Hyperfractionated radiation therapy and concurrent 5-fluorouracil, cisplatin and mitomycin-C in head and neck carcinoma. A pilot study.

Seventeen patients were entered into a Phase I/II trial of concurrent hyperfractionated radiation therapy (7,440 cGy total dose; 120 cGy b.i.d.) combined with constant infusion of 5-fluorouracil (5-FU) (1,000 mg/m2/24 hours for 72 hours) and cisplatin (DDP) (50 mg/m2) for a total of three cycles. Thirteen patients had Stage IV disease; three, Stage III disease; and one, Stage II hypopharyngeal disease. Thirteen of 17 patients had positive cervical lymph nodes, and the mean size of the largest lymph node was 5.5 x 5.1 cm. The patients were not treated with planned adjunctive surgery except for one patient who had a radical neck dissection for massive, rapidly growing cervical adenopathy, which recurred promptly within 1 month before the initiation of protocol therapy. After the initial six patients were entered, mitomycin-C (Mito 8 mg/m2) was added during the second cycle. All the patients completed the planned course of radiotherapy with a median dose of 7,440 cGy and a mean dose of 7,248 cGy except for two patients who died--one from toxicity and the other, suicide. The predominant toxicity was mucositis, which was grade 3/4 in 11 of 15 patients, resulting in an average interruption of radiation therapy of 12 days. Weight loss was significant and was on the average 12% of baseline weight. Hematological toxicity was mild in the 5-FU/DDP group (only one grade 3 toxicity of six) and severe in the 5-FU/DDP/Mito-treated patients (five of eight patients having grade 3/4 toxicity including one leukopenic pneumonitis death). Additional toxicity included one parapharyngeal cellulitis, which responded to antibiotics. Noncompliance with the complex regimen was only seen in three patients. One patient refused b.i.d. radiation therapy, and one patient refused further chemotherapy after the first cycle. Additionally, one patient who had a severe ethanol withdrawal reaction during the first cycle of 5-FU/DDP did not receive further chemotherapy. The complete response rate of both primary site and neck by the protocol regimen alone was 71%. However, two patients, one from each group, did undergo salvage neck dissection, and the locoregional control is currently 73%, with a mean follow-up time of 18.4 months. The feasibility of combining hyperfractionated radiation therapy with aggressive concurrent chemotherapy was demonstrated. The response and local control rate justifies the added toxicity of concurrent chemotherapy and radiation therapy.     

Spirometric indices of early airflow obstruction.

Thirty cigarette smokers and 25 non-smoking controls, all men were evaluated by history, physical examination and simple spirometry. The history and physical examination were not of much use in predicting airflow obstruction. Forced mid-expiratory flow (FEF 25-75%) was abnormally low in 23 of the 30 subjects, while forced expiratory volume in 1 second (FEV1) and FEV1/FVC (forced vital capacity) were less sensitive. Thus simple spirometry is a useful screening tool to detect early airflow obstruction even when it is clinically undetectable.     

Placental p,p''-dichlorodiphenyldichloroethylene and cord blood immune markers

Placental p,p'-dichlorodiphenyldichloroethylene (p,p'-DDE) concentration and cord blood atopic markers were determined in 19 neonates. Increased placental p,p'-DDE was associated with a statistically significant increase in cord plasma interleukin (IL)-13. Furthermore, both cord plasma IL-4/interferon (IFN)-gamma and IL-13/IFN-gamma ratios were significantly positively associated with placental p,p'-DDE concentration.     

Comparative cytological study of lymph node tuberculosis in HIV-infected individuals and in patients with diabetes in a developing country

Tuberculosis (TB) is a common infection affecting patients with human immunodeficiency virus (HIV) and diabetes mellitus (DM). With the increasing incidence of HIV infection and DM in a developing country like India, TB is definitely on the rise. In a given population, one expects to see these three diseases in varying combinations, such as HIV and TB, DM and TB, HIV and DM with TB. In such combinations TB may lack the characteristic clinical and histological picture due to the associated depressed cell-mediated immunity seen in both diseases and TB may have an unusual clinical presentation and cytology picture. In this retrospective study of 36 months, from January 1997 to December 1999, 109 cases diagnosed cytologically as tuberculous lymphadenitis and tested for HIV infection and investigated as well for DM were selected. Forty-six (42%) were nondiabetic HIV patients, 13 (12%) were non-HIV DM patients, and 50 (46%) had TB without HIV infection or DM. The coexistence of both HIV and DM was not noted. The cytomorphological characteristics supplemented by culture studies of each of these three groups were compared in detail and based on these four cytological patterns, Pattern 1, Pattern 2, Pattern 3, and Pattern 4 emerged and were characterized. This study highlights the usefulness of cytomorphology of the lymph nodes to characterize the cytopathological profile of TB in both HIV and DM, which have many clinical and immunological similarities, and indirectly postulate the extent of immune suppression and evolve effective strategies in the management of coexisting diseases. Such a comparative study has not been carried out in the past.     

Immediate breast reconstruction-impact on radiation management

Breast reconstruction is an option for women undergoing modified radical mastectomy due to a diagnosis of breast cancer. In certain patients, breast reconstruction is performed by insertion of a temporary tissue expander prior to the placement of permanent breast implants. Some of these patients, following mastectomy, may require chest wall irradiation to prevent loco regional relapse. The compatibility of radiation and tissue expanders placed in the chest wall is of major concern to the radiation oncologist. Clinically undetectable changes can occur in the tissue expander during the course of radiation therapy. This can lead to radiation treatment set-up changes, variation in tissue expansion resulting in unwanted cosmesis, and deviation from the prescribed radiation dose leading to over and/or under dosing of tumor burden. At Howard University hospital, a CT scan was utilized to evaluate the status of the temporary tissue expander during radiation treatment to enable us to prevent radiation treatment related complications resulting from dosimetric discrepancies. CT images of the tissue expander were obtained through the course of treatment. To avoid a 'geographic miss' the amount of fluid injected into the tissue expander was kept constant following patient's satisfaction with the size of the breast mound. The CT scans allowed better visualization of the prosthesis and its relation to the surrounding tumor bed. This technique ensured that anatomical changes occurring during radiation treatment, if any, were minimized. Repeated dosimetry evaluations showed no changes to the prescribed dose distribution. A CT of the reconstructed breast provides an important quality control. Further studies with greater number of patients are required for confirming this impact on radiation treatment.