[Needs and burdens of palliative care patients with advanced and/or metastatic head and neck tumors]. / Bedürfnisse und Belastungen von palliativmedizinisch mitbetreuten Patienten mit fortgeschrittenen und/oder metastasierten Kopf-Hals-Tumoren.

BACKGROUND: New therapeutic modalities enable good treatment options for patients with advanced and metastatic head and neck cancer. In this context, discussions about the end of life, advance care planning, and palliative concepts are often eclipsed. OBJECTIVE: Analysis of symptom burden and advance directives of palliatively comanaged inpatients using a palliative care self-assessment questionnaire. Based on the Earle quality indicator (QI), the integration of specialized palliative care in deceased inpatients was examined. PATIENTS AND METHODS: Retrospective analysis of head and neck cancer patients cotreated by the palliative care service. Patients were surveyed using the Integrated Palliative Care Outcome Scale (IPOS) questionnaire. RESULTS: The most frequent physical symptoms were weakness (77%), loss of appetite (65%), and poor mobility (65%). Pain was reported by 41% of patients. The most frequent emotional and psychosocial burdens were depression (97%) and worries about illness or treatment (94%), lack of ability to share feelings (77%), lack of information (85%), and organizational problems (77%). In 23% of patients, advanced directives were available. The Earle QI was not achieved. DISCUSSION: Patients report a high degree of symptoms and stress, most often in emotional areas and in terms of communicative and practical needs. This may reflect a need to talk about wishes and expectations concerning the end of life. Palliative care services should aim to address psychosocial needs in particular.

[Extranodal manifestation of classical Hodgkin lymphoma in the head and neck region]. / Extranodale Manifestation klassischer Hodgkin-Lymphome im HNO-Bereich.

BACKGROUND: Extranodal lymphomas occurring in the head and neck region account for 12-15% of all malignant tumors of this locality. Classical Hodgkin lymphoma (cHL) is a rare subtype, representing around 1% of all lymphomas in Waldeyer's ring. Cases diagnosed in the Reference Centre for Lymph Node Pathology at the Pathological Institute of the University of Würzburg were further analyzed in this study. MATERIALS AND METHODS: Histological subtype and EBV association of 21 cases were reviewed in conjunction with clinical data. RESULTS: Data of 12 male and 9 female patients with an average age of 51 years (median 45; 35-72) were reviewed. All samples were taken from the lymphatic tissue of the Waldeyer's ring (nasopharynx n = 15, palatine tonsils n = 5, lingual tonsils n = 1). The most common symptoms leading to a consultation with an otorhinolaryngologist were otalgia, swelling, or impaired nasal breathing. Only four patients showed typical B­symptoms. In 6 cases (29%), an isolated extranodal manifestation was found, 15 patients (71%) showed simultaneous infiltration of cervical lymph nodes during staging, and 6 cases (29%) were EBV positive. CONCLUSION: An exclusively extranodal manifestation of cHL in Waldeyer's ring is rare, whereas infiltration of extranodal tissue in the case of a primary manifestation of lymphoma in cervical nodes can occur more frequently and may often remain undiagnosed. Therefore, a specialized ENT consultation could be a reasonable complementary module in tumor staging to determine the correct tumor extent.

Induction chemotherapy (IC) followed by radiotherapy (RT) versus cetuximab plus IC and RT in advanced laryngeal/hypopharyngeal cancer resectable only by total laryngectomy-final results of the larynx organ preservation trial DeLOS-II.

Background: The German multicenter randomized phase II larynx organ preservation (LOP) trial DeLOS-II was carried out to prove the hypothesis that cetuximab (E) added to induction chemotherapy (IC) and radiotherapy improves laryngectomy-free survival (LFS; survival with preserved larynx) in locally advanced laryngeal/hypopharyngeal cancer (LHSCC). Patients and methods: Treatment-naïve patients with stage III/IV LHSCC amenable to total laryngectomy (TL) were randomized to three cycles IC with TPF [docetaxel (T) and cisplatin (P) 75 mg/m2/day 1, 5-FU (F) 750 mg/m2/day days 1-5] followed by radiotherapy (69.6 Gy) without (A) or with (B) standard dose cetuximab for 16 weeks throughout IC and radiotherapy (TPFE). Response to first IC-cycle (IC-1) with ≥30% endoscopically estimated tumor surface shrinkage (ETSS) was used to define early responders; early salvage TL was recommended to non-responders. The primary objective was 24 months LFS above 35% in arm B. Results: Of 180 patients randomized (July 2007 to September 2012), 173 fulfilled eligibility criteria (A/B: larynx 44/42, hypopharynx 41/46). Because of 4 therapy-related deaths among the first 64 randomized patients, 5-FU was omitted from IC in the subsequent 112 patients reducing further fatal toxicities. Thus, IC was TPF in 61 patients and TP in 112 patients, respectively. The primary objective (24 months LFS above 35%) was equally met by arms A (40/85, 47.1%) as well as B (41/88, 46.6%). One hundred and twenty-three early responders completed IC+RT; their overall response rates (TPF/TP) were 94.7%/87.2% in A versus 80%/86.0% in B. The 24 months overall survival (OS) rates were 68.2% and 69.3%. Conclusions: Despite being accompanied by an elevated frequency in adverse events, the IC with TPF/TP plus cetuximab was feasible but showed no superiority to IC with TPF/TP regarding LFS and OS at 24 months. Both early response and 24 months LFS compare very well to previous LOP trials and recommend effective treatment selection and stratification by ETSS. Clinical trial information: NCT00508664.

[Hearing results after middle fossa removal of small (T1/T2) vestibular schwannomas]. / Hörergebnisse nach transtemporaler Resektion kleiner (T1/T2) Akustikusneurinome.

OBJECTIVE: The aim of this study was to evaluate the hearing results after surgery for T1 and T2 vestibular schwannomas (VS) via the middle cranial fossa (MCF) approach at one institution and to review outcomes in the recent literature. PATIENTS AND METHODS: In our department, 208 consecutive patients have undergone surgery using the MCF approach between December 2005 and February 2015. Audiological testing included pure-tone audiometry, speech-discrimination-tests pre- and postoperatively, as well as a pre- and intraoperative brainstem evoked response audiometry (BERA). Hearing status was categorized according to the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) or Gardner-Robertson classification. Hearing preservation was assessed when postoperative values were still within class A + B. RESULTS: In 167 of the 208 patients, preoperative hearing levels corresponded to class A+B. In 78 tumors, extension of the VS was limited to the internal auditory canal (T1) and in 89 tumors there was an extrameatal growth without touching the brainstem (T2). In 109 patients (65 %), postoperative hearing was still in class A+B. In the group of intrameatal tumors, the hearing preservation rate was even 69 %. The analysis of the literature of the past 16 years revealed comparable results (46-82 %). CONCLUSIONS: Surgery for VS using the MCF approach is an established technique for reliable tumor removal with an adequate rate of hearing preservation. For small tumors without brainstem contact, particularly satisfying results can be achieved. This should be taken into account when discussing the possibility of early hearing preservation surgery.

[Postoperative complications after surgery for vestibular schwannoma via the MCF approach]. / Postoperative Komplikationen nach transtemporaler Resektion von Akustikusneurinomen.

BACKGROUND: The aim of this study was to analyze complications after surgery for vestibular schwannoma (VS) via the middle cranial fossa (MCF) approach. PATIENTS AND METHODS: 112 consecutive patients have been operated on via MCF approach in our department between October 2005 and March 2011. Postoperative complications have been registered during hospital stay as well as during outpatient follow-up. RESULTS: 25 complications occurred in 20 patients, most common was a CSF leak (12%). In 9 cases leakage stopped after conservative management. 3 patients needed lumbar drainage and 1 patient had to undergo revision-surgery. 6 patients suffered from hemorrhage: 2 cerebellar bleedings, 1 subdural hematoma, 2 hematomas of the scalp and 1 bleeding of the sutured wound. All bleedings except the case with subdural hematoma could be managed conservatively. Furthermore, one case of meningitis and one transient ischemic attack were observed. 3 patients suffered from a deep venous thrombosis which led to a lethal pulmonary embolism in one case. CONCLUSIONS: Surgery for VS via the MCF approach is an established method with satisfying functional results and a low -complication rate. CSF leak is a common complication (12%) that can be managed conservatively in most of the cases. Severe complications that may lead to revision surgery are rare (2%). Persisting sequels of these complications occur in less than 1% of the cases.

Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas.

Induction chemotherapy followed by primary radiotherapy in responders is considered an alternative to surgery for advanced cancer of the larynx and hypopharynx (LHC). Comparison of therapeutic approaches is challenging and must respect oncological and functional outcome as well as quality of life during and after treatment. One aspect of primary radiochemotherapy is the option of salvage surgery in case of residual tumor. The outcome after salvage surgery following new organ-preserving strategies has to be examined. All patients undergoing induction chemotherapy with paclitaxel and cisplatin followed by radiotherapy from 01/96 to 07/05 were included. Salvage surgery was performed either for local recurrence or suspected persistent nodal disease. Complete tumor removal, perioperative morbidity, and overall survival were analyzed in a retrospective study. 28 out of 134 patients underwent salvage surgery after primary treatment with induction chemotherapy and radiotherapy for advanced LHC. 15 patients had laryngectomy (LE) with neck dissection (ND), while 1 patient had lasersurgical partial laryngeal resection with ND for local recurrences. Twelve patients had salvage ND for suspicion of persistent lymph node metastases. 73% of LE patients had major postoperative problems such as pharyngocutaneous fistulas. In 56% of the cases, tumor removal turned out to be microscopically incomplete. Eight out of 12 patients who underwent salvage ND because of suspicious lymph nodes (66%) were free of vital tumor. When metastatic disease was present in the neck (4/12), recurrences occurred in 75% during postoperative follow-up. Only 2 out of 20 patients undergoing surgery for histologically proven recurrence after radiochemotherapy (10%) are actually tumor-free and alive after a mean observation time of 43.9 months. Salvage surgery for local recurrence is associated with high morbidity and poor oncological and functional outcome. ND for suspicious persistent nodal disease after radiochemotherapy can be an over-treatment. In our patients, it was burdened with cervical recurrences and distant metastases in presence of histologically confirmed lymph node metastases. In the light of our results, unfavourable outcome after salvage surgery must be pointed out when initially informing patients about different therapeutic options for advanced LHC.

[Middle ear adenoma/middle ear carcinoid--an unproblematic tumor?]. / Mittelohradenom/Mittelohrkarzinoid--ein unproblematischer Tumor?

OBJECTIVES: Adenomas/carcinoid tumors of the middle ear are very rare tumors of young to middle aged patients. The terms adenoma and carcinoid tumor of the middle ear can be used as synonyms, with the WHO favouring the term middle ear adenoma (MEA). These tumors usually present with unspecific clinical symptoms and a long case history. They are classified as benign tumors with only very few reported cases of regional metastasis after years of disease. According to recent literature, the clinical course is usually uncomplicated with complete surgical excision being adequate therapy. METHODS AND PATIENTS: This study describes the clinical course and the diagnostic challenges in four cases of this rare tumor entity. RESULTS: The selected patients (2 males, 2 females, 25-38 years old) showed very similar clinical findings with decreased hearing acuity, tinnitus and sometimes pain. After the primary surgical excision up to 10 further operations were necessary, this being in contrast to the usual clinical course as described in the literature. In two cases a tumor recurrence was documented with one case recurring six times. In this case adjuvant radiotherapy (70 Gy) was performed. The histological differential diagnosis can also be problematic; in one case with a highly atypical morphology it was impossible to arrive at a definite diagnosis during the analysis of a frozen section. CONCLUSION: Adenomas of the middle ear can have a much more complicated clinical course than is suggested by the recent literature. The presented cases in this study and the analysis of previously published cases shows that the typical progression described by the current WHO-classification with unproblematic surgical management of the tumor and an uncomplicated further clinical course does not always correspond to reality. The main reason for this is the difficulty in obtaining a complete surgical excision. Therefore, a well-planned and comprehensive surgical management with a high frequency of follow-up examinations should be chosen. In complicated individual cases adjuvant radiotherapy can be helpful.

[Predictors of nodal metastasising in laryngeal squamous cell carcinomas as decision support for neck dissection: comprehensive analysis of literature]. / Prädiktoren der nodalen Metastasierung des Larynxkarzinoms als Entscheidungshilfe bei der Neck Dissection: Literaturanalyse zur Frage zuverlässiger Parameter.

BACKGROUND: A subset of advanced laryngeal squamous cell carcinomas (SCC) does not metastasize in regional lymph nodes (pN0). However, more than 30 % of tumors without signs of metastasizing in the clinical examination (cN0) show occult metastases. The guidelines of the German ENT-Society intend the extent of neck dissection (ND) depending on clinical stage of tumor and lymph nodes. If laryngeal surgery is followed by an adjuvant radiation/chemotherapy, ND is not always necessary. Histomorphological, immunohistochemical, or molecular parameters with predictive value for nodal metastasizing could support the planning for ND, especially in patients with cN0. METHODS: Within the last 20 years there were many publications concerning this problem. Herein, we analyzed the results of 455 publications. We have chosen studies regarding the predictive value of tumor stage, grading, peritumorous inflammation, invasion of lymphatic vessels, angioneogenesis, proliferation, overexpression of p53 or cyclin D1, inhibitors of cyclin-dependent kinases, growth factors, apoptosis, cell-adhesion, nm23, metalloproteinases, DNA/ploidy as well as tumor genetics. RESULTS: All examined parameters did not allow a fail-safe prediction of the risk for nodal metastasizing. CONCLUSIONS: Up to now, reliable predictors do not exist. The investigation of above mentioned parameters in pre-operative tumor biopsies is not helpful for the planning of ND in the stage cN0 (out of T1).

[Do organizational structures and factors influence the outcome of physiotherapy--a questionnaire survey related to whiplash-associated disorders]. / Beeinflussen organisatorische Strukturen und Faktoren den Erfolg physiotherapeutischer Massnahmen?--Fragebogenuntersuchung am Beispiel der HWS-Beschleunigungsverletzung.

BACKGROUND: The effectiveness of physiotherapy in patients with whiplash injuries of the cervical spine is a subject of critical discussion. Besides the inadequate situation with regard to the medical data available and the financial cuts in drug prescription, organizational factors and structures are assumed to be factors that have an influence on the effectiveness of physiotherapy. AIM: The aim of this study was to evaluate data on training, patient population, communication, prescription activity and therapies of physiotherapists. METHODS: In a survey of 213 physiotherapists in the City of Ulm, data were collected with the aid of questionnaires related to "therapy of whiplash-associated disorders". RESULTS: The results show deficits in the theoretical knowledge of physiotherapists, in the exchange of information and in therapy management. The survey further revealed that 22% of the patients decide themselves which therapy they will undergo. One can assume that these factors have a detrimental effect on the effectiveness of conservative therapy. CONCLUSION: An optimization of the organizational structures is thus urgently required and constitutes the only possibility, in the short to medium term, of improving the effectiveness of physiotherapy in patients with whiplash injuries of the cervical spine.