Screening for infectious foci in breast cancer patients prior to high-dose chemotherapy and stem cell transplantation

Cancer patients treated with high-dose chemotherapy (HDC) followed by peripheral stem cell transplantation are at risk for infections during neutropenia. Our standard policy was to screen for potential infectious foci prior to HDC. Screening for infectious foci consisted of chest and sinus roentgenograms and a visit to the ear-nose-throat surgeon (ENT surgeon) and the dentist. The purpose of this study was to evaluate this approach. Between 1993 and 2000, 73 breast cancer patients received HDC.

RESULTS

All chest roentgenograms were normal. ENT screening yielded in three (symptomatic) patients a potential infectious focus. In 32 patients (44%) a potential dental infectious focus was diagnosed and treated. During neutropenia after HDC clinical infections occurred in 15 patients (21%). In only 5 patients (7%) the infection focus was probably the upper respiratory tract.

CONCLUSION

Potential ENT infectious foci were infrequent and all were symptomatic. Potential dental infectious foci were seen quite often; whether they would have had clinical impact if left untreated remains speculative.

Treatment outcome of bone-anchored craniofacial prostheses after tumor surgery

BACKGROUND

Percutaneous endosseous implants have acquired an important place in the prosthetic rehabilitation of patients with craniofacial defects. The objective of this study was to evaluate the clinical outcome of the use of endosseous implants in the orbital and auricular region as well as to assess the satisfaction of patients with implant-retained craniofacial prostheses after tumor surgery.

METHODS

The clinical outcome and patient satisfaction of implant-retained prostheses in the auricular and orbital region were evaluated in a group of 26 patients with facial defects after tumor surgery by using standardized questionnaires and a clinical assessment. Twelve patients (n = 31 implants) received the implants during ablative tumor surgery, from which 7 patients (n = 20 implants) were treated with radiation therapy after surgery (mean, 65 grays [Gy]). Fourteen patients (n = 44 implants) received the implants after the tumor surgery, from which 5 patients (n = 21 implants) were irradiated after ablative surgery (mean, 54.4 Gy), but before implant placement.

RESULTS

No implants were lost in patients who had not undergone irradiation (100%), whereas 5 implants were lost in the irradiated group (87.8%). The overall implant survival rate was 93.3%. The peri-implant tissues had a healthy appearance, and no cases of osteoradionecrosis occurred. When compared with patients treated with conventional adhesive retained facial prostheses, satisfaction was higher in patients treated with implant-retained facial prostheses.

CONCLUSIONS

From this study, it is concluded that implant-retained facial prostheses are better tolerated than adhesive retained prostheses and offer an improvement in the quality of life. Radiotherapy is not a contraindication for the use of osseointegrated implants in the maxillofacial region, but the loss of implants is higher than in nonirradiated sites.

Imaging of squamous cell carcinoma of the hypopharynx

The hypopharynx is a clinically silent area and early lesions may be asymptomatic for a long period. At presentation, primary squamous cell carcinoma of this area is usually advanced. Almost all of these lesions are studied with imaging as part of the clinical work-up. The goal of this article is to help the practicing radiologist convey a report which provides information that will directly influence treatment of patients with hypopharyngeal carcinoma.

DT-diaphorase activity in normal and neoplastic human tissues; an indicator for sensitivity to bioreductive agents?

DT-diaphorase (DTD) is an important enzyme for the bioreductive activation of the new alkylating indoloquinone EO9. In preclinical studies, EO9 has shown selective anti-tumour activity against solid tumours and under hypoxic conditions. The levels of three reductive enzymes have been determined in three types of human solid tumours, together with corresponding normal tissues and normal liver. DTD enzyme activities were measured in tumour extracts using 2,6-dichlorophenolindophenol (DCPIP) and NADH as substrates; cytochrome P450 reductase or cytochrome b5 reductase activities were assessed with cytochrome c and NADPH or NADH respectively. DTD activity was highest in non-small-cell lung (NSCLC)-tumours (mean 123 nmol DCPIP min-1 mg-1), followed by colon carcinoma (mean 75 nmol min-1 mg-1) and squamous cell carcinoma of the head and neck (6-fold lower than NSCLC). DTD activity was very low in normal liver and normal lung (4-6 nmol min-1 mg-1), while the levels in normal colon mucosa or normal mucosa of the head and neck region were in the same range as the corresponding tumours. The levels of the two other reductive enzymes, cytochrome P450 reductase (CP450R) and cytochrome b5 reductase (Cb5R), were 5 to 25-fold lower than those of DTD in all the tissues, except for normal liver, in which DTD was 2 to 4-fold lower. The degree of variation found for DTD (range 4-250 nmol min-1 mg-1), was not observed for these enzymes (CP450R, 0.8-7.8 nmol cytochrome c min-1 mg-1; Cb5R, 3.5-27.6 nmol min-1 mg-1).(ABSTRACT TRUNCATED AT 250 WORDS)

The importance of correct stage grouping in oncology. Results of a nationwide study of oropharyngeal carcinoma in The Netherlands

BACKGROUND

In the frame of a nationwide study of oropharyngeal carcinoma in the Netherlands (1986-1990), the current International Union Against Cancer 1992/American Joint Committee on Cancer 1988 staging system was evaluated with respect to patient distribution and prognostic value.

METHODS

Data related to epidemiology, treatment and survival from 640 patients referred for primary treatment were analyzed. Staging was first evaluated in a proportional-hazard regression analysis controlled for these data. Next, all possible combinations of T, N, and M were tested in a stepwise backward elimination model until all remaining indicator variables had a P value of less than 0.05. New stages were defined, based on the coefficients of the remaining indicator variables.

RESULTS

The revised stages revealed two advantages compared with the UICC 1992/AJCC 1988 version: a more balanced distribution of patients (31% in Stage I, 31% in Stage II, 18% in Stage III, 14% in Stage IV, and 5% unknown in the revised staging system versus 7% in Stage I, 17% in Stage II, 24% in Stage III, 50% in Stage IV, and 2% unknown in the UICC 1992/AJCC 1988 staging system), and an improved prognostic discrimination for the disease specific survival (5-year results in the revised staging were 67% in Stage I, 42% in Stage II, 28% in Stage III, and 11% in Stage IV, versus 68% in Stage I, 64% in Stage II, 44% in Stage III and 27% in Stage IV in UICC 1992/AJCC 1988).

CONCLUSION

Improvements in the current staging system in patient distribution in the stages in prognostic discrimination is feasible by regrouping the T, N, and M but without redefining the categories themselves.

Radiation-induced tumours of the head and neck

In order to study the induction of malignancy in normal tissues due to ionizing radiation, we reviewed the files of 2500 patients with a tumour of the head and neck treated at the Netherlands Cancer Institute (Antoni van Leeuwenhoek Ziekenhuis), Amsterdam, from 1977 to 1993. We then checked whether or not these patients had been previously irradiated. Patients with a thyroid carcinoma or skin cancer were excluded from the study, since it is generally known that previous irradiation is a risk factor in these tumours. Eighteen patients were found to have a malignancy within a previously irradiated area (0.70 per cent). The mean interval between radiation and diagnosis of the head and neck tumour was 36.5 years. There were five soft tissue sarcomas, nine squamous cell carcinomas and four salivary gland tumours. Fourteen patients were operated upon whereas four received palliative treatment only. The median survival of the total group was 3.5 years. Particularly, in young patients because of the better cancer therapy and prolonged survival one must be aware of the increased risk of radiation-induced tumours.

Expression of growth factors and growth factor receptors in normal and tumorous human thyroid tissues

A number of growth factors have been implicated as stimuli of thyroid cell proliferation; overexpression of these growth factors and/or their receptors may play a role in the growth of thyroid tumors. To determine if immunohistochemical detection of growth factors and/or their receptors correlates with morphological alterations in proliferative lesions of thyroid, we examined the localization of epidermal growth factor (EGF), transforming growth factor-alpha (TGF-alpha) and their common receptor, EGF-receptor (EGF-R), insulin-like growth factor-1 (IGF-1), IGF-1-receptor (IGF-R) and IGF binding proteins (IGFBP)-1, -2, -3, and -4, nerve growth factor (NGF), and its receptor NGF-receptor (NGF-R), transforming growth factor-beta (TGF-beta), and basic fibroblast growth factor (bFGF), in normal thyroid tissue and various thyroid tumors. We applied the streptavidin-biotin technique to formalin-fixed, paraffin-embedded tissues. We studied 8-16 different cases of each of the following: normal human thyroid, multinodular hyperplasia, follicular adenoma, papillary carcinoma, follicular carcinoma, medullary carcinoma, and anaplastic carcinoma. EGF, TGF-alpha, and their receptor EGF-R were widely expressed in normal thyroid and in all the thyroid lesions examined. IGF-1 and IGFBP-1 were diffusely present in all different thyroid tissues as well. There was no difference in staining intensity or distribution that correlated with the pathological process. IGFBP-4 seemed to have a variable expression. IGFBP-2 and -3 were detected only in medullary carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro activity of novel antifolates against human squamous carcinoma cell lines of the head and neck with inherent resistance to methotrexate

A series of 7 human squamous carcinoma cell lines of the head and neck (HNSCC), grown in standard medium containing high folate concentrations and in "folate-conditioned" medium containing nanomolar concentrations of folates, were all found to be sensitive (IC50: less than or equal to 50 nM) in growth-inhibition studies to methotrexate (MTX) following drug exposure for 7 days. However, when MTX exposure was limited to 24 hr, only 2 out of 7 HNSCC cell lines were sensitive to MTX (IC50: less than 500 nM), 2 were moderately sensitive (IC50: 1-2 microM), and 3 exhibited inherent resistance to MTX (IC50: greater than 250 microM). In these last 3 cell lines, the mechanism of resistance was not correlated with altered membrane transport of MTX or changes in dihydrofolate reductase activity, but rather was associated with a 3-fold lower activity of intracellular folylpolyglutamate synthase (FPGS) activity compared to MTX-sensitive HNSCC cells. The 3 cell lines exhibiting inherent resistance to a short exposure to MTX, however, did not show inherent cross-resistance after exposure for 24 hr to one or more of 3 novel antifolate compounds. These compounds, which appear to be more efficiently transported and polyglutamylated than MTX, include: 10-ethyl-10-deazaaminopterin (10-EdAM), 2-desamino-2-methyl-N10-propargyl-5,8-dideazafolic acid (ICI-198,583), and 5,10-dideazatetrahydrofolic acid (DDATHF). These results indicate that antifolate membrane transport and intracellular FPGS activity are important factors in determining sensitivity or resistance of HNSCC cells to short-term antifolate compound exposures.

Mechanisms of acquired resistance to methotrexate in a human squamous carcinoma cell line of the head and neck, exposed to different treatment schedules

Mechanisms of acquired resistance to methotrexate (MTX) were evaluated in HNSCC-11B cells which were made resistant to methotrexate either by continuous (11B-MTX-C) or by pulse exposure (11B-MTX-P) to the drug. 11B-MTX-C cells were 91-fold resistant to methotrexate and 30-fold or 49-fold crossresistant to trimetrexate and 10-EdAM, respectively. Dihydrofolate reductase (DHFR) activity was increased 63-fold in 11B-MTX-C cells together with a decrease in [3H]-methotrexate transport and folylpolyglutamate synthase (FPGS) activity (2.5-fold and 3.8-fold, respectively). Against two novel antifolates targetting enzymes other than DHFR, minor crossresistance was observed for ICI-198, 583, but full sensitivity was retained for DDATHF. 11B-MTX-P cells were 46-fold resistant to methotrexate and 47-fold crossresistant to ICI-198,583 in short-term drug exposure, but showed only minor changes in methotrexate sensitivity following prolonged drug exposure. The resistant phenotype in 11B-MTX-P cells were characterised by a 5.6-fold decrease in FPGS activity. These results suggest that different mechanisms of methotrexate resistance in HNSCC cells in vitro can be obtained dependent on the schedule of exposure to the drug.

Membrane transport of methotrexate in a squamous carcinoma cell line adapted to low folate concentrations

Membrane transport characteristics of the folate analogue methotrexate (MTX) were studied in a human squamous carcinoma cell line of the head and neck (HNSCC) adapted to grow in tissue culture media with nanomolar reduced folate concentrations (SCC-11B-LF), as compared to SCC-11B cells grown in standard medium containing high folate concentrations. We observed that SCC-11B-LF cells exhibited a 10.5-fold increased uptake of [3H]-MTX via the reduced folate/MTX carrier system compared to SCC-11B cells. Affinity labelling of the reduced folate/MTX carrier system suggests that the up-regulation of [3H]-MTX transport mainly results from an increased rate of carrier translocation, and only to a minor extent (15-20%) from an increased amount of carrier protein. The upregulation of MTX transport resulted in a 2.4-fold increased growth inhibitory effect by MTX. These results suggest that membrane transport may play a more important role in MTX-cytotoxicity when SCC-11B cells in vitro are grown in more physiological folate concentrations.