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Objective: Determine human papillomavirus (HPV) incidence in unknown primary squamous cell carcinomas (SCCa) of the head and neck and assess if HPV status influenced survival., Study Design: Historical cohort study., Setting: Tertiary care center., Subjects: Patients with unknown primary SCCa despite a complete workup who underwent neck dissection or excisional biopsy and postoperative comprehensive ± chemoradiotherapy between 2002 and 2009., Methods: HPV fluorescence in situ hybridization (FISH) and p16(INK4a) immunohistochemistry (p16 IHC) were performed. Results were compared with survival, age, race, gender, tobacco use, alcohol use, and nodal stage., Results: Twenty-five patients met the inclusion criteria, of whom 88% were >10 pack year tobacco users. Twenty-eight percent were HPV-positive defined by both p16+ and FISH+. Five-year overall survival was 66.7% in HPV-positive and 48.5% in HPV-negative patients (P = .35). Similarly, 5-year disease-free survival rates were 66.7% in HPV-positive and 48.5% in HPV-negative patients (P = .54). All 3 HPV-positive nonsmokers were survivors, but this was not significant because of the small sample size (P > .05). No other characteristics were associated with survival (P > .05)., Conclusion: Twenty-eight percent of metastatic lymph nodes from occult primary tumors were HPV positive. There was no survival difference associated with HPV status. Most of the HPV-positive patients in this study were tobacco users who had similar survival to HPV-negative patients, so caution should be used in interpreting HPV status in these patients.

Background: The use of percutaneous endoscopic gastrostomy (PEG) for nutrition support is increasing worldwide, but few studies have evaluated the durability of and complications related to the different materials used to manufacture gastrostomy tubes. Latex PEG tubes are widely used in our clinical setting, but no studies have compared their durability with silicone PEG tubes. The aim of the present study was to compare the durability of latex tubes with the durability of silicone tubes., Patients and Methods: A randomized clinical trial was conducted in patients with head and neck cancer with indications for PEG. Sixty patients were randomized to receive either latex or silicone PEG tubes and followed up for 90 days. The analyzed outcomes were duration, peristomal infection, granulated tissue formation, and leakage around the tube., Results: The durability of silicone PEG tubes was significantly greater than the durability of latex PEG tubes. The survival curves showed that silicone PEG tubes lasted twice as long (hazard ratio = 2.0, 95% confidence interval = 1.1-3.7, P = 0.01). No differences were found with regard to rate of peristomal infection, granulated tissue formation, or leakage., Conclusion: Silicone PEG tubes are associated with a reduced need for replacement (attributable to higher durability) compared with latex PEG tubes., (© 2010 The Authors. Digestive Endoscopy © 2010 Japan Gastroenterological Endoscopy Society.)

Despite multiple medical and scientific achievements, cancer remains a leading cause of death worldwide. Next to imaging technologies, molecular methods for early detection and for monitoring of the course of disease are of increasing interest. Thus, over the past years numerous studies have focused on the identification of biomarkers for cancer diagnosis, prognosis and response to therapy. The study of biomarkers seems to pose a high degree of complexity because many different types of molecules may, in principle, serve as potential biomarkers. In addition, these molecules can be produced either by the tumor or by the tumor-host in response to the presence of cancer. In this review the authors will address several major topics encompassed by the field of biomarker research. They will discuss the primary sources from which biomarker candidates can be 'mined' as well as the technological or methodological challenges associated with identification of biomarkers. Furthermore, the review will focus on current biomarker candidates for head and neck squamous cell carcinoma (HNSCC), with particular interest on several molecules yielding potential relevance for detection and prognosis of this type of cancer. Finally, several biomarker candidates with predictive potential for the response to therapy of HNSCC patients will be discussed, since identifying such molecules is crucial for developing individually-tailored and improved therapeutic strategies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Stem cells play a central role in re- and generation of tissues. Special importance has been attributed to them in cancer biology. 2 entities can be discriminated: cancer infiltrating stem cells and cancer initiating stem cells. Infiltrating stem cells will be attracted to the tumor in order to be remodelled for tumor expansion, e. g. endothelial cells or other cancerous tissue components, yet these cells are per se benign. Malignant cancer stem cells are capable to generate a new tumor, histologically identical with the cancer they originate from. Many steps in cancer stem cell biology are not understood to date. It is still believed that CSC are only a minor cell fraction in tumor but capable to differentiate in hierarchical manner into any other tissue type. These stem cells are undergoing many steps of differentiation and dedifferentiation in a steady state. The factors of the micromilieu contributing to this are largely not understood. Still these steps are regarded as the key to tumor initiation, metastases and resistance to therapy. The biological functions and associated signal transduction pathways, e. g. self renewal pathways will be the key to future therapeutical strategies., (© Georg Thieme Verlag KG Stuttgart · New York.)

This article provides an overview of ultrasound and the techniques for its use by otolaryngologists in diagnosing and treating neck masses and lesions. Head and neck ultrasound is extremely useful in diagnosing neck masses and lesions and in facilitating many procedures that are commonly performed on the head and neck. Although in the past these studies were generally performed by radiologists, clinicians are now able to perform high-quality ultrasound studies and ultrasound-guided procedures in the head and neck. Given the advanced knowledge of head and neck anatomy and disease processes that otolaryngologists possess, head and neck ultrasound offers a logical and valuable extension of the physical examination. Recent improvements in ultrasound resolution, portability, and affordability have provided an excellent impetus for otolaryngologists to incorporate ultrasound into their office and operative practices., (Published by Elsevier Inc.)

Ultrasound, as a diagnostic modality, has been developing rapidly. High-resolution ultrasound machines have been reduced to the size of a laptop computer. Ultrasound can be adopted by otolaryngologists for use within the clinic and the operating room. Ultrasound offers several advantages to the pediatric patient population. It is well tolerated and adds a degree of precision to the physical examination. It can be done repeatedly as lesions evolve and treatment is performed. It is valuable for guidance and therapeutic treatment of lesions in the operating room. It is likely that ultrasound use will continue to rapidly grow and evolve as a tool within the field of otolaryngology., (Published by Elsevier Inc.)

Background: Primary treatment of carcinoma of the oro-/hypopharynx or larynx may consist of combined platinum-containing chemoradiotherapy. In order to improve clinical outcome (i.e. local control/overall survival), combined therapy is intensified by the addition of the EGFR inhibitor cetuximab (Erbitux®). Radiation therapy (RT) is carried out as intensity-modulated RT (IMRT) to avoid higher grade acute and late toxicity by sparing of surrounding normal tissues., Methods/design: The REACH study is a prospective phase II study combining chemoradiotherapy with carboplatin/5-Fluorouracil (5-FU) and the monoclonal epidermal growth factor-receptor (EGFR) antibody cetuximab (Erbitux®) as intensity-modulated radiation therapy in patients with locally advanced squamous-cell carcinomas of oropharynx, hypopharynx or larynx.Patients receive weekly chemotherapy infusions in the 1st and 5th week of RT. Additionally, cetuximab is administered weekly throughout the treatment course. IMRT is delivered as in a classical concomitant boost concept (bid from fraction 16) to a total dose of 69,9 Gy., Discussion: Primary endpoint of the trial is local-regional control (LRC). Disease-free survival, progression-free survival, overall survival, toxicity, proteomic and genomic analyses are secondary endpoints. The aim is to explore the efficacy as well as the safety and feasibility of this combined radioimmunchemotherapy in order to improve the outcome of patients with advanced head and neck cancer., Trial Registration: ISRCTN87356938.

Objective: Carcinomas can have influence on the coagulation system by different factors. Locally pathological changes of metabolism, neo-vascularisation, oxygenation and tissue pressure as well as locally and systemically activities of the tumor cells, are part of it. The coagulation situation in patients with head and neck carcinomata is characterized only insufficiently till now., Material and Methods: In a prospective pilot study 20 male patients with squamous-cell carcinomas of the head and neck area were subjected to a detailed coagulation diagnostics pre and post therapeutically and, age and sex corrected, compared with a control group (n=37)., Results: For the routine parameters PTT, Quick, TZ and INR no differences between the groups could be recognized. For the tumour patients a statistically significant increase arose for the acute phase proteins like factor I (fibrinogen), factor VIII, factor IX, von- Willebrand antigen and activity before therapy. Increased values were found also for plasmin, factor II, factor V and the thrombin-antithrombin-III-complex (TAT) whereas the values for antithrombin-III were degraded significantly. In the tumour patients the pre-therapeutical increased values for the activation marker TAT brought themselves back to normal after the tumour ablative therapy., Conclusions: TAT could be suitable as a potential tumour marker but also for relapse tumours. To evidence this, a study of longer duration and with a larger number of patients is necessary., (© Georg Thieme Verlag KG Stuttgart · New York.)

Recurrent disease is one of the main reasons for the persistently poor prognosis of squamous cell carcinoma of the head and neck (HNSCC; European 5-year survival, 42%). The main treatment option for primary and secondary malignancy as well as recurrent disease is surgical therapy. If R0 resection (resection margin >5 mm) for a primary tumor is not viable, survival probability is reduced by 50%. In recurrent or secondary tumors with R1- or -2 resection or in the presence of non-resectable metastases, a palliative situation results in more than 80% of cases. In the case of surgery following radiotherapy or radiochemotherapy, attention should be paid to the criteria for salvage surgery (tissue perfusion, fibrosis, wound healing) and the procedure adapted to focus on functionality. In the case of relapse, primary surgery can potentially be supplemented with adjuvant therapy protocols such as (re-) irradiation, as well as possibly with chemotherapeutic agents or targeted therapies. Interdisciplinary collaboration and case discussions should take place in the context of a tumor board.

Post-therapeutic imaging is crucial for treatment planning and control in patients with malignant lesions in the head and neck. Focussed on CT, PET-CT and MRI, imaging strategies for post-therapeutic follow-up have been developed and investigated during the last few years. This review should help to interpret the results of these studies and make the reader familiar with the latest developments.

The objectives of the study were: first, to determine the prevalence of traditional medicine (TM) and complementary and alternative medicine (CAM) use in head and neck cancer patients in Ireland; second, to educate ourselves on the plethora of CAM/TM options available to patients outside the dominion of conventional medicine. The study design consisted of a cross-sectional survey carried out in three head and neck cancer centres. Self-administered questionnaires were distributed to 110 head and neck cancer patients attending the three cancer centres and data were collected for statistical analysis. A total of 106 patients completed the questionnaire; 21.7% of the participants used CAM/TM since their diagnosis with head and neck cancer. CAM/TM usage was higher in female (34.3%) than in male patients (16.2%). CAM/TM use was more common in the 41-50-year age group, in patients with higher educational levels and those holding strong religious beliefs, and also in married than single patients. The most common types of CAM/TM used were spiritual and laying on of hands. The most common reasons reported for using CAM/TM were to counteract the ill effects of treatment and increase the body's ability to fight cancer. Sources of information on CAM/TM were friends (65%), family (48%) and media (21%). This survey reveals a high prevalence of CAM/TM use in head and neck cancer patients, hence emphasising the need for otolaryngologists to educate themselves on the various therapies available to be able to provide informative advice. There is an urgent need for evidence-based investigation of various CAM/TM therapies currently offered to patients.

The hybrid technique of PET/CT has significantly impacted the imaging and management of HNSCC since its introduction in 2001 and has become the technique of choice for imaging of this cancer. Diagnostic FDG-PET/CT is useful for identification of an unknown primary tumor, delineation of extent of primary tumor, detection of regional lymph node involvement even in a normal-sized node, detection of distant metastases and occasional synchronous primary tumor, assessment of therapy response, and long-term surveillance for recurrence and metastases. The role of PET/CT is evolving in radiation therapy planning. Combined diagnostic PET/CT provides the best anatomic and metabolic in vivo information for the comprehensive management of HNSCC.

Unlabelled: In the first three years after treatment of patients with squamous cell carcinoma of upper aerodigestive tract (UADT), there is a high incidence of recurrences. After the third year, the occurrence of second primary tumor (SPT) is an important cause of morbimortality., Aim: To evaluate the incidence and the characteristics of the SPT in patients with squamous cell carcinoma of UADT, treated with curative intention., Methods: Retrospective study where the incidence, localization and treatment of SPT had been analyzed and survival rates were calculated., Results: Of the 624 analyzed cases, 59 (9.4%) had SPT during follow-up (4 synchronous and 55 metachronous). The SPT free survival rate ranged from 2 to 191.3 months (median of 42.5 months). In 20 cases (33.9%) the SPT was diagnosed after the fifth year of follow-up. The most frequent site of STP was the UADT mucosa (49.1%), followed by the lungs (22.0%) and the esophagus (11.9%). The best survival after-SPT occurred in cases of UADT STP (32.2% in 5 years, median 16.2 months)., Conclusion: The STP incidence was 9.4%. In 33.9% of the cases, the SPT was diagnosed after the fifth year of follow-up. The most frequent localization of STP was the UADT mucosa.

Conclusions: Survivin expression should be studied as a potential hallmark of higher risk oral, oropharyngeal and laryngeal squamous cell carcinomas (SCCs) to develop loco-regional recurrences. These outcomes could have a significant impact on both the treatment modalities and the intensity of post-treatment follow-up. Further investigation is necessary before considering elective neck dissection in patients with laryngeal SCC with high survivin expression., Objectives: Functioning simultaneously at cell division and apoptosis inhibition, survivin, a member of the inhibitor of apoptosis proteins family, plays a pivotal role in determining cell survival. Significant over-expression of survivin has been demonstrated in most human malignancies and correlated with more aggressive forms. This review focuses on the attempts to translate survivin biologic properties toward both a diagnostic/prognostic tool and a novel therapeutic target in head and neck SCC (HNSCC)., Materials and Methods: An exhaustive review of literature was performed to investigate available evidence about survivin expression, biological role and therapeutic potential in HNSCC., Results: Multiple evidence indicates that, in HNSCC cell lines, survivin inhibition by gene therapy and by small molecule inhibitors significantly increases the anti-tumour activity of several cytotoxic and other targeted therapies.

The purpose of this study is to assess patient, tumour and treatment related factors on quality of life (QoL) outcomes of patients who received definitive or postoperative radiotherapy +/- chemotherapy for head and neck (H&N) cancer. In this cross-sectional study, 110 H&N cancer patients were evaluated in follow-up visit and were asked to fill out the European Organisation for Research and Treatment of Cancer QoL Core Questionnaire (QLQ-C-30) and H&N Module (QLQ-H&N35). Patients were also graded for their late side effects using EORTC/RTOG scoring system. The QLQ C-30 and QLQ-H&N35 mean scores were compared using ANOVA analysis for these variables: age, gender, occupation, educational status, social security status, place of residence, tumour localization, clinical stage, comorbidity, Karnofsky performance score, treatment modality and side effects. Median follow-up was 29 (4-155) months. Tumour localization was significant factor affecting physical (P = 0.03), social (P = 0.01), cognitive (P = 0.002) functioning. Treatment modality had significant impact on the physical (P = 0.02) and cognitive scores (P = 0.008). Global QoL was affected significantly by disease stage (P = 0.01) and occupation (P = 0.01). The QLQ-H&N35 scores were found significantly higher in patients with moderate/severe late morbidity. Tumour localization and the treatment modality are the most important factors affecting the QoL of H&N cancer patients treated definitively.

Background: Identifying patients with head and neck cancer at greatest risk of poor health-related quality of life (HRQOL) will facilitate screening for such patients and targeted interventions., Methods: This was a cross-sectional, self-administered survey with medical record review among 65 out-patients with head and neck cancer >6 months from diagnosis and off treatment., Results: Most were men (80%) and white (95%), with a mean age of 60 +/- 13 years. The most prevalent cancer type was squamous cell (88%), site was pharyngeal (40%), and stage was III or IV (80%). Lower total HRQOL was independently associated with gastrostomy (p < .001) and history of radiation therapy (p < .05)(R(2) = 0.27). Certain HRQOL subscales were also independently associated with depression, body mass index, age, and education., Conclusions: Several factors can be used to identify patients with head and neck cancer at risk for persistent reductions in HRQOL requiring intervention.

The present work discusses soft tissue sarcoma in the head and neck area, due to the rare occurrence and the sparse data situation is still a large number of unexplained riddles. The head and neck surgeon plays the central role in the diagnosis and treatment of the vast majority of soft tissue sarcoma in the head and neck area. It is crucial that these tumors immediately should be send to specialized centers. An larger excisional biopsy should be avoided. When histology and tumor extension are secured an interdisciplinary treatment concept should be discussed, or the patient if possible will be introduced in ongoing clinical studies.

Objectives: To measure morbidity and mortality rates following insertion of gastrostomy tubes in head and neck cancer patients. To determine evidence for any relationship between gastrostomy insertion technique and complication rates., Design: A prospective cohort study and qualitative systematic review., Setting: Multi-cancer networks in the South West of England, Hampshire and the Isle of White., Participants: One hundred and seventy-two patients with head and neck cancer undergoing gastrostomy tube insertion between 2004 and 2005. Percutaneous endoscopic gastrostomy (PEG) was performed in 121 patients. Fifty-one patients had radiologically inserted gastrostomy (RIG). Twenty-seven studies reporting outcomes following 2353 gastrostomy procedures for head and neck cancer., Main Outcome Measures: Post-procedure mortality, major and minor complications., Results: In the present series, mortality rates were 1.0% (1/121) for PEG and 3.9% (2/51) for RIG. Overall major complication rates following PEG and RIG were 3.3% (4/121) and 15.6% (9/51) respectively. In our systematic review and meta-analysis of 2379 head and neck cancer patients, we observed fatality rates of 2.2% (95% CI 0.014-0.034) following PEG and 1.8% (95% CI 0.010-0.032) following RIG. Furthermore, major complication rates following PEG were 7.4% (95% CI 5.9-9.3%) and 8.9% (95% CI 7.0-11.2%) after RIG., Conclusions: Procedure related mortality rates following gastrostomy in head and neck cancer patients are higher than those in mixed patient populations. Major complication rates following RIG in head and neck cancer patients are greater than those following PEG. Major complications following PEG in patients with head and neck cancer appear no worse than in mixed pathology groups. We have identified that RIG is associated with increased morbidity and mortality in patients who are ineligible for PEG. The serious nature of the complications associated with gastrostomy particularly in patients with head and neck cancer requires careful consideration by the referring physician.

The head-and-neck squamous-cell carcinomas (HNSCC) represent in order of frequency the fourth leading cause of cancer deaths among men in France. The term HNSCC includes various anatomopathological and clinical entities with different evolution patterns. For this reason, it is necessary to identify prognostic and predictive factors able to help in the choice of the treatment. The clinical factors with a prognostic value are the tumor location, the tumor size and the lymph node status. The degree of differentiation is the most important histologic factor. More recently, the identification of molecular factors has opened the way to new therapies. Thus, the overexpression of EGFR is associated with a poor prognosis. Its inhibition improves the survival of patients. p53 mutations and cyclin D1 amplification are actually subject to intensive research. The tumors associated with HPV infection are distinguishable by a better prognosis. 18-alpha-FDG positron emission tomography emerges as a useful tool for the therapeutic evaluation. The evolution of surgical techniques, the development of induction chemotherapy regimen or concurrent ones with radiotherapy and new techniques of conformal irradiation also results in a better locoregional control.

Objectives: To examine (1) the molecular angiogenic relationship between endothelial and stromal cells of angiofibromas and how this may elucidate the pathogenesis of angiofibromas and (2) the effects of embolization on the expression of angiotrophic factors and proapoptotic and antiapoptotic factors within the tumor., Design: The expression of mesenchymal and endothelial stem/progenitor cell-associated proteins (MECAPs) such as proangiogenic cytokine vascular endothelial growth factor (VEGF), VEGF receptors (VEGFR1, VEGFR2, and VEGFR3), angiopoietin receptors (Tie-1 and Tie-2), and stem cell subset marker CD133 was assessed by immunohistological staining in 7 embolized angiofibroma specimens. Expression of proapoptotic Bax, antiapoptotic Bcl-2 and Bcl-xL, nuclear proliferation protein MiB-1, and hypoxia-inducible factor 1alpha (Hif-1alpha) in peri-ischemic areas of the embolized angiofibromas was also assessed., Setting: A single pediatric institution., Patients: Seven patients (identified from medical records, January 1, 2001, through December 31, 2005) who were diagnosed as having juvenile angiofibroma and who underwent surgical treatment. Archival tissues were retrieved for immunostaining., Main Outcome Measures: The immunostaining results were evaluated by microscopy and the staining intensities were also recorded., Results: All angiofibroma specimens expressed the stem cell subset marker CD133 and MECAPs except VEGFR3 (a few cases). In the only case tested, we found evidence of VEGF-induced angiogenic signaling as the expression of phosphorylated VEGFR2 (Tyr951). Endothelial cells expressed VEGFR1 and VEGFR2 and angiopoietin receptors Tie-1 and Tie-2 but not VEGF. In contrast, VEGF was expressed within stromal cells. Viable tumor adjacent to the ischemic areas demonstrated increased staining intensities to VEGFR2, Tie-1, Tie-2 (all cases), and VEGFR3 (2 cases) and increased nuclear proliferation (5%-20%). All cases expressed proapoptotic and antiapoptotic factors, and the expression of Hif-1alpha was unaffected by ischemia., Conclusions: Stromal cells appear to be similar to mesenchymal stem cells with endothelial differentiation potential in umbilical cord blood cells. Stromal cells support endothelial growth by providing VEGF as a paracrine factor. Under ischemic stress, the embolized tumor tissues show upregulation of angiogenic receptors, retention of Hif-1alpha, and increased nuclear proliferation rates. Specific angiogenesis blockers may represent a novel treatment strategy for angiofibromas.

Background: Synovial sarcoma (SS) is a mesenchymal malignancy, which predominantly occurs at the lower extremities of young adults. Only 3 % of the SS show a primary manifestation in the head and neck region., Methods: A retrospective chart review (years 2002 - 2006) of our Department of Otorhinolaryngology, head and neck surgery, School of Medicine, Bonn, Germany, was performed searching for patients with primary head and neck manifestations of SS., Patients: Four patients (2 female, 2 male) with a median age of 21 (12 - 28) years were assessed at our facility., Results: The location of the SS was the oropharynx respectively, infiltrating adjacent structures. 3 patients underwent radical surgery followed by chemotherapy, 2 in combination with irradiation. 1 patient underwent primary chemotherapy and irradiation. The histological diagnosis was a biphasic SS as well as a monophasic SS in 2 patients respectively. Fluorescence-in-situ-hybridization was performed in order to detect the distinctive chromosomal translocation t(X;18). 2 patients were in complete remission at the recent follow-up, 1 patient died 14 months after diagnosis due to a lethal carotidal haemorrhage. 1 patient was lost to follow-up., Conclusions: The aggressive character of the SS as well as its high recurrence rate afford a radical therapeutic scheme enclosing surgical, chemotherapeutical and radiological treatment as well as a thorough follow-up. The genetic translocation t(X;18) leads the way to the right diagnosis. The prognosis of head and neck SS must be considered as poor. SS should be taken into consideration in head and neck tumors of unclear nature.

The occurrence of edema is a serious problem of patients suffering from cancer and may have various causes. Particularly, the secondary malignant lymphedema poses a special threat to patients. In some cases, it indicates the progression of illness, and in fact also results in mutilating physical changes, which add to the already existing impairments caused by the cancer disease. So far therapeutic interventions are limited. Current management consists of physical therapy and pharmacological interventions. There are few powerful studies concerning the efficiency and hardly any concerning combined or comparative treatment in the literature. Most of them focus on the management of lymphedema in breast cancer patients. Preventive measures and supportive therapy are rarely being discussed. In this case report, we describe the successful use of Selen and Sandostatin in treating a facial edema of a patient with advanced head-neck cancer.

Progressive cancer leads to loss of quality of life. This is particularly true for head and neck cancers as they dramatically affect the patients and in addition to this psychological burden cause a lot of physical disabilities. Patients struggle against retreat and helplessness of their environment, feel ostracized and not any longer being a human. In advanced diseases, surgery is not the first choice of treatment. Ostensible control of symptoms, care of relatives and notice of psychosocial facts are the most important therapeutic issues in these patients. They gain the greatest benefit from palliative care with good control of symptoms. This is highlighted by the following case reports.

Head and neck squamous cell cancer (HNSCC) management is evolving rapidly. Approaches under exploration include induction chemotherapy, altered fractionation radiation with chemotherapy, intensity modulated radiation therapy (IMRT) and the use of biologically targeted drugs to enhance radiation. The goal of the new methods is improving the effectivity without increasing the toxicity. This article will focus maily on locally advanced HNSCC, which frequently remains a clinical challenge, review state-of-the-art therapy and introduce promising novel terapies. For the future the incorporation of new agents, the use of novel biomarkers to accurately assess and individualize therapy, and expanded supportive care approaches will play an increasingly important role.

Head and neck cancer make up about 6% of all tumours worldwide. The distribution pattern shows clear prevalence among males, peaking between the ages of 50 and 60. In 2002, incidence in Europe stood at 143,000, with mortality at 68,000. Over 90% of all head and neck malignancies are squamous cell cancer. The most common carcinogens are tobacco and alcohol. By the time the tumour is first diagnosed, more than two thirds of all patients are staged III or IV according to UICC. Although intensive research has been carried out in the last few years, both in the field of surgery and in conservative cancer treatments (radiotherapy, chemotherapy or immunotherapy), the overall survival rates have unfortunately not markedly increased.

Introduction: The sarcomatoid carcinoma of the superior aerodigestive tracts is a rare malignant tumour which presents diagnostic and therapeutic challenges., Material and Method: We report 11 cases of spindle cell carcinomas of the upper airways., Results: Sex-ratio was 10:1 and the mean age was 57.3 years (30 - 75 years). Nine patients were smokers and 4 presented with a history of radiation exposure. Tumoral locations were as follows: larynx: 6, hypopharynx: 1, oropharynx: 1, nasopharynx: 1, oral cavity: 2. Histological diagnosis in 3 cases required the use of immunohistochemical studies. Four patients were first seen at an advanced stage. This left 9 patients and among them 7 received a curative treatment: 5 by surgery alone, 1 by surgery and radiotherapy, 1 by radiotherapy, 1 by chemo-radiotherapy for the nasopharyngeal lesion and 1 by chemotherapy alone. Two patients died from their disease before treatment. With an average delay of 15.4 months, the rates of global survival and disease-free were 5/9 and 4/9 respectively., Conclusion: The sarcomatoid carcinoma of the upper airways is rare, but not unusual. Its diagnosis benefits from progresses in immunohistochemistry, but also from advances in the field of molecular biology. Its treatment and natural evolution remain controversial.

If we look at the historical development of the treatment of head and neck cancer, we can see that initially, decisions about therapy lay solely in the hands of the surgeons (Otorhinolaryngologists, oral and maxilla-facial surgeons) This was also true of the decision as to whether an operation was feasible or whether primary radio therapy was to be carried out. At the end of the last century, after chemotherapy had become an integral part of curative therapy, inter-disciplinary conferences (tumour boards) were set up so that the surgeons could make joint decisions about therapy together with radio oncologists and medical oncologists. In addition, the increasingly important role of chemotherapy in curative therapy in the last fifteen years has led to a marked increase in the number of clinical studies in head and neck cancer. Inter-disciplinary treatment decisions can be based only on current scientific knowledge and are geared towards a standard treatment as recommended for an individual tumour stage. It is precisely in the upper aerodigestive tract that there are various therapeutical procedures, due to the different site of primaries (oral cavity, oro-, hypoparynx and larynx) and the different grade of locoregional metastasis. One possible way to assure a high degree of transparency of these various therapies and making them available to a high number of colleagues is the development guidelines [1]. Many medical associations and organisations in Austria are currently engaged in the formulation and definition of guidelines, in order to provide the highest possible quality of medical treatment and care for each individual patient. By guidelines are meant recommendations for treatments which allow a certain amount of flexibility in the treatment and provide a medical consensus in line with current scientific knowledge. In principle, they are binding, but in exceptional but reasonable cases, they may (and even must) be departed from. The following proposal is designed to provide a basis for the formulation of guidelines for the treatment of head and neck cancer in Austria. It was put together with help from ENT specialists, medical oncologists and radio oncologists from across Austria. One advantage was certainly the fact that several foreign associations had already drawn up guidelines which could be referred to [2, 3]. Since guidelines are dynamic in nature and must be constantly adapted to correspond to current medical knowledge and research, they are often only available today on websites. For this reason, links to relevant sites are given at the end of this article.

Conclusions: Preoperative gentamicin in combination with vestibular 'prehab' offers a possibility to reduce postoperative malaise and speed up recovery and may be used for patients undergoing such surgery when there is remaining vestibular function., Objectives: Removal of pontine angle tumours in a patient with remaining vestibular function causes symptoms of acute vestibular loss. A simultaneous cerebellar lesion can cause a combined vestibule-cerebellar lesion., Patients and Methods: Twelve patients with pontine angle tumours but with near normal vestibular function were treated with intratympanic gentamicin in combination with vestibular 'prehab' to achieve preoperative vestibular ablation and compensation. After work-up patients started with a home-based vestibular training programme for 14 days. They then received a total of 1.2 ml of 30 mg/ml buffered gentamicin in four intratympanic installations over 2 days. They continued training and returned 6-16 weeks later. All patients were tested with calorics, vestibular video-impulse testing of all six canals, VEMP, subjective visual vertical and horizontal, posturography and pure tone and speech audiometry., Results: There was a loss of caloric reactions and loss of impulses. In two patients the hearing deteriorated and in one hearing improved. All subjects were vestibulary compensated before surgery and no patient complained of dizziness or vertigo after surgery.

Conclusion: Our bedside interviews with patients with head neck cancer are unique and valuable educational experiences for undergraduate medical students., Objective: How can we help medical students to understand patients' thoughts and feelings? We believe that students can learn and practice empathy at the patient's bedside., Subjects and Methods: Sixty medical students in their final year at the University of Tokyo and 10 patients with head and neck cancer were supervised by a professor and senior head and neck surgeons. Questionnaires were delivered to each student before and after bedside teaching, to investigate their impressions on thoughts and feelings of patients with head and neck cancer. Questions to patients were composed of: 1) backgrounds: birthplace, education, occupation and hobby; 2) cancer: the time of the first visit to clinic and the time of referral to the University of Tokyo Hospital; 3) preoperative feelings; 4) impression of surgical treatment and postoperative care; and 5) messages to medical students from the patient. Medical students also asked additional questions., Results: Before the bedside teaching our medical students believed that it must be important to listen to patients (100%); and that it must be possible to encourage patients (50%). After the bedside teaching they noticed that a medical interview could have a positive influence on the patient (93%), probably because of general conversation (45%), the patient's personality (50%), listening to information about the patient's birthplace, education, occupation and hobby (48%), and the instructor's life experiences (25%). Most patients asked medical students to be good doctors who can understand their thoughts and feelings.

Teleconferencing can be used as part of the integrated management of head and neck cancer. An audit of the participants' views would suggest that the meeting is used in the management of complex head and neck issues.

In the years to come health care systems of western industrialized nations are going to be increasingly faced with the results of demographic changes. Especially the part of elderly citizens will grow steadily. Thus, also an increasing number of malignant diseases not only in the head & neck area is expected. Decision-making in cancer therapy for elderly patients is challenging for medical professional since this subject is accompanied by a high rate of uncertainness. For fear of aggressive therapy regimens with subsequent increase of morbidity, in many cases only incomplete diagnostic and therapeutic measures are taken. Reviewing the literature there is almost complete international consensus, that patients suffering from squamous cell cancer of the head & neck should be treated with curative intention, if thorough preoperative assessment of present comorbidities is performed. Furthermore aggressive treatment options should not be excluded. An optimal medical adjustment of relevant concomitant diseases clearly improves the starting point. In comparison to younger control groups therapy associated complications do not occur significantly higher. For this reason elderly patients should be treated with curative intention. Age itself should never be a sole factor deciding which curative therapy should be undertaken. Exceptions could be made in patients with severe general comorbidity.

Background and Purpose: Some reports of reconstructive management of carotid blowout syndrome (CBS) with stent-grafts are promising, but some are unfavorable. This study sought to evaluate the hemostatic efficacy, safety, and outcome of reconstructive, endovascular stent-graft placement in patients with head-and-neck cancers in association with CBS., Methods: Eight patients with head-and-neck cancers with CBS were treated with self-expandable stent-grafts. We evaluated the initial hemostatic results, complications, and outcomes by assessing the clinical and imaging findings., Results: Immediate hemostasis was achieved in all patients. Initial complications included stroke in 1 patient and asymptomatic thrombosis of the carotid artery in 2 patients. Delayed complications included rebleeding, delayed carotid thrombosis, and brain abscess formation. Rebleeding was noted in 4 patients and was successfully managed with a second stent-graft and embolization in 2 of them. Delayed carotid thrombosis with follow-up after 3 months was found in 3 patients, 1 of whom had associated brain abscesses., Conclusion: Although stent-grafts achieved immediate and initial hemostasis in patients with head-and-neck cancers and CBS, long-term safety, stent patency, and permanency of hemostasis appeared unfavorable. This treatment may be for temporary or emergency purposes rather than serving as a permanent measure. We suggest its applications in patients with acute CBS that precludes performance of an occlusion test, as well as when carotid occlusion poses an unusually high risk of neurologic morbidity. We also propose prophylactic antibiotic treatment and combined embolization of pathologic vascular feeders to improve outcomes.

In search of new targeted therapies for squamous cell carcinoma of the head neck (HNSCC), a better understanding of the carcinogenesis is of outmost importance. Recent studies show that not only genetic but also epigenetic alterations initiate the multistep process of tumordevelopment. Epigenetic changes lead to altered gene expression without alterations of the DNA sequence. The best characterized epigenetic change is the methylation of the promoter region of genes, especially of tumorsuppressor genes. The methylation of the promoter region blocks the promoter and therefore represses transcription. The loss of the gene products of tumorsuppressor genes leads to increased proliferation and decreased apoptosis. Methylation of tumorsuppressor genes was shown in precancerous lesions of HNSCC, which emphasizes the importance of methylation as an early biomarker. Several studies of tumor cell cultures show reactivated expression of proteins and as a result reduction of proliferation and induction of apoptosis after treatment with demethylating agentens. This presents a very promising new option for a targeted therapy.

The 5 cases of salivary duct carcinoma (SDC); very rare, but distinct group of highly malignant salivary gland tumor are presented, and difficulties with pathological and clinical diagnosis is discussed. The SDC developed in single cases in parotid salivary gland, submandibular salivary and in mucosa of maxillary sinus, pyriform fossa and oral cavity (check). In 3 cases the second malignant tumor was present--synchronously (SDC + pleomorphic adenoma in parotid gland; SDC + squamous cell carcinoma in hypopharynx) or metachroneously (squamous cell carcinoma of upper lip followed by SDC). In one case the high levels of PSA suggesting of metastases from unknown primary within the prostate gland, or PSA expression related to SDC was observed. The four patients received radical treatment - surgical resection followed by radiotherapy; in one case only palliative treatment was applied, due to patient's poor general condition and high advancement of the primary disease. The observation ranged from 10 to 77 months (average time--31 months). The one patient died 13 months after diagnosis and palliative treatment. The three patients are alive with distant metastases to the lung and bones (77, 38 and 18 months after primary treatment was completed). Only one patient with 10 months observation after treatment is living without symptoms of recurrence or metastases.

Objective: To determine if the development of hypothyroidism has an effect on the outcome of advanced-stage head and neck squamous cell carcinoma., Design: Retrospective database analysis., Setting: Tertiary care center., Patients: The study population comprised 155 patients with advanced-stage head and neck squamous cell carcinoma., Interventions: Patients underwent radiation therapy alone or in combination with chemotherapy and surgery when indicated., Main Outcome Measures: Kaplan-Meier analysis was used to assess survival, not adjusting for timing of the detection of hypothyroidism. The following 2 analyses were then performed to adjust for the timing of detection: (1) hypothyroidism was assessed as a time-varying covariate in a Cox proportional hazards model and (2) a landmark analysis was conducted at 9, 12, 15, 18, 21, and 24 months using the Kaplan-Meier method., Results: Of the 155 patients, 59 developed hypothyroidism, defined as a thyrotropin level greater than 5.5 mIU/L (institutional value). An unadjusted Kaplan-Meier analysis indicated that patients who develop hypothyroidism have significantly better survival than patients who do not (P<.001, log-rank test). After adjusting for the timing of hypothyroidism, a Cox proportional hazards analysis indicated that survival was better, but not statistically significant, for patients who developed hypothyroidism (hazard ratio, 0.62; P=.12); results from a landmark analysis supported this finding (P values ranged from .11 to .19)., Conclusions: Development of hypothyroidism may be associated with improved survival and increased recurrence-free survival. Larger, prospective studies appear warranted to test the beneficial effect of hypothyroidism.

Conclusions: An intensive diagnostic work-up including (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) detects many unknown primary tumours, leads to a low emergence rate of primary tumours, and selects carcinoma of unknown primary with much more favourable results after neck dissection and postoperative radiotherapy., Objective: To investigate the optimal diagnostic approach and best treatment modality for rare head and neck cancer of unknown primary., Patients and Methods: In a retrospective study, 69 patients admitted from 1987 to 2002 with cervical lymph node metastases without apparent primary were reviewed. Test characteristics of all diagnostic procedures were calculated. Disease-free and overall survival rates were calculated. Major prognostic factors were analysed uni-variously., Results: At the primary site FDG-PET showed the best sensitivity with 69% and the highest negative predictive value with 87%. Computed tomography and magnetic resonance imaging had a better specificity with 87% and 95%, respectively. The primary tumour was detected in 23 cases (33%). Frequent primary tumour origin was the palatine tonsil (n=8, 35%), base of the tongue (n=6, 26%) and lung (n=4, 17%). All patients with unknown primary were treated by neck dissection. Adjuvant radiotherapy was performed in 26 patients (57%), concurrent radiochemotherapy was performed in 12 patients (26%). The primary emergence rate was 7%. The 5-year overall survival rate was inferior in patients with detected primary in comparison with patients with unknown primary (22% versus 52%). Significant prognostic factors in case of unknown primary were M stage, smoking, alcohol consumption and tonsillectomy. Radiotherapy but not chemotherapy with carboplatin influenced the overall survival.

Conclusions: The data suggest that branchial cleft cyst (BCC) can be primarily treated with OK-432 sclerotherapy and only the remaining lesions with excision., Objectives: To evaluate the effectiveness of sclerotherapy using OK-432 in the treatment of BCC., Materials and Methods: We treated 12 BCC patients (3 males and 9 females; mean age 25 years) with OK-432 sclerotherapy at an outpatient clinic. The cystic fluids were aspirated and diagnosed by cytomorphology and DNA cytometric analysis to exclude malignancy. The fluid aspirated from the cyst was replaced with an equal volume of OK-432 solution. The sizes of cysts were measured and compared before and after injection. The remaining cysts were excised and histopathologically compared with the excised BCCs that had not been treated with OK-432., Results: Seven of 12 patients (58%) showed a complete response after OK-432 injection, administered one to three times. Three patients (25%) had only partial response and two (17%) were stationary. Five patients with remaining lesions underwent excision. There was no difficulty in dissecting around the cysts and no increased morbidity during operation. None of the patients had evidence of recurrences or malignancies developing during the follow-up period (mean 21 months, range 17-26 months). There were no major side effects except fever after sclerotherapy.

Practitioners can present and discuss decisions about the management of health problems in a variety of ways during consultations. This paper examines in detail how doctors talk with patients in relation to decision-making about treatment. Conversation analyses of decision-making sequences in consultations about diabetes in primary care and about treatment of ear nose and throat (ENT) cancer in a specialist oncology setting, both in the UK, revealed a spectrum of practitioner approaches ranging from more 'bilateral' to more 'unilateral'. This paper identifies the key communicative and organisational features of these approaches and provides some preliminary observations about the implications of these for patient participation in decision-making.

In Germany, 6100 women and 5300 men contract a malignant melanoma of the skin every year. The chances of being cured are good in the early stages of the disease, but the average survival following distant metastasis is only 6 to 9 months. Therefore, early diagnosis is crucial, particularly as the skin is, by nature, a readily accessible organ. The introduction of epiluminescence microscopy has increased diagnostic accuracy significantly. In cases of doubt, complete excision of the suspect pigmented lesion is always advisable. A light skin type, presence of numerous naevi, genetic predisposition (familial history) and increased UV exposure are considered as risk factors. As a rule, adjuvant imunotherapy with interferon-alphais recommended in high-risk patients. A multidisciplinary approach consisting of surgery, radiotherapy, chemotherapy and immunotherapy has proved beneficial in advanced stages of metastasis.

Nutrition in Patients with Head and Neck Cancer. Malnutrition is common in patients with head and neck cancer. Due to natural course of disease or therapy, malnutrition may increase. This leads to a reduced prognosis, quality of life, and should be considered in early stages of the disease. First choice is an enteral feeding via a nasogastral feeding tube or a PEG. In special cases a parenteral nutrition may be necessary.