Calls for Stricter Legislation and Fear in the European Immigrant Community: Reflections of the Public Charge Debate Ongoing in the United States Comment on "A Crisis of Humanitarianism: Refugees at the Gates of Europe"

In the editorial, "A Crisis of Humanitarianism: Refugees at the Gates of Europe," Marianna Fotaki elegantly highlights the changing dynamics of governmental policy toward refugees, forced migrants into Europe and the move away from the principles of humanitarianism.¹ The perceived threats to economy, security, and concerns of globalization and multiculturalism often are manifested as a "cry of wolf " about alleged health risks. This in effect has raised concerns of inadmissibility on health-related grounds and calls for stricter legislation for determining who is eligible for legal permanent residence, precipitated in part by the "public charge" debate occurring in the United States.² As Marianna notes "anti-migration rhetoric is now a permanent fixture of European politics."

Wearable inertial sensors and pressure MAT detect risk factors associated with ACL graft failure that are not possible with traditional return to sport assessments

Introduction

Anterior cruciate ligament reconstruction (ACLR) is associated with poor return to sport and high graft re-rupture rates. This study explored the use of a wearable inertial sensor (ViMove) that incorporates an accelerometer and gyroscope, and MatScan pressure sensing mat (TekScan, South Boston, Massachusetts, USA) to provide objective return-to-sport measures.

Methods

Three cohorts’ ACLR patients, non-athletic controls and elite athletes (Australian seven’s rugby Olympic Gold medallist). Patients performed biometric and functional tests (thigh circumference and triple hop) and the ViMove knee module (consisting of single and double leg squats, hops and box drops) for lower limb alignment assessment, concurrently with force plate.

Results

Elite athletes had less varus/valgus (VV) movement during ViMove exercises compared with the ACLR cohort, who in turn had less VV malalignment than controls. When analysing side-to-side differences, single leg squats and box drop were asymmetrical in the ACL group, with greater malalignment in the reconstructed leg (p<0.05). Subgroup analysis failed to differentiate who passed or failed current return to sport assessment. TekScan pressure plate detected differences in double leg landing and flight time while hopping not detected with ViMove, suggesting ACL patients compensate by offloading the reconstructed leg to improve coronal alignment during double leg activity.

Conclusion

The inertial sensor detected differences in motion for patients following ACLR, which are known to be associated with graft rupture and were not detected with functional return to sport testing. Coupling the device with data from a pressure plate provides a powerful assessment tool detecting alignment differences known to be associate with graft failure only previously detected in formal gait analysis.

Local therapy for triple-negative breast cancer: a comprehensive review

Owing to its aggressive course, triple-negative breast cancer remains an important clinical issue of current interest compared with hormone-receptor positive subtypes. Recent research has focused on determining the optimal local therapy (breast conversation therapy vs mastectomy) for this cancer subtype. In this overview, we examine outcomes based on immunohistochemistry, gene expression profiles, type of local therapy and in the era of neoadjuvant chemotherapy. Based on multiple observational reports risk for locoregional recurrence appears to be similar to reported outcomes in other subtypes. However, distant recurrence continues to be a significant concern for triple-negative breast cancer, indicating the need for better systemic therapies. To date, insufficient evidence exists to determine whether breast conserving therapy or mastectomy results in superior outcomes.

Self-rated health, objective health, and racial discrimination among African-Americans: Explaining inconsistent findings and testing health pessimism

African-Americans sometimes rate their health as Poor/Fair in the absence of chronic diseases. Theoretically, this lack of correspondence between self-rated health and objective health is due to racial discrimination that results in rating one's health negatively and in terms of social rather than health variables. We tested this Health Pessimism model with 2118 African-Americans. Results revealed that Poor/Fair self-rated health was predicted mostly by objective health for the Low Discrimination group but mostly by demographic variables for the High Discrimination group, in a manner consistent with Health Pessimism. Inconsistencies among prior studies might reflect differences in the prevalence of high discrimination among their samples.

Important prognostic factors for lung cancer in tobacco predominant Eastern North Carolina: study based on a single cancer registry

BACKGROUND

It is known that lung cancer incidence and mortality rate are higher in African Americans (AA) than whites. In Eastern North Carolina, there is a higher percentage of AA population than the national average (30.2% vs. 12.4%) and a higher incidence of lung cancer in this region. We investigated demography and survival of lung cancer patients diagnosed and treated in a single institution.

METHODS

The study includes 2351 patients diagnosed with lung cancer between 2001 and 2010 at East Carolina University. AA and whites were compared by age, sex, race, stage, histology, smoking history and insurance information using chi-square analyses. Patient survival was modeled using Cox proportional hazards regression (SAS version 9.2).

RESULTS

The distribution of lung cancer was 70% in whites and 30% in AA. The proportion of AA and whites differed significantly for age, sex, histology, stage, and insurance. Patients aged > 70 (p < 0.0001) and 51-70 (p = 0.0064) died sooner than those ≤ 50 years old. Compared with squamous cell, SCLC had inferior survival (HR = 2.0, 95% CI = 1.7-2.3). Privately insured patients survived longer than those with medicare (p < 0.0001), medicaid (p = 0.0009), or no insurance (p < 0.0001). The survival disadvantage for medicaid (p = 0.0076) and no insurance (p = 0.0033) persisted on multivariable analysis. Race was not a significant predictor of survival on multivariable analysis (p = 0.66).

CONCLUSION

This is one of the largest lung cancer patient populations from a single institution showing demographic differences between the two races with similar survival outcome. Age, histology and type of insurance were strong predictors of survival outcome. Older age, small cell histology and medicaid and no insurance had significantly shorter overall survival.

Pulmonary artery occlusion pressure may overdiagnose pulmonary artery hypertension in sickle cell disease

BACKGROUND

A high prevalence of Pulmonary Hypertension (PH) in sickle cell disease (SCD) has been reported in several studies. However, few studies that describe the hemodynamics have actually measured pulmonary artery occlusive pressure (PAOP). Furthermore, even PAOP has been shown to be unreliable in discriminating pulmonary artery hypertension from pulmonary venous hypertension. We prospectively examined the accuracy of PAOP using simultaneous left ventricular end diastolic pressure (LVEDP) measurement as the gold standard.

HYPOTHESIS

In patients with SCD, PAOP may not reflect LVEDP leading to over-diagnosis of PAH.

METHODS

We prospectively examined hemodynamic data on 26 patients with SCD, at a large academic center, from 2009 through 2011. These patients underwent simultaneous PAOP and LVEDP measurements.

RESULTS

We tested 106 adult SCD patients with 2-D Echocardiography for evaluation of PH. Of the 106 patients, 43 (41%) were found to have a tricuspid regurgitant jet velocity ≥ 2.5 m/sec. Of these 43, 26 patients underwent right heart catheterization (RHC) and simultaneous measurement of LVEDP. Twelve patients among the 106 (11.1%) patients were found to have PH. Eight of these (7.5 %) had PAH by PAOP criteria but only 4/106 (3/7%) had PAH by LVEDP criteria. PAOP significantly underestimated the LVEDP in both the PH group and group with normal hemodynamics (p=0.00004). BNP, and creatinine levels significantly increased in PAH group (p< 0.02, 0.01, 0.03). PAOP misclassified 50% of patients in this sickle cell disease cohort. In conclusion, PAOP may underestimate LVEDP in sickle cell patients with pulmonary hypertension and can lead to misclassification.

Insurance status as a strong predictor of outcome in triple-negative breast cancer (TNBC): A multi-institutional retrospective study

1069

Background: TNBC accounts for about 15-20% of all breast cancer. TNBC has particularly aggressive clinical course and accounts for a disproportionate number of breast cancer relapses and deaths in early stage disease. TNBC also have worse prognosis especially in African American (AA) women compared with white women. This retrospective study aims to investigate various clinical and demographic prognostic factors in TNBC. Methods: 476 TNBC patients who were treated at Eastern Carolina University and University of North Carolina, CH between 4/96 and 9/11 were included in this analysis. We collected data on age, race, grade, lymphovascular invasion (LVI), stage, treatments including surgery, chemotherapy, radiation, chemotherapy drugs, insurance type and year of treatment. Overall Survival (OS) was computed from the date of diagnosis to the date of death or last FU. For disease free survival (DFS), patients were scored if they failed either locally or distally. The Cox proportional-hazards regression model was used to compute hazard ratios. Results: The median age was 52 years (21-88 years) with median FU of 3.7 years. 49% women were white race followed by AA 223 (47%) and Hispanic or other race (5%). Stage (p<0.001), grade (p=0.02), surgery (p<0.0001), adjuvant chemotherapy (p=0.025), LVI (p=0.05) and type of insurance were significant predictor of OS. Similarly, stage (p<0.0001), surgery (p<0.0001), LVI (p=0.03) and insurance were significant predictors for DFS. On multivariate analysis, stage, surgery and adjuvant chemotherapy remained statistically significant predictors. Medicaid vs. Private Insurance also remained a significant detriment of survival (OS: HR=3.6, p<0.0001; DFS: HR=2.8, p<0.0001) as did having No Insurance for OS (HR=2.0, p=0.0074). Conclusions: To our knowledge, this is a largest retrospective study showing type of insurance to be a strong predictor of outcome in this very specific breast cancer subtype which remained significant after adjusting all other variables. Further insight is needed to determine the cause of this finding.

Quality geriatric care as perceived by nurses in long-term and acute care settings

AIMS AND OBJECTIVES

This study focused on differences in nurses' satisfaction with the quality of care of older people and with organisational characteristics and work environment in acute care and long-term care settings.

BACKGROUND

Numerous studies have explored links between nurses' satisfaction with care and work environments on the one hand and a variety of physical, behavioural and psychological reactions of nurses on the other. One key to keeping nurses in the workplace is a better understanding of nurses' satisfaction with the quality of care they provide.

DESIGN

Descriptive design.

METHOD

The self-selected sample included 298 registered nurses and licensed practical nurses who provide care to minority, underserved and disadvantaged older populations in 89 long-term care and <100 bed hospitals in 38 rural counties and eight metropolitan areas in a Southern state. All completed the Agency Geriatric Nursing Care survey, which consisted of a 13-item scale measuring nurses' satisfaction with the quality of geriatric care in their practice settings and an 11-item scale examining obstacles to providing quality geriatric care. Demographic variables were compared with chi-square. Independent t-tests were used to examine differences between nurses in long-term care and acute care settings.

RESULTS

Significant differences were found in level of satisfaction and perceived obstacles to providing quality care to older adults between participants from acute and long-term care. Participants in long-term care had greater satisfaction with the quality of geriatric care than those in acute facilities.

CONCLUSIONS

Nurses in long-term care were more satisfied that care was evidence-based; specialised to individual needs of older adults; promoted autonomy and independence of elders; and was continuous across settings. Participants in acute facilities perceived more obstacles to providing quality geriatric care than nurses in long-term care facilities.

RELEVANCE TO CLINICAL PRACTICE

Modification of hospital geriatric practice environments and leadership commitment to evidence-based practice guidelines that promote autonomy and independence of patients and staff could improve acute care nurses' perceptions of quality of geriatric care.

Blocked randomization with randomly selected block sizes

When planning a randomized clinical trial, careful consideration must be given to how participants are selected for various arms of a study. Selection and accidental bias may occur when participants are not assigned to study groups with equal probability. A simple random allocation scheme is a process by which each participant has equal likelihood of being assigned to treatment versus referent groups. However, by chance an unequal number of individuals may be assigned to each arm of the study and thus decrease the power to detect statistically significant differences between groups. Block randomization is a commonly used technique in clinical trial design to reduce bias and achieve balance in the allocation of participants to treatment arms, especially when the sample size is small. This method increases the probability that each arm will contain an equal number of individuals by sequencing participant assignments by block. Yet still, the allocation process may be predictable, for example, when the investigator is not blind and the block size is fixed. This paper provides an overview of blocked randomization and illustrates how to avoid selection bias by using random block sizes.

Risk factors associated with methamphetamine use and heart failure among native Hawaiians and other Pacific Island peoples

OBJECTIVE

Heart failure (HF), a long term outcome of chronic methamphetamine use (MU), occurs more frequently in racial and ethnic minority populations at high risk for cardiovascular disparities. This study examined the association of socio-demographic and clinical risk factors with MU among heart failure patients who are Native Hawaiians (NH) or other Pacific Island peoples (PIP). DESIGN/SETTING/PATIENT POPULATION: Cross-sectional study of NHs and PIPs with advanced heart failure enrolled in the Malama Pu'uwai Study, a randomized control trial to test an educational intervention to reduce re-hospitalization and/or death. A total of 82 participants were enrolled between 6/1/06 to 12/31/07 and met the following eligibility criteria: 1) self-identified NH or PIP, 2) Left ventricular systolic ejection fraction <or=45%, 3) Age of 21 years or older. Data were analyzed by odds ratios (OR), 95% confidence intervals (CI), and multiple logistic regression analysis.

MAIN OUTCOME MEASURE

Methamphetamine use.

RESULTS

Twenty-two percent of HF participants were identified as being current or prior methamphetamine users. Younger age and non-married status (combined never married or divorced/separated) were independently associated with MU after adjustment for sex, education, and other co-morbidities associated with HF (ie, age >50 years, OR = 0.16, 95% CI, 0.03-0.84; non-married status combined as never married OR = 8.5, CI, 1.5-47; divorced/separated OR = 11, CI 1.8-75).

CONCLUSIONS

RISK FACTORS ASSOCIATED WITH MU IN NH AND PIPS WITH HEART FAILURE INCLUDE: younger age and being divorced/separated or never married. Health care providers should be aware of MU as a contributing factor in the approach and treatment of HF in NHs and PIPs.

Environmental factors of obesity in communities with native Hawaiians

OBJECTIVE

To compare the fast food outlets and exercise resources across 3 communities with varying percentages of Native Hawaiians (NH) and to correlate these findings with obesity prevalence.

METHODS

Data on all food and exercise resources were collected from January through July 2006 within a 1-mile radius in 3 distinct communities (site A = higher % NH to site C = lower % NH). Comparisons between communities were analyzed in 2007 using Fisher's Exact and ANOVA.

RESULTS

Trends in obesity prevalence paralleled the percentage of NHs. After adjusting for population size, site B had a greater number of fast food outlets (p < 0.001) than site A or C, and more exercise facilities compared to site A (p = 0.05). Availability of fast food outlets was significantly greater at site A compared to site C (p = 0.03). Usage of exercise facilities was not significantly different between sites although exercise resources were in 'poorer' condition at site A compared to site B or C (p < or = 0.05).

DISCUSSION

Results confirm the increased frequency of obesogenic environmental factors and their correlation with obesity trends across 3 distinct NH communities. These results suggest that environmental factors may offer another means for reducing obesity disparities in minority communities.

Erythrocyte membrane ATP binding cassette (ABC) proteins: MRP1 and CFTR as well as CD39 (ecto-apyrase) involved in RBC ATP transport and elevated blood plasma ATP of cystic fibrosis

In addition to the better-known roles of the erythrocyte in the transport of oxygen and carbon dioxide, the concept that the red blood cell is involved in the transport and release of ATP has been evolving (J. Luthje, Blut 59, 367, 1989; G. R. Bergfeld and T. Forrester, Cardiovasc. Res. 26, 40, 1992; M. L. Ellsworth et al., Am. J. Physiol. 269, H2155, 1995; R. S. Sprague et al., Am. J. Physiol. 275, H1726, 1998). Membrane proteins involved in the release of ATP from erythrocytes now appear to include members of the ATP binding cassette (ABC) family (C. F. Higgins, Annu. Rev. Cell Biol. 8, 67, 1992; C. F. Higgins, Cell 82, 693, 1995). In addition to defining physiologically the presence of ABC proteins in RBCs, accumulating gel electrophoretic evidence suggests that the cystic fibrosis transmembrane conductance regulator (CFTR) and the multidrug resistance-associated protein (MRP1), respectively, constitute significant proteins in the red blood cell membrane. As such, this finding makes the mature erythrocyte compartment a major mammalian repository of these important ABC proteins. Because of its relative structural simplicity and ready accessibility, the erythrocyte offers an ideal system to explore details of the physiological functions of ABC proteins. Moreover, the presence of different ABC proteins in a single membrane implies that interaction among these proteins and with other membrane proteins may be the norm and not the exception in terms of modulation of their functions.

Brainstem tolerance to conformal radiotherapy of skull base tumors

PURPOSE

The aim of this study was to analyze the long-term incidence of brainstem toxicity in patients treated for skull base tumors with high dose conformal radiotherapy.

METHODS AND MATERIALS

Between 1974 and 1995, 367 patients with chordomas (n = 195) and chondrosarcomas (n = 172) of the base of skull have been treated with combined megavoltage photon and 160 MeV proton radiotherapy. Following 3D treatment planning with delineation of target volumes and critical nontarget structures dose distributions and dose-volume histograms were calculated. Radiotherapy was given an 1.8 Gy or CGE (=Cobalt Gray Equivalent) dose per fraction, with prescribed target doses ranging from 63 CGE to 79.2 CGE (mean = 67.8 CGE). Doses to the brainstem surface were limited to < or = 64 CGE and to the brainstem center to < or = 53 CGE.

RESULTS

Follow-up time ranged from 6 months to 21.4 years (mean = 42.5 months). Brainstem toxicity was observed in 17 of 367 patients attributable to treatment, resulting in death of three patients. Actuarial rates of 5 and 10-year high-grade toxicity-free survival were 94 and 88%, respectively. Increased risk of brainstem toxicity was significantly associated with maximum dose to brainstem, volume of brainstem receiving > or = 50 CGE, > or = 55 CGE, and > or = 60 CGE, number of surgical procedures, and prevalence of diabetes or high blood pressure. Multivariate analysis identified three independent factors as important prognosticators: number of surgical procedures (p < 0.001), volume of the brainstem receiving 60 CGE (p < 0.001), and prevalence of diabetes (p < 0.01).

CONCLUSIONS

Tolerance of brainstem to fractionated radiotherapy appears to be a steep function of tissue volume included in high dose regions rather than the maximum dose of brainstem alone. In addition, presence of predisposing factors as well as extent of surgical manipulation can significantly lower brainstem tolerance in the individual patient.

Radiation in management of patients with dermatofibrosarcoma protuberans

PURPOSE

The preferred treatment of dermatofibrosarcoma protuberans (DFSP) is wide resection, namely, margins > or = 3 cm beyond the evident disease and histologically negative margins. We assess the success achieved by radiation combined with surgery for positive/close margins or by radiation alone for those tumors that are not resectable for technical/medical reasons. The literature on this point is virtually nonexistent.

MATERIALS AND METHODS

The outcome of treatment of 18 patients with DFSP by radiation alone (n = 3) and radiation and surgery (n = 15) at the Massachusetts General Hospital was assessed. All of the lesions at the time of the treatment by radiation alone or combined with surgery were less than 10 cm. This was the maximum dimension. The actual tumor volume was much less than indicated by this maximum dimension, as the tumors were usually relatively flat.

RESULTS

The 10-year actuarial local control rate was determined to be 88%. Local control was realized in the three patients treated by radiation alone, with follow-up periods of > or = 9 years. Among 15 patients treated by radiation and surgery, there have been three local failures; the 10-year actuarial local control rate was 84%. The three local failures occurred in 12 patients whose surgical margins were positive. One of these three local failures developed in the group of two patients whose lesions were scored as grade II.

CONCLUSION

Radiation in well-tolerated dose schedules is an effective option in the management of patients with DFSP. This appears to be true for radiation alone or postoperatively for margin-positive disease (primary or recurrent).

Local control of T3 carcinomas after accelerated fractionation: a look at the "gap"

PURPOSE

To study the effects of midcourse treatment break or gaps related to the local control of T3 carcinoma of the oropharynx and larynx following accelerated hyperfractionated radiation therapy.

METHODS AND MATERIALS

All patients were treated at the Massachusetts General Hospital from 1979 through 1994 with treatment consisting of 1.6 Gy per traction, two fractions a day for the treatment of T3 carcinoma of the oropharynx and larynx. They were entered in the head and neck data base. Their treatment dates, treatment breaks, and doses vs. local control were analyzed and compared. A p-value of 0.05 was considered statistically significant.

RESULTS

A total of 162 patients were available for review. Due to the acute severe mucosal effects, most of the patients required a midcourse pause or "break" after a dose of 38.4-48 Gy before treatment could be resumed and completed. The data indicate that (a) prolongation of the treatment gap for more than 14 days, (b) total treatment course longer than 45 days, (c) total dose less than 67 Gy, and (d) male gender adversely affected local control. In spite of the gaps, the female patients with advanced carcinomas enjoyed the benefits of improved local control after the accelerated hyperfractionated radiation therapy.

CONCLUSIONS

Accelerated hyperfractionation radiation therapy using 1.6 Gy per fraction/twice-a-day (b.i.d.) for a total dose of 70.4 Gy in 6 weeks is effective in achieving high local control of T3 squamous cell carcinoma of the oropharynx and larynx. The midcourse treatment gap should be as short as possible with the projected total dose and time. Should the gaps be unduly prolonged due to various circumstances, further increase in the total dose, for example, 72-75 Gy, and/or increase of the fraction sizes, for example, 1.8-2.0 Gy/f b.i.d. after the gap may be necessary to compensate for the adverse effects of the tumor regeneration from the prolonged gap.

Radiation therapy for chordomas of the base of skull and cervical spine: patterns of failure and outcome after relapse

PURPOSE

To determine the patterns of failure and outcome following relapse of chordomas of the base of skull and cervical spine.

METHODS AND MATERIALS

Between November 1975 and October 1993, 204 patients were treated for chordoma of the base of skull or cervical spine, of which 63 have developed relapse. These 63 patients constitute the main focus of this study. Forty-five patients presented with base of skull and 18 with cervical spine tumors. All patients received combined proton and photon beam radiation. The median prescribed dose was 70.1 cobalt-Gray equivalent (CGE) (range 66.6-77.4). There were 25 males and 38 females, with a median age of 41 years (range 7-66). Median follow-up was 54 months (range 8-158).

RESULTS

Sixty-three of the 204 patients treated (31%) had treatment failure. Among the 63 patients who relapsed, 60 (95%) experienced local recurrence, and in 49 patients (78%), this was the only site of failure. Two of 63 patients (3%) developed regional lymph node relapse and 3 of 63 (5%) developed surgical pathway recurrence (1 left neck, 1 palate and 1 nasal cavity). Thirteen of 204 patients relapsed in distant sites, accounting for 20% (13 of 63) of all patients with recurrence in this series. The most common metastatic sites were lungs and bones presenting in 7 of 13 and 6 of 13 patients, respectively. Only 2 of 13 patients failed with isolated distant metastasis. The actuarial 3- and 5-year survival rates after local relapse (60 patients) were 44 and 5%, respectively. Following distant failure (13 patients), the 3- and 5-year survival rates were 25 and 12%, respectively. After any relapse (63 patients) the corresponding survival rates were 43 and 7%. Following local relapse, 49 of 60 patients underwent salvage therapy consisting of subtotal resection in most patients (46 of 49). The remaining 11 of 60 patients received supportive care only. Salvage therapy resulted in stable or improved status without subsequent disease progression in 26 of 49 (53%), and progressive disease in 16 of 49 patients (33%). The actuarial 2- and 5-year overall survival rates following relapse for the 49 patients who underwent salvage treatment were 63 and 6%, which favorably compared to the 2-year survival rate of 21% for those who received supportive care only (p = 0.001).

CONCLUSION

Local relapse is the predominant type of treatment failure for chordomas of the base of skull and cervical spine. Salvage treatment may relieve symptoms; however, most patients will ultimately succumb to their disease. Poor long-term survival rates following relapse emphasize the importance of a combined treatment approach with experienced surgeons and radiation oncologists at the time of primary treatment. For most patients, only permanent local tumor control will offer a chance of cure.

Local control of oropharyngeal carcinoma by irradiation alone

The authors of this study reviewed the management of 402 patients with squamous cell carcinomas of the faucial tonsil and the base of the tongue. These patients received radiation therapy at Massachusetts General Hospital and the Massachusetts Eye and Ear Infirmary from 1970 through 1993. Radiation therapy remains the treatment of choice for these lesions. Although the data from this review were not randomized, the accelerated hyperfractionated radiation therapy twice-daily program was shown to achieve significantly higher 5-year local tumor control rates and disease-specific survival rates than the conventional once-daily radiation therapy program (historical control). In patients with early tumors of the faucial tonsil (cancer stages T1 and T2), the 5-year actuarial local tumor control and disease-specific survival rates following the twice-daily radiation therapy program were 91% and 77%, respectively. In patients with advanced tumors (T3), the corresponding rates following twice-daily radiation therapy showed marked improvement and were 80% and 68%. While the treatment results for carcinoma of the base of the tongue generally were inferior to those for carcinoma of the faucial tonsil, they were still much better after the twice-daily program than after conventional once-daily irradiation. For patients with carcinoma of the base of the tongue, the local tumor control and disease-specific survival rates for T1 and T2 lesions were 85% and 76%, respectively. For T3 lesions, the corresponding rates were 54% and 53%. Extensive T4 tumors are better managed by combined surgery and postoperative irradiation. Residual metastatic nodal disease is managed by neck dissection.

The effect of the overall treatment time of fractionated irradiation on the tumor control probability of a human soft tissue sarcoma xenograft in nude mice

PURPOSE

To study the impact of the overall treatment time of fractionated irradiation on the tumor control probability (TCP) of a human soft tissue sarcoma xenograft growing in nude mice, as well as to compare the pretreatment potential doubling time (Tpot) of this tumor to the effective doubling time (Teff) derived from three different schedules of irradiation using the same total number of fractions with different overall treatment times.

METHODS AND MATERIALS

The TCP was assessed using the TCD50 value (the 50% tumor control dose) as an end point. A total of 240 male nude mice, 7-8 weeks old were used in three experimental groups that received the same total number of fractions (30 fractions) with different overall treatment times. In group 1, the animals received three equal fractions/day for 10 consecutive days, in group 2 they received two equal fractions/day for 15 consecutive days, and in group 3 one fraction/day for 30 consecutive days. All irradiations were given under normal blood flow conditions to air breathing animals. The mean tumor diameter at the start of irradiation was 7-8 mm. The mean interfraction intervals were from 8-24 h. The Tpot was measured using Iododeoxyuridine (IudR) labeling and flow cytometry and was compared to Teff.

RESULTS

The TCD50 values of the three different treatment schedules were 58.8 Gy, 63.2 Gy, and 75.6 Gy for groups 1, 2, and 3, respectively. This difference in TCD50 values was significant (p < 0.05) between groups 1 and 2 (30 fractions/10 days and 30 fractions/15 days) vs. group 3 (30 fractions/30 days). The loss in TCP due to the prolongation of the overall treatment time from 10 days to 30 days was found to be 1.35-1.4 Gy/day. The pretreatment Tpot (2.4 days) was longer than the calculated Teff in groups 2 and 3 (1.35 days).

CONCLUSION

Our data show a significant loss in TCP with prolongation of the overall treatment time. This is most probably due to an accelerated repopulation of tumor clonogens. The pretreatment Tpot of this tumor model does not reflect the actual doubling of the clonogens in a protracted regimen.

Base of skull and cervical spine chordomas in children treated by high-dose irradiation

PURPOSE

To evaluate the outcome of children with base of skull or cervical spine chordomas treated by high dose irradiation.

METHODS AND MATERIALS

Eighteen children, 4 to 18 years of age, with base of skull or cervical spine chordomas, received fractionated high-dose postoperative radiation using mixed photon and 160 MeV proton beams. The median tumor dose was 69 Cobalt Gray-equivalent (CGE) with a 1.8 CGE daily fraction.

RESULTS

The median follow-up was 72 months. The 5-year actuarial survival was 68% and the 5-year disease-free survival (DFS) was 63%. The only significant prognostic factor was the location: patients with cervical spine chordomas had a worse survival than those with base of skull lesions (p = 0.008). The incidence of treatment-related morbidity was acceptable: two patients developed a growth hormone deficit corrected by hormone replacement, one temporal lobe necrosis, and one fibrosis of the temporalis muscle, improved by surgery.

CONCLUSION

Chordomas in children behave similarly to those in adults: children can receive the same high-dose irradiation as adults with acceptable morbidity.

Cell proliferation kinetics in human tumor xenografts measured with iododeoxyuridine labeling and flow cytometry: a study of heterogeneity and a comparison between different methods of calculation and other proliferation measurements

The influence of overall treatment time in the results of fractionated radiation treatment was initially established in experimental tumors and, subsequently, in the clinic. The availability of techniques (antibodies against halogenated thymidine analogues and flow cytometry) which permit determinations of the duration of the synthesis phase, the labeling index, and the tumor potential doubling time (Tpot) in a short period of time and requiring only a small biopsy of tumor tissue, has expanded interest in the relationship between tumor cell proliferation and response to irradiation. A valuable tool in the study of this relationship are human tumor xenografts. Previous studies have shown a substantial intratumoral heterogeneity in the determinations of Tpot. Different methods of calculation of the kinetic parameters have been published. We have conducted a heterogeneity analysis and an evaluation of the different calculation methods in order to define the validity of Tpot as a proliferation rate measurement in human tumor xenografts. Results show the intertumoral variability in Tpot [between different types of human tumor xenografts systems (coefficient of variation = 88.2%)] to be greater than mean intratumoral variation (coefficient of variation = 30.8%); this suggests that this variation is potentially adequate to serve as a predictor of response. The diverse calculation methods provided significantly different absolute values but not different tumor ranking, probably because the time interval between labeling and sampling was maintained, for all the samples, between 6 and 8 h. Our study has found significant differences between the labeling index and the S-phase fraction determined with the DNA profile in 9 out of 10 tumor types. No correlation was found between the DNA index of the tumors in this series and their proliferation rate.

Thymoma. Histologic subclassification is an independent prognostic factor

BACKGROUND

Several histologic classifications of thymomas have been proposed, and attempts have been made to correlate the different histologic subtypes to clinical behavior and prognosis. Recently, Marino and Müller-Hermelink and Kirchner et al. proposed a new morphologic classification of thymomas based on the resemblance of the neoplastic cells to subtypes of the normal thymic epithelial cells. In this classification, six categories of thymic epithelial tumors are recognized. They define four categories of thymoma: medullary, mixed, organoid (predominantly cortical), and cortical, and two subgroups of thymic carcinomas: well differentiated thymic carcinoma and high grade carcinomas.

METHODS

The authors studied 116 patients with thymic epithelial tumors classified according to the proposals of Marino and Müller-Hermelink and Kirchner et al. to assess the effect of histologic classification and other factors (stage, size of tumor, lymphoid hyperplasia, myasthenia gravis, age, sex, and treatment) on survival, and freedom from relapse.

RESULTS

Eight cases (7%) were medullary, 32 cases (28%) mixed, 20 cases (17%) organoid (predominantly cortical), 21 cases (18%) cortical, 29 cases (25%) well differentiated carcinoma (WDTC), two cases (2%) high grade carcinoma, and four cases (3%) unclassifiable. Fifty-two patients were in stage I, 32 stage II (16 IIA, 16 IIB), 28 stage III, and four Stage IVA. Only stage (P = 0.0001; hazard ratio = 5.36) and histology (P = 0.0019; hazard ratio = 8.010) were significant in predicting recurrence. Histology was highly correlated with stage, but by multivariate analysis was an independent factor in predicting relapse (P = 0.0281; hazard ratio = 5.92). None of the medullary or mixed thymomas recurred, even though 30% were invasive. Patients with WDTC recurred more often and earlier than patients with organoid and cortical thymoma (log rank, P = 0.0001). The actuarial freedom from relapse for patients with WDTC was 58% at 5 years and 46% at 10 years compared with 100% for other subtypes. Both advanced stage (III and IV) and the WDTC histologic subtype significantly increased the risk of death from thymoma (log rank, P = 0.0001). The actuarial survival of patients with WDTC was 80% at 5 years and 54% at 10 years, whereas that of patients with the other subtypes was 100% at 5 and 10 years. Five of seven relapses and six of seven deaths from thymoma occurred in patients with WDTC. In Stage II patients, one of 16 minimally invasive (Stage IIA) tumors recurred, compared with 3 of 16 grossly invasive (Stage IIB) tumors, indicating that microscopic assessment of invasion is important in staging.

CONCLUSIONS

The histologic classification of Marino and Müller-Hermelink has prognostic significance, independent of tumor stage. Medullary and mixed thymomas were benign tumors with no risk of recurrence, even when capsular invasion was present. Organoid and cortical thymoma showed intermediate invasiveness and a low, but significant, risk of late relapse, even with minimal invasion. WDTC were always invasive and had a significantly increased risk of relapse and death, even for Stage II patients. Adjuvant therapy appears unnecessary for medullary and mixed thymomas, even when invasive.

Proliferating cell nuclear antigen and mitotic activity in rectal cancer: predictor of response to preoperative irradiation

PURPOSE

This study examines the association between the pathologic response of rectal cancer after irradiation and its pretreatment proliferative state as assayed by proliferating cell nuclear antigen (PCNA) and mitotic activity.

PATIENTS AND METHODS

Ninety patients with clinical stage T3 and T4 rectal cancer received preoperative irradiation followed by surgery. Pretreatment tumor biopsies were scored for PCNA activity (number of tumor cells staining immunohistochemically with an anti-PCNA monoclonal antibody) and the number of mitoses per 10 high-powered fields (hpf). Postirradiation surgical specimens were examined for extent of residual disease.

RESULTS

The tumors of 33 of 90 patients (37%) exhibited marked pathologic downstaging (no residual tumor or cancer confined to the rectal wall) after preoperative irradiation. Two features were independently associated with the likelihood of marked pathologic regression after preoperative irradiation: lesion size and PCNA/mitotic activity. When stratified by tumor size, marked tumor regression occurred most frequently in smaller tumors with high PCNA/mitotic activity compared with larger tumors with lower PCNA/mitotic activity. Intermediate downstaging rates were seen for small or large tumors with moderate PCNA/mitotic activity.

CONCLUSION

Tumor PCNA/mitotic activity predicts the likelihood of response to irradiation, which may aid in formulating treatment policies for patients with rectal cancer.

Postoperative radiation therapy for high-risk colon carcinoma

PURPOSE

This study examines the experience of patients treated with postoperative radiation therapy after resection of high-risk colon carcinoma in an effort to assess the potential role of this modality in combination with current systemic therapies.

PATIENTS AND METHODS

From 1976 to 1989, 203 patients received postoperative radiation therapy with and without concurrent fluorouracil (5-FU) chemotherapy following resection of modified Astler-Coller B2, B3, C2, and C3 colon tumors. Of the 203 patients, 30 (15%) were identified as having residual local tumor after subtotal resection, whereas 173 (85%) had no known residual disease. The 173 patients treated with adjuvant radiation therapy were compared with a historical control group of 395 patients undergoing surgery only.

RESULTS

Three groups of patients who appeared to benefit from postoperative radiation were identified. Improved local control and recurrence-free survival rates were seen for patients with stage B3 and C3 colon carcinoma treated with postoperative radiation therapy compared with a similarly staged group of patients undergoing surgery only. Irradiated patients whose tumors had an associated abscess or fistula formation had improved local control and recurrence-free survival rates compared with a similar group of patients undergoing surgery only. There appears to be a subset of patients with residual local disease after subtotal resection that may be salvaged by high-dose postoperative radiation therapy.

CONCLUSION

Selected groups of patients with colon carcinoma may benefit from postoperative radiation in addition to current systemic therapies. Integration of 5-FU and levamisole with postoperative radiation therapy should be considered for patients with (1) stage B3 and C3 lesions, (2) tumors associated with abscess or fistula formation, and (3) residual local disease after subtotal resection.

Preoperative radiation, surgical margins, and local control of extremity sarcomas of soft tissues

The relationship between status of the surgical margin and local control of soft tissue sarcoma of the extremities by preoperative radiation therapy has been assessed in 132 consecutive patients from 1974 to 1988. The 5-year actuarial local control rate was 94% for all patients; the rates were 97% and 82% for the 104 tumors with negative margins and the 28 tumors with positive margins, respectively. The local control rate was independent of the extent of the negative margin. For primary sarcomas, the local control rates were 96%, 97%, and 100%, respectively, for margins that were negative at < or = 1 mm or > 1 mm, or the specimens were negative for tumor; for positive margins the result was 83%. The overall local control rate was lower (not significant) for recurrent than for primary sarcomas: 88% vs. 94%. On the other hand, when stratifying by margin status, no difference was observed in local control results, i.e.: (1) 97% and 91% for primary and recurrent tumors with negative margins, respectively, and (2) 83% and 80% for primary and recurrent tumors with positive margins, respectively. Local control was not significantly higher in those patients who were treated by surgical resection (S), radiation (RT), and re-excision of the previous tumor bed than in those whose radiation therapy was started after the biopsy and followed by one surgical resection. For primary sarcomas that were resected with negative margins the results were: 100% of 15 patients treated by S-RT-S and 96% of 75 patients treated by RT-S.

Resection margins in carcinoma of the head of the pancreas. Implications for radiation therapy

A retrospective review of the pathology and clinical course of 72 patients undergoing resection of carcinoma of the head of the pancreas was undertaken to identify the frequency of tumor involvement at standard surgical transection margins (stomach, duodenum, pancreas, and bile duct) as well as the peripancreatic soft tissue margin and the potential clinical significance of these findings. Of 72 patients undergoing resection, 37 patients (51%) were found to have tumor extension to the surgical margins. The most commonly involved margin was peripancreatic soft tissue (27 patients) followed by pancreatic transection line (14 patients) and bile duct transection line (4 patients). For 37 patients with tumor present at a resection margin, there were no survivors beyond 41 months. No difference in survival or local control was seen between 14 patients receiving postoperative radiation therapy and 5-fluorouracil (5-FU) compared with 23 patients not receiving additional treatment. In contrast, the 5-year actuarial survival and local control of 35 patients undergoing resection without tumor invasion to a resection margin was 22% and 43%, respectively. The 5-year survival and local control of 16 patients receiving adjuvant radiation therapy and 5-FU was 29% and 42%, respectively, whereas these figures were 18% and 31% for 19 patients not receiving adjuvant therapy (p > 0.10). Because residual local tumor after resection is common, preoperative radiation therapy may be beneficial in this disease. It should minimize the risk of dissemination during operative manipulation and facilitate a curative resection by promoting tumor regression. Because local failure rates approach 60% after resection and adjuvant therapy even in cases having clear resection margins, intraoperative radiation therapy to the tumor bed at the time of resection also might be considered. Protocols evaluating the feasibility and efficacy of preoperative radiation therapy and resection with intraoperative radiation therapy for patients with pancreatic cancer are underway.