Passive high explosive neutron inspection (PHENIX): a new method to confirm the presence or absence of high explosives for nuclear treaty verification

Advanced instruments and methods need to be developed now to create a technical basis to support the negotiation of future nuclear arms control treaties. One new capability that is anticipated is the ability to confirm either the declared presence or declared absence of high explosive (HE) material in the presence of special nuclear material (SNM). Towards this goal, Passive HE Neutron Inspection (PHENIX) has been developed and demonstrated as a method for confirming the presence or absence of HE in the presence of plutonium. The method exploits the inherent presence of neutrons associated with the decay of plutonium as an internal probe source for performing prompt gamma-ray neutron activation analysis (PGNAA), searching for the presence of HE as revealed by the emission of characteristic gamma rays following neutron absorption in hydrogen and nitrogen which are building blocks of present-day, military-grade HE. Tests using stoichiometrically-correct hemishells of mock HE with plutonium show that a system can be expected to positively confirm the presence or absence of these signatures, supporting determination of HE presence or absence with Pu, in a few hours. To protect other potentially sensitive gamma-ray signatures from a treaty accountable item, an analog information barrier has been conceptualized and tested which physically prevents the collection of gamma-ray spectral data outside of user selected energy windows strategically chosen to view only narrow spectral regions corresponding to the hydrogen (2223.2 keV) and nitrogen (9807.2 keV, 10,318.2 keV, and 10,829.2 keV) PGNAA signatures.

Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India

This study from southern India showed that the trabecular microarchitecture and proximal hip geometry were significantly impaired in postmenopausal women with diabetes as compared to age and BMI matched non-diabetic controls. This is despite there being no significant difference in bone mineral density at the femoral neck and hip not between both groups. One-third of the study subjects with type 2 diabetes had prevalent vertebral fractures. Bone mineral density assessment as a standalone tool may not adequately reflect bone health in subjects with diabetes.

INTRODUCTION

There is limited information with regard to bone health in Indian postmenopausal women with type 2 diabetes. We studied the bone mineral density (BMD), trabecular bone score (TBS), prevalent vertebral fractures (VF), proximal hip geometry, and bone mineral biochemistry in ambulatory postmenopausal women with and without type 2 diabetes mellitus (T2DM).

METHODS

This was a cross-sectional study conducted at a tertiary care center. BMD, TBS, prevalent vertebral fractures, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied.

RESULTS

A total of 202 ambulatory postmenopausal women known to have type 2 diabetes mellitus with mean (SD) age of 65.6 (5.2) years and 200 age and BMI matched non-diabetic controls with mean (SD) age of 64.9 (4.7) years were recruited from the local community. Although the prevalence of lumbar spine osteoporosis was significantly lower among cases (30.7%) as compared to controls (42.9%), the prevalence of degraded bone microarchitecture (TBS < 1.200) was significantly higher among cases (51%) than in controls (23.5%); P < 0.001. Prevalent vertebral fractures were not significantly different in cases and controls. The various geometric indices of the proximal hip were significantly impaired in subjects with diabetes as compared to controls.

CONCLUSION

This study may highlight the utility of the trabecular bone score and hip structural analysis in subjects with diabetes, where the bone mineral density tends to be paradoxically high, and may not adequately predict fracture risk.

Phase II trial of post-operative radiotherapy with concurrent cisplatin plus panitumumab in patients with high-risk, resected head and neck cancer

BACKGROUND

Treatment intensification for resected, high-risk, head and neck squamous cell carcinoma (HNSCC) is an area of active investigation with novel adjuvant regimens under study. In this trial, the epidermal growth-factor receptor (EGFR) pathway was targeted using the IgG2 monoclonal antibody panitumumab in combination with cisplatin chemoradiotherapy (CRT) in high-risk, resected HNSCC.

PATIENTS AND METHODS

Eligible patients included resected pathologic stage III or IVA squamous cell carcinoma of the oral cavity, larynx, hypopharynx, or human-papillomavirus (HPV)-negative oropharynx, without gross residual tumor, featuring high-risk factors (margins <1 mm, extracapsular extension, perineural or angiolymphatic invasion, or ≥2 positive lymph nodes). Postoperative treatment consisted of standard RT (60-66 Gy over 6-7 weeks) concurrent with weekly cisplatin 30 mg/m² and weekly panitumumab 2.5 mg/kg. The primary endpoint was progression-free survival (PFS).

RESULTS

Forty-six patients were accrued; 44 were evaluable and were analyzed. The median follow-up for patients without recurrence was 49 months (range 12-90 months). The probability of 2-year PFS was 70% (95% CI = 58%-85%), and the probability of 2-year OS was 72% (95% CI = 60%-87%). Fourteen patients developed recurrent disease, and 13 (30%) of them died. An additional five patients died from causes other than HNSCC. Severe (grade 3 or higher) toxicities occurred in 14 patients (32%).

CONCLUSIONS

Intensification of adjuvant treatment adding panitumumab to cisplatin CRT is tolerable and demonstrates improved clinical outcome for high-risk, resected, HPV-negative HNSCC patients. Further targeted monoclonal antibody combinations are warranted.

REGISTERED CLINICAL TRIAL NUMBER

NCT00798655.

Phase II randomized trial of radiation therapy, cetuximab, and pemetrexed with or without bevacizumab in patients with locally advanced head and neck cancer

BACKGROUND

We previously reported the safety of concurrent cetuximab, an antibody against epidermal growth factor receptor (EGFR), pemetrexed, and radiation therapy (RT) in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). In this non-comparative phase II randomized trial, we evaluated this non-platinum combination with or without bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF).

PATIENTS AND METHODS

Patients with previously untreated stage III-IVB SCCHN were randomized to receive: conventionally fractionated radiation (70 Gy), concurrent cetuximab, and concurrent pemetrexed (arm A); or the identical regimen plus concurrent bevacizumab followed by bevacizumab maintenance for 24 weeks (arm B). The primary end point was 2-year progression-free survival (PFS), with each arm compared with historical control. Exploratory analyses included the relationship of established prognostic factors to PFS and quality of life (QoL).

RESULTS

Seventy-eight patients were randomized: 66 oropharynx (42 HPV-positive, 15 HPV-negative, 9 unknown) and 12 larynx; 38 (49%) had heavy tobacco exposure. Two-year PFS was 79% [90% confidence interval (CI) 0.69-0.92; P < 0.0001] for arm A and 75% (90% CI 0.64-0.88; P < 0.0001) for arm B, both higher than historical control. No differences in PFS were observed for stage, tobacco history, HPV status, or type of center (community versus academic). A significantly increased rate of hemorrhage occurred in arm B. SCCHN-specific QoL declined acutely, with marked improvement but residual symptom burden 1 year post-treatment.

CONCLUSIONS

RT with a concurrent non-platinum regimen of cetuximab and pemetrexed is feasible in academic and community settings, demonstrating expected toxicities and promising efficacy. Adding bevacizumab increased toxicity without apparent improvement in efficacy, countering the hypothesis that dual EGFR-VEGF targeting would overcome radiation resistance, and enhance clinical benefit. Further development of cetuximab, pemetrexed, and RT will require additional prospective study in defined, high-risk populations where treatment intensification is justified.

Negative predictive value of surveillance PET/CT in head and neck squamous cell cancer

BACKGROUND AND PURPOSE

Optimizing the utilization of surveillance PET/CT in treated HNSCC is an area of ongoing research. Our aim was to determine the negative predictive value of PET/CT in patients with treated head and neck squamous cell cancer and to determine whether negative PET/CT reduces the need for further imaging surveillance.

MATERIALS AND METHODS

We evaluated patients with treated HNSCC who underwent posttreatment surveillance PET/CT. During routine clinical readouts, scans were categorized as having negative, probably negative, probably malignant, or malignant findings. We followed patients clinically and radiographically for at least 12 months from their last PET/CT (mean, 26 months; median, 28 months; range, 12-89 months) to determine recurrence rates. All suspected recurrences underwent biopsy for confirmation.

RESULTS

Five hundred twelve patients (1553 scans) were included in the study. Two hundred fourteen patients had at least 1 PET/CT with negative findings. Of the 214 patients with a scan with negative findings, 19 (9%) eventually experienced recurrence, resulting in a NPV of 91%. In addition, a subgroup of 114 patients with 2 consecutive PET/CT examinations with negative findings within a 6-month period was identified. Only 2 recurrences were found in this group, giving a NPV of 98%.

CONCLUSIONS

In patients treated for HNSCC, a single PET/CT with negative findings carries a NPV of 91%, which is not adequate to defer further radiologic surveillance. Two consecutive PET/CT examinations with negative findings within a 6-month period, however, resulted in a NPV of 98%, which could obviate further radiologic imaging in the absence of clinical signs of recurrence.

Fast-neutron spectrometry using a ³He ionization chamber and digital pulse shape analysis

Digital pulse shape analysis (dPSA) has been used with a Cuttler-Shalev type (3)He ionization chamber to measure the fast-neutron spectra of a deuterium-deuterium electronic neutron generator, a bare (252)Cf spontaneous fission neutron source, and of the transmitted fast neutron spectra of a (252)Cf source attenuated by water, graphite, liquid nitrogen, and magnesium. Rise-time dPSA has been employed using the common approach for analyzing n +(3)He→(1)H+(3)H ionization events and improved to account for wall-effect and pile-up events, increasing the fidelity of these measurements. Simulations have been performed of the different experimental arrangements and compared with the measurements, demonstrating general agreement between the dPSA-processed fast-neutron spectra and predictions. The fast-neutron resonance features of the attenuation cross sections of the attenuating materials are clearly visible within the resolution limits of the electronics used for the measurements, and the potential applications of high-resolution fast-neutron spectrometry for nuclear nonproliferation and safeguards measurements are discussed.

Phase I trial of pemetrexed in combination with cetuximab and concurrent radiotherapy in patients with head and neck cancer

BACKGROUND

We studied the combination of pemetrexed, a multi-targeted antifolate, and cetuximab, an mAb against the epidermal growth factor receptor, with radiotherapy in poor prognosis head and neck cancer.

PATIENTS AND METHODS

Patients received pemetrexed on days 1, 22, and 43 on a dose-escalation scheme with starting level (0) 350 mg/m(2) (level -1, 200 mg/m(2); level +1, 500 mg/m(2)) with concurrent radiotherapy (2 Gy/day) and cetuximab in two separate cohorts, not previously irradiated (A) and previously irradiated (B), who received 70 and 60-66 Gy, respectively. Genetic polymorphisms of thymidylate synthase and methylenetetrahydrofolate reductase were evaluated.

RESULTS

Thirty-two patients were enrolled. The maximum tolerated dose of pemetrexed was 500 mg/m(2) in cohort A and 350 mg/m(2) in cohort B. Prophylactic antibiotics were required. In cohort A, two dose-limiting toxicities (DLTs) occurred (febrile neutropenia), one each at levels 0 and +1. In cohort B, two DLTs occurred at level +1 (febrile neutropenia; death from perforated duodenal ulcer and sepsis). Grade 3 mucositis was common. No association of gene polymorphisms with toxicity or efficacy was evident.

CONCLUSION

The addition of pemetrexed 500 mg/m(2) to cetuximab and radiotherapy is recommended for further study in not previously irradiated patients.

Patient safety on the otolaryngology service: the role of an established rapid response system

OBJECTIVE

To study the medical emergencies occurring on a tertiary otolaryngology service identified using a rapid response system (RRS).

DESIGN

Retrospective chart review of RRS activations during 21 months.

SETTING

Specialised otolaryngology care unit within the University of Pittsburgh Medical Center Presbyterian/Montefiore Hospital, a tertiary, academic, teaching hospital in the USA.

INTERVENTION(S)

None.

RESULTS

1171 unit admissions. Unit mortality was 5.1/1000 admissions. 53 patients were involved in 67 RRS activations (4/53 deaths). 32 of 67 events were due to respiratory derangements, most commonly pneumonia. 18 of 67 events were due to cardiovascular abnormalities, most commonly hypertension and myocardial infarction. 11 of 67 events were secondary to mental status changes, several of which were related to adverse drug events. 6 of 67 events were secondary to acute bleeding. 23 of 67 events occurred within 24 h of patient transfer/admission, 14 of those after operations. RRS activation was a marker for in-hospital death (RR 42.2, 95% CI 7.9 to 225.2) compared with that in patients not activating the RRS.

CONCLUSIONS

Although otolaryngology care units attempt to prevent adverse events, emergencies still occur. RRSs identify deteriorating otolaryngology patients who are at increased risk for mortality. RRSs are an efficient mechanism of intervention during a medical emergency. RRSs provide a convenient method of identifying medical/system errors and educational opportunities.

Osteoblastoma of the hyoid bone

Osteoblastoma is a rare bone tumor that usually affects the vertebrae. We present the first known case of osteoblastoma arising in the hyoid bone, in a patient who presented with a neck mass and dysphagia. The radiographic appearance of the tumor is similar to that of low-grade chondrosarcoma, with well-defined expansion of the bone and central chondroid matrix.

Response assessment by combined PET-CT scan versus CT scan alone using RECIST in patients with locally advanced head and neck cancer treated with chemoradiotherapy

PURPOSE

RECIST have limitations when applied to potentially curable locally advanced squamous cell carcinoma of the head and neck (SCCHN). [¹⁸F]fluorodeoxyglucose-positron emission tomography (PET) scan may be useful in assessing treatment response and predicting patient outcome.

PATIENTS AND METHODS

We studied patients with previously untreated stages III-IVb SCCHN treated with primary concurrent chemoradiotherapy on five prospective clinical trials. Response was assessed by clinical exam, computed tomography (CT), and PET portions of combined PET-CT scan ∼8 weeks after completion of chemoradiotherapy.

RESULTS

Fifty-three patients were analyzed. Complete response (CR) was demonstrated in 42 patients (79%) by clinical exam, 15 (28%) by CT, and 27 (51%) by PET. CR as assessed by PET, but not as assessed by clinical exam or CT using RECIST, correlated significantly with progression-free status (PFS) (P < 0.0001). The 2-year PFS for patients with CR and without CR by PET was 93% and 48%, respectively (P = 0.0002).

CONCLUSIONS

A negative PET scan on combined PET-CT after chemoradiotherapy is a powerful predictor of outcome in patients receiving curative chemoradiotherapy for SCCHN. PET-CT is indicated for response evaluation in this setting to improve the accuracy of post-treatment assessment by CT.

Theory of planned behavior and multivitamin supplement use in Caucasian college females

The objective of this study was to identify predictors of the use of multivitamin supplements (MVS) among Caucasian college females utilizing the Theory of Planned Behavior (TPB). Variables of the TPB and the self-reported use of multivitamin supplements were measured by two separate surveys within 1 week with a convenience sample of 96 Caucasian college student females. Two attitudinal beliefs and one control belief significantly predicted behavioral intention to use multivitamin. A belief that taking multivitamin supplements helps to feel and look good was the most important predictor of the use of multivitamin supplements. EDITORS' STRATEGIC IMPLICATIONS: Findings from this study, although in need of replication, suggest that prevention campaigns would be more successful if messages used to reach these females were consistent with perceived beliefs regarding benefits of using MVS. More broadly, TPB appears to offer a useful framework for understanding or predicting behavior based on psychological constructs theorized to influence behavior.

Role of limited parotidectomy in management of pleomorphic adenoma

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed.

As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

Influence of range of motion in resistance training in women: early phase adaptations

The purpose of this investigation was to compare partial range-of-motion versus full range-of-motion training in the development of maximal upper-body strength in women. A 1 repetition maximum bench press was used as the criterion measurement. A 10-week, 2 days per week training regimen was used. Subjects were divided into 3 groups. Group 1 (n = 13) trained with 3 full range-of-motion sets on the bench press. Group 2 (n = 8) trained with 3 partial range-of-motion sets. Group 3 (n = 8), serving as a quasi-control, trained with an equal combination of partial and full range-of-motion sets. Findings indicated that each of the 3 groups experienced an increase in bench-press strength from pre- to posttest. In addition, a statistically significant difference was found between the full range-of-motion group and the partial and mixed groups (p < 0.5). This finding suggests that lifting through a full range of motion was superior to the other training regimens used in this study. However, this investigation also indicated that the partial technique had a positive effect on strength across time within the parameters of this study.

An analysis of full range of motion vs. partial range of motion training in the development of strength in untrained men

The purpose of this investigation was to compare partial range of motion versus full range of motion training in the development of maximal strength. The bench press was used as the criterion measurement. The study was conducted over a 10-week period with training sessions occurring twice per week. Subjects were divided into 3 groups. Group 1 (N = 11) trained with 3 full range of motion sets on the bench press. Group 2 (N = 15) trained with 3 partial range of motion sets. A partial repetition was defined as one that is beyond the sticking point 2 to 5 inches from full extension of the elbows. Group 3 (N = 30) trained with a combination of partial and full range of motion sets. All subjects were pre- and posttested on the bench press through a full range of motion using a 1 repetition maximum. Each of the 3 groups demonstrated statistically significant increases in strength from pre- to posttest. No differences were found between groups. These findings appear to suggest that partial range of motion training can positively influence the development of maximal strength. Therefore, those involved in the strength and conditioning profession can confidently including this method as an adjunct to their normal training protocols when working with individuals similar to those found in this investigation. It is suggested that additional research be conducted to further establish the effectiveness of partial range of motion training in developing maximal strength.

Using self-efficacy to predict weight loss among young adults

Many healthcare professionals support the idea that weight control and healthy eating should be emphasized early in a person's life to prevent obesity during middle and older adulthood. Unfortunately, although many weight loss programs are available to consumers, few are successful. Recently, constructs of behavioral theories have been integrated into weight loss programs and used to promote changes in health behaviors. In this study, methods used to increase self-efficacy for weight loss were incorporated into a 12-week program designed for weight loss promotion in young adults. Results found that as self-efficacy improved, eating habits improved and weight loss was greater. This study supports the hypothesis that using behavioral techniques to improve self-efficacy can be effective in weight loss promotion and can produce positive outcomes.

A comparative study of four serological tumor markers for the detection of breast cancer

Breast cancer is currently the third most common cause of cancer in the world. Circulating tumor antigens are often used as a minimally invasive tool for noting breast cancer progression. The objective of this study was to compare four tumor antigens (CA 15-3, CA 27.29, alpha-fetoprotein [AFP], and carcinoembryonic antigen [CEA]) for their diagnostic efficacy in breast cancer patients. It was hypothesized that CA 15-3 would proved to be superior to CA 27.29, CEA, and AFP in assay performance. Tumor marker assays were performed according to the manufacturers' directions. Assays used in this study were CA 15-3 and CA 27.29 (Fujirebio Diagnostics/Centocor Inc.), AFP (Abbott Inc.), and CEA (Hybritech Inc.). A total of 554 patient samples were obtained from an area hospital, plus 200 healthy adult samples which were used for the determination of normal reference intervals. The patients included patients with no disease (184), with non-malignant disease (11), with breast cancer (87), and with other types of cancer (272). Diagnostic percent sensitivities for each marker were: CA 15-3 (63%), CA 27.29 (39%), CEA (22%), and AFP (22%). Diagnostic specificities for each marker were comparable, ranging from 80-88%. Analytical parameters were evaluated for the assays and compared favorably. We concluded that CA 15-3 was the best tumor antigen for use as a diagnostic aid and monitoring agent.

Management of swallowing in supraglottic and extended supraglottic laryngectomy patients

BACKGROUND

Aspiration of food and liquid following supraglottic and supracricoid laryngectomy has been documented and found to be the most frequent major postoperative complication that extends hospitalization. The advantages as well as disadvantages of discharging a patient with percutaneous endoscopic gastrostomy (PEG) placement and home therapy versus an aggressive in-hospital dysphagia management program remain controversial. The present investigation examines an aggressive in-patient postoperative dysphagia management program following decannulation.

METHODS

Twenty-one patients participated in a four-part dysphagia management program following decannulation: patient education, indirect therapy, swallowing evaluation, and nutrition education.

RESULTS

Eleven patients achieved functional swallowing goals prior to discharge with no reports of pneumonia or rehospitalization over a 3-month follow-up period. Six patients were discharged with a tracheostomy and duo tube; five of these patients were started on an oral diet the same day of decannulation. Four patients decannulated prior to discharge did not achieve functional swallowing.

CONCLUSION

Certain patients can achieve functional swallowing goals prior to discharge and avoid the cost and surgical placement of a PEG. This group required an additional 2 to 3 days of hospitalization; however, the usual and customary charges for aggressive dysphagia management in this group were exceeded by charges for PEG placement and in-home therapy according to pricing guidelines for the hospital where these patients were treated. Specific patient profiles of those who were unsuccessful relate to extent of surgery, ie, supraglottic + base of tongue (SUPRA + BOT) and supraglottic + vocal fold (SUPRA + VF) resection, and non-compliance. Complicated patients often require longer rehabilitation and may benefit from a PEG at the time of surgery.

Chemoradiation for metastatic SCCA: role of comorbidity

OBJECTIVES

A previous study of 371 patients with extracapsular spread (ECS) of cervical metastases from squamous cell carcinoma (SCCA) of the head and neck revealed a survival advantage for patients treated with adjuvant chemoradiation, compared with those treated with surgery and radiation or surgery alone. While all patients in the study were offered adjuvant chemotherapy, only 35% selected this option. Comorbidity was identified as a reason for declining chemotherapy. Recently, Piccirillo demonstrated that the Modified Medical Comorbidity Index (MMCI) is a valid instrument to classify and quantify severity of comorbidity. We applied this instrument to previously reported patients with ECS to determine 1) how comorbidity affected treatment selection, 2) whether the survival advantage of adjuvant chemoradiation persisted after controlling for comorbidity, and 3) the impact of comorbidity on outcome.

STUDY DESIGN

This was a nonrandomized, retrospective study.

METHODS

Patients in the initial study underwent resection of the primary tumor and neck dissection. Eligible patients elected to receive chemoradiation, radiation, or no further treatment. Comorbidity scores were assigned according to the MMCI. Data were analyzed according to disease-specific survival and overall survival.

RESULTS

The study population consisted of 330 patients. More severe comorbidity was related to higher overall mortality rates after controlling for treatment. Adjuvant chemoradiation resulted in improved disease-specific and overall survival compared with adjuvant radiation after adjusting for severity of comorbidity.

CONCLUSIONS

These results substantiate the benefits of adjuvant chemoradiation for patients with SCCA of the head and neck. Furthermore, these results reinforce the importance of comorbidity as a prognostic indicator for this population of patients.

Numerical studies of backscattering enhancement of electromagnetic waves from two-dimensional random rough surfaces with the forward-backward/novel spectral acceleration method

The forward-backward method with a novel spectral acceleration algorithm (FB/NSA) has been shown to be a highly efficient O(Ntot) iterative method of moments, where Ntot is the total number of unknowns to be solved, for the computation of electromagnetic (EM) wave scattering from both one-dimensional and two-dimensional (2-D) rough surfaces. The efficiency of the method makes studies of backscattering enhancement from moderately rough impedance surfaces at large incident angles tractable. Variations in the characteristics of backscattering enhancement with incident angle, surface impedance, polarization, and surface statistics are investigated by use of the 2-D FB/NSA method combined with parallel computing techniques. The surfaces considered are Gaussian random processes with an isotropic Gaussian spectrum and root-mean-square surface heights and slopes ranging from 0.5 lambda to lambda and from 0.5 to 1.0, respectively, where lambda is the EM wavelength in free space. Incident angles ranging from normal incidence up to 70 degrees are considered in this study. It is found that backscattering enhancement depends strongly on all parameters of interest. America

Surgical treatment of squamous cell carcinoma of the base of tongue

INTRODUCTION

Squamous cell carcinoma (SSC) of the tongue base has historically been shown to be associated with a poor prognosis. We reviewed our experience with primary surgery followed by postoperative radiation therapy (XRT) to determine the impact of our treatment protocols on outcome.

METHODS

We retrospectively reviewed the records of all patients presenting to the University of Pittsburgh with previously untreated SSC of the tongue base between 1980-1997. Patients who were treated nonoperatively were excluded from analysis. Surgical excision of the primary was performed with ipsilateral neck dissection. The contralateral neck was dissected when the primary lesion was located in the midline or for clinically positive contralateral neck nodes. Postoperatively, most patients (93%) received XRT to the primary site and neck. Adjuvant chemotherapy was offered if histologic signs of aggressive behavior were identified (multiple nodes or extracapsular spread).

RESULTS

Of 87 patients identified, 39 (45%) were initially seen with T1 or T2 tumors. Seventy-nine patients (91%) were initially seen with stage III or IV disease. Contralateral neck dissection was performed in 36 patients (41%). Metastatic disease was demonstrated in 84% of ipsilateral neck nodes and in 47% of contralateral neck nodes. Occult metastases were found in 61% of clinically N0 necks. Local recurrence occurred in 5 patients, regional recurrence occurred in 12 patients, and distant metastases developed in 22 patients. Overall and disease-specific survival rates at 5 years for all patients were 49% and 56%, respectively. The 5 year disease-specific survival rates for stage I, stage II, stage III, and stage IV disease were 100%, 86%, 62%, and 48%. The 5-year disease-specific survival rate was 88% for T1 lesions, 64% for T2 lesions, 58% for T3 lesions, and 30% for T4 lesions (p <.05, log-rank test).

CONCLUSIONS

Surgical treatment of SCC of the tongue base is highly effective in achieving local disease control and disease-free survival for early lesions. Because both functional outcome and survival are poor after surgical treatment of advanced lesions, we now offer brachytherapy with XRT or participation in a combined chemoradiation protocol rather than primary surgical therapy to patients with advanced disease. Prospective studies are needed to compare the effect of these organ-preserving therapies with traditional combined surgery and XRT to determine the effect on functional outcome and quality of life.

Nasal T-cell lymphoma: case report and review of diagnostic features

A 73-year-old man was referred to us for evaluation of extensive nasal crusting and progressive erosion of the nasal midline structures. Clinical examination suggested that the patient had a T-cell lymphoma, a suspicion that was confirmed on immunohistochemical analysis. The patient was treated with combination chemo- and radiotherapy and exhibited a marked response. At the 14-month followup, he remained disease-free.

Proposal of standardization on screening tests for detection of distant metastases from head and neck cancer

A standardized approach to screening for distant metastases must be flexible. This reflects the fact that the issues involved have not been adequately studied to allow evidence-based recommendations. Effective and responsible application of screening for distant metastasis would improve our ability to council patients regarding important therapeutic decisions. It would also have important consequences on healthcare economics. Screening recommendations should reflect the stage of the primary tumor and the histologic cell type because these two parameters most clearly correlate with the risk for distant metastases. The most commonly encountered distant metastases are pulmonary. The most sensitive validated screening technique is just computed tomography (CT). Advanced technologies such as simultaneous positron emission tomography/CT may replace these prior technologies in the near future. Recommendations for routine screening following curative treatment are subjective at this time. Careful history and physical examination remains the basis for the follow-up evaluation. The sensitivity and cost effectiveness of imaging studies in this setting remains unstudied and contentious.

The role of topical antibiotic prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction

OBJECTIVES/HYPOTHESIS

Patients undergoing contaminated head and neck surgery with flap reconstruction have wound infection rates of 20% to 25% with parenteral antibiotic prophylaxis. Studies suggest that perioperative antimicrobial mouthwash reduces oropharyngeal flora and may prevent wound infections. We hypothesized that the addition of topical antibiotics to a parenteral prophylactic regimen would reduce the incidence of wound infection in these high-risk patients.

STUDY DESIGN

We performed a randomized, prospective clinical trial.

METHODS

Patients received either 1) parenteral piperacillin/tazobactam (3.375 g every 6 hours for 48 h) or 2) parenteral piperacillin/tazobactam plus topical piperacillin/tazobactam administered as a mouthwash immediately before surgery and once a day for 2 days postoperatively, with piperacillin/tazobactam added to the intraoperative irrigation solution. The wounds of all patients were evaluated daily using predefined objective criteria.

RESULTS

Sixty-two patients met inclusion criteria and were enrolled in the study. The overall wound infection rate was 8.1% (95% confidence interval [CI], 2.7%-17.8%). Two of 31 patients (6.4%) who received parenteral antibiotics alone developed a wound infection compared with 3 of 31 patients (9.7%) randomly assigned to receive topical plus parenteral antibiotics. This difference was not statistically significant (P = >.05). Infection rate was not associated with flap type (rotational vs. free tissue transfer), mandibular reconstruction, age, gender, tumor site, stage, surgical duration, or blood loss.

CONCLUSIONS

These results suggest that piperacillin/tazobactam is a highly effective antibiotic for prevention of wound infection in patients undergoing flap reconstruction following contaminated head and neck surgery. However, the addition of topical piperacillin/tazobactam does not appear to enhance the prophylactic benefit of parenteral antibiotics alone.

Prevention of radiation-induced mucositis

Radiation-induced mucositis is an important dose-limiting acute side effect associated with the treatment of tumors of the upper aerodigestive tract. The toxicity of radiation therapy increases with prior or concurrent administration of some chemotherapeutic agents. Pretreatment eradication of infection, maintenance of oral hygiene, and treatment breaks, as necessary, have been the mainstay of the therapeutic options for patients with radiation-induced mucositis. Recent research has begun to clarify the pathophysiology of radiation-induced mucositis. This suggests that new, more effective agents for both prevention and treatment may be forthcoming in the near future. Currently, no highly effective and widely accepted prevention or treatment exists.

Selective neck dissection in the management of the clinically node-negative neck

OBJECTIVE

To evaluate the efficacy of the selective neck dissection (SND) in the management of the clinically node-negative neck.

STUDY DESIGN

Case histories were evaluated retrospectively.

METHODS

The results of 300 neck dissections performed on 210 patients were studied.

RESULTS

The primary sites were oral cavity (91), oropharynx (30), hypopharynx (16), and larynx (73). Seventy-one necks (23%) were node positive on pathological examination. The number of positive nodes varied from 1 to 9 per side. Of necks with positive nodes, 17 (24%) had extracapsular spread. The median follow-up was 41 months. Recurrent disease developed in the dissected neck of 11 patients (4%). Two recurrences developed outside the dissected field. The incidence of regional recurrences was similar in patients in whom nodes were negative on histological examination (3%) when compared with patients with positive nodes without extracapsular spread (4%). In contrast, regional recurrence developed in 18% of necks with extracapsular spread. This observation was statistically significant. Patients having more than two metastatic lymph nodes had a higher incidence of recurrent disease than the patients with carcinoma limited to one or two nodes. Recurrence rate in the pathologically node positive (pN+) necks was comparable to recurrence in those pathologically node negative (pNO) necks in the patients who did not have irradiation.

CONCLUSION

SND is effective for controlling neck disease and serves to detect patients who require adjuvant therapy.

Process versus content in eyewitness metamemory monitoring

Three studies (Ns = 200, 135, and 187 college undergraduates) contrasted process versus content accounts of eyewitness metamemory monitoring. Subjective vividness, a cue related to memory content, was a better predictor of confidence and accuracy than were cues related to the retrieval process. Participants who were asked to recall, rather than recognize, event details displayed greater insight into accuracy, primarily because vividness was a more valid accuracy cue under recall conditions. Results reinforce the value of recall-based protocols for eliciting eyewitness testimony and suggest some specific conditions (e.g., yes-no recognition) under which investigators should be especially cautious in relying on confidence to infer accuracy. In addition, results point to a general framework for understanding moderating effects on eyewitness metamemory accuracy.

More aggressive behavior of squamous cell carcinoma of the anterior tongue in young women

OBJECTIVE

To review the combined experience from two large medical centers in treating young female patients with anterior tongue cancer to determine the clinical course of this unique subset of patients.

STUDY DESIGN

Retrospective study.

METHODS

Seventeen female patients less than 40 years of age (group A) and 17 older patients, both male and female, greater than 40 years of age (group B) who had treatment for invasive squamous cell carcinoma of the anterior tongue were studied. The charts were reviewed for the clinical staging, treatment, and outcome of each patient. The disease-free survival and recurrence rates were compared between the two cohorts.

RESULTS

The mean disease stage between the groups was II. The survival analysis showed a significant difference between the two groups in recurrences (group A = 65%, group B = 41%; P = .02). Further, of the patients who had recurrence, the young women did so significantly earlier in their disease course than the older patients (group A = 14 mo, group B = 40 mo; P < .05). Although the survival differences did not reach statistical significance (P = .15), the power of the study was low (power = 0.26) resulting in a high-level type II error.

CONCLUSION

These data suggest that young women with squamous cell carcinoma of the anterior tongue have significantly higher rates of recurrent disease and the interval to recurrence is significantly shorter than in older patients. Further investigation is warranted until a statistically significant cohort is accrued; until that time, these patients warrant an aggressive initial treatment and close surveillance for recurrence.

Incidence of unsuspected metastases in lateral cervical cysts

OBJECTIVE

Solitary cystic squamous cell carcinoma metastases may be difficult to distinguish clinically from a benign cervical cyst. We sought to identify the incidence of solitary cystic squamous cell carcinoma metastasis in patients presenting with apparently benign cervical cysts.

STUDY DESIGN

Retrospective review.

METHODS

The records of all patients who presented with isolated lateral cervical cysts between 1983 and 1999 were reviewed. Patients with a clinically apparent primary malignancy, a history of head and neck cancer, a history of irradiation, or age less than 18 years were excluded from analysis, as were patients with a histological diagnosis of nonsquamous cell malignancy or those without a final histological diagnosis.

RESULTS

One hundred twenty-one adult patients presented with an initial diagnosis of lateral cervical cyst. Metastatic squamous cell carcinoma was demonstrated histologically after surgical excision in 12 patients (9.9%). The incidence of malignancy was significantly greater in patients greater than 40 years of age (23.5%, P < .0001). Results of preoperative fine-needle aspiration (FNA) were negative for malignancy in five cases of metastatic squamous cell carcinoma. Panendoscopy with directed biopsies revealed an occult primary in the base of tongue in three patients, tonsil in one patient, and nasopharynx in one. No primary was found in six patients, despite repeated examinations and close follow-up.

CONCLUSIONS

Solitary cervical cysts in patients older than 40 years of age should be presumed to be carcinoma until proven otherwise. A negative FNA result may be misleading, because of hypocellularity of the cyst fluid. Excisional biopsy should be undertaken with provisions made for frozen-section analysis of the specimen and contingency panendoscopy with directed biopsies of Waldeyer's ring if frozen-section histological examination reveals malignancy.

Process versus content in eyewitness metamemory monitoring

Three studies (Ns = 200, 135, and 187 college undergraduates) contrasted process versus content accounts of eyewitness metamemory monitoring. Subjective vividness, a cue related to memory content, was a better predictor of confidence and accuracy than were cues related to the retrieval process. Participants who were asked to recall, rather than recognize, event details displayed greater insight into accuracy, primarily because vividness was a more valid accuracy cue under recall conditions. Results reinforce the value of recall-based protocols for eliciting eyewitness testimony and suggest some specific conditions (e.g., yes-no recognition) under which investigators should be especially cautious in relying on confidence to infer accuracy. In addition, results point to a general framework for understanding moderating effects on eyewitness metamemory accuracy.

Early detection and treatment of skin cancer

The incidence of skin cancer is increasing by epidemic proportions. Basal cell cancer remains the most common skin neoplasm, and simple excision is generally curative. Squamous cell cancers may be preceded by actinic keratoses-premalignant lesions that are treated with cryotherapy, excision, curettage or topical 5-fluorouracil. While squamous cell carcinoma is usually easily cured with local excision, it may invade deeper structures and metastasize. Aggressive local growth and metastasis are common features of malignant melanoma, which accounts for 75 percent of all deaths associated with skin cancer. Early detection greatly improves the prognosis of patients with malignant melanoma. The differential diagnosis of pigmented lesions is challenging, although the ABCD and seven-point checklists are helpful in determining which pigmented lesions require excision. Sun exposure remains the most important risk factor for all skin neoplasms. Thus, patients should be taught basic "safe sun" measures: sun avoidance during peak ultraviolet-B hours; proper use of sunscreen and protective clothing; and avoidance of suntanning.

Family planning services and programmes in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on the family planning services and programmes in the Region. Data were collected using a questionnaire which explored the following areas: the presence of population or family planning policies and family planning activities, the family planning services available, promotional and educational activities on family planning, quality assurance, family planning data collection, analysis and dissemination, and the use of such information. The results indicate that 13 of the countries have national policies on population and family planning but even in those that do not, family planning services are widely available. The scope of the services provided varied. There is still a need to implement or strengthen family planning programmes in the Region, a need which is recognized by the countries themselves.

Primary surgery as treatment for early squamous cell carcinoma of the tonsil

BACKGROUND

The management of tonsil carcinoma has gradually evolved such that the literature is replete with outcome summaries of this disease treated with primary RT and chemotherapy. Recently there have been no reports of patient outcomes with primary surgical therapy. Nonsurgical treatment is warranted when tumors are unresectable or if the patient refuses surgery. Our policy has been to treat operable squamous cell carcinoma (SCCA) of the tonsil with surgery. The decision to use adjuvant therapy is based on the surgical and histologic findings. We herein report our results with this treatment protocol.

METHODS

A retrospective review of 162 patients with SCCA of the tonsil was performed. Eighty-four patients were treated with surgery, which was followed by RT and/or chemotherapy if histologic signs of aggressive behavior were identified. Patients were followed 2 to 15 years after treatment.

RESULTS

Of the 9 patients with stage I disease, 89% are without evidence of recurrent disease and 91% of patients with stage II tonsil cancers are also disease free. The survival rates for stage III and stage IV cancer patients are 79 and 52%, respectively.

CONCLUSION

Our data suggest that patients with early tonsil cancer can be effectively treated with surgery. Surgery allows pathologic staging so that patients with advanced tumors can be treated with adjuvant therapy.

Cancer of the tongue in patients less than forty

INTRODUCTION

It is the opinion of many surgeons that the biologic potential of cancer that develops in young people is different compared with older patients. Prior reports on small series of patients addressing this issue have inadequate statistical power to resolve the question.

METHODS

By use of the techniques of meta-analysis, patients less than 40 years old who had undergone treatment of squamous cell carcinoma (SCC) of the oral tongue were examined. Twenty-eight patients who were encountered in the Department of Otolaryngology, University of Pittsburgh School of Medicine, and 94 patients were identified in the literature for a total of 122 patients <40 years old. A control group of 150 patients, aged 40 years and older treated for SCC of the oral tongue between 1982 and 1994 was identified.

RESULTS

Three-year disease-free survival in the group of patients aged less than 40 was 53.3% compared with 3-year disease free survivorship of 55.0% in the older cohort of patients.

CONCLUSION

These data strongly suggest that the outcomes of treatment for SCC of the oral tongue in young patients are similar compared with patients older than 40 with similar extent of disease.

Risk factors for local recurrence of adenoid cystic carcinoma: the role of postoperative radiation therapy

PURPOSE

Postoperative radiation therapy is often advocated in the treatment of patients with adenoid cystic carcinoma (ACC) of the head and neck. A retrospective analysis was performed to determine prognostic factors for local recurrence after surgery and to examine the role of postoperative radiation therapy.

MATERIALS AND METHODS

A retrospective analysis of 58 patients undergoing surgery for ACC of the head and neck at the University of Pittsburgh Medical Center from 1974 to 1994 was performed. Patients were followed up for a minimum of 24 months for the development of recurrent disease. The association of recurrence was correlated with clinical factors (age, sex, site, and stage); postoperative treatment (radiation therapy v no radiation); and pathologic variables (grade, margins of resection, and perineural invasion), and appropriate statistical analysis was performed.

RESULTS

Recurrent disease developed in 59% of patients, despite the addition of postoperative radiation therapy in 83% of patients. Tumor site was the single most important factor for the development of locally recurrent disease and was correlated with primary tumor stage and resection margins. Local recurrence rates were decreased (P = .07) in patients with negative surgical margins who were irradiated.

CONCLUSIONS

Larger perspective randomized trials are necessary to evaluate the efficacy of postoperative radiation, and new treatments need to be investigated to improve local control rates for ACC of the head and neck.

Skin metastases from head and neck squamous cell carcinoma: incidence and impact

BACKGROUND

Squamous cell carcinoma (SCC) of the upper aerodigestive tract rarely metastasizes to the skin. This study was designed to review the incidence of skin metastases, to identify associated risk factors, and to investigate the prognostic significance of skin metastases.

METHODS

A cohort of 2491 patients treated for SCC originating in the upper aerodigestive tract were evaluated retrospectively. Patients who developed skin metastases were evaluated with respect to tumor stage, treatment, and outcome. Patients with skin metastases were compared with patients who developed distant metastases at other sites and with those who did not develop distant metastases.

RESULTS

Skin metastases developed in 19 (0.763%) patients. The median time to occurrence was 6 months. Ninety percent of patients died of disease within a median of 3 months (1 to 16 months) following diagnosis. The development of skin metastasis is most closely related to the presence of two or more cervical metastases and/or extracapsular spread of tumor in the cervical metastases. Similar risk factors were identified for the development of distant metastases to other sites.

CONCLUSION

Metastasis to skin is a rare occurrence which has prognostic significance similar to distant metastasis to other areas.

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract

BACKGROUND

Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated.

METHODS

A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome.

RESULTS

Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months.

CONCLUSIONS

ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Spontaneous ex vivo apoptosis of peripheral blood mononuclear cells in patients with head and neck cancer

Proportions of apoptotic (TUNEL+) peripheral blood mononuclear cells (PBMCs) were measured by flow cytometry in patients with head and neck cancer and normal controls at the time of blood draws (0 time) and after 24-h incubation. PBMCs were incubated at 37 degrees C in medium (spontaneous apoptosis) and in the presence of CH-11 antibody (anti-Fas) or tumor necrosis factor (TNF)-alpha, both capable of inducing DNA fragmentation in activated T cells expressing the TNF family of receptors. PBMCs obtained from the patients had significantly higher (P < 0.0001) proportion of apoptotic cells than PBMCs of controls at 0 time as well as after 24-h incubation. Ex vivo apoptosis included all subsets of PBMCs: CD3+ T cells, CD16+ CD56+ natural killer cells, CD19+ B cells, and CD14+ monocytes, as determined by two-color flow cytometry. However, T cells represented the largest PBMC subset undergoing apoptosis, and lymphocytes rather than monocytes were the major TUNEL+ PBMC population. Among T cells, the level of spontaneous ex vivo apoptosis was nearly as high as that of CH-11 antibody-induced or TNF-alpha-induced apoptosis, indicating that activated Fas+ and TNFR1+ T cells were preprogrammed in vivo to die. Also, elevated levels of spontaneous apoptosis at time 0 in patients with head and neck cancer (P < 0.0001) indicated that a higher fraction of PBMCs was undergoing apoptosis in vivo in patients than controls. Together, the data suggest that an increased rate of turnover of lymphocytes is associated with cancer and may be responsible for functional lymphocyte imbalance, even in treated patients who have no evident disease.

Determination of olanzapine in human breast milk by high-performance liquid chromatography with electrochemical detection

A reversed-phase high-performance liquid chromatographic-electrochemical assay was developed and validated for the quantification of olanzapine in human breast milk. The assay involved a solid-phase extraction (SPE) of olanzapine and its internal standard on a Bond Elut Certify LRC mixed-mode cartridge. After conditioning of the SPE cartridge, human milk (1 ml) was passed through the cartridge. The cartridge was washed with five separate washing steps to remove endogenous compounds, and the analytes were eluted with ethyl acetate-ammonium hydroxide (98:2, v/v) solution. The eluate was evaporated to dryness (gentle stream of nitrogen at 40 degrees C), and the residue was dissolved in mobile phase. The extract was injected onto a YMC basic column (150 mmx4.6 mm I.D., 5 microm particle size) at a flow-rate of 1 ml/min. A mixture of 75 mM phosphate buffer, pH 7.0-acetonitrile-methanol (48:26:26, v/v/v) was used as the mobile phase. Standard curves with a lower limit of quantitation of 0.25 ng/ml of olanzapine were linear (r2> or =0.9992) over a range of 0.25-100 ng/ml. Based on the analysis of quality control (QC) samples, the average inter-day accuracy (RE) was 99.0% with an average precision (CV) of 6.64% over the entire range. The stability of olanzapine in human milk was established after three freeze-thaw-heat cycles and storage at -70 degrees C for 10 months. The validated method was used to measure olanzapine concentrations in human milk during a clinical trial.

Allergic rhinitis and rhinosinusitis. Is there a connection between allergy and infection?

Each year allergic rhinitis and rhinosinusitis account for millions of office visits and billions of dollars spent on prescription and nonprescription drugs. Although the causes and symptoms of these two ailments differ, there is evidence that they are linked. The authors explain how effective control of allergy symptoms can reduce the incidence and severity of rhinosinusitis.

Detection of intracellular tumor necrosis factor alpha in stimulated fetal cells

BACKGROUND

It is unknown if immature fetal cells produce tumor necrosis factor (TNF) alpha in the same manner that adult cells do. The aim of this study was to determine the feasibility of early detection of intracellular TNF produced by circulating human monocytes (Mo) and lymphocytes (Ly) using flow cytometry and to compare the stimulation profiles of mature and fetal cells.

MATERIAL AND METHODS

Fetal umbilical cord blood (n = 10) and adult volunteer blood (n = 10) were obtained. In vitro stimulation with endotoxin (LPS) and ionomycin-PMA was performed. Brefeldin A was added to prevent extracellular transport of TNF. Cell type was determined by using CD-14 marker separating monocyte and lymphocyte populations. Anti-human TNF monoclonal antibody was used to detect intracellular TNF by flow cytometry analysis.

RESULTS

Thirty to sixty thousand cells were analyzed per sample. Average TNF expression of stimulated fetal Mo was 28.2%, and that of fetal Ly was only 1.1%. Adult stimulated Ly had an average TNF expression of 31.9%, and adult Mo, 29.6% (P < 0.05 for adult Ly vs fetal Ly).

CONCLUSION

TNF flow cytometry analysis allows assessment of individual cell types and their ability to produce that cytokine. Fetal cells are able to produce TNF when stimulated, but the stimulation profile of Ly differs from that of adult samples. This observation may be of clinical importance in evaluating the response of immature cells to a septic stimulus. Flow cytometry is reliable, reproducible, quick, and easily obtained from a small sample of peripheral blood. Clinical use will be applicable once appropriate controls are developed, as reported in this study.

Squamous cell carcinoma of the sinonasal tract invading the orbit

OBJECTIVE/HYPOTHESIS

The treatment of squamous cell carcinoma (SCC) of the sinonasal tract has evolved from routine exenteration of the orbital contents to sparing of the orbit when the SCC does not transgress the periorbita. Nonetheless, the influence of this change in treatment over the rate of local recurrence or survival has not been clearly elucidated. The objective was to ascertain whether orbital sparing surgery for the treatment of SCC of the paranasal sinuses influences the rate of local recurrence or survival.

STUDY DESIGN

This is a retrospective study of patients presenting with SCC arising in the sinonasal tract, treated primarily at the University of Pittsburgh Medical Center from 1977 to 1990, including meta-analysis of the English literature regarding SCC of the sinonasal tract.

METHODS

Review of medical records regarding demographics, histology, extension of tumor, pathologic results, type of surgery, adjunctive therapy, and outcome. Articles for meta-analysis were identified by Medline search and cross-referencing.

RESULTS

Fifty-eight patients with orbital invasion, including bone and/or soft tissue invasion, were included in the study. Patients presenting with invasion of the bony orbit without soft tissue invasion were treated with maxillectomy and/or ethmoidectomy, sparing the orbital contents. Patients presenting with invasion of the orbital bones and soft tissues were treated with ethmoidectomy or maxillectomy, including orbital exenteration. At 3 years' follow-up, 52% of the patients whose orbit was exenterated were alive and without evidence of disease, compared with 59% of the patients whose orbit was spared. This difference was not statistically significant. Similarly, the rate of local recurrence was not statistically significant (P > .05). A meta-analysis of the literature revealed similar results.

CONCLUSIONS

Our data suggest that sparing of the soft tissues of the orbit when the periorbita has not been transgressed by SCC does not downgrade the rate of cure or local control.

Clinical significance of decreased zeta chain expression in peripheral blood lymphocytes of patients with head and neck cancer

Patients with squamous cell carcinoma of the head and neck (SCCHN) frequently have impaired immune responses. Alterations in T-cell receptor-associated signaling molecules in tumor-infiltrating as well as circulating lymphocytes have been reported in these patients. Using quantitative flow cytometry analysis, we have demonstrated that expression of the zeta chain is significantly decreased relative to normal controls in both CD8+ and CD4+ T cells as well as CD3- CD56+ CD16+ natural killer cells in the peripheral blood of patients with SCCHN who, as a result of previous therapies, have no evident disease. Patients with a more aggressive type of SCCHN and those who experienced a recurrence or had a second primary cancer within the last 2 years of the study had the lowest zeta chain expression. In addition, SCCHN patients showed a significantly greater spontaneous ex vivo apoptosis, as measured by a terminal deoxynucleotide transferase-mediated dUTP nick end labeling assay, in PBMCs, compared to normal controls. The observed decreased expression of zeta in T and natural killer cells coincided but did not directly correlate with significantly increased spontaneous apoptosis of lymphocytes obtained from treated patients with no evident disease. The results suggest that in patients with SCCHN, zeta chain defects and lymphocyte apoptosis are manifestations of long-lasting negative effects of tumor on the immune system.