Incidence and risk factors for secondary extralaryngeal dystonia in patients with laryngeal dystonia

BACKGROUND AND OBJECTIVES

Laryngeal dystonia (LD) is a focal dystonia affecting adductor and/or abductor muscles of the larynx. It can be isolated or may spread to extra laryngeal muscles. The aim of this study was to report the characteristics of LD over time in a large single-center study with a long follow-up.

METHODS

Retrospective review of patients with LD referred to our institution between 1991 and 2021. Demographic data, time to diagnosis, type of LD, follow-up and spread of dystonia [SD] were recorded. Risk factors for spread of dystonia during follow-up were analyzed.

RESULTS

Over the 30-year period, 516 patients (77.3 % female, median age 50 years, range 5-87 years) were analyzed. Three hundred and fifteen patients (61 %) had adduction laryngeal dystonia, 136 patients (26.4 %) had abduction laryngeal dystonia, 46 patients (8.9 %) had adductor respiratory laryngeal dystonia, 12 patients (2.3 %) had mixed laryngeal dystonia, and seven patients (1.4 %) had singer's laryngeal dystonia. A previous history of dystonia was found in 47 patients (9.1 %). A laryngeal tremor was found in 68 patients (13.2 %). Since the onset of symptoms, LD was diagnosed after a median of 3 years (IQR: 1.0, 7.0). SD occurred in 55 patients (10.7 %) after a median time of 4 year (IQR: 1.5, 13.0). Patients with mixed laryngeal dystonia had higher probability of SD (p = 0.018).

DISCUSSION

This study reports a large European study of LD, with a long follow-up. SD occurred in 10.5 % of patients. Patients with mixed laryngeal dystonia had a higher probability of SD. A close follow-up may be recommended for patients with mixed laryngeal dystonia.

Oncological and Surgical Outcomes of Patients Treated by Transoral CO2 Laser Cordectomy for Early-Stage Glottic Squamous Cell Carcinoma: A Retrospective Chart Review

OBJECTIVE

To investigate the feasibility and the outcomes of transoral laser CO₂ microsurgery (TLM) for resection of early-stage squamous cell carcinoma (SCC) of the vocal folds through several additional surgical procedures and tips improving the glottic exposure.

METHODS

Retrospective chart review of patients treated by TLM cordectomy in a single European University Hospital for early-stage vocal fold SCCs (Tis, T1a, T1b, and T2). The following TLM outcomes were studied regarding the tumor size (Tis and T1a vs T1b and T2) and the margin status (negative vs positive/suspicious): patient position; type of laryngoscope; requirement to external counter pressure; resection of supraglottic structures (eg, ventricular band, epiglottic petiole, and suprahyoid epiglottis); pre- and postoperative complications; overall survival; disease-specific survival (DSS); and disease-free survival (DFS).

RESULTS

A total of 148 patients were included. The TLM was realized in 95.3% of cases. External counter pressure, partial, or total vestibulectomy were necessary in 65.9%, 57.4%, and 4.2% of cases, respectively. A resection of the epiglottic petiole was required in 24.8% of cases. The realization of both epiglottis petiole resection and vestibulectomies were significantly higher in patients with T2 and T1b SCCs compared to those with T1a and Tis SCCs (P = .01). Different procedure tips were described for improving the laryngeal exposition. The 5-year laryngeal preservation rate, DSS, and DFS were significantly better in patients without SCC involvement of the anterior commissure, and did not vary according to the margin status. The laryngeal exposure difficulties did not impact the margin status.

CONCLUSION

The exposure of glottis is possible in 95% of cases of early-stage vocal cord SCC but requires the use of several additional surgical procedures, especially for anterior commissure SCCs. The SCC involvement of the vocal fold anterior commissure is associated with lower DSS, DFS, and laryngeal preservation rate.

Multidimensional Voice Quality Evaluation After Transoral CO2 Laser Cordectomy: A Prospective Study

OBJECTIVE

To investigate voice quality changes of patients treated by transoral laser cordectomy (TLC) for early glottic cancer according to the type of cordectomies.

METHODS

A total of 164 consecutive male patients with an early glottic cancer were prospectively recruited from the Department of Otolaryngology-Head and Neck Surgery of the Georges Pompidou European Hospital. Depending on the tumor characteristics, patients benefited from type I to VI CO₂ cordectomy regarding the European Laryngological Society classification. The following voice quality outcomes were pre- to postoperatively assessed: voice handicap index (VHI), perceptual grade of dysphonia, roughness, breathiness, maximum phonation time, and acoustic parameters.

RESULTS

Fifty-five patients with Tis, T1, or T2 vocal fold cancer completed the study (mean age: 61.7 years). Of these patients, 34 and 21 composed group 1 (types I-III TLC) and group 2 (types IV-VI TLC), respectively. Voice handicap index, grade of dysphonia, and breathiness significantly improved from pre- to 3- and 6-month posttreatment in group 1. In group 2, only VHI significantly improved from pre- to 3- and 6-month posttreatment. Acoustic and aerodynamic measurements did not change throughout the postoperative course. Patients with types I to III TLC exhibited better postoperative voice outcomes compared to those treated by types IV to VI TLC.

CONCLUSION

Irrespective to the types of TLC, the subjective voice quality of patients treated by CO₂ laser cordectomy for early glottic cancer significantly improved from pre- to 3- and 6-month posttreatment. The usefulness of aerodynamic and acoustic measurements as postoperative outcomes of voice quality changes remain controversial and require future studies considering multidimensional assessment of voice.

[Radiation-induced head and neck pain: Management with botulinum toxin a injections]

PURPOSE

To report the results of Botulinum Toxin A (BTA) for radiation-induced head and neck pain.

MATERIALS AND METHODS

This single-center retrospective study included all the patients treated at our institution with botulinum toxin A injections for radiation-induced head and neck pain between 2006 and 2017. Pain was evaluated by each patient on a visual analogue scale (VAS) (between 0 and 10) before, and 1 month after the injection.

RESULTS

Sixteen patients were included in this series. The mean value of the pain was 8.5 before and 8 after the first injection. The difference was statistically significant (p<0.01). Major response occurred in 15 patients (VAS≤3 after BTA) and complete response in 11 patients (VAS=0 after BTA).

CONCLUSION

Botulinum toxin is an effective treatment for radiation-induced head and neck pain.

Oromandibular Dystonia: Demographics and Clinical Data from 240 Patients

Objective

To report demographic data from a large cohort of patients with oromandibular dystonia (OMD).

Methods

This is a retrospective review of patients with OMD referred to our institution between 1989 and 2015. Demographic (age of onset, gender, and familial history of dystonia) and clinical (type of OMD, associated dystonia, and etiology of dystonia) data were collected from a cohort of 240 individuals.

Results

The mean age of onset of OMD was 51.6 years old, with a female predominance (2:1). A family history of dystonia was found in 6 patients (2.5%). One hundred and forty-nine patients (62.1%) had the jaw-opening type of OMD, 48 patients (20.0%) had the jaw-closing type, and 43 patients (17.9%) had a mixed form of OMD. Lingual dystonia was also present in 64 (26.7%) of these patients. Eighty-two patients (34.2%) had a focal dystonia, 131 patients (54.6%) had a segmental dystonia, and 27 patients (11.3%) had a generalized dystonia. One hundred and seventy-one patients (71.3%) had idiopathic OMD.

Conclusion

OMD is a chronic and disabling focal dystonia. Our study found a prevalence of female patients, an onset in middle age and a predominantly idiopathic etiology. Unlike other studies, jaw-opening was found to be the most frequent clinical type of OMD.

Complications of Postoperative Radiation Therapy after Partial Laryngectomy in Supraglottic Cancer: A Long-Term Evaluation

This retrospective study, based on a series of 90 patients with invasive squamous cell carcinoma of the supraglottis, was designed to document the functional outcome and complications after postoperative radiation therapy following partial laryngeal surgery. The surgical procedure was a standard supraglottic laryngectomy in 62 patients and a supracricoid partial laryngectomy in 28 patients. All of the patients had an unremarkable postoperative course and achieved locoregional control. The average dose delivered to the remaining larynx was 51.2 Gy (range 25–71 Gy). The average dose delivered to the neck was 50.6 Gy (range 2270 Gy). The patients were treated at 180-cGy per fractions in a continuous course technique with a cobalt 60 beam. In 5 patients (5.5%) complications led to cessation of postoperative radiation therapy, and the total dose delivered to the remaining larynx and neck was less than 40 Gy. All patients were followed up for a minimum of 10 years or until death. The 5-, 10-, and 15-year actuarial survival estimates were 71.5%, 44.3%, and 36.3%, respectively. The 5-, 10-, and 15-year actuarial severe complication estimates were all 11.2%. Overall, severe complications occurred in 15 patients. Severe complications led to death in 3 patients (3.3%), permanent gastrostomy in 3 (3.3%), and permanent tracheostomy in 1 (1.1%). A severe complication never resulted in completion of total laryngectomy. In univariate analysis, the mean dose delivered to the larynx was the only variable statistically related to the incidence of a severe complication. The mean dose delivered to the larynx was statistically higher (P = 0.014) in patients who had severe complications (60 Gy) than in patients who did not (50 Gy).

Supracricoid Hemilaryngopharyngectomy in Patients with Invasive Squamous Cell Carcinoma of the Pyriform Sinus

Supracricoid hemilaryngopharyngectomy (SCHLP) was performed in 147 patients over a 19-year period for previously untreated invasive squamous cell carcinoma of the pyriform sinus. With a minimum of 3 years' follow-up, the current retrospective series was designed to document the incidence, risk factors, and consequences of local recurrence following SCHLP. Before operation, 97.4% of patients had an induction chemotherapy regimen. A complete clinical response and a complete histologic regression were noted in 21.7% and 16.8% of patients, respectively. A significant statistical relationship (p = .0001) was noted between complete clinical response and complete histologic regression. Postoperative radiotherapy was used in 49.8% of patients. The overall local recurrence rate was 8.2%. The 5-year actuarial (Kaplan-Meier life-table method) local control estimate was 90.4%. As a function of T stage, the 5-year actuarial local control estimates were 96.2%, 91.1%, 92.9%, and 62.6% in patients with tumors classified as T1, T2, T3, and T4a, respectively. On univariate analysis, the overall local recurrence rate varied significantly, from 5.3% to 55.6% if the apex of the pyriform sinus was invaded (p = .02), 6.9% to 18.7% if the posterior pharyngeal wall was invaded (p = .03), and 6.3% to 60% if the margins of resection were positive (p = .02). In a stepwise regression model, positive margins of resection (odds ratio, 8.4; 95% confidence interval, 2.2 to 32.2; p = .002) and invasion of the apex of the pyriform sinus (odds ratio, 6.1; 95% confidence interval, 1.1 to 33.3; p = .04) were the variables statistically associated with an increased risk of local recurrence. Local recurrence resulted in a statistically significant increased risk of nodal recurrence (p = .005) and death (p < .004). The overall laryngeal preservation rate was 91.2%. From an oncological perspective, these results suggest that SCHLP should become a major tool in the armamentarium of the head and neck surgeon and should be integrated into future trials aimed at organ preservation in patients with invasive squamous cell carcinoma of the pyriform sinus.

Assessment of margins in transoral laser and robotic surgery

The growing practice of endoscopic surgery has changed the therapeutic management of selected head and neck cancers. Although a negative surgical margin in resection of neoplasm is the most important surgical principle in oncologic surgery, controversies exist regarding assessment and interpretation of the status of margin resection. The aim of this review was to summarize the literature considering the assessment and feasibility of negative margins in transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). Free margin status is being approached differently in vocal cord cancer (1-2 mm) compared with other sites in the upper aerodigestive tract (2-5 mm). Exposure, orientation of the pathological specimen, and co-operation with the pathologist are crucial principles needed to be followed in transoral surgery. Piecemeal resection to better expose deep tumor involvement and biopsies taken from surgical margins surrounding site of resection can improve margin assessment. High rates of negative surgical margins can be achieved with TLM and TORS. Adjuvant treatment decision should take into consideration also the surgeon's judgment with regard to the completeness of tumor resection.

Expression and mutational status of treatment-relevant targets and key oncogenes in 123 malignant salivary gland tumours

BACKGROUND

Malignant tumours of the salivary glands (MSGT) are rare and pleomorphic entities. Patients with advanced disease may benefit from targeted therapy; however, specific targets for optimising and personalising treatments are yet to be identified.

DESIGN

Immunohistochemistry for C-KIT, EGFR, HER2, MUC1, phospho-mTOR, androgen/estrogens/progesterone receptors and Ki67 was carried out and evaluated in terms of progression-free and overall survival. High throughput molecular screening of key oncogenes was done in 107 patients using routine diagnostic methods and Sequenom technology.

RESULTS

Several therapy leads were identified, including high levels of HER2 and androgen receptors in salivary duct carcinomas, C-KIT in myoepithelial carcinomas and EGFR in mucoepidermoid carcinomas. Recurrent mutations involving downstream elements of the EGFR pathway were found in HRAS, notably in tumours with a myoepithelial component, and in other key oncogenes (KRAS/NRAS/PI3KCA/BRAF/MAP2K). On the other hand, <1% of samples had EGFR or HER2 mutations.

CONCLUSION

Several tumour subtypes overexpressed targets of directed therapies suggesting potential therapy leads. Genotyping results suggest activation downstream of EGFR in 18 of the 107 samples that could be associated with low efficacy of EGFR inhibitors. Other molecules, such as PI3K/MEK or mTOR inhibitors, may have anti-tumour activity in this subgroup. The high mutation rate in HRAS highlights a novel key oncogenic event in MSGT.

Immunotherapy of HPV-associated head and neck cancer: Critical parameters

Various arguments support the development of a vaccine targeting human papillomavirus (HPV) for the treatment of HPV-associated head and neck cancer. However, the mucosal localization of this tumor, the HPV-driven downregulation of MHC Class I molecules and various other immunosuppressive mechanisms must be carefully considered to improve the clinical efficacy of such an immunotherapeutic strategy.

Transoral robotic total laryngectomy

OBJECTIVES/HYPOTHESIS

Minimally invasive surgery has become the standard of care in many organ systems. Head and neck surgery has incorporated transoral surgery, either laser microsurgery or robotic resection, in the management of pharyngeal and laryngeal cancers. To date, the laryngeal procedures have taken the form of partial laryngectomy, as transoral approaches have not allowed reconstruction following total laryngectomy. We present the first series of transoral total laryngectomies.

STUDY DESIGN

Multinational, multi-institutional prospective consecutive case series.

METHODS

Case series of completed and attempted transoral robotic surgery (TORS) total laryngectomy performed under an institutional review board protocol. The procedure was developed in the cadaver laboratory and applied to selected individuals requiring total laryngectomy for recurrent laryngeal cancer or post-therapeutic organ dysfunction.

RESULTS

TORS total laryngectomy was successfully performed in five patients and was unsuccessful in two others. Two of the patients had postoperative fistulae, and all seven are without evidence of recurrent cancer and are swallowing orally without gastrostomy supplementation.

CONCLUSIONS

TORS total laryngectomy is feasible and can be taught to other surgeons. Potential benefits of this approach are present for patients undergoing salvage laryngectomy and include improved wound healing and functional results. This procedure further extends the applications of robotic head and neck surgery.

[Evaluation of quality of life and swallowing in patients with cancer of the oropharynx treated with assisted transoral robotic surgery]

OBJECTIVES

To present the preliminary results of the qualiit of life and quality of swallowing in a series of 15 patien! treated with oropharyngectomy by transoral robotic-assisted (CTAR) (robot da Vinci, Intuitive Surgical ).

MATERIALS AND METHODS

A prospective monocentric non-randomized study of 15 patients with cancer of the oropharynx. Were analyzed: demographics, quality of life questionnaires (QLQ-C30 and H&N 35 EORTC) and quality of swallowing questionnairex (MDADI, DHI and EAT 10) with an average of 1 year after the end of the treatment.

RESULTS

Fifteen patients (10 males and 5 females), mean age of 65 years (47-73 years) were included. The tumours were classified as: cT1: 4; cT2: 10 cT3: 1. Five of the 15 patients received postoperative chemoradiotherapy as histo-pathological studies showed multiple metastatic cervical lymph nodes +/- capsular rupture. For the analysis of the quality of life and quality of swallowing, the patients were divided into two groups. Group A included patients who underwent CTARs and group B, patients operated by CTAR with adjuvant chemoradiotherapy. At 12 months of the procedure, all patients had a deglutition considered as normal without feeding tube nor tracheostomy. With the three scales used, the quality of swallowing was satisfactory for all patients. It was better for patients in group A than for patients in group B. In terms of quality of life, the EORTC QLQ-C30 scale showed our patients had a high rate of satisfaction scale in "health and overall quality of life". For the EORTC H&N35 questionnaire, mean scores for "specific symptoms" were also low except for the following three items "dry mouths", "sticky saliva" and "sexuality problem". The first two items were statistically more frequent (p = 0.02 and p = 0.001) in group B patients.

CONCLUSION

After transoral robotic-assisted oropharyngectomy, patients have a good quality of life and swallowing. Postoperative chemoradio-therapy compromises the quality of swallowing. Multicentric studies are required to confirm these preliminary results.

PD-1-expressing tumor-infiltrating T cells are a favorable prognostic biomarker in HPV-associated head and neck cancer

Head and neck cancers positive for human papillomavirus (HPV) have a more favorable clinical outcome than HPV-negative cancers, but it is unknown why this is the case. We hypothesized that prognosis was affected by intrinsic features of HPV-infected tumor cells or differences in host immune response. In this study, we focused on a comparison of regulatory Foxp3(+) T cells and programmed death-1 (PD-1)(+) T cells in the microenvironment of tumors that were positive or negative for HPV, in two groups that were matched for various clinical and biologic parameters. HPV-positive head and neck cancers were more heavily infiltrated by regulatory T cells and PD-1(+) T cells and the levels of PD-1(+) cells were positively correlated with a favorable clinical outcome. In explaining this paradoxical result, we showed that these PD-1(+) T cells expressed activation markers and were functional after blockade of the PD-1-PD-L1 axis in vitro. Approximately 50% of PD-1(+) tumor-infiltrating T cells lacked Tim-3 expression and may indeed represent activated T cells. In mice, administration of a cancer vaccine increased PD-1 on T cells with concomitant tumor regression. In this setting, PD-1 blockade synergized with vaccine in eliciting antitumor efficacy. Our findings prompt a need to revisit the significance of PD-1-infiltrating T cells in cancer, where we suggest that PD-1 detection may reflect a previous immune response against tumors that might be reactivated by PD-1/PD-L1 blockade.

Expression and prognostic significance of directed therapy targets and mutational analysis of the EGFR pathway in malignant salivary gland tumors

5554

Background: Malignant salivary gland tumors are rare and pleomorphic entities (24 sub types, WHO 2005). Curative treatment relies on surgery sometimes completed by radiotherapy. Management of non-surgical, locally advanced or metastatic tumors is difficult as conventional chemotherapies are ineffective. Directed therapies may provide important benefits for these patients. The aim of this work was to assess the expression and prognostic value of directed therapy targets on salivary gland tumors and search for mutations within the key players of the EGFR pathway. Methods: Immunochemistry on formalin fixed paraffin embedded (FFPE) samples from 124 patients for c-KIT, EGFR, c-ERBB2, MUC1, phospho-mTOR, androgen/estrogens/progesterone receptors and Ki67 was performed and related to progression free interval and survival. DNA was extracted from FFPE samples and conditional for treatment mutations of EGFR/KRAS/BRAF were assessed. An additional high throughput screening for mutations of key oncogenic genes was performed. Results: EGFR was the most expressed marker, found across almost all histotypes. Expression of the other markers was heterogeneous but some potential therapy leads were suggested by high levels of C-ERBB2 and androgen receptors in salivary duct carcinomas or C-KIT over expression in myoepithetial carcinomas. Tumor grade and a high proliferation index (Ki67>20%) were associated with progression free interval and survival. None of the other marker was. No mutation was found in EGFR/KRAS/BRAF. 7% (7/104) of the tumors harbored a mutation at the codon 61 of HRAS. In epithelial and epithelial-myoépithélial carcinoma, the mutation rate reached 33%. Mutations of PI3K and p53 were the most frequently found in the broader screen. Conclusions: Several tumor subtypes expressed frequently some targets of directed therapies suggesting potential therapy leads. The EGFR/MAPK pathway seems intact suggesting a low efficacy of small kinase inhibitors such as erlotinib or gefitinib. The mutation of H-RAS, known to be important but not sufficient to trigger urothelial carcinoma, could be a key oncogenic event in tumors with a myoepithelial component.

An unusual human papillomavirus type 82 detection in laryngeal squamous cell carcinoma: case report and review of literature

Squamous cell carcinoma (SCC) of the larynx is extremely rare in adolescent or younger adult and typically has an aggressive nature. The mechanism of laryngeal oncogenesis is complex and little is known about the role of human papillomaviruses (HPVs) in SCC in young age. HPV infection may occur during birth or latter by oro-genital contact. Most HPV genotypes detected were HPV 6, 11, 16, 18, 33 and 51. Herein, we report a case of invasive laryngeal SCC expressing an HPV 82 in an 18 year-old man with a history of unexplored severe acute dysphonia that started in early childhood.