G. B. Snow

Modern imaging techniques and ultrasound-guided aspiration cytology for the assessment of neck node metastases: a prospective comparative study

SummaryAlthough palpation has proved to be an unreliable staging procedure, the indications for and the implications of more reliable radiologic staging methods for the neck in patients with a primary squamous cell carcinoma of the head and neck remain controversial. Only a very accurate imaging technique can replace neck dissection in clinical NO disease. This study compares the value of palpation with computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US) with or without guided aspiration cytology for neck node staging. One hundred and thirty-two patients with squamous cell carcinoma of the head and neck were examined radiologically before undergoing a total of 180 neck dissections as part of their treatment. CT, US and MRI proved to be significantly more accurate than palpation for cervical lymph node staging. The accuracy of US-guided aspiration cytology was significantly better than of any other technique used in this study. Modern imaging techniques are essential for appropriate assessment of neck node metastases. In view of advances in the accuracy of contemporary imaging, the need for elective treatment of the neck requires reappraisal.

Multiple Head and Neck Tumors Frequently Originate from a Single Preneoplastic Lesion

The development of second primary tumors has a negative impact on the prognosis of head and neck squamous cell carcinoma. Previously, we detected genetically altered and tumor-related mucosal lesions in the resection margins in 25% of unselected head and neck squamous cell carcinoma patients (Tabor MP, Brakenhoff RH, van Houten VMM, Kummer JA, Snel MHJ, Snijders PJF, Snow GB, Leemans CR, Braakhuis BJM: Persistence of genetically altered fields in head and neck cancer patients: biological and clinical implications. Clin Cancer Res 2001, 7: 1523-1532). The aim of this study was to determine whether first and second primary tumors are clonally related and originate from a single genetically altered field. From 10 patients we analyzed the first tumor of the oral cavity or oropharynx, the >3-cm remote second primary tumor, and the mucosa from the tumor-free margins from both resection specimens. We compared TP53 mutations and loss of heterozygosity profiles using 19 microsatellite markers at chromosomes 3p, 9p, 13q, and 17p. In all patients, genetically altered mucosal lesions were detected in at least one resection margin from both first and second primary tumor. Evidence for a common clonal origin of the first tumor, second primary tumor, and the intervening mucosa was found for at least 6 of 10 patients. Our results indicate that a proportion of multiple primary tumors have developed within a single preneoplastic field. Based on different etiology and clinical consequences, we propose that independent second primary tumors should be distinguished from second field tumors, that arise from the same genetically altered field the first tumor has developed from.

Age-dependence of human papillomavirus DNA presence in oral squamous cell carcinomas

The aetiology of oral cancer is thought to be multifactorial. Apart from the two known major risk factors (tobacco and alcohol), a viral aetiology has been proposed, with special reference to human papillomavirus (HPV). 35 cases of oral squamous cell carcinoma (OSCC), seen at the Departments of Oral & Maxillofacial Surgery and Oral Pathology and Otolaryngology of the Free University of Amsterdam, were analysed as well as 12 biopsies of clinically and histologically normal gingival mucosa collected from healthy individuals after tooth extractions, using the polymerase chain reaction (PCR) and two different sets of primers that are able to detect a broad spectrum of HPV types. An overall HPV positivity of 54.3% in OSCC was found, the majority of positive cases (78.9%) harbouring HPV type 16. In contrast, no positivity for HPV was detected in the clinically normal oral mucosal samples analysed. Furthermore, a significant association between HPV presence and age was found: patients older than 60 years showed a lower prevalence of the virus (29.4%) compared with patients below this age (77.8%) (P < 0.05). The results from the present study suggest an association between HPV and OSCC, particularly in patients under the seventh decade.

Micrometastases from squamous cell carcinoma in neck dissection specimens

SummaryThe incidence of micrometastases in cervical lymph nodes from squamous cell carcinomas of the head and neck was studied using routine histopathological examination. Micrometastases were found in 66 lymph nodes in 41 of the 92 tumor-positive neck dissection specimens. The detection of these micrometastases influenced postoperative treatment in 3 of the 77 patients with neck node metastases. The value of additional sectioning for detecting micrometastases was thus assessed. Sectioning at a deeper level in 600 originally histopathologically negative lymph nodes from 64 patients revealed 7 additional micrometastases in 5 patients. Antikeratin staining with a mixture of two monoclonal antibodies (AE1 and AE3) revealed 4 micrometastases in 739 originally histopathologically negative lymph nodes in 3 of 13 patients studied. Because of the unknown prognostic significance of micrometastases and the consequent arbitrary consequences for postoperative treatment, present findings show that the extra workload of immunostaining and deeper sectioning does not warrant their routine use in clinical practise.

Assessment of tumour invasion into the mandible: the value of different imaging techniques

Abstract. In oral carcinomas close to the mandible, tumour invasion of the mandible is important in selecting segmental or marginal resection. Imaging may play a role in assessing tumour invasion. This study compares the accuracy of panoramic X-ray, CT and MR imaging in assessing invasion of the mandible in 29 patients. At histopathology, 6 patients had mandible erosion, 12 had invasion and 11 had an intact mandible. Magnetic resonance imaging had the highest sensitivity (94 %), but a low specificity (73 %), with 3 of 11 intact mandibles interpreted as positive. Furthermore, MR often overestimated the extent of tumour invasion. On the other hand, CT and panoramic X-ray had a lower sensitivity (64 and 63 %, respectively) and a higher specificity (89 and 90 %, respectively). Computed tomography (using 5-mm sections) and panoramic X-ray had a similar accuracy, and negative findings do not exclude invasion. Magnetic resonance imaging was the most sensitive technique but had more false positives and frequently overestimated the extent of tumour invasion. Because none of the radiological techniques are accurate enough, clinical examination seems at present to remain the most important modality in deciding between segmental and marginal resection. Tumour invasion at CT or panoramic X-ray is a strong argument for a segmental resection.

Adenoid cystic carcinoma of the salivary glands: clinicopathological survey of 51 patients.

A clinicopathological study of 51 cases of adenoid cystic carcinoma in the head and neck region seen over a period of 20 years is presented. The correlation between various histological features and their impact on the results is attempted. Longterm results with respect to loco-regional recurrences, distant metastases and survival with various modalities of therapy are presented. Although this is a small series, radical surgery in keeping with the aim of avoiding undue mutilation, thus preserving the quality of life, followed by a full course of radiotherapy has been the mainstay of treatment and the results here presented justify this approach.

Ultra-sonic nebulizers as a potential source of methicillin-resistant Staphylococcus aureus causing an outbreak in a university tertiary care hospital

An outbreak of methicillin-resistant Staphylococcus aureus (MRSA) occurred on a head and neck surgical (HNS) ward of a university hospital in Amsterdam. The outbreak lasted from May 2000 until November 2000, and MRSA spread to two intensive care units. Amplified fragment length polymorphism analysis indicated that a single clone was responsible for the outbreak. Phage-typing indicated that this clone was of a type that was uncommon in The Netherlands. Strict isolation of patients, according to the Dutch national guidelines, was instituted. During the outbreak, surveillance culture specimens, from patients, healthcare workers, and the environment, were obtained at regular intervals. MRSA was found in the dust filters of nebulizers through which air from the room was filtered and subsequently humidified. These nebulizers were used to humidify tracheostomies. The dust filters were not maintained according to the guidelines. Restricted use and cleaning and disinfection of all ultra-sonic nebulizers led to termination of the outbreak. The outbreak illustrates that to terminate transmission of outbreak strains of MRSA, meticulous measures are necessary, which not only include strict isolation precautions, but also decontamination of the environment. In addition, it demonstrates the necessity of adhering to cleaning and disinfection guidelines for all medical and nursing equipment used in the hospital.

Relationships of vitamins A and E and beta-carotene serum levels to head and neck cancer patients with and without second primary tumors.

SummarySecond primary tumors constitute one of the most challenging problems in head and neck cancer. Their etiology is not yet fully understood. For this reason, we studied the relationships of vitamins A and E and beta-carotene serum levels in patients with head and neck cancer with and without second primary tumors. The results indicate lowered levels of beta-carotene in both groups of patients, while the levels of vitamin A and vitamin E were statistically significantly lower in patients with second tumors than in the group with a single head and neck cancer. This suggests that low vitamin A and vitamin E levels may play a role in the etiology of second tumors in head and neck cancer patients.

Radical surgical treatment in craniofacial osteosarcoma gives excellent survival. A retrospective cohort study of 14 patients

14 patients with an osteosarcoma of the craniofacial bones were evaluated retrospectively. 10 patients were males and 4 were females, ages varied from 10 to 74 years with a mean of 37 years. Ten tumours were located in the maxilla and four in the mandible. All patients underwent surgical resection of the tumour. One patient was irradiated postoperatively with 67.5 Gy and another patient received adjuvant chemotherapy with melphelan. Follow-up ranged from 6 months to 10 years with a mean of 4 years 2 months. Of 14 patients, 5 have died of local disease of whom 1 also had distant metastasis. Disease-free survival was 82.5% after 2 years and 68.8% after 5 years. Overall survival was 79.1% after 5 years. Univariate statistical analysis was carried out, revealing age < 35 years (P = 0.033) and radical surgery (P = 0.007) as statistically significant factors in disease-free survival. It is concluded that radical surgery in young patients with a craniofacial osteosarcoma gives long-term disease-free survival.

Histological reclassification of 101 intraoral salivary gland tumours (new WHO classification).

The epithelial salivary gland tumours have for many years been categorised according to the 1972 World Health Organisation (WHO) classification. In 1990 a proposed revision of this classification was elaborated. In this study 101 intraoral salivary gland tumours were reclassified accordingly. In 29 of the cases the original histological diagnosis was changed, which in most cases, occurred in the benign or malignant tumour groups. In seven cases the diagnosis was changed from benign to malignant or vice versa. The results of this study show that the histological classification of intraoral salivary gland tumours remains difficult, even when applying the new WHO classification.