Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis.

BACKGROUND: Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization. METHODS: MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year. RESULTS: In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia. CONCLUSION: The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.

Inferring super-spreading from transmission clusters of COVID-19 in Hong Kong, Japan, and Singapore.

Super-spreading events in an outbreak can change the nature of an epidemic. Therefore, it is useful for public health teams to determine whether an ongoing outbreak has any contribution from such events, which may be amenable to interventions. We estimated the basic reproductive number (R0) and the dispersion factor (k) from empirical data on clusters of epidemiologically linked coronavirus disease 2019 (COVID-19) cases in Hong Kong, Japan and Singapore. This allowed us to infer the presence or absence of super-spreading events during the early phase of these outbreaks. The relatively large values of k implied that large cluster sizes, compatible with super-spreading, were unlikely.

Sinonasal malignant melanoma: an analysis of 115 cases assessing outcomes of surgery, postoperative radiotherapy and endoscopic resection.

BACKGROUND: Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection. METHODOLOGY: Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome. RESULTS: 115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome. CONCLUSIONS: Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.

Sublingual lymph node metastasis of early tongue cancer: report of two cases and review of the literature.

Sublingual lymph node metastasis of early stage squamous cell carcinoma of the tongue (SCCT) is seldom reported. Lymphatic tissue in the floor of mouth, which intervenes between the tongue and neck, will be left behind by a primary tumour resection with discontinuous neck dissection. The authors present two cases of early stage SCCT with sublingual lymph node metastasis, review the literature, and discuss the management of the floor of mouth for early stage SCCT. The authors suggest that more attention should be paid to possible sublingual lymph node metastasis for T1/T2 SCC of the ventral tongue with deeply endophytic infiltration.

A prospective, split face, single-blinded study looking at the use of an infrared device with contact cooling in the treatment of skin laxity in Asians.

BACKGROUND: Although monopolar radiofrequency treatment is effective in the improvement of skin laxity, the pain and cost that are associated with this method suggest the need for alternative treatment options. Recently, an infrared device with contact cooling has been shown to be effective in the treatment of skin laxity, with ultrastructural changes observed that are similar to those that are observed following treatment with a monopolar radiofrequency device. However, no control was included in previous studies. OBJECTIVE: To conduct a prospective, split-face, single-blinded study to look at the efficacy and complications among Asians of treatment for skin tightening with an infrared device with contact cooling. METHOD: Thirteen Chinese women were treated. An infrared device with contact cooling (Titan, Cutera, Brisbane, CA) was used to treat one side of the face and the untreated side served as the control. The treatment was performed twice with a 4-week interval between the treatments and the patients were followed up by subjective assessment using a structured questionnaire 1 and 3 months after the second (and last) treatment. In all cases, pre- and post-treatment clinical photographs were taken. Two independent observers assessed the photographs. RESULTS: Twenty-three percentage of patients reported mild improvement, 15% reported moderate improvement, and 54% reported significant improvement 3 months after their second (and last) treatment. In terms of objective assessment, 41% of patients were identified to have some degree of improvement of the treated side 3 months after their second treatment. Compared with the untreated side, the treated side improved significantly (P = 0.031) at 1 and 3 months after the second treatment. Blistering occurred in one patient, which had resolved completely by the 3-month follow-up visit. CONCLUSION: An infrared device with contact cooling can be used effectively and safely for the treatment of skin laxity, especially in smaller anatomical areas.

Induction of matrix metalloproteinases by Epstein-Barr virus latent membrane protein 1 isolated from nasopharyngeal carcinoma.

Epstein--Barr virus latent infection is associated with human malignancies including Burkitt's lymphoma, gastric carcinoma and the highly invasive nasopharyngeal carcinoma (NPC). Increased expression of EBV latent membrane protein 1, LMP1, is correlated with tumor progression and metastasis in NPC. LMP1 induces cellular proteins including cytokines and matrix metalloproteinases (e.g., MMP1, MMP2 and MMP9). MMPs are endopeptidases involved in the degradation of extracellular matrix proteins; and their upregulation in cancer implicates their potential role in tumor metastasis. In light of the role of LMP1 in cytokine dysregulation and the fact that MMPs are regulated by cytokines, we examined whether LMP1 promotes NPC metastasis via the induction of MMPs. To delineate the oncogenic role of LMP1 in NPC, we first investigated the induction of MMP1, MMP2, MMP3 and MMP9 in LMP1-positive NPC tumor samples (n=15) by quantitative RT-PCR. We showed a significant induction of MMP1 and MMP3 transcripts in the EBV LMP1-positive NPC tissues, compared with biopsies obtained from the adjacent non-tumor tissues. To investigate the role of LMP1 in MMP expression in NPC, we cloned the LMP1 gene from NPC samples and transiently expressed it in MRC5 cells (human lung fibroblasts). Following transfection, a time-dependent elevation of endogenous MMP3 expression was found in the LMP1-transfectants by quantitative RT-PCR and Western analysis. Taken together, we observed that MMP3 is upregulated in LMP1-positive NPC tumors and LMP1-expression in fibroblasts is associated with MMP3 and cytokine expression. Our results suggest that LMP1 may contribute to invasiveness of NPC cells via the expression of MMP3 in fibroblasts.

The prevalence and risk factors of post-inflammatory hyperpigmentation after fractional resurfacing in Asians.

BACKGROUND: Ablative laser resurfacing is considered to be the main therapeutic option for the treatment of wrinkles and acne scarring. However, in Asians, post-inflammatory hyperpigmentation (PIH) is a common adverse effect of laser resurfacing. Fractional resurfacing is a new concept of skin rejuvenation whereby zones of micro thermal injury are generated in the skin with the use of a 1,540-nm laser. The risk and prevalence of hyperpigmentation in dark-skinned patients using this approach have not been studied. OBJECTIVE: To assess the prevalence and risk factors of PIH that is associated with the use of fractional resurfacing in Asians. METHOD: A retrospective study of 37 Chinese patients who were treated with fractional resurfacing for acne scarring, skin rejuvenation, and pigmentation was carried out. In all of the cases, pre- and post-treatment clinical photographs (from standardized and cross-polarized views) were taken using the Canfield CR system. Two independent observers assessed the photographs. A prospective study of treatments of nine different density and energy levels that were applied to the forearms of 18 volunteers was also performed. Clinical photographs were assessed pre- and post-treatment for evidence of PIH. RESULT: In the retrospective study, 119 treatment sessions were performed. Sixty-eight treatment sessions were high energy, low density; 51 sessions were low energy, high density. Patients who underwent a high energy but low-density treatment (range of energy 7-20 mJ; average energy 16.3 mJ, 1,000 MTZ) were associated with a lower prevalence of generalized PIH (7.1% vs. 12.4%) than those who underwent a low energy but high-density (range of energy 6-12 mJ; average energy 8.2 mJ, 2,000 MTZ) treatment. However, the difference was not statistically significant. Localized PIH occurred in the peri-oral area among patients who did not receive air cooling as an adjunctive therapy. CONCLUSION: Both the density and energy of the treatment determines the risk of PIH in dark-skinned patients. Density may be of more important but further studies are necessary to determine this. Cooling to prevent bulk tissue heating is also important, especially in small anatomical areas. By using adequate parameters, the risk of PIH in dark-skinned patients can be significantly reduced.

Sustained elevation of Epstein-Barr virus antibody levels preceding clinical onset of nasopharyngeal carcinoma.

We have monitored Epstein-Barr virus (EBV) IgA antibody levels of 39 nasopharyngeal carcinoma (NPC) cases for up to 15 years before clinical onset of NPC, and assessed preclinical serologic status of another 68 cases. Our results identify a serologic window preceding diagnosis when antibody levels are raised and sustained. This window can persist for as long as 10 years, with a mean duration estimated to as 37+/-28 months. Ninety-seven of these 107 NPC cases exhibited such a window. Cases that did not may reflect individual antibody response to EBV. Serologic screening at enrollment identified those cases who had already entered the window and became clinically manifested earlier (median=28 months) than those who entered the window after enrollment (median=90 months). The former account for 19 of 21 cases diagnosed within 2 years of screening. Nasopharyngeal carcinoma risk levels among seropositive subjects were also highest during this period. Both prediction rates and risk levels declined thereafter; cases detected at later times were composed of increasing proportions of individuals who entered the serological window after screening. Our findings establish EBV antibody as an early marker of NPC and suggest that repeated screening to monitor cases as they enter this window has considerable predictive value, with practical consequences for cancer treatment.

An animal study of the effects on p16 and PCNA expression of repeated treatment with high-energy laser and intense pulsed light exposure.

BACKGROUND AND OBJECTIVE: Non-ablative skin rejuvenation treatments that involve the use of laser/light sources together with cooling devices have gained much popularity in recent years due to the lack of down time that is associated with them. One important but neglected issue is long-term safety. Does the repeated use of non-ablative skin rejuvenation lead to photoaging? Are we creating another sun-bed phenomenon? Recently, we performed an in vitro study to examine the effect of sub-lethal QS 755 nm lasers on the expression of p16INK4a on melanoma cell lines, and found that sub-lethal laser damage could increase DNA damage, which led to an increase in p16 expression. Our objective was to assess the cutaneous effect of repeated exposure to high-energy lasers and intense pulsed light sources on male Institute of Cancer Research (ICR) mice. STUDY DESIGN/MATERIALS AND METHODS: Twenty-eight male ICR mice were divided into four groups. Other than the control group, all groups received either laser (585 nm pulsed dye laser or 1,320 nm Nd:YAG laser) or intense pulsed light (IPL) treatment. All four groups were anesthetized with a mixture of Hypnorm/Dormicum before treatment. The animals were irradiated twice a week for 6 months. Signs of toxicity such as mortality and weight loss were checked once a week. Skin tumor formation was evidenced by lesions of greater than 1 mm in diameter that persisted for 2 weeks. At the end of the 6 months, the expression of proliferating cell nuclear antigen (PCNA) and p16 in the mouse skin was determined by immunohistochemical staining and immunoblotting using specific monoclonal antibodies for mouse PCNA and p16. The results were expressed as mean +/- standard error of the mean (SEM). Statistical difference was assessed by multiple ANOVA. A P-value of <0.05 was considered to be significant. RESULTS: At the end of the 6 months, none of the animals had developed any signs of toxicity such as mortality or weight lost. There was no evidence of tumor formation. There were significant elevations of p16 and PCNA in all treated groups as compared to the control group (ANOVA P < 0.05). This particularly applied to the group that was treated with the 1,320 nm Nd:YAG laser. CONCLUSION: The repeated use of high-energy laser and intense pulsed light source did not cause any toxicity in mice. The changes in p16 and PCNA imply that further studies are necessary to consider the implications of repeated exposure to longer wavelength radiation in human skin.

Elevation of plasma osteopontin level in patients with undifferentiated nasopharyngeal carcinoma.

AIMS: We evaluated the clinicopathologic relevance of plasma osteopontin (OPN) level in nasopharyngeal carcinoma patients. METHODS: Seventy-two plasma samples were collected from patients with undifferentiated nasopharyngeal carcinoma (NPC) before radiotherapy. Plasma OPN level was determined by quantitative sandwich enzyme immunoassay. The plasma OPN level was evaluated for its clinicopathologic relevance. RESULTS: The mean plasma OPN level was significantly higher in NPC patients than in normal controls (184.66 vs 75.89 ng/ml, p<0.001). In addition, high OPN level was found in the patients with advanced cancer and was correlated with neck node metastasis (p<0.05). CONCLUSIONS: Our findings indicated a potential role of OPN in the pathogenesis and nodal metastasis of undifferentiated NPC.

Clinicopathologic significance of plasma matrix metalloproteinase-2 and -9 levels in patients with undifferentiated nasopharyngeal carcinoma.

UNLABELLED: Increased in plasma pro-MMP2 and pro-MMP9 levels in patients with advanced stage NPC were observed. Plasma pro-MMP2 is a significant independent prognostic marker for undifferentiated NPC. AIM: Upregulation of matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9) expression is observed in many cancers and high level of these proteins are found in peripheral blood of many cancer patients. In this study, we aimed at evaluating the plasma pro-MMP2 and pro-MMP9 pro-enzymes (pro-MMP2 and pro-MMP9) levels and their clinical significances in patients with undifferentiated nasopharyngeal carcinoma (NPC). METHODS: The plasma pro-MMP2 and pro-MMP9 levels were measured in 40 NPC patients and 40 normal individuals by enzyme linked immunosorbant assay. RESULTS: By using the Cox-regression model, a high pro-MMP2 level was found to be significantly correlated with poorer survival. Patients with plasma pro-MMP2 below 650 ng/ml had higher 5-year survival rate of 89%, compared with 50% for patients with plasma pro-MMP2 above 650 ng/ml. CONCLUSIONS: A high level of plasma pro-MMP2 was associated with poor survival of NPC patients independent of sex, age and stage.

The study of p16 and p15 gene methylation in head and neck squamous cell carcinoma and their quantitative evaluation in plasma by real-time PCR.

Epigenetic silencing of the p16 and p15 genes by promoter methylation are commonly observed in human epithelial malignancies, including head and neck squamous cell carcinomas (HNSCC). In this study, a methylation-specific polymerase chain reaction (MSP) was used to evaluate the methylation status of the p16 and p15 genes in 73 HNSCC surgical specimens. p16 and p15 gene methylation was also examined in 29 paired metastatic lymph nodes and 29 paired histologically, normal resection margin mucosae. The quantity of cell-free methylated p16 and p15 DNA in the plasma samples of 20 HNSCC patients and 24 healthy controls was also examined using a fluorescence-based real-time PCR assay. The frequencies of p16 and p15 methylation in the primary tumour were 49% and 60%, respectively. Concordant methylation of p16 and p15 in tumour samples and metastatic lymph nodes was found in 59 and 38% of cases, respectively. A significantly higher prevalence of p15 methylation was found in histologically-normal surgical margin epithelia of HNSCC patients with chronic smoking and drinking habits compared with non-smokers and non-drinkers. In addition, methylated p16 and p15 DNA levels were significantly higher in the plasma of HNSCC patients (mean 56 copies/ml plasma and 65 copies/ml plasma, respectively) compared with normal controls (mean 6 copies/ml plasma and 16 copies/ml plasma, respectively). In conclusion, promoter methylation of the p16 and p15 genes is involved in the pathogenesis of HNSCC and may be related to chronic smoking and drinking. The differential levels of methylated p16 and p15 DNA in plasma might be potential useful markers in screening high-risk populations for early HNSCC and monitoring their treatment response.

Role of skin cooling in improving patient tolerability of Q-switched Alexandrite (QS Alex) laser in nevus of Ota treatment.

BACKGROUND: The development of a high-energy laser device with very short pulse duration has revolutionized the treatment of nevus of Ota. Nevertheless, patients still suffer from complications that range from the pain and swelling that occur immediately after laser surgery to post-operative pigmentary changes and scarring. However, the simultaneous use of skin surface cooling and laser surgery may limit the damage of non-target tissue. OBJECTIVES: To assess whether epidermal cooling reduces the pain and swelling that commonly occur after laser treatment for nevus of Ota. STUDY DESIGN/PATIENTS AND METHODS: Thirty-seven patients with nevus of Ota were recruited from a dermatology outpatient clinic. Before treatment, the research nurse used an ink pen to divide the lesions into two halves. Half of each lesion was treated with a Q-switched Alex laser system that had a cool sapphire plate in contact as a mean of skin cooling. The other half was treated with the same laser, but with the cooling device switched off. Immediately after treatment, and again 1 week later, the patients answered a questionnaire, which assessed the symptoms that are associated with laser surgery. Dose assessment was performed in each half of the nevus to obtain the optimal fluence that could be used for the treatment of nevus of Ota before the entire half was treated. RESULTS: There was no difference in terms of the optimal fluence that was used, but in terms of immediate pain the patients associated the side that was treated with the cooling plate with a significantly lesser degree of pain than the non-cooled side (P = 0.001). Eighty two percent of the patients preferred the cooled side to the non-cooled side. CONCLUSIONS: Pre- and post-operative skin cooling is effective in improving the tolerability of nevus of Ota patients to Q-switched laser treatment. However, the use of cooling during laser treatment of nevus of Ota did not allow the use of higher fluence.

Surgical complications and outcome of pediatric liver transplantation in Hong Kong.

PURPOSE: The aim of this study was to analyze the early and late results of pediatric liver transplantation, with particular reference to complications that required surgical or radiologic intervention. METHODS: The records and code sheets of children who underwent liver transplantation in the authors' institution between September 1993 and December 2001 were reviewed. RESULTS: Twenty-nine children (16 boys and 13 girls) underwent 31 liver transplantations (23 living donor, 8 cadaveric donor) during the study period. The ages of the children ranged from 4 months to 132 months (median, 16 months). Eighteen children had complications that required surgical or radiologic interventional procedures. Complications included, among others, hepatic vein thrombosis (n = 1, 3%), hepatic vein stenosis (n = 2, 7%), portal vein thrombosis (n = 2, 7%), biliary stricture (n = 3, 10%), bile leakage (n = 2, 7%), hepatic artery pseudoaneurysm (n = 1, 3%), jejuno-jejunostomy leakage (n = 1, 3%), graft hepatitis (n = 1, 3%), and posttransplant lymphoproliferative disorder (n = 2, 7%). In addition, 6 children (21%) suffered from intraabdominal bleeding from a variety of causes. After appropriate interventions, at a median follow-up of 38 months (range, 1 to 96 months), patient and graft survival rates were 79% and 74%, respectively. The retransplantation rate was only 7%. There was no incidence of hepatic artery thrombosis. All living donors remain alive and well. CONCLUSIONS: Complications are inevitable in pediatric liver transplantation. However, with timely recognition and active intervention, a good outcome can be achieved.

Clinicopathologic significance of bcl-2 expression in the surgical treatment of oral tongue carcinoma.

AIM: There is still controversy on the incidence of positive expression of bcl-2 and its prognostic significance for oral tongue carcinoma patients who are treated by surgery. The present study aims at resolving the controversy on the clinicopathologic significance of bcl-2 in a well selected group of patients who satisfy the recruitment criteria: (1) oral tongue carcinoma, (2) squamous cell carcinoma, (3) primary surgical treatment. METHOD: Bcl-2 expression was studied by immunohistochemistry on glossectomy specimens of 73 patients. The expression of bcl-2 was correlated with clinicopathologic data. RESULTS: Of the 73 tumours, 11% had positive expression of bcl-2. Bcl-2 expression was not significantly correlated with tumour grade, stage, nodal metastasis and survival. CONCLUSION: Bcl-2 expression played a minor role in oral tongue carcinoma. It had no significant correlation with tumour grade, stage and nodal metastasis. It also had no prognostic value on survival for patients who were treated by primary surgery.

Ten-year experience with liver transplantation at Queen Mary Hospital: retrospective study.

OBJECTIVE: To report the experience with liver transplantation at the Queen Mary Hospital from 1991 to 2000. DESIGN: Retrospective study. SETTING: Liver transplant centre of a University teaching hospital, Hong Kong. PATIENTS: One hundred and forty-eight patients (127 adults and 21 children) who underwent a total of 155 liver transplants using 75 cadaver grafts (full-size, 67; reduced-size, 5; split, 3) and 80 living donor grafts (left lateral segment, 15; left lobe, 6; right lobe, 59) from October 1991 to December 2000 were reviewed. MAIN OUTCOME MEASURES: Graft and patient survival rate. RESULTS: The most common disease indications for liver transplantation were chronic hepatitis B-related liver disease (n=74) in adults and biliary atresia (n=14) in children. Eighteen patients had hepatocellular carcinoma. Forty-eight (31%) liver transplants (three ABO-incompatible) were performed in high-urgency situations for patients requiring intensive care. The proportion of living donor liver transplants was 47.7% in adults and 73.9% in children. The overall 1-year and 5-year patient survival rates were 82% and 77%, respectively. The survival of high-risk recipients, such as those with fulminant hepatic failure (80%), chronic hepatitis B (81%), or hepatocellular carcinoma (94%), was not inferior to that of other patients. CONCLUSION: Over the last decade, the promotion of (cadaver) organ donation through public education coupled with innovative techniques in living donor liver transplantation have enabled a liver transplantation programme to be established in Hong Kong with gratifying results.

Living donor liver transplantation without the use of blood products.

We report on two patients who presented with unresectable hepatocellular carcinoma complicating hepatitis B liver cirrhosis. After evaluation, both patients were accepted for liver transplantation. Being aware of the scarce availability of cadaveric liver grafts and the long waiting time, family members volunteered to be donors for the two patients. Living donor liver transplantation using right lobe liver grafts, including the middle hepatic vein, was subsequently performed without the use of blood products in both the donors and recipients. All involved recovered uneventfully from their respective operations.

Prospective randomized study of post-operative chemotherapy with levamisole and UFT for head and neck carcinoma.

AIMS: A prospective randomized study was conducted to evaluate the benefit of adjuvant levamisole/UFT (futraful and uracil) chemotherapy in head and neck squamous cell carcinoma. METHODS: Sixty-five patients with stage III and IV squamous cell carcinomas of oral cavity, oropharynx, hypopharynx and larynx with no distant metastasis were randomized for the chemotherapy study. Thirty-one patients were randomized for chemotherapy and two of them were subsequently excluded. In this study, a total of 29 patients on levamisole/UFT therapy and 34 patients on the control group were analysed. The main outcome was measured by the 5-year disease-free actuarial survival rate. RESULTS: The rates of distant metastasis were 10% for chemotherapy group and 32% for control group (P=0.06). The 5-year disease-free actuarial survival rates for patients with and without adjuvant chemotherapy were 57% and 39% respectively (P=0.207). CONCLUSIONS: A trend of better distant control in head and neck cancer patients with post-operative adjuvant oral chemotherapy was observed. The side effects were minimal. However, there was no statistically significant improvement in the overall long-term survival. It may be of value to conduct a large-scale multi-centre prospective randomized study to verify the efficacy of levamisole and UFT as post-operative adjuvant chemotherapy for the control of distant metastasis in high-risk population.

Management of extensive cervical nodal metastasis in nasopharyngeal carcinoma after radiotherapy: a clinicopathological study.

OBJECTIVES: To evaluate the efficacy of afterloading brachytherapy following radical neck dissection (RND) in the management of extensive cervical lymph node disease in nasopharyngeal carcinoma after radiotherapy; and to examine prospectively prognostic factors and the pathologic behavior of neck disease. PATIENTS: Twenty-seven patients with nasopharyngeal carcinoma who had extensive cervical lymph node metastasis following external radiotherapy were treated with RND. Thirteen of them also underwent afterloading brachytherapy with iridium wire (Ir 192). The RND specimens of the 27 patients were also examined with step serial whole-specimen sectioning. RESULTS: All patients survived and their wounds healed primarily. Pathologic examination revealed 183 tumor-bearing lymph nodes that contained tumors in the neck: level I, 4% (8/183); level II, 53% (96/183); level III, 34% (62/183); level IV, 5% (9/183); and level V, 4% (8/183). Extracapsular tumor extension was seen in 84% of patients. Multivariate analysis identified the number of tumor-bearing lymph nodes detected in the specimens to be the only significant factor that affected control of disease. Although the neck disease in the group of patients who had afterloading brachytherapy was more extensive, the 3-year actuarial tumor control for the groups with and without brachytherapy were 60% and 61%, respectively. CONCLUSIONS: Recurrent cervical lymph nodes after radiotherapy in nasopharyngeal carcinoma are extensive and RND is mandatory for a successful salvage. When the nodal metastasis infiltrate or adhere to surrounding tissue, afterloading brachytherapy with iridium wire can provide satisfactory local tumor control.

The predictive value of the 1997 American Joint Committee on Cancer stage classification in determining failure patterns in nasopharyngeal carcinoma.

BACKGROUND: A retrospective analysis of treatment outcomes in patients with nasopharyngeal carcinoma (NPC) was performed in which the newly revised 1997 American Joint Committee on Cancer (AJCC) stage classification was applied and compared with the 1988 AJCC and Ho stage classifications, with emphasis on the predictive value of different staging systems in determining failure patterns in NPC. METHODS: Three hundred and twenty-four patients with newly diagnosed NPC treated between September 1989 and August 1991 and originally staged according to Ho stage classification were re-staged according to the 1988 and 1997 AJCC stage classifications. In addition to stage grouping, patients were also classified into the following prognostic categories to study the failure patterns: early disease group (T1-2N0-1), advanced local disease group (T3-4N0-1), advanced nodal disease group (T1-2N2-3), and advanced locoregional disease group (T3-4N2-3). The overall survival (OAS), relapse-free survival (RFS), local relapse-free survival, nodal relapse-free survival, and distant metastases-free survival were compared among different stage groups and prognostic categories in the three staging systems. RESULTS: In the new AJCC system, the percentages of patients with Stage I, II, III, and IV disease were 15.1%, 31.5%, 28.1%, and 25.3%, respectively, whereas most patients were classified as having Stage IV disease (65.7%) in the old AJCC system and Stage II or III disease (74.1%) in the Ho system. The 5 year OAS rates in the 1997 AJCC Stage I, II, III, and IV disease were 97.7%, 78.7%, 79.5%, and 61.4%, respectively. The corresponding 5 year RFS rates were 95.7%, 64.7%, 54.5%, and 41.1%. Using the 1997 AJCC system to define the four prognostic categories, the early disease group had the lowest incidence of relapse (27.6%) and death (18.4%), whereas the advanced locoregional disease group had the highest incidence of relapse (61.4%) and death (43.2%). Both the advanced local disease group and the advanced nodal disease group had similar rates of relapse (46.7% vs. 47.2%), but local relapse was the major cause of failure in the former group (61.8%), whereas distant metastases was the major cause in the latter group (44%). CONCLUSIONS: Using the 1997 AJCC staging system, the authors observed a better distribution of patient numbers as well as segregation of survival curves among different stage groups. Moreover, prognostic categories with distinct prognosis and failure patterns were definable by the new system, which has important implications in selecting appropriate patient treatment strategies.