Recurrent HNSCC Harbor an Immunosuppressive Tumor Immune Microenvironment Suggesting Successful Tumor Immune Evasion

PURPOSE

Recurrent tumors (RT) of head and neck squamous cell carcinoma (HNSCC) occur in up to 60%, with poor therapeutic response and detrimental prognosis. We hypothesized that HNSCC RTs successfully evade antitumor immune response and aimed to reveal tumor immune microenvironment (TIME) changes of primary tumors (PT) and corresponding RTs.

EXPERIMENTAL DESIGN

Tumor-infiltrating leukocytes (TIL) of 300 PTs and 108 RTs from two large independent and clinically well-characterized HNSCC cohorts [discovery cohort (DC), validation cohort (VD)] were compared by IHC. mRNA expression analysis of 730 immune-related genes was performed for 18 PTs and RTs after adjuvant chemoradiotherapy (CRT). The effect of chemotherapy and radiation resistance was assessed with an in vitro spheroid/immunocyte coculture model.

RESULTS

TIME analysis revealed overall decrease of TILs with significant loss of CD8⁺ T cells (DC P = 0.045/VC P < 0.0001) and B lymphocytes (DC P = 0.036/VC P < 0.0001) in RTs compared with PTs in both cohorts. Decrease predominantly occurred in RTs after CRT. Gene expression analysis confirmed loss of TILs (P = 0.0004) and B lymphocytes (P < 0.0001) and showed relative increase of neutrophils (P = 0.018), macrophages (P < 0.0001), dendritic cells (P = 0.0002), and mast cells (P = 0.0057) as well as lower overall expression of immune-related genes (P = 0.018) in RTs after CRT. Genes involved in B-lymphocyte functions and number of tertiary lymphoid structures showed the strongest decrease. SPP1 and MAPK1 were upregulated in vivo and in vitro, indicating their potential suitability as therapeutic targets in CRT resistance.

CONCLUSIONS

HNSCC RTs have an immunosuppressive TIME, which is particularly apparent after adjuvant CRT and might substantially contribute to poor therapeutic response and prognosis.

CD3 and CD20 immune cell densities in primary tumors, lymph node metastasis, and recurrent disease samples of head and neck squamous cell carcinoma

6551

Background: Immune cell (IC) infiltrates in primary tumors (PT) have been identified as prognostic markers in head and neck squamous cell carcinoma (HNSCC). IC densities may differ among PT, lymph node metastasis (LNM) and recurrent disease (RD) and by primary disease site (oral cavity- OC, oropharynx- OP, hypopharynx- HP, larynx- L). Here, we compare CD3 and CD20 IC densities in PT, LNM and RD in paired samples from different disease sites and determine the prognostic impact of IC infiltrates. Methods: Tissue microarrays with 425 PT, 198 LNM and 46 RD samples--each in triplicate--were stained immunohistochemically for CD3 and CD20 in the same slide. Immune cell densities per mm2 were determined using a digital image analysis software (QuPath). Individual means were calculated from triplicates of each sample. IC infiltrates from different sample types (PT, LNM, RD) and primary tumor sites were compared using Kruskal-Wallis and Mann-Whitney-U tests. Paired samples were compared using Wilcoxon signed rank test. IC densities were classified as CD3 high/low and CD20 high/low for each primary tumor site using the individual median as a cut-off. Overall survival (OS) was calculated using the Kaplan-Meier method. P-values for each hypothesis were corrected using a false discovery rate of 5%. Results: CD3 and CD20 IC densities differed significantly by sample type (both p<0.0001) and primary site (CD3: p=0.012, CD20: p=0.0017). CD3 and CD20 densities were significantly lower in PT compared to LNM or in RD compared to PT and LNM. Paired samples (n=172) revealed a significantly higher CD3 and CD20 density (both p<0.0005) in LNM compared to PT, but no significant differences between PT and RD (n=28, p>0.05). CD3 densities were significantly higher than CD20 densities in all sample types. CD3high patients had the best prognosis in all sites except for OC (q<0.05) independent of CD20 status. In OC, CD3 density was not prognostic, but CD3low/CD20high patients had the worst OS compared to CD3low/CD20low and CD3high/CD20high or even CD3high/CD20low patients (p=0.018) who had the best prognosis. Conclusions: IC densities of CD3 and CD20 vary by sample type and primary site. Except for OC, in all sites the prognostic impact is determined by CD3high, whereas in OSCC only the combination of CD3 and CD20 IC densities achieves a good prognostic value. Interestingly, CD3low/CD20high patients have the worst overall survival in OC patients. Further work is needed to understand the interaction of B- and T cell infiltrates in the tumor, especially in OC.

Cross-sectional increase of adherence to multidisciplinary tumor board decisions

BACKGROUND

Cancer research has made great progress in the recent years. With the increasing number of options in diagnosis and therapy the implementation of tumorboards (TUBs) has become standard procedure in the treatment of cancer patients. Adherence tests on tumor board decisions are intended to enable quality assurance and enhancement for work in tumor boards in order to continuously optimize treatment options for cancer patients.

METHODS

Subject of this study was the adherence of the recommendations made in three of 14 tumorboards, which take place weekly in the Center for Integrated Oncology (CIO) at the University Hospital Bonn. In total, therapy recommendations of 3815 patient cases were checked on their implementation. A classification into four groups has been made according to the degree of implementation. A second classification followed regarding the reasons for differences between the recommendation and the therapy which the patient actually received.

RESULTS

The study showed that 80.1% of all recommendations in the three TUBs were implemented. 8.3% of all recommendations showed a deviance. Most important reasons for the deviances were patient wish (36.5%), patient death (26%) and doctoral decision, due to the patient's comorbidities or side effects of the treatment (24.1%).Interestingly, deviance in all three tumor boards in total significantly decreased over time.

CONCLUSIONS

Aim of the study was to clarify the use of tumor boards and find approaches to make them more efficient. Based on the results efficiency might be optimized by increased consideration of patients` preferences, improved presentation of patient-related data, more detailed documentation and further structuring of the tumor board meetings.

MERTK as a novel therapeutic target in head and neck cancer

Although head and neck cancer (HNSCC) is the sixth most common tumor entity worldwide therapy options remain limited leading to 5-year survival rates of only 50 %. MERTK is a promising therapeutic target in several tumor entities, however, its role in HNSCC has not been described yet. The aim of our study was to investigate the biological significance of MERTK and to evaluate its potential as a novel therapeutic target in this dismal tumor entity. In two large HNSCC cohorts (n=537 and n=520) we found that MERTK is overexpressed in one third of patients. In-vitro, MERTK overexpression led to increased proliferation, migration and invasion whereas MERTK inhibition with the small molecule inhibitor UNC1062 or MERTK knockdown reduced cell motility via the small GTPase RhoA.

Taken together, we are the first to show that MERTK is frequently overexpressed in HNSCC and plays an important role in tumor cell motility. It might therefore be a potential target for selected patients suffering from this dismal tumor entity.

PD-L1 (CD274) and PD-L2 (PDCD1LG2) promoter methylation is associated with HPV infection and transcriptional repression in head and neck squamous cell carcinomas

Background

DNA methylation of the immune checkpoint gene PD-L1 has recently been shown to be associated with PD-L1 mRNA expression in various malignancies. This study aimed to investigate the association of PD-L1 and PD-L2 methylation with mRNA expression, immune cell infitration, protein expression and human papilloma virus (HPV) infection in head and neck squamous cell carcinoma (HNSCC) patients.

Results

DNA methylation of PD-L1 and PD-L2 correlates inversely with mRNA expression (PD-L1: p ≤ 0.002; PD-L2: p ≤ 0.014). Methylation of specific CpG-sites of both PD-L1 and PD-L2 were further significantly associated with HPV infection in the TCGA cohort. Immune cell infiltrates correlated significantly with PD-L1 and PD-L2 methylation. In the validation cohort, PD-L1 protein expression was associated with PD-L1 hypomethylation (p = 0.012).

Conclusions

DNA methylation of PD-L1 and PD-L2 is associated with transcriptional silencing and HPV infection in HNSCCs. Additional studies are warranted to test PD-L1 and PD-L2 methylation as predictive biomarkers for response to immunotherapies (e.g. pembrolizumab and nivolumab) that target the PD-L1/PD-L2/PD-1 immune checkpoint axis.

Materials and Methods

PD-L1 and PD-L2 promoter methylation and its mRNA expression were analyzed based on Infinium HumanMethylation450 BeadChip and RNA-Seq (both Illumina, Inc.) data in a representative HNSCC patient cohort (n = 528) enrolled by The Cancer Genome Atlas (TCGA) Research Network. A validation cohort consisting of 168 HNSCC patients treated at the University Hospital Bonn was analyzed regarding PD-L1 and PD-L2 promoter methylation by means of methylation-specific quantitative real-time PCR. PD-L1 protein expression in the validation cohort was quantified via immunohistochemistry (PD-L1 antibody clone 22C3, Dako/Agilent Technologies, Inc.).

Comparison of quantification algorithms for circulating cell-free DNA methylation biomarkers in blood plasma from cancer patients

Background

SHOX2 and SEPT9 methylation in circulating cell-free DNA (ccfDNA) in blood are established powerful and clinically valuable biomarkers for diagnosis, staging, prognosis, and monitoring of cancer patients. The aim of the present study was to evaluate different quantification algorithms (relative quantification, absolute quantification, quasi-digital PCR) with regard to their clinical performance.

Methods

Methylation analyses were performed in a training cohort (141 patients with head and neck squamous cell carcinoma [HNSCC], 170 control cases) and a testing cohort (137 HNSCC cases, 102 controls). DNA was extracted from plasma samples, bisulfite-converted, and analyzed via quantitative real-time PCR. SHOX2 and SEPT9 methylations were assessed separately and as panel [mean_SEPT9/SHOX2] using the ΔCT method for absolute quantification and the ΔΔCT-method for relative quantification. Quasi-digital PCR was defined as the number of amplification-positive PCR replicates. The diagnostic (sensitivity, specificity, area under the curve (AUC) of the receiver operating characteristic (ROC)) and prognostic accuracy (hazard ratio (HR) from Cox regression) were evaluated.

Results

Sporadic methylation in control samples necessitated the introduction of cutoffs resulting in 61–63% sensitivity/90–92% specificity (SEPT9/training), 53–57% sensitivity/87–90% specificity (SHOX2/training), and 64–65% sensitivity/90–91% specificity (mean_SEPT9/SHOX2/training). Results were confirmed in a testing cohort with 54–56% sensitivity/88–90% specificity (SEPT9/testing), 43–48% sensitivity/93–95% specificity (SHOX2/testing), and 49–58% sensitivity/88–94% specificity (mean_SEPT9/SHOX2/testing). All algorithms showed comparable cutoff-independent diagnostic accuracy with largely overlapping 95% confidence intervals (SEPT9: AUC_training = 0.79–0.80; AUC_testing = 0.74–0.75; SHOX2: AUC_training = 0.78–0.81, AUC_testing = 0.77–0.79; mean_SEPT9/SHOX2: AUC_training = 0.81–0.84, AUC_testing = 0.80). The accurate prediction of overall survival was possible with all three algorithms (training cohort: HR_SEPT9 = 1.23-1.90, HR_SHOX2 = 1.14-1.85, HR_{meanSEPT9/SHOX2} =1.19-1.89 ; testing cohort: HR_SEPT9 =1.22-1.67, HR_SHOX2 = 1.15-1.71, HR_{meanSEPT9/SHOX2} = 1.12-1.77).

Conclusion

The concordant clinical performance based on different quantification algorithms allows for the application of various diagnostic platforms for the analysis of ccfDNA methylation biomarkers.

Electronic supplementary material

The online version of this article (10.1186/s13148-017-0425-4) contains supplementary material, which is available to authorized users.

Evaluation of FGFR3 as a Therapeutic Target in Head and Neck Squamous Cell Carcinoma

BACKGROUND

Although head and neck squamous cell carcinoma (HNSCC) is the sixth most common tumour entity worldwide, it remains a clinical challenge. Large-scale explorative genomic projects have identified several genes as potential targets for therapy, including fibroblast growth factor receptor 3 (FGFR3).

AIMS

The aim of this study was to investigate the biological significance of wild-type and mutated FGFR3 to evaluate its potential as a novel therapeutic target in HNSCC.

METHODS

FGFR3 protein expression was analysed in a large HNSCC tissue cohort (n = 536) and FGFR3 mRNA expression from The Cancer Genome Atlas (TCGA; n = 520). Moreover, FGFR3 wild-type and mutant versions were overexpressed in vitro, and both proliferation and migration was assessed with and without BGJ398 (a specific FGFR1-3 inhibitor) treatment.

RESULTS

Although FGFR3 expression for both cohorts decreased during tumour progression, high FGFR3 expression levels were observed in a small subset of patients. In vitro, FGFR3 overexpression led to increased proliferation, whereas migration was not altered. Moreover, FGFR3-overexpressing cells were more sensitive to BGJ398. Cells overexpressing FGFR3 mutant versions showed increased proliferation compared to wild-type FGFR3 under serum-reduced conditions and were largely as sensitive as the wild-type protein to BGJ398.

CONCLUSIONS

Taken together, the results of this study demonstrate that although FGFR3 expression decreases during HNSSC progression, it plays an important role in tumour cell proliferation and thus may be a potential target for therapy in selected patients suffering from this dismal tumour entity.

Free-Circulating Methylated DNA in Blood for Diagnosis, Staging, Prognosis, and Monitoring of Head and Neck Squamous Cell Carcinoma Patients: An Observational Prospective Cohort Study

BACKGROUND

Circulating cell-free DNA methylation testing in blood has recently received regulatory approval for screening of colorectal cancer. Its application in other clinical settings, including staging, prognosis, prediction, and recurrence monitoring is highly promising, and of particular interest in head and neck squamous cell carcinomas (HNSCCs) that represent a heterogeneous group of cancers with unsatisfactory treatment guidelines.

METHODS

Short stature homeobox 2 (SHOX2) and septin 9 (SEPT9) DNA methylation in plasma from 649 prospectively enrolled patients (training study: 284 HNSCC/122 control patients; testing study: 141 HNSCC/102 control patients) was quantified before treatment and longitudinally during surveillance.

RESULTS

In the training study, 59% of HNSCC patients were methylation-positive at 96% specificity. Methylation levels correlated with tumor and nodal category (P < 0.001). Initially increased methylation levels were associated with a higher risk of death [SEPT9: hazard ratio (HR) = 5.27, P = 0.001; SHOX2: HR = 2.32, P = 0.024]. Disease recurrence/metastases were detected in 47% of patients up to 377 days earlier compared to current clinical practice. The onset of second cancers was detected up to 343 days earlier. In the testing study, sensitivity (52%), specificity (95%), prediction of overall survival (SEPT9: HR = 2.78, P = 0.022; SHOX2: HR = 2.50, P = 0.026), and correlation with tumor and nodal category (P <0.001) were successfully validated.

CONCLUSIONS

Methylation testing in plasma is a powerful diagnostic tool for molecular disease staging, risk stratification, and disease monitoring. Patients with initially high biomarker levels might benefit from intensified treatment and posttherapeutic surveillance. The early detection of a recurrent/metastatic disease or a second malignancy could lead to an earlier consecutive treatment, thereby improving patients' outcomes.

PD-L1: a novel prognostic biomarker in head and neck squamous cell carcinoma

Background

The PD-1 receptor and its ligands PD-L1 and PD-L2 are known to be significantly involved in T-cell regulation. Recent studies suggest that PD-L1 expression in malignant tumors contributes to an immunosuppressive microenvironment and disruption of antitumoral immune response. Drugs targeting this pathway are already tested in clinical trials against several tumor entities with promising results. However, until now comprehensive data with regard to PD-L1 and PD-L2 expression in head and neck squamous cell carcinoma (HNSCC) is still lacking.

Patients and methods

We assessed PD-L1 and PD-L2 expression via immunohistochemistry in two independent cohorts of 293 HNSCC patients.

Results

A significant subset of HNSCC showed high expression levels of PD-L1. Most remarkable, we detected a strong correlation between PD-L1 expression and overall survival time in both HNSCC cohorts. Further, in multivariate cox proportional hazard models, PD-L1 dominates as the strongest prognostic factor of patient's outcome in HNSCC, leaving even tumor stage and distant metastasis behind. Moreover, strong PD-L1 expression was associated with the presence of distant metastases in a subset of cases.

Conclusions

In summary, while the significance of PD-L2 in HNSCC seems to minor, we show that PD-L1 expression is common in HNSCC and, more importantly, a both robust and strong prognostic biomarker. In this respect, our results provide hints on further application of therapies targeting the PD-1/PD-L1 pathway in HNSCC. Investigation of response and outcome of patients receiving anti-PD-1/PD-L1 containing therapies in correlation with PD-L1 expression analysis should be an important task for the future.

STATEMENT OF TRANSLATIONAL RELEVANCE

In spite of improved treatment options and increasing knowledge of molecular alterations in HNSCC, the survival rate has not been dramatically changed in the past decades. Pies are missing in HNSCC. One promising candidate in cancer immune therapy is PD-L1.

Drugs targeting PD-L1 or its receptor PD-1 are subject of several clinical studies in different cancer entities. However, comprehensive data about PD-L1 expression in HNSCC and therefore a rational basis for anti PD-L1/PD-1 therapy in HNSCC is lacking. Here, we provide wide-ranging data about PD-L1 expression in HNSCC of all major localizations. We observed a strong correlation between expression of PD-L1 and reduced overall survival time. Furthermore, high PD-L1 expression was identified as a strong prognostic factor of patient's outcome when verified together with recognized prognostic factors.

[Interventional radiology in the head and neck region]

In interventional neuroradiology, endovascular embolization represents an important and helpful tool in the treatment of multiple head and neck diseases. These interventional procedures may be performed with curative intent, to reduce the surgical risk within a multimodal treatment concept, or to improve or at least maintain a good quality of life within a palliative therapy concept. In addition to a good understanding of disease pathology, knowledge of vascular anatomy, including collateral vessels and dangerous extracranial-intracranial anastomoses, is essential for successful treatment, as is implementation of an established technique using appropriate material. Indications for endovascular embolization are i. otherwise unmanageable bleeding (caused by e. g., trauma, vascular malformation, or tumor), ii. reduction of perioperative bleeding by preoperative embolization in case of a hypervascularized tumor, iii. selective induction of tumor necrosis by palliative embolization to enhance local tumor control. Major complications such as stroke, loss of vision, and cranial nerve palsy are mostly due to a lack of preinterventional evaluation. Regarding neurological deficits, interventions within the supply region of the external carotid artery have a complication rate below 1%.

PITX3 DNA methylation is an independent predictor of overall survival in patients with head and neck squamous cell carcinoma

BACKGROUND

Molecular biomarkers assisting risk-group assignment and subsequent treatment stratification are urgently needed for patients with squamous cell cancer of the head and neck region (HNSCC). Aberrant methylation is a frequent event in cancer and, therefore, a promising source for potential biomarkers. Here, the methylation status of the paired-like homeodomain transcription factor 3 (PITX3) was evaluated in HNSCC.

METHODS

Using a quantitative real-time PCR, PITX3 methylation was assessed in a cohort of 326 HNSCC patients treated for localized or locally advanced disease (training cohort). The results were validated with Infinium HumanMethylation450 BeadChip data from a 528 HNSCC patient cohort (validation cohort) generated by The Cancer Genome Atlas (TCGA) Research Network.

RESULTS

PITX3 methylation was significantly higher methylated in tumor compared to normal adjacent tissue (NAT; training cohort: median methylation NAT 32.3%, tumor 71.8%, p < 0.001; validation cohort: median methylation NAT 16.9%, tumor 35.9%, p < 0.001). PITX3 methylation was also significantly correlated with lymph node status both in the training (p = 0.006) and validation (p < 0.001) cohort. PITX3 methylation was significantly higher in HPV-associated (p16-positive) tumors compared to p16-negative tumors (training cohort: 73.7 vs. 66.2%, p = 0.013; validation cohort: 40.0 vs. 33.1%, p = 0.015). Hypermethylation was significantly associated with the risk of death (training cohort: hazard ratio (HR) = 1.80, [95% confidence interval (CI) 1.20-2.69], p = 0.005; validation cohort: HR = 1.43, [95% CI 1.05-1.95], p = 0.022). In multivariate Cox analyses, PITX3 added independent prognostic information. Messenger RNA (mRNA) expression analysis revealed an inverse correlation with PITX3 methylation in the TCGA cohort.

CONCLUSIONS

PITX3 DNA methylation is an independent prognostic biomarker for overall survival in patients with HNSCC and might aid in the process of risk stratification for individualized treatment.

Ectopic Myoglobin Expression Is Associated with a Favourable Outcome in Head and Neck Squamous Cell Carcinoma Patients

BACKGROUND/AIM

Ectopic myoglobin (MB) expression, mediated by alternative and hypoxia-inducible transcription, has recently been demonstrated in several epithelial tumours. This study aimed to examine the expression of MB in hormone-independent head and neck squamous cell carcinomas (HNSCCs).

PATIENTS AND METHODS

Using imunohistochemistry, ectopic MB expression was analyzed on tissue microarrays (TMAs) of 524 patients with localized and locally advanced primary and recurrent HNSCC who had undergone surgical treatment with curative intent. Associations of MB expression with survival and clinicopathological parameters were analyzed.

RESULTS

MB expression was found in 45.8% of HNSCC patients being significantly lower in normal adjacent tissue (NAT) compared to primary and recurrent tumours (p<0.001) and significantly associated with a favourable overall survival (OS) in HNSCC [p=0.037, hazard ratio (HR)=0.72, 95% confidence interval (CI)=0.53-0.98]. Furthermore, MB expression negatively correlated with human papillomavirus (HPV) status (p=0.013).

CONCLUSION

MB is differentially expressed in HNSCC and correlates with a better OS.

PITX2 and PANCR DNA methylation predicts overall survival in patients with head and neck squamous cell carcinoma

BACKGROUND

Squamous cell carcinoma of the head and neck region (HNSCC) is a common malignant disease accompanied by a high risk of local or distant recurrence after curative-intent treatment. Biomarkers that allow for the prediction of disease outcome can guide clinicians with respect to treatment and surveillance strategies. Here, the methylation status of PITX2 and an adjacent lncRNA (PANCR) were evaluated for their ability to predict overall survival in HNSCC patients.

RESULTS

PITX2 hypermethylation was associated with a better overall survival (hazard ratio, HR = 0.51, 95%CI: 0.35-0.74, p<0.001), while PANCR hypermethylation was significantly associated with an increased risk of death (HR = 1.64, 95%CI: 1.12-2.39, p=0.010).

METHODS

Quantitative, methylation-specific real-time PCR assays for PITX2 and PANCR were employed to measure bisulfite-converted DNA from formalin-fixed, paraffin-embedded (FFPE) tissues in a cohort of 399 patients with localized or locally advanced HNSCC who received curative-intent treatment (surgery with optional adjuvant radiochemotherapy or definite radiochemotherapy).

CONCLUSIONS

PITX2 and PANCR methylation status were shown to be independent predictors for overall survival in HNSCC patients. Tissue-based methylation testing could therefore potentially be employed to identify patients with a high risk for death who might benefit from a more radical or alternative treatment.

Targeting DDR2 in head and neck squamous cell carcinoma with dasatinib

Squamous cell carcinoma of the head and neck (HNSCC) is the tenth most common tumor entity in men worldwide. Nevertheless therapeutic options are mostly limited to surgery and radio-chemotherapy resulting in 5-year survival rates of around 50%. Therefore new therapeutic options are urgently needed. During the last years, targeting of receptor tyrosine kinases has emerged as a promising strategy that can complement standard therapeutical approaches. Here, we aimed at investigating if the receptor tyrosine kinase DDR2 is a targetable structure in HNSCC. DDR2 expression was assessed on a large HNSCC cohort (554 patients) including primary tumors, lymph node metastases and recurrences and normal mucosa as control. Subsequently, DDR2 was stably overexpressed in two different cell lines (FaDu and HSC-3) using lentiviral technology. Different tumorigenic properties such as proliferation, migration, invasion, adhesion and anchorage independent growth were assessed with and without dasatinib treatment using in-vitro cell models and in-vivo zebrafish xenografts. DDR2 was overexpressed in all tumor tissues when compared to normal mucosa. DDR2 overexpression led to increased migration, invasion, adhesion and anchorage independent growth whereas proliferation remained unaltered. Upon dasatinib treatment migration, invasion and adhesion could be inhibited in-vitro and in-vivo whereas proliferation was unchanged. Our data suggest treatment with dasatinib as a promising new therapeutic option for patients suffering from DDR2 overexpressing HNSCC. Since dasatinib is already FDA-approved we propose to test this drug in clinical trials so that patients could directly benefit from this new treatment option.

Expression and role of the embryonic protein SOX2 in head and neck squamous cell carcinoma

Recently, SOX2 has been identified as a potential lineage-specific oncogene in lung squamous cell carcinomas. Since head and neck squamous cell carcinomas (HNSCC) are morphologically and clinically highly related to lung squamous cell carcinomas, we hypothesized that SOX2 also plays an oncogenic role in this tumor entity. We assembled a cohort of 496 patients with HNSCC, including 253 metastases and 135 recurrences. SOX2 amplification (FISH) and SOX2 protein expression (immunohistochemistry) were correlated with molecular and clinicopathological parameters. In order to investigate the functional role of SOX2 in human HNSCC, SOX2 knockdown and overexpression in SCC-25 cells were generated by lentiviral constructs and subjected to cell cycle analysis, proliferation and apoptosis assays. Furthermore, SOX2 expression was correlated with the expression of proliferation and apoptosis-related proteins in primary HNSCC samples. SOX2 amplification was detected in 21% of primary HNSCC and mostly observed in a concordant manner between primary tumors and corresponding metastatic tissues. Overall, SOX2 amplification resulted in protein overexpression and was mutually exclusive with human papillomavirus infection. SOX2 protein overexpression was associated with clinicopathological parameters of worse outcome. Functionally, SOX2 induced the expression of the antiapoptotic protein BCL-2 and enhanced resistance to apoptosis-inducing agents including cisplatin, indicating SOX2 as a mediator of therapy resistance in human HNSCC. Targeting SOX2 and related molecular downstream pathways such as BCL-2 may enhance therapy efficacy in SOX2-expressing HNSCC.

[Management of atypical cervical mycobacteriosis in childhood]

Atypical mycobacteriosis is a rare cause of cervical lymphadenitis that most frequently affects immunoincompetent children between the ages of 12 months and 5 years. The typical clinical manifestation is a painless unilateral cervical mass. The nonspecific clinical symptoms and laboratory parameters complicate diagnosis and, therefore, therapeutic management. Various therapeutic options, including surgery, antimycobacterial drug therapy and wait-and-scan approaches are discussed in the literature. Complete surgical excision has become the established treatment of choice. However, controlled randomized studies that clearly demonstrate the benefits of a particular type of therapy are lacking.

Fibroblast growth factor receptor-1 as a potential therapeutic target in sinonasal cancer

BACKGROUND

Despite multimodal treatment, sinonasal malignancies have an unfavorable prognosis. The purpose of this study was to elucidate if these tumors harbor amplifications of the fibroblast growth factor receptor 1 (FGFR1) gene, which has recently been identified as a potential therapeutic target in squamous cell lung cancer.

METHODS

One hundred twelve primary tumors (including squamous cell carcinoma [SCC], carcinoma associated with an inverted papilloma, sinonasal undifferentiated carcinoma [SNUC], adenocarcinoma, adenoid cystic carcinoma [ACC], esthesioneuroblastoma, and 9 corresponding lymph node metastases) were assessed by fluorescence in situ hybridization (FISH) for FGFR1 copy number status. Human papillomavirus (HPV) status was assessed by p16 immunohistochemical as a surrogate marker.

RESULTS

FGFR1 amplification was found in subsets of sinonasal SCCs (20%), carcinomas associated with an inverted papilloma (33%), and SNUCs (5%). In all cases, metastatic tumor samples shared the same FGFR1 amplification status as the corresponding primary tumor tissue. None of the FGFR1-amplified tumors expressed p16.

CONCLUSION

FGFR1 amplification represents a potential molecular target in a subset of patients with sinonasal cancer. © 2014 Wiley Periodicals, Inc. Head Neck 36: 1253-1257, 2014.

[Treatment results of nasopharyngeal carcinoma in adults]

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a rare tumor entity in Germany in contrast to endemic countries in Asia or Africa. This retrospective study investigated patient characteristics and prognostic factors with respect to different NPC treatment strategies.

PATIENTS AND METHODS

A total of 63 NPC patients treated during the period 1990-2009 at the University Hospital Bonn, Germany, were included.

RESULTS

The median age of the patients was 56.4 years, the male:female ratio was 3.2:1, 23.8% were in Union Internationale Contre le Cancer (UICC) stage I/II and 76.2% were in stage III/IV. Most of the carcinomas were WHO type III (57.1%), followed by World Health Organization (WHO) type II (33.3%) and at last WHO type I (9.6%). The 5-year overall survival rate after concomitant chemoradiotherapy (RCT) was 75% and after radiotherapy (RT) 60%. The mortality rate increased by 3.5 times with each increase in T-stage (p ≤ 0.047). The recurrence rate (RR) after RCT was 34% and after RT alone 68% (p ≤ 0.04). Tumor ablation increased the RR significantly (p ≤ 0.047).

CONCLUSION

Combined chemotherapy and RT is an effective treatment of NPC disease and clearly superior to RT alone. Tumor ablation before RCT/RT worsens the prognosis and is now obsolete.

[Interdisciplinary emergency departments : first experiences from the ENT and head and neck perspective]

BACKGROUND

Centralized emergency departments are becoming a major source of health care in Germany. In this study, we evaluated the importance for ENT health care.

METHODS

In a retrospective study, all ENT emergency patients between May and July 2011 were characterized by diagnosis, therapy, and urgency (measured using the Manchester Triage System [MTS]). General epidemiological data from the emergency department were recorded between 2009 and 2011.

RESULTS

Between 2009 and 2011, 50,699 patients were treated in the centralized emergency department of the University Hospital Bonn. A total of 15,658 (30.8%) needed ENT health care. During May 2011 to July 2011, ENT emergency patients had not only a wide variety of diseases but also a broad range of ages (0-98 years). Using the MTS, emergency patients (4% acute emergencies) were identified and urgency was determined prior to first contact with the physician.

CONCLUSION

ENT emergency care plays an important role for centralized emergency departments. Most of the patients have ENT diseases treatable as an outpatient in a single visit. MTS can be used to determine the appropriate level of urgency.

[Analysis of quality of life outcome for nasopharyngeal carcinoma patients after treatment]

BACKGROUND

This retrospective study analysed patient characteristics and quality of live (QoL) for patients with nasopharyngeal carcinoma (NPC) after treatment.

MATERIAL AND METHODS

A cross-sectional investigation was conducted to assess the QoL of 20 NPC patients with cancer-free survival of more than one year, which were treated with radiotherapy (RT) or chemoradiotherapy (RCT) during the period 2001-2009 at the University Hospital Bonn, Germany. The QoL was assessed by the FACT-NP (functional assessment of cancer therapy-nasopharyngeal) questionnaire.

RESULTS

The median age of the patients was 57 ± 13 years and the male/female ratio was 2.33/1.3 (15%) patients were treated with RT and 17 (85%) with RCT. The global QoL was good in our patients. Xerostomia, chewing, decrease of gustatory sense, discontent with sexual life and ear problems were of major concern with the majority of patients and affected the QoL negatively. Pain, lost of working ability, emotional distress, or family problems were no significant factors.

CONCLUSION

The expected reduction of QoL after treatment must be explained in detail to the NPC patient. The integration of the family and partner, an antidepressant therapy or psycho-oncological support can be useful and necessary.

[Facial impalement in childhood : obtain an overview before actionism]

Facial impalement in childhood is very rare. In most cases, it is caused by accident. We present two young patients who suffered a facial impalement injury and were treated in the interdisciplinary emergency room of the University Hospital Bonn, Germany. The degree of injury could not be completely determined during the first examination. Serious complications could be excluded after examination via computed tomography (CT) and surgical exploration. The indication to use CT or magnetic resonance imaging in childhood has to be considered in order to obtain full and exact information about the extent of injury.

Cyclic AMP-mediated upregulation of the expression of neuronal NO synthase in human A673 neuroepithelioma cells results in a decrease in the level of bioactive NO production: analysis of the signaling mechanisms that are involved

The expression level of neuronal nitric oxide synthase (nNOS) can vary depending on the (patho)physiological conditions. Here we document a marked induction of nNOS mRNA, protein, and total NO production in response to dibutyryl cyclic AMP (db-cAMP) in human A673 neuroepithelial cells. However, the upregulation of nNOS was associated with a decreased level of production of bioactive NO and by an increase in the level of generation of reactive oxygen species (ROS). ROS production could be prevented by the NOS inhibitor L-NAME, suggesting nNOS itself is involved in ROS generation. Sepiapterin supplementation of db-cAMP-treated A673 cells could restore full bioactive NO production, most likely by preventing the uncoupling of nNOS. nNOS was upregulated by other stable analogues of cAMP, by the activator of adenylyl cyclase forskolin, by isoproterenol or by dopamine through activation of D1 receptors, and by inhibitors of phosphodiesterase. cAMP did not change the half-life of the nNOS mRNA. Inhibitors of protein kinase A (PKA), H-89 and R(p)-cAMPS, produced a partial inhibition of basal and cAMP-induced nNOS expression. cAMP response element binding and modulator transcription factors (CREB and CREM), typical target proteins of PKA, were expressed in A673 cells, as was the coactivator CREB binding protein (CBP). cAMP-stimulated induction of nNOS was significantly enhanced in A673 cells stably transfected with wild-type CREB and almost abolished in cells transfected with KCREB (containing a mutation of the DNA binding domain). In A673 cells transfected with CREB(133) (containing a mutation of the phosphorylatable serine 133), the overall level of nNOS expression was reduced, but the expressional stimulation by cAMP remained. This suggests that CREB bypasses, in part, the classical requirement for phosphorylation and association with CBP. Three members of the recently described four-and-a-half-LIM-domain proteins (FHL1-FHL3) were found to be expressed in A673 cells; FHL-1 and FHL-3 were upregulated by cAMP. These proteins can provide direct activation function to both CREB and CREM, and may be responsible for the PKA-independent component of CREB and CREM activity.

[Primary fallopian tube cancer--an Austrian multicenter study]

Incidence and prognostic factors of primary carcinomas of the Fallopian tubes were studied in a retrospective multi-centre analysis of 81 women during the period of 1980 to 1990. Data from 13 departments (university as well as general hospitals) were included in the present study which was designed to evaluate the state-of-the-art of diagnosis and treatment of carcinoma of the Fallopian tubes in Austria, and to compare the results with those from the literature. Stages were classified according to the modified FIGO-system for ovarian cancer; grading followed the criteria of Hu, Taylor and Hertig. The mean age of the patients was 62.1 years. Thirty-seven (45.7%) tumours were found to be in stage I, sixteen (19.8%) in stage II, nineteen (23.4%) in stage III, and nine (11.1%) tumours in stage IV. In 66 Patients, the tumour could be radically removed. The surgical method applied in 68 cases was removal of the uterus, the adnexa, and/or the omentum, or lymph nodes. Post-operatively, patients underwent an adjuvant therapy which was either irradiation (n = 32; 39.5%), or chemotherapy (n = 34; 42.0%). Fifteen patients had no therapy after operation. The five-year survival rate for stages I and II was 75% compared to 17% in stages III and IV.

[PAP IV in pregnancy--a retrospective multicenter study]

An analysis was made of the procedure when PAP IV occurs in pregnancy. 63 patients between 1. 1. 1985 and 1. 4. 1990 from 6 main hospitals in Vienna were included in this study. In 30 cases, a cone biopsy was made during pregnancy, whilst in 33 cases, the operation was performed after delivery. In both groups, the tissue showed in the histological examination nearly the same incidence rate of carcinoma stage Ia, carcinoma in situ as well as mild, moderately severe, and severe dysplasia. A significant frequency was found for a delivery before the 35th week of gestation, if conisation was done during pregnancy. An increased negative foetal outcome was also found if the operation was performed after the 16th week of gestation. Conservative procedure showed a better foetal outcome with the same security, in that carcinoma stage Ib was never overlooked. On-target biopsy under colposcopic control, combined with a conisation 8 to 10 weeks after delivery, is therefore recommended.

Low-dose ethanol for inhibition of preterm uterine activity

Inhibition of preterm labor by tocolytic agents reduces the incidence of preterm birth. Betamimetic drugs are the most widely used tocolytic. However, they are from time to time contraindicated, their administration involves potential risks for mother and fetus, and their tocolytic effect is sometimes insufficient. Ethanol infused in intoxicating doses was the first clinically useful tocolytic agent, but because of its potential risks to the fetus, its use is now infrequent. We have examined the efficacy of ethanol infused at much lower rates, alone or in combination with ritodrine, to inhibit preterm uterine contractions. Fifty-four women between 20 and 36 weeks of gestation participated in the study. In 14, betamimetics were contraindicated and they were given ethanol alone. In 38, ritodrine infusions (0.2 gm/min) had failed to arrest preterm labor and they were then given ethanol with ritodrine (0.2 gm/min) The dose of ethanol was 0.11 gm/kg/hour on the average, which is approximately equivalent to the metabolic rate. Altogether, 64 treatments were given, 14 with ethanol alone and 50 combined with 0.2 gm/min ritodrine. In 81% of the treatments, contractions were suppressed within 15.3 hours on the average. Preterm birth (infant less than 2500 gm) was prevented in 70% of the patients. No adverse effects attributable to ethanol were observed. Treatment with low-dose intravenous infusion of ethanol is a cheap, efficacious, and low-risk method to stop preterm uterine activity and is clinically useful for prevention of preterm birth. Possible mechanism of this effect is discussed.

[Value and significance of obstetric monitoring methods]

In a retrospective study on 224 births, 200 continuous tracings recorded during intrapartum cardiotokography were analysed for the presence of alarm signals and the incidence of fetal acidosis assessed by fetal blood sampling. Moreover, we classified the 200 monitored parturitions according to the presence of risk at the beginning and/or the appearance of alarm signals during labour into 4 groups. In 17% of the parturitions without initial risk alarm signals were subsequently recorded on CTG, whereas alarm signals occurred in 35% of high-risk births. In both groups fetal distress, as assessed by fetal blood sampling, was detected in 4%. In all investigated cases we simulated a policy of intrapartum monitoring by intermittent auscultation (IA) up to the pushing period. The CTG tracings were analysed retrospectively, whilst counting the fetal heart rate every fifteen minutes. The possible results and consequences of IA were compared with the actual results and management based on CTG alone. Vice the real management, were the decision for operative delivery after the suspected diagnosis of fetal distress had been confirmed by fetal blood sampling. The results of all three methods were compared. The superiority of CTG over IA in detecting alarming situations and fetal distress, was proven statistically. In order to prevent the unnecessary operative delivery of an infant erroneously considered to be distressed, it is mandatory to check the indication by fetal blood sampling.

[Possibilities and value of discontinuous labor monitoring by cardiotocography. A retrospective study based on a continuous cardiotocogram]

The effectiveness of fictitious discontinuous intrapartum CTG monitoring was investigated and compared with available continuous CTG's by means of a retrospective analysis of 200 CTG tracings. CTG is a method of high sensitivity and offers, together with foetal intrapartum blood sampling, a possibility to detect foetal distress with high specificity and predictive value. From these CTG tracings the fictitious periods of time were assessed according to a certain schema to give women a possibility of being unrestricted in their activities without intrapartum monitoring while at the same time they were under satisfactory surveillance to notice sufficiently early any foetal distress that might lead to severe acidosis. The study was subdivided into 4 groups: Group 1: Patients at no risk during pregnancy and/or risk on admittance or during labour, no alarming signs from the foetus during the intrapartum period. Group 2: No risk, but with alarming signs from the foetus. Group 3: Patients at risk, no alarming signs from the foetus. Group 4: Patients at risk and with alarming signs from the foetus. The results suggest the possibility of discontinuous intrapartum monitoring according to a certain schema up to the second stage of labour, at minimum intrapartum risk for the baby, especially if there were no risks during pregnancy and at the beginning of delivery. According to these results 83% of all patients in labour would not have needed continuous CTG for more than half of the time spent in the labour ward. Only one in 6 deliveries (17%) would have required continuous monitoring.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intravaginal treatment of colpitis maculosa with an oestriol-containing vaginal cream (author's transl)]

43 patients with colpitis maculosa (average age 60.2 years) were selected for an open control therapeutic study with Ortho-Gynest vaginal cream (Ortho-Cilag). The cream contains 0.5 mg of oestriol per single applicator filling. The treatment lasted from 3 to 4 weeks, success being evaluated by clinical documentation and cytological evaluation of vaginal smears before and after treatment. 10 patients (23.3%) were treated successfully, 29 (67.4%) showed a distinct improvement both clinically and cytologically, whilst the remaining 4 (9.3%) showed only moderate improvement. Hence, 39 patients (90.7%) were classified as having been successfully or partly successfully treated. Severe symptoms disappeared completely or were greatly alleviated in 91.4% cases. Moderate symptoms vanished in 59.7%. 58.1% showed a complete normalisation of the former atrophic vaginal skin. Blood spotting and reddening of the vaginal wall vanished completely. A change from dry to moist vagina occurred in 77.3% patients. Discharge vanished completely in 80.6% cases. No untoward side effects were recorded.