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PubMed1999

Multimodal approach of cranial ultrasound in children.

The potential uses of cranial ultrasound have been overlooked for years because of the advent of fascinating neuroimaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) study. In this article, the authors introduce the developments and refinement in modern pediatric neurosonology. In the past, only neonates with widely open fontanels seemed to be good candidates for cranial ultrasound study. Actually, any tiny skull defect can be used as an acoustic window. And the thin skulls of children do not hinder the ability of ultrasound to obtain acceptable image transcranially. Today, many CT and MRI studies can be replaced with the advanced cranial ultrasound if clinicians or neurologists recognize the advantages. Cranial ultrasound can provide Doppler hemodynamic studies which CT and MRI can not. Only ultrasound can provide convenient, real-time intraoperative guidance and continuous bedside monitoring in patients who need neurological intensive care. Cranial ultrasound also plays an important role in follow-up studies because it is convenient, economical, and safe, especially in children. To obtain all the benefits from an ultrasound study, one has to realize the "multimodal" applications of it, including the applications of all acoustic windows, multifrequency transducers, and hemodynamic study with the aid of power Doppler and contrast agents. With a multimodal approach, physicians can achieve the utmost from the powerful modern cranial ultrasound in pediatric patients.

Child↗
PubMedDate not supplied

Multimodality therapy in advanced paranasal sinus carcinoma: superior long-term results.

PURPOSE: This study was conducted to determine the efficacy of multimodality treatment for stage III and IV, locoregionally advanced paranasal sinus carcinoma. PATIENTS AND METHODS: A subgroup analysis of 19 consecutive patients with stage III or IV paranasal sinus carcinoma treated with multimodality therapy from head and neck cancer protocols between 1984 and 1996 were analyzed for outcome. Sixteen patients received induction chemotherapy consisting of three cycles of cisplatin and 5-fluorouracil, followed by traditional resection (14 patients) or surgical debulking (two patients). Surgery was followed by concomitant chemoradiotherapy with hydroxyurea and 5-fluorouracil in a week-on, week-off sequence in 15 patients. One patient received standard radiation therapy. An additional three patients were treated with a sequence of surgical resection followed by concomitant chemoradiotherapy. The median total dose to the primary tumor was 60 Gy (range, 45-74 Gy). RESULTS: The overall survival at 5 and 10 years by lifetable analysis was 72.7% and 53.9%, respectively, and the disease-free survival at both 5 and 10 years was 66.6%. Local control was 76.1% at both 5 and 10 years. In the subgroup of patients treated with induction chemotherapy, 87% (14/16) achieved a clinical response. A complete response was confirmed at the time of surgery in five patients, whereas 11 patients had residual disease in the surgical specimen. Regional and distant failures were unusual (one patient each), with a 10-year regional control rate of 93% and a distant control rate of 95.5%. Serious, nonreversible long-term complications included two cases of unilateral blindness, one cataract, and one case of ototoxicity. DISCUSSION: An excellent long-term outcome with respect to local control, overall survival, and disease-free survival is achieved in locoregionally advanced paranasal sinus cancer treated with induction chemotherapy, surgery, and concomitant chemoradiotherapy. The 15 patients treated with this regimen had 10-year overall survival, disease-free survival, and local control rates of 56%, 73%, and 79%, respectively. These results are encouraging and are superior to the 40% survival achieved with surgery and radiation therapy. Further investigation of this regimen is warranted.

Adult↗
PubMed1999

Multimodal cancer treatment mediated by a replicating oncolytic virus that delivers the oxazaphosphorine/rat cytochrome P450 2B1 and ganciclovir/herpes simplex virus thymidine kinase gene therapies.

Multimodal therapy is generally more effective than single-agent treatment for cancer. rRp450 is an engineered herpes simplex viral mutant that replicates in and kills tumor cells in a relatively selective fashion. It also expresses, in infected cells, the cyclophosphamide (CPA)-sensitive rat cytochrome P450 2B1 (CYP2B1) and the ganciclovir (GCV)-sensitive herpes simplex virus thymidine kinase (HSV-TK) transgenes. We show that cultured rat 9L and human U87deltaEGFR glioma cells, infected and lysed by rRp450, also exhibit supra-additive sensitivity to both CPA and GCV, as determined by Chou-Talalay synergy analysis. DNA cross-linking, assayed by ethidium bromide fluorescence, was significantly inhibited in the presence of GCV, suggesting that interactions between the CPA/CYP2B1 and GCV/HSV-TK gene therapies occurred at the level of DNA repair. In vivo, regression of 9L s.c. tumor volumes in athymic mice was achieved only by the multimodal treatment allowed by rRp450 viral oncolysis combined with CPA/CYP2B1 and GCV/HSV-TK gene therapies, whereas all other treatment combinations produced only tumor growth retardation.

Animals↗
PubMed1999

[A long-survival case of gastric cancer with multiple liver metastasis: usefulness of intraoperative multimodality therapy and post-operative intra-arterial chemotherapy for liver lesions].

A 62-year-old man was found to have advanced cancer of the gastric cardia with multiple liver metastasis. Total gastrectomy was performed, and 11 hepatic lesions were simultaneously treated by intraoperative multimodality therapy. The therapy included hepatic resections for seven easily-resectable lesions, microwave coagulation therapy for two lesions, and ethanol injection therapy for two. Post-operative intra-arterial infusion of 1,000 mg of 5-FU was performed weekly or every two weeks through the hepatic artery using a reservoir. No recurrence was found during the follow-up period of 35 months. When local control is obtained during surgery in patients with gastric cancer with multiple liver metastasis, intraoperative multimodality therapy and post-operative intra-arterial chemotherapy should be performed for liver lesions.

Adenocarcinoma↗
PubMedDate not supplied

Multimodality management of a case of primary osteogenic sarcoma of the zygoma.

Craniofacial osteogenic sarcomas are rare primary malignant bone tumors and very few cases involving zygomatic bone were reported in literature. We present our experience of multimodality management of a case of primary osteogenic sarcoma of zygoma. Wide radical excision of the tumor including the parotid gland was done followed by three cycles of adjuvant chemotherapy and fifty Gy of external radiotherapy. The patient is disease-free at two years follow-up. Till 1970s, craniofacial osteogenic sarcomas were managed mainly by radical surgery with a high local failure rate. With the advances made in the field of radiotherapy and chemotherapy, multimodality therapy is playing a major role in the treatment of these aggressive tumors with better overall and disease-free survival.

Adult↗
PubMed2000

Therapy which enhances surgical recovery: the potential for multimodality, fast-track surgery in the 21st century.

Hospital stay will be greatly reduced following major operations in the years to come. Already, minimally invasive procedures, selected anesthetic techniques and the use of appropriate pharmaceutical agents have reduced postoperative hospitalization. However, surgeons and their anesthesiology colleagues have combined many of these therapies in a multimodality approach, which has greatly shortened surgical convalescence following major surgery. The literature reports that patients can be discharged following recovery in 48 hours following a partial colectomy, in 1-2 days following pneumonectomy and in 4-5 days following knee or hip replacement operations. This multimodality approach appears to greatly reduce postoperative stress. Postoperative hospitalization will continue to be reduced throughout the coming century.

Combined Modality Therapy↗
PubMedDate not supplied

Curative management of adenocarcinoma of the oesophagus--pro multimodal approach.

The incidence rates of adenocarcinoma (AC) of the oesophagus were reported to increase rapidly in the Western Countries, especially within white males. Due to the late appearance of tumour specific symptomes, most of the carcinomas are diagnosed at advanced stages. Because of the majority of the patients presenting with lymph node metastases even in localized disease, the long term results with surgery alone are disappointing. Overall less than 35% can be cured and three year survival rates (3-YSR) rarely exceed 25% in patients with locally advanced tumours (T3/4N0-1M0). For these reasons multimodal approaches have been investigated recently. Preoperative chemoradiation seems to be most promising in improving the curative power of the treatment. Beside a couple of phase II studies, 2 phase III trials proved superiority of multimodal treatment compared with surgery alone in localized AC (1,2) by increasing 3-YSR from about 10% to 30%. These trials were critisized because of incomplete tumour staging and a possible stratification bias. However, recent phase II studies from the US and from our own group (3,4) confirmed the role of preoperative chemoradiation also in properly staged (including endoscopic ultrasound) locally advanced AC. Both trials showed complete resection rates of 90% and based on very high local tumour control rates of above 90% long term survival reached about 40% in these high risk patients. These impressive data were injured by perioperative mortality rates of 15%, which were obviously increased by the preoperative treatment. Thus, preoperative chemoradiotherapy is very likely to increase cure rates in patients with AC of the oesophagus. To prove this, well designed phase III trials are warranted.

Adenocarcinoma↗
PubMed2000

Notch signaling as a target in multimodality cancer therapy.

Notch signaling is an extremely conserved and widely used mechanism controlling cell fate determination. Recent evidence shows that Notch receptors regulate cell differentiation, proliferation and apoptosis in many cells, including neoplastic cells. In the context of cancer experimental immunotherapy and multimodality therapy, the Notch signaling network is acquiring increasing importance for its possible roles in both neoplastic cells and the immune system. In this review, we discuss: (i) the roles of Notch signaling in cancer cells and the immune system; and (ii) strategies through which Notch-targeting biologicals may be used to increase the effectiveness of multimodality cancer treatment, including cancer vaccines.

Animals↗
PubMed2001

[Very high frequency electromagnetic irradiation in multimodal treatment of patients with disseminated infiltrative pulmonary tuberculosis].

Multimodality treatment involving very high-frequency electromagnetic radiation (VHFER) in combination with the antioxidants alpha-tocopherol and sodium thiosulfate, which had been performed in 27 patients with disseminated infiltrative pulmonary tuberculosis, was effective. As compared to patients receiving chemotherapy in combination with electromagnetic radiation (n = 29) and routine chemotherapy alone (n = 29), these patients had more benefits from the multimodality treatment in terms of bacterial isolation cessation and reduced hospital stay by 1.5-2 months, minimal pneumofibrotic changes occurred in 63% of the patients. Combined VHFER and antioxidative therapy were found to exert a normalizing effect on lipid peroxidation and immunity.

Adolescent↗
PubMed2001

[Therapeutic effect of multimodal therapy, such as cryosurgery, locoregional immunotherapy and systemic chemotherapy against far advanced breast cancer].

A total of 6 breast cancer patients, 5 with local recurrent tumors on their anterior chest wall and 1 with far advanced primary breast tumor, underwent multimodal therapy in which cryosurgery was performed in combination with local injection of the non-specific immunopotentiator OK-432. This multimodal therapy was repeated as many times as possible. In addition, 3 patients whose general condition was relatively good were treated with mild chemotherapy. In every patient who underwent cryosurgery combined with locoregional immunotherapy, eradication or reduction of tumor was observed for several months. Of 3 patients who underwent cryosurgery, locoregional immunotherapy and systemic chemotherapy, the tumor burden decreased markedly in 2 patients and rapid tumor growth was suppressed in 1 patient, even though the diameter of tumor was over 5 cm in all cases. There were no side effects caused by either cryosurgery or locoregional immunotherapy. Little toxicity was observed throughout the mild chemotherapy. These results indicated that cryosurgery in combination with local injection of OK-432 should be a feasible modality against unresectable breast cancer on the chest wall, and that this therapeutic effect might be augmented by mild chemotherapy.

Aged↗
PubMed2001

[Multimodal treatment including intraoperative irradiation for advanced pancreatic cancer with extended metastasis].

From January 1987 to December 1999, we treated 11 advanced pancreatic cancer patients with extended metastasis with multimodal treatment. Two patients received external radiation therapy (ERT) and systemic chemotherapy, 1 received intraoperative radiation therapy (IORT) and ERT and arterial infusion chemotherapy (AIC), 2 received IORT and AIC, 4 received only IORT, 2 received only AIC, and 15 did not receive any of these treatments. There was a significant difference in the survival rate between treatment and no treatment cases (median survival of 177 days and 109 days, respectively) (p = 0.04). A significant difference in the survival rate was also observed between IORT cases and no treatment cases (median survival of 212 days and 109 days, respectively) (p = 0.02). However, there was no significant difference in the survival rate between AIC cases and no treatment cases (median survival of 177 days and 109 days, respectively) (p = 0.10). Therefore, our experience suggests that multimodal treatment including intraoperative irradiation is effective for advanced pancreatic cancer patients with extended metastasis.

Adult↗
PubMed2001

[Multimodality therapy concepts in stomach carcinoma].

The prognosis of gastric cancer is still poor even after curative R0 resection. Therefore, among various multimodality treatments a lot of phase II/III studies have been carried out evaluating preoperative chemotherapy. Although some positive results have been obtained after this procedure, neoadjuvant chemotherapy is still an experimental approach. In the future the prediction and evaluation of response must be defined more exactly. Using intraoperative radio- or intraperitoneal (hyperthermal) chemotherapy reduction of regional relapse or peritoneal carcinomatosis could be obtained without increased survival in general. According to experience in Japan adjuvant (immuno-)chemotherapy can increase the overall survival rates and even in the Western hemisphere some actual studies with adjuvant chemo- +/- radiotherapy could demonstrate a benefit of survival in patients with lymph node metastases. Nevertheless, multimodality treatment strategies must be investigated in further uniform prospective study protocols.

Clinical Trials as Topic↗
PubMed2001

[Multimodality therapy concept in stage I-IIIA small cell bronchial carcinoma. Case follow-up over 15 years].

We analysed our results of multimodal therapy including chemotherapy, radiotherapy and surgery in 150 consecutive patients with SCLC stage I-IIIa operated on in our hospital between 1983 and 2000. Median age: 58 years, stages see Table 2. Patients with proven SCLC had induction chemotherapy prior to surgery. All patients received three cycles of adjuvant chemotherapy, some with additional radiotherapy. Perioperative mortality: 2%. Median survival: 22.4 months. R0 resection was possible in 84% of all patients. Pre- and post-surgery staging differed in the majority of the patients. Rotes of 1-, 2- and 5-year survival were 79%, 47%, and 32%, respectively. A median survival of 22.4 months in multimodally treated LD-SCLC, most of them stage IIb/IIIa appears promising. Randomized studies based on clinical staging procedures are not recommended. Survival data are promising.

Carcinoma, Bronchogenic↗
PubMed2002

Obsessive-compulsive hoarding: symptom severity and response to multimodal treatment.

BACKGROUND: Compulsive hoarding and saving symptoms, found in many patients with obsessive-compulsive disorder (OCD), are part of a clinical syndrome that has been associated with poor response to medications and cognitive-behavioral therapy (CBT). We sought to determine whether patients with the compulsive hoarding syndrome had more severe symptoms and functional impairment than nonhoarding OCD patients and whether they would respond to intensive, multimodal treatment previously found to be effective for treatment-refractory OCD. METHOD: We studied 190 consecutive patients with DSM-IV OCD treated openly for approximately 6 weeks with intensive CBT, medication, and psychosocial rehabilitation in a partial hospitalization program for severely ill OCD patients. Twenty of the 190 patients (11%) were identified as having the compulsive hoarding syndrome. All patients were assessed before and after treatment with the Yale-Brown Obsessive Compulsive Scale (YBOCS), Hamilton Rating Scale for Depression (HAM-D). Hamilton Rating Scale for Anxiety (HAM-A). and Global Assessment Scale (GAS). We compared the symptom severity and response to treatment of compulsive hoarders versus nonhoarding OCD patients. RESULTS: Compulsive hoarders were significantly older than nonhoarders (p < .001). Hoarders had significantly lower GAS scores and higher HAM-A scores than nonhoarders both before (p = .04) and after (p = .002) treatment, but had similar pretreatment YBOCS scores. Both groups improved significantly with treatment as assessed by YBOCS score (p < .001), but nonhoarders had significantly greater decreases in YBOCS scores than hoarders (p = .02). CONCLUSION: While the compulsive hoarding syndrome appears to be a distinct, more disabling, variant of OCD that does not respond as robustly to treatment, it may still improve significantly with intensive, multimodal treatment tailored to its specific features and associated deficits.

Adolescent↗
PubMed2002

Target-specific multimodality endovascular management of carotid artery blow-out syndrome.

We describe a novel multimodality endovascular approach to safely control hemorrhage from a carotid artery pseudoaneurysm and tumor vasculature associated with a squamous cell carcinoma. This approach was used in the case of a 68-year-old man who had previously undergone a laryngectomy, chemotherapy, and brachytherapy and who subsequently experienced acute oropharyngeal bleeding. Angiography detected a carotid artery pseudoaneurysm and significant tumor vascularity. A target-specific multimodality approach was taken to embolize the potential etiologies for both the current and any future hemorrhages. Stent-assisted coiling of the pseudoaneurysm was successful. The tumor blush was treated with polyvinyl alcohol particles and both retrievable and nonretrievable coils. Endovascular surgeons have become increasingly involved in the management of patients with carotid injuries and with neoplasms in and around the skull base. Current endovascular technology provides a rapid target-specific approach to the treatment of carotid artery blow-out syndrome and has a greater potential to lower morbidity than does carotid sacrifice.

Aged↗
PubMed2001

[Multimodal evoked potentials in malabsorption syndrome].

The multimodal evoked potentials (visual, somatosensory and auditory brainstem) in 23 patients with malabsorption syndrome of different origin were investigated. The diagnosis of the disease was confirmed on the basis of histological examination and result of D-ksyloza test. The control group consisted of 30 healthy persons. Examination of visual evoked potentials revealed significant prolongation of latency of P 100 component in examined group in comparison with controls. Latency of N13 and N20 of somatosensory evoked potentials in patients with malabsorption syndrome were also significantly prolonged when compared to controls, otherwise transit time to cortex (TTC) was merely prolonged. Auditory brainstem potentials were also abnormal. Changes involved prolongation of latency of I, III and V responses and prolongation of interpeak latencies of I-III, III-V, I-V as well. The amplitudes of the examined evoked potentials between patients and controls did not differ significantly. On the basis of obtained results in was pointed out that different specific afferent systems are affected in patients with malabsorption syndrome what seems to be connected with vitamin's deficiency, especially B12 and E. Authors conclude that multimodal evoked potentials examinations are useful in the diagnosis and monitoring of the disease, specially in subclinical cases.

Adult↗
PubMed2002

Results of multimodality treatment for 141 patients with brain arteriovenous malformations and seizures: factors associated with seizure incidence and seizure outcomes.

OBJECTIVE: Previous reports of seizure outcomes after arteriovenous malformation (AVM) treatment have involved single-treatment modality (surgery, radiosurgery, or embolization) series. Such series reflect only selected lesions, of certain sizes, locations, and other clinical and anatomic characteristics, that are amenable to the single therapy, limiting the analysis of those factors. We report the results of AVM treatment using a multimodality approach that we think encompasses a broader spectrum of treatable brain AVMs. We tested for factors associated with seizure presentation and seizure outcomes. METHODS: Between 1991 and 1999, the multidisciplinary neurovascular unit at Massachusetts General Hospital treated 424 patients with brain AVMs. Treatment consisted of surgical resection, radiosurgery, or embolization, either alone or in combination. One hundred forty-one patients (33%) experienced seizures before treatment. We studied the following factors: sex, age, AVM size, AVM location, occurrence of intracranial hemorrhage, seizure type, duration of seizure history, treatment modality, and AVM obliteration. We tested for statistical associations between these factors and seizure presentation and outcomes. Clinical follow-up monitoring was via mailed questionnaires. RESULTS: When we compared the 141 patients with seizures with the 283 patients who did not experience seizures (total of 424 patients), male sex, age of less than 65 years, AVM size of more than 3 cm, and temporal lobe AVM location were statistically associated with seizures (P < 0.01, P < 0.05, P < 0.0001, and P < 0.01, respectively). Posterior fossa and deep locations were statistically associated with no seizures (P < 0.0001). One hundred ten (78%) of the 141 patients who experienced seizures before treatment responded to the mailed questionnaires, with a mean follow-up period of 2.9 years. A detailed comparison of responders and nonresponders demonstrated no statistically significant differences in pertinent characteristics. As determined with the Engel Seizure Outcome Scale, there were 73 (66%) Class I (free of disabling seizures), 11 (10%) Class II (rare disabling seizures), 1 (0.9%) Class III (worthwhile improvement), and 22 (20%) Class IV (no worthwhile improvement) outcomes. Three patients died during the follow-up period. We tested for factors associated with Engel Class I outcomes. Sex, age, and AVM size were not associated with Class I outcomes. Short seizure history, association of seizures with intracranial hemorrhage, generalized tonicoclonic seizure type, deep and posterior fossa AVM locations, surgical resection, and complete AVM obliteration were statistically associated with Class I outcomes (P < 0.0001, P < 0.05, P < 0.05, P < 0.05, P < 0.001, and P < 0.001, respectively). When only completely obliterated AVMs were considered, there were no statistically significant differences between surgery, radiosurgery, and embolization. CONCLUSION: Certain factors, as identified in an analysis of a wide spectrum of treatable brain AVMs, can facilitate predictions of the incidence of seizure presentation with AVMs, as well as seizure outcomes after multimodality treatment.

Adolescent↗
PubMed2002

[A case report of advanced huge hepatocellular carcinoma (H.C.C.) accompanied by tumor embolism to the inferior caval vein (Vv3) that was treated with surgical extended right lobectomy after multimodal therapy].

We performed multimodal therapy for a huge hepatocellular carcinoma with tumor embolism (Vv3), for which excision was judged impossible. After treatment, a hepatectomy to the primary lesion was finally carried out and long-term survival was achieved. A 52-years-old man with right lateroabdominal pain had a huge occupied hepatocellular carcinoma that was detected in October 2000. A tumor embolism, which invaded the inferior vena cava, was also seen. The residual liver was judged to have insufficient capacity for a right hepatic lobectomy. A percutaneous transhepatic portal embolism (PTPE) was carried out against the right portal vein to increase in the left lobe capacity. The chemo-radiotherapy (36 Gy to the right hepatic vein and systemic administration of CDDP) and transcatheter arterial chemoembolization were added to the feeding arteries of the hepatic tumor. When a decrease in the postcaval vein tumor embolism was observed, the extended right hepatic lobectomy was performed. The postoperative course was good, and the patient was discharged from the hospital on postoperative day 41. Though lung metastasis and new lesions in left lobe were seen in a recurrence, two years and ten months since the start of the systemic chemotherapy. This case suggested that even if a huge liver cancer with vascular invasion is judged impossible to excise, multimodal therapy with the aim of surgical treatment helps retain the possibility to later chose hepatectomy for the primary lesion and improve prognosis.

Carcinoma, Hepatocellular↗