Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study.

BACKGROUND: Western multicenter studies on distal pancreatectomy with celiac axis resection (DP-CAR), also known as the Appleby procedure, for locally advanced pancreatic cancer are lacking. We aimed to study overall survival, morbidity, mortality and the impact of preoperative hepatic artery embolization (PHAE). METHODS: Retrospective cohort study within the European-African Hepato-Pancreato-Biliary-Association, on DP-CAR between 1-1-2000 and 6-1-2016. Primary endpoint was overall survival. Secondary endpoints were radicality (R0-resection), 90-day mortality, major morbidity, and pancreatic fistulae (grade B/C). RESULTS: We included 68 patients from 20 hospitals in 12 countries. Postoperatively, 53% of patients had R0-resection, 25% major morbidity, 21% an ISGPS grade B/C pancreatic fistula, and 16% mortality. In total, 82% received (neo-)adjuvant chemotherapy and median overall survival in 62 patients with pancreatic ductal adenocarcinoma patients was 18 months (CI 10-37). We observed no impact of PHAE on ischemic complications. CONCLUSIONS: DP-CAR combined with chemotherapy for locally advanced pancreatic cancer is associated with acceptable overall survival. The 90-day mortality is too high and should be reduced. Future studies should investigate to what extent increasing surgical volume or better patient selection can improve outcomes.

Correction to: Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study.

In the original article, the institutional author the E-AHPBA DP-CAR study group was misspelled. It is correct as reflected here. The original article has also been corrected.

Classification of parotidectomies: a proposal of the European Salivary Gland Society.

The objective of this study is to provide a comprehensive classification system for parotidectomy operations. Data sources include Medline publications, author's experience, and consensus round table at the Third European Salivary Gland Society (ESGS) Meeting. The Medline database was searched with the term "parotidectomy" and "definition". The various definitions of parotidectomy procedures and parotid gland subdivisions extracted. Previous classification systems re-examined and a new classification proposed by a consensus. The ESGS proposes to subdivide the parotid parenchyma in five levels: I (lateral superior), II (lateral inferior), III (deep inferior), IV (deep superior), V (accessory). A new classification is proposed where the type of resection is divided into formal parotidectomy with facial nerve dissection and extracapsular dissection. Parotidectomies are further classified according to the levels removed, as well as the extra-parotid structures ablated. A new classification of parotidectomy procedures is proposed.

Perception of survival/laryngeal preservation trade-off in advanced T-stage laryngeal cancer.

OBJECTIVES: To evaluate the perception of the survival/laryngeal preservation trade-off in advanced T-stage laryngeal cancer. MATERIAL AND METHODS: The Cochrane, PubMed, Embase, and Science Direct databases were searched using the keywords "cancer, neoplasms, trade-off. One hundred and eighty four articles were found; 176 of these, without data in the Abstract documenting the survival/laryngeal preservation trade-off for advanced T-stage laryngeal cancer, were excluded. Eight articles, totaling 1,052 interviewees, were read to document modalities of evaluation, trade-off thresholds, and variables influencing the perception of trade-off. RESULTS: Evaluation of trade-off was based on responses in group discussions, interviews and questionnaires and on patient file analysis. One study reported that 28.2% of respondents could not make a decision between options, and in 4 studies 22% to 80% of respondents would not consider jeopardizing survival. A mean 2-3 year gain (range, 6 months to 5 years) in survival was required before preferring total laryngectomy to chemoradiotherapy. The percentage loss of disease-free survival tolerated by respondents who would consider a trade-off to preserve the larynx ranged from 5% to 100%, for a median 30%. Variables influencing trade-off comprised respondent status (patient/healthcare provider/healthy subject) and characteristics (job, having children) and treatment data (amount and modalities of information delivered, survival estimates after radiation therapy, health status after treatment). A time for reflection after diagnosis and good quality information were important for respondents. CONCLUSION: Several consequences emerge from these data. The first is to consider induction chemotherapy, to give the patient time to make an informed choice. The second is to not to give up teaching total laryngectomy The third is to determine whether the team's own results match the information delivered to patients.

Gene expression signatures and molecular markers associated with clinical outcome in locally advanced head and neck carcinoma.

The purpose of this study was to identify molecular markers associated with tumor recurrence and survival in patients with locally advanced head and neck squamous cell carcinoma (HNSCC). We studied the expression profile of 63 pre-treatment tumor biopsies obtained from locally advanced HNSCCs treated with standard treatments. Cluster analysis identified three tumor subtypes associated with significant differences in local recurrence-free survival (LRFS) (P<0.001), progression free-survival (PFS) (P<0.009) and overall survival (OS) (P<0.004). Tumor subtype 1, associated with short LRFS, PFS and OS, showed features of epithelial-mesenchymal transition and undifferentiation. It also overexpressed genes involved in cell adhesion, NF-κB and integrin signalling. Tumor subtype 3, associated with longer LRFS, PFS and OS, showed a high degree of differentiation and overexpressed genes located in chromosomal regions 19q13 and 1q21. Tumor subtype 2, which had an intermediate clinical outcome between subtype 1 and subtype 3, overexpressed genes involved in branching morphogenesis. Finally, we validated the association between gene cluster classification and patient survival using Gene Set Enrichment Analysis and two HNSCC data sets obtained from two independent patient cohorts. In conclusion, we generated a gene prognostic signature associated with survival in locally advanced patients using the expression profile of the pre-treatment tumor biopsy. Independent prospective studies would be necessary to assess if the proposed survival signature could help to guide clinical management of HNSCC.

Pharyngocutaneous fistula in irradiated patients: systematic review and our experience.

OBJECTIVE: Radiotherapy is considered a risk factor for pharyngocutaneous fistula after a total laryngectomy. This study aimed to analyse the impact of exclusive radiotherapy versus chemoradiotherapy and the time interval between radiotherapy and surgery on the risk of pharyngocutaneous fistula. METHOD: This study was a retrospective revision of 171 patients treated with a total laryngectomy after radiotherapy or chemoradiotherapy. RESULTS: Pharyngocutaneous fistula occurred in 33 patients (19.3 per cent). Patients previously treated with chemoradiotherapy showed a non-significant higher pharyngocutaneous fistula rate compared with patients treated with radiotherapy (25.0 per cent vs 18.0 per cent; p = 0.455). Patients with a pharyngocutaneous fistula after chemoradiotherapy treatment required a surgical repair more frequently than patients treated with radiotherapy (p = 0.005). There were no significant differences in the pharyngocutaneous fistula rate depending on the time interval between radiotherapy and surgery (p = 0.580). CONCLUSION: There were no differences in the pharyngocutaneous fistula rate after total laryngectomy depending on the previous treatment with radiotherapy or chemoradiotherapy, or depending on the interval between radiotherapy treatment and surgery.

Salvage surgery after locoregional failure in head and neck carcinoma patients treated with chemoradiotherapy.

With the increasing use of concomitant chemoradiotherapy (CCRT) in the treatment of advanced head and neck carcinoma, surgery has lost ground as the first therapy and is reserved as a salvage treatment in cases of locoregional failure. The objective of our study was to review our experience in patients who had a local or regional recurrence after treatment with CCRT. Thirty-two patients underwent salvage surgery after CCRT: 24 were treated with a local or locoregional resection and 8 patients with a neck dissection only. In patients who had surgery involving the primary location of the tumor, some kind of reconstruction was required in 83% of cases. One or more postoperative complications occurred in nine patients. The median hospital stay was 18.5 days. There was a significant difference in hospital stay in relation to the appearance of surgical complications. Five-year adjusted survival after salvage surgery was 34.2% (CI 95% 13.2-55.2%). Adjusted survival was related to the status of the resection margins and appearance of neck nodes with extracapsular spread in the neck dissection. In conclusion, salvage surgery after CCRT involves extensive resections, requiring reconstruction techniques with regional or microanastomosed free flaps in most cases, achieving acceptable outcomes.

Predictive value of transcriptional expression of Krüppel-like factor-6 (KLF6) in head and neck carcinoma patients treated with radiotherapy.

PURPOSE: To analyse the relationship between the transcriptional expression of Krüppel-like factor-6 (KLF6) and local response to treatment with radiotherapy in patients with head and neck squamous cell carcinoma (HNSCC). METHODS: We determined the transcriptional expression of KLF6 in tumour biopsies obtained before treatment with radiotherapy in 83 HNSCC patients. The KLF6 expression was categorized according to the local control of the disease with a recursive partitioning analysis. RESULTS: During the follow-up period, 27 patients (32.5%) had a local recurrence of the tumour. Patients with local recurrence had significantly higher levels of KLF6 expression than patients in which radiotherapy achieved local control of the disease (P = 0.029). Five-year local recurrence-free survival for patients with a high transcriptional expression of KLF6 (n = 46) was 51.1% (95% CI 36.4-66.2%), and for patients with low expression it was 85.6% (95% CI 73.9-97.3%) (P = 0.0001). The results of a multivariate analysis showed that patients with a high KLF6 expression had a 3.8 times higher risk of local recurrence after treatment with radiotherapy (95% CI 1.4-10.5, P = 0.008). CONCLUSION: Transcriptional expression of KLF6 was significantly related to local control in HNSCC patients treated with radiotherapy. Patients with high levels of KLF6 expression had a significantly higher risk of local recurrence after treatment.

Elective neck dissection during salvage surgery after radiotherapy in patients with head and neck squamous cell carcinoma.

SUMMARY: Elective neck dissection in patients with recurrent head and neck squamous cell carcinoma (HNSCC) without evidence of neck disease (crN0) is poorly defined. A retrospective review was carried out on 165 crN0 patients treated with salvage surgery and elective neck dissection. Multivariate Cox analysis and recursive partitioning analysis were used to evaluate prognostic factors. The frequency of occult neck node metastases in the neck dissection (rpN+) was 16.4%. The risk of occult metastases for glottic rpT1-T2 recurrences was 5.9%, for glottic rpT3-T4 recurrences 13.2%, for non-glottic rpT1-T2 recurrences 16.1% and for locally advanced (rpT3-T4) non-glottic recurrences 31.1%. Patients with occult neck node metastases (rpN+) had a 5-year adjusted survival rate of 38.1%, while patients without nodal disease (rpN0) had a 5-year adjusted survival rate of 71.1% (p = 0.0001). Elective neck dissection can be omitted in crN0 patients with rT1-T2 glottic recurrence. We consider it advisable to perform elective neck dissection in all other situations.

Post-irradiation neuromyotonia in bilateral facial and trigeminal nerve distribution.

We describe a patient with episodic involuntary contraction in the lower facial and masseter muscles, in whom we recorded neuromyotonic discharges. The neuromyotonia was a delayed effect of radiation therapy and responded to carbamazepine therapy.

Can cure be achieved in patients with head and neck carcinomas? The problem of second neoplasm.

The improvement in locoregional control of head and neck carcinomas over the last few decades does not appear to modify the final survival of these patients, mainly due to the appearance of distant metastases and second neoplasms. This article reviews the topic of second neoplasm in patients with an index tumor in the head and neck, making a special point of the incidence and epidemiology of second neoplasms, the influence on prognosis, etiopathogenic theories and the possibility of prevention.

Foramen thyroideum: a comparative study in embryos, fetuses, and adults.

The incidence and characteristics of foramen thyroideum (FT) in embryonic and/or fetal larynges have not been established. In the present study, 90 adult larynges and 53 embryonic-fetal larynges were studied. The incidence of FT during the embryonic-fetal period (57%) was statistically different from the adult period (31%) (P = 0.005). All the FT found in the adult period contained vessels and/or nerves, while in the embryonic and fetal period only 63% presented neurovascular elements (P < 0.001). The origin of FT in the embryonic period and its persistence during adult life is discussed.

An anatomical study of anastomoses between the laryngeal nerves.

OBJECTIVE: To systematize the anatomy of the connecting branches between laryngeal nerves. METHODS: Microdissection of 90 larynges obtained from necropsies (57 men and 33 women; age range, 41-95 y). RESULTS: Anastomoses between the internal and recurrent nerves appeared in four different patterns: 1) Galen's anastomosis, as the connection between the dorsal branches of both nerves (100%); 2) arytenoid plexus, as the connection between the arytenoid branches of both nerves, in relation with the arytenoid muscle, and divided in a deep part (100%) and a superficial part (86%); 3) cricoid anastomosis, previously only described in cows, located in the front of the cricoid lamina (6/10 cases); and 4) thyroarytenoid anastomosis, as the connection of a descending branch of the internal laryngeal nerve and an ascending branch of the recurrent nerve (14%). Anastomosis between the internal laryngeal and the external laryngeal nerves appeared as a connecting branch throughout the foramen thyroideum (21%). Anastomosis between the external laryngeal and recurrent nerves appeared as a connecting branch throughout the cricothyroid muscle (68%). CONCLUSION: At least two anastomoses (Galen's anastomosis and arytenoid plexus) appeared in 21% of hemilarynges, and 79% of cases had three or more anastomoses between the laryngeal nerves. The different prevalence of this complex anastomotic pattern suggests functional differences in the sensory and motor innervation of individual subjects.

Function preservation in stage III squamous laryngeal carcinoma: results with an induction chemotherapy protocol.

Until recently, standard treatment for stage III laryngeal carcinoma (LC) was total laryngectomy and radiotherapy. Recent data suggest that induction chemotherapy (ICH) plays a role in preserving function in advanced head and neck cancer. No reports to date prospectively evaluate ICH exclusively in stage III LC. The authors designed a sequential phase II trial to assess if ICH allowed a conservative treatment in this disease. The objective of the first part of the study was to rule out a complete response rate with ICH below 30% with P < .05. ICH protocol consisted of three courses of cisplatin 100 mg/M2 on day 1 and 5-fluorouracil 5000 mg/M2 continuous infusion over 120 hours. Radiotherapy was administered to patients who attained a complete response (CR). Functional surgery (FS) was planned for patients with partial response. A total laryngectomy followed by radiotherapy was performed when FS was not feasible. Fifty-two previously untreated patients (all males) with squamous stage III LC were diagnosed in our institution, and 46 were entered in the ICH trial. After 9 patients were included, data showed 7 (78%) CR, ruling out a CR rate of less than 30%. After ICH, a CR was achieved in 29 (63%) of 46 patients. At the end of treatment, 35 patients (76%) had a functioning larynx. With a median follow-up of 3 years, larynx function was preserved in 26 (57%) of 46 patients and in 64% of survivors. Four-year actuarial larynx function preservation, overall survival, and disease-free survival were 55%, 77%, and 67%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary tracheoesophageal puncture vs esophageal speech.

We studied the cost-efficiency profile of tracheoesophageal puncture with prosthesis insertion in alaryngeal patients who were given the opportunity of choosing between esophageal and prosthetic voice. A primary tracheoesophageal puncture was made in 28 patients who were undergoing total laryngectomy. Five of the patients were excluded from the study because of failure to phonate correctly with their prostheses. The remainder were given esophageal speech instruction while they were using tracheoesophageal speech, and were permanently allowed to shift between both techniques of alaryngeal voice. Seventy percent of the patients (16/23) left the prosthetic voice to use only esophageal speech, even though they agreed that prosthetic voice was superior to esophageal voice. The remaining 30% (7/23) continued to use tracheoesophageal speech almost exclusively. In the authors' opinion, primary tracheoesophageal punctures significantly provide both psychological and practical help, as they supply an immediate and clear postoperative voice, and one of every three patients will use them for daily oral communication. Nevertheless, esophageal speech is still the method of voice restoration preferred in our region by those of our patients who managed to learn it.

Montgomery salivary bypass tube in the reconstruction of the hypopharynx. Cost-benefit study.

This study analyzes the postoperative complications and the functional results in 61 patients who underwent total laryngectomy with partial or total (circumferential) pharyngectomy reconstructed with a pectoralis major myocutaneous flap, in relation to the use of the Montgomery Salivary Bypass Tube (MSBPT). There were no significant differences regarding frequency of postoperative cervical complications in relation to the use of the MSBPT. The median hospital stay for patients without the MSBPT (36 days) was significantly higher than that for patients with the MSBPT (25 days). Although the MSBPT did not modify the rate of complications at the cervical level, it did reduce their severity. A financial study showed the cost-effectiveness of using the MSBPT. Systematic use of the MSBPT is recommended after total laryngectomy with partial or total pharyngectomy reconstructed with a pectoralis major myocutaneous flap.

Influence of age on laryngeal carcinoma.

The constant increase in human life expectancy has led to a higher proportion of oncologic patients of advanced age. The clinical characteristics of 272 patients with laryngeal carcinoma diagnosed when they were 70 or older are compared with those of a group of younger patients with the same kind of tumor. The advanced age group showed a higher proportion of women, less tobacco and alcohol use, a predominance of glottic location, and a higher previous morbidity. The T category was similar in both groups, but the advanced age group had a higher proportion of N0 tumors. The planning of treatment was similar in the two groups of patients, except for less use of both chemotherapy and partial larynx surgery in the advanced age group. Results in terms of local and regional control, distant metastasis, and 5-year adjusted survival were similar in both groups of patients. The results suggest that advanced age is not a determining factor when considering radical treatment in a patient with laryngeal carcinoma.

[Adenolymphoma or Warthin's tumor: review of 30 cases]. / Adenolinfoma o tumor de Warthin: revisión de 30 casos.

Perusal of Warthin's tumors treated during the past 20 years (1969-1989) in our Hospital department. As a whole 229 tumors of salivary glands were operated upon, 30 of them being adenolymphomata. The parameters of our series were confronted with those given by the cases of the literature. In the paper are also reminded the several theories concerning the origin of this tumor.

[Nasopharyngeal carcinoma. An epidemiological and clinical study]. / Carcinoma de nasofaringe. Estudio epidemiológico y clínico.

Clinical and epidemiological data from 46 cases of nasopharyngeal carcinoma retrieved from our E.N.T. department data base are analysed. These tumors represent about 5% of all head and neck carcinomas seen at our department between 1984 and 1989. Neither geographic origin nor occupation of patients have proved significant to the epidemiological analysis. Patients are most frequently in their sixth decade of life at presentation, with a clear male predominance, but not as marked as in other locations of head and neck tumours. As in other series, a significant relationship between nasopharyngeal tumours and alcohol and tobacco consumption has been discarded. Most patients were in good condition at diagnosis. Sublocation (usually on the lateral and/or posterior walls of the nasopharynx), predominance of undifferentiated carcinomas and isolated neck adenopathy as presenting symptom, are all features found in our series as well as in other reports. In contrast, the time between first symptom and diagnosis has been moderately longer in our patients. Cranial nerve and base of skull involvement have been found in 20% and 37% of cases, respectively. A great proportion of patients present with advanced disease: T3-T4 tumours in 67%; clinically detectable adenopathy in 69.5%; and distant metastasis in 4.3% of cases. Almost 75% of our patients showed stage IV disease at diagnosis.

[The treatment of carcinoma of the pyriform sinus at Santa Creu I Sant Pau Hospital of Barcelona. The role of surgery]. / Tratamiento del carcinoma del seno piriforme en el Hospital de la Santa Creu I Sant Pau de Barcelona: papel de la cirugía.

The paper deals with the retrospective review done by the AA. about the treatments used for squamous carcinomata of the pyriform sinus at Santa Creu i Sant Pau Hospital, Barcelona, between the years 1984-1990. In this term 76 sinus pyriform carcinomata were diagnosed, 12 of which (16%) were managed palliatively. In the other 64 cases radical treatment was advised and followed: 5 cases underwent radical cobalt-therapy; polychemotherapy followed by radiotherapy in 27; surgery plus radiotherapy in 7; and polychemotherapy completed with surgery and radiotherapy in the remaining 25 cases. Considerations on the realized pharyngectomies and their reconstructive steps and complications are commented. Inventory and end results in each group are reported. The beneficial local influence was evident when surgery was employed (100% with surgery plus radiotherapy and 92% with polychemotherapy, surgery and radiotherapy). Local control was inferior if surgery was discarded (20% in radiotherapy and 37% by polychemotherapy followed by radiotherapy). Actuarial survival for the lump sum amounted for the 40 percent after 5 years follow-up. It must be emphasized that these groups are not comparable because the choice treatment in each case was indicated in view of the initial stage.