[Updated S2k AWMF guideline on obstructive sialadenitis]. / Aktualisierte AWMF-S2k-Leitlinie zur obstruktiven Sialadenitis.

The update of this guideline was an important step to define standards for the use of sialendoscopy and other emerging minimally invasive techniques for the therapy of sialolithiasis and other obstructive salivary gland diseases. The current actualization was necessary to adapt the diagnostic and therapeutic algorithms to the current scientific knowledge. In this article they are presented in a shortened version with a focus on conservative therapeutic measures which are especially relevant for daily practice.

Interrater Reliability of Ultrasound in the Diagnosis of Sialolithiasis.

PURPOSE: The aim of this study was to assess the interrater reliability of ultrasound for diagnosing sialolithiasis. MATERIALS AND METHODS: A total of 100 consecutive patients with signs of obstructive sialadenopathy were evaluated. The patients all underwent ultrasound examinations in a standardized manner conducted by one specialist with extensive experience in the management of salivary gland disorders and proficiency in head and neck ultrasonography. The video recordings were sent to six colleagues with comparable experience without providing any further information about the patients' medical history and physical examination. RESULTS: The overall agreement between the seven observers was substantial, with a κ of 0.765 for the 100 cases and a percentage agreement level of 88.29 ±â€Š3.01 % (range: 83-94 %). The range of agreement on this video set for observer pairs varied from substantial to almost perfect agreement (0.663 to 0.878). Among the few false-negative findings (5.4 %), 71.8 % were due to distal sialolithiasis. Two-thirds of the false-positive findings (3.7 %) were due to fibrotic stenosis. CONCLUSION: The study confirmed the diagnostic value of ultrasound in sialolithiasis and demonstrated a very high level of interrater agreement, even in the absence of additional clinical patient information, thus further underscoring the importance of ultrasound as the examination of first choice in sialolithiasis.

Reducing tumor growth and angiogenesis using a triple therapy measured with Contrast-enhanced ultrasound (CEUS).

BACKGROUND: To evaluate the in vivo response by detecting the anti-angiogenic and invasion-inhibiting effects of a triple-combination-therapy in an experimental-small-animal-squamous-cell-carcinoma-model using the "flash-replenishment" (FR) method to assess tissue hemodynamics via contrast-enhanced-ultrasound (CEUS). METHODS: Human hypopharynx-carcinoma-cells were subcutaneously injected into the left flank of 22-female-athymic-nude-rats. After seven days of subcutaneous tumor growth, FR-measurements were performed on each rat. Treatment-group and control-group were treated every day for a period of one week, with the treatment-group receiving solvents containing a triple therapy of Upamostat®, Celecoxib® and Ilomastat® and the control-group solvents only. On day seven, follow-up measurements were performed using the same measurement protocol to assess the effects of the triple therapy. VueBox® was used to quantify the kinetic parameters and additional immunohistochemistry analyses were performed for comparison with and validation of the CEUS results against established methods (Proliferation/Ki-67, vascularization/CD31, apoptosis/caspase3). RESULTS: Compared to the control-group, the treatment-group that received the triple-therapy resulted in a reduction of tumor growth by 48.6% in size. Likewise, the immunohistochemistry results showed significant decreases in tumor proliferation and vascularization in the treatment-group in comparison to the control-group of 26%(p ≤ 0.05) and 32.2%(p ≤ 0.05) respectively. Correspondingly, between the baseline and follow-up measurements, the therapy-group was associated with a significant(p ≤ 0.01) decrease in the relative-Blood-Volume(rBV) in both the whole tumor(wt) and hypervascular tumor(ht) areas (p ≤ 0.01), while the control-group was associated with a significant (p ≤ 0.01) increase of the rBV in the wt area and a non-significant increase (p ≤ 0.16) in the ht area. The mean-transit-time (mTT) of the wt and the ht areas showed a significant increase (p ≤ 0.01) in the follow-up measurements in the therapy group. CONCLUSION: The triple-therapy is feasible and effective in reducing both tumor growth and vascularization. In particular, compared with the placebo-group, the triple-therapy-group resulted in a reduction in tumor growth of 48.6% in size when assessed by CEUS and a significant reduction in the number of vessels in the tumor of 32% as assessed by immunohistochemistry. As the immunohistochemistry supports the CEUS findings, CEUS using the "flash replenishment"(FR) method appears to provide a useful assessment of the anti-angiogenic and invasion-inhibiting effects of a triple combination therapy.

Laser lithotripsy of salivary stones: Correlation with physical and radiological parameters.

BACKGROUND AND OBJECTIVES: Sialolithiasis is a common disease of the major salivary glands. Owing to the variety of conservative and minimally invasive techniques, it is now possible to treat most cases of sialolithiasis without removal of the affected salivary gland. One treatment option is the endoscopic removal of the calculi. In cases of larger concretions, intraductal disintegration using laser-induced shock waves can be appropriate to allow endoscopic removal. In the present study, we investigated whether physical and radiological parameters of salivary stones can effectively predict the applicability of laser lithotripsy. Furthermore, we determined to what extent the applied laser energy resulted in tissue damage. STUDY DESIGN/MATERIALS AND METHODS: In addition to basic parameters like size and density, we analysed 47 salivary stones using fluorescence spectroscopy, infrared spectroscopy, Raman spectroscopy, and dual-energy computed tomography. Subsequent fragmentation of all stones was performed with a Ho:YAG laser in a near-contact manner. Fragmentation rates were calculated and correlated with the previously measured physical and radiological parameters. Finally, to test for tissue damage, we performed HE-histology of salivary duct mucosa treated with the same laser energy used for stone fragmentation. RESULTS: Blue light excitation induced either green or red fluorescence emission. Dual-energy CT resulted in evidence of calcium-containing material. Infrared spectroscopy and Raman spectroscopy, both identified carbonate apatite as the main component of salivary stones. Disintegration into pieces smaller than 2 mm was possible in all cases. Fragmentation rates depended on the energy per pulse applied but not on any of the analysed physical and radiological parameters. In contrast to lithotripsy with 500 mJ per pulse, which was associated with no tissue damage, lithotripsy with 1,000 mJ per pulse resulted in damage of salivary duct mucosa. This suggests that the optimal laser energy for stone fragmentation is between 500 and 1,000 mJ per pulse. CONCLUSION: Laser lithotripsy using Ho:YAG laser is a highly efficient treatment, at least in vitro. All salivary stones could be disintegrated irrespective of their physical and radiological composition.

DCE-MRI biomarkers for monitoring an anti-angiogenic triple combination therapy in experimental hypopharynx carcinoma xenografts with immunohistochemical validation.

BACKGROUND: Novel anti-angiogenic treatments are increasingly complementing established cancer therapy strategies in head and neck tumors. Contrast-enhanced magnetic resonance imaging (MRI) can be applied for early and non-invasive therapy monitoring by non-invasive quantitative assessment of tumor microcirculation as in vivo imaging biomarkers of therapy response. PURPOSE: To monitor the anti-angiogenic effects of a novel combination therapy on experimental head and neck squamous cell carcinomas (HNSCC) with dynamic contrast-enhanced (DCE)-MRI. MATERIAL AND METHODS: Athymic rats (n = 18) with subcutaneous HNSCC xenografts were investigated by DCE-MRI before and after 7 days of a daily triple therapy regimen combining the COX-II-inhibitor celecoxib, the matrix-metalloproteinase-inhibitor GM6001, and the uPA-inhibitor upamostat. Quantitative measurements of tumor blood flow (tBF), tumor blood volume (tBV), and permeability-surface area product (PS) were calculated and validated by immunohistochemistry. RESULTS: Mean tBF and tBV in triple-therapy animals decreased significantly from day 0 to day 7 (tBF, 41.0 ± 14.2 to 20.4 ± 5.7 mL/100 mL/min; P < 0.01; tBV, 17.7 ± 3.9 to 7.5 ± 3.3%; P < 0.01). No significant effects on PS were observed in either group (P > 0.05). Immunohistochemical analysis showed a significantly lower tumor vascularity in the therapy group than in the control group (CD31), significantly fewer Ki-67+ proliferating tumor cells and significantly more Capase-3+ apoptotic tumor cells (P < 0.05). Significant (P < 0.05) correlations were observed between tBF/tBV and CD31 (tBF, r = 0.84; tBV, r = 0.70), tBV and Ki-67 (r = 0.62), as well as tBF and caspase-3 (r = -0.64). CONCLUSION: DCE-MRI may be a suitable tool for the non-invasive monitoring of the anti-vascular effects of this innovative triple therapy regimen with potential for clinical translation.

CD133 induces tumour-initiating properties in HEK293 cells.

The pentaspan protein CD133 (Prominin-1) is part of the signature of tumour-initiating cells for various cancer entities. The aim of the present study was to investigate the impact of ectopic CD133 expression on tumourigenic properties of otherwise CD133-negative, non-tumourigenic cells in vitro and in vivo. CD133 was stably transfected into human embryonic kidney 293 (HEK293) which was then sorted for the expression of CD133. The effects of CD133 on cell proliferation were assessed upon standard cell counting of sorted cells at various time points. Severe combined immunodeficient (SCID) mice (n = 30) were injected with HEK293 CD133(high) and CD133(low) transfectants (5 × 10(3), 1 × 10(5), or 5 × 10(6) cells per injection). The expression of CD133, Ki67, CD44s, CD44v6, and EpCAM was analysed upon immunohistochemical staining of cryosections with specific antibodies. In vitro, ectopic expression of CD133 did influence neither cell proliferation nor cell cycle distribution of otherwise CD133-negative HEK293 cells. However, CD133(high) cells generated tumours in vivo in SCID mice with at least 1,000-fold increased frequency compared to CD133(low) cells. Tumour load was also significantly increased in CD133(high) cells as compared to those tumours formed by high numbers of CD133(low) cells. Immunohistochemistry stainings disclosed no changes in Ki67, CD44s, CD44v6, or EpCAM once tumours were formed by either cell type. CD133 induces tumour-initiating properties in HEK293 cells in vivo and is potentially involved in the regulation of tumourigenicity. Future research will aim at the elucidation of molecular mechanisms of CD133-induced tumourigenicity.

µ-Slide Chemotaxis: a new chamber for long-term chemotaxis studies.

BACKGROUND: Effective tools for measurement of chemotaxis are desirable since cell migration towards given stimuli plays a crucial role in tumour metastasis, angiogenesis, inflammation, and wound healing. As for now, the Boyden chamber assay is the longstanding "gold-standard" for in vitro chemotaxis measurements. However, support for live cell microscopy is weak, concentration gradients are rather steep and poorly defined, and chemotaxis cannot be distinguished from migration in a single experiment. RESULTS: Here, we describe a novel all-in-one chamber system for long-term analysis of chemotaxis in vitro that improves upon many of the shortcomings of the Boyden chamber assay. This chemotaxis chamber was developed to provide high quality microscopy, linear concentration gradients, support for long-term assays, and observation of slowly migrating cells via video microscopy. AlexaFluor 488 dye was used to demonstrate the establishment, shape and time development of linear chemical gradients. Human fibrosarcoma cell line HT1080 and freshly isolated human umbilical vein endothelial cells (HUVEC) were used to assess chemotaxis towards 10% fetal calf serum (FCS) and FaDu cells' supernatant. Time-lapse video microscopy was conducted for 48 hours, and cell tracking and analysis was performed using ImageJ plugins. The results disclosed a linear steady-state gradient that was reached after approximately 8 hours and remained stable for at least 48 hours. Both cell types were chemotactically active and cell movement as well as cell-to-cell interaction was assessable. CONCLUSIONS: Compared to the Boyden chamber assay, this innovative system allows for the generation of a stable gradient for a much longer time period as well as for the tracking of cell locomotion along this gradient and over long distances. Finally, random migration can be distinguished from primed and directed migration along chemotactic gradients in the same experiment, a feature, which can be qualified via cell morphology imaging.

Carcinoma ex pleomorphic adenoma with special reference to the prognostic significance of histological progression: a clinicopathological investigation of 41 cases.

AIMS: To investigate a large series of cases of carcinoma ex pleomorphic adenoma (CEPA) to determine prognostic factors. METHODS AND RESULTS: Thirty cases of CEPA associated with primary pleomorphic adenoma (PA) and 11 cases of CEPA associated with recurrent PA were investigated. The median follow-up was 57.7 months, and ranged from 4 to 156 months. Purely intraductal carcinoma was found in 15 cases. Intraductal and extraductal intracapsular carcinoma together was found in one case. Extracapsular carcinoma was found in 25 cases. Prognosis was good for CEPA that was purely intraductal, extraductal intracapsular, or up to 5 mm extracapsular, and poor for CEPA that was 8 mm or more extracapsular. There were relatively more cases of CEPA with extracapsular invasion of 8 mm or more from recurrent PA than from primary PA, and the prognosis for CEPA associated with recurrent PA was worse than that for CEPA associated with primary PA. CONCLUSIONS: The threshold for distinguishing minor extracapsular invasion with good prognosis from wide extracapsular invasion with poor prognosis is 5 mm. The worse prognosis for CEPA associated with recurrent PA indicates the necessity for close surveillance of patients with recurrent PA.

Intraductally applied contrast-enhanced ultrasound (IA-CEUS) for evaluating obstructive disease and secretory dysfunction of the salivary glands.

Obstructive diseases of the salivary glands are a common problem, usually based on sialolithiasis, duct stenosis, foreign bodies or other more rare causes. Secretory dysfunction, often associated with Sjögren syndrome or post radiation treatment, is also a frequent problem. Several diagnostic tools exist to classify the disease; however conventional radiological imaging or ultrasound does not provide a diagnosis in 5-10% of all cases. Intraductally applied contrast-enhanced ultrasound (IA-CEUS) improves the visualization of obstructive diseases of the salivary glands. IA-CEUS is a promising tool for assessing the ductal system and to diagnose and characterize abnormalities. This study describes the assessment of IA-CEUS in diagnosing different obstructive and chronic inflammatory conditions of the salivary glands.

Multimodal therapy for synergic inhibition of tumour cell invasion and tumour-induced angiogenesis.

BACKGROUND: Squamous cell carcinoma of the head and neck (SCCHN) are highly invasive tumours with frequent local and distant recurrence. Metastasis formation requires degradation of the extracellular matrix, which is fulfilled by membrane-associated proteases such as the urokinase plasminogen activator (uPA). WX-UK1 is a competitive active site inhibitor of the protease function of uPA that impairs on the capacity of tumour cells to invade in vitro. METHODS: In the present study, effects of combinations of WX-UK1 with matrix metalloprotease inhibitors (MMP, galardin) and cyclooxygenase-2 (COX-2, celecoxib) inhibitors on tumour cell proliferation, invasion, and angiogenesis induction were evaluated. Matrigel invasion chambers and a spheroid co-cultivation model with human fibroblast served to determine the invasive potential of both FaDu (SCCHN) and HeLa (cervical carcinoma) cells, each treated with combinations of Celecoxib, Galardin, and WX-UK1. RESULTS: Blocking of single protease systems resulted in a significant 50% reduction of tumour cell invasion using WX-UK1, while the triple combination was even more effective with 80% reduction of invasion. Additionally, a sprouting assay with HUVEC was used to test the anti-angiogenetic potential of the triple combination, resulting in a 40% decrease in the sprouting rate. CONCLUSIONS: A combined approach targeting different families of proteases and cyclooxygenases represents a promising adjuvant therapy.

Salivary Gland Disorders in Children and Adolescents: A 15-year Experience.

Introduction Diseases of the salivary glands are rare in children and adolescents, with the exception of viral-induced infections. Objective To determine the clinical course of the disease, the diagnostic procedures, the treatment and the outcome of all children and adolescents affected with salivary gland diseases at our clinic over a period of 15 years. Methods A retrospective chart review including a long-term follow-up was conducted among 146 children and adolescents treated for salivary gland disorders from 2002 to 2016. Results Diagnosing acute sialadenitis was easily managed by all doctors regardless of their specialty. The diagnosis of sialolithiasis was rapidly made only by otorhinolaryngologists, whereas diagnosing juvenile recurrent parotitis imposed difficulties to doctors of all specialties - resulting in a significant delay between the first occurrence of symptoms and the correct diagnosis. The severity-adjusted treatment yielded improvements in all cases, and a full recovery of 75% of the cases of sialolithiasis, 73% of the cases of juvenile recurrent parotitis, and 100% of the cases of acute sialadenitis. Conclusions Due to their low prevalence and the lack of pathognomonic symptoms, salivary gland diseases in children and adolescents are often misdiagnosed, resulting in an unnecessarily long period of suffering despite a favorable outcome following the correct treatment.

VTIQ and VTQ in combination with B-mode and color Doppler ultrasound improve classification of salivary gland tumors, especially for inexperienced physicians.

BACKGROUND: Ultrasound is the method of choice for preoperative evaluation of masses of the parotid glands. However, existing methods do not allow for definite differentiation between the most common benign and malignant tumors. OBJECTIVE: Thus, we evaluated the benefits of Virtual Touch Quantification (VTQ) and Virtual Touch imaging quantification (VTIQ) for improving preoperative evaluation of parotid tumors. METHODS: We investigated eight lymph nodes and 41 tumors of the parotid gland via ultrasound, color Doppler ultrasound, VTIQ and VTQ shear wave imaging. Each examination consisted of pictures and videos, which were evaluated by twelve examiners. Initially, each examiner predicted whether the mass was benign or malignant based on B-mode and Doppler images. Then each examiner viewed the VTIQ and VTQ shear wave images and reevaluated the predictions, which were then compared with the histopathological outcomes. RESULTS: In tumors, the sensitivity was 36% based only on B-mode and color Doppler sonography, which increased to 42% with the addition of VTIQ and VTQ. Likewise, the specificity also increased from 78% to 85%. CONCLUSIONS: VTQ and VTIQ provide additional data that improve the capability to distinguish between benign and malignant tumors allowing for an increase in both the sensitivity and specificity.

Does acoustic radiation force elastography improve the diagnostic capability of ultrasound in the preoperative characterization of masses of the parotid gland?

OBJECTIVES:: Ultrasound is the method of choice for preoperative evaluation of tumours of the parotid glands. However, existing methods do not allow for clear differentiation between the most common benign tumours and malignant tumours. The aim of our study was to evaluate if acoustic radiation force, Virtual Touch Quantification (VTQ) elastography helps to improve the preoperative evaluation of parotid masses. METHODS:: We investigated the parenchyma of 102 parotid glands, 14 lymph nodes of healthy volunteers and 51 tumours of the parotid gland via ultrasound, colour Doppler ultrasound and VTQ. The results were matched with histopathology and analyzed. RESULTS:: The perfusion in pleomorphic adenoma, the most frequent benign tumour of the parotid gland, was significantly lower in comparison to malignant tumours. All tumours showed statistically significant higher perfusion in comparison to the parenchyma or the lymph nodes of the gland. Shear wave velocity of the user-defined region of interest was statistically significant more frequently an overflow value higher than 8.5 m/s in total tumours in comparison to parenchyma or lymph nodes. The different tumour types presented no significant difference in the shear wave velocity. CONCLUSIONS:: VTQ in combination with classical ultrasound examination provides additional data useful in distinguishing between benign and malignant tumours and thus shows promise for integration into preexisting ultrasound protocols. However, despite the improvement, clear differentiation of tumours is still not possible and further investigation is recommended.

Ultrasound elastography in diagnosis and follow-up for patients with sialolithiasis.

OBJECTIVES:: This study aims to answer whether acoustic radiation force impulse imaging (ARFI) can reasonably be employed in initial examination and follow-up during therapy in patients with sialolithiasis, one of the most common non-malignant disorders of the salivary glands. METHODS:: Mechanical tissue properties of affected and contralateral healthy salivary glands were analyzed by ARFI in 129 patients with sialolithiasis. In different subgroup analyses, ARFI shear wave velocity values were compared between healthy and diseased submandibular or parotid glands, salivary glands with calculi exhibiting different sizes, as well as before and after therapy. The patients' symptoms were evaluated by a standardized questionnaire. The t-test (2 groups) or the One-way ANOVA test (>2 groups) was used for the estimation of stochastic probability in intergroup comparisons. RESULTS:: Submandibular or parotid glands affected by sialolithiasis were found to exhibit significant lower ARFI values as compared to the healthy contralateral glands in the same individuals. ARFI values in submandibular glands with a single calculus of more than 5 mm in diameter or with multiple calculi as well as in parotid glands with calculi exhibiting diameters of more than 5 mm were significantly higher as compared to the respective healthy contralateral glands. No significant differences in ARFI values of affected salivary glands were detected between patients with low or high symptom perception. CONCLUSIONS:: ARFI provides an easy, quick and reliable diagnostic tool for the objective assessment of disease severity and progression in patients with sialolithiasis that can simply be implemented in pre-existing ultrasound protocols.

Ultrasound elastography in diagnosis and follow-up for patients with chronic recurrent parotitis.

PURPOSE: Chronic recurrent parotitis (CRP) is a non-obstructive disease with episodes characterized by painful swelling of the parotid gland. It presents in both a juvenile and an adult form, with no clear information on its actual origin. Diagnosis is based on patient medical history and ultrasound examination but is frequently not correctly identified. Acoustic Radiation Force Impulse Imaging (ARFI) is a novel ultrasound elastography technology that has recently been implemented in the diagnostic work-up of patients with malignancies. This study aimed to answer whether ARFI can reasonably be employed in the initial examination and follow-up during therapy in patients with CRP. MATERIAL AND METHODS: Mechanical tissue properties of the salivary glands were analyzed by ARFI in 37 parotid glands of patients with CRP. RESULTS: Having integrated ARFI into our diagnostic protocol for CRP, affected parotid glands were found to exhibit lower tissue elasticity compared to both healthy contralateral glands in the same individuals as well as those of healthy individuals. Most importantly, this method enabled us to quantitatively assess the patient benefit of therapy regarding the recovery of the glands' diseased parenchyma. CONCLUSIONS: ARFI provides a quick, easy, and reliable diagnostic tool for the assessment of disease severity and progression in patients with CRP that can be seamlessly implemented into preexisting ultrasound protocols.

Does Virtual Touch IQ elastography help to improve the preoperative diagnosis of parotid tumors: A prospective trial.

BACKGROUND: It is difficult to assess tumors of the parotid gland preoperatively. However, it is essential for the surgeon to know which kind of tumor is present. Ultrasound is the method of choice, but there is still no reliable differential diagnostic tool for determining whether a tumor is malignant or benign. OBJECTIVE: The aim of our study was to examine the value of Virtual Touch imaging quantification (VTIQ) elastograpy in distinguishing between malignant and benign tumors as well as in identifying the most common benign tumor types. METHODS: The parenchyma of 100 parotid glands and 12 lymph nodes of healthy volunteers and 50 tumors of the parotid gland were analyzed via ultrasound, color Doppler ultrasound, and VTIQ, and the results were then compared with histopathology. RESULTS: In comparison with benign tumors, in malignant tumors the tumor border was diffuse, the perfusion higher, and the VTIQ quality much lower. Share wave velocity of the user-defined region of interest was more frequently higher than 6.8 m/s in malignant tumors in comparison to benign tumors. CONCLUSIONS: VTIQ in combination with ultrasound examination provides additional information for distinguishing between benign and malignant tumors and shows promise for integration into preexisting ultrasound protocols.

Salivary Gland Disorders in Children and Adolescents: A 15-year Experience

Abstract Introduction Diseases of the salivary glands are rare in children and adolescents, with the exception of viral-induced infections. Objective To determine the clinical course of the disease, the diagnostic procedures, the treatment and the outcome of all children and adolescents affected with salivary gland diseases at our clinic over a period of 15 years. Methods A retrospective chart review including a long-term follow-up was conducted among 146 children and adolescents treated for salivary gland disorders from 2002 to 2016. Results Diagnosing acute sialadenitis was easily managed by all doctors regardless of their specialty. The diagnosis of sialolithiasis was rapidly made only by otorhinolar- yngologists, whereas diagnosing juvenile recurrent parotitis imposed difficulties to doctors of all specialties - resulting in a significant delay between the first occurrence of symptoms and the correct diagnosis. The severity-adjusted treatment yielded improve- ments in all cases, and a full recovery of 75% of the cases of sialolithiasis, 73% of the cases of juvenile recurrent parotitis, and 100% of the cases of acute sialadenitis. Conclusions Due to their low prevalence and the lack of pathognomonic symptoms, salivary gland diseases in children and adolescents are often misdiagnosed, resulting in an unneces- sarily long period of suffering despite a favorable outcome following the correct treatment.