Response measurement after intraarterial chemoradiation in advanced head and neck carcinoma: magnetic resonance imaging and evaluation under general anesthesia?

BACKGROUND: The objectives of this prospective trial were to evaluate the diagnostic accuracy and predictive value of magnetic resonance imaging (MRI) and to use MRI evaluation under general anesthesia (EGA) 6 to 8 weeks after chemoradiation to determine local control. METHODS: Eighty-two consecutive patients with advanced-stage squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or supraglottic larynx were treated with selective targeted chemoradiation. All patients who completed treatment and survived had a minimum follow-up of 3 years. MRI and EGA were performed from 6 to 8 weeks after treatment. Posttreatment MRI findings were compared with pretreatment MRI findings and were graded for risk of local recurrence/residual disease on a 4-point scale. The diagnosis of treatment failure was based on tissue biopsies, which were obtained during EGA or later during follow-up. The predictive value of MRI was analyzed by using a Cox proportional hazards model. RESULTS: Only 1 patient with MRI Grade 0 or 1 findings (discrete mass < 10 mm; n = 62 patients) had residual disease 6 to 8 weeks after treatment that was detected during EGA. In 5 patients with MRI findings of Grade 2a and 2b (mass > 10 mm; n = 20 patients), residual disease was detected. After 2 years, 23 patients had a local failure (28%). Twelve local failures were found among 62 patients who had MRI findings of Grade 0 and 1. Posttreatment MRI emerged as an independent predictive factor (hazard ratio, 3.0; P = .014) for local control. CONCLUSIONS: Posttreatment MRI studies provided predictive information on local control in addition to pretreatment predictors. In patients with focal masses < 10 mm, the combination of response evaluation under general anesthesia and posttreatment MRI from 6 to 8 weeks after chemoradiation hardly provided more information on the local control than posttreatment MRI alone.

Pretreatment probability model for predicting outcome after intraarterial chemoradiation for advanced head and neck carcinoma.

BACKGROUND: Concurrent chemoradiation is being used increasingly to treat patients with advanced-stage head and neck carcinoma. In the current study, a clinical nomogram was developed to predict local control and overall survival rates for individual patients who will undergo chemoradiation. METHODS: Ninety-two consecutive patients with UICC TNM Stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and supraglottic larynx were treated with selective-targeted chemoradiation (acronym: RADPLAT). All living patients had a minimum follow-up of 2 years. In addition to general factors, the following parameters were analyzed in a multivariable analysis: primary tumor volume, lymph node tumor volume, total tumor volume, lowest involved neck level, comorbidity, pretreatment hemoglobin level, pretreatment weight loss, and unilateral/bilateral intraarterial infusion. Relevant factors for local control and survival were analyzed using the Cox proportional hazards model. RESULTS: At 5 years, the local control and overall survival rates for the whole group were 60% and 38%, respectively. Primary tumor volume (hazard ratio [HR], 1.03; P = 0.01) and unilateral infusion (HR, 5.05; P = 0.004) were found to influence local control significantly. Using tumor volume as a continuous variable, an adjusted risk ratio of 1.026 was found, indicating that each 1-cm(3) increase in volume was associated with a 2.6% decrease in probability of local control. Primary tumor volume (HR, 1.01; P = 0.003), comorbidity (American Society of Anesthesiologists [ASA] physical status 1 vs. > 1; HR, 2.47; P = 0.01), lowest involved neck level (HR, 3.45; P = 0.007), and pretreatment weight loss > 10% (HR, 2.04; P = 0.02) were found to be significant predictors of worse overall survival. Variables from the multivariable analysis were used to develop a nomogram capable of predicting local control and overall survival. CONCLUSIONS: Tumor volume was found to play a significant role in predicting local control and overall survival in patients with advanced-stage head and neck carcinoma who were treated with targeted chemoradiation. The nomograms may be useful for pretreatment selection of patients with advanced-stage head and neck carcinoma.

Daily cyclic changes in the urinary excretion of 5-hydroxyindoleacetic acid in patients with carcinoid tumors.

BACKGROUND: Vasoactive peptides produced by neuroendocrine tumors can induce characteristic symptoms of the carcinoid syndrome (flushing, diarrhea, and wheezing). To what extent external factors provoke these symptoms and how excretion of 5-hydroxyindoleacetic acid (5-HIAA), the degradation product of serotonin, varies throughout the day remain unknown. In this study, we investigated whether symptoms and daily activity are related to 5-HIAA excretion and whether 24-h urine collection is needed. METHODS: In 26 patients with metastatic carcinoid (14 men and 12 women; median age, 60 years) urine was collected in portions of 4 or 8 h during 2 days. Patients were asked to keep a diary in which they noted symptoms of flushes, consistency of stools, activities, and food intake. RESULTS: Excretion of 5-HIAA in 24-h urine was increased in 88% of the patients (median, 515 micromol/24 h). Overnight-collected urine appeared the most representative for 24-h collection concentrations (correlation coefficient = 0.81). We found no clear correlation between symptoms of the carcinoid syndrome and degree of activity. Watery diarrhea was reported only by patients with strong variations in 5-HIAA excretion. One-half of the patients (n = 16) exhibited a high variability in urinary 5-HIAA excretion throughout the day, with increased concentrations most prominent in morning collections (P = 0.0074) and lower concentrations in the evening (P = 0.0034). In the other patients these curves were flat. CONCLUSIONS: Cyclic changes in patients relate to high variability in 5-HIAA excretion. Overnight-collected urine can replace the 24-h urine collection, and marked variations in 5-HIAA excretion seem to be associated with severity of diarrhea.