Orchiectomy alone in clinical stage I nonseminomatous testis cancer: a critical appraisal.

Sixty-two consecutive patients with clinical stage I nonseminomatous testicular cancer were entered into a prospective study to receive no treatment after orchiectomy until clinical evidence of recurrent disease. Of 59 evaluable cases, 41 (69.5%) remained continuously disease free for a median duration of 30 months (range, 18 to 46 months), and evidence of metastatic disease developed in 18 patients (30.5%) from 2 to 36 months after orchiectomy. The median disease-free interval for relapsing patients was 6 months. Retroperitoneal metastases developed in ten patients; seven patients had pulmonary metastases, and one patient had progressive elevation of the serum alpha-fetoprotein level. Relapses were significantly more frequent in patients with either embryonal carcinoma, infiltrating testicular cancer (pT greater than 1), peritumoral vascular invasion, or in those who underwent transscrotal biopsy. One patient with relapse refused salvage therapy and died. The remaining 17 patients have been rendered disease free with cisplatin combination chemotherapy and/or surgery. However, two patients showed further recurrence, with one in the lung and the other one also in the retroperitoneal nodes. In our opinion, surveillance following orchiectomy will provide useful information in clinical stage I nonseminomatous testicular cancer, but it is a difficult study. For the time being, it should be restricted to specialized centers only. In the meanwhile, retroperitoneal lymphadenectomy remains the standard treatment.

Early stage Hodgkin's disease: ten-year results of a non-randomised study with radiotherapy alone or combined with MOPP.

From September 1976 to June 1982, 201 consecutive patients with stage I (A and B)-IIA Hodgkin's disease were stratified in two groups according to prognostic factors. The F group included 116 patients with favourable presentation: they were staged with laparotomy and treated with subtotal or total nodal radiotherapy alone. The U group included 85 cases with unfavourable presentation who were staged by laparoscopy and treated with 3MOPP (mechlorethamine, vincristine, procarbazine, prednisone)-radiotherapy-3MOPP. At 10 years the F group showed a freedom from progression (FFP) of 71% with significant difference between stage I and II (85% vs. 59%; P = 0.003) and an overall survival of 84%. The results of the U group were: FFP 83%, overall survival 74%, and the findings were not influenced by stage. FFP in patients with bulky vs. not bulky lymphoma was 70% vs. 87% (P = 0.04). No secondary acute non-lymphocytic leukaemia developed among patients treated with radiotherapy and in continuous complete remission, while acute leukaemia occurred in the F group patients who received salvage chemotherapy (4 of 31 cases) and in the U group (3 of 85 cases). Present results confirm the usefulness of radiotherapy alone in favourable pathological stage IA. All other disease stages will require a different strategy that should consist of radiotherapy combined with short-term effective regimens, such as ABVD (doxorubicin, bleomycin, vinblastine and decarbazine) or VBM (vinblastine, bleomycin and methotrexate) to reduce the incidence of MOPP-associated gonadal dysfunction and leukaemogenesis.

Hallervorden-Spatz disease: MR and pathologic findings.

PURPOSE: To compare the MR findings of eight cases with clinical diagnosis of Hallervorden-Spatz disease (HSD) with the pathologic findings of two other cases of HSD. MATERIALS AND METHODS: The eight imaged cases were studied with 0.5-T (seven cases) and/or 1.5-T (five cases) units. Six patients also had CT scans. The two other cases with proven HSD had detailed histologic evaluation. RESULTS: The 1.5-T findings showed abnormalities confined to the pallidum, which presented a diffuse low signal intensity in T2-weighted images, and an anteromedial area of high signal intensity (eye-of-the-tiger sign). In 0.5-T studies, low signal intensity was less evident and poorly detectable in spin echo, but gradient-echo images could enhance its demonstration; the area of high signal intensity was always well demonstrated. In three cases (three with 1.5 T, one with 0.5 T) a central spot of low signal intensity was seen in this area. The pathologic cases, in addition to neuroaxonal swellings and iron deposits, exhibited areas of "loose" tissue with vacuolization and lesser amounts of iron in the anteromedial part of the pallidum, in a location corresponding to the area of high signal intensity of the imaged cases. CONCLUSION: Comparison of MR findings with the pathologic studies demonstrates that the low signal intensity in T2-weighted images at 1.5 T corresponds to iron deposits in a dense tissue, and that the high signal intensity of the eye-of-the-tiger sign corresponds to an area of loose tissue with vacuolization. No correlation was found in the two pathologic cases for the central spot of low signal intensity.

Magnetic resonance imaging in the initial staging of Hodgkin's disease and non-Hodgkin lymphoma.

Seventy-four consecutive previously untreated patients with Hodgkin's disease (HD) and non-Hodgkin lymphomas (NHL) were evaluated with chest, abdominal and pelvic magnetic resonance (MRI) for initial staging. All patients underwent routine radiological staging procedures which included chest radiographs and lymphography (LAG). These studies were followed in most of cases by laparoscopy, during which biopsies of the liver and the spleen were taken, and bone marrow aspiration and histology. A correlation of the results of MRI with both other imaging studies and histopathologic diagnoses was performed, and discordant cases were assessed to determine the impact on clinical staging. Additional evidence of disease involvement was provided mainly in the chest, where MRI demonstrated the presence of unsuspected disease in 21% of involved patients (9 of 42). Retroperitoneal lymph nodes were correctly assessed in 97% of cases if MRI was compared with LAG. Extranodal abdominal disease was identified both in the spleen (14%) and in the liver (1%). Bone marrow abnormalities were detected in 19% of patients (14 of 74). MRI findings influenced the staging of HD and NHL patients in 11 of 74 cases (15%).

MRI as an adjunct to echocardiography for the diagnostic imaging of cardiac masses.

Nine patients underwent magnetic resonance imaging (MRI) as part of the diagnostic evaluation for cardiac masses; eight of them had been preliminarily studied by 2D-echocardiography (US). MRI did not add to the US diagnostic information in patients affected by intracavitary masses. It represented the definitive diagnostic modality in two patients with intramural pathology: one with ventricular rhabdomyoma, the second with an echinococcyal cyst located within the left atrial wall. The complementary role of MRI to US in cardiac masses is discussed.

Magnetic resonance imaging of the gastrointestinal tract: investigation of baby milk as a low cost contrast medium.

After the incidental observation of the high signal intensity of the upper GI tract in a nourished baby, we tested eight baby milks; five different fresh commercial milks, one sweetened and condensed and two lyophilized milks in order to compare their ability to contrast MR images. The images were obtained with a 1.5 T magnet whereas the "in vitro" water proton relaxation time (T1 and T2) measurements were carried out at 0.5 T. After having selected the most effective lyophilized product, that was prepared according to the manufacturer's instructions, a group of 23 adult patients, 17 males and 6 females, with a mean age of 55.8 years (range 37 to 71 years) were examined. Thirteen patients had gastric cancer and ten patients had rectal or rectosigmoid junction tumors. The most effective imaging sequence was a spin-echo T1.w. After oral intake of milk a good contrast of the stomach, with sufficient distribution in the duodenum and the very proximal bowel, was achieved in all 13 patients with gastric cancer, as was a good depiction of the rectum and the recto-sigmoid junction after enema achieved in the 10 patients with rectal cancers. Disadvantages of lyophilized milk as a contrast agent are due to partial intestinal absorption, inhomogeneous distribution and irregular intestinal passage, whereas a clear advantage of lyophilized milk as a contrast agent is its good acceptance and palatable, inexpensive and non invasive properties. Because of these limitations lyophilized milk cannot be considered a real oral contrast medium but it can enhance MR imaging of the upper abdomen, and mainly of the lower GI tract in infants and adults.

Ewing's sarcoma: an approach to radiological diagnosis.

All the pertinent radiographs of 83 patients with histologically proven Ewing's sarcoma were reviewed. Forty-nine patients were in the pediatric age group, and 34 were adults. The mean age, the symptoms and time from symptoms to diagnosis were evaluated in the 2 groups. The site of primary involvement was in 54% the long bones, 35% the flat bones, 8% the small bones and 3% extraosseous. For the primary site we considered the diagnostic results of the standard radiographic investigations and in some cases the usefulness of angiography, xeroradiography and telethermography. At presentation we also evaluated the possible diffusion of the disease with standard radiographic surveys (chest and skeletal, including limbs) and with foot lymphography in selected cases. In this way, 57 patients (69%) were considered to have localized disease. In this group, we also considered the value of the periodic radiographic follow-up, which enabled us to disclose the appearance of metastases (chest 64%, bone 54%, lymph nodes 11%) in 28 cases (49%). Finally, we made a comparison of the different radiologic and epidemiologic findings between children and adults.

Oophorectomy in advanced breast cancer: clinical radiologic correlations.

The radiograms of the chest and skeleton of 49 patients with advanced breast cancer treated with bilateral ovariectomy were reviewed. The modifications in the secondary localizations and/or their appearance after castration were compared with the findings of the clinical examination. Appearance or progression of intrathoracic lesions, like the appearance or progression of osteolytic lesions, corresponded to a progression of the disease in other sites. Osteoblastic evolution of osteolytic lesions and the appearance of osteoblastic lesions in bones undamaged before ovariectomy were signs of a favorable response to therapy. The response of chest and bone metastases is usually rather early, and the first radiographic survey should be performed about 3 months after ovariectomy.

Locally advanced breast cancer treated with primary chemotherapy: comparison between magnetic resonance imaging and pathologic evaluation of residual disease.

AIMS AND BACKGROUND: We evaluated the response of locally advanced breast cancer to induction chemotherapy using MRI techniques. The size and vitality of any residual pathologic tissue was quantified by means of morphologic and dynamic analysis. A curve derived from the dynamic parameters shows the uptake intensity with respect to the time elapsed since administration, which is related to vascularization and therefore indirectly reflects the angiogenesis of malignant tissue. METHODS AND STUDY DESIGN: A group of 30 patients were examined with MRI for staging purposes before undergoing treatment and subsequently to assess the response to treatment. Alterations in size and dynamic parameters were closely monitored. RESULTS: The overall accuracy was 90%, the sensitivity 96%, the specificity 75%, the positive predictive value 92.5% and the negative predictive value 66%. Interestingly, analysis of the dynamic curves made it possible to obtain additional information regarding the angiogenetic activity of the residual tumor. CONCLUSIONS: Evaluation of the response to treatment by means of conventional imaging and clinical examination can be particularly difficult because of the fibrosis induced by cytotoxic drugs or the small volume of residual disease. The additional information supplied by MRI could therefore allow a more conservative surgical approach in selected cases of optimal response to treatment, as well as a much more accurate follow-up. Furthermore, the variation in dynamic parameters according to the vitality of residual disease could in the future become a useful tool for monitoring the effectiveness of anti-angiogenetic drugs.

Langerhans cell histiocytosis mimicking malignancy: a radiological appraisal.

AIMS: To analyze the radiologic characteristics, clinical course and long-term follow-up of 7 radiologically uncommon pediatric cases of Langerhans cell histiocytosis and to identify prognostic factors related to imaging patterns. METHODS: The clinical records and complete imaging data of 75 patients with LCH diagnosed and treated at the National Cancer Institute of Milan between January 1975 and December 1993 were analyzed, and 43 cases presenting as unifocal bone lesions were identified. The plain film, computed tomography and magnetic resonance characteristics enabled the identification of 7 radiologically aggressive and rapidly progressive cases, which were analyzed at presentation and during follow-up. RESULTS: Although at disease presentation bone lesions appeared lytic destructive, rapidly progressive and often involved adjacent soft tissues, after adequate therapy the disease course was invariably benign and led to almost complete restoration of normal structure and function. Long-term follow-up confirmed the favorable outcome and lack of disease recurrence in all cases. CONCLUSIONS: There is no correlation between radiologically aggressive characteristics and final outcome in Langerhans cell histiocytosis. Radiologists and pediatric oncologists should be acquainted with less common radiologic forms which, at presentation, can mimic more ominous diseases. If recognized and adequately treated, monostotic forms almost invariably have a benign prognosis.

Usefulness of chest and skeletal survey to assess the time of relapse in breast cancer.

The pertinent radiographs of 151 patients treated with radical mastectomy who showed relapse in the chest and/or in the skeleton as first site were reevaluated. Diagnostic accuracy was calculated by comparing the first examination considered as positive with the previous ones reported as negative. For chest lesions the accuracy was 80% (70% for parenchymal nodular densities), with no difference between symptomatic and asymptomatic patients. For bone metastases retrospective evaluation confirmed the radiological report (i.e., the time of relapse), in 73.8%, with a value of 89.7% in symptomatic and 53.4% in asymptomatic patients. The site of involvement and morphological characteristics of the lesions did not influence the diagnostic accuracy. Therefore chest examination and, for symptomatic patients, radiographic bone survey still represent a useful modality to assess the diffusion of breast cancer. For asymptomatic patients other modalities, such as bone scan and biochemical tests, should be utilized.

Indirect lymphography of the breast with iotasul: a vanishing hope?

Using a new aqueous nonionic contrast medium (Iotasul, Schering) we attempted visualization of axillary lymph nodes in patients with breast carcinoma. Intradermal infusion into the areola consistently opacified the subareolar plexus and latero-cranial lymphatic trunk. Axillary nodes were visualized in 78.6% of patients, but only 5.7% of surgically excised nodes were partially or totally opacified. Eleven patients underwent axillary lymph node dissection and histology confirmed metastases in 4, of which only two were detected by lymphography. Breast lymphography is inadequate for routine clinical application, and radical axillary dissection remains the mainstay for documentation of nodal metastases.

Reliability of diagnostic imaging after orchiectomy alone in follow-up of clinical stage I testicular carcinoma: excessive cost with potential risk.

From 1981 to 1984, 86 consecutive patients with previously untreated nonseminomatous testicular carcinoma were classified as clinical radiological stage I and treated with orchiectomy alone. The follow-up program included chest x-ray and lymphangiography (LAG) every month and abdominal computed tomography (CT) bimonthly. All patients were followed for 15 to 63 months after orchiectomy (median 32 mo.). Metastases developed in 23 patients (26.7%) and in 13/23 there was retroperitoneal lymphadenopathy. Time of relapse after orchiectomy ranged from 2 to 36 months (median 7 mo.) with a shorter interval for chest (4 mo.) compared with retroperitoneal metastases (7 mo.). Lung metastases were readily identified at an early stage (less than 2 cm) whereas more than one-third of retroperitoneal nodal metastases were greater than 5 cm at time of diagnosis. LAG detected metastases in 8/11 patients (72.7%), abdominal CT in 8/10 (80%), and both together (LAG and CT) 7/8 (87.5%). In clinical stage I nonseminomatous testicular carcinoma, the high incidence of concomitant but often asymptomatic regional and distant metastases and the relatively high cost and inconvenience of follow-up using abdominal CT imaging, LAG and chest x-ray suggest that orchiectomy is best combined with retroperitoneal node dissection at time of initial presentation to insure more accurate and safe staging of tumor dissemination.

[Diagnostic imaging of liver metastasis]. / Diagnostica per immagini delle metastasi epatiche.

The early diagnosis and monitoring of hepatic metastases are now achieved by different imaging modalities, some using ionizing radiations (computed tomography and angiography), some based on other energy sources (sonography and magnetic resonance), but all coming within the radiological area, which offers concrete possibilities of integration and the necessary organization. These modalities are sometimes used only for percutaneous histological samplings with minimal invasiveness. The progress in hepatic resective surgery and the possibility of orthotopic liver transplantation for some neoplastic histotypes, together with the alternatives provided by interventional radiology, have brought a continuous updating of the specialist' interest in the morphological and functional definition of hepatic metastatic disease, with the specific aim of choosing the best therapeutic strategy. Hepatic metastases have the greatest impact on the survival of patients with gastrointestinal neoplasms, especially colonic adenocarcinoma. Intraoperative sonography and CT arterial portography currently provide greatest diagnostic sensitivity in terms of spatial resolution but cannot be considered as methods of choice, the former for obvious reasons and the latter because of its invasiveness and complexity. The alternatives are to be sought in spiral CT and the new MR sequences which can undoubtedly provide a decisive improvement in the diagnostic standards currently available. Profoundly changed, but no less important, is the role of angiography, which still provides the anatomical support for hepatic surgery and the means for alternative treatments, such as chemoembolization and continuous infusional chemotherapy.

Late metastasis fro neuroblastoma mimicking Ewing's sarcoma.

The case of an unusual late metastasis of neuroblastoma to the calcaneum, appearing as a sole recurrence 9 years after surgery, is reported. The radiographic features of the osseous lesion were very suggestive of primary bone malignancy, Ewing's sarcoma as the first option, with extraosseous spread to the soft tissues.

New imaging techniques in staging lymphomas.

A variety of imaging modalities are used to evaluate patients with lymphoma, mainly Hodgkin's disease. During the past few years, the improvement of diagnostic techniques has had a great impact on both staging and patient treatment. This review of the current status of imaging presents the possibilities of available diagnostic tools in the assessment of lymphomatous involvement of different organs and apparatus, emphasizing those aspects that might influence patient management and treatment. For central nervous system lymphomas, pre- and postcontrast computed tomography and magnetic resonance have completely replaced other radiologic methods. Similarly, because it seems clear that computed tomography will replace lymphography by the end of this decade, just as computed tomography and magnetic resonance imaging are expected to entirely replace staging laparotomy, the possibilities of these diagnostic tools and their impact on diagnosis and follow-up are also discussed.

[Effect of ovariectomy on bone metastases of breast cancer: analysis of radiographic pictures]. / L'influenza dell'ovariectomia sulle metastasi ossee da carcinoma della mammella: analisi dei quadri radiografici.

The radiograms of the skeleton of 41 patients with advanced breast cancer treated with bilateral ovariectomy were reviewed. The modifications in the secondary localizations and/or their appearance after castration were compared with the findings of the clinical examination. Appearance and progression of osteolytic lesions, corresponded to a clinical progression of the disease. Osteoblastic evolution of osteolytic lesions and the appearance of osteoblastic lesions in bones undamaged before ovariectomy were signs of a favorable response to therapy.

[Neuroblastoma: radiological findings in 124 cases (author's transl)]. / Neuroblastoma: risultati dell'indagine radiologica in 124 casi.

All the pertinent radiographs of 124 patients with histologically proven neuroblastoma were evaluated. The radiological features of the primary tumor and radiographic characteristics of metastases were also analyzed. Finally the value of radiological investigations to define the diffusion of the disease in comparison with laboratory and clinical findings were considered.

[Magnetic resonance in neoplasms of the adipose, fibrous and muscular tissues]. / La risonanza magnetica nelle neoplasie dei tessuti adiposo, fibroso e muscolare.

Two-hundred and three MR examinations were reviewed of 177 patients with lipomatous, fibrous and muscular tissues tumors which were evaluated at staging or during the follow-up. All examinations were obtained with a 1.5T superconductive magnet, and both T1 and T2-weighted images were acquired. Its high-contrast resolution, its direct multiplanarity and its allowing both T1 and T2-weighted images to be obtained, are the most important characteristics of MR imaging. In our experience, MRI demonstrated a high overall accuracy (96.1%)-95.2% at restaging alone--with similar sensitivity both at the staging of the disease (100%) and during the follow-up (97%). Overall sensibility was 97.6%. MR specificity in histologically proven relapses was 87.9%. Even though it is gradually assessing itself as the most important method in the evaluation of soft tissues masses, MRI allows an histological diagnosis to be made only in lipomatous tumors and in benign fibrous tumors, due to their specific signal features. The commonest though aspecific finding is a soft tissue mass with relatively low signal intensity in T1 and high signal intensity in T2-weighted images. In our opinion, MR imaging is the method of choice during the follow-up of the disease, whereas it is probably a complementary technique in the staging.

[Histiocytosis X: radiologic evaluation of 52 patients]. / Istiocitosi X: valutazione radiologica in 52 pazienti.

Fifty-two patients with histologically proven histiocytosis X and intrathoracic and/or bone lesions have been evaluated. In the group, bone lesions appear clearly prevalent (51/52 patients) mainly as localized monostotic disease (31/51). Flat bones were more frequently involved, with special evidence for skull and ribs. Short as well as long bones were only seldom compromised, almost only in polyostotic and generalized disease. On the basis of our experience the most suggestive radiological findings in bone to diagnose an histiocytosis X were the following: preferential involvement of a flat bone, osteolytic pattern, sharp borders (72.9%), rare evidence of pathological fracture (20%) and periostitis (10%). On the contrary, the involvement of the neighbouring soft tissues (38.8%) appears to be significant.