Radiation and Concurrent Carboplatin Administration in Locally Advanced Head and Neck Cancer

Aims and Background

To improve local control in patients with locally advanced inoperable head and neck cancer we administered carboplatin concurrently with radiation.

Methods

Thirty-nine patients entered the study. There were 35 men and 4 women with a median age of 58 years (range, 24-74) and a median performance status of 90 (range, 60-100) of the Karnofsky scale. The primary site included nasopharynx (5 patients), oropharynx (n=10), hypopharynx (n=5), larynx (n=12), oral cavity (n=2), paranasal sinuses (n=3), salivary glands (n=1) and unknown (n=1). Histology was squamous cell carcinoma in all cases. All patients were irradiated with a 60Co unit. According to the protocol, they should receive 66-70 Gy to the tumor area and 45 Gy to the tumor-free area of the neck. Carboplatin was administered at a dose of 400 mg/m2 on days 2, 22 and 42.

Results

Totally, 112 cycles of carboplatin were administered, of which 106 (95%) were at full dose. Median dose intensity of carboplatin actually delivered was 170 mg/m2/week (range, 57-200). All patients were irradiated, although only 30 (77%) received >66 Gy. After the completion of combined treatment, 23 (59%, 95% C.I. 42-74%) achieved a CR and 10 (26%, 95% C.I. 13-42%) a PR. Grade 3-4 myelotoxicity was noticed in 60% of the patients. Other grade 3-4 toxicities included stomatitis (13%), dysphagia (5%) and weight loss (3%). Median time to progression was 18 months (range, 2-25).

Conclusions

Radiation and concurrent administration of carboplatin determined a high CR rate in patients with HNC, although the superiority of this combined modality approach over radiation alone has to be proven in phase III trials.

Accelerated Bifractionated Radiation with Concurrent Cisplatin Administration in Locally Advanced Head and Neck Cancer: A Feasibility Study

Aims and Background

To test the feasibility of accelerated interrupted twice-daily radiation and concurrent cisplatin administration in patients with locally advanced head and neck cancer.

Patients and Methods

Nineteen patients with locally advanced head and neck cancer were treated with accelerated bifractionated radiation with concurrent administration of cisplatin. There were 18 men and 1 female with a median age of 60 years (range, 17–71) and median performance status of 90 (-range, 80–100). Sixteen patients (85%) presented with stage IV disease. Primary site included the nasopharynx (n = 7), oropharynx (n = 5), hypopharynx (n = 1) and larynx (n = 6). Radiation consisted of two fractions of 1.6 Gy each daily, five times weekly to a total dose of 64 Gy. Cisplatin was administered at a dose of 100 mg/m2 on days 2 and 28 of the treatment period.

Results

Nine patients achieved a complete response (47%; 95% CI, 25%–70%) and 5 a partial response (26%; 95% CI, 7%–46%). Grade III–IV toxicity included leukopenia (16%), mucositis (26%), dry mouth (5%), weight loss (16%) and infection (5%). After a median follow-up of 27.11 months (range, 1–33+), 9 patients have died. Median time to progression was 11 months (range, 1–32+) and median survival 25 months (range, 1–32+).

Conclusions

Accelerated twice-daily radiation with concurrent cisplatin is effective in locally advanced head and neck cancer and can be safely given with manageable toxicity.

Identification of Drug-Like Inhibitors of Insulin-Regulated Aminopeptidase Through Small-Molecule Screening

Intracerebroventricular injection of angiotensin IV, a ligand of insulin-regulated aminopeptidase (IRAP), has been shown to improve cognitive functions in several animal models. Consequently, IRAP is considered a potential target for treatment of cognitive disorders. To identify nonpeptidic IRAP inhibitors, we adapted an established enzymatic assay based on membrane preparations from Chinese hamster ovary cells and a synthetic peptide-like substrate for high-throughput screening purposes. The 384-well microplate-based absorbance assay was used to screen a diverse set of 10,500 compounds for their inhibitory capacity of IRAP. The assay performance was robust with Z'-values ranging from 0.81 to 0.91, and the screen resulted in 23 compounds that displayed greater than 60% inhibition at a compound concentration of 10 μM. After hit confirmation experiments, purity analysis, and promiscuity investigations, three structurally different compounds were considered particularly interesting as starting points for the development of small-molecule-based IRAP inhibitors. After resynthesis, all three compounds confirmed low μM activity and were shown to be rapidly reversible. Additional characterization included activity in a fluorescence-based orthogonal assay and in the presence of a nonionic detergent and a reducing agent, respectively. Importantly, the characterized compounds also showed inhibition of the human ortholog, prompting our further interest in these novel IRAP inhibitors.

Genetic ablation of IP3 receptor 2 increases cytokines and decreases survival of SOD1G93A mice

Amyotrophic lateral sclerosis (ALS) is a devastating progressive neurodegenerative disease characterized by the selective death of motor neurons. Disease pathophysiology is complex and not yet fully understood. Higher gene expression of the inositol 1,4,5-trisphosphate receptor 2 gene (ITPR2), encoding the IP₃ receptor 2 (IP₃R2), was detected in sporadic ALS patients. Here, we demonstrate that IP₃R2 gene expression was also increased in spinal cords of ALS mice. Moreover, an increase of IP₃R2 expression was observed in other models of chronic and acute neurodegeneration. Upregulation of IP₃R2 gene expression could be induced by lipopolysaccharide (LPS) in murine astrocytes, murine macrophages and human fibroblasts indicating that it may be a compensatory response to inflammation. Preventing this response by genetic deletion of ITPR2 from SOD1^G93A mice had a dose-dependent effect on disease duration, resulting in a significantly shorter lifespan of these mice. In addition, the absence of IP₃R2 led to increased innate immunity, which may contribute to the decreased survival of the SOD1^G93A mice. Besides systemic inflammation, IP₃R2 knockout mice also had increased IFNγ, IL-6 and IL1α expression. Altogether, our data indicate that IP₃R2 protects against the negative effects of inflammation, suggesting that the increase in IP₃R2 expression in ALS patients is a protective response.

Serum Fcεrii Receptor (SCD23) as an Evaluating Factor for Grass Pollen Immunotherapy

CD23 is a protein on the surface of certain hemopoietic cells and it is considered to be the low affinity receptor for immunoglobulin IgE, (FcεRll/CD23). The regulation of the expression of CD23 depends on the type of cell on which it is found. Like most of the FcR receptors, it is released in a soluble form (sCD23) in the extracellular fluid. This form is found in increased levels in the serum of allergic patients and in neoplastic diseases. We studied total IgE and sCD23 in the serum of 30 allergic patients undergoing immunotherapy, 15 allergic patients treated only symptomatically for grass pollen (GP) allergy, 15 healthy and subjects. We found that the mean values of total IgE and sCD23 after the course of hyposensitization were decreased compared to those before treatment as well as to those GP allergic patients under conventional therapy and to healthy adults. However, only the CD23 decrease was statistically significant. Therefore, we speculate that determination of sCD23 may be useful for (a) the general evaluation of allergic patients and (b) the immunological monitoring of patients under immunotherapy.

Effect of Organic Fertilization Treatment, Frying Oil and Cultivar Variety on the Volatile Profile of Potato Tubers

The effect of organic fertilization and frying oil (olive, soybean and corn oil) on the volatiles’ profile of three potato cultivars (Voyager, Spunta and Lady Rosetta) was studied. During cultivation, nine treatments (T) involving the combination of nitrogen, phosphorus and potassium fertilization were applied: T1: control treatment; T2: N1, P1, K1; T3: N1, P1, K2; T4: N1, P2, K1; T5: N1, P2, K2; T6: N2, P1, K1; T7: N2, P1 K2; T8: N2, P2, K1; and T9: N2, P2, K2, where Ν1=1.3 g Ν per plant; N2=2.0 g Ν per plant; P1=3.1 g P2O5 per plant; P2=5.2 g P2O5 per plant; Κ1= 4.0 g K2O per plant; and Κ2= 6.6 g K2O per plant. The main volatile compounds identified by HS-SPME GC/MS analysis were esters, alcohols, carbonyl compounds and hydrocarbons. Principal Component Analysis revealed that nitrogen fertilization affected the volatiles’ profile only when high fertilization of P2O5 (5.2 g/plant) and K2O (6.6 g/plant) was applied.

Benefits of using BODIPY–porphyrin dyads for developing deep-red lighting sources

The syntheses, as well as the photophysical and electrochemical characterization, of two novel BODIPY–porphyrin dyads and their first application in lighting schemes are provided.

Laryngeal cancer: epidemiological data from Νorthern Greece and review of the literature

BACKGROUND

Cancer of the larynx accounts for 1% to 2.5% of all human neoplasms and is the most common malignancy of the Head and Neck region. The purpose of this study is to analyze epidemiological data of patients with laryngeal cancer and to point out the geographical variations.

METHODS

This is the first systematic recording of the laryngeal cancer epidemiological data in Northern Greece. During the period 1992-2010 1,638 patients were diagnosed with and treated for malignant head and neck tumors. One thousand one hundred and four cases (67.4%) were malignant laryngeal tumors, 98.4% of which (1,088 cases) were squamous cell carcinomas (SCC). Only 16 patients (1.5%) presented with other types of malignancies.

RESULTS

The average age of the SCC patients was 62.1 years. Only 35 patients were women (3.2%). More than 60% of the patients were farmers or labor workers, 86.9%, were smokers, 43.2% were consuming alcohol on a daily basis and 36.1% had a positive family history of malignancy. Concerning tumor location, 60.2% were glottic cancers. T staging revealed that 1.2% of the cases were carcinomas in situ, 28% T1 tumors, 19% T2, 32 % T3, and 20% T4. Tumor grading showed that 43% of the cases were G1, 42.1% were G2, and 11.8% were G3.

CONCLUSIONS

The pathogenesis of laryngeal carcinoma is the result of the combined action of endogenous and environmental factors. The recording and analysis of the epidemiology of the disease is important for its better study and understanding.

Cyclin D1, EGFR, and Akt/mTOR pathway. Potential prognostic markers in localized laryngeal squamous cell carcinoma

INTRODUCTION

EGFR (epidermal growth factor receptor), cyclin D1 and Akt/mTOR pathways are active in head and neck cancer. The aim of this study was to explore biomarker expression, their correlations with clinicopathological parameters and their prognostic utility in a cohort of patients with localized squamous laryngeal carcinoma.

PATIENTS AND METHODS

We assessed relative messenger RNA expression of EGFR, Akt1, 2, and 3, mTOR and CCND1, copy number variants of the EGFR and CCND1 genes and immunohistochemical protein expression of EGFR, p-Akt308, p-Akt473, pmTOR, PTEN, p53 and cyclin D1 in paraffin-embedded tissue samples of localized laryngeal carcinomas.

RESULTS

In 289 patients with T3-4 (77.8%), node-negative (84.1%) tumors of the larynx, high EGFR and CCND1 mRNA correlated with no or ex-smoking, (p = 0.003 and p = 0.029, respectively), while low Akt3 mRNA correlated with alcohol abuse, N0 stage, total laryngectomy, and absence of neck dissection. At a median follow-up of 74.5 months, high mTOR mRNA expression was marginally associated with shorter disease-free survival (hazard ratio [HR] = 1.54; p = 0.093) and high Akt3 mRNA with shorter overall survival (HR = 1.49; p = 0.0786), in univariate analysis. In multivariate analysis, node-positive status, subglottic-transglottic location, surgery other than total laryngectomy and mTOR/CCND1 mRNA interaction with a hazard ratio of 2.16 (p value for interaction:  0.0010) were independent predictors of relapse, while node-positive status and subglottic-transglottic location were associated with higher risk for death.

CONCLUSION

In localized laryngeal cancer, clinicopathological parameters and an interaction of high mTOR and CCND1 mRNA expression were found to be associated with poor patient outcome.

Effectiveness of current teaching methods in Cardiology: the SKILLS (medical Students Knowledge Integration of Lower Level clinical Skills) study

INTRODUCTION

The aim of the study is to assess reported changes in medical students' capacity to attain five basic cardiological clinical skills, following a one-month intensive cardiology course provisioned in the core curriculum.

MATERIALS AND METHODS

An anonymous questionnaire comprising self reported performance in the five skills, namely 1) arterial blood pressure measurement, 2) cardiac auscultation, 3) electrocardiogram (ECG) carry out, 4) ECG interpretation and 5) defibrillation, was distributed to 177 fifth year students of the Athens Medical School upon initiating the cardiology course (pre-training group) and to 59 students matched for sex, age, year of study and training centre, following completion of the course (post training group). Comparison of pre- and post- training performance was evaluated using the χ(2) test.

RESULTS

No change was noted with regards to blood pressure measurement, cardiac auscultation or defibrillation. By contrast, a statistically significant improvement was reported for ECG execution (54.3 versus 81.4%; p<0.001) and interpretation (from 33.1 to 89.8%; p<0.001).

CONCLUSIONS

Improvement in the execution and interpretation of ECGs seems to be among the strengths of the cardiology training program. Further studies including larger samples from multiple medical schools and objective assessment of skill execution might facilitate accurate training evaluation and define opportunities for improvement.

Identification and validation of gene expression models that predict clinical outcome in patients with early-stage laryngeal cancer

BACKGROUND

Despite improvement in therapeutic techniques, patients with early-stage laryngeal cancer still recur after treatment. Gene expression prognostic models could suggest which of these patients would be more appropriate for testing adjuvant strategies.

MATERIALS AND METHODS

Expression profiling using whole-genome DASL arrays was carried out on 56 formalin-fixed paraffin-embedded tumor samples of patients with early-stage laryngeal cancer. We split the samples into a training and a validation set. Using the supervised principal components survival analysis in the first cohort, we identified gene expression profiles that predict the risk of recurrence. These profiles were then validated in an independent cohort.

RESULTS

Gene models comprising different number of genes identified a subgroup of patients who were at high risk of recurrence. Of these, the best prognostic model distinguished between a high- and a low-risk group (log-rank P<0.005). The prognostic value of this model was reproduced in the validation cohort (median disease-free survival: 38 versus 161 months, log-rank P=0.018), hazard ratio=5.19 (95% confidence interval 1.14-23.57, P<0.05).

CONCLUSIONS

We have identified gene expression prognostic models that can refine the estimation of a patient's risk of recurrence. These findings, if further validated, should aid in patient stratification for testing adjuvant treatment strategies.

Tumor-associated macrophages in breast cancer: distinct subsets, distinct functions

Macrophages display remarkable plasticity, allowing these cells to adapt to changing microenvironments and perform functions as diverse as tissue development and homeostasis, inflammation, pathogen clearance and wound healing. Macrophage activation can be triggered by Th1 cytokines and pathogen-associated or endogenous danger signals, leading to the formation of classically activated or M1 macrophages. On the other hand, anti-inflammatory mediators, including IL-4, IL-10, TGF-β and M-CSF, induce diverse anti-inflammatory types of macrophages, known under the generic term M2. In human breast carcinomas, tumor-associated macrophage (TAM) density correlates with poor prognosis. In mouse models of breast cancer, eliminating macrophages from the tumor site, either via genetic or therapeutic means, results in retarded tumor progression. Over the years, multiple signals from the mammary tumor microenvironment have been reported to influence the TAM phenotype and TAM have been propagated as anti-inflammatory M2-like cells. Recent developments point to the existence of at least two distinct TAM subpopulations in mammary tumors, based on a differential expression of markers such as CD206 or MHC II and different in vivo behaviour: perivascular, migratory TAM which are less M2-like, and sessile TAM found at tumor-stroma borders and/or hypoxic regions that resemble more M2-like or "trophic" macrophages. Hence, a further refinement of the molecular and functional heterogeneity of TAM is an avenue for further research, with a potential impact on the usefulness of these cells as therapeutic targets.

Prognostic utility of angiogenesis and hypoxia effectors in patients with operable squamous cell cancer of the larynx

Angiogenesis is active in localised laryngeal squamous cell carcinoma. We assessed relative messenger RNA (mRNA) and immunohistochemical (IHC) expression of Vascular Endothelial Growth Factors (VEGF) A, B, C, their receptors VEGFR1, 2, 3, Neuropilins 1, 2 (NRP1, 2) and Hypoxia-Inducible Factor 1A (HIF1A) in paraffin-embedded localised laryngeal carcinomas. In 289 patients with T3-4 (77.8%), node-negative (84.1%) tumours of the larynx, high VEGFA and VEGFR1 mRNA correlated with advanced T stage, while low VEGFB and VEGFC mRNA with alcohol abuse and supraglottic primary, respectively (p<0.05). Age <55 was associated with high IHC expression of VEGFA, C and poor tumour differentiation with high IHC VEGFA. At a median follow-up of 74.5months, patients with VEGFR1-high tumours had significantly poorer disease-free survival (Hazard Ratio [HR] 1.93, p=0.008) and shorter overall survival (OS, HR 1.71, p=0.041). An association with dismal OS was seen for high VEGFR3 tumoural mRNA expression (HR 1.76, p=0.02). IHC expression of VEGF family proteins in the tumour was not prognostic and had poor concordance with mRNA expression (kappa<0.1, p=NS). In multivariate analysis, node-positive status, non-supraglottic localization, high VEGFR1 mRNA and high IHC VEGFA expression were significantly associated with relapse, while node-positive status, high VEGFR1 and VEGFC mRNA expression in the tumour with risk of death. In laryngeal cancer, upregulated mRNA expression of VEGFR1 and VEGFC is associated with poor patient outcome.

Tumor-associated macrophages in breast cancer: distinct subsets, distinct functions

Macrophages display remarkable plasticity, allowing these cells to adapt to changing microenvironments and perform functions as diverse as tissue development and homeostasis, inflammation, pathogen clearance and wound healing. Macrophage activation can be triggered by Th1 cytokines and pathogen-associated or endogenous danger signals, leading to the formation of classically activated or M1 macrophages. On the other hand, anti-inflammatory mediators, including IL-4, IL-10, TGF-β and M-CSF, induce diverse anti-inflammatory types of macrophages, known under the generic term M2. In human breast carcinomas, tumor-associated macrophage (TAM) density correlates with poor prognosis. In mouse models of breast cancer, eliminating macrophages from the tumor site, either via genetic or therapeutic means, results in retarded tumor progression. Over the years, multiple signals from the mammary tumor microenvironment have been reported to influence the TAM phenotype and TAM have been propagated as anti-inflammatory M2-like cells. Recent developments point to the existence of at least two distinct TAM subpopulations in mammary tumors, based on a differential expression of markers such as CD206 or MHC II and different in vivo behaviour: perivascular, migratory TAM which are less M2-like, and sessile TAM found at tumor-stroma borders and/or hypoxic regions that resemble more M2-like or "trophic" macrophages. Hence, a further refinement of the molecular and functional heterogeneity of TAM is an avenue for further research, with a potential impact on the usefulness of these cells as therapeutic targets.

Amino triazolo diazepines (Ata) as constrained histidine mimics

Two synthetic routes for the synthesis of amino-triazolodiazepine (Ata) scaffolds are presented. The scope of both of these proceeding through key intra- and intermolecular Huisgen cycloaddition reactions is discussed. The replacement of the His-Pro dipeptide segment in angiotensin IV by the dipeptide mimetic Ata-Gly and subsequent biological evaluation in two inhibitory enzyme assays validated the use of the Ata moiety as a His mimic given the equipotency of both peptidic analogs.

Mononuclear phagocyte heterogeneity in cancer: different subsets and activation states reaching out at the tumor site

Mononuclear phagocytes are amongst the most versatile cells of the body, contributing to tissue genesis and homeostasis and safeguarding the balance between pro- and anti-inflammatory reactions. Accordingly, these cells are notoriously heterogeneous, functioning in distinct differentiation forms (monocytes, MDSC, macrophages, DC) and adopting different activation states in response to a changing microenvironment. Accumulating evidence exists that mononuclear phagocytes contribute to all phases of the cancer process. These cells orchestrate the inflammatory events during de novo carcinogenesis, participate in tumor immunosurveillance, and contribute to the progression of established tumors. At the tumor site, cells such as tumor-associated macrophages (TAM) are confronted with different tumor microenvironments, leading to TAM subsets with specialized functions. A better refinement of the molecular and functional heterogeneity of tumor-associated mononuclear phagocytes might pave the way for novel cancer therapies that directly target these tumor-supporting cells.

High affinity nanobodies against the Trypanosome brucei VSG are potent trypanolytic agents that block endocytosis

The African trypanosome Trypanosoma brucei, which persists within the bloodstream of the mammalian host, has evolved potent mechanisms for immune evasion. Specifically, antigenic variation of the variant-specific surface glycoprotein (VSG) and a highly active endocytosis and recycling of the surface coat efficiently delay killing mediated by anti-VSG antibodies. Consequently, conventional VSG-specific intact immunoglobulins are non-trypanocidal in the absence of complement. In sharp contrast, monovalent antigen-binding fragments, including 15 kDa nanobodies (Nb) derived from camelid heavy-chain antibodies (HCAbs) recognizing variant-specific VSG epitopes, efficiently lyse trypanosomes both in vitro and in vivo. This Nb-mediated lysis is preceded by very rapid immobilisation of the parasites, massive enlargement of the flagellar pocket and major blockade of endocytosis. This is accompanied by severe metabolic perturbations reflected by reduced intracellular ATP-levels and loss of mitochondrial membrane potential, culminating in cell death. Modification of anti-VSG Nbs through site-directed mutagenesis and by reconstitution into HCAbs, combined with unveiling of trypanolytic activity from intact immunoglobulins by papain proteolysis, demonstrates that the trypanolytic activity of Nbs and Fabs requires low molecular weight, monovalency and high affinity. We propose that the generation of low molecular weight VSG-specific trypanolytic nanobodies that impede endocytosis offers a new opportunity for developing novel trypanosomiasis therapeutics. In addition, these data suggest that the antigen-binding domain of an anti-microbial antibody harbours biological functionality that is latent in the intact immunoglobulin and is revealed only upon release of the antigen-binding fragment.

Haemoparasites, such as African trypanosomes, have developed potent immune evasion mechanisms to avoid antibody-mediated elimination. Consequently, trypanosome surface antigen-specific immunoglobulins in the absence of complement are non-trypanocidal. In contrast, certain monovalent nanobodies (Nb), monomeric antigen-binding domains derived from camelid Heavy-Chain Antibodies (HCAb) and which have a much lower molecular weight (15 kDa) than classical antibodies (150 kDa), efficiently lyse trypanosomes both in vitro and in vivo. This is surprising as classically immunoglobulin effector functions are mediated via the Fc-domain, which is absent from the Nb. We demonstrate that the Nb-mediated trypanolysis depends on the low molecular weight, monovalency and high affinity and is associated with loss of motility, a major block to endocytosis, energy depletion and cell death. Overall, targeting the parasite surface with low molecular weight, high affinity Nbs is sufficient to exert a direct therapeutic action. Therefore, the exploitation of Nbs against African trypanosomiasis represents a novel therapeutic strategy. Furthermore, demonstration that a high affinity antigen-binding Nb or Fab fragment lacking an effector domain (i.e., Fc-domain or an attached toxin) can exert a direct biological function, suggests that intact antibodies likely harbour latent functionality which only become revealed upon removal of the Fc-domain.

Induction chemotherapy followed by concomitant radiotherapy and weekly cisplatin versus the same concomitant chemoradiotherapy in patients with nasopharyngeal carcinoma: a randomized phase II study conducted by the Hellenic Cooperative Oncology Group (HeCOG) with biomarker evaluation

BACKGROUND

Concomitant administration of radiation therapy (RT) and chemotherapy with cisplatin (CCRT) is considered standard treatment in patients with locally advanced nasopharyngeal cancer (LA-NPC). The role of induction chemotherapy (IC) when followed by CCRT in improving locoregional control remains controversial.

PATIENTS AND METHODS

Totally, 141 eligible patients with LA-NPC were randomized to either three cycles of IC with cisplatin 75 mg/m(2), epirubicin 75 mg/m(2) and paclitaxel (Taxol) 175 mg/m(2) (CEP) every 3 weeks followed by definitive RT (70 Gy) and concomitant weekly infusion of cisplatin 40 mg/m(2) (investigational arm, 72 patients) or to the same CCRT regimen alone (control arm, 69 patients).

RESULTS

Sixty-two patients (86%) received three cycles of IC. No difference between the arms was observed in the number of patients who completed RT (61 versus 64, P = 018). Overall and complete response rates were very similar in the two arms and so were 3-year progression-free and overall survival rates. Grade III or IV toxic effects from IC were infrequent, apart of alopecia. Mucositis, weight loss and leukopenia were the most prominent side-effects from CCRT.

CONCLUSION

IC with three cycles of CEP when followed by CCRT did not significantly improve response rates and/or survival compared with that of CCRT alone.

The role of tumor size and patient's age as prognostic factors in laryngeal cancer

BACKGROUND AND AIM

The loco-regional recurrence of laryngeal carcinoma in patients who underwent total laryngectomy is related to numerous factors. Aim of the present study was to investigate the role of patient's age and tumor size in the recurrence rate of patients. Additional aim of the current study was to investigate the possible associations between the size of the tumor and other characteristics.

PATIENTS AND METHODS

In 1st Department of Otorhinolaryngology of AHEPA University Hospital, from 1992 to 2007, 255 patients with laryngeal carcinoma underwent total laryngectomy. Accurate data regarding the size of the tumor were obtained. Total laryngectomy was the initial treatment in 212 patients, while in the remaining 43 patients was performed as salvage surgery after recurrence.

RESULTS

The median tumor size was 2.74 cm (0.8-5.5 cm). There was no significant difference in the median tumor size between the patients who had recurrence (2.87 cm) and the disease free patients (2.69 cm). The median size of glottic tumors (2.47 cm) was smaller than that of supraglottic (2.95 cm) and of subglottic tumors (3.27 cm) (p<0.05). Among the 255 patients, recurrence of the tumor occurred in 73 (28.7%). Statistical analysis of the data showed that the tumor size was affecting the recurrence rate in a different manner, according the stage of the tumor. The recurrence rate in T3 neoplasms was higher in larger tumors than in smaller (13.2% for tumors<2cm, 62% for tumors>4cm), while T4 carcinomas appeared to have the opposite behavior (66.5% for tumors <2cm, 23% for tumors >4cm). The median tumor size in T4 patients that recurred was smaller than in those with no recurrence (2.8 cm Vs 3.3 cm). This behavior was observed in T4 tumors from all sites. Patients who experienced recurrence and had positive neck lymph nodes at the time of the initial diagnosis appeared to have smaller laryngeal tumors (2.7 cm), compared to with the same group of patients with no recurrence (3.5 cm). Supraglottic location and advanced T stage showed a statistically significant impact on disease free survival, based on Cox regression model.

CONCLUSIONS

Smaller sized tumors in patients with locally advanced laryngeal cancer (T4) or regionally (N+) appear to have more aggressive behavior and higher recurrence rate. Thus, the small tumor size could be regarded as an unfavorable prognostic factor for those laryngeal cancer cases.

The value of 11C-5-hydroxy-tryptophan positron emission tomography in neuroendocrine tumor diagnosis and management: experience from one center

Many neuroendocrine tumors (NET) are small and may escape localization by conventional imaging techniques. In such cases, 11C-5-hydroxy-tryptophan (11C-5-HTP) positron emission tomography (PET) has been tested as an additional diagnostic tool. Nine patients with clinically, biochemically and/or histologically confirmed NET and negative computerized tomography (CT) or magnetic resonance imaging (MRI), and 111In-pentetreotide (Octreoscan) scintigraphy underwent imaging with 11C-5-HTP-PET/CT in order to: 1) detect the primary tumor lesion in three patients; 2) detect residual disease in two patients with appendiceal carcinoid, one with rectal carcinoid, one with midgut carcinoid, and one with ectopic ACTH secretion (EAS) due to residual pulmonary carcinoid; and 3) restage a patient with medullary thyroid carcinoma (MTC) and hepatic metastases. 11C-5-HTP-PET/CT detected lesions in the mediastinum in a patient with EAS due to a pulmonary carcinoid, further hepatic metastases in a patient with carcinoid syndrome (CS) from a NET of unknown primary, further hepatic metastases in the patient with MTC, and hepatic metastases in the patient with midgut carcinoid. The 11C-5-HTP-PET/CT findings contributed to radical cure of the patient with recurrent EAS, and pointed towards bilateral adrenalectomy in the patient with EAS without evident primary tumor. In addition, 11C-5- HTP-PET/CT directed towards combined surgical and medical treatment in the patient with CS and multiple rather than single hepatic metastases and in the patient with midgut carcinoid, and towards continuation of medical treatment in the patient with MTC. 11C-5-HTP-PET/CT is a useful imaging technique, providing additional information for the diagnosis, staging and decision-making regarding management of patients with NET.

Management of the clinically negative neck (N0) of supraglottic laryngeal carcinoma: a systematic review

AIM

The most effective therapeutic approach for patients with supraglottic laryngeal carcinoma (SGLC) and clinically negative neck (cN0) remains a subject of much debate. The purpose of this systematic review was to answer the following question: among patients with SGLC and cN0 neck, are the survival and occurrence of neck metastases significantly different between patients that received neck dissection and those that had another therapeutic treatment (radiotherapy, combined therapy, 'wait and see' policy)?

MATERIALS AND METHODS

An electronic literature search was performed in MEDLINE, EMBASE, Cochrane Library and CENTRAL databases, followed by extensive hand-searching for the identification of relevant studies. The following inclusion criteria were established: the study should (a) include a comparison of neck dissection with one of the other therapeutic procedures for cN0 of SGLC; (b) report the therapy for the initial supraglottic cancer; and (c) use time-to-event analysis of its results. Six studies were eventually identified and systematically reviewed.

RESULTS

All studies included in the systematic review were retrospective (n=792 patients). The survival (overall, disease-specific and neck disease-free) and the site of neck recurrence of the patients with N0 supraglottic cancer were not significantly different between patients in the neck dissection treatment group and those of the rest of the therapeutic strategies examined (neck radiotherapy, combined therapy and 'wait and see' policy).

CONCLUSIONS

The present systematic review highlights the need for further well-designed prospective studies that will provide more reliable answers to the debatable issue of the management of cN0 of SGLC. Currently, based on the best available evidence, it seems that neck dissection is not superior to radiotherapy or combined therapy or a 'wait and see' policy in terms of survival and control of neck disease.

Preoperative evaluation, surgical procedure, follow up and results of 150 cochlear implantations

BACKGROUND

The cochlear implantation is among the most important achievements of medicine and biotechnology in the last 20 years, because it allows individuals who had never heard or had lost their hearing to perceive sound and improve their quality of life. Selection criteria for candidates are strict and are evaluated in each individual by a scientific committee specially trained for implantations which includes Ear Nose and Throat (ENT) surgeon, audiologist, psychiatrist and speech therapist.

PATIENTS AND METHODS

In our department, the first cochlear implantation was performed in 1995. During the last ten years more than 250 individuals have been evaluated due to profound hearing loss and 170 of them were found to be suitable candidates for cochlear implantation. One hundred and fifty (150) have already been operated and most of them are children with congenital hearing loss. No major or permanent complications were recorded in any of our 150 patients. Activation and fitting/mapping of the cochlear implant is initiated three weeks post-operatively. Regular follow-up and mapping of the implant are held, more frequently in children, along with specialized speech therapy. Each new mapping is evaluated according to the record of the patient with regard to the acoustic perception of sounds and speech and the discrimination of individual elements of phonation based on a protocol that we have created for the needs of Greek language.

RESULTS

Speech discrimination (AHEPA Hospital protocol), before the Implantation, at the activation of the cochlear implant and till 4 years of the follow-up showed that in our patients, we obtained better and faster results in post-speech acquisition adults with recent or chronic deafness and in children with congenital deafness operated before the 5th year of age, who underwent special preoperative speech therapy programme, fact which is in agreement with current literature. Patient satisfaction evaluated by "Sanders" psychometrics tests, was achieved in accordance to pre-operative expectations.

CONCLUSIONS

In our patients, we observed better and faster results in children with congenital deafness operated before the third year of age, in post-speech acquisition adults with recent deafness and in post-speech acquisition adults with chronic deafness but with auditory memory reserve.

Distribution of organotin compounds in the bivalves of the Aegean Sea, Greece

Five bivalve species--Mytilus galloprovinciallis (Mediterranean mussels), Venus gallina (stripped venus), Modiola barbatus L. (bearded horse mussels), Pecten jacobeus (scallops) and Callista chione (hard clams)--were collected from seven areas in Aegean Sea, Greece, between August 2001 and January 2003 and analyzed for organotins (OTs). The concentrations (as geometric means) found were 17.1 ng g-1 for tributyltin (TBT), 18.8 ng g-1 for dibutytltin (DBT), 7.8 ng g-1 for monobutyltin (MBT) and 13.0 ng g-1 for triphenyltin (TPhT) (wet weight), which are at similar or lower levels than those reported worldwide. Studying OTs distribution between different bivalve species, lower concentrations were observed in mediterranean mussels, possibly due to their growth in water column (grown on sea net pens in mussel farms), in contrast to the free-ranging species, collected from fishing grounds. Concentrations of the OTs in the examined bivalves varied seasonally.

Fenton and photo-Fenton treatment of a synthetic tannin used in leather tannery: a multi-approach study

The aim of this work was to compare the behaviour of Fenton and photo-Fenton (UV-A, UV-C) processes to treat synthetic tannin (syntan) used in leather tannery which is one of the most polluting industries, releasing many xenobiotics. Both oxidation processes were performed at pH 3.0 and temperature 40-45 degrees C, which is the original temperature of the re-tanning process, in synthetic solutions containing 100 and 300 mg/L of COD equivalent of syntan. The efficiency of the applied oxidation processes was monitored by chemical oxygen demand (COD), oxidation redox potential (ORP) and aromaticity (UV280) and double bond (UV254) absorbance measurements. Acute toxicity test on Daphnia magna was performed to monitor toxicity in untreated and treated syntan solution. Gas chromatography-mass spectrometry (GC-MS) was applied to identify by-products of partial oxidation occurring in treated samples. The effective ratio of H2O2/FeSO4 for photo-Fenton processes was found to be feasible in terms of reagents used in the process.

Paclitaxel and gemcitabine vs. paclitaxel and pegylated liposomal doxorubicin in advanced non–nasopharyngeal head and neck cancer. An efficacy and cost analysis randomized study conducted by the Hellenic Cooperative Oncology Group

BACKGROUND

The prognosis of patients with recurrent and/or metastatic head and neck cancer (HNC) is poor. Median survival of these patients following chemotherapy is in the range of 6 to 9 months. In the present randomized phase III trial we compared two new combinations containing new drugs with proven activity in phase II studies with patients with HNC.

PATIENTS AND METHODS

From November 1999 until November 2004, 166 eligible patients with HNC were enrolled in the study. They were treated with paclitaxel 175 mg/m(2) on day 1 and gemcitabine 1000 mg/m(2) on days 1 and 8 every 3 weeks (group A, 85 patients) or with paclitaxel, as in group A, and pegylated liposomal doxorubicin 40 mg/m(2) on day 1 every 4 weeks (group B, 81 patients).

RESULTS

There was no significant difference in response rate (20% versus 29%, P = 0.21), time to disease progression (median; 4.4 months versus 6.0 months, P = 0.09) and survival (median; 8.6 months versus 11.05 months, P = 0.25). Both regimens were generally well tolerated. The most frequently reported side effect, apart from alopecia, was neutropenia. Overall, there was no significant difference in severe toxicity between the two treatment arms.

CONCLUSIONS

The present study could not demonstrate a survival benefit with either regimen. Both treatments were well tolerated. Randomized studies comparing each of the two regimens with standard chemotherapy are warranted.

Prognostic value of VEGFC, HER2 and HER3 gene expression in recurrent squamous cell head and neck tumors

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Background: The main prognostic variables of head and neck squamous cell carcinoma (HNSCC) are the location and size of the tumor and the presence of cervical lymph node metastases. Differential gene expression of members of the HER and VEGF families is a common feature in HNSCC. To elucidate the prognostic value and the interrelation of these factors we performed a detailed gene expression analysis within HNSCC tissue samples Methods: We analyzed fresh frozen tissue from 48 recurrent HNSCC tumors stored at -80oC. RNA was isolated with the RNeasy kit (Qiagen, Inc.), followed by kinetic one-step RT-PCR for the expression of 8 candidate genes (EGFR, HER2, HER3, HER4, VEGFA, VEGFB, VEGFC and VEGFD). Raw data (Ct values) were normalized to RPL37A expression (housekeeper gene) and candidate gene expression between patient groups with differential clinical outcomes was analyzed by using Genedata Expressionist and GraphPad Prism 4 software packages. Median patient follow-up from initial diagnosis was 27 months. Results: Overexpression of VEGFA and EGFR was prominent in most tumors, but did not appear to have any prognostic value. However, VEGFC expression was significantly higher (p = 0.0002) in the tumors of patients with poor overall survival (< 27 months). Interestingly, these tumors were further characterized by significantly lower expression levels of HER2 and HER3. Median survival of patients with tumor VEGFC expression levels of >600 was calculated to be 42 months from initial diagnosis (Kaplan-Meier Survival Analysis), compared to 182 months in the rest of the patients. Conclusions: We have found that elevated VEGFC expression and low expression of HER2 and HER3 correlate with poor outcome in recurrent HNSCC patients. VEGFC preferably binds to the VEGFR3, which is predominantly expressed on lymphatic vessels. Overexpression of VEGFC may therefore result in the establishment of intratumoral lymphatic vessels, which have been shown to facilitate the dissemination of tumor cells into lymph nodes and the formation of distant metastases. We conclude that the determination of VEGFC, HER2 and HER3 expression may be of high prognostic value in HNSCC patients and that it may serve in the early identification of aggressive HNSCC subtypes.

No significant financial relationships to disclose.

Laryngeal tuberculosis presenting as supraglottic carcinoma: case report and literature review

Laryngeal tuberculosis is a rare extra-pulmonary manifestation of tuberculosis, and frequently presents with tumour-like symptoms and clinical findings. Uncommon clinical features are to be expected by the ENT specialist, who should be aware of these recently changing presentations. Despite the dramatic reduction of the incidence of the disease during the last few decades, a perceptible increase in case reports has lately been noted and may prove significant. Treatment remains conservative and long-term follow-up is suggested. A relevant case of laryngeal tuberculosis presenting as a supraglottic carcinoma is presented, its diagnosis and management are detailed, and suggestions are offered based on a literature review.

Long-term treatment of deep venous thrombosis with a low molecular weight heparin (tinzaparin): a prospective randomized trial

OBJECTIVES

Evaluation of the effectiveness and safety of the low molecular weight heparin (LMWH) tinzaparin versus unfractionated heparin (UFH) followed by acenocoumarol in proximal deep venous thrombosis (DVT).

DESIGN

Prospective, randomized clinical trial.

MATERIAL AND METHODS

Consecutive patients (n=108) with acute leg DVT, confirmed by duplex, were randomized to either tinzaparin alone or UFH and acenocoumarol for 6 months. Patients were evaluated ultrasonographically at entry, 1, 3, 6 and 12 months. Thrombus regression, reflux distribution and the incidence of complications were studied. A cost-analysis, comparing the two treatments, was performed.

RESULTS

The overall incidence of major events (mortality, DVT recurrence, pulmonary embolism, major bleeding, heparin-induced thrombocytopenia) was significantly different (p=0.035) in favor of tinzaparin (7 versus 17 events). The ultrasonographic clot volume score (an index of recanalization) decreased significantly in both treatment groups. However, tinzaparin produced significantly more extended overall recanalization from 3 months onwards (p<0.02). Thrombus regression was equivalent or in favor of tinzaparin in the different DVT subgroups and venous segments, but the statistical significance varied. Reflux showed non-significant differences overall or in subgroups. A cost-analysis resulted in favor of LMWH.

CONCLUSIONS

A fixed daily dose of tinzaparin for 6 months was at least as effective and safe as UFH and acenocoumarol. Regarding major events and recanalization, there was a significant benefit in favor of tinzaparin. Long-term DVT treatment with tinzaparin could represent an alternative to conventional treatment.

Factors influencing tumour relapse after total laryngectomy

OBJECTIVES

To determine the prognostic factors predictive of tumour recurrence after surgical treatment for laryngeal carcinoma with total laryngectomy.

STUDY DESIGN/METHODS

Retrospective review of 308 patients with laryngeal carcinoma who underwent total laryngectomy in the ENT Department of AHEPA University Hospital between 01/01/1992 and 31/12/1999. In 238 patients, total laryngectomy was performed as primary treatment of laryngeal carcinoma, and in 70 others as treatment of tumour recurrence following radiotherapy or partial surgery. Follow-up was standardized, following a strict protocol, the mean follow-up time was 68 months.

RESULTS

During post-operative follow-up, recurrences were observed in 96 of 308 patients (31%). The relapse rates were 27% (65 of 238) for patients treated with primary total laryngectomy, and 44% (31 of 70) for those treated for recurrence following previous treatment. The difference in relapse rates was statistically significant. In 39 of 238 (16%) cases treated with primary total laryngectomy cervical lymph node infiltration was present at diagnosis and radical or modified neck dissection was performed. The tumour recurrence rate in this group was 46% (18 of 39), while in metastatic node-free patients the relapse rate was 24% (47 of 199) [p < 0.05]. Primary laryngectomy was effective in 82% of glottic, 70% of supraglottic, and only 59% of transglottic carcinoma. Concerning primary tumour extension at the time of surgery, total laryngectomy proved effective in 85% of T2 tumours, 81% of T3, and only 55% for T4. The higher recurrence rates for supraglottic and transglottic tumours seem related mainly to the higher rates of cervical lymph node metastasis at diagnosis. The majority of tumour recurrences were observed during the first two years of post-operative follow-up. Thus, 76% of the 308 patients remained disease-free after the first year of post-operative follow-up, 68% after the second year, and 67% after the fifth follow-up year. Of the 96 recurrences documented until now, 91 were loco-regional (19 at the tracheostomy), and only 5 involved distant metastases. Sixteen of the 308 patients (5%) subjected to total laryngectomy have since developed second primary neoplasms, most often involving the lungs (10 patients).

CONCLUSIONS

Prognostic factors for recurrence following total laryngectomy include: performance of total laryngectomy as salvage surgery, degree of tumour extension, infiltration of cervical lymph nodes at the time of initial diagnosis, poor initial tumour differentiation and trans-glottic/sub-glottic tumour localization.

Video-assisted transcervical thymectomy

BACKGROUND

The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described.

METHODS

Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space.

RESULTS

No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study.

CONCLUSION

Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.

Greek adolescents, fitness, fatness, fat intake, activity, and coronary heart disease risk

BACKGROUND

A dramatic increase in adult mortality rates from coronary heart disease (CHD) in Greece, accompanied by increased prevalence of CHD risk factors in children, has been documented. However, there is controversy about the independent effects of certain lifestyle parameters on primary CHD risk factors.

AIMS AND METHODS

To examine the association between CHD risk factors (HDL-C, LDL-C, HDL-C/TC, triglycerides, systolic and diastolic blood pressure) and lifestyle parameters (fitness, fatness, fat intake, and physical activity) in 210 12-year old Greek pupils.

RESULTS

Correcting for the fixed factors of gender and maturation, analyses of covariance (ANCOVA) with backward elimination of the lifestyle covariates revealed significant associations between three CHD risk factors (HDL-C, HDL-C/TC, systolic blood pressure) and physical activity levels. In contrast, the covariates aerobic fitness, fatness and fat intake failed to reach significance with any of the CHD risk factors.

CONCLUSIONS

In Greek schoolchildren, primary CHD risk factors are mainly associated with physical activity levels, independently of fitness, fatness, and/or fat intake. Prevention strategies should concentrate on enhancing physical activity early in life, if the increased prevalence of Greek adult CHD mortality is to be diminished.

Management of tracheal stenosis with a titanium ring and nasal septal cartilage

Surgical management of subglottic laryngeal and upper tracheal stenosis remains a formidable challenge. The significant number of proposed techniques only highlights the difficulties associated with effectively managing this problem. Between 1996 and 1999, seven patients with stenosis of the upper trachea were treated. The stenosis resulted from long-term intubation during intensive-care hospitalization in five patients and from tracheotomy complications in the other two. Six patients were male and one female, their ages ranging between 13 and 60 years. The mean postoperative observation period was 3 years (1.5-4.5 years). In all patients, the stenosis exclusively involved the upper tracheal segment, measuring from 2 to 5 cm in length. The stenotic area of the trachea is exposed, and the local application of a solution of mitomicin C for a duration of 4 min is performed. A graft consisting of cartilage and mucosa is harvested from the nasal septum and is fixed with sutures to a titanium semi-ring. After the fixation of the graft on the ring, the entire construct is placed on the stenosed segment of the exposed trachea. The graft must cover the anterior exposed face of the trachea with the lateral members of the semicircular titanium ring adjacent to the lateral walls of the trachea, externally. The lateral tracheal walls are attracted laterally with sutures and are attached on the edges of the semicircular titanium ring. Four of the patients in whom no tracheotomy had been performed preoperatively needed none at all intraoperatively, and they were decannulated normally at the end of the procedure. Tracheotomy was deemed necessary for one patient's safety and was maintained for 7 days. In one patient with a preoperative tracheotomy, the point of the tracheotomy was displaced lower on the trachea and was maintained there for 7 days. The course of management described here and employed on seven patients involves a safe surgical procedure with excellent results. The placement of the titanium ring offers very good support for the graft and maintains the patency of the tracheal lumen. The main reasons for the failure of techniques using only cartilage grafts are therefore avoided. The number of cases presented here is certainly too small to establish definite conclusions; however, the initial results are extremely satisfying and urge us to suggest the use of this method in indicated cases.

How often is total laryngectomy necessary for the treatment of T1 failures after radiotherapy or cordectomy?

Between 1992 and 1998, 547 patients (pts) with laryngeal SCC were diagnosed and treated in our department, 145 (27%) of whom presented with glottic tumors T1N0M0 (125 T1a and 20 T1b). Seventy-eight (54%) were treated surgically with cordectomy and 67 (46%) with radiotherapy. After a median follow-up time of 43 months, 22 (15.2%) of the 145 pts presented with recurrent disease. In more detail, 16 (13%) of the 125 T1a pts and 6 (30%) of the 20 T1b pts had recurrences. Among the 78 surgically treated patients only 4 (5%) had recurrence, while 18 (27%) of the radiotherapy group relapsed. The difference is statistically significant (log rank test, P = 0.0001 < 0.05). After salvage treatment, of the 67 pts of the radiotherapy group 57 (85%) remain disease-free, 49 (73%) retaining their larynx intact and 1 only having undergone cordectomy. Among the cordectomy group 75 (96%) pts remain disease-free with only 1 having had a total laryngectomy. Using the Kaplan-Meier method and calculating the disease-free survival regardless of salvage treatment, there is no doubt that surgical treatment statistically is more successful than radiotherapy (log rank test, P = 0.01 < 0.05). Analysis of parameters such as tumor differentiation and T1a or T1b staging, which indeed influence the overall recurrence rate, did not alter the favorable outcome after surgical treatment.

Factors influencing quality of life in laryngectomized patients

The aim of this study is to estimate the quality of life postlaryngectomy. A questionnaire was used. Fifty-six patients were enrolled answering 26 questions. The mean age was 60.2 (40-76) years and median post-treatment time 43 (7-120) months. The most frequent complaints of the patients were increased bronchial discharge (66%) and reduced olfactory function (63%). Communication problems with strangers was mentioned by 57% and with their family by 29%. With regard to the psychological status, 30% were ashamed of their voice, 32% were ashamed of their appearance, 42% stated that they were rather depressed, and 30% were feeling lonely. More than 3 out of 4 patients believed that their everyday life had been altered. Half of the patients experienced financial difficulties and 37% were not participating in social meetings outside their house. Statistical analysis was used in order to calculate the severity of each category of problems which the patient faced using the scale from 0 to 1. The average grade for functional disorders was 0.31, for communication problems 0.47, for psychological problems 0.29, for social problems 0.27, and for financial problems 0.51.

Paclitaxel and gemcitabine in advanced non-nasopharyngeal head and neck cancer: a phase II study conducted by the Hellenic Cooperative Oncology Group

BACKGROUND

Paclitaxel as monotherapy or in combination with other drugs has demonstrated significant activity in patients with squamous cell carcinoma of the head and neck region (SCCHN). Preclinical studies have shown gemcitabine to be highly active in SCCHN cell lines.

PURPOSE OF THE STUDY

To evaluate the activity and toxicity of the combination of paclitaxel by three-hour infusion and gemcitabine as first-line chemotherapy in patients with recurrent and/or metastatic head and neck cancer (HNC).

PATIENTS AND METHODS

From September 1996 until May 1998, 44 patients with non-nasopharyngeal recurrent and/or metastatic HNC entered the study. There were 37 men and seven women with a median age of 61 years (range 35-79) and a median performance status of 1 (range 0-2). The location of the primary tumor in the majority of them was either the larynx or the oral cavity. Treatment consisted of six cycles of gemcitabine 1100 mg/m2 over 30 min on days 1 and 8 immediately followed on day 1 by paclitaxel 200 mg/m2 by three-hour infusion. The treatment was repeated every three weeks.

RESULTS

Twenty-four (55%) patients completed all six cycles of treatment. A total of 205 cycles were administered, 165 (81%) of them at full dose. The median relative dose intensity (DI) of gemcitabine was 0.93 and of paclitaxel 0.95. Except for alopecia, which was universal, grade 3-4 toxicities included neutropenia (21%), thrombocytopenia (5%), anemia (5%), infection (5%), flu-like syndrome (5%) and peripheral neuropathy (2%). Five (11%) patients achieved complete and 13 (30%) partial responses, for an overall response rate of 41%. After a median follow-up of 13 months, the median time to progression was four months and median survival nine months.

CONCLUSIONS

The combination of paclitaxel and gemcitabine is active and well tolerated in patients with recurrent and/or metastatic HNC-randomized studies comparing this combination with other regimens are warranted.

[Voice rehabilitation after total laryngectomy. Voice prostheses or esophageal replacement voice?]

BACKGROUND

During the last years tracheoesophageal fistula has a well established role and in several units is now the principal means of speech rehabilitation following laryngectomy. The purpose of this study is to present the long term results after using the Provox voice prosthesis and to compare the phonetic results obtained with this means of speech rehabilitation with esophageal speech.

PATIENTS, METHODS, AND RESULTS

During the last 7 years, 265 laryngectomy patients were trained in our Department in an effort to develop esophageal speech. One hundred and twelve of them developed comprehensive speech of various quality. In another group consisting of 35 patients, a Provox low-resistance, self-retaining prosthesis was fitted. Twenty-nine of them developed a very good voice. Ten patients of each group were tested in order to estimate the quality of voice of the two methods. Three measurements were obtained from each patient: the maximal intensity, the maximal phonation time, and the number of syllables with one breath.

CONCLUSION

All the results confirmed the better quality of the tracheo-esophageal speech. The main two advantages of the prosthesis are the effortless speech due to the low resistance of the valve and the simple maintenance by the patient. The most important disadvantage is the cost and the need to occlude the stoma during phonation. Conclusively each method of speech rehabilitation should be selected individually according to the needs, desire, and abilities of every patient.