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Background: The prognosis for children with recurrent/refractory sarcomas is poor. We determined the overall response rate (ORR) and overall survival (OS) of children with recurrent/refractory sarcomas who were given ifosfamide, carboplatin, and etoposide (ICE) in three Children's Cancer Group (CCG) phase I/II trials., Procedure: Children with recurrent/refractory sarcoma were treated with ifosfamide (1,800 mg/m2/day on day 0-4), carboplatin (400 mg/m2/day on day 0-1), etoposide (100 mg/m2/day on day 0-4) and either rhG-CSF (10 microg/kg/day vs. 5 microg/kg/day, CCG-0894, 71 patients), PIXY321 (500-1,000 microg/m2/day, CCG-0924, 14 patients), or rhG-CSF (5 microg/kg/day) and IL-6 (2.5-5 microg/kg/day, CCG-0931, 12 patients)., Results: Ninety-seven patients were evaluable for tumor response, 56 male and 41 female, median age 14.1 years (range 2.8-22.5 years). Tumor types were osteosarcoma (OTS) (n = 34), rhabdomyosarcoma (n = 27), Ewing sarcoma (EWS) (n = 21), soft tissue sarcoma-not otherwise specified (n = 5), undifferentiated sarcoma (n = 6), fibrosarcoma (n = 2), peripheral primitive neuroectodermal tumor (n = 1), and extraosseous Ewing (n = 1). The ORR was 51% (27% complete response [CR]). OS at 1 and 2 years was 49% and 28%, respectively. Patients with CR or partial response (PR) had significantly increased 1- and 2-year OS, 71% and 41%, respectively, (P < 0.001). Rhabdomyosarcoma patients with embryonal histology had significant improvement in 1- and 2-year OS: 82% and 46%, respectively, compared with other histologies, (P < 0.005)., Conclusions: The ORR to ICE reinduction chemotherapy in children with recurrent/refractory sarcoma was 51%. OS of 1 and 2 years appeared significantly improved in patients who had CR or PR following ICE reinduction therapy or who had rhabdomyosarcoma with embryonal histology.

Objective: To explore whether the recombinant protein (Human papillomavirus (HPV) type16 E7 peptide(38-61) linked with an immunoglobulin G fragment) will generate protective immunity in mouse model., Methods: In our study, we combined the HPV16 E7 peptide(38-61) with a murine IgG heavy chain constant region to construct a chimeric protein compound, which was highly expressed as inclusion bodies in a bacterial expression system with Escherichia coli. The purified chimeric protein was injected into C57BL/6 mice and the efficiency of the chimeric vaccine candidate was evaluated by antibody response assay, T cell proliferation assay, CTL assay, tumor challenge assay and therapeutic experiment., Results: The chimeric vaccine candidate was able to induce anti-HPV antibodies as well as to elicit HPV16 E7-specific CTLs and T cell proliferation in a pre-clinical mouse model. It was also able to effectively protect mice against the challenge of HPV16-positive tumor cells, and to eradicate HPV16-expressing tumors in mice., Conclusions: The chimeric protein vaccine can induce E7-specific immune responses and protect mice against challenge of HPV16-positive tumor, even eradicate developed tumor. The results indicated a possibility to use the chimeric protein vaccine to protect human against HPV infection.

Human papillomavirus Type 16 (HPV16) infections can cause neoplasia, which is thought to be closely associated with the development of cervical cancers. In the study, we attempted to construct a DNA plasmid encoding a HPV16 capsid protein (L1) and a HPV16 oncoprotein (E7), which was capable of preventing HPV16 infection and eliminating HPV16-infected cells. A plasmid, L1E7hpSCA1, encoding the L1 and E7 genes with the codon usage optimized for mammalian cell expression, was constructed. Mutations were introduced into the E7 gene sequence for reducing its oncogenicity. C57BL/6 mice were intramuscularly immunized at tibialis anterior (TA) muscles with the newly constructed L1E7hpSCA1 plasmid. The immune responses induced by the L1E7hpSCA1 plasmid (with codon optimization) and a control L1E7pSCA1 plasmid (without codon optimization) were compared. It is shown that the L1E7hpSCA1 was able to induce much stronger immune responses than the L1E7pSCA1. Sera obtained from immunized animals were found to contain anti-HPV16 antibodies as detected by ELISA and hemagglutination inhibition (HAI) assays. Cytotoxicity and interferon-gamma assays showed that spleenocytes from immunized animals were able to recognize and lyze E7 expressing tumor TC-1 cells. Moreover, the growth of E7 expressing tumor mass was inhibited in vaccinated mice. In vivo tumor protection test indicated that tumor formation was prevented in the experimental animals (67%) after vaccination with L1E7hpSCA1, while for the control group injected with L1E7pSCA1 only and the animal group injected with pSCA1 only, tumor formation was observed in all experimental animals. Our results suggest that the L1E7h gene (with codon optimization) is more effective against HPV16 than the L1E7 gene (without codon optimization). The L1E7hpSCA1 plasmid was able to provide protection against E7 expressing tumor, and it might have the potential to be a vaccine candidate for HPV prevention.

Aim: To assess the efficacy of using ultrasonography (USG) in monitoring the progress of exit site infection (ESI) in patients undergoing continuous ambulatory peritoneal dialysis (CAPD)., Methods: Twenty-two cases of newly diagnosed ESI and 20 cases with normal exit sites as controls were assessed by using USG. The exit sites were reassessed by using USG after finishing a course of antibiotic therapy, and the sonographic findings were correlated with the clinical outcome., Results: Out of the 22 cases of ESI, 21 cases had definite sonolucent zones around the external cuffs, while one case had normal sonographic findings. Of the 20 control cases of normal exit sites, 16 had normal sonographic findings, and four had sonolucent zones around the external cuffs. Exit site infections correlated with positive sonographic findings as compared to normal exits (P <0.0001). The 21 cases of ultrasonic-positive ESI were re-examined after antibiotic therapy, and 10 of these had a post-treatment sonolucent rim around the distal cuff < or =1 mm thick, while 11 cases were persistently > mm thick. The former group was shown to have a more favourable outcome (P=0.013). And despite variable USG findings, all eight patients with Pseudomonas aeruginosa-related ESI had an unfavourable clinical outcome., Conclusion: Ultrasonography of the exit sites in CAPD patients is a useful adjunctive tool in the management of ESI. A sonolucent zone around the external cuff >1 mm thick following a course of antibiotic treatment and the involvement of the proximal cuff are associated with poor clinical outcome. In ESI caused by Pseudomonas aeruginosa, the clinical outcome was uniformly poor irrespective of the sonographic findings.

We report results of unrelated cord blood transplants (UCBT) in 29 pediatric recipients in one center and the risk factors associated with survival. Median age: 9 years (0.5-20); diagnosis: ALL (9), AML (4), CML (1), HD (3), HLH (1), NHL (3), NBL (2); B-thal (1), FA (1), FEL (1), Krabbe (1), WAS (1), SAA (1); median follow-up: 11 months; conditioning: total body irradiation (TBI)-ablative (14), chemotherapy-ablative (6) and reduced intensity chemotherapy (9); GVHD prophylaxis: MMF/FK506 (18), cyclosporin A (CsA)+steroids+/-MMF (7) or CsA+methotrexate (MTX) (4); median total nucleated cells (TNC): 3.8 x 10(7)/kg (1.1-11); median CD34+: 2.3 x 10(5)/kg (0.2-9.9); and HLA match: 2 (6/6), 5 (5/6), 22 (4/6). Neutrophil engraftment by cumulative incidence curves 63% (median 28 (95% confidence interval (CI) 18-32)). Probability of >/=grade II acute graft-versus-host disease (aGVHD) by day +60 27%, >/=grade III aGVHD 20% and chronic graft-versus-host disease 3%. Estimated 1-year overall survival (OS) 46% (95% CI 30-71) and standard risk 60% (95% CI 29-100%). Variables associated with improved survival by multivariate analysis include non-TBI-ablative conditioning (P=0.024), CD34+/kg (P=0.038) and gender (P=0.048). These results suggest that CD34/kg cell dose and non-TBI-ablative conditioning may be important variables influencing OS following UCBT in pediatric recipients. Given the small number of patients, these results should be viewed cautiously.

Tacrolimus (FK506)/mycophenolate mofetil (MMF) has been demonstrated to be an effective salvage therapy for steroid-resistant chronic graft-versus-host disease (GVHD), but its effectiveness as prophylaxis for acute GVHD (aGVHD) is unknown. We investigated the safety and efficacy of FK506/MMF in preventing aGVHD and sparing the use of methotrexate and methylprednisolone in childhood and adolescent allogeneic stem cell transplant (AlloSCT) recipients. Thirty-four childhood and adolescent patients (median age, 7 years; range, 0.5-21 years; 24 males and 10 females) undergoing 37 AlloSCTs for malignant (n = 22) and nonmalignant (n = 12) disorders received FK506 (0.03 mg/kg/d by continuous intravenous infusion) and MMF (15 mg/kg per dose orally or intravenously twice daily). Stem cell sources included 22 umbilical cord blood donors (21 unrelated and 1 related), 6 related bone marrow donors, and 9 related peripheral blood donors. Malignant diagnoses included 7 acute lymphoblastic leukemias, 3 acute myeloid leukemias, 1 acute promyelocytic leukemia, 2 non-Hodgkin lymphomas, 4 Hodgkin diseases, 3 chronic myeloid leukemias, and 2 neuroblastomas; nonmalignant diagnoses included 2 beta-thalassemias, 1 sickle cell disease, 4 aplastic anemias, 1 Wiskott-Aldrich syndrome, 1 Hurler syndrome, 2 hemophagocytic lymphohistiocytoses, and 1 myelodysplastic syndrome. The probability of developing grade > or =II aGVHD was 45.4% +/- 9.7% (7 related bone marrow/related peripheral blood; 5 umbilical cord blood), and for chronic GVHD it was 38.1% +/- 19.7%. FK506/MMF was well tolerated. Three patients had grade III to IV neurotoxicity (disorientation and leukoencephalopathy); 4 patients developed grade III to IV nephrotoxicity (all received concomitant nephrotoxins). Patients who achieved target mycophenolic acid levels (1.0-3.5 microg/mL) before day +30 had a significantly reduced incidence of developing grade >/=II aGVHD (16.7% +/- 15.2% versus 100%; P <.02). These results suggest that FK506/MMF is well tolerated and may be a safe and effective methotrexate- and methylprednisolone-sparing alternative GVHD prophylaxis regimen after AlloSCT. Further pharmacokinetic and pharmacodynamic studies are ongoing in pediatric and adolescent AlloSCT recipients to define optimal MMF dosing.

Reduced intensity (RI) allogeneic stem cell transplantation (AlloSCT) was initially demonstrated in adults following HLA-matched family and unrelated adult donor AlloSCT. There is little information about RI AlloSCT in children. We report results of a pilot study of RI AlloSCT in 21 recipients (< or =21 years). Age: median 13 (0.5-21) years, 8F:13M, 14 unrelated cord blood units (UCB) (10 4/6, 4 5/6), two related BM (6/6, 5/6), four related PBSC (2 6/6, 2 5/6), and one related BM+PBSC (6/6). RI: fludarabine, busulfan (n=14); fludarabine, cyclophosphamide (n=4); fludarabine, melphalan (n=1); total body irradiation, fludarabine, cyclophosphamide (n=1); or fludarabine, cyclophosphamide, and etoposide (n=1). Graft-versus-host disease prophylaxis: FK506 0.03 mg/kg/day and mycophenolate mofetil 15 mg/kg/q 12 h. UCB median nuc/kg and CD34/kg was 4.3 x 10(7)/kg (0.9-10.8) and 1.9 x 10(5)/kg (0.3-6.9), and related BM/PBSC median nuc/kg and CD34/kg was 8.3 x 10(8) (4.7-18.9) and 5.0 x 10(6)/kg (4.6-6.4). Maximal chimerism following unrelated cord blood transplantation, 100% x 7, 98% x 1, 95% x 2, 55% x 1, and 0% x 3; related PBSC/BM, 100% x 5, 65% x 1, and 55% x 1. Graft failure occurred in 5/21 (24%). In summary, RI AlloSCT in children is feasible and tolerable (< or =25% GF) and results in > or =85% of recipients initially achieving > or =50% donor chimerism.

Purpose: We have previously demonstrated a >80% complete response (CR) rate with cyclophosphamide/prednisone (Cy/Pred) chemotherapy alone in patients with post-transplant lymphoproliferative disease (PTLD) after solid organ transplantation (SOT), but only a 58% 2-year event-free survival. The response rate to immunotherapy (rituximab) is only about 46% with a 54% relapse/progression rate. In this study, we investigated the use of a combination of Cy/Pred with rituximab as treatment for this disease., Experimental Design: Patients received two to six courses of cyclophosphamide (600 mg/m(2), on day 1 of each course) and prednisone (1 mg/kg, every 12 h x 10 doses), given every 3 weeks. The first two courses were given in combination with 4-6 weekly doses of rituximab (375 mg/m(2), i.v.). Imaging studies were done every 2 months to document response., Results: There were six PTLD patients (two fulminant); age, 4-23 year; sex, male:female (3:3); status post SOT (two cardiac, two liver, two renal); median onset, 39 months (10-144 months). Fifty percent were polyclonal, 100% were CD20+, and 83% were EBV+. The overall response rate was 100% (five CRs and one PR). All five CRs showed no evidence of disease, and one PR eventually progressed and died of fulminant disease. All allografts in surviving patients were functional. There was no grade III/IV toxicity and/or no infectious complications related to the combination of Cy/Pred with rituximab. Median follow-up was 12.5 months (range, 4-29 months)., Conclusions: These preliminary results suggest that the combination of Cy/Pred and targeted immunotherapy (rituximab) is well tolerated and may be more efficacious in patients with PTLD after SOT. Future prospective larger trials with longer follow-up investigating this combination will be required to confirm these preliminary results.

Purpose: The Hispanic-American population is the fastest growing in the United States. Although many studies have looked at the performance of prostate specific antigen (PSA) in the detection of prostate cancer in white and black men, few have looked at it in relation to Hispanic men. The objective of this study was to compare the performance of PSA and PSA density (PSAD) in the detection of prostate cancer in Hispanic and white men., Materials and Methods: A total of 404 consecutive Hispanic and 341 consecutive white men with elevated serum PSA and/or abnormal digital rectal examination underwent transrectal ultrasound with lesion directed and systematic peripheral zone biopsies from 1996 to 2001 at a single institution by 2 investigators (ETG, MCB). Before biopsy all patients underwent volume measurements of the entire prostate. Of these patients 242 Hispanic and 255 white men had a total PSA between 2.5 and 10 ng/ml. Serum PSA and calculated PSAD were compared between the positive and negative biopsy groups, and between Hispanic and white men., Results: Of the 242 Hispanic and 255 white men 85 (35.1%) and 63 (24.7%) had cancer, respectively (p = 0.0147). There was no significant difference in age among the groups. There was no significant difference in median PSA between Hispanic and white men, or white men with malignant versus benign disease. There was a significant difference in median PSA in Hispanic men with malignant versus benign disease (6.3 vs 5.2 ng/ml, p = 0.0072). For PSAD there was a significant difference between Hispanic men with malignant versus benign disease (0.17 vs 0.12, p <0.0001) and white men with malignant versus benign disease (0.13 vs 0.11, p = 0.0019). Overall there was a difference in PSAD between positive and negative biopsy groups, and there was a significant difference in PSAD between Hispanic and white men (0.13 vs 0.11, p <0.0001)., Conclusions: This study shows for the first time that at similar levels of total PSA, PSAD is higher in Hispanic than in white men. Furthermore, these data show that while PSA was able to discriminate between malignant versus benign disease in Hispanic men, it was not able to do so in white men. Given the large number of patients in this series perhaps different PSAD cutoffs need to be defined for Hispanic men. Further study in this area is warranted.

Objective: To evaluate the diagnostic value of the noninvasive method of image-guided needle aspiration cytology (NAC) in the assessment of radiologically detected pelvic and retroperitoneal space-occupying lesions (excluding the pancreas, kidney and adrenal)., Study Design: NAC was performed under computed tomographic or ultrasound guidance on 112 patients suspected of having a pelvic or retroperitoneal mass. Cytologic examination was performed on site after staining smears with the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The NAC diagnosis was supported by examining cell blocks; further support was obtained with a tissue biopsy in some cases. Additionally, pertinent immunoperoxidase and/or histochemical studies were done., Results: Eighteen cases were diagnosed as inflammatory lesions, 17 cases consisted of normal cellular elements, and 12 cases showed scanty material and were considered unsatisfactory/inadequate for a diagnosis. Five cases were suspicious for malignancy, and in 39 cases metastatic tumors were diagnosed from a previously known primary. Thirteen cases were diagnosed as lymphoma, and in 8 cases a diagnosis of soft tissue sarcoma was made. There were no false positive diagnoses of malignancy. Cell block preparations and immunohistochemistry were helpful with tumor typing, although lymphoma subtyping and soft tissue tumor typing generally required open biopsy., Conclusion: NAC, as the first-line investigation, is not only useful in the diagnosis of space-occupying lesions of the pelvic and retroperitoneal region but can also help in choosing appropriate management. The technique is most useful in diagnosing metastases but is also helpful in excluding malignancy in some cases and in suggesting diagnoses of lymphomas and soft tissue tumors.

The free vibration characteristics of a torus with a circular cross section are studied by using the three-dimensional, small-strain, elasticity theory. A set of three-dimensional orthogonal coordinates system, comprising the polar coordinate (r, theta) at each circular cross section and the circumferential coordinate phi around the ring, is developed. Each of the displacement components u(r), v(theta), and w(phi) in the r, theta, and phi directions, respectively, is taken as a product of the Chebyshev polynomials in the r direction and the trigonometric functions in the theta and phi directions. Eigenfrequencies and vibration mode shapes have been obtained via a three-dimensional displacement-based extremum energy principle. Upper bound convergence of the first seven eigenfrequencies accurate to at least six significant figures is obtained by using only a few terms of the admissible functions. The eigenfrequency responses due to variation of the ratio of the radius of the ring centroidal axis to the cross-sectional radius are investigated in detail. Very accurate eigenfrequencies and deformed mode shapes of the three-dimensional vibration are presented. All major modes such as flexural thickness-shear modes, in-plane stretching modes, and torsional modes are included in the analysis. The results may serve as a benchmark reference for validating other computational techniques for the problem.

Multiple sclerosis (MS) patients occasionally present with homeostatic disturbances suggestive of hypothalamic dysfunction; however, the hypothalamus often appears normal on imaging, apart from confirmation in a few necropsy studies. In this article we describe a Chinese woman with atypical clinical presentation. She presented with relapsing symptoms and signs consistent with hypothalamic dysfunction including hyperprolactinema, syndrome of inappropriate secretion of anti-diuretic hormone (SIADH), hypersomnolence and temperature dysregulation. Serial MRI depicted the atypical reversible changes in the hypothalamus, correlating with the observed homeostatic abnormalities.

The aim of this study was to evaluate the diagnostic value of the noninvasive method of image-guided needle aspiration cytology (NAC) in the assessment of radiologically detected vertebral and intervertebral space-occupying lesions. NAC was performed under computed tomographic (CT) guidance on 70 patients suspected of having a vertebral or intervertebral lesion. Cytologic examination was performed on site after staining smears with the Papanicoloau method. In addition, air-dried smears, fixed smears, filter preparations from needle washings, and cell blocks were studied. The NAC diagnosis was supported by examining cell blocks, which showed the reliability of histologic architecture; further support was obtained with a tissue biopsy in some cases. Additionally, immunoperoxidase and/or histochemical studies were done. Ten cases were diagnosed as inflammatory/degenerative lesions, and in 2 cases a diagnosis of neurofibroma was made. Twelve cases consisted of normal cellular elements, 7 cases were unsatisfactory/inadequate for diagnosis, and 4 cases were suspicious for malignancy. In 32 cases, a variety of metastatic tumors were diagnosed, while in 3 cases, a diagnosis of chordoma was made. Based on our study, we feel that NAC, as a first line of investigation, is not only useful in the diagnosis of space-occupying lesions of vertebral and intervertebral regions, but can also help in deciding on appropriate management. Also, histologic architecture from cell blocks can be correlated with cytology, and such material can be used for histochemical and immunomarker studies., (Copyright 2002 Wiley-Liss, Inc.)

Tumefactive demyelinating lesion may sometimes mimic intracranial neoplasm or abscess and pose a diagnostic problem both clinically and radiologically. The diagnosis is even more complicated since multiple sclerosis is relatively uncommon among Chinese and due to low incidence of oligoclonal protein in the cerebrospinal fluid. We present a Chinese lady with tumefactive demyelinating lesion, which mimic cystic neoplasm and cerebral abscess. The use of perfusion and diffusion weighted imaging obviated unnecessary surgical biopsy.

Cerebral abscess may sometimes mimic necrotic tumor and cystic metastases both clinically and radiologically. The imaging findings may be indistinguishable on conventional magnetic resonance imaging. Although recent studies have shown that cerebral abscess displays restricted diffusion on diffusion-weighted imaging (DWI), it is not pathognomic. Necrotic tumor and cystic metastases may occasionally have restricted diffusion on DWI. Since the urgency of surgical intervention and approach of surgery is different, MR Spectroscopy may be used in conjunction with DWI in establishing the correct diagnosis.

The aim of the study was to investigate the feasibility of using digital subtraction in contrast-enhanced MR imaging of the brain to reduce the MR contrast dosage without jeopardizing patient care. Fifty-two patients with intracranial lesions, either intra-axial or extra-axial, detected by computerized tomography were selected for contrast-enhanced MR imaging with half-dose and full-dose of gadopentetate dimeglumine. The half-dose unsubtracted, full-dose unsubtracted, and half-dose subtracted MR images were visually assessed by counting the number of enhancing brain lesions in the images and quantitatively analyzed by computing their lesion contrast-to-background ratios (CBR). The visual conspicuity of the half-dose subtracted MR images was comparable to that of the full-dose unsubtracted MR images ( p>0.05), whereas the CBR of the half-dose subtracted images was approximately two to three times higher than that of the full-dose unsubtracted images. The half-dose subtracted T1-weighted spin-echo images might be able to replace the conventional standard-dose T1-weighted spin-echo images in MR imaging of the brain.

The continual reassessment method (CRM) is a sequential design used in phase I cancer trials to determine the maximal dose with acceptable toxicity. It has been established that the CRM is consistent under model misspecification but not generally. When the method does not converge to the target percentile, some dose-response models will be more sensitive than others in terms of how close the converged recommendation is to the target. In this article, we interpret the main condition under which the CRM is consistent and apply it to evaluate the sensitivity of the model used with the CRM. The technique presented is found to be a useful supplement to simulation when planning a phase I trial.

Gasparini and Eisele (2000, Biometrics 56, 609-615) propose a design for phase I clinical trials during which dose allocation is governed by a Bayesian nonparametric estimate of the dose-response curve. The authors also suggest an elicitation algorithm to establish vague priors. However, in situations where a low percentile is targeted, priors thus obtained can lead to undesirable rigidity given certain trial outcomes that can occur with a nonnegligible probability. Interestingly, improvement can be achieved by prescribing slightly more informative priors. Some guidelines for prior elicitation are established using a connection between this curve-free method and the continual reassessment method.

In many phase II clinical trials, interim monitoring is based on the probability of a binary event, response, defined in terms of one or more time-to-event variables within a time period of fixed length. Such outcome-adaptive methods may require repeated interim suspension of accrual in order to follow each patient for the time period required to evaluate response. This may increase trial duration, and eligible patients arriving during such delays either must wait for accrual to reopen or be treated outside the trial. Alternatively, monitoring may be done continuously by ignoring censored data each time the stopping rule is applied, which wastes information. We propose an adaptive Bayesian method that eliminates these problems. At each patient's accrual time, an approximate posterior for the response probability based on all of the event-time data is used to compute an early stopping criterion. Application to a leukemia trial with a composite event shows that the method can reduce trial duration substantially while maintaining the reliability of interim decisions.

Late temporal lobe necrosis is a well-known and serious complication in patients with nasopharyngeal carcinoma (NPC) following radiotherapy. Owing to the close proximity to the skull base, the medial temporal lobes are inevitably included in the target volume of irradiation. Patients with NPC provide a unique opportunity in study of delay radiation effect in normal human brain. The objective of this study was to evaluate late temporal lobe radiation injury by combined multi-section diffusion weighted and perfusion weighted MR imaging. We prospectively studied 16 patients with typical clinical symptoms of late temporal lobe necrosis or other abnormalities in the temporal lobes incidentally detected by conventional MR imaging. All patients had a previous history of radiotherapy for histologically proven NPC. Conventional T1- and T2-weighted images, fast gradient echo with echo-planar diffusion-weighted and perfusion-weighted MR imaging were performed. Apparent diffusion coefficient (ADC) map and relative cerebral blood volume (rCBV) map were computed via commercially available software. MR diffusion and perfusion images were then analyzed and graded by two independent observers with focusing on the diffusion and perfusion mismatch. The temporal lobe lesions displayed marked high diffusion on the ADC map. The rCBV map also revealed marked hypoperfusion in these temporal lobe lesions in all patients. The areas of abnormality on the rCBV map were significantly larger than the lesions on the ADC map in 14 patients (observer 1) and 13 patients (observer 2). Since late temporal lobe necrosis is probably caused by damage of the endothelium of vessels and ischemia, perfusion and diffusion mismatch might imply injured tissue but potentially salvageable brain tissue. A mismatch may be potentially used to predict the response to treatment in-patients with late temporal lobe necrosis.

Pulmonary artery aneurysm is a rare disease entity. The majority of cases are associated with congenital cardiovascular diseases, infection, and trauma; idiopathic pulmonary artery aneurysm is extremely rare. Although conventional and digital subtraction pulmonary angiography remains as the imaging modality of choice for the pulmonary vessels, it is invasive and sometimes may be inaccurate. With the advent of spiral computed tomographic angiography (CTA), pulmonary artery aneurysm can be diagnosed noninvasively and accurately. We report a case of a 68-year-old man with idiopathic pulmonary artery aneurysm of the descending branch of right pulmonary artery where the true caliber of the aneurysm was significantly underestimated in the digital subtraction pulmonary angiography. The literatures of this rare condition are reviewed with the emphasis on the application of CTA in this disease.

Spontaneous intracranial hypotension is a rare phenomenon characterized by postural headache, neck rigidity, nausea and vomiting. Imaging findings on magnetic resonance imaging (MRI) is characteristic with diffuse intracranial pachymeningeal thickening and enhancement following intravenous gadolinium. We present a case of spontaneous intracranial hypotension with two unusual imaging findings; pachymeningeal enhancement of the spinal canal and enlargement of the pituitary gland in addition to the diffuse intracranial pachymeningeal enhancement. In this case report, we will discuss the clinical features, MRI findings and underlying pathophysiology of this rare condition.

Background: We evaluated the ability of diffusion-weighted (DW) magnetic resonance (MR) imaging to differentiate between hepatic abscess and cystic or necrotic liver tumor., Methods: DW MR imaging was performed in 18 patients who had liver masses with large cystic or necrotic cavities detected by computed tomography or ultrasonography. The final diagnoses were pyogenic abscess (five cases), fungal abscess (one), hepatocellular carcinoma (five), cystic metastasis (four), and hepatic cyst (three). Signal intensities on the DW images and apparent diffusion coefficient (ADC) maps were noted. ADCs in all lesions were calculated and compared with Student's t test., Results: All lesions, except hepatic cysts, showed either heterogeneous or homogeneous rim enhancement on postgadolinium images. All abscess cavities showed hyperintensity on DW images and hypointensity on ADC maps. Conversely, the cystic or necrotic portions of all tumors showed hypointensity on DW images and hyperintensity on ADC maps. The mean ADCs (mm(2)/s) were 0.67 +/- 0.35 x 10(-3) in hepatic abscess, 2.65 +/- 0.49 x 10(-3) in cystic or necrotic tumor, 2.93 +/- 0.52 x 10(-3) in hepatic cyst, and 1.98 +/- 0.37 x 10(-3) in normal liver parenchyma., Conclusion: DW MR imaging, with the help of ADCs, may be a useful noninvasive imaging technique in differentiating hepatic abscess from cystic or necrotic tumor.

The objective of the study was to evaluate the capability and reliability of the magnetic resonance (MR) diffusion-weighted imaging (DWI) in differentiation between hydronephrosis and pyonephrosis. Single-shot echoplanar MR diffusion-weighted imaging was performed in 12 patients who had dilatation of the renal pelvis and calyces detected by ultrasonography (US). Microbiological tests confirmed that there were four cases of pyonephrosis and eight cases of hydronephrosis. Signal intensities of the collecting (pelvicalyceal) systems on the diffusion-weighted images and apparent diffusion coefficient (ADC) maps were noted. ADC values of the pelvicalyceal system in all patients were computed and compared using Student's t test. On diffusion-weighted images, the pelvicalyceal system of the hydronephrotic kidney was hypointense while the pelvicalyceal system of the pyonephrotic kidney was markedly hyperintense. The mean ADCs of the hydronephrotic and pyonephrotic renal pelvis were 2.98 +/- 0.65 x 10(-3) and 0.64 +/- 0.35 x 10(-3) mm(2)/s, respectively. The extremely low ADC of the renal pelvis of the pyonephrotic kidney accounted for its signal hyperintensity on diffusion-weighted images as well as signal hypointensity on ADC maps. In conclusion, the MR diffusion-weighted imaging may be a reliable tool to differentiate pyonephrosis from hydronephrosis.

Nowadays, new fluoroscopic machines are usually equipped with a dose-area product (DAP) meter for dose measurement. In our hospital, DAP meters have been used in the Diagnostic Radiology Department for dose audit since June 1997. Demographic patient data, name of radiologist, fluoroscopic duration and DAP readings of every case were recorded by radiographers. In early 1999, questionnaires were distributed to radiologists who had performed fluoroscopic examinations during the auditing period. 23 radiologists with varying years of experience completed the questionnaire and their practice was analysed. Since familiarization with the examination technique would affect radiologists' practice, these radiologists were divided into two groups for analysis. Radiologists with less than 3 years of experience were grouped together as junior radiologists, whilst others were grouped as senior radiologists. Results of the questionnaire indicated that radiologists generally found DAP meters useful for dose evaluation in the process of technique refinement. Radiologists aware of being under continuous surveillance of their practice showed significant reduction of doses (junior radiologists 25%, p<0.005; senior radiologists 36%, p<0.05) and fluoroscopic times (junior radiologists 36%, p<0.001; senior radiologists 18%, p<0.05) compared with radiologists who were unaware that they were under surveillance but with similar radiological experience. This effect is believed to be because of increased awareness of radiation dose through audit. In addition, this "audit effect" may also affect junior radiologists in decision-making regarding the number of radiographs (p<0.05), but no effect was found for senior radiologists (p>0.5).

A 23-year-old female university student was presented with recent onset of non-specific headache and dizziness. She had no neurological deficit on neurological examination and magnetic resonance imaging of the brain revealed diffuse enhancement in the basal cisterns and cerebral sulci. She was treated as tuberculous meningitis but she did not improve and developed respiratory arrest. Autopsy showed primary multifocal leptomeningeal gliomatosis.

Traditional designs for phase I clinical trials require each patient (or small group of patients) to be completely followed before the next patient or group is assigned. In situations such as when evaluating late-onset effects of radiation or toxicities from chemopreventive agents, this may result in trials of impractically long duration. We propose a new method, called the time-to-event continual reassessment method (TITE-CRM), that allows patients to be entered in a staggered fashion. It is an extension of the continual reassessment method (CRM; O'Quigley, Pepe, and Fisher, 1990, Biometrics 46, 33-48). We also note that this time-to-toxicity approach can be applied to extend other designs for studies of short-term toxicities. We prove that the recommended dose given by the TITE-CRM converges to the correct level under certain conditions. A simulation study shows our method's accuracy and safety are comparable with CRM's while the former takes a much shorter trial duration: a trial that would take up to 12 years to complete by the CRM could be reduced to 2-4 years by our method.

We report a case of a 54-year-old man who had documented traumatic acute subdural hematoma. He suffered from a transient episode of confusion and a follow-up CT scan of brain 6 h after the initial scan showed resolution and redistribution of the subdural hematoma. In this case report, we review the literature for the underlying pathophysiology of this uncommon phenomenon.

The objective of this study was to evaluate the therapeutic effectiveness of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with dynamic susceptibility contrast-enhanced magnetic resonance imaging (DSC-MRI). Seventeen patients with histopathologically proven HCC were included in this study. All patients underwent MR examinations with conventional T1- and T2-weighted images, gadolinium-enhanced images, and DSC-MRI before TACE treatment. Hepatic blood volume (HBV) maps were reconstructed from the time-intensity curves. The same MRI sequences and techniques were repeated 24 h and 6 weeks after TACE. Serial changes in tumor perfusion on HBV maps were correlated with vascularity in hepatic angiography. All tumors were hypointense on T1-weighted images and hyperintense on T2-weighted images. Heterogeneous enhancement was observed in all tumors before and immediately after TACE. Hyperperfusion was noted in most of the tumors on HBV map before TACE and moderate to marked hypoperfusion following TACE. The degree of tumor perfusion on HBV map correlated well with the vascularity in angiography. In conclusion, the noninvasive nature of DSC-MRI is useful to evaluate the effectiveness of TACE. Invasive procedures, such as angiography, are seldom necessary.

We examined nine patients with histologically proven nasopharyngeal carcinoma (NPC), treated with radiotherapy, using dynamic susceptibility contrast MRI (DSC-MRI). In eight there was clinical evidence of radionecrosis of the temporal lobe, and one was examined for local recurrence in the nasopharynx. All patients had either high-signal finger-like or cystic lesions in the temporal lobes on T2-weighted images. Heterogeneous contrast enhancement occurred in all patients. Relative regional cerebral blood volume (rrCBV) mapping revealed marked hypoperfusion in all patients. One underwent bilateral temporal lobectomy and radionecrosis was confirmed histologically.

Aims: The purpose of this study was to assess the value of breath-hold 3D gadolinium-enhanced subtraction magnetic resonance angiography (GD-MRA) in the detection of transplant renal artery stenosis (TRAS)., Patients and Methods: Seven patients with suspected post-transplant renal artery stenosis were studied. GD-MRA was performed at 1.5T with a 3D fast spoiled gradient recalled echo (FSPGR) pulse sequence. Before injection of contrast medium, the 3D pulse sequence was performed to obtain a set of non-contrast images for subtraction purposes. Dynamic 3D imaging was performed simultaneously with the bolus injection of 40 ml of gadopentetate dimeglumine. Angiographic images were reconstructed using the Advantage Window workstation (version 2.0 GE Medical Systems) and subtraction was made with the pre-contrast image data. Any signal intensity cut-off or narrowing of more than 50% was regarded as significant stenosis. Ultrasound Doppler (USD) study was performed with both colour and spectral studies. Peak systolic velocity (PSV) of greater than 2.0 m/s and acceleration time (AT) greater than 120ms was regarded as positive for TRAS. These were then compared with the digital subtraction angiography (DSA) as the gold standard., Results: A total of nine examinations performed in seven patients were included in the analysis. MRA correlated with the DSA findings in eight examinations, with one false negative. USG correlated with DSA in six examinations, with two false negative and one false positive case., Conclusion: In our opinion, GD-MRA is a promising and non-invasive technique in the detection of TRAS.

Hypertrophic olivary degeneration (HOD) is a rare type of neuronal degeneration involving the dento-rubo-olivary pathway. It is distinguished from other types of neuronal degeneration in that hypertrophy, rather than atrophy, takes place in the neurons in the inferior olivary nucleus. Prior to the invention of Magnetic Resonance Imaging (MRI), HOD was difficult to be detected, and a firm diagnosis could only be made at autopsy. We present a case of bilateral HOD following surgical excision of a cavernous hemangioma in the brainstem. The literature and imaging findings of this uncommon condition are reviewed.

The aim of the study was to evaluate the usefulness of the magnetic resonance (MR) perfusion maps in the detection of liver tumor perfusion following transcatheter arterial chemoembolization (TACE). MR dynamic susceptibility contrast-enhanced imaging was performed in 12 patients with 10 confirmed hepatocellular carcinoma and 2 confirmed hepatic metastasis using single-shot echoplanar pulse sequence. Time-intensity curves for all hepatic tumors showed a transient signal drop and the hepatic blood volume (HBV) maps were reconstructed. On the HBV maps, most tumors (80%) demonstrated hyperperfusion before TACE and hypoperfusion following TACE. The site and the degree of residual hyperperfusion within the tumor on the HBV maps correlated well with the areas of hypervascularity on the angiograms. In conclusion, the MR perfusion maps can be a promising technique for detecting the perfusion of the residual tumor tissue following TACE.

Calcinosis cutis is an uncommon condition, and calcific deposits in patients with end-stage renal disease are now somewhat rare, due to improvement in management. Since calcific deposits may clinically resemble a tumor, it is feasible to investigate them by fine-needle aspiration cytology (FNAC). A 52-yr-old male with a history of end-stage renal failure presented with a 2-cm mass in the left chest wall. Within 6 mo the mass enlarged to nearly four times its original size. In view of clinical suspicion of malignancy, FNAC was performed. Cytopreparations showed abundant calcium, indicative of soft-tissue calcinosis. The case is interesting, since the known history of end-stage renal failure enabled the FNAC diagnosis of soft-tissue calcinosis.

This study carried out in Hong Kong, identified 29 Chinese patients' perceptions of the importance of nursing care behaviours in an acute setting using a Chinese language translated version of the CARE-Q instrument. Patients ranked items concerned with 'giving the patients' treatments and medication on time' as the most important and 'sits down with the patient' as the least important. Comparisons are made with the results from other cultures and specific Chinese cultural interpretations are drawn to provide direction for nursing care of Chinese patients in Hong Kong and worldwide.

The cytologic findings in a fine-needle aspiration sample are described from a large retroperitoneal mass in a 56-yr-old male. The aspiration was performed under CT guidance using a 22-gauge needle, maintaining negative pressure. For cytologic study, on-site smears were prepared and stained by the Papanicolaou method. Additionally, cytospin, filter preparations, cell blocks from the aspirate, histology, and electron microscopy of the tumor tissue were performed. Also, immunodiagnostic staining for neuron-specific enolase (NSE), chromogranin, S-100 protein, vimentin, HMB45, cytokeratin, and Grimelius preparation was performed on cytologic and histologic material. The cytologic material was characterized by cords, suggestive acinar structures, and small follicle-like clusters of cells, while cell blocks from the aspirate showed oval or spindle-shaped nuclei with a somewhat fasciculated appearance. However, sections from the tumor tissue showed an organoid "zellballen" pattern. The nuclei were round, oval, spindly, and epithelioid, with moderate to scanty cytoplasm, smooth nuclear membranes, fine, evenly dispersed chromatin, slight hyperchromasia, and mild pleomorphism. No intranuclear vacuoles were seen. Positive immunohistochemical staining for NSE, chromogranin, and Grimelius preparation was noted in the tumor cells, while staining for vimentin, HMB45, and cytokeratin was negative. Electron microscopy of the tumor tissue revealed the presence of variable numbers of round, membrane-bound, electron-dense neurosecretory granules. The cytohistologic and ultrastructural findings are presented, as well as the results of immunodiagnostic staining which helped in the diagnosis of retroperitoneal paraganglioma, an infrequently reported tumor.

Gas-liquid chromatographic analyses of three complete series of synthetic positional isomers of methyl thia, selena, and tellura laurate analogs were carried on a nonpolar (SE-30) and a polar (SP-2330) stationary phase. The average ECL (equivalent chain length) values of the thia, selena, and tellura laurate on SE-30 stationary phase were 13.8, 14.8, and 15.7, respectively, while on SP-2330 the average values for the same series were 17.1, 19.0, and 19.1, respectively. Positional isomers with the heteroatom at the 2-position exhibited the lowest ECL values, while those with the heteroatom at the omega-1 position gave the highest ECL values and were readily separated from the other positional isomers of the same series of analogs by this technique.

A case of central neurocytoma occurring in the thalamus, confirmed by electron microscopy and immunohistochemistry, is reported. Computed tomography demonstrated a hypodense mass with an irregular margin arising from the right thalamus, extending into the lateral ventricle and crossing the midline. It contained areas of calcification and showed slight enhancement after contrast injection. On magnetic resonance imaging (MRI) scan, the tumour was hypointense to the brain in T1-weighted images and was heterogeneously hyperintense to the brain in T2-weighted images.

Over a period of 16 months, a total of 175 patients with newly diagnosed nasopharyngeal carcinoma (NPC) were evaluated with plain radiography and computed tomography (CT) of nasopharynx and base of skull. 54 of 175 patients (30.9%) had CT evidence of skull base erosion. Plain radiography failed to demonstrate the skull base erosion in 22 of 54 patients (40.7%) and underestimated the extent of bony involvement in another 21 patients (38.9%). In 14 of 54 patients (25.9%), there was also false suspicion of bony erosion in the plain films in one or more regions of the skull base which was not substantiated by CT and subsequent clinical course. The present study shows that plain radiography lacks sensitivity and specificity in detecting skull base erosion by NPC. CT evaluation of NPC patients should include thin CT sections of base of skull for detection of subtle bone erosion, and this would allow better decision concerning the shielding of the pituitary-hypothalamic axis during radiotherapy for improvement in therapeutic ratio. For the investigation of individuals highly suspicious of harboring NPC, even when the plain radiography is negative, CT should still be performed as this may give the only clue to the presence of a small submucosally spreading NPC.

Purpose: To study the role of computed tomography in the pre-therapy evaluation of nasopharyngeal carcinoma., Methods and Materials: The computed tomography of 119 new patients of nasopharyngeal carcinoma were evaluated independent of clinical findings for neck node metastases, and then compared with clinical findings. Contrast enhanced axial scans were obtained at 5 mm intervals with the infraorbitomeatal line parallel to the gantry. Scans were obtained from the supra-sellar cistern to the C5 or C6 vertebra for the evaluation of the base of skull, nasopharynx, paranasopharyngeal space and the upper and mid neck., Result: The present study confirmed the disparity of nodal extent documented by clinical palpation and computed tomography. Of the 37 patients who have no clinically palpable node (N0), computed tomography showed nodal involvement in 11 (29.7%) of them, and they were up-staged from N0 to N1. Computed tomography showed multiple or bilateral nodes in seven (58.3%) of the 12 patients with AJC N1 disease and they were hence up-staged to N2. All together, there were 28 (23.5%) patients who have no computed tomography evidence of nodal involvement by tumor. In agreement with clinical experience, the most commonly involved nodal groups were the upper internal jugular and upper spinoaccessary, followed by the lateral retropharyngeal. The percentage of nodes which were not clinically palpable was roughly the same for different regions (15-30%), except, as expected, that all the retropharyngeal nodes were not palpable. The risk of harboring retropharyngeal node was proportional to the size of the largest node in the ipsilateral neck., Conclusion: A significant proportion of patients with clinically negative neck (N0) or AJC N1 disease will be upstaged by computed tomography, thus supporting its routine use in pre-therapy evaluation of nasopharyngeal carcinoma.

Background and Purpose: This clinical trial investigates the effectiveness of intravenous glycerol therapy in patients with acute cortical infarction in whom intracerebral hemorrhage was rigorously excluded., Methods: Within 48 hours of symptoms from their first ischemic stroke, 113 hospital inpatients were randomized into the trial, provided that hemorrhage was excluded by computed tomography and informed consent was obtained. Patients were stratified into alert, semicoma, and coma groups using the Glasgow Coma Scale. Treatment was allocated according to a double-blind, randomized protocol; 56 patients received 500 mL of 10% glycerol in saline over 4 hours on 6 consecutive days, and 57 patients received corresponding placebo treatment with saline. Using a variety of objective scoring systems, patient follow-up was up to 6 months., Results: Corresponding measures of outcome in the glycerol and placebo groups were similar. At 6 months, respective mortality rates were 17 of 56 and 16 of 57, and mean +/- SD improvements in scores were 9.98 +/- 14.40 vs 10.51 +/- 12.68 (long-term), 1.12 +/- 7.20 vs 1.57 +/- 6.30 (prognostic), -1.94 +/- 5.53 vs -2.06 +/- 5.34 (Glasgow Coma Scale), and 21.72 +/- 23.40 vs 11.94 +/- 18.10 (Barthel Index rating in survivors). Hemolysis (generally subclinical) was the only adverse effect., Conclusions: There was no clinically or statistically significant difference in outcome between the groups; a trend toward greater functional recovery among survivors was evident after treatment with glycerol.

Background and Purpose: Hitherto, treatment of acute cerebral hemorrhage with intravenous glycerol has not been evaluated in rigorous clinical studies with sufficient patient numbers., Methods: We undertook a double-blind, stratified and randomized, placebo-controlled clinical trial. Only patients with a first stroke admitted to the hospital within 24 hours after onset of symptoms were recruited, provided computed tomography confirmed hemorrhage and informed consent was obtained. After stratification into alert, semicoma, and coma subgroups using the Glasgow Coma Scale, 107 patients received active treatment (500 ml of 10% glycerol in saline by intravenous infusion over 4 hours on 6 consecutive days) and 109 were given corresponding saline treatment. Using a variety of objective scoring systems, patients were followed up for up to 6 months., Results: At follow-up, all measures of outcome in the treated and control groups were very similar. At 6 months, respective mortality rates were 37 of 107 and 33 of 109. Corresponding mean +/- SD improvements in Scandinavian Stroke Study Group scores were 8.35 +/- 16.9 versus 11.55 +/- 15.6 (long-term) and 0.64 +/- 7.3 versus 2.40 +/- 6.9 (prognostic), and improvements in the Barthel Index ratings were 10.72 +/- 24.7 versus 13.95 +/- 23.3, respectively. Glasgow Coma Scale score improvements in the survivors were 0.81 +/- 1.5 and 1.16 +/- 1.7 in the treated and control groups, respectively. Hemolysis (generally subclinical) was the only adverse effect of glycerol noted., Conclusions: In the absence of any clinically or statistically significant difference in outcome between the treated and control groups, this trial provides no justification for glycerol therapy following acute cerebral hemorrhage.

In 137 normal CT scans of the nasopharynx, the parapharyngeal spaces at the nasopharynx level were asymmetrical in 30%. Their difference in width and distance from the midline was greater than 1 mm in 51% and 44% respectively. Fat was absent in the interpterygoid fascia in 20%, in the alar fascia in 28%, in the prevertebral space in 35%, and in the retropharyngeal space in 99% of patients. Assessment of tumour extension to the paranasopharyngeal space usually relies on symmetry and fascial fat planes. As either feature may not be present in the normal person, the relation of the tumour to two lines representing two fascial planes is proposed as a complementary method for the evaluation of tumour extension.

A case of secondary hypertension due to an aldosteronoma coexisting with renal artery stenosis is reported. Tumor resection resulted in an immediate but short-lived clinical relief. Follow-up aortography revealed progressive arterial stenosis and infrarenal aortic occlusion. Differential renal venous renin and renal scintigraphy suggested renovascular hypertension. It is necessary to search for a second curable lesion if hypertension remains uncontrollable after surgical correction of an apparent cause.

In a prospective study of 262 consecutive patients with nasopharyngeal carcinoma (NPC), using computed tomography (CT) as their baseline evaluation, erosion of the base of the skull and intracranial extension into the middle cranial fossa were found in 31.3% and 12.2% of patients, respectively. Thirty-four of these patients had cranial nerve involvement at presentation; 30 of them had involvement of one or more of the third to sixth cranial nerves. Most cases of intracranial extension of tumor were accompanied by erosion of the base of the skull, but the reverse was not true. All patients with cranial nerve palsy involving the third to sixth cranial nerves had associated erosion of the ipsilateral base of the skull. The CT evaluation of patients with cranial nerve involvement who are believed to harbor NPC should include thin cuts of the base of the skull for detection of subtle bone erosion. This may be the only clue to the presence of a small NPC. The prognostic significance of cranial nerve involvement, base of the skull erosion, and intracranial extension of the tumor on the survival of the group of 84 patients who had T4 tumors was evaluated with regression analysis using the Cox model. Only cranial nerve involvement was found to be a significant factor influencing survival.

Spinal cord ganglioglioma is a rare tumor most often encountered in the first three decades. Scanty computed tomography (CT) reports on the tumor describe it as a hypodense or cerebrospinal fluid (CSF) dense area with little contrast enhancement despite its solid nature. We report two cases of spinal ganglioglioma both involving almost the whole spinal cord. On magnetic resonance imaging (MRI), the tumors appear hypointense to the spinal cord on T1 and hyperintense to the cord on T2 images, and were mainly solid at exploration. It is important to recognize these tumors as long survival can be achieved after surgical resection.

In a prospective study using CT as the initial means of radiologic evaluation in 262 patients with proved nasopharyngeal carcinoma, the paranasopharyngeal space was found to be the most commonly involved region (84.4%), both uni- and bilaterally. Unilateral involvement was found in 44.3% of patients (116/262) and bilateral involvement in 40.1% (105/262). The other structures or regions that were involved, in decreasing order of frequency, were the sphenoid sinus (26.7%), nasal fossa (21.8%), and ethmoid sinus (18.3%). Erosion of the base of the skull and intracranial intracranial extension into the middle cranial fossa were common (31.3% and 12.2%, respectively). The primary tumor in the nasopharynx was found to be contiguous with metastatic upper cervical nodes through paranasopharyngeal extension of tumor in 35 patients (13.4%). A qualitative method to assess the degree of paranasopharyngeal extension is proposed. The extent of paranasopharyngeal extension so evaluated was correlated with other attributes of tumor extent (p = .0001), namely, nasal or oropharyngeal extension, which constitutes a T3-level tumor, and erosion of the base of the skull or orbit, which constitutes a T4-level tumor. The extent of paranasopharyngeal extension was also correlated with local control of the tumors (p = .0001). At a median follow-up of 27 months, only three (7.9%) of the 38 patients with no paranasopharyngeal extension had nasopharyngeal relapse, while 12 (11.2%) of the 107 and 17 (34.7%) of the 49 patients with types 1 and 2 paranasopharyngeal extension, respectively, had nasopharyngeal relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

Biliary cystadenoma and cystadenocarcinoma are rare tumours which have a good prognosis after complete surgical removal. Correct pre-operative diagnosis depends on the imaging characteristics of the tumours. We have observed some unusual features including multifocal tumours with attachment to other abdominal organs, tumour presenting as cholangitic abscess, and distant metastasis after apparently complete resection by hemihepatectomy.