FOXA1 acts upstream of GATA2 and AR in hormonal regulation of gene expression

Hormonal regulation of gene expression by androgen receptor (AR) is tightly controlled by many transcriptional cofactors, including pioneer factors FOXA1 and GATA2, which, however, exhibit distinct expression patterns and functional roles in prostate cancer. Here, we examined how FOXA1, GATA2, and AR crosstalk and regulate hormone-dependent gene expression in prostate cancer cells. ChIP-seq analysis revealed that FOXA1 reprograms both AR and GATA2 cistrome by preferably recruiting them to FKHD-containing genomic sites. By contrast, GATA2 is unable to shift AR or FOXA1 to GATA motifs. Rather, GATA2 co-occupancy enhances AR and FOXA1 binding to nearby ARE and FKHD sites, respectively. Similarly, AR increases, but not re-programs, GATA2 and FOXA1 cistromes. Concordantly, GATA2 and AR strongly enhance the transcriptional program of each other, whereas FOXA1 regulates GATA2- and AR-mediated gene expression in a context-dependent manner due to its reprogramming effects. Taken together, our data delineated for the first time the distinct mechanisms by which GATA2 and FOXA1 regulate AR cistrome and suggest that FOXA1 acts upstream of GATA2 and AR in determining hormone-dependent gene expression in prostate cancer.

Retrospective review of diagnostic performance of intracranial translucency in detection of open spina bifida at the 11-13-week scan

OBJECTIVES

To evaluate diagnostic performance of intracranial translucency (IT) for detection of open spina bifida and interobserver agreement for visualization of IT during the 11-13-week scan.

METHODS

A retrospective study was undertaken in a tertiary referral center. Two hundred 11-13-week scans for nuchal translucency, performed by sonographers certified by The Fetal Medicine Foundation, U.K., were reviewed independently for IT by two expert observers. When IT was not seen, the observers determined whether this was due to poor IT image quality or the presence of spina bifida. Discordant cases were reviewed by a third observer and the majority decision was used for analysis. All observers were blinded to individual pregnancy outcome and the number of cases with spina bifida.

RESULTS

There were 191 normal fetuses, eight fetuses with open spina bifida and one with closed spina bifida (this case was excluded from analysis). IT was seen in 150 fetuses and all were normal. In six of the 49 cases in which IT was not seen, IT non-visibility was attributed to open spina bifida; among these cases, four fetuses had open spina bifida and two were normal. In the remaining 43 cases (including 39 normal fetuses), IT non-visibility was attributed to inadequate image quality. Sensitivity was 50% (4/8) and specificity was 99% (150/152). Concordance between the two observers concerning IT visibility was 79%, (κ = 0.47, representing moderate agreement).

CONCLUSION

There was moderate interobserver agreement for visualization of IT on images obtained for nuchal translucency measurement at 11-13 weeks. When IT was confidently seen, open spina bifida could be excluded. However, non-visibility of IT correctly diagnosed only 50% of fetuses with open spina bifida.

Malignant pleural mesothelioma in Singapore

AIM

To examine the clinical characteristics and outcomes of malignant pleural mesothelioma (MPM) in Singapore.

METHODS AND MATERIALS

A retrospective case note review of patients diagnosed with MPM between 1997 and 2007. Overall survival (OS), locoregional recurrence-free survival (LRS) and metastasis-free survival (MFS) were estimated using Kaplan Meier method and comparison were done using log rank test. Multivariate analysis was not done due to the small number of patients.

RESULTS

There were 39 patients diagnosed with MPM. Fifty-nine percent of patients presented with Stage III and IV disease. Eight (21%) patients had surgery with 2 patients receiving trimodality treatment and adjuvant chemotherapy respectively. Three patients received adjuvant RT and one patient had no adjuvant therapy. Twelve patients received palliative RT or chemotherapy. Median follow-up was 27.0 weeks. Median overall survival (OS) for all patients was 8.0 months (95% CI 6.3-9.7). One-year and 2-year OS were 25.6% and 6.4% respectively. Thirty-eight patients died of progressive disease and one patient died of other cause. Locoregional recurrences and distant metastases occurred in 3/8 and 5/8 surgically treated patients respectively. Overall, distant metastases occurred in 44% of patients. Surgery did not affect survival outcomes although patients with dual modality treatment showed a trend towards improved survival. Epithelioid tumours had better prognosis (median OS 10.2 months) compared to biphasic (median OS 8.0 months) and sarcomatoid tumours (median OS 1.4 months).

CONCLUSION

Future management of MPM will need to emphasize on both locoregional and systemic control and hence, inclusion of patients in clinical trials for multimodality treatment should be encouraged.

Cochlear implantation in postirradiated ears: outcomes and challenges

OBJECTIVES

Radiotherapy to head and neck tumors can potentially damage the auditory pathways. This has relevance in cochlear implants and there is a need for clinical studies to confirm the feasibility of cochlear implantation in these patients.

METHODS

The records of all patients who had received cochlear implants at our institution were reviewed in this retrospective study and those who had prior irradiation for head and neck tumors were further studied. Case controls consisted of comparable cochlear implant recipients who did not have prior radiotherapy.

RESULTS

Four of 230 patients met the criteria for further study. They had received radiotherapy for nasopharyngeal carcinoma 11 to 28 years ago and the postimplant follow-up period ranged from 9 to 46 months. The implanted ear of each patient had favorable preoperative promontory stimulation results. Postimplant, all patients were satisfied with their hearing outcomes and the improvement in speech discrimination scores was comparable to the controls. These cases also illustrated specific clinical concerns, including 1) radiation-induced endocrine dysfunction was common and, if overlooked, could result in increased anesthetic risks, and 2) irreversible eustachian tube dysfunction led to chronic middle ear problems, which complicated surgery; the use of modified surgical techniques overcame these difficulties.

CONCLUSIONS

Deafened postirradiated patients with nasopharyngeal carcinoma were able to achieve good postimplant hearing outcomes comparable to those of nonirradiated patients. Should cochlear implantation be indicated in patients who have had prior radiation to the head and neck, specific preoperative, intraoperative, and postoperative issues have to be addressed.

Effect of radiotherapy on retro-cochlear auditory pathways

OBJECTIVES

The cochlea may be damaged by modern conventional radiotherapy (RT) for head and neck cancers when the ear is included in the radiation field. It is unclear however, if the retro-cochlear auditory pathways are affected as well, which has clinical significance in cochlear implantation. This study aims to investigate the integrity of the retro-cochlear auditory pathways in patients who had received RT for nasopharyngeal carcinoma.

STUDY DESIGN

Prospective study.

METHODS

Patients who were newly diagnosed with nasopharyngeal carcinoma and treated by RT alone were studied. Evoked response audiometry and PTAs were carried out prior to and after RT (at 3, 18, and 48 months postRT). In addition, evoked response audiometry was also performed during the 3rd, 5th, and 7th week of RT. Waves 1 to 5, 1 to 3, and 3 to 5 latencies were measured. The values recorded during and postRT were compared with those recorded before RT. In addition, a subset of ears that demonstrated postRT sensorineural hearing loss were identified so that their respective wave 1 to 5 interwave latencies could be similarly compared. Wilcoxon signed ranks test was used in the statistical analysis. To confirm that the cochlea and internal auditory meatus receive significant doses of radiation, the RT treatment plans of nine other nasopharyngeal carcinoma patients treated by the same RT technique were analyzed to derive dose-volume histograms of these structures.

RESULTS

Twenty-seven patients (20 males and 7 females) with a mean age of 51.2 (range 36-75) years participated in the study. There was no statistically significant difference in waves 1 to 5, 1 to 3, and 3 to 5 interwave latencies recorded during RT and postRT as compared with those recorded before RT (P > .05). Pre- and postRT wave 1 to 5 latencies of the 16 ears that had postRT hearing deterioration were also not statistically significant (P = .366). The mean radiation doses delivered to the cochlea and internal auditory meatus ranged from 24.1 to 62.2 Gy and 14.4 to 43.4 Gy, respectively.

CONCLUSION

This study suggests in patients who have had RT for nasopharyngeal carcinoma, the retro-cochlear auditory pathways are functionally intact even in the longer term.

Surgery and adjuvant radiotherapy vs concurrent chemoradiotherapy in stage III/IV nonmetastatic squamous cell head and neck cancer: a randomised comparison

We compared concurrent combination chemotherapy and radiotherapy with surgery and adjuvant radiotherapy in patients with stage III/IV nonmetastatic squamous cell head and neck cancer. Patients with non-nasopharyngeal and nonsalivary resectable squamous cell head and neck cancer were randomised to receive either surgery followed by adjuvant radiotherapy (60 Gy over 30 fractions) or concurrent combination chemotherapy and radiotherapy (66 Gy in 33 fractions). Combination chemotherapy comprised two cycles of i.v. cisplatin 20 mg m^{− 2} day^{− 1} and i.v. 5-fluorouracil 1000 mg m^{− 2} day^{− 1}, both to run over 96 h given on days 1 and 28 of the radiotherapy. A total of 119 patients were randomised. At a median follow-up of 6 years, there was no significant difference in the 3-year disease-free survival rate between the surgery and concurrent chemoradiotherapy (50 vs 40% respectively). The overall organ preservation rate or avoidance of surgery to primary site was 45%. Those with laryngeal/hypopharyngeal disease subsite had a higher organ-preservation rate than the rest (68 vs 30%). Combination chemotherapy and concurrent irradiation with salvage surgery was not superior to conventional surgery and postoperative radiotherapy for resectable advanced squamous cell head and neck cancer. However, this form of treatment schedule with a view to organ-preservation can be attempted especially for those with laryngeal/hypopharyngeal and possibly oropharyngeal disease subsites.

Prenatal ultrasound findings of lissencephaly associated with Miller-Dieker syndrome and comparison with pre- and postnatal magnetic resonance imaging

OBJECTIVE

To report on the prenatal ultrasound findings in fetuses with lissencephaly associated with Miller-Dieker syndrome (MDS) and to compare these findings with those of magnetic resonance imaging (MRI).

METHODS

Cases of MDS confirmed by postnatal chromosome microdeletion analysis were identified through review of patient records. Prenatal ultrasound scans were reviewed retrospectively by two radiologists. For cerebral cortical development, the Sylvian, parieto-occipital and calcarine fissures, and the cingulate sulcus and sulci over the cerebral convexity were evaluated. If one or more of these fissures or sulci were not visualized at the expected gestational age or their appearance was abnormal for gestational age, cortical development was considered delayed. Prenatal and postnatal MRI examinations were reviewed by a pediatric neuroradiologist.

RESULTS

There were seven cases of MDS. In three cases, the prenatal diagnosis of agyria/lissencephaly was prospectively suspected by ultrasound at 23, 26 and 30 weeks, and subsequently confirmed by prenatal MRI. When we retrospectively reviewed the prenatal ultrasound scans of all fetuses, all had delayed cortical development identified on ultrasound performed after 23 weeks' gestation. In all cases the Sylvian fissure was abnormal on both ultrasound and MRI. In one fetus, a normal cortical appearance for gestational age was seen at the initial 20-week ultrasound examination, but delayed cortical development was identified at a 24-week scan. Mild ventriculomegaly was seen in six fetuses and dysgenesis of the corpus callosum in one. Extracranial abnormalities were detected in five fetuses. Delayed cortical development was seen in two fetuses with mild ventriculomegaly, but no other fetal anomalies.

CONCLUSIONS

In fetuses with MDS, delayed cortical development can be suspected on ultrasound as early as 23 weeks' gestation. This finding warrants further investigations including MRI and FISH analysis for chromosome 17p13.3 deletion.

How early are fetal cerebral sulci visible at prenatal ultrasound and what is the normal pattern of early fetal sulcal development?

OBJECTIVES

To evaluate the time of appearance and pattern of development of fetal cerebral sulci at prenatal ultrasound.

METHODS

We studied 50 normal fetuses for visibility of cerebral sulci, especially sulci which appear early in anatomical studies, namely the parieto-occipital fissure, calcarine sulcus, cingulate sulcus, convexity sulci and insula/Sylvian fissure. The gestational ages of the fetuses studied ranged from 15.6 to 29.6 weeks.

RESULTS

Sulci could be seen by transabdominal ultrasound as early as 18.5 weeks. Medial hemispheric sulci and the insula were visible earlier and more confidently than convexity sulci. The earliest gestational ages at which specific sulci could be seen in any fetus were as follows: parieto-occipital fissure 18.5 weeks, calcarine sulcus 18.5 weeks, cingulate sulcus 23.2 weeks and convexity sulci 23.2 weeks. In the present series, the gestational ages at which these sulci were always visible were as follows: parieto-occipital fissure >20.5 weeks, calcarine sulcus >21.9 weeks, cingulate sulcus >24.3 weeks and convexity sulci >27.9 weeks. The insula and its margin (the circular sulcus) and the overgrowing opercula undergo characteristic maturation. The circular sulcus at the margin of the insula was initially smooth but started becoming angular after about 17 weeks as it started to be overgrown by the parietal and temporal lobe opercula. Initially the insula/operculum angle was obtuse. An acute angle was first evident at 23.2 weeks and in all fetuses older than 24.5 weeks. Our ultrasound data were consistent with anatomical studies and fetal magnetic resonance imaging findings.

CONCLUSIONS

Some cerebral sulci can be seen at prenatal ultrasound as early as 18.5 weeks. Familiarity with the normal pattern of sulcal development and the discriminating gestational ages for the appearance of different sulci may allow early suspicion of lissencephaly.

Design of a prognostic index score for metastatic nasopharyngeal carcinoma

The survival outcome of patients with systemic cancer differs significantly between individuals even within the same tumour type. We set out to illustrate this by analysing the factors determining survival in patients with metastatic disease from nasopharyngeal carcinoma (NPC) and to design a scoring system based on these prognostic factors. Patients referred between January 1994 and December 1999 were retrospectively analysed. Factors analysed included patient (age group, gender, performance status (BS) at diagnosis of metastases), disease (number of metastatic sites, specific metastatic sites, disease-free interval (DFI), metastases at presentation, presence of locoregional recurrence), and laboratory factors (leucocyte count, haemoglobin level, albumin level). Univariate and multivariable analyses were performed using the Cox proportion hazards model. A numerical score was derived from the regression coefficients of each independent prognostic variable. The prognostic index score (PIS) of each patient was calculated by totalling up the scores of each independent variable. Independently significant, negative prognostic factors were liver metastasis, lung metastasis, anaemia, poor PS, distant metastasis at initial diagnosis, and a DFI of <6 months. Three prognostic groups based on the PIS were obtained: (i) good risk (PIS=0-6); (ii) intermediate risk (7-10); (iii) poor risk (>or=11). The median survivals for these groups were 19.5, 10, and 5.8, months, respectively, (log rank test: P<0.0001). The variable prognosis of patients with disseminated NPC can be assessed by using easily available clinical information (patient, disease and laboratory factors). The PIS system will need to be validated on prospectively collected data of another cohort of patients.

Gemcitabine in metastatic nasopharyngeal carcinoma of the undifferentiated type

BACKGROUND

We conducted two parallel phase II trials in chemonaïve and previously treated patients with metastatic nasopharyngeal carcinoma (NPC) to evaluate the tumour response, progression-free and overall survival, and toxicity of gemcitabine.

PATIENTS AND METHODS

Gemcitabine 1250 mg/m2 was given on days 1 and 8 of a 21-day cycle. Patients with an Eastern Cooperative Oncology Group performance status <2, adequate renal, hepatic and bone marrow function, and radiologically measurable NPC were eligible.

RESULTS

Twenty-five chemonaïve and 27 previously treated patients were enrolled. The overall response rate was 28% [95% confidence interval (CI) 14% to 48%] for the chemonaïve and 48% (95% CI 31% to 66%) for previously treated patients. Toxicities greater than or equal to grade 3 occurred in 15 (60%) chemonaïve and 13 (48%) previously treated patients. Neutropenia was uncommon in chemonaïve patients, but occurred in 37% of previously treated patients. The median time to progression was 3.6 months (range 0.9-7.9) for chemonaïve and 5.1 months (0.9-13.1) for previously treated patients. Median overall survival time was 7.2 months (1.4-15.6) and 10.5 months (2.4-15.0) for chemonaïve and previously treated patients, respectively.

CONCLUSIONS

Gemcitabine has moderate activity in NPC with minimal toxicity, and is also an effective salvage agent for patients who have failed or progressed after treatment with other agents.

Cerebellopontine angle involvement by nasopharyngeal carcinoma

OBJECTIVE

This article describes a series of patients with nasopharyngeal carcinoma involvement of the cerebellopontine angle and discusses the clinical significance of this entity.

SETTING

Tertiary referral center.

STUDY DESIGN

Retrospective case study.

PATIENTS

Patients who were diagnosed with nasopharyngeal carcinoma with clinical features of cerebellopontine involvement by tumor.

INTERVENTIONS

Cerebellopontine involvement by tumor confirmed by computed tomography, magnetic resonance imaging, or both.

RESULTS

Patients with this entity either had advanced disease or had been treated previously for advanced nasopharyngeal carcinoma. They had varied clinical features attributable to cerebellopontine involvement, such as sensorineural deafness, dizziness, facial palsy, and facial numbness.

CONCLUSIONS

Cerebellopontine angle involvement by nasopharyngeal carcinoma is a difficult entity, both from the diagnostic and therapeutic points of view. In high-risk patients, particularly in patients who were previously treated for advanced nasopharyngeal carcinoma, a high index of suspicion for nasopharyngeal carcinoma involvement of the cerebellopontine angle is warranted when they experience unexplained neurootologic symptoms such as sensorineural hearing loss, dizziness and facial palsy.

Diagnostic value of Epstein-Barr viral serology in nasopharyngeal carcinoma

Although Epstein-Barr virus (EBV) IgA serology has been established as an effective marker for nasopharyngeal carcinoma (NPC), it remains unclear how useful or cost-effective it is as a screening test. This article is aimed at establishing how these tests could be used most effectively in the diagnosis of NPC in an otolaryngology outpatient clinic. A total of 111 consecutive patients with NPC and an equal number of control subjects were studied. Forty-seven patients with NPC had early (AJCC stages 1 and 2) and 64 had advanced (stages 3 and 4) disease. A positive early antigen (EA) serology result was found in 81.2% of NPC patients and in none of the controls. Negative EA and viral capsid antigen (VCA) serology results were present in 2.7% of NPC patients and in 46.8% of controls. Negative EA and positive VCA serology results were found in 30.0% of NPC patients with early disease, 7.8% of NPC patients with advanced disease, and 53.2% of controls. Given its high specificity, serology for EA is recommended as a clinically useful screening test. Serology for VCA, although highly sensitive, has an unacceptably high false-positive rate, and its cost-effectiveness as a universal screening test is questionable.

Induction chemotherapy followed by concurrent chemoradiotherapy in stage III unresectable non-small cell lung cancer

The favourable experience with the combination regimen of vinorelbine, ifosfamide and cisplatin (NIP) in patients with metastatic non-small cell lung cancer (NSCLC) has led to a protocol assessing this regimen as an induction treatment in patients with stage III unresectable NSCLC, followed by thoracic radiotherapy with concurrent daily cisplatin as a radiosensitizer. Two cycles of NIP were administered 21 days apart; each cycle comprised i.v. vinorelbine 25 mg/m2 on days 1 and 8, i.v. ifosfamide 3 g/m2 on day 1 with MESNA as uroprotection, and i.v. cisplatin 50 mg/m2 on day 1. Radical thoracic radiotherapy commenced on day 43 to a total dose of 64 Gy and i.v. cisplatin 6 mg/m2 was given concurrently prior to each fraction of radiation as a sensitiser. Two more cycles of NIP were given to patients who responded favourably to the induction treatment about 2 weeks after completion of radiation. Between July 1995 and July 1997, 44 patients were treated with this protocol. This treatment schedule was generally well tolerated. Grade 3-4 neutropenia occurred in 50% of the patients and neutropenic sepsis was seen in 8. Grade 3-4 oesophagitis was uncommon. Most of the patients were able to complete the induction and concurrent chemoradiotherapy phase. Major response occurred in 75% of the patients with 2 (4.5%) complete responses (CR). A total of 6 patients achieved CR after chemoradiotherapy. At a median follow-up of 35 months, the median overall survival for all patients was 15 months with a 3-year survival rate of 24%. The median overall survival for stage IIIA patients was 19 months with a 3-year survival rate of 39% in contrast to 13 months' median overall survival and only 15% 3-year survival rate for stage IIIB. The NIP regimen results in a high response rate in NSCLC and this treatment programme seems to benefit selected patients with stage III disease.

Prediction of perinatal outcome in fetuses suspected to have intrauterine growth restriction: Doppler US study of fetal cerebral, renal, and umbilical arteries

PURPOSE

To determine and compare the diagnostic performance of fetal middle cerebral (MCA), renal (RA), and umbilical (UA) arterial Doppler ultrasonography (US) for prediction of adverse perinatal outcome in suspected intrauterine growth restriction (IUGR).

MATERIALS AND METHODS

Two hundred ninety-three small-for-gestational age fetuses (24-39 weeks at recruitment and US-estimated weight or abdominal circumference below 10th percentile) were prospectively examined with Doppler US of the UA, MCA, and RA. Clinicians were blinded to MCA and RA Doppler measurements.

RESULTS

Seventy-six fetuses (25.9%) had at least one major or minor adverse perinatal outcome. Major outcomes included stillbirth, neonatal death, neurologic complication, and necrotizing enterocolitis. The MCA pulsatility index (PI), compared with the UA PI and RA PI, was more sensitive (72.4% vs 44.7% and 8.3%) but less specific (58.1% vs 86.6% and 92.6%) in predicting adverse outcome. The UA PI had the highest positive likelihood ratio (ratio, 3.3); the MCA PI had the lowest negative likelihood ratio (ratio, 0.48). When gestational age at the first Doppler US examination was less than 32 weeks, the MCA PI had a sensitivity of 95.5% and negative predictive value of 97.7% for major adverse outcome (negative likelihood ratio, 0.10).

CONCLUSION

In suspected IUGR, while an abnormal UA PI is a better predictor of adverse perinatal outcome than an abnormal MCA or RA PI, a normal MCA PI may help to identify fetuses without major adverse perinatal outcome, especially before 32 weeks gestational age.

Prognostic factors in 677 patients in Singapore with nondisseminated nasopharyngeal carcinoma

BACKGROUND

The objective of the current study was to describe the survival of nasopharyngeal carcinoma (NPC) patients in Singapore, verify the prognostic value of the revised 1997 TNM staging system, and develop a multivariate prognostic model for NPC. In addition, the authors also examined the prognostic value of characteristics of lymph node spread and parapharyngeal involvement.

METHODS

A prospectively maintained database containing clinical and computed tomography scan data was used to reclassify 677 NPC patients treated between 1992 and 1994 according to the new staging system. Records were linked with the death registry to ascertain the patient's vital status and date of death. Overall and stage specific survival were analyzed using the Kaplan-Meier method and the log rank test. Univariate and multivariate Cox proportional hazards regression analysis were used to obtain prognostic models.

RESULTS

Two hundred seventy-four deaths (40.5%) occurred. The 5-year survival rate was 56.6% (95% confidence interval [95% CI], 52.3%, 60.7%). The stage specific 5-year survival rates were: Stage I, 88%; Stage IIA, 75%; Stage IIB, 74%; Stage III, 60%; Stage IVA, 35%; and Stage IVB, 28%. TNM stage was found to be a statistically significant prognostic factor (P < 0.0001). Cranial nerve (hazard ratio [HR]: 2.77), orbit (HR: 5.71), and intracranial involvement (HR: 2.46) conferred a particularly bad prognosis in univariate analysis. Independently significant prognostic factors were age; lymph node status; and paraoropharyngeal, cranial nerve, orbit, and nasal involvement. Among lymph node positive patients, independently significant prognostic lymph node characteristics were Ho level and laterality. Although parapharyngeal involvement appeared to be prognostically unimportant, paraoropharyngeal involvement distinguished a subgroup with a poorer prognosis (HR: 1.84; 95% CI, 1.45, 2.34; P < 0.0001). Lateral spread to the medial infratemporal fossa and beyond also was found to confer a poorer prognosis.

CONCLUSIONS

The results of the current study show that the revised 1997 TNM staging system is prognostically useful. Subdivision into paraoropharyngeal involvement and using the medial infratemporal fossa to delineate prognostically significant lateral spread should be considered in future revisions.

Concurrent chemoradiotherapy followed by adjuvant chemotherapy in Asian patients with nasopharyngeal carcinoma: toxicities and preliminary results

PURPOSE

Nasopharyngeal carcinoma (NPC) is endemic in Singapore. Nearly 60% of the patients diagnosed with NPC will present with locally advanced disease. The North American Intergroup study 0099 reported improved survival outcome in patients with locally advanced NPC who received combined chemoradiotherapy when compared to radiotherapy alone. Hence we explored the feasibility and efficacy of a similar protocol in our patients.

METHODS AND MATERIALS

Between June 1996 and December 1997, 57 patients were treated with the following schedule as described. Radical radiotherapy (RT) of 66-70 Gy to the primary and neck with cisplatin (CDDP) 25 mg/m2 on days 1-4 given by infusion over 6-8 hours daily on weeks 1, 4, and 7 of the RT. This is followed by a further 3 cycles of adjuvant chemotherapy starting from week 11 from the first dose of radiation (CDDP 20 mg/m2/d and 5-fluorouracil [5-FU] 1 gm/m2/d on days 1-4 every 28 days).

RESULTS

The majority of patients (68%) had Stage IV disease. About 54% of patients received all the intended treatment; 75% received all 3 cycles of CDDP during the RT phase and 63% received all three cycles of adjuvant chemotherapy. The received dose intensity of CDDP and 5-FU of greater than 0.8 was achieved in 58% and 60% of the patients respectively. Two treatment-related deaths due to reactivation of hepatitis B and neutropenic sepsis respectively, were encountered. At median follow-up of 16 months, 14 patients had relapsed, 12 systemically and 2 loco-regionally.

CONCLUSION

Due to the acceptable tolerability of such a protocol in our cohort of patients, we have embarked on a Phase III study to confirm the results of the 0099 Intergroup study in the Asian context.

Vinorelbine, ifosfamide and cisplatin in advanced non-small cell lung cancer

Between September 1994 and July 1997, 78 patients with advanced/metastatic, non-small cell lung cancer (NSCLC) were selected for the NIP (vinorelbine, ifosfamide, and cisplatin) protocol. The study group included 43 males; age range 34-74 years; median age 56 years; median follow-up for all patients was 14 months and for surviving patients, 30 months. Histological distribution included 55 adenocarcinomas (70.5%), 8 squamous cell carcinomas, and 9 large cell carcinomas. Stage distribution was 14 stage IIIB (malignant effusions) and 64 stage IV or recurrent metastatic; sites of metastasis were lungs, -26; liver-19; bones-27; brain-7; adrenals-3; distant nodes-2; skin-2. The NIP regimen was well tolerated by most of the patients but nausea/vomiting was noted in 55% of the cycles administered, most of them of grade 1-2 severity. Fifteen neutropenic episodes (5%) were encountered. Response to NIP was: 44 partial responses (56%); 1 complete response (1%); overall response, 58%. For stage IIIB, overall response was 36%, while for stage IV/metastatic, overall response was 63%. The median time to progression was 7 months for stage IIIB and 8 months for stage IV/metastatic disease and the overall median survival achieved was 14 months, with 60% of patients alive after one year. No significant difference in survival outcome was noted between patients with metastatic disease and those with stage IIIB (malignant effusion) disease. The NIP regimen has produced encouraging results in advanced NSCLC, as well as a favourable toxicity profile. The efficacy of NIP as a palliative tool should be assessed. A randomized trial to compare NIP with a two-drug combination of vinorelbine and cisplatin has been initiated.

Factors contributing to delayed diagnosis in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) can be difficult to diagnose. Not only is the post-nasal space (PNS) inaccessible to examination, it is frequently occupied by normal lympho-epithelium which can make differentiation from NPC difficult. Together with its frequent atypical presentation, it is not surprising that the diagnosis is missed or delayed. This is undesirable as the treatment of early NPC carries an excellent prognosis. The aim of this study is to ascertain the extent of the problem of missed or delayed diagnosis and to study the factors responsible. This was a retrospective study of all newly diagnosed patients with NPC from the Singapore General Hospital and treated in the Department of Therapeutic Radiology in the year 1996 (1 January-31 December). A total of 126 patients were studied. Eighteen patients (14.3 per cent) were found to have delayed diagnosis of more than a month. The delay ranged from 1.2 to 25 months (mean 7.2 months). Factors identified which contributed to delayed diagnosis included i) Clinicians not considering a diagnosis of NPC ii) Clinicians suspecting NPC but misled by the results of investigations iii) Patients refusing investigation or defaulting follow-up. Nearly a fifth of patients with NPC had delayed diagnosis. Many of the factors responsible for the delays appear to be preventable by better patient education and counselling, doctors having sharper clinical acumen and skills in NPC diagnosis and the hospital administration having a system of tracking down high risk patients who default.

Concurrent chemoradiotherapy in patients with locally advanced nasopharyngeal carcinoma of the undifferentiated type

The result with radiotherapy alone in patients with locally advanced nasopharyngeal carcinoma (NPC) was disappointing. Encouraging results have been reported with the use of concurrent chemoradiotherapy in patients with locally advanced squamous cell carcinoma of the head and neck. Hence, we decided to explore the use of this treatment schedule in patients who presented with locally advanced disease (UICC/AJCC classification system). Between July 1995 and March 1996, 14 patients with locally advanced NPC were treated with the following schedule: radiation therapy was given conventionally to a total of 66 to 70 Gy to both the nasopharynx and neck with or without parapharyngeal/intracavitary boost; chemotherapy consisted of intravenous cisplatin at 20 mg/m2/day and intravenous 5-flurouracil 1000 mg/m2/day, infused over 8 hours on days 1 to 4 during the first and fifth week of radiation therapy. Depending on the patient's tolerability and clinical assessment of toxicity, a third cycle of chemotherapy was planned 4 to 5 weeks after the second cycle, upon the completion of the radiotherapy. Twelve patients completed all intended treatment. Two patients failed to do so due to treatment-related mortality. The median follow-up duration was 30 months. Limiting toxicities were myelosuppression and oropharyngeal mucositis. The overall response rate was a 100% at both the primary and nodal sites of disease. The median disease-free survival was 21 months. Forty per cent of the patients were alive at 3 years. This treatment schedule was associated with an unacceptable treatment-related death rate. As a result, this protocol was terminated.

The pattern of nodal recurrence following definitive radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The pattern of nodal metastasis in previously untreated nasopharyngeal carcinoma (NPC) has been studied and reported. In order to analyse the pattern of recurrent nodal disease in previously treated NPC, a retrospective study on 68 patients who underwent radical neck dissection for regionally recurrent NPC was conducted.

METHODS

Seventy-four neck dissections were performed on 68 patients who developed nodal recurrence after a mean disease-free interval of 39.2 months. None of the patients had evidence of local or systemic disease at the time of surgery. Histopathological reports of the 74 neck dissections were analysed with regard to the number of positive nodes as well as the number of involved nodal levels.

RESULTS

Of the 65 neck dissection specimens with analysable data, 31 showed metastatic disease at a single nodal level with a mean number of positive nodes of 1.2, while 34 showed metastatic disease at multiple levels with a mean number of positive nodes of 6.6. Nodal recurrence occurred at level II with the greatest frequency (78.5%). Of the 31 specimens with single level nodal involvement, 21 (67.7%) occurred at level II. Isolated involvement at the other levels did occur, but was uncommon (range 3-16%). Of the 34 specimens with multiple level nodal involvement, 30 (88.2%) showed involvement at level II. Once more than one level was involved, the frequency of involvement at any given level was at least 30%.

CONCLUSION

The predominant involvement at level II and the high frequencies of involvement at all levels support the use of a classical radical neck dissection in treating recurrent nodal disease in NPC.

Phase II trial of a paclitaxel and carboplatin combination in Asian patients with metastatic nasopharyngeal carcinoma

PURPOSE

An earlier phase II trial of paclitaxel in patients with metastatic nasopharyngeal carcinoma (NPC) demonstrated a response rate of 22%. Hence we proceeded to study the combination of paclitaxel and carboplatin in these patients.

PATIENTS AND METHODS

The 21-day regimen was as follows: i.v. paclitaxel 175 mg/m2 over three hours preceded by standard premedications, followed by i.v. carboplatin dosed at AUC of six infused over one hour. Only chemotherapy-naive patients with histological diagnoses of undifferentiated carcinoma of the nasopharynx, systemic metastases and radiologically measurable lesions were eligible.

RESULTS

Thirty-two patients were accrued to this study. Twenty patients (62%) had at least two sites of metastasis. The main grade 3-4 toxicity was neutropenia (31%). Nine patients (28%) developed neutropenic sepsis, which caused the demise of one of them. Twenty-four patients (75%) responded to treatment, with one (3%) attaining a complete response. The median time to progression of disease was seven months and the median survival was 12 months. At one year, 52% of the patients were alive.

CONCLUSIONS

The combination of paclitaxel and carboplatin is an active regimen in NPC. Its convenience of administration and good tolerability make it an attractive alternative regimen to consider for patients with metastatic disease.

A novel nonmetallized tip for electrospray mass spectrometry at nanoliter flow rate

We report the fabrication of a durable nonmetallized nanospray tip. This nanospray tip does not require complex preparation procedures such as chemical treatment, deposition of gold or SiOx vapor. It was fabricated by pulling a heated glass capillary of 1.1 mm internal diameter to produce a fine tip with an orifice of 10-15 microns in diameter. A 10 microns gold-plated tungsten wire was inserted through the capillary tip. This tungsten wire played a central role in the operation of this durable nanospray tip by providing electrical contact. This type of nanospray tip could withstand electrical discharges and sustained spraying of solution at nanoliter flow rate for more than 3 h. Using insulin (35 microM) and myoglobin (1 microM) solutions, useful mass spectrum could be acquired with low fmol sensitivity.

Long-term post-irradiation middle ear effusion in nasopharyngeal carcinoma

This study aimed to find out if there were factors which influenced the development of long-term middle ear effusion (MEE) in patients irradiated for nasopharyngeal carcinoma. Thirty-five patients (70 ears) were studied for 2-8 years (mean 5.5 years) post-radiotherapy. The factors studied were (a) sex (b) age (c) tumour size and (d) presence of pre-radiotherapy MEE. Only the presence of pre-radiotherapy MEE was found to be statistically significant (P = 0.004, Fisher's exact test). Stepwise multiple regression analysis showed the presence of pre-radiotherapy MEE was a predictor of post-radiotherapy MEE with an odds ratio of 0.67. It is postulated that irreversible Eustachian tube dysfunction occurs when the tube which has been damaged by tumour is further damaged by irradiation. This may explain the frequent persistent otorrhea when ventilation tubes are used to treat post-radiotherapy MEE in patients with nasopharyngeal carcinoma. In conclusion, an ear with pre-irradiation MEE was almost seven times more likely to have long-term post-irradiation MEE than an ear without pre-irradiation MEE.

Long-term hearing status after radiotherapy for nasopharyngeal carcinoma

This paper evaluates the hearing status in the long-term, of patients who have had radiotherapy for nasopharyngeal carcinoma (NPC) and also discusses the hearing losses from a disability point of view, which takes into account binaural hearing. Forty patients who have had NPC successfully treated by a single radical course of radiotherapy of 70-80 Gy were studied at 2-12 years (mean 6.2 years) after radiotherapy. Each patient was examined clinically and with a pure-tone audiogram. Averaged hearing thresholds over 0.5, 1.0, 2.0 and 4.0 kHz were evaluated and a value > 30 dB was considered abnormal. The findings were compared with age-matched controls. The median hearing threshold for each ear in NPC patients was found to be 31.9 dB (range 10.0-86.3 dB) and that for controls 17.5 dB (7.5-38.8 dB) (P < 0.0005, Wilcoxon's matched pairs test). In NPC patients, 44 ears (55.0%) had abnormal hearing, of which 17 (21.3%), 5 (6.3%) and 22 (27.5%) ears had predominantly sensori-neural, conductive and mixed hearing losses, respectively. Nineteen ears had middle ear effusions, accounting for the majority of mixed and conductive hearing losses. In terms of individual patients, 8 (20.0%) and 18 (45.0%) patients had abnormal hearing in one year (monaural hearing disability) and both ears (binaural hearing disability), respectively. In conclusion, a substantial proportion of patients who have had radiotherapy for NPC, have hearing disability in the long-term, as compared to normal controls.

Intrathecal methotrexate overdose

We report two cases of intrathecal methotrexate overdose. A 3-y-old girl with acute lymphoblastic leukaemia and a 4-y-old boy with Burkitt's lymphoma were to receive an intrathecal injection of methotrexate after completion of intravenous methotrexate infusion. Instead of 12.5 mg, they both received a dose of 125 mg. Both children developed generalized convulsion 3 h after the overdose, but afterwards recovered completely. Intravenous folinic acid and dexamethasone rescue were employed, but no attempt was made to exchange the cerebrospinal fluid. In addition to the staff's failure to check the drug label carefully, the marked resemblance of the two dose preparations of methotrexate (50 mg/5 ml and 500 mg/5 ml) may have been contributory.

Localised nodal non-Hodgkin's lymphoma--a study of 42 cases treated by radiotherapy

The records of 42 patients with stage I and II nodal non-Hodgkin's lymphoma treated by radiotherapy with and without chemotherapy were analysed with regards to clinical presentation, investigations, treatment, radiotherapy techniques and results. The 5-year overall survival rates for all, low grade, intermediate grade and high grade histology types are 69.5%, 100%, 64.4% and 46.9% respectively. The 5-year relapse-free survival rates of those treated by initial radiotherapy alone for all, low grade and intermediate-high grade histology types are 54.8%, 46.9% and 59.4% respectively.

Patient profile and survival in 270 computer tomography-staged patients with nasopharyngeal cancer treated at the Singapore General Hospital

This is a report analysing the patient profile and survival results in 270 patients with nasopharyngeal carcinoma treated with radiation therapy between July 1987 and December 1988. The patients had a median age of 52.6 months, and a male-female ratio of 2.5:1. Ninety-four percent of patients were Chinese. The commonest presentation was that of a neck mass (found in approximately 65% of patients). Approximately two-thirds presented with disease more advanced than Ho's stage II. At a median follow-up of 52.6 months, the 5-year actuarial survival rate was 53% and the freedom from relapse rate was 57%. One hundred and seven patients died within the observation period. Of these, 46 patients had disease in the post nasal space, 41 in the neck and 60 in sites outside the head and neck.

Hearing disability before and after radiotherapy for nasopharyngeal carcinoma

This paper evaluates post-irradiation hearing changes in patients with nasopharyngeal carcinoma (NPC) from a disability orientated approach, which takes into account binaural hearing. Newly diagnosed patients with NPC were studied before radiotherapy, and at four to 12 months (mean 9.2 months) after radiotherapy, provided they remained disease-free. Each patient was examined clinically and with pure tone audiograms. Tympanometry was used to confirm middle ear effusion. Averaged hearing thresholds over 0.5, 1 and 2 kHz were evaluated. If abnormal (> 30 dB), the resultant hearing disability was illustrated by a modified Glasgow Plot. Twenty-three males and 10 females completed the study. Middle ear effusions resulted in 39.3 per cent (binaural in two patients) and 33.3 per cent (binaural in five patients) of patients having hearing disability pre- and post-irradiation respectively. No patient had hearing disability as a result of a sensorineural loss. It is recommended that future reporting of post-irradiation hearing changes in patients with NPC, as in middle ear surgery, be considered from a disability-orientated approach.

Lip and intraoral tumours: a local perspective

Lip and intra-oral cancer is an uncommon disease in Singapore among the local population. The incidence is less than 1.5% of all cancers reported to the Singapore Cancer Registry which recorded a total of 18,049 cases of all types of cancer in a 5-year period from 1978 to 1982. The Department of Plastic Surgery at Singapore General Hospital has been conducting a multidisciplinary clinic for the management of head and neck tumours since 1984. The results of the distribution, age, sex and racial differences, risk factors and modalities of treatment of the various types of cancer affecting the lip and intraoral region were analysed in a prospective study. A total of 69 cases were analysed and of these 59 (85.5%) were squamous cell carcinoma (SCC) of varying grades of malignancy, the remaining comprising adenoidcystic and mucoepidermoid carcinoma, malignant melanoma and a single case of ameloblastoma. A number of predisposing factors such as smoking, alcohol and the chewing of betel nuts could be identified in the history of patients suffering from cancers involving the buccal mucosa and tongue. As the numbers involved in non-SCC are small in this study, the discussion will be confined to patients presenting with squamous cell carcinoma only.

Prenatal sonographic diagnosis of Pena-Shokeir syndrome type I, or fetal akinesia deformation sequence

We report on a familial case of Pena-Shokeir syndrome type I (fetal akinesia deformation sequence) born to healthy parents. The antenatal ultrasound diagnosis was based on hydramnios, restricted limb movements, decreased fetal chest movements, small chest, arthrogryposis, clubfoot, fixed extension of knees, fixed flexion of elbows, camptodactyly, kyphosis of thoracic spine, cryptorchidism, and small muscle bulk. Thymic hyperplasia was noted at autopsy.

Sonographic diagnosis of leiomyosarcoma of the inferior vena cava: correlation with computed tomography and angiography

We describe a patient with leiomyosarcoma of the inferior vena cava. There has been no previous report of the sonographic diagnosis of this rare entity.

Etiological factors associated with the development of periventricular leukomalacia

Prenatal, intrapartum and postnatal factors are compared between 15 preterm infants, known to have periventricular leukomalacia (PVL) on ultrasound and 15 infants of similar birthweight and gestation who ultrasonographically showed no evidence of cystic lesions, and who are known to be neurologically normal at follow up. Prenatally, the incidence of antepartum haemorrhage was significantly higher in the PVL group. Intrapartum factors were similar between the two groups but postnatally, the PVL group had significantly lower PaCO2 readings during the first 72 h of life. It is postulated that a severe maternal bleed in late pregnancy and neonatal hypocarbia could significantly decrease cerebral perfusion and cause areas of ischaemia and infarction resulting in periventricular leukomalacia.

Periventricular leukomalacia: ultrasonic diagnosis and neurological outcome

The ultrasonographic findings and neurological development of 15 preterm infants, born between August 1981 and July 1984, who developed periventricular leukomalacia (P.V.L.) are described. The incidence of P.V.L. in infants with a birth weight less than 1 500 g was 2.3%. Nine of the 15 infants demonstrated areas of increased echogenicity in the periventricular regions prior to the development of cystic changes. The mean age for the appearance of cysts was 26 days. At follow-up 14 infants showed evidence of abnormal motor development and 8 infants had visual defects. All infants appear to have normal hearing, but 3 infants show signs of delayed speech. To date, only 2 infants demonstrate signs of mental retardation, but many of the infants are too young to assess intelligence accurately.

Fetal renal cystic disease: sonographic-pathologic correlation

Renal cystic disease encompasses a complex group of pathologic and clinical entities, with varied yet distinctive sonographic features. An accurate assessment of the fetal genitourinary tract and the amniotic fluid volume by sonography can lead to a specific prenatal diagnosis in most cases. This article emphasizes the usefulness of sonographic-pathologic correlation in understanding renal cystic disease. The entities discussed are infantile polycystic kidney disease (Osathanondh and Potter type I), multi-cystic renal dysplasia (type II), adult polycystic kidney disease (type III) and renal cystic dysplasia associated with obstructive uropathy (type IV). Sonograms of six correctly diagnosed cases between November 1982 and November 1984 were retrospectively reviewed and correlated with their pathologic findings. The differential diagnosis and possible pitfalls are discussed. In addition, the impact on perinatal management and the role of genetic counselling will be emphasized.

Reliability of amniotic fluid volume estimation from ultrasonograms: intraobserver and interobserver variation before and after the establishment of criteria

This study assesses levels of intraobserver and interobserver agreement for the determination of decreased and normal amniotic fluid volumes, both before and after the development of criteria. Good to excellent levels of agreement were obtained. Agreement may be higher after the development of criteria and may be higher for more experienced ultrasonographers.

Diagnosis and evolution of periventricular leukomalacia: a study with real-time ultrasound

Periventricular leukomalacia is an ischemic lesion in periventricular white matter of premature infants. Hemorrhage into the ischemic area occurs in up to 25% of cases. We report two cases in which the diagnosis of periventricular leukomalacia was made during life with real-time ultrasound scanning. In one case, serial scans demonstrated the evolution of echodense regions, observed in the first 3 days of life, to cystic echolucent areas at 4 weeks. In the second case, periventricular echodense areas did not precede the occurrence of cystic echolucent lesions. This may reflect a more chronic ischemic cerebral insult (consistent with recurrent apnea and bradycardia) rather than a presumed acute episode of cerebral ischemia (with or without secondary hemorrhage) sustained by the first case. Real-time ultrasound scanning is a simple, non-invasive technique with which to document the evolution of periventricular leukomalacia, and thus to define the clinical neurological correlates in the neonatal period.

Perinatal factors that influence the incidence of subependymal and intraventricular hemorrhage in low birthweight infants

A total of 95 preterm infants, delivered consecutively in a perinatal center, over a 9-month period, were studied serially with real-time ultrasound for detection of subependymal/intraventricular hemorrhage (SEH/IVH); all infants were less than or equal to 32-week gestation and/or less than or equal to 1500 gm birthweight. Detailed statistical analysis was carried out to determine the influence of perinatal factors on the occurrence of SEH/IVH. The incidence of SEH/IVH was 34%; severe hemorrhage (Grade III-IV) occurred in only 13%. Gestational age was an important factor associated with SEH/IVH. Thus, the incidence in infants less than or equal to 29-weeks gestation was 45%, whereas in infants greater than 29-weeks gestation age, it was 19% (p less than 0.01). The overall incidence of SEH/IVH in the group which was less than or equal to 29-weeks gestation and delivered by cesarean section was 53%, whereas in those infants delivered vaginally it was 47%. In infants whose gestational age was less than or equal to 29-weeks, the incidence of hemorrhage was 47% if delivered vaginally and presenting as a vertex and 31% if delivered by cesarean section. In infants greater than 29-weeks gestation, the incidence of SEH/IVH was 42% in those delivered by the vaginal vertex route, 5% if presentation was vertex and delivered by cesarean section (p less than 0.05). In infants greater than 29-weeks gestation, cesarean section in vertex presentation decreased the incidence of SEH/IVH when compared with vaginal vertex delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence, severity, and timing of subependymal and intraventricular hemorrhages in preterm infants born in a perinatal unit as detected by serial real-time ultrasound

Real-time ultrasound scans were performed on 66 low-birth-weight infants within the first six hours of life (mean, two hours), and then at 12, 24, 48, and 72 hours, and thereafter at weekly intervals. All of the infants were born in a perinatal unit. The incidence of intraventricular hemorrhage and subependymal hemorrhage was 31%. Eight of 20 infants had small hemorrhages (Papile, grades I and II); seven infants sustained grade III hemorrhages, and five infants sustained grade IV hemorrhages. All hemorrhages occurred in the first 72 hours of life; 25% were diagnosed with the first scan (ie, within the first six hours of life). The infants especially at risk were those less than 29 weeks' gestation. Five infants developed progressive posthemorrhagic ventriculomegaly that subsided spontaneously by age 8 weeks. The mortality in the study group was only 4.5%.