Balazs B. Lörincz

New treatment strategies for HPV-positive head and neck cancer

Epidemiological studies show an increasing incidence of human papilloma virus-associated oropharyngeal cancer. HPV-positive head and neck squamous cell carcinoma (HNSCC) is recognized as a special subgroup of HNSCC. Because HPV-positive patients are often younger and have an outstanding prognosis, long-term toxicities of therapy have become an important issue. Current clinical trials focus on a reduction of treatment-related toxicity and the development of HPV-specific therapies. New treatment strategies include a dose reduction of radiotherapy, the use of cetuximab instead of cisplatin for chemoradiation and transoral robotic surgery (TORS). Increasing comprehension of the molecular background of HPV-associated HNSCC has also lead to more specific treatment attempts including immunotherapeutic strategies. Whereas recently published data shed light on immune mechanisms resulting in a tolerogenic niche for HPV and HPV-associated HNSCC, other studies focus on specific vaccination of HPV-positive HNSCC. This study will summarize current therapy approaches and illustrate ongoing clinical trials in the field of HPV-positive HNSCC.

Functional outcomes, feasibility, and safety of resection of transoral robotic surgery: Single-institution series of 35 consecutive cases of transoral robotic surgery for oropharyngeal squamous cell carcinoma

This is a single‐institution prospective study in a tertiary care center to evaluate feasibility, completeness of resection, and functional outcomes for oropharyngeal squamous cell carcinoma (SCC) treated primarily with transoral robotic‐assisted resection.

Endonasal dilatation of the Eustachian tube (EET) in children: feasibility and the role of tubomanometry (Estève) in outcomes measurement

Studies on endonasal dilatation of the Eustachian tube (EET) utilizing a balloon catheter have shown encouraging results over the last years. This retrospective analysis presents our outcomes with EET in children with chronic obstructive dysfunction of the Eustachian tube, as well as the role of tubomanometry (TMM, Estève) as a diagnostic tool in the pre- and postoperative assessment of the Eustachian tube (ET) dysfunction. The data of 33 children, having undergone EET between September 2010 and March 2014, were retrospectively evaluated. They were assessed using tubomanometry before and after the EET. The R-data as the rate of Eustachian tube function in tubomanometry (TMM) were pre- and postoperatively matched with the clinical outcomes. Moreover, the patients’ complaints before and after the procedure were analyzed. We did not see any EET-related complications in children. Most patients noticed a relief of their complaints. In the same time, tubomanometry was not able to show improved tube function or favorable postoperative changes in the R-data. Ear-related symptoms (e.g. otorrhea, otalgia, hearing loss) have been improved. EET is a feasible method in adults as well as in children to treat chronic tube dysfunction. However, tubomanometry does not seem to be the adequate tool to evaluate the tube function and thus the success rate of EET in children with chronic dysfunction of the Eustachian tube.

Initial learning curve of single-incision transaxillary robotic hemi- and total thyroidectomy--A single team experience from Europe.

INTRODUCTION The primary advantage of robotic thyroidectomy is to avoid a neck scar. On the other hand, this sophisticated technique implies some potential risks otherwise not associated with conventional thyroidectomy, increased costs, and prolonged operating times. With all these factors being an important issue, we analysed the data of our initial European series in order to understand the nature of the learning curve for this technique. METHODS Ten patients underwent transaxillary robotic thyroidectomy for benign disease, performed consistently by the same surgeon with the same team, within a timeframe of 12 months. There were four total thyroidectomies and six hemithyroidectomies. Operating times broken down into creating the working space, docking the robot, and console work (including wound closure), were prospectively recorded and evaluated. RESULTS By the end of the initial learning curve comprising ten patients, the total operating time for a robotic hemithyroidectomy and for a total thyroidectomy has decreased by 49% to 190 min, and by 31% to 229 min, respectively. Intraoperative complications were successfully managed without conversion to open access surgery. CONCLUSION The learning curve for transaxillary robotic thyroidectomy is rather steep; reasonable progress in terms of operating times can be achieved within the first ten cases. Consistency in the team and careful patient selection are paramount factors for success.

Bone Ablation without Thermal or Acoustic Mechanical Injury via a Novel Picosecond Infrared Laser (PIRL)

Background and Objective A precise means to cut bone without significant thermal or mechanical injury has thus far remained elusive. A novel non-ionizing ultrafast pulsed picosecond infrared laser (PIRL) may provide the solution. Tissue ablation with the PIRL occurs via a photothermal process with thermal and stress confinement, resulting in efficient material ejection greatly enhanced through front surface spallation photomechanical effects. By comparison, the Er:YAG laser (EYL) ablates via photothermal and cavitation-induced photomechanical effects without thermal or acoustic confinement, leading to significant collateral tissue injury. This study compared PIRL and EYL bone ablation by infrared thermography (IRT), environmental scanning electron microscopy (ESEM), and histology. Study Design Prospective, comparative, ex vivo animal model. Setting Optics laboratory. Subjects and Methods Ten circular area defects were ablated in ex vivo chicken humeral cortex using PIRL and EYL at similar average power (~70 mW) under IRT. Following fixation, ESEM and undecalcified light microscopy images were obtained and examined for signs of cellular injury. Results Peak rise in surface temperature was negligible and lower for PIRL (1.56°C; 95% CI, 0.762-2.366) compared to EYL ablation (12.99°C; 95% CI, 12.189-13.792) (P < .001). ESEM and light microscopy demonstrated preserved cortical microstructure following PIRL ablation in contrast to diffuse thermal injury seen with EYL ablation. Microfractures were not observed. Conclusion Ablation of cortical bone using the PIRL generates negligible and significantly less heat than EYL ablation while preserving cortical microstructure. This novel laser has great potential in advancing surgical techniques where precision osseous manipulation is required.

Facial mimetic, cosmetic, and functional standardized assessment of the facial artery musculomucosal (FAMM) flap.

OBJECTIVE To objectively assess donor site morbidity after harvesting the facial artery musculomucosal flap. Use of the FAMM-flap in oral cavity reconstruction remains sporadic. This case series describes our newly developed standardized assessment of this flap in a floor of mouth (FOM) reconstructive setting. METHODS Standardized postoperative assessment of the FAMM flap for donor site wound complications, functional, facial mimetic and oncologic outcomes. RESULTS There were no wound complications. Oral competence remained intact, tongue mobility was good to excellent, average word articulation score was 98%, and mimetic function excellent in all patients. Three patients experienced ipsilateral upper lip anesthesia, and five patients were noted to have slight dysfunction of the orbicularis oris resulting in a loss of lip height at rest. CONCLUSION The FAMM flap is a reliable option for reconstruction of ablative defects of the FOM, and should be considered a workhorse flap for oral cavity defects. Unlike the submental island flap, a complete level I dissection may be concurrently performed without compromising the vascular supply to the FAMM flap.

Decision management in transoral robotic surgery: Indications, individual patient selection, and role in the multidisciplinary treatment for head and neck cancer from a European perspective

Transoral robotic surgery (TORS) has become an accepted first‐line treatment for T1 and T2 head and neck squamous cell carcinoma (HNSCC). The growing popularity of this procedure is the result of mounting skepticism as to the survival and quality of life (QOL) benefits of primary chemoradiation over definitive surgery, the rising incidence of human papillomavirus (HPV)‐positive oropharyngeal squamous cell carcinoma (OPSCC) in progressively younger patients, and the advantages of TORS over transoral laser microsurgery (TOLM) and open surgery.

Robotic-assisted selective and modified radical neck dissection in head and neck cancer patients

INTRODUCTION Recently, several authors introduced various methods and published feasibility studies on novel robotic-assisted neck dissection techniques for head and neck cancer patients. Cosmesis and general appearance have become important concerns of cancer patients today. Especially in the head and neck area, a conspicuous scar can reduce patient satisfaction after surgery. With conventional neck dissection techniques, a long scar in the neck is unavoidable. Therefore, the development of robotic assisted neck dissection provides the patients with a scarless neck in these situations. However, there are some limitations of the application of these techniques in their current stage of development. METHODS This study was performed using a systematic literature review. RESULTS The reviewed clinical studies show that robotic-assisted neck dissection yields similar functional and early oncologic outcomes to that of conventional neck dissection, as well as excellent cosmetic satisfaction of patients. Despite these benefits, some disadvantages can be observed, in terms of longer operation times as well as higher procedure costs. CONCLUSION Besides the similar oncologic and functional outcomes compared with the open procedure so far, more prospective, controlled, multicenter studies are required to establish robotic-assisted neck dissection as an alternative standard and to justify its added costs beyond the cosmetic advantages.

Automatic periodic stimulation of the vagus nerve during single-incision transaxillary robotic thyroidectomy: Feasibility, safety, and first cases

Automatic periodic stimulation (APS) of the vagus nerve during thyroid surgery may provide the patient with increased safety to prevent impending thermal or stretch‐related injury to the recurrent laryngeal nerve (RLN).

Perspectives in chemosensitivity and chemoresistance assays and their implementation in head and neck cancer.

Therapeutic options for patients with head and neck squamous cell carcinoma include surgery, radiation and chemotherapy. The latter plays a major role in the treatment selection of recurrent, metastatic or therapy resistant tumours, these being some of the major challenges in head and neck oncology. For these patients, chemosensitivity and chemoresistance assays would be paramount to identify their individual therapy options. In this review, seven common assays will be described and discussed in the context of several studies. Further, a new assay will also be presented, currently being validated in a European Union funded project. Comparisons will be drawn to evaluate the sensitivity and specificity of these assays in identifying individual treatment options, and their potential implementation in head and neck malignancies will be discussed. There is an unmet demand for the development of ex vivo diagnostic tools that may predict response in head and neck cancer on the way towards an individualized treatment for these patients.