Kurkunpääsyövän uusiutuminen : ennustetekijät ja hoito

Laryngeal cancer is one of the most common head and neck cancers. The treatment of laryngeal squamous cell carcinoma (LSCC) has evolved towards non-surgical treatment, namely radiotherapy and chemoradiotherapy. However, the treatment outcome of LSCC has not improved. LSCC recurs in up to 30% of patients. The current knowledge on prognostic factors for recurrence is too limited to aid in treatment decisions. In this study, the treatment outcome and recurrences of 342 patients treated with curative intent for LSCC at the Finnish university hospitals during 2001-2005 were evaluated. The outcome of T1a glottic carcinomas was excellent; none of the patients died of LSCC. The results for T2 carcinomas was worse than expected; the 5-year disease-specific survival for glottic and supraglottic carcinomas in this group was 78% and 54%, respectively. The results for T3-4 carcinomas were comparable with those reported in the literature. Recurrence was observed in 22% of patients and 91% of the recurrences occured within 36 months of treatment. None of the patients with glottic T1a tumors had recurrence after 36 months, which questions the feasibility of routine 5-year follow-up for this patient group. WHO performance status >0, presence of neck metastases, and non-surgical primary treatment were significant independent predictors of recurrence. Local recurrence of glottic LSCC could be successfully salvaged. Regional or distant recurrence and any recurrence of supraglottic LSCC carried a poor prognosis. These results underline the importance of sufficiently aggressive primary treatment, particularly for supraglottic LSCC. Some LSCCs persist or recur after non-surgical treatment. Currently, there are no validated tools to identify these tumors. In this study, the expression of survivin, an inhibitor of apoptosis, Wrap53β, a protein associated with DNA double-strand break repair and telomere elongation, and p16INK4a, a surrogate marker for human papillomavirus infection, and their relation to treatment response and prognosis was investigated in LSCC tissue samples of 149 Finnish and Swedish T2-3N0M0 glottic LSCC patients treated with radiotherapy or chemoradiotherapy. Survivin showed no predictive or prognostic value. Cytoplasmic expression of Wrap53β was associated with reduced disease-free survival and overall survival. P16INK4a expression was rare in LSCC patients (7%) and more common among patients under the age of 60. In this younger patient group, none of the patients with p16INK4a expression experienced tumor recurrence. Surgery is the only standard salvage option for patients with LSCC recurrence after non-surgical therapy. Other salvage options are being investigated, one of which is boron neutron capture therapy (BNCT). In BNCT, non-radioactive boron, B10, commonly in a compound of boronophenylalanine-fructose (BPA-F), is infused intravenously. This substance has a tendency to accumulate preferably in tumor cells. After infusion, the tumor is irradiated with epithermal neutrons. This leads to boron neutron capture reaction, which releases lethal doses of radiation within the cells containing BPA-F. BNCT has the ability to deliver high doses of radiation to the tumor with low toxicity to surrounding tissues. In the current study, BNCT toxicity and outcome were evaluated in a group of nine patients with persistent or recurrent LSCC after primary non-surgical treatment. Of the eight evaluable tumors, six (75%) responded to BNCT. No serious (Grade 4-5) toxicity was encountered. Despite good responses, only one patient was permanently cured without surgery. With treatment intensification, BNCT could show potential as a larynx-sparing treatment.Kurkunpääsyöpä on yleisimpiä pään ja kaulan alueen syöpiä. Kurkunpään levyepiteelisyövän hoidossa on siirrytty yhä enemmän kurkunpäätä säästäviin, ei-kirurgisiin hoitomenetelmiin: sädehoitoon ja kemosädehoitoon. Ennuste ei kuitenkaan ole parantunut ja syöpä uusiutuukin jopa 30%:lla potilaista. Uusiutumisen ennustekijöitä tunnetaan, mutta ei riittävästi, jotta niistä olisi hoitopäätöksiä ohjaaviksi tekijöiksi. Tutkimuksessa selvitettiin kaikkien vuosina 2001-2005 Suomen yliopistollisissa sairaaloissa parantavalla tavoitteella hoidettujen 342 kurkunpääsyöpäpotilaiden hoitotulokset ja syövän uusiutumien erityispiirteet. Äänihuulten pienten, T1a-luokan, syöpien hoitotulokset olivat erinomaiset: yksikään ei kuollut kurkunpääsyöpään. T2-luokan syöpien ennuste oli huonompi kuin on yleisesti raportoitu: äänihuulisyöpäpotilaiden 5-vuotiselossaoloennuste syöpäkuolleisuuden osalta oli tässä ryhmässä 78% ja äänihuulten yläpuolista syöpää sairastavien potilaiden vain 54%. Suurten, T3-4-luokan, syöpien hoitotulokset olivat kansainvälisellä tasolla. Uusiutuma todettiin 22%:lla potilaista. Riskiä lisäsivät alentunut toimintakyky, kaulan etäpesäkkeet ja ei-kirurginen hoito. Uusiutumista 91% havaittiin 36kk sisällä hoidon päättymisestä. Yksikään T1a syöpä ei uusiutunut 36kk seurannan jälkeen ja tässä ryhmässä viisivuotisen seurannan mielekkyys on kyseenalainen. Paikallisesti uusiutuneen äänihuulisyövän ennuste on hyvä. Mikäli syöpä leviää muualle tai alkuperäinen kasvain on ollut äänihuulitason yläpuolella, ennuste on huono. Erityisesti äänihuulitason yläpuolisia syöpiä tulee siis hoitaa aggressiivisesti. Osa kurkunpääsyövistä ei reagoi ei-kirurgiseen hoitoon tai uusiutuu hoidon jälkeen. Tämän ennustamiseen ei kuitenkaan toistaiseksi ole keinoja. Tutkimuksessa selvitettiin ohjelmoidun solukuoleman estäjiin kuuluvan survivinin, DNA-vaurioiden korjaamiseen osallistuvan Wrap53β:n, ja papilloomavirusinfektion sijaismerkkiaineena käytetyn, p16INK4a:n, esiintymistä kurkunpääsyöpäkudoksessa ja tämän yhteyttä hoitovasteeseen ja ennusteeseen suomalais-ruotsalaisessa 149 sädehoidetun tai kemosädehoidetun T2-T3N0M0 äänihuulisyöpäpotilaan aineistossa. Survivinin ja hoitotulosten välillä ei havaittu yhteyttä. Wrap53β:n solulimaan painottuva esiintyminen ennusti lyhyempää syövätöntä elossaoloa ja lyhyempää elinaikaa. P16INK4a esiintyi vain 7%:ssa näytteistä ja esiintyminen oli yleisempää alle 60-vuotiailla potilailla. Näillä nuoremmilla p16INK4a:ta ilmentävää kurkunpääsyöpää sairastavilla potilailla ei havaittu lainkaan taudin uusiutumia. Boorineutronikaappaushoidossa (BNCT) potilaalle annetaan ei-radioaktiivista booriyhdistettä (BPA-F tai BSH) suonensisäisesti ja tämän jälkeen kasvainta sädetetään neutroneilla. Seuraavassa boorineutronikaappausreaktiossa kasvainsoluihin kertynyt boori hajoaa vapauttaen kuolettavan määrän säteilyä booria sisältävissä soluissa. BNCT vaikuttaa ideaalisesti vain syöpäsoluhin säästäen ympäröiviä kudoksia. Tutkimuksessa tarkasteltiin hoidon vaikuttavuutta ja haittavaikutuksia yhdeksällä BNCT-hoitoa saaneella potilaalla, joiden kurkunpääsyöpä ei ollut reagoinut ei-kirurgiseen hoitoon tai joiden tauti oli uusiutunut. Hoitovaste saatiin arvioitua kahdeksalla potilaalla, joista kuuden (75%) kasvain reagoi BNCT:lle. Vakavia haittavaikutuksia ei havaittu. Hoitovasteesta huolimatta vain yhden potilaan syöpä parani pysyvästi ilman kirurgiaa. BNCT voisi olla käyttökelpoinen kurkunpäätä säästävä hoitomuoto uusiutuneessa syövässä, jos hoitoa saadaan tehostettua

Sialendoscopy in treatment of adult chronic recurrent parotitis without sialolithiasis

The aim of this prospective study was to evaluate the efficacy of sialendoscopy in the management of adult chronic recurrent parotitis without sialolithiasis. In addition, preliminary results of an initial randomized placebo-controlled trial of single-dose intraductal steroid injection given concurrently with sialendoscopy, are presented. Forty-nine adult patients with chronic recurrent parotitis without sialoliths were included in this study. They underwent sialendoscopy and were randomized to receive either a concurrent intraductal injection of isotonic saline solution or 125 mg of hydrocortisone. Symptom severity was evaluated with visual analogue scale (VAS) and by recording symptom frequency and course with a multiple-choice questionnaire completed preoperatively and at 3, 6, and 12 months after the procedure. The mean VAS score was 5.6 preoperatively and dropped to 2.9 at 3 months, 3.0 at 6 months, and 2.7 at 12 months after the procedure. The VAS score and the frequency of symptoms were significantly lower at 3 (p <0.001), 6 (p <0.001) and 12 (p <0.001) months after the procedure when compared with the preoperative scores indicating that sialendoscopy reduces the symptoms of recurrent parotitis. However, complete permanent resolution of symptoms was rare. Single-dose steroid injection concomitant to sialendoscopy provided no additional benefit, but the current study is not sufficiently powered to determine a clinical difference between the steroid and non-steroid groups. Sialendoscopy appears to reduce the symptoms of chronic recurrent parotitis. While total permanent symptom remission is rare, sialendoscopy can be considered a safe and relatively efficacious treatment method for this patient group.Peer reviewe

Sialendoscopy under local anaesthesia

Conclusions: In most cases, both diagnostic and interventional sialendoscopy are well tolerated under local anaesthesia (LA) or under local anaesthesia with sedation (LAS), with reasonably low patient-reported discomfort. Sialendoscopy can be considered a patient-friendly and relatively painless, gland-preserving, minimally invasive procedure suitable for day surgery. Objective: To investigate patient experience and compliance in sialendoscopy under LA/LAS. Methods: This prospective study was conducted at an academic tertiary-care university hospital. During a period of 22 months, 89 patients between ages 16-81 years underwent diagnostic or interventional sialendoscopy under LA (20%) or LAS (80%). After the operation the patients filled in a questionnaire formulated by the authors concerning their procedure-related experiences. Patients' demographic data, ASA status score, pre- and intra-operative blood pressure and heart rate measurements, affected gland, operation time, intervention type, as well as pre-, peri-, and postoperative medication were gathered later from the medical records. Results: The level of discomfort and pain experienced during the operation was assessed as 'mild' or 'none' by 85% and 89% of the patients, respectively. The level of pain experienced after the operation was 'major' in 4% of patients and 'mild' or 'none' in the majority (87%) of patients. The patients' estimations showed no significant difference between the diagnostic and interventional procedures, although it seems that patients who underwent stone removal by transoral incision experienced the operation as a bit more uncomfortable and painful than other patients. Afterwards 97% of patients stated that they would agree to a new LA/LAS sialendoscopy in the future if needed.Peer reviewe

Presentation of second primary cancers in young laryngeal carcinoma patients

Background: Laryngeal squamous cell carcinoma (LSCC) is rare in the young. Objectives: We characterized the clinical behavior of LSCC and assessed the presentation of second primary tumors (SPCs) in this patient population. Materials and methods: Data from the Finnish Cancer Registry (FCR) were used to identify an epidemiological series of LSCC patients diagnosed at the age of 40 years or under, during 1953-2012 in Finland. Data regarding primary treatment, survival, and SPCs were available. To further characterize the comorbidity and lifestyle factors of young patients with LSCC, institutional data were collected of patients treated at the Helsinki University Hospital during 1967-2012. Results: We identified 151 patients, with a mean follow-up of 252 months. The 10-year overall survival (OS) was 75% and the disease-specific survival was 84%. SPCs were diagnosed in 26% (n = 39), with a median delay of 28 years. Of the 35 patients in the institutional series from Helsinki, 22 (63%) were current or former smokers. LSCC recurred in 28% of patients. Conclusions and Significance: The delay to SPCs in young patients was significantly longer compared with the general LSCC population. As factors underlying this phenomenon cannot be identified by this retrospective study, further studies are warranted.Peer reviewe

Sinonasal Oncocytic Papilloma—A Series of 20 Cases With Special Emphasis on Recurrences

Objective Reports on sinonasal oncocytic papilloma (SNOP) are scarce. The aim of this retrospective study was to evaluate the clinical features of this rarest form of sinonasal papilloma with special emphasis on the pattern of recurrences and on the potential factors predicting them. Study Design Retrospective study. Methods Between the years 1994 and 2016, 20 patients (mean age 66 years; range 30-87) were diagnosed with SNOP at the Department of Otorhinolaryngology-Head and Neck Surgery, HUS Helsinki University Hospital (Helsinki, Finland). Hospital charts were reviewed to record various medical and sociodemographic patient characteristics, and the archived histological specimens were re-evaluated. Postoperative follow-up time varied between 26 days and 167 months. Results Maxillary sinus was the most common (60%) tumor location. None of the tissue samples showed dysplasia. Recurrence rate was 39% and the median time span to the first recurrence was 25 months (range 7-71). Smokers had more often a recurrence than nonsmokers (75% vs. 31%). Patients with perioperative purulent rhinosinusitis during the primary surgery had a higher recurrence rate compared with those without (60% vs. 31%). Tumors located in the sinuses recurred more often than those located in the nasal cavity (45% vs. 29%). However, all these findings remained statistically nonsignificant. None of the cases showed malignant transformation during the follow-up. Conclusion SNOP has a propensity to recur. History of smoking, purulent rhinosinusitis during the primary surgery, and tumor location in the sinuses outside the nasal cavity seem to contribute to an increased trend in the risk of recurrence.Peer reviewe

Bacterial biofilm in salivary stones

PurposeTo assess the susceptibility of salivary stones to bacterial biofilm formation, which may be involved in the development of salivary gland infection, and to investigate a relation between microbiological aspects and patient characteristics.MethodsThis prospective study comprises of 54 patients with sialolithiasis attended in Helsinki University Hospital during 2014-2016. A total of 55 salivary stones were removed, and studied for biofilm formation using fluorescence microscopy and sonication. The isolated organisms were quantified and identified using matrix-assisted laser desorption ionization time-of-flight mass spectrometry.ResultsBiofilm formation was confirmed on the surface of 39 (70.9%) stones. A total of 96 microorganisms were isolated from 45 salivary stones (81.8%). Two or more organisms were isolated in 33 (73.3%) cases. The main isolates were Streptococcus mitis/oralis (n=27; 28.1%), followed by Streptococcusanginosus (n=10; 9.6%), Rothia spp. (n=8; 8.3%), Streptococcusconstellatus (n=7; 7.3%), and Streptococcusgordonii (n=6; 6.2%). In all patients showing pre-operative (12 cases) or peri-operative (three cases) drainage of pus, the presence of biofilm was detected in microscopy (p=0.004). Four patients showed post-operative infection, and in three of them (75.0%), the presence of biofilm was detected. Increased number of pus drainage was found among patients with reflux symptoms or use of proton-pump inhibitors.ConclusionsSalivary stones are susceptible to bacterial biofilm formation, which could be related with the development and severity of the inflammation and the refractory nature of the disease. Sonication of salivary gland stones could be a useful method for finding the etiology of the chronic infection.Peer reviewe

Reply to "Do not de-escalate oncology care in oropharyngeal cancer routinely"

Non peer reviewe

Boron neutron capture therapy for locally recurrent head and neck squamous cell carcinoma : An analysis of dose response and survival

Background and purpose: Head and neck squamous cell carcinoma (HNSCC) that recurs locally is a therapeutic challenge. We investigated the efficacy of boron neutron capture therapy (BNCT) in the treatment of such patients and the factors associated with treatment response and survival. Methods and materials: Seventy-nine patients with inoperable, locally recurred HNSCC were treated with L-boronophenylalanine-mediated BNCT in Espoo, Finland, between February, 2003 and January, 2012. Prior treatments consisted of surgery and conventionally fractionated radiotherapy to a median cumulative dose of 66 Gy (interquartile range [IQR], 59-70 Gy) administered with or without concomitant chemotherapy. Tumor response was assessed using the RECISTv. 1.0 criteria. Results: Forty patients received BNCT once (on 1 day), and 39 twice. The median time between the 2 treatments was 6 weeks. Forty-seven (68%; 95% confidence interval [CI], 57-79%) of the 69 evaluable patients responded; 25 (36%) had a complete response, 22 (32%) a partial response, 17 (25%) a stable disease lasting for a median of 4.2 months, and 5 (7%) progressed. The patients treated with BNCT twice responded more often than those treated once. The median follow-up time after BNCT was 7.8 years. The 2-year locoregional progression-free survival rate was 38% and the overall survival rate 21%. A high minimum tumor dose and a small volume were independently associated with long survival in a multi-variable analysis. Conclusions: Most patients responded to BNCT. A high minimum tumor dose from BNCT was predictive for response and survival. (C) 2019 The Authors. Published by Elsevier B.V.Peer reviewe

Tonsillar surface swab bacterial culture results differ from those of the tonsillar core in recurrent tonsillitis

Objectives/Hypothesis We aimed to determine whether there was a difference between core and surface bacteriology of Finnish adults with recurrent or chronic tonsillitis to understand whether a surface swab is worthwhile and which bacteria are involved. Study Design Case series. Methods Uninflamed tonsillar surface swabs and core biopsies were taken prior to and during surgery, respectively, in 103 patients aged 16 to 66 years undergoing tonsillectomy for recurrent or chronic tonsillitis. The McNemar test was used to determine differences between the surface and core in the most prevalent bacterial species. Results Twenty-seven bacterial species were isolated in addition to normal flora and were more commonly found in the core (1.11 surface and 4.75 core bacteria isolated per patient). Viridans group streptococci were the most commonly detected bacteria, found in 88% of the patients, mainly in the core. The bacteria in general were mainly isolated from the core. Of the 10 most prevalent bacteria, only group C beta-hemolytic streptococci showed no difference between detection from core and surface swabs. Other bacteria found mainly in the core include Prevotella melaninogenica, Staphylococcus aureus, and fusobacteria. Conclusions There is discord between the surface and core bacteria. A different population of bacteria exists in the core, especially anaerobic bacteria, suggesting that a core sample may be useful in evaluating recurrent and chronic tonsillitis. Level of Evidence 4 Laryngoscope, 2019Peer reviewe

Prospective experience of percutaneous endoscopic gastrostomy tubes placed by otorhinolaryngologist-head and neck surgeons : safe and efficacious

Percutaneous endoscopic gastrostomy (PEG) is often the treatment of choice in head and neck cancer (HNC) patients needing long-term nutritional support. Prospective studies on PEG tube placement in an otorhinolaryngologist service are lacking. At our hospital, otolaryngologist-head and neck (ORL-HN) surgeons-have performed PEG insertions for HNC patients since 2008. We prospectively analyzed 127 consecutive HNC patients who received their PEG tubes at the Department of Otorhinolaryngology-head and neck surgery, and evaluated the outcome of PEG tube insertions performed by ORL-HN surgeons. To compare time delays before and after, PEG placement service was transferred from gastrointestinal surgeons to ORL-HN surgeons, and we retrospectively analyzed a separate group of 110 HNC patients who had earlier received PEG tubes at the Department of Gastrointestinal Surgery. ORL-HN surgeons' success rate in PEG insertion was 97.6%, leading to a final prospective study group of 124 patients. Major complications occurred in four (3.2%): two buried bumper syndromes, one subcutaneous hemorrhage leading to an abscess in the abdominal wall, and one metastasis at the PEG site. The most common minor complication was peristomal granulomatous tissue affecting 23 (18.5%) patients. After the change in practice, median time delay before PEG insertion decreased from 13 to 10 days (P <0.005). The proportion of early PEG placements within 0-3 days increased from 3.6 to 14.6% (P <0.005). PEG tube insertion seems to be a safe procedure in the hands of an ORL-HN surgeon. Independence from gastrointestinal surgeons' services reduced the time delay and improved the availability of urgent PEG insertions.Peer reviewe