Development and evaluation of ultrasound image tracking technology based on Mask R-CNN applied to respiratory motion compensation system

Background

For respiration induced tumor displacement during a radiation therapy, a common method to prevent the extra radiation is image-guided radiation therapy. Moreover, mask region-based convolutional neural networks (Mask R-CNN) is one of the state-of-the-art (SOTA) object detection frameworks capable of conducting object classification, localization, and pixel-level instance segmentation.

Methods

We developed a novel ultrasound image tracking technology based on Mask R-CNN for stable tracking of the detected diaphragm motion and applied to the respiratory motion compensation system (RMCS). For training Mask R-CNN, 1800 ultrasonic images of the human diaphragm are collected. Subsequently, an ultrasonic image tracking algorithm was developed to compute the mean pixel coordinates of the diaphragm detected by Mask R-CNN. These calculated coordinates are then utilized by the RMCS for compensation purposes. The tracking similarity verification experiment of mask ultrasonic imaging tracking algorithm (M-UITA) is performed.

Results

The correlation between the input signal and the signal tracked by M-UITA was evaluated during the experiment. The average discrete Fréchet distance was less than 4 mm. Subsequently, a respiratory displacement compensation experiment was conducted. The proposed method was compared to UITA, and the compensation rates of three different respiratory signals were calculated and compared. The experimental results showed that the proposed method achieved a 6.22% improvement in compensation rate compared to UITA.

Conclusions

This study introduces a novel method called M-UITA, which offers high tracking precision and excellent stability for monitoring diaphragm movement. Additionally, it eliminates the need for manual parameter adjustments during operation, which is an added advantage.

Effectiveness of Stereotactic Ablative Radiotherapy for Systemic Therapy Respondents with Inoperable Pulmonary Oligometastases and Oligoprogression

Stereotactic ablative radiotherapy (SABR) may improve survival in patients with inoperable pulmonary oligometastases. However, the impact of pulmonary oligometastatic status after systemic therapy on SABR outcomes remains unclear. Hence, we investigated the outcomes of SABR in 45 patients with 77 lung tumors and the prognostic value of pulmonary oligoprogression. Eligibility criteria were pulmonary oligometastases (defined as ≤5 metastatic lung tumors), controlled extrapulmonary disease (EPD) after front-line systemic therapy, SABR as primary local treatment for inoperable pulmonary metastases, and consecutive imaging follow-up. Oligometastatic lung tumor was classified into controlled or oligoprogressive status. Overall survival (OS), in-field progression-free survival (IFPFS), out-field progression-free survival (OFPFS), and prognostic variables were evaluated. With 21.8 months median follow-up, the median OS, IFPFS, and OFPFS were 28.3, not reached, and 6.5 months, respectively. Two-year OS, IFPFS, and OFPFS rates were 56.0%, 74.2%, and 17.3%, respectively. Oligoprogressive status (p = 0.003), disease-free interval < 24 months (p = 0.041), and biologically effective dose (BED₁₀) < 100 Gy (p = 0.006) were independently associated with inferior OS. BED₁₀ ≥ 100 Gy (p = 0.029) was independently correlated with longer IFPFS. Oligoprogressive status (p = 0.017) and EPD (p = 0.019) were significantly associated with inferior OFPFS. Grade ≥ 2 radiation pneumonitis occurred in four (8.9%) patients. Conclusively, SABR with BED₁₀ ≥ 100 Gy could provide substantial in-field tumor control and longer OS for systemic therapy respondents with inoperable pulmonary oligometastases. Oligoprogressive lung tumors exhibited a higher risk of out-field treatment failure and shorter OS. Hence, systemic therapy should be tailored for patients with oligoprogression to reduce the risk of out-field treatment failure. However, in the absence of effective systemic therapy, SABR is a reasonable alternative to reduce resistant tumor burden.

Ex Vivo Expanded Circulating Tumor Cells for Clinical Anti-Cancer Drug Prediction in Patients with Head and Neck Cancer

Simple Summary

The conventional methods that seek to predict clinical treatment response are based on the number of circulating tumor cells (CTCs) present in liquid biopsies or genetic profiling of extracted CTCs. This paper presents a novel process by which CTCs can be extracted from blood samples taken from head and neck cancer patients and then expanded ex vivo to form organoids that can be tested with a panel of anti-cancer treatments. The resulting drug sensitivity profiles derived from cisplatin treatment of organoids were subsequently found to correlate with clinical treatment response to cisplatin in patients. CTCs extracted from liquid biopsies for ex vivo expansion negates the need for complicated and potentially risky biopsies of tumor material, thereby supporting the application of this procedure for checkups and treatment monitoring.

Abstract

The advanced-stage head and neck cancer (HNC) patients respond poorly to platinum-based treatments. Thus, a reliable pretreatment method for evaluating platinum treatment response would improve therapeutic efficiency and outcomes. This study describes a novel strategy to predict clinical drug responses in HNC patients by using eSelect, a lab-developed biomimetic cell culture system, which enables us to perform ex vivo expansion and drug sensitivity profiling of circulating tumor cells (CTCs). Forty liquid biopsies were collected from HNC patients, and the CTCs were expanded ex vivo using the eSelect system within four weeks. Immunofluorescence staining confirmed that the CTC-derived organoids were positive for EpCAM and negative for CD45. Two illustrative cases present the potential of this strategy for evaluating treatment response. The statistical analysis confirmed that drug sensitivity in CTC-derived organoids was associated with a clinical response. The multivariant logistic regression model predicted that the treatment accuracy of chemotherapy responses achieved 93.75%, and the area under the curves (AUCs) of prediction models was 0.8841 in the whole dataset and 0.9167 in cisplatin specific dataset. In summary, cisplatin sensitivity profiles of patient-derived CTCs expanded ex vivo correlate with a clinical response to cisplatin treatment, and this can potentially underpin predictive assays to guide HNC treatments.

Chemoradiotherapy for Inoperable Carotid Body Leiomyosarcoma: A Case Report and Review of Literature

Vascular leiomyosarcoma is an extremely rare tumor and is associated with poor prognosis among leiomyosarcoma. Surgical resection remains the main treatment option. But outcome of definitive treatment with chemoradiotherapy in inoperable patients is not clear. Here, we report treatment and outcome of definitive chemoradiotherapy in a case of vascular leiomyosarcoma. A 64-year-old man with the initial presentation of pulsatile right neck mass was diagnosed with right carotid body leiomyosarcoma. He refused surgical intervention due to risk of carotid body injury and ischemic stroke. Successful tumor control was achieved with carboplatin-based concurrent chemoradiotherapy. Investigational liquid biopsy for circulating sarcoma cells was also performed to analyze drug sensitivity profile of this rare tumor. One year after treatment, the disease remained well controlled and there was no evidence of baroreflex failure or treatment-related late toxicities. To our best knowledge, this is the first case report of right carotid body leiomyosarcoma controlled with definitive concurrent chemoradiotherapy. The approach of personalized multi-modality treatment will be a focus of our future investigation.

A Combined Systemic Strategy for Overcoming Cisplatin Resistance in Head and Neck Cancer: From Target Identification to Drug Discovery

Simple Summary

The efficiency of cisplatin is limited by drug resistance in head–neck cancer (HNC) patients. In this study, we established a cisplatin resistance (CR) cell model, generated CR related transcriptome profiling, and combined application of bioinformatics methodology to discover a possible way to overcome CR. Analysis of the functional pathway revealed that mitotic division is a novel mechanism significantly contributing to CR. Spindle pole body component 25 (SPC25), a kinetochore protein, was overexpressed in CR cells and significantly correlated with worse HNC patient survival. The silencing of SPC25 increased cisplatin sensitivity and reduced cancer stemness property. Integration of CR transcriptome profiling and drug database discovered a natural extract compound, celastrol, possessing a potent cytotoxic effect in CR cells to reverse CR. Thus, we combined systemic strategies to demonstrated that a novel biological process (mitotic cell division), a hub gene (SPC25), and a natural compound (celastrol) as novel strategies for the treatment of refractory HNC.

Abstract

Cisplatin is the first-line chemotherapy agent for head and neck cancer (HNC), but its therapeutic effects are hampered by its resistance. In this study, we employed systemic strategies to overcome cisplatin resistance (CR) in HNC. CR cells derived from isogenic HNC cell lines were generated. The CR related hub genes, functional mechanisms, and the sensitizing candidates were globally investigated by transcriptomic and bioinformatic analyses. Clinically, the prognostic significance was assessed by the Kaplan–Meier method. Cellular and molecular techniques, including cell viability assay, tumorsphere formation assay, RT-qPCR, and immunoblot, were used. Results showed that these CR cells possessed highly invasive and stem-like properties. A total of 647 molecules was identified, and the mitotic division exhibited a novel functional mechanism significantly related to CR. A panel of signature molecules, MSRB3, RHEB, ULBP1, and spindle pole body component 25 (SPC25), was found to correlate with poor prognosis in HNC patients. SPC25 was further shown as a prominent molecule, which markedly suppressed cancer stemness and attenuated CR after silencing. Celastrol, a nature extract compound, was demonstrated to effectively inhibit SPC25 expression and reverse CR phenotype. In conclusion, the development of SPC25 inhibitors, such as the application of celastrol, maybe a novel strategy to sensitize cisplatin for the treatment of refractory HNC.

Tumor motion tracking based on a four-dimensional computed tomography respiratory motion model driven by an ultrasound tracking technique

Background

An ultrasound image tracking algorithm (UITA) was combined with four-dimensional computed tomography (4DCT) to create a real-time tumor motion-conversion model. The real-time position of a lung tumor phantom based on the real-time diaphragm motion trajectories detected by ultrasound imaging in the superior-inferior (SI) and medial-lateral (ML) directions were obtained.

Methods

Three different tumor motion-conversion models were created using a respiratory motion simulation system (RMSS) combined with 4DCT. The tumor tracking error was verified using cone-beam computed tomography (CBCT). The tumor motion-conversion model was produced by using the UITA to monitor the motion trajectories of the diaphragm phantom in the SI direction, and using 4DCT to monitor the motion trajectories of the tumor phantom in the SI and ML directions over the same time period, to obtain parameters for the motion-conversion model such as the tumor center position and the amplitude and phase ratios.

Results

The tumor movement was monitored for 90 s using CBCT to determine the real motion trajectories of the tumor phantom and using ultrasound imaging to simultaneously record the diaphragm movement. The absolute error of the motion trajectories of the real and estimated tumor varied between 0.5 and 2.1 mm in the two directions.

Conclusions

This study has demonstrated the feasibility of using ultrasound imaging to track diaphragmatic motion combined with a 4DCT tumor motion-conversion model to track tumor motion in the SI and ML directions. The proposed method makes tracking a lung tumor feasible in real time, including under different breathing conditions.

Effectiveness of stereotactic ablative radiotherapy in patients with advanced hepatocellular carcinoma unsuitable for transarterial chemoembolization

Background:

Stereotactic ablative radiotherapy (SABR) can deliver tumoricidal doses and achieve long-term control in early hepatocellular carcinoma (HCC). However, limited studies have investigated the safety and effectiveness of SABR in patients with advanced diseases that is unsuitable for transarterial chemoembolization (TACE).

Methods:

In this observational study, we reviewed the medical records of patients with Barcelona Clinic Liver Cancer (BCLC) stage C disease treated with linear accelerator-based SABR between 2008 and 2016. Their tumors were either refractory to TACE or TACE was contraindicated. Overall survival (OS), in-field progression-free survival (IFPFS), and out-field progression-free survival were calculated using Kaplan–Meier analysis. The Cox regression model was used to examine the effects of variables. Treatment-related toxicities were scored according to the Common Terminology Criteria for Adverse Events (version 4.03) and whether patients developed radiation-induced liver disease (RILD) after SABR.

Results:

This study included 32 patients. The mean maximal tumor diameter and tumor volumes were 4.7 cm and 135.9 ml, respectively. Patients received linear accelerator-based SABR with a median prescribed dose of 48 Gy (30–60 Gy) in three to six fractions. Based on the assessment of treatment response by using the Response Evaluation Criteria in Solid Tumors (version 1.1), 19% of patients achieved a complete response and 53% achieved a partial response. After a median follow-up of 18.1 months (4.0–65.9 months), 10, 19, and 9 patients experienced in-field failure, out-field hepatic recurrence, and extrahepatic metastases, respectively. The estimated 2-year OS and IFPFS rates were 54.4% and 62.7%, respectively. In a multivariate analysis, a pretreatment Cancer of the Liver Italian Program (CLIP) score of ⩾2 (p = 0.01) was a prognostic factor for shorter OS, and a biologically effective dose (BED) of < 85 Gy₁₀ (p = 0.011) and a Child–Pugh score of ⩾6 (p = 0.014) were prognostic factors for inferior IFPFS. In this study five and eight patients developed classic and nonclassic RILD, respectively.

Conclusions:

SABR can serve as a salvage treatment for patients with HCC with BCLC stage C disease unsuitable for TACE, in particular, in those with a baseline CLIP score of ⩽1. A BED₁₀ of ⩾85 Gy is an appropriate prescribed dose for tumor control. Because out-field relapse is the major cause of treatment failure, SABR in combination with novel systemic modalities should be investigated in future studies.

Abstract 3114: In vitro culture system for circulating tumor cell

Circulating tumor cells (CTCs) detection could be considered a real-time “liquid biopsy” approach and contains several advantages such as being minimally invasive, easy and safe to perform, multiple samples can be taken over time, better prognosis to indicate an elevated risk of metastases, improved therapy monitoring, and providing live disease status information. CTC analysis is a promising new diagnostic field for estimating the risk for metastatic relapse and metastatic progression in patients with cancer. However, the number of CTCs is very low so the establishment of cell culture from CTCs becomes the most challenging over the past year. In this study, we development a cost-effective and reproducible in vitro system for primary CTC cultures or established cell lines from CTCs. 8 CTC cell lines were generated from patients including breast cancer, small cell lung cancer, pancreatic cancer and expanded for more than one year. These cell lines exhibit the tissue-specific markers and also correlated with clinical treatment response from patients. This system provides an opportunity for broad applications of CTCs for personalized oncology and advancing precision medicine.

Citation Format: Chen Yin-Ju, Long-Sheng Lu, Hsin-Lun Lee, Lai-Lei Ting, Jeng-Fong Chiou. In vitro culture system for circulating tumor cell [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3114.

Piperlongumine inhibits cancer stem cell properties and regulates multiple malignant phenotypes in oral cancer

Piperlongumine (PL), a natural product of Piper longum, inhibits multiple malignant phenotypes. Therefore, the present study examined whether PL suppresses cancer stemness in oral cancer. The cellular effects of PL were determined by examining alterations in tumor sphere formation, cell migration, invasion, proliferation ability, chemosensitivity and radiosensitivity. Reverse transcription-quantitative polymerase chain reaction analysis and western blotting were performed in order to determine molecular expression levels. The present study revealed that PL inhibited cancer stem cell-forming ability and suppressed the expression of the stemness-related transcription factors SRY-Box 2, POU class 5 homeobox 1, and Nanog homeobox. However, it increased the expression of the differentiation marker cytokeratin 18. PL also suppressed cell migration and invasion, resulting in the elimination of the epithelial-mesenchymal transition. Furthermore, PL increased chemo- and radiosensitivity and suppressed tumor growth in vitro and in vivo. The results of the present study suggested that PL inhibits malignant phenotypes via the suppression of cancer stemness in oral cancer. Thus, PL may serve as an effective therapeutic agent for oral cancer.

Clinical parameters for predicting radiation-induced liver disease after intrahepatic reirradiation for hepatocellular carcinoma

BACKGROUND

Few data are available on the tolerance of reirradiation in patients with hepatocellular carcinoma (HCC). This study determined the clinical parameters contributing to the development of radiation-induced liver disease (RILD).

METHODS

We included 36 patients with HCC who received 2 courses of radiotherapy (RT) to the liver. Using α/β = 15 for tumor and α/β =8 for normal liver tissue for biologically equivalent doses in 2 Gy fractions, mean cumulative to the hepatic tumor and normal liver were 87.7 Gy15 and 31.1 Gy8, respectively. Hepatic toxicities were classified according to the Common Terminology Criteria for Adverse Events, Version 4.0. Clinical data, including liver function test results, radiological study findings, and RT parameters before and after both courses of RT were retrieved for analysis. Using multivariate analysis, logistic regression was used to identify the predictors of RILD, and Cox regression was performed to explore the prognostic factors for overall survival (OS).

RESULTS

Thirteen patients (36 %) developed RILD after reirradiation. Nine of them died because of progressive liver failure without evidence of tumor progression and were categorized to have lethal RILD. A pretreatment Child-Turcotte-Pugh (CTP) score ≥6 was the only predictor of RILD [odds ratio (OR): 15.83, p = 0.001] and lethal RILD [OR: 72.56, p = 0.005]. In addition, a CTP score ≥6 and the presence of portal vein tumor thrombosis before reirradiation were 2 prognostic factors for OS.

CONCLUSION

Despite a limited sample size, residual liver function using a preirradiation CTP score ≥6 is a clinical parameter associated with an increased risk of RILD in patients requiring hepatic reirradiation.

Serum level of interleukin-21 is elevated in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is an inflammatory disease of the sinuses and mucosa with unclear pathogenesis. Interleukin (IL)-21 is mainly expressed in activated cluster of differentiation (CD)4(+) T cells and has potent regulatory effects on the immune system.

OBJECTIVE

This study is to determine whether IL-21 in the blood is correlated with CRS.

METHODS

The blood samples from CRS patients and normal controls were analyzed in correlation with clinical features. The eosinophil percentage was counted, and serum levels of total immunoglobulin E (IgE) and IL-21 were analyzed by enzyme-linked immunosorbent assay (ELISA). In addition, IL-21 and interferon (IFN)-γ secreted from stimulated peripheral blood mononuclear cells (PBMCs) were measured by ELISA, and their mRNA expression levels were analyzed by real-time quantitative polymerase chain reaction (RT-qPCR). Disease severity was scored based on computed tomography (CT) scan, nasal endoscopy, and global osteitis scoring scale (GOSS).

RESULTS

A total of 55 CRS and 37 healthy subjects were recruited. The average levels of serum total IgE were 20 kU/L in normal group, 290 kU/L in CRS with nasal polys (CRSwNP), and 187 kU/L in CRS without nasal polys (CRSsNP). IL-21 levels were 28 pg/mL in normal group, 54 pg/mL in CRSwNP, and 71 pg/mL in CRSsNP. Both IgE and IL-21 were significantly elevated in both CRS patient subgroups. However, no significant difference was found between these two patient subgroups. The serum IL-21 levels correlated well with the disease severity in the patients. In addition, the secreted IL-21 was enhanced significantly in the patient's PBMCs stimulated by phytohemagglutin (PHA).

CONCLUSION

IL-21 could be a target for diagnosis and treatment of CRS.

EGFR mutations are associated with favorable intracranial response and progression-free survival following brain irradiation in non-small cell lung cancer patients with brain metastases

BACKGROUND

The presence of epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer (NSCLC) is associated with increased radiosensitivity in vitro. However, the results from clinical studies regarding the radiosensitivity in NSCLC with mutant EGFR are inconclusive. We retrospectively analyzed our NSCLC patients who had been regularly followed up by imaging studies after irradiation for brain metastases, and investigated the impact of EGFR mutations on radiotherapy (RT).

METHODS

Forty-three patients with brain metastases treated with RT, together with EGFR mutation status, demographics, smoking history, performance status, recursive partitioning analysis (RPA) class, tumor characteristics, and treatment modalities, were included. Radiological images were taken at 1 to 3 months after RT, and 3 to 6 months thereafter. Radiographic response was evaluated by RECIST criteria version 1.1 according to the intracranial images before and after RT. Log-rank test and Cox regression model were used to correlate EGFR mutation status and other clinical features with intracranial radiological progression-free survival (RPFS) and overall survival (OS).

RESULTS

The median follow-up duration was 15 months. Patients with mutant EGFR had higher response rates to brain RT than those with wild-type EGFR (80% vs. 46%; p = 0.037). Logistic regression analysis showed that EGFR mutation status is the only predictor for treatment response (p = 0.032). The median intracranial RPFS was 18 months (95% CI = 8.33-27.68 months). In Cox regression analysis, mutant EGFR (p = 0.025) and lower RPA class (p = 0.026) were associated with longer intracranial RPFS. EGFR mutation status (p = 0.061) and performance status (p = 0.076) had a trend to predict OS.

CONCLUSIONS

Mutant EGFR in NSCLC patients is an independent prognostic factor for better treatment response and longer intracranial RPFS following RT for brain metastases.

The effect of diminished osteogenic signals on reduced osteoporosis recovery in aged mice and the potential therapeutic use of adipose-derived stem cells

Adipose-derived stem cells (ADSCs) have been shown to be pluoripotent and explored for their usage in tissue engineering. Previously, we have established a cell-based approach comprised of platelet-enriched plasma and osteo-progenitor cells for treating osteoporosis in an ovariectomized-senescence-accelerated mice (OVX-SAMP8) model. In the present study, we intend to explore the feasibility of using ADSCs as a cell-based therapeutic approach for treating osteoporosis, and to examine the effects of aging on the pluoripotency of ADSCs and the efficiency of bone formation both in vitro and in vivo. Flow cytometry was used to characterize ADSCs isolated from young and aged female SAMP8 mice and showed that the highly positive expression of surface markers such as CD44 and CD105 and negative for CD34 and CD45. Therefore, to compare the aging effects on the growth kinetics and differentiation potential of young and aged ADSCs, we found that there was a significant decline in both the proliferation rate (approximately 13.3%) and osteo-differentiation potential in aged ADSC. Subsequently, young and aged ADSCs were transplanted into the bone marrow of osteoporotic mice (OVX-SAMP8) to evaluate their bone formation ability. ADSC transplants were shown effective in restoring bone mineral density in the right/left knees, femurs and spine, 4 months post-transplantation; mice which received young ADSC transplants showed significantly higher bone regeneration (an average of 24.3% of improved BMD) over those received aged ADSCs. In conclusion, these findings showed that aging impedes osteoporosis-ameliorating potential of ADSC by diminishing osteogenic signal, and that ADSC could be used as a potential cell-based therapy for osteoporosis.

A 2-year follow-up of swallowing function after radiation therapy in patients with nasopharyngeal carcinoma

OBJECTIVE

To evaluate over a 2-year period the serial swallowing function of patients with nasopharyngeal carcinoma (NPC) after completing radiotherapy (RT).

DESIGN

Prospective longitudinal follow-up.

SETTING

University hospital.

PARTICIPANTS

Patients with NPC (N=76) referred for RT: 53 of them at 1 year after RT, and 23 at 2 years after RT.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed a questionnaire and had a video-recorded fluoroscopic swallowing study before RT and 1 month, 1 year, and 2 years after RT.

RESULTS

The highest incidence of dysphagia symptoms and retropharyngeal soft tissue swelling occurred in the first month after RT and decreased over time. Pharyngeal transit time was prolonged continuously up to 1 year after RT. Epiglottic vallecular stasis and pharyngeal mucosal coating were worst in the first month after RT and stable afterwards. Aspiration was uncommon during the first 2 years after RT.

CONCLUSIONS

At a 2-year follow-up after RT, patients with NPC had a progressively increasing pharyngeal transit time, although the subjectively identified symptoms of dysphagia decreased after the first month after RT.

Normoxically overexpressed hypoxia inducible factor 1-alpha is involved in arsenic trioxide resistance acquisition in hepatocellular carcinoma

BACKGROUND

The aim of this study was to examine the underlying signaling mechanisms of arsenic trioxide (ATO)-mediated anticancer effects and the responsible biomarker(s) for the acquired resistance in human heptatocellular carcinoma (HCC).

MATERIALS AND METHODS

The therapeutic effects of ATO were examined using 2 characteristically distinct HCC cell lines, Hep-J5 (overexpressing HIF-1α/GRP78) and SK-Hep-1 (the matched control). ATO-mediated proliferation inhibition, oxidative stress, and apoptosis were analyzed using flowcytometric analysis and western blotting. The role of HIF-1α and GRP78 in HCC resistance to ATO treatment was determined using RNA silencing and inhibitor approaches.

RESULTS

SK-Hep-1 cells, lacking both HIF-1α and GRP78 expressions were responsive to ATO-induced apoptosis via an oxidative-nitrosative mechanism. Intracellular glutathione depletion and lipid peroxidation have been identified as the early cascade of events preceding apoptosis via cytochrome c release and the severe drop of mitochondrial membrane potential (MMP). Conversely, Hep-J5 cells, with normoxic coexpression of HIF-1α and GRP78, were resistant to ATO-induced apoptosis. GRP78-silenced Hep-J5 cells remained resistant to ATO treatment. In contrast, ATO resistance in Hep-J5 cells was overcome by the addition of YC-1, a HIF-1α inhibitor.

CONCLUSIONS

HIF-1α was identified as the major positive modifier for ATO resistance acquisition in HCC, and it represents a prime molecular target for overcoming ATO resistance.

Effects of functional electrical stimulation on dysphagia caused by radiation therapy in patients with nasopharyngeal carcinoma

PURPOSE

This study aimed to assess the effectiveness of functional electrical stimulation on the swallowing function of irradiated nasopharyngeal carcinoma patients with dysphagia.

MATERIALS AND METHODS

Twenty nasopharyngeal carcinoma subjects with dysphagia were divided into a functional electrical stimulation (FES) and a home rehabilitation program (HRP) group. Each subject completed a quality of life questionnaire on swallowing and a videofluoroscopic study at the commencement and the end of the procedures. The FES group received functional electrical stimulation of the supra-hyoid muscles over 15 sessions. The HRP group performed self-swallowing exercises at home. The evaluation parameters included the quality of life questionnaire scores, the penetration-aspiration scale (PAS), the movement of the hyoid bone, and the amount of pyriform sinuses stasis.

RESULTS

Most swallowing outcomes of the FES group improved after FES. The quality of life score (p=0.003), the duration of the movement of thin barium through the hyoid (p=0.001), the moving speed of paste barium through the hyoid (p=0.028), and the pyriform sinus stasis area of the paste barium (p=0.026) reached significant difference in the FES group. Most swallowing outcomes did not improve in the HRP group. The degree of improvement in the movement speed of the hyoid bone in the thin barium (p=0.018) and the PAS of the paste barium (p=0.016) were statistically significantly greater in the FES group than in the HRP group.

CONCLUSION

FES will improve the swallowing function of NPC patients with dysphagia and bring about better quality of life.

Malignancies of the ear in irradiated patients of nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

To report on the clinical profiles and treatment experiences of patients with second primary ear malignancy after treatment of nasopharyngeal carcinoma (NPC).

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective review of the clinical outcomes and pathology of 11 irradiated NPC patients who subsequently had second primary malignancies of the ear at a single institution.

RESULTS

Ten tumors were squamous cell carcinoma and one tumor was chondrosarcoma occurring within the radiation field of previous treatment for NPC. The interval between previous radiotherapy and diagnosis of ear malignancy was 3 to 27 years with a median time of 17 years. Six tumors were located in the external auditory canal, two in the middle ear cavity, two in the periauricular region and one in the mastoid cavity. Four patients underwent surgery, and the other seven patients underwent surgery plus adjuvant radiotherapy. The 3-year disease-free and overall survival rates were 30.3% and 20%, respectively.

CONCLUSIONS

Postirradiated malignancy of the ear is extremely rare, but is one of the causes of death for NPC long-term survivors despite curative-intended treatment with surgery plus adjuvant radiotherapy is instituted.

Radiotherapy of classic Kaposi's sarcoma in Taiwan, an area where classic Kaposi's sarcoma is not prevalent

BACKGROUND

Classic Kaposi's sarcoma (KS), a neoplastic disease of vascular endothelial cells of the skin, is relatively prevalent in Eastern Europe and the Mediterranean region and radiation is one of the standard therapies. The clinical presentation and treatment results of classic KS from other regions have rarely been reported.

PATIENTS AND METHODS

Between 1994 and 2006, patients who had histologically confirmed KS and no immunodeficiency status due to human immunodeficiency virus infection or organ transplantation, and were treated with radiotherapy at Department of Oncology, National Taiwan University Hospital, Japan, were reviewed.

RESULTS

A total of 17 classic KS patients, with a median age of 69 years, were studied over a period of 12 years. All classic KS lesions involved lower extremities. Radiotherapy was delivered with either a 60Co unit or a linear accelerator, with the most commonly prescribed treatment being 3 Gy per fraction to a total dose of 39 Gy. In addition, several techniques using bolus were adopted to improve the radiation distribution over the skin of lower extremities. All irradiated KS lesions responded, with a complete response rate of 76%. The overall survival and progression-free survival rates of the group at 5 years were 85% and 58%, respectively.

CONCLUSION

Radiation therapy for classic KS patients in a non-prevalent area, such as Taiwan, is safe and effective.

Results of three-dimensional conformal radiotherapy and thalidomide for advanced hepatocellular carcinoma

PURPOSE

To evaluate the effectiveness of three-dimensional conformal radiotherapy and thalidomide in the treatment of advanced hepatocellular carcinoma.

METHODS

Between 1999 and 2003, 121 patients (mean age, 54.4 +/- 12.4 years; range, 20-81 years) with advanced hepatocellular carcinoma received three-dimensional conformal radiotherapy and thalidomide. Radiation was delivered in 1.5 Gy fractions twice daily for 5 days a week, for a total dose of 45-75 Gy. Mean treatment volume was 429.52 +/- 408.50 cm(3) (range, 26.89-2284.82 cm(3)). Thalidomide was given concomitantly: 200 mg/day in 109 patients, 300 mg/day in 8 patients and 400 mg/day in 4 patients. Treatment responses, survival rates and factors affecting survival were analyzed.

RESULTS

Treatment responses were observed in 61% of the patients. Liver cirrhosis (P = 0.001) and tumor size (P = 0.001) significantly affected the tumor responses. Overall survival at 6, 12 and 24 months was 84.8, 60.0 and 44.6%, respectively. On univariate analysis, liver cirrhosis (P = 0.003), Karnofsky performance status (P = 0.007), tumor size (P < 0.001), portal vein tumor thrombosis (P < 0.001) and alpha-fetoprotein level (P = 0.003) were shown to significantly affect survival. On multivariate analysis, only thrombosis (P = 0.039) and alpha-fetoprotein level (P = 0.006) were shown to be factors affecting survival.

CONCLUSIONS

Three-dimensional conformal radiotherapy with thalidomide seems to be effective in the treatment of advanced hepatocellular carcinoma.

A clinical staging system and treatment guidelines for maxillary osteoradionecrosis in irradiated nasopharyngeal carcinoma patients

PURPOSE

To develop a clinical staging system for maxillary osteoradionecrosis (ORN) in irradiated nasopharyngeal carcinoma (NPC) patients.

METHODS AND MATERIALS

The data of maxillary ORN cases among 1,758 irradiated NPC patients were analyzed. A staging system based on the degrees of bone exposure (E), infection (I), and bleeding (B) was developed. Correlations between various clinical parameters and stages of maxillary ORN and relationships between treatment modalities and outcomes at each stage were evaluated. Cumulative success of treatment and risk factors that affect treatment outcomes were analyzed.

RESULTS

The incidence of maxillary ORN was 2.7% (48/1,758). TNM stage of NPC (p < 0.001), radiation dose (p = 0.029), and tooth extraction (p < 0.001) appeared to have significant influences on disease severity. Success rates between conservative therapy and surgical treatment were not significantly different for Stage I ORN but differed significantly for Stage II (p = 0.013) and Stage III (p = 0.008) lesions. Grade 3 infection and bleeding significantly jeopardized treatment success (p = 0.043 and 0.015, respectively). The risk ratios of treatment failure for Grade 3 infection and bleeding were 2.523 (p = 0.034) and 3.141 (p = 0.027), respectively.

CONCLUSIONS

More serious maxillary ORN tended to occur in cases with more advanced NPC, higher radiation dose, and history of tooth extraction. Surgical treatment was usually required in Stage II and III ORN. The grades of infection and bleeding are important factors in guidance of treatment and prediction of outcomes.

The application of Aquaplast Thermoplastic as a bolus material in the radiotherapy of a patient with classic Kaposi's sarcoma at the lower extremity

BACKGROUND

The classic Kaposi's sarcoma (KS) patients usually present with progressive skin lesions over the lower extremities, following an indolent course. Although radiotherapy is an effective treatment for KS, radiation over these lesions is not without difficulty. The intrinsic difficulty resides in how a homogenous radiation dose over superficial lesions involving large areas and irregular surface is properly delivered. Several bolus techniques have thus been invented.

MATERIALS AND METHODS

The Aquaplast RT Thermoplastic is a new type of bolus material that can be easily molded and conformed to the curvature of skin, with the equivalence to soft tissue in radiation interaction.

RESULTS

This material was applied as the bolus for the irradiation of a classic KS patient, whose disease involved multiple skin areas over the right heel and ankle. Large parallel-opposed irradiation fields delivered by 60Co were used. Computed tomography demonstrated a close conformity of the bolus built-up by Aquaplast RT Thermoplastic to the surface of the ankle and foot. A dosimetry measurement further confirmed an adequate and homogenous distribution of desired dose around the lesions of the lower extremity. After a total dose of 39 Gy, divided in 13 fractions, the lesions remitted completely.

CONCLUSION

Our data suggest that the use of Aquaplast RT Thermoplastic as a bolus material is helpful in delivering adequate dose to skin lesions of the lower extremities.

Early restaging whole-body 18F-FDG PET during induction chemotherapy predicts clinical outcome in patients with locoregionally advanced nasopharyngeal carcinoma

PURPOSE

This study was undertaken to evaluate the utility of whole-body (18)F-FDG PET in monitoring therapeutic effect during induction chemotherapy (IC) and in predicting prognosis in patients with locoregionally advanced nasopharyngeal carcinoma (NPC).

METHODS

Fifty patients who had histologically proven, locoregionally advanced NPC without distant metastasis and had received IC were recruited in this study. The study cohort consisted of 19 females and 31 males (age 17-72 years, mean 45.9+/-11.9). Whole-body (18)F-FDG PET was performed in each patient after completion of one (33 patients) or two (17 patients) courses of IC. Each patient was restaged on the basis of the (18)F-FDG PET results. Patients who were downstaged to stage I or II were classified as major responders; the rest were classified as non-major responders.

RESULTS

Only 1 of the 23 major responders subsequently developed local recurrence. At the time of data analysis, all major responders were alive; by contrast, of the 27 non-major responders, 15 had locoregional recurrence or distant metastasis and nine had died (seven of NPC and two of treatment-related complications). Kaplan-Meier survival analysis showed significantly longer recurrence-free survival and overall survival in major responders (56.4+/-9.2 and 58.1+/-2.2 months) as compared with non-major responders (33.7+/-23.2 and 44.7+/-20.0 months), with p<0.0001 and p=0.0024, respectively.

CONCLUSION

The results of this study suggest that early restaging by a single whole-body (18)F-FDG PET scan after the first or second course of IC is useful for predicting therapeutic response and outcome in patients with locoregionally advanced NPC.

Post-radiation Pap smear for Chinese patients with cervical cancer: a ten-year follow-up

BACKGROUND

To study the performance of routine follow-up Pap smears after curative radiotherapy (RT) for Chinese cervical cancer (CC) patients.

METHODS

In 1996, 50 patients with non-metastatic CC received curative RT. Forty-six patients had routine follow-up Pap smears and constituted the study group. Details regarding clinical characteristics were retrospectively abstracted. Pap smear results were obtained via national Pap smear database linkage and chart review. The Pap smear results during recurrence-free survival (RFS) were analyzed and compared with clinical outcomes to study the performance characteristics.

RESULTS

After 34 (2 approximately 105) months' median follow-up, the clinical outcomes were isolated central recurrence (ICR), other recurrence (OR), and no evidence of disease (NED) for six, 20, and 20 patients, respectively. During 22 months' median RFS (range 2-105), 422 Pap smears (including missing data, n = 33) were performed. Most of the Pap smear results were within normal limits (65.8%) or benign (reactive changes or atrophy with inflammation) (25.2%). Atypical cells, low-grade squamous intraepithelial lesion (LSIL), high-grade intraepithelial lesion (HSIL), and carcinoma were found in ten (2.6%), 11 (2.8%), 11 (2.8%), and three (0.8%) specimens, respectively. Follow-up of the 21 atypical cells/LSIL smears among seven patients revealed five NED with normal/benign smears, one NED with HSIL and one OR with HSIL. Follow-up of the 11 HSIL smears among four patients revealed two ICR, one OR and one NED with HSIL. Follow-up of the three carcinoma smears revealed three ICR (one followed by HSIL in a repeat Pap smear before ICR). The sensitivity for the detection of ICR by carcinoma smears was 50%, with a specificity and positive predictive value (PPV) of 100%.

CONCLUSION

Few (approximately 3%) of the routine follow-up Pap smears after CC patients receiving curative RT were HSIL/carcinoma, but most (4/6) of these patients turned out to be ICR.

Impact of magnetic resonance imaging versus CT on nasopharyngeal carcinoma: primary tumor target delineation for radiotherapy

BACKGROUND

Our aim was to assess the capacity of CT versus MRI for delineating to the primary tumor extent of nasopharyngeal carcinoma (NPC) in treated patients.

METHODS

From December 1997 to April 2000, 258 patients with NPC were enrolled. We focused on the primary tumor extension and the discrepancy between CT and MRI. The delineation of tumor invasion was crucial for determination of the gross tumor volume (GTV) before radiation therapy.

RESULTS

A total of 104 patients (40.3%) had intracranial infiltration detected by MRI, whereas CT showed negative findings (p = 6.879 x 10(-11)). Once the pterygopalatine fossa was involved, the chance of intracranial invasion was increased (96.1%). The detectable percentage of pterygopalatine fossa involvement accompanying intracranial invasion was higher with MRI than with CT (96.1% vs 56.9%).

CONCLUSIONS

More detailed information about T and N classification of NPC was provided by MRI than by CT, which led to better target delineation for radiotherapy.

Comparison of clinical and molecular surveillance in patients with advanced nasopharyngeal carcinoma after primary therapy

BACKGROUND

The importance of detecting recurrence at an early stage in patients with malignant disease is well recognized. Circulating Epstein-Barr virus (EBV) DNA can be detected in patients with nasopharyngeal carcinoma (NPC). The objective of the current study was to assess the effectiveness of plasma EBV DNA monitoring in the early detection of NPC recurrence compared with conventional methods.

METHODS

Patients with NPC in two prospective clinical trials who had locoregional recurrences or distant metastases were recruited into the study. Clinical data on these patients were scrutinized for evidence of recurrence. EBV DNA copy numbers in the prospectively collected plasma samples were assayed retrospectively with real-time quantitative polymerase chain reaction analysis.

RESULTS

At the time of clinical recurrence, 65% of 26 patients with locoregional recurrences and all but 1 of 28 patients with distant failure had circulating EBV DNA. The difference between the time from completion of treatment to positivity for circulating EBV DNA and the time from completion of treatment to the first observed clinical abnormality was not statistically significant for patients with local recurrence (P=0.84). However, the time to the first detection of circulating EBV DNA was significantly shorter among patients with distant metastases (P<0.0001). The Kaplan-Meier estimated median time to the emergence of plasma EBV DNA was 190 days, with a 95% confidence interval (CI) of 95-300 days, and the median time to the first observed clinical abnormality was 295 days (95% CI, 276-361 days).

CONCLUSIONS

Monitoring plasma EBV DNA levels surpassed traditional methods for the early detection of distant failure in patients with NPC. The role of this technique should be evaluated in prospective studies that incorporate complementary advanced imaging technology.

Pain trajectory of Taiwanese with nasopharyngeal carcinoma over the course of radiation therapy

The purpose of this study was to describe the characteristics and management of pain among patients with nasopharyngeal carcinoma (NPC) prior to and during the 7-week course of radiation therapy (RT) in Taiwan. Twenty-nine men and 11 women with NPC participated in this prospective, longitudinal study. A modified Brief Pain Inventory was used to assess pain and its interference with daily activities weekly. Medical records were reviewed to abstract pain management and disease data. Findings showed that the pain intensity and pain interference scores escalated prominently at Week 3 and peaked at Week 5, representing the time course of RT complications. Pain prior to RT exacerbated the RT-induced mucositis pain. The pain related to RT for NPC was often severe and undertreated, and affected swallowing and talking more than sleeping or other general activities. We recommend interventions to control pain be instituted prior to Week 3 to minimize the potentiation of subsequent pain.

Quality of life in patients of nasopharyngeal carcinoma: validation of the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35

The authors followed the guidelines of translation and pilot testing of the EORTC QLQ-C30 and EORTC-QLQ-H&N35 questionnaires. The questionnaires were given to 50 nasopharyngeal carcinoma patients under active treatment and 50 under follow-up at our institution from November 2000 to June 2001. A retest was conducted 2 weeks after the first interview/form completion for the follow-up group. The intraclass correlation coefficients of the two questionnaires were moderate to high in the follow-up group. Cronbach's alpha coefficients of all scales of the two questionnaires were > or = 0.70 except that of cognitive functioning. Correlation of scales measuring similar dimensions of the QLQ-C30 and the SF-36 were moderate to high, while that of the QLQ-H&N35 and the QLQ-C30 and the SF-36 were moderate to low. Patients in the active treatment group had more serious acute problems due to disease and chemotherapy. Patients in the follow-up group had more serious chronic problems due to radiation therapy. We concluded that the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35 had moderate to high test-retest reliability, high internal consistency in most scales, and could show the expected differences between patients in active treatment and follow-up group.

Symptom profile of nasopharyngeal cancer patients during radiation therapy

PURPOSE

This prospective, longitudinal study was aimed to describe the prevalence, severity, and pattern of symptoms over the course of radiation therapy in persons with nasopharyngeal carcinoma and to explore symptom severity by treatment modality.

DESCRIPTION OF STUDY

Thirty-seven patients completed this study, and 46% received chemotherapy before radiation therapy. A self-reported radiation symptom checklist and an objective mucositis assessment tool were used weekly to document oropharyngeal, skin, nose or ear, or more general side effects, and mucositis.

RESULTS

Oropharyngeal problems were the most severe complaints during radiation therapy. All patients experienced dry mouth, taste change, difficulty in swallowing, difficulty in opening their mouths, hoarseness, sore throat, and observable mucositis. Most reported moderate-to-severe dry mouth, difficulty in swallowing, and sore throat from weeks 3 through 7. Skin problems were not prominent until week 4. Patients also lost an average of 3.9 kg during the therapy. Sequential chemotherapy and radiation therapy was associated with more severe oropharyngeal problems than radiation therapy alone, but no significant differences in other problems were found.

CLINICAL IMPLICATIONS

Despite recognition of the oropharyngeal side effects associated with irradiation, effective management protocols for such symptoms have not been implemented in the studied institution. The frequency and intensity of the symptoms reported indicate an urgent need for increased vigilance about radiation-related side effects and pain management. As well, patient education about expected side effects may help mitigate the anxiety that patients experience when these symptoms occur.

Induction chemotherapy with mitomycin, epirubicin, cisplatin, fluorouracil, and leucovorin followed by radiotherapy in the treatment of locoregionally advanced nasopharyngeal carcinoma

PURPOSE

Survival in advanced nasopharyngeal carcinoma (NPC) is compromised by distant metastasis. Because mitomycin is active against hypoxic and G0 cells, which may help to eradicate micrometastasis, we investigated the effect of mitomycin-containing cisplatin-based induction chemotherapy.

PATIENTS AND METHODS

Recruited for this study were American Joint Committee on Cancer (AJCC) 1992 staging system stage IV NPC patients with the following adverse features: obvious intracranial invasion, supraclavicular or bilateral neck lymph node metastasis, large neck node (> 6 cm), or elevated serum lactate dehydrogenase (LDH) level. Patients were given three cycles of chemotherapy before radiotherapy. The chemotherapy comprised a 3-week cycle of mitomycin, epirubicin, and cisplatin on day 1 and fluorouracil and leucovorin on day 8 (MEPFL).

RESULTS

From January 1994 to December 1997, 111 patients were recruited. The median follow-up period was 43 months. The actuarial 5-year overall survival rate was 70% (95% confidence interval [CI], 60% to 80%; n = 111). For patients having completed radiotherapy (n = 100), the 5-year locoregional control rate was 70% (95% CI, 55% to 84%) and the distant metastasis-free rate was 81% (95% CI, 73% to 89%). The 5-year distant metastasis-free rate of N3a and N3b disease of AJCC 1997 staging system were 79% (95% CI, 62% to 95%) and 74% (95% CI, 60% to 89%), respectively. By Cox multivariate analysis, high pretreatment serum LDH level (P = .04) and neck nodal enlargement before radiotherapy (P = .001) were adverse prognostic factors of survival.

CONCLUSION

The good 5-year survival of N3 disease supports the effectiveness of induction MEPFL in the primary treatment of advanced NPC. Further investigation to incorporate concurrent chemoradiotherapy is warranted.

Factors affecting the overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site: experience with 60 cases

OBJECTIVE

To analyze the factors affecting overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site after a full course of radiotherapy.

DESIGN

Retrospective analysis of 60 consecutive patients treated by surgical resection of the recurrent tumors, with a mean follow-up of 43.1 months (range, 19-96 months).

SETTING

Academic tertiary referral center.

RESULTS

The overall survival and locoregional relapse-free survival were 56% and 60% at 2 years, respectively, and 30% and 40% at 5 years. Twenty-nine (81%) of 36 patients died with uncontrolled local disease. The T stage of the recurrent tumors appeared to be an important prognostic factor. Age, sex, pathologic findings, and disease-free interval (time between previous radiotherapy and local recurrence) were not significant prognosis-affecting factors by the log-rank test. Multivariate analysis showed that patients with recurrent tumors of undifferentiated carcinoma, sarcoma, or small cell carcinoma had unfavorable prognoses. Uncontrolled local disease and the emergence of distant metastasis predicted grave results as well. Postoperative irradiation showed some benefit to patients, but the difference was not statistically significant.

CONCLUSIONS

The T stage of the recurrence was the prominent prognosis-affecting factor in patients with recurrent nasopharyngeal carcinoma who received salvage surgery. Patients with local recurrence should be carefully selected for the salvage surgery. We recommend this surgery for patients with rT1, rT2, or limited rT3 lesions. The results of surgical resection in terms of local control and overall survival were slightly better than those of high-dose reirradiation, with fewer late complications.

DNA content of nasopharyngeal carcinoma: an independent prognostic indicator

The purpose of this study was to examine whether tumor DNA content correlated with prognosis in nasopharyngeal carcinoma (NPC). DNA flow-cytometric analysis in fresh specimens of nasopharyngeal biopsy from 123 patients with clinical suspicion of NPC was collected initially. Histopathologic study and successful flow-cytometric analysis had 28 lymphoid hyperplasias and 87 NPCs. Seventeen NPC patients were treated elsewhere and were excluded. A total of 98 patients, including 28 lymphoid hyperplasias and 70 NPCs, formed the materials of this study. There were 34 (49%) diploid and 36 (51%) aneuploid in NPC patients. No lymphoid hyperplasias were aneuploid. The mean of S-phase fraction was higher in NPC than in lymphoid hyperplasia (P < .001), indicating higher cellular activity in NPC. DNA content failed to associate with age, gender, pathology, distant metastasis, and stage, indicating that DNA content was an independent prognostic indicator and possibly a clinical parameter. The log-rank test of overall survival curves was significant for stage (P = .002) and DNA ploidy (P = .042); it was almost significant for S-phase fraction (P = .057). Because the follow-up duration was not long enough, univariate and multivariate analysis were not significant for stage, ploidy, and S-phase fraction, except for distant metastasis. It is also most likely colinearity of clinical stage and distant metastasis that explained why clinical stage could not show significance in prognosis. Interestingly, the DNA content appeared to be a potential prognostic parameter in overall survival, although it was not statistically significant (P = .052). Our data suggested that NPC patients with aneuploid DNA and high S-phase fraction tend to have poor prognosis and should be treated more aggressively, even in the early stage of the disease.

Symptom profile of nasopharyngeal cancer patients during radiation therapy

PURPOSE

This prospective, longitudinal study was aimed to describe the prevalence, severity, and pattern of symptoms over the course of radiation therapy in persons with nasopharyngeal carcinoma and to explore symptom severity by treatment modality.

DESCRIPTION OF STUDY

Thirty-seven patients completed this study, and 46% received chemotherapy before radiation therapy. A self-reported radiation symptom checklist and an objective mucositis assessment tool were used weekly to document oropharyngeal, skin, nose or ear, or more general side effects, and mucositis.

RESULTS

Oropharyngeal problems were the most severe complaints during radiation therapy. All patients experienced dry mouth, taste change, difficulty in swallowing, difficulty in opening their mouths, hoarseness, sore throat, and observable mucositis. Most reported moderate-to-severe dry mouth, difficulty in swallowing, and sore throat from weeks 3 through 7. Skin problems were not prominent until week 4. Patients also lost an average of 3.9 kg during the therapy. Sequential chemotherapy and radiation therapy was associated with more severe oropharyngeal problems than radiation therapy alone, but no significant differences in other problems were found.

CLINICAL IMPLICATIONS

Despite recognition of the oropharyngeal side effects associated with irradiation, effective management protocols for such symptoms have not been implemented in the studied institution. The frequency and intensity of the symptoms reported indicate an urgent need for increased vigilance about radiation-related side effects and pain management. As well, patient education about expected side effects may help mitigate the anxiety that patients experience when these symptoms occur.

Induction with mitomycin C, doxorubicin, cisplatin and maintenance with weekly 5-fluorouracil, leucovorin for treatment of metastatic nasopharyngeal carcinoma: a phase II study

The combination of cisplatin and 5-fluorouracil (5-FU) (PF) is the most popular regimen for treating metastatic nasopharyngeal carcinoma (NPC) but it is limited by severe stomatitis and chronic cisplatin-related toxicity. A novel approach including induction with mitomycin C, doxorubicin and cisplatin (MAP) and subsequent maintenance with weekly 5-FU and leucovorin (FL) were designed with an aim to reduce acute and chronic toxicity of PF. Thirty-two patients of NPC with measurable metastatic lesions in the liver or lung were entered into this phase II trial. Mitomycin C 8 mg m(-2), doxorubicin 40 mg m(-2) and cisplatin 60 mg m(-2) were given on day 1 every 3 weeks as initial induction. After either four courses or remission was achieved, patients received weekly dose of 5-FU 450 mg m(-2) and leucovorin 30 mg m(-2) for maintenance until disease progression. With 105 courses of MAP given, 5% were accompanied by grade 3 and 0% were accompanied by grade 4 stomatitis. The dose-limiting toxicity of MAP was myelosuppression. Forty per cent of courses had grade 3 and 13% of courses had grade 4 leukopenia. No grade 3 or 4 cisplatin-related toxicity was observed. The overall response rate was 94% (95% confidence interval (CI) 84.9-100%) with a complete response rate (CR) of 6% (95% CI: 0-15.2%) and a good partial response (PR) rate of 28% (95% CI 11.7-44.6%), which was optionally defined as observance of only equivocal lesion identifiable under imaging study. Twenty-seven cases entered weekly FL maintenance phase. The median duration of maintenance with weekly FL was 38 weeks (8-91 weeks). There was no grade 3 or 4 toxicity noted during weekly FL. The median progression-free survival and overall survival were 11.6+/-0.4 and 18.1+/-3.6 months respectively. Six patients with a median follow-up of 19.8 months (9.6-41.0 months) were still alive and five of them had disease under control with FL. Good responders (CR and good PR) had better survival than less satisfactory responders (PR and stable disease) (P = 0.05). From Cox's multivariate regression analysis, the only significant prognostic factor for survival was good response to MAP (P = 0.042). Liver metastasis was the only significant variable in the best subset regression model that predicted good response to MAP (CR and good PR) (P = 0.027). MAP was an effective combination for metastatic NPC with minimal stomatitis and cisplatin-related toxicity but had significant myelosuppression. Weekly FL was a maintenance therapy with minimal side-effects. The response rate and overall survival of MAP-FL were better than series previously reported even when a subset of patients with poor prognosis was selected. MAP-FL's role as neoadjuvant or adjuvant therapy is worthy of further study.

Treatment, outcomes, and prognostic factors of ear cancer

Cancer of the ear is rare and a consensus has not been reached as to the most appropriate treatment. In this retrospective study, we examined the treatment modalities, prognostic factors, and outcomes of patients treated for ear cancer at the National Taiwan University Hospital during a 15-year period. The disease-free survival rates of patients with three different disease grades were compared using the log-rank test. The effects of prognostic factors on survival were examined with Cox's proportional hazard model. Of the 61 ear cancer patients treated from January 1982 through October 1996, 47 (36 men, 11 women; mean age, 54.6 yr) had complete records and were included in this study. The tumor originated from the middle ear in 29 (62%) patients and from the external ear canal in 18 (38%). A total of 37 patients underwent radical mastoidectomy to remove the gross tumor, while six underwent wide excision of the tumor. Concomitant parotidectomy or neck dissection was performed in seven patients. Thirty-eight patients received postoperative radiation therapy and five patients received chemotherapy for palliative treatment of recurrent or inoperable tumors. All but four (9%) of 43 patients developed facial nerve palsy postoperatively. There were no deaths directly related to surgery or other major complications, including cerebrospinal fluid leakage, meningitis, or hemiparesis. The 5-year disease-free survival rate was 53% overall (n = 47), but differed significantly among patients with different grades of disease (p = 0.038): 66% for grade I (n = 27), 44% for grade II (n = 17), and 0% for grade III (n = 3). Multivariate analysis revealed that cervical lymph node metastasis was a poor prognostic factor (relative hazard, 16.4; p < 0.001). These results suggest that mastoidectomy with postoperative radiation therapy can yield satisfactory outcomes, even in some cases of advanced (grade II) disease.

Experience of radiotherapy in lethal midline granuloma with special emphasis on centrofacial T-cell lymphoma: a retrospective analysis covering a 34-year period

Lethal midline granuloma (LMG) is characterized by progressive ulceration and destruction of the midfacial tissue. It occurs more frequently in Oriental than in Western populations. Because of the progress in clinical pathology and immunohistochemistry, most cases have been proven to be malignant lymphomas, especially of T-cell lineage. We describe 92 cases of lethal midline granuloma or centrofacial malignant lymphoma in the period 1959-1993. All received complete courses of radiotherapy. Twenty of them also received combination chemotherapy. Thirty-six cases had specimens available for immunohistochemical study; 25 (69%) of these had a T-cell phenotype, and 6 (17%) were of B-cell lineage. The dose to the nasal region was in the range of 3000-7500 cGy in 11-58 days, and to the neck 3000-6400 cGy in 11-48 days. The overall survival rate for the LMGs was 59.5% at 5 years and 56.2% at 10 years (Kaplan-Meier). Combined chemotherapy seemed not to improve the overall survival in this study (p = 0.63), but the patient number was too small to make a firm conclusion. Based on the results of this study, we recommend a dose of 4500-5000 cGy to the midfacial region, since a higher dosage did not improve the treatment results (p = 0.88). Irradiation has a definite role in good locoregional control of this disease. The recent clarification of the disease nature and the recognition of the background clinicopathological features should provide valuable information for future patient management and prospective studies.

Chromosome aberrations induced in human lymphocytes after partial-body irradiation

Chromosomal aberrations in peripheral blood lymphocytes obtained from two patients before and after they received one fraction of partial-body irradiation for palliative treatment were analyzed. Blood samples were taken 30 min and 24 h after radiation treatment. The yield of dicentrics obtained from case A 30 min after a partial-body (about 21%) treatment with 8 Gy was 0.066/cell, while the yield obtained 24 h after radiation treatment was 0.071/cell. The fraction of irradiated lymphocytes that reached metaphase at 52 h was 0.08 as evaluated by mixing cultures of in vitro irradiated and unirradiated blood. The yield of dicentrics for blood from case B 30 min after 6 Gy partial-body (about 24%) irradiation was 0.655/cell, while the yield 24 h after irradiation was 0.605/cell. The fraction of irradiated cells was 0.29. Estimation of doses and irradiated fractions for the two cases using the method proposed by Dolphin and the Qdr method is discussed. Although there was no significant difference between the mean yields of dicentrics per cell obtained 30 min and 24 h after radiation treatment, the data obtained at 24 h seemed more useful for the purpose of dose estimation. When a higher dose (8 Gy) was delivered to a smaller percentage of the body, underestimation of the dose was encountered.

Determination of changes in tumor blood perfusion after hydralazine treatment by dynamic paramagnetic-enhanced magnetic resonance imaging

Magnetic resonance imaging, using the paramagnetic chelate gadopentetate dimeglumine as a perfusing agent, was used to investigate the effect of the vasoactive drug hydralazine on tumor blood perfusion. The method requires measurements of the magnetic resonance image intensity changes with time on a pre-selected region of interest in the tumor image, immediately following intravenous injection of gadopentetate dimeglumine. The present study showed that the initial slope of the intensity-time curve can be used, to a first approximation, to infer tumor blood perfusion. With the dynamic imaging technique, it was demonstrated that, in the KHT sarcoma implanted intramuscularly in the hind leg of C3H/HeN mice, intraperitoneal administration of hydralazine reduced the volume-averaged tumor blood perfusion in a dose-dependent manner. The intrinsically high spatial resolution of magnetic resonance imaging allows a detailed study of the heterogeneous nature of tumor blood perfusion. The potential applications of this imaging technique to study the differential effects of hydralazine on perfusion between tumor and normal tissues will be discussed. The clinical utility of the technique should be promising because of its non-invasive nature.