Autotransplanted jejunum in head and neck cancer

Functional and Radiological Evaluation of Free Jejunal Transplant Reconstructions After Radical Resection of Hypopharyngeal or Proximal Esophageal Cancer

Cancer of the pharyngoesophageal junction (PEJ) is associated with late onset of symptoms, high morbidity, and a dismal prognosis. Radical surgery with pharyngolaryngectomy and reconstruction with a free vascularized jejunal transplant has been increasingly practiced in the treatment of these patients. This strategy is not devoid of challenges, and the present study is aimed at evaluating the long-term functional outcome among patients who have undergone such surgical treatment. Ten patients (mean age 59 years) with a mean follow-up time of 54 months were included. Clinical assessment, health-related quality of life (HRQL) questionnaires, and a standardized radiography examination were used for evaluation. The Karnofsky index ranged from 60 to 90 (mean 82). Global QL scores (EORTC QLQ-C30) had a mean value of 74, and the mean scores for dysphagia-related items of the EORTC QLQ OES-18 questionnaire were within the lower range. Radiographic signs of disturbed bolus transport through the jejunal transplant were found in all patients examined despite the grading of dysphagia from 0 to 1. The Watson dysphagia score varied between 0.5 and 45.0 (mean 16.2). No correlations were found between radiographic findings and the clinical evaluations or the outcomes assessed by the HRQL questionnaires. HRQL was found to be generally good after cancer of the PEJ and jejunal transplant insertion. Most patients reported mild dysphagia. Radiologic signs of disturbed bolus passage were common, but their clinical impact seemed questionable.

Reconstruction of the hypopharynx: current trends

PURPOSE OF REVIEW

Reconstruction of the hypopharynx continues to present a clinical challenge for the reconstructive surgeon. Trends continue to evolve as many viable options exist, depending on individual patient characteristics and institutional preferences. The article reviews the most current literature available on the subject.

RECENT FINDINGS

Surgical resections resulting in pharyngoesophageal defects require timely reconstruction to minimize patient morbidity while optimizing quality of life, specifically in regards to speech and swallowing. Contemporary reconstructive options include various gastrointestinal flaps, pedicled myocutaneous flaps, and fasciocutaneous free flaps. Institutional trends often depend on the availability, training, and expertise of the reconstructive surgeon. The current options available differ in their complication rate and overall morbidity, and must take into account each patient's general medical health. Increased availability of surgeons trained in microvascular reconstruction and the continued high published success rates have made free flaps an attractive option for hypopharyngeal reconstruction. Functional outcome regarding swallowing and speech rehabilitation after free flap reconstruction is promising.

SUMMARY

With continued publication of overall high success rates coupled with superior functional outcome and increased availability of surgeons trained in microvascular reconstruction, fasciocutaneous free flap reconstruction of the hypopharynx will probably surpass intestinal flaps in reliability and popularity.

Chirurgie réparatrice en cancérologie ORL : principales méthodes et indications

Oncologic cervicofacial surgery and plastic surgery have had a common evolution over the last 50 years where progress erasing from one was beneficial to the other one. We review here the historical evolution of these specialties and present the state of the art of plastic surgery in the field of cervicofacial oncology.

Ethanol decreases negative cell-cycle-regulating proteins in a head and neck squamous cell carcinoma cell line

Epidemiologic studies have provided evidence of an alcohol-associated increased risk of upper aerodigestive tract cancers. Recently we reported ethanol-induced proliferation in a squamous cell carcinoma of the head and neck (SCCHN) cell line, but the underlying mechanisms are unknown. In order to further clarify these findings, major G0/G1-regulating proteins were investigated in the present study. Synchronized cells of a SCCHN line (JP-PA) and a human immortalized keratinocyte line (HaCaT)-used as a control-were cultured with or without 10(-3) M ethanol for up to 96 h. At distinct time intervals the expression of cyclin D1 and the inhibitors p16, p18, p19 and p21 were determined by Western blot analyses. In both lines ethanol had no influence on the protein expression of cyclin D1. In contrast, distinct downregulations of p21, p18 and p19 were detectable at the protein level. The p16 protein was not expressed in the SCCHN line and was unchanged in the control line after the addition of ethanol. In these in vitro experiments the marked downregulation of important cell-cycle inhibitors may accelerate progression from the G1 to the S phase of the cell cycle. The relevance of our findings to in vivo conditions remains speculative, but the observed mechanisms of significantly reduced expression of cell-cycle inhibitor proteins may be involved in the carcinogenesis of head and neck malignancies.

Reconstruction with free jejunal autograft after circumferential pharyngolaryngectomy: eighty-three cases

The free jejunal autograft (FJA) has become a common procedure for pharyngeal reconstruction after circumferential pharyngolaryngectomy. In order to evaluate the postoperative outcome and the functional and carcinologic results, we retrospectively reviewed 83 cases of reconstruction with FJA. Fifty-one patients had received no prior radiotherapy, and 25 had received prior radiotherapy for their hypopharyngeal tumor or for another previous primary. Seven patients underwent a secondary reconstruction. In the postoperative course, there were 2 postoperative deaths, 4 graft failures (5%), and 11 salivary fistulas. The median time to removal of the nasogastric tube was 16 days, and to discharge, 23 days. Forty-eight patients received postoperative radiotherapy, with good tolerance. At 1 year postoperatively, 98% of the patients were able to eat a solid or soft diet. The postoperative radiotherapy did not impair the quality of the functional results in a long-term assessment. The vocal results were disappointing. The 3-year survival rate was 40%. The main carcinologic failures (45 patients) were locoregional recurrences (20 patients) and metastasis, which was the cause of death in 34% of the cases. It seems clear that FJA allows one-stage reconstruction and good swallowing rehabilitation, tolerates postoperative radiotherapy, and increases the quality of life in these patients with a poor prognosis.

[Removal of the small intestine in autologous jejunum transplantation for reconstruction of the mouth cavity is a secondary intervention with few complications]

Reconstruction after radical tumor resection in the oropharyngeal region still represents an interdisciplinary challenge. Autotransplantation of the jejunum is a popular procedure, in which the abdominal surgeon's main task is that of harvesting enteral tissue. To evaluate this technique, a careful analysis of accompanying perioperative abdominal complications was performed. Additionally, we reexamined 35 of 66 patients still living after a follow-up period of 21 (range 2-63) months on average. The perioperative mortality of 90 patients treated for oropharyngeal malignancy using the described procedure was 7.8%. None of the perioperative deaths was caused by an abdominal complication associated with enteral resection. One abdominal reoperation was performed because of abdominal wall dehiscence. For reasons not related to enteral resection, four further patients had to be relaparotomized, two of them during their hospital stay and two after leaving hospital. In five cases we observed minor complications which could be treated nonsurgically. In the follow-up reexamination we detected no abdominal late-onset complication except small incisional hernias in six cases. Finally, we concluded that despite an elevated overall operative risk in this population, complications owing to jejunal resection were comparably low. The data regarding the rate of complications classify jejunal resection as a safe procedure for reconstructive purposes in patients suffering from oropharyngeal malignancy.

Myocutaneous flaps in patients with head and neck cancer retain their immunological capacities in an activated functional state

Free/pedicled myocutaneous flaps used as functional replacement after radical dissection of advanced stage squamous cell carcinomas of the oral cavity/oropharynx were examined by immunohistochemistry (APAAP-technique). Biopsies from eight patients were taken at the time of surgery and at 3 and 5 months post-operatively. Fifteen monoclonal antibodies were used to detect surface antigens as markers of phenotypic changes of immune competent cells. In post-operative biopsies all antigens investigated increased significantly. Significantly higher numbers of CD45RO+ (P < 0.01) and CD45RA+ (P < 0.001) leukocytes were detectable. The majority of these leukocytes were TcR alpha/beta +/CD3+ T-cells, which increased in the CD4 (P < 0.05) and the CD8 (P < 0.001) subset. In addition, B-cells (P < 0.05), granulocytes (P < 0.05), NK cells (CD16+ lymphocytic cells; P < 0.05) and mature macrophages (25F9+cells; P < 0.01) were increased. Intra- and subepidermally a significantly (P < 0.01) higher number of dendritic-/Langerhans cells (CD1a+) was detectable. In post-operative biopsies, the activation-associated antigens ICAM-1, VCAM and HLA-DR were expressed on significantly more mononuclear-/endothelial cells and on keratinocytes. Our findings indicate that the myocutaneous flaps still contained cells with immunological capacities.

Antiproliferative effects of the biologically active metabolite of vitamin D3 (1,25 [OH]2 D3) on head and neck squamous cell carcinoma cell lines

In addition to a role in calcium and phosphate homeostasis other vitamin D receptor (VDR) mediated effects have been discovered during the past few years for the biologically active metabolite of vitamin D, 1,25(OH)2D3. An antiproliferative, differentiation-inducing effect on non-malignant and neoplastic cells of different origin has now been described. We examined the influence of 1,25(OH)2D3 on human squamous cell carcinomas of the head and neck (SCCHN). A differentiated (JP-PA) and undifferentiated (LF-FR) SCCHN line was studied with respect to proliferative capacity (using [3H]-thymidine uptake and cell number) and cell cycle distribution as determined by flow cytometry (FACS). Both cell lines were positive for VDR, which was found to be increased after the addition of 10(-7) M 1,25(OH)2D3, as shown by FACS analyses. The administration of 1,25(OH)2D3 at a concentration between 10(-7) M and 10(-10) M caused a dose-dependent moderate growth inhibition, as reflected by down-regulation of DNA synthesis (reduced [3H]-thymidine uptake) and a decrease in cell numbers. The JP-PA cell line showed a significant growth reduction for both concentrations tested, whereas for LF-FR a significant inhibition was detected only for 10(-7) M. The addition of 10(-7) M 1,25(OH)2D3 caused a blockade in the transition of cells from G1 to S phase in both cell lines, with a significant accumulation of cells in the G0/G1 phase. Our results demonstrate a receptor-mediated, dose-dependent inhibition of neoplastic growth by 1,25(OH)2D3 in human SCCHN lines.

Optimized growth medium for primary culture of human oral keratinocytes

The effect of different media additives in defining optimal growth conditions for primary cultures of human oral keratinocytes was studied. A cocultivation technique with irradiated Swiss-3T3-fibroblasts in 96-well plates enables the comparison of additives for primary keratinocyte cultures derived from one patient. 3H-labeled thymidine uptake showed no growth or growth inhibition with adenine, choleratoxin or transferrin compared to basal medium (Dulbecco's modified Eagle's medium (DMEM) and 10% fetal calf serum). Among single additives, 5 micrograms/ml hydrocortisone, 5 micrograms/ml insulin, 10 ng/ml EGF, 2 micrograms/ml bovine pituitary extract, and 10(-9) M triiodothyronine showed the greatest capacity to promote keratinocyte growth. With all possible combinations of additives, maximum stimulation was found with a combination of EGF (10 ng/ml), insulin (5 micrograms/ml), and hydrocortisone (5 micrograms/ml); none of the other combinations were more effective. Our data indicate that in short-term cultures (up to 5 days) various media additives described in the literature are not necessarily required in this system of primary culture of human oral keratinocytes.