Surgical site infection in clean-contaminated wounds after multimodal treatment of advanced oral squamous cell carcinoma.

OBJECTIVES: The aim of this study was to assess the incidence rate for surgical site infections (SSI), patient- and therapy-related risk factors in UICC stage III and IV oral squamous cell carcinoma patients treated with preoperative radiochemotherapy, ablative surgery and immediate microvascular free flap reconstruction. MATERIAL AND METHODS: This retrospective analysis included 85 patients with oral squamous cell carcinoma treated by neoadjuvant radiochemotherapy, tumor surgery and immediate free flap reconstruction. Patient-, therapy-related factors and blood parameters were collected for this selective cohort. RESULTS: The incidence for SSI was 44.7% and for transplant loss 14.1%. Minor BMI changes (p = 0.010), diabetes (p = 0.003), edentulous status (p = 0.006) and cessation of alcohol consumption (0.034) showed to be significant patient-related risk factors. No therapy-related factors were found to be significantly influencing the risk for SSI. Neutrophil counts (p = 0.027) and GGT (p = 0.002) were found to be significantly linked to SSI. CONCLUSION: The not so common treatment option for oral squamous cell carcinomas showed no more risk for SSI compared to standard treatment options. Preserving the ability for healthy nutrition has a significant impact on the development of SSI. This applies not only to the presented and particular treatment option.

Neoadjuvant radiotherapy plus radical surgery for locally advanced stage III/IV oral cancer: Analysis of prognostic factors affecting overall survival.

OBJECTIVES: Preoperative radiotherapy followed by surgery is an effective treatment option for solid tumors including locally advanced squamous cell cancers of the head and neck region. Histopathologic response to radiation has been shown to be associated with survival. However, the relative prognostic importance of regression grade compared to other potential biomarkers has not been established yet. MATERIALS AND METHODS: One-hundred forty-four oral squamous cell carcinoma patients with stage III/IV disease were included in this analysis. Patients had received preoperative radiotherapy (RT) up to 50Gy total dose in combination with 5-Fluorouracil (5-FU)/Mitomycin C (MMC) or with Cetuximab, followed by radical surgery six to eight weeks later. Outcome data were obtained from the patient's files. Survival rates were estimated by the Kaplan-Meyer method. Cox-proportional-hazard regression models were used to compare the risk of death among patients stratified according to risk factors. RESULTS: Five-year overall survival (OS) was 58% in the presented collective. Regression grade 4 (HR 3.58; p<0.001) was most significantly associated with reduced survival, followed by elevated neutrophils (HR 2.22; p=0.01), the combination of elevated neutrophils plus elevated CRP (HR 2.40; p=0.01), and elevated CRP alone (HR 1.74; p=0.03). In a multivariate analysis, the regression grade remained the most influential predictor of outcome (HR 4.23; p<0.001). CONCLUSION: In a comparative analysis, tumor response to pre-operative radiotherapy remains the strongest prognostic factor for treatment outcome, while elevated CRP, as well as neutrophils, were also found to be of significance.

Causes and timing of delayed bleeding after oral surgery.

OBJECTIVES: This study examines a cohort of patients who suffered bleeding requiring hemostatic intervention after oral surgery. The reasons for bleeding and the interval between surgery and onset of bleeding are investigated. MATERIALS AND METHODS: Between 1998 and 2009, 1,819 cases were eligible for this retrospective study. Factors (independent parameters) influencing the interval (dependent variable) were analyzed using negative binomial count regression models (NegBin II). The significance of each regressor's effect was tested using Wald's test and the total effect using likelihood ratio test. RESULTS: Of the patients examined, 1,101 (60.1 %) did not take anticoagulants, 394 (21.5 %) took phenprocoumon, 233 (12.7 %) took acetylsalicylic acid, 33 (1.8 %) took clopidogrel, 17 (0.9 %) took more than one anticoagulant, and 78 (4.3 %) had a congenital blood disorder. After simple tooth extraction, 95.3 % suffered bleeding; 69.7 % of extractions were performed in the molar region. Later that day of surgery, 66.0 % of all patients showed bleeding. The bleeding interval was significantly prolonged by anticoagulant therapy with phenprocoumon, by congenital clotting disorders. CONCLUSIONS: Normal tooth extractions are underestimated for their risk for postoperative bleeding, especially in the molar region. Anticoagulant therapy or congenital blood disorders present oral surgeons with a further challenge. CLINICAL RELEVANCE: Performing surgery before midday allows surgeons managing postoperative bleeding themselves for a better patient satisfaction. Intensified information about correct postoperative behavior is crucial. Prolonged blood coagulation should intensify follow-up checks. Patients with congenital blood disorders and patients at high risk for bleeding with the need for substitution of platelets or clotting factors should receive inpatient care. More potent, local applicable coagulant agents are required for these patients.

Survival of patients with pathologic T0N+ oral and oropharyngeal cancer after neoadjuvant therapy and surgery: the minority report.

OBJECTIVES: Treatment outcome of patients with oral and oropharyngeal squamous cell carcinoma (OOSCC) achieving complete pathologic response at the primary site (ypT0) but incomplete response in loco-regional lymph nodes after preoperative chemoradiation (ypN+) is poorly described in the literature. This study's objective was to assess the survival of patients with OOSCC with ypT0N+ disease. STUDY DESIGN: 176 patients with primary locally advanced OOSCC undergoing preoperative chemoradiotherapy were stratified according to the pathologic TNM classification into 6 groups: ypT0N0M0 (46%), ypT0N+M0 (10%), ypTNM I (24%), ypTNM II (4%), ypTNM III (6%), and ypTNM IV (10%). RESULTS: Three-year overall survival (OS) and recurrence-free survival (RFS) rates for the ypT0N+M0 group were both 61.8% and were similar to those of the ypTNM I group (OS 62.4%; RFS rate of 59.2%). CONCLUSIONS: Survival analyses showed that patients with OOSCC with ypT0N+ disease have a similar prognosis to those with pathologic TNM stage I.

Impact of elective neck dissection on regional recurrence and survival in cN0 staged oral maxillary squamous cell carcinoma.

To evaluate the impact of elective neck dissection (END) on regional recurrence and survival in cN0 staged patients with maxillary squamous cell carcinoma (SCC). Eighty-six patients with maxillary SCC and clinically staged N0 cervical lymph-nodes were evaluated in this single center retrospective study. Seventy-four of 86 patients were included in this analysis, of which 36 patients were treated with END, 38 without END. Following END, pathohistologically verified regional lymph-nodes in the initially cN0 neck were found in three (8%) patients. In both the +END and non-END group regional recurrences occurred exclusively in patients with T4 primaries. The overall regional recurrence rate was 17% in the +END and 18% in the non-END group, respectively. The 5-year overall survival rate for all tumor stages combined (T1-T4) was 86% in the +END group and 82% in the -END group. Within the patients groups with T4 tumors, 5-year overall survival was 81% for the +END group and 56% for the -END group. Over all tumor stages combined (T1-T4), END did not significantly improve overall survival rates and did not prevent the rate of regional recurrence in cN0 staged patients with maxillary alveolar, gingival and palatal SCC. However, in the subgroup of patients with locally advanced T4 tumors, their seemed to be a clear tendency towards improvement of overall survival in the END group. END can therefore be recommended for these patients.

Radiosensitization of head and neck cancer cells by the phytochemical agent sulforaphane.

BACKGROUND AND PURPOSE: Sulforaphane is a naturally occurring compound found in broccoli and other cruciferous vegetables. Recently it gained attention because of its antiproliferative properties in many cancer cell lines. The aim of this study was to investigate whether sulforaphane could act as a radiosensitizer in head and neck squamous cell carcinoma cell lines. MATERIALS AND METHODS: Four head and neck squamous cell carcinoma cell lines (i.e., (HNSCC) SCC9, SCC25, CAL27, and FADU) were treated with sulforaphane and subsequently irradiated. Then proliferation and clonogenic assays were performed. Apoptosis was detected by flow cytometry. Possible regulation of Akt and Mcl-1 was investigated by western blotting. RESULTS: Sulforaphane and radiation in combination leads to stronger inhibition of cell proliferation and of clonogenic survival than each treatment method alone. Western blot analysis of Akt and Mcl-1 showed no changed expression. CONCLUSION: Sulforaphane is a promising agent in the treatment of head and neck cancer due to its antiproliferative and radio-sensitizing properties. A combination of sulforaphane and radiation decreases clonogenic survival. Apoptosis is not regulated through Akt or the Mcl-1 protein.

Betulinic acid a radiosensitizer in head and neck squamous cell carcinoma cell lines.

BACKGROUND AND PURPOSE: Betulinic acid, a pentacyclic triterpene, is a new cytotoxic compound active on melanoma, neuroblastoma, glioblastoma and head and neck squamous cell carcinoma (HNSCC) cells. In combination with irradiation it has been shown to have an additive effect on growth inhibition in melanoma cells. In this study, the radiosensitizing effect of betulinic acid on sequential irradiation was investigated in HNSCC cell lines. MATERIAL AND METHODS: Two HNSCC cell lines, SCC9 and SCC25, were treated with increasing doses of betulinic acid and sequentially irradiated with a single boost of 4 Gy from a conventional radiation source. The cells were counted, the surviving fraction was determined, and colony-forming assays were performed. RESULTS: It could be shown that betulinic acid alone inhibits cell survival, affects cell survival additively in combination with irradiation and decreases clonogenic survival in both cell lines when applied alone. CONCLUSION: Betulinic acid could be a promising treatment agent in radioresistant head and neck cancer. A combination of betulinic acid with radiotherapy seems to be beneficial.

The cyclooxygenase-2 inhibitor nimesulide, a nonsteroidal analgesic, decreases the effect of radiation therapy in head-and-neck cancer cells.

BACKGROUND: No data are available on the effects of the cyclooxygenase-2 (COX-2) inhibitor nimesulide in combination with irradiation on the survival of head-and-neck carcinoma cells. MATERIAL AND METHODS: Two head-and-neck carcinoma cell lines (SCC9 and SCC25) were treated with nimesulide (50-600 microM) and irradiated concomitantly or sequentially. Early effects on cell survival were investigated by counting cell numbers, long-term effects by colony-forming assays. Cell-cycle effects were analyzed 24-72 h after treatment with nimesulide by flow cytometry. RESULTS: Unexpectedly, nimesulide solely inhibited cell proliferation without affecting colony-forming ability. In addition, no evidence for a radiosensitizing effect of nimesulide in short-term assays was seen. Nimesulide alone had no effect on clonogenic survival alone or in combination with radiation. CONCLUSION: Nimesulide differentially affects cell proliferation and clonogenic survival and may decrease the efficacy of radiotherapy. Short-term assays to assess tumor growth may not correctly predict the clinically relevant long-term effect of COX-2 inhibitors.

Inhibition of cytotoxicity of cisplatin by cyclooxygenase-2 inhibitor nimesulide in head and neck cancer cell lines.

Although head and neck cancer is a common malignancy, investigations have not yet improved the poor prognosis of patients. Therefore, it is important to find new cancer treatment modalities. Recent studies showed that cyclooxygenase, especially its isoform cyclooxygenase-2, is involved in tumorigenesis, tumor growth and metastasis. Inhibition of this enzyme by cyclooxygenase inhibitors has been shown to be antiproliferative in numerous cancer cell lines. The aim of this study was to investigate if the selective cyclooxygenase-2 inhibitor nimesulide could enhance cytotoxicity of the standard chemotherapeutic agent cisplatin. Head and neck squamous cell cancer cells were incubated with nimesulide and/or cisplatin, and counted after 24, 48 and 72 h treatment. Visualization of apoptotic cells was done by immunohistochemistry. We demonstrated that nimesulide inhibits the cytotoxic effect of cisplatin in HNSCC cells. Therefore, COX-2 inhibitor nimesulide may not be a good partner for cisplatin in combination therapy for cancer.

The effect of nimesulide, a selective cyclooxygenase-2 inhibitor, on Ets-1 and Ets-2 expression in head and neck cancer cell lines.

BACKGROUND: The protooncogenes Ets-1 and Ets-2 are involved in carcinogenesis of different tumors. Nimesulide, a selective cyclooxygenase-2 (COX-2) inhibitor, has antiproliferative effects on tumor cells. The question arises whether nimesulide influences Ets-1 and Ets-2 synthesis in head and neck tumors. METHODS: Expression of Ets-1 and Ets-2 was analyzed in tumor tissues by immunohistochemistry. The influence of nimesulide and an extracellular signal-regulated kinase (ERK) inhibitor on cell proliferation of two head and neck cancer cell lines and Ets-1 and Ets-2 expression was determined by automated cell counting and Western blotting, respectively. RESULTS: Immunohistochemistry showed a high expression of Ets-1 and Ets-2 in tumor tissues. In both cell lines, Ets-1 and Ets-2 expression were reduced after 24 and 48 hours by nimesulide. CONCLUSION: Both Ets-1 and Ets-2 are overexpressed in head and neck cancer specimens. Inhibition of Ets-1 and Ets-2 expression in head and neck cancer cell lines by nimesulide might explain the proapoptotic property of this COX-2 inhibitor.

Combination of betulinic acid with cisplatin--different cytotoxic effects in two head and neck cancer cell lines.

Betulinic acid (BetA), a new experimental cytotoxic compound that is active against human melanoma cells and neuroectodermal tumor cells, has recently been shown to be also effective against head and neck squamous carcinoma cells (HNSCC). In this study we investigated BetA in combination with cisplatin in squamous cell carcinoma cell lines of the tongue. SCC25 and SCC9 were treated with BetA and/or cisplatin. Cells were counted with an automated analyzing system. Caspase activation was determined using the M30 Cyto-Death ELISA, expression of the anti-apoptotic protein Mcl-1 by Western blot analysis. Visualization of apoptotic cells was achieved by immunohistochemistry. Synergistic cytotoxic effect and the induction of apoptosis under combined treatment was observed in SCC25 cells only after 24 or 48 h, whereas treatment of SCC25 cells for 72 h with BetA and cisplatin showed antagonism or subadditive effects. In SCC9 cells, antagonism occurred over an increase of dose and time during treatment. Furthermore, we could not demonstrate a significant alteration in the expression of the anti-apoptotic protein, Mcl-1. Our in vitro data demonstrate that BetA seems to be an unlikely candidate for combination with cisplatin in the treatment of head and neck cancer.

Changes in Mcl-1 expression in rectal cancer in relation to neo-adjuvant radiotherapy.

BACKGROUND: Expression of the antiapoptotic protein myeloid cell leukemia-1 (Mcl-1) may be disordered in malignancies of the rectum. High levels of Mcl-1 may correlate with unfavourable clinical outcome. AIM OF THE STUDY: The aim of the study was to determine the biologic significance and the prognostic value of the protein Mcl-1 in a group of patients with rectal cancer using immunohistochemical staining in archival specimens. PATIENTS AND METHODS: Expression of the Bcl-2 family member Mcl-1 was determined in 23 rectal malignancies. Half of the patients with rectal cancer were treated with preoperative short-term radiation therapy of 25 Gy followed by radical surgery; the other patients were treated just with radical surgery. Differences in Mcl-1 expression between irradiated and non-irradiated rectal cancer cells were analysed immunohistochemically, and Mcl-1 expression was correlated with overall survival. Induction of Mcl-1 expression by irradiation versus control in colorectal cancer cells was detected using Western blot. RESULTS: Mcl-1 was expressed at high levels in 35% of all specimens. Significantly stronger expression was detected in specimens of irradiated rectal cancer compared with non-irradiated tissues (p-value: 0.005). No association was seen between marker expression patterns and clinicopathological data of the respective patients. CONCLUSION: Our findings indicate that irradiated rectal cancer produces significantly higher levels of the antiapoptotic protein Mcl-1 than non-irradiated rectal carcinoma. The data also suggest that the high level of Mcl-1 was induced by the radiotherapy. As Mcl-1 is an antiapoptotic regulator, its over-expression in irradiated rectal cancer could constitute a detrimental development antagonizing the potential benefit of adjuvant radiotherapy. Further evaluation of the correlation between Mcl-1 expression and overall survival seems warranted.

Expression levels of Akt in nimesulide-treated squamous carcinoma cell lines of the head and neck.

Nimesulide, a selective cyclooxygenase-2 (COX-2) inhibitor, is known to induce apoptosis in various cell lines. So far, the molecular targets that account for this effect are unknown. Akt and extracellular-signal regulated kinase (ERK) are both important signaling molecules, which promote survival in different types of cancer, including head and neck cancer. The aim of our study was to describe the effect of treatment with nimesulide and ERK inhibitor PD 98059 on the expression patterns of Akt within the head and neck cancer cell lines SCC 9 and SCC 25. SCC 9 and SCC 25 cells were cultured in RPMI and treated with nimesulide and PD 98059. Protein expression levels were semi-quantified by Western blot analysis. Apoptosis was examined using the M30 antibody that binds to a caspase cleaved cytoskeletal protein for detection of early apoptosis in immunofluorescence studies. In both cell lines, nimesulide treatment induced apoptosis and resulted in a decrease of Akt expression. ERK inhibition had no effect on Akt expression, and combined application of both agents had the same effect as treatment with nimesulide alone. In conclusion, nimesulide induces apoptosis and promotes down-regulation of Akt-expression in squamous cell carcinoma cells, independently of ERK activity.