Langerhans Cell Histiocytosis Mimicking Malignancy: A Radiological Appraisal

Aims

To analyze the radiologic characteristics, clinical course and long-term follow-up of 7 radiologically uncommon pediatric cases of Langerhans cell histiocytosis and to identify prognostic factors related to imaging patterns.

Methods

The clinical records and complete imaging data of 75 patients with LCH diagnosed and treated at the National Cancer Institute of Milan between January 1975 and December 1993 were analyzed, and 43 cases presenting as unifocal bone lesions were identified. The plain film, computed tomography and magnetic resonance characteristics enabled the identification of 7 radiologically aggressive and rapidly progressive cases, which were analyzed at presentation and during follow-up.

Results

Although at disease presentation bone lesions appeared lytic destructive, rapidly progressive and often involved adjacent soft tissues, after adequate therapy the disease course was invariably benign and led to almost complete restoration of normal structure and function. Long-term follow-up confirmed the favorable outcome and lack of disease recurrence in all cases.

Conclusions

There is no correlation between radiologically aggressive characteristics and final outcome in Langerhans cell histiocytosis. Radiologists and pediatric oncologists should be acquainted with less common radiologic forms which, at presentation, can mimic more ominous diseases. If recognized and adequately treated, monostotic forms almost invariably have a benign prognosis.

Locally Advanced Breast Cancer Treated with Primary Chemotherapy: Comparison between Magnetic Resonance Imaging and Pathologic Evaluation of Residual Disease

Aims and Background

We evaluated the response of locally advanced breast cancer to induction chemotherapy using MRI techniques. The size and vitality of any residual pathologic tissue was quantified by means of morphologic and dynamic analysis. A curve derived from the dynamic parameters shows the uptake intensity with respect to the time elapsed since administration, which is related to vascularization and therefore indirectly reflects the angiogenesis of malignant tissue.

Methods and Study Design

A group of 30 patients were examined with MRI for staging purposes before undergoing treatment and subsequently to assess the response to treatment. Alterations in size and dynamic parameters were closely monitored.

Results

The overall accuracy was 90%, the sensitivity 96%, the specificity 75%, the positive predictive value 92.5% and the negative predictive value 66%. Interestingly, analysis of the dynamic curves made it possible to obtain additional information regarding the angiogenetic activity of the residual tumor.

Conclusions

Evaluation of the response to treatment by means of conventional imaging and clinical examination can be particularly difficult because of the fibrosis induced by cytotoxic drugs or the small volume of residual disease. The additional information supplied by MRI could therefore allow a more conservative surgical approach in selected cases of optimal response to treatment, as well as a much more accurate follow-up. Furthermore, the variation in dynamic parameters according to the vitality of residual disease could in the future become a useful tool for monitoring the effectiveness of anti-angiogenetic drugs.

Usefulness of Chest and Skeletal Survey to Assess the Time of Relapse in Breast Cancer

The pertinent radiographs of 151 patients treated with radical mastectomy who showed relapse in the chest and/or in the skeleton as first site were reevaluated. Diagnostic accuracy was calculated by comparing the first examination considered as positive with the previous ones reported as negative. For chest lesions the accuracy was 80 % (70 % for parenchymal nodular densities), with no difference between symptomatic and asymptomatic patients. For bone metastases retrospective evaluation confirmed the radiological report (i.e., the time of relapse), in 73.8 %, with a value of 89.7 % in symptomatic and 53.4 % in asymptomatic patients. The site of involvement and morphological characteristics of the lesions did not influence the diagnostic accuracy. Therefore chest examination and, for symptomatic patients, radiographic bone survey still represent a useful modality to assess the diffusion of breast cancer. For asymptomatic patients other modalities, such as bone scan and biochemical tests, should be utilized.

Intravascular lymphomatosis (IL) in a child mimicking a posterior fossa tumor

Intravascular lymphomatosis (IL) is a rare entity only recently included in lymphoma classification, whose main feature is the exclusive or predominant growth of neoplastic cells within blood vessels. The vast majority of the patients affected by IL belong to the 7th or 8th decade of life and present with skin rash or CNS diffuse necrotic or demyelinating lesions. Case report. SS, a 13-year-old girl, was admitted to a Neurosurgery Unit because of endocranic hypertension, where, after CT and MRI documenting a IV ventricle 3 cm diameter tumor, she was submitted to complete tumor excision: extemporary diagnosis was suggestive of medulloblastoma. When referred to us she had persistent fever with normal blood and spinal fluid cultures. Whole CNS MRI did not give evidence of residual or metastatic disease while CSF cytology showed only pleiocytosis. Treatment was started according to our ongoing protocol for medulloblastoma with pre-radiation chemotherapy. Before delivering radiotherapy (RT), upon review of histologic specimens, the definitive diagnosis of IL B-phenotype was made. The girl was re-admitted and, after a complete re-staging, chemotherapy was intensified according to our schedule for high-grade B-cell lymphoma and CNS was irradiated up to a total dose of 25 Gy. She remained alive in continuous complete remission at 21 months after diagnosis. The case here reported is unique for age, tumor presentation, and, so far, favourable outcome, in spite of the delayed histological diagnosis.

Management of medulloblastoma and ependymoma in infants: a single-institution long-term retrospective report

To reduce the sequelae from CNS irradiation (RT), 16 children younger than 3 years with medulloblastoma-PNET (13 cases) and ependymoma (3 cases) were treated between 1987-1993 according to different postsurgical chemotherapy (CT) programs. None of these patients presented with metastases. Eleven patients were rendered disease-free by surgery, while 5 had residual tumor. Adjuvant therapy depended on patients' age, postsurgical status and parents' consent to radiotherapy (RT). Nine of the 16 infants remained alive in continuous complete remission from the first neoplasm (median follow-up 7 years). Three of them had been treated with CT alone and 6 with combined CT + RT (posterior fossa 4, whole CNS 2). Seven patients relapsed a median of 13 months after diagnosis, and all 7 of them died of their disease. Despite the omission of RT in 6 of the 16 patients and administration of only focal RT in 8 of the 16, the outcome of this series was satisfactory. Local failure (in 5/7 patients) was the major problem, despite the high dose of RT used in 2 of these 5. In 4 of 6 evaluable children school performance was satisfactory. One child in whom the entire CNS was irradiated developed glioblastoma multiforme 120 months after the first diagnosis of medulloblastoma.

[Locally advanced breast tumors. Role of magnetic resonance in the assessment of response to preoperative therapy and of neoplastic residue before the operation]

INTRODUCTION AND PURPOSE

Induction chemotherapy is the preoperative treatment for locally advanced breast carcinoma. The patients affected with this kind of tumor were previously considered inoperable. The sequential use of different cytotoxic drugs reduces the tumor mass effectively, thus allowing resection and improving patients prognosis. Tumor debulking is at times so significant that conservative treatment can even be considered. A reliable assessment of the response to drug therapy by conventional diagnostic procedures is usually hindered by chemotherapy-induced fibrosis. Magnetic resonance imaging (MRI) is a better tool for distinguishing fibrosis from still vascularized pathologic tissue and thus permits more accurate evaluation of tumor response to chemotherapy, namely tumor debulking and residual viability.

MATERIAL AND METHODS

We selected 27 patients with breast cancer and submitted them to MRI both before and after chemotherapy. All examinations were performed with a high field system using 3D Flash sequences with optimized spatial and temporal resolution.

RESULTS AND DISCUSSION

The morphologic and dynamic parameters of MRI were in agreement with pathologic findings. In case of persistent disease after chemotherapy, MRI demonstrated increased contrast agent uptake at restaging, with dynamic curves indicating early and intense uptake. In case of marked post-chemotherapy changes, the dynamic curves had a shorter and less steep trend. Finally, when no or very little (few microns) tumor tissue was left, MRI showed no uptake.

CONCLUSIONS

Our initial experience indicates MRI as a valid too for monitoring chemotherapy response in breast cancer patients.

Treatment of childhood post-irradiation sarcoma of bone in cancer survivors

PATIENTS AND METHODS

This is a retrospective review of five children with post-irradiation bone sarcoma (PIS). Age at PIS onset ranged between 10 and 17 years (median 11). They were treated with a chemotherapy regimen, similar to that in use for primary osteogenic sarcoma, consisting of vincristine and high-dose methotrexate alternated with cisplatinum and ifosfamide, given for 12 months.

RESULTS

In all children chemotherapy induced a complete clinical remission. Four of them were alive in continuous complete remission at 1, 2, 4, and 12 years from the diagnosis of bone sarcoma. One girl recurred 3 years from PIS diagnosis and was salvaged by repeating the same chemotherapy program: she remained alive in second complete remission 8 years from relapse.

CONCLUSIONS

In spite of an intensive treatment previously given for the primary tumor, this drug schedule proved to be feasible and short-term side effects were manageable. Chemotherapy alone, using an intensive regimen effective for primary osteogenic sarcoma, may be an adequate therapy for childhood post-irradiation sarcoma.

[Diagnostic imaging of liver metastasis]

The early diagnosis and monitoring of hepatic metastases are now achieved by different imaging modalities, some using ionizing radiations (computed tomography and angiography), some based on other energy sources (sonography and magnetic resonance), but all coming within the radiological area, which offers concrete possibilities of integration and the necessary organization. These modalities are sometimes used only for percutaneous histological samplings with minimal invasiveness. The progress in hepatic resective surgery and the possibility of orthotopic liver transplantation for some neoplastic histotypes, together with the alternatives provided by interventional radiology, have brought a continuous updating of the specialist' interest in the morphological and functional definition of hepatic metastatic disease, with the specific aim of choosing the best therapeutic strategy. Hepatic metastases have the greatest impact on the survival of patients with gastrointestinal neoplasms, especially colonic adenocarcinoma. Intraoperative sonography and CT arterial portography currently provide greatest diagnostic sensitivity in terms of spatial resolution but cannot be considered as methods of choice, the former for obvious reasons and the latter because of its invasiveness and complexity. The alternatives are to be sought in spiral CT and the new MR sequences which can undoubtedly provide a decisive improvement in the diagnostic standards currently available. Profoundly changed, but no less important, is the role of angiography, which still provides the anatomical support for hepatic surgery and the means for alternative treatments, such as chemoembolization and continuous infusional chemotherapy.

New imaging techniques in staging lymphomas

A variety of imaging modalities are used to evaluate patients with lymphoma, mainly Hodgkin's disease. During the past few years, the improvement of diagnostic techniques has had a great impact on both staging and patient treatment. This review of the current status of imaging presents the possibilities of available diagnostic tools in the assessment of lymphomatous involvement of different organs and apparatus, emphasizing those aspects that might influence patient management and treatment. For central nervous system lymphomas, pre- and postcontrast computed tomography and magnetic resonance have completely replaced other radiologic methods. Similarly, because it seems clear that computed tomography will replace lymphography by the end of this decade, just as computed tomography and magnetic resonance imaging are expected to entirely replace staging laparotomy, the possibilities of these diagnostic tools and their impact on diagnosis and follow-up are also discussed.

[Value of magnetic resonance in the staging of non-small-cell lung carcinoma]

In the last six years, 544 consecutive patients with nonsmall-cell bronchogenic carcinoma were studied with MRI. MR results were compared with surgical specimens and pathologic findings. Both TNM classification and ATS nodal mapping were considered. Local tumor extent (T parameter) was correctly identified in 67.2% of cases, understaged in 19.4% and overstaged in 13.4%. Lymph node metastases (N parameter) were adequately assessed in 55.5% of cases, understaged in 20.3% and overstaged in 24.2%. Considering two groups of patients, the first one with early stage disease (T1-T2, N0-N1) and the second one with advanced stages (T3-T4, N2-N3), MRI exhibited 84.6% overall accuracy, 57.3% sensitivity and 93.7% specificity for the T parameter and 72.3% accuracy, 65.2% sensitivity and 75.1% specificity for the N parameter. In conclusion, MRI did not provide the expected results in the staging of nonsmall-cell bronchogenic carcinoma, but improvement will probably be achieved with technological evolution.

Heart involvement in lymphomas. The value of magnetic resonance imaging and two-dimensional echocardiography at disease presentation

BACKGROUND AND METHODS

Thirty-six patients with mediastinal lymphoma were studied with chest magnetic resonance imaging (MRI) and two-dimensional echocardiography at presentation to define the extent of the disease in the paracardiac area.

RESULTS

Involvement of cardiac structures was present in 23 of 36 patients (64%). Pericardial contiguity was detected in 23 of 23 patients (100%) by MRI and in 18 of 23 patients (78%) by echocardiography. Pericardial effusion, present in 17 patients (74%), and pericardial infiltration, present in 7 patients (30%), were detected by both techniques in 71% and 86%, respectively. Myocardial infiltration was identified in two of two patients (100%) by MRI and in one of two patients (50%) by two-dimensional echocardiography. Extrapericardial disease was identified in 100% of patients by MRI but only in 30% of patients by echocardiography.

CONCLUSIONS

Extracardiac and intracardiac involvement is a frequent event in mediastinal lymphomas and should be carefully evaluated with different imaging modalities, mainly MRI, for correct diagnosis and proper management.

Hallervorden-Spatz disease: MR and pathologic findings

PURPOSE

To compare the MR findings of eight cases with clinical diagnosis of Hallervorden-Spatz disease (HSD) with the pathologic findings of two other cases of HSD.

MATERIALS AND METHODS

The eight imaged cases were studied with 0.5-T (seven cases) and/or 1.5-T (five cases) units. Six patients also had CT scans. The two other cases with proven HSD had detailed histologic evaluation.

RESULTS

The 1.5-T findings showed abnormalities confined to the pallidum, which presented a diffuse low signal intensity in T2-weighted images, and an anteromedial area of high signal intensity (eye-of-the-tiger sign). In 0.5-T studies, low signal intensity was less evident and poorly detectable in spin echo, but gradient-echo images could enhance its demonstration; the area of high signal intensity was always well demonstrated. In three cases (three with 1.5 T, one with 0.5 T) a central spot of low signal intensity was seen in this area. The pathologic cases, in addition to neuroaxonal swellings and iron deposits, exhibited areas of "loose" tissue with vacuolization and lesser amounts of iron in the anteromedial part of the pallidum, in a location corresponding to the area of high signal intensity of the imaged cases.

CONCLUSION

Comparison of MR findings with the pathologic studies demonstrates that the low signal intensity in T2-weighted images at 1.5 T corresponds to iron deposits in a dense tissue, and that the high signal intensity of the eye-of-the-tiger sign corresponds to an area of loose tissue with vacuolization. No correlation was found in the two pathologic cases for the central spot of low signal intensity.

Magnetic resonance imaging in the initial staging of Hodgkin's disease and non-Hodgkin lymphoma

Seventy-four consecutive previously untreated patients with Hodgkin's disease (HD) and non-Hodgkin lymphomas (NHL) were evaluated with chest, abdominal and pelvic magnetic resonance (MRI) for initial staging. All patients underwent routine radiological staging procedures which included chest radiographs and lymphography (LAG). These studies were followed in most of cases by laparoscopy, during which biopsies of the liver and the spleen were taken, and bone marrow aspiration and histology. A correlation of the results of MRI with both other imaging studies and histopathologic diagnoses was performed, and discordant cases were assessed to determine the impact on clinical staging. Additional evidence of disease involvement was provided mainly in the chest, where MRI demonstrated the presence of unsuspected disease in 21% of involved patients (9 of 42). Retroperitoneal lymph nodes were correctly assessed in 97% of cases if MRI was compared with LAG. Extranodal abdominal disease was identified both in the spleen (14%) and in the liver (1%). Bone marrow abnormalities were detected in 19% of patients (14 of 74). MRI findings influenced the staging of HD and NHL patients in 11 of 74 cases (15%).

Reliability of diagnostic imaging after orchiectomy alone in follow-up of clinical stage I testicular carcinoma: excessive cost with potential risk

From 1981 to 1984, 86 consecutive patients with previously untreated nonseminomatous testicular carcinoma were classified as clinical radiological stage I and treated with orchiectomy alone. The follow-up program included chest x-ray and lymphangiography (LAG) every month and abdominal computed tomography (CT) bimonthly. All patients were followed for 15 to 63 months after orchiectomy (median 32 mo.). Metastases developed in 23 patients (26.7%) and in 13/23 there was retroperitoneal lymphadenopathy. Time of relapse after orchiectomy ranged from 2 to 36 months (median 7 mo.) with a shorter interval for chest (4 mo.) compared with retroperitoneal metastases (7 mo.). Lung metastases were readily identified at an early stage (less than 2 cm) whereas more than one-third of retroperitoneal nodal metastases were greater than 5 cm at time of diagnosis. LAG detected metastases in 8/11 patients (72.7%), abdominal CT in 8/10 (80%), and both together (LAG and CT) 7/8 (87.5%). In clinical stage I nonseminomatous testicular carcinoma, the high incidence of concomitant but often asymptomatic regional and distant metastases and the relatively high cost and inconvenience of follow-up using abdominal CT imaging, LAG and chest x-ray suggest that orchiectomy is best combined with retroperitoneal node dissection at time of initial presentation to insure more accurate and safe staging of tumor dissemination.

Orchiectomy alone in clinical stage I nonseminomatous testis cancer: a critical appraisal

Sixty-two consecutive patients with clinical stage I nonseminomatous testicular cancer were entered into a prospective study to receive no treatment after orchiectomy until clinical evidence of recurrent disease. Of 59 evaluable cases, 41 (69.5%) remained continuously disease free for a median duration of 30 months (range, 18 to 46 months), and evidence of metastatic disease developed in 18 patients (30.5%) from 2 to 36 months after orchiectomy. The median disease-free interval for relapsing patients was 6 months. Retroperitoneal metastases developed in ten patients; seven patients had pulmonary metastases, and one patient had progressive elevation of the serum alpha-fetoprotein level. Relapses were significantly more frequent in patients with either embryonal carcinoma, infiltrating testicular cancer (pT greater than 1), peritumoral vascular invasion, or in those who underwent transscrotal biopsy. One patient with relapse refused salvage therapy and died. The remaining 17 patients have been rendered disease free with cisplatin combination chemotherapy and/or surgery. However, two patients showed further recurrence, with one in the lung and the other one also in the retroperitoneal nodes. In our opinion, surveillance following orchiectomy will provide useful information in clinical stage I nonseminomatous testicular cancer, but it is a difficult study. For the time being, it should be restricted to specialized centers only. In the meanwhile, retroperitoneal lymphadenectomy remains the standard treatment.

Lymphangiography and computerized tomography in testicular carcinoma: how accurate in early stage disease?

The usefulness of lymphangiography and computerized tomography was evaluated in 167 consecutive patients with pathological stages I and II testicular carcinoma and metastases of less than 5 cm. Lymphangiography demonstrated 74.4 per cent sensitivity, 77.6 per cent specificity and 76.0 per cent over-all accuracy. Computerized tomography revealed comparable results, with 74.3 per cent over-all accuracy, 73.7 per cent sensitivity and 75.0 per cent specificity. The combination of lymphangiography and computerized tomography performed in 35 patients consistently improved the diagnostic possibilities of either technique alone in patients with positive nodes, reducing the false negative rate from 27 to 10 per cent. On the other hand, this combination increased the false positive rate from 25 to 37 per cent in patients with negative nodes. In patients with clinical stage I disease for whom a wait-and-see policy after orchiectomy is adopted at our institute both methods must be considered mandatory. In all other situations computerized tomography alone should be the preferred procedure in the diagnosis of retroperitoneal lymph node metastases from testicular carcinoma.

Indirect lymphography of the breast with iotasul: a vanishing hope?

Using a new aqueous nonionic contrast medium (Iotasul, Schering) we attempted visualization of axillary lymph nodes in patients with breast carcinoma. Intradermal infusion into the areola consistently opacified the subareolar plexus and latero-cranial lymphatic trunk. Axillary nodes were visualized in 78.6% of patients, but only 5.7% of surgically excised nodes were partially or totally opacified. Eleven patients underwent axillary lymph node dissection and histology confirmed metastases in 4, of which only two were detected by lymphography. Breast lymphography is inadequate for routine clinical application, and radical axillary dissection remains the mainstay for documentation of nodal metastases.

Oophorectomy in Advanced Breast Cancer: Clinical Radiologic Correlations

The radiograms of the chest and skeleton of 49 patients with advanced breast cancer treated with bilateral ovariectomy were reviewed. The modifications in the secondary localizations and/or their appearance after castration were compared with the findings of the clinical examination. Appearance or progression of intrathoracic lesions, like the appearance or progression of osteolytic lesions, corresponded to a progression of the disease in other sites. Osteoblastic evolution of osteolytic lesions and the appearance of osteoblastic lesions in bones undamaged before ovariectomy were signs of a favorable response to therapy. The response of chest and bone metastases is usually rather early, and the first radiographic survey should be performed about 3 months after ovariectomy.

Retroperitoneal metastases from ovarian carcinoma: reassessment of 365 patients studied with lymphography

From 1973 through 1978, 365 patients with ovarian carcinoma were evaluated with lymphography. The extent of disease was assessed by clinical and conventional radiologic examinations, peritoneoscopy with visualization of diaphragmatic leaves, peritoneal cytology, and, in some patients, exploratory laparotomy. The highest incidence of metastases was found in advanced stages (31.1% in stage III and 60% in stage IV) and in recurrences (75.9%). In 87 patients with early disease, the incidence was 9.2%. In 36 pretreated patients with no evidence of disease, this incidence was 11.1%. Biopsies of the nodes were performed in 96 patients: radiologic accuracy was confirmed in 33 of 33 positive and in 55 of 63 negative cases. Of the patients, 33% had metastases only in the pelvic nodes, and 7.9% only in the paraaortic nodes; in 79.1%, both chains were involved simultaneously. These data confirm the importance of lymphography in diagnosis, treatment planning, and surveillance of ovarian carcinoma.

Ewing's Sarcoma: An Approach to Radiological Diagnosis

All the pertinent radiographs of 83 patients with histologically proven Ewing's sarcoma were reviewed. Forty-nine patients were in the pediatric age group, and 34 were adults. The mean age, the symptoms and time from symptoms to diagnosis were evaluated in the 2 groups. The site of primary involvement was in 54 % the long bones, 35 % the flat bones, 8 % the small bones and 3 % extraosseous. For the primary site we considered the diagnostic results of the standard radiographic investigations and in some cases the usefulness of angiography, xeroradiography and telethermography. At presentation we also evaluated the possible diffusion of the disease with standard radiographic surveys (chest and skeletal, including limbs) and with foot lymphography in selected cases. In this way, 57 patients (69 %) were considered to have localized disease. In this group, we also considered the value of the periodic radiographic follow-up, which enabled us to disclose the appearance of metastases (chest 64 %, bone 54 %, lymph nodes 11 %) in 28 cases (49 %). Finally, we made a comparison of the different radiologic and epidemiologic findings between children and adults.