Surgical treatment of nasopharyngeal cancer - a consensus recommendation from two Chinese associations.

BACKGROUND: Surgical treatment is playing an increasingly important role in the management of nasopharyngeal carcinoma (NPC). This consensus focuses on the indications for optimal surgery, and surgical methods in the whole process of treatment for NPC to provide a useful reference to assist these difficult clinical decisions. METHODOLOGY: A thorough review of available literature on NPC and surgery was conducted by the Association for the prevention and treatment of nasopharyngeal carcinoma in China, international exchange and promotion Association for medicine and healthcare, and the Committee on nasopharyngeal cancer of Guangdong provincial anticancer association. A set of questions and a preliminary draft guideline was circulated to a panel of 1096 experienced specialists on this disease for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the experts in two authoritative medical science and technology academic groups in the prevention and treatment of NPC in China for review and reconsideration. RESULTS: The initial round of questions showed variations in clinical practice even among similar specialists, reflecting the lack of high-quality supporting data and resulting difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of surgery, including indications and surgical approaches. CONCLUSION: By standardizing the surgical indications and practice, we hope not only to improve the surgical outcomes, but also to highlight the key directions of future clinical research in the surgical management of NPC.

Functional assessment of military aircrew applicants in a hypobaric chamber.

BACKGROUND: Aircrew are exposed to environmental pressure changes. In the Republic of Singapore Air Force (RSAF), applicants assessed to be at intermediate risk of otic barotrauma undergo a hypobaric chamber assessment ["trial of chamber" (TOC)] to functionally evaluate their suitability for military aircrew vocations. AIMS: To identify factors associated with TOC failure among applicants with otorhinolaryngological conditions. METHODS: All applicants to RSAF aircrew vocations who were assessed to be at intermediate risk of otic barotrauma over a 3-yr period were identified using the RSAF Aeromedical Centre's electronic database. Their medical records, as well as the TOC assessment records of the subset of applicants who underwent TOC, were reviewed for demographic data, clinical findings, and TOC outcomes. RESULTS: Of the 483 identified applicants, 374 (77%) had abnormal otoscopic findings, 103 (21%) had rhinitis symptoms, and 6 (1%) had previous ENT surgery. 123 (25%) underwent TOC, of which 20 (16%) failed. Holding other predictor variables constant, the odds of TOC failure increased by 0.79 per unit decrease in BMI (95% CI 0.63-0.99), and the odds of TOC failure increased by 0.93 per kg decrease in body weight (95% CI 0.87-1.00). An abnormal tympanogram was not a statistically significant predictor of TOC failure (OR 1.96, 95% CI 0.59-6.42). Of the 47 applicants who passed TOC and were eventually recruited, none subsequently developed otic barotrauma (mean follow-up, 3.3 yr ± 1.5 yr). CONCLUSIONS: Applicants with lower weight and BMI are more likely to develop otic barotrauma with environmental pressure change. Tympanometry cannot be reliably used to identify applicants who would more likely pass TOC.

Correlations of tumour permeability parameters with apparent diffusion coefficient in nasopharyngeal carcinoma.

Background and Purpose: Functional imaging has an established role in therapeutic monitoring of cancer treatments. This study evaluated the correlations of tumour permeability parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and tumour cellularity derived from apparent diffusion coefficient (ADC) in nasopharyngeal carcinoma (NPC). Material and Methods: Twenty NPC patients were examined with DCE-MRI and RESOLVE diffusion-weighted MRI (DW-MRI). Tumour permeability parameters were quantitatively measured with Tofts compartment model. Volume transfer constant (Ktrans), volume of extravascular extracellular space (EES) per unit volume of tissue (Ve), and the flux rate constant between EES and plasma (Kep) from DCE-MRI scan were measured. The time-intensity curve was plotted from the 60 dynamic phases of DCE-MRI. The initial area under the curve for the first 60 s of the contrast agent arrival (iAUC60) was also calculated. They were compared with the ADC value derived from DW-MRI with Pearson correlation analyses. Results: Among the DCE-MRI permeability parameters, Kep had higher linearity in inverse correlation with ADC value (r = -0.69, p = <0.05). Ktrans (r = -0.60, p=<0.05) and iAUC60 (r = -0.64, p = <0.05) also had significant inverse correlations with ADC. Ve showed a significant positive correlation with ADC (r = 0.63, p = <0.05). Conclusions: Nasopharyngeal tumour vascular permeability parameters derived from DCE-MRI scan were correlated linearly with tumour cellularity measured by free water diffusability with ADC. The clinical implementations of these linear correlations in the quantitative assessments of therapeutic response for NPC patients may be worth to further explore.

Prognostic and therapeutic evaluation of nasopharyngeal carcinoma by dynamic contrast-enhanced (DCE), diffusion-weighted (DW) magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS).

Nasopharyngeal carcinoma (NPC) is an aggressive head and neck malignancy, and radiotherapy (with or without chemotherapy) is the primary treatment modality. Reliable tumour assessment during the treatment phase, which can portend the efficacy of radiotherapy and early identification of potential treatment failure in radioresistant disease, has been implicit for better cancer management. Technological advancement in the last decade has fostered the development of functional magnetic resonance imaging (fMRI) techniques into a promising tool for diagnostic and therapeutic assessments in head and neck cancer. Apart from conventional morphological assessment, early detection of the physiological environment by fMRI allows a more thorough investigation in monitoring tumour response. This article discusses the relevant fMRI utilities in NPC as an early prognostic and monitoring tool for treatment. Challenges and future developments of fMRI in radiation oncology are also discussed.

Treatment outcomes of nasopharyngeal carcinoma in modern era after intensity modulated radiotherapy (IMRT) in Hong Kong: A report of 3328 patients (HKNPCSG 1301 study).

PURPOSE: To evaluate treatment outcomes, failure patterns and late toxicities in patients with nasopharyngeal carcinoma (NPC) treated by intensity modulated radiotherapy (IMRT) in 6 public hospitals in Hong Kong over a 10-year period from 2001 to 2010. MATERIAL AND METHODS: Eligible patients were identified through the Hong Kong Cancer Registry data base. Clinical information was retrieved and verified by oncologists working in the individual centers. Treatment details, survival outcomes and late toxicities were analyzed. RESULTS: A total of 3328 patients were recruited. The median follow-up time was 80.2 months. The 8-year actuarial overall survival (OS), local failure-free survival (LFFS), regional failure-free survival (RFFS), distant failure free survival (DFFS), progression-free survival (PFS) for the whole group was 68.5%, 85.8%, 91.5%, 81.5% and 62.6% respectively. Male gender, older age, advanced T and N stage were adverse prognostic factors for OS, DFFS and PFS, whereas use of chemotherapy in form of concurrent chemo-irradiation (CRT), neoadjuvant + CRT, or CRT + adjuvant chemotherapy were favorable prognostic factors for OS and PFS. The local control was adversely affected by advanced T stage. N stage remained as the single adverse prognostic factor for regional control. Distant metastasis was the commonest site of failure. CONCLUSION: IMRT is an effective treatment for NPC with excellent overall loco-regional control. Distant metastasis is the major site of failure. Concurrent chemotherapy with cisplatin has an established role in NPC patients treated by IMRT.

Cost minimization analysis of capecitabine versus 5-fluorouracil-based treatment for gastric cancer patients in Hong Kong.

BACKGROUND: EOX (epirubicin, oxaliplatin, Xeloda; capecitabine) and FOLFOX4 (5-fluorouracil (5-FU), leucovorin, oxaliplatin) are the common chemotherapy regimens used in the treatment of advanced gastric cancer (aGC) in Hong Kong. This study aimed to compare the costs of these therapies for aGC patients from both the healthcare and societal perspectives. It should be noted that, while FOLFOX4 is routinely administered in an outpatient setting in North America and Europe, inpatient setting is adopted in Hong Kong instead, incurring hospitalization cost as a result. METHODS: Fifty-eight patients were identified from the electronic records in two public tertiary hospitals, with 45 and 13 receiving EOX and FOLFOX4 regimens, respectively. Healthcare cost was direct medical costs including drugs, clinic follow-up, hospitalization, diagnostic laboratories, and radiographs. Societal cost refers to indirect costs such as patient time and travel costs. Cost items were further classified as "expected" or "unexpected". All cost data was expressed in US dollars. RESULTS: Patients in the EOX and FOLFOX4 arm received an average of 5.3 and 7.8 cycles of treatment, respectively. The capecitabine-based regimen group had a higher expected medication cost per cycle when compared to the 5-FU-based treatment group (US$290.3 vs US$66.9, p < .001), but lower expected hospitalization costs (US$76.9 vs US$1,269.2, p < .001). The total healthcare cost and total societal cost per patient was reduced by 67.2% (US$5,691.9 vs US$17,357.4, p < .001) and 25.3% (US$3,090.5 vs US$4,135.1, p = .001), respectively, in the capecitabine-based regimen group. Sensitivity analyses based on full cycle regimen costs and net capecitabine or 5-FU/leucovorin costs still showed EOX to be less costly than FOLFOX4. CONCLUSION: The capecitabine-based regimen, EOX, was found to generate significant cost saving from both the healthcare and societal perspectives in regions in which FOLFOX4 is given in an inpatient setting.

Adjuvant S-1 chemotherapy after curative resection of gastric cancer in Chinese patients: assessment of treatment tolerability and associated risk factors.

INTRODUCTION: The use of adjuvant chemotherapy with S-1 (tegafur, gimeracil, and oteracil potassium) has been shown to improve the outcome of patients with gastric cancer. There are limited data on the tolerability of S-1 in Chinese patients. In this multicentre retrospective study, we assessed the toxicity profile in local patients. METHODS: Patients with stage II-IIIC gastric adenocarcinoma who had undergone curative resection and who had received S-1 adjuvant chemotherapy were included in the study. Patient demographics, tumour characteristics, chemotherapy records, as well as biochemical, haematological, and other toxicity profiles were extracted from medical charts. Potential factors associated with grade 2-4 toxicities were identified. RESULTS: Adjuvant S-1 was administered to 30 patients. Overall, 19 (63%) patients completed eight cycles. The most common grade 3-4 adverse events included neutropaenia (10%), anaemia (6.7%), septic episode (16.7%), diarrhoea (6.7%), hyperbilirubinaemia (6.7%), and syncope (6.7%). Dose reductions were made in 22 (73.3%) patients and 12 (40.0%) patients had dose delays. Univariate analyses showed that patients who underwent total gastrectomy were more likely to experience adverse haematological events (P=0.034). Patients with nodal involvement were more likely to report adverse non-haematological events (P=0.031). Patients with a history of regular alcohol intake were more likely to have earlier treatment withdrawal (P=0.044). Lower body weight (P=0.007) and lower body surface area (P=0.017) were associated with dose interruptions. CONCLUSIONS: The tolerability of adjuvant S-1 in our patient population was similar to that in other Asian patient populations. The awareness of S-1-related toxicities and increasing knowledge of potential associated factors may enable optimisation of S-1 therapy.

Should all nasopharyngeal carcinoma with masticator space involvement be staged as T4?

INTRODUCTION: The prognostic significance of the involvement of anatomical masticator space (MS) in nasopharyngeal carcinoma (NPC) was retrospectively reviewed. MATERIAL AND METHODS: 1104 Patients with non-metastatic NPC treated with radical radiotherapy between 1998 and 2010 were re-staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging system; tumors with medial pterygoid muscle (MP) and/or lateral pterygoid muscle (LP) involvement but did not fulfill the criteria for T3 or T4 were staged as TX. The tumor volume data, dosimetric data and survival endpoints of different T stage diseases were analyzed and compared to study the significance of MS involvement. RESULTS: The overall MS involvement rate was 61.0%. The median volumes of the primary gross tumor volume were 9.6ml, 15.2ml, 19.9ml, 32.6ml and 77.3ml for T1, T2, TX, T3 and T4, respectively (p<0.001). T1, T2 and TX tumors received higher minimum dose to the gross tumor volume and planning target volume than T3 and T4. Multivariate analysis showed that age, gender, T-/N-classification and the use of chemotherapy were significant prognostic factors for various survival end-points. Patients with TX disease had similar survival rates as with T1-T2; and had a significantly better 5-year overall survival rate (86.6% vs. 76.6%; p=0.013) and a trend of higher 5-year distant failure-free survival rate (91.5% vs. 81.3%; p=0.09) than patients with T3 disease. CONCLUSION: NPC with the involvement of MP and/or LP alone should be classified as T2 disease.

Limitation of radiological T3 subclassification of rectal cancer due to paucity of mesorectal fat in Chinese patients.

OBJECTIVES: To describe the thickness of mesorectal fat in local Chinese population and its impact on rectal cancer staging. DESIGN: Case series. SETTING: Two local regional hospitals in Hong Kong. PATIENTS: Consecutive patients referred for multidisciplinary board meetings from January to October 2012 were selected. MAIN OUTCOME MEASURES: Reports of cases that had undergone staging magnetic resonance imaging for histologically proven rectal cancer were retrospectively retrieved and reviewed by two radiologists. All magnetic resonance imaging examinations were acquired with 1.5T magnetic resonance imaging. Measurements were made by agreement between the two radiologists. The distance in mm was obtained in the axial plane at levels of 5 cm, 7.5 cm, and 10 cm from the anal verge. Four readings were obtained at each level, namely, anterior, left lateral, posterior, and right lateral positions. RESULTS: A total of 25 patients (16 males, 9 females) with a median age of 69 (range, 38-84) years were included in the study. Mean thickness of the mesorectal fat at 5 cm, 7.5 cm, and 10 cm from the anal verge was 3.1 mm (standard deviation, 3.0 mm), 9.8 mm (5.3 mm), and 11.8 mm (4.2 mm), respectively. The proportions of patients with mean mesorectal fat thickness of <15 mm were 100%, 84%, and 75% at 5 cm, 7.5 cm, and 10 cm from the anal verge, respectively. The thickness of mesorectal fat was the least anteriorly, and <15 mm at all three arbitrary levels (P<0.001). CONCLUSION: The thickness of mesorectal fat was <15 mm in the majority of patients and in most positions. Tumours invading 10 mm beyond the serosa on magnetic resonance imaging may paradoxically threaten the circumferential resection margin in Chinese patients. Use of T3 subclassification of rectal cancer in Chinese patients may be limited.

Quality of life in head and neck cancer survivors at 1 year after treatment: the mediating role of unmet supportive care needs.

PURPOSE: The aim of the study was to test a hypothesised model that supportive care needs (SCNs) have a mediating effect on the relationship between characteristics of (Chinese) head and neck cancer (HNC) survivors and their quality of life (QoL). METHODS: A total of 285 Chinese HNC survivors who had finished cancer treatment 1 year earlier completed a self-reported survey covering demographic and clinical characteristics, the Chinese version of the Short-Form Supportive Care Needs Questionnaire (SCNS-SF34-C), the supplementary module of access to healthcare and ancillary support services and the Functional Assessment of Cancer Therapy for Head and Neck Cancer (FACT-H&N). RESULTS: The final path model showed that optimism, educational level, any coexisting disease, number of somatic symptoms, household income, eating ability, support from others, whether the cancer is under control or not and travelling time from home to hospital have direct or indirect effects, or both, on the QoL of HNC survivors, by way of unmet SCNs in the psychological, physical and/or health system information domains, which account for 64 % of the variance in the total FACT-H&N score. CONCLUSIONS: Our study demonstrated the mediating effects of SCNs in the association between HNC survivors and their QoL. Early needs assessment may help healthcare professionals to identify the actual needs of these survivors, and providing the information that HNC survivors want is a significant factor in meeting their psychological needs and thereby improving their overall QoL.

Perceived unmet supportive care needs and determinants of quality of life among head and neck cancer survivors: a research protocol.

AIM: To describe a study protocol designed to explore the associations among the perceived unmet supportive care needs, quality of life and the demographic and clinical characteristics of head and neck cancer survivors. BACKGROUND: The prognoses for people with head and neck cancer are improving with medical advances. However, studies have reported that such cancer survivors experience poor quality of life. Current studies mainly focus on Western populations and there is limited research investigating the needs of head and neck cancer survivors. DESIGN: A mixed-design method is proposed, which will include two phases. Phase I will use a quantitative cross-sectional design and Phase II a qualitative descriptive approach. METHODS: The participants will be recruited from the outpatient departments of three public hospitals in Hong Kong. In Phase I, a questionnaire will be used to collect demographic and clinical characteristics, supportive care needs, necessary access to various supportive services and quality of life. Semi-structured interviews will be conducted in Phase II. The study is supported by a grant from the Health and Health Services Research Fund, Hong Kong, September 2011. DISCUSSION: The study will generate in-depth information on the needs of head and neck cancer survivors, to help healthcare professionals allocate resources better and develop new services, which can be more person-centred, to meet the needs of the these survivors.

Predictive factors and radiological features of radiation-induced cranial nerve palsy in patients with nasopharyngeal carcinoma following radical radiotherapy.

OBJECTIVES: To identify the key predictive factors of radiation-induced cranial nerve palsy in patients with nasopharyngeal carcinoma (NPC). METHOD AND MATERIALS: From November 1998 to December 2007, all consecutive patients with newly diagnosed NPC who were curatively treated with radiotherapy and subsequently developed radiation-induced cranial nerve palsy (RICNP) were included in our study. Patients with cranial nerve palsy due to disease recurrence were excluded. Their records were retrospectively reviewed. RESULTS: Amongst 965 patients with NPC treated with radical radiotherapy, 41 developed new cranial nerve palsy. After exclusion of 5 patients with cranial nerve palsy due to recurrence, 36 (3.7%) developed RICNP. The median follow-up was 8.9 years (range, 3.2-11.3 years). Ten of the 36 patients had cranial nerve palsy at presentation. Twenty-seven patients had single cranial nerve palsy and 9 patients had multiple cranial nerve palsy. The most commonly involved cranial nerve was cranial nerve XII, with 30 patients having palsy of cranial nerve XII and 6 of them having bilateral cranial nerve XII palsies. Magnetic resonance imaging features of radiation-induced hypoglossal nerve palsy were demonstrated in our study. Multivariate analysis revealed that cranial nerve palsy at presentation was an independent prognostic factor for the development of RICNP. Other factors including T staging, N staging, gender, age, radiotherapy technique and the use of chemotherapy have no significant relationship with the risk of developing RICNP. CONCLUSION: RICNP in patients with NPC is not a rare complication, and cranial nerve palsy at presentation is an important prognostic factor.

The battle against nasopharyngeal cancer.

This is a review of the evolving efforts to understand and combat nasopharyngeal carcinoma (NPC), a most peculiar cancer with a distinctly skewed geographic and ethnic distribution. Multifactorial etiology with dynamic interplay of genetic predisposition, Epstein-Barr virus (EBV) infection and environmental carcinogens is suggested. With changing lifestyle in Hong Kong, the age-standardized incidence rate has decreased by more than 50% during the past 30 years. The advent of megavoltage radiotherapy has transformed this once lethal cancer into one that is readily curable. Advances in technology and addition of chemotherapy have led to gratifying improvements. Overall survival exceeding 75% at 5 years could now be achieved; series using advanced technique with intensity-modulation consistently achieved excellent locoregional control. Studies are on-going to develop more potent systemic therapy for distant control. Serious late toxicities remain a serious concern demanding further improvement in radiotherapy technique and optimization of dose fractionation. Translational researches are increasingly important for the ideal goals of prevention, early detection and more accurate prognostication/prediction to work toward personalized medicine. The battle against NPC is one of the most fascinating successes in oncology, it is highly hopeful that with international collaborations and concerted efforts, we can totally conquer this cancer.

The strength/weakness of the AJCC/UICC staging system (7th edition) for nasopharyngeal cancer and suggestions for future improvement.

BACKGROUND AND PURPOSE: To evaluate the current AJCC/UICC staging system (7th edition) for nasopharyngeal carcinoma and to explore for future improvement. MATERIALS AND METHODS: A total of 985 patients, initially staged with preceding 5-6th edition, were retrospectively re-staged with the 7th edition. All were assessed by magnetic resonance imaging, and all 945 non-disseminated patients were irradiated with conformal/intensity-modulated technique. RESULTS: Staging factors by both the 5-6th edition and the 7th edition were strongly significance for important endpoints (p<0.001). Down-staging of the previous T2a to T1 and, stages IIA to I in the 7th edition was appropriate. However, the impacts on overall stage distribution and prognostication were minimal. Further down-staging of the current T2 to T1, N2 to N1, stages II to I, and merging of N3a and N3b, stages IVA and IVB were suggested. With the 7th edition, the 5-year disease-specific survival (DSS) was 100% for stage I, 95% for II, 90% for III, 67% for IVA, 68% for IVB and 18% for IVC. The corresponding DSS for the proposed stages I, II, III and IV were 95%, 86%, 67% and 18%, respectively. CONCLUSIONS: The changes introduced in the 7th edition were appropriate, but the magnitude of improvement was minimal. With improving results by modern management, further simplification of the staging system is suggested. The proposed system could lead to more accurate prognostication, further validation is warranted.

Nasopharyngeal carcinoma: salvage of local recurrence.

Local control of nasopharyngeal carcinoma has substantially improved with advancing radiotherapy technology and appropriate combination with chemotherapy. However, when local recurrence occurs, this is one of the most difficult challenges. Aggressive treatment is indicated because long term salvage is achievable particularly for early recurrence, but high risk of complications is a serious concern. Treatment options include different methods of surgery and/or re-irradiation with/without chemotherapy. Available information in the literature is grossly inadequate; most reports compose of small series of highly selected patients with heterogeneous characteristics and treatment. No randomized trials have been performed to evaluate the therapeutic ratio of different treatment methods. This article reviews available treatment options, their therapeutic benefits and risks of complications; the objective is to provide information for developing treatment recommendations and suggestions for future improvement.

Radical radiotherapy for nasopharyngeal carcinoma in elderly patients: the importance of co-morbidity assessment.

Elderly patients represent a unique challenge for radical treatment in nasopharyngeal carcinoma (NPC) because of age and co-morbid conditions. We sought to evaluate the outcome of this particular group of patients and to identify key factors affecting treatment outcome. From 1998 to 2008, 990 consecutive NPC patients without distant metastasis were treated with radical radiotherapy with planned total dose >66 Gy. Among them, 103 (10.4%) patients were elderly aged >70 (group A). Their clinical characteristics and outcome were compared with those aged <70 (group B). Mortality at 90 days was used as a proxy of early deaths related to treatment. Co-morbidities were measured by the Adult Co-morbidity Evaluation 27 (ACE-27). Group A presented more commonly with poorer performance status. They showed higher rates of acute reaction, radiotherapy incompletion and mortality at 90 days (7.8% vs. 1.2%, p<0.001). The 5-year overall survival rates were 43.9% and 78.1% for groups A and B, respectively (p<0.001). No difference in failure free survival rates was noted. For group A, ACE-27 was the only predicting factor for mortality at 90 days [ACE-27 2-3 vs. 0-1: HR 15.86 (2.68-93.95), p=0.002], and the most important prognostic factors for overall survival included age, presenting stage and ACE-27 (p<0.05). Elderly NPC patients had poorer tolerance to radiotherapy. Early deaths related to treatment were not uncommon. A reasonable disease control can still be attained after radical radiotherapy for those who were able to survive through the peri-radiotherapy period. Patient selection and treatment approach with reference to ACE-27 should be considered.

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.

Occupational contact dermatitis in manual cloud seeding operations.

This is a case report on irritant contact dermatitis secondary to calcium oxide exposure during manual cloud seeding operations. A less hazardous substitute such as sodium chloride should be considered wherever possible. Cloud seeding operations are briefly discussed in this report, and the impact of calcium oxide exposure as an occupational hazard is elaborated.