Mediastinal Hodgkin's Disease Research Articles

Reconstruction d’une pariétectomie thoracique transfixiante par grille de titane malléable, une solution élégante à propos d’un cas

Several surgical techniques are available for full thickness chest wall reconstruction. The choice has to be adapted to the size of the loss of tissue, its location, and must finally be accepted by the patient's. We propose a new and unpublished solution. We have in our care a 54 years-old patient suffering from a previous loss of chest wall tissue measuring 7 cm(2) due to surgical treatment of mediastinal Hodgkin's disease with sternal and costal invasion. Because of the sequelae, the goal focused on aesthetic reconstruction. Heartbeat was visible under the skin due to a loss of secondary left breast tissue from an initial treatment with absorbable Vicryl(©) mesh followed by a local skin, and glandular flap. Our choice of reconstruction consisted of inserting a moldable titanium mesh followed by 200 g implants in each breast during the same operation. We did not experience any complications and the patient is satisfied with the results. No example of reconstruction using only a moldable titanium mesh was found in the literature on chest wall reconstruction. Our elegant choice is innovative in our discipline. However, this reconstruction materiel is already part of therapy procedures in other specialized surgeries. This case report illustrates the various facets of our speciality: bring a solution at once repair, aesthetic and unique according to the request of the patient. The use of a moldable titanium mesh allows the reconstruction of stable chest wall. The small size does not present any functional difficulties, but rather unsightly sequel.

Late-onset cervicoscapular muscle atrophy and weakness after radiotherapy for Hodgkin disease: a case series

Patients with cervical or mediastinal Hodgkin disease (HD) classically underwent chemotherapy plus extended-field radiation therapy. We report six patients who gradually developed severe atrophy and weakness of cervical paraspinal and...

Exhaled Nitric Oxide and Nitric Oxide Synthase Expression in Hodgkin's Disease

Hodgkin's disease (HD) is a malignant lymphoma with frequent mediastinal involvement, characterized by a significant inflammatory infiltration. Exhaled nitric oxide (FENO), is present in healthy humans, and has been proven to be increased in eosinophilic diseases such as allergic asthma. We investigated whether FENO is increased in mediastinal HD and whether NO is produced by lymphoma tissue. To this aim FENO was measured in 56 HD patients, 17 with and 39 without bulky mediastinal involvement, in the period from January 2007 to December 2008. Thirty-seven patients were reassessed after remission. Lymph node biopsies of 10 patients were evaluated for inducible (iNOS) and constitutive (eNOS) nitric oxide synthase expression by immunohistochemistry. FENO resulted significantly related to the mediastinal mass maximum diameter (p=0.009) and was significantly higher in patients with as compared to those without bulky mediastinal disease (38.7 ppb, CI 95% 19.3-58.0, versus 20.7 ppb, CI 95% 16.6-24.7; p=0.009). iNOS and eNOS immunoreactivity was observed in tumour and inflammatory cells (eosinophils and histiocytes). Only in patients with bulky mediastinal HD there was a significant decrease in FENO (from 50.4 ppb CI 95% 18.0-82.8 to 11.1 ppb CI 95% 4.4-17.8, p=0.011). In conclusion, high FENO and NOS expression in lymph-nodes indicate that NO is a component of the inflammatory network of HD. FENO may be proposed for the assessment and follow up of bulky mediastinal HD patients.

Subcutaneous Calcification as a Delayed Complication of Radiotherapy: A Case Report and Review of the Literature

Subcutaneous calcification following radiotherapy is a very rare late complication. Here we report a case of radiotherapy for Hodgkin's disease in a patient with ichthyosis. Our review of the literature revealed that subcutaneous calcifications occurred in previously normal skin following irradiation. In our case the calcification developed in abnormal skin after telecobalt radiotherapy for mediastinal Hodgkin's disease. Ichthyosis is a systemic cutaneous disease and may increase the risk of late radiation complications.

Thoracic positron emission tomography using18F-fluorodeoxyglucose for the evaluation of residual mediastinal Hodgkin disease

Residual mediastinal masses are frequently observed in patients with Hodgkin disease (HD) after completed therapy, and the discrimination between active tumor tissue and fibrotic residues remains a clinical challenge. We studied the diagnostic value of metabolic imaging by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in detecting active mediastinal disease and predicting relapse. Twenty-eight HD patients with a residual mediastinal mass of at least 2 cm after initial therapy or after salvage chemotherapy were prospectively assigned to 29 examinations with FDG PET and were evaluated as 29 “subjects.” Patients were monitored for at least 1 year after examination and observed for signs of relapse. Median follow-up was 28 months (range, 16 to 68 months). A PET-negative mediastinal tumor was observed in 19 subjects, of whom 16 stayed in remission and 3 relapsed. Progression or relapse occurred in 6 of 10 subjects with a positive PET, whereas 4 subjects remained in remission. The negative predictive value (negative PET result and remission) at 1 year was 95%, and the positive predictive value (positive PET result and relapse) was 60%. The disease-free survival for PET-negative and PET-positive patients at 1 year was 95% and 40%, respectively. The difference was statistically significant. A negative FDG PET indicates that an HD patient with a residual mediastinal mass is unlikely to relapse before 1 year, if ever. On the other hand, a positive PET result indicates a significantly higher risk of relapse and demands further diagnostic procedures and a closer follow-up.

Thoracic positron emission tomography using18F-fluorodeoxyglucose for the evaluation of residual mediastinal Hodgkin disease

AbstractResidual mediastinal masses are frequently observed in patients with Hodgkin disease (HD) after completed therapy, and the discrimination between active tumor tissue and fibrotic residues remains a clinical challenge. We studied the diagnostic value of metabolic imaging by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in detecting active mediastinal disease and predicting relapse. Twenty-eight HD patients with a residual mediastinal mass of at least 2 cm after initial therapy or after salvage chemotherapy were prospectively assigned to 29 examinations with FDG PET and were evaluated as 29 “subjects.” Patients were monitored for at least 1 year after examination and observed for signs of relapse. Median follow-up was 28 months (range, 16 to 68 months). A PET-negative mediastinal tumor was observed in 19 subjects, of whom 16 stayed in remission and 3 relapsed. Progression or relapse occurred in 6 of 10 subjects with a positive PET, whereas 4 subjects remained in remission. The negative predictive value (negative PET result and remission) at 1 year was 95%, and the positive predictive value (positive PET result and relapse) was 60%. The disease-free survival for PET-negative and PET-positive patients at 1 year was 95% and 40%, respectively. The difference was statistically significant. A negative FDG PET indicates that an HD patient with a residual mediastinal mass is unlikely to relapse before 1 year, if ever. On the other hand, a positive PET result indicates a significantly higher risk of relapse and demands further diagnostic procedures and a closer follow-up.

Syncytial variant of nodular sclerosing hodgkin's disease diagnosed by sputum cytology - A case report

Mediastinal Hodgkin's disease in young females is usually of the nodular sclerosing type. Pulmonary involvement is seen in 15-50%cases of Hodgkin's disease. It is possible to suggest a diagnosis of Hodgkin's disease in sputum by the presence of Reed-Sternberg cells. We report herewith a case of a 22-year-old female diagnosed bypost-bronchoscopy sputum cytology and confirmed by histopathology. A transthoracic fine needle aspiration biopsy proved inconclusive.

Abnormal Flow Volume Loops in Patients With Intrathoracic Hodgkin's Disease

To study the incidence of upper airway obstruction, as measured on the flow volume loop (FVL), in patients with bulky mediastinal Hodgkin's disease; to correlate the FVL with CT of the chest; and to follow the changes in the FVL after treatment of the tumor. Retrospective study of pulmonary function tests (PFTs) and chest CTs performed as part of a clinical trial for Hodgkin's disease. Memorial Sloan-Kettering Cancer Center, a comprehensive cancer care center. Twenty-five patients (15 men and 10 women; age range, 20 to 57 years) with bulky mediastinal Hodgkin's disease enrolled in a clinical trial of chemotherapy followed by external beam radiation therapy. Fourteen of 25 patients (56%) had an abnormal FVL prior to therapy; after chemotherapy, only 7 of 25 patients (28%) had an abnormal FVL. The abnormal patterns seen were either those typical of fixed obstruction or variable extrathoracic obstruction. No patient had a pattern typical of variable intrathoracic obstruction. On chest CT scan, 16 patients had grade-I tracheal deformity; 6 had grade-II deformity, and 3 had grade-III deformity. All three patients with grade-III deformity had a fixed obstruction pattern, as did three patients with a grade-I pattern. Patients with a fixed pattern on FVL had significant decreases in inspiratory and expiratory flow rates. FVL abnormalities suggesting upper airway obstruction occurred in > 50% of patients with bulky mediastinal Hodgkin's disease. A fixed pattern of obstruction was associated with the lower flow rates and severe tracheal distortion on CT; these patients may warrant special attention prior to general anesthesia or invasive procedures. Asymptomatic patients with abnormal FVLs but normal tracheal profiles need not undergo extensive evaluation. No patients showed the expected pattern typical of intrathoracic obstruction, but rather the major effect was on the inspiratory loop. The authors speculate on the mechanism for this unexpected finding.

Restaging with gallium scan identifies chemosensitive patients and predicts survival of poor-prognosis mediastinal Hodgkin's disease patients.

Following treatment of mediastinal Hodgkin's disease (HD), residual masses are frequent and gallium scanning has proven to be of value in the evaluation of their specificity (fibrosis or active disease). This study assessed, for relapse and survival, the predictive value of restaging gallium scan of patients with a residual mass on computed tomography scan after induction chemotherapy. Between 1/89 and 12/97, in 53 newly diagnosed HD patients with a residual mediastinal mass, a gallium scan was performed after chemotherapy (3 or 4 courses) and always before consolidative radiotherapy. Characteristics at diagnosis were: nodular sclerosis histology, 89%; bulky mediastinal disease, 79%; B-symptoms, 51%. gallium scan was positive in 16 patients (30%) and negative in 37 (70%). At median follow-up period of 36 months, freedom-from-progression rate was 86% versus 19% (P<0.0001) for patients with negative vs positive gallium scans, respectively. The 5-year overall survival (OS) rate was 68% and differed significantly (P<0.0001) between negative (91%) and positive (25%) gallium scanning groups. The specificity of gallium scanning was 91% and the sensitivity 72% with a positive predictive value of 81% and a negative predictive value of 86%. Evaluation with gallium scan after induction chemotherapy identifies chemosensitive patients among those with poor-prognosis mediastinal HD. Although relapse may occur in patients with negative gallium scan, a postive gallium scan is highly predictive of failure and poor outcome, and treatment should thus be modified.

Hodgkin’s Disease: Internal Mammary Lymph Nodes Relapse Diagnosed by Gallium-67 Scintigraphy

This article presents the case of a 62-year-old man with treated Hodgkin's disease who had internal mammary lymph nodes relapse after a complete initial response. These masses were gallium avid. These findings were explained by histologically documented Hodgkin's relapse, the first such case reported in that localization without chest wall involvement. The literature on mediastinal Hodgkin's disease and diagnostic procedures are reviewed.

Hodgkin disease: use of Tl-201 to monitor mediastinal involvement after treatment.

To compare thallium-201 scintigraphy with gallium-67 scintigraphy in the detection of residual or recurrent mediastinal Hodgkin disease after treatment. The authors performed planar Ga-67 and Tl-201 scintigraphy in 39 patients aged 7-18 years (27 with mediastinal primary disease) after primary treatment. These scans and those in a control group of 14 patients with newly diagnosed known mediastinal Hodgkin disease were evaluated independently by two radiologists for abnormal mediastinal activity. Results were compared with chest computed tomographic (CT) findings and with the clinical criteria of disease status. Interobserver agreement and consensus agreement on gallium and thallium scan findings were evaluated with the kappa statistic, and the specificity of the two imaging methods was analyzed. All study patients were judged to be free of mediastinal disease with CT and the clinical criteria. Interobserver agreement on findings in the treated and control patients was stronger with gallium scintigraphy (kappa +/- SD = 0.956 +/- 0.044) than with thallium scintigraphy (kappa = 0.638 +/- 0.110). Specificity of ratings based on thallium (85% +/- 6) and gallium (90% +/- 5) scintigraphic findings of mediastinal disease did not differ significantly (P = .48). Specificity improved when the results of the two examinations were combined (97% +/- 2). Thallium scintigraphy can help to predict the absence of mediastinal Hodgkin disease after treatment.

Radiation following chemotherapy for mediastinal Hodgkin's disease: the outcome of various doses for bulky tumors

Twenty-one patients with bulky mediastinal disease responding to chemotherapy received consolidation with low-dose mediastinal radiation (19.8–25.2 Gy). Their 5-year mediastinal failure rate (10%) was equivalent to that of 10 similar patients who received higher doses of 30–44 Gy (20%). Low-dose radiation may be appropriate for these patients. Prospective studies are required to verify these findings.

Comparison of gallium scan, computed tomography, and magnetic resonance in patients with mediastinal Hodgkin's disease

In patients with Hodgkin's disease, the use of gallium-67 scintigraphy (Ga-67) compared to conventional staging and restaging techniques is still controversial. In particular, in a combined modality treatment with chemotherapy and radiotherapy given in sequence, its role in detecting active disease after chemotherapy may be useful in planning the subsequent radiotherapeutic strategy. From March 1990 to September 1994, 125 patients with previously untreated histologically proven Hodgkin's disease were enrolled in two different prospective trials according to clinical stage. Staging procedures included Ga-67, chest-abdominal computed tomography (CT), and/or magnetic resonance (MR). All three tests were performed in 53 patients at staging and in 47 at restaging. Results of Ga-67 at staging were compared to conventional procedures or pathological findings. Results of Ga-67, CT scan, and MR at restaging were compared to disease outcome during the follow-up. Finally a cost/benefit ratio for each test was determined. At staging, Ga-67 showed lower sensitivity than CT and MR (90 vs. 96 and 100%, respectively) because of the number of false-negative images. Nevertheless, by using both CT and Ga-67 scan, the sensitivity is equal to that observed with MR (100%). At restaging, Ga-67 is superior to CT scan and equivalent to MR in detecting true negative patients (specificity: 98% vs. 45% vs. 92%). As a single technique, Ga-67 scan cannot substitute for CT scan or MR in staging patients with Hodgkin's disease. Nevertheless, Ga-67 scan has an important role in defining complete remission after treatment and therefore in planning subsequent treatment. Considering the lower costs of CT scan plus Ga-67 ($320) versus MR alone ($810), the two tests may be considered procedures of choice in staging as well as in restaging patients with Hodgkin's disease.

23 Bulky mediastinal Hodgkin's disease (HD): The efficacy of low-dose radiation (LDRT) following chemotherapy (CHT)

23 Bulky mediastinal Hodgkin's disease (HD): The efficacy of low-dose radiation (LDRT) following chemotherapy (CHT)

77 P - Pulmonary impairment in long-survivors of hodgkin's disease (HD)

Patients (pts) with HD can suffer from pulmonary toxicity after both chemotherapy (CT) (particularly after bleomycin) and radiotherapy (RT) (the mantle field involves mediastinum and lung apices). Pts and methods Spirometry, carbon monoxide diffusion capacity (KCO), analyses of blood gases at rest and during exercise were performed in 27 pts (age: 27–59 yrs), 5 – 23.9 yrs (median: 13,1) after the end of therapy (mediastinal RT, 20–45 Gy: 23 pts, bleomycin: 16 pts). Results Dyspnoea on exertion was reported in 8 pts. The mean values of the vital capacity (VC), residual volume/total lung capacity (RV/TLC) and KCO significantly deviated from the predicted normal values (p = .003, P 2 during exercise. Conclusions A mild restrictive pulmonary defect is a common finding in long-survivors of HD. Pts irradiated for bulky mediastinal HD or treated for relapse have a higher risk of clinically significant respiratory impairment.

Enlargement of a mediastinal mass during treatment for Hodgkin's Disease may be due to accumulation of fluid within thymic cysts

A patient with Hodgkin's Disease (HD) is described as one in whom a mediastinal mass showed progressive enlargement during the first two cycles of chemotherapy owing to accumulation of fluid within thymic cysts. This phenomenon was identified by computed tomography. Dependence on plain radiography would have led to an erroneous diagnosis of progressive HD. We suggest that in all cases of mediastinal HD, apparent failure to respond to treatment must be further investigated by computed tomography or magnetic resonance imaging. Such a policy should avoid unnecessary changes in therapy when enlargement of thymic cysts causing mediastinal widening is mistakenly interpreted as being due to progressive disease.

Gd-DTPA-Enhanced MR Imaging in Mediastinal Hodgkin's Disease

Gd-DTPA-enhanced MR imaging of 15 patients with primary mediastinal Hodgkin's disease was done before, during and after treatment. A total of 43 MR examinations were performed. After successful treatment, 13 patients had residual masses with reduced signal intensity (SI) ratio in the T2-weighted images. The majority of these also had decreased contrast enhancement as compared with the corresponding primary tumour. There was a significant positive correlation between the contrast enhancement and the SI ratios in the T2-weighted images of the primary tumours and/or the residual masses. Necrosis was seen in 3 of the primary tumours and one patient had a cystic residual mass. These necrotic/cystic lesions were easier to detect with the use of Gd-DTPA. Low SI ratio in the T2-weighted image and low contrast enhancement of the residual mass seem to indicate residual inactivity. Gd-DTPA facilitates the differentiation between cystic/necrotic and solid lesions.

Gd-DTPA-Enhanced MR Imaging in Mediastinal Hodgkin's Disease

Gd-DTPA-Enhanced MR Imaging in Mediastinal Hodgkin's Disease

Gd-DTPA-Enhanced MR Imaging in Mediastinal Hodgkin's Disease

Gd-DTPA-enhanced MR imaging of 15 patients with primary mediastinal Hodgkin's disease was done before, during and after treatment. A total of 43 MR examinations were performed. After successful treatment, 13 patients had residual masses with reduced signal intensity (SI) ratio in the T2-weighted images. The majority of these also had decreased contrast enhancement as compared with the corresponding primary tumour. There was a significant positive correlation between the contrast enhancement and the SI ratios in the T2-weighted images of the primary tumours and/or the residual masses. Necrosis was seen in 3 of the primary tumours and one patient had a cystic residual mass. These necrotic/cystic lesions were easier to detect with the use of Gd-DTPA. Low SI ratio in the T2-weighted image and low contrast enhancement of the residual mass seem to indicate residual inactivity. Gd-DTPA facilitates the differentiation between cystic/necrotic and solid lesions.

Mediastinal Hodgkin disease in children: response to therapy.

To determine the frequency of thymic and nodal enlargement at computed tomography (CT) in pediatric patients with Hodgkin disease, time to resolution of mediastinal disease, frequency of residual masses, and ability to distinguish between thymic hyperplasia and residual fibrosis with CT. CT scans of 60 pediatric patients with Hodgkin disease were reviewed. Diagnosis of a residual or recurrent mass was based on surgical, gallium-67 scintigraphic, and clinical findings. In 18 (78%) of 23 patients who underwent serial chest CT, the mediastinum reverted to normal within a mean of 6.3 months. Of these 18 patients, four developed recurrent mediastinal widening due to thymic hyperplasia. Five patients had residual mediastinal masses. Benign fibrosis was confirmed in two patients at biopsy and presumed in three patients on the basis of Ga-67 scintigraphic findings. Recurrent lymphoma was not identified. Mediastinal masses resolve in the majority of pediatric patients with Hodgkin disease. Residual mediastinal widening is indicative of fibrosis, while an enlarged thymus at follow-up more likely represents hyperplasia rather than recurrent disease.