Quality of life in patients of nasopharyngeal carcinoma: validation of the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35

The authors followed the guidelines of translation and pilot testing of the EORTC QLQ-C30 and EORTC-QLQ-H&N35 questionnaires. The questionnaires were given to 50 nasopharyngeal carcinoma patients under active treatment and 50 under follow-up at our institution from November 2000 to June 2001. A retest was conducted 2 weeks after the first interview/form completion for the follow-up group. The intraclass correlation coefficients of the two questionnaires were moderate to high in the follow-up group. Cronbach's alpha coefficients of all scales of the two questionnaires were > or = 0.70 except that of cognitive functioning. Correlation of scales measuring similar dimensions of the QLQ-C30 and the SF-36 were moderate to high, while that of the QLQ-H&N35 and the QLQ-C30 and the SF-36 were moderate to low. Patients in the active treatment group had more serious acute problems due to disease and chemotherapy. Patients in the follow-up group had more serious chronic problems due to radiation therapy. We concluded that the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35 had moderate to high test-retest reliability, high internal consistency in most scales, and could show the expected differences between patients in active treatment and follow-up group.

Serologic markers of Epstein-Barr virus infection and nasopharyngeal carcinoma in Taiwanese men

BACKGROUND

It is probable but unproven that Epstein-Barr virus (EBV) has a role in nasopharyngeal carcinoma. We determined whether antibodies against EBV are present before the development of nasopharyngeal carcinoma.

METHODS

A total of 9699 men were enrolled between 1984 and 1986. Blood samples were examined for IgA antibodies against EBV capsid antigen and neutralizing antibodies against EBV-specific DNase. During 131,981 person-years of follow-up, 22 pathologically confirmed new cases of nasopharyngeal carcinoma that were diagnosed more than one year after recruitment were ascertained through linkage with the National Cancer Registry of Taiwan.

RESULTS

The cumulative risk of nasopharyngeal carcinoma per 100,000 person-years was 11.2 for subjects who tested positive for neither serologic marker, 45.0 for those who had one marker, and 371.0 for those who had both markers. After adjustment for age and the presence or absence of a family history of nasopharyngeal carcinoma, the relative risk of nasopharyngeal carcinoma was 32.8 for subjects with both markers (95 percent confidence interval, 7.3 to 147.2; P<0.001) and 4.0 for subjects with one marker (95 percent confidence interval, 1.6 to 10.2; P=0.003), as compared with subjects with neither marker. The longer the duration of follow-up, the greater the difference in the cumulative incidence of nasopharyngeal carcinoma between seropositive and seronegative subjects.

CONCLUSIONS

IgA antibodies against EBV capsid antigen and neutralizing antibodies against EBV DNase are predictive of nasopharyngeal carcinoma.

Induction chemotherapy with mitomycin, epirubicin, cisplatin, fluorouracil, and leucovorin followed by radiotherapy in the treatment of locoregionally advanced nasopharyngeal carcinoma

PURPOSE

Survival in advanced nasopharyngeal carcinoma (NPC) is compromised by distant metastasis. Because mitomycin is active against hypoxic and G0 cells, which may help to eradicate micrometastasis, we investigated the effect of mitomycin-containing cisplatin-based induction chemotherapy.

PATIENTS AND METHODS

Recruited for this study were American Joint Committee on Cancer (AJCC) 1992 staging system stage IV NPC patients with the following adverse features: obvious intracranial invasion, supraclavicular or bilateral neck lymph node metastasis, large neck node (> 6 cm), or elevated serum lactate dehydrogenase (LDH) level. Patients were given three cycles of chemotherapy before radiotherapy. The chemotherapy comprised a 3-week cycle of mitomycin, epirubicin, and cisplatin on day 1 and fluorouracil and leucovorin on day 8 (MEPFL).

RESULTS

From January 1994 to December 1997, 111 patients were recruited. The median follow-up period was 43 months. The actuarial 5-year overall survival rate was 70% (95% confidence interval [CI], 60% to 80%; n = 111). For patients having completed radiotherapy (n = 100), the 5-year locoregional control rate was 70% (95% CI, 55% to 84%) and the distant metastasis-free rate was 81% (95% CI, 73% to 89%). The 5-year distant metastasis-free rate of N3a and N3b disease of AJCC 1997 staging system were 79% (95% CI, 62% to 95%) and 74% (95% CI, 60% to 89%), respectively. By Cox multivariate analysis, high pretreatment serum LDH level (P = .04) and neck nodal enlargement before radiotherapy (P = .001) were adverse prognostic factors of survival.

CONCLUSION

The good 5-year survival of N3 disease supports the effectiveness of induction MEPFL in the primary treatment of advanced NPC. Further investigation to incorporate concurrent chemoradiotherapy is warranted.

Occupational exposure to wood, formaldehyde, and solvents and risk of nasopharyngeal carcinoma

Our objective was to evaluate the link between occupational exposures to wood dust, formaldehyde, and solvents and the development of nasopharyngeal carcinoma (NPC). A case-control study was conducted among 375 newly diagnosed cases of NPC in Taipei, Taiwan, and 325 community controls matched to cases on sex, age, and geographical residence (99 and 87% response rates, respectively). Most cases (>90%) were diagnosed with WHO Types 2 or 3 (nonkeratinizing and undifferentiated carcinomas), whereas the remaining cases were diagnosed with WHO Type 1 (squamous cell carcinomas). A complete occupational history was obtained via a personal interview and blindly assessed by an industrial hygienist for intensity and probability of exposure to wood dust, formaldehyde, and solvents. Information on socio-demographic characteristics, cigarette smoking, dietary consumption of nitrosamines, and other potential confounding factors was obtained via a personal interview. Blood specimens were tested for human leukocyte antigen class I/II genotypes, polymorphisms in cytochrome P450 2E1 genotype, and various anti-EBV antibodies known to be associated with NPC. Analysis was performed using logistic regression; relative risk (RR) estimates and 95% confidence intervals (CI) were calculated. Individuals exposed to wood dust had an adjusted RR of 1.7 (95% CI = 1.0-3.0). Those exposed to wood dust for >10 years had an adjusted RR of 2.4 (95% CI = 1.1-5.0; p(trend) = 0.02). Risk was strongest for those first exposed before the age of 25 years and those seropositive to EBV. Individuals exposed to formaldehyde were at a more modest and nonsignificant increased risk of NPC (RR = 1.4; 95% CI = 0.93-2.2). Those exposed to formaldehyde for >10 years had an adjusted RR of 1.6 (95% CI = 0.91-2.9). The association between formaldehyde and NPC was stronger in analyses restricted to EBV seropositive individuals (RR = 2.7; 95% CI = 1.2-5.9). However, no dose response was observed with increasing duration or cumulative use. No association was observed between solvent exposure and NPC (RR = 1.2; 95% CI = 0.86-1.7). Occupational exposure to wood dust is likely to be involved in the development of NPC, a finding that is consistent with the known link between wood exposure and nasal adenocarcinomas. Formaldehyde exposure is less clearly linked to NPC, whereas exposure to solvents is unlikely to be involved in NPC pathogenesis.

An analysis of excitatory amino acids, nitric oxide, and prostaglandin E2 in the cerebrospinal fluid of pregnant women: the effect on labor pain

It is still unclear which neurotransmitters are involved in labor pain. We measured the concentrations of excitatory amino acids, nitric oxide, and prostaglandin E2 in the cerebrospinal fluid (CSF) of pregnant women, particularly in those with labor pain. The patients included in the study consisted of women who underwent cesarean delivery either with labor pain (Labor Pain group, n = 40) or without labor pain (Nonlabor Pain group, n = 58). All patients received spinal anesthesia (intrathecal injection of 10-12 mg of bupivacaine) for the operation, and 2 mL of CSF was collected before bupivacaine injection. Concentrations of aspartate and glutamate (0.50 +/- 0.06 microM and 0.79 +/- 0.10 microM, respectively) were significantly larger in the Labor Pain group than in the Nonlabor Pain group (0.35 +/- 0.03 microM and 0.54 +/- 0.04 microM, P < 0.05). There were no significant differences in the concentrations of nitric oxide and prostaglandin E2 between the groups. A positive correlation was found between CSF concentrations of excitatory amino acids and labor pain.

IMPLICATIONS

The excitatory amino acids, aspartate and glutamate, play a role in labor pain. N-methyl-D-aspartate receptor antagonists may be useful for labor pain and postlabor uterine contraction pain relief.

Intracranial relapse of nasopharyngeal carcinoma manifested as sudden deafness

OBJECTIVE

To differentiate tumor relapse from postirradiation sudden deafness (PISD) in patients with nasopharyngeal carcinoma (NPC).

STUDY DESIGN

A retrospective study from December 1991 to November 1999.

SETTING

University hospital.

PATIENTS

Twenty-five irradiated NPC patients with sudden deafness were investigated. All patients received local examination of ears, nose, nasopharynx, and throat fields, as well as a battery of audiologic and neurotologic tests.

RESULTS

Three patients with sudden deafness within 3 years after irradiation received a diagnosis of tumor relapse. Magnetic resonance imaging revealed cerebellopontine angle metastasis in one and intracranial invasion in two. Comparison of the remaining 22 NPC patients who had PISD showed that the mean interval between the completion of irradiation to the onset of sudden deafness was 10+/-5 years.

CONCLUSION

Magnetic resonance imaging should be performed to exclude intracranial relapse if sudden deafness develops in a patient with NPC within 5 years after irradiation.

Clinical characteristics of tricho-rhino-phalangeal syndrome type I in Taiwanese

Tricho-rhino-phalangeal syndrome type I (TRPS-I) is a malformation syndrome characterized by distinctive craniofacial and skeletal abnormalities. Only one case of TRPS-I has been previously reported in Taiwan. This retrospective study analyzed the clinical, roentgenographic, and histopathologic findings in seven patients with a diagnosis of TRPS-I who were treated at a hospital in Tainan during a 6-year period from 1994 to 1999. Physical examination revealed fine, sparse, and short scalp hair, a pear-shaped nose, long philtrum, thinning of the lateral portion of the eyebrows, and brachydactyly of the thumbs and big toes. The stature and intelligence of these patients were normal. Histopathologic examination of the scalp in two patients showed hypotrichosis without inflammation or scarring. Roentgenographic evaluation of both hands and feet showed cone-shaped proximal epiphyses of the middle phalanges in all patients. The findings of this report suggest that TRPS-I is not rare among Taiwanese, although the island-wide incidence is not known. The diagnosis of this syndrome in our department was greatly facilitated by our prior experience with treatment of the first patient in this series because TRPS-I is readily recognizable by its characteristic clinical and roentgenographic features. The identification of these features is important to the facilitation of genetic and cosmetic counseling. In addition to the typical craniofacial manifestations, all patients in this study showed brachydactyly of the big toes. This additional feature appears to offer an easy way to recognize the syndrome clinically.

Specific IgA antibodies to recombinant early and nuclear antigens of Epstein-Barr virus in nasopharyngeal carcinoma

Nasopharyngeal carcinoma is a common cancer in Taiwan. The Epstein-Barr virus (EBV) is closely associated with nasopharyngeal carcinoma. The sera of patients with nasopharyngeal carcinoma have IgA antibodies to a variety of EBV latent and replicated antigens. Recently, an enzyme-linked immunosorbent assay (ELISA) kit, combining both the EBV early antigen (EA) and nuclear antigen (EBNA-1) became commercially available. The purpose of this study was to assess its clinical application. Serum IgA antibodies to the EBV EA and EBNA-1 were measured by using the ELISA kit in various groups of subjects. Fluorescence antibody (FA) tests against EBV viral capsid antigen (VCA) and EA in the IgA and IgG classes were also studied for comparison. The DNA content analysis was also carried out to investigate the association with IgA antibody titres using ELISA. The sensitivity, specificity and accuracy of the ELISA test were 98.1%, 81.8% and 88.7% respectively. It was far better than any FA tests. The IgA antibody titres showed no association with DNA content analysis. Univariate analysis of various factors revealed that IgA antibody titres were statistically correlated to N stage (P = 0.0291) and M status (P = 0.001). However, there was no association with the age, sex, T stage and clinical stage. Multivariate analysis of various factors was found to be statistically significant in patients with T4 (P = 0.0133), N3 (P = 0.0244) or M1 (P = 0.001) respectively. Serial testing of antibody titres in 22 previously untreated patients found a trend of decreasing IgA antibody titres after initial treatment when the tumours disappeared (P = 0.0358). The ELISA kit to identify specific IgA antibodies with the combination of EBV EA and EBNA-1 recombinant antigens has high sensitivity and acceptable specificity and accuracy in the diagnosis of nasopharyngeal carcinoma. This assay should be useful for early diagnosis and mass screening of patients.

Failure of grommet insertion in post-irradiation otitis media with effusion

Nasopharyngeal carcinoma (NPC) survivors with post-irradiation otitis media with effusion (OME; 100 ears) were divided into 2 groups. One group underwent grommet insertion, and the other group was treated by repeated myringotomies plus aspiration to evaluate the outcome of the OME. Computed tomography, magnetic resonance imaging, audiometry, and local checks of the ear, nose, and nasopharyngeal fields were performed to evaluate the sinus and middle ear conditions over a long-term (more than 10 years) follow-up period. The results in these NPC survivors with OME indicated that the prevalence of middle ear complications in the myringotomized group (33%) was less than that in the grommeted group (90%). Grommets alone cannot eradicate inflammation outside the middle ear cavity, but rather, they can aggravate it by superinfection. We therefore recommend that controlling the radiation-induced inflammation in areas such as the ears, nose, sinuses, and nasopharynx is most important. In conclusion, post-irradiation OME should be treated in a different way from conventional OME. Restated, grommet insertion is contraindicated in post-irradiation OME.

Phase I clinical trial of curcumin, a chemopreventive agent, in patients with high-risk or pre-malignant lesions

Curcumin (diferuloylmethane), a yellow substance from the root of the plant Curcuma longa Linn., has been demonstrated to inhibit carcinogenesis of murine skin, stomach, intestine and liver. However, the toxicology, pharmacokinetics and biologically effective dose of curcumin in humans have not been reported. This prospective phase-I study evaluated these issues of curcumin in patients with one of the following five high-risk conditions: 1) recently resected urinary bladder cancer; 2) arsenic Bowen's disease of the skin; 3) uterine cervical intraepithelial neoplasm (CIN); 4) oral leucoplakia; and 5) intestinal metaplasia of the stomach. Curcumin was taken orally for 3 months. Biopsy of the lesion sites was done immediately before and 3 months after starting curcumin treament. The starting dose was 500 mg/day. If no toxicity > or = grade II was noted in at least 3 successive patients, the dose was then escalated to another level in the order of 1,000, 2,000, 4,000, 8,000, and 12,000 mg/day. The concentration of curcumin in serum and urine was determined by high pressure liquid chromatography (HPLC). A total of 25 patients were enrolled in this study. There was no treatment-related toxicity up to 8,000 mg/day. Beyond 8,000 mg/day, the bulky volume of the drug was unacceptable to the patients. The serum concentration of curcumin usually peaked at 1 to 2 hours after oral intake of crucumin and gradually declined within 12 hours. The average peak serum concentrations after taking 4,000 mg, 6,000 mg and 8,000 mg of curcumin were 0.51 +/- 0.11 microM, 0.63 +/- 0.06 microM and 1.77 +/- 1.87 microM, respectively. Urinary excretion of curcumin was undetectable. One of 4 patients with CIN and 1 of 7 patients with oral leucoplakia proceeded to develop frank malignancies in spite of curcumin treatment. In contrast, histologic improvement of precancerous lesions was seen in 1 out of 2 patients with recently resected bladder cancer, 2 out of 7 patients of oral leucoplakia, 1 out of 6 patients of intestinal metaplasia of the stomach, I out of 4 patients with CIN and 2 out of 6 patients with Bowen's disease. In conclusion, this study demonstrated that curcumin is not toxic to humans up to 8,000 mg/day when taken by mouth for 3 months. Our results also suggest a biologic effect of curcumin in the chemoprevention of cancer.

Factors affecting the overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site: experience with 60 cases

OBJECTIVE

To analyze the factors affecting overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site after a full course of radiotherapy.

DESIGN

Retrospective analysis of 60 consecutive patients treated by surgical resection of the recurrent tumors, with a mean follow-up of 43.1 months (range, 19-96 months).

SETTING

Academic tertiary referral center.

RESULTS

The overall survival and locoregional relapse-free survival were 56% and 60% at 2 years, respectively, and 30% and 40% at 5 years. Twenty-nine (81%) of 36 patients died with uncontrolled local disease. The T stage of the recurrent tumors appeared to be an important prognostic factor. Age, sex, pathologic findings, and disease-free interval (time between previous radiotherapy and local recurrence) were not significant prognosis-affecting factors by the log-rank test. Multivariate analysis showed that patients with recurrent tumors of undifferentiated carcinoma, sarcoma, or small cell carcinoma had unfavorable prognoses. Uncontrolled local disease and the emergence of distant metastasis predicted grave results as well. Postoperative irradiation showed some benefit to patients, but the difference was not statistically significant.

CONCLUSIONS

The T stage of the recurrence was the prominent prognosis-affecting factor in patients with recurrent nasopharyngeal carcinoma who received salvage surgery. Patients with local recurrence should be carefully selected for the salvage surgery. We recommend this surgery for patients with rT1, rT2, or limited rT3 lesions. The results of surgical resection in terms of local control and overall survival were slightly better than those of high-dose reirradiation, with fewer late complications.

Use of bacterially expressed EBNA-1 protein cloned from a nasopharyngeal carcinoma (NPC) biopsy as a screening test for NPC patients

EBV serological tests have been used for many years as accessory diagnostic predictors of nasopharyngeal carcinoma (NPC). To increase the sensitivity and specificity of the NPC detection rate, a novel enzyme-linked immunosorbent assay (ELISA) was established using a bacterially-expressed GST-EBNA-1 protein, containing the EBNA-1 sequence cloned from an NPC patient. Serum samples were collected from age- and gender-matched patients with NPC, community control subjects and hospital control patients and tested using this ELISA. The positivity rates were 78.7% (247/314) in NPC, 11.5% (28/244) in hospital controls and 3.8% (10/263) in the community control group. These serum samples were also tested for IgA anti-VCA antibodies and their ability to neutralize EBV DNase and the sensitivities of the anti-VCA antibody and DNase-neutralization tests also were analyzed. The optimum combination is VCA plus EBNA-1, which can identify 92.5% (287/310) of NPC patients, and shows a specificity of 92.7% (242/261) for normal individuals.

DNA content of nasopharyngeal carcinoma: an independent prognostic indicator

The purpose of this study was to examine whether tumor DNA content correlated with prognosis in nasopharyngeal carcinoma (NPC). DNA flow-cytometric analysis in fresh specimens of nasopharyngeal biopsy from 123 patients with clinical suspicion of NPC was collected initially. Histopathologic study and successful flow-cytometric analysis had 28 lymphoid hyperplasias and 87 NPCs. Seventeen NPC patients were treated elsewhere and were excluded. A total of 98 patients, including 28 lymphoid hyperplasias and 70 NPCs, formed the materials of this study. There were 34 (49%) diploid and 36 (51%) aneuploid in NPC patients. No lymphoid hyperplasias were aneuploid. The mean of S-phase fraction was higher in NPC than in lymphoid hyperplasia (P < .001), indicating higher cellular activity in NPC. DNA content failed to associate with age, gender, pathology, distant metastasis, and stage, indicating that DNA content was an independent prognostic indicator and possibly a clinical parameter. The log-rank test of overall survival curves was significant for stage (P = .002) and DNA ploidy (P = .042); it was almost significant for S-phase fraction (P = .057). Because the follow-up duration was not long enough, univariate and multivariate analysis were not significant for stage, ploidy, and S-phase fraction, except for distant metastasis. It is also most likely colinearity of clinical stage and distant metastasis that explained why clinical stage could not show significance in prognosis. Interestingly, the DNA content appeared to be a potential prognostic parameter in overall survival, although it was not statistically significant (P = .052). Our data suggested that NPC patients with aneuploid DNA and high S-phase fraction tend to have poor prognosis and should be treated more aggressively, even in the early stage of the disease.

Intrathecal cyclooxygenase inhibitor administration attenuates morphine antinociceptive tolerance in rats

Several lines of evidence suggest that the N-methyl-D-aspartate receptor (NMDA) and nitric oxide (NO) systems are involved in morphine tolerance. Cyclooxygenase (COX) inhibitors may also play a role in morphine tolerance by interacting with both systems. In the present study, we examined the effects of the COX inhibitors N-(2-cyclohexyloxy-4-nitrophenyl) methanesulphonamide (NS-398, selective COX2 inhibitor) and indomethacin (non-selective COX inhibitor) on the development of antinociceptive tolerance of morphine in a rat spinal model. The antinociceptive effect was determined by the tail-flick test. Tolerance was induced by injection of morphine 50 micrograms intrathecally (i.t.) twice daily for 5 days. The effects of NS-398 and indomethacin on morphine antinociceptive tolerance were examined after administering these drugs i.t. 10 min before each morphine injection. Neither NS-398 nor indomethacin alone produced an antinociception effect at doses up to 40 micrograms. NS-398 and indomethacin did not enhance the antinociceptive effect of morphine in naïve and morphine-tolerant rats. However, they shifted the morphine antinociceptive dose-response curve to the left when coadministered with morphine during tolerance induction, and reduced the increase in the ED50 of morphine (dose producing 50% of the maximum response) three- to four-fold. Collectively, these findings and previous studies suggest that COX may be involved in the development of morphine tolerance without directly enhancing its antinociceptive effect.

Morphine tolerance increases [3H]MK-801 binding affinity and constitutive neuronal nitric oxide synthase expression in rat spinal cord

N-Methyl-D-aspartate (NMDA) receptor antagonists and nitric oxide synthase (NOS) inhibitors inhibit morphine tolerance. In the present study, a lumbar subarachnoid polyethylene (PE10) catheter was implanted for drug administration to study alterations in NMDA receptor activity and NOS protein expression in a morphine-tolerant rat spinal model. Antinociceptive tolerance was induced by intrathecal (i.t.) morphine infusion (10 micrograms h-1) for 5 days. Co-administered (+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-imine maleate (MK-801) (10 micrograms h-1 i.t.) with morphine was used to inhibit the development of morphine tolerance. Lumbar spinal cord segments were removed and prepared for [3H]MK-801 binding assays and NOS western blotting. The binding affinity of [3H]MK-801 was higher in spinal cords of morphine-tolerant rats (mean (SEM) KD = 0.41 (0.09) nM) than in control rats (1.50 (0.13) nM). There was no difference in Bmax. Western blot analysis showed that constitutive expression of neuronal NOS (nNOS) protein in the morphine-tolerant group was twice that in the control group. This up-regulation was partially prevented by MK-801. The results suggest that morphine tolerance affects NMDA receptor binding activity and increases nNOS expression in the rat spinal cord.

The roles of pain facilitatory systems in opioid tolerance

Opioids are powerful analgesic agents and have been widely used in clinical pain management for decades. Nevertheless, both acute and chronic opioids administration may produce tolerance, as indicated by a lowered responsiveness to the drugs at a later time. Koob and Bloom described two possible mechanisms of drug tolerance: a within-system and a between-systems adaptation. Opioid receptors uncoupling from G-proteins and receptor down-regulation, in particular the receptor's high affinity sites, are well-known mechanisms (the within-system) of opioid tolerance. A series of recent studies have proposed that a between-systems, particularly the pain facilitatory systems (opiate-activated opponent systems), may also involve in the development of opioid tolerance. Several lines of evidence suggest that N-methyl-D-asparate (NMDA) receptors activation and the subsequent nitric oxide (NO) production probably play a between-systems mechanism of opioid tolerance. Recently, our and others' studies also found that cyclooxygenase (COX) inhibitors could attenuate the opioid tolerance without enhancing morphine's antinociceptive effect. Taking all these findings together, the pain facilitatory systems included the NMDA-receptors, NO, and COX systems may also play important roles in opioid tolerance. In summary, except the opioid receptor uncoupling and opioid receptor down-regulation, chronic morphine treatment may also activate pain facilitatory systems (NMDA receptor activation, NO production, and COX ac-tivation) during opioid tolerance development. It implies that some complicated interactions may happen among the opioid receptor, NMDA-receptor, NO, and COX systems and are worth further investigations.

Evoked responses of the anterior cingulate cortex to stimulation of the medial thalamus

In the present study we characterized the field potentials in the anterior cingulate cortex (ACC) evoked by electrical stimulation of the medial thalamus (MT), and elucidated the synaptic organization of the ACC. Male Sprague Dawley rats were maintained in general anesthesia by alpha-chloralose (50 mg/kg, i.v.). Tungsten micro-electrodes were used for electric stimulation and recordings. The field potentials and multiple unit activities in the ACC were evoked by electric stimulation of the MT where the nociceptive responses were identified. A MT-evoked positive-negative potential was recorded on the medial frontal surface. The polarity of the surface negative potential was reversed between 0.5 to 1.0 mm in the deep layer of the ACC. Maximum evoked negative potential appeared at about 4 mm anterior to the bregma and 1 mm lateral to the midline. The maximum evoked positive potential occurred at about 3 mm anterior to the bregma and 1 mm lateral to the midline. The evoked multiple unit activities coincided with the deep negative field potential at a latency between 16 ms and 24 ms at a depth between 0.5 mm and 1.5 mm in the ACC. These electrophysiological findings confirmed that nociceptive information in the MT is transmitted to the ACC and trans-synaptically activates deeper and more superficial layers of cortical neurons.

Dietary exposure to nitrite and nitrosamines and risk of nasopharyngeal carcinoma in Taiwan

Previous studies of nasopharyngeal carcinoma (NPC) have found elevated risks with higher consumption of salted fish and preserved foods, particularly during childhood. These foods can contain high levels of nitrosamines; however, most studies have not estimated exposure to nitrosamines directly. We conducted a case-control study in Taiwan to evaluate dietary intakes and NPC risk. A total of 375 cases (99% response rate) and 327 controls (88% response rate) were interviewed about their diet as an adult and at age 10 using a food-frequency questionnaire. We interviewed mothers of participants about their child's diet at age 10, age 3 and during weaning and the mother's diet while she was breast-feeding. Mothers of 96 cases and 120 controls were interviewed. Nitrosamine and nitrite levels were assigned to 66 foods based on published values. Intake of nitrosamines and nitrite as an adult was not associated with risk of NPC. High intakes of nitrosamines and nitrite during childhood and weaning were associated with increased risks of NPC for foods other than soy products. Adjusted odds ratios for the highest quartile were 2.2 [95% confidence interval (CI) 0.8-5.6] for age 10, 2.6 (95% CI 1.0-7.0) for age 3 and 3.9 (95% CI 1.4-10.4) for weaning diet. Intakes of nitrite and nitrosamines from soybean products during childhood and weaning were inversely associated with risk. Soybeans contain known inhibitors of nitrosation, and thus may explain the inverse association we observed. Our results suggest that nitrosamine and nitrite intake during childhood may play a role in the development of NPC.

Herpes zoster oticus treated with acyclovir and prednisolone: clinical manifestations and analysis of prognostic factors

Herpes zoster oticus is a cranial polyneuropathy with facial nerve involvement as its main feature. The prognosis of the facial palsy is usually poor. Thirty patients with herpes zoster oticus suffering from facial palsy were admitted for parenteral acyclovir and oral prednisolone. Multiple regression analysis of improvement of facial palsy showed three significant covariates: age, multiple nerve palsies, and the initial grading of the palsy. The recovery of the facial palsy treated with acyclovir and prednisolone was good, and possibility of a good outcome was greater when the initial grade of the palsy was higher. Multiple nerve palsies and age had negative effects on the improvement.

Dysphagia after radiotherapy: endoscopic examination of swallowing in patients with nasopharyngeal carcinoma

Dysphagia is a late sequela compromising the lives of more than one fourth of patients with nasopharyngeal carcinoma (NPC) who survive long after radiotherapy. By using fiberoptic endoscopic examination of swallowing as a modality for dysphagia evaluation, we were able to easily recognize the functional and anatomic changes in 31 dysphagic NPC patients. The majority of patients were found to aspirate after the act of swallowing (77.4%). Seventeen (54.8%) had tongue atrophy, and 9 (29%) had vocal cord palsy. Dysfunctions such as dry mouth (45.2%), velopharyngeal incompetence (58%), premature leakage (41.9%), delay or absence of swallow reflex (87.1%), poor pharyngeal constriction (80.6%), pharyngeal residue retention (83.9%), penetration or aspiration (93.5%), and silent aspiration (41.9%) were noted in these patients. Multiple dysfunctions were demonstrated in each patient. Abnormality of pharyngeal constriction and/or aberrant upper esophageal sphincter function played the major role in the postswallow aspiration of these irradiated NPC patients. Clinically compromised patients (weight loss of > or =5 kg in 1 year or pneumonia) had more of the above anatomic and functional impairments. The radiation dosage and volume bore no correlation to the time of symptom onset, or to the occurrence of functional changes.

Usefulness of the C1 transverse process as a reference guide in the dissection of the upper lateral neck

In this investigation we dissected 3 cadavers with the lateral cervical approach to assess the usefulness of the transverse process of the atlas (TPA) as a reference guide in the upper lateral neck. Our results indicate that all the important structures in this space can be identified systematically. Lateral to the TPA sits the posterior belly of the digastric muscle, the stylohyoid muscle, and the occipital artery. Anterior to the TPA, the styloid process can be exposed. The internal jugular vein and cranial nerves X, XI, and XII sit between the styloid process and the TPA. Superior to the TPA, tracing the carotid sheath upward, the carotid canal and jugular foramen can be reached. Anteroinferior to the jugular foramen, the hypoglossal nerve emerges from the cranial cavity through the hypoglossal canal. Posterior to the TPA, the suboccipital triangle can be recognized. Within the triangle, the vertebral artery and its accompanying venous complex can be identified.

Second primary epithelial malignancy of nasopharynx and nasal cavity after successful curative radiation therapy of nasopharyngeal carcinoma

Patients with head and neck cancer are at high risk of developing additional second primary tumors in the aerodigestive tract as a result of the field cancerization phenomenon. In this context, the appearance of a new neoplasm often poses a problem in differential diagnosis between recurrence and new primary tumor. Twelve patients with nasopharyngeal carcinoma (NPC) who received radiation therapy for the primary tumor and developed a second epithelial malignancy in the nasal cavity or nasopharynx during the follow-up period are presented in this report. The differentiation between the 2 entities based on the spatiotemporal relations, histological features, and the status of Epstein-Barr virus in tumor lesions are also presented. Our study showed that the epithelial malignancy after NPC having late-onset or prolonged interval (range, 5 to 18 years), different histological patterns (keratinizing squamous cell carcinoma, neuroendocrine carcinoma, or small cell carcinoma) distinct from the primary NPC (differentiated or undifferentiated nonkeratinizing carcinoma), and absence of Epstein-Barr virus, indicate a newly developed tumor rather than recurrent NPC. Our observations showed for the first time that second primary epithelial malignancy developed in the nasal cavity or nasopharynx years after curative therapy for NPC with a prevalence of 0.4% (12/2,794). Wild-type p53 protein was expressed more often in the original NPC (9 of 12) than in the second tumors (4 of 10), but the significance was not statistically significant (P = .2048). Genomic analysis for p53 mutation and in situ hybridization for human papillomavirus showed negative results, indicating that both important molecular events in NPC or head and neck cancer play a small role in this particular type of newly developed second malignant tumor. More studies are warranted for further clarification for the development of second epithelial malignancies in treated NPC patients.

Epstein-Barr virus-encoded latent membrane protein 1 co-expresses with epidermal growth factor receptor in nasopharyngeal carcinoma

Latent membrane protein 1 (LMP-1) is the only Epstein-Barr virus (EBV)-encoded oncogenic protein that has been detected in nasopharyngeal carcinoma (NPC), a cancer that is closely associated with EBV. Previous in-vitro studies have demonstrated that LMP-1 can upregulate epidermal growth factor receptor (EGFR) in epithelial cells. It was not established whether this cellular effect exists in NPC. To assess the association between LMP-1 and EGFR in NPC tissues, 60 NPC specimens were examined by immunohistochemistry using anti-LMP-1 antibody (CS 1-4) and anti-EGFR antibodies (EGFR 1, EGFR 1005). The results revealed that 41 (68.3%) specimens were immunopositive for LMP-1 and 44 (73.3%) specimens over-expressed EGFR. Morphologically, the expressions of LMP-1 and EGFR were homogeneously distributed in the tumor nests. In addition, the correlation between LMP-1 and EGFR was statistically significant (P<0.001, chi2 test, d.f. = 1). To elucidate further the correlation between LMP-1 and EGFR in vivo and in situ, an indirect dual immunofluorescence assay was conducted, using secondary antibodies conjugated with fluorescein isothiocyanate (FITC) or indocarbocyanine (Cy3). The results disclosed an intimate co-expression of LMP-1 and EGFR. In summary, the data indicate that over-expression of EGFR is a common phenomenon in NPC, and that EGFR is co-expressed with LMP-1 in NPC. Thus, EBV may play a role in the tumorigenesis of NPC through the effects of LMP-1 and EGFR.

Induction with mitomycin C, doxorubicin, cisplatin and maintenance with weekly 5-fluorouracil, leucovorin for treatment of metastatic nasopharyngeal carcinoma: a phase II study

The combination of cisplatin and 5-fluorouracil (5-FU) (PF) is the most popular regimen for treating metastatic nasopharyngeal carcinoma (NPC) but it is limited by severe stomatitis and chronic cisplatin-related toxicity. A novel approach including induction with mitomycin C, doxorubicin and cisplatin (MAP) and subsequent maintenance with weekly 5-FU and leucovorin (FL) were designed with an aim to reduce acute and chronic toxicity of PF. Thirty-two patients of NPC with measurable metastatic lesions in the liver or lung were entered into this phase II trial. Mitomycin C 8 mg m(-2), doxorubicin 40 mg m(-2) and cisplatin 60 mg m(-2) were given on day 1 every 3 weeks as initial induction. After either four courses or remission was achieved, patients received weekly dose of 5-FU 450 mg m(-2) and leucovorin 30 mg m(-2) for maintenance until disease progression. With 105 courses of MAP given, 5% were accompanied by grade 3 and 0% were accompanied by grade 4 stomatitis. The dose-limiting toxicity of MAP was myelosuppression. Forty per cent of courses had grade 3 and 13% of courses had grade 4 leukopenia. No grade 3 or 4 cisplatin-related toxicity was observed. The overall response rate was 94% (95% confidence interval (CI) 84.9-100%) with a complete response rate (CR) of 6% (95% CI: 0-15.2%) and a good partial response (PR) rate of 28% (95% CI 11.7-44.6%), which was optionally defined as observance of only equivocal lesion identifiable under imaging study. Twenty-seven cases entered weekly FL maintenance phase. The median duration of maintenance with weekly FL was 38 weeks (8-91 weeks). There was no grade 3 or 4 toxicity noted during weekly FL. The median progression-free survival and overall survival were 11.6+/-0.4 and 18.1+/-3.6 months respectively. Six patients with a median follow-up of 19.8 months (9.6-41.0 months) were still alive and five of them had disease under control with FL. Good responders (CR and good PR) had better survival than less satisfactory responders (PR and stable disease) (P = 0.05). From Cox's multivariate regression analysis, the only significant prognostic factor for survival was good response to MAP (P = 0.042). Liver metastasis was the only significant variable in the best subset regression model that predicted good response to MAP (CR and good PR) (P = 0.027). MAP was an effective combination for metastatic NPC with minimal stomatitis and cisplatin-related toxicity but had significant myelosuppression. Weekly FL was a maintenance therapy with minimal side-effects. The response rate and overall survival of MAP-FL were better than series previously reported even when a subset of patients with poor prognosis was selected. MAP-FL's role as neoadjuvant or adjuvant therapy is worthy of further study.

Cigarette smoking, alcohol consumption and risk of nasopharyngeal carcinoma in Taiwan

OBJECTIVES

Nasopharyngeal carcinoma (NPC) is rare in most countries but occurs with relatively high frequency among southern Chinese populations throughout the world. A case-control study of NPC was conducted in Taiwan to investigate the importance of active and passive cigarette exposure and alcohol consumption as risk factors for this disease.

METHODS

375 histologically confirmed incident NPC cases (99% response rate) were prospectively identified from two hospitals in Taipei between July 1991 and December 1994 and administered a detailed questionnaire. 327 healthy community controls individually matched to cases on sex, age and residence were selected (88% response rate).

RESULTS

After multivariate adjustment, the odds ratio (OR) and 95% confidence interval (CI) was 1.7 (1.1-2.9 with p = 0.03 for increasing dose-response) for those who smoked for > or = 25 years compared with non-smokers. Passive smoking during childhood or adult life was not associated with an increased risk of disease. Alcohol consumption was not associated with NPC risk. The OR for subjects with > or = 15 grams of ethanol per day compared to non-drinkers was 1.1 (95% CI = 0.7-1.7).

CONCLUSIONS

Our results suggest that long term cigarette smoking is associated with NPC but that low level exposure to cigarette smoke via passive exposure and alcohol consumption are not associated with disease risk.

Snt309p modulates interactions of Prp19p with its associated components to stabilize the Prp19p-associated complex essential for pre-mRNA splicing

The SNT309 gene was identified via a mutation that causes lethality of cells in combination with a prp19 mutation. We showed previously that Snt309p is a component of the Prp19p-associated complex and that Snt309p, like Prp19p, is associated with the spliceosome immediately after or concomitantly with dissociation of U4 from the spliceosome. We show here that extracts prepared from the SNT309-deleted strain (DeltaSNT309) were defective in splicing but could be complemented by addition of the purified Prp19p-associated complex. Isolation of the Prp19p-associated complex from DeltaSNT309 extracts indicated that the complex was destabilized in the absence of Snt309p and dissociated on affinity chromatography, suggesting a role of Snt309p in stabilization of the Prp19p-associated complex. Addition of the affinity-purified Prp19p-Snt309p binary complex to DeltaSNT309 extracts could reconstitute the Prp19p-associated complex. Genetic analysis further suggests that Snt309p plays a role in modulating interactions of Prp19p with other associated components to facilitate formation of the Prp19p-associated complex. A model for how Snt309p modulates such interactions is proposed.

Treatment, outcomes, and prognostic factors of ear cancer

Cancer of the ear is rare and a consensus has not been reached as to the most appropriate treatment. In this retrospective study, we examined the treatment modalities, prognostic factors, and outcomes of patients treated for ear cancer at the National Taiwan University Hospital during a 15-year period. The disease-free survival rates of patients with three different disease grades were compared using the log-rank test. The effects of prognostic factors on survival were examined with Cox's proportional hazard model. Of the 61 ear cancer patients treated from January 1982 through October 1996, 47 (36 men, 11 women; mean age, 54.6 yr) had complete records and were included in this study. The tumor originated from the middle ear in 29 (62%) patients and from the external ear canal in 18 (38%). A total of 37 patients underwent radical mastoidectomy to remove the gross tumor, while six underwent wide excision of the tumor. Concomitant parotidectomy or neck dissection was performed in seven patients. Thirty-eight patients received postoperative radiation therapy and five patients received chemotherapy for palliative treatment of recurrent or inoperable tumors. All but four (9%) of 43 patients developed facial nerve palsy postoperatively. There were no deaths directly related to surgery or other major complications, including cerebrospinal fluid leakage, meningitis, or hemiparesis. The 5-year disease-free survival rate was 53% overall (n = 47), but differed significantly among patients with different grades of disease (p = 0.038): 66% for grade I (n = 27), 44% for grade II (n = 17), and 0% for grade III (n = 3). Multivariate analysis revealed that cervical lymph node metastasis was a poor prognostic factor (relative hazard, 16.4; p < 0.001). These results suggest that mastoidectomy with postoperative radiation therapy can yield satisfactory outcomes, even in some cases of advanced (grade II) disease.

Familial and sporadic cases of nasopharyngeal carcinoma in Taiwan

BACKGROUND

Nasopharyngeal carcinoma (NPC) has a striking geographic/ethnic distribution, with especially high rates among southern Chinese. Previous studies have indicated that a family history of NPC is associated with increased risk and noted familial clustering in low-risk populations.

MATERIALS AND METHODS

We investigated differences between sporadic and familial cases of NPC in a case-control study of 375 histologically confirmed NPC cases (99% response rate) and 328 age-, sex-, and geographically-matched controls (88% response rate). All participants answered a detailed risk factor interview and donated blood for EBV and CYP 2E1 testing.

RESULTS

Subjects with a first degree relative with NPC had on odds ratio (OR) of 7.6 (95% confidence interval (CI) = 2.3-25), while those with a family history of any other cancer had only a slightly elevated risk of disease (OR = 1.4; 95% CI = .93-2.2). Of the cases, 25 (6.7%) were familial--having at least one first degree relative with NPC. No significant difference was seen between familial and sporadic cases with respect to sex, age, ethnicity, histology or stage. There was a nonsignificant (p = 0.16) increase in T1N2 tumors among familial cases, suggesting a more aggressive tumor. Family history of other cancers, EBV serologies, or the distribution of the RsaI c2 form of the allele of cytochrome P450 2E1 were also not significantly different between the two groups.

CONCLUSIONS

In conclusion, while genetic factors are likely to play an important role in NPC pathogenesis, our results provide little evidence that a familial form of NPC exists with characteristics notably distinct from sporadic cases.

Nasopharyngeal angiofibroma: a reappraisal of clinical features and treatment at National Taiwan University Hospital

Nasopharyngeal angiofibroma (NAF), occurring mostly in young men, is a histologically benign tumor with aggressive clinical behavior that includes repeated epistaxis and intractable nasal obstruction. This paper reviews our recent experience at National Taiwan University Hospital (NTUH), and compares the results with those of a previous study (1955-1980) at NTUH to highlight the developments in the treatment of NAF. Fifteen patients with a diagnosis of NAF from 1984 to 1997 were included, and their clinical presentations, radiographic studies, treatments, and outcomes were retrospectively analyzed. The results showed that the clinical and demographic features were similar in the two studies. The average number of patients decreased from 2.1 patients in the previous study to 1.1 patients in this study. The duration of symptoms in the current study (8 months) was shorter than that of the previous study (16 months). Previously, the treatment consisted of radiation followed by surgery if there was residual tumor. The current treatment modality is preoperative transarterial embolization followed by surgery. The estimated intraoperative blood loss was reduced from 750 mL in the first study to 400 mL in this study. The recurrence rate decreased from 11% to 7% and the absolute relapse-free rate rose from 56% to 73%. Owing to the development of modern imaging techniques, the advent of preoperative arterial embolization, and advances in surgical techniques, successful removal of highly vascular tumors has become more feasible. Preoperative selective embolization followed by excision is an effective treatment modality. This strategy, an alternative to radiotherapy, not only avoids the long-term complications induced by radiation, but also reduces the tumor recurrence rate.

Nasopharyngeal swab and PCR for the screening of nasopharyngeal carcinoma in the endemic area: a good supplement to the serologic screening

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a common head and neck cancer in Taiwan. Early detection is the best way to improve survival for this disease. A prospective study was designed to assess the feasibility of a new screening method for NPC by use of polymerase chain reaction (PCR) based on the close association of NPC and Epstein-Barr virus (EBV).

METHODS

One hundred thirty-three different tissues from nasopharynx, nose, and sinus were investigated by use of PCR to check for the presence of EBV genome. Subsequently, from April 1996 to March 1997, 55 patients were enrolled in a prospective screening study. All patients underwent nasopharyngeal swabs before biopsy. Polymerase chain reaction detection of EBV genome was conducted on swab samples. Anti-EBV viral capsid antigen (VCA) in IgA and IgG class were checked at the same visit.

RESULTS

The EBV genome was present in 91.4% (85/93) of NPC tissues and in 25.0% (10/40) of non-NPC tissues (p < .001, chi2 test). Of the 55 swabs, 49 (89.1%) specimens obtained enough cells for PCR examination. Thirty of these 49 patients were pathologically proved NPC. The presence of EBV were 86.7% (26/30) in NPC group and 42.1% (8/19) in non-NPC group. The sensitivity and specificity were 86.7% and 57.9%, respectively, which were similar to those of serologic method (87.5% and 43.5%) when the cut-off point was set at anti-VCA IgG > or = 160 and IgA > or = 10. Combining both methods elevates the specificity to 84.2%.

CONCLUSIONS

The sensitivity of this PCR screening method is similar to that of the serologic method. Combining both methods can greatly increase the specificity, indicating this new method is a good supplement to the serologic screening of this endemic disease.

Vascular pathology of malignant cervical lymphadenopathy: qualitative and quantitative assessment with power Doppler ultrasound

BACKGROUND

Malignant vascular pathology has traditionally been studied with invasive angiography or in vitro immunohistochemistry. The objective of this study was to investigate the vascular patterns and vascular density of benign and malignant cervical lymphadenopathy using power Doppler ultrasound combined with a computed quantitative image processing system.

METHODS

Investigations of 189 cervical lymph node lesions were undertaken prospectively using a 5-10 MHz linear array transducer in power mode. The types of vascular patterns displayed with power Doppler ultrasound, after sweep-scanning over the whole lymph node, were classified as hilar, spotted, peripheral, or mixed. Quantitative assessment of vascularity was made by sampling three parallel planes of each lymph node. A computed image processing system automatically calculated the density of vascular signals (called the "vascularity index" in this study) within the lymph node plane.

RESULTS

Malignant lymph node lesions were shown to have higher vascularity indices (0.169+/-0.147, P < 0.01). The vascular patterns of benign lesions were mostly of avascular or hilar type (in 83% of cases). Malignant lesions were characterized by patterns of mixed (47%), spotted (20%), or peripheral type (11%). When vascular pattern (nonhilar type) and vascularity index (maximum > or = 0.09) were combined, the specificity for diagnosing malignant lymphadenopathy was as high as 97%. Variance in tumor vascularity was noted in both the benign and malignant groups.

CONCLUSIONS

Power Doppler ultrasound combined with a computed image processing system provided an objective tool for assessing tumor vascularity quantitatively. Using this modality, the vascular pathology of malignant lymphadenopathy was found to be characterized by higher vascular density and aberrant vascular patterns.

Increased mutagen sensitivity in patients with head and neck cancer is less pronounced in patients with nasopharyngeal carcinoma

BACKGROUND

Mutagen sensitivity tested with bleomycin sulfate can determine a susceptible phenotype, which is relevant only in organs and tissues that have direct contact with the external environment. Patients with head and neck cancers have more mutagen sensitivity than control subjects without cancer, and the hypersensitive phenotype has a risk for the development of a second primary cancer. Head and neck cancers, however, represent a heterogeneous group of neoplasm. The biological behavior of nasopharyngeal carcinoma (NPC) and other head and neck cancers differs.

OBJECTIVE

To evaluate the difference in mutagen sensitivity among patients without cancer, patients with NPC, patients with oral or oropharyngeal cancer (ORC), and patients with laryngeal or hypopharyngeal cancer (LHC).

DESIGN

Peripheral blood was cultured at 37 degrees C, using 5% carbon dioxide, for 72 hours. After 67 hours of incubation, bleomycin in a concentration of 30 IU/L was added to induce chromatid breaks. The number of chromatid breaks per cell was scored in 50 metaphases of cultured lymphocytes and compared in the 4 groups.

SUBJECTS

Patients with histologically proven squamous cell carcinoma of the mucosa of the upper digestive tract, which included 3 groups: patients with NPC, patients with ORC, and those with LHC. Control subjects were hospital inpatients with no tumor history. There were 35 patients in each group.

RESULTS

The mean (+/-SD) number of breaks per cell in the control group and in the groups with NPC, ORC, and LHC were 0.80 (+/-0.32), 1.03 (+/-0.45), 1.30 (+/-0.44), and 1.35 (+/-0.46), respectively. All the cancer groups had significantly higher mean breaks per cell and a higher prevalence of hypersensitivity than the control group. Patients with NPC had a significantly lower mean number of breaks per cell than the group with ORC or that with LHC.

CONCLUSIONS

Patients with NPC had less mutagen sensitivity than those with ORC or LHC. Our results support the clinical and epidemiological findings of a difference between NPC and other head and neck cancers. Environmental factors might play a less pronounced role in the carcinogenesis of NPC.

CYP2E1 genetic polymorphisms and risk of nasopharyngeal carcinoma in Taiwan

BACKGROUND

Nasopharyngeal carcinoma occurs disproportionately among individuals of Chinese descent. The cytochrome P450 2E1 enzyme (CYP2E1) is known to activate nitrosamines and other carcinogens that are possibly involved in the development of this disease. Certain alleles of the CYP2E1 gene are thought to be more highly expressed than others, and their distribution varies between Asian and Caucasian populations. We conducted a case-control study to investigate whether such variations affect the risk of developing nasopharyngeal cancer.

METHODS

Three hundred sixty-four patients with nasopharyngeal carcinoma (96% of 378 eligible patients) and 320 control subjects (86% of 374 eligible subjects) were studied. A risk factor questionnaire was administered to participants to assess factors postulated to be linked to nasopharyngeal carcinoma. Peripheral blood was obtained from all subjects and DNA was purified from nucleated cells. A polymerase chain reaction-based restriction fragment length polymorphism assay that used the restriction enzymes Rsa I and Dra I was used to detect wild-type and variant forms of the CYP2E1 gene.

RESULTS

Individuals homozygous for an allele of the CYP2E1 gene that is detected by Rsa I digestion (c2 allele) were found to have an increased risk of nasopharyngeal carcinoma (relative risk [RR] = 2.6; 95% confidence interval [CI] = 1.2-5.7); this effect was limited to nonsmokers (RR = 9.3; 95% CI = 2.7-32) and was not affected by alcohol consumption.

CONCLUSIONS

Our findings suggest that the CYP2E1 genotype is a determinant of nasopharyngeal carcinoma risk.

Electrophysiological study of the connection between medial thalamus and anterior cingulate cortex in the rat

We characterized the neuronal properties of the anterior cingulate cortex (ACC) evoked by electrical stimulation of the medial thalamus (MT). MT stimulation sites were found by their neuronal responses to noxious stimuli. Of 487 units identified histologically in the rat ACC, 94% were activated trans-synaptically at different areas of the ACC. Six percent of MT-evoked ACC units were activated antidromically and all of these units projected to a specific nucleus of MT. We suggest that MT nuclei mediate different aspects of nociceptive information to specific ACC areas, and that nociceptive information in the MT is modulated reciprocally by activities from the ACC.

Undifferentiated carcinoma of the major salivary glands

BACKGROUND

Undifferentiated carcinoma of the salivary glands is a rare disease, the incidence of which is highest among the Inuit of Greenland and North America. It was demonstrated to be closely related to Epstein- Barr virus (EBV) infection. However, the relation of EBV to this tumor has not been studied to any great extent here in Taiwan because of the small number of cases.

METHODS

Twelve cases of undifferentiated carcinoma of the salivary glands from the period 1977-1996 were retrieved from the cancer registry at National Taiwan University Hospital. The clinical data were analyzed retrospectively based on the medical records. Eleven formalin fixed, paraffin embedded tissue sections were used for in situ hybridization with an antisense probe complementary to EBV-encoded RNA 1 (EBER1).

RESULTS

Ten of 12 tumors originated from the parotid gland and 2 from the submandibular gland. The patients' ages ranged from 22 to 63 years, with an average of 38.1 years. One patient was lost to follow-up, 2 patients died of metastatic disease, and the remaining 9 patients were all alive and disease free at last follow-up. The actuarial 5-year survival rate was 79.8%. In situ hybridization demonstrated EBER1 in 9 of the undifferentiated carcinomas with lymphoid stroma, but EBER1 was not demonstrated in the other 2 tumors without lymphoid stroma.

CONCLUSIONS

Undifferentiated carcinoma with lymphoid stroma of the major salivary glands is closely associated with EBV. The mainstay of treatment is surgery and postoperative radiotherapy. The outcomes in this series were good except for two elderly patients who died of rapid and progressive distant metastases.

Stretch-activated nonselective cation, Cl- and K+ channels in apical membrane of epithelial cells of Reissner's membrane

Ion channels on the apical membrane of epithelial cells (the surface facing the endolymph) of acutely isolated Reissner's membrane from guinea-pig cochlea were investigated by using patch-clamp technique in cell-attached and inside-out configurations. Three types of ion channel were identified: namely, a stretch-activated nonselective cation, a chloride and a potassium channel. When the pipette was filled with high-K+ endolymph-like solution, the most significant channel activity was nonselective cation channels (85/110, 77% patches). The current versus voltage relationship was linear with a unitary conductance of 22.1 +/- 0.4 pS and reversal potential (Vr) of 2.3 +/- 0.8 mV (n = 18). The channel exhibited a lower conductance (14.0 +/- 0.6 pS, n = 8) to Ca2+. The open probability was low (NPo approximately 0.1) in cell-attached configuration under +60 mV pipette potential and increased when the membrane was stretched with negative pressure. The channel was blocked by 10 microM extracellular Gd3+. The two other types of channels were a small voltage-sensitive Cl- channel (6.0 +/- 0.3 pS; 91/99, 92% patches) and a K+ channel (approximately 30 pS; 29/191, 15% patches). These channels might play roles in the regulation of cell volume, in balancing the hydrostatic pressure across Reissner's membrane and in maintaining the electrochemical composition of endolymph.

Evaluation of multiple antibodies to Epstein-Barr virus as markers for detecting patients with nasopharyngeal carcinoma

Five serological tests were assessed for their sensitivity for screening and early detection of nasopharyngeal carcinoma (NPC). The tests included the detection of antibodies to various gene products of EBV: viral capsid antigen (VCA) using an indirect immunofluorescence assay (FA), DNase using an activity neutralisation test (NT), Dnase using an enzyme-linked immunosorbent assay (ELISA), DNA polymerase (DP) using NT, and major DNA binding protein (MDBP) by ELISA. Sera from 100 NPC outpatients and 20 NPC patients, who were detected in a prospective study, were examined. The results showed that levels of antibody to DNase detected by ELISA and to DP detected by NT and the positivity rate for VCA by FA increased with NPC stage. More species of EBV antibody became detectable as NPC progressed. The detection of anti-MDBP antibody by ELISA was suitable for screening for NPC. Anti-DP antibody detected by NT was a valuable marker both for early detection and prognosis of NPC. Detection of anti-DNase antibody by ELISA was the most sensitive method for detection of NPC. No single test was sufficient to detect all the NPC patients and a combination of anti-DNase by ELISA with other tests are recommended to identify NPC patients.

Clonal versus polyclonal Epstein-Barr virus infection in nasopharyngeal carcinoma cell lines

In most nasopharyngeal carcinoma (NPC) biopsy specimens, the Epstein-Barr virus (EBV), particularly in the terminal repeat region genomic structure, reveals a clonal pattern. To evaluate this phenomenon in vitro, we infected EBV-negative NPC cell lines, which express secretory component (SC) protein on their cell surface, with EBV particles. The viral particles were obtained either from a subcloned single cell or from the original B95-8 cell line. EBV infection was performed by incubating IgA anti-EBV and EBV particles with NPC cells and confirmed by direct in situ PCR hybridization. Southern blot analysis of EBV terminal repeat in EBV-infected NPC cell lines was performed using a Xhol 1.9-kb DNA fragment from the right terminus of the EBV genome as a probe. We found that all four NPC cell lines (ie, NPC-TWO1; 03, 04, and 06) expressed SC protein on their surfaces and could be infected by EBV through the EBV IgA-SC complex. Southern blot analysis in the single cell-subcloned B95-8 cell line showed a clonal EBV terminal repeat with a higher molecular size; whereas the original B95-8 line revealed the polyclonal EBV DNA pattern. A similar clonal EBV genomic pattern with lower molecular size was seen in all EBV-infected NPC cell lines. For comparison, six NPC biopsy specimens were also examined; of these, five showed a single band, and the remaining showed one major band and several lower molecular-sized bands. The EBV genomic DNA in the infected cells was shown to be an episomal form. We conclude, therefore, that a single (clonal) form of EBV genome can be obtained from a mixed population of epithelial tumor cells, even when they are infected by multiple virions with single or multiple form(s) of the EBV genomic pattern.

Salvage surgery for recurrent nasopharyngeal carcinoma

OBJECTIVE

To assess the efficacy of salvage surgery for patients with recurrent nasopharyngeal carcinoma (NPC) at the primary site after radiotherapy.

DESIGN

Retrospective analysis of 24 patients treated by transpalatal, transmaxillary, or transmandibular approach to resect the recurrent tumor, with maximum follow-up of 50 months.

SETTING

Academic tertiary referral center.

RESULTS

Radiotherapy before salvage surgery included 1 to 3 courses of radiation to the nasopharynx, with doses ranging from 60 to 190 Gy. Eighteen (75%) of the patients relapsed within 2 years, and 6 (25%) relapsed more than 6 years after the last irradiation. In 4 of 6 late-relapsing cases, the histopathological type changed to keratinizing squamous cell carcinoma, which is rare in cases of NPC in Taiwan. Fourteen patients (58%) survived for 8 to 50 months after surgery (median, 18 months). The surgical complications were tolerable.

CONCLUSIONS

Salvage surgery is feasible in selected patients with recurrent disease at the primary site. Thus, we can offer alternative retreatment in addition to external irradiation for patients with recurrent NPC.

Postirradiation laryngeal osteosarcoma: case report and literature review

BACKGROUND

Laryngeal sarcoma is a rare disease entity. In review of the literature, chondrosarcoma is the most common sarcoma, followed by fibrosarcoma. Osteosarcoma is very rare; there are only seven cases reported in the literature. Postirradiation sarcoma is a late complication of radiotherapy. Osteosarcoma is the most common type in this group. The larynx is often involved in the radiation field of treatment for head and neck malignancies. However, postirradiation laryngeal osteosarcoma has not yet been reported.

METHODS

We present a 56-year-old man who under went radiotherapy for nasopharyngeal carcinoma 32 years ago and later developed a laryngeal osteosarcoma.

RESULTS

The patient underwent total laryngectomy but died 1 year and 9 months later with locally extensive disease.

CONCLUSIONS

We report the first case of postirradiation laryngeal osteosarcoma. In addition to surgical treatment, adjunctive therapies should be considered for this group of patients.

Characterization and relative abundance of maxi-chloride channels in Epstein-Barr virus (EBV) producer: B95-8 cells

Several Epstein-Barr virus (EBV)-transformed cell lines were used to investigate the pathogenesis of lymphoproliferative diseases and nasopharyngeal carcinoma. The studies focus on the events occurring inside the membrane. On only one occasion, the cell membrane of EBV-transformed B lymphocytes from a cystic fibrosis patient was found to express defective Cl channels (CFTR; Cystic Fibrosis Transmembrane conductance Regulator), as in the airway epithelial cell. No other type of channel in EBV-transformed cells has so far been investigated. In this study, the cell membrane of the B95-8 cell was examined by the patch-clamp technique and compared to the non-EBV-infected BJAB cell. The high conductance (approximately 300 pS) maxi-chloride (Cl) channel activity was the most frequently observed event in inside-out configurations. Under similar experimental conditions, we have found a significantly higher probability of detecting maxi-Cl channel activity on the cell membrane of B95-8 cells (69%) than on BJAB cells (27%), or as previously reported on resting murine B lymphocytes (38%) or intact human T lymphocytes (37%). The relative abundance of the maxi-Cl channel on B95-8 cells may be linked to EBV infection and/or secretory ability.

Radiation-induced malignant fibrous histiocytoma in patients with nasopharyngeal carcinoma

OBJECTIVE

To evaluate the prevalence, 15-year cumulative incidence, time interval, and prognosis of radiation-induced malignant fibrous histiocytoma of the head and neck in long-term survivors of nasopharyngeal carcinoma.

DESIGN

Cohort.

SETTING

Tertiary care hospital.

PATIENTS

Eight long-term survivors of nasopharyngeal carcinoma with malignant fibrous histiocytoma in the maxillary sinus or nasal cavity.

MAIN OUTCOME MEASUREMENT

Survival of postirradiation malignant fibrous histiocytoma in patients with nasopharyngeal carcinoma.

RESULTS

The prevalence of radiation-induced malignant fibrous histiocytoma in long-term survivors of nasopharyngeal carcinoma was 0.38%. The 15-year cumulative incidence was 2.2%. Most tumors occurred in the maxillary sinus and were characterized by spindle-shaped tumor cells with plump nuclei arranged in a whorl or storiform pattern in a fibrous stroma. The mean interval between malignant fibrous histiocytoma and nasopharyngeal carcinoma was 121 months. Local recurrence developed in all cases within 9 months after surgery. Six patients died of disease without distant metastasis within 30 months. Two patients were alive with disease for 20 and 32 months, respectively.

CONCLUSIONS

Radiation-induced malignant fibrous histiocytoma in the head and neck region in long-term survivors of nasopharyngeal carcinoma is rare. It takes a long time to occur after irradiation and is locally invasive with poor prognosis.

[Sequence analyses of Epstein-Barr virus (EBV) Bam HI F DNA fragment in EBV associated diseases]

In order to compare nucleotide differences of Epstein-Barr virus (EBV) Bam HI F DNA fragment from various EBV associated diseases, polymerase chain reactions (PCR) were used to amplify a subfragment (nucleotides 55,381-56,020) of the F fragment from different tissue DNAs, including 20 NPCs, 2 B-cell lymphomas, 2 T-cell lymphomas, 3 infectious mononucleosis (IM), and 3 normal controls. DNA sequences were determined by PCR direct sequencing or sequencing after DNA cloning. The PCR products were cloned into pGEM-3Z vector, then the resulting recombinant plasmids were used to transform DH5 alpha competent cells. Plasmid DNAs from the correct transformants were prepared for DNA sequencing. The results showed that the proportion of the f variant in NPCs, B-cell lymphomas, T-cell lymphomas, IMs, and normals were 40%, 0%, 0%, 33%, and 33%, respectively. Because the f variant was not specifically more prevalent in NPC tissues compared to the non-tumor tissues, we speculate that there is no strong association between the f variant and NPC. These results were different from other reports. Coinfection of the F strain and the f variant was found both in some NPC patients and normal individuals. Analyses of Bam HI F subfragments of 35 EBV isolates from the 30 tissue DNAs revealed that there were changes at four corresponding positions of the B95-8 strain. They were nucleotide T at 55,473 replaced by G, an insertion of TGT after nucleotide 55,543, nucleotide A at 55,564 replaced by G, and nucleotide T at 55,958 replaced by C. These 4 nucleotide changes may confer a character of Taiwan strains. The nucleotides of the F strain at coordinates 55,519, 55,596, 55,680, 55,703, and 55,895 were T, T, A, A, and C, and those for the f variant were C, C, C, C, and T. These two patterns were not correlated with types A and B of EBV.

Differential expression of EBER1 in nontumor nasopharyngeal biopsies and nontumor component of nasopharyngeal carcinoma

The close association of Epstein-Barr virus (EBV) and nasopharyngeal carcinoma (NPC) is well documented and the expression of EBV-related latent genes has been shown in NPC. Nevertheless, the status of EBV infection in the nontumor epithelial and lymphoid cells is not known. In this study, we detected EBV in the nontumor component of NPC and nontumor nasopharyngeal biopsies by in situ hybridization using digoxigenin-labeled antisense EBER1 oligoprobe in 346 nasopharyngeal biopsies. Latent membrane protein (LMP) and ZEBRA were detected by immunohistochemistry in cases containing EBER1-positive cells. The EBV-positive epithelial and lymphoid cells were identified by immunostains for cytokeratin and lymphoid phenotypes. In the nontumor nasopharyngeal biopsies, 21 (11.7%) of 179 cases had EBV-harboring lymphocytes in the lymphoid tissue, while the overlying mucosa was all negative. LMP was demonstrated in lymphoid cells of 14 (66.7%) of these 21 samples. These EBV-positive lymphocytes were B lymphocytes by combined phenotype study. EBER1-containing metaplastic squamous cells were demonstrated in the overlying mucosa close to the tumor tissue in 14 (8.4%) of 167 NPC samples. In contrast, the respiratory epithelial cells in these cases were all negative. Two (1.2%) of these cases had EBV-positive lymphocytes in the lymphoid stroma. Four of the 346 cases had ZEBRA-positive cells. This study demonstrated that latent infection and, occasionally, active replication of EBV were present in stromal B lymphocytes in nasopharyngeal tissue with and without NPC. EBER1 was found only in the metaplastic squamous cells in the mucosa of nasopharyngeal tissues with NPC, but not in those without NPC.

Nasopharyngeal carcinoma with dermatomyositis. Analysis of 12 cases

OBJECTIVES

To evaluate the incidence rate of nasopharyngeal carcinoma with dermatomyositis, the influence of dermatomyositis on clinical course, and complications and survival of patients with nasopharyngeal carcinoma after radiotherapy.

DESIGN

A retrospective study of 12 patients with nasopharyngeal carcinoma associated with dermatomyositis, with a maximum follow-up of 228 months.

SETTING

Academic tertiary referral center.

PATIENTS

There were 6441 new patients with nasopharyngeal carcinoma who were seen at the National Taiwan University Hospital, Taipei, during the period from 1970 through 1993. Twelve patients were found to have dermatomyositis.

MAIN OUTCOME MEASURE

Clinical manifestations of nasopharyngeal carcinoma with dermatomyositis.

RESULTS

Twenty-seven (26%) of 104 patients with dermatomyositis had an associated malignancy. Twelve of these patients were diagnosed as having nasopharyngeal carcinoma. The typical skin manifestation of dermatomyositis was found in all 12 patients. Myopathy occurred in 10 patients. Three patients died of recurrence of nasopharyngeal carcinoma, one died of a second malignancy, one died of upper gastrointestinal bleeding, and one became unavailable for follow-up. The other six patients have had disease-free survival, with a mean follow-up period of 100.5 months (range, 5 to 228 months). The 1-year survival rate was 83.8%, and the 5-year survival rate was 69.4%.

CONCLUSIONS

In Taiwan, dermatomyositis is associated with an increased incidence rate of nasopharyngeal carcinoma. A search for nasopharyngeal carcinoma in patients with dermatomyositis should be performed in areas prevalent for nasopharyngeal carcinoma. If present, nasopharyngeal carcinoma can precede, occur concurrently with, or follow the diagnosis of dermatomyositis. Treatment of nasopharyngeal carcinoma may affect myositic or cutaneous disease. The prognosis and survival rates of nasopharyngeal carcinoma remained unaffected by dermatomyositis. No complications were noted owing to the radiotherapy used to treat dermatomyositis.

Cytochrome P4502E1 genetic polymorphisms and risk of nasopharyngeal carcinoma: results from a case-control study conducted in Taiwan

CYP2E1 is responsible for the metabolic activation of nitrosamines believed to be involved in the pathogenesis of various tumors. Nasopharyngeal carcinoma (NPC) is a tumor thought to be linked to nitrosamine exposure. To investigate the possible role of CYP2E1 genetic polymorphisms in the etiology of this tumor, we investigated 50 histologically confirmed NPC cases from Taiwan and 50 controls matched to cases on age, sex, and residence. Samples were examined for RFLPs in the CYP2E1 gene by PCR amplification followed by digestion with DraI and RsaI. Among healthy controls, the allelic frequency of wild-type and variant forms of CYP2E1 were 79 and 21%, respectively, using DraI enzyme digestion and 82 and 18%, respectively, using RsaI enzyme digestion. As compared with individuals who were homozygous for the wild-type CYP2E1 gene, those found to be homozygous for the variant form of the gene by DraI digestion were at a 5-fold excess risk of disease (95% confidence interval = 0.95-16). Similarly, subjects homozygous for the variant form of the CYP2E1 gene by RsaI digestion were at 7.7-fold excess risk of developing NPC (95% confidence interval = 0.87-68). Individuals found to be heterozygous for the gene were at similar risk of disease compared to those homozygous for the wild-type gene. A strong association was observed between the RFLPs detected by DraI and RsaI digestion of CYP2E1; a correlation coefficient of 0.86 for controls and 0.91 for cases was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Eustachian tube function of patients with nasopharyngeal carcinoma

Prolonged observations of the eustachian tube (ET) function were made on 40 ears of 20 patients with nasopharyngeal carcinoma (NPC) who survived more than 5 years after radiotherapy in a state of remission. The ET function tests included passive opening, inflation-deflation, and clearance, and were performed before, at 6 months, and at 5 years after radiotherapy. The test results were found to be worst at 6 months after radiotherapy and improved at 5 years after radiotherapy. Tubal obstruction and inflammation are the main causes of the ET malfunction that results in otitis media with effusion (OME) in NPC patients after radiotherapy. Insertion of a ventilation tube into the ear with OME can relieve tubal obstruction but can aggravate inflammation. Thus, myringotomy and aspiration of effusion and local treatment may be preferable to insertion of a ventilation tube in NPC patients with OME. When hearing improvement in prolonged survival of NPC patients with OME is needed, the use of amplification is recommended.