Advances toward fully automated in vivo assessment of oral epithelial dysplasia by nuclear endomicroscopy-A pilot study.

BACKGROUND: Uncertainties in detection of oral epithelial dysplasia (OED) frequently result from sampling error especially in inflammatory oral lesions. Endomicroscopy allows non-invasive, "en face" imaging of upper oral epithelium, but parameters of OED are unknown. METHODS: Mucosal nuclei were imaged in 34 toluidine blue-stained oral lesions with a commercial endomicroscopy. Histopathological diagnosis showed four biopsies in "dys-/neoplastic," 23 in "inflammatory," and seven in "others" disease groups. Strength of different assessment strategies of nuclear scoring, nuclear count, and automated nuclear analysis were measured by area under ROC curve (AUC) to identify histopathological "dys-/neoplastic" group. Nuclear objects from automated image analysis were visually corrected. RESULTS: Best-performing parameters of nuclear-to-image ratios were the count of large nuclei (AUC=0.986) and 6-nearest neighborhood relation (AUC=0.896), and best parameters of nuclear polymorphism were the count of atypical nuclei (AUC=0.996) and compactness of nuclei (AUC=0.922). Excluding low-grade OED, nuclear scoring and count reached 100% sensitivity and 98% specificity for detection of dys-/neoplastic lesions. In automated analysis, combination of parameters enhanced diagnostic strength. Sensitivity of 100% and specificity of 87% were seen for distances of 6-nearest neighbors and aspect ratios even in uncorrected objects. Correction improved measures of nuclear polymorphism only. The hue of background color was stronger than nuclear density (AUC=0.779 vs 0.687) to detect dys-/neoplastic group indicating that macroscopic aspect is biased. CONCLUSIONS: Nuclear-to-image ratios are applicable for automated optical in vivo diagnostics for oral potentially malignant disorders. Nuclear endomicroscopy may promote non-invasive, early detection of dys-/neoplastic lesions by reducing sampling error.

Molecular Diagnosis for Nodal Metastasis in Endoscopically Managed Cervical Cancer: The Accuracy of the APTIMA Test to Detect High-risk Human Papillomavirus Messenger RNA in Sentinel Lymph Nodes.

STUDY OBJECTIVE: To evaluate the feasibility and accuracy of a commercially available test to detect E6/E7 mRNA of 14 subtypes of high-risk HPVs (APTIMA; Hologic, Bedford, MA) in the sentinel lymph nodes of CC patients laparoscopically operated. DESIGN: Prospective pilot study. SETTING: The study was conducted in the Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany. PATIENTS: 54 women with HPV-positive CC submitted to laparoscopic sentinel node biopsy alone or sentinel node biopsy followed by systematic pelvic and/or para-aortic endoscopic lymphadenectomy. INTERVENTIONS: All removed sentinel lymph nodes (SLNs) underwent sample collection by cytobrush for the APTIMA assay before frozen section. MEASUREMENTS: Results obtained with the HPV mRNA test were compared with the definitive histopathological analysis of the SLNs and additional lymph nodes removed. RESULTS: A total of 125 SLNs (119 pelvic and 6 paraaortic) were excised with a mean number of 2.3 SLNs per patient. Final histopathologic analysis confirmed nodal metastases in 10 SLNs from 10 different patients (18%). All the histologically confirmed metastatic lymph nodes were also HPV E6/E7 mRNA positive, resulting in a sensitivity of 100%. Four histologically free sentinel nodes were positive for HPV E6/E7 mRNA, resulting in a specificity of 96.4%. CONCLUSION: The HPV E6/E7 mRNA assay in the SLNs of patients with CC is feasible and highly accurate. The detection of HPV mRNA in 4 women with negative SLNs might denote a shift from microscopic identification of metastasis to the molecular level. The prognostic value of this findings awaits further verification.

The role of HPV RNA transcription, immune response-related gene expression and disruptive TP53 mutations in diagnostic and prognostic profiling of head and neck cancer.

Stratification of head and neck squamous cell carcinomas (HNSCC) based on HPV16 DNA and RNA status, gene expression patterns, and mutated candidate genes may facilitate patient treatment decision. We characterize head and neck squamous cell carcinomas (HNSCC) with different HPV16 DNA and RNA (E6*I) status from 290 consecutively recruited patients by gene expression profiling and targeted sequencing of 50 genes. We show that tumors with transcriptionally inactive HPV16 (DNA+ RNA-) are similar to HPV-negative (DNA-) tumors regarding gene expression and frequency of TP53 mutations (47%, 8/17 and 43%, 72/167, respectively). We also find that an immune response-related gene expression cluster is associated with lymph node metastasis, independent of HPV16 status and that disruptive TP53 mutations are associated with lymph node metastasis in HPV16 DNA- tumors. We validate each of these associations in another large data set. Four gene expression clusters which we identify differ moderately but significantly in overall survival. Our findings underscore the importance of measuring the HPV16 RNA (E6*I) and TP53-mutation status for patient stratification and identify associations of an immune response-related gene expression cluster and TP53 mutations with lymph node metastasis in HNSCC.

Overexpression of the Hedgehog signalling pathway in head and neck squamous cell carcinoma.

BACKGROUND: Overexpression of the Hedgehog (HH) signalling pathway has been described in several malignancies and is associated with a poor prognosis. HH signalling blockade reduces tumour growth in vitro and in vivo. We aimed to determine whether head and neck squamous cell carcinomas (HNSCCs) express HH proteins in comparison to healthy mucosa. PATIENTS AND METHODS: Formalin-fixed and paraffin-embedded tissue sections of 10 patients with HNSCC were stained with fluorescence-labelled antibodies for cytokeratin and HH proteins (SHH, PTCH1/2, SMO, Gli1-3) and photographs were taken with a laser scanning microscope. The pixel count and colour intensity were analysed in RGB (red/green/blue) colour mode, and expression levels were compared to healthy mucosa. RESULTS: Image analysis in RGB mode provided objective evidence for the over-expression of HH signalling components in HNSCC, particularly with regard to the transcription factors Gli1 (10-fold) and SHH (5-fold) in comparison with healthy mucosa. The lowest levels were found for Gli3 in HNSCC. CONCLUSIONS: We postulate pivotal roles of Gli1 and SHH expression in the carcinogenesis of HNSCC. HH pathway overexpression appears to be involved in the initiation of tumour growth and spread due to its stem cell-modulating properties. Detection of HH pathway components, and especially Gli1 and SHH, in HNSCC might offer a promising target for further anticancer research in HNSCC.

[Factors influencing the changed Quality of Life after postbariatric Abdominoplasty]. / Einflussfaktoren auf die veränderte Lebensqualität nach postbariatrischer Abdominoplastik.

INTRODUCTION: The improvement of health-related quality of life (HRQoL) via post-bariatric tightening operations and their effects on long term weight stability is considered to be ensured. This study investigates the relevancy of influencing factors. PATIENTS, MATERIAL AND METHODS: For the data analysis, the HRQoL was ascertained before and after the abdominoplasty using the 36-Item Short-Form Health Survey questionnaire. In addition, the occurrence frequency of bloating-symptoms was recorded. It was checked whether this occurrence was related to a rectus plication simultaneously performed with the abdominoplasty. Inclusion criterion was obesity ≥ I° prior to the weight loss. Exclusion criteria were a postoperative, newly manifested and serious disease, as well as a pregnancy during the observation period. The results were compared to the German population (standard). RESULTS: The postoperative HRQoL was significantly improved as far as the physical healthscale (KSK) is concerned (preOP: 40,19 ± 12,27; postOP: 47,72 ± 9,89; p < 0,001). Preoperatively, the KSK and the PSK (psychological health scale) were statistically significant below the value of the normal population (KSK: p < 0,001; PSK: p < 0,01). There were no significant differences postoperatively (KSK: p = 0,051; PSK: p = 0,118). Patients on which an additional rectus plication was performed (n = 9) suffered significantly more often from bloating-symptoms than patients without this surgical step (n = 21) (p < 0,05). Patients with bloating-symptoms < 4/W (vs > 4/W) had a significantly better vitality (< 4/W: 61,09 ± 24,95; > 4/W: 34,29 ± 21,49; p < 0,05) and a better general health (< 4/W: 68,04 ± 23,23; > 4/W: 44,71 ± 27,8; p < 0,05). Compared to the standard, patients with bloating-symptoms > 4/W had a poorer vitality (p < 0,05). CONCLUSION: Based on the analysis, a postoperative improvement of the HRQoL in the formerly obese can be assumed. It can also be predicated that there is a postoperative adjustment of the HRQoL compared to that of the German population. Furthermore, a rectus plication that is performed in addition to the abdominoplasty more frequently leads to bloating-symptoms, which, in turn, worsen the HRQoL. The diagnosis of a depressive disorder is a good predictor for a worse HRQoL outcome.

Therapeutic options for treatment of Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is a rare malignant neuroendocrine carcinoma of the skin. Owing to the aggressiveness of this tumor and the bad overall survival, we reviewed the therapeutic strategies, including surgery, radiation, and chemotherapy to find out the potentially best treatment option for one patient treated at our hospital. In addition, we investigated MCC biopsies using the FLAVINO assay to find out if individual chemoresponse testing might be a useful supplement in decision-making for the optimal therapeutic option for our MCC patient. The different results achieved using cisplatin, docetaxel, and cetuximab led to the conclusion that an individual chemoresponse testing in a predictive short-time assay might potentially be a useful diagnostic tool in identifying potentially effective chemotherapy treatments.

Inclusion mucous cysts of the nose: a late complication after septorhinoplasty in two cleft lip patients.

BACKGROUND: Mucous cysts of the nose are a rare complication of rhinoplasty. They may develop as a result of implantation or herniation of mucosa. The entrapped epithelium may proliferate, forming a subcutaneous cyst. PATIENTS AND METHODS: Two patients with unilateral cleft lip nose deformity had previously undergone corrective rhinoplasty. Years after the operation, they noticed a growing mass in the nasal dorsum and presented for revision rhinoplasty. Complete surgical removal was performed by an open approach, and plastic reconstruction was performed with a rib cartilaginous graft. RESULTS: In both cases, histopathological investigation revealed a mucous cyst. No recurrence of disease was observed over 2 years of monitoring. CONCLUSION: Nasal mucous cysts are not specific complications of corrective surgery for cleft lip nose. Displacement of fragments of epithelium should be avoided to prevent this unwanted sequela. For complete removal, open rhinoplasty is recommended.

Nitric oxide synthase (NOS2/3) expression in head and neck squamous cell carcinomas in correlation with clinical patterns.

BACKGROUND: Increased nitric oxide synthase (NOS) expression has been demonstrated in a number of carcinomas and is discussed to play a key role in tumor progression. The aim of this immunohistochemical study was to examine the protein expression rates of endothelial (e)NOS and inducible (i)NOS in head and neck squamous cell carcinomas (HNSCCs) and oral mucosa and to correlate the results with clinicopathologic factors (TN stage). PATIENTS AND METHODS: Protein expression patterns of NOS were studied immunohistochemically (score 0-7) in 58 patients with HNSCC and 7 mucosa samples, and the results were correlated with tumor stages. RESULTS: In oral mucosa, iNOS was only expressed in the basal epithelial layers and in macrophages, eNOS in endothelial cells and lymphocytes. In contrast, both NOS isoforms were expressed in HNSCC with preference at the tumor margins. 64% of tumor specimens demonstrated a positive eNOS immunoreactivity (score > or =3), 55% a positive iNOS immunoreactivity. NOS protein expression rates reached higher scores in tumors of patients with lymph node metastasis (N > 0; iNOS protein expression rate p < 0.05). CONCLUSIONS: HNSCCs are able to express both NOS protein isoforms in relevant amounts, and we presume that synthesized NO is able to support angiogenetic patterns and facilitate tumor progression and lymphatic spread.

Adult Granulosa Cell Tumor of the Testis: A Case Report with a Review of the Literature.

Adult granulosa cell tumor (AGCT) of the testis represents a very rare testicular neoplasm that is poorly understood clinically. Here we report the case of a 22-year-old male who presented with unspecific scrotal symptoms. Scrotal sonography disclosed a 6 mm hypoechoic intratesticular lesion. Histological examination after orchiectomy revealed a homogeneous and well demarcated neoplasm with monomorphic cells with nuclear grooving and microfollicular formation of the so-called Call-Exner bodies. Immunohistology showed positive stainings of vimentin, calretinin, and inhibin with negative stainings of the typical germ cell tumor markers. Thus, the diagnosis of a benign AGCT was made. The patient is well one year after surgery. A total of 91 previous AGCT cases were identified in the literature. Median age of the cases reported to date is 44 years, median tumor size 3.2 cm. 54.3% of the AGCT cases were located on the left side. 12 cases (13.2%) were of malignant nature. Testis-sparing surgery would be the treatment of choice, but only two of all cases had received that procedure. The present report aims to increase the clinical knowledge of AGCT and specifically to increase the clinician's vigilance with respect to testis-sparing surgery in probably benign testicular masses.

Efficacy and the toxicity of the interstitial high-dose-rate brachytherapy in the management of recurrent keloids: 5-year outcomes.

PURPOSE: Recurring keloids are a clinical challenge. Interdisciplinary treatments are required in most cases. Owing to the wide variety of concepts, the optimal treatment regime remains unclear. Our clinic established a protocol of perioperative interstitial high-dose-rate brachytherapy with three fractions of 6 Gy and achieved an excellent 2-year local control rate of 94% (In search of the optimal treatment of keloids: Report of a series and a review of the literature). This report is an update on our long-term results of prospective study. Twenty-nine patients were included with a median followup of 5 years. METHODS AND MATERIALS: From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. Brachytherapy was given in three fractions with a single dose of 6 Gy in 5-mm tissue depth and covered the scar in total length. Followup visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and annually thereafter. Therapeutic outcome was assessed in terms of recurrence, acute and late complications, and cosmetic results. RESULTS: No procedure-related complications occurred. Improvement of keloid-related symptoms was noticed in all patients after treatment. After a median followup of 49.7 months (range: 7.9-91.9 months), three keloid recurrences and two hypertrophied scars were observed. CONCLUSIONS: Our results suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy and other treatment procedures. Our three-fraction treatment schedule reduces the treatment period to 2 days and is therefore convenient for the patients.

Fatal leaflet escape in an Edwards TEKNA aortic prosthesis.

The case is reported of a 26-year-old male patient who died eight years after the replacement of an aortic valve with a bileaflet mechanical valve (TEKNA; Edwards, USA). Following prosthesis implantation, the patient had been in a good state of health, and his death occurred unexpectedly. Forensic autopsy revealed a leaflet escape, with two fragments of the leaflet being found bilaterally in the common iliac arteries. Death occurred due to an acute cardiac insufficiency. Immunohistochemical investigations revealed fresh myocardial fiber necroses. Stereomicroscopic and scanning electron microscopic investigations demonstrated surface erosions of the leaflet. Although the valve was withdrawn from the market in June 2000, it had previously been implanted in over 18,000 patients. Thus, from a clinical viewpoint, the question of using a prophylactic replacement in affected patients must be discussed.

Perioperative Interstitial High-Dose-Rate Brachytherapy for the Treatment of Recurrent Keloids: Feasibility and Early Results.

PURPOSE: To prospectively evaluate high-dose-rate brachytherapy in the treatment of therapy-resistant keloids and report first results, with emphasis on feasibility and early treatment outcome. METHODS AND MATERIALS: From 2009 to 2014, 24 patients with 32 recurrent keloids were treated with immediate perioperative high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiation therapy and presented with recurrences in the pretreated areas. Two or more different treatment modalities had been tried in all patients and had failed to achieve remission. After (re-)excision of the keloids, a single brachytherapy tube was placed subcutaneously before closing the wound. The target volume covered the scar in total length. Brachytherapy was given in 3 fractions with a single dose of 6 Gy in 5 mm tissue depth. The first fraction was given within 6 hours after surgery, the other 2 fractions on the first postoperative day. Thus, a total dose of 18 Gy in 3 fractions was administered within 36 hours after the resection. RESULTS: The treatment was feasible in all patients. No procedure-related complications (eg, secondary infections) occurred. Nineteen patients had keloid-related symptoms before treatment like pain and pruritus; disappearance of symptoms was noticed in all patients after treatment. After a median follow-up of 29.4 months (range, 7.9-72.4 months), 2 keloid recurrences and 2 mildly hypertrophied scars were observed. The local control rate was 94%. Pigmentary abnormalities were detected in 3 patients, and an additional 6 patients had a mild delay in the wound-healing process. CONCLUSIONS: The early results of this study prove the feasibility and the efficacy of brachytherapy for the prevention of keloids. The results also suggest that brachytherapy may be advantageous in the management of high-risk keloids or as salvage treatment for failure after external beam therapy.

Oral brush biopsy analysis by MALDI-ToF Mass Spectrometry for early cancer diagnosis.

OBJECTIVES: Intact cell peptidome profiling (ICPP) with MALDI-ToF Mass Spectrometry holds promise as a non-invasive method to detect head and neck squamous cell carcinoma (HNSCC) objectively, which may significantly improve the early diagnosis of oral cancer. The present study was designed to discriminate between tumour samples and non-cancer controls (healthy mucosa and oral lesions) by analysing complete spectral patterns of intact cells using MALDI-ToF MS. MATERIALS AND METHODS: In the first step, a database consisting of 26 patients suffering from HNSCC was established by taking brush biopsy samples of the diseased area and of the healthy buccal mucosa of the respective contralateral area. After performing MALDI-ToF MS on these samples, classification analysis was used as the basis for further classification of an additional 26 blinded samples including HNSCC, oral lesions and healthy mucosa. RESULTS: By analysing spectral patterns of the blinded samples, all cancerous lesions were defined accurately. One incorrect evaluation (false positive) occurred in the lesion cohort, leading to a sensitivity of 100%, a specificity of 93% and an overall accuracy of 96.5%. CONCLUSION: ICPP using MALDI-ToF MS is able to distinguish between healthy and cancerous mucosa and between oral lesions and oral cancer with excellent sensitivity and specificity, which may lead to more accurate early diagnosis of HNSCC.

Intracranial extension of Schneiderian inverted papilloma: a case report and literature review.

Inverted papilloma is an uncommon primary nasal tumor. Despite its benign nature, this tumor represents three typical characteristics: a high propensity of recurrence, local aggressiveness and association with malignancy. Inverted papilloma can reduce the patient's quality of life due to compromised nasal function, extension to the orbit and brain. The authors reported the unusual case of a 72-year-old male patient with inverted papilloma, which fatally extended to the intracranial temporal fossa after multiple recurrences. To the authors' knowledge, this is the twelfth case in the literature of inverted papilla extending into the temporal fossa. The current and pertinent literature in English, French and German was reviewed, and an algorithm for managing inverted papilloma was also proposed.

Different approaches to volume assessment of lymph nodes in computer tomography scans of head and neck squamous cell carcinoma in comparison with a real gold standard.

BACKGROUND: Volume assessment in head and neck squamous cell carcinoma (HNSCC) is becoming a more and more clinical important parameter, especially in treatment planning and response control. Various authors showed a significant impact of tumour volume on treatment outcome and local control. Regarding the increasing impact of induction chemotherapy and primary chemoradiation on HNSCC, the need for an adequate measuring tool to judge treatment response becomes obvious. This study was performed to compare the momentary 'gold standard', the diameter-based approach, and tumour volume assessment in HNSCC with approaches based on segmentation algorithms in computer tomography (CT) scans. METHODS: CT scans were taken as part of the standardized staging investigations. Using these image data, 30 lymph nodes were defined and segmented. The segmentations were carried out with the newly developed software called 'NeckSegmenter'. After obtaining informed consent from the patient, neck dissection was performed and the excised lymph nodes underwent analysis of their true volume. The datasets were compared with each other and put in correlation with the segmented volumes. RESULTS: Pearson's correlation index showed a higher correlation of the segmented volumes (r = 0.7979) with the true volumes than the results generated via diameter-based equation (r = 0.7974). Furthermore, the diameter-generated volumes show clearly too high volumes at 130% (confidence interval: 107.7-156.7%). The volumes generated with the segmentation are at 89.18% (confidence interval: 73.52-108.16%). CONCLUSION: The data show a higher reliability for volumes estimated by the segmentation-based approach than the widely used diameter-based approach.

Oral brush biopsy analysis by matrix assisted laser desorption/ionisation-time of flight mass spectrometry profiling--a pilot study.

Oral squamous cell carcinomas (OSCCs) often present as advanced tumours requiring aggressive local and regional therapy and result in significant functional impairment. The objective is to develop pre-symptomatic screening detection of OSCC by a brush biopsy method which is less invasive than the conventional biopsy for histology. Given the molecular heterogeneity of oral cancer, it is unlikely that even a panel of tumour markers would provide accurate diagnosis. Therefore, approaches such as the matrix-assisted-laser-desorption/ionisation-time-of-flight-mass-spectrometry (MALDI-TOF-MS) allow several biomarkers or peptide profile patterns to be simultaneously assessed. Brush biopsies from 27 patients with histology-proven OSCCs plus 40 biopsies from 10 healthy controls were collected. MALDI-TOF-MS profiling was performed and additional statistical analysis of the data was used to classify the disease status according to the biological behaviour of the lesion. For classification a support vector machine algorithm was trained using spectra of brush biopsy samples to distinguish healthy control patients from patients with histology-proven OSCC. MALDI-TOF-MS was able to distinguish between healthy patients and OSCC patients with a sensitivity of 100% and specificity of 93%. In summary, MALDI-TOF-MS in combination with sophisticated bioinformatic methods can distinguish OSCC patients from non-cancer controls with excellent sensitivity and specificity. Further improvement and validation of this approach is necessary to determine its feasibility to assist the pre-symptomatic detection of head and neck cancer screening in routine daily practice.