Treatment with ozone/oxygen-pneumoperitoneum results in complete remission of rabbit squamous cell carcinomas.

Head and neck squamous cell carcinomas (HNSCC) represent a group of metastasizing tumors with a high mortality rate in man and animals. Since the biomolecule ozone was found to inhibit growth of various carcinoma cells in vitro we here applied the highly aggressive and lethal VX2 carcinoma HNSCC tumor model of the New Zealand White rabbit to test whether ozone exerts antitumorous effects in vivo. Therapeutic insufflation of medical ozone/oxygen (O(3)/O(2)) gas mixture into the peritoneum (O(3)/O(2)-pneumoperitoneum) at an advanced stage of tumor disease led to a survival rate of 7/14 rabbits. Six of the seven surviving rabbits presented full tumor regression and the absence of local or distant lung metastases. Insufflation of pure oxygen (O(2)) resulted in a survival rate of 3/13 animals accompanied by full tumor remission in 2 of the 3 surviving animals. Of the 14 sham-treated animals only 1 had spontaneous tumor remission and survived. No adverse effects or changes in standard blood parameters were observed after repeated intraperitoneal insufflations of the O(3)/O(2) or O(2) gas. Animals with O(3)/O(2)-induced tumor eradication developed tolerance against reimplantation of the VX2 tumor. This could be reversed by immune suppression with a combination of dexamethasone and cyclosporin A suggesting an antitumorous effect of O(3)/O(2)-mediated activation of the body's own immunosurveillance. Although the exact mechanisms of action are still unclear the present data point to O(3)/O(2)-pneumoperitoneum as a promising new strategy in anticancer therapy.

Block copolymer carrier systems for translymphatic chemotherapy of lymph node metastases.

The presence of lymph node metastases relevantly and significantly impairs disease-specific survival in patients suffering from squamous cell carcinoma of the upper aerodigestive tract. In a VX2 animal tumor model, we present an interstitial translymphatic therapeutic approach using cis-diaminedichloro-platinum(II) (CDDP) conjugated to a poly(ethylene oxide)-block-poly(lysine) (PEO-b-PLys) block copolymer tracking systems for the successful treatment of lymph node metastases. Most effective was the application of a high cargo-load CDDP tracking system (48 wt. % CDDP) curing 90% of the animals and causing only minor local side-effects. Systems containing 1 or 10 wt. % of CDDP were less effective but still cured 50% of the animals. Moreover, the administration of 1 or 10 wt. % of CDDP consistently limited tumor growth to the draining lymph nodes (50%) and prevented systemic distribution of the metastasis even'with 1 wt. % CDDP load. The systems contained 0.25-0.003 mg/kg per body weight CDDP compared to 1 ml/kg per body weight as usually used for intravenous administration. This approach encourages further and more detailed research of a CDDP-based interstitial translymphatic administration of chemotherapy for lymphogenic metastasizing carcinomas in different body regions.

In-vitro investigations evaluating the detection spectrum of cervical lymph nodes via handheld gamma probe.

BACKGROUND: Currently the significance of the sentinel node (SN) biopsy also for head and neck cancer is discussed intensively. Based on the complex anatomic structures of this region with a low distance between primary and sentinel node as well as approximately 300 lymph nodes an intensive discussion of the methodical basis of sentinel node detection seems to be essential. Thus it was the aim of the present study to examine the detection spectrum of a gamma probe for identification of cervical lymph nodes using an in vitro model to describe and objectify the particularities of measurement existing in the head and neck region. MATERIAL/METHODS: In an in vitro model the detection spectrum of a gamma probe is examined in 29 different series of measurements (variation of the specimen filled with 99m pertechnetat regarding activity, position, collimator distance, tissue sheath). RESULTS: The presented in vitro model reflects the clinical problem of narrow intranodal activity of neighbouring lymph nodes and reveals a direct relation between the number of radiation sources and their isolated evidence. Using muscle tissue with a thickness of 0.4 cm, two two-rowed radiation sources, the more powerful is placed 1.5 cm behind the other specimen, with a lateral difference of 3 cm, can be resolved only with a maximal detector distance of 1 cm. Not the difference of the tissue but the thickness of the tissue is decisive for detection. CONCLUSION: Especially for pharyngeal and laryngeal lymph nodes a transcutaneous measurement reflecting the exact localisation of hot nodes in the area of the deep jugular lymph nodes is not possible with increasing tissue thickness. The described results require a critical discussion of the different detection techniques varying among the different working groups of this field.

Complications after CO(2) laser surgery of laryngeal cancer in the elderly.

CONCLUSION: Cancer of the larynx in elderly patients should be treated with curative intention, if the extension of the primary tumour allows safe resection. Transoral CO(2) laser microsurgery is associated with a low rate of major complications and can be regarded as suitable even for elderly patients. Age itself should never be the sole factor in deciding which therapy should be undertaken. OBJECTIVES: In the industrialized nations the age group beyond 75 years will grow steadily, requiring special attention by medical professionals in the future. Nowadays laryngeal cancer is often treated by transoral CO(2) laser microsurgery. Because of a variety of comorbidities, the incidence of perioperative complications in the group of elderly patients is of increasing interest. To date, no references in the literature have discussed complications after transoral CO(2) laser microsurgery in this age group. Patients and methods. Twenty-four patients over the age of 75 suffering from squamous cell carcinoma of the larynx and treated by transoral CO(2) laser microsurgery since 1998 were analysed for intraoperative and postoperative complications. RESULTS: There was no evidence of surgery-related complications at all. Postoperatively, 6 of 24 patients complained about dysphagia. Due to intraoperative placement of nasogastric feeding tubes in these six cases further complications such as pneumonia resulting from aspiration could have been avoided.

Differential expression of desmosomal plakophilins in various types of carcinomas: correlation with cell type and differentiation.

Plakophilins (PKPs) are a set of 3 constitutive armadillo repeat proteins of the desmosomal plaque, termed PKP 1, PKP 2, and PKP 3, which have been shown to be functionally relevant for desmosomal adhesion. We have performed a systematic immunohistochemical study of the 3 PKPs in oral and pharyngeal squamous cell carcinomas (SqCCs; n = 40); colorectal, pancreatic, and prostate adenocarcinomas (n = 31), and hepatocellular carcinomas (HCCs; n = 8). In SqCCs, PKP 1 and PKP 3 revealed common desmosome-type immunostaining, their expression level being inversely correlated with the degree of malignancy. Instead, staining for PKP 2 was limited. In contrast, all adenocarcinomas contained PKP 2 and-often abundantly-PKP 3 in desmosome-typical pattern, whereas PKP 1 was expressed only in prostate tumors. The presence of PKP 3 in adenocarcinomas was confirmed by immunoblotting. In HCCs, only PKP 2 was detected. Under certain staining conditions, focal nuclear immunoreactivity for PKP 1 was observed in some SqCCs and HCCs. Our results, which are inconsistent with previously published data to some extent, indicate a principal preservation of the cell type and differentiation-related expression patterns of PKPs in normal epithelia. For PKP 1, a suppressor function of malignant behavior seems conceivable, whereas the putative functional significance of its occurrence in tumor cell nuclei requires further studies.

The auricular VX2 carcinoma: feasibility of complete tumor resection.

BACKGROUND: The aim of the study was to test the feasibility of resection of VX2 auricular squamous cell carcinoma (SCC) in New Zealand White rabbits (NZW), its influence on the regional and distant metastases and the general prognosis. MATERIALS AND METHODS: In 71 NZW rabbits, successful in sano wide margin resection of auricular VX2 SCC was performed 7 days after tumor induction. The animals were sacrificed and examined for metastases after 6 weeks. RESULTS: Local recurrences occured in 7% of the animals. In 28.2% lymph node (LN) and in 15.5% distant metastases developed. Regional metastases presented in 100% of the animals with recurrence and in 22.7% of the RO animals (p < 0.001). Distant metastases presented in 80% of the animals with local recurrence and in 10.6% of the R0 animals (p < 0.001). Of the animals with local control, those with N+ had a significantly higher incidence of distant metastases (46.7%) compared to those with N0 (0%, p < 0.001). Local control and LN involvement were found to be important prognostic factors for early tumor-related death. CONCLUSION: The VX2 auricular model resembles head and neck (HN) SCC in humans morphologically, pathophysiologically and as a complex neoplastic disease. In the experimental setting it behaved similarly to the clinical situation of wait-and-see in N0 HNSCC patients. Tumoral microemboli present a possible mechanism for the development of recurrences.

Reduced cisplatin sensitivity of head and neck squamous cell carcinoma cell lines correlates with mutations affecting the COOH-terminal nuclear localization signal of p53.

PURPOSE: Head and neck squamous cell carcinomas (HNSCC) are the most frequent malignancies of the upper aerodigestive tract. Cisplatin resistance is a major problem in the treatment of a large number of HNSCC cancer patients. In this study, nine randomly selected HNSCC cell lines were investigated regarding expression, presence of mutations, nucleocytoplasmic distribution of p53, and sensitivity to cisplatin. EXPERIMENTAL DESIGN: Protein expression was evaluated by Western blot analysis. The whole open reading frame of p53 was determined by reverse transcription-PCR sequencing. Nucleocytoplasmic distribution was evaluated by confocal laser scanning microscopy. The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide viability assay was used to test for cisplatin sensitivity. RESULTS: p53 mutations were found in all nine investigated HNSCC cell lines. Nuclear p53 signal was detected in six cell lines, whereas three cell lines exhibited total loss of nuclear p53 signal. Nuclear signal depended on the presence or absence of the COOH-terminal nuclear localization signal in p53. Cisplatin sensitivity was highly reduced in the group with loss of nuclear p53 signal compared with those with detectable nuclear signal. Transfection of wild-type and mutant p53 into a rat embryonic cell system showed highly reduced activity of the nuclear localization signal mutant p53 protein. CONCLUSION: Taken together, these data suggest that "loss of nuclear p53 signal" correlates with cisplatin resistance in HNSCC. If these results can be validated on a larger number of tumor samples, including fresh tumor tissues, it potentially could help in sparing a subgroup of HNSCC patients the side effects associated with unnecessary chemotherapy by identifying cisplatin nonresponders before chemotherapy induction.

Cytokeratins 6 and 16 are frequently expressed in head and neck squamous cell carcinoma cell lines and fresh biopsies.

BACKGROUND: Cytokeratins (CK) are members of intermediate filaments, which are predominantly found in epithelial cells. Different types of epithelia are characterized by a distinct composition of CK. Recently immunohistochemical investigations demonstrated that, among others, CKs 6, 14, 16 and 17 are regularly expressed in benign stratified squamous epithelium of the head and neck as well as in squamous cell carcinoma of the head and neck (HNSCC) in contrast to CKs 1, 10 and 11, that were only rarely expressed in these tissues. MATERIALS AND METHODS: Total RNA was isolated from 15 primary cell lines derived from HNSCC and from 15 tissue samples of oro- and hypopharyngeal carcinomas obtained from surgery specimens. CK expression was evaluated by RT-PCR, Western blot analysis and immunohistochemistry. RESULTS: CK6 and 16 were found to be expressed in both groups at almost 100%. The expression level of CK14 remained constant (73%) in both groups, at the RNA and protein level. CK17 was more frequently present in tumour specimens than in HNSCC cell lines. The immunohistochemical results of the surgical tumour specimens confirmed the results of Western blot analysis. CONCLUSION: The presented results show high and stable expression rates for CK6 and CK16 in HNSCC. These results will serve as a basis for further investigations concerning the search for circulating tumour cells and micrometastases. In addition, we found that cytokeratin expression in HNSCC is different on the RNA level compared to the protein level.

Lymph node metastasis in an animal model: effect of piecemeal laser surgical resection.

BACKGROUND AND OBJECTIVES: Endoscopic laser surgical resection of advanced squamous cell carcinoma (SCC) often requires division of the tumor into several pieces. It is unknown if this approach influences the incidence of regional and distant metastases. STUDY DESIGN/MATERIALS AND METHODS: In 143 rabbits VX2 SCC was induced. Eight days later the tumor was resected by two different methods. In the first group en bloc cold steel resection was performed. In the second group piecemeal laser resection was performed. On the 51th day the animals were sacrificed and examined for lymph node and distant metastases. RESULTS: After piecemeal laser resection 47.7% of the animals had lymph node metastases compared to 24.6% after en bloc resection (P = 0.01). The incidence of distant metastases did not differ for the two groups. CONCLUSIONS: In our model narrow margin piecemeal laser resection was associated with a higher incidence of metastases compared to wide en bloc surgical resection. The exact mechanism responsible for this increase is unclear.

Metaanalysis of the significance of matrix metalloproteinases for lymph node disease in patients with head and neck squamous cell carcinoma.

BACKGROUND: The objective of the current metaanalysis was to evaluate the expression patterns of matrix metalloproteinases (MMPs) in patients with head and neck squamous cell carcinoma (HNSCC), to evaluate reported series, and to determine whether there is an expressed value to quantitate the risk of metastasis. METHODS: A review of the published literature was conducted according to defined selection criteria. Fixed and random effects models were applied for estimation of the summarized odds ratio and 95% confidence intervals, including a test for homogeneity of the odds ratios of the studies. Finally, forest plots were created to allow for visual comparison of the results and an estimation of heterogeneity. RESULTS: The heterogeneity of data collection and statistical methods did not allow final judgments on the significance of immunohistochemical MMP expression analysis in patients with HNSCC or the impact of MMPs in predicting metastatic behavior. Fourteen studies with 710 patients for 5 different MMPs (MMP-1, MMP-2, MMP-3, MMP-9, and MMP-14) were included in the current metaanalysis. The results indicated that MMP-2, MMP-3, MMP-14 possibly played a role in the metastatic behavior of HNSCC tumors. CONCLUSIONS: The authors recommended the standardization of staining procedures and evaluation protocols as a necessary step to allow for valid comparisons of the multitude of results published by different study groups.

Effectiveness of radiochemotherapy on lymph node metastases in patients with stage IV oropharyngeal cancer.

Radiochemotherapy plays a leading role in the treatment of patients with advanced squamous cell carcinomas (SCC) of the oropharynx. The aim of the present study was to estimate its effectiveness on lymph node (LN) metastases. Seventeen patients with advanced UICC stage IV oropharyngeal SCC (1xT2, 4xT3, 12xT4, 2xN1, 15xN2) were observed prospectively. They were treated with radiochemotherapy (total radiation doses 60-70.6 Gy). One to four months after neck dissection (ND) was performed. Specimens were histologically examined for metastases according to the neck levels obtained from. Local control was achieved in 14/17 (82.4%) patients and regional-in 10/17 (58.8%) patients. Of 566 LN studied, 29 exhibited signs of involvement. Two from 29 were found in neck level I, 20/29 in II, 6/29 in III and 1/29 in IV. In 13/29 LN the metastases had completely regressed under treatment whereas 16/29 LN (7 patients) contained vital tumoral tissue. The observed high incidence of vital LN metastases, which abide the radiochemotherapy, advocates further studies, concerning the value of planed ND after radiochemotherapy.

Chlamydia pneumoniae IgA seropositivity and sudden sensorineural hearing loss.

A prospective study was designed to evaluate a possible role of an endured infection with Chlamydia pneumoniae or Chlamydia trachomatis as a cause for sudden sensorineural hearing loss. For this in 60 patients with a first episode of a sensorineural hearing loss and-60 sex-matched and aged-matched controls, following a complete otoneurological diagnosis blood tests for IgA, IgM and IgG with regard to Chlamydia pneumoniae and trachomatis were evaluated. We found a statistically significant higher prevalence of IgA positivity of Chlamydia pneumoniae in patients with sudden sensorineural hearing loss (chi2-test, p < 0.017). For this, Chlamydia pneumoniae may be a possible cause for sudden sensorineural hearing loss. A targeted antibiotic therapy, as it has been discussed for myocardial infarction, might possibly open an additional treatment option for sudden sensorineural hearing loss.

The sentinel node concept in head and neck cancer: solution for the controversies in the N0 neck?

BACKGROUND: The majority of patients with head and neck squamous cell carcinoma (HNSCC) who have a clinical N0 neck undergo neck dissection (ND) even though no lymph node metastases may be detected. With this background, our investigation critically analyzes the value of sentinel lymphadenectomy. METHODS: Ninety patients with HNSCC, all staged with an N0 neck, underwent intraoperative 99mTc-radiolabeled detection of up to three hot nodes (SN1-3) during elective ND and primary site resection. RESULTS: Sentinel lymphadenectomy (SN1-3) detected occult metastatic spread in 20 (22%) of 90 patients, whereas failure occurred in three of 90 patients. Metastatic spread was directed to level II in the majority (66.7%) of cases. If only the SN1 had been examined, the procedure would have failed in nine (39%) of 23 patients. CONCLUSION: Sentinel lymphadenectomy correctly identified the stage of metastatic disease in 97% of patients in cases in which up to three sentinel nodes were identified. If only the lymph node with the highest tracer activity had been excised, 39% of cancer-positive necks would have been missed. Selective ND identified metastatic disease in the additional 3% of patients.

The lymphatic system of the major head and neck glands in rats.

Many studies concerning therapy and also investigations on lymphogenic metastatic spread of head and neck malignancies require animal models. This article completes the existing findings with regard to the lymphatic system of the head and neck region of the rat. Investigations (light microscopy, immuno-histochemistry, enzyme histochemistry, lympho-graphy) on architecture, distribution and density of the intraglandular lymphatic flow of the major head and neck glands (infraorbital lacrimal gland, extraorbital lacrimal gland, Harderian gland, parotid gland, major sublingual gland, mandibular gland and thyroid gland) in rats were performed. Architecture of the seven major head and neck glands in rats do not differ from other regions of the upper aerodigestive tract. While the Harderian gland shows the highest density of lymphatics, within the major sublingual gland only scare lymph vessels could be identified. Distribution and density of initial lymphatics influence directly the transmission of inflammatory and malignant diseases. The presented results are the morphologically and anatomically basis to initiate further investigations in the rat animal model emphasizing special questions concerning the lymphatic system of the major head and neck glands e.g. lymphatic drainage and new treatment concepts in cases of lymphogenic metastatic spread.

Value of sentinel lymphadenectomy in head and neck cancer.

The increasing interest in the so-called sentinel node concept, which has recently been adapted to squamous cell carcinomas of the upper aerodigestive tract, can be explained by encouraging results in other tumor entities. Although the publications on this topic do not yet allow a final judgment on the significance of sentinel lymphadenectomy in head and neck squamous cell carcinoma, early results emphasize the importance of this new diagnostic and therapeutic concept. The basic prerequisite is a detailed knowledge of the existing method-specific limitations in this anatomic region. Critical and careful evaluation of the sentinel node concept is mandatory prior to its application to other tumor entities. Sentinel lymphadenectomy for head and neck cancer may prove helpful if the indications for its use are clearly defined.

The value of screening for multiple arterio-venous malformations in hereditary hemorrhagic telangiectasia: a diagnostic study.

Occult visceral arterio-venous malformations (AVMs) may be a constant threat to patients suffering from hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome (M. ROW). HHT patients predominantly become symptomatic through chronic, recurrent epistaxis, a symptom that can alert physicians at an early stage of the disease. The purpose of this study was to investigate whether occult, visceral arterio-venous malformations could be detected by screening imaging studies in patients suffering from HHT. In a comprehensive diagnostic study, Rendu-Osler-Weber patients were examined for potential visceral arterio-venous malformations by physical examination and non-invasive imaging techniques. The Department of Otolaryngology of the Philipps University of Marburg is a major referral center and coordinated the screening procedures. Thirty-five individuals with the presumed diagnosis of HHT gave informed consent to the screening investigations. Eighteen of 35 individuals were found to suffer from visceral vascular malformations; most of the AVMs were diagnosed in the lung, but also the liver, spleen, brain and eyes were affected. Six patients could be treated preventively by arterial embolization for AVMs of the lung, liver and brain. Comprehensive screening for occult AVMs in HHT patients seems to be justified to avert potential complications in this group of patients.

Optimal treatment of vascular birthmarks.

Optimal functional and cosmetic outcomes for vascular lesions require a thorough preoperative diagnosis of vascular anomalies, since correct classification of each vascular lesion has a direct influence on the treatment of choice. Many different classification systems have been discussed controversially. Based on clinical practicality and significant accuracy of forecast with regard to the clinical course of a lesion, Mulliken and Glowacki's biologic classification gained most clinical relevance and has become accepted as the official classification scheme by the International Society for the Study of Vascular Anomalies (ISSVA). Based on comprehensive description of relevant literature results, the current communication shall give an overview of differing, internationally accepted treatments. Although conservative management can be proposed for uncomplicated hemangiomas occurring in infancy, the proliferative progression of these lesions provides an adequate indication for treatment, while vascular malformations, which usually persist throughout life, always require therapeutic intervention if they start to cause clinical symptoms. Based on individual parameters (such as diameter, location and growth dynamics), different treatments, including cryotherapy, corticosteroids, laser therapy, sclerotherapy, surgery, and/or embolization, can be performed successfully. Currently, however, none of these treatments represents the solitary treatment of choice.

Value of endotracheal tube safety in laryngeal laser surgery.

BACKGROUND AND OBJECTIVES: Due to the increased popularity of laryngeal laser therapy, surgeons and anesthesiologists are inevitably confronted with questions concerning the choice of the most efficient endotracheal tube (ETT) for laryngeal laser surgery, especially with regard to possible endolaryngeal tube fires, or combustions. The purpose of this study was to determine the current practice in endolaryngeal laser surgery in Germany. STUDY DESIGN/MATERIALS AND METHODS: A questionnaire was sent to 152 ENT Departments in Germany, care was taken that the responders could send back the questionnaire anonymously. Among other questions the participants were asked for the number of lasersurgical treatments of the larynx performed in the past, the usual type of ETTs in use, whether other safety precautions were taken during CO2 laser surgery of the larynx and for intraoperative complications like tube ignition, fires or combustions. RESULTS: Eighty six of the 152 addressed ENT departments replied. In laryngeal laser surgery, 59/86 departments regularly use special laser tubes in daily routine (74.5%). In about 20,000 lasersurgical procedures, 15 incidents of ETT fire have been reported. In six of the reported 15 cases a tube fire occurred despite the fact that special laser tubes had been utilized. CONCLUSIONS: The present study could demonstrate that the use of special laser tubes does not necessarily protect against ETT fire. Thus, even when using special laser tubes other safety measures should be taken. In view of the maximum safety for the patient it has to be stated, that the safety during surgery correlates definitely with the experience of the surgeon. The weakest point of ETTs is usually situated in the cuff region.

Lymph node topography of the head and neck in New Zealand White rabbits.

Investigations of the lymphogenic metastatic spread of VX2 carcinomas in New Zealand White rabbits require an exact knowledge of the topography of cervical and facial lymph nodes. The topography of neck lymph nodes was evaluated from 16 rabbits macroscopically, histologically and by lymphographic investigations, and the possibility of their surgical removal (neck dissection) was examined. The upper aerodigestive tract and the ear of New Zealand White rabbits drain via four consistent groups of 12-18 lymph nodes. Except for the paratracheal lymph node, they are all easily accessible to surgery. The data presented in this study encourage the use of induced VX2 carcinomas in New Zealand White rabbits as an animal model to study the lymphogenic metastatic spread of squamous cell carcinomas of the head and neck. Such investigations could lead to an improvement of surgical and pharmaceutical treatment of this tumour entity.

Functional anatomy of the lymphatic drainage system of the upper aerodigestive tract and its role in metastasis of squamous cell carcinoma.

BACKGROUND: Although there is a significant understanding of the vascular anatomy of the upper aerodigestive tract (UADT), there is less detailed knowledge of the architecture and drainage patterns of the lymphatic system. Detailed knowledge of the lymphatic system is critical for understanding the role of sentinal node identification in the management of different cancers. METHODS: We have combined microscopic techniques with in vivo and in vitro lymphographic studies to survey the architecture and drainage patterns of the lymphatic system of the UADT in 850 organ specimens. RESULTS: These studies show an interaction of superficial and deep lymphatic networks that vary in density but have a constant distribution characterized by predictable patterns of lymph drainage into the regional lymph nodes. CONCLUSIONS: Detailed knowledge of the lymphatic system of the UADT contributes to a better understanding of the patterns of metastatic spread of carcinomas of the UADT and provides a strong rationale for the practice of sentinel node identification in the management of these tumors.