Postoperative Adjuvant Chemoradiotherapy for Rectal Cancer: Analysis of Acute and Chronic Toxicity

Aims and background

The aim of the study was to evaluate acute and chronic toxicity of combined postoperative standard radiation therapy to the pelvis and 5-fluorouracil plus levamisole in resectable rectal cancer.

Methods

Between July 1990 and September 1993, 58 patients with histologically confirmed adenocarcinoma of the rectum entered the prospective study. The schedule consisted of 5-fluorouracil, 450 mg/m2 i.v. for 5 days, and from day 28 5-fluorouracil, 450 mg/m2 i.v. weekly for 24 weeks, plus levamisole given orally at the dose of 150 mg every day for 3 days every 2 weeks for 6 months; radiotherapy (180 cGy/day) 5 days a week for a total dose of 45 Gy was administered from day 28.

Results

After the first cycle of chemotherapy (before radiotherapy), overall toxicity was mild. During chemoradiotherapy, dose-limiting toxicity was grade 3 diarrhea and proctitis, for which the combined treatment was interrupted for more than 7 cumulative days in 28 patients. During the 24 weeks of weekly 5-fluorouracil (after radiotherapy), no severe toxicity was reported. Three-year survival and progression-free survival were 65% and 50–55%, respectively.

Conclusions

Although adjuvant chemoradiotherapy is usually feasible, in our study toxicity was severe in a substantial proportion of patients, probably due to the schedule applied. We are evaluating the feasibility and toxicity of a combined treatment which includes 5-fluorouracil in continuous chronomodulated infusion during radiotherapy.

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND

As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years.

METHODS

Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients.

RESULTS

Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446).

CONCLUSIONS

The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

Anaplastic thyroid cancer: a case report of a long term survival patient and review of literature data

Anaplastic thyroid carcinoma (ATC) is a very rare disease accounting for less than 2% of all thyroid malignancies and associated to a dismal prognosis. The median survival is between 3 to 9 months with less than 10% of patients alive at 3 years after the time of diagnosis. This low cure rate is due to the late clinical presentation as a bulky unresectable tumour mass often associated with synchronous lung metastases (20-50%). A multimodality treatment consisting in a radical surgery followed by radiotherapy and chemotherapy is reported to be associated with better clinical outcomes while young age (< 65 years), tumour size (< 6.5 cm) and absence of distant metastases at time of diagnosis are recognized as strong prognostic factors of survival. We report the case of a 65 year-old man who was referred to our hospital for an ATC which extended to the external right tracheal wall and muscolar layer of esophagus. The patient underwent radical thyroidectomy with bilateral neck dissection followed by 3 cycles of adjuvant chemotherapy (Cisplatin /Epirubicin) and subsequent radiochemotherapy with Cisplatin as radiosensitizer. At more than 6 years since diagnosis the patient is still alive without evidence of local recurrence or distant metastases. Therefore, aggressive multimodality treatment after radical surgery might improve clinical outcomes and perhaps should be tested in prospective clinical trials.

Ruthenium-106 eye plaque brachytherapy in the conservative treatment of uveal melanoma: a mono-institutional experience

BACKGROUND

Traditional treatment for uveal melanoma is the enucleation of the eye with outcomes cosmetically unacceptable and loss of useful vision. Plaque brachytherapy, compared to enucleation, had the advantage to preserve the eye with outcomes cosmetically acceptable and preservation of vision.

PATIENTS AND METHODS

From July 1990 to December 2009 one hundred forty-two (142) patients (51 males and 91 females) with small to medium uveal melanoma were treated with 106Ru plaque brachytherapy. The patients underwent a complete staging before brachytherapy with indirect ophthalmoscopy and ultrasounds. Mean tumour thickness was 3.26 mm (1.6-6 mm). The dose scheduled was 80-100 Gy to the apex with a maximum dose of 800 Gy to the sclera.

RESULTS

One hundred forty-two have been treated, nine patients had lost the follow-up and drop out; 133 patients were assessed. Mean follow-up was 7.7 years (6 months-18 years). The overall survival at 5, 10 and 15 years was 92%, 85% and 78% respectively. Cancer fee survival was 95%, 90% and 83%, respectively at 5, 10 and 15 year. Radiation-induced toxicity was represented in 47 patients with a 5 year actuarial survival rate free from complications of 54%.

CONCLUSIONS

106Ru plaque brachytherapy is a valid approach for treatment of uveal melanoma. This technique is efficacy and safe, with a low toxicity profile.

Radiotherapy and hepatocellular carcinoma: update and review of the literature

Historically radiotherapy has always played a limited role for the treatment of HCC due to the low tolerance of the liver and the subsequent risk of radiation induced liver disease (RILD). Technologist advancements in radiation planning and treatment delivery such as Stereotactic Body Radiotherapy (SBRT) combined with Image Guided Radiotherapy (IGRT) has allowed us to further increase tumor dose while maximally sparing the surrounding not involved liver. Furthermore, together with the growing knowledge of radiobiological models in liver disease, several mono-institutional retrospective and prospective series are reporting very encouraging results. Therefore, radiotherapy might play a significant role for the treatment of unresectable HCC, alone or combined with other locoregional treatment such as transarterial chemoembolisation (TACE). The rationale for studying this technique is really strong and it should be tested in well designed prospective randomized clinical trials.

Chronic anemia due to mitomycin C is drug dose-dependent, normocytic, progressive, related to erythropoietin levels and quantitatively predictable: implications for radiochemotherapy

Mitomycin C (MC) is used as therapy against solid tumors, also combined with other chemotherapeutic agents or radiotherapy. It may cause acute, subacute, or chronic anemia capable of modifying the results of chemo- and radiotherapy. Erythropoietin may be lowered by cancer itself or because of chemoradiotherapy. There are few studies investigating the relationship between erythropoietin and chronic anemia.We prospectively analyzed the chronic anemia and erythropoietin in 38 patients with solid cancer. Patients were 40 to 82 years of age. MC was randomly given every 3 weeks as a single drug at 10 or 20 mg/m². When myelotoxicity occurred the next therapy cycle was delayed until recovery. RBC indices, hemolysis, erythropoietin, liver and kidney function were studied. MC cycles were 136 (3.6 ± 1.4 per pt), 32 being delayed because of myelotoxicity.Hematocrit, hemoglobin and RBC were inversely related to the cumulative dose (r = 0.70 to 0.86; p 0.03 to 0.01) of MC. Other tests remained stable. Anemia occurred almost twofold earlier in the 20 mg/m² group (p=0.049). basal erythropoietin, already lower than in age and sex watched 81 non cancerous subjects (p<0.001), decreased during MC therapy (p<0.01). For each given MC mg/m² a 0.0372 Hb mg/dl reduction occurred. Chronic anemia due to MC is accompanied by erythropoietin reduction. These results can help in designing chemoradiotherapy.

Metabolic responses in non-small cell lung cancer after hypofractionated stereotactic radiotherapy PET and hypofractionated radiotherapy

BACKGROUND

The aim of our study was to evaluate the pattern of local failure after stereotactic body radiotherapy (SBRT) of non small cell lung cancer (NSCLC) lesions relating to different type of 18F-FDG positron emission tomography (PET) response.

METHODS

Thirteen NSCLC patients for a total of 15 lesions (primary early or locally advanced and metastases) underwent PET before and 6 months after SBRT. Maximum standard uptake value (SUVmax) <2.5 was considered as cut off for complete response (CR) while lesion reduction > or =50% with residual value above 2.5 for partial response (PR).

RESULTS

With a median follow up of 30 months pre- and post-SBRT mean SUV max values were 8.2 (range 14.2-3.7) and 2.4 (range 12.9-0), respectively. No "in field recurrence" was observed while 3 cases of "out field recurrence" occurred as regional nodes progression at 7.8 and 14 months after treatment. Three years overall survival, local control and distant metastases free survival were respectively 66.7%, 63.3% and 44.4%. Actuarial 75% and 53.3% 3-year local control, 60% and 40% 3-years distant metastases free survival were observed for complete and partial PET response, respectively, after SBRT. Thereafter, 60% and 50% 3-year overall survival were observed for complete and partial response.

CONCLUSIONS

Clinical results were significantly better for "responder" than "non responder" and for "complete" than "partial response" group. Moreover, our data seem to confirm that a significant subset of patients maintain a low metabolic activity without developing local relapse on longer follow up.

Comparison of the effectiveness and tolerability of intravenous or oral glucocorticoids associated with orbital radiotherapy in the management of severe Graves' ophthalmopathy: results of a prospective, single-blind, randomized study

Eighty-two consecutive patients with moderate-to-severe and active Graves' ophthalmopathy were randomly treated with orbital radiotherapy combined with either oral (prednisone; starting dose, 100 mg/d; withdrawal after 5 months) or iv (methylprednisolone; 15 mg/kg for four cycles and then 7.5 mg/kg for four cycles; each cycle consisted of two infusions on alternate days at 2-wk intervals) glucocorticoids. The two groups did not differ for age, gender, duration of hyperthyroidism and ophthalmopathy, prevalence of smokers, thyroid volume, and pretreatment ocular conditions. Both groups of patients received radioiodine therapy shortly before treatment for Graves' ophthalmopathy. Follow-up lasted for 12 months. A significant reduction in proptosis (from 23.2 +/- 3.0 to 21.6 +/- 1.2 mm in the iv glucocorticoid group, P < 0.0001; and from 23 +/- 1.8 to 21.7 +/- 1.8 mm in oral glucocorticoid group, P < 0.0001) and in lid width (from 13.3 +/- 2.5 to 11.8 +/- 2.2 mm, and from 13.6 +/- 2.0 to 11.5 +/- 1.9 mm, respectively; P < 0.001 in both cases) occurred, with no difference between the two groups. Diplopia significantly improved in both groups: it disappeared in 13 of 27 (48.1%) iv glucocorticoid patients (P < 0.005) and in 12 of 33 (36.4%) oral glucocorticoid patients (P < 0.03). The degree of amelioration of diplopia did not significantly differ between the two groups (P = 0.82). Optic neuropathy improved in 11 of 14 iv glucocorticoid (P < 0.01) and only in 3 of 9 oral glucocorticoid (P = 0.57) patients, with no significant difference in these outcomes. The Clinical Activity Score decreased from 4.5 +/- 1.2 to 1.7 +/- 1.0 (P < 0.0001) in the iv glucocorticoid group and from 4.2 +/- 1.1 to 2.2 +/- 1.2 (P < 0.0001) in the oral glucocorticoid group; final Clinical Activity Score was significantly lower in iv glucocorticoid than in oral glucocorticoid patients (P < 0.01). By self-assessment evaluation, 35 (85.3%) iv glucocorticoid and 30 (73.2%) oral glucocorticoid patients reported an improvement of ocular conditions (P = 0.27). Overall, both treatments produced favorable effects in most patients, but responders in the iv glucocorticoid group (36 of 41, 87.8%) were more than in the oral glucocorticoid group (26 of 41, 63.4%) (P < 0.02). Moreover, iv glucocorticoid treatment was better tolerated than oral glucocorticoid treatment. Side effects occurred in 23 (56.1%) iv glucocorticoid and 35 (85.4%) oral glucocorticoid patients (P < 0.01); in particular, cushingoid features developed in 5 of the former and 35 of the latter patients. One iv glucocorticoid patient had severe hepatitis of undetermined origin at the end of glucocorticoid treatment, followed by spontaneous recovery. In conclusion, high-dose iv glucocorticoid and oral glucocorticoid (associated with orbital radiotherapy) are effective in the management of severe Graves' ophthalmopathy, but the iv route seems to be more effective and better tolerated than the oral route and associated with a lower rate of side effects.

Oral 5-fluorouracil in squamous cell carcinoma of the skin in the aged

Multiple or recurrent squamous cell skin carcinoma is a rare tumor in the aged. These patients are currently treated with 5-fluorouracil (5-FU) cream as a local chemotherapy; in cases in which the disease progresses, few treatments are available. Two reports deal with the treatment of progressive squamous cell skin carcinoma with systemic 5-FU, but in only eight patients age less than 70 years. We prospectively investigated oral 5-FU therapy in 14 consecutive patients (average age 76 1/2 years) with histologically proven squamous cell skin carcinoma. The disease was aggressive, multiple, or recurrent and had not been eradicated by surgery, radiation therapy, topical 5-FU cream, and non-5-FU chemotherapy. Oral 5-FU was administered as mannitol-coated 5-FU tablets at the daily dose of 175 mg/m2 for 3 weeks every 5 weeks. Toxicity, effectiveness, quality of life, and compliance to therapy were evaluated. Total cycles amounted to 55 (range: 2-6, mean: 4 for each patient) at an average dose intensity of 740 mg/m2/week for from 12 to 36 weeks. Only gastrointestinal toxicity World Health grade I occurred. Quality of life and compliance to therapy were 90%. Therapy induced measurable improvement in nine patients (64.3%): two partial remissions (14.3%), three minimal remissions (21.4%), and four arrests of disease (28.6%) with a median duration of 30+ months. The study ended because of a lack of patients. We can conclude that, if elderly patients require chemotherapy because of progressive multiple or advanced squamous cell skin carcinoma, appreciable results may be obtained with oral 5-FU as a single agent.

[Usefulness of the modified Dixon technique associated with gadolinium administration in the characterization of adrenal masses]

We investigated the usefulness of modified Dixon technique at 0.5 T after Gadolinium (Gd) administration in the characterization of adrenal masses. One hundred and one patients (45 men, 56 women; mean age: 60.5 +/- 13.5 years) with 125 adrenal masses found at previous US or CT of the abdomen were submitted to MRI. The study protocol included preliminary T1-weighted, PD and T2-weighted SE images. A bolus of 0.1 mmol/kg Gd-DTPA was administered and then T1-weighted SE scans were acquired with modified Dixon technique (TR = 450-600 ms, TE = 30 ms, 192 x 192 matrix, no craniocaudal presaturation). Acquisition time is twice as long with this technique as with conventional SE sequences, but three sets of T1-weighted images are acquired: conventional SE, fat-suppressed and water-suppressed images. The diagnosis was made at surgery (18 lesions) and fine-needle biopsy (34 lesions), or with stable US follow-up findings for at least 1 year (73 masses). Adrenocortical adenomas (no. 88) were homogeneously isointense to liver in pre- and postcontrast images, but 32 of them exhibited a small high intensity spot in enhanced fat-suppressed images. Malignant lesions and pheochromocytomas (no. 19) had inhomogeneous signal intensity, with relatively higher signal on T2-weighted and Gd-enhanced fat-saturated images. Fat-water images were useful to assess fatty and myeloid components within myelolipomas (no. 7). Benign conditions were distinguished from malignant conditions with 90% sensitivity, 93% specificity and 92.5% diagnostic accuracy. To conclude, modified three-point Dixon technique after contrast agent administration appears to be another useful diagnostic application of midfield MRI to characterize adrenal tissues.

Carbogen and nicotinamide combined with unconventional radiotherapy in glioblastoma multiforme: a new modality treatment

PURPOSE

A new radiotherapy schedule to treat glioblastoma multiforme after surgery, combining nicotinamide and carbogen.

METHODS AND MATERIALS

We analyzed 36 patients with glioblastoma multiforme treated after surgery with radiotherapy, Nicotinamide and Carbogen as follows: 7 patients were treated with accelerated fractionation: two fractions/day, 1.5 cGy/fraction, 6 h interval, 5 days/week, total dose 60 Gy in 4 weeks; 8 patients were treated with the same irradiation scheduling plus Nicotinamide at the dose of 4 g and 2 g in capsules, respectively, 1 h before the first and the second irradiation fraction; 21 patients were treated with accelerated radiotherapy, Nicotinamide, and Carbogen (inhaled 10 min before radiotherapy and during the whole course of irradiation). On the basis of surgical removal our patients were subdivided in three groups: totally resected, with residual tumor <50%, or >50%. Radiotherapy with accelerated fractionation was completed in the scheduled time without side effects on the whole group of patients and Carbogen inhalation did not cause significant change of cardiopulmonar parameters. The toxicity observed was predominant in the gastrointestinal tract and was related to Nicotinamide.

RESULTS

The median survival time (M.S.T.) was 10 months, as reported by others authors with conventional treatment, but in patients without surgical residual tumor and submitted to the complete treatment schedule, the survival at 35 months was around 25%.

CONCLUSIONS

We conclude that this method is feasible with acceptable toxicity; analyzing the survival curves appears to be a trend towards an improvement in survival in the subgroup of patients with gross total removal treated with the combination of Carbogen, Nicotinamide, and accelerated fractionation.

Radiological findings in nine AIDS patients with Rhodococcus equi pneumonia

Rhodococcus equi (R. equi) infections have been incidentally reported as a cause of pulmonary infection in severely immunocompromised hosts, including AIDS patients. Our purpose is to describe the radiological findings in nine AIDS patients with R. equi pneumonia assessed by bronchoalveolar lavage (BAL), biopsies, cultures of sputum, and hemocultures. All patients were examined by chest radiographs and contrast-medium-enhanced chest CT. Dense pulmonary consolidations with or without cavitations accounted for the most striking radiological patterns. Chest CT also revealed six mediastinal involvements, strongly mimicking a lymphoma. Two of them had multiple bilateral pulmonary nodular opacities. Pleural effusion was not identified. Although intensive therapies were administered, seven among nine patients died within few months. In an AIDS patient living in a rural area or exposed to horses and presenting these radiological patterns, the possibility of R. equi pneumonia should be considered in the differential diagnosis along with other infectious diseases or lymphomas.

[Adrenal myelolipomas: their magnetic resonance assessment]

Adrenal myelolipomas are rare nonfunctioning neoplasias consisting of a variable mixture of mature fat and bone marrow tissue. In the present study MRI appearances of six adrenal myelolipomas are presented. MR exams of six patients in which a conclusive diagnosis of adrenal myelolipomas was reached by means of surgery (1 case), US-guided fine-needle biopsy (3 cases) and typical diagnostic imaging in association with stability on US follow-up for at least two years (2 cases) were retrospectively evaluated. MR sequences protocol included pre- and post-contrast (Gd-DTPA) SE T1-weighted images and SE proton density and T2-weighted images. Five adrenal masses were examined by means of combination of gadolinium administration with a SE T1-weighted modified three-point Dixon technique. Three different MR structural patterns were pointed out: a) homogeneous hyperintense masses on T1-weighted images with intermediate signal on T2-weighted images, suggestive for predominantly fat-containing lesions (2 cases); b) heterogeneous masses with fat intensity areas and hyperintense areas on T2-weighted images and on post-contrast T1-weighted images, suitable for mixed fatty and myeloid elements (2 cases); c) nodules hypointense to the liver on T1-weighted images and hyperintense on T2-weighted images and after gadolinium administration, suggesting tumors primarily composed of myeloid cells (2 cases). A precise determination of fatty and myeloid elements within the lesions was observed by means of "water" and "fat" images provided by modified three-point Dixon technique. In conclusion, MRI allows to determine the various structural components of myelolipomas and therefore appears to be a very reliable technique in the diagnosis and characterization of the different structural patterns of this rare adrenal pathology.

[Inflammatory aneurysm of the abdominal aorta: TC assessment of the postoperative course]

This study was aimed at investigating CT reliability in the postoperative follow-up of inflammatory abdominal aortic aneurysms (IAAA) previously treated with prosthesis positioning. During the last 5 years, 13 male patients operated on for subrenal IAAA with intraluminal prosthesis positioning, were followed-up with CT. All CT images were reviewed by three radiologists to assess prosthesis integrity; the possible presence of intraluminal thrombosis was investigated, together with pre/postprosthetic dilatation and the involvement of inferior vena cava, ureters and third duodenal segment. The prostheses were intact and no signs of intraluminal thrombosis were depicted in all patients; a periprosthetic dilation of abdominal aorta associated with parietal thrombosis was observed in one patient. Nine patients exhibited mild-moderate thickening of the original aortic or iliac walls; the inferior vena cava was involved in 6 of them and the left ureter in one. Contact with the III duodenal segment was found in 3 patients. In conclusion, CT proves to be a reliable technique in the postoperative follow-up of IAAA, yielding accurate information about the prosthesis, the aortoiliac walls and retroperitoneal structures. Moreover, in our experience late postoperative complications were not of major clinical importance.

[Occult post-traumatic osteochondral changes in the knee. Assessment with magnetic resonance]

Occult posttraumatic osteochondral injuries of the knee are bone and/or cartilage abnormalities which cannot be detected on plain radiographs. This study was aimed at investigating MR capabilities in the detection and characterization of occult bone and/or cartilage injuries in symptomatic patients with previous musculoskeletal trauma of the knee. We retrospectively selected 60 patients (45 men and 15 women; mean age: 33.1 +/- 16.3 years; range: 12-70 years) from our patients submitted to MRI of the knee during a 3-year period. These patients had a history of previous acute musculoskeletal trauma, negative conventional radiographs and MR signal intensity changes of the osteochondral structures. MR protocol included: SE T1-, PD and T2-weighted images and GRE T2-weighted images; imaging planes were the sagittal, the axial and the coronal planes. Plain radiographs and MR images were interpreted by three experienced readers in musculoskeletal radiology. Our reviewers confirmed normal conventional radiographic findings in all the patients enrolled in the study. According to morpho-topographic and signal intensity patterns, we identified three types of occult posttraumatic injuries: bone contusions or bone bruises or occult subcortical fractures (n 30), osteochondral injuries (n 26) and chondral injuries (n 4). A bone contusion was defined as a typical subcortical area of signal loss, with various shapes, on T1-weighted images and increased signal intensity on T2-weighted images. The cortical bone and articular cartilage below were normal in all cases. On the contrary, osteochondral lesions presented an association of cartilage and bone injuries with the same M(R) signal abnormalities. Thinning and focal interruptions of the cortical bone were demonstrated in all cases. Chondral lesions were characterized by a sudden discontinuity and irregularity of cortical bone outline and by small high-intensity spots in cartilage thickness on T2-weighted images, in the absence of any subchondral bone abnormality. Finally, 42 of 60 patients (70%) had an anterior cruciate ligament tear and 28 (45%) had a medial meniscus tear. In conclusion, MRI appears a very useful tool in the detection and characterization of the different types of occult bone and/or cartilage injuries of the knee in the patients with previous acute trauma. Moreover, the correct and early diagnosis of an osteochondral lesion does affect prognosis.

Synthetic thymic fraction 5: effects of high dose administration on circulating lymphocytes in patients

The synthetic pentapeptide (Arg-Lys-Asp-Val-Tyr; TP-5) corresponding to the active site of the hormone thymopoietin, was given at the dose of 300 mg/m2/day (1 day), higher than the usually administered, to a group of 27 immunodepressed patients in order to determine the tolerability and the immunomodulatory activity. The examination of a series of hematological parameters including counts of differential clustering of lymphocytes by cytofluorimetric analysis was performed 24 hr and 48 hr after treatment, and repeated at different intervals up to 14 days after treatment. TP-5 caused a significant increase of circulating lymphocytes and particularly of CD3+CD4+ and CD3+CD8+ subtypes, peaking at 48 hr and maintaining the increased values up to the last examination on day 14 from treatment. A faster increase (zenith at 24 hr) was observed for CD4+ cells, in comparison with CD8+ cells (zenith at 48 hr). The number of patients that increased total lymphocytes or lymphocyte subset after treatment ranged between 52.6 (CD4+ cells) and 69.2% (NK cells), whereas about 7.7% (NK cells) to 36.9% (CD4+ cells) remained unchanged and a smaller amount of 10.5% (CD4+ and CD8+ cells) or 23.1% (NK cells) showed a decrease greater than 10% of their respective basal value. No significant relationship between responders and non-responders can be found on the basis of previous treatments, cancer type, sex or age.

A phase II study of oral fluorouracil for gastrointestinal cancer

Prolonged exposure to 5-fluorouracil (5-FU) is effective for gastrointestinal malignancy (GIM) and it is considered synergistic or additive to concurrent radiotherapy. Oral 5-FU (OF) could represent an easy therapy. The present study prospectively tested the toxicity and effectiveness of OF in GIM by means of 5-FU mannitol-coated tablets (MCT) at 275 or 225 mg/m2/day according to the patients age (65 years cut-off) for a period of 4 weeks every 7 weeks. Also the drug given over 5 days a week for 4 weeks was studied to assess OF toxicity over a time corresponding to that used in standard radiotherapy. Quality of life (LQ) was analyzed. Patients were 27 individuals (20 males), aged 43-70 years, pretreated with radiotherapy (four patients) or i.v. 5-FU-based chemotherapy (five patients), and with progressive malignancy of colorectum (six patients), stomach (five patients), pancreas (four patients) and liver (two patients). The total number of cycles was 91 and 16 patients had more than two cycles. Myelotoxicity was consistently absent; other toxicities greater than WHO grade 1 were: nausea (grade 2 in four patients), diarrhea (grade 2 in six and grade 3 in 11), palmar erithema (grade 2 in one), brown-turning skin (grade 2 in one) and CNS (grade 2 in one). Diarrhea was less frequent (p = 0.007) in gastric and in colorectal than in pancreas and liver cancer patients. In the 10 patients given the drug of 5 days a week, diarrhea was practically absent. LQ was above 90%. Fourteen patients (51%) had total arrest of disease, and 2 among 16 colorectal cancer patients had PR (12.5%). In conclusion, the MCT-OF was tolerated and as effective as the classic i.v. 5-FU at nonmyelosuppressive dose. The MCT-OF dose recommended for further studies is 275 mg/m2/day (or 225 above 65 years) for 4 weeks followed by a 2 week rest period.

Non-autoimmune hyperthyroidism associated with isolated bilateral ocular lymphoma mimicking Graves' disease with ophthalmopathy: a cause of misdiagnosis

A very rare association of non-autoimmune hyperthyroidism due to nodular goiter with isolated bilateral non-Hodgkin's ocular lymphoma is described. A 66-year-old woman presented with bilateral proptosis, marked periocular swelling, conjunctival hyperemia and chemosis, severe extraocular muscle impairment with diplopia. Thyroid function tests showed normal free thyroid hormone concentrations with undetectable serum thyrotropin levels. Patient was placed on antithyroid drug treatment, ocular conditions deteriorated. More than two years later, when first seen in our institution, orbital CT scan showed the presence of a retro-ocular mass that, at biopsy, proved to be B-cell non-Hodgkin's lymphoma, apparently with no localization in other sites. Thyroid evaluation revealed subclinical hyperthyroidism due to an autonomous thyroid nodule in the left lobe of the gland. Radiotherapy of the orbit was followed by a dramatic regression of lymphoma, but further staging some months later showed involvement of several abdominal lymph node structures. This case underscores the need of a thorough diagnostic work-up of ocular disease resembling Graves' ophthalmopathy, even when it is bilateral and associated with overt or subclinical hyperthyroidism.

[Hematoma and fat necrosis of the breast: mammographic and echographic features]

The mammary gland is a common site for traumas which often lead to the formation of intraglandular hematomas. The abundance of fat tissue in this gland accounts for the relatively high frequency of fat necrosis and self-digestion of fat by lipases after traumas, i.e., fat necrosis, cystosteatonecrosis, lipophagic granuloma. Broadly speaking, hematomas are easily diagnosed by both mammography and US. However, scarring and the formation of lipophagic granulomas due to hemorrhage result in the diagnostic features which are difficult to distinguish from malignant breast nodules. In our study, we examined 40 patients with a clinically detected nodule and/or hematoma with skin retraction or thickening related to trauma. In 26 women, the trauma dated to 7-60 days before our observation, in 4 women to a year before and in 4 other women to more than two years before; 6 women had undergone breast surgery in the last two years. Mammography and US were performed at first observation; later, every six months, the patients were followed-up with US and a single targeted radiograph. The mammographic features at first observation were classified as follows: a single nodule (9 patients, 22.5%), a patchy nodule (7 patients, 17.5%), diffusely increased gland density (8 patients, 20%), radiolucent nodules (10 patients, 25%), nodules with calcifications (6 patients, 15%), no findings (2 patients, 5%). US demonstrated a fluid collection in 12 patients (30%), a solid nodule in 6 patients (15%), a cystic nodule in 10 patients (25%), diffuse parenchymal abnormalities in 4 patients (10%), calcified nodules in 6 patients (15%) and no findings in 2 patients (5%). US-guided needle biopsy was performed in 10 patients. Five patients underwent surgical biopsy: 4 had a lipophagic granuloma and the other one a chronic inflammation. Follow-up at two years allowed hematoma evolution to a scar or cystosteatonecrosis to be monitored. To conclude, the authors analyze the diagnostic problems related to the different mammographic and US patterns trying to suggest, on the basis of their own experience, the best imaging follow-up for breast trauma patients.

Anaplastic thyroid-carcinoma - a retrospective clinical and immunohistochemical study

We reviewed 34 patients with histologically proven anaplastic thyroid carcinoma, representing 3.1% of all thyroid carcinomas treated from 1970 to 1992 in our Institution. Mean age at diagnosis was 63.1+/-10.3 years. Initial treatment consisted of near total thyroidectomy in 14 patients, partial thyroidectomy in 6 and no more than a biopsy in 14. After surgery 11 patients received external radiotherapy associated with chemotherapy (R+C), 8 patients had only chemotherapy (C), and 11 patients had only radiotherapy (R). Two patients, both in the group treated with R+C, are still alive, with a survival from the diagnosis of 23 and 26 months, respectively. Mean survival of the group treated with R+C (16.1+/-8.2 months) was significantly higher than that of patients treated only with C (6.2+/-4.4 months; p<0.01) or only with R (5.1+/-2.6 months; p<0.0004). In the group treated with R+C, patients submitted to near total or partial thyroidectomy had a mean survival of 15.0+/-8.8 months, similar to that of patients who had only a biopsy (17.2+/-7.9 months), suggesting that the outcome was affected by post-surgical therapy rather than by surgery per se. Twenty-two tumors were also assayed by immunohistochemistry for p53 and PCNA expression. p53 was expressed in 16/22 (72.2%) cases, with no correlation with sex, age, presence of differentiated component or survival. Comparing tumors with <30% or >30% p53 positive cells a tendency to longer (but not significant) survival was found in tumors with lower p53 expression. PCNA was expressed in all cases, with a percentage of positive cells ranging from 15% to 90%, and was not correlated with sex, age, differentiation, or survival. A positive correlation was found between PCNA and p53 expression (r=0.58; p=0.0039). In conclusion, our data indicate that in anaplastic thyroid carcinoma the use of combined R+C has some advantages with respect to single therapy. As in other aggressive malignancies; p53 and PCNA expression is increased irrespective of the response to therapy or the outcome.

Pharmacokinetics and tolerance of nicotinamide combined with radiation therapy in patients with glioblastoma multiforme

The pharmacokinetic properties of nicotinamide and its tolerance were studied in seven patients affected by glioblastoma multiforme and treated with two fractions per day of radiation therapy. Nicotinamide was given orally at two daily doses of 4 g and then 2 g separated by a 6-h-interval. The treatment was well tolerated in almost all patients and had no effect on blood pressure, cardiac rhythm or body temperature. Pharmacokinetic analysis showed peak plasma levels (Cmax) above 100 mg/l 45 minutes after the administration of both doses. This was followed by a biexponential decay of plasma concentrations with a thermal half life of 9.4h. Tumours were irradiated 1 hour after each drug dose to match with drug Cmax in plasma, and although it is too early to evaluate the tumour response, the drug levels achieved should be sufficient to improve radiation therapy.

Carbogen breathing in patients with glioblastoma multiforme submitted to radiotherapy. Assessment of gas exchange parameters

It has been reported that carbogen breathing yields a remarkable increase of radiosensitivity in murine tumour models. Hence, application of carbogen might be promising in radiotherapy of human tumours. We describe a method to increase arterial oxygenation and to ensure stability of O2 and CO2 during carbogen breathing in patients with malignant disease. We measured in 6 patients with histologically proven intracranial glioblastoma multiforme arterial blood gases, inspired and expired gas concentrations and vital signs either baseline and during carbogen breathing. The highest values of arterial oxygenation were achieved after 10 min of carbogen breathing and they remained stable up to 15 min. In none of our patients was N2 wash-out from the lungs completed in 15 min of carbogen breathing. In conclusion, carbogen breathing increased arterial oxygenation in patients with intracranial malignant diseases. The system used is reliable and of practical use. Monitoring of expired gas concentrations is highly recommended.

Phase II trial of 5-fluorouracil and the natural l isomer of folinic acid in the treatment of advanced colorectal carcinoma

Between February 1991 and July 1992, 79 previously untreated patients with metastatic colorectal carcinoma were enrolled in a phase II study of combined 5-fluorouracil (5-FU) and l-folinic acid (FA). 5-FU 370 mg/m2/day was administered for 5 consecutive days as an intravenous (i.v.) bolus injection preceded by l-FA 100 mg/m2/day with the same administration modality. Treatment was given every 4 weeks until progression. 79 patients were evaluable for toxicity and 64 for response. 2 patients (3%) achieved a complete remission and 8 (12.5%) a partial remission, 33 (52%) had stable disease and 21 patients (33%) had progressive disease. Median duration of remission was 32.5 weeks and median survival for all evaluable patients was 64.5 weeks. Substantial to severe side-effects occurred in 39% of patients. Dose-limiting toxicity (grade 3-4) was mainly diarrhoea (18%) and mucositis (15%). Nausea/vomiting, cutaneous toxicity, leucopenia, alopecia and conjunctivitis of grade 3-4 occurred respectively in 6, 4, 2.5, 1 and 1% of cases. Toxicity appeared to be substantially similar to that characteristic of combined 5-FU and the chiral mixture of d,l-FA. Efficacy was within the range of that observed with the 5-FU/d,l-FA combination, although at the lower level.

Cisplatin-cyclophosphamide-mitomycin combination chemotherapy with supportive care versus supportive care alone for treatment of metastatic non-small-cell lung cancer

BACKGROUND

Patients with TNM stage IV non-small-cell lung cancer have short survival times. Previous controlled studies comparing chemotherapy and supportive care for the treatment of this type of cancer have not given consistent results, have included patients with different disease stages, and have rarely reported drug dose intensity.

PURPOSE

The present trial was designed to assess the safety and the effect on survival of supportive care alone versus chemotherapy with cisplatin, cyclophosphamide, and mitomycin combined with appropriate supportive care in patients with stage IV non-small-cell lung cancer.

METHODS

Patients (n = 102) with stage IV non-small-cell lung cancer were randomly assigned to one of two treatment regimens. The combined modality group (52 patients) received supportive care along with cisplatin (75 mg/m2), cyclophosphamide (400 mg/m2), and mitomycin (10 mg/m2) given intravenously at 3-week intervals. The supportive care group (50 patients) received supportive care alone. Randomization was stratified on the basis of histology (squamous versus nonsquamous cell carcinoma), performance status (Karnofsky), and weight loss (during the 6 months preceding randomization). The two groups were well matched for age and sex. Survival analysis was performed after the last patient died.

RESULTS

The median number of chemotherapy cycles was 3.5 per patient. Mean weekly delivered doses of drugs were as follows: cisplatin, 22.1 mg/m2; cyclophosphamide, 118 mg/m2; and mitomycin, 2.9 mg/m2. Toxic effects due to chemotherapy were generally mild, but peripheral neuropathy and hematologic and renal toxic effects were observed. In the supportive care group, mean survival was 6.1 months (median, 4.0 months); six patients lived at least 12 months and two lived at least 18 months. In the combined modality group, mean survival was 11.3 months (median, 8.5 months); 20 patients lived at least 12 months, 13 lived at least 18 months, and five lived at least 24 months. Difference in survival was statistically significant (P < .0001). Survival was directly related to initial performance status in both groups (P < .01) and was significantly (P < .01) longer for patients with squamous cell carcinoma than for those with nonsquamous cell carcinoma.

CONCLUSIONS

The combination of supportive care and cisplatin-cyclophosphamide-mitomycin therapy offers a survival advantage over supportive care alone in patients with advanced non-small-cell lung cancer.

IMPLICATIONS

Metastatic non-small-cell lung cancer, generally considered to be unresponsive or marginally responsive to chemotherapy, can be treated with chemotherapy, with an expectation of prolonging patient survival. Although the results of the present study are encouraging, clinical research should continue to be directed toward developing more effective treatments for this disease.

Eosinophilic gastroenteritis: possible role of sonography in diagnosis and follow-up

Eosinophilic gastroenteritis (EGE) is a rare disease of unknown etiology. The clinical and radiological diagnoses have to be confirmed by histological examination of biopsy specimens. The authors now present a case of a 19-year-old man with recurrent epigastric pain and vomiting, whose sonographic features and eosinophilia suggested the diagnosis of EGE, which was subsequently confirmed by histology. Sonographic follow-up permitted an effective evaluation of the evolution of the disease under steroid therapy.

[The echographic aspects of prostatic carcinoma before and after radiation treatment]

The authors evaluated the US patterns of 50 prostatic carcinomas before and after radiation therapy, analyzing the correlation of US patterns with histologic (bioptic) findings and with treatment outcome. Before radiation therapy, 28 tumors were hypoechoic, 8 were isoechoic and 14 mixed. In 18 of 28 hypoechoic carcinomas, the lesion showed a progressive increase in echogenicity, becoming completely isoechoic 9-18 months after the end of treatment. In this group of patients the final response to treatment was complete in 17 cases and partial in 1; during the follow-up (24-90 months, mean 48 months) neither local recurrences nor distant metastases were observed. In 10 of 28 hypoechoic carcinomas, a hypoechoic area of variable size was still clearly recognizable within the lesion after a minimum period of 18 months since the end of treatment. Nine of these patients underwent histology and persistent carcinomas were found in 8 of them; one patient developed distant metastases. In the group of isoechoic and mixed carcinomas, no significant differences were observed in the US patterns relative to treatment outcome. Persistent prostatic carcinoma after radiation therapy seems not to affect its US pattern. If the tumor is hypoechoic before treatment, the persistence of a hypoechoic area within the lesion 18 months after the end of treatment must be regarded as a possible therapeutic failure and histologically verified. On the contrary, the evolution of the lesion toward isoechogenicity is usually related to a favorable outcome. If the tumor is isoechoic or mixed before treatment, a reliable US evaluation is not possible and the correct assessment of the response to treatment can only be made with multiple biopsies.

[Prostatic carcinoma: the importance of echographic monitoring of gland volume after radiotherapy]

Prostatic volume modifications were retrospectively analyzed by means of serial endorectal US in 50 patients affected with prostatic adenocarcinoma previously submitted to external radiotherapy. A progressive reduction in glandular volume (of low, medium, and high grade) was observed in 48/50 patients respectively within 3 months, between 3 and 6 months, and 6-9 months after treatment. After 9 months only lesser modifications were observed. A statistically significant correlation (p less than 0.05) was found between volume decrease percentage and histologic grading of the tumor, but not with its stage. Within the groups of patients affected with similar-grade neoplasms, a statistically significant difference (p less than 0.05) was observed, relative to the decrease rate of prostatic volume, between the patients with complete response and those with partial or no response. US monitoring of prostatic volume after radiotherapy, if correlated with histologic grading, can yield early predictive elements as to treatment outcome, thus contributing to select non-responsive patients to submit to biopsy and, if necessary, to therapeutic alternatives or combinations. Longer-term studies are needed to prove its effectiveness, to prognostic purposes, in the single patient.

High-dose intravenous immunoglobulin treatment in Graves' ophthalmopathy

We have evaluated the efficacy of high-dose intravenous immunoglobulin treatment in Graves' ophthalmopathy, and have carried out a prospective randomized clinical trial, including a single-blind evaluation, whereby 14 patients were assigned to two different treatment groups: 7 patients were treated with intravenous immunoglobulin and orbital radiotherapy (Group 1) and 7 patients were given intravenous immunoglobulin alone (Group 2). The results of the intravenous immunoglobulin treatment were also compared with those obtained in a Historical Control Group (12 patients) treated with systemic methylprednisolone and orbital irradiation. Degree of ocular involvement and response to treatment were assessed by ophthalmopathy index. The mean initial and final ophthalmopathy index showed no significant difference among the three groups. Comparison between the mean initial and final ophthalmopathy index showed a statistically significant reduction (p less than 0.005) in all three groups, the observed changes being confirmed by orbital computerized tomography in Groups 1 and 2. Corticosteroid treatment was associated with major and minor side effects, while no important adverse reactions were observed during intravenous immunoglobulin treatment. Even considering our results as preliminary, we conclude that intravenous immunoglobulin treatment is effective and safe in improving Graves' ophthalmopathy.

[The combined therapy of Basedow's ophthalmopathy with retrobulbar radiotherapy and i.v. immunoglobulins. The preliminary results]

The most frequently used medical treatment of Graves' ophthalmopathy is the combination of orbital irradiation and systemic corticosteroid. In this study the effectiveness of "high dose intravenous immunoglobulin" (IVIG) in Graves' ophthalmopathy treatment is explored. 11 patients were treated with orbital radiotherapy combined with systemic corticosteroid (Group 1), while 10 patients were treated with the combination of orbital irradiation and IVIG (Group 2). The therapeutic effect was assessed by an ophthalmopathy index based on the American Thyroid Association, classification of ocular changes of Graves' ophthalmopathy. All signs and symptoms of endocrine ophthalmopathy improved significantly in both groups. The mean ophthalmopathy index decreased from 7.0 +/- 1.3 to 3.4 +/- 1.5 in Group 1, and from 7.0 +/- 1.8 to 3.0 +/- 2.1 in Group 2. Statistical analysis showed no significant difference between Group 1 and 2 mean initial and final ophthalmopathy index, and a significant difference between initial and final ophthalmopathy index both in Group 1 and 2. While side effects were present in Group 1 treated with systemic corticosteroid, no side effect was observed in patients treated with IVIG. These preliminary results suggest that IVIG is safe and effective in the treatment of Graves' ophthalmopathy.

Orbital cobalt irradiation combined with retrobulbar or systemic corticosteroids for Graves' ophthalmopathy: a comparative study

Combined therapy with systemic corticosteroids and orbital cobalt radiotherapy has been shown to be an effective treatment of severe Graves' ophthalmopathy. The potentially serious side-effects of large doses of systemic corticosteroids prompted us to evaluate the use of retrobulbar corticosteroids instead of systemic corticosteroids. Forty-four patients with active Graves' ophthalmopathy were given orbital cobalt irradiation (total dose 2000 rads) and retrobulbar methylprednisolone acetate (14 bilateral injections at 20-30 d intervals). The degree of ocular involvement and responses to treatment were evaluated by numerical scoring (ophthalmopathy index, OI) and clinical assessment. Excellent or good responses were observed in 11 out of 44 patients (25%), 24 (55%) showed slight responses, and no change was found in 9 patients (20%). The initial OI mean score was 5.9; the final score was 3.2, with a change of -2.7 (P less than 0.001). Regression or partial improvement was observed in most cases (35/44, 80%) with soft tissue changes, and in all 9 cases with sight loss due to optic neuropathy. Proptosis, corneal lesions and extra-ocular muscle involvement were less responsive, since regression or partial improvement was observed in 39% (12/31), 50% (8/16) and 31% (13/42), respectively. No major side-effects were observed. The effects of this type of therapy and those obtained by combined therapy with systemic corticosteroids and orbital radiotherapy were compared in two groups of 30 patients each, randomly assigned to either treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Orbital cobalt radiotherapy and systemic or retrobulbar corticosteroids for Graves' ophthalmopathy

Orbital radiotherapy and corticosteroids are two well-established medical treatments for severe Graves' ophthalmopathy. In this report we analyze the results obtained by the combination of orbital radiotherapy and systemic or retrobulbar corticosteroids in patients with severe Graves' ophthalmopathy. Orbital cobalt radiotherapy was carried out by a cobalt unit, delivering a total of 2,000 rads to each eye in 10 daily doses. Systemic corticosteroid treatment was started with 70-80 mg methylprednisolone/day for 2-3 weeks with subsequent progressive reduction of the dose until discontinuation of the drug after 5-6 months. Retrobulbar corticosteroid therapy was performed by 14 bilateral injections of 40 mg methylprednisolone acetate at 20- to 30-day intervals. Results were evaluated both on clinical grounds and by numerical scoring (ophthalmopathy index, OI). Excellent or good responses were obtained in the majority of 72 patients by combined treatment with orbital cobalt radiotherapy and systemic corticosteroids. Soft tissue changes, newly developed eye muscle dysfunction and optic neuropathy showed the most beneficial effects from treatment, whereas proptosis, corneal lesions and long-standing eye muscle abnormalities responded to a lesser extent. The results of a controlled clinical trial showed that the combined treatment was more effective than the administration of systemic methylprednisolone alone. Because relevant side effects of systemic corticosteroid therapy were observed in 4 cases, the clinical validity of retrobulbar corticosteroids in substitution for systemic corticosteroids was evaluated in 44 patients. Excellent or good responses were observed in 25% of these patients, slight responses being obtained in 55% and no change in 20%.(ABSTRACT TRUNCATED AT 250 WORDS)