Metastatic carcinoma in the cervical lymph nodes from an occult primary: a conservative approach to the role of radiotherapy

This retrospective study examines the results of treatment for cervical lymph node metastases from an unknown primary epithelial cancer of squamous cell or anaplastic histology. The analysis covers a series of 87 consecutive unselected patients at the Middlesex Hospital, London, in the years between 1954 and 1986. Fifty-eight patients received radiation therapy with a view to cure, 25 patients were treated with radiotherapy to a palliative dose, 1 patient only had a radical neck dissection, and 3 patients received no treatment apart from excision biopsy. In contrast to common practice in the United States, only a single patient received prophylactic radiation to the nasopharynx as part of the initial therapy. Overall actuarial survival for all patients (87) at 2 years was 43% and at 5 years 33%, and in the radically treated group (58) it was 52% and 40%, respectively. Only 6 of the 87 patients (7%) subsequently revealed a primary tumor above the clavicles. Overall disease control above the clavicles was achieved in 53% (46/87), but was 64% (37/58) in the radically treated group. Guidelines for radiation therapy are discussed in view of these results.

A microcomputer-based vital records data base with interactive graphic assessment for states and localities

Vital records data bases describe large populations over long periods of time, yet their organization and size often preclude or discourage their use. We constructed a microcomputer-based data base of all singleton births in Massachusetts, 1975-84. The original data were stored in 700,000 records, each 174 bytes long, occupying a total of over 120 megabytes (MB). By removing redundant information and unique identifiers, and packing the data, we store 21 fields of this information in a 16-byte record resulting in a data base of 11.1 MB, a saving of over 90 percent of disk space. By using programs written expressly for this data base, we can display a birth weight frequency plot of the entire data set in under 65 seconds on an IBM-compatible PC-AT. Comparable assessments in SAS-PC took over 105 minutes and in main frame SAS on an AS-9000 took over 37 CPU seconds. Implementing similar systems for state registries on births, deaths, cancers, and birth defects potentially offers investigators easy access to vast stores of information and would enable public health officials to produce timely reports, initiate a variety of surveillance activities, and respond rapidly to residents' inquiries about clusters and anomalous disease patterns.

Metastatic adenocarcinoma in the cervical lymph nodes from an occult primary

Cervical lymph node metastases as the only site of disease is a rare presentation of an adenocarcinoma of unknown primary origin. This retrospective analysis examines the records of ten consecutive patients at the Middlesex Hospital with this diagnosis between 1954 and 1986. The diagnostic protocol employed and the results of radical treatment are evaluated. Nine patients received radiation therapy with intent to cure, and one patient had a radical neck dissection. Overall actuarial survival for all patients (10) at 2 years was 23% and at 5 years 0%. Only two of the 10 patients subsequently revealed a primary tumour--both below the clavicles. Disease control above the clavicles was not achieved in a single patient despite radical treatment.

First interim progress report on the second British Institute of Radiology Fractionation Study: short versus long overall treatment times for radiotherapy of carcinoma of the laryngopharynx

Preliminary data from a second British Institute of Radiology Fractionation Trial comparing short (less than or equal to 4 weeks) and long (greater than 4 weeks) overall treatment times are reported. The intake of patients ran from January, 1975 to December, 1985 when 611 patients with carcinoma of the laryngo-pharynx were registered in this prospective, randomized, multicentre clinical trial. No significant differences have, so far, been demonstrated between the two arms of the trial with respect to observed survival rates, tumour-free or laryngectomy-free rates. Further long-term follow-up is continuing.

T-cell receptor VT beta genes in natural populations of mice

The composition of 15 VT beta gene subfamilies has been examined by Southern hybridization among a broad spectrum of colony bred rat and mouse species extending phylogenetically from Rattus to Mus musculus domesticus. Most mouse species contain a similar content of VT beta genes as determined by the number of hybridizing restriction fragment (RF) bands. Furthermore, the extent of restriction fragment length polymorphism (RFLP) appears to be limited. Some VT beta gene families, however, are missing from Rattus (VT beta 7, VT beta 12) and M. shortridgei (VT beta 9, VT beta 16). Extension of the VT beta survey to a panel of 38 wild caught mice reveals that nearly a third lack specific hybridization to the VT beta 5 probe. Previous reports have established that the mouse inbred strains SJL, C57BR, C57L, and SWR lack 50% of their VT beta repertoire, including VT beta 5 (Behlke et al. 1985). This study demonstrates that natural populations of mice also carry a significantly reduced VT beta gene repertoire.

Birth weight-specific infant mortality due to congenital anomalies, 1960 and 1980

The impact of mortality due to congenital anomalies in single-delivery births was compared in 1960 and 1980 birth cohorts; data were used from the 1960 National Center for Health Statistics national linkage of birth and death certificates and the 1980 National Infant Mortality Surveillance project. In 1960 there were 14,714 deaths due to congenital anomalies, compared with 8,674 in 1980, a 41 percent reduction. The infant mortality risk (IMR) due to congenital anomalies fell 31 percent. This is in contrast with the observed 54 percent decline in IMR due to all causes. This reduction in mortality due to congenital anomalies occurred for both whites and blacks in the postneonatal period and for whites only in the neonatal period. Changes ranged from a 1.8 percent increase for the black neonatal mortality risk to a 46.6 percent decrease for the white postneonatal mortality risk. In spite of these relative reductions, the absolute percentage of all infant deaths due to congenital anomalies had increased from 15.8 percent in 1960 to 24.1 percent in 1980. Two categories, cardiovascular and central nervous system anomalies, accounted for 72 percent of infant deaths due to congenital anomalies in 1960 and for 59 percent in 1980; cardiovascular anomalies accounted for 48 percent of all deaths due to congenital anomalies in 1960 and 40 percent in 1980. Infant mortality risks in the United States showed a 2:1 black to white ratio in both 1960 and 1980. However, for infant mortality due to congenital anomalies, the black and white mortality risks were approximately equal in both 1960 and 1980. For infants with birth weights of 500-2,499 g, the risk of neonatal mortality for blacks was less than half the risk for whites.

The radiologist as guinea pig: radiation hazards to man as demonstrated in early radiologists, and their patients

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N-methyl-N-nitrosourea induces dysplasia and cell surface markers of neoplasia in long-term rat bladder organ cultures

Untreated organ cultures of normal rat bladder can be maintained for long periods, up to 160 days, in a supplemented Waymouth's medium MB 752/1. During that time, the urothelium retains a similar appearance to that seen in vivo, namely a three-cell thick epithelium with specialised superficial cells whose characteristic surface features are identifiable by scanning electron microscopy. These superficial cells cover the major part of the explants, but the surface features of basal and intermediate cells can be observed on the cut edges and re-epithelialising surfaces of the explant. These are described and illustrated. When normal cultures are treated with the direct-acting carcinogen, N-methyl-N-nitrosourea (MNU), the in vitro response of the urothelium resembles to a certain extent the in vivo response to MNU instilled directly into the bladder. A histological progression is seen through mild to severe dysplasia which resembles carcinoma in situ. However, no marked changes in growth pattern, such as the development of papillary or nodular hyperplasia are seen. It is suggested that this is related to the failure of the vascular and stromal elements of the explants to respond to MNU treatment in vitro. The development of urothelial dysplasia is reflected by marked changes in cell surface differentiation, including development of pleomorphic microvilli, which closely resemble those seen following MNU treatment in vivo. These changes appeared earlier and were far more severe in vitro than in vivo. The significance of pleomorphic microvilli in bladder cultures is considered. A few were seen in control cultures but primarily on epithelial outgrowths onto the Millipore filter support, suggesting a relationship to the distance of the urothelium from viable stromal support. In the MNU-treated cultures, they were numerous and found on the surface of cells covering most of the explants. They were not solely related to the proliferative state of the urothelium in these cultures. This in vitro culture system provides a useful model with which to study the effects on the urothelium of various known and suspect carcinogens.

High dose cisplatin compared with high dose cyclophosphamide in the management of advanced epithelial ovarian cancer (FIGO stages III and IV): report from the North Thames Cooperative Group

A randomised study comparing cisplatin 120 mg intravenously with cyclophosphamide 2 g intravenously, each drug being given every month for six months followed by a low dose regimen for a further six months in responding patients, was carried out in 86 patients with advanced epithelial ovarian carcinoma (FIGO stages III and IV). Patients given cisplatin were found to have a longer median survival time than those given cyclophosphamide (19 months compared with 12 months) and a longer median duration of complete clinical response (18 months compared with eight months). The difference in disease free survival was statistically significant even after factors such as age, stage of disease, and the completeness of initial surgery had been taken into account. This study suggests that cisplatin is a more effective chemotherapeutic agent than cyclophosphamide for advanced ovarian cancer and should be the agent of choice in future trials comparing combination chemotherapy with a single agent.

Invasive bladder cancer treated by radical external radiotherapy

Fifty-three consecutive, unselected patients with invasive bladder cancer, Stage T2 to T3, treated by radical radiotherapy have been reviewed. Cystectomy was reserved for patients with significant worsening of disease during treatment, histologically confirmed persistent or recurrent invasive tumour after treatment, or patients with intolerable symptoms due to radiation cystitis. In 64% of our patients a favourable tumour response to radiotherapy was seen, while a further 31% showed disease progression either during or on completion of radiotherapy. Cystectomy was performed on 22% of patients, mainly for radiation cystitis, and was not associated with a significant operative mortality rate. The crude 5-year survival rate was 42%. We conclude that radical radiotherapy is as effective as other forms of treatment for invasive bladder cancer, but that there remains a need to identify those bladder tumours destined to respond poorly to radiotherapy at an earlier stage.

The subcellular basis of damage to the human urinary bladder induced by irradiation

The effects of x-irradiation on the subcellular structure of the human urinary bladder were investigated by electron microscopic examination of biopsies taken during check cystoscopies from 25 patients between 1 month and 22 years after completion of a course of therapeutic radiation. All tissues of the bladder wall were damaged to some extent by the treatment. In the urothelium this was reflected by the development of more than the usual numbers of lysosomes and autophagic vacuoles in all cell layers. In the bladder wall, large often binucleate or multinucleate fibroblasts were prominent and persistent in all specimens and were associated with the development of progressive fibrosis. The vasculature and the muscle coats of the bladder wall were also damaged. In the blood vessels many endothelial cells were oedematous or necrotic and some intravascular coagulation was also observed. Smooth muscle cells became oedematous soon after irradiation, and after longer time intervals there was focal death and loss of individual muscle cells. The observed degeneration and extensive necrosis of the bladder wall, which involved severe destruction and disorganization of the muscular layers, is sufficient to explain the clinical sequelae of bladder irradiation, namely loss of elasticity, reduced capacity and incomplete micturition with residual urine.

Oral rehydration fluids used in the treatment of diarrhoea. Analysis of the osmolalities, and sodium, potassium and sugar contents of commercial and home-made products

Analysis of 91 commercial dietary "clear" fluids, including carbonated beverages, cordials, powdered drinks, jellies, fruit juices, fruit juice drinks, syrups, and soups showed a range of zero to 175 mmol/L of sodium, zero to 52.1 mmol/L of potassium, zero to 839 mmol/L of reducing sugars and an osmolality of 50 to 914 mmol/kg water. Home-made oral rehydration solutions prepared by a group of mothers and medical staff members also showed unacceptably wide variability in their composition. The composition of products specifically indicated for the treatment of diarrhoea was also remarkably diverse, with a range of 24 to 100 mmol/L of sodium, 14.2 to 21.0 mmol/L of potassium, 45 to 326 mmol/L of glucose, and 170 to 460 mmol/kg water osmolality. On the basis of our current knowledge of water and electrolyte absorption, neither the commercial dietary "clear" fluids nor the home-made solutions can be recommended for the treatment of diarrhoea. Of the therapeutic products, only "Unicef Oral Rehydration Salts" has been subjected to clinical trails and found safe and effective. However, the formulation of Diolyte appears appropriate for the treatment of mild diarrhoeal dehydration.

Evaluation of the role of computed tomography in radiotherapy treatment planning

The role of computed tomography (CT) in radiotherapy treatment planning was assessed in a series of 231 patients in whom treatment was planned with radical intent. For each patient, a treatment plan was produced by the best conventional techniques in use at the Middlesex Hospital. Each patient then underwent a CT scan in which the treatment conditions were closely simulated. As a result of the CT scan images, alteration was made to the planned treatment in 47% of 198 assessable patients. Large differences were seen in the usefulness of CT treatment planning for tumours in different sites, with the greatest contribution made to treatment of tumours of the sinuses and nasopharynx and of the bladder. Although its unit cost is high, computed tomography can be a very useful tool in radiotherapy treatment planning and can contribute uniquely to improved patient management for adequately selected patients.

Examination of vocal fold movement by ultra-short pulse X radiography

Antero-posterior radiographs of the larynx lack spatial and temporal resolution, due to the movement of the vocal folds during phonation. By utilising the electrolaryngograph to monitor vocal fold movement, single X-ray pulses of 30 nanoseconds duration have been triggered at pre-determined points during the cycle of vocal fold movement to visualise these in normal phonation.

Studies on enterotoxigenic Escherichia coli isolated from persons without diarrhoea in Western Australia

The epidemiology of enterotoxigenic Escherichia coli (ETEC) was studied in children without diarrhoea in two remote Aboriginal communities in tropical north-western Australia. Serial surveys of the same individuals during different seasons showed that isolations were much more frequent in the wet monsoonal summer than in the dry winter. All E. coli were isolated from symptomless children aged 5 years or less; in addition, clearance of ETEC carriage without treatment was observed in all individuals within 3 months of isolation. Of the 58 ETEC strains isolated, 40 had either an H32 or an O126 antigen. Five O antigens which have never been associated with ETEC (O2, O41, O71, O77 and O157) were found. A recently proposed system to detect ETEC, using groups of polyvalent antisera, would have detected only 3 out of these 58 ETEC strains.

A modified infant mouse assay for bacterial enterotoxins

The reproducibility of the infant mouse assay for Escherichia coli ST and heat-labile enterotoxins of Aeromonas spp. is improved if both intestinal weight to remaining body weight ratio (IW/RBW) and the amount of diarrhoea produced are considered as criteria for classifying enterotoxigenic strains. Animals with profuse diarrhoea may have IW/RBW ratios below the widely accepted critical value for a positive test. Using pools of supernatants from broth cultures of three different strains of E. coli, 15% of ST producers would have been regarded as negative using IW/RBW ratio as the only criterion of a positive test. In testing single supernatants, 25% of ST producing E. coli would not have been correctly classified using IW/RBW alone. A scoring system which incorporates IW/RBW ratios and the amount of diarrhoea produced improves the usefulness of the test by allowing clear separation of positive and negative strains. The scoring system is also applicable to older mice for assay of E. coli ST so that a wider age range of mice can be used allowing increased use of animal facilities.

Long-term organ culture of normal human bladder

Normal adult human bladder obtained at cystoscopy has been maintained in long-term organ culture. Several media were tested for their ability to maintain viability and normal tissue morphology. The optimum medium was Ham's F-12 nutrient mixture, supplemented with 10% fetal calf serum, hydrocortisone (1 microgram/ml), and FeSO4, (0.45 microgram/ml). During the first 28 days in vitro, epithelial damage incurred at biopsy and during preparation of the cultures was repaired, and epithelialization of cut stromal surfaces occurred. A wave of cell proliferation was identified by [3H]thymidine autoradiography, 24-h labeling indices rising to a peak of up to 50% on the cut sides of the cultures between 7 and 21 days and falling to 0 to 5% by 21 to 28 days. The regenerating epithelium showed all the normal features of urothelial cell differentiation when examined by scanning and transmission electron microscopy. From 28 days, histology and scanning and transmission electron microscopy showed the cultured urothelium in most cultures to resemble closely that in the normal bladder in vivo, and in this mature state cultures were maintained for 100 days. Urothelium derived from certain patients, although showing normal surface maturation, developed enlarged intercellular spaces or intraepithelial mucin-containing acini. A study of the cytology of cells shed into the medium at different stages in culture showed that culture viability and epithelial differentiation could be monitored easily in long-term culture by this nondestructive means.

Early and late morphological changes (including carcinoma of the urothelium) induced by irradiation of the rat urinary bladder

Effects of X-irradiating the urinary bladder of female F344 rats with a single dose of 20 Gy were studied by light and electron microscopy. The animals were killed 1 week-20 months post-irradiation, and all tissues of the bladder wall were found to be affected by the irradiation. In the urothelium, damage was initially restricted to the basal cells but slowly extended to intermediate cells, and by 6 months post-irradiation the urothelium was focally hyperplastic. Twenty months post-irradiation, transitional-cell carcinomas were found in 10 of the surviving 17 animals (59%). The blood vessels in the bladder wall showed damage to both the endothelial cells and the smooth muscle. The fibroblasts in the connective tissue of the bladder wall appeared to show increased secretion after irradiation, and there was abundant collagen deposition, resulting in severe fibrosis of the bladder wall. After a latent period of a few months, focal degeneration and extensive necrosis of the smooth muscle cells were seen, leading to severe destruction and disorganization of the muscular coats of the bladder wall. Thus, a single dose of irradiation of 20 Gy was sufficient to produce severe fibrosis of the bladder wall with smooth muscle degeneration and to induce carcinoma of the urothelium in most of the treated animals within 20 months.

Seventh interim progress report of the british institute of radiology fractionation study of 3F/week versus 5F/week in radiotherapy of the laryngo-pharynx

A fresh analysis of the data entered into the multicentre BIR fractionation trial of 3F/week versus 5F/week in radiotherapy of the laryngopharynx has been undertaken. Completed records of the 732 patients initially entered into the trial have now risen from 687 at the last report to 706. The data have been analysed in a manner similar to that adopted previously so as to measure the effects of the two regimes on both tumour and normal tissues, and some additional analyses have now also been made. There have been some modifications in the results in the various sub-groups which may be due to an inadequate number of patients having been followed up for long enough at the time of the previous analyses. More data for late radiation damage to normal tissues and new radiobiological findings have suggested possible explanations for the differences which have emerged between the two groups. The apparent differences between the sub-groups containing patients with highly localized tumours, which were reported in our previous report, are now less marked and not statistically significant.