Delayed diagnosis of tuberculosis: risk factors and effect on mortality among older adults in Hong Kong

OBJECTIVE

To assess the risk factors and effects of delayed diagnosis on tuberculosis (TB) mortality in Hong Kong.

METHODS

All consecutive patients with TB notified in 2010 were tracked through their clinical records for treatment outcome until 2012. All TB cases notified or confirmed after death were identified for a mortality survey on the timing and causes of death.

RESULTS

Of 5092 TB cases notified, 1061 (20.9%) died within 2 years of notification; 211 (4.1%) patients died before notification, 683 (13.4%) died within the first year, and 167 (3.3%) died within the second year after notification. Among the 211 cases with TB notified after death, only 30 were certified to have died from TB. However, 52 (24.6%) died from unspecified pneumonia/sepsis possibly related to pulmonary TB. If these cases are counted, the total TB-related deaths increases from 191 to 243. In 82 (33.7%) of these, TB was notified after death. Over 60% of cases in which TB diagnosed after death involved patients aged ≥80 years and a similar proportion had an advance care directive against resuscitation or investigation. Independent factors for TB notified after death included female sex, living in an old age home, drug abuse, malignancy other than lung cancer, sputum TB smear negative, sputum TB culture positive, and chest X-ray not done.

CONCLUSIONS

High mortality was observed among patients with TB aged ≥80 years. Increased vigilance is warranted to avoid delayed diagnosis and reduce the transmission risk, especially among elderly patients with co-morbidities living in old age homes.

Optimising the utility of pleural fluid adenosine deaminase for the diagnosis of adult tuberculous pleural effusion in Hong Kong

INTRODUCTION

Pleural fluid adenosine deaminase level can be applied to rapidly detect tuberculous pleural effusion. We aimed to establish a local diagnostic cut-off value for pleural fluid adenosine deaminase to identify patients with tuberculous pleural effusion, and optimise its utility.

METHODS

We retrospectively reviewed the medical records of consecutive adults with pleural fluid adenosine deaminase level measured by the Diazyme commercial kit (Diazyme Laboratories, San Diego [CA], United States) during 1 January to 31 December 2011 in a cluster of public hospitals in Hong Kong. We considered its level alongside early (within 2 weeks) findings in pleural fluid and pleural biopsy, with and without applying Light's criteria in multiple scenarios. For each scenario, we used the receiver operating characteristic curve to identify a diagnostic cut-off value for pleural fluid adenosine deaminase, and estimated its positive and negative predictive values.

RESULTS

A total of 860 medical records were reviewed. Pleural effusion was caused by congestive heart failure, chronic renal failure, or hypoalbuminaemia caused by liver or kidney diseases in 246 (28.6%) patients, malignancy in 198 (23.0%), non-tuberculous infection in 168 (19.5%), tuberculous pleural effusion in 157 (18.3%), and miscellaneous causes in 91 (10.6%). All those with tuberculous pleural effusion had a pleural fluid adenosine deaminase level of ≤100 U/L. When analysis was restricted to 689 patients with pleural fluid adenosine deaminase level of ≤100 U/L and early negative findings for malignancy and non-tuberculous infection in pleural fluid, the positive predictive value was significantly increased and the negative predictive value non-significantly reduced. Using this approach, neither additionally restricting analysis to exudates by Light's criteria nor adding closed pleural biopsy would further enhance predictive values. As such, the diagnostic cut-off value for pleural fluid adenosine deaminase is 26.5 U/L, with a sensitivity of 87.3%, specificity of 93.2%, positive predictive value of 79.2%, negative predictive value of 96.1%, and accuracy of 91.9%. Sex, age, and co-morbidity did not significantly affect prediction of tuberculous pleural effusion using the cut-off value.

CONCLUSION

We have established a diagnostic cut-off level for pleural fluid adenosine deaminase in the diagnosis of tuberculous pleural effusion by restricting analysis to a level of ≤100 U/L, and considering early pleural fluid findings for malignancy and non-tuberculous infection, but not Light's criteria.

Newer fluoroquinolones for treating respiratory infection: do they mask tuberculosis?

Possible masking of tuberculosis (TB) in treatment of community-acquired respiratory infection by newer fluoroquinolones has not been examined in randomised controlled trials. We undertook a randomised, open-label controlled trial involving adults with community-acquired pneumonia or infective exacerbation of bronchiectasis encountered in government chest clinics in Hong Kong. 427 participants were assigned by random permutated blocks of 20 to receive either amoxicillin clavulanate (n = 212) or moxifloxacin (n = 215). Participants were followed for 1 yr for active pulmonary TB. Excluding three participants with positive baseline culture, 13 developed active pulmonary TB: 10 (4.8%) out of 210 were given amoxicillin clavulanate, and three (1.4%) out of 214 were given moxifloxacin. The difference was significant by both proportion and time-to-event analysis. Post hoc analysis showed a significant decrease in the proportion with active pulmonary TB from 4.8% to 2.4% and 0% among participants given amoxicillin clavulanate (n = 210), moxifloxacin for predominantly 5 days (n = 127) and 10 days (n = 87), respectively. The log rank test for trend also showed a significant difference between the three subgroups. Regression models reaffirmed the linear effect; the adjusted odds ratio (95% confidence interval) of active pulmonary TB after moxifloxacin exposure up to predominantly 10 days was 0.3 (0.1-0.9). Newer fluoroquinolones appear to mask active pulmonary TB.

Effect of Flos carthami on stress-activated protein kinase activity in the isolated reperfused rat heart

The apoptotic death of cardiomyocytes due to ischemia/reperfusion is one of the major complications of heart disease. Ischemia/reperfusion has been shown to lead to the activation of the stress-activated protein (SAP) kinases and the p38/reactivating kinase (p38/RK). In this study, the direct effect of an aqueous Flos carthami (FC) extract on SAP kinases was investigated. When isolated rat hearts were perfused by Langendorff mode with media containing FC extract prior to the induction of global ischemia and the subsequent reperfusion, SAP kinase activity was inhibited 95%. Untreated ischemic/reperfused hearts showed a 57% elevation in the activity of SAP kinase. The in vitro effect of these FC extracts on SAP kinase was also tested. At a concentration of 10 microg/ml, the aqueous FC extract resulted in 50% inhibition of SAP kinase activity in ischemic heart tissue. Our results showed that FC affected both the interaction of SAP kinase with c-jun as well as the phosphotransferase reaction. These results clearly demonstrate that extracts from Flos carthami exerted inhibitory effects on SAP kinase. The administration of the FC extract may lead to a modulation of the apoptotic effect of SAP kinase activation induced during ischemia/reperfusion.

Olfactory function in patients with nasopharyngeal carcinoma following radiotherapy

The aim of this study was to examine the impact of radiation treatment on olfactory function in patients with nasopharyngeal carcinoma (NPC). An olfactory function test battery was administered to 25 adult NPC patients having received radiotherapy, 24 adult nasopharyngeal carcinoma patients awaiting to receive radiation treatment, and 36 adult normal control subjects. Members of the three groups were matched in terms of age, educational level, and full-scaled IQ score. Comparing the test results revealed that the NPC patients with radiotherapy had olfactory information processing impairments including absolute threshold, odour-tactile cross-modality matching, verbal identification of odours, and recall and recognition of identity of odours. The deficits of suprathreshold olfactory functioning in these patients did not seem to arise from impaired absolute threshold sensitivity. Provided that the results are reproducible, an evaluation of olfactory functioning in NPC patients during the period of radiotherapy may be useful for detecting or even avoiding side effects of radiation.

Aorta wall motion monitoring by 1-d MRI of perpendicular diameters

A method for monitoring the cross-sectional size of blood vessels rapidly is introduced. The method creates a one-dimensional (1-D) profile of a strip along the diameter of a vessel using magnetic resonance imaging (MRI). The strips can be much wider than pixels in a typical two-dimensional (2-D) image to increase the signal-to-noise ratio. A second strip perpendicular to the first is also imaged sequentially to allow the detection, estimation, and correction of errors in diameter measurements resulting from the strip inadvertently covering a chord, rather than a diameter. Diameter measurements derived from 1-D profiles agree with measurements derived from 2-D images. This method is nearly an order of magnitude faster than 2-D MRI and has the potential for real-time implementation. J. Magn. Reson. Imaging 1999;10:833-840.

Neuropsychological function in patients with nasopharyngeal carcinoma after radiotherapy

A neuropsychological test battery was administered to 27 adult patients with nasopharyngeal carcinoma (NPC) who had received radiotherapy, 28 adult patients with NPC awaiting radiotherapy, and 35 normal adult controls. The 27 patients with radiotherapy had a conventional dosage, 220 cGy per fraction, or less. The median interval between the completion of radiotherapy and the evaluation of neuropsychological function was 1.7 years. Groups were matched for age and educational level. The results showed that our NPC group with radiotherapy had neuropsychological impairments in the areas of auditory attention/concentration, immediate and delayed verbal recall and immediate visual recall, and recent memory, higher-order visuospatial abilities, and bimanual dexterity. Thus neuropsychological dysfunction may occur in patients with NPC within the first 2 years after radiotherapy.

The clinical implications of hydronephrosis and the level of ureteral obstruction in stage IIIB cervical cancer

PURPOSE

There are two criteria for the diagnosis of Stage IIIB cervical cancer in the FIGO staging system: tumor fixation to the pelvic side wall and/or the presence of hydronephrosis due to tumor. However, we often encounter hydronephrosis without tumor fixed to the pelvic side wall or the level of ureteral obstruction not corresponding to the main tumor mass in the pelvis. The clinical implication of these phenomena remains unclear. We investigated the Stage IIIB population treated at the Mallinckrodt Institute of Radiology and hypothesized that, if hydronephrosis presents without tumor fixation to the pelvic side wall or if the level of ureteral obstruction is above the main pelvic tumor mass, it most likely resulted from external compression of ureter(s) by enlarged lymph nodes and, consequently, a worse outcome is expected.

METHODS AND MATERIALS

From 1959 to 1989, there were 297 patients with Stage IIIB cervical cancer who received definitive radiation therapy at the Mallinckrodt Institute of Radiology and were assessable for the presence of hydronephrosis and the level of ureteral obstruction. There were 281 patients who presented with tumor fixed to the pelvic side wall, and 62 of them were associated with concurrent hydronephrosis. An additional 16 patients presented with hydronephrosis without tumor fixation to the pelvic side wall. Among these 78 documented cases of hydronephrosis, the level of ureteral obstruction was above the true pelvis in 39 patients, and below the true pelvis in the other 39. Radiation therapy was individualized according to tumor extension and configuration; para-aortic lymph nodes were not routinely treated except in patients with clinical evidence of nodal metastasis.

RESULTS

The progression-free survival (PFS) at 5 years was 35% in 62 patients with hydronephrosis and tumor fixed to the pelvic side wall vs. 43% in 213 patients with tumor fixed to the pelvic side wall only (p=0.12). However, PFS at 5 years decreased to 23% in 16 patients who presented with hydronephrosis without tumor fixation to the pelvic side wall (p < 0.001). When the level of ureteral obstruction was investigated, 5-year PFS was 39% vs. 22%, respectively, for the obstruction below vs. above the true pelvis (p=0.02). The majority of patients with ureteral obstruction above the true pelvis died of distant metastasis.

CONCLUSIONS

The additional presence of hydronephrosis did not significantly worsen the PFS among Stage IIIB patients with tumor fixation to the pelvic side wall. However, hydronephrosis without tumor extending to the pelvic side wall or the level of ureteral obstruction above the true pelvis was associated with poor outcome due to a significant increase in distant failure. We propose that this population be separated from current Stage IIIB classification.

Early stage nasopharyngeal carcinoma: radiotherapy dose and time factors in tumor control

OBJECTIVE

To evaluate radiotherapy dose and length of treatment in the control of early stage nasopharyngeal carcinoma (NPC) treated with a combination of external radiotherapy and brachytherapy,

MATERIALS & METHODS

We reviewed the records of 133 patients with early stage nasopharyngeal carcinoma (stage I or II, AJC/UICC staging system) who received definitive radiotherapy in Chang Gung Memorial Hospital from 1979 to 1991. The median follow-up time was 7.1 years with a minimum of 2 years. All patients were treated with megavoltage external radiotherapy to the nasopharynx area (63-72 Gy) followed by high dose rate intracavitary brachytherapy (5-16.5 Gy in one to three fractions, spaced 1-2 weeks apart). The median total dose and time of irradiation was 75 Gy (69.8-81.4 Gy) and 11.6 weeks (7.8-20 weeks) respectively. Survival analysis was used to examine the effect of several variables on prognosis.

RESULTS

The 5-year rates were 86.4% for local control, 84.7% for disease free survival, 88.5% for actuarial survival and 84.2% for overall survival. The treatment group (combination of time and dose of irradiation) was the most important prognostic factor according to Cox's proportional hazard model. Patients receiving radiation at a total dose of < or = 75 Gy completed in < 12 weeks showed the best prognosis.

CONCLUSION

Treatment time and total treatment dose are both important factors in treating early stage NPC. Decreasing the total radiation time to < 12 weeks and not exceeding a radiation dose of 75 Gy gave the best results.

Adaptive rival penalized competitive learning and combined linear predictor model for financial forecast and investment

We propose a prediction model called Rival Penalized Competitive Learning (RPCL) and Combined Linear Predictor method (CLP), which involves a set of local linear predictors such that a prediction is made by the combination of some activated predictors through a gating network (Xu et al., 1994). Furthermore, we present its improved variant named Adaptive RPCL-CLP that includes an adaptive learning mechanism as well as a data pre-and-post processing scheme. We compare them with some existing models by demonstrating their performance on two real-world financial time series--a China stock price and an exchange-rate series of US Dollar (USD) versus Deutschmark (DEM). Experiments have shown that Adaptive RPCL-CLP not only outperforms the other approaches with the smallest prediction error and training costs, but also brings in considerable high profits in the trading simulation of foreign exchange market.

Concurrent 5-fluorouracil, leucovorin, etoposide, cisplatin and radiotherapy for locally advanced non-small cell lung cancer

BACKGROUND

The prognosis of Stage III unresectable non-small cell lung cancer may be improved by concurrent chemoradiotherapy. In this study, we attempted to evaluate the feasibility, tolerance, efficacy and toxicities of the combination of thoracic radiation and chemotherapy with a novel regimen that included 5-fluorouracil, leucovorin, etoposide and cisplatin (the FLEP regimen) in the treatment of this group of patients.

PATIENTS AND METHODS

From July 1995 to September 1996, 20 untreated patients with locally advanced non-small cell lung cancer were enrolled in the study. Radiation at a dose of 44 Gy was initially delivered in daily fractions of 2 Gy 5 days a week to the tumor and mediastinum, followed by a boost to the tumor (20 to 26 Gy according to patients tolerance). Concurrently with thoracic irradiation, patients were treated with chemotherapy consisting of cisplatin at the dose of 60 mg/m2/d for 1 day, etoposide at the dose of 60 mg/m2/d for 2 days, and 5-FU 500 mg/m2/d plus leucovorin 50 mg/d infusion for 48 hours. Cycles of chemotherapy were repeated every 3 weeks for a maximum of 3 cycles.

RESULTS

Seventeen of 20 patients were assessable. The overall response rate was 70.6% (95% confidence interval = 49-92%). No complete response was achieved. The median response duration for all responding patients is not yet estimable, with a range of 3.5 to 15.5+ months. Eleven patients remain progression-free for 4 to 15 months. The median survival for the entire group is not estimable. The major toxicity was esophagitis. Other grade 3 or 4 toxicities were not frequently observed.

CONCLUSION

Combined-modality therapy with FLEP regimen and radiation is a promising treatment with a high response rate and acceptable toxicity for locally advanced non-small cell lung cancer.

Sustained complete remission after incomplete chemoradiation complicated with pelvic cellulitis in a patient with recurrent cervical carcinoma

We report on a 52-year-old female patient with a bulky, recurrent cervical carcinoma involving the vagina and bladder, who developed entero-recto-vesicovaginal fistulas and sepsis with pelvic cellulitis after external radiation of 40 Gy and 2 courses of concurrent chemotherapy. Chemoradiation was interrupted and an ileostomy was performed. After recovery, no residual tumor was detectable. Thirteen months after ceasation of chemoradiation, repair of vesicovaginal and rectovaginal fistulas via posterior sagittal approach was performed. Revision of double bowel ileostomy and ileo-T-colostomy was performed 17 months later. The patient enjoyed the restoration of enteral and urinary function only temporarily. She developed rectovesical fistula and underwent an ileostomy again 6 months later. She had another episode of peritonitis and upper gastrointestinal bleeding and expired at 4 years from initiation of salvage therapy. She had no evidence of cancer recurrence during a series of laparotomies and biopsies. The dramatic regression of the tumor may be attributed to its extraordinary radiosensitivity or chemosensitivity. The acute pelvic inflammatory complications may also contribute to the tumor cell killing. The prognosis of recurrent cervical carcinoma is invariably poor except in small tumors confined to vagina. This case gives support to the efficacy of chemoradiation and the potential role of biologic therapy in treatment of this dismal disease.

Acute toxicities and feasibility of altered fractionated radiotherapy in nasopharyngeal carcinoma

BACKGROUND

Altered fractionated radiotherapy (AFR) has been used for many years in the treatment of cancer. Although AFR therapy improves tumor control, it also increases acute radiation toxicities, which may make patients withdraw from treatment. Here, we report on the efficacy of AFR in the treatment of nasopharyngeal cancer (NPC).

METHODS

From September 1993 to October 1994, 68 NPC patients received AFR in Chang Gung Memorial Hospital-Linkou. The efficacy of two types of AFR were studied: (a) Hyperfractionated radiotherapy (HFT) in which irradiation was given twice a day throughout the radiotherapy course with a total radiation dose of 81.6 Gy/68 fractions in 7 weeks; and (b) Concomitant boost radiotherapy (CBT) in which additional concommitant radiotherapy was administered only during the last 2 weeks of the radiotherapy course. The total radiation dose of CBT was 72.3 Gy/42 fractions in 6 weeks. Twenty-six patients received HFT and 42 received CBT.

RESULTS

The percentage of grade 3 complications was 73% in CBT and 65% in HFT. The mean number of treatment days was 57.1 in HFT (median, 53; range 48-63) and 43.9 in CBT (median, 43; range 40-60). No patient withdrew from or prolonged the treatment because of acute radiation toxicities.

CONCLUSION

Our results demonstrated that NPC patients can tolerate HFT and CBT radiotherapy with sufficient psychological support. Further randomized trials will be continued in our institution.

A longitudinal study of multimodal evoked potentials in patients following radiotherapy for nasopharyngeal carcinoma

Radiation rhombencephalopathy and radiation myelopathy may occur in patients months or years after radiotherapy for malignancy of the head and neck. We obtained multimodal evoked potentials longitudinally in 26 patients with proven nasopharyngeal carcinoma. Recordings were made before radiotherapy and at 1 week, 3 months, 9 months, 15 months, and 24 months after radiotherapy. All absolute latencies of evoked response before and after radiation were within normal limits. However, the I-III interpeak latencies of brainstem auditory evoked potentials and the onset latencies of motor evoked potentials in the whole group of patients at 15 months after radiation were significantly longer than those before radiotherapy, whereas the latencies at 24 months were not significantly different. The N20 latencies of somatosensory evoked potentials after radiotherapy were significantly prolonged at 3 months of follow-up; the prolongation then became normal. They indicate that a subclinical reversible radiation-induced dysfunction may occur in the auditory, sensory, and motor systems.

Localised plasmacytomas in Taiwan: comparison between extramedullary plasmacytoma and solitary plasmacytoma of bone

The clinical features and response to therapy of 32 Chinese patients with localised plasmacytoma are presented, and a comparison between extramedullary plasmacytoma (EMP) and solitary plasmacytoma of bone (SPB) is made. Twenty-two patients had SPB and ten had EMP, accounting for 9% of all of our plasma cell neoplasms. Both groups had a male predominance with a median age of 54 years for SPB and 63 years for EMP. The common sites of SPB included vertebral bodies (15) and the skull (4). Most EMPs occurred in the oronasopharynx (6) and paranasal sinuses (2). An M-protein was detected in eight patients with SPB and in six with EMP. Seventeen patients with SPB and seven with EMP received radiation therapy, and all achieved initial local control. The pattern of failure in 22 patients with SPB manifested as local recurrence in two, multiple bone metastases without bone marrow plasmacytosis in two, multiple EMP progression in two, and development of multiple myeloma (MM) in one. There were two local recurrences, one further solitary bone involvement and one MM conversion in the EMP group. Local recurrence or dissemination was associated with the appearance of M-protein or an increase in the M-protein level in both groups. There was no significant difference in M-protein status or incidence and patterns of failure between the two groups. Patients with EMP had a more favourable overall survival than those with SPB (P = 0.03). The 5 year disease-free survival rate was 79% for EMP and 58% for SPB (P = 0.53). Patients aged less than 60 years had a better overall survival in the SPB group, but location of tumour, presence of M-protein, radiation dose and chemotherapy did not influence prognosis in either group. Our results indicate that adequate local therapy can result in long-term survival with a low frequency of MM progression for patients with localised plasmacytomas, and both EMP and SPB appear to be similar in terms of frequency and patterns of failure.

Combination chemotherapy with carmustine and cisplatin before, during, and after radiotherapy for adult malignant gliomas

Twenty-two patients, aged 16 to 67, who had malignant gliomas after surgical resection were treated with carmustine and cisplatin intravenous infusion before, during, and after radiotherapy. All patients had subtotal or total resection, or biopsy as the initial procedure. Twenty-one patients who had at least 2 cycles of chemotherapy and finished the whole course of radiotherapy were considered to be evaluable for responses. Among them, 5 had glioblastoma multiforme, 16 had anaplastic astrocytoma. The median time to tumor progression was 35 weeks (range 12-130 weeks) and median survival time was 66 weeks (range 10-156 weeks). Early progression occurred more frequently in patients with biopsy only and subtotal resection, and in patients with glioblastoma than in those with anaplastic astrocytoma. This combined modality treatment program was associated with reversible hematologic toxicity which was severe in 2 patients, and with ototoxicity in 1 patient, nephrotoxicity in 2 patients. Combination of carmustine and cisplatin with cranial irradiation for malignant gliomas is moderately toxic and appears to offer no obvious survival advantage compared with radiation therapy plus BCNU alone.

Solitary plasmacytoma of bone

From 1978 to 1992, 19 patients were diagnosed with solitary plasmacytoma of bone (SPB) accounting for 5.5% of plasma cell neoplasms in Chang Gung Memorial Hospital. Fourteen were male and five were female, with ages ranging from 21 to 71 years (median, 53 years). M-protein was detected at diagnosis in five patients, and during follow-up in three. The most common sites of SPB were the vertebral bodies, with seven involving the thoracic, four involving the lumbar and two involving the cervical spine. The remaining sites included the skull in four, and femur and pelvis in one each. Fifteen of the patients received local radiotherapy, local control was achieved in all; nine patients were alive with no evidence of disease for seven to 77 months, two patients remained in apparent remission at 14 and 92 months, two patients progressed to multiple myeloma at 12 and 84 months, one patient developed extramedullary plasmacytoma at three months, and one patient died of intercurrent disease at four months. The four patients who were not treated with radiation therapy ultimately developed local recurrence or dissemination within four years. In our series, local recurrence or dissemination was always associated with the appearance of, or an increase in, the M-component; thus, measurement of M-protein is helpful in assessing tumor control or progression. Based on our experience and a review of the literature, it is recommended that irradiation of the primary sites is the treatment of choice. Chemotherapy is indicated in those patients with disease progression, recurrence, or dissemination.

Comparison of radiotherapy and surgical results of early stage glottic cancer: a retrospective analysis

From March 1977 to October 1989, 85 patients with early stage glottic cancer were treated with either radiotherapy or surgery at Chang Gung Memorial Hospital (CGMH). Patients were excluded from the analysis of local control if they died or remained disease-free with a follow-up period of less than two years. Of the 26 patients treated with definitive radiotherapy, initial control of the primary lesions was achieved in 100% of stage T1s, 76% of T1, and 57% of T2 patients. Surgical salvage of radiation failure was achieved in 83% of the patients, giving the ultimate local control of 100% for T1s, 94% for T1, 86% for T2 patients. Of the 44 patients treated with definitive surgery, initial control of the primary lesions was achieved in 100% for T1s, 95% for T1, and 78% for T2 patients. Salvage of the surgical failure was 50%, giving the ultimate control in this group of 100% for T1s, 95% for T1, 83% for T2. There was no difference in either initial or ultimate control of T1 and T2 lesions between patients treated with primary radiotherapy and primary surgery. Voice preservation rates were 73% and 34% in the radiotherapy and surgery group, respectively. When divided into two groups according to the times they were being treated, we found that surgery preserved a comparable number of larynges as radiotherapy did after 1988 (60% vs 77%, p = 0.33). It is concluded that radiotherapy and surgery could achieve the same good local control results and long-term survival and comparable functional results of early stage glottic cancer, if conservative surgery is carefully selected for each patient.(ABSTRACT TRUNCATED AT 250 WORDS)

A multivariate analysis of prognostic factors in management of pineal tumor

PURPOSE

A multivariate analysis of prognostic factors of treatment outcome of pineal tumor.

METHODS AND MATERIALS

From February 1979 to June 1987, 25 patients with primary pineal tumors were treated in our department. Patients were treated with either AECL Co-60 unit or 10 MV linear accelerator to the primary tumor with an adequate margin or to the whole brain (median dose of 36 Gy) with or without a cone-down boost of 10 to 20 Gy. Craniospinal irradiation was performed in two patients with positive CSF cytology. Minimum follow-up was 40 months. Patients were further stratified according to tumor type. Group I consisted of seven patients with pineal germinoma. Group II included nine patients with nongerminoma, and Group III represented nine patients treated without a histological verification but clinical diagnosis.

RESULTS

The relapse-free survival (RFS) of Group I patients was 100% and 86% at 2 and 5 years, respectively. Relapse-free survival was 55% and 21% at 2 and 5 years, respectively, for Group II patients. Six of 9 patients in Group II died of disease due to either local recurrence or tumor seeding. Eight of 9 patients in Group III remain no evidence of disease, and RFS was 89% at 2 and 5 years. Multivariate analysis revealed that tumor histology is the only significant prognosticator. Age, gender, type of surgical procedure, RT field, and tumor dose were not. Cox's regression model also failed to demonstrate a significant correlation of tumor seeding with the type of surgery.

CONCLUSION

The type of tumors in the pineal region dictates the treatment outcome. Definitive radiation therapy is effective in controlling germinoma, whereas a more aggressive approach is needed to improve local control for nongerminoma. For a localized pineal lesion, we advocate that treatment can be tailored to the primary tumor with adequate margins. However, for locally advanced tumors whole brain or craniospinal irradiation should be considered. No definitive correlation between type of surgery and the probability of tumor seeding was identified.

Concurrent radiotherapy and continuous 5-fluorouracil infusion in the management of locally advanced esophageal cancer

From 1987 to 1989, a total of 22 patients with locally advanced non-metastatic esophageal cancer were treated by a combination of radiation therapy (RT) and chemotherapy (CT). RT, consisting of 250 cGy tumor dose per fraction with four fractions per week up to a total dose of 6000 cGy, was given concurrently with CT: 96 hours of continuous 5-fluorouracil (5-FU) infusion at a dose level of 250 g/kg/day. RT+CT was repeated every other week for a total of six cycles in 11 weeks. Toxicity data revealed that only mild to moderate mucositis, nausea/vomiting and myelosuppression occurred, and no patients developed unacceptable levels of toxicity necessitating discontinuation of the 5-FU infusion. Complete response (CR) was noted in nine out of 22 (41%) patients. The median progression-free survival period (MPFS) was 10 months, and the median absolute survival (MAS) was 13 months. Corresponding figures for our 61 previously RT treated patients (matched for sex, age, histopathology, tumor extent and location with current study group) were: CR rate, 8%; MPFS, three months; and MAS, six months. Kaplan and Meiers' survival curves and Log Rank test revealed a statistically significant difference in favor of the combined modality group (PFS, p = 0.0001; AS, p = 0.0001). The relatively good response rate and survival data appear to warrant further dose escalation in 5-FU since no major dose limiting toxicities were observed at 25 mg/kg/day.

Impact of prophylactic cranial irradiation in adenocarcinoma of the lung

Out of 148 patients who had metastatic adenocarcinoma of the lung and were referred to Chang Gung Memorial Hospital for treatment from 1979 to 1987, 20% had symptomatic brain metastases. We have attempted to determine the subset of high-risk patients who might benefit from prophylactic cranial irradiation. In 25 patients with a complete remission, 36% (n = 9) eventually developed brain metastases after a minimum follow-up of 24 months. Patients with initial mediastinal node metastases showed a higher incidence of brain metastases (75%) than those harboring only hilar node metastases (25%, p = 0.03). Age, sex, tumor location and clinical staging had no significant correlation in the prognosis of brain metastases. Since the median recurrence-free survival rate of six months for patients with brain metastases was significantly shorter than for those without (14 months), we recommend that prophylactic cranial irradiation be conducted in complete responders with mediastinal nodal lesions to see if such treatment will prolong patients' recurrence-free survival via a reduction in brain metastases, thus improving their quality of life.

Assessment of atrial natriuretic peptide resistance in cirrhosis with head-out water immersion and atrial natriuretic peptide infusion

The nature of sodium retention in cirrhosis complicated by ascites has been studied for the last 30 years. Resistance to the natriuretic action of atrial natriuretic peptide (ANP) may play a potential role in this sodium retention. To further evaluate this possibility, we studied 12 patients with biopsy-proven cirrhosis and ascites on 2 consecutive days after a 7-day period off diuretics while receiving a 20 mmol/day sodium restricted diet. Following a crossover design, patients underwent head-out water immersion (HWI) for 3 h and were infused with a alpha-human ANP for 2 h on 2 consecutive days. Blood and urine samples were collected hourly. Five patients displayed a natriuretic response to HWI, sufficient to achieve negative sodium balance, and these patients were termed responders. Each of these five patients also displayed a natriuretic response to ANP infusion. In contrast, the other seven patients (nonresponders) consistently failed to develop a natriuretic response to either maneuver. The two groups had similar elevations in plasma ANP concentrations, but at baseline differed in terms of plasma sodium, plasma renin activity, and serum aldosterone. Despite higher serum aldosterone concentrations, nonresponders excreted less potassium than responders during the peak effect of the interventions, suggesting greater sodium delivery to the aldosterone-sensitive nephron segment in responders. We conclude that the inability to mount an adequate sodium excretory response to HWI in patients with cirrhosis may be conveyed through increased antinatriuretic factors that decrease the sodium delivery to the medullary collecting duct and inhibit the natriuretic effect of ANP at that site.

A morphological and morphometric analysis of the optic nerve in the hypothyroid rat

This investigation was designed to morphologically evaluate the effects of hypothyroidism on the development of myelin and axons in the rat optic nerve. Four pups from each group of normal and propylthiouracil-induced hypothyroid rats were sacrificed at 14, 21, 28, and 35 postnatal days. Optic nerves were studied by both light and electron microscopes. The hypothyroid animals had significantly reduced body and brain weights compared to those of their age-matched controls. In the hypothyroid animals, the cross-sectional area of the optic nerve, the fiber density, and fiber occupancy were significantly diminished compared to those of the controls. The mean individual fiber size was unaffected. However, the relationship between the total axonal area to myelin thickness was similar in the control and experimental groups, implying that the feedback mechanism between myelinating cells and axons was not affected by hypothyroidism. Thus, this study indicates that the principal insult of neonatal hypothyroidism results in a delay in myelin acquisition of myelinated fibers, resulting in diminished cross-sectional area of the optic nerve, fiber density, and fiber occupancy.

High-dose-rate afterloading technique in the radiation treatment of uterine cervical cancer: 399 cases and 9 years experience in Taiwan

Carcinoma of the uterine cervix has been the leading malignant neoplasm treated in our department. A comparative study was carried out using conventional low dose rate (LDR) with 137Cs sources (less than or equal to 100 cGy/hr) versus high dose rate (HDR) with 60Co sources (greater than 100 cGy/min) in the intracavitary (IC) application following external pelvic irradiation. A total of 399 patients were treated with external RT plus HDR radiation treatment alone from February 1980 through December 1985. Stage IIb and IIIb comprised 79.4% of cases (317 cases). The rate of initial complete response of the tumor, local control, and survival rate seemingly were better in the HDR group, but there was no significant difference statistically. The actuarial survival rates in all cases/definitive RT cases are 85%/85% for Stage 0-IIa, 53%/70% for IIb, 43%/49% for IIIa, 43%/53% for IIIb, 42%/47% for IVa, respectively. Complications were similar and the rectal complications were slightly higher in HDR group. The combination of pelvic irradiation with HDR intracavitary irradiation was more convenient for patients and also for personnel. The HDR technique may be a good substitution for IC treatment.

Prognostic factors of nasopharyngeal carcinoma: a multivariate analysis

Between 1979 and 1985, 561 patients with nasopharyngeal carcinoma were reviewed to determine prognostic factors that may influence survival. Sex (p = 0.294) and histopathology (p = 0.677) had no correlation to the actuarial survival, whereas the site of cervical metastasis (p = 0.001) and the radiation doses to the nasopharynx and regional lymph nodes (p = 0.03) were both significant when one used univariate analyses. Cox's multivariate regression model revealed that the presence rather than the site of distant metastases was the single most important independent factor influencing the treatment outcome (p less than 0.0001). The addition of chemotherapy, on the other hand, did not show a survival benefit even when one took available confounding factors into account. There are, however, survival advantages associated with: (a) young age (less than or equal to 40 years), (b) asymptomatic status, (c) Stage I or II lesions, and (d) biopsy via nasopharynx instead of neck nodes. These favorable prognostic factors may be used for therapeutic guidance and end-result reporting.

[Evaluation of compensator used in radiation therapy]

A radiation beam incident on an irregular or sloping surface produces skewing of isodose curves and may give rise to unacceptable nonuniformity of the dose distribution within the target volume or cause excessive irradiation of sensitive tissues. The concept of using a compensator, first introduced by Ellis, to circumvent the skewness of isodose curves was elegant. Other workers followed suit elaborating further and extending the procedures. The treatment of chest wall tumors is of special interest and compensators were frequently used in their management. The compensators of aluminum and copper were systematically examined for 6 and 10 MV X-rays. Compensating thickness ratios was determined from equivalent dose measurement at compensating depth by placing compensator at the regular blocking tray for maintaining the skin sparing feature of high energy photon beams. The compensator must compensate not only for the reduction of the primary beam attenuation due to tissue deficit, but also for the loss of scattering by the missing tissues. It was found that the compensating thickness ratios (CTR) was not a constant value and was dependent on the tissue deficit, field size, compensating depth and the material of compensator, but was independent of the energy. As the tissue deficit is increased, the CTR decreases, since the loss of scattering for the deficit volume can be compensated by the lowered attenuation of the compensator. As the field size is increased, the CTR decreases. From the study of central axis depth dose for various deficit thickness, normalized at the median plane of no tissue deficit, it was found that compensator can compensate the dose accurately to one depth only and the compensation to other depth is approximate, and that the compensating error is increased with greater tissue deficit and further depth. The effectiveness of the compensating system with a stair-step polystyrene phantom representative of varying tissue deficits over a small treatment field (20 cm x 20 cm) was also studied with film dosimetry and the error was within 3%. The compensator thickness ratios must be measured in different radiation beams from different treatment machines and in different irradiation conditions because there are major difference between the CTR data obtained directly from experiments and the data besed on calculation from attenuation coefficient mu, physical density rho or electronic density, rho e. The specific CTR reported for aluminum and copper in the literature should only be used as a guideline.

Prospective hormone study of hypothalamic-pituitary function in patients with nasopharyngeal carcinoma after high dose irradiation

With the aim of evaluating the effect of high dose irradiation (6,500 cGy/36 fractions or higher) to pituitary fossa, a prospective study was carried out in patients with nasopharyngeal cancer by a serial determination of several hormones in the serum, before and after the course of radiation therapy (RT). The radiation treatment field was at least 1 cm above the skull base with bilateral parallel opposing fields. Hormone assays were performed three times on each patient: (1) prior to, (2) one month after, (3) 15-18 months after radiation therapy. The study included determination of serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), cortisol, growth hormone (GH) and prolactin concentrations and LH-releasing hormone, thyrotrophin-releasing hormone stimulation and insulin tolerance tests were also carried out. Complete profiles were obtained in 24 patients (16 males and 8 females), aged 16-67 years. The results showed a significant decrease in the level of serum peak value of LH in males 18 months after therapy, and also in GH both one month and 18 months after therapy. A significant increase in the peak value of serum TSH observed after therapy. Decreased serum FSH, cortisol and prolactin levels were noted, but these did not reach statistical significance. The decrease in GH level appeared earlier and was more sensitive than that found for the other hormones, and could prove to be a useful parameter for clinical evaluation. None of the patients showed any clinically recognizable symptoms or signs of hormone deficiency in the 18-33 months following completion of the radiation therapy.

Clinical significance of cranial nerve deficit in the therapy of nasopharyngeal carcinoma

The results of radiation treatment of nasopharyngeal carcinoma (NPC) have recently been improved, but the prognosis remains relatively poor in cases with cranial nerve (CN) involvement. A total of 109 cases with histologically-proven NPC and cranial nerve involvement treated during 1979-1985 were reviewed and analysed. Definitive radiotherapy (RT) was given to patients with a high upper margin of the RT field at 2.5 cm above the base of the skull to a total dose of 70.2 Gy/39 fractions/8 weeks, with two applications of intranasopharyngeal brachytherapy. There were 37 cases (34%) in Group I (upward invasion only) and 72 cases (66%) in Group II (bidirectional invasion). Abducens, trigeminal, oculomotor and facial were the commonly involved nerves. Headache was the major symptom at diagnosis and was present in 82.6% of the patients, significantly higher than in general NPC cases (p less than 0.005). Fifty per cent (31/62) achieved complete response to definitive RT, but it did not correlate well with survival rate. The residual neurological deficit of each CN ranged from 31 to 57%. The actuarial 5-year survival rates of Groups I and II were similar in spite of neck lymph node metastasis in Group II (33% (I) compared with 24% (II); p greater than 0.05). Cases with single CN deficit did not show better results than those with multiple CN involvements. Five-year survivors were seen only in those who received a complete course of definitive RT.

Hyperresponsiveness to water immersion in sodium retaining cirrhotics: the role of atrial natriuretic factor

Cirrhotics do not respond uniformly to head-out water immersion (HWI). Some cirrhotics have an exaggerated natriuresis while others are unresponsive. We studied the humoral and urinary responses to HWI in 5 cirrhotics and compared this to 5 normals on the same 20 mM sodium intake. These cirrhotics had a documented tendency to salt and water retention but had minimal or no evidence of significant ascites. Plasma levels of atrial natriuretic factor (ANF) increased during immersion in both groups. However, the rise in plasma ANF from baseline during each hour of immersion was significantly greater in the cirrhotics (p less than 0.01), than in the normal volunteers. In these cirrhotics, HWI not only corrected the pre-immersion tendency to sodium retention, but by 3 hours had produced an exaggerated natriuretic response (p less than 0.05). It is possible that the greater risk of ANF in cirrhotics is responsible for this natriuretic response. However the reason for the larger rise in cirrhotics is unclear; presumably either a greater central redistribution of plasma volume occurs in cirrhotics following immersion, or there may be greater sensitivity of the ANF release system in cirrhotics.

Role of atrial natriuretic peptide in the natriuretic response to central volume expansion induced by head-out water immersion in sodium-retaining cirrhotic subjects

PURPOSE

It is possible that abnormalities in atrial natriuretic peptide may be involved in the pathogenesis of sodium retention in edema states. We performed a study in a group of 12 sodium-retaining cirrhotic subjects to determine the role of this peptide in mediating differences in the natriuretic response to central volume expansion induced by head-out water immersion.

PATIENTS AND METHODS

Each patient was maintained for seven days on a 20-mmol sodium intake, and then studied on both control and immersion days. On each day, measurements of the following were obtained: plasma atrial natriuretic peptide, hematocrit, electrolytes, creatinine, plasma renin activity, serum aldosterone, urinary cyclic guanosine monophosphate (cGMP), blood pressure, and pulse rate.

RESULTS

In six subjects, immersion resulted in a marked natriuresis sufficient to induce negative sodium balance by the third hour, and these subjects were termed "responders." In these six patients, baseline pre-immersion levels of plasma renin activity and serum aldosterone were all below 3 ng/liter/second and 4 nmol/liter, respectively. In the other six subjects, the natriuretic response to immersion was markedly blunted and insufficient to induce negative sodium balance, and these subjects were termed "non-responders." In these subjects, baseline pre-immersion levels of plasma renin activity and aldosterone were all above 3.5 ng/liter/second and 5 nmol/liter, respectively, and were significantly elevated compared with the responders, and compared with the normal range for control subjects consuming the same sodium intake. In both groups of cirrhotic subjects, baseline levels of plasma atrial natriuretic peptide and cGMP excretion were significantly and comparably elevated compared with the normal range for control subjects ingesting the same sodium intake. Despite the marked difference in the natriuretic response to immersion in both responders and non-responders, there was a significant and comparable further elevation of plasma atrial natriuretic peptide and urinary cGMP excretion during immersion, compared with the control day.

CONCLUSION

These results suggest that the relative resistance to the natriuretic action of atrial natriuretic peptide in the non-responders compared with the responders is mediated by anti-natriuretic factors acting at a level parallel with or beyond atrial natriuretic peptide release or coupling to its cGMP-linked receptors.

Acute effects of peritoneovenous shunting on plasma atrial natriuretic peptide in cirrhotic patients with massive refractory ascites

Plasma immunoreactive alpha-human atrial natriuretic peptide (ANP) was measured in six cirrhotic patients with massive refractory ascites, under strict metabolic conditions, while they were receiving a 20-meq sodium diet, both before and at two-hour intervals for eight hours following peritoneovenous shunting (PVS). The mean preoperative level of ANP was 75 +/- 18 pg/ml, which was found to be significantly higher than the normal range for this laboratory (8 to 24 pg/ml) (p less than 0.05). This value was also significantly higher than the value of 21 +/- 5 pg/ml (p less than 0.05) obtained in six patients with cirrhosis but without ascites. Following shunt insertion, an immediate natriuresis and diuresis were observed in five of the six cirrhotic patients with refractory ascites. In these five, right atrial pressure and ANP rose immediately, followed by a rise in the level of urinary cyclic guanosine monophosphate. The sixth subject had a delayed rise in right atrial pressure, and correspondingly the rise in ANP, the diuresis, and natriuresis were delayed. The changes in ANP following PVS were positively correlated with changes in right atrial pressure (p less than 0.05), urinary cyclic guanosine monophosphate (p less than 0.05), urinary sodium excretion (p less than 0.05), and urine volume (p less than 0.01). These results suggest that ANP may be important in mediating the acute response to PVS.

Role of atrial natriuretic peptide and urinary cGMP in the natriuretic and diuretic response to central hypervolemia in normal human subjects

The response of plasma atrial natriuretic peptide (ANP) and urinary cGMP excretion to central hypervolemia induced by water immersion was assessed twice in five healthy male subjects, once while immersed in water to the neck for 3 h and again on a control day. Plasma ANP and urinary cGMP were measured by radioimmunoassay. Compared with the control day, overall change in plasma ANP on the immersion day was significant (p less than 0.05). In response to water immersion, plasma ANP increased from a base-line level of 13.2 +/- 3.1 (mean +/- SEM) to 24.2 +/- 5.5 pg/mL by 0.5 h of immersion and was sustained at that level throughout the immersion period. Plasma ANP returned to the base-line level at 1 h postimmersion. Urinary cGMP excretion increased significantly by 1 h of immersion and was sustained at that level throughout water immersion and 1 h postimmersion (p less than 0.05). During water immersion urine flow, urinary sodium and potassium excretion, free water clearance, and osmolar clearance increased while plasma renin activity, serum aldosterone, and blood pressure fell; all changes were significant (p less than 0.05). Creatinine clearance and hematocrit did not show any significant changes. These data suggest that an increase in plasma ANP may contribute to the natriuretic and diuretic response to central hypervolemia, and that the measurement of urinary cGMP may be a valuable marker of ANP biological responsiveness.