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Background: The eighth international symposium for sentinel node biopsy (SNB) in head and neck cancer was held in 2018. This consensus conference aimed to deliver current multidisciplinary guidelines. This document focuses on the surgical aspects of SNB for oral cancer., Method: Invited expert faculty selected topics requiring guidelines. Topics were reviewed and evidence evaluated where available. Data were presented at the consensus meeting, with live debate from panels comprising expert, nonexpert, and patient representatives followed by voting to assess the level of support for proposed recommendations. Evidence review, debate, and voting results were all considered in constructing these guidelines., Results/conclusion: A range of topics were considered, from patient selection to surgical technique and follow-up schedule. Consensus was not achieved in all areas, highlighting potential issues that would benefit from prospective studies. Nevertheless these guidelines represent an up-to-date pragmatic recommendation based on current evidence and expert opinion., (© 2019 Wiley Periodicals, Inc.)

Background: The purpose of this study was to analyze the effect of fractionation schedule on local control in postoperative radiotherapy (RT) for sinonasal malignant melanoma., Methods: Sixty-three patients who were treated with surgery and postoperative RT in 4 accredited head and neck cancer centers in the Netherlands between 1998 and 2013 were retrospectively studied. Outcomes with conventional fractionation (2-2.4 Gy per fraction; n = 27) were compared to hypofractionation (4-6 Gy per fraction; n = 36). The primary endpoint was local control and the secondary endpoint was toxicity., Results: Comparable local control rates were found after 2 and 5 years (63% vs 64% and 47% vs 53%; P = .73 for, respectively, conventional fractionation vs hypofractionation). Local recurrences were predominantly present ipsilateral (92%) and within the irradiated volume (88%). Late toxicity grade ≥ 3 was observed in 2 of 63 patients, 1 patient in both groups., Conclusion: Radiotherapy fractionation schedule did not influence the local control rate or the incidence of late toxicity in patients treated with surgery and RT for sinonasal malignant melanoma in this retrospective analysis. Due to this retrospective nature and the limited number of patients, strong recommendations cannot be made. Expected toxicity, patient convenience, and workload may be taken into account for the choice of fractionation schedule until conclusive evidence becomes available., (© 2017 Wiley Periodicals, Inc.)

Despite the wide use of cisplatin-based concomitant chemoradiotherapy (CCRT) for head and neck squamous cell carcinoma (HNSCC), data on the optimal regimen and cumulative dose are scarce and frequently conflicting. We aimed to evaluate the compliance and the impact of the cumulative dose of cisplatin on overall survival (OS), disease-free survival (DFS), loco-regional control (LRC), and distant-metastasis-free survival (DMFS) in a retrospective study. Between 2008 and 2015, 279 patients with HNSCC scheduled for CCRT (three courses of 3-week 100 mg/m 2 cisplatin) were identified. Of the whole group, 14% did not receive any cisplatin and 26% received daily cisplatin. In patients planned for three courses (n = 167), 56% received 3, 20% received 2, and 24% received one course. After median follow-up of 31.6 months, the actuarial OS, DFS, LRC, and DMFS rates at 3 years for patients received cumulative dose of ≥200 mg/m 2 were significantly better compared to those received <200 mg/m 2 ; 74 vs. 51% for OS, 73 vs. 49% for DFS, 80 vs. 58% for LRC (p < 0.001), and 85 vs. 76% for DMFS (p = 0.034). At multivariate analysis, the cumulative cisplatin dose (≥200 vs. <200 mg/m 2 ) was significantly predictive for OS (HR 2.05; 95% CI 1.35-3.13, p = <0.001). Borderline GFR (60-70 mL/min) at baseline predicts compliance for ≥two courses (p = 0.003). In conclusion, considerable proportion of patients did not receive all pre-planned courses of cisplatin. Patients receiving cumulative cisplatin dose ≥200 mg/m 2 had significantly better outcome than those receiving <200 mg/m 2 and cumulative dose <200 mg/m 2 might even be detrimental. These findings increased the bulk of slowly growing evidence on the optimal cumulative dose of cisplatin. Baseline GFR might predict compliance.

Background: The head and neck region has rich regional lymphatic network, with a theoretical risk on contralateral metastasis from oropharyngeal cancer (OPC). There is a long-standing convention to irradiate the great majority of these tumors electively to both sides of the neck to reduce the risk of contralateral regional failure (cRF), but this can induce significant toxicity. We aimed to identify patient groups where elective contralateral irradiation may safely be omitted., Methods: PubMed and EMBASE were searched for original full-text articles in English with a combination of search terms related to the end points: cRF in OPC primarily treated by radiotherapy only to the ipsilateral neck and identifying predictive factors for increased incidence of cRF. The data from the identified studies were pooled, the incidence of cRF was calculated and the correlation with different predictive factors was investigated., Results: Eleven full-text articles met the inclusion criteria. In these studies, 1116 patients were treated to the ipsilateral neck alone. The mean incidence of cRF was 2.42% (range 0-5.9%, 95% CI 1.6-3.5%). The incidence of cRF correlated only with T-stage (p=0.008), and involvement of midline (p=0.001). However, the significant correlation with T-stage can be explained by the very low incidence of cRF among T1 (0.77%), and disappeared when the incidence of cRF was compared between T2, T3,and T4 (p=0.344)., Conclusion: The incidence of cRF in patients with OPC is very low, with involvement of midline providing the most significant prognosticator. These results call for trials on unilateral elective irradiation in selected groups., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Importance: Dermatography (medical tattooing) is often overlooked as an adjuvant procedure to improve color mismatch in the head and neck area, and its effect on patient satisfaction and quality of life has not been evaluated, to our knowledge., Objective: To analyze the effect of dermatography on the subjective perception of the appearance of scars and skin grafts and the quality of life in head and neck patients., Design, Setting, and Participants: Case series of patients undergoing dermatography at the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, between July 1, 2007, and April 1, 2015. Participants were invited to respond to 2 questionnaires measuring their scar or graft appearance and their quality of life before and after dermatography as an adjuvant treatment for benign or malignant head and neck tumors., Intervention: Use of dermatography., Main Outcomes and Measures: Two questionnaires evaluating a visual analog scale score (range, 0-10) and multiple questions on a 5-point scale focusing on satisfaction with the appearance and the quality of life., Results: Among 76 patients, 56 (74%) were included in the study. The mean (SD) age of the study cohort was 56.5 (16.0) years, and 42 (75%) were female. The mean improvement in scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4 points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of approximately 1 point across 9 questions was observed. The answers to all patient satisfaction and quality-of-life questions on both questionnaires improved significantly after dermatography., Conclusions and Relevance: Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients., Level of Evidence: 4.

Background: Locoregional treatment is often insufficient to guarantee long-term disease-free survival (DFS) in American Joint Committee on Cancer stage IIIB melanoma, and, in order to improve survival, effective neoadjuvant and adjuvant strategies are needed . Selecting patients for these strategies requires risk stratification, for which clinical and molecular biomarkers can be used. We aimed to detect clinical biomarkers to identify high-risk stage IIIB melanoma patients., Patients and Methods: We performed retrospective analysis of stage IIIB melanoma patients who underwent lymph node dissection (LND) in our institution between 2000 and 2015. Sentinel node-positive patients with ulcerated primary tumors, as well as patients with clinically detectable nodal metastasis with non-ulcerated tumors, were included. Baseline characteristics, melanoma-specific survival (MSS), and DFS were assessed, and prognostic factors for recurrence and survival were analyzed, using univariate and multivariate analysis., Results: Overall, 250 patients were included. Median follow-up was 52 months (interquartile range 29-108 months), median MSS was 141 months, and median DFS was 36 months. Five- and 10-year MSS was 59 and 52 %, respectively, and 5- and 10-year DFS was 47 and 41 %, respectively. Age >50 years, Breslow thickness >2 versus ≤2 mm, and N2 versus N1 disease all carried an increased risk of death by melanoma. Age >50 years and extracapsular extension carried an increased risk of disease recurrence after LND., Conclusions: Age >50 years, Breslow thickness >2 mm and N2 versus N1 disease are prognostic factors for poor survival in stage IIIB melanoma. These characteristics can be used to further stratify risk of death by melanoma in this already high-risk patient population and to help select the appropriate population for adjuvant therapy (trials).

Sentinel node biopsy is a widely used staging procedure in melanoma. It is usually performed using the triple technique: lymphatic mapping after injection of a radiopharmaceutical, blue dye injection, and the use of a gamma probe. Blue dye offers visual confirmation of the location of the sentinel lymph node (SN). There are some disadvantages such as blurring of the surgical field, skin coloring, and possible anaphylactic reactions. We aimed to answer the question whether patent blue is truly necessary for correct intraoperative identification of the SN. One day preoperatively, lymphoscintigraphy (with or without single-photon emission computed tomography with integrated computed tomography) is performed and the location of the SN is marked on the skin. Perioperatively, patent blue is injected around the tumor. A handheld gamma-ray detection probe is used to determine the location of the incision and detect the SN during the operation. SNs are pursued in all regions indicated by imaging. In only six of the 681 patients (0.9%) a blue, not radioactive, sentinel node was removed. In one of them (0.15%), this was the only node excised. None of these lymph nodes harbored metastases. This study suggests that blue dye has no additional value in finding the sentinel node and is of low significance in detecting metastases. Therefore, blue dye can be safely omitted from the standardized triple technique. It may be useful in selected cases according to the surgeon's discretion.

Objective: Assessment of the impact of a sentinel node biopsy (SNB)-based strategy in cT1/T2 N0 oral cancer on the course of health related quality of life, psychological distress, and shoulder disability, and evaluation of the patients' perspective on neck management strategies., Study Design: Fifty-two patients (39 SNB negative; 13 SNB positive) completed the European Organization for Research and Treatment of Cancer (EORTC) questionnaires-QLQ-C30 and QLQ-H&N35, and the HADS, IES, and SDQ questionnaires at baseline, after SNB diagnosis and at 6 months of follow-up. Objective shoulder measurements were performed after 2 years and interviews were conducted after 4.5 months of follow-up., Results: All the scores of the questionnaires were not significantly different between SNB negative and SNB positive patients. Objective shoulder functioning was similar. Most patients preferred a SNB-based strategy to an elective neck dissection strategy., Conclusions: The impact of a SNB-based strategy in patients with cT1/T2 N0 oral cancer is comparable for SNB-negative and SNB-positive patients in terms of health-related quality of life, psychological distress and shoulder functioning. Most patients preferred the SNB-based strategy over the elective neck dissection strategy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Fluorescence guidance is an upcoming methodology to improve surgical accuracy. Challenging herein is the identification of the minimum dose at which the tracer can be detected with a clinical-grade fluorescence camera. Using a hybrid tracer such as indocyanine green (ICG)-(99m)Tc-nanocolloid, it has become possible to determine the accumulation of tracer and correlate this to intraoperative fluorescence-based identification rates. In the current study, we determined the lower detection limit of tracer at which intraoperative fluorescence guidance was still feasible., Methods: Size exclusion chromatography (SEC) provided a laboratory set-up to analyze the chemical content and to simulate the migratory behavior of ICG-nanocolloid in tissue. Tracer accumulation and intraoperative fluorescence detection findings were derived from a retrospective analysis of 20 head-and-neck melanoma patients, 40 penile and 20 prostate cancer patients scheduled for sentinel node (SN) biopsy using ICG-(99m)Tc-nanocolloid. In these patients, following tracer injection, single photon emission computed tomography fused with computed tomography (SPECT/CT) was used to identify the SN(s). The percentage injected dose (% ID), the amount of ICG (in nmol), and the concentration of ICG in the SNs (in μM) was assessed for SNs detected on SPECT/CT and correlated with the intraoperative fluorescence imaging findings., Results: SEC determined that in the hybrid tracer formulation, 41 % (standard deviation: 12 %) of ICG was present in nanocolloid-bound form. In the SNs detected using fluorescence guidance a median of 0.88 % ID was present, compared to a median of 0.25 % ID in the non-fluorescent SNs (p-value < 0.001). The % ID values could be correlated to the amount ICG in a SN (range: 0.003-10.8 nmol) and the concentration of ICG in a SN (range: 0.006-64.6 μM)., Discussion: The ability to provide intraoperative fluorescence guidance is dependent on the amount and concentration of the fluorescent dye accumulated in the lesion(s) of interest. Our findings indicate that intraoperative fluorescence detection with ICG is possible above a μM concentration.

Objectives/hypothesis: Evaluation of treatment results of orthovoltage X-rays for a selection of previously untreated favorable basal cell carcinomas (BCC) in the head and neck area concerning local control, cosmetic and functional outcome, and toxicity profile., Methods: A consecutive series of patients with primarily treated BCCs who were irradiated by means of orthovoltage X-rays in the Netherlands Cancer Institute in Amsterdam between January 2000 and February 2015 were retrospectively evaluated., Results: Two hundred fifty-three BCCs in 232 patients were primarily treated with orthovoltage X-rays. The local control rates at 1, 3, and 5 years for this selection of basal cell carcinomas were 98.9%, 97.5%, and 96.3%, respectively. Tumor size was the only significant predictor for local control because BCCs < 20 mm had a significantly higher 5-year local control rate than lesions ≥ 20 mm (96.8% vs. 89.4%, P = 0.041). Acute toxicity healed spontaneously without medical intervention, and late toxicity rates were low. Functional impairments were negligible, and the cosmetic outcome was excellent., Conclusion: Orthovoltage therapy for well-selected favorable BCCs in the head and neck area resulted in excellent local control rates, a low toxicity profile, and apparently satisfactory functional and cosmetic outcomes. Orthovoltage irradiation is a good alternative for surgery for BCCs with favorable histologic prognosis at locations that are at risk for postoperative functional or cosmetic changes, such as the nose or canthus., Level of Evidence: 4. Laryngoscope, 126:1796-1802, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To examine health utilities in patients with cT1-2 oral cavity squamous cell carcinoma following different diagnostic and treatment modalities for the neck and to investigate the relation between shoulder morbidity and health utility., Design: Cross-sectional survey., Setting: Two Dutch hospitals., Participants: Four subgroups of patients with oral cavity cancer who underwent watchful waiting, sentinel lymph node biopsy, elective supraomohyoid neck dissection or therapeutic modified radical neck dissection., Main Outcome Measures: Patients received the EuroQol-5D-3L questionnaire and the shoulder disability questionnaire. Mean health utility, visual analogue scale and shoulder disability scores were calculated., Results: A total of 181 patients (62%) returned the questionnaires. Mean health utilities, adjusted for age, gender and time since treatment were 0.804, 0.863, 0.834 and 0.794 for the watchful waiting, sentinel lymph node biopsy, supraomohyoid neck dissection and modified radical neck dissection subgroups, respectively. Mean shoulder disability scores (higher score means more shoulder complaints) for these subgroups were 8.64, 10.57, 18.92 and 33.66. Patients with shoulder complaints had a mean utility of 0.78 while patients without shoulder complaints had a mean utility of 0.90., Conclusions: This study shows that more invasive procedures appear to result in lower health utility. The high health utility for patients after sentinel lymph node biopsy supports a role for this procedure in patients with oral cancer., (© 2015 John Wiley & Sons Ltd.)

Merkel cell carcinoma (MCC) is a rare primary cutaneous neuroendocrine carcinoma. It occurs predominantly in the head and neck area and often behaves aggressively. In this single-institution retrospective observational cohort study, we describe the results of a treatment strategy that we developed over the past decades. Endpoints of this study were local, regional and distant control, disease-specific survival and overall survival. In total 47 patients with head and neck MCC, diagnosed in the Netherlands Cancer Institute-Antoni van Leeuwenhoek (NKI-AvL) between 1984 and 2012, were included in this study. Local tumor control was 82 % (95 % CI 71-95 %) at 5 years. Regional lymph node metastases were found at the moment of diagnosis in 13 cases (28 %). In the group of patients who were initially cN0, the 5-year regional control was 80 % (68-95 %). The 5-year metastasis-free interval probability was 80 % (68-94 %). The disease-specific survival (DSS) at 5 years was 70 % (56-86 %). An overall survival of 54 % (40-72 %) was found at 5-year follow-up and of 37 % (23-59 %) at 10-year follow-up. Univariable Cox regression analysis of many clinical and pathological variables did not identify any predictors for DSS. The MCC has a high propensity for locoregional and distant spread in the head and neck region. Undertreatment, especially of the lymph nodes in the neck, is a serious problem as regional (micro)metastasis are common even in T1 tumors. Future research will have to elucidate the role of the sentinel lymph node procedure versus the elective selective node dissection and standardized elective local and regional radiotherapy in the head and neck area.

Purpose: Loco-regional control and organ preservation are significantly improved with concomitant cisplatin/radiotherapy and are compromised with less than 5% grade 3 nephrotoxicity (creatinine clearance 15-29 mL/min). However, although clinically important, in none of the randomized trials is grade 2 nephrotoxicity (defined as creatinine clearance 59-30 mL/min) mentioned. In this study, we assessed nephrotoxicity in daily practice among patients treated with high-dose cisplatin (100 mg/m² on days 1, 22, and 43), concurrently with chemoradiotherapy (CCRT) and the impact on treatment modifications., Methods: 208 patients with advanced-stage malignancies of the head and neck region were evaluated. All patients were treated with high-dose cisplatin CCRT. The main outcome parameters were nephrotoxicity (defined as creatinine clearance grade 2 or more) and cumulative doses of cisplatin and radiation., Results: 133 patients (64%) completed all pre-planned courses of cisplatin. Nephrotoxicity was the main reason to discontinue the chemotherapy. Grade 3 nephrotoxicity was seen in 16 patients (8%) while grade 2 nephrotoxicity was seen in 53 patients (25%). Thirty six patients (17%) could not complete the pre-planned chemotherapy due to nephrotoxicity., Conclusions: In head and neck cancer patients, nephrotoxicity grade 2 is under-reported but is the major factor for discontinuing cisplatin during CCRT.

(1) BACKGROUND: The purpose of this retrospective study was to evaluate the recurrence and survival rates of metastatic melanoma of unknown primary origin (MUP), in order to further refine current recommendations for the surgical treatment; (2) METHODS: Medical data of all MUP patients registered between 2000 and 2011, were analyzed. Seventy-eight patients were categorized in either lymph node (axilla, groin, head-and neck) or subcutaneous MUP. Axillary node MUPs were generally treated with dissections of levels I-III, inguinal node MUPs with combined superficial and deep groin dissections, and head-and-neck node MUPs with neck dissections to various extents, based on lymph drainage patterns. Subcutaneous lesions were excised with 1-2 cm margins. The primary outcome was treatment outcomes in terms of (loco)regional recurrence and survival rates; (3) RESULTS: Lymph node MUP recurred regionally in 11% of patients, with an overall recurrence rate of 45%. In contrast, subcutaneous MUP recurred locally in 65% of patients with an overall recurrence rate of 78%. This latter group had a significantly shorter disease-free interval than patients with lymph node MUP (p = 0.000). In the entire study population, 5-year and 10-year overall survival rates were 56% and 47% respectively, with no differences observed between the various subgroups; (4) CONCLUSION: The relatively low regional recurrence rate after regional lymph node dissection (11%) supports its current status as standard surgical treatment for lymph node MUP. Subcutaneous MUP, on the contrary, appears to recur both locally (65%) and overall (78%) at a significantly higher rate, suggesting a different biological behavior. However, wide local excision remains the best available option for this specific group.

Purpose To evaluate the hybrid approach in a large population of patients with melanoma in the head and neck, on the trunk, or on an extremity who were scheduled for sentinel node (SN) biopsy. Materials and Methods This prospective study was approved by the institutional review board. Between March 2010 and March 2013, 104 patients with a melanoma, including 48 women (average age, 54.3 years; range, 18.5-87.4 years) and 56 men (average age, 55.2 years; range, 22.4-77.4 years) (P = .76) were enrolled after obtaining written informed consent. Following intradermal hybrid tracer administration, lymphoscintigraphy and single photon emission computed tomography/computed tomography were performed. Blue dye was intradermally injected prior to the start of the surgical operation (excluding patients with a facial melanoma). Intraoperatively, SNs were initially pursued by using gamma tracing followed by fluorescence imaging (FI) and, when applicable, blue-dye detection. A portable gamma camera was used to confirm SN removal. Collected data included number and location of the preoperatively and intraoperatively identified SNs and the intraoperative number of SNs that were radioactive, fluorescent, and blue. A two-sample test for equality of proportions was performed to evaluate differences in intraoperative SN visualization through FI and blue-dye detection. Results Preoperative imaging revealed 2.4 SNs (range, 1-6) per patient. Intraoperatively, 93.8% (286 of 305) of the SNs were radioactive, 96.7% (295 of 305) of the SNs were fluorescent, while only 61.7% (116 of 188) of the SNs stained blue (P < .0001). FI was of value for identification of near-injection-site SNs (two patients), SNs located in complex anatomic areas (head and neck [28 patients]), and SNs that failed to accumulate blue dye (19 patients). Conclusion The hybrid tracer enables both preoperative SN mapping and intraoperative SN identification in melanoma patients. In the setup of this study, optical identification of the SNs through the fluorescent signature of the hybrid tracer was superior compared with blue dye-based SN visualization.

Background: In head/neck melanomas, near-the-injection-site sentinel nodes (NIS-SNs) may be missed on planar lymphoscintigraphy and/or SPECT/CT. The aim of the present study is to establish the performance of a portable gamma camera (PGC) to detect NIS-SNs in a simulation phantom set-up, and subsequently in head/neck melanoma patients scheduled for a SN procedure., Methods: Five plastic Eppendorf tubes filled with technetium-99m-albumin nanocolloid were used to simulate 4 radiotracer deposit sites, as traditionally injected in melanoma patients, and 1 NIS-SN. A PGC was used with 2 pinhole collimators (2.5 and 4.0 mm). Image acquisition time was 1 minute with the camera positioned at various distances (range 1.5-15.5 cm). Results were compared with conventional lymphoscintigraphy and SPECT/CT acquired with a dual-head gamma camera as well with a gamma probe. Additionally, the same PGC setting was used in a case series of 3 patients with head/neck melanomas., Results: The simulated NIS-SN was differentiated from the injection site at a distance of 3 mm with the 2.5-mm pinhole and at 5 mm with the 4-mm pinhole when the PGC was positioned at 1.5 cm distance. Planar lymphoscintigraphy, SPECT/CT, and the gamma probe depicted the NIS-SN separated from the injection site at distances of 7, 10, and 22 mm, respectively. In all 3 patients, 6 NIS-SNs were depicted with the PGC., Conclusion: A high-resolution PGC, positioned close to the skin, is able to detect SNs at distances of at least 3 mm from the injection site. A further clinical evaluation of this device to establish its added value in reducing false-negative procedures and potential recurrences is necessary.

Purpose: Lymphoscintigraphic imaging and adequate interpretation of the lymphatic drainage pattern is an essential step in the sentinel lymph node biopsy (SLNB) procedure. In oral cancer, identification of the sentinel lymph node (SLN) can be challenging. In this study, interobserver variability in defining SLNs on lymphoscintigrams was evaluated in patients with T1-T2 stage N0 oral cancer., Methods: Sixteen observers (head and neck surgeons, nuclear medicine physicians or teams of both) from various institutes were asked which criteria they use to consider a hot focus on the lymphoscintigram as SLN. Lymphoscintigrams of 9 patients with 47 hot foci (3-9 per patient) were assessed, using a scale of 'yes/equivocal/no'. Bilateral drainage was seen in four of nine cases. In three cases additional late single photon emission computed tomography (SPECT)/CT scanning was performed. Interobserver variability was evaluated by kappa (к) analysis, using linear weighted pairwise comparison of the observers. Conservative (equivocal analysed as no) and sensitive (equivocal analysed as yes) assessment strategies were investigated using pairwise kappa analysis., Results: Various definitions of SLN on lymphoscintigrams were given. Interobserver variability of all cases using a 3-point scale showed fair agreement (71%, к(w) = 0.29). The conservative and sensitive analyses both showed moderate agreement: conservative approach к = 0.44 (in 80% of the hot foci the observers agreed) and sensitive approach к = 0.42 (81%) respectively. Multidisciplinary involvement in image interpretation and higher levels of observer experience appeared to increase agreement., Conclusion: Among 16 observers, there is practice variation in defining SLNs on lymphoscintigrams in oral cancer patients. Interobserver variability of lymphoscintigraphic interpretation shows moderate agreement. In order to achieve better agreement in defining SLNs on lymphoscintigrams specific guidelines are warranted.

Objectives: Results of the Dutch multi-institutional trial on sentinel lymph node (SLN) biopsy in oral cancer., Patients and Methods: Patients were consecutively enrolled from 4 institutions, with T1/T2 oral cancer and cN0 neck based on palpation and ultrasound guided fine needle aspiration cytology. Lymphatic mapping consisted of preoperative lymphoscintigraphy. For intraoperative SLN detection a gamma-probe was used and in some patients additional blue dye. SLN negative patients were carefully observed, SLN positive patients were treated by neck dissection, radiotherapy or a combination of both. Endpoints of the study were risk of occult lymp node metastases, neck control, accuracy, 5-year disease-free survival (DFS), overall survival (OS) and disease-specific survival (DSS)., Results: Twenty of 62 patients (32%) had positive SLNs. Macrometastases were found in 9 patients, micrometastases in 8, and isolated tumour cells in 3 patients. Median follow-up was 52.5 months. Of the 42 SLN negative patients, 5 developed a regional recurrence of whom 4 patients could be successfully salvaged. DFS, OS and DSS of SLN negative patients were 72.0%, 92.7% and 97.4%, and for SLN positive patients these numbers were 73.7%, 79.7%, 85.0%, respectively (DFS: p=0.916, OS: p=0.134, DSS: p=0.059, respectively). Neck control rate was 97% in SLN negative and 95% in SLN positive patients. Sensitivity was 80% and negative predictive value 88%., Conclusion: SLN biopsy is able to reduce the risk of occult lymph node metastases in T1/T2 oral cancer patients from 40% to 8%, and enables excellent control of the neck., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: Recent innovations such as preoperative SPECT/CT, intraoperative imaging using portable devices and a hybrid tracer were evaluated in a multimodality approach for sentinel node (SN) mapping and biopsy in head and neck malignancies., Material and Methods: The evaluation included 25 consecutive patients with head and neck malignancies (16 melanomas and 9 oral cavity squamous cell carcinomas). Patients were peritumorally injected with the hybrid tracer ICG-(99m)Tc-nanocolloid. SNs were initially identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT/CT) 2 hours after tracer administration. During surgery a portable gamma camera in combination with a near-infrared fluorescence camera was used in addition to a handheld gamma ray detection probe to locate the SNs., Results: In all patients the use of conventional lymphoscintigraphy, SPECT/CT and the additional help of the portable gamma camera in one case were able to depict a total of 67 SNs (55 of them visualized on planar images, 11 additional on SPECT/CT and 1 additional with the portable gamma camera). A total of 67 of the preoperatively defined SNs together with 22 additional SNs were removed intraoperatively; 12 out of the 22 additional SNs found during operation were located in the vicinity of the injection site in anatomical areas such as the periauricular or submental regions. The other 10 additional SNs were found by radioguided post-resection control of the excision SN site., Conclusion: In the present series 26% additional SNs were found using the multimodal approach, that incorporates SPECT/CT and intraoperative imaging to the conventional procedure. This approach appears to be useful in malignancies located close to the area of lymphatic drainage such as the periauricular area and the oral cavity., (Copyright © 2013 Elsevier España, S.L.U. and SEMNIM. All rights reserved.)

Conventional sentinel node (SN) mapping is performed by injection of a radiocolloid followed by lymphoscintigraphy to identify the number and location of the primary tumor draining lymph node(s), the so-called SN(s). Over the last decade research has focused on the introduction of new imaging agents that can further aid (surgical) SN identification. Different tracers for SN mapping, with varying sizes and isotopes have been reported, most of which have proven their value in a clinical setting. A major challenge lies in transferring this diagnostic information obtained at the nuclear medicine department to the operating theatre thereby providing the surgeon with (image) guidance. Conventionally, an intraoperative injection of vital blue dye or a fluorescence dye is given to allow intraoperative optical SN identification. However, for some indications, the radiotracer-based approach remains crucial. More recently, hybrid tracers, that contain both a radioactive and fluorescent label, were introduced to allow for direct integration of pre- and intraoperative guidance technologies. Their potential is especially high when they are used in combination with new surgical imaging modalities and navigation tools. Next to a description of the known tracers for SN mapping, this review discusses the application of hybrid tracers during SN biopsy and how the introduction of these new techniques can further aid in translation of nuclear medicine information into the operating theatre.

Background: The purpose of this study was to provide anatomic guidance for the extent (technique) of suboccipital node dissection., Methods: Five human cadaver necks (9 sides) were studied. Boundaries were the superior nuchal line and external occipital protuberance (cranial), the nuchal ligament (medial), an imaginary line through C7 (caudal), and the posterior wall of the auditory channel (anterior). The overlying skin and complete thickness of the cranial part of the trapezius muscle and fascia sheath was included (deep)., Results: An average number of 4 lymph nodes per suboccipital side were found. Diameters ranged from 1 to 6 mm. Twenty nodes (63%) were located in the subcutaneous tissue, 12 (37%) were found just underneath the superficial fascia of the trapezius muscle., Conclusion: Suboccipital nodes are small and mainly located in the subcutaneous layer, with a minority just underneath the superficial fascia of the trapezius muscle. This anatomic knowledge was used to refine the suboccipital dissection., (Copyright © 2013 Wiley Periodicals, Inc.)

For treatment of early stage (Tis-T2) laryngeal cancer the main choice is between microlaryngoscopy with carbon dioxide laser resection (laser surgery) and radiotherapy. Because both treatments provide excellent tumour control, secondary outcome variables such, as quality of voice may be of importance in treatment preference. In this study tumour outcomes and quality of voice were analysed for a cohort of patients with early stage (Tis-T2) laryngeal (glottic) carcinoma. The "physical subscale" of the voice handicap index questionnaire (VHI) and a validated five-item screening questionnaire were used. Analysis of 89 patients treated with laser surgery and 159 patients treated with radiotherapy revealed a 5-year local control of 75 and 86 % (p = 0.07). Larynx preservation (5-year) was, however, superior in patients treated with laser surgery, 93 vs 83 % (p < 0.05). Tumour outcomes were also analysed per tumour stage and none were of significant difference. Quality of voice was analysed in 142 patients. VHI scores were 12.4 ± 8.9 for laser surgery and 8.3 ± 7.7 for radiotherapy (p < 0.05), with a higher score reflecting a worse outcome. VHI scores per tumour stage for laser surgery and radiotherapy were, respectively, 12.0 ± 9.9 and 7.9 ± 7.5 in T1a (p = 0.06), 16.7 ± 9.0 and 4.9 ± 6.6 in T1b (p < 0.05). Outcomes of the five-item questionnaire showed voice deficiency in 33 % for laser surgery and 23 % for radiotherapy in T1a (p = 0.330) and 75 and 5 % for T1b (p = 0.001). Oncologic outcomes of laser surgery and radiotherapy were comparable. Larynx preservation is, however, preferable in patients initially treated with laser surgery. According to subjective voice analysis, outcomes were comparable in T1a lesions. Depth of laser resection is of influence on voice deficiency displayed by a significantly higher percentage of voice deficiency in patients treated with laser surgery for T1b lesions.

Purpose: To determine the incidence and pattern of cervical lymphatic drainage in patients with melanomas located on the upper limb or trunk, and to evaluate our current neck dissection protocol for those patients with a N+ neck., Methods: Of 1192 melanoma patients who underwent sentinel node biopsy, 631 were selected with a primary tumor on the upper limb or trunk. All lymphoscintigrams, SPECT/CT images and operative reports were reviewed to determine the exact locations of sentinel nodes visualized preoperatively and dissected during operation., Results: Thirty-nine (6.2 %) of 631 patients with a melanoma on the upper limb or trunk showing cervical lymph node drainage were identified. In 34 (87 %) of 39 patients, sentinel nodes were excised from level IV or Vb, and in 30 of those 39 patients simultaneous from the axilla. In the remaining five patients (13 %), sentinel nodes were collected from level IIb, level III or the suboccipital region. All collected sentinel nodes were located in the intended dissection area for N+ patients. Thirteen patients (33 %) had a total of 22 tumor-positive sentinel nodes in either the axilla (n = 10), level IV (n = 2), Vb (n = 9) or suboccipital (n = 1)., Conclusions: Only a minority of the patients with upper limb or trunk melanomas demonstrated lymphatic drainage to cervical lymph node basins, with preferential drainage to levels IV and Vb. Our current dissection protocol of levels II-V, with or without extension to the suboccipital region, in those patients with involved cervical sentinel nodes seems sufficient.

Objectives: We describe our experience in the reconstruction of large 3-layer lip defects using free revascularized lower-arm and fibula flaps., Methods: Between 2005 and 2009, nine patients underwent free-flap reconstruction after oncological surgery involving the lip and chin with or without mandibular involvement. The flap techniques are described, and postoperative functional and aesthetic results were recorded., Results: There were no flap failures. All patients showed intact oral function and good aesthetic results. Two patients died of distant metastases, 8 months and 17 months after surgery., Conclusions: Three-layer defects of the lip ideally require free-flap reconstruction, which has a high probability of achieving good functional and aesthetic results.

Unlabelled: The purpose of this study was to compare the lymphoscintigraphic drainage patterns of a hybrid sentinel node tracer consisting of the fluorescent dye indocyanine green (ICG) and (99m)Tc-nanocolloid with the drainage pattern of (99m)Tc-nanocolloid alone, the current standard tracer in many European countries., Methods: Twenty-five patients with a melanoma in the head and neck region (n = 10), a melanoma on the trunk (n = 6), or penile carcinoma (n = 9) who were scheduled for sentinel node biopsy were prospectively included. First, the standard (99m)Tc-nanocolloid procedure was performed. After injection at the lesion site, lymphoscintigraphy was performed with a 10-min dynamic study and static planar images at 10 min and 2 h after injection, followed by SPECT/CT. The same scintigraphic procedure was repeated after injection of hybrid ICG-(99m)Tc-nanocolloid the same afternoon in 10 patients or the next morning in 15 patients. The paired images of both injections were evaluated, and count rates in the sentinel nodes were calculated and compared. Sentinel nodes were surgically localized using blue dye, a γ-ray detection probe, a portable γ-camera, and a fluorescence camera., Results: Lymphatic drainage was visualized in all 25 patients using (99m)Tc-nanocolloid, leading to the identification of 66 sentinel nodes in total. These same sentinel nodes were also identified during the second scintigraphic procedure with ICG-(99m)Tc-nanocolloid. Moreover, a high correlation between the radioactive counting rates in the sentinel nodes of both scintigraphic studies was observed (mean R(2) = 0.83). Intraoperatively (4-23 h after the second injection), all preoperatively identified sentinel nodes could be localized using radio- and fluorescence guidance combined. In total, 95% of the sentinel nodes could be intraoperatively visualized by means of fluorescence imaging, whereas merely 54% stained blue. Ex vivo, all radioactive sentinel nodes were fluorescent and vice versa. No adverse reactions were observed., Conclusion: The lymphatic drainage pattern of ICG-(99m)Tc-nanocolloid is identical to that of (99m)Tc-nanocolloid. This observation, together with the added value of intraoperative fluorescence guidance, warrants wider evaluation of hybrid ICG-(99m)Tc-nanocolloid as a tracer for sentinel node procedures.

Purpose: For oral cavity malignancies, sentinel lymph node (SLN) mapping is performed by injecting a radiocolloid around the primary tumour followed by lymphoscintigraphy. Surgically, SLNs can then be localized using a handheld gamma ray detection probe. The aim of this study was to evaluate the added value of intraoperative fluorescence imaging to the conventional radioguided procedure. For this we used indocyanine green (ICG)-(99m)Tc-nanocolloid, a hybrid tracer that is both radioactive and fluorescent., Methods: Fourteen patients with oral cavity squamous cell carcinoma were peritumourally injected with ICG-(99m)Tc-nanocolloid. SLNs were preoperatively identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT)/CT for anatomical localization. During surgery, SLNs were detected with a handheld gamma ray detection probe and a handheld near-infrared fluorescence camera. Pre-incision and post-excision imaging with a portable gamma camera was performed to confirm complete removal of all SLNs., Results: SLNs were preoperatively identified using the radioactive signature of ICG-(99m)Tc-nanocolloid. Intraoperatively, 43 SLNs could be localized and excised with combined radio- and fluorescence guidance. Additionally, in four patients, an SLN located close to the primary injection site (in three patients this SLN was located in level I) could only be intraoperatively localized using fluorescence imaging. Pathological analysis of the SLNs revealed a metastasis in one patient., Conclusion: Combined preoperative SLN identification and intraoperative radio- and fluorescence guidance during SLN biopsies for oral cavity cancer proved feasible using ICG-(99m)Tc-nanocolloid. The addition of fluorescence imaging was shown to be of particular value when SLNs were located in close proximity to the primary tumour.

Purpose: This study was designed to examine the feasibility of combining lymphoscintigraphy and intraoperative sentinel node identification in patients with head and neck melanoma by using a hybrid protein colloid that is both radioactive and fluorescent., Methods: Eleven patients scheduled for sentinel node biopsy in the head and neck region were studied. Approximately 5 h before surgery, the hybrid nanocolloid labeled with indocyanine green (ICG) and technetium-99m ((99m)Tc) was injected intradermally in four deposits around the scar of the primary melanoma excision. Subsequent lymphoscintigraphy and single photon emission computed tomography with computed tomography (SPECT/CT) were performed to identify the sentinel nodes preoperatively. In the operating room, patent blue dye was injected in 7 of the 11 patients. Intraoperatively, sentinel nodes were acoustically localized with a gamma ray detection probe and visualized by using patent blue dye and/or fluorescence-based tracing with a dedicated near-infrared light camera. A portable gamma camera was used before and after sentinel node excision to confirm excision of all sentinel nodes., Results: A total of 27 sentinel nodes were preoperatively identified on the lymphoscintigraphy and SPECT/CT images. All sentinel nodes could be localized intraoperatively. In the seven patients in whom blue dye was used, 43% of the sentinel nodes stained blue, whereas all were fluorescent. The portable gamma camera identified additional sentinel nodes in two patients. Ex vivo, all radioactive lymph nodes were fluorescent and vice versa, indicating the stability of the hybrid tracer., Conclusions: ICG-(99m)Tc-nanocolloid allows for preoperative sentinel node visualization and concomitant intraoperative radio- and fluorescence guidance to the same sentinel nodes in head and neck melanoma patients.

Background and Objectives: The aim of this study is to evaluate lymphatic drainage with sentinel node location data in patients with head and neck cutaneous melanoma, and to determine the implications for the extent of therapeutic neck dissections., Methods: Sixty-five patients with head and neck cutaneous melanoma without evidence of regional metastases at ultrasound guided fine needle aspiration cytology examination were included. Lymphatic drainage patterns were investigated using planar and dynamic lymphoscintigraphy, and SPECT/CT. Biopsy of sentinel nodes was guided by images and gamma probe. The incidence of discordant sentinel nodes was determined by comparing actual drainage patterns to "O'Briens map" and to the treatment guidelines of The Netherlands Cancer Institute., Results: Sentinel node identification was successful in 98% of the patients. Fifteen patients (23%) were diagnosed with a tumor-positive sentinel node. Two sentinel node-negative patients (3%) developed a regional lymph node metastasis (false-negative ratio: 12%). Twenty-three percent of the harvested sentinel nodes were discordant according to "O'Brien's map," while 14% were discordant according to the treatment guidelines of The Netherlands Cancer Institute (P < 0.001)., Conclusions: Almost a quarter of head and neck melanomas metastasize outside clinically predicted neck levels. Neck surgery guidelines of The Netherlands Cancer Institute provide for a smaller number of discordant sentinel nodes., (Copyright © 2011 Wiley-Liss, Inc.)

The indications of photodynamic therapy (PDT) of oral cavity and oropharynx neoplasms are not well defined. The main reason is that the success rates are not well established. The current paper analyzes our institutional experience of early stage oral cavity and oropharynx neoplasms (Tis-T2) to identify the success rates for each subgroup according to T stage, primary or non-primary treatment and subsites. In total, 170 patients with 226 lesions are treated with PDT. From these lesions, 95 are primary neoplasms, 131 were non-primaries (recurrences and multiple primaries). The overall response rate is 90.7% with a complete response rate of 70.8%. Subgroup analysis identified oral tongue, floor of mouth sites with more favorable outcome. PDT has more favorable results with certain subsites and with previously untreated lesions. However, PDT can find its place for treating lesions in previously treated areas with acceptable results.

Background: The additional value of single photon emission computed tomography with CT (SPECT/CT) for detection and localization of sentinel nodes in patients with a melanoma of the head and neck was determined., Methods: Thirty-eight patients received conventional lymphoscintigraphy followed by hybrid SPECT/CT. The number of sentinel nodes visualized and anatomic information provided were analyzed. Changes in surgical approach due to additional information from the SPECT/CT were evaluated in 20 patients., Results: SPECT/CT visualized a mean of 2.6 sentinel nodes per patient (range, 1-6). SPECT/CT depicted an additional sentinel node in 16% of the patients and clearly showed the anatomic location of the hot nodes in all patients. The surgical approach was adjusted on the basis of SPECT/CT images in 11 patients (55%)., Conclusion: SPECT/CT visualizes more sentinel nodes than conventional images and shows their anatomic location. SPECT/CT is recommended in patients with a melanoma in the head or neck., (© 2010 Wiley Periodicals, Inc. Head Neck, 2011.)

Background: The aims of this prospective study were to determine the diagnostic value of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) and brain MRI in melanoma patients with palpable lymph node metastases and to assess the impact of these imaging modalities on their management., Materials and Methods: Between October 2006 and March 2009, PET/CT and brain MRI were performed in 70 melanoma patients with palpable nodal lymph node metastases and without evidence of systemic dissemination after physical examination. Hypermetabolic PET/CT lesions were examined by histology or cytology or were imaged further and followed if no pathology confirmation could be obtained., Results: PET/CT findings changed the intended regional node dissection in 26 patients (37%). PET/CT was false negative in 4 patients (6%) and false positive in 1 (1%). This resulted in a sensitivity of 87%, specificity of 98%, accuracy of 93%, positive predictive value of 96%, and negative predictive value of 91%. MRI revealed brain metastases in 5 patients (7%). The overall survival of patients without additional lesions on PET/CT was 84% after 2 years, which was better than the 56% in patients with additional metastases (P < .001)., Conclusions: PET/CT has an 87% sensitivity and 98% specificity in the detection of other metastases in melanoma patients with palpable lymph node involvement. PET/CT leads to a change in the planned regional node dissection in 37% of the patients in this study. MRI revealed brain metastases in 5 patients (7%). PET/CT findings correlate with survival.

Unlabelled: We introduced and evaluated a portable gamma-camera for intraoperative visualization of sentinel nodes in the head and neck region., Methods: Planar lymphoscintigraphy and SPECT/CT were performed after peritumoral injection of (99m)Tc-nanocolloid in 25 patients (head and neck melanoma or oral cavity carcinoma). Sentinel nodes were localized intraoperatively with a portable gamma-camera and a hand-held gamma-probe. The portable gamma-camera was used to determine the distribution of remaining radioactivity after excision of the sentinel nodes., Results: The portable gamma-camera visualized all 70 preoperatively identified sentinel nodes. Sentinel nodes at difficult sites could be localized more efficiently, and in 6 patients, 9 additional nodes (1 tumor-positive) were identified with the portable gamma-camera after excision., Conclusion: Intraoperative identification of sentinel nodes in the head and neck region with a portable gamma-camera is feasible and might lead to detection of more sentinel nodes.

The value of SPECT/CT for detection and localization of sentinel nodes is reviewed. SPECT/CT depicts extra sentinel nodes and identifies non-nodal tracer accumulation. SPECT/CT is indicated in patients with complex lymphatic drainage as often present in patients with head, neck and scapular melanoma, breast cancer patients with extra-axillary sentinel nodes and patients with tumors draining to pelvic nodes. SPECT/CT also clarifies the drainage pattern of inconclusive conventional images (non-visualization or unclear location of the nodes).

This study introduced a dual-masker forward masking technique and evaluated whether this objective method could measure electrode independency in a cochlear implant; more particularly, whether the optimal locations and number of active electrodes could be determined. This method further enabled the investigation of the efficacy of current steering, because the proposed recording method could also be described as applying a sequentially current steered masker. The paradigm requires 5 frames involving 2 maskers and 1 probe and is referred to as the Apple Core method (MP5-AC). For each recording, both the masker and probe amplitude were varied independently, producing 3-D eCAP plots that showed the eCAP amplitude for independent variations of masker and probe amplitudes. A simple quantitative model was developed to aid interpretation of the results. Theory and model were clinically tested in 14 patients. On the basis of the model, the multi-variate, color-coded plots could be subdivided into seven distinct regions, each depicting a unique relationship between the probe and the maskers. The model's predictions supported interpretation of the results, and indicated independence for the probe electrode contacts only at lower current levels and/or at greater inter-electrode separations. The clinical results revealed a lack of selectivity in the electrode array for stimulus levels larger than 600 microA. This suggests that sequential current steering is only capable of producing a single excitation area at higher current levels, or smaller electrode distances, without additional loudness correction being applied. Thus, the MP5-AC paradigm provided insight concerning the independence of electrodes and the efficacy of current steering in clinical patients. However, its current clinical applicability is limited because measurements were adequate only in anesthetized patients.

Sentinel node mapping is becoming a routine procedure for staging of various malignancies, because it can determine lymph node status more precisely. Due to anatomical problems, localizing sentinel nodes in the head and neck region on the basis of conventional images can be difficult. New diagnostic tools can provide better visualization of sentinel nodes. In an attempt to keep up with possible scientific progress, this article reviews new and innovative tools for sentinel node localization in this specific area. The overview comprises a short introduction of the sentinel node procedure as well as indications in the head and neck region. Then the results of SPECT/CT for sentinel node detection are described. Finally, a portable gamma camera to enable intraoperative real-time imaging with improved sentinel node detection is described.

Objective: Residual charge on recording electrodes leads to elevated potentials after the end of the stimulus, which can easily overload the electrically evoked compound action potential (eCAP) recording systems (neural response imaging or neural response telemetry). A new method for dealing with this problem was tested in a series of animal experiments., Material and Methods: We developed an amplifier with a compensation circuit that reduces the effect of the residual charge by electrical subtraction at the input. Using this amplifier we compared different artefact rejection protocols simultaneously in chronically implanted guinea pigs. A new, systematic nomenclature for the various forward masking schemes, based on the number of frames involved, is proposed., Results: Proper adjustment of the compensation circuit reduces the overload time from > 200 micros to < 30 micros, but the compensation signals influence the final output signal considerably. To eliminate this deliberately introduced, reproducible artefact, an additional artefact rejection scheme is necessary. With alternating polarity (AP) and forward masking paradigms we could reliably record the N1 peak. Forward masking responses reveal shorter latencies for cathodic-first biphasic stimuli than for anodic-first pulses. The average of these two closely resembles the response obtained with the AP paradigm., Conclusions: It is worthwhile implementing the electrical compensation method proposed herein in clinical neural response imaging or neural response telemetry systems, as it represents a more robust way of assessing the eCAP.

Background: The use of selective neck dissection (SND) in the treatment of clinically node-positive necks remains controversial., Methods: A total of 48 patients with laryngeal and hypopharyngeal carcinoma underwent 53 primary, therapeutic SNDs (levels II-V) and were retrospectively evaluated., Results: Regional metastases were staged as pN1 in 8 patients, pN2a in 3, pN2b in 29, and pN2c in 8. Of the primarily treated necks 45 of 53 (85%) were irradiated postoperatively. Extracapsular spread was found in 27 neck specimens (51%). Regional recurrences in level I occurred in one patient (1.8%) and in level II-V in 5 patients (9.4%). The actuarial overall survival at 4 years was 36.5%., Conclusions: In selected cases therapeutic SND (levels II-V) in node positive (N1,2) patients with laryngeal or hypopharyngeal carcinoma does not lead to increased risk for recurrence in level I or other levels of the neck and is therefore a safe procedure.

Objective: This blind crossover study evaluates the effect of the number of electrodes of the Clarion CII cochlear implant on speech perception in silence and in noise using a "high-rate" continuous interleaved sampling (CIS) strategy., Material and Methods: Nine users of this implant with 3-11 months of experience of an 8-channel CIS strategy [833 pulses per second (pps)/channel, 75 micros/phase] were fitted in a random order with 8-, 12- and 16-channel CIS strategies (+/- 1,400 pps/channel, 21 micros/phase). After 1 month of exclusive use of each strategy the performance was tested with consonant-vowel-consonant words in silence (sound only) and in speech-shaped background noise with signal-to-noise ratios (SNRs) of + 10, + 5, 0 and -5 dB., Results: With "high-rate" strategies most patients' speech understanding in noise improved, although the optimum number of electrodes was highly variable. Generally, faster performers benefited from more active electrodes, whilst slower performers deteriorated. If each patient's optimal strategy was determined by a weighted sum of the test results at +10, + 5 and 0 dB SNR, the average phoneme score improved from 57% to 72% at a SNR of + 5 dB, and from 46% to 56% at a SNR of 0 dB. The average phoneme score in silence was approximately 85% for all strategies., Conclusion: We conclude that speech perception (especially in noise) can improve significantly with "high-rate" speech processing strategies, provided that the optimum number of electrodes is determined for each patient individually.

A 35-year-old man with morbid obesity was admitted to our hospital to undergo gastric banding gastroplasty by the laparoscopic approach. Aside from his morbid adiposity, with a body mass index (BMI) of 49.9 kg/m2, the patient was healthy. During the procedure, he developed ventricular fibrillation (VF) while a diathermic knife was being used. After defibrillation, his heart rate returned to normal. The postoperative clinical course was uneventful, and there was no evidence of permanent heart failure. Although the VF could have been caused by patient- or material-related variables, it was most likely the result of unwanted electrical effects. Specifically, the occurrence of an arc between the patient's tissue and the tip of the electrode during cutting in the coagulation mode can lead to low-frequency current. The modified low-frequency current may produce arrhythmias. Thus, the use of the coagulation mode to cut tissue in the cardiac region during laparoscopic procedures could increase the risk for arrhythmias. An understanding of the physical principles of electrosurgery, as well as familiarity with the equipment and its various functions, is essential for the patient's safety. In addition, cardioversion equipment should be readily available on every surgical unit.

Objective: Evaluation of diagnostic procedures and treatment results in patients with lymph node metastases of squamous cell carcinoma in the head and neck region with an unknown primary., Design: Retrospective, descriptive., Patients and Methods: In 1979-98, 39 patients (30 male, 9 female; mean age 59 years; range: 39-88) were treated for cervical lymph node metastases of squamous cell carcinoma with an unknown primary. According to protocol, all patients underwent ENT examination, radiodiagnostic procedures and, if possible, examination under general anaesthesia of the upper respiratory and digestive tracts. Most patients were treated by neck dissection followed by bilateral radiotherapy to the neck and to mucosal sites of suspected origin. The data were collected from medical records. The number of patients who had had no local or regional recurrence and were still alive after 5 years were calculated by the Kaplan-Meier method., Results: There was a median interval of three months (3-100 weeks) between the first symptoms and presentation in our clinic. During this period an extensive search for a primary tumour was performed. Most lymph nodes metastases (37/44; 84%) were found at level II and III. The N-stage was as follows: N1 (6), N2 (14), N3 (19). In two patients a primary tumour was diagnosed 20 and 37 months after treatment, respectively, both at mucosal sites which were not irradiated. A five-year locoregional recurrence-free interval was seen in 66%. The five-year overall survival rate was 52% and was significantly related to the extent of the cervical lymph node metastases., Conclusion: Early treatment of patients with cervical lymph node metastases from an unknown primary tumour improves survival rates. Radiation therapy of the laryngo-pharyngeal axis seems effective in preventing outgrowth of an occult primary.

There are indications that endolymph homeostasis is controlled by intracellular cAMP levels in cells surrounding the scala media. Cholera toxin is a potent stimulator of adenylate cyclase, i.e. it increases cAMP levels. We hypothesized that perilymphatic perfusion of cholera toxin might increase endolymph volume by stimulating adenylate cyclase activity, providing us with a pharmacological model of acute endolymphatic hydrops (EH). Guinea pig cochleas were perfused with artificial perilymph (15 min), with or without cholera toxin (10 microg/ml). The endocochlear potential (EP) was measured during and after perfusion. The summating potential (SP), evoked by 2, 4 and 8 kHz tone bursts, was measured via an apically placed electrode 0, 1, 2, 3 and 4 h after perfusion. Thereafter, the cochleas were fixed to enable measurement of the length of Reissner's membrane, reflecting EH. After perfusion the EP increased significantly over time in the cholera toxin group as compared to the controls. Also, the SP increased gradually at all frequencies in the cholera toxin group. Comparison within animals showed that the increase in SP became significant after 2 h at 4 kHz, after 3 h at 2 kHz and after 4 h at 8 kHz. In the control group the SP did not change significantly. The compound action potential (CAP) amplitude decreased monotonically over time at all frequencies in both the cholera toxin group and the control group, but it decreased faster in the cholera toxin group. Also, the cochlear microphonics amplitude decreased over time at all frequencies in both groups, but the decrease was significant only in the cholera toxin group after 3 h at 2 and 4 kHz. Quantification of the length of Reissner's membrane showed a small but insignificant enlargement in the cholera toxin treated animals compared to controls. These results are in accord with our view that EH is accompanied by an increase in SP and a decrease in CAP. Our results partially confirm previous results of Feldman and Brusilow (Proc. Natl. Acad. Sci. USA (1973) 73, 1761-1764). New aspects in relation to that study are the significantly increased EP and SP. In the classical EH model, based on obstruction of the absorptive function of the endolymphatic sac, increased SPs are accompanied by decreased EPs. In this cholera toxin model of EH, it is unlikely that the endolymphatic sac is involved. Apparently, EH can be based on mechanisms located in the cochlea itself as opposed to mechanisms located in the endolymphatic sac.

Background: Malnutrition has been recognized as a poor prognostic indicator for cancer treatment-related morbidity and mortality in general, and it is reported to affect 30-50% of all patients with head and neck cancer. In this study, the correlation of nutritional status with 3-year survival was studied prospectively in 64 patients with T2-T4 carcinomas of the head and neck who were treated surgically with curative intent; the surgery was often followed by radiotherapy., Methods: All patients underwent nutritional screening according to six different parameters on the day prior to surgery. Overall and disease specific survival analyses were performed with a follow-up period of at least 3 years. Survival analyses were performed with the log rank test and the Cox proportional hazards model., Results: Lymph node stage, nonradical resection margins, and occurrence of major postoperative complications were demonstrated to affect disease specific survival for the group as a whole. None of the investigated nutritional parameters were correlated with survival. When men and women were analyzed separately, however, a preoperative weight loss of >5% did have a prognostic value for men. The combination of male gender, preoperative weight loss, and major postoperative complications were related to early death., Conclusions: Apart from the well-known prognostic parameters lymph node status (T classification) and status of surgical margins, preoperative weight loss and occurrence of major postoperative complications were also found to have a negative effect on the survival of male patients undergoing surgery for advanced head and neck cancer.

Background: Melanoma recurring locoregionally after isolated limb perfusion (ILP) constitutes a therapeutic dilemma. Major amputation is a deterrent option for local control and palliation in these patients who have a rather poor prognosis. Little is known about the feasibility and efficacy of repeat ILP in these situations., Study Design: From 1978 to 1993, 28 patients with recurrent melanoma after ILP were retreated with various ILP procedures using melphalan. Eighteen patients underwent reperfusion by a single and four by a multiple normothermic schedule. Hyperthermia was applied in six repeat ILP procedures., Results: A complete remission was achieved in 14 (74 percent) of 19 patients with measurable disease, with a median limb recurrence-free interval of 11 months. A partial remission was obtained in one patient (5 percent). Two patients had no change of disease and two patients had progressive disease. In the remaining nine patients, all macroscopic tumor tissue was excised before or during the repeat ILP procedure. The median limb recurrence-free interval of these nine patients was 15 months. After a median follow-up period of 30 months after repeat ILP, seven (25 percent) of the 28 total patients were alive without disease. Acute regional tissue toxicity was more severe after repeat ILP than after the first procedure (p < 0.05). Long-term regional morbidity occurred in 11 percent of the patients., Conclusions: A high complete remission rate can be obtained with repeat ILP using melphalan. However, the high limb recurrence rate and relatively short limb recurrence-free interval need improvement. Increased acute regional toxicity after repeat ILP can be explained by the use of more intensive schedules.