Post-treatment imaging appearances in head and neck cancer patients

Surgery and radiotherapy (with or without chemotherapy) for head and neck cancer can create a daunting array of radiological appearances post-treatment. The role of the radiologist lies not only in detecting recurrent neoplastic disease, but also identifying non-neoplastic changes that may account for clinical presentation and symptoms in this patient group. There are a number of non-neoplastic as well as neoplastic changes and disease entities that can present on surveillance imaging, such as primary resection and reconstructive surgical change, surgical neck dissection changes, radionecrosis, post-treatment denervation change, and radiotherapy-related secondary tumours. Some of these require conservative management, while others require more active treatment. Awareness and recognition of the imaging appearances of these post-treatment changes is therefore critical for the radiologist involved in the multidisciplinary care of the head and neck cancer patient.

Spaces of social inclusion and belonging for people with intellectual disabilities

People with intellectual disabilities (IDs) have been defined as 'socially excluded' and policies of 'social inclusion' invoked to counter this through a focus on paid work and independent living. For many people with IDs this is either not desired or not possible, and as a result many have sought out alternative spaces and activities of inclusion. The paper provides a critique of social exclusion and inclusion, and then goes onto examine (using two case studies) the ways in which people with IDs develop feelings of attachment and belonging within artistic spaces. The paper concludes that not only do these spaces provide mostly positive outcomes for individual people, but also have a potential role in 'reinscribing' the social and cultural understanding of people with IDs.

Common things are common: a case series of oral foreign bodies in paediatric patients

Reports of foreign bodies in the oral cavity are few in number. Three cases of children of varying ages, presenting with oral foreign bodies, and their subsequent diagnosis and management, are described. The importance of considering foreign bodies, as part of a differential diagnosis in paediatric patients, where aetiology is uncertain and clinical appearance is unusual, is highlighted.

Emesis in dogs: a review

Emesis is a common presenting sign in small animal practice. It requires a rational approach to management that is based upon a sound understanding of pathophysiology combined with logical decision making. This review, which assesses the weight of available evidence, outlines the physiology of the vomiting reflex, causes of emesis, the consequences of emesis and the approach to clinical management of the vomiting dog. The applicability of diagnostic testing modalities and the merit of traditional approaches to management, such as dietary changes, are discussed. The role and usefulness of both traditional and novel anti-emetic drugs is examined, including in specific circumstances such as following cytotoxic drug treatment. The review also examines areas in which common clinical practice is not necessarily supported by objective evidence and, as such, highlights questions worthy of further clinical research.

Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness

BACKGROUND

Artificial nutrition support is required to optimise nutritional status in many patients. Traditional methods of placing feeding tubes may incur clinical risk and financial costs. A technique facilitating placement of nasogastric and post-pyloric tubes via electromagnetic visual guidance may reduce the need for X-ray exposure, endoscopy time and the use of parenteral nutrition. The present study aimed to audit use of such a system at initial implementation in patients within an acute NHS Trust.

METHODS

A retrospective review was undertaken of dietetic and medical records for the first 14 months of using the Cortrak system. Data were collected on referral origin, preparation of the patient prior to insertion, placement success rates and need for X-ray. Cost analysis was also performed.

RESULTS

Referrals were received from primary consultants or consultant intensivists, often on the advice of the dietitian. Fifty-nine percent of patients received prokinetic therapy at the time of placement. Thirty-nine tube placements were attempted. Sixty-nine percent of referrals for post-pyloric tube placement resulted in successful placement. X-ray films were requested for 22% of all attempted post-pyloric placements. Less than half of nasogastric tubes were successfully passed, although none of these required X-ray confirmation. The mean cost per tube insertion attempt was 111 pounds.

CONCLUSIONS

This system confers advantages, particularly in terms of post-pyloric tube placement, even at this early stage of implementation. A reduction in clinical risk and cost avoidance related to X-ray exposure, the need for endoscopic tube placement and parenteral nutrition have been achieved. The implementation of this system should be considered in other centres.

Long-term endometrial effects in postmenopausal women with early breast cancer participating in the Intergroup Exemestane Study (IES)--a randomised controlled trial of exemestane versus continued tamoxifen after 2-3 years tamoxifen

BACKGROUND

The antiestrogen tamoxifen may have partial estrogen-like effects on the postmenopausal uterus. Aromatase inhibitors (AIs) are increasingly used after initial tamoxifen in the adjuvant treatment of postmenopausal early breast cancer due to their mechanism of action: a potential benefit being a reduction of uterine abnormalities caused by tamoxifen.

PATIENTS AND METHODS

Sonographic uterine effects of the steroidal AI exemestane were studied in 219 women participating in the Intergroup Exemestane Study: a large trial in postmenopausal women with estrogen receptor-positive (or unknown) early breast cancer, disease free after 2-3 years of tamoxifen, randomly assigned to continue tamoxifen or switch to exemestane to complete 5 years adjuvant treatment. The primary end point was the proportion of patients with abnormal (> or =5 mm) endometrial thickness (ET) on transvaginal ultrasound 24 months after randomisation.

RESULTS

The analysis included 183 patients. Two years after randomisation, the proportion of patients with abnormal ET was significantly lower in the exemestane compared with tamoxifen arm (36% versus 62%, respectively; P = 0.004). This difference emerged within 6 months of switching treatment (43.5% versus 65.2%, respectively; P = 0.01) and disappeared within 12 months of treatment completion (30.8% versus 34.7%, respectively; P = 0.67).

CONCLUSION

Switching from tamoxifen to exemestane significantly reverses endometrial thickening associated with continued tamoxifen.

First results of a phase III multicenter randomized controlled trial of intensity modulated (IMRT) versus conventional radiotherapy (RT) in head and neck cancer (PARSPORT: ISRCTN48243537; CRUK/03/005)

LBA6006

Background: Xerostomia is the most common late toxicity of RT to the head and neck. IMRT dose distributions reduce the dose delivered to parotid gland. PARSPORT investigated the role of IMRT in reducing xerostomia in patients with head and neck cancer. Methods: The PARSPORT trial compared two radiotherapy delivery methods in the treatment of patients with pharyngeal tumors (T1–4, N0–3, M0). Patients received 65Gy in 30 fractions over 6 weeks delivered using either CT planned parallel opposed lateral fields or parotid-sparing IMRT. Stratification was by site of tumor and center. The primary endpoint was incidence of LENT-SOMA ≥G2 xerostomia one year after treatment. Secondary endpoints included acute toxicities (CTCAE v3) and other late RTOG and LENT-SOMA radiation toxicities. Proportions of patients with ≥G2 toxicity were compared using exact tests. For secondary endpoints a significance level of 1% was used. Results: 94 patients (47 RT; 47 IMRT) were randomized between 2003 and 2007 from six UK centers. 80 patients had oropharyngeal tumors and 14 hypopharyngeal. Radiotherapy was given as primary treatment in 71 patients and post-operatively in 23. 22 patients had AJCC stage I/II disease. Median follow-up was 31.9 months (IQR: 26.6 –38.8). Twelve month LENT-SOMA ≥G2 xerostomia scores were observed in 74% (25/34) of RT and 40% (15/38) of IMRT patients (p=0.005). Corresponding values at 18 months were 71% (15/21) and 29% (9/31) (p=0.004). On the RTOG scale, 12 month ≥G2 xerostomia was reported in 64% (21/33) RT vs 41% (15/37) IMRT patients (p=0.06). The 18 month incidence was 81% 17/21 RT vs 20% (6/30) IMRT (p<0.001). Acute radiotherapy related ≥G2 fatigue was more prevalent in the IMRT group (76% vs 41% p=0.001). No differences in acute mucositis or pain scores were seen. At 12 months, no statistically significant differences were seen in other late toxicities. No differences were observed between overall survival and locoregional control rates. Conclusions: Sparing the salivary glands through use of IMRT significantly reduces the incidence of xerostomia in patients with pharyngeal tumors.

[Table: see text]

BC2001: A multicenter phase III randomized trial of standard versus reduced volume radiotherapy for muscle invasive bladder cancer (ISCRTN:68324339)

5022

Background: Radiotherapy (RT) is an alternative to radical cystectomy in the management of muscle invasive bladder cancer. Limitations are probability of attaining and maintaining local tumour control and risk of late bladder toxicity. BC2001 tests whether concomitant chemotherapy (CT) improves loco-regional control and whether RT volume modification reduces late toxicity without detriment to tumour control. Methods: Pts were randomized in a 2x2 factorial design to (i) RT vs RT + concomitant CT (5FU 500mg/m2 d1–5 wks 1 & 4 + mitomycin C 12mg/m2 d1) and/or (ii) standard RT to tumour and whole bladder with 1.5cm margin (sRT) vs reduced volume RT (rvRT) where tumour + 1.5cm margin was treated to 100(±5)% target dose and remaining bladder received 80% target dose. RT dose was 55Gy/20F or 64Gy/32F according to local practice. RT volume comparison results (primary endpoint RTOG toxicity at 1 yr) are reported. Target sample size was 480 pts but the RT randomisation closed early due to slow recruitment. Estimated power is 73% (two-sided α = 0.05) to detect a 20% difference in G3/4 toxicity. Results: 219 pts were recruited (108 sRT; 111 rvRT); 49 received neoadjuvant CT; 31 sRT and 33 rvRT were randomised to concomitant CT. Median age was 74 yrs. Median follow up is 36 mths. There was no difference in loco-regional disease-free survival (LRDFS: HR = 1.06, 95% CI: 0.62–1.84) nor overall survival (HR = 0.99, (0.61 - 1.35)) between randomised RT groups. 2yr LRDFS is 71% in both RT groups. 27 (16) sRT vs 32 (15) rvRT pts have had local (invasive) recurrences (p = 0.09); 32 pts have undergone salvage cystectomy. No difference was seen in CTC G3/4 acute toxicity (26% sRT vs 21% rvRT, p = 0.35), RTOG G3/4 toxicity at 12 mths (8% sRT vs 4% rvRT, p = 0.27) nor Lent Som G3/4 toxicity at 12 mths (45% sRT vs 34% rvRT, p = 0.21). Bladder capacity fell significantly in sRT group (mean reduction at 12 mths: 59mls, 95%CI: 47–118mls, p = 0.02) but not in rvRT group. Conclusions: RT in the modern era can attain local control in most patients with T2-T3 bladder cancer. Acute and late toxicity was less than anticipated in both treatment groups. Modifying standard RT volumes had minimal effect on local control and toxicity in this trial. 2 yr toxicity and quality of life data will be presented.

No significant financial relationships to disclose.

SPARE: A qualitative study investigating randomization barriers in a Selective Bladder Preservation trial (SBP) (ISCRCTN: 61126465)

5077

Background: Recruitment to randomised trials is challenging, especially when treatment strategies are complex. While studies have demonstrated barriers to recruitment, few have investigated why patients accept or refuse randomisation. The SPARE feasibility study included such an investigation to highlight difficulties that might be dealt with as the study progressed and to inform procedures for a subsequent phase III trial. Methods: Patients had newly diagnosed invasive bladder cancer and were receiving neoadjuvant chemotherapy prior to invitation to a randomised trial (SPARE) that offered the possibility of radical cystectomy or SBP. Patients allocated SBP received cystectomy or radiotherapy dependent on chemotherapy response. 15 acceptors and 10 decliners to randomisation participated in the qualitative substudy. Methods included recorded transcribed interviews and a ‘framework analysis.’ Results: Both groups experienced initial confusion, ‘muddled’ communication, information overload, and lack of time leading to misunderstandings about the trial. Perceived side effects did not necessarily inform decisions. Decision to participate was seldom made unilaterally. Individual specialist input by, and continuity between, professionals and their patients, appeared to make decision making easier. Acceptors were inclined to altruism and trust in the medical profession, often agreeing to participate with minimum understanding regarding randomisation and/or equipoise and a ‘nothing to lose’ attitude as long as withdrawal from the trial was possible. Decliners tended to opt for radiotherapy, perceived as a rational choice in the context of this trial; many abhorred the thought of surgery that was perceived as undermining and a ‘treatment in reserve.’ Conclusions: Health professionals need to consider streamlining procedures and recognise patient preferences in terms of treatments offered and information received. Recognition of the complexity of communicating equipoise and randomisation may increase ‘informed consent’ levels and recruitment rates. A further qualitative substudy investigating doctor/patient consultations in real time with confidential feedback is proposed to optimise recruitment rates.

No significant financial relationships to disclose.

Quantitative estimates of the effects of concomitant chemotherapy on acute dysphagia in patients receiving radical treatment for head and neck cancer

e22134

Purpose: To generate quantitative parameters describing the effect of concomitant chemotherapy on incidence of grade 3 dysphagia (CTCAE v3.0, assisted feeding) using dose response curves in patients receiving radical treatment for head and neck cancer. Methods: Patients treated at a single centre in prospective phase I and II trials of concomitant chemo-IMRT (CRT) (n=85) and the phase III trial of IMRT vs. conventional radiotherapy (PARSPORT) (n=82) formed the basis of this non-randomized comparison. Patients in the PARSPORT trial received radiation alone (RT). Radiation dose for all patients was radiobiologically equivalent to at least 70Gy in 35 fractions. Concomitant chemotherapy was cisplatin (100 mg/m2) on days 1 and 29. G3 dysphagia was recorded prospectively. Dose volume histograms (DVH) were generated for the pharyngeal mucosa. The mean dose (converted to equivalent dose in 2Gy/fraction, MD2) was used as a univariate descriptor of the DVH, for the generation of the dose response curves. A logistic function of the form p=1/[1+(MD50/D)k] was fitted where, p is the probability of the incidence of toxicity, D is the mean dose, MD50 is the mean dose at which 50% of patients experience toxicity and k describes the increase in incidence with increasing dose. The dose response curves were fitted using non-linear logistic regression. Results: The mean MD2 to the pharyngeal mucosa were 56Gy and 55.8Gy respectively, in the CRT and RT groups. There was a statistically significant difference of 25% (95% CI: 10–38, p=0.002) in the incidence of G3 dysphagia between the CRT (68%) and RT (43%) groups. Fitting dose response curves to the clinical data yielded parameter values (95% CIs) of MD50=46 Gy (42–49), k=4.8 (2.3–7.2) for the CRT group and MD50= 58 Gy (55–61), k=3 (1.6-.45) for RT group. Dose response gradients for CRT and RT showed approximately 1.95% and 1.3% increase (respectively) in probability of G3 dysphagia resulting from an increase in mean dose of 1Gy between doses of 30Gy to 70Gy. Conclusions: Addition of concomitant chemotherapy increases the incidence of G3 dysphagia by 0.65% for every 1 Gy increase in radiation dose. The observed MD50 for G3 dysphagia is lower for RT alone (46 Gy vs. 58 Gy).

No significant financial relationships to disclose.

First results of a phase III multicenter randomized controlled trial of intensity modulated (IMRT) versus conventional radiotherapy (RT) in head and neck cancer (PARSPORT: ISRCTN48243537)

LBA6006

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

[Table: see text]

Peruvian Vibrio cholerae O1 El Tor strains possess a distinct region in the Vibrio seventh pandemic island-II that differentiates them from the prototype seventh pandemic El Tor strains

A collection of environmental and clinical strains of Vibrio cholerae O1 isolated from the beginning of the Latin American epidemic of cholera in 1991 to 2003 from multiple locations in Peru were characterized and compared with V. cholerae O1 El Tor strains of the seventh pandemic from the rest of the world (Asia, Africa, Australia and Europe) using a multilocus virulence gene profiling strategy and DNA sequencing. Peruvian strains differed from El Tor strains from the rest of the world by the failure of PCR to amplify genes VC0512, VC0513, VC0514 and VC0515 in the Vibrio seventh pandemic island-II (VSP-II) gene cluster. Sequencing of the VSP-II gene cluster and its flanking regions in one Peruvian strain (PERU-130) confirmed the PCR results, indicating that the Peruvian strain had low DNA homology (46.6 %) compared to the reference strain N16961 within the VSP-II region encompassing genes VC0511 to VC0515. Based on these differences in VSP-II, and based on the overall similarity between the pulsotypes of the Peruvian strains and the El Tor reference strain N16961, we concluded that the Peruvian, Eurasian and African strains belonged to the same clonal complex, and that the Peruvian strains represented variants that had independently evolved for a relatively short time. Since these ORFs in VSP-II of Peruvian strains are unique and conserved, they could form the basis for tracking the origin of the Peruvian strains and therefore of the Latin American pandemic.