Controversies in diagnostic approaches to the indeterminate follicular thyroid nodule.

In this paper we review the controversies in diagnostic approaches to follicular thyroid nodules with indeterminate cytology. The authors consider some of the controversies surrounding the indeterminate follicular thyroid nodule, including the definition and the postoperative outcome. Among the techniques that may improve preoperative diagnostic accuracy are large needle aspiration biopsy and immunohistochemistry for galectin-3.

Axillary sentinel lymph nodes in breast cancer: a single lymphatic pathway drains the entire mammary gland.

AIM: To report the pattern of lymphatic mapping following intrasubdermal injections of radiocolloid and of blue dye in different sites of the breast. METHODS: Prior to surgery 137 breast cancer patients underwent intrasubdermal injection of 30-50 MBq 99mTc-colloidal albumin over the tumour site (ISI group). Ten minutes before surgery, 2 ml patent blue was injected in the subareolar area (SAI group) in 117/137 patients, while 20 patients received intrasubdermal blue-dye in the quadrant opposite the tumour site (OQI group). The different injection routes were considered concordant when the hottest sLN was also blue. RESULTS: In 134/137 patients radiocolloid drained to one or more axillary nodes, while blue nodes were found in 98/117 SAI patients and in 17/20 OQI patients. Multiple hot nodes were found in 63/134 cases and multiple blue nodes in 35/115. In patients in whom both tracers reached the axilla, the hottest node was also blue in 108/115 cases (93/98 SAI and 15/17 OQI patients). In the seven discordant cases, the hottest node was not blue, but in two cases the blue node was also radioactive. CONCLUSIONS: Superficial lymphatic drainage from the breast most frequently merges to a single axillary lymph node, irrespective of the site of tracer injection. In a few cases different injection sites identify different, often closely interconnected sLNs.

Dislocation of small bowel volume within box pelvic treatment fields, using new "up down table" device.

PURPOSE: To present the impact of a novel minimization device, the up down table (UDT), on the volume of small bowel included within a 4-field pelvic irradiation plan. METHODS: A polystyrene bowel displacement standard mold was created and added to a customized vacuum cushion (Vac Lok) formed around the abdomen and legs of each patient in the prone position. Two hundred seventy-seven consecutive patients with pelvic malignancies treated with the UDT device were compared with 1 historic series (68 cases) treated at our division. Small bowel contrast dyes at the time of simulation were used in all patients. RESULTS: The average volume of small bowel within the planning target volume (high-dose volume, calculated with Gallagher method) was 100 cm(3) (median 49 +/- 114) in the series treated with standard box technique and 23 cm(3) (median 0 +/- 64) in the series treated with the UDT (p < 0.001). The average volume of small bowel included in any isodose (any-dose volume) was 505 cm(3) (median 447 +/- 338) and 158 cm(3) (median 69 +/- 207), respectively (p < 0.001). The incidence of G1, G2, and G3 acute enteric toxicity (Radiation Therapy Oncology Group criteria) in the UDT series was 16%, 15%, and 1.5%; in the standard box technique, it was 28%, 25%, and 3%, respectively (p < 0.05). The incidence of acute enteric toxicity directly correlated with the irradiated small bowel volume. In the UDT series, the 5-year actuarial incidence of G3 chronic enteric toxicity was 1.8%. The setup procedures, analyzed in 18 cases, revealed no systematic errors and a standard deviation equal to +/-5 mm for random errors. CONCLUSIONS: The UDT technique is comfortable, inexpensive, highly reproducible, and permits an almost full bowel displacement from standard radiotherapy fields.

Immobilization devices between routine and quality assurance.

AIMS AND BACKGROUND: To evaluate the impact of immobilization devices in reducing treatment errors and delivering high doses to limited target volumes. The clear advantages are matched with quality control necessity. METHODS: The Authors examine two fundamental aspects of the topic: 1) the immobilization of head and neck and the relative implications in reducing the skin-sparing at the build-up region; 2) the rationale and management of quality assurance procedures in the immobilization devices utilization, with a particular reference to pelvic radiation treatment. CONCLUSIONS: The immobilization devices utilization certainly leads to an optimization in the execution of radiation treatments. Nevertheless, in the choice for their routine use, the Authors suggest to follow some "conceptual rules" with the aim of successfully matching each of the discussed aspects connected with their utilization.

Radiotherapy in the elderly with lung carcinoma: the experience of the Italian "Geriatric Radiation Oncology Group".

One hundred ninety-six patients aged > or = 70 years, with non small-cell lung carcinoma and no evidence of metastasis on staging, observed over a 6-month period in 20 Italian Radiotherapy Centers, were analyzed in order to assess indications for treatment, tolerance of radiotherapy (assessed in terms of completion of planned doses and toxicity), and quality of life using the Performance Status and a concise activity of life test. Of the 196 patients studied in 20 Italian Centers, 182 (98%) underwent radiotherapy, 109(60%) of whom with radical intent and 73 (40%) with palliative intent. Of 179 assessable patients undergoing radiation treatment, 163 (91%) completed the treatment as originally planned. Of the 64 assessable patients who completed palliative radiotherapy, relief of symptoms was observed in a percentage ranging from 78% to 86%. Analysis of parameters assessing the quality of life, showed no significant differences in general and functional conditions, as assessed before and upon completion of radiotherapy.

Radiation therapy of bone metastases in the elderly: a multicentric survey of the Italian "Geriatric Radiation Oncology Group".

External radiation therapy (ERT) has been reported to be the elective treatment of symptomatic bone metastases. A nationwide survey on the use of ERT in elderly patients with bone metastases has been conducted by the Italian "Geriatric Radiation Oncology Group" with a three-fold aim: define the state of the art of ERT, evaluate the analgesic efficacy and identify the optimal dosage and schedule, if any. 347 patients aged 70 or over, treated in 29 different institutions for a period of six months were analyzed. Conclusive results were: a significant pain relief achieved shortly after ERT completion; an improvement in the quality of life; a decrease in the dose of analgesics and consequently, a reduction in treatment-related costs. Unfortunately the optimal treatment schedule remains unidentified; ERT was neither aggressive nor toxic in this series of elderly patients.

Quality assurance procedures in radiotherapy of rectal neoplasms.

Major uncertainties which impact on pre- or postoperative radiotherapy of rectal neoplasms and operational measures taken to lower the risks in prescription, planning, delivery and follow-up of radiotherapy, are examined. In prescription, major problems related with the selection of treatment dose and volumes, are considered. In planning, irradiation techniques and systems for intestinal loop displacement from treatment site, are analyzed. In dose delivery, methods used to ensure treatment reproducibility and support care, are examined. Finally, in follow-up procedures used in the evaluation of disease progress, late side-effects, and life quality, are discussed.

[Quality control in radiotherapy. Computerized management of the "total" oncologic follow-up]. / Il controllo di qualità nella radioterapia. La gestione informatizzata del follow-up oncologico "totale".

Since 1992, in the Rovigo Radiotherapy Department, we have computerized the management of oncologic follow-up to minimize all "non-medical" times during the different phases. System efficiency was analyzed and the results follow: 1) the absolute number of follow-up visits, compared with the standard reference year (1991), shows that we were able to double our "performance" within the time unit, with the same "resources"; 2) the average number of follow-up visits per malignancy within 6 months of the diagnosis and then every seventh month, approximated to the number of scheduled visits; 3) the number of cancer relapses in the patients who could not be submitted to a specific antiblastic treatment (a reversed efficacy indicators) progressively reduced from 13.7% to 12.6% and 10.4% respectively, in 1992, 1993 and 1994; 4) secondary lesion diagnosis, an indirect efficacy parameter, was found to be accurate; 5) the cost of follow-up per malignancy reduced, in 6 months' periods, especially in the cancers with easier clinical diagnosis (-32% for breast cancer, -50% for head and neck cancer), by as much as 43,639,000 Italian liras in 1994 (relative to 1993); 6) the scheduled visits began only 12 minutes late, as studied on 2,346 visits. To conclude, the computed management of medical records improves our Department's efficiency, with no additional cost for the patients.

[Cyclophosphamide and total lymph node irradiation as conditioning for bone marrow transplant in severe aplastic anemia]. / Ciclofosfamide (CTX) ed irradiazione linfonodale totale (TNI) come condizionamento al trapianto di midollo osseo (BMT) nelle anemie aplastiche gravi (AAG).

Personal experience is outlined with a preparative regimen consisting of total nodal irradiation (TNI) and cyclophosphamide in patients with severe aplastic anemia undergoing bone marrow transplantation (BMT). Nine patients (median age 23) previously having blood transfusions received BMT at the BMT Center in Pesaro. All patients were prepared for transplantation with cyclophosphamide 50 mg/kg/day (day -6, -5, -4, -3), and 7.5 Gy total nodal irradiation day -1, with a dose rate of 26 cGy/m. Six out of eight evaluable transplanted patients are still surviving 3 to 23 months with a median follow-up of 16.5 months. This preoperative regimen is extremely effective in decreasing rejection following transplantation for severe aplastic anemia. Future investigation must be aimed at the elimination of graft-versus-host-disease and control of fatal infections.

[Natural history of cancer of the breast. Probability of developing bone metastases]. / Storia naturale del cancro della mammella. Probabilità di sviluppo di metastasi ossee.

The incidence of bone metastases in 448 patients with breast cancer was evaluated. 374 out of 448 cases showed negative bone scan at initial clinical staging and were followed up during a period of at least 5 years with serial bone scans. The results of bone scans were compared on the basis of clinical stage (according to the International UICC classification), of lymph node involvement (groups N0, N + ) and of complementary therapy after surgery (radiotherapy v/s hormone-chemotherapy). Cumulative probability of bone metastases in breast cancer showed a linear trend with annual mean rate of 5% (1st yr 2%; 2nd yr 8%; 3rd yr 15%; 4th yr 22%; 5th yr 29%; 10th yr 59%). Statistical analysis in different clinical stages showed mild difference not statistically significant, neither in lymph node involvement (NO v/s N + ) nor in complementary therapy (radiotherapy v/s hormone-chemotherapy).

[Laser-photo-radiotherapy in the treatment malignant tumors]. / La laserfotoradioterapia nel trattamento dei tumori maligni.

Photoradiation therapy or, as more recently defined, photodynamic therapy (PDT) has been effective in the treatment of several kinds of cancers, above all of the skin, lung, esophagus and bladder. It is based on the preferential retention by tumor and photosensitizing properties of certain porphyrins. We began to investigate this technique experimentally in 1978 and clinically in september 1982, with report of the initial results in 38 patients in 1985. In this paper we describe our more recent experience of PDT in 18 patients affected by different tumors and treated with a new double argon-dye laser system. These tumors included 8 carcinomas of the esophagus, 5 basal cell skin cancers, 2 carcinomas of the lung, 2 squamous cell carcinomas of the oral cavity and 1 early gastric cancer. Clinical results and technical problems of PDT are discussed.

Sleeve lobectomy in the treatment of bronchogenic carcinoma.

From 1980 to 1985, 44 sleeve lobectomies were carried out in patients with bronchial cancer. Sixteen patients received preoperative radiotherapy. Perioperative mortality was 6.8%. There were seven anastomotic complications (three fistulae and four stenoses) and two recurrences at the anastomosis. Overall actuarial survival was 45% at four years. These results seem to suggest that sleeve lobectomy should be considered an elective rather than a compromise procedure and a viable alternative to pneumonectomy. Preoperative radiotherapy neither increases complications nor has a negative effect on outcome. It contributes towards reducing local recurrences and maximizes tissue salvage. Long-term survival is related to stage or histology, factors generally governing the survival of lung cancer operated patients, although the TNM classification is ill-suited to identifying tumors which can be resected by a sleeve lobectomy.

Steward's midline granuloma. A case report.

Steward's type of neoplastic disease is rare. Much has been discussed on the histopathology of this granuloma. Most authors define it as a neoplasm of the lymphoid system, and it is a subgroup of the "midline granuloma syndrome". We report a case of a 19-year-old first treated with chemotherapy (cyclophosphamide and prednisone) and then with radiotherapy, with good results.

[Dosimetry of the bladder and the rectum: comparison between the measured and calculated dose (author's transl)]. / Dosimetria della vescica e del retto: confronto fra le dosi misurate e le dosi calcolate.

The authors examine 62 cases of curietherapy in the deep vagina on 21 cases of utero-vaginal applications and make a comparison between two dosimetric methods used to measure the dose to the rectum and to the bladder: the direct measure by the Siemens Gammameter dosimeter and the Chassagne-Horiot method. Very large differences were found between the doses evaluated by the two methods. The values with the direct measure were often found to be higher than the calculated ones. When the measurements were done by different doctors, the result was almost the same.