Regulatory T-cells activated in metastatic draining lymph nodes possibly suppress cancer immunity in cancer tissues of head and neck squamous cell cancer.

Regulatory T cells (Tregs) play an important role in creating an immunosuppressive microenvironment in cancer tissues. However, the mechanisms by which Tregs are activated and suppress cancer immunity remain unclear. To elucidate these mechanisms, we performed a T cell receptor (TCR) repertoire analysis of Tregs and conventional T cells in peripheral blood, draining lymph nodes (DLNs), and cancer tissues of patients with head and neck squamous cell cancer (HNSCC). We found that the TCR repertoire was skewed in cancer tissue and metastatic DLNs (M-DLNs) compared with non-metastatic DLNs, and TCR repertoire similarities in Tregs and CD8+ T cells between M-DLNs and cancer tissue were high compared with those at other sites. These results suggest that Tregs and CD8+ T cells are activated in M-DLNs and cancer tissues by cancer antigens, such as neoantigens, and shared antigens and Tregs suppress CD8+ T cell function in a cancer antigen-specific manner in M-DLNs and cancer tissue. Moreover, M-DLNs might be a source of Tregs and CD8+ T cells recruited into the cancer tissue. Therefore, targeting Tregs in M-DLNs in an antigen-specific manner is expected to be a novel immunotherapeutic strategy for HNSCCs.

Autoimmune Thyroiditis Shifting from Hashimoto's Thyroiditis to Graves' Disease.

In 15-20% of cases, Graves' disease (GD) shifts to Hashimoto's thyroiditis (HT), while the shift from HT to GD is rare. We present a case of a patient in whom HT shifted to GD, along with a literature review. A 50-year-old woman with myxedema was diagnosed with Hashimoto's disease due to hypothyroidism and the presence of antibodies against thyroid peroxidase (TPOAb) and thyroglobulin (TgAb); she also had thyroid stimulating antibodies (TSAb) without any signs of GD. Although thyroid hormone replacement therapy improved her thyroid function, 2 months later, hyperthyroidism appeared and did not improve after discontinuation of the replacement therapy. The patient was diagnosed with GD, which improved with antithyroid agent administration. To date, only 50 cases regarding conversion from HT to GD have been reported. The median age is 44 years (range, 23-82 years), and the median time of conversion is 7 years (range, 0.1-27 years). The male-to-female ratio of HT conversion to GD is 1:9, closer to that of regular GD (1:10) than that of general HT (1:18). All patients received thyroid hormone replacement therapy for hypothyroidism due to HT. Continuous evaluation of TSAb levels is recommended in HT, particularly in cases of TSAb-positive and those under replacement, since it may help predict conversion to GD. Evaluating the clinical characteristics of patients with HT preceding GD is crucial to ensure appropriate treatment and reduce the risk of adverse events.

Immune-checkpoint molecules on regulatory T-cells as a potential therapeutic target in head and neck squamous cell cancers.

Immune-checkpoint inhibitors improve the survival of head and neck squamous cell carcinoma (HNSCC) patients. Although recent studies have demonstrated that the tumor immune microenvironment (TIME) has critical roles in immunotherapy, the precise mechanisms involved are unclear. Therefore, further investigations of TIME are required for the improvement of immunotherapy. The frequency of effector regulatory T-cells (eTregs) and the expression of immune-checkpoint molecules (ICM) on eTregs and conventional T-cells (Tconvs) both in peripheral blood lymphocytes (PBL) and tumor-infiltrating lymphocytes (TIL) from HNSCC patients were analyzed by flow cytometry and their distributions were evaluated by multi-color immunofluorescence microscopy. High frequency eTreg infiltration into HNSCC tissues was observed and high expressions of CD25, FOXP3, stimulatory-ICM (4-1BB, ICOS, OX40 and GITR) and inhibitory-ICM (programmed cell death-1 [PD-1] and cytotoxic T-lymphocyte-associated protein-4 [CTLA-4]) were found on invasive eTregs. In contrast, the expression of stimulatory-ICM on Tconvs was low and the expression of inhibitory-ICM was high. In addition, ICM-ligands (programmed cell death-1 [PD-L1], galectin-9 and CEACAM-1) were frequently expressed on cancer cells. PD-L1 and galectin-9 were also expressed on macrophages. PD-1+ T-cells interacted with PD-L1+ cancer cells or PD-L1+ macrophages. This suggested that in TIL, eTregs are highly activated, but Tconvs are exhausted or inactivated by eTregs and immune-checkpoint systems, and ICM and eTregs are strongly involved in the creation of an immunosuppressive environment in HNSCC tissues. These suggested eTreg targeting drugs are expected to be a combination partner with immune-checkpoint inhibitors that will improve immunotherapy of HNSCC.

Immune Status of Cervical Lymph Nodes in Head and Neck Cancer-A Surgical Oncology Perspective.

Neck dissection for cervical lymph node metastasis is an established procedure for head and neck cancer (HNC). However, with the advent of immunotherapy, head and neck surgical oncologists need to rethink removing all lymph nodes, including those with immune function. We investigated the anti-cancer immune response of the cervical lymph nodes in four patients with human papillomavirus type 16 (HPV16)-positive head and neck squamous cell carcinoma. Using lymphocytes extracted from local, metastatic, and non-metastatic lymph nodes and peripheral blood from these patients, we performed an intracellular flow cytometric cytokine assay using anti-IFNγ and anti-TNF-α monoclonal antibodies to detect HPV16 E6- and E7-specific T cells. HPV status and p16 immunostaining were determined by in situ detection using the HPV RNAscope method and immunohistochemistry. In one case, E6-specific and E7-specific CD8+ T cells were detected in proximal metastatic nodes and distal non-metastatic nodes. This finding suggests that non-metastatic nodes should be preserved for their immune function during neck dissection and that the immune function of non-metastatic lymph nodes is important when administering immunotherapy. In this context, head and neck surgical oncologists treating HNC should consider the place of immunotherapy and neck dissection in the treatment of HNC.

Artesunate and cisplatin synergistically inhibit HNSCC cell growth and promote apoptosis with artesunate­induced decreases in Rb and phosphorylated Rb levels.

In the treatment of head and neck cancer, cisplatin is often used as a therapeutic agent; however, its efficacy is limited and it can cause renal dysfunction as an adverse effect. For this reason, the use of cisplatin is limited in elderly patients with reduced renal function. Recently, artemisinin, which was developed as an antimalarial drug, was found to have antitumor effects and is effective in combination with other anticancer drugs. In the present study, the antitumor effects of artemisinin and its derivatives as well as their combination with cisplatin and iron on head and neck squamous cell carcinoma cell lines, were investigated. Cell viability was determined by a cell viability assay, the cell cycle was analyzed by flow cytometry, cell death was assessed with annexin V and propidium iodide staining, and western blotting was used to analyze retinoblastoma protein (Rb), phosphorylated (p­)Rb, and other cell cycle­associated molecules. A total of four artemisinin compounds were examined and it was found that artesunate and dihydroartemisinin had a significant inhibitory effect on growth. It was also identified that the combination of artesunate, cisplatin, and iron inhibited cell proliferation and caused S/G2­M cell cycle arrest. In addition, western blotting of Rb, a molecule involved in the cell cycle, showed that artesunate induced the loss of not only Rb but also p­Rb. These results suggested that artesunate is a useful drug in combination with cisplatin.

Dynamic Analysis Of Male "Extra-high Voice" Using Multi-row Detector Computed Tomography.

OBJECTIVES/HYPOTHESIS: Some people who practice singing on a daily basis may be able to produce a voice higher than the upper limit of the normal range (extra high voice), but there is much regarding the movement of the larynx that remains unknown. We have been conducting dynamic analysis of the larynx using multi-row detection computed tomography (MD-CT) at our university and report herein an analysis of the extra high voice. STUDY DESIGN: Observational. METHODS: Images of a normal male participant capable of extremely high-frequency speech (the highest speech range is C7 [2093 Hz] and the singing application range is up to B5 [988 Hz]) during speech were captured by MD-CT. The acquisition time was 2 seconds, and the rise of the voice from low to high and then to very high tones was recorded. Ten frames per second were analyzed as three-dimensional images. RESULTS: In the fundamental frequency range from A3 to D5 (220-587 Hz), laryngeal elevation movements were observed as the voice rose in pitch. However, posterior upward displacement of the laryngeal cartilage was observed as the frequency range increased from E5 to B5 (659-988 Hz). CONCLUSIONS: In the E5-B5 range, laryngeal movements were different from those observed in the previous range. MD-CT analysis is useful in the study of this range because it allows visualization of laryngeal movements that are unclear using endoscopy or external examination.

A Novel Treatment Strategy for Advanced Lacrimal Sac Carcinomas Confirmed by p16 Immunostaining.

This article aims to describe the two cases in which chemotherapy and chemoradiotherapy were effective for advanced HPV-related lacrimal sac squamous cell carcinoma and avoided the need for radical surgery. This was an interventional study of two patients with advanced lacrimal sac squamous cell carcinoma. Two patients with advanced lacrimal sac squamous cell carcinoma were treated at our University Hospital between January 2020 and February 2021. Diagnosis of HPV-related lacrimal sac carcinoma was done by p16 immunostaining and RNA in situ hybridization. Received neoadjuvant chemotherapy and chemoradiotherapy, also minimally invasive surgery to remove any residual tumor if the final response, were unfavorable. HPV-related carcinoma was decided by checking p16 and RNA status. Response was assessed by computed tomography, magnetic resonance imaging, positron emission tomography-computed tomography, and endoscopic images. Both patients had positive p16 staining also HPV RNA in situ hybridization. Received definitive chemoradiotherapy instead of radical surgery after showing a partial response to neoadjuvant chemotherapy. A complete response was achieved in one patient and the other had a partial response, leaving a small residual tumor in the nose that was successfully removed by endonasal endoscopic surgery. Cure was achieved in two patients with HPV-related lacrimal sac squamous cell carcinoma by neoadjuvant chemotherapy followed by definitive chemoradiotherapy, with only one requiring minimally invasive surgery. This is a new direction in the treatment of p16-positive lacrimal sac carcinoma, especially for advanced cases, whereby molecular biological indicators can be used to avoid highly invasive surgery and preserve quality of life without compromising prognosis.

Thyroid Gland Flap for Minimally Invasive Reconstructive Head and Neck Surgery.

Head and neck surgery sometimes causes small defects, and salvage surgery after chemoradiotherapy poses some risk because of damage to the surgical site from the previous treatment. We have developed a novel thyroid gland flap for head and neck surgical reconstruction and here we describe elevating the flap, including arc rotation, size, and suture technique, and our outcomes to date. METHODS: Thyroid gland flap reconstruction was performed in 13 cases (11 patients) between July 2009 and May 2020. The clinical importance and adverse effects of the procedure were examined. Thyroid function and blood flow of the flap were assessed, and the status of the flap and irradiated recipient tissue was examined histopathologically. RESULTS: Median age at surgery was 64.6 years (range 49-77 years). Two of the patients underwent reconstruction with a thyroid gland flap twice. There were 4 cases of primary head and neck cancer resection with neck dissection in which the flap was harvested from the thyroid gland as reinforcement. In 1 case, surgery was performed for cervical esophageal diverticulum. In all cases, the arc was limited to 6 cm and suturing was basic. There were no complications of the surgical procedure, and the postoperative course was uneventful. Contrast-enhanced computed tomography revealed adequate enhancement of the flap. Postoperative thyroid function was normal. The thyroid gland flap was firmly adapted and fused with the irradiated recipient tissue. CONCLUSION: The thyroid gland flap could be an effective tissue flap fed by the superior thyroid arteriovenous pedicle for head and neck reconstruction.

Thyroid gland flap minimizes mucosal defects at supracricoid partial laryngectomy with cricohyoidoepiglottopexy.

Wound infection is a major complication after supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP) for radiation therapy failure. A 60-year-old man received chemoradiotherapy for a glottic carcinoma. CHEP, reusing the thyroid gland flap (TF), was performed because the cancer recurred after a salvage vertical partial laryngectomy following radiation therapy failure. The TF was sutured to the supraglottis and cricoid cartilage mucosa to minimize mucosal defects before the hyoid bone and cricoid cartilage were sutured. Wound healing after CHEP was good without infection. After decannulation, oral food intake was possible without aspiration, and speech function was comparable to that of other patients who had supracricoid partial laryngectomies. Histopathological examination revealed a close connection between the TF and its surrounding tissues without fibrous scarring. TF may improve wound healing after CHEP for radiation failure by minimizing mucosal defects.

Distribution of descending necrotizing mediastinitis and efficacy of distribution-specific drainage.

BACKGROUND: Descending necrotizing mediastinitis (DNM) resulting from oropharyngeal and cervical abscess is a life-threatening condition. This study attempted to improve our recognition of the extension and distribution of the abscess for ideal thoracic drainage. METHODS: We performed a retrospective clinical analysis of seven patients who underwent thoracic drainage for DNM with available clinical data. For mapping and classification of the distribution of the abscess, computed tomography and intraoperative findings were utilized. RESULTS: To cure patients, cervical drainage and thoracic drainage were performed 14 and 11 times, respectively. The operation time for thoracic drainage and intraoperative blood loss were 141±77 min and 103±103 g, respectively. The mean hospital stay was 66±41 days. All patients are alive without recurrence. We divided the abscess distribution into nine categories including the anterior thoracic wall, according to the computed tomography and intraoperative findings. The rate of abscess descended gradually toward the lower mediastinum. Abscesses were not necessarily continuous, and skipped lesions were occasionally noted. CONCLUSIONS: We were able to cure all seven patients with DNM. It might be helpful to recognize the exact distribution of the abscess and distribution-specific drainage using a new map and classification of thoracic abscess.

Pathological and Virological Studies of p16-Positive Oropharyngeal Carcinoma with a Good Response to Neoadjuvant Chemotherapy.

Human papillomavirus (HPV)-related, p16-positive oropharyngeal carcinoma is considered to be sensitive to anticancer drugs, and the standard treatment is therefore chemoradiotherapy, rather than surgery, especially for aggressive disease. However, with this higher sensitivity, chemotherapy alone may achieve a pathological complete response (CR), making radiation therapy unnecessary. A 46-year-old man with p16-positive squamous cell carcinoma (SCC) of the lateral oropharynx (palatine tonsil) underwent neoadjuvant chemotherapy. This achieved clinically significant tumor shrinkage and therefore surgery was performed for subsequent definitive treatment. Clinical and CT findings indicated a good effect of neoadjuvant chemotherapy on the tumor. A biopsy prior to chemotherapy revealed SCC, which demonstrated p16 immunoreactivity and positive signals for high-risk HPV by RNA in situ hybridization. The post-chemotherapy surgical specimen showed pathological CR and no p16 positive cells nor positive signals for high-risk HPV those were detected in the pre-chemotherapy specimen. There are some reports of chemotherapy alone achieving pathological CR in cases of p16-positive oropharyngeal carcinoma, but none have included high-risk HPV RNA findings. This is the first report of the disappearance of cancer cells as well as p16 staining and a positive signal for high-risk HPV. Achieving pathological CR confirmed by immunohistochemistry and high-risk HPV RNA in situ hybridization in a solid tumor with chemotherapy alone suggests that chemotherapy may have both an antitumor effect and an antiviral effect. Forgoing subsequent radiotherapy and undergoing surgery might be unnecessary and follow-up instead might be sufficient in such cases. Into the future, in an optimal tailored treatment approach, the option of neoadjuvant chemotherapy should be considered for management of p16-positive oropharyngeal carcinoma. Other options such as tumor immunotherapy are also expected to be effective.

Incisionless facial resection for Kadish stage C olfactory neuroblastoma: Transcaruncular approach with combined endonasal and skull base surgery.

This case report describes resection without facial incision for aggressive Kadish stage C olfactory neuroblastoma (ONB). We performed resection via transcaruncular approach with combined endonasal and skull base surgery. This multidisciplinary team surgical approach is expected to lead to a new strategy for this type of tumor in the future.

Identification of cisplatin-resistant factor by integration of transcriptomic and proteomic data using head and neck carcinoma cell lines.

Cisplatin is an important drug for the treatment of head and neck squamous cell carcinoma (HNSCC). Determining chemoresistant factors prior to treatment will lead to great benefits for clinicians and patients. Here, we evaluated chemoresistant factors by integrating proteomic and transcriptomic data using HNSCC cell lines to identify a more precise chemoresistant factor in HNSCC. We used four HNSCC cell lines: cisplatin-sensitive, acquired cisplatin resistance, naturally cisplatin-resistant, and acquired 5-FU resistance. Proteomic analysis was performed using iTRAQ, tandem mass spectrometry, and liquid chromatography-electrospray ionization-tandem mass spectrometry. Transcriptomic analysis was performed using microarrays. By integrating these independent data, common factors were addressed and functional analysis was performed using small interfering RNAs (siRNAs) to change the chemosensitivity. Using iTRAQ analysis, 7 proteins were identified as specific for cisplatin chemoresistance factors. Transcriptomic analysis revealed hundreds of potential candidate factors. By combining and integrating these data, S100A2 was identified as a potential cisplatin-specific chemoresistance factor. Functional analysis with siRNA revealed that the expression of S100A2 was reduced and cisplatin sensitivity recovered in the acquired and naturally cisplatin-resistant cell lines, but not in the cisplatin-sensitive cell lines. S100A2 was identified as a cisplatin-specific chemoresistance factor by integrating the transcriptomic and proteomic results obtained using HNSCC cell lines. This is a novel technique that allows for a precise identification, also known as a comprehensive analysis. Our findings indicate that these proteins could be used as biomarkers of HNSCC treatments, providing physicians with new treatment strategies for patients with HNSCC, showing chemoresistance.

A novel larynx-preserving pharyngectomy technique using a thyroid gland flap after chemoradiotherapy.

This case report describes larynx-preserving pharyngectomy after chemoradiotherapy using a thyroid gland flap. A thyroid gland flap has good blood supply and reconstruction can be done in the same surgical field. The thyroid gland flap has potential as a novel appropriate flap for use in head and neck surgery.