Biomedical subjects
Publications and source records attributed to P Dulguerov.
Sialolithiasis is a relatively frequent occurrence; however, cases of sialolithiasis originating around a "foreign body" nidus are rare. We describe a patient with submandibular sialolithiasis organized around a vegetal nidus and discuss the etiology of the case.
PURPOSE OF THE STUDY: To assess whether early stage (pT1-2,pN0-1) oral cavity carcinoma is adequately treated by radical surgical resection alone. MATERIAL AND METHODS: Prospective multicenter study. Of 105 patients with cT1-2 cN0-1 oral carcinoma treated in conformity with the study design, 12 had to be excluded because of tumor-positive margins or pN stage > N1. The remaining 93 patients were monitored for at least 2 years. RESULTS: Seventeen patients had local or regional recurrence develop. In 12 of the 17 patients locoregional control was achieved by second treatment. Overall, the 4-year disease-specific survival probability was 94%. Patients treated initially without selective neck dissection had significantly higher recurrence rates than those with neck dissection, although the survival probability was not adversely affected. CONCLUSIONS: Early (pT1-2, pN0-1) squamous cell carcinoma of the oral cavity is adequately treated by surgery alone, provided the resection margins are tumor free. On the basis of the presented data, we would also advocate routine selective neck dissection.
OBJECTIVE: To present our initial experience with sialendoscopy of the parotid duct. STUDY DESIGN METHODS: Diagnostic and interventional sialendoscopy procedures were performed in 79 and 55 cases, respectively. Diagnostic sialendoscopy was used to classify ductal lesions into sialolithiasis, stenosis, sialodochitis, and polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolithiasis 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. RESULTS: Diagnostic sialendoscopy was possible in all cases, with an average duration of 26+/-14 minutes and no complications. Interventional sialendoscopy was successful in 85% of cases, with an average duration of 73+/-43 minutes (+/- standard deviation). Multiple procedures were performed in 45% of cases, general anesthesia was used in 24%, and parotidectomy in 2%. Multiple sialoliths were found in 58% of ducts and associated with more procedures under general anesthesia and longer operations. The average size of sialoliths was 3.2+/-1.3 mm; larger stones were associated with more procedures under general anesthesia, longer and multiple procedures, use of fragmentation, and sialendoscopy failures. Sialolithiasis fragmentation was required in 10% of cases, with a success rate of 70%. Semirigid sialendoscopes performed better than flexible ones. Complications were mostly minor but were encountered in 12% of cases. CONCLUSIONS: Diagnostic sialendoscopy is a new technique for evaluating salivary duct disease, a technique which is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, preventing open gland excision.
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 I 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 patient's age. In view of the newly available diagnostic and therapeutic techniques for sialolithiasis, a conservative attitude to submandibular gland resection appears justified.
BACKGROUND: Accelerated radiotherapy (RT) represents a promising method with which to improve the treatment outcome in patients with head and neck carcinoma. However, its applicability to elderly patients has not been well established. This study assessed treatment toxicities, patient compliance, and oncologic results in patients age >/= 70 years who were treated with an accelerated concomitant boost RT schedule. METHODS: Between 1991 and 1997, 39 patients aged >/= 70 years (mean, 75 +/- 6 years) presenting with carcinomas of the oral cavity, pharynx, or larynx were treated radically with a modified concomitant boost RT schedule (planned dose of 69.9 grays [Gy] over 38 days). Based on American Joint Committee on Cancer staging, there were 14 patients with Stage I-II disease and 25 patients with Stage III-IV disease. Eighty-one patients age < 70 years who were treated with the same RT schedule served as a comparative group. The median follow-up for the surviving patients was 19 months (range, 3-65 months) and 23 months (range, 2-76 months), respectively, for the elderly and younger patient groups. RESULTS: The planned RT schedule was completed in all cases. Three patients (8%) in the elderly group and none in the younger group had an unplanned treatment interruption because of acute toxicity or lack of compliance (P = 0.03). The median tumor dose (69.9 Gy; range, 67-73 Gy) and the median overall treatment time (41 days; range, 36-60 days) were identical in both groups. According to the Radiation Therapy Oncology Group grading system, Grade 3-4 acute reactions were observed in 66% of elderly patients and in 71% of younger patients. Ten elderly patients (26%) and 19 younger patients (23%) required a nasogastric tube or a percutaneous gastrostomy for feeding, with a median weight loss of 4.1 kg and 4.4 kg, respectively, in the 2 groups. Grade 3-4 late complications were observed in 3% of the elderly patients and 10% of the younger patients (P = 0.43). Both elderly and younger patients had similar results with regard to 3-year actuarial overall survival (68% vs. 62%; P = 0.48) and locoregional control (73% vs. 68%; P = 0.31). CONCLUSIONS: The current study suggests that an accelerated concomitant boost RT schedule is feasible in elderly patients who are physically healthy enough to undergo curative treatment. The acute and late toxicities appear to be similar to those observed in younger patients, and treatment outcomes appear to be comparable.
OBJECTIVE: To evaluate the possibility, complications, and efficacy of endoscopic neck dissection (END) in a porcine model. DESIGN: Experimental self-controlled study. SUBJECTS: Minipigs. INTERVENTION: Endoscopic neck dissection was performed using general anesthesia with techniques adapted from laparoscopic surgery. The tissue specimens removed were divided according to porcine equivalents of human neck groups. After the completion of END, open-neck dissection was performed using standard surgical techniques, and the remaining tissue within each neck group was retrieved. A pathologist evaluated each specimen without knowing its exact origin in terms of neck group or side and the type of surgical technique used. For each specimen, the number of retrieved lymph nodes and their anatomical integrity were analyzed. RESULTS: Ten neck dissections were performed in 8 minipigs without any major complications. The number of retrieved lymph nodes by END was 18.4 +/- 7.4 (mean +/- SD). Completed open-neck dissection retrieved an additional 3.3 +/- 1.8 lymph nodes. The efficacy rate of END was 88% +/- 10% (+/ -SD). The majority of retrieved lymph nodes were intact, with less than 5% of nodes exhibiting crushing artifacts. CONCLUSIONS: Endoscopic neck dissection in a porcine model seems to be free of major complications and able to retrieve the majority of neck lymph nodes. A larger number of animals and their survival need to be studied before human studies can begin.
BACKGROUND: 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). METHODS: Between January 1991 and September 1996, 21 patients treated with accelerated concomitant boost RT schedule (69.9 Gy in 5. 5 weeks) for laryngeal (n = 10) or hypopharyngeal (n = 11) carcinomas and who remained free of disease at 1-year minimum follow-up were evaluated. The functional outcome was assessed by the subjective Performance Status Scale for Head and Neck cancer (PSSHN) and general QOL by the European Organization for Research and Treatment of Cancer Core QOL questionnaire (EORTC QLQ-C30). The median length of follow-up was 37 months (range, 13 to 75). RESULTS: The PSSHN scores were 89, 84, and 86, respectively, for eating in public, understandability of speech and normalcy of diet (100 = normal function). Significantly lower scores for understandability of speech were observed in patients with advanced and laryngeal carcinomas. Normalcy of diet was affected negatively by the severity of xerostomia. All mean functional scale scores of the EORTC QLQ-C30 module were 20% to 25% below the higher score. Most of these scale scores were significantly affected by the severity of xerostomia. CONCLUSIONS: Patients treated with concomitant boost RT for laryngeal and hypopharyngeal carcinomas appear to have similar QOL and functional outcome to those reported for patients treated with conventional or hyperfractionated RT. As expected, many QOL scales were affected by the severity of xero- stomia.
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.
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PURPOSE: To evaluate the accuracy of magnetic resonance (MR) sialography in detecting salivary glandular calculi and ductal stenoses. MATERIALS AND METHODS: In a prospective study, 64 salivary glands in 61 consecutive patients with acute or recurrent parotid or submandibular glandular swelling were examined by using three-dimensional (3D) extended-phase conjugate-symmetry rapid spin-echo (EXPRESS) MR imaging. Transverse and sagittal-oblique source images and maximum intensity projection images were obtained. All MR images were analyzed independently by two radiologists, without knowledge of the final diagnosis. The reference standard was conventional sialography, ultrasonography (US), and sialendoscopy with or without surgery in 31 glands and was conventional sialography and US in 33 glands. RESULTS: Final diagnoses included sialolithiasis (n = 23), sialolithiasis and stenosis (n = 9), stenosis without lithiasis (n = 11), early Sjögren syndrome without ductal stenosis (n = 2), ductal displacement (n = 3), and normal salivary glands (n = 16). The sensitivity, specificity, and positive and negative predictive values of MR sialography to detect calculi were 91%, 94%-97%, 93%-97%, and 91%, respectively. False-negative readings occurred due to calculi with a diameter of 2-3 mm in nondilated salivary ducts. Ductal stenosis was assessed, with a sensitivity of 100%, specificity of 93%-98%, positive predictive value of 87%-95%, and negative predictive value of 100%. Interobserver agreement was very good (kappa = 0.85-0.97). CONCLUSION: MR sialography with 3D EXPRESS imaging enables reliable prediction of salivary gland calculi and stenoses.
Intractable aspiration is a life-threatening problem and often requires a procedure for blocking or separating the larynx from the bronchial tree. The disadvantage of these techniques is a compromise of phonation. We report the use of a speech fistula after laryngotracheal diversion to restore voice. It allows for the definitive treatment of aspiration, while maintaining the use of the vocal folds for phonation.
OBJECTIVE: To evaluate and compare the performances of FDG-PET imaging, MRI and clinical examination in the detection of residual tumour 3 months after treatment of patients with head and neck squamous cell carcinoma. PATIENTS: A consecutive sample of 50 patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx or larynx, or a cervical lymph node metastasis from an unknown primary site excluding T1 lip and T1 vocal cord tumours. METHODS: Treatment outcome was assessed after 3 months by clinical examination, MRI, and FDG-PET scan. Sensitivity, specificity and accuracy were calculated relative to proven biopsy of residual tumour or a clinical follow-up of 4 months. RESULTS: Residual cancer was confirmed in 8 patients (16%), while the clinical follow-up was unsuspicious in the remaining 42 patients. PET-FDG had a sensitivity of 100% as compared to MRI (88%) and clinical examination (63%). Specificity was higher for clinical examination (90%), intermediate for MRI (83%) and lowest for PET-FDG (74%). CONCLUSIONS: This study finds very high sensitivity for PET-FDG in the detection of residual tumour. However, its lower specificity, lack of anatomical resolution, and high cost, require further studies to determine its role in routine screening.
INTRODUCTION: Early stage oral cavity carcinoma is curable in most cases. This study follows the course of early stage squamous cell carcinoma of the oral cavity after radical surgical resection, in order to assess the necessity of further treatment modalities. MATERIAL AND METHODS: In a prospective multicentric study, 110 patients with T1-T2 and N0-N1 (without capsular invasion) squamous cell carcinoma of the oral cavity were enrolled. All patients were treated exclusively by surgical resection with histopathologically proven negative margins. RESULTS: Among 96 patients (14 excluded because of positive margins), followed-up for 3 years, 18 presented a local or regional recurrence. In 12 of these 18 loco-regional control was reestablished by second treatment. Overall, the 4-year disease-specific survival probability was 94%. Patients treated initially by selective neck dissection had significantly lower recurrence rates than those without neck surgery. CONCLUSION: Early (T1-2, N0-1) squamous cell carcinoma of the oral cavity is adequately treated by surgery alone. The surgical procedure should include margin-free resection of the primary combined with selective neck dissection. Systematic postoperative radiotherapy does not appear necessary. Neck dissection is advocated in N0 patients as well.
INTRODUCTION: Objective evaluation methods for facial nerve function are yet to be standardised. Unresolved issues include what should be measured for different facial movements and how these measurements should be performed. METHODS: 5 facial mimics were analysed in normal subjects and in patients with facial paralysis. For each mimic the best measurement was determined and two global indexes derived. RESULTS: The best measurements were of surfaces close to the moving facial zone. These measurements and the global indexes correlated well with gradings by the House-Brackmann scale.
INTRODUCTION: In many institutions patients are evaluated to rule out an infectious focus in the ENT sphere prior to cardiac surgery. In a prospective clinical study we assessed the contribution of history and clinical examination in the detection of ENT infections. METHODS: From October 1998 to January 2000, 68 patients were evaluated by self-administered questionnaire and an ENT examination. Dental status was evaluated separately by a dentist. RESULTS: The patient population was divided into two groups: The first group consisted of 23 patients (33.8%) with at least one ENT symptom: in 22 the examination was normal and one patient had viral pharyngitis. 5 patients in this group presented a postoperative infectious complication. The second group comprised 45 patients (66.2%) without a history suggestive of a possible infectious focus: in 44 the examination was normal and one patient presented otitis media with effusion. 2 patients in this group had a postoperative infectious complication. DISCUSSION: Routine ENT examination is not necessary prior to cardiac surgery. The patient history can be used to select patients for further evaluation.
AIM: The objective of this study was to compare screening ultrasound (US) obtained in patients with squamous cell carcinoma of the head and neck with F-18-FDG PET and to evaluate if US obtained before F-18-FDG PET has the potential to enhance patient management by the detection of additional lesions. METHOD: 28 patients were prospectively included in the study (7 females and 21 males; range: 28-82 years). All had one follow-up examination after surgical treatment and/or radiotherapy using a combination of US and F-18-FDG PET on the same day (6-35 months after the end of treatment). Outcome was determined by either biopsyproven cancer recurrence or negative clinical follow-up for additional 6 months after this examination. RESULTS: Regarding only the regions of the neck evaluated with both methods, US detected 25 suspect lesions vs. 9 lesions detected by F-18-FDG PET. Descriptive statistical analysis showed better sensitivity, specificity and accuracy of F-18-FDG PET. Only in 3 patients a lesion was detected in the same anatomical region using both methods. One patient was false positive with both methods. In another patient US detected a calcified right carotid artery plaque that lead to surgical therapy. CONCLUSION: F-18-FDG PET is better for the detection of clinically relevant lesions in the follow-up of patients with squamous cell carcinoma of the head and neck. In this study, the additional value of morphological information obtained by screening US performed before the PET scan is limited. US may not be a suitable test to improve interpretation of PET examinations.
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PURPOSE: To assess the impact of treatment interruption on the potential gain in locoregional control obtained with accelerated radiotherapy (RT) compared with conventionally fractionated RT in patients with oropharyngeal carcinomas. METHODS AND MATERIALS: 152 patients treated with radical RT for oropharyngeal carcinomas between 1979 and 1996 were retrospectively analyzed. According to the American Joint Committee on Cancer (AJCC) staging system, there were 6/30/43/73 stages III/III/IV. Sixty-one patients were treated with a conventional RT schedule (median dose 70 Gy in 35 fractions), and 91 patients with either of two 5/5.5-week accelerated RT schedules (median dose 69.6-69.9 Gy in 41 fractions). Discounting weekends, RT was interrupted for 2 consecutive days or more in 53 patients (median duration 11 days, range 2-97), including 67% of the patients in the conventional RT group and 13% in the accelerated RT group. Median follow-up for surviving patients was 55 months (range 23-230). The Cox proportional hazards model was used for the multivariate analysis of factors influencing locoregional control. RESULTS: In univariate analysis, factors associated with a significant decrease in locoregional control included WHO performance status > or =1, advanced AJCC stages (III and IV), conventional RT fractionation, overall treatment time > or =44 days (median), and RT interruption. In the multivariate analysis, when introduced into the model individually, the three significant therapeutic factors remained significant after adjustment for the forced clinical variables. However, when the three therapeutic factors were introduced together into the model, beside the AJCC stage (P = 0.017), only RT interruption remained a significant independent adverse prognostic factor (P = 0.026). CONCLUSIONS: This multivariate analysis highlights the potential negative impact of treatment gaps on locoregional control in oropharyngeal carcinomas. This suggests that treatment interruption may be an even more important parameter than the type of RT schedule per se. Thus, when assessing the relative merit of two RT schedules, inclusion of the other therapeutic factors in a multivariate model is mandatory in order to avoid misinterpretation of the results.