[Statement on the lower age limit for outpatient adenotomies and tonsillotomies]

At the beginning of 2023, there have been significant changes to the regulations for outpatient surgery in Germany, which were set out in a trilateral self-administration agreement between the umbrella association of statutory health insurance companies, the German Hospital Association and the Federal Association of Statutory Health Insurance Physicians. Among other things, a catalog stated circumstances under which an operation should not be carried out on an outpatient basis or should only be carried out with doubt. This catalog explains the patient's age: up to the first year of life, inpatient performance of a service can be justified. This formulation in itself means that children from one year of age on should regularly undergo outpatient surgery.In the german scientific societies for otolaryngology, head and neck surgery as well as for anesthesiology and intensive care medicine, doubts arose as to whether this age limit could also be scientifically justified for operations in the throat such as adenotomy or tonsillotomy.A search was carried out in international guidelines and in the international literature and the statements were evaluated. The results of this literature search were discussed with representatives of the Pediatric Otorhinolaryngology Working Group (AG PädHNO) of the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) and the scientific working group for pediatric anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) in conferences.The consensus revealed that a strict age limit of the first year of life is not appropriate for the outpatient performance of adenotomies and tonsillotomies. First of all, specifying a strict age limit is questionable because, regardless of age, a number of other medical and social factors influence the responsible performance of outpatient operations. Furthermore, the age limit of one year is not considered appropriate in view of literature, guidelines and practical experience in the international area. The assessment of the literature and the consideration of the implementation in the international area make an age limit in the range of 2-3 years seem more appropriate.This review provides the responsible doctors with a variety of insights, aspects and arguments so that they can make their decision to carry out these operations on an outpatient or inpatient basis appropriately and responsibly.

Positionspapier: ICD-Codierung der chronischen Rhinosinusitis mit Nasenpolypen (CRSwNP) im ICD-10-GM als Grundlage für eine Therapie mit Biologika – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA), der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) und des Deutschen CRS-Registers

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der Schleimhäute von Nase und Nasennebenhöhlen. In Deutschland sind 3 verschiedene monoklonale Antikörper für die Indikation „Zusatztherapie zu intranasalen Glukokortikosteroiden für die Behandlung Erwachsener mit schwerer chronischer Rhinosinusitis mit Nasenpolypen“ zugelassen. Um die Verordnung in der zugelassenen Indikation (In-Label) zu dokumentieren, ist neben einer Dokumentation zahlreicher medizinischer Parameter die korrekte Auswahl der ICD-10-GM-Codierung entscheidend. Hierfür existieren in Deutschland bislang keine konsentierten Empfehlungen.

Methoden Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium von AeDA, DGHNO-KHC und Deutschem CRS-Register Codierungsmöglichkeiten von CRS und CRSwNP analysiert und auf dieser Basis eine konsentierte Empfehlung für die ICD-10-GM-Codierung in Deutschland ausgesprochen.

Ergebnis Die Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme ICD-10-GM (International Classification of Diseases, 10. Revision, German Modification) ist die amtliche Klassifikation zur Verschlüsselung von Diagnosen in der ambulanten und stationären Versorgung in Deutschland. Der ICD-10-GM unterscheidet nicht adäquat zwischen heute anerkannten klinischen und immunologischen Differenzierungen der CRSsNP und der CRSwNP. Dennoch wird insbesondere bei indiziertem Einsatz von Biologika in der Therapie der schweren CRSwNP eine möglichst exakte Verschlüsselung mit den Codes J33.8 (im Einzelfall J33.1 oder J33.9) empfohlen.

Schlussfolgerungen Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue Behandlungsansätze mit monoklonalen Antikörpern für Patienten mit schwerer, unkontrollierter Erkrankung. Hier geben wir Empfehlungen für eine adäquate ICD-10-GM-Codierung in Deutschland.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Dupilumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the nasal and paranasal mucosa. A Type-2 inflammation is described as the most common endotype. Since October 2019 the anti-IL-4/-IL-13 antibody dupilumab has been approved in Germany as an add-on therapy to intranasal corticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps, when systemic corticosteroids alone or surgery do not provide adequate disease control. While recommendations for the use of dupilumab in CRSwNP exist at both national and international levels, until now it has not been adequately established, how therapy should be monitored and when it should be discontinued in the German Health Care System.

METHODS

 A literature search was performed analyzing previous data on the treatment of CRSwNP with dupilumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to 05/2022 were included.

RESULTS

 Based on international literature and previous experience, recommendations are given by an expert panel for follow-up and possible therapy breaks, therapy intervals or termination of therapy when using dupilumab for the indication CRSwNP in the German health care system based on a documentation form.

CONCLUSIONS

 Understanding the immunological basis of CRSwNP opens new non-surgical therapy approaches with biologics for patients with severe courses. The authors give recommendations for follow-up, possible therapy breaks, therapy intervals and a termination for dupilumab treatment as add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP that cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Vagus nerve stimulation for conservative therapy-refractive epilepsy and depression

Numerous studies confirm that the vagus nerve stimulation (VNS) is an efficient, indirect neuromodulatory therapy with electrically induced current for epilepsy that cannot be treated by epilepsy surgery and is therapy-refractory and for drug therapy-refractory depression. VNS is an established, evidence-based and in the long-term cost-effective therapy in an interdisciplinary overall concept.Long-term data on the safety and tolerance of the method are available despite the heterogeneity of the patient populations. Stimulation-related side effects like hoarseness, paresthesia, cough or dyspnea depend on the stimulation strength and often decrease with continuing therapy duration in the following years. Stimulation-related side effects of VNS can be well influenced by modifying the stimulation parameters. Overall, the invasive vagus nerve stimulation may be considered as a safe and well-tolerated therapy option.For invasive and transcutaneous vagus nerve stimulation, antiepileptic and antidepressant as well as positive cognitive effects could be proven. In contrast to drugs, VNS has no negative effect on cognition. In many cases, an improvement of the quality of life is possible.iVNS therapy has a low probability of complete seizure-freedom in cases of focal and genetically generalized epilepsy. It must be considered as palliative therapy, which means that it does not lead to healing and requires the continuation of specific medication. The functional principle is a general reduction of the neuronal excitability. This effect is achieved by a slow increase of the effectiveness sometimes over several years. Responders are those patients who experience a 50% reduction of the seizure incidence. Some studies even reveal seizure-freedom in 20% of the cases. Currently, it is not possible to differentiate between potential responders and non-responders before therapy/implantation.The current technical developments of the iVNS generators of the new generation like closed-loop system (cardiac-based seizure detection, CBSD) reduce also the risk for SUDEP (sudden unexpected death in epilepsy patients), a very rare, lethal complication of epilepsies, beside the seizure severity.iVNS may deteriorate an existing sleep apnea syndrome and therefore requires possible therapy interruption during nighttime (day-night programming or magnet use) beside the close cooperation with sleep physicians.The evaluation of the numerous iVNS trials of the past two decades showed multiple positive effects on other immunological, cardiological, and gastroenterological diseases so that additional therapy indications may be expected depending on future study results. Currently, the vagus nerve stimulation is in the focus of research in the disciplines of psychology, immunology, cardiology as well as pain and plasticity research with the desired potential of future medical application.Beside invasive vagus nerve stimulation with implantation of an IPG and an electrode, also devices for transdermal and thus non-invasive vagus nerve stimulation have been developed during the last years. According to the data that are currently available, they are less effective with regard to the reduction of the seizure severity and duration in cases of therapy-refractory epilepsy and slightly less effective regarding the improvement of depression symptoms. In this context, studies are missing that confirm high evidence of effectiveness. The same is true for the other indications that have been mentioned like tinnitus, cephalgia, gastrointestinal complaints etc. Another disadvantage of transcutaneous vagus nerve stimulation is that the stimulators have to be applied actively by the patients and are not permanently active, in contrast to implanted iVNS therapy systems. So they are only intermittently active; furthermore, the therapy adherence is uncertain.

Positionspapier: Empfehlungen zur Anwendung von Mepolizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the paranasal sinus mucosa with eosinophilic inflammation as the most common endotype. The anti-IL5 antibody mepolizumab was approved for the treatment of severe CRSwNP in the EU in November 2021.

METHODS

 A literature search was performed to analyze the immunology of CRSwNP and determine the available evidence by searching Medline, Pubmed, and the German national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 12/2021 that investigated the effect of mepolizumab in CRSwNP were considered.

RESULTS

 Based on the international literature and previous experience, recommendations for the use of mepolizumab in CRSwNP in the German health care system are given by an expert panel on the basis of a documentation form.

CONCLUSIONS

 Understanding about the immunological basis of CRSwNP opens new non-surgical therapeutic approaches with biologics for patients with severe courses. Mepolizumab is approved since November 2021 for add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP who cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Omalizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine TH2-Inflammation zugrunde liegt. IgE-Antikörper spielen dabei eine wichtige Rolle. Der anti-IgE-Antikörper Omalizumab wurde im August 2020 für die Therapie der schweren CRSwNP zugelassen.

Methoden In einer Literatursuche wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Omalizumab bei dieser Erkrankung ermittelt durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinien-Registern und der Cochrane Library.

Ergebnisse Basierend auf diesen Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Omalizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung Omalizumab ist zugelassen für Patienten ab 18 Jahren mit schwerer chronischer Rhinosinusitis mit Nasenpolypen als Zusatztherapie zu intranasalen Kortikosteroiden (INCS), wenn durch eine Therapie mit INCS keine ausreichende Krankheitskontrolle erzielt werden kann.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.

[First time online 92nd annual meeting of the DGHNO-KHC 2021 - a critical assessment based on the participant's evaluation]

First time ever, the 92^nd annual meeting of the DGHNO-KHC was carried out completely in an online format in May 2021 due to the new framework conditions caused by the corona pandemic. The participants from the ranks of members, guests and industrial partners were asked to complete an evaluation questionnaire from the responsible State Medical Association of North Rhine, which was supplemented with questions about the new virtual format. The publication summarizes the evaluation of the 187 (10 % of the total number of participants) medical/scientific and 25 industrial exhibitors (60 % of the participating industrial partners) responses and provides an initial conclusion. Roughly speaking, the congress was rated positively by the medical/scientific participants despite the total lack of social interaction and scientific open debates. On the industrial side, the picture was different. The medical participants were asked about the future format of the next annual ENT congresses. 16 % were in favor of a purely online congress, 67 % in favor of a face-to-face congress with online elements, and only 17 % in favor of a purely face-to-face congress. The question, which type of exhibition would be preferred in the future for industrial partners, 68 % were in favor of a purely face-to-face exhibition as part of a face-to-face congress. 32 % accepted a combination of presence with online elements. A future complete online industrial exhibition was voted out with 0 % approval.

[Regional distribution of the cochlear implant (CI) centers in Germany]

The treatment of patients with severe hearing loss or deafness with a cochlear implant (CI) represents a standard in Germany today. However, there is hardly any data on the current number of clinical CI centers (CI clinics) and their geographical distribution. The patient self-help organization, German Cochlear Implant Society (DCIG), and the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) have therefore initiated a survey to determine the regional distribution, the range of services, the consideration of existing quality standards and cooperation with patient self-help organizations of the individual clinical CI centers.For this purpose, a total number of 170 ENT departments or their directors (37 professors and 133 chief physicians), respectively, were contacted by e-mail and provided with a questionnaire. The survey took place from October 2019 to February 2020.Of the 170 departments contacted, 71 (41.8 %) took part in the survey. Of these, 70 departments (98.6 %) confirmed to perform CI surgeries. Thus, 41.8 % of all clinics contacted reported to perform CI surgeries (70 of 170 clinics), while this information was not available from 99 clinics. All 70 clinical CI centers (100 %) reported to conduct CI surgeries on adults, 60 centers (85.7 %) also on children (< 18 years). 36 departments (51.4 %) reported that the total number of CI surgeries at their facility in 2018 was more than 50. In 64 departments (91.4 %), the recommendations of the DGHNO-KHC on CI care (according to the White Paper CI care 2018) were followed. A collaboration between the department and patient self-help organization was confirmed by 67 institutions (95.7 %). The geographical distribution of the clinical CI centers showed a heterogeneous distribution pattern between the individual federal states and also within the respective federal state.The work presented here is a first assessment of the situation with regard to the regional distribution of clinical CI centers in Germany. A clustering of CI centers was noticeable in metropolitan areas, sometimes with several facilities in one city. The predominant attention to quality-related aspects, such as the consideration of the DGHNO-KHC white paper and the cooperation with patient self-help, is gratifying. The limitations of the study result from limited participation in the survey (41.8 % of the contacted clinics).

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) – Teil 1: Dupilumab

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhaut, der oftmals eine Typ-2-Inflammation zugrunde liegt. Durch die Entwicklung von Biologika, die in diese Entzündungsmechanismen eingreifen können, steht eine neuartige Therapiemöglichkeit zur Verfügung.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und der Wirkung von Biologika sowie deren mögliche unerwünschte Wirkungen werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Biologika bei CRSwNP entwickelt und auf dieser Grundlage einen Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten ist vor der Verordnung bzw. Verabreichung von Biologika erforderlich. Das vorliegende Positionspapier enthält wichtige Informationen hierzu und einen Vorschlag für eine Patienteninformation.

Positionspapier: Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis (CRS) betrifft weltweit ca. 5–12 % der Allgemeinbevölkerung und wird traditionell eingeteilt in einen Phänotyp ohne (CRSsNP) und einen mit Ausbildung von Nasenpolypen (CRSwNP). Wurden Nasenpolypen bis vor kurzem eher als mechanisches Hindernis mit der Notwendigkeit einer operativen Beseitigung betrachtet, wird die CRSwNP heute als eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhäute angesehen, der als Endotyp häufig eine T2-Inflammation zugrunde liegt. Biologika, die mit diesen Entzündungsmechanismen interferieren, stellen interessante neue Therapiemöglichkeiten dar.

Methoden Das aktuelle Wissen zur Immunologie der CRSwNP und Wirkung von Biologika wurde mittels einer Literaturanalyse durch Recherchen in Medline, PubMed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library zusammengestellt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium Empfehlungen für die Anwendung von Biologika bei CRSwNP im deutschen Gesundheitssystem auf der Grundlage eines Dokumentationsbogens gegeben.

Schlussfolgerung Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue nichtoperative Therapieansätze mit Biologika für Patienten mit schweren Verlaufsformen.

Positionspapier: Empfehlungen zur Behandlung der chronischen Rhinosinusitis während der COVID-19-Pandemie im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNO-KHC) – Diese Empfehlungen basieren auf dem EAACI Positionspapier „Treatment of chronic RhinoSinusitis with nasal polyps (CRSwNP) in the COVID-19 pandemics – An EAACI Position Paper”, Allergy, 2020 und wurden auf die Situation im deutschen Gesundheitswesen angepasst

Hintergrund  Von der chronischen Rhinosinusitis (CRS) sind weltweit etwa 5–12 % der Allgemeinbevölkerung betroffen. Die CRS gilt als chronische Atemwegserkrankung, die nach den Empfehlungen der WHO ein Risikofaktor für COVID-19-Patienten sein kann. Die entzündlichen Veränderungen der Nasenschleimhäute bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) sind in den meisten Fällen vom Entzündungsendotyp 2 (T2).

Methoden  Der aktuelle Wissensstand sowohl zu COVID-19 als auch zu den Behandlungsmöglichkeiten von CRSwNP wurde durch eine Literaturrecherche in Medline, Pubmed, internationalen Leitlinien, der Cochrane Library und im Internet analysiert.

Ergebnisse  Auf Grundlage der internationalen Literatur, der aktuellen Empfehlungen der WHO und anderer internationaler Organisationen sowie der bisherigen Erfahrungen gab ein Expertengremium von EAACI und ARIA Empfehlungen für die Behandlung von CRSwNP während der COVID-19-Pandemien.

Schlussfolgerung  Intranasale Kortikosteroide stellen die Standardbehandlung für CRS bei Patienten mit einer SARS-CoV-2-Infektion dar. Chirurgische Behandlungen sollten auf ein Minimum reduziert werden und nur bei Patienten mit lokalen Komplikationen und solchen, für die keine anderen Behandlungsmöglichkeiten bestehen, durchgeführt werden. Systemische Kortikosteroide sollten bei COVID-19-Patienten vermieden werden. Die Behandlung mit Biologika kann bei nicht infizierten Patienten unter sorgfältiger Überwachung fortgesetzt werden und sollte während einer SARS-CoV-2-Infektion vorübergehend unterbrochen werden.

Identification of Rare and Common HPV Genotypes in Sinonasal Papillomas

Sinonasal papillomas are rare, usually benign tumors arising from the Schneiderian membrane. Human papillomaviruses (HPV) can infect differentiating skin and mucosal cells and can induce uncontrolled growth patterns. Their effect on development of sinonasal papillomas has been discussed controversially in recent years. A monocentric, retrospective study was conducted to investigate histopathologic features of sinonasal papillomas and to establish an assay for HPV detection and genotyping in papillomas. Schneiderian papillomas are divided into three groups according to histopathologic features: the largest group are inverted papillomas, followed by fungiform (exophytic) and oncocytic papillomas. HPV screening was performed with high sensitivity by PCR employing My09/11 and 125 consensus primers. Adding a third primer pair (GP5+/GP6+) d increase sensitivity. Reverse hybridization microarrays achieved HPV genotyping better than pyrosequencing in our setting. HPV infection rates were higher in papillomas (46.7%) than infection rates reported for healthy mucosa (up to 13%). P16(INK4a) was not a reliable surrogate marker for HPV infection in sinonasal papillomas. Data from our study endorses the hypothesis that HPV infection promotes formation of sinonasal papillomas. However, apart from HPV genotypes that are frequently found in e.g. anogenital lesions (such as 6, 11, or 16), tissue samples of sinonasal papillomas also displayed infection with "rare" HPV types (such as 58, 42, 83, or 91).

Induction chemotherapy (IC) followed by radiotherapy (RT) versus cetuximab plus IC and RT in advanced laryngeal/hypopharyngeal cancer resectable only by total laryngectomy-final results of the larynx organ preservation trial DeLOS-II

Background

The German multicenter randomized phase II larynx organ preservation (LOP) trial DeLOS-II was carried out to prove the hypothesis that cetuximab (E) added to induction chemotherapy (IC) and radiotherapy improves laryngectomy-free survival (LFS; survival with preserved larynx) in locally advanced laryngeal/hypopharyngeal cancer (LHSCC).

Patients and methods

Treatment-naïve patients with stage III/IV LHSCC amenable to total laryngectomy (TL) were randomized to three cycles IC with TPF [docetaxel (T) and cisplatin (P) 75 mg/m2/day 1, 5-FU (F) 750 mg/m2/day days 1-5] followed by radiotherapy (69.6 Gy) without (A) or with (B) standard dose cetuximab for 16 weeks throughout IC and radiotherapy (TPFE). Response to first IC-cycle (IC-1) with ≥30% endoscopically estimated tumor surface shrinkage (ETSS) was used to define early responders; early salvage TL was recommended to non-responders. The primary objective was 24 months LFS above 35% in arm B.

Results

Of 180 patients randomized (July 2007 to September 2012), 173 fulfilled eligibility criteria (A/B: larynx 44/42, hypopharynx 41/46). Because of 4 therapy-related deaths among the first 64 randomized patients, 5-FU was omitted from IC in the subsequent 112 patients reducing further fatal toxicities. Thus, IC was TPF in 61 patients and TP in 112 patients, respectively. The primary objective (24 months LFS above 35%) was equally met by arms A (40/85, 47.1%) as well as B (41/88, 46.6%). One hundred and twenty-three early responders completed IC+RT; their overall response rates (TPF/TP) were 94.7%/87.2% in A versus 80%/86.0% in B. The 24 months overall survival (OS) rates were 68.2% and 69.3%.

Conclusions

Despite being accompanied by an elevated frequency in adverse events, the IC with TPF/TP plus cetuximab was feasible but showed no superiority to IC with TPF/TP regarding LFS and OS at 24 months. Both early response and 24 months LFS compare very well to previous LOP trials and recommend effective treatment selection and stratification by ETSS.

Clinical trial information

NCT00508664.

Studies for estimating the biologic behavior and prognosis of paragangliomas in the head and neck

Despite a large number of histopathologic and immunohistochemical studies, the biologic behavior and prognosis of paragangliomas (glomus tumors) of the head and neck still remain uncertain. In the present study 36 specimens from 32 patients who underwent surgery for a paraganglioma were examined. The examinations included routine histology, quantitative DNA analysis based on image cytometry, immunohistochemical detection of the proliferating cell nuclear antigen (PCNA) along with visualization of nucleolar organizer regions (AgNOR). According to LeCompte, the paragangliomas were histologically divided into three subcategories: 16 patients had a paragangliomatous tumor. 14 patients had an adenomatous tumor, and 6 patients had an angiomatous tumor. Quantitative DNA analysis revealed three categories of tumors with characteristical DNA pattern; DNA type I tumors were pure diploid, DNA type II tumors had stemlines at 2c and 4c and were therefore recognized as diploid-tetraploid. Aneuploid cells were not apparent in these two groups. DNA type III tumors had stemline ploidies exceeding 2c and 4c. Aneuploid cells were present in all of these tumors. The biologic behavior of these lesions therefore must be recognized as suspicious. DNA type III tumors and adenomatous tumors showed the highest values for the PCNA scores, indicating a higher proliferation rate and a more rapid growth pattern in these lesions. Twenty patients could be followed over a period of up to 110 months. Five of these patients developed a recurrent tumor. All of them had DNA type III tumors. The DNA indices showed significantly higher values in the recurrent tumor group. The 2c deviation index (DI) and the entropy value had the highest prognostic significance. No correlation to clinical follow-up was found for the AgNOR score. Based on these results, prognostic indices for paragangliomas were developed: patients with a tumor having a 2c DI exceeding 2.0, entropy value of more than 4.0. 5c exceeding rate more than 8.0, and a PCNA score more than 20.0% can be recognized as being at high-risk for developing recurrent disease.

[Fluorine-18]fluorodeoxyglucose positron emission tomography, DNA ploidy and growth fraction in squamous-cell carcinomas of the head and neck

BACKGROUND

Positron emission tomography (PET) offers an opportunity to examine noninvasively cellular functions with different tracers. [(18)F]Fluorodeoxyglucose (FDG) is most commonly used in identifying malignant tumors. Several tumor biologic characteristics (tumor cell viability, growth faction, treatment response to radiation, cell membrane dysfunction, recurrence rate) are suggested to be characterized by [(18)F]FDG PET. The aim of this study was to assess which other tumor biologic characteristics of squamous-cell carcinoma of the head and neck are correlated with [(18)F]FDG PET.

METHODS

[(18)F]FDG PET was performed in 14 patients with squamous-cell carcinomas of the upper digestive tract (TNM classification T(2)-T(4), N(1)-N(3)). After attenuation correction, predefined areas of the tumor were semiquantitatively analyzed by the technique of the region of interest and calculated as standard uptake values (SUV). Afterwards, 5 biopsies of different tumor regions were obtained during endoscopy in each patient under general anesthesia, and a correlation between SUV of [(18)F]FDG PET and tumor biologic parameters was attempted. These parameters included: quantitative DNA measurements (i.e. 2c deviation index, 5c exceeding rate), immunohistochemical assessment of growth fraction (i.e. Ki67-MIB-1, PCNA) along with morphological tumor front grading.

RESULTS

The results revealed a marked variation of proliferation and cellular differentiation in various regions of the tumor for all parameters examined. There was a close correlation between [(18)F]FDG uptake and growth fraction (r = 0.83 for Ki67-MIB-1 and r = 0.8 for PCNA). A poor correlation was found between DNA aneuploidy (r = 0.4) or tumor front grading (r = 0.12) and [(18)F]FDG uptake.

CONCLUSIONS

Our results confirm previous clinical and histologic observations that squamous-cell carcinomas of the upper digestive tract are heterogeneous tumors. Ki67 antigen, which has been shown to be of predictive value for proliferation and individual prognosis, correlated with [(18)F]FDG uptake. Using [(18)F]FDG PET, the main proliferation centers of inhomogeneous squamous-cell carcinomas could be identified with possible clinical implications for patient management.

Histological grading, growth fraction and DNA-ploidy as criteria for the treatment of pharyngeal and supraglottic squamous cell carcinomas: a preliminary, prospective study

BACKGROUND

Individualized treatment for patients with squamous cell carcinomas is most desirable. Biologic parameters of tumors may provide relevant criteria to achieve this goal. The aim of this study was: (1) to avoid elective neck dissection in patients with squamous cell carcinomas of the pharynx and supraglottis staged N0 by ultrasonography; (2) to administer postoperative radiotherapy only in patients staged 'highly aggressive' by biologic tumor parameters, in order to reduce patient morbidity and to improve quality of life.

STUDY DESIGN AND METHODS

This prospective trial was performed in 35 patients (any T stage, N0 or N1 by ultrasonographic examination). Tumor biopsies were taken for histological examination and for evaluation of some biological tumor markers. These parameters comprised DNA cytometric examinations, histological grading of the tumor front and immunohistochemical staining for proliferation markers (MIB1, PCNA). Based on these parameters, tumors were classified into 'low aggressive' (group 1) and highly aggressive (group 2) behavior. In all patients, second primaries were excluded by endoscopy, and the presenting tumor was resected with clear margins. In cases of ultrasonographically enlarged lymph nodes, functional neck dissection was performed. When biologic tumor profile showed low aggressive behavior (group 1), no postoperative radiotherapy was advised. In cases of highly aggressive tumors, radiotherapy was recommended postoperatively independent of all other parameters (group 2a and 2b).

RESULTS

The average follow-up was 36 months (range 16-65 months). Fifteen patients were included in group 1, 20 patients in group 2. Three patients with highly aggressive tumors who refused RTx were regarded independently (group 2b). In this pilot study of 35 patients, there was no difference in disease-free survival between group 1 and group 2a. Twenty-five of 35 patients were alive with no evidence of disease 29-65 months after treatment (3 died of disease; 5 died of second primary carcinomas; 2 died independent of disease). Eleven of 15 patients survived disease free in group 1, 13/17 in group 2a. In group 2b, 2 out of 3 patients, who were advised but refused postoperative radiotherapy, had recurrences.

CONCLUSIONS

The results of this preliminary study point towards usefulness of some tumor biologic parameters in decision making for individualized treatment in patients with squamous cell carcinomas.

[Epithelium-stroma interaction in cholesteatoma of the middle ear]

BACKGROUND

Local Infiltration and bony destruction are characteristic features of cholesteatomas. The aim of the study was assessment of cell ploidy, proliferation rates and expression of cell adhesion molecules to analyze the pathogenetic role of matrix (epithelium) in cholesteatoma. The cellbiologic parameters were compared to clinical findings.

PATIENTS AND METHOD

Tissue samples from 48 patients with cholesteatomas were analyzed by: routine histology, quantitative DNA-cytometry with the DNA indices: 2cDeviation Index (2cDI) and 5c Exceeding Rate (5c ER), immunhistochemical analysis of proliferation rate (ki67-MIB1 and PCNA), cell adhesion molecules, cell-cell interaction: E-Cadherin, alpha 1 beta 6-Integrin, Inter-Cellular-Adhesion-Molecule (I-CAM), cell-matrix interaction: CD44v4/5, CD 44v6, alpha v-, beta 3-Integrinchains and vascular-Cell-Adhesion-Molecule (V-CAM). Clinical data included patient age, history of ear disease, pre-operative audiometry, intra-operative size and extension of the cholesteatoma, destruction of ossicles and petrous bone. For comparison healthy squamous epithelium was obtained from the external ear canal of 10 patients during stapes surgery.

RESULTS

Ossicular destructions were found in 34 cases. Three patients had mesotympanic cholesteatomas, four patients had mesotympanic and epitympanic involvement. In 37 patients cholesteatomas extended into the mastoid and in four patients the perilabyrinth and the petrous apex were reached. DNA-cytometric examination of matrix showed normal diploid values and no aneuploid cells (DNA-content > 5c) in all patients. The proliferation rates of the matrix were increased in comparison to normal epithelium. Cell adhesion molecules for intercellular bindings were expressed in similar pattern in cholesteatomas and in normal epithelium. Cell adhesion molecules for cell matrix bindings showed new or increased expression in cholesteatomas. No significant correlation between proliferation and clinical findings could be established.

CONCLUSION

The study confirms previous suggestions that the growth of cholesteatomas is not stimulated by the matrix. The increased proliferation of the matrix is a result of the inflammatory process in the cholesteatoma and is correlated to the size of the cholesteatoma. On a cellular or molecular level no correlation between bone destruction through the cholesteatoma and proliferation rate of the cholesteatomas could be established. These findings support suggestions that the perimatrix of the cholesteatomas is the main pathogenetic factor.

Biologic characteristics of paragangliomas of the nasal cavity and paranasal sinuses

Paragangliomas of the nasal cavity and paranasal sinuses are extremely rare. This study was conducted to investigate the biologic characteristics of these lesions on different molecular levels and to estimate their biologic behavior. Operative specimens of three patients who underwent surgery for a paraganglioma of the nasal cavity (one case) or paranasal sinuses (two cases) were investigated by routine histology, quantitative DNA analysis, and immunohistochemical assessment of proliferation markers (i.e., Proliferating Cell Nuclear Antigen, PCNA; Ki67-MIB-1), the expression of cell-surface antigens, which reflect the tumor-stroma interaction (i.e., CD 44 v0.4/5 and 6, CD 54, CD 106), oncogene products (nm-23; p53), and bcl-2 as a marker of apoptosis. Histologically, two tumors were paragangliomas of the adenomatous subtype, one lesion was classified as angiomatous. According to DNA analysis, aneuploid cells were detected in all tumors. Two of three paragangliomas were classified as a DNA type III pattern, implying a high percentage of aneuploid cells and an aggressive behavior. Immunohistochemically, paragangliomas of the nasal cavity showed increased scores for both proliferation markers tested, indicating a rapid growth pattern. According to the expression of cell-surface markers and oncogene products, these tumors displayed an aggressive behavior and an infiltrating growth pattern. The highest value for the parameters of quantitative DNA analysis and highest proliferation scores were found in a tumor of a patient who developed multiple tumor recurrences after radical excision of the lesion with clear margins, and finally died of disease. In conclusion, paragangliomas of the nasal cavity and paranasal sinuses examined in this study should be regarded as suspicious concerning their biologic and clinical behavior. Radical excision, and in cases with highly aggressive biology, postoperative radiation therapy are recommended. Tumor biologic examinations can help to recognize high-risk patients for developing recurrences and possibly lesions with a malignant behavior and to enhance our understanding of the biology of these extremely rare tumors of the nasal cavity and paranasal sinuses.

Patterns of chromosomal aberrations in metastasizing and nonmetastasizing squamous cell carcinomas of the oropharynx and hypopharynx

Although several cytogenetic events of the tumor progression cascade have been identified in the past, the specific types of chromosomal alterations that lead to the development of lymph node metastases are still unknown. Operative specimens of 20 patients (10 patients with metastasizing tumors, 10 patients with nonmetastasizing tumors) with squamous cell carcinomas of the oropharynx and hypopharynx, along with the corresponding lymph node metastases, were investigated by quantitative DNA measurements and comparative genomic hybridization (CGH). Nonmetastasizing tumors (N0) displayed overrepresentations on chromosomes 10q (8 cases); 5p (7 cases); 3q and 20q (6 cases each); 8q (5 cases); 1p and 21q (4 cases each); 7p and 20p (3 cases each); and 2p, 15q, and 19q (2 cases each). Loss of chromosomal material was found on 5q, 9p, and 14q (2 cases each). Metastasizing tumors (N+) demonstrated overrepresentations on chromosomes 5p, 15q, and 22q (6 cases each); 3q and 11q13 (5 cases each); 20p and 21q (4 cases each); and 10q (3 cases). In 2 cases, an overrepresentation of the chromosomal arm 3q was accompanied by a loss of chromosomal arm 3p. Less frequent overrepresentations were observed on chromosomes 1q and 17q. Deletions were found on chromosomes 18q (3 cases), 3p, 4q, 5q, and 19p (2 cases each); and sporadic deletions occurred on 2q, 6q, 8p, 9p, 10p, 13q, 14q, 15q, and 16q. Whereas overrepresentations on chromosomes 1p and 7p occurred exclusively in N0 tumors, overrepresentations on chromosomes 1q, 11q, and 22q, along with deletions on 18q, were only observed in N+ tumors. Quantitative DNA measurements revealed a significantly higher percentage of aneuploid cells and a higher degree of DNA entropy in the N+ tumors. Chromosomal overrepresentations on chromosomes 1q, 8q, 11q, 18q, and 19q occurred more frequently in the metastases than in the corresponding primary tumors. Pairwise analysis of chromosomal alterations in the primary tumors and associated lymph node metastases revealed a genetic relationship, although a greater number of chromosomes on average were affected in the lymph node metastases. Quantitative DNA measurements demonstrated greater aneuploid values in the metastases. Recurring patterns of chromosomal alterations in N0 and N+ tumors were demonstrated in this study. In general, metastasizing tumors are characterized by overrepresentations on chromosomes 11q13 and 22q, and deletions on 18q. These aberrations suggest an elevation along the tumor progression cascade.

Proliferative activity and cytometric characteristics in polyps of the nasal cavity and paranasal sinuses

Although several investigations have revealed the influence of cytokines, allergy, and environmental factors in polyp development, the etiology of nasal polyps is still unknown. To estimate the biology of this common disease the operative specimens of 50 patients who underwent surgery for polyps of the nasal cavity and the paranasal sinuses were examined; of these, 10 patients had recurrent disease and 23 patients had an allergy. The investigations included routine histology and quantitative DNA measurements, along with immunohistochemical identification of proliferation markers (i.e., MIB-1; proliferating cell nuclear antigen, PCNA). Histologically, most polyps revealed an infiltration with lymphocytes, eosinophilic granulocytes, and plasma cells. Twenty-five percent had a squamous metaplasia of the respiratory epithelium. Quantitative DNA analysis demonstrated diploid stemlines and lack of aneuploid cells with a DNA content exceeding 5c in most cases. Immunohistochemical detection of proliferation markers showed low proliferation rates in all cases. In 27 polyps no MIB-1 expression was detected, and in 7 polyps no PCNA expression was detected. The polyps of the 23 patients with proven allergic diathesis did not reveal higher scores for the parameters of DNA analysis (i.e., ploidy status and percentage of aneuploid cells) and proliferation scores. Nasal polyps of 10 patients with recurrent disease displayed higher scores for proliferation markers, and in five cases aneuploid cells with 5c exceeding rate (5cER) of 1.5-11.7% were detected. According to these results, polyps of the nasal cavity and paranasal sinuses showed low proliferation scores and were diploid. The data demonstrated that there was no increase of proliferation activity or ploidy shift toward aneuploidy in patients with allergy. Nevertheless, in recurrent disease some increase in proliferation activity and some changes in the parameters of the DNA analysis occurred, indicating more aggressive behavior of recurrent polyps in single cases.

[Tumor biologic prognostic parameters in T1N0M0 squamous cell carcinoma of the oral cavity]

BACKGROUND

Conventional prognostic factors in squamous cell carcinomas are tumor stage, tumor size, evidence of lymph node metastases, extracapsular spread of lymph node metastases, and Broder's grading. Unfortunately these parameters are only of limited value in predicting the biological behavior and ultimately the prognosis of a particular tumor. The present study was conducted for determining objective prognostic factors based on tumor biologic examinations in patients with squamous cell carcinomas of the oral cavity. These parameters were compared to the conventional prognostic factors.

PATIENTS AND METHODS

Operative specimens of fourty-two patients who underwent surgery for a squamous cell carcinoma of the oral cavity with clinical TNM stage T1N0M0 were examined. All tumors were radically excised with histologic clear margins, which were confirmed by serial sections. The examinations included morphologic multifactorial tumor front grading, quantitative DNA analysis, and immunohistochemical assessment of proliferation markers (i.e. proliferating cell nuclear antigen [PCNA] and MIB1) and of oncogene products (i.e. p53; nm23). Prognostic significance of particular parameters was evaluated by univariate and multivariate Cox regression models.

RESULTS

In clinical follow-up of 70 months on average, 6 patients developed local recurrences and 5 patients lymph node metastases. Three patients died of disease. Tumors which recurred had increased values for 2 c Deviation Index, 5 c Exceeding Rate along with high tumor front grading scores and proliferation scores. Using multivariate Cox regression analysis, parameters which were highly significant for prognosis were 5 c Exceeding Rate, tumor front grading score and PCNA score. None of the clinical parameters achieved statistical significance in the multivariate model. Tumors which recurred had also increased expression rates for p53 and nm23. Nevertheless this was statistically not significant.

CONCLUSIONS

Tumor biologic examinations provide important informations about the clinical aggressiveness and ultimately about the prognosis of a particular tumor. Tumors with aggressive behavior can already be identified during initial diagnosis, which has consequences for the therapeutic management of the patients.

[Biology and growth velocity of tumors of the globus jugulotympanicum and glomus caroticum]

BACKGROUND

Paragangliomas (glomus tumors) of the head and neck are rare tumors, arising from the paragangliomatous tissue either of the carotid region or the jugular or the tympanic region. This study was conducted to investigate the possible differences in the tumor biology of these lesions depending on their site of origin.

METHODS

Nineteen specimens (10 jugulotympanic and 9 carotid glomus tumors) were investigated by quantitative DNA measurements and immunohistochemical assessment of proliferation markers (PCNA, Ki67), oncogenes (p53, nm23), different cell surface antigenes (CD44 4/5 and 6, CD54, CD106), and bcl 2 as a marker for apoptosis.

RESULTS

Depending on the location of the tumors these measurements revealed significant differences in tumor biology with higher proliferation scores and a higher number of aneuploid tumors in those of the carotid region, suggesting a more aggressive behavior compared to those of the jugulotympanic region.

CONCLUSIONS

The results also indicate a difference between the two groups in the risk of developing metastases or recurrent disease. They generally help to enhance our understanding of the biology of paragangliomas of the head and neck.

[Long-term functional outcome of Laccourreye hemipharyngectomy-hemilaryngectomy with reference to oncologic outcome]

BACKGROUND

Various techniques for the treatment of hypopharyngeal malignancies are used to achieve disease control while preserving laryngeal function.

PATIENTS AND METHODS

This study details the long-term results of 22 patients (ages 39-80; average age 57 years) following hemipharyngo-hemilaryngectomy (described by Laccourreye) for unilateral hypopharyngeal squamous cell carcinomas (G2-G3; T1-T4; N0-N3). Follow-up was 16-83 months (average 43) and included extensive speech and swallowing assessment. From 1989-1994 the procedure was performed in 26 patients. Two died within one year postoperatively, two were lost for follow-up, and 22 were included in this study.

RESULTS

One patient developed recurrent disease with liver metastasis; two patients were successfully treated for recurrent disease. Two patients developed second primary tumors, while all others had no signs of recurrent disease. Fourteen patients had no difficulties eating or drinking. Six patients could only eat soft foods, and two patients required a gastrostomy feeding tube. Nineteen patients had a useful but hoarse voice, and three patients had severe difficulties when communicating. Modulation of voice was decreased because the supraglottic structures (mainly false cord and scar tissue) were used for phonation. Eighteen patients were completely satisfied with their voice. The tracheotomy was closed in 18 patients within six months, while four patients required a tracheostoma for more than two years.

CONCLUSIONS

These data show that function-preserving surgical techniques can be successfully used in hypopharyngeal carcinomas even for patients with advanced disease. Useful functional results for swallowing, voice, and airway were achieved in most patients undergoing this procedure.

Prognostic indicators for squamous cell carcinoma of the oral cavity: a clinicopathologic correlation

Fifty-three patients with T1 squamous cell cancer of the floor of mouth and ventral surface of the tongue with a known clinical outcome were retrospectively analyzed and arbitrarily divided into "aggressive" and "nonaggressive" groups based on their clinical behavior. Various host and tumor factors were then evaluated in an attempt to determine whether the tumor behavior could have been predicted. The paraffin-embedded tumor specimens were evaluated for tumor differentiation, tumor thickness and tumor invasion, microvessel density, and p53 expression. In addition, a composite morphologic grading score was obtained by combining cell differentiation, nuclear polymorphism, mitosis activity, depth of infiltration, type of infiltration, and lymphatic infiltration. No single technique appeared capable of identifying "aggressive" behavior, although possibly an evaluation of composite factors might show promise in the future.

Inverted papillomas of the paranasal sinuses and the nasal cavity: DNA indices and HPV infection

Inverted papillomas are rare tumors of the nasal cavity and paranasal sinuses. These tumors are commonly regarded as benign lesions; nevertheless, malignant transformation occurs in up to 13% of cases. In the present retrospective study, specimens from 21 patients with inverted papillomas of the paranasal sinuses and the nasal cavity were investigated in order to analyze the distribution of genetic imbalance and to classify chromosomal aneuploidy in these tumors as a predictor for their biological behavior. Currently, human papilloma viruses (HPVs) are accepted as tumor-inducing and -promoting agents involved in benign and malignant tumors of mucosal tissues in the upper aerodigestive tract. To date more than 80 HPV types have been identified by differences in the nucleotide sequences. Several types (e.g., HPV16, HPV18) are associated with an increased risk for developing cancer. Other types (e.g., HPV6/11) are identified more frequently in benign lesions of stratified mucous membranes. We detected HPV genomes by universal and specific primer polymerase chain reaction. Using degenerated primers derived from the L1 major envelope gene, an amplification of HPV DNA fragments of the correct size was observed in 7 of 21 cases. In one specimen, where an inverted papilloma associated with a squamous cell carcinoma was histologically confirmed, HPV18-specific primers detected the HPV18 genome. The tumors in which an amplification of HPV DNA fragments were observed showed the highest proliferation scores along with the highest rate of aneuploid cells detected by quantitative DNA analysis.

Heterogeneity of squamous cell carcinomas of the head and neck--analysis of tumor biologic factors and proliferation rates

Specimens obtained from five different tumor regions in 12 patients who underwent surgery for squamous cell carcinoma (SCC) of the oropharynx were examined. The evaluation of each biopsy included quantitative DNA measurements based on image analysis, immunohistochemical assessment of proliferations markers (i.e., Ki67-MIB1, proliferating cell nuclear antigen [PCNA]), and morphological tumor-front grading. From single cell measurements, several DNA indices were derived which are known to reflect tumor aneuploidy. The results revealed a marked variation of proliferation and cellular differentiation in different regions of tumors and a wide intraindividual variation between particular tumors for all markers examined. There was good correlation between DNA data and proliferative cell fractions (Ki67 score, PCNA score). With the use of diagrams, three-dimensional distribution of proliferation rates and markers reflecting tumor aggressiveness within each tumor was obtained. The results confirmed previous clinical and histological observations that SCCs of the oropharynx are heterogeneous tumors. One might expect that the regions with increased proliferation and aggressiveness may predict the location of possible tumor recurrence.

[Examinations with DNA cytometry of mouth and oropharyngeal lavage fluid as a screening method in diagnosis of malignancies of the mouth cavity and oropharynx]

BACKGROUND

Due to a high rate of false negative results, cytologic examinations of scrapings are currently not very common in diagnosing squamous cell carcinomas of the upper aerodigestive tract. The purpose of the present study was to determine whether cytometric and cytologic examinations are suitable in diagnosing squamous cell carcinomas of the oral cavity and oropharynx.

METHODS

Cytologic and cytometric examinations of rinsing fluid from the mouth and throat were performed in 14 patients with histologically confirmed squamous cell carcinomas of the oral cavity and oropharynx. The patients were asked to rinse their mouth and throat with 10 ml of Ringer's solution. The rinsing fluid was centrifuged and fixed. The sediment was then smeared onto glass slides and stained according to the technique of Feulgen. Quantitative DNA measurements were then performed using a TV-based image analysis system. The DNA indices, 2 c DI, 5 c EE, and DNA entropy were determined from the single-cell measurements.

RESULTS

The results of the carcinoma patient group were compared to those obtained in 19 patients without any evidence of cancer (control group). With this method, malignant and benign cells could be distinguished in all cases, i.e., all patients with a carcinoma could be identified as positive by this examination, whereas patients without evidence of cancer were identified as negative in all cases.

CONCLUSIONS

The results of this pilot study show that quantitative DNA measurements might be a suitable tool for non-invasive screening of patients who are at high risk for developing a carcinoma in the upper aerodigestive tract and for follow-up of patients in order to detect tumor recurrence after successful initial treatment.

Predicting recurrence and survival in patients with laryngeal cancer by means of DNA cytometry, tumor front grading, and proliferation markers

The cure rates for squamous cell carcinoma of the larynx have improved little over the past few decades. Despite the large number of therapeutic and histopathologic studies that have been performed, there are currently no morphologic or cytologic markers available to predict outcome in patients with laryngeal cancer. In an attempt to create such a system, tissues from 40 patients who underwent surgery for carcinoma of the larynx were examined for this pilot study. The examinations included routine histology, morphologic grading at the tumor front, immunohistochemical identification of the proliferation markers proliferating cell nuclear antigen (PCNA) and Ki67, and quantitative DNA analysis. By means of the stepwise multivariate Cox regression analysis with forward selection, factors that were highly correlated to the development of recurrent disease and survival were determined. We found that the results of the DNA analysis (ie, 2c deviation index, DNA malignancy grade), along with the morphologic tumor front grading and Ki67 score, were closely related to prognosis (p < .01). All of these factors reflect tumor biology. No correlation was found for the Broders grading or for any other clinical parameter. With the test battery used in this preliminary study, patients at high risk for developing tumor recurrences could be recognized. The advantages of this technique are that it is an objective assessment of the tumor and that it can be performed on preoperative biopsy specimens. This might influence decisions regarding therapeutic management and could eventually lead to more appropriate and individualized therapy.

[Adenomatous neoplasia of the middle ear]

Adenomatous neoplasm occurring in the middle ear is rare. The clinical findings are non-specific and include otological symptoms as well as sometimes functional deficits of the lower cranial nerves. The final diagnosis will be made only after elaborate histological examinations because of the inconsistent radiological and clinical findings. DNA analysis yields some information on the prognosis of this tumour. We report on a case where a primary adenomatous neoplasm developed in the middle ear, and discuss our concept of therapy.

DNA measurements for monitoring chemotherapy in advanced head and neck carcinomas

BACKGROUND

Quantitative DNA measurements have demonstrated prognostic relevance in various malignancies, including head and neck cancer. The application of DNA measurements in monitoring and predicting the outcome of chemotherapy in treating patients with head and neck cancer was investigated.

METHODS

Twenty-five patients with advanced squamous cell carcinomas of the head and neck who underwent primary chemotherapy with three courses of cisplatin and 5-fluorouracil (5-FU) were examined in this study. Cytologic smears from the tumor site, as well as from normal mucosa, were taken before and 1 week after each course of chemotherapy. Quantitative DNA measurements were performed using an automatic microscope and a TV-based image analysis system. The DNA parameters (ie, mean DNA content of the tumor cells, 2c deviation index (2c DI), 5c exceeding rate (5c ER), DNA malignancy grade, and stemline analysis) were determined from the single cell measurements.

RESULTS

Tumors which responded to chemotherapy showed a shift of the mean DNA content and stemline towards euploidy and a decrease of aneuploid tumor cells with a DNA content of more than 5c. Tumors which did not respond to chemotherapy showed a persistent high percentage of aneuploid tumor cells and a high malignancy grade. These changes in the DNA content were observed after the first course of chemotherapy. In a clinical follow-up, patients with a shift of the DNA data towards euploidy during chemotherapy showed a significant longer recurrence-free interval than patients with residual aneuploid cell clones.

CONCLUSIONS

Quantitative DNA measurements appear to be useful in monitoring therapy and to predict the outcome after chemotherapy. Although no typical constellation was found which predicts good or bad response, the DNA data suggest that changes in the data after the first course of chemotherapy may correlate with outcome.

Comparison of cytophotometric characteristics to histology and proliferation markers in acoustic neuromas

Specimens of histologically confirmed acoustic neuromas obtained during operation in 25 patients were examined. Quantitative DNA measurements were performed with an image analysis system. From the single cell measurements, the mean DNA content of all tumor cells, 2c deviation index (2c DI), DNA entropy, DNA grade of neoplasia, and percentage of tumor cells with a DNA content of more than 5c (5c exceeding rate) were derived, as well as the mean nuclear area of the tumor cells. Proliferating cell nuclear antigen (PCNA) was identified immunohistochemically. A PCNA score was developed in determining PCNA-positive cells in a total amount of 1,000 cells. Results of quantitative DNA measurements and PCNA scores were compared to clinical symptoms, histology, and time between first onset of symptoms and diagnosis of the tumor. Quantitative DNA measurements revealed the existence of hyperdiploid tumor cells in all neuromas. According to the frequency with which they occurred, tumors could be divided into two categories: 1) tumors with a high percentage of hyperdiploid cells ("hyperdiploid tumors") and 2) those with a low percentage ("diploid tumors"). Hyperdiploid tumors showed increased values for the 2c DI, mean DNA content, DNA grade of neoplasia, and DNA entropy as signs of increased proliferation. In addition, the PCNA scores were higher in these tumors, indicative of increased DNA synthesis. The mean nuclear area was higher in these tumors. No correlation was found between the results of the DNA analysis and the PCNA score, or the clinical data and the predominant histologic subtype.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of quantitative DNA measurements and cytomorphology in squamous cell carcinomas of the upper aerodigestive tract with and without lymph node metastases

Cytologic smears of squamous cell carcinomas (UICC T2 through T4) from the mucosa of the upper aerodigestive tract without cervical lymph node metastases (n = 10) and with metastases (n = 20) were examined. Subsequently, the cytologic smears of the metastases (n = 20) obtained by fine-needle aspiration or following neck dissection were evaluated morphologically. Each specimen was then stained with Papanicolaou and Feulgen techniques, and quantitative DNA measurements were performed with an image analysis system. Morphologically, the primary tumors with metastases revealed an increased mean nuclear perimeter and mean nuclear area compared with tumors unassociated with metastases. On quantitative DNA measurements, the tumors with metastases had an increased DNA content, a higher 2c deviation index, and a higher DNA malignancy grade and increased number of aneuploid cells. The specimens obtained from the metastatic nodes yielded the highest values for mean DNA content, 2c deviation index, aneuploidy, and malignancy grade. The stem lines of metastasis were always nondiploid. These data indicate a positive correlation between aneuploid tumor cell clones in primary cancer and the manifestation of lymph node metastases.

[Importance of whole body skeletal scintigraphy within the scope of staging of neoplasms in the ENT area]

Concerning malignant tumours of the oral cavity, pharynx and larynx, bone metastases are in general rarely seen. For the specification to which patients the whole body bone scintigraphy as detection method should be applied, the findings of 370 patients were analysed retrospectively. In respect of primary staging, bone metastases could be found by scintigraphy in only 1.4% of the patients. On the other hand, there was a detection rate of 12% during the further course of the disease, especially in case of clinical symptoms pointing at spreading metastases or in tumour recurrences. Nevertheless, positive scan findings which were not due to metastases could be found in both groups with equal frequency (12 and 13%, respectively). Therefore the routine performance of whole body bone scintigraphy as a screening method does not seem to be useful in the primary staging of cancer of the mouth, pharynx and larynx. Contrary to this, in the follow-up of these tumours bone scanning proves to be a valuable and sensitive method for detecting skeletal metastases.

[Antineoplastic effectiveness and unwanted side effects of polychemotherapy of extensive oro- and hypopharyngeal cancers--results of a prospective therapy study with 5-FU/cisplatin versus 5-FU/carboplatin]

60 patients with advanced carcinomas of the oropharynx and hypopharynx underwent chemotherapy, either with 5-FU/Cisplatin (n = 30) or with 5-FU/Carboplatin (n = 30). The remission-rates (complete and partial remissions) were comparable in both groups. The rate of complete remissions, however, was statistically significant higher in the cisplatinum group (6 patients) than in the carboplatinum group (1 patient). 2 patients of the 5-FU/Cis-group and 4 patients of the 5-FU/Carbo-group developed a progressive disease during chemotherapy. Statistically significant differences were found in the nephrotoxic and myelotoxic side effects between both therapy groups: nephrotoxic side effects were more frequent in the 5-FU/Cis-group, whereas myelotoxic side effects occurred mainly in the 5-FU/Carbo-group. The chemotherapy with 5-FU/Carboplatin was better tolerated by the patients than in the 5-FU/Cisplatinum-group. In the 5-FU/Carbo-group especially a lower rate and severity of loss in weight, nausea, vomiting, alopecia and mucositis/stomatitis was observed. No statistically significant differences were found in ototoxic side effects between both groups.

[Changes in transitory evoked otoacoustic emissions in chemotherapy with cisplatin and 5FU]

The aim of this study was to detect changes of transient evoked otoacoustic emissions (TEOAE) during chemotherapy with cisplatin and fluorouracil (5FU). A review of the literature reveals that the incidence of cisplatin ototoxicity varies from 9% to 50%; this variation is due to differences in doses, duration of administration, to the criteria for ototoxicity and on audiological methods. Three cycles of chemotherapy (1000 mg/m2 5FU from day 1 to 5 and 100 mg/m2 cisplatin on day 1) were given to 12 patients; the OAE were measured before chemotherapy and after each administration. In 86% of the ears measured we found changes in the TEOAE; the mean values for the amplitude of the TEOAE decreased about 13% after the end of the chemotherapy. Pure tone thresholds were reduced in almost 50% of the measured ears. The decrease of amplitude of TEOAE is an early sign of an ototoxic secondary effect, probably due to damage to the outer hair cells. TEOAE is a sensitive method for detecting ototoxicity in cisplatin-treated patients and more reliable than pure-tone audiometry or evoked acoustic potentials.

Auditory brain stem responses in patients with human immunotropic virus infection of different stages

Thirty patients (26 men, 4 women) with human immunotropic virus infection of different stages were examined. Eleven patients had a history of i.v. drug abuse, nine patients had a history of treated lues infection, and one patient suffered from Kaposi's sarcoma. At the time of the examination, opportunistic infections or acute encephalitis were not apparent in any patient. All patients underwent otoneurological examinations, including pure-tone audiometry, caloric vestibular testing, and recording of the auditory brain stem responses (ABR). Six patients reported onset of hearing impairment during the last 3 yr. Two of them had flat sensorineural hearing loss; in the other cases, pure-tone audiometry showed high tone hearing loss with negative recruitment. ABRs were normal in 19 cases, with the latencies for waves III and V and for the I-V interpeak latency significantly delayed when compared to the values of the control group. The frequency of abnormal ABR findings did not correlate to the stage of the disease. The results of the study indicate that auditory and, more specifically, ABR abnormalities commonly occur in human immunotropic virus disease. More studies are necessary to prove whether the ABR is suitable to monitor therapeutic effects.

Quantitative DNA measurements in malignant and benign lesions of the upper aerodigestive tract

Thirty-six patients underwent biopsy of clinically suspicious lesions of the mucosa of the upper aerodigestive tract. The biopsy material was evaluated histologically and cytologic smears out of the same lesion underwent quantitative DNA analysis using a numerical index derived from the single cell DNA content. In 30 patients, histologically diagnosed squamous cell cancer was confirmed by DNA analysis with the malignancy grade correlating with the morphologic differentiation of the tumor. Six lesions were histologically benign: i.e. dysplasia (n = 3), hyperplasia (n = 2) and chronic inflammation (n = 1). DNA analysis confirmed the benign nature in 4 cases, but in 2 cases of dysplasia, a diagnosis of malignancy was made. From these results, there appears to be an excellent correlation between DNA analysis and the histologic diagnosis of malignancy. It remains to be proven if this technique of DNA analysis will prove to be a more accurate determinant of malignant potential in premalignant conditions and a method to determine aggressiveness of behavior. An added advantage is that this technique can be performed on cytologic smears, without the need for incisional biopsy.

Auditory-evoked brain-stem responses and auditory disorders in patients with Bell's palsy

Out of 121 patients examined with acute unilateral facial paralysis, 93 were determined to have idiopathic facial palsy (Bell's palsy). The examination included pure-tone and speech audiometry, stapedial reflex recordings, temporal bone radiography and auditory-evoked brain-stem response testing (ABR). If a retrocochlear lesion was suspected, computed tomography or magnetic resonance imaging was performed. Patients with sensorineural hearing loss affecting all frequencies were compared to one group with hearing loss affecting only high frequencies and to another group with ABR findings suggesting a cochlear lesion. No association could be made between the etiology of these pathological results and the concurrent facial paresis. Most of them were probably caused by unrelated disorders of the auditory system. In cases with prolonged inter-peak latencies representing brain-stem responses, abnormal ABRs could be caused by the same pathology as the paralysis. This might well suggest the presence of a neuropathy in both the central auditory system and the facial tracts.

[Malignant melanoma of the mucous membranes of the upper aerodigestive tract. Clinical, histological and immunohistochemical characteristics]

Malignant melanomas of the mucous membranes are rare tumors. They make up about 10% of all malignant melanomas of the head and neck; 15 of the authors' cases are reviewed in this article. Six of these had neck lymph node metastasis when first diagnosed. The tumors were surgically removed in all patients. Thirteen patients developed at least one tumor recurrence, ten patients distant metastasis. Eight patients died of the tumor condition; the mean survival time of all patients was 33.4 months. While the tumors could be classified histologically into four types, this had no bearing on the course of the disease. In many cases, primary tumor and metastasis or recurrent tumor differed histologically. Melanin pigment was found in 13 tumors. Mucosal melanomas can be regarded as a discrete tumor entity because their biological behavior differs from that of malignant melanomas of the skin. However there are no morphological differences between the two tumor entities. Ophthalmological and dermatological examinations must be performed in all patients with mucosal melanoma to exclude metastasis of the skin or choroid melanoma.