Interstitial Brachytherapy with Ir-192 Low-Dose-Rate in the Treatment of Primary and Recurrent Cancer the Oral Cavity and Oropharynx

AIM: To evaluate the impact of postoperative interstitial brachytherapy with and without external radiotherapy in the treatment of primary and recurrent squamous cell carcinoma of the oral cavity and oropharynx. PATIENTS AND METHODS: Between 1985 and 1997, a total of 318 patients were treated by interstitial Ir-192 low-dose-rate brachytherapy as part of their primary (n = 236) or recurrent treatment (n = 82). There were 263 male (83%) and 55 (17%) female patients. The distribution of UICC (1997) stages was as follows: I (61 patients, 19%), II (71 patients, 22%), III (58 patients, 18%), IV (128 patients, 40%). The primary tumor site was located in the oral cavity in 201 patients (63%), in the oropharynx in 86 patients (27%), lower lip in 19 patients (6%) and other regions in twelve cases (4%). Treatment concepts did not vary over the time and were dictated by the initial tumor extension: a total of 175 patients (55%) received a combination of surgery, interstitial brachytherapy (23-25 Gy) and external radiotherapy (50-60 Gy), 60 patients (19%) surgery and interstitial brachytherapy (45-55 Gy) alone. Advanced disease not amenable to primary surgery was either treated by radiochemotherapy and interstitial brachytherapy in 39 patients (12%) or a combination of interstitial brachytherapy, external radiotherapy and interstitial hyperthermia in 44 patients (14%). RESULTS: Overall survival rates following primary and recurrent treatment were 50 +/- 4% and 29 +/- 5%, respectively, at 5 years (p < 0.0001). A significant impact on overall survival rate was noted for UICC stage: patients in stage I/II had survival rates of 64 +/- 5% and 57 +/- 10%, respectively, while patients in stage III/IV had survival rates of 39 +/- 5% and 15 +/- 5%, respectively, at 5 years (p < 0.0001). In addition, grading (p = 0.01) and hemoglobin levels (p = 0.05) had a significant influence on overall survival. Local tumor control rates for all patients were 74 +/- 3% and 57 +/- 7% at 5 years following primary and recurrent treatment (p = 0.01), respectively. The 145 patients treated for primary disease by a uniform concept of surgery, interstitial brachytherapy and external radiotherapy achieved excellent local control rates with 92 +/- 4% (stage I/II) and 65 +/- 6% (stage III/IV) at 5 years. Late treatment-related toxicity with soft tissue necrosis and/or osteonecrosis requiring mandibular resection was 7.5%. CONCLUSION: Local tumor excision followed by postoperative interstitial brachytherapy with and without external radiotherapy is associated with excellent locoregional control, a low risk of chronic sequelae and may therefore considered as a new approach avoiding mutilating radical surgery.     

Impact of treatment extending to 60 Gy on the outcome of radiotherapy for nasopharyngeal carcinoma

PURPOSE: To clarify the impact of treatment duration on the outcome of nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS: Forty-three patients with NPC were treated with definitive radiotherapy from January 1980 through May 1996. The male-to-female ratio was 32:11, and median age was 58 years (10-78 years). According to the fifth UICC classification, 4 patients were stage I, 12 were stage II, 6 were stage III, and 21 were stage IV. Twenty-nine patients received chemotherapy. Each patient was treated to various doses according to their disease extension. Thus, treatment duration was defined as the duration from the start of radiotherapy to the end of 60 Gy. The median follow-up period was 63 months (2-164 months). RESULTS: The 5-year overall and disease-free survival rates of all patients were 66% and 59%, respectively. The 5-year disease-free survival rates of the patients treated with the short treatment duration (< or = 8 weeks) and those treated with the long treatment duration (> 8 weeks) were 76% and 38%, respectively (p = 0.008). CONCLUSION: Long treatment duration may lead to poor treatment outcome in NPC.     

Differentiated Thyroid Cancer: Prognostic Factors and Influence of Treatment on the Outcome in 441 Patients

BACKGROUND: Differentiated thyroid cancer (DTC) is a rare tumor entity with excellent prognosis. Thus, assessment of the efficacy of different treatment modalities requires follow-up for such a long period that the validity of the conclusion may be limited because diagnostic and therapeutic standards have changed substantially. Accordingly, the indication for external radiotherapy is still controversial. The aim of the present retrospective study is to evaluate prognostic factors and the influence of treatment on outcome of differentiated thyroid cancer from a large data base. PATIENTS AND METHODS: Records of 441 patients (317 females, 124 males; mean age 46 years) with 270 follicular and 171 papillary thyroid carcinomas (pT1-4, pN0-3) were reviewed. Treatment was surgery in 440, radioiodine therapy in 338, postoperative external radiotherapy (50-60 Gy) in 223 patients. In 182 cases the three modalities were combined. RESULTS: The 5-year actuarial survival rate of the whole study population was 95%, 10-year survival 92%. 10-year survival was significantly influenced by: tumor stage (pT1: 100%, pT2: 94%, pT3: 94%, pT4: 79%; p = 0.0005), age (< 40 years: 100%, 41-60 years: 91%, > 60 years: 79%; p = 0.0001) and the presence of lymph node metastases in the follicular subtype (pN0: 96%, pN1-3: 81%; p = 0.02). No significant differences in survival were found according to gender or histological subtype. External radiotherapy yielded a non-significant (p = 0.06) increase in the 10-year survival rate (87% vs 46%; p = 0.06) in patients with pT4 tumors (n = 60). CONCLUSION: Prognostic factors predominantly confirmed those reported in the literature. Further clinical studies should clarify, if the trend towards better survival in irradiated patients with pT4 tumors can be confirmed in larger patient groups.     

Lokal rezidiviertes und metastasiertes malignes Melanom Langzeitergebnisse und Prognosefaktoren nach perkutaner Radiotherapie

PURPOSE: Radiotherapy (RT) is used as last resort for patients with advanced cutaneous malignant melanoma (MM). Herein our 20-year clinical experience is presented analyzing different endpoints and prognostic factors in patients with locally advanced, recurrent or metastatic MM. PATIENTS AND METHODS: From 1977 to 1995, 2,917 consecutive patients were entered in the MM registry of our university hospital. RT was indicated in 121 patients (56 females, 65 males) for palliation in locally advanced recurrent and metastatic MM stages UICC IIB to IV. At the time of RT initiation, 11 patients had primary or recurrent lesions which were either not eligible for surgery or had residual disease (R2) after resection of a primary or recurrent MM lesion (UICC IIB); 57 patients had lymph node (n = 33) or in-transit metastases (n = 24) (UICC III), and 53 had distant organ metastases (7 M1a, 46 M1b) (UICC IV). The time from first diagnosis to on-study RT averaged overall 19 months (median: 18; range: 3 to 186 months). In 77 patients conventional RT and in 44 patients hypofractionted RT was applied with 2 to 6 Gy fractions up to a mean total RT dose of 45 (median: 48; range: 20 to 66) Gy. RESULTS: At 3 months follow-up, complete response (CR) was achieved in 7 (64%), overall response (CR + PR) in all (100%) UICC IIB patients, in 25 (44%) and 44 (77%) of 57 UICC III patients, and in 9 (17%) and 26 (49%) of 53 UICC IV patients. Tumor progression during RT occurred in 25 (21%) patients. Patients with CR survived longer (median: 40 months) than those without CR (median 10 months) (p < 0.01). At the time of evaluation and last FU (December 31, 1996), 26 patients were still alive: 6 (55%) stage UICC IIB, 17 (30%) stage UICC III, and 3 (6%) stage UICC IV patients (p < 0.01). Univariate analysis revealed following prognostic factors for CR and long-term survival: UICC stage (p < 0.001), primary location in the head and neck, total RT dose > 40 Gy (all p < 0.05), while age, gender and primary histological subtype had no impact. In multivariate analysis, UICC stage was the only independent favorable prognostic factor for achievement of CR and long-term survival (p < 0.001). CONCLUSION: External RT provides effective palliation in advanced UICC stages. The UICC staging system is a good predictor of initial and long-term tumor response in metastatic MM. Prospective randomized trials using RT with or without adjuvant therapy for advanced MM are justified.     

FDG uptake, glucose transporter type 1, and Ki-67 expressions in non-small-cell lung cancer: correlations and prognostic values

PURPOSE: FDG uptake mediated by glucose transporter type 1 (Glut-1) and tumor proliferative activity assessed by Ki-67 expression provide prognostic information in patients with non-small-cell lung cancer (NSCLC). Here, we compared the prognostic significances of FDG uptake, and of Glut-1 and Ki-67 expressions in patients with NSCLC. METHODS: NSCLC patients (n=53, F:M=16:37, age 61.9+/-12.1 years) who underwent curative resection after FDG-PET were enrolled. Thirty-one patients had stage I, 15 stage II, and 7 stage III disease. Patients were treated by surgery only (n=12), surgery plus adjuvant oral chemotherapy (n=32), or surgery plus adjuvant intravenous chemo- or radio-therapy (n=9). Maximum standardized FDG uptake values (maxSUV), and the Glut-1 and Ki-67 expressions of resected tumors were analyzed for correlations and relations with tumor recurrence. The median follow-up duration was 15 months. RESULTS: Thirteen (24.5%) of the 53 patients experienced recurrence during a median follow-up of 8 months and significant correlations were found between maxSUV, Glut-1, and Ki-67 expressions (r=0.48-0.79, p<0.001). Univariate analysis revealed that disease-free survival (DFS) was significantly correlated with maxSUV (<7 versus > or =7, p=0.001), % Ki-67 expression (<25% versus > or =25%, p=0.047), tumor size (<3 cm versus > or =3 cm, p=0.027), and tumor cell differentiation (well/moderate versus poor, p=0.011). However, multivariate Cox proportional analysis identified maxSUV as the only determinant of DFS (p=0.005). Patients with a maxSUV of > or =7 (n=14) had a significantly lower 1-year DFS rate (57.1%) than those with a maxSUV of <7 (n=39, 89.7%). CONCLUSION: FDG uptake is more valuable than Glut-1 or Ki-67 expression in terms of predicting prognosis in patients with resected NSCLC.     

Multimodality Therapy Including Radiotherapy and Chemotherapy Improves Event-Free Survival in Stage C Esthesioneuroblastoma

BACKGROUND: To evaluate the efficacy of multimodality therapy in patients with esthesioneuroblastoma (ENB). PATIENTS AND METHODS: From 01/1979 through 08/2001, 47 patients with ENB (20 men, 27 women, age 5-81 years), were registered from 18 oncologic centers. There were 14 tumors stage B and 33 stage C according to the Kadish classification. Initial treatment included surgery alone in seven patients, radiotherapy (RT) with or without chemotherapy (CTX) in twelve, surgery plus postoperative RT in 15, and multimodality therapy (surgery plus pre- or postoperative CTX plus postoperative RT) in 13. RESULTS: The 5-year overall survival (OS) for the whole group was 64 +/- 8% and the 5-year event-free survival (EFS) 50 +/- 8%. Patients with multimodality treatment had a significantly better 5-year EFS (74 +/- 13%) compared to the other patients (41 +/- 9%; p = 0.05), while the 5-year OS was not significantly different between the treatment groups (p = 0.39). For patients with Kadish stage C, multimodality therapy (n = 11) resulted in superior 5-year EFS (72 +/- 14% vs 17 +/- 9%; p = 0.01). These patients tended to have an improved OS (69 +/- 15% vs 47 +/- 12%; p = 0.19) compared to the other treatment groups. None of the patients with multimodality treatment had a metastatic relapse. CONCLUSION: Multimodality treatment (surgery plus pre- or postoperative CTX plus postoperative RT) appears to be highly efficient in preventing local and systemic relapse in patients with advanced ENB. Timing and optimal agents of CTX need to be further evaluated.     

Comparison of radiochemotherapy alone to surgery plus radio(chemo)therapy for non-metastatic stage III/IV squamous cell carcinoma of the head and neck

Background and Purpose

The standard treatment for non-metastatic stage III/IV squamous cell carcinoma of the head and neck varies worldwide. This study compared the outcomes of radiochemotherapy alone to surgery followed by radio(chemo)therapy (radiotherapy plus/minus concurrent chemotherapy).

Patients and Methods

Data from 148 patients treated with radiochemotherapy alone were matched to 148 patients treated with surgery plus radio(chemo)therapy. Groups were matched 1:1 for nine potential prognostic factors including age, gender, performance status, tumor site, histologic grade, T category, N category, AJCC stage, and hemoglobin level before radiotherapy, and compared for locoregional control, metastases-free survival, and overall survival.

Results

Locoregional control rates at 1, 2, and 3 years were 81%, 73%, and 67% after surgery plus radio(chemo)therapy and 81%, 74%, and 65% after radiochemotherapy alone (p = 0.89). Metastases-free survival rates were 86%, 80%, and 75% after surgery plus radio(chemotherapy) versus 87%, 80%, and 72% after radiochemotherapy alone (p = 0.57). Overall survival rates were 80%, 64%, and 63% after surgery plus radio(chemo)therapy versus 83%, 68%, and 60% after radiochemotherapy alone (p = 0.96). On multivariate analyses, T category (p < 0.001), N category (p = 0.004), and hemoglobin level prior to radiotherapy (p < 0.001) were associated with locoregional control. Histologic grade (p = 0.045), T category (p < 0.001), N category (p = 0.003), and hemoglobin level prior to radiotherapy (p < 0.001) were associated with metastases-free survival. Histologic grade (p = 0.030), ECOG perfor-mance status (p = 0.033), T category (p = 0.007), N category (p = 0.024) and hemoglobin level before radiotherapy (p < 0.001) were associated with overall survival.

Conclusion

Outcomes of radiochemotherapy alone appeared similar to those of surgery plus radio(chemo)therapy. Randomized trials comparing both treatments for different tumor sites are warranted.     

Biochemische Kontrolle nach konformaler, dreidimensionaler Strahlentherapie des Prostatakarzinoms

BACKGROUND: To evaluate biochemical control after 3-D radiation therapy of prostate cancer. PATIENTS AND METHODS: 180 patients with a median follow-up of 30.5 months (12-67 months) were evaluated. Median dose to the prostate was 70 Gy. 72% of the patients received short-term neoadjuvant hormonal therapy and 28% received radiation therapy alone. Biochemical failure was defined according to the ASTRO consensus criteria. RESULTS: Pre-treatment PSA levels were higher for patients with combined therapy as compared to radiation alone (median: 13.5 ng/ml vs. 8.8 ng/ml, p = 0.003). Biochemical no-evidence of disease (bNED) survival for all patients was 73% at 3 years. In univariate analysis the following factors were predictive for bNED survival: pre-treatment PSA (< or = 20 ng/ml vs. > 20 ng/ml; 3-years bNED 82% vs. 49%; p < 0.001); age (< 72 years vs. > or = 72 years; 3-years bNED 69% vs. 78%; p = 0.049); tumor differentiation (grade 1 vs. grade 2 vs. grade 3; 3-years bNED 89% vs. 74% vs. 46%; p = 0.002); PSA-nadir value (< or = 0.5 ng/ml vs. > 0.5 ng/ml; 3-years bNED 84% vs. 51%; p < 0.001); time to PSA-nadir (< or = 12 months vs. > 12 months; 3-years bNED 66% vs. 82%; p = 0.04). There was a trend to a lower bNED survival in patients with T3/T4 disease (T1/T2 vs. T3/T4; 3-years bNED 80% vs. 60%; p = 0.059). Neoadjuvant hormonal therapy or dose to the prostate had no significant impact on bNED survival. In multivariate analysis pretreatment PSA, tumor differentiation, PSA-nadir, time to PSA-nadir and age were independent prognostic factors. CONCLUSIONS: Despite of having higher initial PSA-values patients treated with conformal radiotherapy and short-term neoadjuvant hormonal therapy had the same bNED survival as patients treated with conformal radiotherapy alone. Patients with initial PSA values above 20 ng/ml, with T3 or T4 disease or with poorly differentiated tumors had a low biochemical control. For this group of patients intensified therapy should be considered.     

Evaluation of prognostic factors and two radiation techniques in patients treated with surgery followed by radio(chemo)therapy or definitive radio(chemo)therapy for locally advanced head-and-neck cancer

BACKGROUND AND PURPOSE: Conventional radiotherapy (RT) still is the standard technique for head-and-neck cancer in many centers worldwide, whereas other centers replaced this technique by 3-D conformal RT, which is associated with more appropriate dose distributions. Comparative studies regarding outcome and toxicity are lacking. This study compared both techniques for overall survival (OS), metastases-free survival (MFS), loco-regional control (LC), and toxicity in stage III/IV head-and-neck cancer. PATIENTS AND METHODS: Data of 345 patients irradiated for stage III/IV squamous cell head-and-neck cancer were retrospectively analyzed. Patients received conventional RT (group A, n = 166) or 3-D conformal RT (group B, n = 179). Both techniques were compared for outcomes and toxicity. Eleven further potential prognostic factors were investigated: age, gender, performance status, tumor site, grading, T-stage, N-stage, AJCC-stage, chemotherapy, surgery, pre-RT hemoglobin. RESULTS: 3-year-OS was 62% in group A and 57% in group B (p = 0.15). 3-year-MFS was 67% and 76% (p = 0.46), 3-year-LC was 65% and 68%, respectively (p = 0.71). On multivariate analysis, gender (p = 0.005), performance status (p < 0.001), T-stage (p = 0.002), and N-stage (p < 0.001) were associated with OS. MFS was influenced by performance status (p < 0.001) and N-stage (p < 0.001), LC by gender (p = 0.021), T-stage (p < 0.001), and pre-RT hemoglobin level (>or= 12 better than < 12 g/dl, p = 0.004). Grade 2-3 xerostomia was less frequent with 3-D conformal RT (43% vs. 58%, p = 0.06). Otherwise, toxicities were similar. CONCLUSION: Both RT techniques resulted in similar treatment outcomes. Because xerostomia was less with 3-D conformal RT, this technique appeared beneficial for patients, in whom one parotid gland can be spared. Outcome was associated with gender, performance status, tumor stage, and pre-RT hemoglobin.     

Hemoglobin as an Independent Prognostic Factor in the Radiotherapy of Head and Neck Tumors

PURPOSE: The purpose of this study was to analyze the prognostic value of baseline hemoglobin levels before radiotherapy in patients with head and neck tumors. PATIENTS AND METHODS: In a retrospective study with a median follow-up of 43 months, we analyzed the results of 214 patients irradiated for head and neck cancer between January 1, 1990 and January 1, 1998 (180 men and 34 women; median age 58 years). The treatment concept consisted in adjuvant radiotherapy in 58 patients, 77 patients received definitive radiochemotherapy, 42 patients definitive radiotherapy, and 37 patients reirradiation for in-field recurrence. Baseline hemoglobin values were divided in four groups of the same patient number (quartiles). Several known prognostic factors like sex, age, tumor stage, histologic grading, performance status, and treatment scheme were analyzed for their influence on overall and event-free survival and correlated with pretreatment hemoglobin values (Kaplan-Meier method). In addition, univariate und multivariate logistic regression analyses were carried out to evaluate the effect of baseline hemoglobin on response rates. RESULTS: The median survival (event-free survival) of all patients amounted to 15 months (10 months). 25%, 50%, and 75% of patients had hemoglobin values < 11.2 g/dl, < 12.7 g/dl, and < 13.9 g/dl, respectively. In the univariate analysis, the following variables were significant prognostic factors for overall/event-free survival (log-rank test): treatment concept (p < 0.001/p < 0.001), tumor stage (p < 0.001/p < 0.001), general condition (p < 0.001/p < 0.001), and pretreatment hemoglobin (p = 0.014/p = 0.05). Multivariate analysis (Cox) proved these parameters to be independent of each other. In addition, response rate after radiation showed a strong association between hemoglobin and local control probability (p = 0.02). CONCLUSION: In this retrospective analysis, baseline hemoglobin level was shown to be an independent significant prognostic factor in radiotherapy of head and neck cancer patients. Therefore, the value of tumor anemia as a prognostic factor should be emphasized more.     

Physical activity level during a round of golf on a hilly course

BACKGROUND: Regular physical activity plays a role in preventive medicine. Our study aimed at establishing the duration of different levels of exercise intensity during a round of golf. METHODS: Participants: we studied 21 male and 9 female golfers (mean age 53 +/- 11 and 54 +/- 13 years respectively) volunteering for a round of golf on a hilly course. Measures: we recorded mean heart rate (HR) of every 15 seconds. Blood pressure was taken on each tee. Maximum HR (HRmax) reserve of each subject was calculated from the difference between pre-exercise and maximum HR attained during a test to volitional exhaustion on a cycle ergometer. A percentage of this value was added to the resting HR and was expressed as a percentage of HRmax reserve. RESULTS: Before start mean HR (+/- SD) was 86 +/- 11 beats per minute (BPM), during play 113 +/- 18, and during rest after play 100 +/- 24 BPM. Mean maximal HR of holes were 135 +/- 21 BPM. Mean systolic blood pressure was 145 +/- 30 before play, 137 +/- 31 on tees during play and 119 +/- 15 mmHg after play. A mean of 82 +/- 51 minutes was spent at 50-74% of HRmax reserve. 21 +/- 27 and 23 +/- 38 minutes were spent in the two higher intensity classes. An average of 106 +/- 77 minutes were spent at or above the individual heart rate equivalent of 100 W, the mean heart rate for this time was 128 +/- 17 BPM. Creatine kinase (+47%; p < 0.001), uric acid (+9%; p < 0.001) and HDL-cholesterol (+6%; p < 0.05) increased, triglycerides decreased by 18% (p < 0.01). CONCLUSIONS: The HR level during the golfround not using an electric cart relative to the maximum attained on the ergometer reaches the exercise intensity of 50 to > 85% HRmax reserve for a mean of over 2 hours, much longer than the 20-60 min recommended for endurance training.     

Anemia and Elevated Systemic Levels of Vascular Endothelial Growth Factor (VEGF)

BACKGROUND: Tissue hypoxia is a major stimulus for the up-regulation of vascular endothelial growth factor (VEGF). Anemia might theoretically impact on angiogenesis via impairment of tissue oxygenation. We have investigated this hypothesis in patients with solid cancers and benign diseases. PATIENTS AND METHODS: 49 patients with untreated locoregionally confined solid cancers of the head and neck, cervix, rectum and lung and 59 additional patients with non-malignant diseases (36 normemic patients without serious diseases and 23 patients with renal anemia) were enrolled and the impact of anemia on plasma VEGF levels were determined. VEGF was measured with a commercially available sandwich enzyme immunoassay technique. RESULTS: Plasma levels of VEGF were 16.2 +/- 12.7 pg/ml in 36 normemic patients without malignant disease, 49.2 +/- 34.5 pg/ml in 49 patients with cancers (p < 0.001), and 89.9 +/- 67.8 pg/ml in 23 patients with renal anemia (p = 0.001). VEGF levels in cancer patients were significantly correlated with hemoglobin (hb) levels and platelet counts (each p = 0.001), but not with type of tumor, stage, histology or age. Patients with cancers had higher plasma levels of VEGF than patients with non-malignant diseases in case of hb > or = 12 g/dl (33.1 +/- 17.5 vs 16.6 +/- 13.0 pg/ml, p < 0.001) and in case of hb between 11.0 and 11.9 g/dl (56.1 +/- 26.4 vs 18.5 +/- 14.5 pg/ml, p = 0.038). In case of a hb < 11 g/dl, plasma VEGF levels were significantly elevated in patients with and without cancers (67.0 +/- 47.5 vs 88.9 +/- 68.8 pg/ml, n.s.). In a multivariate model, a significant association between low hb levels and increased plasma levels of VEGF was confirmed. In 16 patients with renal anemia, changes in hb under erythropoietin treatment were inversely correlated with changes in plasma VEGF levels with decreasing VEGF after increase in hb (p = 0.01). CONCLUSIONS: Anemic patients have elevated levels of VEGF. The data suggest that anemia might impact on the progression of angiogenesis in malignant and benign diseases.     

Ground-glass opacity on thin-section CT: value in differentiating subtypes of adenocarcinoma of the lung.

OBJECTIVE: The purpose of this study was to determine whether thin-section CT could be used to differentiate small localized bronchioloalveolar carcinoma from peripheral adenocarcinoma having a bronchioloalveolar (replacement) growth pattern of alveolar lining cells and from adenocarcinoma not having a replacement growth pattern on the basis of the extent of ground-glass opacity revealed by thin-section CT. MATERIALS AND METHODS: One hundred twenty-four small, surgically resected, peripheral adenocarcinomas from 119 patients (67 men and 52 women; mean age, 60 years) were studied. Lesion diameters were 0.4-2.0 cm (median, 1.5 cm). The extent of ground-glass opacity within lesions on preoperative thin-section CT was reviewed retrospectively by three thoracic radiologists. On the basis of replacement growth of alveolar lining cells, small adenocarcinomas were classified histologically as localized bronchioloalveolar carcinomas (n = 42) or as adenocarcinomas with (n = 53) or without (n = 29) a replacement growth pattern of alveolar lining cells. RESULTS: The percentage of lesions that had ground-glass opacity was significantly greater in localized bronchioloalveolar carcinomas (mean, 56.7%+/-33.0%) than in adenocarcinomas with a replacement growth pattern (mean, 26.3%+/-25.3%, p < .001) or in adenocarcinomas without a replacement growth pattern (mean, 8.3%+/-4.7%, p < .001). CONCLUSION: Determination of the ground-glass opacity area in each tumor as revealed on thin-section CT was useful for differentiating small localized bronchioloalveolar carcinomas from small adenocarcinomas not having a replacement growth pattern.     

Prediction rule for characterization of hepatic lesions revealed on MR imaging: estimation of malignancy

OBJECTIVE: Our aims were to establish factors that are most predictive of hepatic lesion malignancy and to formulate a prediction rule. MATERIALS AND METHODS: A cross-sectional study of 227 abdominal MR imaging examinations revealed 85 lesions in 67 patients (29 men, 38 women; age range, 29-78 years; mean age, 51.4 years) who were being examined for primary malignancy (n = 42) or unknown lesion characterization (n = 25). All were referred for MR imaging after CT or sonography. Patient demographics (age, sex, history of malignancy), lesion size and morphology, quantitative T2 calculation, and pattern of enhancement on gadopentetate dimeglumine administration were evaluated for predictive ability. RESULTS: Thirty-two liver lesions were malignant (eight colon cancer, five breast cancer, four cervical cancer, three renal cancer, three lung cancer, and nine miscellaneous cancers), 53 were benign (37 hemangiomas, 15 cysts, and one focal nodular hyperplasia). Calculated T2 relaxation times (mean +/- standard deviation [SD]) were as follows: malignant tumors (91.72 +/- 21.9 msec), hemangiomas (136.1 +/- 26.3 msec), cysts (284.1 +/- 38.2 msec) (p < 0.001). Logistic regression analysis indicated that lesion size and sex and age of patient were not significant independent predictors (p > 0.05). However, the combination of a history of malignancy, T2 value, and gadopentetate dimeglumine-enhancement pattern allowed generation of a prediction rule with an area under the receiver operating characteristic curve of 0.95. The patient's weight, lesion morphology, and cell type of the primary malignancy did not provide additional predictive information (p > 0.2). CONCLUSION: We recommend using the combination of T2 quantification and patient history of malignancy before deciding to administer gadopentetate dimeglumine for optimal lesion characterization, especially for equivocal lesions with T2 values between 90 and 130 msec. These factors allowed the construction of a prediction rule for lesion characterization.     

Exposure to sun radiation as a risk factor for the occurrence of basal cell carcinoma in the Montenegrian population

BACKGROUND/AIM: [corrected] Basal cell carcinoma (BCC) is the most frequent form of carcinomas in the whites. Among the environmental factors, the most important risk factor for its occurrence is the expasure to sun radiation. The aim of this study was to assess the role of the sun radiation in the development of basal cell carcinoma BCC in the Montenegrian population. METHODS: A case-control study was conducted in a period from 2002-2003. The study group included 100 histopatologically confirmed cases with BCC, while the control group included 100 patients from the same population, who did not present skin cancer and who were individually matched with the cases from the study group by sex and age (+/- 5 years). All the participants were interviewed using an epidemiological questionnaire. For statistical analysis, the chi-squared test and univariate logistic regression analysis were used. RESULTS: The risk for development of BCC was increased in the persons: that always had burns with no tan during the exposure to sunlight (OR = 1.75; 95% CI = 1.20-2.55; p = 0.003); that developed sunburns after two hours of the exposure to sunlight (OR = 3.72; 95% CI = 2.39-5.79; p < 0.001) that kept light tan or remained without changes in childhood and adolescence after the repeated exposures to sunlight (OR = 2.92; 95% CI = 1.89-4.52; p < 0.001) that often had severe and painful sunburns (OR = 4.48; 95% CI = 2.74-7.33; p < 0.001). CONCLUSION: Our study confirmed the significance of sunlight exposure for the development of BCC.     

Validity of the CALER and OMNI-bike ratings of perceived exertion

PURPOSE: To test the validity of the Cart and Load Effort Rating (CALER) and OMNI bike RPE scales. METHODS: Children (16 boys aged 9.5 +/- 0.7 and 16 girls aged 9.4 +/- 0.8) performed a progressive exercise test on a cycle ergometer to exhaustion. Random effects models and correlation analysis were used to determine the association of the undifferentiated perceived exertion from the CALER and OMNI bike scales with heart rate and V O2 for concurrent validity and the association of the CALER scale with the validated OMNI bike scale for construct validity. Tests of proportions were performed to compare the proportion of maximal RPE scale (CALER, OMNI bike) with the proportion of maximal heart rate achieved during the final stage of the exercise test. RESULTS: Concurrent validity of the CALER and OMNI bike scales was established, as increases in scores of both scales were associated with (P < or = 0.001 regression) increases in heart rate (r = 0.88 and 0.89) and V O2 (r = 0.92 and 0.93). Construct validity of the CALER scale was established through a significant (P < or = 0.001 regression) relationship with the OMNI bike scale (r = 0.93). The proportion of maximal CALER (75 +/- 20%) and OMNI bike (74 +/- 19%) scales were less (P < or = 0.001) than the peak percentage of the predicted maximal heart rate (94.5 +/- 3%). CONCLUSIONS: Validity for both the CALER and OMNI bike RPE scales was established for a progressively increasing exercise paradigm. However, the proportion of maximal perceived exertion scores from both scales was lower than the proportion of predicted maximal heart rate achieved during the final stage of the exercise test.     

Prognostic Impact of Hemoglobin Level Prior to Radiotherapy on Survival in Patients with Glioblastoma

PURPOSE: To evaluate prognostic factors in patients with glioblastoma treated with postoperative or primary radiotherapy. PATIENTS AND METHODS: From 1989 to 2000, a total of 100 patients underwent irradiation as part of their initial treatment for glioblastoma. All patients had undergone surgery or biopsy followed by conventional external-beam radiotherapy. 85 patients who received the planned dose of irradiation (60 Gy in 30 fractions) were analyzed for the influence of prognostic factors. 73/85 (86%) of patients were given postoperative irradiation, while 12/85 (14%) of patients were primarily treated with radiotherapy after biopsy. RESULTS: The median overall survival was 10.1 months (range, 3.7-49.8 months), the 1- and 2-year survival rates were 41% and 5%, respectively. Univariate analysis revealed age < or = 55 years (p < 0.001), pre-radiotherapy hemoglobin (Hb) level > 12 g/dl (p = 0.009), and pre-radiotherapy dose of dexamethasone < or = 2 mg/day (p = 0.005) to be associated with prolonged survival. At multivariate analysis, younger age (p < 0.001), higher Hb level (p = 0.002), lower dose of dexamethasone (p = 0.026), and a hemispheric tumor location (p = 0.019) were identified as independent prognostic factors for longer survival. The median survival for patients with an Hb level > 12 g/dl was 12.1 months compared to 7.9 months for those with a lower Hb level. Contingency-table statistics showed no significant differences for the two Hb groups in the distribution of other prognostic factors. CONCLUSION: The results indicate that lower Hb level prior to radiotherapy for glioblastoma can adversely influence prognosis. This finding deserves further evaluation.     

Filling defect in a pulmonary arterial stump on CT after pneumonectomy: radiologic and clinical significance

OBJECTIVE: The objectives of our study were to determine the incidence of filling defects in pulmonary arterial stumps on CT after pneumonectomy and to evaluate their radiologic and clinical significance. MATERIALS AND METHODS: We retrospectively reviewed 401 contrast-enhanced chest CT scans of 147 consecutive patients (male-female ratio, 123:24; mean age, 60 years) who underwent pneumonectomy (right, 60; left, 87) from 1996 to 2002 in our institution. CT findings were analyzed for the presence or absence of a filling defect in the vascular stump and its size, shape, and interval change on follow-up CT. CT findings were also evaluated for the length of the vascular stump and the presence of embolism in the contralateral pulmonary arteries, pneumonia, bronchopleural fistula, and bronchiolitis obliterans with organizing pneumonia. Intrathoracic or stump recurrence was also assessed in patients with lung cancer. The medical records of lung cancer patients were reviewed for the cause of pneumonectomy and stage and cell type of cancer at surgery. Statistical tests were performed to determine the relationship between the filling defect and other radiologic and clinical findings. RESULTS: A filling defect in the vascular stump was seen on CT scans of 18 patients after pneumonectomy (12%), and all had undergone the surgery for lung cancer. It was more frequently found in the right-sided stump (23.3%) than in the left-sided stump (4.6%) (p = 0.001). The vascular stump was longer in patients with a filling defect (37.2 +/- 6.8 [1 SD] mm) than those without this finding (25.0 +/- 12.5 mm) (p < 0.001). Other radiologic and clinical findings were not significantly related to the presence of the filling defect in the vascular stump. CONCLUSION: A filling defect in the pulmonary arterial stump seen on CT after pneumonectomy is thought to be an in situ thrombus caused by stasis of blood flow and is not related to pulmonary embolism, tumor recurrence, or other complications after pneumonectomy.     

Esthesioneuroblastoma in Childhood and Adolescence

BACKGROUND AND PURPOSE: Only 3% of all malignant intranasal tumors are esthesioneuroblastomas (ENB) and only 20% of these rare neuroectodermal tumors are diagnosed up to 20 years of age. Radiotherapy and surgery are established treatment modalities for these patients, but the role of chemotherapy, especially in a multimodal approach, is not well defined. To investigate the influence of radio- and chemotherapy, the treatment and course of the disease in children and adolescents with ENB were analyzed retrospectively. PATIENTS AND METHODS: 19 unselected patients (nine male and ten female) diagnosed with ENB < or = 20 years of age were included in this analysis. Median age at diagnosis was 14.0 years (range, 5-20 years). The tumors were Kadish stage B in 4/19 patients and stage C in 15/19 patients. 17 patients underwent surgery, either without further therapy (n = 4), followed by radiotherapy (n = 1) or as part of multimodal regimens (n = 12). Two patients received radio- and chemotherapy without surgery. Complete resection (R0) was achieved in 15 out of 17 patients with surgery including all five patients with preoperative chemotherapy due to unresectable primary at diagnosis. RESULTS: The 5-year overall survival (OS) for the whole group was 73% +/- 12% and the 5-year event-free survival (EFS) 55% +/- 13%. None of the four patients with stage B experienced tumor progression so far, whereas seven out of 15 patients with stage C did (5-year EFS 47% +/- 14%; not significant). Patients with Kadish stage C and multimodal treatment strategies combing surgery, chemo- and radiotherapy had a significantly better outcome than patients with stage C and less than three treatment modalities (65% +/- 17% vs. 20% +/- 18%; p = 0.02). CONCLUSION: These data indicate a benefit of multimodal treatment regimens combining surgery, chemo- and radiotherapy for pediatric patients with ENB Kadish stage C. Chemotherapy appears to improve resectability, EFS, and OS. Radiotherapy is an integral part in the management of children and young adolescents with ENB in Kadish stage B and C.     

Fracture Risk (FRISK) Score: Geelong Osteoporosis Study

PURPOSE: To develop and evaluate a fracture risk (FRISK) score based on multiple-site bone mineral density (BMD) measurements and other risk factors, to enable prediction of future fracture occurrence. MATERIALS AND METHODS: All participants gave written informed consent, and the study was approved by the Barwon Health Research and Ethics Advisory Committee. BMD was measured at the femoral neck and spine in two concurrently recruited groups: women 60 years of age or older who had sustained a low-trauma fracture of the hip, spine, humerus or distal forearm during a 2-year ascertainment period (n = 231; mean age, 74 years +/- 7 [standard deviation]) and a population-based random sample of women who had not sustained a fracture during the recruitment period (n = 448; mean age, 72 years +/- 8). Falls in the previous year and the number of self-reported fractures in adult life were recorded. Coefficients of a multiple logistic regression model were used as weightings for a combined model. A longitudinal population-based sample was used to assess the fracture risk equation (n = 600; median age, 74 years; interquartile range, 67-82 years). RESULTS: The FRISK score was obtained from the following equation: 9.304 - 4.735BMD(SP) - 4.530BMD(FN) + 1.127FS + 0.344NPF + 0.037W, where BMD(SP) is spinal BMD (in grams per square centimeter), BMD(FN) is femoral neck BMD, FS is falls score, NPF is number of previous fractures, and W is weight (in kilograms). The FRISK score successfully predicted 75% of fractures 2 years after baseline measurements in subjects in the longitudinal study with 68% specificity. CONCLUSION: This study resulted in the derivation of a fracture risk score that successfully predicted 75% of fractures 2 years after baseline.