Adil Benlyazid

Postoperative Radiotherapy in Head and Neck Mucosal Melanoma: A GETTEC Study

OBJECTIVE to report patterns of failure according to treatment modality, with an emphasis on the role of postoperative radiotherapy in patients with localized head and neck mucosal melanoma (HNMM) treated during a 28-year period in a multi-institutional setting. DESIGN retrospective review. SETTING french medical institutions. PATIENTS a total of 160 patients with nonmetastatic HNMM treated from 1980 through 2008. INTERVENTIONS treatment modality consisted of surgery alone (hereinafter, S group) (n = 82 patients) or with postoperative radiotherapy (hereinafter, SRT group) (n = 78). Patients and tumor characteristics were similar in the 2 groups. There was a nonsignificant trend (P = .11) for more locally advanced tumor stage (38.9%) in the SRT group compared with the S group (24.5%). RESULTS patients in the S group had an increased probability of locoregional recurrence as a first event (55.6%) compared with those in the SRT group (29.9%; P < .01). After adjusting for tumor stage (T1/T2 vs T3/T4), the subdistribution hazard ratio of locoregional relapse was 0.31, (95% confidence interval [CI], 0.15-0.61; P < .01).The rate of distant metastasis as a first event was significantly higher in the SRT group (40.6%) compared with the S group (19.9%; P = .01). Regardless of their treatment, patients who had a locoregional relapse during follow-up had an increased risk of subsequent distant metastasis (hazard ratio, 3.07; 95% CI, 1.65-5.67) and death (hazard ratio, 3.01; 95% CI, 1.91-4.78). CONCLUSIONS this large retrospective study suggests that postoperative radiotherapy improves the locoregional control of HNMM. The higher rate of distant metastasis was due to more advanced disease in the SRT group.

Pilot Study of Neoadjuvant Treatment with Erlotinib in Nonmetastatic Head and Neck Squamous Cell Carcinoma

Purpose: To determine the safety and efficacy of erlotinib given as neoadjuvant treatment in patients with head and neck squamous cell carcinoma (HNSCC). Further objectives were to identify markers of response to erlotinib and to assess the pharmacodynamic effects of erlotinib in tumor cells. Experimental Design: Patients with locally advanced nonmetastatic HNSCC were treated with erlotinib 150 mg daily pending surgical management. Tumor samples were collected before and after erlotinib treatment and were analyzed using immunohistochemistry. Epidermal growth factor receptor copy number was determined in tumors using CISH analysis. Results: Between November 2003 and December 2005, 35 patients were included in the study. Neoadjuvant treatment with erlotinib in HNSCC patients was well tolerated and did not necessitate modification to routine surgical procedures. Among 31 evaluable patients, erlotinib was given for a median of 20 days. At the time of surgery, tumor shrinkage was observed in nine patients (29%). Immunohistochemistry analyses were done for 31 patients and showed a decrease in phosphorylated tyrosine residues and phosphorylated erk immunostaining after erlotinib treatment. In a retrospective analysis, baseline p21waf expression in the basal-like cell layer was statistically positively correlated with clinical response to treatment. Epidermal growth factor receptor copy number did not correlate with response to erlotinib. Conclusion: Neoadjuvant treatment of HNSCC with erlotinib was well tolerated. Baseline p21waf expression was associated with response to erlotinib and so might be useful as a tool to select patients for erlotinib therapy in this setting.

Initial Multi-institutional Experience with Transoral Robotic Surgery

Objective To assess the initial experience for transoral robotic surgery (TORS), as observed in the French TORS group. Study Design A multi-institutional prospective cohort study. Setting Seven tertiary referral centers. Subjects and Methods One hundred thirty consecutive patients who were scheduled for a TORS between October 2008 and March 2011 were included. The operative times, conversion rates, morbidity, and alternatives were described. The serious adverse effects encountered were analyzed, and recommendations for avoiding them are specified. Results Most of the patients (65%) had a laryngeal (supraglottic) and/or hypopharyngeal resection. Thirty-nine of the 130 patients receiving TORS would have had a transoral laser resection as their alternative surgery. The tumor exposure was suboptimal in 26% of the cases. Six of the 130 patients needed conversion to an open approach. There were 15 postoperative hemorrhages and 2 deaths due to posthemorrhage complications in patients with significant comorbidities at 9 and 18 days after the surgery. The median setup and procedure times were 52 ± 46 and 90 ± 92 minutes, respectively. The learning curve was characterized by better selection and management of potential patients. Conclusion The visualization offered by the robotic assistance allowed transoral resections of tumors that were difficult to resect or unresectable by laser surgery. Self-assessment of surgical exposure and a decrease in the need to convert to an open procedure over time suggested improvement in TORS-related surgical skills. Nevertheless, strict patient selection is essential. Even with a minimally invasive approach, some patients will need a tracheostomy for safety reasons.

Management of the Neck in the Setting of Definitive Chemoradiation: Is There a Consensus? A GETTEC Study

BackgroundThe management of the neck remains controversial in the definitive chemoradiation setting of advanced N2–3 head and neck squamous cell carcinoma. Most published data favor omission of neck dissection (ND) after complete response for N2–3 or selective ND for residual diseaseMethodsWe studied the patterns of care in the French-Belgian Groupe d’Etude des Tumeurs de la Tête Et du Cou (GETTEC) through a questionnaire-based survey.ResultsEighteen percent of institutions never performed up-front ND, 20% rarely, 40% sometimes, 14% often, and 8% systematically. Induction chemotherapy was indicated in 30% of the cases, and most ND were performed either between induction and radiation or after chemoradiation for residual disease. Response to chemoradiation was assessed by computed tomographic scan and positron emission tomography in 72% of cases. Selective ND was more common than radical ND.ConclusionsOmission of ND based on computed tomographic scan and positron emission tomography–based complete response to chemoradiation is the most common strategy for advanced nodal disease among centers. However, neck management strategies vary among institutions, and some institutions continue advocating systematic ND before irradiation. The new treatment options and the changing epidemiology, namely docetaxel-based induction chemotherapy and human papilloma virus–related head and neck squamous cell carcinoma having better response profiles and prognosis, are adding to the nonconsensual approach. The best therapeutic index in terms of neck management remains to be defined in this evolving context.

Transoral minimally invasive robotic surgery for carcinoma of the pharynx and the larynx: a new approach.

Partial laryngectomy is an old but well-accepted surgical treatment for selected carcinomas of the larynx. Actually, the transcervical approach remains the most popular even if the transoral laser approach is useful in some cases. Transoral robotic surgery is a new promising surgical procedure in head and neck oncology as an alternative to conventional surgery with decreased morbidity. The aim of this study is a description of the state of the art by a review of the literature. We emphasize limits and future prospects on this topic with a special focus on dependability.

Gene expression profiling on pre- and post-erlotinib tumors from patients with head and neck squamous cell carcinoma†‡

The purpose of our work was to identify genomic predictive markers of erlotinib response in patients with head and neck squamous cell carcinoma (HNSCC).

La chirurgieminimale invasive transorale robot-assistée: quelles applications ? Quel avenir ?

Transoral robotic surgery (TORS) is a new technique that provides several unique advantages, which include a three-dimensional magnified view, the ability to see and work around curves or angles, and the availability of two or three robotic arms. Via this review of the literature, we discuss the limits and future prospects on this topic. Preliminary data suggest that TORS may provide a technique for ablation and reconstruction of pharyngeal defects with promising new transoral indications. It may also provide new opportunities of transoral surgery for oropharyngeal and supraglottic carcinoma. TORS is a promising surgical procedure contingent on the development of new associated functions such as an image guidance system. Successful development of this new tool will also depend on the quality of clinical works and research programs.RésuméLa chirurgie transorale robot-assistée (TOAR) offre une vision tridimensionnelle magnifiée du site opératoire qui peut être indirecte, une instrumentation avec une mobilité accrue portée par deux à trois bras, permettant ainsi d’accéder à des espaces anatomiques jusqu’alors difficiles d’accès par voie transorale. L’objet de cet article est d’établir les limites et les perspectives via une revue de la littérature. Les premiers travaux rapportent l’expérience de chirurgie d’exérèse et de reconstruction en région pharyngolaryngée. Le robot chirurgical appliqué en chirurgie endoscopique ORL est un outil prometteur sous réserve, cependant, du développement attendu de nouvelles fonctions comme un système de guidage par l’image. Le bon développement de ce nouvel outil dépendra également de la qualité des travaux et programmes de recherche dans ce domaine.