Different cellular p16(INK4a) localisation may signal different survival outcomes in head and neck cancer.

BACKGROUND: Recently, the management of head and neck squamous cell carcinoma (HNSCC) has focused considerable attention on biomarkers, which may influence outcomes. Tests for human papilloma infection, including direct assessment of the virus as well as an associated tumour suppressor gene p16, are considered reproducible. Tumours from familial melanoma syndromes have suggested that nuclear localisation of p16 might have a further role in risk stratification. We hypothesised p16 staining that considered nuclear localisation might be informative for predicting outcomes in a broader set of HNSCC tumours not limited to the oropharynx, human papilloma virus (HPV) status or by smoking status. METHODS: Patients treated for HNSCC from 2002 to 2006 at UNC (University of North Carolina at Chapel Hill) hospitals that had banked tissue available were eligible for this study. Tissue microarrays (TMA) were generated in triplicate. Immunohistochemical (IHC) staining for p16 was performed and scored separately for nuclear and cytoplasmic staining. Human papilloma virus staining was also carried out using monoclonal antibody E6H4. p16 expression, HPV status and other clinical features were correlated with progression-free (PFS) and overall survival (OS). RESULTS: A total of 135 patients had sufficient sample for this analysis. Median age at diagnosis was 57 years (range 20-82), with 68.9% males, 8.9% never smokers and 32.6% never drinkers. Three-year OS rate and PFS rate was 63.0% and 54.1%, respectively. Based on the p16 staining score, patients were divided into three groups: high nuclear, high cytoplasmic staining group (HN), low nuclear, low cytoplasmic staining group (LS) and high cytoplasmic, low nuclear staining group (HC). The HN and the LS groups had significantly better OS than the HC group with hazard ratios of 0.10 and 0.37, respectively, after controlling for other factors, including HPV status. These two groups also had significantly better PFS than the HC staining group. This finding was consistent for sites outside the oropharynx and did not require adjustment for smoking status. CONCLUSION: Different p16 protein localisation suggested different survival outcomes in a manner that does not require limiting the biomarker to the oropharynx and does not require assessment of smoking status.

Diet, GSTM1 and GSTT1 and head and neck cancer.

A decreased incidence of squamous cell carcinoma of the head and neck (SCCHN) associated with fruit and vegetable intake may act through chemopreventive compounds, which may be more available to persons homozygous for the deletion genotypes of the glutathione S-transferase (GST). We evaluated interactions between fruits and vegetables and GSTM1 and GSTT1 on incidence of SCCHN using data from a case-control study of 149 cases and 180 age- and gender-matched controls. After adjustment for age, gender, race, tobacco and alcohol use, weekly consumption of four or more servings of raw vegetables was inversely associated with SCCHN [odds ratio (OR) = 0.66, 95% confidence intervals (CI) 0.30-1.3]. Contrary to expectation, relatively high intake of cooked vegetables (14 or more weekly servings) and legumes (two or more weekly servings) were associated with increased incidence (OR = 2.5, 95% CI 1.1-6.0; OR = 2.5, 95% CI 1.2-5.2, respectively). In general, our results did not suggest a clear or consistent pattern of modification by GST genotypes of the association between foods and SCCHN. For example, eating cruciferous vegetables, foods of a priori interest, and having the GSTM1-deletion genotype was not associated with the expected reduction in incidence compared with abstaining from cruciferous vegetable intake and having the GSTM1-present genotype. Among non-consumers of cruciferous vegetables, the GSTM1-deletion genotype was inversely associated with SCCHN (OR = 0.55, 95% CI 0.07-4.2). Raw vegetables were associated with a reduction in incidence only among persons with the GSTM1-deletion genotype (OR = 0.69, 95% CI 0.29-1.6), whereas either factor alone had a null association. Future research of GST-diet interactions and SCCHN would benefit from larger, population-based studies.

Chemoradiation for locally advanced squamous cell carcinoma of the head and neck for organ preservation and palliation.

OBJECTIVES: To measure the efficacy and toxic effects of our chemoradiotherapy regimen by means of response and survival in patients with advanced squamous cell carcinoma of the head and neck (HNSCC) for organ preservation in resectable disease or palliation in unresectable disease. DESIGN: All patients underwent evaluation by the multidisciplinary head and neck cancer team, with pathological diagnosis and staging. All patients underwent assessment for response to therapy using results of physical examination and radiologic imaging. Patients were followed up at 3-month intervals for a planned period of 5 years. SETTING: Academic center. PATIENTS: Thirty-eight previously untreated patients with newly diagnosed HNSCC were treated from June 1, 1996, through December 31, 1998, of whom 20 had resectable and 18 had unresectable tumors. INTERVENTION: Patients received intravenous cisplatin, 100 mg/m(2) for 1 hour on days 1 and 29; a 24-hour continuous infusion of fluorouracil, 1000 mg/m(2) on days 1 through 4 and 29 through 32; and radiation therapy, 150 rad twice daily for 12 days. The patients were given a 7- to 10-day break, and radiation therapy was restarted on day 29 for 12 additional days (total dose, 7200 rad). MAIN OUTCOME MEASURES: Complete, partial, and total response rates; disease-free survival; overall survival; and toxic effects. RESULTS: Toxic effects of treatment were moderately severe, including grades III to IV mucositis (89%), neutropenia (71%), and renal toxic effects (8%). In the 18 patients in the unresectable group, complete response in the 17 primary tumors and 15 cervical nodal metastases was achieved in 12 (71%) and 9 (60%), respectively; in the 20 patients undergoing organ preservation, complete response rates were 100% in the 23 primary tumors and 15 cervical nodal metastases. Complete response for all 38 patients was achieved in 31 (82%). In the unresectable group, the Kaplan-Meier relapse-free survival estimate is 56%, with follow-up from 29 to 45 months. In the organ preservation group, 75% of patients are alive without disease, and 8 have been followed up for 36 to 48 months. Of the 5 patients who have died, only 2 died of disease, with recurrences at 13.0 and 16.5 months. CONCLUSIONS: Chemoradiotherapy consisting of cisplatin, fluorouracil, and twice-daily external beam radiation is highly effective in achieving durable complete responses in patients with resectable HNSCC undergoing organ preservation and patients with unresectable HNSCC undergoing palliation. Toxic effects of this regimen were moderate to severe.

Localized laryngotracheobronchial amyloidosis: case report and review of the literature.

Although localized laryngotracheobronchial amyloidosis is rare, the otolaryngologist--head and neck surgeon should be familiar with this condition. Its characteristic appearance can suggest its presence in a patient who has the typical initial symptoms. Biopsies during direct laryngoscopy and bronchoscopy can play both a diagnostic and therapeutic role. After an appropriate examination to rule out systemic involvement, the patient should be managed with conservative surgery, although the use of a CO2 laser might be more efficacious than conventional surgery. With appropriate diagnosis and treatment, patients should expect a favorable prognosis. In this article, we describe a new case of localized laryngotracheobronchial amyloidosis in a 67-year-old woman, and we review the literature on this subject.

Risk of head and neck cancer and the alcohol dehydrogenase 3 genotype.

Squamous cell carcinoma of the head and neck (SCCHN), including the oral cavity, pharynx and larynx, is an excellent tumor model to evaluate gene-environment interactions, including alcohol and alcohol-metabolizing enzymes such as alcohol dehydrogenase (ADH). We conducted a hospital-based case-control study including 182 cases with newly diagnosed SCCHN and 202 controls with non-neoplastic conditions of the head and neck that required surgery. The joint effects of lifetime alcohol use and the presence of the ADH3 'rapid' allele (ADH3(*)1) was evaluated in relation to the risk of SCCHN. Logistic regression was used to estimate the interaction between alcohol use and ADH3 genotype with adjustment for tobacco use, age, sex and race. The interaction was evaluated on both the multiplicative and additive scales. The risk of SCCHN was increased nearly 6-fold with consumption of 40 or more alcoholic beverages per week [odds ratio (OR) = 5.9; 95% confidence interval (CI) = 2.0-17.7; adjusted for age, sex, race and years of tobacco use]. We did not find any increase in risk for ADH3*1 homozygotes (OR = 0.9; CI = 0.4-1.9) or heterozygotes (OR = 0.8; CI = 0.4-1.7) relative to ADH3(*)2 homozygotes. There was no suggestion of an interaction between any alcohol use variable and the ADH3(*)1 genotype. For example, the interaction term, including the continuous variable average number of drinks per week and the ADH3 genotypes, was non-significant (P = 0.22). The study does not indicate an important role for the ADH3 (*)1 polymorphism in SCCHN, but larger numbers are needed to more precisely estimate the interaction, if any, with ADH3.

Nodal volume reduction after concurrent chemo- and radiotherapy: correlation between initial CT and histopathologic findings.

BACKGROUND AND PURPOSE: The role of concurrent chemoradiation for treatment of head and neck squamous cell carcinoma is expanding. We sought to evaluate the CT appearance of diseased and normal cervical lymph nodes before and after concurrent chemoradiation and to correlate lymph node volume reduction as revealed by CT with histopathologic findings of resected nodes. METHODS: Using concurrent chemoradiation, we treated seven patients with locally advanced head and neck squamous cell carcinoma. Our chemotherapeutic regimen consisted of cisplatin (100 mg/m2 body surface area administered on days 1 through 4 and 29 through 32) and 5-fluorouracil (1000 mg/m2 body surface area, administered on days 1 through 4 and 29 through 32). Radiotherapy was administered twice per day on dosing days 1 through 42 to a total dose of 7200 cGy to the primary tumor and 6000 cGy to the involved lymph nodes. Pre- and post-treatment CT scans were used to calculate lymph node volumes for all CT-positive (size criteria or extracapsular spread or both) diseased nodes (n = 19) and one normal node per patient (n = 7). Volume reduction was determined by CT results and correlated with the histopathologic findings of resected nodes. RESULTS: Average volume reduction (+/- standard error of the mean) for the 19 diseased nodes was 91%+/-4% and for the seven normal nodes was 55%+/-21% (P < .02, two-sided t test). Fifteen of 19 of the diseased lymph nodes showed extracapsular spread before treatment and none of 19 after treatment. The histopathologic findings of resected nodes included persistent tumor in one of the 19 diseased lymph nodes. Six of seven patients remained alive and disease-free, with an average follow-up duration of 24 months. CONCLUSION: Nodal volume reduction of greater than 90% was associated with eradication of tumor as assessed by histopathologic analysis of resected nodes. Serial CT scans obtained both before and after concurrent chemoradiation may be useful for predicting which patients will benefit from adjuvant surgical therapy.

GSTM1, GSTT1, GSTP1, CYP1A1, and NAT1 polymorphisms, tobacco use, and the risk of head and neck cancer.

Squamous cell carcinoma of the head and neck (SCCHN), including the oral cavity, pharynx, and larynx, provides an ideal tumor model to investigate gene-environment interaction. We conducted a hospital-based case-control study including 182 cases with newly diagnosed SCCHN and 202 controls with nonneoplastic conditions of the head and neck that required surgery. Lifetime tobacco use and risk of SCCHN were evaluated in relation to the polymorphisms of GSTM1, GSTT1, GSTP1, CYP1A1, and NAT1. The main effects of genotype were associated with a slightly increased risk of SCCHN for GSTP1 [age-, race-, and sex-adjusted odds ratio (OR), 1.2; confidence interval (CI), 0.8-1.9], GSTT1 (OR, 1.2; CI, 0.7-2.3), and NAT1 (OR, 1.1; CI, 0.7-1.7). The joint effects of genotype combinations showed some excess risk for the combination of the GSTM1 null genotype and the CYP1A1 Ile/Val polymorphism (OR, 2.6; CI, 0.7-10.3). The analysis of the joint effects (interaction) of the "at-risk" genotypes and tobacco use did not reveal any interaction on either the multiplicative or additive scale for GSTM1, GSTP1, or CYP1A1. However, there was a suggestion of an interaction on the additive scale between the pack-years of tobacco use and the GSTT1 null genotype. The combined heterozygote and homozygote NAT1*10 genotypes also had a suggestive interaction with tobacco smoking history. The results of this study suggest a possible gene-environment interaction for certain carcinogen metabolizing enzymes, but larger studies that fully evaluate the interaction are needed.

Hypoxia and vascular endothelial growth factor expression in human squamous cell carcinomas using pimonidazole as a hypoxia marker.

Hypoxia in human tumors is associated with poor prognosis, but the molecular mechanisms underlying this association are poorly understood. One possibility is that hypoxia is linked to malignant progression through vascular endothelial growth factor (VEGF) induction and the associated angiogenesis and metastasis. The present clinical study measures hypoxia and VEGF expression on a cell-by-cell basis in human squamous cell carcinomas to test the hypothesis that hypoxia and VEGF protein expression are coupled in human tumors. Eighteen patients with invasive squamous cell carcinoma of the uterine cervix and head and neck have been investigated by a quantitative image analysis of immunostained sections from their tumors. The hypoxia marker pimonidazole was used to measure tumor hypoxia, and a commercially available antibody was used to measure VEGF protein expression. A quantitative immunohistochemical comparison of hypoxia and VEGF protein expression revealed no correlation between the two factors.

Nasopharyngeal carcinoma: evidence for improved survival with combined chemoradiation.

Radiation therapy has been the traditional treatment for nasopharyngeal carcinoma. Patients with advanced disease have a higher rate of locoregional as well as distant metastases, which has warranted the addition of chemotherapy in an attempt to improve survival. This retrospective study was designed to determine the absolute survival of patients with nasopharyngeal cancer treated with radiation alone, compared to that of patients receiving concurrent chemoradiation. Between December 1975 and December 1993 eight patients were treated with radiotherapy alone and 14 patients were treated with concurrent chemoradiation using 5-fluorouracil and cisplatin. Analysis of Kaplan-Meier cumulative absolute survival plots revealed that patients receiving chemoradiation survived longer than those receiving radiation alone (p = 0.0321). Patients with lymphoepithelioma, as opposed to squamous cell carcinoma, and patients younger than 30 years were also found to have longer survival, although these differences were not statistically significant (p = 0.0913 and p 0.04044, respectively).

p53 mutations in head and neck cancer: new data and evaluation of mutational spectra.

It has been suggested that the frequency, type, and location of p53 mutations (mutational spectra) can be linked to specific exogenous and endogenous carcinogenic agents and processes. Squamous cell carcinoma of the head and neck (SCCHN) provides an excellent tumor model to evaluate the utility of the p53 mutational spectra, given that it has well-defined and strong risk factors (tobacco and alcohol). The purpose of this analysis was to establish the pattern of p53 mutations in SCCHN and evaluate this mutational spectrum in comparison to the spectra for other cancers with similar and different risk factors, including cancers of the esophagus, lung, and colon. p53 mutational data were obtained from head and neck tumors collected at the University of North Carolina Hospitals and the published literature. A total of 14 of 33 tumors from the University of North Carolina Hospitals (42%) were found to have a p53 mutation. The alterations included three transversions, seven transitions, two deletions, and two suspected codon 47 polymorphisms. In general, SCCHN and esophageal cancer share a similar mutational pattern in contrast to colon cancer. These two aerodigestive tract cancers were statistically different from lung cancer, despite sharing tobacco as a major risk factor. For example, G-->T transversions, a mutation type considered to be characteristic of exogenous DNA-damaging agents including tobacco smoke carcinogens, varied among tobacco-related cancer sites (14% SCCHN, 11% esophageal, and 31% lung) in contrast to colon cancer (6%). The comparison of mutational spectra for SCCHN and other cancers indicates that the effects of both tobacco and alcohol exposure may yield a pattern of p53 mutations that reflects elements of both exogenous and endogenous exposures.

Tracheotomy and the intensive care unit patient.

Transportation of the intensive care unit (ICU) patient to the operating room for tracheotomy has been implicated as an unnecessary source of complications and has been cited as a relative indication for percutaneous tracheotomy. However, there is very little evidence in the literature to support this claim. We evaluated 100 consecutive patients who were transported from the ICU to the operating room for tracheotomy. There were no complications related to patient transportation. A total of five complications occurred, all unrelated to patient transportation. Two patients receiving pressure control ventilation developed a pneumothorax on postoperative days 7 and 8, respectively. There were three minor complications directly related to the tracheotomy: peristomal cellulitis, tracheitis, and hemorrhage of less than 25 cc on postoperative day 1. The minor complications were treated appropriately and resolved without any adverse sequelae. We provide a detailed review of 100 consecutive ICU patient tracheotomy cases and compare this with 109 tracheotomies in non-ICU patients. Transportation of the ICU patient does not appear to increase the risk of complications during tracheotomy and should not be cited as a cause of complications in the percutaneous tracheotomy literature. The results with standard surgical tracheotomy in the controlled setting of the operating room should serve as the standard by which other procedures are judged.

Management of complications resulting from laryngeal cancer treatment.

The most frequently encountered complications in the treatment of laryngeal cancer are discussed. Preoperative and surgical problems and complications encountered secondary to radiation and chemotherapy are included, along with airway obstruction, failure to diagnose, pharyngocutaneous fistula, stomal stenosis, and poor voice and aspiration are among the topics covered.

Alterations of the p16 gene in head and neck cancer: frequency and association with p53, PRAD-1 and HPV.

Alterations, especially homozygous deletions, of the putative tumor suppressor gene, p16 (p16INK4A, MTS1, CDKN2) have been found in tumor cell lines from a variety of neoplasms. Recent studies have reported frequent p16 gene deletions in cell lines from squamous cell carcinomas of the head and neck (SCCHN), although the prevalence of alterations was variable in primary tumors. This study determined the prevalence of point mutations and deletions of the p16 gene in 33 SCCHN. In addition, the association of p16 gene alterations and abnormalities of p53, PRAD-1 (cyclin D1), and the presence of human papillomavirus (HPV) was examined. We found an overall prevalence of p16 alterations of 36% (nine deletions, three single base substitutions, including one polymorphism). Seven tumors (of 29, 24%) had an alteration of p16 and p53; five (of 33, 15%) had alterations of p16 and PRAD-1; three (of 29, 10%) had alterations of all three genes. In addition, of the five tumors with human papillomavirus detected, only one also had a p16 gene alteration. The results indicate a potentially important role for the p16 gene in head and neck tumorigenesis. In addition, the presence of tumors with multiple somatic gene alterations suggest a possible interaction in the dysregulation of the cell cycle.

Immunohistochemical characterization of nitric oxide synthase activity in squamous cell carcinoma of the head and neck.

This study was designed to investigate the presence of nitric oxide in human squamous cell carcinoma of the head and neck. We localized the activity of nitric oxide synthase in these tumors through immunohistochemical analysis using antibodies to L-citrulline (a byproduct of nitric oxide synthase), to inducible nitric oxide synthase, and to constitutive nitric oxide synthase. We found presence of inducible enzyme in squamous cells throughout these tumors, with the highest intensity staining occurring directly around keratin pearls. Our findings suggest that inducible nitric oxide synthase activity is present in squamous cell carcinomas of the head and neck, leading us to conclude that inducible nitric oxide synthase may play a significant role in tumor growth.

Effect of Lactobacillus acidophilus on antibiotic-associated gastrointestinal morbidity: a prospective randomized trial.

Oral antibiotic therapy can alter the gastrointestinal microflora and result in troublesome gastrointestinal complaints. Patients who have experience with broad-spectrum antibiotics may be reluctant to start or to comply with antibiotic therapy due to the associated discomfort. In the field of otolaryngology, oral antibiotic therapy is commonplace, and patient intolerance of a particular antibiotic may result in compromise to a less effective choice. Yogurt, which contains Lactobacillus acidophilus, is often recommended by practitioners to help reduce the side effects of oral antibiotic therapy. We wanted to objectively evaluate the effect of orally administered L. acidophilus on the gastrointestinal side effects of oral broad-spectrum antibiotic therapy. Twenty-seven outpatients, 10 years of age or older, with ear, sinus, or throat infections, in whom amoxicillin/clavulanate was felt to be the antibiotic of choice, were randomly assigned to amoxicillin/clavulanate only, or amoxicillin/clavulanate and Lactobacillus treatment groups. Each patient was advised by the nursing staff to consume a well-balanced diet, and a detailed explanation of the medication schedule was given. A questionnaire was given to each patient at the conclusion of therapy. The data were analyzed using Spearman's rank-order correlations. Concomitant therapy of L. acidophilus with amoxicillin/clavulanate was associated with a significant decrease in patient complaints of gastrointestinal side effects and yeast superinfection. Almost all patients (89%) reported resolution of infection during the course of therapy. We believe that use of L. acidophilus is warranted in patients on broad-spectrum antibiotic therapy with gastrointestinal complaints.

ras mutations and expression in head and neck squamous cell carcinomas.

Mutational activation and overexpression of the family of ras proto-oncogenes have been associated with many human tumors. The role of mutations of H-ras, K-ras, and N-ras, as well as expression of the respective protein products (p21s) in normal mucosa, dysplastic mucosa, and squamous cell carcinomas (SCCs) of the head and neck has not been fully described. In our study, 51 tumors (40 paraffin embedded and 11 fresh frozen) were examined to determine if mutational activation of ras is an important molecular event in head and neck SCC. Analyses of codons 12, 13, and 61 of H-ras, K-ras, and N-ras revealed no mutations, suggesting that mutational activation of ras is not important in the majority of head and neck SCCs. Immunocytochemistry (ICC) was used to define the expression of H-ras, K-ras, and N-ras in normal mucosa, dysplastic mucosa, and SCC of the head and neck and to determine if expression of ras family members correlated with early or late events in the development of SCC. Expression of p21N-ras in nine samples of histologically normal head and neck mucosa revealed moderate staining in the basal proliferative layers with progressively less staining as cells matured. The most superficial layers of normal mucosa failed to express p21N-ras. A low level of p21H-ras was expressed in all layers of normal mucosa while K-ras was not expressed. ICC of SCC tumor sections revealed cytoplasmic expression of N-ras in nine of nine tumors, H-ras in five of nine tumors, and K-ras in one of nine tumors. Expression of H-ras, K-ras, and N-ras in head and neck SCC was not related to histologic differentiation or TNM staging; however, p21N-ras was overexpressed in seven of nine tumors. Furthermore, the pattern of N-ras expression in dysplastic lesions revealed expression in all layers of the mucosa in contrast to normal mucosa, which expresses p21N-ras primarily in the basal proliferative layer. The change in p21N-ras expression pattern in dysplastic mucosa and its overexpression in the majority of tumors suggest that loss of control of N-ras expression may be an early step in carcinogenesis of head and neck SCC.