Relationship of glutathione and glutathione-S-transferase to cisplatin sensitivity in human head and neck squamous carcinoma cell lines

Factors controlling glutathione metabolism may govern sensitivity to chemotherapeutic agents such as cisplatin. Using a battery of cell lines derived from previously untreated head and neck squamous cell carcinomas, we examined cisplatin resistance relative to (a) glutathione-S-transferase (GST)-pi gene amplification and expression, (b) basal and inducible GST-total and GST-pi enzymatic activity, and (c) cellular levels of reduced glutathione (GSH). Using Southern blot analysis and northern blot hybridization, no relationship between GST-pi gene amplification, mRNA expression and drug resistance could be identified. Despite the capacity of cisplatin to induce GST enzyme activity, the response was variable and unrelated to cisplatin responsiveness. However, an inverse relationship between GSH levels and cisplatin sensitivity was identified. To further clarify these effects, cells were treated with S-allyl cysteine (SAC), a thioallyl derivative isolated from garlic (Allium sativum), which altered cellular GSH in a biphasic manner. Pretreatment with SAC to lower cellular GSH levels followed by exposure to cisplatin significantly enhanced the cytotoxic effects of cisplatin, while SAC alone had no effect on cell growth.

Swallowing of bolus types by postsurgical head and neck cancer patients

BACKGROUND

Clinically, head and neck cancer patients with anterior resections have better postoperative outcomes than do patients with posterior resections.

METHODS

Videofluoroscopy was used to study the swallowing characteristics in postsurgery head and neck cancer patients and normal controls. Most patients received post-operative radiotherapy and chemotherapy, and no cancer recurrence was noted at the time of study, 4-8 months posttreatment. Bolus types included: 3 mL and 10 mL liquid barium, barium paste, and barium-coated cookie. Temporal measurements and a count of the number of swallows required to ingest each material were made from the videotaped data. Statistical analysis using an unbalanced univariate repeated measures ANOVA was performed.

RESULTS

The major differences were found between bolus types, with few differences noted between surgical groups (anterior vs posterior resections) and normal controls. Patients took longer to ingest viscous material, accomplishing this by multiple piecemeal and clearing swallows. Coordination of mastication and swallowing of the cookie was different between normal and patient groups.

CONCLUSIONS

Patients who are able to swallow reasonably well postoperatively maintain normal coordination and timing of swallowing activity and do not vary these parameters to compensate for structural inadequacy. Instead, repeated swallows are used.

[Nursing research on epidural analgesia for chronic cancer pain]

A retrospective study was made on 9 cases with pains due to advanced head and neck cancer, attended to at the Pain Clinic of the National Institute of Oncology and Radiobiology between 1988 and 1991. An epidural catheter was implanted to these patients at the CNS level for the administration of a morphine solution. 7 patients (77.8%) showed total pain relief; and 2 cases showed easily-controlled slight pains. The most frequent complications were; fever (3 cases) and alterations of the level of consciousness (2 cases). No infections were reported. The importance of an adequate preparation of the patient and a strict follow up, where oncology nursing personnel play an important role, is pointed out.

A four-drug pain regimen for head and neck cancers

Twenty patients with end-stage head and neck cancer, unresponsive to either acetaminophen with codeine or oxycodone hydrochloride, were placed on a four-drug analgesic regimen consisting of methadone hydrochloride, Trilisate or acetaminophen, a tricyclic antidepressant, and, in most cases, hydroxyzine. All drugs could be delivered through a feeding tube, making this regimen appropriate for dysphagic patients. The efficacy of this nonparenteral regimen was assessed by structured pretreatment and posttreatment interviews that addressed pain intensity, activity, and sleep levels. All of the patients showed improvement in their pain levels and 16 of the 20 had a > or = 50% improvement in all of their pain ratings (P < .01) that persisted until death (2 to 10 months later). Excellent results and ease of administration make this regimen a good choice for analgesia in terminal patients.

[Multidisciplinary treatment for organ/function preservation in head and neck cancer]

Neo-adjuvant chemotherapy (NAC) improved quality of life for surviving patients by providing effective organ/function preservation. Regrettably, however, many randomized trials did not show that NAC significantly improved survival. Many design limitations of these trials make it impossible to draw definitive conclusion. So neo-adjuvant trials should investigate the issue of optimal number of chemotherapy cycles on response (clinical/histologic) and on survival. Future work also should study the integration of biologic response modifiers, differentiation agents, other cytotoxic agents and irradiation into primary therapy. Concomitant chemoradiotherapy is the only approach in this category that has shown potential by increasing survival in randomized studies. This survival benefit has appeared in trials in both resectable and unresectable head and neck squamous cell carcinoma. Recent data from numerous phase II study trials supported the promise of concurrent cisplatin (including carboplatin) and radiotherapy. All the positive single-agent concomitant trials used suboptimal doses of active drugs like BLM, MTX etc, and full doses of relatively inactive drugs like MMC. This indicates that chemotherapy enhances radiotherapy. Recent date from numerous phase II trials now support the promise of concurrent cisplatin (or carboplatin)/radiotherapy. The lack of overlapping toxicities allows optimal administration of both modalities. Concomitant multi-agent chemoradiotherapy began as a result of positive studies with concomitant single-agent chemoradiotherapy. But, this combined therapy increased acute toxicity. Nevertheless, early results from the randomized trials are encouraging, with survival favoring the concomitant arm. The future trials will be required more patients, longer follow-ups and careful assessments of toxicity and quality of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of life, appetite, and weight change in patients receiving dose-intensive chemotherapy

Quality of life was assessed by self-report questionnaires in 30 patients receiving dose-intensive chemotherapy for either non-small-cell lung cancer (20 patients) or recurrent head and neck cancer (10 patients). Megestrol acetate was given daily to try to improve appetite and prevent the weight loss usually associated with this chemotherapy. Appetite did not change significantly overall during the first 4 weeks of chemotherapy, but it did improve in those patients still receiving chemotherapy at 8 weeks. Changes in global quality of life were significantly correlated with changes in appetite, fatigue, energy level, and physical function. Thus, these parameters may have more relevance to patients' perceptions of quality of life than does weight change, and should be used more frequently as endpoints in studies of supportive care and palliative treatment of patients with cancer.

Biology and chemoprevention of head and neck cancer

Head and neck cancer remains a common cause of mortality and morbidity in the United States and throughout the world. In spite of advances in the management of patients with advanced disease, overall survival in this group remains poor. Furthermore, although cancer mortality is lower in patients with early-stage disease, treatment results in significant morbidity, and these patients also face the risk of developing a second primary tumor. Chemoprevention is an innovative approach to decrease overall cancer morbidity and mortality using substances that are capable of preventing cancer progression. Head and neck cancer is an excellent model for chemoprevention, as its biology is consistent with the two concepts important for the development of chemoprevention strategies: field cancerization and multistep carcinogenesis. Several classes of compounds have been evaluated in chemoprevention trials. The most frequently studied agents, the retinoids, were found frequently to induce remissions in patients with oral leukoplakia. Furthermore, retinoids prevented progression to malignancy in one randomized maintenance study. Other agents, including beta-carotene and vitamin E, have been found also to have activity in the management of oral leukoplakia. However, the clinical role of chemopreventive agents in reducing cancer mortality remains to be defined. Two studies, one in head and neck cancer and one in lung cancer, have shown the ability of retinoids to prevent the development of second primary tumors. Current large randomized trials are defining the effectiveness of these agents in reducing the mortality of aerodigestive tract tumors in individuals at high risk.

Symptom control problems in an Indian hospice

Symptom control is the essence of palliative care but is not without problems, especially in the difficult socio-economic conditions of a developing country. We present our experience with over 2000 hospice admissions over six years in India's first hospice, to highlight our problems and the measures we have taken to solve them. The prevalent habit of tobacco smoking and chewing in India gives rise to a high incidence of head and neck cancers which form 50% of our admissions. Another 24% is formed by breast and gynaecological cancers. The difficult symptoms in head and neck cancers are pain, dysphagia, fungation and trismus. Almost 25% of our head and neck cancers have feeding tubes, which we feel are justified and most useful for medication and basic nutrition. Difficult problems in gynaecological cancers are pain, chronic blood loss, ulcerations and fistulae. The inadequate or sporadic availability of oral and injectable morphine adds to our problems in pain control. Non-compliance of patients to take adequate medications and the resistance from relatives make it sometimes difficult to achieve optimum symptom control. India has many systems of alternate and unorthodox medicine. We find that these are best tried outside the hospice unless they are in fully-studied clinical trials. In the end there is always the difficult choice of either remaining in the hospice for optimal symptom control or going back to their homes, where this may not be available.

Vascular grafts in head and neck reconstructive surgery

The best management of advanced head and neck tumors invading the carotid artery utilizes a collaborative, anticipatory approach. Preoperative characterization of the anatomy and extent of tumor involvement, coupled with the physiologic assessment of the cerebrovascular circulation through the variety of adjunctive studies, facilitates operative planning. Careful preoperative evaluation allows the surgeon to make the most informed decision regarding extracranial carotid artery reconstruction, should carotid artery resection be required for adequate tumor removal. When the preoperative evaluation indicates that adequate cerebral perfusion or collateral reserve will not be maintained with carotid artery occlusion, carotid artery reconstruction needs to accompany any resection of this vessel. Autogenous saphenous vein remains the graft conduit of choice, but prosthetic materials may be used. Graft patency and healing require appropriate concomitant soft-tissue coverage of any overlying mucosal or cutaneous defects.

Expression of syndecan-1 is induced by differentiation and suppressed by malignant transformation of human keratinocytes

Syndecans comprise a family of integral membrane proteoglycans that presumably participate in cell-matrix interactions and the modulation of growth factor response. Expression of syndecan-1, a cell surface proteoglycan that binds basic fibroblast growth factor (bFGF) and extracellular matrix components, was studied in cultured human keratinocytes from the oral mucosa and in tissue sections derived from various epithelia and carcinomas of the head and neck. For the study, polyclonal antibodies were raised against the core protein of human syndecan-1. The affinity-purified antibody (designated anti-P117) was shown to react specifically with syndecan-1. Abundant expression of syndecan-1 was detected in frozen sections of various stratified epithelia as well as in cultured keratinocytes. Keratinocytes located in the spinous cell layers showed intense immunoreactivity for syndecan-1, while basal cells stained rather weakly, suggesting that the expression of syndecan-1 could be stimulated during the differentiation of keratinocytes. Cultured human keratinocytes were induced to terminally differentiate by increasing the extracellular calcium concentration of the medium. Parallel to the induction of involucrin expression, the mRNA levels of syndecan-1 were found to increase, suggesting that syndecan-1 is indeed induced during keratinocyte differentiation. The molecular mass and glycosaminoglycan composition of syndecan-1 did not change markedly during calcium-induced differentiation. Malignant transformation was associated with marked reduction of syndecan-1 expression, based on the immunoreactivity of anti-P117 in frozen sections from squamous cell carcinomas (SCCs) of the head and neck.(ABSTRACT TRUNCATED AT 250 WORDS)

[Detection of somatostatin receptors in tumors in the area of the head and neck and their clinical importance]

The development of a radiolabelled somatostatin analogue Indium-111-Pentetreotide makes the detection of somatostatin receptor-bearing tumours by scintigraphic techniques possible. The existence of high-affinity binding sites for somatostatin has been described previously for most endocrine active tumours of the gastroenteropancreatic system (GEP), malignant lymphomas, small cell lung carcinomas, a subgroup of breast tumours and several types of neuroendocrine related human tumours. Using this new diagnostic tool we investigated some head and neck tumours of neuroendocrine origin (carcinoid of larynx, Merkel cell carcinoma, paragangliomas) with the newly developed radiolabelled somatostatin analogue Indium-111-Pentetreotide whether in vivo visualisation of somatostatin receptors might be possible. In cases not accessible for surgery but with a positive receptor status we started a specific therapy with the somatostatin analogue octreotide. The preliminary results suggest that this new isotopic scanning technique in a diagnostic tool and a predictive method for an effective therapy of those head and neck tumours which revealed highly specifically a positive receptor status. The therapeutical results using the somatostatin analogue octreotide indicate that this new concept is an ideal therapeutic strategy for those neuroendocrine head and neck tumours which cannot be controlled by surgical procedures.

Hemodynamic changes in the head and neck after ligation of the unilateral carotid arteries: a study using color Doppler imaging

For evaluation of the hemodynamics of the collateral circulation to the ligated external carotid artery (ECA) region, we measured the blood flow direction and volume in branches of the ECA in patients with unilateral carotid artery ligation before and during digital suppression of the common carotid artery (CCA) on the ligated and nonligated sides with color Doppler imaging and angiography. The main collateral pathway to the ligated ECA region was the ipsilateral occipital artery through Richter's anastomosis from the vertebral artery in the case of unilateral ECA ligation, and was the contralateral carotid artery in the case of unilateral CCA, ECA, and internal carotid artery resection. The superior and inferior labial arteries were important as the collateral pathway from the contralateral ECA.

Comparison of piroxicam and acetylsalicylic acid for pain in head and neck cancers: a double-blind study

This double-blind, placebo controlled study compared the analgesic efficacy of piroxicam with acetylsalicylic acid (ASA) in patients having continuous pain with advanced head and neck cancers. They were randomly divided into two groups of 25 patients each; 36 of these 50 patients completed the study. After four days of treatment, there was a significant reduction in a modified numerical rating scale (NRS) of pain in the piroxicam group as well as in the ASA group. There was a concomitant increase in the hours of sleep in the piroxicam group and in the ASA group. The decrease in NRS and the increase in sleeping hours was not statistically significantly different between the two groups. Patients receiving piroxicam had a low incidence of upper gastrointestinal side-effects compared with those receiving ASA. The results of this study suggest that piroxicam can be used as first line treatment in place of ASA in patients with head and neck cancers suffering from moderate to severe pain. The advantages are less frequent dosing, better patient compliance and few side-effects.

Intracranial pressure changes during bilateral radical neck dissections

The management of the contralateral neck in patients with head and neck cancer who have undergone a radical neck dissection (RND) is controversial. A number of these patients will require a second RND. Sacrifice of both internal jugular veins (IJV) has been felt to lead to increased intracranial pressure (ICP) with subsequent neurologic sequelae. From 1987 to 1991 four patients had staged bilateral RNDs at the West Virginia University. In these patients a subarachnoid bolt was placed to directly monitor ICP. Jugular bulb, mean arterial, pulmonary artery, and central venous pressures were monitored. Electroencephalographic (EEG) monitoring was also performed. All patients demonstrated elevations in ICP immediately on head rotation. Further marked elevations were noted immediately after IJV ligation with a maximum peak at 30 minutes. Pressure levels of greater than 40 mm Hg were observed in three of four patients. Systemic hypertension was observed in response to elevated ICP (Cushing's reflex). All patients studied recovered from surgery without significant sequelae. Within 24 hours the ICP had returned to normal in all patients. Three patients required intraoperative intervention to lower their ICP. We demonstrate that even in a staged second RND there are significant rises in ICP. These are to a level that suggests emergency medical intervention is required. We feel that when the second IJV is sacrificed an increase in ICP should be anticipated, monitored, and treated accordingly.

Ionized serum calcium levels following combined treatment for cancer of the head and neck

Thyroid function may be reduced after treatment of cancer of the head and neck, and hypothyroidism is much more common after combination therapy. Whether hypoparathyroidism and subsequent hypocalcemia also occur after such treatment is unknown. Few related studies have been published in which changes in total serum calcium have been studied after cancer treatment with radioactive iodine or external radiation. Twenty-two disease-free head and neck cancer patients were studied, 1 to 3 years after multimodal treatment, to determine if changes in serum ionized calcium levels or thyroid function were present. Our results suggest that parathyroid function, as represented by ionized calcium levels remains normal after multimodality (surgery, radiation and/or chemotherapy) combined treatment.

The effect of surgical intervention for head and neck cancer on whole salivary flow: a pilot study

For many patients, rehabilitation and quality of life after treatment of head and neck cancer are issues that confront both them and their physicians. Various levels of xerostomia are often reported as one of the side effects of treatment. This study evaluated the effects of surgical intervention (alone) that involve major salivary glands on whole salivary flow. Five subjects with head and neck cancer who lost a submandibular gland at surgery were evaluated before and after treatment to determine resting and stimulated whole salivary flow rates. Three subjects demonstrated a decrease in resting and three a decrease in stimulated flow rates compared with pretreatment levels. Two subjects rebounded to near or above presurgery flow rates. Although a trend was identified for a decrease in resting and stimulated flow rates, the sample size was too small to statistically validate this trend. The decreases in flow rates recorded at the last test were of insufficient magnitude to elicit a complaint of xerostomia.

The effect of an acute fast on human head and neck carcinoma xenograft. Growth effects on an 'isolated tumor vascular pedicle' in the nude rat

The effects of nutritional state on tumor growth are poorly understood. Most animal studies to date suggest an inhibitory effect of nutritional depletion on tumor growth and a stimulatory effect of nutritional repletion or overfeeding. We have modified an "isolated tumor vascular pedicle" model in the nude rat to study the growth and tumor-specific nutrient utilization of the FaDu cell line of human hypopharyngeal squamous carcinoma. Two weeks after tumor implantation, rats were randomized to either a fed or fasted study group for an additional 7 days. Tumors were significantly larger in the fasted group (0.602 +/- 0.215 g vs 0.362 +/- 0.104 g; P < .02). Whole blood nutrient gradients were determined across the tumor and systemic tissues in both groups. The nutrient gradients across these tissues were significantly different in the fed animals and approached statistical significance in the fasted animals. In addition, there appeared to be a greater utilization of glucose in the fed group (-0.401 +/- 0.904 mmol/L vs -0.298 +/- 0.589 mmol/L), while there was a greater production of lactate in the fasted group (0.798 +/- 0.518 mmol/L vs 0.046 +/- 0.639 mmol/L; P < .1). Flow cytometric analysis revealed no difference in the percentage of cells in any particular stage of the cell cycle between the two groups. These results suggest that the maintenance of adequate body weight may be beneficial not only to the nutrition of the cachectic tumor-bearing host but may also prevent a ketotic state or state of lipolysis that may be preferential to the tumor.

The effects of radiation therapy on salivary function in patients with head and neck cancer

Eighty nasopharyngeal carcinoma (NPC) patients and another eighty head and neck cancer (HNC, non-NPC) patients were enrolled as two experimental groups to study their salivary function by using Tc99m sialography. Twenty healthy subjects were also employed as a control group. The patients received an intravenous injection of 4 mCi of 99mTc-pertechnetate (Tc-99mO4-). The data were collected at a rate of 1 frame per 15 seconds for the total time of 30 minutes, and the patients received stimulations for salivary secretion by ingesting 0.5cc of lemon juice 15 min after the start of data acquisition. The salivary function was measured on Pre-RT (radiation therapy), During-RT and Post-RT periods. The results showed no statistical significance for maximum uptake (%) and excretion rate (%) between Control and Pre-RT group on parotid or submandibular glands function. This was the same in the age groups (age below 40 and age above 40) and sex groups. The NPC group had a decreasing maximum uptake (%) 3 months after RT on both parotid glands and submandibular glands, whereas the HNC group showed no obvious difference. The excretion rate (%) of both parotid and submandibular glands reached its lowest mark after 3-6 months in both the NPC and HNC groups and then started to recover progressively. For NPC patients, the radiation damage to the parotid glands was greater than to the submandibular glands, whereas the effect was reversed on HNC patients. It is important that the radiation therapist should preserve salivary function whenever possible.

[Cyst in the second branchial cleft: review of 3 cases]

Three cases of cysts arising from the second branchial cleft are described. They were completely removed. Histopathological examination revealed that cysts were lined with columnar (respiratory type) epithelium. The authors take this opportunity to review the underlying pathogenic mechanism, the clinical manifestations and therapeutic procedures.

Radiation therapy and pain in patients with head and neck cancer

Pain is commonly present at the time of diagnosis of head and neck cancer. Pain occurs in all patients treated for oropharyngeal cancer. This study examined the prevalence, severity and characteristics of pain in patients treated with radiation therapy for cancer involving the head and neck and oral cavity. Pain increases throughout the course of radiation and persists following treatment and in some patients continues for 6-12 months. Pain frequently requires systemic analgesics in addition to oral rinses.

[Importance of increased interstitial fluid pressure in therapy of malignant tumors of the head-neck area]

Animal experiments showed that elevated interstitial fluid pressure (IFP) is associated with poor blood supply and inadequate supply of drugs to solid tumours. IFP is approximately 0 mmHg in most normal tissues. Up to now there have been only few studies showing elevated interstitial pressure in human tumours in situ: Mammary carcinomas, cervical carcinomas and colorectal cancers have an elevated IFP. We measured IFP in squamous cell carcinomas of the head and neck region in humans using the "wick-in-needle" technique. In all lesions (n = 25), the IFP was elevated (4-39 mmHg). The IFP increased with tumour size. The highest IFP was 39 mmHg in a 26 ml tumour. These results show that squamous cell carcinomas of the head and neck region in humans have an elevated interstitial fluid pressure. The elevation of IFP associated with inadequate delivery of drugs to the interstitium of malign tumours may reduce the response to therapy.

Intravenous fluid administration and urine output during radical neck surgery

This study examines perioperative urine output (UO) and hemodynamics in 24 patients who underwent radical head and neck surgery. The hypothesis tested was that "UO was not important in patients with normal renal function as long as hemodynamics were maintained." Intraoperatively, a "wet" group (13 patients) had generous amounts of intravenous (IV) fluid administered during surgery receiving 1,018 +/- 58 mL.h-1. The other "dry" group (11 patients) had fluids restricted to 426 +/- 23 mL.h-1. The intraoperative UOs for the wet and dry groups were 1.33 +/- 0.27 and 0.39 +/- 0.10 mL.kg-1 x h-1, respectively (p < 0.05). Postoperatively, the UOs for the wet and dry groups were 1.9 +/- 0.3 and 1.1 +/- 0.1 mL.kg-1 x h-1, respectively (p < 0.05). Perioperatively, there were no statistically significant differences between groups in systemic or pulmonary hemodynamics. Postoperatively, ordinary indices of renal function remained normal in both groups. We conclude that intraoperative oliguria due to moderate fluid restriction is not detrimental to renal outcome as long as systemic hemodynamics are maintained. Furthermore, not only does this relatively "dry" status not compromise hemodynamics, it affords the patient other benefits.

[Morbidity and the morphofunctional aspects of myocutaneous flaps used in the head and neck area]

The authors analysed the data obtained from their experiences in extensive head and neck resections as well as reconstructive treatments using myocutaneous flaps. They tried to evaluate the reconstructive approach in terms of morbidity and functional results. Sixty-nine patients, treated from January 90 to November 92 for advances intra-oral cancer, were considered in this study. The reconstructive procedure in 68 cases was the pectoralis major myocutaneous flap while in 5 cases the trapezius flap was utilized. Even though the oncological results were poor, the functional ones were quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory in 83% of the cases. The morbidity related to both flap procedures was low and the patients' life quality was good. Indeed, the use of a free flap offers additional advantages, without necessarily compromising safety of the reconstruction. Free flaps in general allow greater leeway in flap design and donor-site choice than pedicled flaps. Several reports have already demonstrated the versatility, usefulness and reliability of these flaps, especially in intra-oral reconstruction. The intricate nature of microsurgery and the expense of microsurgical equipment inhibit this kind surgery in many institutions around the world where the standard myocutaneous flaps would be a more practical procedure. In conclusion, even those patients with a poor prognosis may be considered potential candidates for demolitive and reconstructive treatment with which satisfactory results may be obtained.

Antitumor activity of combinations of antibodies directed against different epitopes on the extracellular domain of the human EGF receptor

The receptor (EGFR) for epidermal growth factor (EGF) and transforming growth alpha (TGF alpha) is often overexpressed in certain types of human malignancy and high levels of expression of the receptor and/or coexpression of growth factors. EGF and TGF alpha have also been correlated with poor prognosis in many patients. We have produced a number of rat monoclonal antibodies (MAbs) against four distinct epitopes on the external domain of the EGF receptor and are currently evaluating their potential for therapeutic use. Nine of these of MAbs were found to inhibit the binding of TGF and EGF to the receptor on tumor cells and these MAbs were able to inhibit the growth in vitro and in vivo of tumor cells that overexpress the EGF receptor. Here, we describe the results of experiments to determine the antitumor activity of combination treatment with two antibodies directed against separate epitopes on the external domain of human EGFR. Our results showed that treatment of human tumor xenografts with a combination of two anti-EGFR MAbs that bind to two distinct epitopes on the external domain of EGF receptor was not as effective as treatment with ICR62 alone, which binds to epitope C on the EGFR and is of IgG2b isotype. A phase I clinical trial with antibody ICR62 is currently underway in Royal Marseden Hospital (UK) in patients with head and neck and lung carcinomas.