Different cellular p16(INK4a) localisation may signal different survival outcomes in head and neck cancer.

BACKGROUND: Recently, the management of head and neck squamous cell carcinoma (HNSCC) has focused considerable attention on biomarkers, which may influence outcomes. Tests for human papilloma infection, including direct assessment of the virus as well as an associated tumour suppressor gene p16, are considered reproducible. Tumours from familial melanoma syndromes have suggested that nuclear localisation of p16 might have a further role in risk stratification. We hypothesised p16 staining that considered nuclear localisation might be informative for predicting outcomes in a broader set of HNSCC tumours not limited to the oropharynx, human papilloma virus (HPV) status or by smoking status. METHODS: Patients treated for HNSCC from 2002 to 2006 at UNC (University of North Carolina at Chapel Hill) hospitals that had banked tissue available were eligible for this study. Tissue microarrays (TMA) were generated in triplicate. Immunohistochemical (IHC) staining for p16 was performed and scored separately for nuclear and cytoplasmic staining. Human papilloma virus staining was also carried out using monoclonal antibody E6H4. p16 expression, HPV status and other clinical features were correlated with progression-free (PFS) and overall survival (OS). RESULTS: A total of 135 patients had sufficient sample for this analysis. Median age at diagnosis was 57 years (range 20-82), with 68.9% males, 8.9% never smokers and 32.6% never drinkers. Three-year OS rate and PFS rate was 63.0% and 54.1%, respectively. Based on the p16 staining score, patients were divided into three groups: high nuclear, high cytoplasmic staining group (HN), low nuclear, low cytoplasmic staining group (LS) and high cytoplasmic, low nuclear staining group (HC). The HN and the LS groups had significantly better OS than the HC group with hazard ratios of 0.10 and 0.37, respectively, after controlling for other factors, including HPV status. These two groups also had significantly better PFS than the HC staining group. This finding was consistent for sites outside the oropharynx and did not require adjustment for smoking status. CONCLUSION: Different p16 protein localisation suggested different survival outcomes in a manner that does not require limiting the biomarker to the oropharynx and does not require assessment of smoking status.

Hypoxia and vascular endothelial growth factor expression in human squamous cell carcinomas using pimonidazole as a hypoxia marker.

Hypoxia in human tumors is associated with poor prognosis, but the molecular mechanisms underlying this association are poorly understood. One possibility is that hypoxia is linked to malignant progression through vascular endothelial growth factor (VEGF) induction and the associated angiogenesis and metastasis. The present clinical study measures hypoxia and VEGF expression on a cell-by-cell basis in human squamous cell carcinomas to test the hypothesis that hypoxia and VEGF protein expression are coupled in human tumors. Eighteen patients with invasive squamous cell carcinoma of the uterine cervix and head and neck have been investigated by a quantitative image analysis of immunostained sections from their tumors. The hypoxia marker pimonidazole was used to measure tumor hypoxia, and a commercially available antibody was used to measure VEGF protein expression. A quantitative immunohistochemical comparison of hypoxia and VEGF protein expression revealed no correlation between the two factors.

Alterations of the p16 gene in head and neck cancer: frequency and association with p53, PRAD-1 and HPV.

Alterations, especially homozygous deletions, of the putative tumor suppressor gene, p16 (p16INK4A, MTS1, CDKN2) have been found in tumor cell lines from a variety of neoplasms. Recent studies have reported frequent p16 gene deletions in cell lines from squamous cell carcinomas of the head and neck (SCCHN), although the prevalence of alterations was variable in primary tumors. This study determined the prevalence of point mutations and deletions of the p16 gene in 33 SCCHN. In addition, the association of p16 gene alterations and abnormalities of p53, PRAD-1 (cyclin D1), and the presence of human papillomavirus (HPV) was examined. We found an overall prevalence of p16 alterations of 36% (nine deletions, three single base substitutions, including one polymorphism). Seven tumors (of 29, 24%) had an alteration of p16 and p53; five (of 33, 15%) had alterations of p16 and PRAD-1; three (of 29, 10%) had alterations of all three genes. In addition, of the five tumors with human papillomavirus detected, only one also had a p16 gene alteration. The results indicate a potentially important role for the p16 gene in head and neck tumorigenesis. In addition, the presence of tumors with multiple somatic gene alterations suggest a possible interaction in the dysregulation of the cell cycle.

p53 mutations in head and neck cancer: new data and evaluation of mutational spectra.

It has been suggested that the frequency, type, and location of p53 mutations (mutational spectra) can be linked to specific exogenous and endogenous carcinogenic agents and processes. Squamous cell carcinoma of the head and neck (SCCHN) provides an excellent tumor model to evaluate the utility of the p53 mutational spectra, given that it has well-defined and strong risk factors (tobacco and alcohol). The purpose of this analysis was to establish the pattern of p53 mutations in SCCHN and evaluate this mutational spectrum in comparison to the spectra for other cancers with similar and different risk factors, including cancers of the esophagus, lung, and colon. p53 mutational data were obtained from head and neck tumors collected at the University of North Carolina Hospitals and the published literature. A total of 14 of 33 tumors from the University of North Carolina Hospitals (42%) were found to have a p53 mutation. The alterations included three transversions, seven transitions, two deletions, and two suspected codon 47 polymorphisms. In general, SCCHN and esophageal cancer share a similar mutational pattern in contrast to colon cancer. These two aerodigestive tract cancers were statistically different from lung cancer, despite sharing tobacco as a major risk factor. For example, G-->T transversions, a mutation type considered to be characteristic of exogenous DNA-damaging agents including tobacco smoke carcinogens, varied among tobacco-related cancer sites (14% SCCHN, 11% esophageal, and 31% lung) in contrast to colon cancer (6%). The comparison of mutational spectra for SCCHN and other cancers indicates that the effects of both tobacco and alcohol exposure may yield a pattern of p53 mutations that reflects elements of both exogenous and endogenous exposures.

GSTM1, GSTT1, GSTP1, CYP1A1, and NAT1 polymorphisms, tobacco use, and the risk of head and neck cancer.

Squamous cell carcinoma of the head and neck (SCCHN), including the oral cavity, pharynx, and larynx, provides an ideal tumor model to investigate gene-environment interaction. We conducted a hospital-based case-control study including 182 cases with newly diagnosed SCCHN and 202 controls with nonneoplastic conditions of the head and neck that required surgery. Lifetime tobacco use and risk of SCCHN were evaluated in relation to the polymorphisms of GSTM1, GSTT1, GSTP1, CYP1A1, and NAT1. The main effects of genotype were associated with a slightly increased risk of SCCHN for GSTP1 [age-, race-, and sex-adjusted odds ratio (OR), 1.2; confidence interval (CI), 0.8-1.9], GSTT1 (OR, 1.2; CI, 0.7-2.3), and NAT1 (OR, 1.1; CI, 0.7-1.7). The joint effects of genotype combinations showed some excess risk for the combination of the GSTM1 null genotype and the CYP1A1 Ile/Val polymorphism (OR, 2.6; CI, 0.7-10.3). The analysis of the joint effects (interaction) of the "at-risk" genotypes and tobacco use did not reveal any interaction on either the multiplicative or additive scale for GSTM1, GSTP1, or CYP1A1. However, there was a suggestion of an interaction on the additive scale between the pack-years of tobacco use and the GSTT1 null genotype. The combined heterozygote and homozygote NAT1*10 genotypes also had a suggestive interaction with tobacco smoking history. The results of this study suggest a possible gene-environment interaction for certain carcinogen metabolizing enzymes, but larger studies that fully evaluate the interaction are needed.

Bilateral nasolacrimal duct mucocele, a rare cause of respiratory distress: CT findings in two newborns.

Two newborns presented with severe respiratory distress caused by nasal obstruction. CT showed bilateral soft-tissue masses located under the inferior turbinates at the level of the inferior meatuses. Histologic examination showed the lesions to be compatible with nasolacrimal mucoceles. The embryology and radiographic features of this rare anomaly are discussed.

Nodal volume reduction after concurrent chemo- and radiotherapy: correlation between initial CT and histopathologic findings.

BACKGROUND AND PURPOSE: The role of concurrent chemoradiation for treatment of head and neck squamous cell carcinoma is expanding. We sought to evaluate the CT appearance of diseased and normal cervical lymph nodes before and after concurrent chemoradiation and to correlate lymph node volume reduction as revealed by CT with histopathologic findings of resected nodes. METHODS: Using concurrent chemoradiation, we treated seven patients with locally advanced head and neck squamous cell carcinoma. Our chemotherapeutic regimen consisted of cisplatin (100 mg/m2 body surface area administered on days 1 through 4 and 29 through 32) and 5-fluorouracil (1000 mg/m2 body surface area, administered on days 1 through 4 and 29 through 32). Radiotherapy was administered twice per day on dosing days 1 through 42 to a total dose of 7200 cGy to the primary tumor and 6000 cGy to the involved lymph nodes. Pre- and post-treatment CT scans were used to calculate lymph node volumes for all CT-positive (size criteria or extracapsular spread or both) diseased nodes (n = 19) and one normal node per patient (n = 7). Volume reduction was determined by CT results and correlated with the histopathologic findings of resected nodes. RESULTS: Average volume reduction (+/- standard error of the mean) for the 19 diseased nodes was 91%+/-4% and for the seven normal nodes was 55%+/-21% (P < .02, two-sided t test). Fifteen of 19 of the diseased lymph nodes showed extracapsular spread before treatment and none of 19 after treatment. The histopathologic findings of resected nodes included persistent tumor in one of the 19 diseased lymph nodes. Six of seven patients remained alive and disease-free, with an average follow-up duration of 24 months. CONCLUSION: Nodal volume reduction of greater than 90% was associated with eradication of tumor as assessed by histopathologic analysis of resected nodes. Serial CT scans obtained both before and after concurrent chemoradiation may be useful for predicting which patients will benefit from adjuvant surgical therapy.

Laryngopyocele as a cause of airway obstruction.

Symptomatic laryngoceles are unusual lesions. Laryngopyoceles are even more unusual, with a total of 32 cases reported in the world literature. Two cases of laryngopyocele presenting as airway obstruction are described along with a review of the anatomy, etiology, clinical course, and management of this lesion. An argument is made supporting the resection of the symptomatic laryngocele to prevent the rapid respiratory obstruction that may occur in the presence of a laryngopyocele.

Tracheotomy and the intensive care unit patient.

Transportation of the intensive care unit (ICU) patient to the operating room for tracheotomy has been implicated as an unnecessary source of complications and has been cited as a relative indication for percutaneous tracheotomy. However, there is very little evidence in the literature to support this claim. We evaluated 100 consecutive patients who were transported from the ICU to the operating room for tracheotomy. There were no complications related to patient transportation. A total of five complications occurred, all unrelated to patient transportation. Two patients receiving pressure control ventilation developed a pneumothorax on postoperative days 7 and 8, respectively. There were three minor complications directly related to the tracheotomy: peristomal cellulitis, tracheitis, and hemorrhage of less than 25 cc on postoperative day 1. The minor complications were treated appropriately and resolved without any adverse sequelae. We provide a detailed review of 100 consecutive ICU patient tracheotomy cases and compare this with 109 tracheotomies in non-ICU patients. Transportation of the ICU patient does not appear to increase the risk of complications during tracheotomy and should not be cited as a cause of complications in the percutaneous tracheotomy literature. The results with standard surgical tracheotomy in the controlled setting of the operating room should serve as the standard by which other procedures are judged.

Measurement of laryngeal resistance in the evaluation of botulinum toxin injection for treatment of focal laryngeal dystonia.

In the past, there has been no consistent, objective method of following patients undergoing botulinum toxin injections for treatment of laryngeal dystonia. Herein, the application of translaryngeal resistance measurements to 15 dysphonic patients is described. Laryngeal resistance is calculated from analysis of translaryngeal pressure and airflow during the utterance /pi/, and found to fall predictably after successful toxin injection. In our series of patients, laryngeal resistance dropped by 69.1% after initial toxin injection. The changes in resistance over time correlate with subjective impressions of voice quality. Translaryngeal resistance measurements can be used objectively to follow patients longitudinally after injection and to collect objective data for analysis. No previously described measurements have met all these criteria. Laryngeal resistance measurement is an ideal method of documenting the results of botulinum toxin injection for the treatment of focal laryngeal dystonia.

Surgical salvage for stomal recurrence: a multi-institutional experience.

Recurrence of squamous cell cancer following total laryngectomy constitutes an extremely difficult therapeutic problem. Satisfactory management is elusive and frustrating to the head and neck oncologist. Various recommended therapeutic regimens include symptomatic treatment, palliation with chemotherapy and radiation, and aggressive surgical salvage. While surgery offers the only realistic chance at cure, this procedure is fraught with significant morbidity and a poor success rate. In an attempt to clarify the role of surgical salvage in these patients, experience with 57 patients with stomal recurrence presenting to three head and neck surgical groups will be presented. Forty-one of these patients subsequently underwent definitive surgery. The overall 2-year survival for operated patients was 16% with a 24% determinate survival. Further analysis revealed a 45% 5-year survival with type 1 and 2 lesions and 9% survival with types 3 and 4. Recommendations regarding indications for surgery are made based on this experience.

ras mutations and expression in head and neck squamous cell carcinomas.

Mutational activation and overexpression of the family of ras proto-oncogenes have been associated with many human tumors. The role of mutations of H-ras, K-ras, and N-ras, as well as expression of the respective protein products (p21s) in normal mucosa, dysplastic mucosa, and squamous cell carcinomas (SCCs) of the head and neck has not been fully described. In our study, 51 tumors (40 paraffin embedded and 11 fresh frozen) were examined to determine if mutational activation of ras is an important molecular event in head and neck SCC. Analyses of codons 12, 13, and 61 of H-ras, K-ras, and N-ras revealed no mutations, suggesting that mutational activation of ras is not important in the majority of head and neck SCCs. Immunocytochemistry (ICC) was used to define the expression of H-ras, K-ras, and N-ras in normal mucosa, dysplastic mucosa, and SCC of the head and neck and to determine if expression of ras family members correlated with early or late events in the development of SCC. Expression of p21N-ras in nine samples of histologically normal head and neck mucosa revealed moderate staining in the basal proliferative layers with progressively less staining as cells matured. The most superficial layers of normal mucosa failed to express p21N-ras. A low level of p21H-ras was expressed in all layers of normal mucosa while K-ras was not expressed. ICC of SCC tumor sections revealed cytoplasmic expression of N-ras in nine of nine tumors, H-ras in five of nine tumors, and K-ras in one of nine tumors. Expression of H-ras, K-ras, and N-ras in head and neck SCC was not related to histologic differentiation or TNM staging; however, p21N-ras was overexpressed in seven of nine tumors. Furthermore, the pattern of N-ras expression in dysplastic lesions revealed expression in all layers of the mucosa in contrast to normal mucosa, which expresses p21N-ras primarily in the basal proliferative layer. The change in p21N-ras expression pattern in dysplastic mucosa and its overexpression in the majority of tumors suggest that loss of control of N-ras expression may be an early step in carcinogenesis of head and neck SCC.

Blood transfusion and other risk factors for recurrence of cancer of the head and neck.

To determine whether perioperative blood transfusion affected the recurrence rate of squamous cell cancer of the head and neck, we performed a retrospective study of all patients with stage III and IV disease treated surgically at the University of North Carolina, Chapel Hill, between 1983 and 1986. Those who recurred were compared with those who did not in regard to 16 prognostic variables, including whether or not they had received a perioperative blood transfusion. Analyzing each variable separately, five were significantly related to recurrence. These were (1) surgical margin status, (2) stage, (3) presence of pathologically positive nodes, (4) blood transfusion status, and (5) type of treatment. However, because several of these variables were clearly interrelated, the same data were subjected to a multivariate regression analysis specifically designed to identify significant prognostic variables independent of their association with other variables. By this analysis, only margin status and the presence or absence of a blood transfusion were statistically significant predictors of recurrence.

Immediate mandibular replacement using reconstruction plates.

Mandibular reconstruction at the time of tumor resection remains a surgical dilemma. Primary reconstruction allows for immediate reconstitution of mandibular form and function. Various methods have been attempted, but none enjoys uniform success. With advances in the field of microvascular surgery have come numerous options in replacing these defects. These procedures, however, require special surgical teams and are associated with an increase in operative time as well as morbidity at the donor site. An alternative method involves the use of mandibular reconstruction plates to bridge the defect between segments. This review focuses on 19 patients whose jaws were reconstructed in this fashion. Although not free of complications, mandibular plate reconstruction offers the advantages of (1) lack of donor site morbidity, (2) expediency, (3) excellent mandibular contour, and (4) the ability to reconstruct the condyle when necessary. The technique, results, and complications associated with this procedure are discussed.

Unique chromosomal rearrangement and mucin production in a novel salivary myoepithelial cell strain.

Pleomorphic adenoma is the most frequently occurring benign neoplasm of the salivary glands. We describe the culture characteristics, biochemical properties, immunohistochemical staining, and genetic rearrangements found in a novel cell strain (UNC4) established from a human benign pleomorphic adenoma. Serum and/or butyrate stimulation of UNC4 cultures results in upregulation of mucin production. This is confirmed by periodic acid-Schiff, periodic acid-Schiff digest, alcian blue, and mucicarmine staining as well as by gel electrophoresis. Fluorescent immunohistochemical studies detect cellular cytokeratin, desmin, and epithelial membrane antigen. Immunofluorescent staining for S100 protein is negative. Examination of the karyotype of UNC4 reveals a unique rearrangement between one chromosome 8 and the two chromosome 9s involving the 8q12 locus. UNC4 represents an in vitro model of a benign salivary gland neoplasm that can provide the basis for further molecular and biochemical studies on genetic rearrangement and salivary mucin production.

The prevention of postoperative stridor and laryngospasm with topical lidocaine.

Tonsillectomy and adenoidectomy can predispose to stridor and laryngospasm in the immediate postextubation period. A prospectively randomized study of 133 patients undergoing tonsillectomy and adenoidectomy was undertaken to determine if the topical application of 4 mg/kg of 4% lidocaine at the time of intubation would decrease the incidence of postoperative stridor and laryngospasm. Taken together, eight (12%) of 67 control patients suffered stridor or laryngospasm vs two (3%) of 66 patients receiving lidocaine. It is concluded that lidocaine administered topically at the time of intubation for adenotonsillectomy helps prevent postoperative stridor and laryngospasm. Surgery of the upper aerodigestive tract often involves not only the technical aspects of the surgical procedure but also concomitant management of the airway. This can present a challenge to even the most adept otolaryngologist and anesthesiologist. Accidental extubation is always possible, and reintubation can be difficult in the presence of blood and saliva. The difficulty is often compounded with a patient who is not completely paralyzed.

Oncogene amplification in squamous cell carcinoma of the head and neck.

Cellular oncogenes appear to be involved in the control of normal cell growth and differentiation. The abnormal activation of these genes in naturally occurring and experimentally induced cancers may have an important role in the expression of the malignant phenotype in cancer cells. Mechanisms for the activation of these genes include chromosomal translocation, point mutation, and DNA amplification. The amplification of specific oncogenes correlates with clinical prognosis in several human malignancies, including breast cancer and neuroblastoma. We examined 21 fresh-frozen human squamous cell carcinomas of the aerodigestive tract for amplification of 10 known cellular oncogenes (c-myc, N-myc, L-myc, N-ras, H-ras, K-ras, erb-B, erb-B2, raf, and int-2), using Southern blotting techniques. Eleven of 21 tumors demonstrated a two-fold to 11-fold amplification of the int-2 oncogene, one member of a family of genes related to basic fibroblast growth factor. Amplification of c-myc, a gene that codes for a DNA-binding protein involved in the regulation of cell growth, was seen in two tumors. None of the other eight genes studied were amplified in any of the tumor specimens.

Treatment of the clinically negative neck in advanced cancer of the head and neck.

The proper management of the clinically negative neck in primary squamous cell carcinomas of the head and neck remains controversial. Although many clinicians believe that elective neck dissection or neck irradiation are equally effective for controlling subclinical disease, previous studies have not directly addressed this question. The charts of 195 patients with advanced primary squamous carcinoma, yet with clinically negative necks, were reviewed. There were no significant differences in the rates of neck cancer recurrence among the elective neck irradiation, dissection, and combined treatment groups. Elective neck irradiation and neck dissection in patients with clinically negative nodes seemed equivalent in their ability to control neck disease. The decision as to which form of therapy is preferable must therefore be based on other criteria.

Partial vs total esophagectomy for advanced carcinoma of the hypopharynx.

Cancer of the hypopharynx is an aggressive disease with a poor prognosis irrespective of the therapeutic regimen instituted. Controversy centers around the extent of surgery required to adequately ablate the advanced cancers, particularly related to the role of esophagectomy. A literature review and analysis of 43 cases of advanced hypopharyngeal cancer treated with total laryngopharyngectomy and partial esophagectomy support the argument that in carefully selected situations, a partial esophagectomy is oncologically an adequate operation.

Simultaneous chemoradiation in the treatment of advanced head and neck cancer.

Fifty-eight patients with either advanced or unresectable squamous cell carcinoma of the head and neck were randomly selected to receive either twice daily radiation alone or twice daily radiation plus concomitant chemotherapy with cisplatin and fluorouracil (5-fluorouracil). There was no advantage in survival or time to progression with the addition of chemotherapy to twice daily radiation for patients with advanced resectable cancers. In the group of patients with unresectable cancers, however, there was a statistically significant advantage to the addition of chemotherapy, both in terms of disease-free survival and date to progression.