Cancer of the pyriform sinus: trends towards conservative treatment

Despite progress in diagnostic methods, radiotherapeutic and surgical techniques, and the development of new chemotherapeutic agents, the prognosis of pyriform sinus carcinomas has not improved in a significant way over the last 2 decades. Whatever the treatment approach, for all stages combined, the overall survival at 5 years remains modest and rarely exceeds 30%. Deaths from distant metastases, second cancers and intercurrent diseases represent 30-40% of cases. For this, any improvement in loco-regional control does not necessary translate into a gain in survival. Thus, for these patients it is judicious to consider not only the loco-regional control but also the quality of life since larynx preservation is concerned. In this review article, the results of different treatment approaches are illustrated by the most representative series in the recent literature. Early stages (T1-2) are managed conservatively either by radical radiotherapy or conservative surgery, although the former is the most frequently utilized as it requires less stringent patient selection. For more advanced stages (T3-4), recent tendencies appear to lean toward the use of primary radical radiotherapy with or without chemotherapy, with surgery reserved for persistent or recurrent tumor. However, this strategy is still under study and the initial results should be confirmed.     

The possible advantage of hyperfractionated thoracic radiotherapy in the treatment of locally advanced nonsmall cell lung carcinoma: results of a North Central Cancer Treatment Group Phase III Study

BACKGROUND: A three-arm Phase III randomized trial was performed to compare response rates, time to local or distant progression, and survival for patients with unresectable (Stage IIIA or IIIB) nonsmall cell lung carcinoma treated with standard fractionated thoracic radiotherapy (SFTRT) versus accelerated hyperfractionated thoracic radiotherapy (AHTRT) with or without combination etoposide and cisplatin chemotherapy. METHODS: This trial was initiated in 1992 by the North Central Cancer Treatment Group. Patients with Stage IIIA or IIIB nonsmall cell lung carcinoma were eligible. They were randomly assigned to either SFTRT (6000 centigray [cGy] in 30 fractions) or AHTRT (150 cGy twice daily to a total dose of 6000 cGy, with a 2-week break after the initial 3000 cGy); the AHTRT was given alone or with concomitant cisplatin (30 mg/m2, Days 1-3 and 28-30) and etoposide (100 mg/m2, Days 1-3 and 28-30). RESULTS: A total of 110 patients were entered on study. Eleven patients were declared ineligible or off study on the day of study entry. This analysis was confined to the 99 eligible patients. This article reports mature follow-up, because more than 80% of the patients have died. The median follow-up of living patients was 2.5 years. There were suggestions of improvement in the rates of freedom from local recurrence and survival for patients treated with AHTRT (with or without chemotherapy) as opposed to SFTRT (P = 0.06 and P = 0.10, respectively). The improvement in survival associated with AHTRT (with or without chemotherapy) was statistically significant for the subgroup of patients with nonsquamous cell carcinoma after adjustment for other potentially confounding factors (P = 0.02). No differences in freedom from systemic progression or survival were found in a comparison of AHTRT with chemotherapy and AHTRT without chemotherapy. CONCLUSIONS: These results suggest that treatment of Stage IIIA or IIIB nonsmall cell lung carcinoma with AHTRT with or without chemotherapy may improve freedom from local progression and survival as compared with SFTRT, especially for patients with nonsquamous cell carcinoma. The statistical powers to detect the observed differences in median time to local progression and survival were approximately 55% and 35%, respectively. Therefore, further investigation comparing SFTRT with AHTRT is warranted.     

The use of hyperfractionated radiotherapy in soft-tissue sarcomas

In classical irradiation, the local control can be negatively influenced by the accelerated clonogenic tumoral repopulation. A modality of control of this phenomenon can be accelerated hyperfractionated irradiation. The aim of this paper is the study of the effect of this type of irradiation in soft tissue sarcomas on patients of the Radiological-Oncological Clinic Ia?i. Accelerated hyperfractionated irradiation causes a favorable response in the primary tumor with good local tolerance, but the "free of disease" period depends on the aim of irradiation (preoperative, postoperative or single therapeutical procedure).     

Electrovaporization as a treatment modality for transurethral resection of the prostate: influence of generator type

OBJECTIVES: To study the influence of the electrosurgical generator on the vaporization efficacy during electrovaporization (EVAP) using different vaporization elements. METHODS: Electrical properties of human prostatic (in vivo) and bovine myocardium (in vitro) tissue were measured under electroresection and electrovaporization conditions. The effective output power of four different generators ("old generation" Force 4 and Force 40 and "new generation" Force 300 and Force FX) was measured at different impedance loads. In vitro, the coagulation and vaporization capabilities of the electrosurgical generators in combination with resection and vaporization elements were studied on homogeneous tissue (bovine myocardium). RESULTS: The electrical impedance of human prostatic tissue and bovine myocardium increases from 400 to 1000 ohms when coagulated. The effective output power of the old generation electrosurgical devices depends strongly on tissue impedance. This implies that working on already coagulated tissue using such devices is not well controlled and not reproducible. By contrast, new generation electrosurgical devices correct for the higher impedance of coagulated tissue, thus delivering constant output power and corresponding tissue effects. CONCLUSIONS: For an effective application of the EVAP technique, the use of a new generation impedance independent electrosurgical unit is highly recommended.     

Writing as a therapeutic modality

1. Most psychiatric and mental health professionals are experienced with writing in some form as a tool for encouraging patients to express feelings and identify stressors. 2. Narrative writing, or journal writing, can also help patients identify areas of conflict in their lives and to clarify complicated issues. 3. Writing can be used effectively with patients who are reluctant or embarrassed to speak openly in one-on-one interactions.     

Induction therapy for esophageal cancer with paclitaxel and hyperfractionated radiotherapy: a phase I and II study

OBJECTIVE: Induction chemoradiotherapy followed by surgery may improve survival rates among patients with esophageal carcinoma. We designed a novel intense induction regimen with paclitaxel and high-dose hyperfractionated radiotherapy to maximize complete response rates. METHODS: Forty patients with esophageal cancer were treated in a phase I and II trial of induction chemotherapy (cisplatin, 5-fluorouracil, and paclitaxel) at three dosage levels (75, 125, and 100 mg/m2) and concurrent hyperfractionated radiotherapy (45 Gy to the mediastinum, 58.5 Gy to the tumor). The mean age was 62 years, and 32 patients (80%) had adenocarcinoma. Twenty-eight of 40 (70%) patients had locally advanced tumors (T3, or stage IIB or greater). RESULTS: The average hospitalization for induction treatment was 17 days. Toxicity was substantial, with esophagitis necessitating nutritional support the most common complication. The maximum tolerated dose of paclitaxel was 100 mg/m2. Two patients died during induction treatment. Thirty-six patients (90%) underwent resection. The median length of stay was 10 days, and two patients died after the operation. Fourteen of 36 patients (39%) had a pathologic complete response. Patients who received all prescribed chemotherapy had a higher pathologic complete response rate (50%) than did patients who required dose reduction (17%; p = 0.076). The 2-year survival rate was 61% (95% CI 35% to 86%) with a median follow-up of 11.9 months. CONCLUSIONS: Paclitaxel at a dose of 100 mg/m2 appears to have acceptable toxicity. The high pathologic complete response rate in this regimen is encouraging, but it is associated with substantial toxicity. The toxicity of this regimen is not acceptable and will require substantial reduction in the radiation component. Survival data are too short-term to confirm enhanced survival.     

Controlled clinical trials of hyperfractionated and accelerated radiotherapy in otorhinolaryngologic cancers

From 1978 to March 1998, (1,867 patients) were accrued in head and neck trials comparing hyperfractionation (HF) and accelerated fractionation (AF) to classical fractionation (CF). Two randomized trials (867 pts) led to positive conclusions in favour of the HF & AF arms: 1) EORTC trial 22791 (356 patients, 1980-87) compared CF (70 Gy/35-40 fr/7-8 wks) to HF (80.5 Gy/70 fr/7 wks, using 2 fr x 1.15 Gy/day) in T2 T3, N0-N1 < 3 cm in oropharyngeal carcinoma. Locoregional control (LRC) was higher (p = 0.01) in HF versus CF. At 5 years, 56% of the patients are LRC free with HF versus 38% with CF on the latest update (February 1998). This improvement of LRC also resulted in a significant overall survival (p = 0.05). There was no difference in late normal tissue damage between the two treatment modalities. Overall, this is the largest improvement documented in a randomised trial for oropharyngeal cancers during the past decade. 2) EORTC trial 22851 (511 patients, 1985-1995) compared AF (72 Gy/45 fr/5 wks) to CF (70 Gy/35 fr/7 wks) in T2 T3 T4 head & neck cancers (hypopharynx excluded). Acute and late toxicity were increased in the AF arm. Late severe sequelae occurred in 14% of patients of the AF arm versus 4% in the CF arm. Two cases of radiation-induced myelitis occurred after doses of 42 and 48 Gy to the spinal cord. The AF arm is significantly better for locoregional control (p = 0.017) and for time to progression (p = 0.012) resulting in a 15% locoregional gain at 5 years over the CF arm. This improvement is of larger magnitude in patients with poorer prognosis (N3 any T, T4 any N) than in patients with more favourable stage. Multivariate analysis confirmed AF as an independent pronostic factor for local control (p = 0.03). Specific survival shows a non significant advantage (p = 0.06) in favour of the AF arm. This trial shows that accelerated radiotherapy is able to improve locoregional control in a large variety of head and neck squamous cell carcinomas. A less toxic scheme should however be investigated before moving AF schemes in standard practice. To conclude, these two schemes derived from experimental radiobiology concepts resulted in a significant improvement of locoregional control. Hyperfractionation resulted in an improved locoregional and survival benefit. Although HF is presently the most reliable regimen to improve locoregional control, the validity of the concept of AF is also confirmed. Better schemes of AF should now be evaluated to reduce late toxicity.     

Accelerated hyperfractionated radiotherapy combined with induction and concomitant chemotherapy for inoperable non-small-cell lung cancer--impact of total treatment time

PURPOSE: To determine the importance of fall characteristics, body habitus, function, and hip bone mineral density as independent risk factors for hip fracture in frail nursing home residents. SUBJECTS AND METHODS: In this prospective, case-control study of a single, long-term care facility, we enrolled 132 ambulatory residents (95 women and 37 men) aged 65 and older, including 32 cases (fallers with hip fracture) and 100 controls (fallers with no hip fracture). Principal risk factors included fall characteristics, body habitus, measures of functional assessment, and hip bone mineral density by dual-energy X-ray absorptiometry. RESULTS: In multivariate analysis, including only those with knowledge of the fall direction (n=100), those who fell and suffered a hip fracture were more likely to have fallen sideways (odds ratio 5.7, 95% confidence interval [CI] 1.7 to 18, P= 0.004) and have a low hip bone mineral density (odds ratio 1.9, 95% CI 0.97 to 3.7, P=0.06) than those who fell and did not fracture. When all participants were included (n=132) and subjects who did not know fall direction were coded as not having fallen to the side, a fall to the side (odds ratio 3.9, 95% CI 1.3 to 11, P=0.01), low hip bone density (odds ratio 1.8, 95% CI 1.03 to 3, P=0.04), and impaired mobility (odds ratios 6.4, 95% CI 1.9 to 21, P=0.002) were independently associated with hip fracture. Sixty-seven percent of subjects (87% with and 62% without hip fracture) had a total hip bone mineral density greater than 2.5 SD below adult peak bone mass and were therefore classified as having osteoporosis using World Health Organization criteria. CONCLUSIONS: Among frail elderly nursing home fallers, the preponderance of whom are osteoporotic, a fall to the side, a low hip bone density, and impairment in mobility are all important and independent risk factors for hip fracture. These data suggest that, among the frailest elderly, measures to reduce the severity of a sideways fall and improve mobility touch on new domains of risk, independent of bone mineral density, that need to be targeted for hip fracture prevention in this high-risk group.     

食管癌全程三维适形放疗后程加速超分割的疗效观察

Objective:The aim of the study was to evaluate the therapeutic effect and safety of whole-course three-dimen-sional conformal radiotherapy (3DCRT) combined with late-course accelerated hyperfractionated radiotherapy (LCAFR) on patients with esophageal carcinoma.Methods:one hundred and one patients with esophageal carcinoma were divided into two groups.Observing group (49 cases) were treated by whole-course 3DCRT.Patients in control group (52 cases) were treated by conventional radiotherapy.Clinical efficiencies and radiation toxicities were compared between two groups.Re-sults:The side effects including radiation esophagitis (63.2%) and tracheitis (49.0%) decreased in observing group,but there was no significant difference between two groups (69.2% and 55.7% in controls).The 1-,2- and 3-year tumor local control rates and overall survival rates in the observing group were significantly improved compared with the control group,being respectively 87.8%,75.5%,63.3% vs 71.2%,55.8%,42.3% and 85.7%,71.4%,46.7% vs 69.2%,51.9%,26.9% (all P < 0.05).Conclusion:The therapeutic effect of whole-course 3DCRT combined with LCAFR for esophageal carcinomas is superior to conventional radiotherapy.     

Chemotherapy as a part of each treatment fraction in a twice-a-day hyperfractionated schedule: a new chemoradiotherapy approach for advanced head and neck cancer

In allergic asthma, there is convincing evidence that changes in eosinophil and lymphocyte state of activation in blood may reflect disease activity. We evaluated whether simple blood eosinophil or lymphocyte counts in atopic children with asthma could reflect the degree of allergic sensitization. Seventy-six asthmatic children, sensitized to house dust mites (HDM), in stable conditions at the time of the study, and 53 sex- and age-matched controls (CTR) were studied. As compared to CTR, allergic patients showed higher eosinophil numbers and percentages (p < 0.001) but similar lymphocyte numbers and proportions (p > 0.1). Both in CTR and in allergic patients, eosinophil counts did not correlate with lymphocyte counts (p > 0.05; each comparison) but positive correlations were observed between eosinophil numbers and percentages and paper radio immunosorbent test (PRIST) levels or radio-allergo sorbent test (RAST) classes (p < 0.001; each comparison). When allergic asthmatic individuals were subdivided according to their age into two subgroups (Gr), no differences were found in eosinophil and lymphocyte counts and in PRIST levels and RAST values between Gr1 (< or =5 years old [preschool children]) and Gr2 (>5 years old [school children]) (p > 0.05; each comparison). Interestingly, although positive correlations between eosinophil counts and PRIST levels were found in both subgroups (p < 0.05; each comparison), only in Gr2 did eosinophil counts correlate positively with RAST classes (p < 0.001). No correlations between lymphocyte counts and PRIST levels or RAST classes were demonstrated (p > 0.05; each comparison). These data suggest that although blood eosinophilia was similar in preschool and in allergic asthmatic school children sensitized to HDM, only in the oldest children did blood eosinophil counts appear to be related to the degree of HDM-specific sensitization.     

Pharmacokinetics of nicotine carbomer enemas: a new treatment modality for ulcerative colitis

BACKGROUND: Ulcerative colitis is largely a disease of nonsmokers, and transdermal nicotine is of therapeutic value in the active disease. Because side effects are common, we developed a topical enema formulation of nicotine. OBJECTIVE: To study the pharmacokinetics of nicotine complexed with a polyacrylic carbomer and administered by enema to eight healthy volunteers and to eight patients with active ulcerative colitis, verified sigmoidoscopically. PATIENTS AND METHODS: All 16 subjects were nonsmokers. The mean age for normal subjects was 33 years; the mean for patients with ulcerative colitis was 60 years. Median stool frequency for patients with ulcerative colitis was four daily. Patients were taking 5-amino salicylic acid compounds and five were taking oral prednisolone (median dose, 12 mg daily). Nicotine, 6 mg, complexed with carbomer 974P, 400 mg, was administered in a 100 ml enema after an overnight fast, with serial blood measurements taken over 8 hours. Serum nicotine and cotinine were measured by gas liquid chromatography. Area under the concentration-time curves were calculated by the trapezoidal method, and the terminal elimination half-life was derived by extrapolation of the log-linear terminal phase. RESULTS: With the exception of nicotine time to reach peak concentration, which was longer in patients (median of 60 minutes compared with 45 minutes; p < 0.005), other comparisons between normal subjects and patients showed no statistically significant difference, although there was considerable inter-subject variation. Maximum concentration of nicotine, 8.1 +/- 3.5 ng/ml, in the 16 subjects occurred after a median of 60 minutes (range, 30 to 180 minutes); maximum cotinine concentrations of 60.4 +/- 11.5 ng/ml occurred after 4 hours. Side effects in five subjects were mild (four subjects) or moderate (one subject) and included lightheadedness, nausea, and headache; these five subjects were female lifelong nonsmokers of low body weight. CONCLUSION: Because most of the active ingredient of nicotine is converted to continine on the first pass through the liver, substantial concentrations can be achieved at the site of disease with only modest rises in serum nicotine, which are responsible for side effects; cotinine has low pharmacologic activity. Topical administration of nicotine may be useful treatment for distal ulcerative colitis.     

Communication modality as a determinant of persuasion: The role of communicator salience.

Reports 2 studies, using a total of 304 university students, in which a likable or unlikable communicator delivered a persuasive message via writing, audiotape, or videotape. In both studies the likable communicator was more persuasive in video- and audiotape than in writing, but the unlikable communicator was more persuasive in writing. Thus, communicator likability was a significant determinant of persuasion only in the broadcast modalities. Other findings suggest that Ss process more communicator cues when exposed to video- and audiotape messages than when exposed to written ones and that communicator-based (rather than message-based) cognitions predicted opinion change primarily in video and audiotape conditions rather than in written ones. It is concluded that video- and audiotapes enhance communicator-related information, so that communicator characteristics exert a disproportionate effect on persuasion when messages are broadcast. Findings are also discussed in relation to "vividness" phenomena. (40 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pneumocephalus as a complication of posterior fossa surgery in the sitting position

A case of pneumocephalus complicating posterior fossa surgery in the sitting position is presented. Rapid diagnosis was obtained by computerised tomography. This condition should be suspected whenever a patient demonstrates delayed recovery or neurological deficit after craniotomy and nitrous oxide anaesthesia. The literature on the subject is reviewed.     

Electropotential measurements as a new diagnostic modality for breast cancer

BACKGROUND: Proliferative changes in breast epithelium are an intrinsic aspect in the development of breast cancer, and result in regions of epithelial electrical depolarisation within the breast parenchyma, which can extend to the skin surface. Diagnostic information might be obtained from a non-imaging and non-invasive test based on skin-surface electropotentials. METHODS: In 661 women, scheduled for open biopsy at eight European centres, we studied whether measurements of breast electrical activity with surface sensors could distinguish benign from malignant breast disease. A depolarisation index was developed. RESULTS: We found a highly significant trend of progressive electrical changes according to the proliferative characteristics of the biopsied tissue. Discriminatory information was obtained in both premenopausal and postmenopausal women, and the index was not related to age. The best test performances were for women with palpable lesions. The median index was 0.398 for non-proliferative benign lesions, 0.531 for proliferative benign lesions, and 0.644 for cancer (ductal carcinoma-in-situ and invasive). A specificity of 55% was obtained at 90% sensitivity for women with palpable lesions when a discriminant based on age and the depolarisation index was used. INTERPRETATION: This new modality may have diagnostic value, especially in reducing the number of unnecessary diagnostic tests among women with inconclusive findings on physical examination. Understanding and control of the biological variability of these electrical phenomena will be important in the improvement of this test. Studies in populations with a lower cancer prevalence are needed to assess further the diagnostic value of this approach.     

Middle fossa cyst presenting as a delayed complication of temporal lobectomy: case report

The antibiotic susceptibilities of 43 strains of Escherichia coli O157:H7 identified in the summer of 1996 in Japan were investigated. Growth of 90% of O157 strains was inhibited at a concentration of < or = 0.5 micro/ml by several agents including fosfomycin with glucose-6-phosphate.     

Costs of conventional radical radiotherapy versus continuous hyperfractionated accelerated radiotherapy (CHART) in the treatment of patients with head and neck cancer or carcinoma of the bronchus. Medical Research Council CHART Steering Committee

We have compared the results of targeted manual rescreening of 1211 randomly selected smears with the results of PAPNET-assisted rescreening of 1613 cervical smears, containing at least 6.3% low-grade squamous intraepithelial lesion (SIL). PAPNET diagnosis and the targeted rescreening diagnosis were compared with the initial report, issued on the corresponding smear. Reproducibility scores for inadequacy, presence of endocervical and endometrial cells, specific infections and squamous cell abnormalities were determined. The reproducibility scores for the diagnosis of inadequate smears and specific infections were lower with the PAPNET-assisted rescreening. The detection of squamous cell abnormalities was excellent for both methods (> 0.95), with a higher detection rate for false-negative smears with the PAPNET testing system.     

Real-life exposure as a primary therapeutic factor in the desensitization treatment of fear.

Conducted a 2 * 3 factorial study to assess the theory and efficacy of systematic desensitization and to identify the factors responsible for its effects. 54 female undergraduate aquaphobics received 1 of 6 treatment conditions administered individually by trained psychologists and psychological assistants: (a) systematic desensitization with/without repeated exposure, (b) predesensitization with/without repeated exposure, and (c) no office treatment with/without repeated exposure. Results reveal considerable subjective and behavioral improvement associated primarily with the repeated exposure treatment, which consisted of sessions of graded exposure to real water situations. Reduction of anxiety to the imagined stimuli in systematic desensitization showed little transfer to the real situations in the absence of exposure, suggesting that actual exposure may be a primary therapeutic factor in the desensitization treatment of fear. A follow-up evaluation revealed the durability of the aquaphobic improvements, and evidence of beneficial side effects which appeared primarily attributable to training in self-relaxation. (38 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)