Renato Musumeci

Natural history of dysgerminoma

Data on 56 patients with pure dysgerminoma are discussed. Forty-nine patients were classified as having new disease or were to have reassessment of disease, and seven cases were to be restaged (one with and six without clinical evidence of disease). Of new and reassessment cases, 44 patients underwent lymphography, 16 underwent peritoneoscopy with diaphragmatic inspection and 30 had peritoneal cytologic testing performed. Positive lymphography resulted in restaging in 31.6% of patients. Diaphragmatic inspection was always negative. Peritoneal cytologic testing was positive for malignant cells in three patients and worsened the stage in one. Pathologic staging of disease was as follows: Stage IA, 24; Stage IB, one Stage IC, one; Stage III peritoneal disease, two. Stage III retroperitoneal disease, 12; Stage III peritoneal and retroperitoneal disease; four. The 5-year relapse-free survival rates were 91% in patients with pathologic Stages IA, IB, and IC; 74% in those with Stage III retroperitoneal disease, and 24% in patients with Stage III peritoneal disease or peritoneal plus retroperitoneal disease. The results indicate that the prognosis is excellent for patients with Stage I and Stage III retroperitoneal disease whereas peritoneal involvement is associated with a poor prognosis.

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.

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

Seventy-four consecutive previously untreated patients with Hodgkins 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%).

The value of staging laparotomy in non‐Hodgkin's lymphomas. (With emphasis on the histiocytic type)

Laparotomy with splenectomy and multiple tissue biopsies was performed in 106 adult patients with non‐Hodgkins lymphoma (histiocytic—76, lymphocytic—25, and mixed type—5). The histologic pattern at initial biopsy showed nodular lymphoma in 33% and diffuse lymphoma in 67%. Diffuse histiocytic was the most frequently observed histologic type in this series (54%). Before laparotomy, 92% of patients had primary lymphatic and 8% primary extralymphatic involvement. Waldeyers ring involvement accounted for 27% of all patients. Systemic symptoms were present in 7%. Clinical stage (Ann Arbor Classification as proposed for Hodgkins disease) was as follows: I—29%, II—32%, IIs— 2%, III—24%, IIIs—8%, and IV—5%. After staging laparotomy these figures were 25%, 29%, 1%, 20,% 8%, and 17%, respectively (down stage 23%, up stage 4%). Spleen was involved in 23%, liver in 12%, gastrointestinal tract in 5%, and bone marrow in 12%. In 27%, lesions were occult to conventional diagnostic methods. Although not sampled in all patients, splenic hilar, celiac, and mesenteric nodes were the most frequent occult sites of intra‐abdominal lymphoma. With clinical methods, false negative findings for spleen involvement were 12% and for liver 11%. Spleen involvement occurred more often in nodular (29%) than in diffuse lymphoma (19%). There was no appreciable difference in the splenic infiltration among histiocytic (22%), lymphocytic (24%), and mixed (20%) types. With the exception of one case, there were no patients with hepatic involvement without concomitant splenic involvement. Lymphography yielded a 96% accuracy proving once more to be a sufficiently reliable diagnostic method. Two patients died after laparotomy because of acute peritonitis and acute pancreatic necrosis, respectively. Otherwise, the incidence and type of complications were found acceptable. Collectively, our findings indicate that staging laparotomy is a useful procedure in non‐Hodgkins lymphomas to identify occult lesions before planning treatment and to gain more information on the natural history of these diseases.

Lymphangiography in patients with ovarian epithelial cancer: an evaluation of 289 consecutive cases.

From January, 1973, to June, 1976, 226 patients with palpable ovarian masses were evaluated preoperatively by lymphography. Histology showed 166 cases of malignant epithelial tumors, 26 benign tumors, and 34 malignant special tumors (not included in this report). Furthermore, the group of patients included 99 recurrences of ovarian epithelial cancer and 24 patients who underwent restaging diagnostic procedures without clinical evidence of disease. Lymphography was negative in all patients with benign tumors. In the 289 cases of epithelial cancer, lymphangiography gave evidence of nodal metastases in 88 (30%). When the histological subtype was considered, the highest incidence of metastases was in undifferentiated carcinoma (50%) and the lowest, in mesonephroid carcinoma (14%). According to the stage before lymphography, nodal metastases were found in 8% of Stage I, 0% of Stage II, 29% of Stage II, and 53% of Stage IV cases. The incidence of metastases was 46% in patients studied for recurrent disease and 17% in patients studied for restaging. Fifty‐four percent of patients had metastases only in the pelvic nodes and 18% only in the para‐aortic chains; in 28% both chains were involved simultaneously. Bilateral involvement was found in 63% of the positive cases. Retroperitoneal node biopsies were performed in 68 patients (36%). The radiologic/histologic correlation was 100% in the lymphangiographically positive cases; 81% in the negative cases, with nine false‐negative reports; and 87% in all cases.

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.

Esophageal squamous cell carcinoma: MRI evaluation of mediastinum

Thirty-two patients with esophageal spinocellular (squamous cell) carcinoma were studied with superconductive magnet in order to evaluate local and extraluminal extent, as well as mediastinal lymph node spread of the disease. In the absence of adenopathy, the localized tumors were considered susceptible to surgical treatment. All patients were operated on within 21 days. The resectability criteria were correctly evaluated in 75% of cases; sensitivity and specificity were 86 and 67%, respectively. Unsatisfactory results were obtained in the evaluation of mediastinal adenopathies. We conclude that magnetic resonance imaging (MRI) is useful in the preoperative evaluation of resectability criteria in patients with esophageal squamous cell carcinoma.

Germ cell tumors of the ovary: The experience of the national cancer institute of milan. I. Dysgerminoma

The experience of the Istituto Nazionale Tumori of Milan on dysgerminoma is presented. Between 1970 and December of 1982, 25 patients were treated with a unique protocol which considered surgery and radiotherapy with different schedules according to the extension of the disease. With this treatment protocol all 13 patients at Stage I were alive and free of disease with a median follow-up of 77 months. Of 12 patients at Stage III (10 retroperitoneal and 2 retroperitoneal and peritoneal) 4 relapsed. The 5-year relapse-free survival of Stage III patients was 61.4% and the overall survival 89.5%. Amenorrhea due to radiation dose absorbed by the contralateral shielded ovary was found in 7.7%. The excellent results in Stage I patients were balanced by the unsatisfactory results in Stage III patients. A more aggressive treatment and the knowledge of other prognostic factors seem necessary.

Nondysgerminomatous tumors of the ovary treated with cisplatin, vinblastine, and bleomycin: Long-term results

Twenty-four consecutive patients with nondysgerminomatous germ cell tumor of the ovary were treated after surgery with cisplatin, vinblastine, and bleomycin (PVB regimen). The cycle was repeated every 3 weeks for three to five courses. Fourteen patients had endodermal sinus tumor, and 10 had mixed germ cell tumors. Stage of disease (FIGO, 1986) was as follows: stage I, 6; stage IIc-IV, 17; and recurrence, 1 patient. All patients were monitored by alpha-fetoprotein and human chorionic gonadotropin. Only 1 patient had received previous chemotherapy. All 5 patients without residual disease and with negative marker levels in which PVB was used as adjuvant treatment were free of disease for a median duration of 59 months from the start of PVB. Of the 19 patients with measurable disease (evident disease or positive marker levels), complete remission was obtained in 16 (84%), but 5 of these relapsed. Therefore, treatment with PVB failed in 8 out of 19 patients (42%) with measurable disease. Toxicity was evident, but no patient died of it. Menses were regular in 11 patients whose initial surgery was conservative. PVB regimen is an effective but not a satisfactory treatment. The considerable failure rate of PVB treatment suggests the investigation of other regimens.

Radiographic Findings in Previously Untreated Children with Non-Hodgkin's Lymphoma

The initial radiographs of 51 consecutive, previously untreated children with non-Hodgkins lymphoma were reviewed. The chest radiograph was abnormal in 37%, with pleural effusions seen in 14% of patients. Lymphography, readily performed in children, was positive in 30% of the successful studies. There was a high incidence of bone lesions (18% of patients), due in large part to involvement of the facial bones; all were symptomatic and/or seen on the routine chest and abdominal radiographs. Intrinsic disease of the small bowel (10%) and colon (8%) was also associated with symptoms, so that the value of routine barium studies in asymptomatic children is questioned.