Willy Lehmann

Standardized Uptake Value of 2-[18F] Fluoro-2-Deoxy-d-Glucose in Predicting Outcome in Head and Neck Carcinomas Treated by Radiotherapy With or Without Chemotherapy

PURPOSE In patients with head and neck cancer enrolled onto a prospective study of positron emission tomography (PET), pretreatment 2-[(18)F] fluoro-2- deoxy-D-glucose (FDG) uptake was evaluated as a predictor of local control and disease-free survival (DFS) after treatment by radiotherapy (RT) with or without chemotherapy. PATIENTS AND METHODS We studied 63 patients with carcinomas of the head and neck who had an FDG-PET scan before radical RT. Tumor FDG uptake was measured with the semiquantitative standardized uptake value (SUV). All patients but one were treated with accelerated or hyperfractionated RT schedules. Thirteen patients received concomitant cisplatin-based chemotherapy. RESULTS In 25 patients who presented with any component of treatment failure, the SUV was significantly higher than in the remaining patients without any such failure. Patients having tumors with high FDG uptake had a significantly lower 3-year local control (55% v 86%, P =.01) and DFS (42% v 79%, P =.005) compared with patients having low uptake tumors. In the multivariate analysis, the only factor that retained its significance for DFS was SUV category, whereas T category was of borderline significance. For local control, T category remained a significant factor, whereas a lower local control was observed for tumors with a high SUV compared with those with low SUV. CONCLUSION FDG uptake, as measured by the SUV, has potential value in predicting local control and DFS in head and neck carcinomas treated by RT. High FDG uptake may be a useful parameter for identifying patients requiring more aggressive treatment approaches.

Specificity of parotid sialendoscopy

Objective To present our initial experience with sialendoscopy of the parotid duct.

Postparotidectomy facial nerve paralysis: possible etiologic factors and results with routine facial nerve monitoring.

Objective: Analyze the incidence and factors responsible for postparotidectomy facial nerve paralysis when the surgery is performed with the routine use of facial nerve monitoring. Study Design: A prospective, nonrandomized study. Methods: Seventy consecutive patients underwent parotidectomy with intraoperative facial nerve monitoring. Two devices were used: a custom mechanical transducer and a commercial electromyograph‐based apparatus. All patients were analyzed, including those with cancer and those with deliberate or accidental sectioning of facial nerve branches. The outcome variables were the motor facial nerve function according to the House‐Brackmann grading scale (HB) at 1 week (temporary paralysis) and 6 to 12 months (definitive paralysis). Facial nerve grading was performed blindly from reviewing videotapes. Results: The overall incidence of facial paralysis (HB > 1) was 27% for temporary and 4% for permanent deficits. Most of the deficits were partial, most often concerning the marginal mandibular branch. Temporary deficits with HB scores of greater than 2 were only present in patients with parotid cancer or infection. Permanent deficits were present in three patients, including one patient with facial nerve sacrifice. Factors significantly associated with an increased incidence of temporary facial paralysis include the extent of parotidectomy, the intraoperative sectioning of facial nerve branches, the histopathology and the size of the lesion, and the duration of the operation. Conclusions: Despite a stringent accounting of postoperative facial nerve deficits, these data compare favorably to the literature with or without the use of monitoring. An overall incidence of 27% for temporary facial paralysis and 4% for permanent facial paralysis was found. Although the lack of a control group precludes definitive conclusions on the role of electromyograph‐based facial nerve monitoring in routine parotidectomy, the authors found its use very helpful.

Submandibular diagnostic and interventional sialendoscopy: new procedure for ductal disorders

We present our initial experience with submandibular sialendoscopy, a new therapeutic approach for disorders of Whartons duct. We review the sialendoscopes used and discuss their respective merits. We evaluated and treated 129 consecutive patients with suspected ductal disorders. Diagnostic sialendoscopy was used for classifying ductal lesions as sialolithiasis, stenosis, sialodochitis, or polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolith fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms. Diagnostic sialendoscopy was possible in 131 of 135 glands (97%), with an average (±SD) duration of 28 ± 15 minutes. Interventional sialendoscopy was attempted in 110 cases, with an average duration of 71 ± 41 minutes, with a success rate of 82%. Multiple sialendoscopies were necessary in 25% of cases. General anesthesia was used in 12% of cases. Submandibular gland resection was performed in 4%. The average size of the stones was 4.9 ± 2.9 mm. Multiple sialoliths were found in 31 cases (29%). Sialolith fragmentation was required in 26%. Larger and multiple stones often required longer and multiple procedures and general anesthesia, and more often resulted in failures. Semirigid endoscopes had a higher success rate (85%) than flexible sialendoscopes (54%). Complications were mostly minor, but were encountered in 10% of cases. Diagnostic sialendoscopy is a new technique for evaluating salivary duct disorders that is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, thus preventing open gland excision.

The Role of FDG-PET in the Preoperative Assessment of N-Staging in Head and Neck Cancer

This prospective study based on 48 patients showed that FDG-PET has a significantly higher sensitivity for the detection of lymph node metastases compared with palpation and it appears that FDG-PET has a similar sensitivity to CT-scanning. According to our data, FDG-PET is a highly specific method in the evaluation of neck nodes. This new imaging technique allows a tridimensional study and is easy to interpret. Therefore, FDG-PET seems to be a valuable imaging technique for the detection of cervical lymph node metastasis.

Carotid body paraganglioma with metastases.

The diagnosis of a carotid body paraganglioma with metastases led us to a critical review of the literature of 106 cases with metastasis reported between 1893 and 1980. The percentage of tumors with metastasis is in the order of 11.5% to 13%. There is no proven histological criterion from which to assert or infer their malignancy.

Histopathology of submandibular glands removed for sialolithiasis

A Detailed Description of the Pars Media of the Cricothyroid Muscle GEORGE L CHARPIED CCC MS (presenter); GREGORY A GRILLONE MD FACS; Boston MA Objectives: For proper understanding of the function of the larynx in medicosurgical management of laryngeal pathology, a thorough understanding of its structure is necessary. The pars media is a significant muscle that is poorly understood. This strap-like muscle is thought to be part of the cricothyroid muscle but is seldom mentioned in the literature on laryngeal structure. Our objective was to describe its anatomy, histology, histochemistry, morphometry, and neural innervation, in preparation for EMG studies. Methods: Thirty-six human larynges (72 hemilarynges) obtained from IRB-approved postmortem examinations were cleaned and preserved in formalin. Exposure of the pars media was via either a lateral approach (removal of thyroid lamina) or a medial approach (removal of the vocal folds). Under the guidance of a dissecting microscope, descriptions of muscle attachments and relationships were documented with line drawings and photographs. Hematoxylin and eosin, silver, and Mallorys trichrome staining, as well as computerized morphometry, further documented the pars medias structure. Results: The pars media is a large strap-like muscle with attachments to the thyroid cartilage and cricoid arch. It is innervated by the middle division of the internal branch of the superior laryngeal nerve. Its myoneural junctions are lined up along its longitudinal axis and not diffuse in distribution. In other features it appears similar to other intrinsic laryngeal muscles but less like the cricothyroid proper. Its medial surface attachment near the root of the inferior horn of the thyroid cartilage places it within less than a millimeter of the muscular process of the arytenoid cartilage. Conclusion: These data appear to show that the pars media deserves more attention than it has been given. Its orientation within the thyroid and nonrecurrent laryngeal nerve innervation make it a candidate for arytenoid reanimation. This understanding of the human pars media, further electromyographic examinations to discern function are planned.

Histopathology of Submandibular Glands Removed for Sialolithiasis

We reviewed the clinical history of 48 consecutive patients who underwent submandibular gland removal for radiologically proven sialolithiasis. The specimens were examined by a pathologist blinded to the clinical data. A histopathologic classification into 1 of 3 grades was established by evaluating the degrees of atrophy, fibrosis, and inflammation. A correlation between the clinical and pathological variables was sought in order to define clinical variables that would predict abnormal submandibular glands that required extirpation. A significant percentage of the submandibular glands exhibited normal histologic findings. The patients with normal submandibular glands had a clinical evolution similar to that of other patients with severely damaged glands. The only clinical variable that correlated with increased histopathologic alteration was the patients age. In view of the newly available diagnostic and therapeutic techniques for sialolithiasis, a conservative attitude to submandibular gland resection appears justified.

Frey syndrome treatment with botulinum toxin

The goal of this work is to present our results of the intradermic infiltration with botulinum toxin in patients with Frey syndrome. Sixteen hemifaces in 15 patients were studied. Gustatory stimulation was evoked by sucking on a slice of lemon while measurements were done on both hemifaces, with the normal side being used as a control. Skin temperature and color (erythema) were measured with a digital surface thermometer and a skin chromameter, respectively. Sweat quantity and surface were measured by using the previously described blotting paper and iodine-sublimated paper histogram methods, respectively. Testing was repeated 2 weeks after skin infiltration with botulinum toxin (dilution of 50 U/mL). The interinjection distances were 1 cm, and 0.1 mL (5 U) was infiltrated at each injection site. Frey syndrome complaints disappeared in all patients. Small residual amounts of sweat were measurable. The difference in sweat quantity before and after botulinum toxin infiltration was significant in every patient (P < 0.001). Skin temperature and color measurement gave inconclusive results. In conclusion, Frey syndrome treatment with botulinum toxin is an efficient and well-tolerated technique. Further work should address the optimal injection parameters.

ASSESSMENT OF QUALITY OF LIFE IN PATIENTS TREATED WITH ACCELERATED RADIOTHERAPY FOR LARYNGEAL AND HYPOPHARYNGEAL CARCINOMAS

This study was conducted to evaluate quality of life (QOL) and functional outcome in patients with carcinomas of the larynx and hypopharynx treated with accelerated radiotherapy (RT).