Frans J. M. Hilgers

Salivary gland carcinoma : Independent prognostic factors for locoregional control, distant metastases, and overall survival: Results of the Dutch Head and Neck Oncology Cooperative Group

We analyzed the records of patients with malignant salivary gland tumors, as diagnosed in centers of the Dutch Head and Neck Oncology Cooperative Group, in search of independent prognostic factors for locoregional control, distant metastases, and overall survival.

A new low-resistance, self-retaining prosthesis (Provox) for voice rehabilitation after total laryngectomy.

Prosthetic rehabilitation of voice after total laryngectomy has gained wide acceptance in the last 10 years. Several reliable voice prostheses have been developed and used successfully.

Systematic approach to the treatment of chylous leakage after neck dissection

Chylous leakage is an uncommon complication after neck dissection for which several treatment modalities have been described in literature. It occurs in 1% to 2.5% of radical neck dissections, with the majority (75% to 92%) being on the left side. In a consecutive series of patients, we investigated the effect of a systematic approach to the complication.

The development of a prognostic score for patients with parotid carcinoma

Understanding of prognostic factors in parotid carcinoma has grown considerably. In particular, clinical tumor staging and histologic classification have been found to be prognostically important. Univariate and multivariate analyses have indicated that other variables, such as age, pain, skin invasion, and facial nerve impairment, are important predictors as well. In an actual patient, some of these factors are present and others are absent. However, a clinical tool incorporating this information, resulting in an individualized prognosis based on the combined effects of present adverse prognostic factors, has never been devised.

Postlaryngectomy Voice Rehabilitation: State of the Art at the Millennium

Total laryngectomy or laryngopharyngectomy remains the procedure of choice for advanced laryngeal/hypopharyngeal carcinoma, either as a primary procedure or as salvage following irradiation alone or concurrent chemoradiation therapy. Over the past 25 years there has been significant improvement in the rehabilitation of these patients, with speech restoration that has dramatically altered and improved their quality of life. This article reviews postlaryngectomy voice rehabilitation with a historical background as well as the present state-of-the-art tracheoesophageal shunt voice with an artificial valve. Finally, this article reviews and compares artificial valve prostheses as to their voice characteristics, patient satisfaction, complications associated with the procedure, and devices used at a center in Europe (The Netherlands Cancer Institute, Amsterdam) and a North American center (The Wharton Head and Neck Center, Princess Margaret Hospital, University of Toronto, Canada).

Functional outcomes and rehabilitation strategies in patients treated with chemoradiotherapy for advanced head and neck cancer: a systematic review

Organ preservation with radiotherapy and concomitant chemotherapy has become an accepted treatment modality in advanced head and neck cancer. Unfortunately, organ preservation is not synonymous with function preservation. The aim of this review was to systematically assess the effects of the disease and chemoradiotherapy (CRT) on functions such as swallowing, mouth opening, nutrition, pain and quality of life in patients with head and neck cancer. Another aim was to search for (evidence-based) techniques or strategies known to alleviate or rehabilitate the loss of function(s) associated with CRT. Two databases were searched (time period, January 1997 to August 2007) for the terms head and neck cancer, chemotherapy or cisplatin and radiotherapy, and the functional outcomes swallowing, trismus, nutrition, pain and quality of life or a variation of those words. In total, 15 relevant articles were identified that met the inclusion criteria. The majority of the studies that met the criteria focused on the outcomes swallowing, quality of life, and nutrition. Two studies reported on the outcome pain, but no paper reported on the outcome trismus. Only two papers mentioned rehabilitation options, but specific information was lacking. Further long-term prospective research is essential, not only to determine the function impairment caused by the tumor and CRT, but also to assess the effects of known and newly developed rehabilitation measures. Therefore, in September 2006, the Netherlands Cancer Institute started a randomised clinical trial (RCT): Prevention of trismus, swallowing and speech problems in patients treated with chemoradiotherapy for advanced head and neck cancer. This systematic review was carried out to collect the baseline information for the future outcomes of this RCT.

Does the combination of radiotherapy and debulking surgery favor survival in paranasal sinus carcinoma

PURPOSE To determine the contribution of debulking surgery on local control and survival in paranasal sinus tumors. As most patients present with locally advanced disease, the possibility of radical surgery is limited. Consequently, radiotherapy is often needed as monotherapy or as an adjunct to surgery. METHODS AND MATERIALS Between 1977 and 1996, 73 patients (50 male: 23 female) with a paranasal sinus carcinoma were treated. The histology distribution was as follows: squamous cell carcinoma, 55%; adenocarcinoma, 19%; adenoid cystic carcinoma, 11%; and undifferentiated carcinoma, 15%. The clinical T classification was (UICC/TNM 1997): T2 14%, T3 27%, and T4 59%. Pathological neck nodes were found in 11% of patients. Treatment consisted of surgery only in 3, chemotherapy only in 1, radiotherapy only in 18, both surgery and radiotherapy in 50 patients. One patient did not receive any treatment at all. Three patients had concurrent chemotherapy. Median follow-up was 66 months (range, 1-213 months). RESULTS Five-year local control (LC) was 65% with combination of radiotherapy and debulking surgery in comparison with 47% with radiotherapy alone, but this difference was not statistically significant (p = 0.58). However, combination treatment gave significantly better 5-year overall survival (OS) (60% vs. 9%; p = 0.001) and 5-year disease-free survival (DFS) (53% vs. 6%; p < 0. 0001). Cox-regression analysis showed that pathologic N status (p = 0.04), palliative intention of treatment (p = 0.018), clinical orbital invasion (p = 0.003), and orbital wall invasion (p = 0.003) were parameters significantly associated with poor local control. Total radiation dose of greater than 65 Gy (p = 0.05) and treatment consisting of radiotherapy alone (p = 0.002) were associated with worse overall survival; for disease-free survival clinical orbital invasion (p = 0.0005), age of greater than 65 years (p = 0.013) and pathologic T4 classification (p = 0.002) were significant factors for an unfavorable outcome. In 19 of 73 patients, 26 serious (mainly ophthalmological) complications were reported; in the majority of these, the visual tract was (partly) included in the treatment fields because of tumor extension. To analyze on which basis patients were selected for the combination therapy, a logistic regression was performed, concluding that clinical T4 classification (p = 0.05), radiological evidence of skull base invasion (p = 0.005), age of greater than 65 years (p = 0.026), radiological evidence of nasopharynx invasion (p = 0.02), clinical suspicion of palate invasion (p = 0.02), and radiological evidence of skin invasion (p = 0.009) were associated with choosing radiotherapy alone. CONCLUSION Debulking surgery of paranasal sinus malignancies followed by high-dose radiotherapy to the involved sites was associated with better survival and (although not statistically significant) local control. Patient selection, based on clinical and radiological impression of tumor extension, was the main factor explaining these favorable results. We favor this combination regimen because the surgery gives quick relief of complaints and, at the same time, offers an excellent histologically proven staging method, enabling radiotherapy to be adjusted to the involved sites, thereby decreasing the risk of complications. This can all be achieved with a very low orbital exenteration rate.

Value of resection of pulmonary metastases in head and neck cancer patients

Literature shows no data about a complete cohort of head and neck cancer patients who developed pulmonary metastases. In this study, we investigate factors related to survival, with emphasis on the role of a pulmonary metastasectomy.

Development and Clinical Evaluation of a Second-generation Voice Prosthesis (Provox®2), Designed for Anterograde and Retrograde Insertion

Prosthetic voice restoration has considerably improved the results of vocal rehabilitation after total laryngectomy, and is presently the method of choice for many health-care providers treating laryngectomized patients. The Provox voice prosthesis, developed in the Netherlands Cancer Institute, is an indwelling device that has been applied in recent years with regular success. Its retrograde replacement method, using a disposable guide wire, assures reliable, atraumatic positioning of the prosthesis in the tracheoesophageal fistula. However, the method sometimes may be uncomfortable for the patient; therefore an adapted prosthesis and new replacement equipment were developed, which enable bidirectional insertion, i.e. not only in the traditional retrograde manner through the pharynx, but especially in an anterograde manner through the stoma. This second-generation voice prosthesis (Provox 2) was studied in a prospective clinical trial in 44 patients (33 experienced patients, seven first-time replacements and four primary insertions). The study demonstrated that the anterograde insertion with the Provox 2 system was applicable in all patients, making the voice prosthesis even easier to handle than with the traditional retrograde method. A stenosis of the pharyngoesophageal segment no longer interfered with the replacement. In addition, the patients judged the new method as being favourable, reporting significantly less discomfort during the replacement procedure (paired Students t-test: p < 0.0001). Furthermore, the adapted voice prosthesis could be removed from the tracheoesophageal fistula without excessive force (mean 7.9 N, range 6.0-14.0 N), more easily than the original Provox (mean 20.9 N, range 5.5-25.0 N). It can be concluded that this second-generation indwelling voice prosthesis (Provox 2) seems to be a further improvement in the application of this voice rehabilitation system, not only simplifying the replacement procedure, but also diminishing the discomfort for the patient.

Scintigraphic assessment of salivary function and excretion response in radiation-induced injury of the major salivary glands

Background. Both loss of the secretory function and impairment of the excretion may play a role in radiationinduced injury of the major salivary glands after radiotherapy for head and neck malignancies. Therefore, quantitative 99mTc‐pertechnetate (99mTc) salivary scintigraphy to assess trapping, secretion, and excretion, was used to analyze irradiation‐induced changes in relation to the radiation dose and the time interval after radiotherapy.