Role and extent of neck dissection for persistent nodal disease following chemo-radiotherapy for locally advanced head and neck cancer: how much is enough?

PURPOSE

Neck dissection (ND) is routinely performed for persistent nodal disease after definitive chemo-radiotherapy (CRT) for locally advanced head and neck cancer. This study analyzes the role and extent of ND necessary after CRT based on pathologic outcome.

PATIENTS AND METHODS

The study is based on 42 patients undergoing 48 ND's for persistent nodal disease after CRT. Patients were treated to a median radiation dose of 70.4 Gy at 1.8-2 Gy per fraction concurrently with platinum based chemotherapy. Patients with documented residual disease in neck, based on clinical or radiological examination underwent ND at a median interval of 59 days after completion of CRT.

RESULTS

Of the 42 patients undergoing ND, 11 (26%) had positive findings on pathologic evaluation. The clinical and treatment characteristics were similar for node negative and positive patients. The involved nodal level(s) were always confined within the clinically documented persistent disease. The median percentage of positive nodes to total nodes removed was 10%. Almost 50% of positive nodes removed had only microscopic or minute viable cancer pathologically. The outcome was better for pathologically node negative patients in comparison to node positive patients.

CONCLUSION

The results of this study suggest that standard ND appears to be an excessive treatment for persistent nodal disease after CRT. Limited ND or even gross nodal resection confined to involved nodal level(s) as identified clinically or radiologically should be tested in a prospective randomized trial for reducing treatment related morbidity while maintaining excellent loco-regional control.

Effects of mutations of aspartic acid 63 on the metal-binding properties of the recombinant N-lobe of human serum transferrin

Mutations of the aspartic acid residue at position 63 of the N-lobe of human serum transferrin substantially alter the metal ion- and anion-binding properties of the protein. Substitution of serine, asparagine, glutamic acid, or alanine results in the loss of a key component of the interface in the interdomain cleft and the metal-binding ligand, aspartic acid, leading in all cases to an increased preference for NTA rather than carbonate as the "synergistic" anion relative to the wild-type protein. Excess bicarbonate is required to eliminate the NTA and obtain the "correct" visible spectrum. Carbonate replaces NTA via an intermediate. Blue shifts for the characteristic absorption band of each mutant show a range of effects on the Fe-O (Tyr) interaction. Titration with Co(III) yielded the molecular absorption coefficient for each mutant except D63A, where Co(III) appeared to oxidize the tyrosine residues and damage the ability of the mutant to bind metal. The chelator, Tiron, removes iron from hTF/2N with a simple saturation kinetic mode with respect to the ligand concentration. Chloride inhibits the release in an interesting manner: the effect is initially sharp and then levels off with a minimum k(obs) at [KCl] = 0.5 M. However, the reaction of the D63 mutants with Tiron results in the formation of the ternary complexes Fe-hTF/2N-Tiron. Significant red shifts for the characteristic absorption bands of these complexes suggest a different ligation of Tiron in the mutants from that in wild-type hTF/2N.

Utilizing physician leadership to reduce length of stay

With the proliferation of prospective payment, managed care and the concomitant shift in risk from payer to provider, hospitals are investing in utilization management programs to reduce cost per case while maintaining or improving clinical quality. This article discusses a major component of the utilization management program at the Cleveland Clinic Foundation: the use of physician champions. Overall, the length of stay reduction initiative resulted in a shorter average length of stay by 1.8 days (22 percent).

Intellectual and psychosocial status of remedial students

The Kaufman Brief Intelligence Test and Measures of Psychosocial Development were given to assess 49 remedial and 33 average college students. Significant differences were found between the two groups on intellectual and developmental variables. The results are discussed and concerns for staff noted.

Morphologic changes in the human patellar tendon after bone-tendon-bone anterior cruciate ligament reconstruction

Magnetic resonance imaging (MRI) was performed on 15 patients, an average of 2.5 years after arthroscopically assisted bone-tendon-bone (BTB) anterior cruciate ligament (ACL) reconstruction, to evaluate the patellar tendon donor site. Five patients who had arthroscopically assisted ACL reconstruction using the semitendinosus tendon as a graft also were scanned bilaterally and evaluated. The mean difference between the involved and uninvolved patellar tendon length was -0.2 mm for the BTB patients and -2.6 mm for the semitendinosus patients. The mean difference between patellar tendon width for the BTB patients was 1.1 mm and 1.9 mm for the semitendinosus patients. The mean difference between patellar tendon thickness was 0.4 mm for the BTB surgery group and 0.02 mm for the semitendinosus surgery group. None of the differences were statistically significant. Results indicate that harvesting the central one third of the patellar tendon does not significantly affect the length, width, or thickness of the tendon at least 22 months after arthroscopically assisted BTB-ACL.