Attenuation of radiation dose by the skull base bone in patients with nasopharyngeal carcinoma: clinical importance

PURPOSE

To measure the degree of attenuation of radiation dose by the skull base bone in patients with nasopharyngeal carcinoma (NPC) and to study its clinical importance.

MATERIALS AND METHODS

Isodose distribution in 11 patients with NPC who received bilaterally opposed large-field irradiation (1.8 Gy per fraction) was studied with a three-dimensional treatment planning system with tissue inhomogeneity correction. Also studied were the sites of local tumor recurrence in 37 patients with NPC and skull base destruction (>/=0.5 cm) or intracranial invasion treated with radiation therapy from January 1989 to December 1992. Regression analyses were performed.

RESULTS

In the dosimetric study, the low-dose areas (<1.65 Gy) were located at the level of the skull base in all 11 patients. A significantly positive correlation between the maximum width of the skull base bone and the low-dose volume (<1.65 Gy) was demonstrated (P =.003, linear regression). In the clinical study, local tumor recurrence was noted in 18 patients (49%). The sites of local recurrence included skull base in 16 patients (43%) and nasopharynx in six patients (16%). Wider skull base bone was a significant predictor of skull base recurrence after radiation therapy (P =.03, logistic regression).

CONCLUSION

Herein demonstrated is the inadequacy of the radiation dose over the skull base due to attenuation by the skull base bone. The relationship between width of skull base bone and skull base tumor recurrence also is established.

Intraoperative stroke under epidural anesthesia for bipolar hemiarthroplasty in a patient with multiple myeloma: a case report

A 56-yr-old, 58-kg woman with right femoral neck fracture underwent right bipolar hemiarthroplasty. Her medical problems included diabetes mellitus and multiple myeloma. Epidural anesthesia was performed uneventfully. No other drug except for local anesthetic (2% lidocaine) was administered during the procedure. Unfortunately, we "witnessed" the dramatically hemodynamic change of an intraoperative stroke, which was preceded by a hypotensive episode and followed by sustained hypertension. The stroke was presented with decreased level of consciousness initially and confirmed by the brain CT, which revealed acute infarction at the right middle cerebral artery territory, four days after the procedure. Multiple mechanisms such as intraoperative hypotensive episode and vascular atherosclerotic change due to poor controlled diabetes mellitus might be involved in the event. In the meanwhile, hyperviscosity (3.7 centipoise units of the patient v.s. 1.4-1.8 centipoise units of normal range) caused by multiple myeloma might also have contributed to the intraoperative stroke. Clinical presentation of this case will be discussed.

Effect of isoflurane versus nicardipine on blood flow of lumbar paraspinal muscles during controlled hypotension for spinal surgery

STUDY DESIGN

This study compared the effects of isoflurane and nicardipine on regional blood flow of the lumbar paraspinal muscles.

OBJECTIVES

The purpose of this study was to determine whether treatment with hypotensive agents result in ischemia of the lumbar paraspinal muscles, thereby facilitating surgical procedures.

SUMMARY OF BACKGROUND DATA

Despite the general acceptance of controlled hypotension as effective in reducing blood loss during spinal surgery, the changes of blood flow that occur at the lumbar paraspinal muscles when this technique is applied remain unclear. The use of laser Doppler flowmetry allows changes of muscle blood flow to be easily detected in real time with minimal invasion, thereby allowing differences among distinct pharmacological approaches for induction and maintenance of controlled hypotension to be evaluated.

METHODS

The prehypotensive and hypotensive (reduction of mean arterial pressure by 20 mm Hg) blood flow of the lumbar paraspinal muscles were assessed with a laser Doppler flowmeter in 40 patients undergoing lumbar spinal surgery. The first half of the patients (n = 20) received isoflurane, whereas the second half received nicardipine to achieve arterial hypotension.

RESULTS

Compared with the prehypotensive state, during the hypotensive state, patients in the isoflurane group exhibited a 17% to 46% (mean, 33.7%) decrease in lumbar paraspinal muscle blood flow, whereas patients in the nicardipine group exhibited a 24% to 177% (mean, 82.5%) increase in lumbar paraspinal muscle blood flow. Statistical analysis showed a significant difference in the changes of flux after induced hypotension between the isoflurane and nicardipine group (P < 0.001).

CONCLUSIONS

Depending on the pharmacological treatment used to achieve arterial hypotension in spine surgery, there will be either a reduction in paraspinal muscle blood flow (ischemia) or an enhancement of this blood flow (hyperemia).

High external parametrial dose can increase the probability of radiation proctitis in patients with uterine cervix cancer

OBJECTIVE

The aim of this study was to evaluate the relationship between external parametrial dose and radiation proctitis after external irradiation and high-dose-rate intracavitary (HDR-IC) brachytherapy among patients with cervical cancer.

METHODS

From May 1993 through December 1996, 191 patients with stage IB-IVA cervical cancer were managed by curative-intent radiotherapy. External irradiation to the whole pelvis (44-45 Gy/ 22-25 fractions) was delivered to all patients initially. One hundred twenty-seven patients received additional bilateral parametrial and sidewall boost (5.4-14.4 Gy/ 3-8 fractions) with 4-cm midline shielding. HDR-IC brachytherapy, 19.2-24 Gy/ 5 fractions to Point A, was given after external irradiation. Patients receiving an external dose of 44-45, 50-54, and >54 Gy were categorized as no parametrial boost (NPMB), low parametrial boost (LPMB), and high parametrial boost (HPMB) group, respectively. The actuarial proctitis rate was compared among the three groups.

RESULTS

Three-year overall and Grade 2-4 proctitis rates were 30 and 15%, respectively. Overall proctitis rates were 12, 34, and 51% in the NPMB, LPMB, and HPMB groups (P < 0.0001), respectively. Grade 2-4 proctitis rates were 5, 17, and 27% in the NPMB, LPMB, and HPMB groups (P = 0.0022), respectively. In multivariate analysis of overall and Grade 2-4 radiation proctitis, external parametrial dose was the only independent prognostic factor (P = 0.0002 and 0.0030, respectively).

CONCLUSION

Regardless of central shielding after 44-45 Gy whole pelvis irradiation, more patients with high external parametrial dose developed radiation proctitis. Incomplete midline shielding of the upper rectum may be the cause. Diminishing the external beam doses further may decrease rectal complications.

Two-stage operation for treatment of a large dissecting popliteal cyst after failed total knee arthroplasty

A symptomatic popliteal cyst after total knee arthroplasty (TKA) is rare, occurring most frequently as a result of intra-articular knee pathology. We present a case of a large dissecting popliteal cyst 7 years after TKA with symptoms of severe calf pain and functional disability. The symptomatic cyst was excised completely in a first-stage operation, and the severely worn TKA was corrected by a second-stage surgical procedure. The patient in this report was pain free and had satisfactory range of knee motion 5 years after the index revision TKA, without recurrence of effusion or popliteal cyst formation.

Intramedullary femoral nails: one or two lag screws? A preliminary study

Failures of proximal femoral nails that treat unstable femoral fractures have been reported. In this communication, a finite element model to include a proximal femoral nail within a fractured femur was used to carry out preliminary investigations into configurations of single or double lag screws. The effects of the different types of fracture were investigated. The results show that in order to share the load evenly between two lag screws, a good configuration seems to be to have a slightly larger screw above the lower screw. This also ameliorates stresses in the nail at the lag screw insertion holes. However, using two screws in this way can lead to large stresses in the cancellous bone in the femoral head, and these stresses may be significant in the initiation of cut-out.

Deep vein thrombosis after total knee arthroplasty

BACKGROUND AND PURPOSE

The incidence of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) in the Asian population is probably higher than is commonly assumed by clinicians. The purpose of this study was to investigate the incidence of DVT after TKA in a southern Taiwanese population and to determine whether routine prophylaxis against DVT is indicated.

MATERIALS AND METHODS

The incidence of DVT was investigated in 107 ascending venograms performed in 105 knees in 102 patients after TKA. Observations were made and interpreted by orthopedic radiologists blinded to the clinical condition of the patients. The correlation of DVT with the medical conditions, anesthesia type, and local physical findings were analyzed.

RESULTS

The overall incidence of DVT after TKA was 63.6% (68/107); 95.6% (63/68) of cases involved the distal veins in the calf and only 4.4% (3/68) involved the proximal vein at the popliteal level. There was no higher incidence of thrombosis in the femoral and iliac veins, and no pulmonary embolism. Approximately 70% of patients with DVT were symptomatic and required treatment. There was no statistically significant correlation of DVT with medical condition, including diabetes mellitus, hypertension, body weight, varicosity, history of thromboembolic disorder and congestive heart failure, or the type of anesthesia or bone cement used. There was a positive correlation of DVT with local physical findings including calf girth enlargement, leg edema, and skin discoloration, and a negative correlation with findings including Homans' sign, cord induration, venous engorgement, and knee effusion.

CONCLUSION

The incidence of DVT after TKA in this southern Taiwanese cohort was similar to that in Western populations, and higher than is commonly assumed by clinicians at this facility. However, the rate of proximal thrombosis and pulmonary embolism was much lower than in previous studies from Western populations. The majority of cases of DVT involved the veins in the calf; approximately 70% of patients were symptomatic and required treatment.

Laparoscopic-assisted vaginal myomectomy

STUDY OBJECTIVE

To evaluate the safety and efficacy of combined laparoscopic and vaginal approach in dealing with uterine myomas.

DESIGN

Retrospective case study (Canadian Task Force classification II-2).

SETTING

Tertiary care major teaching hospital.

PATIENTS

Thirty-one women with symptomatic fundal and/or posterior wall uterine myomas.

INTERVENTION

Laparoscopic-assisted vaginal myomectomy performed by one of the authors from July 1996 to December 1998.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SD operating time, blood loss, and length of hospital stay were 79.19+/-18.31 minutes, 150.00+/- 103.28 ml, and 3.10+/-0.75 days, respectively. No patients developed serious complications, and only two minor complications occurred.

CONCLUSION

After laparoscopic inspection and location of uterine myomas, dealing with posterior and fundal uterine myomas by the vaginal route makes hemostasis and uterine repair easier than by purely laparoscopic approach.

Dermatofibrosarcoma protuberans: treatment results of 35 cases

BACKGROUND AND PURPOSE

This study evaluates the treatment results of patients with dermatofibrosarcoma protuberans.

PATIENTS AND METHODS

Between August 1987 and July 1998, 35 consecutive patients with pathologically proved dermatofibrosarcoma protuberans received surgery with or without radiation therapy. Their treatment results were analyzed retrospectively.

RESULTS

The patient ages ranged from 5 to 67 years (median 37 years). There were 24 males and 11 females. The anatomic sites of tumor were: trunk in 21, extremity in eight, and head and neck region in six. The maximal dimension of tumor ranged from 1.5 to 25 cm. Surgery techniques included local excision and wide excision with or without graft or flap. Adjuvant radiation therapy was given to 11 patients, with a dose ranging from 46 to 68 Gy (one pre-operative, ten post-operative). At a median follow-up of 50 months (range 11-131 months), there were 11 patients (nine patients without radiation therapy) who developed local failure. Salvage therapy (excision with or without radiation therapy) was given to all of them, and ten achieved disease control. Some patients had treatment-related moderate cosmetic or functional problems.

CONCLUSIONS

Dermatofibrosarcoma protuberans is a malignancy of a high cure rate, and adjuvant radiation therapy can reliably decrease the local recurrence rate and prevent mutilation and functional deficit caused by repeated surgery.

Suppressive effect of penta-acetyl geniposide on the development of gamma-glutamyl transpeptidase foci-induced by aflatoxin B(1) in rats

The suppressive effects of penta-acetyl geniposide, (Ac)(5)-GP, on the hepatotoxic lesions-induced by aflatoxin B(1) (AFB(1)) were investigated in male Wistar rats. Rats were divided into six groups: groups I and II served as normal and solvent control, respectively; group III was given AFB(1) (2 mg/kg body weight) alone; group IV was given (Ac)(5)-GP (2 mg/kg) alone; and groups V and VI received both AFB(1) (2 mg/kg body weight) and (Ac)(5)-GP (1 mg and 2 mg/kg body weight, respectively). Rats received treatments for 8 weeks, then were maintained on basal diet for 32 weeks. At the end of the experiment (week 40), the liver lesions (e.g. fatty change, eosinophilic and bile duct dilation) and preneoplastic changes in rats of groups V and VI were reduced when they were compared with group III. There were no liver lesions and preneoplastic changes in rats treated with (Ac)(5)-GP alone. Although no differences in the total number of gamma-glutamyl transpeptidase (GGT)-positive foci was observed between the groups treated with AFB(1) along with or without (Ac)(5)-GP, the treatment of (Ac)(5)-GP significantly reduced the number of AFB(1)-induced GGT positive foci (with diameter larger than 0.3 mm). These results indicated that the protective effect of (Ac)(5)-GP on early hepatocarcinogenesis-induced by AFB(1) was associated with the inhibition of GGT foci development.

Multivariate analysis of pulmonary fibrosis after electron beam irradiation for postmastectomy chest wall and regional lymphatics: evidence for non-dosimetric factors

BACKGROUND AND PURPOSE

To evaluate the factors associated with pulmonary fibrosis after postmastectomy electron beam irradiation of chest wall and regional lymphatics in patients with breast cancer.

MATERIALS AND METHODS

From July 1987 through July 1994, 109 women with stage II and III breast cancer receiving modified radical mastectomies were managed by postoperative electron beam irradiation. Doses of 46 to 50.4 Gy were delivered to the chest wall covered with bolus, internal mammary nodes, supraclavicular nodes and axillary lymph nodes via 12 or 15 MeV single portal electron beam. Seventeen patients received additional 10-16 Gy surgical scar boost via 9 MeV electron beam. Comparison of pre-treatment and post-treatment chest X-ray films were used to monitor the development of pulmonary fibrosis.

RESULTS

Only Grade 1 radiation-induced late pulmonary toxicity was noted in 33 patients (29%). Twenty-six patients (24%) developed pulmonary fibrosis under unbolused chest wall. Lung fibrosis under bolused chest wall was noted in 11 patients (10%). Statistical difference (P<0.01) was noted between the incidence of fibrosis in these two sites. In multivariate analysis of lung fibrosis under unbolus-covered chest wall, the independent prognostic factors are low body mass index (BMI) (P<0.01), tamoxifen taking (P=0.03), and no treatment interruption (P=0.03). No independent factor was associated with lung fibrosis under bolus-covered chest wall in multivariate analysis.

CONCLUSIONS

In the analysis of pulmonary fibrosis induced by unbolused electron beam, BMI rather than body weight and body height is a strong prognostic factor. Tamoxifen and short overall time can predispose the development of lung fibrosis.

Inhibitory effect of esculetin on oxidative damage induced by t-butyl hydroperoxide in rat liver

Increasing evidence regarding free radical-generating agents and inflammatory processes suggests that accumulation of reactive oxygen species can cause hepatotoxicity. A short-chain analog of lipid hydroperoxide, t-butyl hydroperoxide (t-BHP), can be metabolized to free radical intermediates by cytochrome P-450 in hepatocytes, which in turn can initiate lipid peroxidation, affect cell integrity and result in cell injury. In this study, we used t-BHP to induce hepatotoxicity in vitro and in vivo and determined the antioxidative bioactivity of esculetin, a coumarin compound. Our investigations showed that pretreatment with esculetin (5-20 microg/ml) significantly decreased the leakage of lactate dehydrogenase (LDH) and alanine transaminase (ALT), and also decreased the formation of malondialdehyde (MDA) in primary cultured rat hepatocytes induced by a 30-min treatment with t-BHP. An in vivo study in rats showed that pretreatment with esculetin (i.p.) at concentrations of 0.5 and 5 mg/kg for 5 days before a single i.p. dose of t-BHP (0.1 mmol/kg) significantly lowered the serum levels of the hepatic enzyme markers (ALT and AST) and reduced oxidative stress in the liver. Histopathological evaluation of the rat livers revealed that esculetin reduced the incidence of liver lesions induced by t-BHP, including hepatocyte swelling, leukocyte infiltration, and necrosis. Based on the results described above, we speculate that esculetin may play a chemopreventive role via reducing oxidative stress in living systems.

Intracortical osteosarcoma: report of a case

Intracortical osteosarcoma is the rarest anatomic variation of osteosarcoma. There have been only 12 cases reported in the English-language literature. We present a case of osteosarcoma in an 18-year-old Taiwanese man that originated within the cortex of the tibial diaphysis. The initial radiograph revealed a lytic mass confined to the cortex, mimicking a benign bone lesion. Histopathologic examination of the biopsy specimen showed an osteoblastic osteosarcoma mingled with some fibroblastic foci. He underwent en bloc resection, and a metallic prosthetic intercalary stem was used to replace the larger bone defect. Adjuvant chemotherapy was administered before and after the operation. He was free of disease during 40 months of follow-up. A review of all reported cases of intracortical osteosarcoma revealed that the initial method of treatment plays an important role in local recurrence and distant metastasis. Local excision and curettage leads to the worst results. The outcomes of more recently reported cases have improved because of early awareness of the possibility of malignancy and advances in chemotherapy. However, whether patients with intracortical osteosarcoma have a different prognosis from those with conventional osteosarcoma cannot be determined, because of the small number of intracortical osteosarcoma cases available for analysis.

Serial analysis of gene expression: from gene discovery to target identification

Serial Analysis of Gene Expression (SAGE) is a sequence-based genomics tool that features comprehensive gene discovery and quantitative gene expression capabilities. As an 'open' system, SAGE can reveal which genes are expressed and their level of expression rather than merely quantifying the expression level of a predetermined, and presently incomplete, set of genes as carried out by 'closed' system gene expression profiling platforms such as microarrays. These distinguishing attributes enable SAGE to be used as a primary discovery engine that can characterize human disease at the molecular level while illuminating potential targets and markers for therapeutic and diagnostic development, respectively.

Specific induction of glutathione S-transferase GSTM2 subunit expression by epigallocatechin gallate in rat liver

The antitumor effect of green tea polyphenols has been well characterized in numerous papers. However, the mechanism of their action is still poorly defined. In this study, epigallocatechin gallate (EGCG), the main ingredient of green tea extract, was studied for its effect on the expression of glutathione S-transferases (GSTs) in rat liver to examine the mechanism of action. Liver samples were collected from Sprague-Dawley rats treated with EGCG in H(2)O by portal vein perfusion and examined for total GST activity and GST expression. The results showed that the induction of GST activity by EGCG was dose- and time-dependent. GST activity was increased about 28-fold at 12 hr after treatment. Three GST subunits (GSTA1/2, GSTM1, and GSTM2) were examined by Western blot for changes in protein level affected by EGCG (1 mg/kg weight). Only GSTM2 revealed a significant time-dependent increase, with a maximal induction of approximately 2.0-fold. The differential effect of EGCG on GST subunit expression was also verified by immunocytochemical examination and showed strong induction of the GSTM2 (but not the GSTA1/2 and GSTM1) level in liver section. This induction occurred as early as 3 hr after treatment and extended gradually outward from the hepatic veins as treatment time increased. The change in the GSTM2 protein level was accompanied by a corresponding alteration in mRNA quantity ( approximately 2.0-fold of control). Our report is the first to demonstrate a specific induction of the GSTM2 subunit by a chemopreventor and suggests a primary influence of EGCG on GSTM2 gene expression.

Effect of N-(biphenylyl-methyl)imidazole, a type 1 angiotensin II receptor inhibitor, on the contractile function of the rat corpus cavernosum

The effect of N-(biphenylyl-methyl)imidazole, losartan potassium, a newly developed antihypertensive type 1 angiotensin II receptor antagonist on the rat erectile function, was studied. Sexually active 9-week-old male spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto (WKY) rats were given losartan 60 mg/kg intraperitoneal injections. Mean blood pressure (MBP) dropped significantly in both SHR and WKY rats (for SHR: from 140 +/- 8 to 114 +/- 5 mm Hg, p < 0.05, n = 8; for WKY: from 113 +/- 7 to 79 +/- 9 mm Hg, p < 0.05, n = 8). On the contrary, the intracavernous pressure (ICP) of SHR and WKY rats did not differ significantly from that of the corresponding controls receiving saline injections (p > 0.05, n = 8 for each group). For the chronic study, the rats were fed with losartan 30 mg/kg/day for 30 days. MBP decreased significantly in SHR but not in WKY rats (for SHR: from 137 +/- 7 to 113 +/- 5 mm Hg, p < 0.05, n = 8; for WKY: from 110 +/- 6 to 107 +/- 5 mm Hg, p > 0.05, n = 8). The ICP of the losartan-treated rats was not significantly different from that of control rats (p > 0.05, n = 8 for each group). In contrast, WKY rats receiving guanethidine 1 mg/kg/day for 30 days showed significantly decreased ICP. Angiotensin II (10(-9)-10(-5) M) and losartan (10(-9)- 10(-5) M) did not induce significant contractile responses of the cavernosal strip when tested in vitro. On the other hand, methoxamine 10(-4) M induced good contractile responses. In conclusion, the present study demonstrated that angiotensin II did not cause significant change in the contractile status of rat corpus cavernosum. Correspondingly, the type 1 angiotensin II inhibitor effectively lowered blood pressure but did not affect cavernosal contractile function, thus is useful clinically in the treatment of hypertensive disorders without significant detrimental effects on male sexual function.

Improved PCR-based subtractive hybridization strategy for cloning differentially expressed genes

An improved PCR-based subtractive hybridization strategy was used to clone apoptosis-related genes induced by all-trans retinoic acid (ATRA) from human promyelocytic leukemia cell line HL-60 cells. The protocol used the cap-finder method, long-distance PCR, streptavidin magnetic bead-mediated subtraction and spin column chromatography. Twenty-seven clones related to apoptosis were identified by reverse dot blot assay. Seventeen were known genes, of which seven have been reported to be apoptosis related. The remaining 10 were unknown genes, five of which were sequenced and named apr-1 to apr-5. apr-1, apr-2, apr-3 and TNF were reidentified by reverse dot blot, and it is suggested that they might be related to apoptosis. The results suggest that this strategy might be efficient for large-scale cloning of differentially expressed genes in target cells.

Induction of apoptosis by hibiscus protocatechuic acid in human leukemia cells via reduction of retinoblastoma (RB) phosphorylation and Bcl-2 expression

Hibiscus protocatechuic acid (PCA), a phenolic compound isolated from the dried flower of Hibiscus sabdariffa L. (Malvaceae), demonstrated antioxidant and antitumor promotion effects in our previous study. In the present study, Hibiscus PCA was found to inhibit the survival of human promyelocytic leukemia HL-60 cells in a concentration- and time-dependent manner. The study revealed that HL-60 cells underwent internucleosomal DNA fragmentation and morphological changes characteristic of apoptosis after a 9-hr treatment with Hibiscus PCA (2 mM). Flow cytometric analysis of the DNA content of cells treated with PCA for 12 hr showed that the cells were distributed mainly in the hypodiploid phase (apoptotic peak, 46.7%), less in the G(1) (34.2%) and S phase (14.0%), and few in the G(2)/M phase (5.1%). Moreover, PCA treatment caused an increase in the level of hypophosphorylated retinoblastoma (RB; 180% of control at the 6-hr time point) and, on the contrary, a decline in hyperphosphorylated RB. A rapid loss of RB was observed when the treatment period was extended. Further studies showed that Hibiscus PCA application reduced Bcl-2 protein expression to 47%, and increased Bax protein expression to 181% after 1.5 hr as compared with time 0. Overexpression of Bcl-2 in HL-60 cells delayed the occurrence of Hibiscus PCA-induced apoptosis. These data suggest that Hibiscus PCA is an apoptosis inducer in human leukemia cells, and that RB phosphorylation and Bcl-2 protein may play a crucial role in the early stage.

Healing of superior vena cava defect in mediastinal seminoma with invasion

We present an unusual case of mediastinal seminoma with direct intraluminal invasion into the superior vena cava (SVC) and extension to the right atrium. Magnetic resonance imaging demonstration of the SVC defect due to tumor invasion was important for determining treatment strategy because rapid posttherapeutic tumor regression may increase the risk of SVC rupture. Gradual healing of the SVC defect at the tumor entrance site was attained using a tailored treatment plan with radiotherapy and chemotherapy.

Development of brain injury in mice by Angiostrongylus cantonensis infection is associated with the induction of transcription factor NF-kappaB, nuclear protooncogenes, and protein tyrosine phosphorylation

Eosinophilic meningitis or meningoencephalitis caused by Angiostrongylus cantonensis is endemic to the Pacific area of Asia, especially Taiwan, Thailand, and Japan. Although eosinophilia is an important clinical manifestation of A. cantonensis infection, the role of eosinophils in the progress of the infection remains to be elucidated. In this experiment, we showed that A. cantonensis-caused eosinoplia and inflammation might lead to the induction of NF-kappaB and protooncogene expression via activation of the tyrosine phosphorylation signal pathway. After mice were infected daily with 30 third-stage larvae of A. cantonensis by oral adminstration for 6 weeks, no significant differences PKC-alpha, MEK-1, ERK-2, JNK, and p38 protein expression were found between the control and infected mice. However, the protein tyrosine phosphorylation levels, NF-kappaB, and iNOS protein products were significantly increased by 3.5-, 3.3-, and 6.3-fold, respectively, after 3 weeks of A. cantonensis infection. The same pattern was found for c-Myc, c-Jun, and c-Fos proteins, which were elevated by 3.2-, 2.3-, and 3.4-fold, respectively, compared to control animals after 3 weeks. The expression potency of these proteins started increasing in week 1, reaching maximal induction in week 3, and then declining in week 5 after A. cantonensis infection. Another consistent result was noted in the pathological observations, including eosinophilia, leukocyte infiltration, granulomatous reactions, and time responses in brain tissues of infected mice. These data suggest that the development of brain injury by eosinophlia of A. cantonensis infection is associated with NF-kappaB and/or nuclear protooncogenes expression, which is activated by the tyrosine phosphorylation pathway.

Tumor promotion of N-nitroso-N-(3-keto-1, 2-butanediol)-3'-nitrotyramine derived from nitrosation of Maillard reaction product in CD-1 mice

N-Nitroso-N-(3-keto-1,2-butanediol)-3'-nitrotyramine (NO-NTA) is a product of a model browning system generated in the presence of sodium nitrite. Our previous study showed that NO-NTA had genotoxicity and proved to be an initiator and promoter on mouse C3H10T1/2 cells. In this study, a two-stage skin carcinogenesis protocol was used to promote CD-1 mouse skin carcinogenesis using NO-NTA. Twice weekly, for 38 weeks, topical application of NO-NTA at the concentration of 250 nmol to mice previously initiated with benzo(a)pyrene (BaP) caused 90% tumor incidence. However, no tumors were observed in mice treated with BaP or treated with NO-NTA alone. The NO-NTA-promoted tumors that were observed histologically in mice showed well-differentiated squamous cell carcinoma with invasion into the subcutaneous region. Application of the same amount of NO-NTA not only caused significant induction of hyperplasia but also epidermal ornithine decarboxylase (ODC) activity. Treatment of mouse skin (1 cm(2)) with various amounts of NO-NTA (10, 50, or 250 nmol) caused production of hydrogen peroxide by 1.63-, 1.91-, and 2. 38-fold, respectively, and marked induction of myeloperoxidase (MPO) by 21-, 39-, and 61-fold. These results indicate that NO-NTA is a new tumor promoter and may induce tumor promotion by oxidant stress in CD-1 mouse skin.

Elective neck irradiation for nasopharyngeal carcinoma

BACKGROUND

This study was conducted to evaluate the effectiveness of elective neck irradiation (ENI) for nasopharyngeal carcinoma (NPC), and to analyze factors associated with ENI failure.

METHODS

A radiation port covering the side of a neck without gross nodal metastasis was qualified for evaluation of the effectiveness of ENI. From 1988 through 1992, a total of 261 patients with N0 (130 cases), N1 (91 cases), and N3 (40 cases) NPCs were studied. All patients were irradiated with 60Co teletherapy or 10 MV x-ray to a total dose of 46.8 Gy/26 fractions, followed by a boost treatment to the primary site to a total dose of 64.8 to 75.6 Gy/36-42 fractions. All ENI ports received irradiation to a dose of 46.8 to 60.8 Gy. The duration of follow-up was 6 to 10 years, with a median of 8.1 years. Factors associated with to the risk of ENI failure were analyzed.

RESULTS

(1) The overall 5-year actuarial local control rate and actuarial survival rate were 74% and 63%, respectively. (2) Among the 261 cases in which ENI treatment was used, the treatment failed in 12 cases, accounting for a crude ENI failure rate of 5%. The overall 5- and 10-year cumulative risk of ENI failure was 5% and 7%, respectively. (3) Time from the start of treatment to ENI failure ranged from 9 to 66 months, with a median of 17 months. (4) Of the 12 patients for whom EMI failed, 11 (92%) had recurrence in the upper neck, and one in the lower neck. (5) Existence of prior failure at the primary site was the only factor significantly correlated with the risk of ENI failure (p < 0.001). The 5-year cumulative risk of ENI failure for patients with local failure vs. those without was 16% vs. 1% (p < 0.0001).

CONCLUSION

Moderate-dose ENI was highly effective in the control of subclinical disease in the neck for NPC. ENI failure was closely associated with prior failure at the primary site, implying that local primary tumor failure may lead to an increased potential for metastasis to the neck.

Treatment of painful heels using extracorporeal shock wave

BACKGROUND AND PURPOSE

Shock wave therapy has been shown to improve many tendinopathies at the tendon-bone junction. The purpose of this study was to investigate the safety and effectiveness of extracorporeal shock wave therapy for the treatment of painful heels.

METHODS

Sixty-six patients, including 45 women and 21 men with an average age of 47.70 years (range, 19-75 years), were included in the study. Each patient received 1,000 impulses of shock waves at a 14-kV generator voltage at the affected site under local anesthesia. Twelve patients received a second treatment, and two patients received a third treatment.

RESULTS

Of 58 patients with 6 weeks' follow-up, five (9%) were complaint-free, 21 (37%) were significantly better, 27 (47%) were slightly better, and five (9%) were unchanged. Of 41 patients with 12 weeks' follow-up, 11 (27%) were complaint-free, 22 (54%) were significantly better, seven (17%) were slightly better, and one (2%) was unchanged. The results at 12 weeks were much better than those at 6 weeks. The effect of shock waves on painful heels continued between 6 and 12 weeks. Twelve patients who did not respond favorably to the first treatment showed significantly better results after a second treatment. Two patients who had a third treatment also achieved satisfactory results. There were no device-related problems or systemic or local complications.

CONCLUSIONS

Extracorporeal shock wave therapy is a new modality that is safe and effective in the treatment of painful heel spurs.

Concomitant boost radiation therapy for inoperable non-small-cell lung cancer: preliminary report of a prospective randomized study

PURPOSE

The radiation therapy results for patients with inoperable non-small-cell lung cancer (NSCLC) have been disappointing. Tumor dose escalation using concomitant boost technique (CBT) has been shown to improve local control in a few prospective studies. This trial was carried out to prospectively assess the radiation response and acute toxicity of CBT in comparison to the conventional treatment technique (CTT).

METHODS AND MATERIALS

Ninety-seven consecutive eligible patients were entered in this prospective clinical trial between November 1994 and February 1998. Patients were randomized to receive either CBT (43 patients) or CTT (54 patients) radiation therapy. These patients either refused chemotherapy or were judged as unsuitable for chemotherapy. Patients in the CBT group received 46.8 Gy in 26 fractions using large fields that encompassed the gross and occult disease. A concomitant boost of 18.2 Gy (0.7 Gy per fraction) was delivered to the gross disease using small fields with 1.5-cm margins. The small fields were treated concurrently with the large fields and the total dose to the tumor area was 65 Gy in 26 fractions. Patients in the CTT group received 70.8 Gy in 38 fractions. The acute toxicity between each group was compared. The response rate was analyzed and compared by treatment group, gender, age, stage, histology, initial Karnofsky performance score (KPS), severity of acute toxicity, and maximum body weight loss (MBWL) during treatment course.

RESULTS

The demographic parameters such as sex, age, and stage were evenly distributed in each treatment group. The majority of these patients had Stage IIIA and IIIB disease. Overall median treatment times were 39 days for the CBT group of patients and 62 days for the CTT group. No treatment-related mortality was found. There were 2 patients in the CTT group with acute RTOG Grade 3 lung toxicity, and no Grade 3 lung or esophageal toxicity was observed in CBT group. The response rates, assessed by radiographic images, were 69.8% and 48.1% for the CBT and CTT patients, respectively. Univariate and multivariate analysis revealed that patients in the CBT group, patients with better KPS, and patients with more severe acute toxicity had a higher response rate.

CONCLUSION

This study demonstrates that concomitant boost radiation therapy is tolerable, and produces a superior response rate than conventional radiation therapy for patients with inoperable NSCLC. The length of treatment was reduced from 38 to 26 treatment days, almost a 30% reduction.