Sinonasal inverted papilloma associated with squamous cell carcinoma

Background

The aims of the study were to review single-institution experiences with sinonasal inverted papilloma associated with squamous cell carcinoma (IP/SCC), to analyze the presence of human papillomavirus (HPV) and to evaluate the role of radiotherapy.

Patients and methods

Five patients with IP/SCC were identified in the prospective institutional databases (1995–2005) and HPV status was determined in all five tumors.

Results

Four out of five patients had T3-4 tumors; no nodal involvement was seen in any of them. Four patients had curative surgery, supplemented in three of them with radiotherapy. Debulking surgery was performed in the patient with a non-resectable tumor followed by radical radiotherapy. Tumor was controlled locally in three patients at 8, 46 and 58 months post-surgery. Local failure occurred in two patients: after endoscopic resection of a T1 tumor (the recurrent tumor was successfully salvaged with additional surgery) and in a patient with an inoperable tumor. No regional or distant metastases occurred. HPV status was determined in all five tumors and three of them were found positive for HPV type 11.

Conclusions

In operable sinonasal IP/SCC, upfront surgery and postoperative radiotherapy to the tumor bed with dose levels comparable to those used for invasive SCC are recommended. For non-resectable disease, radical radiotherapy to a dose of 66–70 Gy could be of benefit.     

Association of single nucleotide polymorphisms within cytokine genes with juvenile idiopathic arthritis in the Czech population

OBJECTIVE: To examine the possible association of juvenile idiopathic arthritis (JIA) with polymorphisms within cytokine genes in the Czech population. METHODS: In a case-control study, genotypes of 130 patients with JIA (63 male, 67 female; age at onset 7.6 +/- 4.4 yrs; 43 oligoarticular, 72 polyarticular, 15 systemic form) were compared to 102 healthy unrelated blood donors. Using the polymerase chain reaction technique with sequence-specific primers from the 13th IHWG workshop, we analyzed 19 single nucleotide polymorphisms within 12 different cytokine genes [interleukin (IL)-1a, IL-1beta, IL-2, IL-4, IL-6, IL-10, IL-12, transforming growth factor (TGF)-beta, interferon (IFN)-g], and related molecules (IL-1R, IL-1RA, IL-4Ra). Genotype frequencies were compared using chi-square analysis, and the significance level was corrected for the number of independent tests. RESULTS: Significant positive association was found for the G allele of the IL-4 -1098 T/G polymorphism, which was carried by 10% of cases and 25% of controls [odds ratio (OR) 0.32, 95% confidence interval (CI) 0.16-0.67, corrected p = 0.038). Also, a nonsignificant increase in the frequency of the IL-1beta +3962 C allele was detected in cases (96%) versus controls (84%) (OR 4.65, 95% CI 1.64-13.2, corrected p = 0.091). We did not replicate previously found associations with the IL-1a, IL-6, IL-10, and IL-1RA polymorphisms. CONCLUSION: Our study showed association with JIA for the IL-4 -1098 T/G polymorphism. It also underlines the genetic contribution of IL-1 polymorphisms to the pathogenesis of JIA, as another polymorphism within the IL-1beta may influence the risk of the disease.     

Serum cystatin C in patients with head and neck carcinoma

BACKGROUND: The balance between proteinases of various classes and their inhibitors was found to be of critical importance for local invasion and metastasizing of tumor cells. The aim of the present study was to determine the changes in the serum cystatin C concentration in patients with squamous cell carcinoma of the head and neck. METHODS: In the sera of 34 patients with squamous cell carcinoma of the head and neck, the concentration of cysteine proteinase inhibitor cystatin C was determined using ELISA. The serum samples were collected at diagnosis (group A) and 7 to 407 days (median, 59 days) after the therapy (group B). The sera of 30 healthy blood donors served as controls (group C). RESULTS: A significant increase in the median concentration of cystatin C was found in the patients' sera (group A: 573 ng/ml, P<0.0001; group B: 551 ng/ml, P<0.0001) compared to control group C (320 ng/ml), whereas no difference was observed between groups A and B (P>0.05). Cystatin C concentrations in the sera of group A correlated with the site of primary tumor (P=0.035), being higher in the patients with non-laryngeal tumors (658 ng/ml) than in those with larynx primaries (529 ng/ml). There was a significant trend (RS=-0.535, P=0.049) towards lower cystatin C concentrations with an increasing time delay in post-treatment serum sampling (group B), which was observed in the patients with no relapse of the disease and a sampling later than 45 days after the completion of therapy. CONCLUSIONS: These results add to the knowledge of the role of cystatin C in invasive behavior of squamous cell carcinoma of the head and neck, and suggest its potential role as a tumor marker in this particular type of cancer.     

Radiotherapy for parapharyngeal space tumors

A wide variety of tumors, both benign and malignant, occur in the parapharyngeal space. Depending on histology and extent, treatment may include surgery and/or radiotherapy (RT). Herein we discuss the role of RT in the management of some of the more commonly encountered neoplasms, including salivary gland tumors, paragangliomas, schwannomas, and soft-tissue sarcomas.     

Recommendations from Gynaecological (GYN) GEC-ESTRO Working Group (IV): Basic principles and parameters for MR imaging within the frame of image based adaptive cervix cancer brachytherapy

The GYN GEC-ESTRO working group issued three parts of recommendations and highlighted the pivotal role of MRI for the successful implementation of 3D image-based cervical cancer brachytherapy (BT). The main advantage of MRI as an imaging modality is its superior soft tissue depiction quality. To exploit the full potential of MRI for the better ability of the radiation oncologist to make the appropriate choice for the BT application technique and to accurately define the target volumes and the organs at risk, certain MR imaging criteria have to be fulfilled. Technical requirements, patient preparation, as well as image acquisition protocols have to be tailored to the needs of 3D image-based BT. The present recommendation is focused on the general principles of MR imaging for 3D image-based BT. Methods and parameters have been developed and progressively validated from clinical experience from different institutions (IGR, Universities of Vienna, Leuven, Aarhus and Ljubljana) and successfully applied during expert meetings, contouring workshops, as well as within clinical and interobserver studies. It is useful to perform pelvic MRI scanning prior to radiotherapy ("Pre-RT-MRI examination") and at the time of BT ("BT MRI examination") with one MR imager. Both low and high-field imagers, as well as both open and close magnet configurations conform to the requirements of 3D image-based cervical cancer BT. Multiplanar (transversal, sagittal, coronal and oblique image orientation) T2-weighted images obtained with pelvic surface coils are considered as the golden standard for visualisation of the tumour and the critical organs. The use of complementary MRI sequences (e.g. contrast-enhanced T1-weighted or 3D isotropic MRI sequences) is optional. Patient preparation has to be adapted to the needs of BT intervention and MR imaging. It is recommended to visualise and interpret the MR images on dedicated DICOM-viewer workstations, which should also assist the contouring procedure. Choice of imaging parameters and BT equipment is made after taking into account aspects of interaction between imaging and applicator reconstruction, as well as those between imaging, geometry and dose calculation. In a prospective clinical context, to implement 3D image-based cervical cancer brachytherapy and to take advantage of its full potential, it is essential to successfully meet the MR imaging criteria described in the present recommendations of the GYN GEC-ESTRO working group.     

Operative strategy in postero-medial fracture-dislocation of the proximal tibia

Objective

In 1981, Moore introduced a new classification for dislocation-type fractures caused by high-energy mechanisms. The most common medial Moore-type fractures are entire condyle fractures with the avulsion of the median eminence (tibial anterior cruciate ligament (ACL) insertion). They are usually associated with a posterolateral depression of the tibial plateau and an injury of the lateral menisco-tibial capsule. This uniform injury of the knee is increasingly observed in the recent years after skiing injuries due to the high-speed carving technique. This uprising technique uses shorter skis with more sidecut allowing much higher curve speeds and increases the forces on the knee joint.The aim of this study was to describe the injury pattern, our developed operative approach for reconstruction and outcome.

Methods

A total of 28 patients with 29 postero-medial fracture dislocation of the proximal tibia from 2001 until 2009 were analysed. Clinical and radiological follow-up was performed after 4 years on average (1 year in minimum). Evaluation criteria included the Lysholm score for everyday knee function and the Tegner score evaluating the activity level. All fractures were stabilised post primarily. The surgical main approach was medial. First, the exposure of the entire medial condyle fracture was performed following the fracture line to the articular border. The posterolateral impaction was addressed directly through the main fracture gap from anteromedial to posterolateral. Small plateau fragments were removed, larger fragments reduced and preliminarily fixed with separate K-wire(s). The postero-medial part of the condyle was then prepared for main reduction and application of a buttress T-plate in a postero-medial position, preserving the pes anserinus and medial collateral ligament. In addition, a parapatellar medial mini-arthrotomy through the same main medial approach was performed. Through this mini-arthrotomy, the avulsed anterior eminence with attached distal ACL is retained by a transosseous suture back to the tibia.

Results

We could evaluate 26 patients (93%); two patients were lost to follow-up due to foreign residence. Median age was 51 years (20–77 years). The fractures were treated post primarily at an average of 4 days; in 18 cases a two-staged procedure with initial knee-spanning external fixator was used. All fractures healed without secondary displacement or infection. As many as 25 patients showed none to moderate osteoarthritis after a median of 4 years. One patient showed a severe osteoarthritis after 8 years. All patients judge the clinical result as good to excellent. The Lysholm score reached 95 (75–100) of maximal 100 points and the Tegner activity score 5 (3–7) of maximal 10 points (competitive sports). The patients achieved a median flexion of 135° (100–145°).

Conclusion

In our view, it is crucial to recognise the different components of the injury in the typical postero-medial fracture dislocation of the proximal tibia. The described larger medial approach for this type of medial fracture dislocation allows repairing most of the injured aspects of the tibial head, namely the medial condyle with postero-medial buttressing, the distal insertion of the ACL and the posterolateral impaction of the plateau.     

Patterns of failure in patients with locally advanced head and neck cancer treated postoperatively with irradiation or concomitant irradiation with Mitomycin C and Bleomycin

PURPOSE: The long term results and patterns of failure in patients with squamous cell head and neck carcinoma (SCHNC) treated in a prospective randomized trial in which concomitant postoperative radiochemotherapy with Mitomycin C and Bleomycin (CRT) was compared with radiotherapy only (RT), were analyzed. PATIENTS AND METHODS: Between March 1997 and December 2001, 114 eligible patients with Stage III or IV SCHNC were randomized. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56-70 Gy. Chemotherapy included Mitomycin C 15 mg/m2 after 10 Gy and 5 mg of Bleomycin twice weekly during irradiation. Median follow-up was 76 months (48-103 months). RESULTS: At 5 years in the RT and CRT arms, the locoregional control was 65% and 88% (p = 0.026), disease-free survival 33% and 53% (p = 0.035), and overall survival 37% and 55% (p = 0.091) respectively. Patients who benefited from chemotherapy were those with high-risk factors. The probability of distant metastases was 22% in RT and 20% in CRT arm (p = 0.913), of grade III or higher late toxicity 19% in RT and 26% in CRT arm (p = 0.52) and of thyroid dysfunction 36% in RT and 56% in CRT arm (p = 0.24). The probability to develop a second primary malignancy (SPM) was 34% in the RT and 8% in the CRT arm (p = 0.023). One third of deaths were due to infection, but there was no difference between the 2 groups. CONCLUSION: With concomitant radiochemotherapy, locoregional control and disease free survival were significantly improved. Second primary malignancies in the CRT arm compared to RT arm were significantly less frequent. The high probability of post treatment hypothyroidism in both arms warrants regular laboratory evaluation.