Ductal carcinoma in situ of breast: detection and treatment pattern in Hong Kong.

INTRODUCTION: The treatment of ductal carcinoma in situ has been widely reported in the western and other Asian countries, but the relevant data in Hong Kong are relatively limited. This study aimed to evaluate the latest detection and treatment pattern for ductal carcinoma in situ in Hong Kong so as to guide planning of future service provision. METHODS: This was a retrospective case series study. A total of 573 patients who registered with the Hong Kong Breast Cancer Registry, and were diagnosed and treated in Hong Kong from January 2001 to December 2011 were reviewed. RESULTS: Compared with invasive breast cancer patients, patients with ductal carcinoma in situ were younger (median, 48.6 vs 50.3 years; P<0.001), had a higher education level (P<0.001), had a higher total monthly family income (P<0.001), and more common breast-screening habits (P<0.001). Significantly more patients with ductal carcinoma in situ underwent breast-conserving surgery than their invasive cancer counterparts (55.8% vs 36.7%; P<0.001). The percentage of screen-detected ductal carcinoma in situ was relatively lower than that reported in other studies, but was still much higher than that in invasive breast cancer patients (29.0% vs 4.7%; P<0.001). Screen-detected patients with ductal carcinoma in situ tended to choose a private hospital instead of a public hospital for treatment (P=0.05) and to undergo breast-conserving surgery (P=0.02). With a median follow-up of 3 years, the crude local recurrence rate after mastectomy and breast-conserving surgery was 0.4% and 3.3%, respectively; 44% of recurrent tumours had developed invasive components. No regional recurrence, distant recurrence, or cancer-related deaths were recorded. CONCLUSIONS: In the absence of a population-based breast screening programme in Hong Kong, ductal carcinoma in situ is more frequently found in the higher social classes and managed in the private sector. The clinical outcome of ductal carcinoma in situ is excellent and more than half of the patients can be successfully managed with breast-conserving surgery.

The evolution of psychological distress trajectories in women diagnosed with advanced breast cancer: a longitudinal study.

BACKGROUND: Anxiety and depression (distress) over the first year following the initial adjuvant therapy for advanced breast cancer (ABC) remain poorly documented in non-Caucasian populations. This study describes trajectories of distress and their determinants in Chinese women with ABC. METHODS: Of the 228 Chinese women newly diagnosed with ABC recruited from six oncology units, 192 completed an interview before their first course of chemotherapy (baseline) and follow-up interviews at 1.5, 3, 6, and 12 months thereafter. At baseline, participants were assessed for supportive care needs, psychological distress, physical symptom distress, optimism, and cancer-related rumination. At follow-up, participants completed the measure of psychological distress. Latent growth mixture modeling was used to identify trajectory patterns of distress. Multinominal logistic regression was used to identify predictors of trajectory patterns adjusted for demographic and medical characteristics. RESULTS: Four distinct trajectories of anxiety and depression were identified. Most women showed low-stable levels of anxiety (68%) and depression (68%), but one in 11 women were chronically anxious (9%) and depressed (9%). Optimism, negative cancer-related rumination, and physical symptom distress predicted both anxiety and depression trajectories. Psychological needs predicted anxiety trajectories. Women in the low-stable distress group reported high optimism, low psychological supportive care needs, low physical symptom distress, and low negative cancer-related rumination. CONCLUSION: Most women with ABC did not experience psychological distress over 12 months following diagnosis of ABC. Preventive interventions should focus on women at risk of high persistent distress and reducing rumination, providing emotional support, and managing physical symptoms.

Replication study of SNP associations for colorectal cancer in Hong Kong Chinese.

BACKGROUND: Recent genome-wide association studies of colorectal cancer (CRC) have identified common single-nucleotide polymorphisms (SNPs) mapping to 10 independent loci that confer modest increased risk. These studies have been conducted in European populations and it is unclear whether these observations generalise to populations with different ethnicities and rates of CRC. METHODS: An association study was performed on 892 CRC cases and 890 controls recruited from the Hong Kong Chinese population, genotyping 32 SNPs, which were either associated with CRC in previous studies or are in close proximity to previously reported risk SNPs. RESULTS: Twelve of the SNPs showed evidence of an association. The strongest associations were provided by rs10795668 on 10p14, rs4779584 on 15q14 and rs12953717 on 18q21.2. There was significant linear association between CRC risk and the number of independent risk variants possessed by an individual (P=2.29 × 10(-5)). CONCLUSION: These results indicate that some previously reported SNP associations also impact on CRC risk in the Chinese population. Possible reasons for failure of replication for some loci include inadequate study power, differences in allele frequency, linkage disequilibrium structure or effect size between populations. Our results suggest that many associations for CRC are likely to generalise across populations.

Validation of the Chinese version of the short-form Supportive Care Needs Survey Questionnaire (SCNS-SF34-C).

BACKGROUND: There is no instrument available in Chinese for assessing psychosocial needs. This study aimed to assess the validity and reliability of the Chinese version of the Supportive Care Needs Survey short form (SCNS-SF34-C) in Chinese women with breast cancer (BC). METHODS: The Chinese version of the 34-item SCNS-SF34-C, a self-report measure for assessing psychosocial unmet needs, was administered to 348 Chinese women with BC at the outpatient oncology unit. Exploratory factor analysis (EFA) tested the factor structure. The internal consistency, convergent, divergent, and discriminant validity of the identified factor structure were assessed. RESULTS: In contrast to the five-factor structure identified in the original 34-item SCNS-SF34, our EFA produced a 33-item solution accounting for 54% of score variance comprising four-factors: (1) Health system, information, and patient support, (2) Psychological needs, (3) Physical and daily living, and (4) Sexuality needs. Separate dimensions for Health system and information, and the Patient care and support domains were not supported. Cronbach alphas ranged from 0.75 to 0.92. Correlations of psychological and physical symptom distress measures indicated acceptable convergent validity. No correlation with optimism and positive affect measures indicated divergent validity. Discriminant validity was demonstrated by effective differentiation between clinically distinct patient groups (no active treatment versus active treatment; advanced BC versus localized BC). DISCUSSION: The Chinese version of the Supportive Care Needs Survey has suitable factor structure and psychometric properties for use in assessing psychosocial needs among Chinese women with BC. Further validation is needed for other cancer types.

Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer centre.

OBJECTIVE: Delayed presentation is an important obstacle to improving cancer treatment outcomes. We aimed to study the magnitude of this problem in Hong Kong and the factors associated with delayed presentation of patients with symptomatic breast cancers. DESIGN: Retrospective study using self-administered questionnaires. SETTING: Clinical Oncology Department in a regional public hospital in Hong Kong. PATIENTS: A total of 158 Chinese women with breast cancer referred to our hospital between October 2006 and December 2007 consented to participate in this study. Among these, 59 (37%) patients were referred after having surgery in private sector. RESULTS: The mean total delay (from first symptom to treatment) was 22 weeks. The mean patient delay (from first symptom to first consultation) was 13 weeks, constituting the largest component (60%) of the total delay. After symptom onset, the delay exceeded 12 weeks for consulting a doctor in 29%, and for receipt of treatment in 52% of them. Low family income (

Should young age be a contra-indication to breast conservation treatment in Chinese women? Twelve-year experience from a public cancer centre in Hong Kong.

OBJECTIVE: It has been proposed that young women should not be treated by breast conservation treatment because of a higher risk of local recurrences and worse survival. We therefore examined whether breast conservation treatment in young Chinese women yielded inferior clinical outcomes compared to modified radical mastectomy. DESIGN: Retrospective study. SETTING: Clinical oncology department in a public hospital in Hong Kong. PATIENTS: A total of 258 Chinese women with invasive breast cancer, aged below 40 years, and referred between January 1994 and July 2006. RESULTS: A total of 124 (48%) and 134 (52%) patients were treated by breast conservation treatment and modified radical mastectomy, respectively. Mastectomy patients tended to have larger primary tumours (P<0.001) and more nodal involvement (P<0.001). At a median follow-up of 6.5 years, there was no significant difference in the local failure-free survival rate (92% vs 93%, P=0.324) and loco-regional failure-free survival rate (89% vs 88%, P=0.721) in patients having breast conservation treatment and mastectomy. Probably due to their earlier presentation with disease, the former actually had better 6-year distant failure-free survival (88% vs 71%, P=0.002) and overall survival (92% vs 81%, P=0.173) rates. Multivariate analyses showed that both the resection margin status (hazard ratio=2.77, P=0.050) and the presence of peritumoural vascular invasion (hazard ratio=3.01, P=0.038) were independent predictors of local recurrence; the nodal status (hazard ratio=3.91, P<0.001) was the only predictive factor for overall survival. The choice of breast conservation treatment (vs modified radical mastectomy) had no apparent adverse impact on all the clinical outcome parameters analysed. CONCLUSION: Breast conservation treatment is a reasonable option for many suitably selected young Chinese women.

Surveillance mammography after breast conservation therapy in Hong Kong: effectiveness and feasibility of risk-adapted approach.

Annual surveillance mammography is commonly recommended after breast conservation therapy (BCT). We retrospectively reviewed its effectiveness on 511 invasive and non-invasive breast cancers treated with BCT between 1994 and 2003. The median follow-up was 5.9 years. The 5-year actuarial ipsilateral breast tumour recurrence (IBTR) rate was 4.5% and contralateral breast cancer (CBC) rate was 2.0% (representing eight times increase in risk). IBTR of 43% and 62% CBC were first detected by surveillance mammography. The IBTR detection rates per 1000 mammograms were 5.2 for patients (n=349) with one or more IBTR risk factors (age 45, positive/close margins or histological grade 3) and 0.6 for patients (n=162) without. No survival difference was observed between different modes of IBTR detection (p=0.342). In conclusion, a risk-adapted approach of limiting ipsilateral surveillance to patients with IBTR risk is possible but its implementation will be complicated by the continued need of contralateral surveillance.

Evaluation of the prognostic value of 2005 St Gallen risk categories for operated breast cancers in Hong Kong.

Incorporating various new and conventional risk factors, the 2005 St Gallen risk categorization is a potentially useful prognostic tool for breast cancers. We conducted a retrospective study to evaluate its application in Hong Kong. Of the 902 included female breast cancers with median follow-up of 5.4 years, 7%, 63% and 30% patients were classified as low-, intermediate- and high-risk categories, respectively. Their corresponding 5-year distant disease-free survivals (DDFS) were 100%, 92% and 72%, respectively (p<0.00005). In the intermediate-risk category, node-positive patients had marginally inferior 5-year DDFS than node-negative patients (89% vs. 93%, p=0.0551). In the high-risk category, patients having HER2 overexpressed tumors and 1-3 positive nodes had significantly better DDFS than other patients with > or = 4 positive nodes (89% vs. 65%, p=0.0001). Overall, the 2005 St Gallen risk categorization had high prognostic value. However, the impact of HER2 overexpression might be affected by reproducibility of HER2 tests.

HER2 overexpression of breast cancers in Hong Kong: prevalence and concordance between immunohistochemistry and in-situ hybridisation assays.

OBJECTIVES: To evaluate the prevalence of human epidermal growth factor receptor 2 (HER2) gene overexpression in breast cancer patients encountered in Hong Kong and the concordance of HER2 findings from primary immunohistochemistry assays and confirmatory in-situ hybridisation assays. DESIGN: Retrospective study. SETTING: Department of Clinical Oncology in a public hospital in Hong Kong. PATIENTS: All patient referrals between July 2006 and June 2007 with newly diagnosed invasive breast cancer (for prevalence evaluation), and all patients treated at our unit with confirmatory in-situ hybridisation tests performed within the study period (for concordance evaluation). RESULTS: There were 272 consecutive breast cancer patients eligible for prevalence evaluation. The distribution for immunohistochemistry staining in 249 cases for scores 0, 1+, 2+, and 3+ were 99 (40%), 40 (16%), 58 (23%), and 52 (21%) respectively. In the remaining 23 patients, four and 19 breast cancers were unscored and reported by immunohistochemistry to be HER2-positive and -negative, respectively. The overall HER2 overexpression rate (3+ or reported as positive) was 21%. HER2 overexpression was associated with grade 3 histology (P<0.001) and negative hormonal receptor status (P<0.001). However, it was not associated with age (P=0.525), T-classification (P=0.740), N-classification (P=0.691), nor group stages (P=0.433). Of the 37 patients with confirmatory in-situ hybridisation tests performed, 10 (71%) of 14 with immunohistochemistry staining of 3+ and 1 (4%) of 23 with immunohistochemistry staining of 2+ were found to have HER2 gene amplification. CONCLUSIONS: More than 25% of HER2 overexpression identified by immunohistochemistry assays in this Hong Kong cohort could not be verified by confirmatory in-situ hybridisation assays. Compliance with the latest guidelines for HER2 testing should improve the future accuracy and concordance.

Preliminary results of a randomized study on therapeutic gain by concurrent chemotherapy for regionally-advanced nasopharyngeal carcinoma: NPC-9901 Trial by the Hong Kong Nasopharyngeal Cancer Study Group.

PURPOSE: This randomized study compared the results achieved by concurrent chemoradiotherapy (CRT) versus radiotherapy (RT) alone for nasopharyngeal carcinoma (NPC) with advanced nodal disease. PATIENTS AND METHODS: Patients with nonkeratinizing/undifferentiated NPC staged T1-4N2-3M0 were randomized to CRT or RT. Both arms were treated with the same RT technique and dose fractionation. The CRT patients were given cisplatin 100 mg/m2 on days 1, 22, and 43, followed by cisplatin 80 mg/m2 and fluorouracil 1,000 mg/m2/d for 96 hours starting on days 71, 99, and 127. RESULTS: From 1999 to January 2004, 348 eligible patients were randomly assigned; the median follow-up was 2.3 years. The two arms were well-balanced in all prognostic factors and RT parameters. The CRT arm achieved significantly higher failure-free survival (72% v 62% at 3-year, P = .027), mostly as a result of an improvement in locoregional control (92% v 82%, P = .005). However, distant control did not improve significantly (76% v 73%, P = .47), and the overall survival rates were almost identical (78% v 78%, P = .97). In addition, the CRT arm had significantly more acute toxicities (84% v 53%, P < .001) and late toxicities (28% v 13% at 3-year, P = .024). CONCLUSION: Preliminary results confirmed that CRT could significantly improve tumor control, particularly at locoregional sites. However, there was significant increase in the risk of toxicities and no early gain in overall survival. Longer follow-up is needed to confirm the ultimate therapeutic ratio.

Wide local excision and radiotherapy for the treatment of ductal carcinoma in situ of the breast: the Hong Kong experience.

AIMS: Breast conservation treatment for ductal carcinoma in situ (DCIS) was unpopular in the Chinese population and the outcome was seldom reported. We conducted a single-centre retrospective study to examine the clinical outcome of women in Hong Kong. MATERIALS AND METHODS: Seventy-five Chinese women were treated with wide local excision and radiotherapy for DCIS of the breast between 1994 and 2003. Only 26 (34.7%) women had non-palpable DCIS detected by screening mammograms. All women were treated with whole breast irradiation of 50 Gy in 2 Gy daily fractions, with 50 (66.7%) women receiving an additional electron boost of 10-16 Gy. RESULTS: The median follow-up was 5.1 years (range 2.0-10.7). At the last assessment, four women developed local recurrences, but all remained disease-free after salvage mastectomy. The 5-year actuarial local failure-free rate and cause-specific survival rate were 92.9% (95% confidence interval 89.4-96.4) and 100.0%, respectively. Cosmetic results were rated as good to excellent in all women. On univariate analysis of prognostic factors for local failure, only a close (< or = 2 mm) final resection margin approached statistical significance (hazard ratio 9.108; 95% confidence interval 0.946-87.655; P = 0.056). The 5-year actuarial local failure-free rates for women with a close (< or = 2 mm) final resection margin and women with wider margins were 77.0 and 98.2%, respectively. CONCLUSIONS: Despite geographical and demographic differences, the clinical outcome after wide local excision and radiotherapy for DCIS of the breast in Chinese women is comparable with that in Western series. Efforts are needed to achieve cosmetically acceptable tumour-free margins greater than 2 mm.

Treatment of stage IV(A-B) nasopharyngeal carcinoma by induction-concurrent chemoradiotherapy and accelerated fractionation.

PURPOSE: To explore a more effective strategy for treating nasopharyngeal carcinoma with extensive locoregional disease. METHODS AND MATERIALS: Between October 1998 and January 2003, 49 patients with Stage IV(A-B) disease infiltrating or abutting neurologic structures were treated with induction-concurrent chemotherapy and accelerated radiotherapy (RT). A combination of cisplatin and 5-fluorouracil was used in the induction phase and single-agent cisplatin in the concurrent phase. All patients were irradiated with conformal techniques at 2 Gy/fraction, six daily fractions weekly, to a total dose of 70 Gy. RESULTS: Although 92% of patients had one or more acute toxicities Grade 3 or worse, 96% completed the whole course of RT, and 92% had five or more cycles of chemotherapy. The great majority of toxicities were uneventful, but 1 patient died of neutropenic sepsis. With a median follow-up of 3.1 years, 20 patients had failure at one or more sites and 15 patients died. The 3-year locoregional and distant failure-free rate was 77% and 75%, respectively, and the overall survival rate was 71%. At last follow-up, 27% of patients had developed late Grade 3 or worse toxicity (24% were hearing impairments), but none had radiation-induced neurologic damage. CONCLUSION: The current strategy achieved encouraging results for this poor prognostic group, and confirmation of the therapeutic gain by a prospective randomized trial is warranted.

Retrospective analysis on treating nasopharyngeal carcinoma with accelerated fractionation (6 fractions per week) in comparison with conventional fractionation (5 fractions per week): report on 3-year tumor control and normal tissue toxicity.

BACKGROUND AND PURPOSE: To assess the therapeutic gain achieved by accelerated fractionation for non-keratinizing/undifferentiated nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS: During January 1994 to October 1997, 325 patients were treated to a total dose of 66 Gy in 33-37 fractions: 167 (irradiated before mid-January 1996) with 5 daily fractions (CF) and subsequent 158 with 6 daily fractions (AF) per week. Their median treatment times were 46 and 39 days, respectively. Additional boost to parapharyngeal extension had been given to 181 and Cisplatin-based chemotherapy to 57 patients (24 concurrent with radiotherapy). RESULTS: The AF group had significantly higher progression-free rate than the CF group (74 vs. 63% at 3 years, P=0.02 by the log-rank test). However, the difference in disease-specific survival (86 vs. 80%, P=0.39) and overall survival (81 vs. 78%, P=0.9) did not reach statistical significance. Strongly significant improvement in local failure-free rate was achieved for patients with T3-4 tumors (87 vs. 62%, P<0.01). Multivariate analyses showed that fractionation was an independent significant factor for overall progression: hazard ratio=0.63, 95% confidence interval: 0.41-0.98, P=0.04. Among the 268 patients treated with radiotherapy alone, those treated by AF had significantly higher incidence of acute reaction grade > or=3 (72 vs. 13%, P<0.01). However, all patients completed the scheduled dose without excessive prolongation, and no significant increase in late complications was observed (20 vs. 15% at 3 years, P=0.19). CONCLUSIONS: The current analyses suggested that acceleration to 6 daily fractions per week could significantly improve the progression-free rate for NPC without excessive late toxicity. Improvement in local control was confined to T3-4 tumors.

Central pontine myelinolysis: report of two occurrences after cisplatin-containing chemotherapy for nasopharyngeal carcinoma.

We report two patients with the classical clinical syndrome of central pontine myelinolysis following cisplatin based chemotherapy for nasopharyngeal carcinoma. The diagnosis was supported by typical features on magnetic resonance imaging. Rapid correction of hyponatraemia was the most likely cause. A short course of corticosteroids was tried in both patients. Although one patient experienced almost complete recovery, the other still suffered from residual motor deficit. The importance of careful monitoring of the rate of electrolyte correction is emphasized.

Post-mastectomy radiotherapy after immediate autologous breast reconstruction in primary treatment of breast cancers.

AIM: To assess the clinical outcome of breast cancer patients with immediate autologous breast reconstruction and post-mastectomy radiotherapy (PMRT) as primary treatment. MATERIALS AND METHODS: Twenty-five women with breast cancer treated with immediate autologous breast reconstruction and post-mastectomy radiotherapy as primary treatment between 1995 and 2001 in Pamela Youde Nethersole Eastern Hospital of Hong Kong were retrospectively studied. Radiation doses of 50 Gy (in 2 Gy daily fraction) were given to the reconstructed breasts, except one who was given 45 Gy (in 1.8 Gy daily fraction). Nine women (36%) were treated without bolus, whereas the other 16 women (64%) were treated with 0.5 cm thick bolus on alternate days. The main outcome measures include local control, treatment complications and cosmetic outcome. RESULTS: Median follow-up was 3.7 years (range: 1.0-6.6 years). Two women (8%), who were treated without bolus, developed chest wall recurrences. The overall 5-year, actuarial, local failure-free rate and disease-specific survival rate were 89.8% and 77.9%, respectively. Apart from mild acute skin reactions, no significant acute radiotherapy side-effects were observed. No flap necrosis or flap loss was seen. The cosmesis of the reconstructed breasts were rated as good to excellent in 85% of the surviving patients. There was no observed adverse effect on cosmesis by adding bolus on alternate days. CONCLUSION: PMRT after immediate autologous tissue-flap breast reconstruction is well tolerated and is not associated with increased incidence of complications. Adding 0.5 cm bolus on alternate days might improve local control without causing adverse cosmetic effect. The concern of adverse effects of radiotherapy should not exclude the choice of immediate breast reconstruction in suitable patients.

Breast conservation treatment in Hong Kong-early results of 203 patients: retrospective study.

OBJECTIVE: To study the clinical outcomes of patients with invasive or non-invasive breast cancer after breast conservation treatment. DESIGN: Retrospective study. SETTING: Clinical oncology department of a public hospital, Hong Kong. PATIENTS: Two hundred and three patients who received postlumpectomy radiotherapy at the Pamela Youde Nethersole Eastern Hospital between January 1994 and June 1999. INTERVENTIONS: Adjuvant radiotherapy with or without systemic adjuvant treatment. MAIN OUTCOME MEASURES: Actuarial local control rate, progression-free survival rate, disease-specific survival rate, and cosmetic score. RESULTS: The median follow-up was 3.5 years. Two of the 25 patients with carcinoma in situ only developed local recurrence; the 5-year actuarial local control rate was 91.3%. Among the 178 patients with invasive cancer, seven had a local recurrence and 12 developed distant metastases without local failure. The 5-year actuarial local control, progression-free survival, and disease-specific survival rates for patients with invasive cancer were 95.5%, 85.8%, and 95.2%, respectively. The risk of local recurrence was significantly increased for younger patients (age <40 years) and those with positive final margins. Cosmetic scores were rated good to excellent by 95.6% of patients. CONCLUSIONS: The early clinical outcomes of these patients are comparable to those in large overseas trials, which have demonstrated the equivalence of mastectomy and breast conservation treatment in terms of survival. In addition to mastectomy, with or without breast reconstruction, breast conservation treatment should be offered as an alternative to suitable Chinese women. To maximise local control, further excision or mastectomy is recommended for patients with positive final margins.

Venous thromboembolism in the Chinese population--experience in a regional hospital in Hong Kong.

OBJECTIVE: To estimate the incidence and determine the characteristic features of venous thromboembolism in the Hong Kong Chinese population. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. SUBJECTS AND METHODS: Data were collected during a period of four years (1997-2000). Patients with duplex doppler ultrasonography or venography-documented venous thromboembolism and new episodes of deep vein thrombosis were identified from Department of Diagnostic Radiology records. Patients with high-probability ventilation-perfusion scans were identified from Department of Nuclear Medicine records and these scans were taken as evidence of pulmonary embolism. Patients with intermediate-probability ventilation-perfusion scans, with pulmonary embolism documented by either pulmonary angiography or spiral computed tomography scan, were also included in the study. Patients with autopsy-verified fatal pulmonary embolism were identified from Department of Pathology records. Patients with deep vein thrombosis at other sites were sought from patient discharge diagnostic coding data. Medical records were reviewed for patient characteristics and conditions associated with the development of venous thromboembolism. RESULTS: Three hundred and seventy-six Chinese patients had venous thromboembolism during the study period. Of these, 352 had peripheral deep vein thrombosis, five had deep vein thrombosis at other sites (cerebral sinus and portal vein thrombosis), 40 had pulmonary embolism (26 had concomitant deep vein thrombosis), and six had fatal pulmonary embolism shown at autopsy. CONCLUSION: The calculated annual incidence of venous thromboembolism in Hong Kong Chinese people was estimated at 16.6 events per 100,000 population, which is lower than incidence rates reported in Caucasians. The four conditions most commonly associated with venous thromboembolism were medical illness, malignancy, orthopaedic surgery, and intravenous drug use. Conditions associated with venous thromboembolism in patients younger than 45 years included intravenous drug use, thrombophilia, pregnancy, and the use of oral contraceptives.

Nasopharyngeal carcinoma---time lapse before diagnosis and treatment.

This is a descriptive study of 168 patients with nasopharyngeal carcinoma who were referred to public oncology departments for primary treatment between July and September 1996. The mean duration from the onset of the symptoms to histological diagnosis was 5.0 months; the duration ranged from 6.1 months (for patients presenting with nasal symptoms) to 1.8 months (for those with cranial nerve dysfunction). The mean period between the onset of symptoms and the seeking of medical advice was 2.9months. For 54% of the patients, there was a further delay of up to 2.4 months between the initial medical consultation and referral to the appropriate specialist. The majority (84%) of patients attended public institutions for histological confirmation. The mean total time taken from the onset of symptoms to the commencement of radiotherapy was 6.5 months (range, 1.3-74.0 months)---45% of the delay was attributed to the patient, 20% to initial consultations, 14% to diagnostic arrangement, and 21% to preparation for radiotherapy. Concerted efforts are needed to minimise further the time between the onset of symptoms and treatment. A substantial reduction in this delay can be achieved if both public and primary care doctors were made more aware of the significance of relevant symptoms.

MRI of the hypothalamus and pituitary gland in patients with hyperprolactinaemia following radiotherapy for nasopharyngeal carcinoma.

PURPOSE: Neuroendocrine dysfunction is a known complication of cranial radiation. While growth hormone deficiency is the most common laboratory finding, hyperprolactinaemia is one of the most common symptomatic dysfunction in adult female patients with nasopharyngeal carcinoma (NPC) following radiotherapy. This analysis aims to study the magnetic resonance imaging (MRI) features of the hypothalamus and the pituitary gland in affected patients. METHODS: MRI was performed in 24 patients NPC with hyperprolactinaemia detected 10-52 months following one course of radical radiotherapy. The region of study included the nasopharynx, the hypothalamus and the pituitary gland in 20 patients, while in the remaining four patients, this was limited to the pituitary gland. The estimated radiation dose to the hypothalamus and the pituitary gland was 66 Gy, and six patients also had adjuvant chemotherapy. There was no clinical evidence of tumour recurrence in all 24 patients when hyperprolactinaemia was detected. RESULTS: None of the 24 patients showed any MRI evidence of structural abnormality in the hypothalamic-pituitary region. CONCLUSION: MRI did not reveal any structural abnormality in the hypothalamic-pituitary region of patients who developed hyperprolactinaemia following radiotherapy for NPC.

A phase II study of pemetrexed combined with cisplatin in patients with recurrent or metastatic nanopharyngeal carcinoma.

Pemetrexed is a novel chemotherapy agent with good efficacy and toxicity profiles. This phase II study aimed at evaluating its use in combination with cisplatin for recurrent or metastatic nasopharyngeal carcinoma (NPC). All participating patients had metastatic or recurrent NPC with prior treatment by platinum-based chemotherapy. The study regimen comprised of pemetrexed 500 mg/m(2) and cisplatin 75 mg/m(2), repeated 3-weekly for 4 cycles. Efficacy evaluation was based on both radiological and biochemical responses. Patients with no progressive disease and good tolerance were given another 2-4 cycles. Fifteen patients were treated for a total of 4-8 cycles (median, 6 cycles); 9 had distant metastases and 6 had loco-regional recurrences only. Reduction of DNA copies of EB virus by ≥50% was observed in 93% accessible patients, with 21% of them being biochemical complete response (CR). Radiologically, 1 (7%) patient achieved CR, 2 (13%) achieved partial response and 8 (53%) had stable diseases. The median time to progression was 30 weeks. Treatment was well tolerated with only 1 (7%) patient developing grade 4 toxicity (of anemia). The most common grade 3 toxicities were neutropenia (27%) and anemia (20%). The baseline mean total QOL scores (as measured with FACT-H&N version 4) was 100.4 and showed no significant change after the fourth cycle (95.6, p=0.20) and sixth cycle (91.9, p=0.15). Pemetrexed in combination with cisplatin is a well tolerated regimen with encouraging efficacy for metastatic and recurrent NPC. Further evaluation of its role in the management of NPC is warranted.