18F-FDG PET/CT, cytoreductive surgery and intraperitoneal chemohyperthermia for the therapeutic management in peritoneal carcinomatosis: a pilot study / 18F-FDG PET/TC, cirugía citorreductora y quimiohipertermia intraperitoneal para el tratamiento terapéutico de la carcinomatosis peritoneal: estudio piloto

Aim. Peritoneal carcinomatosis is a common evolution of neoplasms and the terminal stage of disease. A new therapeutic technique, based on the total surgical removal of peritoneal lesions (peritonectomy procedure - PP) combined with the intraperitoneal chemohyperthermia (IPCH), has been developed. Proper patient selection is mandatory for optimizing the results of treatment. The aim of this study was to investigate the role of [(18)F]fluoro-2-deoxy-d-glucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) in patients with peritoneal carcinosis selected to undergo PP and IPCH. Furthermore, we aimed to identify characteristic patterns of abdominal18F-FDG uptake and to correlate these patterns with available anatomic findings after surgery. Methods. Patients with either histologically confirmed peritoneal carcinosis or suspected upon clinical follow-up and/or imaging findings were prospectively submitted to pre-surgery 18F-FDG PET/CT scan. Only those patients without evidence of extra-peritoneal metastases at PET/CT scan were treated with PP and IPCH. Results. 11 patients with peritoneal carcinomatosis (5 colorectal, 4 ovarian, 1 pancreatic) and 1 unknown primitive cancer, were eligible for the study. In all cases PET/CT scan showed multiple peritoneal implants. In 6 out of 11 cases (54%) metastases were evidenced by 18F-FDG PET/CT: 2 cases with liver metastases; 1 case with bone metastases; 3 patients with lymph-node lesions. Two distinct imaging patterns, with focal or diffuse increased 18F-FDG uptake, were recognized. Conclusions. PP + IPCH of patients selected by 18F-FDG PET/CT seems to be safe and feasible. PET/CT scan appears as a reliable tool for the detection, characterization of peritoneal implants with potential impact in the therapeutic management of these patients (AU)

Objetivo. La carcinomatosis peritoneal es una evolución común de las neoplasias y constituye el estadio terminal de la enfermedad. Se ha desarrollado una nueva técnica, basada en la extirpación quirúrgica de las lesiones peritoneales (procedimiento de peritonectomía - PP), combinada con quimiohipertermia intraperitoneal (IPCH). La adecuada selección de los pacientes es primordial, a fin de optimizar los resultados del tratamiento. El objetivo de este estudio fue investigar el papel de la tomografía de emisión de positrones con [(18)F]fluoro-2-deoxy-d-glucosa/tomografía computarizada (18F-FDG PET/TC) en pacientes con carcinomatosis peritoneal, seleccionados para someterse a PP e IPCH. Además, tratamos de identificar los patrones característicos de la captación abdominal de 18F-FDG y correlacionar dichos patrones con los hallazgos anatómicos disponibles tras la cirugía. Métodos. Se realizaron exámenes 18F-FDG PET/TC de manera prospectiva, y previamente a la cirugía, a los pacientes con carcinomatosis peritoneal histológicamente confirmada, o sospechada mediante seguimiento clínico y/o hallazgos de imagen. Solo puede tratarse con PP y IPCH a aquellos pacientes que no reflejen evidencia de metástasis extraperitoneales en los exámenes PET/TC. Resultados. Se seleccionó para el estudio a 11 pacientes con carcinomatosis peritoneal (5 colorrectales, 4 ováricas, una pancreática) y un cáncer primitivo desconocido. En todos los casos, el examen PET/TC reflejó múltiples implantes peritoneales. En 6 de los 11 casos (54%) las metástasis fueron evidenciadas mediante 18F-FDG PET/TC: 2 casos con metástasis hepáticas, un caso con metástasis óseas, y 3 pacientes con lesiones ganglionares. Se reconocieron 2 patrones de imagen distintos, con aumento de captación focal o difusa de 18F-FDG. Conclusiones. La combinación PP + IPCH de los pacientes seleccionados mediante 18F-FDG PET/TC parece ser una técnica segura y factible. La PET/TC se revela como una herramienta fiable para la detección y caracterización de los implantes peritoneales, con un impacto potencial sobre el tratamiento terapéutico de dichos pacientes (AU)

(18)F-FDG PET/CT, cytoreductive surgery and intraperitoneal chemohyperthermia for the therapeutic management in peritoneal carcinomatosis: A pilot study.

AIM: Peritoneal carcinomatosis is a common evolution of neoplasms and the terminal stage of disease. A new therapeutic technique, based on the total surgical removal of peritoneal lesions (peritonectomy procedure - PP) combined with the intraperitoneal chemohyperthermia (IPCH), has been developed. Proper patient selection is mandatory for optimizing the results of treatment. The aim of this study was to investigate the role of [(18)F]fluoro-2-deoxy-d-glucose Positron Emission Tomography/Computed Tomography ((18)F-FDG PET/CT) in patients with peritoneal carcinosis selected to undergo PP and IPCH. Furthermore, we aimed to identify characteristic patterns of abdominal(18)F-FDG uptake and to correlate these patterns with available anatomic findings after surgery. METHODS: Patients with either histologically confirmed peritoneal carcinosis or suspected upon clinical follow-up and/or imaging findings were prospectively submitted to pre-surgery (18)F-FDG PET/CT scan. Only those patients without evidence of extra-peritoneal metastases at PET/CT scan were treated with PP and IPCH. RESULTS: 11 patients with peritoneal carcinomatosis (5 colorectal, 4 ovarian, 1 pancreatic) and 1 unknown primitive cancer, were eligible for the study. In all cases PET/CT scan showed multiple peritoneal implants. In 6 out of 11 cases (54%) metastases were evidenced by (18)F-FDG PET/CT: 2 cases with liver metastases; 1 case with bone metastases; 3 patients with lymph-node lesions. Two distinct imaging patterns, with focal or diffuse increased (18)F-FDG uptake, were recognized. CONCLUSIONS: PP+IPCH of patients selected by (18)F-FDG PET/CT seems to be safe and feasible. PET/CT scan appears as a reliable tool for the detection, characterization of peritoneal implants with potential impact in the therapeutic management of these patients.

Recent advances in the prevention of anthracycline cardiotoxicity in childhood.

The prevention of anthracycline cardiotoxicity is particularly important in children who can be expected to survive for decades after cancer chemotherapy with these agents. The rapid increase in clinical toxicity at doses greater than 550 mg/m(2) of doxorubicin (DOX) has made this dose the limiting one in order to avoid DOX-induced cardiac failure. However, arbitrary dose limitation is inadequate because of variability of individual tolerance. Decreasing myocardial concentrations of anthracyclines (ANT) and their metabolites and schedule modification of administration can reduce anthracycline cardiotoxicity. Anthracycline structural analogues such as epirubicin, idarubicin and mitoxantrone have been used in clinical practice. In addition, the liposomal ANT, which can be incorporated into a variety of liposomal preparations, are a new class of agents that may permit more specific organ targeting of ANT, thereby producing less cardiac toxicity. Much interest has focused on the administration of ANT in conjunction with another agent that will selectively attenuate the cardiotoxicity. As is known, the ANT chelate iron and the DOX-iron complex catalyzes the formation of extremely reactive hydroxyl radicals. Many agents, such as dexrazoxane (DEX), able to remove iron from DOX, have been investigated as anthracycline cardioprotectors. Clinical trials of DEX have been conducted in children and significant short-term cardioprotection with no evidence of interference with antitumor activity has been demonstrated. Whether long-term cardiac toxicity will also be avoided in surviving patients has not yet been determined.

[The effectiveness and tolerability of losartan and effect on left ventricular mass in patients with essential hypertension]. / Efficacia e tollerabilità del losartan ed effetto sulla massa ventricolare sinistra in pazienti con ipertensione essenziale.

The purpose of our study was to evaluate the antihypertensive efficacy, tolerability and effects on left ventricular mass of losartan over 10 months in patients with essential hypertension. Losartan is a selective angiotensin II receptor-antagonist. The whole study comprised 89 hypertensive patients who were randomized, at baseline, to 10 months of double-blind once daily treatment with losartan 50 mg (L Group, n = 49, mean age 55 +/- 13 years) or hydrochlorothiazide 25 mg (HCTZ Group, n = 40, mean age 56 +/- 10 years). Routine hematology, blood chemistry and urinalysis were performed before and after 5 and 10 months; standard electrocardiography, ambulatory non invasive 24-hours blood pressure monitoring, M-mode echocardiography, psychometric test and quality of life evaluation were obtained from all the patients before and after 10 months. In patients non responding after 4 weeks, hydrochlorothiazide 25 mg or losartan 50 mg was added in the L Group and in the HCTZ Group, respectively (L-HCTZ Group). The results showed good tolerability and a significant mean systolic and diastolic blood pressure reduction in all groups (L Group from 157/96 +/- 9/7 to 137/85 +/- 9/5 mmHg, p < 0.001; HCTZ Group from 158/97 +/- 11/8 to 150/91 +/- 9/7 mmHg, p < 0.003; L-HCTZ Group from 159/98 +/- 9/5 to 141/88 +/- 6/4 mmHg, p < 0.001), although L and L-HCTZ treatment were more effective during 24 hours than HCTZ. Moreover, a remarkable reduction in left ventricular mass index was obtained after 10 months only in the L Group (from 138.4 +/- 26.2 to 127.2 +/- 23.1 g/m2, p < 0.04) and in the L-HCTZ Group (from 140 +/- 20.3 to 125.5 +/- 20.1 g/m2, p = 0.126). Finally, in patients treated with losartan the results of psychometric test significantly improved (L Group: p < 0.05; L-HCTZ Group: p < 0.05) and a positive remarkable change in the quality of life was observed (L Group: p < 0.05; L-HCTZ Group: p = 0.083). In conclusion, losartan in monotherapy or in association with hydrochlorothiazide, was well tolerated, respected the quality of life, and produced a significant and remarkable reduction in blood pressure and left ventricular mass in hypertensive patients.

[Complete congenital atrioventricular block: a case report and review of the literature]. / Blocco atrioventricolare completo congenito; descrizione di un case e revisione della letteratura.

The description of a clinical case of a newborn with congenital complete atrioventricular block, due to maternal connective-tissue disease, is the occasion for a review of the literature. The clinical elements allowing an early diagnosis and treatment of these patients, who often need a permanent pacemaker, are described.

[Myocardial infarct without Q wave in the elderly: diagnostic evaluation using vectorcardiography]. / Infarto miocardico senza onda Q in età geriatrica: valutazione diagnostica con tecnica vettorcardiografica.

The diagnosis of previous non-Q wave myocardial infarction by standard electrocardiographic investigation is uncertain, particularly in elderly patients because of concomitant disease. We have studied 31 elderly patients (aged 63-72 years) with a diagnosis of non-Q wave myocardial infarction between 1-6 months after this acute event. The patients underwent clinical-anamnestic examination, standard electrocardiography, vectorcardiography according to the Frank system and M-mode and 2-D echo-cardiography with continuous and pulsated Doppler. The ECG showed ST-T anomalies in 12 patients (38.7%) whereas the VCG showed anomalies of QRS-loop normal convexity in 27 patients (87%) and 16 of these (51.6%) showed bites criteria (duration > or = 10 msec, voltage > or = 0.1 mV, present at least on two planes). By echocardiography, regional hypo-akinesia was observed in 19 patients (61.3%). Although bites are not only present in myocardial infarction, they indicate an interruption of myocardial gradual electric activation, compatible with fibrous areas, and should be evaluated as a part of the clinical-anamnestic, laboratory and instrumental data.

[Clinical usefulness of quantitative two-dimensional echocardiographic analysis of segmental kinesis of the left ventricle in monitoring of patients with neoplasms treated with anthracyclines]. / Utilitá clinica dell'analisi ecocardiografica bidimensionale quantitativa della cinesi segmentaria del ventricolo sinistro nel monitoraggio dei pazienti neoplastici trattati con antracicline.

To determine whether serial quantitative two-dimensional echocardiographic analysis of left ventricular wall motion could be effective in selecting patients in whom anthracycline treatment must be stopped, 26 patients (18 M and 8 F, mean age 10 +/- 3, range 6 to 16 years) with malignancy, receiving doxorubicin or daunomycin were followed up. Left ventricular regional wall motion abnormalities were detected in 11 patients (42%), while left ventricular ejection fraction at rest (although progressively decreased from baseline value [63 +/- 2 vs 55 +/- 2%; p = 0.0001]) was still in normal range. The following distribution of left ventricular contraction abnormalities was noted: septal, anteroseptal and posteroseptal akinesis with posterior wall hypokinesis in one patient; septal, anteroseptal and posteroseptal akinesis with anterolateral free-wall hypokinesis in another; septal, anteroseptal and posteroseptal hypokinesis in four; lateral and posterolateral free-wall hypokinesis in one; septal, anteroseptal, posteroseptal and posterior hypokinesis in four. The drug was discontinued in only two patients with akinesis, since we regarded this contraction abnormality as a predictive index of more serious and extensive myocardial damage. We began to detect hypokinesis when cumulative doses of doxorubicin or daunorubicin were 155-420 mg/m2 and 270-285 mg/m2 respectively, while akinesis was seen at doses of 395 mg/m2 of body-surface area for doxorubicin and 575 mg/m2 for daunorubicin. Follow-up examination was conducted six months after the last dose of anthracycline, and improvement or recovery of left ventricular regional wall motion abnormalities was noted in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[The diagnosis of the cardiologic risk in patients destined for lung removal surgery]. / Diagnosi del rischio cardiologico in pazienti destinati a chirurgia di exeresi polmonare.

The expanding role of pulmonary surgery could be expected to lead to an increase in postoperative morbidity and mortality unless surgical risk factors are identified by means of a careful preoperative assessment. A careful and intelligent preoperative evaluation can reduce the morbidity and mortality after lung resection by ensuring the appropriate selection of patients and a rational choice of operative procedure. To evaluate the cardiologic risk in patients undergoing lung resection, 18 of them underwent a diagnostic protocol based on non invasive analysis including ECG, stress test with basal and exercise blood gas analysis, M- and B-mode and Doppler echocardiography. This protocol was able to identify possible cardiologic risk in the perioperative period without applying invasive techniques and with a good cost-benefits ratio.

[Diagnosis of delayed upper left ventricular activation: limits of electrocardiography and usefulness of vectorcardiography]. / La diagnosi di ritardo di attivazione ventricolare sinistra superiore: limiti dell'elettrocardiografia e utilità della vettorcardiografia.

The electrocardiographic (ECG) diagnosis of delayed ventricular left superior activation (DVLSA) is often difficult and uncertain, even when all the criteria proposed in clinical literature are fulfilled. The vectorcardiography (VCG) always permits an accurate diagnostic evaluation because the contour of the QRS loop describes successively the various phases of ventricular depolarization. Sensitivity and specificity of ECG in diagnosing DVLSA have been calculated referring to VCG analysis. The QRS loop initial forces orientation in the frontal plane, a VCG highly reliable criterion, was considered especially significant for this purpose. The sensitivity and specificity of ECG were, respectively, 75% and 95%. Moreover, this study has confirmed the low performance of frontal plane QRS axis criterion and the necessity of polyparametric method for a correct ECG-VCG diagnosis of DVLSA. However, the VCG is more reliable than ECG in such diagnosis because it allows thoroughly to analyze QRS-loop initial forces.