Intracranial non-Hodgkin lymphoma occurring after treatment of Hodgkin disease

Patients with successfully treated Hodgkin disease are at increased risk for the development of second malignancies. We present two cases of intracranial non-Hodgkin lymphoma that appeared following successful treatment of Hodgkin disease. The appearance of the lymphomas on computed tomographic images is shown, and possible predisposing factors, differential diagnosis, and clinical implications are discussed.     

New staging and response criteria for non-Hodgkin lymphoma and Hodgkin lymphoma

The International Harmonization Project developed recommendations for the use of positron emission tomography (PET) in managing patients who have lymphoma. It provided guidance as to the interpretation of fluorodeoxyglucose (FDG) PET and generated response definitions, incorporating metabolic imaging with the goal of improving interpretation of response and comparability among studies, leading to accelerated new agent development, more rapid availability of more effective therapies, and the enhancement of outcome for patients with lymphoma.     

电视胸腔镜活检在诊断和治疗纵隔恶性淋巴瘤中的意义

目的探讨经电视胸腔镜活检(VATMLB)在纵隔恶性淋巴瘤诊断和治疗中的意义。方法自2007年6月—2011年10月经电视胸腔镜行前纵隔淋巴瘤活检14例,并进行病理组织学和免疫组织化学检测,明确诊断,并根据病理分型(WHO分型)采用相应化疗方案或(和)联合放疗方案治疗,并对治疗效果进行随访。结果 14例均活检成功,无手术并发症,病理结果:霍奇金淋巴瘤8例,大B细胞淋巴瘤5例,外周T细胞淋巴瘤1例。根据其病理分型给予相应方案化疗或化疗联合放疗,随访3⁵5个月,完全缓解(CR)4例(28.6%),部分缓解(PR)8例(57.1%),稳定(SD)1例(7.1%),进展恶化(PD)1例(7.1%)。总有效率:85.7%。1年生存率为100%(10、10),2年生存率100%(6/6),3年生存率66.7%(2/3)。结论电视胸腔镜纵隔活检能够取得足够肿瘤组织进行病理组织学和免疫组织化学检查准确诊断纵隔淋巴瘤并对纵隔淋巴瘤分型,对于指导纵隔淋巴瘤诊断、治疗和预后的判断具有重要的意义,具有准确、安全、微创等优点。     

影像学技术在霍奇金淋巴瘤诊疗中的价值

在我国,霍奇金淋巴瘤（HL）占全部恶性淋巴瘤的10.9％,约90％起源于淋巴结,通常呈对称性淋巴结肿大,很少累及结外组织.HL对放疗、化疗很敏感,是可治愈的肿瘤之一.该文主要就CT成像、MRI、67Ga成像、PET或PET/CT在HL诊断及预后评估等方面的应用作一综述,以进一步提高对HL影像学表现及其临床应用的认识.     

Comparison of adaptive radiotherapy techniques for the treatment of bladder cancer

Objective

Day-to-day anatomical variations complicate bladder cancer radiotherapy treatment. This work quantifies the impact on target coverage and irradiated normal tissue volume for different adaptive strategies.

Methods

20 patients were retrospectively planned using different three-dimensional conformal radiotherapy treatment strategies for whole-bladder carcinoma: (i) “conventional” treatment used isotropic expansion of the clinical target volume (CTV) by 15 mm to the planning target volume (PTV) for daily treatment; (ii) “plan of the day” used daily volumetric on-treatment imaging [cone beam CT (CBCT)] to select from four available plans with varying superior PTV margins; (iii) “composite” strategies used on-treatment CBCTs from Fractions 1–3 to inform a composite CTV and adapted PTV (5- and 10-mm margins for composite 1 and composite 2, respectively) for subsequent treatment. Target coverage was evaluated from available CBCTs (the first three fractions then the minimum weekly thereafter), and the reduction in the irradiated volume (i.e. within the 95% isodose) was quantified.

Results

Plan of the day improved target coverage (i.e. all of the bladder within the 95% isodose throughout the treatment) relative to conventional treatment (p=0.10), while no such benefit was observed with composite 2. Target coverage was reduced with composite 1 relative to conventional treatment. The mean irradiated volume was reduced by 17.2%, 35.0% and 14.6% relative to conventional treatment, for plan of the day, composite 1 and composite 2, respectively (p<0.01 in all cases). No parameters predictive of large changes in bladder volume later in the treatment were identified.

Conclusions

Adaptive techniques can maintain or improve target coverage while allowing for reduced irradiated volume and possibly reduced toxicity. The plan-of-the-day technique appeared to provide the optimal balance between target coverage and normal tissue sparing.

Advances in knowledge

This study suggests that plan-of-the-day techniques will provide optimal outcomes for adaptive bladder radiotherapy.Muscle-invasive bladder cancer affects over 3000 new patients every year in the UK [1]. Although patients can undergo radical cystectomy, bladder preservation offers comparable outcomes with the added advantage of the patient retaining their own bladder [2]. This means that there is increasing interest in bladder preservation. Patients are treated with maximal transurethral resection of the bladder, neoadjuvant chemotherapy and radiotherapy [3]. Use of concurrent radiosensitisers further improves outcomes [4,5]. With combined modality treatment, local control rates of 70–80% can be achieved. Although this is promising, there is scope for improvement. Higher radiotherapy doses may offer increased local control, but are limited by normal tissue toxicity, with some patients experiencing significant urinary and bowel toxicity [6].Radiotherapy for bladder cancer in the UK involves irradiation of the entire bladder, with a generous margin to account for variations in bladder position, shape and size. However, this is likely to be a suboptimal approach, leading to unnecessarily high doses to normal tissue where bladder volume remains small, while failing to achieve target coverage for patients who encounter increasing bladder volume throughout treatment [7]. Henry et al [8] found that 26% of bladder patients monitored using cone beam CT (CBCT) required replanning owing to increasing bladder volume (53%), decreasing bladder volume (38%) and decreasing rectal volume (9%). The authors recommended development of adaptive radiotherapy protocols for these patients. Strategies aimed at reducing these variations by coaching patients to achieve consistent bladder volumes through drinking protocols have generally met with limited success, despite good patient compliance [9].Daily variations throughout treatment make bladder radiotherapy technically challenging and, with the incidence of bowel toxicity, mean that adaptive strategies could be beneficial. Burridge et al [10] retrospectively investigated the potential of a “plan-of-the-day” approach to this problem, which involved generating three plans based on the bladder volume seen on the radiotherapy planning (RTP) scan with variable superior expansion margins (5, 10 and 15 mm) but uniformity in other directions (15 mm). Based on CBCT images acquired throughout treatment (days 1–5 and weekly thereafter), the optimal plan was selected for treatment. The study demonstrated an average small bowel sparing of 31 cm³ (maximum 76 cm³) compared with non-adaptive techniques.Adaptive techniques are complicated by intrafractional bladder filling: Lotz et al [11] demonstrated that bladder filling rates varied significantly in healthy volunteers, although flow rates for individuals were consistent. To investigate an adaptive plan-of-the-day strategy, Murthy et al [12] acquired megavoltage CT images before and after each treatment fraction, finding that >16% of patients no longer had their bladder contained within the required region at the end of treatment. Studies often account for this effect with an additional 2- to 3-mm margin for intrafractional expansion, although customised approaches have been investigated [13].Alternative adaptive strategies can be broadly classed as “composite” plan approaches. These involve acquisition of several images of patient anatomy on successive days, from which a composite clinical target volume (CTV) [and planning target volume (PTV)] is determined as the union of CTVs observed on each scan. Pos et al [14] used this approach to define a composite CTV based on the observed position on CT scans for the first five fractions, subsequently expanding 10 mm isotropically to a composite PTV. This allowed a 40% reduction in overall irradiated volume with minimal compromise to target coverage.The current work aims to expand on previous studies by making a direct quantitative comparison between different adaptive approaches for whole-bladder radiotherapy within the same patient cohort. Unlike earlier studies, a patient-specific comparison of the appropriateness of each technique will be provided to investigate whether the optimal adaptive strategy varies for particular patients, and whether the optimal strategy could be determined and adopted early in treatment. It was impractical to investigate all of the above approaches owing to subtle variations between investigators and so the focus is on specific examples of each broad approach.     

FDG PET for imaging pericardial manifestations of Hodgkin lymphoma

A 61-year-old man with Hodgkin lymphoma (mixed type), with lymph node manifestations and extranodal and bone marrow involvement in both supra- and infradiaphragmatic locations (stage 4), had dyspnea and tachycardia on echocardiography. There were pleural and pericardial effusions and thickening of the epicardium and pericardium. These findings and computed tomographic findings were suspicious for manifestations of Hodgkin lymphoma. The pericardial findings were demonstrated on F-18 fluorodeoxyglucose positron emission tomographic imaging.     

Usefulness of FDG-PET imaging for the radiotherapy treatment planning of pyothorax-associated lymphoma

Pyothorax-associated lymphoma (PAL) is a non-Hodgkin's lymphoma developing in the pleural cavity after a long-standing history of chronic pyothorax (CP). F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) imaging is a useful modality for determination of disease extent of various malignant tumors, including malignant lymphoma, but there have been no reports describing the usefulness of FDG-PET imaging in PAL. Here we report a case of PAL that relapsed after chemotherapy and was successfully treated by radiotherapy. FDG-PET imaging revealed that the tumor was localized to a soft-tissue attenuation mass behind the CP cavity in the right thorax, but did not infiltrate the CP cavity. A total dose of 40 Gy was administered to the area that included the PET-positive lesion, instead of including the entire CP cavity in the radiation field. Although computed tomography (CT) showed a residual mass, no FDG uptake was indicated by FDG-PET imaging performed just after the end of radiotherapy, and additional irradiation was not performed. No sign of relapse was found by FDG-PET imaging 3 months later. FDG-PET imaging was useful for both the planning of radiotherapy and assessing the treatment response of PAL.     

前纵隔淋巴瘤的CT征象

目的 探讨前纵隔淋巴瘤的CT表现特征.方法 收集10例经组织病理学证实CT表现为单纯前纵隔肿块的淋巴瘤患者资料,回顾性分析其CT征象.结果 10例均表现为前纵隔巨大肿块,均跨区生长,8例向双侧生长,2例偏一侧生长.10例前纵隔肿块中,7例肿块由多个结节融合而成,增强呈结节样强化.7例大血管受压明显移位,5例侵犯上腔静脉,7例侵犯左头臂静脉,6例合并少量胸腔积液,5例合并心包积液.结论 前纵隔淋巴瘤CT表现有一定特征,仔细分析大部分能与前纵隔其他恶性肿瘤进行鉴别.     

Fluorine-18 fluorodeoxyglucose PET-CT for extranodal staging of non-Hodgkin and Hodgkin lymphoma

PURPOSE

We aimed to evaluate the role of fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸F-FDG PET-CT) involving care-dose unenhanced CT to detect extranodal involvement in patients with non-Hodgkin and Hodgkin lymphoma.

MATERIALS AND METHODS

Lymphoma patients (35 Hodgkin lymphoma, 75 non-Hodgkin lymphoma) who were referred for ¹⁸F-FDG PET-CT imaging, following a diagnostic contrast-enhanced CT (CE-CT) performed within the last month, were included in our study. A total of 129 PET-CT images, and all radiologic, clinical, and pathological records of these patients were retrospectively reviewed.

RESULTS

In total, 137 hypermetabolic extranodal infiltration sites were detected by ¹⁸F-FDG PET-CT in 62 of 110 patients. There were no positive findings by CE-CT that reflected organ involvement in 40 of 137 ¹⁸F-FDG-positive sites. The κ statistics revealed fair agreement between PET-CT and CE-CT for the detection of extranodal involvement (κ=0.60). The organs showing a disagreement between the two modalities were the spleen, bone marrow, bone, and thyroid and prostate glands. In all lesions that were negative at CE-CT, there was a diffuse ¹⁸F-FDG uptake pattern in the PET-CT images. The frequency of extranodal involvement was 51% and 58% in Hodgkin and non-Hodgkin lymphoma patients, respectively. There was a high positive correlation between the maximum standardized uptake values of the highest ¹⁸F-FDG-accumulating lymph nodes and extranodal sites (r=0.67) in patients with nodal and extranodal involvement.

CONCLUSION

¹⁸F-FDG PET-CT is a more effective technique than CE-CT for the evaluation of extranodal involvement in Hodgkin and non-Hodgkin lymphoma patients. PET-CT has a significant advantage for the diagnosis of diffusely infiltrating organs without mass lesions or contrast enhancement compared to CE-CT.Lymphomas are common hematological malignancies that predominantly affect the lymph nodes. However, both non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) may affect any organ or tissue in the body. The lymphomatous infiltration of tissues other than the lymph nodes or lymphoid organs is described as extranodal lymphoma. The most common sites of lymphomatous infiltration are skin, stomach, spleen, Waldeyer’s ring, central nervous system, bone, and lungs. The distribution and prevalence of affected organs vary according to the histological type and stage of the disease (1–4).The presence of extranodal involvement is very important for staging NHL and HL. In general, extranodal involvement is more common in NHL than in HL, while it is frequently observed in recurrent disease and immune deficiency-related lymphomas (2–4). Moreover, primary and secondary extranodal diseases have different prognostic implications. Lymphomas that initially appear to have the bulk of the disease at extranodal sites are described in primary extranodal lymphoma and categorized as stage I or II. In secondary extranodal lymphoma, there is secondary involvement of the extranodal sites from primary nodal disease, which is categorized as stage III or IV. Except for the thymus and spleen, extranodal infiltration also indicates stage IV disease in HL. All of these data demonstrate the vital importance of diagnosis of extranodal lymphoma when designing treatment protocols at primary staging or restaging (3–5).Cross-sectional anatomical imaging techniques, particularly computed tomography (CT), have been the primary modality for the diagnosis, staging, restaging, and follow-up of patients with lymphoma. However, these modalities have several limitations when detecting nodal or extranodal disease, because CT is based only on anatomical structural changes, such as the enlargement of lymph nodes or organs, presence of masses, and abnormal contrast enhancements. In NHL or HL, these structural abnormalities are detected in 60% to 90% of patients by CT (6–8). Normal-sized organs or nodes and diffuse lymphomatous infiltrations without mass effects reduce the sensitivity of anatomical imaging modalities.Fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography-computed tomography (PET-CT) is a hybrid imaging technique that simultaneously provides functional and anatomical information. This provides a significant advantage for the evaluation of lymphoproliferative malignancies, particularly for the detection of lymphomatous involvement in organs and nodes of normal size without any mass. Several studies suggest that the sensitivity and specificity of ¹⁸F-FDG PET-CT for the assessment of nodal and extranodal involvement were higher than those of standard contrast-enhanced CT (CECT) (3, 4, 7–11). These benefits make ¹⁸F-FDG PET-CT the standard imaging technique for the initial staging, therapy response evaluation and restaging of patients with lymphoma.The aim of this study was to evaluate the utility of ¹⁸F-FDG PET-CT involving care-dose unenhanced CT for the detection of extranodal involvement in patients with NHL and HL. The ¹⁸F-FDG PET-CT results were retrospectively compared with the diagnostic CE-CT data; follow-up results were used as a reference standard.     

组织蛋白酶D在霍奇金淋巴瘤组织的表达及意义

目的：探讨组织蛋白酶D(CaihepsinD，CathD)在霍奇金淋巴瘤(Hodgldn lymphoma，HL)组织中的表达及意义。方法：应用免疫组织化学方法对霍奇金淋巴瘤进行CathD、CD34、CD45RO、CD20染色。探讨组织蛋白酶D在霍奇金淋巴瘤发病中的作用。结果：CathD主要表达于阻组织中的组织细胞和树突状细胞，其表达明显多于反应性增生淋巴组织；CathD不表达于RS／Variants(RS／V)细胞；其表达与血管生成无相关性；HL中主要的反应性增生淋巴细胞为T细胞。结论：CathD的表达与HL中微血管生成无相关性，可能与局部细胞免疫增强有关。     

Breast radiotherapy: an Australasian survey of current treatment techniques

Prior to the dissemination of evidence-based quality assurance guidelines, the Australian National Breast Cancer Centre Radiation Oncology Group conducted a process survey of breast radiotherapy treatment delivery throughout Australia. A process survey was conducted in August/September 1998. This survey comprised questions enquiring about treatment positioning, immobilization devices used, planning strategies, simulation and dose computation methods, treatment prescribing and quality assurance. The survey was sent to 123 Australian fellows of the Royal Australian and New Zealand College of Radiologists (RANZCR) and to the six directors of New Zealand radiation oncology departments. Fifty-eight questionnaires were returned of which 38 were received from individuals and 20 represented a reply from a department with a routine breast radiotherapy protocol (representing an average of 4.5 radiation oncologists per reply). The study identified great consistency between departments with respect to dose and fractionation for breast tangents. The study also identified some areas of treatment planning and delivery that varied between individuals or departments. These mainly reflected a lack of evidence in some areas of radiotherapy treatment delivery. The circulation of quality assurance guidelines will perhaps improve consistency of radiotherapy techniques in which studies have identified that technique changes improve outcome. This study identified that these areas include the taking of simulation and port films and the use of off-axis dosimetry. Further studies are required for areas of radiotherapy treatment delivery that have little evidence for or against their implementation.     

新材料、新术式在颈椎病手术中的应用

近年来,由于生物力学和材料学的研究发展,在脊柱的稳定、固定等领域进行了深入研究。在总结传统术式易出现问题的基础上,出现了新的固定材料和相应的固定工具,发展出了新的手术方式。本文简略介绍一些应用在颈椎病治疗中的新材料和新术式。1颈椎病传统术式1.1前方入路1.1.1 Smith-Robinson’s technique颈前入路,将病变间隙的上一锥体及下一椎体前缘和椎间盘凿除,深度为椎体的1/2或2/3,然后进行植骨融合。因为颈椎的骨质增生主要是椎间不稳所造成的,此技术目的是椎间融合以加强稳定。但因不直接去除增生的骨赘,术后早期效果不明显,增生的骨…     

Regression of mediastinal Hodgkin disease after therapy: evaluation of time interval

Ninety-one patients with Hodgkin disease of the upper torso who had mediastinal masses were studied to determine the frequency of residual mass and the time required for resolution or stabilization of the mass. In 72 of these patients, radiographs from sufficient intervals were available for determination of the rate of regression. In 62 patients (86%), the mediastinum returned to normal width within 11 months, regardless of the size of the mass. The mediastinum returned to normal in all but one patient with small masses. The intrathoracic relapse rate did not correlate with the regression time of the masses, but relapse occurred more than twice as often in patients with residual mediastinal widening.