Primary lung sarcomas: long survivors obtained with iterative complete surgery

Primary lung sarcomas are uncommon histologic types of primary lung cancer and presents a wide spectrum of clinical behaviour. Nine patients treated at Antoine Lacassagne Cancer Center between 1982 and 1995 were studied. The median age was 63 years (range, 35-73 years) and the most common histologic types were malignant fibrous histiocytoma (four) and leiomyosarcoma (three). All of them underwent surgery, six patients had a complete surgery and three patients incomplete resections. The median overall survival for all patients was 36 months. In the subgroup of patients with initial complete resection, the median survival was significantly longer (47 months) than in the subgroup of patients with incomplete resection (6 months) (P<0.05, log-rank test). Moreover, two patients had a second complete resection for ipsilateral lung relapse and were long survivors (overall survival of 58 and 83 months, respectively). The ability to achieve a complete second surgery stress the possible benefit of an early detection of local recurrence. Because no specific symptom was linked with the local relapse, a systematic CT scan every 2 or 3 months could be required.

Comparison between nasogastric tube feeding and percutaneous fluoroscopic gastrostomy in advanced head and neck cancer patients

Wasting is a major complication of advanced head and neck cancer and the aim of this study was to compare nasogastric tube feeding (NG) and percutaneous fluoroscopic gastrostomy (PFG) in these patients. The goal of these two methods of nutritional support was to improve or maintain the initial nutritional status during treatment. A total of 90 patients, all stage IV oropharynx or hypopharynx tumor, were reviewed from a prospective databank. All these patients were treated by concomitant chemotherapy and twice-daily continuous radiotherapy with no acceleration. Fifty patients were managed by PFG, and the rest by NG. Mechanical failure, duration of feeding, complications, nutritional evaluation and quality of life were analysed. Mechanical failure occurred in 32 of the 40 NG patients and in seven of the gastrostomy group. In the PFG group, 80% of patients conserved their nutritional support after the end of the radiotherapy, none patient in the NG group. In the PFG group, two presented a wound infection and six had aspiration pneumonia while in the NG group, 21 had aspiration pneumonia probably due to the NG tube (gastroesophageal reflux). The feeding methods were found to be equally effective at maintaining body weight and body mass index at time 1 (3 weeks) and at time 2 (6 weeks). Advantages were associated with PFG cosmesis, mobility and quality of life. PFG is a safe and effective method of providing enteral nutrition during treatment to patients with advanced head and neck cancer and offers important advantages over NG.

[Testicular seminoma and multifocal aseptic osteonecrosis following chemotherapy]

INTRODUCTION

Multifocal osteonecrosis has a wide variety of etiologies, but in the cancer patient several risk factors could have a synergic effect (chemotherapy, radiotherapy, corticosteroid, metabolism disorder).

EXEGESIS

A patient with testicular seminoma receiving cisplatin-based chemotherapy and short-term corticosteroid developed multifocal osteonecrosis. Early diagnosis of osteonecrosis is important to prevent orthopedic complications.

CONCLUSION

Cisplatin could represent one of the possible etiologies of multifocal osteonecrosis. Magnetic resonance imaging has a high sensitivity and specificity in the diagnosis of osteonecrosis and should be used when this condition is suspected.

[Ultrasound guidance technique in celiac plexus block]

The aim of our study was to describe the technique and the efficacy of ultrasound-guidance for celiac plexus block in cancer patients in our institution Antoine Lacassagne Center. Celiac plexus block was performed in 13 cancer patients under ultrasound-guidance (n=13). All patients had excruciating epigastric and generalized abdominal pain caused by cancer. Feasibility and complication rates were analyzed. Notable pain relief was obtained in 9/13 (69%) of the patients and the technical success rate was 93% (12/13). There were 2 minor complications: orthostatic arterial hypotension (n=1) and transient left shoulder pain (n=1). Color Doppler sonography improved visualization of the 21 Gauge Chiba needle when the needle shaft was vibrated. Echogenic foci were observed around the origin of the celiac trunk and superior mesenteric artery in all cases. Ultrasound guidance is safe and effective and should be attempted for celiac plexus block whenever possible.

Percutaneous cementoplasty for pelvic bone metastasis

The aim of this retrospective study was to prove the effectiveness of percutaneous cementoplasty in pelvic bone metastases. We studied the data entered in a multicenter prospective database on 18 cancer patients (average age 58 years) who underwent percutaneous computed tomography (CT) or fluoroscopy-guided cementoplasty from September 1996 to September 1998. The metastatic sites were: acetabulum (n = 12), iliac bone (n = 2), and sacrum (n = 4). Indications were pain recurrence (n = 9) or no relief (n = 3) after radiotherapy, and 6 procedures were performed before radiation. Mean follow-up was 4.6 months, ranging from 11 days up to 24 months. Improvement in pain and walking was obtained in 81.8% cases, and it was generally maintained, except in 1 patient who experienced pain again at day 15 because of an acetabular fracture. Percutaneous cementoplasty is a safe and efficient technique, and is mandatory when radiotherapy fails or when rapid resolution of pain is requested.

Systematic percutaneous fluoroscopic gastrostomy for concomitant radiochemotherapy of advanced head and neck cancer: optimization of therapy

Wasting is a major complication of advanced head and neck cancer. Concomitant chemotherapy and twice-daily continuous radiotherapy with no acceleration represents a promising treatment modality for these tumors, but increases the risk of mucositis. This report describes the results achieved with percutaneous fluoroscopic gastrostomy (PFG) and its impact on the quality of life of patients with head and neck cancer in terms of their nutritional status. A total of 50 stage IV tumors of the oropharynx and hypopharynx recorded in a prospective database were reviewed retrospectively. All patients were managed by PFG, which was found to be a safe and effective technique with no technical failures. PFG feeding resulted in a mean increase in body weight of 2.5 kg within 3 weeks. The body mass index (BMI) was maintained at 3 and 6 weeks. Minor complications occurred, but no major complications were noted. The overall procedure-related mortality rate was nil. Further prospective investigations are necessary to determine whether treatment of wasting improves patient survival.

[Percutaneous endoscopic gastrostomy: cost/benefit analysis in patients with carcinoma of the upper aero-digestive tract]

The aim of this retrospective study was to evaluate the cost and benefit of percutaneous fluoroscopic gastrostomy feeding (PFG) in 70 cancer patients with advanced stage disease of the upper-aero digestive tract; we retrospectively analyzed the consequences in terms of nutritional status (evaluated by weight and body mass index), the possibility to lead a treatment by high dose chemo-radiotherapy to the end of the therapeutic schedule, the feasibility, complications and cost ratios. Three weeks after the procedure, no major complication was observed, the initial nutritional threshold was conserved. PFG is a safe and effective technique; the additional cost is low (2%) compared with the total cost of hospitalization.

Sonographic discovery of a pharyngocele

Cervical sonography was performed in a 25-year-old man who was referred to our department because of the recent appearance of a left anterolateral cervical mass. This mass had the sonographic properties of air; it communicated with and extended the piriform sinus as well as deformed the left lamina of the thyroid cartilage. A preliminary diagnosis of left pharyngocele was confirmed by CT. To our knowledge, this is the first sonographic description of such an abnormality.

[Chemotherapy of malignant inoperable gliomas. The association of fotemustine-cisplatine-etoposide as neoadjuvants]

Efficiency of chemotherapy (CT) on non removable HGG has not been proven and neoadjuvant brain irradiation (RT) following biopsy is the standard treatment. We aimed to define whether combination of polychemotherapy and radiotherapy is synergistic in non removable HGG. It has been proven that F, CDDP and VP16 can reach therapeutic levels in brain after intravenous standard dose injections. The aim of this study was to assess that (i) neoadjuvant CT is safe; (ii) feasibility and efficacions of F (100 mg/m2.d1)/CDDP (100 mg/m2.d1-3 TD)/VP16 (75 mg/m2.d1-3) q21-28d regimen; (iii) Delayed RT is not unsafe: RT was performed when tumor progression or toxicity appeared. This study included 16 patients with symptomatic non removable HGG. Two of them had anaplastic gliomas and 14 glioblastomas multiforme. None of them had a prior chemotherapy regimen. Objective response was evaluated with CT scan or MRI during chemotherapy. Toxicity was moderate and mainly hematological (grade III-IV thrombopenia = 10/67 cycles; leukopenia = 13/67). Objective response rates were 5/16 (31 p. 100) (CR = 1; PR = 4; Median duration of response: 20 weeks). Median survival was 55 weeks in the 14 grade IV patients. Three/16 patients are still alived with respectively 22, 30, 40 months survival: These results confirm the neoadjuvant chemotherapy efficacy. It may be a useful tool before RT for non removable HGG.

Cost-benefit analysis of percutaneous interventional radiological procedures in cancer patients

The goal of this work was to evaluate the costs and benefits of percutaneous interventional radiological procedures (PIRP) in terminal cancer patients, from the perspective of the Radiodiagnostics Department. The subjects were 225 patients who underwent different kinds of treatments, such as placement of endovenous or urinary stents, percutaneous gastrostomy, alcoholization of metastatic disease, celiac plexus block, tumor embolization, and inferior vena caval filter. We retrospectively analyzed the consequences in terms of survival, quality of life and cost ratios and found that this study fully justifies the use of interventional radiology in palliative oncology: 60% and 40% of the patients, respectively, were still alive at 1 month and 3 months; the additional cost of PIRP procedures is low (< 12%) compared with the total cost of hospitalization.

Inferior vena cava hypoplasia with intrahepatic venous continuation: sonographic, angiographic and MR features including MR angiography

In cases of inborn or acquired obstacles on the inferior vena cava (IVC), the derived blood flow usually goes through collaterals in the azygos or the hemiazygos venous systems. Exceptionally, a collateral pathway through the portal system or through an anastomosis in between hepatic veins, shunting the IVC interruption, is encountered. In the present paper, the authors describe the fortuitous discovery of a IVC hypoplasia in its retrohepatic segment. MR venography, correlated with fluoroscopic angiography, clearly depicted an intrahepatic collateral circulation consisting of a double aneurysmal communication between an inferior right hepatic vein and the main right hepatic vein.

[Brain metastases and chemotherapy]

INTRODUCTION

The epidemiology of brain or central nervous system metastases is poorly documented. Retrospective studies based on autopsies that were aimed at investigating the incidence and prevalence of brain metastases have revealed the shortfalls in tumour registers. The exact role of cerebral metastases has not been addressed within the scope of cancer considered as a public health issue.

CURRENT KNOWLEDGE AND KEY POINTS

The prognosis of brain metastases should not be considered either on general or a priori basis as being poorer than that of other metastatic sites. Evaluation of the role of focal radiation therapy and chemotherapy is still in progress. Appropriate use of therapeutical strategies directed at brain tumors generally improves the condition of most patients. It also usually increases survival and enhances the quality of life.

FUTURE PROSPECTS AND PROJECTS

The role of chemotherapy in current therapeutical strategies has not yet been defined and should be investigated and developed.

Concomitant b.i.d. radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in unresectable squamous-cell carcinoma of the pharynx: clinical and pharmacological data of a French multicenter phase II study

PURPOSE

The aim of this phase II study conducted on unresectable squamous cell carcinoma (USCC) of the oro- and hypopharynx was to associate twice-a-day (b.i.d.) continuous nonaccelerated radiotherapy with concomitant cisplatin (CP)-5-fluorouracil (5-FU) chemotherapy, both given at full dose. Feasibility, efficacy, survival, and pharmacokinetic-pharmacodynamic relationships were analyzed.

METHODS AND MATERIALS

Fifty-four consecutive patients with strictly USCC of oro- and/or hypopharynx received continuous b.i.d. radiotherapy (RT) (2 daily fractions of 1.2 Gy, 5 days a week, with a 6-h minimal interval between fractions). Total RT dose was 80.4 Gy on the oropharynx and 75.6 Gy on the hypopharynx. Three chemotherapy (CT) courses of CP-5-FU were given during RT at 21-day intervals (third not delivered after the end of RT). CP dose was 100 mg/m2 (day 1) and 5-FU was given as 5-day continuous infusion (day 2-day 6: 750 mg/m2/day cycle 1, 750 mg total dose/day cycle 2 and 3). Pharmacokinetics was performed for 5-FU (105 h follow-up) and CP (single sample at 16 h). Special attention was paid to supportive care.

RESULTS

Good feasibility of RT was observed (85.2% of patients with total dose > 75 Gy). Five patients received 1 CT cycle, 34: 2 cycles, and 15: 3 cycles. The most frequent and severe acute toxicities were mucositis with grade 3-4 occurring in 28% at cycle 1 and 86% at cycle 2, as well as neutropenia (43% at cycle 2). Locoregional control at 6 months was observed in 66.7% of patients. No late toxicity above grade 2 RTOG was noticed. CP dose and 5-FU AUC(0-105h) were significantly linked to grade 3-4 neutropenia (cycle 2). Cumulative total platinum (Pt) concentration and Karnofsky index were the only independent predictors of locoregional control at 6 months. Finally, total RT dose and total Pt concentration were the only independent predictors of specific survival.

CONCLUSION

This protocol showed good locoregional response with an acceptable toxicity profile. Pharmacokinetic survey is probably an effective approach to further reduce toxicity and improve efficacy. A multicentric randomized phase III study, now underway, should confirm these encouraging results.

[Germinal tumor metastases. Case report]

Germinoma is the most frequent type of intracranial germ-cell tumor initial presentation is usually acute intracranial hypertension. MRI investigations are non-specific. Most of the time, only stereotactic surgery is performed before treatment. Metastases are rare but germ cells can disseminate both by infiltration and via ventricular and subarachnoid pathways. Abdominal and pelvic metastases occur in 10 p. 100 of patients who have received ventriculosomatic shunting. Since germinoma is well known to be a very radiosensitive tumor, patients are usually given radiation therapy. Chemotherapy seems to be an interesting alternative treatment.

Systematic ultrasonography in asymptomatic dense breasts

The purpose of this study was to evaluate the role of ultrasonography in breast cancer screening. 350 Bilateral ultrasound (US) were performed in 350 asymptomatic patients with dense breasts. 7.5, 10 And 13 MHz transducers were used (Esaote Biomedica, Italy). In 185/350 patients, sonograms were normal, abnormalities were seen in 165/350: cysts (117), solid nodules (44) and mixed echogenicity nodules (4). All but two solid lesions were benign. Both malignant lesions were invasive carcinomas, 18 and 11 mm in diameter. In retrospect, they were palpable, but not visible on mammograms. Retroprospective review revealed that 24.7 of cysts and 31% solid nodules could be seen on mammograms. In 4 patients with fibroadenomas, US made a false positive diagnosis of breast cancer. Follow-up was obtained for 6 to 18 months in 45% of patients. Routine supplemental US evaluation for patients with mammographically dense breasts does not appear to significantly contribute to the accuracy of the work-up.

Prognostic significance of computed tomography in tumors of the oral cavity and oropharynx treated with neoadjuvant chemotherapy

BACKGROUND

Despite its high response rate, the use of neoadjuvant chemotherapy remains controversial. Pretherapeutic identification of subgroups of patients who are likely to respond to chemotherapy is of the utmost importance.

PURPOSE

In this study, we have attempted to determine the relationship between specific radiological parameters and the response to neoadjuvant chemotherapy. In addition, we have determined if these parameters could yield prognostic information on recurrence and/or survival.

PATIENTS AND METHODS

Fifty-four patients with a squamous cell carcinoma of the oral cavity or base of tongue who had had a contrast-enhanced CT scan and neoadjuvant chemotherapy were included in this analysis. All clinical, radiological, surgical, histological, and radiotherapeutical parameters as well as the follow-up data were analyzed by a chi-square test. The method of Kaplan-Meyer was used to determine disease-free intervals and crude survival. The log-rank method was used for testing differences in local failures and survival.

RESULTS

Twenty-eight patients were classified as having isodense nodes and 20 patients as having hypodense nodes. Nodal density was not related to tumor size or primary site. N stage was not correlated with the density of the nodes. Patients with hypodense nodes had a significantly lower disease-free interval and survival than patients with isodense nodes. The relation between overall response to chemotherapy and the hypodensity of the nodes didn't reach a significant level.

CONCLUSION

No relation was found between overall response to chemotherapy and N-stage or tumor density. Disease-free interval and crude survival was strongly related to response to chemotherapy.

[Venous endoprosthesis. Palliative treatment of superior caval syndrome of neoplastic origin]

Twenty-three patients with SVC syndrome were evaluated with CT and venography. The superior vena cava or its tributaries were either stenosed or thrombosed. The etiology was malignant in all cases: non small cell carcinoma (16 cases), mediastinal nodal metastasis (3 cases), lymphomas (2 cases), pleural mesothelioma (1 case), small cell carcinoma (1 case). The length of the stenosis ranged from 20 to 70 mm. The stents were placed via a femoral, jugular or brachial approach. Stenting was achieved in 22/23 patients (96%). Clinical symptoms subsided in 20/22 patients (87%). Mean follow-up was 15 weeks. Stents remained patent in 17/20 patients (78%). Stenting is a safe and effective treatment of SVC syndrome in patients with malignant conditions.

[Comparative study of power Doppler and color Doppler in breast diseases]

In order to evaluate the interest of power doppler in breast studies, we studied 27 breast lesions in 22 patients. This series includes 8 malignant lesions, 11 benign lesions, and 8 enlarged lymph nodes. We used a Esaote Biomedica ultrasound machine with a 7 MHz transducer. We compared power doppler and pulsed doppler for every lesion. Power doppler was more sensitive in 3 out of 8 malignant tumors, 8 out of 11 benign lesions, and 5 out of 8 lymph nodes involvement. This study shows the value of power doppler in breast studies. The increased sensitivity, however, is balanced by a decreased specificity.

[MRI of uterine leiomyosarcoma. Apropos of 2 cases]

Prognosis is poor for uterine leiomyosarcomas. Diagnosis is often an unexpected pathology discovery after hysterectomy for fibroma. Prognosis depends on the degree of locoregional extension and thus on early diagnosis. Echography and computed tomography scan are note very specific. There is little literature on imagining studies, and particularly on MRI in this pathology. Yet MRI, especially the T2 weighted sequences, is quite interesting for evaluating tumour extension in the uterus. It can be used whenever an abnormal increase in size is observed during the per- or postmenopausal period in a women with a fibroma. We report two cases of uterine leiomyosarcoma explored by MRI and review the literature.

[Echography of the superficial lymph nodes]

We reviewed the literature on the echographic examination of diseased superficial lymph nodes in the cervical, axillary, the internal mammary and inguinal regions. The anatomy and the technique of the echographic examination were reviewed followed by the role and limitations of computed tomography and magnetic resonance imaging. The echographic presentation of normal, inflammatory and tumoral lymph nodes was discussed in light of the indications for echography of the superficial lymph nodes in ear-nose-throat and breast cancer and in cases of lymphomas.

[Pelvic gynecological cancers. Is hepatic echography useful?]

An examination of liver echographies performed over an 11 year period in 2,335 female patients with pelvic gynaecology cancers revealed that the incidence of benign lesions (96 cases) was greater than the number of metastases discovered (79 cases). Regular hepatic echography in cancers of the uterus leads to a median survival of 4 months. Hepatic echography can be useful for the detection of benign lesions in cases of cancer of the uterus and for the detection of benign or malignant lesions in cases of cancer of the ovary. Routine post-therapeutic hepatic echography is only useful in cancer of the cervix. For cancer of the ovary, abdomino-pelvic computed tomography should be performed; liver tests are sufficient in cases of cancer of the endometrium.

Very high frequency (13 MHz) ultrasonographic examination of the normal neck: detection of normal lymph nodes and thyroid nodules

Very high frequency (13 MHz) ultrasonographic examination of the neck successfully visualized one or more normal lymph nodes (weakly echoic oval structures with an echoic central hilum) in 67.6% of 1000 healthy volunteers. Efficacy was not related to recent ear, nose, and throat infection, sex, or age. The longitudinal-transverse diameter ratio was greater than or equal to 2 in 86.2% of cases. No signal was detected with color Doppler imaging. One or more thyroid nodules were also identified in 34.7% of the subjects: the frequency was 44% in women and 42% in subjects over 50 years of age.

[Gastric leiomyosarcoma. Ultrasonographic endoscopy and MRI]

Leiomyosarcoma of the stomach is an unfrequent tumor, for which the prognosis is better than for cancer of the stomach. Its development is often subserosal, thus explaining its clinical latency and its large volume at the time of diagnosis. While many publications report about the merits of conventional imaging for this type of pathology, few authors have considered ultrasonographic endoscopy, and even fewer magnetic resonance imaging. The authors present one case for which these two recent techniques were implemented, as well as a review of the literature.