Determination of aortic valve area in valvular aortic stenosis by direct measurement using intracardiac echocardiography: a comparison with the Gorlin and continuity equations.

OBJECTIVES: This study sought to 1) show that intracardiac echocardiography can allow direct measurement of the aortic valve area, and 2) compare the directly measured aortic valve area from intracardiac echocardiography with the calculated aortic valve area from the Gorlin and continuity equations. BACKGROUND: Intracardiac echocardiography has been used in the descriptive evaluation of the aortic valve; however, direct measurement of the aortic valve area using this technique in a clinical setting has not been documented. Despite their theoretical and practical limitations, the Gorlin and continuity equations remain the current standard methods for determining the aortic valve orifice area. METHODS: Seventeen patients underwent intracardiac echocardiography for direct measurement of the aortic valve area, including four patients studied both before and after valvuloplasty, for a total of 21 studies. Immediately after intracardiac echocardiography, hemodynamic data were obtained from transthoracic echocardiography and cardiac catheterization. RESULTS: Adequate intracardiac echocardiographic images were obtained in 17 (81%) of 21 studies. The average aortic valve area (mean +/- SD) determined by intracardiac echocardiography for the 13 studies in the Gorlin analysis group was 0.59 +/- 0.18 cm2 (range 0.37 to 1.01), and the average aortic valve area determined by the Gorlin equation was 0.62 +/- 0.18 cm2 (range 0.31 to 0.88). The average aortic valve area determined by intracardiac echocardiography for the 17 studies in the continuity analysis group was 0.66 +/- 0.23 cm2 (range 0.37 to 1.01), and that for the continuity equation was 0.62 +/- 0.22 cm2 (range 0.34 to 1.06). There was a significant correlation between the aortic valve area determined by intracardiac echocardiography and the aortic valve area calculated by the Gorlin (r = 0.78, p = 0.002) and continuity equations (r = 0.82, p < 0.0001). CONCLUSIONS: In the clinical setting, intracardiac echocardiography can directly measure the aortic valve area with an accuracy similar to the invasive and noninvasive methods currently used. This study demonstrates a new, quantitative use for intracardiac echocardiographic imaging with many potential clinical applications.

Cutaneous malignant lymphoma.

The skin as the first site of non-Hodgkin's lymphoma is uncommon. Between 1967-1982 only 61 evaluable patients were seen; lymphoma was confined to the skin in 43. Most histological subtypes of non-Hodgkin's lymphoma were represented with diffuse histiocytic tumors accounting for 28 (46%). Overall, there was a 5-year survival rate of 52% with a median of 75 months. For patients with disseminated lymphoma involving the skin, the median survival was 18 months and there were no 10 year survivors. Patients with disease confined to the skin had 5 and 10-year survival rates of 62 and 57%, and a median survival of 159 months. Significant prognostic indicators included the site and bulk of tumor, but not the histological subtype. For small bulk localized tumors radiotherapy achieved local control in all patients and an over 80% five-year relapse-free rate. We conclude that lymphomas confined to the skin can be adequately treated by radiotherapy, whereas disseminated tumors require systemic therapy in addition. The management of bulky cutaneous lymphoma remains controversial.

Malignant salivary gland tumors.

A retrospective review of 403 patients with salivary gland tumors seen between 1958 and 1980 and a mean follow-up of 10 years is reported. The median age was 58 (7-94) years and the male to female ratio 1.3:1. There were 293 (72%) parotid, 83 (21%) submaxillary and 27 (7%) tumors developed at other sites. Among these were 84 (22%) mucoepidermoid (all degrees of differentiation), 87 (22%) adenocystic carcinomas, 70 (17%) adenocarcinomas, 25 (6%) acinic, 26 (6%) squamous cell, 44 (11%) undifferentiated, 52 (13%) mixed and 12 (3%) nonspecified carcinomas. A painless lump was the first symptom in 338 (84%) patients. The first planned treatment was surgery in 110 (27%), radiotherapy in 50 (12%), and surgery and radiotherapy combined in 239 (59%) patients. Following the first treatment, the primary parotid tumor was controlled by surgery in 17/70 (24%), by irradiation in 6/39 (15%) and surgery and radiation combined in 134/182 (74%) patients. Altogether, regional metastases developed in 36 (12%) and distant metastases in 36 (12%) of 293 patients with parotid tumors. For the submandibular tumors the primary tumor was controlled by surgery in 9/31 (29%), 0/4 (0%) by irradiation, and in 32/46 (70%) by surgery and irradiation. Here, regional and distant metastases developed in 16/84 (19%) and 19/84 (23%) patients. Among the other sites the primary tumor was controlled by surgery in 4/9 (44%), 0/7 (0%) by irradiation, and in 8/11 (73%) by surgery and radiotherapy combined. In this group 4/27 (15%) and 5/27 (18%) patients developed regional and distant metastases. The 5- and 10-year cause specific survival rates were 65 and 59% for the parotid tumors, 61 and 48% for the submaxillary tumors and 62 and 52% for the other sites. These results clearly demonstrate the advantages of combining surgery and radiotherapy as the first planned treatment for most tumors.

Lymphoreticular tumors of the orbit.

Lymphoreticular tumors in the orbit are uncommon. Only 42 patients were identified from over 2000 patients with tumors of lymphoid tissue seen between 1958 and 1979. The patients were divided into 3 groups: primary malignant, secondary malignant, and benign lymphoma. In the primary malignant lymphoma groups, there were 24 patients with a median age of 64 (40 to 87) years and a 2.4:1 female to male ratio: 2 cases were bilateral. In 19 (79%) patients with the lymphoma limited to one orbit the tumor was controlled in every case with doses from 25 to 45 Gy. There were no serious complications. Subsequently lymphoma developed at other sites in 7 (37%) patients. The 5 and 10 year cause specific actuarial survival rates were 70 and 62%. In the 8 patients with secondary malignant lymphoma, the orbital disease was controlled by irradiation, although all patients required further treatment and died of their disease. Radiotherapy controlled all 7 patients with benign lymphoma without any complications.

Multiple primary squamous cell carcinomas in the upper digestive tract.

Multiple squamous cell carcinomas are common and patients carry a constant and excessive risk of developing a new cancer at any time (13-21 X the normal). Among 6,203 cases of primary squamous carcinoma of the upper digestive tract, 648 patients (10.4%) developed two or more independent tumors. Altogether, 761 additional malignancies were observed, with up to five cancers being seen in individual patients. There were 279 patients with a prior or synchronous cancer and 409 patients who developed 462 metachronous tumors. There was a substantial risk for developing a second primary cancer in the upper aerodigestive tract. Overall the observed to expected ratio was 2.48, specifically 2.32 for males and 2.89 for females.

Basal and squamous cell carcinoma of the eyelids and their treatment by radiotherapy.

We report 1,166 tumors of the eyelids that were treated by single or fractionated exposures to doses of 20-60 Gy. The five year tumor control rate was 95% for basal cell and 93.3% for squamous cell carcinoma. Irradiation was equally successful in primary cases and in those recurrent following surgery. Recurrence following irradiation was managed by surgery or further irradiation. The cosmetic and functional results were generally excellent and readily accepted by most patients. The overall complication rate was 9.6% with fewer than one-half rated as serious; these problems mainly occurred with large tumors that had destroyed normal tissues. In only 14 (1.2%) patients was death related to the tumor. Approximately one-half of the patients received a dose of 35 Gy in five daily fractions, one-quarter, 20 to 22.5 Gy in a single exposure and the others with larger tumors 42.5-60 Gy in 10 to 30 exposures in two to six weeks. Radiotherapy is a safe and cost effective treatment for eyelid tumors.

Outcome analysis of localized gastrointestinal lymphoma treated with surgery and postoperative irradiation.

One hundred thirteen patients with localized gastrointestinal lymphoma treated by surgery and postoperative irradiation between 1967 and 1985 were reviewed. At 15 years, actuarial survival of this group was 40.6%, with a cause-specific survival of 69.2% and a relapse-free rate of 64%. Two-thirds of relapses occurred at distant sites. In Stage IA and IIA patients with no residuum or with positive resection margins, (N = 90) only site of involvement and stage predicted for relapse. Age, histologic subtype group, and depth of bowel wall invasion did not affect relapse risk. In the very favorable group (Stage IA, IIA, no residuum or microscopic residuum), 8.4% of patients with stomach lymphoma relapsed compared to 25% of patients with small bowel lymphoma. The risk of early relapse was higher in those with Stage IIA small bowel lymphoma than those with Stage IA small bowel lymphoma. We continue to recommend adjuvant abdominal irradiation for patients with Stage IA, IIA completely resected stomach lymphoma and Stage IA completely resected small bowel lymphoma. We recommend combined modality therapy for patients with completely resected Stage IIA small bowel lymphoma and all other localized gastrointestinal lymphoma where visible residual disease is present.

Analysis of supradiaphragmatic clinical stage I and II Hodgkin's disease treated with radiation alone.

Patients with clinical Stage I and II Hodgkin's disease have been managed at the Princess Margaret Hospital for over 20 years, without the use of routine staging laparotomy. Our experience identified as adverse prognostic factors presence of a large mediastinal mass, B symptoms, and advanced age in presence of unfavorable histology (20). We had suggested previously that the use of extended field radiation therapy (XRT) was associated with a lower risk of relapse than involved field XRT or mantle XRT. There has been a trend over the past decade to select those patients with favorable prognostic factors for treatment with XRT alone and to use mantle plus upper abdominal XRT (extended field XRT) to treat them. A retrospective study of patients with clinical Stage I and II Hodgkin's disease treated at the Princess Margaret Hospital between 1978 and 1986 was conducted to determine the impact of patient selection and extended field radiation on outcome. The study involved 250 patients with supradiaphragmatic disease selected for treatment with radiation alone on the absence of adverse prognostic factors. Radiation techniques included involved field radiation in selected patients (those with upper neck involvement), mantle radiation in the earlier years, and mantle plus upper abdominal radiation in the later years of the study. Actuarial survival was 83.3% at 8 years; cause-specific survival was 90.1% and the relapse-free rate 71.6%. Local tumor control was 94.6%; only two patients had true infield failure. Multivariate analysis showed that significant prognostic factors included age, histology, and erythrocyte sedimentation rate. Extent of the radiation treatment volume was significant and influenced the risk of relapse, particularly out-of-field relapse, independently of other factors. A dose of 35 Gy was found to be sufficient for control of clinical disease. This study validated a previously developed model for the selection of clinically staged patients with Stage I and II Hodgkin's disease for treatment with radiation alone. Careful selection of these patients can yield excellent results without requiring that staging laparotomy be routinely performed or the use of systemic chemotherapy as the initial treatment.

Angioscopic assessment of coronary lesions underlying thrombus.

This study examines the characteristics of coronary lesions in which thrombus is found as assessed by angioscopy before percutaneous transluminal coronary angioplasty in patients with various coronary syndromes. Our findings demonstrate that the plaque underlying intracoronary thrombus is usually yellow and/or disrupted, and support in vitro observations that lipid-rich plaques are highly thrombogenic and that disruption of these plaques is associated with in situ thrombosis.

Angioscopy of culprit coronary lesions in unstable angina pectoris and correlation of clinical presentation with plaque morphology.

This study demonstrates that plaque disruption and thrombus are absent in a considerable number of patients with unstable angina and that culprit lesion morphologies as assessed by angioscopy may differ among the various clinical subsets of patients. Although plaque disruption and thrombus undoubtedly play an important role in the pathogenesis of unstable angina, alternative mechanisms may be responsible for ischemia in some patients.

Role of radiation therapy in localized non-Hodgkin's lymphoma.

Relapse occurs in 50% of patients receiving radiation for clinical stage (C.S.) I and II nodal and extranodal non-Hodgkin's lymphoma (N.H.L.). Prior to the introduction of intensive chemotherapy those failing primary control with irradiation and most of those who relapsed died of their disease with a resultant overall mortality of 50%. An analysis of Princess Margaret Hospital results with radiation for C.S. I and II N.H.L. between January 1967 and December 1978 revealed that tumour bulk, age, stage and histology were of independent prognostic significance. It was possible to group patients using combinations of these attributes so that each group encompassed only patients with similar outcomes. Such prognostic groups were identified separately within the low grade and the intermediate plus high grade categories of the Working Formulation. Patients with a high probability of cure with radiation were so defined. Also those patients in whom chemotherapy would be optimal initial therapy were also defined. Such patients were in the intermediate plus high grade histology groups. Thirty percent of all patients with low grade histology lymphoma had an actuarial survival of 83%, and relapse-free rate of 63% at 10 years. By implication, approximately 20% of all patients with these histologies seen at the Princess Margaret Hospital for the same time period achieved prolonged relapse-free survival by localized therapy. This is at variance with the implications of staging from studies where laparotomy and multiple bone marrow biopsies have been used. Such aggressive staging procedures suggest truly localised disease in only 5-6% of patients with low grade lymphoma. A significant relationship between radiation dose and disease control was demonstrated only for patients with intermediate and high grade lymphoma of medium or large bulk. A minimum tumour dose of 30 Gy was required for optimal local control with radiation.

Ovarian irradiation and prednisone following surgery and radiotherapy for carcinoma of the breast.

Following surgery and regional radiotherapy for operable carcinoma of the breast in premenopausal women, ovarian irradiation (2000 rad in five daily fractions) plus prednisone (7.5 mg per day) results in delayed recurrence and prolonged survival.

Nasopharyngeal angiofibroma: a twenty year study.

A control rate of approximately 80% has been obtained in 45 cases of juvenile nasopharyngeal angiofibroma treated by a single moderate dose of radiotherapy at the Princess Margaret Hospital, Toronto. The remaining patients ultimately achieved control generally after further irradiation. Immediate side-effects of the treatment have been minimal, and no late complications have been observed. In 2-20 years' follow-up, no irradiation-induced tumors have been found. Superiority of irradiation in these cases over surgery is emphasized, as well as the importance of using sophisticated techniques to limit the volume of tissues irradiated and protect vulnerable radiosenstitive structures. Because tumor regression can be expected to continue for many months after treatment has been completed, a policy of observation following radiotherapy is recommended.

Malignant submandibular gland tumors. A review of 91 patients.

A retrospective review of 91 patients with submandibular gland carcinoma seen between 1958 and 1984, is reported. Among these were 37 (41%) adenoidcystic carcinomas, 14 (15%) adenocarcinomas, 14 (15%) mucoepidermoid carcinomas, and 10 (11%) malignant mixed tumors. The median patient age was 58 (26-93) [corrected] years and the male to female ratio was was 1.2:1. At diagnosis, 15 (16.5%) patients had regional metastases and six (7%) had distant metastases. The first planned treatment was surgery in 30 (33%) patients, radiotherapy in five (5%), and surgery and radiotherapy combined in 54 (59%) patients. The 5- and 10-year cause-specific survival rates were 60 and 48%, respectively, and the relapse-free rates 42 and 34%. The locoregional control at 5 years was 30% when surgery was the only treatment, and 69% when combined with radiation. These results suggest the advantages of combining surgery and radiotherapy as the first planned treatment for most tumors.

Acute epithelioma--an aggressive squamous cell carcinoma of the skin.

This report describes an aggressive squamous cell carcinoma of the skin for which we suggest the name acute epithelioma. It is frequently larger than 2 cm and has a characteristic morphology with raised, rolled, vascular but not everted edges. Commonly there is a central crust covering a foul discharge on a papilliferous base. The biopsy is characteristically ambiguous but often that of a well differentiated squamous cell carcinoma. Irrespective of the history, which is usually short, all tumors have a period of rapid growth. Among 193 patients with squamous cell carcinomas of the eyelids or external ear, 24 (12%) of the tumors were designated as being acute epitheliomas. For the eyelids 15/125 (12%) patients were in this group; 10 (67%) had tumors larger than 2 cm, five (33%) developed regional metastases, and three (20%) had tumor related deaths. Irradiation controlled the primary tumor in 15 (100%) patients. Among the 68 ear tumors, nine (13%) were called acute epitheliomas. Eight (89%) were larger than 2 cm, three (33%) developed regional metastases, and two (22%) patients had tumor related deaths. Irradiation controlled the primary tumor in seven (78%) patients. It is postulated that these acute epitheliomas are virus induced tumors that develop in actinicly damaged and immunologically suppressed skin. Following treatment, careful follow-up is recommended because of their metastatic and lethal potential.

Malignant parotid tumors. Prognostic factors and optimum treatment.

A retrospective study of 271 patients with parotid carcinoma seen between 1958 and 1980 is reported. Among these were 64 (24%) mucoepidermoid tumors (all degrees of differentiation), 50 (18%) adenocarcinomas, 40 (15%) malignant mixed tumors, 39 (14%) adenoid cystic carcinomas, 37 (14%) undifferentiated, 21 (8%) acinic, and 20 (7%) squamous cell carcinomas. The proportion of advanced (T3T4) to early (T1T2) tumors was 1.7:1. At diagnosis, 42 (15%) patients had regional metastases. An analysis for prognostic factors showed that the histology, tumor stage, regional metastases (No vs. N+), age, and damage to the facial nerve all influence cause-specific survival. After multivariate analysis the tumor size and the presence of regional metastases were the two most significant factors (p less than 0.0001 and 0.004). The prognostic characteristics were similar for the 67 (25%) patients treated by surgery and for the 169 (62%) patients treated with surgery and postoperative radiotherapy. Patients treated with combined therapy had a 10-year relapse-free rate of 62% compared to 22% for those treated by surgery alone (p = 0.0005).

Dosimetry of radioactive gold grains for the treatment of choroidal melanoma.

The dosimetry of small permanent gold grain implants for treating choroidal melanoma has been studied. A means of planning the source configuration required to deliver a desired minimum dose to a tumour has been developed. The interaction of the variable parameters, source activity, number of sources used, geometrical arrangement, and implant diameter, within the physical limitations imposed by the eye and the practical limitations occurring in clinical practice, are discussed.

Half-body radiotherapy in the treatment of canine lymphoma.

In a Phase I-II study, half-body radiotherapy was used to treat 14 dogs with multicentric lymphoma. Using this technique, a radiation dose of 7 Gray (Gy) was delivered to one half of the body in a single exposure. The other half of the body was treated approximately 28 days later. Of 14 treated dogs, 11 (79%) had a measurable decrease in tumor size. Five dogs achieved a complete or partial remission with a mean duration of 102 and 54 days, respectively. In predicting response to therapy, poor prognostic factors included large tumor burdens, advanced disease stage, and chemotherapy-resistant tumors. Side effects of treatment were divided chronologically into acute (radiation sickness, tumor lysis), subacute (bone marrow suppression), and chronic (radiation pneumonitis, lymphoma-cell leukemia) syndromes. Complications were more severe in tumor-bearing dogs when compared with healthy control animals. Dogs with small tumor burdens and minimal internal disease had fewer complications compared with those with more advanced disease.

Half-body radiotherapy. Evaluation of the technique in normal dogs.

Eight healthy mongrel dogs were treated with half-body irradiation (HBI) in a pilot study to evaluate the technique and radiotolerance of different organs. Cranial and caudal half-body fields were established using the 13th thoracic vertebra as the dividing point. Under general anesthesia, either 7 or 8 Gray (Gy) were delivered to one half of the body using opposing radiation portals. The other half of the body was similarly treated 28 days later. The dogs were monitored for 12 months. Significant radiation effects included transient bone marrow suppression and radiation sickness. There were no serious or life-threatening problems, but the 8 Gy group consistently showed more severe clinical signs and histologic changes than the 7 Gy group. Total body irradiation in two fractions of 7 or 8 Gy given 1 month apart appears to be a safe treatment that can be developed for therapy in veterinary oncology.

Eastern Health Board Regional Orthodontic Service: an initial audit.

This initial audit of 600 recently assessed Eastern Health Board orthodontic patients suggests that a large number of them (47 per cent) requires referral for routine restorative and preventive dental care. Closer links are needed with general dental practitioners and community dental surgeons to resolve these needs. The trend for a high referral of females and Class 11 Division 1 malocclusion type correlated well with studies in other countries.