Michal Zabrodsky

Endoscopic CO2 laser surgery for early glottic cancer in patients who are candidates for radiotherapy: Results of a prospective nonrandomized study

Treatment of early glottic malignancies is controversial, particularly if postoperative endoscopy shows minimal/no residual disease.

The Role of Narrow Band Imaging in the Detection of Recurrent Laryngeal and Hypopharyngeal Cancer after Curative Radiotherapy

Narrow band imaging is considered a significant improvement in the possibility of detecting early mucosal lesion of the upper aerodigestive tract. Early detection of mucosal neoplastic lesions is of utmost importance for patients survival. There is evidence that, especially in patients previously treated by means of curative radiotherapy or chemoradiotherapy, the early detection rate of recurrent disease is quite low. The aim of this study was to prove whether the videoendoscopy coupled with NBI might help detect recurrent or secondary tumors of the upper aerodigestive tract. 66 patients previously treated by means of RT or CRT with curative intent were enrolled in the study. All patients underwent transnasal flexible videoendoscopy with NBI mode under local anesthesia. When a suspicious lesion was identified in an ambulatory setting, its nature was proved histologically. Many of these changes were not identifiable by means of conventional white light (WL) endoscopy. The accuracy, sensitivity, specificity, and positive and negative predictive value of the method are very high (88%, 92%, 76%, 96%, and 91%, resp.). Results demonstrate that outpatient transnasal endoscopy with NBI is an excellent method for the follow-up of patients with carcinomas of the larynx and the hypopharynx primarily treated with radiotherapy.

The Role of NBI HDTV Magnifying Endoscopy in the Prehistologic Diagnosis of Laryngeal Papillomatosis and Spinocellular Cancer

Narrow band imaging (NBI) HDTV (high definition television) magnifying endoscopy is considered to be superior for the accurate display of the microvascular patterns of superficial mucosal lesions. Observation of changes in intraepithelial papillary capillary loops (IPCL) can help distinguish benign from malignant lesions as part of an “optical biopsy.” However, IPCL changes in papillomas may be mistaken for spinocellular cancer (SCC). The aim of the study was to determine whether observing microvascular changes alone is sufficient for discriminating between laryngeal SCC and papillomatosis. An additional aim was to identify associated characteristics that could clarify the diagnosis. The study included 109 patients with a suspected laryngeal tumor or papilloma. HDTV NBI magnifying endoscopy was performed during direct laryngoscopy. It was possible to visualize IPCL changes in 82 out of 109 patients (75.2%). In 71 (86.6%) patients, the diagnosis was correctly determined. In 4 (4.9%) cases, the diagnosis of SCC was expressed on the basis of finding pathologic IPCL, but histology did not demonstrate malignancy. To achieve a correct diagnosis using HDTV NBI magnifying endoscopy, it is important not only to observe changes in the shape of IPCL but also to note possible papillary structures with central-axis capillaries typical of papillomatosis.

Combined bipolar radiofrequency surgery of the tongue base and uvulopalatopharyngoplasty for obstructive sleep apnea.

Introduction The aim of the study was to investigate the effectiveness of combined bipolar radiofrequency surgery of the tongue base (RFBT) and uvulopalatopharyngoplasty (UPPP) in a single session for obstructive sleep apnea and whether this combination is safe and well tolerated. Material and methods Seventy-nine patients with obstructive sleep apnea and both palatal and retroglossal obstruction underwent UPPP with bipolar RFBT. The control group consisted of 35 patients treated by UPPP alone. Results The apnea-hypopnea index significantly decreased from 28.7 to 14.1. The oxygen desaturation index decreased from 15.1 to 10.3. Mean oxygen saturation was unchanged. Subjectively, the Epworth Sleepiness Scale was significantly improved from 10.6 to 7.3, and the snoring level decreased from 8.4 to 6.0. The overall treatment success rate increased from 41.9% for UPPP alone to 51.7% for UPPP + RFBT. No serious adverse events occurred. Two patients had postoperative bleeding from the tonsillar bed after UPPP. Four patients had ulceration of the base of the tongue after RFBT with spontaneous cure. One patient had a taste change in half of the tongue that resolved within two months. Conclusions Combined bipolar RFBT and UPPP in a single session is well tolerated and safe surgery in the treatment of obstructive sleep apnea. It is effective in reducing respiratory parameters and subjective symptoms of obstructive sleep apnea. Further advantages are a single session, simple feasibility, bipolar technique and short time of the procedure.

A New Strategy for the Surgical Management of RLN Infiltrated by Well-Differentiated Thyroid Carcinoma

Well-differentiated thyroid carcinoma (WDTC) represents the most common endocrine malignancy. Despite excellent prognoses exceeding 90% in 10-year follow-up, there are clinically controversial issues. One of these is extrathyroidal tumour extension invading recurrent laryngeal nerve (RLN). The spread outside of the thyroid parenchyma and invasion to the surrounding structures, classified as always T4a, are the most important negative prognostic factor for the WDTC. Conversely, resection of the RLN leads to vocal cord paralysis with hoarseness, possible swallowing problems, and finally decreased quality of life. We propose a new algorithm for intraoperative management based on the MACIS classification, which would allow swift status evaluation pre/intraoperatively and consider a possibility to preserve the infiltrated RLN without compromising an oncological radicality. In the case of a preoperative vocal cord paralysis (VCP) and confirmation of the invasive carcinoma, a resection of the RLN and the nerve graft reconstruction are indicated. Preoperatively, unaffected vocal cord movement and intraoperatively detected RLN infiltration by the invasive WDTC require an individual assessment of the oncological risk by the proposed algorithm. Preservation of the infiltrated RLN is oncologically acceptable only in specific groups of patients of a younger age with a minor size of primary tumour.

Influence of Radiofrequency Surgery on Architecture of the Palatine Tonsils

Radiofrequency surgery is a widely used modern technique for submucosal volume reduction of the tonsils. So far there is very limited information on morphologic changes in the human tonsils after radiofrequency surgery. We performed histopathological study of tonsillectomy specimens after previous bipolar radiofrequency induced thermotherapy (RFITT). A total of 83 patients underwent bipolar RFITT for hypertrophy of palatine tonsils. Tonsil volume reduction was measured by 3D ultrasonography. Five patients subsequently underwent tonsillectomy. Profound histopathological examination was performed to determine the effect of RFITT on tonsillar architecture. All tonsillectomy specimens showed the intact epithelium, intact germinal centers, normal vascularization, and no evidence of increased fibrosis. No microscopic morphological changes in tonsillectomy specimens after bipolar RFITT were observed. RFITT is an effective submucosal volume reduction procedure for treatment of hypertrophic palatine tonsils with no destructive effect on microscopic tonsillar architecture and hence most probably no functional adverse effect.

Abstract A120: The infiltration of Th17 cells in tumor microenvironment negatively correlate with the prognosis of the patients with head and neck squamous cell carcinoma

Introduction: Head and Neck squamous cell carcinoma (HNSCC) remains to the malignancies with the unsure prognosis. Regarding the etiology, we are facing different clinical manifestation, behavior and overall survival. This fact can be explained by the differences in the immune response of the patients. Understanding of the basic principles of the immune system of HNSCC patients would help us to better combine the therapeutical strategies with the respect to the immune cell subpopulations and their regulation. One of the most important cells are Th17 lymphocytes, which are increased in the peripheral blood and the microenvironment of many types of cancers. Methods: 178 patients with primary HNSCC were included to the study. Samples of the peripheral blood and from the primary tumors, metastatic lymph nodes and non-affected lymph nodes were collected at the moment of surgical therapy and measured by flow cytometry. The data were analyzed by the Cox regression and compared with the group of healthy blood donors. Sixty six tumors out of 178 primary tumors were localized in the tonsillar region, 50 in the root of the tongue, 33 in the larynx and 8 in hypopharynx. The average follow-up was 40 months. Results: For the prognosis of the patients the most important oncological parameters were T and N stadium of the disease (p = 0.02, resp. p = 0.03), radicality of the surgery (p = 0.006), presence of the adverse prognostic risk factors (p = 0.01). From the analyzed parameters of the immune system we found negative prognostic correlation of the level of B lymphocytes (CD19+; p = 0.03) and the positive prognostic correlation of the level of naive CD4+ T cells (CD4+CD45RA+, p = 0.02) in the peripheral blood of the patients. We found strong negative prognostic correlation of the Th17 cells (CD4+CD161+) in the peripheral blood (p = 0.04) and also in the tumor microenvironment (p = 0.005). Conclusion: We can conclude that the examination of parameters of immune system could be helpful for better understanding of biological behavior and interaction of the HNSCC. The level of Th17 cells in both periphery and in the tumor microenvironment correlate with the worst survival of the patients with the HNSCC. The analyses of the Th17 level in the peripheral blood before the therapy could help us with the prediction of the cause of the disease. The future studies should be focused on the changes in immune cells infiltration in response to the different therapeutical strategies in HNSCC oncology. Acknowledgments: The research was supported by AZV MZ CR (grant No. NV16-28594A and NV16-28600A). Note: This abstract was not presented at the conference. Citation Format: Jan Boucek, Michal Zabrodsky. The infiltration of Th17 cells in tumor microenvironment negatively correlate with the prognosis of the patients with head and neck squamous cell carcinoma [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A120.

Abstract A141: Prognostic value of cancer stem cells (CSC) in head and neck squamous carcinoma (HNSCC)

Introduction: Cancer stem-cell (CSC) theory of tumorigenesis has been established during the last decade. There are phenotypically different subpopulations of cells in found in HNSCC tissue including diverse cancer cells, stromal cells and infiltrating inflammatory cells. According to a CSC theory only a small subpopulation of tumor cells can reproduce themselves and sustain the tumor growth. CSC subpopulation can retain some of the markers (surface epitopes) typical for normal stem cells, the most often mentioned being CD44+, CD29+, CD24+ and CD133+ markers. Isolated CSCs can be transplanted to the immunodeficient animal host and drive a tumor growth. Material and Methods: Peripheral blood samples together with primary tumor, metastatic and non-metastatic lymph node tissue samples were collected from 178 patients with primary HNSCC. We examined peripheral blood from all patients with the focus on lymphocyte subpopulation (CD3+, CD4+CD25+, CD4+/CD8+, CD19+, CD4+CD45RA+, CD8+CD28-, CD3-CD16+CD56+, CD4+CD25+Foxp3+, CD4+161+, CD8+161+) before the commencement of anti-tumor therapy. The level of the markers of cancer stem cells (CD44+, CD133+, CD29+) on the surface of the cancer cells, the infiltration of immunocompetent cells in the tumor microenvironment of specimens from primary tumors, from metastases to the neck lymph nodes and in control lymph nodes was measured, where samples were taken during the surgery. The correlation of cancer stem cells (CD44+, CD133+, CD29+) with the prognosis of the patient was analyzed with a special interest. Mean follow-up was 40 months. Results: A significant representation of cells expressing characteristics of CSCs has been identified in the tumor microenvironment of HNSCC. Subpopulation of CD44 + keratinocytes directly correlated with the presence of negative histological features (angioinvasion, lymphangioinvasion, perineural spread) (p = 0.007), i.e. factors significantly influencing the patient´s prognosis (p = 0.03). Conversely, CD133 + cells in the primary tumor negatively correlated with N stage (p = 0.04), thus suggesting that a higher proportion of CD133 + keratinocytes in the primary tumor yields lower metastatic potential. Presence of CD44 + and CD29 + keratinocytes does not correlate with N stage (p = 0.8 respectively. P = 0.4). Conclusion: Cells with CSCs characteristics can be shown in the HNSCC tumor tissue. Presence of certain subpopulations of keratinocytes (CD44+, CD133+) expressing the cell surface markers of CSCs can elucidate the patient´s prognosis. The therapy targeted to the cancer stem cells, in combination with immunotherapy, could increase the survival of the patients with HNSCC. Acknowledgements: The research was supported by AZV MZ CR (grant No. NV16-28594A and NV16-28600A) Note: This abstract was not presented at the conference. Citation Format: Michal Zabrodsky, Jan Boucek. Prognostic value of cancer stem cells (CSC) in head and neck squamous carcinoma (HNSCC) [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A141.

Abstract B85: The relation between Treg and cancer stem cells in microenvironment of head and neck squamous cell carcinoma.

Head and neck squamous cell carcinoma (HNSCC) remains one of the most difficult problems in the current oncology. Overall survival of the patients have not improved in more than 30 years and have not reached approximately 50% at 5 years for all stages. The combination of surgery with radiation or chemotherapy resulted in limited improvement in survival rates, although there was shown the efficacy of concomitant chemo-radiation in organ preservation. On the other hand, identification of some biological or immunological markers (e.g. HPV, Treg) allowed us to better understand the behavior of the disease. Cancer stem-cell (CSC) theory of tumorigenesis has been established during the last decade. HNSCC is histologically heterogeneous and in tumor microenvironment plays important role also diverses cancer cells, stromal cells and infiltrating inflammatory cells. But only a small subpopulation of CSCs has been identified to be responsible to development and the growth of solid tumors. Several surface epitopes have been published as distinguishing markers for CSCs identification. The most often mentioned are CD44+, CD29+, CD24+ and CD133+ markers. Regulatory T cells (Treg, CD4+CD25+Foxp3+) were described as one of the critical factors for regulation or inhibition of effective anti-cancer immune response and, consequently, the prognosis and survival for different types of tumors, including HNSCC. There were 119 patients with HNSCC included in the study from September 2010. Out of 119 primary tumors 50 were localized in the tonsillar region, 42 in the root of the tongue, 20 in the larynx and 7 in hypopharynx. All patients underwent primary surgical therapy, in dependence on the final pathological staging 15 underwent adjuvant chemo-radiation, 73 adjuvant radiation and 31 had no adjuvant therapy. Follow-up of all of them has been provided on author´s department. The presence of the immunocompetent cells in the tumor microenvironment of specimens from primary tumors, from metastases to the neck lymph nodes and from control lymph nodes was correlated with the numbers of HNSCC cancer stem cells (CD44+, CD29+, CD133+) in a subgroup of patients (68), where samples were taken during the surgery. The number of Treg in specimens from primary tumors was significantly higher than from metastatic neck lymph nodes or in neck lymph nodes without metastatic extension (5.53%, SD 4.12 vs. 3.96%, SD 2.64 vs. 4.9%, SD 3.31, p=0.01). CD44+ or CD29+ or CD133+ cancer stem cells were detected in the tumor microenvironment and the numbers of all of these cells were dramatically higher in samples from primary tumors than from metastases or from control lymph nodes (CD44+: 47.1%, SD 26.4 vs. 28.3%, SD 30.2 vs. 6.5%, SD 16.4, p=0.0002; CD29+: 18.3%, SD 21.7 vs. 12.0%, SD 14.1 vs. 4.4%, SD 12.1, p=0.0028; CD133+: 6.1%, SD 8.7 vs. 3.6%, SD 4.8 vs. 0.6%, SD 0.8, p=0.0002). There was a significant correlation of Treg infiltration with percentage of CD44+ cancer cells (Treg high vs. Treg low group, CD44+ 54.4%, SD 31.3 vs. 40.4%, SD 20.4, p= 0.04) in the samples of primary tumors. We can conclude that examination of these parameters could be helpful for better understanding of biological behavior of the HNSCC and could help us with prognostication and choice of treatment strategy in HNSCC patients. Acknowledgments: The research was supported by IGA MZ CR (grant No. 11542). Citation Format: Jan Boucek, Michal Zabrodsky, Jan Betka, Tomas Eckschlager, Blanka Rihova. The relation between Treg and cancer stem cells in microenvironment of head and neck squamous cell carcinoma. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology: Multidisciplinary Science Driving Basic and Clinical Advances; Dec 2-5, 2012; Miami, FL. Philadelphia (PA): AACR; Cancer Res 2013;73(1 Suppl):Abstract nr B85.

Abstract B94: The role of Th17 cells in the head and neck squamous cell carcinoma evolution.

Head and neck squamous cell carcinoma (HNSCC) is the most frequent histotype of the mucosal malignant tumor in this region. Many new diagnostic and therapeutic modalities have been implemented in the diagnostic and treatment protocols however all of them failed to prove a significantly improved overall survival of patient. Surgery combined with radiotherapy and chemotherapy remains a mainstay of the current treatment approaches. A better understanding of the tumor behavior and its immunological profile and microenvironment (e.g. HPV, Treg) allowed us to modify the treatment strategy. Regulatory T cells (Treg, CD4+CD25+Foxp3+) were described as one of the critical factors for regulation or inhibition of effective anti-cancer immune response. Increased Treg frequency in the peripheral circulation was proven to correlate with the progression HNSCC. In many cancers a synergy of Treg and Th17 (CD4+161+) has been shown. So far, little is known about the importance of Tc17 (CD8+161+) in HNSCC. Particularly, the relationship between Tc17 and tonsillar cancers could be very interesting, because the CCL20 receptor (ligand for CCR6 overexpressed on Tc17) was also frequently found in tonsillar epithelia. There were 119 patients with HNSCC included in the study from September 2010. Out of 119 primary tumors 50 were localized in the tonsillar region, 42 in the root of the tongue, 20 in the larynx and 7 in hypopharynx. All patients underwent primary surgical therapy, in dependence on the final pathological staging 15 underwent adjuvant chemo-radiation, 73 adjuvant radiation and 31 had no adjuvant therapy. We examined periphery blood from all patients with the focus on lymphocyte subpopulation (CD3+, CD4+CD25+, CD4+/CD8+, CD19+, CD4+CD45RA+, CD8+CD28-, CD3-CD16+CD56+, CD4+CD25+Foxp3+, CD4+161+, CD8+161+) before the start of anti-tumor therapy. The infiltration of immunocompetent cells in the tumor microenvironment of specimens from primary tumors, from metastases to the neck lymph nodes and from control lymph nodes was measured in a subgroup of patients (68), where samples were taken during the surgery. The correlation of Treg and Th17 resp. Tc17, was analyzed with a special interest. The percentage of Th17 cells (CD4+CD161+) in peripheral blood does not differ in patients with HNSCC (5.8%, SD 2.5) and in healthy controls (5.6%, SD 3.5, p = 0.46) and also the presence of Tc17 (CD8+CD161+) in peripheral blood shows the same pattern in both groups (7.0%, SD 5.5 vs. 8.0%, SD 4.3, p = 0.31). The percentage of Th17 cells detected in primary tumors was significantly much higher than in metastatic neck lymph nodes or in neck lymph nodes without metastatic extension (7.1%, SD 7.2 vs. 4.2%, SD 3.0 vs. 4.8%, SD 2.0, p=0.01 resp. p=0.03). There was no difference in the infiltration of Tc17 cells, nor was also observed increased infiltration by Tc17 tonsillar carcinomas compared with other localizations of HNSCC. Very interesting and highly significant was the correlation of Treg infiltration with percentage of Th17 (Treg high vs. Treg low group, CD4+161+: 5.14%, SD 4.63 vs. 8.99%, SD 8.6, p= 0.03) in the samples of primary tumors. Our results show that Th17 are increasingly detected in the primary HNSCC. Their importance for the prognosis of patients could be analyzed over a longer period of time. Acknowledgments: The research was supported by IGA MZ CR (Grant No. 11544 and 11542). Citation Format: Michal Zabrodsky, Jan Betka, Tomas Eckschlager, Blanka Rihova, Jan Boucek. The role of Th17 cells in the head and neck squamous cell carcinoma evolution. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology: Multidisciplinary Science Driving Basic and Clinical Advances; Dec 2-5, 2012; Miami, FL. Philadelphia (PA): AACR; Cancer Res 2013;73(1 Suppl):Abstract nr B94.