Georges Lawson

Positron Emission Tomography With Fluorodeoxyglucose for Suspected Head and Neck Tumor Recurrence in the Symptomatic Patient

Objective To analyze the impact of positron emission tomography with fluorodeoxyglucose (FDG‐PET) in the treatment of patients suspected of having head and neck cancer recurrence.

Subtotal carbon dioxide laser arytenoidectomy by endoscopic approach for treatment of bilateral cord immobility in adduction.

Subtotal carbon dioxide (CO2) laser ary tenoidectomy for endoscopic treatment of bilateral immobility of the vocal folds in adduction is a variant of total arytenoidectomy. The principal modification involves preservation of a thin posterior shell providing good postoperative fixation of the arytenoid region. The risk of aspiration is thus averted and collapse of arytenoid mucosa into the larynx during inspiration is prevented. The risk of synechia with the posterior commissure is avoided. The CO2 laser is operated at a working distance of 400 mm with a continuous 7-W beam in superpulse mode. Operation time is thus reduced to approximately half an hour and the risk of postoperative edema is reduced. Tracheotomy is not necessary. Forty-one patients, including 16 men and 25 women, were treated by this technique between 1985 and 1994. Their mean age was 55 ± 17 years, ranging from 11 to 83 years. Follow-up ranged from 1 month to 111 months (9 years 3 months), with a mean of 56 ± 29 months (4 years 8 months). The mean peak forced expiratory flow-peak inspiratory flow ratio (normal = 1), which permits a measurement of respiratory quality, is improved from 3.7 ± 1.4 preoperatively to 1.6 ± 0.5 postoperatively (p < .001). Postoperative voice measurements show a mean vocal intensity of 61 ± 3 dB hearing level, a mean maximum phonation time of 8 ± 4 seconds, and a mean phonation quotient of 397 ± 150 mlVs. As for vocal quality, 38% of the patients now have a near-normal voice according to our high-resolution frequency analysis, and all of the patients retained satisfactory voice quality.

Oncologic Outcomes After Transoral Robotic Surgery : A Multi-institutional Study

IMPORTANCE Large patient cohorts are necessary to validate the efficacy of transoral robotic surgery (TORS) in the management of head and neck cancer. OBJECTIVES To review oncologic outcomes of TORS from a large multi-institutional collaboration and to identify predictors of disease recurrence and disease-specific mortality. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of records from 410 patients undergoing TORS for laryngeal and pharyngeal cancers from January 1, 2007, through December 31, 2012, was performed. Pertinent data were obtained from 11 participating medical institutions. INTERVENTIONS Select patients received radiation therapy and/or chemotherapy before or after TORS. MAIN OUTCOMES AND MEASURES Locoregional control, disease-specific survival, and overall survival were calculated. We used Kaplan-Meier survival analysis with log-rank testing to evaluate individual variable association with these outcomes, followed by multivariate analysis with Cox proportional hazards regression modeling to identify independent predictors. RESULTS Of the 410 patients treated with TORS in this study, 364 (88.8%) had oropharyngeal cancer. Of these 364 patients, information about post-operative adjuvant therapy was known about 338: 106 (31.3) received radiation therapy alone, and 72 (21.3%) received radiation therapy with concurrent chemotherapy. Neck dissection was performed in 323 patients (78.8%). Mean follow-up time was 20 months. Local, regional, and distant recurrence occurred in 18 (4.4%), 15 (3.7%), and 10 (2.4%) of 410 patients, respectively. Seventeen (4.1%) died of disease, and 13 (3.2%) died of other causes. The 2-year locoregional control rate was 91.8% (95% CI, 87.6%-94.7%), disease-specific survival 94.5% (95% CI, 90.6%-96.8%), and overall survival 91% (95% CI, 86.5%-94.0%). Multivariate analysis identified improved survival among women (P = .05) and for patients with tumors arising in tonsil (P = .01). Smoking was associated with worse overall all-cause mortality (P = .01). Although advanced age and tobacco use were associated with locoregional recurrence and disease-specific survival, they, as well as tumor stage and other adverse histopathologic features, did not remain significant on multivariate analysis. CONCLUSIONS AND RELEVANCE This large, multi-institutional study supports the role of TORS within the multidisciplinary treatment paradigm for the treatment of head and neck cancer, especially for patients with oropharyngeal cancer. Favorable oncologic outcomes have been found across institutions. Ongoing comparative clinical trials funded by the National Cancer Institute will further evaluate the role of robotic surgery for patients with head and neck cancers.

Correcting vocal fold immobility by autologous collagen injection for voice rehabilitation. A short-term study.

We report on a short-term clinical study of injectable autologous collagen (Vocalogen) used to correct dysphonias arising from vocal fold immobility. The collagen is extracted from skin taken from the lower abdominal quadrant area or from just above the bikini line. About 30 cm2 of skin are required to provide 2 mL of injectable collagen. The histologic examination of the preparation before injection disclosed the presence of elastin fibers and some clusters of epithelial cells, beside the collagen fibers. The collagen is naturally reticulated, and the molecule is preserved in its entirety. The technique is exactly the same as that reported for bovine collagen: injection into Reinkes space, under general anesthesia, monitored by direct microlaryngoscopy. The amount injected is also similar: 1.5 mL for correction of glottic insufficiency in which the immobile vocal fold is in the intermediate position. Eight patients were injected, and the average follow-up was 4.5 months. Voice assessments made before and after the treatment included stroboscopy, subjective and perceptual judgments, and aerodynamic and acoustic measurements. The functional results were similar to those obtained with bovine collagen. No complications arose. The probability of any hypersensitivity reaction, always a possibility to be feared with bovine collagen, is negligible with the autologous collagen. Long-term results are as yet unknown, but from the fact that the collagen molecular structure is intact and there is little risk of foreign body response, it would be expected that autologous preparations would be more stable than bovine collagen; this appears to be the case in cosmetic applications. Autologous collagen could be employed for the same indications as bovine collagen, provided that a delay of 45 days (the time required to prepare the injectable collagen) is acceptable. The amount of collagen required is also a limiting factor, since the patients own skin is the starting donor material.

CO2 laser in the diagnosis and treatment of early cancer of the vocal fold.

A total of 74 patients underwent cordectomy using CO2 laser for either diagnosis or treatment of an early cancer of the vocal fold. Type I cordectomy consisted in the resection of the entire epithelium, while leaving the vocal ligament intact. Type II cordectomy involved removal of the vocal fold from the vocal process to the anterior commissure and passing through the inferior thyroarytenoid muscle. Type IIIA required vocal fold resection along the internal side of the thyroid ala, while type IIIB included removal of the anterior commissure. Type I cordectomies were carried out with an Acuspot micromanipulator, which provided a 250-μm-diameter beam for a working distance of 400 mm, and in the shot-by-shot cutting mode with 3 W power superpulse. This cordectomy was carried out in 39 patients and a dysplasia or an early carcinoma were detected in 45.9% of cases. Type II and type III procedures were performed with the Microslad micromanipulator having a 700-μm-diameter beam in the continuous cutting mode, 7 W power superpulse. Fifteen cases were treated by type II cordectomy, of which 3 T1aN0M0 cases underwent postoperative radiotherapy due to insufficient resections and 2 cases with T1bN0M0 tumors later underwent reconstructive laryngectomy. A type III cordectomy was used for 14 cases of TlaNOMO carcinomas and 3 cases of severe dysplasia. The margins of resection were found to be positive histologically in 23.5% of these cases, making frozen section examinations mandatory at time of surgery. Results of all procedures showed that voice was best after a type I cordectomy where only the epithelium was resected. In the type II and type III cordectomies, the quality of voice depended on the development of a fibrous fold and the absence of anterior synechia in the healed larynx.

Prognostic value of cell proliferation markers, tumour suppressor proteins and cell adhesion molecules in primary squamous cell carcinoma of the larynx and hypopharynx.

Abstract. In an attempt to identify molecular prognostic markers, a series of laryngeal and hypopharyngeal carcinomas was examined for PCNA, Ki67, p27Kip1, p53, E-cadherin and CD44 by immunohistochemistry and for DNA content by flow cytometry. No correlation was found between E-cadherin, CD44, p53 or DNA ploidy and the clinicopathological data. The fraction of cancer cells immunolabelled for p27Kip1 correlated with tumour differentiation, but not with lymph node metastasis. In contrast, the PCNA, Ki67 and S-phase fractions of cancer cells were significantly higher in tumours with lymph node metastasis than in those without lymph node metastasis and were correlated with pathological T-stages and with tumour dedifferentiation. In univariate analysis, advanced pathological T-stage, lymph node metastasis and high fractions of cancer cells immunolabelled for PCNA or Ki67 inversely correlated with overall and disease-free survival. In multivariate analysis, lymph node metastasis was the only factor significantly associated with poor survival. The data suggest that immunohistochemical investigation of PCNA and Ki67 and flow cytometric analysis of S-phase fractions may be useful predictive markers of biological aggressiveness in laryngeal carcinomas.

Carbon Dioxide Laser Microsurgery of Benign Vocal Fold Lesions: Indications, Techniques, and Results in 251 Patients

Two hundred fifty-one carbon dioxide laser-assisted cases of microphonosurgery are reported. Our series includes 167 women (66.5%) and 84 men (33.5%), with a mean age of 41 (±11) years. Single lesions represent 67.8% (n = 170) of the cases, with 20% (n = 50) being nodules, 18% (n = 44) Reinkes edema, 9% (n = 23) polyps, 8% (n = 19) sulci and related lesions, 6% (n = 16) mucosal cysts, 4% (n = 10) scars, 2% (n = 4) granulomas, and 2% (n = 4) vascular corditis. The cases with 2 or 3 lesions represented 32% (n = 81). Carbon dioxide laser-assisted microphonosurgery is efficient, provided the working parameters are strictly adhered to: micromanipulator micropoint providing a 250-μm laser beam for a 400-mm working distance; 0.1-second single pulses; and maximum power of 3 W with the superpulse wave. Glutaraldehyde-cross-linked collagen remains our filling material of choice in cases of vocal fold atrophy. Fibrin glue is useful for covering the resection area and for setting the microflaps. Microphonosurgery cannot be dissociated from speech therapy, the planning and duration of which, in relation to the procedure, depend on the nature of the initial lesion. Twenty to 30 sessions are usually adequate, but 6 months may be necessary in the case of sulcus vergetures. Our operating technique is derived from the microphonosurgery procedures with cold instruments. In addition to the classic advantage with regard to hemostasis, the carbon dioxide laser micropoint seems to make the dissection of microflaps easier.

Diagnosis and management of laryngopharyngeal reflux disease.

Purpose of reviewLaryngopharyngeal reflux should no longer be underestimated because of its negative impact on the lives of patients and its potentially dangerous long-term complications. Recent findingsBoth laryngopharyngeal reflux and gastroesophageal reflux disease are caused by mucosal injury from acid and pepsin exposure, but the esophagus has intrinsic antireflux defenses that prevent mucosal injury (bicarbonate production, mucosal tissue resistance and esophageal motor function with acid clearance) whereas the pharynx and the larynx do not. Symptoms felt to be most related to reflux (≥ 95%) are throat clearing, persistent cough, heartburn/dyspepsia, globus sensation (lump in the throat) and voice-quality change, while the physical examination findings include (≥ 95%) arytenoid erythema, vocal-cord erythema and edema, posterior commissure hypertrophy, and arytenoid edema. In this regard, the reflux symptom index and the reflux finding score are very useful clinical tools. Patients are proposed an empirical therapeutic trial including behavioural and dietary recommendations and a 3-month twice-daily proton-pump inhibitor therapy. The proton-pump inhibitor should be taken 30–60 min before meals. Nonresponders undergo an assessment, ideally based on esogastroduodenoscopy and ambulatory multichannel intraluminal impedance and pH monitoring. Transnasal esophagoscopy in the outpatient setting is a safe alternative. When medical management fails, patients with demonstrable high-volume reflux and lower sphincter incompetence are often candidates for surgical intervention. SummaryThe algorithm proposed by Ford has structured and confirmed our attitude on a day-to-day basis.

Outcomes following transoral robotic surgery: Supraglottic laryngectomy.

To describe a single center outcomes following transoral robotic surgery for supraglottic laryngectomy (TORS–SL).

Treatment of vocal fold immobility by glutaraldehyde-cross-linked collagen injection: long-term results.

Fifty-three cases of unilateral vocal fold immobility treated by glutaraldehyde—cross-linked (GAX) collagen over a 6-year period with a mean follow-up of 4.5 years were reviewed for assessment of the immediate and long-term effects on phonation. The mean amount injected was 1.47 mL. No long-term local or systemic reaction to the collagen was seen. The median preoperative maximum phonation time (MPT) was 7.5 seconds, the median immediate postoperative MPT 12 seconds, and the median long-term postoperative MPT 11 seconds. The median preoperative phonatory quotient (PQ) was 564 mL/s. The median immediate postoperative PQ was 320 mL/s, whereas the median long-term postoperative PQ was 385 mL/s. The quantitative improvement in the voice as measured by the PQ was thus 67% for the short range and 49% for the long range. The decline in the results over time was 20.3%. Vocal frequency analysis showed that the fundamental frequency and harmonics returned and were maintained in the long term for more than 80% of the patients with the help of speech therapy. This relative stability is explained by the findings of previous histological work. The fact that collagen, unlike Teflon, does not cause an inflammatory reaction and the partial maintenance of the improvement achieved, which is to be compared with the instability of the effects produced by resorbable substances, make it the “least objectionable” injectable for the treatment of unilateral glottic fold immobility. One must overcompensate 20% to 30%, given the results of the long-term stability studies.