ABVD alone and a PET scan complete remission negates the need for radiologic surveillance in early-stage, nonbulky Hodgkin lymphoma.

BACKGROUND: Patients with early-stage, nonbulky classic Hodgkin lymphoma (cHL) undergo intensive posttreatment radiologic surveillance despite having a low risk of disease recurrence. The current study attempted to evaluate the risk of disease recurrence and the value of radiologic surveillance in patients treated with the combination of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) alone who achieved a complete remission (CR) as noted on posttreatment positron emission tomography (PET). METHODS: Forty-seven patients who underwent therapy with interim and/or posttreatment PET scans were evaluated for disease recurrence during ≥ 24 months of follow-up. Their presenting characteristics and imaging results were assessed and interpreted in relation to clinical outcome. RESULTS: All 47 patients were eligible for analysis. The majority of patients were female (35 patients) with a median age of 28 years (range, 17 years-65 years.). The nodular sclerosing subtype was the predominant histology (41 patients). A total of 34 patients were staged with IIA disease, 6 with IA disease, 6 with IIB disease, and 1 with IIEA disease (lung) (according to Cotswolds modification of the Ann Arbor staging system). All patients completed 6 cycles of planned ABVD therapy and achieved a CR. Two had a positive PET scan (1 interim scan and 1 posttreatment scan); both were biopsy-proven sarcoidosis. Two patients developed disease recurrence at 7 months and 24 months, respectively, after negative interim and posttreatment imaging. One case of recurrence was identified through surveillance imaging and the other was identified simultaneously by the patient and surveillance scan. A total of 45 patients experienced a durable CR; 21 had additional unscheduled imaging/workup during surveillance to investigate symptoms or imaging signs of concern. CONCLUSIONS: Because of a low risk of disease recurrence, posttreatment radiologic surveillance appears to be unnecessary in patients with early-stage, nonbulky (CD20 negative) cHL who achieve a PET-detected CR with the ABVD combination alone. This will reduce cumulative radiation exposure and health care costs in a predominantly young patient population.

Assessment of therapy responses and prediction of survival in malignant pleural mesothelioma through computer-aided volumetric measurement on computed tomography scans.

PURPOSE: The purposes of this study were (1) to calculate the tumor volume in patients with malignant pleural mesothelioma using computed tomography (CT) scan images and a computer-aided measurement technique and (2) to investigate whether the baseline volume, or volume change after chemotherapy, predicts patient survival. METHODS: We compiled the clinical characteristics and outcome from 30 patients enrolled in two clinical trials at our cancer center in which the patients were treated with induction chemotherapy followed by surgery and radiation. CT scans of 30 patients were obtained at baseline and after two cycles of chemotherapy. Tumor volumes were calculated using a semiautomated computer algorithm. Overall survival was measured using a landmark time at 3 months post-treatment start date such that all patients had already received two cycles of chemotherapy and a follow-up scan. Association of volume changes with overall survival were determined by a Cox Proportional Hazards Model or log-rank test. The relationship between both pre and postoperative clinical stage and baseline tumor volume was analyzed using the rank sum test. RESULTS: The median baseline tumor volume was 473 cm(3) (range, 61 cm(3)-2108 cm(3)). Patients with high preoperative stages (III and IV) had larger baseline tumor volume than those with low preoperative stages (I and II) (p = 0.05). Patients with baseline volumes smaller than 619 cm(3) tended to survive longer than those with baseline volumes larger than or equal to 619 cm(3) (p = 0.07). Percentage change of tumor volume from baseline to first follow-up CT after two cycles of chemotherapy was significantly associated with overall survival (hazard ratio: 1.94 [95% confidence interval, 1.05-3.60], p = 0.04). Whereas the relative change in modified RECIST measurements was not significantly associated with overall survival (hazard ratio: 1.06 [95% confidence interval, 0.96-1.16], p = 0.25). By classifying changes of tumor volumes between two scans into two groups, i.e., "increase" and "decrease," a significant difference in survival was found between those who increased and decreased after two cycles of chemotherapy (p = 0.03). CONCLUSIONS: Changes in tumor volume after two cycles of chemotherapy predicted overall survival in patients with malignant pleural mesothelioma. Tumor volume at baseline was shown to be associated with preoperative clinical stage and survival. Computer-aided volumetric measurements may enable more reliable therapeutic response assessment and could provide additional prognostic information.

Tricuspid valve replacement: bioprosthetic or mechanical valve?

Significant morbidity and mortality is associated with tricuspid valve replacement, and controversy still exists as to the ideal prosthesis in this position. This study aimed to identify the risk factors for low cardiac output and mortality, and whether bioprosthetic or mechanical valves perform better in the tricuspid position. Results of 121 tricuspid valve replacements in 104 patients between January 1966 and December 2002 were reviewed. Most patients were in New York Heart Association functional class III or IV. Perioperative mortality was 19%. On multivariate analysis, age and preoperative jaundice were significant predictors of low cardiac output; age, jaundice, atrial fibrillation, and bypass time were significant predictors of mortality. Mechanical valves were significantly more prone to thromboembolism, whereas bioprostheses suffered structural valve deterioration. There were no significant differences in anticoagulation or bleeding episodes between the two groups, nor in valve-related events, deaths, and long term survival. There was no significant difference in performance so as to recommend one type over the other, but bioprosthetic valves may be more favorable as they fail predictably.

Coronary artery bypass grafting in an immune thrombocytopenic purpura patient using off-pump techniques.

We performed an off-pump coronary artery bypass grafting (OPCABG) procedure on a 60-year-old woman with idiopathic thrombocytopenic purpura (ITP) whose platelet count was 42 x 10(3) per microliter on admission. She was treated with immunoglobulin G (IgG) (0.5 g.kg(-1).d(-1)) for 4 days, resulting in a platelet count rise to 187 x 10(3) per microliter. She subsequently underwent an uneventful OPCABG procedure without requiring any blood transfusions. The combination of OPCABG and preoperative IgG therapy appears to be an ideal strategy for ITP patients requiring coronary revascularization.