[Head and neck paragangliomas]. / Hoved-/halsparagangliomer.

Head and neck paragangliomas (HNPGs) are rare tumours of neural crest origin that are benign in the majority of cases. In this article HNPGs are outlined with emphasis on genetic predisposition, diagnostics and counselling. The literature on HNPGs identified using PubMed is reviewed. Several susceptibility genes have been identified and hereditary mutations are detectable in 30% of the patients with HNPGs. Genetic analyses, guided by the family history and clinical findings, should be offered to all patients with HNPGs and at risk relatives.

Salivary gland carcinoma in Denmark 1990-2005: outcome and prognostic factors. Results of the Danish Head and Neck Cancer Group (DAHANCA).

To describe outcome and prognostic factors in a national Danish series of patients treated for salivary gland carcinoma. From three Danish nation-wide registries and supplementary patient records, 871 patients diagnosed with primary major or minor salivary gland carcinoma in the period from 1990 to 2005 were identified. A total of 796 (91%) histological specimens were revised according to the WHO 2005 classification. The median follow-up time was 78 months. Three hundred and thirty-four patients (38%) experienced recurrence. Crude survival, disease-specific survival and recurrence-free survival after 5 and 10 years were 66%, 76%, 64% and 51%, 69%, 58%, respectively. In multivariate analysis age, latency, stage, microscopic margins, vascular invasion and histological grade were all independent prognostic factors with regards to crude and disease-specific survival. Stage, microscopic margins, vascular invasion and histological grade were independent prognostic factors for recurrence-free survival. Age over 61 years, latency under 8 months, stage 3+4 disease, involved or close microscopic margins, vascular invasion and high histological grade are all independent prognostic factors with a negative impact on survival in salivary gland carcinoma patients. This knowledge can be helpful in guiding clinicians in daily work and choice of treatment across the large variety of salivary gland carcinoma subtypes.

Radiological imaging of the neck for initial decision-making in oral squamous cell carcinomas--a questionnaire survey in the Nordic countries.

BACKGROUND: Fast and accurate work-up is crucial to ensure the best possible treatment and prognosis for patients with head and neck cancer. The presence or absence of neck lymph node metastases is important for the prognosis and the choice of treatment. Clinical lymph node (N)-staging is done by palpation and diagnostic imaging of the neck. We investigated the current practice of the initial radiological work-up of patients with oral squamous cell carcinomas (OSCC) in the Nordic countries. METHODS: A questionnaire regarding the availability and use of guidelines and imaging modalities for radiological N-staging in OSCC was distributed to 21 Head and Neck centres in Denmark (n = 4), Finland (n = 5), Iceland (n = 1), Norway (n = 4) and Sweden (n = 7). We also asked for a description of the radiological criteria for determining the lymph nodes as clinical positive (cN+) or negative (cN0). RESULTS: All 21 Head and Neck centres responded to the questionnaire. Denmark and Finland have national guidelines, while Norway and Sweden have local or regional guidelines. Seventeen of the 19 centres with available guidelines recommended computed tomography (CT) of the cN0 neck. The waiting time may influence the imaging modalities used. Lymph node size was the most commonly used criteria for radiological cN+, but the cut-off measures vary from 0.8 to 2.0 cm. CONCLUSION: Overall, CT is the most commonly recommended and used imaging modality for OSCC. Despite availability of national guidelines the type and number of radiological examinations vary between centres within a country, but the implementation of a fast-track programme may facilitate fast access to imaging. The absence of uniform criteria for determining the lymph nodes of the neck as cN+ complicates the comparison of the accuracy of the imaging modalities. Well-defined radiological strategies and criteria are needed to optimise the radiological work-up in OSCC.

[Large fibrovascular polyp in the oesophagus]. / Stor fibrovaskulær polyp i øsofagus.

We describe a 45 year-old man with a fibrovascular polyp attached to the entrance of the oesophagus. The patient had a history with regurgitation of polypose foreign body 4-5 years ago with spontaneous remission. Later the patient developed dysphagia, chest pain and weight loss. Gastroscopy revealed a large polyp in the oesophagus and biopsies showed no malignancy. Excision was intended to be performed endoscopically, but due to size, risk of bleeding and recurrence the operation was changed to a transcervical procedure. After one week the patient could eat and drink normally.

Salivary gland carcinoma in Denmark 1990-2005: a national study of incidence, site and histology. Results of the Danish Head and Neck Cancer Group (DAHANCA).

To describe the incidence, site and histology (WHO 2005) of salivary gland carcinomas in Denmark. Nine hundred and eighty-three patients diagnosed from 1990 to 2005 were identified from three nation-wide registries. The associated clinical data were retrospectively retrieved from patient medical records. Histological revision was performed in 886 cases (90%). Based on histological revision, 31 patients (3%) were excluded from the study leaving 952 for epidemiological analysis. The mean crude incidence in Denmark was 1.1/100,000/year. The male vs. female ratio was 0.97 and the median age was 62 years. The parotid gland was the most common site (52.5%) followed by the minor salivary glands of the oral cavity (26.3%). The most frequent histological subtypes were adenoid cystic carcinoma (25.2%), mucoepidermoid carcinoma (16.9%), adenocarcinoma NOS (12.2%) and acinic cell carcinoma (10.2%). The revision process changed the histological diagnosis in 121 out of 886 cases (14%). The incidence of salivary gland carcinoma in Denmark is higher than previously reported. More than half of salivary gland carcinomas are located in the parotid gland with adenoid cystic carcinoma being the most frequent subtype. Histological classification of salivary gland carcinomas is difficult and evaluation by dedicated pathology specialists might be essential for optimal diagnosis and treatment.

Good results in patients with defects after intraoral tumour excision using facial artery musculo-mucosal flap.

INTRODUCTION: The purpose of this article was to assess our experience with the facial artery musculomucosal (FAMM) flap technique for reconstruction of the oral cavity after tumour ablation. We also introduce new surgical developments for this technique. MATERIAL AND METHODS: We retrospectively examined 22 cases involving FAMM flap surgery during the period from July 2007 to December 2009, focusing on postoperative complications and flap survival. We describe a new method for closing the donor defect using the buccal fat pad, as well as a method for harvesting a broader flap than is traditionally described. RESULTS: Among the 22 cases studies, seven (32%) experienced postoperative complications. However, 57% of these cases had undergone preoperative radiotherapy. The complications we observed included problems relating to integration, partial necrosis and bleeding. There were no reported complications relating to the donor site. CONCLUSION: The FAMM flap is a suitable technique for reconstruction following tumour ablation. Our study also suggests that while preoperative radiotherapy is a contraindication for this treatment, neck dissection surgery is not.

Reconstruction using free jejunal transfer after resection of cancer of the upper oesophagus.

INTRODUCTION: Treatment of cancer of the upper part of the oesophagus is challenging. Even after intended curative treatment, less than half of the patients are alive after five years. This retrospective study evaluates all the patients who had the upper oesophagus reconstructed by use of a free jejunal transfer following cancer resection from February 2000 to May 2008 at the University Hospital of Aarhus. MATERIAL AND METHODS: Twenty patients aged 46-75 years were included. In all 20 cases, the diagnosis was squamous cell carcinoma, T3 or T4. All patients suffered from severe dysphagia prior to surgery. The median follow-up time was 23 months at 31 January 2010. RESULTS: No perioperative mortality was experienced. Thirteen patients are now dead; nine due to the cancer of the oesophagus and four due to other causes. The median survival time of the 13 diseased patients was 15.3 months. The seven patients who remain alive have a median survival time of 40.2 months. None of these patients have shown signs of recurrence of the oesophageal cancer. All the patients regained their capacity to swallow and thereby increased their quality of life. No complications were experienced in relation to the abdominal procedure of harvesting the jejunal transfer. Three patients developed a fistula and in one case this required minor surgery. Eight patients needed to have a dilatation procedure performed. CONCLUSION: Reconstruction of the oesophagus with a free jejunal transfer is a suitable treatment for selected patients with cancer in the upper oesophagus.

[Spontaneous subcutaneous facial emphysema]. / Spontant subkutant facialt emfysem.

In this case we report how a previously healthy 35-year-old man developed a spontaneous monosymptomatic facial emphysema. The emphysema was found in large parts of deep and superficial compartments of the facial muscles, intraorbital to the optical nerve and along the blood vessels to the larynx level. The reason for this was never determined, but the differential diagnostics include allergic reaction, oesophagus/larynx rupture, infection, fracture of the facial bones, trauma or self-inflicted damage. The patient's symptoms receded over a course of four days to complete recovery.

[Reconstruction of the maxilla with pedicled temporalis muscle after maxillectomy]. / Maksilrekonstruktion med stilket temporalislap efter maksillektomi.

INTRODUCTION: Removal of the maxilla requires adequate restoration of the maxillary structure to replace form and functions, especially vocal and eating functions. A host of reconstructive options are available to restore the maxilla, most of which include free-flap reconstruction. The aim of this study was to clinically evaluate the use of pedicled temporalis flap for reconstruction of the maxilla and to assess patient quality of life. MATERIAL AND METHODS: In the period 2000-2007, a total of 32 patients with malignant tumours of the maxilla were operated with immediate reconstruction of the maxilla using pedicle temporalis muscle flap at the ENT department, Aarhus University Hospital. Follow-up was implemented in 2007. Twenty-seven of 28 patients alive at the time of the follow-up participated in the study. The patients were evaluated objectively as well as subjectively by answering the EORTC's standard questionnaire concerning quality of life and functional results. RESULTS: Few patients had complaints and these where mostly minor functional deficits. The most common complaints were slightly impaired mouth opening. One temporalis muscle flap necrotized and was removed. Three patients developed oro-nasal/antral fistula, witch were later closed using local flaps. CONCLUSION: The follow-up study of the 27 patients showed a most satisfactory result evaluated objectively as well as subjectively using the EORTC questionnaire.

[Reconstruction after maxillectomy using the temporalis muscle flap--our experience]. / Rekonstrukcja po maksylektomii z zastosowaniem plata miesnia skroniowego--doswiadczenia wlasne.

THE AIM OF STUDY: The study presents a method of a reconstruction of the palatum after maxillectomy. This method is choosen in selected cases of malignant tumors of the maxilla. MATERIAL AND METHODS: The method is combined of preparation of the temporalis muscle flap and its dislocation it under arcus of zygoma into the oral cavity. The surface of the flap covered with temporal fascia is oriented into the oral cavity and has been stitched in the hole of the palatum. The surface of the flap covered with periostium is connected to postoperative cavity of the maxilla. The flap covered the palatum tightly divides oral cavity from postoperative cavity of the maxilla. The vascular pedicle of the flap, with deep temporal vessels supply blood for proper healing of the palatum. Oncologic control of the postoperative cavity is performed using imaging investigation (computer tomography, magnetic resonance). The loss of tissue in the temporal fossa is covered by temporal fossa fat or synthetic material. RESULTS AND CONCLUSIONS: The reconstruction method brings satisfactory functional result. The method allows to avoid using inconvenient prostheses--obturators of palatum--in patients after maxillectomy. Complications in this method as postoperative perforation of the palatum and necrosis of the muscle flap are rare--less than 5% cases.

Prospective study of 18FDG-PET in the detection and management of patients with lymph node metastases to the neck from an unknown primary tumor. Results from the DAHANCA-13 study.

BACKGROUND: The benefit of a complementary fluorodeoxyglucose-positron emission tomography (FDG-PET) scan to standard workup for carcinoma of unknown primary (CUP) and metastatic neck lesions was prospectively studied. METHODS: Sixty-seven patients underwent standardized diagnostic workup according to national guidelines including panendoscopies, multiple mucosal biopsies, and diagnostic CT/MRI scans. Median follow-up was 40 months (range, 2-65 months). RESULTS: In 60 eligible patients, FDG-PET indicated a primary tumor or metastatic disease in 30 patients (50%). Additional investigations confirmed a primary tumor in 18 patients: hypopharynx in 5, oropharynx in 5, nasopharynx in 2, lung in 1, axilla in 1, bone in 1, rectum in 1, as well as multiple metastatic lesions from CUP in 2 patients. In retrospect, MRI was able to detect 1 of the PET-detected primaries, leading to an overall detection rate of PET of 29% in CUP. A therapeutic change of treatment was made in 25% as a consequence of FDG-PET. PET before panendoscopy demonstrated fewer false-positive pathological foci. CONCLUSION: FDG-PET is a valuable tool in addition to conventional extensive workup in CUP and neck metastases. Consequently, FDG-PET is now recommended as an early diagnostic modality in the workup of these patients.

The Danish national guidelines for treatment of oral squamous cell carcinoma.

The treatment strategy for oral squamous cell carcinoma in Denmark has traditionally varied between the different head and neck oncology centres. A study group within the Danish Society for Head and Neck Oncology (DSHHO) was formed with the aim of optimising and standardising the treatment strategy. The approach was to use single modality treatment for stage I, stage II and some stage III and combined modality treatment for stage III and IV. Surgery was the preferred treatment when it was considered possible to perform a radical excision of the tumour and possible lymph node metastases with acceptable aesthetic and functional outcome. The implementation of a recognised national guideline facilitates prospective studies on a large well-characterised cohort. This increases the possibility of obtaining valid data on parameters such as morbidity, loco-regional control and survival. In addition the establishment of a reference program facilitates national monitoring of the treatment using defined indicators and standards.

Histopathologic parameters in the evaluation of T1 squamous cell carcinomas of the oral cavity.

BACKGROUND: Prognostic indicators that could assist in a more precise selection of patients with small oral carcinomas for differentiated therapy would be valuable. A significant fraction of patients with stage I disease have a relatively poor prognosis despite the small size of the tumor, but in general stage I tumors of the oral cavity have a favorable prognosis. METHODS: Seventy-eight patients with stage I (T1N0M0) oral squamous cell carcinoma from two different ENT departments were included in the study. The pretreatment biopsy specimens were graded according to the modified classification of Jakobsson et al. Eight individual parameters were recorded, four parameters describing the tumor cell population and four parameters describing the tumor/host interaction. RESULTS: The only significant prognostic parameter for disease-specific survival was "mode of invasion." The histologic mean score was not significantly correlated to disease-specific or crude survival. CONCLUSIONS: Mode of invasion is the most important histologic parameter when evaluating the prognosis. Histologic evaluation of small squamous cell carcinomas of the oral cavity may assist the design of a differentiated treatment strategy (eg, monotherapy vs combined treatment).