Phase II study of neoadjuvant therapy with docetaxel, cisplatin, panitumumab, and radiation therapy followed by surgery in patients with locally advanced adenocarcinoma of the distal esophagus (ACOSOG Z4051)

BACKGROUND

Preoperative chemoradiotherapy (CRT) improves outcomes in patients with locally advanced but resectable adenocarcinoma of the esophagus. ACOSOG Z4051 evaluated CRT with docetaxel, cisplatin, and panitumumab (DCP) in this patient group with a primary end point of a pathologic complete response (pCR) ≥35%.

PATIENTS AND METHODS

From 15 January 2009 to 22 July 2011, 70 patients with locally advanced but resectable distal esophageal adenocarcinoma were enrolled. Patients received docetaxel (40 mg/m(2)), cisplatin (40 mg/m(2)), and panitumumab (6 mg/kg) on weeks 1, 3, 5, 7, and 9 with RT (5040 cGy, 180 cGy/day × 28 days) beginning week 5. Resection was planned after completing CRT. PCR was defined as no viable residual tumor cells. Secondary objectives included near-pCR (≤10% viable cancer cells), toxicity, and overall and disease-free survival. Adverse events were graded using the CTCAE Version 3.0.

RESULTS

Five of 70 patients were ineligible. Of 65 eligible patients (59 M; median age 61), 11 did not undergo surgery, leaving 54 assessable. PCR rate was 33.3% and near-pCR was 20.4%. Secenty-three percent of patients completed DCP (n = 70) and 92% completed RT. 48.5% had toxicity ≥grade 4. Lymphopenia (43%) was most common. Operative mortality was 3.7%. Adult respiratory distress syndrome was encountered in two patients (3.7%). At median follow-up of 26.3 months, median overall survival was 19.4 months and 3-year overall survival was 38.6% (95% confidence interval 24.5% to 60.8%).

CONCLUSIONS

Neoadjuvant CRT with DCP is active (pCR + near-pCR = 53.7%) but toxicity is significant. Further evaluation of this regimen in an unselected population is not recommended.

CLINICALTRIALSGOV IDENTIFIER

NCT00757172.

Worldwide esophageal cancer collaboration

The aim of this study is to report assemblage of a large multi-institutional international database of esophageal cancer patients, patient and tumor characteristics, and survival of patients undergoing esophagectomy alone and its correlates. Forty-eight institutions were approached and agreed to participate in a worldwide esophageal cancer collaboration (WECC), and 13 (Asia, 2; Europe, 2; North America, 9) submitted data as of July 1, 2007. These were used to construct a de-identified database of 7884 esophageal cancer patients who underwent esophagectomy. Four thousand six hundred and twenty-seven esophagectomy patients had no induction or adjuvant therapy. Mean age was 62 +/- 11 years, 77% were men, and 33% were Asian. Mean tumor length was 3.3 +/- 2.5 cm, and esophageal location was upper in 4.1%, middle in 27%, and lower in 69%. Histopathologic cell type was adenocarcinoma in 60% and squamous cell in 40%. Histologic grade was G1 in 32%, G2 in 33%, G3 in 35%, and G4 in 0.18%. pT classification was pTis in 7.3%, pT1 in 23%, pT2 in 16%, pT3 in 51%, and pT4 in 3.3%. pN classification was pN0 in 56% and pN1 in 44%. The number of lymph nodes positive for cancer was 1 in 12%, 2 in 8%, 3 in 5%, and >3 in 18%. Resection was R0 in 87%, R1 in 11%, and R2 in 3%. Overall survival was 78, 42, and 31% at 1, 5, and 10 years, respectively. Unlike single-institution studies, in this worldwide collaboration, survival progressively decreases and is distinctively stratified by all variables except region of the world. A worldwide esophageal cancer database has been assembled that overcomes problems of rarity of this cancer. It reveals that survival progressively (monotonically) decreased and was distinctively stratified by all variables except region of the world. Thus, it forms the basis for data-driven esophageal cancer staging. More centers are needed and encouraged to join WECC.

Induction cisplatin-irinotecan followed by concurrent cisplatin-irinotecan and radiotherapy in locally advanced esophageal cancer: A single institution’s initial clinical experience

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Background: Phase I and Phase II trials of induction Cisplatin (C) and Irinotecan (I) followed by concurrent C+I and radiotherapy (RT) have produced encouraging clinical and pathologic response rates in esophageal cancer. However, to date published data detailing clinical outcome with this regimen is limited. Methods: A retrospective review of 17 patients with locally advanced esophageal cancer was performed to characterize toxicity and outcomes for this regimen in our institutional experience. Patients were treated during the period from August 2003 to July 2006 and staged comprehensively with EUS, CT and PET. Induction therapy with weekly I (65mg/m2) and C (30mg/m2) was administered (wks1,2,4,5). Those without progression received weekly I (65mg/m2) and C (30mg/m2) (wks 8,9,11,12) concurrent with RT. Patients considered surgical candidates based on pre- treatment clinical stage, medical co-morbidities, and pre-operative re-staging were offered an esophagectomy. Results: The patient demographics were as follows: 15 men, 2 women, median age 63 (45–76), white 53%, black 47%, adenocarcinoma 59%, squamous cell carcinoma 41%, 47% stage T3N1, 94% node positive, 6% M1a, and 29% T4 primary tumors. The mean RT dose was 50.4 Gy and median number of elapsed days of RT was 43 days. All patients completed induction C+I. Grade 3–4 hematologic toxicity (CTC v3.0)neutropenia (47%), anemia (6%), thrombocytopenia(18%). One patient died of a TE fistula 22 days after completing therapy. Two patients (12%) progressed during therapy. An esophagectomy was performed on 41% (7/17) of patients; 6 of 7 were R0, 71% (5/7) were downstaged, 14% (1/7) pCR. At median follow-up of 15 months, 8/17 (47%) pt are alive NED, 3/17 are alive with disease, 3/17 dead of disease and 3/17 are dead of other causes. Median DFS is 7 months and median local RFS is 7 months. Median OS has not been reached at 15 months. Conclusions: In this population with very advanced disease, I+C+RT have produced promising OS and local control outcomes with greater toxicity than in previously reported experiences with this regimen.

No significant financial relationships to disclose.

The ostrich (Struthio camelus) blastoderm and embryo development following storage of eggs at various temperatures

1. The gross morphology of blastoderms in fresh unstored ostrich eggs and in eggs subjected to different regimen of storage and incubation was studied. Then the effects of storage duration of eggs (1, 2 and 3 weeks) and storage temperature (15, 20 and 25 degrees C) on blastoderm and embryo development were investigated.2. Only incubation following overnight storage at 18 degrees C advanced blastoderm development (1.5-fold increase in diameter) to a stage comparable to hypoblast. 3. Storage of eggs at 15 or 20 degrees C did not affect blastoderm stage and size whereas, at 25 degrees C, the blastoderm doubled in size and appeared to have advanced to a primitive streak stage. Embryo development was reduced after 2 weeks of storage regardless of the storage temperature. 4. After oviposition and during pre-incubation storage the ostrich blastoderm develops progressively over time in a temperature-dependent manner towards the hypoblast stage and beyond but the viability of the blastoderm and embryo development is seriously compromised by 2 weeks of storage.

Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung

BACKGROUND

Endoscopic ultrasound (EUS)-guided fine needle aspiration is a safe, cost-effective procedure that can confirm the presence of mediastinal lymph node metastases and mediastinal tumor invasion. We studied the accuracy of EUS in a large population of lung cancer patients with and without enlarged mediastinal lymph nodes on computed tomographic (CT) scan.

METHODS

From 1996 to 2000 all patients referred to our institution with lung tumors and no proven distant metastases were considered for EUS and surgical staging. Patients had endoscopic ultrasound with fine needle aspiration of abnormal appearing mediastinal lymph nodes and evaluation for mediastinal invasion of tumor (stage III or IV disease). Patients without confirmed stage III or IV disease had surgical staging.

RESULTS

Two hundred seventy-seven patients met the inclusion criteria, including 121 who had EUS. Endoscopic ultrasound and fine needle aspiration detected stage III or IV disease in 85 of 121 (70%). Among patients with enlarged lymph nodes on CT, 75 of 97 (77%) had stage III or IV disease detected by EUS. Among a small cohort of patients without enlarged mediastinal lymph nodes on CT, 10 of 24 (42%) had stage III or IV disease detected by EUS. For mediastinal lymph nodes only, the sensitivity of endoscopic ultrasound and CT was 87%. The specificity of EUS (100%) was superior to that of CT (32%) (p < 0.001).

CONCLUSIONS

Endoscopic ultrasound with fine needle aspiration identified and histologically confirmed mediastinal disease in more than two thirds of patients with carcinoma of the lung who have abnormal mediastinal CT scans. Although mediastinal disease was more likely in patients with an abnormal mediastinal CT, EUS also detected mediastinal disease in more than one third of patients with a normal mediastinal CT and deserves further study. Endoscopic ultrasound should be considered a first line method of presurgical evaluation of patients with tumors of the lung.

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience

BACKGROUND

The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients.

METHODS

The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses.

RESULTS

EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement.

CONCLUSION

EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.

Hypersensitivity pneumonitis: current concepts and future questions

Hypersensitivity pneumonitis (extrinsic allergic alveolitis) caused by inhaled allergens can progress to disabling or even fatal end-stage lung disease. The only truly effective treatment is early recognition and control of exposure. Although patients produce antibody exuberantly, the immunopathogenesis involves cellular immunity--notably, CD8(+) cytotoxic lymphocytes, multinucleate giant cell granulomas, and ultimately interstitial fibrosis. Many causative agents have been recognized in occupational dusts or mists, but most current new cases arise from residential exposure to pet birds (pigeons and parakeets), contaminated humidifiers, and indoor molds. The symptoms and physical findings are nonspecific. Serum IgG containing high titers of specific antibody to the offending antigen is elevated. Pulmonary function tests show restrictive and diffusion defects with hypoxemia, especially after exercise. Occasionally, small airways disease causes obstruction. Radio-graphic changes vary according to the stage of the disease and are best evaluated by means of high-resolution computed tomography. In typical cases, the history of a known exposure and the presence of a characteristic interstitial lung disease with serologic confirmation of IgG antibody to the offending antigen suffice for diagnosis. In more obscure cases, observation of changes after a natural environmental exposure, bronchoalveolar lavage, and lung biopsy might be indicated. Among the many questions that remain are the following: What is the prevalence of hypersensitivity pneumonitis and how often is it the cause of chronic interstitial fibrosis? What is the long-term prognosis? Why do most individuals exposed to these antigens develop a vigorous antibody response whereas only a few develop the disease? How does exposure to endotoxin and cigarette smoking affect the disease? To answer these questions, standardized and validated clinical laboratory immunochemical tests are needed, in addition to a systematic approach to diagnosis, classification of disease severity, risk assessment, and management. This review is limited to the disease caused by airborne allergens and focuses on its immunopathogenesis, eliciting agents, clinical manifestations, diagnosis, management, and prognosis.

Tumor marker expression is predictive of survival in patients with esophageal cancer

BACKGROUND

This study was designed to determine the prognostic value of immunohistochemical tumor marker expression in a population of patients with node-negative esophageal cancer treated with complete resection alone.

METHODS

Resection specimens were collected from 61 patients with node-negative T1 (n = 31), T2 (n = 14), and T3 (n = 16) esophageal cancer. A panel of 10 tumor markers was chosen for immunohistochemical analysis, based on associations with differing oncologic mechanisms: apoptosis (p53), growth regulation (transforming growth factor-alpha, epidermal growth factor receptor, and Her2-neu), angiogenesis (factor VIII), metastatic potential (CD44), platinum resistance (p-glycoprotein and metallothionein), 5-fluorouracil resistance (thymidylate synthetase), and carcinogenic detoxification (glutathione S-transferase-pi).

RESULTS

Complete resection was performed in all patients (44 adenocarcinoma, 17 squamous cell carcinoma), with no operative deaths. Multivariable analysis demonstrated a significant relationship between cancer-specific death and the following variables: low-level P-gp expression (p = 0.004), high-level expression of p53 (p = 0.04), and low-level expression of transforming growth factor-alpha (p = 0.03). In addition, the number of involved tumor markers present was strongly predictive of negative outcome (p = 0.0001).

CONCLUSIONS

This study supports the prognostic value of immunohistochemical tumor markers, specifically the expression pattern of P-gp, p53, and transforming growth factor-alpha, in patients with esophageal carcinoma treated with complete resection alone.

Endotoxin-stimulated innate immunity: A contributing factor for asthma

Exposure to airborne endotoxin in infancy may protect against asthma by promoting enhanced T(H)1 response and tolerance to allergens. On the other hand, later in life, it adversely affects patients with asthma. Endotoxin binding to receptors on macrophages and other cells generates IL-12, which inhibits IgE responses. It also generates cytokines like IL-1, TNF-alpha, and IL-8, which cause inflammation. These signal transduction pathways resemble those leading to the generation of cytokines, such as IL-4, IL-13, and IL-5, which are responsible for the inflammation of IgE-mediated allergic disease. The main difference seems to be that endotoxin recruits neutrophils, but IgE recruits eosinophils, and the details of the tissue injury from these granulocytes differ. Sources of airborne endotoxin include many agricultural dusts, aerosols from contaminated water in many industrial plants, contaminated heating and air-conditioning systems, mist-generating humidifiers, and damp or water-damaged homes. Acute inhalation of high concentrations of endotoxin can cause fever, cough, and dyspnea. Chronic inhalation of lesser amounts causes chronic bronchitis and emphysema and is associated with airway hyperresponsiveness. Airborne endotoxin adversely affects patients with asthma in 3 ways: (1) by increasing the severity of the airway inflammation; (2) by increasing the susceptibility to rhinovirus-induced colds; and (3) by causing chronic bronchitis and emphysema with development of irreversible airway obstruction after chronic exposure of adults. The most effective management is mitigating exposure. The potential of drug treatments requires further clinical investigation.

Predictors of survival for esophageal cancer patients with and without celiac axis lymphadenopathy: impact of staging endosonography

BACKGROUND

Esophageal cancer patients with M1a disease are reported to have poor survival. We hypothesized that patients with celiac lymph node metastases (CLN) identified by endoscopic ultrasonography (EUS) would predict a cohort with significantly worse survival postoperatively. Accurate preoperative identification of this group will facilitate future adjuvant studies.

METHODS

During the study period, 211 patients with esophageal cancer underwent EUS staging. Patients with evaluable celiac axis (n = 182) were included in this study. Survival of patients with and without CLNs was compared and the factors affecting overall survival were assessed. A subgroup analysis based on CLN status was performed in the subgroup of patients who underwent surgical procedures.

RESULTS

Follow-up data was available in 91.2% (166 of 182) of the patients. As staged by EUS, T1, T2, T3, and T4 tumors accounted for 9.3%, 11.5%, 56%, and 21% of the cases, respectively. At least one CLN was imaged by EUS in 40% (72 of 182). The 5-year survival in patients with CLNs detected by EUS was 13% (95% confidence interval, 5% to 21%) compared with 30% (95% confidence interval, 21% to 40%) in patients with no CLNs detected by EUS (p = 0.007). In the subgroup of patients who underwent surgical procedures (n = 68), patients with CLN involvement had worse survival compared with those who did not have malignant involvement of CLNs at the time of their operation (median survival 39.8 versus 13.8 months, p = 0.0008). In a Cox proportional model, adjusting for race and the type of therapy, patients with CLN involvement or advanced EUS American Joint Committee on Cancer stage were more likely to have worse survival (p < 0.05)

CONCLUSIONS

EUS base line findings correlate with long term survival in patients with esophageal cancer. Patients with M1a disease as identified by EUS had a significantly worse postoperative survival when compared with non-M1a patients. This cohort of patients will be ideal for the study of induction therapy since the effect of down staging can be assessed before operation.

The 30th anniversary of the American Board of Allergy and Immunology: then and now

Thirty years ago the Allergy Subspecialty Boards of the American Board of Pediatrics (ABP) and the American Board of Internal Medicine (ABIM) merged to form the American Board of Allergy and Immunology (ABAI). The ABAI mission was to: establish qualifications and examine physician candidates for certification as specialists in allergy and immunology; serve the public, physicians, hospitals, and medical schools by providing the names of physicians certified by the Board; assist educational and professional organizations to improve the quality of care and availability of allergists to deliver such care, to establish and improve standards for the teaching of allergy and immunology, to establish standards for training programs, and to encourage development of increased opportunities for training of physicians interested in allergy and immunology. This mission statement has guided the activities of the Board ever since by providing a strong focus on the 2 major responsibilities: examining and certifying candidates in a fair objective way, and setting standards for the content and conduct of training programs.

CALGB 9380: a prospective trial of the feasibility of thoracoscopy/laparoscopy in staging esophageal cancer

BACKGROUND

The staging of esophageal cancer is imprecise. Thoracoscopic/laparoscopic (TS/LS) staging has been proposed as a more accurate lymph node (LN) staging method. We report the experience of an Intergroup NCI trial (CALGB 9380) evaluating the feasibility and accuracy of this staging modality.

PATIENTS AND METHODS

From February 1995 to September 1999, 134 patients were entered in the study. This study represents the analysis of final data on 113 patients. TS/LS was considered feasible if TS and 1 LN sampled at least 3 LN by LS; a confirmed positive node was found; or T4 or M1 disease was documented. If this was accomplished in more than 70% of patients, TS/LS was believed to be feasible.

RESULTS

The LN stations most frequently sampled in the thorax (134 patients) were levels 2 (33%), 3 (38%), 4 (40%), 7 (76%), 8 (69%), 9 (55%), and 10 (43%) and in the abdomen levels 17 (70%) and 20 (55%). The frequency of positive LN by level were as follows: 2 (10%), 3 (8%), 4 (10%), 7 (10%), 8 (25%), 9 (10%), 10 (10%), 17 (34%), and 20 (27%). Noninvasive tests (computed tomographic scan, magnetic resonance imaging, esophageal ultrasound scan) each incorrectly identified TN staging as noted by missed positive or false-negative LN or metastatic disease found at TS/LS staging in 50%, 40%, and 30% of patients, respectively. Median operating time was 210 minutes (range, 40 to 865 minutes). Median postoperative hospital stay was 3 days (range, 1 to 35 days). There were no deaths or major complications. Seventy-three percent of patients met the definition for feasibility. In 30 patients TS was not feasible. Positive LN disease was found in 43 patients; 32 were deemed N0. Ten patients had T4/M1 disease. Of the 32 potentially resectable N0 patients, 14 patients had preoperative induction therapy; 13 patients went directly to operation with N0 confirmed in 9 patients, NX in 1 and N1 in 3. Three patients were unresectable, 1 patient died, and 1 was lost to follow-up.

CONCLUSIONS

In summary, the feasibility of TS/LS was confirmed. It doubled the number of positive LNs identified by conventional, noninvasive staging. The overall accuracy remains to be defined by analysis of the LN negative group in follow-up. Although the positive predictive value was high, further study is warranted to confirm the role of TS/LS in the staging algorithm of esophageal cancer.

Mechanism of topical glucocorticoid treatment of hay fever: IL-5 and eosinophil activation during natural allergen exposure are suppressed, but IL-4, IL-6, and IgE antibody production are unaffected

BACKGROUND

Allergic rhinitis is traditionally defined as an IgE- and mast cell-mediated hypersensitivity reaction. Allergen challenge models suggest that cytokines and eosinophil mediators may also play roles. However, the causal relationship among inflammatory cells, their products, and patients' symptoms during natural allergen exposure has not been established.

OBJECTIVE

We sought to elucidate the mechanisms of seasonal allergic rhinitis and the beneficial effects of topical glucocorticoids.

METHODS

Thirty patients with ragweed-induced hay fever and a strongly positive serologic test response for ragweed IgE antibody received budesonide nasal spray or placebo in a randomized, parallel, double-blind study. Nasal wash fluids and sera were collected before and during the hay fever season. The levels of inflammatory mediators and allergen-specific immunoglobulins were measured by immunoassay. The activation markers on blood eosinophils were quantitated by flow cytometry.

RESULTS

Compared with placebo-treated patients, budesonide-treated patients had strikingly reduced symptoms. In the placebo group, nasal symptoms correlated with nasal lavage fluid eosinophil-derived neurotoxin and IL-5 levels. At the season peak, the budesonide-treated group had significantly lower nasal fluid eosinophil-derived neurotoxin, IL-5, and soluble intracellular adhesion molecule-1 levels. In the treated group eosinophil expression of CD11b was suppressed at the season peak. In contrast, levels of IL-4 and IL-6 in nasal fluid and the seasonal increases in serum ragweed-specific IgE and nasal fluid IgA antibodies did not differ between groups.

CONCLUSION

Eosinophilic inflammation plays a critical role in seasonal allergic rhinitis symptoms. One of the therapeutic effects of glucocorticoids is to suppress this inflammation.

Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediastinotomy in patients with lung cancer and suspected mediastinal adenopathy

BACKGROUND AND STUDY AIMS

The use of endoscopic ultrasonography (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has become an important aid in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy/mediastinotomy (MED), but the cost-effectiveness of the two techniques has not been compared. The aim of this study was to apply a decision-analysis model to compare the cost-effectiveness of EUS and MED in the preoperative staging of patients with non-small-cell lung cancer.

PATIENTS AND METHODS

A decision-analysis model was designed, taking as entry criteria lung cancer and abnormal mediastinal lymph nodes verified by computerized tomography (CT). Performance characteristics of MED and EUS were retrieved from the published literature, as were life expectancy data. Direct actual costs of the relevant procedures were retrieved from the billing system of our hospital.

RESULTS

The cost per year of expected survival is US$ 1.729 with the EUS strategy, and US$ 2.411 with the MED strategy. The advantage conferred by EUS remains even when the negative predictive value of EUS is as low as 0.22.

CONCLUSION

Because of its low cost and high yield, EUS-guided FNA is a cost-effective aid assessing mediastinal lymphadenopathy.

Lung cancer staging and treatment in multidisciplinary trials: Cancer and Leukemia Group B cooperative group approach. Thoracic Surgeons of CALGB

BACKGROUND

Aggressive routine surgical staging is necessary to evaluate patients to be treated on cooperative oncology protocols. Less than 1% of lung cancer patients in the United States are currently being treated in a clinical trial. Only with results from large, prospective trials can the questions of neoadjuvant and adjuvant therapy be answered.

METHODS

An outline describing the schema of preoperative patient evaluation, surgical staging, and the definition of surgical staging and resection procedures appropriate for patients considered for cooperative group protocol is presented. Current Cancer and Leukemia Group B (CALGB) protocols are used in the discussion as examples of this systematic approach.

CONCLUSIONS

Over the next few years, it will be important to enter the maximum number of patients into combined modality studies to identify the role of neoadjuvant treatment in lung cancer. Entry of patients into protocols will also make their pathological specimens and clinical information available for basic science research related to treatment results. Adherence to a logical sequence of patient evaluation as outlined above will optimize patient care, as well as accrual to cooperative group studies.

Does IgE bind to and activate eosinophils from patients with allergy?

Human eosinophils have been reported to express both the mRNA and protein for the high affinity IgE receptor (FcepsilonRI); it is speculated that this receptor plays a role in eosinophil mediator release in allergic diseases. However, questions still remain. How much of the FcepsilonRI protein is actually expressed on the cell surface of the eosinophil? If they are present, are these IgE receptors associated with effector functions of eosinophils? To address these issues, we studied blood eosinophils from patients with ragweed hay fever. A high level of low affinity IgG receptor (FcgammaRII, CD32), but no expression of FcepsilonRI, was detectable on the eosinophil surface by standard FACS analysis. However, after in vitro sensitization with biotinylated chimeric IgE (cIgE), cell-bound cIgE was detected by PE-conjugated streptavidin. This cIgE binding was partially inhibited by anti-FcepsilonRI mAb, suggesting that eosinophils do express minimal amounts of FcepsilonRI detectable only by a sensitive method. Indeed, FACS analysis of whole blood showed that eosinophils express approximately 0.5% of the FcepsilonRI that basophils express. When stimulated with human IgE or anti-human IgE, these eosinophils did not exert effector functions; there was neither production of leukotriene C4 or superoxide anion nor any detectable degranulation response. In contrast, eosinophils possessed membrane-bound human IgG and showed functional responses when stimulated with human IgG or anti-human IgG. Thus, IgG and/or cytokines, such as IL-5, appear to be more important for eosinophil activation in allergic diseases than IgE.

Surgical management of esophageal carcinoma

Surgical management of esophageal carcinoma is reviewed. The anatomy and biology are briefly mentioned, since these factors mitigate against the success of surgery. Staging, the key to proper treatment allocation and prognosis, is discussed, including the use of endoscopic ultrasonography, positron emission tomography, and thoracoscopy/laparoscopy. Patient selection and preparation for surgery are important considerations. Surgical techniques are then discussed, as are the advantages and disadvantages of various approaches, the morbidity of surgical resection, survival, and quality-of-life issues. Adjuvant treatment strategies (preoperative radiation, induction chemotherapy, induction chemoradiotherapy, and postoperative treatment) are summarized.

Physiologic consequences of pneumonectomy. Consequences on the pulmonary function

The cardiac sequelae following pneumonectomy should be anticipated by a thorough preoperative evaluation of cardiac risk factors, and any identified significant risk should be evaluated and corrected. The most common cardiac complication following pneumonectomy is atrial dysrhythmia. The possible causes, significant correlates, and rationale for prophylaxis are discussed. With a large portion of the pulmonary vascular bed removed by pneumonectomy, the possibility and consequences of right ventricular dysfunction are outlined. Finally, the rare but catastrophic occurrence of cardiac herniation is described.

The natural history of asthma in adults: the problem of irreversibility

Asthma is common, affecting 5% to 10% of adults; asthma is progressive, leading to irreversible obstruction in 80% of elderly patients; and asthma is complex, often complicated by coexisting lung diseases. This loss of lung function results from 4 independent pathologic conditions: (1) airway remodeling, especially in the small airways, from the lymphocytic-eosinophilic inflammation that characterizes asthma; (2) bronchiectasis; (3) postinfectious pulmonary fibrosis; and (4) emphysema and chronic bronchitis from tobacco smoke. Deterioration in lung function develops faster in nonallergic patients with intrinsic asthma during the period shortly after onset of asthma and in older patients. About 4% of patients die of asthma, and most are elderly. Death most often results from complications of irreversible obstruction or cardiotoxicity of bronchodilator therapy. More research is needed to improve therapy for preventing remodeling of small airways, to confirm the frequency of bronchiectasis and postinfectious fibrosis and to determine their causes, and to develop diagnostic criteria to identify these complications. Meanwhile, clinicians treating adult asthmatic patients need to be aggressive in preventing the damage from cigarette smoke; in immunizing for influenza and pneumococcus infection and identifying and treating respiratory infections, particularly at times of acute exacerbations; in diagnosing and managing bronchiectasis; and in objectively confirming the efficacy of asthma therapy to prevent illness from overtreatment with glucocorticoids and bronchodilators.

Esophageal cancer staging: improved accuracy by endoscopic ultrasound of celiac lymph nodes

BACKGROUND

Clinical staging of esophageal cancer is required for optimal therapy but remains imprecise. Pathologic verification of involved lymph nodes could potentially direct treatment allocation. With the rising incidence of distal and gastroesophageal junction adenocarcinomas, assessment of the celiac axis lymph nodes (CLNs) becomes important because it is a common nodal drainage basin. Endoscopic ultrasound (EUS) permits evaluation of CLNs and biopsy by fine-needle aspiration. This study examined the usefulness of this staging tool.

METHODS

A consecutive series of 62 patients with esophageal cancer considered resectable by computed tomographic scan underwent EUS for T and N staging and were retrospectively studied. A CLN visualized by EUS as greater than 5 mm was considered positive. Fine-needle aspiration of the CLN was performed routinely. Endoscopic ultrasound and computed tomographic staging were compared on the basis of pathologic verification of CLNs.

RESULTS

It was possible to evaluate CLNs by EUS in 59 (95%) of 62 patients: positive in 19, negative in 40. In EUS-positive patients, fine-needle aspiration was positive in 15, falsely negative in 2, and not done in 2. By computed tomographic scan, CLNs were negative in 57 patients and positive in 2. The CLNs were positive in 23 of 54 patients eligible for CLN pathologic verification. All positive CLNs not identified by EUS (7 false-negative EUS) were microscopic foci in one or two nodes and were associated with T3 tumors. Sensitivity and specificity of EUS were 72% and 97%, respectively, compared with 8% and 100% for computed tomographic scan. When EUS identified CLNs, fine-needle aspiration confirmed positivity in 88% of cases.

CONCLUSIONS

Endoscopic ultrasound with fine-needle aspiration is useful in the detection and confirmation of CLN metastasis. In T3 tumors of the distal esophagus, a negative EUS result does not substantiate absence of CLN disease. Endoscopic ultrasound with fine-needle aspiration may be important in guiding treatment for patients with distal adenocarcinoma and documenting disease before neoadjuvant therapy.

Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on health care charges

BACKGROUND

Asthma is a common and costly condition. Concomitant asthma and allergic rhinitis (AR) have been shown to increase the medication costs for people with asthma. No studies have compared medical care costs of those with and without concomitant AR.

OBJECTIVES

We sought to determine the prevalence and incremental medical care costs of concomitant AR.

METHODS

For each member of a population-based asthma cohort, we used all their medical charts within Olmsted County to record age at first diagnosis of asthma; the presence and age of any diagnosis of AR; and the total, ambulatory, and respiratory care-related costs of medical care. Costs were compared for age- and sex-specific strata of people with asthma who did and did not have AR.

RESULTS

AR was most commonly diagnosed in people whose asthma was diagnosed before age 25 (prevalence of 59%) and uncommonly diagnosed in anyone after age 40 (prevalence <15%). Yearly medical care charges were on average 46% higher for those with asthma and concomitant AR than for persons with asthma alone, controlling for age and sex. We were unable to assess the impact of treatment of AR on medical care charges.

CONCLUSIONS

Physicians should consider the diagnosis of AR (prevalence >50%) in all symptomatic children and young adults with asthma. Further evaluation is necessary to evaluate the ability of treatment to decrease the incremental costs of AR in persons with asthma.

Local staging of esophageal cancer using endoscopic magnetic resonance imaging: prospective comparison with endoscopic ultrasound

BACKGROUND AND STUDY AIMS

The magnetic resonance endoscope consists of a non-ferrous endoscope with a radiofrequency receiver coil incorporated into its tip. The aim of this study was to assess the accuracy of endoscopic magnetic resonance imaging for the local staging of esophageal cancer.

PATIENTS AND METHODS

Prospectively, 15 patients with biopsy-proven cancer of the esophagus (n = 9) or gastroesophageal junction (n = 6) underwent endosonography followed by imaging by the magnetic resonance endoscope. The results of endoscopic magnetic resonance imaging were assessed blindly, then compared with those of endosonography, which served as the gold standard.

RESULTS

Endoscopic magnetic resonance imaging of transmural tumor invasion agreed with ultrasonography in 11/15 cases and of nodal state in 12/15 cases. Endoscopic magnetic resonance images were inadequate in four cases as a result of motion artifacts.

CONCLUSIONS

Endoscopic magnetic resonance imaging of esophageal cancer diagnoses local staging that is comparable to endosonography. In future, the combination of endoscopic and conventional magnetic resonance scanning may provide comprehensive staging of esophageal cancer.

Specialists achieve better outcomes than generalists for lung cancer surgery

OBJECTIVE

A push toward care provided by generalists as opposed to specialists has occurred in the health-care marketplace despite a lack of provider specific outcome data. The objective of this study was to determine whether the outcome of patients undergoing lung cancer surgery is different between general surgeons (GSs) and thoracic surgeons (TSs).

DESIGN

Examination of data from a state-wide severity-adjusted administrative hospital discharge database.

SETTING/PARTICIPANTS

Patients undergoing lung cancer resection in all nonfederal acute care hospitals within South Carolina.

MAIN OUTCOME MEASURES

Mortality by specialty adjusted for case mix.

RESULTS

From 1991 to 1995, 1,720 resections for lung cancer were performed in South Carolina. One hundred thirty-seven cases were excluded because surgeons did not meet the predefined criteria for board certification, leaving 1,583 resections for analysis. One-half of lobectomies and nearly 60% of pneumonectomies were performed by GSs. Patients were similar in age, sex, gender, race, and the proportion in each severity of illness subclass. Mortality was significantly higher in patients who underwent lobectomy by GSs vs TSs (5.3% vs 3.0%; p<0.05) and in patients with extreme comorbidities (43.6% vs 25.4%; p=0.03) or age >65 years (7.4% vs 3.5%; p<0.05). Seventy percent of TSs performed > 10 cases in the series, whereas 75% of GSs performed <10 (p=0.05). Logistic regression analysis failed to identify any significant variable that might explain the mortality differences between TSs and GSs.

CONCLUSION

Mortality is lower for lung cancer resection when the surgery is performed by a TS.

Intrathoracic aberrant thyroid: identification critical for appropriate operative approach

True aberrant thyroid in the chest is a rarely described entity. More commonly, "aberrant" thyroid is a substernal goiter that is an extension of the cervical gland inferiorly and can be removed safely with the classic "collar" incision. Aberrant intrathoracic thyroid typically derives its blood supply from intrathoracic sources and requires an alternate surgical approach for adequate exposure. The ability to identify these rare intrathoracic thyroids is critical for safe surgical excision.

Aerosol beclomethasone dipropionate spray compared with theophylline as primary treatment for chronic mild-to-moderate asthma. The American Academy of Allergy, Asthma and Immunology Beclomethasone Dipropionate-Theophylline Study Group

BACKGROUND

Inhaled corticosteroids and oral theophylline are effective treatments for moderate asthma.

OBJECTIVE

We sought to compare the benefits and adverse reactions of theophylline and aerosol beclomethasone spray.

METHODS

A multicenter, double-blind, double-placebo, randomized, controlled trial of 1-year duration was performed. Seven hundred forty-seven patients with asthma received either beclomethasone dipropionate aerosol spray (84 microg four times per day) or sustained-release theophylline twice per day in doses adjusted for optimum control of the disease. The main outcome measures were daily diary of symptoms and peak flow rates (recorded on a mark-sense computer-readable form); supplemental bronchodilator use; doctor's office or hospital visits and absence from work or school; spirometry; methacholine testing; adverse experiences; and cortisol blood measurements.

RESULTS

Both treatment strategies reduced symptoms promptly and achieved low absenteeism from work or school and low rates of emergency treatment for asthma. Both maintained nearly normal pulmonary function. Beclomethasone was statistically significantly more effective in reducing symptoms, supplemental bronchodilator and systemic glucocorticoid doses, bronchial hyperresponsiveness, and eosinophilia. However, the magnitude of these differences was small. Theophylline caused more headache, nervousness, insomnia, and gastrointestinal distress, and more patients discontinued treatment because of side effects. Beclomethasone caused more oropharyngeal candidiases and hoarseness and reduced morning plasma cortisol levels before and after cosyntropin. It reduced the rate of growth in children. No new cataracts or glaucoma developed.

CONCLUSION

Theophylline effectively controlled symptoms at lower than the customarily recommended blood level. The risk/ benefit profiles of these agents suggest that inhaled corticosteroids may be the preferred agent for most adult patients and for some children.

Pitfalls and complications of esophageal prosthesis, laser therapy, and dilation

Although often diagnosed and treated by gastroenterologists, thoracic surgeons should be skilled partners in the management of esophageal obstruction. Knowledge of pitfalls and complications of any procedure is a prerequisite to success. This article focuses on problems encountered in dilatation, laser ablation, and stenting of esophageal strictures. Dilatation of both benign and malignant strictures requires knowledge of the different types of dilators and the ability to adapt to different stricture characteristics. Although lower morbidity makes laser ablation of malignant obstruction attractive, this author finds its use to be restrictive. The advent of expandable metal stents offers the potential for fewer early complications when compared with plastic protheses but, as discussed, morbidity may be different rather than less.

Attained adult height after childhood asthma: effect of glucocorticoid therapy

BACKGROUND

Although oral and inhaled glucocorticoid therapy may impair growth in children with asthma, the effect of glucocorticoid therapy and asthma on attained adult height has not been extensively studied in representative children in the community.

OBJECTIVES

The study was designed to compare the attained adult height of children with asthma with the attained adult height of nonasthmatic children and to compare the attained adult height of asthmatic children treated with glucocorticoids with the attained adult height of asthmatic children who did not receive glucocorticoids.

METHODS

Residents of Rochester, Minnesota, with onset of asthma from 1964 to 1987 and age- and sex-matched non-asthmatic residents of Rochester were studied. Glucocorticoid exposure was assessed from medical records. The mean of 5 stadiometer measurements of adult height, adjusted for sex and parental height, was analyzed.

RESULTS

One hundred fifty-three patients with asthma (mean age at onset, 6.1 +/- 4.8 years) and 153 age- and sex-matched nonasthmatic subjects were studied. Adult height of patients with asthma (mean age at measurement, 25.7 +/- 5.2 years) was not significantly different from the adult height of non-asthmatic subjects; the overall difference, adjusted for mid-parental height, was -0.20 cm (95% confidence interval from -0.27 to 1.64). The adult height of asthmatic children treated with glucocorticoids was not significantly different from the adult height of patients with asthma not treated with glucocorticoids; the difference after adjusting for mid-parental height was -0.2 cm (95% confidence interval from -0.1 to 0.6).

CONCLUSIONS

We conclude that the attained adult height of patients with asthma is not different from the adult height of age- and sex-matched nonasthmatic subjects and that the attained adult height of asthmatic children treated with glucocorticoids is not significantly different from the adult height of children not treated with glucocorticoids.

The effect of fluticasone propionate aqueous nasal spray on eosinophils and cytokines in nasal secretions of patients with ragweed allergic rhinitis

Cytokines active on eosinophils are important in the pathogenesis of allergic diseases. A study was conducted to determine if nasal eosinophilia in allergic rhinitis is associated with an increase in eosinophil-active cytokines in nasal secretions and to compare the effects of fluticasone propionate aqueous nasal spray with astemizole and placebo on the levels of these cytokines. Forty-five patients with moderately severe ragweed allergic rhinitis were randomly assigned to receive 2 weeks of treatment with fluticasone propionate aqueous nasal spray 200 micrograms once daily, astemizole 10 mg once daily, or placebo. Nasal lavage was performed in July (preseason), August (peak season), September (after 2 weeks of treatment), and October (postseason). The number of eosinophils, the amount of eosinophil-derived neurotoxin (EDN), and the amount of eosinophil survival-enhancing activity were measured. Total mean nasal symptom scores, concentrations of nasal eosinophils and EDN, and eosinophil survival-enhancing cytokine activity in nasal secretions were significantly lower after 2 weeks of treatment with fluticasone propionate compared with astemizole or placebo. Survival-enhancing activity was detected in the nasal secretions of 25 patients. By blocking activity with monoclonal antibodies, specific cytokines were identified (granulocyte macrophage-colony stimulating factor, 3 samples; interleukin-3, 2 samples; interleukin-5, 5 samples). In conclusion, eosinophil-active cytokine concentrations parallel the nasal symptoms of patients with ragweed allergic rhinitis. Unlike astemizole, fluticasone propionate significantly lowers cytokine activity in nasal tissue, which may contribute to the therapeutic efficacy of the drug.

Incidence and outcomes of asthma in the elderly. A population-based study in Rochester, Minnesota

STUDY OBJECTIVE

To estimate the incidence of asthma in an elderly population and to describe the clinical characteristics, use of health services, and long-term survival of persons with onset of asthma after age 65 years.

DESIGN

Retrospective cohort study.

SETTING

Rochester, Minn.

PATIENTS

All Rochester, Minn, residents age 65 years or older who met criteria for onset of definite or probable asthma from 1964 through 1983.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Ninety-eight Rochester residents (52 female, 46 male) with onset of asthma at or after age 65 years were identified. The age- and sex-adjusted incidence was 95/100,000 (95% confidence interval, 76 to 115/100,000). The age-specific incidence of asthma was 103/100,000 in residents aged 65 to 74 years, 81/100,000 in those aged 75 to 84 years, and 58/100,000 in residents older than 85 years. Only 11% had allergy skin tests, 24% had at least one office peak flow measurement, and 43% had at least one spirometry measurement. After the diagnosis of asthma, 40% had unscheduled ambulatory visits, 22% had emergency department visits, and 42% had at least one hospitalization for asthma. Observed survival was not significantly different from expected survival.

CONCLUSIONS

Asthma is common in the elderly. Diagnostic evaluation was less intensive than present guidelines recommend. Following the diagnosis of asthma, a substantial proportion of these individuals required unscheduled ambulatory visits, emergency department visits, or hospitalizations. Asthma with onset after age 65 years was not associated with reduced survival.

p53 overexpression in squamous cell carcinoma of the esophagus

BACKGROUND

Coastal South Carolina has a high incidence of squamous cell carcinoma of the esophagus (SCCE) among black residents. Overexpression and mutations of the p53 tumor suppressor gene have been noted in SCCE from other high-incidence regions. The purpose of this study was to determine the frequency of p53 overexpression in this region both in patients with SCCE and in normal subjects.

METHODS

Normal and malignant tissue obtained at esophagoscopy and normal esophageal mucosa (NEM) from random autopsies were studied with monoclonal antibodies to the p53 gene product. Total cellular RNA was extracted from SCCE, reverse transcribed to complementary DNA, and a portion of the p53 gene was amplified via polymerase chain reaction and sequenced.

RESULTS

Immunohistochemical studies on SCCE from nine patients showed that six (67%) were positive, two (22%) were negative, and one was indeterminate for p53 overexpression. The corresponding normal samples showed that three (33%) had p53-positive cells in the basal epithelial layer, whereas six did not. NEM from 18 random forensic cases displayed p53 overexpression in seven (39%). Eight of the nine tumors had p53 mutations.

CONCLUSIONS

p53 overexpression and mutations are frequently found in SCCE from patients in coastal South Carolina. Overexpression in normal epithelium from random autopsy cases may indicate an inherited or acquired predisposition in this geographic region.

Pulmonary blastoma: a rare lung malignancy

We describe a case of pulmonary blastoma, a rare lung malignancy which affects a younger population. Despite its usually indolent presentation, it is an aggressive malignancy with a prognosis similar to that for bronchogenic carcinoma.

Mechanisms of right ventricular dysfunction after pulmonary resection

BACKGROUND

Significant right ventricular (RV) dysfunction as measured by increased end-diastolic volume and reduced ejection fraction has been documented in the postoperative period after pulmonary resection. We hypothesized that changes in RV contractile state or afterload may contribute to this RV pump dysfunction.

METHODS

In part one of the study, RV preload was altered on postoperative day 2 (n = 6) by rapid infusion of Hespan to a total of 250, 500, and 1,000 mL. The relationship between RV stroke work and end-diastolic volume was plotted using linear regression. This preload recruitable stroke work relation had been previously validated as a load-insensitive index of RV contractility. The slopes of the preoperative relation (n = 35) and postoperative relation were compared. In part two of the study, RV afterload was reduced by continuous infusion of prostaglandin E1 (n = 6) through postoperative day 2 and RV pump function was assessed.

RESULTS

Comparison of the slopes of the preload recruitable stroke work relation plotted preoperatively and on postoperative day 2 revealed no significant difference, indicating no change in RV contractile state. Infusion of prostaglandin E1 in the postoperative period (n = 6) significantly reduced pulmonary vascular resistance (3.67 +/- 0.19 versus baseline 5.72 +/- 0.19 dyne . s . cm-5/ m2; p < 0.05). However, RV ejection fraction remained significantly reduced (0.34 +/- 0.01 versus baseline 0.42 +/- 0.01; p < 0.05) and end-diastolic volume significantly increased (105 +/- 5 versus baseline 93 +/- 2 mL/m2; p < 0.05). Heart rate was increased compared with baseline throughout the postoperative period.

CONCLUSIONS

The present study suggests that RV dysfunction after pulmonary resection is not caused by primary alterations in contractility or immediate changes in afterload. Better control of heart rate with minimal effect on inotropy may enhance RV pump function.

Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer

BACKGROUND

Esophageal endoscopic ultrasonographic (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has been introduced only recently. The utility of EUS/FNA in diagnosing and staging bronchogenic carcinoma is unknown.

METHODS

After a thoracic computed tomographic scan, 27 patients with known or suspected lung cancer underwent EUS. Accessible abnormal mediastinal lymph nodes were aspirated under EUS guidance. Patients with positive cytologic studies did not undergo further testing, whereas the remaining patients underwent mediastinal exploration. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest computed tomography and EUS/FNA:

RESULTS

Twenty-two of 27 patients had mediastinal adenopathy by computed tomography scan. Sixteen patients had positive findings on EUS, 15 with positive FNA (10 non-small cell lung cancer; 5 small cell lung cancer) and 1 with T4 status. Fourteen patients with positive FNA had lymph nodes sampled at level 5, level 7, or both. Of 11 patients with negative EUS/FNA, 2 had positive findings at operation (sensitivity 89%). The diagnosis of lung cancer was established in 7 patients.

CONCLUSIONS

The results showed that EUS/FNA improves the accuracy of computed tomographic scan in the staging of lung cancer. By accessing lymph nodes at levels 5 and 7, EUS/FNA complements mediastinoscopy and is considered the staging modality of choice in these regions. Positive EUS/FNA can obviate the need for further invasive staging.

Isolation of differentially expressed genes in carcinoma of the esophagus

BACKGROUND

The genetic alterations that occur in the transformation of normal esophageal mucosa (NEM) to carcinoma of the esophagus (CAE) are not well understood. Differential display of mRNA is a recently described technique that uses reverse transcription and PCR to compare cDNA from paired normal and malignant tissue to determine whether there is either genetic loss (putative tumor suppressor gene) or overexpression (putative oncogene) in malignant cells. Our goal was to identify some of these genes from patients with CAE.

METHODS

Specimens of NEM and corresponding CAE were obtained from patients at endoscopy or surgical resection and immediately snap frozen. Total RNA was isolated, reverse transcribed to cDNA, and PCR amplified with a predefined 10-mer oligonucleotide. The products were displayed on a polyacrylamide gel. Differential bands were isolated and sequenced and/or used as probes for Northern analysis.

RESULTS

Application of the differential display method resulted in the isolation of 49 cDNA clones from three patients with CAE. Sequencing of the clones has revealed five unique sequences not previously reported and one that has been identified as histone H3.3. Northern analysis of histone H3.3 has revealed overexpression in four of six CAEs but not the paired NEM. In addition, whereas only 5 of 13 normal human cell lines of various origins overexpressed this gene, 11 of 12 human cancer cell lines (9 of 9 adenocarcinomas) overexpressed it.

CONCLUSIONS

Differential display can be used to isolate potential oncogenes and tumor suppressor genes. We have identified five unique sequences and one known gene that may contribute to the development of CAE.

Ragweed immunotherapy in adult asthma

BACKGROUND

Although allergen immunotherapy is effective for allergic rhinitis, its role in treating asthma is unclear.

METHODS

We examined the efficacy of immunotherapy for asthma exacerbated by seasonal ragweed exposure. During an observation phase, adults with asthma who were sensitive to ragweed kept daily diaries and recorded peak expiratory flow rates between July and October. Those who reported seasonal asthma symptoms and medication use as well as decreased peak expiratory flow were randomly assigned to receive placebo or ragweed-extract immunotherapy in doses that increased weekly for an additional two years.

RESULTS

During the observation phase, the mean (+/- SE) peak expiratory flow rate measured in the morning during the three weeks representing the height of the pollination season was 454 +/- 20 liters per minute in the immunotherapy group and 444 +/- 16 liters per minute in the placebo group. Of the 77 patients who began the treatment phase, 64 completed one year of the study treatment and 53 completed two years. During the two treatment years, the mean peak expiratory flow rate was higher in the immunotherapy group (489 +/- 16 liters per minute, vs. 453 +/- 17 in the placebo group [P = 0.06] during the first year, and 480 +/- 12 liters per minute, vs. 461 +/- 13 in the placebo group [P = 0.03] during the second). Medication use was higher in the immunotherapy group than in the placebo group during observation and lower during the first treatment year (P = 0.01) but did not differ in the two groups during the second year (P = 0.7). Asthma-symptom scores were similar in the two groups (P = 0.08 in year 1 and P = 0.3 in year 2). The immunotherapy group had reduced hay-fever symptoms, skin-test sensitivity to ragweed, and sensitivity to bronchial challenges and increased IgG antibodies to ragweed as compared with the placebo group; there was no longer a seasonal increase in IgE antibodies to ragweed allergen in the immunotherapy group after two years of treatment. Reduced medication costs were counterbalanced by the costs of immunotherapy.

CONCLUSIONS

Although immunotherapy for adults with asthma exacerbated by seasonal ragweed exposure had positive effects on objective measures of asthma and allergy, the clinical effects were limited and many were not sustained for two years.

Comparison of different treatments for unresectable esophageal cancer

Many patient with esophageal cancer have advanced disease that in not amenable to curative treatment. For these individuals the relief of dysphagia is of utmost importance to the quality of their remaining survival time. This article reviews and compares the methods of palliation with focus on indications and contraindications, advantages as well as disadvantages of each technique, success rates, and complications. Tumor characteristics, the physician's experience, the institution's capabilities, cost, and patient preference will influence choice of palliation. Methods are often complementary rather than competitive.

Thoracoscopic staging of esophageal cancer: a prospective, multiinstitutional trial. Cancer and Leukemia Group B Thoracic Surgeons

BACKGROUND

Lymph node metastasis has been shown to be an important prognosticator in esophageal cancer. A prospective, multiinstitutional study of thoracoscopic lymph node staging in patients with biopsy-proven esophageal cancer was undertaken at University of Maryland, Medical University of South Carolina, and Brigham and Women's Hospital.

METHODS

Forty-nine patients underwent thoracoscopic staging between September 1991 and August 1993. Five procedures were incomplete due to adhesions. Preoperative computed tomography, magnetic resonance imaging, esophageal ultrasound, and bronchoscopy were performed. After our initial experience with the left side of the chest, thoracoscopic staging was done through the right side of the chest unless specific indications dictated otherwise. Beginning in January 1993 routine laparoscopic/mini-laparotomy lympho node staging of the celiac axis was performed.

RESULTS

Satisfactory thoracoscopic lymph node staging was achieved in 44 patients (95%). Of 33 patients undergoing esophageal resection, 29 were correctly staged (88%). Since initiating concomitant laparoscopic lymph node staging, we have correctly staged all of the last 9 patients with regard to celiac lymph nodes as well. Information regarding T status obtained at thoracoscopy was as follows: 3 patients were correctly "downstaged" to T3 despite preoperative noninvasive tests suggesting T4. In 2 patients thoracoscopy correctly predicted T4 invasion, whereas in 2 patients, thoracoscopy missed T4 lesions.

CONCLUSIONS

Thoracoscopy is a valuable tool for staging intrathoracic tumors. Preoperative staging of esophageal cancer may allow better allocation of adjuvant therapy. This pilot study suggests that thoracoscopic staging can correctly predict thoracic lymph node status with high accuracy and aid in better defining T status.