A Computerized Database for Head and Neck Cancer Registry

Aims

Over the last years, the management of patients with head and neck cancer has become extremely complex, and the knowledge and information needed to care for a patient can no longer be trusted to the memory or manual systems. Recent advances in data processing technology offer the potential for creating ideal instruments to organize, store and analyze such information.

Methods

We developed a computerized database management system (H&N-CDMS) which fulfils the following requisites: easy to use even by operators not expert in informatics; minimum possibility of insertion of ambiguous data; use for clinical and research purposes; can be interconnected in a network of similar database operating in other centers; can be expanded to image processing.

Conclusions

The configuration of the system is described and its main characteristics are discussed: data entry and coding facilities, data accuracy and standardization, security and anonymity, data retrieval and analysis. H&H-CDMS is a user-friendly tool for head and neck cancer data management in clinical and research environments.

[A computerized database for managing otorhinolaryngologic oncology patients]

In recent years the management and interdisciplinary treatment of oncological patients has become extremely complex due to the progress made in diagnosis and therapy. As a result, the knowledge required to treat patients can no longer be simply memorized or manually filed. Computer technology provides the ideal instrument for organizing, saving and analyzing data from head and neck tumor patients. The authors have prepared a computerized database to meet the following needs: ease of use, even for non computer savvy users; minimal ambiguity for data entry; use for both clinical and scientific purposes; possibility to create a network with similar database at other Centers; possibility to expand to include image management. The archive is based on a personal computer with an INTEL 80486 microprocessor, 40 Mb RAM, DOS 6.0. and Windows 3.1. The software includes four main routines: a) formulation and management of tables where oncological data are gathered; b) entry and management of patient-related clinical data; c) statistical processing for epidemiological and oncological research and; d) management of basic computer services. In clinical practice the database allows the following: a) preparation of a monthly chart of check-ups, b) rapid tracking of patients lost to followup, c) printout of a summary of the clinical history of each patient at the time of check-up and rapid updating at the end of the examination, d) automatic production of forms such as discharge letters and reports to be shared with related services (i.e. medical oncology, radiotherapy). In addition, the database is a powerful, versatile research tool which can promptly provide all sorts of oncological data and can automatically prepare tables, diagrams, correlations, survival curves. The system was developed from 1993 to 1995 and has been operative, with a few minor modifications and updates, since 1995. Today the database contains more than 1200 oncological cases and the system is used daily by medical and paramedical personnel alike. Approximately 15 new cases are entered a month and 80 cases updated after follow-up.

[Surfactants of the airways. Critical review and personal research]

The literature proving the presence of a surface tension lowering substance (STLS) on the lining layer of mammalian Eustachian tube (ET) is critically reviewed. A further review of the chemical studies on tubal washings based on chromatographic analysis methods (TLC and HPLC) is performed, and is concluded that ET epithelium is coated by a mixture of phospholipids, similar but not identical to the pulmonary surfactant and with similar but less powerful surface activity. In both cases, and with minor differences between the different mammalian species, phosphatidylcholine (PC), and in particular its disaturated fraction, dipalmitoilphosphatidylcholine (DPPC), is the predominating and the most active compound. ET surfactant is synthesized by ET epithelium and secreted in form of osmiophilic multilamellar bodies into the tubal lumen. The exact function of the ET surfactant is not fully understood: it may play an important role in ET physiology by facilitating the tubal opening to allow for aeration of the middle ear and adequate drainage or could act as a release agent, preventing solid-to-solid adhesion of the tubal walls and contrasting the adhesive action of the glycoproteins of the mucous blanket. On the other hand a phospholipidic surfactant seems to be produced by the mucosa of the other parts of the upper airways, i.e. nose and trachea. In this case a surface active agent could act in preventing the transudation of serum into the lumen, in enhancing the phagocytosis or in facilitating the mucociliary transport. Recent data on humans, suggesting that a relative deficiency or an alterated production of tubal surfactant could play a role in the pathogenesis of secretory otitis media (SOM) or middle ear effusion (MEE), are reviewed. Administration of exogenous surfactant or pharmacological stimulation of the production of tubal surfactant could improve ET function and be of value in some cases of SOM. Personal data, suggesting than ambroxol (a drug stimulating the production of pulmonary surfactant by the alveolar type II pneumocytes) exerts a similar activating effect on the tubotympanal secretory cells, are reported. These data support the results of clinical studies on the treatment of SOM with ambroxol.

Sinus infection in intensive care patients

Sinusitis is a complication known to accompany nasotracheal intubation, but its frequency has not been well established. During a two-year-period, 1,126 patients in an intensive care unit have been studied. Twenty-seven of them (2%) developed a bacterial sinusitis. The diagnosis is established on the basis of an unexplained clinical sepsis, imaging evidence of fluid in the maxillary sinus, and antral puncture. Microbiological samples showed Gram-negative micro-organisms, in particular Pseudomonas aeruginosa, and an elevated percentage of Staphylococcus aureus and Escherichia coli. The likely predisposing factors (nasogastric and/or nasotracheal tubes) are discussed. Aetiology, diagnosis and management of the disease are discussed in detail. The importance of prompt removal of nasal instrumentation and of early sinus drainage, in addition to broad-spectrum antibiotic therapy, is emphasized.

[High-dose carboplatin superselective intraarterial chemotherapy in advanced head and neck cancer]

Advances in vascular radiology techniques for superselective transfemoral arterial infusion prompted us to evaluate the effects of high-dose rapid regional carboplatin infusion for patients with advanced head and neck squamous cell carcinomas. Twenty untreated patients received three infusions of carboplatin (300-350 mg/m2) every 2 weeks with this method. All the infusions were performed without any complication. Treatment was well tolerated, with moderate (Grade 1-3 WHO) local toxicity (stomatitis, dermatitis and alopecia) and minimal (Grade 1-2 WHO) myelosuppression. The total response index (complete response plus partial response) was 94% for primary tumors and 50% for neck metastases. Neoadjuvant chemotherapy employing superselective rapid infusion of high-dose carboplatin is a feasible, relatively nontoxic, effective technique and may have important applications in multimodality therapy of untreated patients with advanced head and neck cancer.

Proliferative characteristics of head and neck tumors. In vivo evaluation by bromodeoxyuridine incorporation and flow cytometry

Cell proliferation of head and neck cancers was studied in 52 patients using in vivo bromodeoxyuridine (BUDR) incorporation. Patients received 250 mg BUDR intravenously several hours prior to biopsy of the tumor tissue. Bivariate flow cytometry was used and enabled us to rapidly obtain DNA ploidy, labelling index (LI), DNA synthesis time (TS) and tumor potential doubling time (Tpot). This method was found to be suitable to obtain complete cytokinetic data in 46/52 (88.5%) patients. The mean BUDR LI was 7.9% (range 2-18%); mean TS was 11.6 h (range 6-28.5 h); mean Tpot was 5.7 days (range 2-30 days). BUDR LI and TS were significantly correlated with histological differentiation grading: G3 tumors showed higher LI values and shorter TS values than G1/G2 tumors. A similar correlation was found between LI or TS and tumor dimensions. Tpot was also significantly lower in larger tumors, such as in those with a higher grading. No significant correlation was found between LI or TS and DNA ploidy (50% of the tumors in our series were DNA aneuploid), while Tpot was found to be 10 days in diploid tumors, compared to only 6.3 days for the aneuploid tumors (p < 0.05). All cases with documented lymph node involvement (N+) showed significantly higher LI, and shorter TS and Tpot values if related to nodal free ones (Tpot = 10 days in N+ patients and 6.3 days in N- patients; p < 0.05). The results of this study suggest that the method employed is clinically feasible and could be a useful aid in defining the prognosis of head and neck cancer patients.(ABSTRACT TRUNCATED AT 250 WORDS)

A short-term infusion regimen of Cisplatin, 5-Fluorouracil and L-folinic Acid in advanced head and neck-carcinoma

Treatment of advanced head and neck cancer is still a matter of controversy. Although current chemotherapy regimens are able to induce high response rates, they have not shown improved survival. We employed a combination of cisplatin (CDDP), 5-fluorouracil (5FU) and 1-folinic acid (1-FA) in a 6-hour infusion schedule easy to administer on an outpatient basis. 49 patients have been included to date. The treatment plan consists of 5-FU (375 mg/m(2)) plus 1-FA (100 mg/m(2)) in a 4-hour i.v. infusion followed by a 2-hour i.v. administration of CDDP (20 mg/m(2)). This therapy was repeated for five consecutive days and recycled every 3-4 weeks. Out of 46 evaluable patients there were 6 complete responses (CR) and 23 partial responses (PR) for an overall response rate of 63%. Overall survival was 10.2 months (mean). Untreated patients had a higher probability of response as well as patients with naso-oropharyngeal primary tumor. Toxicity was generally mild with leukopenia, anemia and vomiting being the most frequent side effects. In conclusion, this combination appears well tolerated and active in the palliation of advanced head and neck cancer. However we think that increasing dose intensity of standard regimens and experimental new therapeutic approaches are needed to improve the clinical outcome of this disease.

Endothelin-induced vasoconstriction in rabbit nasal mucosa

Nasal blood flow is finely regulated by local release of neurotransmitters, neuropeptides and other bioactive molecules acting via paracrine mechanisms. We have investigated the effects of endothelin-1 (ET-1), a potent vasoconstrictor peptide, on the blood perfusion of rabbit nasal mucosa by laser Doppler flowmetry. After injection with ET-1, a potent and prolonged nasal vasoconstriction was observed. ET-immunoreactivity has previously been detected in nasal tissues and it is therefore suggested that ET-1 may participate in the regulation of nasal blood flow via paracrine mechanisms.

Occurrence, distribution and possible role of the regulatory peptide endothelin in the nasal mucosa

Nasal blood flow is finely regulated by local release of neurotransmitters, neuropeptides and other bioactive molecules acting via paracrine mechanisms. We have investigated the occurrence and distribution in human nasal mucosa of endothelin, a potent vasoconstrictor peptide, by immunocytochemistry and the effect of systemic administration of endothelin-1 on vascular perfusion of rabbit nasal mucosa by laser Doppler flowmetry. Endothelin-like immunoreactivity was demonstrated within vascular endothelial cells in both developing and mature human mucosa. Nasal epithelial cells and some connective tissue cells, presumed to be macrophages, also displayed specific immunostaining. In rabbits injected with endothelin-1, a potent and prolonged nasal vasoconstriction was observed. It is suggested that endothelin released locally may participate in the regulation of nasal blood flow via paracrine mechanisms. Since endothelin has growth-promoting actions on several cell types, it is also tentatively proposed that this regulatory peptide may play a role during development of the nose.

Effect of ambroxol on rabbit eustachian tube surfactant

The effect of ambroxol administration on phospholipid and phosphatidyl-choline contents of rabbit eustachian tube and lung washings and on [14C]-choline incorporation by rabbit eustachian tube and lung tissue has been studied. Despite minor differences, the drug exerts the same activating effect in both locations. The results add a further piece of evidence to the several similarities existing between the lung surfactant and the surface-active substances present on the eustachian tube.

[Presence of the regulatory peptide endothelin in the vascular endothelium of the human nasal mucosa]

Endothelin is a 21-amino acid peptide originally isolated from cultured endothelial cells. Besides being the most potent vasoconstrictor peptide. Endothelin is known to produce a wide range of biological effects: contraction of smooth airway muscle, stimulation of cell growth and modulation of hormone and neurotransmitter release. The aim of the present study was to use immunocytochemical techniques in investigating the possible occurrence of endothelin in normal human nasal mucosa. Endothelial cells of both capacitance and resistance blood vessels of the mucosa displayed endothelin-like immunoreactivity. It is reasonable to presume that endothelin, produced and released locally by endothelial cells, may play a role in controlling blood flow, in neuromodulation and in wound healing via a paracrine mechanism.

Use of serum markers in the diagnosis and management of laryngeal cancer

Many neoplastic diseases are reported to be accompanied by the presence or associated with an increase in biological substances identified as tumour markers. The most common markers implicated in head and neck cancers are CEA, TPA, LASA, SCC, CA 19-9, and ferritin. These markers (except SCC) were evaluated in 50 patients with a laryngeal carcinoma, in 20 patients with benign lesions, and in 20 healthy subjects. The results show for each marker assayed the following sensitivity values (true positives): CEA, 10%; CA 19-9, 30%; TPA, 30%; LASA, 90%; ferritin, 60%. Specificity (true negatives) was as follows: CEA, 85%; CA 19-9, 99.4%; TPA, 98%; LASA, 99.8%; ferritin, 97%. LASA and ferritin seem to be the most suitable markers for patient monitoring because of their higher sensitivity in all phases of cancer disease.

Disaturated phosphatidylcholine in rabbit eustachian tube surfactant

A chemical analysis of phospholipids in rabbit Eustachian tube and in its lavages shows phosphatidylcholine (PC) as being the predominating compound, followed by sphingomyelin and phosphatidylethanolamine. As in the lung surfactant, the majority of tubal PC is represented by its disaturated form dipalmitoylphosphatidylcholine (DPPC), known as a powerful surface-active agent. The concentration of PC and DPPC is higher in tubal washing than in the whole tissue, suggesting the existence of an active secretory process. Incubation of tubal mucosa with 14C-choline resulted in the biosynthesis of radiolabelled PC and DPPC at a ratio similar to the lung. These data provide further evidence for the existence of a surface-active agent in the Eustachian tube, chemically similar to the lung surfactant and probably produced through similar metabolic pathways.

Iron status in children undergoing tonsillectomy and its short-term modification following surgery

Red cell and iron status parameters were studied in a group of 44 children undergoing tonsillectomy for recurrent throat infections and in a control group of 40 healthy children. In the patient group, before tonsillectomy, 8 children presented a latent iron deficiency and 15 a decrease in serum ferritin levels. This altered iron status can be attributed to a reduced intestinal iron absorption, due to recurrent infections. One and seven days following surgery there was a significant fall in serum iron, serum transferrin and transferrin saturation, in parallel with an increase of serum ferritin and alpha-2 globulins levels. These modifications cannot be attributed to the blood loss, as proven by the constancy of haemoglobin level and of other red cell parameters, but to an unspecific reaction to surgical stress, as observed in fever, traumas and inflammation. They reflect an altered processing of iron, with a temporary block of its release to plasma and an increased storage within the reticuloendothelial cells.

Presence of phospholipidic lamellar bodies on the mucosa of rabbit eustachian tube. Ultrastructural aspects

Electron microscopy of the rabbit eustachian tube showed the presence of osmiophilic lamellar bodies in the cytoplasm of secretory cells and of osmiophilic free lamellar membranes in the lumen of tubal glands or above the epithelium. Similar structures have been reported in other parts of the respiratory system and in the pulmonary alveoli. The functional significance of these morphological observations is suggestive of a surface-tension-lowering effect on the mucosal lining layer of the eustachian tube and of a possible relationship to the phospholipid surfactant of the lung.

Prognostic parameters in metastatic spread of laryngeal cancer: clinico-histopathological correlations

The authors present a series of 130 patients with laryngeal tumours submitted to total or horizontal laryngectomy and to neck dissection. The possible correlations between the staging and histology of the primary lesion, tumour marker (LASA) and the incidence of lymph node metastases are examined. The information provided by clinical and histopathological parameters is no doubt useful, but the margin of clinical error is high. On the contrary, the tumour marker concentration (LASA) was significantly higher in the patients whose lymph nodes were found to be histologically invaded, than in those without metastatic spread. Consequently, the LASA test may assume clinical importance before surgical therapy and in the follow-up of treated patients.