Importance: The rapidly expanding 2019 novel coronavirus pandemic (COVID-19, caused by the SARS-CoV-2 virus) has challenged the medical community to an unprecedented degree. Physicians and healthcare workers are at added risk of exposure and infection during the course of the patient care. Due to the rapid spread of this disease through respiratory droplets, healthcare providers such as otolaryngologists-head & neck surgeons who come in close contact with the upper aerodigestive tract during diagnostic and therapeutic procedures are particularly at risk. Here we present a set of safety recommendations based on our review of literature and communications with physicians with first-hand knowledge of safety procedures during the 2019 COVID-19 pandemic.Observations: A high number of healthcare providers were infected during the first phase of the pandemic in Wuhan province. Subsequently, by adopting strict safety precautions, other regions were able to achieve high levels of safety for healthcare providers without jeopardizing the care of patients. We reviewed the most common procedures related to the examination and treatment of upper aerodigestive tract diseases. Each category was reviewed based on the potential risk imposed to healthcare workers. Specific recommendations were made, based on the literature, when available, or consensus best practices. Specific safety recommendations were made for performing tracheostomy in COVID-19 patients. Conclusions and Relevance: Preserving highly skilled healthcare work force is a top priority for any community and healthcare system. Based on the experience of healthcare systems in Asia and Europe, by following strict safety guidelines, the risk of exposure and infection of healthcare providers could be significantly reduced, while providing high levels of care. The provided recommendations could be used as broad guidance for all healthcare workers who are involved with the care of COVID-19 patients.

Despite our improved understanding of cancer, the 5-year survival rate for head and neck squamous cell carcinomas (HNSCC) patients remains relatively unchanged at 50% for the past three decades. HNSCC often metastasize to locoregional lymph nodes, and lymph node involvement represents one of the most important prognostic factors of poor clinical outcome. Among the multiple dysregulated molecular mechanism in HNSCC, emerging basic, preclinical, and clinical findings support the importance of the mTOR signaling route in HNSCC progression. Indeed, we observed here that the activation of mTOR is a widespread event in clinical specimens of HNSCC invading locoregional lymph nodes. We developed an orthotopic model of HNSCC consisting in the implantation of HNSCC cells into the tongues of immunocompromised mice. These orthotopic tumors spontaneously metastasize to the cervical lymph nodes, where the presence of HNSCC cells can be revealed by histological and immunohistochemical evaluation. Both primary and metastatic experimental HNSCC lesions exhibited elevated mTOR activity. The ability to monitor and quantitate lymph node invasion in this model system enabled us to explore whether the blockade of mTOR could impact on HNSCC metastasis. We found that inhibition of mTOR with rapamycin and the rapalog RAD001 diminished lymphangiogenesis in the primary tumors and prevented the dissemination of HNSCC cancer cells to the cervical lymph nodes, thereby prolonging animal survival. These findings may provide a rationale for the future clinical evaluation of mTOR inhibitors, including rapamycin and its analogs, as part of a molecular-targeted metastasis preventive strategy for the treatment of HNSCC patients.

Self-reported and objective measures indicate that few American adults know much about HNC including risk factors such as tobacco use and HPV infection and common symptoms. Strategies to improve public awareness and knowledge of signs, symptoms, and risk factors may decrease the disease burden of HNC and are important topics for future research.

In histologically tumor-free surgical margins, elevated levels of eIF4E predict a significantly increased risk of recurrence. Elevated levels of eIF4E in tumor margins may identify patients who could benefit from additional therapy.

Control of translation initiation is one means by which cells regulate growth and proliferation, with components of the protein-synthesizing machinery having oncogenic potential. Expression of latency protein LMP2A by the human tumor virus Epstein-Barr virus (EBV) activates phosphatidylinositol 3-kinase/Akt located upstream of an essential mediator of growth signals, mTOR (mammalian target of rapamycin). We show that mTOR is activated by expression of LMP2A in carcinoma cells, leading to wortmannin-and rapamycin-sensitive inhibition of the negative regulator of translation, eukaryotic initiation factor 4E-binding protein 1, and increased c-Myc protein translation. Intervention by this DNA tumor virus in cellular translational controls is likely to be an integral component of EBV tumorigenesis.Epstein-Barr virus (EBV) is an opportunistic pathogen that can manifest itself in human disease years after primary infection, specifically in lymphoid and epithelial cell malignancies of both immune-competent and immune-compromised hosts. EBV-associated cancers include Burkitt's lymphoma, Hodgkin's lymphoma, posttransplant lymphoproliferative disease, non-Hodgkin's lymphomas of AIDS, nasopharyngeal carcinoma, and gastric carcinoma (33). Despite its sporadic association with most tumors, EBV is deemed causal when present, based in part on the uniformity in every tumor cell of what in circulating peripheral blood lymphocytes is a variably reiterated EBV terminal repeat sequence (6, 32). Circularization of the viral genome within cells by random recombination of its terminal repeats produces fused ends of a length distinct for each infected cell. Homogeneity of the repeats in tumor cells provides a viral marker of clonality that implies EBV infection precedes cellular expansion and is thus factorial (26, 28).Fused termini, which may vary by as many as 20 reiterations of the 500-bp repeat unit (6), comprise the first intron of an open reading frame that encodes EBV latency protein LMP2A (20,36). LMP2A is a transmembrane protein with transforming potential in epithelial cells and is expressed in several EBV-associated malignancies (33,38). In carcinoma cells infected in vitro, we previously showed that expression levels of LMP2A vary inversely with the size of intron 1, with episomes with the fewest terminal repeat units expressing the most LMP2A (23). In culture, cells maintaining episomes with the fewest terminal repeats became predominant (23). The selective advantage apparently conferred by LMP2A may relate to its activation of the phosphatidylinositol 3-kinase (PI3-kinase) and serine/threonine kinase Akt signaling pathway, which has a prominent role in cell proliferation and survival (24,31,38,41).The cellular kinase mammalian target of rapamycin (mTOR) has a central role in regulating cap-dependent translation initiation and has emerged as a principal mediator of cell growth and proliferation by its regulation of cellular machinery for protein synthesis (Fig. 1) (16). Activation of mTOR is mediated by several upstream sig...

Purpose: Overexpression of eIF4E in surgical margins of head and neck cancer patients is an independent risk factor for recurrence. We hypothesize that overexpressed eIF4E is functionally active in tumor margins through activation of the Akt/mammalian target of rapamycin (mTOR) pathway Experimental Design: Western blots and/or immunohistochemistry were performed to determine whether phosphorylation of mTOR and activation of its downstream molecules eIF4E-binding protein-1 (4E-BP1) and p70 S6 kinase and the upstream modulator of mTOR, Akt, were expressed in margins overexpressing eIF4E.Results: There was a significant association between phospho-4E-BP1 and eIF4E expression of a margin or a significant difference in phospho-4E-BP1 expression between the eIF4E-positive and -negative margins (P < 0.01). A significant association between eIF4E and phospho-p70 S6 kinase as well as eIF4E and phospho-mTOR was also noted (P < 0.05). Western blot analysis indicated a highly significant difference in the phosphorylation status of 4E-BP1 between tumors and resection margins. A total of 89% of the 4E-BP1-expressing margins expressed more of the phosphorylated (␤, ␥, and ␦) isoforms, whereas 81% of the 4E-BP1-expressing tumors expressed more of the unphosphorylated ␣ isoform. A similar difference in Akt activation was noted between eIF4E-positive margins and tumors (P < 0.05).Conclusions: Overexpression of eIF4E is functionally active in tumor margins through activation of the Akt/ mTOR signaling pathway. The greater degree of expression of downstream targets and upstream regulators of mTOR in margins compared with the tumors indicates preferential activation of the Akt/mTOR signaling pathway in margins overexpressing eIF4E. Rapamycin analogs can potentially be used as adjuvant therapy for patients with eIF4E-positive margins.

Background The recent epidemic of head and neck squamous cell carcinomas (HNSCC) associated with human papilloma virus (HPV) has not addressed its association with lymphoid tissue in the oropharynx or the potential role of Epstein-Barr virus (EBV)/HPV co-infection. Methods The prevalence of HPV and EBV infection/co-infection and CD21 mRNA expression were determined in normal and cancerous tissues from the oropharynx using in situ hybridization (ISH), p16 and quantitative reverse transcriptase PCR (qRT-PCR). The effects of co-infection on tumorigenicity were evaluated using proliferation and invasion assays. Results Normal oropharynx, tonsil, non-cancer base of tongue (BOT) and BOT from sleep apnea patients, demonstrated EBV positivity ranging from 7-36% depending on the site and methods of detection used (qRT-PCR or ISH). Among non-malignant BOT samples HPV positivity was noted only in 20%. The percent of tonsil and BOT cancers positive for HPV (up to 63% and 80%, respectively) or co-infected with HPV/EBV (up to 25% and 70%, respectively) were both significantly associated with cancer status. Notably HPV/EBV co-infection was observed only in malignant tissue originating in lymphoid-rich oropharynx sites (tonsil, BOT). CD21 mRNA (the major EBV attachment receptor) was detected in tonsil and BOT epithelium, but not in soft palate epithelium. Co-infected cell lines showed a significant increase in invasiveness (p<0.01). Conclusions There is a high prevalence of HPV/EBV infection and co-infection in BOT and tonsil cancers, possibly reflecting their origins in lymphoid-rich tissue. In vitro, cells modeling co-infection have an increased invasive potential.

Molecular therapeutics identifies an aberration in tumors to select patients that benefit from molecular targeted therapy. Overexpression of eIF4E in histologically ''tumor-free'' surgical margins of head and neck squamous cell cancer (HNSCC) patients is an independent predictor of recurrence and is functionally activated through the Akt/mammalian target of rapamycin (mTOR) pathway. Although mTOR inhibitors are cytostatic agents, best used in combination therapy, we hypothesize that they can be used as long-term single agents in an HNSCC model of minimal residual disease (MRD). CCI-779, an mTOR inhibitor, arrested growth of a phosphatase and tensin homologue deleted on chromosome 10 (PTEN) abnormal HNSCC cell line FaDu, inhibiting phosphorylation of 4E-binding protein 1, resulting in increased association with eIF4E and inhibition of basic fibroblast growth factor and vascular endothelial growth factor. Fluorescence in situ hybridization detected PTEN abnormalities in 68% of patient tumors and 35% of tumor-free margins. CCI-779 inhibited growth of established tumors in nude mice. However, in the MRD model, there were significant differences in the tumorfree rate between the control (4%) and the treatment group (50%), and the median tumor-free time was 7 versus 18 days, respectively (P < 0.0001). In those animals that formed tumors, CCI-779 caused a significant decrease in the tumor volume. The Kaplan-Meier curve showed that CCI-779 significantly increased survival (P < 0.0001). The mTOR pathway was inhibited in peripheral blood mononuclear cells potential surrogate markers of response to therapy. Stable transfection of FaDu with luciferase allowed us to monitor the effects of CCI-779 with bioluminescence imaging in the MRD model. These results pave the way for a clinical trial using targeted molecular therapy with CCI-779 as a single agent for mTORactivated residual cells. [Cancer Res 2007;67(5):2160-8]