Integrated Diagnostic Model That Incorporates Epstein-Barr Virus DNA, Imaging, and Nasal Endoscopy to Stratify Primary Tumor and Lymph Nodes in a Patient with N1 Nasopharyngeal Carcinoma: Multidisciplinary Management

Nasopharyngeal carcinoma (NPC) is an epithelial malignancy, with a high metastatic potential. Epstein-Barr virus (EBV) infection plays a fundamental role, even if it is not well understood. The diagnosis of the disease in its early stage is infrequent. Imaging studies, positron emission tomography scans in addition to clinical examination, endoscopic examination, and biopsy provide information on the extent of the disease. The application of neoadjuvant chemotherapy followed by concomitant chemoradiation can improve the control of NPC. In March 2016, a 54-year-old male with NPC cT1 cN2 cM0, stage III (8th edition of American Joint Committee on Cancer (AJCC) staging system) underwent to a two-step treatment: induction chemotherapy by TPF regimen (docetaxel, cisplatin, 5-fluorouracil), followed by concomitant chemoradiotherapy (weekly cisplatin). The quantity of free plasma EBV-DNA can be related to the disease stage, and the detection of EBV-DNA during follow-up can be predictive of distant metastases. Especially, either plasma or serum EBV-DNA titer is estimated to reflect tumor volume. Biologically, such EBV-DNA reflects reproduced or released DNA from dead or dying tumor cells. On the other hand, EBV-specific DNA released as exosome may reflect the biological feature of the alive NPC tumor cell. The follow-up is ongoing after 21 months from a complete response.

Multimodal imaging for clinical target volume definition in prone whole-breast irradiation: a single institution experience

Aim: The aim was identification of reference structures for breast clinical target volume (CTV) in prone position, throughout image fusion process. Materials & methods: We analyzed breast glandular tissue distribution in 20 diagnostic MRIs, referring to structures reported in ESTRO guidelines for supine irradiation. The volume containing breast glandular tissue in all cases was defined as MRI prone CTV (MRIpCTV). Then in ten subsequent patients planned for prone irradiation, MRI and computed tomography (CT) simulation was acquired. MRIpCTV was defined followed by our findings and transferred to CT for definitive delineation. Results: MRIpCTV was defined by the caudal edge of clavicular head, 3 mm above inframammary fold, by the medial thoracic artery, by a plane passing through the lateral surface of pectoralis muscles, by the anterior surface of pectoralis muscles and 3 mm from the skin. Deformed CTV was consistent with anatomy on CT; the limits chosen for MRIpCTV fit adequately also for CT. Conclusion: Prone irradiation is an alternative set up for selected cases, so the sample is very small. However, our suggestions could be of aid in defining prone CTV. The good consistency between MRI and CT seems to confirm that MRI may be unnecessary in routine practice.

Radiological aspects of cancer of the esophagus

The role radiology plays in the study of cancer of the esophagus (CE) involves three different diagnostic steps: identification of CE; staging of CE and postoperative follow-up. This study comprises 117 cases of CE, all surgically confirmed: in 57/117 CE, resection of the neoplasm with subsequent reconstruction of the digestive tract proved possible; in the remaining 60/117 non-resectable CE, a Celestin prosthetic tube was positioned. The radiological diagnosis was correct in 92.3% of the cases, the diagnostic error (9/117: 7.7%) being mainly due to under-diagnoses (6/9) rather than false negatives (3/9). Conventional radiology provided satisfactory results in the staging of CE. Among the postoperative complications in the 57 resected patients, fistulae (13/57) and mediastinal abscesses (1/57) were early complications, whereas stenosis of the anastomosis (5/57) and neoplastic recurrences (3/57) were late complications. The possible role of diagnostic delay in the poor prognosis of CE, as well as its possible causes, are discussed in this paper.