CT-scan prediction of thyroid cartilage invasion for early laryngeal squamous cell carcinoma.

Treatment choice for laryngeal cancer may be influenced by the diagnosis of thyroid cartilage invasion on preoperative computed tomography (CT). Our objective was to determine the predictive value of CT for thyroid cartilage invasion in early- to mid-stage laryngeal cancer. Retrospective study (1992-2008) of laryngeal squamous cell carcinoma treated with open partial laryngectomy and resection of at least part of the thyroid cartilage. Previous laser surgery, radiation therapy, chemotherapy and second primaries were excluded. CT prediction of thyroid cartilage invasion was determined by specialized radiologists. Tumor characteristics and pathologic thyroid cartilage invasion were compared to the radiologic assessment. 236 patients were treated by vertical (20 %), supracricoid (67 %) or supraglottic partial laryngectomy (13 %) for tumors staged cT1 (26 %), cT2 (55 %), and cT3 (19 %). The thyroid cartilage was invaded on pathology in 19 cases (8 %). CT's sensitivity was 10.5 %, specificity 94 %, positive predictive value 13 %, and negative predictive value 92 %. CT correctly predicted thyroid cartilage invasion in only two cases for an overall accuracy of 87 %. Among the false-positive CT's, tumors involving the anterior commissure were significantly over-represented (61.5 % vs. 27 %, p = .004). Tumors with decreased vocal fold (VF) mobility were significantly over-represented in the group of false-negatives (41 vs. 13 %, p = .0035). Preoperative CT was not effective in predicting thyroid cartilage invasion in these early- to mid-stage lesions, overestimating cartilage invasion for AC lesions and underestimating invasion for lesions with decreased VF mobility.

Joint practice guidelines for radionuclide lymphoscintigraphy for sentinel node localization in oral/oropharyngeal squamous cell carcinoma.

Involvement of the cervical lymph nodes is the most important prognostic factor for patients with oral/oropharyngeal squamous cell carcinoma (OSCC), and the decision whether to electively treat patients with clinically negative necks remains a controversial topic. Sentinel node biopsy (SNB) provides a minimally invasive method of determining the disease status of the cervical node basin, without the need for a formal neck dissection. This technique potentially improves the accuracy of histological nodal staging and avoids over-treating three-quarters of this patient population, minimizing associated morbidity. The technique has been validated for patients with OSCC, and larger-scale studies are in progress to determine its exact role in the management of this patient population. This article was designed to outline the current best practice guidelines for the provision of SNB in patients with early-stage OSCC, and to provide a framework for the currently evolving recommendations for its use. These guidelines were prepared by a multidisciplinary surgical/nuclear medicine/pathology expert panel under the joint auspices of the European Association of Nuclear Medicine (EANM) Oncology Committee and the Sentinel European Node Trial Committee.

F-18 fluorodeoxy-D-glucose positron emission tomography scan in the initial evaluation of patients with a primary melanoma thicker than 4 mm.

Metabolic imaging with F-18 fluorodeoxy-D-glucose positron emission tomography is one of the most sensitive and non-invasive techniques, and has proved useful in melanoma. We designed, in 2004, at the Institute Gustave Roussy, a prospective study to determine the value of F-18 fluorodeoxy-D-glucose positron emission tomography scanning in the detection of regional and/or distant metastasis in 25 new patients referred for the treatment of a primary melanoma thicker than 4 mm (tumor node metastases stage T4). The sentinel lymph node biopsy was proposed for all the patients without a palpable regional lymph node. Abnormal positron emission tomography scan findings were correlated to available histological data and to the course of the disease. The F-18 fluorodeoxy-D-glucose positron emission tomography scan identified 0/2 intact primary melanomas, 1/4 residual primary melanomas after limited excision, 0/6 lymph node basins with micrometastasis, 4/4 lymph node basins with enlarged palpable lymph nodes and 0 distant metastasis. The sensitivity and specificity of positron emission tomography scans for microscopic lymph node disease in basins were, respectively, 0 and 92%. A false-positive F-18 fluorodeoxy-D-glucose positron emission tomography result in a cervical basin led to a useless cervical lymph node dissection. In three patients, the positron emission tomography scan was positive in distant sites but none of these foci represented a true metastasis. In conclusion, it is not useful to include a positron emission tomography scan in the initial work-up of patients with primary melanoma, even in patients with thick primary melanomas (>4 mm). Sentinel lymph node biopsy remains the technique of choice for the most accurate initial staging.

Salvage surgery after failure of very accelerated radiotherapy in advanced head-and-neck squamous cell carcinoma.

PURPOSE: To assess the efficacy and toxicity of salvage surgery for local or cervical nodal recurrence after accelerated radiotherapy for locally advanced head-and-neck squamous cell carcinoma (HNSCC). METHODS AND MATERIALS: We reviewed the medical records of the 136 patients with HNSCC who had been treated in three consecutive clinical trials at the Institut Gustave-Roussy using a very accelerated radiotherapy regimen (62 to 64 Gy with 2 daily fractions of 1.8 to 2 Gy over 3.5 weeks). Sixty-nine patients of the 136 initial patients (51%) had local or neck lymph nodes relapse, or both. RESULTS: Sixteen of these 69 patients (23%) had undergone salvage surgery for recurrence locally (n = 8) or in the cervical nodes (n = 8). All 16 had initially been diagnosed with locally advanced oropharyngeal carcinoma (T4, 11 patients; T3, 5 patients), and 13 had initially had cervical node involvement. After salvage surgery, 6 patients had had a local recurrence; 7, cervical node recurrence; and 3, distant metastasis. Thus, salvage surgery had been successful only in 3 patients. The 3- and 5-year overall actuarial survival rates were 20% and 11%, respectively. Eight patients had major postoperative wound complications, including carotid rupture in three cases. CONCLUSION: Salvage surgery for relapse after very accelerated radiotherapy for advanced HNSCC is infrequently feasible and is of limited survival benefit. It should be used only in carefully selected cases.

Tetranucleotide microsatellite instability in surgical margins for prediction of local recurrence of head and neck squamous cell carcinoma.

PURPOSE: Postoperative radiotherapy is used to prevent local recurrence of head and neck squamous cell carcinoma in patients with positive surgical margins. We sought to determine whether tetranucleotide microsatellite instability could be detected in surgical margins and used to predict local recurrence. EXPERIMENTAL DESIGN: We prospectively collected tumor and surgical margin specimens from patients with head and neck squamous cell carcinoma who had undergone surgical resection at Institut Gustave-Roussy during a 1-year period. Margins were considered positive if extensive pathological examination revealed either carcinoma within 5 mm or dysplasia. We tested five tetranucleotide microsatellite markers (UT5085, L17686, D9S753, ACTBP2, and CSF1R) in the tumor specimens and paired surgical margins of the patients whose margins were negative on pathological examination. RESULTS: Pathological examination revealed that among the 76 patients, 22 had positive margins; therefore, these patients were excluded. Of the 54 remaining patients, 26 (48%) had tumors informative for markers UT5085, L17686, or both; the other 3 markers were not informative. Seven (27%) of the 26 informative tumors had the same instability pattern in the surgical margins. At a median follow-up of 26 months, 5 of the 7 local recurrences occurred in patients with molecularly positive surgical margins. A strong, independent association was found between positive surgical margins and local recurrence (P = 0.01; hazard ratio, 6.49). CONCLUSIONS: Tetranucleotide microsatellite instability in surgical margins may be a useful biomarker to predict local recurrence of head and neck squamous cell carcinoma in patients with apparently disease-free margins.

Management of advanced and recurrent squamous cell carcinoma of the inner nasal lining.

UNLABELLED: Ten cases of advanced and eight cases of recurrent carcinomas of the inner nasal lining were managed in our department between June 1996 and June 2003. Six tumours were managed by operation alone, four by a combination of operation and radiotherapy, two by a combination of chemotherapy and operation, and five by a combination of chemotherapy, operation and radiotherapy. One patient died before the end of treatment. One patient had a combination of chemotherapy and radiotherapy. Eleven patients had reconstructions. RESULTS: After a mean follow up of 2.7 years (range: 3 months to 7 years), 15 patients were disease-free. Two patients had died of their disease, and one had died of an unrelated cause. Reconstruction was satisfactory in six of the eight cases that were evaluated. Prostheses were satisfactory in four of six cases.

Brachytherapy for T1-T2 floor-of-the-mouth cancers: the Gustave-Roussy Institute experience.

PURPOSE: In a retrospective analysis, we evaluated the Gustave-Roussy Institute's experience of locoregional control, survival, and complications of low-dose rate brachytherapy for carcinoma of the floor of the mouth. METHODS AND MATERIALS: Between 1970 and 1985, 160 patients with previously untreated carcinoma of the floor of the mouth received interstitial brachytherapy as definitive treatment. Of the 160 patients, 79 (49%) had T1 and 81 (51%) had T2 lesions, and 127 (79%) had N0 and 33 (21%) had N1; 84% of tumors arose from the anterior floor of the mouth. Brachytherapy was performed with 192Ir wires, according to the Paris system rules, followed by neck dissection (T2 or N1) or follow-up (T1N0). RESULTS: With a follow-up period of 9-19 years, the observed survival rates were 89% at 2 years and 76% at 5 years, and the local control rates were 93% in T1 and 88% in T2 tumors. A low rate of distant metastases was noticed (5%); 31% of patients developed a second primary cancer. Severe mucosal necrosis was observed in <10% of patients. Any grade of bone necrosis was seen in 18% of cases (only 2.5% had G3 necrosis). This complication occurred more frequently in patients with poor dental status and in those treated without dental protection during implantation (p <0.001). CONCLUSION: Radical brachytherapy offers excellent local control (89%) and an acceptable rate of complications (<10% severe necrosis) that may be significantly decreased with dental care and the use of protective devices. The high incidence of second malignancies remains a major concern in these patients.

Sentinel node biopsy in early oral squamous cell carcinomas: a 10-year experience.

OBJECTIVES/HYPOTHESIS: To evaluate the reliability of the sentinel node (SN) biopsy in early oral squamous cell carcinomas. STUDY DESIGN: Prospective cohort study. METHODS: We conducted a primary prospective study on 53 consecutive patients presenting T1, T2 N0 squamous cell carcinomas of the oral cavity between January 2000 and June 2003. Primary results demonstrated a negative predictive value of 100%. The series was then extended until June 2010, with a total number of 166 successful procedures. RESULTS: The cohort accounted for 118 males and 48 females with a mean age of 56 years. The median follow-up period was 36 months. There were 42 patients (25%) with positive SNs, 14 of them (33%) only harboring micrometastasis. The negative predictive value of the sentinel node biopsy was 95.2%. The SN involvement was strongly correlated with the tumor location (34% of SN+ for the tongue vs. 13% for the floor of mouth, P = .003), tumor stage (18% of SN+ for T1 vs. 40% for T2, P = .002), depth of invasion (median depth for SN+ lesions was 6.5 mm vs. 4 mm for SN- lesions, P = .028), and lymphovascular involvement (P = .002). The false-negative rate of frozen section examination was 42%. CONCLUSIONS: The sentinel node biopsy appears to be an excellent staging method in early oral cancers. This study also provides evidence that routinely undiagnosed micrometastasis may have clinical significance.

Implications of a positive sentinel node in oral squamous cell carcinoma.

BACKGROUND: The role of sentinel node biopsy in head and neck cancer is currently being explored. Patients with positive sentinel nodes were investigated to establish if additional metastases were present in the neck, their distribution, and their impact on outcome. METHODS: In all, 109 patients (n = 109) from 15 European centers, with cT1/2,N0 tumors, and a positive sentinel lymph node were identified. Kaplan-Meier and univariate and multivariate logistic regression analysis were used to identify variables that predicted for additional positive nodes and their position within the neck. RESULTS: A total of 122 neck dissections were performed in 109 patients. Additional positive nodes were found in 34.4% of cases (42/122: 18 same, 21 adjacent, and 3 nonadjacent neck level). Additional nodes, especially if outside the sentinel node basin, had an impact on outcome. CONCLUSIONS: The results are preliminary but suggest that both the number and the position of positive sentinel nodes may identify different prognostic groups that may allow further tailoring of management plans.

Oral cavity squamous cell carcinoma in 260 patients aged 80years or more.

PURPOSE: We report the experience of two French cancer centers in the treatment of oral cavity squamous cell carcinoma (SCC) in patients aged 80 years. MATERIALS AND METHODS: Two hundred and sixty patients aged 80 years with a primary oral cavity SCC were included in this retrospective analysis. RESULTS: Sex ratio was near to 1. Tobacco or alcohol intoxication was the main risk factor for 66% of men and 16% of women and leukoplakia, lichen planus, or oral traumatism for 55% of women and 11% of men (p<0.0001). Two hundred patients received a loco-regional (LR) treatment with a curative intent (surgery and/or radiotherapy), 29 with a palliative intent and 31 did not receive a LR treatment. Curative treatments were initially planned to be adapted to age in 118 patients (59%). The median disease-specific survival (DSS) was 29 months. In multivariate analysis, the independent prognostic factors for DSS were stage (HR=0.42 [0.24-0.72]), age (HR=0.43 [0.24-0.75]) and performance status (HR=0.50 [0.27-0.95]). The median overall survival (OS) was 14 months. In multivariate analysis, the independent prognostic factors for OS were age (HR=0.52 [0.35-0.79]), stage (HR=0.56 [0.38-0.84]), tumor differentiation (HR=0.60 [0.33-0.93]) and performance status (HR=0.6 [0.37-0.97]). In patients treated with a curative intent, treatment adapted to age was not associated with a decreased overall survival or disease-specific survival as compared with the standard treatment. However, prophylactic lymph node treatment in stages I-II tumors decreased the rate of nodal recurrence from 38% to 6% (p=0.01). CONCLUSION: This study emphasizes the need for prospective evaluation of standard and adapted schedules in elderly patients with oral cavity cancer.

Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation.

BACKGROUND: The purpose of this study is to review our experience with the use of the facial artery musculo-mucosal (FAMM) flap for floor of mouth (FOM) reconstruction following cancer ablation to assess its reliability, associated complications, and functional results. METHODS: This was a retrospective analysis of 61 FAMM flaps performed for FOM reconstruction from 1997 to 2006. RESULTS: No total flap loss was observed. Fifteen cases of partial flap necrosis occurred, with 2 of them requiring revision surgery. We encountered 8 other complications, with 4 of them requiring revision surgery for an overall rate of revision surgery of 10% (6/61). The majority of patients resumed to a regular diet (85%), and speech was considered as functional and/or understandable by the surgeon in 93% of the patients. Dental restoration was successful for 83% (24/29) of the patients. CONCLUSION: The FAMM flap is well suited for FOM reconstruction because it is reliable, has few significant complications, and allows preservation of oral function.

Functional results with advanced hypopharyngeal carcinoma treated with circular near-total pharyngolaryngectomy and jejunal free-flap repair.

BACKGROUND: Patients treated by a circular pharyngolaryngectomy for advanced hypopharyngeal carcinoma have a poor prognosis and disappointing speech restoration. METHODS: Three carefully selected patients underwent a near-total laryngectomy circular pharyngectomy with jejunal free flap repair and dynamic tracheopharyngeal shunt for treatment of advanced hypopharyngeal carcinoma. They received induction chemotherapy and postoperative radiotherapy. We assessed the functional outcome. RESULTS: There was no major local complication. One year after the end of radiotherapy, all patients were able to eat solid diets. Two patients were able to speak immediately after the end of the treatment. After speech re-education, a high-quality tracheopharyngeal voice was restored in all three patients. Performance Status Scale for Head and Neck Cancer Patients (PSSHN) showed a mean score equal to 81/100 at 1 year. CONCLUSIONS: In selected patients, near-total laryngectomy circular pharyngectomy with tracheopharyngeal shunt and jejunal free-flap repair offers good voice rehabilitation without impairing swallowing function.

Treatment of the N0 neck during salvage surgery after radiotherapy of head and neck squamous cell carcinoma.

BACKGROUND: The morbidity and mortality rates of salvage surgery in patients with local recurrence of head and neck squamous cell carcinoma (HNSCC) after radiotherapy are high. The aim of this study was to determine the rate of occult neck node metastasis and the surgical morbidity of patients after salvage surgery for local relapse after definitive radiotherapy. METHODS: Thirty patients who underwent salvage surgery with a simultaneous neck node dissection for a local relapse after definitive radiotherapy for HNSCC between 1992 and 2000 were included in this study. The primary tumor sites were oral cavity in six patients, oropharynx in 17, supraglottic larynx in three, and hypopharynx in four. Initially, seven patients had T2 disease, eight had T3, and 15 had T4. RESULTS: Twelve patients (40%) experienced postoperative complications, including two deaths. There was no cervical lymph node metastasis (pN0) in 29 of the 30 patients. Fifteen patients (50%) had a recurrence after salvage surgery, including 11 new local recurrences and four patients with distant metastasis. CONCLUSIONS: The risk of neck node metastasis during salvage surgery for local recurrence in patients treated initially with radiation for N0 HNSCC is low. Neck dissection should be performed in only limited area, depending on the surgical procedure used for tumor resection.

Postoperative radiotherapy for primary mucosal melanoma of the head and neck.

BACKGROUND: Primary head and neck mucosal melanoma (HNMM) has a poor prognosis with a low local control rate and frequent distant metastases. The objective of the current study was to determine the impact of postoperative radiotherapy on local control and survival. METHODS: One hundred forty-two patients with primary HNMM treated between 1979 and 1997 were reviewed. Of these, 69 patients with confirmed primary mucosal melanoma, absence of metastatic disease, and definitive management by surgery with or without postoperative radiotherapy and follow-up at the Institut Gustave-Roussy (Villejuif) were selected. The site of primary HNMM was sinonasal in 46 patients, oral in 19 patients, and pharyngolaryngeal in 4 patients. Twenty-two patients (32%) had a locally advanced tumor (T3-T4) and 17 patients had regional lymph node metastases after pathologic examination (pN > 0). Thirty patients underwent surgery alone and 39 received postoperative radiotherapy. Patients with locally advanced tumors had received postoperative radiotherapy more frequently than those with small tumors (P = 0.02). RESULTS: Thirty-seven patients (54%) experienced local disease recurrence and 47 patients (68%) developed distant metastasis. The overall survival rates were 47% at 2 years and 20% at 5 years. In the Cox multivariate analysis, patients with early T-classification tumors who received postoperative radiotherapy had a better local disease-free survival (P = 0.004 and P = 0.05, respectively) compared with patients with late T-classification tumors who did not receive postoperative radiotherapy. Patients with advanced T-classification and pN > 0 stage had a shorter distant metastasis disease-free survival compared with patients with early T-classification and pN < 0 stage. Patients with advanced T-classification tumors had a shorter overall survival compared with patients with early T-classification tumors (P = 0.003). CONCLUSIONS: The prognosis of patients with HNMM was poor. Patients had a high rate of distant metastasis and a low rate of local control. The current study suggested that postoperative radiotherapy increased local control even for patients with small tumors.