Carissimo Biagini

Treatment by splenic irradiation in 22 chronic lymphocytic leukemia patients.

Twenty-two patients with chronic lymphocytic leukemia, score 2 according to Rai et al. (10), who received only a course of splenic irradiation are reviewed. Splenic doses ranged from 420 to 1080 rad. Response to splenic irradiation was rated by evaluating peripheral lymphocytosis, hepatosplenomegaly, adenomegaly and disease-related symptoms. Following splenic irradiation, 8 patients showed a significant reduction in splenomegaly; 7 patients showed a significant reduction in peripheral lymphocytosis (< 10,000/mm3), which has lasted from 15–42 months without any other treatment. In 14 patients, response to splenic irradiation was partial, and it has successively been necessary to treat 12 patients with chemotherapy. Methods of splenic irradiation, survival, clinical and hematologic behavior are discussed in detail.

Hodgkin's disease stage I and II with exclusive subdiaphragmatic presentation. The experience of the Departments of Radiation Oncology and Hematology, University "La Sapienza" of Rome.

During the period 1978 to 1994, 1054 patients with Hodgkins disease were evaluated and treated at the Departments of Radiation Oncology and Hematology, University “La Sapienza”, Rome. A total of 549 patients presented with clinical or pathological stage I and II; 37 of these had Hodgkins disease below the diaphragm (BDHD), and 512 above the diaphragm (ADHD). A comparison of patients with BDHD versus those with ADHD showed that the first group had a higher male to female ratio. A comparison of cases with stage II BDHD versus those with stage II ADHD showed that patients with BDHD were older (48 years vs 28 years), had different histologic features and a higher incidence of systemic symptoms (67% vs 33%). Stage II BDHD patients had a worse prognosis; in fact, there were significant differences in the overall survival and relapse-free-survival rates for cases with stage II BDHD versus those with stage II ADHD (overall survival, 46% vs 80%, P<0.001; relapse-free survival, 44% vs 69%, P<0.005). Stage was found to be the most important prognostic factor for BDHD cases without systemic symptoms treated with radiation therapy alone. The type of infradiaphragmatic presentation (intra-abdominal vs peripheral disease) did not influence outcome, probably due to the more aggressive therapy received by the intra-adbominal group. Treatment recommendations for BDHD cases should be tailored to the stage and the presence or absence of intra-abdominal localization. For patients with stage IA extended fields, irradiation (inverted Y) is sufficent. However, combined modality therapy should be the treatment of choice for stage II cases, particularly in the presence of intra-abdominal disease. Patients with systemic symptoms also require combined modalities.

Fractionated total body irradiation in allogeneic bone marrow transplantation in leukemia patients: analysis of prognostic factors and results in 136 patients

BACKGROUND AND PURPOSE The results of a single-institution series of patients with chronic and acute leukemias are analyzed with regard to literature-reported predictor variables. MATERIALS AND METHODS Between 1985 and 1994, 136 patients, 82 patients with chronic myeloid leukemia (CML) and 54 with acute leukemia (AL), received a uniform preparatory regimen of fractionated total body irradiation (TBI; 12 Gy in 3 days) plus different chemotherapy regimens before bone marrow transplantation. Eighty-six patients were considered to be in early phase of disease (CML in chronic phase or AL in first complete remission) and 50 in advanced phase (all those beyond first remission or first chronic phase). Ninety-five patients received unmanipulated allogeneic BM, and 41 T-lymphocyte-depleted BM. RESULTS The 5-year overall survival (OS) and disease-free survival (DFS) of the whole series were 43% and 31%, and median survival was 43 and 10 months, respectively. A Cox proportional hazard model identified variables related to overall and disease-free survival. For OS, graft versus host disease (GVHD) was the first independent variable (P < 0.0001), followed by age (P < 0.001), T-depletion (P < 0.01), disease status (P < 0.05) and type of leukemia (P < 0.05). With regard to DFS, only T-depletion (P < 0.0001), disease status (P < 0.01) and GVHD (P < 0.01) resulted predictor factors. Early complications after BMT were reported in 59 patients, TBI-induced delayed toxicity in 9 patients, and 16 patients suffered late complications. CONCLUSIONS Our results confirm the curability of early phase leukemias with standard fractionated TBI-induced Allogeneic bone marrow transplantation (ABMT). With an homogeneous fractionated TBI schedule as employed in our series, T-cell depletion negatively affected the outcome.

Involvement of the bone marrow by non-Hodgkin's lymphomas: incidence, histology and pathologic correlations.

The Lukes and Collins system of classification was applied to 151 cases of non-Hodgkins lymphoma who had bone marrow biopsies taken immediately after histologic diagnosis. Incidence and histologic pattern of bone marrow involvement at the time of initial diagnosis were determined for each subtype of lymphoma. Thirty-three patients (21.8 %) had bone marrow involvement. The frequency of bone marrow involvement was high for undefined and convoluted lymphocyte lymphomas (66.6 %) and low to intermediate for follicular centre cell (20.3 %) and small lymphocyte lymphomas (20.0 %). Within the FCC lymphomas the non-cleaved cell type had a higher incidence of marrow involvement than the cleaved cell type (41.6 % vs 8.9 %). The follicular and diffuse histologic patterns in the diagnostic node did influence the incidence of marrow invasion in the non-cleaved cell type (75 % vs 25 %). A low incidence of marrow involvement was observed for the immunoblastic lymphomas (14.2 %); evidence of marrow infiltration was never observed in patients with true histiocytic lymphoma.

Recurrence of Hodgkin’s Disease after 10 Years: Observation of 5 Cases

Five patients whose Hodgkins disease recurred 10 years or more after the achievement of complete remission are reported. Four out of 5 patients had shown an advanced stage at the onset of disease and therefore had received combination chemotherapy (ABVD or MOPP-like) as primary treatment. Involved-field irradiation was delivered as consolidation therapy in 1 patient only. All pathologically proven relapses occurred in a previously affected area and the histologic subtype differed from the primary subtype. The time interval between the achievement of the first complete remission and the relapse was 120, 170 and 190 months in 3, 1, and 1 patient, respectively. All 5 patients are alive in second complete remission. This paper emphasizes the risk of late relapse even after a prolonged disease-free interval for patients with Hodgkins disease. Close follow-up is therefore recommended also in this clinical setting.

The Role of Restaging Laparotomy in Hodgkin'S Disease

The role of restaging laparotomy (RL) in Hodgkins disease was studied in 41 patients. Two patients were in clinical stage I, 16 in clinical stage II, 13 in clinical stage III and 10 in clinical stage IV. Eight cases had previously received radiation therapy alone, 26 chemotherapy and 7 combined chemo-, and radiotherapy. The patients were divided into 2 groups, depending on the results of the preoperative clinical reevaluation. Group 1 included 20 patients with suspicion of persistent disease; in 6 (30%) RL was positive. Group 2 consisted of 21 cases with clinical appearance of complete response; RL was positive in one case (4.7%). The results of the comparison confirm the high rate of false positive findings in CT and lymphography. RL appears as a valuable procedure in patients with positive or doubtful clinical findings at reevaluation after radical therapy, in order to reduce the risk of unnecessary treatment.

Radiation Therapy for Local-Regional Recurrences of Rectal Carcinoma following Primary Surgery

Aims and background Several studies have emphasized the role of radiation therapy for patients with pelvic recurrences of rectal carcinoma following primary surgery. The occurrence of local-regional relapse usually means a poor prognosis and often a poor quality of life, so that different authors consider the prognosis of patients relapsing after surgery worse than those with primary inoperable tumors or those with residual disease after resection. Methods Between January 1988 and January 1995, 43 patients with local recurrence of rectal carcinoma were treated at our Institution. Twenty-three had previously been operated by abdominoperineal resection and 20 by anterior resection. Thirteen cases also received adjuvant chemotherapy. All patients underwent irradiation with a 6-15 MeV linear accelerator; 8 (19%) received a total dose of up to 45 Gy on the pelvis and 35 (81%) higher than 45 Gy. Eighteen cases (42%) underwent 3-6 courses of chemotherapy with 5-fluorouracil and folates during radiation. Results Treatment tolerance was satisfactory. All cases underwent restaging at 45 days from completion of treatment. Sixteen cases (37%) showed a radiologic response >50%. Median overall survival after relapse was 18.8 months. There were no statistical significant differences in survival between patients treated exclusively with radiation and those treated with chemo-radiothera-py (17 vs 22 months). The results of patients who received doses higher than 45 Gy were statically better (P < 0.05) than those irradiated up to 45 Gy. A slight increase in survival was demonstrated in cases submitted to radical surgery after combined treatment (25 months). Twenty-seven cases (63%) obtained pain control after radiation therapy (median pain remission, 11 months). Conclusions Our results seem to encourage radiation therapists, surgeons and oncologists to have a more curative attitude in the treatment of selected patients with local-regional recurrences of rectal cancers by using multi-modality therapy.