Local control after the use of adjuvant electron beam intraoperative radiotherapy in patients with high-risk head and neck cancer: the UCSF experience

PURPOSE

We assess the effect of electron beam intraoperative radiotherapy (EB-IORT) on local-regional control and any associated complications in patients with locally advanced or recurrent head and neck cancer.

MATERIALS AND METHODS

The records of 30 patients with head and neck cancer who received EB-IORT from March 1991 to December 1994 were retrospectively reviewed. The indications for EB-IORT in 25 patients were recurrent or persistent disease despite previous treatment with full-course external-beam radiotherapy and/or one or more resections. In five other cases the indication was extensive primary disease with multiple high-risk factors for local recurrence, including extension into the base of the skull, advanced extensive disease, and perineural or bony invasion. All patients had a Karnofsky performance score > or = 70 prior to EB-IORT. Median age was 65 years. Final pathology revealed positive or close surgical margins in all patients. The areas treated were generally inaccessible to catheter placement for brachytherapy. The most common histology was squamous cell carcinoma. EB-IORT was given as a single fraction of 1500 cGy to the 90% isodose with 6 or 9 Mev electrons using cone sizes ranging from 2.5 to 7 cm in diameter. Data were analyzed to determine the local-regional control rate, survival, and complications after EB-IORT.

RESULTS

With a median follow-up time of 30 months, nine patients (27%) had only local recurrence. Of these, only one recurrence was inside the EB-IORT field and eight were outside the EB-IORT field. Two patients (7%) developed distant metastases only and one patient (3%) had both local recurrence and distant metastasis. Seven patients died, five with disease. Twenty-two patients are known to be alive, 15 (68%) of whom have no evidence of disease. One patient was lost to follow-up after 12 months; when last examined he was free of disease. Five patients (16%) have had mild-to-moderate transient complications probably related to EB-IORT. The 3-year actuarial local-regional control rate was 60%.

CONCLUSIONS

Our data suggest that EB-IORT may play an important role in decreasing local recurrence in patients with multiple high-risk factors. Despite previous full-course external beam radiotherapy and extensive resections, EB-IORT did not confer significant additional long-term morbidity. Although results are encouraging, randomized studies are required to definitively establish the role of EB-IORT in the management of advanced or recurrent head and neck cancer.

EtOH self-administration in anticipation of noise stress in C57BL/6J mice

C57BL/6J mice were studied for self-administration of ethanol (EtOH) during a signal period that preceded delivery of an environmental stressor (noise) in the home cage. Animals were given 5 weeks of conditioning in which a 5-min period of 75-dB pulsed noise (SIGNAL) preceded a 20-min period of more intense, 90-dB pulsed noise (NOISE) five times daily. EtOH (10% w/v) was then provided in a choice procedure, and drink tube contacts were monitored by computer. Mice that had received the 5 weeks of SIGNAL and NOISE pairings showed an increase in EtOH-seeking behavior, as reflected in EtOH tube contacts during the SIGNAL period. The increase was significant as compared to contacts during baseline or QUIET periods and also as compared to contacts during the same period for control (Ctrl) mice that had received only the 75-dB SIGNAL during conditioning. A subsequent test for passive avoidance confirmed that the 75-dB SIGNAL was aversive for mice that had received noise conditioning but not for Ctrl mice. In sum, the results were in accord with a priori predictions that mice would not show increased EtOH tube contacts during occurrence of intense noise itself but would show increased contacts during the signal that preceded noise. These results were interpreted as preliminary evidence that C57BL/6J mice show self-administration of EtOH in anticipation of an environmental stressor.

Reversal of drug-resistance by exposure of mcf-7 or mcf-7 cddp human breast-carcinoma cells to sr-4233 or etanidazole under hypoxic conditions

Drug resistance is a major problem in cancer therapy. The MCF-7/CDDP cell line, a subline of the MCF-7 human breast carcinoma cell line which is resistant to cis-diamminedichloroplatinum(II), is also resistant to carboplatin, D-tetraplatin and to a lesser degree to melphalan, thiotepa and BCNU compared with the MCF-7 parental cell line. This resistance persists both under normally oxygenated conditions and after 2 h of exposure to hypoxic conditions prior to exposure to the antitumor alkylating agents under normally oxygenated conditions. When the MCF-7 parental cells and MCF-7/CDDP cells were treated with SR-4233 (20 muM) or etanidazole (5 mM) for 2 h prior to and during exposure to the antitumor alkylating agents there was no change in the sensitivity and resistance patterns of the cell lines. However, if the MCF-7 parental cells and the MCF-7/CDDP cells were exposed to SR-4233 (20 muM) or etanidazole (5 mM) for 2 h under hypoxic conditions followed by release of the hypoxia and exposure to the antitumor alkylating agents for 1 h under normally oxygenated conditions the resistance of the MCF-7/CDDP was reversed so that both the MCF-7 parental and MCF-7/CDDP cell lines were essentially equally sensitive to the six antitumor alkylating agents. These results indicate that non-cytotoxic concentrations of modulators such as SR-4233 or etanidazole may be useful in reversing resistance to the.

The role of the comprehensive breast center

Continuous progress in breast health and breast cancer care has been made over the past few decades. Major advances include the widespread use of screening mammography, resulting in mortality reduction; the evolution of multimodality treatment planning, resulting in more coordinated care; and the use of adjuvant chemotherapy, resulting in prolonged survival. In addition, the emergence of a new consumerism has resulted in more research funding, political activism, and legislative mandates in many states for screening mammography reimbursement and informed consent laws. The development of comprehensive breast centers represents another measure of success in the area of health care delivery, which has traditionally been fragmented. This article will describe the role of the NP in relation to a comprehensive breast center, as well as how the NP can improve the provision of primary breast care, identify quality in potential consultants, and effectively collaborate and communicate with other members of the health care team, including the patient and family.

Serological detection of HBeAg and anti-HBe using automated microparticle enzyme immunoassays

Fully automated microparticle enzyme immunoassays (EIA) were developed for the detection of HBeAg (IMx HBe) and antibodies against HBeAg (IMx anti-HBe), respectively. Specimens from blood donors, diagnostic and hospital patients and individuals with a variety of infectious and immune diseases were tested both in house and at four clinical sites. The overall agreement between IMx HBe and Abbott HBe RIA/EIA was 99.7% (2985 of 2994) and between IMx anti-HBe and anti-HBe RIA/EIA was 95.8% (2330 of 2432). Almost all anti-HBe discordant specimens (94.1%, 96 of 102) were reactive by IMx anti-HBe but negative by anti-HBe RIA/EIA. off anti-HBe discordant specimens were also reactive for anti-HBc. The IMx anti-HBe assay was 2- to 4-fold more sensitive than the current RIA as determined by serial dilution of anti-HBe reactive specimens. The ability of these IMx assays to detect HBeAg and anti-HBe in 199 HBsAg reactive specimens was also evaluated. 43.7% (87 of 199) and 66.3% (132 of 199) specimens were reactive for HBeAg and anti-HBe by IMx, respectively. Only one specimen was negative for both IMx assays compared to 14 (7.0%) non-reactive for both HBe and anti-HBe RIA. There were 24 specimens (12.1%) positive for both HBeAg and anti-HBe by IMx compared to 1 (0.5%) positive by the corresponding RIAs. This increased detectability of anti-HBe in HBsAg carriers using IMx anti-HBe may result from increased sensitivity for 'free' anti-HBe and/or increased ability to detect anti-HBe in immune complex. IMx anti-HBe also detected more reactives among volunteer blood donor specimens reactive for anti-HBc but negative for HBsAg (55.5%, 86 of 155), compared to RIA (38.7%, 60 of 155). IMx anti-HBe may be useful in confirming prior exposure to HBV in blood screened positive by Corzyme.

Detection apparatus for multiple heterogeneous chemiluminescence immunoassay configurations

We describe an apparatus for measuring signals emanated from two heterogeneous chemiluminescence immunoassay (CLIA) configurations: antibody-coated polystyrene beads, in reaction tray wells, and microparticles captured by a porous matrix. An optics and fluidics design which allows the use of a common detection head for these two different assay configurations is described. The detection head moves along three Cartesian coordinates to create a localized light-tight compartment around each individual disposable reaction vessel. Reproducibility of the light seal, trigger solution delivery, and mixing is achieved for acridinium-labeled CLIA. The coated polystyrene beads configuration is tested using beta HCG, CEA, and TSH assays. The microparticle-capture configuration is tested using beta HCG and HBsAg assays. The microparticle capture CLIA has shorter incubation times and the potential for ease of automation.

Self-harming behavior in incarcerated male delinquent adolescents

This report describes self-harming behavior in males in a juvenile incarceration center. Three groups of adolescents were examined: self-harmers, those referred for a psychiatric examination, and the incarcerated general population. Compared to the general population, the youth in the two mental health groups were younger, had greater family needs, had more educational problems, were more likely to have escaped from a previous placement, and committed more rule violations. The self-harming group, when compared with the psychiatrically referred group, had a greater number of prior offenses, were more disruptive in school, performed worse on a problem-solving task, and committed more rule violations. Issues of psychopathology and treatment are discussed.

Early prenatal care in urban black and white women

If the ultimate success of efforts to improve pregnancy outcome depends on assurance that prenatal care begins in the first trimester, it is important to identify potentially modifiable factors associated with the start of care as well as the groups in which it is most likely to be late. This topic was explored in a population-based study of low birthweight in 766 black women and 462 white women who gave birth in Alameda County, California, in 1987. Variables related to insurance coverage and financial status showed the greatest difference between early and late attenders at prenatal care in both groups. At virtually every level of almost every variable studied, black women were less likely than white women to begin prenatal care in the first trimester. The data suggested that some of the difference in the timing of prenatal care may be due to lack of awareness of, or failure to pay attention to, the signs of early pregnancy. We conclude that, although addressing problems of insurance coverage and financial status is critical to the solution of the problem of late initiation of prenatal care, as financing difficulties are solved, attention should be paid to women's internal factors such as depression and denial as modifiers of the earliness of seeking prenatal care.

Cocaine and the risk of low birth weight

In a population-based case-control study, we assessed the relation between cocaine use and the risk of low birth weight in Alameda County, California, excluding women who used heroin and/or methadone during pregnancy. After adjustment for confounders, the relative risk of low birth weight in users of cocaine throughout pregnancy was 4.0 (95% CI = 1.8, 8.9). Cocaine use was estimated to account for 10 percent of cases of low birth weight in Black women in Alameda County.

Self-directed EMG training for the control of pain and spasticity in paraplegia: a case study

A 25-year-old paraplegic woman was able to gain control of her debilitating leg and bladder spasms and abdominal pain using self-directed EMG biofeedback. The case is significant in that she previously had only cursory exposure to biofeedback as an undergraduate student and received only minimal support and direction from an instructor. She proceeded through daily home practice using a borrowed EMG unit and audiotapes from Lester Fehmi's Open Focus series. Records were kept of the frequency and intensity of her pain and spasms, as well as the frequency and procedures of her home practice. She also maintained a record of specific psychosocial events in her life, which, over time, showed a strong, consistent pattern of influence on the recurrence and severity of her symptoms. The woman's physician declared her medical progress remarkable and encouraged her biofeedback work. At 2-year follow-up, she remains virtually symptom- and medication-free. Her successful biofeedback training program provides support for the value of client-directed biofeedback in selected cases.

Case report of a complication of coil placement during transvenous embolization of spermatic veins

Coil embolization of an incompetent spermatic vein of a patient resulted in a complication from the use of a sidehole catheter. Alternative procedures are suggested to avoid the problem.

Renal vascular complications associated with the percutaneous removal of renal calculi

Significant immediate and delayed vascular complications occurred in 4 of 140 patients (3 per cent) undergoing percutaneous removal of renal and ureteral calculi. An understanding of renovascular anatomy, use of a safety guide wire and intraoperative availability of an angiographic balloon catheter may help to prevent and to treat bleeding problems.

Dual stiffness Malecot (Stamey) catheter

A new catheter with a soft plastic shaft and a stiff mushroom has been developed for drainage of various fluid-filled cavities. It can be introduced with a flexible guidewire system. Its dual stiffness provides greater comfort for and acceptance by the patient.

Kimray-Greenfield vena cava filter: percutaneous introduction

A percutaneous technique is described for the introduction of Kimray-Greenfield filters into the vena cava through either the internal jugular or femoral approach.

Three-dimensional teaching model for coronary angiography

In order to improve the understanding and interpretation of cine coronary arteriograms obtained in various angled projections, a three-dimensional wire model was constructed. The main coronary arteries and most important muscular branches are simulated by a wire skeleton. The model can be rotated to simulate the standard right and left anterior oblique and left lateral projections. The degree of rotation is indicated on the base of the model. By tilting the model, cephalad and caudad tube angulation can be simulated. By placing the model in front of the cine projector, the shadows of the wires can be superimposed upon the projected cine coronary arteriogram. This simple, inexpensive model has greatly improved the three-dimensional understanding of the coronary arterial tree in various angled and nonangled views and in our practice had led to the development of additional useful projections.

Uptake of tritium-labelled biogenic amines by the prostomium of the polychaete Nereis virens (Sars) (Annelida)

The uptake of tritium-labelled 5-HT, noradrenaline, 5-hydroxytrytophan, DOPA and dopamine by the cerebral ganglion and prostomial nervous system of the polychaete Nereis virens has been examined using radioautography at the level of the light microscope. Pronounced uptake of (3)H-5HT occurred in the antennal, palpal, tegumentary and nuchal nerves as well as in ganglionic nuclei 13, 14, 15, 16, 17, 20, 24 and 25, the mid-brain neuropile, the neurosecretory neuropil and the infracerebral organ; (3)H-NA uptake was observed in small cells in the prostomial epidermis, and the infracerebral organ; (3)H-dopamine only in one of two common types of epidermal mucus cells. Prostomial muscles labelled generally with (3)H-NA and at specific sites with (3)H-5HT. These observations support the concept of an efferent serotonergic system originating in several cerebral ganglionic nuclei and serving prostomial muscle and epidermis. Evidence for an afferent adrenergic system is less substantial. The role of dopamine remains obscure.

Renal artery aneurysms: an angiographic sign of transplant rejection

Intrarenal arterial aneurysm is an uncommon manifestation of allograft rejection. We present two cases of transplant rejection with aneurysm formations. One case simulated polyarteritis nodosa, while in the other, the aneurysm appeared similar to those seen in post-stenotic arterial dilatation.

Subacute cadmium intoxication in jewelry workers: an evaluation of diagnostic procedures

An outbreak of cadmium intoxication in a jewelry factory provided an opportunity for evaluating the usefulness of diagnostic procedures used to evaluate human cadmium toxicity. Blood cadmium levels in workers exposed to cadmium were higher (.93 micrograms/100ml vs .38 micrograms/100 ml) than in unexposed workers. A dose-response relationship was noted between blood cadmium level and symptom prevalence in four symptoms (dyspnea, chest pain, dysuria, and dizziness). Segmental hair analysis revealed highest cadmium levels (up to 19 micrograms/gm) in segments formed prior to cadmium exposure, suggesting that extrinsic contamination was the primary source of cadmium in the hair. beta2-microglobulin levels were within normal limits. No significant renal or pulmonary dysfunction was noted. Symptoms ceased after a cadmium-containing brazing alloy used in jewelry production was replaced, yet urine cadmium levels remained persistently elevated in four workers. Blood cadmium determinations were found to be useful in evaluating symptoms potentially related to cadmium intoxication.

The use of a one-day luteinizing hormone assay for timing of artificial insemination in infertility patients

A 1-day rapid assay for luteinizing hormone (RLH) was developed by combined alteration of incubation temperatures and immune-complex precipitation of a commercially available LH kit. The RLH assay, compared with the standard 3-day assay, had the following characteristics: standard curve slope values of --2.47 and --2.314; assay sensitivity of 5.5 and 3.8 mIU/ml of serum; average coefficients of variation for the standard curves of 13.6% and 14.1% and for serum controls of 10.6% and 13.1%, respectively. Two consecutive RLH assays of split samples were highly correlated (r = 0.9908; P less than 0.001), as were split aliquots measured by RLH or the 3-day assay (r = 0.993; P less than 0.001). When 52 samples from portions of 5 normal menstrual cycles were assayed in both systems, agreement was again high (r = 0.9871; P less than 0.001). Representative curves of both RLH and standard LH assays, together with other data, are presented to show the feasibility of applying this method for timing of artificial insemination.