Examining prognostic factors and patterns of failure in nasopharyngeal carcinoma following concomitant radiotherapy and chemotherapy: impact on future clinical trials.

PURPOSE: Concomitant chemotherapy and radiotherapy (CCRT), followed by adjuvant chemotherapy, has improved the outcome of nasopharyngeal carcinoma (NPC). However, the prognosis and patterns of failure after this combined-modality treatment are not yet clear. In this report, the prognostic factors and failure patterns we observed with CCRT may shed new light in the design of future trials. METHODS AND PATIENTS: One hundred forty-nine (149) patients with newly diagnosed and histologically proven NPC were prospectively treated with CCRT followed by adjuvant chemotherapy between April 1990 and December 1997. One hundred and thirty-three (89.3%) patients had MRI of head and neck for primary evaluation before treatment. Radiotherapy was delivered either at 2 Gy per fraction per day up to 70 Gy or 1.2 Gy per fraction, 2 fractions per day, up to 74.4 Gy. Chemotherapy consisted of cisplatin and 5-fluorouracil. According to the AJCC 1997 staging system, 32 patients were in Stage II, 53 in Stage III, and 64 in Stage IV (M0). RESULTS: Univariate analysis revealed that WHO (World Health Organization) Type II histology, T4 classification, and parapharyngeal extension were poor prognostic factors for locoregional control. Multivariate analysis revealed that T4 disease was the most important adverse factor that affects locoregional control, the risk ratio being 5.965 (p = 0.02). Univariate analysis for distant metastasis revealed that T4 and N3 classifications, serum LDH level > 410 U/L (normal range, 180-460), parapharyngeal extension, and infiltration of the clivus were significantly associated with poor prognosis. Multivariate analysis, however, revealed that T4 classification and N3 category were the only two factors that predicted distant metastasis; the risk ratios were 3.994 (p = 0.02) and 3.390 (p = 0.01), respectively. Therefore, based on the risk factor analysis, we were able to identify low-, intermediate-, and high-risk patients. Low-risk patients were those without the risk factors mentioned above. They consisted of Stage II patients with T2aN0, T1N1, and T2aN1 categories and of Stage III patients with T1N2 and T2aN2 categories. Their risk of recurrence is low (4%). Intermediate-risk patients were those with at least one univariate risk factor. They are Stage II patients with T2bN0 and T2bN1 categories and Stage III patients with T2bN2 and T3N0-2 categories. The risk of recurrence is modest (18%). High-risk patients have risk factors by multivariate analysis. They are stage T4 or N3 patients. Their risk of recurrence is high (36%). CONCLUSION: Low-risk patients have an excellent outcome. Future trials should focus on reducing treatment-associated toxicities and complications and reevaluate the benefit of sequential adjuvant chemotherapy. The recurrence in treatment of intermediate-risk patients is modest; CCRT and adjuvant chemotherapy may be the best standard for them. Patients with T4 and N3 disease have poorer prognosis. Hyperfractionated radiotherapy may be considered for the T4 patients. Future study in these high-risk patients should also address the problem of distant spread of the disease.

Household oven doors: a burn hazard in children.

Contact with hot oven doors is an important cause of burns in pediatric patients. These burns are of particular concern because of their frequent localization to the hands, with the resulting negative implications for financial cost, long-term cosmesis, and hand function. A 5-year review of pediatric oven door burn cases admitted to a burn referral center was conducted. Of the 14 cases identified, the median age was 12 months. The median total body surface area (TBSA) was 1.75% (range, 0.5%-4.5%). Twelve of 14 cases involved 1 or both hands. The median length of hospital stay was 10 days. In 7 cases, burns were sustained from contact to an external surface of the oven. Based on the results obtained, we propose several prevention strategies.

Long-term survival of nasopharyngeal carcinoma following concomitant radiotherapy and chemotherapy.

PURPOSE: The purpose of this study is to demonstrate long-term survival of nasopharyngeal carcinoma treated with concomitant chemotherapy and radiotherapy (CCRT) followed by adjuvant chemotherapy. METHODS AND PATIENTS: One hundred and seven patients with Stage III and IV (American Joint Committee on Cancer, AJCC, 1988) nasopharyngeal carcinoma (NPC) were treated with concomitant chemotherapy and radiotherapy (CCRT) followed by adjuvant chemotherapy between April 1990 and December 1997 in Koo Foundation Sun Yat-Sen Cancer Center, Taipei. The dose of radiation was 70 Gray (Gy) given in 35 fractions, 5 fractions per week. Two courses of chemotherapy, consisting of cisplatin and 5-fluorouracil, were delivered simultaneously with radiotherapy in Weeks 1 and 6 and two additional monthly courses were given after radiotherapy. According to the AJCC 1997 staging system, 32 patients had Stage II disease, 44 had Stage III, and 31 had Stage IV disease. RESULTS: With median follow-up of 44 months, the 5-year overall survival rate in all 107 patients was 84.1%, disease-free survival rate was 74.4%, and locoregional control rate was 89.8%. The 3-year overall survival for Stage II was 100%, for Stage III it was 92.8%, and for Stage IV, 69. 4% (p = 0.0002). The 3-year disease-free survival for Stage II was 96.9%, for Stage III it was 87.7%, and for Stage IV it was 51.9% (p = 0.0001). CONCLUSION: CCRT and adjuvant chemotherapy is effective in Taiwanese patients with advanced NPC. The prognosis of AJCC 1997 Stage II and III disease is excellent, but, for Stage IV (M0), it is relatively poor. Future strategies of therapy should focus on high-risk AJCC 1997 Stage IV (M0) cohort.

Sports-specific concerns in the young athlete: baseball.

The sport of baseball is played by millions of children across America and around the world. Although generally considered a safe activity, it is estimated that there are over 100,000 acute baseball injuries yearly in the 5- to 14-year age range in the United States, many of which present to the emergency department. Acute injuries often involve ball impact to the face and hands; baseball is the leading cause of sport-related eye injury. Ball impact particularly to the chest results in a small but steady number of fatalities each year, many of which are widely publicized events. In addition to acute injury, many young baseball players are affected by chronic and acute conditions of the elbow. In this article, we review the history, epidemiology, and common injury patterns that are specific to baseball. Case reports are included, as well as a section on the physical examination of the elbow.

Concomitant radiotherapy and chemotherapy for early-stage nasopharyngeal carcinoma.

PURPOSE: Early-stage nasopharyngeal carcinoma (NPC) continues to carry a failure rate of 15% to 30% when treated with radiotherapy alone; the benefit of concomitant radiotherapy and chemotherapy (CCRT) in early-stage NPC is unclear. The purpose of this report is to describe our efforts to improve treatment outcome in early-stage NPC after CCRT. PATIENTS AND METHODS: Of 189 newly diagnosed NPC patients without evidence of distant metastases who were treated in our institution between 1990 and 1997, 44 presented with early-stage (stage I and II) disease according to the American Joint Committee on Cancer (AJCC) 1997 NPC staging system. Twelve of these patients were treated with radiotherapy alone and 32 with CCRT. Each patient's head and neck area was evaluated by magnetic resonance imaging or computed tomography. Radiotherapy was administered at 2 Gy per fraction per day, Monday through Friday, for 35 fractions for a total dose of 70 Gy. Chemotherapy consisting of cis-diamine-dichloroplatinum and fluorouracil was delivered simultaneously with radiotherapy in weeks 1 and 6 and sequentially for two monthly cycles after radiotherapy. RESULTS: Patients who were treated with radiotherapy alone primarily had stage I disease, whereas none of those who were treated with CCRT had stage I disease (11 of 12 patients v none of 32 patients; P =.001). The locoregional control rate at 3 years for the radiotherapy group was 91.7% (median follow-up period, 34 months) and was 100% for the CCRT group (median follow-up period, 44 months) (P =.10). The 3-year disease-free survival rate in the radiotherapy group was 91.7% and was 96.9% in the CCRT group (P =.66). CONCLUSION: Our results reveal excellent prognosis of AJCC 1997 stage II NPC treated with CCRT. Stage II patients with a greater tumor burden treated with CCRT showed an equal disease-free survival, compared with stage I patients treated with radiotherapy alone. A prospective randomized trial is underway to confirm the role of CCRT in stage II NPC.

Usefulness of the C1 transverse process as a reference guide in the dissection of the upper lateral neck.

In this investigation we dissected 3 cadavers with the lateral cervical approach to assess the usefulness of the transverse process of the atlas (TPA) as a reference guide in the upper lateral neck. Our results indicate that all the important structures in this space can be identified systematically. Lateral to the TPA sits the posterior belly of the digastric muscle, the stylohyoid muscle, and the occipital artery. Anterior to the TPA, the styloid process can be exposed. The internal jugular vein and cranial nerves X, XI, and XII sit between the styloid process and the TPA. Superior to the TPA, tracing the carotid sheath upward, the carotid canal and jugular foramen can be reached. Anteroinferior to the jugular foramen, the hypoglossal nerve emerges from the cranial cavity through the hypoglossal canal. Posterior to the TPA, the suboccipital triangle can be recognized. Within the triangle, the vertebral artery and its accompanying venous complex can be identified.

Salvage neck dissection for cervical recurrence of nasopharyngeal carcinoma.

OBJECTIVE: To evaluate the effectiveness of salvage neck dissection as part of a multidisciplinary treatment approach in persistent or recurrent metastatic nasopharyngeal carcinoma, after failure of initial radiotherapy at the regional site. DESIGN: A retrospective study of 31 patients treated during a 14-year period from March 1981 through May 1995, with a maximum follow-up of 152 months. Factors evaluated include patients' sex, age, and initial stage of tumor, mobility and number of nodal recurrences, surgical and pathological findings, and postoperative irradiation. SETTING: Academic tertiary referral center. PATIENTS: Twenty-six men and 5 women were studied; one patient had neck dissection to both sides of the neck on separate occasions, for a total of 32 operations. All patients had pathologically proved nasopharyngeal carcinoma and had been previously treated at the primary site and both sides of the neck with definitive radiotherapy. INTERVENTION: Patients underwent a radical, modified radical, or level I-sparing radical neck dissection. MAIN OUTCOME MEASURE: Surgical morbidity, time to recurrence at the regional site, and survival time. RESULTS: Clinically, there was a disease predilection of 81% at levels II and V. Surgical morbidity was minimal. Regional control was achieved in 20 (65%) of the patients, and the overall 5-year survival was 67%. Tumor involvement of the posterior triangle musculature and spinal accessory nerve was associated with failure to control neck disease. Extracapsular nodal extension correlated with a poor survival outcome. CONCLUSION: Control of regional disease by salvage neck dissection when radiotherapy has failed is both safe and effective in properly selected patients.