A Vermey

Detection of unknown occult primary tumors using positron emission tomography

The potential of positron emission tomography (PET) with 18F‐fluoro‐2‐deoxy‐D‐glucose (FDG) to detect primary tumors after unsuccessful conventional diagnostic workup was assessed in patients with metastatic disease from an unknown primary tumor.

Protocol for the Prevention and Treatment of Oral Sequelae Resulting from Head and Neck Radiation Therapy

In addition to the desired antitumor effects, head and neck radiation therapy induces damage in normal tissues that may result in oral sequelae such as mucositis, hypo‐salivation, radiation caries, taste loss, trismus, soft‐tissue necrosis, and osteoradionecrosis. These sequelae may be dose‐limiting and have a tremendous effect on the patients quality of life, Current policies to prevent these sequelae primarily are based on clinical experience and show great diversity. A protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy, based on fundamental research and data derived from the literature, is presented. The protocol is particularly applicable in centers with a dental team. This team should be involved at the time of initial diagnosis so that a successful preventive regimen is an integral part of the overall cancer treatment regimen.

Detection of unknown primary head and neck tumors by positron emission tomography

The purpose of this study was to investigate the potential of using positron emission tomography (PET) with 18F-labeled fluoro-2-deoxy-D-glucose (FDG) to detect unknown primary tumors of cervical metastases. Thirteen patients with various histologic types of cervical metastases of unknown primary origin were studied. Patients received 185-370 MBq FDG intravenously and were scanned from 30 min after injection onward. Whole-body scans were made with a Siemens ECAT 951/31 PET camera. PET identified the primary tumor in four patients: plasmocytoma, squamous cell carcinoma of the oropharynx, squamous cell carcinoma of the larynx, and bronchial carcinoma, respectively. All known metastatic tumor sites were visualized. PET did not identify a primary tumor in one patient in whom a squamous cell carcinoma at the base of the tongue was found in a later phase. In the remaining eight patients, a primary lesion was never found. The follow up ranged from 18 to 30 months. A previously unknown primary tumor can be identified with FDG-PET in approximately 30% of patients with cervical metastases. PET can reveal useful information that results in more appropriate treatment, and it can be of value in guiding endoscopic biopsies for histologic diagnosis.

The significance of the doctor-patient relationship in coping with cancer

The uncertainty and anxiety experienced by cancer patients and their ways of coping with uncertainty and anxiety were studied on the basis of a questionnaire completed by 418 patients. The study shows that 28.2% of the patients had a low and 33.5% had a high uncertainty score, while 50% had a low and 9% had a high anxiety score. Four ways of coping with uncertainty and anxiety can be distinguished, of which the use of self-instruction means was most common. Expert help proved to be important for reduction of uncertainty. For reduction of anxiety the support of the home environment and of fellow-patients was also of importance. The implications of these findings for the doctors performance and for the care of cancer patients are discussed.

Synovial chondromatosis of the temporo‐mandibular joint. Report of three cases and a review of the literature

Synovial chondromatosis of the temporo‐mandibular joint is a rare affection, characterized by the formation of cartilage particles in the synovial membrane. These particles can break through and enter the joint compartments. The diagnosis must be considered for patients who complain of slowly progressive swelling, pain, and crepitus in the region of the temporo‐mandibular joint. When the changes are not visible on plain X‐rays due to absence of ossification, important diagnostic information can be obtained by a technetium 99m (99m Tc) bone scan and a computerized tomography (CT) sialogram. The diagnosis can be established only by histopathologic examination of surgically removed particles or resected synovial membrane. Discussed are 25 cases of histopathologically verified chondromatosis of the temporo‐mandibular joint reported in the literature, as well as 3 new cases seen and treated at the University Hospital Groningen since 1970. A good clinical result can be obtained by removal of all particles and synovectomy. Condylectomy is seldom required.

Osteosarcoma of the jaw bones. Long-term follow-up of 48 cases

To evaluate the incidence and treatment results of osteosarcoma of the jaw (OSJ) in the Netherlands, data from 48 patients with a histologically proven diagnosis of osteogenic sarcoma of the maxilla or mandible were retrospectively analysed. Patient files, covering the period from 1964 to 1992, were obtained from all university hospitals in the Netherlands and the Netherlands Cancer Institute. The incidence of OSJ in the Netherlands is estimated to be at least 0.14 per 1,000,000. The overall 10-year survival was 59%. Distant metastasis occurred in 21% and local recurrences in 31% of the cases. Survival was significantly better in case of radical surgery and small tumours. Long-term survival after treatment of OSJ was good if complete surgical excision was achieved. Radiotherapy should only be considered to prevent local recurrence if surgery is not complete. The possible benefit of current chemotherapy in preventing metastatic disease is still questionable. Since other malignant neoplasms associated with OSJ occurred in 17% of the cases, lifelong follow up is mandatory for the detection of these second primary malignancies.

Malignant struma ovarii treated by ovariectomy, thyroidectomy, and 131I administration

A 36‐year‐old woman presented with an intraperitoneally disseminated malignant struma ovarii, diagnosed by histopathology and 131I scintigraphy. The serum thyroglobulin level was elevated, and immunoperoxidase staining for thyroglobulin was positive for disease both in the tumor cells lining the follicles and in the colloid. The patient was treated successfully by a bilateral ovariectomy followed by a total thyroidectomy and administration of radioactive iodine. The clinical behavior and the presence of thyroglobulin in both serum and tumor tissue demonstrate the similarity between neoplastic thyroid tissue in the ovary and in the thyroid gland.

A SURVEY OF PREVENTION AND TREATMENT REGIMENS FOR ORAL SEQUELAE RESULTING FROM HEAD AND NECK RADIOTHERAPY USED IN DUTCH RADIOTHERAPY INSTITUTES

Radiation treatment plays an important role in the management of head and neck cancer. Unfortunately several radiation-induced side effects may occur including mucositis, hyposalivation, radiation caries, trismus and osteoradionecrosis. It is generally accepted that most side effects can be prevented or reduced in severity. The purpose of this investigation was to make a survey of the prevention and treatment regimens for oral sequelae resulting from head and neck radiotherapy applied in all radiotherapy institutes in the Netherlands, and to evaluate the differences in these regimens. In all Dutch centers (n = 20) in which irradiation of head and neck cancer patients is performed, members of the staff responsible for prevention and treatment of oral side effects were interviewed. Questions referred to composition of the dental team, screening and care pre-irradiation, care during irradiation, and care post-irradiation. There appeared to be a great diversity in the preventive approach of the head and neck cancer patient in Dutch radiotherapy institutes. The most comprehensive counseling was performed by those centers in which a dental team was active, particularly when an oral hygienist was a member of such a team. The diversity is among others based on lack of well-defined guidelines in many centers, the spread of a relatively small patient group over a rather large number of centers, absence of a dental team in some centers, absence of an oral hygienist in some dental teams, and the observation that a rather large number of patients were not referred, or not timely referred to the dental team. There seems to be a need for the development of a general protocol for the prevention of oral complications applicable in all centers.

Poly(l-lactide) bone plates and screws for internal fixation of mandibular swing osteotomies

This study evaluated bone healing after mandibular swing osteotomies fixed with biodegradable poly(L-lactide) (PLLA) bone plates in four patients. A step osteotomy treated with two PLLA bone plates (n=3), and a straight osteotomy treated with one PLLA bone plate (n=1) were performed. Bone healing was uneventful in all patients; only in the patient with the straight osteotomy was callus observed. After 5.5 years, radiologic changes at the site of implantation were observed in the remaining patient. Histologic examination revealed a nonspecific foreign-body reaction on highly crystalline PLLA remnants which were still present. It is concluded that the PLLA bone plates provided enough strength to enable undisturbed bone healing. The long-term degradation results are comparable with those of other studies on as-polymerized PLLA implants.

COMPARISON OF EPITHELIAL DYSPLASIA - THE 4NQO RAT PALATE MODEL AND HUMAN ORAL-MUCOSA

Epithelial dysplasia in the rat palatal mucosa was induced by application three times a week of the carcinogen 4-nitroquinoline 1-oxide (4NQO). With the Epithelial Atypia Index (EAI), the successive stages of 4NQO-induced epithelial dysplasia were compared with specimens of human oral epithelial dysplasia. It appeared that there was a close similarity between the histologic features of 4NQO-induced dysplasia in the rat palatal mucosa and human oral epithelial dysplasia. Thus, the 4NQO rat palate model seems to be appropriate to study and assess new treatment modalities of premalignant epithelial lesions of the oral mucosa in man.