Guido B. van den Broek

Computed tomography-based tumour volume as a predictor of outcome in laryngeal cancer: Results of the phase 3 ARCON trial

PURPOSE Retrospective studies indicate that larger tumour volume is a strong prognostic indicator for poor tumour control after (chemo)radiotherapy for laryngeal cancer. The impact of tumour volume on the outcome of patients treated within a prospective study comparing accelerated radiotherapy (AR)±carbogen breathing and nicotinamide (ARCON) was investigated. METHODS AND MATERIALS Of 345 patients with cT2-4 laryngeal cancer, pre-treatment computed tomography (CT) scans of 270 patients were available for tumour volume calculation. Contouring of the primary tumour and involved lymph nodes was reviewed by one experienced head and neck radiation oncologist. Kaplan-Meier plots were used for analysis of outcome. RESULTS Of 137 AR and 133 ARCON patients, 57 and 80 versus 56 and 77 patients had glottic and supraglottic tumours, respectively. A correlation between primary tumour volume and T-stage was observed (Rs=.51, P<.01). In both treatment arms no correlation was detected between the primary tumour volume and local control (LC), regional control (RC) and metastasis-free survival (MFS). A strong correlation between total nodal volume and N-stage was found (Rs=.93, P<.01). Both in the AR and ARCON groups total nodal volume was not associated with poorer RC rate. However, based on individual lymph node analyses, nodal control was in favour of ARCON, irrespective of volume (P<.01). CONCLUSION Neither primary tumour volume, nor total nodal volume is a prognostic factor for patients with cT2-4 laryngeal cancer treated with accelerated radiotherapy±carbogen breathing and nicotinamide. Additional analyses based on individual nodal volumes demonstrate an excellent regional control rate and a significant benefit of ARCON.

Recurrences after thyroglossal duct cyst surgery: Results in 207 consecutive cases and review of the literature.

A thyroglossal duct cyst is the most common form of congenital anomaly in the neck. Surgical removal is very effective. However, in some cases, a cyst recurs. The purpose of this study was to identify factors that predispose to recurrence of a thyroglossal duct cyst.

Reirradiation of head and neck cancer: Long‐term disease control and toxicity

The purpose of this study was to report long‐term disease control and late radiation toxicity for patients reirradiated for head and neck cancer.

Office-Based Procedures for the Diagnosis and Treatment of Laryngeal Pathology

INTRODUCTION Since the development of distal chip endoscopes with a working channel, diagnostic and therapeutic possibilities in the outpatient clinic in the management of laryngeal pathology have increased. Which of these office-based procedures are currently available, and their clinical indications and possible advantages, remains unclear. MATERIAL AND METHODS Review of literature on office-based procedures in laryngology and head and neck oncology. RESULTS Flexible endoscopic biopsy (FEB), vocal cord injection, and laser surgery are well-established office-based procedures that can be performed under topical anesthesia. These procedures demonstrate good patient tolerability and multiple advantages. CONCLUSION Office-based procedures under topical anesthesia are currently an established method in the management of laryngeal pathology. These procedures offer medical and economic advantages compared with operating room-performed procedures. Furthermore, office-based procedures enhance the speed and timing of the diagnostic and therapeutic process.

Safety of flexible endoscopic biopsy of the pharynx and larynx under topical anesthesia

Recent advancements in transnasal endoscopy enable a shift in diagnostic workup of lesions in the pharynx and larynx, from an examination with biopsy under general anesthesia to an office-based examination with flexible endoscopic biopsy under topical anesthesia. Procedural complications were evaluated to assess the safety of office-based flexible endoscopic biopsy in patients with benign and malignant laryngopharyngeal lesions. Patients who underwent flexible endoscopic biopsy from 2012 to 2016 were evaluated retrospectively. Complications were classified using the Clavien–Dindo classification of surgical complications. A total of 201 flexible endoscopic biopsies were performed in 187 patients. Two Clavien–Dindo grade I (laryngospasm and anterior epistaxis), one grade II (laryngeal bleeding), and one grade IIIb (laryngeal edema) complication were observed. The first complication was self-limiting and the other three required an intervention. All patients fully recovered without sequelae. Flexible endoscopic biopsy appears to be a safe office-based procedure for the diagnosis of benign and malignant laryngopharyngeal lesions.

Office-based procedures for diagnosis and treatment of esophageal pathology

Diagnostic and therapeutic office‐based procedures under topical anesthesia are emerging in the daily practice of laryngologists and head and neck surgeons. Since the introduction of the transnasal esophagoscope, office‐based procedures for the esophagus are increasingly performed.

Long-term survival after relapsed NUT carcinoma of the larynx

To the Editor: We would like to comment on the manuscript entitled: “NUT carcinoma in children and adults: a multicentre retrospective study,” published in June 2017.1 In their paper, Lemelle et al. demonstrate the poor outcome of nuclear protein in testis (NUT) carcinoma after amultimodality approach. Only one out of 12 patients survived.1 In this letter, we report on a patient with a relapsed NUT carcinoma of the larynx in complete remission 5 years after the end of treatment. To our knowledge, this is the first patient described with a recurrent NUT carcinoma and treated successfully with a multimodality approach. Recently, NUT carcinoma has become a frequently described topic in the literature. Given the nonspecific histologic appearance and the fact that diagnosis requires the ability of a center to perform FISH or reverse transcription PCR, NUT carcinoma is frequently misdiagnosed.1,2 Recent insights into the oncogenetic mechanisms lead to new thoughts about the possibilities for diagnosis and treatment.3 Nevertheless, most patients reported in recent literature still die within 1 year from diagnosis.1,4 In December 2010, a 13-year-old Caucasian male was diagnosed with an undifferentiated sarcoma arising from the epiglottis, compatible with a desmoplastic small round cell tumor. Chemotherapy according to the P6 protocol, containing cyclophosphamide, doxorubicin, vincristine, ifosfamide, and etoposide, resulted in a very good partial response.5 Radiotherapy (60/2.0 Gy) to the tumor extension before onset of chemotherapy followed. Complete remission was confirmed by laryngoscopy and magnetic resonance imaging 2 months after end of treatment. In June 2012, the patient developed a local relapse. International revision of the biopsy specimens demonstratedNUT carcinoma, characterized by the BRD3–NUT rearrangement gene. Salvage treatment was proposed. The patient was treated with a supraglottic hemilaryngectomy, post-operative radiotherapy (elective dose of 50/1.67Gy on the bilateral neck levels II-III-IV with integrated boost dose up to 60/2.0Gy on the tumorbed and two marginally enlarged retropharyngeal nodes), combined with cyclophosphamide and topotecan chemotherapy. Five years after the end of treatment, the patient is alive with a normal laryngeal function and without evidence of disease. Just like our patient, seven of 12 patients reported by Lemelle et al. developed a local relapse.1 Recently, a number of publications advocate a multimodel strategy that fits the aggressive behavior of NUT carcinoma.6,7 In line with this, we argue for an aggressive combined approach with radiotherapy and surgery, whenever possible, as part of the upfront multimodality treatment.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract

OBJECTIVE Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications. MATERIAL AND METHODS A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed. RESULTS Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare. CONCLUSIONS By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.

Digital Video Laryngoscopy and Flexible Endoscopic Biopsies as an Alternative Diagnostic Workup in Laryngopharyngeal Cancer: A Prospective Clinical Study

Objectives: An office-based workup strategy for patients with laryngopharyngeal lesions suspicious for carcinoma is analyzed. The feasibility of office-based transnasal flexible endoscopic biopsies under local anesthesia and the impact on the diagnostic workup are evaluated. Methods: This study is a prospective analysis of patients with laryngeal, oropharyngeal, and hypopharyngeal lesions suspicious for carcinoma. One hundred eighty-eight participants were divided into 2 groups. The first group underwent an office-based biopsy procedure under local anesthesia using a flexible digital video laryngoscope with instrument channel (n = 53), and the second group underwent a biopsy procedure under general anesthesia using rigid laryngopharyngoscopy (n = 135). Results: Office-based flexible endoscopic biopsies were tolerated well, and there were no complications. These biopsies were 92.5% successful in acquiring a definitive diagnosis. Costs were reduced. Diagnostic workup time and time until start of therapy were reduced to 2 days and 27 days, respectively. Conclusion: Office-based biopsy under local anesthesia using flexible digital video laryngoscopy is safe, cost-effective, and successful in providing a histopathological diagnosis. It reduces the diagnostic workup time significantly in patients with laryngeal, oropharyngeal, and hypopharyngeal cancer, while also reducing the necessity to subsequently perform a rigid laryngopharyngoscopy under general anesthesia.