Treatment of high-risk Hodgkin lymphoma with a modified Stanford V regimen in the AHOPCA: Substituting chemotherapy agents and hampered outcomes

BACKGROUND/OBJECTIVES

High-risk Hodgkin lymphoma (HRHL) in children is curable with combined modality therapy. The Association of Pediatric Hematology-Oncology of Central America (AHOPCA) is a consortium of cancer centers from Central America. In 2004, AHOPCA implemented a guideline with a short course of chemotherapy (mStanfordV), strict diagnostics, and radiation guidelines, aimed at reducing abandonment and improving outcomes.

METHODS

Newly diagnosed children less than 18 years of age with high-risk HL (Ann Arbor stages: IIB, IIIB, IV) from AHOPCA centers were staged with chest radiography and ultrasound or computed tomography. Therapy was a modified Stanford V (mStanfordV), substituting cyclophosphamide for mechlorethamine and involved field radiation.

RESULTS

Of 219 patients with HRHL, 181 patients were eligible and evaluable; 146 (81%) were boys, 22% being less than 6 years; 43 were stage IIB, 84 IIIB, and 54 IV. Thirty-one (17%) abandoned therapy, 28 (15%) progressed, 30 (17%) relapsed, and eight (4%) died of toxicity. Radiation guidelines were not followed. Five-year abandonment-sensitive event-free survival and overall survival (AS-EFS, AS-OS ± SE) for the cohort were 46% ± 4% and 56% ± 4%; 5-year AS-OS for stages IIB, IIIB, and IV was 76% ± 7%, 59% ± 7%, and 35% ± 7% (p = .0006).

CONCLUSION

Despite instituting a short treatment guideline, it did not improve the abandonment rate (17%) and did not achieve the reported outcomes of Stanford V. The cyclophosphamide dose used to replace merchlorethamine was inadequate. Despite strict guidelines, the radiation therapy application was inaccurate. Weekly chemotherapy may have adversely affected abandonment of therapy by increasing the burden of travel time. Based on these results, AHOPCA established a new abandonment strategy and a new guideline.

Exploratory survey of image quality on CR digital mammography imaging systems in Mexico

The purpose of this study was to assess the current status of image quality and dose in computed radiographic digital mammography (CRDM) systems. Studies included CRDM systems of various models and manufacturers which dose and image quality comparisons were performed. Due to the recent rise in the use of digital radiographic systems in Mexico, CRDM systems are rapidly replacing conventional film-screen systems without any regard to quality control or image quality standards. Study was conducted in 65 mammography facilities which use CRDM systems in the Mexico City and surrounding States. The systems were tested as used clinically. This means that the dose and beam qualities were selected using the automatic beam selection and photo-timed features. All systems surveyed generate laser film hardcopies for the radiologist to read on a scope or mammographic high luminance light box. It was found that 51 of CRDM systems presented a variety of image artefacts and non-uniformities arising from inadequate acquisition and processing, as well as from the laser printer itself. Undisciplined alteration of image processing settings by the technologist was found to be a serious prevalent problem in 42 facilities. Only four of them showed an image QC program which is periodically monitored by a medical physicist. The Average Glandular Dose (AGD) in the surveyed systems was estimated to have a mean value of 2.4 mGy. To improve image quality in mammography and make more efficient screening mammographic in early detection of breast cancer is required new legislation.

Management of pediatric radiation dose using Canon digital radiography

A Canon CXDI-11 digital radiography (DR) system has been in use at Shands Hospital at the University of Florida for the past 2 1/2 years. A first clinical implementation phase was utilized to develop imaging protocols for adult patients, with a second phase incorporating pediatric chest and abdominal studies a few months later. This paper describes some of the steps taken during the modality implementation stages, as well as the methodologies and procedures utilized to monitor compliance by the technologists. The Canon DR system provides the technologist with an indication of the radiation exposure received by the detector (and thus of the patient dose) by means of an indirect exposure level number called the reached exposure (REX) value. The REX value is calculated by the system based on the default grayscale curve preselected for a given anatomical view and used by the system to optimize the appearance of the image. The brightness and contrast of the image can be modified by the user at the QC/control screen for the purpose of improving the appearance of the image. Such changes modify the actual grayscale curve (position and slope, respectively) and thus the calculated REX value. Thus, undisciplined use of the brightness and contrast functions by the technologist can render the REX value meaningless as an exposure indicator. The paper also shows how it is possible to calibrate AEC (phototimer) systems for use with the Canon DR system, and utilize the REX value as a valuable dose indicator through proper training of technologists and strict, disciplined QC of studies. A team consisting of the site's medical physicist, radiologists, and technologists, as well as Canon engineers, can work together in properly calibrating and setting up the system for the purposes of monitoring patient doses (especially pediatric) in DR studies performed in a Canon DR system.

Implementation of a radiology electronic imaging network: the community teaching hospital experience

Because of their typically small in-house computer and network staff, non-university hospitals often hesitate to consider picture archiving and communication system (PACS) as a solution to the very demanding financial, clinical, and technological needs of today's Radiology Department. This article presents the experiences of the 3-year process for the design and implementation of the Radiology Electronic Imaging Network (REIN) in the Department of Radiology at The Western Pennsylvania Hospital (WPH). WPH embarked on this project in late 1994 to find a solution to the very pressing demands to reduce operating costs and improve service to primary care clinicians, both on-site and at WPH-affiliated clinics. A five-member committee consisting of in-house medical, administrative, information services, and medical physics staff was formed to design a network that would satisfy specific needs of WPH by using a phased mini-PACS approach and to select the various vendors to implement it. Suppliers for individual mini-PACS were selected to provide modality-specific solutions. For the backbone network, vendors were evaluated based on their technological progress, competence and resources, the commitment of the company to the imaging network business, and their willingness to embark on a mid-sized PACS project such as this. Based on patient volume, workflow patterns, and image quality requirements, the committee produced proposals detailing number and location of workstations, short- and long-term memory requirements, and so on. Computed tomography/magnetic resonance imaging, computer radiography, ultrasound, nuclear medicine, digital fluoroscopy, and angiography mini-PACS have been implemented over the past 2 years, and most of these are already integrated into the main REIN. This article presents detailed information concerning the design, selection and implementation processes, including storage requirement calculations. This indicates that PACS implementation is achievable for community hospitals with small computer, networking, and physics departments. Also presented are recommendations concerning design and vendor selection, that may be helpful for similar institutions.

The effects of three different regimens of oral contraceptives and three different intrauterine devices on the levels of hemoglobin, serum iron and iron binding capacity in anemic women

The effects on hemoglobin, iron and iron binding capacity (IBC) in 150 moderately anemic women of 1) a 21-day low-dose combined pill, 2) the same low-dose combined pill for 21 days, followed by 7 days of an iron-containing pill, 3) the same low-dose combined pill administered for 63 consecutive days, followed by 7 days of no pill intake, 4) Lippes IUD, 5) TCu 220C and 6) Progestasert were studied. The three pill regimens were associated with an increase in hemoglobin and serum iron after 12 months. However, the iron pill and 63-day schedule groups produced an increase in hemoglobin and iron at the 6th month ans a diminution of IBC at 12 months. The Lippes and TCu 220C groups did not show any change in hemoglobin, iron or iron binding capacity after 12 months. The Progestasert group showed an increase in hemoglobin and iron levels at 6 and 12 months, and a diminution of IBC at 12 months. The pill and Progestasert have advantages as contraceptives in anemic women.