Miriam E. Vincent

Patterns of relapse in locally advanced head and neck cancer patients who achieved complete remission after combined modality therapy

Relapse patterns in patients with locally advanced head and neck cancer who achieved complete remission were evaluated. After combined modality therapy with induction chemotherapy followed by surgery and/or radiotherapy, 71 of 103 patients were clinically free of disease. The 5‐year recurrence rate was estimated at 51%, with a 39% local and 26% distant failure rate by 5 years. The factors significantly affecting the relapse patterns were: (1) the site of the primary tumor (those with oral cavity lesions were more likely to fail locally, whereas hypopharynx patients had a higher risk of distant metastases); (2) the type of definitive local treatment (those patients who received surgery and radiotherapy were at lower risk of pure local failure); (3) TN Stage (patients with T4N3 or T3N3 tumor were at higher risk of both local and distant failure); and (4) time to response and presence of oropharyngeal lesions (patients who had a longer period from diagnosis to final complete response [CR] and patients with oropharyngeal primaries were at higher risk for simultaneous local and distant failure). Type of chemotherapy, patient age, tumor differentiation, and response to induction chemotherapy did not significantly influence the patterns of relapse. A combined modality approach with induction chemotherapy, surgery, and/or radiotherapy does not seem to reduce the incidence of distant metastases significantly.

A prospective randomized trial of methotrexate versus cisplatin in the treatment of recurrent squamous cell carcinoma of the head and neck

A prospective randomized study was conducted to determine the relative effectiveness, toxicity and tolerance of methotrexate (MTX) versus cisplatin (DDP) in patients with recurrent head and neck squamous cell carcinoma. Forty‐four patients were randomized to receive either MTX, 40 mg escalated to 60 mg/m2 IV push weekly, or DDP, 50 mg/m2 6 hour infusion days 1 and 8 every 4 weeks. All patients had objectively measurable disease and a performance status greater than 60% (Karnofsky scale). All had been treated with surgery and/or radiotherapy. No patients had prior chemotherapy. Prior treatment, performance status, and site of primary disease were comparable in both groups. Complete and partial objective responses were achieved in 23.5% of the MTX group and 28.6% of the DDP group (P = 0.51). Median duration of response was 84 days in the MTX group and 92 days in the DDP group. Median survival of patients was 6.1 months with MTX and 6.3 months with DDP. Mucositis was noted in 38% of patients in the MTX group (P = 0.001) compared to none in the DDP group. Vomiting occurred in 87% of patients in the DDP group (P < .0001) compared to 10% of patients in the MTX group. This study demonstrates that in the treatment of recurrent head and neck squamous cell carcinoma, MTX and DDP are equally effective, although MTX appears to be better tolerated. Cancer 52:206‐210, 1983.

The anatomy and complications of “t” versus vertical closure of the hypopharynx after laryngectomy

The early postoperative hypopharyngeal anatomy of 37 consecutive patients undergoing total laryngectomy at the Boston Veterans Administration Hospital between July 1977 and April 1980 was studied by barium swallow radiographs and correlated with the technique of closure. The “pseudoepiglottis,” a structure radiographically resembling a normal epiglottis, was seen arising from the anterior hypopharynx near the base of the tongue in 21 of 28 evaluable patients. It occurred in all patients with vertical closures vs. 67% of patients with a “T” shaped closure. The average length in the “T” closure group was 9.6 mm (range 0.35) vs. 18.4 mm (6.40) in the vertical group, a statistically significant difference (p<0.05).

Ceruletide-assisted cholecystography: a clinical assessment.

The cholecystokinetic effect of ceruletide, a synthetic decapeptide similar in action to cholecystokinin, was examined in both a randomized and nonrandomized study in 81 patients scheduled for routine oral cholecystograms. Intramuscular injection of ceruletide in a dose of 0.3 microgram/kg resulted in a mean maximum contraction of the gallbladder of 68% and a mean time until maximum contraction of 28 minutes. Visualization of the cystic duct occurred in 57 patients (70%); the common duct was seen in 67 (83%). Ceruletide demonstrated superior gallbladder contraction when compared to fatty meals and demonstrated no interference with a subsequent upper gastrointestinal series.

Teleradiology for remote diagnosis: A prospective multi-year evaluation

Teleradiology has been used for nearly 3 years at our institution to provide urgent radiologic interpretations for two outpatient clinics and an affiliated hospital. The purpose of this study was to evaluate the clinical reliability of the existing system. Teleradiology images were interpreted using 1600×1200 pixel display stations. The original films from the same cases were subsequently interpreted, usually by another radiologist. The initial and final interpretations were compared. Discrepancies were rated and adjudicated by another senior radiologist. These data were compared to peer review interobserver discrepancy rates. Among the 2688 teleradiology examinations evaluated, there were major discrepancies in 31 (1.15%). In three instances teleradiology rather than film interpretation was considered correct. Abnormalities missed on teleradiology were apparent in all but two at adjudication. Among the 628 peer-review cases, there were 6 (0.96%) major discrepancies. Major teleradiology diology discrepancy rates are statistically similar to film-based peer review discrepancy rates. Teleradiology is suitable for providing radiologic services to remote medical facilities.

Tumor regression and temporary restoration of immune response after plasmapheresis in a patient with recurrent oral cancer.

A major response to plasmapheresis is reported in a patient with advanced, recurrent squamous cell cancer of the oral cavity, similar to that previously reported in three of six comparable patients. Tumor regression followed temporary reduction of inhibition of normal lymphocyte response to phytohemagglutinin (PHA) by the patients serum (from 99% to zero) and partial restoration of the patients lymphocyte response (from 2% to 38% of control). The IgE level rose both overall and during some exchanges; this correlate of tumor response had been noted earlier. The tumor showed extensive necrosis, but the clinical effects were relatively short‐lived and the patient died 11 weeks later. Biopsy specimens taken early in apheresis showed intense new infiltration of tumor by lymphocytes and monocytes; later biopsy specimens showed predominantly plasma cells with trapping and lysis of tumor cells. No other anti‐cancer therapies had been used for 16 months before this trial, and no replacements were given other than saline and albumin.

Computed tomographic angiography

Computed tomographic angiography performed by the intravenous administration of contrast medium was evaluated in 86 vascular patients. This experience demonstrates a new approach to the evaluation of patients with symptomatic aortic aneurysms, in whom computed tomographic angiography will aid in evaluating the need for emergency surgery. Nonoperative patients are serially evaluated by computed tomographic angiography to detect significant changes in the geometric configuration of their aneurysms. Computed tomographic angiography was beneficial in the evaluation of the patency of vascular reconstructive procedures such as femoropopliteal bypass, aortoiliac bypass and application of a vena caval device. More clinical experience and possibly a rapid sequence technique are needed to evaluate patients with portasystemic shunts.

Abstracts Papers presented at the Eleventh Annual Session of the Society of Gastrointestinal Radiologists, October 1, 1981, Boca Raton, Florida

Papers Presented at the Eleventh Annual Session of the Society of Gastrointestinal Radiologists, October 1, 1981, Boca Raton, Florida ESOPHAGEAL NODULARITY A NORMAL VARIANT OF THE ESOPHAGEAL MUCOSA Seth N. Glick, M.D. Steven K. Teplick, M.D. Department of Diagnostic Radiology Hahnemann Medical College and Hospital 230 North Broad Street Philadelphia, PA. 19102 Small superficial round nodules (2-4 mm) are frequently observed on routine double contrast esophagrams. They may be focal or diffuse, and appear as fine granularity or sharply defined filling defects. Endoscopic~lly, they are seen as white excrescences on a normal mucosal background. However, they may not be appreciated, unless specifically sought, becaUse of inadequate lumenal distension. Biopsy reveals normal or slightly hyperplastic squamous epithelium and vacuolated epithelial cells containing abundant glycogen. This has been termed glycogenic acanthosis. Esophageal symptoms are usually absent or cannot be correlated with this morphology. We evaluated 300 consecutive esophagrams considered to demonstrate adequate mucosal detail. Nodularity was found in 30%. These were usually confirmed endoscopically when sought. In addition to true nodules, pseudo-nodules may be caused by several types of artifacts such as transverse esophageal folds. Several pathologicconditions may resemble the normal esophageal nodules, however, radiologic and clinical criteria can usually make the distinction. The Esophageal Survey in Upper Gastrointestinal Radiography Dean D. T. Maglinte, M.D., Katharine L. Krol, M.D., Lloyd D. Caudill, M.D., David L. Brown, M.D., and William Michael McCune, M.D. Gastrointestinal Radiology Section Methodist Hospital and Graduate Medical Center, 1604 North Capitol Ave., Indianapolis, IN 46206 When an upper gastrointestinal study is requested on a patient with non-specific abdominal complaints, there are no guidelines as to what should be the minimum esophageal survey. Of 200 patients referred for upper gastrointestinal series, 40 (20%) had radiographic evidence of esophageal disease. Reflux esophagitis, frequently considered difficult to diagnose radiographically, was demonstrated in 31 (16%). A non-invasive carcinoma, varices and a leiomyoma were found. It is suggested that a thorough evaluation of the esophagus consisting of double contrast, single contrast distention radiograph, fluoroscopic motility assessment and mucosal relief study be included in every upper gastrointestinal series. This minimum multiphasic routine evaluation offers the potential for improvement in diagnostic accuracy with little additional examination time. Barium Swallow After Total Laryngectomy Koehler RE, Balfe DM, Setzen M, Weyman P J, Baron RL, Ogura J Department of Radiology and Divls]on of Otolaryngology, Washington University School of Medicine, St. Louis, Mo Dysphagia is a frequent problem in patients who have undergone total laryngectomy and the barium swallow is often useful for evaluaHng the cause for the symptoms. The examination may be di f f icul t to interpret, however, because a variety of anatomic changes may be produced by radiation, infection, fistula, recurrent tumor or the operation itself. We analyzed radiographs and clinical information on 43 patients with total laryngectomy with followup periods ranging from g months to 17 years. Recurrent tumor was found in IS patients and was evident radiographically as a mass deviating the neopharynx in 14. Benign strictures in nine patients apeared either as a long symmetrical r~arrowing or as a very short, weblike narrowing. Fistulas were demonstrated in 12 patients and presaged the development of recurrent tumor in five. Cricopharyngeal muscular-dysfunctlon accounted for the dysphagia in five cases. An understanding of these patterns leads to more accurate interpretation of the postoperative barium swallow and the radiographic findings often indicate the correct diagnosis with a high degree of confidence. 0364-2356/82/0007-0087

Adenocarcinoma and Barrett's esophagus: An overrated risk?

01.80 9 1982 Springer-Verlag New York Inc.