[Clinical analysis of 138 multiple primary cancers diagnosed of digestive system malignant tumor initially]

Objective: To study the clinical characteristics, strategy of treatment and prognosis of multiple primary cancers(MPC) diagnosed of digestive system malignant tumor firstly. Methods: From January, 2000 to December, 2015, the clinical, follow-up and prognostic data of 138 MPC patients diagnosed of digestive system malignant tumor firstly were retrospectively analyzed. Results: 138 cases were found in 10 580 cases with malignant tumors, and the incidence was 1.30%. There were 129 cases of duplex primary cancers, 8 cases of triple primary cancers and 1 case of quintuple primary cancers. The repetitive primary cancer was occurred in digestive system (61cases, 44.2%) most frequently, with the next in respiratory system (46 cases, 33.3%). 52.2% (72 cases) suffered second primary cancer in 2 years after first primary cancer diagnosed, and 75.4% (104 cases) in 5 years. The median overall survival in patients with all cancer lesions radically treated was 168 months, better than any other treatment (68 months, P<0.05). Conclusions: The second primary cancers of MPC cases initially diagnosed of digestive system malignant tumor most frequently occurred in the digestive system and respiratory system. More concern should be attracted in follow-up, especially in the first 5 years. The key to improve patient' prognosis was radical treatment to every primary cancer.

Clinical Characteristics and Outcomes for Solitary Fibrous Tumor (SFT): A Single Center Experience

Solitary fibrous tumor (SFT) is a mesenchymal neoplasm of fibrous origin. The 2013 WHO classification of soft tissue tumors defines malignant forms as hypercellular, mitotically active (>4 mitosis/10 high-power fields), with cytological atypia, tumor necrosis, and/or infiltrative margins. With an IRB-approved protocol, we investigated patient records and clinicopathologic data from our Sarcoma Database to describe the clinical characteristics of both benign and malignant SFT. All pathology specimens were reviewed by two pathologists. Descriptive statistics and univariate/multivariate survival analysis were performed. Patient records and Social Security Death Index were used to evaluate vital status. Of 82 patients, 47 (57%) were women and 73 (89%) were Caucasian. Median age was 62 years (range, 20 to 89). Thirty-two (39%) patients succumbed to the disease. Primary tumor site was lung/pleura in 28 (34%), abdomen/pelvis in 23 (28%), extremity in 13 (16%), and head/neck in 9 (11%) patients. Pathology was described as benign in 42 (51%) and malignant in 40 (49%) patients. Compared to benign SFT, malignant histology is associated with larger tumor size, higher mitotic counts, metastatic disease at diagnosis, and greater use of chemotherapy and radiation therapy. Gender, age, and tumor site were not significantly different between benign and malignant subtypes. By univariate analysis, only benign vs. malignant variant and complete resection positively impacted overall survival (P = 0.02 and P<0.0001, respectively). In the multivariable analysis of overall survival, receiving chemotherapy or not receiving surgery were two variables significantly associated with higher failure rate in overall survival: patients with chemotherapy vs. no chemotherapy (P = 0.003, HR = 4.55, with 95% CI: 1.68–12.34) and patients without surgery vs. with surgery (P = 0.005, HR = 25.49, with 95% CI: 2.62–247.57). Clear survival differences exist between benign and malignant SFT. While surgery appears to be the best treatment option for benign and malignant SFT, better systemic therapies are needed to improve outcomes of patients with metastatic, malignant SFT.

[Clinical analysis on extramedullary plasmacytoma in the upper airway]

OBJECTIVE

To investigate the clinical manifestation, treatment and prognosis of extramedullary plasmacytoma(EMP) in the upper airway, and to improve the diagnosis and outcome of EMP treatment.

METHOD

Clinical data of 26 EMP cases were reviewed retrospectively, and then compared with multiple myeloma(MM) patients presenting with lesions in upper airway.

RESULT

Of 26 cases, 9 cases with the tumors occurred in nasal cavities, 7 in nasal sinuses, 6 in pharyngeal, 4 in throat, mainly manifesting with local masses and relevant symptoms. The manifestations of clinical, endoscopy findings and pathologic results in EMP patients were not distinguishable from the lesions of MM patients, while MM patients often accompanied by other findings, such as anemia and bone damage. Involvement of neck lymph nodes was more common in MM patients than in EMP patients. Ten patients were treated with surgery, and 16 patients with surgery and radiotherapy. Of the seven EMP patients with involvement of neck lymph nodes, four patients received additional chemotherapy besides surgery and radiotherapy, and no local relapse and MM happened in them, while of the three patients only received surgery and radiotherapy, one local relapse were found and one progressed to MM.

CONCLUSION

The diagnosis of EMPs mainly depends on pathological results. The judgment of pathologists and application of molecular biology technology are vital for the diagnosis of EMP in upper airway, and MM must be excluded very carefully in the diagnosis of EMP. Surgery combined with radiotherapy is the main treatment for EMP in the upper airway, and the prognosis is good but the follow-up should be taken. Besides surgery and radiotherapy, chemotherapy is beneficial for the EMP patients accompanied with lesions in neck lymph nodes.

Trends in the survival of patients diagnosed with cancers in the respiratory system in the Nordic countries 1964-2003 followed up to the end of 2006

BACKGROUND

Previous studies have shown that there have been systematic differences between the Nordic countries in population-based relative survival of patients with respiratory cancer (lung, pleura, larynx, nose and sinuses).

MATERIAL AND METHODS

Relative survival of patients with respiratory cancer diagnosed in the Nordic countries in 1964-2003 and followed up to the end of 2006 was studied and contrasted with developments in incidence and mortality.

RESULTS

For cancer of the lung, relative survival is lower in Danish patients than in the other countries during the first months of follow-up after diagnosis. For cancer of pleura, the relative survival ratios indicate that there may be problems in the official coding of the causes of death in Denmark, Norway and Sweden. There has been little improvement in survival of patients with cancer of the respiratory organs in the Nordic countries over time.

CONCLUSIONS

The slightly lower survival of Danish lung cancer patients may be related to a less favourable stage distribution and to an increased prevalence of causal factors, affecting the mortality due to competing risks of death. A reclassification of official causes of death at the cancer registry may be needed for cancer of the pleura in order to make the corresponding mortality rates comparable between countries.

Lung cancer patients with previous or simultaneous the upper aerodigestive cancers

There have been few reports on clinical characteristics of lung cancer patients with previous or simultaneous upper aerodigestive cancers. To evaluate them, we conducted a retrospective study. The medical records of all lung cancer patients at our division from January 1984 through July 2008 were reviewed. Twenty-one (1.7%) of 1242 patients had previous or simultaneous upper aerodigestive cancers. Twenty patients were smokers. For non-small cell lung cancer (NSCLC), 6 patients underwent surgical resection and 3 were treated with chemotherapy. Three small cell lung cancer (SCLC) patients had chemotherapy. None of the severe complication related to the comorbidities were observed. The median survival for NSCLC and SCLC patients was 15 and 6 months, respectively. For patients with upper aerodigestive cancers, smoking cessation, a chest radiograph or computed tomography scan at least yearly and swift evaluation of signs or symptoms that are suggestive of lung cancer should be recommended.

Creating a medical home for the child with recurrent respiratory papillomatosis

Juvenile onset recurrent respiratory papillomatosis is a chronic disease of the pediatric airway caused by human papillomavirus. This paper discusses the etiology, epidemiology, symptomatology, diagnosis, and treatment of this disease. The role of the pediatric nurse practitioner is described in applying the medical home model. Comprehensive primary care is described for children with recurrent respiratory papillomatosis, including well child care, episodic illness management, and care coordination.

[Modern approaches to the organization of oncological care for patients with tumours of upper respiratory tract]

Despite reports of successful treatment of oncological diseases of the upper respiratory tract, many patients with this pathology still apply for medical aid too late. Squamous cell carcinoma remains the predominant problem. Clinical symptoms of metastases are absent in 60% of the lethal cases with locally spreading tumours. The most common causes of death among these patients are obstruction of the upper air passages, invasion of tumour cells into the brain, local and systemic metastasis. It is concluded that the improvement of early diagnosis of malignant neoplasms of the upper respiratory tract and organization of specialized care for subjects with pre-tumor processes requires joint efforts of oncologists and otorhinolaryngologists. The achievement of this goal would enhance the effectiveness of the treatment of this pathology.

The epidemiology and treatment of mesothelioma in South East England 1985-2002

OBJECTIVES

To describe trends in the incidence of mesothelioma for men and women in South East England and the geographical variation at the level of primary care trust. To describe treatment patterns by cancer network of residence, and relative survival by cancer network, disease stage and treatment modality.

METHODS

5753 cases were extracted from the Thames Cancer Registry database. We calculated age standardised incidence rates for each year, age specific incidence rates in 10 year age groups, and we used linear regression to compute the average annual percentage change in age standardised incidence. We used Poisson regression to analyse generational trends in incidence.

RESULTS

Men had five times higher incidence of mesothelioma than women. In men, there was an overall 4% increase per year between 1985 and 2002. Over the same period, the overall increase in incidence for women was 5% per year. The incidence was highest in men aged over 70 years, and men aged over 80 years had the highest increase of 8% per year. The incidence rate ratio increased for men born between 1892 and 1942 and started to slow for those born from 1947 onwards. Areas along the Thames and its estuary had the highest incidence. There was some variation by cancer network in the proportion of patients receiving cancer surgery, radiotherapy and chemotherapy. There were no discernable differences in relative survival by cancer network of residence or disease stage but those receiving combined treatment had higher 5 year survival.

CONCLUSIONS

Mesothelioma incidence has increased in South East England, particularly for men aged over 70 years. The highest incidence occurs along the Thames and its estuary, reflecting areas of asbestos use in shipbuilding and industry in the past. More research is needed to understand the interrelationships of prognostic factors, treatment choices and survival, and to determine the best care and support for these patients and their families.

The activator protein-1 transcription factor in respiratory epithelium carcinogenesis

Respiratory epithelium cancers are the leading cause of cancer-related death worldwide. The multistep natural history of carcinogenesis can be considered as a gradual accumulation of genetic and epigenetic aberrations, resulting in the deregulation of cellular homeostasis. Growing evidence suggests that cross-talk between membrane and nuclear receptor signaling pathways along with the activator protein-1 (AP-1) cascade and its cofactor network represent a pivotal molecular circuitry participating directly or indirectly in respiratory epithelium carcinogenesis. The crucial role of AP-1 transcription factor renders it an appealing target of future nuclear-directed anticancer therapeutic and chemoprevention approaches. In the present review, we will summarize the current knowledge regarding the implication of AP-1 proteins in respiratory epithelium carcinogenesis, highlight the ongoing research, and consider the future perspectives of their potential therapeutic interest.

[The combined treatment of juvenile outset recurrent respiratory papillomatosis]

OBJECTIVE

To explore the effective treatment of juvenile outset recurrent respiratory papillomatosis (JO-RRP).

METHOD

Thirty six patients of JO-RRP from 1993 to 2004 were analyzed retrospectively. Twenty seven patients were underwent laser excision by laryngoscope and nine patients were underwent laser excision through laryngostomy. Twenty eight patients who recurrenced more than two times in one year or involved extent of disease more than two anatomical subregion were give interferon after operation one week in addition.

RESULT

All patients had normal deglutition, 28 cases (77.8%) had been succeed in decannulation. The complications included hoarseness in 8 cases, laryngeal stenosis in 6 cases and pulmonary infection in 3 cases.

CONCLUSION

The laser surgery by larynoscope and laryngostomy are two kinds of effective treatments for JO-RRP. The interferon therapy after the operation can restrain the recrudescence effectively.

Carcinoid tumors

Carcinoid tumors are rare, slow-growing neuroendocrine neoplasms that often are indolent and may not become clinically apparent until there has been metastatic spread or evidence of carcinoid syndrome. Recent evidence has revealed that the overall incidence of carcinoid tumors has been steadily increasing, and although the disease was thought to be relatively benign, it is now considered one of increasing malignancy. Carcinoid tumors derive from different embryonic divisions of the gut: foregut carcinoid tumors commonly originate in the lungs, bronchi, or stomach; midgut carcinoid tumors in the small intestine, appendix, or proximal large bowel; and hindgut carcinoid tumors in the distal colon or rectum. Carcinoid syndrome, although rare, is most associated with midgut carcinoid tumors. The diagnosis of a carcinoid tumor often is coincidental with surgery performed for another reason. Treatment and prognosis are dependent on the location of the primary tumor and the degree and extent of metastasis at the time of diagnosis.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is a benign, often multi-focal neoplasm. A potentially fatal manifestation of human papilloma virus infection, the condition is characterised by multiple warty excrescences on the mucosal surface of the respiratory tract. RRP is rare--incidence is estimated at 3.5 per million person-years, with a prevalence of 4 in 100,000 children. Affected children usually require multiple interventions; the impact on patients, their families, and the healthcare system is considerable. Treatment of RRP accounts for an estimated dollar 109 million annual expenditure in the USA.

Is there disparity in the care of minority patients with upper aerodigestive tract malignancy?

The data presently available indicate that there is unequal (disparate) care in patients with head and neck cancer. The reasons for this are likely multifactorial and require further study. Complicating such work is the need for subgroup analysis. For example, Hispanics are not a homogeneous ethnic group; hence, differences in social perception, cultural mores, and available medical resources can be demonstrated that can directly impact care and outcome. Appropriate epidemiologic studies are needed with more underserved minority patients to analyze these differences further and to address such differences.

[Treatment of patients with respiratory papillomatosis: experience analysis]

The authors of the article analyze clinical observations of 240 patients with respiratory papillomatosis (aged 7 months to 56 years), treated in the ETN clinic of Moscow Regional Research Clinical Institute in 1984-2003 using endolaringeal microsurgical techniques, such as ultrasound desintegration and laser photodestruction of papillomas. Additional therapy included immunocorrection with T-activin and leukomax, discrete plasmopheresis, antiviral therapy with zovirax, and photodynamic therapy. Having compared various methods and their combinations, the authors conclude that "clinical recovery" (no relapses within more than 2.5 years), was achieved in 41.4 +/- 0.5% - 77.8 +/- 0.2% patients.

Airway hemangiomas: contemporary management

METHODS

A review of the literature and the author's pediatric otolaryngology experience regarding the clinical presentation and contemporary management of airway hemangiomas, with an emphasis on subglottic hemangiomas.

CONCLUSION

A myriad of medical and surgical treatment options exist for children with airway hemangiomas. Careful application of these technologies allows for satisfying outcomes in most cases.

Management of lymphatic malformations

PURPOSE OF REVIEW

Innovative otolaryngologists, plastic surgeons, craniofacial surgeons, pediatric surgeons, radiologists, anesthesiologists, neonatologists, obstetricians, and scientists have continued to advance our understanding of the etiology, diagnosis, and treatment of lymphatic malformations. This article reviews the publications over the past 2 years with respect to these advances.

RECENT FINDINGS

Fast-sequence MRI limits motion artifacts and allows prenatal MR to be used as a complementary study to ultrasound in the evaluation of large congenital neck masses. Three-dimensional ultrasonography may also be helpful in evaluating prenatal lymphatic malformations. Fluorescence in situ hybridization techniques can be used to evaluate lymphatic malformations for prenatal chromosomal analysis with emphasis on chromosomes 13, 18, 21, X, and Y. The sclerosing agent OK-432 is effective for macrocystic lymphatic malformations but showed less promise for microcystic lesions, mixed lesions, and lesions outside the head and neck region. Somnoplasty shows promise for reduction of tongue lymphatic malformations. Surgical excision, staged when necessary, continues to be integral to management in many cases.

SUMMARY

Basic science research has furthered understanding of lymphatic malformations. Clinical research has expanded and refined our diagnostic and therapeutic options for patients with these lesions. Further identification of genes selectively expressed by lymphatic endothelium should facilitate identification of usable vascular markers that can enable analysis of the underlying biology, physiology, pathology, and treatment of the lymphatic system and its malformations.

[Respiratory tract diseases in the elderly]

According to recent definitions the person enters a senile age after 65. Each person starts ageing after the completion of maturation. The phenomenon of ageing is highly individual and differs among people with respect to its rate and affected systems and organs. This may be responsible for a frequent inequality of metrical and biological age. Ageing is a multisystem process which also leads to alterations in symptomatology of many diseases. The process of ageing has been very well described, especially in the cardiovascular system. In contrast, ageing of the respiratory tract is far less recognised and still remains a subject of debates. The elderly are affected by the same diseases as younger individuals. The most common diseases at this age are respiratory tract infections, tuberculosis, chronic obstructive pulmonary diseases and bronchial asthma. Their course may be, however, different in the elderly not only due to the physiologic process of ageing but also frequent comorbidities. This fact should be taken into account when establishing a diagnosis and treatment regimens. A therapy of the older person usually requires a highly individualized approach.

Clinical applications of tumor volume measurements for predicting outcome in patients with squamous cell carcinoma of the upper aerodigestive tract

Gross tumor volume (GTV) at the primary site, as derived from pretreatment CT findings, can help predict local control of squamous cell carcinoma at different head and neck subsites after treatment with nonsurgical organ preservation. Local recurrence is more likely with large tumors than with small lesions in the same anatomic subsite, and GTV is often more strongly associated with local control than is tumor stage. This review discusses tumor volume calculation-technique, current literature, and potential clinical applications-and aims to help the reader to understand the role of GTV calculations and to integrate this knowledge into clinical practice.

A breath of fresh air? Report of the 2003 British Thoracic Society Winter Meeting

An overview of some of the key topics presented at the BTS Winter Meeting held in London on 3-5 December 2003.

Diagnosis and management of pulmonary metastasis from recurrent respiratory papillomatosis

OBJECTIVE

We sought to review the current and proposed management, as well as bring about discussion, of managing the patient with distal tracheal and pulmonary parenchymal involvement by recurrent respiratory papillomatosis (RRP).

DESIGN, SETTING, AND PATIENTS

We conducted a review of 6 patients with pulmonary metastasis from RRP at 3 academic tertiary care hospitals. Interventions included surgical and medical management with antiviral, chemotherapeutic, and/or immune-modulating agents.

RESULTS

Although treatment with alpha-2-beta interferon, isotretinoin, and methotrexate have not proved to eradicate pulmonary involvement by RRP, possible epithelial stabilization and slowing of disease progression are noted.

CONCLUSIONS

The rates of distal tracheal and pulmonary metastasis as seen in our cohort were higher than previously reported. Approximately 12% of our patients with RRP have distal tracheal spread and as many as 7% of all patients with RRP at our institutions have pulmonary dissemination. Also, high suspicion for malignant conversion to squamous carcinoma in the patient with pulmonary spread should be maintained. In addition, aggressive treatment, although not proved to eradicate the pulmonary disease, should be undertaken due to the high morbidity and mortality associated with pulmonary dissemination of RRP in our cohort.

Predictors of Remission in Juvenile-Onset Recurrent Respiratory Papillomatosis

OBJECTIVE

To determine factors associated with remission of juvenile-onset recurrent respiratory papillomatosis (JORRP).

DESIGN

Longitudinal study.

SETTING

Twenty-two tertiary care centers located across the United States.

STUDY PARTICIPANTS AND METHODS

The study included 165 patients diagnosed as having JORRP between January 1, 1997, and December 31, 2000. Kaplan-Meier curves and Cox proportional hazards models were used to determine associations between predictors and remission.

INTERVENTIONS

Surgical excision and drug therapy.

MAIN OUTCOME MEASURES

Remission of JORRP, defined as no surgical procedures for at least 1 year, as associated with age at diagnosis, drug therapy in the first year after diagnosis, number of surgical procedures in the first year after diagnosis, and number of anatomical sites of disease at diagnosis. Demographic factors (sex and race) and Medicaid status were also evaluated.

RESULTS

Older age at diagnosis was positively associated with remission of JORRP (hazards ratio for every increase of 1 year in age, 1.13; 95% confidence interval, 1.03-1.23).

CONCLUSIONS

Younger children were found to have persistent disease and often underwent an increased number of surgical procedures in the first year after diagnosis of JORRP. Sex and race were not important factors in determining remission.

Lower airway papillomatosis in children

Laryngeal papilloma in children is a frequent disease caused by human papilloma virus (HPV) type 6 or type 11. This disease has a tendency to recur and the changes are histologically benign. In some cases papilloma may affect the lower levels of the respiratory tract. In this study, among 90 patients treated for laryngeal papillomatosis, in four children papilloma of trachea, bronchi and lung tissue were detected in endoscopic and radiological examination. This constitutes 4.4% of all patients. Compact nodules and acquired cysts between 5 and 50 mm long were found in chest X-rays and in computerised tomography. These cysts appeared from 4 to 8 years after establishing a diagnosis of laryngeal papilloma, and 1 year after recognising papilloma in the trachea. In all four children the presence of nodules and cysts in the lungs was preceded by recurrent pneumonia, emphysema or atelectasis of the lungs. All children with laryngeal papillomatosis should have a chest X-ray. Detection of acquired cyst-like changes in lung tissue in children with laryngeal papillomatosis is a warning of future papilloma in the trachea and bronchi, with involvement of lung tissue. In differential diagnosis of these changes in the lungs we should take into consideration the presence of papilloma in the bronchi. A prognosis of papillomatosis in the lower airways in children is always serious.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a relatively rare disease caused by members of the human papilloma virus family. Lesions may occur anywhere throughout the respiratory tract but show a predilection for squamo-columnar epithelial junctions, frequently leading to hoarseness and upper airway obstruction. Rarely, it can progress to squamous cell carcinoma. The impact of recurrent respiratory papillomatosis on patients, their families, and the health care system is considerable. Unfortunately, despite extensive investigational studies, no cure is available for the disease. This article reviews the aetiology of and therapeutic options for recurrent respiratory papillomatosis.

Adenosquamous carcinoma of the upper aerodigestive tract: a clinicopathologic study of 12 cases and review of the literature

PURPOSE

Adenosquamous carcinoma is an uncommon, controversial neoplasm. To further comprehend its natural history, the clinical and pathological features of 12 new cases were reviewed and analyzed collectively with those described in the English literature.

MATERIALS AND METHODS

Twelve cases of adenosquamous carcinoma of the upper aerodigestive tract with adequate follow-up and available microscopic slides and paraffin tissue blocks were identified in the anatomic pathology files of Presbyterian Hospital of the University of Pittsburgh Medical Center over the period 1983-2001.

RESULTS

The 8 men and 4 women ranged in age from 34 to 81 years (mean, 62.8 years). The larynx (5 cases) and the floor of the mouth (4 cases) were the most common sites of origin. Nine patients had cervical lymph nodes positive for carcinoma (8 at diagnosis), 7 experienced local recurrences, and 2 developed distant metastases. Four of 10 (40%) patients with follow-up died of disease. Combining our cases with those in the literature (total of 58 cases) revealed similar findings: 64.7% were associated with positive cervical lymph nodes, 46.7% experienced local recurrences, 23.1% developed distant metastases, and 42.9% died of their disease at a mean follow-up period of 24.7 months.

CONCLUSIONS

Adenosquamous carcinoma is an aggressive neoplasm with a tendency for early lymph node metastasis, frequent local recurrence, occasional distant metastasis, and death from disease, usually within 2-3 years. Surgery with neck dissection is the treatment of choice.

Therapeutic outcome of Epstein-Barr virus positive T/NK cell lymphoma in the upper aerodigestive tract

Expression of the natural killer (NK) cell antigen CD56 is uncommon in malignant lymphoma, but when it is, it is almost exclusively of the non-B cell lineage and show a preference for the nasal and nasopharyngeal region. T/NK cell lymphoma is known to be aggressive and refractory to treatment. It is highly associated with the Epstein-Barr Virus (EBV), but clinical investigations are rarely reported, that is until recently. We report here, on the clinical features and therapeutic outcomes of patients with T/NK cell lymphomas and its association with EBV. We reviewed fifty-four cases with peripheral T cell lymphomas in the upper aerodigestive tract between Jan. 1987 and Aug. 1998 from the Severance Hospital, Yonsei University College of Medicine. The diagnosis of T/NK cell lymphoma was made according to the expression of the NK cell markers, CD56 antigen and cytoplasmic CD3epsilon, in tumor specimens, by immunohistochemistry. Epstein-Barr early region (EBER) RNA was detected using in situ hybridization on paraffin-embedded sections. Among the 54 cases with malignant lymphomas occurring in the upper aerodigestive tract, 20 had T/NK cell lymphoma (37%). The primary sites of T/NK cell lymphomas were the nasal cavity, 12 cases (60%), the tonsils, 4 cases (20%), the nasopharynx, 2 cases (10%), and the oropharynx, 2 case (10%). There were no differences between the features, at diagnosis or therapeutic modalities for patients with T/NK cell lymphoma and non-T/NK cell lymphoma. The complete remission rate of T/NK cell lymphomas was lower than non-T/NK cell lymphomas (65% vs 85%, p=0.02). The overall survival of T/NK cell lymphomas was 13 months (1-74 month), which was significantly lower than non-T/NK cell lymphomas [60.6% with a median follow up of 22 months (1-101 month, p=0.02)]. Disease free survival of T/NK cell lymphomas was 22 months (4-66 month), significantly lower than non-T/NK cell lymphomas [73.8% with a median follow up of 22 months (2-95 month), p=0.04]. The overall survival rates for T/NK cell lymphomas were significantly lower than for EBV positive non-T/NK cell lymphomas (p=0.018). EBER RNA was detected in the paraffin-embedded tissue sections of all T/NK cell lymphomas, compared to only 17.6% (6 of 34 cases) for non- T/NK cell lymphomas. In conclusion, as patients with T/NK cell lymphomas showed poor clinical outcomes, and a high association with EBV positivity, clinical trials with more investigational therapeutic strategies, and further research into the relationship of EBV infection with pathogenesis of T/NK cell lymphoma is warranted.

Racial and ethnic disparities in the receipt of cancer treatment

A disproportionate number of cancer deaths occur among racial/ethnic minorities, particularly African Americans, who have a 33% higher risk of dying of cancer than whites. Although differences in incidence and stage of disease at diagnosis may contribute to racial disparities in mortality, evidence of racial disparities in the receipt of treatment of other chronic diseases raises questions about the possible role of inequities in the receipt of cancer treatment. To evaluate racial/ethnic disparities in the receipt of cancer treatment, we examined the published literature that addressed access/use of specific cancer treatment procedures, trends in patterns of use, or survival studies. We found evidence of racial disparities in receipt of definitive primary therapy, conservative therapy, and adjuvant therapy. These treatment differences could not be completely explained by racial/ethnic variation in clinically relevant factors. In many studies, these treatment differences were associated with an adverse impact on the health outcomes of racial/ethnic minorities, including more frequent recurrence, shorter disease-free survival, and higher mortality. Reducing the influence of nonclinical factors on the receipt of cancer treatment may, therefore, provide an important means of reducing racial/ethnic disparities in health. New data resources and improved study methodology are needed to better identify and quantify the full spectrum of nonclinical factors that contribute to the higher cancer mortality among racial/ethnic minorities and to develop strategies to facilitate receipt of appropriate cancer care for all patients.

Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas

PURPOSE

To evaluate delayed complications after esophageal expandable metallic stent placement.

MATERIALS AND METHODS

From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction).

RESULTS

Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement.

CONCLUSION

Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.

Squamous cell carcinoma of the esophagus infiltrating the respiratory tract is less sensitive to preoperative concurrent radiation and chemotherapy

BACKGROUND

The prognosis of upper thoracic esophageal cancer is poor when compared with middle and lower thoracic esophageal cancer because the tumor easily infiltrates the respiratory tract and surgical en-bloc resection is difficult. Recently, preoperative chemoradiation therapy has been shown to lead to down-staging of the disease and improve prognosis. But the benefit of this therapy for tumors infiltrating the respiratory tract remains unknown.

STUDY DESIGN

Fifty-six patients with thoracic esophageal cancer infiltrating neighboring organs, but with no hematogeneous metastasis, were given preoperative concurrent chemotherapy (5-fluorouracil and cisplatin) and radiation (40 Gy) therapy. When a clinical response was observed, making a curative resection potentially possible, patients were scheduled for esophagectomy with extended lymphadenectomy. Patient prognosis with respect to the organs infiltrated by the tumors was estimated by calculating survival curves using the Kaplan-Meier method and comparing the curves by the log-rank test.

RESULTS

The prognosis was significantly poorer for patients with tumors infiltrating the respiratory tract (T) or aorta plus respiratory tract (A + T) than for patients with tumors infiltrating the aorta alone (A) or other organs (Oth) (p < 0.05 for Oth versus T; p < 0.05 for Oth versus A + T; p < 0.0001 for A versus T; p < 0.0001 for A versus A + T by log-rank test). Patients positive for respiratory tract invasion (T, T + A), compared with those negative for respiratory tract invasion (A, Oth), showed a poorer clinical response to chemoradiation (3.0%, 45.5%, 39.4%, and 9.1% versus 4.3%, 82.6%, 4.3%, and 8.7% in complete response (CR), partial response (PR), nonresponse (NC) and progressive disease (PD), respectively, p = 0.0156) and surgical resectability (36.4% vs. 87.0%, p = 0.0003). Histologic effectiveness (8.3%, 50.0%, and 41.7% versus 25.0%, 70.0%, and 5.0% in grade 3, grade 2, and grade 1, respectively, for patients with respiratory tract invasion versus those without it, p = 0.0189) and histologic stages (8.3%, 8.3%, 8.3%, 8.3%, 25.0%, and 41.7% versus 20.0%, 0%, 15.0%, 25.0%, 40.0%, and 0% in pathologic CR, stage I, stage IIA, stage IIB, stage III, and stage IV, respectively, for patients with respiratory tract invasion versus those without it, p = 0.0496) were significantly better in patients negative for respiratory tract invasion; the percentages of patients with lymph node metastasis did not differ significantly between the two groups. Comparison of the recurrence patterns showed that local failure was most common in patients with respiratory tract invasion, and distant failure was the leading cause of recurrence in patients without it.

CONCLUSIONS

Because the prognosis of patients with thoracic esophageal cancer infiltrating the respiratory tract is extremely poor, partially because of the low local effectiveness of preoperative concurrent chemotherapy and radiation therapy, caution is needed when deciding on salvage surgery.

Neoplasia of the respiratory tract

Tumors of the equine respiratory tract occur infrequently. An accurate diagnosis of neoplasia of the respiratory tract is critical because the prognosis is usually grave. The clinical signs and diagnostic procedures are discussed for tumors of the nasal and paranasal sinuses, nasopharynx/larynx, guttural pouch and thorax including lung, pleura, and thymus.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a disease characterized by the growth of wart-like neoplasms anywhere along the aerodigestive tract. The etiologic agent is the human papillomavirus, of which 90 subtypes have been described. The age distribution of those affected appears to be a bimodal curve, with the first peak around 5 years of age and the second occurring in adults in the third decade of life. The mainstay of treatment is surgical resection to maintain an adequate airway; patients often require multiple surgeries. The epidemiology, pathogenesis, clinical features, and treatment options are discussed. Current evidence regarding prognosis and the multifactorial nature of pathogenesis are also reviewed.

[Primary melanoma of the respiratory tract]

4 cases of melanoma of the respiratory tract (trachea and bronchi) are analysed clinico-morphologically. A case of melanoma with a primary multiple location (trachea and the main bronchus), rapid recurrence after surgery and radiation therapy is described in detail. Melanocytic nature of the tumor is proved immunohistochemically.

Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene-covered Z-stent

PURPOSE

To prospectively evaluate the clinical efficacy of polyethylene-covered metallic Z-stents in treatment of dysphagia secondary to malignant esophageal obstruction and esophagorespiratory fistula.

MATERIALS AND METHODS

Thirty-five patients with dysphagia due to malignant esophageal obstruction (n = 32) and esophagorespiratory fistula (n = 3) were treated with polyethylene-covered Gianturco-Rösch Z-stents.

RESULTS

Thirty-nine stents were placed in 35 patients. Stent placement was technically successful in all patients. Improvement in dysphagia was achieved in 34 of 35 patients. The average dysphagia score decreased from 3.1 (dysphagia to liquids) to 0.6 (essentially normal diet). An esophagorespiratory fistula was completely sealed in two of three patients. All 35 patients were followed up clinically at 1 day and 1 week and at 3-month intervals (range, 1 week to 18 1/2 months; mean, 4.8 months). Recurrent dysphagia or aspiration occurred in only three of 34 (9%) patients whose disease was initially palliated and was easily treated in all cases. Nine complications occurred in eight patients (23%) and included chest pain that required analgesia (n = 3), food impaction (n = 1), stent migration (n = 2), and upper gastrointestinal tract hemorrhage (n = 3).

CONCLUSION

Polyethylene-covered stents are a relatively safe and effective means of long-term palliation in patients with severe malignant esophageal obstruction and esophagorespiratory fistula. These stents are easily deployed, and the rate of stent migration is relatively low.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is an uncommon clinical disorder of the respiratory epithelium caused by HPV. It shares an identical viral etiology with genital condyloma and, in all likelihood, is transmitted at the time of birth (juvenile onset RRP) or through intimate sexual contact (adult onset RRP). Despite the precision of the surgical laser under magnification of the operating microscope, a substantial proportion of patients with RRP, adults as well as pediatric, require repeated operations at frequent intervals because of severe hoarseness and upper airway obstruction. For the management of at least a subset of patients, the efficacy of adjuvant agents (interferon is a leading choice) should be investigated in a multi-institutional clinical trial. For the potential prophylactic benefit, cesarean sections in selected high-risk expectant mothers should be considered.

[Molecular-biological aspects of juvenile respiratory papillomatosis and its combined treatment]

Systemic clinical and molecular-biological analyses of cause-effect relations between human papillomatosis virus (HPV) and juvenile respiratory papillomatosis (JRP) disclosed general mechanism of HPV infection initiation and stages of tumor genesis. However, there is no consent on the universal etiopathogenetic approach to the disease treatment. The authors give some results to the disease treatment. The authors give some results of present-day combined treatment of JRP which includes surgical removal of papillomas and modulation of immunity by interferon preparations.

Solitary plasmacytoma of bone and extramedullary plasmacytoma: two different entities?

BACKGROUND

The objective of this study was to evaluate the similarities between solitary plasmacytoma of bone (SPB) and extramedullary plasmacytoma (EP).

PATIENTS AND METHODS

The clinical features, treatment and survival of 54 patients with localized plasmacytoma (LP) 1990 were carefully reviewed. Follow-up was expected to continue until June 1993.

RESULTS

Thirty-two patients were classified as having SPB and 22 EP. Most of the patients were males. particularly those in the SPB group. Their median age at diagnosis was 54 years and no significant difference between the two groups was observed. SPB occurred most frequently in the vertebral column (42%) and EP in the upper respiratory tract (73%). Fifteen patients with SPB and 2 with EP had paraproteinemia at diagnosis, multiple myeloma (MM) became evident in 75% of the patients with persistent paraprotein after therapy, and in only 22% of those in whom it disappeared. Four patients in the SPB group had immunoparesis, and 3 developed MM. Disease progression toward MM was significantly different (p=0.003) in the two groups, while overall survival differences were not significant (p=0.07) unless unrelated causes were excluded (p=0.02). Adjuvant chemotherapy did not seem to limit diffusion of the disease.

CONCLUSIONS

Although EP and SPB are both localized forms of plasma cell dyscrasias, SPB seems to have a greater tendency to progression MM. It appears, however, that the apparent stronger propensity of SPB to progress is actually due to the great number of cases that at diagnosis conceal an occult MM.

Decision tree model describing alternate health care choices made by oncology patients

What common sense decision strategies do patients with cancer use when they are making health care choices that include alternate therapies? Existing research indicates that oncology patients are making alternate choices while associated with biomedicine. Often patients' decision strategies are exploited by the alternate system to promote and market alternate products. Although some of these practices are benign, others are dangerous or may interfere or delay successful treatment in biomedicine. Therefore, it seems important for biomedical professionals to understand patients' common sense decision patterns. A decision tree model, outlining patients' decision strategies, has recently been developed through intensive interviews with 300 patients who were diagnosed with cancer of the respiratory and digestive systems. The two-phase methodology included, first, a context sensitive approach to develop the model, followed by a predictive approach testing the model developed in the first phase on a separate yet similar random sample of patients. The discussion in this article focuses on the research, the patterns of the decision tree model, and the implications and adaptability of this model to nursing practice.

Mucous membrane plasmacytosis of the upper aerodigestive tract. A clinicopathologic study

We report 9 patients with an unusual plasma cell proliferative disorder of the upper aerodigestive tract. Six patients were men and three, women. The age at presentation ranged from 40 to 67 years with a mean of 54 years. Symptoms at presentation included dysphonia, dysphagia, difficulty breathing, and oral pain. These plasma cell lesions typically produced a cobblestone or warty appearance of the upper aerodigestive tract mucosa including the larynx, pharynx, palate, lips, mouth, tongue, and trachea in varying combination of multiple sites in each patient. Histologically, all lesions were characterized by psoriasiform epithelial hyperplasia with dyskeratosis and dense subepithelial plasmacytosis. Plasma cells were mature but so expansive and diffuse in infiltration as to suggest extramedullary plasmacytoma. Immunohistochemistry for kappa and lambda light chain showed polyclonal immunoglobulin content in all cases examined. Microbial cultures and Warthin-Starry stains were negative for organisms. A variety of treatments including antibiotic therapy, corticosteroid administration, and surgical resection were unsuccessful. In two patients, the process required tracheostomy. This disorder has not been previously described with the exception of a single reported case, which is included in this series. The etiology, pathogenesis, and successful management of mucous membrane plasmacytosis remain unknown.

[Natural killer activity in respiratory papillomatosis and its changes after interferon treatment]

A method to determine changes in the activity of natural killers (NK) in treatment of juvenile respiratory papillomatosis in children and correlation with the clinical course of the disease was developed and studies with whole blood specimens were carried out before interferon (IF) treatment and after it. Initially high levels of NK activity and their subsequent decline were observed in the cases where IF treatment had no effect, whereas initially low levels with subsequent increase after treatment or normal levels remaining unchanged in the course of treatment were typical of the patients manifesting some clinical effect of the treatment. These studies confirm the possibility of the modulating effect of IF, and the method may be used in mass surveys and working with children.

[The effect of exogenous interferon on the in vitro production of alpha- and gamma-interferon by the lymphocytes of patients with respiratory papillomatosis]

The influence of various interferon concentrations in vitro on alpha- and gamma-interferon production by lymphocytes of children suffering from respiratory papillomatosis was studied for optimization of interferon therapy. Most of the children with clinical improvement after interferon treatment showed proportional dependence of alpha-interferon production upon exogenous interferon concentrations and stability of gamma-interferon production. In children without clinical improvement, initial production of both interferons was reduced significantly in the absence of IF in the medium, but no changes occurred when exogenous interferon was present in the medium. The test proposed here may be used for the determination of patients' sensitivity to interferon and for individualization of interferon treatment schedules in other long-lasting recurrent diseases.

Antibodies in patients with recurrent respiratory papillomatosis treated with lymphoblastoid interferon

Serum specimens from 53 evaluable patients enrolled in a clinical trial of lymphoblastoid interferon in recurrent respiratory papillomatosis were screened for the presence of interferon-binding antibodies by an indirect enzyme immunoassay and evaluated for neutralizing antibody measured as the inhibition of antiviral activity. Immunoglobulin G antibodies that specifically bound lymphoblastoid interferon were detected in 66% (35 of 53) of patients; neutralizing antibody was detected in 11 of the 35 patients having binding antibody (and in none of the patients who were negative for binding antibody). The incidence of detectable neutralizing antibody in this study population was 20.8% (11 of 53), which is markedly higher than in previous reports of lymphoblastoid interferon in patients with other diseases (i.e., less than 1% incidence). The cumulative dose received at the time of detection of neutralizing antibody ranged from 163 to 385 MU per square meter of body surface. Neutralizing antibody was detectable at a median time of 120 days after initiation of interferon therapy, and binding antibody appeared earlier in those patients (median 59 days) than in patients in whom only binding antibody was produced (median 116 days). Despite the tendency of binding antibody to appear either in patients in whom neutralizing antibody was eventually formed, the detection of binding antibody was not necessarily predictive of the subsequent development of neutralizing antibodies. Binding antibody persisted after neutralizing antibodies had become undetectable.(ABSTRACT TRUNCATED AT 250 WORDS)

[The interferon status and circulating immunoglobulins during the interferon therapy of respiratory papillomatosis in children]

Studies on the functional activity of interferon (IF) system (interferon status and serum immunoglobulins levels) and its changes in the course of interferon therapy of juvenile respiratory papillomatosis are presented. The initial disorders in alpha-IF production and levels of circulating IF came to normal after interferon therapy. Correlative changes of the following parameters occurred: a decrease in the level of circulating IF and IgM and simultaneous increase in the level of alpha-IF and IgG which, however, did not always correlate strictly with the course of the disease and the kind of preparation used.

Long-term response of recurrent respiratory papillomatosis to treatment with lymphoblastoid interferon alfa-N1. Papilloma Study Group

BACKGROUND

We earlier reported that patients with recurrent respiratory papillomatosis responded to six months of treatment with lymphoblastoid interferon alfa-n1. Because another study of patients treated for one year with leukocyte interferon alfa-n3 found that the growth rate of papillomas was slowed in the first six months but returned to base line during months 7 through 12 despite persistent interferon treatment, we now report the long-term results in our original study patients who were followed for a median of four years after the original one-year crossover study.

METHODS

After the patients in our study had completed the first study year, their physicians could continue or recommence treatment with lymphoblastoid interferon alfa-n1 in a dose of either 2 MU per square meter of body-surface area per day or 4 MU per square meter every other day. The extent of disease was measured by endoscopy when clinically indicated.

RESULTS

Data on late-follow-up were obtained for 60 of the 66 patients. There were 22 complete remissions and 25 partial remissions; 13 patients had no response. The median duration of the complete remissions was 550 days, and 15 patients continued to be in complete remission. The median duration of partial remissions was 400 days and seven patients were still in partial remission. Thirteen of 28 patients responded to a second course of interferon after an interruption in treatment of at least one month. The rate of response in the 11 of 53 patients who had neutralizing antibody to interferon was the same as in the patients without the antibody.

CONCLUSIONS

Patients with severe recurrent respiratory papillomatosis may have a sustained or repeated response to treatment with lymphoblastoid interferon alfa-n1. We recommend that patients with recurrent respiratory papillomatosis who require surgery every two to three months be given a six-month trial of interferon alfa-n1.