Multidisciplinary treatment of olfactory neuroblastoma: Patterns of failure and management of recurrence.

PURPOSE: Esthesioneuroblastoma is an uncommon malignancy of the head and neck for which there is no defined treatment protocol. The purpose of this study is to report our experience with the treatment and patterns of failure of this disease. METHODS AND MATERIALS: From 1994 to 2012, 37 previously unreported patients with esthesioneuroblastoma were evaluated, and 32 eventually treated for cure at 2 academic medical centers. All patients were staged with Kadish criteria. The mean and median follow-ups were 96.1 and 76.5 months respectively (range 6-240 months). RESULTS: The Kadish stage was A in 6 patients, B in 13 patients, and C in 13 patients. Four patients were initially treated with concurrent chemo-radiation therapy. Twenty-eight patients were treated with primary surgery. Two (2) underwent open medial maxillectomy and 26 underwent craniofacial resection (open - 17, endoscopic - 9). Three patients received curative surgical resection only. Seven patients failed either within the cranial axis or distantly, 6 of the 7 are dead of disease, 10-194 months following initial treatment. Six patients had isolated neck recurrences, 4/6 were salvaged with neck dissection and additional chemo-radiation and remain alive 30-194 months following initial treatment. Estimated overall survival rate at 10 years was 78% based on Kadish and T stages. CONCLUSION: In this retrospective analysis of 32 patients, Kadish stage C and stage T3/T4 tumors were associated with worse outcome. Total radiation dose of 60 Gy, margin status, patient age, were not found to have significant prognostic value.

The effect of residual hydrocarbons in soil following oil spillages on the growth of Zea mays plants.

Liquid hydrocarbon pipeline accidents, including leaks due to the illegal or unauthorized collection of petroleum from oil pipelines, are a widespread phenomenon that can lead to pollution that may negatively affect soil quality and plant growth. The aim of this study is to evaluate hydrocarbon uptake and accumulation in Zea mays plants grown on soil affected by spills of fossil fuels. The experiments were conducted in microcosm, mesocosm and field tests. The potential transfer of contaminants from soil to plant and their effects on plant growth were investigated. The results from both the laboratory and field experiments showed that the plants grew better in the uncontaminated soil than in the soil polluted by hydrocarbons. Despite their significantly lower aerial biomass, plants grown in contaminated soil did not show any significant differences in C > 12 concentration, either in shoots or roots, compared to the control plants. Thus, the decrease in plant yield might not be attributed to hydrocarbons accumulation in the plant tissues and may rather be due to a reduced soil fertility, which negatively affected plant growth. Under our experimental conditions, the hydrocarbons present in the contaminated soil were not absorbed by the plants and did not accumulate in plant tissue or in grains, thus avoiding the risk of them entering the food chain.

Heavy metal distribution between contaminated soil and Paulownia tomentosa, in a pilot-scale assisted phytoremediation study: influence of different complexing agents.

The distribution of Cd, Cu, Pb and Zn between a contaminated soil and the tree species Paulownia tomentosa was investigated in a pilot-scale assisted phytoremediation study. The influence of the addition of EDTA, tartrate and glutamate at 1, 5 and 10mM concentrations on metal accumulation by the plant and on metal mobilization in soil was evaluated. Root/shoot metal concentration ratios were in the range of 3-5 for Zn, 7-17 for Cu, 9-18 for Cd and 11-39 for Pb, depending on the type and concentration of complexing agent. A significant enhancement of metal uptake in response to complexing agent application was mainly obtained in roots for Pb (i.e. 359 mg kg(-1) for EDTA 10mM and 128 mg kg(-1) for the control), Cu (i.e. 594 mg kg(-1) for glutamate 10mM and 146 mg kg(-1) for the control) and, with the exception of glutamate, also for Zn (i.e. 670 mg kg(-1) for tartrate 10mM and 237 mg kg(-1) for the control). Despite its higher metal mobilization capacity, EDTA produced a metal accumulation in plants quite similar to those obtained with tartrate and glutamate. Consequently the concentration gradient between soil pore water and plant tissues does not seem to be the predominant mechanism for metal accumulation in Paulownia tomentosa and a role of the plant should be invoked in the selection of the chemical species taken up. Metal bioavailability in soil at the end of the experiment was higher in the trials treated with EDTA than in those treated with tartrate and glutamate, the latter not being significantly different from the control. These findings indicated the persistence of a leaching risk associated to the use of this chelator, while an increase of the environmental impact is not expected when glutamate and tartrate are applied.

Absorption of selenium by Lactuca sativa as affected by carboxymethylcellulose.

Several organic compounds of high molecular weight present in soil interact with selenium and may act as active binding agents affecting its availability in soil, and, consequently, selenium uptake by plants. This study is aimed at investigating the effects of polysaccharides on selenium speciation in soil and on selenium absorption by Lactuca sativa L. plants. Three-week-old seedlings were transplanted into pots filled with soil, and sodium selenite at rates of 1.5 and 5mgSekg(-1) of soil, or sodium selenate at a rate of 1.5mgSekg(-1) of soil were applied. Carboxymethylcellulose (CMC) was added to the soil at rates of 0, 3 and 30mgkg(-1) of soil. After 48 and 110d from transplanting plants were harvested, separated into root and shoot, and fresh and dry matter weights were recorded. Total selenium was determined in both soil and plant samples. A sequential extraction was used to investigate the different Se oxidation states and assess the availability of Se in soil after the final harvesting. Both selenite and selenate were absorbed by roots, but plants amended with Se(VI+) showed higher selenium concentration than plants amended with Se(IV+). Selenite appears to be less mobile than selenate both in soil and plants. The addition of carboxymethylcellulose to soil decreased the amount of selenium absorbed by plants. CMC interacted with Se, making it less mobile as evidenced by the increase in the insoluble fractions. The insoluble Se forms in soil may represent environmental Se sinks potentially available for plants if the substrate is re-used for subsequent growth cycles and selenium species are mobilized as a result of biological and chemical processes.

Mechanisms of immune suppression in patients with head and neck cancer: presence of CD34(+) cells which suppress immune functions within cancers that secrete granulocyte-macrophage colony-stimulating factor.

Production of granulocyte-macrophage colony-stimulating factor (GM-CSF) by murine tumors has been shown to induce immune suppressive cells having homology with GM progenitor cells. The purpose of this study was to determine if human head and neck cancers secrete GM-CSF, if this is associated with an intratumoral presence of similar cells expressing the hematopoietic progenitor cell antigen CD34, and if such CD34(+) cells suppress functions of intratumoral T cells. This was evaluated with fresh head and neck cancers, and in some instances regional lymph nodes and control tissue. Ten of the 14 squamous cell carcinomas (SCCs) studied secreted greater than 5 ng GM-CSF/g tissue. GM-CSF was not secreted in significant levels by either the other cancer types or by control normal muscle. Each of the high GM-CSF-secreting SCCs, but none of the cancers that did not secrete GM-CSF, contained cells expressing the hematopoietic progenitor cell antigen CD34 that had the capacity to grow into colonies in soft agar. Available regional lymph nodes from patients with high GM-CSF-producing cancers also contained CD34(+) cells. Depletion of CD34(+) cells from dissociated cancers increased interleukin 2 secretion by the intratumoral lymphocytes while addition of the CD34(+) cells to dissociated cancers reduced interleukin 2 production, indicating that the presence of CD34(+) cells within GM-CSF-producing head and neck SCCs results in suppressed functional competence of lymphocytes within the SCCs. These results show that GM-CSF-secreting SCCs contain cells expressing the hematopoietic antigen CD34 which are inhibitory to the capacity of lymphocytes within the SCCs to secrete interleukin 2.

Effect of metal reconstruction plates on cobalt-60 dose distribution: a predictive formula and clinical implications.

PURPOSE: We sought to create a predictive formula for the dose perturbations caused by head and neck reconstruction plates in the delivery of postoperative radiotherapy with 60Co beams. MATERIALS AND METHODS: The dose perturbation effects of Vitallium and Titanium reconstruction plates and flat metal plates of aluminum (13Al), stainless steel (26Fe), tin (50Sn) and lead (82Pb) irradiated with a 60Co beam were measured in polystyrene phantoms using a film dosimetry system. We then used these results to create formulas to predict the effect of a metal reconstruction plate dependent upon its effective atomic number. RESULTS: Percentage dose increases secondary to back scattering were 10% at 1 mm in front of the Vitallium plate and 40% at the plate while the percentage dose decrease was 29% at the plate and 10% 1 mm behind the plate. For the Titanium plate, the percentage dose increase was 5% at 1 mm in front the plate and 25% at the plate while the percentage dose decrease was 20% at the plate and 5% 1 mm behind the plate. For flat plates the percentage dose increases and decreases, respectively, at the plate surfaces were: 13Al (8%, 6%), 26Fe (35%, 16%), 50Sn (60%, 24%), and 82Pb (85%, 13%). A second order polynomial predicting the back scatter and shadowing effects was created, Y = a + bZ + cZ2, where Z is the effective atomic number of the plate while a, b, and c are the following constants: for back scatter a = 0.854 +/- 0.082, b = 0.0212 +/- 0.0044, c = -0.00011 +/- 0.00004 and for shadowing a = 1.108 +/- 0.021, b = -0.0141 +/- 0.0011, c = 0.00014 +/- 0.00001. CONCLUSIONS: It is possible to predict the effect of a metal reconstruction plate upon the delivered postoperative radiotherapy dose. The dose perturbations around the plate only exist for a few millimeters, but this is substantially greater than the thickness of a normal tissue or tumor cell. Perhaps a coating of a low effective atomic number, biologically inert, substance might allow for greater dose homogeneity and decrease the risks of plate failure or tumor recurrence.

Human squamous cell carcinomas of the head and neck chemoattract immune suppressive CD34(+) progenitor cells.

CD34(+) progenitor cells have previously been shown to be mobilized in patients with squamous cell carcinoma of the head and neck (HNSCC). The present study showed that these CD34(+) cells inhibit the capacity of intratumoral lymphoid cells to become activated in response to stimulation through the TCR/CD3 complex. The mechanisms that could lead to the accumulation of CD34(+) cells within the tumor tissue were assessed. This was accomplished through in vitro studies that determined if HNSCC produce soluble factors that chemoattract CD34(+) cells. The migration of cord blood CD34(+) cells, which were used as a readily available source of progenitor cells, was stimulated by products derived from HNSCC explants and primary HNSCC cultures. This stimulated migration was due to chemotaxis because it was dependent on an increasing gradient of HNSCC-derived products. CD34(+) cells that were isolated from the peripheral blood of HNSCC patients were similarly chemoattracted to the HNSCC-derived products. The majority of the chemotactic activity produced by HNSCC could be attributed to vascular endothelial cell growth factor (VEGF). These studies indicate that HNSCC can chemoattract immune inhibitory CD34(+) progenitor cells through their production of VEGF.

Bi-directional stimulation of adherence to extracellular matrix components by human head and neck squamous carcinoma cells and endothelial cells.

Head and neck squamous cell carcinoma (HNSCC) cultures were established from two patients to determine if cancer and endothelial cells bi-directionally regulate their adherence to extracellular matrix components (ECM), an important process for tumor vascularization and metastasis. Soluble products from endothelial cells transiently enhanced adherence by HNSCC to ECM and increased surface levels of beta 1 and beta 4 integrins, although not beta 3. HNSCC products enhanced endothelial cell adherence to fibronectin and laminin, and beta 1 and beta 4 expression. These data show bi-directional enhancement of adherence to ECM and integrin expression among endothelial and tumor cells, which may facilitate metastasis and neovascularization.

Malignant neoplasms of the hard palate and upper alveolar ridge.

Malignant neoplasms of the hard palate and upper alveolar ridge can arise from the epithelial (mucosal), salivary, hematopoietic, or mesenchymal tissues in this region. Unlike other regions in the head and neck, only about two thirds of malignant neoplasms of the hard palate are squamous cell carcinomas, and few large series have reported treatment protocols and outcomes for patients with these tumors. In this review, we will describe our series of 51 patients with malignant neoplasms of the hard palate and upper alveolar ridge. This review will emphasize the surgical treatment program and rehabilitative techniques developed at the University of Pittsburgh.

Identifying obstructive sleep apnea in patients presenting for laser-assisted uvulopalatoplasty.

The authors report on a series of 850 patients with snoring who were evaluated for laser-assisted uvulopalatoplasty (LAUP). Stepwise multivariate linear regression was employed to correlate patient symptoms and characteristics to the respiratory disturbance index (RDI). Body mass index, falling asleep while driving, snoring every night, and stopping breathing during sleep were found to correlate strongly with an increasing RDI (variance of 25%). Logistic multivariate linear regression analysis was used to predict the outcome of apnea (RDI>10). This model selected all of the above variables, as well as age, male sex, and the total number of symptoms, as being strong predictors of apnea. A receiver operating characteristic curve was used to describe the ability of this model to predict apnea. The authors conclude that otolaryngologists play an important role in the evaluation of OSAS, especially when a snoring patient may undergo LAUP, and they present an algorithm for the evaluation of such a patient. The authors believe that the clinical assessment, including a thorough history and a complete physical examination, remains extremely important in this evaluation. At present, the authors strongly recommend referral for a PSG if there is any suspicion of OSAS.

Neutropenic enterocolitis. A new complication of head and neck cancer chemotherapy.

Neutropenic enterocolitis is a recognized complication of immunosuppression or chemotherapy for leukemia. It presents as severe abdominal pain and tenderness, fever, and diarrhea associated with granulocytopenia. Gastrointestinal symptoms associated with chemotherapy for head and neck neoplasms include nausea and emesis, but not acute abdominal distress. We present, to our knowledge, the first case of neutropenic enterocolitis in a patient receiving cisplatin and fluorouracil chemotherapy for metastatic head and neck cancer.

In vitro urokinase type plasminogen activator levels and total plasminogen activator activity in squamous cell carcinomas of the head and neck.

OBJECTIVE: Determine total plasminogen activator (PA) activity and urokinase-type plasminogen activator (u-PA) levels in cell-free supernatants derived from primary and metastatic squamous cell carcinoma of the head and neck. DESIGN: Plasminogen activator activity was measured by spectrophotometric assay with chromogenic substrate Val-Leu-Lys-para-nitroanilide. Urokinase-type plasminogen activator levels were measured with enzyme-linked immunosorbent assay technique. RESULTS: Fourteen established squamous cell carcinoma lines from patients with head and neck cancer were assayed for both total PA activity and u-PA levels at 24 to 48 hours of incubation. Compared with control and fibroblast-conditioned media, cell lines established from squamous cell carcinoma of the head and neck had significantly (P < .005) higher levels of both total PA activity and u-PA levels. Linear regression analysis showed a positive correlation (r = .65, P = .007) between total PA activity and u-PA levels. CONCLUSIONS: Squamous cell carcinomas of the head and neck are able to activate plasminogen and produce u-PA in vitro. The production of PA by squamous cell carcinomas of the head and neck may play an important role in the biology of invasion and metastasis.

The effect of postoperative radiation therapy on pharyngoesophageal reconstruction with free jejunal interposition.

Free tissue transfer of a jejunal segment was undertaken for laryngopharyngoesophageal reconstruction in 20 patients who received postoperative irradiation therapy. Treatment consisted of 1.8- to 2-Gy-fractions, the average total dose was 55.57 Gy (range, 40 to 66 Gy). Anastomotic strictures (six) were encountered early in the series and associated with stapled anastomoses. Hand-sewing the jejunoesophagostomy eliminated the problem. Enteric cutaneous fistula, bowel necrosis, and hemorrhagic enteritis were not observed. We conclude that the application of postoperative irradiation therapy to patients requiring jejunal interposition grafts is feasible.

Malignant craniopharyngioma.

Craniopharyngiomas are histologically and cytologically benign epithelial tumors of the central nervous system that may be locally aggressive and tend to recur after excision. Malignant change in craniopharyngiomas is extremely rare; we found only 4 such reports in the literature. In this report, we describe a case of squamous cell carcinoma arising in a previously benign craniopharyngioma in a 42-year-old woman. The patient was diagnosed with craniopharyngioma in 1982; during the subsequent 15 years she experienced 7 tumor recurrences, for which surgical resections and 3 courses of radiotherapy were performed. In 1998, the tumor recurred with involvement of the nasal cavity and sphenoid and ethmoid sinuses. Histologic evaluation revealed foci of typical adamantinomatous craniopharyngioma associated with a moderately differentiated squamous cell carcinoma. The transition of typical craniopharyngioma to squamous cell carcinoma was well demonstrated, suggesting that carcinoma arose from the underlying craniopharyngioma. Radiation may have been a contributing factor to carcinogenesis in this case.

Primary malignant melanoma of the larynx.

Primary malignant melanoma of the larynx is a rare clinical entity. Only 53 cases have been reported in the medical literature to date. This report describes a case of primary malignant melanoma arising in the larynx and diagnosed by histologic examination of an excisional biopsy specimen. The patient was a 53-year-old man with a history of smoking and hoarseness. There was no clinical evidence of other primary malignant melanocytic lesions. Microscopically, the tumor consisted of polygonal-epithelioid cells admixed with more elongated, spindle-shaped cells. The majority of the cells demonstrated dark brown cytoplasmic and nuclear melanin. Marked pleomorphism and abnormal mitoses were also identified. Despite significant ulceration and disruption of the epithelium, in situ malignant melanocytes were recognized within the remaining portion of the epithelium. Immunohistochemical studies were positive for S100, HMB-45, and vimentin, while cytokeratin and iron stains were negative. Based on the clinical and histologic findings, a diagnosis of primary malignant melanoma of the larynx was established.

Identification of the asexual state of Rhizopus species on histologic tissue sections in a patient with rhinocerebral mucormycosis.

Mucormycosis is an infection caused by a group of fungi in the order Mucorales in the phylum Zygomycota. The most well-known form of this disease is rhinocerebral mucormycosis, which usually develops in diabetic or immunocompromised patients. The fungal hyphal elements are easily detected in biopsy specimens by direct or histologic examination. However, the confirmatory identification of the genus or species requires culture of the specimen. This article presents a case of rhinocerebral mucormycosis in which presumptive identification of the genus was made without microbiologic cultures and was based on the extraordinarily rare appearance of fungal sporangia and sporangiospores in histologic tissue sections. Identification of these structures allowed an early and accurate diagnosis of rhinocerebral invasive mucormycosis.

Patterns of spread in recurrent head and neck squamous cell carcinoma.

OBJECTIVE: To examine the pattern of spread regarding recurrent disease in primary head and neck squamous cell carcinoma. STUDY DESIGN AND SETTING: A retrospective study reviewed 128 patients who underwent primary tumor resection and postoperative radiation and/or chemoradiation for squamous cell carcinoma at Loyola University Medical Center from July 1993 to August 1998. Patterns of spread of recurrent disease were grouped according to site of recurrence and compared with the histopathology. RESULTS: Of 128 patients, 40 (32%) had recurrent disease, 22 (17%) died without disease, and 66 (51%) are disease free. Although the recurrences in patients who were N0 were primarily local-regional (8/11), the majority of recurrences in patients that were N+ with extracapsular nodal spread involved distant sites (18/24); 17/18 involved metastasis to the lung. SIGNIFICANCE: This study gives the first report at our institution of patterns of spread in recurrent head and neck squamous cell cancer and compares these patterns within subgroups of patients based on the extent of neck disease at the time of primary surgical resection. CONCLUSION: Not only was there a higher rate of recurrent disease in patients with extracapsular nodal spread, there was a much higher involvement of distant metastatic sites as opposed to local-regional recurrence more often seen with the N0 neck. The most common site of distant metastasis was the lung.

Extracranial lower cranial nerve sheath tumors.

OBJECTIVE: The purpose of this article is to review the clinicoradiographic features of lower cranial nerve sheath tumors and to outline surgical approaches that allow the safe and complete resection of these lesions. METHODS: Thirteen patients with lower cranial nerve sheath tumors of the infratemporal fossa were surgically treated between 7/88 and 10/99. A retrospective chart analysis provided details pertaining to clinical manifestations, radiographic assessment, intraoperative findings, tumor histology, and postoperative results. RESULTS: The most common presenting symptoms were neck pressure and voice change while submucosal palatal fullness and vocal cord paralysis were the most common presenting signs. All tumors were removed via lateral skull base approaches and the most common postoperative sequelae was dysphasia. CONCLUSION: Lower cranial nerve sheath tumors of the infratemporal fossa usually reach considerable size before diagnosis because of a naturally slow growth rate in this relatively silent location. The safe surgical removal of these tumors, based on superior control of the internal carotid artery, can be achieved through the use of contemporary lateral skull base techniques.

Protein phosphatases 1 and 2A maintain endothelial cells in a resting state, limiting the motility that is needed for the morphogenic process of angiogenesis.

Angiogenesis that is induced by cancers, including those of the head and neck, requires endothelial cells to shift from a nonmotile resting state to an increased level of motility. Using a human microvascular endothelial cell line, this study shows the importance of the serine/threonine protein phosphatases 1 (PP1) and 2A (PP2A) in restricting endothelial cell motility. Treatment of endothelial cells with increasing concentrations of the PP1 and PP2A inhibitor okadaic acid resulted in cell rounding and increased motility, which was accompanied by cytoskeletal disorganization involving a loss of filamentous beta-tubulin and F-actin. These effects occurred at okadaic acid levels that selectively inhibit PP2A and became more prominent with higher levels that inhibit both PP2A and PP1. This study shows the importance of PP1 and PP2A in maintaining cytoskeletal organization, thereby limiting endothelial cell motility, and suggests that pharmacologic approaches to enhance PP1 and PP2A activities may be useful in preventing key events of the angiogenic process.

Increased levels of immune inhibitory CD34+ progenitor cells in the peripheral blood of patients with node positive head and neck squamous cell carcinomas and the ability of these CD34+ cells to differentiate into immune stimulatory dendritic cells.

OBJECTIVES: This study determined whether mobilization of immune inhibitory CD34+ cells by head and neck squamous cell carcinomas (HNSCC) is most prominent in patients who are node positive and whether these CD34+ cells could differentiate into immune stimulatory dendritic cells. STUDY DESIGN AND SETTING: Peripheral blood from patients with head and neck cancer was used to measure the frequency of CD34+ cells and their capacity to differentiate into immune stimulatory dendritic cells. RESULTS: This study demonstrated that increased CD34+ cell levels were most prominent in patients who were node positive and patients with recurrent disease. These CD34+ cells differentiated into dendritic cells that were able to present tetanus toxoid to autologous T-cells. CONCLUSIONS: Immune suppressive CD34+ cells that are prominent in patients with HNSCC who are node positive are able to develop into immune stimulatory dendritic cells. SIGNIFICANCE: Differentiation of tumor-mobilized CD34+ cells into dendritic cells may be an immunotherapeutic approach to stimulate antitumor reactivity.