[Clinical guidelines for diagnosis, treatment and monitoring of patients with non-invasive breast cancer]

Breast cancer is the most common malignancy in women. Early diagnosis and more effective treatment of invasive breast cancer resulted in significant mortality reduction, improvement of survival and the quality of life of the patients. The management od non-invasive breast cancer, on the contrary, is still controversial and the problem of overdiagnosis and overtreatment of patients come to evidence. In the following text a multidisciplinary team of experts brings the first consensus guidelines aimed to standardize and optimize the criteria and management in diagnosis, treatment and monitoring of non-invasive breast cancer patients in the Republic of Croatia.

Tamoxifen in trimodal therapy with cytotoxic drugs and hyperthermia in vivo significantly enhance therapeutic efficacy against B16-F10 melanoma

AIMS AND BACKGROUND

The aim of the study was to investigate whether use of the antiestrogen tamoxifen and heat treatment in combined therapy with the well-known anticancer drugs cisplatin, dacarbazine and cyclophosphamide enhances their therapeutic efficacy on mouse B16-F10 melanoma in vivo. The results of systemic melanoma therapy have been mostly disappointing. Therefore, there is still a great need for strategies that can improve existing chemotherapy options.

METHODS AND STUDY DESIGN

The tumor model for the investigation of antitumor activity was a mouse B16-F10 melanoma transplanted into the footpad of C57BL/6 Zgr/Hr mice. Drugs were given intraperitoneally 15 min before the application of local hyperthermia, and tumor growth and mouse survival were followed.

RESULTS

Hyperthermia alone determined a significant delay of tumor growth, but mouse survival was not affected. In bimodal combinations with hyperthermia, all the tested antitumor drugs significantly increased both tumor growth delay and mouse survival. Tamoxifen alone did not show any inhibitory effect on B16-F10 melanoma in vivo. However, in the trimodal therapy with a particular drug and hyperthermia, it potentiated the inhibitory effects of the respective bimodal treatments, especially that of cyclophosphamide and hyperthermia.

CONCLUSIONS

Our results obtained on the mouse B16-F10 melanoma in vivo confirmed the enhanced therapeutic efficacy of the trimodal therapy tamoxifen, hyperthermia and anticancer drug combinations in melanoma treatment. Further studies should optimize the heat-drug time scheduling and drug doses that will result in the best possible therapeutic achievement for these trimodal therapy options.

Tamoxifen in Trimodal Therapy with Cytotoxic Drugs and Hyperthermia in Vivo Significantly Enhance Therapeutic Efficacy against B16-F10 Melanoma

Aims and background

The aim of the study was to investigate whether use of the antiestrogen tamoxifen and heat treatment in combined therapy with the well-known anticancer drugs cisplatin, dacarbazine and cyclophosphamide enhances their therapeutic efficacy on mouse B16-F10 melanoma in vivo. The results of systemic melanoma therapy have been mostly disappointing. Therefore, there is still a great need for strategies that can improve existing chemotherapy options.

Methods and study design.

The tumor model for the investigation of antitumor activity was a mouse B16–F10 melanoma transplanted into the footpad of C57BL/6 Zgr/Hr mice. Drugs were given intraperitoneally 15 min before the application of local hyperthermia, and tumor growth and mouse survival were followed.

Results

Hyperthermia alone determined a significant delay of tumor growth, but mouse survival was not affected. In bimodal combinations with hyperthermia, all the tested antitumor drugs significantly increased both tumor growth delay and mouse survival. Tamoxifen alone did not show any inhibitory effect on B16–F10 melanoma in vivo. However, in the trimodal therapy with a particular drug and hyperthermia, it potentiated the inhibitory effects of the respective bimodal treatments, especially that of cyclophosphamide and hyperthermia.

Conclusions

Our results obtained on the mouse B16–F10 melanoma in vivo confirmed the enhanced therapeutic efficacy of the trimodal therapy tamoxifen, hyperthermia and anticancer drug combinations in melanoma treatment. Further studies should optimize the heat-drug time scheduling and drug doses that will result in the best possible therapeutic achievement for these trimodal therapy options.

[Multiple primary malignancies]

Multiple primary malignancies, metachronous or synchronous, in a single patient are relatively rare event with the increase of incidence in recent decades. The aim of this research is to study their incidence in patients hospitalized at the Division of Radiotherapy, Department of Oncology, University of Zagreb, School of medicine, University Hospital Centre Zagreb from 2003 to 2009. The incidence of multiple primary malignancies was 2.4%. Among 103 patients, 97 had two, and 6 three primary tumors. Eighty-three cases were metachronous, while 20 cases were synchronous malignancies. The frequency was higher in females than males and their age at diagnosis of tumors was younger than in males. The most common tumor combinations in males were: prostate cancer-digestive system malignancy (especially colorectal cancer) and viceversa, and hematological malignant tumors-digestive system malignancy; while in women there were: breast cancer-cancer of contralateral breast and hematological malignant tumors (especially lymphoma non Hodgkin)-breast cancer. The incidence of multiple primary malignancies is expected to increase due to the better screening programs for early detection of malignancies as well as considerable improvement in their treatment and longer life expectancy.

[Side effects of radiotherapy in oral cavity: diagnosis, prevention and treatment guidelines]

To avoid, or at least to reduce complications in patients who require head and neck radiotherapy, adequate oral cavity treatment is necessary before the therapy. Recent management guidelines speak of possibilities of preventing osteoradionecrosis with hyperbaric oxygen, using long-wave ultrasound in stimulating osteoblasts growth, and surgical transfer of submandibular salivary glands to submental area with 99% effectiveness in preventing xerostomia, besides traditional therapy. Preventive measures are naturally the best choice, since late complications treatment is not needed as often, and should draw special attention of physicians and patients. Since wide a spectrum of preventive and curative measures is required, the need exists for standard teams to look after the patients during and after radiotherapy, and which should include, besides radiotherapist, oral or maxillofacial surgeon in cooperation with oral medicine specialist.

Treatment of cancer-related anemia

Anemia with consequent tissue hypoxia is common problem in cancer patients. Developed via various patophysiological mechanisms, it has deleterious effect on quality of life and survival of patients with cancer. Recognition of symptoms and timely initiation of treatment improve patients' quality of life, as well as efficacy of oncological treatment. Red blood cells transfusions are well known and efficient way of anemia correction. They are "golden standard" in treatment of cancer-related anemia today, and are unavoidable in almost all patients with hemoglobin concentration below 80 g/L. Newest therapy guidelines in developed countries, supported by recent literature, encourage use of recombinant human erythropoietin (rHu-EPO), although detailed meta-analyses and prospective randomized clinical trials have shown that rHu-EPO decreases the need for transfusions in only 9-45% patients with cancer, only if they have mild anemia, rHu-EPO increases incidence of thromboembolic events, and suspicion arises that it supports tumor cells growth and multiplication. Therefore, it is necessary to define subgroups of patients which are best candidates for rHu-EPO therapy, to accomplish lower intensity of transfusion therapy.

Possible prognostic significance of p53 and Ki 67 in inverted sinonasal papilloma

The aim of this study is to test the possible prognostic significance of p53 and Ki67 expression in inverted papilloma of the lateral nasal wall and adjacent sinuses regarding their malignant potential and recurrence. 49 biopsies of the lateral nasal wall and adjacent sinuses obtained from 41 patients from three hospitals were investigated. Immunohistochemically demonstrated p53 and Ki67 expression was measured and statistically evaluated. p53 immunoreactivity was demonstrated in most of papillomas with carcinomas but only in two benign papillomas, while Ki67 demonstrated stronger immunoreactivity in carcinomas and surrounding epithelium. Immunohistochemical staining of inverted sinonasal papillomas for p53 and Ki67 can give useful information concerning the existence of synchronous carcinoma and, in case of high Ki67, a hint toward possible recurrence.

Erdheim-Chester disease and concomitant tuberculosis successfully treated with chemotherapy and long-term steroids

Erdheim-Chester disease (ECD) is a rare histiocytosis usually affecting the skeletal system, but visceral organs and central nervous system involvement are common as well. Probability exists that immunomodulatory therapies and disorders can play a role in clinical course of the disease. Because of rarity of the disorder, it is hard to classify it and standardize the treatment options, but, according to published material and our experience, cytotoxic chemotherapy and long-term steroids have therapeutic benefit. Although this approach can probably be accepted as standard of care management, novel therapeutic modalities should be explored, and pathogenesis and disorder classification should be cleared out as well. The case of ECD affecting skeletal system and lungs and concomitant laryngeal tuberculosis successfully treated with chemotherapy and long-term steroid therapy is presented.

Photodynamic therapy with 5,10,15,20-tetrakis(m-hydroxyphenyl) bacteriochlorin for colorectal liver metastases is safe and feasible: results from a phase I study

BACKGROUND

The prognosis for patients with liver metastases from colorectal carcinoma is limited because of the low number of patients who are eligible for curative hepatic resection. In this phase I study, 31 liver metastases in 24 patients with nonresectable metastases from colorectal carcinoma were treated with photodynamic therapy (PDT).

METHODS

The photosensitizer 5,10,15,20-tetrakis(m-hydroxyphenyl)bacteriochlorin (mTHPBC) was intravenously administered in a dose of .6 mg/kg (n = 12) or .3 mg/kg (n = 12). After 120 hours (n = 18) or 48 hours (n = 6), tumors were illuminated for 300 to 600 seconds through percutaneously inserted optical fibers with a light dose of 60 J/cm of diffuser (740 nm).

RESULTS

Tumor necrosis at 1 month after PDT was achieved in all treated lesions. Laser treatment was associated with mild pain (n = 8) and transient subclinical hepatotoxicity (n = 21). In one patient, PDT damage to the pancreas was inflicted, and in another patient, PDT damage of the skin occurred, but no serious clinical complications from PDT were reported. Administration of .6 mg/kg of mTHPBC led to transient phlebitis in 10 patients, and 3 patients experienced mild skin phototoxicity after excess light exposure.

CONCLUSIONS

Colorectal liver metastases that are ineligible for resection can be safely and effectively treated with interstitial mTHPBC-based PDT.

Model of total skin electron treatment using the 'six-dual-field' technique

During implementation of the total skin electron treatment, using six-dual-field technique, at radiotherapy department a large number of measurements are needed. To assess depth dose curve required by clinicians and dose uniformity over a whole treatment plane, combinations of different irradiation parameters are used (electron energy, beam angle, scatterers). Measurements for each combination must be performed. One possible way to reduce number of measurements is to model the treatment using the Monte Carlo simulation of electron transport. We made a simplified multiple-source Monte Carlo model of electron beam and tested it by comparing calculations and experimental results. Calculated data differs less than 5 percent from measurements in the treatment plane. During the treatment patient can be approximated using cylinders with different diameters and orientations. We tried to model the depth dose variations in the total skin electron treatment not just around the body cross-section (simplified to cylinders of different diameters), but also along the body to account for the variations in body curvature longitudinally. This effect comes down to the problem of modeling distribution in different cylinders, but varying the longitudinal orientation of those cylinders. We compared Monte Carlo calculations and film measurements of depth dose curves for two orientations of the cylindrical phantom, which were the simplest for experimental arrangement. Comparison of the results proved accuracy of the model and we used it to calculate depth dose curves for a number of other cylinder orientations.

A multicenter Phase I safety study of intratumoral photoactivation of talaporfin sodium in patients with refractory solid tumors

BACKGROUND

Photodynamic therapy (PDT) currently is approved for the palliative treatment of malignancies of the aerodigestive tract using laser-activated porfimer sodium. A new approach has been developed, based on intratumoral placement of a nonlaser light device that activates talaporfin sodium, that may expand the use of PDT to include a broader range of treatment-resistant malignancies. The safety of this approach was assessed in a Phase I study in patients with locally advanced, refractory tumors.

METHODS

Twenty-one patients with radiation-resistant or chemotherapy-resistant or inoperable malignancies were enrolled in four cohorts representing four light doses. Patients were treated with a single intratumoral light device and a fixed photosensitizer dose. Safety assessments were based on review of adverse events (AEs) and serious adverse events (SAEs), and independent evaluation of computed tomography (CT) images.

RESULTS

The observed occurrence of treatment-related AEs and SAEs was minimal. No cutaneous phototoxicity was observed in any patient. The overall observed tumor response rate was 33%.

CONCLUSIONS

Photoactivation of talaporfin sodium using intratumoral nonlaser light was found to be safe in the patient population of the current study at all light dose levels tested.

Expression of cancer/testis tumor associated antigens in cervical squamous cell carcinoma

We investigated the expression of tumor-associated antigens (TAA) of the cancer/testis (C/T) gene family in cervical squamous cell carcinomas. First, we focused on the HeLa cervical cancer derived cell line, and we found that it expresses MAGE-A1, MAGE-A2, MAGE-A3, MAGE-A4, MAGE-A6, MAGE-A12, GAGE-3/6, LAGE-1, and PRAME genes, encoding defined C/T TAA. In contrast, no expression of MAGE-A10, BAGE, GAGE-1/2, or NY-ESO-1 genes was observed. Corresponding gene products could also be detected by immunoblotting and immunocytochemistry, taking advantage of monoclonal antibodies recognizing discrete TAA. Capitalizing on these data, a monoclonal antibody predominantly recognizing MAGE-A4 TAA in paraffin-embedded sections (57B) was used to investigate the C/T gene expression in clinical tumor samples. A group of 60 patients was studied, and 57B positivity was detectable to different extents in 33% of the cases (20/60). In 13 of them (21%), staining of over 50% of the tumor cells was evident, whereas healthy cells always scored negative. Remarkably, MAGE-A4 expression was significantly (p < 0.05) more frequently detectable in poorly differentiated tumors (8/13) than in well-differentiated or moderately differentiated cancers (3/15 and 9/32, respectively) and in stage FIGO II as compared with stage FIGO Ib tumors (12/23 and 5/24, respectively, p = 0.04). Interestingly, staining was mostly nuclear in well-differentiated tumors, but involved both nuclei and cytoplasm in less differentiated cancers. Positivities of comparable frequency were also detectable in a smaller series of specimens upon staining with MAGE-A1- or NY-ESO-1/LAGE-1-specific reagents. Considering the high tumor specificity of C/T TAA, our data provide the rationale for the design of immunotherapy procedures targeting these antigens in cervical cancers.

Inverted sinonasal papilloma--a report of 31 cases and review of the literature

Inverted papilloma is an epithelial neoplasm of the lateral nasal wall and adjacent sinuses characterized by a marked propensity for recurrence and a significant association with carcinoma. In this retrospective study we present 31 cases treated by our departments between 1982 and 1999. The aim was to compare our results to those of other authors especially regarding surgical management. The male to female ratio of these patients was 2:1 and most patients were in the 6th and 7th decades of life. Conservative surgery was used in most cases as the initial treatment. The overall recurrence rate was low and there were 3 cases associated with carcinoma. We conclude that the results of conservative surgery in selected cases are comparable to those using radical methods. A review of the literature is presented and particular attention is dedicated to the literature concerning analysis of p53 expression, HPV and Epstein-Barr infection and apoptosis in inverted papilloma.

Inertia of endocrine systems due to hormone binding to circulatory proteins

It is often presumed that the main role of hormone binding to albumins and binding proteins (BPs) is to reduce oscillating levels of free hormone molecules and to transport steroid hormones. This paper is an attempt to define possible consequences of hormone molecules binding to carrier proteins in circulation. Binding to albumins and BPs prevents exact and quick control of hormone actions. Hormones without significant protein binding govern vital and fast acting regulatory mechanisms (blood glucose or calcium) in which any added inertia might be dangerous. In the presented model, the added inertia for a partially bound hormone (H) is defined as: H(bound)/H(free). Values, calculated from the reported data, range from 0.4 for GH to more than 2000 for T(4). In comparison to albumins, high-affinity BPs make more stable reserve that would cover periods of low or no hormone secretion. At the same time, hormone molecules are taken away from the blood level control and thus might be considered sequestrated. For hormones without protein binding, the well-perfused areas of the body, or the areas with increased capillary permeability, would be more exposed, making an uneven distribution among target tissues. For the hormone that binds blood proteins, places of secretion and tissue perfusion become unimportant, since the hormone is being liberated anywhere in the circulation (i.e., for strongly bound IGFs, IGF binding proteins do not just stabilize proinsulin actions of IGF-1, but also make all parts of body to be under the same exposure to liberated IGFs, an important feature to promote a symmetrical bone growth). Estrogens are known to stimulate liver secretion of different BPs. A possible explanation is that in the follicular phase there is a small initial mass of granulosa cells, and it takes time to saturate free estrogen carriers, before the normal free hormone level can be reached and FSH secretion inhibited. Less inert peptide inhibin might suppress FSH before free estrogens reach the required level. Without inhibin suppression, an increased FSH level with an increased number of growing follicles can be expected. Estrogens increased production of BPs augments inertia of the estrogen loop and possibly modulates the FSH/estrogen negative feedback.

Total skin electron treatment of extensive cutaneous lesions in Kaposi sarcoma

We report on a 62-year-old HIV-negative male patient with Kaposi sarcoma. After 8 years of treatment of smaller localized skin lesions with surgery and local radiotherapy, the patient developed extensive lesions of the whole skin. The extent of the lesions required the administration of the total skin electron therapy (TSET). Until then, TSET had been used at our Department only for the treatment of mycosis fungoides. The dose delivered was 30 Gy higher than in a conventional radiotherapy treatment, where doses are usually between 8 and 24 Gy. Six months after the TSET therapy, the lesions completely regressed, except for two large facial lesions, which were surgically removed. Major side effects were mild erythema and hyperpigmentation of the skin. Erythema disappeared a month after the therapy.

Pilocarpine in the prevention of postirradiation xerostomia

During radiation therapy to the head and neck region, salivary gland hypofunction commonly develops. The aim of our study was to evaluate whether the sialogogue pilocarpine given during radiation therapy may reduce the severity of xerostomia and salivary dysfunction. Our results showed the pilocarpine-treated group to have a lower frequency of oral symptoms during the treatment than the placebo-treated group. Although salivary flow decreased in all patients, the pilocarpine-treated group had smaller flow reductions. No drug effect was observed in the glands that were completely irradiated. Thus, pilocarpine appeared to stimulate salivary tissues outside the radiation field.

The Zagreb method of partial laryngectomy: a retrospective study 1970-1986

The Zagreb method of partial laryngectomy is an original method of laryngeal reconstruction following tumor extirpation using the sternohyoid muscle fascia. This material is distant from the immediate tumor site, resistant to infection, saliva and shrivelling, thus being very appropriate for covering major laryngeal defects. Statistical data analysis included clinical records from 1970, when the method was introduced at ENT Department, Zagreb School of Medicine, till 1986. During the study period, 574 patients were admitted for operative treatment of laryngeal carcinoma, and the partial method was employed in 350 (61%) of them. This percentage has generally remained unchanged to the present, because the use of fascia has extended the partial procedure applications and subsequent reconstruction. This has allowed a more extensive tumor excision without strictly following classical horizontal and vertical laryngectomy, with the additional use of so-called partial laryngectomy on demand. Records on the follow-up (5-20 years) after this type of surgery revealed an 87% survival rate (n = 304).

Nasal polyps in children

During the 1980-1995 period, 957 patients were admitted for nasal polyposis, 59 (6.2%) of them children. Results were analyzed with respect to localization of the polyps, allergy, histologic picture, bacteriologic tests, radiologic findings of paranasal sinuses, cytology of nasal mucosa, therapeutic approach, and tendency to relapse. Forty children (22 boys and 18 girls) were analyzed. Their mean age was 11.1 years. Unilateral polyposis was found in 29, and bilateral in 11 children. Antrochoanal polyps (ACP) were found in 30, bilateral nasal polyps in 5, polyps in maxillary sinus in 5, and allergy in 8 children. Inflammation of the maxillary sinus was present in 93% of children with ACP. Their correlation between ACP and inflammation in maxillary sinus suggested that edema of the sinus mucosa have led to protrusion through the ostium and formation of the nasal polyp.

Endothelin-secreting tumors and the idea of the pseudoectopic hormone secretion in tumors

Ectopic hormone secretion in tumor cells is here described as an amplification of hormone production already present in normal, nonendocrine tumor-originated tissue. This idea is tested on the available data regarding endothelin-1 (ET-1) secreting tumors. The endothelins are ubiquitous regulatory peptides produced by various tissues. The precursor cells of many tumor types secrete endothelins. ET-1 protein expression was detected in situ in all tested prostate cancers as well as in normal prostate tissue. The majority of hepatocellular carcinomas produce ET-1, while ET-1 is secreted by the normal hepatic stellate cells. Human breast cancer cells produce immunoreactive ET-1. Similar data exist for pancreatic tissue, the thyroid and large bowel. We can conclude that tumor cells might sustain endothelin secretions already present in the normal tumor-originated tissue. The model that is presented of the pseudoectopic hormone secretion consists of relations between a few parameters. The proportion of hormone-secreting tumors (Th) among all tumors (T) of that organ depends on the amount of the hormone-secreting cells (Ch) among all cells (C) susceptible to malignant transformation. The corrective factor (k) was introduced in the expression Th/T=Ch/C*k, to represent specific conditions altering the malignant transformation probability for a certain normal hormone-secreting cell. In prostate, breast and colon, the kvalue is predicted to be approximately 1, suggesting that ET-1-secreting normal cells are not more prone to the malignant transformation than their neighbours. In liver and pancreas, the incidence of ET-1-secreting tumors outnumbers the proportions of normal ET-1-secreting cells (k values >1). In these organs, normal ET-1-secreting cells seem more likely to turn malignant in comparison to their neighbours, perhaps due to their function, position and exposition to oncogenic factors, or even due to their ET-1 secretion. There are similar data for thyroid and adrenal glands. No ET-1 secretion was reported in kidney neoplasms. Normal renal ET-1 secreting cells might be less prone to turn malignant than other renal cells. Unlse the normal lung tissue, small cell lung cancers often secrete adrenocorticotrophic hormone (ACTH). The pancreatic islet cells do not secrete gastrin, but their tumors often do. Constant k would exceed 1 in both cases. We speculate that these tumors might originate from a small subset of cells with the described feature. Tumor cells sometimes lack features of the normal tissue, as in the cases of the steroid receptor-negative breast cancer. These tumors might originate from the hypothetical subset of receptor-free breast cells. Benign breast epithelial cells lacking oestrogen receptors have been described in cases of megalomastia. These cells might be constituents of normal breasts or, perhaps, present only in cases of increased breast cancer risk.

A contribution to the etiopathogenesis of nasal polyps

The first author studied nasal polyposis from the epidemiological, clinical, immunologic and histologic points of view. Based on the year-long studies, the authors have isolated three issue of common interest to rhinologists since ancient times, i.e. relationship between allergy and nasal polyposis, predilection sites of the origin of polyposis, and the development process underlying the genesis of polyps.

Undifferentiated nasopharyngeal cancer (UCNT): current diagnostic and therapeutic aspects

Undifferentiated carcinoma of the nasopharynx (UCNT) is a particular head and neck epidermoid lineage tumor related to the Epstein Barr Virus (EBV). It has geographically selective endemic epidemiologic features, without relation to external carcinogens. Its systemic agressiveness is the source of most disease-related demises, because radiotherapy achieves excellent local control and a significant percentage of cure in patients with exclusive locoregional disease. Difference in the staying systems currently in use, the recent changes in imaging and radiotherapy technology, and the lack of distinction between UCNT and squamous cell carcinoma (SCC) of the nasopharynx in Western literature reports make for some difficulty in therapeutic results evaluation when analyzing available literature. Its chemosensitivity is a relatively recent acknowledged fact, and its use in metastatic patients results in a high percentage of objective responses, many of long duration. Neoadjuvant cisplatin-based chemotherapy seems to be of benefit, but outstanding controversies in this regard will be soon answered through ongoing phase III trials. After a review of the current literature of all the above-mentioned aspects of this fascinating nosologic entity, our own experience, both in metastatic and locoregional disease patients is analyzed.

Etiopathogenesis of nasal polyps

An acute process is practically never the cause of polyps, for despite the reaction being hyperergic, it spreads through the entire circumference of the mucosa. In chronic noxa the infiltrates will not be diffusely distributed and may in certain places be too large to form protuberances in the mucosa by themselves. The essence of this chronic process is a further proliferation of the connective tissue, especially around the blood and lymph vessels. Chronic oedemas in the mucosa of the nose and the paranasal sinuses are transported through venous and lymphatic vessels towards the nasal meatus, more towards the middle one than the upper one. In this region not only are there lymphatic vessels, but here also lies the borderline between low and raised tissue pressure. That is the place where most nasal polyps appear. Respiratory allergy is much more frequent in recurrent nasal polyposis (78%) than in the group of patients with non-recurrent polyposis (18%). Through histochemical analysis of nasal polyps, eosinophils are found in both recurrent and non-recurrent polyps (74% and 44%, respectively), as well as in the nasal mucosa (32% vs. 15%) which is statistically significant.

[70 years' of the Otorhinolaryngology Clinic at the Medical School of Zagreb in Salata]

The author has chronologically divided the development of the ENT Department, School of Medicine, University of Zagreb into four periods corresponding to schedule time of the four ENT heads, Masek, Sercer, Gusić and Krajina. The ENT Department was founded as the first among the clinical subjects of the School of Medicine, University of Zagreb and, therefore, special attention has to be paid to it within the study of the development of the Zagreb School of Medicine.

Implication of tumour antigens and immune complexes in laryngeal cancer

In the last 3 years tumour antigens (TA) and immune complexes (IC) were examined in 33 respectively 83 patients with cancer of the larynx. These tests were repeated several times during treatment and during the checking period. Tumour antigens were prepared from squamous cell carcinoma of the larynx using a modification of the methods by Bloom et al. and Halliday. Immune complexes in the serum were determined by the polyethylene glycol (PEG) test. In some cases the sensitivity to antigen was changed during the observation period. Constantly elevated immune complexes speaks in favour of recurrence in most of our cases.

Vertical partial laryngectomy on demand

The author proposes the term 'vertical partial laryngectomy on demand' for all modifications of vertical laryngectomies (frontal, frontolateral, vertical and hemilaryngectomy). This term includes two conditions: the first is complete oncological removal of the tumour (proven by histological examination and with the use of magnification or the operating microscope during the operation); secondly, reconstruction of the laryngeal defect by various procedures. The author uses the sternohyoid fascia in vertical and frontolateral partial laryngectomies. From 120 operated cases, a five-year survival rate of 81 per cent was achieved. The fascia showed resistance to post-operative complications and irradiation.

The influence of palato-cranial base (basomaxillary) angle on the length of the caudal process of the nasal septum in man

The authors investigated and defined the relationship between the length of the caudal process of the quadrangular lamina and the palato-cranial base (basomaxillary) angle. The length of the caudal process was measured by an indirect method during surgical exposure in 71 patients with nasal septum deformity. The usual cephalometric reference points were used to form the angle reference lines; the points were marked over X-rays and traced on transparent paper using the "against the light" technique. It was found that the caudal process was longer than 3 cm (range 3.1-4.2 cm, mean value 3.45, standard deviation 0.34) when there existed a palato-cranial base angle; contrary, it was always shorter than 3 cm (range 1.9-3.0 cm, mean value 2.40, standard deviation 0.33) when the reference lines were parallel. That means that the angulation between the reference lines assigning the angle predisposes a longer caudal process, making possible a backward growth of this cartilaginous baton, and therefore the occurrence of some particular types of septal deformities. Finally, the authors suggest another name for the palato-cranial base angle, i.e. the basomaxillary angle, because it is simpler, shorter and still clear enough.

Critical review of Vidian neurectomy

The author presents the critical review of Vidian neurectomy since 1961. Golding-Wood (1961, 1962) recommended this type of operation in vasomotor rhinitis. Many authors modified this operation. The author concludes that Vidian neurectomy is indicated in the cases of vasomotor rhinitis with profuse secretion refractory to conservative treatment.

[Juvenile papillomatosis of the larynx]

Juvenile laryngeal papilloma is the most common childhood neoplasm of the larynx. It is most often multiple and is characterized by a strong tendency to recur. Seventy-eight children with primary juvenile laryngeal papillomatosis (JLP) were treated at the ENT Department of the Zagreb University School of Medicine in the last 20 years and in the last 6 years interferon has been introduced into the therapy. Causes of the recurrence and the resistance to the therapy have been investigated. It has been shown that the administration of interferon has a certain effect on the tumor growth, but it has no effect against tumor recurrence. In patients with a severe clinical course the epithelial atypia of basal layer of papilloma and the increased enzymatic activity have been found.

The influence of the caudal process on the formation of septal deformities

The aim of the paper was to confirm the variations in the length of the caudal process and its relationship to the skull shape (occipitopetal or frontopetal) in various pathological septal deformities according to Mladina's classification. The length of the caudal process was measured during septal surgery in a group of 46 patients suffering from nasal obstructions caused by septal deformities. Measurements were made with an indirect method: the distance between the lower anterior rim of the pyriform aperture and the deepest point of the caudal process, which could still be surgically prepared, was taken as a function of its length (so called X-value). To establish the skull shape lateral cranial X-rays were made for each patient. Certain types of septal deformities were found to be more frequent in patients with longer caudal processes (type 2 and 5), than in cases when they were shorter (type 1 and 6). Twentyseven out of 46 patients were found to have frontopetal skulls, and X values were smaller than 3 cm. The occipitopetal skull shape was found in 19 patients whose values exceeded 3 cm. Caudal process and the skull shape, therefore, may affect development of particular types of septal deformities. Even more, it can be presumed that the septal response to trauma will depend upon some of these factors.

Investigations in exaggerated juvenile laryngeal papillomas

In the period between 1983 and 1986, 11 cases of juvenile laryngeal papillomas (JLP) were treated because of recurrences which were removed many times. One special group of 4 cases was isolated from these 11 cases in which papillomas grew very rapidly and were resistant to all management. Histological, biochemical and immunological investigations were made and the data are given.

Histochemical analysis of nasal polyps

In the last 3 years, 86 nasal polyps from 76 patients were examined. Special attention was paid to the group of recurrent nasal polyps, which redeveloped from 2 to 17 times. Histological analysis was performed concerning the eosinophils, mast cells, acid and neutral mucopolysaccharides, acetylcholinesterase and fluorescence on monoamines. Macroscopically, nasal mucosa in 53 patients was considered for control purposes. The comparison was made and the results of the examination reviewed.

Androgen receptors in normal and neoplastic laryngeal tissue

Androgen cytoplasmic (ARc) and nuclear (ARn) receptors were analyzed in normal and cancerous laryngeal tissue obtained from male and female patients. In men, neither ARc nor ARn were detectable in most of the normal larynx tissue specimens, while either ARc, ARn, or both were present in eight of 16 laryngeal carcinomas. In women, all three normal and two of four malignant laryngeal tissue specimens possessed ARc without ARn. The presence of androgen receptors in some laryngeal carcinomas shows that these tumors are possibly hormone sensitive, and hormonal therapy should be considered in treating these tumors.

Extent of partial laryngectomies

Clinical experience of laryngeal cancer gave a relatively better prognosis compared with cancer, in other locations in our field. Histological examinations of laryngeal cancer showed that in most of our cases the tumours had an even, microscopically localized growth. Serial sections in our cases confirmed this observation. In the period 1970-78, 52 combined procedures were made out of the frame of vertical or horizontal partial laryngectomy. In the follow-up of 6-14 years, only 6 patients died directly of the tumour. The analysis of our cases is reviewed.

Tumor antigens and immune complexes in laryngeal cancer

The sensitivity of an antigen prepared from tumor extract in three concentrations was examined in patients with cancers of the larynx of different extent (T1-T4) with or without metastases. At the same time circulating immune complexes in the serum were investigated by the polyethylene glycol precipitation method. Positive antigen reactions were found in 34% of the cases examined and enhanced immune complexes alone in 66%. These results were compared before and after the operative procedures and their relationship to the phytohaemagglutinin was assessed. Differences in these results appeared to be related to the size of the tumors (T1-T4) and to the presence of metastases.

[Interferon in the treatment of recurrent laryngeal papillomas]

The authors present their first experiences in the treatment of recurrent laryngeal papillomas with human leukocyte Interferon (HLI). Because of the impossibility of avoiding recurrences, the results were not satisfactory in most of the cases. The schedule for therapy has not yet been determined definitely.

Histological structure of vocal fold lamina propria in foetal larynx

Previous investigations of vocal fold lamina propria in adult human larynx have revealed a highly specific organization and distribution of the connective fibres. The authors tried to elicit the developmental characteristics of that process using a material of foetal larynxes, ranging in foetal age from 13 to 23 weeks. The specimens were embedded in paraffin and then serially sectioned in both horizontal and vertical plane. The specific technique of differentiating elastic fibres from collagen fibres was utilized. The distribution and organization of connective tissue in foetal vocal fold lamina propria differed from that in adults and no straight elastic fibres were demonstrated as the first sign of later differentiation.