Partially hyperfractionated accelerated radiotherapy and concurrent chemotherapy for advanced nasopharyngeal carcinoma

PURPOSE

A newly designed concomitant chemoradiotherapy was undertaken to assess the feasibility and efficacy for advanced nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

Sixty-three patients with biopsy-proven NPC were entered in this Phase II trial from March 1992 to November 1993. Most patients present with Stage IV disease (93.4%) and poorly differentiated epidermoid carcinoma or undifferentiated carcinoma were the major pathologic type. Radiotherapy was delivered using a telecobalt unit and 10 MV x-rays and by altered fractionation (72-74 Gy/45 fractions/6 weeks). Chemotherapy with cisplatin 75 mg/m2, 2 h infusion at day 1, followed by 5-FU 400 mg/m2/day, continously infused for 4 days was given concurrently during the first and fifth weeks of radiotherapy.

RESULTS

The major toxicity was mucositis (61% belong to Grade 3, 31% to Grade 2). Weight loss, leucopenia, and skin reaction were frequently encountered. Three patients withdrew from treatment at 15, 25, and 55.5 Gy, three patients interrupted the radiotherapy for 1-4.5 weeks, and two patients refused the second cycle of concomitant chemotherapy due to toxicities. The initial tumor response showed 100% overall response rate, with 90.5% complete response. After a median follow-up time of 38 months, five patients failed at the primary and/or neck (four recurrent and one persistent), and 14 patients developed distant metastases alone. The 3-year primary disease-free, regional disease-free, distant disease-free, and overall survival rates are 89.1, 92.8, 74.3, and 73.6%, respectively. The late complication rate is acceptable so far.

CONCLUSIONS

Our data indicates that concurrent chemoradiotherapy for advanced NPC is both feasible and effective, with acceptable toxicities. Distant metastases are the major site of treatment failure. Postradiation adjuvant chemotherapy to eradicate subclinical distant metastasis should be further studied.

Preliminary report of outpatient weekly adjuvant chemotherapy for high-risk nasopharyngeal carcinoma

Distant metastasis has become the most frequent failure site-more so than locoregional relapse-after adequate radiotherapy in nasopharyngeal carcinoma (NPC). A prospective study was initiated to test the role of postradiation adjuvant chemotherapy using a weekly schedule for selected patients with high-risk NPC (N3, T4N2b-2c, and N2b-2c, with one of nodal size > 4 cm, or residual disease after radiotherapy). Through July 1993 to August 1994, a total of 20 patients were entered into the study: 16 men and four women, with a median age of 49 years and age range of 27-75 years. Pathology showed WHO type I:II:III = 2:13:5. Previous treatment consisted of concurrent chemoradiotherapy (16 patients), radiotherapy alone (two), and neoadjuvant chemotherapy followed by radiotherapy (two). Postradiation adjuvant chemotherapy was usually started 2 months after radiotherapy, using a weekly FP schedule (5-fluorouracil 1,250 mg/m2 + cisplatin 25 mg/m2, mixed in 100 ml saline, 24 h continuous i.v. infusion) for 18 weeks. The treatment of five patients was at 5, 6, 10, 14, and 15 weeks because of leukopenia-induced mortality, sudden death unrelated to adjuvant chemotherapy, a patient's refusal, and distant metastasis (the last two cases) during adjuvant chemotherapy. The major toxicity was leukopenia (grade I, 20%; grade II, 45%; grade III, 15%; and grade IV, 10%). Ten patients (50%) developed distant metastasis after a median follow-up time of 20 months. Our preliminary data indicate that postradiation adjuvant chemotherapy with a weekly FP regimen at our dosage is not recommended for high-risk NPC.

Detailed deletion mapping with a refined physical map of 7q31 localizes a putative tumor suppressor gene for breast cancer in the region of MET

In breast cancer, loss of heterozygosity (LOH) has been described on the long arm of chromosome 7 at band q31, suggesting the presence of a tumor suppressor gene in this region. To define the deleted region, we analysed 73 cases of breast cancer and matched normal DNAs with 17 polymorphic markers. A minimal area of LOH was identified as the chromosomal interval flanked by markers D7S687 and metH, spanning a segment of 2 Mb on chromosome 7q31. Of the 73 breast cancer patients studied, all were informative for at least one marker in this region and nine patients showed LOH at one or more loci (12.3%). To define the physical size of the deletion and to ensure the correct interpretation of the LOH deletion studies, we redefined the physical map of markers within this region of 7q31. We present a new physical order for markers at 7q31. More significantly, we have mapped the minimum deletion of 7q31 in the breast cancers studied to date to a physical distance of 1000 kb, contained on a single YAC clone, which includes the MET receptor tyrosine kinase but no other known genes.

Bilateral enophthalmos associated with hydrocephalus and ventriculoperitoneal shunting

BACKGROUND

Progressive bilateral enophthalmos in the absence of previous trauma is rare.

METHODS

Three patients with progressive bilateral severe enophthalmos whose only significant medical history was that of congenital hydrocephalus were treated by ventriculoperitoneal shunt placement.

RESULTS

The patients demonstrated severe bilateral enophthalmos with poor eyelid apposition to the globes resulting in superficial keratopathy. Orbital computed tomographic scans confirmed the severe enophthalmos, with apparent reduced orbital fat volume. Orbital bony anatomy appeared normal.

CONCLUSIONS

Bilateral progressive enophthalmos may be associated with hydrocephalus and ventriculoperitoneal shunting. The causal mechanism remains speculative.

Vascular dementia of Binswanger's type: clinical, neuroradiological and 99mTc-HMPAO SPET study

In 24 patients with vascular dementia of Binswanger's type (VDBT) and 14 age-matched neurologically normal volunteers, we investigated the relationship between clinical features, white matter lesions (leuco-araiosis) and cerebral atrophy on computed tomographic (CT) scan, and regional cerebral blood flow. All subjects underwent the Mini-Mental State Examination of Taiwan, version 1 (MMSE-T1), for assessing the severity of cognitive impairment. The patients were subdivided into two groups, one with mild to moderate (group I, MMSE-T1 scores: 11-24, n=11), and the other with severe dementia (group II, MMSE-T1 scores: below 10, n=13). White matter degeneration was evaluated with densitometric methods. Loss of brain parenchyma was estimated with seven linear measurements (Evan's ratio, third ventricle ratio, width of temporal horn tip, anterior-posterior length of temporal horn, anterior-posterior length of Sylvian fissure and width of frontal interhemispheric fissure) by CT scans. Regional cerebral blood flow was determined with technetium-99m hexamethylpropylene amine oxime (HMPAO) single-photon emission tomography (SPET). In neuroimaging studies, subcortical leuco-araiosis was localized at the frontal region in group I patients and scattered diffusely in group II patients. 99mTc-HMPAO SPET analysis revealed reduction of regional cerebral blood flow in the frontal lobe in group I patients and widespread reduction of regional cerebral blood flow in group II patients. A correlation between frontal leuco-araiosis and perfusion defect of the frontal pole was demonstrated in group I patients, showing findings typical of subcortical dementia. There was no difference in frontal atrophic measurements between group I patients and controls. Ratios of volumes of lost brain parenchyma and leuco-araiosis were significantly higher in group II patients than in the age-matched controls, corresponding to a diffuse cerebral perfusion defect. These results suggest that patients with VDBT have early frontal lobe involvement with posterior progression. Patients with mild VDBT are more likely to show reduction of frontal cerebral blood flow and leuco-araiosis, while those with severe VDBT are more likely to have diffuse leuco-araiosis, cerebral hypoperfusion and brain atrophy.

Serotonin modulates ethanol-induced depression in cerebellar Purkinje neurons

In the present study, we found that local application of serotonin (5-HT) potentiated ethanol-induced depressions of the spontaneous activity of Purkinje neurons in urethane-anesthetized rats. 5-HT also potentiated depressions induced by gamma-aminobutyric acid; however, this modulatory response was quantitatively smaller than 5-HT-induced potentiation of ethanol depression. Previous reports suggested that the release of 5-HT can be regulated by presynaptic 5-HT autoreceptors. We found that local application of methiothepin, which may induce 5-HT overflow through the inhibition of presynaptic autoreceptors, facilitated ethanol-mediated responses. This methiothepin effect was greatly diminished in neonatally 5,7-dihydroxytryptamine-lesioned animals, suggesting a presynaptic mechanism was involved. We also found that the 5-HT1A antagonist UH301 did not attenuate 5-HT-facilitated ethanol reactions. On the other hand, local application of 5-HT1B agonist CGS12066B potentiated ethanol-induced depression. Taken together, our data suggest that 5-HT can modulate ethanol-mediated electrophysiological depression, possibly mediated through 5-HT1B receptors in the cerebellum.

Antioxidant-sensitive regulation of inflammatory-response genes in Kaposi's sarcoma cells

Kaposi's sarcoma (KS) is a multifocal vascular lesion characterized by abnormal proliferation of endothelial-like KS cells linked to a pronounced leukocyte infiltration. KS lesions contain novel herpes-like DNA sequences, KSHV, hypothesized to originate from the viral pathogen for KS. Using cultured KS cells that retain the KSHV sequences, diverse signals, including tumor necrosis factor alpha, interleukin (IL) 1 beta, polyinosinic acid/polycytidylic acid and lipopolysaccharide, induced the expression of the cytokine IL-6 and cellular adhesion molecules involved in leukocyte recruitment, including vascular adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1). The thiol-antioxidant pyrrolidine dithiocarbamate (PDTC) selectively inhibited > 90% of the activation of nuclear factor kappa B-like DNA binding activity in KS cells. PDTC also reduced by > 85% induced levels of VCAM-1 and IL-6 at the mRNA, protein, and functional levels in KS cells. In contrast, PDTC did not inhibit the induced expression of either ICAM-1 or E-selectin. These studies show that PDTC differentially modulates the expression of inflammatory response genes in KS cells that contain KSHV, suggesting that reduction-oxidation-sensitive events are involved in the regulation of these genes. These studies also suggest that thiol-antioxidants such as PDTC may play a potentially therapeutic role in the treatment of KS by preventing induction of specific inflammatory response genes that may be involved in the pathogenesis of KS.

Cost of patient follow-up after potentially curative lung cancer treatment

The two objectives of this study were to determine the range of recommended follow-up strategies for patients with lung cancer treated with curative intent and to estimate the cost of such follow-up. Ten articles delineating eight specific follow-up strategies were identified from a Medline search of the literature for 1980 through 1995. An economic analysis was done of the costs associated with the identified strategies. Charge data obtained from the Part B Medicare Annual Data file and the Hospital Outpatient Bill file were used as a proxy for cost. Follow-up intensity varied widely across strategies for 5 years of posttreatment follow-up. Medicare-allowed charges for 5-year follow-up ranged from a low of $946 to a high of $5645. When Medicare-allowed charges were converted to a proxy for actual charges by a conversion ratio of 1.62, the range was $1533 to $9145, a fivefold difference in charges. There was no indication that more intensive, higher-cost strategies increased survival or quality of life. The published literature, including textbooks, holds few answers in this area.

Effect of acupuncture on cardiopulmonary function

OBJECTIVE

To evaluate the relationship between acupuncture and cardiopulmonary function in healthy people.

SUBJECTS AND METHODS

Healthy male volunteers were divided into 3 groups, 16 of persons each Group 1 was treated with acupuncture at points Neiguan (PC6) and Zusanli (ST36): Group 2 was treated with acupuncture at non-acupoints, and Group 3 was taken as control. The effects of resting cardiopulmonary functions were measured with gas analysis system. The resting heart rate (HR), oxygen consumption (VO2), and carbon dioxide production (VCO2) were recorded over a thirty-minute period at intervals of five minutes, 15 minutes, and 25 minutes. Electroacupuncture was given to Groups 1 and 2. The analysis of variance and t test were used in data analysis.

RESULTS

In the acupuncture groups, resting heart rate and carbon dioxide production decreased (P < 0.05) and oxygen consumption also decreased slightly, although it was statistically insignificant (P > 0.05).

CONCLUSION

Our results indicate that acupuncture can decrease the resting heart rate and carbon dioxide production, thus lowering the metabolic rate.

Panencephalitic Creutzfeldt-Jakob disease. Unusual presentation of magnetic resonance imaging and proton magnetic resonance spectroscopy

We present serial magnetic resonance imaging (MRI) scans on a biopsy-verified case of Creutzfeldt-Jakob disease (CJD). The initial MRI scan demonstrated increased T2 signal-intensity within the basal ganglia and thalami. Subsequent MRI scans demonstrated a thin cortex, increased T2 signals diffusely within the white matter including U-fibers, and hypointense T2 signals within the basal ganglia, and thalami. Proton magnetic resonance spectroscopy (1H-MRS) study showed an absence of creatine, choline and N-acetylaspartate signals. By these characteristic findings, serial MRI and MRS studies may be helpful in differentiating CJD from other dementing illnesses.

Malignant soft tissue sarcoma of the hypopharynx successfully treated by radiotherapy alone

Sarcoma of the hypopharynx has been reported very rarely in the literature, only six cases having been found among all head and neck malignancies reported to SEER (Surveillance, Epidemiology, and End Results) during 1973-1987. We report a 14-year-old boy with a huge malignant soft tissue sarcoma arising from the hypopharynx. Tracheostomy and feeding gastrostomy were performed as emergency life-saving procedures. Surgical resection had been attempted, but abandoned. Because of the rapidity of tumor growth, we gave the patient a course of accelerated radiotherapy (170 cGy/fraction, two fractions per day) with a total dose of 7140 cGy within one month. A series of endoscopy and imaging studies demonstrated complete regression of the tumor, and the patient is currently alive without evidence of disease 3.5 years after treatment. We conclude that for an unresectable tumor without distant metastasis, radiation therapy may be tried. The time, dose, and fractionation of radiotherapy should be carefully designed and individualized.

The cap-choke catheter antenna for microwave ablation treatment

A matched-dipole type catheter antenna is described for intracavitary and/or transluminal microwave treatment of diseases that may be responsive to thermal ablation therapy. This cap-choke antenna consists of an annular cap and coaxial choke design that can yield SAR distributions in and can produce heating of tissue surrounding the distal end of the catheter antenna. The cap-choke antenna is simple in construction, provides the desired specific absorption rate (SAR) distribution, and is efficient, i.e., the measured power reflection coefficient is 2% in tissue equivalent phantom modeling materials.

Electrophysiological and electrochemical responses of NMDA in the cerebellum: interactions with nonadrenergic pathway

In the present experiments, we measured N-methyl-D-aspartate (NMDA)-induced norepinephrine (NE) release and extracellular action potentials in the cerebellar cortex of urethane-anesthetized rats. The overflow of NE was measured using a Nafion coated-carbon fiber electrode and in vivo chronoamperometry. We found that both NMDA and quisqualate evoked NE release. Our previous work demonstrated that the electrophysiological activity of cerebellar Purkinje neurons could be either excited or inhibited by local NMDA application. It was reported that bicuculline antagonized NMDA-induced inhibition in Purkinje neurons, suggesting that a GABAergic mechanism was activated during NMDA application. We and others previously found that GABA-mediated electrophysiological depressions were enhanced by NE acting via beta-adrenergic receptors while these responses were decreased by activation of alpha-adrenergic receptors. Since NMDA evokes overflow of endogenous NE, the electrophysiological depression induced by NMDA may contain an NE-mediated modulatory component. In this study, we first examined the interaction of NMDA with beta-adrenergic agonist. We found that local application of isoproterenol facilitated NMDA- or GABA-mediated electrophysiological depressions of the Purkinje neurons. Applications of phenoxybenzamine, which antagonized the alpha-adrenergic response of synaptically released NE, also facilitated NMDA-elicited depression. In contrast, the depression induced by GABA, which did not induce NE overflow, was not potentiated by phenoxybenzamine. The facilitation of NMDA-induced depression by phenoxybenzamine was antagonized by the beta-adrenergic antagonist timolol. Taken together, these data suggested that the nonadrenergic pathway is involved in NMDA-induced electrophysiological responses in the cerebellum. NMDA may induce neuronal depression through modulation of GABAergic inhibition via NMDA-evoked NE release onto cerebellar Purkinje neurons.

Combined treatment of IL-1 alpha and TNF-alpha potentiates the antitumour effect of hyperthermia

Vasoactive cytokines, such as IL-1 alpha and TNF-alpha, modulate the homeostatic state at the endothelial surface and cause various types of pathological damage in vascular systems. We investigated the potential therapeutic effects of IL-1 alpha and TNF-alpha in combination with hyperthermia on SCK tumours grown in the legs of A/J mice. We first determined the effect of cytokines on tumour blood perfusion with the (86)Rb uptake method. When the host mice were given an i.p. injection of 25 mu g/kg IL-1 alpha or 50 mu g/kg TNF-alpha, the tumour blood perfusion markedly declined to 46 and 82% of control, respectively. The combination of IL-1 alpha and TNF-alpha reduced the 86Rb uptake to 41% bf control. Hyperthermia at 42.5 degrees C for 1 h reduced the tumour blood flow to 71% of control. The tumour blood perfusion decreased further to 20% of control when the tumours were heated for 1 h at 42.5 degrees C starting 4h after the injection of both IL-1 alpha and TNF-alpha. The changes in clonogenic cell numbers in SCK tumours, as determined by the in vivo-in vitro assay, following various treatments was also investigated. At 4 h after an i.p. injection of 25 mu g/kg IL-1 alpha or 50 mu g/kg TNF-alpha, the clonogenicity of SCK tumours significantly decreased to 29 or 37% of control, respectively. Heating at 42.5 degrees C for 1 h caused a decline in the clonogenic cell number to 30% of control. When both IL-1 alpha and TNF-alpha were given and tumours were heated 4h later at 42.5 degrees C for 1 h, the clonogenic cell number markedly declined to 0.4% of control. The time needed for control tumours to reach 4 x their initial volume was about 3 days, and treatment with IL-1 alpha or hyperthermia alone induced a tumour delay growth by about 1 day. The combined injection of IL-1 alpha and TNF-alpha followed by a heating at 42.5 degrees C for 1 h delayed the tumour growth by 6 days. The results in this study suggest that prior impairment of blood circulation by the combined treatment of IL-1 alpha and TNF-alpha potentiates hyperthermic damage in tumours.

High complete response rate of concomitant chemoradiotherapy for locally advanced squamous cell carcinoma of the uterine cervix

A prospective study with a newly designed schedule of concomitant chemoradiotherapy was initiated for 42 patients with previously untreated squamous cell carcinoma of the uterine cervix. Their ages ranged from 34 to 77 years, median 57 years. There were 13 FIGO stage IIB, 1 IIIA, 27 IIIB, and 1 IVA. Radiotherapy was administered using 1.8 Gy/day, 5 days a week, to the whole pelvis (50.4 Gy/28 fractions) with local boost if indicated. Intracavitary brachytherapy of 5 Gy for five times was delivered after 1-2 weeks of rest. The first 21 patients received concomitant chemotherapy of biweekly PEB regimen (100 mg/m2 etoposide + 50 mg/m2 cisplatin + 50 mg/m2 bleomycin) for two to three cycles during external irradiation. The chemotherapy for the latter 21 patients was modified to weekly PEBF (50 mg/m2 etoposide + 20 mg/m2 cisplatin + 10 mg/m2 bleomycin + 800 mg/m2 5-FU, mixed in normal saline, 24-hr continuous iv infusion) for five to six cycles. All except 1 patient achieved complete response (97.6%) and sustain so after a median follow-up time of 30 months. There were three relapses--one with persistent pelvic disease and two with distant metastasis. Two-year overall survival and disease-free survival rates were 97.6 and 92.9%, respectively. Myelosuppression was moderate but fully recovered. Other acute toxicities were tolerated except for 1 patient who encountered grade IV radiation colitis with cecum perforation and required surgery. As to late morbidity, the incidence of radiation proctitis was high (21.4%) but of a mild degree, with 1 patient needing repeated transfusion. One patient developed chronic cystitis with an acontractile bladder. Our preliminary results show that concomitant chemoradiotherapy for advanced cervical carcinoma is both feasible and effective with acceptable toxicities. Further follow-up is mandatory to ensure whether this high complete response protocol will translate into long-term local control and survival.

Expression of p53 protein in colorectal carcinoids

OBJECTIVE

To determine the frequency and prognostic significance of p53 protein expression in colorectal carcinoid tumors.

DESIGN

Thirty-one paraffin-embedded specimens of colorectal carcinoid tumor were studied by immunohistochemical staining to detect p53 protein expression. The association of p53 expression with tumor site, tumor size, invasion level, tumor stage, DNA pattern, and patient survival were analyzed.

RESULTS

p53 protein was detected in five (16%) of 31 colorectal carcinoid tumors. There was a correlation between p53 overexpression and tumor site, tumor size, tumor stage, and DNA ploidy (P < .05) but not for the depth of tumor invasion (P = .06). In addition to tumor size, invasion, stage, and DNA aneuploidy, p53 protein overexpression was also indicative of a poor prognosis (P < .001).

CONCLUSIONS

The overexpression of p53 protein is uncommon in colorectal carcinoid tumors. However, the expression of p53 protein has a correlation with clinicopathologic-predicting criteria in colorectal carcinoid tumors and may be used as an associated prognostic parameter to assess patient survival.

Radio frequency electromagnetic exposure: tutorial review on experimental dosimetry

Radio frequency (RF) dosimetry is the quantification of the magnitude and distribution of absorbed electromagnetic energy within biological objects that are exposed to RF fields. At RF, the dosimetric quantity, which is called the specific absorption rate (SAR), is defined as the rate at which energy is absorbed per unit mass. The SAR is determined not only by the incident electromagnetic waves but also by the electrical and geometric characteristics of the irradiated subject and nearby objects. It is related to the internal electric field strength (E) as well as to the electric conductivity and the density of tissues; therefore, it is a suitable dosimetric parameter, even when a mechanism is determined to be "athermal." SAR distributions are usually determined from measurements in human models, in animal tissues, or from calculations. This tutorial describes experimental techniques that are used commonly to determine SAR distributions along with the SAR limitations and unresolved problems. The methods discussed to obtain point, planar, or whole-body averaged SARs include the use of small E-field probes or measurement of initial rate of temperature rise in an irradiated object.

Primary sternal osteomyelitis

A case report of primary sternal osteomyelitis, a rare clinical entity, is presented. Treatment of primary sternal osteomyelitis is antibiotics and complete debridement of the infected bone and anterior periosteum. If the posterior sternal periosteum is not involved, it should be left intact. The defect can be covered with skeletal muscle flaps, which improves healing and minimizes recurrence. This approach led to a complete and timely cure.

Is Kaposi's-sarcoma-associated herpesvirus detectable in semen of HIV-infected homosexual men?

We explored a possible route of transmission of Kaposi's-sarcoma-associated herpes virus (KSHV) with nested and unnested PCR techniques. We looked for KSHV DNA sequences in semen of HIV-positive homosexual men and HIV-negative healthy semen donors. With unnested primers we found KSHV sequences in 21 of 33 (64%) homosexual men and in none of 30 healthy donors. With a nested PCR assay, 30 of 33 (91%) specimens from the homosexual men and 7 of 30 (23%) specimens from healthy donors had detectable KSHV sequences. Over 5 years of follow-up, 13 of 30 KSHV-positive homosexual men (43%) developed KS compared with none of the 3 KSHV-negative homosexual men.