Growth of head and neck squamous cell carcinoma in nude mice: potentiation of laryngeal carcinoma by 17 beta-estradiol.

We successfully transplanted and serially perpetuated human head and neck tumors in nude mice by using tumor tissue derived from 10 of 14 (71%) independently obtained surgical specimens. Tumor growth was achieved with specimens derived from cancers of the floor of the mouth, hypopharynx, and larynx. Tumors in nude mice retained their histological stage of differentiation and human species origin. Prompted by reports of increased estrogen receptors in laryngeal carcinomas, we tested the effect of estradiol treatment on the growth of laryngeal tumor implants. Time to tumor formation was decreased and tumor size was increased in estradiol-treated animals relative to placebo-treated animals. The results demonstrate that estradiol treatment potentiates growth of laryngeal tumors in nude mice. This tumor model can also be used to evaluate antihormonal therapy in the treatment of some laryngeal carcinomas.

Frequent p53 mutations in head and neck cancer.

Squamous cell carcinomas of the head and neck (SCCHN) are associated strongly with the use of tobacco and alcohol, but little is known about the molecular pathogenesis of these tumors. In the present study, we analyzed SCCHN for mutations in the tumor suppressor gene p53 by immunocytochemistry and complementary DNA sequencing. Overexpression of p53 protein was detected in 13 (100%) of 13 SCCHN cell lines and in tumor cells cultured directly from 10 (77%) of 13 patients with SCCHN. Direct evidence for p53 mutations was obtained by sequencing p53 complementary DNA from eight SCCHN cell lines and two tumor xenografts. The genetic alterations included seven missense mutations resulting in single amino acid substitutions, a mutation encoding a stop codon, one 10-base pair deletion, and one 2-base pair addition. All seven missense mutations were G to T transversions, five of which were clustered at codons 245 and 248. A similar high frequency of G to T transversions predominates in lung cancer, another tobacco-related disease. Mutation of the p53 gene is the most common genetic alteration detected in SCCHN and implicates this gene locus as a critical site of specific damage by mutagenic carcinogens in tobacco, one of the important risk factors in the etiology of this disease.

Amplification of the int-2 gene in human head and neck squamous cell carcinomas.

Head and neck squamous cell carcinomas (SCC) from 21 patients were analyzed for structurally rearranged or amplified proto-oncogenes by Southern blot hybridization. The int-2 proto-oncogene was amplified 3-5 fold in 5 (50%) of 10 laryngeal SCC and 2-3 fold in 5 (45%) of 11 nonlaryngeal SCC of the head and neck. Adjacent histologically normal tissue from the same patients had single int-2 gene copy number. Coamplification of int-2 and the epidermal growth factor receptor (c-erbB-1) gene was found in one laryngeal SCC and one SCC metastatic to the neck. No amplification or structural alterations of proto-oncogenes c-erbB-2/HER2, c-myc, H-ras-1, or K-ras-2 was detected in any of the head and neck tumors. In a survey of head and neck tumor-derived cell lines, int-2 was amplified 9 fold in a hypopharyngeal tumor cell line (FaDu), but not amplified in 3 laryngeal tumor cell lines. int-2 has been localized to the q13 band of chromosome 11. We used chromosome 11 specific probes to demonstrate that int-2 amplification was not due to complete or partial chromosome 11 duplication. int-2 amplification was localized to 11q13, but did not extend to the ets-1 locus 11q23. The results indicate that int-2 is frequently amplified in SCC of the head and neck and suggest that int-2 amplification may correlate with clinical disease progression.

Overexpression of EMS1/cortactin in NIH3T3 fibroblasts causes increased cell motility and invasion in vitro.

Cortactin, a p80/85 protein first identified as a src kinase substrate, is thought to be involved in the signaling pathway of mitogenic receptors and adhesion molecules mediating cytoskeletal reorganization. The cortactin gene, EMS1, maps to chromosome 11q13, a region amplified in head and neck squamous cell carcinomas (HNSCC) and breast cancer, which display lymph node metastasis and an unfavorable clinical outcome. To further address the role of cortactin in the malignant phenotype of cells, we stably overexpressed cortactin in NIH3T3 fibroblasts and evaluated the effects of elevated cortactin on cellular proliferation, motility and invasiveness. Cortactin overexpressing cells did not display any striking morphological changes, nor any significant differences in cell proliferation or saturation density as compared to control NIH3T3 cells. Furthermore, the cortactin overexpressing cells were anchorage dependent for growth. Interestingly, cortactin overexpressing cells were more motile and invasive in modified Boyden chamber assays. These results suggest that overexpression of cortactin may play a role in tumor progression by influencing tumor cell migration and invasion.

Amplification and expression of EMS-1 (cortactin) in head and neck squamous cell carcinoma cell lines.

Amplification of chromosome 11q13 DNA sequences is detected in approximately 30% of primary head and neck squamous cell carcinomas (HNSCC). The amplified region includes genes for cyclin D1, hst-1, int-2, and more recently, ems-1. Ems-1 encodes an 80/85kd cytoskeletal associated protein termed cortactin, which has been shown to bind F-actin and is a pp60src substrate. We investigated 16 HNSCC cell lines for ems-1 DNA amplification and gene expression by western blotting and immunofluorescence using mAb 4F11. Amplification of ems-1 DNA was detected in 8/16 (50%) cell lines and was related directly to over-expression of cortactin by western blotting and immunofluorescence. Western blotting detected both forms of cortactin, p80 and p85, at equal intensity. Immunofluorescent staining revealed low levels of cortactin localized to the cytoplasm and surface membrane in normal bronchial epithelial cells and tumor cell cultures with single copy ems-1 DNA. In contrast, tumor cell cultures with ems-1 DNA amplification demonstrated intense, homogeneous cortactin cytoplasmic staining. These results suggest that overexpression of p80/85 may be a useful marker to identify 11q13 amplification, a molecular alteration correlated with the presence of lymph node metastasis in head and neck cancer.

Inhibition of head and neck squamous cell carcinoma growth and invasion by the calcium influx inhibitor carboxyamido-triazole.

Local invasion and lymph node metastasis are correlated with a decreased overall survival in head and neck cancer patients and warrant new strategies to intervene in the metastatic cascade. One approach is to focus on the intracellular signaling pathways underlying the metastatic process. A common regulatory point in several signal transduction pathways is intracellular calcium homeostasis. We assessed the effect of a novel calcium influx inhibitor, carboxyamido-triazole (CAI), on the growth and invasive phenotype of cell lines derived from head and neck squamous cell carcinoma (HNSCC). CAI inhibited the growth of FaDu and EVSCC17M cells in a dose-dependent (IC50, 13-15 microM) and reversible manner. CAI also caused a generalized attenuation of receptor-mediated calcium elevation to several calcium mobilization agonists, including epidermal growth factor and bradykinin. The effects of CAI on the invasive phenotype of HNSCC cell lines were assessed by a chemo-invasion assay. HNSCC cell lines exhibited a range of invasive potential as measured by the capacity of tumor cells to penetrate a reconstituted basement membrane of Matrigel. HNSCCs were classified as highly invasive (EVSCC14M and EVSCC17M) or weakly invasive (EVSCC18, EVSCC19M, UMSCC10A, and FaDu). Treatment of HNSCC cell lines with 10 microM CAI for 24 h reduced invasion 2-14-fold in a dose-dependent manner. HNSCCs also exhibited different motilities as measured by a chemotaxis assay. EVSCC14M and EVSCC17M were highly motile, whereas EVSCC18, EVSCC19M, UMSCC10A, and FaDu were less motile. CAI reduced the migration of all cell lines. Conditioned medium from HNSCC cell lines was analyzed by zymography for production of Mr 72,000 type IV collagenase [matrix metalloproteinase (MMP)-2)] and Mr 92,000 type IV collagenase (MMP-9). All HNSCC cell lines secreted MMP-2 and/or MMP-9 into conditioned medium. Treatment of cells with 10 microM CAI for 24 h resulted in a reduction of both MMP-2 and MMP-9 production. The results demonstrate that CAI blocks cellular proliferation, migration, chemoinvasion, and MMP production by HNSCC in vitro and identify calcium-dependent signaling as a new target for inhibition of the malignant phenotype of HNSCC.

Cancer of the hypopharynx and cervical esophagus: management concepts.

Treatment of cancer of the pharyngoesophageal region requires a multidisciplinary team approach using combined radiotherapy and surgery. Since patients with this cancer usually present for treatment after their tumors have reached advanced stages, their nutritional status is usually poor and must be dealt with prior to instituting therapy. Resection must be radical and usually produces a multifunctional defect. Reconstructive choices are varied, depending on the patient's general condition, the abilities of the head and neck surgeon, and the availability of other surgical specialties to help with reconstruction. Although treatment has become safer and provides a more functional existence, pharyngoesophageal cancer is still a deadly disease that kills two out of three patients.

Complications of flaps and grafts in the oral cavity and pharynx.

A study has been presented which was designed to determine the complications of flaps and grafts in oral cavity and pharyngeal reconstruction. The complications are related to three basic areas: 1. pre and postoperative metabolic and nutritional considerations, 2. flap or graft choice and design at the site of reconstruction, and 3. basic surgical technique in exposure, resection and flap handling. Ways to avoid these complications have been discussed.

Epiglottic reconstruction and subtotal laryngectomy.

Vertical hemilaryngectomy has been expanded aggressively in recent years so that, in some cases, the term subtotal laryngectomy would be more appropriate. Reconstruction after these extended resections is a problem. Intraluminal stenting has not been successful in cases where resection has been aggressive. The resulting lumen is inadequate. As a means of overcoming this problem, the epiglottic reconstruction procedure has been promoted. This paper presents experiences with 12 patients who underwent epiglottic reconstruction after subtotal laryngectomy. Indications, anatomic details, and overall results using this reconstructive technique are outlined. It is the conclusion of the author that epiglottic reconstruction is an effective procedure for preservation of function after subtotal laryngectomy.

Ectopic gastric mucosa in the cervical esophagus.

Ectopic gastric mucosa is a known entity of the mid and lower esophagus which was initially described by Schmidt in 1805. The presence of ectopic gastric mucosa in the cervical esophagus, however, was not described. A review of the literature reveals that ectopic gastric mucosa of the cervical esophagus is not uncommon, but symptoms rarely have been attributed to its presence. This paper reports five patients with isolated inflamed ectopic gastric mucosa in the cervical esophagus who presented with odynophagia and/or dysphagia. Physical examination was unremarkable in each case, and an acid barium esophagram was negative in four of five patients. Factors that distinguish these patients from other cases of odynophagia and dysphagia, as well as detailed clinical findings and treatment, are described. Debate exists as to whether the origin of ectopic gastric mucosa is congenital or acquired. The embryology, gross and microscopic anatomy, and pathologic features are outlined. Patients with persistent dysphagia should have flexible fiberoptic esophagoscopy with an index of suspicion to the existence of ectopic gastric mucosa. Inflamed or ulcerated ectopic gastric mucosa in the cervical esophagus should be treated to relieve symptoms and because of the potential for complications.

Glomus vagale: paraganglioma of the vagus nerve.

Review of the experience of a single institution with a rare tumor may give inadequate and biased information. In an effort to better understand issues related to diagnosis and subsequent management of paraganglioma of the vagus nerve, review of the experience at two university medical centers was undertaken. A review of the records of all patients with a diagnosis of vagal paraganglioma at the University of Pittsburgh and the Eastern Virginia Medical School was undertaken. Presenting signs and symptoms, treatment, and subsequent outcome were assessed. Data on 19 patients with vagal paraganglioma were available. The most common initial finding was a neck mass. Forty-seven percent (9/19) had vocal cord paralysis at presentation. Angiography was beneficial in helping to make the diagnosis and in identifying synchronous tumors. History of familial paraganglioma was present in 47% (9/19). Multiple paragangliomas were diagnosed in 53% (10/19) cases in our study. Of the patients with familial vagal paraganglioma, 89% (8/9) had multiple paraganglioma. All patients treated with surgery had postoperative vocal cord paralysis. Elective management of patients with bilateral vagal paraganglioma is a special dilemma. Radiation therapy of selected "operable" patients may be indicated because of the potential for bilateral vocal cord paralysis in these patients and its attendant sequela.

Combined treatment of advanced cancer of the laryngopharynx and cervical esophagus.

Advanced cancer of the laryngopharynx and cervical esophagus is difficult to treat because of the malnutrition produced by pain and obstruction and the problems related to reconstruction. This paper presents the initial results of a regimen used in 14 patients in which there is rapid reversal of nutritional deficiencies, radical resection, and reconstruction using the gastric pull-up technique and administration of postoperative radiotherapy. Excellent overall palliation and decreased hospitalization have been achieved using this regimen without diminishing chances for cure.

Changing face of treatment of peritonsillar abscess.

Changing trends in the treatment of peritonsillar abscess are demonstrated by this retrospective study of 74 patients treated from 1975 through 1980 by a standardized regimen. This included needle aspiration at three points, intravenous antibiotics, hydration, and pharyngeal douches. The patients ages ranged from 11 to 73 years. There were 45 males and 29 females. Needle aspiration was positive in 52 patients (70%) and repeat aspiration was necessary in 10% of patients. Tonsillectomy was performed in 42 patients. No recurrent peritonsillar abscesses occurred during the 1 to 5 year follow-up of the 32 patients who did not have tonsillectomy. Recurrent tonsillitis did occur in 4 of these patients and 3 of them had a past history of recurrent tonsillitis. The authors conclude that treatment of peritonsillar abscess should consist of needle aspiration, intravenous antibiotics and supportive measures. Interval tonsillectomy should be performed only when there is a history of recurrent tonsillitis or previous peritonsillar abscess.

A basic model to study acoustic evaluation of airway obstruction.

Listening to a human airway to determine obstruction is a highly subjective art and an important clinical tool. Sophisticated acoustic monitoring techniques should be developed and tested in the laboratory before they are applied in the clinic. We describe construction of an acoustic tube model to study the mechanism of noise generation in a simulated obstructed human airway. Spectral differences were demonstrated between different amounts and locations of obstruction and changes resulting from variations in airflow using Fast-Fourier transform techniques. With this analog model, systematic research can be conducted to define expected patterns in obstructed human airways for use in the clinical setting.

Functional evaluation of pharyngoesophageal reconstructive techniques.

This work represents a 12-year experience from the Eastern Virginia Medical School, Norfolk, with 115 patients who had pharyngoesophageal resections for cancer treatment. Each patient received reconstruction by one of four major techniques: deltopectoral flaps (n = 43), pectoralis myocutaneous flaps (n = 36), gastric pull-ups (n = 19), and free jejunal autografts (n = 17). An analysis of the procedures with emphasis on the functional results indicates that each technique has advantages in specific circumstances. Guidelines for the application of these techniques are presented.

The kleeblattschadel deformity: neurologic outcome with early treatment.

Despite its alarming appearance, the kleeblattschadel anomaly, when it occurs in the absence of a recognizable mental retardation syndrome, is not associated with primary abnormalities of the central nervous system. Early medical and surgical efforts may result in a satisfactory cosmetic and neurologic outcome.

Voice quality and intelligibility characteristics of the reconstructed larynx and pseudolarynx.

The ideal laryngeal substitute would provide a voice with good intelligibility, volume, and character. The basic components of these qualities are being studied in our laboratories to refine laryngeal reconstruction and replacement techniques. Exact definition of these characteristics may then be translated into specific requirements for reconstruction. In this study the phonation of laryngectomees using hand-held artificial laryngeal devices and patients with reconstructed larynges was compared with that of normal speakers. Presentations were evaluated by adult listeners with normal voice and hearing, and intelligibility scores were developed. These studies show, in part, that the fundamental frequencies at which various artificial speech aids are used do not significantly correlate with user intelligibility. Computerized spectral analysis was then utilized to ascertain the unique acoustic characteristics of the voices. Further computer analysis was carried out to determine what characteristics of the normal speakers' voices were shared in common with patients using artificial devices and patients with reconstructed larynges. Initial attempts at using these findings in laryngeal reconstruction based on computer modeling will be presented.

Nasal patency and the effectiveness of nasal continuous positive air pressure in obstructive sleep apnea.

Nasal airway obstruction may exacerbate sleep apnea and is difficult to quantify on clinical examination. In this study, we examined the relationship among nasal patency, the frequency of sleep apnea events, and effective nasal continuous positive air pressures. Acoustic rhinometry was used as an objective measurement of nasal cross-sectional areas in 76 patients without nasal symptoms who underwent study with diagnostic polysomnography because of obstructive sleep apnea. Patients with persistent obstructive sleep apnea were titrated to nasal continuous positive air pressure in a split night study. All subjects had a mean apnea/hypopnea index of 28, and those with obstructive sleep apnea had a mean apnea/hypopnea index of 43. Mean cross-sectional areas 1 to 4 cm into the nose were 1.7, 1.1, 2.1, and 2.8 cm2, respectively (F = 39, p < 0.001). However, there was no correlation between the apnea/hypopnea index and the cross-sectional area at the four distances (r = 0.03, 0.06, 0.02, and 0.02, respectively, p = not significant). Correlations between nasal continuous positive air pressures and cross-sectional areas did not reveal a significant relationship at any of the four sites (r = 0.09, 0.07, -0.03, 0.00, respectively). Findings in patients with apnea were also compared with those in patients without apnea and significant differences were not found (F = 0.019, p = not significant). Although it would seem intuitive that increased nasal obstruction is associated with the severity of obstructive sleep apnea and difficulty with the use of nasal continuous positive air pressure, this study shows that nasal patency, as measured by acoustic rhinometry, does not correlate with the severity of obstructive sleep apnea, as determined by the apnea/hypopnea index or the effective nasal continuous positive air pressure.

Growth and histopathology of human head and neck squamous cell carcinoma implanted intraorally in nude mice.

A human squamous cell carcinoma (SCC) from the floor of the mouth (FOM) was implanted by a needle aspiration technique in the FOM site of athymic nude mice. Mice were killed at 3-week intervals, and the oral cavity, mandible, and neck were sectioned and examined histologically. Tumor growth was observed in 65% of the animals, with histologic features consistent with the engrafted human invasive SCC. These features included invasion of connective tissue in 92%, invasion of muscle in 77%, invasion and destruction of bone in 54%, and vascular invasion in 15% of the mice. In contrast, FOM tumor implanted subcutaneously on back sites of nude mice was totally encapsulated by fibrous connective tissue with evidence of capsular invasion. SCC from other head and neck sites showed similar locally invasive growth after intraoral implantation in nude mice. The results demonstrate the invasive characteristics of human head and neck SCC grown in the homologous oral cavity site in nude mice and support the nude mouse as a biologically relevant in vivo model in the investigation of the biologic characteristics and therapy of head and neck carcinoma.

Systemic causes of dysphagia in adults.

Dysphagia is associated with many systemic disorders. This article presents information that can be used to assist with developing a differential diagnosis in patients who have dyshpagia without an obvious localized cause. The essentials of the history, physical examination, endoscopy, and special tests are outlined.