Imaging foreign bodies in head and neck trauma: a pictorial review

Open injuries bear the risk of foreign body contamination. Commonly encountered materials include gravel debris, glass fragments, wooden splinters or metal particles. While foreign body incorporation is obvious in some injury patterns, other injuries may not display hints of being contaminated with foreign body materials. Foreign objects that have not been detected and removed bear the risk of leading to severe wound infections and chronic wound healing disorders. Besides these severe health issues, medicolegal consequences should be considered. While an accurate clinical examination is the first step for the detection of foreign body materials, choosing the appropriate radiological imaging is decisive for the detection or non-detection of the foreign material. Especially in cases of impaired wound healing over time, the existence of an undetected foreign object needs to be considered.

Here, we would like to give a practical radiological guide for the assessment of foreign objects in head and neck injuries by a special selection of patients with different injury patterns and various foreign body materials with regard to the present literature.

Detectability of foreign body materials using X-ray, computed tomography and magnetic resonance imaging: A phantom study

PURPOSE

To evaluate the effectiveness of plain radiography (X-ray. XR), computed tomography (CT) and magnetic resonance imaging (MR) in visualising commonly seen foreign bodies. A special focus was put on objects relevant to head and neck surgery.

METHOD

Thirty-four commonly encountered objects of different compositions including wood, plastic, and glass were embedded in a gelatin gel phantom and imaged using XR, CT and MR. The success rates of radiologists in detecting and correctly identifying the foreign objects were evaluated. Subjective visibility was rated on a 4-point Likert scale. Objective visibility was analysed using region of interest-based contrast for CT.

RESULTS

Sensitivity in foreign bodies detection was highest in MR (97.1 %) followed by CT (86.0 %) and x-ray (61.8 %). Success rates for the correct identification of the objects and material types were highest in MR (33.3 % and 39.2 %, respectively) followed by CT (25.5 % for both) and XR (16.7 % and 15.7 %). Overall, subjective visibility was rated higher in CT and MR imaging ("good visibility"), as compared to XR ("poor visibility"). Interreader agreement was high across modalities (Kendall's W = 0.935, 0.834 and 0.794 for XR, MR and CT, respectively).

CONCLUSIONS

Detection and identification of non-ferromagnetic objects was most successful in MR followed by CT imaging in this experimental setup.

Preclinical efficacy of copanlisib in cetuximab sensitive and resistant tumors of HNSCC

6031

Background: Copanlisib is a highly selective, pan-class I PI3K inhibitor with preferential activity against the p110α and p110δ isoforms that lead to downregulation of PI3K signaling. Copanlisib has been approved for the treatment of follicular lymphoma in the US. Here, we explored the anti-tumor activity of copanlisib in head and neck squamous cell carcinoma (HNSCC), where Pi3K signaling has been defined as alternate signaling in cetuximab resistant tumors. Further, TCGA data show up to 56% of HNSCC display either amplification or mutational changes in the Pi3K pathway making Pi3K an attractive target. Methods: Using a mouse-clinical trial set-up we profiled 20 patient derived HNSCC xenograft models for their sensitivity to cetuximab or copanlisib as single agent as well as in combination. Models were selected from our HNSCC PDX platform based on Pi3K mutational status, with 6 models harboring hot spot mutations, HPV positivity (n=3) and/or cetuximab resistance based on previous drug screenings (n=12). Treatment response was defined as tumor regression, stabilization or progression expressed as relative tumor volume (RTV) after 3 weeks of treatment: RTV<0,7 responder, RTV>1,2 progressor. Results: Copanlisib single agent treatment resulted in moderate activity with 5 responders (25%). In cetuximab resistant tumors (n=12) combined treatment led to an improved tumor response in 75% (n=9) whereas 41% (n=5) resulted in tumor control. Pi3KCA mutation was not predictive for treatment response to either cetuximab or copanlisib. No PTEN mutation was detected in the selected cohort. Increased Pi3K signaling activity evaluated through gene expression profiling and computed with GSEA pathway analyses was positively correlated with response. Conclusions: The anti-tumor responses observed in monotherapy or in combination treatment support further investigation for the potential of PI3K inhibition in HNSCC with high expression of Pi3K pathway signature as a potential predictive biomarker.

Volatile Organic Compounds in the Breath of Oral Squamous Cell Carcinoma Patients: A Pilot Study

Objective

To assess the feasibility of detecting signature volatile organic compounds in the breath of patients with oral squamous cell carcinoma.

Study Design

Prospective cohort pilot study.

Setting

University hospital.

Subjects and Methods

Using gas chromatography and mass spectrometry, emitted volatile organic compounds in the breath of patients before and after curative surgery (n = 10) were compared with those of healthy subjects (n = 4). It was hypothesized that certain volatile organic compounds disappear after surgical therapy. A characteristic signature of these compounds for diseased patients was compiled and validated.

Results

Breath analyses revealed 125 volatile organic compounds in patients with oral cancer. A signature of 8 compounds that were characteristic for patients with oral cancer could be detected: 3 from this group presented were absent after surgery.

Conclusion

The presented results confirmed the hypothesis of an absence of cancer-associated volatile organic compounds in the breath after therapy. In this pilot study, we proved the feasibility of this test approach. Further studies should be initiated to establish protocols for usage in a clinical setting.

Drill-related root injury caused by intraoperative intermaxillary fixation: an analysis of 1067 screw applications

BACKGROUND/AIMS

Intermaxillary fixation is a standard procedure for the treatment of mandibular fractures or in orthognathic surgery. Predrilling for screws poses the risk of accidental tooth root injury, potentially leading to further pathological processes. Limited evidence about accidental tooth injury during intermaxillary fixation is available due to heterogenous study designs. The aim of this study was to evaluate the risk of root trauma using predrilled transgingival fixation screws and the clinical consequences for the affected teeth.

MATERIALS AND METHODS

In this retrospective study, the data of open reduction and internal fixation surgery files with intraoperative application of predrilled intermaxillary fixation screws were analysed. The postoperative radiographic images were evaluated for the occurrence of tooth root injury. Patients diagnosed with root injury were clinically followed up with respect to the dental health for the affected teeth.

RESULTS

A total of 133 radiologically diagnosed tooth root injuries were recorded (12.5% of screws). The median follow-up interval was 16 months (range: 3-77 months). The return rate was 49.5% for all patients. Of these, four of the injured teeth (3%) needed endodontic treatment. No toothache was reported, no tooth was lost, and no negative impact on periodontal health was clinically evident.

CONCLUSION

Intermaxillary fixation with predrilled transgingival screws is a safe way to manage mandibular fractures. The incidence of tooth root injury is not uncommon, but the adverse side effects are rare and the health of the affected teeth is mostly not compromised.

Comparative treatment planning study on sequential vs. simultaneous integrated boost in head and neck cancer patients: Differences in dose distributions and potential implications for clinical practice

AIM

The purpose of this work was to compare sequential (SeqB) versus simultaneous integrated boost (SIB) radiotherapy plans delivered with volumetric modulated arc therapy (VMAT) for patients with locally advanced squamous cell cancer of the head and neck (HNSCC).

PATIENTS AND METHODS

SeqB and SIB plans using VMAT for 10 HNSCC patients given definitive chemoradiation were generated and analysed for differences in dose distribution, coverage, conformity and homogeneity to the planning target volumes (PTV) 1-3 and sparing of organs at risk (OAR).

RESULTS

The mean delineated volumes ± standard deviations were 137.7 ± 44.8, 351.3 ± 83.9 and 895.6 ± 120.5 cm3 for PTV1-3. The mean volumes encompassed by the corresponding 95 % isodoses were 281 (+ 110 %) ± 73.4, 712.2 (+ 115 %) ± 146.4 and 1381.1 (+ 54 %) ± 217.3 cm3 with SeqB and 138.2 (+ 7 %) ± 40.1, 380.4 (+ 11 %) ± 91.9 and 1057.3 (+ 21 %) ± 161.4 cm3 with SIB for PTV1-3, respectively. Both strategies achieved excellent PTV coverage. SeqB provided significantly better coverage of PTV1 and 3, worse conformity for PTV1-3 and a higher mean dose than prescribed (111-115 %) to PTV2 and 3 (p ≤ 0.007). Both strategies provided satisfactory OAR sparing.

CONCLUSION

This study showed significant dosimetric differences with potential clinical relevance between two VMAT boost strategies regarding coverage, conformity and dose to the PTVs. SIB might cause less toxicity. A clinical phase III/IV trial endorsed by the German Head and Neck Clinical Trials Group (IAG-KHT) will evaluate differences in acute/late toxicity as well as in locoregional recurrences between the two boost techniques.

Expression of Estrogen Receptors in OSCC in Relation to Histopathological Grade

BACKGROUND/AIM

Estrogen receptor (ER)-mediated pathways are involved in the pathogenesis of several tumors. Preliminary studies have demonstrated a significant effect of ER agonists and antagonists on oral squamous cell carcinoma (OSCC) cell lines. Recent results suggest that ER subtype-specific expression patterns might depend on the grade of differentiation of OSCC. Therefore, the aim of the present study was to evaluate the expression of ERα and ERβ in OSCC and its correlation to histological tumor grade and gender.

MATERIALS AND METHODS

Tumor sections of 25 patients (13 males and 12 females) retrieved from OSCC databases with two different histological gradings (well-differentiated, poorly differentiated) were evaluated. The detection of ERα and ERβ expression in tumor cells and corresponding healthy mucosa adjacent to tumor was performed using immunohistochemistry.

RESULTS

Well-differentiated OSCC showed no significant difference between the expression of ERβ in tumor cells and corresponding mucosa. In poorly-differentiated OSCC the expression of ERβ was significantly higher in tumor cells than in corresponding mucosa. In patients without regular alcohol and/or nicotine abuse, there was no significant difference of ERβ expression in OSCC compared to corresponding healthy mucosa in contrast to patients having these risk factors. Expression of ERα was found in one tumor.

CONCLUSION

ERβ is the predominant ER sub-type expressed significantly higher in poorly-differentiated OSCC tumors compared to healthy mucosa adjacent to the tumor. Different expression patterns in relation to histological grade might suggest an influential role of ERβ in tumor (de-) differentiation of OSCC.

Abstract 2434: Identification of new treatment options for platinum-resistant head and neck cancer in a panel of broadly characterized patient-derived xenografts

Background-Aims: Cell lines and thereof established xenografts have a limited value for preclinical drug evaluation and biomarker analysis due to clonal selection and cellular dedifferentiation. We started establishing a large panel of patient derived xenografts from head and neck squamous cell carcinomas displaying the heterogeneity of this disease. Using these models we evaluate sensitivity to standard treatment, search for predictive biomarkers and test the sensitivity of experimental drugs and new treatment approaches.

Methods: Specimens from head and neck tumor surgery were transplanted subcutaneously to immunodeficient mice within 24 hours. In case of engraftment, after 3rd passage, groups of 6 mice were treated with 5-FU, MTX, Cetuximab, Carboplatin, Docetaxel and in addition with the not yet approved drug Everolimus. Treatment was applied for 3 weeks. Response to treatment was evaluated by comparing growth inhibition of treated tumors in relation to a control group. Patient tumors and derived xenografts were evaluated for HPV status by immunohistochemical staining of p16INK4A and detection of HPV-16 E6 and E7 viral DNA by PCR. Primary tumor and the derived xenografts are screened for common oncogenic mutations using the Illumina TruSeq Amplicon - Cancer Panel. In addition transcription of mTOR pathway members were analyzed in more detail using RT-PCR and protein expression analysis.

Results: In total, 70 tumor samples were transplanted resulting in 26 stably growing patient derived xenografts, 23 failed and 21 remain presently ongoing. Tumors remained histologically similar through several passages. Response to treatment varied considerably. We observed a remarkably large number of platin resistant tumors (9/11) in our study group. With our approach to identify alternative treatment options, we observed with the mTOR inhibitor everolimus a significant growth inhibition in 7 of 9 platin resistant tumors. Correlation of response with mutations in common oncogenes will be evaluated by sequencing and gene expression studies.

Conclusion: Using newly developed patient derived xenografts of head and neck squamous cell carcinomas we identified a high sensitivity to the mTOR inhibitor everolimus. These results demonstrate that these models provide an excellent tool for preclinical drug and biomarker evaluation, systems biology and provide rationale hypotheses for further clinical trials.

Citation Format: Konrad Klinghammer, Jan D Raguse, Moritz Siedmann, Michael Becker, Ulrich Keilholz, Jens Hoffmann, Iduna Fichtner. Identification of new treatment options for platinum-resistant head and neck cancer in a panel of broadly characterized patient-derived xenografts. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2434. doi:10.1158/1538-7445.AM2013-2434

Abstract 2783: Establishment and characterization of patient-derived xenografts of head and neck tumors

Background-Aims: The introduction of first targeted therapy with Cetuximab has improved survival of head and neck cancer. However there is still a large population with intrinsic resistance. To evaluate the mechanisms and find alternative treatments we started establishing a large panel of patient derived xenografts from head and neck squamous cell carcinomas displaying the heterogeneity of this disease, as cell lines and thereof established xenografts have only a limited value for preclinical drug evaluation and biomarker analysis due to clonal selection and cellular dedifferentiation. Using these models we evaluate new treatment options, identify predictive biomarkers and test the sensitivity of experimental drugs and treatment approaches.

Methods: Specimen from head and neck tumor samples were transplanted subcutaneously to immunodeficient mice within 24 hours. In case of engraftment groups of 5-6 mice were treated after 3rd passage with 5-FU, MTX, Cetuximab, Carboplatin, Docetaxel and Everolimus. Treatment was applied for 3 weeks. Response to treatment was evaluated by comparing growth inhibition of treated tumors in relation to a control group. Patient tumors and xenografts were evaluated for HPV status by immunohistochemical staining of p16INK4A and detection of HPV-16 E6 and E7 viral DNA by PCR. Primary tumor and the derived xenografts are screened for common oncogenic mutations using the Illumina TruSeq Amplicon - Cancer Panel and for genetic expression profiles by Affymetrix analysis

Results: In total, 70 tumor samples were transplanted resulting in 26 stably growing patient derived xenografts and 21 remain presently ongoing. So far only 23 xenotransplanted tumors did not grow. This results in an engraftment rate of &gt;60%. Tumors remained histologically similar through several passages. Engraftment was not related to growth fraction of the primary tumor, ranging from 10 to 90% evaluated by Ki67 staining. In a few cases we were able to establish xenografts from primary tumors and synchronous metastases. These showed high similarity concerning growth rate and drug sensitivity. Response to treatment varied considerably. Significant growth inhibition in relation to the control group was observed in 8 of 11 (72%) treated tumors for Everolimus, in 4/11 (36%) for 5-FU, 3/11 (27%) for MTX, in 3/11 (27%) for Carboplatin, in 3/11 (27%) for Cetuximab and in 6/11 (54%) for Docetaxel. Out of the established xenografts four primary tumors were classified as HPV positive but only one of them remained positive after several passages in mice.

Conclusion: Our newly established head and neck cancer panel provides an excellent tool for preclinical drug and biomarker research. Together with the molecular genetic characterization, these patient derived xenografts can be used for modeling the systemic biology of the tumor and can help to develop new rational hypotheses for further clinical trials.

Citation Format: Konrad Klinghammer, Jan D Raguse, Moritz Siedmann, Michael Becker, Ulrich Keilholz, Jens Hoffmann, Iduna Fichtner. Establishment and characterization of patient-derived xenografts of head and neck tumors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2783. doi:10.1158/1538-7445.AM2013-2783

Lower-extremity lymphedema following neck dissection – an uncommon complication after cervical ligation of the thoracic duct

Thoracic duct injuries and chylous fistula are well-known complications of neck dissection, occurring in 1-2% of cases. Management of these injuries can be conservative or operative. Conservative treatment consists of fat restricted diet or total parenteral nutrition reducing the volume of chyle production. Operative management includes exploration of the neck or if necessary open thoracotomy to ligate the thoracic duct. Following cervical thoracic duct ligation only few complications like chylothorax or chylous ascites are described in the literature. To the best authors knowledge, this is the first report in the english literature describing lower-extremity lymphedema following cervical thoracic duct ligation.

[The central island tongue flap for the reconstruction of the anterior floor of the mouth]

BACKGROUND

There are several techniques described for the reconstruction of the anterior floor of mouth after tumour surgery. Here, we point out the advantages of the central island tongue flap for this indication.

PATIENTS AND METHODS

We report on 20 patients with medium sized defect in the anterior floor of mouth, which was reconstructed with the central island tongue flap. Besides this surgical technique, we discuss the results of oral rehabilitation after a follow-up period of at least 3 months.

RESULTS

There was now flap necrosis or loss, and the median time for flap formation was less than 45 min. In the follow-up we found successful oral rehabilitation in speech and swallowing.

Gemcitabine in the treatment of advanced head and neck cancer

AIMS

Several new chemotherapy agents show varying degrees of activity in head and neck cancer. One of them is gemcitabine, which is a new nucleoside analogue with an innovative cytostatic mode of action. Gemcitabine has demonstrated a broad spectrum anti-tumoural effect and a favourable toxicity profile. These attributes prompted us to introduce gemcitabine into the treatment of head-and-neck tumours.

MATERIALS AND METHODS

Ten heavily pre-treated patients with recurrent and incurable squamous-cell carcinoma of the head and neck (SCCHN) were treated with Gem. The initial cycle consisted of six administrations of the drug (1250 mg/m2 once weekly intravenously over 30 min) followed by a week without cytotoxic treatment. All following cycles were composed of two infusions once weekly (d1, 8), followed by a week of rest.

RESULTS

Toxic effects, length of survival and tumour response was assessable in eight patients owing to one suicide and loss of one patient for follow-up. One complete remission, two partial remissions and three 'no change' situations (stable disease) were observed, yielding a response rate of 37.5%. Median survival was 8 months (range 3-12). The incidence of haematological toxicity was low, with grade 3-4 neutropenia in less than 10%. Flu-like symptoms were reported by one-third of patients.

CONCLUSIONS

In this small phase-II study, gemcitabine demonstrated a high anti-tumoural activity in SCCHN, with a favourable toxicity profile. Gemcitabine seems to be a promising new drug without severe burden even for patients who are refractory to other cytostatic drugs. Within recent years, the activity and tolerability of gemcitabine was documented in several phase I and phase II trials, especially in combination with cisplatin, and paclitaxel resp, carboplatin/paclitaxel, cisplatin/ifosfamide, and 5-fluorouracil/paclitaxel. The results of these trials will be outlined in the discussion.

A metabolically active dermal replacement (Dermagraft) for vestibuloplasty

This article describes the use of tissue-engineered dermal replacement in the vestibular extension instead of palatal donor tissue or (split-thickness) skin graft. In three patients the living human-derived fibroblast skin substitute (Dermagraft) was implanted on the wound surface after mucogingival junction and supraperiosteal dissection. Following application of Dermagraft, epithelial closure starting from the resection margins of the defect was observed, obviating further surgical treatment. Vestibular depth was increased and no scarring or frena occurred. Tissue-engineered dermal replacement consisting of living human fibroblasts appears to be a useful substitute for autogenous grafts in pre-prosthetic surgery, offering the advantages of unlimited availability, good colour match and no donor site morbidity.

The buccal fad pad lined with a metabolic active dermal replacement (Dermagraft) for treatment of defects of the buccal plane

The buccal fad pad flap (BFPF) is an easy to raise pedicled flap for closure of intraoral defects with barely any donor defect. The major disadvantage of the BFPF is the missing epithelial lining, which can induce fibrous tissue formation with resulting functional impairment. To overcome this problem we lined the BFPF with a dermal replacement (Dermagraft) consisting of living metabolic active fibroblasts. In six patients, defects resulting from tumour removal were reconstructed with a combination of the BFPF and Dermagraft and followed up for at least 2 years. In all patients a defect closure was achieved with no functional impairment. The clinical character which was achieved was more a type of defect regeneration than a flap closure. The availability of bioengineered metabolic active tissue can overcome the major problem of the BFPF as an option for defect closure of the buccal side. Furthermore the regeneration of the defects optimises clinical tumour monitoring.

[Esthetic rehabilitation of rhinophyma]

BACKGROUND

Rhinophyma is an uncommon progressively disfiguring process of the nose which occurs most often in middle-aged white men. The supposed association with increased alcohol abuse often leads to psychological problems for the person concerned.

PATIENTS AND METHODS

We describe ten cases of patients with slowly progressive tumorous deformation of the nose. They were treated with a stepwise surgical approach consisting of tangential excision for debulking, sculpting with scissors, and finally contouring by dermabrasion.

RESULTS

An esthetically pleasing result was achieved in all cases, making social reintegration for the patients possible. In the follow-up of at least 12 months no recurrence was seen and no scars occurred.

Recombinant human erythropoietin in the treatment of head and neck tumour anaemia

At the time of first diagnosis, patients with squamous cell carcinoma in the head and neck are often in the advanced stage of their disease, therefore surgery is not a viable option for treatment. These patients also present frequently a high grade of anaemia as a result of either the malignant process itself or of the following therapy. The incidence of anaemia and the need for transfusion depends on several factors, such as the type and intensity of radiotherapy and radiochemotherapy. Multimode therapeutic concepts such as radio-chemotherapy are being applied with increasing frequency, resulting in an ever increasing need for transfusion with great effects on the patient's quality of life. Even more important to tumour patients is the role of the haemaglobin (Hb) value as a prognostic factor for survival and/or local tumour control. A large number of studies show that recombinant human erythropoietin (r-HuEPO) is effective in the treatment of tumour-induced anaemia and prevention and correction of chemotherapy and radiotherapy-induced anaemia. The simultaneous application of r-HuEPO with chemotherapy can prevent patients with head and neck tumours from developing anaemia or can reduce the extent of the anaemia and the need for transfusion. Comparable effects were observed both in patients undergoing platinum-based and non-platinum-based chemotherapy. The direct correlation between anaemia, tumour hypoxia and poor response to radio and/or chemotherapy has been clinically proven. Recombinant human erythropoietin administration improves the therapeutic outcome and the patients' prognosis.