Prospective comparison of FDG and FET PET/CT in patients with head and neck squamous cell carcinoma.

AIM: The clinical usefulness of 2-deoxy-2-[F-18]fluoro-D-glucose-positron emission tomography (FDG-PET) in head and neck squamous cell carcinoma (HNSCC) is now well-documented. However, its sensitivity is greater than its specificity due to false-positive results in inflammatory or infectious lesions, which are frequent in this area, in particular after treatment by surgery and/or radiotherapy. O-2-fluoro-(18F)-ethyl-L-thyrosine (FET) has been reported not to be taken up by such lesions, and a preliminary study indicated that this may be clinically useful in HNSCC. We performed a prospective study to compare the diagnostic performances of FDG and FET PET/CT in the different settings of HNSCC. MATERIALS AND METHODS: Twenty-seven patients (20 men and seven women, aged 48-76, among 30 patients included) and 69 suspected cancer sites are now evaluable on basis of postsurgical histology and/or follow-up greater than 6 months; 15 patients were referred for initial staging and 12 during posttherapy follow-up, a recurrence being suspected in eight of them. FDG and FET PET/CT were performed on two different days, the patient fasting for 6 h, 1 h after injection of 5 MBq/kg of body mass of each radiopharmaceutical. Both PET/CT examinations were blind read more than 6 months after the end of inclusions in a random order for each tracer and with a time interval greater than 1 month between FDG and FET PET/CT blind readings. RESULTS: Overall diagnostic performances, derived from blind reading: FDG PET/CT on a per patient basis: sensitivity 100%, specificity 71%, accuracy 93%; FDG PET/CT on a per site basis: sensitivity 95%, specificity 63%, accuracy 83%; FET PET/CT on a per patient basis: sensitivity 70%, specificity 100%, accuracy 78%; FET PET/CT on a per site basis: sensitivity 64%, specificity 100%, accuracy 78%. At site level, sensitivity was significantly greater with FDG (p<0.02) and specificity with FET (p<0.01). The statistical level of significance was not reached at patient level. CONCLUSION: Although its good specificity was confirmed, FET did not appear to be suited as a first-line PET tracer in HNSCC imaging and cannot replace FDG for staging due to insufficient sensitivity. However, it was useful in a few selected cases to favor a wait and see attitude when a FDG+ FET- focus was discovered in patients referred for systematic FDG PET during follow-up. In contrast, second primary cancers should not be ruled out if FDG was clearly positive in the lungs or the digestive tract.

Conservative surgery in T3-T4 pharyngolaryngeal squamous cell carcinoma: an alternative to radiation therapy and to total laryngectomy for good responders to induction chemotherapy.

OBJECTIVE: To evaluate the possibility of preservation of the larynx after neoadjuvant chemotherapy by performing a conservative surgery instead of total laryngectomy initially planned, in patients with previously untreated laryngeal and piriform sinus squamous cell carcinoma (SCC). STUDY DESIGN: Retrospective study. METHODS: A total of 115 patients treated at Tenon Hospital with induction chemotherapy from 1985 to 1995, all with initial indication of radical surgery, were available for the study. The clinical tumor response was evaluated after three cycles of chemotherapy. According to this response, to preserve laryngeal functions, some patients had a modification of the treatment initially planned: radiation therapy essentially for complete responders, and conservative surgery for some partial responders. RESULTS: Of 69 patients with laryngeal cancer, 14 were treated by partial laryngectomy and 19 by radiation therapy; of 46 patients with piriform sinus cancer, 8 were treated by partial surgery and 12 by radiation therapy; the other patients were treated as was initially planned (total laryngectomy with partial pharyngectomy). Overall survival rates, estimated by the Kaplan-Meier method, were not statistically different between the three treatment groups. The laryngeal functions were preserved in 54% of the patients who were alive at 3 years. CONCLUSION: This report is a retrospective study, but these results suggest the possibility of using conservative surgery, instead of initially planned total laryngectomy, for good responders to induction chemotherapy with a small residual tumor.

Osteoradionecrosis of the hyoid bone: a report of 3 cases.

PURPOSE: Osteonecrosis of the hyoid bone is an uncommon disease that has only been described occasionally in the literature. MATERIALS AND METHODS: We report 3 cases of osteonecrosis of the hyoid bone after radiation therapy for carcinoma at various sites in the head and neck region. RESULTS: Imaging computed tomography (CT) scans were performed for all 3 cases and did aid in the diagnosis. In 1 case, a 201thallium scintigraphy and a bone scan (99mtechnetium-diphosphonate) were performed and this confirmed the diagnosis of osteoradionecrosis. CONCLUSION: Osteoradionecrosis of the hyoid bone may be misdiagnosed as recurrent neoplasm. Although recurrent or persistent neoplastic disease must initially be ruled out, it is subsequently important to correctly identify osteonecrosis of the hyoid bone, because its surgical treatment is simple and the prognosis is good.

The "sign of the rising tide" during swallowing fiberoscopy: a specific manifestation of Zenker's diverticulum.

Pooling of secretions in the hypopharynx is a common sign of an impaired upper esophageal sphincter. Until now, no specific manifestation, observed by flexible laryngoscopy, of Zenker's diverticulum has been reported. Direct visualization of the diverticulum can be missed during flexible laryngoscopic examination. In this series of 12 patients with hypopharyngeal diverticulum, we have described a manifestation of Zenker's diverticulum obtained on videofiberoscopy during cream swallowing. We have called it the "sign of the rising tide" because it describes the backup of cream visible in the hypopharynx as a wave after its complete disappearance. Barium swallow study is necessary to confirm the presumptive diagnosis. This relevant manifestation seems to be specific for Zenker's diverticulum, since it is not observed in other upper esophageal sphincter disorders, and it disappears when surgical treatment is successful.

Role of pharyngeal propulsion as an indicator for upper esophageal sphincter myotomy.

Thirty-eight patients with swallowing disorders underwent cricopharyngeal myotomy. The causes of the disorders were muscular in 12 cases, neurologic in 12, cricopharyngeal achalasia in 7, and unknown in 7. Surgery succeeded in 21 patients, gave a partial improvement in 4, and failed in 13. The quality of residual pharyngeal propulsion on clinical, manometric, and radiologic assessment appeared to be a more important predictor of surgical outcome than upper esophageal sphincter relaxation and the major factor in establishing the indications for cricopharyngeal myotomy. Achalasias in the elderly and oculopharyngeal muscular dystrophies had the most favorable outcome.

Laryngeal tardive dyskinesia.

Neuroleptic treatment frequently induces movement disorders, the tardive dyskinesias. These are frequently seen in the orobuccolingual region. Although the beginning of neuroleptic treatment can cause acute dystonia and breathing difficulty, chronic neuroleptic treatment has only rarely been shown to affect the laryngeal musculature. Laryngeal abnormal movements were assessed in 12 patients receiving chronic neuroleptic treatment who showed orobuccolingual abnormal movements. The Abnormal Involuntary Movement Scale was systematically assessed in all patients. Clinical examination revealed that 8 had speech disorders, 8 had breathing difficulties, and 5 had swallowing disorders. Laryngeal endoscopy showed that 10 of the patients had intermittent partial obstruction of the glottis, due to repetitive abnormal adduction of the vocal cords. Percutaneous electromyography of the thyroarytenoid muscles showed spontaneous irregular and prolonged muscular contractions, while the patients were at rest and when speaking. The patients were not aware of these movements. In view of this finding, laryngeal dyskinesia should be considered and studied as a possible side-effect of chronic neuroleptic use.

Safety of preoperative enoxaparin in head and neck cancer surgery.

BACKGROUND: Thromboembolism is a risk in major head and neck cancer surgery patients predisposed to thrombosis. This study was designed to determine whether enoxaparin (a low molecular weight heparin) administered prior to surgery induces perioperative bleeding. METHODS: Forty patients scheduled for major cervicofacial cancer surgery were randomized in a double-blind study to receive either 20 mg enoxaparin or placebo, 12 hours before surgery. Blood losses were measured at the end of surgery and 6 hours later. RESULTS: Bleeding was equal in the placebo group and in the enoxaparin group, with losses of 648 +/- 106 mL and 602 +/- 106 mL (p = 0.76), respectively. Six hours after surgery, blood collected was 159.3 +/- 25.7 mL in the placebo group vs 151.4 +/- 21 mL in the enoxaparin group (p = 0.81). CONCLUSION: Preoperative administration of enoxaparin is safe in head and neck cancer surgery, but further studies are required to evaluate its efficacy in preventing thromboembolism.

Swallowing disorders in muscular diseases: functional assessment and indications of cricopharyngeal myotomy.

Thirty-four patients with an identified muscular disease were referred to our department for assessment and treatment of swallowing difficulties. Their ages ranged from 16 to 91 years (mean 59). The diagnoses were oculopharyngeal dystrophy in 17 patients, Steinert myotonic dystrophy in 6, mitochondrial myopathies in 4, polymyositis in 3, and other types in 4 patients. The main consequences of the dysphagia were weight loss (12 patients), pulmonary infections (15 patients), modified food consistency (18 patients) and non-oral feeding (3 patients). Several techniques were used to assess the different stages of deglutition: physical examination during swallowing, videofluoroscopy, pharyngoesophageal manometry, videofibroscopy of the pharynx during swallowing. Major pathological features found in the pharynx were decreased pharynx peristaltis and impaired UES relaxation. Cricopharyngeal myotomy was performed in 11 myopathic patients (median follow-up 24.9 months), while it was unnecessary, refused or contraindicated in the other patients. The procedure was successful in 8 patients whose dysphagia was dramatically improved, and failed in 3 patients. Pharyngeal perstaltis was severely impaired only in the 3 failures and was partly preserved in the improved cases. We conclude that pharyngeal function is the major prognostic factor. Cricopharyngeal myotomy is an effective treatment in those cases where cricopharyngeal dysfunction is a predominant problem or where pharyngeal peristaltis is partly impaired, since the procedure removes one obstacle. It is contraindicated when pharynx propulsion is severely impaired.

Postneuroleptic laryngeal dyskinesias: a cause of upper airway obstructive syndrome improved by local injections of botulinum toxin.

We report a case of laryngeal dyskinesia resulting in severe rest and exercise dyspnea. A 51-year-old man treated for 2 years with flupentixol, an incisive neuroleptic, developed severe dyspnea due to intermittent, rhythmic, and dystonic movements of the vocal cords and upper airway. Local injections of botulinum toxin resulted in spectacular regression of laryngeal spasms and major improvement in breathing. This case emphasizes the risk of upper respiratory dyskinesias associated with neuroleptic treatment and shows the feasibility of a new local treatment in this life-threatening disorder.

[Deglutition disorders in Lyme disease with severe neurological involvement]. / Troubles de la déglutition au cours d'une maladie de Lyme avec atteinte neurologique grave.

A 67-year old man consulted for dysphagia to solid food and weight loss. Four years earlier he had developed Lyme disease with severe neurological involvement. Magnetic resonance imaging showed, on T2-weighted sequences, multifocal high-intensity signals located in the periventricular white matter and the brain stem. The disorders of deglutition were evaluated by cineradiography and manometry which showed deficient relaxation of the superior esophageal sphincter and delayed initiation of the pharyngeal phase; intrapharyngeal propulsion was preserved. On the basis of these findings cricopharyngeal myotomy was performed with subsequent improvement of the disorders. Treatment with doxycycline was prescribed. The significance of these deglutition disorders as regards infection and neurology is discussed and it should have therapeutic implications.

[Abnormal movements of the larynx. Diagnostic approach and therapeutic perspectives]. / Les mouvements anormaux du larynx. Approche diagnostique et perspective thérapeutique.

Laryngeal movement disorders of neurological cause are actually misunderstood. In the course of chorea, or tardive post neuroleptic dyskinesia, vocal, swallowing for threatening breathing troubles could occur. Ten patients with generalized dyskinesias were studied by endoscopy with flexible laryngoscope and laryngeal electromyogram. Four of them were choreic and six had tardive dyskinesia (one had a severe breathing disorder). Nine patients had abnormal movement disorders (MD) involving intrinsic laryngeal musculature. MD were spontaneous or were triggered by vocalization. These facts suggest that dyskinesia as they involved the upper airway tract could be life threatening. Laryngeal electromyography is a useful method for diagnosis and treatment of these dyskinesia. As in spasmodic dysphonia, botulinum toxin could be helpful in this local treatment.

[Mega-dolicho carotid arteries. Role of non-invasive imaging. Apropos of 3 clinical cases]. / Mégadolicho-artères carotidiennes. Place de l'imagerie non invasive. A propos de trois cas cliniques.

Three cases of aberrant (elongated and tortuous) carotid arteries of the neck are reported. In 2 patients the carotid artery abnormalities were discovered at diagnostic work-up for: 1) sudden deafness, 2) persistent pharyngeal discomfort. Both patients presented a pulsating bulge in a pharyngeal wall with no lesion of the mucosa. In the third patient, the arterial abnormality was a peroperative discovery. All patients presented factors of risk for vascular disease. In the 2 symptomatic patients, Doppler U.S. and magnetic resonance imaging made it possible to confirm the diagnosis and to eliminate other vascular or tumoral disorders. The indications and limitations of the various available diagnosis imaging procedures are assessed.

Postlaryngectomy voice restoration. A prospective study in 83 patients.

From July 1985 until May 1990, 83 patients underwent a total laryngectomy. We prospectively studied voice restoration in 81 of them (two died postoperatively). Esophageal voice was used by 19 patients; a tracheoesophageal procedure (myomucosal shunt, primary or secondary puncture with Blom-Singer prosthesis) by 41; and 21 patients had no voice restoration. Results were assessed according to voice quality and usage. Tracheoesophageal speech had a success rate of 73% (good voice, daily use) after 1 month, while esophageal voice proved to have only a 5% success rate. Thirty patients (37%), however, remained without a substitute voice. The reasons for their exclusion are presented; they include a high rate of refusal.

[Upper functional dysphagia. Apropos of 33 cases]. / Dysphagies fonctionnelles hautes. A propos de 33 cas.

Upper functional dysphagia, occurring in the absence of tumoral obstruction, includes swallowing disorders caused by a disturbance of the reflex, velopharyngoesophageal time of deglutition. Thirty-three patients with such disorders have been studied. Fourteen suffered from a neurologic affection (including 4 brainstem tumors and 6 cerebrovascular neurologic disease), 10 from myopathy, 9 from a localized affection of the upper sphincter of the esophagus. Diverticula were excluded from this study. The exploration resorted to fiberendoscopy of esophageal follow-through, pharyngoesophageal manometry, radiocinema, and MRI for some of the latter patients. Cricopharyngeal myotomy was carried out in 16 of these patients, with good results in 10 and failures in 6. The role of the various additional examinations and of myotomy is discussed.

[Vocal restoration by tracheo-esophageal fistula. Evaluation of a 5 years' experience]. / La restauration vocale par procédé de fistule trachéo-oesophagienne. Bilan de 5 années de pratique.

Between december 1985 and august 1990, 70 patients with total laryngectomy had their voice restaured by creation of tracheo-esophageal fistula. The tracheo-esophageal fistula was created during laryngectomy in 33 cases (20 punctures with Blom Singer prostheses, 13 surgical shunts), a few weeks later after surgery of radiotherapy in 17 cases or when production of esophageal voice feld in 20 cases. No major complication was observed. Results following voice recovery were satisfactory in 78.5% of cases (normal voice), one month after the procedure. Results are better when tracheo-oesophageal fistula was used initially (88%), than performed secondary (55%). After one year, results were satisfactory in 75.5% of cases.

[Difficult intubations. A prospective study]. / Les intubations difficiles. Une étude prospective.

A prospective tubing of tracheal tubing in view of general anesthia was performed in 441 adults undergoing scheduled surgery. Before surgery, the anesthesists and ENT specialists tried to independently predict the cases of difficult tubing, according to different criteria. Tubing actually was difficult in 38 patients (8.6ù) instead of the 21 (55.2%) expected by the ENT specialists and/or the anesthesists. These difficulties were solved by bronchoscopy, which allowed tubing to be performed with a guide-probe (3 cas), by scheduled fiberendoscopy (6), tracheotomy (1), nasotracheal tubing (1), spontaneous ventilation (2), and orotracheal tubing in 25 cases. Current knowledge of the predictive criteria is incomplete: anesthesists must be aware of the assistance techniques required in case of difficult tubing in a non-ENT context.

[Perilymphatic fistula]. / Fistule périlymphatique.

Perilymphatic fistulae are the first cause of perceptive deafness that may be amenable to surgical treatment. After a complete study of the literature, we have made a retrospective analysis of 48 ear explorations in 37 children. These children presented with a variable degree of progressive or fluctuating perceptive deafness without any obvious etiology. Computed tomography, especially aimed at detecting an abnormality in the patency of the aqueduct of the cochlea, seems to be the most efficient criterion of selection to establish an indication for surgical exploration. The extent of the perilymphatic fistulae and their location, mainly at the level of the fissura ante fenestram, call to our mind the possibility of an arrest in the differentiation of the otic capsule, with a persistent anomalous patency of the aqueduct of the cochlea. The results of this study mainly demonstrate stabilizations of hearing, while spectacular improvements still are anecdotal. On the other hand, morbidity is very low and mainly results from insufficient surgery to fill in the fistula. Further studies are needed, especially to better understand the pathophysiology of the perilymphatic fistulae, and their results must certainly be appreciated in the longer term.

Low prevalence of cisplatin-induced neuropathy after 4-day continuous infusion in head and neck cancer.

The toxicity of cisplatin on peripheral nerves was studied using electrophysiologic recordings in 52 patients with head and neck squamous cell carcinoma. Induction chemotherapy (cisplatin: 25 mg/m2/day, days 1-4; 5-fluorouracil: 1 g/m2/day, days 1-4) was administered by continuous infusion every 3 weeks. Electrophysiologic recordings were performed before and after the completion of three courses of chemotherapy (cisplatin total dose: 250-300 mg/m2). The comparison between the recordings showed 14% of the patients had an increase in the latency of the soleus muscle monosynaptic reflex as studied by the Hoffman reflex and 9% showed a decrease in the conduction velocity of the cutaneous sensory fibers of the median nerve. These results indicated a low prevalence of cisplatin-induced neuropathy. The respective roles played by the continuous infusion of the drug and by the potentiation of neurotoxic effects resulting from the association of cisplatin with other neurotoxins is discussed to explain this low toxicity.