Verrucous carcinoma of the larynx: determining the best treatment option.

BACKGROUND: Verrucous carcinoma (VC) of the larynx is a rare variant of well-differentiated squamous cell carcinoma, characterized by locally invasive, exophytic warty growth. The purpose of the present study was to evaluate the experience with this rare disease in Slovenia over a 23-year period and to weigh the potential for cure of different treatment options against the functional outcome. MATERIALS AND METHODS: The databases of the Cancer Registry of Slovenia as well as of the registries of all three departments licensed for the treatment of laryngeal cancer in the country were used for the identification of patients. Presentation, diagnosis, treatment and outcome were reviewed retrospectively. RESULTS: From 1980 to 2002, 30 patients were diagnosed with VC of the larynx, representing 1.23% of all laryngeal malignancies. The most frequent site of origin was the glottis. Twenty-three patients had surgery (functional 13; total laryngectomy 10), three patients had radiotherapy, and a combination of irradiation and concomitant chemotherapy was used in four patients. Only one tumor recurred, six months after primary radiation treatment, but was successfully salvaged with a total laryngectomy. The 5-year overall survival rate of 75% was not significantly different from an age- and sex-matched cohort from the Slovenian population (P=0.071). CONCLUSIONS: In VC of the larynx, determination of treatment options should be dictated by voice preservation strategies. Surgery remains the gold standard of treatment. However, concomitant radiochemotherapy emerges as an attractive alternative to mutilating surgical procedures.

Prognostic value of E-cadherin expression in thyroid follicular carcinoma.

AIMS: To evaluate the expression of E-cadherin, its association with various clinicopathological features and its possible relation with distant metastasis-free survival (DMFS) in follicular carcinoma of the thyroid. METHODS: E-cadherin expression was assessed immunohistochemically in sections from paraffin embedded tissues in a group of 54 patients with follicular carcinoma and its variants who were followed for a median of 7.25 years. RESULTS: Reduced E-cadherin expression, defined as <90% of cells showing membrane positivity, was found in 15 tumours and was significantly associated with widely invasive growth, insular morphology and lesser degree of differentiation, but was not related to patient sex and age or tumour size. In univariate analysis, DMFS was significantly worse in male patients (P<0.03), widely invasive tumours (P=0.0002), moderately/poorly differentiated tumours (P<0.05) and tumours showing reduced E-cadherin expression (P=0.0001). In multivariate analysis, the degree of invasiveness and E-cadherin expression were the only independent prognostic factors. Among widely invasive cases, those with reduced E-cadherin expression had significantly worse DMFS than those with preserved expression. CONCLUSIONS: Our findings suggest that E-cadherin expression could be used as a prognostic marker in widely invasive follicular carcinomas of the thyroid. Larger studies are needed to assess its prognostic value in the group of minimally invasive carcinomas.

Reduced tumor oxygenation by treatment with vinblastine.

Vinblastine (VLB) previously has been shown to perturb tumor blood flow, but the effect of these perturbations on tissue oxygenation is not known. The recent development of electron paramagnetic resonance (EPR) oximetry now has made it feasible to measure the effects of changes of perfusion on the pO(2) in tumors and normal tissues as a function of time and dose. We measured changes in tumor perfusion by Patent blue staining, tumor blood volume and microvascular permeability by contrast-enhanced magnetic resonance imaging, and tumor oxygenation by EPR in s.c. SA-1 murine tumors. We found that treatment with VLB induced dose-dependent reduction in tumor perfusion. One hour after i.p. treatment of mice with 2.5 mg/kg VLB, tumor perfusion was reduced to 20% of the pretreatment value and returned to close to original values within 48 h. A transient tumor blood flow-modifying effect of VLB was demonstrated also by contrast-enhanced magnetic resonance imaging; reduction of tumor blood volume and microvascular permeability was found. Reduced tumor oxygenation was found as measured by EPR oximetry, with the same time course of changes in tumor blood flow. Tumor oxygenation was reduced to 50% of pretreatment value 1 h after the treatment with 2.5 mg/kg VLB and returned to pretreatment levels within 24 h after the treatment. Although the directions of the changes in perfusion and oxygenation were similar, they were quantitatively different. Reduction in oxygenation of normal tissues, muscle, and subcutis also occurred but was smaller and returned to pretreatment values more quickly compared to the changes induced in the tumors. In conclusion, the present study demonstrates that VLB causes a profound reduction in tumor blood flow and oxygenation, which may have implications in controlling side effects of therapy and the planning of combined treatment with VLB, either with other chemotherapeutic drugs or with radiotherapy.

Effect of primary treatment on survival in anaplastic thyroid carcinoma.

AIMS: Anaplastic thyroid carcinoma (ATC) is a fatal disease despite combined treatment consisting of chemotherapy, radiotherapy and surgery. The optimal sequence of treatment modalities is not known. The purpose of our retrospective non-randomized study was to find out whether timing of the treatment modality had any influence on survival, and to find out if primary surgery prolongs survival in comparison to primary chemotherapy and/or radiotherapy. METHODS: From our database of 162 patients with ATC treated at the Institute of Oncology Ljubljana from 1972-98, 79 patients (26 men, 53 women; age: 40-86 years, mean age 65 years) were included in this retrospective study. The 83 patients with distant metastases on admission, with the survival shorter than one month or patients without any treatment were excluded. The 79 patients were classified into (1) primary surgery group (n=26) and (2) primary chemotherapy and/or radiotherapy group (n=53), including the 12 patients in whom surgery was performed after chemotherapy and/or radiotherapy. The survival of both groups was compared by log-rank test and group characteristics by ANOVA and(2 test using SPSS program. RESULTS: In comparison to the primary surgery group, the patients from the primary chemotherapy and/or radiotherapy group were older and had faster growing, and larger tumours, which were not confined to the thyroid, and more frequently had regional metastases. There was no difference in the survival of the two groups (P=0.17). Survival for longer than one year was observed in 25% of patients with primary surgery and in 21% of patients with primary chemotherapy and/or radiotherapy. The best results (50% survival at one year) were obtained in patients in whom the tumour was surgically removed after primary chemotherapy and radiotherapy. CONCLUSION: This study suggests that the timing of the treatment modalities has an impact on survival and that treatment should start with chemotherapy and/or radiotherapy, with surgery to follow if possible.)

Prognostic factors in follicular carcinoma of the thyroid--a multivariate survival analysis.

AIMS: Multivariate studies of the diagnosis, treatment and prognosis of patients with follicular carcinoma of the thyroid gland are relatively scarce. The aim of our multivariate analysis was to study the factors associated with survival of patients with follicular carcinoma in Slovenia, in an iodine-deficient region. METHODS: This retrospective study was carried out in a group of 154 patients (113 women, 41 men; median age 61 years) with follicular carcinoma of the thyroid treated at the Institute of Oncology in Ljubljana between 1972-1992. Data on patient gender, age, disease history, extent of disease, morphological characteristics, mode of therapy and survival were collected. Statistical correlations between possible prognostic factors and survival were analysed by univariate and Cox's multivariate analysis. RESULTS AND CONCLUSIONS: The 10-year survival of the 154 patients was 60%. Multivariate analysis showed that tumour differentiation, primary tumour size, vascular invasion, distant metastases, regional lymph-node metastases, histological tumour type and age were independent prognostic factors for survival. The best prognosis was found in patients with well-differentiated T1 or T2 tumours, without extensive vascular invasion, without distant or regional metastases and aged under 46 years. Patients with Hürthle-cell type carcinomas had better prognosis than those with the follicular type. The worst prognosis was found in patients with poorly differentiated T4 tumours, with extensive vascular invasion, with distant or regional metastases and aged over 60 years.

Role of serum thyroglobulin in the pre-operative evaluation of follicular thyroid tumours.

AIMS: There is no reliable diagnostic test for pre-operative differentiation between benign and malignant follicular and Hurthle cell neoplasms. Measurements of serum thyroglobulin (Tg) are currently only used post-operatively as a marker of recurrent disease or distant metastases in the follow-up of patient with differentiated thyroid cancer. In this study pre-operative serum Tg measurements were performed with the aim of investigating whether Tg levels differ in benign and malignant follicular and Hurthle cell neoplasms. METHODS: In 516 patients who underwent thyroid surgery at the Institute of Oncology in Ljubljana, Slovenia, from 1990 to 1996, serum Tg concentration was measured in addition to the standard pre-operative tests (fine-needle aspiration biopsy, ultrasonography, 99mTc scanning and hormonal profile). After the operation, patients were divided into 11 groups based on their histological diagnosis (papillary cancer--classic, papillary cancer--follicular variant, papillary cancer oncocytic variant, occult papillary cancer, follicular adenoma, follicular cancer, Hurthle cell adenoma, Hurthle cell cancer, anaplastic cancer, medullary cancer, nodular goiter) and the serum Tg values of the different groups were compared. RESULTS: In groups of patients with follicular and Hurthle cell cancer, median Tg values were higher (2895 and 638.5 ng/ml) and, statistically, differed significantly from the serum Tg values in all other groups (P<0.01). Sensitivities and specificities of the tests were 71.8% and 80.4% for follicular cancer and 55.6% and 83.8% for Hurthle cell cancer, while positive and negative predictive values were 75.6% and 77.1% for follicular cancer and 75% and 68.4% for Hurthle cell cancer. CONCLUSIONS: These results indicate that pre-operative serum Tg measurements might be an important additional diagnostic tool in the pre-operative work-up of patients with thyroid tumours.

Effect of vinblastine on cell membrane fluidity in vinblastine-sensitive and -resistant HeLa cells.

The electron paramagnetic resonance method (EPR) was used to study the effects of vinblastine (VLB) on cell membrane fluidity in wild-type HeLa cells (HeLa K) and its subclone, which is resistant to several drugs (HeLa CA). HeLa CA cells, obtained by treatment of HeLa K with CDDP, were found to be more resistant to VLB than to CDDP. The experimentally observed EPR spectra were correlated with the calculated spectra obtained by computer simulation. The results indicate that the cell membrane of HeLa K and HeLa CA cells is heterogeneous and can be described with at least three types of coexisting domains with different fluidity characteristics. The two more fluid domains of HeLa CA cells were found to be more fluid than in HeLa K cells. The fluidity of the less fluid domain remained unchanged but its portion in the membrane was increased. VLB treatment did not affect the membrane fluidity of HeLa CA cells significantly. On the other hand, 1 h of treatment of HeLa K cells with 1 ng/ml VLB did not change the fluidity characteristics of membrane domains but decreased the portion of the less fluid domains. This was also reflected in an average increase of the entire membrane fluidity. The observed changes were detected at VLB concentrations which were far below the cytotoxic level.

Medullary carcinoma of the thyroid glad: diagnostic cytopathological characteristics.

Sixty fine needle aspiration biopsy samples of the medullary carcinoma of the thyroid, 49 primary and 11 recurrent/metastatic, were reexamined in order to determine diagnostic features and value of auxiliary techniques. In the smears, tumor cells were present either as single cells or in loose cohesive groups; in about one third of cases, three-dimensional groups predominated. Cells were of different shapes round-to-oval, polyhedral and spindle. The aspirates contained one or all three cell types. Large mononucleated cells were present in 47/60 cases and, in addition, in 34 of these multinucleated cells with nuclei arrayed in semicircular rows were present. Plasmacytoid and dendritic cells, observed in 58/60 cases, appear to be an important diagnostic feature. Red cytoplasmic granules and amyloid deposits could serve as an additional diagnostic clue. Among the auxiliary techniques, the demonstration of calcitonin and CEA immunoreactive cells proved to be the most helpful.

The dynamics of serum thyroglobulin elimination from the body after thyroid surgery.

Thyroglobulin (Tg) is a glycoprotein produced exclusively by the thyroid. It can be found in the serum of healthy people as well as of those with various thyroid disorders. Elimination of Tg from the body occurs through the liver. The data on Tg serum half-life in the literature are scarce, and the reported values vary from 6-96 h. The aim of our study was to determine the Tg half-life after surgical removal of the thyroid gland. Knowing the exact half-life of Tg would enable rational timing of sampling serum for determination of Tg after thyroid surgery or chemotherapy and/or irradiation for evaluation of treatment in patients with differentiated thyroid cancer (DTC). In 11 patients (10 females and one male, aged 27-85 years) serum samples were taken 24, 48, 72 and 168 h after a near-total or total thyroidectomy. Serum Tg levels were determined and Tg half-life calculated by the use of a one-compartment kinetic model. Mean Tg half-life was 65.2 h (SEM = 4.3), and Tg levels decrease below 5-10 ng/ml approximately only 25 days after thyroidectomy (7-10 x t1/2). Therefore, earlier determination of Tg cannot be used either for reliable detection of distant metastases or for evaluation of the effect of chemotherapy and/or irradiation.

Antitumor effectiveness of bolus versus split dose vinblastine treatment in EAT tumors in mice.

Vinblastine (VELBE) is one of the first chemotherapeutic agents used in the treatment of malignancies. To explore the effectiveness of various treatment regimens, bolus versus 24-hour continuous VELBE treatment was tested on an EAT tumor model in mice. Continuous VELBE infusion was simulated by splitting the bolus VELBE dose into 4 fractions, injected at 8-hour intervals. A comparison of antitumor effectiveness between bolus and split dose VELBE treatment was determined by three assays: cell survival, tumor growth delay and animal survival. The cell survival curves of both bolus and split dose VELBE treatments indicated a biphasic response with an initial fast reduction in cell survival followed by a plateau. However, split dose treatment was significantly more effective than bolus treatment at all doses tested (p < 0.001). Tumor growth delay of the split dose VELBE treatment was 6.9 days and of the bolus VELBE treatment 3.0 days, indicating that the split dose treatment is approximately 2-times more effective (p < 0.001). Median survival time of mice treated with split VELBE dose (24.0 days) was significantly longer compared to that of mice treated with bolus VELBE dose (16.5 days) (p < 0.001). The median survival time of control untreated mice (16.0 days) and bolus treated mice did not differ (p = 0.24). Our study shows that at the same VELBE dose the split dose VELBE treatment is more effective than VELBE administered in bolus.

Anaplastic thyroid carcinoma in fine needle aspirates.

OBJECTIVE: To analyze the diagnostic problems with fine needle aspiration biopsy in anaplastic thyroid carcinoma (ATC) and to describe the cytomorphologic characteristics in 113 cases. STUDY DESIGN: A retrospective analysis of 113 fine needle aspirates and 67 surgical specimens from 113 patients with ATC admitted to the Institute of Oncology, Ljubljana, in 1972-1992. RESULTS: In a series of 113 fine needle aspirates of ATC, 3 (2.7%) were inadequate, 3 (2.7%) suboptimal and 107 (94.7%) diagnostic of malignancy. On reexamination, 96/107 (89.7%) were diagnosed as ATC, 6 (5.6%) as differentiated thyroid carcinoma, and 5 (4.6%) as a malignant tumor not otherwise specified. As to the predominant cell population, fine needle aspirates showed three different cell patterns: (1) pleomorphic cell (43 cases), (2) round cell (33 cases), and (3) spindle cell pattern (7 cases). In the present retrospective analysis we identified three main reasons for inadequate or nonrepresentative fine needle aspiration biopsy sampling: (1) tumor regressive changes (necrosis, hemorrhage, leukocytic infiltration), (2) extensive tumor fibrosis, and (3) distinct differentiated and anaplastic patterns in the same tumor. CONCLUSIONS: The major diagnostic problem with fine needle aspiration biopsy (FNAB) of ATC is related to sample quality. Cytomorphologic features of ATC are highly specific and easy to recognize. Due to the simple technique and high diagnostic accuracy, FNAB is the method of choice in patients with ATC.

Marginal vacuoles in fine-needle aspirates of follicular thyroid carcinoma.

Marginal vacuoles (MV) found in Giemsa-stained fine-needle aspirates of the thyroid gland have been observed in toxic and also in non-toxic goiters. The aim of our retrospective study was to disclose the incidence and diagnostic significance of MV in 46 smears from 43 patients with primary and/or metastatic follicular thyroid carcinoma (FTC). Typical MV, MV-like structures, or both were found in 14 of 36 specimens (39%) of the primary tumor and in four of seven specimens (57%) obtained from metastases of FTC. No association between the appearance of MV/MV-like structures and degree of tumor differentiation was demonstrated. On the other hand, MV or/and MV-like structures were more frequently (69%) documented in hyperthyroid patients (P < 0.05). Accordingly, our study demonstrated relatively frequent appearance of MV or MV-like structures in FTC independent of tumor differentiation. Their appearance, however, seems to be associated with hyperthyroidism.

Effects of vinblastine on cell membrane fluidity and the growth of SA-1 tumor in mice.

Cell membranes can be targets of some anti-cancer drugs. Therefore, the purpose of this study was to determine whether vinblastine (VLB) can also affect the tumor cell membrane. On the in vivo SA-1 tumor model, alteration of cell membrane fluidity (measured by electron paramagnetic resonance, EPR), cytotoxicity and morphological changes of the SA-1 tumor cells after VLB treatment were studied. The cytotoxic effect of VLB was biphasic, with an initial fast increase in cytotoxicity followed by a plateau. The surviving cells had increased membrane fluidity and were morphologically changed. The dose-response curve of VLB on membrane fluidity was also biphasic with an initial fast increase in membrane fluidity followed by a plateau. Since dose-response curves of VLB cytotoxicity and its effect on membrane fluidity were similar, there was a high correlation between both effects. The effect of VLB on membrane fluidity was the most pronounced at 24 h and 48 h after treatment. The results of this study indicate that VLB affects cell membrane by increasing the membrane fluidity of SA-1 tumor cells in vivo in a dose-and time-dependent manner. Therefore, this finding may be beneficially implemented also in priming cells for other cytotoxic drugs and for appropriate timing of drug sequence in combined schedules.

Interactions of interferon and vinblastine on experimental tumor model melanoma B-16 in vitro.

In this study, we tried to define in vitro interactions of two antitumor agents that have different sites and different mechanisms of action. Vinblastine (VLB) in combination with human recombinant interferon-alpha A/D (rHuIFN-alpha A/D) and in combination with murine recombinant interferon-gamma (rMuIFN-gamma) was studied. The effect of the combination was determined with cell growth kinetics assay on B-16 melanoma and the interaction defined by means of Spector's formula. Both the combination of rHuIFN-alpha A/D with VLB and the combination of rMuIFN-gamma with VLB synergistically inhibited cell growth in vitro. There was a positive biochemical modulation between the two drugs, but it is still unknown whether it occurred at the level of uptake into the cell, metabolism within the cell or egress from the cell.

Results of combined modality treatment in poorly differentiated and anaplastic thyroid carcinoma.

From 1973-1989 34 patients with poorly differentiated primarily inoperable and 89 with anaplastic giant-cell thyroid tumours entered a study on individualized multimodal treatment. The aim of the study was to find an effective, non-aggressive chemotherapy (ChT) and explore the possibility of individualized combined treatment. Infusions of low doses of vinblastine or cisplatinum or adriamycin or novantrone were used for perturbation of cellular kinetics in the tumours. Sequential fine-needle aspiration biopsies of tumours were performed for monitoring the drug-induced changes in tumour cells and for cytomorphological studies and DNA measurements, on the basis of which ChT was individualized. During the period of accumulation of cells in the S or G2 + M phases, drugs particularly effective in the respective phases were used. The same principle was used in planning a combination of ChT and irradiation. In the group of poorly differentiated carcinomas only 5/34 patients had MR to ChT. In 17/34 patients after ChT the tumour was removed surgically, 19/34 have NED 11+ to 72+ months after treatment. The results in 89 patients with anaplastic carcinoma are worse: 13/89 patients died before or at the beginning of treatment, of 77 treated patients only 10 could be operated on, 7 survived for more than one year (13+ to 72+ months). Only 1/77 patients survived for more than 5 years. A combination of DNA measurements and cytomorphological studies is a useful method for the understanding of tumour behaviour under treatment.

Influence of vinblastine containing chemotherapy on tumor tissue membrane fluidity; an EPR study. A case report.

The influence of vinblastine (VLB) in combined chemotherapy on tumor cell membrane fluidity of a patient with exulcerated soft tissue sarcoma was studied by the electron paramagnetic resonance method (EPR). Tissue samples were taken before and after applications of VLB, Cis-Platinum (CDP) and combined intraarterial chemotherapy (IAC) and incubated with the spin probe, the palmitic acid methylester spin label analog, MeFasl (10, 3) incorporating into the cell membranes. EPR spectra of the labelled tissue samples were measured. Within few days after application of the chemotherapeutic drugs some oscillations of the membrane fluidity in the tissue were observed, while after a longer period of few weeks the relative amount of cells with greater membrane fluidity was found to decrease. Furthermore, an unexpected gradual increase in the EPR signal intensity after incubation of the tissue with the spin probe, probably due to an oxidative process in this particular sarcoma tissue was observed. These data could be useful for understanding of drug induced changes in cell membranes and for future timing of drug treatments in combined schedules.

Amphicrine--composite calcitonin and mucin-producing--carcinoma of the thyroid.

A case of thyroid carcinoma in a 38-year-old male with a high serum level of calcitonin is reported. The tumor was composed of polygonal argyrophilic cells, signet ring Alcian blue-positive cells, and a minority of amphicrine elements. The same polymorphic cellular component was seen at the ultrastructural level. Anticalcitonin immunoperoxidase revealed that the majority of cells were positive, including the amphicrine cells. In spite of calcitonin production it is felt that cases similar to the present one should be distinguished from "ordinary medullary" carcinoma and the terms "amphicrine" or "composite calcitonin and mucin-producing carcinoma" are proposed.