Effect of simultaneous pulsed hyperthermia and pulsed radiation treatment on survival of SiHa cells

Relatively mild temperatures (40-41.5 degrees C) can sensitize human cells to radiation without the development of thermal tolerance to radiosensitization. Therefore there may be a therapeutic benefit to adding mild hyperthermia to brachytherapy regimens for the treatment of cancer. However, the required heating times are long (approximately 48 h) which renders this approach somewhat impractical. A novel alternative is to combine pulsed brachytherapy with pulsed hyperthermia to enable the total radiation dose to be given at an elevated temperature while the total heating time is kept short. A treatment schedule in which 1 Gy radiation pulses were given once per hour during 5-min heating pulses also delivered once per hour, was investigated in vitro in the human cervical carcinoma line, SiHa. The degree of cytotoxicity and thermoradiosensitization of the cells were assessed by cell survival using the colony forming assay. Cells were exposed to pulsed hyperthermia alone (5 min at 45 degrees C, delivered once per hour), acute hyperthermia alone (45 degrees C), pulsed radiation alone (1 Gy per hour), acute radiation alone, and simultaneous pulsed hyperthermia and pulsed radiation. Pulsed heating alone caused little cytotoxicity. However when pulsed heating was added to pulsed radiation, the level of cytotoxicity was greater than for pulsed radiation alone or acute radiation alone. The effect was also greater than would be predicted from a simple additive effect of pulsed radiation and pulsed heating. In conclusion, pulsed heating at 45 degrees C sensitized cells to pulsed radiation without the development of thermal tolerance.

Outcome in breast cancer managed without an initial axillary lymph node dissection

PURPOSE

The role of an elective axillary lymph node dissection (AxLND) in the initial management of patients with early stage breast cancer has recently become controversial. The objective of this current study is to review the reasons as to why patients from a single institution were managed without an initial AxLND and their outcome in terms of survival and recurrence rates.

MATERIALS AND METHODS

A retrospective analysis was conducted on 126 women referred to the Princess Margaret Hospital with the diagnosis of breast cancer who did not undergo an initial AxLND.

RESULTS

The median age of this population was 69 years, with the vast majority (93%) being post-menopausal. Fifty-seven patients had T1 tumors and the remainder had T2-3 tumors. Adjuvant radiation therapy to the breast was administered to 65 patients and systemic adjuvant treatment was administered to 24 patients. In approximately one-third of these cases, the reasons cited for not performing an AxLND were related to the patient's age, a medical contraindication, or the patient's choice. The 5-year actuarial cause-specific survival was 92%; the local breast relapse-free rate (RFR) was 85% and the axillary RFR was 86%. No patients in this study experienced debilitating symptoms from their axillary disease. Only 16 patients underwent a subsequent AxLND, with the lymph nodes being pathologically uninvolved in six of these patients.

CONCLUSION

This study supports the concept that. in selected patients, adopting an approach of a delayed AxLND does not appear to compromise the patients' outcome, with only 13% of patients requiring a subsequent AxLND.

Gestational breast cancer

OBJECTIVE

To study the problems of breast imaging in gestational breast cancer.

PATIENTS AND METHOD

Retrospective review of the charts of 19 patients with breast cancer detected during pregnancy or lactation or within 1 year of delivery, who were referred to a tertiary centre for adjuvant therapy between 1986 and 1996. For 10 patients who underwent breast imaging, mammograms and breast ultrasonograms or reports were requested from outside facilities.

RESULTS

The patients ranged in age from 23 to 41 years (mean 31 years). All 19 patients presented with palpable tumours; in 7 patients, the tumours were stage T2 or higher; in 11 patients, the tumours were at an advanced stage with positive axillary nodes. In 11 of the patients there was a delay in diagnosis, which ranged from 2 to 16 months. Of the 8 mammograms that could be reviewed, 5 showed infiltrating ductal carcinomas with typical features, which were detected as a mass (in 1 case), a mass with microcalcifications (in 1 case), microcalcifications (in 2 cases) and asymmetry (in 1 case). Three mammograms were negative, including 1 obtained from a patient with extensive comedocarcinoma. Breast ultrasonograms obtained from 4 patients (2 of whom also had mammograms) showed solid hypoechoic masses; in 2 of the ultrasonograms, the masses simulated a benign lesion.

CONCLUSIONS

Although breast cancer during pregnancy and lactation is rare, this study suggests that radiologists should include it in the differential diagnosis of a solid breast mass seen during pregnancy or lactation. Clinicians appear to be reluctant to use breast imaging in these patients; however, this can lead to a delay in diagnosis. Ultrasonography is the modality of choice for initial analysis of such a mass in this age group. Mammography with shielding of the abdomen is recommended if there is suspicion of cancer. Clinical, mammographic and sonographic findings should be integrated for optimum interpretation.

T1/T2 glottic cancer managed by external beam radiotherapy: the influence of pretreatment hemoglobin on local control

PURPOSE

Pretreatment hemoglobin (Hb) level has been reported to be an important prognostic factor for local control and survival in various malignancies. However, in many settings, the adverse effect of a low Hb may be related to more advanced disease. The purpose of this analysis was to assess the influence of pretreatment Hb on local control in a large series of patients with a localized cancer (T1/T2 glottic cancer, AJCC 1992) treated in a standard fashion.

MATERIALS AND METHODS

Between January 1981 and December 1989, 735 patients (median age 63; 657 males, 78 females) with T1/T2 glottic cancer were treated with radiation therapy (RT). The standard RT prescription was 50 Gy in 20 fractions over 4 weeks (97% of patients). Factors studied for prognostic importance for local failure included pretreatment Hb, age, sex, T category, anterior commissure involvement, subglottic extension, and tumor bulk (presence of visible tumor vs. subclinical disease).

RESULTS

With a median follow-up of 6.8 years (range 0.2-14.3), 131 patients have locally relapsed for an actuarial 5-year relapse-free rate of 81.7%. The 5-year actuarial survival was 75.8%. The mean pretreatment hemoglobin level was 14.8 g/dl and was similar in all prognostic categories. On multivariate analysis, using the Cox proportional hazards model, pretreatment Hb predicted for local failure after RT. The hazard ratio (HR) for relapse was calculated for various Hb levels. For example, the HR for a Hb of 12 g/dl vs. a Hb of 15 g/dl was 1.8 (95% confidence interval 1.2-2.5). Previously established factors, including gender, T category, subglottic extension, as well as tumor bulk, were also prognostically important for local control.

CONCLUSIONS

This analysis, in a large number of similarly treated patients, indicates that pretreatment Hb is an independent prognostic factor for local control in patients with T1/T2 carcinoma of the glottis treated with RT. The underlying biology of this observation needs to be explored, and using this information, it may be possible to develop strategies to improve treatment outcome.

Relationship between thermal dose and outcome in thermoradiotherapy treatments for superficial recurrences of breast cancer: data from a phase III trial

PURPOSE

The objective of this study was to determine whether the thermal dose delivered during hyperthermia treatments and other thermal factors correlate with outcome after combined radiation and hyperthermia of breast carcinoma recurrences. Data were from the combined hyperthermia and radiation treatment arms of four Phase III trials, which when pooled together, demonstrated a positive effect of hyperthermia.

METHODS AND MATERIALS

Four Phase III trials addressing the question of whether hyperthermia could improve the local response of superficial recurrent breast cancer to radiation therapy were combined into a single analysis. Thermal dosimetry data were collected from 120 of the 148 breast cancer recurrence patients who received hyperthermia. The data were analyzed for correlations between thermal parameters as well as important clinical parameters and outcome (complete response rate, local disease free survival, time to local failure, and overall survival).

RESULTS

Five thermal parameters were tested, all associated with the low regions of the measured temperature distributions. Max(TDmin) and Sum(TDmin) were associated with complete response where TDmin is the minimum thermal dose measured by any of the tumor temperature sensors during a treatment: Max(TDmin) is the maximum of TDmin over a series of treatments. Using a categorical relationship with a cutoff of 10 min for Sum(TDmin), the complete response rate was 77% for Sum(TDmin) > 10 min and 43% for Sum(TDmin) < or = 10 min (p = 0.022, adjusted for study center and significant clinical factors). The overall complete response rate for hyperthermia and radiation was 61% compared to 41% for radiation alone. Either Max(TDmin) or Sum(TDmin) were also associated with local disease free survival, time to local failure and overall survival.

CONCLUSIONS

An earlier report of this trial demonstrated a significant benefit when hyperthermia was added to radiation in the treatment of breast cancer recurrences. The analysis of thermal factors demonstrates that parameters representative of the low end of the measured temperature distributions are associated with initial complete response rate, local disease-free survival, time to local failure and overall survival.

Prenatal diagnosis of a deletion of 18q in a fetus associated with multiple-marker screen positive results

We report here the observations of positive maternal serum screening tests for Down syndrome, cytogenetic and molecular analysis, and dysmorphic fetal features in a pregnancy with 18q-syndrome. A 33-year-old primigravida was referred for genetic counselling because of multiple-marker screen positive results. At 14 weeks' gestation, the woman had a Down syndrome risk of 1:107 calculated from a maternal serum alpha-fetoprotein (MSAFP) level of 1.49 multiples of the median (MOM), a total human chorionic gonadotrophin (hCG) level of 2.42 MOM, and a serum unconjugated oestriol (uE3) level of 0.55 MOM. At 17 weeks' gestation, a repeat test showed a Down syndrome risk of 1:10 calculated from an MSAFP level of 1.09 MOM and a free beta-hCG level of 12.3 MOM. Genetic amniocentesis revealed a de novo deletion of 18q22.2-qter. Intrauterine fetal death occurred at 21 weeks' gestation. At birth, the fetus manifested clinical findings of the 18q-syndrome. The phenotype was correlated with the extent of the deletion. Linkage analysis of the family confirmed the extent and paternal origin of the deletion.

Perinatal features of omphalocele-exstrophy-imperforate anus-spinal defects (OEIS complex) associated with large meningomyeloceles and severe limb defects

Omphalocele-Exstrophy-Imperforate anus-Spinal defects (OEIS complex), a combination of omphalocele, exstrophy of the bladder, an imperforate anus and spinal defects, arises from a single localized defect in the early development of the mesoderm that will later contribute to infraumbilical mesenchyme, cloacal septum, and caudal vertebrae. In this report, we document the perinatal features of two cases of OEIS complex associated with meningomyeloceles and severe lower limb defects, and discuss the prenatal diagnosis, inheritance, and differential diagnosis of this association of malformations. Although long-term survival can be achieved by successful corrective surgery, the associated structural defects such as large meningomyelocele and severe limb aplasia or hypoplasia, as seen in our patient, can influence the patient's quality of life. We would like to emphasize that an accurate prenatal diagnosis of OEIS complex and associated malformations is important for the detailed counseling of the family as well as appropriate perinatal management by the obstetricians, pediatric surgeons, urologists, neurosurgeons, and neonatologists.

Cytotoxic effects of Ad5CMV-p53 expression in two human nasopharyngeal carcinoma cell lines

Nasopharyngeal carcinoma (NPC) is a malignant disease of the head/neck region with a 5-year survival level of approximately 65%. To explore novel therapeutic strategies in the management of this disease, the potential of Ad5CMV-p53-mediated gene transfer to NPC cells was investigated in vitro. Two NPC cell lines, CNE-1 and CNE-2Z, were infected with either Ad5CMV-p53 or Ad5CMV-beta-galactosidase and evaluated for transduction efficiency and cytotoxicity. At a multiplicity of infection of 50 plaque-forming units (pfu)/cell, Ad5CMV-beta-galactosidase infection and beta-galactosidase expression were detected in almost 100% of treated NPC cells. High levels of recombinant p53 protein expression were also observed in the NPC cell lines when treated with Ad5CMV-p53 at 50 pfu/cell. Expression of recombinant p53 was dose and time dependent, with peak levels observed at 24 h. A marked increase in WAF1/CIP1 expression was also observed in NPC cells after Ad5CMV-p53 infection. Expression of bcl-2 and bax were minimally detectable at baseline; infection with Ad5CMV-p53 induced no changes in the protein levels in the NPC cells. Growth of NPC cells treated with Ad5CMV-p53 was observed to be significantly inhibited when determined by either the 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide or clonogenic assay. Infection with Ad5CMV-p53 at 25 pfu/cell resulted in survival levels of 0.35 and 11% in CNE-1 and CNE-2Z cells, respectively. Chromatin condensation and DNA fragmentation were also observed, demonstrating that these cells were undergoing apoptosis. However, when GM38 (normal human fibroblasts) were subjected to identical treatments, they demonstrated significantly lower infection efficiency and transgene expression and were resistant to Ad5CMV-p53-mediated cytotoxicity. These data demonstrate the efficacy of Ad5CMV-p53-mediated gene therapy in human NPC, thus warranting additional investigations of this therapeutic strategy.

Prenatal diagnosis of cephalothoracopagus janiceps monosymmetros

We report a case of cephalothoracopagus janiceps monosymmetros that was diagnosed prenatally by ultrasound at 23 weeks' gestation. Obstetric ultrasound demonstrated conjoined female twins with a single fused cranial vault irregular in contour, duplicated cerebra, one face, two eyeballs, a fused thorax, two hearts, two thoracic spines, eight limbs, and polyhydramnios. The pregnancy was terminated and all the features described prenatally were observed at necropsy. The asymmetrical fused faces consisted of a ventral humanoid face with micrognathia, microphthalmia, low-set ears, a normal nose, and an opposite reduced face with partial facial features of a central narrowed fissure and paired synotic ears. The conjoined twins had fused umbilical cords, omphalocoele, and a single oesophagus, stomach, and duodenum, but duplicated pancreases, spleens, and central nervous, cardiopulmonary, hepatic, and genito-urinary systems. The common gastrointestinal tract bifurcated at the level of the jejunum. Our case documents a very uncommon variety of asymmetrical cephalothoracopagus janiceps with duplicated central nervous systems.

Skeletal deformities of acardius anceps: the gross and imaging features

A morphology based imaging review is presented of the characteristic skeletal deformities associated with acardius anceps in three acardiac twins. These fetuses demonstrated poorly developed skulls, limb reduction defects, and phocomelia of the upper limbs, as well as narrow thoracic cages with or without the complete development of ribs, clavicles, scapulae, and cervical, thoracic, or lumbar vertebrae. However, their lower limbs and pelvic girdles were almost normal. The authors conclude that skeletal development is likely to be jeopardized in the area adjacent to the heart and in the cephalic portion of the body in fetuses with acardius anceps, and suggest vascular deficiency and hypoperfusion as pathogenetic mechanisms in this type of skeletal deformity.

Cebocephaly, alobar holoprosencephaly, spina bifida, and sirenomelia in a stillbirth

Cebocephaly and sirenomelia are uncommon birth defects. Their association is extremely rare; however, the presence of spina bifida with both conditions is not unexpected. We report on a female still-birth with cebocephaly, alobar holoprosencephaly, cleft palate, lumbar spina bifida, sirenomelia, a single umbilical artery, and a 46,XX karyotype, but without maternal diabetes mellitus. Our case adds to the examples of overlapping cephalic and caudal defects, possibly related to vulnerability of the midline developmental field or axial mesodermal dysplasia spectrum.

Cutis marmorata telangiectatica congenita associated with an elevated maternal serum human chorionic gonadotrophin level and transitory isolated fetal ascites

A 34-year-old woman with an abnormal maternal serum screening result and a Down syndrome risk of 1:60 calculated from a maternal serum alpha-fetoprotein (AFP) value of 1.4 multiples of the median (MoM) and a human chorionic gonadotrophin (hCG) level of 4.32 MoM at 18 weeks' gestation was found to have isolated fetal ascites at 23 weeks' gestation. Spontaneous resolution occurred 10 weeks after the initial presentation. After birth, the neonate had generalized cutis marmorata telangiectatica congenita (CMTC), large vascular plaques on the scalp with superficial ulceration and crusts, a small atrial septal defect, a patent ductus arteriosus, hepatomegaly, micrognathia, seizures, an abnormal electroencephalogram, congenital retinal detachment, glaucoma and widely spaced toes. Our patient illustrates that CMTC in utero may be associated with a markedly elevated maternal serum hCG level as well as transitory isolated fetal ascites. However, such associations can be coincidental and further collaborative studies and cases will be necessary before it can be determined that a disproportionately elevated hCG level and transitory isolated fetal ascites are predictive of CMTC in utero.

First report of distal obstructive uropathy and prune-belly syndrome in an infant with amniotic band syndrome

We describe the first report of distal obstructive uropathy and prune-belly syndrome in an infant with amniotic band syndrome. Prenatal ultrasonographic examination in the third trimester revealed intermittent oligohydramnios, bilateral hydronephrosis, and megacystis. Postnatally, the infant was found to have a scalp defect, a skin pedicle, pseudosyndactyly and constriction rings on the hands, marked distention of the abdomen, a fibrous band attached to the proximal urethra causing urethral stricture, a swollen penile shaft, bilateral talipes equinovarus, and syndactyly of the feet. Multiple fibrous amniotic bands could be identified in the placenta. Our case shows that fetal distal obstructive uropathy can be associated with the congenital constriction band syndrome.

In utero urinary bladder perforation, urinary ascites, and bilateral contained urinomas secondary to posterior urethral valves: clinical and imaging findings

We report on a rare in utero appearance of urinary bladder perforation, urinary ascites, and bilateral contained urinomas secondary to posterior urethral valves. The findings on prenatal sonography, postnatal voiding cystourethrography, and magnetic resonance imaging are described.

Progressive fetal axillary cystic lymphangioma with coexistent naevus flammeus

We report the rare occurrence of a progressive fetal axillary cystic lymphangioma coexistent with an overlying naevus flammeus. The fetus at 22 weeks' gestation was found to have a 37 x 35 mm left axillary multiloculated mass without colour-flow imaging. Amniocentesis showed a normal 46,XX karyotype. Multiple fine-needle aspirations of the mass in the second and third trimesters obtained blood-stained chocolate-coloured fluid containing numerous erythrocytes and lymphocytes but proved ineffective in lessening the progressive growth of the mass. The mother underwent caesarean delivery and a healthy neonate was born with a 141 x 81 mm left axillary cystic lymphangioma and a 50 x 35 mm coexistent naevus flammeus. The neonate was well after simple excision of the lesions. Although cystic lymphangiomas arising in the axilla enlarge progressively during fetal life, our case suggests a good prognosis and except for genetic evaluation, no prenatal intervention is required.

Prenatal diagnosis, pathology, and genetic study of fetus in fetu

We report the prenatal diagnosis, pathology, cytogenetics, and molecular studies of a retroperitoneal fetus in fetu. Prenatal ultrasonography of the host fetus in the third trimester showed an anencephalic, acardiac mass with identifiable extremities and spine within an intra-abdominal cystic mass. Pathological examination revealed a fetiform mass weighing 20 g with four extremities, digits, vertebral bodies, an oral cavity with developing teeth, primitive male external genitalia, a urinary bladder, a cloaca with an external opening, large intestines, a membranous capsule, and an umbilical cord with one artery, one vein, and Wharton's jelly. Histological examination demonstrated nerve bundles in the fibrocollagenous tissue below the cuboidal surface epithelium of the membranous capsule, and absence of lamina elastica interna and vasa vasorum in the single artery of the umbilical cord. Both the host infant and the fetus in fetu had a normal 46,XY karyotype. Molecular analysis using informative genetic markers showed no genetic difference between the host infant and the fetiform mass. We report this case as an unusual example of fetus in fetu in co-existence with an amnion-like membrane containing nerve bundles and with a well-formed umbilical cord. We demonstrate that fetus in fetu can be diagnosed prenatally if the fetiform mass has well-developed limbs and spine. We emphasize the necessity for suspicion of fetus in fetu when a well-defined encapsulated cystic mass with calcified solid components is detected prenatally in a fetus by ultrasonography.

Intracellular pH and heat sensitivity in two human cancer cell lines

BACKGROUND AND PURPOSE

The majority of studies which have demonstrated a linear correlation between intracellular pH (pHi) and thermosensitivity have used rodent cell lines. In order to understand the therapeutic potential of this strategy, it is necessary to determine whether similar observations can be obtained with human cancer cells.

MATERIALS AND METHODS

Human breast cancer MCF-7, and nasopharyngeal carcinoma CNE-1 cell lines were heated at 43 degrees C under extracellular pH (pHe) conditions of 7.2 or 6.8, +/- NaHCO3. We studied the function of the Na+/H+ antiport, one of the primary membrane regulators of pHi, pHi level, and clonogenic survival after these treatments.

RESULTS

After 2-h exposure to 43 degrees C at pHe 7.2, antiport activity in MCF-7 cells was > 50% relative to that of unheated cells, in contrast to < 20% relative activity for CNE-1 cells. Respective survival levels under these conditions were 0.25 and 0.04. The addition of 5-(N-ethyl-N-isoproply) amiloride (EIPA), a potent inhibitor of Na+/H+ antiport, had no effect on MCF-7 cells, but enhanced cytotoxicity for CNE-1 cells, when heated at pHe 6.8 without NaHCO3. Analysis of the correlation between log surviving fraction and pHi demonstrated that this relationship was much steeper for CNE-1 compared to MCF-7 cells.

CONCLUSION

The relationship between pHi levels and thermosensitivity observed in rodent cells can also apply to two human cancer cell lines: MCF-7 and CNE-1, with the latter cells being apparently more amenable to manipulations of pHi regulation compared to the former.

Prenatal diagnosis of supernumerary der(22)t(11;22) associated with the Dandy-Walker malformation in a fetus

We present the first report of prenatally diagnosed Dandy-Walker malformation with the karyotype of partial trisomy 11 and 22 due to familial translocation t(11;22)(q23;q11) inherited in three generations. We demonstrate that the Dandy-Walker malformation can be an associated congenital malformation of supernumerary der(22)t(11;22) syndrome and emphasize the importance of chromosomal analysis and genetic counselling in the obstetric management of prenatally diagnosed Dandy-Walker malformation.

Prenatal diagnosis of asphyxiating thoracic dysplasia (Jeune syndrome)

Asphyxiating thoracic dysplasia (ATD), or Jeune syndrome, is an uncommon autosomal recessive skeletal disorder characterized by a small thorax, varying degrees of rhizomelic brachymelia, polydactyly, pelvic abnormalities, and renal anomalies. We describe prenatal sonographic examinations in the third trimester of a fetus with abnormal small thorax, short limbs, polyhydramnios, and absence of fetal respiratory movements. At 36 weeks gestation, the fetal biparietal diameter was 93 mm, compatible with 37 weeks; the long-bone lengths measured < 5th percentile; the thoracic circumference (TC) measured 230 mm (< 5th percentile); the abdominal circumference (AC) measured 286 mm (25th percentile), and the TC/AC ratio was 0.80 (lower limit of normal). Our case shows that, although a discrepancy between gestational age and TC is prominent, TC/AC ratio may reach lower limit of normal in cases of fetal ATD, when fetal growth is compromised.

Prenatal diagnosis of terminal deletion 7q and partial trisomy 3p in fetuses with holoprosencephaly

Chromosome aberrations, mendelian mutations and exogenous agents can cause holoprosencephaly. Therefore, etiologic evaluation of holoprosencephaly is necessary for obstetricians and genetic counselors, once a prenatal diagnosis of holoprosencephaly has been made. We present four pregnancies in three women in which routine sonographic examinations led to the prenatal diagnosis of holoprosencephaly. Prenatal cytogenetic analysis and fluorescence in situ hybridization demonstrated a 46,XY,del(7)(pter-->q32:) and a 46,XY,der(2)t(2;3)(q37;p21)pat karyotype respectively in two fetuses with cyclopia, and a 46,XX,der(2)t(2;3)(q37;p21)pat and a 46,XX,der(7)t(3;7)(p23;q36) karyotype respectively in two fetuses with premaxillary agenesis. In conclusion, terminal deletion 7q and partial trisomy 3p in holoprosencephalic fetuses indicates that genes contributing to craniofacial development reside in these critical regions. Proper prognostic evaluation in further pregnancies requires expertise in cytogenetics and genetic counseling.

Influence of heat on Na(+)-dependent HCO3-/Cl- exchanger function in a thermoresistant cell line

During previous studies on the relationship between thermosensitivity and intracellular pH (pHi) regulation in mammalian cells, we observed that the thermoresistant TR-4 cells appeared to be resistant to manipulations of the Na+/H+ antiport, one of the two primary membrane regulators of pHi. We hypothesized that this might be due to up-regulation of the alternate pHi regulator, the Na(+)-dependent HCO3-/Cl- exchanger, in the TR-4 cells. We have now evaluated the effect of heat exposure on the function of the Na(+)-dependent HCO3-/Cl- exchanger in both the parent RIF-1 and the thermoresistant variant TR-4 cells. We also assessed thermosensitivity of the cell lines under conditions of either pHe 7.2 or 6.8, with NaHCO3, with or without the addition of DIDS, an inhibitor of HCO3-/Cl- exchanger function. After 2h of heating at 43 degrees C, relative exchanger function declined to around 50% for the TR-4 cells and 10% for the RIF-1 cells. DIDS (0.2 mM) enhanced thermal cytotoxicity in both cells lines, by around 1 log when the cells were heated at neutral conditions, and by around 1.5 log when the condition became acidic. Results from pHi measurements during heating reflected the clonogenic survival data in that lower pHi levels were associated with the conditions when DIDS was present. We conclude that in the TR-4 cells, the Na(+)-dependent HCO3-/Cl- exchanger appears to be a more important regulator of pHi than the Na+/H+ antiport.

Male breast cancer: an 11 year review of 66 patients

A review was conducted of 66 men with carcinoma of the breast seen at this institution between 1981 and 1992. The results of the study suggest that there are many similarities between breast cancer in men and women. The most common clinical presentation was a lump in the breast. The majority of tumors were T1 or T2, and infiltrating ductal carcinoma was the predominant histological type. Axillary nodal status and histological grade were predictive of survival. The pattern of recurrence and survival rates were similar to those seen in women. Some differences, however, were evident. Tumors were centrally located in the majority of patients and there was a high frequency of nipple involvement. The hormone receptor positivity rate was high and the median age at presentation was older. In comparison to a previous report of the same disease from this institution 10 years ago, fewer patients underwent radical surgical procedures and more patients received adjuvant systemic therapy. These approaches are justified since there are many biological similarities between breast cancer in men and women.

A concealed penis mimicking penile agenesis in an infant with trisomy 13

Penile agenesis results from failure in the development of the genital tubercle and is rarely associated with chromosomal abnormalities. We report on an echographic prenatal diagnosis of penile agenesis associated with trisomy 13. At birth, the contour of the penile shaft and the glans could not be seen. However, a careful palpation allowed us to determine that the penile shaft was concealed and normal in size, rather than penile agenesis being present. To our knowledge, a concealed penis associated with trisomy 13 has not previously been described.

Prenatal diagnosis and perinatal aspects of abdominal wall defects

We retrospectively reviewed 27 cases of omphalocele and 15 cases of gastroschisis occurring among 62, 572 deliveries between 1987 and 1994. All cases had undergone prenatal sonographic examinations at a mean gestational age of 28 weeks. In cases of omphalocele, 59.3% (16/27) of fetuses were associated with multiple malformations and 16% (4/25) had chromosomal abnormalities. Among the 4 cases with an abnormal karyotype, three cases were associated with extracorporeal livers and two cases were associated with umbilical cord cysts. Prenatal ultrasound examinations during the second and third trimesters were able to detect 66.7% (18/27) of the cases of omphalocele and 66.7% (10/15) of the cases of gastroschisis. Failure in correctly diagnosing abdominal wall defects by prenatal ultrasound occurred mostly in cases associated with small defects, ruptured omphalocele, multiple fetal anomalies, intrauterine fetal death, twin pregnancies, or cases referred in late gestation. A comparison of perinatal data between omphalocele and gastroschisis reveals fetuses with omphalocele carry higher risks of associated malformations, chromosomal abnormalities, prematurity, and neonatal death. Although fetuses with gastroschisis have higher incidences of oligohydramnios and small for gestational age, the fetal prognosis after pediatric surgery is good.

Concurrent papillary and squamous carcinoma in a thyroglossal duct cyst: a case report

Carcinomas of thyroglossal duct cysts are rare. Most are papillary carcinomas; only about 5% are squamous cell carcinomas. Only one case of mixed papillary and squamous cell carcinoma of a thyroglossal duct cyst has been reported so far. The authors present a second case, that of a 38-year-old man who was first seen with a midline neck lump. It was diagnosed clinically as a thyroglossal duct cyst and was locally excised. Pathological examination showed both a concurrent papillary carcinoma and a squamous cell carcinoma. Treatment consisted of a near-total thyroidectomy, ablative radioactive iodine and adjuvant external radiation therapy. The authors review the literature and explain the rationale behind their choice of treatment.

Prenatal diagnosis of partial monosomy 13q associated with occipital encephalocoele in a fetus

The pre- and postnatal findings of a fetus with a de novo del(13)(pter-->q21:) and an occipital encephalocoele are described. Maternal serum alpha-fetoprotein (AFP) screening at 19 weeks' gestation demonstrated a high level of 2.5 multiples of the median (MOM) and ultrasonography at 27 weeks' gestation showed severe intrauterine growth retardation, cardiomegaly, an occipital encephalocoele, and a calvarial defect. Genetic amniocentesis revealed a karyotype of 46,XX,del(13)(pter-->q21:). The proband postnatally displayed additional abnormalities such as microphthalmia, hypertelorism, large low-set ears, and micrognathia. We discuss the association of central nervous system (CNS) malformations with 13q deletions and emphasize that pregnancies with neural tube defects warrant cytogenetic analysis, especially when additional fetal abnormalities and neonatal dysmorphism are observed.

The relationship between thermosensitivity and intracellular pH in cells deficient in Na+/H+ antiport function

BACKGROUND AND PURPOSE

We have demonstrated previously the relationship between intracellular pH (pHi) level and heat survival in mammalian cells. To explore this in further detail, we studied thermosensitivity in CCL 39 and their variant PS120 cells, which lack Na+/H+ antiport function.

MATERIALS AND METHODS

CCL39 and PS120 cells were heated with or without amiloride, or 5-(N-ethyl(-N-isopropyl) amiloride (EIPA), inhibitors of Na+/H+ antiport function. Antiport activity and pHi measurements were made using the fluorescent dye 2,7-biscarboxyethyl-5(6)-carboxyfluorescein (BCECF). A clonogenic assay was used to assess survival after heating.

RESULTS

Enhanced cytotoxicity was observed when CCL39 cells were heated with either EIPA (15 microM) or amiloride (2.5 mM) at pHe7.3 in the presence of NaHCO3. Under the same conditions, thermal enhancement of PS120 cells was observed only with amiloride at 2.5 mM. When the cells were heated at pHe 6.5 in bicarbonate-free medium, both EIPA and amiloride enhanced thermal cytotoxicity in CCL39 cells, but only the higher dose of amiloride sensitized the variant PS120 cells. Surviving fraction was related to pHi, but the data fell into two clusters, depending on whether or not both Na+/H+ antiport and the Na(+)-dependent HCO3-/Cl- exchangers were functioning.

CONCLUSIONS

We confirm that Na+/H+ antiport function can mediate thermosensitivity, and corroborate a linear correlation between pHi level and log survival after heating, but suggest that this relationship is complicated by other factors such as membrane exchanger function, and extracellular pH levels during heating.

Partial duplication of 3q and distal deletion of 11q in a stillbirth with an omphalocele containing the liver, short limbs, and intrauterine growth retardation

We describe a female stillbirth with duplication of 3q21-->qter and deletion of 11q23-->qter resulting from an unbalanced segregation of a maternal t(3;11) reciprocal translocation. The proband had some of the clinical features consistent with those seen in patients with dup(3q) syndrome or distal del(11q) syndrome. Prenatal sonographic examination showed short limbs, intrauterine growth retardation, and an omphalocele containing the liver.

Radiotherapy with or without hyperthermia in the treatment of superficial localized breast cancer: results from five randomized controlled trials. International Collaborative Hyperthermia Group

PURPOSE

Claims for the value of hyperthermia as an adjunct to radiotherapy in the treatment of cancer have mostly been based on small Phase I or II trials. To test the benefit of this form of treatment, randomized Phase III trials were needed.

METHODS AND MATERIALS

Five randomized trials addressing this question were started between 1988 and 1991. In these trials, patients were eligible if they had advanced primary or recurrent breast cancer, and local radiotherapy was indicated in preference to surgery. In addition, heating of the lesions and treatment with a prescribed (re)irradiation schedule had to be feasible and informed consent was obtained. The primary endpoint of all trials was local complete response. Slow recruitment led to a decision to collaborate and combine the trial results in one analysis, and report them simultaneously in one publication. Interim analyses were carried out and the trials were closed to recruitment when a previously agreed statistically significant difference in complete response rate was observed in the two larger trials.

RESULTS

We report on pretreatment characteristics, the treatments received, the local response observed, duration of response, time to local failure, distant progression and survival, and treatment toxicity of the 306 patients randomized. The overall CR rate for RT alone was 41% and for the combined treatment arm was 59%, giving, after stratification by trial, an odds ratio of 2.3. Not all trials demonstrated an advantage for the combined treatment, although the 95% confidence intervals of the different trials all contain the pooled odds ratio. The greatest effect was observed in patients with recurrent lesions in previously irradiated areas, where further irradiation was limited to low doses.

CONCLUSION

The combined result of the five trials has demonstrated the efficacy of hyperthermia as an adjunct to radiotherapy for treatment of recurrent breast cancer. The implication of these encouraging results is that hyperthermia appears to have an important role in the clinical management of this disease, and there should be no doubt that further studies of the use of hyperthermia are warranted.

CVS-exposed limb deficiency defects with or without other birth defects: presentation of six cases born during a period of nine years

We report on six cases with CVS-exposed limb-"reduction" defects born in our hospital during a period of 9 years (1986-1994). Four cases were associated with other birth defects. One had an oromandibular-limb hypogenesis syndrome with a cleft lip and jejunal atresia, a second had an oromandibular-limb hypogenesis (Hanhart) syndrome, a third had severe flexion deformity at the hips and hyperextension at the knees with meconium peritonitis and intestinal obstruction, and a fourth had Poland anomaly. Detailed clinical descriptions, prenatal diagnosis, photographs, and radiographs are presented. Our presentation adds to the information on severe limb abnormalities after CVS and suggests CVS-exposed limb defects may be associated with other birth defects resulting from vascular insufficiency or intrauterine compression. We suggest that detailed post-CVS sonographic followups are necessary for each CVS-exposed case to identify not only the possible fetal limb reduction, but also vascular disruption-type malformations and compressive deformities.

Ultrasound-guided fluid aspiration and prenatal diagnosis of duplicated hydrometrocolpos with uterus didelphys and septate vagina

We report on a case of duplicated hydrometrocolpos with uterus didelphys, a septate vagina, lower vaginal atresia, a persistent urogenital sinus, left ear agenesis, a single umbilical artery, and an imperforate anus, but without the associated features of McKusick-Kaufman syndrome such as polydactyly and congenital heart defects. Ultrasound-guided fluid aspiration of the fetal intrapelvic cystic mass helped to decompress the distended genital organs, decrease the severity of the urinary tract obstruction, delineate the ultrasonographic image of duplicated hydrometrocolpos to differentiate it from other intrapelvic cystic masses, and obtain fluid for cytological analysis.

Cytogenetic evaluation of cystic hygroma associated with hydrops fetalis, oligohydramnios or intrauterine fetal death: the roles of amniocentesis, postmortem chorionic villus sampling and cystic hygroma paracentesis

BACKGROUND

Pregnancies complicated by fetal cystic hygroma in the second and third trimesters are often associated with hydrops fetalis, oligohydramnios or intrauterine fetal death which may make genetic assessment more difficult. We investigated the roles of amniocentesis, postmortem chorionic villus sampling and cystic hygroma paracentesis in cytogenetic evaluation of cystic hygroma under such circumstances.

METHODS

Thirty-five fetuses of cystic hygroma associated with hydrops fetalis, oligohydrammos, or intrauterine fetal death were studied. All fetuses were delivered at Mackay Memorial Hospital, Taipei, Taiwan between January, 1987 and July, 1995. Data collected included maternal age, prenatal sonograms, gestational age at diagnosis, fetal karyotypes and diagnostic procedures.

RESULTS

Of 35 fetuses, all had hydrops fetalis, 19 had suffered IUFD at the time of diagnosis, and 10 had severe oligohydramnios. Cytogenetic studies were performed via amniocentesis, postmortem chorionic villus sampling, or cystic hygroma paracentesis. Successful karyotyping was achieved in 32 fetuses and the karyotype of 45,X was found in 24 fetuses. In cases with IUFD, successful karyotyping rates on cells from amniotic fluid, chorionic villi and cystic hygroma fluid were 88.9% (8 of 9), 69.2% (9 of 13) and 20% (1 of 5), respectively, whereas, in cases with living hydropic fetuses, successful karyotyping was achieved in 12 of 12 amniotic fluid and 5 of 5 cystic hygroma fluid samples.

CONCLUSIONS

Amniocentesis is a better method for cytogenetic evaluation of fetal cystic hygroma associated with intrauterine fetal death than postmortem chorionic villus sampling and cystic hygroma paracentesis. However, in the case with a living hydropic fetus and oligohydramnios, cystic hygroma paracentesis appears to be a practical alternative for cytogenetic assessment.

Prenatal detection of the separation of the great toe, toe syndactyly, and large bilateral choroid plexus cysts in a fetus with trisomy 18

Prenatal sonographic presentation of toe deformities is associated with fetal aneuploidies. This report presents a second-trimester fetus with large bilateral choroid plexus cysts, clenched hands, separation of the great toe, toe syndactyly, abnormal double maternal serum biochemical screening results, and trisomy 18. We suggest a careful ultrasound screening of the fetal limbs and other organs once a choroid plexus cyst has been identified. If abnormal sonographic findings are present, or if the results of the maternal serum biochemical screening are abnormal, karyotyping should be recommended.

The stress-activated protein kinase pathway mediates cell death following injury induced by cis-platinum, UV irradiation or heat

BACKGROUND

Stimuli that stress cells, including inflammatory cytokines, ultra-violet irradiation, DNA-damaging chemotherapeutic drugs and heat shock, stimulate a recently identified cytoplasmic signaling system that is structurally related to the mitogen-activated protein kinase pathway. This pathway consists of a cascade of protein kinases including stress-activated protein kinase (SAPK), also termed Jun N-terminal kinase (JNK), and two kinases that activate it, MEKK and SEK/MKK4. Despite rapid progress in delineating the components of this pathway, the cellular consequence of its activation remains to be defined.

RESULTS

We have screened cells for defects in SAPK signaling and identified a cell line, previously characterized for its thermotolerance properties, as being more refractive to SAPK activation induced by heat stress than its thermosensitive parental line. Stable expression of dominant inhibiting SEK mutants in thermosensitive parental cells specifically and effectively blocked SAPK activation after heat shock. These lines also became markedly resistant to the cytocidal effects of thermal stress, confirming the phenotype of the thermotolerant line. These cell lines defective in SAPK activation were also resistant to the lethal effects of the DNA-damaging drug cis-platinum.

CONCLUSIONS

Experimentally induced stable blockade of SAPK activation in cells with normal thermosensitivity is sufficient to confer resistance to cell death induced by diverse stimuli including heat and the chemotherapeutic agent cis-platinum. These results suggest that activation of the SAPK pathway by diverse cell stressors plays a critical part in mediating the toxicity of these treatments and inducing cell death. SAPK activation in this context could broadly influence cellular response to stress, modulate apoptosis during development or determine the clinical response of tumor cells to cytotoxic therapies.

Prenatal diagnosis of partial monosomy 3p and partial trisomy 2p in a fetus associated with shortening of the long bones and a single umbilical artery

The prenatal and postnatal findings of a fetus with partial deletion of 3p25 -> pter and duplication of 2p25.3 -> pter are described. The proband postnatally displayed mental and growth retardation, psychomotor delay, microcephaly, ptosis, micrognathia, a narrow palate, and cryptorchidism. All of these anomalies were consistent with those described in 3p- and partial trisomy 2p syndromes, and also frequently seen in patients with other chromosomal disorders. However, the prenatal sonograms revealed unusual shortening of the long bones, a single umbilical artery, and normal development of the skull. Our case suggests that skeletal growth retardation of the long bones may occur earlier than that of the skull in fetuses associated with chromosomal aberrations such as del(3p)/dup(2p). Shortening of the long bones and a single umbilical artery together with other abnormalities detected by prenatal ultrasound thus warrant a fetal cytogenetic study.

The potential role of HSP70 as an indicator of response to radiation and hyperthermia treatments for recurrent breast cancer

Twenty-three patients with recurrent breast cancer participating in a Phase III trial evaluating radiotherapy (XRT) with or without hyperthermia (HT) were included in a parallel study of heat shock protein (hsp) expression. The patients had core biopsies and/or fine needle aspirates (FNA) performed on their tumours, before and after treatment. These were analysed for hsp content using immunohistochemical staining with a monoclonal antibody to the inducible form of hsp 70. The proportion of samples containing identifiable cancer cells was greater for the core biopsy specimens (80%) than with FNA (60%). Staining intensity was analysed using either the majority score, i.e. the staining intensity (on a relative scale from 0 to 3) for the largest proportion of tumour cells, or the arithmetic score, which is the sum of the product of percentage of tumour cells and their staining intensity. The staining intensity for hsp's after treatment correlated inversely with the probability of attaining a complete response (CR). Specifically, the median and maximum scores for the biopsy specimens were significantly inversely related to the probability of attaining CR. The results suggest that this technique may be useful in predicting for thermotolerance development, though more data is needed to confirm the utility of the technique. Results from this study corroborate data from other clinical studies which suggest that tumours with elevated hsp levels may demonstrate resistant biologic behaviour.

Echo-guided lymphatic drainage by fine-needle aspiration in persistent isolated septated fetal nuchal cystic hygroma

We report two cases of large, persistent, isolated, fetal nuchal cystic hygromas that underwent echo-guided lymphatic drainage by fine-needle aspiration during the second and third trimesters. Multiple punctures and fluid tapping from cystic hygromas under sonographic guidance proved to be easy procedures and not deleterious to the fetuses. The decompression effect caused by lymphatic drainage in utero can prevent polyhydramnios, irreversible fetal facial deformity and progression to hydrops fetalis. Furthermore, when carried out during the third trimester, especially before delivery, it helps avoid birth injury, dystocia and neonatal asphyxia.

The effect of heat on Na+/H+ antiport function and survival in mammalian cells

PURPOSE

Because intracellular pH (pHi) is a determinate of thermosensitivity, it is important to understand the relationship between heat cytotoxicity and the mechanisms responsible for pHi regulation, such as the Na+/H+ antiport. The objective of this study is to elucidate the relationship between heat damage and Na+/H+ antiport activity.

METHODS AND MATERIALS

Various cell lines, EMT6, RIF-1, and its thermoresistant variant TR-4, and CCL39, and its variant that lacks the Na+/H+ antiport (PS120), were all heated using a water bath. Parallel assessments of antiport function and pHi were made using the fluorescent dye 2,7-biscarboxyethyl-5(6)-carboxyfluorescein (BCECF).

RESULTS

Exposure of EMT6 cells to 43-46 degrees C for 30-60 min caused progressive decline in antiport activity, in parallel with cytotoxicity. When the same degree of cytotoxicity was induced by ionizing radiation, no alteration in Na+/H+ antiport function was observed. Despite a 10-fold lower survival in RIF-1 compared to TR-4 cells after heating, there was no difference in the thermosensitivity of their antiports. Antiport activity in the TR-4 cells, however, was higher than that of RIF-1 cells both before and during heating. Intracellular pH for TR-4 cells decreased minimally during heating, in contrast to a decline of 1 pH unit in RIF-1 cells despite similar relative levels of antiport activity, suggesting that in this pair of cell lines, antiport activity does not play a major pHi regulatory role. PS120 and CCL39 cells and similar survival levels when heated at pHe 7.2 in the presence of NaHCO3, which allows function of the other major regulator of pHi, the Na+ -dependent HCO3-/Cl- exchanger. This occurred despite a drop in pHi in the PS120 cells during heating. A reduced survival was observed, however, in PS120 cells after 43 degrees C for 30-60 min at either pHe 6.5 or pHe 7.2 in the absence of NaHCO3. Intracellular pH was consistently greater for PS120 than CCL39 cells.

CONCLUSION

We demonstrated that damage to the Na+/H+ antiport likely reflects early heat-induced change in membrane function, but is not a primary target for heat cytotoxicity. Although there is an association between survival, antiport function, and pHi level under most treatment conditions, the precise role of the Na+/H+ antiport in mediating thermal cytotoxicity remains uncertain.

The relationship between intracellular pH and heat sensitivity in a thermoresistant cell line

To explore further the relationship between intracellular pH (pHi) and thermosensitivity, we compared survival and pHi levels in RIF-1 cells and a thermoresistant variant, TR-4 cells, while heating under different conditions of acid or neutral extracellular pH (pHe). We also added 5-(N-ethyl-N-isopropyl) amiloride (EIPA), a potent inhibitor of one of the major membrane regulators of pHi, the Na+/H+ antiport, and/or removed NaHCO3 to inactivate the alternate membrane regulator of pHi, the HCO3-/Cl- exchanger. At pHe 7.3 with NaHCO3, EIPA (15 microM) did not enhance the cytotoxicity of heat in either cell line. At pHe 6.8 with NaHCO3, EIPA enhanced thermal cytotoxicity for RIF-1 cells only, but without NaHCO3, at pHe 6.8 or 6.5, EIPA treatment during heating resulted in a significant decrease in survival of TR-4 cells also. Measurements of pHi levels immediately after heating correlated with the survival data, demonstrating a linear relationship between pHi and log surviving fraction for both cell lines. This relationship, however, is different between the two cell lines in that the TR-4 cells are more resistant to reduction in pHi with heating, and for any given pHi level to demonstrate a higher correlation is different for the two cell lines, suggesting a difference in the relationship between pHi and log surviving fraction between the TR-4 and RIF-1 cells.

Prenatal diagnosis of omphalocele associated with umbilical cord cyst

BACKGROUND

To study the cytogenetics, ultrasound findings, biochemical screening, perinatal outcome, and associated abnormalities in cases of omphaloceles associated with umbilical cord cysts.

METHODS

From 1988 to 1994, three cases of omphaloceles with umbilical cord cysts were identified at Mackay Memorial Hospital. We compared the clinical data of our three cases with six other cases in the published literature.

RESULTS

Two cases of omphaloceles with umbilical cord cysts were affected with trisomy 18. One had bilateral choroid plexus cyst, intrauterine growth retardation, low levels of maternal serum alpha-fetoprotein and free beta-human chorionic gonadotropin, and the other had cleft lip and palate, single umbilical artery and intrauterine growth retardation. An elevated level of maternal serum alpha-fetoprotein was found in the case with normal karyotype. Elevated levels of amniotic fluid alpha-fetoprotein were found in two cases. Rupture of the umbilical cord cyst and disruption of the umbilical cord occurred in one case at delivery. Based on the gross and microscopic examinations, the cord cysts we observed are likely to be pseudocysts.

CONCLUSION

The umbilical cord cysts most commonly associated with omphaloceles are pseudocysts and allantoic cysts. Among our three cases and the six other cases published in the literature, four out of these nine cases were trisomy 18. Prenatal diagnosis of omphaloceles or umbilical cord cysts by ultrasound warrants cytogenetic analysis and detailed sonogram to rule out the possible combination of both abnormalities and trisomy 18. If an omphalocele is associated with a large umbilical cord cyst and a normal karyotype, cesarean section is recommended to prevent the dilemma of intrauterine vascular compromise of umbilical blood flow during labor.

Benign parotid adenomas: a review of the Princess Margaret Hospital experience

BACKGROUND

The morbidity of treating benign parotid tumors is an important issue because the majority of patients are young. We therefore undertook this study to evaluate the outcome for these patients treated at the Princess Margaret Hospital.

METHODS

A retrospective review was conducted on all patients registered with benign parotid tumors between 1970 and 1987.

RESULTS

Seventy-six patients were included in this review; postoperative radiotherapy (XRT) was administered to 55 patients. Median follow-up time was 12.5 years. Postoperative XRT was particularly important for patients with recurrent disease. The risk of both temporary and permanent facial nerve paralyses increased with each operation. No patients in this study developed a malignancy.

CONCLUSIONS

We recommend that all patients with benign parotid tumors be treated with a complete parotidectomy with preservation of the facial nerve. Consideration to postoperative XRT should be given to patients in whom there was tumor spillage, residual disease, or recurrences.

A variable microwave array attenuator for use with single-element waveguide applicators

The effectiveness of hyperthermia treatments is often limited by temperature inhomogeneity that arises in the treatment field due to variable tissue properties and blood flow. Moreover, blood flow can change during a treatment, leading to the formation of hot and cool areas even if the initial temperature distribution is uniform. A variable microwave array attenuator has been constructed, that will enable the field patterns of single element microwave waveguide hyperthermia applicators to be altered during treatment, to improve temperature homogeneity. The coupling bolus was designed with an array of individually controlled elements, each filled with a microwave absorbing saline solution. Additions or withdrawals of saline are made to alter the power deposition in a specific area of the treatment field. Thermographic measurements were made in muscle equivalent phantom materials, with the bolus/waveguide assembly. Results showed that the variable array attenuator was able to significantly alter the heating pattern of a large waveguide applicator.

Lentigo maligna of the head and neck. Results of treatment by radiotherapy

BACKGROUND AND DESIGN

Although surgical excision is considered the treatment of choice for lentigo maligna, some elderly patients presenting with large lesions in the head and neck region may not be suitable candidates for surgical management. Radiotherapy has been used for this tumor at the Princess Margaret Hospital, Toronto, Ontario, for over the past 20 years with encouraging results. Fifty-four patients treated between 1968 and 1988 were identified, and their records were reviewed to determine treatment outcome.

RESULTS

Younger patients with smaller lesions were treated with surgical excision (n = 18) and achieved an actuarial tumor control rate of 94% at 3 years. Older patients with larger lesions located in the head and neck area were treated by radiotherapy (n = 36), with an actuarial tumor control rate of 86% at 5 years. Three of the four patients not achieving tumor control by radiation were successfully treated with surgical excision, and two of them proved to have malignant melanomas (both Clark's level II) when examined histologically. One patient with residual pigmentation 4 months after treatment was unavailable for follow-up. No patients developed metastatic melanoma. The late cosmetic appearance was acceptable in the majority of irradiated patients, with 11% showing poor cosmesis due to progressive skin pallor, atrophy, and telangiectasia in the treated area.

CONCLUSION

Conventional fractionated radiation therapy with superficial x-rays is a simple and effective method of management for lentigo maligna of the head and neck region. It is an excellent alternative treatment to surgical excision, with low morbidity and acceptable long-term cosmetic results.

Effect of vascular occlusion on tumour temperatures during superficial hyperthermia

Tumour temperature heterogeneity during hyperthermia has been attributed to irregular tumour vascular perfusion. We have compared temperature distributions in human tumours subjected to superficial hyperthermia under conditions of normal and occluded blood flow. Three patients with recurrent malignant melanoma on the leg were treated with radiation followed by hyperthermia 60-90 min later on days 1, 8 and 22. Heating (15-30 min) with normal blood flow was followed by 15 min of heating with tourniquet occlusion, although the tourniquet had to be intermittently released when the patients complained of discomfort. Hyperthermia was delivered using either a 1.4 MHz ultrasound or 915 MHz microwave applicator. Temperatures were monitored using superficial and interstitial thermometers in tumour and normal tissues. When the tourniquet was applied, the amount of power required to maintain peak temperatures was decreased by a factor of 3-10. With normal blood flow, there was a significant degree of temperature heterogeneity within the treatment volume, both within normal and tumour tissues, which improved with tourniquet application. The T90 and T50 indices increased both in normal tissues and tumour following the tourniquet occlusion, with the temperature increments being greater for normal tissues. Temperatures at depth were increased despite the reduction in applied power and the temperature profiles were smoother when the tourniquet was applied. No cutaneous, vascular or neuromuscular side effects were observed amongst these three subjects either acutely or at 1 month follow-up. These studies demonstrate directly that the temperature heterogeneity which exists in human tumours subjected to external heating can be reduced by occluding the blood supply.

Phylloides tumor of the breast: a report of 14 cases

The objective of this retrospective study is to determine the role of radiation therapy in the management of benign phylloides tumors. Fourteen patients with a diagnosis of benign phylloides tumor (PT) and registered at the Princess Margaret Hospital are included in the study. Definitive surgery consisted of either lumpectomy in seven patients or mastectomy in the other seven patients. One patient died of her disease, and the remaining patients had no evidence of disease at last follow-up (median 38.4 months). Among these 13 patients, 4 had at least one recurrence and the recurrence rate was higher for the group who underwent lumpectomy (43% compared with 28%). One patient was treated by lumpectomy and adjuvant radiation therapy, and had no subsequent recurrence (follow-up time 35.5 months). The role for radiation therapy in the management of this disease remains unclear.

Squamous cell carcinoma of the lip: analysis of the Princess Margaret Hospital experience

We reviewed 117 patients with squamous cell carcinoma of the lip who were treated at the Princess Margaret Hospital between 1976 and 1985. Ninety-eight cancers arose from the lower lip, 18 from the upper lip and 1 from the commissure. Two patients had lymph node metastases at presentation. Sixty-one patients were treated with radiation therapy following a biopsy, 28 underwent surgery followed by post-operative radiation, and 28 had surgery alone. With a median follow-up time of 5.4 years, the 5-year actuarial overall and cause-specific survival rates were 81% and 99%, respectively. Local failure developed in 4 patients after radiation treatment, 3 of whom were salvaged by surgery. Six patients developed regional metastases after initial treatment, 4 of whom were salvaged with surgery and/or radiotherapy. Two patients died from lip cancer. After a univariate analysis, the only factor which predicted for nodal failure was T stage of the primary lesion, with a 4% risk of nodal failure for T1 lesions vs. 20% for T2/3 lesions (p = 0.03). No other patient, tumour or treatment variables influenced loco-regional control or survival in a statistically significant manner. Cosmetic and functional outcome were evaluated in 8 patients whose radiation treatments were administered 13 years ago. No patients had compromised lip function, and the majority had minimal cosmetic sequelae from their radiation therapy. Based on the excellent results of this review, we would continue to recommend radiation therapy as an effective treatment modality for patients with lip cancer because of the ease by which the entire tumour can be encompassed whilst maintaining excellent cosmetic and functional outcome.