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.

[Neck dissection following chemoradiation for node positive head and neck carcinomas]. / Place du curage ganglionnaire après chimioradiothérapie dans les carcinomes épidermoïdes des voies aérodigestives supérieures avec atteinte ganglionnaire initiale (nasopharynx exclu).

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.

[T1-T2 NO hypopharyngeal cancers treated with surgery alone. A GETTEC study (French Neck Study Group)]. / Cancers de l'hypopharynx T1-T2 "N0" traités par chirurgie exclusive. Etude GETTEC.

OBJECTIVE: Consider whether surgery alone in the treatment of early cancers of the hypopharynx can give identical or better results in terms of survival and local control than radiotherapy. METHODS: Forty-five patients were operated on during the years 1991-2004. Surgical treatment consisted in a resection by the transoral approach in four patients and 41 patients had a partial pharyngolaryngectomy. An elective neck dissection was performed on 43 patients. RESULTS: The 1-, 3-, and 5-year overall survival rates were 100, 95, and 75%. The 1-, 3-, and 5-year locoregional control rates were 93, 88, and 82% and were influenced by the presence of dysplasia on surgical margins (p=0.027). The oncological occurrences observed were five local recurrences, two nodal recurrences, ten second primary cancers, and two metastases. Five locoregional failures out of seven were controlled after a second treatment. CONCLUSION: Surgery alone gives completely satisfactory results in terms of survival and locoregional control. In case of recurrence, this makes it possible to operate on patients in nonirradiated areas with lower morbidity and mortality and better results. These results must be confirmed by a randomized trial.

Mid-term rhinosinusal consequences of bony orbital decompression in Graves' disease: a retrospective study.

OBJECTIVES: The aim of this work was to detect and study mid-term rhinosinusal complications arising after bony orbital decompression via the inferior palpebral approach in patients with Graves' ophthalmopathy. MATERIALS AND METHODS: This retrospective study considered 48 patients treated for proptosis from 1999 to 2001 who underwent bony orbital decompression via the inferior palpebral approach. Nineteen (19) of these patients agreed to participate further by consenting to follow-up examinations performed specifically for the purpose of this study, which consisted of ophthalmologic (visual acuity, proptosis) and ENT (nasal dysfunction, rhinoscopy) examinations. RESULTS: Mean mid-term postoperative follow-up of the 19 patients was 43.5 months (+/-12 months). Predominant rhinosinusal signs (rhinorrhea, altered sense of smell, nasal obstruction) were observed in 20% of this group (4 patients) without any unfavorable effect on daily life. Fiber-optic rhinoscopy disclosed mucosal secretions and edema in 5% (one patient). CONCLUSION: Mid-term complications of bony orbital decompression via an inferomedial approach are relatively rare. Late postoperative sinusitis has not been reported. Signs of minor nasal dysfunction may occur but would have little impact on quality of life.

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses.

INTRODUCTION: Small cell neuroendocrine carcinoma (SNEC) of the sinonasal tract is a rare disease. OBJECTIVE: Report a descriptive study of a relatively large cohort of SNEC of the nasal cavity and paranasal sinuses. METHOD: The medical records of 21 patients presenting with nasal and paranasal SNEC to various French hospitals, from 1989 to 2003, were analysed to determine the clinical features and current treatment of the disease. RESULTS: Patient data were obtained from eight French hospitals. Twelve of the patients were male and nine were female, with a mean age at presentation of 55 years (range: 27 to 79 years). Patients' staging for nasal cavity malignancy was: T1, four; T2, three; T3, one; T4, 13; N0, 18; N2, three; M0, 20; and M1, one. None of the patients suffered from SNEC of the sinonasal tract with ectopic hormone production. Immunohistochemistry proved useful for diagnosis in 20 cases. Twelve cases were positive for cytokeratin, 14 for chromogranin, eight for neuron-specific enolase and 11 for neuron-specific synaptophysin. One patient had an adenocarcinoma and an inverted papilloma associated with neuroendocrine carcinoma. Patients underwent surgery (11 cases), radiotherapy (14 cases) and chemotherapy (12 cases). Recurrence occurred in 10 cases. Five patients had visceral metastases or cervical lymph node involvement. Nine of the patients died within four years of onset of the disease. CONCLUSION: Small cell neuroendocrine carcinoma of the sinonasal tract is an uncommon neoplasm with aggressive clinical behaviour. Recurrence is frequent and the prognosis is poor. However, the current treatment of these neuroendocrine neoplasms varies widely.

[Endoscopic closure of septal perforations by mucosal rotation flaps]. / Fermeture endoscopique des perforations septales par lambeau de rotation.

OBJECTIVES: We present a technique of endoscopic endonasal closure of average sized (0.5 - 2 cm) to large (>2 cm) septal perforations. MATERIAL AND METHODS: The surgical technique involves a mucosal rotation flap on a unilateral posterior pedicle without interposition material. We reviewed our experience with eleven patients with average sized and large septal perforations treated over an 8-year period. RESULTS: We based our evaluation on the model proposed by Younger and Blokmanis. Our results were comparable with earlier publications. One-phase closure was achieved in 75% of patients (55% to 90% in the literature reporting all techniques, including external septorhinoplasty and midfacial degloving). CONCLUSION: Our preliminary series provides a basis for a new approach to this condition. The technique is promising for large perforations. This technique could also be considered for other nasal fossae in the event of failed closure. It also offers a way to obtain excellent closure of the anterior portion of the perforation, relieving the patient of the most annoying symptoms. The technique does not contraindicate other procedures which may be performed during the same operation or later.