Papillomaviruses in head and neck disease: pathophysiology and possible regulation

Human papillomaviruses (HPVs) are etiologic agents of both benign and malignant epithelial tumors. More than 60 different types of viruses are known, each associated with tissue site and lesion type specificities and differing probabilities of malignant progression. HPVs type 6 and type 11 cause benign papillomas of mucosal squamous epithelium in the aerodigestive tract, with only rare conversion to malignancy. HPV 16 is the most frequently detected HPV in the genital tract, inducing flat lesions with a significant risk of malignant conversion. In the aerodigestive tract, HPV 16 is found only rarely in benign lesions but is detected in 5-20% of squamous carcinomas. In the aerodigestive tract, HPVs frequently cause latent infection, i.e., viral DNA present in tissue but no evidence of clinical or histologic disease. Approximately 10% of the general population may have latent infections. Regulation and activation of latent infections are not well understood, although it is clear that viral functions are tightly regulated by the state of differentiation of the squamous host cell. Control of viral transcription may be the key to prevention of viral activation, and thus control of disease. Among the possible agents under investigation are retinoids, growth factors, anti-sense RNA which interferes with viral expression, and estrogen metabolites. All of these agents modulate either viral expression or cell differentiation or both. It is hoped that in the near future one or more of these agents will be useful in preventing HPV-associated disease.

Chemosensitivity of head and neck cancer with the rapid thymidine incorporation assay and its clinical application

The chemosensitivity of various head and neck cancers was investigated with the 5-day rapid thymidine incorporation assay in soft agar culture. The evaluability rate was 56%. Head and neck cancers were sensitive in vitro, in decreasing order, to peplomycin, cisplatin, bleomycin, 5-fluorouracil, mitomycin C, and doxorubicin. Primary tumors and neck metastases exhibited the same sensitivity, with 21% of all specimens tested responding. In vitro chemosensitivities were similar among patients younger than 69 years of age and those older than 70. The predictive accuracy for sensitivity tested prospectively in five cases was 80% and that for resistance in four was 75%.

The role of peptide growth factors in head and neck carcinoma

Peptide growth factors are proteins that stimulate cellular proliferation by binding to specific cell membrane receptors. Evidence is accumulating that abnormal regulation of growth factors may contribute to carcinogenesis. The epithelial growth factors, EGF and TGF-alpha, which share the same receptor, EGFR, may play a pivotal role in the development and maintenance of head and neck cancer; preliminary studies concerning TGF-beta and IL-2 are inconclusive. There is increased production of TGF-alpha and EGFR mRNA in the majority of fresh tissues and cell lines from patients with SCCHN. This increase results from transcriptional activation of the gene(s). Therapies directed at the regulation of gene transcription may be useful in chemoprevention or modulation of disease. Nuclear studies that target up-regulated growth factor receptors may improve the ability to detect microscopic regional metastatic disease.

Head and neck cancer resection and reconstruction: from past to present

1. Head and neck tumors occur predominantly in men between 50 and 70 years of age who typically abuse tobacco or alcohol. These individuals often have poor oral hygiene and dentition as well as nutritional deficits, and achlorhydria, anemia, and iron and riboflavin deficits are common. 2. The tumor and treatment of head and neck cancer may cause many devastating effects, such as facial disfigurement, dysphagia, alterations in airway and communication, partial or total loss of taste and smell, xerostomia, pain, or fatigue. Treatment and rehabilitation may take months. 3. Although advances in technology and reconstructive surgery have not improved the overall survival rate, they preserve appearance, function, and, ultimately, the patient's quality of life.

[Ototoxicity of cis-diammine glycolato platinum, 254-S]

Ototoxicity of cis-diammine glycolato platinum, 254-S, was evaluated from the results obtained in phase II studies for head & neck cancer, lung cancer, breast cancer, gastrointestinal cancer, urogenital cancer and gynecological cancer at 114 institutions, and in randomized comparative study of 254-S plus vindesine vs. cisplatin plus vindesine for advanced non-small cell lung cancer conducted at 41 institutions. In these studies, 254-S was administered at doses ranging from 80 to 100 mg/m2, repeated at least 2 times at 4-week intervals. Impaired hearing was examined in a hearing audiometry test before and after 254-S administration. The incidence of impaired hearing was 25.8% (16/62) in the 254-S phase II studies. The incidences in the randomized comparative study were 17.6% (3/17) for the 254-S/vindesine group and 20.0% (3/15) for the cisplatin/vindesine group. From these results, the ototoxicity of 254-S was thought to be similar to that of cisplatin in incidence and type.

Vasodepressor carotid sinus syncope associated with a neck mass

We present the hemodynamic and autonomic features of recurrent purely vasodepressor syncope episodes in a patient with left-sided malignant cervical adenopathy involving the carotid sinus. Extreme hypotension lasting 10 to 30 minutes, without change in heart rate, occurred spontaneously and 20 seconds after head-turning. The baseline respiratory sinus arrhythmia, heart rate response to standing and Valsalva's maneuver, and cold-induced blood pressure elevation were normal, indicating normal baroreceptor function between episodes. The episodes abated after 1 week of bedrest but reappeared within 1 day of discharge from the hospital. Syncope no longer occurred after intracranial section of the left glossopharyngeal nerve and upper rootlets of the left vagus. Autonomic testing remained normal postoperatively. A review of the literature indicates that purely vasodepressor syncope has been more common with left carotid sinus lesions.

Interstitial hypertension in head and neck tumors in patients: correlation with tumor size

Elevated interstitial fluid pressure (IFP) is associated with poor blood supply and inadequate delivery of drugs to solid tumors. IFP was measured in squamous cell carcinomas of the head and neck region in humans using the wick-in-needle technique. In all lesions (n = 19), the IFP was elevated (4-33 mm Hg). Furthermore, the IFP increased with tumor size. The highest IFP was 33 mm Hg in a 24-ml tumor. In one tumor, the IFP was found to be negative (-2.6 mm Hg), which is comparable to that in human skin or subcutaneous tissue. The histopathology of this tumor was benign. If this pressure difference between malignant and benign lesions can be confirmed in a large number of tumors, then the IFP could be used to aid tumor detection during needle biopsy. The value of IFP as a predictor of response to radiotherapy, photodynamic therapy, hyperthermia, and chemotherapy should be assessed prospectively.

Urinary pyridinium cross-links as markers of bone resorption in tumor-associated hypercalcemia

Osteoclastic activity is increased in tumor-associated hypercalcemia, which, thus, constitutes an excellent opportunity to assess new markers of the bone resorption rate. We have measured the fasting urinary excretion of the pyridinium cross-links pyridinoline (Pyr) and deoxypyridinoline (D-Pyr) in 36 hypercalcemic cancer patients (mean +/- SD, 3.2 +/- 0.4 mmol/L for total serum Ca and 1.66 +/- 0.24 mmol/L for Ca2+). Thirty-two of them were reevaluated after treatment with iv bisphosphonates. Urinary Pyr and D-Pyr levels were higher than those in healthy controls (130 +/- 62 vs. 40 +/- 19 nmol/mmol creatinine for Pyr and 20 +/- 15 vs. 6 +/- 3 nmol/mmol creatinine for D-Pyr; P less than 0.001 for both). This represented a mean 3.3-fold increase over the normal mean compared to 5.8- and 3.4-fold increases for fasting urinary Ca and hydroxyproline, respectively. Individual values were elevated in 83% and 75% of the cases for Pyr and D-Pyr compared to 97% and 83% for urinary Ca and hydroxyproline, respectively. The levels of Pyr and D-Pyr tended to be higher in patients with head and neck tumors than in patients with breast cancer. Urinary Pyr and D-Pyr correlated with each other (r = 0.72; P less than 0.001) and were highly correlated with hydroxyproline (r = 0.68 and 0.83, respectively; P less than 0.001 for both), but poorly correlated with urinary Ca (r = 0.21; P = NS and r = 0.42; P = 0.01, respectively), suggesting that these markers reflect different events of bone resorption. Similarly, after bisphosphonate therapy, urinary Pyr and D-Pyr levels fell by 31% and 50%, respectively, compared to 38% for hydroxyproline and 76% for urinary Ca. There was a significant correlation between posttreatment D-Pyr and serum Ca levels (r = 0.43; P less than 0.05). In summary, we found that the urinary excretion of Pyr and D-Pyr was markedly increased in hypercalcemic cancer patients and was adequately lowered by bisphosphonate therapy. The urinary excretion of the pyridinium cross-links, especially D-Pyr, should be helpful to specifically quantitate bone matrix resorption and monitor the inhibition of bone resorption in cancer patients receiving antiosteolytic drugs.

Vascular evaluation of head and neck masses by magnetic resonance imaging

The vascularity of head and neck masses and their relation to major vessels is an important factor in the differential diagnosis and surgical strategy. Magnetic resonance imaging (MRI) can be tailored to enhance vascular flow by making use of two flow phenomena--time of flight and phase. Fifteen patients with head and neck masses were evaluated by flight flow-sensitive MRI sequences. The inflow-sensitive images were superior to standard unenhanced and gadolinium-enhanced spin echo images in the assessment of tumor vascularity. They were also useful in assessing the relationship of the head and neck masses to the adjacent vessels. The limitation of these inflow-sensitive sequences is the inability to differentiate flow from fat or subacute hemorrhage. Inflow-sensitive MRI obviates the need for diagnostic angiography in most head and neck masses.

[Results of incremental drug pain therapy in patients with head-and-neck tumors]

46 patients with progressive tumors in the head and neck region (18 x oropharynx, 13 x hypopharynx, 9 x larynx and 6 x other localization) were treated with a increasing analgetic therapy regimen (WHO schedule) for their cancer pain. The results of the therapy were recorded and controlled with the aid of scale methods. A good result was recorded with the administration of (a) peripheral analgetics on 42% of therapy days and (b) weak nonnarcotic opiates in combination with peripheral analgetic drugs and partially with psychopharmaceuticals (17.5%) on 51% of therapy days. A therapy with strong opiates (regularly in combination) was necessary on 7% of all therapy days. A total of 4848 therapy days have been considered here. The principles and problems of such a stepwise treatment schedule are discussed.

Lung function and radiation response

This study investigated whether impaired respiratory function affected the response to radiotherapy. A prospective study was performed in which lung function, arterial oxygen and haemoglobin concentration were examined, before treatment with radical radiotherapy, in 141 patients with advanced non-small cell lung cancer and head and neck cancer. The findings were considered to reflect the physiological conditions present at the time of radiotherapy and these were related to acute normal tissue reactions and tumour control. Although 53% of the patients showed some impairment of lung function and 47% demonstrated a haemoglobin oxygen saturation below the normal range, oxygen partial pressure was below expected levels in fewer patients (27%) and total arterial oxygen content was below normal in only 12% of patients. No correlation was found between the tests performed and the severity of acute morbidity or with local tumour control. In the patients with carcinoma of the bronchus, there was a trend for incomplete tumour control to be associated with a lower haemoglobin level, but this did not reach statistical significance. In patients selected for curative radiotherapy, lung function would not appear to be an important factor influencing the response of normal tissues or tumour to irradiation.

Intrathecal narcotics for relief of pain from head and neck cancer

We describe our experience with nine patients with head and neck pain of malignant origin who were treated with continuous low-dose intrathecal morphine via a lumbar catheter and implantable subcutaneous drug delivery pump. All patients had failed prior attempts at oral narcotic pain control due to either poor pain control or intolerable side effects. Using a visual analogue scale where the most severe pain is rated as 10 and no pain is rated as 0, the mean visual analogue scale was reduced from 7.6/10 (range, 5 to 10/10) before implantation to 1.9/10, 2.0/10, and 0.5/10 at 1 week, 1 month, and 2 months after implantation, respectively. Complications were acceptable. We conclude that intrathecal administration of morphine is a safe and effective means of pain control. This method deserves serious consideration in patients with intractable pain secondary to head and neck malignancy.

[Transcranial Doppler ultrasonography in head and neck tumors]

Transcranial Doppler ultrasound (TCD) recording is a non-invasive diagnostic procedure for the evaluation of the cerebral collateral flow in patients, in whom therapeutic ligation or resection of the common and/or internal carotid artery is planned. Patients are first examined under resting conditions, and then under manual compression of the ipsilateral carotid artery. Since January 1989, 31 ENT and neurosurgical patients have been examined. In all patients an immediate decrease in flow velocity in the middle cerebral artery (mca) of about 25% to 90% was recorded. In 42.8% of the patients the mca flow velocity reached 90% or more of its value under normal conditions within a short period. In 29% of the patients the mca flow velocity under manual compression of the carotid artery remained under 50% of its original value. In 68% of the cases TCD with manual compression of the carotid artery showed reliable results for the function of cerebral collateralisation as a prognostic factor of the risk of ischaemia due to haemodynamic changes after carotid ligation. In these cases no further examination of the cerebral collateral flow conditions was needed. The method is inexpensive, reproducible, and in comparison with cerebral angiography, convenient and non-hazardous for the patient.

Phase II trial of mitoxantrone in head and neck carcinoma

Nineteen patients with measurable and incurable head and neck carcinoma (17 squamous cell and two adenoid cystic) received intravenous bolus doses of 14 mg/m2 mitoxantrone in the first course. The doses were escalated or de-escalated by 2 mg/m2 in subsequent courses, based on leukocyte nadir, to achieve mild (3,000-3,999/mm3) or moderate (2,000-2,999/mm3) toxicity and response. The courses were repeated every 3 weeks. All 60 courses were evaluated for toxicity. Leukopenia was mild, moderate, severe (1,000-1,999/mm3), and life-threatening (less than 1,000/mm3) in 17%, 23%, 42%, and 2% of courses, respectively. Mild thrombocytopenia (100,000-129,999/mm3) occurred in two courses. The median interval to nadir leukopenia was 14 days (range 7-36) with a median of 13 days (range 3-50) to recover to normal. After the first course, leukopenia was mild in 16%, moderate in 32%, severe in 26%, and life-threatening in 5%. One patient died of pulmonary embolism 8 days after the first course and had concomitant leukocyte count of 700/mm3. Eighteen patients had at least one course resulting in leukopenia. Three of six patients receiving greater than or equal to 4 courses (cumulative dose 56-102 mg/m2) had an asymptomatic decrement of 14%, 17%, and 29%, respectively, in radionuclide left ventricular ejection fraction. The other toxicities were mild. In the 16 patients with squamous cell carcinoma that could be evaluated for response, one had a partial response lasting 8 months, and six had stable disease. One of the two patients with parotid adenoid cystic carcinoma had a minor response lasting 16 months. Mitoxantrone on a bolus schedule has minimal activity and is not indicated in head and neck squamous cell carcinoma.

A comparison of epidermal growth factor receptor (EGFR) and c-erbB-2 oncogene expression in head and neck squamous cell carcinomas

The proto-oncogenes c-erbB-2 and epidermal growth factor (EGF) receptor which encode 2 closely homologous transmembrane glycoproteins have been found amplified and/or overexpressed in a range of epithelial malignancies. In a series of 46 head and neck squamous cell cancers (SCCs), immunohistochemical reactivity for the EGF receptor was detected in all cases, particularly at the invading edge of cellular islands of SCC and in the basal cells of normal adjacent squamous epithelium. Southern blot analysis demonstrated EGF receptor gene amplification in 3 cases. In contrast, strong membrane staining for the c-erbB-2 oncoprotein was not detected in any sample, and there were no cases of c-erbB-2 gene amplification. Despite a close structural and (presumed) functional homology between these 2 receptor-oncoproteins in the development of malignancy, we report that their expression in SCCs is markedly different. Furthermore, unlike the situation for breast cancer, quantitation of the c-erbB-2 or EGF receptor oncoproteins is unlikely to yield important prognostic information in this group of patients.

Pain management in advanced carcinoma of the head and neck

Although pain is one of the most feared consequences of cancer, pain management is rarely discussed in the literature on head and neck cancer. The pain experienced by patients with head and neck malignancies, of a biologic origin, is compounded by the emotional distress caused by alterations in function and cosmesis. Control of pain is possible, but an effective program must include more than pain medication. A current treatment program is presented, based on scientific study and clinical experience. The most helpful pain medication is immediate-release, liquid morphine sulfate (20 mg/mL) administered every 4 hours. A nonsteroidal anti-inflammatory drug may also be used and it may decrease the amount of morphine necessary. Stool softeners must be provided, and anti-nausea medication is often given. Steroid drugs are regularly used to increase appetite, decrease edema, and enhance the patient's sense of well-being. Factors related to the selection and dosage of medications are discussed.

Is melanoma changing?

Nine hundred ninety-five cases of melanoma of the head and neck were divided into two groups so that certain comparisons could be made concerning the behavior of melanoma over a 55-year period. One hundred twelve melanomas of the ocular system were excluded from this review. The first group consisted of 660 melanomas seen during a period from 1932 to 1972. The second group consisted of 223 melanomas seen during a period from 1973 to 1987. Thirteen parameters, including sex, age, distribution, pre-existing mole, amelanotic melanoma, delay in diagnosis, classification, levels, local recurrence, regional metastasis, systemic metastasis, morbidity, and survival, were studied to assess the behavior and the variations. There is no question that the most important aspect of the favorable changes that have occurred are because of earlier diagnosis and better management by a larger group of well-trained specialists. There are some subtler changes that could possibly indicate biologic alterations, but this requires more time and study to substantiate.

Epidural buprenorphine or morphine for the relief of head and neck cancer pain

We present three cases in which epidural buprenorphine or morphine was used for intractable cancer pain of the head and neck. Excellent pain relief and minimal side effects offered by epidural opioids were of significant benefit. The use of epidural opioids prior to the administration of high doses of oral morphine may be the treatment of choice for pain from malignancy of the head and neck, especially when there is tumor extension or distant metastasis.

von Willebrand factor in head and neck cancer

Laboratory abnormalities in blood coagulation factors are common in patients with cancer but the significance is unknown. Twenty-eight patients with head and neck cancer were studied at the time of diagnosis. Twenty-five were advanced-stage (III or IV) patients. Levels of clotting factors, antithrombin III, and plasminogen were normal. Levels of von Willebrand factor (vWF), both antigenic and functional (ristocetin cofactor), were elevated. This group of patients were followed for a minimum of 41 months (median, 48 months). Fifteen patients died within the follow-up period. von Willebrand factor levels were significantly higher in these 15 than the 13 survivors. Extreme elevation of ristocetin cofactor (greater than 300 U/dl) was seen in six of the 15 patients who died and in none of the survivors. Plasma vWF is elevated in head and neck cancer and the level measured at the time of diagnosis may have prognostic and potentially therapeutic implications.

The melanocyte and melanoma

This paper reviewed some of the interesting biological aspects of melanocytes and their relationship to the nevus and to melanoma. It also proposed a rationale for "adequate" surgery in the management of melanoma according to level, depth, margins, and trends in treatment. These propositions were derived from an analysis of 995 cases of melanoma of the head and neck.

Mutagen sensitivity in patients with head and neck cancers: a biologic marker for risk of multiple primary malignancies

Eighty-four patients with head and neck cancers were evaluated for in vitro sensitivity to mutagens and then followed longitudinally for development of multiple primary malignancies. We assessed mutagen sensitivity by exposing lymphocytes to bleomycin in vitro and quantitating the bleomycin-induced chromosomal breaks per cell. The mutagen-hypersensitive patients, ie, those who expressed greater than 1.0 break per cell, were significantly more likely to develop multiple primary cancers than were patients who were less sensitive (less than or equal to 1.0 break per cell) (relative risk = 4.4; 95% confidence limits = 1.2, 15.8). This relationship was independent of age, sex, site, and treatment of first primary cancer and tobacco or alcohol exposures. Sensitivity to bleomycin-induced chromosomal damage serves as an indicator of genetic susceptibility to multiple primary malignancies in patients with head and neck cancers.

[Tractotomy and partial nucleotomy as a form of therapy in refractory pain of the trigeminal nerve and cancer pain in the head and neck area]

Persistent trigeminal neuralgia, herpes zoster neuralgia of the first division of the trigeminal nerve and pain caused by cancer situated in the head and neck pose frustrating problems for patients and physicians. Tractotomy and/or partial vertical nucleotomy of the subnucleus caudalis nervi trigemini offers a logical approach to the treatment of such pain, since these structures contain fibres of the Vth nerve, as well as the somatosensory fibres of the VIIth, IXth and Xth nerve. Tactile and some thermal sensitivity of the face is preserved and anaesthesia dolorosa and keratitis neuroparalytica is avoided. Over the past 30 years 370 patients with therapy-refractory trigeminal pain, pain due to cancer of the head and neck and herpes zoster trigeminal pain were treated by means of tractotomy (personal series of V. Grunert), including 30 patients who underwent partial vertical nucleotomy. The mean age of the patients was 68 years (range 54-84 years). The mortality in this series was 0.9% (4 patients; one operative mortality due to air embolism, one postoperative cardiac failure following myocardial infarction and two intracerebral haematomas). 60% of the patients with persistent trigeminal neuralgia were pain-free and 28% improved, whereas 12% were unchanged or suffered from recurrent pain. Of the patients with cancer who complained of pain derived from the Vth, VIIth, IXth and Xth nerve, 40% demonstrated marked pain relief and 60% showed no improvement. Tractotomy and partial vertical nucleotomy offer a valuable method in experienced hands for relieving pain where other methods have failed.