Breast Cancer Cell-Derived Adenosine Enhances Generation and Suppressor Function of Human Adaptive Regulatory T Cells.

INTRODUCTION: Adaptive regulatory T cells (Tr1) are induced in the periphery by environmental stimuli. CD73 expression and adenosine (ADO) production by tumor cells may influence Tr1 generation and their immunosuppressive activity. MATERIAL AND METHODS: Tr1 were generated in co-cultures of CD4+CD25neg T cells, autologous immature dendritic cells (iDC), and irradiated ADO-producing CD73+ or non-producing CD73neg breast cancer (BrCa) cell lines (TU). The expression of ectonucleotidases and other surface markers on Tr1 was determined by flow cytometry. Tr1-mediated suppression of proliferation was evaluated in CFSE-based assays. Luciferase-based ATP detection assays and mass spectrometry were used to measure ATP hydrolysis and ADO levels. Cytokine levels were measured by ELISA or Luminex. CD73 expression on tumor cells or T cells in TU tissues was assessed by immunofluorescence. RESULTS: CD73+ TU induced higher numbers of Tr1 cells (p < 0.01) than CD73neg TU. Tr1TU73+ hydrolyzed more exogenous ATP, produced more ADO, and mediated higher suppression than Tr1TU73neg (p < 0.05 for all). ARL67156, an ectonucleotidase inhibitor, and ZM241385, A2A receptor antagonist, reduced suppression of proliferation mediated by Tr1TU73+ cells (p < 0.01). Basal-like primary BrCa cells expressed higher levels of ectonucleotidases and induced more Tr1 than less aggressive primary luminal-like BrCa. CONCLUSION: BrCa producing ADO (CD73+ TU) favor the induction of Tr1, which expresses CD39 and CD73, hydrolyzes ATP to ADO, and effectively suppresses anti-tumor immunity.

Acceptance and adoption of transoral robotic surgery in Germany.

PURPOSE: Since its introduction over a decade ago, the use of robotic surgery (RS) in head and neck surgery has widely spread around the globe, with very differential adoption of this novel surgical technique in different parts of the world. In this study, we analyze the acceptance and adoption of robotic surgery in the head and neck in Germany. MATERIALS AND METHODS: A cross-sectional analysis using a questionnaire evaluating the acceptance and adoption of RS was performed. Questionnaires were distributed to all chairmen /-women of Otorhinolaryngology, Head and Neck Surgery Departments in Germany. RESULTS: A total of 107 respondents completed the questionnaire (65.2%). At university hospitals, 71.4% of the respondents indicated that a robotic system was available, and 21.4% responded that robotic surgery was performed at their institution; 22.7% and 0.04%, respectively, at non-university hospitals. The overall adoption rate was 0.8%. The most common cases performed were TORS resection in the oropharynx. Main reasons for not adopting this technique were costs, lack of interest and available co-operations. CONCLUSION: This study provides evidence of the extent of adoption of TORS in Germany; main perceived barriers to adoption are costs with lack of cost-covering reimbursement and insufficient co-operations with other disciplines as well as hospital administration resulting in a very low adoption rate of this technique over the past decade. Results from this study may assist in decision-making processes on adopting this technique in the future.

Significance and management of incidentally diagnosed metastatic papillary thyroid carcinoma in cervical lymph nodes in neck dissection specimens.

BACKGROUND: The management of patients with incidentally discovered metastatic thyroid cancer in cervical lymph nodes in neck dissection specimens for other pathologies is unclear. METHODS: Retrospective review of neck dissection specimens for nonthyroid malignancy during a 30-year period was undertaken to identify incidental metastatic papillary thyroid cancer (PTC). RESULTS: Twenty-six patients had an incidental finding of PTC in lymph node(s) in neck dissection specimens. Subsequent ultrasound of the thyroid showed nodules in 20 patients. Eleven (42%) underwent total thyroidectomy, 1 (4%) had a lobectomy, and 14 (54%) were kept under active surveillance only. At a median follow-up of 48 months (range 10-189 months), all patients who had undergone surgery and those under surveillance were free of PTC recurrence. CONCLUSION: Evaluation for detection of a primary thyroid tumor is essential in all patients with incidentally discovered metastatic PTC. Decision regarding surgery or surveillance is dependent on clinical and radiological tumor features and patient factors.

CD31 and VEGF are prognostic biomarkers in early-stage, but not in late-stage, laryngeal squamous cell carcinoma.

BACKGROUND: Patients suffering from squamous cell carcinoma of the larynx (LSCC) with lymphatic metastasis have a relatively poor prognosis and often require radical therapeutic management. The mechanisms which drive metastasis to the lymph nodes are largely unknown but may be promoted by a pro-angiogenic tumor microenvironment. In this study, we examined whether the number of microvessels and the expression level of vascular endothelial growth factor (VEGF) in the primary tumor are correlated with the degree of lymph node metastasis (N-stage), tumor staging (T) and survival time in LSCC patients. METHODS: Tissue-Microarrays of 97 LSCC patients were analyzed using immunohistochemistry. The expression of VEGF was scored as intensity of staining (low vs high) and the number of CD31-positive vessels (median

Ectonucleotidase CD39 expression in regional metastases in head and neck cancer.

INTRODUCTION: CD39 is the rate-limiting enzyme in the generation of immunosuppressive adenosine and its expression and activity are significant in tumor progression. Squamous cell carcinoma of the head and neck (HNSCC) shows an overall poor prognosis due to high local recurrence rates and early metastatic spread. MATERIAL AND METHODS: Primary tumor specimens and lymph node specimens harvested during neck dissection of 65 patients with a diagnosis of HNSCC were subjected to immunohistochemical and H-score analysis of CD39 expression. Demographics, histopathology and subsequent outcome were analyzed. RESULTS: The primary cancer was squamous cell carcinoma in all patients (male/female 55:10). H-score for CD39 expression in the primary lesion and metastatic lymph nodes was significantly higher in advanced compared to early stages with no significant differences among different tumor locations. High intratumoral and intrametastatic CD39 expression was associated with an inferior patients' overall survival at a mean follow-up of 83.4 months (6-204 months). CONCLUSION: CD39 expression in HNSCC correlated positively with tumor stage and appears to predict poor prognosis. Therefore, CD39 expression in primary lesions and metastatic lymph nodes seems to identify patients at high risk in HNSCC of all tumor sites. Immunotherapeutic approaches targeting CD39 might be promising for this patient population.

CD73 expression in lymph node metastases in patients with head and neck cancer.

INTRODUCTION: CD73 is an enzyme crucial in the metabolism of immunosuppressive adenosine. In cancer, it has various functions including tumor growth and metastases. Squamous cell carcinoma of the head and neck has an overall poor prognosis, also due to early spread of metastatic cells. MATERIALS AND METHODS: Tumor and lymph node specimens of 65 patients with HNSCC were subjected to immunohistochemical and H-score analysis of CD73 expression. Demographics, diagnoses, histopathology and subsequent outcome were analyzed. RESULTS: The primary cancer was squamous cell carcinoma in all patients (male/female 55:10) with the following locations: oral cavity n:16, oropharynx n:28, hypopharynx n:11 and larynx n:10. H-score for CD73 expression in the primary lesion and metastatic lymph nodes was significantly higher in advanced compared to early stages with no significant differences among tumor locations. High CD73 expression was associated with reduced overall survival rates at a mean follow-up of 83.4 months (6-204 months). CONCLUSIONS: CD73 expression in HNSCC correlated positively with tumor stage and was associated with poor prognosis. Therefore, CD73 expression in primary lesions and regional metastases appears to predict HNSCC patients at high risk of all tumor sites. Therapeutic approaches targeting CD73 might seem promising for this patient population.

Foxp3 expression in lymph node metastases in patients with head and neck cancer.

INTRODUCTION: The prevalence and activity of regulatory T cells in patients with cancer correlates with poor prognosis. These cells are characterized by their expression of Forkhead box protein-3 (Foxp3). Squamous cell carcinoma is the most prevalent type of cancer in the head and neck region with overall poor survival rates, also due to early spread of metastatic cells. MATERIAL AND METHODS: Primary tumor specimens as well as lymph node specimens harvested during neck dissection of 65 patients with a diagnosis of HNSCC were subjected to immunohistochemical and H-score analysis of Foxp3 expression. Demographics, diagnoses, histopathology and subsequent outcome were analyzed. RESULTS: The primary cancer was squamous cell carcinoma in all patients (male/female 55:10) with the following tumor locations: oral cavity n = 16, oropharynx n = 28, hypopharynx n = 11 and larynx n = 10 (Stage III n = 18; Stage IVA n = 45; Stage IVB n = 2). The H-score for Foxp3 expression in the primary lesion as well as metastatic lymph nodes was significantly higher in advanced stages compared to early stages with differences among tumor locations, which were not significant. High Foxp3 expression was associated with inferior overall survival rates at a mean follow-up of 83.4 months (6-204 months) Conclusions: Foxp3 expression in HNSCC varied from the anatomical site and correlated positively with tumor stage and was associated with poor prognosis. Therefore, Foxp3 expressions in primary lesions as well as lymphogenic metastases appear to predict high-risk HSNCC patients. Novel therapeutic approaches targeting Foxp3+ cells might seem promising for this patient population.

Reduction of Radiation Dosage in Visualization of Paranasal Sinuses in Daily Routine.

Background. Preoperative imaging of the nose and paranasal sinus is standard in otorhinolaryngology. Previous studies on phantoms demonstrated the potential for dose reduction of cone beam computed tomography (CBCT) by varying the application parameters. Methodology. Based on previous studies, the standard protocol of paranasal sinus imaging by CBCT was altered. One hundred and fifty examinations using the old protocol (01/2010-01/2011, high dosage) and 150 examinations using the new protocol (09/2012-09/2013, low dosage) were evaluated and compared for the visibility of 17 anatomical structures, the Lund-Mackay Score, and technical parameters. Results. Alteration of the protocol resulted in a significant reduction in dosage (6.64 mGy versus 2.88 mGy). Both groups showed the same amount of pathology (Lund-Mackay Score: 4.95 ± 3.79 versus 5.26 ± 5.77; p = 0.558). There was a significant better visibility of the anatomical structures (all visible = 1, nothing visible = 4) (results: 1.25 versus 1.17; p = 0.001) in the low-dosage group. Conclusion. Despite a significant reduction in the applied dosage, reliable visualization of the bony anatomy of the anterior skull base is possible by CBCT. This demonstrates the need for the discussion of the required clinical imaging quality.

A european multicenter study evaluating the flex robotic system in transoral robotic surgery.

OBJECTIVES/HYPOTHESIS: To evaluate the application of the Flex Robotic System in transoral robotic surgery (TORS). STUDY DESIGN: Multicenter, prospective, open-label, single-armed clinical study. METHODS: A prospective clinical follow-up multicenter study was performed from July 2014 to October 2015 assessing the safety and efficacy of the Medrobotics Flex Robotic System for access and visualization of the oropharynx, hypopharynx, and larynx as well as for resection of benign and malignant lesions. A total of 80 patients were enrolled. Access and visualization of five anatomic subsites (base of tongue, palatine tonsil area, epiglottis, posterior pharyngeal wall, and false vocal cords) were individually graded by the surgeon. Setup times, access and visualization times, surgical results, and adverse events were documented. RESULTS: The relevant anatomic structures could be exposed and visualized properly in 75 patients, who went on to have a surgical procedure performed with the Flex Robotic System. Access and visualization of the palatine tonsil area, posterior pharyngeal wall, epiglottis, and posterior pharyngeal wall were excellent. However, false vocal cords and vocal cords were more difficult to expose. Seventy-two patients were treated successfully with the Flex Robotic System. There were no serious or unanticipated device-related adverse events caused by the Flex Robotic System. CONCLUSIONS: Lesions in the oropharynx, hypopharynx, and larynx could be successfully resected with the Flex Robotic System, specifically developed for TORS. Our study provides evidence that the Flex Robotic System is a safe and effective tool in TORS. Laryngoscope, 2016 127:391-395, 2017.

Visualization of anatomy in normal and pathologic middle ears by cone beam CT.

Cone beam computed tomography (CBCT, syn. digital volume tomography = DVT) was introduced into ENT imaging more than 10 years ago. The main focus was on imaging of the paranasal sinuses and traumatology of the mid face. In recent years, it has also been used in imaging of chronic ear diseases (especially in visualizing middle and inner ear implants), but an exact description of the advantages and limitations of visualizing precise anatomy in a relevant number of patients is still missing. The data sets of CBCT imaging of the middle and inner ear of 204 patients were analyzed regarding the visualization of 18 different anatomic structures. A three-step scale (excellent visible, partial visible, not visible) was taken. All analyses were performed by two surgeons experienced in otology and imaging. The indications for imaging were chronic middle ear disease or conductive hearing loss. Previously operated patients were excluded to rule out possible confounders. In dependence of a radiological pathology/opacity of the middle ear, two groups (with and without pathology) were built. Regarding the possibility of excellent visualization, significant differences were only found for small bony structures: incu-stapedial joint (25.8 vs. 63.5 %), long process of incus (42.7 vs. 88.8 %), head of stapes (27.0 vs. 62.6 %), anterior crus of stapes (16.9 vs. 40.9 %) and posterior crus of stapes (19.1 vs. 42.6 %). The other structures (semicircular canals, skull base at mastoid and middle ear, jugular bulb, sinus sigmoideus, facial nerve) could be visualized well in both groups with rates around 85-100 %. Even CBCT shows little limitations in visualization of the small structures of the middle and inner ear. Big bony structures can be visualized in normal as well as in pathologic ears. Overall, due to pathology of middle ear, an additional limitation of evaluation of the ossicular chain exists. In future, studies should focus on comparative evaluation of different diseases and different radiological modalities and be performed by radiologists and otologists together to improve the quality of reports and to answer clinical questions more satisfactorily.

Utility of the Highly Articulated Flex Robotic System for Head and Neck Procedures: A Cadaveric Study.

OBJECTIVE: Robotic head and neck surgery potentially reduces the morbidity associated with traditional open procedures. This study's goal was to employ a novel highly articulated robotic system (Flex Robotic System) for head and neck procedures, including a postauricular facelift approach thyroidectomy, submandibular gland (SMG) removal, and cervical lymphadenectomy. STUDY DESIGN: It was hypothesized that the Medrobotics Flex Robotic System could be used for transcervical head and neck surgical procedures. METHODS: Three fresh upper body human cadavers were used. The Flex Robotic System was used to complete a thyroidectomy, neck dissection, and SMG removal on each cadaver. RESULTS: A postauricular incision and flap was manually raised. The robotic system was positioned on the right side of the cadaver's head. The system's manually controlled flexible instruments and highly shapeable, robot-assisted scope were used to perform a thyroid lobectomy. Neck dissection and SMG removal were also performed. CONCLUSIONS: Although a promising technology, the current robotic system (Intuitive Surgical Inc, Sunnyvale, California, USA) has limitations due to its rigid and large configuration, which decreases exposure and access. The new system's shapeable, computer-assisted scope seeks to reduce some of these difficulties and may be better adapted for transcervical approaches to the neck operations.

Mutant KRAS Conversion of Conventional T Cells into Regulatory T Cells.

Constitutive activation of the KRAS oncogene in human malignancies is associated with aggressive tumor growth and poor prognosis. Similar to other oncogenes, KRAS acts in a cell-intrinsic manner to affect tumor growth or survival. However, we describe here a different, cell-extrinsic mechanism through which mutant KRAS contributes to tumor development. Tumor cells carrying mutated KRAS induced highly suppressive T cells, and silencing KRAS reversed this effect. Overexpression of the mutant KRAS(G12V)gene in wild-type KRAS tumor cells led to regulatory T-cell (Treg) induction. We also demonstrate that mutant KRAS induces the secretion of IL10 and transforming growth factor-ß1 (both required for Treg induction) by tumor cells through the activation of the MEK-ERK-AP1 pathway. Finally, we report that inhibition of KRAS reduces the infiltration of Tregs in KRAS-driven lung tumorigenesis even before tumor formation. This cell-extrinsic mechanism allows tumor cells harboring a mutant KRAS oncogene to escape immune recognition. Thus, an oncogene can promote tumor progression independent of its transforming activity by increasing the number and function of Tregs. This has a significant clinical potential, in which targeting KRAS and its downstream signaling pathways could be used as powerful immune modulators in cancer immunotherapy.

Effect of training frequency on the learning curve on the da Vinci Skills Simulator.

BACKGROUND: The purpose of this study was to evaluate the effect of training on the performance outcome with the da Vinci Skills Simulator. METHODS: Forty novices were enrolled in a prospective training curriculum. Participants were separated into 2 groups. Group 1 performed 4 training sessions and group 2 had 2 training sessions over a 4-week period. Five exercises were performed 3 times consecutively. On the last training day, a new exercise was added. RESULTS: A significant skills gain from the first to the final practice day in overall performance, time to complete, and economy of motion was seen for both groups. Group 1 had a significantly better outcome in overall performance, time to complete, and economy of motion in all exercises. There was no significant difference found regarding the new exercise in group 1 versus group 2 in nearly all parameters. CONCLUSION: Longer time distances between training sessions are assumed to play a secondary role, whereas total repetition frequency is crucial for improvement of technical performance. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1762-E1769, 2016.

Prognostic value of level IV metastases from head and neck squamous cell carcinoma.

BACKGROUND: The purpose of this study was to evaluate the prognostic value of level IV metastases in head and neck squamous cell carcinoma (HNSCC). METHODS: The clinical and histopathological data of 111 patients with HNSCC with pN+ neck who underwent a primary tumor resection with unilateral or bilateral neck dissection were analyzed. RESULTS: Level IV metastases were histopathologically proven in 33 patients (29.7%). Pulmonary metastases were observed in 12 of 33 patients (36.4%) with level IV metastases, and in 13 of 78 patients (16.7%) without level IV metastases (p = .04). Multivariate analyzes revealed a significant association between level IV metastases and pulmonary metastases (p = .038). However, an influence on overall (p = .65) or disease-free survival (p = .66) was not observed. CONCLUSION: Level IV metastases seem to be a predictive factor for pulmonary metastases but not for overall and disease-free survival in patients with HNSCC.

Indications of cone beam CT in head and neck imaging.

CONCLUSION: Cone Beam Computed Tomography (CBCT) can be widely used in imaging of bony structures of the anterior and lateral skull base. Significant differences of applied dosages result from the different protocols of the various indications. OBJECTIVES: CBCT is increasingly being used in head and neck imaging. Until now, no precise knowledge about its dedicated usage existed. METHODS: All CBCT of 2012 and 2013 were analysed with regard to the technical parameters, the performance, and the indication for imaging. RESULTS: In total, 1862 patients were examined in 2012 and 2013. The top eight indications of the anterior skull were (1) chronic rhinosinusitis with disturbed nasal breathing (30.3%); (2) chronic rhinosinusitis (17.6%); (3) midfacial traumatology (13.7%); (4) disturbed nasal breathing (12.8%); (5) acute rhinosinusitis (7.9%); (6) polyposis nasi (6.3%); (7) search for focus (3.9%); and (8) persistent rhinorrhea (1.2%). For the lateral skull base, the top eight were (1) control after cochlear implantation (28.4%); (2) cholesteatoma (19.7%); (3) visualization of ear anatomy (8.7%); (4) chronic otitis media mesotympanalis (6.3%); (5) conductive hearing loss (5.1%); (6) suspected mastoiditis (4.8%); (7) pathology of external auditory canal (4.8%); and (8) otosclerosis (3.3%). Applied dosage for the anterior skull base was significantly lower than for the lateral skull base (2.90 mGy vs 5.92 mGy, p < 0.05); 2.4% and 3.6% of patients' images, respectively, had to be repeated.

Transoral surgery for oropharyngeal tumors using the Medrobotics(®) Flex(®) System - a case report.

INTRODUCTION: Transoral resection of pharyngeal tumors with acceptable oncological and functional results can be challenging due to their location in a narrow anatomic space. CASE PRESENTATION: In this case report, we demonstrate successful visualization and resection of a squamous cell carcinoma of the oropharynx using the novel Medrobotics(®) Flex(®) System. The Medrobotics(®) Flex(®) System (Medrobotics Corp., Raynham, MA, USA) is an operator controlled flexible endoscope system that includes a rigid endoscope and computer-assisted controllers, with two external channels for the use of compatible, 3.5mm flexible instruments. DISCUSSION: In a 74-year old female patient a T1 squamous cell carcinoma of the oropharynx was visualized and completely resected using this system. The Medrobotics(®) Flex(®) System is a promising device for transoral approaches in resection of tumors within the pharynx. CONCLUSION: Good visualization, access, and flexibility of the endoscope and instruments are hereby clear advantages of the system compared to commonly used systems.

Transoral surgery using a novel single-port flexible endoscope system.

The transoral resection of pharyngeal and laryngeal tumors is challenging due to their location in a narrow anatomic space. In this study, the visualization and resection in the area of the pharynx and larynx using a novel computer-assisted flexible endoscopic robotic system are evaluated. The Medrobotics(®) Flex(®) System (Medrobotics Corp., Raynham, MA, USA) is an operator-controlled flexible endoscope robotic system that includes a flexible endoscope and computer-assisted controllers, with two accessory channels for the use of compatible, 3.5 mm flexible instruments. In six human cadavers, four basic procedures (tonsillectomy, base of tongue resection, hemi-epiglottectomy and resection of false vocal cords) were performed bilaterally by two surgeons. Success in appropriate visualization of the target structure and resection was documented. The driving and resection time was determined for each procedure. An appropriate exposure and resection within the pharynx and larynx was achieved in all cases. Both surgeons experienced a learning curve in driving the system and performing the procedures. The Medrobotics Flex(®) system is a promising tool for transoral resections within the pharynx and larynx. Good visualization, access, and resectability are hereby clear advantages of the system compared to commonly used systems.

Establishing a transoral robotic surgery program in an academic hospital in Germany.

The application of robot technology in the field of surgery has grown rapidly in recent years. Also in Europe, robot-assisted surgery has become increasingly popular, predominantly in the fields of urology and gynecology. Transoral robotic surgery (TORS) is widely practiced in North America after receiving FDA approval in 2009. This technique was also adopted and is being practiced at specialized institutions in various European countries, including Germany. Due to significant differences in the health-care system and divergent developments of the use of transoral surgery in the treatment of laryngeal and pharyngeal malignancies in the last decade between North America and Europe, there are unique barriers and challenges to introducing TORS in these two parts of the world. This article describes experiences in developing a TORS program at an academic hospital in Germany. Specifically, steps that were required to obtain institutional approval and financial support, as well as to train surgeons and allied health-care personnel, and to establish a sufficient and adequate technique for reprocessing the used instruments are presented. Introducing a TORS program in Europe is still a challenge in regard to financial issues, acceptance, and practicability and therefore it is only practiced in specialized centers, although systems are widely available and often used in the same hospital by urology departments.