Nuclear-DNA content and p53 immunostaining in oral squamous-cell carcinoma - an analysis of a consecutive 10-year material

In a retrospective analysis of 91 consecutive oral carcinomas we reviewed all patient records and weighed clinicopathological parameters against the results of image DNA cytometry and p53 immunhistochemical staining of the initial diagnostic biopsies. Eighty-seven percent of the biopsies were either aneuploid or nondiploid and there was a significant correlation between poorly differentiated tumours and aneuploidy. Sixty-nine percent of the tumours were p53 positive. DNA aberration or p53 positivity had no significant impact on prediction of survival or susceptibility to radiotherapy. In a multivariate analysis, T category had the greatest predictive value concerning survival. There was no correlation between p53 positivity and smoking.

Breathing and swallowing in normal man--effects of changes in body position, bolus types, and respiratory drive

BACKGROUND

Coordination of breathing and swallowing is essential for airway protection and dyscoordination may cause morbidity and mortality.

METHODS

Using a recently developed technique for high accuracy respiratory measurements of airflow during swallowing, we investigated the effects of body position (upright vs left lateral), bolus type (spontaneously swallowed saliva vs water), and respiratory drive (normo- vs hypercapnia) on coordination of breathing and swallowing in 32 healthy volunteers.

KEY RESULTS

Swallows were in all cases (100%) proceded by expiration and 98% were also followed by expiration, regardless of body position, bolus type, or respiratory drive. While the endpoint of postswallow apnea correlated well to the endpoint of pharyngeal swallowing, duration of preswallow apnea was highly variable. In a small fraction of swallows followed by inspiration (3%), the expiratory phase before swallowing and duration of postswallow apnea was significantly longer. Body position and respiratory drive affected the increase in upper esophageal sphincter tone during inspiration. Increased respiratory drive also reduced swallowing frequency and shortened duration of preswallow apnea. Water swallows had longer duration of preswallow apnea.

CONCLUSIONS & INFERENCES

Swallowing occurs during the expiratory phase of respiration, and the fraction of swallows preceded and followed by expiration approach 100% in healthy humans. This integration between breathing and swallowing remains unchanged regardless of body position, bolus characteristics, or respiratory drive. Our results provide a platform for future studies aiming at understanding how this integration is changed by aging, diseases, and drugs.

Swallowing and respiratory pattern in young healthy individuals recorded with high temporal resolution

The coordination of swallowing and respiration is essential for a safe swallow. Swallowing consists of several subsecond events. To study this, it is important to use modalities with high temporal resolution. In this study, we have examined young healthy individuals with simultaneous videofluoroscopy, videomanometry and respiratory recording, all with high temporal resolution. The onset of 13 predetermined swallowing and respiratory events and the surrounding respiratory phase pattern were studied in different body positions and during different respiratory drives. An increased respiratory drive was induced by breathing 5% CO(2). The results demonstrated a highly repeatable and fixed temporal coordination of the swallowing pattern despite body position and respiratory drive. Previous studies have demonstrated a period of centrally controlled apnoea during swallowing. This apnoea period has a variable length, varying from 1 to 5 s. During increased respiratory drive, we could demonstrate a significantly shorter period of apnoea during swallowing, mainly due to an earlier resumption of respiration. The high temporal recordings in this study have revealed that swallowing during expiration is present basically in all healthy individuals. This swallowing respiratory pattern seems to be appropriate for a safe swallow. This knowledge will be used as a reference for future studies on how swallowing and respiratory coordination might be altered due to ageing and diseases.

Neuronal Survival and Glial Reactions after Recurrent Laryngeal Nerve Resection in the Rat

OBJECTIVES/HYPOTHESIS

Complete axonal injury to the recurrent laryngeal nerve (RLN) leads to permanent loss of coordinated function of the intrinsic muscles of the larynx. The aim of the present study was to investigate retrograde reactions, neuronal survival, and glial reactions in the nucleus ambiguus after a distal resection of the RLN to evaluate the potential need for neuroprotective substances.

STUDY DESIGN AND METHODS

A segment of the left RLN was resected in 31 adult rats. Before sacrifice of the animals at 2 to 28 days postlesion, the motor neurons in the nucleus ambiguus were retrogradely traced by the use of Fluorogold. Brainstems were isolated and processed for neuron quantification and immunohistochemical analysis. Neuron counts were performed in the nucleus ambiguus on serial sections. Glial reactions were investigated in the nucleus ambiguus using immunohistochemistry.

RESULTS

No decrease in the number of motor neurons in the nucleus ambiguus could be demonstrated up to 1 month postlesion. Astroglia and microglia showed increased immunoreactivity at 7 to 14 days postinjury, followed by a slight decline in glial reaction. Microglia revealed no signs of transformation into macrophages during the study period, further indicating the absence of neuronal loss.

CONCLUSIONS

Neuronal death does not occur within 1 month postlesion as a result of resection of the RLN in the adult rat, and neuroprotective substances should therefore be of minor value after RLN injury. Glial reactions appear in a similar fashion as after other peripheral nerve lesions not causing neuronal loss.

Fiber-type composition and fiber size of the human cricopharyngeal muscle and the pharyngeal constrictor muscle

BACKGROUND

Despite a similar density of nicotinic acetylcholine receptors, the upper esophageal sphincter is sensitive to partial neuromuscular block, whereas the pharyngeal constrictor muscle is more resistant. In order to postulate possible mechanisms behind this difference in pharmacological response, basic knowledge of morphological and physiological features of these muscles is needed. The aim of this study was to compare the muscle fiber-type composition, the size and the morphology of the muscle fibers of the cricopharyngeal muscle, the main component of the upper esophageal sphincter, with that of the pharyngeal constrictor muscle.

METHODS

Muscle specimens were obtained from five patients undergoing surgery with laryngectomy. Muscle fiber type was determined by myosin heavy chain immunohistochemistry and the muscle fiber cross-sectional area was measured for each fiber type by planimetry. Morphology of muscle fibers was evaluated by histochemistry.

RESULTS

The muscle fiber cross-sectional area was generally smaller in the cricopharyngeal muscle compared with the pharyngeal constrictor muscle (P < 0.001). The composition of fiber types showed a large interindividual variability with no distinct difference between the studied muscles. Aberrant histological features were common in both the cricopharyngeal muscle and the pharyngeal constrictor muscle.

CONCLUSION

The main morphological difference between the neuromuscular blocking agents sensitive cricopharyngeal muscle and the more resistant pharyngeal constrictor muscle is a uniformly smaller size of contributing fiber types in the cricopharyngeal muscle than in the pharyngeal constrictor muscle. The muscle fiber-type composition does not differ between the two studied muscles.

Acetylcholine receptor density in human cricopharyngeal muscle and pharyngeal constrictor muscle

BACKGROUND

Upper esophageal sphincter resting tone is reduced during partial neuromuscular block, whereas contraction of the pharyngeal constrictor muscle is only slightly affected. We hypothesized that this difference may arise from differential nicotinic acetylcholine receptor (nAChR) density, the density supposedly being lower in the more sensitive cricopharyngeal muscle than in the resistant pharyngeal constrictor muscle. The aim of this study was to determine the density of nAChR in the main component of the upper esophageal sphincter, the cricopharyngeal muscle, and in the pharyngeal constrictor muscle.

METHOD

After approval by the institutional ethics committee and informed consent, muscle specimens were obtained from five patients undergoing surgery with laryngectomy for malignancies of the larynx or thyroid gland. None had received radiation therapy to the affected area. The nAChR from these tissue specimens were solubilized and incubated with 125I-alpha-bungarotoxin. The quantity of radioligand-receptor complex was measured by radioactive decay in a liquid scintillation counter. The receptor density was expressed as femtomoles per milligram of protein (fmol/mg protein).

RESULTS

The nAChR density was determined to 6.8 (3.5) fmol/mg protein (mean (SD)) in the cricopharyngeal muscle and 5.6 (2.1) fmol/mg protein in the pharyngeal constrictor muscle (P = 0.22). Although we could not find any difference in mean nAChR density, contrary to our hypothesis, the density in four of the five patients was higher in the cricopharyngeal muscle than in the pharyngeal constrictor muscle.

CONCLUSION

Our results indicate that the density of nicotinic acetylcholine receptors is similar in the cricopharyngeal muscle and in the pharyngeal constrictor muscle. Nicotinic acetylcholine receptor density, as determined by 125I-alpha-bungarotoxin assay, cannot explain the difference in response to neuromuscular blocking drugs between the investigated muscles.

Pharyngeal function and airway protection during subhypnotic concentrations of propofol, isoflurane, and sevoflurane: volunteers examined by pharyngeal videoradiography and simultaneous manometry

BACKGROUND

Anesthetic agents alter pharyngeal function with risk of impaired airway protection and aspiration. This study was performed to evaluate pharyngeal function during subhypnotic concentrations of propofol, isoflurane, and sevoflurane and to compare the drugs for possible differences in this respect.

METHODS

Forty-five healthy volunteers were randomized to receive propofol, isoflurane, or sevoflurane. During series of liquid contrast bolus swallowing, fluoroscopy and simultaneous solid state videomanometry was used to study the incidence of pharyngeal dysfunction, the initiation of swallowing, and the bolus transit time. Pressure changes were recorded at the back of the tongue, the pharyngeal constrictor muscles, and the upper esophageal sphincter. After control recordings, the anesthetic was delivered, and measurements were made at 0.50 and 0.25 predicted blood propotol concentration (Cp50(asleep)) for propofol and 0.50 and 0.25 minimum alveolar concentration (MAC)(awake) for the inhalational agents. Final recordings were made 20 min after the end of anesthetic delivery.

RESULTS

All anesthetics caused an increased incidence of pharyngeal dysfunction with laryngeal bolus penetration. Propofol increased the incidence from 8 to 58%, isoflurane from 4 to 36%, and sevoflurane from 6 to 35%. Propofol in 0.50 and 0.25 Cp50(asleep) had the most extensive effect on the pharyngeal contraction patterns (P < 0.05). The upper esophageal sphincter resting tone was markedly reduced from 83 +/- 36 to 39 +/- 19 mmHg by propofol (P < 0.001), which differed from isoflurane (P = 0.03). Sevoflurane also reduced the upper esophageal sphincter resting tone from 65 +/- 16 to 45 +/- 18 mmHg at 0.50 MAC(awake)(P = 0.008). All agents caused a reduced upper esophageal sphincter peak contraction amplitude (P < 0.05), and the reduction was greatest in the propofol group (P = 0.002).

CONCLUSION

Subhypnotic concentrations of propofol, isoflurane, and sevoflurane cause an increased incidence of pharyngeal dysfunction with penetration of bolus to the larynx. The effect on the pharyngeal contraction pattern was most pronounced in the propofol group, with markedly reduced contraction forces.

Leakage around voice prosthesis in laryngectomees: treatment with local GM-CSF

OBJECTIVES

The aim of this study was to investigate the possibility of treating leakage around voice prosthesis by local injection of granulocyte-macrophage colony-stimulating factor (GM-CSF).

STUDY DESIGN

Three patients with nonhealing leaking tracheoesophageal (TE) fistula, resistant to common treatment, were treated with local GM-CSF.

MATERIAL AND METHODS

Fistula size was measured and photo documented before and after treatment.

RESULT

In all three patients, the fistula shrank, and the leakage ceased. No side effects were observed.

CONCLUSION

Local injection with GM-CSF seems to be a simple and effective way of decreasing a leaking TE-fistula in laryngectomized patients. A great advantage was that the procedure could be done with the voice prosthesis in place.

Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia

Congenital high-airway obstruction syndrome (CHAOS) is due to rare malformations and has been reported previously in only few cases. If the diagnosis can be made prenatally, the ex utero intrapartum treatment (EXIT) procedure may be life-saving. A healthy 28-year old nulli-para was referred because of isolated ascites found at gestational week 16 during routine ultrasound scan. Repeated scans showed overdistended hyperechogenic lungs with inverted diaphragm and a dilated trachea, which was interpreted as a CHAOS resulting from laryngeal atresia. The ascites eventually disappeared. An EXIT procedure was performed at 35 weeks of gestation. Anesthesia of the mother was induced with thiopental, succinylcholine and fentanyl followed by intubation, and maintained with isoflurane and nitrous oxide. A low abdominal midline incision was performed followed by a low transverse incision of the uterus. The fetal head, right arm and shoulder were delivered and intramuscular anesthesia was administered to the fetus. Immediate laryngoscopy confirmed the diagnosis and a tracheostomy was therefore performed. Surfactant was given after a few minutes of ventilation. Compliance improved and when the fetus was easy to ventilate, it was delivered. The baby is developing normally at 18 months of age. Surgical correction of the malformation will be performed after two years of age. It is concluded that some fetuses with a prenatal diagnosis of CHAOS can benefit from the EXIT procedure at delivery. This necessitates a multidisciplinary management team.

[Fiberoptic endoscopy confirms the cause of upper respiratory obstruction in small children. The most common causes to referrals are sleep apnea syndrome and inspiratory stridor]

Guidelines for the clinical investigation of young children with stridor and sleep apnea are presented. Clinical examination and flexible videolaryngoscopy performed in local anaesthesia are the most important diagnostic tools for this group of children. If the impairment is severe or an objective evaluation is needed the child should also undergo nocturnal polygraphic recording and lung function tests. Out of 43 children examined with flexible videolaryngoscopy 21 had positive findings, laryngomalacia being the most common diagnosis. Flexible videolaryngoscopy is a good complement to laryngoscopy under general anaesthesia. It can be performed as early as in the neonatal period.

The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium

BACKGROUND

Residual neuromuscular block caused by vecuronium alters pharyngeal function and impairs airway protection. The primary objectives of this investigation were to radiographically evaluate the swallowing act and to record the incidence of and the mechanism behind pharyngeal dysfunction during partial neuromuscular block. The secondary objective was to evaluate the effect of atracurium on pharyngeal function.

METHODS

Twenty healthy volunteers were studied while awake during liquid-contrast bolus swallowing. The incidence of pharyngeal dysfunction was studied by fluoroscopy. The initiation of the swallowing process, the pharyngeal coordination, and the bolus transit time were evaluated. Simultaneous manometry was used to document pressure changes at the tongue base, the pharyngeal constrictor muscles, and the upper esophageal sphincter. After control recordings, an intravenous infusion of atracurium was administered to obtain train-of-four ratios (T4/T1) of 0.60, 0.70, and 0.80, followed by recovery to a train-of-four ratio of more than 0.90.

RESULTS

The incidence of pharyngeal dysfunction was 6% during the control recordings and increased (P < 0.05) to 28%, 17%, and 20% at train-of-four ratios 0.60, 0.70, and 0.80, respectively. After recovery to a train-of-four ratio of more than 0.90, the incidence was 13%. Pharyngeal dysfunction occurred in 74 of 444 swallows, the majority (80%) resulting in laryngeal penetration. The initiation of the swallowing reflex was impaired during partial paralysis (P = 0.0081). The pharyngeal coordination was impaired at train-of-four ratios of 0.60 and 0.70 (P < 0.01). A marked reduction in the upper esophageal sphincter resting tone was found, as well as a reduced contraction force in the pharyngeal constrictor muscles. The bolus transit time did not change significantly.

CONCLUSION

Partial neuromuscular paralysis caused by atracurium is associated with a four- to fivefold increase in the incidence of misdirected swallowing. The mechanism behind the pharyngeal dysfunction is a delayed initiation of the swallowing reflex, impaired pharyngeal muscle function, and impaired coordination. The majority of misdirected swallows resulted in penetration of bolus to the larynx.

TP53 mutations do not correlate with locoregional recurrence in stage I tongue carcinomas

BACKGROUND

The abrogation of the TP53 gene is considered to play a central role in the development of human cancers. Exons 5-8 harbor mutations most frequently, mainly of the missense type, resulting in accumulation of the p53 protein. The importance of these alterations as prognostic factors, are issues of controversy.

MATERIAL AND METHODS

Thirty-four patients suffering from stage I tongue carcinoma had been treated with a local surgical excision of the tumor. Seventeen patients had developed a local recurrence in the tongue or cervical (regional) metastases while 17 patients, matched for age and gender to the former group, had no recurring disease within follow-up. Protein p53 was detected through immunohistochemical (IHC) analysis using antibody CM1. Exons 5-8 of the TP53 gene were amplified through the Polymerase Chain Reaction (PCR). The presence of mutations analyzed by CDGE (Constant Denaturant Gel Electrophoresis) and detected mutations were subjected to sequencing.

RESULTS

20 out of 34 tumors (59%) showed mutated TP53, 18 tumors were IHC p53 positive, but the correlation between CDGE and IHC was only 56%. Sequencing of the gene was possible in 8 cases.

CONCLUSIONS

Neither the presence of mutations nor immunostaining had any impact on the risk of recurrence expressed as life-table analysis of time to recurrence.

Predictive value of malignancy grading systems, DNA content, p53, and angiogenesis for stage I tongue carcinomas

AIM

To assess the clinical value of malignancy grading systems compared with nuclear DNA content, protein p53, and angiogenesis for predicting recurrence of stage I (UICC, 1987) tongue carcinomas.

METHODS

Histopathological malignancy grading according to Jakobsson and tumour front grading according to Bryne et al were performed on haematoxylin and eosin slides. DNA analysis was performed by image cytometry. Protein p53 and angiogenesis were evaluated by immunohistochemical analysis using antibody CM1 and antibody against factor VIII related antigen, respectively.

RESULTS

49 patients with stage I carcinomas of the mobile tongue were included, all treated by local surgical excision alone. Eight patients (16%) suffered from local recurrence during follow up, and 13 (27%) had regional recurrence. Both Jakobsson's malignancy grading system and p53 immunoreactivity proved to be useful predictors of regional recurrence in a Cox multivariate regression analysis.

CONCLUSIONS

Histopathological malignancy grading systems provide valuable prognostic information and can still compete with current biological markers in this respect.

Nuclear DNA content and p53 overexpression in stage I squamous cell carcinoma of the tongue compared with advanced tongue carcinomas

AIMS

To evaluate the predictive value of the nuclear DNA content (image cytometry) and p53 overexpression (immuno-histochemistry using antibody CM-1) in uniformly treated stage I carcinomas of the mobile tongue. Also, to compare stage I carcinomas with advanced tongue carcinomas (stages II-IV).

METHODS

Archival formalin fixed, paraffin wax embedded tumour specimens from 54 patients with stage I squamous cell carcinoma and 37 patients with advanced squamous cell carcinoma were analysed. Mean follow up time of the stage I carcinomas was 71 months (median, 62.5; range, 6-175).

RESULTS

Twenty three patients (stage I) had recurring disease: 10 had local recurrence (in the tongue) and 13 had regional recurrence (cervical metastases). Locally recurring stage I carcinomas had a more pronounced DNA deviation than the other stage I carcinomas and this degree of deviation was comparable with the DNA content of advanced carcinomas. Stage I carcinomas that developed regional recurrences overexpressed p53 more frequently. In Cox multivariate regression analysis of time to recurrence, DNA deviation was a significant parameter in tumours that recurred locally (p = 0.032). p53 overexpression was the only parameter close to significance for regional recurrence (p = 0.065).

CONCLUSIONS

Nuclear DNA content and p53 immunostaining are of value for the prediction of recurrence of stage I squamous cell carcinomas of the mobile tongue. Stage I tongue carcinomas that are prone to local recurrence show the same DNA content as do advanced tongue carcinomas.

Preneoplastic oral lesions: the clinical value of image cytometry DNA analysis, p53 and p21/WAF1 expression

BACKGROUND

Various mucosal lesions are frequently encountered in the oral cavity. Neither macroscopic nor microscopic evaluation of these lesions gives any reliable information concerning the risk of cancer development.

MATERIAL AND METHODS

From 21 patients, 29 mucosal lesions were found to precede development of invasive squamous cell carcinoma or carcinoma in situ at the same location. The lesions were matched to 29 control lesions, with the same grade of dysplasia and from exactly the same locations but without subsequent cancer during a mean follow up of 112 months (46-194). The specimens were evaluated using Image Cytometry DNA analysis and immunohistochemical analysis of p53 and p21/WAF1 expression.

RESULTS

Lesions prior to carcinomatous development displayed a higher degree of DNA aberration as compared with the control lesions. p53 and p21/WAF1 evaluation did not reveal any differences between cases and controls.

CONCLUSION

Image Cytometry DNA analysis is an useful adjunct to histopathological evaluation of oral mucosal lesions for prediction of risk of malignant transformation.

Swallowing disorders after esophageal atresia evaluated with videomanometry

BACKGROUND

Patients with repaired esophageal atresia often show persistent motility disorders of the esophagus.

METHODS

In this study, the authors used a newly developed method, videomanometry, to study intraluminal pressures and function of the pharynx and upper esophagus in such a group of patients and compared the results with those in healthy age-matched controls.

RESULTS

A significant difference was found between timing of the pharynx contraction and upper esophageal sphincter (UES) relaxation, indicating a dyscoordination of swallowing in the patient group. Transit time of bolus from the pharynx to the esophagus was also shorter for the patient group. Such dyscoordination may be a risk factor that can cause aspiration and respiratory symptoms.

CONCLUSION

UES resting pressure and residual pressure on swallowing, did not differ between the two groups.

[A revolutionary Japanese method for treatment of lymphangioma]

Large cystic lymphangiomas of the neck (hygroma colli) have traditionally been treated surgically or by local injection of various sclerosing agents. Owing to the infiltrative growth of these cysts, radical surgery has often been difficult due to the risk of damage to nerves and adjacent organs; and the use of available sclerosing agents has often resulted in disfigurement due to extensive scarring, thus rendering secondary surgery even more difficult. However, OK-432, a new agent for local injection, has been tested with good results, especially in Japan. In five consecutive paediatric cases of lymphangioma, we found ultrasound-guided injection of the cysts with OK-432 to yield good response without complications. In three cases, the lymphangioma disappeared leaving the child's appearance quite normal, and there has been no recurrence. In one case, the lymphangioma disappeared but apparently recurred within half a year (during which time we had lost contact with the family). This was the only case of small cysts (cavernous lymphangioma), which are putatively more resistant to OK-432. The only child to be operated also had thoracic lymphangioma which was not injected, though the cervical part which was injected was reduced by 50 per cent pre-operatively, the final outcome being excellent with no visible cysts in any region. Thus, hitherto our results suggest the therapeutic effect of OK-432 to be good, and further clinical investigation is planned.

Stromelysin-3 mRNA expression in dysplasias and invasive epithelial cancer of the larynx

Matrix metalloproteinases are believed to play an important role in tumor progression, invasion and metastasis. In order to investigate if the expression of stromelysin-3 (ST3) mRNA could add prognostic information concerning invasive laryngeal cancer and/or be indicative of a high risk for tumor progression in laryngeal dysplasias ST3 expression was analyzed by in situ hybridisation of formalin fixed paraffin embedded laryngeal specimens. Furthermore, all specimens underwent image cytometry (ICM) DNA analysis, and, p53 immunostaining. Invasive epithelial cancer, both localized (T1, T2) cancers, cured, as well as not cured, by radiotherapy, and cases with regional lymph node metastases were studied. Furthermore, high grade and low grade dysplasias, selected for rapid, slow and non-progression, as well as non-neoplastic inflammatory lesions were investigated. Expression of the ST3 gene was found in 9 out of 14 (64%) invasive cancer lesions, and in 3 out of 10 (30%) dysplasias, thus indicating that ST3 expression correlates to tumor progression. The ST3 positive laryngeal cancer lesions displayed a higher degree of DNA aberration than the ST3 negative lesions thus suggesting that ST3 positivity could indicate highly malignant tumors. Of the three ST3 positive dysplasias, the first progressed rapidly to cancer in situ with suspected microinvasion. The second ST3 positive dysplasia progressed to invasive cancer within five months. The third ST3 positive dysplasia had been radically excised and hereby cured. All but one of the dysplastic lesions showed p53 immunoreactivity, and all dysplasias exhibited aneuploid cells. ST3 expression appears to be a late event in the multistage process of carcinogenesis and could prove useful as an indicator of dysplasias with imminent risk for progression to invasive cancer.

Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers

BACKGROUND

Functional characteristics of the pharynx and upper esophagus, including aspiration episodes, were investigated in 14 awake volunteers during various levels of partial neuromuscular block. Pharyngeal function was evaluated using videoradiography and computerized pharyngeal manometry during contrast bolus swallowing.

METHODS

Measurements of pharyngeal constrictor muscle function (contraction amplitude, duration, and slope), upper esophageal sphincter muscle resting tone, muscle coordination, bolus transit time, and aspiration under fluoroscopic control (laryngeal or tracheal penetration) were made before (control measurements) and during a vecuronium-induced partial neuromuscular paralysis, at fixed intervals of mechanical adductor pollicis muscle train-of-four (TOF) fade; that is, at TOF ratios of 0.60, 0.70, 0.80, and after recovery to a TOF ratio > 0.90.

RESULTS

Six volunteers aspirated (laryngeal penetration) at a TOF ratio < 0.90. None of them aspirated at a TOF ratio > 0.90 or during control recording. Pharyngeal constrictor muscle function was not affected at any level of paralysis. The upper esophageal sphincter resting tone was significantly reduced at TOF ratios of 0.60, 0.70, and 0.80 (P < 0.05). This was associated with reduced muscle coordination and shortened bolus transit time at a TOF ratio of 0.60.

CONCLUSIONS

Vecuronium-induced partial paralysis cause pharyngeal dysfunction and increased risk for aspiration at mechanical adductor pollicis TOF ratios < 0.90. Pharyngeal function is not normalized until an adductor pollicis TOF ratio of > 0.90 is reached. The upper esophageal sphincter muscle is more sensitive to vecuronium than is the pharyngeal constrictor muscle.

p53 immunostaining and image cytometry DNA analysis in precancerous and cancerous squamous epithelial lesions of the larynx

BACKGROUND

Squamous epithelial cancer can develop from progressive epithelial changes connoted dysplasias. Histopathologic evaluation/grading of these lesions is difficult and gives poor information concerning the risk for progression to cancer. Squamous cell carcinoma of the head and neck (SCCHN) frequently show p53 alteration and DNA-ploidy aberration. Could these markers be used as indicators for malignancy risk in the larynx?

METHODS

Immunohistochemical staining (IHC), with the CM-1 antibody against p53, and image cytometry (ICM) DNA analysis were performed in 60 lesions from 12 patients--and 21 controls--who were initially seen with laryngeal lesions prior to cancer in situ (cis) or invasive cancer diagnosis at the same site.

RESULTS

All but one of the invasive cancers, and 77% of the lesions which preceded cancer or cancer in situ, showed positive p53 immunostaining, as compared with only 10% of the controls. All but one of the invasive cancer lesions, and 77% of the precancerous lesions, showed aberrant DNA-ploidy results, whereas all controls were diploid. When DNA and p53 analysis were combined, only one of the lesions preceding cis or invasive cancer was negative.

CONCLUSIONS

Both p53 immunoreactivity and DNA-ploidy aberration appear to be early events in the multistep process of squamous epithelial carcinogenesis. Immunohistochemical staining p53 analysis and ICM DNA analysis does increase the diagnostic sensitivity for cancerous and true precancerous lesions in the larynx.

Advanced laryngeal cancer T3-T4 in Sweden: a retrospective study 1986-1990. Survival and locoregional control related to treatment

Different treatment modalities for advanced laryngeal cancer are much discussed in the literature. One-hundred-and-sixty patients with T3-4, N0-3, M0-1 laryngeal cancer diagnosed in Sweden between 1986 and 1990 were retrospectively analysed. One hundred (65 T3: 35 T4) received radical radiotherapy with salvage surgery (RRSS) in case of residual or recurrent disease. Thirty-eight (11T3: 27 T4) patients received surgery with or without radiotherapy (S +/- RT). Twenty-two patients received no treatment. After a median follow up of 4.4 years, the estimated 5-year actuarial corrected survival and 3-year locoregional control were 59% and 44% for T3 RRSS and 47% and 54% for T3 S +/- RT. No significant difference between the different treatment modalities was found. The 5-year corrected survival rate and the locoregional control at 3 years between T4-RRSS (32%; 26%) and T4-S + RT (58%; 68%) groups were significantly different (p < 0.05 and p < 0.01). This might suggest that surgery with or without radiotherapy still has its place as a treatment modality for patients with advanced T4 laryngeal carcinoma.

Nuclear DNA content and p53 immunostaining in metachronous preneoplastic lesions and subsequent carcinomas of the oral cavity

BACKGROUND

Clinical evaluation of preneoplastic lesions of the oral cavity is difficult. Histopathologic grading of dysplasias shows large variability and does not give reliable information concerning the risk for progression to cancer.

METHODS

DNA image cytometry and p53 immunostaining were performed to describe the pattern of DNA aberration and p53 overexpression in confined preneoplastic lesions and in the subsequent carcinomas developing at the same site in 20 patients.

RESULTS

Hyperplastic and/or inflammatory lesions showed a diploid DNA pattern in 81% of the cases and 23% were p53-positive. Dysplastic preneoplastic lesions showed a nondiploid/ aneuploid DNA pattern in 73% and 64% were p53-positive. The subsequent invasive carcinomas were nondiploid/aneuploid in 86% and p53-positive in 69% of cases.

CONCLUSIONS

Analysis of nuclear DNA content and p53 immunostaining appears to be useful as an adjunct to histopathology in the evaluation of true precancerous lesions.

Interferon-alpha/beta can impede development of carcinogen-induced squamous-cell tumors in the esophagus of C57B1 mice

The effect of treatment with murine interferon-alpha/beta preparations on diethylnitrosamine-induced squamous-cell tumors in the esophagus of C57B1 mice was investigated. Diethylnitrosamine was administered in the drinking water for 18 weeks. Interferon was given intraperitoneally during the same 18 weeks or from the end of the period of carcinogen exposure until termination of the experiment. In mice given interferon and diethylnitrosamine synchronously, a significantly lower tumor index (number of tumors/cm of esophageal mucosa) was observed as compared to all control groups. Treatment with interferon after the administration of the carcinogen was terminated had no effect on the appearance of tumors. These data suggest that interferon therapy can exert certain effects on carcinogenesis.

Primarily nasal origin of exhaled nitric oxide and absence in Kartagener's syndrome

The exact origin of nitric oxide (NO) in exhaled air is not known. We wanted to further investigate at what site exhaled NO is produced and to determine whether children with Kartagener's syndrome exhibited altered levels of exhaled NO. NO was measured by chemiluminescence technique in air sampled directly from the nose and in normally exhaled air of four children (2.5-13 years old) with Kartagener's syndrome, 20 healthy children, four healthy adults, and four conscious tracheostomized adults. NO was almost absent (98% reduced) in air sampled directly from the nose in four children with Kartagener's syndrome (4 +/- 1 parts per billion (ppb)), compared to age-matched controls (221 +/- 14 (ppb)). Tracheostomized adult subjects had considerably higher NO values in nasally (22 +/- 3 ppb) and orally (14 +/- 2 ppb) exhaled air, compared to levels in air exhaled through the tracheostomy (2 +/- 0 ppb). Treatment with intranasal corticosteroids for 14 days, or with antibiotics for 1 week, did not affect exhaled NO. These results clearly show that, basically, all NO in exhaled air of healthy subjects originates from the upper respiratory tract, with only a minor contribution from the lower airways. Furthermore, the absence of nasal NO in children with Kartagener's syndrome could be of use as a simple noninvasive diagnostic test.

Involvement of aberrant p53 expression and human papillomavirus in carcinoma of the head, neck and esophagus

Biopsies from 34 patients with cancer of the head, neck or esophagus, 2 laryngeal papillomas, and 2 normal tonsils were analysed for human papillomavirus (HPV), Epstein Barr virus (EBV) genomes and mutated or elevated levels of p53. In 4 biopsies p53 was also analysed by DNA sequencing. HPV type 31 was found in one laryngeal cancer with normal p53 and HPV type 16 in two tonsil cancers with aberrant p53 expression. EBV was detected by PCR in 11 biopsies, but in situ hybridisation and immunohistochemistry, did not confirm this finding. Aberrant p53 expression was observed in approximately half of the tumours. These results support the involvement of both aberrant p53 expression and HPV in the aetiology of squamous cell carcinoma of the head and neck.

Nuclear DNA content, proliferating-cell nuclear antigen (PCNA) and p53 immunostaining in predicting progression of laryngeal cancer in situ lesions

Squamous epithelial cancer in situ (CIS) of the upper aerodigastric tract is a histopathologically well-defined condition. However, in clinical practice, morphological grading of dysplasia is difficult and shows large variability. The biology of CIS remains enigmatic, and there is yet no reliable way to predict whether a CIS lesion will progress to invasive cancer, remain stable or regress. In the search for markers able to foretell clinical outcome, we performed image DNA cytometry (ICM) and immunohistochemical staining for PCNA as well as p53 in 38 laryngeal CIS lesions, of which 9 progressed to invasive cancer. The majority of the CIS lesions displayed high-grade DNA aberration, a high PCNA-positive rate, and every third lesion was p53-positive by immunostaining. The lesions which progressed to invasive cancer showed a clear tendency towards more pronounced DNA aberration, a higher percentage of intense PCNA staining and more frequent p53 positivity. By combining the results from the analyses of DNA, PCNA and p53 in a prognostic index for each individual case, we correctly classified 82% of the lesions as progressors or non-progressors.

Further studies on the carcinogenic-free interval following exposure in experimental esophageal tumorigenesis

247 C57B1 male mice were killed after Diethylnitrosamine (DEN) treatment at various time intervals ranging from one day to nine months. The number of esophageal tumors was divided by the length of the resected esophagus (i.e. Tumor Index = TI). Animals treated for up to 2 months had a TI of 0.1. Since the histological examination of the esophagi in those animals revealed only normal histology, the conclusion drawn was that the TI of 0.1 was a methodological error in assessing esophageal tumors by transillumination. Three months' treatment with DEN resulted in a 9-fold increased TI and 6 months' treatment in a 69-fold increased TI. Other groups of animals treated with DEN for the same period of time were allowed to survive 7, 9 or 12 months without further treatment. Animals treated with DEN for 1 day but followed without further treatment for 7 months demonstrated a 3.5-fold increased TI. For animals treated with DEN for only 14 days, (TI 0.1) and followed for 7 months with a carcinogenic-free diet, a 7-fold TI was observed. For the group of animals treated for 3 months (TI 0.9) but allowed to survive to complete 7 months on a carcinogen-free diet, a 5-fold higher TI was recorded. DEN animals treated for 6 months (TI 6.9) but allowed to survive 3 additional months had a TI of 9.6. A similar TI, namely 9.7, was found when the carcinogen-free interval was prolonged for 6 more months. These results suggest that clones of esophageal cells are "programmed" for tumor growth at an early stage of DEN treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Proliferating cell nuclear antigen (PCNA) expression and nuclear DNA content in predicting recurrence after radiotherapy of early glottic cancer

Proliferating cell nuclear antigen (PCNA) is a DNA replication protein maximally elevated in late G1 and S phases of the cell cycle. By using monoclonal antibodies, the expression of PCNA can be quantified and the rate of tumour cell proliferation estimated. The degree of DNA aberration in a tumour cell population reflects its genetic instability and has been implicated as a prognostic factor in an increasing number of solid tumours. The nuclear DNA content can be assessed by densitometric image cytometry DNA analysis. Both PCNA and DNA analysis can be performed on histological sections from paraffin embedded biopsies. In search of efficient and reproducible methods to identify early glottic cancers with increased risk for recurrence after radiotherapy, the PCNA expression as well as the DNA content of the diagnostic biopsies from 28 T1N0M0 glottic cancers were assessed. The group of tumours which recurred locally after radiotherapy displayed lower PCNA expression and higher DNA aberration than the group of tumours which were cured. Moreover, a combination of both parameters improved the possibility to discriminate the two groups. For T1 glottic cancer displaying high grade of genetic instability or low grade of proliferation, treatment regimes other than radiotherapy and closer follow-ups could be considered.

The prognostic value of cytometric DNA analysis in early stage tongue cancer

In spite of a small size and seemingly localised properties T1 tongue cancer does recur after surgical treatment, locally and/or in regional lymph-nodes, in 30-40% of the patients, and 50% of patients with recurrent disease die because of their cancer. If these patients could be identified by analysis of relevant parameters on the primary biopsy reflecting the biological properties of the tumours more extensive treatment regimes could be given selectively. In 47 primary biopsy specimens from patients with T1N0M0 squamous cell carcinoma of the mobile tongue the aberration in cellular DNA content was significantly higher in the group of tumours which recurred after surgical treatment compared with the non-recurrent group. Tumours in females recurred more frequently than in males. No significant correlation between recurrence and grade of histological differentiation or tumour thickness could be found. Image cytometry DNA analysis provides an objective and reproducible assessment of the nuclear DNA content which could facilitate selection of adequate treatment strategies.

Image cytometry DNA analysis of dysplastic squamous epithelial lesions in the larynx

The Feulgen-DNA content of cell nuclei from the human larynx was assessed in 62 lesions from 14 patients with dysplastic and cancerous lesions and in 14 control patients with non-neoplastic chronic laryngitis. All the carcinomas displayed aneuploid cell nuclei, and the cellular DNA content was substantially altered in dysplasias which later progressed to cancer in situ or invasive cancer. Thus the process of laryngeal carcinogenesis can be monitored not only by histological changes, but also by cellular DNA aberrations. Quantitative DNA analysis appears to be a complement to the histopathological evaluation of laryngeal lesions in the search for neoplasia.

Control cells for image cytometric DNA analysis of esophageal tissue and the influence of preoperative treatment

The nuclear DNA content of 4,960 normal cells in 30 esophagectomy specimens was assessed by image cytometry. In relation to intermediate squamous epithelial cells, the mean transmission values were 25.6% higher for basal squamous epithelial cells, 10.1% higher for fibroblasts and 16.2% lower for lymphocytes. The interslide coefficient of variation (CV) was similar for intermediate and basal squamous epithelial cells, 20.2% and 18.9%, respectively, while fibroblasts and lymphocytes displayed lower interslide CVs, 10.5% and 8.8%, respectively. In spite of their high interslide CVs, the mean DNA values of intermediate and basal squamous epithelial cells had the highest intraslide correlation. This correlation indicates that the preparative and analytical differences between slides that result in alterations in mean DNA values affect squamous epithelial cells of similar origin, size and shape in an analogous manner. Basal squamous epithelial cells replicate their DNA and contain more than the diploid amount; therefore, normal intermediate squamous epithelial cells are suggested as control cells to define the 2c reference value for further DNA studies on squamous epithelial lesions of the esophagus. Preoperative irradiation, with or without chemotherapy, did not alter the DNA values of the investigated control cells.

Carcinoembryonic antigen, CA 19-9 and CA 50 in monitoring human squamous cell carcinoma of the esophagus

The serum levels of Carcinoembryonic antigen, CA 19-9 and CA 50 were assessed in 60 patients with squamous cell carcinoma of the esophagus during the course of the disease. In 53 patients, the effect of preoperative or final treatment on tumor marker levels could be analysed, and the change in tumor marker levels discriminated significantly the patients who showed tumor mass/symptom regress from the patients who displayed progress or undecided change. Progress later in the course of the disease was reflected by a statistically significant increase in all three tumor marker assays, and in 8/18 (44%) patients the tumor marker increase was seen prior to other signs of tumor progression. The appearance of distant metastases was associated (11/12) with increase in CEA levels.

Image cytometry DNA analysis of diethylnitrosamine-induced dysplasias and invasive squamous cell carcinomas of the esophagus in mice

The nuclear DNA content was assessed by image cytometry in squamous epithelial dysplasias and invasive squamous cell carcinomas of the esophagus induced by diethylnitrosamine (DEN) in mice. The study comprises 48 lesions: 27 lesions with low grade (i.e. slight and moderate) dysplasia, 18 with high grade dysplasia (i.e. severe dysplasia and CIS), and 3 with invasive squamous cell carcinoma. In addition, 5 parallel run control specimens were also investigated. The results demonstrated that only 3.7% (or 1/27) low grade dysplasias but as much as 72.2% (or 13/18) high grade dysplasias, and all three invasive squamous cell carcinomas displayed non-diploid DNA values. Three of 18 high grade dysplasias and all three invasive squamous cell carcinomas demonstrated aneuploid cell nuclei. The results of the present work indicate that the esophageal mucosa of the mouse permit investigation--under controlled conditions--of the nuclear DNA alterations occurring during carcinogenesis in this organ. The results presented herein thus substantiate the theory of increasing DNA aberrations occurring during carcinogenesis in the human esophagus.

Image cytometry DNA analysis of invasive squamous cell carcinoma of the esophagus

The Feulgen-DNA content of squamous carcinoma cell nuclei from the human esophagus was assessed in punch biopsies from 47 untreated patients. Forty-four of the 47 biopsies (93.6%) demonstrated aneuploid cell populations, and the remaining 3 (6.4%) were non-diploid. Previous studies have demonstrated that in esophageal dysplasias adjacent to invasive squamous cell carcinoma, DNA in single cells is substantially altered. Thus the process of esophageal carcinogenesis can be monitored not only by histological changes, but also by DNA aberrations in single cells. Quantitative DNA measurement appears, therefore, to be a complement to the histological evaluation of esophageal lesions with suspected, but not unequivocal, evidence of neoplastic growth.

Tumor markers carcinoembryonic antigen, CA 50, and CA 19-9 and squamous cell carcinoma of the esophagus. Pretreatment screening

Pretreatment serum levels of the tumor markers carcinoembryonic antigen (CEA), CA 50, and CA 19-9 in 95 patients with squamous cell carcinoma of the esophagus and 32 age-matched controls were compared. Thirty-nine percent of the cancer patients showed elevated (greater than or equal to 5 micrograms/l) serum CEA levels, 41% had elevated (greater than or equal to 17 U/ml) CA 50 levels, and 13% showed elevated (greater than or equal to 37 U/ml) CA 19-9 levels. The tumor markers showed a considerable degree of complementarity, and combined tumor marker analysis increased the sensitivity to 59%. Raised CEA levels were found significantly more frequently in intrathoracically localized tumors than in cervical cancers. Patients surviving less than 6 months showed a higher rate of elevated CEA assays than those who survived 6 to 18 months. No certain correlation was established between tumor marker elevation and tumor stage or tumor differentiation.

Comparison of bronchoalveolar lavage fluid recovered during bronchoscopy with local or general anesthesia

Bronchoalveolar lavage (BAL) is a diagnostic technique through which information is obtained about conditions in peripheral parts of the bronchoalveolar tree. To determine the impact of general anesthesia on BAL fluid composition, nine patients underwent BAL while under general anesthesia and 16 healthy controls had BAL with local anesthesia. The percentage of recovered fluid and total cell counts were significantly lower in patients under general anesthesia than in controls. The number of viable cells, the proportions of the various cells, and the BAL albumin-serum albumin ratio did not differ between the groups. Thus, general anesthesia with controlled ventilation, as performed in this study, apparently does not seriously after the prerequisites for BAL.

Toluidine staining of diethylnitrosamine-induced esophageal dysplasias in mice

The dismal healing rate of esophageal cancer can be improved through identification of risk groups and deployment of methods to effect early diagnosis. Vital staining of epithelial surfaces is a method clinically used to detect carcinoma and dysplasia. Several reports have been published supporting the value of this technique in detecting tumours of different organs. Because of the large surface area of the esophageal mucosa, vital staining can offer a valuable tool for obtaining biopsies, with a high degree of accuracy. In the present investigation, experimentally induced esophageal tumours in mice with various degrees of dysplasia have been stained with toluidine blue. The colour uptake was correlated to the degree of dysplasia observed, as well as to epithelial damage. Toluidine blue uptake correlated significantly to both dysplasia and epithelial damage. The exact way in which toluidine blue is incorporated in the tissue is still not known and needs further investigation.

Toluidine staining of diethylnitrosamine-induced esophageal dysplasias in mice

The dismal healing rate of esophageal cancer can be improved through identification of risk groups and deployment of methods to effect early diagnosis. Vital staining of epithelial surfaces is a method clinically used to detect carcinoma and dysplasia. Several reports have been published supporting the value of this technique in detecting tumours of different organs. Because of the large surface area of the esophageal mucosa, vital staining can offer a valuable tool for obtaining biopsies, with a high degree of accuracy. In the present investigation, experimentally induced esophageal tumours in mice with various degrees of dysplasia have been stained with toluidine blue. The colour uptake was correlated to the degree of dysplasia observed, as well as to epithelial damage. Toluidine blue uptake correlated significantly to both dysplasia and epithelial damage. The exact way in which toluidine blue is incorporated in the tissue is still not known and needs further investigation.

Esophagitis and cancer of the esophagus

Early diagnosis is an important factor in the effort to increase the healing rates of esophageal cancer; another consideration is the establishment of a reliable method of identifying risk groups. Alcohol abuse is known to be associated with a higher risk of esophageal cancer. The current investigation, based on a retrospective study of the records of patients with esophageal cancer, reveals a strong connection between cancer development and chronic esophagitis due mainly to reflux in about 10% of the patients. In the literature this connection has been suspected but never so clearly shown. The clinical implication may be a more rigorous approach to long-standing esophagitis in elderly patients.

A clinical comparison of the results of two different methods of closing tympanic membrane perforations

A series of myringoplasties is presented and those cases that did not heal perfect are discussed. In order to evaluate whether some changes in the technique could further improve the results, another series incorporating these changes was operated after and the results are presented. Differences in healing and post-operative hearing between the two groups of patients are evaluated.