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Background Although children with special health care needs (CSHCN) represent a minority of the population, they go through more hospitalizations, more admissions to the Emergency Department (ED), and receive a major number of medical prescriptions, in comparison to general pediatric population. Objectives of the study were to determine the reasons for admission to the ED in Italian CSHCN, and to describe the association between patient’s demographic data, clinical history, and health services requirements. Methods Ad hoc web site was created to collect retrospective data of 3479 visits of CSHCN to the ED in 58 Italian Hospitals. Results Seventy-two percent of patients admitted to ED were affected by a previously defined medical condition. Most of the ED admissions were children with syndromic conditions (54%). 44.2% of the ED admissions were registered during the night-time and/or at the weekends. The hospitalization rate was of 45.6% among patients admitted to the ED. The most common reason for admission to the ED was the presence of respiratory symptoms (26.6%), followed by gastrointestinal problems (21.3%) and neurological disorders (18.2%). 51.4% of the access were classified as ‘urgent’, with a red/yellow triage code. Considering the type of ED, 61.9% of the visits were conducted at the Pediatric EDs (PedEDs), 33.5% at the Functional EDs (FunEDs) and 4.6% at the Dedicated EDs (DedEDs). Patients with more complex clinical presentation were more likely to be evaluated at the PedEDs. CSHCN underwent to a higher number of medical procedures at the PedEDs, more in comparison to other EDs. Children with medical devices were directed to a PedED quite exclusively when in need for medical attention. Subjects under multiple anti-epileptic drug therapy attended to PedEDs or FunEDs generally. Patients affected by metabolic diseases were more likely to look for medical attention at FunEDs. Syndromic patients mostly required medical attention at the DedEDs. Conclusions Access of CSHCN to an ED is not infrequent. For this reason, it is fundamental for pediatricians working in any kind of ED to increase their general knowledge about CHSCN and to gain expertise in the management of such patients and their related medical complexity.

Liposoluble contrast media, used in lymph nodes x-ray examination, have some specific features, when compared with idrosoluble contrast media. They rarely diffuse through the lymphatic walls, they produce an intense and homogeneous opacity of the lymph nodes and they remain in the lymph nodes for several months. For these reasons, it was thought to substitute the iodine of the liposoluble contrast medium with I131, and to use this radioactive material for therapy in primary and secondary malignant growth of lymph nodes. Since October 1961 a series of 30 patients was treated, 22 with malignant lymphomas of various type, 8 with metastases from carcinoma of the uterus or malignant melanomas of the legs. The radioactive contrast medium was injected into the feet following the technique suggested by Kinmonth. This tecnique allowed the irradiation of lymph nodes from the inguinal to the lumbo-aortic included. Favourable results were obtained: a marked and durable reduction of the diseased lymph nodes was observed in most cases. The long permanence of the contrast medium in the lymph nodes allowed to follow the size and shape of lymph nodes up to 6 months after injection. No signs of bone marrow damage were observed. The intralymphatic radiotherapy has advantages in respect of the transcutaneous radiotherapy: 1) Irradiation of the lymph nodes from inside, without damage of other tissues; 2) simultaneous irradiation of lymph nodes in different locations, giving a high dose to each lymph node, but a low total body dose; 3) Continuous irradiation; 4) Single inoculation of the radioactive material, even without hospitalization. The limitations of the method are due to the impossibility to reach all the lymph node districts and the lymph nodes completely obliterated by carcinoma metastases, which are by-passed. As these preliminary results suggest, the intralymphatic radiotherapy is best indicated in malignant lymphomas.

Three cases of malignant lymphoma involving retroperitoneal nodes, in which the clinical diagnosis could be clearly established by lymphangiography, are reported. In two cases the left retroperitoneal node chain apparently was the only site of involvement. In one case the right retroperitoneal chain showed recurrence after two years, with roentgenologic findings identical with those described for the left chain. Lymph node biopsy confirmed the roentgenologic diagnosis in the first case, and hepatic biopsy became conclusive only after lymphangiography in the third patient. In the second case it was possible by lymphangiography to detect pathologic lymph nodes in the retroperitoneal space in the absence of positive physical and other roentgenologic and laboratory findings.

A new clinical classification for Hodgkin's disease is proposed by the Committee for the Study of Malignant Lymphomas of the National Cancer Institute of Milan in cooperation with the Institute of Radiology of the University of Milan. The method of treatment of Hodgkin's disease adopted in these Institutes is also outlined. The histologic classification includes paragranuloma, nodular sclerosis, granuloma and sarcoma. Stage I: disease limited to a single peripheric lymphatic region. Within this stage two groups can be recognized: a) involvement of one single lymph node or few nodes limited to a small area of the region (unifocal lesions); b) involvement of many nodes spread throughout the region (uniregional lesions). Stage II: disease limited to two contiguous lymphatic regions, or to few deep nodes (mediastinal, retroperitoneal). Stage III: disease limited to two non contiguous peripheric lymphatic regions, or to many peripheric and/or deep (mediastinal, retroperitoneal) regions, provided the involvement is either above or below the diaphragm. Stage IV: generalized disease with involvement of lymph nodes above and below the diaphragm, or involvement of one or more lymphatic regions with concomitant involvement of visceral organs, bones, marrow, nervous system and skin. Systemic symptoms and signs, fatigue, fever, night sweats, loss of weight, itching, anemia, lymphocytopenia, high erythrosedimentation rate) must be recorded in each case to evaluate prognosis and proper treatment, bu are not considered in this classification for lymph node staging. Primary visceral, bone, nervous and cutaneous involvement is exceptional; therefore staging for such lesions is not considered in this classification. In all stages endolymphatic radiotherapy with Lipiodol F 131I is indicated (10 ml in each foot with 2.5 mc/ml, corresponding to a tumor-dose of 15 - 20,000 rads). This is considered as a radical as well as a prophylactic treatment for those lymph nodes adequally filled with the contrast material; in case of non filling or incomplete filling of part of the lymph node chain, treatment will be completed with external radiation therapy. Stage I and II are treated with radical and prophylactic radiotherapy. If systemic symptoms and signs are still present after radiotheraphy, a course with anticancer drugs will be administered. Radiation therapy is given with high voltage or Co60 units. In radical treatments tumor doses of at least 3,000 r within 3–4 weeks are administered to all involved lymphatic regions. Prophylactic radiotherapy is indicated for regions clinically free of disease but contiguous to the involved areas, with tumor doses not less than 3,000 r in 3–4 weeks. In stage II radical radiotherapy follows a course with chemotherapy. In stage IV chemotherapy is the treatment of choice; palliative radiotherapy is given to any bulk of tumors, wherever the location, when specific symptoms can be attributed to the masses. The anticancer drug of choice is methyl-bis-(β-chloro-ethyl)-amine HCl(HN2) 0.4 mg/kg i.v., for those patients who did not receive any previous course of chemotherapy. Otherwise, as well as during the course of the disease, other polyfunctional alkylating agents, vinblastine (alone or in combination with chlorambucil), methylhydrazine, and corticosteroids will be administered according to each clinical situation. Radical surgery followed by radical radiotherapy is reserved for primary lymphatic involvement only in specially selected patients in stage I with unifocal lesions. Primary involvement of the stomach, small bowel or colon is treated by surgical extirpation and radiotherapy. Splenectomy is indicated when this viscus is the only site of involvement. During pregnancy radiation therapy is not administered below the diaphragm. Chemotherapy is not given during the first 4 months of pregnancy. The need for one internationally accepted clinical classification of Hodgkin's disease is stressed.

Images Fig. 2 Fig. 5 Fig. 3 Fig. 1 Fig. 4 p482-3-a

Arteriography was carried out on 54 patients with benign and malignant tumors of soft tissues of the extremities. Results are reported and the most significant angiographic pictures of 28 cases are illustrated in detail. These include 2 neurilemmomas, 1 gigantocellular tumor (sesamoid tumor), 1 synovial gigantocellular tumor, 1 venous racemose hemangioma, 1 capillary-racemose hemangioma, 8 fibrosarcomas, 1 rhabdomyosarcoma, 1 neurosarcoma, 3 synovialsarcomas, 1 malignant mesehnchimoma, 1 mixed epithelioconnectival tumor, 5 ablastic sarcomas, 2 epitheliomas. The arteriographic aspects observed are compared with those described in the literature in order to outline the present knowledge on arteriographic semeiology and diagnosis in benign and malignant tumors of soft tissues. As concerns arteriographic semieology, seven main radiological signs are recognized by the authors, or: 1) displacement of vessels surrounding the growth; 2) dilatation of centripetal and centrifugal vessels; 3) changes in the circulation time; 4) vessels neoformation. Four main angiographic aspects of the newly formed intratumoral vascular network are described; 5) tumor impregnation by the contrast medium; 6) intratumoral blood collections; 7) arterovenous shunts. The frequency and extend of the mentioned radiological features are varying, and different arteriographic pictures may be seen according to tumors type and malignancy. In the majority of benign tumors nearly similar pictures are seen, characterized by absent or scarce vessels of normal appearance. Fibromatous tumors show a homogeneous moderate retention of the contrast medium. Vascular tumors, and particularly some types of angioma, may exhibit rather typical features which consent an angiographic diagnosis of the tumor type. As concerns malignant tumors, rather polymorphic arteriographic pictures are seen in fibrosarcomas, as to tumor vascularization and structural arrangement. Occasionally, vessels are scarce and of normal appearance, and the angiographic pattern resembles that of fibroma; in other cases vessels are more abundant. with irregular caliber and course. The greatest vascular atypia seems to correspond to the histologically most malignant variety of fibrosarcoma. A characteristic common to all observed cases of fibrosarcomas was an evident homogeneous impregnation by the contrast medium. The presence of intratumoral lacune and arterovenous shunts is exceptional. Mention is given of pictures obtained in lipo- and mixosarcomas, sarcomas of muscular origin and angiosarcomas, whereas synovialsarcomas and ablastic sarcomas are more thoroughly considered. Synovialsarcomas are scarcely known in the arteriographic literature. In the three cases observed by the authors, the arteriographic picture resembled that of some types of fibrosarcoma, with abundant and rather atypical vessels, absence of blood lacunae or shunts, regular retention of the contrast medium. These angiographic features, the site, and the roent-genographically visualized skeletal changes ought to consent a radiological diagnosis of the tumor type. In ablastic sarcomas the arteriographic picture is always characterized by a very marked vascular atypia. The frequent occurrence of intratumoral lacunae and arterovenous shunts is suggestive of the high malignancy of these forms. Side effects at the level of limb circulation are also frequently encountered. Tumor impregnation by the contrast medium varies from case to case. To conclude, arteriography is claimed to be able to reveal, in many cases, the presence of a tumor, and to determine its malignancy. The type of the tumor is hardly recognizable, except for some particular cases. Caution is needed in interpreting arteriographic pictures, for the presence of several factors may invalidate the findings. Error causes are analyzed and discussed. Arteriography cannot replace biopsy, but rather complete it as a method of diagnostic ascertainment. Arteriography seems to be clinically indicated: 1) in early diagnosis of cancer of soft tissues of extremities, mainly when the lesion is still scarcely extended or deeply situated; 2) to ascertain tumor extent, to outline its limits towards healthy soft tissues and its anatomical relationships to the bone and vessels. These findings are very significant from a therapeutical, either surgical or radiological, standpoint. 3) to check therapy results. After radiotherapy, arteriography may show a gradual normalization of the angiographic picture of malignancy. In surgically treated cases arteriography may occasionally differentiate between recurrence and cicatricial hardening or granulomatous processes at the operation site. 4) to study tumor vascularization and impregnation; number, site, and course of the supplying vessels. These data are valuable not only for surgical purposes, but also for the application of modern therapeutical methods, such as the introduction of antimitotic or radioactive substances into the afferent circulation.

The results of histological examination of lymph nodes in 18 cases of lymphosarcoma, reticulum-cell sarcoma, and Hodgkin's disease, treated with Lipiodol F I181 through the lymphatic vessels, are reported. The most significant changes induced by this therapy consisted of optically empty cavities of different shape and size; of degenerative changes of the neoplastic cells; of stromal reactions, with hystiocites and giant cells. These changes were of various degrees, according to the type of tumor and the amount of Lipiodol F I181 injected. The authors believe that the histological data presented, together with the clinical and radiological results already published, confirm the effectiveness of the intralymphatic radiotherapy in the treatment of malignant lymphomas.

The Committee for the Study of Malignant Lymphomas of the National Cancer Institute of Milano in cooperation with the Institute of Radiology, University of Milano presents a new clinical classification for lymphosarcoma and reticulum cell sarcoma as well as the method of treatment adopted in these Institutes. For primary lymph node lesions the staging is identical to that already proposed for Hodgkin's disease. Stage I: disease limited to a single peripheric lymphatic region. Within this stage two groups can he distinguished: a) involvement of one single lymph node or few nodes limited to a small area of the region (unifocal lesions); b) involvement of many nodes spread throughout the region (uniregional lesions). Stage II: disease limited to two contiguous peripheric lymphatic regions, or to few deep nodes (mediastinal, retroperitoneal). Stage III: disease limited to two non contiguous peripheric lymphatic regions, or to many peripheric and/or deep (mediastinal, retroperitoneal) regions, provided the involvement is either above or below the diaphragm. Stage IV: generalized disease with involvement of lymph nodes above and below the diaphragm, or involvement of one or more lymphatic regions with concomitant involvement of visceral organs, bones, marrow, nervous system and skin. For primary pharyngeal lesions the T.N.M. nomenclature has been adopted. T1: unifocal lesion (e.g. nasopharynx, tonsil, uvula); T2: multifocal lesions (e. g. nasopharynx and tonsil, tonsils, tonsil and base of the tongue); T3: unifocal lesion with extension beyond the anatomical confine of the site of origin (e. g. base of the skull, paranasal sinuses, jaw, orbit); T4: multifocal lesions with extension beyond the anatomical confine of the site of origin. N0: no adenopathy; N1: ipsilateral contiguous adenopathy (submental and/or cervical); N2: bilateral contiguous adenopathy; N3: bilateral contiguous and/or supravicular adenopathy (unilateral or bilateral); N4: distant adenopathy. M–-: absence of metastases; M+: presence of metastases (visceral, osseous, nervous, cutaneous). The remaining primary extranodal lesions (visceral, osseous, cutaneous, etc.) are classified as local, regional and diffuse. Systemic symptoms and signs (fatigue, fever, night sweats, more than 10% weight loss, itching, anemia, leukocytosis, lymphocytopenia, high erythrosedimentation rate) must be recorded in each case to evaluate prognosis and proper treatment but are not important for staging the disease. In all stages with primary lymph node lesions endolymphatic radiotherapy with Lipiodol F I131 is indicated (10 ml in each foot with 2–5 mc/ml giving a tissue-dose of 15-20,000 rads). This is considered as radical as well as prophylactic treatment for those lymph nodes adequatelly filled with the contrast medium. In case of non filling or incomplete filling of part of the lymph node chains, treatment will be completed with external radiation therapy. Stage I and II are treated with radical radiation therapy. No prophylactic radiotherapy is given. If systemic symptoms and signs are still present after radiotherapy a course with anticancer drugs will be administered. Radiation therapy is given with high voltage or Co60 units. In radical treatments tumor doses of at least 3,000 rads within 3–4 weeks are administered to all involved lymphatic regions. In stage III radical radiotherapy follows a course of chemotherapy. In stage IV chemotherapy is the treatment of choice. Palliative radiotherapy is given to any bulk of tumors, wherever the location, when specific symptoms can be attributed to the masses. For primary pharyngeal lesions the primary focus (T1, T2, T3, T4) is always treated with radical radiation therapy (Co60 unit) which includes in the whole Waldeyer's ring. Prophylactic radiotherapy (Co60 unit with doses not less than 3,000 rads in 3–4 weeks) is given in N0 to the ipsilateral and in N1 to the contralateral submental and cervical lymphatic regions. In N1 and N2 the lymph node bearing areas are given radical radiation therapy. In N3 are irradiated prophylactically also the contralateral submental, cervical and supraclavicular lymphatic regions if clinically free of disease. Endolymphatic radiotherapy is performed only in T1 T2 T3 T4, N3 N4, M–- or M+ cases; otherwise diagnostic lymphangiography is performed and when pathologic nodes are present or suspected they are irradiated with Co60. Chemotherapy is given after the course of radiotherapy in N2 cases only if radical treatment has not been accomplished, while is always administered in combination with radical radiotherapy in N3 cases, and is considered the treatment of choice with palliative radiation therapy in N4 and M+ cases. The drug of choice is methyl-bis-(β-chloro-ethyl)-amine HCl (HN2) 0.4 mg/kg i.v. (single dose) for those patients who did not receive any previous course of chemotherapy. Otherwise, as well as during the course of the disease and in maintenance therapy, other polyfunctional alkylating agents, but chiefly chlorambucil (0.1–0.2 mg/kg/die, p. o.), vinblastine (0.10–0.15 mg/kg/week, i.v.), alone or every two weeks in combination with small daily doses of chlorambucil (5 mg/die, p. o.), methylhydrazine, hydroxyurea, and corticosteroids will be administered according to each clinical situation. Relapses in oropharynx can be treated with intraarterial infusions of amethopterine, vinblastine and cyclophosphamide. Radical surgery followed by a course of radiotherapy is reserved for primary lymphatic involvement only in specially selected patients in Stage I with unifocal lesions. Primary involvement of stomach, small bowel and colon is treated by surgical extirpation and radiotherapy. Splenectomy, lobectomy or pneumonectomy is indicated when these viscus are the only site of involvement. During pregnancy radiation therapy is not administered below the diaphragm and chemotherapy is not given during the first 4 months. The need for one internationally accepted clinical classification for lymphosarcoma and reticulum cell sarcoma is stressed.

This monograph summarizes the experience gained at the University of Milan, Italy and the National Cancer Institute in Milan in the application of endolymphatic therapy in the treatment of lymphomas. It is divided into nine chapters dealing with such topics as the status of radical and palliative treatment of malignant lymphomas, clinical and histopathological staging, diagnostic evaluation, and the natural history and spread of the disease. The authors then describe the technique and special instruments which they designed to administer endolymphatic therapy, as well as the clinical results obtained from 1961 through 1969. A total of 426 patients were treated by endolymphatic therapy; 208 had Hodgkin's disease, 95 had lymphosarcoma, and 123 had reticulum-cell sarcoma. It became obvious that homogeneous distribution of contrast medium in the lymph node is essential for successful treatment. For this reason, extravasation, lymphatic blockage, and bypassing of abnormal tumor-filled nodes were all felt to be factors which would adversely influence homogeneous distribution of the therapeutic agent. Radiographs taken before and after endolymphatic therapy show a significant decrease in the size of nodes after therapy. Recurrences and appearances of disease in new locations were rarely found if the patients were treated during early stages of the disease, but they were not infrequent in more advanced stages. Lymph nodes removed at surgery or postmortem examination were studied in order to assess the effect of irradiation. Satisfactory destruction was found close to the vacuoles in which the oil was located. This book is a concise summary of the authors' experience in endolymphatic therapy. It is doubtful that this method of therapy will be used widely, due to the uncertain distribution of contrast medium, the difficulty in calculating delivered dosages, and the fact that external radiotherapy or chemotherapy has achieved such good results. To the interested reader it becomes obvious that many questions about endolymphatic therapy remain unanswered. It is unfortunate that this monograph does not summarize the experience of other investigators in this field as well. Neverthelcss, it represents the most extensive endolymphatic therapy material available in the English language.

The retroperitoneal node chains in 36 patients with rectal and sigmoid cancer have been explored by lymphangiography (Lipiodol F). The lymphangiograms were definitely abnormal especially in the external iliac chains in 20 cases and suspicious in four. Iliac lymphadenectomy was performed in seven patients and was positive for metastatic involvement in three. The lymphangiographic findings could represent either a direct lymph pathway, connecting the rectum to the external iliac nodes, or a sign of retrograde metastases. Endolymphatic radiotherapy (Lipiodol F131I) was carried out in four patients. This therapeutic approach can be applied in patients with rectal cancer before surgery to irradiate small metastases. It is concluded that in all resectable patients with rectal, sigmoid and colon cancers lymphangiography should be routinely performed and lymphadenectomy carried out in those cases showing retroperitoneal metastases.