With regard to the achievement of partial or complete response (CR), computed tomography (CT) and PET-CT results correlated in 45.5% of the patients after the completion of chemotherapy, and in 18.7% after the completion of the entire treatment (chemotherapy or chemoradiotherapy). Among the patients from the advanced-stage group (stages III/IV stage and/or bulky HL), morphological PR in CT scans after two to three courses of chemotherapy was more often associated with a lack of metabolic CR in posttreatment PET-CT scanning (p = 0.022) than in other patients. Post-treatment PET-CT scanning was shown to be highly prognostic of a relapse-free follow-up (p < 0.0001) and superior to post-treatment CT imaging in relapse prediction (p < 0.0001). CONCLUSIONS: Compared to CT, PET-CT was more accurate in residual masses assessment. Notable ability of PET-CT in relapse-free follow-up prediction encourages to more common use of PET-CT in clinical practice. Further clinical research on the need for RT in patients with PR in CT parallel to CR in PET-CT is required.

Investing in new technology: the PET experience.

As funding available to health services is limited, demonstrating the cost effectiveness of new technologies is an important step in their introduction. This is especially challenging for diagnostic technologies, for which the usual paradigm of reliance on well-designed, randomised controlled trials may not be appropriate. A recently completed Health Technology Assessment of fluorine-18 deoxyglucose (FDG)-positron emission tomography (PET) imaging in cancer management, focused on addressing whether the introduction of PET imaging would be beneficial to patients in the NHS in Scotland, exemplifies some of the challenges. Although a substantial body of published literature exists for this technology, most of the studies report diagnostic accuracy rather than improved patient outcomes. Direct evidence that such improvement occurs, and is sufficient to meet the NHS' criteria for cost effectiveness, from well-designed trials would constitute the most immediately persuasive case for the introduction of PET imaging. In the absence of such evidence, collaboration is required between a variety of disciplines to synthesise evidence from a variety of sources to create informative decision models that estimate long-term patient outcomes. The use of such decision models enabled the Health Technology Board for Scotland (now a part of NHS Quality Improvement Scotland) to determine that FDG-PET imaging is likely to be cost effective in selected applications and identified long-term patient benefits that it would not be possible to study in a randomised controlled trial.

CT-guided core-needle biopsy in the diagnosis of mediastinal lymphoma.

The advent of radiologic guidance techniques for percutaneous biopsy has changed the approach to the routine diagnosis of mediastinal lymphoma. The aim of the present study was to evaluate the diagnostic accuracy of CT-guided percutaneous core-needle biopsy (PCNB) in the clinical management of patients with mediastinal lymphoma. The results of 49 CT-guided PCNB of mediastinal lymphoma performed under local anesthesia in 42 ambulatory patients were analyzed. A positive diagnosis of lymphoma was obtained in 30 of 42 patients, with an overall success rate of 71.5%. The technique was equally successful in the diagnosis of Hodgkin's and non-Hodgkin's lymphoma. There were no major complications. Percutaneous CT-guided CNB of mediastinal lymphoma is a quick, safe, accurate, and efficient alternative to open biopsy in the evaluation of mediastinal lymphoma, mainly at presentation. It should become the preferred initial diagnostic procedure for obtaining histologic samples in patients with suspected mediastinal lymphoma.

Evaluation of tumour metabolism and multidrug resistance in patients with treated malignant lymphomas.

The management of patients with treated malignant lymphomas requires functional methods to differentiate a residual soft tissue mass. Patients with treated Hodgkin's lymphoma (HL, n = 20, 68 malignant lesions, three benign lesions) or non-Hodgkin's lymphoma (NHL, n = 26, 46 malignant lesions, one benign lesion) were studied with positron emission tomography (PET) and fluorine-18 deoxyglucose (FDG). Oxygen-15 labelled water was used (n = 14, 25 lesions) in addition to FDG in order to obtain information on the tissue perfusion. Long-term follow-up studies with PET and FDG were performed in nine patients up to 511 days after the initiation of second-line therapy. Fourteen patients underwent single-photon emission tomography (SPET) with technetium-99m sestamibi immediately prior to the first PET examination. PET with FDG displays a high sensitivity for the detection of viable tumour tissue, all the malignant lesions being correctly classified in this study. The possible limitations are inflammatory processes, which may obscure tumour detection due to increased FDG uptake, and malignant lesions with low FDG uptake due to reduced perfusion. Difficulties exist in the prognosis of long-term response, since the change in FDG uptake may be variable. Long-term therapy outcome was correlated with the slope values obtained from the standardized integral uptake (SIU) data, which provides a new approach for the evaluation of PET follow-up studies. 99mTc-sestamibi, which should reflect the multidrug resistance, was evaluated with respect to therapy outcome. A high uptake of 99mTc-sestamibi was observed in patients with stable disease or better. The data support the hypothesis that sestamibi may reflect multidrug resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of small bowel double contrast enema in clinical interventions]. / Die Wertigkeit des Dünndarmdoppelkontrasteinlaufes im klinischen Einsatz.

The double contrast enema is the most effective morphological screening method for the evaluation of the whole small bowel. Its sensitivity is 85%, its specifity 96.7%. In specific clinical problems the number of pathological roentgen findings rises: from 34.4% when all indications are taken into consideration to 58% in indications specific to the small intestine such as Morbus Crohn or the malabsorption syndrome. Search for tumours and the double contrast of the small bowel in unclear gastro-intestinal bleeding are unproductive. The weak point of this screening method is the lower part of the small intestine. Therefore, the selective peroral or retrograde analysis of the terminal ileum supplement the contrast method. A precondition for good results is an adequate technical standard. Besides the clinical results some technical results are therefore discussed such as contrast medium quantities, examination and X-ray time, radiation exposure and influences on the image quality.

EOE-13 in the detection of hepatosplenic lymphoma.

Thirty-nine patients with lymphoma were evaluated prospectively to determine the usefulness of Ethiodol-Oil-Emulsion-13 (EOE-13) in the detection of hepatosplenic lymphoma by computed tomography. The detection rate in the spleen increased from 8% (before EOE-13 infusion) to 92% (after EOE-13 infusion). In ten of 39 patients (25%) in this series, lymphomatous disease was recognized only on the postinfusion computed tomographic scan. The postinfusion EOE-13 study demonstrated additional visceral abnormalities in 38% of the patients. The potential usefulness, limitations, and toxicity of this hepatosplenic-specific imaging agent are discussed.

[Use of liposome-bound x-ray contrast substances for the diagnosis of splenic lesions in generalized lymphoma in SJL/J mice]. / Primenenie rentgenokontrastnykh veshchestv, sviazannykh s liposomam, dlia diagnostiki porazhenii selezenki pri generalizovannoi limfome myshei SJL/J.

An X-ray procedure for diagnosis of splenic lesions in sjl/j mice with generalized lymphoma, using verographin contained in liposomes, is discussed. Intravenous injections of the preparation were followed by changes in X-ray pictures of the spleen in 9 out of 21 mice aged 11-13 weeks which were interpreted as total or local lesions. The X-ray diagnoses were confirmed by histological examination. Due to application of the method lesions with diameters down to 1 mm may be detected.

Use of intravenous liposoluble contrast material for the examination of the liver and spleen in lymphoma.

An experimental contrast material has been developed that, after intravenous injection, selectively opacifies the spleen and liver on computed tomography (CT). The contrast material contains iodinated ester of poppy seed oil in an emulsified form. Clinical trials were recently initiated to test the value of this contrast agent in Hodgkin's and non-Hodgkin's lymphomas. We present here two of our initial patients in whom we found lesions in the spleen or liver following the infusion of the experimental contrast material that were not visualized on the precontrast and urographic contrast material enhanced CT scans.

Alternative therapy for recurrent Hodgkin's disease. Radiotherapy combined with hyperthermia by electromagnetic radiation to create complete remission in 11 patients without morbidity.

Eleven patients with recurrent Hodgkin's disease have returned to apparent normality after simple treatment regimes with radiotherapy and hyperthermia from 434 MHz electromagnetic radiation. None have experienced any complication or sequelae from this treatment. All the patients with recurrent active Hodgkin's disease who attended the author's practice since February 1976 have been treated with this combined treatment and are reported here.

[Endolymphatic curietherapy by lymphography with labelled lipiodol in Hodgkin's disease. A report on 408 cases (author's transl)]. / La curiethérapie endolymphatique par lymphographie au lipiodol marqué dans la maladie de Hodgkin. 408 observations.

The results of 373 lymphography examinations with radioactive lipiodol, conducted in 408 patients with Hodgkin's disease for diagnostic and prophylactic therapeutic purposes, during investigations carried out from 1966 to 1973 are analyzed. Tolerance was always excellent, especially from the hematological point of view. The efficacy of the procedure can be assessed by the fact that there were only 6% of failures (21/373) in glandular regions irradiated in this way for prophylactic purposes. Relapses occur more frequently in the inguino-iliac and lumbo-aortic regions than in the pelvic chains which were perfectly protected. This technique also enables both pelvic irradiation and ovarian protection in young women without any risk of failure. The procedure is particularly indicated in the following cases: supradiaphragmatic stages I and II, whatever the sex, and stage III especially in women. In sub-diaphragmatic stages I and II, it allows, in favourable cases, the ovarian function in women to remain intact by limiting external irradiation to invaded regions only.

Lymphatic dynamics of liver by hepatic lymphography using lipiodol ultra fluid.

Hepatic lymphography by intra-parenchymal injection of four to ten millilitres (ml) of lipiodol ultrafluid, our modification of functional hepatography, performed on sixty one patients helped study lymphatic dynamics of liver. In conditions associated with significant hepatic venous outflow obstructions, such as hepatic cirrhosis, inflammatory diseases of liver and primary or secondary malignant lesions of the liver, this study delineated liver lymphatics and portal and para aortic lymph nodes. In one case mediastinal nodes were also delineated by flow of lipiodol from the bare area of the liver via trans-diaphragmatic and pleural lymphatic. The lymphangio-architecture of the opacified nodes depicted the nature of pathology inflicting them and the liver. Lipiodol in the lymphatic system, staying longer than the freely diffusible aqueous contrast, provided more detail and better information.

Postlymphographic cerebral lipid embolization in the vena cava superior syndrome.

A recent case of Lipiodol Ultrafluid embolism to the brain is reported. Pathogenetic concepts involving right-to-left shunts, and lympho-venous shunts with pulmonary capillary overloading are reviewed. In addition, it is suggested that a local disturbance in cerebral circulation due to a cava superior syndrome may contribute to the severe cerebral symptoms.

Hepatosplenography by intravenous injection of a new iodized oily emulsion.

Hepatosplenography with intravenously injected iodized lipid emulsion has been performed in 30 cases and the results reported. The side effects were minor and transient, as the elimination is rapid. The uptake in the liver was satisfactory and permitted tomography both of the liver and the spleen. Small neoplasms and splenic nodules in Hodgkin's disease could be detected and located accurately.

[Complications of lymphography. A propos of 5 cases]. / Complications de la lymphographie. A propos de cinq observations

Complications noted following lymphography have been published by several authors. The authors report here a series of 5 cases occurring in patients with mediastinal and lung cancer. They report the various clinical manifestations resembling fat embolism, the free interval and general signs, pulmonary, neurological, hematological and dermatological symptoms associated with inconstant laboratory abnormalities which permit one to suggest a complex pathogenesis: --Immuno-allergic (early shock due to circulating antibodies). --Mechanical and vascular: incomplete removal of low viscosity lipiodol by the pulmonary macrophage system permits liberation of micro-vascular emboli. --By abnormality of blood coagulation and the onset of a syndrome of widespread intravascular coagulation. Better recognition of the pathogenesis associated with the development of new therapeutic principles, should permit better prevention and control of these complications.

Lymphography--technique, indications and principles of interpretation.

The findings in 277 patients investigated by ethiodol lymphography are reviewed, and the applications and limitations of the procedure are presented. The non-specificity of findings is the principal reason for the lack of acceptance of this procedure, and the confusing entity of tuberculous lymphadenitis is discussed.