- Email: [email protected]
STAGING OF HEAD-AND-NECK CANCER
275
STAGING OF HEAD-AND-NECK CANCER
SIR,-Distant metastases are present in 10-12% ofhead-and-neck due to squamous cell carcinoma. The metastases increases with TNM stage to 19 5% for cancers
risk of distant IV-MO. In
stage
52% of distant metastases the site is the lung. Moreover, prospective panendoscopic studies ofhead-and-neck cancer patients have stressed the high rate of synchronous second primary carcinomas in the lung, oesophagus, or head-and-neck area.22 We have done a cost-benefit audit of current investigations used to stage advanced head-and-neck cancer, with particular emphasis on bone scan, ultrasonography, and endoscopy. 130 consecutive patients with previously untreated and inoperable stage IV squamous cell carcinomas of the head and neck entered a prospective trial of neoadjuvant chemotherapy. Pretreatment evaluation included measurement of serum calcium, chest X-ray, laryngoscopy, oesophagoscopy, bronchoscopy, abdominal ultrasonography, and bone scan. 10 patients (7’ 5%) had distant metastases to the lung (6), bone (2), skin (1), or to lung, bone, and liver (1). Bone scan disclosed asymptomatic bone metastases in only 1 patient. Since the only patient with liver metastases also had lung and bone secondaries the TNM stage was in no case modified by the abdominal ultrasound
findings. 15 patients
had hypercalcaemia (above 2 -60 nmol/1) but 11 of these had no detectable distant metastases. 19 patients (18%) had multiple synchronous primary carcinomas-7 in the head-and-neck area, 9 in the oesphagus, and 3 in the bronchial tree. Oesophagoscopy disclosed 9 asymptomatic carcinomas (ie, all the oesophagus-associated carcinomas) while bronchoscopy revealed only 2 of the 3 primary lung carcinomas. On cost-benefit grounds bone scan, abdominal ultrasonography, and bronchoscopy cannot be recommended in a planned pretreatment evaluation of inoperable stage IV head-and-neck cancer, and we suggest that only chest X-ray, serum calcium measurement, be retained. and
oesophagoscopy
Department of Medicine, Institut Jean-Godinot, 51056 Reims, France; and Otolaryngology Department, Hopital Robert Debré, Reims
F. MARECHAL P. CONINX M. LEGROS S. NASCA D. LEBRUN A. CATTAN
Serum cortisol (* ——— W)and plasma ACTH (0---0) before and during continuous etomidate infusion.
The etomidate infusion had
an acute
sedative effect
on
the
psychotic agitation. Within a few days the hypertension and hypokalaemia were improved as cortisol levels fell. No other severe side-effects of etomidate were seen over 14 days of etomidate infusion. To our knowledge, this is the first demonstration of the prompt and beneficial effect of etomidate on hypercortisolism. ACTH levels fell too, though not to normal values. The mechanism for the blocking of ACTH release is unknown. A comparable effect’of ketoconazole on cortisol and ACTH release during long-term treatment of patients with Cushing’s disease has been described,33 but again the decrease in ACTH was not explained. Etomidate seems to affect both cortisol and ACTH release more strongly and more rapidly than ketoconazole does. Medizinische Klinik Innenstadt,
University of Munich, D-8000 Munichen 2, West Germany; and Institut für Anaesthesiologie, University of Munich
ROLAND GÄRTNER MICHAEL ALBRECHT OTTO ALBRECHT MÜLLER
OA, Fink R, Baur X, Ehbauer M, Madler M, Scriba PC. ACTH in plasma: and determination. GIT Labormed 1979; 2: 117-24. 2. Allolio B, Stuttmann R, Fischer H, Leonhardt W, Winkelmann W. Long-term etomidate and adrenocortical suppression. Lancet 1983; i: 626. 3. Angeli A, Frairia R. Ketoconazole therapy in Cushing’s disease. Lancet 1985; i: 821. 1. Müller
extraction
1. Merino O. An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 1977; 40: 145-51. 2. McGuirt W. Multiple simultaneous tumours in patients with head and neck cancer. Cancer 1982; 50: 1195-99.
INCIDENCE OF HYPOTHERMIA Nov 2 editorial indicates that hypothermia is of death, while Dr Lloyd (Dec 21/28, p 1434) casts doubt on this interpretation. We have reported’ a doubling of the death rate in old people in January and February, 1985, over the rate in similar periods in 1983 and 1984 when the winters were milder. The prolonged cold periods in January and February, 1985, certainly played a part in the increased death rates. We expected an increase in hypothermia among those admitted to hospital but this did not happen; the patients were dying before they arrived at hospital. We cannot say that their deaths were due to hypothermia but this must have played a part. Equally, necropsy will not reveal evidence of hypothermia, merely intercurrent disease which most old people will have anyway. To say that a patient has had a cerebrovascular accident does not mean that he died of this. An episode of hypothermia after a stroke could be responsible for a death that might not otherwise have happened. Since October, 1985 (up to January 1, 1986) this hospital has received 13 elderly hypothermic patients. I do not consider that hypothermia is rare. If the weather is too cold the patients die at home and are not registered as hypothermic. If the weather is milder then more patients survive to reach hospital with hypothermia.
&R,-Your
uncommon as a cause
EFFECT OF ETOMIDATE ON HYPERCORTISOLISM DUE TO ECTOPIC ACTH PRODUCTION
SIR,-We have made use of the fact that etomidate suppresses adrenocortical function to treat a patient with hypercortisolism due to ectopic corticotropin (ACTH) production. Because of severe hypokalaemia, alkalosis, hypertension, and psychosis, a 53-year-old man was transferred to our intensive care unit. Ectopic ACTH production was demonstrated by the absence of a gradient for ACTH levels in both jugular veins, right atrial, and the cubital veins. High resolution cranial computerised tomography was negative, and ACTH did not increase after administration of corticotropin-releasing factor. Furthermore, cortisol remained high during administration of high-dose dexamethasone. The acute psychotic agitation of the patient prompted us to try continuous etomidate infusion for treatment of both the psychosis and the
hypercortisolism. Plasma cortisol was 45 g/dl and ACTH (by radioimmunoassayl) 345 pg/ml. During continuous infusion of etomidate (supplied by Janssen as 125 mg/ml alcoholic solution) at 15- 30 mg/h cortisol levels fell to 5 pg/dl within 8 h. On reduction of the etomidate infusion, cortisol levels increased and vice versa. In contrast to the response in healthy people2 and to short-term infusions ACTH also decreased, to 92 pg/ml after 3 days of etomidate infusion; and it did not increase within 2 days, when etomidate infusion was stopped. was
Accident and
Emergency Department, Hope Hospital, Salford M6 8HD, and MRC Trauma Unit 1. Randall PE, Heath
Emerg Med
DF, Little KA. How 1985; 2: 174-75.
P. E. RANDALL common is
accidental
hypothermia?
Arch
STAGING OF HEAD-AND-NECK CANCER
SIR,-Distant metastases are present in 10-12% ofhead-and-neck due to squamous cell carcinoma. The metastases increases with TNM stage to 19 5% for cancers
risk of distant IV-MO. In
stage
52% of distant metastases the site is the lung. Moreover, prospective panendoscopic studies ofhead-and-neck cancer patients have stressed the high rate of synchronous second primary carcinomas in the lung, oesophagus, or head-and-neck area.22 We have done a cost-benefit audit of current investigations used to stage advanced head-and-neck cancer, with particular emphasis on bone scan, ultrasonography, and endoscopy. 130 consecutive patients with previously untreated and inoperable stage IV squamous cell carcinomas of the head and neck entered a prospective trial of neoadjuvant chemotherapy. Pretreatment evaluation included measurement of serum calcium, chest X-ray, laryngoscopy, oesophagoscopy, bronchoscopy, abdominal ultrasonography, and bone scan. 10 patients (7’ 5%) had distant metastases to the lung (6), bone (2), skin (1), or to lung, bone, and liver (1). Bone scan disclosed asymptomatic bone metastases in only 1 patient. Since the only patient with liver metastases also had lung and bone secondaries the TNM stage was in no case modified by the abdominal ultrasound
findings. 15 patients
had hypercalcaemia (above 2 -60 nmol/1) but 11 of these had no detectable distant metastases. 19 patients (18%) had multiple synchronous primary carcinomas-7 in the head-and-neck area, 9 in the oesphagus, and 3 in the bronchial tree. Oesophagoscopy disclosed 9 asymptomatic carcinomas (ie, all the oesophagus-associated carcinomas) while bronchoscopy revealed only 2 of the 3 primary lung carcinomas. On cost-benefit grounds bone scan, abdominal ultrasonography, and bronchoscopy cannot be recommended in a planned pretreatment evaluation of inoperable stage IV head-and-neck cancer, and we suggest that only chest X-ray, serum calcium measurement, be retained. and
oesophagoscopy
Department of Medicine, Institut Jean-Godinot, 51056 Reims, France; and Otolaryngology Department, Hopital Robert Debré, Reims
F. MARECHAL P. CONINX M. LEGROS S. NASCA D. LEBRUN A. CATTAN
Serum cortisol (* ——— W)and plasma ACTH (0---0) before and during continuous etomidate infusion.
The etomidate infusion had
an acute
sedative effect
on
the
psychotic agitation. Within a few days the hypertension and hypokalaemia were improved as cortisol levels fell. No other severe side-effects of etomidate were seen over 14 days of etomidate infusion. To our knowledge, this is the first demonstration of the prompt and beneficial effect of etomidate on hypercortisolism. ACTH levels fell too, though not to normal values. The mechanism for the blocking of ACTH release is unknown. A comparable effect’of ketoconazole on cortisol and ACTH release during long-term treatment of patients with Cushing’s disease has been described,33 but again the decrease in ACTH was not explained. Etomidate seems to affect both cortisol and ACTH release more strongly and more rapidly than ketoconazole does. Medizinische Klinik Innenstadt,
University of Munich, D-8000 Munichen 2, West Germany; and Institut für Anaesthesiologie, University of Munich
ROLAND GÄRTNER MICHAEL ALBRECHT OTTO ALBRECHT MÜLLER
OA, Fink R, Baur X, Ehbauer M, Madler M, Scriba PC. ACTH in plasma: and determination. GIT Labormed 1979; 2: 117-24. 2. Allolio B, Stuttmann R, Fischer H, Leonhardt W, Winkelmann W. Long-term etomidate and adrenocortical suppression. Lancet 1983; i: 626. 3. Angeli A, Frairia R. Ketoconazole therapy in Cushing’s disease. Lancet 1985; i: 821. 1. Müller
extraction
1. Merino O. An analysis of distant metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 1977; 40: 145-51. 2. McGuirt W. Multiple simultaneous tumours in patients with head and neck cancer. Cancer 1982; 50: 1195-99.
INCIDENCE OF HYPOTHERMIA Nov 2 editorial indicates that hypothermia is of death, while Dr Lloyd (Dec 21/28, p 1434) casts doubt on this interpretation. We have reported’ a doubling of the death rate in old people in January and February, 1985, over the rate in similar periods in 1983 and 1984 when the winters were milder. The prolonged cold periods in January and February, 1985, certainly played a part in the increased death rates. We expected an increase in hypothermia among those admitted to hospital but this did not happen; the patients were dying before they arrived at hospital. We cannot say that their deaths were due to hypothermia but this must have played a part. Equally, necropsy will not reveal evidence of hypothermia, merely intercurrent disease which most old people will have anyway. To say that a patient has had a cerebrovascular accident does not mean that he died of this. An episode of hypothermia after a stroke could be responsible for a death that might not otherwise have happened. Since October, 1985 (up to January 1, 1986) this hospital has received 13 elderly hypothermic patients. I do not consider that hypothermia is rare. If the weather is too cold the patients die at home and are not registered as hypothermic. If the weather is milder then more patients survive to reach hospital with hypothermia.
&R,-Your
uncommon as a cause
EFFECT OF ETOMIDATE ON HYPERCORTISOLISM DUE TO ECTOPIC ACTH PRODUCTION
SIR,-We have made use of the fact that etomidate suppresses adrenocortical function to treat a patient with hypercortisolism due to ectopic corticotropin (ACTH) production. Because of severe hypokalaemia, alkalosis, hypertension, and psychosis, a 53-year-old man was transferred to our intensive care unit. Ectopic ACTH production was demonstrated by the absence of a gradient for ACTH levels in both jugular veins, right atrial, and the cubital veins. High resolution cranial computerised tomography was negative, and ACTH did not increase after administration of corticotropin-releasing factor. Furthermore, cortisol remained high during administration of high-dose dexamethasone. The acute psychotic agitation of the patient prompted us to try continuous etomidate infusion for treatment of both the psychosis and the
hypercortisolism. Plasma cortisol was 45 g/dl and ACTH (by radioimmunoassayl) 345 pg/ml. During continuous infusion of etomidate (supplied by Janssen as 125 mg/ml alcoholic solution) at 15- 30 mg/h cortisol levels fell to 5 pg/dl within 8 h. On reduction of the etomidate infusion, cortisol levels increased and vice versa. In contrast to the response in healthy people2 and to short-term infusions ACTH also decreased, to 92 pg/ml after 3 days of etomidate infusion; and it did not increase within 2 days, when etomidate infusion was stopped. was
Accident and
Emergency Department, Hope Hospital, Salford M6 8HD, and MRC Trauma Unit 1. Randall PE, Heath
Emerg Med
DF, Little KA. How 1985; 2: 174-75.
P. E. RANDALL common is
accidental
hypothermia?
Arch