Long-term speech and swallowing function after primary resection and sentinel node biopsy for early oral squamous cell carcinoma.

OBJECTIVES: Analysis of long-term speech and swallowing function and subjective quality of life (QOL) after primary resection and sentinel node biopsy (SNB) in patients with early stage (cT1/T2) oral squamous cell carcinomas (OSCC). MATERIAL AND METHODS: Eighty-one consecutive patients treated primarily by transoral resection without flap reconstruction and SNB for a cT1/T2 OSCC were included. Completion neck dissection (CND) was indicated in case of occult disease in the sentinel nodes. Adjuvant radiation (aRT) was administered according to the ultimate lymph node status. All patients showed no evidence of disease at time of analysis. Speech and swallowing function were assessed using standardized clinical examinations (11-item, articulation test) and validated questionnaires on subjective QOL (MDADI, FIGS). Median follow-up was 60 months (range 13-159 months) after initial treatment. RESULTS: In all assessments for speech and swallowing, the entire study cohort achieved very high scores, with mean values located in the highest 10% of the scales. Neither tumor size nor site, age, pN-category, CND, and aRT had significant impact on functional outcomes and subjective QOL with the exception of lower scores in the global and physical scores of MDADI after CND or aRT, and articulation in the population over 60 years of age. CONCLUSION: Transoral resection without reconstruction and SNB for early OSCC achieves excellent outcome with regard to speech, swallowing and subjective QOL.

Radiotherapy-induced anti-tumor immune response and immune-related adverse events in a case of recurrent nasopharyngeal carcinoma undergoing anti-PD-1 immunotherapy.

BACKGROUND: Treatment of recurrent nasopharyngeal carcinoma is a challenging clinical problem. We report the case of a 46 year old male showing excellent response and signs of immunostimulation following re-re-irradiation for recurrent nasopharyngeal carcinoma under systemic treatment with pembrolizumab. CASE PRESENTATION: Patient was first diagnosed with locoregionally advanced, non-keratinizing nasopharyngeal carcinoma in 2010. After achieving complete remission following induction chemotherapy and concurrent curative chemoradiation, the patient subsequently developed distant and locoregionally recurrent disease. He received various treatments (neck dissection, radiotherapy to a bony metastasis, palliative chemotherapy, stereotactic re-irradiation of local recurrence) before initiation of anti- PD-1 immunotherapy with pembrolizumab in January of 2016. Following marked local progression 6 months thereafter, we performed re-re-irradiation of the recurrent tumor after careful evaluation and treatment planning. While treatment was well tolerated, the patient subsequently developed marked clinical and radiological signs of immunostimulation with mucosal irritation and swelling of lacrimal and salivary glands as described in the report. Immunotherapy with pembrolizumab was reinitiated, with re- staging showing excellent response with regression of all tumorous lesions. At the time of this report, following near complete recovery of inflammatory symptoms, the patient remains in excellent condition and free from recurrence under treatment with pembrolizumab. CONCLUSIONS: To our knowledge, we report the first observation of a combined effect of immunotherapy and radiotherapy in a patient with recurrent nasopharyngeal carcinoma. Demonstrating distinct signs of immunostimulation as well as excellent tumor response in a heavily pretreated patient progressing under anti-PD-1 immunotherapy, the case adds to the rising paradigm of an immunostimulatory effect of radiotherapy in patients undergoing treatment with immune checkpoint inhibitors.

PD-L1 is a positive prognostic factor in squamous cell carcinoma of the nasal vestibule.

BACKGROUND: Aim was to analyse the role of PD-L1 in squamous cell carcinomas of the nasal vestibule. Advanced squamous cell carcinoma of the nasal vestibule is a highly aggressive tumour. The role of PD-L1 expression is unclear in this tumour type. METHODOLOGY: Forty-six patients diagnosed between 1995 and 2014 were analyzed. Baseline characteristics and outcome were correlated to immunohistochemical staining of PD-L1. PD-L1 positivity of tumour cells and tumour infiltrating immune cells (TIIC) was defined by any staining of more than 1% of the tumour cells. RESULTS: PD-L1 expression was interpretable in 31 of 46 patients (67.4%). PD-L1 positivity was present in 14 (45.2%) patients tumour cells and 17 (54.8%) patients TIIC. PD-L1 positivity of tumour cells was associated with a favourable disease free survival (p=0.019). CONCLUSIONS: Positivity for PD-L1 in tumour cells is a prognostic factor in squamous cell carcinoma of the nasal vestibule and might enable a patient-tailored treatment.

Benefit of 18F-fluorocholine PET imaging in parathyroid surgery.

OBJECTIVES: To assess the additional diagnostic value of 18F-fluorocholine PET imaging in preoperative localization of pathologic parathyroid glands in clinically manifest hyperparathyroidism in case of negative or conflicting ultrasound and scintigraphy results. METHODS: A retrospective, single-institution study of 26 patients diagnosed with hyperparathyroidism. In cases where ultrasound and scintigraphy failed to detect the location of an adenoma in order to allow a focused surgical approach, an additional 18F-fluorocholine PET scan was performed and its results were compared with the intraoperative findings. RESULTS: A total of 26 patients underwent 18F-fluorocholine PET/CT (n = 11) or PET/MRI (n = 15). Adenomas were detected in 25 patients (96.2%). All patients underwent surgery, and the location predicted by PET hybrid imaging was confirmed intraoperatively by frozen section and adequate parathyroid hormone drop after removal. None of the patients needed revision surgery during follow-up. CONCLUSIONS: These results demonstrate that 18F-fluorocholine PET imaging is a highly accurate method to detect parathyroid adenomas even in case of previous localization failure by other imaging examinations. KEY POINTS: • With 18 F-fluorocholine PET imaging, parathyroid adenomas could be detected in 96.2%. • 18 F-fluorocholine imaging is a highly accurate method to detect parathyroid adenomas. • We encourage its use, where ultrasound fails to detect an adenoma.

Multi-slice SPECT/CT vs. lymphoscintigraphy and intraoperative gamma ray probe for sentinel node mapping in HNSCC.

To assess the diagnostic potential of multi-slice single-photon emission computed tomography/computed tomography (SPECT/CT) for preoperative sentinel node (SN) mapping in early stage head and neck squamous cell carcinoma (HNSCC). Retrospective case-control study including data of consecutive HNSCC patients treated between November 2011 and December 2015. The diagnostic accuracy of multi-slice SPECT/CT was assessed with regard to the gold standard intraoperative gamma ray detection probe, using McNemar's test and calculating the area under the ROC curve. Additionally, the hot spot yield of SPECT/CT and planar lymphoscintigraphy (LS) was compared. Compared to the intraoperative gold standard, SPECT/CT showed an overall positive predictive value of 60.3% [confidence interval (CI) 46.6-73.0%)], a negative predictive value of 96.3% (CI 93.6-98.1%), and an accuracy of 90.8% (CI 89.1-92.4%). SPECT/CT detected more hot spots than LS and provided detailed anatomical information as well as relevant additional findings with potential impact on further patient management. Sentinel lymph node biopsy proved to be a reliable and safe procedure with an excellent SN excision rate (97%). Multi-slice SPECT/CT is a highly accurate diagnostic test and matches the gold standard intraoperative gamma ray detection probe.

Pneumo-thorax/mediastinum/(retro)peritoneum/ scrotum - a full house of complications following JET ventilation.

We present a patient who presented to our clinic with airway obstruction secondary to oropharygeal cancer. He underwent emergent tracheostomy with JET ventilation, the latter resulting in a "full house" of barotraumatic complications including pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and pneumo-scrotum. Free air, while sometimes dramatic as in our case, need not always be a cause for alarm and can often be managed expectantly. Our patient was treated with only a chest drain and otherwise made an uneventful recovery.

Extending the limits of reconstructive microsurgery in elderly patients.

BACKGROUND: Population aging strongly affects the demographic development of industrialized countries. While microsurgical procedures were initially believed to be only feasible in patients of younger age because of the duration of the surgical procedure and the higher risk of vascular insufficiency due to age-related comorbidities, it has become evident that these procedures are beneficial even for patients at an advanced age. METHODS: We retrospectively investigated microsurgical procedures in a patient cohort (n = 25 with 27 free flaps) with a minimum age of 78 years with regard to patients' characteristics, flap survival, and postoperative surgical and medical complications. RESULTS: Median age was 81 years (IQR 6). Most defects were located in the head and neck region. The mean operation time was 384 min (standard deviation (SD) 131). Flap failure was observed in three cases (11%). The median length of hospital stay was 17 days (interquartile range (IQR) 8). The mean ASA score was 2.48. Patients' age and ASA group did not correlate. The mortality rate was 4%. Postoperative surgical complications were observed in 11 cases (41%), while 19 patients (70%) showed one or more medical complications. Higher ASA classes tended to show more postoperative complications. However, neither age nor operating time nor ASA status showed significant influence on the occurrence of postoperative medical or surgical complications. CONCLUSION: There is growing demand for structural and functional restoration using free tissue transfer in an aging population. If there are no alternative treatment options available promising similar structural and functional preservation, free tissue transfer is justifiably in very old patients despite a potentially increased flap failure. As such, free tissue transfer is used as a curative treatment concept aiming at a maximum of patients' independence and early ambulation. Occurrence of complications can be diminished by adequate patient selection and thorough perioperative care.

No benefit for regional control and survival by planned neck dissection in primary irradiated oropharyngeal cancer irrespective of p16 expression.

The aim of the study was to assess regional control and survival in primary irradiated oropharyngeal cancer patients with advanced neck disease (≥cN2a) receiving planned neck dissection (PND) irrespective of the nodal response compared to salvage neck dissection (SND) in case of regional persistence or reccurence in relation to tumoral p16 overexpression. 96 consecutive patients treated at the University Hospital of Zurich, Switzerland were included. Tissue microarray-based scoring of p16 expression was obtained. 5 years overall (OS) and disease-specific survival (DSS) in the PND and SND cohort were 70 vs. 57 % (p = 0.20) and 80 vs. 65 % (p = 0.14), respectively. Regional control in PND and SND achieved 95 vs. 87 % (p = 0.29), respectively. There was no statistically significant impact of neck treatment (PND vs. SND) on regional control or survival among patients with p16-negative tumors (5 years OS 59 vs. 50 %, p = 0.66; 5 years DSS 59 vs. 57 %, p = 0.89) nor among patients with p16-positive tumors (5 years OS 84 vs. 67 %, p = 0.21; 5 years DSS 95 vs. 81 %, p = 0.24). The type of neck dissection after primary intensity-modulated radiotherapy (IMRT) had no impact on regional control and survival even in human papillomavirus (HPV)-associated disease. Therefore we are convinced that based on the accuracy of newer diagnostic modalities the surveillance of a radiologically negative neck after primary chemoradiation (CRT) is oncologically safe irrespective of p16 expression of the tumor.

Multilocular sinonasal malignant melanoma: a poor prognostic subgroup?

Clinical observations show that two subtypes of sinonasal malignant melanoma exist: uni- and multilocular melanoma. The aim of this retrospective study was to determine the prevalence and outcome of multilocular sinonasal malignant melanoma. All patients with sinonasal malignant melanoma treated at our institution between 1992 and 2011 were included. Survival and recurrence data were analyzed related to the distribution pattern of the tumors and other factors. Twenty-five patients were identified and included in the analysis. Seven patients (28 %) suffered from multilocular, the remaining 18 patients (72 %) from unilocular sinonasal malignant melanoma. The first group showed a significantly worse disease-free survival, whereas disease-specific and overall survival did not differ between the two subtypes. Multilocular sinonasal malignant melanoma is associated with an unfavorable disease-free survival compared to its unilocular counterpart.

[Total thyroidectomy in patients with amiodarone-induced hyperthyroidism: when does the risk of conservative treatment exceed the risk of surgery?]. / Totale Thyreoidektomie bei amiodaroninduzierter Hyperthyreose: Wann übersteigt das Risiko der konservativen Therapie das Risiko der chirurgischen Behandlung?

Amiodarone plays a pivotal role in the treatment of ventricular and supraventricular arrhythmias. However, amiodarone-induced hyperthyroidism (AIH) is one of the most feared complications, which necessitates interdisciplinary treatment and careful balancing of the risks of conservative treatment against those of total thyroidectomy. In this article we discuss the pharmacological aspects of amiodarone and its diverse effects on the thyroid. Furthermore, we present diagnostic and therapeutic strategies and report our positive experiences with total thyroidectomy in patients with AIH. Particularly in patients for whom continuation of amiodarone treatment is compulsory, a well-timed total thyroidectomy is a reliable therapeutic option, with minimal complication rates and immediate amelioration of symptoms.

Merkel cell carcinoma of the head and neck: a single institutional experience.

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy occurring mostly in older immunocompromized Caucasian males. A growing incidence of MCC has been reported in epidemiological studies. Treatment of MCC usually consists of surgical excision, pathological lymph node evaluation, and adjuvant radiotherapy. This paper reports the experience of a single tertiary center institution with 17 head and neck Merkel cell carcinoma patients. Median followup for the cohort was 37.5 months. After five years, recurrence-free survival, disease specific survival, and overall survival were 85%, 90%, and 83%, respectively. Our limited data support the use of adjuvant radiotherapy. We also report two cases of MCC located at the vestibule of the nose and two cases of spontaneous regression after diagnostic biopsy. About 40% of our patients were referred to our center for surgical revision and pathological lymph node evaluation. Increased awareness of MCC and an interdisciplinary approach are essential in the management of MCC.

High sex determining region Y-box 2 expression is a negative predictor of occult lymph node metastasis in early squamous cell carcinomas of the oral cavity.

BACKGROUND: The transcription factor sex determining region Y (SRY)-box 2 (SOX2) (3q26.3-q27) has been recently identified as a recurrently activated major oncogene in squamous cell carcinoma of various sites. Its prognostic value in head and neck squamous cell carcinoma (HNSCC) is currently unclear. AIM: To correlate SOX2 protein expression with the occurrence of occult lymph node metastasis and relapse free survival in early oral SCC. METHODS: SOX2 expression in 120 T1/T2 oral SCC patients was evaluated using a tissue microarray technique. Intensity of SOX2 expression was quantified by assessing the Intensity/Reactivity Scores (IRSs). These scores were correlated with the lymph node status of biopsied sentinel lymph nodes and recurrence. Log rank univariate and Cox regression multivariate analysis was used to determine statistical significance. RESULTS: Twenty-six of 120 primary tumours (21.7%) showed high SOX2 expression. High expression levels of SOX2 significantly correlated with negative lymph node status in univariate (p=0.001) and multivariate analysis (p=0.003). Sensitivity was found to be 95.6% with a negative predictive value of 92.3%. Specificity was 32% with a positive predictive value of 45.7%. CONCLUSION: SOX2 up-regulation is frequent in early SCC of the oral cavity and associated with decreased risk of lymphatic metastasis. SOX2 immunohistochemistry may be used as a predictor for lymph node metastasis in squamous cell carcinoma of the oral cavity.

The value of 18F-FDG-PET/CT imaging for sinonasal malignant melanoma.

The aim this study was to evaluate imaging findings using position emission tomography (PET) in combination with computed tomography (CT) and 18F-fluorodeoxyglucose ((18)F-FDG) in sinonasal malignant melanoma (SNMM) of the head and neck in a retrospective analysis of a consecutive cohort of patients. (18)F-FDG-PET/CT examinations were performed for initial staging and compared with CT or magnetic resonance tomography (MRI), and (18)F-FDG-PET alone. Medical records were reviewed retrospectively with regard to the location and the size of the tumor. Furthermore, locoregional and distant metastases with a consecutive change in therapy detected by (18)F-FDG-PET/CT were assessed. Ten patients suffering from sinonasal malignant melanoma were staged and followed by (18)F-FDG-PET/CT imaging. A total of 34 examinations were obtained. (18)F-FDG-PET/CT depicted all primary tumors adequately. Aside from one cerebral metastasis all regional and distant metastases were truly identified by using this method. In summary, if available, (18)F-FDG-PET/CT is a valuable imaging modality for staging and re-staging sinonasal malignant melanoma to evaluate expansion of the primary tumor, locoregional disease, and distant metastases.

Improved treatment outcomes with (18) F-FDG PET/CT for patients with advanced head and neck squamous cell carcinoma.

BACKGROUND: The aim of this study was to assess the impact of (18) F-fluoro-2-deoxy-D-glucose ((18) F-FDG) PET/CT on survival for patients with head and neck squamous cell carcinoma correlated with a matched patient cohort. METHODS: In all, disease in 58 patients was initially staged using (18) F-FDG PET/CT. A case-control analysis was done with 63 patients who disease was staged without (18) F-FDG-PET/CT. RESULTS: Disease-specific survival (DSS) and overall survival (OS) did not show significant differences between both groups. Statistical analysis revealed no difference in DSS and OS between the 2 groups for patients treated by radiochemotherapy (p = .975 and p = .671). In the analysis of survival in patients treated by a combined approach (surgery + radiochemotherapy), a significant difference in favor of patients evaluated by (18) F-FDG PET/CT was found (p = .05 and p = .027). CONCLUSIONS: Addition of (18) F-FDG PET/CT in patients treated by surgery and conformal radiochemotherapy improves outcome. This may be due to the more comprehensive topographic orientation of the primary tumor for the surgeon.

Is there a correlation between 18F-FDG-PET standardized uptake value, T-classification, histological grading and the anatomic subsites in newly diagnosed squamous cell carcinoma of the head and neck?

UNLABELLED: (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET)/CT imaging of squamous cell carcinoma of the head and neck (HNSCC) renders the possibility to study metabolic tumor activity by measuring FDG-uptake expressed as maximum standardized uptake value (SUV(max)). A correlation between SUV(max) and several factors including T-classification, histological tumor differentiation or different anatomic subsites is of potential interest in HNSCC. The aim of this study was to evaluate how metabolic tumor activity derived from FDG-PET correlates with prognostic clinical and pathological parameters including these factors. 262 patients with HNSCC undergoing PET/CT for initial staging were assessed separately for a potential correlation between SUV(max) and T-classification, histological grading, and anatomical subsites of the primary tumor. Nonparametric testing showed a significant correlation between SUV(max) and T-classification (P < 0.001). On the contrary, no statistically significant correlation was found between SUV(max) and histological tumor grading. Furthermore, no statistical significant correlation between the different anatomical subsites and SUV(max) were found. There was no significant correlation of SUV(max) and tumor grading after adjustment for T-stage and anatomical localization of the tumor, neither. CONCLUSION: Metabolic tumor activity correlates with T-stage of HNSCC. However, histological tumor grading does not correlate with SUV(max). The role of primary tumor SUV(max) as a predictor of outcome or survival remains unclear. Clinicians should therefore exercise caution in attributing any clinical importance to SUV(max) obtained from a single PET/CT exam.

[Sialolipoma of the parotid gland]. / Sialolipom der Glandula parotis.

Sialolipoma is a relatively new and rare variant of lipoma of the salivary glands characterized by the combination of classical lipoma morphology with non-neoplastic ductulo-acinary salivary tissue components. Including the presented case, 27 sialolipomas, 14 of them localized in the parotid gland, have been published. We describe the clinical, radiological and pathomorphological characteristics of a parotid sialolipoma in a 43-year-old man.

[Differential diagnosis of groin pain: isolated, symptomatic dissection of the infrarenal aorta and iliac arteries]. / Zur Differentialdiagnose des Leistenschmerzes: die isolierte, symptomatische Dissektion der infrarenalen Aorta und Beckenarterien.

INTRODUCTION: Pelvic and inguinal pain are a rare manifestation of arterial disease. METHODS: Description of four patients with acute or chronic pelvic or inguinal pain due to symptomatic dissection of the infrarenal aorta and/or iliac arteries. RESULTS: In two cases the dissection was limited to the left iliac artery with an entry at the beginning of the common iliac artery. The re-entry was located in the distal external iliac or common femoral artery. In one patient additionally a infrarenal abdominal aortic aneurysm was found. In the other two patients the entry of the spontaneous dissection was in the position of the infrarenal aorta, with extension in one iliac artery. In two patients the diagnosis of Erdheim-Gsell media necrosis was histologically confirmed. CONCLUSIONS: Spontaneous arterial dissection should be considered in patients with pelvic or inguinal pain. Absence of thoracic symptoms is possible if the entry of the dissection is distal, within the infrarenal aorta or iliac arteries. Prompt diagnosis with duplex sonography, CT, arteriography or MRA is indicated. The type of reconstruction depends on the extent of the dissection and the concomitant arterial disease.