Jeroen Meulemans

Learning Curve in Tracheal Allotransplantation

The first vascularized tracheal allotransplantation was performed in 2008. Immunosuppression was stopped after forearm implantation and grafting of the recipient mucosa to the internal site of the transplant. Nine months after forearm implantation, the allograft was transplanted to the tracheal defect on the radial blood vessels. Since then, four additional patients have undergone tracheal allotransplantation, three (patients 2–4) for long‐segment stenosis and one (patient 5) for a low‐grade chondrosarcoma. Our goal was to reduce the time between forearm implantation and orthotopic transplantation and to determine a protocol for safe withdrawal of immunosuppressive therapy. Following forearm implantation, all transplants became fully revascularized over 2 months. Withdrawal of immunosuppression began 4 months after graft implantation and was completed within 6 weeks in cases 2–4. Repopulation of the mucosal lining by recipient cells, to compensate for the necrosis of the donor mucosa, was not complete. This resulted in partial loss of the allotransplant in patients 2–4. In patient 5, additional measures promoting recipient cell repopulation were made. The trachea may be used as a composite tissue allotransplant after heterotopic revascularization in the forearm. Measures to maximize recipient cell repopulation may be important in maintaining the viability of the transplant after cessation of immunosuppression.

Tracheal autotransplantation: guidelines for optimal functional outcome.

Tracheal autotransplants can repair extensive hemilaryngectomy defects. This technique was introduced into the clinic some 10 years ago as a means of avoiding the mutilation of a total laryngectomy in selected patients with laryngeal cancer. Our goal was to give the morphometric guidelines that guarantee an optimal functional outcome.

Midface prosthetic rehabilitation

Purpose of reviewMidfacial defects resulting from head and neck oncological resections can be addressed by microvascular reconstructive techniques using autologous tissue. In specific indications, however, prosthetic rehabilitation can give a superior aesthetic outcome, combined with a less intensive surgical strain on the patient. In other situations, the combination of both approaches can restore much extended defects satisfactorily. This review lists the indications, technical prerequisites for success, and outcome of midface prosthetic rehabilitation. Recent findingsWith increasing numbers of patients treated, the optimal treatment protocol has become clear, and is now validated by long-term results in accumulating patient numbers. Modern three-dimensional planning techniques and three-dimensional printing of drill-guides, custom-made implants, abutments and epitheses further increase the predictability of success and the aesthetic outcome. SummaryMidface prosthetic rehabilitation nowadays has a definite place in the armamentarium of the head and neck oncologic surgeon and is invaluable in restoring quality of life and social functioning of patients with extensive midfacial defects following oncological resections.

Molecular Markers and Chemotherapy for Advanced Salivary Cancer

Recent advances in our understanding of the molecular biology of salivary gland neoplasms have yielded diagnostic targets and potential therapeutic targets that have started to change our approach and choice of treatment strategies. Currently, these options are mainly investigated in recurrent and metastatic salivary gland cancer (SGC). Although the results of both cytotoxic and targeted molecular biological systemic therapy for locoregional recurrence and distant spread of SGC remain largely unpredictable, targeted therapy can be the treatment of choice in selected cases today. Molecular analysis is required as part of the diagnostic workup to help select patients with recurrent and metastatic SGC who may benefit from targeted or standard treatment regimens.

Salvage Transoral Laser Microsurgery for Radiorecurrent Laryngeal Cancer: Indications, Limits, and Outcomes

Purpose of ReviewThe aim of this report is to identify relevant literature reports on salvage transoral laser microsurgery (TLM); to consider its oncologic and functional outcomes, as well as reported complications; and to address indications and limitations of salvage TLM.FindingsThe weighted average of local control after first salvage TLM was 57%. Repeated TLM procedures for second or third recurrences were required in up to 41% of cases, resulting in a weighted average of local control with TLM alone of 67%. The rate of definite laryngeal preservation was 73%. The ultimate local control rate, including cases that required total laryngectomy, was 90%. The overall complication rate after salvage TLM was 14%.SummarySalvage TLM of radiorecurrent laryngeal cancer yields excellent oncologic outcomes. Serious complications are scarce, hospitalization times are short, and functional outcomes in terms of voice and swallowing are favorable when compared to open conservation laryngeal surgery. The key to success is an optimal patient selection.

Up-front and Salvage Transoral Robotic Surgery for Head and Neck Cancer: A Belgian Multicenter Retrospective Case Series

Introduction/aim We analyzed the functional and oncologic outcomes of primary and salvage transoral robotic surgery (TORS) procedures, performed in three Belgian institutions with a similar philosophy. Patients and methods A total of 86 patients who underwent TORS between 24-12-2009 and 25-09-2015 were retrospectively reviewed. Descriptive statistics, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS; Kaplan–Meier), and the variation of these outcomes according to whether patients had primary or salvage TORS were evaluated (univariate log-rank analysis). Results Of 86 patients, 56 (65.1%) underwent TORS as a primary treatment and 30 (34.9%) as a salvage procedure for recurrent or second primary cancer. Tumor location was mainly oropharynx (N = 63; 73.3%) followed by supraglottic larynx (N = 11; 12.8%), hypopharynx (N = 11; 12.8%), and glottic larynx (N = 1; 1.2%). In the up-front TORS group, most tumors were classified as cT1 (N = 23; 41.1%)/pT1 (N = 24; 42.9%) or cT2 (N = 27; 48.2%)/pT2 (N = 27; 48.2%) and cN0 (N = 18; 32.1%), cN1 (N = 13; 23.2%), or cN2 (N = 25; 44.6%). In the salvage TORS group, most tumors were cT1-rT1 (N = 18; 60.0%)/pT1-rpT1 (N = 18; 60.0%) or cT2-rT2 (N = 12; 40.0%)/pT2-rpT2 (N = 7; 23.3%) and cN0 (N = 25; 83.3%). Neck dissection was performed in 87.5% of primary cases and 30.0% of salvage cases. In the up-front TORS group, patients were postoperatively submitted to follow-up (N = 13; 23.2%) or received adjuvant radiotherapy, either as single modality (N = 26; 46.4%) or with concomitant cisplatin (N = 15; 26.8%). On the other hand, most salvage TORS patients did not receive any adjuvant therapy (N = 19; 63.3%). Mean and median follow-up was 23.1 and 21.2 months, respectively. Functional results were excellent (no definitive tracheostomy, long-term tube feeding in 1.8% of primary cases, and 20% of salvage cases). In the up-front TORS group, estimated 2-year OS was 88.5% (SE = 5.0%), 2-year DSS was 91.8% (SE = 4.6%) and 2-year DFS was 86.1% (SE = 5.3%). In the salvage TORS group, estimated 2-year OS was 73.5% (SE = 10.9%), 2-year DSS was 93.3% (SE = 6.4%), and 2-year DFS was 75.8% (SE = 9.7%). Comparing outcome of primarily treated patients to salvage patients, a non-statistically significant trend toward better OS (p = 0.262) and DFS (p = 0.139) was observed. Conclusion This retrospective study confirms favorable oncologic and functional outcomes of TORS for selected head and neck malignancies, both in the primary and in the salvage setting.

Development and external validation of a risk-prediction model to predict 5-year overall survival in advanced larynx cancer

TNM‐classification inadequately estimates patient‐specific overall survival (OS). We aimed to improve this by developing a risk‐prediction model for patients with advanced larynx cancer.

Up-Front and Salvage Transoral Laser Microsurgery for Early Glottic Squamous Cell Carcinoma: A Single Centre Retrospective Case Series.

Introduction/aim Transoral laser microsurgery (TLM) is a minimally invasive surgical alternative for radiotherapy (RT) in the primary management of early glottic cancer. More recently, TLM emerged also as a possible salvage treatment for selected radiorecurrent cancers. We reviewed outcomes of primary and salvage TLM performed in a Belgian tertiary referral center. Patients and methods A retrospective review of records from 142 consecutive patients who underwent TLM was performed. Oncologic outcomes were evaluated by means of descriptive statistics and Kaplan–Meier estimates. Variation of estimated outcomes between different subgroups was evaluated using Log-Rank analysis. Results Of 142 patients, 109 (76.8%) underwent TLM as a primary treatment and 33 (23.2%) were treated in a salvage setting for recurrent or second primary glottic cancer. cT classification in the up-front TLM group was cT1a in 72 (66.1%), cT1b in 11 (10.1%), and cT2 in 26 (23.9%) patients. In the salvage group, patients were cT/rT classified as cT1a–rT1a in 17 (51.5%), cT1b–rT1b in 1 (3.0%), cT2–rT2 in 14 (42.4%), and cT3–rT3 in 1 (3.0%) patients. All patients were cN0. Second-look TLM was performed in 28 patients (19.7%), and RT was associated as adjuvant therapy in 5 patients (3.5%). Mean follow-up was 51.6 months (SD = 38.4 months). Three-year overall survival (OS) was 94.1% (SE = 2.2%), 3-year disease-specific survival (DSS) 100%, 3-year disease-free survival (DFS) 80.1% (SE = 3.8%), 3-year local recurrence-free survival (RFS) 81.0% (SE = 3.7%), and 3-year ultimate local control rate with laser alone 89.2% (SE = 3.0%). Upon subgroup analysis, no differences in OS, DSS, and DFS were observed between the up-front and salvage group (log rank; p = 0.306, p = 0.298, and p = 0.061 respectively). However, local RFS and ultimate local control rate with laser alone were significantly higher in the primary treated TLM group (log rank, p = 0.014 and p = 0.012). Five-year laryngeal preservation rate was 89.7% (SE = 3.5%) in the total population, 100% in the upfront group, and 64.9% (SE = 9.8%) in the salvage group, a difference which proved statistically significant (Log-Rank, p < 0.001). Conclusion This retrospective study confirms excellent oncologic outcomes of up-front TLM for early glottic cancer. In the salvage setting, TLM allows avoidance of total laryngectomy in the majority of cases.

Carbon Dioxide Laser Microsurgical Median Glossotomy for Resection of Lingual Dermoid Cysts

Dermoid cysts are epithelial-lined cavities with skin adnexae in the capsule. Only 7% is present in the head and neck. Between 2004 and 2013, four patients with a lingual dermoid cyst underwent a microsurgical carbon dioxide laser resection via a median sagittal glossotomy approach. This approach is an elegant technique combining superior visualization, hemostasis, and little postoperative edema with good wound healing, allowing for perfect function preservation of the tongue.