[Current immuno-oncology in head and neck cancer]. / Status quo der Immunonkologie bei Plattenepithelkarzinomen des Kopf-Halsbereichs.

For many years surgery, radiotherapy and chemotherapy dominated the treatment in head and neck malignancies. Refinements of the particular techniques, either in surgery or in radiooncology, brought some progress. However, clinical outcome data are still not satisfying and side effects and long term toxicities are significant. Apart of the improvement of overall results, the reduction of side effects stays a main goal in this field. Targeted therapies as well as immune modulating therapies represent a new generation in the treatment of cancer. The development of new and highly effective substances makes rapid progress and immunotherapy has become a standard in the treatment of recurrent head and neck cancer. The following chapter will give you an actual review about the status quo of immunotherapy in head neck malignancies.

Long-term improvement of clinical symptoms after endoscopic sinus surgery in patients suffered from endocrine ophthalmopathy and orbital complications of rhinosinusitis.

Background: Rhinosinusitis may cause serious complications, such as secondary orbital infections, resulting in expansion and erosion of process through the orbital wall. Aims: The aim is to evaluate long-term outcome of ESS in patients suffered from endocrine ophthalmopathy and orbital complications of rhinosinusitis. Material and methods: Thirteen patients with loss of vision, endocrine ophthalmopathy and orbital complication of rhinosinusitis were treated by ESS. Preoperative and postoperative vision was rated by best-corrected visual acuity (BCVA) testing. Nine (69%) have been reinvestigated after 6 years by ophthalmology examination and 10-point scale for assessment of clinical symptoms. Results: The mean BCVA significantly increased after surgery comparing to results before surgery (0.84, 0.62; respectively) (p = .007). The mean values of 10-point scale for subjective assessment of symptoms 6 years after surgery were: headache 2.11, sinonasal pressure 1.72, subjective estimation of vision quality on the affected eye was 7.33 and olfaction 7.66. None of the patients developed impairment of vision loss in postoperative period. Conclusions: Long-term outcome of ESS showed decreased symptoms in patients who had endocrine ophthalmopathy and orbital complication of rhinosinusitis. Significance: ESS has numerous advantages for patients with orbital complication and vision loss comparing to conservative treatment and should be considered even in abscess absence.

New vessel formation in peritumoral area of squamous cell carcinoma of the head and neck.

BACKGROUND: This study was conducted to investigate the dynamic process of new vessel formation, fundamental for tumor growth and metastasis, in head and neck squamous cell carcinoma (HNSCC). METHODS: We used immunohistochemistry, confocal laser-scanning microscopy, and reverse transcriptase-polymerase chain reaction to study endothelial cell and concomitant pericyte development with markers CD133, CD34, VEGFR-2, CD31, vWF, and STRO-1 in tumor and peritumoral tissues of 18 patients with HNSCC. RESULTS: Highly compressed and structurally abnormal vessels with barely any activity of new vessel formation were found in tumor tissue, whereas the adjacent peritumoral tissue vessels showed a normal architecture with tight endothelial cell-pericyte interaction and a high activity of angiogenesis. Endothelial precursor cells expressing CD133/VEGFR-2 could be incorporated into these newly formed vessels, forming cell clusters from which a thin endothelial lining could emanate. CONCLUSIONS: These data show a high activity of new vessel formation in the peritumoral stroma of HNSCC, with endothelial precursor cells being incorporated into these structures.

[Follow up in head and neck cancer]. / Nachsorge bei Kopf-Hals-Karzinomen.

Some principle questions rise in follow up of tumour patients: Is there a chance to detect tumour recurrence or a second primary early enough to give the patient reasonable options of cure or at least lead to a better survival? What means will be necessary to achieve this goal? Do the means justify the outcome? This paper determines and compares current regimens and strategies in the follow up of head and neck cancer patients. It stresses not only the questions stated above, but also stresses additional points of view in the follow up like speech and swallow rehabilitation, as well as social reintegration and psychological support of head and neck tumour patients. Standard follow up includes facilities for speech and swallow rehabilitation. Summarizing the literature follow up mainly is based on the clinical examination and the work up of the recent medical history. Since most relapses occur within the first two years, recommendation of visit-intervals is every two months, range should be risk-adapted. Up to now there is no evidence for better overall survival using sumptuous means like repeated panendoskopies, laboratory parameters, CT's, MRIs or PETs for detecting disease relapse in the asymptomatic patient. In high risk cancer patients the intervals will be shortened compared to the average schedule recommended. Additional tests will be initiated on demand only. Since clinical evaluation of symptoms in head and neck cancer patients is difficult to assess there is an increased responsibility with respect to the indication for extended diagnostic work up. Therefore this should be reserved for well equipped and highly trained ENT Oncologists.

Quantitation of microvessel density in squamous cell carcinoma of the head and neck by computer-aided image analysis.

OBJECTIVE: Angiogenesis is the formation of new blood vessels from a preexisting vascular network. In healthy individuals it is normally suppressed and observed only transiently during development, reproduction and wound healing. However, growth, invasion, and metastasis of most solid tumors are dependent on angiogenesis. Without formation of new blood vessels, also termed as neovascularization, tumors cannot exceed a size of about 1 mm3. Therefore, neovascularization is a basic requirement for nutrition and oxygenation of tumor cells. Numerous studies in different solid as well as non-solid tumors have evaluated the prognostic value of tumor neovascularization. In solid tumors the increased microvessel density, the pathological correlate to tumor neovascularization, has been linked to a worse prognosis of the disease. The aim of the current study was to assess the prognostic value of tumor neovascularization for recurrences in squamous cell carcinoma of the head and neck by determining microvessel density. Data was collected using an automated-computerized method and as well as a manual counting method. BASIC RESEARCH DESIGN: Immunohistochemistry was performed to detect intratumoral microvessels in tumor samples of 50 patients with squamous cell carcinoma of the head and neck. We used a monoclonal mouse antibody directed against the CD34 antigen. After immunostaining, the entire tumor section was scanned microscopically at low power (x 40) to identify hot spots, which are the areas of highest neovascularization. Individual tumor microvessels were then counted under high power (x 200) to obtain a vessel count in a defined area, and the average vessel count in 4 hot spots was taken as the microvessel density. Microvessel counting was performed twice by computerized method, as well as manually by two independent investigators without any previous knowledge of patients' pertinent clinical data. Subsequently, both counting techniques were statistically compared with each other. RESULTS: On computer-aided image analysis an increased microvessel density was significantly correlated with recurrence of disease (p = 0.02). Repetitive computer counts yielded similar results (p = 0.08), whereas repeated manual counts by two investigators varied significantly (p = 0.04). However, no further statistical correlations between microvessel density and patients clinical data i.e. tumor status, lymph node status, overall survival, or disease free interval could be found. Furthermore, estimation of overall survival of patients with an increased microvessel density by Kaplan-Meier curves revealed non-significant results. CONCLUSION: There is mounting evidence that suggests, that assessment of tumor neovascularization might provide a novel approach of prognostication in patients with squamous cell carcinomas of the head and neck. In particular, in the present study, the degree of angiogenesis of a tumor, as assessed by microvessel density, was found to be correlated with recurrent disease in squamous cell carcinoma of the head and neck. Computer aided image analysis, an automated technique, constitutes a time-efficient and reproducible technique for quantification of tumor vascularization. We suggest that this computerized microvessel determination could be used as a reliable method for microvessel counts, which, furthermore, seems to be superior to manual counting. However, for a reliable and reproducible assessment of tumor neovascularization, validation procedures and quality control protocols are mandatory.

Differential expression pattern of cyclooxygenase-1 and -2 in head and neck squamous cell carcinoma.

OBJECTIVE: The enzyme cyclooxygenase catalyzes the first step of the synthesis of prostanoids Cyclooxygenase has been shown to exist in two distinct isoforms: cyclooxygenase-1 is constitutively expressed as a housekeeping enzyme in most tissues whereas the inducible cyclooxygenase-2 has been reported to be involved in inflammatory processes and in the carcinogenesis of squamous cell carcinoma. The aim of this study was to investigate the distribution patterns of cyclooxygenase-1 and -2 in peritumoral lymphocytic infiltrates and tumor cells of head and neck carcinoma. MATERIAL AND METHODS: Immunohistochemical analysis was performed using paraffin-embedded tumor specimens from 24 patients suffering from oropharyngeal, hypopharyngeal and oral squamous cell carcinomas. RESULTS: We observed that cyclooxygenase-2 immunoreactivity, compared to that of cyclooxygenase-1, was significantly increased in peritumoral lymphocytic infiltrates as well as in tumor cells. CONCLUSION: The expression of cyclooxygenase-2 in both tumor specimens and the surrounding peritumoral lymphocytic infiltrates supports the hypothesis that cyclooxygenase may be one of several important links between chronic inflammation and carcinogenesis.

CD9 expression on lymphatic vessels in head and neck mucosa.

CD9, a member of the transmembrane 4 superfamily, is involved in cell adhesion, migration, and tumor metastasis. Little is known about its vascular expression pattern. In this study, we investigated CD9 expression on endothelial cells in the mucosa of the head and neck and compared it with vascular tumors. Using immunohistochemistry, expression of CD9 was studied in 17 samples of head and neck mucosa and skin (laryngeal mucosa: n = 2, oral: n = 6, and epidermis: n = 9) and a variety of vascular tumors (lymphangiomas: n = 9, juvenile nasopharyngeal angiofibromas: n = 4, hemangiomas: n = 7, angiosarcomas: n = 5, and Kaposi's sarcomas: n = 7) and compared with the expression of CD34 and PAL-E (blood vessel markers) and the lymphatic marker podoplanin. Regular lymphatic endothelium and lymphangiomas were strongly positive for CD9 and podoplanin but were mostly negative for PAL-E and CD34. By contrast, blood vessel endothelium and hemangiomas were strongly positive for PAL-E and CD34 but were mostly negative for CD9 and podoplanin. Weak to moderate CD9 reactivity was also observed on EC of juvenile nasopharyngeal angiofibromas, angiosarcomas, and Kaposi's sarcomas. Expression of CD9 by lymphatic EC was confirmed by reverse-transcriptase PCR and Western blot analyses. CD9 may be useful as a marker for lymphatic EC. It could promote the adherence of inflammatory and tumor cells to lymphatic EC and participate in the growth and maintenance of the lymphatic capillary net.

Motility-related protein-1/CD9 expression in head and neck squamous cell carcinoma.

INTRODUCTION: Motility-related protein (MRP)-1/CD9 is implicated in cell adhesion and motility and was shown to be clearly involved in tumor prognosis and angiogenesis. Elevated MRP-1/CD9 expression on tumor cells has been linked to a favorable prognosis in breast cancer, colon cancer, lung cancer, and HNSCC. Because MRP-1/CD9 is associated with angiogenesis, it might play a role in tumor angiogenesis as well. METHODS: We analyzed MRP-1/CD9 expression in HNSCC specimens and cell lines by real-time RT-PCR and in HNSCC biopsy specimens and stromal vessels by immunohistochemistry. Kruskal Wallis and Chi2 test, univariate and multivariate Cox regression, and Kaplan-Meier methods were used for statistical analysis. RESULTS: Real-time and PCR RT showed elevated expression of MRP-1/CD9 in one (SCC25) of four HNSCC cell lines and two of six HNSCC patients, whereas two cell lines (SCC9 and JPPA) and one HNSCC patient had lower MRP-1/CD9 levels compared with other specimens. Immunohistochemistry demonstrated strong MRP-1/CD9 IR expression on tumor cells in 13 patients (39%), whereas 21 patients (61%) had less to medium MRP-1/CD9 IR expression. Increased MRP-1/CD9 expression on tumor cells was correlated with prolonged patient survival (p =.02) and a longer disease-free interval (p =.004), a diminished recurrence rate (p =.02), and lower stages of neck lymph nodes (p =.04). MRP-1/CD9 IR was also found in a subpopulation of vessels that seem to be less in tumor specimens than in normal mucosa (p <.0001). MRP-1/CD9+ vessels are podoplanin+ and are therefore regarded as lymphatic vessels. CONCLUSIONS: Our results revealed that elevated MRP-1/CD9 expression on HNSCC is linked to a favorable clinical outcome and confirmed reports of MRP-1/CD9 expression in other carcinomas. MRP-1/CD9+ vessels were found to be lymphatic in nature. The number and staining intensity of these vessels is decreased in tumor tissue, which suggests a stabilizing role for this protein in lymphangiogenesis.

Vascular endothelial growth factor C and vascular endothelial growth factor receptor 3 expression in squamous cell carcinomas of the head and neck.

BACKGROUND AND METHODS: VEGF proteins and their receptors are involved in tumor vessel neoformation. The third VEGF receptor, VEGFR3 (flt-4) is important during both blood vessel development and lymphatic vessel formation. Because HNSCC preferentially metastasizes to regional lymph nodes, we investigated the expression of VEGFR3 and its ligand VEGF-C in head and neck squamous cell carcinomas by semiquantitative RT-PCR (4 HNSCC cells lines and 6 HNSCC specimens) and by immunohistochemistry (18 HNSCC specimens). VEGFR3 protein expression was confirmed by Western blotting in four HNSCC cell lines and six HNSCC specimens. RESULTS: Semiquantitative mRNA analysis showed VEGF-C mRNA expression in three (SCC9, SCC25, LFFR) of four HNSCC cell lines and all six HNSCC specimens. VEGFR3 mRNA was found in two HNSCC cell lines (JPPA and SCC25) and only weakly detected in the other two HNSCC cell lines (SCC9 and LFFR). High amounts of VEGFR3 mRNA were shown in all six patients' tumor specimens. VEGFR3 Western blot analysis yielded a distinct band at the predicted size of 210 kD in JPPA and SCC9 and hardly detectable bands in SCC25 and LFFR cell lines. All six HNSCC specimens displayed strong VEGFR3 protein bands. Immunohistochemistry in 18 HNSCC specimens assigned strong to mediate VEGF-C IR and minor VEGFR3 IR to tumor cells and strong VEGF-C and VEGFR3 IR to tumor surrounding vessels. In addition, intense VEGF-C immunostaining was observed on perivascular and mononuclear cells in the tumor surrounding stroma. Subtyping of VEGFR3+ microvascular tumor vessels revealed partially double immunolabeling with CD34 and flk-1, indicating a common origin of blood and lymphatic vessels. The expression of VEGF-C on tumor cells could be correlated with recurrences, and larger primary tumors had more VEGF-C-positive vessels. CONCLUSIONS: The broad expression of VEGF C and VEGFR3 in HNSCC suggests involvement in tumor lymph angiogenesis and vascular angiogenesis, promoting tumor growth and propagation of cancer cells. This implies that inhibitors of lymph angiogenesis could become effective therapeutic options similar to classical angiogenesis inhibitors.