Single-cycle induction chemotherapy before chemoradiotherapy or surgery in functionally inoperable head and neck squamous cell carcinoma: 10-year results.

INTRODUCTION: The response to induction chemotherapy (IC) predicts local control after conservative treatment of laryngeal, meso- and hypopharyngeal head and neck squamous cell carcinoma (HNSCC) and can thus help to avoid surgery. Single-cycle induction chemotherapy may help to maintain a low local recurrence rate while keeping the overall toxicity manageable. However, long-term data on single-cycle IC response by tumor location is lacking. METHODS: N = 102 patients with functionally inoperable primary HNSCC of the larynx (n = 43), hypopharynx (n = 42) or mesopharynx/tongue (n = 17) received one cycle of docetaxel (75 mg/m2, d1) plus cisplatin (30 mg/m2, d1-3) or carboplatin (AUC 1.5, d1-3) and a response evaluation 3 weeks later. Responders (≥ 30% tumor size reduction and ≥ 20% SUVmax decrease in 18F-FDG PET/CT) were recommended chemoradiotherapy (CRT), and non-responders surgery. RESULTS: The overall response rate was 72.5%. All 74 responders and 10 non-responders received primary CRT, and 18 patients received primary surgery after single-cycle IC. Overall 10-year local recurrence-free survival (LRFS) was 73.7%. Three-year LRFS was 88.2% (mesopharynx/tongue), 88.2% (larynx), and 73.3% (hypopharynx); p = 0.17. 3-year distant metastasis-free survival (DMFS) was 94.1% (mesopharynx/tongue), 88.0% (larynx) and 76.4% (hypopharynx); p > 0.05. This influenced the 3-year cancer-specific survival (CSS) for larynx (91.2%) vs. hypopharynx tumors (60.8%); p = 0.003, but CSS was not different to tumors in the mesopharynx/tongue (81.4%); p > 0.05. CONCLUSIONS: A single-cycle induction chemotherapy for HNSCC enables surgery plus adjuvant therapy as well as chemoradiotherapy. The long-term local and distant disease control was good but varied between tumors in the larynx and mesopharynx/tongue vs. hypopharynx.

[Inter- and intrafraction imaging during stereotactic body radiation therapy: Which solutions for which tumours?] / Imagerie inter- et intrafractions en radiothérapie stéréotaxique extracrânienne : quelles solutions pour quelles tumeurs ?

Due to high dose gradients, stereotactic body radiation therapy requires high precision in the location of the tumour. Uncertainties in the positioning can introduce serious damage on organs at risk and consequently can reduce tumour local control. A better tumour location can be achieved by controlling its position with an efficient inter and intrafraction imaging procedure. The various imaging techniques available on treatment systems are presented and performances are discussed. Finally, propositions are given in terms of imaging system according to the location treated by stereotactic body radiation therapy.

[Image-guided radiotherapy for head and neck carcinoma]. / Radiothérapie guidée par l'image des cancers ORL.

Intensity-modulated radiotherapy, combined with chemotherapy, is the recommended treatment of locally advanced head and neck carcinoma, as a definitive treatment or as an adjuvant treatment following surgery. This technique offers the ability to sculpt the dose closely to the tumor volume. With this close conformity, it is essential to ensure that every day during the treatment the patient position and anatomy are similar to those at the time of treatment planning. Inevitably, there will be uncertainties introduced in this process and a planning target volume margins are added around the tumour volume to compensate for these uncertainties. Various imaging technologies have been integrated with linear accelerators to deal with patient position and potentially reduce the margins. This forms the foundations of image-guided radiotherapy. In patients with head and neck carcinoma systematic and random set-up uncertainties are frequent. The 3D volumetric image guidance systems are efficient to reduce these uncertainties. After a summary about the different sources of uncertainties, this review will present successively the different techniques of image-guided radiotherapy for head and neck carcinomas, along with their advantages and limitations. Then we will focus on the methods used to reduce the set-up uncertainties and finally discuss the concept of adaptive radiotherapy and its application in clinical practice.

Imaging features of sinonasal tumors on positron emission tomography and magnetic resonance imaging including diffusion weighted imaging: A pictorial review.

INTRODUCTION: Sinonasal inflammatory conditions account for a major component of head and neck pathologies, whereas neoplasms involving the sinonasal region make up only 2-3% of all head and neck lesions. The symptoms of sinonasal tumors are nonspecific; imaging plays a critical role in distinguishing benign and malignant disease and may illustrate characteristic radiological features of specific sinonasal tumors. OBJECTIVE: Aim was to determine the utilization of multimodality imaging, specifically the metabolic information provided by 18-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) and diffusivity characteristics seen with diffusion weighted images (DWI) of magnetic resonance imaging (MRI), in a wide range of benign and malignant sinonasal tumors drawn from over 200 sinonasal lesions from our institution and supplemented by the literature. CONCLUSION: In this pictorial essay, we have reviewed common imaging characteristics of frequently encountered in sinonasal tumors and divided them into benign and malignant categories to facilitate creation of focused differential diagnoses.

Voxel-wise correlation of functional imaging parameters in HNSCC patients receiving PET/MRI in an irradiation setup.

PURPOSE: The purpose of this study was to demonstrate the feasibility of voxel-wise multiparametric characterization of head and neck squamous cell carcinomas (HNSCC) using hybrid multiparametric magnetic resonance imaging and positron emission tomography with [18F]-fluorodesoxyglucose (FDG-PET/MRI) in a radiation treatment planning setup. METHODS: Ten patients with locally advanced HNSCC were examined with a combined FDG-PET/MRI in an irradiation planning setup. The multiparametric imaging protocol consisted of FDG-PET, T2-weighted transverse short tau inversion recovery sequence (STIR) and diffusion-weighted MRI (DWI). Primary tumours were manually segmented and quantitative imaging parameters were extracted. PET standardized uptake values (SUV) and DWI apparent diffusion coefficients (ADC) were correlated on a voxel-wise level. RESULTS: Images acquired in this specialised radiotherapy planning setup achieved good diagnostic quality. Median tumour volume was 4.9 [1.1-42.1] ml. Mean PET SUV and ADC of the primary tumours were 5 ± 2.5 and 1.2 ± 0.3 10-3 mm2/s, respectively. In voxel-wise correlation between ADC values and corresponding FDG SUV of the tumours, a significant negative correlation was observed (r = -0.31 ± 0.27, p < 0.05). CONCLUSION: Multiparametric voxel-wise characterization of HNSCC is feasible using combined PET/MRI in a radiation planning setup. This technique may provide novel insights into tumour biology with regard to radiation therapy in the future.

A Comparison of the Diagnostic Accuracy and Reliability of Subjective Grading and Computer-Aided Assessment of Intranodal Vascularity in Differentiating Metastatic and Reactive Cervical Lymphadenopathy.

PURPOSE: Ultrasound is a well-established imaging modality in the assessment of malignant cervical lymphadenopathy. With the use of Doppler ultrasound, intranodal vascularity can be evaluated. However, the major limitation of ultrasound is operator dependency. Therefore, this study aimed to evaluate and compare the diagnostic accuracy and reliability of the subjective grading and computer-aided approach in assessing intranodal vascularity for the differentiation of benign and malignant lymph nodes. MATERIALS AND METHODS: The present study retrospectively assessed 99 power Doppler ultrasound images of cervical lymph nodes and evaluated the degree of intranodal vascularity using qualitative subjective grading (QSG) and quantitative computer-aided (QCA) methods. The diagnostic accuracy of the two methods in distinguishing metastatic and reactive nodes and their inter- and intra-rater reliability in assessing intranodal vascularity were evaluated and compared. RESULTS: The results showed that the QCA method was more accurate than the QSG method with a significantly higher sensitivity (67.8 % and 61.9 %, respectively, p < 0.05) and specificity (73.3 % and 57.3 %, respectively, p < 0.05). Using the intranodal vascularity index as determined by the QCA approach, the optimum cut-off to differentiate metastatic and reactive cervical lymph nodes was 32 %. The QCA method showed higher inter- and intra-rater reliability than the QSG method. CONCLUSION: In the assessment of the degree of intranodal vascularity, the QCA method was more accurate and reliable than the QSG method in distinguishing metastatic and reactive lymph nodes.

Incidental head and neck findings on 18F-fluoro-deoxy-glucose positron emission tomography computed tomography.

OBJECTIVE: The overlapping risk factors for lung and head and neck cancer present a definite risk of synchronous malignant pathology. This is the first study to specifically review incidental positron emission tomography computed tomography findings in the head and neck region in lung carcinoma patients. METHODS: A retrospective review was performed of all lung cancer patients who underwent positron emission tomography computed tomography imaging over a five-year period (January 2008 - December 2012), identified from the Liverpool thoracic multidisciplinary team database. RESULTS: Six hundred and nine patients underwent positron emission tomography computed tomography imaging over this period. In 76 (12.5 per cent) scans, incidental regions of avid 18F-fluoro-deoxy-glucose uptake were reported in the head and neck region. In the 28 patients who were fully investigated, there were 4 incidental findings of malignancy. CONCLUSION: In lung cancer patients undergoing investigative positron emission tomography computed tomography scanning, a significant number will also present with areas of clinically significant 18F-fluoro-deoxy-glucose uptake in the head and neck region. Of these, at least 5 per cent may have an undiagnosed malignancy.

Reconstruction of the segmental mandibular defect using a retroauricular or modified face-lift incision with an intraoral approach in head and neck cancer.

CONCLUSIONS: This is the first report of mandibular reconstruction using the retroauricular (RA) or the modified face-lift (MFL) approach in head and neck cancer. This approach may have advantages over the conventional approach, especially in its superior aesthetic results. OBJECTIVE: The fibular osseous or osteocutaneous free flap is a widely accepted option for the reconstruction of mandibular defects. Recently, we devised an RA or an MFL approach for neck dissection (ND) using an endoscopic or robotic surgical system. Here, we performed the reconstruction of a segmental mandibular defect with a fibular free flap using the RA or the MFL approach. METHODS: A total of five patients underwent mandibular reconstruction with the RA or MFL approach for mandibular discontinuity, which developed after the surgical extirpation of head and neck cancer. We performed ND, segmental mandibulectomy, and the reconstruction of the mandibular defect via RA or MFL incisions. RESULTS: An osseous free flap was used for the reconstruction in two patients and the osteocutaneous free flap was used in three patients. The mean operation times for mandibulectomy and ND were 82 (range 45-120) min and 156 (range 140-180) min, respectively. No significant complications were noted. All flaps survived successfully.

[Pilomatrixoma - an important differential diagnosis of facial masses]. / Das Pilomatrixom - eine wichtige Differenzialdiagnose von Raumforderungen der Kopf- und Gesichtshaut.

BACKGROUND: Pilomatrixoma are rare tumors usually arising from the sebaceous glands in the subcutaneous tissue. They are the most frequent superficially localized tumors of the cheek and parotid region in children. About 20% of all tumors in this area in children are pilomatrixoma. Currently there are only a few studies in the literature which describe characteristic findings in these tumors. The purpose of the present study was to describe clinical, sonographical and morphological characteristics of these rare tumors. PATIENTS AND METHODS: Clinical records of 6 patients which were operated on for a pilomatrixoma were retrospectively analyzed. All tumors were completely excised followed by an histopathological examination on H&E stained specimens. RESULTS: All patients reported about a slowly growing painless mass in the parotid area or nuchal. Sonographically tumors displayed as hyperechoic masses with a dorsal sound extinction, due to hypercalcification. Histopathologically all tumors were characterized by typical basaloid and ghost cells, accompanied by a foreign-body reaction. CONCLUSION: Pilomatrixoma are an important differential diagnosis of unclear masses in the head and neck especially in children. The sonographical characteristics are variable and unspecific. A fine-needle aspiration biopsy is not recommended, since false malignant cytologic findings occur quite often. Therapeutically complete excision is required. Usually no adjuvant therapy is necessary, and the prognosis is good.

Nasal type natural killer T-cell lymphoma involving nasooropharynx and larynx.

Lymphoma is one of the malignant non-squamous tumors involving the head and neck. Lymphomas in this region are mostly B-cell type in origin and usually seen in Waldeyer's ring. In this article, we report a 45-year-old female case of primary natural killer T cell lymphoma-nasal type involving the nasooropharynx and larynx. This is a very rare entity with poor prognosis.

Intensity-modulated radiotherapy vs. parotid-sparing 3D conformal radiotherapy. Effect on outcome and toxicity in locally advanced head and neck cancer.

BACKGROUND AND PURPOSE: Intensity-modulated radiotherapy (IMRT) has rapidly become standard of care in the management of locally advanced head and neck squamous cell carcinoma (HNSCC). In this study, our aim was to retrospectively investigate the effect of the introducing IMRT on outcome and treatment-related toxicity compared to parotid-sparing 3D conformal radiotherapy (3DCRT). MATERIAL AND METHODS: A total of 245 patients with stage III and IV HNSCC treated with primary radiotherapy between January 2003 and December 2010 were included in this analysis: 135 patients were treated with 3DCRT, 110 patients with IMRT. Groups were compared for acute and late toxicity, locoregional control (LRC), and overall survival (OS). Oncologic outcomes were estimated using Kaplan-Meier analysis and compared using a log-rank test. Acute toxicity was analyzed according to the Common Terminology Criteria for Adverse Events v3.0 and late toxicity was scored using the RTOG/EORTC late toxicity scoring system. RESULTS: Median follow-up was 35 months in the IMRT group and 68 months in the 3DCRT group. No significant differences were found in 3-year LRC and OS rates between the IMRT group and 3DCRT group. Significantly less acute mucositis ≥ grade 3 was observed in the IMRT group (32% vs. 44%, p = 0.03). There was significantly less late xerostomia ≥ grade 2 in the IMRT group than in the 3DCRT group (23% vs. 68%, p < 0.001). After 24 months, there was less dysphagia ≥ grade 2 in the IMRT group although differences failed to reach statistical significance. CONCLUSION: The introduction of IMRT in the radiotherapeutic management of locally advanced head and neck cancer significantly improved late toxicity without compromising tumor control compared to a parotid-sparing 3D conformal radiotherapy technique.

Comparison of ( 18 ) F-FLT PET and ( 18 ) F-FDG PET for detection of cervical lymph node metastases in head and neck cancers.

CONCLUSION: Despite low uptake of tracer, 3'-deoxy-3'-(18)F-fluorothymidine (FLT) PET could detect cervical lymph node metastases as well as 2-deoxy-2-(18)F-fluoro-d-glucose (FDG) PET. OBJECTIVE: The diagnostic efficacy of FLT PET was compared with that of FDG PET regarding nodal staging of head and neck squamous cell cancers. METHODS: Twenty-three patients were examined with FLT PET and FDG PET. PET images were evaluated qualitatively for regions of focally increased metabolism and maximum standardized uptake values (SUV) were calculated for semiquantitative analysis. RESULTS: The mean (± SD) FLT SUV in visualized metastatic lymph nodes was 4.8 ± 2.9 as compared with 6.9 ± 4.9 for FDG SUV (p < 0.001). Significant correlations were found between the area of metastatic lymph nodes and both FLT SUV (r = 0.8; p < 0.0001) and FDG SUV (r = 0.84; p < 0.0001). The false-positive (over-staged) and false-negative (under-staged) rates for lymph node staging by FLT PET were 4% (1/23) and 17% (4/23), respectively. Those for FDG PET were 9% (2/23) and 13% (3/23). All metastatic lymph nodes measuring more than 9 mm in short-axis diameter were correctly detected by FLT PET. However, both FLT and FDG PET had low sensitivity for detecting the lymph node metastases ≤ 9 mm in short-axis diameter and tumor deposits < 5 mm.

Surveillance low-dose chest computed tomography for head and neck cancer patients.

Based on the recent results of the National Lung Cancer Screening Trial, the National Comprehensive Cancer Network now recommends annual screening with low-dose computed tomography for high-risk individuals (generally defined as 45- to 60-year-old current or former smokers). As head and neck cancer patients are at a high risk for (second) lung cancers, annual surveillance computed tomography should be considered for head and neck cancer patients.

Methods for estimating the site of origin of locoregional recurrence in head and neck squamous cell carcinoma.

PURPOSE: Methods to estimate the likely origin of recurrences after radiation therapy for head and neck squamous cell carcinoma are compared. METHODS AND MATERIALS: A total of 25 patients meeting the following inclusion criteria were randomly selected: curatively intended intensity-modulated radiotherapy planned on a positron emission tomography-computed tomography (PET/CT) scan during the period 2005-2009; squamous cell carcinoma in the oral cavity, pharynx or larynx; complete clinical response followed by locoregional recurrence; and a CT scan at recurrence before any salvage therapy. Exclusion criteria were previous cancer in the area, surgery prior to radiotherapy, or a synchronous cancer. Three methods of estimating focal points of recurrence origin and two volume overlap methods assigning the recurrences to the most central target volumes encompassing at least 50% or 95% of the recurrence volumes were tested. Treatment planning and recurrence scans were rigid and deformable co-registered in order to transfer focal points to the treatment planning scan. Double determinations of all volumes, points, and co-registrations were made. RESULTS: The volume overlap methods assigned the recurrences to significantly more peripheral target volumes than focal methods (p < 0.0001 for all comparisons of 95% overlap vs. focal methods, p < 0.028 for all comparisons of 50% overlap vs. focal methods). Repeated registrations of the same point had higher reproducibility with deformable registration than with rigid registration (median distance 0.31 vs. 0.35 cm, p = 0.015). No significant differences were observed among the focal methods. CONCLUSION: Significant differences between methods were found which may affect strategies to improve radiotherapy based on pattern of failure analyses.

[Indications of intraoperative ultrasound in head and neck surgery]. / Indikationen für den intraoperativen Ultraschall bei Eingriffen im Kopf-Hals-Bereich.

BACKGROUND: A possible use of B-scan sonography arises from the difficulty in transferring information by means of imaging to the intraoperative situation, which is now possible with navigation systems in complicated surgical procedures in the field of otolaryngology. A solution to this problem offers the intraoperative use of ultrasonography for orientation in soft tissue surgery. PATIENTS AND METHOD: A prospective study involving 115 patients in total entailed scanning with a small part linear and fingertip probe with either 10 and 7.5 MHZ. An ultrasound endoscope featuring a 7.5 MHZ convex probe was used to image endolarygeal processes. RESULTS: Indications included panendoscopies, parotidectomies, submandibulectomies, lymph node exstirpations and abscess incisions. The colour doppler sonography was used in reconstructive surgery involving microvascular transplants. The display of soft tissue tumours provided information about tumour size as well as demarcation or infiltration of neighbouring structures. The fingertip probe and the ultrasound endoscopy served to evaluate areas that were morphologically difficult to access. After clamping the radial artery when harvesting the forearm flap, a sufficient perfusion of the thumb and later the sufficiency of the vascular anastomosis could be verified. CONCLUSION: The intraoperative use of sonography is an inexpensive non-invasive procedure that can be performed by the surgeon himself and allows quick and reliable orientation during difficult operations.

Endovascular management of carotid blowout.

OBJECTIVE: To highlight pertinent aspects of emergent endovascular management of carotid rupture, or carotid blowout syndrome (CBS), an emergent, life-threatening complication of head and neck cancer and its treatments. METHODS: A retrospective chart review was conducted of all patients with carotid blowouts at the authors' institution from 2008-2010. A systematic literature review was also performed. RESULTS: Eight patients (three women and five men) with an average age of 61 years (range 47-78 years) were reviewed. Seven patients had a positive history for squamous cell carcinoma of the neck, and five patients had active malignant disease. Carotid arterial deconstruction using liquid embolic material, coil embolization, or both achieved immediate hemostasis in every case (100%). No patients died as a result of their initial hemorrhage, but one patient had lethal hemorrhage at 1 day postoperatively. Two patients experienced nonlethal postoperative complications. At an average follow-up of 3 months (range<1-8 months), three patients were alive, three had died as a result of their underlying disease, and two had died of other causes. CONCLUSIONS: The treatment of patients with terminal malignant disease and CBS should provide maximum relief and minimize the risks of repeat surgery, morbidity, and mortality. Endovascular management of CBS with deconstructive techniques achieves immediate hemostasis and definitive treatment. The risks of intraoperative mortality and recurrent hemorrhage are low.

Cone-beam imaging: applications in ENT.

Cone-beam imaging is an X-ray based volume acquisition method providing 3D images of the head. The reconstructed volume is "isotropic"; spatial resolution varies according to material, equaling or exceeding that of CT but with a much lower radiation intensity. The drawbacks comprise a reduced signal-to-noise ratio and poor density resolution precluding soft-tissue exploration, notably of tumoral processes. This technique is very effective for the study of inflammatory and infectious processes of the head. In dental exploration, its intrinsic qualities enable screening for sinusitis of dental origin with a precision unobtainable on CT. Cone-beam imaging will, in the near future, become the reference examination in sinus assessment. Finally, this technique, at least using the most powerful apparatuses, seems very promising in ear pathology exploration. First applications in chronic otitis, dysplasia, deformity and trauma have been encouraging. Its low sensitivity to metallic artifacts makes it the technique of choice in the follow-up of cochlear implants.