Quantitative multiplexed quantum dot immunohistochemistry

Quantum dots are photostable fluorescent semiconductor nanocrystals possessing wide excitation and bright narrow, symmetrical, emission spectra. These characteristics have engendered considerable interest in their application in multiplex immunohistochemistry for biomarker quantification and co-localisation in clinical samples. Robust quantitation allows biomarker validation, and there is growing need for multiplex staining due to limited quantity of clinical samples. Most reported multiplexed quantum dot staining used sequential methods that are laborious and impractical in a high-throughput setting. Problems associated with sequential multiplex staining have been investigated and a method developed using QDs conjugated to biotinylated primary antibodies, enabling simultaneous multiplex staining with three antibodies. CD34, Cytokeratin 18 and cleaved Caspase 3 were triplexed in tonsillar tissue using an 8h protocol, each localised to separate cellular compartments. This demonstrates utility of the method for biomarker measurement enabling rapid measurement of multiple co-localised biomarkers on single paraffin tissue sections, of importance for clinical trial studies.

Gene expression analysis of myeloid and lymphoid lineage markers during mouse haematopoiesis

Expression profiling of haematopoietic cells is hampered by the heterogeneous nature of haematopoietic tissues and the absolute rarity of early unrestricted progenitors. To overcome this, the expression profile of lymphoid and myeloid-associated genes (LEF1, EBF, CD19, Sox-4, B29, CD45, C-fms, lysozyme, PU.1 and CD5) were investigated in 40 mouse myeloid haematopoietic precursors covering the entire haematopoietic hierarchy from multipotential to committed single lineages. The lineage-specific expression seen in single-cell studies was confirmed by examining fractionated bone marrow, whole tissues and differentiation of the multipotent cell line FDCP (Factor Dependent Cell Paterson) mix. Analysis of the 40 single myeloid precursors failed to detect expression of lymphoid-associated genes, LEF1, EBF, CD19 and CD5, despite detection in lymphoid cell controls. Surprisingly, the lymphoid-associated genes, Sox-4 and B29 were detected in the single myeloid precursors, which was confirmed in bone marrow and a multipotential myeloid cell line. The pattern of Sox-4 and B29, is consistent with a potential role in the commitment of bipotential granulocytic/macrophage precursors towards the granulocyte or macrophage lineage. In addition to providing baseline values for myeloid and lymphoid lineage markers during mouse haematopoiesis, these results highlight the importance of single-cell analysis in the study of complex tissues.

Colonic epithelial apoptosis during conventional and endoluminal aortic surgery

Background

This study characterized the initial modes of colonic mucosal injury during aneurysm surgery and correlated these with proinflammatory cytokine release into the colonic and systemic circulations.

Methods

Twenty-four patients undergoing conventional open aortic aneurysm repair and ten who had endovascular aneurysm repair (EVAR) were recruited. Mucosal biopsies were taken from the sigmoid colon immediately before and after surgery, for histological examination. Inferior mesenteric vein (IMV) and peripheral blood from patients who had conventional surgery was assayed for interleukin (IL) 1β, IL-6 and tumour necrosis factor (TNF) α. Only peripheral blood from patients who had EVAR was assayed.

Results

Conventional aneurysm repair resulted in a threefold increase in columnar epithelial apoptosis. There was a 26-fold increase in IL-6 in IMV blood within 5 min of reperfusion, with an equivalent rise in peripheral blood after 30 min. A 20-fold rise in peripheral blood TNF-α was observed after surgery. Splanchnic IL-6 correlated positively with cross-clamp time and increased apoptosis. No histological changes were seen after EVAR. There were no intraoperative cytokine changes during EVAR, although a postoperative increase in IL-6 and TNF-α was observed.

Conclusion

The lack of columnar epithelial apoptosis following EVAR reflects the relatively minor ischaemic injury incurred during this procedure.

Intra-tumoural microvessel density in human solid tumours

Over the last decade assessment of angiogenesis has emerged as a potentially useful biological prognostic and predictive factor in human solid tumours. With the development of highly specific endothelial markers that can be assessed in histological archival specimens, several quantitative studies have been performed in various solid tumours. The majority of published studies have shown a positive correlation between intra-tumoural microvessel density, a measure of tumour angiogenesis, and prognosis in solid tumours. A minority of studies have not demonstrated an association and this may be attributed to significant differences in the methodologies employed for sample selection, immunostaining techniques, vessel counting and statistical analysis, although a number of biological differences may account for the discrepancy. In this review we evaluate the quantification of angiogenesis by immunohistochemistry, the relationship between tumour vascularity and metastasis, and the clinicopathological studies correlating intra-tumoral microvessel density with prognosis and response to anti-cancer therapy. In view of the extensive nature of this retrospective body of data, comparative studies are needed to identify the optimum technique and endothelial antigens (activated or pan-endothelial antigens) but subsequently prospective studies that allocate treatment on the basis of microvessel density are required.

Tomato Ve disease resistance genes encode cell surface-like receptors

In tomato, Ve is implicated in race-specific resistance to infection by Verticillium species causing crop disease. Characterization of the Ve locus involved positional cloning and isolation of two closely linked inverted genes. Expression of individual Ve genes in susceptible potato plants conferred resistance to an aggressive race 1 isolate of Verticillium albo-atrum. The deduced primary structure of Ve1 and Ve2 included a hydrophobic N-terminal signal peptide, leucine-rich repeats containing 28 or 35 potential glycosylation sites, a hydrophobic membrane-spanning domain, and a C-terminal domain with the mammalian E/DXXXLphi or YXXphi endocytosis signals (phi is an amino acid with a hydrophobic side chain). A leucine zipper-like sequence occurs in the hydrophobic N-terminal signal peptide of Ve1 and a Pro-Glu-Ser-Thr (PEST)-like sequence resides in the C-terminal domain of Ve2. These structures suggest that the Ve genes encode a class of cell-surface glycoproteins with receptor-mediated endocytosis-like signals and leucine zipper or PEST sequences.

Disappearance of well-differentiated carcinoma of the prostate: effect of transurethral resection of the prostate, prostate-specific antigen, and prostate biopsy

OBJECTIVES

To characterize the effect of prostate-specific antigen (PSA) and transurethral resection of the prostate (TURP) on the rate of diagnosis of well-differentiated (WD) prostate cancer (PCa) and PCa mortality.

METHODS

All cases of PCa and rates of TURP at both Wilford Hall and Brooke Army Medical Centers between 1984 and 1995 were reviewed. Tumor grade was compared between prostate needle biopsy and TURP. The pattern of diagnosis was analyzed annually and for two time periods: pre-PSA (1984 to 1988) and post-PSA (1989 to 1995).

RESULTS

The number of WD tumors fell by 50% over the period of study and was caused by a fall in number of TURPs as well as in WD tumors detected by TURP. PSA for early detection of PCa began in 1988, and within 5 years a more than 50% fall in the rate of metastatic disease was witnessed. These two events (PSA screening and fall in TURPs) led to an increase from 57% to 92% of tumors that were both clinically significant and potentially curable.

CONCLUSIONS

These data help explain the fall in the rate of diagnosis of WD PCa. The resultant increase in the diagnosis of moderately and poorly differentiated PCa, coupled with the dramatic fall in the rate of diagnosis of metastatic PCa, may explain the reports of a fall in PCa mortality. If this observation is replicated in other populations, it may provide further impetus for a stronger recommendation for early detection with PSA and digital rectal examination.

Increased incidence of testicular cancer in active duty members of the Department of Defense

OBJECTIVES

Multiple reports have noted an increase in testicular cancer incidence in virtually all world populations. We sought to determine whether an increase in testicular cancer incidence has occurred in active duty members of the Department of Defense (DOD).

METHODS

The total number of tumors accessioned at all DOD tumor registries, encompassing virtually all tumors diagnosed in active duty personnel, was obtained from the centralized DOD tumor registry. The number of men on active duty in the DOD was obtained from the Defense Manpower Data Center.

RESULTS

The rate of testicular cancer increased from 8.62/100,000 active duty men in 1988 to 15.38/100,000 in 1996.

CONCLUSIONS

These data corroborate observations from multiple other populations that the incidence of testicular cancer is increasing. The explanation for this observation is unknown.

Impact of zidovudine use on risk and risk factors for perinatal transmission of HIV. Perinatal AIDS Collaborative Transmission Studies

OBJECTIVES

To evaluate the impact of perinatal zidovudine use on the risk of perinatal transmission of HIV and to determine risk factors for transmission among women using perinatal zidovudine.

DESIGN

Prospective cohort study of 1533 children born to HIV-infected women between 1985 and 1995 in four US cities.

METHODS

The association of potential risk factors with perinatal HIV transmission was assessed with univariate and multivariate statistics.

RESULTS

The overall transmission risk was 18% [95% confidence interval (CI), 16-21]. Factors associated with transmission included membrane rupture > 4 h before delivery [relative risk (RR), 2.1; 95% CI, 1.6-2.7], gestational age < 37 weeks (RR, 1.8; 95% CI, 1.4-2.2), maternal CD4+ lymphocyte count < 500 x 10(6) cells/l (RR, 1.7; 95% CI, 1.3-2.2), birthweight < 2500 g (RR, 1.7; 95% CI, 1.3-2.1), and antenatal and neonatal zidovudine use (RR, 0.6; 95% CI, 0.4-0.9). For infants exposed to zidovudine antenatally and neonatally, the transmission risk was 13% overall but was significantly lower following shorter duration of membrane rupture (7%) and term delivery (9%). The transmission risk declined from 22% before 1992 to 11% in 1995 (P < 0.001) in association with increasing zidovudine use and changes in other risk factors.

CONCLUSIONS

Perinatal HIV transmission risk has declined with increasing perinatal zidovudine use and changes in other factors. Further reduction in transmission for women taking zidovudine may be possible by reducing the incidence of other potentially modifiable risk factors, such as long duration of membrane rupture and prematurity.

Functional analysis of a replication origin from Saccharomyces cerevisiae: identification of a new replication enhancer

Yeast replication origins have a modular arrangement of essential DNA sequences containing the ARS consensus sequence (ACS) flanked by auxiliary DNA elements which stimulate origin function. One of the auxiliary elements identified at several origins is a DNA replication enhancer that binds the Abf1p protein. We have isolated an ARS sequence from Saccharomyces cerevisiae based on its ability to bind Abf1p. Here we present a detailed molecular dissection of this ARS, designated ARS 1501, and we demonstrate that it functions as a genomic replication origin on chromosome XV . Mutagenesis of the Abf1p DNA-binding sites revealed that these sequences did not contribute significantly to ARS function. Instead, a new DNA element important for replication, designated REN1501, has been located 5' to the T-rich strand of the ACS. We show that REN1501 functions in either orientation and at variable distances from the ACS, defining this element as a DNA replication enhancer. Most significantly, point mutations within this element decreased the stability of plasmids bearing ARS 1501, suggesting that REN1501 binds a protein important for replication initiation. Only three elements found at origins are known to specifically bind proteins. These include the ARS essential sequences and the Abf1p and Rap1p DNA-binding sites. We show that the function of REN1501 at the origin cannot be replaced by a Rap1p DNA-binding site or a site that binds the transcriptional factor Gal4p and can only be partially substituted for by an Abf1p recognition sequence. This implies that the role of the REN1501 element at the ARS 1501 origin is specific, and suggest that the frequency of origin firing in eukaryotic cells may be regulated by origin-specific enhancers.

Natural history of human immunodeficiency virus disease in perinatally infected children: an analysis from the Pediatric Spectrum of Disease Project

OBJECTIVE

To describe the progression of human immunodeficiency virus (HIV) disease through clinical stages from birth to death among a large number of perinatally infected children.

METHODS

The Pediatric Spectrum of Disease (PSD) project, coordinated by the Centers for Disease Control and Prevention (CDC), has conducted active surveillance for HIV disease since 1988 in seven geographic regions. PSD data are collected from medical and social service records every 6 months through practitioners at each participating hospital clinic. We analyzed data from perinatally HIV-infected children born between 1982 and 1993. The natural history of HIV disease was divided into five progressive stages using the clinical categories in the CDC 1994 pediatric HIV classification system: stage N, no signs or symptoms; stage A, mild signs or symptoms; stage B, moderate signs or symptoms; stage C, severe signs or symptoms; and stage D, death. A five-stage Markov model was fitted to the PSD data. To compare the estimates from the PSD project with the published estimates, we also fitted an alternative Markov model using acquired immunodeficiency syndrome (AIDS; 1987 case definition) in place of stage C and also calculated standard Kaplan-Meier estimates.

RESULTS

A total of 2148 perinatally HIV-infected children were included in the analysis. The estimated mean times spent in each stage were: N, 10 months; A, 4 months; B, 65 months; and C, 34 months. We estimated that a child born with HIV infection has a 50% (95% confidence interval [CI], 40%-60%) chance of severe signs or symptoms developing by 5 years of age and a 75% (95% CI, 68%-82%) chance of surviving to 5 years of age. For a child in stage B, there is a 60% (95% CI, 49%-71%) chance of severe signs or symptoms developing within the next 5 years and a 65% (95% CI, 56%-73%) chance of surviving 5 more years. The estimated mean time from birth to stage C was 6.6 (95% CI, 5.7-7.5) years, and the estimated mean survival time from birth was 9.4 (95% CI, 8.1-10.7) years. From the alternative Markov model, the estimated mean time from birth to AIDS was 4.8 (95% CI, 4.5-5.2) years.

CONCLUSION

Markov modeling using the revised pediatric classification system allowed us to describe the natural history of HIV disease in children before diagnosis of AIDS. On average, children progress to moderate symptoms in the second year of life and then remain moderately symptomatic for more than half of their expected lives, underscoring their need for clinical care before the onset of AIDS. The results from the Markov model are useful in family counseling, health care planning, and clinical trial designs.

Characteristics of persons with late AIDS diagnosis in the United States

To describe characteristics of persons with late (at or after death) acquired immunodeficiency syndrome (AIDS) diagnosis, we analyzed national surveillance data among all persons with AIDS diagnosed through December 1991 under the pre-1993 AIDS case definition and with a known date of death. Late diagnosis was present in 15.8% of 163,202 decreased persons with AIDS and in 15.3% of decreased men with AIDS, 20.6% of women, 12.1% of whites, 20.0% of blacks, 21.1% of Hispanics, 12.3% of men who have sex with men (MSM), 21.9% of injecting drug users (IDU), and 19.6% of persons exposed to human immunodeficiency virus (HIV) through heterosexual contact. When age, race/ethnicity, sex, geographic region, and transmission mode were included in logistic regression analyses, among adults/adolescents, late diagnosis was more likely among persons 40 years or older than among those 13-39 years old, among blacks and Hispanics than among whites, and among IDU and persons exposed to HIV through heterosexual contact than among MSM. Although children (less than 13 years of age) were more likely to have late diagnosis than adults and adolescents, late diagnoses among children did not differ significantly by race/ethnicity, sex, geographic region, or transmission mode. Late AIDS diagnosis, especially among ethnic minorities and IDU and their sex partners, may represent delays in HIV diagnosis and care. In addition to not receiving early clinical intervention, persons who are diagnosed later in the course of HIV disease represent missed opportunities for receiving prevention efforts such as education, counseling, and substance abuse treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Laryngeal preservation by induction chemotherapy plus radiotherapy in locally advanced head and neck cancer: the M. D. Anderson Cancer Center experience

Standard treatment of locally advanced laryngeal, hypopharyngeal, and some oropharyngeal cancers includes total laryngectomy. In an attempt to preserve the larynx through induction chemotherapy, we conducted two consecutive phase II studies. From March 1986 to February 1991, 64 patients with advanced untreated but resectable head and neck cancer who would require total laryngectomy were enrolled on one of two cisplatin-based induction regimens: cisplatin-bleomycin-5-fluorouracil (PBF) in 31 patients and cisplatin-5-fluorouracil (PF) in 33; all received definitive radiotherapy. Surgery was reserved for patients who achieved less than a partial response to chemotherapy and patients with residual or recurrent disease after sequential chemotherapy plus radiotherapy. Overall complete plus partial response rates to both cisplatin-based regimens were comparable. The combined PF and PBF overall response rates were 75% for laryngeal cancer, 78% for hypopharyngeal cancer, and 75% for oropharyngeal cancer. Complete response rates after radiotherapy were 88%, 83%, and 50%, respectively. Neutropenia (< 1,000 cells/mm3) was the most common hematologic toxic effect: it occurred in 44% of patients who received PF and 16% of those who received PBF. Grade > or = 3 mucositis occurred in 50% of patients who received PF and 4% who received PBF. The data suggest that laryngeal preservation was feasible in all three primary-site subgroups. With follow-up of 15+ to 54+ months, 44% of patients with laryngeal cancer, 28% with hypopharyngeal cancer, and 22% with oropharyngeal cancer are alive with laryngeal preservation. The overall 2-year survival rates for patients with cancer of the larynx, hypopharynx, and oropharynx were 71%, 46%, and 38%, respectively.

Squamous cell carcinoma of the maxillary sinus

Eighty-five patients with squamous cell cancer of the maxillary sinus received all of their treatment at The University of Texas M.D. Anderson Cancer Center between the years 1971 and 1986. Their records were evaluated according to stage, disease at presentation, symptoms and signs at presentation, treatment, and outcome. There were no differences in locoregional control or survival between groups treated with surgery alone vs surgery plus radiotherapy. Careful analysis of the data indicates that there was almost certainly some selection bias for the patients undergoing combination therapy, as most of this group had historically adverse prognostic factors identified. Those patients who underwent radiotherapy alone or chemotherapy presented with either metastatic or locally advanced disease and were treated with palliative intent; therefore, comparison between this group and standard therapy groups was impossible in this retrospective review. Although it is tempting to speculate that combination therapy improved locoregional control and survival in patients with more advanced disease, none of the data presented in this review reach statistical significance. Furthermore, there is no difference in survival in this population compared with a study at this institution 20 years ago. Squamous cell cancer of the maxillary sinus continues to be a challenging neoplasm. Radiotherapy may improve locoregional control and survival in a group of patients with more advanced disease and may have its greatest utility in earlier-stage disease. A multi-institutional prospective trial is needed to find ways to improve outcome in this patient population.

Orbital preservation in maxillectomy

Twenty-eight previously untreated patients with squamous carcinoma of the maxillary sinus underwent maxillectomy with preservation of the orbital contents at the M. D. Anderson Cancer Center between 1971 and 1986. Eighteen patients had part or all of the orbital floor resected; nine patients were treated with radiotherapy, and nine had surgery only. Only 3 of 18 patients in this group (17%) retained significant function in the ipsilateral eye. Furthermore, local recurrence in this group was common (44%), regardless of whether postoperative radiotherapy was used. Ten patients retained the bony orbital floor; if the radiation fields did not include the eye, problems were minimal. Strong consideration should be given to orbital exenteration at the time of surgery, when the orbital floor is resected--especially if postoperative radiation fields will include the eye.

Biologic, foster, and adoptive parents: care givers of children exposed perinatally to human immunodeficiency virus in the United States. The Pediatric Spectrum of Disease Clinical Consortium

Children born to human immunodeficiency virus (HIV)-infected mothers often do not live with a biologic parent because of drug use, illness, or death of the mother. Public health officials need to know the number and proportion of children who will require care by someone other than a biologic parent (alternative care giver). The Pediatric Spectrum of Disease project, conducted in six different geographic regions in the United States, assesses issues specific to HIV in children. Among the information being collected in this study are data regarding the primary care giver. Of 1683 children born to HIV-infected mothers and enrolled through 1990, 55% (937) were living with a biologic parent, 10% (169) with another relative, 28% (455) were in foster care, 3% (55) had been adopted, and 4% (67) lived in group settings or with other care givers. In all locations and for all racial/ethnic groups, children of mothers who used intravenous drugs were more likely to be living with an alternative care giver than were children of mothers who had not used intravenous drugs (odds ratio 4.15). However, there were striking variations by study location (odds ratio range 1.4 to 7.2). The data suggest that maternal drug use may be the most important factor determining whether a child lives with a biologic parent and that there are also regional differences in alternative care placement.

Multidimensional scaling of head and neck metastases

A mathematical analysis, called multidimensional scaling, was applied to two sets of data on metastases from head and neck cancers. The analysis places lymph nodes in an imaginary space (here termed a 'nodalgram') such that distances between nodal clusters are proportional to differences in the occurrence of tumor metastases. Two-dimensional scaling explains 93% of the variance in clinical data from 1008 patients and 91% of the variance in pathological data from a different set of 415 patients. These independent results are closely correlated, and both explain vastly more of the data than expected by chance. The dimensions of the nodalgram are not related to anatomical coordinates of the nodes, suggesting that a representation of these structures in an abstract space explains the spread of cancers better than an analysis of spread in real space. Surprisingly, a plot of the extent to which metastases from different primary sites spread along the nodalgram dimensions is closely related to the normal anatomical locations of the primaries. This shows that although the nodalgram may be difficult to interpret, it must have some biological significance. In conclusion, multidimensional scaling successfully quantifies a pattern in the spread of head and neck cancers.

Mivacurium infusion during nitrous oxide-isoflurane anesthesia: a comparison with nitrous oxide-opioid anesthesia

STUDY OBJECTIVE

To determine the potentiation of the neuromuscular blockade induced by a titrated infusion of mivacurium in the presence of isoflurane versus a nitrous oxide (N2O)-opioid anesthesia.

DESIGN

An open-label, controlled study.

SETTING

The inpatient anesthesia service of two university medical centers.

PATIENTS

Thirty adults divided into two groups.

INTERVENTION

An intravenous infusion of mivacurium during anesthesia with N2O-opioid or N2O-isoflurane.

MEASUREMENTS AND MAIN RESULTS

A neuromuscular blockade was monitored by recording the electromyographic activity of the adductor pollicis muscle resulting from supramaximal stimulation at the ulnar nerve at 2 Hz for 2 seconds at 10-second intervals. The mivacurium infusion rate was significantly less in the presence of isoflurane [4.0 +/- 0.8 micrograms/kg/min (mean +/- SEM)] than during N2O-opioid anesthesia (6.4 +/- 0.6 micrograms/kg/min). The recovery rates did not differ between anesthetic groups. After the termination of the infusion, spontaneous recovery to T4/T1 of at least 0.75 occurred in an average of 17.9 +/- 1.5 minutes, with a mean recovery index (T25-75) of 6.0 +/- 0.7 minutes.

CONCLUSION

Isoflurane anesthesia reduces the infusion rate of mivacurium required to produce about 95% depression of neuromuscular function.

Desmoplastic melanoma. Histologic correlation with behavior and treatment

Desmoplastic (neurotrophic) melanoma is a histologic variant of cutaneous melanoma that has a distinct clinical behavior. To better understand this behavior and to treat the disease more effectively, the medical records of 16 patients treated for this disease over a 12-year period were reviewed. Thirteen patients had head and neck lesions, the ear being a common site. The average thickness of the lesions was 5.75 mm. Six (46.2%) of 13 patients had local recurrence of disease. Only two patients (15.4%) developed regional node metastases. None of the patients with clinically NO desmoplastic melanoma were found to have positive nodes after elective neck dissection, regardless of the thickness of the primary lesion. Wide excision of the primary lesion with frozen section control of surgical margins and careful examination for the presence of perineural invasion is important in determining the extent of surgical resection.

Polyamine metabolism in carcinoma of the oral cavity compared with adjacent and normal oral mucosa

In this study, polyamine biosynthesis required for cellular proliferation showed elevated levels in neoplastic cells. Putrescine, spermidine, and spermine, as well as the rate-limiting enzyme ornithine decarboxylase, were measured to evaluate differences in tissue concentration in squamous cell carcinoma of the oral cavity, and in the normal adjacent, buccal, and retromolar trigone tissues. Mean polyamine levels (nanomoles per gram of tissue +/- standard error of the mean) were significantly elevated in tumor tissue at 136 +/- 42 nmol/g for putrescine compared with 41 +/- 9 nmol/g in adjacent, 25 +/- 5 nmol/g in buccal, and 41 +/- 14 nmol/g in retromolar trigone tissues. Tumor spermidine was 415 +/- 41 nmol/g compared with 192 +/- 34 nmol/g in adjacent, 184 +/- 34 nmol/g in buccal, and 214 +/- 63 nmol/g in retromolar trigone tissues. Tumor spermine was 461 +/- 41 nmol/g compared with 236 +/- 30 nmol/g in adjacent, 233 +/- 35 nmol/g in buccal, and 269 +/- 59 nmol/g in retromolar trigone samples. Ornithine decarboxylase activity was highly variable in tumor tissues. High levels of polyamines appear to be specific for this malignancy, whereas ornithine decarboxylase activity is not. Measurement of polyamine content may be useful in evaluating epithelial changes in the oral cavity.

13-cis-retinoic acid in the treatment of oral leukoplakia

13-cis-Retinoic acid has been reported to be effective in treating oral leukoplakia. We randomly assigned 44 patients with this disease to receive 13-cis-retinoic acid (24 patients) or placebo (20), 1 to 2 mg per kilogram of body weight per day for three months, and followed them for six months. There were major decreases in the size of the lesions in 67 percent (16 patients) of those given the drug and in 10 percent (2 patients) of those given placebo (P = 0.0002); dysplasia was reversed in 54 percent (13 patients) of the drug group and in 10 percent (2 patients) of the placebo group (P = 0.01). The clinical response to the drug correlated with the histologic response in 56 percent (9 of 16) of the patients evaluated. Relapse occurred in 9 of 16 patients two to three months after treatment ended. The toxic effects of the drug were acceptable in all but two patients. Cheilitis, facial erythema, and dryness and peeling of the skin were common; conjunctivitis and hypertriglyceridemia also occurred. All adverse reactions could be reversed by reducing the dose or temporarily discontinuing the drug. We conclude that 13-cis-retinoic acid, even in short-term use, appears to be an effective treatment for oral leukoplakia and has an acceptable level of toxicity.

A prospective study of shoulder disability resulting from radical and modified neck dissections

A prospective longitudinal study of shoulder function after 103 neck dissections involving either preservation or sacrifice of the spinal accessory nerve is presented. The postoperative evolution and course of trapezius muscle denervation and resultant shoulder dysfunction were objectively determined for both radical and modified nerve sparing neck dissections. All patients were enrolled in a program of physical therapy aimed at maintaining range of motion at the shoulder joint. Shoulder function was examined preoperatively and for 12 months postoperatively with manual muscle strength testing, range of motion measurements, and electrodiagnostic testing. Results indicate that modified nerve sparing dissections are followed on the average by a significant, but temporary and reversible phase of shoulder dysfunction. By comparison, radical neck dissection is followed by profound and permanent trapezius muscle weakness and denervation.

Squamous carcinoma of the external ear

The medical records of 486 patients with pathologically proved squamous carcinoma of the skin of the external ear were analyzed. It is a disease of elderly white men, and the helix is the most common site of origin. Well-differentiated squamous carcinoma is the most frequent histologic variant. Ninety-five percent of our patients were treated surgically with above-clavical control in 87 percent and 28 percent survival. The low survival rate was related to the old age of the patients who frequently died of intercurrent disease and second cancers. A 12 percent incidence of nodal metastases is comparable with the incidence reported in other series. Aggressive surgical ablation and the selected use of adjunctive postoperative irradiation appear justified in those patients with locally invasive tumors, multiple nodal metastases, and extracapsular invasion.

Chemotherapy of malignant major salivary gland neoplasms: a 25-year review of M. D. Anderson Hospital experience

From 1950 through 1975, 671 patients with malignant major salivary gland neoplasms were referred to M. D. Anderson Hospital and Tumor Institute. Thirty-six patients with advanced local or metastatic disease subsequently underwent 62 evaluable trials with a variety of chemotherapeutic agents, either alone or in combination. Six patients achieved a partial response, with a median duration of 3 months. Ten additional patients had stable disease for 2 or more months. Anthracyclines appeared to be the most effective agents in this study, with three partial responses of six evaluable trials. The longest partial response (10 months) occurred in a patient receiving combination chemotherapy plus BCG immunotherapy. Pulmonary metastases were most commonly responsive to chemotherapy. The median intervals from diagnosis to death or to last follow-up and from initiation of chemotherapy to death or to last follow-up were 30 months and 6 months, respectively. Further therapeutic trials are necessary before response rates to single chemotherapeutic agents or combinations can be accurately assessed. In view of the poor prognosis of patients with recurrent disease, postoperative adjuvant studies with chemoimmunotherapy in patients with a high risk of recurrence are planned.