Risk of carotid blowout after reirradiation of the head and neck: a systematic review

PURPOSE

Carotid blowout (CB) is a rare but frequently fatal complication of head-and-neck (H&N) cancer or its treatment. We sought to determine the reported rate of CB in patients receiving salvage reirradiation for H&N cancer.

METHODS AND MATERIALS

A literature search identified 27 published articles on H&N reirradiation involving 1554 patients, and a pooled analysis was performed to determine the rate of CB. Treatment parameters, including prior radiation dose, interval from prior radiation, dose and fractionation of reirradiation, use of salvage surgery, and chemotherapy, were abstracted and summarized. The cumulative risk of CB was compared between groups using Fisher's exact test.

RESULTS

Among 1554 patients receiving salvage H&N reirradiation, there were 41 reported CBs, for a rate of 2.6%; 76% were fatal. In patients treated in a continuous course with 1.8-2-Gy daily fractions or 1.2-Gy twice-daily fractions, 36% of whom received concurrent chemotherapy, the rate of CB was 1.3%, compared with 4.5% in patients treated with 1.5 Gy twice daily in alternating weeks or with delayed accelerated hyperfractionation, all of whom received concurrent chemotherapy (p = 0.002). There was no statistically significant difference in the rate of CB between patients treated with or without concurrent chemotherapy, or between patients treated with or without salvage surgery before reirradiation.

CONCLUSION

Carotid blowout is an infrequent but serious complication of salvage reirradiation for H&N cancer. The rate of CB was lower among patients treated with conventional or hyperfractionated schedules compared with regimens of accelerated hyperfractionation, though heterogeneous patient populations and treatment parameters preclude definite conclusions. Given the high mortality rate of CB, discussion of the risk of CB is an important component of informed consent for salvage reirradiation.

ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck cancer

Recurrent and second primary head-and-neck squamous cell carcinomas arising within or in close proximity to previously irradiated fields are a common clinical challenge. Whereas surgical salvage therapy is recommended for resectable disease, randomized data support the role of postoperative reirradiation in high-risk patients. Definitive reirradiation is an established approach for patients with recurrent disease who are medically or technically inoperable or decline radical surgery. The American College of Radiology Expert Panel on Head and Neck Cancer reviewed the relevant literature addressing re-treatment after prior definitive radiation and developed appropriateness criteria for representative clinical scenarios. Examples of unresectable recurrent disease and microscopic residual disease after salvage surgery were addressed. The panel evaluated the appropriateness of reirradiation, the integration of concurrent chemotherapy, radiation technique, treatment volume, dose, and fractionation. The panel emphasized the importance of patient selection and recommended evaluation and treatment at tertiary-care centers with a head-and-neck oncology team equipped with the resources and experience to manage the complexities and toxicities of re-treatment.

Infant brain tumors: incidence, survival, and the role of radiation based on Surveillance, Epidemiology, and End Results (SEER) Data

PURPOSE

To evaluate the incidence of infant brain tumors and survival outcomes by disease and treatment variables.

METHODS AND MATERIALS

The Surveillance, Epidemiology, and End Results (SEER) Program November 2008 submission database provided age-adjusted incidence rates and individual case information for primary brain tumors diagnosed between 1973 and 2006 in infants less than 12 months of age.

RESULTS

Between 1973 and 1986, the incidence of infant brain tumors increased from 16 to 40 cases per million (CPM), and from 1986 to 2006, the annual incidence rate averaged 35 CPM. Leading histologies by annual incidence in CPM were gliomas (13.8), medulloblastoma and primitive neuroectodermal tumors (6.6), and ependymomas (3.6). The annual incidence was higher in whites than in blacks (35.0 vs. 21.3 CPM). Infants with low-grade gliomas had the highest observed survival, and those with atypical teratoid rhabdoid tumors (ATRTs) or primary rhabdoid tumors of the brain had the lowest. Between 1979 and 1993, the annual rate of cases treated with radiation within the first 4 months from diagnosis declined from 20.5 CPM to <2 CPM. For infants with medulloblastoma, desmoplastic histology and treatment with both surgery and upfront radiation were associated with improved survival, but on multivariate regression, only combined surgery and radiation remained associated with improved survival, with a hazard ratio for death of 0.17 compared with surgery alone (p = 0.005). For ATRTs, those treated with surgery and upfront radiation had a 12-month survival of 100% compared with 24.4% for those treated with surgery alone (p = 0.016). For ependymomas survival was higher in patients treated in more recent decades (p = 0.001).

CONCLUSION

The incidence of infant brain tumors has been stable since 1986. Survival outcomes varied markedly by histology. For infants with medulloblastoma and ATRTs, improved survival was observed in patients treated with both surgery and early radiation compared with those treated with surgery alone.

ACR Appropriateness Criteria: single brain metastasis

Single brain metastasis represents a common neurologic complication of cancer. Given the number of treatment options that are available for patients with brain metastasis and the strong opinions that are associated with each option, appropriate treatment for these patients has become controversial. Prognostic factors such as recursive partitioning analysis and graded prognostic assessment can help guide treatment decisions. Surgery, whole brain radiation therapy (WBRT), stereotactic radiosurgery or combination of these treatments can be considered based on a number of factors. Despite Class I evidence suggestive of best therapy, the treatment recommendation is quite varied among physicians as demonstrated by the American College of Radiology's Appropriateness Panel on single brain metastasis. Given the potential concerns of the neurocognitive effects of WBRT, the use of SRS alone or SRS to a resection cavity has gained support. Since aggressive local therapy is beneficial for survival, local control and quality of life, the use of these various treatment modalities needs to be carefully investigated given the growing number of long-term survivors. Enrollment of patients onto clinical trials is important to advance our understanding of brain metastasis.

Pattern of failure after limited margin radiotherapy and temozolomide for glioblastoma

PURPOSE

To evaluate the pattern of failure after limited margin radiotherapy for glioblastoma.

METHODS AND MATERIALS

We analyzed 62 consecutive patients with newly diagnosed glioblastoma treated between 2006 and 2008 with standard fractionation to a total dose of 60 Gy with concurrent temozolomide (97%) or arsenic trioxide (3%). The initial clinical target volume included postoperative T2 abnormality with a median margin of 0.7 cm. The boost clinical target volume included residual T1-enhancing tumor and resection cavity with a median margin of 0.5 cm. Planning target volumes added a 0.3- or 0.5-cm margin to clinical target volumes. The total boost planning target volume (PTV(boost)) margin was 1cm or less in 92% of patients. The volume of recurrent tumor (new T1 enhancement) was categorized by the percent within the 60-Gy isodose line as central (>95%), infield (81-95%), marginal (20-80%), or distant (<20%). For comparison, an initial planning target volume with a 2-cm margin and PTV(boost) with a 2.5-cm margin were created for each patient.

RESULTS

With a median follow-up of 12 months, radiographic tumor progression developed in 43 of 62 patients. Imaging was available for analysis in 41: 38 (93%) had central or infield failure, 2 (5%) had marginal failure, and 1 (2%) had distant failure relative to the 60-Gy isodose line. The treated PTV(boost) (median, 140 cm(3)) was, on average, 70% less than the PTV(boost) with a 2.5-cm margin (median, 477 cm(3)) (p < 0.001).

CONCLUSIONS

A PTV(boost) margin of 1cm or less did not appear to increase the risk of marginal and/or distant tumor failures compared with other published series. With careful radiation planning and delivery, it appears that treatment margins for glioblastoma can be reduced.

Long-term outcomes of IMRT for breast cancer: a single-institution cohort analysis

PURPOSE

To evaluate long-term outcomes of adjuvant breast intensity-modulated radiation therapy (IMRT), with a comparison cohort receiving conventional radiation (cRT) during the same period.

METHODS AND MATERIALS

Retrospective review identified patients with Stages 0-III breast cancer who underwent irradiation after conservative surgery from January 1999 to December 2003. Computed tomography simulation was used to design standard tangential breast fields with enhanced dynamic wedges for cRT and both enhanced dynamic wedges and dynamic multileaf collimators for IMRT. Patients received 1.8-2-Gy fractions to 44-50.4 Gy to the whole breast, followed by an electron boost of 10-20 Gy.

RESULTS

A total of 245 breasts were treated in 240 patients: 121 with IMRT and 124 with cRT. Median breast dose was 50 Gy, and median total dose was 60 Gy in both groups. Patient characteristics were well balanced between groups. Median follow-ups were 6.3 years (range, 3.7-104 months) for patients treated with IMRT and 7.5 years (range, 4.9-112 months) for those treated with cRT. Treatment with IMRT decreased acute skin toxicity of Radiation Therapy Oncology Group Grade 2 or 3 compared with cRT (39% vs. 52%; p = 0.047). For patients with Stages I-III (n = 199), 7-year Kaplan-Meier freedom from ipsilateral breast tumor recurrence (IBTR) rates were 95% for IMRT and 90% for cRT (p = 0.36). For patients with Stage 0 (ductal carcinoma in situ, n = 46), 7-year freedom from IBTR rates were 92% for IMRT and 81% for cRT (p = 0.29). Comparing IMRT with cRT, there were no statistically significant differences in overall survival, disease-specific survival, or freedom from IBTR, contralateral breast tumor recurrence, distant metastasis, late toxicity, or second malignancies.

CONCLUSIONS

Patients treated with breast IMRT had decreased acute skin toxicity, and long-term follow-up shows excellent local control similar to a contemporaneous cohort treated with cRT.

Nuclear RFLP variation in Eucalyptus camaldulensis Dehnh. from northern Australia

Eucalyptus camaldulensis Dehnh. is the most widely planted eucalypt in the tropics. Natural populations are riparian and sampling strategies for breeding programmes have assumed that gene flow among drainage basins is limited. RFLP variation, within and among 31 populations from river systems across northern Australia, was analysed to test this hypothesis. To allow comparisons within and between river systems, trees were sampled from up to three populations per river system. Allele frequencies were correlated with longitude for more than half the 33 RFLP loci surveyed. Genetic identity was greatest between populations in closest geographic proximity, irrespective of river system, suggesting that sampling strategies for breeding programmes should be based on geographic distance rather than river system. The level of genetic variation was similar throughout the geographic range examined (mean H(E) = 0.49). However, there was evidence of a barrier to gene flow between populations in the east and west of the species range. The RFLP data support morphological evidence of hybridisation between E. camaldulensis and E. tereticornis Sm. in several populations in northeast Queensland and the genetic divergence of E. camaldulensis subsp. simulata Brooker and Kleinig.

Acalculous cystinuria

We compared quantitative urinary cystine values in stone-forming family members and unaffected relatives based on an index stone-forming patient. A family pedigree of 39 members was identified. Quantitative urinalyses and serum biochemical profiles were collected with the subjects on similar diets over 72 hours. Detailed medical histories were obtained. Three family members are stone-forming cystinuric patients with a mean urinary cystine excretion of 496 mg/g of creatinine per day. Six persons without a history of stones (mean age 50) had a mean urinary cystine excretion of 364 mg/g of creatinine per day. Thirty-four family members had elevated urinary cystine concentrations (mean 151 mg/g of creatinine per day), and only two family members had normal urinary cystine excretion. Fifteen subjects with elevated urinary cystine values (> 150 mg/g of creatinine per day) had no history of urinary stones despite a mean age of 44 years. Urinary electrolytes and volumes were similar in the stone-forming and non-stone-forming groups. Thirty-nine per cent of the persons from this family pedigree had elevated quantitative urinary cystine concentrations and no history of urinary stones despite a mean age of 44 years. Acalculous cystinuria is an elevated urinary cystine concentration without evidence of urinary stone disease. Despite abnormal urinary cystine excretion, acalculous cystinuria does not necessarily culminate in clinical urinary stone disease.

Effect of growth hormone or chromium picolinate on swine metabolism and inflammatory cytokine production after endotoxin challenge exposure

OBJECTIVE

To determine whether recombinant porcine somatotropin (PST) or chromium picolinate (CrP) affected cytokine production and metabolism in swine after endotoxin challenge exposure.

ANIMALS

20 Poland China X Landrace pigs, 5/group.

PROCEDURE

Pigs were given CrP-supplemented feed at body weight of 20 kg; PST treatment began at 60 kg, and both treatments continued through body weight of 90 kg. At 90 kg, pigs were challenge exposed with 20 micrograms of lipopolysaccharide (LPS)/kg of body weight. Blood samples were obtained at various times through 24 hours after LPS challenge exposure.

RESULTS

In all pigs not given PST, glucose concentration decreased 2 to 4 hours after LPS. In PST-treated pigs, blood glucose concentration was decreased at 6 to 8 hours after LPS. Plasma insulin concentration paralleled changes in glucose concentration. Nonesterified fatty acid concentration was high 2 to 24 hours after LPS in pigs not given PST and at 6 to 24 h in PST-treated pigs. Plasma urea nitrogen concentration was high at 6 to 24 hours after LPS in pigs not given PST. The urea nitrogen values in PST-treated pigs were lower at all times. Serum aspartate transaminase activity was high 6 to 24 hours after LPS in pigs not given PST, whereas PST treatment prevented the increase in this enzyme activity. In untreated (PST) pigs, plasma bilirubin (total and direct) concentrations were high 4 to 8 hours after LPS and returned to normal at 24 hours. The PST- and CrP-treated pigs maintained normal plasma bilirubin concentrations. Interleukin 6 activity was unaffected by CrP and PST treatments. Treatment with CrP and PST decreased the tumor necrosis factor alpha response to LPS, compared with that in control pigs.

CONCLUSIONS

PST, and to a lesser extent CrP, provide protection against the adverse metabolic effects of LPS-induced septic shock.

Urinary stone disease: a practical guide to metabolic evaluation

Urolithiasis is the third most common affliction of the urinary tract, after infections and diseases of the prostate. Approximately 10% of the North American population will have at least one urinary calculus by age 70. A thorough history and physical examination will usually confirm the diagnosis of urinary stone disease. A simplified laboratory evaluation may be performed for patients with a single stone episode. A more extensive evaluation is required for patients with recurrent, metabolically active stones and patients at high risk (ie, cystine stone formers and those who develop bladder dysfunction or nephrosclerosis). Intravenous pyelography with tomography remains the gold standard for imaging of the urinary tract to confirm the diagnosis and formulate a treatment plan.

Endoscopic management of upper tract urothelial tumors

We evaluated renal-preserving endourology in the diagnosis and management of upper tract urothelial tumors. Referral patients were identified for the endourologic management of upper urinary tract tumors between January 1990 and May 1996 at two tertiary care referral centers. Chart reviews, indications for intervention, and treatment outcomes were assessed. Twenty patients (mean age 66 years; range 32-89; males 14; females 6) underwent endourologic diagnosis and/or management of upper tract urothelial neoplasms. Mean follow-up was 25 months. The diagnosis of transitional cell carcinoma (TCC) was endoscopically confirmed in all cases. Twenty-one biopsies were performed for pathological diagnoses; one identified pathological muscle that assisted in clinical staging. Percutaneous approaches were required in four patients (six kidneys) as a result of inadequate retrograde access or excessive tumor burden. Four (44%) renal pelvic tumors recurred after long-term follow-up; ureteral recurrences occurred in 4 (80%) of 5 patients. Open surgery was required in six patients for excessive tumor burden/concurrent muscle invasive bladder tumors. No endoscopically managed patient developed metastatic disease. No patient died as a result of TCC. Endourologic biopsies are small, yet sufficient for pathological diagnoses of upper tract tumors; most biopsies lack muscle to evaluate staging. Recurrent upper tract tumors are common and may require multiple staged endoscopic interventions. Successful endoscopic management of upper urinary tract neoplasms is primarily related to tumor burden and pathological grade. Minimally invasive endourologic management of upper tract tumors should be considered in select patients. Open surgical management does not equate with failure.

An unusual pelivc mass: cystic fibroadenoma of the prostate

Cystic fibroadenoma is an extremely rare benign lesion of the prostate. Herein we report a case of such a lesion in a 52-year-old man initially thought to have locally advanced prostate cancer.

Automatic spring-loaded biopsy gun with ultrasonic control for renal transplant biopsy

The automatic spring-loaded biopsy gun with 18-gauge needle was used to perform 20 renal transplant biopsies. A total of 35 needle passes were used during the 20 biopsies to obtain 31 cores of renal tissue (ratio of successful cores to passes 0.88). Nineteen of 20 biopsies (95%) resulted in renal tissue sufficient for diagnosis. One patient experienced gross hematuria that required blood transfusion and resulted in temporary ureteral clot obstruction. We believe the automatic spring-loaded biopsy gun with ultrasonic control allows rapid, accurate, and safe histologic assessment of the renal allograft, and we recommend this system for routine use.

Comparison between wheat, triticale, rye, soyabean oil and strain of laying bird on the production, and cholesterol and fatty acid contents of eggs

1. The effects of feeding three types of cereal grain (wheat, triticale or rye) and soyabean oil (0 or 20 g/kg) over a 12-week period on the production, yolk cholesterol and yolk fatty acid concentrations of three strains of laying pullets were studied. 2. Pullets fed on wheat- or triticale-based diets had higher body weight gains, egg productions, egg weights, egg mass and lower yolk cholesterol concentrations than pullets fed on rye-based diets. However, there were no significant differences between the cereals in yolk cholesterol content. 3. There were no significant differences between the three cereals in total food consumption of pullets nor of yolk weight nor yolk concentration of palmitic, stearic and oleic acids. 4. Pullets fed on triticale-based diets had higher yolk linoleic acid concentrations and lower yolk oleic acid: linoleic acid ratios than pullets fed on rye- or wheat-based diets. 5. Soyabean oil supplementation increased egg production, egg mass, yolk linoleic concentration and yolk unsaturated to saturated fatty acid ratio, but reduced yolk oleic acid: linoleic acid ratio. 6. There were differences between strains of pullets in weight gain, food consumption, rate of lay, egg weight and yolk cholesterol, but not in yolk fatty acid concentrations. 7. It was concluded that wheat- or triticale-based diets gave good production of eggs of lower cholesterol content, that soyabean oil supplementation gave eggs with a high unsaturated to saturated fatty acid ratio and that two strains of layers produced eggs with lower yolk cholesterol concentrations than a third strain.