Survival After Distant Metastasis in Head and Neck Cancer.

BACKGROUND/AIM: In addition to locoregional recurrence distant metastases can limit the survival of patients with head and neck cancer. The aim of the study was to analyze survival after distant metastasis of head and neck cancer. PATIENTS AND METHODS: Patients with head and neck cancer and M0 status at initial diagnosis, who were treated with curative intent but developed distant metastases without synchronous locoregional recurrence were analyzed. Predictors for the duration of survival were evaluated using Cox regression analysis. RESULTS: A total of 46 patients developed distant metastases which were detected after a mean time of 16 months, most were lung (59%) and bone metastases (24%). The most common therapy for distant metastasis was palliative chemotherapy; due to poor general condition, 21% of patients were treated with best supportive care. The mean survival was 7.5 months, the overall survival at 1 and 2 years after diagnosis of distant metastasis were 40.4% and 26.2%, respectively. Regression analysis showed no significant predictors for prolonged survival, however, the three patients surviving at the time of data collection were treated by surgical resection of solitary metastases. CONCLUSION: In cases of distant metastases, due to poor prognosis of the patients, palliation is important and the treatment approach should be chosen taking into account the general condition of the patient. In individual cases, resection of solitary metastases may be useful.

Localization and treatment of lingual venous and arteriovenous malformations.

Venous and arteriovenous malformations of the tongue can cause haemorrhage, airway obstruction, difficulties in chewing and swallowing, speech problems as well as orthodontic abnormalities. The purpose of the present study was to evaluate their exact topography, clinical features, morphologic aspects and management. A retrospective review on all patients with venous and arteriovenous malformations of the tongue who presented between 1998 and 2010 was performed. Medical records were analysed with respect to age and sex distribution, exact localization, symptoms and clinical presentation, management and treatment outcome. Forty-four patients with tongue malformations were analysed. The malformations affected all areas of the tongue as well as the base of the tongue without predilection areas. Nd:YAG laser and CO2 laser therapy provided good results primarily in localized malformations, while in advanced malformations the management was multi-modal since a complete surgical excision was often impossible. The hypothesis that vascular malformations of the tongue occur more frequently along the course of the feeding vessels cannot be confirmed. The therapeutic approach is determined by the exact topography, haemodynamic properties, morphologic aspects and related clinical symptoms as well as patient-specific features.

Incurable recurrences in patients with oropharyngeal and hypopharyngeal carcinomas.

BACKGROUND: Carcinomas of the oropharyngeal and hypopharynx are difficult to treat because of their aggressive tendency to metastasize and their high recurrence rate. METHODS: A retrospective review of 79 patients with recurrences of oropharyngeal or hypopharyngeal carcinomas was performed. The courses of disease from recurrence diagnosis to the valuation date or death were analyzed. RESULTS: The median survival for patients classified as incurable at recurrence diagnosis amounted to 8 months (95% confidence interval [CI], 5-10 months), patients initially classified as curable at the time of recurrence diagnosis survived an estimated 12 months (95% CI, 8-22 months). No significant differences regarding the survival after diagnosed recurrence could be observed depending on the tumor location or tumor stage. CONCLUSION: The knowledge about the courses of disease and especially the remaining lifetime after diagnosed incurability could facilitate the planning of the remaining lifetime in order to achieve the best possible quality of life.

Visualisation of the Bonebridge by means of CT and CBCT.

BACKGROUND: With the Bonebridge, a new bone-anchored hearing aid has been available since March 2012. The objective of the study was to analyse the visualisation of the implant itself as well as its impact on the representation of the bony structures of the petrosal bone in CT, MRI and cone beam CT (CBCT). METHODS: The Bonebridge was implanted unilaterally in two completely prepared human heads. The radiological imaging by means of CBCT, 64-slice CT, 1.5-T and 3.0-T MRI was conducted both preoperatively and postoperatively. The images were subsequently evaluated from both the ENT medical and nd radiological perspectives. RESULTS: As anticipated, no visualisation of the implant or of the petrosal bones could be realised on MRI because of the interactive technology and the magnet artefact. In contrast, an excellent evaluability of the implant itself as well as of the surrounding neurovascular structures (sinus sigmoideus, skull base, middle ear, inner ear, inner auditory canal) was exhibited in both the CT and in the CBCT. CONCLUSION: The Bonebridge can be excellently imaged with the radiological imaging technologies of CT and CBCT. In the process, CBCT shows discrete advantages in comparison with CT. No relevant restrictions in image quality in the evaluation of the bony structures of the petrosal bones could be seen.

Localization of lymphatic malformations of the neck.

BACKGROUND: The head and neck region is the most common site for lymphatic malformations. The aim of the present study was to analyze the exact localizations of lymphatic malformations of the neck. METHODS AND RESULTS: The patients' charts of 48 patients with lymphatic malformations of the neck were retrospectively analyzed regarding gender, age at diagnosis, age at initial presentation, morphologic type, size, and localization. The median age of the patients at presentation was 11.9 years. Macrocystic malformations were observed in 13 patients (27%), mainly in the lateral neck. Microcystic lesions occurred in 22 patients (46%), predominantly in the floor of mouth. Mixed lymphatic malformations occurred in 13 patients (27%) without a preferred localization. The morbidity of patients with microcystic and mixed lesions was higher than of patients with macrocystic lymphatic malformations. CONCLUSION: The cause for the different localization of microcystic and macrocystic lymphatic malformations is still not clarified. One reason may is the different structure of the surrounding connective tissue, which is compact in the floor of mouth and loose in the neck lateral neck so that macrocystic cysts can arise. Maybe both types of malformation have a different etiology. However, this will have to be clarified in further studies.

Lymphatic malformations of the orbit.

OBJECTIVES: Lymphatic malformations of the orbit are rare lesions that constitute approximately 1% to 8% of all orbital masses. They are difficult to treat since they do not remain within anatomic boundaries and tend to penetrate into normal orbital structures. The aim was to analyze clinical courses and therapy options in patients with lymphatic malformations of the orbit. METHODS: Thirteen patients with orbital lymphatic malformations confirmed by magnetic resonance imaging between 1998 and 2009 were enrolled in this study. Patients' charts were retrospectively reviewed to analyze clinical courses and treatment options. RESULTS: Four patients suffered from isolated intraorbital lymphatic malformations without conjunctival involvement, in three of them the masses were completely resected, in one patient close controls were performed. Three patients had isolated intraorbital lymphatic malformations with conjunctival involvement. Surgical volume reduction of the exterior parts of the lymphatic malformation were performed without any complications and satisfying outcome in these cases. Six patients suffered from intra- and periorbital lymphatic malformations. In 3 patients a watch-and-wait strategy was initiated. In the other 3 patients a surgical therapy was performed, one patient additionally received sclerotherapy with OK-432; however, these 3 patients suffered from residual lymphatic malformations. CONCLUSION: The presented cases underline the inconsistencies in the malformations behavior and underscore the inability to make specific recommendations regarding treatment. The treatment decision should be based on the size and location of the lymphatic malformation. The untreated patient must be watched for signs of visual detoriation, which may signal the need for therapeutic intervention.

Interstitial HDR brachytherapy for advanced recurrent squamous cell carcinoma of the head and neck.

BACKGROUND: Surgical treatment remains the mainstay therapy for recurrence of head and neck cancer after previous radiotherapy. In inoperable cases, interstitial high-dose rate brachytherapy is a treatment option for local dose escalation. PATIENTS AND METHODS: A retrospective analysis of all patients who were treated solely with brachytherapy for advanced non-resectable recurrences of squamous cell carcinomas of the head and neck and who previously received radiotherapy was performed. RESULTS: A total of 12 patients with advanced recurrences were treated with interstitial brachytherapy with a fraction dose of 2-3 Gy and a total focal dose of 20-33 Gy. The shortest survival after brachytherapy was 4 weeks. The longest clinical course without evidence of local recurrence is 4 years and 11 months. CONCLUSION: In selected cases brachytherapy can be used as the last-line or palliative therapy for patients with advanced recurrence head and neck carcinomas. Possible complications and the reduction of quality of life due to tracheostomy should be considered.

Risk of lymph node metastases after en bloc cold steel, en bloc laser-, and piecemeal laser surgical resection of auricular VX2 carcinoma.

There is some controversy in the literature if lymph vessels are enduring sealed during piecemeal CO2 laser surgery of squamous cell carcinomas of the head and neck or a propagation of tumor cells into the lymphatics occurs. The aim of the present study was to analyze the incidence of lymph node and distant metastases after different methods of resection of a VX2 carcinoma in an animal model. A solid auricular VX2 carcinoma was induced in 200 rabbits. Seven days later, an en bloc cold steel (group A), en bloc laser surgical resection with CO2 laser in continuous wave mode with 2 W (group B), or piecemeal laser surgical resection after transection of the tumor with CO2 laser in continuous wave mode with 2 W (group C) or 20 W (group D) was performed. The animals were killed and the incidence of lymph node and distant metastases was compared between the different groups. Of the rabbits, 21.1 % developed lymph node metastases and 10 % pulmonary metastases. The incidence of lymph node metastases was 17.4 % in group A, 20.4 % in group B, 26 % in group C, and 20 % in group D. These differences were not statistically significant. En bloc cold steel, en bloc laser-, or piecemeal laser surgical resections include similar risk of postoperative metastases. Propagation of tumor cells cannot be excluded with certainty by any of these methods.

Age-dependent differences of the anterior skull base.

OBJECTIVE: Imaging of the anterior skull base and paranasal sinuses is essential before surgery of the nose and paranasal sinuses. It is important to know individual anatomical variations to define a "dangerous ethmoid" to prevent complications such as considerable bleeding or injury to the brain. This study aimed to analyze the relevant parameters with special regard to age-dependent differences. METHODS: This was a retrospective, single center study of 865 patients. Data from cone beam computed tomography (CBCT) of 116 patients less than 18 years of age and 749 adult patients were analyzed. Keros type, the course of the anterior ethmoid artery, the course of the uncinate process and the angle between the lateral lamella and the cribriform of the olfactory fossa were evaluated. RESULTS: Different frequencies of the course of the uncinate process between young and adult persons could be shown: onset at the lamina papyracea 67% vs. 64%; onset at the skull base, 22% vs. 26%; and onset at the middle turbinate, 11% vs. 10%. Differences in the course of the anterior ethmoid artery could be evaluated in the same way: course at the skull base, 49% vs. 44%; free course with a distance to the skull base of less than 3mm, 11% vs. 19%; and free course with a distance to the skull base more than 3mm, 40% vs. 37%. Significant differences could be found in the frequencies of the height of the olfactory fossa: Keros type I, 28% vs. 16%; Keros type II, 51% vs. 60%; and Keros type III, 21% vs. 24%. The angle between the lateral lamella and the cribriform plate showed significant differences dependent on the course of the anterior ethmoid artery (skull base=123° vs. distance<3mm=117° vs. distance>3mm=110°) and dependent on the height of the olfactory fossa (Keros type I=135° vs. Keros type II=117° vs. Keros type III=104°). Analysis of the angle as a factor of age and Keros type showed a significant difference in Keros type I (125° vs. 132°) and Keros type II (105° vs. 110°). CONCLUSION: Cone beam computed tomography (CBCT) of the anterior skull base allows the assessment of individual anatomical-radiological risk profiles and the identification of a "dangerous ethmoid". Significant age-dependent differences in the frequencies of anatomic landmarks and the angles of the ethmoid roof could be evaluated and led to significantly different risk profiles between children and adults.

Prevalence of level V metastases in node-positive head and neck squamous cell carcinoma.

BACKGROUND: The dissection of level V neck lymph nodes often results in a decline of postoperative quality of life due to shoulder dysfunction and pain. The necessity of level V dissection is debatable. The aim of the present study was to evaluate the prevalence of level V metastases in patients with node-positive squamous cell carcinomas of the head and neck. PATIENTS AND METHODS: A review of the clinical and pathological reports was conducted to ascertain the prevalence and distribution of cervical metastases according to neck level V. Statistical analysis was performed using Fisher's exact test. RESULTS: Level V metastases were found in 19 out of 104 (18.3%) patients. There was only one patient with level V metastases without involvement of other levels. There was no statistically significant correlation between level V lymph node metastasis and several clinical factors. CONCLUSION: It seems to be feasible to omit dissection of level V in patients without clinical evidence for level V disease without compromising oncological safety.

Combined inhibitors of angiogenesis and histone deacetylase: efficacy in rat hepatoma.

AIM: To evaluate the antitumoral effect of combined inhibitors of angiogenesis and histone deacetylases in an experimental rat hepatoma model. METHODS: MH7777A hepatoma cells were injected into the liver of male Buffalo rats. After 7 d treatment with the vascular endothelial growth factor receptor antagonist PTK787/ZK222584 (PTK/ZK), the histone deacetylase inhibitor MS-275, tamoxifen (TAM) and/or retinoic acid was initiated (n ≥ 8 animals/group). Natural tumor development was shown in untreated control groups (control 1 with n = 12, control 2 with n = 8). The control groups were initiated at different time points to demonstrate the stability of the hepatoma model. For documentation of possible side effects, we documented any change in body weight, loss of fur and diarrhea. After 21 d treatment, the rats were euthanized. Main target parameters were tumor size and metastasis rate. Additionally, immunohistochemistry for the proliferating cell nuclear antigen (PCNA) and TdT-mediated dUTP-biotin nick end labeling (TUNEL) assay were performed. RESULTS: The control groups developed large tumor nodules with extrahepatic tumor burden in the lung and abdominal organs (control 1: 6.18 cm(3) ± 4.14 cm(3) and control 2: 8.0 cm(3) ± 4.44 cm(3) 28 d after tumor cell injection). The tumor volume did not differ significantly in the control groups (P = 0.13). As single agents MS-275 and PTK/ZK reduced tumor volume by 58.6% ± 2.6% and 48.7% ± 3.2% vs control group 1, which was significant only for MS-275 (P = 0.025). The combination of MS-275 and PTK/ZK induced a nearly complete and highly significant tumor shrinkage by 90.3% ± 1% (P = 0.005). Addition of TAM showed no further efficacy, while quadruple therapy with retinoic acid increased antitumoral efficacy (tumor reduction by 93 ± 1%) and side effects. PCNA positive cells were not significantly reduced by the single agents, while dual therapy (MS-275 and PTK/ZK) and quadruple therapy reduced the PCNA-positive cell fraction significantly by 9.1 and 20.6% vs control 1 (P < 0.05). The number of TUNEL-positive cells, markers for ongoing apoptosis, was increased significantly by the single agents (control 1: 6.9%, PTK/ZK: 11.4%, MS-275: 12.2% with P < 0.05 vs control 1). The fraction of TUNEL-positive cells was upregulated highly significantly by dual therapy (18.4%) and quadruple therapy (24.8%, P < 0.01 vs control 1). For the proliferating (PCNA positive) and apoptotic cell fraction, quadruple therapy was significantly superior to dual therapy (P = 0.01). CONCLUSION: Combined PTK/ZK and MS-275 were highly effective in this hepatoma model. Quadruple therapy enhanced the effects microscopically, but not macroscopically. These results should be investigated further.

Sclerotherapy of lymphangiomas of the head and neck.

Lymphangiomas are congenital malformations of the lymphatic system that consist of cysts of varying size. Although they are benign, they can undergo progressive growth with compression and infiltration of adjacent structures. Surgical excision has been the cornerstone of treatment, although total excision of the lymphangioma can be a major challenge and may be associated with severe complications. Therefore, a variety of nonsurgical methods have been proposed to reduce the surgical morbidity and to decrease the recurrence rate. Percutaneous sclerotherapy of lymphangioma involves the injection of sclerosing substances into the lymphangioma cysts. During the past years, different sclerosants and sclerosant techniques have been developed. This review summarizes the current knowledge on sclerotherapy of lymphangiomas of the head and neck.

Microcystic lymphatic malformations of the tongue: diagnosis, classification, and treatment.

OBJECTIVE: To describe a classification of microcystic lymphatic malformations of the tongue and to investigate different treatment methods. DESIGN: Retrospective review of patients treated for microcystic lymphatic malformations of the tongue. Lymphatic malformations were classified into the following 4 groups according to their extent: isolated superficial microcystic lymphatic malformations of the tongue (stage I); isolated lymphatic malformations of the tongue with muscle involvement (stage II; stage IIA, involving a part of the tongue; stage IIB, involving the entire tongue); microcystic lymphatic malformations of the tongue and the floor of mouth (stage III); and extensive microcystic lymphatic malformations involving the tongue, floor of mouth, and further cervical structures (stage IV). PATIENTS: Twenty patients with microcystic lymphatic malformation of the tongue. MAIN OUTCOME MEASURES: Medical records were reviewed for demographic data and extent and treatment of the lymphatic malformations. RESULTS: Three patients had stage I disease; 5 patients, stage II; 3 patients, stage III; and 9 patients, stage IV. In 6 patients, the lymphatic malformations could be completely removed by carbon dioxide laser surgery; the remaining 13 patients had persistent disease. CONCLUSIONS: The initial stage seems to predict outcome. Carbon dioxide laser therapy provides good results primarily in stages I and IIA lymphatic malformations. In advanced lymphatic malformations (stages IIB, III, and IV), an interdisciplinary approach is necessary, because complete surgical excision is often impossible owing to the diffuse growth behavior, and therefore recurrence and persistence are common.

Polysomnography outcomes following transoral CO2 laser microsurgery in pediatric patients with laryngomalacia.

OBJECTIVE: Laryngomalacia is the most common cause of stridor in newborns and infants. The aim of the contribution was to present objectified data of the outcome of transoral CO(2) laser microsurgery in patients with laryngomalacia utilizing polysomnography (PSG). PATIENTS AND METHODS: This retrospective study comprised 21 patients who were diagnosed to suffer from laryngomalacia. Diagnosis was confirmed by pharyngo-laryngoscopy under spontaneous breathing. If there was evidence for laryngomalacia a transoral CO(2) lasersurgical intervention and/or epiglottopexy was performed in the same session. 8 patients, on whom the following should be focused, received pre- and postoperative PSG which was performed for efficiency control of the applied treatment. RESULTS: All 21 patients underwent invasive treatment for laryngomalacia (lasersurgical division of the aryepiglottic folds: n=13; epiglottopexy: n=5; combined procedure: n=3). All patients were successfully extubated after surgery. In 20/21 cases breathing improved clearly after one single intervention. Stridor disappeared completely in the further course of the disease. In the 8 patients who received pre- and postinterventional PSG, lasersurgical interventions were performed. Statistical analysis of pre- and postoperative PSG revealed that MOAI/h (mixed obstructive apnea index/hour) improved significantly (p=0.016, Wilcoxon-Signed-Rank Test). Also desaturation/hour improved in the postoperative course (p=0.11). CONCLUSION: The presented concept describes an effective and reliable approach for diagnostics and treatment for laryngomalacia. To objectify the success of supraglottoplaty in patients suffering from severe laryngomalacia a pre- and postoperative PSG seems to be useful and advisable. The present results of PSG demonstrate that children with laryngomalacia to benefit from lasersurgical division of the aryepiglottic folds and/or epiglottopexy. This fact is supported by the postoperative improved clinical aspect.

Evaluation of children with lymphatic malformations of the head and neck using the Cologne Disease Score.

OBJECTIVES: To assess the disease-related impairments of children with lymphatic malformations of the head and neck and their changes after therapy using the Cologne Disease Score (CDS). METHODS: 29 children with lymphatic malformations of the head and neck were evaluated regarding their symptoms before and after therapy using the CDS. The Wilcoxon test for dependent groups was used to compare the CDS at initial visit before treatment and last visit after treatment. RESULTS: The CDS of patients belonging to the moderate (initial CDS: more than eight points) and advanced disease group (initial CDS: five, six or seven points) significantly increased after therapy while the patients in the severe disease group (initial CDS: lower than four points) showed no significant improvement of CDS. Patients with stage IV and especially stage V lymphatic malformations according to de Serres showed considerably lower pre- and posttherapeutic CDS levels than those of stage I and II. CONCLUSIONS: The visual impairment is not mapped by the CDS, therefore item vision should be added to the CDS to make an evaluation of all lymphatic malformations of the head and neck possible. The present series could show that especially patients with a moderate or advanced disease according to the CDS may profit from therapeutic interventions.