Laryngeal graft after total laryngectomy in humans: A SWiM analysis

Evaluation of the results of laryngeal transplantation (LT) in humans. Analysis of 3 bibliographic databases with the keywords "larynx, transplantation, autograft". In total, 626 abstracts were read and 25 articles selected. The main objective was to analyze the characteristics of laryngeal transplant patients. The accessory objectives comprised analysis of operative technique, immunosuppressive treatment and results. Four articles were selected for analysis. Two patients were transplanted after total laryngectomy for laryngeal carcinoma and 2 after laryngeal trauma. Three of the 4 patients had true transplantation with arterial, venous and neural microanastomosis. Two patients were decannulated and the tracheostomy tube was maintained in the other 2. Three of the 4 patients had good-quality phonation and could feed without a gastric tube. One patient died of carcinoma progression and 1 patient had to be explanted 14 years after transplantation. The number of LTs reported is too small for scientific determination of the place of this intervention in laryngology. The published results could, at first sight, suggest that the future of LT is uncertain. However, several elements, also suggest that otolaryngologists should continue to take an interest in this technique.

Predicting Acute Radio-Induced Toxicity for Head and Neck Cancer Patients: Combining Dosimetry with Biomarker Data, Disclosing a Synergistic Effect

PURPOSE/OBJECTIVE(S)

We aimed to establish the added value of combining dosimetry with a binary blood assay for radiosensitivity based on quantification of pATM protein (RADIODTECT©) to predict acute radiotherapy (RT) induced mucositis (MUC) and dysphagia (DYS) in head & neck cancer patients (pts).

MATERIALS/METHODS

We enrolled 101 pts prospectively scored for acute toxicity with CTCAE. We considered four endpoints: grade≥2 (G2+) and grade≥3 (G3+) MUC, G2+, and G3+ DYS. We dichotomized the pATM concentration to define radiosensitive (RS) vs. radioresistant (RR) pts using previously described cutoffs for G2+ (57.8 ng/mL) and G3+ toxicity (46 ng/mL). We did RADIODTECT© and toxicity scoring blindly. We considered two already published NTCP models, including (i) the Equivalent Uniform Dose to the oral cavity (n = 0.05, EUD_OC, Odds Ratio [OR] = 1.02) and the mean dose to the parotid glands (Dmean_PG, OR = 1.06) for MUC and (ii) EUD_OC (OR = 1.04), the glottic larynx EUD (n = 0.35, EUD_GL, OR = 1.02) and the volume of pharyngeal constrictor muscles receiving>50Gy (V50Gy_CM, OR = 1.02) for DYS. To account for the association of toxicity with the dose distribution in multiple organs at risk (OARs), we derived a "Weighted Dose Score" (WDS) as a linear combination of the dose factors, using their β-coefficients (= lnOR) as weights. WDS for MUC (WDS_OM) = 0.06*Dmean_PG + 0.02*EUD_OC WDS for DYS (WDS_DYS) = 0.02*V50Gy_CM + 0.02*EUD_GL + 0.04*EUD_OC We used WDS as a comprehensive dose feature to fit a dose response and allowed WDS50 (i.e., the WDS associated with 50% toxicity probability) to be different for RR (WDS50_RR) and RS pts (WDS50_RS). The dose-modifying factor (DMF) is the ratio of WDS50_RS/WDS50_RR. It measures the horizontal shift of the dose-response curve when comparing RS vs. RR pts.

RESULTS

We scored G2+ and G3+ MUC in 80 and 41 pts; G2+ and G3+ DYS in 73 and 35 pts. The average concentration of pATM was 57.4ng/mL (sd 22.3ng/mL): 53/101 pts were classified as RS for G2+ toxicity and 35/101 as RS for G3+. On the whole cohort, the RADIODTECT© did not significantly associate with the risk of toxicity. However, we found two different dose-response curves at low WDS. There, the intrinsic biological sensitivity significantly affects the toxicity probability: ORs for RADIODTECT© are 2.6/2.4 for G2+/G3+ DYS, 6.4/2.9 for G2+/G3+ MUC. Furthermore, the difference in the incidence of side effects in RR vs. RS pts decreases as the WDS increases, reaching a region where the doses of OARs play a significant role. When combined with WDS, the RADIODTECT© effectively predicted RS pts, with DMF ranging from 0.77 for G3+ DYS to 0.40 for G2+ MUC.

CONCLUSION

These findings support the hypothesis that dose and biomarkers act synergistically; biologically based radiosensitivity plays a significant role when OARs are exposed at lower doses, while high doses of OARs determine toxicity irrespective of the underlying single pt biological characterization.

La pratique tabagique après l’annonce d’un cancer : étude qualitative auprès des patients diagnostiqués d’un carcinome épidermoïde des voies aérodigestives supérieures dans un centre de lutte contre le cancer

Le tabac est un facteur de risque majeur du cancer des voies aérodigestives supérieures. Le sevrage tabagique permet d’améliorer l’état de santé du patient, son taux de survie, et de diminuer les comorbidités et le risque d’autres cancers. La recommandation du sevrage tabagique est donc importante. Cependant, le taux d’arrêt du tabac après l’annonce de ce cancer reste faible. Il est donc nécessaire de comprendre les raisons d’une poursuite ou de l’arrêt de la pratique tabagique après l’annonce de la maladie. Dans cet objectif nous avons réalisé une enquête qualitative au sein d’un centre de lutte contre le cancer. Après des observations de consultation, nous avons rencontré des patients afin de recueillir leur expérience, leurs usages et pratiques, et ainsi leurs représentations du tabac malgré la maladie. Ces données qualitatives nous ont permis de mieux comprendre les différentes raisons qui permettent à certains patients d’envisager ou bien de débuter un processus de sevrage, et ceux pour qui l’arrêt définitif du tabac est difficile à envisager même à la suite de l’annonce du cancer.

Reverse blood flow in cervicofacial veins after venous ligations: Potential implications in microsurgery

INTRODUCTION

The consequences on the cervicofacial venous circulation of major cervicofacial vein ligations are poorly known. We aimed to highlight by using Doppler Ultrasound flow differences in the cervicofacial venous network in the case of unilateral or bilateral ligation of main venous collector trunks (external jugular vein [EJV] and internal jugular vein [IJV]) METHODS: A Doppler ultrasound was performed on 10 healthy volunteers, 8 patients with previous bilateral ligation of the EJV, 8 with a unilateral ligation of the EJV, and 8 with a unilateral ligation of the EJV and IJV, after modified radical neck dissection. The diameter, the flow direction and the peak systolic velocity (PSV) of the superficial temporal vein, the facial vein (FV) and the IJV were measured.

RESULTS

Healthy patients had a similar right and left PSV for all the veins studied, with always antegrade flows. Patients with previous ligations had some significant right/left differences and retrograde flows.

CONCLUSION

A redistribution of venous blood flow on the contralateral side of the face and neck seems to take place in the case of unilateral ligation of the EJV and/or IJV. Retrograde flows are sometimes observed in the case of previous ligation of the EJV and/or IJV and might compromise the success of venous microanastomoses.

[Impact of reconstructive or minimal invasive surgery on the assessment of current definitions of postoperative clinical target volume for head and neck cancers]

Advances in the reconstructive surgery and minimally invasive endonasal endoscopic surgery of head and neck is poorly evaluated in terms of their impact on radiotherapy planning and outcomes. These surgical advances have resulted in reduced morbidity with equivalent or better tumor control. In the absence of a recommendation on how to delineate target volumes in patients with flaps or to consider margins after endoscopic endonasal surgery, radiotherapy practices are inevitably heterogeneous. Efforts are needed to increase the therapeutic index of postoperative radiotherapy in these situations. We analysed the rare existing literature and outlined a preliminary basis for a recommendation. Strengthening of multidisciplinarity to accurately define target volumes in these complex and relatively new situations, and "delineation concertation meetings" between radiologists, surgeons and radiation oncologists could probably contribute to improved outcomes.

The immune microenvironment of HPV-negative oral squamous cell carcinoma from never-smokers and never-drinkers patients suggests higher clinical benefit of IDO1 and PD1/PD-L1 blockade

Background

Never-smokers and never-drinkers patients (NSND) suffering from oral squamous cell carcinoma (OSCC) are epidemiologically different from smokers drinkers (SD). We therefore hypothesized that they harbored distinct targetable molecular alterations.

Patients and methods

Data from The Cancer Genome Atlas (TCGA) (discovery set), Gene Expression Omnibus and Centre Léon Bérard (CLB) (three validation sets) with available gene expression profiles of HPV-negative OSCC from NSND and SD were mined. Protein expression profiles and genomic alterations were also analyzed from TCGA, and a functional pathway enrichment analysis was carried out. Formalin-fixed paraffin-embedded samples from 44 OSCC including 20 NSND and 24 SD treated at CLB were retrospectively collected to perform targeted-sequencing of 2559 transcripts (HTG EdgeSeq system), and CD3, CD4, CD8, IDO1, and PD-L1 expression analyses by immunohistochemistry (IHC). Enrichment of a six-gene interferon-γ signature of clinical response to pembrozulimab (PD-1 inhibitor) was evaluated in each sample from all cohorts, using the single sample gene set enrichment analysis method.

Results

A total of 854 genes and 29 proteins were found to be differentially expressed between NSND and SD in TCGA. Functional pathway analysis highlighted an overall enrichment for immune-related pathways in OSCC from NSND, especially involving T-cell activation. Interferon-γ response and PD1 signaling were strongly enriched in NSND. IDO1 and PD-L1 were overexpressed and the score of response to pembrolizumab was higher in NSND than in SD, although the mutational load was lower in NSND. IHC analyses in the CLB cohort evidenced IDO1 and PD-L1 overexpression in tumor cells that was associated with a higher rate of tumor-infiltrating T-cells in NSND compared with SD.

Conclusion

The main biological and actionable difference between OSCC from NSND and SD lies in the immune microenvironment, suggesting a higher clinical benefit of PD-L1 and IDO1 inhibition in OSCC from NSND.

Day-care unit for rigid panendoscopy of the upper aerodigestive tract: A study of 436 procedures

OBJECTIVES

To assess the role of day-care management of upper aerodigestive tract (UADT) panendoscopy and to study criteria for conventional hospital admission and reasons for conversion.

PATIENTS AND METHODS

Retrospective study, from January 2011 to May 2013. Inclusion criteria UADT panendoscopy for carcinoma assessment. Study variables, age, gender, tumor location, reason for panendoscopy, TNM stage, previous external radiotherapy, home-to-hospital distance and Apfel, Detsky and ASA scores. A day-care and a conventional admission group were compared using Fisher's test for ASA score, student's test for age and Pearson's chi² test for the other variables.

RESULTS

Four hundred and thirty-six panendoscopies were performed: 252 in day-care, including 4 cases of conversion and 184 with conventional admission. There were no significant differences between groups for age, gender, tumor location, TNM stage, reason for panendoscopy, previous external radiotherapy, home-to-hospital distance or Apfel score. A significant difference was observed for ASA score (P<0.0001) and Detsky score (P=0.03). In 39% of cases, the reason for hospital admission without criteria defined by the French Society of Anesthesia and Intensive Care Medicine (SFAR) and French Health Authority (HAS) was the patient's refusal of day care. In 10% of conventional admissions, day-care was not implemented because of psychosocial factors.

CONCLUSION

Day-care management is appropriate for UADT panendoscopy in selected patients. The reasons for the high rate of patient refusal should be studied.

French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Guidelines (short version) of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) on patient pathway organization in ENT: The therapeutic decision-making process

OBJECTIVES

The authors present the guidelines of the French Otorhinolaryngology - Head and Neck Surgery Society (SFORL) for patient pathway organization in head and neck cancer, and in particular for multidisciplinary team meetings. The present article concerns the therapeutic decision-making process.

METHODS

A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.

RESULTS

It is recommended that: an organ specialist should contribute to all multidisciplinary meetings on head and neck cancer; all members of the multidisciplinary meeting should have specific knowledge in head and neck cancer; any referring physician who does not follow the multidisciplinary meeting's advice should justify that decision; there should be sufficient time to prepare, discuss and sum up the cases dealt with in the multidisciplinary team meeting.

[Lacrimal duct tumors: diagnostic and therapeutic dilemmas]

INTRODUCTION

Fewer than 250 primary tumors of the lacrimal duct have been reported in the international literature. Because their signs and symptoms are nonspecific and usually subclinical, delayed diagnosis is common. Treatment for malignant epithelial tumors is surgical, with or without radiation.

PATIENTS AND METHODS

The present study is a retrospective analysis of five patients with malignant lacrimal duct tumors.

RESULTS

Three patients were diagnosed with carcinoma requiring wide en bloc surgical resection with surgical reconstruction. One underwent adjuvant radiation therapy. Another experienced simultaneous local and lymph node recurrence after 3 years and underwent curative surgery. Two additional patients were diagnosed with diffuse malignant large B-cell non-Hodgkins lymphoma.

DISCUSSION

Early symptoms of lacrimal duct tumors are nonspecific and mimic acute dacryocystitis. Lacrimal system CT, MRI and rhinoscopy may allow for earlier diagnosis. Surgical treatment requires resection with wide margins and reconstruction of the medial canthal region.

CONCLUSION

Only an early diagnosis can reduce the impairment related to surgery and the extent of the required reconstruction, as well as improve survival.

[Mandibular hemangiopericytoma, a malignant vascular tumor]

INTRODUCTION

Hemangiopericytoma is a rare tumor, arising from pericytes, which are perivascular cells belonging to the capillar walls.

OBSERVATION

A 41 year old man consulted for a mandibular tumor. The clinical and radiographic diagnosis was difficult. The biopsy performed in the operative room led to an embolization decided in emergency, and proved the definitive diagnosis. Despite the embolization, bleeding during surgical excision of the tumor compelled us to perform an external carotid artery ligature. The mandibular reconstruction was performed using a trapezium osteo-muscular flap.

DISCUSSION

As reported in the literature, the radiographic diagnosis of hemangiopericytoma is difficult, the malignant potential is variable and the recommended treatment is surgical excision.