Single-cycle induction chemotherapy selects patients with advanced laryngeal cancer for combined chemoradiation: a new treatment paradigm

PURPOSE

Primary chemoradiotherapy in patients with advanced laryngeal cancer can achieve high rates of organ preservation without sacrificing survival compared with radiation alone or conventional laryngectomy. Appropriate selection of patients for organ preservation approaches could enhance overall treatment outcome and quality of life. We conducted a phase II organ preservation trial for patients with stage III and IV larynx cancer to determine whether late salvage surgery rates could be decreased and survival improved by selecting patients for organ preservation based on response to a single cycle of induction chemotherapy.

PATIENTS AND METHODS

The chemotherapy was cisplatin 100 mg/m2 on day 1 and fluorouracil 1,000 mg/m(2)/d for 5 days. Patients who achieved less than 50% response had immediate laryngectomy. Patients who achieved more than 50% response went on to concurrent chemoradiotherapy. Histologic complete responders after chemoradiotherapy received two more cycles of chemotherapy. Patients with residual disease after chemoradiotherapy had planned salvage surgery.

RESULTS

Of 97 eligible patients, 73 (75%) achieved more than 50% response and received chemoradiotherapy. A total of 29 patients (30%) had salvage surgery; 19 patients (20%) had early salvage surgery after the single cycle of induction chemotherapy, three patients (3%) had late salvage surgery after chemoradiotherapy, six patients (6%) eventually had salvage surgery for recurrence, and one patient had laryngectomy for chondroradionecrosis. The median follow-up time was 41.9 months. The overall survival rate at 3 years is 85%. The cause-specific survival rate was 87%. Larynx preservation was achieved in 69 patients (70%).

CONCLUSION

These results confirm excellent larynx preservation and improved overall survival rates compared with historical results.

The atypical Spitz tumor of uncertain biologic potential: a series of 67 patients from a single institution

BACKGROUND

Atypical Spitz tumors (AST) are rare spitzoid melanocytic proliferations with an uncertain malignant potential. ASTs have overlapping features of both Spitz nevi and spitzoid melanoma, and consequently generate controversy with diagnosis and management. Sentinel lymph node biopsy (SLNB) has been proposed as a possible means to gain additional insight into the true biologic potential of these tumors; however, previous reports on the use of SLNB in ASTs have been limited by small numbers of patients and short durations of follow-up.

METHODS

The authors extracted data from their institution's prospective melanoma database, collected between 1994 and 2007, for all patients with ASTs of uncertain biologic potential. They reviewed the clinical features of these patients, including the sentinel lymph node status, and the histological features of the tumors.

RESULTS

A total of 67 patients with ASTs were identified, with a median age of 23.7 years. The mean depth was 2.4 mm. Of these, 57 had a SLNB performed, with 27 (47%) having a positive sentinel lymph node. SLNB-positive cases had a significantly lower mean age than SLNB-negative cases (17.9 vs 28.7 years; P = .013); however, no other significant differences were observed. All 27 patients with a positive SLNB were alive and disease free with median follow-up of 43.8 months. One patient who did not receive a SLNB developed recurrent disease with regional and distant metastases.

CONCLUSIONS

ASTs do not appear to behave like conventional melanoma. There is a high incidence of microscopic lymph node deposits in SLNBs, but despite this finding, patients have a favorable prognosis. Our findings raise several questions regarding the malignant potential of ASTs, and the role of SLNB in their management.

Infiltrating lymphocytes and human papillomavirus-16--associated oropharyngeal cancer

OBJECTIVES/HYPOTHESIS

Human papillomavirus-16 (HPV-16)-associated carcinoma of the oropharynx has a favorable prognosis. Such patients have elevated CD8+ T-lymphocyte levels that correlate with response to chemotherapy and survival. Tumor-infiltrating lymphocyte (TIL) subpopulations were assessed in pretreatment biopsies from a prospective patient cohort to determine if TIL subsets differed by HPV status, clinical factors, or patient outcome or correlated with peripheral blood T-cell levels.

STUDY DESIGN

Retrospective immunological correlative study of patients entered in a prospective Phase 2 clinical trial.

METHODS

Measured were CD8, CD4, CD68, and Treg (FoxP3) lymphocytes by immunohistochemistry in a tissue microarray created from patients (n=46) with advanced oropharyngeal cancer. Correlations with peripheral blood levels, HPV status, expression of epidermal growth factor receptor (EGFR), clinical tumor, and patient characteristics and outcome were determined. Median follow-up was 6.6 years.

RESULTS

HPV-16-positive patients had improved survival (P=.016). Degree of T-cell infiltration did not differ by HPV status but was significantly related to disease-specific survival (DSS) and overall survival (OS). Even after adjusting for HPV status, we found that CD8, FoxP3, and total T cells were significantly associated with DSS (P=.0236, P=.0040, and P=.0197, respectively) and OS (P=.0137, P=.0158, and P=.0115, respectively). Less T-cell infiltration (P=.0130) and CD4 cells in particular (P=.0792) were associated with higher EGFR expression.

CONCLUSIONS

Improved outcomes are associated with increased TILs independent of HPV status and suggest the local immune response may be more related to factors such as tumor size, EGFR expression, or performance status than HPV status. Further study of larger numbers of patients and infiltrates combined with functional analysis of individual subsets may be necessary to detect significant differences in local immunity in HPV-16-related cancers.

Early prediction of outcome in advanced head-and-neck cancer based on tumor blood volume alterations during therapy: a prospective study

PURPOSE

To assess whether alterations in tumor blood volume (BV) and blood flow (BF) during the early course of chemo-radiotherapy (chemo-RT) for head-and-neck cancer (HNC) predict treatment outcome.

METHODS AND MATERIALS

Fourteen patients receiving concomitant chemo-RT for nonresectable, locally advanced HNC underwent dynamic contrast-enhanced (DCE) MRI scans before therapy and 2 weeks after initiation of chemo-RT. The BV and BF were quantified from DCE MRI. Preradiotherapy BV and BF, as well as their changes during RT, were evaluated separately in the primary gross tumor volume (GTV) and nodal GTV for association with outcomes.

RESULTS

At a median follow-up of 10 months (range, 5-27 months), 9 patients had local-regional controlled disease. One patient had regional failure, 3 had local failures, and 1 had local-regional failure. Reduction in tumor volume after 2 weeks of chemo-RT did not predict for local control. In contrast, the BV in the primary GTV after 2 weeks of chemo-RT was increased significantly in the local control patients compared with the local failure patients (p < 0.03).

CONCLUSIONS

Our data suggest that an increase in available primary tumor blood for oxygen extraction during the early course of RT is associated with local control, thus yielding a predictor with potential to modify treatment. These findings require validation in larger studies.

The tumor suppressor gene rap1GAP is silenced by miR-101-mediated EZH2 overexpression in invasive squamous cell carcinoma

Rap1GAP is a critical tumor suppressor gene that is downregulated in multiple aggressive cancers, such as head and neck squamous cell carcinoma, melanoma and pancreatic cancer. However, the mechanistic basis of rap1GAP downregulation in cancers is poorly understood. By employing an integrative approach, we demonstrate polycomb-mediated repression of rap1GAP that involves Enhancer of Zeste Homolog 2 (EZH2), a histone methyltransferase in head and neck cancers. We further demonstrate that the loss of miR-101 expression correlates with EZH2 upregulation, and the concomitant downregulation of rap1GAP in head and neck cancers. EZH2 represses rap1GAP by facilitating the trimethylation of histone 3 at lysine 27, a mark of gene repression, and also hypermethylation of rap1GAP promoter. These results provide a conceptual framework involving a microRNA-oncogene-tumor suppressor axis to understand head and neck cancer progression.

Tailored risk notification for women with a family history of breast cancer

BACKGROUND

Evidence indicates that although first-degree relatives of breast cancer cases are at increased risk of developing the disease themselves, they may be underutilizing screening mammography. Therefore, interventions to increase the use of mammography in this group are urgently needed.

METHODS

A randomized two-group design was used to evaluate an intervention to increase mammography use among women (N = 901) with at least one first-degree relative with breast cancer. A statewide cancer registry was used to obtain a random sample of breast cancer cases who identified eligible relatives. The mailed intervention consisted of personalized risk notification and other theoretically driven materials tailored for high-risk women.

RESULTS

An overall significant intervention effect was observed (8% intervention group advantage) in mammography at post-test. There was an interaction of the intervention with age such that there was no effect among women <50 years of age and a fairly large (20% advantage) effect among women 50+ and 65+. Health insurance, education, and having had a mammogram in the year before baseline assessment were positive predictors of mammography at post-test. Perceived risk, calculated risk, and relationship to index cancer case were not associated with mammography receipt.

CONCLUSION

The intervention was successful in increasing mammography rates among high-risk women 50+ years of age. Further work is needed to determine why it was ineffective among younger women.

Recurrent laryngeal nerve monitoring in thyroid and parathyroid surgery: the University of Michigan experience

OBJECTIVES/HYPOTHESIS

Intraoperative monitoring of the recurrent laryngeal nerve (RLN) is finding increasing acceptance during thyroidectomy. Recently, a laryngeal surface electrode was introduced to enable another form of noninvasive monitoring of the RLN. The present report examines the University of Michigan experience with RLN monitoring using the postcricoid surface electrode.

STUDY DESIGN

All patients undergoing partial or total thyroidectomy or parathyroidectomy from January 1999 to July 2001 were considered candidates for the study. Audiologists trained in intraoperative electrophysiological techniques performed all of the monitoring.

METHODS

Data collected on each patient included 1) stimulation threshold for a laryngeal compound muscle action potential on initial RLN identification, 2) stimulation threshold of the laryngeal compound muscle action potential on completion of the procedure, and 3) flexible fiberoptic evaluation of the larynx at the initial postoperative visit and at the 3-month follow-up visit. The average duration of follow-up was 9.8 months with a range of 3 to 60 months.

RESULTS

The average minimum current required for stimulation on first identification of all nerves was 0.57 mA (+/-0.48 mA). After completion of the procedure a mean threshold level of 0.42 mA (+/-0.55 mA) was obtained during direct RLN stimulation. Post-dissection stimulation of the RLN on the side of tumor dissection was 0.92 mA (+/-0.65 mA) compared with a stimulation threshold of 0.76 mA (+/-0.57 mA) for the nontumor side.

CONCLUSIONS

Electromyographic monitoring of the RLN using a postcricoid surface electrode provides a safe, simple, and effective method for intraoperative monitoring during thyroid or parathyroid surgery. Further, evoked electromyography confirms RLN integrity at the conclusion of surgery.

Genetic and expression profiles of squamous cell carcinoma of the head and neck correlate with cisplatin sensitivity and resistance in cell lines and patients

PURPOSE

The choice of treatment for squamous cell carcinoma of the head and neck (SCCHN) is still primarily based on the tumor-node-metastasis classification. However, it is reasonable to believe that biological profiles of SCCHN may be independently associated with response to therapy. The aim of the present study was to examine genetic changes and gene expression profiles that might correlate with sensitivity to cisplatin [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay] in 10 SCCHN cell lines.

EXPERIMENTAL DESIGN

Five cisplatin-sensitive and five cisplatin-resistant cell lines [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay] were studied by comparative genomic hybridization, spectral karyotyping, and cDNA microarray analysis (21,632 sequence-validated human cDNA; confirmation by reverse transcriptase-PCR for selected genes). For the MET proto-oncogene, which showed low expression in the chemosensitive cell lines, we did immunohistochemical staining on SCCHN of 29 patients who received induction chemotherapy.

RESULTS

The five cisplatin-resistant cell lines showed significantly more genetic imbalances (regions of loss and amplification) and chromosomal abnormalities by comparative genomic hybridization and spectral karyotyping, respectively, than did the five cisplatin-sensitive cell lines. Microarray studies identified approximately 60 genes that clearly distinguish between the two groups of cell lines. Some of these genes are known to be involved in tumor progression, metastasis, and drug resistance. We identified low expression of c-met (immunohistochemistry) as a predictive factor for complete response in nondiploid tumors (P = 0.026).

CONCLUSIONS

We conclude that cisplatin sensitivity and resistance are related to distinctive differences in the genetic and expression profiles in individual SCCHN tumor cell lines and in SCCHN patients. The genes we have identified may serve as potential targets for novel treatment strategies.

Inactivation or loss of TTP promotes invasion in head and neck cancer via transcript stabilization and secretion of MMP9, MMP2, and IL-6

PURPOSE

Invasion is the critical step in progression of a precancerous lesion to squamous cell carcinoma of the head and neck (HNSCC). Invasion is regulated by multiple proinflammatory mediators. Tristetraprolin (TTP) is an mRNA-degrading protein that regulates multiple proinflammatory mediators. TTP may serve as an excellent treatment target. Rap1 is a ras-like oncoprotein that induces critical signaling pathways. In this study, the role of rap1 in TTP-mediated invasion was investigated.

EXPERIMENTAL DESIGN

Using complementary approaches, we modulated TTP and altered expression of interleukin (IL)-6 and matrix metalloproteinase (MMP) 2/9, which were quantified by ELISA and zymogram. Invasion was evaluated in vitro using the oral-cancer-equivalent (OCE) three-dimensional model and in vivo in the chick chorioallantoic membrane (CAM). The role of rap1 and p38 were established using knockdown strategies.

RESULTS

Downregulation of TTP significantly increased invasion via secretion of MMP9/2 and IL-6. In the novel OCE and CAM invasion models of HNSCC, cells with downregulated TTP destroyed the basement membrane to invade the underlying connective tissue. Rap1 induces p38 mitogen-activated protein kinase (p38)-mediated inactivation of TTP. Inactive TTP enhances transcript stability via binding to the 3'-untranslated region (UTR). High IL-6 and MMP9 are prognostic for poor clinical outcomes in patients with HNSCC.

CONCLUSIONS

Targeting the rap1-p38-TTP cascade is an attractive novel treatment strategy in HNSCC to concurrently suppress multiple mediators of invasion.

Tristetraprolin regulates interleukin-6, which is correlated with tumor progression in patients with head and neck squamous cell carcinoma

BACKGROUND

Tumor-derived cytokines play a significant role in the progression of head and neck squamous cell carcinoma (HNSCC). Targeting proteins, such as tristetraprolin (TTP), that regulate multiple inflammatory cytokines may inhibit the progression of HNSCC. However, TTP's role in cancer is poorly understood. The goal of the current study was to determine whether TTP regulates inflammatory cytokines in patients with HNSCC.

METHODS

TTP messenger RNA (mRNA) and protein expression were determined by quantitative real-time-polymerase chain reaction (Q-RT-PCR) and Western blot analysis, respectively. mRNA stability and cytokine secretion were evaluated by quantitative RT-PCR and enzyme-linked immunoadsorbent assay, respectively, after overexpression or knockdown of TTP in HNSCC. HNSCC tissue microarrays were immunostained for interleukin-6 (IL-6) and TTP.

RESULTS

TTP expression in HNSCC cell lines was found to be inversely correlated with the secretion of IL-6, vascular endothelial growth factor (VEGF), and prostaglandin E2 (PGE(2) )(.) Knockdown of TTP increased mRNA stability and the secretion of cytokines. Conversely, overexpression of TTP in HNSCC cells led to decreased secretion of IL-6, VEGF, and PGE(2) . Immunohistochemical staining of tissue microarrays for IL-6 demonstrated that staining intensity is prognostic for poor disease-specific survival (P = .023), tumor recurrence and development of second primary tumors (P = .014), and poor overall survival (P = .019).

CONCLUSIONS

The results of the current study demonstrated that down-regulation of TTP in HNSCC enhances mRNA stability and promotes secretion of IL-6, VEGF, and PGE(2) . Furthermore, high IL-6 secretion in HNSCC tissue is a biomarker for poor prognosis. In as much as enhanced cytokine secretion is associated with poor prognosis, TTP may be a therapeutic target to reduce multiple cytokines concurrently in patients with HNSCC.

Hextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group

Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and physiological levels of glucose. In preclinical studies, its use in shock models was associated with an improvement in outcome compared with alternatives, such as albumin or 6% hetastarch in saline. In a prospective, randomized, two-center study (n = 120), we compared the efficacy and safety of Hextend versus 6% hetastarch in saline (HES) for the treatment of hypovolemia during major surgery. Patients at one center had a blood sample drawn at the beginning and the end of surgery for thromboelastographic (TEG) analysis. Hextend was as effective as HES for the treatment of hypovolemia. Patients received an average of 1596 mL of Hextend: 42% received >20 mL/kg up to a total of 5000 mL. No patient received albumin. Hextend-treated patients required less intraoperative calcium (4 vs 220 mg; P < 0.05). In a subset analysis of patients receiving red blood cell transfusions (n = 56; 47%), Hextend-treated patients had a lower mean estimated blood loss (956 mL less; P = 0.02) and were less likely to receive calcium supplementation (P = 0.04). Patients receiving HES demonstrated significant prolongation of time to onset of clot formation (based on TEG) not seen in the Hextend patients (P < 0.05). No Hextend patient experienced a related serious adverse event, and there was no difference in the total number of adverse events between the two groups. The results of this study demonstrate that Hextend, with its novel buffered, balanced electrolyte formulation, is as effective as 6% hetastarch in saline for the treatment of hypovolemia and may be a safe alternative even when used in volumes up to 5 L.

IMPLICATIONS

Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and a physiological level of glucose. It is as effective as 6% hetastarch in saline for the treatment of hypovolemia but has a more favorable side effects profile in volumes of up to 5 L compared with 6% hetastarch in saline.

Rap1 stabilizes beta-catenin and enhances beta-catenin-dependent transcription and invasion in squamous cell carcinoma of the head and neck

PURPOSE

In head and neck squamous cell carcinoma (HNSCC) cells, Rap1 shuttles between the nucleus and cytoplasm. Prior findings suggested that Rap1 may modulate the beta-catenin-independent Wnt pathway in some settings, but the role of Rap1 in beta-catenin-dependent Wnt signaling remains undefined.

EXPERIMENTAL DESIGN AND RESULTS

We observed that beta-catenin bound to active Rap1 in vitro and Rap1 activated beta-catenin/T-cell factor (TCF)-dependent transcription. Immunofluorescence studies showed that ectopic expression of Rap1 increased nuclear translocation of beta-catenin. Overexpression of active Rap1 facilitated an increase in beta-catenin-mediated transcription that was abrogated by dominant-negative TCF4. Conversely, small interfering RNA-mediated inhibition of endogenous Rap1 expression inhibited beta-catenin/TCF-mediated transcription as well as invasion of HNSCC. Furthermore, inhibition of Rap1 expression downregulated the expression of matrix metalloproteinase 7, a transcriptional target of beta-catenin/TCF. In HNSCC cells stably transfected with beta-catenin or treated with lithium chloride or Wnt3A to stabilize endogenous beta-catenin, inhibition of Rap1 expression led to decreases in the free pool of beta-catenin. Immunohistochemical studies of tissue from HNSCC patients revealed that increased beta-catenin intensity correlated with higher tumor stage. Furthermore, the prognostic effect of active Rap1 on tumor N stage was found to depend on cytosolic beta-catenin expression (P < 0.013). When beta-catenin is high, higher Rap1GTP intensity is associated with more advanced N stage.

CONCLUSIONS

The findings suggest that Rap1 enhances beta-catenin stability and nuclear localization. In addition to indicating that Rap1 has a significant role in regulating beta-catenin and beta-catenin-dependent progression to more advanced N-stage lesions, these data highlight Rap1 as a potential therapeutic target in HNSCC.

Wide excision without radiation for desmoplastic melanoma

BACKGROUND

Adjuvant radiation has been proposed for the treatment of patients with desmoplastic melanoma, who reportedly have local recurrence rates as high as 40-60%. The authors investigated local recurrence rates at a tertiary referral center to determine the success of wide excision alone for patients with desmoplastic melanoma.

METHODS

A review of a prospectively maintained melanoma clinical data base identified 65 patients between March 1997 and March 2004 with pure cutaneous desmoplastic melanoma. Complete surgical, histopathologic, and staging information was collected along with data on outcome, including local, regional, and distant recurrence and survival.

RESULTS

Similar to previous reports, patients with desmoplastic melanoma had a male-to-female ratio of 2 to 1, a mean age of 65.0 years (range, 31-92 yrs), and the majority of their tumors (55%) were located on the head and neck. The mean Breslow depth at diagnosis was 4.21 mm, with 38% of tumors thicker than 4.0 mm. All patients in this series underwent wide excision without radiation therapy. Surgical margins < or = 2 cm were obtained for all trunk and extremity lesions and for 63% of head and neck lesions that measured > 1 mm in depth (63%). Margins of 1-2 cm were obtained for the remaining patients. Among 49 patients who had a minimum of 2 years of follow-up (mean, 3.7 yrs), the local recurrence rate was 4% (2 of 49 patients). Seventy-eight percent of the patients studied remained alive with no evidence of disease.

CONCLUSIONS

Local recurrence rates in the current series were considerably lower than the historically reported rates. This finding suggests that, for patients with desmoplastic melanoma, wide local excision with careful attention to appropriate margins produces excellent local control rates without the need for adjuvant radiation.

Non-attendance at outpatient clinics: is it related to the referral process?

Non-attendance at outpatient clinics is a complex problem and previous studies have concentrated on hospital-related factors. It has been suggested that non-attendance might be related to the referral process, including the selection of patients for referral and the quality of communication between GP and patient. These issues are examined in a study of 1492 patients given first-time appointments at ENT and gastroenterology clinics. Non-attendance rates were 26 and 20% respectively. Non-attendance was not related to the nature, severity or duration of the patients' presenting problems at the time of referral or to their perception of the need for referral. Resolution of symptoms did not appear to be a major reason for non-attendance. Patients were significantly less likely to attend if they had been unable or only partly able to discuss their health problem with their general practitioner. Those who had requested referral were equally likely to default.

The effect of multidirectional mechanical vibration on peripheral circulation of humans

The physiological response of humans to vibration has intrigued researchers for some time, and recently in relation to its potential as a non-pharmacological means to improve peripheral blood flow. A new vibration device [Arapal Technologies Ltd (ATL), Christchurch, New Zealand] for pain relief that purportedly delivers multidirectional vibration waveforms, has been developed. The aim of the study was to quantify the effect of 30 min of mechanical vibration (60 Hz) using two ATL massage devices concurrently upon local peripheral blood flow in healthy humans. On the basis of past work it was expected that acute exposure of the body to the vibratory stimulus would increase local peripheral blood flow. In a randomized cross-over design, mean blood flow (MBF) to the calf was measured using venous occlusion plethysmography before, during 3 min and after 30 min exposure to the vibratory devices or placebo (non-vibratory) devices. Statistical analysis revealed no consistent differences between conditions and considerable individual variability. The MBF increase tended to be higher in the vibration condition than the placebo condition (P=0.16, 95% likely range=-14.4% to 82.2%), the mean increase from resting blood flow at the post-test was 26+/-49% in the vibration condition and 12+/-39% in the placebo condition. It took approximately 22 min of exposure to the vibratory stimulus to elicit peak blood flow (18 min with the placebo). Improvements in local blood flow may be beneficial in the therapeutic alleviation of pain or other symptoms resulting from acute or chronic musculoskeletal injuries.

The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population

Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors' study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.

Classification of TP53 mutations and HPV predict survival in advanced larynx cancer

OBJECTIVES/HYPOTHESIS

Assess tumor suppressor p53 (TP53) functional mutations in the context of other biomarkers in advanced larynx cancer.

STUDY DESIGN

Prospective analysis of pretreatment tumor TP53, human papillomavirus (HPV), Bcl-xL, and cyclin D1 status in stage III and IV larynx cancer patients in a clinical trial.

METHODS

TP53 exons 4 through 9 from 58 tumors were sequenced. Mutations were grouped using three classifications based on their expected function. Each functional group was analyzed for response to induction chemotherapy, time to surgery, survival, HPV status, p16INK4a, Bcl-xl, and cyclin D1 expression.

RESULTS

TP53 mutations were found in 22 of 58 (37.9%) patients with advanced larynx cancer, including missense mutations in 13 of 58 (22.4%) patients, nonsense mutations in four of 58 (6.9%), and deletions in five of 58 (8.6%). High-risk HPV was found in 20 of 52 (38.5%) tumors. A classification based on Evolutionary Action score of p53 (EAp53) distinguished missense mutations with high risk for decreased survival from low-risk mutations (P = 0.0315). A model including this TP53 classification, HPV status, cyclin D1, and Bcl-xL staining significantly predicts survival (P = 0.0017).

CONCLUSION

EAp53 functional classification of TP53 mutants and biomarkers predict survival in advanced larynx cancer.

LEVEL OF EVIDENCE

NA. Laryngoscope, 126:E292-E299, 2016.

Role of membrane type 1-matrix metalloproteinase and gelatinase A in head and neck squamous cell carcinoma invasion in vitro

The proteolytic activity of gelatinase A, a member of the matrix metalloproteinase (MMP) family, is considered to be a critical factor in tumor cell penetration of the extracellular matrix. To express catalytic activity, however, gelatinase A requires activation by another MMP, membrane type 1-matrix metalloproteinase (MT1-MMP). The head and neck squamous cell carcinoma cell line, UM-SCC-1, forms a quiescent monolayer atop collagen unless stimulated with epidermal growth factor (EGF; 3.5 nmol/L), which induces single cell invasion within 48 hours. To determine the role of the MT1-MMP/gelatinase A protease system in an in vitro stromal invasion model, expression vectors for MT1-MMP and gelatinase A were transfected into UM-SCC-1 (SCC-1/MT and SCC-1/gelA, respectively). SCC-1/MT tumor cells were found to invade in the absence of growth factor stimulation. Additionally, these cells displayed shorter onset to invasion and penetrated deeper into the collagen gel with EGF stimulation than did control vector transfectants. SCC-1/gelA cells similarly demonstrated invasion in the absence of EGF and a heightened invasive potential under EGF-stimulated conditions. These results suggest that the MT1-MMP/gelatinase A protease system participates in squamous cell carcinoma invasion of collagenous matrices.

Positron emission tomography-CT prediction of occult nodal metastasis in recurrent laryngeal cancer

BACKGROUND

The purpose of this study was to evaluate the predictive value of positron emission tomography (PET)-CT in identifying occult nodal metastasis in clinically and radiographically N0 patients with recurrent laryngeal cancer undergoing salvage laryngectomy.

METHODS

Retrospective review of 46 clinically and radiographically N0 patients with recurrent laryngeal cancer who underwent a PET-CT examination before salvage laryngectomy with neck dissection from January 1, 2002, to December 31, 2014, was performed.

RESULTS

Two patients (16.7%) had true-positive PET-CT results, whereas 10 patients (83.3%) had false-negative scans, 1 patient (2.9%) had a false-positive result and 33 patients (97.1%) had a true-negative PET-CT. The sensitivity of PET-CT was 16.7% (95% confidence interval [CI], 3.5% to 46.0%) with a specificity of 97.1% (95% CI, 83.8% to 99.9%), positive predictive value (PPV) of 66.7% (95% CI, 20.2% to 94.4%), and negative predictive value (NPV) of 76.7% (95% CI, 62.1% to 87.0%).

CONCLUSION

PET-CT has poor sensitivity and NPV making PET-CT an imperfect predictor of nodal disease in recurrent laryngeal cancer. © 2017 Wiley Periodicals, Inc. Head Neck 39: 980-987, 2017.

Gastrointestinal leiomyosarcoma in an Egyptian fruit bat (Rousettus aegyptiacus)

A 10-year-old female Egyptian fruit bat (Rousettus aegyptiacus) was evaluated for weakness and lethargy. Despite clinical improvement after supportive therapy, the bat was found dead the following day. Gross necropsy identified a mass associated with the duodenal wall and right renal cortex. Microscopically, the duodenal and gastric tunica muscularis and serosa and the right renal cortex were effaced by interlacing bundles of neoplastic spindle cells that were diffusely and strongly positive for vimentin and alpha-smooth muscle actin. The neoplastic cells also had mild to moderate cytoplasmic labeling for laminin and S100 and were negative for c-kit and desmin. On the basis of cell morphology and the immunophenotype, this tumor was diagnosed as a gastrointestinal leiomyosarcoma.