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Kennedy MM, Salepci E, Myers C, Strome M, Lott DG. A Heterotopic Mouse Model for Studying Laryngeal Transplantation. J Vis Exp 2023. [PMID: 36715410 DOI: 10.3791/63619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Laryngeal heterotopic transplantation, although a technically challenging procedure, offers more scientific analysis and cost benefits compared to other animal models. Although first described by Shipchandler et al. in 2009, this technique is not widely used, possibly due to the difficulties in learning the microsurgical technique and time required to master it. This paper describes the surgical steps in detail, as well as potential pitfalls to avoid, in order to encourage effective use of this technique. In this model, the bilateral carotid arteries of the donor larynx are anastomosed to the recipient carotid artery and external jugular vein, allowing for blood flow through the graft. Blood flow can be confirmed intraoperatively by the visualization of blood filling in the graft bilateral carotid arteries, reddening of the thyroid glands of the graft, and bleeding from micro vessels in the graft. The crucial elements for success include delicate preservation of the graft vessels, making the correct size arteriotomy and venotomy, and using the appropriate number of sutures on the arterial-arterial and arterial-venous anastomoses to secure vessels without leakage and prevent occlusion. Anyone can become proficient in this model with sufficient training and perform the procedure in approximately 3 h. If performed successfully, this model allows for immunologic studies to be performed with ease and at low cost.
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Affiliation(s)
- Maeve M Kennedy
- Head and Neck Regenerative Medicine Laboratory, Center for Regenerative Medicine, Mayo Clinic Arizona
| | - Egehan Salepci
- Head and Neck Regenerative Medicine Laboratory, Center for Regenerative Medicine, Mayo Clinic Arizona; Department of Otorhinolaryngology, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital
| | - Cheryl Myers
- Head and Neck Regenerative Medicine Laboratory, Center for Regenerative Medicine, Mayo Clinic Arizona
| | - Marshall Strome
- Department of Otolaryngology, Vanderbilt University; Cleveland Clinic Head and Neck Institute
| | - David G Lott
- Head and Neck Regenerative Medicine Laboratory, Center for Regenerative Medicine, Mayo Clinic Arizona; Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, Mayo Clinic Arizona;
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Kohli N, Blitzer A, Jahn A, Cho YJ, Budrewicz J, Enos K, Strome M. Safety and Feasibility of a Novel Esophageal Balloon for Circumferential Cytologic Sampling. Ann Otol Rhinol Laryngol 2020; 130:585-590. [PMID: 33412926 DOI: 10.1177/0003489420964831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES A prior publication introduced the Strome-Blitzer balloon's ability to obtain circumferential esophageal cytologic sampling. This GLP study was requisite for FDA approval to determine if equivalent cell capture and cellularity was observed with the balloon compared to surface sampling brushes and to determine the balloon's usability for naive otolaryngologists. METHODS Three naïve users tested the Hobbs brush and Strome-Blitzer balloon on 4 Yorkshire swine. Four anatomical sites were sampled, beginning distally and ending proximally. In 2 animals, the balloon was used first distally and in the remaining 2, 4 new Hobbs brushes were used distally first. Moving proximally, the balloon and brushes were sequentially alternated. In follow-the-leader fashion, the balloon was introduced trans-orally followed by an endoscope to the desired site. The balloon was inflated exposing the abrasive strips to contact the esophageal mucosa. Moving the balloon 1 to 2 cm superiorly and inferiorly effected circumferential cell capture. The balloon was collapsed and removed, preserving the cellularity. The Hobbs brush was passed through the scope's channel. Four brushes, 1 per quadrant, obtained the samples at an anatomical site. The balloon was rated as pass/fail on the following: delivery, kinking, usability, and malfunction. A blinded veterinary pathologist evaluated the cytology. RESULTS There was no device malfunction, mucosal trauma, or difficulty with device use. Balloon cytologic samples were comparable in cellularity and quality to the brush. CONCLUSION A single balloon sampling was comparable to 4 brushes in capturing diagnostically relevant cellular volumes and architecture. Naïve users easily performed the procedures after reading the guidelines. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Nikita Kohli
- New York Center for Voice and Swallowing Disorders, New York, New York, USA
| | - Andrew Blitzer
- New York Center for Voice and Swallowing Disorders, New York, New York, USA.,Department of Otolaryngology Head & Neck Surgery, Columbia University College of Physicians & Surgeons, New York, New York, USA.,Aero-Di-Namics, New York, New York, USA
| | - Anthony Jahn
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Youngnan Jenny Cho
- Department of Otolaryngology Head & Neck Surgery, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | | | - Karyn Enos
- CBSET, Inc, Lexington, Massachusetts, USA
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Kossatz S, Pirovano G, Demétrio De Souza França P, Strome AL, Sunny SP, Zanoni DK, Mauguen A, Carney B, Brand C, Shah V, Ramanajinappa RD, Hedne N, Birur P, Sihag S, Ghossein RA, Gönen M, Strome M, Suresh A, Molena D, Ganly I, Kuriakose MA, Patel SG, Reiner T. Validation of the use of a fluorescent PARP1 inhibitor for the detection of oral, oropharyngeal and oesophageal epithelial cancers. Nat Biomed Eng 2020; 4:272-285. [PMID: 32165735 PMCID: PMC7136849 DOI: 10.1038/s41551-020-0526-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/06/2020] [Indexed: 11/09/2022]
Abstract
For oral, oropharyngeal and oesophageal cancer, the early detection of tumours and of residual tumour after surgery are prognostic factors of recurrence rates and patient survival. Here, we report the validation, in animal models and a human, of the use of a previously described fluorescently labelled small-molecule inhibitor of the DNA repair enzyme poly(ADP-ribose) polymerase 1 (PARP1) for the detection of cancers of the oral cavity, pharynx and oesophagus. We show that the fluorescent contrast agent can be used to quantify the expression levels of PARP1 and to detect oral, oropharyngeal and oesophageal tumours in mice, pigs and fresh human biospecimens when delivered topically or intravenously. The fluorescent PARP1 inhibitor can also detect oral carcinoma in a patient when applied as a mouthwash, and discriminate between fresh biopsied samples of the oral tumour and the surgical resection margin with more than 95% sensitivity and specificity. The PARP1 inhibitor could serve as the basis of a rapid and sensitive assay for the early detection and for the surgical-margin assessment of epithelial cancers of the upper intestinal tract.
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Affiliation(s)
- Susanne Kossatz
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Nuclear Medicine, University Hospital Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Giacomo Pirovano
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Arianna L Strome
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sumsum P Sunny
- Integrated Head and Neck Oncology Research Program, Mazumdar Shaw Medical Foundation, Narayana Health, Bengaluru, India
- Head and Neck Oncology, Mazumdar Shaw Medical Center, Narayana Health, Bengaluru, India
| | | | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brandon Carney
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Brand
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Summit Biomedical Imaging, New York, NY, USA
| | - Veer Shah
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ravindra D Ramanajinappa
- Integrated Head and Neck Oncology Research Program, Mazumdar Shaw Medical Foundation, Narayana Health, Bengaluru, India
| | - Naveen Hedne
- Head and Neck Oncology, Mazumdar Shaw Medical Center, Narayana Health, Bengaluru, India
| | - Praveen Birur
- Integrated Head and Neck Oncology Research Program, Mazumdar Shaw Medical Foundation, Narayana Health, Bengaluru, India
- Department of Oral Medicine and Radiology, KLES Institute of Dental Sciences, Bangalore, India
| | - Smita Sihag
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald A Ghossein
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Amritha Suresh
- Integrated Head and Neck Oncology Research Program, Mazumdar Shaw Medical Foundation, Narayana Health, Bengaluru, India
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Moni A Kuriakose
- Integrated Head and Neck Oncology Research Program, Mazumdar Shaw Medical Foundation, Narayana Health, Bengaluru, India
- Cochin Cancer Research Center, Kochi, India
| | - Snehal G Patel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thomas Reiner
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA.
- Chemical Biology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Abstract
Vasomotor rhinitis has been treated with multiple regimens with varied success. We have used intranasal cryosurgery to freeze the postganglionic parasympathetics as a definitive therapeutic procedure. A total of 154 cryoneurolysis procedures were performed in a 7-year period. Complete data was evaluable for 144 patients. Concomitant outfracture and cautery of their inferior turbinates was performed for visual access. Initially, 93% of patients treated had significant improvement in their nasal obstruction. Surveys were sent to all patients, with 70% responding. Of the responders, 86% would recommend the procedure to others. On a scale of 1–10, nasal breathing scores improved from a mean of 2.9 preoperatively to 8.0 at present. Data from this patient cohort revealed cryoneurolysis to be an effective alternative to vidian neurectomy and turbinectomy, with a high rate of patient satisfaction and a low recurrence rate.
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Affiliation(s)
- Harsha Girdhar-Gopal
- Joint Center for Otolaryngology, Beth Israel Hospital and Brigham & Women's Hospital, Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
| | - Lee Okurowski
- Joint Center for Otolaryngology, Beth Israel Hospital and Brigham & Women's Hospital, Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
| | - Marshall Strome
- Joint Center for Otolaryngology, Beth Israel Hospital and Brigham & Women's Hospital, Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
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Lerner MZ, Tricoli M, Strome M. Abrasion and blunt tissue trauma study of a novel flexible robotic system in the porcine model. Am J Otolaryngol 2017; 38:447-451. [PMID: 28413075 DOI: 10.1016/j.amjoto.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/09/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to determine if a flexible robotic system caused increased tissue reaction when accessing the oropharynx and hypopharynx compared to intubation controls in only 2 scenarios: high speed tissue impact and multiple unit insertions and retractions. The data obtained were submitted as part of the entirety of information submitted for FDA approval. METHODS This study consisted of 5 groups of Yorkshire pigs (2 animals per group). On Day 0, all animals were intubated. For group 1 (control), a second endotracheal tube was advanced to just above the vocal cords. In abrasion groups 2 and 3, the flexible robotic system was advanced against the oropharyngeal and hypopharyngeal tissues, respectively. In blunt trauma groups 4 and 5, the flexible robotic system was advanced at maximum speed (22mm/s) to collide with oropharyngeal and hypopharyngeal tissues, respectively. Pre- and post-procedure endoscopic assessments of tissue reaction were performed daily for 4 days. An independent reviewer graded tissue reaction using a 0-3 point scale. RESULTS Tissue reaction scores at each observation time point for all test groups were less than or equal to control scores except for one instance of moderate scoring (2 out of 3) on Day 2 for an animal in the blunt trauma group where reaction was likely intubation-related rather than device impact related. Otherwise, all flexible robotic system-treated animal scores were less than 1 by Day 4. CONCLUSIONS In this limited study, the flexrobotic system afforded surgical access to the oropharynx and hypopharynx without an increased level of abrasion or tissue trauma when compared to intubation alone.
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Abstract
Objectives Laryngeal transplantation research has been studied in various animal models. For in-depth, immunology-based transplantation research, however, a thoroughly studied animal model must exist. The purpose of this study was to develop a reliable surgical technique in mice to serve as a model for further study of laryngeal transplantation. Methods Heterotopic laryngeal transplantation was attempted in 15 immunocompetent mice by use of modifications of previously described techniques established in rats. Results Various microvascular techniques were used that led to 8 successful transplants (of 15) with patent vascularity at the time of sacrifice. The first 7 attempts at transplantation were unsuccessful because of technical difficulties related to vessel size, soft tissue traumatic injury, and venous congestion. Subsequently, 8 transplantation procedures were successfully performed after modifications of the surgical technique. Conclusions This pilot study describes the reproducible surgical techniques performed in using mice for studying laryngeal transplantation. Mice are cost-effective and immunologically well studied, and are thus ideal for further laryngeal transplantation research.
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Affiliation(s)
| | - David G. Lott
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Olivia Dan
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
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Lerner MZ, Mor N, Paek H, Blitzer A, Strome M. Metformin Prevents the Progression of Dysplastic Mucosa of the Head and Neck to Carcinoma in Nondiabetic Patients. Ann Otol Rhinol Laryngol 2017; 126:340-343. [PMID: 28103701 DOI: 10.1177/0003489416688478] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Metformin is an oral anti-hyperglycemic agent used to treat type 2 diabetes mellitus (DM). In vitro and animal models have shown that metformin can prevent the progression of oral lesions to carcinoma; however, there is conflicting data in the clinical literature regarding risk reduction for malignancy in head and neck cancer (HNC). STUDY DESIGN Case series. METHODS We present 3 cases in which adjuvant metformin therapy was used to treat recurrent and multifocal dysplastic lesions in previously treated nondiabetic HNC patients. RESULTS Patients included 1 with a history of oral cavity squamous cell carcinoma (SCC) and 2 with a history of laryngeal SCC. Follow-up time ranged between 3 and 33 months. All 3 patients showed complete or partial regression of the remaining mucosal lesions and did not require any additional surgeries. CONCLUSION We present 3 cases of nondiabetic HNC patients with field cancerization who showed a good response to adjuvant therapy with metformin. The nondiabetic population is not affected by confounding factors such as increased risk of malignancy and decreased overall survival that is itself associated with abnormal glucose metabolism and is therefore an excellent cohort in which to study the use of adjuvant metformin therapy in HNC patients.
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Affiliation(s)
- Michael Zvi Lerner
- 1 Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Niv Mor
- 2 Maimonides Medical Center, Voice and Swallowing Disorders, Division of Otolaryngology-Head and Neck Surgery, Brooklyn, New York, USA
| | - Hyung Paek
- 3 Yale New Haven Health System, New Haven, Connecticut, USA
| | - Andrew Blitzer
- 4 New York Center for Voice and Swallowing Disorders, New York, New York, USA
| | - Marshall Strome
- 4 New York Center for Voice and Swallowing Disorders, New York, New York, USA
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Patel AA, Strome M, Blitzer A. Directed balloon cytology of the esophagus: A novel device for obtaining circumferential cytologic sampling. Laryngoscope 2017; 127:1032-1035. [PMID: 28092117 DOI: 10.1002/lary.26472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/20/2016] [Accepted: 11/22/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Current methods of obtaining esophageal cytology include brush biopsy and blind balloon sampling, among others. These methods can be time-consuming if performed in accordance with acknowledged standards. Further, exact site localization can prove to be difficult. We describe a novel device for esophageal sampling using an esophageal balloon with debriding strips contained within the pleats of the balloon. Inflation brings the latter in contact with the surface to be sampled. Cell capture was compared with the commonly used brush technique in a pig model. METHODS Separate balloon and standard brush cytology samples were collected from a pig model. Smear and cell pellet preparations were compared regarding cell density and total volume. RESULTS Adequate samples were obtained with both the brush and balloon. On the cell smear preparations, the cell density was greater when obtained with balloon sampling. Further, the cell pellet volume was significantly greater with the latter as well. The intact morphology of individual rafts of squamous epithelial cells also was comparable between the two methods. In addition, the balloon provided precise mapping of the cytology sites in contrast to the standard brush technique. CONCLUSION We present an innovative new balloon technology for esophageal sampling, which demonstrated a decreased sampling time interval, precise mapping, and increased cellular volume when compared to a commonly used brush technique. LEVEL OF EVIDENCE NA. Laryngoscope, 127:1032-1035, 2017.
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Affiliation(s)
- Amit A Patel
- Head and Neck Surgical Group, New York, New York, U.S.A
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Friedman AD, Dan O, Drazba JA, Lorenz RR, Strome M. Quantitative Analysis of OX62-Positive Dendritic Cell Distribution in the Rat Laryngeal Complex. Ann Otol Rhinol Laryngol 2016; 116:449-56. [PMID: 17672248 DOI: 10.1177/000348940711600610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Dendritic cells (DCs) are key instigators of rejection after transplantation. Their distribution has not been systematically characterized in all locations of the larynx and its surrounding tissues. Methods: Rat larynges were stained with monoclonal antibodies identifying DCs. These cells were then enumerated by a new combination of techniques including immunofluorescence, confocal microscopy, and imaging software. Results: The vast majority of DCs were located in the epithelium and subepithelium of the airway; the mean DC density ranged from 9 cells per square millimeter (0.2% of cells) to 645 cells per square millimeter (10.3% of cells). Their density in the epithelium was 3 to 11 times higher than that in the subepithelium. Non-airway sites (thyroid, parathyroid, muscle, fat) had mean DC densities varying from 3 cells per square millimeter (0.2%) to 57 cells per square millimeter (0.8%). No DCs were detected in cartilage. Conclusions: Dendritic cells are concentrated in the laryngotracheal epithelium and subepithelium and represent a much smaller proportion in the other sites studied. A baseline for laryngeal DC population studies has been established, and a computerized model for consistent quantitation using confocal microscopy has been developed. This unique method will serve as a foundation for investigating DC trafficking after rat laryngeal transplantation.
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Abstract
OBJECTIVE: To study functional outcomes following concurrent chemoradiotherapy of head and neck cancer. METHODS: A retrospective chart review assessed diet, feeding tube use, and tracheotomy pretreatment and 3, 6, 12, and 24 months posttreatment. RESULTS: Of 196 patients who underwent chemoradiotherapy between 1990 and 2002, 148 (76%) required feeding tubes immediately posttreatment; 150 (77%) required nutritional support at 3 months. By 12 months, 92% were tube-free and 83% resumed near-normal diet. Of 17 patients (9%) with tracheotomy posttreatment, 71% were decannulated by 6 months. Stage IV disease strongly predicted prolonged feeding tube use and slow recovery of diet; age ≥60 also predicted slow recovery. Primary site, gender, and radiotherapy schedule did not predict functional recovery after adjusting for stage and age. CONCLUSION: Few patients required tracheotomy before or during chemoradiotherapy. Many patients required feeding tubes and nutritional support for several months following therapy, but most were tube-free and eating near-normal diets within 1 year. EBM rating: C.
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Affiliation(s)
- Lee M Akst
- Department of Otolaryngology and Communicative Disorders, The Cleveland Clinic Foundation, Ohio 44195, USA.
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11
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Abstract
In 1998, the first successful total laryngeal transplant was performed. Outstanding voice quality and swallowing function were achieved, and over the subsequent 14 years, much was learned about tolerance of a transplanted larynx. After approximately a decade, a slowly progressive, chronic rejection process gradually rendered the organ nonfunctional, and the patient and his providers deemed him appropriate for explantation. This is a report of the clinical indications and outcome surrounding the explantation of the first successful total laryngeal transplant.
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Affiliation(s)
- Robert R Lorenz
- Department of Otolaryngology Head & Neck Surgery, Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Lorenz RR, Strome M. Total Laryngeal Transplant Explanted in 2012: 14 Years of Lessons Learned. Otolaryngol Head Neck Surg 2013. [DOI: 10.1177/0194599813495815a169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: In 1998, the first successful total laryngeal transplant was performed at the Cleveland Clinic. The patient was a 40 year-old-man who had suffered an MVA, which left him aphonic. Not only was his larynx completely replaced with a vascularized graft, but also his pharynx, thyroid, parathyroids, and a portion of his trachea. Over the subsequent 14 years, much was learned about tolerance of a transplanted laryngeal complex, marking this surgery as the longest surviving maiden transplanted organ system when immunosuppression was applied. Methods: Outstanding voice quality and swallowing function were achieved, although volitional vocal cord movement was not attempted, and therefore the patient remained stoma dependent for breathing. The scientific advancement of understanding around laryngeal transplantation was concurrently conducted in the laboratory via animal models, which translated into gradual reduction in the level of immunosuppression for the patient without acute rejection. Results: After approximately a decade, a slowly progressive, chronic rejection process gradually rendered the organ non-functional, and the patient and his providers deemed him appropriate for explantation with free-flap reconstruction and tracheoesophageal puncture voice restoration. Pre-operative functional studies showed a reversion back to his original thyroidal tissue as the source of his circulating thyroid hormone. Post-explantation histologic studies demonstrated loss of tissue cellularity and organ architecture. Conclusions: On routine explantation follow-up, the patient was found to have an asymptomatic early stage, human papillomavirus-related oropharyngeal neoplasm that was successfully treated with surgical resection alone. Voice results will be demonstrated over the patient’s 14 year experience, as well as his own perspective on this landmark experience.
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Lott DG, Russell JO, Khariwala SS, Dan O, Strome M. Ten-Month Laryngeal Allograft Survival with Use of Pulsed Everolimus and Anti—αβ T-Cell Receptor Antibody Immunosuppression. Ann Otol Rhinol Laryngol 2011; 120:131-6. [DOI: 10.1177/000348941112000210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: The risks of daily immunosuppression limit the use of laryngeal transplantation as a reconstructive option. Pulsed immunosuppressive dosing can lessen these risks. The study objective was to develop a long-term pulsing regimen that minimizes exposure to immunosuppressive agents. Methods: Rat laryngeal transplantation was performed. Everolimus (1 mg/kg per day) and anti–αβ T-cell receptor (TCR) antibodies (250 μg) were given for 7 days beginning 1 day before transplantation and for 5 days beginning on day 90 after transplantation. On day 180, group 1 (n = 5) received the initial regimen for 3 days, and group 2 (n = 5) received everolimus (1 mg/kg per day) until euthanization, which occurred when parathyroid hormone (PTH) levels dropped to less than 11 pg/mL or at 300 days. Results: Four of the 5 rats in group 1 had normal PTH levels at 300 days. The PTH level for 1 rat was less than 11 pg/mL at 270 days. In group 2, none of the 5 rats had normal PTH levels at 300 days. Two had PTH levels below 11 pg/mL at 270 days, and 3 had PTH levels below 11 pg/mL at 300 days. The allografts that survived beyond 300 days had an essentially normal histologic appearance. Conclusions: Pulsed immunosuppression prevented allograft rejection for 10 months and was more effective than daily everolimus. Short-term perioperative therapy followed by pulsed, tapered dosing is a viable alternative to traditional regimens and may decrease associated risks.
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Strome M, Lott DG. Anti-αβ-T-cell receptor antibodies in the setting of laryngeal transplantation. Immunotherapy 2010; 2:835-45. [PMID: 21091115 DOI: 10.2217/imt.10.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Inhibiting T-cell activation is critically important to the induction of transplantation tolerance. Monoclonal antibodies directed against the αβ-T-cell receptor have been shown to cause selective immunodepletion of this T-cell population and can provide long-term allograft acceptance. This article discusses the role of this promising immunosuppressive agent in scientific research and clinical utilization. Specifically, the article focuses on its efficacy and mechanism of tolerance induction in solid tissue and composite tissue allograft transplantation with a particular focus on laryngeal transplantation.
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Ferlito A, Robbins KT, Shah JP, Medina JE, Silver CE, Al-Tamimi S, Fagan JJ, Paleri V, Takes RP, Bradford CR, Devaney KO, Stoeckli SJ, Weber RS, Bradley PJ, Suárez C, Leemans CR, Coskun HH, Pitman KT, Shaha AR, de Bree R, Hartl DM, Haigentz M, Rodrigo JP, Hamoir M, Khafif A, Langendijk JA, Owen RP, Sanabria A, Strojan P, Vander Poorten V, Werner JA, Bień S, Woolgar JA, Zbären P, Betka J, Folz BJ, Genden EM, Talmi YP, Strome M, González Botas JH, Olofsson J, Kowalski LP, Holmes JD, Hisa Y, Rinaldo A. Proposal for a rational classification of neck dissections. Head Neck 2010; 33:445-50. [PMID: 21319256 DOI: 10.1002/hed.21614] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2010] [Indexed: 11/10/2022] Open
Affiliation(s)
- Alfio Ferlito
- Department of Surgical Sciences, ENT Clinic, University of Udine, Udine, Italy.
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Lott DG, Dan O, Lu L, Strome M. Decoy NF-kappaB fortified immature dendritic cells maintain laryngeal allograft integrity and provide enhancement of regulatory T cells. Laryngoscope 2010; 120:44-52. [PMID: 19877191 DOI: 10.1002/lary.20667] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES/HYPOTHESIS The increased risk of malignancy associated with post-transplant immunosuppression limits the potential of laryngeal transplantation as a reconstructive option. This risk may be mitigated by utilizing decoy nuclear factor kappa B (NF-kappaB) immature dendritic cells (iDC) to provide donor-specific tolerance. The purpose of this study was to explore whether tolerogenic properties of iDC can be applied to composite tissue transplantation. STUDY DESIGN Animal study. METHODS Five iDC-injected mice were euthanized at 15, 30, and 60 days post-laryngeal transplant. Control groups included five transplanted mice without immunosuppression, one iDC-injected mouse euthanized prior to transplantation, one mouse without injection or transplantation, and one mouse administered mature DC to serve as an accelerated rejection control. Larynges were graded for rejection severity according to a grading scale. Draining lymph nodes and spleens were evaluated by flow cytometry to determine immunogenic activity of iDC and T cells locally and peripherally. RESULTS Each time group demonstrated moderate allograft rejection (rejection severity scores: 4.38, 5.10, 5.29). NF-kappaB iDC-treated mice had significantly less rejection at all time points compared to nonimmunosuppressed mice. Flow cytometry showed inhibition of cytotoxic T cell infiltration and expansion of regulatory T cells at the allograft site. CONCLUSIONS iDC immunosuppression maintains laryngeal allograft integrity up to 60 days post-transplantation. Regulatory T cells are enhanced at the allograft site, which serves to suppress immune cell activation and induce self-antigen tolerance. iDC injection may lessen post-transplant comorbidities by decreasing the systemic immune response and favorably affecting concurrent immunosuppressive dose sequencing for laryngeal allograft preservation.
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Affiliation(s)
- David G Lott
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio 44195, USA.
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Lott DG, Dan O, Lu L, Strome M. Long-Term Laryngeal Allograft Survival Using Low-Dose Everolimus. Otolaryngol Head Neck Surg 2010; 142:72-8. [DOI: 10.1016/j.otohns.2009.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 08/27/2009] [Accepted: 10/14/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE: The purpose of this study was to explore the mechanism and utility of everolimus as a single-agent therapy in preventing mouse laryngeal allograft rejection. STUDY DESIGN: Prospective animal study. SETTING: Academic research at a tertiary medical center. SUBJECTS AND METHODS: Fifteen recipient mice (five per group) were injected with everolimus (1 mg/kg/d) until euthanized at 15, 30, and 60 days posttransplantation. Five mice received transplants without immunosuppression and were euthanized at day 15. Larynges were graded for rejection severity. Draining lymph nodes and spleens were evaluated by flow cytometry to assess the systemic immunological environment. RESULTS: Each time group demonstrated minor allograft rejection (rejection severity scores: 2.51, 2.46, 2.78; no rejection, 1; severe, 6). This was not significantly different between groups. Everolimus-treated mice had significantly less rejection at all time points compared with non-immunosuppressed mice. Flow cytometry showed a blunted cytotoxic T-cell response, differentiation favoring regulatory T-cells, and decreased number and function of dendritic cells. CONCLUSIONS: Everolimus successfully prevents laryngeal allograft rejection up to 60 days posttransplantation. It appears to increase the production of regulatory T-cells while decreasing cytotoxic T-cell and dendritic cell response. Everolimus alone or in combination with other immunosuppressants may enable laryngeal transplantation to become a viable reconstructive option following laryngectomy for malignancy.
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Affiliation(s)
- David G. Lott
- Cleveland, OH
- Cleveland Clinic Head and Neck Institute (Dr Lott and Dan), New York, NY
| | - Olivia Dan
- Cleveland, OH
- Cleveland Clinic Head and Neck Institute (Dr Lott and Dan), New York, NY
| | - Lina Lu
- Cleveland, OH
- Cleveland Clinic Surgery Institute and Department of Immunology (Dr Lu), New York, NY
| | - Marshall Strome
- Cleveland, OH
- New York Head and Neck Institute (Dr Strome), New York, NY
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Lott DG, Shipchandler TZ, Dan O, Lorenz RR, Strome M. A new mouse laryngeal transplantation rejection grading system. Laryngoscope 2009; 120:39-43. [DOI: 10.1002/lary.20661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lott DG, Dan O, Lu L, Strome M. Long-term Laryngeal Allograft Survival Using Everolimus. Otolaryngol Head Neck Surg 2009. [DOI: 10.1016/j.otohns.2009.06.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cannady SB, Lee WT, Scharpf J, Lorenz RR, Wood BG, Strome M, Lavertu P, Esclamado RM, Saxton JP, Adelstein DJ. Extent of neck dissection required after concurrent chemoradiation for stage IV head and neck squamous cell carcinoma. Head Neck 2009; 32:348-56. [PMID: 19672875 DOI: 10.1002/hed.21189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The management of initially bulky nodal disease after primary nonsurgical treatment for stage IV head and neck squamous cell carcinoma (HNSCC) continues to be a subject of debate. METHODS A retrospective chart review of neck management in patients after chemoradiation was performed. RESULTS Of the initially positive necks analyzed, 210/329 (65%) had a complete clinical response to treatment and 161 necks underwent neck surgery. Patients were pathologically positive 13.8% and 39.6% of the time after clinical complete or partial response, respectively. Regional recurrence was more frequent in necks with partial clinical (p = .04) or pathologic responses (p < .01) and with primary site recurrences (p < .01). CONCLUSIONS It is still safest at our institution to perform selective neck dissection on patients with > or = N2 neck disease when initially observed to prevent unsalvageable regional recurrence until more accurate interval assessment tools are confirmed.
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Affiliation(s)
- Steven B Cannady
- Department of Otolaryngology, Oregon Health Sciences University, Portland, Oregon, USA.
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Solares CA, Wood B, Rodriguez CP, Lorenz RR, Scharpf J, Saxton J, Rybicki LA, Strome M, Esclamado R, Lavertu P, Adelstein DJ. Does vocal cord fixation preclude nonsurgical management of laryngeal cancer? Laryngoscope 2009; 119:1130-4. [PMID: 19358250 DOI: 10.1002/lary.20225] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine whether vocal cord fixation precludes nonsurgical management of T3/T4 laryngeal carcinoma. STUDY DESIGN A retrospective chart review. METHODS Between 1989 and 2005 patient records with T3/T4 squamous cell carcinoma of the larynx with vocal cord fixation at presentation were reviewed. All were treated with a concomitant cisplatin-based chemoradiotherapy protocol and were part of the institutional head and neck cancer chemoradiotherapy registry. Only patients with adequate pre- and post-treatment fiberoptic evaluations were included. Charts were reviewed for demographics and tumor characteristics; return of vocal cord function; local, regional, or distant recurrence after treatment; and need for salvage surgery. The Kaplan-Meier method was used to estimate outcomes, and the log-rank test was used to compare those patients whose vocal cords remained fixed to those with recovery of function. RESULTS Twenty-three patients met the inclusion criteria, 19 males and 4 females. The median age was 59 years (range, 39-73). Fourteen patients had T3 and nine had T4 tumors. Twelve patients recovered full range of mobility, three had partial recovery, and eight did not recover motion. The median follow-up was 68 months (range, 34-191). Comparing patients with post-treatment partial or fully mobile cords to those with persistent fixation revealed the following: A projected five-year overall survival of 100% versus 25%, (P < .001), freedom from recurrence of 86.7 versus 25% (P < .001), local control without surgery of 86.7% versus 30% (P = .003), and survival with functional larynx of 86.7% versus 25% (P = .008), respectively. CONCLUSIONS Nonsurgical therapy in patients with pretreatment vocal cord fixation is feasible. However, persistence of vocal cord fixation after definitive chemoradiotherapy is a poor prognostic sign and early surgical intervention should be considered. Laryngoscope, 2009.
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Rodriguez CP, Adelstein DJ, Rybicki LA, Saxton JP, Lorenz RR, Wood BG, Strome M, Esclamado RM, Lavertu P, Carroll MA. Clinical predictors of larynx preservation after multiagent concurrent chemoradiotherapy. Head Neck 2008; 30:1535-42. [DOI: 10.1002/hed.20902] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Knott PD, Dan O, Strome M. Induction with T-cell receptor antibody leads to long-term laryngeal allograft function. Am J Otolaryngol 2008; 29:398-402. [PMID: 19144301 DOI: 10.1016/j.amjoto.2007.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 12/09/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE The use of induction therapy with alphabeta T-cell receptor (alphabetaTCR) monoclonal antibody in association with tacrolimus in an allogeneic rat laryngeal transplant model permits rigorous long-term evaluation of potential short-term synergism offered by these agents. MATERIALS AND METHODS The allogeneic model consisted of 19 Brown Norway larynges transplanted to Lewis recipients. Treatment consisted of tacrolimus (1.2 mg/kg per day) alone and in combination with 7 days of alphabetaTCR (0.5 mL/d). Control groups consisted of untreated animals, as well as a semiallogeneic model with Lewis-Brown Norway larynges transplanted to Lewis recipients and treated with tacrolimus monotherapy. Each group consisted of 6 to 11 rats. The median duration of engraftment was 44 days (range, 14-106 days). Graft histopathology was graded according to an established 31-point scale in a blinded fashion. Long-term grafts (>75 days) were followed with serum parathyroid hormone levels. RESULTS Untreated controls experienced almost complete rejection (mean score, 27; SD, 0). Allogeneic transplants treated with tacrolimus monotherapy experienced near-complete rejection (mean score, 25.2; SD, 2.1). Allogeneic transplants treated with combination therapy and followed for a median duration of 100 days demonstrated significantly better rejection scores than controls (mean score, 11.1; SD, 1.7; P = .003). Combination therapy was also significantly more effective in preventing acute rejection than monotherapy with tacrolimus in a semiallogeneic model (mean score, 22.1; SD, 4.6; P < .04). CONCLUSIONS Induction therapy with tacrolimus and alphabetaTCR prevents rejection in an allogeneic model for up to 100 days. This regimen was associated with significantly better histopathologic rejection scores than untreated controls, or monotherapy with tacrolimus in allogeneic or semiallogeneic models.
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Affiliation(s)
- P Daniel Knott
- The Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Lee WT, Tubbs RR, Teker AM, Scharpf J, Strome M, Wood B, Lorenz RR, Hunt J. Use of in situ hybridization to detect human papillomavirus in head and neck squamous cell carcinoma patients without a history of alcohol or tobacco use. Arch Pathol Lab Med 2008; 132:1653-6. [PMID: 18834225 DOI: 10.5858/2008-132-1653-uoisht] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT Head and neck squamous cell carcinoma is commonly associated with tobacco and alcohol use. There are, however, a group of patients without a significant history of tobacco or alcohol use, and the etiology of these tumors is incompletely understood. OBJECTIVE To examine tumors in this subpopulation for association with human papillomavirus (HPV) using newly available in situ hybridization probes. DESIGN Between October 2004 and October 2005, 22 patients who did not use alcohol or tobacco were included. Formalin-fixed, paraffin-embedded tissue sections were used to perform in situ hybridization using newly available probe sets (Ventana Medical Systems, Tucson, Ariz). The slides were examined for the presence of integrated HPV using light microscopy. Positive and negative xenograft controls were run with the assay. Results.-The mean age of the patients was 64 years. There were 14 men and 8 women. The most common anatomic sites included tongue (n = 8), tonsil (n = 7), and larynx (n = 7). All cases and controls were successfully stained. Only 2 cases were positive for high-risk HPV, and both demonstrated an integrated pattern. Both cases were tumors of the tonsil. No cases were positive for low-risk HPV. CONCLUSIONS These results demonstrate that the new probe sets for HPV can be used very efficiently in clinical pathology material of head and neck squamous cell carcinoma. Our data show that high-risk HPV is an uncommon finding in head and neck squamous cell carcinoma from patients who do not have a history of tobacco or alcohol use; low-risk HPV was not seen in any case.
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Affiliation(s)
- Walter T Lee
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Khariwala SS, Dan O, Lorenz RR, Klimczak A, Siemionow M, Strome M. Donor bone marrow in laryngeal transplantation: results of a rat study. Am J Otolaryngol 2008; 29:242-9. [PMID: 18598835 DOI: 10.1016/j.amjoto.2007.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2007] [Accepted: 08/20/2007] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The concept of donor bone marrow transplantation has been successfully used in human solid organ transplantation to increase recipient chimerism. The development of recipient chimerism is associated with a decreased need for immunosuppression and even donor-specific tolerance. In this study, we attempted to augment recipient chimerism by the transfer of donor bone marrow at the time of rat laryngeal transplant. STUDY DESIGN Experimental study in rats. METHODS The study used a well-established semiallogeneic rat laryngeal transplant model with partial major histocompatibility complex (MHC)-mismatched Lewis-Brown-Norway donors and Lewis recipients. Donor bone marrow was introduced at transplantation via (1) intravascular injection and (2) transfer of a vascularized femoral bone graft. Recipients were treated with an established immunosuppressive regimen consisting of everolimus and anti-alphabetaTCR monoclonal antibody for a 7-day perioperative course. Animals received a 5-day boost of the same regimen at 90 days posttransplantation. Parathyroid hormone levels and histological examination were used for rejection surveillance and scoring. RESULTS Animals treated with intravenous bone marrow injection followed by perioperative and pulsed immunosuppression commonly demonstrated early rejection (90%). Animals receiving transfer of vascularized donor femur had an average rejection score of 2.9 (scale, 1-6) at 180 days posttransplantation. Mixed-lymphocyte reaction did not demonstrate donor-specific tolerance in the latter group, and chimerism was less than 1%. CONCLUSIONS In the rat laryngeal transplant model, donor bone marrow does not consistently lead to augmentation of peripheral chimerism using our established pulsed immunosuppression protocol. In many cases, rejection occurred earlier than animals not receiving bone marrow. This may be due to several different factors including (1) an element of graft-vs-host disease, (2) inability to establish bone marrow engraftment due to our short-term perioperative immunosuppression regimen, or (3) preferential rejection of donor bone marrow cells.
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Lorenz RR, Esclamado RM, Teker AM, Strome M, Scharpf J, Hicks D, Milstein C, Lee WT. Ansa Cervicalis-to-Recurrent Laryngeal Nerve Anastomosis for Unilateral Vocal Fold Paralysis: Experience of a Single Institution. Ann Otol Rhinol Laryngol 2008; 117:40-5. [DOI: 10.1177/000348940811700109] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: One treatment option for unilateral vocal fold paralysis (UVFP) is ansa cervicalis-to-recurrent laryngeal nerve (ansa-RLN) anastomosis to provide reinnervation to the affected vocal fold. The advantages of this treatment approach are that it 1) provides vocal fold tone, bulk, and tension, 2) is technically simple, and 3) does not preclude other medialization procedures. We present all patients who have undergone ansa-RLN anastomosis for UVFP at our institution. Methods: An Institutional Review Board-approved retrospective chart review was performed to include all patients who had undergone an ansa-RLN anastomosis procedure for UVFP at our institution. Data from clinical and endoscopic laryngoscopy with stroboscopy were recorded. Statistical analysis was performed on visual and perceptual vocal data. Results: A total of 46 patients were included in the study. Stroboscopic analysis and perceptual vocal evaluation was performed in a blinded fashion on the 21 patients who had preoperative and postoperative stroboscopy. Severity, roughness, breathiness, and strain all improved significantly over time. Glottic closure, vocal fold edge, and supraglottic effort all significantly improved after operation. Of the 38 patients with at least 3 months of follow-up, all except 1 demonstrated evidence of reinnervation. Conclusions: This technique for treating UVFP results in significant improvements in patients' voice and on visual examination.
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Abstract
OBJECTIVES/HYPOTHESIS Dendritic cells (DC) are potent antigen-presenting cells that instigate allograft rejection. Their migration kinetics vary depending on the type of organ transplanted. The timing of donor and recipient DC trafficking in laryngeal transplants is unknown. STUDY DESIGN Prospective animal model. METHODS Lewis to Brown Norway (BN) rat laryngeal allografts and BN to BN isografts were performed without immunosuppression. Recipient animals were sacrificed at seven posttransplant time points. Total DC, as well as recipient and donor DC (in allograft recipients), were enumerated in situ in the airway epithelium and subepithelium using monoclonal antibodies, immunofluorescence, confocal microscopy, and image analysis software. RESULTS Total DC densities in both laryngeal allografts and isografts decreased to approximately 10% of their initial values in the first 3 days and then rose beyond their starting values. In allografts, there was a net efflux of donor DC, reaching a nadir by 3 to 5 days; they were identified in recipient cervical lymph nodes from 12 hours to 5 days. Recipient DC infiltrated the laryngeal allograft, reaching a maximal density by day 7. CONCLUSION The paradigm of donor DC efflux and recipient DC influx has been confirmed in a rat laryngeal transplant model, and the allograft-specific timing of these events has been elucidated. Similarities in total DC migration between allografts and isografts suggest that this phenomenon may not be driven entirely by major histocompatibility mismatch. Further understanding of trafficking may help with the goal of manipulating DC to induce allograft tolerance in the absence of generalized immunosuppression.
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Affiliation(s)
- Aaron D Friedman
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Knott PD, Tamai H, Strome M, Van Lente F, Shu S. RAD inhibition of sarcoma growth: implications for laryngeal transplantation. Am J Otolaryngol 2007; 28:375-8. [PMID: 17980767 DOI: 10.1016/j.amjoto.2006.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Accepted: 11/08/2006] [Indexed: 11/27/2022]
Abstract
PURPOSE Laryngeal transplantation has not been widely accepted because of concerns regarding accelerated tumor recurrences in the setting of nonspecific immunosuppression. Allotransplantation could potentially be offered to patients if immunosuppressive therapy could be demonstrated to exert tumor suppressive properties. Preliminary reports have demonstrated an antiproliferative effect of everolimus (RAD), a derivative of the immunosuppressant rapamycin. MATERIALS AND METHODS Forty-five 10-week-old inbred C57BL/6N (B6) mice were injected subcutaneously with 1 x 10(6) MCA205 sarcoma cells. On the third postinoculation day, the mice were divided into 4 treatment groups, undergoing daily gavage with RAD at 0, 0.2, 1.0, and 5.0 mg/kg per day for 10 consecutive days. Thereafter, treatment with RAD was discontinued and tumor size was measured every 2 days during treatment and biweekly until sacrifice on the 31st postinoculation day. Whole-blood trough levels (C(min)) were measured for each group. RESULTS Mean tumor diameter among the control animals and the mice treated with RAD 0.2 mg/kg per day demonstrated no significant difference (P > .07). Groups treated with RAD 1 and 5 mg/kg per day demonstrated significant growth inhibition between the 7th and the 23rd postinoculation days (P < .0001), with no significant differences being noted between these two groups (P > .09). Mean tumor suppressive whole-blood C(min)'s for the 1 and 5 mg/kg per day groups were 75.6 and 368.9 pg/microL, respectively. CONCLUSIONS RAD delivered at immunosuppressive doses of 1 and 5 mg/kg per day resulted in significant growth restriction of a fibrosarcoma in a murine model.
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Affiliation(s)
- Philip Daniel Knott
- Head and Neck Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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Abstract
The loss of a functional voice because of trauma or laryngectomy can have a devastating impact on a patient's self-esteem and overall quality of life. Unfortunately, even with advances in organ preservation therapy, total laryngectomy is frequently necessary in the treatment of laryngeal carcinoma. Over the past several years, the senior author initiated research into laryngeal transplantation with the goal of restoring lung-powered speech for these patients. The research led to the development of an animal model and several groundbreaking studies in this area. Investigations into the use of irradiation, single-drug and multidrug immunosuppression, and the effects of mammalian target of rapamycin (mTOR) inhibitors have produced significant insight into laryngeal allograft preservation. The laboratory research culminated in the first successful total laryngeal transplant in 1998. The patient had suffered significant laryngeal trauma and strongly desired return of laryngeal phonation. The patient has been maintained on multidrug immunosuppression with minimal difficulties. Now more than 8 years after the procedure, the patient continues to have an excellent voice and dramatically improved quality of life. Recent data suggest that altered immunosuppression schedules and the use of mTOR inhibitors may allow patients to minimize immunosuppression-related adverse effects and ameliorate the risk of developing recurrent or de novo carcinoma. These data, when considered in combination with the progress made over the past 14 years, lead us to believe that the future of laryngeal transplantation is bright.
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Affiliation(s)
- Oscar Calderon
- Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Khariwala SS, Vivek PP, Lorenz RR, Esclamado RM, Wood B, Strome M, Alam DS. Swallowing Outcomes After Microvascular Head and Neck Reconstruction: A Prospective Review of 191 Cases. Laryngoscope 2007; 117:1359-63. [PMID: 17762269 DOI: 10.1097/mlg.0b013e3180621109] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic. METHODS The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect. RESULTS The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet. CONCLUSIONS In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.
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Affiliation(s)
- Samir S Khariwala
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Tan A, Adelstein DJ, Rybicki LA, Saxton JP, Esclamado RM, Wood BG, Lorenz RR, Strome M, Carroll MA. Ability of positron emission tomography to detect residual neck node disease in patients with head and neck squamous cell carcinoma after definitive chemoradiotherapy. ACTA ACUST UNITED AC 2007; 133:435-40. [PMID: 17515501 DOI: 10.1001/archotol.133.5.435] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To report our experience using the neck examination, computed tomography (CT), and positron emission tomography (PET) to clinically evaluate node-positive patients with head and neck squamous cell cancer for residual neck node disease after definitive chemoradiotherapy. DESIGN Retrospective review of all Cleveland Clinic patients with head and neck squamous cell cancer and N2 or N3 neck node involvement at presentation who were treated with definitive concurrent chemoradiotherapy and who underwent clinical restaging after treatment using the neck examination, CT, and PET. SETTING Tertiary care referral institution. PATIENTS Forty-eight patients with 72 positive necks at diagnosis were followed up for a median of 20 months. MAIN OUTCOME MEASURES Palpable nodes on examination, nodes larger than 1 cm, nodes with central necrosis on CT, or any hypermetabolic lymph nodes on PET were considered clinical evidence of residual nodal disease. The true rate of pathologic involvement was determined by histologic examination after planned neck dissection or if regional recurrence developed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for all 3 clinical assessment tools. RESULTS Planned neck dissection was performed in 33 necks and was positive for residual neck node disease in 5 necks. A delayed neck dissection was performed in 5 necks and was positive in 3 necks. The positive predictive value was low for all 3 clinical assessment tools. The addition of PET did not significantly improve the negative predictive value or positive predictive value of CT and the clinical examination. CONCLUSIONS Residual neck node disease after definitive chemoradiotherapy was infrequent and was not well predicted by PET. A positive PET finding in this setting is of little utility. Although a negative PET finding was highly predictive for control of neck disease after chemoradiotherapy, it added little to the clinical neck examination and CT.
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Affiliation(s)
- Ann Tan
- Taussig Cancer Center, Department of Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
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Rodriguez CP, Adelstein DJ, Rybicki L, Saxton JP, Lorenz RR, Wood BG, Strome M, Esclamado RM, Lavertu P, Carroll M. Clinical predictors of larynx preservation (LP) after multiagent concurrent chemoradiotherapy (MCCRT). J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.6075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6075 Background: Identification of patients (pts) with larynx and hypopharynx (HP) squamous cell cancer (SCC) most likely to benefit from a LP strategy remains problematic. We retrospectively reviewed the Cleveland Clinic experience using MCCRT to identify potential clinical predictors for success. Methods: Definitive CCRT was considered appropriate for pts with locoregionally confined larynx or HP SCC except for those with cartilage invasion or laryngeal destruction. Cisplatin (20 mg/m2/day) and 5-FU (1,000 mg/m2/day) were given as continuous intravenous infusions on days 1–4 during the first and fourth weeks of either once or twice daily radiation. Laryngectomy was only performed for locally persistent or recurrent disease. Results: Between 1989 and 2006, 115 pts were treated; 87 (76%) were male, and 102 (89%) were white. The median age was 59 (range 31–77) years. The primary site was the HP in 46 pts (40%) , supraglottis in 50 (43%) and glottis in 19 (17%). Tumor was T1 in 4 (3%), T2 in 31 (27%), T3 in 42 (37%), T4 in 37 (32%), and TX in 1 (1%). Disease was stage II in 8 (7%), III in 34 (30%), and IV in 73 (63%). With a median follow up of 62 (range 5–195) months, the 5-year Kaplan-Meier projected local control rate without surgery is 82%. Residual primary site disease was found in only 5 pts after MCCRT. Primary site recurrence developed in 14 more pts. Surgical salvage was successful in 13 of these 19 pts (68%). The 5-year projected local control rate (including surgical salvage) is 94%. Late complications after successful LP included permanent tracheotomy in 3, and feeding tube dependence in 7 pts. For all 115 pts, the 5-year projected freedom from recurrence is 64%, overall survival 58% and laryngectomy-free survival 52%. Local control without surgery was more likely in pts with T1–2 compared to T3–4 tumors (97% vs. 75%, P=0.01), but was not predicted by age, race, tumor differentiation, primary site, nodal status, stage, radiation schedule (daily vs. twice daily), baseline hemoglobin, or continued smoking. Conclusions: This MCCRT regimen can be expected to result in successful LP in all clinical subsets of appropriately selected pts with larynx and HP SCC. Although local failure was more likely in pts with T3 or T4 tumors, it was infrequent, and subsequent surgical salvage was highly effective. No significant financial relationships to disclose.
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Affiliation(s)
- C. P. Rodriguez
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - D. J. Adelstein
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - L. Rybicki
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - J. P. Saxton
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - R. R. Lorenz
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - B. G. Wood
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - M. Strome
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - R. M. Esclamado
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - P. Lavertu
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
| | - M. Carroll
- Cleveland Clinic Foundation, Cleveland, OH; Duke University Medical Center, Durham, NC; University Hospitals of Cleveland, Cleveland, OH
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Abstract
BACKGROUND Transoral CO2 laser surgery for selected supraglottic tumors results in improved postoperative function and decreased morbidity, with comparable survival to open surgery. Recently, robot-assisted techniques have been reported for the management of supraglottic lesions. There are no reports in the English literature of robotic technology coupled with CO2 laser technology. Our objective was to report the use of such technology. STUDY DESIGN Experimental resection of the supraglottis in a cadaver and a dog model using a commercially available surgical robot coupled with CO2 laser technology. Initial human experience with such technology is reported. METHODS With use of a hollow core fiber that allows the transmission of CO2 laser energy linked to the daVinci Surgical Robot, a supraglottic laryngectomy was performed in an edentulous female cadaver. The FK Laryngo-Pharyngoscope was used for exposure. In a second experiment, a supraglottic partial laryngectomy was performed in an 80 pound dog. On the basis of our experimental experience, a CO2 laser robotic-assisted supraglottic laryngectomy was attempted in three patients. RESULTS Removal of the supraglottic larynx in both a cadaver and canine experimental models was believed to be satisfactory using this technology. Bleeding was easily controlled in the live canine model. A 74-year-old woman with a large supraglottic mass for which she had been offered a total laryngectomy was resected successfully with this technology. The FK Laryngo-Pharyngoscope provided excellent exposure. The patient was able to swallow without difficulty on postoperative day 5. Follow-up endoscopic examination at 1 month showed no evidence of residual laryngeal tumor. Robot-assisted procedures were attempted in two additional patients, but adequate exposure could not be achieved, and more traditional techniques were performed. CONCLUSIONS The use of the daVinci Surgical robot coupled with CO2 laser technology is feasible, as demonstrated by our experimental and clinical data. Although further development of the robotic technology is required at present, the use of robotics coupled with CO2 laser technology may have important implications in the management of supraglottic laryngeal cancer in the future.
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Affiliation(s)
- C Arturo Solares
- Head and Neck Institute, Cleveland Clinic Health System, Cleveland Ohio, USA
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Lee W, Tubbs R, Teker A, Scharpf J, Strome M, Wood B, Lorenz R, Hunt J. Use of a novel in situ hybridization technique to detect human papillomavirus in head and neck squamous cell carcinoma patients without a history of alcohol or tobacco use. Radiother Oncol 2007. [DOI: 10.1016/s0167-8140(07)80089-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- Ramon Esclamado
- Department of Otolaryngology - Head and Neck Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Lee WT, Akst LM, Adelstein DJ, Saxton JP, Wood BG, Strome M, Butler RS, Esclamado RM. Risk factors for hypopharyngeal/upper esophageal stricture formation after concurrent chemoradiation. Head Neck 2006; 28:808-12. [PMID: 16732601 DOI: 10.1002/hed.20427] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Concurrent chemoradiation therapy has been demonstrated to be effective as an organ-sparing treatment for select advanced head and neck squamous cell carcinoma (HNSCC). However, this treatment modality is not without side effects. One side effect is the formation of upper esophageal strictures. As concurrent chemoradiation treatment is used more frequently, it is important to identify risk factors associated with stricture formation. METHODS A retrospective chart review of all patients who had undergone definitive concurrent chemoradiation treatment between 1989 and 2002 was performed. Exclusion criteria included death within 1 year or persistent/recurrent disease that required surgical salvage at the primary site. The outcome measure was stricture formation as determined by both objective findings (barium swallow or endoscopy) and the need for dilation after treatment. RESULTS Of the 222 patients in this cohort, there were enough data for 199 patients to assess for stricture formation. Strictures developed in a total of 41 patients (21%). Significant predictive factors were a twice-daily (BID) radiation fractionation (p = .007), female sex (p = .015), and a hypopharyngeal primary site (p = .01). Age and tumor extent were not significant factors in stricture formation (p = .15 and p = .23, respectively). CONCLUSIONS Symptomatic strictures occur in 21% of patients undergoing concurrent chemoradiation for HNSCC. Female sex, BID radiation fractionation, and a hypopharyngeal primary site are significant predictive factors for stricture formation.
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Affiliation(s)
- Walter T Lee
- Head and Neck Institute, Cleveland Clinic Foundation, Ohio Desk A71, 9500 Euclid Ave., Cleveland, Ohio 44195, USA.
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Nelson M, Hercbergs A, Rybicki L, Strome M. Association between development of hypothyroidism and improved survival in patients with head and neck cancer. ACTA ACUST UNITED AC 2006; 132:1041-6. [PMID: 17043248 DOI: 10.1001/archotol.132.10.1041] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine if the development of hypothyroidism has an effect on the outcome of advanced-stage head and neck squamous cell carcinoma. DESIGN Retrospective database analysis. SETTING Tertiary care center. PATIENTS The study population comprised 155 patients with advanced-stage head and neck squamous cell carcinoma. INTERVENTIONS Patients underwent radiation therapy alone or in combination with chemotherapy and surgery when indicated. MAIN OUTCOME MEASURES Kaplan-Meier analysis was used to assess survival, not adjusting for timing of the detection of hypothyroidism. The following 2 analyses were then performed to adjust for the timing of detection: (1) hypothyroidism was assessed as a time-varying covariate in a Cox proportional hazards model and (2) a landmark analysis was conducted at 9, 12, 15, 18, 21, and 24 months using the Kaplan-Meier method. RESULTS Of the 155 patients, 59 developed hypothyroidism, defined as a thyrotropin level greater than 5.5 mIU/L (institutional value). An unadjusted Kaplan-Meier analysis indicated that patients who develop hypothyroidism have significantly better survival than patients who do not (P<.001, log-rank test). After adjusting for the timing of hypothyroidism, a Cox proportional hazards analysis indicated that survival was better, but not statistically significant, for patients who developed hypothyroidism (hazard ratio, 0.62; P=.12); results from a landmark analysis supported this finding (P values ranged from .11 to .19). CONCLUSIONS Development of hypothyroidism may be associated with improved survival and increased recurrence-free survival. Larger, prospective studies appear warranted to test the beneficial effect of hypothyroidism.
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Affiliation(s)
- Marc Nelson
- Head and Neck Institute, and Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Knott PD, Milstein CF, Hicks DM, Abelson TI, Byrd MC, Strome M. Vocal Outcomes After Laser Resection of Early-Stage Glottic Cancer With Adjuvant Cryotherapy. ACTA ACUST UNITED AC 2006; 132:1226-30. [PMID: 17116819 DOI: 10.1001/archotol.132.11.1226] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To evaluate the vocal outcomes of patients with early-stage glottic carcinoma undergoing laser resection with adjuvant cryoablative therapy. DESIGN Retrospective review. SETTING Tertiary care center. Patients Twenty patients with early-stage glottic carcinoma. Intervention Treatment of early-stage glottic carcinoma with endoscopic carbon dioxide laser resection in conjunction with cryoablation. MAIN OUTCOME MEASURES Disease-free survival and subjective and objective measures of posttreatment voice quality, based on serial videolaryngostroboscopy. RESULTS There was 1 local treatment failure, with an overall mean disease-free follow-up of 32.6 months (range, 3-93 months). Carbon dioxide laser resection and cryoablative therapy were associated with a significant improvement in subjective voice quality (P<.001). Long-term dysphonia was uniformly improved vis-à-vis the pretreatment condition, even among patients with the most advanced disease undergoing the widest resections. Posttreatment web formation was not noted among 4 patients with anterior commissure involvement. CONCLUSIONS Endoscopic laser laryngeal surgery performed in conjunction with cryotherapy for early-stage glottic carcinoma yielded excellent primary site control, while improving subjective and objective measures of voice quality. Combined laser surgery and cryotherapy is a possible alternative to radiotherapy for selected patients with early-stage glottic carcinoma who desire curative therapy, while optimizing vocal outcomes.
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Affiliation(s)
- P Daniel Knott
- Head and Neck Institute and Voice Center, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
OBJECTIVES To understand the effect of adjuvant cryotherapy on glottic wound healing after endoscopic CO2 laser cordectomy. STUDY DESIGN Canine acute injury model with videolaryngostroboscopic and histopathologic outcomes analysis. METHODS Twelve adult male dogs underwent bilateral endoscopic CO2 laser transmuscular cordectomy followed by randomized unilateral endoscopic glottic cryotherapy. The animals were randomly divided into four groups and underwent videolaryngostroboscopy followed by sacrifice at 0, 2, 6, and 12 weeks postoperatively. Three untreated male dogs served as controls. Histopathologic sections were prepared with Alcian blue, Giemsa, hematoxylin-eosin, movat's, Masson's trichrome, and picrosirius stains. RESULTS Videostroboscopy demonstrated an earlier restoration of glottic volume and a return of mucosal waves among vocal folds treated with combined therapy by 6 weeks posttreatment. The mean depth of inflammatory reaction in the vocal cords treated with combined therapy was 1.07 mm versus 1.15 mm in vocal cords treated with CO2 laser therapy alone. At 2 and 6 weeks postoperatively, combined treatment was associated with a decreased volume of collagen. At 12 weeks postoperatively, combined treatment was associated with greater collagen organization, normalized collagen histoarchitecture, and decreased keratinization. CONCLUSIONS Adjuvant cryotherapy appears to alter glottis-specific wound healing, leading to decreased and more organized collagen formation and decreased keratinization with a resultant improvement in glottic function, when compared with CO2 laser surgery alone, in an acute canine injury model. Studies in humans are ongoing to further evaluate the clinical potential of cryotherapy on glottic wound healing.
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Affiliation(s)
- P Daniel Knott
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Ferlito A, Rinaldo A, Silver CE, Shah JP, Suárez C, Medina JE, Kowalski LP, Johnson JT, Strome M, Rodrigo JP, Werner JA, Takes RP, Towpik E, Robbins KT, Leemans CR, Herranz J, Gavilán J, Shaha AR, Wei WI. Neck dissection: then and now. Auris Nasus Larynx 2006; 33:365-74. [PMID: 16889923 DOI: 10.1016/j.anl.2006.06.001] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Accepted: 06/12/2006] [Indexed: 11/26/2022]
Abstract
The significance of metastatic disease in the lymph nodes of the neck as a critical independent prognostic factor in head and neck cancer has long been appreciated. Although 19th century surgeons attempted to remove involved cervical lymph nodes at the time of resection of the primary cancer, a systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdyński in 1888 and popularized and illustrated by Crile in the early 20th century, provided consistent and more effective treatment, and forms the basis of our current techniques. During the first half of the 20th century, developments included preservation of the accessory nerve in selected cases, elective neck dissection performed in association with resection of various primary tumors, bilateral neck dissection and limited neck dissection. The greatest impetus to the status of radical neck dissection came from Martin, whose technique consisted of resection of all lymph nodes from level I-V together with the accessory nerve, internal jugular vein, sternocleidomastoid muscle and various other structures in a single block of resected tissue. Martin's technical precepts were followed until the latter part of the 20th century when modifications in technique began to find general acceptance. The first description of an effective technique of modified radical neck dissection was published in Spanish by Suárez, in 1963. This technique, which preserves important structures, such as the internal jugular vein, sternocleidomastoid muscle and accessory nerve, was refined and popularized by various authors who published their results in the English language literature during the period from 1964 through 1990 and beyond. Modified or "functional" neck dissection avoids much of the morbidity of radical neck dissection while achieving equivalent degrees of control of regional disease in properly selected cases. By the late 20th century, the concept of selective neck dissection, consisting of resection of only the nodal groups at greatest risk for metastasis from a given primary site, was studied and developed. These limited dissections are now widely employed for elective, and in properly selected cases, therapeutic treatment and staging of the neck, and have been proposed for limited cervical recurrences after various chemoradiation protocols. Prospective studies have demonstrated similar rates of neck recurrence and survival after elective selective neck dissection compared to elective modified radical neck dissection. Other modifications and factors applied to treatment of cervical lymph node disease include the use of adjuvant and neo-adjuvant radiation and chemotherapy, a revised system for classification of neck dissections, the identification of various adverse prognostic factors such as extracapsular spread and extranodal soft tissue deposits, application of sentinel lymph node biopsy to staging of the neck, the use of immunohistochemical and molecular techniques for identification of lymph node metastases not detectable by light microscopy, and the possibility of endoscopic neck dissection. The authors conclude that neck dissection, as evolved over the past century, is a fundamental tool in management of patients with head and neck cancer, but is still a work in progress.
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Affiliation(s)
- Alfio Ferlito
- Department of Surgical Sciences, ENT Clinic, University of Udine, Udine, Italy.
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Friedman A, Strome M, Drazba J, Lorenz RR. 10:10 AM: Dendritic Cell Quantification in the Rat Larynx. Otolaryngol Head Neck Surg 2006. [DOI: 10.1016/j.otohns.2006.06.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVE Everolimus (RAD) is an mTOR inhibitor closely related to rapamycin. A potent immunosuppressive agent, it has also shown evidence of antineoplastic properties. SCC VII is a spontaneously arising murine squamous cell carcinoma line. This study examines the effect of everolimus on SCC VII proliferation. The data may provide support for the use of everolimus in transplant recipients with a history of malignancy. METHODS A dose efficacy study was conducted that used a murine model of intradermal tumor growth and pulmonary metastases. The development of intradermal tumors and pulmonary metastases were studied. Of 80 total mice, 40 received intradermal injection of 1 x 10 SCC VII cells and 40 received intravenous injection of 1 x 10 cells to establish pulmonary metastases. Within each group, animals were subdivided into four subgroups that received 1) 1 mg/kg everolimus twice a day, 2) 0.5 mg/kg everolimus twice a day, 3) 7.5 mg/kg cyclosporine per day, and 4) no treatment. Intradermal tumors were measured three times per week. Animals receiving an intravenous tumor injection were killed after 17 days and pulmonary metastases were quantified. Medication trough levels were measured in all treated animals. RESULTS Everolimus showed statistically significant tumor inhibition at 1.0 mg/kg twice a day and 0.5 mg/kg twice a day when compared with animals treated with cyclosporine and with untreated animals (P < .0001). Tumor inhibition was evident in both models studied (intradermal tumors and pulmonary metastasis generation). CONCLUSIONS Everolimus provides potent tumor inhibition in animals inoculated with SCC VII cells. Inhibition of both local and distant spread of disease is evident. Although most immunosuppressives are known to potentiate neoplastic disease, this study supports the use of everolimus immunosuppression in the face of prior malignancy. This data has significant implication for laryngeal transplantation after laryngectomy.
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Affiliation(s)
- Samir S Khariwala
- Head and Neck Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Tan A, Adelstein DJ, Esclamado RM, Rybicki LA, Saxton JP, Wood BG, Lorenz RR, Strome M, Carroll MA. Does positron emission tomography (PET) improve our ability to detect residual neck node (NN) disease in patients with squamous cell head and neck cancer (SCHNC) after definitive chemoradiotherapy? J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.5526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5526 Background: Management of the neck in patients undergoing non-operative treatment for SCHNC is controversial. This study details our experience using the neck exam, computerized tomography (CT), and PET to clinically evaluate patients for residual NN disease after definitive chemoradiotherapy. Methods: We retrospectively reviewed all patients with SCHNC with NN involvement at presentation, who were treated with definitive concurrent chemoradiotherapy using fluorouracil and cisplatin. Clinical restaging by neck exam, CT, and PET was accomplished 8–12 weeks after completion of treatment. Residual palpable nodes on exam, residual nodes larger than 1 centimeter, or with central necrosis on CT, or any residual hypermetabolic lymph nodes on PET were considered to be clinical evidence of residual NN disease. Persistent NN disease was confirmed only if pathologic involvement was identified at the time of neck dissection, or if regional recurrence developed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy (Acc) were calculated for all three clinical assessment tools. Results: The study included 43 patients with 64 positive necks at diagnosis, followed for a median of 11.5 (range 3.9–43.3) months. All but two patients are alive. Planned neck dissection was performed in 26 necks after chemoradiotherapy, and was positive in four. Recurrent primary site or NN disease prompted a delayed neck dissection in eight necks, which was positive in three. The utility of these clinical assessment tools and combinations thereof are detailed in the table . Conclusions: Residual NN disease after definitive chemoradiotherapy was infrequent and not well predicted by PET. A positive PET in this setting is of little utility. Although a negative PET was highly predictive for control of neck disease after chemoradiotherapy, it added little to the clinical neck exam and the CT. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- A. Tan
- Cleveland Clinic Foundation, Cleveland, OH
| | | | | | | | | | - B. G. Wood
- Cleveland Clinic Foundation, Cleveland, OH
| | | | - M. Strome
- Cleveland Clinic Foundation, Cleveland, OH
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Adelstein DJ, Saxton JP, Rybicki LA, Esclamado RM, Wood BG, Strome M, Lavertu P, Lorenz RR, Carroll MA. Multiagent Concurrent Chemoradiotherapy for Locoregionally Advanced Squamous Cell Head and Neck Cancer: Mature Results From a Single Institution. J Clin Oncol 2006; 24:1064-71. [PMID: 16505425 DOI: 10.1200/jco.2005.01.5867] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose A retrospective review with long-term follow-up is reported from the Cleveland Clinic Foundation studying radiation and concurrent multiagent chemotherapy in patients with locoregionally advanced squamous cell head and neck cancer. Patients and Methods Between 1989 and 2002, 222 patients were treated with 4-day continuous infusions of fluorouracil (1,000 mg/m2/d) and cisplatin (20 mg/m2/d) during weeks 1 and 4 of either once daily or twice daily radiation therapy. Primary site resection was reserved for patients with residual or recurrent primary site disease after chemoradiotherapy. Neck dissection was considered for patients with N2 or greater disease, irrespective of clinical response, and for patients with residual or recurrent neck disease. Results With a median follow-up of 73 months, the Kaplan-Meier 5-year projected overall survival rate is 65.7%, freedom from recurrence rate is 74.0%, local control without the need for surgical resection rate is 86.7%, and overall survival rate with organ preservation is 62.2%. Including patients undergoing primary site resection as salvage therapy, the overall local control rate is 92.4%. Regional control rate at 5 years is 92.4%. Among patients with N2-3 disease, regional control was significantly better if a planned neck dissection was performed. Distant control at 5 years was achieved in 85.4% of patients and was significantly worse in patients with hypopharyngeal primary sites and patients with poorly differentiated tumors. Conclusion Concurrent multiagent chemoradiotherapy can result in organ preservation and cure in the majority of appropriately selected patients with locoregionally advanced, nonmetastatic, squamous cell head and neck cancer. Distant metastatic disease was the most common cause of treatment failure. Late functional outcomes will require further investigation.
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Affiliation(s)
- David J Adelstein
- Department of Hematology and Medical Oncology, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Qadeer MA, Colabianchi N, Strome M, Vaezi MF. Gastroesophageal reflux and laryngeal cancer: causation or association? A critical review. Am J Otolaryngol 2006; 27:119-28. [PMID: 16500476 DOI: 10.1016/j.amjoto.2005.07.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Indexed: 11/27/2022]
Abstract
Gastroesophageal reflux disease has been implicated as a causative factor in several laryngeal disorders. Its involvement in laryngeal cancer is of interest not only from a clinicopathologic aspect, but also from a public health perspective. However, despite a number of studies, a causal relationship with laryngeal cancer is uncertain. In this article, we address the current literature in a critical manner to facilitate the understanding of this subject and evaluate the relationship between gastroesophageal reflux disease and laryngeal carcinoma.
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Affiliation(s)
- Mohammed A Qadeer
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Khariwala SS, Knott PD, Dan O, Klimczak A, Siemionow M, Strome M. Pulsed immunosuppression with everolimus and anti-alphabeta T-cell receptor: laryngeal allograft preservation at six months. Ann Otol Rhinol Laryngol 2006; 115:74-80. [PMID: 16466103 DOI: 10.1177/000348940611500111] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Laryngeal transplantation can restore the voice in patients who have undergone laryngectomy. However, the prospect of lifelong immunosuppression is a drawback to this procedure. We present data from a study aimed at minimizing the need for immunosuppression while maintaining graft viability through a novel pulsed-dosing protocol. METHODS Larynges were transplanted from Lewis-brown Norway (RT1(l+n, F1) rats to Lewis (RT1(l)) recipients. All recipients received 7 days of treatment with everolimus and mouse anti-rat alphabeta T-cell receptor (anti-TCR) monoclonal antibodies beginning the day before transplantation. At 90 days after transplantation, all recipients received a pulse of the same treatment combination for 5 days. From 90 to 180 days after transplantation, the rats received no treatment (group 1, n = 5), 2.5 mg/kg everolimus per day (group 2, n = 5), or 1.0 mg/kg everolimus per day (group 3, n = 5). RESULTS Histologic analysis of rats that received everolimus as pulse therapy evidenced no signs of rejection, whereas animals that were untreated after 90 days had normal to mild chronic rejection. T-cell reconstitution occurred 65 days after perioperative immunosuppressive treatment, but less rapidly after pulse therapy. Also, peripheral chimerism was generated in all 3 groups. CONCLUSIONS In the rat laryngeal transplantation model, short-term perioperative therapy with everolimus and anti-TCR followed by pulsing is a viable alternative to the concerns associated with continuous, lifelong immunosuppression.
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Affiliation(s)
- Samir S Khariwala
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
Lifelong immunosuppression carries significant morbidity, and techniques to reduce or eliminate such immunosuppression might expand laryngeal transplantation. This study investigates the ability of donor-specific transfusion to establish tolerance in a rat model of laryngeal transplantation. A total of 289 transplants were performed from Lewis-Brown-Norway donors to Lewis recipients. Donor-specific transfusion was provided as single intravenous injections of donor splenocytes 1 hour before transplantation. Different combinations of in vitro irradiation of donor larynges and postoperative cyclosporine doses provided additional immunomodulation. Allograft rejection was scored histologically at sacrifice 15 or 30 days posttransplant. Multivariate analysis was performed across all groups, and paired analyses compared groups with and without donor-specific transfusion. Donor-specific transfusion did not improve rejection score, although increased cyclosporine dose did (P < .001). Donor splenocyte injection on the day of transplantation does not establish tolerance to laryngeal allografts or permit reduction of other immunosuppression. Other immunomodulatory strategies to establish tolerance in rat laryngeal transplantation require further investigation.
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Affiliation(s)
- Lee M Akst
- Head and Neck Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Scharpf J, Strome M, Siemionow M. Immunomodulation with anti-αβ T-cell receptor monoclonal antibodies in combination with cyclosporine a improves regeneration in nerve allografts. Microsurgery 2006; 26:599-607. [PMID: 17066409 DOI: 10.1002/micr.20294] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To investigate the use of nerve allografts in animals treated with a short-term combined protocol of anti-alpha/beta T-cell receptor monoclonal antibodies and Cyclosporine A (CsA) to induce tolerance and allow for nerve regeneration. STUDY DESIGN An established rat sciatic nerve model was used. A total of 76 rats were used in this experiment (Lew RT1L n=44, Lewis-Brown-Norway (LBN RT1L+N, n=22), Brown-Norway (BN RT1N, n=10). Sciatic nerve (1.5 cm) deficits were created in the Lewis rats and the animals were randomized to seven treatment groups to allow for repair with isograft controls (LEW-LEW) and with both semiallogeneic (LBN-LEW) and full major histocompatability (MHC) mismatched (BN-Lew) allografts. METHODS Nerve regeneration was evaluated at 6 and 12 weeks by somatosensory evoked potentials (SSEP) and standardized pin-prick and toe-spread tests. Nerve samples were harvested at 12 weeks and stained with toluidine blue to assess the total number of myelinated axons, axon area, and myelin sheath thickness. Muscle denervation atrophy was evaluated by gastrocnemius weights. Immunocompetence was investigated through skin grafting and fluorescent activated cell sorting (FACS) analysis. RESULTS Improved functional, electrophysiologic, and histomorphometric outcomes were observed in animals treated with anti-alpha/betaTCR mAbs and CsA after nerve allograft transplantation when compared to animals receiving no treatment and CsA alone. CONCLUSIONS The immunomodulating protocol of combination anti-alpha/beta TCR mAbs and CsA for a 5 week period altered the rejection process, affording nerve regeneration. It may provide for an expanded source of nerve tissue to alleviate the morbidity of harvesting peripheral nerves from multiple sites for those afflicted with extensive peripheral nerve injuries.
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Affiliation(s)
- Joseph Scharpf
- Head and Neck Institute, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Abstract
There is no good surgical, medical or prosthetic solution to the problems faced by those with a larynx whose function is irreversibly damaged by tumor or trauma. Over the past 10 years, the pace of research designed to establish laryngeal transplantation as a therapeutic option for these persons has increased steadily. The biggest milestone in this field was the world's first true laryngeal transplant performed in Cleveland, Ohio in 1998. The recipient's graft continues to function well, in many respects, even after 7 years. However, it has also highlighted the remaining barriers to full-scale clinical trials. Stimulated by these observations, several groups have accumulated data which point to answers to some of the outstanding questions surrounding functional reinnervation and immunomodulation. This review seeks to outline the progress achieved in this field by 2005 and to point the way forward for laryngeal transplantation research in the 21st century.
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Affiliation(s)
- M A Birchall
- Division of Surgery and Oncology, University of Liverpool, Liverpool, UK.
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