Detection of recurrent head and neck squamous cell carcinomas after radiation therapy with 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography

OBJECTIVES/HYPOTHESIS

Fluorodeoxyglucose positron emission tomography (FDG-PET) has been proposed as a sensitive method to diagnose and stage various malignancies. We assessed the efficacy of FDG-PET imaging in distinguishing tumor persistence/recurrence from posttreatment changes following radiation therapy for squamous carcinomas of the head and neck

STUDY DESIGN

Retrospective analysis of FDG-PET results compared with biopsy results or outcome, or both.

METHODS

Twenty-eight patients who had undergone radiation therapy with or without surgery for treatment of squamous cell carcinoma were studied with FDG-PET imaging. There was clinical suspicion for recurrence in each patient, but no obvious mass or lesion to biopsy was found on physical examination or anatomic imaging. The results of FDG-PET imaging were compared with those of biopsy or clinical follow-up of at least 6 months, or both.

RESULTS

FDG-PET imaging was positive in 13 patients, and the presence of active disease was confirmed in 12. Two thirds of the 12 received further cancer treatment. There were 15 negative FDG-PET images. Thirteen of these were confirmed true-negative images, but two studies were false-negative images. The sensitivity and specificity of FDG-PET were 86% and 93%, respectively, with positive and negative predictive values of 92% and 87%, respectively. The overall accuracy was 89%.

CONCLUSION

FDG-PET imaging is a useful modality to distinguish tumor persistence/recurrence from radiation-induced tissue changes in the neck following treatment for head and neck cancer. FDG-PET can identify patients who may benefit from further treatment, and may lead to improved outcome for individual patients.

Extraskeletal myxoid chondrosarcoma of the knee

Extraskeletal myxoid chondrosarcoma is an uncommon neoplasm, accounting for less than 2% of all soft tissue sarcomas. It affects adult males with a median age in the fifth decade at the time of diagnosis. The tumor usually arises in the deep soft tissues, especially in the lower extremities. Patients present with a gradually enlarging mass that may or may not be associated with pain. This report describes a 25-year-old man who initially presented with a 4- to 5-year history of right knee pain and an enlarging mass in the right knee. Evaluation revealed a cartilaginous neoplasm with no evidence of metastatic disease. The tumor was widely excised and an allograft reconstruction was performed. The patient was closely followed with an eventual above the knee amputation for recurrent myxoid chondrosarcoma. At 34 months, retroperitoneal metastases were noted on abdominal CT. The patient underwent a left radical nephrectomy, renal vein thrombectomy and enucleation of the mass in the right kidney, distal pancreatectomy, and splenectomy. The patient received postoperative chemotherapy. Forty-eight months after initial diagnosis, the patient was found to have recurrent abdominal and retroperitoneal lesions. At 64 months, the patient died from complications of extraskeletal myxoid chondrosarcoma.

Peritumoral edema in osteoid osteoma on magnetic resonance imaging

OBJECTIVE

To determine whether there is a relationship between the peritumoral edema caused by osteoid osteoma seen on magnetic resonance (MR) imaging and the patient's age, duration of symptoms, or location of the lesion.

DESIGN AND PATIENTS

All histologically proven osteoid osteomas seen in our institutions during a 5-year period in patients with known age, gender, duration of symptoms, and available radiological and MR imaging examinations were included in this study. The extent of the edema in the bone marrow and extraosseous soft tissue around the nidus of osteoid osteoma on T2-weighted MR imaging were graded from 1 (nonexistent) to 4 (extensive) by two masked observers. The relationships between the patient's age, duration of symptoms, and location of lesions were evaluated by Pearson's correlation coefficient and analysis of variance.

RESULTS

Twenty-seven cases met the inclusion criteria. The observer agreement on grading was good. Patients of 15 years of age or younger had significantly higher grades than patients older than 15 years. There was a moderate negative linear correlation between the patient's age and peritumoral edema. No significant relationship was identified between edema and the duration of symptoms or the location of lesions.

CONCLUSION

Osteoid osteomas in younger patients tend to be associated with more extensive peritumoral edema.

A phase I trial of 96-hour paclitaxel infusion plus accelerated radiotherapy of unrespectable head and neck cancer

PURPOSE

To determine the maximum tolerated dose (MTD) of paclitaxel given as a 96-hour continuous infusion during Weeks 1 and 5 of an accelerated radiotherapy schedule for the definitive treatment of advanced (nonmetastatic) unresectable squamous cell carcinoma of the head and neck (SCCHN).

METHODS AND MATERIALS

Thirteen patients with Stage IV SCCHN were enrolled. Radiotherapy consisted of 70-72 Gy over 6 weeks, with a fractionation scheme of 2 Gy q.d. for 4 weeks followed by 1.6 Gy b.i.d. for 2 weeks, with no planned interruptions. Paclitaxel was administered over a 96-hour continuous infusion during Weeks 1 and 5 of radiotherapy at the following dose levels: Dose Level 1: 40 mg/m(2)/96-hours (3 patients); Dose Level 2: 80 mg/m(2)/96-hrs (5 patients); Dose Level 3: 120 mg/m(2)/96-hours (2 patients); and Dose Level 2A: 100 mg/m(2)/96-hours (3 patients).

RESULTS

The MTD of Paclitaxel was 100 mg/m(2)/96-hours. All but one patient (who experienced progressive disease after receiving 61 Gy and both cycles of paclitaxel) completed therapy as planned. Dose-limiting toxicity occurred in both patients enrolled at Dose Level 3, with one patient experiencing Grade 4 diffuse moist desquamation and the other patient experiencing Grade 4 mucositis and febrile neutropenia. Thus, Dose Level 2A was opened and no dose limiting toxicity was noted. Grade 3 non-dose limiting mucositis and dermatitis occurred at all paclitaxel dose levels. There were no treatment-related deaths. All Grade 3 and 4 toxicities were reversible. Complete responses were seen in 8 of 13 patients, 4 patients achieved partial responses, and 1 patient had no response/progressive disease.

CONCLUSIONS

Infusional paclitaxel over 96 hours during Weeks 1 and 5 of this accelerated radiotherapy schedule is feasible. The MTD of paclitaxel in this protocol was 100 mg/m(2)/96-hours. Dose-limiting toxicities were primarily enhanced epithelial reactions, but febrile neutropenia also occurred. All patients develop non-dose limiting Grade 3 skin and mucosal reactions, reflecting the high treatment intensity. This regimen merits further investigation.

Photodynamic therapy in the treatment of cancer: current state of the art

Photodynamic therapy (PDT) is a treatment modality using a photosensitising drug and light to kill cells. The clinical use of PDT requires the presence of a photosensitising agent, oxygen and light of a specific wavelength which matches the absorption characteristics of the photosensitiser. When the photosensitiser is activated by the appropriate wavelength of light, it interacts with molecular oxygen to form a toxic, short-lived species known as singlet oxygen, which is thought to mediate cellular death. The appeal of PDT in oncology is that the photosensitiser tends to be retained in tumour tissues for a longer period of time as compared with normal tissues resulting in a large therapeutic index. This potential for minimal normal tissue toxicity has prompted an interest in studying PDT as a cancer treatment. Furthermore, the use of PDT is not precluded by prior radiotherapy, chemotherapy or surgery. The development of PDT has been hampered by the limitations of the older photosensitisers, namely limited depth of tissue penetration, and extended skin phototoxicity which limits the number of applications during a course of treatment. However, newer photosensitisers are being developed which allow greater depth of tissue penetration and have minimal skin phototoxicity allowing for multiple fractionated treatments. With such advancements, PDT has great potential to become an integral part of cancer treatment in the future.

Risk factors for osteonecrosis in patients with type 1 Gaucher's disease

This study investigated 51 patients with Type 1 Gaucher's disease clinically and radiographically for the presence of osteonecrosis. Twenty-five female and 26 male patients with a mean age of 37 years were evaluated retrospectively for osteonecrosis of the proximal and distal femur, proximal tibia, and proximal humerus. All patients were examined before enzyme replacement therapy. Gender, age at diagnosis, prior splenectomy, hematocrit, platelet count, acid phosphatase level, radiographs of the long bones, and magnetic resonance quantitative chemical shift imaging of the spine were analyzed to see if any of these values or findings were associated with the presence of osteonecrosis. Splenectomy was an independent risk factor for the presence of osteonecrosis in three of the four major sites and was a multivariate risk factor for osteonecrosis of the proximal femur and tibia. Male gender was the other significant multivariate risk factor for osteonecrosis of the humerus and distal femur when all sites were taken into account.

Seven-week continuous-infusion paclitaxel concurrent with radiation therapy for locally advanced non-small cell lung and head and neck cancers

The goal of these National Cancer Institute-sponsored phase I trials is to determine the feasibility, toxicity, and pharmacokinetics of continuous-infusion (24 hr/d, 7 d/wk, 7 weeks total) intravenous paclitaxel combined with standard, curative-intent thoracic radiation therapy (XRT) for previously untreated, locally advanced non-small cell lung cancer and squamous cell cancer of the head and neck (HNSCC). Eligible patients have locally advanced (T4NXM0 or TXN2-3M0) non-small cell lung cancer ineligible for potentially curative surgical resection or locally advanced HNSCC with an expected 5-year survival rate of less than 25%, as well as a good performance status, adequate hematologic, hepatic, and renal function, and no distant metastases. Non-small cell lung cancer patients receive a total tumor dose of 64.8 Gy megavoltage XRT in 7 weeks at 1.8 Gy once daily, 5 d/wk. Patients with HNSCC receive 70 Gy megavoltage XRT in 7 weeks at 2 Gy once daily, 5 d/wk. Paclitaxel is delivered by continuous intravenous infusion starting 48 hours before XRT and continuing for its duration. The dose of paclitaxel is escalated in cohorts of three patients in a standard phase I design. To date, 49 patients have been entered on both studies and 43 are evaluable for toxicity. Paclitaxel dose is currently at the 17 mg/m2/d dose level, with no dose-limiting toxicity thus far. Clinical outcomes suggest significant activity for this combination. This therapy is feasible and has been well-tolerated through current dose levels. Dose escalation is ongoing.

A phase I single-dose trial of gadolinium texaphyrin (Gd-Tex), a tumor selective radiation sensitizer detectable by magnetic resonance imaging

Gadolinium Texaphyrin (Gd-Tex) is a radiation sensitizer with a novel mechanism of action that sensitizes both oxic and hypoxic cells, localizes selectively in tumors, and is detectable by magnetic resonance imaging (MRI). This Phase I single-dose trial of Gd-Tex administered concurrently with radiation therapy was carried out to determine the maximally tolerated dose (MTD), dose-limiting toxicities, pharmacokinetics, and biolocalization of Gd-Tex as determined by MRI. Adults with incurable cancers of any histology requiring radiation therapy were eligible. A single i.v. dose of Gd-Tex was followed at least 2 h later by radiation therapy. The Gd-Tex dose was escalated in cohorts of 3 to 5 patients. Thirty-eight patients (median age, 58 years; range, 35-77 years) with incurable cancers of the lung (26), cervix (3), or other solid tumors (9) received a total of 41 single administrations of Gd-Tex. The Gd-Tex dose was escalated from 0.6 to 29.6 mg/kg. Irradiated sites included the thorax, brain, pelvis, bone, soft tissue, and sites of nodal metastases. The MTD was 22.3 mg/kg, determined by reversible acute tubular necrosis as the dose-limiting toxicities. Gd-Tex selectively accumulated in primary and metastatic tumors as demonstrated by MRI. No increase in radiation toxicity to normal tissues was seen. The median half-life of Gd-Tex after single-dose administration is 7.4 h. This study demonstrates that Gd-Tex is well tolerated in doses below the MTD, and that there is selective biolocalization in tumors. The maximum recommended dose for single administrations is 16.7 mg/kg.

Decreasing length of hospital stay in treatment of osteoid osteoma

Ninety-eight operative procedures were performed for treatment of osteoid osteoma since 1978 at the authors' institution. During these years there was a progressive decrease in the length of hospital stay, decreasing from a mean of 6.8 days between 1978 and 1980 to 2.6 days between 1994 and 1996. Factors that influenced the length of stay after a surgical procedure include patient age, lesion location, choice of procedure, and surgeon. However, the decline in length of stay with time is independent of these factors, and antedates the era of managed care. Increased reliance on more conservative surgical procedures has markedly diminished the length of hospital stay required in the care of these patients.

Using hypnosis to accelerate the healing of bone fractures: a randomized controlled pilot study

CONTEXT

Hypnosis has been used in numerous medical applications for functional and psychological improvement, but has been inadequately tested for anatomical healing.

OBJECTIVE

To determine whether a hypnotic intervention accelerates bodily tissue healing using bone fracture healing as a site-specific test.

DESIGN

Randomized controlled pilot study.

SETTING

Massachusetts General Hospital, Boston, Mass, and McLean Hospital, Belmont, Mass.

PATIENTS

Twelve healthy adult subjects with the study fracture were recruited from an orthopedic emergency department and randomized to either a treatment (n = 6) or a control group (n = 6). One subject, randomized to the treatment group, withdrew prior to the intervention.

INTERVENTION

All 11 subjects received standard orthopedic care including serial radiographs and clinical assessments through 12 weeks following injury. The treatment group received a hypnotic intervention (individual sessions, audiotapes) designed to augment fracture healing.

MAIN OUTCOME MEASURES

Radiological and orthopedic assessments of fracture healing 12 weeks following injury and hypnotic subjects' final questionnaires and test scores on the Hypnotic Induction Scale.

RESULTS

Results showed trends toward faster healing for the hypnosis group through week 9 following injury. Objective radiographic outcome data revealed a notable difference in fracture edge healing at 6 weeks. Orthopedic assessments showing trends toward better healing for hypnosis subjects through week 9 included improved ankle mobility; greater functional ability to descend stairs; lower use of analgesics in weeks 1, 3, and 9; and trends toward lower self-reported pain through 6 weeks.

CONCLUSION

Despite a small sample size and limited statistical power, these data suggest that hypnosis may be capable of enhancing both anatomical and functional fracture healing, and that further investigation of hypnosis to accelerate healing is warranted.

Dosimetric comparison of centered and off-centered posterior neck electron fields

Approximately rectangular low or medium energy electron fields at extended SSD are often used to boost over the spinal cord in the treatment of head and neck cancer after cord tolerance is reached. A separate abutting photon field is used to continue treatment anterior to the spine. Typically, the electron and photon fields have different central axes and the electron cutout is symmetrically centered in the cone. However, a good match between the photon and electron fields is achieved more readily if the central axis of the electron field is located at the center of the area treated by the photon field. This displaces the electron cutout toward the edge of the cone. We measured and compared the percent depth dose (PDD), output factors and profiles for matched pairs of centered and off-centered rectangular and square cutouts for the 6, 9 and 12 MeV beams of three Varian linacs. The 10 x 10 and 15 x 15 cones were used at SSDs of 100 cm and 110 cm. Differences between centered and off-centered cutouts of the same dimensions were less than 1% for PDD and profiles and less than 5% for output factors. Therefore, the same central axis can be used for abutting photon and electron fields, without requiring extra dosimetric data to account for the off-center location of the electron cutout.

The effect of independent collimator misalignment on the dosimetry of abutted half-beam blocked fields for the treatment of head and neck cancer

BACKGROUND AND PURPOSE

Independent collimation conveniently allows for the junctioning of abutting fields with non-diverging beam edges. When this technique is used at the junction of multiple fields, e.g. lateral and low anterior fields in three-field head and neck set-ups, there should be a dosimetric match with no overdose or underdose at the matchline. We set out to evaluate the actual dosimetry at the central match plane.

MATERIALS AND METHODS

Independent jaws were used to mimic two half-beam blocked fields abutting at the central axis. X-Ray verification film was exposed in a water-equivalent phantom and the dose at the matchline was evaluated with laser densitometry. Collimators were then programmed to force a gap or overlap of the radiation fields to evaluate the effect of jaw misalignment within the tolerance of the manufacturer's specification. Diode measurements of the field edges were also performed. Four beam energies from four different linear accelerators were evaluated.

RESULTS

Small systematic inhomogeneities were found along the matchline in all linear accelerators tested. The maximum dose on the central axis varied linearly with small programmed jaw misalignments. For a gap or overlap of 2 mm between the jaws, the matchline dose increased or decreased by 30-40%. The region of overdose or underdose around the matchline is 3-4 mm wide. The discrepancy between the width of jaw separation and the width of the region of altered dose is explained by a penumbra effect.

CONCLUSION

We recommend that independent jaw alignment be evaluated routinely and provide a simple method to estimate dose inhomogeneity at the match plane. If there is a field gap or overlap resulting in a clinically significant change in dosimetry, jaw misalignment should be corrected. If it cannot be corrected, part of the benefit of asymmetric collimation is lost and other methods of field junctioning may have to be considered. We routinely use a small block over the spinal cord at the mono-isocenter set-up plane for three-field head and neck treatments to prevent an overdose.

Osteoinduction using bone morphogenic protein in irradiated tissue

OBJECTIVE

To prove the efficacy of bone morphogenic protein as an osteoinductive agent in irradiated tissue.

DESIGN

Prospective randomized controlled trial designed to test the effectiveness of recombinant bone morphogenic protein 2 (rBMP-2) combined with solid hydroxyapatite disks in an irradiated tissue bed.

SUBJECTS

Eighteen adult, male, white New Zealand rabbits weighing 3.0 to 3.5 kg.

INTERVENTION

The rabbits were randomly divided, with 9 receiving radiation treatment and 9 receiving no radiation treatment. Each animal underwent implantation of 2 hydroxyapatite disks onto the snout at 9 weeks following radiation treatment. One disk was impregnated with rBMP-2 and the other with buffer only. The animals were killed at 3, 6, or 20 weeks after implantation for analysis.

RESULTS

Histological analysis demonstrated that rBMP-2 was equally effective as an osteoinductive agent in the irradiated and nonirradiated tissue. We also found significantly increased new bone formation in the rBMP-2 group vs the buffer group.

CONCLUSIONS

This study supports the potential clinical utility of rBMP-2 and solid hydroxyapatite in irradiated tissue beds. These findings have interesting implications for patients with head and neck cancer who have undergone radiation therapy and need bony reconstruction.

Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck

BACKGROUND

Most patients receiving accelerated fractionation radiotherapy or chemoradiotherapy for head and neck cancer experience severe mucositis. This can lead to decreased oral intake, resulting in dehydration, severe malnutrition, hospitalization, and/or interruption of radiotherapy.

OBJECTIVE

To evaluate the effect of prophylactic gastrostomy tubes (PGTs) on the rates of weight loss, unplanned interruptions, and hospitalization during high-intensity head and neck radiotherapy.

METHODS

A retrospective review was performed on 88 patients treated for locally advanced head and neck cancer with accelerated twice-a-day radiation (n = 59) or concurrent chemoradiotherapy (n = 29). Prophylactic gastrostomy tubes were placed in 36 (41%) of patients in anticipation of increased acute toxic effects from treatment. The remaining patients without PGTs served as a control group.

RESULTS

Patients without PGTs lost an average 3.1 kg compared with 7.0 kg in the control group (P<.001). There were significantly fewer hospitalizations for nutritional or dehydration issues in those with PGTs than in the control group (13% vs 34%; P = .04, chi2 test). Among those with good performance status, no patient with a PGT required a treatment interruption, compared with 18% of patients without a PGT (P = .08). Sixteen patients (31%) in the control group underwent therapeutic gastrostomy tube placement during or after radiation therapy.

CONCLUSIONS

The use of PGTs significantly reduces weight loss and the rate of hospitalization for dehydration and complications of mucositis. Treatment interruptions may also be avoided by the use of PGTs in patients with good performance status. We encourage patients scheduled for intensive radiation therapy to receive a PGT.

Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment

Osteoid osteoma, a benign bone tumor, has traditionally been treated with operative excision. A recently developed method for percutaneous ablation of the tumor has been proposed as an alternative to operative treatment. The relative outcomes of the two approaches to treatment have not previously been compared, to our knowledge. The rates of recurrence and of persistent symptoms were compared in a consecutive series of eighty-seven patients who were managed with operative excision and thirty-eight patients who were managed with percutaneous ablation with radiofrequency. Patients who had a spinal lesion were excluded. The minimum duration of follow-up was two years. There was a recurrence, defined as the need for subsequent intervention, after operative treatment in six (9 per cent) of sixty-eight patients who had been managed for a primary lesion and in two of nineteen who had been managed for a recurrent lesion. The average length of the hospital stay was 4.7 days for the patients who had a primary lesion and 5.1 days for those who had a recurrent lesion. There was a recurrence after percutaneous treatment in four (12 per cent) of thirty-three patients who had been managed for a primary lesion and in none of five who had been managed for a recurrent lesion. The average length of the hospital stay was 0.2 day for these thirty-eight patients. With the numbers available, we could detect no significant difference between the two treatments with regard to the rate of recurrence. The rate of persistent symptoms (that is, symptoms that did not necessitate additional treatment) was greater than the rate of recurrence. According to responses to a questionnaire, eight (30 per cent) of twenty-seven patients had persistent symptoms after operative treatment and six (23 per cent) of twenty-six patients had persistent symptoms after percutaneous treatment with radiofrequency. Two patients had complications after operative excision, necessitating a total of five additional operations. There were no complications associated with the percutaneous method. The results of the present study suggest that percutaneous ablation with radiofrequency is essentially equivalent to operative excision for the treatment of an osteoid osteoma in an extremity. The percutaneous method is preferred for the treatment of extraspinal osteoid osteoma because it generally does not necessitate hospitalization, it has not been associated with complications, and it is associated with a rapid convalescence.

Transmission blocks for lower neck and inguinal lymph node radiotherapy

We evaluate techniques for radiotherapy to low neck and inguinal lymph nodes. Partial transmission blocks (PTBs) simplify treatment planning, daily setup, and improve reproducibility and dose homogeneity. PTBs minimize the risk for dose misadministration to critical organs. Disadvantages include doses that are potentially lower to the medial cervical lymphatics and higher to the femur. PTBs can surmount common treatment planning problems.

Using quantitative CT to assess adipose distribution in adult men with acquired hypogonadism

OBJECTIVE

Quantitative CT is a powerful tool that may be used to assess distribution of adipose and lean mass and bone mineral density in specific anatomic compartments. Testosterone deficiency (hypogonadism) is increasingly recognized in adult men and is associated with osteoporosis, diminished strength, and an increase in cardiovascular risk. We used quantitative CT to determine whether hypogonadism is associated with fat redistribution and altered bone density.

SUBJECTS AND METHODS

Quantitative CT was performed at the level of the L4 vertebra in 26 men with adult onset testosterone deficiency and 17 eugonadal men of similar body mass index and age. Adipose area in the subcutaneous, visceral, and skeletal muscle areas was determined and trabecular bone density was measured. Values between the groups were compared using t tests.

RESULTS

The ages of the hypogonadal and eugonadal men were 52 +/- 14 years and 51 +/- 8 years (p value not significant), respectively. Subcutaneous fat area was higher in the testosterone-deficient men than in the control subjects (270 +/- 101 cm2 versus 202 +/- 111 cm2; p = .046). Muscle fat area was higher in the hypogonadal men (6 +/- 3 cm2 versus 2 +/- 1 cm2; p = .001). Measurements of visceral fat were similar for both groups. Trabecular bone density was lower in the hypogonadal than in the eugonadal men (112 +/- 38 mg K2HPO4/dl versus 148 +/- 34 mg K2HPO4/dl, respectively; p = .003).

CONCLUSION

Our findings indicate that testosterone deficiency is associated with a decrease in bone density and a redistribution of fat. Quantitative CT is a sensitive method that may be useful in determining alterations in regional adipose deposition in hypogonadal men and in evaluating the benefit of interventional therapy such as testosterone replacement.

Computer-based speech recognition as a replacement for medical transcription

OBJECTIVE

We have implemented computerized speech recognition in a high-volume clinical setting using a newly developed commercial software system. This paper compares the performance of the computerized system with conventional transcription during a trial week followed by 3 months of routine clinical use.

CONCLUSION

The speech recognition system was used for 97% of the cases during the trial week and 87% of cases during the months of continuous use. For a similar mixture of cases, no change occurred in the length of reports after introduction of the computerized system. Speech recognition decreased the time until the report became available by 99% and resulted in a substantial savings in transcription costs. We conclude that speech recognition by computer is practical in a high-volume clinical implementation.

Seven-week continuous-infusion paclitaxel with concurrent radiotherapy for locally advanced head and neck squamous cell cancer: a phase I study

The goal of this National Cancer Institute-sponsored phase I trial is to determine the feasibility, toxicity, and pharmacokinetics of continuous-infusion (24 hr/d, 7 d/wk, 7-week total) intravenous paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) combined with standard curative radiotherapy (RT) for previously untreated, locally advanced head and neck squamous cell cancers. Eligible patients have squamous cell cancers of the head and neck with expected 5-year survival rates of < or =25%; a good performance status; adequate hematologic, hepatic, and renal functions; and no distant metastases. All patients receive 70 Gy megavoltage RT in 7 weeks (2 Gy/d x 5 d/wk). Paclitaxel is delivered by protracted venous infusion starting 48 hours before RT and continuing for its duration. Biopsies for cell-cycle distribution analyses and paclitaxel tissue levels are obtained, if possible, before beginning paclitaxel and after 48 hours just before RT begins. The dose of paclitaxel is escalated in cohorts of three patients. Eighteen patients are evaluable for toxicity. Treatment has been completed through the 6.5 mg/m2/d dose level and is ongoing at 10.5 mg/m2/d. There has been no dose-limiting toxicity thus far. With the exception of anemia, toxicity is commensurate with what would be expected from RT alone. A slowly progressive normocytic anemia with no renal dysfunction was found to be associated with an acquired hypoerythropoietin state. Tumor biopsies have suggested the possibility of paclitaxel-induced mitotic arrest. This therapy is feasible and has been well tolerated through current dose levels with no dose-limiting toxicity. There is a suggestion of biologic activity evidenced by the anemia and the possibility of alteration in cell-cycle distributions. Dose escalation is ongoing.

Radiologic diagnosis of bone metastases

Metastatic cancer often involves the skeleton. Tumor most often reaches the bones by hematogenous spread; however, direct extension from the primary tumor or from another site of metastasis, as well as lymphatic dissemination, may occur. Clinical features depend on the affected sites and the extent of disease. The radioisotope bone scan has been the preferred imaging screening modality. Magnetic resonance imaging is probably more sensitive in the detection of axial lesions, but additional development is needed before it can replace the isotope scan in evaluation of the long bones. For patients presenting with metastatic disease, the appearance of the lesions may help to guide the search for a primary. Some helpful patterns include lytic and sclerotic lesions, "expanded" lesions, "pseudosarcomatous" lesions, acral lesions, and soft tissue ossification. Evaluation of response to therapy is problematic. Progressive sclerosis of a lytic focus generally indicates a positive response. Pitfalls in the evaluation of response include the "flare" phenomenon, which has been observed on radioisotope scans early in the course of therapy.

Seven-week continuous-infusion paclitaxel plus concurrent radiation therapy for locally advanced non-small cell lung cancer: a phase I study

The goal of this National Cancer Institute-sponsored phase I trial is to determine the feasibility, toxicity, and pharmacokinetics of continuous-infusion (24 hr/d, 7 d/wk, 7 weeks total) intravenous paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) when combined with standard, curative-intent radiation therapy (RT) for previously untreated, locally advanced non-small cell lung cancers. Eligible patients have locally advanced (T4NXM0 or TXN2-3M0) non-small cell cancer ineligible for potentially curative surgical resection, a good performance status, adequate hematologic, hepatic, and renal functions, and no distant metastases. All patients receive a total tumor dose of 64.8 Gy megavoltage RT in 7 weeks at 1.8 Gy once daily, 5 d/wk. Paclitaxel is delivered by continuous intravenous infusion starting 48 hours before RT and continuing for its duration. The dose of paclitaxel is escalated in cohorts of three patients in a standard phase I design. To date, 16 patients have entered the trial, and 15 are evaluable for toxicity in this ongoing study. Paclitaxel dose is currently at a 6.5 mg/m2/d dose level, with no dose-limiting toxicity recorded thus far. One patient at the highest dose level has had grade 2 pneumonitis. With the exception of anemia, toxicities are those that would be expected from RT alone. A slowly progressive normocytic anemia with no renal dysfunction was found to be associated with an acquired hypoerythropoietin state. These findings indicate that this therapy is feasible and well tolerated through current dose levels, with no dose-limiting toxicity. Dose escalation is ongoing.

Intensive radiation therapy concurrent with up to 7-week continuous-infusion paclitaxel for locally advanced solid tumors: phase I studies

Patients with locally advanced solid tumors of the lung, head and neck, and malignant astrocytomas usually succumb to their disease despite aggressive standard therapy. Laboratory data suggest that the addition of 1.0 to 10 nmol/L paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ), a microtubule stabilizing drug, to radiation therapy may result in significant radiation sensitization, perhaps due to accumulation of cells at G2/M. Relatively low concentrations (1.0 to 10 nmol/L) appear to be optimal for direct cytotoxicity and radiosensitization in vitro. Within this dose range, more prolonged exposure seems to result in higher response rates. The phase I trials reported here are designed to test the combination of paclitaxel, administered by continuous intravenous infusion (24 hours a day, 7 days a week), and standard, curative-intent radiation therapy. The ultimate goal of this study is to improve local and systemic control and survival for patients with these three tumor types. To date, 39 evaluable patients are enrolled in this study; there has been no dose-limiting toxicity up to 6.5 mg/m2/d. Observed toxicities include anemia, lymphopenia, mucositis, and cutaneous toxicities.

CT and MR imaging in the local staging of primary malignant musculoskeletal neoplasms: Report of the Radiology Diagnostic Oncology Group

PURPOSE

To assess the relative accuracies of computed tomography (CT) and magnetic resonance (MR) imaging in the local staging of primary malignant bone and soft-tissue tumors.

MATERIALS AND METHODS

At four institutions, 367 eligible patients (aged 6-89 years) with malignant bone or soft-tissue neoplasms in selected anatomic sites were enrolled. Patients underwent both CT and MR imaging within 4 weeks before surgery. In each patient, CT scans were interpreted independently by two radiologists and MR images by two other radiologists at the enrolling institution. The CT and MR images were then interpreted together by two of those radiologists and subsequently reread at the other institutions. Imaging and histopathologic findings were compared and were supplemented when needed with surgical findings. Receiver operating characteristic curve analysis and descriptive statistical analysis were performed.

RESULTS

Cases were analyzable in 316 patients: 183 had primary bone tumors; 133 had primary soft-tissue tumors. There was no statistically significant difference between CT and MR imaging in determining tumor involvement of muscle, bone, joints, or neurovascular structures. The combined interpretation of CT and MR images did not statistically significantly improve accuracy. Interreader variability was similar for both modalities.

CONCLUSION

CT and MR imaging are equally accurate in the local staging of malignant bone and soft-tissue neoplasms in the specific anatomic sites studied.