Exclusive radiotherapy of carcinoma of the hypopharynx. Retrospective study of a series of 100 patients

From January 1980 to December 1987, 100 patients with carcinoma of the hypopharynx, staged according to TNM (UICC-1978) criteria, received exclusive radiation therapy at the Radiotherapy Department of the General Hospital of Varese. The median follow-up is 9 months (range: 1-97). Irradiation was delivered with 60Co or with 10 MV photons and tissue-equivalent bolus. Two opposed parallel lateral fields or rotational technique were used, with progressive shrinking of treated volume in order to spare the spinal cord after 45 Gy. Direct fields of electron beams (6-15 MeV) were employed as boosts on the residual nodes. Median total doses: 64.5 Gy to T and N1-3, 45 Gy to N0. A conventional fractionation (2 Gy once a day, 5 times a week) was used in 37 outpatients, while an accelerated hyperfractionated regimen (1.5 Gy twice a day, 5 times a week, with a six hours' interval between each fraction) was employed in 63 inpatients, in order to shorten hospitalization. The five-year overall survival (Kaplan-Meier) of the 100 treated patients is 10%, while the five-year disease-free survival of the 40 patients in complete clinical remission at the end of radiation therapy is 19.8%. The five-year loco-regional control rate after exclusive radiotherapy is 19.1%. Complete remission at the end of treatment seems to represent the only significant prognostic variable affecting survival: five-year overall survival is 32% for the 40 patients achieving complete remission and only 4.4% for the others (p less than 0.05). On the contrary, tumor extension (T class) seems to affect only the two-year local control rate: 35.2% and 10.9% for T1 + T2 and T3 + T4 respectively (p less than 0.1). The main cause of failure after radiation therapy is represented by the lack of control at the primary site (T) alone or associated with regional adenopathies (N). The analysis of isoeffect parameters, according to CRE model, has not shown any evident dose-response relationship for local control. Late effects were observed in 7% of the patients and were similar to those reported in the literature. The occurrence of both distant metastases, 3% in our experience, and secondary tumors (9%) is lower than those previously reported. The present retrospective study strongly reconfirms the inadequacy of exclusive radiation therapy as the sole treatment modality for carcinoma of the hypopharynx and suggests the need of combination therapy (surgery and radiation) as primary treatment.(ABSTRACT TRUNCATED AT 400 WORDS)     

Mucocele of the appendix. Retrospective study of 10 cases

PURPOSE: The purpose of our work was to assess the value of abdominal sonography (US) and computed tomography (CT) in the preoperative diagnosis of appendiceal mucocele. MATERIAL: and methods. We retrospectively reviewed 10 cases of mucocele of the appendix, 7 cases without pseudomyxoma peritonei, and 3 cases with pseudomyxoma peritonei. All cases were investigated radiologically by plain film and US, barium enema was performed in 3 cases and CT in 5 cases. RESULTS: Mucoceles of the appendix are rare and their clinical presentation is not specific. US confirms the appendicular involvement, but often poses the differential diagnosis with acute inflammation, abscess or localized appendicular peritonitis. CT appears as a mandatory examination since it allows accurate preoperative diagnosis period. In this series, the diagnosis was made preoperatively in the 5 cases where CT had been performed. CONCLUSION: US is useful to confirm the abnormal pattern of the appendix but does not allow accurate diagnosis of mucocele. CT is more specific and accurate for diagnosis of mucocele of the appendix.     

Retrospective study of 24 cases of acute appendiceal diverticulitis: CT findings and pathological correlations

Purpose

Appendiceal diverticulitis is relatively rare and is difficult to distinguish clinically and radiologically from acute appendicitis. The aim of this study was to describe the computed tomography (CT) findings of acute appendiceal diverticulitis.

Materials and methods

Among the 1329 patients who underwent appendectomy at our institution between January 2010 and July 2015, 28 were diagnosed pathologically with appendiceal diverticulitis, including 24 patients who were evaluated by preoperative CT. The control group consisted of 38 patients without diverticulitis. Average age of patients, ratio of males to females, appendiceal diameter, presence of a diverticulum, diverticular enhancement, peri-appendiceal fat stranding, peri-appendiceal loculated fluid and perforation, and the presence of appendicolith were evaluated retrospectively.

Results

Peri-appendiceal fat stranding (p < 0.005), appendiceal diameter (p < 0.005), and peri-appendiceal loculated fluid differed significantly between the diverticulitis and non-diverticulitis groups (p < 0.005).

Conclusion

Although relatively uncommon, appendiceal diverticulitis should be included in the differential diagnosis of acute appendicitis. It differs from typical acute appendicitis by the presence of an inflamed diverticulum, seen on CT. These patients are also more likely to have peri-appendiceal extra-luminal loculated fluid, peri-appendiceal fat stranding, and a larger diameter of the appendix. The latter finding is likely due to the increased intraluminal pressure.

     

Role of radiotherapy in the treatment of multiple myeloma]

BACKGROUND: Chemotherapy is the treatment of choice in multiple myeloma; but there are no curative options. Therefore, the treatment rationale is characterized by reduction of symptoms and inhibition of complications. Regarding reduction of pain, treatment of (impending) fractures, and spinal cord compression radiation is an important part of palliative treatment. In our retrospective study we report the effect of radiotherapy on reduction of pain, recalcification and the reduction of neurological symptoms and evaluate factors which have an impact on therapeutic outcome. PATIENTS AND METHODS: From 1, Jan 1988 to 31, Dec 1998, 42 patients (19 women, 23 men; range of ages 46 to 85 years, median age 64.9 years) with 71 target volumes were irradiated (median dose 36 Gy, 2 to 3 Gy 5 times/week) because of symptomatic disease (67/71: osseous pain, 45/71: fractures/impending fractures, 13/71: spinal cord compression) (Tables 1 and 2). The median time from diagnosis to the first course of radiotherapy was 11.9 months (0.3 to 90 months). At the time of first irradiation, 5 and 37 patients were in tumor Stage II and III (Salmon/Durie), respectively. The median value of the Karnofsky performance was 70% (40 to 90%). RESULTS: During follow-up (at least 6 months) in 85% of target volumes complete and partial pain relief (measured by patients' perception and the use of analgetic medication) was achieved; recurrences were seen in 8.8%. In 26/56 (46.4%) lesions evaluable a recalcification was seen whereas 17.9% showed progressive disease (comparison of radiographs before and after radiation). In 22.3% of all lesions initially with impending fracture (4/18) radiotherapy failed because of fracture after treatment (Tables 3 and 4). Simultaneous chemotherapy and a Karnofsky performance > or = 70 had a significant impact on a positive response to treatment, respectively. Spinal cord compression symptoms were reduced in 7/13 (53.8%) of patients (scaled due to the classification by Findlay 1987). The median survival from diagnosis for the entire group was 34.9 months (7.5 to 119.3 months), after irradiation 13.1 months (0.2 to 105.3 months) (Figure 1). CONCLUSION: When adequately indicated radiotherapy has shown to be an effective palliative treatment. Taking under consideration that the results are retrospective we suppose that in multiple myeloma the local response to radiation is supported by a favorable performance status and simultaneous chemotherapy. Irradiation treatment does not change prognosis regarding overall survival.     

Fatigue fractures of the femoral neck. Retrospective study of 12 cases

The authors are performing a retrospective analysis of 12 femoral neck stress fractures gathered between 1977 and 1984 at the "H?pital Regional des Armées de Toulouse". These fractures, localised at the femoral neck, occur after the beginning of training course, latter than by the other localisations. This shift can be explained by the acceleration of training level at the end of the instruction and by the importance of the muscle strain as a releasing factor of this pathology. The clinical is stereotyped, the X ray photographs often point out a fracture mark or a osseous condensation in strips perpendicular to the forces lines. However, the evolutionary potential of this fracture is high and the authors find out three displaced fractures. So they suggest a usual practice towards this pathology including a osseous radiography and scintigraphy the diagnostic should be done during the useful phase of this affection which is the stress prefracture state: stereotyped clinical frame, normal radiography and positive osseous scintigraphy.     

Interstitial radiotherapy of breast cancer. Preliminary report of a prospective study of 165 cases subjected to breast-conserving treatment

The results of a prospective study on breast conserving therapy in early stage breast cancer are presented. From January 1983 to June 1987 165 patients were treated by a standardized therapy-protocol. The criteria for entering the trial were stage T1 to T2 and N0 to N1. Surgical breast conservation was achieved by segmental resection in 148 cases and by tumorectomy in 17 cases. 160 patients underwent axillary lymph node dissection. Obligatory 45 to 50 Gy were delivered percutaneously to the operated breast and optional 50 Gy to the regional lymph nodes (axillary lymph node involvement greater than 3 nodes). In addition, the area of the primary breast lesion itself was boosted interstitially by an Iridium 192 implant (LDR-technique: 15 to 20 Gy, HDR-technique: 10 to 12 Gy). Results: Progression of disease in 10% of the patients (16/165), local recurrence rate in the operated breast: 2% (3/165), axillary recurrence: 0.5% (1/165). 5% of the patients (8/165) died from metastatic disease, two patients died free of recurrence for reasons unrelated to cancer, two other patients died on unknown reasons. Because of the low number of local recurrences and the observation period of 32 months, no statistically contribution on high risk factors for local failure could be found.     

Delayed radiation encephalopathy after radiotherapy for nasopharyngeal cancer: a CT study of 45 cases

The CT features of 45 cases of delayed radiation encephalopathy (including radiation necrosis) following radiotherapy for nasopharyngeal carcinoma are reported. The brain lesions were uni- or bilateral and involved mainly the white matter and subsequently the gray matter of the lower portion of the brain included within the portals of irradiation and its vicinity. The lesions were edematous and hypodense on CT and showed postcontrast enhancement in 50% of the cases. Within the period of follow-up (1-5 years), the lesions showed remissions and exacerbations and in some cases stabilized. In addition, there was progressive cerebral atrophy, manifesting itself mainly as dilatation of the temporal horns, the neighboring cisterns, and sylvian fissures. In some cases that were followed for a long time, the cerebral lesions showed either foci of calcification or encephalomalacia and/or porencephaly.     

Splenic irradiation in the treatment of idiopathic myelofibrosis. Retrospective study of 14 cases

A retrospective study was conducted on 14 patients with idiopathic myelofibrosis after splenic irradiation in order to cure the symptoms due to secondary splenomegaly. Radiation dose ranged from 700 to 2400 cGy, depending on both clinical response and hematological toxicity. Relief of symptoms was observed in all patients (100%); reduction of splenic size ranged from 30 to 70%, with more than 50% reduction in 13/16 cases. Side effects were mild neutropenia and thrombocytopenia, which did not require interruption of treatment; four patients registered a severe anemia. All the hematological side effects stopped with the suspension of treatment. This study shows the beneficial effect of radiation therapy on the symptoms connected to splenomegaly; however, the short duration of response suggests the advantage of splenic low-dose irradiation, to be periodically repeated.     

Multiplanar reconstructions in the study of ethmoid anatomy

Summary Multiplanar and surface reconstructions are useful tools in anatomical studies. Details of ethmoid architecture which are hard to image in axial and coronal scans are well displayed by means of oblique sections. This paper addresses reformatted images of a) the nasal lateral wall; b) the middle meatus lateral wall; c) the lamina basilaris of the middle turbinate and d) the frontonasal duct.     

Role of palliative and symptomatic radiotherapy in bone metastasis]

INTRODUCTION: The presence of bone metastases is a common event in the natural history of nearly all neoplasms which often affects the patient's quality of life greatly. Bone metastases may cause pain and pathologic fractures, or even a cord compression syndrome with severe neurologic symptoms. We tried to assess the optimal irradiation schedule for these patients and to discuss the use of radiopharmaceuticals. MATERIALS AND METHODS: We reviewed the literature focusing on studies investigating the efficacy of hypofractionated radiotherapy for bone metastases. We also addressed the problem of treating multiple skeletal lesions with half-body irradiation and radionuclides. RESULTS: External beam irradiation achieves pain palliation in more than 75% of patients with bone metastases, even with hypofractionation down to a single-dose administration. The results of exclusive radiotherapy in the cord compression syndrome depend on a prompt diagnosis, patient presentation and the intrinsic radiosensitivity of tumor cells. Palsy can always be avoided in these patients. Half-body irradiation can achieve complete pain relief in over 20% of patients and decrease pain markedly in the remaining cases with only a single-dose fraction (6-10 Gy), within 48 hours of irradiation and with little side-effects. Better results in terms of pain relief (80% complete responses) and duration of palliation come from fractionated half-body irradiation (up to 17.5 Gy in 7 fractions), which however has a more delayed response (1-2 weeks) and higher toxicity. The use of radiopharmaceuticals has been recently reevaluated after the introduction of new nuclides: results are similar to those of external beam irradiation (up to 80% responses), but cost and hematologic toxicity are both high. Radiopharmaceuticals can be used within an integrated treatment with external beam irradiation, chemotherapy and biphosphonates. DISCUSSION: The efficacy of external beam irradiation in the palliation of bone metastasis-related symptoms is confirmed by this literature review, even with short treatments and single-dose administrations. This is important for both patient expectations and the necessity for improved resource allocation with reference to the territorial distribution and waiting lists of radiotherapy centers. Finally, as for the role of radiopharmaceuticals, the best nuclides are not widely used yet for the high cost of the treatment, even though they provide similar results to external beam irradiation. The issue of their efficacy in combination with antiblastic drugs and/or external beam irradiation remains open and will be clarified only with further randomized clinical trials.     

Ultrasonographic aspects of hemolytic uremic syndrome in children. Apropos of a series of 21 cases]

The sonographic expression of the hemolytic-uremic syndrome in children is a cortical hyper-echogenicity, which has a real prognostic value in comparison to the clinical criteria. In addition, renal ultrasonography with Doppler is useful to predict the evolution of the condition, and may help the clinician to define the therapeutic choices.     

Radiolesions after radiotherapy of breast cancer]

A study is presented of the late radiolesions which occur after breast cancer irradiation. These lesions are described and the etiological factors are studied, with special emphasis given to the effect of dose and time factors. For the large volume considered in the irradiation of breast cancers, the tolerance dose for normal tissue (skin and connective subcutaneous tissue) can be set at 1,700 rets, that is, 5,600 rads in 28 sessions of 200 rads over a period of 38 days. Technical irradiation problems are given special mention as they can be the cause of dosimetric errors resulting in complications. Dosimetry should be in the whole volume, and not only in a single plane, as is still most often the case.     

Echotomography in the diagnosis of pancreatic carcinoma. Its reliability in a controlled normal and pathological series of cases]

Considering the different points of view about the echotomographic findings in pancreatic carcinoma, the authors refer their results about 89 controlled cases (38 normal pancreas and 51 pancreatic carcinomas). The pancreatic space was correctly identified as normal in 37/38 cases. Echotomography also revealed the presence of 48 pancreatic carcinomas; it gave 3 false negative and 3 false positive results; in 21 cases the size of the tumour was 5 cm or less. In a large number of cases echotomography has correctly defined the extent of the lesion by evaluating its size, the secondary liver localization (95% of accuracy) and the vascular involvement (compressions on the inferior vena cava and obstruction of the splenic vein). Basing on the echotomographic findings the authors classify the pancreatic carcinoma in 2 main types.     

Retrospective audit of inter-fraction motion for pelvic node radiotherapy in prostate cancer patients

IntroductionPelvic lymph nodes move independently to the prostate. When delivering radiotherapy to prostate and pelvic lymph nodes, daily inter- and intra-fraction anatomical changes need to be accounted for. Planning target volume (PTV) margins, grown from the pelvic lymph node clinical target volume need to be determined, to account for this variation in position.MethodsTwenty patients who had daily online image guided radiotherapy to prostate and pelvic lymph nodes between April and December 2018 were selected. Ten pre-treatment verification images using cone beam CT from each patient were registered to pelvic bone anatomy, prostate soft tissue or fiducial markers and pelvic lymph node soft tissue to assess the accuracy of treatment delivery. Population systematic and random errors and PTV margins were calculated.ResultsPTV margins of 0.4 cm, 0.4 cm and 0.7 cm left–right (LR), superior–inferior (SI) and anterior–posterior (AP) respectively were derived for the pelvic lymph nodes when registering to prostate. PTV margins of 0.3 cm, 0.2 cm and 0.4 cm LR, SI and AP respectively were derived for the pelvic lymph nodes when registering to bone. There was a posterior systematic shift of the prostate during the treatment course.ConclusionThere is differential motion of pelvic lymph nodes to prostate and in the era of prostate and pelvic radiotherapy for patients with node positive prostate cancer; there is increasing importance in the accuracy of dose delivery to the involved lymph node. Hence, this group of patients may benefit from personalised radiotherapy PTV margins, especially if the involved pelvic lymph node is within the anterior part of the clinical target volume.Implications for practiceOptimisation of dose delivery to the pelvic lymph nodes when prioritising the prostate in prostate and pelvic lymph node image guided radiotherapy.