Comparison of standard and individually planned infradiaphragmatic fields in irradiation of retroperitoneal lymph nodes.

PURPOSE: In prophylactic irradiation of infradiaphragmatic lymphatic nodes (LN), the width of the paraaortic and pelvic field is given by a line joining the tips of the transverse processes of the 11th thoracic to the 4th lumbar vertebrae. Then the field boundary follows a straight line to the most lateral point of the acetabulum seen on the simulation film. Another method of setting the field border is to project the lateral contours of the large abdominal vessels from T(1)-weighted coronal MR images of the abdomen onto the simulator radiographs and add a 2-cm margin along the so delineated vessels. In our study, we compared both methods as to full enclosure of paraaortic and pelvic lymphatics or nodal miss. MATERIAL AND METHODS: Abdominal CT scans of 81 patients with involvement of paraaortic lymph node regions with LN sizes not exceeding 2.5 cm were examined. The distance from the center of the appropriate vertebra to the center of the most lateral lymph node was referred to the transverse process as well as to the outside contour of the aorta on the left and the vena cava on the right side. Respectively, the LN were measured referenced to the iliac vessels from the 5th lumbar through to the 2nd sacral vertebra. At the level of the hip joint the distance was measured from the midline as determined by a line through the center of the sacrum, perpendicular to a line connecting center of both femoral heads. RESULTS: Our measurements showed that lymph nodes do occur (1) lateral to the transverse processes of the thoracic and lumbar vertebrae as well as (2) outside the 2-cm safety margin from the lateral contour of the large abdominal vessels. CONCLUSION: These data clearly show that the traditional fields for radiation of infradiaphragmatic lymphatic nodes have not been large enough to enclose almost all retroperitoneal and pelvic lymph nodes with certainty. We recommend an expansion of the fields.

Angiotropic large B-cell lymphoma misdiagnosed as urosepsis with multiple organ dysfunction syndrome.

A 53-year-old woman with a history of cervical carcinoma 14 years ago, treated with hysterectomy and radiation therapy, was admitted to the intensive care unit with severe SIRS (systemic inflammatory response syndrome) progressing to shock, multiple organ failure and death within 5 d. Bilateral hydronephrosis diagnosed by sonography and an enlarged left kidney with suspected abscesses verified in a CT-scan suggested the diagnosis of urosepsis. However, multiple microbiological examinations remained sterile. Despite surgical treatment and aggressive intensive care, she died in unresponsive shock. Pathohistologically, an angiotropic large B-cell lymphoma, a rare diffuse intravascular neoplasm of lymphoid origin, was diagnosed. The patient's history of abdominal radiation therapy 14 years earlier as well as multiple negative microbiological specimens in a patient with suspected urosepsis should have initiated the search for a non-infectious cause of the disease.

[Standard versus individually planned irradiation field in radiotherapy of infradiaphragmatic lymph node sites]. / Standard- versus individuell geplantes Bestrahlungsfeld bei Radiotherapie infradiaphragmaler Lymphknotenstationen.

PURPOSE: In prophylactic irradiation of infradiaphragmatic lymphatic nodes, the width of the paraaortic and pelvic field is given by a line joining the tips of the transverse processes of the 11th thoracic to the 4th lumbar vertebra from where the field boundary follows a straight line to the most lateral point of the acetabulum as seen in simulation film. Another way to build the field border is to project the lateral contours of the large abdominal vessels from T1-weighted coronal MR images of the abdomen on the simulator radiographs and add a 2-cm margin along the vessels delineated. In our study, we compared both methods as to full enclosure of paraaortic and pelvic lymphatics or nodal miss. MATERIAL AND METHODS: Abdominal CT scans of 81 patients with involvement of paraaortic lymph node regions were examined with maximum lymph node sizes of 2.5 cm. The distance from the center of the appropriate vertebra to the lateral lymph node contour referring to the transverse process as well as to the outside contour of the aorta on the left and the vena cava on the right side, respectively, the iliac vessels were measured from T12 through S1. At the level of the hip joint the measurement point was given by the caput femoris. RESULTS: Our measurement prove that 10% of the lymph nodes were found lateral from the transverse processes of the thoracic and lumbar vertebras and 12% outside the 2-cm safety margin from the lateral contour of the large abdominal vessels. CONCLUSION: Our data show, that the customary fields for infradiaphragmatic lymphatic nodes have so far not been able to enclose all retroperitoneal and pelvic lymph nodes with certainty.

Fine needle aspiration cytodiagnosis of subacute (de Quervain's) thyroiditis in an endemic goitre area.

Between 1977 and 1989 252 fine needle aspirates (FNAs) of the thyroid from patients with a clinical suspicion of subacute granulomatous (de Quervain's) thyroiditis were examined in the Department of Pathology of the University of Innsbruck, Austria. In the same period 31 cases with preoperative FNA were diagnosed histologically as subacute thyroiditis. Only in three of these cases were the cytological features of de Quervain's thyroiditis found in the preoperative FNA. However, in 13 of these 31 cases a cytological suspicion of malignancy was obtained. Subsequent histological examination revealed an acute phase inflammation of de Quervain's thyroiditis in most of these cases. We conclude that an accurate FNA diagnosis of de Quervain's thyroiditis, particularly in the acute stage, may cause difficulties due to a lack of typical features and the appearance of atypical thyroid follicular cells. For the cytopathologist, accurate clinical information relating to the possibility of de Quervain's thyroiditis is essential if unnecessary surgery is to be avoided.

In vitro and in vivo evaluation of iodine-123-Ro 16-0154: a new imaging agent for SPECT investigations of benzodiazepine receptors.

The flumazenil analogue, Ro 16-0154, a benzodiazepine partial inverse agonist, has been labeled by halogen exchange to enable SPECT investigations of central benzodiazepine receptors in the human brain. The purified 123I-Ro 16-0154 was found to be stable in rat brain preparations and to be metabolized in rat liver preparations. Its pharmacologic properties were comparable to those of flumazenil. The biodistribution in rats (1 hr postinjection) resulted in a high brain-to-blood ratio of 16. Clinical studies revealed images of the benzodiazepine receptor density in the brain. Since the receptor labeling was markedly reduced by injection of flumazenil, it was considered to be specific. Storage defects due to pathologic cerebral blood flow and changed receptor density were detected; this shows the potential usefulness of the substance for diagnostic purposes, e.g., the differential diagnosis of various forms of epilepsy.

[Malignant hemangioendothelioma of the thyroid gland. Pathology, clinical aspects and prognosis]. / Das maligne Hämangioendotheliom der Schilddrüse. Pathologie, Klinik und Prognose.

Malignant hemangioendothelioma (MHE) of the thyroid still constitutes a relatively important part of our surgical material, with 23 MHE (2.0%) among 1153 primary thyroid tumors diagnosed between 1952 and 1987 (biopsy material of the Innsbruck Pathology Institute). 18 of these cases were investigated immunohistochemically; in 14 cases the data on clinical findings and follow-up were complete. Immunohistochemical results confirm the endothelial origin of this tumor and allow MHE to be definitively distinguished from anaplastic carcinomas. Follow-up and prognosis are determined by the aggressive nature of local tumor spread. 13 patients died after a median survival period of 2.4 months (R: 1.2-9.4). Only one patient has remained alive since over 4 1/2 years now. An improvement of the hitherto dismal prognosis is thought to depend on early tumor diagnosis and an ameliorated combined modality treatment.

Fine needle aspiration cytodiagnosis of anaplastic carcinoma and malignant haemangioendothelioma of the thyroid in an endemic goitre area.

Between 1970 and 1987, 20,028 fine needle aspirates (FNA) of the thyroid have been examined in the Department of Pathology of the University of Innsbruck, Austria. During this period 92 cases of anaplastic carcinoma and 16 cases of malignant haemangioendothelioma (MHE) of the thyroid were diagnosed. Forty-three out of these 108 highly malignant tumours of the thyroid underwent FNA pre-operatively (39.1%). Thirty-seven FNA contained numerous cells of a highly malignant tumour. Five specimens (11.8%) contained only necrotic material and inflammatory cells. In one case of an anaplastic carcinoma no malignant cells could be demonstrated in FNA. We conclude that pre-operative FNA of highly malignant thyroid tumours may contribute substantially to subsequent clinical management.