Ductal carcinoma in situ of breast: detection and treatment pattern in Hong Kong

INTRODUCTION

The treatment of ductal carcinoma in situ has been widely reported in the western and other Asian countries, but the relevant data in Hong Kong are relatively limited. This study aimed to evaluate the latest detection and treatment pattern for ductal carcinoma in situ in Hong Kong so as to guide planning of future service provision.

METHODS

This was a retrospective case series study. A total of 573 patients who registered with the Hong Kong Breast Cancer Registry, and were diagnosed and treated in Hong Kong from January 2001 to December 2011 were reviewed.

RESULTS

Compared with invasive breast cancer patients, patients with ductal carcinoma in situ were younger (median, 48.6 vs 50.3 years; P<0.001), had a higher education level (P<0.001), had a higher total monthly family income (P<0.001), and more common breast-screening habits (P<0.001). Significantly more patients with ductal carcinoma in situ underwent breast-conserving surgery than their invasive cancer counterparts (55.8% vs 36.7%; P<0.001). The percentage of screen-detected ductal carcinoma in situ was relatively lower than that reported in other studies, but was still much higher than that in invasive breast cancer patients (29.0% vs 4.7%; P<0.001). Screen-detected patients with ductal carcinoma in situ tended to choose a private hospital instead of a public hospital for treatment (P=0.05) and to undergo breast-conserving surgery (P=0.02). With a median follow-up of 3 years, the crude local recurrence rate after mastectomy and breast-conserving surgery was 0.4% and 3.3%, respectively; 44% of recurrent tumours had developed invasive components. No regional recurrence, distant recurrence, or cancer-related deaths were recorded.

CONCLUSIONS

In the absence of a population-based breast screening programme in Hong Kong, ductal carcinoma in situ is more frequently found in the higher social classes and managed in the private sector. The clinical outcome of ductal carcinoma in situ is excellent and more than half of the patients can be successfully managed with breast-conserving surgery.

The strength/weakness of the AJCC/UICC staging system (7th edition) for nasopharyngeal cancer and suggestions for future improvement

BACKGROUND AND PURPOSE

To evaluate the current AJCC/UICC staging system (7th edition) for nasopharyngeal carcinoma and to explore for future improvement.

MATERIALS AND METHODS

A total of 985 patients, initially staged with preceding 5-6th edition, were retrospectively re-staged with the 7th edition. All were assessed by magnetic resonance imaging, and all 945 non-disseminated patients were irradiated with conformal/intensity-modulated technique.

RESULTS

Staging factors by both the 5-6th edition and the 7th edition were strongly significance for important endpoints (p<0.001). Down-staging of the previous T2a to T1 and, stages IIA to I in the 7th edition was appropriate. However, the impacts on overall stage distribution and prognostication were minimal. Further down-staging of the current T2 to T1, N2 to N1, stages II to I, and merging of N3a and N3b, stages IVA and IVB were suggested. With the 7th edition, the 5-year disease-specific survival (DSS) was 100% for stage I, 95% for II, 90% for III, 67% for IVA, 68% for IVB and 18% for IVC. The corresponding DSS for the proposed stages I, II, III and IV were 95%, 86%, 67% and 18%, respectively.

CONCLUSIONS

The changes introduced in the 7th edition were appropriate, but the magnitude of improvement was minimal. With improving results by modern management, further simplification of the staging system is suggested. The proposed system could lead to more accurate prognostication, further validation is warranted.

Replication study of SNP associations for colorectal cancer in Hong Kong Chinese

BACKGROUND

Recent genome-wide association studies of colorectal cancer (CRC) have identified common single-nucleotide polymorphisms (SNPs) mapping to 10 independent loci that confer modest increased risk. These studies have been conducted in European populations and it is unclear whether these observations generalise to populations with different ethnicities and rates of CRC.

METHODS

An association study was performed on 892 CRC cases and 890 controls recruited from the Hong Kong Chinese population, genotyping 32 SNPs, which were either associated with CRC in previous studies or are in close proximity to previously reported risk SNPs.

RESULTS

Twelve of the SNPs showed evidence of an association. The strongest associations were provided by rs10795668 on 10p14, rs4779584 on 15q14 and rs12953717 on 18q21.2. There was significant linear association between CRC risk and the number of independent risk variants possessed by an individual (P=2.29 × 10(-5)).

CONCLUSION

These results indicate that some previously reported SNP associations also impact on CRC risk in the Chinese population. Possible reasons for failure of replication for some loci include inadequate study power, differences in allele frequency, linkage disequilibrium structure or effect size between populations. Our results suggest that many associations for CRC are likely to generalise across populations.

Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer centre

OBJECTIVE

Delayed presentation is an important obstacle to improving cancer treatment outcomes. We aimed to study the magnitude of this problem in Hong Kong and the factors associated with delayed presentation of patients with symptomatic breast cancers.

DESIGN

Retrospective study using self-administered questionnaires.

SETTING

Clinical Oncology Department in a regional public hospital in Hong Kong.

PATIENTS

A total of 158 Chinese women with breast cancer referred to our hospital between October 2006 and December 2007 consented to participate in this study. Among these, 59 (37%) patients were referred after having surgery in private sector.

RESULTS

The mean total delay (from first symptom to treatment) was 22 weeks. The mean patient delay (from first symptom to first consultation) was 13 weeks, constituting the largest component (60%) of the total delay. After symptom onset, the delay exceeded 12 weeks for consulting a doctor in 29%, and for receipt of treatment in 52% of them. Low family income (<HK$5000 per month; P<0.001) and surgery in public hospitals (P=0.013) were both independent predictors of patient delay. Surgery in public hospitals (P=0.006) and low family income (P=0.005) were the only predictors of doctor/system delay and total delay, respectively.

CONCLUSIONS

Delayed presentation and treatment of symptomatic breast cancer remains an important issue in Hong Kong. Apart from socio-economic factors, limited access to public medical care was likely an important contributing factor in delays related to patients as well as to doctor/system.

Randomized trial of radiotherapy plus concurrent-adjuvant chemotherapy vs radiotherapy alone for regionally advanced nasopharyngeal carcinoma

BACKGROUND

Current practice of adding concurrent-adjuvant chemotherapy to radiotherapy (CRT) for treating advanced nasopharyngeal carcinoma is based on the Intergroup-0099 Study published in 1998. However, the outcome for the radiotherapy-alone (RT) group in that trial was substantially poorer than those in other trials, and there were no data on late toxicities. Verification of the long-term therapeutic index of this regimen is needed.

METHODS

Patients with nonkeratinizing nasopharyngeal carcinoma staged T1-4N2-3M0 were randomly assigned to RT (176 patients) or to CRT (172 patients) using cisplatin (100 mg/m(2)) every 3 weeks for three cycles in concurrence with radiotherapy, followed by cisplatin (80 mg/m(2)) plus fluorouracil (1000 mg per m(2) per day for 4 days) every 4 weeks for three cycles. Primary endpoints included overall failure-free rate (FFR) (the time to first failure at any site) and progression-free survival. Secondary endpoints included overall survival, locoregional FFR, distant FFR, and acute and late toxicity rates. All statistical tests were two-sided.

RESULTS

The two treatment groups were well balanced in all patient characteristics, tumor factors, and radiotherapy parameters. Adding chemotherapy statistically significantly improved the 5-year FFR (CRT vs RT: 67% vs 55%; P = .014) and 5-year progression-free survival (CRT vs RT: 62% vs 53%; P = .035). Cumulative incidence of acute toxicity increased with chemotherapy by 30% (CRT vs RT: 83% vs 53%; P < .001), but the 5-year late toxicity rate did not increase statistically significantly (CRT vs RT: 30% vs 24%; P = .30). Deaths because of disease progression were reduced statistically significantly by 14% (CRT vs RT: 38% vs 24%; P = .008), but 5-year overall survival was similar (CRT vs RT: 68% vs 64%; P = .22; hazard ratio of CRT = 0.81, 95% confidence interval = 0.58 to 1.13) because deaths due to toxicity or incidental causes increased by 7% (CRT vs RT: 1.7% vs 0, and 8.1% vs 3.4%, respectively; P = .015).

CONCLUSIONS

Adding concurrent-adjuvant chemotherapy statistically significantly reduced failure and cancer-specific deaths when compared with radiotherapy alone. Although there was no statistically significant increase in major late toxicity, increase in noncancer deaths narrowed the resultant gain in overall survival.

Should young age be a contra-indication to breast conservation treatment in Chinese women? Twelve-year experience from a public cancer centre in Hong Kong

OBJECTIVE

It has been proposed that young women should not be treated by breast conservation treatment because of a higher risk of local recurrences and worse survival. We therefore examined whether breast conservation treatment in young Chinese women yielded inferior clinical outcomes compared to modified radical mastectomy.

DESIGN

Retrospective study.

SETTING

Clinical oncology department in a public hospital in Hong Kong.

PATIENTS

A total of 258 Chinese women with invasive breast cancer, aged below 40 years, and referred between January 1994 and July 2006.

RESULTS

A total of 124 (48%) and 134 (52%) patients were treated by breast conservation treatment and modified radical mastectomy, respectively. Mastectomy patients tended to have larger primary tumours (P<0.001) and more nodal involvement (P<0.001). At a median follow-up of 6.5 years, there was no significant difference in the local failure-free survival rate (92% vs 93%, P=0.324) and loco-regional failure-free survival rate (89% vs 88%, P=0.721) in patients having breast conservation treatment and mastectomy. Probably due to their earlier presentation with disease, the former actually had better 6-year distant failure-free survival (88% vs 71%, P=0.002) and overall survival (92% vs 81%, P=0.173) rates. Multivariate analyses showed that both the resection margin status (hazard ratio=2.77, P=0.050) and the presence of peritumoural vascular invasion (hazard ratio=3.01, P=0.038) were independent predictors of local recurrence; the nodal status (hazard ratio=3.91, P<0.001) was the only predictive factor for overall survival. The choice of breast conservation treatment (vs modified radical mastectomy) had no apparent adverse impact on all the clinical outcome parameters analysed.

CONCLUSION

Breast conservation treatment is a reasonable option for many suitably selected young Chinese women.

Major late toxicities after conformal radiotherapy for nasopharyngeal carcinoma-patient- and treatment-related risk factors

PURPOSE

To retrospectively analyze the factors affecting late toxicity for nasopharyngeal carcinoma.

METHODS AND MATERIALS

Between 1998 and 2003, 422 patients were treated with a conformal technique with 2-Gy daily fractions to a total dose of 70 Gy. Conventional fractionation (5 fractions weekly) was used in 232 patients and accelerated fractionation (6 fractions weekly) in 190 patients. One hundred seventy-one patients were treated with the basic radiotherapy course alone (Group 1), 55 patients had an additional boost of 5 Gy in 2 fractions (Group 2), and 196 patients underwent concurrent cisplatin-based chemotherapy (Group 3).

RESULTS

The 5-year overall toxicity rate was significantly greater in Group 3 than in Group 1 (37% vs. 27%, p = 0.009). Although the overall rate in Group 2 was not elevated (28% vs. 27%, p = 0.697), a significant increase in temporal lobe necrosis was observed (4.8% vs. 0%, p = 0.015). Multivariate analyses showed that age and concurrent chemotherapy were significant factors. The hazard ratio of overall toxicity attributed to chemotherapy was 1.99 (95% confidence interval, 1.32-2.99, p = 0.001). The mean radiation dose to the cochlea was another significant factor affecting deafness, with a hazard ratio of 1.03 (95% confidence interval, 1.01-1.05, p = 0.005) per 1-Gy increase. The cochlea that received >50 Gy had a significantly greater deaf rate (Group 1, 18% vs. 7%; and Group 3, 22% vs. 14%).

CONCLUSION

The therapeutic margin for nasopharyngeal carcinoma is extremely narrow, and a significant increase in brain necrosis could result from dose escalation. The significant factors affecting the risk of deafness included age, concurrent chemoradiotherapy, and greater radiation dose to the cochlea.

HER2 overexpression of breast cancers in Hong Kong: prevalence and concordance between immunohistochemistry and in-situ hybridisation assays

OBJECTIVES

To evaluate the prevalence of human epidermal growth factor receptor 2 (HER2) gene overexpression in breast cancer patients encountered in Hong Kong and the concordance of HER2 findings from primary immunohistochemistry assays and confirmatory in-situ hybridisation assays.

DESIGN

Retrospective study.

SETTING

Department of Clinical Oncology in a public hospital in Hong Kong.

PATIENTS

All patient referrals between July 2006 and June 2007 with newly diagnosed invasive breast cancer (for prevalence evaluation), and all patients treated at our unit with confirmatory in-situ hybridisation tests performed within the study period (for concordance evaluation).

RESULTS

There were 272 consecutive breast cancer patients eligible for prevalence evaluation. The distribution for immunohistochemistry staining in 249 cases for scores 0, 1+, 2+, and 3+ were 99 (40%), 40 (16%), 58 (23%), and 52 (21%) respectively. In the remaining 23 patients, four and 19 breast cancers were unscored and reported by immunohistochemistry to be HER2-positive and -negative, respectively. The overall HER2 overexpression rate (3+ or reported as positive) was 21%. HER2 overexpression was associated with grade 3 histology (P<0.001) and negative hormonal receptor status (P<0.001). However, it was not associated with age (P=0.525), T-classification (P=0.740), N-classification (P=0.691), nor group stages (P=0.433). Of the 37 patients with confirmatory in-situ hybridisation tests performed, 10 (71%) of 14 with immunohistochemistry staining of 3+ and 1 (4%) of 23 with immunohistochemistry staining of 2+ were found to have HER2 gene amplification.

CONCLUSIONS

More than 25% of HER2 overexpression identified by immunohistochemistry assays in this Hong Kong cohort could not be verified by confirmatory in-situ hybridisation assays. Compliance with the latest guidelines for HER2 testing should improve the future accuracy and concordance.

Treatment of Stage IV(A-B) nasopharyngeal carcinoma by induction-concurrent chemoradiotherapy and accelerated fractionation: impact of chemotherapy schemes

PURPOSE

The aim of this study was to evaluate the impact of different chemotherapy regimens in patients with advanced nasopharyngeal carcinoma (NPC) treated by induction-concurrent chemoradiotherapy.

METHODS AND MATERIALS

Between 1998 and 2003, 75 Stage IV(A-B) NPC patients were treated with 3 cycles of induction chemotherapy with cisplatin plus 5-fluorouracil (PF) (n = 41) or cisplatin plus gemcitabine (PG) (n = 34), followed by accelerated radiotherapy in concurrence with 2 cycles of cisplatin. In 18 (24%) patients, cisplatin was completely replaced by carboplatin in both concurrent cycles, mainly because of borderline renal functions.

RESULTS

The median follow-up was 3.6 years. The 3-year locoregional failure-free survival, progression-free survival, and overall survival of the whole group were 80%, 68%, and 80% respectively. No significant difference was found between patients treated with either induction regimens. However, patients with only carboplatin in the 2 concurrent cycles had significantly inferior 3-year locoregional failure-free survival (56% vs. 86%, p = 0.014), progression-free survival (39% vs. 72%, p = 0.001), and overall survival (61% vs. 87%, p = 0.046) when compared with the rest of the group. In multivariate analysis, the complete replacement of cisplatin by carboplatin during concurrent chemoradiotherapy was still an independent adverse factor in locoregional failure-free survival (hazard ratio, 3.662; 95% CI, 1.145-11.765; p = 0.029) and progression-free survival (hazard ratio, 3.390; 95% CI, 1.443-7.937; p = 0.005).

CONCLUSIONS

The more convenient PG regimen is as effective as the PF regimen as induction chemotherapy for patients with advanced NPC. Replacing cisplatin with carboplatin in the concurrent phase carries a poor prognosis.

Surveillance mammography after breast conservation therapy in Hong Kong: effectiveness and feasibility of risk-adapted approach

Annual surveillance mammography is commonly recommended after breast conservation therapy (BCT). We retrospectively reviewed its effectiveness on 511 invasive and non-invasive breast cancers treated with BCT between 1994 and 2003. The median follow-up was 5.9 years. The 5-year actuarial ipsilateral breast tumour recurrence (IBTR) rate was 4.5% and contralateral breast cancer (CBC) rate was 2.0% (representing eight times increase in risk). IBTR of 43% and 62% CBC were first detected by surveillance mammography. The IBTR detection rates per 1000 mammograms were 5.2 for patients (n=349) with one or more IBTR risk factors (age 45, positive/close margins or histological grade 3) and 0.6 for patients (n=162) without. No survival difference was observed between different modes of IBTR detection (p=0.342). In conclusion, a risk-adapted approach of limiting ipsilateral surveillance to patients with IBTR risk is possible but its implementation will be complicated by the continued need of contralateral surveillance.

Evaluation of the prognostic value of 2005 St Gallen risk categories for operated breast cancers in Hong Kong

Incorporating various new and conventional risk factors, the 2005 St Gallen risk categorization is a potentially useful prognostic tool for breast cancers. We conducted a retrospective study to evaluate its application in Hong Kong. Of the 902 included female breast cancers with median follow-up of 5.4 years, 7%, 63% and 30% patients were classified as low-, intermediate- and high-risk categories, respectively. Their corresponding 5-year distant disease-free survivals (DDFS) were 100%, 92% and 72%, respectively (p<0.00005). In the intermediate-risk category, node-positive patients had marginally inferior 5-year DDFS than node-negative patients (89% vs. 93%, p=0.0551). In the high-risk category, patients having HER2 overexpressed tumors and 1-3 positive nodes had significantly better DDFS than other patients with > or = 4 positive nodes (89% vs. 65%, p=0.0001). Overall, the 2005 St Gallen risk categorization had high prognostic value. However, the impact of HER2 overexpression might be affected by reproducibility of HER2 tests.

Wide Local Excision and Radiotherapy for the Treatment of Ductal Carcinoma in situ of the Breast: the Hong Kong Experience

AIMS

Breast conservation treatment for ductal carcinoma in situ (DCIS) was unpopular in the Chinese population and the outcome was seldom reported. We conducted a single-centre retrospective study to examine the clinical outcome of women in Hong Kong.

MATERIALS AND METHODS

Seventy-five Chinese women were treated with wide local excision and radiotherapy for DCIS of the breast between 1994 and 2003. Only 26 (34.7%) women had non-palpable DCIS detected by screening mammograms. All women were treated with whole breast irradiation of 50 Gy in 2 Gy daily fractions, with 50 (66.7%) women receiving an additional electron boost of 10-16 Gy.

RESULTS

The median follow-up was 5.1 years (range 2.0-10.7). At the last assessment, four women developed local recurrences, but all remained disease-free after salvage mastectomy. The 5-year actuarial local failure-free rate and cause-specific survival rate were 92.9% (95% confidence interval 89.4-96.4) and 100.0%, respectively. Cosmetic results were rated as good to excellent in all women. On univariate analysis of prognostic factors for local failure, only a close (< or = 2 mm) final resection margin approached statistical significance (hazard ratio 9.108; 95% confidence interval 0.946-87.655; P = 0.056). The 5-year actuarial local failure-free rates for women with a close (< or = 2 mm) final resection margin and women with wider margins were 77.0 and 98.2%, respectively.

CONCLUSIONS

Despite geographical and demographic differences, the clinical outcome after wide local excision and radiotherapy for DCIS of the breast in Chinese women is comparable with that in Western series. Efforts are needed to achieve cosmetically acceptable tumour-free margins greater than 2 mm.

Treatment of stage IV(A-B) nasopharyngeal carcinoma by induction-concurrent chemoradiotherapy and accelerated fractionation

PURPOSE

To explore a more effective strategy for treating nasopharyngeal carcinoma with extensive locoregional disease.

METHODS AND MATERIALS

Between October 1998 and January 2003, 49 patients with Stage IV(A-B) disease infiltrating or abutting neurologic structures were treated with induction-concurrent chemotherapy and accelerated radiotherapy (RT). A combination of cisplatin and 5-fluorouracil was used in the induction phase and single-agent cisplatin in the concurrent phase. All patients were irradiated with conformal techniques at 2 Gy/fraction, six daily fractions weekly, to a total dose of 70 Gy.

RESULTS

Although 92% of patients had one or more acute toxicities Grade 3 or worse, 96% completed the whole course of RT, and 92% had five or more cycles of chemotherapy. The great majority of toxicities were uneventful, but 1 patient died of neutropenic sepsis. With a median follow-up of 3.1 years, 20 patients had failure at one or more sites and 15 patients died. The 3-year locoregional and distant failure-free rate was 77% and 75%, respectively, and the overall survival rate was 71%. At last follow-up, 27% of patients had developed late Grade 3 or worse toxicity (24% were hearing impairments), but none had radiation-induced neurologic damage.

CONCLUSION

The current strategy achieved encouraging results for this poor prognostic group, and confirmation of the therapeutic gain by a prospective randomized trial is warranted.

Survival outcome of patients with nasopharyngeal carcinoma with first local failure: a study by the Hong Kong Nasopharyngeal Carcinoma Study Group

BACKGROUND

The purpose of this article is to report the overall survival (OS) outcome of patients with nasopharyngeal carcinoma (NPC) with local failure who received salvage treatment and to identify prognostic factors for OS.

METHODS

Between January 1996 and December 2000, 2915 patients received primary radiotherapy (RT) with or without chemotherapy for nonmetastatic NPC. At a median follow-up of 3.1 years, 319 patients had developed local failure as the first failure, with or without synchronous regional/distant failure. OS was calculated from the start of primary RT. Univariate and multivariate analyses were performed to identify prognostic factors for OS in patients with isolated local failure.

RESULTS

The T classification distribution of the local failure (rT classification) was as follows: 68 (21%) rT1 to T2a, 92 (29%) rT2b, 82 (26%) rT3, and 77 (24%) rT4. The rT classification was the same as the initial T classification in 82% of patients. Two hundred seventy-five patients (86%) had isolated local failure, and 232 (84%) of them did not have any distant metastasis or regional failure develop during follow-up. Salvage treatment was given to 200 patients (73%) with isolated local failure. One hundred fifty-nine patients (80%) received reirradiation (108 external beam RT [EBRT], 44 brachytherapy, and seven EBRT plus brachytherapy), 22 patients (11%) underwent nasopharyngectomy with or without postoperative RT, and 19 patients (9%) were treated with chemotherapy alone. Four patients died of RT complications, and one died of chemotherapy toxicity in the absence of active NPC. The 3-year actuarial OS for patients with isolated local failure was 74%. On multivariate analysis, advanced initial T classification (hazard ratio [HR], 1.44; p = .0006) and the use of salvage treatment (HR, 0.54; p = .0038) were independent prognostic factors. For the subgroups of patients who had the same recurrent and initial T classification, salvage treatment was associated with improved OS only in the subgroup with T1 to T2 local failure (n = 127; p = 0.0446), but not in the subgroups with T3 (n = 48) or T4 (n = 54) disease.

CONCLUSIONS

Most patients with first local failure have localized disease. Salvage treatment is feasible in most of the patients with clinically isolated local failure. Patients who had early initial T classification have a more favorable prognosis. Subgroup analysis suggests that salvage treatment only prolongs survival in patients with T1 to T2 recurrent disease.

Preliminary Results of a Randomized Study on Therapeutic Gain by Concurrent Chemotherapy for Regionally-Advanced Nasopharyngeal Carcinoma: NPC-9901 Trial by the Hong Kong Nasopharyngeal Cancer Study Group

Purpose

This randomized study compared the results achieved by concurrent chemoradiotherapy (CRT) versus radiotherapy (RT) alone for nasopharyngeal carcinoma (NPC) with advanced nodal disease.

Patients and Methods

Patients with nonkeratinizing/undifferentiated NPC staged T1-4N2-3M0 were randomized to CRT or RT. Both arms were treated with the same RT technique and dose fractionation. The CRT patients were given cisplatin 100 mg/m2 on days 1, 22, and 43, followed by cisplatin 80 mg/m2 and fluorouracil 1,000 mg/m2/d for 96 hours starting on days 71, 99, and 127.

Results

From 1999 to January 2004, 348 eligible patients were randomly assigned; the median follow-up was 2.3 years. The two arms were well-balanced in all prognostic factors and RT parameters. The CRT arm achieved significantly higher failure-free survival (72% v 62% at 3-year, P = .027), mostly as a result of an improvement in locoregional control (92% v 82%, P = .005). However, distant control did not improve significantly (76% v 73%, P = .47), and the overall survival rates were almost identical (78% v 78%, P = .97). In addition, the CRT arm had significantly more acute toxicities (84% v 53%, P < .001) and late toxicities (28% v 13% at 3-year, P = .024).

Conclusion

Preliminary results confirmed that CRT could significantly improve tumor control, particularly at locoregional sites. However, there was significant increase in the risk of toxicities and no early gain in overall survival. Longer follow-up is needed to confirm the ultimate therapeutic ratio.

Nasopharyngeal intraepithelial lesion: latent Epstein-Barr virus infection with malignant potential

AIMS

To study the morphology and immunohistochemical expression of nasopharyngeal intraepithelial lesions and to understand their place in nasopharyngeal carcinogenesis.

METHODS AND RESULTS

Nine cases of nasopharyngeal intraepithelial lesion (NPIL) were diagnosed during nasopharyngeal biopsy screening for nasopharyngeal carcinoma (NPC). Two cases were associated with early invasion. All cases demonstrated specific histological features and consistent positivity on in-situ hybridization for Epstein-Barr virus (EBV)-encoded RNA. Pure NPIL lesions showed low-grade morphology while lesions associated with early invasion were high grade. Immunohistochemical studies showed increased expression of bcl-2 and essentially negative findings for BZLF1 and LMP1. High-grade lesions had relatively stronger expression of bcl-2 and p53.

CONCLUSIONS

NPIL harbours latent EBV infection and has malignant potential. Multiple steps are involved in its occurrence and progression. Low-grade and high-grade lesions should be managed differently.

Post-mastectomy Radiotherapy after Immediate Autologous Breast Reconstruction in Primary Treatment of Breast Cancers

AIM

To assess the clinical outcome of breast cancer patients with immediate autologous breast reconstruction and post-mastectomy radiotherapy (PMRT) as primary treatment.

MATERIALS AND METHODS

Twenty-five women with breast cancer treated with immediate autologous breast reconstruction and post-mastectomy radiotherapy as primary treatment between 1995 and 2001 in Pamela Youde Nethersole Eastern Hospital of Hong Kong were retrospectively studied. Radiation doses of 50 Gy (in 2 Gy daily fraction) were given to the reconstructed breasts, except one who was given 45 Gy (in 1.8 Gy daily fraction). Nine women (36%) were treated without bolus, whereas the other 16 women (64%) were treated with 0.5 cm thick bolus on alternate days. The main outcome measures include local control, treatment complications and cosmetic outcome.

RESULTS

Median follow-up was 3.7 years (range: 1.0-6.6 years). Two women (8%), who were treated without bolus, developed chest wall recurrences. The overall 5-year, actuarial, local failure-free rate and disease-specific survival rate were 89.8% and 77.9%, respectively. Apart from mild acute skin reactions, no significant acute radiotherapy side-effects were observed. No flap necrosis or flap loss was seen. The cosmesis of the reconstructed breasts were rated as good to excellent in 85% of the surviving patients. There was no observed adverse effect on cosmesis by adding bolus on alternate days.

CONCLUSION

PMRT after immediate autologous tissue-flap breast reconstruction is well tolerated and is not associated with increased incidence of complications. Adding 0.5 cm bolus on alternate days might improve local control without causing adverse cosmetic effect. The concern of adverse effects of radiotherapy should not exclude the choice of immediate breast reconstruction in suitable patients.

Accuracy of nasopharyngeal carcinoma staging by magnetic resonance imaging

To audit the accuracy of magnetic resonance (MR) staging of nasopharyngeal carcinoma (NPC) in daily reporting, the MR images of 101 adult patients with newly diagnosed NPC reported between December 1996 and February 2002 were reviewed retrospectively. Based on the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) TNM staging criteria (1997), the tumour staging obtained from the MR reports and the MR films was compared by two experienced head and neck radiologists. The number of patients being upstaged, downstaged or unchanged was noted. In all stages, the NPC staging obtained from the MR reports revealed 18 (17.8%) understaged, eight (7.9%) overstaged and 75 (74.2%) the same stage when compared to the staging obtained from the MR films based on the AJCC/UICC criteria. The percentage of patients being understaged or overstaged, in decreasing order of frequency, were stages II, III, IV and I. Magnetic resonance of NPC should be reported by radiologists who are not only familiar with the pathology of this condition and its pattern of spread but who should also base their reports on the AICC/UICC staging criteria. The necessity to improve our MR staging accuracy is largely because it determines the type of therapy to be given and this has to be appropriate and adequate for a successful treatment.

Venous thromboembolism in the Chinese population--experience in a regional hospital in Hong Kong

OBJECTIVE

To estimate the incidence and determine the characteristic features of venous thromboembolism in the Hong Kong Chinese population.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

SUBJECTS AND METHODS

Data were collected during a period of four years (1997-2000). Patients with duplex doppler ultrasonography or venography-documented venous thromboembolism and new episodes of deep vein thrombosis were identified from Department of Diagnostic Radiology records. Patients with high-probability ventilation-perfusion scans were identified from Department of Nuclear Medicine records and these scans were taken as evidence of pulmonary embolism. Patients with intermediate-probability ventilation-perfusion scans, with pulmonary embolism documented by either pulmonary angiography or spiral computed tomography scan, were also included in the study. Patients with autopsy-verified fatal pulmonary embolism were identified from Department of Pathology records. Patients with deep vein thrombosis at other sites were sought from patient discharge diagnostic coding data. Medical records were reviewed for patient characteristics and conditions associated with the development of venous thromboembolism.

RESULTS

Three hundred and seventy-six Chinese patients had venous thromboembolism during the study period. Of these, 352 had peripheral deep vein thrombosis, five had deep vein thrombosis at other sites (cerebral sinus and portal vein thrombosis), 40 had pulmonary embolism (26 had concomitant deep vein thrombosis), and six had fatal pulmonary embolism shown at autopsy.

CONCLUSION

The calculated annual incidence of venous thromboembolism in Hong Kong Chinese people was estimated at 16.6 events per 100,000 population, which is lower than incidence rates reported in Caucasians. The four conditions most commonly associated with venous thromboembolism were medical illness, malignancy, orthopaedic surgery, and intravenous drug use. Conditions associated with venous thromboembolism in patients younger than 45 years included intravenous drug use, thrombophilia, pregnancy, and the use of oral contraceptives.

Breast conservation treatment in Hong Kong-early results of 203 patients: retrospective study

OBJECTIVE

To study the clinical outcomes of patients with invasive or non-invasive breast cancer after breast conservation treatment.

DESIGN

Retrospective study.

SETTING

Clinical oncology department of a public hospital, Hong Kong.

PATIENTS

Two hundred and three patients who received postlumpectomy radiotherapy at the Pamela Youde Nethersole Eastern Hospital between January 1994 and June 1999.

INTERVENTIONS

Adjuvant radiotherapy with or without systemic adjuvant treatment.

MAIN OUTCOME MEASURES

Actuarial local control rate, progression-free survival rate, disease-specific survival rate, and cosmetic score.

RESULTS

The median follow-up was 3.5 years. Two of the 25 patients with carcinoma in situ only developed local recurrence; the 5-year actuarial local control rate was 91.3%. Among the 178 patients with invasive cancer, seven had a local recurrence and 12 developed distant metastases without local failure. The 5-year actuarial local control, progression-free survival, and disease-specific survival rates for patients with invasive cancer were 95.5%, 85.8%, and 95.2%, respectively. The risk of local recurrence was significantly increased for younger patients (age <40 years) and those with positive final margins. Cosmetic scores were rated good to excellent by 95.6% of patients.

CONCLUSIONS

The early clinical outcomes of these patients are comparable to those in large overseas trials, which have demonstrated the equivalence of mastectomy and breast conservation treatment in terms of survival. In addition to mastectomy, with or without breast reconstruction, breast conservation treatment should be offered as an alternative to suitable Chinese women. To maximise local control, further excision or mastectomy is recommended for patients with positive final margins.

MRI of the hypothalamus and pituitary gland in patients with hyperprolactinaemia following radiotherapy for nasopharyngeal carcinoma

PURPOSE

Neuroendocrine dysfunction is a known complication of cranial radiation. While growth hormone deficiency is the most common laboratory finding, hyperprolactinaemia is one of the most common symptomatic dysfunction in adult female patients with nasopharyngeal carcinoma (NPC) following radiotherapy. This analysis aims to study the magnetic resonance imaging (MRI) features of the hypothalamus and the pituitary gland in affected patients.

METHODS

MRI was performed in 24 patients NPC with hyperprolactinaemia detected 10-52 months following one course of radical radiotherapy. The region of study included the nasopharynx, the hypothalamus and the pituitary gland in 20 patients, while in the remaining four patients, this was limited to the pituitary gland. The estimated radiation dose to the hypothalamus and the pituitary gland was 66 Gy, and six patients also had adjuvant chemotherapy. There was no clinical evidence of tumour recurrence in all 24 patients when hyperprolactinaemia was detected.

RESULTS

None of the 24 patients showed any MRI evidence of structural abnormality in the hypothalamic-pituitary region.

CONCLUSION

MRI did not reveal any structural abnormality in the hypothalamic-pituitary region of patients who developed hyperprolactinaemia following radiotherapy for NPC.

Retrospective analysis on treating nasopharyngeal carcinoma with accelerated fractionation (6 fractions per week) in comparison with conventional fractionation (5 fractions per week): report on 3-year tumor control and normal tissue toxicity

BACKGROUND AND PURPOSE

To assess the therapeutic gain achieved by accelerated fractionation for non-keratinizing/undifferentiated nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

During January 1994 to October 1997, 325 patients were treated to a total dose of 66 Gy in 33-37 fractions: 167 (irradiated before mid-January 1996) with 5 daily fractions (CF) and subsequent 158 with 6 daily fractions (AF) per week. Their median treatment times were 46 and 39 days, respectively. Additional boost to parapharyngeal extension had been given to 181 and Cisplatin-based chemotherapy to 57 patients (24 concurrent with radiotherapy).

RESULTS

The AF group had significantly higher progression-free rate than the CF group (74 vs. 63% at 3 years, P=0.02 by the log-rank test). However, the difference in disease-specific survival (86 vs. 80%, P=0.39) and overall survival (81 vs. 78%, P=0.9) did not reach statistical significance. Strongly significant improvement in local failure-free rate was achieved for patients with T3-4 tumors (87 vs. 62%, P<0.01). Multivariate analyses showed that fractionation was an independent significant factor for overall progression: hazard ratio=0.63, 95% confidence interval: 0.41-0.98, P=0.04. Among the 268 patients treated with radiotherapy alone, those treated by AF had significantly higher incidence of acute reaction grade > or=3 (72 vs. 13%, P<0.01). However, all patients completed the scheduled dose without excessive prolongation, and no significant increase in late complications was observed (20 vs. 15% at 3 years, P=0.19).

CONCLUSIONS

The current analyses suggested that acceleration to 6 daily fractions per week could significantly improve the progression-free rate for NPC without excessive late toxicity. Improvement in local control was confined to T3-4 tumors.

Metastatic tumour of the tunica vaginalis testis from carcinoma of the stomach

A 50-year-old man with advanced inoperable gastric adenocarcinoma and diffuse peritoneal metastasis received six cycles of palliative chemotherapy and responded clinically with weight gain. Two months after the completion of chemotherapy, however, he developed a left hydrocele. Aspiration yielded 70 ml of yellowish hydrocele fluid, which contained metastatic adenocarcinoma cells, consistent with a gastric primary tumour. A diagnosis of malignant hydrocele was made. Two weeks later, he developed a painful recurrent left hydrocele with increasing pain and swelling. Left orchidectomy was performed. Tiny white mural nodules measuring 1 mm in size were noted on the tunica vaginalis. No focal lesion was noted in the testis. On microscopic examination, the tunica vaginalis showed reactive mesothelial hyperplasia and extensive lymphatic permeation by poorly differentiated adenocarcinoma, consistent with a gastric primary tumour.

Quadruple primary neoplasms in a 27-year-old woman

A27-year-old woman was referred to our department on 3 February 1998 with a diagnosis of malignant melanoma associated with cystic teratoma of ovary. She had had a laparotomy and bilateral salphingo-oophorectomy on 5 January 1998. Pathology revealed tumour involvement of left ovary, left parametrium and malignant ascites, the right ovary showed polycystic disease, the uterus showed simple hyperplasia of endothelium, the omentum had no tumour and subdiaphragmatic scrapping was negative. On histological examination of the tumour, the cystic portion was basically a cystic teratoma with presence of skin, glial and bony tissue, the solid portion consisted of sheets of undifferentiated tumour cells, which on immunohistochemical staining shown strong positivity to HMB 45 and S-100. Ultrastructual examination confirmed melanocytic differentiation.

Her chest X-ray was clear. Computed tomography of abdomen and pelvis suggested bilobar liver metastasis and significant para-aortic lymphadenopathy. The alpha-fetoprotein (αFP) and beta-human chorionic gonadotrophin (β-hCG) were within normal limits. The diagnosis was a malignant melanoma arising in cystic teratoma of ovary, stage IV disease.

Her past medical history included multiple primary neoplasms. She had right thigh cutaneous histiocytoma at the age of 20 years, with complete excision performed. She developed poorly differentiated invasive ductal carcinoma of left breast (stage pT2N0M0) at the age of 21 years and had a left mastectomy and left axillary clearance; no postoperative adjuvant treatment was given. She also recently had multiple thyroid nodules which shown atypical cells, suggestive of a follicular neoplasm, and total thyroidectomy was contemplated.

Evaluation of her family revealed a strong family history of malignancy. Her twin sister died of a primary brain tumour at the age of 8 years. Her father died of lung cancer at the age of 45 years. Her paternal grandfather died of lung cancer in his 60s. Her paternal grandmother died of primary liver cancer in her 60s. One of her paternal half-uncles (mutual grandfather, different grandmothers) died of a primary brain tumour in his 50s while another died of lung cancer in his 70s. There was no positive family history of malignancy on her maternal side (Figure 1).

She was treated with combination chemotherapy using cisplatin (75 mg/m2) and cyclophosphamide (750 mg/m2). However, she deteriorated rapidly after the first cycle of chemotherapy and died on 16 March 1998.

Nasopharyngeal carcinoma in situ: two cases of an emerging diagnostic entity

BACKGROUND

The association of Epstein-Barr virus (EBV) with the oncogenesis of nasopharyngeal carcinoma (NPC) is well established. Latent infection by EBV with clonal proliferation has also been demonstrated in preinvasive lesions of NPC. In situ hybridization for EBV-encoded RNA (ISH EBER) now serves as an ancillary test in the definitive diagnosis of these lesions.

METHODS

Two cases of nasopharyngeal carcinoma in situ (NPCIS) are presented in this study. Their biopsies were studied by ordinary light microscopy, the ISH EBER technique, and immunostaining for bcl-2. Tissue samples from 100 high risk subjects negative for NPC and NPCIS, who served as controls, were also studied using the ISH EBER technique.

RESULTS

NPCIS was characterized by abnormal light microscopic appearance as well as positive staining by the ISH EBER technique; these features were not observed in samples from the 100 high risk subjects. Immunostaining for bcl-2 protein was positive but less specific. Postradiotherapy biopsies of the two patients were negative for NPCIS.

CONCLUSIONS

With the help of the ISH EBER technique, the diagnosis of NPCIS is now possible in routine surgical pathology. As this entity is rare, it is necessary to have a high degree of suspicion when evaluating biopsies from high risk individuals. Radiotherapy for patients with NPCIS is justified in view of the risk of cancer progression and the possibility of a coexisting invasive carcinoma.

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.

Primary cutaneous plasmacytoma--report of two cases and review of the literature

Primary cutaneous plasmacytomas are very rare. In this report, we describe two such cases and review the literature on this entity. Both patients presented with a slowly growing, painless, and solitary mass on the chest wall. Histologically, one case was composed of mature-looking plasma cells, while the other was composed of immature and anaplastic plasma cells, infiltrating the dermis. The epidermis was spared. Kappa light-chain restriction was demonstrated by immunohistochemical techniques in both cases. There was no evidence of marrow disease even on repeated marrow biopsies, although extracutaneous lesions were detected in one patient. One remained in complete remission 6 years following local irradiation. The other patient was treated with local irradiation and systemic chemotherapy, with a complete response, but this was followed by multiple cutaneous recurrences and further remissions by treatment with cytotoxic agents. The present cases and those reported in the literature illustrate well the variable clinical course of primary cutaneous plasmacytoma. Although cure can apparently be achieved in some patients by local radiation therapy, more than half of the cases relapse or progress to myelomatosis. The disease-related mortality is at least 40%. Thus cutaneous plasmacytoma appears to be more aggressive than noncutaneous extramedullary plasmacytomas and should be separately categorized from them in future studies.

Central pontine myelinolysis: report of two occurrences after cisplatin-containing chemotherapy for nasopharyngeal carcinoma

We report two patients with the classical clinical syndrome of central pontine myelinolysis following cisplatin based chemotherapy for nasopharyngeal carcinoma. The diagnosis was supported by typical features on magnetic resonance imaging. Rapid correction of hyponatraemia was the most likely cause. A short course of corticosteroids was tried in both patients. Although one patient experienced almost complete recovery, the other still suffered from residual motor deficit. The importance of careful monitoring of the rate of electrolyte correction is emphasized.