Therapeutic outcome of Epstein-Barr virus positive T/NK cell lymphoma in the upper aerodigestive tract

Expression of the natural killer (NK) cell antigen CD56 is uncommon in malignant lymphoma, but when it is, it is almost exclusively of the non-B cell lineage and show a preference for the nasal and nasopharyngeal region. T/NK cell lymphoma is known to be aggressive and refractory to treatment. It is highly associated with the Epstein-Barr Virus (EBV), but clinical investigations are rarely reported, that is until recently. We report here, on the clinical features and therapeutic outcomes of patients with T/NK cell lymphomas and its association with EBV. We reviewed fifty-four cases with peripheral T cell lymphomas in the upper aerodigestive tract between Jan. 1987 and Aug. 1998 from the Severance Hospital, Yonsei University College of Medicine. The diagnosis of T/NK cell lymphoma was made according to the expression of the NK cell markers, CD56 antigen and cytoplasmic CD3epsilon, in tumor specimens, by immunohistochemistry. Epstein-Barr early region (EBER) RNA was detected using in situ hybridization on paraffin-embedded sections. Among the 54 cases with malignant lymphomas occurring in the upper aerodigestive tract, 20 had T/NK cell lymphoma (37%). The primary sites of T/NK cell lymphomas were the nasal cavity, 12 cases (60%), the tonsils, 4 cases (20%), the nasopharynx, 2 cases (10%), and the oropharynx, 2 case (10%). There were no differences between the features, at diagnosis or therapeutic modalities for patients with T/NK cell lymphoma and non-T/NK cell lymphoma. The complete remission rate of T/NK cell lymphomas was lower than non-T/NK cell lymphomas (65% vs 85%, p=0.02). The overall survival of T/NK cell lymphomas was 13 months (1-74 month), which was significantly lower than non-T/NK cell lymphomas [60.6% with a median follow up of 22 months (1-101 month, p=0.02)]. Disease free survival of T/NK cell lymphomas was 22 months (4-66 month), significantly lower than non-T/NK cell lymphomas [73.8% with a median follow up of 22 months (2-95 month), p=0.04]. The overall survival rates for T/NK cell lymphomas were significantly lower than for EBV positive non-T/NK cell lymphomas (p=0.018). EBER RNA was detected in the paraffin-embedded tissue sections of all T/NK cell lymphomas, compared to only 17.6% (6 of 34 cases) for non- T/NK cell lymphomas. In conclusion, as patients with T/NK cell lymphomas showed poor clinical outcomes, and a high association with EBV positivity, clinical trials with more investigational therapeutic strategies, and further research into the relationship of EBV infection with pathogenesis of T/NK cell lymphoma is warranted.

Racial and ethnic disparities in the receipt of cancer treatment

A disproportionate number of cancer deaths occur among racial/ethnic minorities, particularly African Americans, who have a 33% higher risk of dying of cancer than whites. Although differences in incidence and stage of disease at diagnosis may contribute to racial disparities in mortality, evidence of racial disparities in the receipt of treatment of other chronic diseases raises questions about the possible role of inequities in the receipt of cancer treatment. To evaluate racial/ethnic disparities in the receipt of cancer treatment, we examined the published literature that addressed access/use of specific cancer treatment procedures, trends in patterns of use, or survival studies. We found evidence of racial disparities in receipt of definitive primary therapy, conservative therapy, and adjuvant therapy. These treatment differences could not be completely explained by racial/ethnic variation in clinically relevant factors. In many studies, these treatment differences were associated with an adverse impact on the health outcomes of racial/ethnic minorities, including more frequent recurrence, shorter disease-free survival, and higher mortality. Reducing the influence of nonclinical factors on the receipt of cancer treatment may, therefore, provide an important means of reducing racial/ethnic disparities in health. New data resources and improved study methodology are needed to better identify and quantify the full spectrum of nonclinical factors that contribute to the higher cancer mortality among racial/ethnic minorities and to develop strategies to facilitate receipt of appropriate cancer care for all patients.

Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas

PURPOSE

To evaluate delayed complications after esophageal expandable metallic stent placement.

MATERIALS AND METHODS

From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction).

RESULTS

Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement.

CONCLUSION

Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.

Squamous cell carcinoma of the esophagus infiltrating the respiratory tract is less sensitive to preoperative concurrent radiation and chemotherapy

BACKGROUND

The prognosis of upper thoracic esophageal cancer is poor when compared with middle and lower thoracic esophageal cancer because the tumor easily infiltrates the respiratory tract and surgical en-bloc resection is difficult. Recently, preoperative chemoradiation therapy has been shown to lead to down-staging of the disease and improve prognosis. But the benefit of this therapy for tumors infiltrating the respiratory tract remains unknown.

STUDY DESIGN

Fifty-six patients with thoracic esophageal cancer infiltrating neighboring organs, but with no hematogeneous metastasis, were given preoperative concurrent chemotherapy (5-fluorouracil and cisplatin) and radiation (40 Gy) therapy. When a clinical response was observed, making a curative resection potentially possible, patients were scheduled for esophagectomy with extended lymphadenectomy. Patient prognosis with respect to the organs infiltrated by the tumors was estimated by calculating survival curves using the Kaplan-Meier method and comparing the curves by the log-rank test.

RESULTS

The prognosis was significantly poorer for patients with tumors infiltrating the respiratory tract (T) or aorta plus respiratory tract (A + T) than for patients with tumors infiltrating the aorta alone (A) or other organs (Oth) (p < 0.05 for Oth versus T; p < 0.05 for Oth versus A + T; p < 0.0001 for A versus T; p < 0.0001 for A versus A + T by log-rank test). Patients positive for respiratory tract invasion (T, T + A), compared with those negative for respiratory tract invasion (A, Oth), showed a poorer clinical response to chemoradiation (3.0%, 45.5%, 39.4%, and 9.1% versus 4.3%, 82.6%, 4.3%, and 8.7% in complete response (CR), partial response (PR), nonresponse (NC) and progressive disease (PD), respectively, p = 0.0156) and surgical resectability (36.4% vs. 87.0%, p = 0.0003). Histologic effectiveness (8.3%, 50.0%, and 41.7% versus 25.0%, 70.0%, and 5.0% in grade 3, grade 2, and grade 1, respectively, for patients with respiratory tract invasion versus those without it, p = 0.0189) and histologic stages (8.3%, 8.3%, 8.3%, 8.3%, 25.0%, and 41.7% versus 20.0%, 0%, 15.0%, 25.0%, 40.0%, and 0% in pathologic CR, stage I, stage IIA, stage IIB, stage III, and stage IV, respectively, for patients with respiratory tract invasion versus those without it, p = 0.0496) were significantly better in patients negative for respiratory tract invasion; the percentages of patients with lymph node metastasis did not differ significantly between the two groups. Comparison of the recurrence patterns showed that local failure was most common in patients with respiratory tract invasion, and distant failure was the leading cause of recurrence in patients without it.

CONCLUSIONS

Because the prognosis of patients with thoracic esophageal cancer infiltrating the respiratory tract is extremely poor, partially because of the low local effectiveness of preoperative concurrent chemotherapy and radiation therapy, caution is needed when deciding on salvage surgery.

Neoplasia of the respiratory tract

Tumors of the equine respiratory tract occur infrequently. An accurate diagnosis of neoplasia of the respiratory tract is critical because the prognosis is usually grave. The clinical signs and diagnostic procedures are discussed for tumors of the nasal and paranasal sinuses, nasopharynx/larynx, guttural pouch and thorax including lung, pleura, and thymus.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a disease characterized by the growth of wart-like neoplasms anywhere along the aerodigestive tract. The etiologic agent is the human papillomavirus, of which 90 subtypes have been described. The age distribution of those affected appears to be a bimodal curve, with the first peak around 5 years of age and the second occurring in adults in the third decade of life. The mainstay of treatment is surgical resection to maintain an adequate airway; patients often require multiple surgeries. The epidemiology, pathogenesis, clinical features, and treatment options are discussed. Current evidence regarding prognosis and the multifactorial nature of pathogenesis are also reviewed.

[Primary melanoma of the respiratory tract]

4 cases of melanoma of the respiratory tract (trachea and bronchi) are analysed clinico-morphologically. A case of melanoma with a primary multiple location (trachea and the main bronchus), rapid recurrence after surgery and radiation therapy is described in detail. Melanocytic nature of the tumor is proved immunohistochemically.

Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene-covered Z-stent

PURPOSE

To prospectively evaluate the clinical efficacy of polyethylene-covered metallic Z-stents in treatment of dysphagia secondary to malignant esophageal obstruction and esophagorespiratory fistula.

MATERIALS AND METHODS

Thirty-five patients with dysphagia due to malignant esophageal obstruction (n = 32) and esophagorespiratory fistula (n = 3) were treated with polyethylene-covered Gianturco-Rösch Z-stents.

RESULTS

Thirty-nine stents were placed in 35 patients. Stent placement was technically successful in all patients. Improvement in dysphagia was achieved in 34 of 35 patients. The average dysphagia score decreased from 3.1 (dysphagia to liquids) to 0.6 (essentially normal diet). An esophagorespiratory fistula was completely sealed in two of three patients. All 35 patients were followed up clinically at 1 day and 1 week and at 3-month intervals (range, 1 week to 18 1/2 months; mean, 4.8 months). Recurrent dysphagia or aspiration occurred in only three of 34 (9%) patients whose disease was initially palliated and was easily treated in all cases. Nine complications occurred in eight patients (23%) and included chest pain that required analgesia (n = 3), food impaction (n = 1), stent migration (n = 2), and upper gastrointestinal tract hemorrhage (n = 3).

CONCLUSION

Polyethylene-covered stents are a relatively safe and effective means of long-term palliation in patients with severe malignant esophageal obstruction and esophagorespiratory fistula. These stents are easily deployed, and the rate of stent migration is relatively low.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is an uncommon clinical disorder of the respiratory epithelium caused by HPV. It shares an identical viral etiology with genital condyloma and, in all likelihood, is transmitted at the time of birth (juvenile onset RRP) or through intimate sexual contact (adult onset RRP). Despite the precision of the surgical laser under magnification of the operating microscope, a substantial proportion of patients with RRP, adults as well as pediatric, require repeated operations at frequent intervals because of severe hoarseness and upper airway obstruction. For the management of at least a subset of patients, the efficacy of adjuvant agents (interferon is a leading choice) should be investigated in a multi-institutional clinical trial. For the potential prophylactic benefit, cesarean sections in selected high-risk expectant mothers should be considered.

[Molecular-biological aspects of juvenile respiratory papillomatosis and its combined treatment]

Systemic clinical and molecular-biological analyses of cause-effect relations between human papillomatosis virus (HPV) and juvenile respiratory papillomatosis (JRP) disclosed general mechanism of HPV infection initiation and stages of tumor genesis. However, there is no consent on the universal etiopathogenetic approach to the disease treatment. The authors give some results to the disease treatment. The authors give some results of present-day combined treatment of JRP which includes surgical removal of papillomas and modulation of immunity by interferon preparations.

Solitary plasmacytoma of bone and extramedullary plasmacytoma: two different entities?

BACKGROUND

The objective of this study was to evaluate the similarities between solitary plasmacytoma of bone (SPB) and extramedullary plasmacytoma (EP).

PATIENTS AND METHODS

The clinical features, treatment and survival of 54 patients with localized plasmacytoma (LP) 1990 were carefully reviewed. Follow-up was expected to continue until June 1993.

RESULTS

Thirty-two patients were classified as having SPB and 22 EP. Most of the patients were males. particularly those in the SPB group. Their median age at diagnosis was 54 years and no significant difference between the two groups was observed. SPB occurred most frequently in the vertebral column (42%) and EP in the upper respiratory tract (73%). Fifteen patients with SPB and 2 with EP had paraproteinemia at diagnosis, multiple myeloma (MM) became evident in 75% of the patients with persistent paraprotein after therapy, and in only 22% of those in whom it disappeared. Four patients in the SPB group had immunoparesis, and 3 developed MM. Disease progression toward MM was significantly different (p=0.003) in the two groups, while overall survival differences were not significant (p=0.07) unless unrelated causes were excluded (p=0.02). Adjuvant chemotherapy did not seem to limit diffusion of the disease.

CONCLUSIONS

Although EP and SPB are both localized forms of plasma cell dyscrasias, SPB seems to have a greater tendency to progression MM. It appears, however, that the apparent stronger propensity of SPB to progress is actually due to the great number of cases that at diagnosis conceal an occult MM.

Decision tree model describing alternate health care choices made by oncology patients

What common sense decision strategies do patients with cancer use when they are making health care choices that include alternate therapies? Existing research indicates that oncology patients are making alternate choices while associated with biomedicine. Often patients' decision strategies are exploited by the alternate system to promote and market alternate products. Although some of these practices are benign, others are dangerous or may interfere or delay successful treatment in biomedicine. Therefore, it seems important for biomedical professionals to understand patients' common sense decision patterns. A decision tree model, outlining patients' decision strategies, has recently been developed through intensive interviews with 300 patients who were diagnosed with cancer of the respiratory and digestive systems. The two-phase methodology included, first, a context sensitive approach to develop the model, followed by a predictive approach testing the model developed in the first phase on a separate yet similar random sample of patients. The discussion in this article focuses on the research, the patterns of the decision tree model, and the implications and adaptability of this model to nursing practice.

Mucous membrane plasmacytosis of the upper aerodigestive tract. A clinicopathologic study

We report 9 patients with an unusual plasma cell proliferative disorder of the upper aerodigestive tract. Six patients were men and three, women. The age at presentation ranged from 40 to 67 years with a mean of 54 years. Symptoms at presentation included dysphonia, dysphagia, difficulty breathing, and oral pain. These plasma cell lesions typically produced a cobblestone or warty appearance of the upper aerodigestive tract mucosa including the larynx, pharynx, palate, lips, mouth, tongue, and trachea in varying combination of multiple sites in each patient. Histologically, all lesions were characterized by psoriasiform epithelial hyperplasia with dyskeratosis and dense subepithelial plasmacytosis. Plasma cells were mature but so expansive and diffuse in infiltration as to suggest extramedullary plasmacytoma. Immunohistochemistry for kappa and lambda light chain showed polyclonal immunoglobulin content in all cases examined. Microbial cultures and Warthin-Starry stains were negative for organisms. A variety of treatments including antibiotic therapy, corticosteroid administration, and surgical resection were unsuccessful. In two patients, the process required tracheostomy. This disorder has not been previously described with the exception of a single reported case, which is included in this series. The etiology, pathogenesis, and successful management of mucous membrane plasmacytosis remain unknown.

[Natural killer activity in respiratory papillomatosis and its changes after interferon treatment]

A method to determine changes in the activity of natural killers (NK) in treatment of juvenile respiratory papillomatosis in children and correlation with the clinical course of the disease was developed and studies with whole blood specimens were carried out before interferon (IF) treatment and after it. Initially high levels of NK activity and their subsequent decline were observed in the cases where IF treatment had no effect, whereas initially low levels with subsequent increase after treatment or normal levels remaining unchanged in the course of treatment were typical of the patients manifesting some clinical effect of the treatment. These studies confirm the possibility of the modulating effect of IF, and the method may be used in mass surveys and working with children.

[The effect of exogenous interferon on the in vitro production of alpha- and gamma-interferon by the lymphocytes of patients with respiratory papillomatosis]

The influence of various interferon concentrations in vitro on alpha- and gamma-interferon production by lymphocytes of children suffering from respiratory papillomatosis was studied for optimization of interferon therapy. Most of the children with clinical improvement after interferon treatment showed proportional dependence of alpha-interferon production upon exogenous interferon concentrations and stability of gamma-interferon production. In children without clinical improvement, initial production of both interferons was reduced significantly in the absence of IF in the medium, but no changes occurred when exogenous interferon was present in the medium. The test proposed here may be used for the determination of patients' sensitivity to interferon and for individualization of interferon treatment schedules in other long-lasting recurrent diseases.

Antibodies in patients with recurrent respiratory papillomatosis treated with lymphoblastoid interferon

Serum specimens from 53 evaluable patients enrolled in a clinical trial of lymphoblastoid interferon in recurrent respiratory papillomatosis were screened for the presence of interferon-binding antibodies by an indirect enzyme immunoassay and evaluated for neutralizing antibody measured as the inhibition of antiviral activity. Immunoglobulin G antibodies that specifically bound lymphoblastoid interferon were detected in 66% (35 of 53) of patients; neutralizing antibody was detected in 11 of the 35 patients having binding antibody (and in none of the patients who were negative for binding antibody). The incidence of detectable neutralizing antibody in this study population was 20.8% (11 of 53), which is markedly higher than in previous reports of lymphoblastoid interferon in patients with other diseases (i.e., less than 1% incidence). The cumulative dose received at the time of detection of neutralizing antibody ranged from 163 to 385 MU per square meter of body surface. Neutralizing antibody was detectable at a median time of 120 days after initiation of interferon therapy, and binding antibody appeared earlier in those patients (median 59 days) than in patients in whom only binding antibody was produced (median 116 days). Despite the tendency of binding antibody to appear either in patients in whom neutralizing antibody was eventually formed, the detection of binding antibody was not necessarily predictive of the subsequent development of neutralizing antibodies. Binding antibody persisted after neutralizing antibodies had become undetectable.(ABSTRACT TRUNCATED AT 250 WORDS)

[The interferon status and circulating immunoglobulins during the interferon therapy of respiratory papillomatosis in children]

Studies on the functional activity of interferon (IF) system (interferon status and serum immunoglobulins levels) and its changes in the course of interferon therapy of juvenile respiratory papillomatosis are presented. The initial disorders in alpha-IF production and levels of circulating IF came to normal after interferon therapy. Correlative changes of the following parameters occurred: a decrease in the level of circulating IF and IgM and simultaneous increase in the level of alpha-IF and IgG which, however, did not always correlate strictly with the course of the disease and the kind of preparation used.

Long-term response of recurrent respiratory papillomatosis to treatment with lymphoblastoid interferon alfa-N1. Papilloma Study Group

BACKGROUND

We earlier reported that patients with recurrent respiratory papillomatosis responded to six months of treatment with lymphoblastoid interferon alfa-n1. Because another study of patients treated for one year with leukocyte interferon alfa-n3 found that the growth rate of papillomas was slowed in the first six months but returned to base line during months 7 through 12 despite persistent interferon treatment, we now report the long-term results in our original study patients who were followed for a median of four years after the original one-year crossover study.

METHODS

After the patients in our study had completed the first study year, their physicians could continue or recommence treatment with lymphoblastoid interferon alfa-n1 in a dose of either 2 MU per square meter of body-surface area per day or 4 MU per square meter every other day. The extent of disease was measured by endoscopy when clinically indicated.

RESULTS

Data on late-follow-up were obtained for 60 of the 66 patients. There were 22 complete remissions and 25 partial remissions; 13 patients had no response. The median duration of the complete remissions was 550 days, and 15 patients continued to be in complete remission. The median duration of partial remissions was 400 days and seven patients were still in partial remission. Thirteen of 28 patients responded to a second course of interferon after an interruption in treatment of at least one month. The rate of response in the 11 of 53 patients who had neutralizing antibody to interferon was the same as in the patients without the antibody.

CONCLUSIONS

Patients with severe recurrent respiratory papillomatosis may have a sustained or repeated response to treatment with lymphoblastoid interferon alfa-n1. We recommend that patients with recurrent respiratory papillomatosis who require surgery every two to three months be given a six-month trial of interferon alfa-n1.