Quality of life and health-related utility after trans-oral surgery for head and neck cancers.

PURPOSE: The purpose of this study was to assess utility coefficients of health states following two minimally invasive surgical approaches for head and neck cancer, namely trans-oral robotic surgery and trans-oral laser microsurgery. Those utility coefficients will be later exploited in an economic evaluation study comparing the two approaches. METHODS: The above cited economic evaluation will be done from the Swiss healthcare system perspective and, as such, Swiss healthcare professionals were interviewed to elicit utility coefficients. Health states, ranging from remission to palliative care, were described using clinical vignettes. A computerized tool (UceWeb) implementing standard gamble and rating scale methods was used. RESULTS: Utility coefficients for 18 different health states were elicited with the two methods from 47 individuals, for a total of 1692 values. Elicited values varied from 0.980 to 0.213. Comparison with values elicited in previous studies show the need for population-specific elicitation, mainly for the worst health states. CONCLUSION: Herein we report health utility coefficients for the Swiss population for health states following minimally invasive trans-oral surgery. This study provides utility values that can be used not only for a specific cost-utility analysis, but also for future studies involving the same health states.

Cost-utility of two minimally-invasive surgical techniques for operable oropharyngeal cancer: transoral robotic surgery versus transoral laser microsurgery.

BACKGROUND: In the past few decades, a re-evaluation of treatment paradigms of head and neck cancers with a desire to spare patients the treatment-related toxicities of open surgery, has led to the development of new minimally invasive surgical techniques to improve outcomes. Besides Transoral Laser Microsurgery (TLM), a new robotic surgical technique namely Transoral Robotic Surgery (TORS) emerged for the first time as one of the two most prominent and widely used minimally invasive surgical approaches particularly for the treatment of oropharyngeal cancer, a sub-entity of head and neck cancers. Recent population-level data suggest equivalent tumor control, but different total costs, and need for adjuvant chemoradiation. A comparative analysis of these two techniques is therefore warranted from the cost-utility (C/U) point of view. METHODS: A cost-utility analysis for comparing TORS and TLM was performed using a decision-analytical model. The analyses adopted the perspective of a Swiss hospital. Two tertiary referral centers in Lausanne and Zurich provided data for model quantificantion. RESULTS: In the base case analysis TLM dominates TORS. This advantage remains robust, even if the costs for TORS reduce by up to 25%. TORS begins to dominate TLM, if less than 59,7% patients require adjuvant treatment, whereby in an interval between 55 and 62% cost effectiveness of TORS is sensitive to the prescription of adjuvant chemoradiation therapy (CRT). Exceeding 29% of TLM patients requiring a revision of surgical margins renders TORS more cost-effective. CONCLUSION: Non-robotic endoscopic surgery (TLM) is more cost-effective than robotic endoscopic surgery (TORS) for the treatment of oropharyngeal cancers. However, this advantage is sensitive to various parameters, i.e.to the number of re-operations and adjuvant treatment.

Sinonasal cancer: Analysis of oncological failures in 156 consecutive cases.

BACKGROUND: Sinonasal cancers are rare and associated with a poor prognosis. The purpose of this study was to report our experience and analyze the risk factors for oncologic failures. METHODS: A retrospective review of 156 consecutive patients treated with curative intent for sinonasal malignancy between 1995 and 2005 at tertiary cancer center was performed. Demographic, clinical, morphological, and pathological parameters were correlated with oncologic outcomes. RESULTS: Complete response was obtained for 134 patients. Sixty-eight patients relapsed, among which 51 had local recurrence. Nine of these 51 patients (17.6%) underwent successful salvage therapy. Five-year local failure and overall survival rates were 50.0% and 61.1%, respectively. Maxillary sinus tumors, intracranial invasion, and N > 0 classification at initial diagnosis were significantly and independently associated with local failure and survival in multivariate analysis. CONCLUSION: Local control after initial treatment is primordial to optimizing outcomes because of the poor results of salvage therapy.

Nodal recurrence of sinonasal cancer: does the risk of cervical relapse justify a prophylactic neck treatment?

BACKGROUND: Sinonasal cancers are rare and no high-level evidence exists to determine their optimal management. Prophylactic neck treatment issue remains controversial. The aim of this study was to analyze the pattern of neck failure and to identify any prognostic factors that may influence neck control. METHODS: A retrospective review of 155 consecutive patients treated for sinonasal malignancy, without prophylactic neck treatment, between 1995 and 2005 at tertiary cancer center was performed. Demographic, clinical, morphological and pathological parameters were correlated with oncologic outcomes. RESULTS: Eight out of 155 patients (5%) presented initially with neck node metastasis. Complete remission was obtained for 133 patients after treatment completion. During follow up, 16 out of 133 patients (12%) were affected with regional recurrence. Neck failure occurred in 8 out of 51 patients with local failure and in 8 out of 82 patients locally controlled. Isolated nodal failure was observed in 5 patients initially cN0 out of 133 (3.8%) representing 7.3% of all recurrences and 3 of them underwent successful salvage therapy. None of the tested factors were significantly associated with neck control (p>0.05). Lymph node at diagnosis time was significantly and independently associated with poor survival (p=0.0012). CONCLUSION: Isolated neck relapse, when local control is achieved, is rare and salvage treatment is effective. Routine prophylactic neck treatment has little interest. However, this approach could be profitable to few selected patients, who remain to be defined. Further investigations are needed.

Clinical significance of erythropoietin receptor expression in oral squamous cell carcinoma.

BACKGROUND: Hypoxic tumors are refractory to radiation and chemotherapy. High expression of biomarkers related to hypoxia in head and neck cancer is associated with a poorer prognosis. The present study aimed to evaluate the clinicopathological significance of erythropoietin receptor (EPOR) expression in oral squamous cell carcinoma (OSCC). METHODS: The study included 256 patients who underwent primary surgical resection between October 1996 and August 2005 for treatment of OSCC without previous radiotherapy and/or chemotherapy. Clinicopathological information including gender, age, T classification, N classification, and TNM stage was obtained from clinical records and pathology reports. The mRNA and protein expression levels of EPOR in OSCC specimens were evaluated by Q-RT-PCR, Western blotting and immunohistochemistry assays. RESULTS: We found that EPOR were overexpressed in OSCC tissues. The study included 17 women and 239 men with an average age of 50.9 years (range, 26-87 years). The mean follow-up period was 67 months (range, 2-171 months). High EPOR expression was significantly correlated with advanced T classification (p < 0.001), advanced TNM stage (p < 0.001), and positive N classification (p = 0.001). Furthermore, the univariate analysis revealed that patients with high tumor EPOR expression had a lower 5-year overall survival rate (p = 0.0011) and 5-year disease-specific survival rate (p = 0.0017) than patients who had low tumor levels of EPOR. However, the multivariate analysis using Cox's regression model revealed that only the T and N classifications were independent prognostic factors for the 5-year overall survival and 5-year disease-specific survival rates. CONCLUSIONS: High EPOR expression in OSCC is associated with an aggressive tumor behavior and poorer prognosis in the univariate analysis among patients with OSCC. Thus, EPOR expression may serve as a treatment target for OSCC in the future.

Marsupialization of vocal fold retention cysts: voice assessment and surgical outcomes.

OBJECTIVES: Although total excision remains the standard treatment for vocal fold retention cysts, postoperative deficits and damage to the vocal folds still occur. Marsupialization is a more conservative technique and can prevent these complications. METHODS: In this prospective clinical series, 25 patients underwent the marsupialization procedure. Under a direct laryngomicroscope, the cystic wall margin was retracted medially with microforceps. An incision was made with microscissors encircling the equator of the cyst. The cyst contents drained from the cystic cavity when the capsule was sectioned. For 7 patients with concomitant marked vocal fold atrophy, strap muscle transposition laryngoplasty was simultaneously performed. RESULTS: All patients had complete preoperative and postoperative voice parameter analyses. A subjective improvement in voice quality was reported by 23 of the 25 patients (92%). A small recurrent vocal fold cyst was detected in 1 patient. Small vocal fold deficits and sulcus vocalis were detected in 2 and 4 patients, respectively. Only 1 patient described a worse voice after operation. No other complications were noted. CONCLUSIONS: Marsupialization of vocal fold retention cysts is a simple, relatively safe, and effective surgical treatment. Voice improvement, a low incidence of recurrence, and minimal vocal fold deficits demonstrate the validity of this technique. Marked preoperative vocal fold atrophy or postoperative glottal gap can be managed with medialization laryngoplasty.

The impact of virus in N3 node dissection for head and neck cancer.

This study is to determine the impact of virus in surgical outcomes among patients of head and neck cancer with N3 lymph node metastasis. A retrospective analysis was conducted for 32 patients with operable N3 neck metastasis undergoing surgical treatment between January 1987 and October 2006. The nuclei of the tumor cells were investigated for the presence of human papillomavirus (HPV) and Epstein-Barr virus (EBV) DNAs and were taken into account as the variable for survival analysis. The primary sites were oropharynx in 11 patients, tongue in 3, buccal mucosa in 1, hypopharynx in 8 and unknown primary in 9. The five-year cumulative overall survival rate was 40.7% and 5-year cumulative regional control rate was 55.8%. The 5-year cumulative overall survival rate of patients with unknown primary site (72.9%) and HPV or EBV positive in the tumor (77.8%) were significantly higher than those patients with known primary site (31.3%) and HPV or EBV negative in the tumor (27.4%), respectively (P = 0.0335 and P = 0.0348, log rank test). In conclusion, surgery with adjuvant therapy offers reasonable outcomes for operable N3 node in head and neck cancer in our cohort. In addition, patients with HPV or EBV positive in the tumor have a better survival.