Head and Neck Surgery

Background: Patients with severe dyspnea consecutive to locally advanced obstructive head and neck squamous cell carcinoma (HNSCC) or subglottic stenosis requiring definitive or temporary tracheotomy are frequently difficult to ventilate and intubate. Materials and Methods: We describe a new procedure to perform tracheotomy easily and safely in patients with major obstruction of the upper airway. A catheter, specifically designed for cricothyroidotomy, was inserted into the trachea under local anesthesia. Then, general anesthesia was induced and the catheter was used as a guide for dilatation tracheotomy.

CPT11 isa a topoisomerase I inhibitor with substantial anti tumor activity. Preclinical data suggest that prolonged exposure has better efficacy and possibly less toxicity. A dose-escalation phase I study of CPT11 continuous I.v (c.i.v.) over 14-days every 3 to 5 weeks was conducted in order to de• termine the maximal tolerated dose (MTD). Since March 1996, 15 patients (pt) have been enrolled with the following characteristics: median age: 57 (range 29-70): median PS 1 (range 0-2): sex: 12 FI3 M, primary sites: col• oractal cancer 8, unknown primary 1, other 6; all heavily pre-treated. Only 10 patients evaluable for toxicity and PK. Already at the first dose of 12.5 mglm 2 /d dose limiting toxicity was encountered consisting of cumulative gr 3-4 diarrhea 3/5 pt and gr 3-4 neutropenia 2/5 pt. At a dose of 10 mg/m 2 /d 1/4 pt had gr 4 diarrhea (despite high dose of loperamide) and myelosup• pression was not dose limiting. Other side effects were moderate: fatigue 2 pt, thrombocy1openia 1 pt; alopecia was minimal. One response (not yet confirmed) in colorectal cancer was observed. Substantial Interpatlent and intrapatient variability in systemic exposure was observed. The mean total AUC of CPT11 was 8.9 ± 5.4 and 8.0 ±0.2 h./lg/ml at 12.5 and 10 mg/m 2 /d respectively. For SN38 AUC values were 0.93 ± 0.47 and 0.59 ± 0.06 h./lg/ml. The active lactone torms of CPT11 and SN38 accounted for by 36 ± 9% and 64 ± 6% respectively, of total drug exposure. At 12.5 mg/m 2 /d, plasma levels were higher during the second course. This increase was not due to changes in the fraction of CPT11 metabolized to SN38 which was stable over both courses (mean values: 10.3 ± 5.1 and 8.0 ± 1.7% at 12.5 and 10 mg/m 2 /d respectively). The MTD of this schedule (175 mg/m 2 ) is much lower than that with short infusion (350 mg/m2). AUC metabolic ratio SN38ICPT11 is higher and a cumulative effect was observed. The dose of 140 mg/m2/d leads to a SN38 AUC close to that of 350 mg/m2 short infusion (0.59 vs 0.45 /lg/ml) and is probably the recommended dose. The dose of 10 mg/m 2 over a 17-21-days c.i.v. is under evaluation. 1144 PUBLICATION Effect of food on the pharmacokinetics of toremifene M. Anttila. Orlan Corporation, Orlan Pharrna. R&D. Turku. Finland

Post-therapy follow-up for patients with head and neck cancer other than upper aerodigestive tract squamous cell carcinoma should meet several objectives: to detect both local, regional or distant recurrences, to evaluate acute and long-term treatment-related side effects, to guide the rehabilitation process, and to provide psychosocial support when needed. To our knowledge, there are no published reports in the literature dedicated to the follow-up of patients with these tumours. A comprehensive literature search for post-treatment follow-up strategies spanning from 1980 to 2012 was performed on several databases. This review focuses on malignant salivary gland tumors, soft tissue sarcomas, cutaneous squamous cell carcinomas, and sinonasal adenocarcinomas. Given the varying biological behavior and treatment-related factors and based on the literature, different recommendations are made on the followup of patients with the above-mentioned tumors. Keywords Head and neck Á Upper aerodigestive tract cancer Á Follow-up Á Surveillance This paper was written by members and invitees of the International Head and Neck Scientific Group (http://www.IHNSG.com).

Neck dissection is an important part of the surgical treatment of head and neck squamous cell carcinoma (HNSCC). The historical concept of neck dissection implied the removal of all lymph node-bearing tissue in the neck, which began in the late nineteenth century. However, more conservative variations of neck dissection have been performed and promoted as well. Anatomic, pathologic, clinical investigations, and prospective studies have demonstrated that the lymphatic dissemination of HNSCC occurs in predictable patterns. Supported by these studies, selective neck dissection (SND), which consists of the removal of select levels of lymph nodes in the neck that have the highest risk of harboring undetected metastases, has become widely accepted in the treatment of the clinically uninvolved neck. More recently, evidence supports using SND in a therapeutic setting in selected cases of HNSCC with limited metastatic disease. Additionally, even more targeted dissections referred to as super-selective neck dissection have been explored for selected patients undergoing elective node dissection for supraglottic cancer and as an adjuvant therapy for salvage of residual lymphadenopathy confined to a single neck level following chemoradiation. In the future, the trend to tailor treatment to individual patients and to limit toxicity and morbidity may further increase the use of SND. The indications have to be guided by further research, in relation with non-surgical treatment options while optimizing oncological effectiveness. Keywords Head and neck Á Squamous cell carcinoma Á Selective neck dissection Á Elective neck dissection Á Therapeutic neck dissection

Selective neck dissection (SND) is known to be a valid procedure to stage the clinically N0 neck but its reliability to control metastatic neck disease remains controversial. This study analysed if selective neck dissection is a reliable procedure to prevent regional metastatic disease in head and neck squamous cell carcinoma (HNSCC). We retrospectively analysed the medical records of 163 previously untreated patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx and hypopharynx treated initially in our departement from January 1990 to December 2002. All patients had unilateral or bilateral SND, in combination with surgical resection of the primary tumour. SND was performed in 281 necks. Finally, 146 patients who underwent 249 SND (39 I-III, I-IV, 210 II-IV, II-V) had adequate follow-up and were assessed for the regional control. The median follow-up was 37 months (1-180 months). The end points of the study were neck control following SND and overall survival. Twenty-Wve percent (30/119) of patients staged cN0 had lymph node (LN) metastasis. Overall, regional recurrence was observed in 2.8% of the necks (7/249): 1.6% (4/249) in dissected Weld and 1.2% (3/249) in undissected Weld. Seventy-eight percent (194/249) of the necks were staged pN0 with a subsequent failure rate of 1.5% (3/194); 16% (39/249) were staged pN1 and postoperative radiotherapy (PORT) was proposed in 21 of these patients. The failure rate with PORT was 9.5% and 5.5% without PORT. Six percent (16/ 249) of the necks were staged pN2b and all had PORT with one subsequent recurrence. Extracapsular spread (ECS) was reported in 16.5% of positive SND specimens (9/55); all by one were treated by PORT with a subsequent failure rate of 22% (2/9). At 3 years, overall survival for the whole population was 70% and statistically highly correlated with pN stage (p<0.001). These results support the reliability of SND to stage the clinically N0 neck. SND is a deWnitive operation not only in pN0 but also in most pN1 and pN2b necks. PORT is not justiWed in pN1 neck without ECS. In pN2b necks, the low rate of recurrence supports adjuvant PORT. The presence of ECS, despite adjuvant PORT, remains associated with a higher risk of recurrence.

It has been established that an appropriately indicated selective neck dissection can achieve the same oncologic results as more extensive dissections. An even more modified selective neck dissection, termed superselective neck dissection, involves the compartmental removal of the fibrofatty tissue contents within the defined boundaries of two or fewer contiguous neck levels. Evidence from retrospective studies suggests that superselective neck dissection (SSND) is oncologically sound for two indications: elective treatment of the clinically N0 neck and salvage treatment of persistent lymph node disease after chemoradiotherapy. While there is broader support for the former scenario, evidence that SSND may constitute optimal treatment in the latter is in conformity with the trend toward developing surgical techniques that provide better functional outcomes without compromising efficacy. Keywords Neck dissection Á Selective neck dissection Á Superselective neck dissection Á Neck metastases Á Neck levels This paper was written by members and invitees of the International Head and Neck Scientific Group (www.IHNSG.com).

Aim. To emphasise the pattern of lymphatic dissemination in the parapharyngeal space from thyroid cancer. Patients and method. Among 696 patients treated for thyroid cancer between 1986 and 2001, parapharyngeal metastasis was diagnosed in three patients, previously treated for papillary thyroid carcinoma. Results. All three patients have been treated by surgical resection through lateral cervical approach. Two of them were controlled regionally whereas the remaining one had a submucosal pharyngeal metastasis locally resected 27 months after parapharyngeal resection. Conclusions. Parapharyngeal metastasis is rare, but should be a recognized pattern of lymphatic dissemination from thyroid carcinoma to avoid unnecessary radioiodine and because surgical resection is efficacious with acceptable morbidity.

Surgery after proper imaging (MRI or CT scan) is the main stay of treatment for salivary gland tumors. Although excision margins should be ≥5 mm for malignant tumors in cases of parotid gland carcinoma, the facial nerve should be preserved whenever it is not infiltrated. Adjuvant external radiation is indicated for malignant tumors with high-risk features such as close (or invaded) margins, perineural speed, lymphatic and/or vascular invasion, lymph-node involvement and high-grade histology. A Phase II trial testing adjuvant concomitant cisplatin plus radiation therapy versus adjuvant radiation therapy alone after surgery is currently under investigation for high-risk salivary gland cancer. For inoperable cancers, photons combined with proton boost seem to be a valuable option. Even if protons or carbon ions are promising, access to the latter is limited for usual treatment. For recurrent and/or metastatic cancer, polychemotherapy (cisplatin based) gives a 25% response rate in adenoid cystic carcinoma and should be used when the disease is overtly in progression. Targeted therapies with anti-EGF receptor molecules, antiangiogenic agents and tyrosine kinase inhibitors are ongoing, but more trials are needed to establish their efficacy, as is the use of bortezomib followed by doxorubicin. The products of fusion oncogenes, which have a pathogenic role in some adenoid cystic carcinoma and mucoepidermoid carcinomas, are of interest as potential therapeutic targets.

Background. Parapharyngeal space nodal metastases are usually secondary to malignancies of the pharynx and sinonasal tract, although localization of lymphomas is also possible. Parapharyngeal metastases arising from thyroid papillary carcinoma are instead an exceedingly rare event, with only 10 cases reported up to now in the literature. Methods. We describe two cases of parapharyngeal metastasis from thyroid papillary carcinoma in a man and a woman, aged 40 and 52 years, respectively. Results. Both patients had a lesion that clinically appeared to be located in the parapharyngeal space; they underwent CT and MRI, which detected a cystic mass in the poststyloid compartment. In the first patient, fine-needle aspiration cytology failed in identifying the histologic nature of the lesion, which was excised through a transcervical approach. A diagnosis of metastatic thyroid papillary carcinoma was rendered and therefore the patient underwent total thyroidectomy. In the second patient, a total thyroidectomy, previously scheduled for multinodular goiter, was performed along with the removal of the parapharyngeal mass. Definitive histologic findings revealed that the two parapharyngeal masses were cystic metastases from a thyroid papillary carcinoma. Both patients received postoperative 131 I treatment. Twenty-four months after surgery, the first patient is free of disease, whereas the second one has clear signs of abnormal 131 I uptake in the lungs. Conclusions. The differential diagnosis of a parapharyngeal poststyloid mass should also include metastasis from thyroid papillary carcinoma. When the lesion displays a cystic appearance on imaging, it is advisable to rule out a thyroid primary by ultrasonographic examination. The occurrence of a metastasis in such unusual site, even though rarely reported, does not seem to significantly affect the prognosis of the disease.

For patients with advanced regional disease, neck dissection following (chemo)radiotherapy remains controversial. Selective neck dissection (SND) was reported as suitable after chemoradiation in patients with advanced regional disease. Reduced morbidity represents the major advantage of SND. In a situation in which there is a major fibrosis around the previously invaded nodes, resection of 1 or more nonlymphatic structures may be required. The current classification of SND could be implemented by the addition of extended selective neck dissection (ESND). The standard basic procedures for SND spare the sternocleidomastoid muscle (SCM), the internal jugular vein (IJV), and the spinal accessory nerve (SAN). When an SND is associated with the resection of 1 or more nonlymphatic structures, it should be termed ESND. All additional nonlymphatic structure(s) removed should be identified in parentheses. The proposal to subclassify SND not only in accord with the resected lymph node levels but also upon the nonlymphatic structures removed may be of some help to avoid potential misinterpretation. V

Purpose/Objective: Despite advances in radiotherapy planning and delivery systems, conformal head and neck radiotherapy continues to require labor-intensive target delineation on axial slices of a treatment-planning CT scan. In addition to being time-consuming and complex, manual contouring is also potentially inaccurate. The purpose of this study was to design a computer algorithm that could accurately and automatically contour the cervical lymph node levels (Ia-V) for patients receiving conformal radiotherapy/IMRT. Materials/Methods: We selected a head and neck CT scan that could be used as a reference model for creating standard lymph node regions. We then separately contoured individual nodal levels on each axial image from the reference CT scan using PRISM radiotherapy planning software, according to a standardized imaging-based classification (Som PM, Curtin HD, Mancuso A. An Imaging-Based Classification for the Cervical Nodes Designed as an Adjunct to Recent Clinical Based Nodal Classification. Arch Otolaryngol Head Neck Surg. 125:388-96, 1999). Nodal regions were therefore defined as a series of two dimensional contours in three dimensional space. We generated an image registration algorithm that could coregister two unique CT scans. The algorithm uses mutual information to measure similarities (or discrepancies) between the scans. Mutual information is an entropy-based measurement of image alignment derived from probabilistic measures of image intensity values. By assuming the anatomy has similar characteristics between the reference CT scan and a second patient CT scan, the algorithm can transform a region from the reference image set to the patient image set. Results: A sample image transformation is shown in Figure 1. The first image is from the reference CT scan and demonstrates the reference nodal regions. The second image is from a test patient and shows the transformed test contours resulting from the image registration process. Conclusions: While the alignment of the transformed contours on the test image are close enough to suggest this approach is promising, they do not exactly conform to clinical criteria. We are first attempting to further refine the algorithm by incorporating landmark-based initialization to enhance the deformation from mutual information. Following completed development, this algorithm will be integrated with the PRISM radiation therapy planning system so that it can be evaluated in a clinical setting.

Preliminary results only concern oropharyngeal tumors. Analysis of laryngeal/hypopharyngeal tumors is in progress. No significant difference was observed between the average GTV-CT (32.0 cc) and GTV-MR (29.9 cc). However, the GTV-CTϩMR was 31% larger than the GTV-CT indicating that individual volumes were not totally overlapping. Qualitative analysis indicated that MR was much better in discriminating muscle and parapharyngeal space infiltration. It was also found to be very helpful to delineate regions which were highly contaminated by teeth filling on CT slices. The average GTV-PET (20.3 cc) was smaller than the average GTV-CT (pϭ0.013) or the average GTV-MR (pϭ0.050). The use of PET only increased by 11% and 17% the volume delineated by CT and MR, respectively. The qualitative difference between PET, and CT or MR was not straightforward. When all 3 imaging modalities were combined, the average resulting GTV was 37% larger than the average GTV-CT. Conclusions: Differences in GTV delineation of oropharyngeal tumors could be observed depending on the imaging modalities used. Interestingly, the GTV-PET was always smaller than the GTV-CT or the GTV-MR. Whether such differences will impact on the delineation of the CTV and on the dose distribution is still unknown. In view of these results, comparison with a "Gold Standard" was urgently needed. We have therefore developed a unique method of three-dimensional macroscopic tumor specimen reconstruction for laryngeal tumors. Comparison of GTV delineated on macroscopic slices with coregistered preoperative CT, MR and FDG-PET slices should bring a definitive answer to the accuracy of the imaging modalities. This analysis is in progress.