A web-based prediction score for head and neck cancer referrals

OBJECTIVE

Following the announcement of the NHS Cancer Plan in 2000, anyone suspected of having cancer has to be seen by a specialist within 2 weeks of referral. Since this introduction, studies have shown that only 6.3%-14.6% of 2-week referrals were diagnosed with a head and neck cancer and that majority of the cancer diagnoses were via other referral routes. These studies suggest that the referral scheme is not currently cost-effective. Our aim is to develop a scoring system that determines the risk of head and neck cancer in a patient, which can then be used to aid GP referrals.

DESIGN

Retrospective data were collected from 1075 patients with 2-week head and neck cancer referrals from general practitioners. The retrospective data collected included patients' demographics, risk factors and relevant investigations. The data were used as input into a logistic regression to arrive at our model. Our approach included data analysis, machine learning techniques, statistical inference and model validation metrics to arrive at the best performing model. The model was then tested with more data from 235 prospective patients.

RESULTS

Using our results from the logistic regression, we created a web-based tool that GPs can use to calculate their patient's probability of cancer and use this result to assist in their decision regarding referral. Our prototype can be seen in Figure 2.

CONCLUSION

We have created a prototype scoring system that can be hosted online to assist GPs with their referrals with a sensitivity of 31% and specificity of 92%. While we acknowledge that there are several limitations to our model, we believe we have created a novel preliminary scoring system that has the potential to be improved dramatically with further data and be very helpful for GPs in a long run.

The extent of lateral lymph node dissection in differentiated thyroid cancer in the N+ neck

The management of the lateral neck in metastatic differentiated thyroid cancer (DTC) varies widely. Most groups advocate dissection of nodal levels II-IV but many perform a more extensive dissection. We aimed to asses whether there was any evidence for a modified radical neck dissection over a selective neck dissection by looking at the extent to which DTC metastases to levels I and V. We performed a review of the current literature including adult and paediatric patients who underwent a lateral neck dissection for metastatic DTC. The primary endpoint was histological confirmation of metastases in nodal levels I and V. 650 abstracts were identified and reviewed. 23 papers were included in the study. The incidence of level V metastases during routine level V dissection in patients with DTC is 20 % and the incidence of level I metastases during routine level I dissection in patients with DTC is 8 %. Histologically proven metastases were found in 22.5 % of level V neck dissection of which 2.5 % were pre-operatively suspected of metastases. 20 % had histologically proven metastases to level I of which 12 % were pre-operatively suspected of metastases. Our study has shown a 20 % incidence of level V metastases in the N+ neck suggesting that level V should be part of a planned neck dissection. Evidence is lacking for routine dissection of level I. A future prospective study is required to asses the question of risk factors for lateral nodal metastases, recurrence and survival.

A 20-year retrospective study of tonsil cancer incidence and survival trends in South East England: 1987-2006

BACKGROUND

There has been an increasing incidence of tonsil cancer worldwide. Documenting these changes is crucial to cancer prevention and control measures, resource allocation and understanding disease aetiology.

OBJECTIVE

To analyse the changing epidemiology of tonsil cancer in South East England over a 20-year period between 1987 and 2006.

DESIGN

A retrospective, quantitative study using secondary anonymised data obtained from the Thames Cancer Registry, London. Data were analysed using spss v.17 and survival analyses with Kaplan-Meier and Cox regression.

SETTING

This study was conducted in South East of England comprising London, Kent, Surrey and Sussex counties with an average population of 12 million. This population increased from 10.7 to 11.8 million (a 10% increase) between 1987 and 2006.

PARTICIPANTS

All patients with tonsil cancer in South East England registered with the Thames Cancer Registry (ICD-10 code C09) between 1987 and 2006. A total of 1794 patients' data were analysed. Ethical Considerations: Ethical approval was granted by the Kent Research Ethics Committee.

MAIN OUTCOME MEASURES

Data were analysed for demographic trends including gender, age at diagnosis, yearly incidence and survival.

RESULTS

Tonsil cancer incidence has increased significantly from 0.60 to 1.45 per 100,000 in the 20 years (P < 0.001). This increase is mainly amongst men and age groups 40-59 years with a significant reduction in age at diagnosis by 2 years from 61.6 years in the first decade to 59.6 years in the second decade (P < 0.001). Survival was worse in men, older age groups and in the presence of synchronous tumours (P < 0.001). There has been a statistically significant increase in median survival times from tonsil cancer by about 3 years from 2.7 years in the first decade to 5.7 years in the second decade of this study (P < 0.001).

CONCLUSIONS

Tonsil cancer incidence has increased in the 20 years of this study in South East England, especially amongst men and age groups 40-59 years. There has also been significant reduction in the mean age at diagnosis and an increase in median survival times for tonsil cancer. Further studies are needed to explain these trends.

Uninstrumented ventral surgery for subaxial cervical spine tuberculosis: Clinical and radiological outcome

The clinical and radiological outcomes in 14 patients with subaxial cervical spine tuberculosis following uninstrumented anterior decompression surgery and medical treatment were retrospectively reviewed. All the patients underwent an anterior decompression with bone graft followed by immediate mobilization or a period of bed rest for 4 to 6 weeks. The clinical status and whole spine curvature of the cervical spine were assessed preoperatively and at follow up. There was an improvement in the Nurick's grade from a preoperative mean of 2.4 (range 0 - 5) to 1.2 (range 0 - 4) at follow up (p = 0.004). The whole spine curvature showed an improvement in 5 patients, was maintained in 6 patients and showed a kyphotic change in 1 of the 12 patients at follow up. There was evidence of good bony fusion in 12 of the 14 patients for whom data were available at follow up. Anterior decompression with autologous iliac bone graft led to a good clinical and radiological outcome in patients with subaxial cervical spine tuberculosis.

Surgical care practitioner – a confusing and misleading title

In March 2005 the Department of Health released the Curriculum Framework for the Surgical Care Practitioner for consultation. The curriculum framework has been developed by a working party drawn from The Royal College of Surgeons of England (RCSE) Council and an NHS Changing Workforce Programme steering group, which represented a number of involved associations. As well as inviting responses on the curriculum itself, the consultation invited comments with respect to the title of 'surgical care practitioner'.

Are patients happy with SCPs operating?

The traditional model of surgical service is in the process of change. Classically, a consultant surgeon would have the services of an SpR, staff and associate specialist (SAS) and SHO in clinic and theatre. The implementation of the New Deal and the European Working Time Directive has led to a significant reduction in the number of hours worked by junior doctors. Consequently, nearly all SHOs are working a full-shift pattern and most SpRs are moving onto full-shift rotas to ensure out-of-hours service is maintained. This reduction in the number of junior doctors available during the normal working day has increased the development of extended roles for non-medical professionals.

A study of out-of-hours facilities in otolaryngology: current provision and problems

'Action on ENT' has recently published advice as to the minimum requirements for equipment required to provide a safe and suitable out-of-hours service in ENT. Our objectives were to determine the availability of a dedicated ENT treatment room for seeing patients out of hours, appropriately maintained specialized ENT equipment and availability of appropriate assistance. In addition, the mechanism for disinfection of nasoendoscopes out of hours was determined. Telephone questionnaires of 106 ENT units in England, which provide an out-of-hours ENT service, were taken. At each unit the standard questionnaire was answered by the first on-call ENT doctor. One hundred and one units (95 percent) had access to a dedicated treatment room out of hours. The number of units with a microscope was 91 (86 percent), headlight/lamp and mirror was 105 (99 percent), flexible nasoendoscope was 86 (81 percent) and cautery (electrical or chemical) was 105 (99 percent). Seventy-nine units (75 percent) found that their treatment rooms were adequately stocked, and 62 units (58 per cent) had assistance available when needed. Twenty-four units (23 percent) sterilized their scopes adequately, 22 units (21 percent) used endosheaths, 26 units (24 percent) used a variety of inadequate cleaning methods, and 34 respondents (32 percent) were unsure how their scopes were cleaned. This survey has shown that not all ENT units have appropriately equipped out-of-hours facilities. There is a need for nationally agreed guidelines stating the minimum equipment and assistance required to provide a safe, adequate and suitable out-of-hours service. National guidelines on out-of-hours disinfection of flexible nasoendoscopes are also required.

Isolated ring-enhancing lesion of the brainstem in a patient with cyanotic heart disease: role of stereotactic intervention

A 23-year-old man with cyanotic heart disease, presented with a ring-enhancing mass in the brainstem. Stereotactic intervention for this clinically and radiologically diagnosed pyogenic abscess, revealed a tuberculoma. Antituberculous therapy led to complete recovery. Stereotactic intervention is an ideal management strategy in patients with cyanotic heart disease and an isolated ring-enhancing mass in the brainstem.

Skull base chondroblastoma: a case report

Chondroblastoma is a rare tumor of the skull. Temporal bone is the commonest site of involvement in the skull. We present a thirty one year old man who presented with painless swelling over the left temporal bone, which was near totally excised after preoperative embolization. Management of this unusual tumor and its complications are discussed.

Biochemical, genetic, and functional analyses of the phosphorylation sites on the Epstein-Barr virus-encoded oncogenic latent membrane protein LMP-1

LMP-1 is the only Epstein-Barr virus-encoded latent protein known to have the properties of a transforming oncogene in rodent fibroblasts and the only latent protein, besides EBNA-1, detected in nasopharyngeal carcinoma and Hodgkin's lymphoma biopsies. LMP-1 is characterized by serine/threonine phosphorylation and rapid turnover (half-life, 2 to 3 h) due to specific proteolytic cleavage, which causes release of a phosphorylated C-terminal fragment (p25) into the cytoplasm. We used biochemical, functional, and mutational analyses to identify sites of phosphorylation. All of the phosphorylation sites detected lie in the C-terminal domain. In particular, we identified S-313 and T-324 as functionally important sites. Prevention of phosphorylation at S-313, by altering it to a glycine, prevented detectable phosphorylation of both LMP-1 and p25, indicating that it is a major site on both forms of the molecule. However, lack of detectable phosphorylation had no effect on p25 cleavage or on the ability of LMP-1 to transform Rat-1 fibroblasts. Alteration of S-313 to an aspartate resulted in a form of LMP-1 that was toxic to Rat-1 cells. Alteration of T-324 to a glycine residue had no detectable effect on the ability of LMP-1 to become serine phosphorylated or transform Rat-1 cells. Alteration of T-324 to a glutamate, however, inhibited all detectable phosphorylation and resulted in a form of LMP-1 that was unable to transform Rat-1 fibroblasts. These results are discussed in the context of a model in which LMP-1 function is modulated by phosphorylation and dephosphorylation at S-313 and T-324.

All three domains of the Epstein-Barr virus-encoded latent membrane protein LMP-1 are required for transformation of rat-1 fibroblasts

LMP-1, the Epstein-Barr virus latent membrane protein 1, is the only protein encoded by the virus that has been shown to have the properties of a transforming oncogene in rodent fibroblasts such as Rat-1 cells. LMP-1 is phosphorylated and proteolytically cleaved in Rat-1 cells in a manner similar to that seen in human lymphocytes. In this study, we demonstrate that all three major domains of LMP-1 (N-terminal, transmembrane, and C-terminal domains) are required for the ability to transform Rat-1 cells in culture, as assayed by loss of contact inhibition. This study is the first demonstration of a functional role for the C-terminal domain of LMP-1. Our analysis suggests that there are at least three distinct regions of the C terminus involved in signalling. Amino acids 306 to 334, which generate a toxic signal in the absence of amino acids 334 to 364, and the last 23 amino acids, 364 to 386, are essential for transformation. Biochemical analysis of the LMP-1 mutants with the three domains deleted indicate that the mutant N-terminal with the domain deleted is phosphorylated normally but is inefficiently cleaved compared with the wild-type LMP-1. The mutant with the transmembrane domain deleted is also phosphorylated but is not cleaved, showing that phosphorylation of LMP-1 does not require membrane association. The nontransforming mutant with the C-terminal domain deleted that lacks the last 23 amino acids is phosphorylated and cleaved. Therefore, these processing events alone are insufficient to generate a transforming signal.

Secretion of an epidermal growth factor-like growth factor by epidermal growth factor-independent rat mammary carcinoma cells

Rat mammary carcinoma (RMC) cells derived from serially transplantable mammary tumors are independent of epidermal growth factor (EGF) for long-term growth in serum-free medium. This phenotype is in contrast to that of normal mammary epithelial cells or cells derived from nontransplantable tumors that express an absolute requirement for EGF for growth in culture. The results of the experiments reported here indicate that EGF-independent RMC cells secrete a growth factor with potent EGF-like mitogenic activity. Conditioned media obtained from these cells can substitute for EGF for the growth of the EGF-dependent cell line MCF-10. This growth factor is neither EGF nor transforming growth factor alpha and does not compete with 125I-EGF for binding to EGF receptors. Phosphotyrosine Western blot analysis of lysates obtained from EGF-independent RMC cells revealed the presence of a 190 kilodalton (kDa) protein that was distinct from the EGF receptor. Similarly, growth of MCF-10 cells to confluence in serum-free medium supplemented with conditioned medium growth factor in place of EGF resulted in the disappearance of the EGF receptor band and appearance of the 190 kDa band in phosphotyrosine Western blots. The 190 kDa tyrosine-phosphorylated protein detected in cells stimulated by the conditioned medium factor is unlikely to be the c-erbB-2 protein, as indicated by negative results in immunoprecipitation experiments and in vitro kinase assays. In summary, EGF-independent RMC cells secrete a factor with potent EGF-like mitogenic activity. This suggests that an autocrine loop involving this growth factor mediates EGF independence in these cells.

Multiple growth factor independence in rat mammary carcinoma cells

In previous studies we demonstrated that rat mammary tumor (RMT) cells that are serially transplantable consist of cells that are independent of growth factors strictly required by normal rat mammary epithelial (RME) cells for growth in serum-free culture. The present studies were designed to determine the extent of the growth factor independence of several cell lines derived from these tumors and to determine if the cells that expressed growth factor independence in vitro are also tumorigenic in vivo. Cells from a transplantable mammary carcinoma (8-12 RMT) were seeded into culture in serum-free medium in the absence of either insulin (IN), epidermal growth factor (EGF), or cholera toxin (CT), and cell populations independent of the individual factors were developed. Next, the three growth factor independent populations were tested for their ability to grow in the absence of multiple growth factors. 8-12 RMT cells did not lose proliferative potential when multiple growth factors were deleted from the medium. Indeed, 8-12 RMT cells could be serially propagated in serum-free medium supplemented solely with bovine serum albumin (BSA) and ethanolamine. Cell lines independent of single growth factors were also developed from two other transplantable tumors (1-9 RMT and 7-15 RMT). In contrast to the 8-12 RMT-derived cell lines, deletion of additional growth factors from the media of the 1-9 RMT and 7-15 RMT-derived cells resulted in dramatic losses in growth potential. These results suggest that independence of individual growth factors is mediated by different mechanisms, since cells from different tumors can stably express independence of one, two, or three or more factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Processing of the Epstein-Barr virus-encoded latent membrane protein p63/LMP

We have analyzed the processing of the Epstein-Barr virus-encoded latent membrane protein (p63/LMP) in lymphoblastoid cell lines, Burkitt's lymphoma cell lines, and rodent fibroblasts transfected with the p63/LMP gene. Pulse-chase analysis by immunoprecipitation, under denaturing conditions, reveals a half-life of 2 h. This is due to turnover in the plasma membrane with cleavage of the protein, resulting in a 25,000-molecular-weight (p25) fragment derived from the carboxy-terminal portion of LMP. This fragment is rich in proline and acidic amino acids and sheds into the cytoplasm, where it appears to accumulate, being present in a six- to sevenfold molar excess over p63/LMP in immunoprecipitation analyses. p25 is, like p63/LMP, also phosphorylated (pp25) on serine and threonine residues, in the same ratio and to approximately the same extent as the intact p63/LMP molecule. Amino acid sequence analysis and carboxy-terminal labeling suggest that p25 is derived through a single cleavage adjacent to the sequence LGAPGGGPDNGPQDPD.