New category of probable invasive pulmonary aspergillosis in haematological patients.

The European Organization for Research and Treatment of Cancer and the Mycosis Study Group (EORTC-MSG) radiological definitions of invasive pulmonary aspergillosis (IPA) may lack diagnostic sensitivity. We evaluated applying less restrictive radiological criteria, when supported by specific microbiological findings, to define IPA in acute myeloid leukaemia (AML), lymphoproliferative diseases (LD) and allogeneic stem cell transplant (allo-SCT) patients. Overall, 109 consecutive episodes of proven/probable IPA in 56 AML, 31 LD and 22 allo-SCT patients diagnosed from February 2006 through to January 2011 were considered. IPA was diagnosed with EORTC-MSG criteria (control group, 76 patients) or without prespecified radiological criteria (study group, 33 patients). The latter differed from the former by the inclusion of patients with pulmonary infiltrates not fulfilling the three EORTC-MSG IPA specific findings of dense, well-circumscribed lesions with or without halo sign, air crescent sign or cavity. All the analysed clinical and mycological characteristics, 3-month response to antifungal therapy and 1- and 3-month cumulative survival were comparable in the control and study groups in AML, LD and allo-SCT patients. Seventeen of 33 (51.5%) patients of the study group fulfilled EORTC-MSG radiological criteria at subsequent imaging performed a median of 15 days (range, 6-40 days) after documentation of the pulmonary infection. Our study seems to confirm the possibility of revising the EORTC-MSG criteria by extending the radiological suspicion of IPA to less specific chest computerized tomography scan findings when supported by microbiological evidence of Aspergillus infection in high-risk haematological patients.

NMR exposure sensitizes tumor cells to apoptosis.

NMR technology has dramatically contributed to the revolution of image diagnostic. NMR apparatuses use combinations of microwaves over a homogeneous strong (1 Tesla) static magnetic field. We had previously shown that low intensity (0.3-66 mT) static magnetic fields deeply affect apoptosis in a Ca2+ dependent fashion (Fanelli et al., 1999 FASEBJ., 13;95-102). The rationale of the present study is to examine whether exposure to the static magnetic fields of NMR can affect apoptosis induced on reporter tumor cells of haematopoietic origin. The impressive result was the strong increase (1.8-2.5 fold) of damage-induced apoptosis by NMR. This potentiation is due to cytosolic Ca2+ overload consequent to NMR-promoted Ca2+ influx, since it is prevented by intracellular (BAPTA-AM) and extracellular (EGTA) Ca2+ chelation or by inhibition of plasma membrane L-type Ca2+ channels. Three-days follow up of treated cultures shows that NMR decrease long term cell survival, thus increasing the efficiency of cytocidal treatments. Importantly, mononuclear white blood cells are not sensitised to apoptosis by NMR, showing that NMR may increase the differential cytotoxicity of antitumor drugs on tumor vs normal cells. This strong, differential potentiating effect of NMR on tumor cell apoptosis may have important implications, being in fact a possible adjuvant for antitumor therapies.

Ear involvement in acute promyelocytic leukemia at relapse: a disease-associated 'sanctuary'?

Extramedullary (EM) involvement occurs infrequently in acute promyelocytic leukemia (APL) and usually involves skin and CNS. We describe seven patients (four observed at a single institution) who relapsed in various sites of the auditory apparatus, including the external canal and middle ear (temporal bone). Front-line treatment included ATRA and chemotherapy (six patients) or chemotherapy alone (one patient). Three patients had concomitant hematologic relapse, two had molecular relapse and two were in hematologic and molecular remission when ear localization was documented. Local symptoms that stimulated further diagnostic studies included ear bleeding/discharge in the first patient, but were mild in the others (hypoacusia, five patients; earache, two patients). Ear involvement by leukemia was documented by histological and/or molecular studies after local surgery in five cases, and by CT scan or NMR in the remaining patients. We suggest that the ear might represent a specific sanctuary for disease involvement in APL.

Thrombotic thrombocytopenic purpura: prospective neurologic, neuroimaging and neurophysiologic evaluation.

BACKGROUND AND OBJECTIVES: Neurologic symptoms are present in 60% of patients with thrombotic thrombocytopenic purpura (TTP) on initial examination and ultimately develop in about 90% of cases during the course of the disease. Despite central nervous system involvement being frequent, abnormalities in the brain of patients with TTP are infrequent on neuroimaging (CT/MRI) and neurophysiologic (EEG) evaluation, often reversible and mainly limited to symptomatic stages of the disease. The aim of our study was to establish the value of a complete neurologic screening as part of the work up of TTP. DESIGN AND METHODS: We prospectively evaluated 16 TTP patients, performing serial neurologic, neuroimaging and EEG examinations, independently of the presence of an objective central nervous system involvement. RESULTS: Our study shows that a complete neurologic evaluation is of modest help in improving the diagnosis of TTP, but may be useful for the neurologic management. INTERPRETATION AND CONCLUSIONS: Accurate neuroimaging and, especially, EEG evaluation and monitoring allowed us to identify patients who could benefit from anticonvulsive therapy, avoiding the unnecessary administration of the latter. The prognostic utility of complete neurologic screening in TTP remains to be conclusively demonstrated in larger prospective neurologic studies.

Acute myeloid leukemia and lung cancer occurring in a chronic lymphocytic leukemia patient treated with fludarabine and autologous peripheral blood stem-cell transplantation.

An increased incidence of different malignancies associated to chronic lymphocytic leukemia (CLL) has been reported. The association of CLL and acute leukemia is a rare event described in < 1% of CLL, the type of acute leukemia being either from the lymphoid or more often from the myeloid lineage. The coexistence of acute myeloid leukemia (AML) and CLL in the same patient has been occasionally reported. Most of these cases have been associated with the administration of chemotherapy or radiotherapy for CLL, suggesting that the former may be a secondary leukemia. On the other hand, CLL could precede, but could also be diagnosed at the same, or delayed time as AML, suggesting the presence of other leukemogenic factors. We describe the exceptional development of AML and lung cancer in a patient with previously diagnosed CLL in minimal residual disease status after fludarabine treatment followed by autologous peripheral blood stem-cell transplantation.

Hodgkin's disease during pregnancy: diagnostic and therapeutic management.

OBJECTIVES: To evaluate the possibility that women affected by Hodgkin's disease (HD) during their second or third trimester of pregnancy can safely carry their pregnancy to term. METHODS: From 1986 to 1997, 6 women came to our Center during the second trimester of pregnancy and were diagnosed as having HD. Three of these 6 patients were treated with chemotherapy before delivery and 3 of them were kept under observation and started treatment after delivery. RESULTS: All 6 women gave birth to a healthy female. CONCLUSIONS: The pregnancy does not worsen the course of the illness and does not compromise long-term clinical remission and recovery.

Sternoclavicular joint disease in psoriatic arthritis.

The radiological and tomographic aspects of the sternoclavicular joint were examined in 10 patients with psoriatic arthritis to evaluate better how this joint was affected using different radiological techniques. Imaging of the sternoclavicular joint showed that computed tomography provides a better visualisation of erosions, subchondral cysts, and sclerosis than standard radiography and conventional linear tomography.

[NMR of phakomatoses]. / La RNM nelle facomatosi.

23 patients affected by phakomatoses were studied with NMR, including tuberous sclerosis (11 cases), Sturge-Weber's disease and Von Recklinghausen's neurofibromatosis (6 cases). SE sequence was used performing T1-WIs with TR = 350-750 ms and TE = 20-30 ms and T2-WIs with TR = 1500-2100 ms and TE = 50-100 ms. Tuberous sclerosis was characterized in each case by the presence of hiperintense areas in T2-WIOs, associated in 9 cases to subependimal microcalcifications. Sturge-Weber-disease showed: cerebral or lobar emiatrophia, abnormal vascularization and cortical calcifications. Cerebral neurofibromatosis was characterized by extra-assial tumors, associated in 4 cases to gliomas of the optical pathways. The AA. conclude that NMR is the choice examination in the evaluation of phakomatoses.

[Nuclear magnetic resonance in pathology of the central nervous system in children]. / La risonanza magnetica nucleare nella patologia del sistema nervoso centrale in età pediatrica.

The following study aims to establish the role of MRI in investigation of the CNS in children. 300 patients are examined, 220 affected by CNS disease. The examinations were performed using SE sequence (T1-weighted images TR = 350-700 ms TE = 30-60 ms; T2-weighted images TR = 1500-2000 ms TE = 50-200 ms). In most of the patients general anesthesia or sedation was necessary. Patients are divided into groups based on pathology and the advantages and shortcomings of MRI are discussed. In conclusion, MRI should be the technique of choice in the evaluation of malformative affections, white matter and inflammatory disease; it should be complementary to CT and angiography in tumors and vascular pathology.

[Use of computerized tomographic iodoventriculography in the diagnosis of intraventricular cysticercosis]. / Utilità della TC iodoventricolografia nella diagnosi della cisticercosi intraventricolare.

It has been reported a case of intraventricular cysticrecosis of the fourth ventricle. The Authors discuss the utility of CT iodoventriculography with reference to the diagnosis of such disease.

Pneumocephalus and tension pneumocephalus after posterior fossa surgery in the sitting position: a prospective study.

Thirty patients subjected to posterior fossa surgery in the sitting position were evaluated postoperatively by CT scans in order to assess the true incidence of pneumocephalus and subsequent development, if any, of tension pneumocephalus. This prospective survey shows that the postoperative incidence of intracranial air was 100%, while no progression towards tension pneumocephalus producing severe neurological deterioration was observed. It can thus be claimed that, although the sitting position may favour the development of tension pneumocephalus also other factors contribute to its pathogenesis. Finally, neither nitrous oxide nor temperature play any significant role in the development of this complication.

[Computerized tomography in the evaluation of neurologic complications of preventive therapy of acute lymphatic leukemia]. / La tomografia computerizzata nella valutazione delle complicanze neurologiche della terapia profilattica della leucemia linfatica acuta.

The authors examined by means of computed tomography 12 patients with ALL treated with radiotherapy combined with cytostatic chemotherapy and presenting clinical signs of CNS damage. The CT scan findings are correlated with clinical signs, mainly distinguishing between symptoms of either diffuse or focal damage. An attempt is made in order to evaluate the possible role of Methotrexate and X-Ray therapy in the pathogenesis of the CNS lesions.

The orbicularis oculi response after hemispheral damage.

The corneal and blink reflexes were evaluated in 20 normal subjects and in 30 patients with motor deficits secondary to unilateral hemispheral lesions of vascular origin. In the normal population there were no differences between subjects below and subjects above 50 years of age. In the patients the reflex evoked by electrical stimulation of the cornea of the clinically affected side was depressed in 24 out of 30 cases. The depression mainly affected the afferent branch of the circuit, which triggers both homolateral and contralateral orbicularis oculi discharge (afferent abnormality). In three cases the depression was exerted concomitantly on the efferent branch (afferent and efferent abnormality) and only in one case was it limited to the efferent branch (efferent abnormality). The late R2 component of the blink reflex was depressed in 15 out of 30 patients. The early R1 component was slightly facilitated on the affected side. The changes of the corneal reflex and of the R2 component of blink reflex were similar, but the blink reflex had a greater safety factor. The patients with an abnormal corneal reflex had more extensive damage than had the patients with normal corneal response, as shown by computer tomography, but the site of the lesion was comparable in the two groups. Conduction through the brain stem circuits mediating the orbicularis oculi response is normally under pyramidal facilitatory influences while facial motoneurons are subjected to pyramidal inhibition. After pyramidal damage the transmission of impulses in the brain stem was slowed down, ultimately to a degree that abolished the reflex. Removal of pyramidal inhibition on facial motoneurons is probably the basis of the slight facilitation of the R1 component of the blink reflex.