Heinrich Rudert

An interdisciplinary approach to the care of patients with Wegener's granulomatosis: Long-term outcome in 155 patients

OBJECTIVE To examine the outcome in 155 consecutive patients with Wegeners granulomatosis (WG) followed up for a median of 7 years. METHODS Treatment was adapted to the activity and extent of disease, with regular evaluation by an interdisciplinary team accompanied by group education about vasculitis. RESULTS The estimated median survival time was 21.7 years (95% confidence interval [95% CI] 15.60-27.86). Twenty-two patients died; 19 deaths were attributable to WG and/or its treatment. Significant predictors of survival at diagnosis were age >50 years (hazard ratio [HR] 5.45, 95% CI 1.97-15.02), kidney involvement with impaired renal function (HR 5.42, 95% CI 1.76-16.68), and lung involvement (HR 3.75, 95% CI 1.26-11.16). At some stage, 142 patients received prednisone and cyclophosphamide (CYC), usually as daily CYC plus mesna as uroprotection, 50 patients received trimethoprim/sulfamethoxazole, and 45 received methotrexate. Complete remission was achieved in 83 of the 155 patients. One or more relapses occurred in 99 patients after either complete or partial remission. CYC-induced cystitis and myelodysplastic syndrome occurred in 17 and 11 patients, respectively. A cumulative dose of 100 gm or more of CYC resulted in a 2-fold greater risk of CYC-related morbidity than with lower CYC doses. Serious infections occurred in 41 patients. CONCLUSION An interdisciplinary approach to the care of 155 WG patients resulted in a median survival of >21 years. Kidney or lung involvement at diagnosis was predictive of a >3-fold higher mortality. Although CYC remains essential in the treatment of WG, it was administered as briefly as possible and under close surveillance to avoid permanent CYC-related morbidity, which can lead to serious therapeutic problems in chronic relapsing WG.

Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society.

Abstract The European Laryngological Society is proposing a classification of different laryngeal endoscopic cordectomies in order to ensure better definitions of postoperative results. We chose to keep the word “cordectomy” even for partial resections because it is the term most often used in the surgical literature. The classification comprises eight types of cordectomies: a subepithelial cordectomy (type I), which is resection of the epithelium; a subligamental cordectomy (type II), which is a resection of the epithelium, Reinke’s space and vocal ligament; transmuscular cordectomy (type III), which proceeds through the vocalis muscle; total cordectomy (type IV); extended cordectomy, which encompasses the contralateral vocal fold and the anterior commissure (type Va); extended cordectomy, which includes the arytenoid (type Vb); extended cordectomy, which encompasses the subglottis (type Vc); and extended cordectomy, which includes the ventricle (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach used and the degree of resection in order to facilitate use of the classification in daily practice. Each surgical procedure ensures that a specimen is available for histopathological examination.

Transoral Carbon Dioxide Laser Resection of Supraglottic Carcinoma

Between 1981 and 1994, 34 patients with squamous cell carcinoma of the supraglottis were treated by transoral carbon dioxide laser resection, 12 of them palliatively. Additional treatment included neck dissection in 21 patients and radiotherapy in 24 patients. The 3-year overall survival was 62%, and the actuarial survival 80%. The overall survival for T1 and T2 tumors was 71%, and that for T3 and T4 tumors was 47%. The overall 3-year survival for the early stages, I and II, was 88%, and that for the advanced stages, III and IV, was 50%. These results are comparable to the outcome after conventional open partial resection. Given the significantly lower morbidity (only 7 patients required tracheostomy), we do not observe an age limit anymore. The transoral method can be recommended as curative treatment in T1 and T2 tumors and in selected T3 and T4 tumors in concert with neck dissection and/or radiotherapy. In patients with advanced inoperable tumors, laser surgery is an excellent alternative to tracheostomy and palliative radiotherapy. Prerequisites for successful application of the transoral carbon dioxide laser resection are adequate resection techniques.

Endoscopic resections of glottic and supraglottic carcinomas with the C02 laser

Clinical experiences with transoral CO2 laser resections of glottic and supraglottic carcinomas are presented. 47 patients with variously sized supraglottic tumors and 114 patients with early glottic cancers were treated at the University of Kiel from 1979 to 1993. Although 10 patients with glottic tumors developed recurrences, curative treatment was possible with either repeat laser surgery (3 cases), irradiation (3 cases) or salvage laryngectomy (3 cases). One patient refused further treatment. Among the 30 patients with supraglottic lesions treated for cure 18 are currently alive and free of disease. 6 patients died with no evidence of disease, 2 patients died from secondary malignancies and 3 patients succumbed to their tumors. Present findings justify routine use of laser resections of laryngeal neoplasms, although patients must still be carefully selected for treatment.

Antibodies against oncoproteins E6 and E7 of human papillomavirus types 16 and 18 in patients with head‐and‐neck squamous‐cell carcinoma

Human papillomaviruses (HPVs) have been recognized as an essential pathogenic factor in anogenital cancer. HPV DNA has also been found in a subgroup of head‐and‐neck squamous‐cell carcinomas (HNSCCs), and a causative role of the virus in the development of these tumors has been suggested by the concomitant inactivation of the tumor‐suppressor protein pRb. Using 4 second‐generation ELISAs, we found antibodies against at least 1 of the oncoproteins E6 and E7 of the high‐risk HPV types 16 and 18 in 11 of 92 sera (12%) taken from HNSCC patients at or near diagnosis, in 1 of 52 sera (2%) taken from HNSCC patients >6 months after diagnosis and in 10 of 288 sera (3.5%) taken from sex‐ and age‐matched healthy control individuals of the normal population. In 11 of the 12 seropositive HNSCC cases, antibodies were directed against HPV16 proteins. In patients, the HPV16 antibodies were mostly of high titer, and in 6 cases, antibodies against both HPV16 oncoproteins were present. Seven of the 8 HPV16 antibody–positive sera from the control group were of low titer, and none of the 10 antibody‐positive sera reacted with both oncoproteins of the same HPV type. The HPV type of the antigens detected by the antibodies in HNSCC patients correlated well with that of the HPV DNA found in the tumor. Of 19 patients known to have HPV16 DNA–positive tumors, 7 (37%) also had HPV16 E6 and/or E7 antibodies. Our finding suggests that the antibodies were formed in an immune response against HPV E6 and E7 proteins expressed in the HNSCC and thus strongly supports the concept of a biologically active role of HPV in the development of a subgroup of HNSCC. Int. J. Cancer 85:815–818, 2000.

Ultrasound-guided interstitial Nd:YAG laser treatment of voluminous hemangiomas and vascular malformations in 92 patients

In many cases voluminous vascular anomalies of the head and neck region are still treated with conventional surgery, although neodymium:yttrium‐aluminum‐garnet (Nd:YAG) laser therapy offers a valuable treatment alternative. Ninety‐two patients with voluminous hemangiomas and vascular malformations were treated with interstitial Nd:YAG laser therapy (power density, 1300 to 3300 W/cm2), partly complemented by a noncontact‐mode Nd:YAG laser light application (energy density, 1000 to 2500 J/cm2). The vascular tumors had a diameter of more than 3 cm in at least two dimensions. Treatment was carried out under ultrasound and manual control. Nearly 60% of the patients (n = 55) showed a complete clinical regression. Thirty‐three patients (35.8%) had a partial regression and were satisfied with the treatment outcome. Four patients were treated unsuccessfully with the laser, and three of them subsequently underwent conventional surgery. Only nine of the 92 patients (9.8%) showed cosmetic or functional impairments. The results of this first consecutive series study with a retrospective clinical evaluation of the interstitial Nd:YAG laser therapy of voluminous hemangiomas and vascular malformations in a large patient group demonstrate a high effectiveness of this novel therapy modality.

Transoral carbon-dioxide laser resection of hypopharyngeal carcinoma.

Abstract. In hypopharyngeal carcinoma, open partial resection is rarely feasible because of the high rate of chronic aspiration. Transoral laser surgery, however, is not associated with major swallowing problems. Between 1991 and 1995, a total of 29 patients with cancer of the hypopharynx were treated using laser surgical resection. In 25 patients, a neck dissection was performed, and 26 patients were radiated postoperatively. The 5-year overall survival was 48% and tumor-related survival 58%. The outcome was significantly (P<0.048) dependent on the preoperative lymph node status (N0=74%, N+=34% overall survival). Accordingly, the 5-year survival in stage I and stage II tumors was 71% and in stage III and IV tumors 47%. The highest local control rate was achieved in patients with carcinoma of the hypopharyngeal walls. A major advantage of laser surgery is that resurfacing of the wounds takes place per secundam. No reconstructions with free vascularized grafts have to be performed. There were no functional deficits regarding speech and swallowing in 94%, 100% and 100% of the surviving patients without local recurrence after 3, 4 and 5 years, respectively. No patient had to have a tracheostomy intraoperatively. Laser surgical treatment in combination with neck dissection and postoperative radiotherapy of selected patients with early cancer of the hypopharynx shows comparable results with open surgical procedures and is superior to radiotherapy alone. Given the low postoperative morbidity, transoral laser surgery with the goal of preserving the larynx should gain more importance in the future.

Cemento-ossifying fibroma of the petromastoid region: case report and review of the literature

The cemento-ossifying fibroma (COF) is a mesodermal, non-odontogenic tumour of ectopic multipotential periodontal membrane blast cells. It is aggressive, locally destructive, and has a high recurrence rate. A case report of COF of the petromastoid region is presented. This location has not been described until now. Trauma may act as a trigger to sudden growth of the atopic periodontal tissue. Due to the aggressive behaviour of this tumour and its frequent recurrence radical surgery is needed.

Zenker's diverticulotomy with the carbon dioxide laser: perioperative management and long-term results.

We analyzed 119 files of patients with Zenkers diverticulum who were treated with CO2 laser systems concerning treatment management, complications, and long-term results. Although the tissue bridge was dissected down to the fundus of the diverticulum, opening the mediastinum, mediastinitis was observed in none of the cases. Of the patients followed up for long-term results, 90.3% were completely symptom-free, and 5.8% of the patients reported an improvement in general condition. In view of the low rate of complications and the low level of morbidity and because of the good functional results, microendoscopic laser surgical diverticulotomy can be recommended as suitable therapy, especially as compared to external approaches or even other endoscopic treatment strategies. The main advantage as compared to staple-assisted esophagodiverticulostomy is that no special equipment is needed and that even small pouches can be treated successfully.

p53 serum antibodies as prognostic indicator in head and neck cancer

Abstract p53 antibodies are a new serological parameter of unknown potential in patients with malignancies. Their occurrence has been described in various types of cancer patients. The mechanism underlying the immunization process is still unclear. We investigated the incidence of p53 serum antibodies in 143 head and neck cancer patients with an enzyme-linked immunosorbent assay. The post-therapy course of two matched study groups (n = 38 each), one p53-antibody-seropositive and one p53-antibody-seronegative, was followed up for 24 months. Thirty-nine head and neck cancer patients (27.3%) were seropositive for p53 antibodies. During the follow-up, the p53-antibody-seropositive patients accounted for more local tumor recurrences (n = 12 versus n = 8) and more tumor-related deaths (n = 11 versus n = 5) than did seronegative patients, and second primary tumors (n = 9 versus n = 0) occurred exclusively in seropositive patients. In total, therapy failures (recurrences, tumor-related deaths, second primaries) were observed in 17/38 cases (44.7%) in the p53-antibody-seropositive group and in 8/38 cases (21.1%) in the p53-antibody-seronegative group. These results, after a follow-up of 2 years, seem to indicate a prognostic value of p53 serum antibodies for therapy failure in patients with head and neck cancer.