Review: Feto-placental vascularization: a multifaceted approach.

Doppler Ultrasound allows the in vivo study of feto-placental hemodynamics. Doppler flow velocity waveforms (FVW's) obtained from the umbilical arteries reflect downstream blood flow impedance, thus giving indirect evidence of vascular villous tree characteristics. Pulsatility Index, which quantifies FVW's, decreases throughout normal pregnancy, indicating decreasing impedance and is often higher in cases of fetal growth restriction (FGR). Different approaches (morphometrical, morphological, mathematical, immunohistochemical and molecular) have contributed to elucidation of which anomalies of the vascular villous tree underlie Doppler findings. 3D ultrasound may be useful in the study of feto-placental perfusion. However, the unsolved question is why developmental villous tree anomalies occur. Crucial to the success of future research is definition of the population studied based on the uniform and correct definition of FGR.

Brain metastases from unknown primary tumour: a prospective study.

The best management of patients with brain metastases from an unknown primary tumour is still unclear, as data are scarce and studies are retrospective. We report 33 patients with biopsy-proven brain metastases from a primary tumour not found at the first investigations, who were treated by surgery and/or radiotherapy and followed with serial CT until death. Median survival time for all patients was 10 months and survival rates at 6 months, 1 year and 2 years were 76 %, 42 % and 15 % respectively. Patients with single brain metastasis treated by gross total resection and whole-brain radiotherapy (WBRT) had a median survival of 13 months with 76% alive at 6 months, 57 % at 1 year and 19% at 2 years. Patients with multiple brain metastases who underwent either WBRT alone or WBRT preceded by gross total resection of the symptomatic lesions had a poorer prognosis: median survival of 6-8 months with 50-100% alive at 6 months, 17-20% at 1 year and none alive at 2 years. In 85% of patients with a single brain metastasis a significant improvement in neurological functions was observed after surgical resection; among patients with multiple brain metastases a neurological improvement was observed in all patients who had a resection of symptomatic lesions and only in a half of patients who had WBRT alone. During the follow-up the primary tumour was found in 27/33 patients (82 %) and was located in the lung in 78%. Between 1987 and 1991 (with limited screening for the primary tumour in the follow-up) the unknown tumours were 6/15 (40%); in the more recent period (1992-1996) (CT-based screening for the primary tumour in the follow-up) no primary tumour remained unknown but overall survival has not significantly improved. The number of brain metastases was the only significant factor affecting survival after both univariate and multivariate analysis. This study suggests that, in patients with both single and multiple brain metastases from an undetected primary site when first studied, surgery and/or WBRT enable the control of the brain disease, partly because the systemic disease may be silent for a prolonged time. Only a few asymptomatic patients may benefit from an early detection and treatment of the primary tumour during the follow-up.

Small cell carcinoma of the esophagus: a case report and review of the literature.

We present a case of small cell esophageal carcinoma (SCEC) treated with alternated chemotherapy (including cisplatin, etoposide, vincristine, cyclophosphamide and doxorubicin) and irradiation (36 Gy) followed by surgery. Despite a pathological complete response, the patient died of regional disease recurrence 29 months after the diagnosis. We reviewed the available literature on SCEC with regard to the incidence, clinical symptoms, radiological signs, diagnostic workup, therapeutic modalities and prognosis of this malignancy.

Hormonal and radiological effects of megavoltage radiotherapy in patients with growth hormone-secreting pituitary adenoma.

Nineteen acromegalic patients (12 females and 7 males, aged 24-71 yr) were studied for 1-6 yr after radiotherapy (RT), administered by X-rays (18 MeV) by linear accelerator, with parallel opposite beams (doses 45-50.4 Gy, 1.8 Gy daily). Basal GH levels gradually decreased from 6.3-76.2 micrograms/L (mean +/- SE, 27.8 +/- 4.9) to 0.3-43.4 micrograms/L (11.7 +/- 3.6 micrograms/L; p < 0.005) at the last assessment. The earliest significant decrease was observed after one yr (14.9 +/- 3.8 micrograms/L; p < 0.005). Significant changes were observed also in IGF-I values (basal values 1.93-6.85 mU/ml, 3.22 +/- 0.30; last assessment 0.55-4.57 mU/mL, 1.58 +/- 0.31; p < 0.01). The earliest significant decrease of IGF-I values was observed after 2 yr (1.61 +/- 0.16 mU/ml; p < 0.005). GH levels < 5 micrograms/L together with normal IGF-I values were observed in 9 patients, 2-4 yr after RT. No changes were observed in PRL values, either in patients with pretreatment normal or elevated PRL levels. The CT and/or MRI picture of macroadenoma disappeared after 6-12 months in 3/12 patients. Moreover, a reduction (20-55%) in the diameter of the adenoma was shown after 6-36 months in other 4 patients. After RT 5/16 (31%) patients required cortisol and 4/19 (21%) thyroid replacement therapy. In 2/3 men a gonadal impairment was shown, that did not occur in the three female patients with normal gonadal function before RT.(ABSTRACT TRUNCATED AT 250 WORDS)

Seminom cicatrice. About a case of spontaneous testicular regression.

This is a case of spontaneous regression of a tumour. Only the French Authors speak about this type of seminoma called them "seminome cicatrice". Probably the immunological defences are fundamental for the complete or partial spontaneous resolution of this type of tumour. Here we describe our clinical and surgical approach. The last control was normal with a relapse-free patient.

Daily low-dose carboplatin and standard radiotherapy in unresectable head and neck and lung cancers: a pilot study.

A total of 14 patients with locally advanced and unresectable head and neck (SCCHN) or non small cell lung cancer were treated with a definitive course of radiation therapy with conventional fractionation and 30 mg/m2 carboplatin (CBDCA) given daily as an i.v. infusion during the 1st, 3rd, 5th and 7th weeks of the combined treatment. The planned tumor dose of at least 7000 cGy was reached in all SCCHN patients except 1 (6600 cGy). The 2 NSCLC patients received 6320 and 5980 cGy, respectively. The planned total CBDCA-dose of 600 mg/m2 was administered in all patients. No treatment delays were required in 10 patients. Interruptions for severe mucositis or myelosuppression occurred in 4 patients (28.6%), but in no case did the delay exceed 1 week. Complete response was obtained in 8 patients (57.1%); 7 of the 12 with SCCHN and 1 of the 2 with NSCLC. The other 6 patients achieved a partial response. Granulocytopenia of WHO grade 3 occurred in 1 patient; apart from vomiting and mucositis, toxicities above grade 2 were not observed.

Utility and limits of an imaging follow-up in evaluation of response and evolution of cerebral tumors after radiotherapy.

CT scans of 110 patients with malignant gliomas treated with radiotherapy, postoperative or alone, were reviewed. Our aim was to assess the utility and limits of an imaging follow-up in evaluating tumor response to treatment and evolution. We have tried to define the densitometric parameters of tumors in various evolutive phases, with special emphasis on variations of contrast enhancement during time. CT scan findings were compared with clinical and therapeutic data.

Prognostic factors in well-differentiated cerebral astrocytomas in the adult.

Eighty-five "well-differentiated" astrocytomas in adults (age, greater than or equal to 18 years), operated on between 1950 and 1982, were retrospectively reviewed. The pilocytic variant was not included. Twenty-four clinical and 8 histological factors were analyzed to investigate their importance in predicting length of survival. Multivariate analysis showed that the following variables were correlated with survival time (P less than 0.01): extent of surgical removal, altered consciousness during preoperative examination, focal deficit as presenting symptom, performance status (Karnofsky rating) after surgery, and vessel size in the surgical specimen. Total removal of the tumor was related to a higher 5-year survival rate (51%) than subtotal removal (23.5%), and none of the patients with partial removal survived more than 5 years. Postoperative radiotherapy (40-55 Gy) improved only the 1- and 3-year survival rates. Based on the significant factors provided by multivariate analysis, a score was developed to detect subgroups with different prognoses. Median survival time ranged from 383 days for patients with a score greater than or equal to 2.5 to 1,533 days for those with a score less than 0.5; no patient with a score greater than or equal to 1.5 survived more than 10 years. The percentage of recurring astrocytomas that showed anaplastic areas in the second biopsy specimen was 79%. Total surgical removal is the most important factor in the management of well-differentiated astrocytomas, whereas the efficacy of postoperative radiotherapy still needs to be confirmed by prospective and randomized studies. The rationale for treating incompletely resected astrocytomas with radiation therapy could lie in the high incidence of malignant transformation.

Primary lymphomas of the brain: a clinico-pathologic review of 37 cases.

The clinico-pathologic data of 37 primary lymphomas of the brain were retrospectively reviewed. The tumors were classified according to the Kiel classification and the Working Formulation System. They represented 1.02% of all primary intracranial tumors of our series. The radiologic prediction appeared to be difficult: the suspicion was maximal when the absence of pathologic vessels at angiography occurred in a meningioma-like lesion at CT. Median survival was 4.53 months in the 16 cases who underwent surgery only versus 25.7 months in the 8 cases operated and irradiated with 40-60 Gy (p less than 0.01). The prognosis of lymphomas of the CNS, even if radioresponsive tumors, remains poor. Most patients relapse after treatment, most often locally in the brain, with a variable frequency of spinal or systemic localization.

Delayed adverse effects after irradiation of gliomas: clinicopathological analysis.

Out of 107 pts. treated with radio- and chemotherapy for low and high grade gliomas (TD: 45-65Gy), 3 cases developed pathologically documented radionecrosis (coagulative necrosis with minimal or no persistent tumor). Clinico-therapeutic modalities were analyzed for all cases and biologically equivalent doses were calculated according to NSD, ED and btu formulas. All cases of radionecrosis fell into the group of doses close to 60Gy/30fx./42d. and NSD = 1758, ED = 1340 and btu = 1161. Isodose curve reconstruction on planes corresponding to histological sections of brains with radionecrosis demonstrated that doses received by areas of necrosis were higher than the calculated mid-plane doses in two cases. Clinical and autoptic incidence of radionecrosis were 2.8% and 10% respectively. High doses of steroids during RT seemed to offer some protection against radionecrosis, while number of chemotherapy cycles did not influence the risk of radionecrosis. A higher autoptic rate of irradiated gliomas is needed in order to obtain a better understanding of a number of unresolved problems.

Effects of radiotherapy on the astrocytomatous areas of malignant gliomas.

Little is known of the histological effects of radiation on low grade astrocytomas, whereas the clinical efficacy of radiotherapy on these tumors is still a matter of discussion. Since it is difficult to have large series of autoptic brains harboring astrocytomas, the wide astrocytomatous areas of conventionally irradiated secondary glioblastomas have been studied in whole mount preparations. It was assumed that these areas were already present at the time of irradiation. In these areas no histologic changes referable to 'short-term' effect of radiation have been found. When the astrocytomatous areas were located in the white matter, they were affected by chronic edema, which usually occurs in periglioblastomatous tissue. In one case necrotic foci in the astrocytomatous areas were interpreted as anaplastic foci damaged by radiation; radiotherapy of astrocytomas might therefore result in the eradication of undetected anaplastic foci.

Radio- and chemotherapy of malignant gliomas. Pathological changes in the normal nervous tissue.

The pathological effects of radio- and chemotherapy on the normal nervous tissue have been studied in 42 brains with malignant gliomas. The brains have been examined by means of the complete study technique. In seven cases the picture of delayed radionecrosis has been found. Apart from this, many histological features have been related to post-operative survival, radiation dose, interval between radiation and death, chemotherapy, steroids, size and activity of the tumour. Some alterations, such as peritumoural necroses, macrophage areas, vessel wall degenerations etc. result from radiotherapy. The relations and pathogenesis are discussed.