[The simultaneous appearance of three uncommon tumours]. / Synchrones Auftreten dreier seltener Tumoren.

A 70-year-old woman presented with nasal obstruction and pain projecting onto the left cheek. The face seemed asymmetric including exophthalmus on the right side. Nasal endoscopic inspection revealed a sarcomatous tumor located on the middle turbinate. The CT showed that the tumor filled the left maxillary sinus completely and had eroded the maxillary bone. In addition, a round, sharply defined intraorbital neoplasm on the right side was identified in the contrast-enhanced MRI. Histological examination of the extirpated intraorbital tumour showed a neurilemmoma. A tissue biopsy of the intranasal tumour falsely suggested an intestinal adenocarcinoma. Multiple neoplasms suspicious of disseminated lung metastases were detected in the CT of the thorax. One round lesion removed by thoracoscopy revealed a carcinoid. The intranasal tumour was excised completely and the histology proved beyond doubt an inverted papilloma.

[Tonsillectomy and tonsillotomy: ENT surgeon and pediatric viewpoints]. / Tonsillektomie und Tonsillotomie: HNO-ärztliche und pädiatrische Sicht.

Tonsillotomy and tonsillectomy are most frequently performed interventions during childhood. There is a need for a critical assessment of indication by using selected criteria. The collaboration of pediatricians and ENT surgeons is essential. Tonsillotomy in children < 6 years of age is associated with lower rates of postoperative bleeding.

[Measurement of quality of life following stapes surgery]. / Lebensqualitätbewertung nach stapesoperationen.

BACKGROUND: The objectives of this study were to compare a German version of the Glasgow Benefit Inventory (GBI) with the original English version and to describe quality of life following stapes surgery. PATIENTS AND METHODS: Audiometry and a questionnaire on handicap in various listening situations were used to assess 36 patients with otosclerosis before and 6 months after stapes surgery. The GBI was used to estimate the change in quality of life following surgery. RESULTS: Postoperative air-bone gap closure was <10 dB in 71% of patients. The postoperative air conduction threshold was <30 dB in 48% of patients. Using the GBI, the mean benefit score was 28 and the general benefit score 42. The social support and physical health scores were both zero. Where the postoperative improvement in air conduction was >15 dB, a significant reduction in handicap in everyday life, watching TV, listening to the radio and making telephone calls was seen. CONCLUSIONS: The German version of the GBI showed an improvement in quality of life in various everyday situations following stapes surgery.

Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas.

Induction chemotherapy followed by primary radiotherapy in responders is considered an alternative to surgery for advanced cancer of the larynx and hypopharynx (LHC). Comparison of therapeutic approaches is challenging and must respect oncological and functional outcome as well as quality of life during and after treatment. One aspect of primary radiochemotherapy is the option of salvage surgery in case of residual tumor. The outcome after salvage surgery following new organ-preserving strategies has to be examined. All patients undergoing induction chemotherapy with paclitaxel and cisplatin followed by radiotherapy from 01/96 to 07/05 were included. Salvage surgery was performed either for local recurrence or suspected persistent nodal disease. Complete tumor removal, perioperative morbidity, and overall survival were analyzed in a retrospective study. 28 out of 134 patients underwent salvage surgery after primary treatment with induction chemotherapy and radiotherapy for advanced LHC. 15 patients had laryngectomy (LE) with neck dissection (ND), while 1 patient had lasersurgical partial laryngeal resection with ND for local recurrences. Twelve patients had salvage ND for suspicion of persistent lymph node metastases. 73% of LE patients had major postoperative problems such as pharyngocutaneous fistulas. In 56% of the cases, tumor removal turned out to be microscopically incomplete. Eight out of 12 patients who underwent salvage ND because of suspicious lymph nodes (66%) were free of vital tumor. When metastatic disease was present in the neck (4/12), recurrences occurred in 75% during postoperative follow-up. Only 2 out of 20 patients undergoing surgery for histologically proven recurrence after radiochemotherapy (10%) are actually tumor-free and alive after a mean observation time of 43.9 months. Salvage surgery for local recurrence is associated with high morbidity and poor oncological and functional outcome. ND for suspicious persistent nodal disease after radiochemotherapy can be an over-treatment. In our patients, it was burdened with cervical recurrences and distant metastases in presence of histologically confirmed lymph node metastases. In the light of our results, unfavourable outcome after salvage surgery must be pointed out when initially informing patients about different therapeutic options for advanced LHC.

The influence of the radicality of resection and dose of postoperative radiation therapy on local control and survival in carcinomas of the upper aerodigestive tract.

PURPOSE: To evaluate dose concepts in postoperative irradiation of carcinomas of the upper aerodigestive tract according to the radicality of resection. PATIENTS AND METHODS: In a retrospective analysis, the charts of 257 patients with histologically-proven carcinoma of the upper aerodigestive tract (40 T1, 80 T2, 53 T3, 84 T4 tumors, with nodal involvement in 181 cases) were reviewed according to the radicality of resection and dose of irradiation administered. Sixty-four patients had tumor-free resection margins (> 3 mm), 66 patients had close resection margins (< 3 mm), and 101 patients had R1 resections, and 26 patients had R2 resections. A median dose of 56 Gy was applied to the primary tumor bed and the cervical lymphatics (2 Gy/fraction, 5 fractions/week). In cases of R1 or R2 resection, or of close margins (< 3 mm), the tumor bed or, respectively, tumor residuals were boosted with doses up to a median of 66 Gy. Locoregional tumor control and survival was investigated by uni- and multivariate analyses according to T-, N-stage, grade of resection, total dose of radiation, and presence or absence of extracapsular tumor spread and lymphangiosis carcinomatosa. RESULTS: An overall 3- and 5-year survival rate of 60% and 45%, respectively, was achieved. Rates for freedom from locoregional recurrence were 77% and 72% at 3 and 5 years, respectively. The survival rates according to the grade of resection at 5 years were 67% for patients resected with tumor-free margins, 59% for patients resected with close margins, 26% for patients with R1 resection, and 27% for patients with R2 resection. Within a median follow-up period of 4.7 years for living patients, a total of 67 recurrences (26%) were observed (in 9% of patients resected with tumor-free margins, in 27% with close margins, in 37% of R1 resected, and in 19% of R2 resected patients). Freedom from locoregional recurrence at 3 years was achieved in 100% of the patients resected with tumor-free margins, in 92% of patients resected with close surgical margins, in 87% of R1 and 69% of R2 resected patients. In multivariate Cox-regression analysis, the variables grade of resection (p = 0.00031) and total dose of irradiation (p = 0.0046) were found as factors influencing locoregional control. Variables influencing survival according to multivariate analysis are T-stage (p = 0.0057), N-stage (p = 0.024), grade of resection (p = 0.000015), total dose of irradiation (p < 0. 000000). Extracapsular tumor spread and lymphangiosis carcinomatosa are factors of borderline significance (p = 0.055, p = 0.066). CONCLUSION: In postoperative radiotherapy of head and neck carcinomas, doses adapted to the risk of locoregional recurrent disease should be applied. Patients with R1 and R2 resections should be treated with doses of more than 68 Gy (2 Gy/fraction, 5 fractions/week) (with close margins [< 3 mm] more than 66 Gy) to achieve an improvement in locoregional control and survival.

Juvenile nasopharyngeal fibroma: androgen receptors and their significance for tumor growth.

Since the publications of Martin, et al. (1948) and Schiff (1959), who were the first to report on the administration of sex hormones to juvenile nasopharyngeal fibroma (JNF) patients, several authors have described the different clinical effects and histologic changes after androgen and estrogen application. Since the mechanism of action of sex steroids in juvenile nasopharyngeal fibroma is almost unknown, the authors have studied androgen receptor binding in cultured tumor fibroblasts from three patients with JNF. Maximum androgen binding (Bmax) of the tumor fibroblasts approximated to that of genital skin fibroblasts, which served as a control androgen target tissue with high receptor density. Furthermore, in vitro experiments showed that the growth rate of tumor fibroblasts increased when testosterone was added to the culture medium, while the addition of two antiandrogens, cyproterone and flutamide, caused a reduction in growth rate. It is concluded from these results that JNF is a hormone-dependent tumor stimulated by testosterone whose growth rate may, at least in vitro, be reduced by antiandrogens such as cyproterone and flutamide.

[Prognostic value of pretreatment CT regarding local control in oropharyngeal cancer after primary surgical resection]. / Computertomographische Vorhersagbarkeit Lokaler Rezidive nach primär operativer Resektion von Oropharynxkarzinomen.

PURPOSE: To evaluate the prognostic implication of tumor infiltration and volume in primarily operated oropharyngeal carcinomas. MATERIAL AND METHODS: In 80 patients with oropharyngeal squamous cell carcinomas (pT 1 = 22, pT 2 = 30, pT 3 = 19 and pT 4 = 9), the tumor volume was measured by pretreatment CT and the extent of tumor infiltration determined by postoperative histologic examination. All patients were followed clinically for local tumor recurrence for at least two years after therapy. The statistical analysis consisted of chi 2 and U tests. RESULTS: The local control rate was 79 % (63/80). Of all evaluated anatomic structures, only midline crossing correlated significantly with local recurrence (p = 0.06). No correlation of tumor volume (p = 0.19) or T stage (p = 0.60) with the local recurrence rate was found. CONCLUSION: After primary surgery, oropharyngeal carcinomas with midline crossing have an increased risk of local recurrence, whereas the tumor volume only has a minor impact on the recurrence rate. This is in contrast to laryngeal or hypopharyngeal carcinomas.

[Diagnostic impact of multiplanar reformations in multi-slice CT of laryngeal and hypopharyngeal carcinomas]. / Diagnostischer Nutzen multiplanarer Reformationen bei der Mehrschicht-CT von Larynx- und Hypopharynxkarzinomen.

PURPOSE: Assessment of the diagnostic value of multiplanar reformations (MPR) in multi-slice computed tomography (MSCT) by comparing relevant anatomic structures of the larynx and hypopharynx. MATERIALS AND METHODS: MSCT of the neck was performed in 69 consecutive patients (including 30 laryngeal and 12 hypopharyngeal carcinomas). From a 4 x 1.0 mm collimation data set, 3.0-mm and 1.25-mm axial slices as well as 3-mm coronal and sagittal slices were reconstructed. Using the histological examination as gold standard, sensitivity and specificity regarding tumor infiltration for all relevant anatomical structures of the larynx and the hypopharynx were determined for each reconstruction and compared with the McNemar test. Moreover, 42 patients with laryngeal and/or hypopharyngeal carcinoma were subjectively evaluated to determine whether the respective reconstructions enables a better topographical visualization of the tumor in relation to surrounding structures and, furthermore, whether this has an influence on the therapeutical strategy (operation versus radiation therapy, type of operation, surgical approach). RESULTS: Sensitivities and specificities were not significantly different between the reconstructions. However, coronal and sagittal MPR provided a better topographical visualization of the tumor in 14 of 42 (33 %) of the patients, and influenced the therapeutical strategy in 8 of 42 (19 %) of the patients. A lowered signal-to-noise ratio impeded the evaluation of the relatively thin 1.25-mm axial slices in more than 23 % of the cases. CONCLUSION: Besides the 3-mm axial slices, coronal and sagittal MPR can improve the topographical visualization of laryngopharyngeal tumors and are recommended for preoperative MSCT of laryngeal and/or hypopharyngeal carcinomas. Additionally reconstructed 1.25-mm axial slices can be discarded since they do not hold a higher value compared to 3-mm axial reconstructions.

Radiological investigations of osteochondrosis dissecans in Standardbred Trotters and Swedish Warmblood horses.

A total of 106 Standardbred Trotters and 27 Swedish Warmblood horses, with a radiological diagnosis of osteochondrosis dissecans, were studied over a six year period. The majority were young horses. No statistical difference in frequency between the sexes was demonstrated. In both breeds osteochondrosis was most common in the hock joints, the site of predilection being the distal dorsal tip of the intermediate tibial ridge. On radiographs the lesions of the hock joints were graded on a scale from 0 to 5 according to size, number and localisation of defects and visible loose bodies. The sizes of the loose bodies estimated radiologically were fairly closely correlated with those found at surgery or autopsy.

Increased levels of urokinase receptor in plasma of head and neck squamous cell carcinoma patients.

Urokinase-type plasminogen activator (uPA) is important for matrix degradation and motility of cancer cells. The binding of uPA to its cell surface receptor on cancer cells is essential for effective invasion. A soluble form of urokinase receptor (suPAR) has been described in serum and ascites of ovarian cancer patients and in plasma samples of non-small cell lung cancer patients. Plasma samples from 36 head and neck squamous cell carcinoma patients and 24 healthy control persons were analysed for the presence of suPAR using enzyme-linked immunosorbent assay (ELISA) and the expression levels were correlated with clinical and histopathological data. Significantly elevated levels of suPAR in blood plasma from head and neck cancer patients were observed (p = 0.000), and the suPAR plasma levels decreased after resection of the carcinoma in 8 of 11 patients. suPAR plasma levels of cancer patients showed no significant correlations with T staging, metastasis, recurrence or differentiation stage of the tumours. The significance of suPAR plasma levels in head and neck squamous cell carcinoma patients for prognosis of the disease is discussed.

Cytotoxic and genotoxic effects of paclitaxel (Taxol) and radiation in a squamous cell carcinoma cell line of the larynx.

Paclitaxel (Taxol) is an antimicrotubular agent which blocks the cells in the G2/M phase of the cell cycle. Because of this mechanism it is presumed that this drug could function as a radiation sensitizer. The cytotoxic and genotoxic effects of paclitaxel and a combination of paclitaxel and radiation were studied in the human laryngeal carcinoma cell line HLac 79. The growth of the cells was significantly reduced at concentrations of paclitaxel as low as 10 nM. Flow cytometry data showed a G2/M block after exposure to paclitaxel. Radiation at 12 and 24 h after drug treatment exerted an additive but no radiation sensitizing effect. As genotoxic effect paclitaxel induced multinucleated cells, possibly in a synergistic manner, at low concentrations (10 nM) and radiation doses up to 3 Gy.

Recurrent neck abscess due to a bronchogenic cyst in an adult.

BACKGROUND: Neck abscesses can originate from congenital cervical cysts. Cervical cysts of bronchogenic origin are rare and often asymptomatic. Common symptoms of bronchogenic cysts are stridor, dyspnoea and dysphagia. The reported patient represents the second published case of a bronchogenic cyst causing a neck abscess in an adult. CASE REPORT: We report a case of a cervical bronchogenic cyst presenting as a recurrent supraclavicular abscess in a middle-aged woman. During extirpation, a fistula was demonstrated to the right upper lobe of the lung, suspected because the cyst inflated synchronously with respiration. DISCUSSION: The symptoms of bronchogenic cysts are due to the effects of compression or fistulas. In the majority of these cysts, a thorough investigation involving history, examination and radiological imaging does not clearly demonstrate a fistula. Therefore, extirpation is both diagnostic and therapeutic. CONCLUSION: A bronchogenic cyst is a very rare cause of a recurrent deep neck abscess. Total extirpation is the treatment of choice.

[Sentinel node mapping in head and neck squamous cell carcinoma]. / Sentinel-Node-Markierung bei Plattenepithelkarzinomen des Kopfes und Halses.

BACKGROUND: Commonly used staging procedures often cannot predict the absence of lymphatic micro- metastases in squamous cell carcinoma (SCC) of the head and neck. Therefore in many cases an elective neck dissection (ND) is necessary. In the surgical therapy of melanoma or breast cancer the presence of metastases can be evaluated securely by identification and examination of the sentinel lymph node (SLN). The type of surgical procedure is usually chosen in regard to the histopathological result. The present study evaluates the applicability of this concept for SCC of the head and neck. METHODS: Radioactive labeled micro-albumin particles were injected preoperatively around the tumor in 38 patients without proven metastases. Following the excision of the primary tumor the sentinel lymph node/s were detected and dissected and ND was completed. Histological examination of the tissue was performed to evaluate whether the SLN reflected the lymphatic status. RESULTS: In two cases (5.1 %) no SLN were detected. ND was completed in 32 cases. In nine cases (28.1 %) the SLN were infiltrated by the primary tumor. In 22 cases (68.8 %) SLN and ND revealed a N(0) stage. In one case (3.1 %) we could not identify a metastasis because of the anatomical closeness of the SLN to the primary. The negative predictive value was 96 %. CONCLUSION: Predictive value regarding metastases to the neck was higher with the detection of SLN than with conventional staging procedures. Whether the detection of a tumor-free SLN is an indication not to perform an elective neck dissection is a matter of discussion, especially under the aspect of the effective reduction of postoperative morbidity.

[Injuries of the head and neck in suicidal intention]. / Verletzungen des Kopfes und des Halses in suizidaler Absicht.

BACKGROUND: Injuries of the head and neck with suicidal intention might create serious situations that require rapid and interdisciplinary treatment. METHODS AND PATIENTS: Twenty-seven patients with suicidal head and neck injuries were treated at the Department of oto-rhino-laryngology, head and neck surgery, University of Wurzburg/Germany, between 1991 and 2002. The medical histories were analyzed retrospectively. RESULTS: Twenty-three of them were male, 4 female. Mean age at time of attempted suicidal was 48 years (18 - 90). One patient was already treated for a psychiatric disorder. None of the patients had a suicidal attempt in the history. Nine patients suffered from a pharynx or larynx trauma after strangulation. Four out of seven patients with cutting or stabbing injuries showed a perforation of the upper airways. Nine patients had gunshot traumas, one of them with perforation of the pharynx. Thirteen patients underwent immediate endoscopy under general anaesthesia followed by a neck exploration in 3 patients. Six patients received a temporary tracheotomy. All patients were considered suicidal for the duration of stay in the ENT-department resulting in a permanent supervision. All patients were transferred to a psychiatric unit as soon as possible for further treatment. A statistically significant accumulation was observed during the last third of a year. Over the period of 11 years, suicidal injuries of the head and neck tend to occur more frequently. CONCLUSIONS: The presented study emphasizes the need of immediate surgical and intensive care treatment of patients with head and neck injuries due to suicide attempts as well as an adequate psychiatric supervision during as well as after the surgical treatment.