[Surgical Treatment of Oropharyngeal Cancer - Recommendations of the Current German S3 Guideline, Part I]. / Chirurgische Therapie des Oropharynxkarzinoms: Empfehlungen der aktuellen S3-Leitlinie ­ Teil I.

In general, a trend towards transoral resection (as opposed to classic open approaches) + neck dissection + adjuvant radio- (chemo-) therapy has been observed for oropharyngeal carcinoma over the last 20 years. Techniques of transoral surgery (TOS), including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have been propagated in retrospective comparisons with conventional surgery or primary radiochemotherapy as gentle, minimally invasive procedures with good late functional results. Meta-analyses of mostly uncontrolled retrospective analyses suggest that TORS may have better disease-free survival (DFS) and a reduced risk of free flap reconstruction compared with open surgery. TORS (TOS) was associated with fewer tumor-positive resection margins (R1), a lower number of recurrences, fewer intraoperative tracheostomies, a shorter inpatient stay and a shorter duration of postoperative nasal tube feeding compared to open surgery. In principle, based on the best evidence currently available from registry studies, stage I-II oropharyngeal carcinomas can be treated either with primary surgery or radiochemotherapy with a comparable chance of survival. With comparable evidence for stage III and IVa, p16neg. oropharyngeal carcinomas, the majority of authors advocate primary surgery followed by adjuvant radiotherapy or radiochemotherapy as the treatment of first choice. For p16pos. patients the results of registry studies are inconsistent, although the largest registry study on 450 HPV-positive stage III patients shows a significant superiority of primary surgery + adjuvant radiochemotherapy. Since all registry studies did not adjust for smoking status, among other factors, the current data situation should be evaluated with the necessary caution.

Interdisciplinary management of skin cancer. / Die interdisziplinäre Behandlung von Hautkrebs.

The interdisciplinary treatment of skin cancer in the head and neck area requires close collaboration between different specialist disciplines. The most common non-melanoma skin cancer tumor entities are cutaneous squamous cell carcinoma and basal cell carcinoma as well as their precursor lesions. One of the less common tumors is Merkel cell carcinoma, which also occurs primarily in light-exposed areas and, in contrast to squamous and basal cell carcinoma, is more likely to metastasize. Due to the low tendency of basal cell carcinoma as well as cutaneous squamous cell carcinoma to metastasize, a cure can often be achieved by surgery. If the tumor growth exceeds certain levels it may require collaboration between dermatology and otorhinolaryngology. The primary goal of this interdisciplinary collaboration is to achieve a functional, cosmetically and aesthetically acceptable result in addition to adequate tumor treatment. Depending on the stage of the tumor and the clinical course, a case may be discussed in an interdisciplinary tumor board in order to determine a personalised, appropriate and adequate treatment concept for each patient, including prevention, therapy and follow-up.

[Update: Epidemiology and Prevention of Oropharyngeal Cancer]. / Update: Epidemiologie und Prävention des Oropharynxkarzinoms.

Due to the association with the causal HPV-16 infection, the oropharyngeal carcinoma spreads into two separate entities depending on HPV-16 positivity. More recent data show a diversified picture of the importance and prevalence of the surrogate parameter p16 (discordance) for a definitive HPV-16 association, which varies worldwide. In the context of prevention options, vaccination is of major and HPV screening of healthy people only of little importance.

Association between malformation type, location and functional deficits in lymphatic malformations of the head and neck in children.

PURPOSE: Lymphatic malformations (LM) are congenital malformations of the lymphatic system, mainly located in the head and neck area. They can be staged based on location according to de Serres and based on different morbidity items using the Cologne Disease Score (CDS), a clinical staging system. In many cases, functional impairment greatly affects the life of patients suffering from lymphatic malformations. The present study aims to analyze a cohort of pediatric patients with LM. METHODS: A retrospective analysis of 144 pediatric patients with head and neck LM was performed. Location, type of malformation (microcystic, macrocystic, mixed), scoring according to two different scoring systems and therapy were analyzed. Kruskal-Wallis test was used to analyze the difference in CDS between the patient groups and Dunn's test was used for post-hoc pairwise comparison. RESULTS: The average age at presentation was 6.1 years. The most common sites were neck (47%), cheek/parotid gland (26%), tongue (17%) and orbit (8%). Macrocystic malformations dominated the lateral neck, while microcystic malformations were predominantly localized in the tongue and floor of mouth. Macrocystic malformations (mean CDS 9.44) were associated with significantly better CDS than microcystic (mean CDS 7.11) and mixed (mean CDS 5.71) malformations (p < 0.001). LM in stage V according to de Serres had the lowest values (mean CDS: 4.26). The most common therapeutic procedures were conventional surgical (partial) resection, laser therapy and sclerotherapy with OK-432. CONCLUSIONS: There is an association between malformation type, location according to de Serres and CDS in children with LM of the head and neck. Patients with microcystic and mixed malformations in stage V had lowest CDS levels.

S3 guideline "actinic keratosis and cutaneous squamous cell carcinoma" - update 2023, part 2: epidemiology and etiology, diagnostics, surgical and systemic treatment of cutaneous squamous cell carcinoma (cSCC), surveillance and prevention.

Actinic keratosis (AK) are common lesions in light-skinned individuals that can potentially progress to cutaneous squamous cell carcinoma (cSCC). Both conditions may be associated with significant morbidity and constitute a major disease burden, especially among the elderly. To establish an evidence-based framework for clinical decision making, the guideline "actinic keratosis and cutaneous squamous cell carcinoma" was updated and expanded by the topics cutaneous squamous cell carcinoma in situ (Bowen's disease) and actinic cheilitis. The guideline is aimed at dermatologists, general practitioners, ear nose and throat specialists, surgeons, oncologists, radiologists and radiation oncologists in hospitals and office-based settings, as well as other medical specialties, policy makers and insurance funds involved in the diagnosis and treatment of patients with AK and cSCC. A separate guideline exists for patients and their relatives. In this part, we will address aspects relating to epidemiology and etiology, diagnostics, surgical and systemic treatment of cutaneous squamous cell carcinoma (cSCC), surveillance and prevention.

[Frailty in Head and Neck Oncology]. / Frailty und ihre Bedeutung in der Kopf-Hals-Onkologie.

Since treatment of elderly patients with head and neck cancer is often challenging due to preexisting comorbidities, continuous efforts are required to raise awareness for frailty, which is a multidimensional state of diminished physiologic reserve resulting in decreased resiliency and increased vulnerability to stressors. Frailty is a predictor of poor clinical outcomes in head and neck cancer patients, but until now there is no standardization of frailty assessment. Pretherapeutic frailty assessment among head and neck cancer patients should be incorporated into routine multidisciplinary management to predict adverse outcomes and tailor a personalized treatment. This article would like to explain the complex syndrome frailty and its importance for head and neck oncology.

[Current Therapy Standards for Soft Tissue Sarcomas in the Head and Neck Area - Part 1]. / Weichgewebesarkome im Kopf-Hals-Bereich: Aktuelle Therapie ­ Teil 1.

The present work discusses soft tissue sarcoma in the head and neck area, due to the new published German S3-Guideline "adult soft tissue sarcoma". The head and neck surgeon plays the central role in the diagnosis and treatment of the vast majority of cases. It is crucial to admit the patients immediately to specialized centers for diagnoses and specific treatment. Regarding correct diagnostic procedures, in contrast to squamous cell carcinoma, a larger accidental excisional biopsy within the tumor tissue is strongly prognostic negative. After confirmation of histology and tumor extension, it is mandatory to discuss the interdisciplinary treatment concept. If possible, introduction of the patient in ongoing clinical studies is key.

[Current Therapy Standards for Soft Tissue Sarcomas in the Head and Neck Area - Part 2]. / Weichgewebesarkome im Kopf-Hals-Bereich: Aktuelle Therapie ­ Teil 2.

In September 2021, the first version of the German S3 guideline on adult soft tissue sarcomas, version 1.0 (AWMF register number 032/044OL) was presented as part of the oncology guideline program of the DKG, German Cancer Aid and the AWMF. After the basic features of soft tissue sarcomas were presented in Part 1, Part 2 describes the specific options for surgical therapy depending on the location in the head and neck area.

Dysphagia, voice problems, and pain in head and neck cancer patients.

PURPOSE: Head and neck cancer (HNC) and its treatment can leave devastating side effects with a relevant impact on physical and emotional quality of life (QoL) of HNC patients. The objectives were to examine the amount of dysphagia, voice problems, and pain in HNC patients, the impact of sociodemographic, behavioral, and clinical factors on these symptoms, the psychometric properties of the EAT-10, and the relationship between these symptoms and QoL variables. METHODS: HNC patients attending for regular follow-up from 07/2013 to 09/2019 completed questionnaires (Eating Assessment Tool-10 (EAT-10); questions from the EORTC QLQ-C30 and EORTC H&N35) on dysphagia, voice problems, pain, fatigue, and QoL collected with the software OncoFunction. Associations between prognostic factors and symptoms were tested with analyses of variance (ANOVAs). Associations between the symptom scales and QoL variables were expressed with Pearson correlations. RESULTS: Of 689 patients, 54.9% suffered from dysphagia, the EAT-10 proved to be a reliable measure. The mean voice score was 37.6 (± 33.9) [range 0-100], the mean pain score 1.98 (± 2.24) [range 0-10]. Trimodality treatment was associated with the highest dysphagia scores. Dysphagia, voice problems, and pain significantly correlated with each other, the highest association was found for dysphagia and pain (r = 0.51). QoL was strongly correlated with dysphagia and pain (r = - 0.39 and r = - 0.40, respectively), while the association with voice problems was weaker (r = - 0.28). CONCLUSION: Dysphagia is an important symptom in HNC patients greatly affecting patients' QoL and significantly correlating with voice problems and pain.

[Vascular malformations of the head and neck]. / Vaskuläre Malformationen im Hals-Nasen-Ohren-Bereich.

Vascular malformations are congenital anomalies of the vascular system that often affect the head and neck region. Vascular malformations are typically present at birth and proportionately grow with the patient. In contrast to vascular tumors, they are composed of dysplastic vessels rather than proliferating cells. The most commonly used classification is that of the International Society for the Study of Vascular Anomalies (ISSVA). According to this classification, simple malformations include venous, capillary, lymphatic, arteriovenous malformations, and arteriovenous fistulas. Symptoms depend on the affected anatomical structures and can range from swelling to life-threatening bleeding, airway obstruction or blindness. Management options for vascular malformations include conservative approaches, surgical intervention, sclerotherapy and embolisation as determined by type of malformation, location and associated complications. This article provides an overview of the major types of vascular malformations that affect the head and neck.

[Update Treatment HPV-16-positive Oropharyngeal Carcinoma]. / Update zur Therapie des HPV-16-positiven Oropharynxkarzinoms.

BACKGROUND: Oropharynx carcinoma (OPSCC) is a genetically heterogeneous tumor group with high prognostic diversity due to its worldwide increase in incidence and the association with the human papillomavirus HPV 16, but also chronic tobacco/alcohol consumption. OBJECTIVE: The review attempts to present the current view on therapy and prevention of OPSCC with respect to association with HPV 16. MATERIAL & METHODS: The overview is based on the current relevant literature as well as current studies. RESULTS & DISCUSSION: The OPSCC presents itself as a very complex, genetically heterogeneous group of head and neck tumors, which should therefore be considered in detail. The currently contradictory trial situation of retrospective studies versus prospective trials, the current TNM classification (8th edition) and the scarce prospective data arguing for non-inferiority of therapy de-intensification attempts currently admonish to encourage a more conservative treatment.

[Trials in head and neck cancer - Highlights of the ASCO Annual Meeting 2021]. / Therapiestudien zu Kopf-Hals-Karzinomen ­ Highlights der ASCO-Jahrestagung 2021.

The therapeutic options in head and neck oncology are rapidly developing, especially through the use of checkpoint inhibitors. Currently, numerous therapeutic studies with new molecular targets or new drug combinations are underway in patients with head and neck cancer. The most important results of the studies presented at the ASCO Annual Meeting 2021 on head and neck cancer will be presented in this paper.

[Immuno oncology treatment in head and neck cancer]. / Immunonkologie bei Kopf-Hals-Tumoren.

In the near future, immunotherapy with checkpoint inhibitors will not only reach the relevant ENT clinics, but also the oncologically integrated ENT practice, since more and more patients under long-term therapy (currently up to 2 years) also have to be seen during clinical follow-up in the specialist practice. In this respect, we also consider as necessary that the basics of immuno-oncology in head and neck tumors are already taught as part of the ENT specialist training. In this review article, the background and the definitions of the therapy sections (first, second line treatment, marker, etc.) should be discussed in detail and the basic tools for understanding this new therapy option should be provided. Since 2017, we have been experiencing a high level of approval dynamics for checkpoint inhibitors in Germany, which is to be assessed as an expression of a new effective principle of action and, after surgery, radiation and chemotherapy, is establishing a fourth strong pillar in the multimodal spectrum against head and neck tumors. Right from the start, the checkpoint inhibitors in the first phase 1b, 2 and 2b studies achieved overall response rates of 16-22 % with overall survival rates of 6-8 months in seriously ill patients with HNSCC who already had a first- and/or even second-line therapy. Nivolumab and Pembrolizumab are currently approved in Germany for the first and second line therapy of relapsed/metastatic squamous cell carcinoma of the head and neck region (HNSCC), Cemiplimab for recurrent/metastatic cutaneous squamous cell carcinoma and Avelumab for metastatic recurrent Merkel-cell carcinoma. The synopsis article about immune checkpoint inhibitors is intended to convey the basic understanding of the principle of action, the indication, toxicity management and the further development within trials in head and neck oncology.

Extracapsular extension of neck nodes and absence of human papillomavirus 16-DNA are predictors of impaired survival in p16-positive oropharyngeal squamous cell carcinoma.

BACKGROUND: Human papillomavirus (HPV)-driven oropharyngeal squamous cell carcinomas (OPSCCs) demonstrate superior outcome compared with HPV-negative OPSCCs. The eighth edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) tumor, lymph node, metastasis (TNM) classification (TNM 2017) modifies OPSCC staging based on p16 positivity as a surrogate for HPV-driven disease. In p16-negative OPSCCs, lymph node (N) categories include extracapsular/extranodal extension (ECE); and, in p16-positive OPSCCs, N categories are based on the number of positive neck lymph nodes omitting ECE status. The objective of the current study was to assess the prognostic impact of positive ECE status and the detection of HPV16 DNA in patients with p16-positive OPSCC. METHODS: In a cohort of 92 patients with p16-positive, lymph node (N)-positive (stage III-IVB) OPSCC who underwent surgery and neck dissection, allowing for a pathologic examination of positive lymph nodes, 66 of 92 patients (71.4%) were p16-positive/HPV16 DNA-positive, 62 of 92 (67%) were ECE-positive, and 45 of 62 (72.6%) were ECE-positive, p16-positive, and HPV16 DNA-positive. Differences in outcome were assessed using Kaplan-Meier plots and Cox proportional hazard regression (CoxR) for tumor-specific survival and overall survival (OS). RESULTS: The mean numbers of positive lymph nodes in ECE-positive patients (5.0 positive lymph nodes; 95% CI, 3.8-6.4 positive lymph nodes) and ECE-negative patients (2.4 positive lymph nodes; 95% CI, 1.8-2.9 positive lymph nodes) were different (P = .0007). ECE affected OS and tumor-specific survival in p16-positive patients (P = .007 and P = .047, respectively) and in p16-positive/HPV16 DNA-positive patients (P = .013 and P = .026, respectively). Related to the unequal distributions of ECE-positive/HPV16 DNA-negative tumors, the TNM 2017 failed to discriminate OS in patients with UICC stage I, II, and III disease (mean OS, 54.5, 73.4, and 45 months, respectively; median OS, 64.7 months, not reached, and 41.1 months, respectively). According to a univariate CoxR, the presence of ECE predicted impaired OS in patients with p16-positive OPSCC (hazard ratio, 3.40; 95% CI, 1.17-9.89; P = .025) and even greater impaired OS in those with p16-positive/HPV16 DNA-positive OPSCC (HR, 8.64; 95% CI, 1.12-66.40; P = .038). Multivariate CoxR confirmed ECE and HPV16 DNA detection as independent predictors. CONCLUSIONS: ECE and HPV16 DNA status should be included in the prognostic staging of patients with p16-positive OPSCC because several lines of evidence demonstrate their impact on survival.

Quality in head neck oncology. / Qualität in der Kopf-Hals-Onkologie.

A professionally qualified, patient- and demand-oriented, economic, high-quality care of patients with head and neck cancer is a challenge. Quality optimization in German head and neck oncology is based on quality-enhancing framework conditions such as the National Cancer Plan, the expansion of clinical cancer registries and the existence of evidence-based guidelines that were drawn up as part of the "Oncology Guidelines Program" initiated in 2008 (S3-guidelines for oral cavity and larynx cancer). There are currently 56 certified head and neck cancer centres in Germany with the aim of objectifiably increasing the quality of treatment and improving the outcomes of patients. Various quality indicators have been developed, there are programs for quality assurance of therapy and within studies. The aim of this review is to present quality standards in head and neck oncology.

[Automatic calculation and visualization of comorbidity scores for decision-making in tumor boards]. / Automatisierte Berechnung und Visualisierung von Komorbiditätsindizes für den Tumorboard-Entscheid.

OBJECTIVE: Comorbidity reduces treatment options for patients with head and neck cancer (HNC). Utilization of ICD-10 codes instead of manual research may facilitate estimation of comorbidity relevant for decision-making in the interdisciplinary tumor board (TB). Providing this information immediately in an intuitively ascertainable way whenever registering a patient for the TB would trigger awareness for comorbidities and shows potentially missing information. MATERIAL AND METHODS: Administrative data was extracted of four databases at our clinic (hospital information system (HIS*-MED), the clinic's tumor database, OncoFlow® and OncoFunction®). After data extraction and record linkage facilitated by python libraries Pandas and Record linkage, ICD-10 codes were rated applying the Charlson Score and prepared for visualization within OncoFlow®. Coding quality was tested assessing the imported and manually researched diabetes status of a 1:1 matched cohort of 240 patients. RESULTS: 29 073 ICD-10 codes of 2087 HNC patients were extracted. Matched data are immediately made available whenever registering a patient for the TB and are visualized in a pictogram within OncoFlow® providing information about comorbidities and missing diagnostics. The precision of diagnostic coding at our clinic was 95.0 %. CONCLUSIONS: The high prevalence of comorbidities in HNC patients with impact on their eligibility for particular treatment indicates the usefulness of our algorithm for providing automatic comorbidity assessment from administrative data for clinical routine and requires high quality of coding diagnoses.

Successful endoscopic recanalization of complete pharyngoesophageal obstruction after therapy of head and neck cancer.

BACKGROUND: Neopharyngeal obstruction after therapy of head and neck cancer is a frequent and clinically challenging problem without evidence-based guideline recommendations. CASE: We present two cases of complete esophageal obstruction after treatment for head and neck cancer. Due to complete obstruction of long distance stricture standard dilatation procedures were impossible to perform. In both cases, recanalization was achieved by combining an antegrade with a retrograde maneuver. In one patient endoscopic cutting with a papillotome was needed. CONCLUSION: Even in complex cases of post-therapeutic stenosis an endoscopic approach may offer a feasible alternative to surgical therapy, especially in the subset of frail patients.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up.

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 1: Epidemiology, Genetics and Diagnosis.

Basal cell carcinoma is the most common malignant tumor among fair-skinned individuals, and its incidence has been rising steadily in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 1 highlights new developments in genetics in particular as well as aspects regarding epidemiology, diagnosis, and histology.

[Analysis of the emergency patients of a university ENT hospital]. / Analyse der Notfallpatienten einer Universitäts-HNO-Notfallambulanz.

OBJECTIVE: The number of patients visiting emergency departments has substantially increased in recent years. The time of visiting an emergency room does not say anything about the true urgency of the treatment. The aim was to analyse the patient population of the emergency outpatient department of a university ENT hospital. METHODS: All patients presenting as an emergency in an ENT university hospital in 2014 were evaluated with regard to demographic data, time of presentation, type of admission, diagnosis and therapy. RESULTS: 4234 patients were treated as emergencies. 56 % presented without referral on their own initiative, 24 % were referred by the general practitioner or ENT specialist, 8 % came by ambulance. 66 % presented outside regular working hours. The highest number of emergencies occurred on Saturdays, followed by Fridays and Sundays. The ten most frequent diagnoses were epistaxis, peripheral-vestibular vertigo, cerumen, tinnitus, otitis externa and media, tonsillitis, nasal bone fracture, acute hearing loss and sinusitis. 715 patients (17 %) were admitted to hospital. In 123 patients surgery was performed under general and in 204 patients under local anesthesia. The most frequent diagnosis of patients presented on their own initiative was cerumen obturans. 8 % presented on their own initiative did not show any pathological findings. CONCLUSION: As there is no ENT emergency service available in the region outside normal office hours, this gap is closed by the emergency outpatient department of the ENT University Hospital. A triage of the patients is necessary in order to distinguish the real emergencies from the easy cases.