[Stomal Cancer Recurrency, A Clinic-Pathological Consideration]

Objectives: Analysis of pre-operative tracheostomy and circumjacent tumour free margins as risk factors in the development of stomal recurrent disease after (pharyngo)laryngectomy. Material and Methods: 124 patients after (pharyngo)laryngectomy were analyzed for disease related data and tumour samples were analyzed for tumour free margins. The overall cohort was divided into patients with/withour pre-operative tracheostomy. Results: 18 patients suffered from recurrent disease (10 stomal, 8 distant metastases). Advanced T-status, female gender, and sub-/glottic tumour manifestation resulted in a higher rate of prior tracheostomy. Pre-operative tracheostomy did not influence the development of stomal recurrency. R0 resection was achieved in 94% of our patients, with significant reduced tumour free margins in patients with stomal recurrency (p=0.002) Conclusion: Pre-operative tracheostomy did not influence the development of stomal recurrent disease. The clinical identification of ventral soft tissue infiltration should result in extensive surgical concepts.

[Current surgical and adjuvant therapy concepts of malignant tumors of the facial skin and the pinna]

Malignant tumors of the skin had been a rare entity 2 decades ago. Today they are spread rapidly worldwide. Malignant neoplasms of the skin, the largest human organ, may occur from all structures and layers. While previously skin cancer -occurred mainly after the age of 60, the incidence increases now in younger ages. Strong sunburns in the childhood and before the age of 20 are important risk factors for the development of malignancies of the skin. An increased exposure to UV rays is found especially in the facial skin, where basal cell carcinoma, squamous cell carcinoma, malignant melanoma and Merkel cell carcinomas are the most common malignancies. Early diagnosis of malignancies and therapy-oriented mostly surgical approaches are crucial for the prognosis of all skin cancers. Therefore under the aspect of the increasing incidence these topics will be pointed out according to the latest findings including current multimodal therapy concepts and future treatment options.

In vitro chemosensitivity of head and neck cancer cell lines

Background

Systemic treatment of head and neck squamous cell carcinoma (HNSCC) includes a variety of antineoplastic drugs. However, drug-resistance interferes with the effectiveness of chemotherapy. Preclinical testing models are needed in order to develop approaches to overcome chemoresistance.

Methods

Ten human cell lines were obtained from HNSCC, including one with experimentally-induced cisplatin resistance. Inhibition of cell growth by seven chemotherapeutic agents (cisplatin, carboplatin, 5- fluorouracil, methotrexate, bleomycin, vincristin, and paclitaxel) was measured using metabolic MTT-uptake assay and correlated to clinically-achievable plasma concentrations.

Results

All drugs inhibited cell growth in a concentration-dependent manner with an IC50 comparable to that achievable in vivo. However, response curves for methotrexate were unsatisfactory and for paclitaxel, the solubilizer cremophor EL was toxic. Cross-resistance was observed between cisplatin and carboplatin.

Conclusion

Chemosensitivity of HNSCC cell lines can be determined using the MTT-uptake assay. For DNA-interfering cytostatics and vinca alkaloids this is a simple and reproducible procedure. Determined in vitro chemosensitivity serves as a baseline for further experimental approaches aiming to modulate chemoresistance in HNSCC with potential clinical significance.

[Emergency management of acute angioedema]

Angioedema is an oedematous swelling of the mucosa or submucosa of the skin. Acute angioedema represents a clinical emergency when the pharynx or larynx are involved and breathing of the patient is impaired. For rapid and effective treatment it is necessary to differentiate between allergic and non-allergic angioedema. Three of the five subforms of non-allergic angioedema are mediated by bradykinin: renin-angiotensin-aldosterone system (RAAS)-blocker-induced angioedema (RAE), hereditary angioedema (HAE) and acquired angioedema (AAE). Antihistamines, corticosteroids and adrenalin can be used to treat allergic angioedema but are ineffective in acute attacks of non-allergic angioedema. In these events the bradykinin-B2-receptor antagonist icatibant (in HAE, or RAE) or C1-INH concentrate (in HAE, or AAE) are therapeutic options for rapid alleviation of acute angioedema. The following article gives an overview of the diagnostics and treatment in the emergency situation of "acute angioedema", especially if swelling of the head-and-neck region is present.

Risiko von Blutungen nach Adenotomie und Tonsillektomie

BACKGROUND

Hemorrhage after tonsillectomy and adenoidectomy remains a serious complication. Therefore, routine preoperative coagulation screening, including activated partial thromboplastin time (aPTT), prothrombin time (PT) and platelet count (PLC), are regularly performed, also for medicolegal reasons. In the recently published statement of the German Society of Otorhinolaryngology, Head and Neck Surgery the need for routine preoperative coagulation screening is discussed, but so far no standardized procedure had been established. According to this statement - at least for children - routine preoperative coagulation screening is not mandatory as long as the thorough medical history provides no evidence for a coagulation disorder ( http://www.hno.org/kollegen/gerinnung_te_ae.html ). The present study was undertaken to determine the occurrence of postoperative hemorrhage on the one hand, and the incidence of abnormal preoperative routine coagulation parameters or pathological anamnesis findings on the other.

PATIENTS AND METHODS

In 688 patients, a standardized clinical history was obtained using a questionnaire. Coagulation screening included aPTT, PT, and PLC was also carried out. Bleeding complications were then correlated with anamnesis features and abnormalities in coagulation screening.

RESULTS

In 39 (5.7%) of the 688 patients we found abnormal coagulation values, which were confirmed in repeated analyses. In six of these a detailed analysis revealed occult coagulation disorders requiring correction only in the case of bleeding complications who were previously unknown. Fifteen patients were already known to have a coagulation disorder, and the anamnesis identified no additional patient at risk. Thus, 21 patients with coagulation disorders requiring correction in the case of a bleeding complication underwent surgery. However, only eight (38%) of these showed abnormal routine coagulation parameters. Surgical treatment of postoperative hemorrhage was required in 12 patients, all of whom had normal values for aPTT, PT and PLC.

CONCLUSION

The frequently performed determination of routine coagulation parameters (aPTT, PT, PLC) is not able to reliably identify relevant coagulation disorders or to predict the risk for postoperative hemorrhagic complications after adenoidectomy or tonsillectomy.

Preoperative Screening for Coagulation Disorders in Children Undergoing Adenoidectomy (AT) and Tonsillectomy (TE): Does it Prevent Bleeding Complications?

BACKGROUND

Bleeding remains the most important complication of adenotonsillectomy in children. Preoperative coagulation tests are widely used to detect unknown bleeding disorders. To determine the efficacy of preoperative coagulation screening in preventing bleeding complications.

PATIENTS

Study group 1: 148 healthy children referred by the otorhinolaryngology department for preoperative pediatric examination. Study group 2: 124 healthy children sent to the hemostaseologic clinic for preoperative investigation of a prolonged PTT.

METHOD

The incidence of relevant coagulation disorders detected by a standardized bleeding history and coagulation screening tests was studied prospectively in 2 study groups planned for AT and/or TE. The frequency of abnormal bleeding was investigated retrospectively in those children who underwent surgery.

RESULTS

Bleeding disorders were detected in 7/148 and 15/124 children in study group 1 and 2 respectively. 141/148 and 79/124 children actually underwent surgery, 62 TE +/- AT + 79 AT alone and 26 TE +/- AT + 53 AT alone respectively. Major bleeding occurred in 1/141 patients (1 TE) in study group 1. Preoperatively, this child had shown normal coagulation screening tests. In 4/79 patients (3 TE, 1 AT) in study group 2, surgery was complicated by major bleeding. Despite extensive testing, no relevant bleeding disorder had been diagnosed in these children preoperatively. Sensitivity of coagulation screening tests for major bleeding was 0 in study group 1.

CONCLUSIONS

In our study, coagulation screening failed to effectively identify patients at risk of bleeding.

Die Kollageninjektion zur Augmentation des insuffizienten Stimmprothesenlagers

After laryngectomy the majority of patients receive a vocal rehabilitation by tracheo-esophageal puncture and insertion of voice prosthesis. Periprosthetic leakage causing aspiration represents a well known complication and is frequently treated by temporary removal of the prosthesis with shrinkage of the shunt. Here we describe 10 patients with such a leakage treated by collagen injection for periprosthetic tissue augmentation. A mean of 1,6 injections were necessary for complete control of the leakage. The injection was well tolerated and was found effective for median period of 9,3 months. In our hands the periprosthetic collagen injection represents an effective and well tolerated procedure for temporary augmentation of tracheo-esophageal leakage in post-laryngectomy patients. However, alternative fillers without pre-testing necessity and longer augmentation intervals should be considered.

Der infraklavikuläre Durchzug des M.-pectoralis-major-Lappens

BACKGROUND

The pectoralis major myocutaneous flap (PMMF) is an important reconstructive tool for lesions in the head and neck region. Using the supraclavicular route, the PMMF reliably transfers large amounts of well-vascularized skin and muscle into defects of the upper aerodigestive tract. However, limited length and arc of rotation as well as excessive bulk can be problematic.

PATIENTS AND METHODS

In the current study, these problems have been addressed by passing the pedicle deeply to the clavicle. Following flap harvest, the pedicle was passed in the subclavicular plane in 15 head and neck cancer patients for primary and secondary reconstruction.

RESULTS

Using this route it was possible to increase the medium length of PMMF to 3 cm compared to the supraclavicular route. No total flap necrosis occurred, however, temporary complications were observed in three of 15 cases (20%)--partial flap necrosis occurred in two cases and fistula formation was observed in one case. This rate is in accordance with complication rates described for the supraclavicular route. However, in long-term follow-ups we observed a fracture of the clavicle in two patients in whom, in contrast to the others, the periostium was not only prepared posteriorly but over the whole circumference.

CONCLUSIONS

The subclavicular route for PMMF increases the length and arc of rotation available for reconstruction without compromising vascular supply to a higher degree than with the conventional supraclavicular route. Furthermore, this concept decreases the bulk of the PMMF pedicle which is functionally and cosmetically favourable. Thus, the subclavicular route of PMMF is safe and allows an extension of the reconstructive possibilities.

Dapson-induzierte Agranulozytose

A 34-year-old female patient with a three year history of generalized granuloma annulare was treated systemically with dapsone (DADPS). Six weeks after the onset of treatment, the patient developed an extensive tonsillitis of the base of the tongue with fever and malaise. Routine laboratory work showed a leukocytopenia with agranulocytosis. Further investigation revealed a marked decrease of the enzyme activity of N-acetyltransferase 2, which plays an important role in dapsone metabolism. Treatment included the cessation of dapsone, antibiotic coverage, and G-CSF leading to the rapid improvement of symptoms and normalization of leukocyte counts. Dapsone-induced angina agranulocytotica is a rare event and is interpreted as an idiosyncratic reaction. Depending on genetic polymorphisms of various enzymes, dapsone can be metabolized to immunologically or toxicologically relevant intermediates. Because of the risk of severe hematologic reactions, dapsone should only be employed for solid indications and with appropriate monitoring.

Increased C-reactive protein in ACE-inhibitor-induced angioedema

AIMS

This study was designed to identify new factors which may contribute to angiotensin-converting-enzyme-inhibitor (ACEI)-induced angioedema.

METHODS

In a retrospective cohort study we examined 25 patients who used an ACEI and presented at our emergency room with acute angioedema as well as 18 patients with unknown cause of angioedema and a total of 21 patients on ACEI-therapy without previous angioedema. We measured markers of inflammation such as acute-phase proteins (C-reactive protein, fibrinogen), leukocyte count and body temperature.

RESULTS

The mean interval between initiation of ACEI treatment and first manifestation of angioedema was 35.8 +/- 5.3 months. During symptomatic angioedema, mean plasma levels of C-reactive protein and fibrinogen were significantly increased by 7.3-fold and 1.5-fold, respectively, while leukocyte count and body temperature were normal. These changes disappeared after successful treatment of angioedema and were not found in patients with angioedema of unknown cause and those receiving ACEI without having experienced angioedema.

CONCLUSION

Our findings demonstrate for the first time that ACEI-induced angioedema is associated with strongly increased plasma levels of CRP. We suggest that CRP is involved in the pathophysiology of ACEI-induced angioedema.

[ACE inhibitor-induced angioedema in the head and neck region. A matter of time?]

BACKGROUND

Angioedema in the head and neck region is potentially life-threatening and may occur as a side effect of inhibitors of the angiotensin-converting-enzyme (ACEI). So far, little is known about the time between the first application of ACEI and the occurrence of angioedema, or of possible cofactors and laboratory changes.

MATERIAL AND METHODS

A total of 21 patients with angioedema during the course of ACEI treatment were compared to 11 patients with angioedema of unknown cause. These were retrospectively analysed for the following criteria: (1) duration of ACEI medication, (2) leading and concomitant diseases, (3) history of allergies, (4) co-medication, (5) laboratory changes, (6) treatment success, and (7) manifestation of recurrent episodes.

RESULTS

The mean interval between the initiation of ACEI therapy and the first occurrence of angioedema exceeded 2 years. Values for the acute phase proteins C-reactive protein (CRP) and fibrinogen were significantly increased in the ACEI group compared to the control group.

CONCLUSIONS

In any case of angioedema in the head and neck region, a side effect of ACEI must be taken into consideration even if the medication has been taken for months or years.

Plattenepithelkarzinome des Kopf-Hals-Bereichs

Biologic therapies able to induce or up-regulate anti-tumor immune responses could represent a complementary approach to improve the conventional treatment of squamous cell carcinomas of the head and neck (SCCHN). Patients with SCCHN are frequently immunocompromised due to the elimination and dysfunction of critical immune effector cells. Therefore, it might be necessary to restore these immune functions to allow for the generation of effective anti-tumor host responses. Simultaneously, to prevent tumor escape from immunological recognition and destruction, it might also be necessary to alter antigenic and immunogenic attributes of the malignant cells. The present overview summarizes general aspects, historical data, and recent advances in the field of immunotherapy of SCCHN, including non-specific immune stimulation, transfer of immunocompetent cells, gene therapy, use of monoclonal antibodies, and anti-cancer vaccines.

[Argon plasma coagulation (APC) for palliative treatment of tracheostomal recurrences]

INTRODUCTION

To reduce tumor recurrences in the tracheostomal region mostly surgical measures come to the fore.

PATIENTS AND METHODS

In six incurable patients with peristomal tumor recurrence, we performed nine palliative tumor reductions using argon plasma coagulation (APC). This electrosurgical non-contact technique has been described to produce effective hemostasis and favorable wound surfaces.

RESULTS

In all nine procedures APC led to rapid and reliable hemostasis. Postoperative bleedings did not occur, and dry wound surfaces adjusted to the level of surrounding body contours considerably facilitated the wound aftercare. After eight of nine APC operations the immediate insertion of conventional cannulas was feasible instead of the tracheostomy tubes needed in the interim, and the patients were again able to change the cannula themselves. Two laryngectomized individuals could resume use of their voice prosthesis.

CONCLUSION

APC is particularly suitable for the palliative surgical treatment of tumor recurrences in the tracheostomal region, because it helps to circumvent typical problems of conventional surgery.

Clinical trial with escalating doses of the antiepidermal growth factor receptor humanized monoclonal antibody EMD 72 000 in patients with advanced squamous cell carcinoma of the larynx and hypopharynx

In this open uncontrolled phase I study, nine patients with stage III and IV squamous cell carcinoma of the head and neck (SCCHN) were treated with five administrations of the humanized antiepidermal growth factor receptor monoclonal antibody EMD 72000 in three consecutive ascending dose groups. Loading doses of 100 mg (group I), 200 mg (group II), and 400 mg (group III) were followed by four weekly maintenance doses of half the loading doses, i.e. 50, 100, and 200 mg, respectively. Two EMD 72000 administrations were scheduled before and three after surgery. The objectives of this trial were (a) to investigate the safety and toxicity of multiple EMD 72000 doses, (b) to determine the cumulative maximum tolerated dose of EMD 72000 at dosages between 300 mg and 1,200 mg, and (c) to determine the serum pharmacokinetics of EMD 72000. In total, 102 adverse events (AEs) were reported: five of toxicity grade 3, 18 of toxicity grade 2, 66 of toxicity grade 1, and 38 of toxicity grade 0. All AEs of toxicity grade 3 were considered to be not or remotely related to EMD 72000. The most frequent study drug-related AEs were fever and a transient elevation of liver enzymes. In all patients, the time to reach peak serum concentrations (tmax) was within 1-3 h of the start of each EMD 72000 infusion. Average peak serum concentrations (Cmax) after correction for dosage appeared to be dose-independent, whereas the half-life (t1/2) showed dose dependency. In conclusion, EMD 72000 was very well tolerated in patients with advanced stage SCCHN. The pharmacokinetic data from this trial suggest the feasibility of conducting future studies with weekly doses of 200 mg EMD 72000.

Relapsing polychondritis in childhood--case report and short review

Relapsing polychondritis (RP) is a disease of unknown etiology and it is characterized by inflammation of the cartilage. While the clinical picture of RP in adults is well described, RP in childhood is poorly documented. We describe a young girl presenting with acute dyspnea, stridor and polyarthritis. The diagnosis of RP was made 2 years after first presentation, when auricular chondritis occurred. Based on a MEDLINE search, reports on RP in childhood were reviewed. The frequency of chondritis and systemic manifestations of RP in children was compared to data in adults and found to be very similar. RP in childhood can be a life-threatening and debilitating disease.

Serum level and tissue expression of c-erbB-1 and c-erbB-2 proto-oncogene products in patients with squamous cell carcinoma of the head and neck

The proto-oncogene products erbB-l (EGF-Receptor) and erbB-2 (HER-2/neu), distinct members of the epidermal growth factor receptor family, are frequently overexpressed in squamous cell carcinoma of the head and neck (SCCHN). The accumulation of these transmembrane proteins may lead to significant amounts of the respective extracellular receptor domains (ECD) that are shed from the tumour cell surface and enter blood circulation, thus representing potential serum tumour markers. For erbB-l and erbB-2, we determined the ECD serum levels with enzyme-linked immunosorbent assays and evaluated the protein expression in tumour tissue by immunohistochemistry. The present study included 49 patients (37 untreated, 12 recurrences) and the same number of age- and sex-matched healthy controls. In 24 patients ECD serum levels were determined before and 6 weeks after surgery. Mean ECD serum levels for erbB-1 and erbB-2 were 54.8+/-1.6 and 153.7+/-6.1 fmol/ml in cancer patients, and 54+/-1.5 and 147.9+/-4.5 fmol/ml in healthy controls, respectively. There was no significant difference between untreated and recurrent disease. Serum ECD follow-ups 6 weeks after surgery revealed a significant 12.3% decline of erbB-1 but no change of erbB-2 values. Immunohistochemistry showed strong staining for erbB-1 in 78% and erbB-2 in 47% of the SCCHN specimens. No correlation was detectable between receptor ECD serum levels and receptor tissue expression, tumour stage, and tumour differentiation. Hence, ECD serum levels of erbB-1 and erbB-2 are not considered to be valuable tumour markers in SCCHN.

Establishment and characterization of four cell lines derived from human head and neck squamous cell carcinomas for an autologous tumor-fibroblast in vitro model

To study interactions between tumor cells and stromal elements, we established carcinoma cell lines as well as tumor-derived and skin fibroblast cultures from four patients with squamous cell carcinoma of the head and neck. For the characterization of the tumor cell lines we a) determined population doubling times, b) assessed morphological features by light and electron microscopy, c) investigated the expression of typical markers by immunohistochemistry, including various intermediate filaments and surface antigens, d) compared these findings with expression patterns in the respective original tumor specimens, e) evaluated p53 mutations in tumor specimens and cell lines, f) performed chromosome analysis, g) investigated the tumorigenicity in athymic mice, and h) tested the formation of both tumor and mixed tumor-fibroblast multicellular spheroids. Tumor cell cultures were considered established cell lines when maintained and passaged over a period of two years after primary explantation. The in vitro morphology of the cell lines showed well preserved characteristics of squamous cell carcinoma, and electron microscopy as well as immunohistochemistry revealed their squamous type of differentiation. All cell lines presented the same p53 genotype as the respective original tumors. Furthermore, they were successfully xenotransplanted into nude mice and formed both pure and mixed three dimensional spheroids. This experimental model allows the in vitro and in vivo investigation of various tumor-fibroblast interactions.

Anti-(epidermal growth factor) receptor monoclonal antibodies for the induction of antibody-dependent cell-mediated cytotoxicity against squamous cell carcinoma lines of the head and neck

Squamous cell carcinomas of the head and neck (SCCHN) frequently display high levels of the epidermal growth factor receptor (EGFR). Since EGFR is expressed on the cell surface it may form a suitable target for anticancer therapy with anti-receptor monoclonal antibodies (mAb). Besides the interference with receptor/ligand interactions, binding of mAb to EGFR leads to immunoglobulin-coated tumour cells that may induce or enhance non-specific immune effector mechanisms like antibody-dependent cell-mediated cytotoxicity (ADCC). In established cell lines of SCCHN (UM-SCC 11B, 14C, 22B, and 8029 NA) we investigated the antitumour activity of allogeneic peripheral blood mononuclear cells (PBMC) in combination with rat (ICR 62), mouse (EMD 55900), and humanized (EMD 72000) anti-EGFR mAb. In addition, autologous PBMC were available for tumour line UD-SCC 4. The EGFR protein content of the tumour cell lines ranged between 170 fmol/mg protein and 8100 fmol/mg protein, and MCF-7 cells served as receptor-negative controls. PBMC activity against SCCHN targets was determined in 96-well microtitre-plate monolayer cultures by the colorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay after coincubation for 4 h, 24 h and 72 h at effector target ratios of 1:1, 5:1, 10:1 and 20:1. PBMC subpopulations were obtained by macrophage depletion (plastic adherence) or natural killer (NK) cell enrichment (magnetic bead negative selection). Prolonged time of exposure and increased effector:target ratios revealed marked antitumour activity of PBMC alone. This non-specific immune destruction was enhanced considerably by humanized and rat, but not mouse anti-EGFR mAb. Increased EGFR protein in tumour cells partly correlated with an intensification of ADCC but was accompanied by decreased primary PBMC cytotoxicity. The utilization of PBMC subpopulations suggested a mainly NK-cell-mediated ADCC, which appeared to benefit directly or indirectly, e.g. via the secretion of cytokines, from other PBMC components. In conclusion, humanized (EMD 72000) and rat (ICR 62) anti-EGFR mAb were able to generate strong antitumour ADCC in target monolayers of SCCHN.

Antitumor activity of anti-epidermal growth factor receptor monoclonal antibodies and cisplatin in ten human head and neck squamous cell carcinoma lines

Head and neck squamous cell carcinomas (HNSCC) frequently display increased levels of epidermal growth factor receptor (EGFR) and since the receptor is located on the cell surface, anti-EGFR antibodies appear to be suitable agents for antitumor therapy. We investigated the effect of murine EMD 55900 and rat ICR 62 monoclonal antibodies (MAb) directed against EGFR both as single agents and in combination with cisplatin. ELISA detection showed the amount of EGFR protein in HNSCC lines UM-SCC-10A, -10B, -11B, -14A, -14B, 14C, -22B and HLac 79, 8029NA, 8029DDP to range between 20 and 8100 fmol/mg protein. Compared to A431 cells, seven HNSCC lines were high and three low receptor expressors. Only low levels of TGF alpha were found in the supernatants of some untreated HNSCC lines, probably due to the consumption of TGF alpha by EGFR. Consequently, occupation of EGFR by MAb led to marked accumulation of TGF alpha in cell supernatants. Colorimetric MTT assay showed both MAbs (0.3-30nM) to have comparable dose-dependent growth inhibition which correlated with the EGFR content of the respective cell lines (p < 0.05). Using 30nM MAb, seven high receptor expressing HNSCC lines were growth inhibited by at least 20% to a maximum of 61% (mean = 38%). Combined treatment with MAb and cisplatin led to a significant decrease in cisplatin IC50 values in 5 cell lines expressing more than 1200 fmol EGFR/mg (dose modification by factor 2.1-4.1). In conclusion, anti-EGFR MAb exert direct antiproliferative activity in HNSCC lines and show additive effects in combination with cisplatin.

Chemosensitivity of head and neck squamous carcinoma cell lines is not primarily correlated with glutathione level but is modified by glutathione depletion

Glutathione has a variety of important physiological functions in cellular metabolism and defense, including protection from radicals, oxidative stress, and electrophilic compounds. On the basis of this interaction with both endogenous and synthetic substances, glutathione and the key enzyme for its conjugation, glutathione S-transferase, appear to be critical determinants in tumor cell resistance to several antineoplastic drugs, e.g. platinum analogs. In ten established head and neck cancer cell lines (UM-SCC 10A, 10B, 11B, 14A, 14B, 14C, and 22B, HLac79, 8029NA, and 8029DDP4) chemosensitivity to cisplatin, carboplatin, 5-fluorouracil, and bleomycin, as well as cellular glutathione content and activity of glutathione S-transferase were determined. The results revealed no correlation between the sensitivity of tumor cells to any of the drugs tested and the level of glutathione or the activity of glutathione S-transferase. However, the cisplatin-resistant subpopulation 8029DDP4 showed the highest glutathione level and marked cross-resistance to bleomycin. Glutathione depletion with buthionine sulfoximine led to moderately increased sensitivity towards cisplatin and carboplatin in all cell lines, but did not affect their response to 5-fluorouracil or bleomycin. These results suggest that the level of glutathione or the activity of glutathione S-transferase is not a suitable parameter for the assessment of chemosensitivity in head and neck squamous-cell carcinoma lines. However, response to platinum analogs is influenced by alterations of the initial intracellular glutathione concentration.

Dose-dependent access of murine anti-epidermal growth factor receptor monoclonal antibody to tumor cells in patients with advanced laryngeal and hypopharyngeal carcinoma

The murine IgG2a monoclonal antibody (mAb) EMD 55900 was produced against the human epidermoid carcinoma cell line A431, with binding occurring to the polypeptide chain of the external domain of human epidermal growth factor receptor (EGF-R). In the present clinical study, 12 patients with advanced squamous cell carcinoma of the larynx or hypopharynx received a single dose of either 20, 100 or 400 mg EMD 55900 3 days prior to laryngectomy and neck dissection. Clinical signs and laboratory parameters of toxicity, development of human anti-mouse antibodies, and mAb plasma concentrations were monitored. In tumor specimens studied from primary tumors and lymph node metastases, expression of EGF-R, distribution of EMD 55900, and occupation of EGF-R by EMD 55900 (double staining) were determined by immunohistochemistry. Single-dose administration of EMD 55900 was very well tolerated in all patients, and good (100 mg) to excellent (400 mg) homogeneous binding of mAb to EGF-R was obtained in the advanced laryngeal and hypopharyngeal carcinomas studied.

Immunohistochemical examination of 11 cell lines derived from human head and neck squamous cell carcinomas, their recurrences or metastases

Since in vitro derived tumor cell lines usually correspond to their tumors of origin, a potential biological difference between a primary tumor and its derivative metastases and recurrent tumors should be reflected in established tumor cell lines. The aim of this study was to determine useful cellular markers in permanent tumor cell lines of head and neck squamous cell carcinomas (SCC) and to evaluate a possible relationship between these markers and the origin of selected cell lines. The cell lines, established in the laboratory of T. Carey at the University of Michigan (UM) (Ann Arbor, Mich., USA), were derived from primary tumor and its metastases (UM-SCC 10A, 10B), primary tumor and its recurrent tumors (UM-SCC 14A, 14B, 14C) and single tumors (UM-SCC 11B, 17A, 22B). An additional tumor cell line (HLac 79) was isolated by H.-P. Zenner (Tubingen, Germany) and a clone (8029 NA) with its cisplatin-resistant subline (8029 DDP4) was established in our laboratory. As markers we chose three groups known to be related to growth behavior and/or tumor differentiation: cytoskeletal proteins, oncogene products and membrane-associated antigens. These markers were detected by immunohistochemical methods using commercially available monoclonal antibodies. The "metastatic" and "recurrent" cell lines showed changes in comparison to the corresponding "parental" lines, which could be associated with a higher degree of de-differentiation, such as the occurrence of vimentin and neuroectodermal proteins, loss of HLA-ABC or HLA-DR and increased expression of epidermal growth factor receptor. The expression of cytokeratins was more stable and dissociation of the classical cytokeratin pairs was observed only in a few cases. Oncogene products were practically identical in cell lines from parental and recurrent or metastatic tumors. These data serve not only as a basis for further experiments with these cell lines but also provide information about the biological significance of various markers in newly established cell lines from primary tumors.

[Morphologic and immunohistochemical studies of organ cultures of human tracheal biopsies]

Most likely the transformation of epithelial cells to carcinoma cells takes place during the process of differentiation. In order to study in vitro carcinogenesis, an experimental system for organ cultures was developed in which human respiratory epithelial from tracheal biopsies differentiate within six weeks. The mucosal and submucosal layer of small tracheal biopsies was cut into pieces measuring 3 x 3 and 5 x 5 mm2, respectively, and placed on Gelita cubes (Braun-Melsungen, Germany) measuring 10 x 10 x 10 mm3 with the epithelium facing up. The culture medium (RPMI 1640 supplemented with 10% fetal calf serum, 200 mM L-glutamine, 100 IU/ml penicillin, and 100 micrograms/ml streptomycin) was added in a way that the tissue lay between the medium and air. Gelita deteriorates in about two to three weeks. However, the cultures are easily transferred to fresh Gelita cubes using the rest of the old Gelita. These organ cultures were fixed at regular intervals, and histological sections were stained with hematoxylin eosin or monoclonal antibodies against cytoskeletal intermediate filament proteins. These morphological and histological studies revealed that the epithelial cells differentiated under these conditions in at least 39 days. The mesenchymal elements remained viable without showing strong proliferation. The implication of these techniques for studying carcinogenesis in vitro is discussed.

Intratumoral PEG-interleukin-2 therapy in patients with locoregionally recurrent head and neck squamous-cell carcinoma

BACKGROUND

An enhanced efficacy of local as compared to systemic administration of interleukin-2 (IL-2) has been demonstrated in several experimental tumors. We previously reported that guinea pigs with palpable tumors and regional micrometastases could be cured by intratumoral injections of polyethylene glycol-modified IL-2 (PEG-IL-2). In the present study this treatment schedule was applied in a clinical situation.

PATIENTS AND METHODS

Nineteen patients with 11 local and 11 regional recurrences of head and neck squamous cell carcinoma (HNSCC) were treated with intratumoral injections of 200,000 U of PEG-IL-2 3 times weekly in courses of 4 weeks.

RESULTS

Treatment was given on an out-patient basis, and was well tolerated. Temporary regional swelling and redness developed in 10 patients, and in 9 of them systemic eosinophilia was documented. Median duration of treatment was 4 weeks (range 2-14 weeks). Seventeen patients were evaluable for response. One complete response (CR; 6%; duration 91 weeks), and 6 stable diseases (SDs; duration 8-57+ weeks) were recorded. The CR and the 3 best SDs (23, 40, 57+ weeks) occurred in patients with a single regional tumor recurrence of relatively small size. During treatment, all 4 developed locoregional edema and redness, and high levels of circulating eosinophils. Median survival was 23 weeks for all patients, and 45+ weeks for the patients with SD.

CONCLUSION

Intratumoral injection of PEG-IL-2 in patients with HNSCC is feasible. This treatment appears beneficial for highly selected patients. The objective response rate is insufficient to justify wide clinical application.

[Immunohistochemical studies of advanced laryngeal and hypopharyngeal carcinomas 3 days after administration of monoclonal antibody against epidermal growth factor receptor]

Sixteen consecutive patients with stage III/IV laryngeal or hypopharyngeal cancer received 0, 20, 100 or 400 mg i.v. of the murine anti EGF-R IgG2a mab EMD 55900 three days before laryngectomy and neck dissection. Presence of macrophages, T-cells (CD3) and T-cell subpopulations (CD4/CD8), NK-cells, complement factors (iC3b, C1q, C4c), and expression of MHC class I, MHC class II, ICAM-1 and IL-2-R were determined in cryostat sections of the surgical specimens and compared to normal tissue of the same patient. The antibody showed good binding to EGF-R of malignant and normal tissue. However, no signs of strong inflammatory reactions were noticed. Infiltration with macrophages was directly correlated with the dose of the administered antibody, even in the basal layer of the normal mucosa. No morphological signs of direct destruction of normal and malignant tissue infiltrated by macrophages or other immunocytes were noticed. This finding was underlined by random infiltration with HLA-DR positive-, T- and NK-cells. Possible long-term effects of this antibody--e.g. non-specific stimulation or improved antigenic processing--must be evaluated in further studies.

[The incurable tumor patient]

In patients suffering from advanced or recurrent cancers that are no longer amenable to curative treatment, palliation and symptomatic care have to take the place of cure. In such cases, palliation aims at relief of pain, alleviation of functional disabilities and restoration of mental and social balance. Since the clinicians effort is concentrated on the control of symptoms of uncontrollable disease, decisions have to be made concerning the relative value of the various methods available for treatment and support in the individual patient. Criteria for the physician's decision-making are important parameters in any approach to the patient with incurable cancer and have particular significance in caring for terminal disease.