Radical Cystectomy in the Treatment of Invasive Bladder Cancer: Long-Term Results in 1,054 Patients.

PURPOSE: To evaluate our long-term experience with patients treated uniformly with radical cystectomy and pelvic lymph node dissection for invasive bladder cancer and to describe the association of the primary bladder tumor stage and regional lymph node status with clinical outcomes. PATIENTS AND METHODS: All patients undergoing radical cystectomy with bilateral pelvic iliac lymphadenectomy, with the intent to cure, for transitional-cell carcinoma of the bladder between July 1971 and December 1997, with or without adjuvant radiation or chemotherapy, were evaluated. The clinical course, pathologic characteristics, and long-term clinical outcomes were evaluated in this group of patients. RESULTS: A total of 1,054 patients (843 men [80%] and 211 women) with a median age of 66 years (range, 22 to 93 years) were uniformly treated. Median follow-up was 10.2 years (range, 0 to 28 years). There were 27 (2.5%) perioperative deaths, with a total of 292 (28%) early complications. Overall recurrence-free survival at 5 and 10 years for the entire cohort was 68% and 66%, respectively. The 5- and 10-year recurrence-free survival for patients with organ-confined, lymph node-negative tumors was 92% and 86% for P0 disease, 91% and 89% for Pis, 79% and 74% for Pa, and 83% and 78% for P1 tumors, respectively. Patients with muscle invasive (P2 and P3a), lymph node-negative tumors had 89% and 87% and 78% and 76% 5- and 10-year recurrence-free survival, respectively. Patients with nonorgan-confined (P3b, P4), lymph node-negative tumors demonstrated a significantly higher probability of recurrence compared with those with organ-confined bladder cancers (P < .001). The 5- and 10-year recurrence-free survival for P3b tumors was 62% and 61%, and for P4 tumors was 50% and 45% , respectively. A total of 246 patients (24%) had lymph node tumor involvement. The 5- and 10-year recurrence-free survival for these patients was 35%, and 34%, respectively, which was significantly lower than for patients without lymph node involvement (P < .001). Patients could also be stratified by the number of lymph nodes involved and by the extent of the primary bladder tumor (p stage). Patients with fewer than five positive lymph nodes, and whose p stage was organ-confined had significantly improved survival rates. Bladder cancer recurred in 311 patients (30%) . The median time to recurrence among those patients in whom the cancer recurred was 12 months (range, 0.04 to 11.1 years). In 234 patients (22%) there was a distant recurrence, and in 77 patients (7%) there was a local (pelvic) recurrence. CONCLUSION: These data from a large group of patients support the aggressive surgical management of invasive bladder cancer. Excellent long-term survival can be achieved with a low incidence of pelvic recurrence.

Clinical outcomes of chemical pleurodesis using a minocycline.

BACKGROUND: Pleurodesis is often used to prevent the re-accumulation of a malignant pleural effusion (MPE). Intrapleural urokinase (IPUK) therapy facilitates lung re-expansion for patients with loculated MPE or a trapped lung that allows subsequent pleurodesis. MPE management has been traditionally regarded as a symptomatic treatment. We tried to evaluate their impact on patient survival. METHODS: There were 314 consecutive patients with symptomatic MPE that underwent minocycline pleurodesis with ( n = 109) and without ( n = 205) the antecedent IPUK therapy between September 2005 and August 2015, who were recruited for the pleurodesis outcome and survival analysis. RESULTS: The rate of successful pleurodesis was similar between the simple pleurodesis group and the IPUK therapy group followed by the pleurodesis group (69.0% versus 70.5%; p = 0.804). The patients who succeeded pleurodesis had a longer survival rate than those who failed in either the simple pleurodesis group (median, 414 versus 100 days; p < 0.001) or the IPUK therapy followed by pleurodesis group (259 versus 102 days; p < 0.001). The survival differences remained when the lung and breast cancer patients were studied separately. CONCLUSION: Successful pleurodesis translated into a better survival rate that promotes performing pleurodesis on lung re-expansion. The apparent shorter survival of the patients with loculated MPE or trapped lung, and those that did not respond to the IPUK therapy, lowered the probability of the survival benefit through the simple physical barrier by the fibrin formation to prevent the tumor spreading. The successfully induced inflammatory response by minocycline is supposed to prohibit the tumor invasion and metastasis. Further studies are warranted to clarify the mechanism and provide opportunities to develop novel therapeutic strategies.

Conventional transbronchial needle aspiration is promising for identifying EGFR mutations in lung adenocarcinoma.

BACKGROUND: Conventional transbronchial needle aspiration (TBNA) is advantageous for the one-step diagnosis and staging of lung adenocarcinoma under topical anesthesia and conscious sedation. We examined its efficacy for identifying EGFR mutations. METHODS: Forty-seven patients with proven or suspected lung adenocarcinoma indicated for hilar-mediastinal lymph node (LN) staging between June 2011 and December 2017 were enrolled. The cellblock was prepared using the plasma-thrombin method. TaqMan PCR was used to detect mutations. Considering cost effectiveness, only the sample with the highest tumor cell fraction in the same patient was chosen for analysis. RESULTS: TBNA provided positive results of malignancy in 27 patients. Seventeen patients (63.0%) had cellblocks eligible for mutation testing. Bronchial biopsy (n = 6), neck LN fine needle aspiration (n = 1), and brushing (n = 1), provided higher tumor cell fractions for analysis in eight patients. TBNA was the exclusive method used in nine patients (19.1%). For patients with an inadequate TBNA cellblock, bronchial biopsy (n = 5), neck LN fine needle aspiration (n = 3), computed tomography-guided transthoracic needle biopsy (n = 1), and brushing (n = 1) were used for analysis. Modification to specimen processing to prevent exhaustion by cytology after June 2016 improved the adequacy of cellblock samples (9/10, 90% vs. 8/17, 47.1%; P = 0.042). CONCLUSIONS: These findings suggest the promising role of conventional TBNA and highlight the challenges of doing more with less in an era of precision medicine.

Prevalence, risk factors, and the desire for help of distressed newly diagnosed cancer patients: A large-sample study.

OBJECTIVE: Beginning in 2007, all newly diagnosed cancer patients at the Koo Foundation Sun Yat-Sen Cancer Center (KF-SYSCC) were screened for psychosocial distress. Our social workers, as part of the psychosocial care team (PCT), have engaged in proactive outreach with patients identified as distressed. The goal of the present study was to assess the prevalence of psychosocial distress and the extent of contact between the PCT and distressed patients. METHOD: Newly diagnosed patients who were treated at KF-SYSCC between 2007 and 2010 for cancer were eligible if there were at least 100 patients with the same type of cancer. Before treatment began, they were screened with the Pain Scale and the Distress Thermometer (DT) and had the option to specify a desire for help. The rates of distress were analyzed by cancer type and by probable related factors. Information regarding contact with the PCT was retrieved from computerized databases. RESULTS: Overall, some 5,335 cancer patients representing 12 major cancer types were included in our study. Of these, 1,771 (33.20%) were significantly distressed. By multivariate logistic regression, younger age, female gender, higher pain score, and disease stage, but not cancer type, were found to be associated with higher rates of distress. Among these distressed patients, 628 (36%) had some contact with the PCT. SIGNIFICANCE OF RESULTS: This Taiwanese study with a large sample size revealed a prevalence rate of psychosocial distress similar to rates found in Western countries. Contact with the PCT was established in only 36% of significantly distressed patients, despite a proactive outreach program. It is very important to have screening results made available in a timely fashion to the psycho-oncology team so that appropriate care can be offered promptly.

Pleural fluid osteopontin, vascular endothelial growth factor, and urokinase-type plasminogen activator levels as predictors of pleurodesis outcome and prognosticators in patients with malignant pleural effusion: a prospective cohort study.

BACKGROUND: Rapidly growing cancer cells secrete growth-promoting polypeptides and have increased proteolytic activity, contributing to tumor progression and metastasis. Their presentation in malignant pleural effusion (MPE) and their predictive value for the outcome of pleurodesis and survival were studied. METHODS: Between February 2011 and March 2012, MPE samples were prospectively collected from 61 patients. Twenty-five patients with non-malignant pleural effusion in the same period were included as controls. Pleural fluid osteopontin (OPN), vascular endothelial growth factor (VEGF), and urokinase-type plasminogen activator (uPA) concentrations were measured. RESULTS: Patients with MPE had higher pleural fluid OPN, VEGF, and uPA concentrations than those with non-malignant pleural effusion, but only differences in VEGF were statistically significant (p = 0.045). Patients with distant metastases had significantly elevated pleural fluid VEGF concentrations than those without (p = 0.004). Pleural fluid OPN, VEGF, and uPA concentrations were positively correlated in most patients. However, there was no significant difference in pleural fluid OPN, VEGF, and uPA concentrations between patients with successful pleurodesis and those without. There was also no significant difference in cancer-specific survival between sub-groups with higher and lower pleural fluid OPN, VEGF, or uPA concentrations. Patients with successful pleurodesis had significantly longer cancer-specific survival than those without (p = 0.015). CONCLUSIONS: Pleural fluid OPN, VEGF, and uPA concentrations are elevated in MPE but are not satisfactory predictors of pleurodesis outcome or survival. Patients with higher pleural fluid VEGF concentration have higher risk of distant metastasis. Evaluating the benefits of therapy targeting the VEGF pathway in these patients warrants further studies.

Comparison of 19-gauge eXcelon and WANG MW-319 transbronchial aspiration needles.

Conventional transbronchial needle aspiration (TBNA) using 19-gauge needles can obtain larger histological specimens for hilar-mediastinal diagnosis. A new 19-gauge eXcelon needle was introduced in Taiwan in July 2012. We prospectively enrolled patients with hilar-mediastinal lesions and pathology results of suspected benign origin or lymphoproliferative processes, to perform TBNA using a 19-gauge eXcelon needle, between July 2012 and December 2012. The results were compared with historical control of TBNA using a WANG MW-319 needle between January 2011 and June 2012. The procedure was performed by the same pulmonologist, and rapid on-site cytologic evaluation was used. The 19-gauge eXcelon needle was used in nine patients with 15 lymph nodes aspirated, with a mean diameter of 23.3 ± 10.7 mm. The mean number of needle passes was 2.7 ± 1.4, with a diagnostic accuracy of 77.8%. The MW-319 needle was used in 12 patients with 18 lymph nodes aspirated, with a mean diameter of 21.3 ± 5.7 mm. The mean number of needle passes was 2.2 ± 0.4, with a diagnostic accuracy of 75.0%. Neither technical nor major clinical complications were noted in either group. We concluded that the 19-gauge eXcelon needle was as safe and effective as the MW-319 needle. A more adequate specimen could be obtained and fewer needle passes were required with the MW-319 needle, although the difference did not reach significance.

Safety of interventional bronchoscopy through complication review at a cancer center.

BACKGROUND AND AIMS: There have been rapid advances in the area of interventional bronchoscopy over the past 15 years, but associated complications have been rarely discussed. A longitudinal evaluation of the same operator's performance at a cancer center is reported. METHODS: A detailed record review of diagnostic and therapeutic bronchoscopy between January 1997 and March 2013 was conducted. RESULTS: Among the 1358 diagnostic bronchoscopies, there were nine major complications requiring premature termination and three pneumothoraces found during follow-up (0.88%). An escalation in the level of care was required for four patients with massive bleeding, asthma attack, sedation intoxication and myocardial ischemia, respectively. Six cases occurred after brushing (0.71%), and five cases before any sampling procedure was conducted. The complication rate was highest for peripheral lesions (1.03%). Among the 109 therapeutic bronchoscopies, no major patient-specific complication occurred except for excessive granulation tissue formation following metallic stenting in one patient with benign tracheal stenosis. CONCLUSION: The complication rate with regard to bronchoscopy is comparable with historical controls according to the related literature, and their occurrence appears to be sporadic, not relevant to patient characteristics and mostly related to the bronchoscopy itself rather than the introduction of new techniques. Bronchoscopy remains safe along with technical innovations. However, risk recognition and effective prevention is essential.

Second primary lung cancers among breast cancer patients treated with anti-estrogens have a longer cancer-specific survival.

BACKGROUND/AIM: Estrogen is thought to play an important role in lung cancer carcinogenesis and progression. The incidence and survival of second primary lung cancer among breast cancer patients with and without anti-estrogen therapy were evaluated. PATIENTS AND METHODS: All women diagnosed with breast cancer and treated at the Sun Yat-Sen Cancer Center between January 2000 and December 2009 were included and followed-up for occurrence and/or death from lung cancer until December 2011. RESULTS: Twenty-six women developed second primary lung cancer among 6,361 breast cancer patients. All but one were adenocarcinoma and none had a smoking habit. Seventeen (65.4%) patients had previously received anti-estrogen treatment. The relative risk of developing second primary lung cancer among those who have received anti-estrogens for breast cancer and those who have not was 1.01 (95% confidence interval (CI)=0.45~2.28; p=0.970). Second primary lung cancer patients who have received anti-estrogens had a longer cancer-specific survival (p=0.007). The multivariate Cox proportional hazards analysis showed that anti-estrogen therapy remained an independent prognostic factor with a hazard ratio of 0.11 (95% CI=0.01~0.97, p=0.002) for second primary lung cancer patients. CONCLUSION: The results of this study further support the fact that estrogen adversely affects the prognosis of patients with lung cancer. However, the role of estrogen in lung cancer carcinogenesis remains to be determined.

Estrogen adversely affects the prognosis of patients with lung adenocarcinoma.

Estrogen has been postulated to contribute to the development and progression of lung cancer. We examined the epidemiologic evidence, explored the characteristics of estrogen receptors (ER) in lung adenocarcinoma, and investigated the effect of estrogen on lung cancer cell migration, including the signaling pathway involved. For epidemiologic evidence, a total of 1434 consecutive non-small cell lung cancer patients who underwent standardized staging and homogenous treatment were prospectively enrolled from January 2002 to December 2008, and followed until December 2012. The possible prognostic factors to be analyzed included stage, age, gender, menopausal status, smoking history and histology. For laboratory study, lung cancer cell lines A549 and PE089 and malignant pleural effusions from the patients with lung adenocarcinoma were used. We found that the premenopausal patients had more advanced disease and a shorter survival among the never-smoking female patients with lung adenocarcinoma. ERß was the predominant ER in the lung cancer cell lines. We proposed a different pathway that estrogen upregulated the expression of osteopontin and then promoted cell migration through αvß3 integrin binding and activated MEK-ERK signaling pathway, which is a common downstream pathway with epidermal growth factor receptor (EGFR) activation. An additive effect of ER antagonists and EGFR antagonists on the inhibition of cell migration was also noted. Our results suggest that estrogen adversely affects the prognosis of patients with lung adenocarcinoma. Osteopontin contributed to the cross-talk between ER and EGFR signaling pathways. Estrogen, with its receptor, has the potential to be a prognosticator and a therapeutic target in lung cancer.

Health services utilisation in breast cancer survivors in Taiwan.

Surveillance guidelines for breast cancer survivors recommend regular history and physical and mammography, and against routine imaging for detecting distant metastasis. Stage 0, I, II breast cancer cases treated at a major cancer center were identified from the Taiwan Cancer Registry. We used multivariable negative binomial and logistic regression analyses on institutional claims data to examine factors contributing to utilisation patterns of surveillance visits and tests in disease-free survivors. The mean number of surveillance visits during months 13 to 60 after cancer treatment initiation was 18.5 (SD 8.2) among the 2,090 breast cancer survivors followed for at least five years. After adjusting for patient and disease factors, the number of visits was the highest among patients mainly followed by medical oncologists compared to surgeons and radiation oncologists. Patient cohorts treated in more recent years had lower number of visits associated with care coordination effort, the adjusted mean being 19.2 visits for the 2002 cohort, and 16.3 visits for the 2008 cohort (p < 0.0001). Although imaging tests were highly utilised, there was a significant decrease in tumor marker testing from the 2002 to the 2008 treatment cohort (adjusted rate 99.4% to 35.1% respectively, p < 0.0001) in association with an institutional guideline change.

Multimodality treatment and long-term follow-up of the primary pulmonary lymphoepithelioma-like carcinoma.

INTRODUCTION: Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a very rare subtype of non-small-cell lung cancer. Most cases are reported in Southeast Asia and are associated with Epstein-Barr virus infections. Because of its rare incidence, the optimal treatment and the results of long-term follow-up are not well understood. This study is an attempt to discover the multimodality treatment results of the primary pulmonary LELC. METHODS: This retrospective study enrolled 21 patients with primary pulmonary LELC treated at 2 hospitals with a multimodality approach, including surgery, chemotherapy, radiotherapy, and targeted therapy. RESULTS: The median follow-up time is 5.9 years and the median survival is 6.4 years. The median overall survival for patients with stage III and with stage IV disease is 3.4 years. In early-stage primary pulmonary LELC, surgery and adjuvant chemotherapy provided good treatment outcome. Advanced primary pulmonary LELC is relatively more chemosensitive and radiosensitive. CONCLUSION: Patients with primary pulmonary LELC showed better prognosis than those with other types of non-small-cell lung cancer and achieved longer survival under multimodality treatment. This disease character is similar to that of nasopharyngeal carcinoma. Accurate pathologic diagnosis is recommended before the treatment. For advanced diseases, platinum-based doublet chemotherapy can be considered the first-line treatment. Radiation dose should consider tumor location, and 5000 to 7000 cGy is frequently applied for pulmonary LELC.

The HADS and the DT for screening psychosocial distress of cancer patients in Taiwan.

PURPOSE: This study assesses the sensitivity and specificity of Mandarin versions of two psychosocial screening tools for adjustment, anxiety and depressive disorders: the Hospital Anxiety and Depression Scale (HADS), and the Distress Thermometer (DT). METHODS: The two scales were used to screen 103 consecutive cancer patients seen for psychiatric evaluation at KF-SYSCC between May and November 2004 prior to their psychiatric interviews. Each scale was tested against clinical psychiatric diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition for their sensitivity and specificity. RESULTS: For the Mandarin version of the DT, receiver operating characteristic (ROC) analyses identified a DT score of 4 as the optimal cut-off, with sensitivity and specificity of 98 and 73%, respectively. For the Mandarin version of the HADS, ROC identified a score of 9 and 8 as the optimal cutoffs for the respective anxiety and depression subscales (HADS-a and HADS-d), with sensitivities and specificities of 84 and 73, 72 and 86%, respectively. For the full scale of the HADS (HADS-t), 15 was identified as the optimal cutoff, which yielded sensitivity and specificity of 84 and 68%, respectively. Using the frequency table, the concordance rate of the two scales was found to be 72-80% based on the above optimal cut-offs. CONCLUSION: The Mandarin versions of the HADS and the DT are efficacious for screening anxiety and depression for our population. Compared with the HADS-t, the DT appears to have not only higher sensitivity, but also higher specificity.

Sex-associated differences in non-small cell lung cancer in the new era: is gender an independent prognostic factor?

BACKGROUND: Women with non-small cell lung cancer (NSCLC) appear to have better survival. This study aimed to evaluate sex differences in NSCLC in recent years. The true effect of gender on the overall survival was analyzed taking other prognostic factors into account. METHODS: A cohort of consecutive NSCLC patients was prospectively enrolled from January 2002 to December 2005, and followed-up until December 2006. They were clinically and pathologically staged and underwent homogenous treatment algorithms. Demographics, histology, and disease stage between sexes were compared. The clinical prognostic factors to be analyzed in addition to gender included stage, age, smoking history and histology. The overall survival of females and males within relevant subgroups defined by smoking history and histology was also compared. RESULTS: Of the 738 patients, 695 were analyzed with a definite stage (94.2%; 315 females and 380 males), which was similar in both sexes. Females were younger (median age: 59.5 years vs. 65.0 years; P<0.001) and more likely to have adenocarcinoma (81% vs. 60.5%; P<0.001). Patients with earlier stage, younger patients, never-smokers and females had better overall survival in univariate analyses and no significant survival difference was noted between adenocarcinoma and squamous cell carcinoma. Multivariate analyses demonstrated age, smoking history and gender to have a hazard ratio 1.46 (95% confidence interval, CI 1.21-1.76; P<0.001), 1.27 (95% CI 0.97-1.65; P=0.082), and 1.18 (95% CI 0.90-1.55; P=0.226), respectively. Subgroup analyses revealed the survival of never-smoker males with adenocarcinoma was similar to that of females. CONCLUSIONS: There are sex-related differences in the clinico-pathologic characteristics and survival of NSCLC patients. The survival advantages of females could be attributed to the younger age and lower smoking prevalence. Never-smokers with adenocarcinoma should be given special attention regardless of sex as they imply better survival with different treatment outcomes.

Computed tomography characteristics of primary pulmonary lymphoepithelioma-like carcinoma.

Primary pulmonary lymphoepithelioma-like carcinoma is a very rare subtype of lung cancer. This report documents the CT features of 16 Chinese patients diagnosed with primary pulmonary lymphoepithelioma-like carcinoma from January 1999 to December 2005. A pre-treatment CT was used to assess the tumour site, size, borders, pleural and vascular involvement, and the presence of lymph node involvement. The majority of the patients were female non-smokers with centrally located tumours. Lymph node involvement and bronchial and vascular encasement were frequent. In an Epstein-Barr virus endemic area, primary pulmonary lymphoepithelioma-like carcinoma is an important differential diagnosis to consider.

Clinicopathologic analysis of acute myeloid leukemia in a single institution: biphenotypic acute myeloid leukemia may not be an aggressive subtype.

BACKGROUND: Most acute leukemias are classified as lymphoid or myeloid lineages by standard microscopic morphology, cytochemistry and a panel of immunologic markers. The World Health Organization classification of acute leukemia incorporates morphologic, cytogenetic, immunologic and clinical features to define the entities that are biologically homogeneous and that have clinical relevance. The purpose of this study was to determine the clinicopathologic characteristics of acute myeloid leukemia (AML) in Taiwan. METHODS: Archival tissues from 70AML patients during the period of 1995 to 2003 were retrieved. Histologic subtype was classified, defined by World Health Organization classification. Clinical data, including age, gender, treatment and outcome, were scrutinized. RESULTS: There were 37 males and 33 females. The median age at onset of disease was 49 years (range, 2-78 years), which was younger in biphenotypic AML (23.5 years) and older in multilineage dysplasia-related AML (61 years). There were 9 cases (13%) with recurrent cytogenetic abnormality, 7 (10%) multilineage dysplasia-related, 7 (10%) therapy-related, 39 (56%) not other categorized and 8 (11%) of ambiguous lineage. The 2- and 5-year overall survival rates of AML were 26.5% and 20.6%, respectively. Histologic subtype was a significant parameter to determine survival (p < 0.05). The median survivals of therapyrelated, multilineage dysplasia-related and biphenotypic AML were 2 months, 9 months and 30.5 months, respectively. CONCLUSION: This was a clinicopathologic study of AML in Taiwan. Histologic subtype plays a significant prognostic role. Multilineage dysplasia- and therapy-related AML have worse prognosis. Biphenotypic AML may not be an aggressive subtype.

Clinicopathological analysis of 598 malignant lymphomas in Taiwan: seven-year experience in a single institution.

The clinicopathological characteristics of malignant lymphomas vary according to geography. The purpose of this study is to determine the distribution and clinicopathological characteristics of malignant lymphomas in Taiwan. Archival tissue from 598 malignant lymphomas during the period of 1995-2002 was retrieved. They were reclassified according to the World Health Organization classification system. Clinical data, including age, gender, clinical staging, and follow-up, were scrutinized. There were 330 males and 268 females. The median age at onset of disease was 56 years for B-cell lymphoma (BCL), 50 years for T/NK-cell lymphoma (TCL), and 26 years for Hodgkin's lymphoma (HL). BCL accounted for 80.6%, TCL for 12.4%, and HL for 7%. The major subtypes of non-HL were diffuse large B-cell lymphoma, follicular lymphoma, plasma cell myeloma, marginal zone lymphoma of mucosa-associated lymphoid tissue type, mantle cell lymphoma, unspecified peripheral TCL, and nasal type T/NK-cell lymphoma. Nodular sclerosing subtype was the most common in HL. The frequencies of TCL and HL were relatively low. For histological subtype, enteropathy-type TCL and primary bone marrow HL had higher frequency and poorer prognosis. The 5-year overall survival of BCL, TCL, and HL was 58.9, 34.7, and 83.5%, respectively. To the best of our knowledge, this is the largest series study of malignant lymphoma in Taiwan. Immunophenotype, histological subtype, and clinical stage play significant roles in prognosis (P < 0.05).

Prevertebral muscle involvement in nasopharyngeal carcinoma.

PURPOSE: The purpose of this study is to evaluate the prevalence and prognostic significance of prevertebral muscle involvement in patients with nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS: Between July 1990 and December 2001, 521 newly diagnosed patients with NPC treated at Koo Foundation Sun Yat-Sen Cancer Center (KF-SYSCC) were examined with magnetic resonance imaging (MRI) for evidence of prevertebral muscle involvement before treatment. Patients were staged according to the 1997 American Joint Committee on Cancer staging classification of NPC based on the physical exams and MRI findings. All patients received radiotherapy with or without chemotherapy. The association between clinical prevertebral muscle involvement and posttreatment outcomes (overall survival, locoregional recurrence, and distant metastasis) were evaluated using Cox regression model to adjust for other prognostic factors. RESULTS: Of 521 patients treated at KF-SYSCC, 181 (35%) patients were found to have prevertebral muscle involvement, one-third in those with Stage II/III tumors and two-thirds in those with Stage IV tumor. In multivariate analysis accounting for all previously known prognostic factors, prevertebral muscle invasion was associated with an increased risk for any recurrence (adjusted relative risk, 2.01; p<0.001), locoregional recurrence (adjusted relative risk, 2.69; p<0.001), and distant metastasis (adjusted relative risk, 2.25; p<0.001), and with a borderline significant increased risk for overall survival (adjusted relative risk, 1.44; p=0.10). CONCLUSIONS: Prevertebral muscle involvement is an independent prognostic factor for NPC recurrence.

Intrapleural urokinase for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients.

BACKGROUND: Pleural fluid loculations or trapped lungs frequently render patients with symptomatic malignant pleural effusions (MPEs) unsuitable for pleurodesis. Thoracoscopic surgery or thoracotomy with decortication is generally not feasible for patients with a poor performance status. MPEs have augmented procoagulant and depressed fibrinolytic activity that contributes to fibrin deposition within the pleural space. The authors conducted an observational prospective cohort study to investigate the use of intrapleural urokinase (IPUK) for such patients and made a comparison with a historical control group. METHODS: Between March of 2000 and August of 2005, 48 consecutive patients with symptomatic MPEs with an average Karnofsky performance scale score of 46.7% were recruited. Dyspnea persisted with the presence of substantial residual loculated MPEs in 36 patients and trapped lungs in 12 patients, when the effectiveness of 8-French intrapleural catheter drainage had decreased despite regular saline flushes. Urokinase was instilled daily through the catheter at a dose of 100,000 IU diluted in 100 ml of normal saline for 3 days. Additional IPUK instillation was required upon partial improvement. The records and chest radiographs of another 52 patients with symptomatic MPEs had met these eligibility criteria between January of 1995 and February of 2000 and received saline flushes only were also reviewed. RESULTS: Immediate lung reexpansion and resolution of dyspnea was achieved in 29 of the 48 patients who underwent IPUK therapy (60.4%). The mean dose of urokinase instillations per patient was 360,000 IU. There were no major complications. A significant association of earlier intervention with the success of IPUK therapy was noted. Responders also had a significantly increased drainage within the 24 hours after the first dose of IPUK. Minocycline pleurodesis was subsequently performed for the 29 IPUK responders. Eighteen patients were followed up until death, with a median survival of 6.5 months. The other remained alive at the time of analysis with a median follow-up of 5 months. Two patients had an immediate failure of pleurodesis at 1 month. Three relapses occurred at 3, 4, and 7 months from pleurodesis, respectively. Twenty-three patients (79.3%) had lifelong pleural symphysis, including 21 having loculated MPEs and two having trapped lungs, respectively. Compared with the historical control group, the IPUK study group had significantly greater improvement on chest radiography and a shorter duration of pleural drainage. CONCLUSION: These results suggest that IPUK is a safe and useful nonsurgical adjunct therapy for loculated MPEs or trapped lungs in medically inoperable cancer patients.

Clinicopathological analysis of malignant lymphoma in Taiwan, defined according to the World Health Organization classification.

We report the distribution and clinicopathological characteristics of malignant lymphomas in Taiwan, defined according to the WHO classification. Data including age and gender of the patients, clinical staging and disease courses were collected for 598 cases of malignant lymphomas. The results showed that the epidemiological characteristics of malignant lymphomas in Taiwan are similar to those in other Asian countries except for a lower incidence rate of T/NK cell lymphoma.

Prognostic significance of parapharyngeal space venous plexus and marrow involvement: potential landmarks of dissemination for stage I-III nasopharyngeal carcinoma.

PURPOSE: To determine whether the parapharyngeal space venous plexus and marrow of the skull base bones are anatomic landmarks of the potential routes for the spread of disease for Stage I-III (American Joint Commission on Cancer 1997 staging system) nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS: A total of 364 patients with NPC were enrolled in this study. The selection criteria were Stage I-III disease and primary radiotherapy at our hospital between 1990 and 2001. All patients had undergone MRI to evaluate the head-and-neck tumors. Patients who had undergone inadequate radiotherapy at a dose of <60 Gy and/or preradiotherapy chemotherapy before the imaging evaluation were excluded from the study. RESULTS: Of the 364 patients treated between 1990 and 2001, 163 (44.8%) had low-risk Stage I-III NPC (without parapharyngeal space extension or T3 disease). The 5-year distant metastasis-free survival rate, with and without adjuvant chemotherapy, was 97% and 96%, respectively. The remaining 201 patients had Stage II-III with parapharyngeal space extension or T3 disease. Their 5-year recurrence-free survival rate, with and without adjuvant chemotherapy, was 76.8% and 53.2% (p = 0.01), respectively. CONCLUSION: Our findings suggest that the risk of distant metastasis in Stage I-III NPC patients without parapharyngeal space extension or T3 disease is extremely low. Invasion into the parapharyngeal space venous plexus and marrow of the skull base bones is associated with distant metastasis, and involvement of these anatomic sites is considered a potential route for hematogenous disease spread in patients with Stage I-III NPC.