DNA Repair Gene ERCC1 and ERCC2/XPD Polymorphisms and Risk of Squamous Cell Carcinoma of the Head and Neck

ORIGINAL ARTICLE DNA Repair Gene ERCC1 and ERCC2/XPD Polymorphisms and Risk of Squamous Cell Carcinoma of the Head and Neck

Erich M. Sturgis, MD; Kristina R. Dahlstrom, BS; Margaret R. Spitz, MD, MPH; Qingyi Wei, MD, PhD

Objective: To determine the effect of the ERCC1 C8092A types after adjustment for age, sex, tobacco smoking, and polymorphism and the ERCC2/XPD G23591A polymor- alcohol use. phism on the risk of squamous cell carcinoma of the head and neck (SCCHN). Results: The DNA was available and genotyping was ul- timately successful for 313 case subjects and 313 con- Design: A hospital-based case-control study. trol subjects. The ERCC1 8092CC genotype and the ERCC2/XPD 23591A allele were associated with nonsig- Subjects: A total of 330 newly diagnosed case subjects nificantly increased risks of SCCHN: odds ratios, 1.15 with SCCHN and 330 cancer-free control subjects (95% confidence interval [CI], 0.84-1.59) and 1.28 (95% matched on age (±5 years), sex, smoking status, and al- CI, 0.93-1.76), respectively, whereas having both risk cohol use. All subjects were non-Hispanic whites. genotypes was associated with an even higher risk of SCCHN: odds ratio, 1.78 (95% CI, 0.99-3.17). When con- Methods: After informed consent was obtained, blood sidering both polymorphisms, we found a significant al- was drawn for genotyping. The ERCC1 C8092A poly- lele dose effect (P=.04). morphism was typed by single-strand conformational polymorphism analysis. The ERCC2/XPD G23591A poly- Conclusions: These 2 polymorphisms may contribute morphism was typed by polymerase chain reaction– to the risk of SCCHN, but larger studies are needed to based restriction fragment length polymorphism analy- confirm their role in SCCHN. Combining common DNA sis with the enzyme StyI. The ␹2 analysis was used to assess repair gene polymorphisms into models of genetic risk differences in genotype and allele frequencies. Multivar- of SCCHN may improve risk estimates. iate logistic regression analysis was performed to esti- mate the risk of SCCHN for individuals having these geno- Arch Otolaryngol Head Neck Surg. 2002;128:1084-1088

NNUAL ESTIMATES show tide polymorphisms (SNPs), will signifi- that the number of cur- cantly influence risk without environmen- rent smokers in the United tal exposures. Therefore, current efforts States has remained rela- have focused on determining genotype fre- tively stable at approxi- quencies in the population and which matelyA 45 million over the past 3 de- SNPs will be important to include in fu- cades, and the absolute incidence of newly ture, more complex, genetic models of can- diagnosed cancers has never exceeded 1.4 cer risk assessment. million.1,2 These facts suggest that most We have previously reported that the smokers never develop cancer and that ge- risk of squamous cell carcinoma of the netic differences probably influence indi- head and neck (SCCHN) was associated viduals’ responses to environmental car- with poor DNA repair phenotype in re- cinogens and consequently their risk for sponse to the classic tobacco carcinogen, From the Departments of Head cancer. Although the concept of genetic benzo[a]pyrene diol epoxide.3-6 The dam- and Neck Surgery (Dr Sturgis) susceptibility may seem intuitive, it is ex- age induced by it is repaired primarily by and Epidemiology (Drs Sturgis, 7 Spitz, and Wei and tremely complex and involves multiple cel- the nucleotide excision repair pathway. 8 Ms Dahlstrom), The University lular systems regulated by hundreds of In 1998, Shen et al identified 31 SNPs of of Texas M. D. Anderson genes. It is unlikely that common genetic ERCC1, ERCC2/XPD, and ERCC4/XPF of Cancer Center, Houston. variants, most of which are single nucleo- the nucleotide excision repair pathway. Be-

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, SEP 2002 WWW.ARCHOTO.COM 1084

©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 cause polymorphisms of the nucleotide excision repair genes may be associated with differences in DNA repair Table 1. Frequency Distribution Analysis capacity,9 we hypothesized that genetic variants in the of Demographic and Risk Factors* nucleotide excision repair pathway may influence risk Cases Controls of SCCHN. In the present study, we examine an SNP of Variable (n = 313) (n = 313) P Value† the 3Ј untranslated region (UTR) of ERCC1 that has been reported to be linked to adult-onset glioma,10 and an SNP Age, y Յ50 99 (31.6) 98 (31.3) of exon 10 of ERCC2/XPD that has been linked to al- 51-63 110 (35.2) 112 (35.8) .99 9 tered DNA repair capacity. Ͼ63 104 (33.2) 103 (32.9) Sex Male 234 (74.8) 229 (73.2) .65 SUBJECTS, MATERIALS, AND METHODS Female 79 (25.2) 84 (26.8) Smoking status Smoker 235 (75.1) 230 (73.5) .65 STUDY SUBJECTS Nonsmoker 78 (24.9) 83 (26.5) Alcohol status Between May 1995 and March 2001, patients with incident Drinker 249 (79.5) 247 (78.9) .84 (newly diagnosed) SCCHN were recruited from patients seen Nondrinker 64 (20.5) 66 (21.1) in the Head and Neck Center at our institution to participate Site in an ongoing molecular epidemiologic study. After providing Oral cavity 109 (34.8) ...... informed consent, all participating patients agreed to donate Pharynx‡ 145 (46.3) ...... 30 mL of blood for biomarker testing and to complete a de- Larynx 59 (18.9) ...... tailed questionnaire eliciting demographic, exposure, and fam- ily history information. Cancer-free control subjects were se- *Unless otherwise indicated, data are number (percentage) of subjects. lected from a pool of healthy controls, identified from enrollees †Two-sided ␹2 test. in a local managed-care organization, to participate in ongo- ‡Includes 126 patients with oropharyngeal cancer and 19 patients with ing hospital-based case-control studies. The control subjects hypopharyngeal cancer. were matched to the case subjects on age (±5 years), sex, smoking status, and alcohol use. To eliminate the possibility of ra- amined the concordance between the genotype frequencies of cial confounders, only non-Hispanic whites were included in 2 polymorphisms. We compared the observed genotype fre- this study. Smokers were defined as those who had smoked more quencies with those calculated from the Hardy-Weinberg equa- than 100 cigarettes in their lifetimes. Drinkers were defined as tion (p2+2pq+q2=1, where p is the frequency of the wild- those who had drunk alcoholic beverages at least once a week type allele and q is 1−p). We calculated the odds ratios (ORs) for more than 1 year. and their 95% confidence intervals (CIs) for the genotypes by logistic regression analysis with adjustment for age, sex, smok- GENOTYPING ing status, and alcohol use. All of the statistical analyses were performed with Statistical Analysis System software (Version We used leukocyte cell pellets obtained from the buffy coat by 6; SAS Institute Inc, Cary, NC). centrifugation of 1 mL of whole blood for DNA extraction and performed polymerase chain reaction (PCR) amplification as previously described.9,10 We used PCR assays to amplify the 3Ј RESULTS UTR of ERCC1 and exon 10 of ERCC2/XPD, which contain the polymorphisms of interest. The primers used were 5Ј- Initially, we identified 330 patients with SCCHN and TGAGCCAATTCAGCCACT-3Ј and 5Ј-TAGTTCCTCAGTTTC- 330 cancer-free control subjects. Of these, DNA was CCG-3Ј, which generate a 255–base pair (bp) fragment for the unavailable or PCR was unsuccessful in 17 patients and 3Ј UTR of ERCC1, and 5Ј-CTGTTGGTGGGTGCCCGTATC- 17 control participants. Consequently, the ultimate TGTTGGTCT-3Ј and 5Ј-TAATATCGGGGCTCACCCTGCAG- sample size was 313 case subjects and 313 control sub- CACTTCCT-3Ј, which generate a 751-bp fragment for exon 10 jects. The subjects were well matched on age, sex, 10 of ERCC2/XPD. As previously described, we used single- smoking status, and alcohol use (Table 1). All subjects strand conformational polymorphism assay to type the ERCC1 Ј were non-Hispanic whites. All cases were incident squa- 3 UTR polymorphism. The restriction enzyme StyI(NewEn- mous cell carcinomas of the oral cavity, oropharynx, gland Biolabs, Beverly, Mass) was used to distinguish the 23591 polymorphism of exon 10 of ERCC2/XPD in which the gain of hypopharynx, or larynx (Table 1). Because only 19 a StyI restriction site occurs in the polymorphic allele. The wild- patients with hypopharyngeal cancer were recruited, type allele has a single StyI restriction site resulting in 2 bands they were grouped with oropharyngeal patients for sub- (507 and 244 bp), and the polymorphic allele has 2 StyI re- group analysis. striction sites and, therefore, has 3 bands (474, 244, and 33 bp, Genotype distributions are summarized in Table 2. not visible). The PCR product was digested with 10 U of StyI, The ERCC1 8092 genotype distribution for case and con- in the ϫ10 buffer supplied with the restriction enzyme and 2% trol subjects were in Hardy-Weinberg equilibrium (P=.88 bovine serum albumin at 37°C for 16 hours. The digestion prod- and P=.54, respectively). The variant ERCC1 8092A al- ucts were separated on a 2% NuSieve 3:1 agarose gel (FMC Bio- lele was less frequent in the case subjects (0.230) than Products, Rockland, Me) and photographed with Polaroid film in the control subjects (0.248), and the homozygous wild- (Cambridge, Mass). type ERCC1 8092CC genotype was more common in the STATISTICAL ANALYSIS case group (58.5%) than in the control group (55.0%), suggesting the ERCC1 A allele has a protective effect. The We first performed univariate analysis to calculate the fre- ERCC2/XPD 23591 genotype distribution in case and con- quency of each allele and genotype. By tabulation, we also ex- trol subjects were in Hardy-Weinberg equilibrium (P=.09

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, SEP 2002 WWW.ARCHOTO.COM 1085

ERCC2/XPD G23591A Genotype†

Cases (n = 313) Controls (n = 313) ERCC1 C8092A Genotype‡ GG GA AA All GG GA AA All CC 95 (30.4) 80 (25.6) 8 (2.6) 183 (58.5) 103 (32.9) 57 (18.2) 12 (3.8)* 172 (55.0) CA 26 (8.3) 78 (24.9) 12 (3.8) 116 (37.0) 38 (12.1) 69 (22.0) 20 (6.4) 127 (40.6) AA 2 (0.6) 7 (2.2) 5 (1.6) 14 (4.5) 1 (0.3) 9 (2.9) 4 (1.3) 14 (4.5) All 123 (39.3) 165 (52.7) 25 (8.0) 313 (100) 142 (45.4) 135 (43.1) 36 (11.5) 313 (100)

*All data are number (percentage) of subjects. †ERCC2/XPD 23591G allele frequency, 0.657/0.669 (cases/controls); ERCC2/XPD 23591A allele frequency, 0.343/0.331 (cases/controls). Test for Hardy-Weinberg equilibrium in the control subjects: P = .94. ‡ERCC1 8092C allele frequency, 0.770/0.752 (cases/controls); ERCC1 8092A allele frequency; 0.230/0.248 (cases/controls). Test for Hardy-Weinberg equilibrium in the control subjects: P=.54.

Table 3. ERCC1 8092 and ERCC2/XPD 23591 Risk/Combination Genotype Frequencies and Risk Estimates*

Odds Ratio (95% Confidence Interval) Cases Controls Genotype (n = 313) (n = 313) Crude Adjusted† ERCC1 8092 AA/AC 130 (41.5) 141 (45.1) 1.00 1.00 CC 183 (58.5) 172 (54.9) 1.15 (0.84-1.58) 1.15 (0.84-1.59) ERCC2/XPD 23591 GG 123 (39.3) 142 (45.4) 1.00 1.00 GA/AA 190 (60.7) 171 (54.6) 1.28 (0.93-1.76) 1.28 (0.93-1.76) Genotype combinations Neither ERCC1 8092CC nor ERCC2/XPD 23591 GA/AA 28 (9.0) 39 (12.5) 1.00 1.00 Either ERCC1 8092CC or ERCC2/XPD 23591 GA/AA 197 (62.9) 205 (65.5) 1.34 (0.79-2.26) 1.34 (0.79-2.27) Both ERCC1 8092CC and ERCC2/XPD 23591 GA/AA 88 (28.1) 69 (22.0) 1.78 (1.00-3.17) 1.78 (0.99-3.17)

*Unless otherwise indicated, data are number (percentage) of subjects. †Adjusted for age, sex, smoking status, and alcohol use. Trend test for the allele dose effect: P = .04.

and P=.94, respectively). The variant ERCC2/XPD 23591A creased risk for pharyngeal cancer: adjusted OR, 1.59 (95% allele was more frequent in the case subjects (0.343) than CI, 1.02-2.49). in the control subjects (0.331), and the homozygous wild- type ERCC2/XPD 23591GG genotype was less common COMMENT in the case group (39.3%) than in the control group (45.4%), suggesting that the ERCC2/XPD A allele in- In this study, we assessed the risk of SCCHN associated creases risk. with ERCC1 8092 and ERCC2/XPD 23591 genotypes in a Risk estimates are summarized in Table 3. The hospital-based, case-control analysis of 626 non- ERCC1 8092CC genotype was associated with a border- Hispanic white subjects closely matched on age, sex, smok- line increased risk of SCCHN: adjusted OR, 1.15 (95% ing status, and alcohol use. Our findings were consistent CI, 0.84-1.59). The ERCC2/XPD 23591A allele was also with the prior report by Chen et al10 of an association be- associated with a borderline increased risk of SCCHN: tween ERCC1 8092CC and adult-onset glioma. The fre- adjusted OR, 1.28 (95% CI, 0.93-1.76). Furthermore, hav- quency of the variant ERCC1 8092A allele in our control ing both of these risk genotypes (ie, both ERCC1 8092CC subjects (0.248) was similar to the control group of Chen and ERCC2/XPD 23591 GA/AA) was associated with a and colleagues (0.270). However, in that study, a signifi- significantly increased risk of SCCHN, and having only cant risk associated with the ERCC1 8092CC genotype was 1 risk genotype was associated with a borderline in- found only in a glioma histologic subgroup of 28 oli- creased risk, suggesting an allele dose effect (trend test, goastrocytomas.10 There are no other case-control data of P=.04). tumor risk associated with the ERCC1 8092 genotype. Subgroup analyses of the combined effect of ERCC1 Our findings are also consistent with an associa- 8092CC and ERCC2/XPD 23591 GA/AA risk genotypes tion between the ERCC2/XPD 23591A allele and de- are summarized in Table 4. In smokers and drinkers, creases in DNA repair capacity reported in a case- the risk estimates approached significance: adjusted OR control study of lung cancer risk.9 Although Lunn et al11 for smokers, 1.46 (95% CI 0.95-2.25) and for drinkers, reported that the ERCC2/XPD 23591A allele is associ- 1.40 (95% CI; 0.94-2.10). Furthermore, the combined ated with better DNA repair as measured by a cytoge- risk genotype was associated with a significantly in- netic assay of chromatid aberrations induced by ␥ irra-

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, SEP 2002 WWW.ARCHOTO.COM 1086

©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table 4. Stratification Analysis of Combination Risk Genotype Frequencies, Odds Ratios, and 95% Confidence Intervals*

Subjects With Both ERCC1 8092CC and ERCC2/XPD GA/AA Genotypes Odds Ratio (95% Confidence Interval)

Variable Cases Controls Crude Adjusted† Age, y Յ50 24 (24.2) 23 (23.5) 1.04 (0.54-2.01) 1.08 (0.54-2.13) 51-63 32 (29.1) 22 (19.6) 1.68 (0.90-3.13) 1.67 (0.89-3.14) Ͼ63 32 (30.8) 24 (23.3) 1.46 (0.79-2.71) 1.40 (0.75-2.61) Sex Male 65 (27.8) 50 (21.8) 1.38 (0.90-2.10) 1.39 (0.90-2.13) Female 23 (29.1) 19 (22.6) 1.41 (0.69-2.84) 1.41 (0.69-2.85) Smoking status Smoker 66 (28.1) 49 (21.3) 1.44 (0.94-2.21) 1.46 (0.95-2.25) Nonsmoker 22 (28.2) 20 (24.1) 1.24 (0.61-2.50) 1.24 (0.61-2.51) Alcohol status Drinker 74 (29.7) 57 (23.1) 1.41 (0.94-2.11) 1.40 (0.94-2.10) Nondrinker 14 (21.9) 12 (18.2) 1.26 (0.53-2.98) 1.26 (0.52-3.02) Site Oral cavity 28 (25.7) 69 (22.0) 1.22 (0.74-2.03) 1.21 (0.72-2.02) Pharynx 45 (31.0) 69 (22.0) 1.59 (1.02-2.48) 1.59 (1.02-2.49) Larynx 15 (25.4) 69 (22.0) 1.21 (0.63-2.30) 1.22 (0.63-2.34)

*Unless otherwise indicated, data are number (percentage) of subjects. †Adjusted for age, sex, smoking status, and alcohol use within each subgroup.

diation, they assessed only 29 subjects, making genotyping environment effect. In other words, these genotypes may subgroup analysis particularly subject to chance find- put individuals at increased risk only if they are also ex- ings. In fact, they reported an ERCC2/XPD 23591 vari- posed to a carcinogen. Some epidemiological data sug- ant A allele frequency of 0.420, which is much higher gest that tobacco and alcohol exposure may have a greater than the 0.331 we found in our 313 control subjects. Fur- effect on pharyngeal cancer risk than on oral cavity or thermore, ERCC2/XPD is a component of the nucleo- laryngeal cancer risk.15 This may explain why we found tide excision repair pathway, which is responsible for re- these risk genotypes to be most common in the pharyn- moval of tobacco-induced adducts and UV-induced dimers geal cancer subgroup. Regardless, these findings in sub- but not the repair of chromatid breaks induced by ␥ ir- group analyses are preliminary, may be due to chance, radiation. and must be confirmed in larger studies. In a study of 96 patients with lung cancer and 94 cancer-free controls, Butkiewicz et al12 also suggested the Accepted for publication February 13, 2002. ERCC2/XPD 23591A allele may have a potential protec- This study is supported in part by start-up funds from tive effect, but a case-control analysis of adult-onset glioma The University of Texas M. D. Anderson Cancer Center found no association with the ERCC2/XPD 23591 geno- (Dr Sturgis) and research grants CA 55769 (Dr Spitz), CA type.13 In comparison, the study by Spitz et al9 of more 70334, ES 11740 (Dr Wei), and CA 16672 (to M. D. Ander- than 450 subjects found that in the case subjects the son Cancer Center) from the National Institutes of Health, ERCC2/XPD 23591A allele was associated with subop- National Cancer Institute, Bethesda, Md. timal DNA repair function as measured by the well- This work was presented in part at the annual meet- established host cell reactivation assay.9 Such subopti- ing of the American Head and Neck Society, Palm Desert, mal DNA repair is associated with increased risk of lung Calif, May 14-16, 2001. cancer14 and SCCHN.3 These discrepancies in results be- We thank Margaret Lung, RN, for assistance with re- tween studies are obviously due to differences in sample cruiting patients; Maureen Goode, PhD, and Chris Yeager, sizes and the assays used. However, these results also sug- BA, BS, for scientific editing; and Deanna Thomas, BS, for gest that these individual genotypes probably have only manuscript preparation. a modest effect on cancer risk, if any, and that more stud- Corresponding author: Erich M. Sturgis, MD, Depart- ies with larger samples are needed to clarify the role of ment of Head and Neck Surgery, Box 441, The University these genotypes in cancer risk. Future genetic models will of Texas M. D. Anderson Cancer Center, 1515 Holcombe probably include multiple genotypes to significantly and Blvd, Houston, TX 77030-4009 (e-mail: esturgis reliably predict cancer risk. Furthermore, efforts to de- @mdanderson.org). termine the effect of such polymorphisms on repair function must be encouraged. REFERENCES It is unlikely that such common genetic variants have a major effect on cancer risk independent of environ- 1. Giovino GA, Schooley MW, Zhu BP, et al. Surveillance for selected tobacco-use mental exposures. The increased risk in those exposed behaviors—United States, 1900-1994. Mor Mortal Wkly Rep CDC Surveill Summ. to tobacco and alcohol suggests a potential gene- 1994;43(suppl S-3):1-43.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, SEP 2002 WWW.ARCHOTO.COM 1087

©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 2. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001. CA 9. Spitz MR, Wu X, Wang Y, et al. Modulation of nucleotide excision repair capac- Cancer J Clin. 2001;51:15-36. ity by XPD polymorphisms in lung cancer patients. Cancer Res. 2001;61:1354- 3. Cheng L, Eicher SA, Guo Z, Hong WK, Spitz MR, Wei Q. Reduced DNA repair 1357. capacity in head and neck cancer patients. Cancer Epidemiol Biomarkers Prev. 10. Chen P, Wiencke J, Aldape K, et al. Association of an ERCC1 polymorphism with 1998;7:465-468. adult-onset glioma. Cancer Epidemiol Biomarkers Prev. 2000;9:843-847. 4. Wang LE, Sturgis EM, Eicher SA, Spitz MR, Hong WK, Wei Q. Mutagen sensi- 11. Lunn RM, Helzlsouer KJ, Parsad R, et al. XPD polymorphisms: effects on DNA tivity to benzo[a]pyrene diol epoxide and the risk of squamous cell carcinoma of repair proficiency. Carcinogenesis. 2000;21:551-555. the head and neck. Clin Cancer Res. 1998;4:1773-1778. 12. Butkiewicz D, Rusin M, Enewold L, Shield PG, Chorazy M, Harris CC. Genetic 5. Li D, Firozi PF, Chang P, et al. In vitro BPDE-induced DNA adducts in peripheral polymorphisms in DNA repair genes and risk of lung cancer. Carcinogenesis. lymphocytes as a risk factor for squamous cell carcinoma of the head and neck. 2001;22:593-597. Int J Cancer. 2001;93:436-440. 13. Caggana M, Kilgallen J, Conroy JM, et al. Associations between ERCC2 poly- 6. Cheng L, Sturgis EM, Eicher SA, Spitz MR, Wei Q. Nucleotide excision repair gene morphisms and gliomas. Cancer Epidemiol Biomarkers Prev. 2001;10:355- expression and the risk for squamous cell carcinoma of the head and neck. Can- 360. cer. 2002;94:393-397. 14. Wei Q, Cheng L, Amos CI, et al. Repair of tobacco carcinogen-induced DNA ad- 7. Hoeijmakers JHJ. Genome maintenance mechanisms for preventing cancer. ducts and lung cancer risk: a molecular epidemiologic study. J Natl Cancer Inst. Nature. 2001;411:366-374. 2000;92:1764-1772. 8. Shen MR, Jones IM, Mohrenweiser H. Nonconservative amino acid substitution 15. Franceschi S, Talamini R, Barra S, et al. Smoking and drinking in relation to can- variants exist at polymorphic frequency in DNA repair genes in healthy humans. cers of the oral cavity, pharynx, larynx, and esophagus in northern Italy. Cancer Cancer Res. 1998;58:604-608. Res. 1990;50:6502-6507.

Call for Photographs

ARCHIVES OF OTOLARYNGOLOGY–HEAD & NECK SURGERY Covers

ith the January 2001 issue, the ARCHIVES OF OTOLARYNGOLOGY introduced nonmedical photographs as cover art for the journal. W We are bombarded with medical and technical information every minute of every day and this is our way of offering you, our readers, a mo- ment to reflect, smile, breathe a little more deeply, maybe even escape for just a second and relax a bit. Do you have a scenic photograph you have taken that you think would make a great cover shot? We’d love to see it! Submissions should be from our readers, reviewers, authors, or anyone affiliated with the journal, and MUST be formatted horizontally. They can be black and white or color and at least 3.5ϫ5 in but no larger than 8ϫ10 in. If you wish to submit a digital photograph, please call our office at (404) 778-2322 for guidelines. Due to le- gal concerns, no recognizable people should appear in the picture, and please include details about where the picture was taken, how you happened to be there, and anything else you think is interesting about the image. We need the photographer’s complete name, highest academic degree, city and state of resi- dence, and a statement explaining how he or she is affiliated with the journal. Send submissions to ARCHIVES OF OTOLARYNGOLOGY, 1440 Clifton Rd NE, Suite 400, Atlanta, GA 30322. If you would like your photo returned, please enclose a self-addressed, stamped envelope. Cover photos will be chosen at the discre- tion of the ARCHIVES editorial staff.

Michael M. E. Johns, MD Editor

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, SEP 2002 WWW.ARCHOTO.COM 1088