Treatment for non-Hodgkin's lymphoma (stage I, II) of the elderly: usefulness of local and regional irradiation and reduced dose chemotherapy.

PURPOSE: To examine the usefulness and safety of a new treatment regimen consisting of irradiation to the involved area and adjacent lymph node area, and reduced dose chemotherapy for elderly patients with non-Hodgkin's lymphoma. METHODS AND MATERIALS: The core of this study was 38 elderly patients older than 65 years old with intermediate or high grade non-Hodgkin's lymphoma, and concomitantly suffering from some other geriatric disease. They received involved area irradiation (40 Gy), adjacent lymph node irradiation (30 Gy), and reduced dose chemotherapy (two cycles of 50-70% ACOP: Doxorubicin, Cyclosphosphamide, Vincristine, Prednisone or 70% MACOP-B: Doxorubicin, Cyclophosphamide, Vincristine, Methotrexate, Bleomycin, Prednisone for 4 weeks). RESULTS: The completion rate of the treatment regimen was 100%. The 5-year local control rate was 98%. The 5-year disease-free survival rate and the 5-year cause-specific survival rate for all patients were 70 and 82%, respectively. No treatment deaths were observed, and the rate of serious complications arising from the treatment was 3%. CONCLUSIONS: The newly conducted treatment regimen proved to be safe and useful for elderly patients with non-Hodgkin's lymphoma concomitantly suffering from some other geriatric disease.

MR evaluation of laryngohypopharyngeal cancer: value of gadopentetate dimeglumine enhancement.

PURPOSE: To investigate the value of gadopentetate dimeglumine-enhanced MR imaging in determining the extent of laryngohypopharyngeal cancer. METHODS: Unenhanced and contrast-enhanced T1-weighted, proton-density-weighted, and T2-weighted images from 24 patients with laryngohypopharyngeal cancer were reviewed and compared with the pathologic findings of resected specimens. In 18 patients, ex vivo MR images of the resected specimens were also compared with pathologic findings. RESULTS: Laryngohypopharyngeal cancer showed intermediate intensity on T1-weighted and proton-density-weighted images, high intensity on T2-weighted images, and moderate enhancement on T1-weighted enhanced images. Cartilage-invaded tumor enhanced moderately, whereas unossified cartilage in contact with tumors but without tumor invasion showed no enhancement. Laryngohypopharyngeal mucosa enhanced intensely; endolaryngeal muscles enhanced less. CONCLUSIONS: Enhanced MR images were more useful in assessing the extent of tumors and the presence of laryngeal cartilage invasion than were proton-density-weighted and T2-weighted images.

High resolution ultrasound of the chest wall.

To study the detailed normal ultrasonic anatomy of the pleura and chest wall, high resolution (7.5 MHz) ultrasonograms were obtained from cadaver chest wall specimens and compared with thin section computed tomograms and anatomical specimens. Ultrasonograms show three layers of the intercostal muscles (internal, external and innermost), covered by the "echogenic pleural line." The "echogenic pleural line" is caused by composite echoes from the inner parietal pleura, and the outer endothoracic fascia, with the fatty tissue covering both sides of the fascia, which are located deep to the chest wall muscles. On ultrasonograms, the subpleural fat tissue, when abundant, appeared as an apron-like structure hanging down from the inner surface of the rib (subpleural fat pad), or diffuse fat accumulation mimicking the pleural thickening.

Computed tomography of neck lymph nodes involved with malignant lymphoma: comparison with ultrasound.

CT images of 24 patients with head and neck lymphoma were retrospectively reviewed, compared with ultrasonograms, and compared with CT images of 13 patients with lymph node metastases. In nine (38%) of 24 patients, some lymph nodes with lymphomatous involvement showed a spotty or linear pattern of contrast enhancement. In two of these nine patients, a dendritic pattern of contrast enhancement between multiple enlarged lymph nodes was observed. The same pattern appeared as spotty, linear, or dendritic hyperechoic areas on the ultrasonogram. None of 13 patients with lymph node metastases showed a spotty, linear, or dendritic pattern of contrast enhancement. Ten of 13 (77%) showed ring-like contrast enhancement on CE-CT images. The spotty or linear contrast enhancement in enlarged lymph nodes and the dendritic contrast enhancement in confluent lymph nodes could be useful CT findings in diagnosing nodal involvement with malignant lymphoma.

[Effective combination therapy using radiation and a daily low dose of cis-platinum for advanced oropharyngeal carcinoma in an elderly patient--report of a case].

An 83-year-old male with advanced oropharyngeal carcinoma was treated with combined radiotherapy and a daily low dose of cis-platinum with excellent results. In the early part of the treatment, radiotherapy was delivered in fractions of 1.8 Gy/day (5 days/week) to a cumulative dose of 20 Gy, concomitantly with UFT (400 mg/day po), but the response was not adequate. Then, instead of UFT, a single intravenous injection of cis-platinum (5 mg) was administered within 30 min after each radiation session without intravenous hydration. The total dose of cis-platinum was 140 mg and that of radiation was 70 Gy. Moderate leukocytopenia and moderate mucositis/dermatitis were observed as side effects, but despite the lack of intravenous hydration no signs of renal toxicity were observed. Partial remission was attained by the end of the therapy, remnant lesions progressively diminished in size, and 4 months later all of them had completely disappeared on the computed tomogram. The prognosis is favorable, and neither recurrence nor metastasis has been found in the 14-month follow-up period since the lesions disappeared.

Digital image processing to remove blur from linear tomography of the lung.

We have studied digital image processing methods to reduce blur in linear tomography of the lung performed with the Fuji computed radiography (FCR) system. One-dimensional unsharp (blur) mask filtering in the direction of tomographic movement was found to be effective in reducing blur. The appearance of the processed tomograms varied depending largely on the properties of the unsharp mask filters applied. With regard to the spatial frequency response of the filter, a high mid-frequency response and a low low-frequency response of the tomographic image data was most effective in obtaining high image quality tomograms. When the standard 2-dimensional unsharp mask technique of the FCR system was additionally applied to the one-dimensional unsharp mask processed tomogram, the clarity of the tomogram was further enhanced. These observations may also be helpful when considering image processing to obtain diagnostically informative digital radiography.

Is postoperative radiotherapy for thymoma effective?

OBJECTIVE: The authors determined the effect of postoperative mediastinal irradiation in preventing local and pleural recurrence of thymoma. SUMMARY BACKGROUND DATA: The role of mediastinal irradiation after incomplete resection or biopsy of an invasive thymoma is well established. However, routine use of adjuvant mediastinal irradiation for patients with thymoma after complete resection remains controversial. METHODS: During the 19-year period from 1973 to 1992, operations were performed on 89 patients with thymoma. Of these 89 patients, 80 patients who underwent gross complete tumor resection including adjacent tissues that appeared to be invaded by tumor were selected for this study. The effects of postoperative mediastinal irradiation on the recurrence rate of thymoma were analyzed according to histologic type, clinical stage, and whether adhesions to or invasion of the pleura or pericardium were present. RESULTS: Recurrence of thymoma was observed in 13 of 80 (16.3%) patients. No recurrence was observed in 23 patients with noninvasive thymoma. In patients with invasive thymoma whose tumor was macroscopically adherent to the pleura but not microscopically invasive (p1), recurrence was observed in 4 of 11 patients (36.4%) when mediastinal irradiation was not performed, but in none of 10 patients who received mediastinal irradiation. However, in patients with microscopic pleural invasion (p2), a high recurrence rate was observed with mediastinal irradiation (40%, 6/15 patients) or without mediastinal irradiation (30%, 3/10 patients). Postoperative mediastinal irradiation for patients with microscopical invasion to pericardium (c2) did not decrease the recurrence rate. Analysis of the mode of recurrence showed that mediastinal irradiation may have been effective in preventing local recurrence, but it did not control the pleural dissemination that was observed in 12 of 13 recurrent cases. CONCLUSIONS: Mediastinal irradiation is not necessary for patients with noninvasive thymoma. In patients with invasive thymoma, postoperative mediastinal irradiation is effective in preventing recurrence in patients with p1 thymoma, but not in patients with p2 or c2 tumors. Further adjuvant therapy should be performed to supplement mediastinal irradiation in patients with p2 or c2 thymoma, even after complete resection.

Size of normal hilar lymph nodes measured in autopsy specimens.

The normal size of lymph nodes for each region of the hilum was determined by direct measurement of the short and long diameters of each node in the transverse plane of the node and the longitudinal diameter in the vertical plane of the node in 30 adult cadavers. The mean short transverse diameters ranged from 3.2 to 6.4 mm, the mean long transverse diameters ranged from 4.9 to 10.0 mm, and the mean longitudinal diameters ranged from 5.7 to 11.3 mm. The largest mean transverse diameters were found in the anterior upper lobe (AUL) and the inferior interlobar (IIL) regions. We noted a different maximum normal size for lymph nodes in each region of the hilum and determined the standard maximum normal short transverse diameters to be as follows: 12 mm for nodes in the right AUL and IIL regions, 10 mm for nodes in the right superior interlobar region and the left AUL and IIL regions, and 8 mm for nodes in other regions. Both the maximum normal long transverse diameters and the longitudinal diameters showed a wider variation, ranging from 18 to 10 mm and from 20 to 12 mm, respectively.

Development of a high-resolution digital tomosynthesis system and its clinical application.

Conventional tomography has been criticized for its low contrast caused by scattered radiation and tomographic blur. The authors developed a digital tomosynthesis system as a substitute for conventional tomography. With the image processor in the system, two types of postprocessing can be performed to improve the quality of synthesized tomograms. One-dimensional spatial frequency filtering effectively reduces linear tomographic blur and enhances image information when an appropriate filter is used. Correction of structure mottle helps enhance the image clarity. The system allows reconstruction of tomograms at any desired depth and performance of tomosynthetic angiography and dual-energy subtraction. The system solves some of the problems associated with plain tomography and dual-energy subtraction and provides diagnostic clinical images.

[Intraoral ultrasound of the tongue tumor].

Transcutaneous ultrasonography scanned through the submandibular triangle has been effectively utilized for the evaluation of tongue tumors. However, because of lacking an appropriate sonic window, tumors located in the anterior portion of the tongue can not be demonstrated on the transcutaneous ultrasonogram. Intraoral ultrasonography using an echoendoscopy was effective for evaluating neoplasms of the tongue, and could clearly demonstrate tongue tumors, which failed to be shown on the transcutaneous ultrasonograms. In addition, intraoral ultrasonograms could provide more accurate anatomical informations concerning the tumor extent than the transcutaneous ultrasonograms.

[Trial of a small image network system in a radiology department of an university hospital].

This paper describes the construction of an image network system in Shinshu University Hospital, and some of its current issues and advantages. Our discussion is based on our experience with a PACS system. SAIPACS, which was installed in 1990 for use in clinical conferencing and pre- and post-graduate education, and with a new CT and MRI network, which was subsequently introduced in 1993. The SAIPACS interconnects eight digital imaging modalities, including CT, MRI, XTV-DR (including digital tomosynthesis), FCR, nuclear medicine (RI), DSA, US, and a film digitizer (FD), with a workstation. Transmission time from the magnetic disk of each imaging modality to the SAIPACS image disk is not rapid enough. Therefore, we need to select images for transfer that are pertinent to our specific purpose, to complete image transmission within a practically acceptable period of time. The new CT/MRI network is composed of two CT units, two MRI systems, an image processing unit and a Universal Gateway. It provides faster image transmission than the SAIPACS system, because there is no need to reform image data to send them in a reversible compressed form. A versatile network system connected to the SAIPACS and CT/MRI network enables digital image data to be processed and edited and images to be transferred back to SAIPACS for clinical or educational use.

The number and size of normal mediastinal lymph nodes: a postmortem study.

For the CT diagnosis of pathologically enlarged nodes, information concerning the size of normal nodes is required. We studied 40 adult cadavers and determined the number and size of normal lymph nodes for each region of the mediastinum, counting all nodes and directly measuring the short and long diameters of each in the transverse plane of the node. The location of each node was classified according to the American Thoracic Society system, and the range and standard maximum sizes of normal lymph nodes in each location were determined. Nodes were found in 90-100% of cadavers in regions 4, 7, and 10; and in 68-85% of cadavers in regions 2 and 6. The average number of lymph nodes found was 3.5-4.8 in regions 4, 6, and 10R; 2.1-2.9 in regions 2, 7, and 10L; and 0.1-1.2 in all other regions. The mean short transverse diameters ranged from 2.4 to 5.6 mm, and the mean long transverse diameters ranged from 3.9 to 10.0 mm. The largest mean short and long transverse diameters were found in region 7, the next largest were in region 10R, followed by regions 4, 5, and 10L. We noted a different maximum normal size of lymph nodes in each region of the mediastinum. The short transverse diameter, which showed a smaller variation, appeared to be a more useful parameter than the long transverse diameter. We propose a standard for maximum normal short transverse diameters for nodes in each region of the mediastinum as follows: 12 mm for nodes in region 7; 10 mm for nodes in regions 4 and 10R; and 8 mm for nodes in other regions. The maximum long transverse diameters showed a wider variation, ranging from 25 to 10 mm.

[Radiation therapy of intracranial germinoma].

The appropriate radiation dose and field for the treatment of intracranial germinoma were investigated in 33 patients. Recurrences were observed in 4 cases treated with local field irradiation only, and all of them were recognized at the margin of the radiation field or under the dose (less than 25 Gy) area. This suggests that whole cranial irradiation (dose of 25 to 30 Gy) should be added even if the tumor is solitary. The effective dose for cerebrospinal dissemination appears to be 25-35 Gy, but prophylactic CNS irradiation seems unnecessary for patients who have not undergone surgical procedures. Changes in mental status were seen in 5 patients (26.3%). Doses of over 59 Gy may be related to this complication.