Role of radiation therapy in a patient with primary pancreatic lymphoma.

Pancreatic lymphoma is an extremely rare disease. The role of radiation therapy as an adjunct to chemotherapy for the treatment of this disease is poorly defined. We present a case of primary pancreatic lymphoma treated with radiation therapy as an adjunct to chemotherapy.

Lower and central tumor location correlates with lymphoscintigraphy drainage to the internal mammary lymph nodes in breast carcinoma.

BACKGROUND: Radiation to the internal mammary chain (IMC) may be indicated for breast carcinoma patients with positive axillary sentinel lymph nodes (SLNs) and lymphoscintigraphic evidence of drainage to the IMC. The purpose of this study was to identify predictors of IMC drainage in patients with positive axillary SLNs. METHODS: The records of 297 breast carcinoma patients with positive axillary SLNs and preoperative lymphoscintigraphy were reviewed between 1995 and 2002. Radiolabeled colloid was injected peritumorally with lymphoscintigraphy performed 30-60 minutes later. Drainage to the regional nodes of 279 patients was seen on lymphoscintigraphy. Associations among patient and tumor-related factors and drainage to the IMC were examined. RESULTS: Drainage to the IMC on lymphoscintigraphy was seen in 63 patients (21%). IMC drainage only occurred in 4 patients, and 59 patients had both axillary and IMC drainage. The only variable that correlated with IMC drainage was tumor location (P = 0.017). Rates of drainage to the IMC were 14.1% for upper outer quadrant (n = 128), 16.7% for upper inner quadrant (n = 30), 31.6% for lower outer quadrant (n = 19), 42.9% for lower inner quadrant (n = 14), and 28.4% for central tumors (n = 88). IMC drainage rates differed significantly between upper and lower tumors (lower 36.4% vs. central 28.4% vs. upper 14.6%, P = 0.003) but not between medial and lateral tumors (medial 25.0% vs. central 28.4% vs. lateral 16.3%, P = 0.077). CONCLUSIONS: Patients with tumors in the lower or central breast and positive axillary SLNs have increased incidence of drainage to the IMC. Preoperative lymphoscintigraphy can help to define the nodal basins at risk for harboring disease.

Factors predictive of having four or more positive axillary lymph nodes in patients with positive sentinel lymph nodes: implications for selection of radiation fields.

PURPOSE: The optimal design of radiation fields for patients with positive sentinel lymph nodes (SLNs) who do not undergo axillary dissection is unknown. We have previously shown that modified breast tangent fields can include most axillary Level I-II lymph nodes. We have also reported that irradiation of the axillary apex/supraclavicular fossa is indicated for patients with four or more positive axillary lymph nodes. To determine the optimal arrangement for patients with positive SLNs, we studied what factors predicted for having four or more positive lymph nodes. METHODS AND MATERIALS: We reviewed the records of 339 consecutive patients with one to three positive SLNs who underwent complete axillary dissection at our institution between 1995 and 2002. We separately analyzed the outcome for those initially treated with surgery (n = 265) and those receiving neoadjuvant chemotherapy (n = 74). A logistic regression model was used to identify independent factors predictive for four or more positive lymph nodes. RESULTS: A total of 28 of 265 patients in the initial surgery group and 20 of 74 patients in the neoadjuvant group had four or more positive lymph nodes. In the initial surgery group, the independent factors associated with four or more positive lymph nodes were no drainage seen on lymphoscintigraphy (rate, 38%, odds ratio [OR] = 5.4, p = 0.03), more than one positive SLN (rate, 24-42%, OR = 2.9, p = 0.02), and lymphovascular space invasion (LVSI; rate, 25%, OR = 4.8, p = 0.01). Of the 106 patients without any of these factors, only 2 had four or more positive lymph nodes. For the patients treated with neoadjuvant chemotherapy, the independent factors were clinical Stage III (rate, 48%, OR = 3.1, p = 0.03), more than one positive SLN (rate, 37-67%, OR = 4.8, p = 0.03), and LVSI (rate, 62%, OR = 8.1, p = 0.02). Of the 28 patients without any of these factors, only 1 had four or more positive lymph nodes. CONCLUSION: It is reasonable to treat with modified tangents fields that include most axillary Level I-II nodes for patients with one positive SLN who do not undergo axillary dissection if drainage is seen on lymphoscintigraphy and no LVSI is present. This approach is also reasonable for patients treated with neoadjuvant chemotherapy who have Stage II disease, no LVSI, and only one positive SLN. The remaining patients have a greater risk of having four or more positive lymph nodes, and, therefore, the high axilla/supraclavicular fossa should also be included in the radiation fields.

Quantitative differentiation of breast lesions based on three-dimensional morphology from magnetic resonance imaging.

OBJECTIVE: The purpose of this study was to develop geometric indices, based on morphologic measurements, of contrast-enhanced breast lesions using three-dimensional magnetic resonance imaging (MRI) that can statistically differentiate between benign and malignant lesions. METHODS: Thirty-three patients with abnormal mammograms were scanned using three-dimensional MRI. The lesion was then extracted from the volume data set using interactive volume-rendering software. From the extracted region of interest, the surface boundary corresponding to the lesion was extracted using an isosurface method. The boundary was represented as a triangular mesh, from which the surface area and volume enclosed by the surface were computed. The following variables were tested for discrimination ability between benign and malignant lesions: 1) the volume-to-surface area (V/S) ratio, 2) spherical shape index (SSI), and 3) resolution reduction for V/S and SSI values (100%, 16%, 8%, 4%, 2%, and 1% resolution). In addition, comparisons were made between the V/S and SSI values at 100% versus their reduced resolutions. RESULTS: Thirty-three subjects (15 malignant tumors and 18 benign tumors) were studied. The SSI index (P = 0.0063) was a significant discriminator for malignancy. The V/S ratio (P = 0.9280) did not seem to be a useful variable in distinguishing benign and malignant masses. The V/S resolution comparisons (P > 0.5897) and the SSI resolution comparisons (P > 0.05) were also not useful discriminating variables. CONCLUSION: The SSI seems to be a useful factor in differentiating between benign and malignant lesions. Current clinical interpretation of breast lesions using MRI may be enhanced by the adjunctive use of this objective postanalysis method.