Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis.

BACKGROUND: Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization. METHODS: MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year. RESULTS: In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia. CONCLUSION: The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.

Sinonasal malignant melanoma: an analysis of 115 cases assessing outcomes of surgery, postoperative radiotherapy and endoscopic resection.

BACKGROUND: Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection. METHODOLOGY: Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome. RESULTS: 115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome. CONCLUSIONS: Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.

Inferring super-spreading from transmission clusters of COVID-19 in Hong Kong, Japan, and Singapore.

Super-spreading events in an outbreak can change the nature of an epidemic. Therefore, it is useful for public health teams to determine whether an ongoing outbreak has any contribution from such events, which may be amenable to interventions. We estimated the basic reproductive number (R0) and the dispersion factor (k) from empirical data on clusters of epidemiologically linked coronavirus disease 2019 (COVID-19) cases in Hong Kong, Japan and Singapore. This allowed us to infer the presence or absence of super-spreading events during the early phase of these outbreaks. The relatively large values of k implied that large cluster sizes, compatible with super-spreading, were unlikely.

Induction of matrix metalloproteinases by Epstein-Barr virus latent membrane protein 1 isolated from nasopharyngeal carcinoma.

Epstein--Barr virus latent infection is associated with human malignancies including Burkitt's lymphoma, gastric carcinoma and the highly invasive nasopharyngeal carcinoma (NPC). Increased expression of EBV latent membrane protein 1, LMP1, is correlated with tumor progression and metastasis in NPC. LMP1 induces cellular proteins including cytokines and matrix metalloproteinases (e.g., MMP1, MMP2 and MMP9). MMPs are endopeptidases involved in the degradation of extracellular matrix proteins; and their upregulation in cancer implicates their potential role in tumor metastasis. In light of the role of LMP1 in cytokine dysregulation and the fact that MMPs are regulated by cytokines, we examined whether LMP1 promotes NPC metastasis via the induction of MMPs. To delineate the oncogenic role of LMP1 in NPC, we first investigated the induction of MMP1, MMP2, MMP3 and MMP9 in LMP1-positive NPC tumor samples (n=15) by quantitative RT-PCR. We showed a significant induction of MMP1 and MMP3 transcripts in the EBV LMP1-positive NPC tissues, compared with biopsies obtained from the adjacent non-tumor tissues. To investigate the role of LMP1 in MMP expression in NPC, we cloned the LMP1 gene from NPC samples and transiently expressed it in MRC5 cells (human lung fibroblasts). Following transfection, a time-dependent elevation of endogenous MMP3 expression was found in the LMP1-transfectants by quantitative RT-PCR and Western analysis. Taken together, we observed that MMP3 is upregulated in LMP1-positive NPC tumors and LMP1-expression in fibroblasts is associated with MMP3 and cytokine expression. Our results suggest that LMP1 may contribute to invasiveness of NPC cells via the expression of MMP3 in fibroblasts.

Elevation of plasma osteopontin level in patients with undifferentiated nasopharyngeal carcinoma.

AIMS: We evaluated the clinicopathologic relevance of plasma osteopontin (OPN) level in nasopharyngeal carcinoma patients. METHODS: Seventy-two plasma samples were collected from patients with undifferentiated nasopharyngeal carcinoma (NPC) before radiotherapy. Plasma OPN level was determined by quantitative sandwich enzyme immunoassay. The plasma OPN level was evaluated for its clinicopathologic relevance. RESULTS: The mean plasma OPN level was significantly higher in NPC patients than in normal controls (184.66 vs 75.89 ng/ml, p<0.001). In addition, high OPN level was found in the patients with advanced cancer and was correlated with neck node metastasis (p<0.05). CONCLUSIONS: Our findings indicated a potential role of OPN in the pathogenesis and nodal metastasis of undifferentiated NPC.

Salvage surgery for recurrent primary nasopharyngeal carcinoma.

Recurrent primary nasopharyngeal carcinoma after radiotherapy exhibits wide local extension [Uttley D, Moore A, Archer DJ. J Neurosurg 1989;71:705-10]. This wide exposure of the nasopharynx and its vicinity is essential for an oncological radical resection to be carried out. The resection should embrace the tumor with an adequate mucosal margin including the cartilaginous portion of the Eustachian tube. Paranasopharyngeal tissues should be included in the resection whenever indicated. The anterolateral approach to the nasopharynx and the paranasopharyngeal space provides adequate exposure required for an oncological resection. Morbidity associated with the operation is low and this is recommended for resection of most recurrent primary nasopharyngeal carcinoma after radiotherapy.

The study of p16 and p15 gene methylation in head and neck squamous cell carcinoma and their quantitative evaluation in plasma by real-time PCR.

Epigenetic silencing of the p16 and p15 genes by promoter methylation are commonly observed in human epithelial malignancies, including head and neck squamous cell carcinomas (HNSCC). In this study, a methylation-specific polymerase chain reaction (MSP) was used to evaluate the methylation status of the p16 and p15 genes in 73 HNSCC surgical specimens. p16 and p15 gene methylation was also examined in 29 paired metastatic lymph nodes and 29 paired histologically, normal resection margin mucosae. The quantity of cell-free methylated p16 and p15 DNA in the plasma samples of 20 HNSCC patients and 24 healthy controls was also examined using a fluorescence-based real-time PCR assay. The frequencies of p16 and p15 methylation in the primary tumour were 49% and 60%, respectively. Concordant methylation of p16 and p15 in tumour samples and metastatic lymph nodes was found in 59 and 38% of cases, respectively. A significantly higher prevalence of p15 methylation was found in histologically-normal surgical margin epithelia of HNSCC patients with chronic smoking and drinking habits compared with non-smokers and non-drinkers. In addition, methylated p16 and p15 DNA levels were significantly higher in the plasma of HNSCC patients (mean 56 copies/ml plasma and 65 copies/ml plasma, respectively) compared with normal controls (mean 6 copies/ml plasma and 16 copies/ml plasma, respectively). In conclusion, promoter methylation of the p16 and p15 genes is involved in the pathogenesis of HNSCC and may be related to chronic smoking and drinking. The differential levels of methylated p16 and p15 DNA in plasma might be potential useful markers in screening high-risk populations for early HNSCC and monitoring their treatment response.

Nasopharyngeal carcinoma: orderly neck node spread.

A prospective study of 271 consecutive patients with newly diagnosed nasopharyngeal carcinoma was undertaken to assess the pattern of cervical nodal involvement with reference to 10 cervical nodal groups and three levels of neck; 204 (75.3%) patients were found to have cervical lymphadenopathy at presentation. Fifty-four (26.5%) of these patients had right cervical lymphadenopathy, 70 (34.3%) had left cervical lymphadenopathy, and 80 (39.2%) had bilateral cervical lymphadenopathy. The occurrence of lymphadenopathy in the 10 cervical nodal groups and the mean size of nodes in these nodal groups were computed. The subdigastric and upper jugular group was involved in more than 95% of cases. The lower the position in the neck, the less frequently the nodal group was involved. The mean size of nodes was largest in the subdigastric and upper jugular region compared with the other groups. The nodes in the upper neck were generally larger than those in the lower neck. The lower two levels of neck were involved without involvement of the upper level of the ipsilateral neck in fewer than 4% of cases. The present study indicates that neck node involvement by nasopharyngeal carcinoma is by orderly spread down the neck, which explains the adverse prognostic significance of neck node involvement in the lower neck. The orderly involvement of the neck nodes suggests that prophylactic irradiation of the neck should be given at least one level beyond the clinical extent of disease, which for patients with no clinically palpable node would mean prophylactic irradiation of the upper neck.

Transpalatal insertion of radioactive gold grain for the treatment of persistent and recurrent nasopharyngeal carcinoma.

PURPOSE: To evaluate the efficacy of radioactive gold grain implant via the split palate approach in the control of locally recurrent or persistent nasopharyngeal carcinoma. METHODS AND MATERIAL: Forty-three patients, 10 for persistent NPC, 28 for first relapse in the nasopharynx, and five for second relapse in the nasopharynx, were treated. The diameter of the tumors at the time of gold grain implant ranged from 0.5 to 5 cm, the number of gold grains inserted varied from 4 to 14, the median number was seven. RESULTS: There was no significant difference in the control of the primary tumor for persistent disease (80% at 5 years), first relapse (61% at 5 years) and second relapse (80% at 3 years), p = 0.8845. The difference in survival between the three subgroups of patients, however, was highly significant (p = 0.0040). Thirty patients had CT evaluation before gold grain implant and the tumor was found confined to the nasopharynx in 21, in the remaining nine patients erosion of the sphenoid sinus or other parts of the base of skull was noted. The difference in the control between those patients with tumors confined to the nasopharynx and those patients with extranasopharyngeal extension of tumor almost reached statistical significance (81% and 44% respectively at 5 years, p = 0.0554). For the six patients who developed local recurrence after gold grain implant and were evaluable for the pattern of failure, the recurrent tumors were considered originating from another region of the nasopharynx in four, and in-field failure in the other two cases. CONCLUSION: Radioactive gold grain implant as salvage treatment provides satisfactory control of persistent and recurrent nasopharyngeal carcinoma. The local control was better when the tumor was localized to the nasopharynx, thus underlines the importance of close follow-up for early recognition of relapse and persistent tumor. However, such patients still suffered from high incidence of regional and distant failure, the pathophysiology and management of which require further investigation.

Locally recurrent nasopharyngeal carcinoma: treatment results for patients with computed tomography assessment.

PURPOSE: To study the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma as restaged by computed tomography (CT). PATIENTS AND METHODS: One hundred forty patients with CT restaged locally recurrent nasopharyngeal carcinoma were reviewed. Patients were restaged at recurrence according to the AJCC stage classification with the following distribution: T1-T2:30%, T3:19%, T4:51%. Ninety-seven patients received reirradiation; among these 62 had external irradiation, 34 had brachytherapy, and 1 had both. Twelve patients received surgery. Thirty-one patients were treated with palliative intent and received either chemotherapy or supportive treatment only. Overall survival (OAS) and performance-adjusted survival (PAS, defined as surviving with a Karnofsky performance score [KPS] > 50) were calculated by Kaplan-Meier method. Multivariate analysis was performed using the Cox model. RESULTS: The median survival for all patients was 23.8 months. After reirradiation, the 3-yr and 5-yr OAS rates were 46% and 36%, respectively. The corresponding PAS rates were 40% and 28%. The 3-yr OAS rates for recurrent T1-2, T3, and T4 disease after reirradiation were 71%, 42%, and 30%; the corresponding 5-yr OAS rates were 57%, 42%, 17%. The 3-yr and 5-yr OAS rates in patients receiving palliative treatments only were 19% and 0%, respectively. The 3-yr OAS rate after surgery was 42%. In the multivariate analysis, older age, recurrent T3-4 disease, and palliative treatment were unfavorable factors in predicting overall survival, whereas recurrent T3-4 disease, baseline KPS < 70, and palliative treatment were unfavorable factors in predicting PAS. A high complication rate was observed after reirradiation, with 34% of patients developing neurological sequel. CONCLUSION: Aggressive treatment for locally recurrent nasopharyngeal carcinoma is warranted especially for those with disease confined to the nasopharynx. Survival after retreatment for more extensive disease remains poor but was still superior to supportive treatment only. Early diagnosis of local recurrence allows prompt administration of treatment and is associated with better outcome. Future studies should aim at improving the therapeutic ratio in the retreatment of recurrent disease especially in patients with more extensive local recurrence.

Sensorineural hearing loss in patients treated for nasopharyngeal carcinoma: a prospective study of the effect of radiation and cisplatin treatment.

PURPOSE: The pattern of sensorineural hearing loss (SNHL) after primary treatment for nasopharyngeal carcinoma (NPC) was studied, and the effect of cisplatin, radiotherapy does, and fractionation were evaluated. METHODS AND MATERIALS: One hundred thirty-two patients, 227 ears, and 1100 audiogram reports were analyzed. Radiotherapy dose ranged from 59.5 to 76.5 Gy. Fifty-two patients received preirradiation cisplatin, total dose 100-185 mg/m(2). Serial postirradiation bone conduction thresholds at 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz were compared with pretreatment thresholds at respective frequencies. Increase of at least 15 dB was considered as significant and was further grouped as transient or persistent SNHL. Univariate and multivariate analyses were performed to identify predicting factors for persistent SNHL. RESULTS: At median follow-up of 30 months, 24.2% of ears developed persistent SNHL. High frequency was more affected than low frequencies, 22 vs. 5.3%. Males were more affected than females, 29.4 vs. 15.5%, p = 0.0132. Incidence of persistent SNHL increased with age, with 0, 17.2, and 37.4% of patients aged under 30, between 30-50 and over 50 affected, respectively, p = 0.0001. High incidence was found in patient with postirradiation serous otitis media (SOM), 46.9%. Chemotherapy with cisplatin and radiation dose or fractionation had no significant effect. Multivariate analysis confirmed age, sex, and postirradiation SOM as significant prognostic factors for persistent SNHL. CONCLUSIONS: Transient and persistent SNHL occurred after radiotherapy, more commonly affecting high frequency. A low dose of preirradiation cisplatin did not increase the risk. A dose fractionation effect of radiotherapy was not confirmed in this study.

Minimum graft size for successful living donor liver transplantation.

BACKGROUND: The extension of living donor liver transplantation to adult recipients is limited by the adequacy of the size of the graft. We evaluate the effect of the graft size on the survival of the recipient in order to establish a clinical guide for the minimum requirement. METHODS: The clinical records of 14 adults and 11 children (body weight 6.1-100 kg) who underwent living donor liver transplantation for chronic or acute liver failure were reviewed. The effect of the graft weight ratio (graft weight divided by standard liver weight of recipient) on graft function and survival was studied. RESULTS: The graft weight ratio ranged from 31 to 203%. The overall graft and patient survival rates were 84% at a median follow-up of 29 months. The survival rate was 95% for recipients with a graft weight ratio >40%, and 40% only for those with a ratio < or =40% (P = 0.016). It was 88% (7/8) when the ratio was >100%, 100% (5/5) when the ratio was 71 to 100%, 100% (7/7) when the ratio was 41 to 70%, and 40% (2/5) only when the ratio was < or =40%. When the graft weight ratio was < or =40%, early graft dysfunction was evident and contributed to the causes of death in three patients. CONCLUSIONS: Preoperative computed tomographic measurement of liver size of a living donor is essential. A graft that represented 40% or less of the recipient's standard liver weight should be regarded as a marginal graft with a lower success rate.

Applicability of living donor liver transplantation to high-urgency patients.

BACKGROUND: Cadaveric liver donors are scarce in Hong Kong, and the application of liver transplantation to high-urgency patients is limited. We evaluated the use of grafts from living donors in this setting. METHODS: From July 1994 to January 1998, 49 consecutive adult patients who were intensive care unit-bound because of acute or chronic liver failure were put on a high-urgency list for liver transplantation. Family members were not solicited for living donation, and the initiation and decision for living donor liver transplantation (LDLT) was based on the donor's voluntary intent. Assessment of the living donor, including blood tests, computed tomographic volumetry, and angiography, was performed only after informed consent was executed. RESULTS: In 25 of 49 (51%) patients, no family member volunteered as living donor; 23 died awaiting donor organs, and 2 received a cadaveric graft. Twenty-four (49%) patients had 36 family members who volunteered as living donors. Before evaluation of living donor was completed, two patients received a cadaveric liver transplant. LDLT was not performed in nine patients because of recipient contraindications (n=4), ABO blood group incompatibility (n=3), and withdrawal of donor (n=2). Eight of these nine patients died, and one received a cadaveric liver graft. The remaining 13 (27%) patients received grafts from living donors. Four of 5 (80%) patients who underwent cadaveric liver transplantation and 11 of 13 (85%) who underwent LDLT survived. Thus, emergency transplantation from living donors increased the applicability of liver transplantation from 10% to 37%, and the survival rate after emergency LDLT (85%) was superior to that of the remaining patients (11%). CONCLUSIONS: When cadaveric organ donation is scarce, emergency liver transplantation from living donors can be applied to high-urgency adult patients.

Extending the limit on the size of adult recipient in living donor liver transplantation using extended right lobe graft.

The feasibility of adult-to-adult living donor liver transplantation (LDLT) is restricted by the adequacy of the graft size. A left lobe graft from a relatively small donor will not meet the metabolic demand of a larger recipient. We report a successful LDLT performed on a 90-kg man using an extended right lobe graft weighing 910 g from his relatively smaller-size brother. The donor-to-recipient body weight ratio was only 0.82. No homologous blood transfusion was required for the donor, and the donor recovered uneventfully except for mild transient hyperbilirubinemia. The graft provided adequate function for the metabolic needs of the recipient despite postoperative septic complications. Both donor and recipient were well with normal liver function at 4 months after operation. LDLT using the extended right lobe liver graft can extend the limit on the size of the adult recipient and may be a viable option even when the donor is relatively small compared with the recipient.

A comparative study of the clinicopathological significance of E-cadherin and catenins (alpha, beta, gamma) expression in the surgical management of oral tongue carcinoma.

PURPOSE: E-cadherin and catenins are important epithelial adhesion molecules in normal epithelium. Loss of E-cadherin-catenin adhesion is an important step in the progression of many epithelial cancers. E-cadherin and catenins expression in carcinoma of the tongue were evaluated in relation to their clinicopathological features and prognostic values. METHOD: Immunohistochemical staining was carried out with E-cadherin and (alpha, beta, gamma)-catenin monoclonal antibodies for 85 surgical specimens of oral tongue carcinoma, nine matched metastatic lymph nodes, and seven locally recurrent tumours. RESULTS: There was under-expression in 85% of E-cadherin, 94% of alpha-catenin, 89% of beta-catenin, and 83% of gamma-catenin in the primary tumours. There was no correlation of E-cadherin/catenin expression with sex, age, cancer stage, and differentiation. Nodal metastasis was found in 68% of patients with weak expression of gamma-catenin compared with 9% with strong expression in primary tumours (chi-square, P = 0.02). E-cadherin was a significant prognostic factor for survival and recurrence; patients with weak E-cadherin expression had 53% 5-year survival compared with 85% with strong expression (Wilcoxon, P = 0.0159). CONCLUSIONS: Both E-cadherin and catenins were highly under-expressed in oral tongue carcinoma, metastatic lymph node, and recurrent tumour. gamma-catenin had predictive value for nodal metastasis. E-cadherin was, however, a more important prognostic factor for recurrence and survival.

The clinicopathologic significance of p53 and p21 expression in the surgical management of lingual squamous cell carcinoma.

The aim of the present study was to evaluate the clinicopathologic significance of p53 and p21 expression in lingual squamous cell carcinomas. Immunohistochemical staining was performed with p53 and p21 monoclonal antibodies on surgical specimens from 87 patients who underwent primary surgical treatment for lingual carcinoma between 1976 and 1996. We found positive expression of p53 in 45 (52%) of 87 cases and of p21 in 49 (56%) of 87 cases. There was no correlation of p53 and p21 expression with cancer stage, T stage, nodal metastasis, and tumor grade. Univariate analysis revealed that p21 expression, tumor stage, T stage, and nodal stage were significant prognostic factors for survival. However, only p21 expression and tumor stage were significant independent prognostic factors for survival in a multivariate Cox regression analysis. Overexpression of p21 but not p53 has prognostic value for survival in the surgical treatment of lingual carcinomas. The combination of stage with p21 expression is recommended for evaluation of prognosis and for management planning.

Thoracoscopic esophageal mobilization for pharyngolaryngoesophagectomy.

BACKGROUND: Pharyngolaryngoesophagectomy (PLE) for hypopharyngeal cancers and tumors of the cervical esophagus is a procedure of significant morbidity and mortality. Conventional esophageal mobilization is performed with the transhiatal dissection technique. Thoracoscopic esophageal mobilization is tested as an alternative to determine whether surgical outcome can be improved. METHODS: From 1994 to 1998, thoracoscopic mobilization was carried out in 30 consecutive patients who underwent PLE (PLE-TS). This was compared to a historical cohort of 30 patients who had PLE with transhiatal mobilization (PLE-TH). RESULTS: In PLE-TS, thoracoscopic esophageal mobilization was successful in 28 patients (93%). Median blood loss was 700 mL (range, 164 to 3,000 mL) compared to 1,000 mL (range, 400 to 2,200 mL) in group PLE-TH, p = 0.21. Thoracoscopy time was 90 minutes (range, 60 to 180 minutes). Total operating time were 392 minutes (range, 180 to 570 minutes) and 300 minutes (range, 150 to 550 minutes) in PLE-TS and PLE-TH, respectively (p = 0.03). Major pulmonary complications occurred in 7 (23%) and 8 (27%) patients in PLE-TS and PLE-TH, respectively (p = 0.77). Cardiac complications occurred in 7 (23%) and 5 (17%) patients in PLE-TS and PLE-TH, respectively (p = 0.52). Thirty-day mortality rates were 3.3% and 10% (p = 0.6) and hospital mortality rates were 13% and 17%, (p = 1.0). CONCLUSIONS: Thoracoscopy was safe and feasible. Morbidity and mortality after PLE was not significantly reduced. The theoretical advantage offered by thoracoscopy may be offset by the lengthened time of one-lung anesthesia.

Treatment of neck nodes in oral cancer.

In a review of 98 patients who were operated upon for squamous oral cancer, a high proportion of them (48%) developed recurrence after a minimum follow-up of 2 years. Nodal status significantly affected the nodal recurrence rate and survival. For N0, N1, N3 tumours, the 2-year nodal recurrence-free rates were 79, 83, 18%, and the 2-year survival rates were 58, 59 and 10%. For small tumours with N0 neck, the group with elective neck dissection and the observed group did not have statistically different nodal recurrence-free rate and overall survival. The 2-year nodal recurrence-free rate was 92% versus 77% (P value > 0.3) and the 2-year survival rate was 56% versus 72% (P value > 0.6). In patients with N1 neck, radical neck dissection was reasonably effective in controlling neck metastasis. Radical neck dissection in an attempt to treat fixed neck nodes (N3) was not successful in controlling the neck disease.

Present status of management of nasopharyngeal carcinoma.

Contemporary imaging with endoscopic examination determines tumor extent and this is reflected in the revised staging system. Radiotherapy remains the primary treatment modality. The use of intensity-modulated radiotherapy aims at enhanced tumor control while reducing adverse effects. Concurrent chemotherapy has shown to improve survival, although its efficacy in endemic regions requires confirmation. Determination of circulating cell-free Epstein-Barr virus DNA might detect early recurrence. For patients who developed recurrence in the neck, surgery provides good salvage. For small tumor in the nasopharynx, good results can be obtained with reirradiation therapy, brachytherapy or surgery. The salvage option depends on the size and location of the tumor as well as the expertise available. The long-term effects of these treatment modalities might be significant.

Prospective randomized study of post-operative chemotherapy with levamisole and UFT for head and neck carcinoma.

AIMS: A prospective randomized study was conducted to evaluate the benefit of adjuvant levamisole/UFT (futraful and uracil) chemotherapy in head and neck squamous cell carcinoma. METHODS: Sixty-five patients with stage III and IV squamous cell carcinomas of oral cavity, oropharynx, hypopharynx and larynx with no distant metastasis were randomized for the chemotherapy study. Thirty-one patients were randomized for chemotherapy and two of them were subsequently excluded. In this study, a total of 29 patients on levamisole/UFT therapy and 34 patients on the control group were analysed. The main outcome was measured by the 5-year disease-free actuarial survival rate. RESULTS: The rates of distant metastasis were 10% for chemotherapy group and 32% for control group (P=0.06). The 5-year disease-free actuarial survival rates for patients with and without adjuvant chemotherapy were 57% and 39% respectively (P=0.207). CONCLUSIONS: A trend of better distant control in head and neck cancer patients with post-operative adjuvant oral chemotherapy was observed. The side effects were minimal. However, there was no statistically significant improvement in the overall long-term survival. It may be of value to conduct a large-scale multi-centre prospective randomized study to verify the efficacy of levamisole and UFT as post-operative adjuvant chemotherapy for the control of distant metastasis in high-risk population.