Depression literacy and health-seeking attitudes in the Western Pacific region: a mixed-methods study

PURPOSE

Depression literacy refers to the ability to recognize depression and make informed decisions about its treatment. To date, relatively little research has been done to examine depression literacy in the Western Pacific region. Given the pervasiveness of depression and the need to enhance mental health care in this region, it is important to gain a better understanding of depression literacy and health-seeking behaviors in this part of the world.

METHODS

This mixed-methods study utilized a convergent parallel design to examine depression literacy and the associated health-seeking attitudes among urban adults from three countries-Cambodia, Philippines, and Fiji. A total of 455 adults completed a quantitative survey on depression knowledge, attitudes, and professional help seeking. Separately, 56 interviewees from 6 focus groups provided qualitative data on their impression and knowledge of depression and mental illness within the context of their local communities.

RESULTS

Overall, results showed that depression knowledge was comparatively lower in this region. Controlling for differences across countries, higher knowledge was significantly associated with more positive attitudes towards mental illness (B = - 0.28, p = 0.025) and professional help seeking (B = 0.20, p < 0.001). Financial stability, such as employment, was also a salient factor for help seeking.

CONCLUSIONS

This study was the first to provide a baseline understanding on depression literacy and highlights the need to increase public knowledge on depression in the Western Pacific. Culturally congruent recommendations on enhancing depression literacy in this region, such as anti-stigma campaigns, use of financial incentives, and family-based approach in health education, are discussed.

Correction to: Depression literacy and health-seeking attitudes in the Western Pacific region: a mixed-methods study

In the original publication of this article, Acknowledgements Section was not included. The Acknowledgements are given below. The original article has been corrected.

Shear Wave Elastography--A New Quantitative Assessment of Post-Irradiation Neck Fibrosis

PURPOSE

Shear wave elastography (SWE) is a new technique which provides quantitative assessment of soft tissue stiffness. The aim of this study was to assess the reliability of SWE stiffness measurements and its usefulness in evaluating post-irradiation neck fibrosis.

MATERIALS AND METHODS

50 subjects (25 patients with previous radiotherapy to the neck and 25 sex and age-matched controls) were recruited for comparison of SWE stiffness measurements (Aixplorer, Supersonic Imagine). 30 subjects (16 healthy individuals and 14 post-irradiated patients) were recruited for a reliability study of SWE stiffness measurements. SWE stiffness measurements of the sternocleidomastoid muscle and the overlying subcutaneous tissues of the neck were made. The cross-sectional area and thickness of the sternocleidomastoid muscle and the overlying subcutaneous tissue thickness of the neck were also measured. The post-irradiation duration of the patients was recorded.

RESULTS

The intraclass correlation coefficients for the intraoperator and interoperator reliability of deep and subcutaneous tissue SWE stiffness ranged from 0.90-0.99 and 0.77-0.94, respectively. The SWE stiffness measurements (mean +/- SD) of deep and subcutaneous tissues were significantly higher in the post-irradiated patients (64.6 ± 46.8 kPa and 63.9 ± 53.1 kPa, respectively) than the sex and age-matched controls (19.9 ± 7.8 kPa and 15.3 ± 8.37 respectively) (p < 0.001). The SWE stiffness increased with increasing post-irradiation therapy duration in the Kruskal Wallis test (p < 0.001) and correlated with muscle atrophy and subcutaneous tissue thinning (p < 0.01).

CONCLUSION

SWE is a reliable technique and may potentially be an objective and specific tool in quantifying deep and subcutaneous tissue stiffness, which in turn reflects the severity of neck fibrosis.

Non-surgical treatment of lung cancer: personalised stereotactic ablative radiotherapy

Stereotactic ablative radiotherapy has emerged as a standard treatment for medically inoperable stage I non-small-cell lung cancer and selected cases of lung metastasis. Techniques to freeze or limit tumour movement during treatment and image-guided radiation delivery are integral to a successful stereotactic ablative treatment without overdose of surrounding normal structures. In this article, the practice in a local oncology institution will be used to illustrate the concept of personalised stereotactic ablative radiotherapy.

Plasma Epstein-Barr viral DNA load at midpoint of radiotherapy course predicts outcome in advanced-stage nasopharyngeal carcinoma

BACKGROUND

To test the hypothesis that prognostication of treatment outcome is feasible by biomarker response at midcourse of chemoradiotherapy (CRT)/radiotherapy (RT), with respect to the plasma load of Epstein-Barr viral (EBV) DNA in nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

One hundred seven patients with stage IIB-IV NPC were prospectively studied. Plasma EBV DNA load was measured by quantitative PCR before therapy (pre-DNA), at completion of 4 weeks of CRT/RT (mid-DNA), and within 3 months of completion of therapy (post-DNA). The end points are post-DNA load, a recognized surrogate of survival, and clinical outcome.

RESULTS

Ninety-three percent of patients had detectable EBV DNA before therapy (median load = 972 copies/ml). EBV DNA became undetectable in 55 (51%) patients at the end of week 4 of therapy. Detectable mid-DNA was associated with worse clinical outcome (median follow-up time, 6.2 years), for distant failure [hazard ratio (HR) 12.02, 95% confidence interval (CI) 2.78-51.93; P < 0.0001], progression-free survival (PFS; HR 4.05, 95% CI 1.89-8.67, P < 0.0001), and overall survival (OS; HR 3.29, 95% CI 1.37-7.90, P = 0.0077). Seventy-four percent of all failures were associated with detectable mid-DNA, whereas 34% of all failures were associated with detectable post-DNA. Stratification by tumor stage (IIB, III, IV) has no significant prognostic effect.

CONCLUSIONS

Unfavorable EBV DNA response at midcourse of RT/CRT is an adverse prognosticator for treatment outcome, is linked to majority of all failures, and discriminates outcome better than tumor stage. The data could provide a basis for trial design that addresses alteration of therapy intensity during the latter phase of CRT, and adjuvant therapy. Validation studies are awaited.

Abstract B273: Multicenter Phase II study of MK-2206 in previously treated patients (pts) with recurrent and metastatic nasopharyngeal carcinoma (NPC): Mayo Clinic Phase II Consortium (Protocol: MC1079)

Background: NPC is endemic to Asia and over 40% of cases harbor PIK3CA amplification. MK2206 is an allosteric AKT inhibitor with activity in NPC in vitro.

Methods: Pts who had progressed after palliative chemotherapy (chemo) for metastatic or recurrent NPC, received oral MK-2206 at 200 mg on Days 1, 8, 15 & 22 of each 28-day cycle until disease progression. Plasma samples were collected at serial time points during cycle 1 for EBV DNA analysis, archived tumor samples were collected where feasible. The primary dual endpoints (2-stage design) consisted of RECIST-defined tumor response rate (RR) and 6-month (m) progression-free survival (PFS) rate. Secondary endpoints were overall survival (OS), PFS and adverse events (AEs).

Results: Of the 21 pts enrolled, the median age was 47 years (range: 32-67), 91% were male, 81% had prior radiotherapy and 81% had &gt; 1 prior line of palliative chemo. At the time of analysis, 20 out of 21 pts have ended treatment. The best responses were: 1 partial response (PR, 5%) lasting 4 ms; 10 stable disease (SD, 50%), 9 progressive disease (PD, 45%). The 6-m PFS rate was 38.9% (95% CI: 18.1-59.3%) and median PFS was 2.7 ms (95% CI: 0.9-7.2 ms). The 6-m OS rate was 67.9% (95% CI: 41.8-84.1%) and median survival has not been reached. In 7 pts who had SD more than or equal to 6 ms, the duration of treatment ranged from 6.4-13.9 ms. Of the 21 pts evaluable for AEs, 12 pts (57%) had at least one grade 3 AE [[Unable to Display Character: &#8211;]] macular rash (6 pts - 29%), dysphagia (2 pts - 10%), hyperglycemia (2 pts - 10%) (see Table 1). The tumor samples of 7 pts were analyzed by FISH; 3 showed PIK3CA amplification, including 1 pt with chromosome 3 polysomy. Amongst these pts, 1 had SD more than 6ms, 1 had SD more than 12 ms, and 1 is still on treatment. Pts who had SD less than 6 m or PD did not have PIK3CA amplification.

Conclusions: MK2206 is well tolerated and has signs of activity in unselected pts with NPC. Preliminary results suggest that PIK3CA amplification may be related to prolonged disease stabilization from MK2206, and analysis for other PIK3CA gene alterations in more samples will be undertaken. Result of the plasma EBV DNA result will be presented.

Prognostication of survival from nasopharyngeal carcinoma by reduction of plasma Epstein-Barr viral DNA load at midpoint of radiotherapy course: A new paradigm of prognostication

6015

Background: To test the hypothesis that prognostication of treatment outcome is feasible by biomarker response at mid-course of chemoradiotherapy (CRT)/ radiotherapy (RT), with respect to the plasma load of Epstein-Barr viral (EBV) DNA in nasopharyngeal carcinoma (NPC). Methods: 107 patients with stage IIB-IV NPC were prospectively studied. Plasma EBV DNA load was measured by quantitative PCR before therapy (pre-DNA), at completion of 4 weeks of CRT/RT (mid-DNA), and within 3 months of completion of therapy (post-DNA). The endpoints are post-DNA load, a recognized surrogate of survival, and clinical outcome. Results: 93% of patients had detectable EBV DNA before therapy (median load = 972 copies/ml). EBV DNA became undetectable in 55 (51%) patients at the end of week 4 of therapy. Detectable mid-DNA was associated with worse clinical outcome (median follow-up time, 6.2 years), for distant failure (HR 12.02, 95% CI 2.78-51.93; P<0.0001), progression-free survival (HR 4.05, 95% CI 1.89-8.67, P<0.0001), and overall survival (HR 3.29, 95% CI 1.37-7.90, P=0.0077). About three-quarters of all failures were associated with detectable mid-DNA, whereas about one-third of all failures were associated with detectable post-DNA. Patients with detectable mid-DNA which disappeared after RT continued to sustain a less favourable prognosis than those with undetectable mid-DNA. Stratification by tumor stage (II, III, IV) has no significant prognostic effect. Conclusions: Unfavorable EBV DNA response at mid-course of radiotherapy/chemoradiotherapy is an adverse prognosticator for treatment outcome, is linked to majority of all failures, and discriminates outcome better than tumor stage. The data could provide a basis for trial design that addresses alteration of therapy intensity during the latter phase of chemoradiotherapy, and adjuvant therapy.

The volumetric relationship of white matter lesion and contrast-enhanced lesion in delayed radiation brain injury: an MRI-based study

PURPOSE

This study investigated the volumetric relationship of white matter lesion (WML) and contrast-enhanced lesion (CEL) in delayed radiation brain injury (RBI) during the course of evolution.

MATERIALS AND METHODS

MRI results in 45 patients with RBI after receiving radiation for nasopharyngeal carcinoma were analyzed. In total there were 75 lobes with RBI and 114 MRI examinations in this study. WML and CEL lesion volumes were measured. The lesion volume change of less than 5% or 0.25 cm(3) was regarded as being static.

RESULTS

The average WML volume was 16.33 cm(3) (ranging 0.11 cm(3) to 102.83 cm(3)), and the average CEL volume was 3.15 cm(3) (ranging 0.03 cm(3) to 27.85 cm(3)). WML was larger than CEL in 164 measurements, and CEL was larger than WML in 10 measurements. In 64.3% follow-ups WML and CEL evolved in the same pattern; and in most follow-ups (93.8%) WML and CEL did not evolve in the opposite directions. A larger WML volume tended to have a larger CEL volume though this relationship was not linear.

CONCLUSION

Evolution of WML and CEL tended to follow the same pattern. WML tended to be larger than CEL, and larger WML tended to be associated with larger CEL.

Angiographic features, collaterals, and infarct topography of symptomatic occlusive radiation vasculopathy: a case-referent study

BACKGROUND AND PURPOSE

Occlusive radiation vasculopathy (ORV) predisposes head-and-neck cancer survivors to ischemic strokes.

METHODS

We analyzed the digital subtraction angiography acquired in 96 patients who had first-ever transient ischemic attack or ischemic strokes attributed to ORV. Another age-matched 115 patients who had no radiotherapy but symptomatic high-grade (>70%) carotid stenoses were enrolled as referent subjects. Digital subtraction angiography was performed within 2 months from stroke onset and delineated carotid and vertebrobasilar circulations from aortic arch up to intracranial branches. Two reviewers blinded to group assignment recorded all vascular lesions, collateral status, and infarct pattern.

RESULTS

ORV patients had less atherosclerotic risk factors at presentation. In referent patients, high-grade stenoses were mostly focal at the proximal internal carotid artery. In contrast, high-grade ORV lesions diffusely involved the common carotid artery and internal carotid artery and were more frequently bilateral (54% versus 22%), tandem (23% versus 10%), associated with complete occlusion in one or both carotid arteries (30% versus 9%), vertebral artery (VA) steno-occlusions (28% versus 16%), and external carotid artery stenosis (19% versus 5%) (all P<0.05). With comparable rates of vascular anomaly, ORV patients showed more established collateral circulations through leptomeningeal arteries, anterior communicating artery, posterior communicating artery, suboccipital/costocervical artery, and retrograde flow in ophthalmic artery. In terms of infarct topography, the frequencies of cortical or subcortical watershed infarcts were similar in both groups.

CONCLUSIONS

ORV angiographic features and corresponding collaterals are distinct from atherosclerotic patterns at initial stroke presentation. Clinical decompensation, despite more extensive collateralization, may precipitate stroke in ORV.

A multicenter randomized controlled trial (RCT) of adjuvant chemotherapy (CT) in nasopharyngeal carcinoma (NPC) with residual plasma EBV DNA (EBV DNA) following primary radiotherapy (RT) or chemoradiotherapy (CRT)

5511

Background: The benefit of adjuvant CT in NPC is unclear. Administering CT after full-dose CRT presents challenges in treatment compliance and toxicity. Post-RT EBV DNA predicts poor survival and may be a biomarker of subclinical residual disease. We conducted a biomarker driven RCT using EBV DNA to select high risk NPC patients (pts) for adjuvant CT while sparing low risk pts from unnecessary toxicity. Methods: Biopsy proven NPC, AJCC stage IIB-IVB, detectable EBV DNA at 6-8 wks post-RT, no persistent locoregional disease or distant metastasis, ECOG 0 or 1, adequate organ function. Randomised with stratification for primary therapy (RT Vs CRT) and tumor stage (II/III Vs IV) to arm A (adjuvant cisplatin 40 mg/m2 and gemcitabine 1000mg/m2, both given on D1+8 q3w x 6 cycles) or arm B (clinical follow-up). EBV DNA and PET scan were performed before and 6 months after randomization. Primary endpoint was relapse free survival and secondary endpoints included toxicity of adjuvant CT. With a hazard ratio of 2, 100 pts were required with a power of 0.8 and an alpha at 0.05. This safety analysis was approved by DMSC. Results: From 9/2006 to 12/2011, 514 pts consented for EBV DNA screening, 95 with detectable EBV DNA consented for adjuvant study. After work-up, 74 were eligible for randomization (37 to arm A; 37 to arm B). The two arms were well balanced in baseline characteristics. 80% received prior neoadjuvant and/or concurrent CT. Staging: IIB (36.5%), III (29.7%), IVA (18.9%), IVB (14.8%). Five pts refused adjuvant CT after randomization. Overall 65% and 57% completed 5 and 6 cycles respectively. Mean dose intensity (DI): 84% for cisplatin (22.5 mg/m2/wk, range 0.0-26.7), 92% for gemcitabine (612.8 mg/m2/wk, range 333.3-777.8). Treatment related adverse events above CTC G2 were summarized in Table. Conclusions: Delivery of 6 cycles of adjuvant CT is feasible with acceptable toxicity after full dose RT or CRT. [Table: see text]

The impact of image-guided radiotherapy (IGRT) for prostate cancer (PC) on radiotherapy (RT)-related acute toxicities and prostate-specific antigen (PSA) kinetics

e15110

Background: IGRT for PC could potentially improve the therapeutic ratio by enhancing accuracy of delivery of radiation to the prostate gland. Our aim is to compare the treatment outcomes in terms of RT-related acute toxicities and PSA kinetics of PC patients (pts) undergoing radical intensity-modulated radiotherapy (IMRT) with or without image-guidance. Methods: A cohort of 21 consecutive pts treated by IGRT (I) from January 2010, when the IGRT system was introduced in our institution, was compared with an immediately precedent cohort of 21 pts receiving IMRT without image-guidance (Non-I). The prescription dose (76Gy in 38 fractions) and the treatment margins were the same between the 2 groups (gps). In the I gp, daily online verification and correction of treatment position was performed with reference to image registration of the daily pre-treatment on-board imaging with the corresponding digitally reconstructed radiographs, based on three-dimensional matching of three intra-prostatic fiducial markers. Androgen deprivation therapy was not used in both gps. Acute toxicities were scored weekly during the course of RT according to the Common Terminology Criteria for Adverse Events Version 4.02. The pre- and the post-RT PSA within 6 months after completion of RT were obtained. The PSA halving time (PSAHT) was calculated by first order kinetics. Results: There was no statistically significant difference regarding the baseline clinical characteristics (age, PSA at diagnosis, Gleason score, T staging) between the gps. No grade 3 or 4 acute genitourinary (GU) or gastrointestinal (GI) toxicities was encountered in either gps. Acute grade 1 or 2 GI toxicities were significantly less frequent in the I gp (23.8% vs 81.0%, p=0.001), and their median duration of such toxicity were also significantly shorter (0.33 week vs 1.38 week, p=0.004).The frequencies of acute grade 1 or 2 GU toxicities were comparable between both gps (66.6% vs 81.0%, p=0.45).The I gp had a shorter median PSAHT than the non-I gp (3.36 week vs 5.49 week, p=0.09). Conclusions: IGRT is effective in reducing acute GI toxicities in treatment of PC, and may have more favorable PSA kinetics.

A phase II study of concurrent cetuximab-cisplatin and intensity-modulated radiotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Based on our previous work on the clinical activity of cetuximab in recurrent nasopharyngeal carcinoma (NPC), we evaluated the feasibility of adding cetuximab to concurrent cisplatin and intensity-modulated radiotherapy (IMRT) in locoregionally advanced NPC.

PATIENTS AND METHODS

Patients with American Joint Committee on Cancer stage III-IVB NPC were given an initial dose of cetuximab (400 mg/m(2)) 7-10 days before receiving concurrent IMRT, weekly cisplatin (30 mg/m(2)/week) and cetuximab (250 mg/m(2)/week).

RESULTS

Thirty patients (median age of 45 years) with stage III (67%), IVA (30%) and IVB (3%) nonkeratinizing NPC were enrolled. Grade 3-4 oropharyngeal mucositis occurred in 26 (87%) patients and 10 (33%) patients required short-term nasogastric feeding. Grade 3 radiotherapy-related dermatitis occurred in six patients (20%) and three patients (10%) had grade 3 cetuximab-related acneiform rash. These grade 3-4 skin and mucosal toxic effects were manageable and reversible. At a median follow-up of 31.8 months [95% confidence interval (CI) 26.2-32.1 months], the 2-year progression-free survival was 86.5% (95% CI 74.3% to 98.8%).

CONCLUSIONS

Concurrent administration of cetuximab, weekly cisplatin and IMRT is a feasible strategy against locoregionally advanced NPC. Preliminary survival data compare favorably with historic data and further follow-up is warranted.

Differences in perceptions of coronary disease among Hong Kong Chinese: implications for the societal readiness in disease prevention

Perceptions of coronary heart disease (CHD) influence individual health behavior, which is central to preventing the disease. Not enough is known about the demographic differences in perceptions of CHD among Chinese communities. This study examined these differences in the perceived seriousness and risk of CHD among Hong Kong Chinese. A self-developed questionnaire was administered to a convenient sample (n = 236). Significant differences were identified in the perceived seriousness and risk of CHD between younger and older age groups (p < 0.001) and groups with lower and higher education levels (p < 0.001), but not between genders (p > 0.05). Over 50% of participants expressed greater concern about infectious disease than about CHD, while two-thirds to over half of female, older, and less educated participants were more concerned about stroke. This study highlighted populations with lower levels of CHD perception that need increased public education. The findings have implications for the societal readiness to establishing ongoing public healthcare strategies to increase awareness of CHD.

Abstract 195: Functional epigenetics identifies a protein phosphatase-1 regulatory subunit gene as a candidate tumor suppressor frequently silenced by promoter CpG methylation in multiple tumors

Protein Phosphatase 1 regulatory subunits (PPP1R) are a family of small molecules which modify the function and protein targeting of protein phosphatase-1 upon their interactions. Deregulated expression of PPP1R members could often be found in cancer cells. For example, ASPP family is well known for its necessity of p53 function while ASPP silencing leads to carcinogenesis or poor prognosis in cancer patients. Here, one of the PPP1R members (TUSC7) was identified which its role in tumor suppression had been investigated

Using semi-quantitative RT-PCR, expression profile of TUSC7 in cancer cell lines was obtained. TUSC7 was frequently silenced in cancer cells. Bisulfite treated tumor DNA was subjected to Methylation-specific PCR (MSP) using primers flanking across the ∼130bp CpG island of the TUSC7 promoter. It was revealed that silencing of TUSC7 was due to promoter hypermethylation in most of the corresponding cancer cell lines which had been further confirmed by bisulfite genomic sequencing (BGS). Treatment with azacytidine and trichostatin restored TUSC7 expression through demethylating the hypermethylated promoter. To quantitatively determine the extensiveness of cancer cell growth inhibition by TUSC7, colony formation assay was used. It was found that ectopic expression of TUSC7 could inhibit the proliferation of tumor cells, Caski (cervical carcinoma), HCT116 (colon carcinoma) and KYSE150 (esophageal squamaus carcinoma cells) by 40-50%. In addition, ectopic expression of TUSC7 increased the amount of phosphorylated GSK-3beta (pSer9-GSK-3beta) as shown in the western blot analysis. pSer-9 GSK-3beta is the inactive form of GSK-3beta. It has been reported that inactive GSK-3beta may affect p53 activities. To summarize, TUSC7 was found to be a tumor suppressor frequently silenced in cancer cells through epigenetic mechanism. TUSC7 may be significant in regulating the activity of GSK-3beta whose signaling is important in carcinogenesis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 195.

Dosimetric comparison of intensity-modulated stereotactic radiotherapy with other stereotactic techniques for locally recurrent nasopharyngeal carcinoma

PURPOSE

Locally recurrent nasopharyngeal carcinoma (NPC) patients can be salvaged by reirradiation with a substantial degree of radiation-related complications. Stereotactic radiotherapy (SRT) is widely used in this regard because of its rapid dose falloff and high geometric precision. The aim of this study was to examine whether the newly developed intensity-modulated stereotactic radiotherapy (IMSRT) has any dosimetric advantages over three other stereotactic techniques, including circular arc (CARC), static conformal beam (SmMLC), and dynamic conformal arc (mARC), in treating locally recurrent NPC.

METHODS AND MATERIALS

Computed tomography images of 32 patients with locally recurrent NPC, previously treated with SRT, were retrieved from the stereotactic planning system for contouring and computing treatment plans. Treatment planning of each patient was performed for the four treatment techniques: CARC, SmMLC, mARC, and IMSRT. The conformity index (CI) and homogeneity index (HI) of the planning target volume (PTV) and doses to the organs at risk (OARs) and normal tissue were compared.

RESULTS

All four techniques delivered adequate doses to the PTV. IMSRT, SmMLC, and mARC delivered reasonably conformal and homogenous dose to the PTV (CI <1.47, HI <0.53), but not for CARC (p < 0.05). IMSRT presented with the smallest CI (1.37) and HI (0.40). Among the four techniques, IMSRT spared the greatest number of OARs, namely brainstem, temporal lobes, optic chiasm, and optic nerve, and had the smallest normal tissue volume in the low-dose region.

CONCLUSION

Based on the dosimetric comparison, IMSRT was optimal for locally recurrent NPC by delivering a conformal and homogenous dose to the PTV while sparing OARs.

Severe oral mucositis associated with cancer therapy: impact on oral functional status and quality of life

GOALS OF WORK

This study determined the incidence of severe oral mucositis (OM), patients' self-reported moderate and severe oral symptoms, and change of quality of life (QoL), as well as examined whether OM severity and pain scores predicted the impairment of oral function and QoL.

PATIENTS AND METHODS

A multicenter approach was used and 137 patients treated with stomatotoxic chemotherapy (45%), high-dose myeloablative chemotherapy with or without concomitant total body irradiation (12%), head and neck irradiation with or without concomitant chemotherapy (44%) completed the OM-specific QoL measure (OMQoL) once or twice weekly over a 4- or 10-week period, along with concurrent measures of OM using WHO Mucositis Grading System and oral symptoms using 10 cm visual analog scale.

MAIN RESULTS

The incidence of severe OM was 50% (n = 68). About 77-80% of patients with severe OM reported moderate or severe mouth or throat pain, and 66-78% reported moderate or severe oral functional problems. The oral symptoms peak and area-under-the-curve (AUC) scores of patients with severe OM (peak 5.6 to 6.8; AUC 3.8 to 5.2) were significantly higher than those without OM and those with mild OM (p < 0.01). The OMQoL subscales peak and AUC scores of patients with severe OM (peak 47.9 to 62.1; AUC -40.1 to -25.8) were significantly lower than those without OM and those with mild OM (p < 0.01). Of those with severe OM, 88-94% had a drop in the OMQoL subscale scores to at least 10 points from the baseline. Pain resulting from OM, in particular throat pain, is most predictive of oral functional impairment (standardized β = 0.53-0.83).

CONCLUSIONS

Severe OM can cause profound pain and oral functional incapability and clinical significant impairment of QoL.

Multicenter phase II study of gemcitabine and oxaliplatin in advanced nasopharyngeal carcinoma--correlation with excision repair cross-complementing-1 polymorphisms

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a platinum-sensitive cancer and excision repair cross-complementing group 1 (ERCC1) polymorphisms have been shown to predict survival in several cancers following platinum therapy.

PATIENTS AND METHODS

This multicenter study evaluated the activity of oxaliplatin and prolonged infusion of gemcitabine ('GEMOX' regimen) in recurrent NPC. Baseline blood samples were genotyped for the presence of ERCC1-118 gene polymorphisms.

RESULTS

Forty-two patients were recruited, of whom most (61%) had metastatic disease. Of the 40 patients evaluated for response, the respective overall response and disease control rates were 56.1% and 90.2%. At a median follow-up of 14.8 months, the respective median overall survival and time to progression were 19.6 months [95% confidence interval (CI) = 12.8-22 months] and 9 months (95% CI = 7.3-10 months). Grade 3-4 toxic effects were uncommon. The distribution of ERCC1-118 genotypes from 29 patients was C/C (n = 17, 40.5%), C/T (n = 10, 23.8%) and T/T (n = 2, 4.8%). No differences in survival or response rates were found between genotypes.

CONCLUSIONS

GEMOX is active in the treatment of recurrent NPC. Detection of single-nucleotide gene polymorphisms from genomic DNA in peripheral blood is feasible in NPC and further studies are warranted.

MRI of radiation-induced tumors of the head and neck in post-radiation nasopharyngeal carcinoma

The aim of this study was to document the sites and MRI features of radiation-induced tumors (RITs) in the head and neck following treatment for nasopharyngeal carcinoma (NPC). The MRI examinations and clinical records of 20 patients with 21 RITs were reviewed retrospectively. RITs developed 3-30 years after radiotherapy and included eleven squamous cell carcinomas, six sarcomas, two neuroendocrine carcinomas, one mucoepidermoid carcinoma and one meningioma. RITs arose in the maxillary region (9), oro/hypopharynx and oral cavity (5), external auditory canal (4), nasopharynx and sphenoid sinus (2) and brain (1). Radiation-induced carcinoma and sarcoma had MRI features that were useful to distinguish them from recurrent NPC. To improve early detection of RITs, the check areas on an MRI of a patient with previous NPC treated by radiation should always include the maxillary region, tongue, and external auditory canal/temporal bone.

A patient-reported outcome instrument to assess the impact of oropharyngeal mucositis on health-related quality of life: a longitudinal psychometric evaluation

GOALS OF WORK

An oropharyngeal mucositis (OM)-specific health-related quality of life measure (OMQoL) has been developed to assess the impact of OM from the perspective of patients. The current paper describes the convergent, concurrent, and known-group validities and responsiveness in relation to clinical and health outcomes.

MATERIALS AND METHODS

A multicenter approach was used, and 137 patients treated with different cancer therapies completed the OMQoL and the European Organization for Research and Treatment of Cancer Quality of Life questionnaire [EORTC QLQ-C30 (Ch)] twice over a 4-week period or weekly over a 7-week period, along with concurrent measures of OM and its related symptoms.

MAIN RESULTS

The OM-related symptom scores correlated highly with the OMQoL, confirming its convergent validity (r = -0.724--0.971, p < 0.01). Moderate correlations between the subscales of the OMQoL and EORTC QLQ-C30 (Ch) were indicative of good concurrent validity (r = 0.450-0.724, p < 0.01). The OMQoL was able to distinguish between patients with different severities of OM (p < 0.01) and types of cancer therapy (p < 0.01), providing evidence of good known-group validity. The changes in effects sizes corresponding to changes in OM curves indicate that the OMQoL is responsive to changes in OM status.

CONCLUSIONS

These findings suggest that the OMQoL has very good psychometric properties and can be used as a health-related quality of life assessment for cancer patients with OM. Much work is still needed in strengthening the psychometric qualities and interpretability of the OMQoL by demonstrating its ability to detect outcome changes over time.

The impact of 18F-FDG PET/CT on assessment of nasopharyngeal carcinoma at diagnosis

The aim of this study was to determine whether the use of whole-body (18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET)/CT alters staging and management of nasopharyngeal carcinoma (NPC) when compared with current staging practice. 52 patients with Stage III-IV NPC without distant metastases on chest X-ray/CT, abdominal ultrasound or bone scan were recruited for the study. Whole-body (18)F-FDG PET/CT and MRI of the head and neck were performed. The scans were compared for extent of the primary tumour (PT), cervical nodal metastases (CNM) and distant metastases (DM). Any discordance in results was assessed with respect to staging and impact on management. MRI and (18)F-FDG PET/CT scans were discordant in 28 (54%) patients. There was discordance in the extent of PT at 28 sites; in all sites, MRI showed more extensive tumour involving the nasopharynx (n = 8), skull base (n = 14), brain (n = 4) and orbit (n = 2). There was also variation among the extent of CNM in four nodes of the retropharyngeal region, with the nodes being positive on MRI. (18)F-FDG PET /CT did not identify any additional distant metastases but did identify a second primary tumour in the colon. The additional use of (18)F-FDG PET/CT did not "up-stage" the overall stage or change management in any patient. In conclusion, there is discordance between MRI and (18)F-FDG PET/CT, and the additional use of (18)F-FDG PET/CT for the current assessment of NPC at diagnosis does not appear to be justified in this cohort of patients.

Concurrent chemoradiotherapy or endoscopic stenting for advanced squamous cell carcinoma of esophagus: a case-control study

BACKGROUND

We evaluated the role of chemoradiotherapy (CRT) for patients with inoperable squamous esophageal cancer.

METHODS

Patients with locally advanced or metastatic squamous esophageal carcinoma who received CRT were recruited. The CRT consists of continuous infusion of 5-fluorouracil at 200 mg/m(2)/day, and cisplatin at 60 mg/m(2) on days 1 and 22, with concurrent radiotherapy for a total of 50 to 60 Gy in 25 to 30 fractions over 6 weeks. Efficacy was assessed by endoscopy and computed tomographic scan before and 8 weeks after completion of the treatment program. Median survival and the need for palliative esophageal stenting were compared with another group of patients who received endoscopic stenting.

RESULTS

From 1996 to 2003, a total of 36 consecutive patients (33 male, mean +/- SD age 63.2 +/- 9.5 years) with T4 disease (81%) with or without cervical nodal metastasis (50%) received CRT, while 36 patients treated with endoscopic stenting alone were recruited as controls. Both groups were comparable in demographics, pretreatment dysphagia score, comorbidities, and tumor characteristics. CRT was completed in 32 patients (89%). There was no treatment-related mortality. Tumor volume was greatly reduced after CRT in 19 patients. Four patients (11%) received salvage esophagectomy 9 to 42 months after CRT. Compared with the stenting group, CRT statistically significantly improved 5-year survival (15% vs. 0%, P = .01), median survival (10.8 months vs. 4.0 months, P < .005), and need for stenting (22% vs. 100%, P = .005).

CONCLUSIONS

Palliative CRT can effectively improve the symptoms of dysphagia in patients with inoperable squamous esophageal carcinoma. It results in better survival compared with endoscopic stenting in these patients.

Feasibility of using interpolated contours of targets and organs at risk in intensity-modulated radiation therapy treatment planning for advanced-stage nasopharyngeal carcinoma

To assess the dosimetric effect of using interpolated contours in planning intensity-modulated radiation therapy (IMRT) for advanced T-stage nasopharyngeal carcinoma. The present study focused on T3-T4 tumours where the proximity of targets to neurological organs poses a stringent test on the feasibility of such an approach. Contours of targets and organs were delineated on CT images of 2.5-mm interval and a reference IMRT plan was generated. An investigative (INV) IMRT plan was then generated with the same planning protocol, but based on interpolated contours that replaced deleted contours on alternate slices. The reference and INV plans were compared. Regarding target coverage, all targets in the INV plans met the acceptance criteria except for the PTV in one case. Regarding organs, the mean dose to 1% volume of the brainstem and spinal cord in the INV plans were kept below their dose limits. No significant differences in the mean doses to others organs were found. Satisfactory target coverage and protection of critical organs to a degree similar to full-scale contouring could be achieved with use of interpolated contours. The saving in manpower time for contouring is expected to significantly improve the throughput of the IMRT planning process.

High frequency ultrasound assessment of skin fibrosis: clinical results

Fibrosis is a common late effect of radiotherapy treatment for cancer patients. Current clinical assessment of radiation-induced fibrosis is generally limited to clinician-based rating scales, which are usually not sufficient for quantitative and objective evaluations. Ultrasonic propagation properties of tissues are widely reported to be sensitive to the alterations of tissue compositions and structures. Based on our previous feasibility study, we used four parameters including skin thickness and three ultrasonic parameters of dermal tissues (attenuation slope [beta], integrated attenuation [IA] and integrated backscatter [IBS]) in the frequency range of 10 to 25 MHz for the assessment of skin fibrosis. Experiments were conducted on the forearm and neck skin in patients with postirradiation fibrosis in the neck region. The palpation score and stiffness of the neck soft tissue were also measured as an indication of fibrotic severity. Comparisons of the results between 38 patients and 20 control subjects showed a significantly smaller beta (p = 0.005) and a significantly larger skin thickness (p < 0.004) and IA (p = 0.04) in the neck skins of the patients. However, age-matched comparisons showed there were neither significant differences among patient subgroups with different fibrotic levels assessed using manual palpation or significant correlations between the four parameters and the overall stiffness of the neck soft tissues (p > 0.05). In conclusion, ultrasound tissue characterization may provide additional information for the assessment of postirradiation skin fibrosis in the neck region. Further studies are necessary to investigate the feasibility of applying the current measurement for differentiating the severity of skin fibrosis.

New measure of health-related quality of life for patients with oropharyngeal mucositis: development and preliminary psychometric evaluation

BACKGROUND

Oropharyngeal mucositis (OM) causes profound impairment of patients' health-related quality of life (HQoL). The aim of the article is to describe the development and preliminary validation of an HQoL instrument, OMQoL, specifically for patients with OM.

METHODS

First, a qualitative phase was conducted to generate items (n = 23). Face validity was assessed by focus group interviews (n = 13). Expert content review (n = 7) was used to ensure content validity. The second step was a quantitative validation phase comprised a multicenter study (n = 210) to help identify subscales of the instrument addressing different dimensions of OM and to measure reliability.

RESULTS

The qualitative interview generated 171 items. Using focus group discussion and expert content review, items were reduced to 41 items. Factor and scaling analyses of these 41 items resulted in 4 subscales, contributed by 31 items, depicting problems with symptoms, diet, social function, and swallowing. The floor effect was modest. The factorial structure was satisfactory with loading >0.40 on each subscale for all items. All corrected item-total corrections were higher than 0.40 (r = 0.457-0.874). The internal consistency reliability of each subscale was high, with Cronbach alpha coefficients ranging from 0.906 to 0.934. The test-retest reliability of the individual items using weighted kappa was good (kappa values 0.610-0.895). The intraclass correlation results for the subscale totals were all in excess of 0.70 (0.864-0.934).

CONCLUSIONS

An initial psychometric analysis of the OMQoL was encouraging. The OMQoL could provide a valuable tool for the assessment of HQoL of patients with OM.

Adjuvant Chemoradiation for Gastric Cancer: Experience in the Chinese Population

AIMS

The role of adjuvant chemoradiation for gastric cancer after curative R0 gastrectomy was first established by the US Intergroup 0116 study. Although confirmatory studies are in progress, few data are available regarding its application to the Chinese population. We describe our radiotherapy technique and report the treatment results in Hong Kong.

MATERIALS AND METHODS

This was a single centre retrospective study on 63 Chinese patients who underwent adjuvant chemoradiation for gastric adenocarcinoma between June 2000 and December 2004. The treatment protocol was based on that of the Intergroup study. Computed tomography planned anteroposterior opposing field arrangement and treatment under breath hold at deep inspiration position were adopted.

RESULTS

In total, 63 patients, mean age 50 years, with gastric cancer stage IB to limited metastatic IV disease were analysed. The median follow-up time was 27.2 months. The relapse-free survival and overall survival at 3 years were 50 and 54%, respectively. The recurrence pattern was dominated by distant failure and only one patient developed isolated locoregional recurrence. Of the 10 patients who had positive microscopic surgical margins after surgery, seven had recurred and died. On multivariate analysis, margin status was the only significant prognosticator for survival. Thirty per cent of patients experienced grade 3 or above acute toxicity (24% haematological, 14% gastrointestinal) and one patient died of neutropenic sepsis. There was one case of grade 3 late toxicity.

CONCLUSIONS

The outcome after adjuvant chemoradiation for gastric cancer seemed to be favourable, with manageable toxicities, in the Chinese population. Locoregional failure was uncommon. Patients with microscopic surgical margin involvement had a very high failure rate despite adjuvant chemoradiation.

Early swallowing problems in a cohort of patients with nasopharyngeal carcinoma: Symptomatology and videofluoroscopic findings

OBJECTIVE

To study the incidence and the degree of swallowing dysfunction in patients with nasopharyngeal carcinoma (NPC) who underwent radiation therapy treatment.

INSTITUTION

The study was conducted in the Prince of Wales Hospital, a tertiary teaching hospital of the Chinese University of Hong Kong.

MATERIALS AND METHODS

From October 1999 to July 2001, a cohort of 20 consecutive patients with newly diagnosed NPC was prospectively studied. Questions about symptoms, including swallowing functions, were asked, and head and neck examination including oromotor examination was performed in the subjects before radiation therapy. All patients were subjected to videofluoroscopy (VFSS) to assess their swallowing function. Abnormalities were scored if they were present on two of three swallow attempts. The patients were reassessed at 6 months and 12 months after radiotherapy by symptom assessment and VFSS.

RESULTS

There were 14 male and 6 female patients. The mean age was 43.9 years. Nine patients had early (stage I and II) disease, whereas 11 patients had advanced (stage III and IV) disease. Nine patients were treated by radiation therapy only and 11 patients by concurrent chemoirradiation. Ninety-five percent of the subjects had subjective dysphagia at 6 and 12 months after radiation therapy. Ninety percent had xerostomia, and 80% had to avoid certain foods at 12 months postradiation therapy. All subjects had to alternate solid food with fluid intake to facilitate swallowing. An average reduction of jaw movement by 1 cm was noted. A large proportion of patients had stasis of food in the pharynx (100% in valleculae and 60% in pyriform fossae) and impaired pharyngeal peristalsis (60%). One quarter of patients had laryngeal penetration.

CONCLUSIONS

Subjective swallowing difficulties were common in patients in the early follow-up period after radiation therapy for NPC according to questionnaire assessment. An objective swallowing study revealed that swallowing dysfunction was persistent 12 months after radiation therapy.

Reliability of measurement of skin ultrasonic properties in vivo: a potential technique for assessing irradiated skin

BACKGROUND/AIMS

Quantitative and objective technique to assess radiation-induced tissue fibrosis is important for clinicians to estimate the efficiency of radiotherapeutic schemes. It has been widely reported that ultrasonic properties are sensitive to changes of acoustic scatterers in biological tissues. Therefore, measurement of ultrasonic properties may serve as a potential assessment technique for irradiated skins. The aim of the present study is to investigate the reliability of such measurement so as to evaluate its potentials for future clinical applications.

METHODS

Ultrasonic parameters including attenuation slope (beta), integrated attenuation (IA) and integrated backscatter (IBS) were measured for the frequency range of 10-25 MHz from echographic signals of the forearm and neck dermis of 20 normal subjects in vivo. The intra- and inter-rater reliability of measurement was assessed in 10 normal subjects using intra-class correlation coefficients (ICC) and Bland-Altman test.

RESULTS

The intra- and inter-rater measurement was demonstrated to be reliable as indicated by high ICC values generally larger than 0.80. In addition, the ultrasonic parameters could successfully differentiate the skins in the neck and forearm regions.

CONCLUSION

The measurement provided reliable information on the ultrasonic properties of the skins and could be potentially applied to comparative clinical trials to assess the late effects of radiotherapy on skins.

Chemotherapy as an adjunct to radiotherapy in locally advanced nasopharyngeal carcinoma

BACKGROUND

A previous meta-analysis investigated the role of chemotherapy in head and neck locally advanced carcinoma. This work had not been performed on nasopharyngeal carcinoma.

OBJECTIVES

The aim of the project was to study the effect of adding chemotherapy to radiotherapy on overall survival (OS) and event-free survival (EFS) in patients with nasopharyngeal carcinoma.

SEARCH STRATEGY

We searched MEDLINE (1966 to October 2003), EMBASE (1980 to October 2003) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2003) and trial registers. Handsearches of meeting abstracts, references in review articles and of the Chinese medical literature were carried out. Experts and pharmaceutical companies were asked to identify trials.

SELECTION CRITERIA

Randomised trials comparing chemotherapy plus radiotherapy to radiotherapy alone in locally advanced nasopharyngeal carcinoma were included.

DATA COLLECTION AND ANALYSIS

The meta-analysis was based on updated individual patient data. The log rank test, stratified by trial, was used for comparisons and the hazard ratios (HR) of death and failure (loco-regional/distant failure or death) were calculated.

MAIN RESULTS

Eight trials with 1753 patients were included. One trial with a 2 x 2 design was counted twice in the analysis. The analysis was performed including 11 comparisons based on 1975 patients. The median follow up was six years. The pooled hazard ratio of death was 0.82 (95% confidence interval (CI) 0.71 to 0.95; P = 0.006) corresponding to an absolute survival benefit of 6% at five years from chemotherapy (from 56% to 62%). The pooled hazard ratio of tumour failure or death was 0.76 (95% CI 0.67 to 0.86; P < 0.00001) corresponding to an absolute event-free survival benefit of 10% at five years from chemotherapy (from 42% to 52%). A significant interaction was observed between chemotherapy timings and overall survival (P = 0.005), explaining the heterogeneity observed in the treatment effect (P = 0.03) with the highest benefit from concomitant chemotherapy.

AUTHORS' CONCLUSIONS

Chemotherapy led to a small but significant benefit for overall survival and event-free survival. This benefit was essentially observed when chemotherapy was administered concomitantly with radiotherapy.

Clinical Studies of Immunomodulatory Activities of Yunzhi-Danshen in Patients with Nasopharyngeal Carcinoma

OBJECTIVES

Nasopharyngeal carcinoma (NPC) is a prevalent tumor in Hong Kong. The immune system of such patients could be adversely affected during the course of conventional chemotherapy or radiotherapy. We investigated the immunomodulatory effects of Traditional Chinese Medicine (TCM) Yunzhi-Danshen capsules in NPC patients treated with radiotherapy.

DESIGN

Randomized, double-blind, placebo-controlled 16-week study.

SETTING/LOCATION

The Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong.

SUBJECTS

Twenty-seven (27) patients with histologically proven NPC, at least 18 years of age.

METHODS

Twenty-seven patients with histologically proven NPC were recruited to take Yunzhi (3.6 g daily) and Dangshem (1.4 g daily) in the form of 12 combination capsules (TCM group) or placebo (12 capsules) daily for 16 weeks, respectively. Flow cytometry was used to assess the percentages and absolute counts of human lymphocyte subsets in whole blood. Plasma concentration of soluble interleukin-2 receptor and soluble tumor necrosis factor receptor 2 was measured by enzyme-linked immunosorbent assay (ELISA). Ex vivo production of tumor necrosis factor-alpha, interleukin (IL)-6, and IL-10 in the whole blood assay culture supernatant was measured by ELISA.

RESULTS

The decreases in percentage and absolute count of T lymphocytes in the TCM group were less than those in the placebo group after they took the capsules for 16 weeks (both p < 0.05). Furthermore, the decreases in absolute count of T suppressor cells plus cytotoxic T lymphocytes, and T helper cells in the TCM group were significantly lower than those in the placebo group after they took the capsules for 16 weeks (both p < 0.05).

CONCLUSION

These results suggest that Yunzhi-Danshen can exert an immunomodulating effect in alleviating lymphopenia during radiotherapy in NPC patients.

Dose–response relationship of nasopharyngeal carcinoma above conventional tumoricidal level: A study by the Hong Kong nasopharyngeal carcinoma study group (HKNPCSG)

BACKGROUND AND PURPOSE

To define the dose-response relationship of nasopharyngeal carcinoma (NPC) above the conventional tumoricidal dose level of 66 Gy when the basic radiotherapy (RT) course was given by the 2D Ho's technique.

PATIENTS AND METHODS

Data from all five regional cancer centers in Hong Kong were pooled for this retrospective study. All patients (n = 2426) were treated with curative-intent RT with or without chemotherapy between 1996 and 2000 with the basic RT course using the Ho's technique. The primary endpoint was local control. The prognostic significance of dose-escalation ('boost') after 66 Gy, T-stage, N-stage, use of chemotherapy, sex and age (< or =40 years vs >40 years) was studied. Both univariate and multivariate analyses were performed.

RESULTS

On multivariate analysis, T-stage (P < 0.01; hazard ratio [HR], 1.58) and optimal boost (P = 0.01; HR, 0.34) were the only significant factors affecting local failure for the whole study population, and for the population of patients treated by radiotherapy alone, but not for patients who also received chemotherapy. The following were independent determinants of local failure for patient groups with different T-stages treated by radiotherapy alone: use of a boost in T1/T2a disease (P = 0.01; HR, 0.33); use of a boost (P < 0.01; HR, 0.60) and age (P = 0.01; HR, 1.02) in T3/T4 tumors. Among patients with T2b tumors treated by radiotherapy alone and given a boost, the use of a 20 Gy-boost gave a lower local failure rate than a 10 Gy-boost. There was no apparent excess mortality attributed to RT complications.

CONCLUSIONS

Within the context of a multi-center retrospective study, dose-escalation above 66 Gy significantly improved local control for T1/T2a and T3/4 tumors when the primary RT course was based on the 2D Ho's technique without additional chemotherapy. 'Boosting' in NPC warrants further investigation. Caution should be taken when boosting is considered because of possible increase in radiation toxicity.

Dynamic susceptibility contrast-enhanced perfusion MR imaging in late radiation-induced injury of the brain

The objective of the study was to evaluate radiation-induced cerebral injury on dynamic susceptibility contrast-enhanced (DSCE) perfusion MR imaging and study its relationship with morphological severity and disease progression. Thirty-one patients with known radiation injury to the temporal lobes where studied. Gradient and spin-echo T2-weighted, gadolinium-enhanced T1-weighted and DSCE perfusion MR imaging were obtained in the coronal plane through the anterior temporal lobe. Regions of interest where selected in the anterior temporal lobes and the superior frontal lobe as control for analysis of perfusion parameters. The mean transit time (MTT) was prolonged in both the High Dose Zone (HDZ) receiving from two-thirds to the total dose of 66-71.2 Gy, and the Intermediary Dose Zone (IDZ) receiving up to 87% of the total dose. The HDZ but not the IDZ showed a low relative cerebral blood volume (rCBV) and relative cerebral blood flow index (rCBFi). The rCBV and rCBFi were significantly lower in both HDZ and LBZ in temporal lobes with severe lesions compared to the temporal lobes with mild lesions but there was no significant difference in bolus transit parameters. The rCBV and rCBFi were significantly lower in both HDZ and IDZ of the swollen temporal lobes compared to those without swelling. It was concluded that DSCE perfusion MR imaging demonstrated a derangement in perfusion in radiation-induced cerebral injury in rCBV, rCBFi and MTT, which were related to the severity of the radiation-induced injury and the dose of irradiation delivered.

A Comparison of Wound Treatments in Nasopharyngeal Cancer Patients Receiving Radiation Therapy

The purpose of this study was to compare the effectiveness of gentian violet and nonadherent absorbent dressing in the healing of postirradiation wounds in nasopharyngeal carcinoma patients. This was a randomized controlled trial. A sample of 146 nasopharyngeal carcinoma patients who had developed postirradiation wounds was assessed. Comparisons were made regarding parameters related to wound healing, including healing time, presence of infection, and wound pain, and also regarding the impact of wound on the patient, including mood changes, restriction of neck movement, social isolation, sleep problem, and disturbance in body image. The results showed that patients in the 2 groups did not have any significant difference on wound-healing time, disturbance in mood, sleep, social interaction, appearance, and neck mobility. However, there was a trend of higher wound pain score, not reaching statistical significance, in the gentian violet group.

Survival outcome of patients with nasopharyngeal carcinoma with first local failure: a study by the Hong Kong Nasopharyngeal Carcinoma Study Group

BACKGROUND

The purpose of this article is to report the overall survival (OS) outcome of patients with nasopharyngeal carcinoma (NPC) with local failure who received salvage treatment and to identify prognostic factors for OS.

METHODS

Between January 1996 and December 2000, 2915 patients received primary radiotherapy (RT) with or without chemotherapy for nonmetastatic NPC. At a median follow-up of 3.1 years, 319 patients had developed local failure as the first failure, with or without synchronous regional/distant failure. OS was calculated from the start of primary RT. Univariate and multivariate analyses were performed to identify prognostic factors for OS in patients with isolated local failure.

RESULTS

The T classification distribution of the local failure (rT classification) was as follows: 68 (21%) rT1 to T2a, 92 (29%) rT2b, 82 (26%) rT3, and 77 (24%) rT4. The rT classification was the same as the initial T classification in 82% of patients. Two hundred seventy-five patients (86%) had isolated local failure, and 232 (84%) of them did not have any distant metastasis or regional failure develop during follow-up. Salvage treatment was given to 200 patients (73%) with isolated local failure. One hundred fifty-nine patients (80%) received reirradiation (108 external beam RT [EBRT], 44 brachytherapy, and seven EBRT plus brachytherapy), 22 patients (11%) underwent nasopharyngectomy with or without postoperative RT, and 19 patients (9%) were treated with chemotherapy alone. Four patients died of RT complications, and one died of chemotherapy toxicity in the absence of active NPC. The 3-year actuarial OS for patients with isolated local failure was 74%. On multivariate analysis, advanced initial T classification (hazard ratio [HR], 1.44; p = .0006) and the use of salvage treatment (HR, 0.54; p = .0038) were independent prognostic factors. For the subgroups of patients who had the same recurrent and initial T classification, salvage treatment was associated with improved OS only in the subgroup with T1 to T2 local failure (n = 127; p = 0.0446), but not in the subgroups with T3 (n = 48) or T4 (n = 54) disease.

CONCLUSIONS

Most patients with first local failure have localized disease. Salvage treatment is feasible in most of the patients with clinically isolated local failure. Patients who had early initial T classification have a more favorable prognosis. Subgroup analysis suggests that salvage treatment only prolongs survival in patients with T1 to T2 recurrent disease.

Multicenter prospective randomized trial comparing standard esophagectomy with chemoradiotherapy for treatment of squamous esophageal cancer: early results from the Chinese University Research Group for Esophageal Cancer (CURE)

We conducted a prospective randomized trial to compare the efficacy and survival outcome by chemoradiation with that by esophagectomy as a curative treatment. From July 2000 to December 2004, 80 patients with potentially resectable squamous cell carcinoma of the mid or lower thoracic esophagus were randomized to esophagectomy or chemoradiotherapy. A two- or three-stage esophagectomy with two-field dissection was performed. Patients treated with chemoradiotherapy received continuous 5-fluorouracil infusion (200 mg/m2/day) from day 1 to 42 and cisplatin (60 mg/m2) on days 1 and 22. The tumor and regional lymphatics were concomitantly irradiated to a total of 50-60 Gy. Tumor response was assessed by endoscopy, endoscopic ultrasonography, and computed tomography scan. Salvage esophagectomy was performed for incomplete response or recurrence. Forty-four patients received standard esophagectomy, whereas 36 were treated with chemoradiotherapy. Median follow-up was 16.9 months. The operative mortality was 6.8%. The incidence of postoperative complications was 38.6%. No difference in the early cumulative survival was found between the two groups (RR = 0.89; 95% confidence interval, 0.37-2.17; log-rank test P = 0.45). There was no difference in the disease-free survival. Patients treated with surgery had a slightly higher proportion of recurrence in the mediastinum, whereas those treated with chemoradiation sustained a higher proportion of recurrence in the cervical or abdominal regions. Standard esophagectomy or chemoradiotherapy offered similar early clinical outcome and survival for patients with squamous cell carcinoma of the esophagus. The challenge lies in the detection of residue disease after chemoradiotherapy.

Treatment results for nasopharyngeal carcinoma in the modern era: the Hong Kong experience

PURPOSE

To analyze the treatment results achievable for nasopharyngeal carcinoma in the modern era to identify the key failures for future improvement and to provide an updated baseline for future trials.

METHODS AND MATERIALS

The results of 2687 consecutive patients treated at all public oncology centers in Hong Kong during 1996-2000 were retrospectively analyzed. The stage distribution (by American Joint Committee on Cancer and International Union Against Cancer staging system, 1997) was 7% Stage I, 41% Stage II, 25% Stage III, and 28% Stage IVA-B. All patients were irradiated with 6-MV photons and the median total dose was 66 Gy. Only 23% of patients had additional treatment with chemotherapy.

RESULTS

The 5-year local, nodal, and distant failure-free rates were 85%, 94%, and 81%, respectively; patients with local failure had significantly higher risk of nodal and distant failures. The 5-year progression-free, overall, and cancer-specific survival rates were 63%, 75%, and 80%, respectively. The presenting stage was the most important prognostic factor for all endpoints: with overall survival decreasing from 90% for Stage I to 58% for Stage IVA-B. The results achieved by the 2070 patients treated by radiotherapy alone were almost identical to that of the whole series, the distant failure-free rate among patients with locoregional control was 89% for Stage I-II and 75% for Stage III-IVB. The 860 patients (32%) staged with magnetic resonance imaging achieved significantly better results than those staged by computed tomography, the overall survival being 93% vs. 83% for Stages I-II, and 72% vs. 63% for Stages III-IVB (p = 0.001).

CONCLUSIONS

Treatment results for nasopharyngeal carcinoma have substantially improved in the modern era; future trials should be based on updated baseline results. Further reduction of distant failure is important for future breakthrough, particularly for patients with advanced disease.

Overall Survival After Concurrent Cisplatin-Radiotherapy Compared With Radiotherapy Alone in Locoregionally Advanced Nasopharyngeal Carcinoma

This phase III randomized study compared concurrent cisplatin-radiotherapy (CRT) versus radiotherapy (RT) alone in patients with locoregionally advanced nasopharyngeal carcinoma. A total of 350 patients were randomly assigned to receive external RT alone or concurrently with cisplatin at a dosage of 40 mg/m(2) weekly. The primary endpoint was overall survival, and the median follow-up was 5.5 years. The 5-year overall survival was 58.6% (95% confidence interval [CI] = 50.9% to 66.2%) for the RT arm and 70.3% (95% CI = 63.4% to 77.3%) for the CRT arm. In Cox regression analysis adjusted for T stage, age, and overall stage, the difference in overall survival was statistically significantly in favor of concurrent CRT (P = .049, hazard ratio [HR] = 0.71 [95% CI = 0.5 to 1.0]). Subgroup analysis demonstrated that there was no difference between overall survival in the arms for T1/T2 stage (P = .74, HR = 0.93 [95% CI = 0.59 to 1.4]), whereas there was a difference between the arms for T3/T4 stage (P = .013, HR = 0.51 [95% CI = 0.3 to 0.88]), favoring the CRT arm. The regimen of weekly concurrent CRT is a promising standard treatment strategy for locoregionally advanced nasopharyngeal carcinoma patients.

Segmentation of nasopharyngeal carcinoma (NPC) lesions in MR images

PURPOSE

An accurate and reproducible method to delineate tumor margins from uninvolved tissues is of vital importance in guiding radiation therapy (RT). In nasopharyngeal carcinoma (NPC), tumor margin may be difficult to identify in magnetic resonance (MR) images, making the task of optimizing RT treatment more difficult. Our aim in this study is to develop a semiautomatic image segmentation method for NPC that requires minimal human intervention and is capable of delineating tumor margins with good accuracy and reproducibility.

METHODS AND MATERIALS

The segmentation algorithm includes 5 stages: masking, Bayesian probability calculation, smoothing, thresholding and seed growing, and finally dilation and overlaying of results with different thresholds. The algorithm is based on information obtained from the contrast enhancement ratio of T1-weighted images and signal intensity of T2-weighted images. The algorithm is initiated by the selection of a valid anatomical seed point within the tumor by the user. The algorithm was evaluated on MR images from 7 NPC patients and was compared against the radiologist's reference outline.

RESULTS

The algorithm was successfully implemented on all 7 subjects. With a threshold of 1, the average percent match is 78.5 +/- 3.86 (standard deviation) %, and the correspondence ratio is 66.5 +/- 7%.

DISCUSSION

The segmentation algorithm presented here may be useful for diagnosing NPC and may guide RT treatment planning. Further improvement will be desirable to improve the accuracy and versatility of the method.

Treatment of nasopharyngeal carcinoma with intensity-modulated radiotherapy: The Hong Kong experience

PURPOSE

To evaluate the efficacy of using intensity-modulated radiotherapy (IMRT) in the primary treatment of nasopharyngeal carcinoma (NPC), including the role of dose escalation above 66 Gy level.

METHODS AND MATERIALS

Between July 2000 and September 2002, 63 newly diagnosed NPC patients were treated with IMRT. The disease was Stage I in 9 (14%), Stage II in 18 (29%), Stage III in 22 (35%), and Stage IV in 14 (22%). The prescribed dose was 66 Gy to the gross tumor volume (GTV) and positive neck nodes, 60 Gy to the planning target volume (PTV), and 54-60 Gy to the clinically negative neck. All 20 (100%) patients with T1-2a tumors received intracavitary brachytherapy (ICB) boost, and 15/42 (36%) patients with T2b-T4 tumors received conformal boost (8 Gy/4 fractions). Nineteen patients with advanced stage disease also received either neoadjuvant or concurrent chemotherapy. Acute and late normal tissue effects were graded according to the Radiation Therapy Oncology Group (RTOG) radiation morbidity scoring criteria. Local relapse-free survival (LRFS), nodal relapse-free survival (NRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were estimated using the Kaplan-Meier method.

RESULTS

With a median follow-up of 29 months (range 8-45 months), 4 patients developed local in-field failure, 1 patient developed regional relapse, and 13 patients developed distant metastases. All 4 patients with local failure had either T3 or T4 disease before primary treatment and did not have ICB or conformal boost. The 3-year actuarial LRFS, NRFS, DMFS, and OS were 92%, 98%, 79%, and 90%, respectively. Multivariate analysis showed that dose escalation above 66 Gy was significantly associated with better PFS and DMFS, whereas GTV size was a significant adverse factor for OS. The worst acute mucositis was Grade 1 or 2 in 36 (59%), and Grade 3 in 25 (41%) patients. Acute dysphagia requiring tube feeding occurred in 5 (8%) patients. The proportion of patients with Grade 2-3 xerostomia was 57% at 3 months, and 23% at 2 years after IMRT. Within the subset of patients with a mean parotid dose of <31 Gy, the proportions with Grade 2-3 xerostomia were 30% and 17% at 3 months and 2 years, respectively.

CONCLUSION

Our experience of using IMRT in the primary treatment of NPC showed a very high rate of locoregional control and favorable toxicity profile. Furthermore, we found that dose escalation above 66 Gy of IMRT-based therapy was a significant determinant of progression-free survival and distant metastasis-free survival for advanced T-stage tumors. Distant metastases represent the predominant mode of treatment failure.

Quality-of-life measurement in patients undergoing radiation therapy for head and neck cancer: a Hong Kong experience

The aims of this study are (1) to establish a reliable and valid quality-of-life (QOL) questionnaire for Chinese patients with head and neck (H&N) cancer who are treated with radiation therapy and (2) to evaluate the impact of the immediate side effects of treatment on the QOL of these patients. The 39-item "Quality of Life Radiation Therapy Instrument with Head and Neck Companion Module" (QOL-RTI/H&N) was translated into Chinese. In the reliability evaluation phase (study module 1), the questionnaire was administered twice to 56 H&N cancer patients, 7 days apart, during the second and third week of radiation therapy. In the validity evaluation phase (study module 2), 138 patients completed the QOL-RTI/H&N before starting and at the end of radiation therapy. Sixty-nine of these 138 patients also completed the QOL-RTI/H&N during the second week of their radiation therapy, at the same time as completing the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) questionnaire. Cronbach alpha coefficients were 0.88 for the general-tool QOL-RTI and 0.90 for the H&N subscale. Test-retest reliability was satisfactory with intraclass correlation coefficients of 0.89 for the general-tool QOL-RTI and 0.75 for the H&N subscale. The instrument can discriminate between patients with stage I or II disease and those with stage III or IV disease (P < .05). Concurrent validity was established by the good agreement with the FACT-H&N (r = 0.86, P < .001). A highly significant deterioration was in the QOL from the baseline to the end of treatment (mean difference for general tool = 1.95, P < .001; mean difference for H&N subscale = 4.85, P < .001). The Chinese QOL-RTI/H&N is a reliable and valid tool for determining the QOL in H&N cancer patients receiving radiation therapy. The immediate side effects of treatment had a significantly negative impact on the patients' QOL. The impact was relatively large for the functional and treatment-site aspects.

Quantitative analysis of cell-free Epstein-Barr virus DNA in plasma of patients with nonnasopharyngeal head and neck carcinomas

PURPOSE

We investigated the detectability of EBV DNA in the plasma of patients with non-nasopharyngeal head and neck carcinomas (NNHNC). Previous studies have shown that EBV is present in the tumor tissue of some NNHNC.

EXPERIMENTAL DESIGN

We recruited 101 patients with NNHNC and 48 healthy controls. Blood samples were taken from controls and patients before treatment. Tumor tissue samples were tested for the presence of EBV in the first 69 patients by in situ hybridization for small EBV-encoded RNA (EBER). Plasma EBV DNA was measured by real-time quantitative PCR in patients and controls.

RESULTS

Squamous cell carcinoma (SCC) was the commonest histology (78 patients) followed by lymphoepithelial carcinoma (8 patients). EBER was detected in tumor cells in 7 of 69 patients tested. All of the EBER-positive tumors were lymphoepithelial carcinoma. Two controls (2 of 48; 4.2%) had detectable plasma EBV DNA. Plasma EBV DNA was detected in all of the patients with EBER-positive tumors, and in 23 of 94 (24.5%) patients with tumors of EBER-negative or unknown status. The proportion of plasma EBV DNA-positive cases in either group was significantly higher than that in the control group (P < 0.0027). Plasma EBV DNA concentrations in patients with EBER-positive tumors (median, 3827 copies/ml) were significantly higher than those in the controls (median, 0 copy/ml; P = 0.0001). Of patients with SCC, 21 (26.9%) had detectable plasma EBV DNA (median concentration, 34 copies/ml). Plasma EBV DNA concentrations in the whole group of patients with SCC (median, 0 copy/ml; interquartile range, 0-4 copies/ml) were also significantly higher than those in the controls (P = 0.001).

CONCLUSIONS

Our data indicate that plasma EBV DNA reflects tumoral EBER status, and it may be of use as a tumor marker for EBER-positive NNHNC. The biological and clinical significance of low levels of circulating EBV DNA in the minority of patients with EBER-negative tumors remain to be elucidated.