Ministry of Health clinical practice guidelines: management of gambling disorders

The Ministry of Health (MOH) has published clinical practice guidelines on Management of Gambling Disorders to provide doctors and patients in Singapore with evidence-based guidance on the management of gambling disorders. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Management of Gambling Disorders for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=26136). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Alloantigen recognition is critical for CD8 T cell-mediated graft anti-tumor activity against murine BCL1 lymphoma after myeloablative bone marrow transplantation

The goal of the current study was to determine whether whole bone marrow cells or splenic CD8(+) T cells from C57BL/6 (H-2(b)) donor mice, which are tolerant to BALB/c (H-2(d)) alloantigens, are capable of mediating graft anti-tumor activity against a BALB/c B-cell lymphoma after injection into irradiated BALB/c hosts. The experimental results show that high doses of splenic CD8(+) T cells mixed with T cell-depleted bone marrow cells from C57BL/6 non-tolerant (normal) donors eliminate the BCL(1) B-cell lymphoma cells and induce lethal graft-versus-host disease (GVHD). CD8(+) T cells from tolerant donors simultaneously lose both their ability to induce GVHD and their anti-tumor activity. Whole bone marrow cell transplants from normal donors eliminated BCL(1) tumor cells without inducing GVHD, and bone marrow cells from tolerant donors failed to eliminate the tumor cells. The infused BCL(1) tumor cells expressed an immunogenic tumor-specific idiotype antigen disparate from host alloantigens, indicating that recognition of the tumor-specific antigen alone was insufficient to elicit graft anti-tumor activity from unimmunized allotolerant donor splenic CD8(+) T cells or whole bone marrow cells. We conclude that CD8(+) T cells from unimmunized normal donor mice require alloantigen recognition to mediate their anti-tumor activity following allogeneic BMT.

Competing risk events determining probability of cause-specific failure in nasopharyngeal carcinoma

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Background: The commonly employed Kaplan-Meier (KM) method is based on the assumption that different failure types (local-regional, distant, etc.) are independent. In reality, these failures occur at different stages in disease progression and are strongly correlated with each other. The assumption of independence of different failure types may violate certain assumptions in the modeling, and hence may affect the clinical interpretation and treatment selection. A better approach to estimate cause-specific failure probability is to calculate cumulative incidence rates by taking into account other events within a competing risk framework, in which the dependency of different failures are considered. Methods: The data was based on a large retrospective cohort study conducted at the Prince of Wales Hospital in Hong Kong, China, in 1996–97. 945 patients with nasopharyngeal carcinoma (NPC) had been treated with a standard protocol and been followed up regularly with a median follow-up period of 69 months (1–122 months). We calculated the cumulative incidence rates of local-regional failure and distant metastasis, and compared the result against KM method. In competing risk analysis, local regional failure, distant metastases and death were considered as competing events during the remaining lifetime of NPC patients from first presentation. Results: The probability of local-regional failure and distant metastasis was higher by KM method than by competing risk method. The result indicated that KM analysis overestimated event rate and the difference became larger in a longer follow-up period, when more competing events occurred. Conclusion: Kaplan-Meier analysis overestimates the probability of cause-specific failure. Competing risk analysis provides us a more accurate method in the determination of the pattern of failure. It provides better evidence to clinicians to enable them to predict the prognosis and select proper therapy.

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No significant financial relationships to disclose.

Paranasopharyngeal space involvement in nasopharyngeal cancer: detection by CT and MRI

Paranasopharyngeal tumour extension (PTE) from nasopharyngeal carcinoma (NPC) is staged in its own subgroup in the American Joint Committee on Cancer classification. Most large clinical trials use computed tomography (CT) to stage PTE, but diagnosis relies on indirect signs of tumour invasion such as asymmetry of the parapharyngeal fat. Magnetic resonance imaging (MRI) has the advantage of directly revealing PTE because of its ability to depict the complex anatomical structures that form the boundary of the nasopharynx. The aim of this study was to compare CT and MRI in the identification of PTE and to determine whether the imaging modality used influenced staging of the disease. The MRI and CT scans of 78 patients (156 parapharyngeal regions) with NPC were assessed for PTE. On MRI, PTE was considered to be positive when there was tumour invasion through the complex anatomical structures of the nasopharyngeal wall. When using CT, it was considered positive when there was: (1) distortion of the parapharyngeal fat plane; or (2) extension beyond a line drawn from the medial pterygoid plate to the lateral aspect of the carotid artery. CT scanning and MRI were compared. PTE was judged to be present in 28 of 78 (36%) patients by MRI and in 41 of 78 (53%) scanning by CT when using criterion 1 or 2. An analysis of the discordant findings revealed that MRI was positive in three sides of the nasopharynx in early tumour extension through the pharyngobasilar fascia but not identified with CT by using criterion 1 or 2. MRI was negative in 20 and 21 sides of the nasopharynx that were judged to be positive on CT by using criterion 1 and 2 respectively. In these patients MRI revealed that the positive CT scan was caused by a large tumour compressing but not invading the parapharyngeal fat space, a metastatic lateral retropharyngeal node, or a combination of the two. The imaging modality used for staging NPC has an impact on the staging of PTE. CT scanning suggested the presence of PTE more frequently than MRI because of its inability to distinguish the primary tumour from lateral retropharyngeal nodes, and direct tumour invasion of the parapharyngeal region from tumour compression. The imaging modality and criteria used for staging PTE should be taken into consideration when assessing the results of clinical studies.

Radiation induced sarcomas of the head and neck following radiotherapy for nasopharyngeal carcinoma

AIM

To report the radiological findings of radiation induced sarcomas (RIS) in the head and neck following radiotherapy for nasopharyngeal carcinoma.

MATERIALS AND METHODS

The clinical notes and radiological studies (MR n = 3, CT n = 4) of four patients were reviewed retrospectively.

RESULTS

RIS developed 5 to 10 years following radiotherapy. Two patients had tumours arising from the alveolar process of the maxilla, one from the nasal cavity, and one patient had a tumour at two sites, involving the external auditory canal and the uvula. Three of the four patients had large tumours at diagnosis with a 3.5-6 cm predominately homogeneous soft tissue mass, complete destruction of bone and extensive local invasion. One was small and localized to the nasal turbinate. Radiation osteitis was identified in two of the four (50%) patients.

CONCLUSION

The site of RIS following radiotherapy for NPC is variable but is invariably within the high dose zone of the radiotherapy. These sarcomas tend to present late with a large soft tissue mass. Radiation osteitis is not a constant feature. As surgery provides the only chance of cure, imaging has an important role in the pre-operative mapping of the extent of tumour. et al.

Staging computed tomography of the thorax for nasopharyngeal carcinoma

BACKGROUND

To assess the role of staging CT of the thorax in advanced nodal stage nasopharyngeal carcinoma and to examine the hypothesis that contiguous spread of nodal metastases from the supraclavicular region to the upper mediastinal region occurs in this cancer.

METHODS

Forty-four patients with newly diagnosed nasopharyngeal carcinoma with neck node metastases to the supraclavicular region (ie, AJCC N3b stage) underwent contrast-enhanced CT (CECT) thorax for staging. CT findings and clinical outcome were analyzed.

RESULTS

No patient was found to have intrathoracic metastasis, although 1 had hepatic metastases on CECT of the thorax, resulting in upstaging in 1 of 44 (2%) of patients. With a median follow-up time of 21 months, 3 patients had lung metastases and 2 had axillary nodal metastases develop without evidence of upper mediastinal nodal metastases.

CONCLUSION

Staging CECT of the thorax has a very low yield in nasopharyngeal carcinoma, even in advanced nodal disease. The hypothesis that contiguous spread of nodal metastases from the supraclavicular region to the upper mediastinum is not substantiated, and no evidence suggests that radiation therapy for N3b-stage disease needs to encompass the upper mediastinum.

Neck node metastases from nasopharyngeal carcinoma: MR imaging of patterns of disease

BACKGROUND

The purpose was to use MR imaging to document the patterns of nodal involvement in the upper neck in nasopharyngeal carcinoma (NPC).

METHODS

The MR images of 150 patients with newly diagnosed NPC were reviewed retrospectively. Nodes were considered abnormal on MR criteria of size, necrosis, and extracapsular spread.

RESULTS

Retropharyngeal nodes (RN) were more frequently involved than nonretropharyngeal nodes (NRNs) (94% vs 76% in 115 patients with nodal metastases). NRN involvement without RN was seen in only 7 of 115 patients (6%). Involvement of RN at the level of the oropharynx (82%) was as common as at the nasopharynx (83%) level. Internal jugular nodes were the most frequently involved NRN nodes (72%). Spinal accessory nodal involvement was also common (57%) but seldom in isolation (8%). Submandibular (3%) and parotid (2%) nodal metastases were uncommon and were always associated with advanced nodal metastases in the ipsilateral RN, internal jugular, and spinal accessory regions.

CONCLUSION

Retropharyngeal nodes are the first echelons of nodal metastases. Direct lymphatic spread to the neck without involvement of the RN nodes is uncommon. RN metastases at the level of the oropharynx are more common than previously suspected, and this should influence radiotherapy planning. NRN outside the internal jugular and spinal accessory chains are rare and only occur when the usual routes of lymphatic spread have already been blocked by tumor.

Hypoglossal nerve palsy in nasopharyngeal carcinoma

BACKGROUND

The aim of the study was to use magnetic resonance (MR) imaging to determine the cause of hypoglossal nerve palsy and the sites of injury in patients with nasopharyngeal carcinoma before radiation therapy and during postradiation therapy follow-up.

METHODS

The clinical records and MR studies of 21 patients with hypoglossal nerve palsy were retrospectively studied. These 21 patients belonged to a cohort of 387 patients with nasopharyngeal carcinoma (153 with newly diagnosed disease and 234 on postradiation follow-up) who underwent MR imaging in a 2.5-year period.

RESULTS

Four patients had hypoglossal nerve palsy at initial diagnosis and all of them had extensive skull base invasion from tumor extending postero-inferiorly to the level of the foramen magnum. The nerve was invaded in the carotid sheath (3), hypoglossal nerve canal (3), and premedullary cistern (1). In 17 patients developing hypoglossal nerve palsy after radiotherapy, only two (12%) had evidence of tumor recurrence. Radiation-induced neuropathy was the probable cause in 14 patients and 1 case was judged indeterminate. MR evidence of fibrosis was demonstrable along the course the nerve in four patients (29%), involving the carotid sheath (4), hypoglossal nerve canal (2), and premedullary cistern (1). No patient had MR evidence of radiation change in the brain stem. Seven patients had a history of a boost dose of radiation to the parapharyngeal region on one or both sides, and nerve palsy occurred on the boosted side in six of them.

CONCLUSION

Hypoglossal nerve palsy on presentation was caused by locally advanced nasopharyngeal tumor whereas a palsy arising after radiation therapy was more frequently caused by postradiation damage rather than cancer.

Caution on the use of altered fractionation for nasopharyngeal carcinoma

Randomized trials and overviews on the value of altered fractionation for head and neck cancers are reviewed. Attention is drawn to the unexpectedly high incidence of temporal lobe necrosis incurred in patients with nasopharyngeal carcinoma. Preliminary analyses suggest that incomplete repair is likely to be the major factor, even a 6-h interfraction interval may be inadequate if substantial volumes of nervous tissues are included within the target volume.

Detection of recurrent chromosomal gains and losses in primary nasopharyngeal carcinoma by comparative genomic hybridisation

Nasopharyngeal carcinoma (NPC) is a common cancer in Southern China but rare in Western countries. To search for genetic alterations in NPC, we examined a series of 20 primary tumours with comparative genomic hybridisation. The identified common chromosomal alterations included gain of chromosomes 1q, 8, 12, 19 and 20 as well as loss of chromosomes 1p, 3p, 9p, 9q, 11q, 13q, 14q and 16q. In concordance with our previous loss of heterozygosity studies in primary NPC, a high incidence of loss was detected on chromosomes 3p (75%), 11q (70%) and 14q (65%). Losses of 9q (60%), 13q (50%) and 16q (40%) were also identified. Novel chromosomal gains were observed on chromosome 12, with a high frequency (70%). Current analysis has revealed a comprehensive profile of the chromosomal regions showing losses and gains in primary NPC. Our findings may provide an entry point for conducting further investigations to locate the putative tumour-suppresser genes and oncogenes that may be involved in the tumourigenesis of NPC.

MRI of local disease in nasopharyngeal carcinoma: tumour extent vs tumour stage

The purpose was to use MRI to study in detail local tumour extension in patients presenting with nasopharyngeal carcinoma (NPC) and to compare the extent of local disease with the current T-stage classification. MR images of 150 patients with newly diagnosed nasopharyngeal carcinoma were obtained on a 1.5 T unit. 10 extranasopharyngeal sites were analysed for tumour involvement. The number of concurrently involved sites was determined. The extent of tumour invasion was compared with staging as defined by the fifth edition of the AJCC classification. The T-stage distribution was T1 21%, T2 16%, T3 41% and T4 22%. The frequencies of tumour invasion into an individual site, and the mean number of other concurrently involved sites were as follows: skull base 63%, 3.9 sites; parapharyngeal 56%, 3.9 sites; nasal cavity 53%, 4.0 sites; oropharyngeal 17%, 5.2 sites; sphenoid sinus 27%, 5.6 sites; cranium 21%, 5.7 sites; infratemporal fossa 2%, 6.3 sites; ethmoid sinus 14%, 6.5 sites; orbit 5%, 7.0 sites; maxillary sinus 5%, 7.1 sites; and hypopharynx 0%, 0 sites. Extranasopharyngeal extension commonly occurred superiorly into the skull base rather than inferiorly to the oropharynx (p < 0.0001). Anatomical sites defined within the same T-stage category had different frequencies of involvement and different frequencies of concurrently involved sites. Oropharyngeal involvement (T2 stage) was associated with a number of concurrently involved sites comparable to structures in the T3 category. Maxillary and ethmoid sinus involvement (T3 stage) were associated with a number of involved sites comparable to the T4 stage. Invasion of the maxillary antrum and orbit are markers of the most bulky form of NPC.

Submental metastases from nasopharyngeal carcinoma

The primary treatment for nasopharyngeal carcinoma is radiotherapy. Despite optimal treatment the incidence of recurrent persistent or recurrent regional disease is significant. It is believed that recurrent regional disease is usually associated with local disease. Recurrent nodal disease commonly involves the subdigastric and upper jugular region and submental involvement is less common. This study includes 25 patients who had palpable submental nodes 2 years or more after radiotherapy. Five of the seven patients with proven malignant submental nodal recurrence of nasopharyngeal carcinoma had no other evidence of disease. Ultrasound accurately identified enlarged nodes and correctly predicted involvement. The ultrasound appearances of these nodes and their impact on management and prognosis is discussed.

Staging and IgA VCA titre in patients with nasopharyngeal carcinoma: changes over a 12-year period

The distributions of 2093 patients with nasopharyngeal carcinoma (NPC), by stage, over a 12-year-period did not show any evidence of a shift towards early stages despite growing awareness of this prevalent malignancy. The IgA VCA titre was determined for 1880 of these patients. The median titre increased from 40 in stage I to 80 in stages II, III, and IV, before rising to 160 in stage V. The percentage of patients with a titre > or = 320 increased steadily with advancing stages. Within the same disease stage, the percentage of patients having a particular titre value and the median titre varied considerably from year to year. Better education of the general population and a better serological marker for screening are needed for the early detection of NPC.

Nasopharyngeal carcinoma---time lapse before diagnosis and treatment

This is a descriptive study of 168 patients with nasopharyngeal carcinoma who were referred to public oncology departments for primary treatment between July and September 1996. The mean duration from the onset of the symptoms to histological diagnosis was 5.0 months; the duration ranged from 6.1 months (for patients presenting with nasal symptoms) to 1.8 months (for those with cranial nerve dysfunction). The mean period between the onset of symptoms and the seeking of medical advice was 2.9months. For 54% of the patients, there was a further delay of up to 2.4 months between the initial medical consultation and referral to the appropriate specialist. The majority (84%) of patients attended public institutions for histological confirmation. The mean total time taken from the onset of symptoms to the commencement of radiotherapy was 6.5 months (range, 1.3-74.0 months)---45% of the delay was attributed to the patient, 20% to initial consultations, 14% to diagnostic arrangement, and 21% to preparation for radiotherapy. Concerted efforts are needed to minimise further the time between the onset of symptoms and treatment. A substantial reduction in this delay can be achieved if both public and primary care doctors were made more aware of the significance of relevant symptoms.

Significant prognosticators after primary radiotherapy in 903 nondisseminated nasopharyngeal carcinoma evaluated by computer tomography

PURPOSE

To evaluate the significant prognosticators in nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

From 1984 to 1989, 903 treatment-naive nondisseminated (MO) NPC were given primary radical radiotherapy to 60-62.5 Gy in 6 weeks. All patients had computed tomographic (CT) and endoscopic evaluation of the primary tumor. Potentially significant parameters (the patient's age and sex, the anatomical structures infiltrated by the primary lesion, the cervical nodal characteristics, the tumor histological subtypes, and various treatment variables were analyzed by both monovariate and multivariate methods for each of the five clinical endpoints: actuarial survival, disease-free survival, free from distant metastasis, free from local failure, and free from regional failure.

RESULTS

The significant prognosticators predicting for an increased risk of distant metastases and poorer survival included male sex, skull base and cranial nerve(s) involvement, advanced Ho's N level, and presence of fixed or partially fixed nodes or nodes contralateral to the side of the bulk of the nasopharyngeal primary. Advanced patient age led to significantly worse survival and poorer local tumor control. Local and regional failures were both increased by tumor infiltrating the skull base and/or the cranial nerves. In addition, regional failure was increased significantly by advancing Ho's N level. Parapharyngeal tumor involvement was the strongest independent prognosticator that determined distant metastasis and survival rates in the absence of the overriding prognosticators of skull base infiltration, cranial nerve(s) palsy, and cervical nodal metastasis.

CONCLUSIONS

The significant prognosticators are delineated after the advent of CT and these should form the foundation of the modern stage classification for NPC.

The prognostic significance of parapharyngeal tumour involvement in nasopharyngeal carcinoma

From 1984 to 1989, 903 treatment-naive non-disseminated nasopharyngeal carcinomas (NPCs) were given primary radical radiotherapy. All patients had computed tomographic and endoscopic evaluation of the primary tumour. Potentially significant parameters were analysed by both univariate and multivariate methods for independent significance. In the whole group of patients, the male sex, skull base and cranial nerves(s) involvement, advanced Ho N-level, presence of fixed or partially fixed nodes and nodes contralateral to the side of the bulk of the nasopharyngeal primary, significantly determined survival and distant metastasis rates, whereas skull base and cranial nerve involvement, advanced age and male sex significantly worsened local control. However in the Ho T2No subgroup, parapharyngeal tumour involvement was the most significant prognosticator that determined distant metastasis and survival rates in the absence of the overriding prognosticators of skull base infiltration, cranial nerve(s) palsy, and cervical nodal metastasis. The local tumour control of the Ho T2No was adversely affected by the presence of oropharyngeal tumour extension. The administration of booster radiotherapy (20 Gy) after conventional radiotherapy (60-62.5 Gy) in tumours with parapharyngeal involvement has led to an improvement in local control, short of statistical significance.

Afterloading radiotherapy for local persistence of nasopharyngeal carcinoma

71 patients suffering from local persistence of nasopharyngeal carcinoma after primary external radiotherapy were treated by afterloading intracavitary 192Ir. 66 (93.0%) had a complete response as evidenced by fibreoptic nasopharyngoscope examination and biopsy 4 weeks after the treatment. Significant prognosticators were studied by both monovariate and multivariate analysis. The early overall clinical stage at first presentation predicted a favourable survival. Local tumour control was adversely affected by advanced T-stage at first presentation, and by using a single 192Ir source, unilaterally applied to treat only one side of the nasopharynx. The intracavitary treatment was tolerated well and treatment complications were confined to the nasopharynx: chronic radiation ulceration (five patients) and diffuse telangiectasia (three patients).

Multicenter phase II trial of mitoxantrone in patients with advanced nasopharyngeal carcinoma in Southeast Asia: an Asian-Oceanian Clinical Oncology Association Group study

PURPOSE

Patients with advanced nasopharyngeal carcinoma (NPC) have a high incidence of recurrence and often develop distant metastases despite local control. This prospective multicenter phase II trial was conducted to evaluate the safety and efficacy of Novantrone (mitoxantrone; Lederle Laboratories, Wayne, NJ) in the therapy of patients with advanced NPC.

PATIENTS AND METHODS

One hundred eight patients with advanced NPC, namely, those with recurrent or persistent disease following primary radiotherapy, or newly diagnosed metastatic disease, were treated with mitoxantrone. Mitoxantrone was administered intravenously at an initial dose of 12 mg/m2 and repeated every 3 weeks, with dose escalation to a maximum of 14 mg/m2. The distribution of histologic subtypes was representative of NPC, with the majority being (61%) undifferentiated (or anaplastic) carcinoma.

RESULTS

The overall response rate (complete response [CR] and partial response [PR]) was 25% (95% confidence interval, 17% to 33%). The median response duration, time to treatment failure, and survival duration were 140, 82, and 394 days, respectively. Histology (poorly differentiated squamous cell) was found to be the only important factor in predicting response (P = .04) based on a multivariate analysis of nine pretreatment characteristics. The major dose-limiting toxicity was leukopenia. The incidences of nausea/vomiting, alopecia, and stomatitis/mucositis were 34%, 6%, and 3%, respectively. None were severe. Two patients had asymptomatic, moderate Alexander-grade cardiotoxicity.

CONCLUSION

This study represents a large, controlled multicenter trial of single-agent mitoxantrone in the treatment of advanced NPC. Mitoxantrone was well tolerated and produced an overall response rate comparable to that of other single-agent therapies used in the treatment of advanced head and neck cancer. Combination trials with mitoxantrone for advanced disease should be considered.

High-dose-rate remote afterloading irradiation of carcinoma of the cervix in Hong Kong: unexpectedly high complication rate

One hundred and thirty-six patients with biopsy-proven carcinoma of cervix were treated with external beam irradiation to the whole pelvis (46 Gy in 23 fractions) and three weekly applications of high-dose-rate (HDR) intracavitary brachytherapy of 7 or 8 Gy per fraction to point A (2 cm above and 2 cm lateral to the cervical os). The actuarial 5-year survival rate was 72% (Stage IB 85%; IIA 64%; IIB 70%; IIIA 25%; IIIB 53%). Patient age above 61 years and Stage III disease were adverse determinants for survival as shown by multivariate analysis. Late complications developed in 47% (65/137) of patients. Grade 3 or above complications occurred in the bladder, small bowel and sigmoid colon/rectum in 5%, 3% and 7% of patients, respectively. The most significant determinant of severe rectal complications was the addition of a lower vaginal tandem (P less than 0.01); the other determinants of rectal complications included a uterine length greater than 5 cm, a total biologically effective dose to the rectum of more than 120 Gy3 and Stage III disease.

Soft tissue sarcoma: the experience of a regional hospital in Hong Kong

The clinical features and treatment results of 66 soft tissue sarcomas (STS) were reported from a regional hospital in Hong Kong. The nature of the locoregional treatment and the grade were the chief prognostic factors governing survival and local control. Radical surgery (amputation/radical local resection) was determined by the site, the extent of the STS and potential functional loss. Complete resection with a variable margin followed by post-operative radiotherapy (60-70 Gy) produced survival and local tumour control similar to that of radical surgery. Incomplete surgery (partial excision/biopsy only) was associated with significantly poorer, survival and local tumour control, despite the administration of radiotherapy. Palliative chemotherapy for metastatic or recurrent STS has been disappointing, with low tumour response rates, while first line and adjuvant chemotherapy was difficult to assess for its efficacy in the present study. The overall survival of non-metastatic STS was comparable to that reported from developed countries. Suggestions are made to improve treatment results of STS in Hong Kong.

Prognostic factors in nasopharyngeal carcinoma investigated by computer tomography--an analysis of 659 patients

A total of 659 freshly diagnosed nasopharyngeal carcinoma (NPC) (1984-1987), were investigated by computed tomography (CT), treated with locoregional radiotherapy to radical dose, and given neoadjuvant chemotherapy (CHEMO) with 2-3 courses of cisplatinum and 5-fluorouracil for bulky (greater than or equal to 4 cm) cervical nodal metastasis and booster radiotherapy (PPB) for parapharyngeal disease. All except 15 patients were fully evaluable with complete data entry till death or to the last follow-up (minimum 2 years). The data have been analysed extensively to identify variables of potential prognostic significance. The assessed factors include patients' sex and age, nasal involvement (NAS), oropharyngeal involvement (ORO), parapharyngeal involvement (PAR), muscle involvement (MU), skull base involvement (BS), cranial nerves (II-VIII) palsy (CN1), cranial nerves (IX-XII) palsy (CN2), intracranial extension (IC), laryngopharyngeal extension (HYP), confinement to nasopharynx (NP), Ho's N-stage (Nho), maximal nodal size (Nmax), nodal mobility (Nf- fixed, Npf- doubt in mobility, Nm- mobile), nodal laterality (unilateral, contralateral, bilateral), nodal multiplicity (single, multiple), and presentation with distant metastasis (M1). These factors have been assessed as to their interdependence and correlation with the clinical course (study endpoints) using both monovariate analyses and Cox's Regression model. Significant association among Ho's T2 and T3 features was identified. Advanced Ho's N-stage correlated significantly with bulky nodes, multiple nodes, fixed nodes, and, contralateral and bilateral nodes. Poor prognostic factors found to be significant by both monovariate analyses and Cox's Regression model included the M1, Nho (advanced), CN1, BS, and CN2 for the actuarial survival (ASR) for all patients (659), the Nho (advanced), CN1, CN2, and BS for the ASR for the non-metastatic patients (628), the absence of NP and the male sex for the local failure rate (628), the Nho (advanced), CN2, and BS for the distant metastasis rate (628), and the Nho (advanced), CN1, and BS for the disease-free survival (DFS) (628). In addition, old age, male sex, and the presence of parapharyngeal disease were probably significant in predicting poor survival (ASR); CN1 was probably significant in predicting more local failures, and, the parapharyngeal disease and the intracranial extension for more distant metastases. The Ho's N-staging is superior to the other N-stage classifications, because once the Ho's N-stage has been determined, other nodal characteristics including nodal size, multiplicity, laterality, and fixity, are prognostically insignificant.

Combined chemotherapy and radiotherapy versus best supportive care in the treatment of inoperable non-small-cell lung cancer

Between October 1984 and July 1988, 119 patients with limited-stage inoperable non-small-cell lung cancer (NSCLC) were randomized to receive either active treatment (arm 1) or best supportive treatment (arm 2). Arm 1 patients received 3 courses of chemotherapy with cisplatin (100 mg/m2, day 1) and etoposide (125 mg/m2 i.v., day 1; 250 mg/m2 p.o., day 2-3), followed by radiotherapy (4,000 cGy/20 fractions/4 weeks). Arm 2 patients only received best supportive care. Fifty-three and 66 patients were randomized to arms 1 and 2, respectively. Thirty-eight patients in arm 1 and 57 in arm 2 were evaluable for survival. Median survivals of arms 1 and 2 were 12.4 and 8.7 months, respectively (p = 0.047). In the multivariate analysis, only age and histology were independent prognostic variables in predicting survival. The overall response rate after chemotherapy was 20.6% (complete remission 5.9%, partial remission 14.7%). Toxicities were mainly anemia, leukopenia, vomiting and alopecia. This study suggests that active treatment has marginal survival benefit in NSCLC though with considerable toxicities.

A retrospective comparison between different stage classifications for nasopharyngeal carcinoma

From 1984 to 1987, 659 patients with untreated nasopharyngeal carcinoma (NPC) were investigated by computed tomography of the nasopharynx and skull base, and fibreoptic nasopharyngoscopy. Thirty-one patients presenting with distant metastasis were treated palliatively; 628 were treated with intent to cure. Prospective staging was performed for the Ho's classification but since all T- and N-stage data required for staging according to the Huang's, the Changsha and the UICC classifications were recorded and stored in a computer database, retrospective staging according to these classifications could be accurately performed. Ho's classification was concluded to be the best in view of highly significant differences between the overall stages in survival and between N-stages in distant metastasis. The number of prognostically distinct overall stages and N-stages was greatest for Ho's classification. Huang's T-stage classification was superior, however, because it emphasized the significant adverse effect on local tumour control of cranial nerve(s) palsy (Tn) and intracranial tumour extension (Tc). Changsha and UICC classifications were demonstrably less powerful in predicting NPC prognosis. Multiple sites of involvement within the nasopharynx by NPC had no adverse influence on local tumour control. The grouping together of both soft-tissue and skull-base lesions into Changsha's T3 has been shown to be unjustified because of significant differences in local failure.

Cranial nerve involvement by nasopharyngeal carcinoma: response to treatment and clinical significance

The incidence of cranial nerve involvement in a group of 564 patients with nasopharyngeal carcinoma was 12%. Most of these patients had multiple cranial nerve involvement with the fifth and sixth nerves being most commonly affected. Different cranial nerves had different chances of recovery after radiotherapy. About half the patients with cranial nerve palsies had complete neurological recovery after radiotherapy. The cranial nerve response, however, was not a significant predictor of local tumour control.

A clinical study of adenocarcinoma of unknown primary site in Hong Kong

Forty-two patients with adenocarcinoma of unknown primary (ACUP) presented to the Prince of Wales Hospital in Hong Kong from 1984 to 1985. They were studied for the site of symptomatic metastases at presentation, survival, and response to treatment. Bony (21) and lymph nodal (14) metastases were common. Survival was short with a median duration of 32 weeks and was not affected by sex, site of metastases at presentation, and development of new metastases. Response to combination chemotherapy with cisplatinum, adriamycin and cyclophosphamide (CAP) occurred in 4/31 (12.9%) patients with two complete responses and two partial responses and the responders survived significantly longer than non-responders with a median survival of 51 and 29 weeks respectively (P less than 0.05). Twenty out of 36 (55.6%) treated with radiotherapy had a positive response including five complete responses and fifteen partial responses but there was no demonstrable improvement in survival for the responders.

A clinical study of 407 cases of nasopharyngeal carcinoma in Hong Kong

Four hundred and seven cases of nasopharyngeal carcinoma were analyzed retrospectively; 403/407 were evaluable for recurrence and survival. Parapharyngeal boost significantly decreased local recurrences in parapharyngeal diseases without base of skull involvement (T2p), but not with base of skull involvement (T3p). Enhanced local control of T2p with boost was significant without neoadjuvant chemotherapy. Tumors localized within the nasopharynx (T1) and tumors with nasal involvement (T2n) suffering from local persistences after external radiation therapy were treated with an intracavitary afterloading method. They had survival and recurrence rates comparable to complete responders to external radiation therapy. Patients with bulky cervical nodes (maximal diameter greater than or equal to 4 cm, N1-N3), treated with neoadjuvant chemotherapy with cis-diamminedichloroplatinum II and 5-fluorouracil, had a regional failure rate, distant metastasis rate, actuarial survival rate, and disease-free survival rate comparable to those with smaller nodes treated with external radiation therapy alone. A simple modification of the Ho's classification by regrouping the T-stages into 'early T-stages' and 'advanced T-stages' and by combining the N1 and the N2 has greatly increased the power of the system in predicting local recurrence and distant metastasis, respectively. There was an overall improvement of the actuarial survival rate and disease-free survival rate over the historical control, and its significance is discussed.

Nasopharyngeal carcinoma with dermatomyositis

From 1976 to 1986, ten out of 1154 consecutive nasopharyngeal carcinoma (NPC) patients were found to have dermatomyositis (DM). Their clinical features and treatment results were analyzed. The skin manifestation was typical of DM and myopathy occurred in seven patients. All the tumor on presentation were early stage and locoregional control after radiotherapy was satisfactory. All but one patient had DM prior to diagnosis of NPC. The prognosis of NPC was not affected by DM with survival being comparable to contemporary controls. The complication of radiotherapy were unusually severe. Chronic radiation skin ulceration occurred in 2 patients and subcutaneous indurated fibrosis affecting both sides of neck occurred in all patients. Acute radiation mucositis was also prominent.

Afterloading intracavitary radiation treatment of nasopharyngeal carcinoma. Description of a technique and preliminary treatment results

A new technique for afterloading intracavitary treatment of nasopharyngeal carcinoma with iridium-192 sources is described, which allows good positioning and fixation of the sources. The method has been used both for treatment of tumour remnants or recurrences after previous external radiation treatment and for achieving a boost dose supplementary to external irradiation. The early results in 73 patients are described.

A randomized study on palliative radiation therapy for inoperable non small cell carcinoma of the lung

Between October 1981 and November 1984, 291 patients with inoperable advanced non-small cell carcinoma of the lung (NSCLC) were randomized to a two-arm study. Eighteen of 291 defaulted treatment and were excluded from the study. Twenty-seven of 273 died during treatment; they were invaluable for treatment response but were included in survival analysis. Without correction for lung attenuation 45 Gy/18 fractions/4 1/2 weeks were given in arm 1 and 31.2 Gy/4 fractions/4 weeks were given in arm 2. One hundred twenty-eight of 273 were included in arm 1 and 145/273 in arm 2. The two arms were comparable in patient age, sex, performance status and symptoms, primary tumor site, histology, stage of the disease, and distribution of metastases and radiation portal size used. Prognosis was poor with an overall median survival of 20 weeks and was similar in both arms. Radiological tumor response was also similar: 53% in arm 1 and 50% in arm 2. However arm 1 was superior than arm 2 in achieving symptom palliation, 71% vs 54%, p less than 0.02. Treatment complications were mild and included mainly radiation oesophagitis and pneumonitis and pulmonary fibrosis. Treatments in both arms were equally well tolerated.

Adjunctive chemotherapy to radical radiation therapy in the treatment of advanced nasopharyngeal carcinoma

Sixty-eight consecutive patients with previously untreated nasopharyngeal carcinoma (NPC) with advanced cervical lymph nodal metastases were studied retrospectively for the effectiveness of combining chemotherapy with radical radiation therapy (RT). In 1981 and 1982, 36 patients were treated with radical radiation therapy alone (arm 1). In 1983, 13 patients were given 2 courses of VBMF prior to RT (arm 2). In 1984, 19 patients were given radical RT sandwiched between 2 courses of PVBMF before and 2 after (arm 3). The three arms were comparable in patient characteristics with similar stages of the disease, sex, age distribution, and rates of completion of the prescribed treatments. There was no significant difference in actuarial or disease-free survival between arm 1 and 3 or arm 2 and 3, but arm 1 compared favorably with arm 2 in actuarial survival (X2 = 9.533, p = 0.002). The distant relapses in arms 2 and 3 occurred at significantly shorter times after diagnosis than those in arm 1 (t = 4.1083, p = 0.0001). Postponement of radiation therapy by chemotherapy might have accounted for the earlier distant relapses in arm 2 and 3. Radiation therapy alone given in radical dose had been demonstrated to achieve significantly more complete responses in cervical nodal metastases than either forms of chemotherapy (VBMF or PVBMF) given just two courses prior to radiation therapy (p less than 0.00003). More controlled clinical trials must be completed before acceptance of chemotherapy as part of a standard radical treatment for advanced nasopharyngeal carcinoma with advanced cervical lymph nodal metastases. In all future trials, closer integration in time sequence between the two treatment modalities is indicated. Meanwhile cervical nodal status (CR vs, PR plus NR) at the end of any treatment was shown to be of paramount prognostic significance.

An accurate method of 192Ir wire implantation for locally advanced carcinoma of breast

An accurate and reproducible method of 192Ir wire implantation of locally advanced breast tumour after locoregional megavoltage external radiotherapy has been described. The method includes the use of cobex cast for breast and tumour immobilization, of computed tomography for tumour localization, of computer for planning and isodose display and of specially made template to guide insertion of trocars and 192Ir wires.