Guillain-Barré syndrome as an atypical manifestation of an esophageal carcinoma.

Guillain-Barré syndrome (GBS) is an acute demyelinating polyradiculoneuropathy normally associated with a preceding infection, but sometimes it can be linked to a subjacent malignancy. We report an unusual case of GBS occurring as the first clinical manifestation of an esophageal adenocarcinoma in a 65-year-old patient. A GBS neuropathy of undetermined origin may be associated with an underlying tumor and esophageal cancer has to be considered in the differential diagnosis.

Impact of adjuvant radiotherapy on biological and clinical parameters in right-sided breast cancer.

PURPOSE: In patients with right-sided breast cancer (BC) the liver might be partially irradiated during adjuvant radiotherapy (RT). Thus, we performed a prospective observational study to evaluate the dose delivered to the liver, and its potential biological impact. PATIENTS AND METHODS: We enrolled 34 patients with right-sided BC treated with adjuvant RT. The RT schedules were either the Canadian (42.5Gy in 16 fx) or standard fractionated (50Gy in 25 fx) regimen respectively with 9 (26.5%) and 25 (73.5%) patients each, ± a boost of 10-16Gy. Each patient had a complete blood count and liver enzymes analysis, before starting and during the last week of treatment. RESULTS: A significant decrease in white blood cells and thrombocytes counts was observed during RT. We observed a significant correlation between certain hepatic parameters and the volume of the irradiated liver and/or the mean liver dose. A significant correlation between the volume of the right lung and the liver mean dose was found (P=0.008). In the bivariate analysis, a significant correlation between fatigue and the white blood cell count's evolution was observed (P<0.025). CONCLUSION: With the standard RT technique, incidental irradiation of the liver was documented in a large number of patients, and some significant hepatic parameters alterations were observed, without an apparent clinical impact, but this study cannot exclude them. The liver mean dose was correlated with the right lung volume suggesting that deep inspiration breath hold (DIBH) techniques may represent a way to decrease the liver dose. These findings need to be evaluated in further larger studies.

[Pretherapeutic and posttherapeutic laryngeal imaging]. / Prä- und posttherapeutische Larynxbildgebung.

Cross-sectional imaging with CT, MRI and more recently PET CT plays an indispensable complementary role to endoscopy in the pretherapeutic diagnostic and staging of laryngeal neoplasms and in the evaluation of the operated or irradiated larynx. Adequate interpretation of the CT, PET CT and MR images requires a thorough knowledge of the patterns of submucosal spread and familiarity with the diagnostic signs of neoplastic invasion as seen with each modality. In addition, one should be aware of the implications of imaging for staging and treatment. Both CT and MR imaging are highly sensitive for the detection of neoplastic invasion of the preepiglottic and paraglottic spaces, subglottic region and cartilage. The high negative predictive value of both CT and MRI allows a relatively reliable exclusion of neoplasm cartilage invasion. The specificity of both CT and MRI is, however, moderately high and both methods may, therefore, overestimate the extent of tumor spread. However, recent investigations have shown that the specificity of MRI may be significantly improved by using new diagnostic criteria which allow differentiation of tumor from peritumoral inflammation in many instances. Both cross-sectional imaging methods also significantly improve the pretherapeutic staging accuracy of laryngeal tumors if used in addition to clinical examination and endoscopic biopsy. In the presence of a submucosal mass, CT and MRI play a key role for the diagnosis, as they may characterize the lesion, reliably depict its submucosal extent and guide the endoscopist to perform deep biopsies which allow the definitive histological diagnosis. Cross-sectional imaging also plays a key role in the evaluation of laryngoceles, recurrent laryngeal nerve paralysis and fractures.

Carbogen breathing combined with radical radiotherapy in advanced head and neck cancer patients with severe co-morbidities.

AIMS: To assess the feasibility of carbogen breathing combined with radical radiotherapy in patients with advanced head and neck cancer who are unfit to receive concomitant chemotherapy. MATERIALS AND METHODS: Twenty patients (median age 66 years) with advanced squamous cell carcinoma of the head and neck were treated with either concomitant boost radiotherapy (75%) or mono-fractionated radiotherapy (25%) combined with carbogen breathing. The median tumour dose was 69.5 Gy. The main sites of disease were the oropharynx in 50%, the oral cavity in 15% and the hypopharynx in 30%. All but one patient had stage III (25%) or IV (70%) disease. The median follow-up for the surviving patients was 26 months (range 6-50 months). RESULTS: Carbogen breathing was well tolerated, permitting its delivery throughout the radiotherapy course. Three patients had treatment interruption because of acute toxicities (median 15 days; range 3-30 days). Grade 3 Radiation Therapy Oncology Group acute toxicity was observed in 80% of the patients (mainly mucositis), and nutritional support was required in eight patients (40%). Grade 2 late toxicity occurred in 30%; one patient presented with grade 4 late toxicity (bone necrosis). The 2-year actuarial locoregional control for all patients and for those treated with accelerated radiotherapy was 56% and 67%, respectively. The corresponding rates for disease-free survival were 45% and 53%. CONCLUSIONS: Considering the poor results of radiotherapy alone in advanced head and neck cancer, these results suggest that carbogen breathing may be a valid alternative for patients with severe co-morbidities who are unfit to receive concomitant chemotherapy.

An efficient procedure for tomotherapy treatment plan verification using the on-board detector.

In this work, a fast and simple procedure for tomotherapy treatment plan verification using the on-board detector (OBD) has been developed. This procedure allows verification of plans with static and dynamic jaws (TomoEDGE). A convolution-based calculation model has been derived in order to link the leaf control sinogram from the treatment planning system to the data acquired by the OBD during a static couch procedure. The convolution kernel has been optimized using simple plans calculated in the Tomotherapy Cheese phantom. The optimal kernel has been found to be a lorentzian function, whose parameter Γ is 0.186 for the 1 cm jaw opening, 0.232 for the 2.5 cm jaw opening and 0.373 for the 5 cm jaw opening. The evaluation has been performed with a γ-index analysis. The dose criterion was 3% of the 95th percentile of the dose distribution and the distance-to-agreement criterion is 2 mm. In order to validate the procedure, it has been applied to around 50 clinical treatment plans, which had already been validated by the Delta4 phantom (Scandidos, Sweden). 96% of the tested plans have passed the criteria. Concerning the other 4%, significant discrepancies between the leaf pattern in the leaf control sinogram and the OBD data have been shown, which might be due to differences in the leaf open time. This corresponds also to a higher sensitivity of this method over the Delta4, adding the possibility of better monitoring the treatment delivery.

The impact of gap duration on local control in anal canal carcinoma treated by split-course radiotherapy and concomitant chemotherapy.

PURPOSE: To investigate the potential benefit of reducing the intersequence gap in patients with anal cancer treated with split-course chemoradiotherapy. METHODS: The study group consisted of 90 patients with anal squamous carcinoma treated between 1981 and 1998, using concomitant chemotherapy (CT) and radiation (RT). Median age was 65 years (range 41-87). RT was delivered in a split course, with a median gap of 37.5 days (range 4-97) between sequences. First (pelvic) sequence delivered a median dose of 40 Gy (range 36-50.4), using AP/PA megavoltage photon beams. Boost treatment (median dose 20 Gy, range 13-26) consisted of either Iridium-192 implantation (49 patients) or external beam RT (41 patients). CT consisted of 1-2 cycles of a 5-day continuous infusion of 5-fluorouracil and bolus mitomycin C, usually administered during the first week of each RT course. Median follow-up was 76.2 months. Univariate and multivariate analyses were performed to determine the factors associated with locoregional control (LRC). RESULTS: Five-year actuarial LRC was 72.5%. Factors associated with poorer LRC (univariate) were: age < or = 65, male gender, and gap > 37.5 days. Number of CT cycles (1 vs. 2 or more), boost technique (brachytherapy vs. external), and T-stage were not significantly associated with LRC. In multivariate analysis, only age (p = 0.01), and gap (p = 0.02) retained their significance. In patients older than 65 years, LRC was 92.3% and 75% for shorter and longer gaps, respectively. In younger patients, the corresponding values for LRC were 73.7% and 50%. CONCLUSION: In anal cancers, split-course RT with > 50 Gy dose delivery is difficult to avoid because of acute toxicity. The present analysis suggests that shortening the gap contributes to optimizing LRC. Gaps longer than 5 weeks correlated with poorer LRC, with especially unsatisfactory results observed in younger patients.

Chemoradiotherapy versus radiotherapy alone for anal cancer: a retrospective comparison.

PURPOSE: To evaluate the effect of adding one cycle of concomitant chemotherapy to curative radiotherapy on tumor control and toxicity in the treatment of anal cancer. METHODS AND MATERIALS: One hundred twenty-five patients completed curative sphincter-conserving treatment, 57 with radiotherapy alone and 68 with concomitant chemo-radiotherapy. Compared with chemoradiotherapy patients, radiotherapy patients were older (median age 71 vs 63) and had less advanced tumors (T3-4 26% vs 51%). Radiotherapy patients were usually treated with a direct perineal cobalt field (mean dose 31 Gy at 5 cm/10 fractions/3 weeks), complemented in most cases by a sacral are field, followed (mean split 54 days) by Iridium-192 implantation (mean dose 23 Gy, Paris system). The large majority of chemoradiotherapy patients received antero-posterior opposed 10 MV photon fields, including pelvic and inguinal nodes (mean dose 38 Gy/19 fractions/4 weeks), followed (mean split 42 days) by implant boost (mean dose 18 Gy). In addition, chemo-radiotherapy patients received starting on day 1 an IV bolus of Mitomycin-C, 0.4 mg/kg (maximum 20 mg) and a 5-day continuous infusion of 5-fluorouracil 600-800 mg/m2/day. Median follow-up was 65 months for radiotherapy and 48 months for chemo-radiotherapy patients. RESULTS: For all 125 patients at 5 years, overall survival was 65.5%, definitive local control 83% and local control with sphincter preservation 68%. Overall and stage for stage, there was no difference in overall, progression-free or cancer-specific survival, nor in local control, local-regional control, or sphincter preservation rates between patients treated with chemoradiotherapy vs. radiotherapy alone. There was no significant difference between the two groups regarding acute or late toxicity. CONCLUSION: This retrospective analysis does not confirm the efficacy of one course of simultaneous Mitomycin-C and 5-fluorouracil, at least in association with full-dose radiotherapy incorporating Iridium-192 boost.

Feasibility and outcome of a progressively accelerated concomitant boost radiotherapy schedule for head and neck carcinomas.

PURPOSE: To evaluate toxicity and treatment outcome in patients with head and neck carcinomas treated with a modified bifractionated concomitant boost radiotherapy schedule. METHODS AND MATERIALS: Eighty-five patients were treated from February 1991 to October 1995. According to clinical TN stage 23 tumors were T1, 33 T2, 20 T3, 9 T4, 44 N0, and 41 N1-N3. The primary tumor was located in the oral cavity in 6 patients, oropharynx in 36, larynx in 19, hypopharynx in 17, and nasopharynx in 7. The basic treatment delivered 50.4 Gy in 28 fractions, once a day, to the primary site and both sides of the neck. During the last 3.5 weeks, a boost to the initial gross disease was delivered in 13 fractions of 1.5 Gy each as a second daily fraction in a progressively accelerated schedule (total dose 69.9 Gy). Eighteen patients had a uni- or bilateral neck dissection, and 2 an adenectomy before radiotherapy. The median follow-up for the surviving patients was 28 months (range: 3-61 months). RESULTS: All the patients completed the planned radiotherapy schedule. According to the RTOG scoring system, 57 patients (67%) presented with Grade 3-4 acute toxicity. Grade 3 dysphagia was observed in 20 patients (23.5%). Three patients died during the 3 months following the treatment. Among 73 patients evaluable for late effects, five developed Grade 3-4 complications. At 3 years actuarial loco-regional control was 67% and overall survival was 62%. CONCLUSIONS: Although longer follow-up is needed to evaluate the definitive results, we conclude that this particular concomitant boost schedule is feasible and appears to be effective. While acute toxicity was greater than in monofractionated schedules, it was manageable, provided that supportive care measures were implemented in a timely fashion.

Impact of clinical and therapeutic factors on major late complications after radiotherapy with or without concomitant chemotherapy for anal carcinoma.

PURPOSE: To investigate factors potentially influencing major late morbidity after sphincter-conserving treatment for anal carcinoma. METHODS AND MATERIALS: Grade 3-4 complications were retrospectively analyzed in 144 evaluable patients (pts), 55 pts after split-course radiotherapy (RT), and 89 after concomitant chemo-RT. First sequence RT delivered a median dose of 39.6 Gy using megavoltage photon beams. Boost treatment used either 192Ir implantation or external beam RT (median dose 20 Gy). Chemotherapy started on day 1 and in 83% of pts consisted of Mitomycin-C (10 mg/m2) and a 5-day infusion of 5-fluorourcil (600-800 mg/m2/day). Uni- and multivariate analyses tested the association of following factors with complication rate: age, gender, stage, anatomic tumor extent, type of biopsy, external RT technique (dose, fraction size, field arrangement), boost type (brachytherapy vs. external), brachytherapy dose and dose rate, overall treatment time, and addition of chemotherapy. RESULTS: Five-year actuarial complication rate was 16%. Two variables were significantly associated with complication rate: anatomic tumor extent (canal or margin vs. both +/- rectum; 10 vs. 31% complications, p = 0.0004) and first sequence prescribed dose (< 39.6 Gy vs. > or = 39.6 Gy; 7 vs. 23% complications, p = 0.012), confirmed as independent factors by Cox analysis. Grade 4 anal morbidity correlated significantly with prior local excision. All six bone complications were observed in pts treated by chemo-RT using large pelvic fields, five occurring in pts older than 66. CONCLUSION: Pts with tumors involving more than one anatomic subsite or treated with the higher first sequence RT dose are at greater risk of major complications. Prior tumor excision and combined modality therapy in older pts appear to favor major anal and bone complications, respectively.

Avoidance of treatment interruption: an unrecognized benefit of accelerated radiotherapy in oropharyngeal carcinomas?

PURPOSE: To assess the impact of treatment interruption on the potential gain in locoregional control obtained with accelerated radiotherapy (RT) compared with conventionally fractionated RT in patients with oropharyngeal carcinomas. METHODS AND MATERIALS: 152 patients treated with radical RT for oropharyngeal carcinomas between 1979 and 1996 were retrospectively analyzed. According to the American Joint Committee on Cancer (AJCC) staging system, there were 6/30/43/73 stages III/III/IV. Sixty-one patients were treated with a conventional RT schedule (median dose 70 Gy in 35 fractions), and 91 patients with either of two 5/5.5-week accelerated RT schedules (median dose 69.6-69.9 Gy in 41 fractions). Discounting weekends, RT was interrupted for 2 consecutive days or more in 53 patients (median duration 11 days, range 2-97), including 67% of the patients in the conventional RT group and 13% in the accelerated RT group. Median follow-up for surviving patients was 55 months (range 23-230). The Cox proportional hazards model was used for the multivariate analysis of factors influencing locoregional control. RESULTS: In univariate analysis, factors associated with a significant decrease in locoregional control included WHO performance status > or =1, advanced AJCC stages (III and IV), conventional RT fractionation, overall treatment time > or =44 days (median), and RT interruption. In the multivariate analysis, when introduced into the model individually, the three significant therapeutic factors remained significant after adjustment for the forced clinical variables. However, when the three therapeutic factors were introduced together into the model, beside the AJCC stage (P = 0.017), only RT interruption remained a significant independent adverse prognostic factor (P = 0.026). CONCLUSIONS: This multivariate analysis highlights the potential negative impact of treatment gaps on locoregional control in oropharyngeal carcinomas. This suggests that treatment interruption may be an even more important parameter than the type of RT schedule per se. Thus, when assessing the relative merit of two RT schedules, inclusion of the other therapeutic factors in a multivariate model is mandatory in order to avoid misinterpretation of the results.

Dose variation at bone/titanium interfaces using titanium hollow screw osseointegrating reconstruction plates.

PURPOSE: To evaluate dose variations at bone/titanium interfaces in an experimental model designed to simulate postoperative radiotherapy in patients with mandibular reconstructions using a titanium hollow-screw osseointegrating reconstruction plate (THORP) system. MATERIALS AND METHODS: The model consisted of a 25 x 25 x 10 mm3 block of fresh bovine femoral diaphysis, to the surface of which a segment of THORP system reconstruction plate was fixed by means of a solid titanium screw 4 mm in diameter and 10 mm in length. Using specially designed thermoluminescent dosimeters (TLD) 2 mm in diameter and 0.13 mm in thickness, dose measurements were carried out at four distances from the screw axis (0.1, 0.3, 0.6, and 1 mm). 60Co and 6-MV photon beams were used at incidences both perpendicular and parallel ("axial") to the screw axis. RESULTS: For 6-MV X-ray beams incident perpendicular to the screw axis, the maximum dose enhancement (due to backscatter) and the maximum dose reduction (due to attenuation) at the bone/titanium interface were 5% (+/- 2%) and 6% (+/- 2%), respectively. The corresponding values for 60Co beams were 6% (+/- 5%) and 10% (+/- 5%). For the axial incidences, a maximum dose enhancement of 5-7% was noted for both 6-MV X-rays and 60Co for beams incident on the surface containing the THORP plate segment, whereas beams incident on the opposite surface induced only a very small dose enhancement (2-3%). CONCLUSION: Using a new experimental model, TLD measurements showed only marginally significant dose variations at bone/titanium interfaces around THORP screws, all measured values being very close to the uncertainty limits (+/- 5%) associated with the method. For both 60Co and 6-MV beams, dose variations appeared smaller for axial than for perpendicular incidences. Because photon beams used in head and neck cancer treatment are most often directed parallel to the screw axes, these results suggest that failures of prosthetic osseointegration are unlikely to be explained by an overdosage at the bone/titanium interface.

Ethmoidal cancers: a retrospective study of 22 cases.

From April 1978 to June 1990, 22 patients with ethmoidal cancer were treated at Fondation Bergonié by a combination of surgery and radiation therapy. The mean age was 59.6 years (range 34-79 years) and the sex ratio is 2.7 (16 males/6 females). Histologic types were: adenocarcinoma, 13 cases; squamous carcinoma, 4 cases; undifferentiated carcinoma, 3 cases and esthesioneuroblastoma, 2 cases. Exposure to wood dust was encountered in 11 patients, especially in cases of adenocarcinoma: 10/13 (77%). Staging according to the classification of the University of Florida was: Stage I, 10 patients; Stage II, 5 patients and Stage III, 7 patients. Resection was considered as complete in 16 cases and only one orbital exenteration was performed. The postoperative radiation therapy delivered a mean given dose of 55.7 Gy (range 50-70 Gy) expressed to the hot spot using a technique adapted to tumor location and extension. Complete remission was achieved in 20 cases. Median follow-up is 28 months. The 5-year overall and disease-free survival are 44% and 38%, respectively. Analysis of recurrences according to staging gives: 5/10 Stage I, 2/5 Stage II and 5/7 Stage III. Recurrence is pejorative since death occurs in all cases within an average of 6 months following salvage treatment, except for three patients still alive within less than 6 months and in second remission. Prognosis of ethmoidal cancer depends on staging and local control.

Assessment of target dose delivery in anal cancer using in vivo thermoluminescent dosimetry.

PURPOSE: To measure anal dose during external beam radiotherapy (EBRT) using in vivo dosimetry, to study the difference of measured from prescribed dose values, and to evaluate possible associations of such differences with acute and late skin/mucosal toxicity and anorectal function. MATERIALS: Thirty-one patients with localized anal carcinoma underwent in vivo measurements during the first EBRT session. Themoluminescent dosimeters (TLD) were placed at the center of the anal verge according to a localization protocol. No bolus was used. Patients received a median dose of 39.6 Gy (range: 36-45 Gy) by anteroposterior opposed AP/PA pelvic fields with 6 or 18 MV photons, followed by a median boost dose of 20 Gy (range: 13-24 Gy). Concomitant chemotherapy (CCT), consisting of 1-2 cycles of continuous infusion 5-fluorouracil (5-FU) and bolus mitomycin-C (MMC), was usually administered during the first weeks of the pelvic and boost EBRT courses. Acute and late skin/mucosal reactions were recorded according to the Radiation Therapy Oncology Group (RTOG) toxicity scale. Anal sphincter function was assessed using the Memorial Sloan Kettering Cancer Center (MSKCC) scale. RESULTS: TLD anal doses differed by a mean of 5.8% (SD: 5.8) in comparison to the central axis prescribed dose. Differences of at least 10% and at least 15% were observed in eight (26%) and three (9.7%) patients, respectively. TLD doses did not significantly correlate with acute or late grade 2-3 skin or mucosal toxicity. However, patients having good-fair MSKCC anal function had a significantly greater mean difference in anal TLD dose (10.5%, SD: 5.9) than patients having excellent function (3.8%, SD: 4.6) (P = 0.004). Prescribed dose values, length of follow-up, and age at diagnosis did not correlate with late sphincter function. CONCLUSIONS: These data show that AP/PA fields using megavoltage photons deliver adequate dose to the anal verge. However, in about one quarter of patients treated with this technique the anal dose varied from the prescribed dose by at least 10%. The observed correlation of TLD values and late sphincter function suggests that direct measurement of the dose delivered to the anal verge might be clinically relevant.

Effect of arytenoid sparing during radiation therapy of early stage glottic carcinoma.

PURPOSE: To retrospectively evaluate the effect of arytenoid shielding on local control and complications in the treatment of early stage glottic carcinomas. MATERIALS AND METHODS: The analysis concerns 71 patients treated with megavoltage photons for stages Tis, T1 and T2 glottic carcinomas. In 31 patients the entire larynx was treated at 2 Gy/day to full dose (group 1, mean field area 41.5 cm2) and in 40 patients a posterior block was placed after a median dose of 54 Gy to protect the arytenoid cartilage (group 2, mean field area 38 cm2). The decision to shield 10-15 mm of the posterior aspect of the treatment volume was based on the presence or absence of involvement of the posterior third of the vocal cords. Median total dose was 70 Gy in both groups. RESULTS: RTOG grade 2 and 3 acute laryngeal complications were observed in 77% and 62.5% of patients in groups 1 and 2, respectively (P = 0.25). The rate of grade 2-3 late laryngeal complications (mostly arytenoid edema) was similar in the two groups (13.6% vs 20%, P = 0.83). Actuarial local control at 5 years was also similar in the two groups (T1: 85% vs 96.6%, P = 0.13 and T2: 82% vs 87.5%, P = 0.86). CONCLUSION: No objective differences could be shown in terms of acute or late laryngeal complications or in terms of local control related to the use of arytenoid shielding. As severe complications are rare and local control is very satisfactory using standard techniques, it is difficult to attribute any advantage to the use of arytenoid blocking.

Radioimmunotherapy of colorectal cancer liver metastases: combination with radiotherapy.

The expected therapeutic gain of a combined radioimmunotherapy (RIT) with conventional radiotherapy (RT) would be a synergy of tumor irradiation, provided that toxic, dose-limiting side effects concern different organs. We have shown in a model of subcutaneous human colon cancer transplants in nude mice that RIT with 131I-labeled anti-CEA antibody fragments combined with fractionated RT give an additive therapeutic effect without increase of side effects. A second study of different timing schedules of RIT and RT has shown that close association of both therapies without delay is more efficient than a therapy with a treatment-free interval of two weeks. In a new model of human colon cancer liver metastases in nude mice, early treatment with RIT and with RT has been curative, whereas therapies initiated later were less efficient, suggesting that the combined therapy is likely to be more efficient in an adjuvant situation after surgery. At the clinical level, six patients with limited liver metastatic disease from colorectal cancer were treated with RIT using 200 mCi 131I-labeled anti-CEA MAb F(ab')2 fragments combined with fractionated external beam RT of 20 Gy to the entire liver. As expected, spontaneously reversible bone marrow toxicity grade 3 to 4 and reversible liver toxicity grade 1 to 3 have been observed. By computerized tomography, three patients showed stable disease and one patient partial remission, whereas two patients had progressive disease. In conclusion, animal experiments have shown a clear advantage of combined RT and RIT, and the clinical study shows the feasibility of such a therapy in patients with colorectal cancer liver metastases.

Combined radioimmunotherapy and radiotherapy of liver metastases from colorectal cancer: a feasibility study.

BACKGROUND: A combination of radioimmunotherapy (RIT) and radiotherapy (RT) should allow one to increase the dose of radiation targeting a particular tumour without the concomitant increase of toxic side effects. This might be obtained if the dose limiting side effect of each individual radiation therapy concerned different organs. METHODS: Six patients with limited liver metastatic disease from colorectal cancer were treated with 6.9 GBq (range 4.7 to 8.4 GBq) 131I-labelled anti-CEA MAb F(ab')2 fragments combined with 20 Gy RT to the liver. Both treatments were given in close association, according to timing schedules evaluated in animals that gave the best results. RESULTS: Reversible bone marrow and liver toxicity was observed in 6 and 5 patients, respectively. Three patients who first received 20 Gy RT to the liver, showed a significant platelet drop upon completion of RT. Repeat computerized tomography (CT) after 2 months showed a minor response in 1 patient and stable disease in 3 patients. CONCLUSION: The study shows potential ways of combining RIT and RT, suggesting that this combination is feasible for the treatment of liver metastases.

Bilateral radical neck dissection with unilateral internal jugular vein reconstruction.

OBJECTIVE: To describe and evaluate the functional and oncologic results of one internal jugular vein replacement after bilateral radical neck dissection (RND). STUDY DESIGN: A retrospective historical cohort study. METHODS: Since 1972 all patients (n = 9) undergoing bilateral RND with resection of both internal jugular veins had a reconstruction of one internal jugular vein. In six cases the RNDs were staged, and in three cases the RNDs were performed simultaneously. In every case a vascular reconstruction was performed with an autologous vein graft. All patients received radiation therapy, in five patients before and in four patients after the vein grafting. Functional results were evaluated in terms of postoperative head and neck and neurologic complications. In some patients a Doppler scan was performed to assess vein patency. Oncologic results are reported as relapse-free survival and mortality intervals. RESULTS: In all patients the postoperative course was uneventful, without neurologic complications. Facial edema was noted in four patients, mild in three and moderate in one. Two patients are alive, with follow-ups of 8 and 18 years. Seven patients are dead, two without evidence of recurrence, four with cervical recurrence after a mean survival of 10 months, and one after distant metastasis after a survival of 7 years. In patients with long-term survival a Doppler scan confirmed the patency of the vein graft. CONCLUSION: The lack of operative complications and the absence of postoperative neurologic complications make a unilateral internal jugular vein replacement after bilateral RND attractive, although the oncologic results remain poor.

Endoscopic neck dissection in human cadavers.

OBJECTIVE: To evaluate the feasibility and efficacy of endoscopic neck dissection (END) in human cadavers. STUDY DESIGN: Experimental self-controlled study. METHODS: END on five human cadavers through three openings: one for the camera, one for the dissecting instrument, and one for a grasping one. The tissue specimens removed were divided into traditional neck groups (I to V). After the completion of END, open neck dissection was performed using standard surgical techniques and the remaining tissue within each neck group was retrieved. The important neck structures (carotid artery, internal jugular vein, cranial nerves X, XI, and XII, phrenic nerve) were evaluated for lesions. A pathologist evaluated each specimen, without knowing its exact origin in terms of neck group or side, and type of surgical technique used. For each specimen, the number of retrieved lymph nodes and their anatomic integrity was analyzed. RESULTS: Ten neck dissections were performed on 5 cadavers, without any major difficulty. An injury of the internal jugular vein occurred twice and once the phrenic nerve was cut. Little tissue was usually left for open surgical dissection. The average number of retrieved lymph nodes by endoscopy was 4.9 +/- 2.7 (mean +/- standard deviation). Completion open neck dissection retrieved an additional 0.5 +/- 0.5 lymph nodes. Efficacy of END was 92 +/- 10%. The majority of retrieved lymph nodes were intact but exhibited important postmortem autolysis artifacts. CONCLUSIONS: Endoscopic neck dissection is possible in human cadavers and is free of lesions to major structures. The majority of neck lymph nodes can be removed endoscopically.

Endoscopic neck dissection in an animal model: comparison of nodal yield with open-neck dissection.

OBJECTIVE: To evaluate the possibility, complications, and efficacy of endoscopic neck dissection (END) in a porcine model. DESIGN: Experimental self-controlled study. SUBJECTS: Minipigs. INTERVENTION: Endoscopic neck dissection was performed using general anesthesia with techniques adapted from laparoscopic surgery. The tissue specimens removed were divided according to porcine equivalents of human neck groups. After the completion of END, open-neck dissection was performed using standard surgical techniques, and the remaining tissue within each neck group was retrieved. A pathologist evaluated each specimen without knowing its exact origin in terms of neck group or side and the type of surgical technique used. For each specimen, the number of retrieved lymph nodes and their anatomical integrity were analyzed. RESULTS: Ten neck dissections were performed in 8 minipigs without any major complications. The number of retrieved lymph nodes by END was 18.4 +/- 7.4 (mean +/- SD). Completed open-neck dissection retrieved an additional 3.3 +/- 1.8 lymph nodes. The efficacy rate of END was 88% +/- 10% (+/ -SD). The majority of retrieved lymph nodes were intact, with less than 5% of nodes exhibiting crushing artifacts. CONCLUSIONS: Endoscopic neck dissection in a porcine model seems to be free of major complications and able to retrieve the majority of neck lymph nodes. A larger number of animals and their survival need to be studied before human studies can begin.

Free-volume viscosity model for fluids in the dense and gaseous states.

A free-volume and friction viscosity model is presented versus pressure and temperature, valid for both gaseous and dense fluids. This model involves only three adjustable parameters for each pure compound. It is able to represent the gas-liquid transition and the behavior in the supercritical conditions. The model has been successfully applied to methane (885 data points for 0.01< or =P< or =200 MPa and 90.7< or =T< or =600 K) and to propane (1085 data points for 0.01< or =P< or =200 MPa and 90< or =T< or =600 K) in the gaseous and dense states (average absolute deviation is 2.59% for methane and 2.50% for propane, with maximum deviation of 14.8% for methane and 9.19% for propane). It has also been applied to hexane, octane, dodecane, benzene, trans-decaline, and 2,2-dimethylpropane (903 data points) in a large pressure range (up to 505.5 MPa). Considering these compounds the maximum deviation is 19.5% (for octane) and the average deviation is 3.51% in the worst case (dodecane, which has data points up to 501.6 MPa).