Impact of Sonic Hedgehog Pathway Expression on Outcome in HPV Negative Head and Neck Carcinoma Patients after Surgery and Adjuvant Radiotherapy

INTRODUCTION

HPV positive patients suffering from head and neck cancer benefit from intensified radiotherapy when applied as a primary as well as an adjuvant treatment strategy. However, HPV negative patients treated with surgery and adjuvant radiotherapy lack validated prognostic biomarkers. It is therefore important to define prognostic biomarkers in this particular patient population. Especially, ´high-risk groups´ need to be defined in order to adapt treatment protocols. Since dysregulation of the sonic hedgehog pathway plays an important role in carcinogenesis, we aimed to assess whether members of the sonic hedgehog-signaling pathway may act as prognostic factors in patients with HPV negative head and neck squamous cell carcinoma.

MATERIALS AND METHODS

In this prospective study, pretreatment tumor biopsies of patients with head and neck squamous cell carcinoma were taken during panendoscopy (2005 to 2008). All patients were treated with surgery and postoperative radiotherapy. After assessment of HPV and p16 status, protein expression profiles of the Sonic hedgehog-signaling pathway were determined by immunohistochemistry and tissue microarray analyses in 36 HPV negative tumor biopsies. Expression profiles of Sonic hedgehog, Indian hedgehog, Patched, Smoothened, Gli-1, Gli-2 and Gli-3 were correlated with patients´ clinical data, local-control rate, disease-free as well as overall survival. Data from The Cancer Genome Atlas databank were used for external validation of our results.

RESULTS

Gli-1 (p = 0.04) and Gli-2 (p = 0.02) overexpression was significantly linked to improved overall survival of HPV negative patients. Gli-2 (p = 0.04) overexpression correlated significantly with prolonged disease-free survival. Cox-multivariate analysis showed that overexpression of Gli-2 correlated independently (HR 0.40, 95% CI 0.16-0.95, p = 0.03) with increased overall survival.

DISCUSSION

Gli-1 and Gli-2 overexpression represents a substantial prognostic factor for overall and disease-free survival in patients with locally advanced HPV negative head and neck cancer undergoing surgery and postoperative radiotherapy.

Challenging a dogma – Surgery yields superior long-term results for T1a squamous cell carcinoma of the glottic larynx compared to radiotherapy

AIMS

The aim of this study was to compare laser surgery, conventional endoscopic surgery and radiotherapy in the treatment of early T1a glottic cancer.

METHODS

We conducted a retrospective analysis of patients with early vocal cord cancer (who underwent either conventional surgery via endoscopy or laryngofissur, or primary radiotherapy) at the Medical University of Vienna. By univariate and multivariate Cox regression models the influence of treatment and other parameters on survival and locoregional control were analysed.

RESULTS

337 Patients were analyzed with a mean follow-up period of 133.8 months. Overall survival rates where similar in all three treatment groups. Five-year, 10-year and 15-year estimates of disease specific survival for laser-treated patients were 100%, for conventional surgery were 100%, 98% and 98%, and for radiotherapy were 96%, 92% and 91%, respectively. Locoregional recurrences were observed after laser surgery in 10%, after conventional surgery in 13% and after radiotherapy in 30% of the patients treated. According to the log-rank test, time to relapse was significantly shorter for irradiated patients compared to patients who underwent surgery (p < 0.0001). Mortality caused by the laryngeal tumour was significantly higher in the radiotherapy group (p = 0.003).

CONCLUSION

Patients undergoing laser or conventional surgery have a significantly lower incidence of locoregional recurrences and longer disease-free intervals when compared to patients treated by radiotherapy.

Superimposed high-frequency jet ventilation for laryngeal and tracheal surgery

OBJECTIVE

To describe our experience with superimposed high-frequency jet ventilation (SHFJV), which does not require any endotracheal tubes or catheters, for performing laryngeal and tracheal surgery.

DESIGN

A case series of 500 patients.

SETTING

A university medical center.

PATIENTS

Four hundred sixty adult patients and 40 children in a consecutive sample who required laryngeal or tracheal surgery under SHFJV.

INTERVENTIONS

The SHFJV uses 2 jet streams with different frequencies simultaneously and is applied using a jet laryngoscope. Ventilation was performed with an air-oxygen mixture, and intravenous agents were used for anesthesia. Arterial blood gas values were analyzed.

MAIN OUTCOME MEASURES

Reported values of oxygenation and ventilation during the application of SHFJV and laryngotracheal surgery.

RESULTS

In 497 patients, adequate oxygenation with a mean +/- SD PaO2 of 91.8 +/- 22.9 mm Hg and ventilation with a PaCO2 of 29.7 +/- 5.5 mm Hg were achieved using SHFJV. The average duration of the application of ventilation was 27 minutes, and the longest duration was 118 minutes. No complications due to the ventilation technique were observed. Laser surgery was performed in 150 patients.

CONCLUSIONS

The use of SHFJV in combination with the jet laryngoscope provides patients with sufficient ventilation during laryngotracheal surgery. Even in patients at high risk because of pulmonary or cardiac disease, this technique can be applied safely. In patients with stenosis, the ventilation is applied from above the stenosis, reducing the risk of barotrauma. The SHFJV can be used for tracheobronchial stent insertion, and laser can be used without any additional protective measures.

[Late functional outcome after reconstruction of the upper aerodigestive tract with free transplanted microvascular anastomosed jejunum]

Since 1983, 90 autologous jejunal transplantations for reconstruction of the upper digestive tract have been performed in 89 patients (9 females, 80 males, average age 56.3 years). 73 patients were operated primarily, in 16 patients a recurrent tumor had been treated. One patient received a second jejunal graft after necrosis. In these heterogenous patients, the primary tumor was located in the hypopharynx 48 times, in the larynx 21 times, in the oropharynx 19 times and twice in the oral cavity. There was nearly always tumor stage III or IV without distant metastases. Following locoregional tumor resection, speech restoration was achieved 35 times by a siphon-like tube, and the upper digestive tract was reconstructed using a patch 18 times and by a tube 28 times. A combination of tube or patch with a siphon-like tube was employed 9 times. In only two of 16 patients with recurrent tumor, speech reconstruction was performed, in the other 14, the upper digestive tract was reconstructed. In those patients, in whom speech reconstruction (by siphon tube or by combination with tube/patch) was intended, this was achieved in 81.5%. Successful functional reconstruction of the upper digestive tract (by patch, tube, combination) could be achieved in about 60% of these patients.

Tubeless laryngotracheal surgery in infants and children via jet ventilation laryngoscope

We present the first use of tubeless superimposed combined high- and low-frequency jet ventilation (SHFJV) with a jet laryngoscope in laryngotracheal surgery in infants and children. Twenty-eight patients underwent 53 operative procedures. The average age of the patients was 7.3 years. The most common diagnoses were laryngeal papillomatosis and subglottic stenosis. The duration of jet ventilation averaged 33 min. The gas exchange was sufficient in each case. The advantages of SHFJV in the surgery of the laryngotracheal area in infants and children are optimal view at the larynx and trachea, maximum space for the handling, application of the laser without risks, no time limitation, suitability for stenosis, and neither anesthetic nor surgical complications.

Videoradiography of free jejunal grafts for rehabilitation of speech in laryngectomized patients

In laryngectomized patients a tracheo-esophageal artificial fistula can be used to achieve air flow from the trachea to the esophagus during speech. A one-way plastic valve is often used for the fistula. A free jejunal graft between the trachea and the esophagus can also be used. To avoid aspiration the transplant is attached to the submental area giving the graft a siphon-like shape. We performed 23 videoradiographic examinations using high-density barium in 14 such patients. The aim was to evaluate the protective function of these grafts against aspiration. Penetration of the bolus and a small amount of residual contrast material in the ascending limb of the graft was a normal finding. If the standard barium bolus reached the descending limb at any time during the examination, this was a sign of aspiration hazard. To avoid aspiration, the vertex of the speech siphon should be higher than the level of the hypopharyngeal anastomosis.

[Ventilation during tracheotomy in extensive, 90% laryngeal stenosis using superimposed high frequency jet ventilation via the jet laryngoscope]

In a 35-year old male patient with laryngeal carcinoma an acute respiratory insufficiency with early hypoxaemia developed due to massive laryngeal stenosis. An endotracheal intubation was not possible since the available lumen was too small. Tracheotomy using local anaesthesia was not possible since spontaneous respiration with a Venturi mask applying 100% oxygen was not sufficient and the patient was becoming restless and agitated due to the hypoxaemia. Transcutaneous jet ventilation was considered to be too risky since the needle would have to pass highly vascularised tumour tissue and the detection of such a small rest lumen would have been quite difficult. Ventilating the patient using a percutaneous catheter would have been very risky as well since, due to the massive stenosis, a sufficient expiration would not be likely and therefore was considered to carry a high risk of barotrauma. The patient was ventilated under general anaesthesia via a specially designed endoscopy tube with integrated jet nozzles applying superimposed high frequency jet ventilation above the stenosis. Since it was possible to achieve sufficient ventilation during the inspection of the larynx the jet laryngoscope was left in place and the supporting apparatus was covered with sterile drapes. The tracheotomy was performed using the superimposed high frequency jet ventilation. Throughout the procedure oxygenation and ventilation were adequate. The laryngectomy performed several days later revealed a cauliflower type protrusion into the tracheal lumen and a 5 cm long stenosis of the larynx with a lumen of 3 mm.

[Ventilation in laryngeal laser-surgical interventions using superimposed high frequency jet ventilation (SHFJV)--a further revision of jet ventilation technique for laryngeal interventions]

In laser surgery of the larynx the surgeon and the anaesthesist have to compete for the limited space available. The surgeon requiring good visibility and an undisturbed operating area whereas the anesthetist has to ensure sufficient ventilation of the patient. Further, complications of anaesthesia and laser must be avoided. These requirements are met by using the jet-tube (jet-laryngoscope) with two integrated nozzles applying simultaneously low- and high-frequency jet-ventilation giving the surgeon total access to the area operated on, and at the same time enables safe ventilation of the patient. Of 334 operations with the tubeless ventilation technique 76 cases were laser surgical interventions. In 6 patients stenoses were enlarged. The average duration of the jet-ventilation was 25 +/- 10 minutes. The maximum duration of a laser surgical intervention was 140 minutes. The age distribution of the patients was 18 months to 82 years. In all patients pulmonary gas exchange was satisfactory. We believe that the advantage of the tubeless jet-ventilation is: optimal visibility and surgical freedom for the surgeon, no time limitation, even in very severe stenoses. Since no volatile anaesthetics or any type of endotracheal tube are applied there is no danger of interaction with the laser when using the SHFJV via the jet-laryngoscope. Application of the tubeless jet-ventilation technique is however limited if patients suffer from severe pulmonary obstruction; likewise highly obese patients and patients in whom massive bleeding occurs are not amenable to tubeless jet-ventilation.

Fine structure of the tendon of the human stapedius muscle: comparison of normals and clinically otosclerotic patients

The tendon of the human stapedius muscle was studied in normal post mortem material and in clinical otosclerotic patients, using light and electron microscopy. Cross section profiles of collagen fibrils were measured in various regions of the tendon and the amount of elastin was estimated. The normal stapedius tendon consisted of three concentrically arranged portions: A cylindrical central part, a tube-like mid-portion, and a cortical layer. The central part was made up of collagen fibrils with only a few elastic fibers, the mid-portion contained collagen fibrils together with significantly more elastic material, while the cortical layer, again, showed a smaller amount of elastic fibers. Mean diameters of collagen fibrils in the central part of the tendon were 65.12 +/- 11.89 nm, in the intermediate layer 41.00 +/- 9.63 nm, and in the cortical layer 70.28 +/- 19.58 nm. Stapedius tendons from clinically otosclerotic patients, though showing the same construction, were characterized by significantly altered collagen fibrillar diameters (Mann-Whitney U-test). In the central part, mean diameters were reduced to 61.05 +/- 14.70 nm, in the mid-portion increased to 50.90 +/- 10.08 nm, and in the cortical layer reduced to 61.09 +/- 8.49 nm. The changes of collagen cross section profiles estimated for the entire tendon were significant as well: 59.68 +/- 18.74 nm in controls versus 57.82 +/- 12.53 nm in otosclerotic patients. Elastin content in the mid-portion of control stapedius tendons increased with age (13% at 35 years of age to 35% at 70 years of age).(ABSTRACT TRUNCATED AT 250 WORDS)

[Functional and cancerologic aspects in the use of jejunum in the ENT area]

In this article, we report about the experiences at our ENT-University Clinic in Vienna in 76 patients with free transplanted microvascularly anastomosed autologous jejunum used for reconstruction following extensive resection of mainly stage IV carcinomas in the head and neck. Jejunum was inserted as a siphon-like tube between the trachea and the hypopharynx in 43 patients primarily for restoration of speech (in 10 cases the pharynx was also reconstructed). In 33 patients, the upper digestive tract was reconstructed, as either patch or tube. They were then evaluated according to functional results of speech and swallowing, aesthetics as well as 5-year survival rates. We achieved good results in 35 speech patients (81.4%) and in 22 swallowing patients (66.6%). The aesthetic function was influenced favourably because the volume of the jejunal transplant fills up the defect in the neck after resection and creates a tolerable neck-shape. The 5-year survival of all available 54 patients was 26%, patients for speech restoration 31.7% and patients for swallowing restoration 17.5%. These results are to be considered under the aspect that patients with swallowing restoration primarily had more severe disease. Complications such as like perioperative mortality and total necrosis can be avoided by careful evaluation of the patients to be operated on. With the experiences gained from this study, we now have exact indications for the use of jejunum grafts and thus can expect very high rates of success.

The expression and cellular distribution of adhesion molecules CD2/LFA-3 and ICAM-1/LFA-1 on mononuclear cells in squamous cell carcinoma of the head and neck

The expressions and cellular distributions of two pairs of adhesion molecules CD2/LFA-3 (leukocyte function-associated antigen-3) and LFA-1/ICAM-1 (intercellular adhesion molecule-1) were examined in inflammatory cellular infiltrates of advanced squamous cell carcinomas of the head and neck by immunohistochemical techniques including double-staining methods. Thirteen patients were investigated using the following monoclonal antibodies (mAbs): CD2, LFA-3 (CD58), ICAM-1 (CD54), LFA-1 (CD11a), the alpha/beta and gamma/delta T-cell receptor, pan T cells and broadly distributed monocyte/macrophage (m/m phi) [Fc gamma RII (CD32), 25F9, RM3/1]. LFA-3 staining was observed on a high number of cells (968 +/- 112 cells/mm2), correlating to the number of Fc gamma RII (CD32; P < 0.01), 25F9 (P < 0.05) and RM3/1 (P < 0.05) positive m/m phi. Its ligand CD2 was found on 365 +/- 126 cells/mm2, representing about 50% of CD3+ cells (730 +/- 286 cells/mm2). CD2 positivity correlated to CD3 and CD8 (P < 0.01) but not to CD4+ T cells. LFA-1 and ICAM-1 were expressed on lymphocytes as well as on m/m phi. ICAM-1+ cells (902 +/- 205 cells/mm2) correlated to CD3+, CD8+ and RM3/1+ cells (P < 0.01). LFA-1 positivity (803 +/- 255 cells/mm2) showed correlations to nearly all investigated antigens, as well as to CD4+ T cells (P < 0.05). These results show that different m/m phi subsets display distinct patterns of adhesion molecule expressions suggesting different pathways of regulation. The CD3+ lymphocyte population revealed a lack of CD2 expression that was more pronounced in the CD4+ subset and indicated impaired lymphocyte function.

[Does the use of free transplanted jejunum segments in advanced laryngeal and hypopharyngeal cancer prolong survival? A matched-pair analysis]

The effect of free transplanted jejunum autografts, inserted after resection of extensive squamous cell carcinoma of the larynx and hypopharynx is evaluated in terms of survival and the development of local and regional recurrences. In a matched-pair analysis, 22 patients with jejunum transplants were compared with 44 patients with the same performance status, in whom after laryngopharyngectomy, the pharynx had been closed with local mucosa. The cumulative survival rate was calculated using the Kaplan-Meier method; the statistical comparison of the survival curves of the two groups was made with the Mantel-Haezel test. Patients of the study group had a statistically significant (p less than = 0.01) better survival rate than those of the control group, the 50% survival rate being 36 and 11 months, respectively. Local recurrences occurred in 9.1% of the patients in both the study group and in controls, and regional recurrences in 40.8 and 43.2%, respectively. This militates against the possibility that the surgery in patients in whom reconstruction with jejunum was possible might have been more radical. Further, it may be speculated that the statistically significant better survival rate is due to the jejunum itself, presumably to a tumourprotective effect of the lymphatic tissue of the transplant.

Autotransplanted jejunum in patients with carcinomas of the head and neck: transport of immunosurveillance against tumor cells?

Autologous jejunum, transplanted as a functional replacement immediately after radical dissection of advanced stages of squamous cell carcinomas of the head and neck and subsequently irradiated, was examined by immunohistochemistry (APAAP/PAP-technique). Biopsies from 9 patients were taken at the time of transplantation and up to 24 months thereafter (group 1) and from 5 patients only once after transplantation (group 2). Twenty-six monoclonal antibodies (mAbs) were used as surface markers to give an overview about phenotypical changes with respect to T-, B- and M phi-antigens. 1) B cells: a general increase of CR2+ (CD21, p less than 0.01) could be noticed after transplantation, immunoglobulin positive cells remained unchanged expect for a significant decrease of IgM+ (p less than 0.01) and IgA1+ (p less than 0.01) cells. 2) The number of T cells (CD3+) showed no significant differences although TcR gamma/delta+ cells decreased (p less than 0.01) in the autotransplant. ICAM-1 (CD54) and IL-2R (CD25) were found on a significant (p less than 0.01) higher number of cells after transplantation. 3) Cells with M/M phi morphology showed increased expression of the Fc gamma receptors (CD64, p less than 0.001; CD32, n.s.; CD16, p less than 0.001), of the complement receptors CR1 (CD35, (p less than 0.001) and CR3 (CD11b, p less than 0.02), of HLA-DQ (p less than 0.01), and of the antigens 25F9 (mature M phi; p less than 0.01) and CD4 (p less than 0.02). Correlation analyses of data obtained from the biopsies of the 14 autotransplanted jejunum cases revealed a CD35+ and a 25F9+ subpopulation of M/M phi. Our findings indicate that despite irradiation autotransplanted jejunum contained cells with immunological capacities. Therefore, the replacement of larynx by autologous jejunum may facilitate not only mechanical but also immunological functions.

Surgical voice rehabilitation after laryngopharyngectomy. Functional results of tracheo-hypopharyngeal shunts by jejunal transplantation

For surgical voice rehabilitation after pharyngolaryngectomy we use the technique of placing a siphonlike jejunal interposition in order to create a tracheohypopharyngeal shunt. In this paper we present the functional benefits of this method of voice rehabilitation. The best results achieved are compared with a normal voice using the following test parameters: electroacoustic sound analyses and voice status. The findings show that the siphon voice is adequate for everyday purposes and can achieve useful social verbal communication.

[Histologic study of the effect of postoperative irradiation on free transplanted jejunal segments]

After the reconstruction of defects resulting from the resection of advanced tumors from the upper aerodigestive tract using free microvascular anastomized jejunum, the autotransplant is influenced by local radiotherapy (cumulative dose 50-70 Gray). Biopsies were taken from 15 patients, stained with haemotoxilin-eosin and Giemsa and compared by means of light microscopy with jejunum taken at the time of transplantation. It was possible to observe a widened mucosal and submucosal space two to three months after radiotherapy, similar to the clinical impression of a radiogenic enteritis. The villi were flat and shortened with no or slight epithelial lesions. Additionally, it was possible to observe an inflammatory infiltration consisting mainly of neutrophilic granulocytes, edemas, and telangiectases. The latter were also evident in nonirradiated autotransplanted jejunum and are therefore not only caused by irradiation. One year after radiotherapy the mucosal membrane was atrophic. Fibrosis was to be seen in the lamina propria, accompanied by widened muscularis mucosae. The submucosal space was also widened and fibrotic to a varying degree. It was possible to detect varying stages of alteration in the vascular system up to a complete obliteration. After two years, changes were more pronounced. At no time could any alteration in the nervous system of the plexus submucosus be observed. All of these changes have to be interpreted as a consequence of irradiation. However, lubrication of the mucosal surface and the motility of the transplant are not altered severely by irradiation and therefore the desired functions of the free transplanted jejunal grafts, such as swallowing and phonation, are carried out sufficiently.(ABSTRACT TRUNCATED AT 250 WORDS)

[What happens to vocal cord dysplasias in variable smoking behavior?]

The influence of smoking with regard to the development and course of laryngeal dysplasias was examined. The case histories of 63 patients with histologically proven dysplasias of the larynx were evaluated in the light of their answers to a questionnaire covering their lifetime smoking habits.

RESULTS

1. The percentage of smokers in the patient group significantly exceeds the percentage of smokers in the general population. 2. The disease is more likely to lead to deteriorated histological findings in smokers. 3. A change in smoking habits at the time of diagnosis has no significant effect on the further course of disease. 4. Non-smokers have higher levels of dysplasia at first biopsy, but the disease is less likely to progress. The development of malignancy was not observed in the non-smoker group.

[Sonography in malignant tonsillar tumors]

In this retrospective study the value of sonography in the preoperative staging of malignant tumours of the tonsils was evaluated in 36 patients. According to our results sonography is indicated in small tumours. In greater tumours, especially if bone destruction could be expected, MR or CT should be performed additionally to sonography. Good results were achieved in assessing the infiltration of the tongue with or without crossing the midline (accuracy 92 to 97%) and the detection of cervical lymph node metastasis (accuracy 94%).

Risk of vocal chord dysplasia in relation to smoking, alcohol intake and occupation

The significance of tobacco smoking, alcohol consumption and occupation as risk factors for the development of vocal chord dysplasia was evaluated in a case-control study. Twenty-seven male patients with dysplasia of the vocal chords were chosen from the I. ENT-University Clinic in Vienna (1985-1988) and compared with 54 controls. The main results are: The relative risk (RR) of a smoker compared to that of a non-smoker for vocal chord dysplasia is 7.27 (6.81-7.73); the RR adjusted for occupation is 3.58 (2.31-4.84). The most important risk factor, however, is occupational exposure. The relative risk of a blue collar worker compared to that of a white collar worker is 11.04 (10.61-11.46), which is reduced only to 10.02 (10.61-11.46) after stratification according to smoking habits.

Invasion of the carotid artery and jugular vein by lymph node metastases: detection with sonography

Knowledge of invasion of the walls of the cervical vessels by tumor is of great clinical importance before surgery. We performed sonography on 83 patients with palpable cervical lymph node metastases in the region of the carotid bifurcation to determine the relationship of the metastases to the carotid artery and jugular vein. In all patients, the sonographic results were proved by surgery. The wall of the carotid artery was hypo-echogenic in 11 of 12 patients with surgically proved tumor invasion of the artery. Four results were false-positive. Palpation or swallowing during real-time scanning showed mobility of the tumor relative to the wall of the artery in 47 patients (57%). In these patients, tumor invasion could be excluded. Bilateral compression or invasion of the internal jugular vein was identified correctly with sonography in all five patients in whom this was confirmed surgically. These results suggest that real-time sonography is a valuable method for determining the relationship between cervical lymph node metastases and the carotid artery and jugular vein.

[Value of sonomorphologic criteria in the identification of regional metastases of squamous cell cancers of the ENT area]

We compared the preoperative ultrasound findings with the histological results of 127 neck dissections for squamous cell carcinoma of the head and neck. We checked several sonomorphological criteria (size, shape, boundary, echo structure, arrangement, mobility) to assess their value in identification of metastatic disease. If all nodes found on ultrasound were classed as metastases, the specificity was 30%, because many lymph nodes showed nonspecific reaction only. Lymph nodes with a rupture of the capsule or central necrosis or being larger than 3 cm, proved to be metastatic in all cases. Round or oval nodes with a size of more than 2 cm were found to be metastatic with an accuracy of 89%. The almost certain (97%) identification of necks with no metastatic lymph nodes allows elective neck dissection to be avoided.

[Intratemporal course of the facial nerve in magnetic resonance imaging]

MR images of the intratemporal portion of the facial nerve were obtained with a 1.5 Tesla permanent magnet whole-body imaging system. The facial nerve was followed from the internal auditory through the temporal bone to the styloid foramen. MR promises to be a sensitive method for the evaluation of intratemporal facial nerve diseases.

[Sonographic assessment of tumorous infiltrations of the extracranial carotid artery]

The role of sonography in evaluation of tumorous infiltrations of the wall of the cervical arteries is discussed upon 75 patients with histologically proved lymphnode metastasis. Direct signs for the infiltration--loss of the echogenic wall of the arteries and indirect signs--length and circumference of the tumor/vessel contact area are evaluated. In 9 patients the infiltrations were correctly diagnosed, 4 patients were false positive. The technic of the sonographic investigation and potential pitfalls are demonstrated. The role of other investigation modalities are discussed.

[Pharyngeal fistula after irradiation and laryngectomy. Problem of the reconstruction of the pharynx]

A 39-year-old patient with an epiglottic carcinoma stage T4N2M0 was treated initially by radiotherapy, but later underwent laryngectomy for irradiation necrosis. A pharyngeal fistula occurred in the irradiated area. After resection of the damaged skin reconstruction was performed by a double skin paddle myocutaneous pectoralis major flap. A recurrence of the fistula in the same area was closed by invagination of the flap. Three years later a massive scar stenosis developed in the reconstructed hypopharynx, so that the patient was unable to swallow. This required a total resection of the scar tissue which extended from the entrance of the hypopharynx to the upper oesophageal sphincter. The gap was bridged by a free microvascular jejunal graft. To date 6 months have elapsed since this operation and the patient is symptom free.

[Extensive recurrent basalioma of the pinna with infiltration of the temporal bone--radical surgical removal of the tumor and primary defect repair (a case report)]

Report on a woman patient, 69 years of age, suffering from a recurrent extensive basalioma of the external ear that was considered inoperable, as the tumour had invaded the petrous bone, the parotid gland, the mandibular joint, and the adjacent nerves. Because of unbearable pain it was decided to perform a radical operation with resection of the tumour, the petrous bone, the parotid gland, the ascending mandibular branch, the facial nerve, and part of the oral mucous membrane. The exposed large cervical vessels, dura mater, and the bony skull--of which the periosteum had to be removed--were primarily covered with a large pectoral muscle island flap and an occipital advanced flap. Twenty-four months after surgery the patient had no relapse and was free from pain.

The role of interstitial irradiation (brachytherapy) with iridium-192 in the treatment of head and neck cancers

The value of interstitial radiotherapy (brachytherapy) in the treatment of malignant tumors of the head and neck is reported, with special regard to different methods of iridium-192 implantation. The advantages and disadvantages of these techniques are discussed. Results obtained in treating patients with oral cancers are presented.

[Reconstruction of defects following pharyngolaryngectomy with free transplanted jejunum]

We report 10 patients undergoing pharyngo-laryngectomy in whom the pharyngeal defect was reconstructed with a free jejunal graft. This method is technically demanding. The advantages are excellent healing due to the excellent blood supply of the edges of the graft, and the almost unlimited supply of jejunum. The use of this method is justified by the immediate restoration of deglutition.

[Ultrasound diagnosis of branchiogenic neck cysts]

16 operatively and histologically proven branchiogenic cysts were evaluated sonographically and the contents of some of them were analysed by microscopy and chemistry. The echographic appearance of all cysts depended on the frequency of the scanheads and ranged from cystic (3.0 MHz) via semi-solid (5.0 MHz) to solid (7.5 MHz). This frequency-related sonographic pattern is caused by the high amount of cholesterin contained in these cysts and permits diagnosis of a branchiogenic cyst.