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.

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.

Single-center retrospective series of fourteen patients with mucosal melanoma of the nasal cavity and paranasal sinuses

OBJECTIVES

Mucosal melanoma of the nasal cavity and paranasal sinuses is a rare and highly aggressive tumor. We report our experience over 20 years in management of this tumor.

PATIENTS AND METHODS

A retrospective study included 14 patients with primary sinonasal mucosal melanoma.

RESULTS

The series comprised 8 male and 6 female patients, with a median age at diagnosis of 67 years. Staging on the American Joint Committee on Cancer classification of sinus cancer was 14% T2, 22% T3, 75% T4a and 7% T4b. All patients underwent primary surgical treatment; 71% received adjuvant external radiotherapy. Median recurrence-free interval was 28.7 months. Two- and 5-year overall survival was 43% and 32%, respectively. Median follow-up was 43 months.

CONCLUSIONS

Mucosal melanomas of the nasal cavity and paranasal sinuses are very specific entities. Limited pathophysiological knowledge still precludes effective medium- and long-term management. Future treatment will probably be based on global adjuvant or neoadjuvant-targeted chemotherapy.

Localized nasopharyngeal amyloidosis

OBJECTIVES

To illustrate, via a case report, how a differential diagnosis of amyloidosis is to be suspected in case of a nasopharyngeal mass.

CASE REPORT

A 59-year-old woman presented with bilateral nasal obstruction with associated episodic tubal dysfunction. Physical examination found a mass occupying the entire nasopharynx, initially suggestive of tumor.

DISCUSSION

Amyloidosis was diagnosed on histopathologic study of the biopsy and surgical specimens. Exploration for systemic disease proved negative. The localized amyloidosis was managed conservatively. At 9 months' follow-up, there was no recurrence.

CONCLUSION

Localized amyloidosis, however rare, should be considered as differential diagnosis in any case of nasal obstruction with tubal dysfunction, even if bilateral. ENT physicians need to recognize and understand this pathology for adapted diagnostic and treatment planning.

Sclerosing polycystic adenosis of the parotid gland: diagnosis and management

OBJECTIVE

To describe diagnostic and therapeutic management of a rare parotid lesion: sclerosing polycystic adenosis.

PATIENT AND METHOD

We report a case of persistent right intraparotid tumefaction.

RESULTS

A 68-year-old man was referred with a right parotid nodule of 2 years' evolution. Cytology diagnosed pleomorphic adenoma, verified on MRI. Conservative subtotal parotidectomy diagnosed sclerosing polycystic adenosis. Over 1 year's regular follow-up, there were no signs of local recurrence.

CONCLUSION

Sclerosing polycystic adenosis of the parotid gland is a rare and recently described entity presenting several analogies to the much more frequent cystic mastitis. Although benign and well-delimited, it requires complete exeresis of the parotid, due to a non-negligible risk of recurrence.

[Comparison between external radiotherapy and laser microsurgery for the treatment of TisT1N0 glottic carcinoma: Clinical modelling and cost-minimization study from the French national health insurance payer's point of view]

OBJECTIVES

The excellent effectiveness of both treatment modalities (radiotherapy, endoscopic laser surgery) for early glottic carcinoma (Tis, TlaN0) is similar (carcinologic, functional and QoL results). This is part of an evidence-based medicine policy, which is to choose the cheapest of various treatment modalities known as equally effective and equally morbid. Is analytical economic approach useful and efficient to guide decision making? The aim of this study is to perform a costminimization analysis using an objective clinical modeling.

MATERIAL AND METHODS

For each modality, probabilities of various events were recorded from review of literature. Only local recurrences which constitute the major end-point affecting survival were considered. French national Health insurance's point of view (as the payer's point of view), with a 100% case-mix based payment system was used. Results of cost-minimization between laser endoscopic surgery and external radiation therapy are: Global Cost of laser endoscopic surgery is about 2613.01 euro. Without (90% of cases) and with recurrence it is about 1700.36 euro and 10826.87 euro respectively. Global Cost of external radiation therapy is about 4490.88 euro. Without (90% of cases) and with recurrence it is about 3578.23 euro and 12704.74 euro respectively.

CONCLUSION

Cordectomy by CO2 laser seems to be an efficient cost-effective alternative to radiotherapy for early glottic carcinoma management from the French national Health insurance perspective.

[Bilateral hypopharyngocele]

OBJECTIVE

Describe the management of bilateral hypopharyngocele in a trumpet player.

MATERIAL AND METHOD

Case report of a professional trumpet player suffering from bilateral hypopharyngocele.

RESULTS

A professional trumpet player was referred for an ORL consultation after he noticed that a bad sound was produced while he was playing associated with cervical pain. A CT scan demonstrated an asymmetric bilateral hypopharyngocele with no other abnormality. Because of the mild symptoms and the professional context, a successful conservative approach was used with antireflux medications. He was advised to seek professional instruction in order to improve his technique. On follow-up examination 6 months later, he had had no further problems since adopting the corrected techniques.

CONCLUSION

Pharyngoceles are rare and easily misdiagnosed. Because of the mild symptoms and the professional context, a conservative medical approach should be proposed (antireflux medications) combined with specific orthophonic and physical therapy to modify breathing and trumpet playing techniques.

Intérêt de la thyroïdectomie dans la prise en charge des kystes du tractus thyréoglosse dégénérés

PURPOSE OF STUDY

To discuss the authors' experience with thyroglossal duct (TD) carcinoma and expose the interest of the thyroidectomy in the management of this entity.

PATIENTS AND METHODS

A retrospective review of all patients with the diagnosis of TD operated on from 1985 to 2002 was performed.

RESULTS

Four cases of papillary TD carcinoma were identified. Two patients were treated by a Sistrunk procedure associated with total thyroidectomy. One patient needed a thyroidectomy fifteen years after the initial management of the papillary thyroglossal duct carcinoma. The last patient had a medical treatment, with no evidence of complication after eleven years of follow up.

CONCLUSION

A microscopic focus of papillary carcinoma, without cyst wall invasion, can be managed by a Sistrunk procedure, with the need for long-term follow up. Treatment of all other thyroglossal duct papillary carcinomas should include thyroidectomy followed by radioactive iodine treatment.

Conformal radiotherapy for paranasal sinus and nasal cavity tumors: three-dimensional treatment planning and preliminary results in 40 patients

PURPOSE

To assess the possibility to deliver a high and homogeneous irradiation with respect to maximal tolerated dose to the visual pathways for paranasal sinus and nasal cavity tumors.

METHODS AND MATERIALS

Forty patients with advanced stage malignant tumors were treated with postoperative (30) or primary (10 patients) conformal radiotherapy (CRT). Five patients were previously irradiated. Six to 15 individually shaped isocentric noncoplanar field arrangements, using a multileaf collimator were designed. Dose-volume histograms (DVH) for the planning target volumes (PTV) and the optic pathways were analyzed in 31 cases.

RESULTS

Median and maximal delivered doses to the PTV were 60 (+/-3) and 66 (+/-4) Gy. Dose distributions for critical organs are detailed. Median follow-up was 19 months (3 to 48). Local, nodal, and metastatic recurrences occurred in 8, 2, and 7 cases, respectively. Major prognostic factor for local recurrences was central nervous system (CNS) involvement. One patient died of meningitis. Two patients developed cataract, and 1 patient ipsilateral blindness due to vascular glaucoma.

CONCLUSION

CRT for locally advanced paranasal sinus and nasal cavity tumors enables the delivery of high homogeneous doses to the PTV with respect to critical organs, with a low toxicity and a high local control.

[Reconstructive subtotal laryngectomy: a personal technique in a series of 100 patients operated on between 1990 and 1997]

Described by Majer and Rieder, modified by Piquet, subtotal laryngectomy with cricohyoidoepiglottopexy (CHEP) allowed to treat intralaryngeal carcinoma with preservation of speech and swallowing. Some modifications were proposed to the procedure to simplify it and to improve functional results. Most important one is the one proposed by Guerrier. In the refined procedure we describe, we didn't do any -pexy to conserved as near as possible from normality morphology and physiology of pharyngolaryngeal unit. Dynamics is preserved by keeping jointly the laryngotracheal tract. In addition, we avoid doing a tracheotomy. We present the functional outcome of 100 patients treated between 1990 and 1997: oral feeding was initiated at the 6th day postoperative, delay to achieve proper swallowing was 11.5 days and median hospitalization duration was 18 days (14 days for non tracheotomized group). The comfort of patients without tracheotomy was greatly increased with a low risk of pneumonia. Such a procedure could be applied every time a laryngeal reconstruction had to be done (partial laryngectomy, laryngeal trauma).

Carcinoma of the oesophagus. Anastomotic leaks after manual sutures--incidence and treatment

Progress in the development of suture materials results in a lower rate of fistulas. Modern techniques for the diagnosis of leakage (contrast study, CT-scan) allow for an early diagnosis and adequate therapy: if possible conservative therapy with drainage of the abscess, adapted antibiotic therapy and parenteral and enteral nutrition are the best methods. In the case of necrosis of the transplant, reoperation permits enables extra time for reconstruction. All the technical possibilities of reconstruction must be known. It is necessary to apply prophylactic precautions to avoid leakage of the anastomosis on the oesophagus.

Self-expanding metal stents for the management of bronchial stenosis and bronchomalacia after lung transplantation

BACKGROUND

Airway stenosis or malacia after lung transplantation, usually as a result of anastomotic ischemia, remains a major problem.

METHODS

The authors report their experience with the Gianturco expandable stent for the management of 23 bronchial stenoses in 18 patients following lung transplantation. Stent placement occurred an average of 5.6 months after transplantation.

RESULTS

Stents were well tolerated and produced immediate symptomatic and functional improvement. The mean follow-up after implantation was 21 months (range, 4 to 48 mo). The authors removed five stents by endoscopy and replaced them, and removed one stent entirely. Laser resection was used to control granulomas or partial fibrosis stenosis that occurred in four stents (14.3%) after an average of 4 months. One stent broke but was still in place and effective 32 months later. One patient died of hemorrhage 4 months after stenting.

CONCLUSION

Although it can still be improved, this expandable metal stent is suitable for the treatment of posttransplantation proximal bronchial stenosis.

Salvage brachytherapy of posterior pharyngeal wall squamous cell carcinoma in a previously irradiated area

PURPOSE

Brachytherapy performed in patients with posterior pharyngeal wall carcinoma in a previously irradiated area is evaluated in terms of local control, survival, and complications.

METHODS AND MATERIALS

Between January 1982 and July 1993, 14 patients were treated with interstitial low dose rate brachytherapy alone for posterior pharyngeal wall squamous cell carcinoma in a previously irradiated area (local recurrences in five cases and second tumors in nine cases). Tumor size ranged from 1 to 4 cm. No patient had a macroscopic nodal involvement or metastase at the time of diagnosis. Median dose delivered was 55 Gy (39 to 60 Gy).

RESULTS

Thirteen patients were assessed for local control. Twelve of them achieved complete macroscopic response within 2 months after brachytherapy. Local relapse occurred in five patients, from 5 to 29 months after brachytherapy. One patient developed distant metastatis without loco-regional relapse. Disease free survival was 69, 59, and 37% at 1, 2, and 5 years, respectively; overall survival was 78, 50, and 21% at 1, 2, and 5 years, respectively. Three patients were still alive without recurrence (8, 8, and 10 years after treatment). We did not observe any severe acute or delayed toxicity.

CONCLUSION

Based on these results, interstitial brachytherapy should be considered as a potentially curative treatment for selected patients with posterior pharyngeal wall squamous cell carcinoma in a previously irradiated area. There are no reports in the literature on this subject.

[Glomangioma: an unusual ethmoid-nasal tumor]

Glomus tumors are benign vascular tumors usually located in the fingertip dermis. Extracutaneous glomus tumors are extremely rare. A new case of sino-nasal glomangioma is reported and both clinical and histological features and biological behavior of glomus tumors in this exceptional site are described.

[Contribution of chemotherapy in the treatment of cancer of the cavum (UCNT): apropos of 47 cases]

The authors present, from a 47 patients retrospective study, the place of BAC chemotherapy in the treatment of undifferenciated nasopharyngeal carcinoma. Twenty three patients treated with exclusive radiation therapy are compared with 24 patients treated with three courses of BAC chemotherapy prior to and after radiation therapy. The procedure using associated chemotherapy permits to increase the 5 years survival rate up to 20% more and to obtain a 100% primary response of the tumor. This encouraging results should be confirmed by a prospective randomized study about a great number of patients.