TORPEdO: A phase III trial of intensity-modulated proton beam therapy versus intensity-modulated radiotherapy for multi-toxicity reduction in oropharyngeal cancer

•There is a lack of prospective level I evidence for the use of PBT for most adult cancers including oropharyngeal squamous cell carcinoma (OPSCC).•TORPEdO is the UK's first PBT clinical trial and aims to determine the benefits of PBT for OPSCC.•Training and support has been provided before and during the trial to reduce variations of contouring and radiotherapy planning.•There is a strong translational component within TORPEdO. Imaging and physics data along with blood, tissue collection will inform future studies in refining patient selection for IMPT.

Pre-treatment tumour perfusion parameters and initial RECIST response do not predict long-term survival outcomes for patients with head and neck squamous cell carcinoma treated with induction chemotherapy

Objectives

Previously, we showed that pre-treatment tumour plasma perfusion (F_p) predicts RECIST response to induction chemotherapy (ICT) in locoregionally advanced head and neck squamous cell carcinoma (HNSCC). The aim here was to determine whether the pre-treatment tumour F_p estimate, changes in tumour F_p or RECIST response post 2 cycles of ICT were prognostic for long-term survival outcomes.

Methods

A prospective study enrolled patients with high stage HNSCC treated with docetaxel (T), cisplatin (P) and 5-fluorouracil (F) (ICT) followed by synchronous cisplatin and intensity modulated radiotherapy. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before and after two cycles of ICT was used to measure F_p and RECIST response.

Results

Forty-two patients were recruited and 37 underwent two scans. The median follow-up was 36 (range 23–49) months. Pre-treatment tumour F_p (stratified by median) was not prognostic for overall survival (p = 0.42), disease specific survival (p = 0.20) and locoregional control (p = 0.64). Neither change in tumour F_p nor RECIST response post two cycles of ICT was prognostic for any outcome (p>0.21).

Conclusion

DCE-MRI parameters do not predict long-term survival outcomes following ICT and RECIST response to ICT may not be an appropriate endpoint to determine early efficacy of a treatment in HNSCC patients.

Taxane, platinum and 5-FU prior to chemoradiotherapy benefits patients with stage IV neck node-positive head and neck cancer and a good performance status

PURPOSE

The benefit of adding docetaxel, cisplatin and 5-fluorouracil (TPF) induction chemotherapy to chemoradiotherapy (CRT) in head and neck squamous cell carcinoma (HNSCC) remains uncertain. We aimed to investigate whether ICT is well tolerated when given with prophylactic treatment against predicted adverse effects and which patients benefit most.

METHODS

A single-centre audit identified 132 HNSCC patients with stage IVa/b neck node-positive disease, prescribed TPF followed by CRT. TPF involved three cycles of docetaxel (75 mg/m² IV) and cisplatin (75 mg/m² IV) on day 1 plus 5-FU (750 mg/m² IV) on days 2-5. Planned CRT was 66 Gy in 30 fractions of intensity-modulated radiotherapy with concurrent cisplatin (100 mg/m² IV) at the beginning of week 1 and 4 (days 1 and 22). All patients received prophylactic antibiotics and granulocyte colony-stimulating factor.

RESULTS

Median follow-up was 39.5 months. 92.4% of patients completed three cycles of TPF; 95.5% of patients started chemoradiotherapy. Grade 3/4 adverse events were low (febrile neutropenia 3.0%), with no toxicity-related deaths. 3-year overall survival was 67.2%; disease-specific survival was 78.7%; locoregional control was 78.3%. Distant metastases rate was 9.8% (3.0% in those without locoregional recurrence). Good performance status (p = 0.002) and poor tumour differentiation (p = 0.018) were associated with improved overall survival on multivariate analysis.

CONCLUSION

With prophylactic antibiotics and granulocyte colony-stimulating factor TPF was well tolerated with good survival outcomes. TPF should remain a treatment option for stage IV neck node-positive patients with a good performance status. The use of tumour grade to aid patient selection for TPF warrants investigation.

Transoral laser microsurgery versus radiotherapy for T2 glottic squamous cell carcinoma: a systematic review of local control outcomes

BACKGROUND

Systematic reviews comparing treatment of early glottic cancer with transoral surgery or radiotherapy demonstrate similar oncological outcomes. Most studies of 'early-stage' laryngeal cancer include Tis, T1a, T1b and T2 cases. The data are dominated by patients with T1 and Tis tumours, although extrapolating these results and applying them for T2 cases may be inappropriate. No previous systematic reviews have focused on T2 cancers as a separate group.

OBJECTIVE OF REVIEW

This review compares local control outcomes for T2 glottic squamous cell carcinoma, treated with transoral microsurgery or external beam radiotherapy.

TYPE OF REVIEW

This is a systematic review of case series and comparison studies, focusing on oncological outcomes.

SEARCH STRATEGY

Independent searches of MEDLINE, EMBASE and the Cochrane Database were conducted by two authors, using the search terms: laryngeal/glottic/vocal cord combined with carcinoma/cancer/tumour and laser/microsurgery or radiotherapy. Studies of adult patients treated for primary T2N0 glottic squamous cell carcinoma (SCC) with laser surgery or curative radiotherapy were included.

EVALUATION METHOD

Full text of studies satisfying the inclusion criteria were reviewed with extraction of local control and survival data and laryngeal preservation rates. The primary endpoint is local control at 5 years.

RESULTS

Initial searches identified 3252 studies. Following full-text review of 183 papers, 59 studies met the inclusion criteria, all level IV evidence. A total of 48 studies specified 5-year local control for 1156 patients treated with transoral laser surgery and 3191 patients treated with radiotherapy. Weighted averages of local control at 5 years demonstrated similar results: 75.81% for radiotherapy versus 77.26% for transoral laser surgery.

CONCLUSIONS

The results of this review indicate no difference in 5-year local control between radiotherapy and transoral surgery for T2 glottic SCC. The data demonstrated higher rates of local failure for T2b compared with T2a cases, although outcomes were similar between laser excision and radiotherapy for each substage. Further research focusing upon functional outcomes for T2 glottic tumours is imperative to guide decision-making, ideally with subgroup analysis of T2a and T2b cases.

Role of 18-Fludeoxyglucose positron emission tomography-computed tomography and subsequent panendoscopy in head and neck squamous cell carcinoma of unknown primary

OBJECTIVES/HYPOTHESIS

Head and neck squamous cell carcinomas of unknown primary (HNSCCUP) accounts for up to 10% of presenting head and neck squamous cell carcinomas. Identification of the primary site allows for directed therapy. Where initial investigations have failed to locate the primary site, 18-fludeoxyglucose positron emission tomography-computed tomography (PET/CT) has emerged as a useful tool with improved sensitivity over positron emission tomography alone. Following PET/CT scan, the role of subsequent panendoscopy ± biopsy has not been fully assessed. We aim to evaluate and quantify the role of PET/CT and subsequent panendoscopy in HNSCCUP.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients with HNSCCUP presenting between January 2005 and December 2010 at a regional oncology referral center were studied. All patients who presented with a metastatic neck node and unknown primary who had undergone PET/CT prior to panendoscopy were included. The accuracy of PET/CT was calculated and compared with panendoscopy and histopathological findings.

RESULTS

Fifty-two patients were included. Twenty-seven PET/CT scans suggested a primary site. Calculated diagnostic parameters were 83% sensitivity, 87% specificity, positive predictive value 89%, and negative predictive value 80%. Three false-positive PET/CT scans were noted after panendoscopy and normal histology. Importantly, three confirmed tongue base tumors were found on panendoscopy, which were undetected on PET/CT.

CONCLUSIONS

PET/CT is a valuable resource for locating tumors in HNSCCUP. It helps direct biopsy and aids in the detection of local and distant metastases along with synchronous primary tumors. Importantly, due to both false-positive and false-negative PET/CT rates, panendoscopy and biopsy remains an essential adjunct investigation irrespective of PET/CT results.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:1354-1358, 2016.

Tumor plasma flow determined by dynamic contrast-enhanced MRI predicts response to induction chemotherapy in head and neck cancer

OBJECTIVES

Non-response to induction chemotherapy (IC) occurs in 30% of head and neck squamous cell carcinoma (HNSCC) and has been predicted by tumor plasma flow (Fp) derived by perfusion computed tomography. The present study was designed to test whether baseline tumor Fp determined by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) would predict IC response.

MATERIALS AND METHODS

A prospective open study powered to test the relationship between tumor Fp and response to IC (docetaxel, cisplatin, 5-fluorouracil) enrolled 50 patients with stage IV HNSCC. Response after two IC cycles was measured by MRI using Response Evaluation Criteria in Solid Tumors in 37 patients. Tumor Fp (primary end point) and multiple parameters in tumors and lymph nodes (secondary end points) were generated at baseline. Differences in baseline DCE-MRI parameters according to IC response were assessed by the Mann-Whitney U test, and predictive value by receiver operating characteristic (ROC) analysis.

RESULTS

Median baseline tumor Fp was 53.2ml/100ml/min in 25 responders and 23.9 in 12 non-responders (U 82; P=0.027; area under ROC curve (AUC) 0.73). Median baseline Fp in lymph nodes was 25.8ml/100ml/min for 37 nodes in 25 responders and 17.1 for 15 nodes in 12 non-responders (U 186, P=0.066; AUC 0.67). Frequency of IC response in 37 patients was 68% overall, 83% for tumor Fp above the median (40.6ml/100ml/min) and 45% below the median. Other DCE-MRI parameters were not associated with IC response.

CONCLUSION

Pre-treatment tumor Fp determined by DCE-MRI predicts IC response in HNSCC.

Prognostic value of hypoxia-associated markers in advanced larynx and hypopharynx squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

To determine the prognostic value of hypoxia-associated markers carbonic anhydrase-9 (CA-9) and hypoxia-inducible factor-1α (HIF-1α) in advanced larynx and hypopharynx squamous cell carcinoma (SCCa) treated by organ preservation strategies.

STUDY DESIGN

Retrospective cohort study.

METHODS

Pretreatment CA-9 and HIF-1α expression, clinicopathologic data, and tumor volume were analyzed in a series of 114 patients with T3-4 SCCa larynx or hypopharynx treated by (chemo)radiation.

RESULTS

Adverse prognostic factors for locoregional control were T4 classification (P = 0.008), and for disease-specific survival were CA-9 positivity (P = 0.039), T4 classification (P = 0.001), larger tumor volume (P = 0.004), N1-3 classification (P = 0.002), and pretreatment hemoglobin < 13.0 g/dl (P = 0.014). With increasing CA-9 expression, there was a trend to increasing tumor recurrence (P trend = 0.009) and decreasing survival (P trend = 0.002). On multivariate analysis, independent variables were T4 classification (hazard ratio [HR] 13.54, P = 0.01) for locoregional failure, and CA-9 positivity (HR = 8.02, P = 0.042) and higher tumor volume (HR = 3.33, P = 0.007) for disease-specific mortality.

CONCLUSION

This is the first study to look specifically at T3 and T4 SCCa larynx and hypopharynx for a relationship between hypoxia-associated marker expression and clinical outcome. Pretreatment immunohistochemical CA-9 expression is an adverse prognostic factor for disease-specific survival, indicating that CA-9 expression may confer a more aggressive tumor phenotype.

A 26-gene hypoxia signature predicts benefit from hypoxia-modifying therapy in laryngeal cancer but not bladder cancer

PURPOSE

Tumor hypoxia is associated with a poor prognosis, hypoxia modification improves outcome, and hypoxic status predicts benefit from treatment. Yet, there is no universal measure of clinical hypoxia. The aim of this study was to investigate whether a 26-gene hypoxia signature predicted benefit from hypoxia-modifying treatment in both cancer types.

EXPERIMENTAL DESIGN

Samples were available from 157 T2-T4 laryngeal cancer and 185 T1-T4a bladder cancer patients enrolled on the accelerated radiotherapy with carbogen and nicotinamide (ARCON) and bladder carbogen nicotinamide (BCON) phase III randomized trials of radiotherapy alone or with carbogen and nicotinamide (CON) respectively. Customized TaqMan low density arrays (TLDA) were used to assess expression of the 26-gene signature using quantitative real-time PCR. The median expression of the 26 genes was used to derive a hypoxia score (HS). Patients were categorized as TLDA-HS low (≤median) or TLDA-HS high (>median). The primary outcome measures were regional control (RC; ARCON) and overall survival (BCON).

RESULTS

Laryngeal tumors categorized as TLDA-HS high showed greater benefit from ARCON than TLDA-HS low tumors. Five-year RC was 81% (radiotherapy alone) versus 100% (CON) for TLDA-HS high (P=0.009). For TLDA-HS low, 5-year RC was 91% (radiotherapy alone) versus 90% (CON; P=0.90). TLDA-HS did not predict benefit from CON in bladder cancer.

CONCLUSION

The 26-gene hypoxia signature predicts benefit from hypoxia-modifying treatment in laryngeal cancer. These findings will be evaluated in a prospective clinical trial.

Nasopharyngeal carcinoma: a retrospective review of demographics, treatment and patient outcome in a single centre

AIMS

Nasopharyngeal cancer (NPC) is relatively uncommon, especially in the Western world. We report our single institution experience of 20 years of data in 128 patients with NPC, including responses to different treatment modalities and outcomes by histological subtype.

MATERIALS AND METHODS

NPC patients presenting from 1992 to 2005 were located on the cancer registry database. Demographic data included age, gender, length of presenting symptoms and stage. World Health Organization classification (2005) was used for histological subtyping. The date of recurrence and survival outcomes were analysed using Kaplan-Meier curves.

RESULTS

Presentation data were analysed from 128 patients; the survival analysis included 123 patients. The median age at presentation was 57.7 years. Stage III and IV presentation rates were 34 and 38%, respectively. The most common presenting symptom was a palpable neck lump (55%) and the median duration of symptoms was 16 weeks. Forty-eight patients received radiotherapy alone and 75 received chemoradiotherapy. The median overall survival in chemoradiotherapy patients was 80.3 months versus 28.5 months with radiotherapy alone (P = 0.003). A significant difference was also seen with recurrence-free survival (RFS) (P = 0.017). Type 1 keratinising carcinoma had a significantly worse overall survival (P = 0.04) and a similar but non-statistically significant trend was seen for RFS (P = 0.051). The multivariate analysis for overall survival showed that histological subtype (hazard ratio 2.7, 95% confidence interval 1.3-5.5, P = 0.034), age (hazard ratio 2.3, 95% confidence interval 1.1-4.9, P = 0.018) and N stage (hazard ratio 3.7, 95% confidence interval 1.4-9.4, P = 0.024) were prognostic factors.

CONCLUSIONS

We present the first large-scale, single-centre retrospective review of NPC in a UK-based population. Demographic data were similar to that in other Western populations, with a significantly worse survival outcome in the keratinising group. Further prospective study of outcome in Western populations accounting for newer radiotherapy techniques such as intensity-modulated radiotherapy and dose escalation, particularly in the keratinising population who were more likely to present with an isolated local recurrence, is recommended.

Prospective technical validation and assessment of intra-tumour heterogeneity of a low density array hypoxia gene profile in head and neck squamous cell carcinoma

BACKGROUND AND PURPOSE

Tumour hypoxia is associated with a poor prognosis in head and neck squamous cell carcinoma (HNSCC), however there is no accepted method for assessing hypoxia clinically. We aimed to conduct a technical validation of a hypoxia gene expression signature using the TaqMan Low Density Array (TLDA) platform to investigate if this approach reliably identified hypoxic tumours.

MATERIALS AND METHODS

Tumour samples (n=201) from 80 HNSCC patients were collected prospectively from two centres. Fifty-three patients received pimonidazole prior to surgery. TaqMan Low Density Array-Hypoxia Scores (TLDA-HS) were obtained by quantitative real-time PCR (qPCR) using a 25-gene signature and customised TLDA cards. Assay performance was assessed as coefficient of variation (CoV).

RESULTS

The assay was sensitive with linear reaction efficiencies across a 4 log(10) range of inputted cDNA (0.001-10 ng/μl). Intra- (CoV=6.9%) and inter- (CoV=2.0%) assay reproducibility were excellent. Intra-tumour heterogeneity was lower for TLDA-HS (23.2%) than for pimonidazole (67.2%) or single gene measurements of CA9 (62.2%), VEGFA (45.0%) or HIG2 (39.4%). TLDA-HS in HNSCC cell lines increased with decreasing pO(2). TLDA-HS correlated with Affymetrix U133 Plus 2.0 microarray HS (p<0.01) and positive pimonidazole scores (p=0.005).

CONCLUSIONS

Gene expression measurements of hypoxia using a 25-gene signature and TLDA cards are sensitive, reproducible and associated with lower intra-tumour heterogeneity than assaying individual genes or pimonidazole binding. The approach is suitable for further assessment of prognostic and predictive capability in clinical trial material.

Molecular and cellular processes underlying the hallmarks of head and neck cancer

The hallmarks of cancer were updated by Hanahan and Weinberg in 2011. Here we discuss the updated hallmarks in relation to what is known of the molecular and cellular processes underlying the development of head and neck squamous cell carcinoma (HNSCC). Several mechanisms are described, and recent surveys of HNSCC suggest a limited number of mutations, from which more mechanisms may emerge. There are also epigenetic changes to the control of normal processes. More than one mechanism underlies each hallmark. Processes essential to the development of HNSCC need not be essential to the proliferation of the fully developed tumour. Attention is paid to the emerging hallmarks, deregulation of cellular energy metabolism and evasion of immune destruction, and enabling characteristics, genome instability and mutation and tumour-promoting inflammation. HNSCC may adapt to hypoxia, suppress HLA expression, and express Toll-like receptors to facilitate inflammation, which support the proliferation of the tumour.

Lack of prognostic effect of carbonic anhydrase-9, hypoxia inducible factor-1α and bcl-2 in 286 patients with early squamous cell carcinoma of the glottic larynx treated with radiotherapy

AIMS

To evaluate the prognostic significance of potential tumour markers of hypoxia and apoptosis in early squamous cell carcinoma of the glottic larynx managed with radiotherapy.

MATERIALS AND METHODS

In total, 382 patients with T1 and T2 squamous cell carcinoma of the glottic larynx (vocal cords) received radical radiotherapy (50-55 Gy, in 16 fractions in 98% of cases). Pre-treatment haemoglobin was available for 328 patients; biopsy samples were available for 286. Immunohistochemistry was carried out for carbonic anhydrase-9 (CA-9), hypoxia inducible factor-1α (HIF-1α) and Bcl-2.

RESULTS

At 5 years, locoregional control was achieved in 88.2%, cancer-specific survival in 95.0% and overall survival in 78.7%. Adverse prognostic factors for locoregional tumour recurrence were pre-treatment haemoglobin <13.0 g/dl (P = 0.035, Log rank test; sensitivity 0.28, specificity 0.84) and stage T2 rather than T1 (P = 0.002). The effect of haemoglobin level on locoregional control was not significant when stratified by the median of 14.2 g/dl (P = 0.43) or as a continuous variable (P = 0.59). High CA-9 (P = 0.11), HIF-1α (P = 0.67) and Bcl-2 (P = 0.77) expression had no prognostic significance.

CONCLUSIONS

High CA-9, HIF-1α and Bcl-2 do not add to the prognostic significance of tumour stage and lower haemoglobin in predicting failure of local control in early glottic larynx squamous cell carcinoma managed with radiotherapy. The effect of haemoglobin was not strong enough to be useful as a prognostic biomarker.

Abstract LB-440: Low density array profiling of head and neck squamous cell carcinoma utilizing a 25-gene signature can reliably identify hypoxic tumors

Purpose: Administering hypoxia modifying therapy to patients with head and neck squamous cell carcinoma (HNSCC) improves outcomes in those with identified hypoxic tumors. As no method for measuring tumor hypoxia has demonstrated clinical utility, this study aimed to validate use of a gene expression signature with a TaqMan Low Density Array (TLDA) platform. Experimental design: Tumor samples (n=201) from 80 HNSCC patients were collected prospectively from two centers. Fifty-three patients received pimonidazole prior to surgery. Hypoxia scores (TLDA HS) were obtained by quantitative real-time PCR (qPCR) using a 25-gene signature and customized TLDA cards. Assay performance was assessed as coefficient of variation (CoV). Relationships with outcome were determined by log-rank analysis. Results: The assay was sensitive with linear reaction efficiencies across a 4log10 range of inputted cDNA (0.001-10 ng/µl). Intra- (CoV=0.5%) and inter- (CoV=0.1%) assay reproducibility were excellent. Intra-tumor heterogeneity was lower for TLDA HS (23.2%) than for pimonidazole (67.2%) or single gene measurements of CA9 (62.2%), VEGFA (45.0%) or HIG2 (39.4%). TLDA HS in HNSCC cell lines increased with decreasing pO2 and was reduced but not completely abrogated in HIF1A silenced cells. TLDA HS correlated with Affymetrix U133 Plus 2.0 microarray HS (p&lt;0.01) and pimonidazole scores (p=0.021). High TLDA HS was associated with worse overall (p=0.037) and recurrence free (p=0.036) survival. Conclusions: Gene expression measurements of hypoxia using a 25-gene signature and TLDA cards are sensitive, reproducible and associated with lower intra-tumor heterogeneity than assaying individual genes or pimonidazole binding. The approach is suitable for application in clinical trials.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-440. doi:1538-7445.AM2012-LB-440

Parotid Gland Tumors: A Survey of UK Management Practice

Objective: Identify if practice variations exist in the management of parotid lesions between otolaryngologists and oral maxillofacial specialists (OMFS). Benign and malignant parotid surgery is undertaken by both otolaryngologists and OMFS. Between the specialties there is debate about the surgical approach to parotid tumors.

Method: An online questionnaire (SurveyMonkey) was sent to members of ENT-UK via email. The members of the British Association of Oral and Maxillofacial Surgeons (BAOMS) were posted a questionnaire that was either returned by post or completed online.

Results: A total of 108 otolaryngologists and 98 OMFS res-ponded to the questionnaire, all of whom performed parotid surgery. The majority (75.2%) of otolaryngologists used facial nerve monitors in all/most cases whereas 73.1% OMFS used them never/seldom. In revision surgery 88.3% of otolaryngologists mostly/always used a facial monitor compared to 38% of OMFS with 39.1% never/seldom using one. The choice of surgery for a presumed pleomorphic adenoma showed the most difference between the two groups: 87.6% of otolaryngologists would perform a partial parotidectomy, yet 34.5% of OMFS would remove the tumor by extracapsular dissection of the tumor without a cuff.

Conclusion: There are marked differences in the approach to parotid disease between OMFS and otolaryngologists, particularly in the intra-operative monitoring and the surgical approach.

Mucosal melanoma of the head and neck: radiotherapy or surgery?

INTRODUCTION

Head and neck mucosal melanoma (MuM) is rare, comprising < 1% of all melanomas in Western Europe.

METHODS

A retrospective analysis of case records of patients treated between 1965 and 2001 was carried out. (Survival outcomes were obtained from the case notes and cancer registry.) The median age of the 68 patients was 63 years (range 29-86 years). Thirty-nine percent were male, and 61% were female. (The minimum follow-up time was 15 months.) The two most common primary sites were the sinonasal complex (65%) and oral cavity (19%). Twenty-one percent of patients presented with metastases (nodal or distant). Fifty-five patients were treated with curative intent: 30 patients with primary radiotherapy and 25 patients with surgery +/- postoperative radiotherapy.

RESULTS

The overall survival was 22% at 5 years, and the cancer-specific survival was 32% at 5 years.

CONCLUSION

MuM has a poor overall prognosis. Poor prognostic indicators are site at presentation and presentation with metastasis. This series is unique in that a significant proportion of patients were given primary radiotherapy as definitive treatment. Surgery may have advantages, particularly for oral cavity MuM. In contrast to previous reports, definitive radiotherapy is worthy of consideration as curative treatment.

The role of nervus intermedius in side specific nasal responses

BACKGROUND

Nervus intermedius (NI) dysfunction is common in patients who have had vestibular schwannoma (VS) surgery. Such patients have a unilateral parasympathetic-denervated nasal cavity. A number of side-specific nasal reflexes have been demonstrated in normal individuals, including hand cold-water immersion. It is not understood whether these reflexes have parasympathetic or sympathic efferent pathways. We aimed to evaluate the side specific nasal reflex to cold-water immersion in post-operative VS patients with NI dysfunction, in order to determine the nature of the efferent pathway of these reflexes.

METHOD

Side specific responses to cold-water immersion were tested by acoustic rhinometry in 10 normal individuals and 18 patients with NI dysfunction (proven by Schirmer s test) after VS surgery.

RESULTS

A consistent pattern of ipsilateral congestion and contralateral decongestion after the cold-water immersion was seen in normal individuals (p smaller than 0.001). We found no consistent response in VS patients both ipsilateral and contralateral to the side of NI dysfunction.

CONCLUSIONS

We confirm the consistent side-specific nasal reflexes to cold-water hand immersion in normal individuals. This is disturbed in patients with NI dysfunction. We have also shown unexpectantly that the contralateral side-specific reflex is disturbed in these patients. These data suggest that the reflex is parasympathetic and crosses the midline.

Potential risk factors associated with the use of cidofovir to treat benign human papillomavirus-related disease

BACKGROUND

Cidofovir is currently being used off-licence to treat different viral infections, such as benign low-risk human papillomavirus (HPV)-related recurrent respiratory papillomatosis (RRP). There are concerns over the safety of this practice as rat studies demonstrated a high malignant transformation rate. As yet, there are no clinical reports of cidofovir-induced malignant changes in humans.

METHODS

Telomerase immortalised human keratinocytes (hTert) stably expressing E6 proteins from either low-risk HPV6b or high-risk HPV16 and vector control cells were treated with either low-dose (5 microg/ml) or higher dose (30 microg/ml) cidofovir for 2 days and the effects evaluated by clonogenic survival assays. Based on these results, gene expression microarray analysis was performed on cidofovir-treated low-risk E6 and vector cells before, during and after drug treatment, and the results verified by real-time PCR.

RESULTS

Both low-risk and high-risk E6-expressing cells show significantly improved long-term survival compared with vector control cells when exposed to 5 microg/ml cidofovir for 2 days, (hTert T6E6 P=0.0007, hTert T16E6 P=0.00023 and hTert vector control P=0.62). Microarray and real-time PCR analyses of low-dose cidofovir-treated low-risk E6-expressing cells revealed changes in gene expression that are known to be associated with malignant progression, which were not observed in drug-treated vector control cells.

CONCLUSIONS

This is the first report that cidofovir can both increase cell survival and induce alterations in gene expression that are known to be associated with malignant transformation in cells transduced only with the E6 gene from low-risk HPV. It is our belief that these data provide cause for concern over the off-license use of this drug to treat RRP.

Effect of temporal bone resection on temporomandibular joint function: a quality of life study

OBJECTIVES

Temporal bone resection for carcinoma may affect quality of life (QOL) and result in temporomandibular joint (TMJ) disorders. The aims of this study were to 1) assess TMJ function after temporal bone resection, and 2) assess the impact of TMJ dysfunction on QOL.

STUDY DESIGN

Chart and patient review and QOL study.

SETTING

Tertiary referral center (Manchester Royal Infirmary).

SUBJECTS AND METHODS

Thirty patients who had undergone temporal bone resection were identified. Thirteen patients were alive and were included in the study. All patients were submitted to a clinical examination to identify TMJ disorders and determine facial nerve function, and they all answered the University of Washington QOL (UW-QOL) questionnaire (version 4).

RESULTS

Eight patients had TMJ disorders with reduced mobility in either direction and/or significant pain. Main factors affecting QOL were pain (P = 0.001), appearance (P = 0.001), and anxiety (P = 0.000). Neither facial nerve palsy nor TMJ disorders affected QOL. The responses to the UW-QOL questionnaire showed that 69 percent of our patients had a good QOL. A total of 61.53 percent of our patients had TMJ dysfunction presenting as restriction of jaw mobility with or without pain.

CONCLUSION

TMJ dysfunction is present in a significant number of patients after temporal bone resection, resulting in longstanding problems, which should be addressed accordingly. Poor QOL results from ongoing pain and psycho-social disturbance.

The role of HPV type in Recurrent Respiratory Papillomatosis

OBJECTIVE

Human Papillomavirus (HPV) 6 and 11 are the aetiological agents responsible for Recurrent Respiratory Papillomatosis (RRP). There is general consensus that HPV11 results in more aggressive disease compared to HPV6.

METHOD

Pubmed was searched using the terms respiratory papillomatosis, HPV 6 and HPV11. Comparisons were made in the outcomes of HPV6 versus HPV11 positive RRP disease.

RESULTS

There are numerous sub-types or variants of both HPV6 and HPV11. These sub-types have different activities at least in-vitro. The numbers of different HPV types within RRP tissue may be more extensive than initially appeared. This depends specifically upon the HPV types tested for.

CONCLUSION

The clinical differences between HPV6 and HPV11 disease may not be accurately predictable as these viruses exist in numerous sub-types. Also, RRP tissue may contain more than one subtype or even be co-infected with other viruses that may influence outcome. In-vitro studies upon cell lines are a reasonable starting point for evaluation of these differences.

Exon array analysis of head and neck cancers identifies a hypoxia related splice variant of LAMA3 associated with a poor prognosis

The identification of alternatively spliced transcript variants specific to particular biological processes in tumours should increase our understanding of cancer. Hypoxia is an important factor in cancer biology, and associated splice variants may present new markers to help with planning treatment. A method was developed to analyse alternative splicing in exon array data, using probeset multiplicity to identify genes with changes in expression across their loci, and a combination of the splicing index and a new metric based on the variation of reliability weighted fold changes to detect changes in the splicing patterns. The approach was validated on a cancer/normal sample dataset in which alternative splicing events had been confirmed using RT-PCR. We then analysed ten head and neck squamous cell carcinomas using exon arrays and identified differentially expressed splice variants in five samples with high versus five with low levels of hypoxia-associated genes. The analysis identified a splice variant of LAMA3 (Laminin α 3), LAMA3-A, known to be involved in tumour cell invasion and progression. The full-length transcript of the gene (LAMA3-B) did not appear to be hypoxia-associated. The results were confirmed using qualitative RT-PCR. In a series of 59 prospectively collected head and neck tumours, expression of LAMA3-A had prognostic significance whereas LAMA3-B did not. This work illustrates the potential for alternatively spliced transcripts to act as biomarkers of disease prognosis with improved specificity for particular tissues or conditions over assays which do not discriminate between splice variants.

Alternative splicing is the process by which cells express a set of different, but related, transcripts from a single gene. When translated, each transcript results in a different protein, resulting in additional cellular complexity. Affymetrix Exon microarrays, which feature multiple probesets targeting different locations throughout each gene, allow the changes in transcription that result from alternative splicing to be investigated in a single genome-wide assay. In addition, the increased number of probesets targeting each gene offers the potential to combine signals in order to increase statistical power, allowing smaller changes to be detected reliably. We developed a novel algorithm to exploit both these aspects of exon arrays and applied it to tumour hypoxia in clinical samples. Our method identified 4 potential transcript variants upregulated in hypoxic cancers, including a splice variant of the Laminin alpha 3 gene, which we were then able to validate by other methods. On further investigation, we found that expression of this particular isoform in head and neck cancers was a strong adverse prognostic factor for survival following primary surgical treatment. This shows that exon arrays can be used to identify clinically relevant splicing events with potential utility as prognostic biomarkers.

Cidofovir induces an increase in levels of low-risk and high-risk HPV E6

BACKGROUND

Cidofovir is a nucleoside analogue that is used off-license to treat recurrent respiratory papillomatosis (RRP) caused by HPV6/11. However, the effect of this drug upon low-risk HPV 6/11 gene expression is unknown.

METHODS

The expression of E6 was evaluated by RT-PCR in HPV-ve C33A cervical carcinoma cells stably transfected with both low- and high-risk HPV E6 cDNA's and in SiHa (HPV16+ve) cervical carcinoma cells after treatment with 2 doses and durations of exposure to cidofovir.

RESULTS

Compared to the vector only transcript, E6 RNA levels showed an 8-fold increase in low-risk and 20-fold increase in high-risk E6-expressing cells. High-risk E6 protein levels were also detected by Western blot in cidofovir-treated C33A Type16 E6-transfected cells.

CONCLUSION

These data may indicate a potential rationale for increased risk of genetic instability and thus transformation due to drug-induced increase in the level of E6.

The impact of radiotherapy on swallowing and speech in patients who undergo total laryngectomy

OBJECTIVES

Quality of life studies have shown no detrimental effect with radiotherapy (RT) in patients who have a total laryngectomy. We wished to determine the effect of RT (initial or postoperative) specifically on the swallowing and voice function in patients treated by total laryngectomy (TL) for carcinoma of the larynx.

DESIGN

Multicenter chart review.

SETTING

Multicenter study in the Greater Manchester and Lancashire area.

PARTICIPANTS

A total of 121 postlaryngectomy patients all of whom had completed definitive treatment at least 6 months before this study. Twenty-six patients had total laryngectomy as a single modality treatment and 95 had total laryngectomy and radiotherapy.

MAIN OUTCOME MEASURES

Swallowing (solid food, soft diet or fluid/PEG) and voice development.

RESULTS

Swallowing was better in the group who had no radiotherapy (P = 0.0037). There was no difference in voice function between the two groups. We also demonstrated that females had a worse swallowing outcome (P = 0.0101), as did advanced nodal stage (P = 0.001).

CONCLUSIONS

RT adversely affects the swallowing results but not the speech results after TL when given either as initial treatment or postoperatively. This should be kept in mind in the decision-making process in the treatment of patients with carcinoma of the larynx.

Audit of clinical coding of major head and neck operations

INTRODUCTION

Within the NHS, operations are coded using the Office of Population Censuses and Surveys (OPCS) classification system. These codes, together with diagnostic codes, are used to generate Healthcare Resource Group (HRG) codes, which correlate to a payment bracket. The aim of this study was to determine whether allocated procedure codes for major head and neck operations were correct and reflective of the work undertaken. HRG codes generated were assessed to determine accuracy of remuneration.

PATIENTS AND METHODS

The coding of consecutive major head and neck operations undertaken in a tertiary referral centre over a retrospective 3-month period were assessed. Procedure codes were initially ascribed by professional hospital coders. Operations were then recoded by the surgical trainee in liaison with the head of clinical coding. The initial and revised procedure codes were compared and used to generate HRG codes, to determine whether the payment banding had altered.

RESULTS

A total of 34 cases were reviewed. The number of procedure codes generated initially by the clinical coders was 99, whereas the revised codes generated 146. Of the original codes, 47 of 99 (47.4%) were incorrect. In 19 of the 34 cases reviewed (55.9%), the HRG code remained unchanged, thus resulting in the correct payment. Six cases were never coded, equating to pound15,300 loss of payment.

CONCLUSIONS

These results highlight the inadequacy of this system to reward hospitals for the work carried out within the NHS in a fair and consistent manner. The current coding system was found to be complicated, ambiguous and inaccurate, resulting in loss of remuneration.

Scientific and clinical aspects of the use of cidofovir in recurrent respiratory papillomatosis

OBJECTIVE

Cidofovir is the most contemporary adjuvant treatment for recurrent respiratory papillomatosis (RRP) and its use is increasing. Cidofovir is potentially harmful. Otolaryngologists should understand the science of cidofovir and review the current published data on the effects of this therapy.

METHOD

Pubmed was searched using the terms cidofovir and papillomatosis. Comparisons were made between published articles.

RESULTS

Thirteen articles were identified between 1998 and 2006, representing the treatment of 142 patients. Cidofovir did result in a significant improvement of papillomatous lesions in the majority (60%) of patients despite the use of different regimes of cidofovir administration. There was no unifying protocol in use. A partial response was demonstrated in 29% of patients. 7.5% had no response however, an additional 3.5% patients were lost to follow-up. No malignant change was reported.

CONCLUSION

Cidofovir does appear to be effective in improving the outcome of patients with RRP. There are no reports of malignant transformation despite concerns raised by toxicology studies.

Clinical and biological factors affecting response to radiotherapy in patients with head and neck cancer: a review

OBJECTIVE

The main aim of this article was to review the clinical and biological factors that have been shown to influence the response of the head and neck squamous cell carcinoma (HNSCC) to primary radiotherapy and briefly discuss how some of these factors could be exploited to improve outcome.

DESIGN

Medline based search covering 1982-2006 to identify the HNSCC literature where the effect of clinical and biological factors on locoregional control and overall survival were investigated.

RESULTS

Clinical factors are routinely used in management decisions. Nevertheless, identically staged tumours receiving the same treatment may have different outcomes. Biological factors such as hypoxia, proliferation and radio-sensitivity play an important role in radiation response. However, these are not currently used in practise because tests that are clinically reliable and feasible are not available.

CONCLUSION

High-quality translational research will allow us to develop biological tests that can be used in routine clinical practise to tailor individual treatment, with the ability to improve patient outcome further by modifying the underlying tumour biology.

Effects of cidofovir on a novel cell-based test system for recurrent respiratory papillomatosis

BACKGROUND

Cidofovir has been reported to have activity against human papillomavirus (HPV) type 16, but no laboratory studies have been performed on HPV type 6, the main cause of recurrent respiratory papillomatosis (RRP).

METHODS

HPV6b E6 cDNA-based C33A (non-HPV cervical carcinoma) cell line was produced. Two different doses of cidofovir were applied to parent C33A, C33AT6E6, and C33AT16E6 (HPV 16). Growth and flow cytometry analysis were performed.

RESULTS

Polymerase chain reaction confirmed HPV6 E6 expression in C33AT6E6 cells. High-dose cidofovir was found to be toxic to all cell lines. Low-dose exposure was found to be toxic to C33AT16E6 cells at 3 days, whereas C33A and C33AT6E6 showed minimal toxicity at 6 days and earlier recovery following drug withdrawal.

CONCLUSIONS

Cidofovir showed nonspecific toxicity against all 3 cell lines tested. HPV16 E6 expressing cells were more sensitive than parent or HPV6 E6 expressing cells. Cidofovir has no selective advantage for the RRP-related HPV6 E6 expressing cell line.

Angioedema of the airway: an unusual case

We report a case of angioedema caused by angiotensin-converting enzyme inhibitor and topical lignocaine spray, administered during nasendoscopy.

Angioedema induced by angiotensin-converting enzyme inhibitors is a rare but well known entity. Allergy to topical lignocaine has been acknowledged as a rare phenomenon when used for dental surgery and for skin anaesthesia, but it has not previously been reported after topical administration prior to nasendoscopy. In the reported case, our patient was unfortunate enough to be allergic to both lisinopril and lignocaine. The result was life-threatening airway obstruction, and the continued use of lignocaine spray sustained the laryngeal oedema. We advise that patients are asked about any and every allergy – specifically, any previous problems with dental procedures – before administration of local anaesthetic spray to the upper aerodigestive tract.

Relation of a hypoxia metagene derived from head and neck cancer to prognosis of multiple cancers

Affymetrix U133plus2 GeneChips were used to profile 59 head and neck squamous cell cancers. A hypoxia metagene was obtained by analysis of genes whose in vivo expression clustered with the expression of 10 well-known hypoxia-regulated genes (e.g., CA9, GLUT1, and VEGF). To minimize random aggregation, strongly correlated up-regulated genes appearing in >50% of clusters defined a signature comprising 99 genes, of which 27% were previously known to be hypoxia associated. The median RNA expression of the 99 genes in the signature was an independent prognostic factor for recurrence-free survival in a publicly available head and neck cancer data set, outdoing the original intrinsic classifier. In a published breast cancer series, the hypoxia signature was a significant prognostic factor for overall survival independent of clinicopathologic risk factors and a trained profile. The work highlights the validity and potential of using data from analysis of in vitro stress pathways for deriving a biological metagene/gene signature in vivo.

Should FDG-PET scanning be routinely used for patients with an unknown head and neck squamous primary?

Background: Between 1 and 2 per cent of head and neck squamous cell carcinoma patients will reveal no evidence of a primary malignancy. The management of this group poses many problems, including the morbidity associated with wide field irradiation as well as the difficulty in treatment when a primary does emerge. The aim of this study was to assess the use of fluoro-deoxy-glucose positron emission tomography (FDG-PET) imaging in patients presenting with an unknown head and neck primary and to consider its routine use in such patients.

Methods: We enrolled 25 patients into our study over a four year period. They all presented with a histologically proven, metastatic, squamous cell carcinoma of the neck for which no primary could be found despite full clinical, endoscopic and radiological evaluation with computed tomography (CT) and/or magnetic resonance imaging (MRI). Additionally, all the patients underwent imaging using FDG-PET. The images were interpreted by two radiologists experienced in PET imaging.

Results: A primary was identified in nine of the 25 patients (42 per cent); however, of these patients, six had false positive results and only three patients were true positives with supportive histology. In the remaining 16 patients, no abnormality was identified on CT, MRI or PET. Of these 16 patients, two eventually displayed a primary carcinoma, the other 14 patients remaining without evidence of any primary.

Conclusion: Despite the high number of positive PET scans, the actual true positive rate was 3/9 (33 per cent); conversely, the true negative rate was 14/16 (88 per cent). We conclude from this study that there is a role for FDG-PET in the patient with an unknown head and neck primary, particularly in the context of a negative PET scan.

Hypoxia in head and neck cancer

A high level of hypoxia in solid tumours is an adverse prognostic factor for the poor outcome of cancer patients following treatment. This review describes the status of research into finding a practical method for measuring hypoxia and treating hypoxic tumours. The application of such methodology would enable the selection of head and neck cancer treatment based on an individual's tumour oxygenation status. This individualization would include the selection not only of surgery or radiotherapy, but also of novel hypoxia-modification strategies.

Synergistic effects of imatinib (STI 571) in combination with chemotherapeutic drugs in head and neck cancer

The tyrosine kinase inhibitor imatinib (STI 571; glivec) is a potent inhibitor of bcr-abl, c-kit and platelet-derived growth factor receptors. Imatinib was evaluated both alone and in combination with established chemotherapeutic agents in adenoid cystic carcinoma (ACC) primary cultures and established cell lines representing squamous cell carcinoma of the head and neck (HNSCC). Over 90% of ACC tumors are c-kit-positive, and these primary cultures proved to be of short-term usefulness in assessing chemosensitivity. Interaction was determined over a wide range of drug combinations using a statistical three-dimensional analysis model. Both ACC short-term cultures and HNSCC cell lines were demonstrated to have a response ranging from additive to synergistic when imatinib and cisplatin were combined. The interaction of imatinib on cisplatin-induced DNA cross-linking was further investigated using the comet-X assay. In contrast, significant antagonism was observed when imatinib and gemcitabine were combined. Since gemcitabine is activated by deoxycytidine kinase (dCK), the effect of imatinib on this enzyme was investigated. A dose-dependent inhibition of dCK was observed, highlighting this kinase as a possible additional secondary molecular target for imatinib. This work demonstrates a synergistic interaction between cisplatin and imatinib, which may prove to be clinically relevant in the future management of both ACC and HNSCC.

Otic drops used to clear a blocked grommet: an in vitro prospective randomized controlled study with blinded assessment

Clinicians often prescribe otic drops anecdotally to try and clear grommets blocked with blood. We carried out an in vitro double-blind randomized controlled study comparing the efficacy of sodium bicarbonate, Locorten Vioform and olive oil drops in clearing Shah grommets placed in 'artificial ears' and blocked with blood in a standardized fashion. There were 33 grommets in each group, and drops were inserted three times a day for 7 days. Olive oil drops cleared 17 of 33 (51.51%), Locorten Vioform cleared one of 33 (3%) and sodium bicarbonate cleared zero of 33 (0%) blocked grommets. Statistical comparison between pairs indicates that olive oil was significantly better than both Locorten Vioform (P < 0.001) and sodium bicarbonate drops (P < 0.001) at clearing grommets blocked with blood.

The assessment of topical nasal drug distribution

The mainstay of treatment of chronic rhinosinusitis is through the administration of topical nasal drugs. The delivery and intranasal distribution of these is therefore of potential clinical significance. Until there is progress in the nasal drug distribution assessment methodology, it will be difficult to improve topical nasal drug delivery, which is known to be suboptimal in many ways. This study reviews intranasal drug delivery assessment methods, the present knowledge and explores future directions for research.

Angiogenesis and the Expression of Vascular Endothelial Growth Factors A and C in Squamous Cell Carcinoma of the Piriform Fossa

BACKGROUND

Angiogenesis is essential for tumor growth and invasion. Vascular endothelial growth factor A (VEGF-A) is a prime mediator of tumor angiogenesis; VEGF-C, another member of the closely related VEGF family of proteins, has major effects on lymphatic endothelial cells and may be important in the process of lymphatic metastasis.

OBJECTIVES

To evaluate the expression of these cytokines in hypopharyngeal squamous cell carcinoma and to ascertain the effects of these proteins on lymphatic metastasis and vascular angiogenesis.

DESIGN

Retrospective analysis of microvessel density and the expression of VEGF-A and VEGF-C.

SETTING

An academic referral center. Subjects Thirty-four patients with stage T2 to T4 squamous cell carcinoma of the piriform fossa.

INTERVENTIONS

Expression of VEGF-A and VEGF-C was determined by immunohistochemistry on formalin-fixed, paraffin-embedded biopsy specimens. Angiogenesis was measured as microvessel density by staining endothelial cells for platelet-endothelial cell adhesion molecule 1/CD31.

RESULTS

Of the 34 tumors, 21 had clinicoradiologic evidence of lymphatic metastasis. Expression of VEGF-C was associated with lymphatic metastasis (P<.001), but not with microvessel density. The VEGF-A expression correlated with microvessel density (P<.001), but neither VEGF-A expression nor microvessel density was associated with lymphatic metastasis.

CONCLUSIONS

The expression of VEGF-C is associated with lymphatic metastasis in squamous cell carcinoma of the piriform fossa. This is not secondary to effects on vascular angiogenesis and is hypothesized to be due to effects on lymphatic endothelial cells.

Soluble Tie-2 receptor levels independently predict locoregional recurrence in head and neck squamous cell carcinoma

BACKGROUND

This study assessed two circulating angiogenic receptors as tumor markers in patients with head and neck squamous cell carcinoma (HNSCC): soluble vascular endothelial factor growth receptor-1 (sVEGFR1) and soluble Tie-2 receptor (sTie2R).

METHODS

Sera from 79 newly presenting patients with HNSCC and from 22 controls were assayed using sandwich ELISA. Median follow-up was 35 months after curative treatment. Analysis was carried out to compare levels between HNSCC patients and controls and to ascertain relationships with clinicopathologic and outcome variables.

RESULTS

Soluble VEGFR1 was not elevated in the HNSCC group and was not related to any of the clinicopathologic or outcome variables. Soluble Tie2R was also not elevated in HNSCC patients or related to the clinicopathologic variables but was associated with locoregional recurrence (p =.009). Raised sTie2R (>64 ng/mL) independently predicted recurrence (p =.007) with a relative risk of 3.0 (95% CI, 1.7-5.0).

CONCLUSIONS

Soluble Tie2R is an independent predictor of locoregional recurrence in HNSCC.

An audit of post-operative analgesia in children following tonsillectomy

Pain following tonsillectomy in children is a significant problem that tends to be underestimated. We audited post-operative pain in 33 children and found significant proportions of children in moderately severe to severe pain, particularly at, or soon after returning to the ward. These findings led to changes in practice that included the administration of pre-operative paracetamol and diclofenac as well as the uniform post-operative prescription of them, with printed instructions to reduce the scope for mistakes by medical staff. Other changes included a uniform policy, with which the nursing staff could become familiar, and the regular formal recording of pain to assist in the recognition of pain and analgesic requirements. On re-auditing two years later, in a group of 100 children, post-operative pain was significantly improved. The proportion experiencing moderately severe to severe pain on returning to the ward, as their maximum pain score and pain score at discharge fell from 70 per cent to 48 per cent, 85 per cent to 56 per cent, and six per cent to two per cent respectively.

Does flying after myringoplasty affect graft take rates?

Flying at altitude soon after myringoplasty may theoretically have an adverse effect on graft take rates owing to variation in external air pressure, together with suboptimal Eustachian tube function, causing graft displacement. We wished to assess the effect of flying after myringoplasty by comparing success rates of patients flying within a week postoperatively (n = 37) with a control group (n = 37) by carrying out a retrospective, controlled cohort study. The primary outcome measure was graft success, defined as a 100% closure at first outpatient follow-up (2.5 months). Our results showed that there was no difference in early graft success rates between the flying group (32/37: 86%) and non-flying group (29/37: 78%)(P = 0.32; 95% CI of difference: -9% to 27%). In conclusion, flying at altitude in a pressurized environment within a week of myringoplasty does not adversely affect early operative success.

Circulating angiogenic cytokines as tumour markers and prognostic factors in head and neck squamous cell carcinoma

This pilot study investigated the potential use of three circulating angiogenesis-related cytokines, basic fibroblast growth factor (bFGF), angiogenin (ANG) and endostatin, as tumour markers and prognostic factors in patients with head and neck squamous cell carcinoma (HNSCC). A total of 30 patients with HNSCC treated with curative intent and 15 healthy controls were studied. Serum (bFGF and ANG) and plasma (endostatin) was assayed by enzyme-linked immunoabsorbance assay (ELISA). None of the cytokines was raised in HNSCC patients when compared with controls. Serum bFGF was not associated with any clinico-pathological or outcome parameters, although there was a trend towards higher levels in more advanced and aggressive tumours. Lower serum angiogenin (sANG) levels were associated with loco-regional disease recurrence (P = 0.036). Using a cut-off level of 400 pg/mL, a low level of sANG predicted tumour recurrence with a relative risk of 4.0 (95% CI: 0.7-24.0). Plasma endostatin was associated with higher histological grade (P = 0.01) and with both disease recurrence (P = 0.045) and death from disease (P = 0.021). Plasma endostatin above a cut-off point of 70 ng/mL could predict tumour recurrence with a relative risk of 4.7 (95% CI: 1.1-19.7). These data suggest that plasma endostatin and sANG have potential roles as prognostic factors and require further investigation.

A quantitative analysis of the intranasal delivery of topical nasal drugs to the middle meatus: spray versus drop administration

The delivery of nasal drugs specifically to the middle meatus is of critical importance in the medical treatment of rhinosinusitis. In this respect, topical nasal drug administration by drops has generally been perceived to be superior to nasal sprays, although there is a lack of evidence to support this notion. This study aims to compare the intranasal delivery of nasal sprays and drops to the middle meatus in vivo, using a novel quantitative method. A surgical patty was placed in the middle meatus. Radio-labelled topical nasal drops and aqueous sprays were administered in a standardized fashion in normal volunteers (10 nasal cavities). The subsequent absorption of administered radio-labelled saline on the patty was measured using a gamma counter. A randomized prospective crossover design was used for the study. The mean percentage (range) of absorbed administered saline on the swab was 8.7 (0.3-39.5) and 9.7 (0.03-20.4) for the spray and drop administration techniques respectively (p = 0.8). Thus, there is wide variation in the delivery of topical nasal drugs and the perceived superiority of nasal drop administration, in terms of delivery to the middle meatus, may be incorrect.

The expression of vascular endothelial growth factor (VEGF) and VEGF-C in early laryngeal cancer: relationship with radioresistance

Angiogenesis is essential for tumour growth and invasion. Vascular endothelial growth factor (VEGF) is a prime mediator of tumour angiogenesis. VEGF-C is a closely related protein that effects lymphatic endothelial cells and may be important in the process of lymphatic metastasis. The purpose of this study was to evaluate the expression of these cytokines in patients with T1 and T2a glottic, squamous cell carcinoma, in comparison with normal epithelial control tissue, to ascertain any association with radioresistance. Twenty-two tumours treated by radiotherapy (13 radiosensitive, nine radioresistant) and seven normal control tissues were studied. The minimum follow-up was 2 years after radiotherapy. Expression of VEGF and VEGF-C was evaluated by immunohistochemistry of formalin-fixed, paraffin-embedded biopsy specimens. Analysis was carried out using a quantitative computer image analyser. Both VEGF and VEGF-C were detectable in tumour and normal control specimens. There was increased expression in tumour specimens of both VEGF (P = 0.03) and VEGF-C (P < 0.001). In addition, the expression of VEGF-C was associated with tumours of higher histological grade (P = 0.021). There was, however, no difference in VEGF and VEGF-C expression between radioresistant and radiosensitive tumours. The expression of VEGF and VEGF-C is increased in early laryngeal squamous cell carcinoma (SCC). However, measuring the expression of these proteins cannot predict radioresistance in this tumour group.

In-the-ear hearing aids within auricular prostheses

We report a child with bilateral congenital microtia in whom cosmetic and auditory rehabilitation has been effected using in-the-ear hearing aids within prostheses overlying the rudimentary external auditory meati after canaloplasty. This novel method of auditory rehabilitation has not been reported before and is suitable in selected cases. The prostheses themselves were successfully secured using a prosthetic contact adhesive we have developed that offers excellent retention, little if any skin reaction, and high patient acceptability.