Lymphocyte subpopulations infiltrating squamous carcinomas of the head and neck: correlations with extent of tumor and prognosis

Because little is known about the mechanisms involved in local tumor-host immune reactions in squamous carcinoma of the head and neck, a study was undertaken to better characterize the types of immune cells present at the local tumor site and determine their relationship to tumor extent, systemic cellular immune parameters, and clinical outcome. In 40 untreated patients, lymphocyte subsets (LS) at the tumor-host interface were quantitated immunohistologically from serial sections of frozen tumor specimens and correlated with concurrently measured peripheral LS levels and in vitro lymphocyte reactivity to phytohemagglutinin (PHA). The majority of infiltrating lymphocytes were T cells with rare B or Leu 7 cells. Proportions of T4 and T8 were similar in peritumor stroma; however, T8 cells predominated tumor parenchyma. Stromal and parenchymal infiltration by LS were not related to peripheral blood LS levels, lymphocyte reactivity, or tumor site. However, parenchymal T11 and T4 cell infiltration was less in advanced primary tumors (T3, T4) than in early tumors (T1, T2) (P = 0.01, P = 0.067, respectively), as was peripheral lymphocyte reactivity to PHA (P = 0.013). Short-term disease-free interval and actuarial survival differed significantly--according to parenchymal T11 and T4 cell infiltration--and were not related to T8, Leu 7, and B-cell infiltration. The findings extend prior studies of lymphocytic infiltration in head and neck cancer and demonstrate the potential importance of differences in tumor stromal and parenchymal infiltration. Together with recent evidence that T4 cells are critical for lymphokine production and for the proliferation of cytotoxic effector cells, the current results suggest that T4 cells play a critical role in the local immune response in squamous carcinoma of the head and neck.

Small cell carcinoma of the head and neck

Treatment methods for patients with small cell carcinoma of the head and neck are changing. Increasing clinical experience with these tumors and a better appreciation of patterns of recurrence, the need for thorough tumor staging, and the importance of chemotherapy as a form of primary therapy have contributed to these changes. Current concepts regarding small cell carcinoma arising in the head and neck are reviewed. Reported results of treatment for a variety of head and neck sites and site-specific relapse rates are summarized. New cases of small cell carcinoma arising in the hypopharynx, paranasal sinus, and from an unknown primary are added to the reported experience in the literature.

Beta endorphin enhances in vitro lymphokine production in patients with squamous carcinoma of the head and neck

Recent studies of the effects of endorphins and other neuropeptides on immune mechanisms suggest that immune reactive cells have specific opioid-like and nonopioid endorphin receptors, and indicate that neuropeptides may participate in regulating in vivo immune functions. Earlier demonstrations of impaired cellular immunity and impaired lymphokine production in patients with cancer of the head and neck prompted an investigation of the in vitro effects of beta-endorphin on the production of leukocyte migration inhibitory factor (LIF) in 29 patients with head and neck cancer and in 45 normal subjects. LIF production in response to phytohemagglutinin was significantly less in the cancer patients compared to normal subjects (p less than .001). beta-endorphin significantly enhanced LIF production in the cancer patients (p = .01) to levels that did not differ significantly from normal levels. A correlation of levels of lymphocyte subpopulations in the cancer patients suggested that enhancement of lymphokine production by beta-endorphin was related to levels of T8 (suppressor/cytotoxic) cells. The results confirm earlier demonstrations of impaired lymphokine production in patients with head and neck cancer and indicate that beta-endorphin can modulate in vitro lymphokine responses in such patients. These findings suggest that neuroendocrine peptides may play an important role in regulating immune function. Further study of the role of neuropeptides in the immune response should provide additional insight into the characterization of cellular immune dysfunction associated with head and neck cancer and should lead to the development of innovative immunotherapeutic treatment strategies.

Definite vs adjuvant radiotherapy. Comparative effects on lymphocyte subpopulations in patients with head and neck squamous carcinoma

The recent association of alterations in T-lymphocyte subpopulations and impaired cellular immunity prompted an investigation of the effects of radiotherapy (RT) on serial levels of lymphocyte subsets in 30 patients with head and neck squamous carcinoma. Percentage and absolute levels of T3, T4, T6, T8, T10, T11, and Leu 7 cells were measured before, during, and after RT at monthly intervals for six months and compared with levels in 40 normal subjects. Sixteen patients received curative and 14 postoperative adjuvant RT. Before treatment, mean subset levels were similar among the patient and normal groups except for elevated Leu 7 (natural killer) cells in patients with stage I and II disease. There were profound decreases in absolute levels of each subpopulation during and after RT. The percentage of T4 (helper/inducer) cells decreased, whereas that of T8 (cytotoxic/suppressor) and Leu 7 cells tended to increase. Compared with normal values, the mean T4/T8 ratio decreased significantly by six months after RT, when absolute levels of the subsets had rebounded to pretreatment levels in the definitive RT group but remained profoundly decreased in the adjuvant group. The differing recovery patterns suggest that factors other than RT may contribute to persistent immunosuppression following RT.

DNA content of human squamous cell carcinoma cell lines. Analysis by flow cytometry and chromosome enumeration

Fifteen squamous cell carcinoma cell lines derived from nine patients were examined for DNA content by flow cytometry and chromosome counts. Using human peripheral blood leukocytes and nucleated trout and chicken red blood cells as standards, the DNA indexes of the squamous cell carcinoma cell lines were found to range from 1.1 to 3.3. The DNA content was a stable characteristic of individual cell lines in multiple passages over a seven-month period. Although flow cytometry could detect abnormal DNA content even in diploid tumor lines, the chromosome number correlated well with the DNA content by flow cytometry. In cases in which more than one cell line was established from the same patient, the individual cell lines were found to differ in their DNA content. The cell lines established from metastatic or recurrent tumors usually had a lower DNA content and chromosome number and exhibited a more aggressive in vitro growth pattern than the primary tumor or earlier recurrence. We hypothesize that "streamlined" and aggressive cell populations may evolve in vivo from more slowly growing hyperploid precursor tumor cell populations when in the course of random loss of DNA or chromosomes those that confer no growth advantage are lost, while those that do confer growth advantage are retained.

In vitro immune modulation by thymosin alpha 1 in patients with head and neck squamous cell carcinoma

To determine if patients with head and neck squamous cell carcinoma represent an appropriate population for immune reconstitution with thymosin alpha 1, leukocyte migration inhibition (LMI) in response to phytohemagglutinin was measured in 24 previously untreated patients with head and neck cancer, and the in vitro effects of thymosin alpha 1 on migration inhibition were assessed. Compared to normal subjects, LMI was impaired in the head and neck cancer patients. Thymosin alpha 1, in vitro, was associated with improvement in LMI in the cancer patients. Improvements in migration response with thymosin alpha 1 appeared to be independent of levels of various T-lymphocyte subpopulations. However, patients with a normal LMI response had lower suppressor/cytotoxic cell levels than normal subjects or patients with impaired LMI. The findings confirm prior reports of the effects of thymic hormones on lymphokine production in vitro and provide rationale for further clinical studies of thymosin alpha 1 in patients with head and neck squamous cell carcinoma.

Intramuscular hemangioma of the head and neck

Intramuscular hemangiomas are unusual tumors in the head and neck region that occur most frequently in the masseter muscle and are often confused with parotid neoplasms. Four cases are described and the literature reviewed. The diagnosis and management of these tumors are discussed in view of the fact that accurate preoperative diagnosis is unusual and tumor recurrence rates high. Increased awareness of the clinical presentation of intramuscular hemangiomas should enhance diagnostic accuracy and facilitate optimal treatment planning.

Predictive factors for tumor response to preoperative chemotherapy in patients with head and neck squamous carcinoma. The Head and Neck Contracts Program

The high tumor response rates associated with intensive chemotherapy in previously untreated patients with advanced head and neck squamous cell carcinoma (HNSCC) led to the initiation of a multi-institutional National Cancer Institute trial. This trial used preoperative chemotherapy in patients with resectable Stage III and IV squamous cell carcinoma of the oral cavity or larynx/hypopharynx. Response rates, toxicity, and a variety of patient and tumor characteristics were analyzed to determine which factors might be useful in predicting tumor response to preoperative chemotherapy. Two hundred eighty-two patients received one course of preoperative cisplatin and bleomycin chemotherapy and were evaluable. There were 22 complete responses (CR) and 114 partial responses (PR) at the primary site (48% response rate). Of 197 patients with clinically positive regional adenopathy, 29 CRs and 73 PRs were observed (52%). Toxicity associated with the chemotherapy regimen was minimal. Primary tumor and regional node responses to chemotherapy were strongly correlated. No significant differences were found in primary or nodal response rates with respect to differing tumor site, stage, histologic differentiation, patient performance status, nutritional status, leukocyte count, hemoglobin level, age, sex, or alcohol use. Primary tumor response, however, was significantly related to T classification (P = 0.048). Nodal response was strongly associated with N classification and nodal size (P = 0.02 and P = 0.075, respectively). These findings suggest that, of the patient and tumor characteristics analyzed, none were more useful in predicting tumor response than clinical tumor staging parameters.

Lymphokine production and lymphocyte subpopulations in patients with head and neck squamous carcinoma

Prior studies of impaired cellular immune reactivity in patients with head and neck squamous carcinoma (HNSC) suggest that immune deficiency associated with tumor growth may be related, in part, to alterations in immunoregulatory functions. To determine if production of soluble mediators of the immune response (lymphokines) is impaired in patients with HNSC, leukocyte migration inhibition in response to phytohemagglutinin was assessed in 32 patients with HNSC and 29 normal subjects and was correlated with levels of specific peripheral blood lymphocyte subpopulations to determine if quantitative levels of immunoregulatory lymphocyte subpopulations were related to in vitro lymphokine production. In the patients with cancer, leukocyte inhibitory factor production was consistently and significantly impaired and was directly related to levels of T4-positive (helper/inducer) lymphocytes. Substantial differences in levels of individual subpopulations were not detected among normal subjects and patients with cancer; however, the mean T4/T8 ratio was substantially increased in the patients with cancer. The findings confirm and extend prior observations of impaired cellular immune mechanisms in patients with HNSC and suggest that impaired lymphokine production may be related to quantitative and qualitative alterations in lymphocyte subpopulations.

Total en bloc resection of the temporal bone and carotid artery for malignant tumors of the ear and temporal bone

A technique for single stage total en bloc resection of the temporal bone and intratemporal carotid artery with immediate reconstruction has been described. This formidable procedure requires the collaborative efforts of neurotologic skull base surgeons, neurosurgeons, and head and neck surgeons. Two patients have undergone this procedure; one with squamous cell carcinoma and one with extensive basal cell carcinoma. The quality of life following this procedure is adequate and the cosmetic deformity can be minimized. Longer follow-up is necessary to determine the value and overall impact of this approach to cancer of the temporal bone on disease free interval and patient survival. Further experience with the technical aspects of this procedure should reduce the operating time, blood loss, and resultant morbidity.

Effects of smoking and age on serum levels of immune reactive proteins

In patients with head and neck squamous carcinoma, prior studies demonstrating correlations among levels of certain immunosuppressive acute phase proteins, tumor extent, and immune reactivity suggest that these protein levels may be useful parameters for assessing tumor status and clinical course after treatment. Because of the consistent association of chronic smoking with the development of cancers of the head and neck, the effects of smoking and age on levels of acute phase proteins (alpha 1-antitrypsin, haptoglobin, alpha 1-acid glycoprotein) and other immune reactive proteins (alpha 2HS-glycoprotein, prealbumin) were determined in smoking and nonsmoking normal subjects. In smokers, levels of alpha 1-antitrypsin were uniquely and significantly elevated and were not related to smoking extent or age. Levels of haptoglobin increased with smoking extent and age. In comparisons of age- and sex-matched smokers and nonsmokers, levels of alpha 1-acid glycoprotein increased with age among both groups. The demonstration of correlations of levels of immunosuppressive acute phase proteins with smoking extent and age among normal subjects suggests that changes in the levels of these proteins may be related etiologically to the association of smoking and age with the development of head and neck cancers.

Preoperative cisplatin and bleomycin therapy in head and neck squamous carcinoma. Prognostic factors for tumor response

A multi-institutional National Cancer Institute trial of preoperative cisplatin (100 mg/sq m, day 1) and intravenous bleomycin sulfate (15-mg/sq m bolus, day 3, followed by 15 mg/sq m/day, 24-hour infusion, days 3 to 7) was carried out in patients with previously untreated, resectable stage III and IV squamous cell carcinoma of the oral cavity or larynx and hypopharynx. Of the first 113 patients who received a single course of induction chemotherapy, eight complete responses and 47 partial responses at the primary site were observed (49%). Of 76 patients who had clinically positive regional adenopathy, 11 complete responses and 31 partial responses of neck nodes were observed (55%). The response rates of the primary tumor and the regional nodes to induction chemotherapy were assessed with respect to several pretreatment patient and tumor characteristics and to reported toxic effects after chemotherapy. Of the factors examined, no prognostic indicators were highly useful to predict the response of the primary tumor. However, the response of regional adenopathy was associated with the initial N class, the site of primary tumor, and the response of the primary tumor to induction chemotherapy.

Improvement of impaired leukocyte migration inhibition by thymosin in patients with head and neck squamous carcinoma

In a preliminary study of the effects of SK-SD and thymosin on leukocyte migration inhibition in patients with squamous carcinoma of the head and neck, the cancer patients had significantly lower leukocyte migration inhibition of SK-SD than normal subjects. Thymosin increased the inhibition to SK-SD in the cancer patients to levels similar to those in normal subjects, and decreased the inhibition in normal subjects. These results confirm and extend the results of previous studies of the effects of thymosin in vitro, which show restoration of immune reactivity in patients with impaired cellular immunity and either no effect or a decrease in immune reactivity in subjects with normal cellular immunity. These combined observations provide a rationale for determining the clinical effects of thymosin in immunoincompetent patients with head and neck cancer and suggest that immunorestorative agents such as thymosin be used with caution in patients with normal cellular immunity.