Radiotherapy for a benign cause of cauda equina compression in a known case of breast carcinoma.

A woman underwent breast conservation surgery and axillary clearance for T1N1M0 breast carcinoma, followed by adjuvant chemotherapy, radiotherapy and hormone therapy. At 3-year follow-up she presented with lumbar back pain and developed bilateral lower limb weakness. MRI spine demonstrated an expansile lesion at L1 causing cauda equina compression. The mass, unusually, was centred on the spinous process; metastases typically involve pedicles. The patient underwent surgical decompression with complete resolution of neurological signs. Histology revealed Masson tumour (intravascular papillary endothelial hyperplasia), a benign vascular lesion. Pain recurrence 9 months later prompted imaging demonstrating recurrent mass. Preoperative embolisation and re-excision was undertaken for recurrent Masson tumour. Recurrence of these lesions is rare and it was felt residual disease was likely. Radiotherapy has been used in isolated cases; therefore, she was treated with adjuvant radiotherapy, the first reported case of radiation in management of extracranial Masson tumour, and remains well 3 years later.

Survival of patients with neck recurrence following radical neck dissection: utility of a second neck dissection?

Treatment of neck recurrence following radical neck dissection is extremely difficult. Retrospective review of 699 radical neck dissections was performed. Recurrence rates, host, tumor, treatment factors, and survival were analyzed. One hundred nineteen patients who had undergone radical neck dissections had recurrence, 69 were considered candidates for salvage surgery. Factors that increased the risk of neck recurrence were neck node (N) status and no adjuvant radiotherapy. Factors associated with radical salvage treatment were young age, good general condition, and low recurrent N classification. Five-year survival for salvage neck dissection was 31%. Young patients and low T and N classification did well. Low recurrent N classification and salvage surgery were associated with good prognosis for recurrence. In our study, radical neck dissection has a regional failure rate of 20%, a third of recurrence cases were offered curative treatment. Of these, 31% were cured with salvage surgery.

Treatment of squamous cell carcinoma of the tongue base: irradiation, surgery, or palliation?

OBJECTIVES: Squamous cell carcinoma of the tongue base has a poor prognosis, and treatment is accompanied by a number of major problems. In view of this, it is important to recognize which patients will benefit from treatment with curative intent and which treatment method to use. METHODS: One hundred sixty-five patients with squamous cell carcinoma of the tongue base were identified on our database. Eighty-two patients were treated by radical irradiation, and 41 by surgery. A further 42 patients were considered unsuitable for curative treatment. RESULTS: The 5-year cause-specific survival rate was 41% for those treated by irradiation, 58% for those treated by surgery, and 9% for untreated patients. There was no difference in the efficacy of treatment methods (p = .5362), but a highly significant difference was seen in survival rate between treated and untreated patients (p = .0028). The decision regarding administration of curative treatment was based on the extent of locoregional involvement at the primary site (p = .0139; odds ratio, 0.43) and in the neck (p = .0078; odds ratio, 0.23). No factors affected the decision to treat by irradiation or surgery. When the observed survival rate was calculated, there was no significant difference in 5-year survival rate between treated and untreated patients (p = .2762). Those with early (T1-2) disease at the primary site had an improved survival rate from 0.5 to 4 years compared with those who were untreated (T3-4; p = .0081; odds ratio, 2.2). In addition, those with early (T1-2) disease had a better survival rate than those with advanced cancers (p = .0139; odds ratio, 2.09). There was, however, no difference in survival rate at 5 years. Those with early disease compared with those with advanced disease were twice as likely to be alive at 2 years; however, all survival advantages had disappeared by 5 years. CONCLUSIONS: In terms of observed survival, treating tongue base squamous cell carcinoma that is locally advanced (T3-4) at presentation offers no survival advantage over palliation alone. Treating early disease (T1-2) doubles the survival rate for up to 4 years, but by 5 years this survival advantage is lost. The present study finds radiotherapy and surgery to be equivalent at controlling this disease.

Cerebral blood volume, genotype and chemosensitivity in oligodendroglial tumours.

INTRODUCTION: The biological factors responsible for differential chemoresponsiveness in oligodendroglial tumours with or without the -1p/-19q genotype are unknown, but tumour vascularity may contribute. We aimed to determine whether dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) could distinguish molecular subtypes of oligodendroglial tumour, and examined the relationship between relative cerebral blood volume (rCBV) and outcome following procarbazine, lomustine and vincristine (PCV) chemotherapy. METHODS: Pretherapy rCBV was calculated and inter- and intraobserver variability assessed. Allelic imbalance in 1p36, 19q13, 17p13, 10p12-15, and 10q22-26 and p53 mutation (exons 5-8) were determined. rCBV was compared with genotype and clinicopathological characteristics (n=37) and outcome following PCV chemotherapy (n=33). RESULTS: 1p/19q loss was seen in 6/9 grade II oligodendrogliomas, 6/14 grade II oligoastrocytomas, 4/4 grade III oligodendrogliomas, and 3/10 grade III oligoastrocytomas. rCBV measurements had good inter- and intraobserver variability, but did not distinguish histology subtype or grade. Tumours with 1p/19q loss had higher rCBV values (Student's t-test P=0.001). Receiver operating characteristic analysis revealed a cut-off of 1.59 for identifying genotype (sensitivity 92%, specificity 76%). Tumours with high and low rCBV showed response to chemotherapy. The -1p/-19q genotype, but not rCBV, was strongly associated with response, progression-free and overall survival following PCV chemotherapy. Tumours with high rCBV and intact 1p/19q were associated with shorter progression-free and overall patient survival than those with intact 1p/19q and low rCBV or high rCBV and 1p/19q loss. CONCLUSION: rCBV identifies oligodendroglial tumours with 1p/19q loss, but does not predict chemosensitivity. The prognostic significance of rCBV may differ in oligodendroglial tumours with or without the -1p/-19q genotype.

An artificial neural network improves prediction of observed survival in patients with laryngeal squamous carcinoma.

The accepted method of modelling and predicting failure/survival, Cox's proportional hazards model, is theoretically inferior to neural network derived models for analysing highly complex systems with large datasets. A blinded comparison of the neural network versus the Cox's model in predicting survival utilising data from 873 treated patients with laryngeal cancer. These were divided randomly and equally into a training set and a study set and Cox's and neural network models applied in turn. Data were then divided into seven sets of binary covariates and the analysis repeated. Overall survival was not significantly different on Kaplan-Meier plot, or with either test model. Although the network produced qualitatively similar results to Cox's model it was significantly more sensitive to differences in survival curves for age and N stage. We propose that neural networks are capable of prediction in systems involving complex interactions between variables and non-linearity.

Feasibility study of the retrospective use of the Adult Comorbidity Evaluation index (ACE-27) in patients with cancer of the head and neck who had radiotherapy.

The Adult Comorbidity Evaluation index (ACE-27) is a relatively new measure of comorbidity and the aim of this study was to assess the feasibility of retrospective examination of casenotes to estimate this index in patients who were given radiotherapy for head and neck cancer. We examined the casenotes of 157 of 168 consecutive patients diagnosed with an index primary tumour of the head and neck at the Clatterbridge Centre of Oncology in 1992 and 1993. Three comorbidity measures, the ACE-27, Charlson comorbidity index (CL) and Washington University Head Neck Cancer Index (WUHNCI) were calculated. In the grading of the ACE-27, 5 patients (3%) were grade 3, 21 (13%) were grade 2, 57 (36%) were grade 1 and 74 (47%) were grade zero. There was a trend in survival by ACE-27 grading with little difference between mild and moderate severity (p=0.08). There were no significant correlations between survival and either the Charlson index (p=0.80) or the WUHNCI (p=0.68). There were no significant correlations of any of the indices or of clinico-demographic factors with recurrence rates.