PET-based prognostic survival model after radiotherapy for head and neck cancer.

PURPOSE: The aims of this multicentre retrospective study of locally advanced head and neck cancer (LAHNC) treated with definitive radiotherapy were to (1) identify positron emission tomography (PET)-18F-fluorodeoxyglucose (18F-FDG) parameters correlated with overall survival (OS) in a training cohort, (2) compute a prognostic model, and (3) externally validate this model in an independent cohort. MATERIALS AND METHODS: A total of 237 consecutive LAHNC patients divided into training (n = 127) and validation cohorts (n = 110) were retrospectively analysed. The following PET parameters were analysed: SUVMax, metabolic tumour volume (MTV), total lesion glycolysis (TLG), and SUVMean for the primary tumour and lymph nodes using a relative SUVMax threshold or an absolute SUV threshold. Cox analyses were performed on OS in the training cohort. The c-index was used to identify the highly prognostic parameters. A prognostic model was subsequently identified, and a nomogram was generated. The model was externally tested in the validation cohort. RESULTS: In univariate analysis, the significant PET parameters for the primary tumour included MTV (relative thresholds from 6 to 83% and absolute thresholds from 1.5 to 6.5) and TLG (relative thresholds from 1 to 82% and absolute thresholds from 0.5 to 4.5). For the lymph nodes, the significant parameters included MTV and TLG regardless of the threshold value. In multivariate analysis, tumour site, p16 status, MTV35% of the primary tumour, and MTV44% of the lymph nodes were independent predictors of OS. Based on these four parameters, a prognostic model was identified with a c-index of 0.72. The corresponding nomogram was generated. This prognostic model was externally validated, achieving a c-index of 0.66. CONCLUSIONS: A prognostic model of OS based on primary tumour and lymph node MTV, tumour site, and p16 status was proposed and validated. The corresponding nomogram may be used to tailor individualized treatment.

Predictive factors for surgical site infection in head and neck cancer surgery: A case-control study.

Surgical Site Infection (SSI) after head and neck cancer surgery may be life threatening and induces increasing in healthcare cost. The objective of this present study was to identify predictive factors associated to surgical site infection in head and neck cancer surgery. Numerous predictive factors were analyzed with univariate case-control method, then with multivariate method. This retrospective study included 71 patients who have been hospitalized in our department during 2010 for a head and neck cancer surgery. The incidence of surgical site infection was 15.5%. The T3-T4 stages were identified as an independent predictive factor (p = 0.04). Our study does not find other predictive factor for a SSI. The NNIS index (National Nosocomial Infections Surveillance), used by the Center for disease control and prevention as predictive factor, was not valid in our study. A specific predictive index should include the tumor stage for Head and Neck Cancer surgery and should be taken into account for the management of a preventive antibiotic treatment.

Diagnostic imaging of salivary gland cancers: REFCOR recommendations by the formal consensus method.

OBJECTIVE: To define the indications for each imaging modality in the screening, characterization, extension and follow-up of salivary gland tumors. MATERIAL AND METHODS: The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method. RESULTS: If a swelling of a salivary gland is palpable for 3 weeks, an ultrasound scan is recommended to confirm a tumoral lesion and rule out differential diagnoses. For a salivary gland tumor, MRI is recommended with diffusion-weighted and dynamic contrast-enhanced techniques. In the case of histologically proven malignancy or a highly suspicious lesion, a CT scan of the neck and chest is recommended to assess the tumor, lymph nodes and metastases. FDG-PET is not currently recommended in routine clinical practice for initial diagnosis, assessment of extension, evaluation of response to treatment, staging of recurrence, or follow-up of salivary gland tumors. CONCLUSION: Assessing salivary tumors is based on MRI. Extension assessment is based on neck and chest CT.

Laryngeal graft after total laryngectomy in humans: A SWiM analysis.

Evaluation of the results of laryngeal transplantation (LT) in humans. Analysis of 3 bibliographic databases with the keywords "larynx, transplantation, autograft". In total, 626 abstracts were read and 25 articles selected. The main objective was to analyze the characteristics of laryngeal transplant patients. The accessory objectives comprised analysis of operative technique, immunosuppressive treatment and results. Four articles were selected for analysis. Two patients were transplanted after total laryngectomy for laryngeal carcinoma and 2 after laryngeal trauma. Three of the 4 patients had true transplantation with arterial, venous and neural microanastomosis. Two patients were decannulated and the tracheostomy tube was maintained in the other 2. Three of the 4 patients had good-quality phonation and could feed without a gastric tube. One patient died of carcinoma progression and 1 patient had to be explanted 14 years after transplantation. The number of LTs reported is too small for scientific determination of the place of this intervention in laryngology. The published results could, at first sight, suggest that the future of LT is uncertain. However, several elements, also suggest that otolaryngologists should continue to take an interest in this technique.

Surgery of sublingual and minor salivary gland cancer: REFCOR recommendations by the formal consensus method.

OBJECTIVE: To determine the indications and modalities for resection in the management of primary sublingual and minor salivary gland cancer, and the specific features of each primary location. MATERIAL AND METHODS: The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method. RESULTS: Histological evidence (submucosal biopsy) is recommended before surgical treatment of minor salivary gland carcinoma. Surgical treatment is recommended, with optimal oncologic margins, adapted to anatomical factors, histologic type and grade and functional consequences, with reconstruction if necessary. CONCLUSION: Treatment of primary minor salivary and sublingual gland cancer is surgical, with wide resection margins. The modalities of resection and reconstruction are highly dependent on tumor location, extension and histologic type.

Lymph node surgery for salivary gland cancer: REFCOR recommendations by the formal consensus method.

OBJECTIVE: To determine the indications for neck dissection in the management of parotid, submandibular or minor salivary gland cancers depending on the clinical situation: i.e., clinical lymph node involvement (cN+) or not (cN0); low or high risk of occult nodal metastasis; diagnosis of malignancy before, during or after surgery. MATERIAL AND METHODS: The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group which drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group according to the formal consensus method. RESULTS: In cN+ salivary gland cancer, ipsilateral neck dissection is recommended. In cN0 salivary gland cancer, ipsilateral neck dissection is recommended, except for tumors at low risk of occult nodal metastasis. If definitive pathology reveals a high risk of occult nodal involvement, additional neck treatment is recommended: ipsilateral neck dissection or elective nodal irradiation. CONCLUSION: The rate of occult lymph node involvement, and therefore the indication for elective neck dissection, depends primarily on the pathologic grade of the salivary gland cancer.

Surgery of major salivary gland cancers: REFCOR recommendations by the formal consensus method.

OBJECTIVE: To determine the role of surgery of the primary tumor site in the management of primary major salivary gland cancer. MATERIAL AND METHODS: The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group, which drafted a non-systematic narrative review of the literature published on Medline, and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method. RESULTS: Treatment of salivary gland tumor is mainly surgical. The gold standard for parotid cancer is a total parotidectomy, to obtain clear margins and remove all intraparotid lymph nodes. For low-grade tumors, partial parotidectomy with wide excision of the tumor is acceptable in the case of postoperative diagnosis on definitive histology. In the event of positive margins on definitive analysis, revision surgery should be assessed for feasibility, and performed if possible. CONCLUSION: Treatment of primary major salivary gland cancer is based on surgery with clear resection margins, as far away as possible from the tumor. The type of surgery depends on tumor location, pathologic type and extension.

Post-treatment monitoring of salivary gland cancer: REFCOR recommendations by the formal consensus method.

OBJECTIVE: To determine the frequency and modality of post-treatment monitoring of primary salivary gland cancer. MATERIAL AND METHODS: The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group who drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method. RESULTS: Clinical monitoring should be adapted to the risk of recurrence: initially every 3 months and progressively spaced out, becoming annual after 5 years. Post-treatment head and neck and chest imaging is recommended at 3 months. Local and regional monitoring can then be carried out yearly or twice yearly with contrast-enhanced head and neck imaging. An annual chest CT scan is recommended for high-grade tumors. For lesions at high risk of late recurrence, very prolonged annual surveillance (up to 15 years) is recommended, including screening for pulmonary metastases. CONCLUSION: Given the wide range of malignant salivary gland tumors, the modalities and frequency of post-treatment monitoring must be adapted to the expected course of the disease.

Management of the neck in the setting of definitive chemoradiation: is there a consensus? A GETTEC study.

BACKGROUND: The management of the neck remains controversial in the definitive chemoradiation setting of advanced N2-3 head and neck squamous cell carcinoma. Most published data favor omission of neck dissection (ND) after complete response for N2-3 or selective ND for residual disease METHODS: We studied the patterns of care in the French-Belgian Groupe d'Etude des Tumeurs de la Tête Et du Cou (GETTEC) through a questionnaire-based survey. RESULTS: Eighteen percent of institutions never performed up-front ND, 20% rarely, 40% sometimes, 14% often, and 8% systematically. Induction chemotherapy was indicated in 30% of the cases, and most ND were performed either between induction and radiation or after chemoradiation for residual disease. Response to chemoradiation was assessed by computed tomographic scan and positron emission tomography in 72% of cases. Selective ND was more common than radical ND. CONCLUSIONS: Omission of ND based on computed tomographic scan and positron emission tomography-based complete response to chemoradiation is the most common strategy for advanced nodal disease among centers. However, neck management strategies vary among institutions, and some institutions continue advocating systematic ND before irradiation. The new treatment options and the changing epidemiology, namely docetaxel-based induction chemotherapy and human papilloma virus-related head and neck squamous cell carcinoma having better response profiles and prognosis, are adding to the nonconsensual approach. The best therapeutic index in terms of neck management remains to be defined in this evolving context.

Returning to work by thyroid cancer survivors 5 years after diagnosis: the VICAN survey.

PURPOSE: Return to work (RTW) following cancer diagnosis is a challenge for both the patient and society. As thyroid cancer (TC) incidence is increasing, this study aims to assess difficulties in returning to work and income changes in TC survivors 5 years post-diagnosis. METHODS: This study belongs to the national VICAN survey conducted in France among TC patients diagnosed between January and June 2010. Data were collected through phone interviews, medical surveys and from the national medico-administrative register in 2012 and 2015. We used multivariate logistic regressions to investigate TC impact on employment and income changes. RESULTS: Of 146 patients, 121(82.9%) were women; the mean age was 42 years (SD = 8.34), 119 (81.3%) were diagnosed at an early stage, and 142(97.6%) underwent thyroidectomy. At 5 years post-diagnosis, 116 (79.7%) of the TC survivors were professionally active, 22 (15.4%) were unemployed and 8 (4.90%) were receiving disability. Among the patients employed at the time of diagnosis (n = 122), 15 (12.3%) had not returned to work 5 years post-diagnosis. Between 2 and 5 years post-diagnosis, there was no significant improvement in rates of RTW. At 5 years post-diagnosis, 90 (61.6%) reported an income decline. All TC survivors who have not returned to work were women and declared higher fatigue. Moreover, in multivariate analyses, not returning to work was associated with weight gain (OR = 8.41 (1.21; 58.23)) and working arrangements (6.90 (1.18-38.48)), while income decline was associated with comorbidities (OR = 2.28 (1.07; 4.86)) and to be engaged in manual work (OR = 2.28 (1.07; 4.88)). CONCLUSION: This study highlights that, despite a good prognostic, up to 12.3% of TC survivors had not returned to work and 61.6% reported an income decline, 5 years post-diagnosis. Weight gain, fatigue, to be a woman and working-type arrangement were associated with higher probability of not returning to work. IMPLICATIONS FOR CANCER SURVIVORS: TC affects a young working population. Our study identified potentially vulnerable TC survivors and important modifiable factors which may help TC survivors to be professionally active and, therefore, increase their overall quality of life.

[Mandibular reconstruction for the treatment of oral carcinomas: state of the art and perspectives]. / Reconstruction mandibulaire en cancérologie: état actuel et perspectives.

INTRODUCTION: Mandibular reconstruction in head and neck oncology uses a number of techniques whose results are inconsistent and whose indications do not benefit from consensus. MATERIALS AND METHODS: A review of the literature allowed us to assemble the available knowledge on current mandibular reconstruction techniques, their functional results, and the research perspectives. RESULTS AND DISCUSSION: Marginal resections lead to dental rehabilitation problems, which can be palliated by alveolar enhancement techniques but whose results have not been validated in cases subjected to irradiation. Reconstruction of segmental substance loss is warranted by the repercussions on the vital prognosis when it is anterior and on the quality of life when it is posterior. The ideal means of reconstruction is the free fibular flap, which is limited by cost, morbidity of the donor site, and selection of the patient's surgical team. For these reasons, it may be necessary to turn to pedicled osteo-myocutaneous flaps, abandoned because of their reputedly very high failure rate, but few have been reported in the literature. CONCLUSION: Poor functional results of mandibular reconstruction plates make this a last-resort solution. Tissue engineering is currently the most promising line of research. It runs counter to the principles of oncology itself because postoperative radiotherapy reduces the osteoinduction potential of the biomaterials proposed.

Guidelines (short version) of the French Society of Otorhinolaryngology (SFORL) on cervical lymphatic malformation in adults and children: Diagnosis.

OBJECTIVES: The authors present the guidelines of the French Society of Otorhinolaryngology (SFORL) for the diagnosis of cervical lymphatic malformation in adults and children. METHODS: A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group, and finalized in a coordination meeting. Guidelines were graded A, B, C or expert opinion, by decreasing level of evidence. RESULTS: The SFORL recommends that complete ENT examination should be performed to identify lesions at high risk of complication or associated with poor prognosis. In case of diagnostic doubt, especially in latero-cervical or oral floor lesions, fine-needle aspiration cytology should be performed before therapeutic decision-making. One or more validated classifications should be used to assess treatment efficacy and monitor progression. The reliability of antenatal diagnosis should be ensured by associating MRI to ultrasound. In antenatal diagnosis, the locoregional extension of the cervical lymphatic malformation should be evaluated accurately for prognosis, and associated malformations should be screened for, to guide treatment options.

[Parapharyngeal tumors: diagnosis and treatment]. / Tumeurs parapharyngées: diagnostic et traitement.

OBJECTIVES: Parapharyngeal space tumors are rare and usually benign. Their treatment is surgical and many approaches have been described. We report our experience in managing these neoplasms. Two points are developed more fully: the correlation between imaging and surgical observation and the reliability of the cervical approach. MATERIAL AND METHODS: A retrospective review of primary parapharyngeal space tumors treated at the Rennes University Hospital between 1992 and 2004 is presented. Nine patients were included, all treated surgically with a cervical approach without parotidectomy. RESULTS: Eight MR imaging and seven CT scans were done. Two retrostyloid tumors and six prestyloid tumors, all independent of the deep lobe of the parotid gland, were found. They were benign in all cases (five salivary tumors and four schwannomas). Two patients treated for a pleomorphic adenoma presented recurrence and were reoperated successfully. The average follow-up was 66 months. None of the patients died. Definitive postoperative complications occurred only for neurogenic tumors. CONCLUSION: The cervical approach is safe and allows the surgical excision of retrostyloid and prestyloid tumors, independent of the deep lobe of the parotid gland. Large tumor (8cm in our study) excision can be done with few complications. An attentive study of preoperative imaging is necessary to choose the best surgical approach.

Maxillofacial brown tumours: Series of 5 cases.

OBJECTIVES: Brown tumours are benign bone tumours secondary to hyperparathyroidism. The authors describe the various clinical features, diagnostic methods and treatment modalities for maxillofacial brown tumours. MATERIAL AND METHODS: This multicentre retrospective study comprised 5 patients (four women and one man, between the ages of 29 and 70 years) with one or several maxillofacial brown tumours observed over a 16-year period from January 2000 to December 2016. RESULTS: Four patients presented secondary hyperparathyroidism in a context of chronic renal failure, one patient presented primary hyperparathyroidism due to parathyroid adenoma. Three patients presented a mandibular brown tumour, and two patients presented a maxillary brown tumour. The diagnosis was based on histological examination and laboratory tests. Brown tumours were treated either surgically or conservatively. A favourable outcome was observed in all cases. CONCLUSION: Brown tumours are rare lesions. This diagnosis must be considered in a context of giant cell tumour associated with hyperparathyroidism. Brown tumours should be treated conservatively.

A PET-based nomogram for oropharyngeal cancers.

PURPOSE: In the context of locally advanced oropharyngeal cancer (LAOC) treated with definitive radiotherapy (RT) (combined with chemotherapy or cetuximab), the aims of this study were: (1) to identify PET-FDG parameters correlated with overall survival (OS) from a first cohort of patients; then (2) to compute a prognostic score; and (3) finally to validate this scoring system in a second independent cohort of patients. MATERIALS AND METHODS: A total of 76 consecutive patients (training cohort from Rennes) treated with chemoradiotherapy or RT with cetuximab for LAOC were used to build a predictive model of locoregional control (LRC) and OS based on PET-FDG parameters. After internal calibration and validation of this model, a nomogram and a scoring system were developed and tested in a validation cohort of 46 consecutive patients treated with definitive RT for LAOC in Lausanne. RESULTS: In multivariate analysis, the metabolic tumour volume (MTV) of the primary tumour and the lymph nodes were independent predictive factors for LRC and OS. Internal calibration showed a very good adjustment between the predicted OS and the observed OS at 24 months. Using the predictive score, two risk groups were identified (median OS 42 versus 14 months, p < 0.001) and confirmed in the validation cohort from Lausanne (median OS not reached versus 26 months, p=0.008). CONCLUSIONS: This is the first report of a PET-based nomogram in oropharyngeal cancer. Interestingly, it appeared stronger than the classical prognostic factors and was validated in independent cohorts markedly diverging in many aspects, which suggest that the observed signal was robust.

[Neck dissection for stage N0 oral cavity carcinoma]. / Evidement cervical dans les carcinomes de la cavité orale classes N0.

OBJECTIVES: The management of N0 neck remains controversial. The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) in managing N0 neck of oral cavity carcinomas. MATERIAL AND METHODS: A retrospective chart review of 77 previously untreated patients with squamous cell carcinomas of the oral cavity with N0 neck from 1988 to 2001 was performed. Cervical treatments were "wait and see" policy in 7 cases, neck dissection in 56 cases, radiotherapy alone in 14 cases. 77 neck dissections were performed in which 62 were selective and 15 were radical modified. RESULTS: On pathologic examination, the average number of lymph nodes was 10.7 per neck. Occult disease (cN0pN+) was detected in 32.5%, and occult extracapsular spread (cN0pN+R+) was detected in 7.8%. The median follow-up was 43 months. The overall neck recurrence rate in patients with controlled primary disease was 2.4%. Recurrent disease developed in 2.9% of the cNOpN0 neck. Regional control rate of the dissected neck was 94%. No cervical recurrence occurred in 11 patients treated with SND alone. There was no survival or recurrence rate difference in T1T2pN0 patients with or without post-operative radiotherapy. Post-operative radiotherapy could be avoided in 27% of the dissected neck. One, 3 and 5 years overall survival rate were 89.3%, 77.7% and 63.2%. CONCLUSIONS: SND is an effective procedure for staging and treating the clinically negative neck of oral cavity cancer.

Hyrtl's fissure: a case of spontaneous cerebrospinal fluid otorrhea.

Spontaneous CSF otorrhea is a relatively rare entity. Adequate diagnosis and treatment are needed to avoid life-threatening complications such as meningitis. Because diagnosis is based on CT findings, identification of the different pathways of congenital fistulas requires detailed knowledge of embryology and anatomy. The facial canal, petromastoid canal, and tympanomeningeal (Hyrtl's) fissure can be responsible for CSF fluid otorrhea in the absence of any abnormality of the adjacent membranous labyrinth. We report the first documented and imaging case of Hyrtl's fissure and its treatment.

Computed tomography in TN stage evaluation of oral cavity and oropharyngeal cancers.

Oral and oropharyngeal carcinomas are characterized by a high incidence of node metastatic involvement and local extension. The study compared the TN stage of patients by clinical and computed tomography (CT) examination to postoperative histopathology. Sensitivity of CT for tumor extension was 82%, predictive value for bone involvement 67%. Clinical examination was poor in predicting the presence (54%) or absence (56%) of node involvement. Sensitivity of CT for assessment of node involvement was 80%, specificity 71%, positive predictive value 67%, and negative 83%. Node involvement was high (30%) in clinically NO necks versus only 9% for negative CT.