Neck involvement and disease recurrence in adenoid cystic carcinoma of the minor salivary glands: the role of surgery in primary and progressive disease.

The aim of this study was to analyse the rates of metastatic events and clinical outcomes of patients with adenoid cystic carcinoma (ACC) of the minor salivary glands and to critically evaluate the role of surgical therapy. A retrospective cohort study was designed including all patients with ACC of the oral minor salivary glands treated in the study department during the years 2010-2017. Relevant clinicopathological data were analysed to determine factors with an impact on overall survival (OS) and progression-free survival (PFS). Forty-one patients with primary ACC of the oral cavity and the oropharynx were included. Cervical metastases were found in 14 patients (34.1%) and were shown to have a significant negative impact on OS (P=0.009) and PFS (P=0.03). Sixteen patients developed disease recurrence during follow-up (39.0%) and most patients exhibited local disease recurrence with or without regional or distant metastases (14/16, 87.5%). Local recurrence was treated successfully with surgery in five cases. We recommend surgical therapy for patients with ACC of the minor salivary glands, including elective neck dissection and microvascular reconstruction, to optimize the planning of adjuvant therapy.

Phase II study of cetuximab in combination with docetaxel in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck after platinum-containing therapy: a multicenter study of the Arbeitsgemeinschaft Internistische Onkologie.

BACKGROUND: Cetuximab and docetaxel have single-agent activity in squamous cell carcinoma of the head and neck (SCCHN). The efficacy of their combination was evaluated in platinum-pretreated patients with recurrent and/or metastatic SCCHN. PATIENTS AND METHODS: A total of 84 patients were treated with docetaxel 35 mg/m(2) weekly for a maximum of 6 cycles and concomitant cetuximab 250 mg/m(2) weekly until disease progression or unacceptable toxicity. The primary endpoint was the objective response rate and secondary endpoints included the response rate in relation to platinum sensitivity, progression-free survival (PFS), overall survival (OS) and toxicity. RESULTS: Nine (11%) patients achieved a partial response and 34 (40%) stable disease, resulting in a disease control rate of 51%. Response to treatment was 49% in previously platinum-sensitive and 50% in previously platinum-resistant disease. The median PFS was 3.1 months and the median OS 6.7 months. The most common grade 3 or 4 adverse events were mucositis (8%), pneumonia (8%), fatigue (8%) and skin reactions (14%). Sepsis occurred in 3 patients. CONCLUSION: Cetuximab plus docetaxel is an active treatment regimen with moderate toxicity in SCCHN patients. However, no superiority in comparison with monotherapy could be shown. Responsiveness and survival were independent of previous platinum sensitivity.

[Surgically assisted rapid maxillary expansion. Effects on the nasal airways and nasal septum]. / Chirurgisch unterstützte transversale Oberkieferdistraktion. Auswirkungen auf Nasenwege und Nasenseptum.

BACKGROUND: Surgically assisted rapid maxillary expansion (SARME) is a standardized method to treat cross bites in maxillofacial surgery. Changes to the nasal airways are assumed due to the anatomic dependence between the palate and the nasal floor. PATIENTS AND METHODS: In this study 19 patients with a transverse deficit of the upper jaw underwent SARME. CT scans were performed 1 month pre- and 6 months postoperatively. Effects to the lower nasal airways, the nasal septum and the hard palate were subsequently evaluated. RESULTS: The mean distraction width of the upper jaws was 5.84 mm (SD 2.19) postoperatively. In addition to the dentoalveolar gain in width, a significant increase in the nasal floor was observed (p<0.001). The anterior part of the nasal floor was increased by 14.11%. An anterior-caudal tilt of the upper jaw was observed in the anterior part measuring 1.5 mm (SD 1.05). No significant deviation of the nasal septum occurred. CONCLUSION: SARME has a significant effect on ear, nose and throat medicine. Nasal airways enlarge significantly, while no significant deviation of the nasal septum is observed.

[Activation of sonic hedgehog signaling in keratocystic odontogenic tumors]. / Aktivierung des Sonic-hedgehog-Signalwegs in keratozystischen odontogenen Tumoren.

BACKGROUND: Keratocystic odontogenic tumors are benign neoplasms of the viscerocranium that occur sporadically as well as in association with Gorlin-Goltz syndrome. Multiple basal cell carcinomas of the skin are another typical feature of Gorlin-Goltz syndrome. Aberrant activation of sonic hedgehog signaling has been reported for sporadic and hereditary basal cell carcinoma caused by specific genetic mutations, but for keratocystic odontogenic tumors, the role of aberrant sonic hedgehog signaling has not yet been evaluated in detail. MATERIALS AND METHODS: In the present study, 131 keratocystic odontogenic tumors were analyzed by immunohistochemistry for the expression of sonic hedgehog signaling proteins SHH, PTCH1, SMO, GLI1, and NMYC on tissue microarray sections. RESULTS: High expression of the analyzed proteins-between 67.3% (PTCH1) and 92.9% (SHH)-was found in the epithelial compartment of the keratocystic odontogenic tumors analyzed. In the stromal compartment of the tumors, high expression of the target proteins was found significantly less frequently (all p-values <0.001). CONCLUSION: Aberrant sonic hedgehog signaling is critically involved in the molecular pathogenesis of keratocystic odontogenic tumors. This finding underlines the neoplastic character of this intraosseous lesion. Because of high recurrence rates after local excision, more radical surgical approaches are recommended for treating keratocystic odontogenic tumors.

Proteomic analysis reveals successive aberrations in protein expression from healthy mucosa to invasive head and neck cancer.

Development of head and neck squamous cell carcinoma (HNSCC) is a multistep process and in many cases involves a phenomenon coined 'field cancerization'. In order to identify changes in protein expression occurring at different stages of tumorigenesis and field cancerization, we analysed 113 HNSCCs and 73 healthy, 99 tumor-distant and 18 tumor-adjacent squamous mucosae by SELDI-TOF-MS on IMAC30 ProteinChip Arrays. Forty-eight protein peaks were differentially expressed between healthy mucosa and HNSCC. Calgizarrin (S100A11), the Cystein proteinase inhibitor Cystatin A, Acyl-CoA-binding protein, Stratifin (14-3-3 sigma), Histone H4, alpha- and beta-Hemoglobin, a C-terminal fragment of beta-hemoglobin and the alpha-defensins 1-3 were identified by mass spectrometry. The alpha-defensins showed various alterations in expression as validated by immunohistochemistry (IHC). Supervised prediction analysis revealed excellent classification of healthy mucosa (94.5% correctly classified) and tumor samples (92.9% correctly classified). Application of this classifier to the tumor-adjacent and tumor-distant mucosa samples disclosed dramatic changes: only 59.6% of the tumor-distant biopsies were classified as normal, 27.3% were predicted as aberrant or HNSCC. Strikingly, 72% of the tumor-adjacent mucosae were predicted as aberrant. These data provide evidence for the existence of genetically altered fields with inconspicuous histology. Comparison of the protein profiles in the tumor-distant-samples with clinical outcome of 32 patients revealed a significant association between aberrant profiles with tumor relapse events (P=0.018; Fisher's exact test, two-tailed). We conclude that proteomic profiling in conjunction with protein identification greatly outperforms histopathological diagnosis and may have significant predictive power for clinical outcome and personalized risk assessment.

Comparison of p16(INK4a) expression with p53 alterations in head and neck cancer by tissue microarray analysis.

We investigated whether there is a relationship between loss of p16(INK4a) protein expression and p53 alterations in head and neck squamous cell carcinomas (HNSCCs). For this purpose, immunohistochemistry was performed on tissue microarrays of 664 tumours; this represents the largest HNSCC cohort studied for molecular biomarkers. Loss of p16(INK4a) protein expression was associated with aberrant p53 expression (negative or overexpressed) in the total cohort, and with TP53 mutations in 200 tumours analysed (p < 0.0001 each). Both loss of p16(INK4a) expression and p53 alterations differed significantly across both tumour sites and stages, being more prevalent in the hypopharynx than in the other tumour sites and in advanced tumour stages. As a possible link between p53 status and p16(INK4a) loss, we found that increased DNA methyltransferase 1 protein levels occurred preferentially in tumours with aberrant p53 (p = 0.001) and negative p16(INK4a) expression (p = 0.0004). In the total cohort, there was a borderline significant difference in patient survival across three p16(INK4a) expression levels (negative, positive, high), with loss of p16(INK4a) expression showing shortest survival. It is suggested that loss of p16(INK4a) expression and p53 alterations should be viewed as related events involved in the early carcinogenic process.

Preoperative paclitaxel/carboplatin radiochemotherapy for stage III/IV resectable oral and oropharyngeal cancer: seven-year follow-up of a phase II trial.

Numerous treatment concepts for advanced but resectable oral and oropharyngeal squamous cell carcinoma exist. In this study, we present the 7-year results of a promising treatment with preoperative simultaneous chemoradiation using paclitaxel and carboplatin within a prospective phase II trial comprising 56 patients. After determination of the local tumor extension, chemoradiation was applied for 4 weeks and up to 40 Gy. Following a recovery period of 3-4 weeks, tumor resection was performed within the initially tattooed resection margins, together with a functional modified neck dissection. The median follow-up time was 44.9 +/- 19.6 months (range 0.76-87.9). After 7 years, 35 (63.3%) patients were alive and 20 (36.4%) had died. In 2 patients (3.6%), the cause of death was related to treatment. After 7 years, the overall survival rate declined to 63.6%, whereas the local recurrence-free probability was still 84.2%. These results confirm the excellent local control and high survival rates of preoperative radiochemotherapy with the combination of paclitaxel/carboplatin.

Clinical application of cone beam digital volume tomography in children with cleft lip and palate.

OBJECTIVES: The diagnostic advantages of digital volume tomography (DVT) over conventional imaging and computed tomography are demonstrated in terms of the respective radiation exposure. The potential role for three-dimensional imaging in cleft lip and palate patients is illustrated on the basis of clinical examples. METHODS: The radiation exposure resulting from scans using a cone beam DVT (NEW TOM QR-DVT 9000, Marburg, Germany) was measured with an Alderson-Rando-Phantom (The Phantom Laboratory, New York, NY) and compared with that resulting from other standard imaging modalities. The patient sample consisted of young children with cleft lip and palate on whom orthodontic and surgical treatment was planned on an interdisciplinary basis at the University-Hospital of Heidelberg. RESULTS: Digital volume tomography allows high-quality three-dimensional imaging of the premaxilla region, with an effective equivalent investigation dose of (110 kV, 5.4 mA) 0.342 mSv based on ICRP recommendations. While the effective equivalent investigation dose for DVT is higher than that for standard imaging techniques (for example digital panoramic radiograph Orthophos Plus DS Ceph (66 kV, 8 mA) 0.016 mSv), it is much lower than that for a normal CT scan (e.g. Picker International Inc., Highland Heights, OH) adjusted at (spiral 130 kV, 125 mA, and 30 mA, 1.5 s) 2.27 mSv. Digital volume tomography provides extensive data important in clinical decision making. CONCLUSIONS: The clinical examples show the good applicability of DVT with a reduced radiation dose.

Efficacy and tolerability of diclofenac potassium sachets in acute postoperative dental pain: a placebo-controlled, randomised, comparative study vs. diclofenac potassium tablets.

This double-blind, randomised, parallel-group trial compared the analgesic efficacy of single 50 mg doses of diclofenac potassium sachets and tablets with placebo in 184 patients with moderate/severe pain after third molar extraction. The primary efficacy variable was the average pain reduction from baseline during the first 2-h postdose, using a visual analogue scale (VAS). During the first 2-h postdose, sachets and tablets significantly reduced pain (p < 0.05) vs. placebo with an incremental benefit seen for sachets over tablets (p < 0.05). Onset of analgesic effect (VAS) was at 30 min for sachets and 45 min for tablets. Pain reduction vs. placebo (VAS) was maintained for 8 h for sachets and tablets (p < 0.05). VAS-findings were confirmed by pain relief and intensity verbal scale assessments. Fewer patients re-medicated vs. placebo. No safety issues were identified. This study demonstrates that both diclofenac potassium sachets and tablets offer patients suffering from acute pain conditions an effective treatment with incremental analgesic benefits seen for sachets.

Amplification of Cyclin L1 is associated with lymph node metastases in head and neck squamous cell carcinoma (HNSCC).

Overrepresentation of chromosomal bands 3q25-q29 has been associated with shortened disease-specific survival in head and neck squamous cell carcinoma (HNSCC). To assess the prevalence of copy number gains (>4 signals per cell) and high-level amplifications (>8 signals per cell) from putative oncogenes in this chromosomal region (CCNL1, SNO, PIK3CA, TP73L), tissue microarray analysis was applied on 280 HNSCCs by fluorescence in situ hybridization. Overall frequency of additional copy numbers was 34.3% for CCNL1, 31.8% for SNO, 39.0% for PIK3CA and 38.3% for TP73L, respectively. In general, gains were more frequently detected in stage IV compared to stage I-III tumours. Performing multivariate logistic regression analysis, a significant association of CCNL1 gains and the presence of lymph node metastases was found, which was independent of anatomical site and T-stage of the primary tumour (P=0.049). Site-specific subgroup analysis further showed that copy number gains of CCNL1 and SNO occurred more frequently in oral carcinomas in advanced clinical stages as compared to N0 oral lesions (CCNL1: P=0.03; SNO: P=0.03). Finally, Kaplan-Meier analysis revealed that high-level amplifications of CCNL1 correlated with shorter overall survival of the patients. Our results indicate that CCNL1 plays a critical role in the loco-regional progression of HNSCC and may serve as an indicator for occult advanced tumour stages.

[Opportunities and chances for tissue chip microarrays in head and neck surgery. A novel technique for the rapid evaluation of potentially novel biomarkers]. / Möglichkeiten und chancen der Gewebechiptechnologie bei Kopf-Hals-Tumoren. Eine neue Technik zur schnellen Analyse von potenziellen Tumormarkern.

Oral squamous cell carcinomas (OSCC) are malignant tumors with a poor prognosis and low long-term survival rates, even when using modern adjuvant and neoadjuvant therapy forms in addition to surgery. For the clinical estimation of each tumor, it is necessary to define stage-dependent molecular and/or cellular parameters as it is known that OSCC develop along a multistep pathway including the loss of tumor suppressor genes and the amplification of oncogenes which result in changes in protein expression. In order to establish a reliable pattern of molecular and cellular biomarkers, a large number of tumor specimens from different stages of the disease need to be analysed. In this study, biopsies of a collective of 293 OSCC in different stages were screened with the novel technique of tissue chip microarrays by fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC). FISH-analysis was performed on the oncogene cyclin D1 and IHC-analysis on the proteins cyclin D1, p53, p16, cdk4, bcl2, mdm2 and rb. Tissue chip technology was shown to facilitate rapid screening for molecular and cellular alterations in different stages of OSCC and revealed reliable and reproducible results that may allow the definition of a multistep pathway model for tumor progression in OSCC.

[Prognostic value of antibodies against p53 in patients with oral squamous cell carcinoma--five years survival rate]. / Prognostische Wertigkeit des Antikörpernachweises gegen p53 bei Patienten mit Plattenepithelkarzinomen der Mundhöhle anhand der 5-Jahresüberlebensrate.

BACKGROUND: p53 gene aberrations are the most common genetic changes seen in human carcinogenesis. Frequently, single point mutations are detected, resulting in increased levels of (an aberrant) p53 protein in tumor cells. The cellular protein produced appears to become immunogenic during tumor development, inducing the production of circulating antibodies against p53. METHODS: For this study, sera from 126 patients with oral squamous cell carcinomas (102 primary tumours and 24 recurrent/secondary tumours) were examined for p53 autoantibodies and their further clinical course was followed up for more than 5 years. 80 sera from internal medicine patients without known or suspected neoplasm served as control. A sandwich ELISA (enzyme linked immuno sorbent assay) designed by Dianova, Hamburg was used to detect p53 autoantibodies. RESULTS: In 18.6 % of the patients with primary oral squamous cell carcinomas, p53 autoantibodies were detected, and also in 50 % of the patients with recurrent or local secondary carcinomas. None of the sera of the control group was positive. Patients with anti-p53 have noticeably poorer prognosis (Log Rank Test, p < 0.005). After a period of 5 years, the overall survival rate of the p53-positive group was 24 % - less than half of that of the p53-negative group with a survival rate of 51 %. CONCLUSIONS: : The detection of p53 autoantibodies definitely permits a clearer prognostic assessment, which in turn influences clinical procedures. If p53 autoantibodies are detected in a patient during therapy, the applied therapeutic method should be reconsidered and the patient be more closely observed than other, p53 negative patients.

[Prospective phase II study of neoadjuvant radiochemotherapy in advanced operable carcinoma of the mouth cavity. 3-year outcome]. / Prospektive Phase-II-Studie zur neoadjuvanten Radiochemotherapie fortgeschrittener, operabler Mundhöhlenkarzinome. 3-Jahres-Ergebnisse.

PURPOSE: The purpose of simultaneous chemoradiotherapy is to increase local-regional control and to decrease the incidence of distant metastases. Regimens containing cisplatin/5-FU chemotherapy are widely accepted as standard treatment in advanced head and neck cancer. Most studies reported promising response and survival data, but also severe mucosal toxicity. In recent years the newly developed drug Taxol demonstrated interesting activity in head and neck cancer as a single agent as well as in combination drug regimens. In the present outpatient phase II trial, we investigated the combination of Taxol/carboplatin with 40 Gy radiotherapy in a neoadjuvant setting of operable stage III/IV squamous cell carcinoma of the oral cavity and oropharynx. PATIENTS AND METHODS: Fifty-three patients were enrolled in this trial during the period from May 1998 to October 2000 and received five cycles weekly of Taxol (40 mg/m2) and carboplatin (AUC 1.5) with conventional radiotherapy (40 Gy). Within 3-4 weeks after chemoradiotherapy resection of the primary tumor and the regional neck nodes was performed. RESULTS: Fifty-two patients were evaluable for toxicity and response. Complete response was observed in 31 of 52 patients (CR 60%), and partial remission was seen in 21 of 52 patients (PR 40%). In 30 of 52 patients complete pathologic response (pCR 58%) was documented in the resection specimens. The 1-, 2-, and 3-year overall survival rate was calculated as 84%. CONCLUSION: Our present results demonstrated impressive clinical and pathological response rates of concurrent Taxol/carboplatin and radiotherapy as a preoperative treatment modality in advanced oral and oropharyngeal cancer.

Recurrent chromosomal imbalances detected in biopsy material from oral premalignant and malignant lesions by combined tissue microdissection, universal DNA amplification, and comparative genomic hybridization.

Biopsies routinely performed for the histopathological diagnosis of oral epithelial lesions before treatment were screened for chromosomal imbalances by comparative genomic hybridization. Comparative genomic hybridization was performed on 12 oral premalignant lesions (OPLs; dysplasias and carcinomas in situ) and 14 oral squamous cell carcinomas (OSCCs). Eight biopsies displayed areas of different histopathological appearance, so that OPLs and OSCCs from the same patient were analyzed. To avoid contamination with nonneoplastic cells, defined cell populations were isolated by micromanipulation with a glass needle. Before comparative genomic hybridization analysis, universal DNA amplification was performed using the DOP-polymerase chain reaction protocol. In the 14 OSCCs examined, the average number of chromosomal imbalances was significantly higher than in the 12 OPLs (mean +/- SEM: 11.9 +/- 1.9 versus 3.2 +/- 1.2; P = 0.003). The DNA copy number changes identified in more than one OPL were gains on 8q (3 of 12) and 16p (2 of 12), as well as losses on 3p (5 of 12); 5q (4 of 12); 13q (3 of 12); and 4q, 8p, and 9p (2 of 12 each). In more than 30% of OSCCs, gains of chromosomal material were identified on 20q (8 of 14); 8q, 11q, 22q (7 of 14 each); 3q, 15q, and 17p (6 of 14 each); and 14q, 17q, and 20p (5 of 14 each), and losses were identified on 3p and 4q (9 of 14 each), 5q (7 of 14), 13q (6 of 14), and 2q and 9p (5 of 14 each). These results were validated by positive and negative control comparative genomic hybridization experiments and microsatellite analysis for the detection of allelic loss. The vast majority of genomic alterations found in OPLs were again identified in OSCCs from the same biopsy, supporting the hypothesis that multiple lesions in the same patient are clonally related. In summary, we show that comprehensive information on the genomic alterations in oral epithelial lesions can be obtained from small biopsies. Such data may identify prognostic indicators that could eventually assist in designing therapeutic strategies.

[Robotics in oral and maxillofacial surgery. Possibilities, chances, risks]. / Robotik in der Mund-, Kiefer- und Gesichtschirurgie. Möglichkeiten--Chancen--Risiken.

Robot systems are being tested in stereotactic neurosurgical interventions, orthopedic surgery of the hip or knee and advancal endoscopic systems for minimally invasive surgery. In contrast to most industrially manufactured products, objects for medical treatment are characterized by plasticity as well as by complex and individual forms. Thus, features of robots in this field have to be further developed in terms of advanced sensory and specific micromotoric systems. Safety and cooperation between surgeon and robot on the patient in the operating room have to be guaranteed. Extensive three-dimensional diagnosis, computer-aided planning and simulation of the intervention as well as sensory systems that monitor the actual performance of the operation are mandatory parts of this concept. In our interdisciplinary study, we aim to examine whether a robot-given a complete preoperative planning and simulation procedure-is able to perform certain surgical operations more precisely than the surgeon. Examples are drilling with depth control, shaping of bone surface by milling, sawing with defined depth in cranial osteotomies, defined preparation of implant sites and the positioning and insertion of dental and other surgical implants, whereby autonomous employment of the robot is not that which is aspired to in these interventions but rather the interactive support of the surgeon.

[Multi-local angiosarcoma of the oral mucosa]. / Multilokuläres Angiosarkom der Mundschleimhaut.

A 64-year-old man presented with a bluish, livid swelling in the region of the lateral alveolar processes of all four quadrants. Evaluation and histopathological findings resulted in the diagnosis of an angiosarcoma at multiple sites. A survey of the literature and an epidemiologic review of our own patients prove this to be an extremely rare occurrence. A partial resection of the maxilla and the mandible on both sides was performed in sano. After discharge, however, a sarcoma was detected in the region of the right scapula 5 months after surgery. Therefore radiation treatment was initiated. The patient died 4 weeks later. The course confirms the poor prognosis of this tumor.