Abstract 3681: A patient derived ex vivo platform CANScript™ predicts distinct therapeutic outcomes to multiple PD-1 checkpoint inhibitors in single tumor biopsies

Background: Emerging clinical evidence using immunotherapy in recent years has demonstrated its power to suppress tumor growth by releasing the brakes on the immune system. For example, blockade of immune checkpoints, such as PD-1, has revolutionized treatment options for patients with aggressive cancers such as head and neck squamous cell carcinoma (HNSCC). However, clinical responses to PD-1 inhibition vary widely among patients while majority of them do not show any anti-tumor response. Multiple FDA-approved drugs against the same immune checkpoints have resulted in globally distinct outcomes in the clinic. There is a huge unmet need to understand these disparities at the individual patient level and to maximize the clinical benefits of these agents.

Methods: Here, we employed a patient-derived ex vivo model, CANScript™ (Majumder B et al. Nature Commun 2015 Feb 27;6:6169 and Goldman A et al. Nature Commun 2015 Feb 11;6:6139), which recreates the native 3D tumor microenvironment, autocrine-paracrine dynamic and response to therapy by incorporating fresh tumor tissue and autologous immune cells with immunotherapy agents. Utilizing late stage HNSCC (N=50) we interrogated phenotypic response to two FDA-approved PD-1 inhibitors, Pembrolizumab (KEYTRUDA) and Nivolumab (OPDIVO). To do this, we used a comprehensive panel of immunological assays to evaluate changes in the immune compartments by flowcytometry and immunohistochemistry (primarily CD8, CD45, FOXP3, CXCR4, CD68, PDL1, PD1), multiplex cytokine profiling (IL6, IL8, IFN-g, IL10, IL12, Perforin, GranzymeB), along with functional/phenotypic effects including tumor proliferation, histological changes and cell death.

Results: The data demonstrated that CANScript™ preserves the tumor-immune contexture and native heterogeneity across different clinical stages and patients. Importantly, we observed that PD-1 blockade resulted in patient-specific therapeutic response, which was characterized by differential distribution and maintenance of infiltrating CD8+ and CD4+ lymphocytes, distinct patterning of cytokines linked to functional dysregulation, and changes in tumor proliferation and apoptosis. Interestingly, data suggest that both Pembrolizumab and Nivolumab act on the same immune network axis but trigger functionally diverse phenotypes in the tumor immune compartment and distinct antitumor effects within an individual patient tumor.

Conclusion: Together, these findings demonstrate the utility of CANScript™ as an ex vivo platform to predict therapeutic response of immune checkpoint inhibitors at the individual patient level. It also highlights mechanistic variations that could impact clinical outcome of these agents having the same molecular target. Such information can re-shape our understanding of patient selection and rational combinations for novel immune checkpoint inhibitors.

Citation Format: Padhma Radhakrishnan, Vasanthakumar Sekar, Nilesh Brijwani, Priyanka Chevour, Babu Balakrishnan, Dency D Pinto, Muthusami Oliyarasi, Debapriya G. Mehrotra, Manjusha Biswas, Sabitha K S, Kodaganur S. Gopinath, Arkasubhra Ghosh, M s Ganesh, Ashok M. Shenoy, Saravanan Thiyagarajan, Biswanath Majumder, Aaron Goldman. A patient derived ex vivo platform CANScript™ predicts distinct therapeutic outcomes to multiple PD-1 checkpoint inhibitors in single tumor biopsies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3681. doi:10.1158/1538-7445.AM2017-3681

Cyclin D1, p53, MIB1, Intratumoral Microvessel Density, and Human Papillomavirus in Advanced Laryngeal Carcinoma: Association with Nodal Metastasis

OBJECTIVE: We sought to study various parameters in laryngeal squamous cell carcinoma (LSCC) that might predict nodal metastasis.

STUDY DESIGN AND SETTING: Sixty-four LSCCs were examined with respect to their histopathology and, using immunohistochemistry, their proliferative capacity (MIB1), p53 and cyclin D1 status, and intratumoral microvessel density. The presence of human papillomavirus was ascertained by the polymerase chain reaction.

RESULTS: Histopathologically, most tumors had an infiltrating/mixed growth pattern and a diminished inflammatory reaction at the growing margin. In addition, 56% of the tumors were positive for MIB1, with 64% showing p53 overexpression; 70% were positive for cyclin D1; and 59% showed increased tumor microvessel density. Of 42 cases analyzed, 9.5% were positive for human papillomavirus 16.

CONCLUSIONS: Of the parameters studied, a diminished lymphocytic inflammatory response at the periphery ( P < 0.05) and cyclin D1 overexpression ( P < 0.001) correlated significantly with cervical nodal metastasis at presentation.

SIGNIFICANCE: Cyclin D1 overexpression, easily assessed on biopsy samples, may thus help in optimizing therapy at the outset.

PMMC Patch Pharyngoplasty Reconstruction After Laryngectomy: Our Experience at a Regional Cancer Institute

To evaluate our results of post laryngectomy pharyngeal defect reconstruction by pectoralis major myocutaneous (PMMC) flap. Retrospective analysis of 48 patients who underwent laryngectomy and PMMC patch pharyngeal reconstruction from year 2009 to 2013 was done. Patient and tumor characteristics were noted, CT scan and histopathology reports were reviewed. 46 (95.8 %) patients were male and 2 (4.2 %) were female. Mean age was 57.2 ± 8.5 years and mean postoperative stay was 22.6 ± 12.0 days. Most common complication was pharyngocutaneous fistula, seen in 13 (27.1 %) cases. Postoperative mortality was low (2.1 %). Post surgery rehabilitation in respect to swallowing and tolerance to radiotherapy was satisfactory in most patients. PMMC patch pharnygoplasty is a reliable option for pharyngeal reconstruction with acceptable complication.

Predicting clinical response to anticancer drugs using an ex vivo platform that captures tumour heterogeneity

Predicting clinical response to anticancer drugs remains a major challenge in cancer treatment. Emerging reports indicate that the tumour microenvironment and heterogeneity can limit the predictive power of current biomarker-guided strategies for chemotherapy. Here we report the engineering of personalized tumour ecosystems that contextually conserve the tumour heterogeneity, and phenocopy the tumour microenvironment using tumour explants maintained in defined tumour grade-matched matrix support and autologous patient serum. The functional response of tumour ecosystems, engineered from 109 patients, to anticancer drugs, together with the corresponding clinical outcomes, is used to train a machine learning algorithm; the learned model is then applied to predict the clinical response in an independent validation group of 55 patients, where we achieve 100% sensitivity in predictions while keeping specificity in a desired high range. The tumour ecosystem and algorithm, together termed the CANScript technology, can emerge as a powerful platform for enabling personalized medicine.

Chondroradionecrosis of larynx a delayed complication of radiotherapy: management and review of literature

Background/objectives Chondroradionecrosis (CRN) of the larynx is a rare and grave complication of radiotherapy which can be fatal if not managed aggressively. A recent trend towards organ preservation protocols towards even advanced stage laryngeal malignancies and with further advances in terms of technology and safety radiation as external beam and intensity modulated varieties are preferred for certain stages of squamous cell carcinomas. Materials and methods We are reporting a series of 4 cases of CRN of the larynx treated in our hospital with 3 cases of stage III carcinoma glottis and one stage III carcinoma supraglottis with no nodal metastasis. One glottis cancer had 2 sittings of laser microlaryngeal excision earlier. All were in grade 4 CRN and one improved with medical line and HBO and the other 3 progressed and salvage laryngectomy and pectoralis major myocutaneous flap to cover the fistulous skin defect was grafted.

CONCLUSION

Laryngeal CRN being a rare and intensely morbid complication of radiotherapy should be suspected and diagnosed at the earliest by endoscopic and imaging methods. Disease progression and chances of tumor recurrence should be followed up with PET CT and a call on salvage laryngectomy with repair of the anterior neck defects with non irradiated musculocutaneous flaps or vascularised tissue transfer should be promptly taken.

Xeroderma pigmentosum: clinicopathological review of the multiple oculocutaneous malignancies and complications

Multiple oculo-cutaneous malignancies are a common manifestation on sun-exposed facial areas in patients with Xeroderma pigmentosum (XP). Commonly seen are the basal cell carcinoma and the squamous cell carcinomas which manifest in the early first decade in contrast to fifth and sixth decade in the general population. XP manifests as photosensitivity, hyperpigmentation, premature skin aging and malignant changes like squamous cell carcinoma, basal cell carcinoma, fibrosarcoma and rarely malignant melanoma as well as internal malignancies. We report 11 cases of Xeroderma pigmentosa managed in our institute which included sex males and five females. All had photosensitivity, hyperpigmentation and consanguinity with facial malignant lesions like SCC and BCC. Ocular signs of photophobia and excessive lacrimation was seen in all the cases while blurring of vision due to corneal clouding, corneal injection, pterygium and limbal SCC were seen in 5 cases. SCC of the lids were seen in 7 cases while BCC seen in 8 cases and limbal and conjunctival SCC seen in one case. All were managed with excision while one case of melanoma with neck secondaries needed radical neck dissection while the other orbital exenteration. Oculo-cutaneous malignancies occur in the sun exposed areas so patients are advised regular follow up with speciality care. Awareness about the rare condition and importance of early detection and prevention of UV rays induced skin damage should be propagated. The disease is ultimately fatal, life can be prolonged by simple preventive measures to minimize sun exposure and early detection of the skin lesions and management.

Laryngeal paraganglioma: a rare clinical entity managed by supraselective embolization and lateral pharygotomy

Laryngeal paragangliomas are benign slow growing tumors with symptoms resembling squamous cell carcinoma. Hoarseness or dysphasia are the commonest presenting symptoms and usually it presents as an submucosal mass on laryngoscopy. Ninety percentage of these tumors occur in the supraglottic larynx and the rest in the glottis and the subglottic region. Functional activity is seen in a few (2.9 %), none are associated with paraneoplastic syndromes. A 35-year-old male presented to us with hoarseness of voice since 4 months duration. Contrast arteriography demonstrated that the left superior thyroid artery supplied >80 % of the blood supply to the laryngeal mass. Supraselective embolization was done from the right femorals under local anaesthesia and sedation which was uneventfull. The tumor was excised from lateral pharyngotomy approach with an partial laryngectomy procedure. Microscopy and immune-histochemistry confirmed it to be paraganglioma. Complete surgical resection or partial laryngectomy with meticulous dissection of surrounding tissues and preservation of neurovascular structures gives an excellent prognosis as far as oncological clearance is concerned. Malignant paragangliomas of the larynx are rare and an major meta-analysis is necessary to provide a true biological behaviour of this tumor.

The utility of second look microlaryngoscopy after trans oral laser resection of laryngeal cancer

In the past few decades more and more number of tumors of the glottis and supraglottis are been treated with single stage transoral laser microsurgery (TOLS). TOLS for the treatment of glottic and supraglottic carcinoma with anterior commissure (A-com) and/paraglottic space involvement is associated with a high rate of recurrence. We prospectively evaluated the outcomes of laser microsurgery and the impact of second look operation in these patients. Twenty-three patients with glottic and supraglottic carcinoma underwent transoral laser micro resection of the lesions. Subsequently five patients underwent second look microlaryngeal evaluation 6-8 months later for non-satisfactory healing, poor voice, and or suspicion of recurrent disease. Patients with A-com involvement and or paraglottic space involvement were followed up longitudinally for the effectiveness and timing of second look microsurgery. After initial transoral laser micro resection, all patients achieved microscopically clear resection margins. At second look microlaryngeal evaluation, local recurrence was found in four of 23 patients. Of these, two patients were salvaged by second look surgery and are disease free, whereas in two others, the larynx had to be subjected to open surgical intervention. One of two had extensive local recurrent tumor and underwent total laryngectomy with neck dissection followed by post-operative radiotherapy. Tracheohyoidopexy was done with successful functional and oncologic outcome for another patient who had local recurrence for the third time. Only the patient who underwent total laryngectomy with neck dissection was subjected to adjuvant post-operative radiotherapy. Finally, larynx was saved in 21 out of 23 patients.

Neck dissection followed by definitive radiotherapy for small upper aerodigestive tract squamous cell carcinoma, with advanced neck disease: an alternative treatment strategy

Treatment options for patients with small upper aerodigestive tracts squamous cell carcinoma (T1, T2) with advanced neck disease (N2, N3) is a topic that generates controversy in terms of thereuptic stratagies. We present the retrospective analysis of 109 patients treated, between 1991 and 2008, by "Neck dissection first approach" for N2, N3 neck node, followed by external beam radiotherapy (RT) with or without chemotherapy for the operated neck and the primary, deemed radiocurable. 94 patients completed the planned treatment and formed the material for this study. The primary (tumor) stage was as follows: T1 (29) and T2 (65) commonly arising from oropharynx; the neck nodes were predominantly N2a (n = 54), followed by N2b (n = 26) and N3 (n = 14) disease. Complete nodal clearence was achieved in 89 patients, with no major post operative complications. With a median follow up of 24 months disease free survival of 70% and overall survival of 61% at 5 years. Recurrence at primary site was noted predominantly with pyriform fossa tumors (n = 8), followed by base of tongue (n = 5) and were T2 lesions. Failure in the neck was seen in predominantly N3 nodes, R1 resection and failure to comply with adjuvant treatment. Neck dissection first approach is a valid treatment option that allows a good control of the disease in the neck, where it often fails if only RT is administered, along with preserving the pharyngolaryngeal function. Care should be excercised so that there should be no delay in initiating the RT following surgery.

Vocal cord paralysis after percutaneous embolization of a vagal paraganglioma--the role of intraoperative nerve monitoring

The value of preoperative embolization is well established in the management of paragangliomas. Percutaneous direct intratumoral embolization has been described as a safe and effective technique to achieve devascularization of these tumors, thereby reducing intraoperative blood loss. However, the present article presents a case in which a patient developed vocal cord palsy after percutaneous embolization of a vagal paraganglioma. In view of the present findings, the possibility of intraoperative nerve monitoring needs to be explored to ensure safety of this procedure.

Evaluation of extensions of sinonasal mass lesions by computerized tomography scan

INTRODUCTION

Cross-sectional imaging has had a significant impact on the management of the sinonasal malignancy. Staging of these lesions has been closely monitored by dependence on computerized tomography (CT) scan and now in small proportion with MRI. The objective of the study was to evaluate the reliability of CT scan in assessing the extensions of the sinonasal mass lesions and their impact on tumor staging.

MATERIALS AND METHODS

All cases of sinonasal lesions were reviewed retrospectively from June 2001 to May 2006 (five years) at KMIO, Bangalore. Only those cases that had CT scan reports and Histopatholgy Examination (HPE) reports were included in the study. All the cases, which were subjected to radiotherapy prior to surgery, were excluded from the study. There were a total of 38 cases with slight male preponderance. Tumor staging was done according to the sixth edition of TNM classification of malignant tumors. Two observers evaluated all the cases (Blinded Study) and sensitivity, specificity, positive predictive value, negative predictive value and predictive accuracy were estimated.

RESULTS

The relation between the CT scan findings and HPE reports was high. Though false positivity was noted more in the ethmoid sinuses, significant impact on tumor staging was noted with false positivity of the nasopharynx. Also, false positivity was noted with orbital wall/content extensions, resulting in unnecessary exenterations of the orbit. However, CT scan reliably predicted infratemporal fossa extension in the absence of trismus. False negativity was noted more often in soft palate, indicating the need of using MRI for delineation of tumor extension. Thus, we conclude that judicious use of CT scan in all cases and MRI in selected cases will translate into better tumor-free resections and improves survival.

Cutaneous leiomyosarcoma, trichoblastoma, and syringocystadenoma papilliferum arising from nevus sebaceus

A 54-year-old man presented with a recurrent swelling on the right occipital region of the scalp. Two months earlier, the patient had undergone an initial local excision of the lesion which had enlarged progressively over the previous 2 years on a hairless patch which had been present since birth. On examination, a 5 x 4-cm, pinkish, firm, ulcerated swelling was seen on the right occipital region with a scar running over it. The lesion was not fixed to the underlying bone and there was no regional lymphadenopathy. X-Ray of the skull was normal and no evidence of metastatic disease was identified. Wide local excision of the tumor was performed and it was sent for histopathologic examination. Specimens and slides of the earlier surgery performed elsewhere were also studied. The specimen of the initial surgery consisted of skin-covered tissue with an exophytic firm growth measuring 6 x 5 x 4 cm. The skin surface was rough with areas of ulceration. No necrosis was noted grossly. Microscopically, three distinct lesions were seen. One was a well-circumscribed tumor located in the superficial dermis with lobules of basaloid cell aggregates with peripheral palisading and with no epidermal connection. The lobules were surrounded by cellular fibrous tissue (Fig. 1). Unlike basal cell carcinoma, however, no cleft between the cellular aggregates and stroma was noted. Foci of pigmentation were seen within cellular lobules and these features were consistent with a diagnosis of tricho-blastoma. The second tumor was seen adjacent to the first, and consisted of duct-like structures and cystic spaces with papillary projections. These were lined by double-layered epithelium with stromal infiltration by plasma cells, which are features of syringocystadenoma papilliferum (Fig. 2). The third lesion was a spindle cell sarcoma which formed the major part of the lesion, diffusely infiltrating the dermis and subcutaneous tissue, elevating and ulcerating the overlying skin. The tumor consisted of interlacing fascicles of spindle cells with oval to elongated nuclei having finely dispersed chromatin and inconspicuous nucleoli. The tumor cells were seen encircling the sweat glands, without destroying them (Fig. 3). Nuclear pleomorphism was minimal, with a mitotic rate of 9-10 per high-power field. A small area of epidermal hyperplasia with acanthosis and papillomatosis overlying malformed highly placed sebaceous glands was the only evidence of a pre-existing nevus sebaceus. The status of the surgical margins was not clearly discernible. The wide excision specimen of the recurrent swelling consisted of a skin-covered nodule with ulceration, measuring 3 x 4 x 3 cm, with a gray-white whorled cut surface. No necrosis was noted grossly. Multiple sections showed only spindle cell sarcoma infiltrating the skin and subcutaneous tissue, morphologically similar to the earlier tumor, with ulceration of the overlying skin. The surgical margins were free from tumor. Immunohistochemical stains on the spindle cell sarcoma showed positive staining for smooth muscle actin (SMA) (Fig. 4), vimentin, epithelial membrane antigen (EMA), and S100. The tumor cells were negative for cytokeratin (CK), HMB45, desmin, glial fibrillary acidic protein (GFAP), CD34, and CD68. Correlating the histomorphology and immunohistochemical findings, a diagnosis of cutaneous leiomyosarcoma with tricho-blastoma and syringocystadenoma papilliferum arising on nevus sebaceus was made. The patient received postoperative radiotherapy and is disease free 8 months after diagnosis.

Human papillomavirus, p53 and cyclin D1 expression in oropharyngeal carcinoma

Forty-two specimens from oropharyngeal (tonsil and base of tongue) squamous cell carcinoma patients (SCC) were studied for presence of HPV 16 by in situ hybridization and by immunohistochemistry for p53 and Cyclin D1 protein overexpression. Thirty-one per cent of cases were HPV-16 positive, which correlates with the prevalence reported worldwide. 74% of cases showed p53 protein overexpression and 79% showed Cyclin D1 overexpression. There was no correlation between HPV status and either p53 or Cyclin D1 overexpression (P>0.05). These three variables also did not correlate with factors such as grade of the tumour, stage of the disease or lymph nodal metastasis at presentation.

Human papillomavirus, p53 and cyclin D1 expression in oropharyngeal carcinoma

Forty-two specimens from oropharyngeal (tonsil and base of tongue) squamous cell carcinoma patients (SCC) were studied for presence of HPV 16 by in situ hybridization and by immunohistochemistry for p53 and Cyclin D1 protein overexpression. Thirty-one per cent of cases were HPV-16 positive, which correlates with the prevalence reported worldwide. 74% of cases showed p53 protein overexpression and 79% showed Cyclin D1 overexpression. There was no correlation between HPV status and either p53 or Cyclin D1 overexpression (P>0.05). These three variables also did not correlate with factors such as grade of the tumour, stage of the disease or lymph nodal metastasis at presentation.

Follicular dendritic cell tumour--a case report

Follicular dendritic cell tumors are rare entities, which are however being increasingly recognised. One such tumor in the parapharyngeal region, diagnostically challenging, and with an unusual histological feature is reported, with a short review of the literature.

Near-total laryngectomy in advanced cancers of the larynx and pyriform sinus: a comparative study of morbidity and functional and oncological outcomes

This prospective study, performed from 1991 to 1996, analyzes the differences in oncological safety, functional utility, and surgical morbidity in 14 advanced lesions of the larynx (10 T3 and 4 T4; 7 N+) and 40 pyriform sinus lesions (1 T2, 20T3, and 19 T4; 29 N+) subjected to Pearson near-total laryngectomy. The laryngeal cancer patients healed much faster, with a minimal wound complication rate of 28%, in comparison to the 68% rate encountered in the pyriform sinus cases (p < .05). The 3-year disease-free survival rate for the laryngeal cancers was 74%, while the 5-year survival rates for pyriform sinus cases were 66% for medial wall lesions and 54% for lateral wall lesions. Lung-powered shunt speech deemed qualitatively superior by acoustic analysis was obtained in 81% of the individuals (93% in laryngeal cases and 76% in pyriform sinus cases). Aspiration-free deglutition was achieved by 90% over periods ranging from 15 to 30 days. This study conclusively attests to the therapeutic efficacy of near-total laryngectomy for advanced lesions of the larynx and pyriform sinus that are unsuitable for radiotherapy, that are deemed too large or risky (because of aspiration) for partial laryngectomy, and that in the past would have merited total laryngectomy.

Neck mestastasis from unknown origin-results of planned primary surgery and post-operative radiation therapy

Ninety-two patients with metastasis of unknown origin were studied between 1986 and 1997 at Kidwai Memorial Institute of Oncology, India. Treatment included planned primary radical neck dissection followed by radiotherapy. Sixty-seven patients completed our multimodal therapy. Thirty-eight of these patients had a median follow-up pf 35.7 months. Nine patients had a median follow-up of 8.3 months. Twenty patients were lost in follow-up after completing the above protocol. Twenty-five patients did not comply with prescribed therapy. Of the followed up patients 78.9% were disease free. The failure rate was 21%, which comprised of regional failure in 16% and liver metastasis in 5%. Primary manifested at base of tongue in 2 patients. In a third world cancer center like ours, advanced neck disease and unreliable follow-up mandate multimodal therapy to be instituted at the first instance. Manifest primaries should be treated on individual basis.

Functional laryngeal surgery - critical determinants of successful rehabilitation

This study addresses the functional outcome and rehabilitative process in 30 partial laryngectomies carried out for laryngeal (22) und hypoorpharyngeal (8) cancers at the department of H/N Surgery, The kidwai Memorial Institute of Oncology. Bangalore, India from 1985-1995, Special emphasis is directed towards post-surgical convalescence after various partial laryngeetomy techniques which include 6 vertical laryngectomies (V L / VPL). 17 supraglottic laryngectomies (SG L), and 7 supracricoid laryngectomies with Cricohyoidepexy (CHP). Rehabilitative success was measured with respect to the ease of dccannulation, resumption of normal deglutition and speech analysis - both objectively using standard speech analytical equipment in a speech laboratory and subjectively using the services of blinded judges to score recorded speech of patients. The speech analysis indicate that past SGL speech was the superior most followed by V L and C H P in that order. Aspiration was deemed as minimal and inconsequential after V L/VPL followed by CHP;and SGL, in the order of severity;the extended modifications to resect the arytenoid and / or basE of tongue and / or piriform fossa faring worse than classic standard technique.

Supracricoid laryngectomy with Cricohyoidopexy--a clinico oncological & functional experience

Supracricoid laryngectomy with Cricohyoidopexy (CHP) is a procedure that is commonly practiced in France & Canada. Eight such procedures were carried out at Kidwai Memorial Institute of Oncology, Bangalore during the period from 1991 through 1996. Four Glottic, 3 transglottic & one supraglottic cancers were subjected to this procedure. The study comprised of 7 males & 1 female. The average age was 52 years. Two procedures were done as salvage procedures for radiotherapy (RT) failures. The patients have a follow-up ranging from one year to six years, except for one who died soon after discharge from hospital secondary to myocardial infarction. Median follow up was four years. The three year acturial disease free survival was 83%. Six out of 8 (75%) were decannulated, and physiologic deglutition without aspiration was established in all patients. Hospital stay ranged from 11 to 62 days averaging 29 days. The speech was analyzed together with other partial laryngectomies and was found to be qualitatively worse than speech after other partial laryngectomy procedures. In addition speech intensity levels after CHP were lower than in other partial laryngectomy procedures. The speech however allowed normal social interaction. This procedure certainly has distinct oncological advantage in encompassing circumferential horse-shoe lesions with minimal subglottic extension which in the past would have received total laryngectomy and needs to be included in the repertoire of speech restorative surgery in laryngeal cancers.

Surgical speech restoration by tracheo-oesophageal puncture--Kidwai experience

This paper addresses our experience with primary (15 patients) and secondary (8 patients) tracheo-oesophageal puncture (TEP) in the laryngectomee. Despite a success rate of 93.3 percent in the primary TEP and 62.5 percent in secondary TEP, in a follow-up period of one month to eight years, prosthesis related problems like maintenance and recurring expenses emerged as significant deterrent factors in adopting prosthetic speech rehabilitation. Successful oesophageal speech training, increased practice of Pearson's near total laryngectomy, prior tracheostomy and advanced disease mandating post-operative radiotherapy in majority of patients are some of the factors in addition to prosthesis after-care maintenance that makes TEP a less practiced option at our center.

Parotid tuberculosis simulating malignancy

An interesting case of parotid tumour simulating malignancy is reported. The rarity of this lesion and the associated clinical and diagnostic problems are emphasized together with the relevant literature.

Electromyography in near-total laryngectomy

OBJECTIVE

To investigate the dynamics of speech shunt muscle in patients with Pearson near-total laryngectomy by needle electromyography and correlation of ability to activate shunt muscle with speech production.

DESIGN AND SETTINGS

Prospective study of patients with near-total laryngectomy at 2 hospital-based academic tertiary care centers.

PARTICIPANTS AND INTERVENTION

Fourteen patients with near-total laryngectomy were subjected to percutaneous needle electromyographic study of the shunt muscle.

MAIN OUTCOME MEASURES

Speech ability, electromyographic evidence of viable muscle in shunt wall, and ability to activate shunt muscle were recorded.

RESULTS

Twelve of 14 patients had good speech; 11 had evidence of viable shunt muscle; and 9 were able to activate muscle by phonation, swallowing, or deep breathing, indicating preserved innervation. Six of the 12 patients with speech ability and 1 of the 2 patients without speech ability were able to recruit motor units during attempted phonation.

CONCLUSIONS

Electromyography demonstrated viable muscle with retained innervation in 64% of the patients with near-total laryngectomy, proving its "dynamic" nature. However, the usefulness of shunt muscle activation in speech and prevention of aspiration needs further confirmation.

Osteosarcoma of the jaw bones

Osteosarcoma of the jaw bone is comparatively rare and accounts for about 6.5% of all osteosarcomas. We treated eight cases of osteosarcoma of the jaw bone involving the mandible and maxilla in equal proportions between 1986-1992. The median age was 31 years and male: female ratio was 5:3. Swelling and bony expansion were the most common presentations. Radiologically six patients had lytic lesions, and histopathologically they were osteoblastic (n = 4), chondroblastic (n = 3) and fibroblastic (n = 1). Three patients, two with mandibular and one with maxillary osteosarcoma underwent radical surgery and six courses of cisplatinum-based chemotherapy. All were alive and disease free 24, 30, and 54 months after treatment. Histologically all three were chondroblastic. Five patients had incomplete or palliative treatment. All patients died of progressive or locally recurrent disease within 2 years.

Vocal rehabilitation after gastric transposition. The critical overview

Re-establishment of effective communication following laryngopharyngo esophagectomy and gastric transposition requires thorough knowledge and flexibility of introducing the entire range of communication options. This study describes our experience with eleven patients of gastric transposition who attended intensive speech therapy and developed gastric speech using different method of speech producing and attaining various levels of proficiency. Application of digital pressure is one of the most effective technique for production of satisfactory and intelligible voice in gastric transposition cases who fail to develop speech by inhalation method.

Efficacy and safety of granulocyte macrophage-colony stimulating factor (GM-CSF) on the frequency and severity of radiation mucositis in patients with head and neck carcinoma

PURPOSE

Based on the clinical evidence of mucosal protection by GM-CSF during cytotoxic chemotherapy, a pilot study was undertaken to determine the safety and mucosal reaction of patients receiving GM-CSF while undergoing definitive conventional fractionated radiotherapy in head and neck carcinoma.

METHODS AND MATERIALS

Patients were considered eligible if buccal mucosa and oropharynx were included in the teleradiation field. Ten adult patients with squamous cell carcinoma of head and neck (buccal mucosa--8 and posterior 1/3 tongue--2) were entered into the trial. Radiation therapy was delivered with telecobalt machine at conventional 2 Gy fraction and 5 fractions/week. The radiation portals consisted of two parallel opposing lateral fields. GM-CSF was given subcutaneously at a dose of 1 microg/kg body weight, daily, after 20 Gy until the completion of radiation therapy. Patients were evaluated daily for mucosal reaction, pain, and functional impairment.

RESULTS

The median radiation dose was 66 Gy. Eight patients received > or = 60 Gy. The tolerance to GM-CSF was good. All 10 patients completed the planned daily dose of GM-CSF without interruption. Mucosal toxicity was Grade I in four patients till the completion of radiotherapy (dose range 50-66 Gy). Six patients developed Grade II reaction, fibrinous mucosal lesions of maximum size 1.0-1.5 cm, during radiotherapy. None developed Grade III mucositis. The maximum mucosal pain was Grade I during GM-CSF therapy. In two patients after starting GM-CSF the pain reduced in intensity. Functional impairment was mild to moderate. All patients were able to maintain adequate oral intake during the treatment period. Total regression of mucosal reaction occured within 8 days following completion of radiotherapy.

CONCLUSIONS

GM-CSF administration concurrently with conventional fractionated radiotherapy was feasible without significant toxicity. The acute side effects of radiotherapy namely mucositis, pain, and functional impairment were nil to minimal. The results are suggestive of mucosal protection by GM-CSF during radiotherapy and warrants further study in randomized double blind trial.

Functional utility and oncologic safety of near-total laryngectomy with tracheopharyngeal speech shunt in a Third World oncologic center

This prospective study analyzes the feasibility, oncologic safety and functional utility of Pearson's near-total laryngectomy with tracheopharyngeal shunt (NTL-TPSS). The procedure was found to give gratifying locoregional control in 30 consecutive advanced T3 and selected T4 tumors involving the larynx (n = 11) and hypopharynx (n = 19) and managed at Kidwai Memorial Institute of Oncology, Bangalore, India. The oncologic "safety" of this technique was established in following examinations, ranging from 18 to 44 months (median, 22.2 months). A locoregional control rate of 74% was obtained. Lung-powered "shunt" speech was acquired with ease in periods ranging from 7 days in speakers deemed "excellent" (15/29) to 20 days in those deemed "satisfactory" (8/29). Except for a single case experiencing temporary aspiration of liquids, patients did not have any swallowing difficulties following removal of nasogastric tubes. The period of hospitalization averaged 22.6 days. The complication rate was 33%, with one patient death (3.3%) occurring. The dynamics of the TPSS were analyzed in selected "speakers" and "non-speakers", using transcutaneous needle electromyography. Analysis of data supports the possibility of dynamic speech modulation. However, the favored anatomic location and design renders the shunts aspiration-proof rather than demonstrating any active sphincteric action.

Synovial sarcoma of the neck

Primary synovial sarcoma of the head and neck region is a rare tumor. This report describes seven cases of primary synovial sarcomas, of which two were in the parapharyngeal region, two in the supraclavicular region, and one each in the hypopharynx, sternocleidomastoid and submandibular regions. Clinical presentations, radiological findings, histopathology and management are reviewed. All patients received multimodal therapy using aggressive surgery, radiotherapy and chemotherapy. Five of the patients are alive and disease free after 24-108 months of follow-up. Achievement of locoregional control appears to be the hallmark of successful therapy.

Diagnosis of clival chordoma by fine needle aspiration of an oropharyngeal mass. A case report

A sphenooccipital chordoma presenting as a large nasopharyngeal mass extending into the oropharynx was diagnosed by transoral fine needle aspiration biopsy (FNAB) and confirmed by subsequent histologic studies. The cytologic features of chordoma are presented, and the diagnostic utility of FNAB in evaluating similar lesions in the head and neck region is discussed.

Cytogenetic and viral studies in nasopharyngeal carcinomas in patients of Indian origin

Four cases of undifferentiated nasopharyngeal carcinomas (NPC) (grade III-IV) in patients of Indian origin were investigated for specific chromosome markers and evidence of Epstein-Barr virus (EBV) positivity. Abnormalities involving chromosome #3, like del (3) (p24-pter) and 3q+(q27-qter) were found in these patients, similar to earlier reports in patients of Chinese and Kenyan origin2,4,13 who however were EBV positive, unlike the patients in this study who were EBV negative. Implications of the cytogenetic and serological data in Indian patients with NPC, available for the first time, may throw some light on the etiology of the disease in this ethnic group where nasopharyngeal carcinoma is also endemic.

Speech evaluation after near total laryngectomy and total laryngectomy--a comparative acoustic analysis

The practice of Pearson's (1981) technique of near total laryngectomy with speech shunt is evaluated acoustically in 11 subjects using matched esophageal speakers. Not only do these patients vocalize earlier with effortless cease, analysis of their speech both subjectively & by acoustic analysis of the parameters seems definitely to be of superior quality. The functional utility of this technique is addressed in this study justifying its more frequent practice in unilateral lesions of larynx and hypopharynx which defy satisfactory control by conventional conservation laryngeal surgery or radiation therapy. The Oncological outcome will be taken up as a part of a future report when follow up of adequate duration occurs in sufficient number of cases.

Rhabdomyosarcoma of the tongue

Although rhabdomyosarcoma (RMS) has a predilection for the head and neck region its occurrence in the tongue is uncommon. We report 2 cases of RMS of the tongue, 1 paediatric and 1 adult patient. The child who had RMS of the alveolar type involving anterior two-thirds of the tongue was treated with surgery and chemotherapy and is disease-free at 84 months of follow-up. The adult patient had locally extensive embryonal RMS of posterior third of the tongue, received chemotherapy and radiotherapy but died with progressive disease at 24 months of follow-up.

Interjugular neck dissection and post-operative irradiation for neck control in advanced glottic cancers--are we justified?

At the Kidwai Memorial Institute of Oncology, advanced laryngeal cancers are subjected routinely to primary surgery and/or post-operative radiotherapy (RT). The surgery consists of wide field laryngectomy which entails total laryngectomy, ipsilateral/bilateral thyroid lobectomy, bilateral paratracheal clearance, and bilateral clearance of levels 2, 3 and 4 lymphatics. Post-operative RT is indicated in event of the following histopathological (HPE) situations to consolidate local-regional control: (1) T4 primary; (2) significant subglottic extension; and (3) jugular/paratracheal metastatic deposits. This prospective study highlights the therapeutic efficacy of this protocol at our centre in 45 consecutive T4/T3 glottic cancers and specifically evaluates the role of interjugular dissection and/or post-operative RT in prevention of regional recurrence. Fifty-two per cent of primary lesions needed a post-surgical upstaging as against 14 per cent of the neck lesions. Accordingly 91 per cent of the cases (41/45) qualified for post-operative RT and 82 per cent (37/41) complied with the prescribed schedule. Recurrent disease in the lateral neck was noted in 2/37 who received the prescribed schedule and 1/4 non-compliant cases; while a recurrent central neck disease was noted in 1/37 and 1/4 of these cases respectively. All cases were followed-up for a period of two years and 66 per cent of the evaluable cases for a period of five years. This study confirms conclusively that our treatment schedule yields extremely gratifying two-year local-regional control rates of 89 per cent which translates into a two and five-year actuarial survival rate of 92 and 70 per cent respectively.

Salivary duct carcinoma

Salivary duct carcinoma is an uncommon malignant tumor that occurs mainly in the parotid gland of elderly men. The 11 cases of salivary duct carcinoma which are included in this study occurred in older men (mean age 56 years) and were located in the parotid (7), submandibular salivary gland (2), and the minor salivary glands in the maxilla (2). The maximum tumor dimension ranged from 3 to 9 cm. Microscopically, all had infiltrating margins, with circumscribed groups of epithelial cells arranged in various patterns; the invasive component was embedded in a desmoplastic stroma. Perineural invasion and lymph node metastasis were noted in seven and three cases, respectively, at the time of initial surgery. Radical surgery was offered to ten patients and postoperative radiotherapy to nine patients. Salivary duct carcinoma appears to be an aggressive tumor with distinctive histological features, which has not been described in the minor salivary glands of the maxilla to date. The clinicopathologic features of these tumors are presented, with a review of the literature.

Scalp flap--a utility and reconstructive option for head and neck surgeons

Regional scalp flaps are invaluable in resurfacing defects resulting from resections in the area of the upper face, orbit and scalp itself. The tissue lies adjacent to the defect, is easy to harvest, and can be termed as a 'durable one-stage' procedure. Scalp defects posterior to the vertex lend themselves to resurfacing by a posterior flap based on the occipital arteriovenous system. Anterior scalp defects including upper face and orbit can be resurfaced by an anterior scalp flap based on the superficial temporal arteriovenous system. While large areas can be resurfaced and the donor site effectively camouflaged, this flap finds less of an acceptance amongst patients with defects in the upper facial region when compared to the scalp defects. We recount our experience with these flaps and describe the high points of the reconstructive procedure and the results obtained in ten consecutive cases carried out over a three year period at the Department of Head and Neck Surgery, Kidwai Memorial Institute of Oncology, Bangalore, India. The short healing time and minimal morbidity make this reconstructive option an attractive one for the practising Head and Neck Surgeon.

Signal transduction in cytotoxic lymphocytes: decreased calcium influx in NK cell inactivated with sensitive target cells

Our laboratory has previously demonstrated that natural killer (NK) cell-mediated cytotoxicity is protein kinase C (PKC)-dependent and that PKC is translocated from the cytoplasm to the plasma membrane during NK cell activation. Furthermore, exposuring NK cells to a sensitive target cell for 4-6 hr at 37 degrees C rendered NK cells functionally inactive and these inactivated effector cells (i) do not turn over PI in response to K562 stimulation and (ii) lose mRNA for perforin and granzyme A and B less than 30 min after contact with K562. In this study, we first confirmed earlier findings that the interaction of sensitive target cells with human NK cells triggers an influx of extracellular calcium into NK cells. In addition, using flow cytometry we demonstrated that there was a delayed maximum uptake of extracellular calcium into functionally inactive NK cells when these cells were reexposed to fresh K562. Finally, we demonstrated that exposuring NK cells to K562 for 4 hr leads to a loss of NK cytotoxic activity and to the maximal expression of CD69.

Neck metastasis from an occult primary--the Kidwai experience

This study highlights our treatment policy in 26 cases of epidermoid metastatic carcinoma in the neck from a primary deemed occult after exhaustive examination of the Upper Aero-digestive Tract (UADT). Planned Radical Neck Dissection (RND) and post-operative radiotherapy (RT) has been the favoured approach in all neck nodes deemed resectable and a loco-regional control rate of 64% was obtaining using this combined modality approach. Pre-operative RT was utilised in three cases with nodal disease of borderline resectability and loco-regional control was achieved in one case. Three cases of massive neck metastasis initially deemed unrectable became amenable to surgical salvage after Radical RT with concurrently administered chemotherapy. Only one of these remained disease free. Overall loco-regional control rate of 55 per cent could be achieved in 20 evaluable patients followed up for two years--three years (mean 30.5 months). Regional failures were noted in 25 per cent of patients while distant spread occurred in 15 per cent, thus accounting for an overall failure rate of 40 per cent. Manifest primaries were documented in 20 per cent, half of which could be salvaged and successfully controlled.

Signal transduction in activated natural killer cells and natural killer cells inactivated with sensitive targets

We have recently demonstrated that the activation of NK cells involves a protein-kinase-C (PKC)-dependent step as well as a phosphatidylinositol (PI)-linked signal transduction system. We have also shown that when NK cells are incubated with sensitive targets for up to 6 h they lose their lytic potential and require IL-2 to regain their lytic activity. PKC is involved in many cell processes such as the transduction of hormonal signals and the machinery of cellular secretion and is activated by diacylglycerol and by a number of phorbol esters, including phorbol myristic acid (PMA). To reinforce the role of PKC in NK-cell-mediated cytotoxicity, we first showed that NK-CMC is inhibited by two agents that inhibit PKC activation, staurosporine and sphingosine. Next, we showed that antibody-dependent cellular cytotoxicity of NK-resistant targets was PKC dependent and Ca2+ dependent. Further, we showed that PMA plus ionophore alone could induce NK killing of resistant targets and that this killing was PKC and Ca2+ dependent. Finally, we contrasted the role of PKC in these activated cells to the role of PKC in cells that have been inactivated with a sensitive target, K562. We showed that PKC is not required for the IL-2-dependent reactivation of NK cells but that Ca2+ is required. To further determine what event in signal transduction is inactivated by K562, we showed that inactivated NK cells do not turnover PI in response to K562 stimulation.

Chondrosarcoma of the hyoid

Two cases of chondrosarcoma of the hyoid bone are described. They were managed with surgical resection and postoperative radiotherapy. These patients are disease free at 26 months and 15 months respectively.

Post laryngectomy rehabilitation the case for planned early speech therapy

This study reflects the efficacy of planned early speech therapy on post laryngectomy rehabilitation. Not only do a larger number of laryngectomees acquire intelligible esophageal speech where therapy is instituted early but also the pace of development and quality of the speech is far superior when compared to those laryngectomees in whom speech therapy was delayed. This paper unequivocally supports the institution of planned early speech therapy in the successful rehabilitation of the laryngectomee. Such therapy can proceed simultaneously with the post operative radiation therapy sans deleterious effects and without prolonging hospital stay with its attendant overheads.

Receptor modulation and early signal transduction events in cytotoxic T lymphocytes inactivated by sensitive target cells

In previous studies, we demonstrated that NK cells and lymphokine-activated killer cells were inactivated early in the lytic process by susceptible but not by resistant target cells (TC). We examined the functional status of human MHC-restricted CTL, after interaction with sensitive TC. Two CTL lines were generated in vitro by stimulation with irradiated PAMO, an EBV-transformed cell line. CTL were incubated for up to 4 h with an equal number of PAMO, then separated by a SRBC rosette assay. CTL lost greater than 60% of their lytic activity during the first 30 min of incubation, and greater than 90% by 4 h as assessed by their inability to lyse fresh TC. Inactivated CTL had 35% less serine esterase activity than did control CTL. IL-2 restored the lytic potential and serine esterase activity to normal values within 72 h. Exposure of CTL to PAMO for 4 h induced the modulation of 22 to 44% of TCR/CD3, CD4/CD8, and class I Ag from the cell surface. In contrast, the expression of CD69, and class II Ag increased and there was no change in the expression of CD2, CD28, or LFA-1 Ag. Furthermore, early metabolic events that usually follow CTL-ligand interaction such as phosphatidylinositol metabolism and transient increase in intracellular calcium, did not occur in inactivated CTL upon challenge with PAMO. PMA and the calcium ionophore A23187, restored cytolytic activity, indicating that protein kinase C can be activated and translocated in inactivated CTL. Our data suggest that TC-induced inactivation of CTL may be due to the modulation of key membrane molecules and the lack of certain secondary messengers involved in signal transduction.

Receptor modulation and early signal transduction events in cytotoxic T lymphocytes inactivated by sensitive target cells

In previous studies, we demonstrated that NK cells and lymphokine-activated killer cells were inactivated early in the lytic process by susceptible but not by resistant target cells (TC). We examined the functional status of human MHC-restricted CTL, after interaction with sensitive TC. Two CTL lines were generated in vitro by stimulation with irradiated PAMO, an EBV-transformed cell line. CTL were incubated for up to 4 h with an equal number of PAMO, then separated by a SRBC rosette assay. CTL lost greater than 60% of their lytic activity during the first 30 min of incubation, and greater than 90% by 4 h as assessed by their inability to lyse fresh TC. Inactivated CTL had 35% less serine esterase activity than did control CTL. IL-2 restored the lytic potential and serine esterase activity to normal values within 72 h. Exposure of CTL to PAMO for 4 h induced the modulation of 22 to 44% of TCR/CD3, CD4/CD8, and class I Ag from the cell surface. In contrast, the expression of CD69, and class II Ag increased and there was no change in the expression of CD2, CD28, or LFA-1 Ag. Furthermore, early metabolic events that usually follow CTL-ligand interaction such as phosphatidylinositol metabolism and transient increase in intracellular calcium, did not occur in inactivated CTL upon challenge with PAMO. PMA and the calcium ionophore A23187, restored cytolytic activity, indicating that protein kinase C can be activated and translocated in inactivated CTL. Our data suggest that TC-induced inactivation of CTL may be due to the modulation of key membrane molecules and the lack of certain secondary messengers involved in signal transduction.

Inhibition of the calpain-mediated proteolysis of protein kinase C enhances lytic activity in human NK cells

Recent evidence from our laboratory has demonstrated that NK/LAK cell activation of human lymphocytes is protein kinase C (PKC)-dependent. Here, we have investigated the translocation of PKC in human NK cells exposed to sensitive targets or to PMA, a phorbol ester. In NK cells exposed to K562 for 6 hr, we observed a weak translocation of PKC whereas in NK cells exposed to PMA more than 90% of cytosolic PKC was translocated to the membrane in less than 5 min. Stimulation of NK cells with an NK-resistant target, however, did not translocate PKC even after 6 hr. Translocation of PKC to the membrane was followed by the appearance of PKM, the cytosolic calcium/phospholipid (Ca2+/PL)-independent form of PKC. The conversion of PKC to PKM was mediated by calpain, an intracellular calcium-dependent thiol proteinase. When we used two inhibitors of calpain, calpain inhibitor I (CI-I) and calpain inhibitor II (CI-II), both caused a dose-related enhancement of NK-CMC when the inhibitors were present throughout the 3-hr chromium release assay. This enhancement could be circumvented by PMA or by the PKC inhibitor H-7. CI-I and CI-II added together caused a greater increase in NK-CMC than when each was added alone. CI-I and CI-II also enhanced antibody-dependent cell-mediated cytotoxicity (ADCC), substantiating further our previous contention that the activation of both NK-CMC and ADCC may involve a common lytic pathway. Activation of NK cells with IL-2 for 18 hr at 37 degrees C was inhibited in the presence of CI-I. To investigate a possible feedback inhibition mechanism due to the buildup of PKC, we examined phosphatidylinositol (PI) metabolism in NK cells activated by IL-2 in either the presence or the absence of CI-I. We observed a significant decrease in PI turnover when NK cells, activated in the presence of IL-2 and CI-I, were stimulated with K562 as compared to NK cells activated by IL-2 alone, then stimulated with K562.