[Collagenase 3 mRNA expression in squamous epithelial carcinomas of the oropharynx]. / Kollagenase-3-mRNA-Expression in Plattenepithelkarzinomen des Oropharynx.

BACKGROUND: Metalloproteinases (MMP) are endopeptidases, which are able to degrade extracellular matrix. It is assumed that MMP play an important role in invasion and metastasis of malignomas. The expression of collagenase-3, also named MMP-13, was already detected in squamous cell carcinoma of the head and neck, but the significance in the process of metastasis is still unclear. PATIENTS AND METHODS: 36 tumor biopsies of oropharyngeal squamous cell carcinoma (10 cases N0, 26 patients N+) and 12 biopsies of normal oropharyngeal mucosa were analysed with reverse transcriptase-PCR and Northern Blot for their mRNA-expression of MMP-13 and TIMP-1, the physiological inhibitor of MMP-13. RESULTS: In 30 of 36 (83.3%) tumor biopsies a MMP-13-mRNA-expression was detected. In 9 of 10 (90%) cases with N0-status and 21 of 26 (80.7%) cases with N(+)-neck the mRNA-expression could be shown. There was no correlation between MMP-13-mRNA-expression and N-status. In 34 tumor biopsies (94.4%) a TIMP-1-expression was detected. MMP-13-mRNA was not detected in normal oropharyngeal mucosa. CONCLUSIONS: It seems that MMP-13-mRNA-expression is not a prognostic factor for metastatic behavior of oropharyngeal cancer and therefore not helpful for further decisions on the therapy.

Lipoma of the larynx. Report of 2 cases and review of the literature.

Among the primary mesenchymal tumors of the hypopharynx and larynx lipomas are very rare, as they often look macroscopically like retention cysts. Up today approximately 112 cases have been described in literature. We present two further cases of laryngeal lipomas, which were removed endoscopically and by an external approach. Both patients were free of local recurrence.

[Manifestations of primary vasculitis in the ENT region]. / Erscheinungsbild primärer Vaskulitiden im HNO-Bereich.

The primary ANCA associated vasculitides, Wegener's granulomatosis (WG), Churg Strauss syndrome (CSS) and microscopic polyangiitis (MPA), frequently affect the ENT region. For several reasons WG is of special significance for the otorhinolaryngologist. First, disease activity limited to the upper respiratory tract (localized WG) often proceeds the systemic vasculitis (generalized WG). The early diagnosis therefore has decisive consequences for stage adapted therapy. Second, in most cases (nearly 80%) WG is diagnosed histologically on biopsy specimens from the ENT region. During the initial phase of WG this is of diagnostic relevance, because at this stage the serologic parameters (acute-phase proteins) usually have a normal value and PR3-ANCA is (still) negative in 2/3 of the patients. Third, in many cases recurrences reveal increased activity in the ENT region, or start in this area. Clinically in most cases chronic rhinosinusitis with crusting and epistaxis is seen, sometimes with septal perforation and/or saddle nose. Apart from this there are often unclear middle ear symptoms with recurrent effusions and the inner ear is sometimes also affected. Laryngeal manifestations are typically located in the subglottic area and lead to subglottic stenosis. In the differential diagnosis, diseases in which epitheloid cell granulomas occur, such as sarcoidosis and TBC, need to be considered, but also foreign body granulomas and fungus diseases. Finally malignant tumours, especially malignant lymphomas, have to be ruled out.

Experimental and clinical results of Er:YAG laser stapedotomy.

BACKGROUND AND OBJECTIVE: At the beginning of the 1980s, different laser types were used for stapes surgery to reduce potential harm to inner ear structures through manipulation with conventional instruments during stapedotomy. Most clinical studies were carried out with the CO2 or the argon laser. The Er:YAG laser has been used rarely in patients with otosclerosis. STUDY DESIGN/MATERIALS AND METHODS: In an experimental study on 54 human petrous bones, the optimal laser energy parameter for dissection of the posterior stapes crus and the footplate perforation were determined. With these parameters, stapedotomy was carried out with the Er:YAG laser in 29 patients with otosclerosis with a conventional dissection of the incudostapedial joint and the stapedius muscle tendon. The Er:YAG laser was used (60 or 100 mJ, 3-6 pulses) for dissection of the posterior stapes crus and footplate perforation. RESULTS: No intra- or postoperative complications were observed in all 29 patients. Vertigo and hearing loss were not observed intra- or postoperatively. The postoperative hearing results (improvement of the air-bone gap) was in all cases satisfactory (median remaining air bone gap, 8.1 dB). The median operation time was 29 minutes (15-42 minutes) and did not show a significant prolongation in comparison to the conventional technique. In 1 of the 29 patients, the footplate perforation needed to be carried out conventionally. CONCLUSION: For the first time, Er:YAG laser parameters have been optimized and refined in a human petrous bone model and were then used in a clinical setting. According to the presented results, the Er:YAG laser seemed to be a very suitable instrument for stapedotomy.

Transcriptional repression of the human fibronectin gene in laryngeal squamous cell carcinoma cells.

PURPOSE: The aim of the experiments was to analyze the mRNA expression pattern and verify the repression of FN gene expression in laryngeal squamous cell carcinoma (SCC) cells in comparison with benign mucosal keratinocytes. METHODS: Messenger RNA from SCC cells and benign keratinocytes was reverse transcribed and subjected to PCR following differential display (DD) analysis of the amplicons. Northern hybridization was carried out to confirm the reduction of the FN-mRNA expression in both laryngeal SCC cells and larynx carcinoma biopsies, in contrast to adjacent normal mucosa. Quantitation of protein synthesis was performed with homogenates of fresh tumor biopsies and their normal phenotypes, as well as of benign keratinocytes and laryngeal SCC cell lines, respectively, using ELISA. In the liposome-mediated transient transfection assay, FN promoter activity was analyzed by linking the FN promoter sequence to the chloramphenicol acetyltransferase (CAT) reporter gene. Transfection efficacy was monitored by co-transfection with pGL3 control vector. RESULTS: A 191 bp mRNA fragment revealing a 99% homology with the human FN-mRNA was detected, the expression of which was repressed 20 times as much in SCC cells as compared to benign phenotypes. Northern hybridization confirmed the distinctly reduced expression of FN-mRNA in both laryngeal SCC cells and larynx carcinoma biopsies, in contrast to adjacent normal mucosa. The quantitation experiments showed a correlation between the range of FN synthesis and the expression of FN-mRNA in cell lines and the biopsies which were used. The 1.28 kb FN gene promoter drove expression of the CAT reporter gene, which was similar to the FN-mRNA expression showed by DD and Northern hybridization. CONCLUSIONS: The mechanisms leading to the low level of FN in many tumors have not yet been sufficiently investigated. Our findings suggest that the decrease of FN in laryngeal SCC cells is transcriptionally regulated.

p53 analysis of laryngeal cancer in exon 4 to 9.

p53 gene mutations are a common genetic alteration in human cancer and codon 72/exon 4 polymorphism of the p53 gene has been implicated in cancer risk. Therefore in this study the p53 gene status of 32 shock-frozen tumor specimens from larynx carcinomas was analyzed by PCR and sequencing of exon 4 through 9. Four mutations (12.5%) in exon 5, 7, 8 and 9 were detected in the carcinoma specimen. Analysis of codon 72 revealed in eight cases a homozygosity for proline (CCC) and in 24 cases heterozygosity or homozygosity for arginine (CGC). The group with the proline/proline genotype had a median age 10.3 years lower than the remaining patients and included the only two non-smokers. Firstly, these results confirm the p53 mutational status of laryngeal cancer without any clinical correlation and secondly may suggest an oncogenic potential for the proline/proline genotype of codon 72 for laryngeal cancer as has already been assumed for lung cancer.

Cyfra 21-1: a serological help for detection of distant metastases in head and neck cancer.

Local and neck recurrences of squamous cell carcinoma of the head and neck (SCCHN) can mostly be detected early when the patient has regular follow-ups. Distant metastases though usually remain undiscovered until they produce clinical symptoms. Since Cyfra 21-1 correlates with the tumor size and stage in SCCHN, we looked for possible connections between Cyfra 21-1 increases and the development of distant metastases. The sera of 830 patients with SCCHN were tested for Cyfra 21-1. The levels were compared with the clinical run of the patients. When Cyfra 21-1 levels rose above the threshold of 3.3 ng/ml (71 out of 830) staging procedures were performed. Tumor growth was found in 50 out of 71 patients with elevated Cyfra levels (70.4%). Cyfra serum levels in those cases either represented development of distant metastases (27 out of 71), or local and neck recurrences. The results of this study show that Cyfra 21-1 is a suitable and helpful serological parameter for the follow-up of patients with SCCHN. In the event of an elevation of Cyfra 21-1 above the threshold during follow-up, we would recommend the performance of a thoracal CT-scan and abdominal omi ultrasound as staging procedures.

Serum p53 autoantibodies in the follow-up of head and neck cancer patients.

p53 autoantibodies (AAB) are a fairly new serological parameter in patients with malignancies. Although the actual mechanism of how they develop is still unclear, it seems that these AAB could be of prognostic relevance. Very few studies demonstrated the usefulness of p53 AAB in the follow-up of cancer patients. In this study, 109 patients with head and neck cancer were investigated using an ELISA for the presence of p53 AAB in their serum and were followed-up for at least 36 months. In 21 of the cancer patients, p53 serum AAB were detected. In 5/21 p53-seropositive AAB patients, a correlation with the clinical course was observed. Sixteen of the p53-positive patients did not show any significant AAB titer changes during the follow-up, and no significant correlation with the clinical course was seen. According to these results, the clinical value of p53 AAB in the follow-up of patients with head and neck cancer seems to be limited.

Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society.

The European Laryngological Society is proposing a classification of different laryngeal endoscopic cordectomies in order to ensure better definitions of post-operative results. We chose to keep the word "cordectomy" even for partial resections because it is the term most often used in the surgical literature. The classification comprises eight types of cordectomies: a subepithelial cordectomy (type I), which is resection of the epithelium; a subligamental cordectomy (type II), which is a resection of the epithelium, Reinke's space and vocal ligament; transmuscular cordectomy (type III), which proceeds through the vocalis muscle; total cordectomy (type IV); extended cordectomy, which encompasses the contralateral vocal fold and the anterior commissure (type Va); extended cordectomy, which includes the arytenoid (type Vb); extended cordectomy, which encompasses the subglottis (type Vc); and extended cordectomy, which includes the ventricle (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach used and the degree of resection in order to facilitate use of the classification in daily practice. Each surgical procedure ensures that a specimen is available for histopathological examination.

An interdisciplinary approach to the care of patients with Wegener's granulomatosis: long-term outcome in 155 patients.

OBJECTIVE: To examine the outcome in 155 consecutive patients with Wegener's granulomatosis (WG) followed up for a median of 7 years. METHODS: Treatment was adapted to the activity and extent of disease, with regular evaluation by an interdisciplinary team accompanied by group education about vasculitis. RESULTS: The estimated median survival time was 21.7 years (95% confidence interval [95% CI] 15.60-27.86). Twenty-two patients died; 19 deaths were attributable to WG and/or its treatment. Significant predictors of survival at diagnosis were age >50 years (hazard ratio [HR] 5.45, 95% CI 1.97-15.02), kidney involvement with impaired renal function (HR 5.42, 95% CI 1.76-16.68), and lung involvement (HR 3.75, 95% CI 1.26-11.16). At some stage, 142 patients received prednisone and cyclophosphamide (CYC), usually as daily CYC plus mesna as uroprotection, 50 patients received trimethoprim/sulfamethoxazole, and 45 received methotrexate. Complete remission was achieved in 83 of the 155 patients. One or more relapses occurred in 99 patients after either complete or partial remission. CYC-induced cystitis and myelodysplastic syndrome occurred in 17 and 11 patients, respectively. A cumulative dose of 100 gm or more of CYC resulted in a 2-fold greater risk of CYC-related morbidity than with lower CYC doses. Serious infections occurred in 41 patients. CONCLUSION: An interdisciplinary approach to the care of 155 WG patients resulted in a median survival of >21 years. Kidney or lung involvement at diagnosis was predictive of a >3-fold higher mortality. Although CYC remains essential in the treatment of WG, it was administered as briefly as possible and under close surveillance to avoid permanent CYC-related morbidity, which can lead to serious therapeutic problems in chronic relapsing WG.

Antibodies against oncoproteins E6 and E7 of human papillomavirus types 16 and 18 in patients with head-and-neck squamous-cell carcinoma.

Human papillomaviruses (HPVs) have been recognized as an essential pathogenic factor in anogenital cancer. HPV DNA has also been found in a subgroup of head-and-neck squamous-cell carcinomas (HNSCCs), and a causative role of the virus in the development of these tumors has been suggested by the concomitant inactivation of the tumor-suppressor protein pRb. Using 4 second-generation ELISAs, we found antibodies against at least 1 of the oncoproteins E6 and E7 of the high-risk HPV types 16 and 18 in 11 of 92 sera (12%) taken from HNSCC patients at or near diagnosis, in 1 of 52 sera (2%) taken from HNSCC patients >6 months after diagnosis and in 10 of 288 sera (3. 5%) taken from sex- and age-matched healthy control individuals of the normal population. In 11 of the 12 seropositive HNSCC cases, antibodies were directed against HPV16 proteins. In patients, the HPV16 antibodies were mostly of high titer, and in 6 cases, antibodies against both HPV16 oncoproteins were present. Seven of the 8 HPV16 antibody-positive sera from the control group were of low titer, and none of the 10 antibody-positive sera reacted with both oncoproteins of the same HPV type. The HPV type of the antigens detected by the antibodies in HNSCC patients correlated well with that of the HPV DNA found in the tumor. Of 19 patients known to have HPV16 DNA-positive tumors, 7 (37%) also had HPV16 E6 and/or E7 antibodies. Our finding suggests that the antibodies were formed in an immune response against HPV E6 and E7 proteins expressed in the HNSCC and thus strongly supports the concept of a biologically active role of HPV in the development of a subgroup of HNSCC.

Tracing human papillomavirus DNA in nasal polyps by polymerase chain reaction.

Human papillomavirus (HPV) infections are related to the genesis of various benign and malignant human neoplasias. The HPV types 16 and 18 seem to be causally related to the development of most squamous cell carcinoma of the anogenital tract and a proportion of carcinomas of the upper aerodigestive tract. The near 100% positivity of the HPV types 6 and 11 in laryngeal papillomatosis is well established. We investigated whether HPV also plays a role in non-neoplastic mucosal entities such as sinunasal polyposis, the genesis of which has been discussed as being triggered by viral infections. On DNA from 39 sinunasal polyps (33 patients), polymerase chain reaction (PCR) was performed using beta-globin primers for demonstration of amplifiable DNA in the tissue extracts. Consensus primers for the detection of several different HPV types were applied to the beta-globin-positive samples. The results were confirmed by Southern blot hybridization using consensus probes. Cycle sequencing was performed on the positive cases. All 39 samples showed positive signals for beta-globin. HPV-DNA investigations showed a slight positive signal in only 1 of the 39 investigated cases (2.6%). Further molecular investigations of this sample, including cycle sequencing, could not confirm this result. All the other tissue samples remained HPV-DNA-negative. Therefore, those HPV types readily detectable with the PCR primers and probes used are not frequently associated with sinunasal polyposis. The data confirm the hypothesis that HPV is correlated to a lesser extent to infectious mucosal lesions than to proliferative lesions. Furthermore, the results emphasize that the presence of HPV in specific lesions does not occur by chance, but represents a specific infection of the mucosa leading to proliferation and even to malignancy.

Transcriptional repression of the human galactocerebrosidase gene in squamous cell carcinomas of the larynx.

Alterations of gene expression in squamous cell carcinoma (SCC) cell lines derived from the larynx and keratinocytes derived from adjacent normal mucosa of the larynx have been studied using the mRNA differential display technique. Lane-to-lane comparison of reverse transcribed mRNA showed a strong repression of a 148 bp fragment in SCC cells. The fragment was reamplified and cloned. Sequencing revealed a 99.3% homology with a region in exon 17 of the human galactocerebrosidase (GALC) gene. Northern blot analysis confirmed the differential expression of this gene in both carcinoma cell lines and laryngeal SCC biopsies in contrast with corresponding normal mucosa. To provide further evidence for the differential expression rate, both types of cells were transiently transfected with a 152 bp (-176 to -24) high regulatory promoter element of the 5' flanking region of the GALC gene. Results of 3 independent transfection experiments indicated a 16-fold repression of the GALC gene expression in SCC cells compared with benign keratinocytes. However, neither mutation nor other alterations of the promoter sequence were detected. Expression of the GALC gene is thus greatly affected in SCCs of the larynx.

[Surgical treatment of auditory canal exostoses]. / Die operative Behandlung von Gehörgangsexostosen.

BACKGROUND: Although complications of surgical removal of external auditory canal exostoses are rare, reported surgical complications include tympanic membrane perforation, postoperative hearing loss, canal stenosis, and facial nerve injuries. PATIENTS AND METHODS: We report on our experience in exostosis surgery, consisting of 59 procedures in 48 patients. Preoperative and postoperative complaints and findings, intraoperative complications, and audiologic results are described and discussed. There has been a minimum of one year of follow-up in every case. RESULTS: Postoperative canal stenosis was seen in 2 cases of preoperative severe persistent external otitis. Temporary threshold shift was recorded in 6 patients. Persistent sensorineural hearing loss occurred in 4 patients. Six of the 10 patients with temporary or persistent hearing loss had already shown preoperative sensorineural hearing loss. Intraoperatively tympanic membrane perforation occurred in 3 cases, accidental opening of the mastoid in 1 case. CONCLUSIONS: Exostosis surgery should be reserved for uninfected ear canals. Meatal skin preservation without circular meatal flap incision is recommended to avoid postoperative canal stenosis. Especially in cases of preexisting sensorineural hearing loss, attention should be focused on the intraoperative noise reduction by tympanic membrane protection and pauses of noise exposition.

Management of Zenker's diverticulum and postlaryngectomy pseudodiverticulum with the CO2 laser.

Dysphagia is a common symptom and can be caused by anterior pharyngeal (pseudodiverticulum after laryngectomy) and posterior pharyngeal (Zenker's) diverticula. The only treatment is surgical. The experience with an endoscopic treatment, especially with the CO(2) laser, is limited. Between 1984 and 1996, 81 patients with dysphagia were treated endoscopically with the CO(2) laser at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Kiel. In 70 patients the swallowing disorder was caused by a hypopharyngeal diverticulum, and in 11 patients it was caused by a pseudodiverticulum after laryngectomy. In the Zenker's group, more than 90% of the patients were treated successfully. Eight of 11 patients with pseudodiverticula were without symptoms, and in the remaining 3 patients dysphagia was improved after laser therapy. The excision technique was superior to the incision procedures. The rate of postoperative complications was generally low. The microendoscopic approach with the CO(2) laser is a recommendable method for the treatment of Zenker's diverticulum and pseudodiverticulum in the postlaryngectomy patient. The surgical technique with the CO(2) laser at low power settings is a less invasive, quick, relatively safe, and effective procedure requiring only short hospitalization.

Transoral carbon dioxide laser resection of supraglottic carcinoma.

Between 1981 and 1994, 34 patients with squamous cell carcinoma of the supraglottis were treated by transoral carbon dioxide laser resection, 12 of them palliatively. Additional treatment included neck dissection in 21 patients and radiotherapy in 24 patients. The 3-year overall survival was 62%, and the actuarial survival 80%. The overall survival for T1 and T2 tumors was 71%, and that for T3 and T4 tumors was 47%. The overall 3-year survival for the early stages, I and II, was 88%, and that for the advanced stages, III and IV, was 50%. These results are comparable to the outcome after conventional open partial resection. Given the significantly lower morbidity (only 7 patients required tracheostomy), we do not observe an age limit anymore. The transoral method can be recommended as curative treatment in T1 and T2 tumors and in selected T3 and T4 tumors in concert with neck dissection and/or radiotherapy. In patients with advanced inoperable tumors, laser surgery is an excellent alternative to tracheostomy and palliative radiotherapy. Prerequisites for successful application of the transoral carbon dioxide laser resection are adequate resection techniques.