Increase in phosphorus losses from grassland in response to Olsen-P accumulation

The Olsen-P status of grazed grassland (Lolium perenne L.) swards in Northern Ireland was increased over a 5-yr period (March 2000 to February 2005) by applying different rates of P fertilizer (0, 10, 20, 40, or 80 kg P ha(-1) yr(-1)) to assess the relationship between soil P status and P losses in land drainage water and overland flow. Plots (0.2 ha) were hydrologically isolated and artificially drained to v-notch weirs, with flow proportional monitoring of drainage water and overland flow. Annually, the collectors for overland flow intercepted between 11 and 35% of the surplus rainfall. Single flow events accounted for up to 52% of the annual dissolved reactive phosphorus (DRP) load. The Olsen-P status of the soil influenced DRP and total phosphorus (TP) concentrations in land drainage water and overland flow. Annual TP loss was highly variable and ranged from 0.19 to 1.55 kg P ha(-1) yr(-1) for the plot receiving no P fertilizer and from 0.35 to 2.94 kg P ha(-1) yr(-1) for the plot receiving 80 kg P ha(-1) yr(-1). Despite the Olsen-P status in the soils ranging from 22 to 99 mg P kg(-1), after 5 yr of fertilizer P applications it was difficult to identify a clear Olsen-P concentration at which P losses increased. Any relationship was confounded by annual variability of hydrologic events and flows and by hydrologic differences between plots. Withholding P fertilizer for over 5 yr was not long enough to lower P losses or to have an adverse effect on herbage P concentrations.

Retrograde endoscopic balloon dilation of chemotherapy- and radiation-induced esophageal stenosis under direct visualization

INTRODUCTION

Esophageal stricture is a common complication following combined chemotherapy and radiation for advanced oropharyngeal cancer and severely compromises patients' quality of life. The severity of the stenosis after concomitant therapy, combined with the proximal location of these strictures, renders standard bougienage techniques difficult, and the risk of perforation significant. Retrograde endoscopic dilation has recently been described as a safe alternative to rigid endoscopic dilation or unguided bougienage. However, the near complete, or complete, stenosis seen in some of these patients may also be unamenable to retrograde endoscopic dilation.

SETTING

Academic, tertiary care referral center.

METHODS

Seven patients with advanced head and neck cancer treated with combined chemotherapy and radiation developed severe dysphagia requiring intervention for near total, or total, upper esophageal stenosis. An alternative technique for dilation is described. In this technique, a flexible endoscope is advanced in a retrograde fashion through the patient's gastrostomy site to the distal edge of the stenotic segment. Under direct visualization, a balloon is advanced up to the stenotic segment and is sequentially inflated to dilate the lumen. This procedure is performed under conscious sedation in an ambulatory setting.

RESULTS

The first patient in the series developed a pneumothorax during attempted passage of the guidewire in a retrograde fashion. Six subsequent patients were successfully dilated using the retrograde progressive balloon dilation technique without any complications. All 6 patients had significant improvement in their oral intake, and 1 patient subsequently had the gastrostomy tube removed.

CONCLUSIONS

A retrograde endoscopic progressive balloon dilation for esophageal dilation under direct visualization provides palliation of swallowing difficulties in patients whose stenoses are not amenable to traditional techniques. The risks of perforation and other complications resulting from blind dilation of strictures may be decreased if an appropriate technique is used on an individualized basis.

Pilot Study of Mucosal Genetic Differences in Early Smokers and Nonsmokers

BACKGROUND

Global gene expression analysis is proving to be an important means of assessing human tumors and may identify key components of carcinogenesis or clinical prognosis. This technique has been successfully applied to head and neck squamous cell carcinoma (HNSCC) and thyroid carcinomas; however, little has been done to evaluate premalignant states.

METHODS

Human buccal mucosal cells were sampled from smokers and nonsmokers using a noninvasive brush technique. The method was validated by assessing the quantity and quality of RNA obtained. The purified RNA was then assayed using cDNA microarrays containing 27,323 cDNA clones to examine the buccal mucosa in these patients for differences in gene expression patterns. Using unsupervised and supervised hierarchical clustering methods, we developed a gene profile signature for an initial training set of smokers and nonsmokers and then used this to predict smoking status in a subsequent test set of subjects. Selected genes were then cross-referenced with previously published gene sets found in HNSCC identified by our group.

RESULTS

Nineteen subjects were used in this pilot analysis, 9 smokers and 10 nonsmokers. Smoking among the study group ranged from 1 to 60 pack years. RNA purified from buccal mucosal brushing demonstrated a high degree of similarity in gene expression profiles among independent samples. Through the application of supervised clustering techniques, we were able to identify 113 genes whose expression differed significantly between samples from smokers and nonsmokers (t test, P < .001). This expression signature was able to accurately predict who within the second set of subjects were smokers, with the exception of one person who had a minimal tobacco history and clustered with the nonsmokers. Cross-referencing data with that found in HNSCC, we were able to identify a tumor suppressor gene involved in the c-myc pathway (Mxi1) that was similarly under-expressed in smokers and cancer patients with progressive disease.

CONCLUSIONS

Although the sample size was small in this preliminary dataset, our analysis revealed several groups of genes that were either over- or under-expressed in the smokers and which could be used to predict smoking exposure. Many of these represent genes of possible interest as early molecular markers for head and neck carcinogenesis.

Classification of DNA methylation patterns in tumor cell genomes using a CpG island microarray

Our group has initiated experiments to epigenetically profile CpG island hypermethylation in genomic DNA from tissue specimens of head and neck squamous cell carcinoma (HNSCC) using a microarray of 12,288 CpG island clones. Our technique, known as a methylation-specific restriction enzyme (MSRE) analysis, is a variation of the differential methylation hybridization (DMH) technique, in that it is not an array comparison of two DNA samples using methylation-specific restriction enzymes. Instead, it is a comparison of a single DNA sample's response to a methylation-sensitive restriction enzyme (HpaII) and its corresponding methylation-insensitive isoschizomer (MspI). Estimation of the reproducibility of this microarray assay by intraclass correlation (ICC) demonstrated that in four replicate experiments for three tumor specimens, the ICC observed for a given tumor specimen ranged from 0.68 to 0.85 without filtering of data. Repeated assays achieved 87% concordance or greater for all tumors after filtering of array data by fluorescence intensity. We utilized hierarchical clustering on a population of 37 HNSCC samples to cluster tumor samples with similar DNA methylation profiles. Supervised learning techniques are now being utilized to allow us to identify associations between specific epigenetic signatures and clinical parameters. Such techniques will allow us to identify select groups of CpG island loci that could be used as epigenetic markers for both diagnosis and prognosis in HNSCC.

Phase II clinical trial of parenteral hydroxyurea and hyperfractionated, accelerated external beam radiation therapy in patients with advanced squamous cell carcinoma of the head and neck: Toxicity and efficacy with continuous ribonucleoside reductase inhibition

BACKGROUND

Almost all concurrent chemoradiation regimens for head and neck are platinum based; however, cisplatin is associated with severe renal, oto-, and neurotoxicity. Hydroxyurea (HU) has been associated with fewer irreversible toxicities. We obtained HU in parenteral form to be administered continually during the radiation treatment. Intravenous HU promised better pharmacokinetics and cell cycle blockade.

METHODS

Participants had biopsy-proven, untreated squamous cell carcinoma of the oral cavity, oropharynx (stage IV) and hypopharynx (stages II-IV). Radiation therapy consisted initially of 74.4 Gy administered in twice daily 1.2-Gy fractions. After 20 patients, the radiation dose was reduced to 60.0 Gy, and another 16 patients were enrolled.

RESULTS

Patients received HU by Continuous Ambulatory Drug Delivery (CADD) pump on a daily x5 schedule during radiation therapy. Because of persistent long-term dysphagia, after 20 patients, the dose of external beam radiation therapy was reduced from 74 to 60 Gy, and the duration of concurrent HU was correspondingly reduced. The new regimen was much better tolerated. The median survival for the group as a whole was 30 months. Within this small study, there were no significant differences in survival, regional control, or local control between the 2 groups.

CONCLUSIONS

Lower doses of concurrent parenteral HU and hyper-fractionated radiation therapy are tolerable and promising.

Molecular Profiling of Tumor Progression in Head and Neck Cancer

OBJECTIVE

To assess gene expression changes associated with tumor progression in patients with squamous cell carcinoma of the oral cavity.

DESIGN

A microarray containing 17 840 complementary DNA clones was used to measure gene expression changes associated with tumor progression in 9 patients with squamous cell carcinoma of the oral cavity. Samples were taken for analysis from the primary tumor, nodal metastasis, and "normal" mucosa from the patients' oral cavity.

SETTING

Tertiary care facility. Patients Nine patients with stage III or stage IV untreated oral cavity squamous cell carcinoma.

RESULTS

Our analysis to categorize genes based on their expression patterns has identified 140 genes that consistently increased in expression during progression from normal tissue to invasive tumor and subsequently to metastatic node (in at least 4 of the 9 cases studied). A similar list of 94 genes has been identified that decreased in expression during tumor progression and metastasis. We validated this gene discovery approach by selecting moesin (a member of the ezrin/radixin/moesin [ERM] family of cytoskeletal proteins) and one of the genes that consistently increased in expression during tumor progression for subsequent immunohistochemical analysis using a head and neck squamous cell carcinoma tissue array.

CONCLUSION

A distinct pattern of gene expression, with progressive up- or down-regulation of expression, is found during the progression from histologically normal tissue to primary carcinoma and to nodal metastasis.

Use of becaplermin in the closure of pharyngocutaneous fistulas

BACKGROUND

We report on the contribution of recombinant platelet-derived growth factor-BB (becaplermin) in treating recalcitrant postlaryngectomy fistulas in two patients with head and neck cancer.

METHODS

Topical becaplermin was applied daily, with periodic wound assessment and photodocumentation.

RESULTS

The two patients with persistent fistula refractory to conventional management have demonstrated rapid improvement after topical application of becaplermin. Each wound exhibited an exuberant granulation response, with a 50% decrease in the size of wound at 1 week. The patients experienced eventual closure, with none having local recurrence of their cancer at 2 years' follow-up.

CONCLUSIONS

Becaplermin seems to be a promising addition to traditional methods of treatment for postlaryngectomy fistulas. In patients with delayed healing, future studies will be required to determine the overall efficacy of such biologic response modifiers in the treatment of pharyngocutaneous fistulas and other chronic wounds of the head and neck.

Decreased Short- and Long-term Swallowing Problems With Altered Radiotherapy Dosing Used in an Organ-Sparing Protocol for Advanced Pharyngeal Carcinoma

OBJECTIVE

To determine the effect of a reduced radiotherapy dose on short- and long-term swallowing problems after organ-sparing treatment.

DESIGN

Prospective case series.

SETTING

Tertiary care referral center.

PATIENTS

A consecutive sample of 29 patients with advanced oropharyngeal or hypopharyngeal cancer who were treated with intravenous hydroxyurea and concomitant hyperfractionated, accelerated radiotherapy.

INTERVENTIONS

Initial experience with 74.4 Gy of radiation demonstrated severe long-term swallowing problems, prompting a dose reduction to 60.0 Gy. Eighteen patients were followed up for this study in the 74.4-Gy group, while 11 were in the 60.0-Gy group.

MAIN OUTCOME MEASURES

Swallowing variables were assessed in both patient groups at 4 months and at 12 months following completion of therapy.

RESULTS

Patient demographics and tumor characteristics were similar in each group, while significant differences were noted in the posttreatment clinical swallowing variables. Persistent severe odynophagia at 4 months (89% [16/18] vs 30% [3/10]) and at 12 months (64% [7/11] vs 11% [1/9]) was greater in the 74.4-Gy group (P =.002). Clinical signs of aspiration were also increased in the 74.4-Gy group, with 81% (13/16) vs 11% (1/9) at 4 months and 60% (6/10) vs 11% (1/9) at 12 months (P<.05). Most striking, however, was the incidence of long-term gastrostomy, with 78% (14/18) of patients receiving 74.4 Gy requiring gastrostomy feedings at 12 months compared with 18% (2/11) in the 60.0-Gy group (P =.002). Local control was unchanged by the altered dosing, with median follow-ups of 43.5 and 24.0 months in the 74.4-Gy and 60.0-Gy groups, respectively.

CONCLUSION

Decreased radiation doses can maintain disease control and reduce treatment-related long-term swallowing complications.

Halting the upward trend in soluble phosphorus transported from a grassland catchment

An upward trend in soluble reactive phosphorus (SRP) concentrations in Northern Ireland rivers leading to increased eutrophication has been reported for the last two decades. To identify if a similar trend could be observed in land drainage waters SRP and other P fractions were measured weekly from 1989 to 1997 in land drainage from a 9-ha grassland catchment in Northern Ireland that had a mean P surplus applied of 23.4 kg P ha(-1) yr(-1). Regressions of annual median concentrations of P fractions in land drainage waters against time for 1989 through to 1997 showed significant increases of SRP and soluble unreactive phosphorus (SUP) of 2.4 and 1.2 microg P L(-1) yr(-1), respectively. However, the annual flow-weighted concentrations and loads of all P fractions did not show significant increases with time. During the period 1998-2000 a change of management was introduced when only maintenance dressings of P were applied to the catchment according to Ministry of Agriculture, Fisheries and Food guidelines. This resulted in significant reductions in SRP concentrations in 2000 compared with 1997.

The digital camera in clinical practice

The benefits of digital photography are certainly numerous and include rapid image production, easy and quick deletion of poor images, no need for film or its associated expenses, decreased costs for enlargements, ease of editing and image storage, effortless placement in presentations or publications. Many physicians believe that the benefits of digital images clearly outweigh any limitations that future technologic advances will minimize. Digital imaging allows for the seamless integration of all patient images (e.g., clinical, radiographic, pathologic) into the medical record. Additionally, manipulating these images with lighting, filters, of other processing techniques may encourage diagnostic advances (e.g., distinguishing between benign and malignant surface lesions). Some drawbacks, however, continue to exist, including cost of the hardware and software, continuously evolving technology, power consumption and battery usage, lower image resolution compared with 35-mm photography, and the need to have backup image files. With decreasing costs, improving resolutions, and enhanced capabilities, digital cameras will overcome these limitations rapidly.

The significance of immunohistochemically demonstrated nodal micrometastases in patients with squamous cell carcinoma of the head and neck

OBJECTIVES/HYPOTHESIS

Patients with primary squamous cell carcinoma of the head and neck have a relatively high risk of occult lymph node metastases. Pathological demonstration of these metastases may be difficult, and the detection of such occult metastases may identify patients who are at an increased risk for early recurrence or reduced survival. Immunohistochemistry may be applied in the identification of occult metastases that may be missed on routine (H&E) histological examination. The aim of the study is to determine the prevalence and prognostic significance of immunohistochemically identified micrometastases in squamous cell carcinoma of the head and neck.

STUDY DESIGN

A retrospective analysis of neck dissection specimens having no evidence of metastatic disease.

METHODS

Lymph nodes from neck dissections performed on 10 patients with squamous cell carcinoma of the head and neck without conventional histological evidence of nodal metastases were subsequently stained for cytokeratins by the monoclonal antibody cocktail AE1/AE3 to detect micrometastases.

RESULTS

Occult micrometastases were found in the lymph nodes 5 of 10 patients examined. There was no association between the site of primary tumor, or T tage, and the presence of occult metastases. Three of five patients found to have occult metastases developed recurrence in the neck, whereas only one of five patients with no evidence of micrometastases had regional recurrence. There was no significant discrepancy in the patient survival rate.

CONCLUSIONS

Metastatic tumor cells are frequently present in lymph nodes, even in patients without histological evidence of nodal metastases by conventional methods. The presence of micrometastases may identify patients at increased risk for recurrence and may indicate poorer prognosis. The true clinical significance of these occult metastases will be determined by a long-term follow-up.

Stage 4 squamous cell carcinoma of the tongue in a child: complete response to chemoradiotherapy

This report describes a complete response to a chemoradiotherapy regimen in a child with an advanced and unresectable squamous cell carcinoma of the tongue. An 8-year-old girl had stage 4 squamous cell carcinoma of the tongue (T4N2M0), causing severe trismus and dysphagia. She received hyperfractionated external beam radiotherapy (total 74.4 Gy) and concomitant intravenous infusion of hydroxyurea (0.313 mg/m2 per min) for 43 days. Grade 3 mucositis and myelosuppression were the main toxicities. There was marked symptomatic improvement, and the patient achieved a complete response. She is disease-free 24 months after treatment, and all the acute symptoms have resolved. The regimen was well tolerated with acceptable toxicity and led to a complete objective response. This regimen needs further evaluation to confirm its efficacy and to ascertain its long-term effects in children.

Assessing the effectiveness of regulatory controls on farm pollution using chemical and biological indices of water quality and pollution statistics

Water quality was measured in 42 streams in the Colebrooke and Upper Bann catchments in Northern Ireland over the period 1990-1998. Despite ongoing pollution control measures, biological water quality, as determined by the invertebrate average score per taxon (ASPT) index, did not improve and there was no appreciable decline in recorded farm pollution incidents. However, the lack of decline in pollution incidents could reflect changes in detection policy, as a greater proportion of incidents were recorded from less polluting discharges such as farm-yard runoff. In contrast, there was an improvement during 1997 and 1998 in annual chemical water quality classification based on exceedence values (90th percentiles) for dissolved oxygen, ammonium and BOD concentrations. In 1998, 11.9% of streams were severely polluted compared to 26.2% in 1990, while the proportion classed as of salmonid water quality, increased from 40.5% in 1990 to 59.6% in 1998. Although water quality in 1996 did not improve relative to 1990 values, there was a notable increasing trend from 1990 in the numbers of samples taken during the summer which had good water quality with low ammonium (<0.6mgN l(-1)) and high dissolved oxygen (> 70% sat). The trend for samples with low BOD (<4 mgl(-1)) was more erratic, but an improvement was apparent from 1994. These improvements in chemical water quality suggest that point-source farm pollution declined after 1990. The fact that this was not reflected in stream biology may reflect the limited time scale for biological recovery. An important factor preventing biological recovery may be the high pollution capacity of manures and silage effluent, so that even reduced numbers of farm pollution incidents can severely perturb stream ecosystems. The intractable nature of farm pollution suggests that there is a need to consider an interactive approach to problem resolution involving both farmers and regulators.

Changes in soil organic carbon storage under grassland as evidenced by changes in sulphur input-output budgets

Information about temporal changes in soil organic carbon (C) pools may be obtained indirectly from changes in input-output budgets of organically combined nutrients such as sulphur (S). Sulphur budgets were therefore evaluated for Northern Ireland (NI) for the period 1940-1990, inclusive. These budgets indicated that the land or soil had acted first as a sink but then as a source for S, and that reserves of soil S built up between 1940 and 1965 were totally depleted by the mid-1980s. Pooled data from six long-term soil-monitoring sites on undisturbed grassland suggested that negative S budgets from the late-1970s onwards had been due to the net mineralization of soil organic matter and thus were indicative of net losses of organic C from surface soil horizons. There was some evidence that the decline in rainfall and fertiliser S inputs from the mid-1960s may have precipitated the breakdown of soil organic matter.

Workforce issues for the academic otolaryngologist

BACKGROUND

The current medico-economic environment has led to profound changes in our health care system and questions of physician surplus. These issues have particularly affected the academic health care system, as research funding and departmental support have decreased, and many young otolaryngologists are questioning academic careers because of these uncertainties. The current study was undertaken to assess the workforce environment for the academic otolaryngologist, particularly the young physician.

METHODS

Surveys were sent to the academic chairmen of all accredited otolaryngology residency programs in the United States, requesting information on faculty appointments--actual and projected-as well as subspecialty appointments and expectations of young faculty.

RESULTS

The response rate was 60% (59/98). Faculty additions have been relatively stable from 1994 to 1998, with approximately 37 assistant professor and 5 associate professor positions filled yearly. Faculty additions were the result of departmental expansion in 83% of cases and spanned many subspecialties. The subspecialty positions most frequently added from 1994 to 1998 were generalists (57), head and neck oncologists (53), pediatric otolaryngologists (48), and otologists (39), with generalists filling 15 positions in 1998. Ninety-three percent of programs anticipate faculty additions in the next 5 years; most will be at the assistant professor level (77%), with 30% of positions for generalists, 20% for head and neck oncologists, and 18% for pediatric otolaryngologists. Faculty expectations are primarily clinical, with research being least important.

CONCLUSIONS

Academic positions are available for the young otolaryngologist, particularly in the fields of general otolaryngology, head and neck oncology, and pediatric otolaryngology.

The workforce in otolaryngology-head and neck surgery: moving into the next millennium

OBJECTIVE

The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck.

STUDY DESIGN

A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios.

RESULTS

The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted.

CONCLUSIONS

This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.

A spatial study of denitrification potential of sediments in Belfast and Strangford Loughs and its significance

The C2H2 inhibition technique was employed to study seasonal denitrification potential rates in sediment slurries from tidal and subtidal sites in Belfast and Strangford Loughs, Northern Ireland. A comparison of denitrification rates obtained from this method with those obtained from the 15N-gas flux method generally showed good agreement. Depth profiles measured up to 1 m showed that denitrification decreased with depth, with highest values in the 0-5-cm fraction. For the Belfast Lough tidal system a multiple regression model was developed which explained 83% of the variation in denitrification potential. The independent variables were water content, sediment temperature, total oxidizable N in porewater and total organic N. The highest rate of denitrification potential, 2100 micromol N m(-2) h(-1), was found in areas where there was a high anthropogenic input of nutrients. Denitrification in sediments in both loughs can play a potentially significant role in removal of NO3- from the overlying water. In Belfast Lough the overall denitrification potential rate matched the external NO3-N inputs, whilst in Strangford Lough it exceeded it by sixfold, which suggests a potential to remove future additional anthropogenic inputs to the Lough.

Long-term swallowing problems after organ preservation therapy with concomitant radiation therapy and intravenous hydroxyurea: initial results

OBJECTIVE

To evaluate the long-term effects on swallowing function of concomitant continuous infusion hydroxyurea and hyperfractionated radiation therapy used to treat advanced head and neck carcinoma.

DESIGN

A prospective evaluation of swallowing function was performed on an inception cohort by analyzing posttreatment videoflouroscopic swallow function studies using radiological descriptors for pharyngeal transport abnormalities and temporal measures of structural movements, as well as by conducting patient interviews to assess alimentation, more than 1 year after tumor treatment (range, 52-124 weeks; median, 70 weeks).

SETTING

Academic tertiary care referral medical center.

PATIENTS

Ten patients, aged 44 to 71 years, with stage III and IV squamous cell carcinoma of the oral cavity, oropharynx, or hypopharynx.

MAIN OUTCOME MEASURE

Radiographic and temporal swallow abnormalities, as well as functional status, were documented and compared with published norms and results of earlier swallowing studies when possible.

RESULTS

Pharyngeal transport dysfunction and anterior segment abnormalities, manifested by epiglottic dysmotility, vallecular residue, laryngeal penetration, or aspiration, were evident in all 10 patients. Posterior segment abnormalities, such as pharyngeal stasis, constrictor dysmotility and piriform residue were documented in 8 patients. Three patients developed late aspiration, and the majority of patients showed persistent or worsened delay in laryngeal movement compared with their earlier posttreatment evaluations. Also, 3 patients developed a hypopharyngeal stricture, and 6 patients continued to require gastrostomy tube supplementation beyond 1 year. There was no association between site of primary, duration to swallowing evaluation, and severity of dysfunction.

CONCLUSION

Prolonged and debilitating functional swallowing abnormalities may occur after this aggressive concomitant chemotherapy and radiotherapy regimen.

Team approach for closure of oroantral and oronasal fistulae

Oroantral and oronasal fistulas present with a broad range of causation, size, duration, and extent of infection involving the nose and paranasal sinuses. Accurate diagnosis of the extent of the disease with appropriate radiographic evaluation will guide the surgeon to select an approach that addresses all of the infected sites. When significant sinus disease is found, an endoscopic approach to restoring drainage in all of the involved sinuses can promote predictably successful closure of oroantral and oronasal fistulas. The multispecialty team approach to this disease, with the concomitant management of the sinusitis and fistula closure, is a significant advance in the successful management of this chronic condition.

Early wound complications in advanced head and neck cancer treated with surgery and Ir 192 brachytherapy

OBJECTIVES

Brachytherapy, either as primary or adjuvant therapy, is increasingly used to treat head and neck cancer. Reports of complications from the use of brachytherapy as adjuvant therapy to surgical excision have been limited and primarily follow Iodine 125 (I125) therapy. Early complications include wound breakdown, infection, flap failure, and sepsis, and late complications may include osteoradionecrosis, bone marrow suppression, or carotid injuries. The authors sought to identify the early wound complications that follow adjuvant interstitial brachytherapy with iridium 192 (IrS92).

STUDY DESIGN

A retrospective chart review of all patients receiving adjuvant brachytherapy at a tertiary medical center over a 4-year period.

METHODS

Nine patients receiving Ir192 brachytherapy via afterloading catheters placed during surgical resection for close or microscopically positive margin control were evaluated. It was used during primary therapy in six patients and at salvage surgery in three. Early complications were defined as those occurring within 6 weeks of surgical therapy.

RESULTS

The overall complication rate was 55% (5/9), and included significant wound breakdown in two patients, minor wound dehiscence in three, and wound infection, bacteremia, and local tissue erosion in one patient each. All complications occurred in patients receiving flap reconstruction and one patient required further surgery to manage the complication. Complication rates were not associated with patient age, site, prior radiotherapy, timing of therapy, number of catheters, or dosimetry.

CONCLUSIONS

The relatively high complication rate is acceptable, given the minor nature of most and the potential benefit of radiotherapy. Further study should be undertaken to identify those patients who will achieve maximum therapeutic benefit without prohibitive local complications.

Reversible sensorineural hearing loss following administration of muromonab-CD3 (OKT3) for cadaveric renal transplant immunosuppression

This prospective study is a follow-up to a case report noting reversible sensorineural hearing loss after administration of OKT3 for immunosuppression in a steroid-resistant renal cadaveric transplant patient who was rejecting his transplant. The objective is to determine the interval estimate for incidence of sensorineural hearing loss following treatment with OKT3. Seven patients were admitted to the Renal Transplant Service at Montefiore Medical Center from July 1996 to July 1997 with steroid-resistant rejection of renal cadaveric transplants and received OKT3 as an immunosuppressant. All 7 patients received 3 audiograms: the first, prior to the administration of the first dose of OKT3, the second, 48 to 72 hours after administration of OKT3, and the third, approximately 2 weeks after administration of OKT3. Five of the 7 patients (71%) demonstrated a sensorineural hearing loss of 15 dB or greater at frequencies of 8 to 12 kHz. Four of the 5 patients with audiographic changes had near-complete to complete recovery of their high-frequency thresholds after discontinuation of the drug regimen. In conclusion, OKT3 can cause sensorineural hearing loss. This side effect is mainly reversible after 2 weeks following discontinuation of the drug. Patients receiving OKT3 should be forewarned of this possible side effect prior to the administration of OKT3.

Benign parotid hypertrophy on +HIV patients: limited late failures after external radiation

PURPOSE

Although 8-10 Gy of external radiation therapy for +HIV associated parotid hypertrophy has achieved high response rates, the responses were transient with only 1/12 of patients retaining cosmetic control at median follow-up procedures of 9.5 months. Retreatment for failures after 8-10 Gy has also been unsatisfactory. Having shown that 24 Gy of external radiation therapy for benign parotid hypertrophy produced more durable cosmetic control than 8-10 Gy, we now report on longer follow-up periods on a group of patients receiving 24 Gy.

MATERIALS AND METHODS

Twenty +HIV patients with clinical and radiographic evidence of lymphoepithelial lesions of the parotid were treated with 24 Gy of external radiation therapy using daily 1.5 Gy fractions; parallel opposed technique and 6 MV photons were used in 19 patients, and unilateral electron treatment was performed for one patient.

RESULTS

With a mean follow-up period of 24 months, the cosmetic control appears durable. We have had no late failures past 24 months. Two patients have complained of modest xerostomia. There was no correlation with size of the cyst and eventual cosmetic result.

CONCLUSIONS

Twenty-four Gy produces durable parotid control for HIV associated lymphoepithelial lesions of the parotid glands in +HIV patients. Failures after 2 years are uncommon and the side effects have been tolerable.