Steffen Dommerich

Simultane radiochemotherapie mit carboplatin bei patienten mit inoperablen fortgeschrittenen Kopf-Hals-Tumoren der stadien UICCIII und IV

HintergrundDie Therapieergebnisse der Behandlung fortgeschrittener Tumoren der Kopf-Hals-Region mit alleiniger Bestrahlung sind unbefriedigend. Eine simultane Radiochemotherapie verbessert diese Resultate vermutlich. In einer retrospektiven Analyse wurden Ergebnisse nach simultaner Radiochemotherapie an der Universität Rostock ausgewertet.Patienten und MethodenVon 1991 bis 1996 wurden 92 Patienten mit Kopf-Hals-Tumoren der Stadien UICC III und IV nach palliativer Operation (n = 37) oder primär (n = 55) mit einer simultanen Radiochemotherapie (1,8 Gy bis 63 Gy; 70 mg Carboplatin/m2 KOF Tage 1 bis 5 und 29 bis 33) behandelt. Analysiert wurden der Remissionsstatus sechs Wochen nach Therapieende, das Gesamt- und tumorspezifische Überleben, die lokale Kontrolle sowie die Akuttoxizität.ErgebnisseSechs Wochen nach Radiochemotherapie erreichten 56,5% der Patienten eine komplette und 36% der Patienten eine partielle Remission, ein “no change” war bei 7,5% der Patienten festzustellen. Bei einer medianen Beobachtungszeit von 42 Monaten (sechs bis 74 Monate) betragen kumulative Gesamtüberlebensrate, tumorspezifische Überlebens- und lokale Kontrollrate nach fünf Jahren 24,3%, 28,9% und 18,0%. Sowohl unials auch multivariat zeigen sich die Operation vor Radiochemotherapie und univariat das UICC-Stadium III als signifikant günstige Prognosekriterien hinsichtlich aller ausgewerteten Kriterien; multivariat ergibt sich ein signifikanter Vorteil hinsichtlich des Gesamtüberlebens für das UICC-Stadium III. Ein prätherapeutischer Hämoglobinwert < 7, 0 mmol/1 (11,27 g/dl) verschlechtert uni- und multivariat signifikant die lokale Kontrolle. Die Akuttoxizität war mit 10% Grad-3- und -4-Mukositiden, 12% Grad-3-Leukopenie vertretbar, eine Thrombopenie Grad 3 sowie eine Leukopenie Grad 4 traten nur jeweils bei einem Patienten auf.SchlußfolgerungDie vorgestellte Therapieoption ist gut durchführbar. Ob eine zusätzliche Operation die Ergebnisse der simultanen Radiochemotherapie verbessern kann, muß in einer randomisierten Studie überprüft werden.AbstractBackgroundThe results of treating advanced tumors in the head and neck region with radiotherapy alone are disappointing. Concurrent radiotherapy and chemotherapy may improve this situation. The treatment results of concurrent radiochemotherapy at the University of Rostock were analyzed retrospectively.Patients and MethodsFrom 1991 to 1996 92 patients with head and neck tumors were treated With concurrent radiochemotherapy (1.8 to 63 Gy; 70 mg/m2 carboplatin day 1 to 5 and 29 to 33) with palliative tumor resection (n = 37) or without surgical treatment (n = 55). Remission rate, overall survival and disease-free survival, local control and acute toxicity were analyzed.ResultsSix weeks after radiochemotherapy 56.5% of patients had a complete remission, 36% a partial remission and 7.5% “no change”. With a median follow-up of 42 months (6 to 74 months) overall survival, disease-free survival and local control were 24.3%, 28.9%, 18.0% 5 years after treatment. All these criteria were significantly better in patients with palliative tumor resection compared to no surgical treatment (uni- and multivariate) and in patients With Stage III than in patients with Stage IV carcinomas (univariate), overall survival was significantly better in patients with Stage III (multivariate). A pretherapeutic Hb level below 7.0 mmol/1 (11.27 g/dl) reduced the local control significantly (uni- and multivariate). Grade III and IV mucositis was detected in 10%, Grade III leucopenia in 12% of treated patients. Grade IV leucopenia and Grade III thrombopenia were observed in 1 patient each.ConclusionThe toxicity of this treatment is tolerable. However, additional trials must be conducted before considering the palliative tumor resection as standard therapy.

Prospective controlled study of microbial colonization of the trachea in tracheotomized and laryngectomized patients with HME (heat and moisture exchanger)

Conclusion: The use of heat and moisture exchangers (HMEs) does not endanger tracheostomy patients in terms of additional exposure to pathogenic microorganisms. Objective: Stoma filters in the form of HMEs cause a beneficial convection of respiratory air in tracheotomized and laryngectomized patients. We investigated whether or not this may lead to an altered microbial ecology in the non-physiologically colonized lower respiratory tract. Materials and methods: To test this hypothesis, material from the trachea of stoma patients was prospectively collected utilizing a standardized swab technique and subsequent aerobic quantitative culture assays of the suspended and serially diluted material. With this approach, we examined the microbial flora in 6 and 5 patients after laryngectomy/tracheostomy, respectively, without any protection, in 11 patients after laryngectomy with a bib, and in 8 laryngectomized patients with an HME. Results: In all three groups, Staphylococcus aureus and Candida albicans were most frequently demonstrated. The microbial count of facultative pathogenic agents ranged between 3×102 colony forming units (cfu)/ml and 106 cfu/ml and was similar in the three groups. With respect to the absence of inflammatory symptoms in every patient, all isolates could be regarded as colonizers. Among the antibiotics tested with each isolate, cefuroxime proved to be the most effective against the facultative pathogenic bacteria.

Intraossäres Hämangiom der Lamina perpendicularis ossis ethmoidalis

ZusammenfassungDie Inzidenz der intraossären Hämangiome ist gering.Bevorzugt betroffene Regionen im Kiefer-Gesichts-Bereich sind die Mandibula, das Jochbein, die Maxilla und das Os frontale und nasale.Das intraossäre Hämangiom ist ein benigner,langsam wachsender,knochenharter Tumor, der die Ursache für knöcherne Deformitäten im Gesicht sein kann. Ältere Frauen sind häufiger betroffen als Männer. Wir berichten über einen 18-jährigen Mann mit einem intraossären kavernösen Hämangiom im Bereich der Lamina perpendicularis ossis ethmoidalis.Einziges Symptom war eine allmählich zunehmende Behinderung der Nasenatmung.In der Diagnostik ist die CT-Untersuchung wegweisend.Intraossäre Hämangiome weisen ein charakteristisches Bild, ähnlich einer Honigwabe, auf.Wegen der seltenen Lokalisation der ossären Hämangiome im Bereich des Nasenseptums wurde differenzialdiagnostisch ein Chondrom,Chondrosarkom und ein Mittelliniengranulom in Erwägung gezogen.Für die Sicherung der Diagnose ist eine Gewebsentnahme aus dem Tumor unerlässlich. Die Therapie der Wahl ist die chirurgische Entfernung des Tumors, die in unserem Fall vom Hemitransfixionsschnitt aus durchgeführt wurde.Nur in Ausnahmefällen kommt die Radiatio zur Anwendung.AbstractThe incidence of intraosseous hemangiomas is very low. Most of them occur in adult females. The mandible,the zygoma,the maxilla, and the frontal and nasal bones are the areas of most frequent localization in the facial region.The intraosseous hemangioma is a benign, slowly growing,bony hard tumor causing facial deformity.It is diagnosed histologically. We report a case of an 18-year-old male with an intraosseous cavernous hemangioma located in the perpendicular lamina of the ethmoid bone. Intraosseous hemangioma often has characteristic signs on a CT scan, with either coarsened trabeculae lying adjacent to the vascular channels or multifocal lytic areas creating a honeycomb pattern.Because of the age of the patient we considered amidline granuloma and a chondrosarcoma. The therapy of choice is surgical excision; radiation is done in exceptional cases only.

Conservative management of post-intubation tracheal tears-report of three cases.

Iatrogenic tracheal rupture is a rare complication after intubation. We present three patients with tracheal tears. In all of these patients, a common finding was a lesion of the posterior tracheal wall with postoperative subcutaneous and emphysema as the first clinical sign of the rupture. Diagnosis and follow-up were based on clinical and endoscopic findings and chest computed tomography (CT) scans. In our cases with progressive subcutaneous and mediastinal emphysema or dyspnea, we performed a tracheotomy and bypassed the lesion with a tracheostomy tube to avoid an increase in air leakage into the mediastinum. Under broad-spectrum antibiotic therapy, no mediastinitis occurred and all patients survived without sequelae. Closure of tracheostomy was scheduled for 1-2 months after tracheal injury. Analysis of surgical and anesthesiological procedures revealed no abnormalities and the accumulation of tracheal injuries was considered as accidental. We found that in clinically stable patients with spontaneous breathing and with no mediastinitis, a conservative management of tracheal tears is a safe procedure.

Polydimethylsiloxane for injection laryngoplasty: two cases necessitating tracheotomy

AbstractThe surgical treatment of glottic insufficiency due to lesions of the recurrent laryngeal nerve has become a routine procedure in the last few decades. In particular, injection laryngoplasty with polydimethylsiloxane (PDMS) has proved to be an easy, effective and safe method for vocal fold medialization. It is a biologically inert substance having almost ideal properties as a filler; complications related to its intralaryngeal use such as migration, or granuloma formation are extremely rare and allergic reactions have not been reported as yet. We discuss two cases representing the first description of acute severe complications after injection laryngoplasty with PDMS.

Die mikrobiologische Oberflächenbesiedlung verschiedener Stimmprothesenarten in der Zeitkinetik

OBJECTIVE For the vocal rehabilitation of laryngectomized patients, voice prostheses are actually one of the best known methods. Caused by the surface colonisation with bacteria and fungi the life time of the prostheses is limited to 3-4 months. MATERIAL AND METHODS In a time period of 127 months we analysed the surface colonisation of 118 voice prostheses. RESULTS The mean life time of the prostheses was 156 days. In reference to the prosthesis model we also recorded different times of usage (ESKA-Herrmann 141, Provox 2 184 and Provox 1 204 days (p>0.05)). In the microbiological examination the dominating bacteria were S. aureus, Klebsiella sp. and Proteus sp. It was possible to cultivate all these bacteria on every type of prosthesis used in the study. In addition C. albicans, C. glabrata, C. krusei and C. tropicalis were the main fungi on the silicone surface. Thereby a more frequent colonisation with C. krusei on ESKA-Herrmann prostheses was measured, caused by the bigger contact area with saliva on this model (p=0.034). CONCLUSIONS Because of the similar position and way of function, all types of voice prostheses are colonized by almost the same species of bacteria and fungi. But in dependency of the type an affinity of individual species to special prostheses exist. The knowledge of these individual affinities is necessary for the further development of voice prostheses. Furthermore the diversity of bacteria and fungi species showed a level of saturation on the surface. This is caused by the limited space on the silicone prostheses.

Tracheostomy cannulas and voice prosthesis

Cannulas and voice prostheses are mechanical aids for patients who had to undergo tracheotomy or laryngectomy for different reasons. For better understanding of the function of those artificial devices, first the indications and particularities of the previous surgical intervention are described in the context of this review. Despite the established procedure of percutaneous dilatation tracheotomy e.g. in intensive care units, the application of epithelised tracheostomas has its own position, especially when airway obstruction is persistent (e.g. caused by traumata, inflammations, or tumors) and a longer artificial ventilation or special care of the patient are required. In order to keep the airways open after tracheotomy, tracheostomy cannulas of different materials with different functions are available. For each patient the most appropriate type of cannula must be found. Voice prostheses are meanwhile the device of choice for rapid and efficient voice rehabilitation after laryngectomy. Individual sizes and materials allow adaptation of the voice prostheses to the individual anatomical situation of the patients. The combined application of voice prostheses with HME (Head and Moisture Exchanger) allows a good vocal as well as pulmonary rehabilitation. Precondition for efficient voice prosthesis is the observation of certain surgical principles during laryngectomy. The duration of the prosthesis mainly depends on material properties and biofilms, mostly consisting of funguses and bacteries. The quality of voice with valve prosthesis is clearly superior to esophagus prosthesis or electro-laryngeal voice. Whenever possible, tracheostoma valves for free-hand speech should be applied. Physicians taking care of patients with speech prostheses after laryngectomy should know exactly what to do in case the device fails or gets lost.

Distribution of circulating natural killer cells and T lymphocytes in head and neck squamous cell carcinoma.

OBJECTIVE Natural killer (NK) cells are capable of eliminating malignantly transformed cells without prior sensitization. In contrast to NK-cells, T lymphocytes possess antitumourous activity that is restricted to major histocompatibility complex (MHC) recognition. The aim of this study was to determine the causes of the different distributions of these cell types in the peripheral blood of patients with head and neck squamous cell carcinomas (HNSCC). METHODS A cohort of 105 subjects was divided into three clinical groups: non-treated HNSCC patients, treated relapse-free HNSCC patients and healthy control subjects. Peripheral blood mononuclear cells (PBMC) were isolated from venous blood, subsets were depleted, flow cytometric counts were made and subsequently correlation analyses with clinical parameters were performed. RESULTS Treated relapse-free HNSCC patients have a significantly increased mean proportion of NK-cells in PBMC of 26.39% (p<0.001), whereas T lymphocytes and natural killer-T-(NKT) cells of treated patients have a significantly decreased mean proportion in PBMC of 55.15% (p<0.05) at least 12 months after treatment. This inverse redistribution of these two subsets is reflected in a significantly increased mean NK/T-ratio of 0.54 (p<0.05) in treated patients. The NK/T-ratio correlates with the systemic invasiveness of the type of therapy patients undergo and is highest after surgery with adjuvant radiochemotherapy (0.64, rs=0.334, p<0.01). This appears to be a post-therapeutic long-term effect in treated patients, as they had a mean relapse-free period until venous puncture of 47.9 months in our study. We also demonstrated age-dependent changes in the peripheral distribution of T- and NK-cells. CONCLUSION These findings reveal new aspects in understanding tumour biology and interactions with the cellular immune system which provide novel starting points for further research.

[Long-term changes in peripheral blood leukocyte and lymphocyte populations in ENT-carcinoma patients. A flow cytometric study in 346 ENT-carcinoma patients and 31 healthy controls].

BACKGROUND AND AIM The aim of this investigation was the quantification of leukocyte/lymphocyte populations in the peripheral blood of ENT-carcinoma patients before and long after therapy. PROBANDS AND METHOD: PBL T-lymphocytes and NK-cells were examined in 346 patients and 31 controls using flow cytometry. In 248 participants additional populations of leukocytes, monocytes, granulocytes, lymphocytes in toto, CD4+- and CD8+-lymphocytes, CD4+8+-lymphocytes, B-lymphocytes, activated T-lymphocytes, NK-cells and CD3+56+-T-lymphocytes were studied. RESULTS We demonstrated a long-term reduction in T-lymphocytes (CD4+-lymphocytes) in patients more than 10 years after receiving therapy, caused mainly, but not solely, by radio/chemotherapy. We also showed a long-term, significant increase in NK-cells after more than 10 years in patients following therapy without renewed carcinoma in comparison to controls, patients prior to therapy or patients with a recurrence of carcinoma. CONCLUSIONS Due to long-term deficits in CD4+-lymphocytes, and considering the possible protective effect of NK-cells in treated patients, an immune-supportive therapy is recommended.

Devitalisierung von Cholestatomanteilen humaner Ossikel durch hydrostatische Hochdrucktechnik

BACKGROUND In cholesteatoma surgery the use of autogenous ossicles for restoration of sound conduction is often limited because of ingrowth of matrix epithelia into the ossicular bone. In an attempt to eliminated these epithelial cells we tested extracorporal high-pressure hydrostatic treatment as a new method for devitalizing the bone but maintaining its structure. METHODS The inpact of different high hydrostatic pressures either on single cell suspensions of fibroblasts and osteoblasts, or on cells in ex-vivo ossicles chain was examined with different methods (quantitative proceedings, live/dead assay). Additional electron microscopic investigations illustrate the influence of high hydrostatic pressure treatment on cell suspensions of osteoblasts. RESULTS High hydrostatic pressure between 150 MPa and 250 MPa showed no effect to cellular material. A safe elimination of cell growth was found after an application of pressures at or above 400 MPa. The electron microscopic investigations illustrate clearly the destruction of cellular membranes after high hydrostatic pressure treatment. CONCLUSIONS These findings give hope that after extracorporal high hydrostatic pressure therapy autogenious ossicles might be used for middle ear recontructions even if they had contact with the cholesteatoma matrix or even were infitrated by keratinized squamous cell epithelia.