Clavicular Nodes Research Articles

098 Guillain Barré syndrome (GBS) – like presentation as a first clinical manifestation of non-Hodgkin’s lymphoma

A variety of peripheral nerve disorders can be seen in association with lymphomas. We present a case of a 68-year-old female who presented with ten days history of rapid onset ascending paresthesias followed by unsteadiness. Neurological examination was remarkable for truncal ataxia with wide-based gait, large fiber sensory impairment (proprioception/vibration). There was some evidence of autonomic instability given labile blood pressure and tachycardia. MRI head and spine were unremarkable, as was the CSF. She was initially treated as acute ataxic variant of GBS with IVIG; however, there was continued clinical deterioration. Electrophysiology three weeks after symptom onset showed minimally delayed F waves, with normal sensory and motor NCS. Nerve Ultrasound revealed pronounced enlargement of C6 nerve root which was confirmed later with MRI of brachial plexus showing thickening and some enhancement of roots and trunks. Subsequent CT CAP and PET scan showed mediastinal, hilar and supraclavicular lymphadenopathy, though no PET uptake in the region of dorsal root ganglion. Biopsy of the right supra- clavicular node was consistent with an anaplastic large cell lymphoma.Atypical presentations of acute neuropathy can be attributed to GBS; however, they should include evalu- ation of a paraneoplastic process which can have similar acute presentations. This case also demonstrates the importance of nerve ultrasound which can be significantly abnormal in sensory neuronopathy with relatively normal electrophysiological testing.s_hasan_s@yahoo.com

Gastric Adenocarcinoma: Epidemiology, Diagnosis and Treatment at Joliot Curie Cancer Institute: About 136 Patients

Objectives: To report the epidemiological, diagnostic and therapeutic aspects of gastric adenocarcinoma at the Joliot Curie Cancer Institute. Results: There were about 136 cases of gastric adenocarcinoma over a 13-year period. The sex ratio was 1.125. The mean age was 54.29 years. The main risk factors found were epigastric pain, (9.6%), a history of gastric cancer surgery, (1.5%), and smoking (15.4%). Epigastric pain was the most frequent symptom, (65.4%), followed by vomiting. Patients were classified WHO 2 and 3 for 61.8% of the cases according to their clinical status. An epigastric mass was found in 44 patients, (32.4%), and ascites in 8 patients, (5.9%). Hepatomegaly and a sus clavicular node were found in 7% of the cases. Anemia was found in 59 patients, (43.3%), and hemoglobin was less than 8 in 16 patients, (11.7%). Localization was mostly antro pyloric (59.6%) and ulcerous-budding cancer dominated the macroscopic aspects (40.41%). The disease was at stage I in 2.4% of the cases, at stage II in 15.6% of the cases, at stage III in 4% of the cases, and at stage IV in 78% of the cases. Histo pathology showed tubulous or intestinal adenocarcinoma in more than 61% of the patients. Curative surgery was performed in 31 patients (22.8%) and palliative surgery in 39 patients (28.7%). Chemotherapy was given to 53 patients (39%), including 46 cases of palliative chemotherapy (33.8%). After a mean follow-up time of six months, there was a local-regional recurrence in 2 patients, metachronous metastasis in 66 patients (48.5% of the cases); death occurs in 23 patients (16.9% off the cases). Conclusion: Gastric adenocarcinoma in West Africa is a heterogenous histopathologic disease dominated by intestinal and tubular subtypes. It is diagnosed at an advanced stage. Its prognosis is very poor. Routine endoscopy and neo adjuvant chemo radiotherapy should be developed.

“Field in field” for the treatment of breast cancer with lymph nodes: A comparative study with conventional radiotherapy using wedge filters

Introduction Treatment of breast cancer with lymph nodes (internal mammary and clavicular nodes) is achieved in most of the centers using a conventional radiotherapy based on electron-photon beams with junctions and wedge filters. Wedge filters correct for surface obliquities but do not provide optimal dose homogeneity within the breast volume. This study aims at comparing treatment plans using the ‘‘field in field” technique, equivalent to a ‘‘simplified” intensity modulation with treatment plans using wedge filters. Material and methods This study focused on eight patients (for half of the patients, the internal mammary nodes were included in the breast fields) treated for breast cancer with lymph nodes using wedge filters. For these patients a ‘‘field in field” plan was prepared retrospectively. Patients were positioned supine with ipsilateral arm above the head and head turned to the opposite treatment side. The prescribed dose was 50 Gy to the PTV breast and 46–50 Gy for the lymph nodes. For both technics, after treatment plan optimization, doses delivered to targets, heart and ipsilateral lung are reported. Results For the 8 patients and for the same coverage of breast and lymph nodes PTV, the volume of 105% (52.5 Gy) of the dose remaining in the breast volume was 2.65–24.29 cc (mean 13.9 cc) with the ‘‘field in field” technic and 9.49–231.63 cc (mean 98.5 cc) with wedge filters technic. For ipsilateral lung, the mean dose, V20 and V30 were respectively 15.1–16.6 Gy (average 15.8 Gy), 25.4–27.1 Gy (average 26.1 Gy), and 17.3–19 Gy (mean 17.9 Gy) for both technics. Conclusion For 8 patients, ‘‘field in field” treatment plans showed that remaining volume of 105% of the dose was up to 10 times smaller than using wedge filters treatment plans. This technics allowed reducing significantly overdosage areas and therefore having a better dose homogeneity in the breast.

Rapidarc vs. tomotherapy for the treatment of chestwall and lymph nodes: A comparative study

Introduction Treatment of chestwall with lymph nodes (internal mammary and clavicular nodes) is achieved in most of the centers with conventional radiotherapy using photons and electrons beams with junctions. The aim of this study is to do a dosimetric comparative study between two technics using modulation irradiation: Tomotherapy and Rapid Arc (RA). Material and methods Seven patients (5 left, 2 right) were treated using Tomotherapy. For these patients a RA plan was prepared retrospectively. Patients were positioned supine with two arms above the head. The prescribed dose was 50 Gy for the chestwall and 46–50 Gy for the lymph nodes. Optimisation constraints were increased until the PTV coverage was acceptable. Tomotherapy plans were computed with a 2.5–5 cm collimation and a 0.287 pitch. RA plans were computed using a 5 mmbolus on the chestwall, 2 arcs (60–180°) and a +/-10° collimator rotation. Doses delivered to targets, heart and both lungs are reported. Results For the 7 patients the heart mean dose was 7.1–8.6 Gy (mean 7.5 Gy) with Tomotherapy and 4.4–18.1 Gy (mean 9.9 Gy) for RA. For the ipsilateral lung, the mean dose, V5, V20 and V30 were respectively 10.1–14.7 Gy, 56.4–85.7%, 14.8–25.9% and 6.2–16.6% for Tomotherapy. For RA, these values were 10.5–16.0 Gy, 65.3–96.0%, 14.8–30.0% and 6.2–16.6%. Conclusion For 5/7 patients RA plans were acceptable but the OAR doses were generally higher than Tomotherapy plans (in particular V5 of lungs and lung mean dose). For 2/7 patients (left side) RA plans were not acceptable.

CT-Scan Based Localization of the Internal Mammary Chain and Supra Clavicular Nodes for Breast Cancer RadiationTherapy Planning

CT-Scan Based Localization of the Internal Mammary Chain and Supra Clavicular Nodes for Breast Cancer RadiationTherapy Planning

CT-scan based localization of the internal mammary chain and supra clavicular nodes for breast cancer radiation therapy planning

Background and purpose To evaluate the influence of the position and the exact localizations of supra clavicular nodes (SCN) and internal mammary chain (IMC) and their variability among patients in order to improve treatment planning in breast cancer (BC) patients. Patients and methods A total of 46 CT scans of the chest were examined. All patients were female treated with breast conserving surgery and radiotherapy. The study was divided into two phases. The first consisted of measurements on 20 diagnostic CT scans, performed in the supine position with both arms over the head. All patients received contrast. This first phase was performed as a training program for radiologist and radiation oncologist to prepare for the second phase of the study: 26 CT scans in treatment position on angled board without injection. For this second group, patients had one arm raised above the head (treated side) and the other kept by the side (contralateral side). Measurements were performed on both sides to evaluate the influence of the arm position. The depths of IM- and SC vessels were measured at five points: (1) the origin of the internal mammary artery, (2) the sterno-clavicular articulation, (3–5) the first, second and third rib interspaces (RI). Measurements of the depth and of the distance between the internal mammary vessels and the middle axis of the sternum were obtained using electronic calipers on a PACS workstation. Results There were important individual variations of the depth of SCN, as follows: 20–84 mm (diagnostic) and 19–64 (treatment position). No differences in the depth of the IMC were found between treated and contralateral side at the region of the I, II, and III rib interspaces. The lateral margin of the IMC was never more than 40 mm from the middle axis of the sternum (I, II, III rib interspaces). There was no difference in the lateral limits of IMC (the distance between the IM vessels and the middle axis of the sternum) between the two sides: treated and contralateral. Conclusions This study shows the importance of the patients' individual anatomy, their position and the large variability in the depth of SCN. It is important to visualize these regions to permit individual dosimetric optimization.

The importance of patient's position in CT-scan based localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for breast cancer (BC) radiation therapy planning

The importance of patient's position in CT-scan based localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for breast cancer (BC) radiation therapy planning

CT-scan Based Localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for Breast Cancer (BC) Radiation Therapy Planning

CT-scan Based Localization of the Internal Mammary Chain (IMC) and Supra Clavicular Nodes (SCN) for Breast Cancer (BC) Radiation Therapy Planning

Systemic therapy for treating locoregional recurrence in women with breast cancer.

Between 10% and 35% of women with operable breast cancer will experience an isolated locoregional recurrence following their primary treatment. There is currently no good evidence that adjuvant systemic treatment is effective in this situation and there is no standard treatment for women who have such a recurrence. To investigate whether additional systemic treatment will improve the result of local therapy in regard to relapse-free and overall survival in women with potentially curatively resected loco-regional recurrence following breast cancer, who have not had a previous or synchronous distant metastases. Searches were done, in the first half of 2001, of the specialised register of the Cochrane Breast Cancer Collaborative Review Group, The Cochrane Library, MEDLINE and EMBASE. In addition, the records of the Early Breast Cancer Trialists' Collaborative Group were checked for any relevant trials. The citations in articles reviewing the treatment of locoregional recurrence of breast cancer were checked. Randomised controlled trials or trials in which women were allocated to treatment or observation by a quasi-random process (such as alternation or date of birth) were eligible. Our aim was to consider separately women with a first incidence of isolated loco-regional recurrence in the treated breast, the chest wall or the regional lymphnode areas (except clavicular nodes) which can be resected without (R0) or with (R1) microscopically demonstrable residual disease. Women with previous or synchronous distant metastases were to be excluded from this part of the review. The second part of the review was to consider women with inoperable loco-regional recurrence and / or clavicular lymphnode involvement, regardless of previous or synchronous metastases. We identified three closed studies in which there were a total of four randomised comparisons of systemic therapy versus observation for women who have received radiotherapy for loco-regional recurrence of breast cancer. One trial assessed Actinomyicin-D and randomised 32 patients in the 1960s and another randomised the same number of women to alpha-interferon versus observation in the early 1980s. The Swiss SAKK trial assessed tamoxifen for "good risk" patients and combination chemotherapy (Vincristine, Doxorubicin and Cyclophosphamide) for "poor risk" patients. It randomised 178 and 50 women respectively during 1982-1991. Where possible, data on relapse-free and overall survival were extracted for these trials and analysed using RevMan 4.1. No attempt was made to pool the results of the studies because of clinical heterogeneity and the small number of randomised patients. Three ongoing trials of chemotherapy versus observation have been identified. The trial of 32 women who received either radiotherapy alone or in combination with systemic administration of Actinomycin-D found that chemotherapy improved the local control rate but had no apparent effect on overall survival. The interferon trial, which also included a total of only 32 patients, showed that the addition of alpha-Interferon to local treatment of locoregional recurrent breast cancer had no apparent effect on the further course of the disease. The Swiss SAKK trial of tamoxifen (178 women randomized) found an improvement in disease-free survival but not in overall survival and no results are available for the 50 women randomized into the concurrent trial of chemotherapy. The three ongoing trials of chemotherapy have a total target accrual of nearly 2000 patients. This systematic review of randomised trials provides insufficient evidence to do other than conclude that the most appropriate form of practice for women with loco-regional recurrence of breast cancer is participation in randomised trials of systemic treatment versus observation.

Melanoma of the clavicular region: multimodal treatment.

Treatment for melanoma that has metastasized to the supraclavicular nodes should be intensive and use a multimodality approach. Retrospective analysis of clinical records. Six primary care centers, 2 of which were referral centers. Eighteen patients diagnosed as having a rare pattern of advanced melanoma metastatic to the clavicular region. Combined radiotherapy, chemotherapy, and thorough surgical excision of the affected nodal basins. Length of survival from time of diagnosis and treatment to time of follow-up. Median survival among the 18 patients was 28 months with a 22% survival rate at 5 years after diagnosis. Among patients who received radiotherapy to the clavicular node basin, mean length of survival was 88.7 months with a 50% 5-year survival rate compared with a mean length of survival of 33.8 months and an 8.3% 5-year survival rate in patients who did not receive radiotherapy (P<.001). Mean survival among patients who had supraclavicular node dissection was 45.8 months with a 23.1% survival rate at 5 years after diagnosis, compared with a mean survival of 52 months and a 20% 5-year survival rate among patients who did not receive therapeutic lymphadenectomy. Of the 11 patients who had therapeutic lymphadenectomy, 2 also received radiotherapy to the supraclavicular nodal basin and continued to be disease-free at 82 and 130 months. All long-term survivors had been treated with intra-arterial chemotherapy. In a series of patients with malignant melanoma metastatic to the clavicular lymph nodes, multimodality treatment using radiotherapy, chemotherapy, and thorough surgical excision of affected nodal basins provided an appreciable 5-year survival rate.