Targeting Nrf2 to treat thyroid cancer

Oxidative stress (OS) is recognized as a contributing factor in the development and progression of thyroid cancer. Nuclear factor erythroid 2-related factor 2 (Nrf2) is a pivotal transcription factor involved in against OS generated by excessive reactive oxygen species (ROS). It governs the expression of a wide array of genes implicated in detoxification and antioxidant pathways. However, studies have demonstrated that the sustained activation of Nrf2 can contribute to tumor progression and drug resistance in cancers. The expression of Nrf2 was notably elevated in papillary thyroid cancer tissues compared to normal tissues, indicating that Nrf2 may play an oncogenic role in the development of papillary thyroid cancer. Nrf2 and its downstream targets are involved in the progression of thyroid cancer by impacting the prognosis and ferroptosis. Furthermore, the inhibition of Nrf2 can increase the sensitivity of target therapy in thyroid cancer. Therefore, Nrf2 appears to be a potential therapeutic target for the treatment of thyroid cancer. This review summarized current data on Nrf2 expression in thyroid cancer, discussed the function of Nrf2 in thyroid cancer, and analyzed various strategies to inhibit Nrf2.

Autophagy regulates anti-angiogenic property of lenvatinib in thyroid cancer

We aimed to explore the role of lenvatinib-mediated autophagy in papillary thyroid cancer (PTC). K1 and BCPAP, were tested for cell viability, proliferation, and apoptosis after treatment with lenvatinib or chloroquine (CQ) or both. The levels of angiogenesis vascular endothelial growth factor A (VEGFA) were measured by ELISA. Transwell and wound-healing assays were performed using endothelial HUVECs cells. The dynamics of microvessels were detected by tubular formation assay. Western blotting was used to determine the expression of LC3-I/II and Atg-7 and alterations in the PI3K/Akt/mTOR and MEK/ERK pathways. In vivo tumor growth assay and immunohistochemical staining (IHC) was also performed. The results showed that lenvatinib inhibited the viability of K1 and BCPAP cells and caused apoptosis. We further showed that lenvatinib also upregulated autophagy levels in thyroid cancer cells in a dose-dependent manner through the PI3K/Akt/mTOR and MEK/ERK pathways. Co-administration of lenvatinib with CQ resulted in a greater decrease of VEGFA in the tumor supernatant than with either lenvatinib or CQ alone. Autophagy inhibition enhanced the cytotoxicity and anti-angiogenic ability of lenvatinib, which was supported by the HUVECs migration, wound healing, and tube formation assays. Inhibiting autophagy chemically or genetically enhanced lenvatinib's cytotoxic effects and anti-angiogenic efficacy in thyroid cancer cells in vitro and in vivo. In conclusion, lenvatinib inhibited cell viability and induced apoptosis and autophagy in human PTC cells. Significantly, the combination of lenvatinib and autophagy inhibition may represent a novel and effective treatment option for PTC, which may be able to overcome drug resistance.

Modified tubeless anesthesia during endoscopy for assessment of head and neck cancers

We evaluated a modified technique of administering anesthesia without a tube and with spontaneous respiration during video-assisted tele-laryngo-tracheo-bronchoendoscopy (TLTBE). The endoscopy was performed as an alternative to rigid ventilatory bronchoscopy during screening for synchronous tumors in the tracheobronchial tree in patients who had head and neck malignancies. Thirty consecutive patients who required diagnostic panendoscopy were selected for this study. During direct-suspension laryngoscopy, anesthesia was delivered by administering intravenous bolus injections of propofol at 0.5 to 2 mg/kg every 5 to 10 minutes. A good view of the larynx, trachea, and main bronchi was obtained with a 50-cm 0° Hopkins telescope, which caused no obstruction of the airway. During laryngoscopy, arterial oxygen saturation levels, pulse rates, and blood pressures were stable in all patients. No apnea was associated with the use of propofol during any procedure, and we observed no intraoperative or postoperative complication in any patient. Video-assisted TLTBE is appropriate for patients with a grade 1 or 2 larynx, good cardiopulmonary function, and no significant airway obstruction. It is a safe and time-saving alternative to rigid ventilatory bronchoscopy for staging primary tumors and for screening for synchronous tumors in the respiratory tract.

Applying Rasch model analysis in the development of the cantonese tone identification test (CANTIT)

OBJECTIVE

Applying Rasch analysis to evaluate the internal structure of a lexical tone perception test known as the Cantonese Tone Identification Test (CANTIT).

DESIGN

A 75-item pool (CANTIT-75) with pictures and sound tracks was developed. Respondents were required to make a four-alternative forced choice on each item. A short version of 30 items (CANTIT-30) was developed based on fit statistics, difficulty estimates, and content evaluation. Internal structure was evaluated by fit statistics and Rasch Factor Analysis (RFA).

STUDY SAMPLE

200 children with normal hearing and 141 children with hearing impairment were recruited.

RESULTS

For CANTIT-75, all infit and 97% of outfit values were < 2.0. RFA revealed 40.1% of total variance was explained by the Rasch measure. The first residual component explained 2.5% of total variance in an eigenvalue of 3.1. For CANTIT-30, all infit and outfit values were < 2.0. The Rasch measure explained 38.8% of total variance, the first residual component explained 3.9% of total variance in an eigenvalue of 1.9.

CONCLUSIONS

The Rasch model provides excellent guidance for the development of short forms. Both CANTIT-75 and CANTIT-30 possess satisfactory internal structure as a construct validity evidence in measuring the lexical tone identification ability of the Cantonese speakers.

Sleep endoscopy with midazolam: sedation level evaluation with bispectral analysis

OBJECTIVE

This study examines subjects' level of consciousness with bispectral analysis in sedation endoscopy of the upper airway.

STUDY DESIGN

A prospective study.

SETTING

University hospital.

SUBJECTS AND METHODS

Bispectral analysis levels recorded in natural sleep of 43 patients with obstructive sleep apnea during an overnight polysomnographic sleep study were directly compared with the levels recorded during midazolam sedation sleep endoscopy in the same subjects. The possible muscle relaxation effect of midazolam was examined via surface chin electrodes. Supine Müller maneuver findings in 50 patients with obstructive sleep apnea were also compared with soft tissue dynamics during midazolam sedation sleep endoscopy.

RESULTS

In our study of the 43 patients with bispectral analysis during natural sleep and midazolam sedation sleep endoscopy, a predominance of bispectral analysis values indicating N1 and N2 sleep was observed during the sedation study. Midazolam failed to achieve deeper levels of sleep with minimal N3 and no convincing rapid eye movement. As N1 and N2 are the stages during which maximal dynamic activities occur, and they make up an average of 70.5% of total sleep time, from 210 sleep studies at our laboratory, the present technique would be ideal as a surgical assessment tool. No muscle relaxation effect could be detected at our protocol dose of midazolam. The supine Müller maneuver findings were significantly different from those observed during sedation sleep.

CONCLUSION

These findings support the value of sleep endoscopy as an efficient and informative technique for the examination of upper airway dynamics relevant to focused surgical planning.

Age sensitivity in the acquisition of lexical tone production: evidence from children with profound congenital hearing impairment after cochlear implantation

OBJECTIVES

This study investigated the effects of implant experience and age at implantation on the Cantonese tone production of children with cochlear implants. The study also examined whether there was a particular age at which children were more responsive to acquiring tones.

METHODS

The study included 45 children who had received unilateral cochlear implants at a mean age of 65.56 months. The subjects were grouped according to their age at cochlear implantation and were assessed annually for 5 years thereafter. A picture-naming task was used to measure their tone production performance.

RESULTS

A simple effect of age at implantation was significant at all testing intervals except at the preoperative data point. Children who were younger than 4 years of age when they received their implants scored significantly higher than did the 2 older groups at various testing intervals. A significant simple effect of implant experience was also found. Progress was most striking in children who received their implants before the age of 4 years.

CONCLUSIONS

For the most effective acquisition of Cantonese lexical tones, children should undergo early cochlear implantation. For children who receive implants before the age of 4 years, benefits are noted in tone production ability in terms of a faster rate of improvement within a shorter period of time.

[Treatment of moderately severe hearing loss with totally implantable hearing aid]

OBJECTIVE

To evaluate the safety and effectiveness of totally implantable hearing aid (Carina) was assessed in adult patients with bilateral moderate to severe hearing loss.

METHODS

Surgical implantations of Carina were performed in three adult patients with bilateral moderate to severe hearing loss. The safety and effectiveness were evaluated in a more than 12 months follow-up by comparison of outcomes of PTA and speech audiometry pre and post-operatively. The daily usage of implants was observed and compared with traditional hearing aids.

RESULTS

The average elevation of unaided threshold elevation on surgical side was 8.3 dB postoperatively. The average functional gain in four speech frequencies of PTA was 35.4 dB HL and the average threshold decrease of speech discrimination was 22.5 dB HL. The subjective scoring of performance of the implants is significantly higher than traditional hearing aid.

CONCLUSIONS

Totally implantable hearing aid (Carina) is an ideal implant to treat moderate to severe hearing loss. Long term follow-up is needed to validate the results.

Tone Perception in Cantonese-Speaking Children with Hearing Aids

Objectives:

In this study we investigated the benefit of using hearing aids for Cantonese tone perception among children with various degrees of hearing impairment.

Methods:

Forty-eight children with moderate to profound hearing loss were investigated. They were required to perform a lexical tone perception test with recorded test stimuli presented at 65 dB in soundproof booths. To allow for comparison, the subjects performed the test under 2 conditions: With their hearing aids turned off (unaided condition) and with them turned on (aided condition).

Results:

The mean tone perception scores for the aided condition were higher than those for the unaided condition across all of the subject groups. Paired sample t-tests showed statistically significant improvement in tone perception in the moderate and severe hearing loss groups (p = .02 and p = .03, respectively). The result obtained from the moderately severe hearing loss group was marginally significant (p = .058). The improvement in tone perception in the profound hearing loss group was insignificant (p = .55).

Conclusions:

The use of a hearing aid is beneficial for Cantonese tone perception in children who have moderate to severe hearing impairment. When a hearing loss is greater than 90 dB, ie, in children who are classified as having profound hearing loss, a hearing aid is not effective in aiding Cantonese tone perception.

The tone production performance of children receiving cochlear implants at different ages

Sixty prelingually deaf children were tested on Cantonese tone production ability at seven time intervals. Results of linear regression showed children in general improved in tone production performance over time. The magnitude of improvement, nevertheless, was different for children implanted at different ages. For children to acquire tone acquisition satisfactory, a critical age of four to receive implant is suggested. Optimally, children should receive their implant before two where they will be able to achieve around 80% accuracy in tone production within 1 yr of implant use. Children received their implant from two to just below 4 yr old achieved high tone production accuracy but needed a longer duration of implant experience. Children who received their implants at the age of 4 yr or older made little, if any, progress in producing tones correctly even after four to 5 yr of implant use.

The combined olfactory test in a Chinese population

OBJECTIVE

To establish an olfactory test in the Hong Kong Chinese population.

STUDY DESIGN

Prospective analysis of the results of a combined olfactory test (COT) for patients with olfactory dysfunction and for normal subjects attending a secondary and tertiary ear, nose and throat centre.

METHOD

Our COT was based on and modified from the Connecticut Chemosensory Research Centre test. It consisted of an odour identification test involving nine substances and a threshold test using a series of threefold dilutions of 1-butanol. From September 1998 to June 2002, 188 Hong Kong Chinese patients with olfactory dysfunction and subjects with normal olfaction were prospectively recruited. The subjects were categorized into normal, hyposmic and anosmic groups. The olfactory function of the main group of subjects (n = 153) was assessed with the COT by a blinded observer and also quantified with a visual analogue scale; the results were analysed to validate the discriminative ability of the COT. Another subgroup of subjects (n = 35) was tested with the COT twice with a two-week interval to evaluate test-retest reliability.

RESULTS

There were 42 normal, 68 hyposmic and 43 anosmic subjects within the main group (total n = 153). The identification scores, threshold scores and combined olfactory scores were statistically significantly different between the anosmic, hyposmic and normal groups of subjects (p < 0.001). The combined olfactory score correlated with the visual analogue score and the correlation coefficient was 0.56 (p < 0.01). The mean time spent on each COT was 8.6 minutes (standard deviation = 3.4 minutes). The test-retest reliability of the COT was satisfactory, with a one-way model intraclass correlation coefficient of 0.87 (n = 35).

CONCLUSION

The satisfactory discriminative ability and test-retest reliability of the COT have been demonstrated in this study. The COT is a feasible method for assessing sense of smell in the Hong Kong Chinese population.

Array-based comparative genomic hybridization analysis identified cyclin D1 as a target oncogene at 11q13.3 in nasopharyngeal carcinoma

Nasopharyngeal carcinoma is highly prevalent in Southern China and Southeast Asia. To unveil the molecular basis of this endemic disease, high-resolution comparative genomic hybridization arrays were used for systematic investigation of genomic abnormalities in 26 nasopharyngeal carcinoma samples. A comprehensive picture of genetic lesions associated with tumorigenesis of nasopharyngeal carcinoma was generated. Consistent chromosomal gains were frequently found on 1q, 3q, 8q, 11q, 12p, and 12q. High incidences of nonrandom losses were identified on chromosomes 3p, 9p, 11q, 14q, and 16q. In addition to previously characterized regions, we have identified several novel minimal regions of gains, including 3q27.3-28, 8q21-24, 11q13.1-13.3, and 12q13, which may harbor candidate nasopharyngeal carcinoma-associated oncogenes. In this study, gain of 11q13.1-13.3 was the most frequently detected chromosomal aberration and a 5.3-Mb amplicon was delineated at this region. Within this 11q13 amplicon, concordant amplification and overexpression of cyclin D1 (CCND1) oncogene was found in nasopharyngeal carcinoma cell lines, xenografts, and primary tumors. Knockdown of cyclin D1 by small interfering RNA in nasopharyngeal carcinoma cell lines led to significant decrease of cell proliferation. The findings suggest that cyclin D1 is a target oncogene at 11q13 in nasopharyngeal carcinoma and its activation plays a significant role in nasopharyngeal carcinoma tumorigenesis.

In vivo real-time diagnosis of nasopharyngeal carcinoma in situ by contact rhinoscopy

BACKGROUND

Nasopharyngeal dysplasia or nasopharyngeal carcinoma in situ (NPCIS) lesions have rarely been reported. Timely diagnosis of the preinvasive lesion may improve prognosis. Contact endoscopy has been documented to accurately differentiate normal cells of the nasopharynx from malignant cells and allows a real-time diagnosis of primary and recurrent nasopharyngeal carcinoma (NPC) in a clinical setting. However, the role of contact endoscopy in the diagnosis of NPCIS is unknown.

METHODS

The superficial cells of the nasopharynx in a patient with NPCIS were examined in vivo under local anaesthesia by use of a contact rhinoscope. The contact endoscopic findings were correlated with the histologic findings of the biopsy.

RESULTS

The atypical cells of the lesion were magnified and visualized under contact endoscopy. Histopathologic analysis of the biopsied tissue confirmed the presence of NPCIS staining positively for Epstein-Barr virus (EBV)-encoded RNA (EBER). No cell-free EBV DNA was detected in the sera of the patient.

CONCLUSIONS

Contact endoscopy can accurately identify the atypical cells of a tiny preinvasive lesion in the nasopharynx in a clinical setting, which may not be evident in routine imaging examination.

Spoken Word Recognition in Children With Cochlear Implants: A Five-Year Study on Speakers of a Tonal Language

OBJECTIVES

To study the effects of age at implantation and duration of implant use on the performance of spoken word recognition of pediatric cochlear implantees in a tonal language setting over a period of 5 years.

DESIGN

Sixty-four children, given implants between the ages 1:01 and 14:09 (years:months), were divided into three age groups. They were tested on open-set word recognition ability at seven time intervals from before surgery to 5 years after surgery. Analyses of variance with repeated measurements were used to examine the effect of their age at implantation and the duration of implant use.

RESULTS

Duration of implant experience was significant in spoken word recognition across the three age groups (p < 0.01). Children given implants below the age of 3 years caught up with the performance of the older children at 12 months after implantation. The difference in score reached statistical significance at 2 and at 3 years after surgery (p = 0.03, p = 0.00).

CONCLUSIONS

The performance of Cantonese-speaking children was similar to that of English-speaking children in that better outcomes were associated with longer implant experience as well as when implantation occurred at a younger age. The children implanted before the age of 3 and who had an implant experience of more than 2 years outperformed the children who were given implants after the age of 6 and also sustained these higher scores throughout 5 years of postimplant testing.

Esophageal perforation and neck abscess from ingested foreign bodies: treatment and outcomes

Over a 6.5-year period, 5,848 patients who had ingested a foreign body were admitted to the ENT unit at the Prince of Wales Hospital in Hong Kong. Potentially serious complications developed in 12 patients (0.21%). Eight patients had an esophageal perforation; three had clinical evidence that their injury had been caused by the foreign body itself and five were deemed to have been injured iatrogenically during esophagoscopy. One of the latter group eventually developed an abscess. Four patients originally presented with an abscess. Three of these patients and the patient who later developed an abscess were treated with neck exploration and surgical drainage. One of the patients who initially presented with an abscess refused surgical treatment and was treated conservatively. Conservative treatment was also initiated for all patients who had a perforation. Patients on the conservative regimen were administered intravenous broad-spectrum antibiotics and were not permitted to take any food or liquids by mouth; they received their nutrition via either enteral feeding or total parenteral nutrition. Conservative treatment was successful in all seven patients with a perforation and no abscess and in the one patient with an abscess who refused surgery. Moreover, all four patients who underwent surgical treatment recovered. Our experience demonstrates that esophageal perforation related to an ingested foreign body can be safely treated by conservative means if the diagnosis is made before significant contamination occurs. Conversely, abscesses (cervical or mediastinal) related to an ingested foreign body should be explored and surgically drained.

Modified tubeless anesthesia during endoscopy for assessment of head and neck cancers

We evaluated a modified technique of administering anesthesia without a tube and with spontaneous respiration during video-assisted tele-laryngo-tracheo-broncho-endoscopy (TLTBE). The endoscopy was performed as an alternative to rigid ventilatory bronchoscopy during screening for synchronous tumors in the tracheobronchial tree in patients who had head and neck malignancies. Thirty consecutive patients who required diagnostic panendoscopy were selected for this study. During direct-suspension laryngoscopy, anesthesia was delivered by administering intravenous bolus injections of propofol at 0.5 to 2 mg/kg every 5 to 10 minutes. A good view of the larynx, trachea, and main bronchi was obtained with a 50-cm 0 degree telescope, which caused no obstruction of the airway. During laryngoscopy, arterial oxygen saturation levels, pulse rates, and blood pressures were stable in all patients. No apnea was associated with the use of propofol during any procedure, and we observed no intraoperative or postoperative complication in any patient. Video-assisted TLTBE is appropriate for patients with a grade 1 or 2 larynx, good cardiopulmonary function, and no significant airway obstruction. It is a safe and time-saving alternative to rigid ventilatory bronchoscopy for staging primary tumors and for screening for synchronous tumors in the respiratory tract.

Tone perception ability of Cantonese-speaking children

Studies have shown that while children acquire all Cantonese tones by age two, they are not able to label them reliably until approximately age 10. One possible explanation for the large age discrepancy may be the different methodologies used. This study aimed to (1) investigate a new research design for the collection of reliable tone perception data from young children; (2) compare lexical and nonlexical items for testing tone perception ability; and (3) identify the relative ease of perceiving the three basic tone contrasts in Cantonese, that is, high level/high rising (T1/T2), high level/low falling (T1/T4), and, high rising/low falling tones (T2/T4). The three tone pairs were presented to 31 children in the form of word and nonword stimuli. It was found that the research design could be used to assess the tone perception knowledge of children as young as 2;09. Significant differences were found between word and nonword stimuli and also in the identification of the T2/T4 contrast in comparison with the other two pairs. Children's overall tone perception abilities are discussed in detail with reference to the role of lexical knowledge and the potential for tone perception confusions arising from differences in fundamental frequencies for tone onset and offset.

Nasopharyngeal carcinoma in situ (NPCIS)--pathologic and clinical perspectives

BACKGROUND

Dysplasia or carcinoma in situ lesions (NPCIS) of the nasopharynx have rarely been reported. The prevalence, biologic behavior, and the transformation period of the pure preinvasive lesions have not been fully explained.

METHODS

All cases of NPCIS were retrospectively reviewed during the period between 1990 and 2000. The clinical features of all cases were studied. The biopsy samples were examined using light microscopy and in situ hybridization (ISH) for EBV-encoded RNA (EBER). The sera taken before and after the transformation were analyzed for anti-viral capsid antigen (VCA) EBV titers and circulating cell-free EBV DNA concentration.

RESULTS

Three cases of NPCIS were identified. Two of the three cases subsequently developed into invasive NPC after initial presentation. The interval of transformation varied from 40 to 48 months. In all three cases, the specimens showed abnormal findings on light microscopy and positive staining for EBER. Elevated anti-VCA titers were present in two of the preinvasive lesions. No cell-free EBV DNA was detected in the sera of these patients during the preinvasive phase of the disease.

CONCLUSIONS

Preinvasive NPC is a rare but distinct entity. Its transformation period can be as long as 4 to 5 years. Elevated anti-VCA titers, in the presence of abnormal cells on light microscopy, should alert the pathologist to perform ISH EBER studies to diagnose this rare condition.

In vivo diagnosis of persistent and recurrent nasopharyngeal carcinoma by contact endoscopy

OBJECTIVE

To evaluate the potential use of contact endoscopy for the diagnosis of persistent and recurrent nasopharyngeal carcinoma in postirradiated patients.

STUDY DESIGN

Prospective study to examine 64 consecutive patients who have been irradiated for nasopharyngeal carcinoma in a clinic setting using contact rhinoscopes (Karl Storz, Tuttlingen, Germany [7215 AA, 0 degrees, and 7215 BA, 30 degrees; 23 cm long. 4 mm in diameter]).

METHODS

The superficial cells of the posterior walls of the nasopharynx were stained with 1% methylene blue and examined with contact rhinoscopes with the patient under local anesthesia at high magnifications (x60 and x150). Biopsy of the areas under examination was performed. The contact endoscopic images were analyzed and correlated with the corresponding histological sections of the biopsy tissues.

RESULTS

Contact endoscopy was performed in 64 patients (54 men; mean age, 42 y) with the use of local anesthesia. Four patterns of contact endoscopic findings were identified: squamous metaplasia (43 cases), postirradiation atypia (10), granulation tissue (6), and malignancy (5). In the last group, the nasopharynx appeared normal in two patients (40%). The findings of contact endoscopy correlated well with the histological findings (kappa reliability coefficient = 0.847; P <.001; diagnostic accuracy, 92.1%). For prediction of persistent and recurrent disease, the sensitivity and specificity of endoscopic findings were both 100%.

CONCLUSION

Contact endoscopy is an accurate, reliable office-based procedure that allows for in vivo and in situ diagnosis of persistent and recurrent nasopharyngeal carcinoma in postirradiated patients.