MRI in head and neck cancer following chemoradiotherapy: what is the optimal delay to demonstrate maximal response?

OBJECTIVES

To investigate the optimal timing for post-chemoradiotherapy (CRT) reference magnetic resonance imaging (MRI) in head and neck cancer, so as to demonstrate a maximal treatment response. To assess whether this differs in human papillomavirus-related oropharyngeal cancer (HPV-OPC) and whether the MRI timing impacts on the ability to predict treatment success.

METHODS

Following ethical approval and informed consent, 45 patients (40 male, mean age 59.7 ± 7.9 years, 33 HPV-OPC) with stage 3 and 4 HNSCC underwent pre-treatment, 6- and 12-week post-CRT MRIs in this prospective cohort study. Primary tumour (n = 39) size, T2w morphology and diffusion weight imaging (DWI) scores, together with nodal (n = 42) size and necrotic/cystic change, were recorded. Interval imaging changes were analysed for all patients and according to HPV-OPC status. MRI descriptors and their interval changes were also compared with 2-year progression-free survival (PFS).

RESULTS

All MRI descriptors significantly changed between pre-treatment and 6-week post-treatment MRI studies (p < .001). Primary tumour and nodal volume decreased between 6- and 12-week studies; however, interval changes in linear dimensions were only evident for HPV-OPC lymph nodes. Nodal necrosis scores also evolved after 6 weeks but other descriptors were stable. The 6-week nodal necrosis score and the 6- and 12-week nodal volume were predictive of 2-year PFS.

CONCLUSION

Apart from HPV-OPC patients with nodal disease, the 6-week post-CRT MRI demonstrates maximal reduction in the linear dimensions of head and neck cancer; however, a later reference study should be considered if volumetric analysis is applied.

KEY POINTS

• This study provides guidance on when early post-treatment imaging should be performed in head and neck cancer following chemoradiotherapy, in order to aid subsequent detection of recurrent tumour. • Lymph nodes in HPV-related oropharyngeal cancer patients clearly reduced in size from 6 to 12 weeks post-treatment. However, other lymph node disease and all primary tumours showed only a minor reduction in size beyond 6 weeks, and this required a detailed volumetric analysis for demonstration. • Timing of the reference MRI following chemoradiotherapy for head and neck cancer depends on whether the patient has HPV-related oropharyngeal cancer and whether there is nodal disease. MRI as early as 6 weeks post-treatment may be performed unless volumetric analysis is routinely performed.

Increased use of pre-operative imaging and laparoscopy has no impact on clinical outcomes in patients undergoing appendicectomy

INTRODUCTION

The aim of this study was to review changes in the management of acute appendicitis in a ten-year period at a large university teaching hospital in London.

METHODS

This was a retrospective cohort study reviewing the medical records of patients who underwent an appendicectomy over a period of 12 months either in 1999 or 2009. Data collected included use of radiological investigations (ultrasonography, computed tomography [CT]), technique of appendicectomy (open [OA] or laparoscopic [LA]), operative time, histopathology and post-operative complications. Univariate and multivariate analysis was performed to assess the influence of variables on the incidence of negative appendicectomy, appendiceal perforation and post-operative complications.

RESULTS

All of the patients operated on in 1999 (n=109) had OA. Of the patients operated on in 2009 (n=164), 67 had OA, 91 had LA and 6 had LA converted to OA. None of the patients in 1999 had CT whereas in 2009 26% of patients had CT (sensitivity 94.7%, specificity 75.0%). This increased use of pre-operative imaging had no effect on negative appendicectomy (25.7% vs 12.8%, p=0.445), perforation (30.0% vs 21.3%, p=0.308) or complication rates (9.2% vs 10.4%). The complication rate was also similar regardless of whether patients had OA or LA (11.9% vs 9.9%). Multivariate analysis revealed that age was the only predictor of negative appendicectomy (p=0.029) or perforation (p=0.014).

CONCLUSIONS

This study shows that significant increase in the use of pre-operative imaging and laparoscopy in the management of patients with acute appendicitis failed to reduce negative appendicectomy, perforation and complications rates. The patient's age was the only predictor of negative appendicectomy and perforation.

Decreasing the prevalence of pressure ulcers using agency standards

Home care patients either have or are at high risk for pressure ulcers. This article describes the outcome of a study that examined the effects of pressure ulcer prevention and treatment standards on the prevalence rate of a home healthcare agency's client caseload. Implications for practice and further research also are discussed.

Pressure ulcer incidence in an acute care setting

The purpose of this prospective study was to determine the incidence of pressure ulcers and to examine factors related to pressure ulcer development in patients in an acute care setting. Adult medical and surgical patients who were free of pressure ulcers at admission were assessed within 36 hours of admission and then three times per week for 2 weeks or until discharge. Instruments included a demographic data form, a skin assessment form, and the Braden Scale for Predicting Pressure Sore Risk. Most subjects had 46 assessments completed. The sample consisted of 149 subjects, with a pressure ulcer incidence rate of 13.4% (n = 20). Subjects who acquired pressure ulcers had lower hemoglobin levels (t = 2.17, p = 0.03), spent more time in bed (t = 3.90, p = 0.0001), and spent less time in a chair (t = 3.2, p = 0.002) than those who did not acquire pressure ulcers. A stepwise logistic regression analysis was used to calculate risk of pressure ulcer development. In the final model, hemoglobin level and hours spent in bed continued to be predictors of pressure ulcer development (chi 2 = 9.306, df = 2, p = 0.0095). All 20 subjects who acquired pressure ulcers were further categorized into groups with stage I (n = 12) or stage II (n = 8) ulcers. Patients with stage I pressure ulcers were primarily receiving post-surgical care (67%), whereas patients who acquired stage II ulcers had medical conditions that affected tissue perfusion, such as respiratory diseases (50%) and diabetes mellitus (12%).

The effectiveness of skin care protocols for pressure ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.

Skin care strategies in a skilled nursing home

1. Pressure ulcers continue to be a serious problem in nursing home settings. They are significant as a source of discomfort and disability among nursing home residents, as well as a source of financial concern for the institutional agencies responsible for resident care. 2. Prevention and intervention at the earliest stages of pressure ulcer development offer the most effective approaches to mediating the human and economic costs imposed by pressure ulcers. 3. Strategies that are effective in reducing both the development and severity of pressure ulcers can be successfully implemented in long-term care settings. Further studies are needed that will provide additional support for the strategies and protocols used in this study.

Evaluation of pressure ulcer prevalence rates for hospice patients post-implementation of pressure ulcer protocols

Hospice patients may be particularly at risk for pressure ulcer development due to several factors. Identifying populations at risk for pressure ulcer development, such as hospice patients, and providing prevention and risk protocols for these populations can substantially reduce the prevalence and incidence of pressure ulcers. However, are hospice patients prone for skin breakdown despite prevention and treatment efforts? This study examines the prevalence of pressure ulcers in hospice patients following the implementation of pressure ulcer prevention and treatment protocols. Levine's theory of conservation of structural integrity formed the theoretical framework for this descriptive study. A midwestern hospital-based hospice agency was the site for this study. All patients 18 years of age and older were included in the study. Pressure ulcer prevalence audits were done at four, eight, 12, and 18 months after protocols were outlined by the hospice staff. Results of the audits revealed prevalence rates of 14.8 percent, 8.5 percent, 13.6 percent, and 23.8 percent, at each of the aforementioned audits. 10 of 15 patients who were pressure ulcer positive were males; the sacral location was most common (seven of 19 ulcers occurred sacrally) with the ischial location being the next common (six of 19 ulcers were ischially located). No ulcers occurred above the waist or in patients below 51 years of age. Recommendations from this study urge that particular prevention attention be given to protocols which address "sitting," due to the predominance of ulcers located in the sacral and ischial regions. In addition, the author concludes that perhaps, pressure ulcers may occur in this population despite the best of efforts to prevent them.

Skin problems: epidemiology of pressure ulcers in a skilled care facility

The majority of nursing home residents have conditions that place them at risk for the development of pressure ulcers. Reported pressure ulcer prevalence rates range from 16% to 35%. Pressure ulcers are multifactorial in origin and necessitate ongoing vigilance by the entire health-care team. Associated risk factors include impairments of circulation, sensation, physical condition, nutrition, mobility, and activity. Stage I pressure ulcers frequently go unrecognized, yet their recognition is essential to prevent further damage. Comprehensive initial assessments of the skin and risk factors of pressure ulcer development at admission will allow for easier reassessment and comparison.

Pressure ulcer prevalence and incidence in a rehabilitation hospital

Pressure ulcers remain a serious health problem, especially in terms of personal suffering and economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time) and the incidence (number of persons developing pressure ulcers over a given time) of pressure ulcers. Skin assessments and risk assessments of the subjects were completed using the Braden Scale for Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.

The prevalence and incidence of pressure ulcers in the hospice setting: analysis of two methodologies

Hospice patients may be at greater risk of pressure ulcer development than most patients. This descriptive study explored the prevalence and incidence of pressure ulcers in the hospice setting, utilizing both a prospective and retrospective methodological approach. Levine's theory of the four principles of conservation formed the theoretical basis for the study, and the Braden Scale for Predicting Pressure Ulcer Risk was used for data collection. Prevalence of pressure ulcers was noted to be 13 percent in the study. Incidence of pressure ulcers was found to be zero percent using prospective methodology and 13 percent using retrospective methodology. Five of eight ulcers (62 percent) occurred within two weeks of patient death. Factors related to pressure ulcer development are presented, as well as a discussion of using research methodologies in the hospice setting. The article suggests the need for preventive protocols for skin care for patients who are at risk for pressure ulcer development.

Incidence and prediction of pressure ulcers in five patient care settings

Pressure ulcers (PU), one example of an alteration in skin integrity, remain a prominent healthcare concern in all patient care settings. Incidence refers to the number of "new cases occurring over a given time period" (NPUAP, 1989, p. 26). Adult patients (n = 190) in five patient care settings who were assessed to be free of PUs on admission were followed over a specified period of time to assess the incidence of pressure ulcer development for each setting. Subjects each had a skin assessment, along with a risk assessment utilizing the Braden Scale. A demographic data form was also completed on each subject. Pressure ulcers developed post-admission in 18 (9%) patients, 11 of whom were acute care patients and eight of whom were patients in skilled care. No patients developed pressure ulcers in the rehabilitation, home care, or hospice settings. Incidence for acute care was 15% and 28% in skilled care. Braden predictor scores were also recommended for each setting and factors associated with pressure ulcer development were discussed.

Tissue plasminogen activator: hospital experience

Tissue plasminogen activator (t-PA) is administered safely and efficiently in the treatment of acute myocardial infarction (MI). A study of 74 patients administered t-PA for acute MI associated with a low complication rate showed an acceptable patency rate, and a good outcome.