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We report the case of a 78-year-old patient with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI) of the right coronary artery, subsequently found to have a large subepicardial mass. The patient underwent a non-invasive multimodal diagnostic work-up including cardiac computed tomography and cardiac magnetic resonance imaging, which led to the diagnosis of subepicardial hematoma following coronary perforation during primary PCI. Due to clinical stability and absence of active bleeding sources, the patient was managed conservatively with gradual absorption of the mass and favorable prognostic outcome.

The term "MINOCA" refers to myocardial infarction with non-obstructed coronary arteries and has been used to define acute myocardial infarction with no angiographic evidence of significant epicardial coronary artery stenosis. Patients with MINOCA represent a rather heterogeneous group of acute coronary syndrome, and this may account for the wide variation in the incidence of MINOCA in different studies. Several pathogenic mechanisms have been suggested to underlie MINOCA, but the condition continues to represent a diagnostic and therapeutic challenge for the cardiologist. Therefore, an adequate diagnostic assessment, carefully characterizing the pathogenic mechanisms, and a selection of more targeted treatments are needed to improve clinical outcomes. In this focused review, we will try to provide answers to the most common questions on the causes, diagnosis, treatment, and outcomes of MINOCA.

Myocardial revascularization, either percutaneous or surgical, is the cornerstone of chronic and acute ischemic coronary artery disease therapy. Periprocedural myocardial injury and infarction are possible complications of these procedures. Several pathogenetic mechanisms have been proposed in the setting of percutaneous (distal embolism, vasospasm, obstruction of a minor vessel) or surgical revascularization (prolonged ischemic time, early graft failure, arrhythmia or severe hypotension during the procedure). High-sensitivity cardiac troponins have emerged as the recommended biomarkers due to their important prognostic implications. However, data regarding diagnostic criteria, management and prognostic implications of these complications are lacking. The present review aims to provide an overview regarding the possible diagnostic criteria, management and prognostic role of periprocedural myocardial injury and infarction.

The exposome concept arises from the need to integrate different disciplines of public health and environmental sciences, mainly including environmental epidemiology, exposure science, and toxicology. The role of the exposome is to understand how the totality of an individual's exposures throughout the lifetime can impact human health. The etiology of a health condition is rarely explained by a single exposure. Therefore, examining the human exposome as a whole becomes relevant to simultaneously consider multiple risk factors and more accurately estimate concurrent causes of different health outcomes. Generally, the exposome is explained through three domains: general external exposome, specific external exposome, and internal exposome. The general external exposome includes measurable population-level exposures such as air pollution or meteorological factors. The specific external exposome includes information on individual exposures, such as lifestyle factors, typically obtained from questionnaires. Meanwhile, the internal exposome encompasses multiple biological responses to external factors, detected through molecular and omics analyses. Additionally, in recent decades, the socio-exposome theory has emerged, where all exposures are studied as a phenomenon dependent on the interaction between socioeconomic factors that vary depending on the context, allowing the identification of mechanisms that lead to health inequalities. The considerable production of data in exposome studies has led researchers to face new methodological and statistical challenges, introducing various approaches to estimate the effect of the exposome on health. Among the most common are regression models (Exposome-Wide Association Study - ExWAS), dimensionality reduction and exposure grouping techniques, and machine learning methods. The significant conceptual and methodological innovation of the exposome for a more holistic evaluation of the risks associated with human health is continuously expanding and will require further investigations related to the application of information obtained from studies into prevention and public health policies.

The term cardiac mass refers to benign or malignant cardiac tumors and cardiac metastases but also to pseudotumors, which is a heterogeneous group consisting of thrombi, vegetations and normal variant structures. While primitive cardiac tumors are rare, metastases and pseudotumors are relatively common. The non-invasive diagnostic approach has not been well established in the literature yet. The first-line non-invasive approach consists of echocardiography, which provides good diagnostic accuracy for masses like thrombi, vegetations and some tumors (mainly myxoma and fibroelastoma). In contrast, for other masses, it does not provide information about the potential malignancy because of poor tissue characterization. Second-line (cardiac computed tomography and cardiac magnetic resonance) or third-line (positron emission tomography-computed tomography) evaluations have been validated in the diagnostic approach to cardiac masses by many studies. In fact, a comprehensive diagnostic approach may establish the diagnosis of malignancy without histological report, which is pivotal for the subsequent therapeutic strategy.The aim of this narrative review is to describe the commonly available non-invasive diagnostic techniques for cardiac masses, their potential and limitations and to suggest a diagnostic pathway for common practice.

In the last decade a new form of participation of the citizens in research activities and in the production of knowledge has emerged.This development has started to reach epidemiological research, as illustrated in the recent section "EpiChange" of the journal Epidemiologia e Prevenzione. The conduction of epidemiological research through the engagement of citizens and new forms of production of knowledge - including peer-production - is still in its infancy. In 2005,we started in Italy a birth cohort, the NINFEA project, which uses the Internet to recruit pregnant women and to follow-up their children. Participants are volunteers who decide to take part in the research project. In this paper, we consider the aspects of the NINFEA project that are consistent with the concept of collaborative production of knowledge. In particular,we discuss issues related to the motivation of the participants, the selection of the research hypotheses to be evaluated and the definition of the population of interest of the study.

Patients with acute or chronic ischemic heart disease have a high incidence of depression, and a variable proportion of patients (ranging from 14% to 47%) suffer from major or subclinical depression. In addition, chronic depression has been shown to be associated with the development or progression of coronary atherosclerosis. Besides a poor quality of life, depressive symptoms in patients with ischemic heart disease result in a poor prognosis, as cardiovascular event rates are 2-2.5 times higher than in their counterparts without depressive symptoms. A variety of pathogenetic mechanisms may play a role, including pathophysiological (dysfunction of the autonomic nervous system or hypothalamic-pituitary-adrenal axis, platelet hyperaggregability, inflammation, endothelial dysfunction and genetic predisposition) and behavioral mechanisms (inadequate therapy adherence, obesity, smoking, sedentary lifestyle). However, in patients with ischemic heart disease, depression often goes undiagnosed or untreated. Several screening procedures including questionnaires for patients with heart disease, along with the help of a psychiatrist, may facilitate not only the diagnosis of depressive symptoms but also the pharmacological and/or physiotherapeutic management. The use of tricyclic antidepressant agents should be avoided in patients with heart disease, whereas selective serotonin reuptake inhibitors have been shown to be safe in this patient population. However, no evidence is available to support that use of these drugs is associated with a reduced risk of cardiovascular events at follow-up. Psychotherapy proved to be effective in reducing depressive symptoms but ineffective in improving prognosis. In this review, epidemiology and pathophysiology of depression in patients with ischemic heart disease are described, with a focus on stratification of depressive symptoms and potential therapeutic strategies.

Renal transplantation is an effective therapeutic tool for patients with end-stage renal diseases (ESRDs). Data reported in this article summarize the results obtained from 30 years' activity in the North Italy Transplant program (NITp), the first transplant organization in Italy that implemented a donor procurement and organ transplantation network. In the NITp kidney allocation is governed by a computerized algorithm, NITK3, put in place in 1997, aimed at ensuring equity, transparency and traceability during the stages of the allocation decision-making process. The NITp working group has recognized the NITK3 criteria and they are periodically reviewed following the results of the analysis of patients' transplantation odds. The results obtained with the use of the NITK3 algorithm have been very satisfactory: after 6 yrs, a significantly higher percentage of patients at immunological risk (sensitized or waiting for re-transplant), of patients waiting for >3 yrs and of patients with 0-1 HLA A,B,DR mismatches have been transplanted. Moreover, a higher percentage of kidneys were used locally (in a hospital within the procurement area), and this is known to stimulate donor procurement. Finally, we performed a preliminary statistical analysis of transplants carried out from 1998-2002 in 5/16 centers of the NITp area, demonstrating the quality of the NITp program in terms of patient and graft survival, and that donor and recipient age are the variables significantly impacting on transplant results.

Nowadays organ transplantation is a life-saving procedure, or anyhow it can considerably improve the life quality of patients suffering from irreversible organ impairment. Monitoring transplantation outcome is the last step of a long process that starts with cadaver donor identification, selection and clinical management, and continues with organ allocation, patient evaluation, surgical operation and clinical follow-up. The National Transplantation Committee has been discussing many of these items and, in 1995, it set up two protocols, one on liver exchange for urgent patients and the other on transplantation in the pediatric patient. The protocols application has met many difficulties, mainly due to the uneven behaviours of the different inter-regional organizations. In this paper we comment on the two main aspects to be submitted to the next National Committee: organ allocation and transplantation outcome. As far as the last point is concerned, the enclosed data are based on the experience of the North Italy Transplant program (NITp), and on that of the major international registries. Without any doubt these data demontrate that organ transplantation is to be ascribed among the successes of medicine in the just closed century.

The aim of this study was to analyze the very early (first 24 hours) effect of successful or failed thrombolytic therapy on the autonomic nervous system. Thirty consecutive patients with a first acute myocardial infarction were enrolled in the study, and admitted to the Coronary Care Unit within 6 hours of the onset of symptoms and treated with systemic thrombolytic therapy. All patients underwent 24-hour Holter monitoring in order to analyze ST segment variation. The autonomic nervous system was evaluated by frequency-domain heart rate variability: low frequency/high frequency ratio (LF/HF) was measured at the beginning of Holter monitoring (T1), 15 min after reperfusion or 1 hour from the start of thrombolytic therapy (T2) and after 24 hours (T3). Reperfusion status was assessed by a > or = 50% reduction in ST segment elevation within 90 min of thrombolytic therapy, and early CK-MB peak. Early coronary reocclusion was detected by early reduction in ST segment elevation followed by stable ST segment re-elevation. Twenty patients (66%) showed successful thrombolytic therapy (Group 1), 5 patients (17%) had no evidence of successful thrombolytic therapy (Group 2) and 5 patients (17%) showed an early reocclusion (Group 3). LF/HF ratio values at T1 were similar in the three groups (5.66 +/- 1.7 vs 5.65 +/- 1.2 vs 5.51 +/- 0.9, NS). At T2, LF/HF ratio was significantly higher in Group 1 and 3 than Group 2 patients (9.21 +/- 1.7 and 11.1 +/- 1.2 vs 5.58 +/- 1.4, respectively, p < 0.001). In Group 1 LF/HF ratio was significantly lower at T3 when compared with T1 and T2 (1.9 +/- 1 vs 5.66 +/- 1.7 and 9.21 +/- 1.7, respectively, p < 0.001). Conversely, in Group 3 LF/HF ratio at T3 was similar to values measured at T1 (5.59 +/- 1.7 vs 5.51 +/- 0.9, respectively, NS) and significantly higher than those detected in Group 1. In Group 2, LF/HF ratio resulted substantially unchanged at T3 (5.49 +/- 1.7, NS). In conclusion, 1) successful thrombolytic therapy induces early beneficial effects on the autonomic nervous system function, as shown by increased heart rate variability values, when compared with failed thrombolytic therapy; 2) however, during the early period following coronary reperfusion, a transient but dramatic increase in sympathetic activity is observed. This could trigger coronary flow instability, thus facilitating reocclusion, by activating different pathogenetic mechanisms (increased vascular tone, platelet activation, thrombogenic factor prevalence); 3) early coronary vessel reocclusion precludes favorable effects of reperfusion on sympatho-vagal balance observed after the first 24 hours.

Purpose: We carried out a retrospective study to assess the different B-mode and color Doppler features of Plummer's disease and to compare them with cytologic findings., Material and Methods: One hundred and eighty autonomous nodules were studied with B-mode US. Mean patient age was 55 years for women and 56 years for men. Twenty-seven patients were also submitted to color Doppler US. Forty-nine autonomous nodules were also submitted to cytologic examination by fine needle aspiration (FNA)., Results: The most frequent US pattern was a hypoechoic solid nodular lesion (59.8%), while 45.6% of the nodules exhibited a mixed US pattern. No mixed areas were found in 100% of the nodules in the patients under 20 and over 60. In contrast, various degrees of mixed areas were found in the patients 20-59 years old, with the highest rate (24.9%) in the 40-49 age range and the lowest rate (6.2%) in the 20-29 age range. The mixed areas were most frequently correlated with bigger nodules and the toxic phase. Calcifications were found in 4.3% of the partially autonomous nodules in 4.1% of the pretoxic nodules and in 8.6% of the toxic nodules. Color Doppler US showed rich internal and peripheral vascularization (pattern A) in 74.1% of the nodules and a mostly perilesional flow (pattern B) in 25.9% of the cases. Pattern A prevailed in the toxic phase (75%), while pattern B in the partially autonomous nodules (85.7%). Simple hyperplasia was the most frequent (63.3%) cytologic feature in the solid nodular lesions, while bleeding (10.2%) was typical of the mixed anechoic nodular lesions. Cytologically undifferentiated lesions were found in the toxic phase of Plummer's disease (50%)., Discussion: Solid lesions in Plummer's disease are characterized by hyperplasia, while the diagnosis of hemorrhagic pseudocyst is typical of mixed lesions., Conclusions: Color Doppler US provides data on the functional phase of Plummer's disease and is a very useful tool to monitor medical treatment results; moreover, it permits to characterize the lesions with the richest vascularization, avoiding inadequate cytologic sampling.

Malignant neuroleptic syndrome (alteration of consciousness, muscle rigidity and hyperthermia) is a potentially lethal condition, due also to its life-threatening complications. In particular, hypokinetic and hyperkinetic arrhythmias can be rare and severe early manifestations of this illness, and they deserve a careful approach because of their drug-refractoriness. Arrhythmias associated with the malignant neuroleptic syndrome depend on various mechanisms: neurotransmitter receptor blockades typical of neuroleptic drugs, clustered lipid droplets among the cardiac myofibrils and possible electrolytic disorder due to diaphoresis. The two cases described here presented hypokinetic and hyperkinetic (supraventricular and ventricular) arrhythmias. The arrhythmias, which failed to respond to antiarrhythmic drugs, were temporarily suppressed by DC shock, over-drive pacing and correction of electrolytic imbalance. In case 1, prolonged bromocriptine treatment was required. Complete wash-out of the causative agents resulted in lasting regression of arrhythmias. In conclusion, a correct treatment and a favourable outcome of this syndrome can be achieved only through early diagnosis.

A 48-year-old woman with no cardiovascular risk factors was admitted to the hospital because of acute dyspnea. At 27-year-old, she developed Hodgkin's disease, that was successfully treated with splenectomy, combined chemotherapy (nitrogen mustard, vincristine, procarbazine, prednisone-MOPP regimen) and radiotherapy (4500 rads). At 43-year-old the lymphoma relapsed and she had further chemotherapy with doxorubicin, bleomycin, vinblastina and dacarbazine. After this treatment, she had an episode of pulmonary edema, attributed to doxorubicin acute cardiotoxicity. She responded to digitalis and diuretics and was discharged with an electrocardiogram (ECG) showing left bundle branch block and a normal echocardiogram. The patient enjoyed good health for several years and 4 months before the present admission the ECG and echocardiogram were unchanged. On this admission there were signs of left ventricular failure with acute pulmonary edema, and a new soft apical murmur (3-4 Levine). The patient required endotracheal intubation and high doses of diuretics, digitalis and vasodilators. The cardiac enzymes were negative, the serial ECGs confirmed left bundle branch block, while the echocardiogram showed moderate to severe mitral regurgitation, akinesia of the interventricular septum and inferior wall with dilation of the left ventricle. A previous silent myocardial infarction was suspected. After recovery, she underwent cardiac catheterization confirming akinesia of the interventricular septum and inferior wall with moderate mitral regurgitation, while coronary angiography showed a critical ostial stenosis of the right coronary artery. In view of a dipyridamole-thallium scan negative for myocardial viability, reperfusion was not attempted. With changes in radiotherapeutic techniques, the incidence of radiation-induced heart disease (pericarditis, myocarditis, conduction abnormalities and, rarely, occlusive coronary artery disease) is declining. Nevertheless, after irradiation of the chest and mediastinum a longterm cardiological follow-up is useful in selecting patients at higher risk of radiation-induced coronary artery disease, who will eventually require coronary angiography and reperfusion intervention.

Inflammatory bowel diseases (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) have frequent extraintestinal (hepatobiliary, cutaneous, ocular, articular, urinary) complications. On the contrary, no data are available about possible thyroid involvement. We studied thyroid morphology and function in 39 patients affected with active IBD (13 UC; 26 CD) before (all) and 45 and 90 days after onset of therapy (21/39), and in 55 normal control subjects. Every time, the following exams were performed: thyroid US (parenchymal assessment, thyroid volume calculation), hormone and immunologic assays (T3, T4, FT3, FT4, TSH; antithyroglobulin and antithyroid microsomal/peroxidase antibodies). A statistically significant increase in thyroid volume was found in IBD (mean: 22.1 ml) compared to control subjects (mean: 15.6 ml), more frequently in CD (18/26 patients; 69.2%) than in UC (2/13 patients; 15.4%). Parenchymal structure was inhomogeneous in the two groups of patients (88.4% CD; 15.4% UC) more frequently than in control subjects (12.7%). Hormone assays demonstrated increased FT4 values in UC (9/13 patients; 69.2%) and decreased T4 values in CD (14/26 patients; 53.8%). IBD patients increased frequency of antithyroglobulin and antithyroid microsomal/peroxidase antibodies. Such abnormalities subsided only partially after therapy. Our data suggest that in IBD there is a frequent thyroid involvement with morphological, hormone, and immunologic abnormalities.

The authors report a case of an acute aortic dissection in a sixty year old patient who two months previously had an ischemic cerebral vascular accident. On the basis of a remittent fever and of raised acute phase proteins the authors suspected a giant cell arteritis as possible pathogenic cause of the clinical presentation. Ruled out infective and neoplastic disorders, after an unhelpful temporal artery biopsy, steroid treatment was introduced at the recommended dosage. Three months after, while reducing steroid therapy, the acute phase proteins raised again to come back to normal values only after restoring full steroid dosage. This pattern of response to steroid treatment may further support the diagnosis of giant cell arteritis even after an unhelpful temporal artery biopsy.

We report a case of a 73-year old railwayman with an asymptomatic large pericardial effusion diagnosed by a routine echocardiogram. By clinical and laboratory tests we excluded an immune, infectious, tuberculous and neoplastic origin of the pericardial effusion. A computed tomography scan of the thorax showed left pleural plaques. Pleural and pericardial biopsies showed fibrohyaline plaques and diffuse aspecific, chronic inflammation consistent with asbestos exposure. By using steroid treatment there was no further evidence of pericardial inflammation or pericardial effusion at 8 month follow-up. Steroid drugs are therefore suggested as a first choice treatment in patients with pleuropericardial effusion as well as chronic asbestos exposure.

The authors report the case of a sixty-seven-year-old man with seronegative rheumatoid arthritis since 1967. After the treatment was discontinued, a symptomatic pericardial effusion developed during an exacerbation of rheumatoid arthritis. Histological findings suggested a rheumatoid origin. Consecutive pericardiocentesis and a concomitant adequate treatment resolved cardiac tamponade, at least during short-term follow-up. However, a long term observation will be necessary to exclude recurrent effusion or evolutive constrictive pericarditis.

Although the efficacy of intravenous thrombolysis in the treatment of acute myocardial infarction has been widely proved, some uncertainty concerning the "temporal window" of administration still persists. The aim of the present investigation was to study whether the late administration of a thrombolytic agent (6 or more hours after the onset of symptoms of acute myocardial infarction) offers any short or long-term advantages with regards to left ventricular function and clinical outcome. We studied 100 consecutive patients at their first episode of myocardial infarction, admitted to Coronary Unit within 24 hours of the onset of symptoms. Of these patients, 62 were administered rt-PA (44 patients within the 6th hour, and 18 between the 6th and 24th hour after the onset of symptoms) and the 38 remaining patients, who did not receive the thrombolytic agent (due to concerns with respect to possible complications), constituted the control group (18 admitted within 6 hours and 20 between 6 and 24 hours). All patients underwent serial electrocardiograms, and echocardiograms upon admission and at discharge to assess the ejection fraction, the asynergy score and the percentage of ischemic area. Furthermore, the survivors were invited for a follow-up examination one year after their acute initial episode. Seven cases of heart failure occurred, before discharge, among the control patients admitted 6 to 24 hours after onset of symptoms, compared with no cases in the subgroup of patients treated with rt-PA during the same time period (p = 0.0068).(ABSTRACT TRUNCATED AT 250 WORDS)

Three patients fulfilling criteria for Sudeck's atrophy (reflex sympathetic dystrophy syndrome--RSDS) are described and etiological, pathogenetic and clinical features of the disease are reviewed. RSDS is associated with a wide variety of precipitating factors, each of whom, often in concomitance with metabolic diseases and psychiatric disturbances, may cause the same clinical syndrome, which continues in a "vicious circle" of feed-back mechanisms, correlated with sympathetic hyperactivity. The symptoms may begin gradually and the disorder progresses in stages lasting from weeks to months. The management has not yet been established. Generally, the earlier the syndrome is recognized, the better the results of treatment will be. Analgesics, salmon calcitonin and physiokinesitherapy are recommended. Psychological support is advisable. In more severe patients sympathetic blockade and surgical sympathectomy may be necessary. The effects of hyperbaric oxygen treatment must still be assessed.

If the quality of results of organ transplantation in NITp is highly satisfactory, the same cannot be said for the number of transplants performed, which only cover 20-25% of the requirement. To understand the causes of organ shortage, a study group of Anaesthesiologists and Transplant Coordinators from the North Italy Transplant Program (NITp) investigated, through a questionnaire addressed to the Heads of 103 Intensive Care Units (ICU) in 92 Hospitals in the NITp area, some of the organizational problems linked to donor identification and treatment and to organ retrieval. The questionnaire took into consideration the number of possible donors identified in 1990, those retrieved and the causes for non retrieving organs and examined a number of variables linked both to retrieval and to ICUs and Hospitals organization. The results show that potential donors were 461: 143 (31%) were used, 138 (30%) were lost due to family opposition to organ donation, 192 (20%) for clinical reasons and 88 (19%) for organizational reasons. The latter figure represents 5% of non retrieval in the most active ICUs and increases to 50% in the Hospitals that had procured no donors in 1990. The main obstacles for ICUs to procure organ donors are: convey the Medical-Legal Committee, carry out of complicated administrative procedures, availability of round the clock specialized equipment for neurological assessment (especially for ICU outside Neurosurgical and Neurological departments), inadequate number of medical and nursing staff, most of all at night, and finally the difficulty in the management of non-traumatic cerebrovascular patients.

Sixteen young patients, with clinical and radiological signs of periventricular leukomalacia (PVL), were investigated with MR imaging. Twelve of them were investigated with US in the perinatal period. The extant 4 patients, older than the others, had a clinical history of PVL. US scans were capable of yielding precise information about the anatomical features of PVL in both the acute and the middle phases. The lesions appeared as hyperechoic areas which subsequently turned to anechoic cavities. MR imaging and CT scans did not present any particular advantage over US scans in the acute phase, but they did detect periventricular damage when the patient was 6-7 months old. MR imaging was superior to CT in detecting the delayed myelination of white matter. Inversion-recovery sequences gave more anatomical details to distinguish normal from abnormal white matter. Spin-echo proton-density images detected periventricular gliosis, which appeared as persistent hyperintense areas. CT might be useful in the acute phase, after US detection of hyperechoic intraparenchymal areas, for it allowed purely ischemic lesions to be distinguished from hemorrhagic ones.

The neck vessels of 60 patients were studied by means of magnetic resonance angiography, with gradient-echo FISP sequences with short TR and TE and with a 25 degrees flip angle. To study arterial neck vessels, sequences were acquired on the coronal and on the sagittal planes, centered on the cricoid. The intracranial tract of the vertebral arteries required axial sequences centered under the floor of the sella turcica. Post-processing was obtained with the maximum intensity projection technique. The coronal and sagittal sequences were rotated on the axial plane from 0 degrees to 180 degrees with 15 degrees interval, while axial sequences were rotated on the sagittal plane from 0 degrees to 180 degrees with the same interval. TR, TE and flip angle values were very important for image quality: the thinner the volumes the more effective resolution power and vessel visualization. These volumes should not exceed 1.5 mm. Axial rotations of coronal sequences from -45 degrees to +45 degrees and of sagittal sequences from 60 degrees to 120 degrees were useful for diagnosis. The intracranial tract of the vertebral arteries was clearly depicted after axial sequences and after 75 degrees and 135 degrees sagittal rotations.

Three cases of primitive suprasellar germinomas are reported: the tumors show typical clinical signs (diabetes insipidus, visual disturbances and anterior pituitary dysfunctions), but CT findings are not so specific. It is very important to reach a correct diagnosis based on clinical and radiological findings, because of a very high radiosensibility of the tumor. The accuracy of preoperative diagnosis has been enhanced by CT in addition to conventional neuroradiological examinations. Due to the possible risk of meningeal spreading following biopsy, some authors prefer to avoid biopsy and to treat directly the patient by radiotherapy; a rapid reduction of the tumor size at the dose of 30 Gy suggests a possible germinoma.

The staging, therapy and course of 91 patients with extranodal NHL of the head and neck treated between 1970 and 1985, were analyzed. The sites involved were: Waldeyer's ring 71 patients, tonsil 59, nasopharynx 12 and extralymphatic sites 20 patients (larynx 6, paranasal sinus 5, orbit 5, oral cavity 3, salivary gland 1). Sixty-three patients had unfavourable histology with 22 patients in stage I; 33 in II; 21 in III; 15 in IV. Chemotherapy plus radiotherapy was used in 43 patients and 34 obtained Complete Remission (CR). Chemotherapy alone was used in 30 patients and in 11 CR was achieved, radiotherapy alone in 18 patients and 11 obtained CR. The actuarial survival rate was 55% and recurrence-free survival, evaluated only in those patients who achieved complete remission, was 80%. Results, as survival and freedom from recurrence, are analyzed in relation to main prognostic factors and therapy, and patterns of recurrence are reported. The present study confirmed the view that radiotherapy combined with chemotherapy represents the best treatment for NHL of the head and neck.