A "royal" total laryngectomy that never was

With this historical vignette, ending the series dedicated to the pioneers of total laryngectomy, published in the EuropeanAnnals of Otorhinolaryngology Head & Neck Diseases to mark the 150th anniversary of the first description of this surgical procedure in humans, the authors recount what history called "The Crown Prince's illness", and wonder what might have happened if the total laryngectomy proposed for Crown Prince Friedrich had finally been performed.

Novel Strategies for Managing Retropharyngeal Lymph Node Metastases in Head and Neck and Thyroid Cancer with Transoral Robotic Surgery (TORS)

Retropharyngeal metastases are encountered in a variety of head and neck malignancies, imposing significant surgical challenges owing to their distinct location and proximity to neurovascular structures. Radiotherapy is the recommended treatment in most cases owing to its oncological efficacy. However, retropharyngeal irradiation affects the superior pharyngeal constrictor muscles and parotid glands, with the potential for long-term dysphagia and xerostomia. A younger oropharyngeal and thyroid cancer patient demographic is trending, fueling interest in treatment de-escalation strategies. Consequently, reducing radiotoxicity and its long-term effects is of special relevance in modern head and neck oncology practice. Through its unique ability to safely extirpate these traditionally difficult-to-access retropharyngeal lymph nodes via a natural orifice, TransOral Robotic Surgery (TORS) can considerably lower the surgical morbidity of retropharyngeal lymph node dissection (RPLND), compared with current existing approaches. This review summarizes the latest developments in the field, exposing current research gaps and discusses specific clinical settings where TORS could enable treatment de-escalation. In early-stage node-negative oropharyngeal cancer, single-modality surgical treatment with TORS RPLND may improve risk stratification of metastasis and recurrence in this region. TORS RPLND is also a potentially viable treatment option in salvage of an isolated retropharyngeal node recurrence or in the primary setting of a thyroid malignancy with a single positive retropharyngeal node. In time, TORS RPLND may provide an alternative de-escalation strategy in these three scenarios. However, with the reported morbidities, further prospective trials with long-term follow-up data are required to prove oncological safety and functional benefits over existing strategies.

Buccal fat pad to improve velum competency after transoral lateral oropharyngectomy

This technical note documents an easily reproducible technique to improve velar competency after transoral lateral oropharyngectomy extending to the velum.

Is transoral robotic surgery a safe and effective multilevel treatment for obstructive sleep apnoea in obese patients following failure of conventional treatment(s)?

A best evidence topic was written according to a structured protocol. The question addressed was whether TransOral Robotic Surgery (TORS) is a safe and effective multilevel treatment for Obstructive Sleep Apnoea (OSA) in obese patients following failure of conventional treatment(s). A total of 39 papers were identified using the reported searches of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing treatments for OSA - primarily CPAP - though highly effective are poorly tolerated resulting in an adherence often lower than 50%. As such, surgery is regaining momentum, especially in those patients failing non-surgical treatment (CPAP or oral appliances). TORS represents the latest addition to the armamentarium of Otorhinolaryngologists - Head and Neck Surgeons for the management of OSA. The superior visualisation and ergonomics render TORS ideal for the multilevel treatment of OSA. However, not all patients are suitable candidates for TORS and its suitability is questionable in obese patients. In view of the global obesity pandemic, this is an important question that requires addressing promptly. Despite the drop in success rates with increasing BMI, the success rate of TORS in non-morbidly obese patients (BMI = 30-35kgm^-2) exceeds 50%. A 50% success rate may at first seem low, but it is important to realize that this is a patient cohort suffering from a life-threatening disease and no option left other than a tracheostomy. As such, TORS represents an important treatment in non-morbidly obese OSA patients following failure of conventional treatment(s).

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There is a paucity of evidence on the subject with complete absence of RCTs.

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The literature supports TORS as a safe multilevel treatment for OSA.

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The effectiveness of TORS for OSA drops with increasing BMI.

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TORS represents an important treatment for OSA in non-morbidly obese patients after failure of conventional treatment(s).

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There is no role for TORS as an OSA treatment in morbidly obese patients.

Transoral robotic reconstructive surgery

Transoral robotic surgery (TORS) has emerged as a technique that allows head and neck surgeons to safely resect large and complex oropharyngeal tumors without dividing the mandible or performing a lip-split incision. These resections provide a reconstructive challenge because the cylinder of the oropharynx remains closed and both physical access and visualization of oropharyngeal anatomy is severely restricted. Transoral robotic reconstruction (TORRS) of such defects allows the reconstructive surgeon to inset free flaps or perform adjacent tissue transfer while seeing what the resecting surgeon sees. Early experience with this technique has proved feasible and effective. Robotic reconstruction has many distinct advantages over conventional surgery, and offers patients a less morbid surgical course. In this review, we discuss the clinical applicability of transoral robotic surgery in head and neck reconstruction, highlighting the benefits and limitations of such an approach, and outlining the guidelines for its utilization.

Sinonasal and nasopharyngeal applications of the hand-held CO2 laser fiber

BACKGROUND

Carbon dioxide (CO(2)) laser provides precision and excellent hemostasis, leading to healing with minimal discomfort and complications. In spite of the advantages, the application of CO(2) laser has been limited in the sinonasal region due to the difficulty in delivering laser energy to the deep, narrow, and confined spaces. The availability of flexible laser fibers and custom-designed hand pieces has rectified these limitations but, until this date, there are no data on their safety and efficacy profile.

METHODS

We conducted a retrospective chart review of patients who underwent sinonasal and nasopharyngeal surgery with a hand-held CO(2) laser at M.D. Anderson Cancer center between 2007 and 2009.

RESULTS

Out of 12 patients, 3 patients had postradiotherapy adhesions, 2 patients had a recurrent sinonasal mucoepidermoid carcinoma and 1 patient each had a ganglioneuroblastoma of the nasopharynx involving the basisphenoid and clivus, recurrent spindle cell melanoma of the nasopharynx, juvenile nasopharyngeal angiofibroma, papilloma of the nasal cavity, pituitary adenoma, spindle cell lipoma of the nasopharynx, and intranasal Rosai-Dorfman disease. The CO(2) laser, along with conventional endoscopic techniques and instruments, was used at 6-12 W continuous mode, to excise the disease. Median blood loss was 88 mL with no laser-related complication in any patient.

CONCLUSION

In sinonasal and nasopharyngeal regions, use of hand-held CO(2) laser fiber provides precision, excellent hemostasis and minimizes tissue manipulation thereby reducing risk to the underlying structures. Thus, it can be an important tool for rhinologists and skull-base surgeons, especially for revision and postradiotherapy cases.

TrkB induces EMT and has a key role in invasion of head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) remains a significant public health problem, accounting for over 5% of all cancer-related deaths, and these deaths primarily result from metastatic disease. The molecular processes involved in HNSCC pathogenesis and progression are poorly understood, and here we present experimental evidence for a direct role of the cell surface receptor tyrosine kinase, TrkB, in HNSCC tumor progression. Using immunohistochemical analysis and transcriptional profiling of archival HNSCC tumor specimens, we found that TrkB and its secreted ligand, brain-derived neurotrophic factor (BDNF), are expresses in greater than 50% of human HNSCC tumors, but not in normal upper aerodigestive tract (UADT) epithelia. Studies with HNSCC cell lines reveal that in vitro stimulation with BDNF, the ligand for TrkB, upregulates the migration and invasion of HNSCC cells, and both transient and stable suppressions of TrkB result in significant abrogation of constitutive and ligand-mediated migration and invasion. Furthermore, enforced overexpression of TrkB results in altered expression of molecular mediators of epithelial-to-mesenchymal transition (EMT), including downregulation of E-cadherin and upregulation of Twist. Using an in vivo mouse model of HNSCC, we were able to show that downregulation of TrkB suppresses tumor growth. These results directly implicate TrkB in EMT and the invasive behavior of HNSCC, and correlate with the in vivo overexpression of TrkB in human HNSCC. Taken together, these data suggest that the TrkB receptor may be a critical component in the multi-step tumor progression of HNSCC, and may be an attractive target for much needed new therapies for this disease.

Outcomes after radiotherapy for basaloid squamous cell carcinoma of the head and neck: a case-control study

BACKGROUND

Basaloid squamous cell carcinoma (BSCC) is an uncommon, high-grade variant of squamous cell carcinoma (SCC) of the head and neck. Its poorer prognosis compared with common SCC remains controversial. The authors investigated the outcomes of patients with BSCC who received radiotherapy and compared them with the outcomes of patients with SCC.

METHODS

From 1994 to 2004, 1007 patients received radiotherapy for head and neck carcinoma with lymph node involvement. The histologic types consisted of 51 BSCC, 431 poorly differentiated SCC (PSCC), and 525 well or moderately differentiated SCC (WMSCC). A case-control analysis was performed with BSCC matched against both PSCC and WMSCC to compare disease-control and survival rates.

RESULTS

Patients with BSCC received treatment modalities similar to those received by patients with SCC: They received induction chemotherapy (12%) or concurrent chemotherapy (33%), and a median radiation dose of 70 Gray. Posttreatment viable tumor was present in 44%, 13%, and 28% of neck dissection specimens from patients with BSCC, PSCC, and WMSCC, respectively. The 5-year disease-free survival rates (63%, 77%, and 76%, respectively) and overall survival rates (85%, 70%, and 71%, respectively) demonstrated no statistically significant differences for BSCC, PSCC, or WMSCC, respectively.

CONCLUSIONS

In this study, a poorer prognosis could not be demonstrated for irradiated patients with BSCC compared with either PSCC or WMSCC. All patients in this study had positive lymph node status, and the majority of patients (84%) had oropharyngeal cancer. The BSCC cohort did have a relatively high rate of viable tumor in their posttreatment neck dissections, and they had a relatively high rate of distant disease. On the basis of the high rate of lung metastases and the possibility of efficient salvage, the authors recommend obtaining a chest computed tomography scan during initial staging and follow-up.

Acquisition of anoikis resistance is a critical step in the progression of oral tongue cancer

We hypothesized that acquisition of resistance to anoikis is a critical step in oral cancer progression. To test this hypothesis, we compared a panel of cell lines derived from human oral tissues across the spectrum of tumor progression from oral keratinocytes (HOK-16B), invasive oral squamous cell carcinoma (Tu167), and finally metastatic carcinoma (TxCS-1, MDA1986) for their sensitivity to detachment from the extracellular matrix. The relationship between stage of tumor progression and anoikis resistance was demonstrated by the apoptotic fractions after 48 h in suspension culture which were 93.33, 61.6, 34.5, and 3.71%, respectively. To further demonstrate that anoikis resistance is important for tumor progression, we selected a highly anoikis resistant cell line, JMAR, by serial passage of the Tu167 cell line in suspension culture. Initially, the JMAR line, and clones derived from it, were characterized for anoikis resistance in vitro, and after 72 h in suspension culture the rates of anoikis in the Tu167 and JMAR lines were found to be 73 and 26%, respectively. The degree of anoikis resistance was found to correlate with survival of nude mice orthotopically injected with 5x10(5) Tu167 or JMAR cells. The JMAR mice had a median survival of 17 days versus over 30 days in mice implanted with the Tu167 line. Finally, we found that in vivo selection in the orthotopic model for a regionally metastatic cell line by implantation of Tu167 into the tongues of nude mice and harvesting and culturing cervical lymph nodes led to production of a cell line, Tu167LN1, which was found to be anoikis-resistant. This cell line had an apoptotic cell fraction of 16.2% (+/-3.14%) after 48 h in suspension culture.

Hearing preservation in conservation surgery for vestibular schwannoma

OBJECTIVE

To evaluate preservation of hearing in the resection of vestibular schwannomas.

STUDY DESIGN

A retrospective case review.

SETTING

Tertiary-care medical center.

PATIENTS

Forty-seven patients (25 men, 22 women) were studied; mean age was 46 years, mean tumor diameter 9.8 mm (range 3-30 mm.)

INTERVENTIONS

All patients underwent resection of vestibular schwannomas by the middle cranial fossa (MCF) or the retrosigmoid (RS) approach.

MAIN OUTCOME MEASURES

Hearing preservation was classified by the criteria outlined by the American Academy of Otolaryngology-Head Neck Surgery. Hearing was assessed preoperatively and postoperatively at 1 month and 1 year. Facial function was graded according to the House-Brackmann scale. Minimum follow-up was 18 months.

RESULTS

Hearing was preserved in 69% of patients who underwent the MCF approach but in only 33% of patients for whom the RS approach was used. The RS approach was used for larger tumors (mean diameter 15 mm) and the MCF procedure for smaller tumors (mean diameter 9 mm). One hundred percent of patients had facial function H/B grade II or better, regardless of approach.

CONCLUSION

Hearing function can be reliably preserved in a high percentage of selected patients undergoing resection of vestibular schwannoma.