Stringent Response Regulators Contribute to Recovery from Glucose Phosphate Stress in Escherichia coli.

In enteric bacteria such as Escherichia coli, the transcription factor SgrR and the small RNA SgrS regulate the response to glucose phosphate stress, a metabolic dysfunction that results in growth inhibition and stems from the intracellular accumulation of sugar phosphates. SgrR activates the transcription of sgrS, and SgrS helps to rescue cells from stress in part by inhibiting the uptake of stressor sugar phosphates. While the regulatory targets of this stress response are well described, less is known about how the SgrR-SgrS response itself is regulated. To further characterize the regulation of the glucose phosphate stress response, we screened global regulator gene mutants for growth changes during glucose phosphate stress. We found that deleting dksA, which encodes a regulator of the stringent response to nutrient starvation, decreases growth under glucose phosphate stress conditions. The stringent response alarmone regulator ppGpp (synthesized by RelA and SpoT) also contributes to recovery from glucose phosphate stress: as with dksA, mutating relA and spoT worsens the growth defect of an sgrS mutant during stress, although the sgrS relA spoT mutant defect was only detectable under lower stress levels. In addition, mutating dksA or relA and spoT lowers sgrS expression (as measured with a P sgrS -lacZ fusion), suggesting that the observed growth defects may be due to decreased induction of the glucose phosphate stress response or related targets. This regulatory effect could occur through altered sgrR transcription, as dksA and relA spoT mutants also exhibit decreased expression of a P sgrR -lacZ fusion. Taken together, this work supports a role for stringent response regulators in aiding the recovery from glucose phosphate stress.IMPORTANCE Glucose phosphate stress leads to growth inhibition in bacteria such as Escherichia coli when certain sugar phosphates accumulate in the cell. The transcription factor SgrR and the small RNA SgrS alleviate this stress in part by preventing further sugar phosphate transport. While the regulatory mechanisms of this response have been characterized, the regulation of the SgrR-SgrS response itself is not as well understood. Here, we describe a role for stringent response regulators DksA and ppGpp in the response to glucose phosphate stress. sgrS dksA and sgrS relA spoT mutants exhibit growth defects under glucose phosphate stress conditions. These defects may be due to a decrease in stress response induction, as deleting dksA or relA and spoT also results in decreased expression of sgrS and sgrR This research presents one of the first regulatory effects on the glucose phosphate stress response outside SgrR and SgrS and depicts a novel connection between these two metabolic stress responses.

Data mining EEG signals in depression for their diagnostic value.

BACKGROUND: Quantitative electroencephalogram (EEG) is one neuroimaging technique that has been shown to differentiate patients with major depressive disorder (MDD) and non-depressed healthy volunteers (HV) at the group-level, but its diagnostic potential for detecting differences at the individual level has yet to be realized. Quantitative EEGs produce complex data sets derived from digitally analyzed electrical activity at different frequency bands, at multiple electrode locations, and under different vigilance (eyes open vs. closed) states, resulting in potential feature patterns which may be diagnostically useful, but detectable only with advanced mathematical models. METHODS: This paper uses a data mining methodology for classifying EEGs of 53 MDD patients and 43 HVs. This included: (a) pre-processing the data, including cleaning and normalization, applying Linear Discriminant Analysis (LDA) to map the features into a new feature space; and applying Genetic Algorithm (GA) to identify the most significant features; (b) building predictive models using the Decision Tree (DT) algorithm to discover rules and hidden patterns based on the reduced and mapped features; and (c) evaluating the models based on the accuracy and false positive values on the EEG data of MDD and HV participants. Two categories of experiments were performed. The first experiment analyzed each frequency band individually, while the second experiment analyzed the bands together. RESULTS: Application of LDA and GA markedly reduced the total number of utilized features by ≥ 50 % and, with all frequency bands analyzed together, the model showed average classification accuracy (MDD vs. HV) of 80 %. The best results from model testing with additional test EEG recordings from 9 MDD patients and 35 HV individuals demonstrated an accuracy of 80 % and showed an average sensitivity of 70 %, a specificity of 76 %, and a positive (PPV) and negative predictive value (NPV) of 74 and 75 %, respectively. CONCLUSIONS: These initial findings suggest that the proposed automated EEG analytical approach could be a useful adjunctive diagnostic approach in clinical practice.

Effects of a culturally informed model of care for Aboriginal and Torres Strait Islander patients with acute coronary syndrome in a tertiary hospital in Australia: a pre-post, quasi-experimental, interventional study.

BACKGROUND: Aboriginal and Torres Strait Islander (Indigenous) peoples with cardiac disease in Australia have worse outcomes than non-Indigenous people with cardiac disease. We hypothesised that the implementation of a culturally informed model of care for Indigenous patients hospitalised with acute coronary syndrome (ACS) would improve their clinical outcomes. METHODS: For this pre-post, quasi-experimental, interventional study, cohorts of Indigenous patients before and after the implementation of a model of care were compared. The novel, culturally informed, multidisciplinary-team model of care was a local programme of care developed to reduce morbidity and mortality from cardiac conditions among Indigenous Australians. All index admissions in the 24-month pre-implementation period (Jan 1 2013, to Dec 31, 2014) were analysed, as were all index admissions in the 12-month post-implementation period (Oct 1, 2015, to Sept 30, 2016). Comparisons were also made with non-Indigenous cohorts in the same timeframes. Admissions were excluded if the patient did not survive to hospital discharge. The study was conducted at Princess Alexandra Hospital, a tertiary hospital in metropolitan Brisbane (QLD, Australia). Data on presentation, comorbidities, investigations, treatment, and for outcomes were manually collected from a consolidated clinical information application. Mortality data were obtained from the Queensland Registry of Births, Deaths, and Marriages. The primary outcome was a composite of death, acute myocardial infarction, unplanned revascularisation, and cardiac readmission at 90 days after index admission, assessed in all patients. FINDINGS: The Indigenous cohorts included 199 patients admitted with ACS before the model of care was implemented (85 [43%] were female and 114 [57%] were male) and 119 admitted post-implementation (62 [52%] were female and 57 [48%] were male). The non-Indigenous cohorts included 440 patients with ACS before the model of care was implemented (140 [32%] were female and 300 [68%] were male) and 467 admitted post-implementation (143 [31%] were female and 324 [69%] were male). Compared with the pre-implementation group, Indigenous patients admitted post-implementation had a significant reduction in the primary outcome (67 [34%] of 199 vs 24 [20%] of 119; hazard ratio 0·60, 95% CI 0·40-0·90; p=0·012), which was driven by a reduction in unplanned cardiac readmissions (64 [32%] of 199 vs 21 [18%] of 119; 0·55, 0·35-0·85; p=0·0060). There was no significant change in non-Indigenous patients between the pre-implementation and post-implementation timeframes in the composite endpoint at 90 days (81 [18%] of 440 vs 93 [20%] of 467; 1·08, 0·83-1·41; p=0·54). Pre-implementation, there was significantly more incidence of the primary outcome in Indigenous patients than non-Indigenous patients (p<0·0001), with no significant difference in the post-implementation period (p=0·92). INTERPRETATION: Clinical outcomes for Indigenous patients admitted to a tertiary hospital in Australia improved after implementation of a culturally informed model of care, with a reduction in the disparity in incidence of primary endpoints that existed between Indigenous and non-Indigenous patients before implementation. FUNDING: Queensland Department of Health Aboriginal and Torres Strait Islander Health Division (now First Nations Health Office).

Depletion of glycolytic intermediates plays a key role in glucose-phosphate stress in Escherichia coli.

In bacteria like Escherichia coli, the accumulation of glucose-6-phosphate (G6P) or its analogs such as α-methyl glucoside-6-phosphate (αMG6P) results in stress that appears in the form of growth inhibition. The small RNA SgrS is an essential part of the response that helps E. coli combat glucose-phosphate stress; the growth of sgrS mutants during stress caused by αMG is significantly impaired. The cause of this stress is not currently known but may be due to either toxicity of accumulated sugar-phosphates or to depletion of metabolic intermediates. Here, we present evidence that glucose-phosphate stress results from depletion of glycolytic intermediates. Addition of glycolytic compounds like G6P and fructose-6-phosphate rescues the αMG growth defect of an sgrS mutant. These intermediates also markedly decrease induction of the stress response in both wild-type and sgrS strains grown with αMG, implying that cells grown with these intermediates experience less stress. Moreover, αMG transport assays confirm that G6P relieves stress even when αMG is taken up by the cell, strongly suggesting that accumulated αMG6P per se does not cause stress. We also report that addition of pyruvate during stress has a novel lethal effect on the sgrS mutant, resulting in cell lysis. The phosphoenolpyruvate (PEP) synthetase PpsA, which converts pyruvate to PEP, can confer resistance to pyruvate-induced lysis when ppsA is ectopically expressed in the sgrS mutant. Taken as a whole, these results provide the strongest evidence thus far that depletion of glycolytic intermediates is at the metabolic root of glucose-phosphate stress.

Induction of the Pho regulon suppresses the growth defect of an Escherichia coli sgrS mutant, connecting phosphate metabolism to the glucose-phosphate stress response.

Some bacteria experience stress when glucose-6-phosphate or analogues like α-methyl glucoside-6-phosphate (αMG6P) accumulate in the cell. In Escherichia coli, the small SgrS RNA is vital to recovery from glucose-phosphate stress; the growth of sgrS mutants is strongly inhibited by αMG. SgrS helps to restore growth in part through inhibiting translation of the ptsG mRNA, which encodes the major glucose transporter EIICB(Glc). While the regulatory mechanism of SgrS has been characterized, little is known about how glucose-phosphate stress connects to other aspects of cell physiology. In the present study, we discovered that mutation of pitA, which encodes the low-affinity transporter of inorganic phosphate, partially suppresses the αMG growth defect of an sgrS mutant. Induction of the stress response was also reduced in the sgrS pitA mutant compared to its sgrS parent. Microarray analysis suggested that expression of phosphate (Pho) regulon genes is increased in the sgrS pitA mutant compared to the sgrS parent. Consistent with this, we found increased PhoA (alkaline phosphatase) activity in the sgrS pitA mutant compared to the sgrS strain. Further, direct induction of the Pho regulon (in a pitA(+) background) also resulted in partial suppression of the sgrS growth defect. The suppression was reversed when Pho induction was prevented by mutation of phoB, which encodes the Pho transcriptional activator. Deletion of individual Pho structural genes in suppressed strains did not identify a single gene responsible for suppression. Altogether, this work describes one of the first studies of glucose-phosphate stress physiology and suggests a novel connection of carbon and phosphate metabolism.

Molecular call and response: the physiology of bacterial small RNAs.

The vital role of bacterial small RNAs (sRNAs) in cellular regulation is now well-established. Although many diverse mechanisms by which sRNAs bring about changes in gene expression have been thoroughly described, comparatively less is known about their biological roles and effects on cell physiology. Nevertheless, for some sRNAs, insight has been gained into the intricate regulatory interplay that is required to sense external environmental and internal metabolic cues and turn them into physiological outcomes. Here, we review examples of regulation by selected sRNAs, emphasizing signals and regulators required for sRNA expression, sRNA regulatory targets, and the resulting consequences for the cell. We highlight sRNAs involved in regulation of the processes of iron homeostasis (RyhB, PrrF, and FsrA) and carbon metabolism (Spot 42, CyaR, and SgrS).

Phenotypic variation and host interactions of Xenorhabdus bovienii SS-2004, the entomopathogenic symbiont of Steinernema jollieti nematodes.

Xenorhabdus bovienii (SS-2004) bacteria reside in the intestine of the infective-juvenile (IJ) stage of the entomopathogenic nematode, Steinernema jollieti. The recent sequencing of the X. bovienii genome facilitates its use as a model to understand host - symbiont interactions. To provide a biological foundation for such studies, we characterized X. bovienii in vitro and host interaction phenotypes. Within the nematode host X. bovienii was contained within a membrane bound envelope that also enclosed the nematode-derived intravesicular structure. Steinernema jollieti nematodes cultivated on mixed lawns of X. bovienii expressing green or DsRed fluorescent proteins were predominantly colonized by one or the other strain, suggesting the colonizing population is founded by a few cells. Xenorhabdus bovienii exhibits phenotypic variation between orange-pigmented primary form and cream-pigmented secondary form. Each form can colonize IJ nematodes when cultured in vitro on agar. However, IJs did not develop or emerge from Galleria mellonella insects infected with secondary form. Unlike primary-form infected insects that were soft and flexible, secondary-form infected insects retained a rigid exoskeleton structure. Xenorhabdus bovienii primary and secondary form isolates are virulent towards Manduca sexta and several other insects. However, primary form stocks present attenuated virulence, suggesting that X. bovienii, like Xenorhabdus nematophila may undergo virulence modulation.

Apex Predator Nematodes and Meso-Predator Bacteria Consume Their Basal Insect Prey through Discrete Stages of Chemical Transformations.

Microbial symbiosis drives physiological processes of higher-order systems, including the acquisition and consumption of nutrients that support symbiotic partner reproduction. Metabolic analytics provide new avenues to examine how chemical ecology, or the conversion of existing biomass to new forms, changes over a symbiotic life cycle. We applied these approaches to the nematode Steinernema carpocapsae, its mutualist bacterium, Xenorhabdus nematophila, and the insects they infect. The nematode-bacterium pair infects, kills, and reproduces in an insect until nutrients are depleted. To understand the conversion of insect biomass over time into either nematode or bacterium biomass, we integrated information from trophic, metabolomic, and gene regulation analyses. Trophic analysis established bacteria as meso-predators and primary insect consumers. Nematodes hold a trophic position of 4.6, indicative of an apex predator, consuming bacteria and likely other nematodes. Metabolic changes associated with Galleria mellonella insect bioconversion were assessed using multivariate statistical analyses of metabolomics data sets derived from sampling over an infection time course. Statistically significant, discrete phases were detected, indicating the insect chemical environment changes reproducibly during bioconversion. A novel hierarchical clustering method was designed to probe molecular abundance fluctuation patterns over time, revealing distinct metabolite clusters that exhibit similar abundance shifts across the time course. Composite data suggest bacterial tryptophan and nematode kynurenine pathways are coordinated for reciprocal exchange of tryptophan and NAD+ and for synthesis of intermediates that can have complex effects on bacterial phenotypes and nematode behaviors. Our analysis of pathways and metabolites reveals the chemistry underlying the recycling of organic material during carnivory. IMPORTANCE The processes by which organic life is consumed and reborn in a complex ecosystem were investigated through a multiomics approach applied to the tripartite Xenorhabdus bacterium-Steinernema nematode-Galleria insect symbiosis. Trophic analyses demonstrate the primary consumers of the insect are the bacteria, and the nematode in turn consumes the bacteria. This suggests the Steinernema-Xenorhabdus mutualism is a form of agriculture in which the nematode cultivates the bacterial food sources by inoculating them into insect hosts. Metabolomics analysis revealed a shift in biological material throughout progression of the life cycle: active infection, insect death, and conversion of cadaver tissues into bacterial biomass and nematode tissue. We show that each phase of the life cycle is metabolically distinct, with significant differences including those in the tricarboxylic acid cycle and amino acid pathways. Our findings demonstrate that symbiotic life cycles can be defined by reproducible stage-specific chemical signatures, enhancing our broad understanding of metabolic processes that underpin a three-way symbiosis.

Examination of Xenorhabdus nematophila lipases in pathogenic and mutualistic host interactions reveals a role for xlpA in nematode progeny production.

Xenorhabdus nematophila is a gammaproteobacterium and broad-host-range insect pathogen. It is also a symbiont of Steinernema carpocapsae, the nematode vector that transports the bacterium between insect hosts. X. nematophila produces several secreted enzymes, including hemolysins, lipases, and proteases, which are thought to contribute to virulence or nutrient acquisition for the bacterium and its nematode host in vivo. X. nematophila has two lipase activities with distinct in vitro specificities for Tween and lecithin. The gene encoding the Tween-specific lipase, xlpA, has been identified and is not required for X. nematophila virulence in one insect host, the tobacco hornworm Manduca sexta. However, the gene encoding the lecithin-specific lipase activity is not currently known. Here, we identify X. nematophila estA, a gene encoding a putative lecithinase, and show that an estA mutant lacks in vitro lipase activity against lecithin but has wild-type virulence in Manduca sexta. X. nematophila secondary-form phenotypic variants have higher in vitro lecithinase activity and estA transcript levels than do primary-form variants, and estA transcription is negatively regulated by NilR, a repressor of nematode colonization factors. We establish a role for xlpA, but not estA, in supporting production of nematode progeny during growth in Galleria mellonella insects. Future research is aimed at characterizing the biological roles of estA and xlpA in other insect hosts.

Masters of conquest and pillage: Xenorhabdus nematophila global regulators control transitions from virulence to nutrient acquisition.

Invertebrate animal models are experimentally tractable and have immunity and disease symptoms that mirror those of vertebrates. Therefore they are of particular utility in understanding fundamental aspects of pathogenesis. Indeed, artificial models using human pathogens and invertebrate hosts have revealed conserved and novel molecular mechanisms of bacterial infection and host immune responses. Additional insights may be gained from investigating interactions between invertebrates and pathogens they encounter in their natural environments. For example, enteric bacteria in the genera Photorhabdus and Xenorhabdus are pathogens of insects that also mutualistically associate with nematodes in the genera Heterorhabditis and Steinernema respectively. These bacteria serve as models to understand naturally occurring symbiotic associations that result in disease in or benefit for animals. Xenorhabdus nematophila is the best-studied species of its genus with regard to the molecular mechanisms of its symbiotic associations. In this review, we summarize recent advances in understanding X. nematophila-host interactions. We emphasize regulatory cascades involved in coordinating transitions between various stages of the X. nematophila life cycle: infection, reproduction and transmission.

Isolation and characterization of Xenorhabdus nematophila transposon insertion mutants defective in lipase activity against Tween.

We identified Xenorhabdus nematophila transposon mutants with defects in lipase activity. One of the mutations, in yigL, a conserved gene of unknown function, resulted in attenuated virulence against Manduca sexta insects. We discuss possible connections between lipase production, YigL, and specific metabolic pathways.

Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region.

PURPOSE: Reirradiation of breast cancer locoregional recurrence (LRR) in the setting of prior post-mastectomy radiation poses a significant clinical challenge due to the high risk for severe toxicity. In an attempt to reduce these toxicities, we have developed pulsed reduced dose-rate radiotherapy (PRDR), a reirradiation technique in which a series of 0.2 Gy pulses separated by 3-min time intervals is delivered, creating an apparent dose rate of 0.0667 Gy/min. Here we describe our early experience with PRDR. PATIENTS AND METHODS: We reirradiated 17 patients with LRR breast cancer to the chest wall, axilla, or supraclavicular region using PRDR. The median prior radiation dose was 60 Gy. We delivered a median PRDR dose of 54 Gy (range 40-66 Gy) in 1.8-2.0 Gy per fraction. Eight patients received concomitant low dose capecitabine for radiosensitization. The median treatment volume was 2,084 cm(3) (range 843-7,881 cm(3)). RESULTS: At a median follow-up of 18 months (range 4-75 months) only 2 patients have had tumor failure in the treatment region. Estimated 2-year local control rate is 92%. Treatment was well tolerated with 4 patients experiencing grade 3 acute skin toxicity. Despite a median cumulative dose of 110 Gy (range 80-236 Gy), there has been only one grade 3 and one grade 4 late toxicity. CONCLUSIONS: With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.

Xenorhabdus nematophila lrhA is necessary for motility, lipase activity, toxin expression, and virulence in Manduca sexta insects.

The gram-negative insect pathogen Xenorhabdus nematophila possesses potential virulence factors including an assortment of toxins, degradative enzymes, and regulators of these compounds. Here, we describe the lysR-like homolog A (lrhA) gene, a gene required by X. nematophila for full virulence in Manduca sexta insects. In several other gram-negative bacteria, LrhA homologs are transcriptional regulators involved in the expression (typically repression) of virulence factors. Based on phenotypic and genetic evidence, we report that X. nematophila LrhA has a positive effect on transcription and expression of certain potential virulence factors, including a toxin subunit-encoding gene, xptD1. Furthermore, an lrhA mutant lacks in vitro lipase activity and has reduced swimming motility compared to its wild-type parent. Quantitative PCR revealed that transcript levels of flagellar genes, a lipase gene, and xptD1 were significantly lower in the lrhA mutant than in the wild type. In addition, lrhA itself is positively regulated by the global regulator Lrp. This work establishes a role for LrhA as a vital component of a regulatory hierarchy necessary for X. nematophila pathogenesis and expression of surface-localized and secreted factors. Future research is aimed at identifying and characterizing virulence factors within the LrhA regulon.

Optimizing Surgical Capacity for a Rural Hospital Through Monte Carlo Simulation.

This article describes the application of Monte Carlo simulation to evaluate operating room (OR) utilization at a small rural hospital in the province of Ontario, Canada. Using input factors that include the duration of procedures, the number of days of operation, and the shift duration, the simulation identifies ways of improving the capacity of the hospital's OR. The analysis was used to implement changes that led to a 38% increase in the number of procedures completed. The hospital also has created capacity for further growth and is adding both new service types and additional revenue-generating contract services. Moreover, based on the success of the analytic model, hospital staff have continued collecting real-time data on OR utilization to enable additional analysis. The findings suggest that rural hospitals can indeed apply currently available data to improve process flow. Furthermore, the lack of analytic resources inside the hospital should not be a barrier because it is possible to create partnerships with educational institutions.

Therapeutic management of metastatic brain tumors.

Whole brain radiation therapy (WBRT) for patients with brain metastases provides increased local control, locoregional control, and median survival over supportive care or steroids alone. In addition, effective palliative relief is realized in the majority of patients. Despite this, median survival with WBRT alone remains fixed at a relatively unfortunate 4-6 months as demonstrated in prospective randomized controlled trials. Key issues in the therapeutic management of brain metastases include techniques to optimize the multimodal application of WBRT in conjunction with surgery, radiosurgery, chemotherapy, and radiosensitizers. Efforts to incorporate these approaches to improve survival are currently under active investigation.

Are we influencing outcome in oropharynx cancer with intensity-modulated radiotherapy? An inter-era comparison.

PURPOSE: To analyze the outcome in all oropharynx cancer patients treated at the University of Wisconsin during 1995-2005 and highlight the methodologic challenge in comparing outcome after intensity-modulated radiotherapy (IMRT) with that of historical controls. METHODS AND MATERIALS: Outcomes were compared in 195 oropharynx cancer patients after definitive radiotherapy with curative intent in the pre-IMRT era (pre-IMRT, n = 105), after IMRT (IMRT+, n = 52) or after non-IMRT techniques during the IMRT era (IMRT-, n = 38). RESULTS: With a median follow-up of 30.4 months, the 3-year overall survival rate in IMRT+, IMRT-, and pre-IMRT patients was 88.2%, 81.1%, and 67.7%, respectively; and for locoregional control was 96.1%, 78.1%, and 81.1%. Patients from the IMRT era more frequently received concurrent chemotherapy (67% vs. 6%, p < 0.001) and underwent adjuvant neck dissection (52% vs. 29%, p = 0.002). Patients with T3-4 disease and bilateral neck disease were significantly less likely to receive IMRT. Cox regression analysis identified IMRT as a significant prognostic factor (p = 0.04); however, after including T stage in the model, IMRT lost independent significance (p = 0.2). Analysis of a potential effect of IMRT on Grade 3+ mucositis or skin reaction was also hampered by the change in other treatment characteristics. CONCLUSIONS: Outcomes in oropharynx cancer have improved at our institution since the introduction of IMRT. However, multiple factors have contributed to this improvement, and presentation of IMRT outcomes without the full context of historical and contemporary controls may yield data that overstate outcome after IMRT.

Planned postradiotherapy neck dissection: Rationale and clinical outcomes.

OBJECTIVES: In this study, we examine pathology results and clinical outcome for patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) who present with advanced neck disease and undergo planned postradiotherapy neck dissection. STUDY DESIGN: Review of all patients with SCCHN treated with primary radiation (or chemoradiation) and postradiotherapy neck dissection at the University of Wisconsin between 1992 to 2005 was performed. One hundred seven neck dissections were identified in 93 patients, 79 unilateral and 14 bilateral. All major treatment and outcome parameters were examined with particular emphasis on the postradiotherapy neck dissection. RESULTS: Thirty of 107 neck dissection specimens (28%) showed evidence of residual carcinoma on pathologic review. The mean number of lymph nodes identified at neck dissection for the entire cohort was 21 per specimen (range, 1-60) with 1.3 nodes per positive neck dissection demonstrating residual carcinoma. No correlation was found between the type of neck dissection performed and the presence of residual nodal disease. Eighty-two evaluated patients (93%) remain free of regional disease recurrence, whereas six patients have subsequently manifested neck recurrence. Four of the six patients who developed regional recurrence showed residual carcinoma in their neck dissection specimen. Five of these patients underwent comprehensive neck dissection (levels I-V); one underwent selective neck dissection (

Comparison of linac based fractionated stereotactic radiotherapy and tomotherapy treatment plans for skull-base tumors.

BACKGROUND AND PURPOSE: To compare and evaluate helical tomotherapy and linac based fractionated stereotactic radiotherapy (FSRT) techniques in the treatment of skull-base tumors. PATIENTS AND METHODS: Ten patients diagnosed with skull-base tumors, originally planned for optically guided FSRT to prescribed doses of 50.4-54 Gy were replanned for treatment with clinically deliverable helical tomotherapy. All original CT scans, MR-CT fusion defined target and normal structure contours, and PTV margins were used for helical tomotherapy planning. Linac based plans utilized one of the following FSRT planning techniques: non-coplanar or coplanar intensity modulated radiation therapy (IMRT), multiple non-coplanar conformal arcs, and non-coplanar conformal radiation therapy (CRT). These plans were used as the standard to which the subsequent tomotherapy plans were compared, using the following criteria: prescription isodose to target volume (PITV) ratios, an inhomogeneity index (II), equivalent uniform dose (EUD) for PTV volumes, mean normalized total doses (NTDmean) for critical structures, and size of 10, 20, and 30 Gy isodose volumes. RESULTS: Use of both linac based FSRT techniques and helical tomotherapy generated highly conformal treatment plans. Tomotherapy plans, which are predominantly coplanar in nature, compared to non-coplanar linac based plans exhibited increased PITV ratios, variable change in II, similar EUD values, and generally comparable NTD(mean) values for organs at risk. When compared to non-coplanar field arrangements, deliverable (as opposed to idealized) tomotherapy plans also resulted in 13-540% increases in low dose isodose volumes. All criteria except for the II, which was generally improved with tomotherapy, were found to be similar when coplanar linac based plans were compared to helical tomotherapy plans. CONCLUSIONS: Results show a distinct advantage in using non-coplanar beam arrangements for treatment of skull-base tumors. In the case where disease spreads far inferiorly, limiting the ability to use non-coplanar arrangements, helical tomotherapy can be used to generate a comparable treatment plan, with potentially superior homogeneity.

Stereotactic Radiosurgery for Poor Performance Status Patients.

PURPOSE: Patients with poor performance status (PS), usually defined as a Karnofsky Performance Status of 60 or less, were not eligible for randomized stereotactic radiosurgery (SRS) studies, and many guidelines suggest that whole-brain radiation therapy (WBRT) is the most appropriate treatment for poor PS patients. METHODS AND MATERIALS: In this retrospective review of our SRS database, we identified 36 patients with PS of 60 or less treated with SRS for central nervous system (CNS) metastatic disease. PS, as defined by the Karnofsky Performance Status, was 60 (27 patients), 50 (8 patients), or 40 (1 patient). The median number of CNS lesions treated was 3. RESULTS: Median overall survival (OS) was 7.2 months (range, 0.73-25.6 months). Fifteen patients (41%) were alive at 6 months, and 6 patients (16.6%) were alive at 1 year. There was no difference in OS in patients who underwent previous WBRT. There were no local failures or cases of radiation toxicity. Distant CNS failures were seen in 9 patients (25%). CONCLUSIONS: Our patients with poor PS had reasonable median OS and relatively low distant CNS failure rates. Patients in this patient population may be ideal candidates for SRS compared with WBRT given the low incidence of distant failure over their remaining lives and the favorable logistics of single-fraction treatment for these patients with debility and their caregivers.

Customized conformal high-dose-rate brachytherapy boost for limited-volume nasopharyngeal cancer.

PURPOSE: To determine the feasibility of and patient outcomes using customized high-dose-rate (HDR) brachytherapy to boost the nasopharynx after external beam radiation therapy (EBRT) in patients with carcinoma of the nasopharynx. METHODS AND MATERIALS: Patients with nonmetastatic squamous cell carcinoma of the nasopharynx were treated using EBRT followed by a HDR brachytherapy boost delivered via customized catheters in a noninvasive, accurate, and reproducible method under direct fiber-optic visualization. Local control (LC), disease-free survival (DFS), and overall survival (OS) were analyzed. We also measured the change in maximum oral aperture as an indication of temporomandibular joint dysfunction. RESULTS: Between March 1996 and July 2003, we treated 38 patients with this customized brachytherapy method. The procedure was well tolerated without any incidents of soft-tissue or bone necrosis and with minimal decrease of oral aperture. Median follow-up time was 47 months (range, 2-84 months); 35 patients had at least 1 year of follow-up. The 5-year actuarial rate of LC, DFS, and OS were 96.0%, 81.4%, and 92.7%, respectively. CONCLUSIONS: The treatment has been well tolerated by all patients. The combination of conformal EBRT with our customized HDR brachytherapy boost has resulted in excellent local control to date, while minimizing temporomandibular joint dysfunction.