Immune checkpoint blockade induced shifts in cytokine expression patterns in peripheral blood of head and neck cancer patients are linked to outcome.

Background: Immune-checkpoint blockade (ICB) of programmed-death-1 (PD-1) with pembrolizumab or nivolumab is approved for treating recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC). NadiHN and ADRISK are phase IIB trials investigating in locally advanced (LA) HNSCC having low or high risk of recurrence the potential benefits from adding nivolumab to post-operative radiotherapy or pembrolizumab to cisplatin-based radio-chemotherapy. Methods: Along five randomized controlled ICB trials including NadiHN and ADRISK, blood samples were taken before and after starting ICB in n=25 patients. Concentrations of vascular endothelial growth factor A (VEGF), CCL2 (MCP-1), interleukin-6 (IL-6), IL-8, interferon-gamma (IFN-γ), and CXCL10 (IP-10) pre- and post-ICB in EDTA-anticoagulated plasma and serum were compared. We used receiver operating characteristic (ROC) curves to identify optimal cutoff for defining subgroups before analyzing overall survival (OS) applying Kaplan-Meier plots and multivariate Cox regression. Results: We detected huge heterogeneity between cytokine patterns in pre-and post-ICB plasma and serum. We observed high correlation between concentrations of some cytokines. Despite absent systematic OS differences after ICB with pembrolizumab or nivolumab or between LA-HNSCC versus R/M HNSCC patients, we noticed improved outcome of patients having lower IFN-γ concentrations pre- and post-ICB and following ICB reduced concentrations of VEGF, IL-6, and IL-8 but not MCP-1. Contrarily, increases in IL-6, IL-8, and VEGF levels correlated with impaired outcome. Multivariate Cox regression revealed five independent OS predictors among cytokines; using natural logarithms of their hazard ratios to estimate an individual's risk of dying, three cytokine-expression pattern (CEP)-risk groups with no death within mean (95% confidence interval) follow-up of 29.2 (22.1-36.2) months and median OS of 11.3 (8.8-13.8) and 2.9 (0.4-5.4) months were found. Conclusion: Whereas individual pre- or post-ICB cytokine concentrations in serum or plasma alone failed to predict the survivor group, CEP-risk groups may support the identification of individual patients with long-lasting benefit from ICB.

[BIOPASS hybrid navigation for endoscopic sinus surgery - an assistance system]. / BIOPASS-Hybrid-Navigation für die endoskopische Nasennebenhöhlenchirurgie ­ ein Assistenzsystem.

Previous navigation systems can determine the position of the "tracked" surgical instrument in CT images in the context of functional endoscopic sinus surgery (FESS), but do not provide any assistance directly in the video endoscopic image of the surgeon. Developing this direct assistance for intraoperative orientation and risk reduction was the goal of the BIOPASS project (Bild Ontologie und prozessgestütztes Assistenzsystem). The Project pursues the development of a novel navigation system for FESS without markers. BIOPASS describes a hybrid system that integrates various sensor data and makes it available. The goal is to abandon tracking and exclusively provide navigation information directly in the video image. This paper describes the first step of the development by collecting and structuring the surgical phases (workflows), the video endoscopic landmarks and a first clinical evaluation of the model version. The results provide the important basis and platform for the next step of the project.

Complications of injections in conservative treatment of degenerative spine disease: a prospective unicentric study.

BACKGROUND: Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction. METHODS: Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated. RESULTS: Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4-73.5%), radiating pain (9.4-34.7%), and nerve root irritation (2-18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up. CONCLUSIONS: Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient.

High-Risk Human Papillomavirus (HR-HPV) DNA Detection in Mouthwashes for Diagnosis of HPV-Driven Oropharynx Cancer and Its Curative Therapy-A Feasibility Study.

Detection of p16 through immunohistochemistry (IHC) is the standard for determining the HPV status of the tumor according the TNM eighth edition released in 2017 and has become crucial for determining the HPV status of oropharyngeal squamous cell carcinomas (OPSCC) with direct impact on staging and prognostication. In recent years, detection of HPV DNA in mouthwashes has been proposed as a noninvasive alternative, both for OPSCCs and for other head and neck squamous cell carcinomas (HNSCCs). However, the prospect of using the mouthwashes to monitor the response to therapy is unclear. To evaluate the effect of curative therapy on the detection of HPV DNA, we performed a prospective study comparing the detection frequency of high-risk HPV DNA (HR-HPV-DNA) in pre- and post-therapy mouthwashes. We collected 137 mouthwashes from 88 pathologically confirmed HNSCC patients for DNA isolation and HPV genotyping with the Inno-LiPA assay. We show that HPV DNA in pretherapeutic mouthwashes can detect HPV-driven HNSCCs with a sensitivity of 50.0% and specificity of 85.4%, alongside a high negative predictive value of 79.5% and an accuracy of 74.5%. Furthermore, we observed a notable decrease in the detection frequency of HR-HPV-DNA after successful treatment (pre-therapy 50.0% (9/18) versus post-therapy 9.7% (3/28)). However, the comparatively low sensitivity regarding detection of HPV-driven OPSCC argues against its use in clinical routine.

[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.

[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.

Frailty Assessed with FRAIL Scale and G8 Questionnaire Predicts Severe Postoperative Complications in Patients Receiving Major Head and Neck Surgery.

INTRODUCTION: Frailty represents a complex geriatric syndrome associated with elevated rates of postoperative complications as shown for several malignant entities, including head and neck cancer. A specific screening instrument to assess frailty in head and neck patients does not exist. Both the FRAIL Scale and the G8 questionnaire are well-established and easy to use as screening tools. The present study's aim was to assess the potential of frailty screening to predict postoperative complications in head and neck patients prior to surgery. PATIENTS AND METHODS: We recorded demographic data, pre-existing medical conditions and clinical characteristics in a prospective cohort of 104 head and neck cancer patients undergoing major head and neck surgery and assessed frailty prospectively on the day of admission utilizing the G8 questionnaire and the FRAIL Scale. We analyzed the link between occurrence of postoperative complications up to the twenty-first postoperative day and age, frailty and other covariates using χ2 tests and receiver operating characteristic (ROC) curves. RESULTS: There was no significant correlation between patients' pre-existing medical conditions and postoperative complications. Whereas chronological age alone did not predict the occurrence of postoperative complications, frailty posed the highest risk for complications. Frailty according to either the G8 questionnaire or the FRAIL Scale predicted occurrence of complications with an area under the curve (AUC) of 0.64 (p = 0.018) and 0.62 (p = 0.039) and severe complications with an AUC of 0.72 (p = 0.014) and 0.69 (p=0.031), respectively. Neither frailty score correlated with age or with each other. CONCLUSION: Prospective screening using the FRAIL Scale or the G8 questionnaire reliably detected frailty in our sample group. Frailty is linked to increased risk of postoperative complications. The correct prediction of severe postoperative complications as shown identifies vulnerable cases and triggers awareness of potential complications. Anticipating risk allows for a more comprehensive view of the patient and triggers decision making towards risk adjustment, and therefore a selective view of alternative treatment modalities.

Diameter of the Cochlear Nerve Canal predicts Cochlear Nerve Deficiency in Children with Sensorineural Hearing Loss.

PURPOSE: Detection of cochlear nerve deficiency (CND) is usually straightforward using magnetic resonance imaging (MRI). In patients in whom MRI cannot be performed or imaging provides equivocal findings, computed tomography (CT) of the temporal bone might offer indirect evidence of CND. Our study aimed to derive a cut-off value for the diameter of the cochlear nerve canal (CNC) and internal auditory canal (IAC) in temporal bone CT to predict CND. MATERIALS AND METHODS: This retrospective study included 70 children with sensorineural hearing loss (32 with CND and 38 control patients). The height, width, and cross-sectional area of the IAC and diameter of the CNCs were determined using temporal bone CT. Receiver operating characteristic (ROC) and Student's t-tests were performed for each parameter. RESULTS: The mean diameter of the CNCs was significantly smaller in children with CND than in the control group (1.2 mm versus 2.4 mm, p < .001). The optimal threshold for CNC for separation of the two groups was 1.9 mm, resulting in a sensitivity of 98.7 % and specificity of 89.2 %. The IAC dimensions could not distinguish between children with CND and controls. CONCLUSION: A CNC diameter of less than 1.9 mm is a reliable predictor of CND in children with sensorineural hearing loss. KEY POINTS: · A small cochlear nerve canal predicts cochlear nerve deficiency (CND). · The size of the internal auditory canal cannot predict CND. · Whenever MRI is impossible or ambigous, CT can rule out CND. CITATION FORMAT: · Sorge M, Sorge I, Pirlich M et al. Diameter of the Cochlear Nerve Canal predicts Cochlear Nerve Deficiency in Children with Sensorineural Hearing Loss. Fortschr Röntgenstr 2022; 194: 1132 - 1139.

[Presentation and evaluation of the haptic-visual ear surgery training system "HaptiVisT"]. / Vorstellung und Evaluation des haptisch-visuellen, ohrchirurgischen Trainingssystems "HaptiVisT".

BACKGROUND: Operations on the temporal bone are a special challenge for ENT surgeons. The aim of the BMBF-funded project was to develop a realistic training system for ear operations in the form of a "serious game". METHODS: The presented prototype of the HaptiVisT system functions as a training system for ear surgeries with visual feedback through a glasses-free 3D monitor and feedback by means of a haptic arm simulating the drill. A variety of training options is guaranteed by three available surgical procedures (antrotomy, mastoidectomy, posterior tympanotomy). A weighted point system enables the measurability of the training success. Following the technical development of the prototype, a prospective evaluation was carried out by eight ENT physicians and four students regarding "learning content" and "user experience". A standardized questionnaire was used (ordinal scale: 1=very good to 5=very bad). RESULTS: Regarding the learning content, the aspects "strengthening anatomy (mean=1.58)", "training hand-eye coordination (1.67)", "transferability into practice (1.83)", "usefulness for practice (1.33)" yielded good to very good scores. "User experience" also showed good results for the aspects "realism (2.29)", "interaction of haptics and optics (2.33)" and "immersion in the training system (1.89)". The "motivation factor" was very high for all test subjects (1.2). CONCLUSIONS: The training system for ear surgeries "HaptiVisT" offers the possibility of immersive training. Integration into the daily clinical routine and in particular into the medical training to become an ENT specialist therefore seems to make sense.

Cytokine Profiles of Head and Neck Squamous Cell Carcinoma Undergoing Dual Immunotherapy With Cetuximab and Pembrolizumab Identify Interferon Gamma-Induced Protein 10 as Novel Biomarker.

Background: Pembrolizumab and cetuximab are antibodies under investigation in head and neck squamous cell carcinoma (HNSCC) either as single agents or combined with cisplatin and other chemotherapeutic drugs, e.g., 5-fluorouracil and/or docetaxel. However, also the combination of both antibodies may have potential in recurrent/metastatic (R/M) HNSCC, in particular in cisplatin-resistant or -refractory cases or patients with comorbid disease, e.g. patients with impaired renal function. Methods: To clarify potential benefit that may result from such combination, we used the FLAVINO assay, a short-time ex vivo assay to compare responsiveness of HNSCC to pembrolizumab, cetuximab and both combined regarding colony formation of epithelial cells of biopsy-derived tumor samples and their cytokine production within three days either without or with stimulation with 10 ng/mL interferon gamma (IFN-γ). Vascular endothelial growth factor A (VEGF), monocyte chemoattractant protein 1 (MCP-1 or CCL2), interleukin 6 (IL-6), IL-8, IFN-γ, and interferon gamma-induced protein 10 (IP-10 or CXCL10) in supernatants were measured by ELISA. Results: We detected huge heterogeneity in response to cetuximab, pembrolizumab and both combined with and without IFN-γ stimulation. Moreover, we detected a link between IFN-γ induced IP-10 release and improved outcome in those HNSCC patients who were capable to respond to IFN-γ and pembrolizumab, cetuximab and both combined with a further increase in IP-10 production. We derived an "IP-10 score" that independent from clinical characteristics of HNSCC patients and therapy regimens applied was able to predict their outcome. Conclusions: The heterogeneity in the ex vivo response of cetuximab, pembrolizumab and both combined with and without IFN-γ stimulation identifies subgroups of HNSCC patients with deviating OS.

Pre-Therapeutic VEGF Level in Plasma Is a Prognostic Bio-Marker in Head and Neck Squamous Cell Carcinoma (HNSCC).

Vascular endothelial growth factor (VEGF) is centrally involved in cancer angiogenesis. We hypothesized that pre-therapeutic VEGF levels in serum and plasma differ in their potential as biomarkers for outcomes in head and neck squamous cell carcinoma (HNSCC) patients. As prospectively defined in the study protocols of TRANSCAN-DietINT and NICEI-CIH, we measured VEGF in pretreatment serum and plasma of 75 HNSCC test cohort (TC) patients. We analyzed the prognostic value of VEGF concentrations in serum (VEGFSerum) and plasma (VEGFPlasma) for event-free survival (EFS) utilizing receiver-operating characteristics (ROC). Mean VEGF concentrations in plasma (34.6, 95% CI 26.0-43.3 ng/L) were significantly lower (p = 3.35 × 10-18) than in serum (214.8, 95% CI 179.6-250.0 ng/L) but, based on ROC (area under the curve, AUCPlasma = 0.707, 95% CI 0.573-0.840; p = 0.006 versus AUCSerum = 0.665, 95% CI 0.528-0.801; p = 0.030), superiorly correlated with event-free survival (EFS) of TC patients. Youden indices revealed optimum binary classification with VEGFPlasma 26 ng/L and VEGFSerum 264 ng/L. Kaplan-Meier plots demonstrated superiority of VEGFPlasma in discriminating patients regarding outcome. Patients with VEGFPlasma < 26 ng/L had superior nodal (NC), local (LC) and loco-regional control (LRC) leading to significant prolonged progression-free survival (PFS) and EFS. We successfully validated VEGFPlasma according the cut-off <26 ng/L as predictive for superior outcome in an independent validation cohort (iVC) of 104 HNSCC patients from the studies DeLOS-II and LIFE and found better outcomes including prolonged tumor-specific (TSS) and overall survival (OS). Outcomes in TC and iVC combined again was related to VEGFPlasma, and multivariate Cox regression revealed that VEGFPlasma was an independent outcome predictor. In HNSCC, pre-therapeutic VEGFPlasma is prognostic for outcomes.

[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.

[Evaluation of an integrated OR based on open standards in Cochlea Implant surgery]. / Evaluation eines integrierten OP-Saals auf Basis offener Standards in der Cochlea-Implantat-Chirurgie.

BACKGROUND: Digitalization in surgery makes it necessary to develop modern surgical concepts. New approaches to system networking with integration and open standardized communication of all medical devices are being pursued. METHODS: At the University Hospital Leipzig, a demonstration of the integrated OR was carried out together with the Innovation Center for Computer Assisted Surgery (ICCAS) using the example of a cochlea implantation. The preoperative management, technical preparation, surgical procedure and postoperative documentation by a total of n = 30 study participants (2 expert groups) were evaluated. In addition to the collection of objective parameters, qualitative questionnaires and quantitative, interval-scaled questions were used. RESULTS: Preoperatively, the digital presentation of the patient's clinical data was considered as helpful by both groups (group 1: median = 5, group 2: median = 4). This also applies to the personalized OR settings, the intraoperative display options and the dynamic, surgeon-centered visualization (median = 4). Similar positive conclusions were drawn for postoperative documentation and postoperative follow-up (median = 4). A significant difference in the final evaluation of the integrated surgical concept between the two expert groups could not be determined (p > 0.05). CONCLUSIONS: The positive study results show that the theoretical idea of system networking based on open standards can be successfully implemented in practice using the example of a cochlea implantation. Thus, the intelligent "operating room of the future" no longer seems to be a fictitious idea, but a realistic image of modern surgical medicine.

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.

Language-based translation and prediction of surgical navigation steps for endoscopic wayfinding assistance in minimally invasive surgery.

PURPOSE: In the context of aviation and automotive navigation technology, assistance functions are associated with predictive planning and wayfinding tasks. In endoscopic minimally invasive surgery, however, assistance so far relies primarily on image-based localization and classification. We show that navigation workflows can be described and used for the prediction of navigation steps. METHODS: A natural description vocabulary for observable anatomical landmarks in endoscopic images was defined to create 3850 navigation workflow sentences from 22 annotated functional endoscopic sinus surgery (FESS) recordings. Resulting FESS navigation workflows showed an imbalanced data distribution with over-represented landmarks in the ethmoidal sinus. A transformer model was trained to predict navigation sentences in sequence-to-sequence tasks. The training was performed with the Adam optimizer and label smoothing in a leave-one-out cross-validation study. The sentences were generated using an adapted beam search algorithm with exponential decay beam rescoring. The transformer model was compared to a standard encoder-decoder-model, as well as HMM and LSTM baseline models. RESULTS: The transformer model reached the highest prediction accuracy for navigation steps at 0.53, followed by 0.35 of the LSTM and 0.32 for the standard encoder-decoder-network. With an accuracy of sentence generation of 0.83, the prediction of navigation steps at sentence-level benefits from the additional semantic information. While standard class representation predictions suffer from an imbalanced data distribution, the attention mechanism also considered underrepresented classes reasonably well. CONCLUSION: We implemented a natural language-based prediction method for sentence-level navigation steps in endoscopic surgery. The sentence-level prediction method showed a potential that word relations to navigation tasks can be learned and used for predicting future steps. Further studies are needed to investigate the functionality of path prediction. The prediction approach is a first step in the field of visuo-linguistic navigation assistance for endoscopic minimally invasive surgery.

The Intelligent ENT Operating Room of the Future. / Der intelligente HNO-Operationssaal der Zukunft.

The increasing plurality and complexity of technical assistance systems pose a challenge for clinically active physicians. Particularly in the operating theater, there is a growing need to integrate medical systems and software solutions into a holistic clinical infrastructure. The primary goal of building a "digital (ENT) operating room of the future" is not just the pure technical improvement of the individual computer-aided equipment and instruments, but rather their dynamic networking and system integration in an open modular system. Promising scientific projects address the question of how to improve the quality, safety and user-friendliness of technical systems in the health care system of the 21st century. The work on SCOT, MD PnP and OR.NET show the various components that make the vision of the ENT operating room of the future tangible and realistic in the overall context.

[Current Status of therapy and prophylaxis of oropharyngeal carcinoma]. / Aktueller Status der Therapie und Prophylaxe des Oropharynxkarzinoms.

Incidence of oropharyngeal carcinoma (OPSCC) is increasing significantly worldwide. Due to its association with chronic tobacco/alcohol consumption, but increasingly also with the human papillomavirus HPV-16, oropharyngeal carcinoma is a genetically heterogeneous tumor group with high prognostic diversification. HPV-associated OPSCC respond significantly better to previous treatment concepts than non-HPV-associated. Both after primary surgical as well as after radiotherapie, radiochemotherapie and anti-EGFR treatment, this tumor group shows a significantly better survival. There is no evidence that in HPV association only primary radiotherapy concepts should be used. Currently, in the 8th edition of the TNM classification (UICC, AJCC), the HPV-associated different prognostic consideration with a rearrangement of the tumor stages and the N status was taken into account. Regardless of the known blur, p16 status detection is the most practicable and least expensive method of detection today, and is therefore consistently recommended (also by the AJCC and UICC TNM committees). HPV16 positive non-smokers differ from HPV-16 negative smokers by nearly 50 % in 5-year survival. Transoral robot surgery (TORS), which is highly acclaimed in the US today, with the Da Vinci Telemanipulator (Intuitive Surgical) has triggered a downright euphoric discussion on the minimally invasive surgery of resectable OPSCC. Based on a stable data set, it is now clear that an R0 resection must be sought regardless of the surgical procedure. Resection margins < 5 mm (R0 < 5 mm) are considered to be an "intermediate risk" situation and, like the N status, influence the adjuvant concept (radiochemotherapy). During and after transoral surgical procedures, the risk of rebleeding should never be underestimated and can not be ruled out with the utmost care.

Functional and cosmetic donor site morbidity of the radial forearm-free flap: comparison of two different coverage techniques.

BACKGROUND: The use of the radial forearm-free flap is a well-established and reliable reconstruction method in head and neck surgery. Usually, the defect of the donor site is covered with full or split-thickness skin grafts. Since 09/2013, a direct closure of the radial forearm donor site has been performed at the ENT University Hospital Leipzig to avoid secondary donor site morbidity. However, few data are available in the literature on long-term cosmetic and functional results compared to the established indirect donor site defect coverage. METHODS: This study investigated patients with radial forearm-free flap harvest from 01/2012 until 03/2015. A total of n = 39 patients were included, with n = 18 being operated by indirect (group 1) and n = 21 by direct closure technique (group 2). For the validation of surgical revisions and wound healing disorders, we carried out clinical investigations as well as interviews. The "POSAS Observer and Patient Scale" was used for assessing the cosmetic outcome and the "Michigan Hand Outcome Questionnaire (MHQ)" for functional criteria. RESULTS: Group 2 showed an increased rate of wound healing problems, however it was not statistically different compared to group 1. Revision surgery was necessary in both groups only each in one case. Using the POSAS, there were no significant differences between both groups in the observer scale for the items vascularity, pigmentation, thickness, relief, pliability, surface area and even for pain, scar itching, color, stiffness, thickness and relief in the patient scale. The functional results (MHOQ) also showed no significantly inferior results for group 2. CONCLUSIONS: The direct closure procedure is quick, simple and can be performed without secondary donor site morbidity. For wound healing, cosmetic and function of the forearm and hand, no inferior results can be measured for the direct procedure compared to the indirect coverage technique.