Publications by authors named "Leif Bäck"

89 Publications

Tracheostomy complications in otorhinolaryngology are rare despite the critical airway.

Eur Arch Otorhinolaryngol 2021 Mar 3. Epub 2021 Mar 3.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland.

Purpose: To identify complications of surgical tracheostomies in otorhinolaryngologic patients and adjust our processes to be properly prepared in the future.

Methods: We reviewed retrospectively all surgical tracheostomies (n = 255) performed by otolaryngologist-head and neck surgeons at Helsinki University Hospital between Jan 2014 and Feb 2017. Patient demographics, surgical details, surgical and medical complications, and tracheostomy-related mortality were recorded from the hospital charts. Risk factors for complications were assessed.

Results: Altogether, 55 (22%) complications were identified in 39 (15%) patients, with pneumonia, accidental decannulation, and bleeding being the most common. No patient or surgery-related factor reached significance in overall complication risk factor analysis. Medical complications were more common after elective tracheostomies compared to emergency procedures (10.6% vs. 3.5%, p < 0.05). Majority of complications (78%) were classified as mild or moderate according to Clavien-Dindo. Only 2 (0.8%) tracheostomy-related deaths were recorded.

Conclusion: In otorhinolaryngologists service, severe complications and tracheostomy-related deaths are very rare. Reducing their prevalence even further with careful planning is possible.
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http://dx.doi.org/10.1007/s00405-021-06707-7DOI Listing
March 2021

Trends in the Management of Non-Vestibular Skull Base and Intracranial Schwannomas.

Cancer Manag Res 2021 18;13:463-478. Epub 2021 Jan 18.

International Head and Neck Scientific Group, Padua, Italy.

The aim of this review is to analyze the latest trends in the management of non-vestibular skull base and intracranial schwannomas in order to optimize tumor control and quality of life. Non-vestibular cranial nerve schwannomas are rare lesions, representing 5-10% of cranial nerve schwannomas. Management decisions should be individualized depending on tumor size, location and associated functional deficits. Generally, large sized schwannomas exerting significant mass effect with increased intracranial pressure are treated surgically. In some cases, even after optimal skull base resection, it is not possible to achieve a gross total resection because tumor location and extent and/or to reduce morbidity. Thus, subtotal resection followed by stereotactic radiosurgery or fractioned radiotherapy offers an alternative approach. In certain cases, stereotactic radiosurgery or radiotherapy alone achieves good tumor control rates and less morbidity to gross total resection. Finally, given the slow growth rate of most of these tumors, observation with periodic radiographic follow-up approach is also a reasonable alternative for small tumors with few, if any, symptoms.
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http://dx.doi.org/10.2147/CMAR.S287410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822088PMC
January 2021

Positive airway pressure therapy for obstructive sleep apnea in patients with Osteogenesis imperfecta: a prospective pilot study.

BMC Musculoskelet Disord 2021 Jan 11;22(1):61. Epub 2021 Jan 11.

Department of Oral and Maxillofacial Diseases, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland.

Background: Obstructive sleep apnea (OSA) is prevalent in individuals with Osteogenesis imperfecta (OI). To date, no study has investigated treatment of OSA in adult individuals with OI using positive airway pressure (PAP). This observational pilot study examined the adherence of adults with OI to treatment of OSA with PAP therapy, and the evolution of self-experienced sleepiness and depression symptoms before and after treatment.

Methods: We included 20 patients, with a mean age of 51 years, who represented varying severity of OI and displayed an apnea and hypopnea index ≥ 5 /sleeping hour as recorded by an overnight polysomnography. PAP therapy was proposed to all patients. Epworth Sleepiness Scale (ESS) questionnaire to evaluate daytime sleepiness, and a validated self-rating depression questionnaire to identify possible depression, were completed prior to PAP therapy and repeated after a minimum of one year. The datasets supporting the conclusions of this article are included within the article.

Results: From the 20 patients, 15 initiated PAP therapy, and two patients later interrupted it. The mean PAP follow-up period was 1230 days. At baseline, an abnormally high ESS score was reported by 29% of the respondents, and an abnormally high number of symptoms suggesting depression by 29%. Follow-up questionnaires were completed by 60% of the patients, of whom 83% were adherent to PAP treatment. ESS score and depression symptoms did not decrease significantly with PAP therapy.

Conclusions: Patients with OI accepted well PAP therapy and remained compliant. Sleepiness and depression persisted unaltered despite good PAP adherence. These unexpectedly poor improvements in symptoms by PAP therapy may be due to subjective depression symptoms and the complexity of factors underlying persisting sleepiness in OI. Further research is needed to confirm this novel finding.
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http://dx.doi.org/10.1186/s12891-020-03932-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798292PMC
January 2021

Enteral tube feeding of head and neck cancer patients undergoing definitive chemoradiotherapy in the Nordic Countries: Survey of the Scandinavian Society for Head and Neck Oncology.

Eur Arch Otorhinolaryngol 2021 Jan 2. Epub 2021 Jan 2.

Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

Purpose: We assessed current policies and perceptions of enteral tube feeding in head and neck cancer (HNC) patients undergoing chemoradiotherapy (CRT). A web-based survey was used to compare the timing and method of tube feeding within and between the five Nordic countries, covering a population of 27 million.

Methods: From each of the 21 Nordic university hospitals, one oncologist and one otorhinolaryngology-head and neck (ORL-HN) surgeon responded to a survey. The respondents were asked whether tube insertion before the onset of CRT, or during CRT as required (prophylactic vs. reactive) was preferred. The use of a pretreatment nutritional screening tool and the choice of feeding route (nasogastric vs. gastrostomy tube) were assessed. In total, we analyzed responses from 21 oncologists and 21 ORL-HN surgeons.

Results: A tendency was observed towards decreasing the use of a PEG tube. Of the 21 university hospitals, only 2 (10%) reported using a prophylactic PEG tube in over half of HNC patients undergoing definitive CRT. The preferred method for reactive tube feeding was by a NG tube in 14 of 21 (67%), and by a PEG in 7 of 21 (33%). In general, both oncologists and ORL-HN surgeons were content with their current policy.

Conclusions: The practices for enteral tube feeding in HNC management vary within and between the Nordic countries. We suggest that unified protocols for tube feeding should be developed for this patient population.
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http://dx.doi.org/10.1007/s00405-020-06545-zDOI Listing
January 2021

Matrix metalloproteinase-7, -8, -9, -15, and -25 in minor salivary gland adenoid cystic carcinoma.

Pathol Res Pract 2021 Jan 22;217:153293. Epub 2020 Nov 22.

Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Oral Pathology and Radiology, University of Turku, Turku University Hospital, Turku, Finland; Research Programs Unit, Translational Cancer Biology Program, University of Helsinki, Helsinki, Finland.

Knowledge on the role of matrix metalloproteinases (MMPs) in adenoid cystic carcinoma (ACC) is limited. MMPs are capable of degrading almost all extracellular and pericellular components to promote invasion and metastasis. This study aimed to evaluate the immunohistochemical expression of MMP-7, -8, -9, -15, and -25 in ACC and to relate the results with clinicopathological factors and survival. The study included 68 patients with minor salivary gland ACC treated at the Helsinki University Hospital (Helsinki, Finland) in 1974-2012. Samples from 52 patients were available, consisting of 44 primary tumours and eight recurrent tumours. We scored immunostaining of MMP-7, -8, -9, -15, and -25 and analysed the immunoscore against clinical and pathological parameters using statistical correlation test. MMP-9 immunoexpression in pseudocysts of ACC and in peritumoural inflammatory cells associated with better survival and fewer treatment failures. High tumoural MMP-7 and -25 associated with better survival. High tumoural MMP-15 associated with poorer survival and high tumoural MMP-9 with advanced stage and regional recurrences. Tumour cells did not show MMP-8 immunopositivity. These results suggest that MMP-9 may contribute to ACC carcinogenesis in different roles. MMP-7, -8, and -9 can stimulate signalling pathways that may promote tissue modulation and metastatic potential. MMP-15 and -25 may reflect prognosis.
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http://dx.doi.org/10.1016/j.prp.2020.153293DOI Listing
January 2021

No changes in nocturnal respiration with hypoglossal neurostimulation therapy for obstructive sleep apnoea.

Clin Respir J 2020 Nov 13. Epub 2020 Nov 13.

Head and Neck Center, ENT Department, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.

Study Objectives: We initiated Hypoglossal Neurostimulation therapy (HGNS) at the Helsinki University Hospital in late 2014. Here, we report our experience.

Methods: We included all 15 HGNS patients. All patients had previously failed both CPAP and oral appliance therapy for sleep apnoea. Overnight polysomnography parameters were analysed before and at 1.5 years with HGNS.

Results: Mean ± SD patient age was 53 ± 6 years; 2 women and 13 men were included. Mean ± SD efficient CPAP level was 11.4 ± 3.4 cm H O. Implantation technically succeeded in all patients. There were no significant changes of AHI and ODI4 after HGNS [median (quartile) 29.2/h (19.8-38.7) versus 30.1/h (15.6-52.6) and 15.0/h (5.9-20) versus 12.5/h (6.9-30.2) respectively].

Conclusion: We did not observe significant changes in AHI and ODI4 indices with HGNS therapy. Larger multicentre randomised controlled trials are necessary before wider international use of HGNS.
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http://dx.doi.org/10.1111/crj.13303DOI Listing
November 2020

Long-term Quality of Life After Treatment of Oropharyngeal Squamous Cell Carcinoma.

Laryngoscope 2020 Aug 25. Epub 2020 Aug 25.

Department of Otorhinolaryngology-Head and Neck Surgery, Turku University and Turku University Hospital, Turku, Finland.

Objectives: To analyze the long-term quality of life (QOL) among oropharyngeal squamous cell carcinoma (OPSCC) survivors.

Study Design: Retrospective chart analysis and patient response to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Core Module (EORTC QLQ-C30), Head and Neck Module (EORTC QLQ-H&N35), and M.D. Anderson Dysphagia Inventory (MDADI) survey questionnaires.

Methods: All survivors of OPSCC diagnosed and treated between 2000 and 2009 in Finland were included. There were 263 survivors (44.2% of all curatively treated patients), of which a total of 164 participated in this study (62.4%). Median follow-up was 11.79 years (range = 8.59-18.53 years, interquartile range [IQR] = 4.64 years). The mean age of the participants was 67.9 years (standard deviation = 8.0 years) at QOL follow-up.

Results: Most survivors reported a good QOL. The EORTC QLQ-C30 global health status median was 75.00 (IQR = 31.25). The single modality treatment group had significantly better QOL outcomes than the combined treatment group. Nonsmokers and previous smokers had significantly better QOL outcomes than patients who smoked at the time of diagnosis. A history of heavy alcohol use resulted in significantly worse QOL outcomes. The p16-positive cancer patients had significantly better QOL outcomes than p16-negative patients. Percutaneous endoscopic gastrostomy (PEG) tube-dependent patients reported a significantly worse QOL than patients without a PEG tube.

Conclusions: Long-term QOL in OPSCC survivors is generally good. In line with previous literature, single modality treatment was superior to combined treatment in long-term QOL outcomes, and it should be pursued whenever possible.

Level Of Evidence: 4 Laryngoscope, 2020.
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http://dx.doi.org/10.1002/lary.29042DOI Listing
August 2020

A detection dog for obstructive sleep apnea: could it work in diagnostics?

Sleep Breath 2020 Dec 29;24(4):1653-1656. Epub 2020 May 29.

Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, PO Box 263, HUS, 00029, Helsinki, Finland.

Purpose: We have previously demonstrated that dogs can be trained to distinguish the urine of patients with obstructive sleep apnea (OSA) from that of healthy controls based on olfaction. Encouraged by these promising results, we wanted to investigate if a detection dog could work as a screening tool for OSA. The objective of this study was to prospectively assess the dogs' ability to identify sleep apnea in patients with OSA suspicion.

Methods: Urine samples were collected from 50 patients suspected of having OSA. The urine sample was classified as positive for OSA when the patient had a respiratory event index of 5/h or more. The accuracy of two trained dogs in identifying OSA was tested in a prospective blinded setting.

Results: Both of the dogs correctly detected approximately half of the positive and negative samples. There were no statistically significant differences in the dogs' ability to recognize more severe cases of OSA, as compared to milder cases.

Conclusion: According to our study, dogs cannot be used to screen for OSA in clinical settings, most likely due to the heterogenic nature of OSA.
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http://dx.doi.org/10.1007/s11325-020-02113-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7679355PMC
December 2020

Factors influencing patient and health care delays in Oropharyngeal Cancer.

J Otolaryngol Head Neck Surg 2020 Apr 23;49(1):22. Epub 2020 Apr 23.

Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, FI-00029 HUS, Helsinki, Finland.

Background: The incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is increasing. Patients with HPV-associated and HPV-unassociated OPSCC differ in many aspects, which may also impact their diagnostic and management timelines. This study aims at studying the patient, primary health care (PHC) and specialist-care (SC) delays and possible differences between these two patient groups in seeking medical care.

Methods: We reviewed all new patients with OPSCC treated between 2016 and 2018 at our institute, which covers a referral area of 1.6 million people. We collected data on patients' symptoms and factors influencing why they sought medical care using a patient-reported questionnaire and hospital records. We compared delays based on patient and tumor characteristics.

Results: In our study population of 83 patients, the median patient delay was 30 days (range, 0-366), with a median PHC delay of 15 days (range, 0 days-2.5 years), and a median SC delay of 54 days (range, 12-231). The SC delay was further divided into diagnostic hospital delay and treatment delay, each with a median length of 16 days (range, 0-237) and 29 days (range, 0-73), respectively. Furthermore, we found that p16 status did not associate with delays. A longer patient delay associated with specific tumor factors, such as a larger primary tumor and a lower UICC 7th edition stage. Patients that had multiple visits or did not have a follow-up visit scheduled at the initial appointment had longer PHC delays. Treatment delay was significantly longer for patients scheduled for (chemo-)radiotherapy than for those undergoing surgery with or without (chemo-)radiotherapy.

Conclusions: Although delays remained short for the majority of OPSCC patients, long delays require further evaluation and improvement of management. Awareness of presenting symptoms among cancer risk patients and prompt referral practice or a follow-up visit at PHC represent key factors to shortening these delays. Ultimately, the causes for delays in SC appear multifactorial and require institutional quality control.
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http://dx.doi.org/10.1186/s40463-020-00413-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181590PMC
April 2020

A descriptive study highlighting the differences in the treatment protocol for oral tongue cancer in Sweden and Finland.

Acta Otolaryngol 2020 Feb 18;140(2):188-194. Epub 2019 Dec 18.

Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.

Stage II cancer of the tongue is mostly managed surgically both locally and regionally. However, indications for postoperative radiotherapy and reconstructive options vary between centers. This paper aims to describe differences in treatment in a geographically homogenous cohort. A retrospective comparison was made between two cohorts of clinical T2N0 tongue cancer from Finland and Sweden. The Finnish cohort included 75 patients and the Swedish 54. All patients had curative intent of treatment and no previous head and neck cancer. Data analyzed consisted of pathological stage, size and thickness of tumor, frequency of reconstruction, radiotherapy delivered, and survival. The Finnish cohort included a higher proportion of patients managed with reconstructive surgery (67%) than the Swedish cohort (0%),  < .00001. More patients were treated with postoperative radiotherapy (84%) in the Swedish cohort than in the Finnish (54%),  < .0002. The Finnish cohort had a higher level of survival and included more frequent downstaging (cTNM to pTNM). Our data indicate a major difference in the management of T2N0 oral tongue cancer. The optimal cut-off size and growth pattern of the tumor warranting reconstruction should be further evaluated in a prospective manner considering both survival and quality of life.
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http://dx.doi.org/10.1080/00016489.2019.1699663DOI Listing
February 2020

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

Head Neck 2020 01 12;42(1):145-146. Epub 2019 Sep 12.

Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland.

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http://dx.doi.org/10.1002/hed.25959DOI Listing
January 2020

Comparison of intubation and tracheotomy in adult patients with acute epiglottitis or supraglottitis.

Eur Arch Otorhinolaryngol 2019 Nov 5;276(11):3173-3177. Epub 2019 Sep 5.

Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, PO Box 263, 00029 HUS, Helsinki, Finland.

Purpose: In acute epiglottitis (AE) or acute supraglottitis (AS), the management of the airway is crucial. We hypothesized that tracheotomized patients recover faster than intubated patients do.

Methods: We retrospectively reviewed all adult AE and AS patients, who underwent intubation or tracheotomy between 2007 and 2018 in a tertiary care center. Patient demographics, treatment, and complications were analyzed.

Results: The cohort comprised 42 patients. The airway was secured with intubation in 50% and with tracheotomy in 50%. All intubated patients (n = 21) and three tracheotomized patients were treated in the intensive care unit (p < 0.0001). Procedure-related complications were encountered in three intubated and eight tracheotomized patients (p = 0.892). Median overall treatment cost was 11.547 € and 5.856 € in the intubated and tracheotomized patient groups, respectively (p < 0.001). The median duration of sick leave after discharge from hospital was 13 days in the tracheotomy group and 7 days in the intubation group (p = 0.097).

Conclusion: Tracheotomy resulted in a less expensive management in securing the airway in AE or AS, but tracheotomized patients had a trend towards more complications and longer sick leaves compared to intubated patients.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1007/s00405-019-05624-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6811371PMC
November 2019

Polyomavirus JCPyV infrequently detectable in adenoid cystic carcinoma of the oral cavity and the airways.

Virchows Arch 2019 Nov 1;475(5):609-616. Epub 2019 Jul 1.

Department of Oral Pathology, University of Turku and Turku University Hospital, Turku, Finland.

Our objective was to assess the presence of three polyomaviruses, namely SV40, JCPyV, and BKPyV, and human papillomaviruses (HPV) in adenoid cystic carcinomas (ACC) of the minor salivary glands (MiSG) in the head and neck region. The study comprised 68 MiSG ACC patients operated during 1974-2012 at the Helsinki University Hospital (Helsinki, Finland). Medical records and 68 histological samples were reviewed. Polyomaviruses were detected with quantitative PCR and the DNA-positive samples were further analyzed for the presence of viral tumor T antigen (T-ag) with immunohistochemistry. HPV genotyping was performed with a Multiplex HPV Genotyping Kit. Only JCPyV DNA was found in ACC samples, being present in 7 (10.3%) out of the 68 samples. The viral load of JCPyV was low varying between 1 to 226 copies/μg DNA. The JCPyV-positive samples originated from trachea (two samples), paranasal sinuses (one), and oral cavity (two). Additionally, JCPyV positivity was found in one lung metastasis of a tracheal tumor and one local disease failure of an oral cavity tumor. Three JCPyV DNA-positive samples showed weak nuclear staining for large T-ag. In conclusion, only JCPyV but not SV40, BKPyV, or HPV was found in ACC from the upper and lower airways. JCPyV copy numbers were low which might support its role as a "hit and run agent" in ACC carcinogenesis.
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http://dx.doi.org/10.1007/s00428-019-02617-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861701PMC
November 2019

Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study.

Eur Arch Otorhinolaryngol 2019 Sep 25;276(9):2577-2584. Epub 2019 Jun 25.

Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

Purpose: Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP.

Methods: We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital.

Results: For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively.

Conclusions: Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.
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http://dx.doi.org/10.1007/s00405-019-05526-1DOI Listing
September 2019

Analysis of 255 tracheostomies in an otorhinolaryngology-head and neck surgery tertiary care center: a safe procedure with a wide spectrum of indications.

Eur Arch Otorhinolaryngol 2019 Jul 15;276(7):2069-2073. Epub 2019 May 15.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029 HUS, Helsinki, Finland.

Purpose: To review indications, patient characteristics, frequency, and safety for surgical tracheostomies performed by otolaryngologist-head and neck surgeons in a single tertiary care center.

Methods: Surgical tracheostomies performed by otolaryngologist-head and neck surgeons at Helsinki University Hospital between January 2014 and February 2017 were retrospectively reviewed. Patient demographics, surgical data, and peri- and postoperative mortality information were collected from the hospital charts. Minimum follow-up was 18 months.

Results: The total population was 255, with a majority (n = 181; 71%) of males. The majority of patients (n = 178; 70%) were classified as ASA 3 or 4. A total of 198 (78%) patients suffered from head and neck cancer. Multiple (14 altogether) indications for tracheostomy were identified, and simultaneous major head and neck tumor surgery was common (in 58%). Altogether, 163 (64%) patients were decannulated during follow-up with a median cannulation period of 9 days (range 1-425). The surgical mortality was 0.4%.

Conclusion: Simultaneously performed major tumor surgery was the most common indication for a tracheostomy. A notable number of patients had impaired physical status, but relatively insignificant comorbidities. Almost two-thirds of the patients were decannulated during follow-up, although some patients remained tracheostomy dependent for a prolonged period. Tracheostomy was found to be a safe procedure.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1007/s00405-019-05466-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582064PMC
July 2019

Is sleep apnea underdiagnosed in adult patients with osteogenesis imperfecta? -a single-center cross-sectional study.

Orphanet J Rare Dis 2018 12 29;13(1):231. Epub 2018 Dec 29.

Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Background: Patients with Osteogenesis imperfecta (OI) suffer from increased bone fracture tendency generally caused by a mutation in genes coding for type I collagen. OI is also characterized by numerous co-morbidities, and recent data from questionnaire studies suggest that these may include increased risk for sleep apnea, a finding that lacks clinical evidence from cohort studies. In this cross-sectional study, 25 adults with OI underwent clinical otorhinolaryngology examination as well as overnight polysomnography to address the question. The participants were aged between 19 and 77 years, and ten of them had mild clinical OI phenotype, seven had a moderately severe phenotype, and eight had a severe phenotype.

Results: We found obstructive sleep apnea (apnea hypopnea index ≥5/h) in as many as 52% of the OI patients in the cohort. Unexpectedly, however, no correlation was present between sleep apnea and daytime sleepiness, experienced bodily pain, severity of OI, Mallampati score, or neck circumference.

Conclusions: Seeing that the usual predictors showed no association with occurrence of sleep apnea, we conclude that obstructive sleep apnea may easily be left as an undetected disorder in individuals with OI. Recurrent nocturnal hypoxia due to episodes of apneas can even affect bone metabolism, thereby further aggravating bone fragility in patients with OI.
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http://dx.doi.org/10.1186/s13023-018-0971-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310950PMC
December 2018

De-escalation of post-treatment surveillance in oropharyngeal cancer.

Head Neck 2019 05 23;41(5):1457-1462. Epub 2018 Dec 23.

Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

Background: The majority of new oropharyngeal squamous cell carcinoma (OPSCC) cases are associated with human papillomavirus and favorable prognosis. Post-treatment follow-up should be targeted to patients at greatest risk for disease recurrence.

Methods: To assess the benefits of routine clinical surveillance in OPSCC, we reviewed all follow-up visits conducted in 2014 at Helsinki University Hospital Department of Otorhinolaryngology.

Results: Of 366 visits, 26 (7%) were from patients presenting with a new symptom, and disease recurrence was detected in four. The presence of a new symptom was significantly associated with disease recurrence (P < 0.001). Of 366 visits, 340 (93%) were from patients presenting without new symptoms, and not a single recurrence was found during these visits.

Conclusions: Based on our findings, and previous studies assessing the prognosis and pattern of recurrent OPSCC, we concluded that the number of routine post-treatment visits can be reduced. Follow-up should rather focus on symptom-directed examinations.
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http://dx.doi.org/10.1002/hed.25593DOI Listing
May 2019

Transoral Robotic Surgery in the Nordic Countries: Current Status and Perspectives.

Front Oncol 2018 27;8:289. Epub 2018 Jul 27.

Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.

The five Nordic countries with a population of 27 M people form a rather homogenous region in terms of health care. The management of head and neck cancer is centralized to the 21 university hospitals in these countries. Our aim was to gain an overview of the volume and role of transoral robotic surgery (TORS) and to evaluate the need to centralize it in this area as the field is rapidly developing. A structured questionnaire was sent to all 10 Departments of Otorhinolaryngology-Head and Neck Surgery in the Nordic countries having an active programme for TORS in December 2017. The total cumulative number of performed robotic surgeries at these 10 Nordic centers was 528 and varied between 5 and 240 per center. The median annual number of robotic surgeries was 38 (range, 5-60). The observed number of annually operated cases remained fairly low (<25) at most of the centers. The present results showing a limited volume of performed surgeries call for considerations to further centralize TORS in the Nordic countries.
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http://dx.doi.org/10.3389/fonc.2018.00289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6072842PMC
July 2018

An evaluation of the diagnostic methods in head and neck cancer of unknown primary site.

Acta Otolaryngol 2018 Oct 17;138(10):930-936. Epub 2018 Jul 17.

a Department of Otorhinolaryngology - Head and Neck Surgery , Helsinki University Central Hospital , Helsinki , Finland.

Background: Various detection methods to identify the primary in head and neck cancer of unknown primary (HN-CUP) require evaluation to improve and standardize management.

Objectives: To evaluate the use of different diagnostic methods, which aim at decreasing the incidence of HN-CUP.

Material And Methods: We conducted a retrospective analysis of patients with HN-CUP at the Helsinki University Hospital during 1995-2011. We evaluated clinical assessment, definitive treatment, histopathology, and follow up. We analyzed the success in identifying the primary site to show any changes in diagnostic methods over time.

Results: Frequency of HN-CUP and success in identifying the primary site have remained constant despite the addition of PET-CT and determination of human papilloma virus (HPV) status in diagnostics. Among 133 patients, the diagnostic work up identified the primary site in 53% and the oropharynx predominated (69%). This left 85 patients with HN-CUP and 5-year overall and disease-free survival rates were 71 and 69%, respectively.

Conclusions: Panendoscopy including tonsillectomy should not be omitted in the work up.

Significance: We demonstrate a steady frequency of HN-CUP and constant success in identifying the primary site. Detection of a primary later in the follow up did not impact the survival.
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http://dx.doi.org/10.1080/00016489.2018.1484567DOI Listing
October 2018

A Prospective Observational Study of Complications in 140 Sialendoscopies.

Otolaryngol Head Neck Surg 2018 10 26;159(4):650-655. Epub 2018 Jun 26.

1 Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

Objectives To evaluate the incidence and nature of complications associated with diagnostic and interventional sialendoscopies and to report intervention failures in a prospective setup. Study Design Prospective observational study. Setting Academic tertiary care university hospital. Subjects and Methods Patients who underwent diagnostic or interventional sialendoscopy between October 2015 and December 2016 were prospectively enrolled. Patient data, operation-related factors, treatment failures, and complications were recorded into a database and analyzed. Results A total of 140 sialendoscopies were attempted or performed on 118 patients; 67 (48%) were for a parotid gland and 73 (52%) for a submandibular gland. The sialendoscopy was interventional in 81 cases (58%), diagnostic in 56 (40%), and not possible to perform in 3 (2.1%). A total of 21 complications were registered for 21 sialendoscopies (15%) and 21 patients (18%). The most common complication was infection, in 9 cases (6.4%). Other observed complications were salivary duct perforation (4 cases), prolonged glandular swelling (3 cases), transient lingual nerve analgesia (2 cases), basket entrapment (2 cases), and transient weakness in the marginal branch of the facial nerve (1 case). All complications were related to interventional procedures or papilla dilatation. Failure to treat occurred in 21 (15%) sialendoscopies: sialendoscopy itself was unsuccessful in 3 cases, and an intended intervention failed in 18 cases. Conclusion Complications in sialendoscopy are usually related to interventional procedures. The complications are mainly minor and temporary but lead to additional follow-up visits, further treatments, and sometimes hospitalization. Sialendoscopic procedures are safe but not free of complications.
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http://dx.doi.org/10.1177/0194599818782418DOI Listing
October 2018

A detection dog for obstructive sleep apnea.

Sleep Breath 2019 Mar 24;23(1):281-285. Epub 2018 May 24.

Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Kasarmikatu 11-13, PL 263, 00029, Helsinki, Finland.

Purpose: We sought to assess whether a dog can be trained to distinguish obstructive sleep apnea patients from healthy controls based on the olfactory detection of urine.

Methods: Urine samples were collected from 23 adult male obstructive sleep apnea patients and from 20 voluntary adult male volunteers. Three dogs were trained through reinforced operant conditioning.

Results: Two of the three dogs correctly detected two thirds of obstructive sleep apnea patients (p < 0.000194 and p < 0.000003, respectively).

Conclusions: We found that dogs can be trained to distinguish obstructive sleep apnea patients from healthy controls based on the smell of urine. Potentially, dogs could be utilized to identify novel biomarkers or possibly screen for obstructive sleep apnea.
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http://dx.doi.org/10.1007/s11325-018-1659-xDOI Listing
March 2019

Systematic review of tonsil surgery quality registers and introduction of the Nordic Tonsil Surgery Register Collaboration.

Eur Arch Otorhinolaryngol 2018 Jun 27;275(6):1353-1363. Epub 2018 Mar 27.

Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, P.O. Box 426, 405 30, Göteborg, Sweden.

Purpose: Surgical quality registers provide tools to measure and improve the outcome of surgery. International register collaboration creates an opportunity to assess and critically evaluate national practices, and increases the size of available datasets. Even though millions of yearly tonsillectomies and tonsillotomies are performed worldwide, clinical practices are variable and inconsistency of evidence regarding the best clinical practice exists. The need for quality improvement actions is evident. We aimed to systematically investigate the existing tonsil surgery quality registers found in the literature, and to provide a thorough presentation of the planned Nordic Tonsil Surgery Register Collaboration.

Methods: A systematic literature search of MEDLINE and EMBASE databases (from January 1990 to December 2016) was conducted to identify registers, databases, quality improvement programs or comprehensive audit programs addressing tonsil surgery.

Results: We identified two active registers and three completed audit programs focusing on tonsil surgery quality registration. Recorded variables were fairly similar, but considerable variation in coverage, number of operations included and length of time period for inclusion was discovered.

Conclusion: Considering tonsillectomies and tonsillotomies being among the most commonly performed surgical procedures in otorhinolaryngology, it is surprising that only two active registers could be identified. We present a Nordic Tonsil Surgery Register Collaboration-an international tonsil surgery quality register project aiming to provide accurate benchmarks and enhance the quality of tonsil surgery in Denmark, Finland, Norway and Sweden.
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http://dx.doi.org/10.1007/s00405-018-4945-0DOI Listing
June 2018

Sacrifice and extracranial reconstruction of the common or internal carotid artery in advanced head and neck carcinoma: Review and meta-analysis.

Head Neck 2018 06 5;40(6):1305-1320. Epub 2018 Feb 5.

Coordinator of the International Head and Neck Scientific Group.

Background: Sacrifice and reconstruction of the carotid artery in cases of head and neck carcinoma with invasion of the common or internal carotid artery is debated.

Methods: We conducted a systematic search of electronic databases and provide a review and meta-analysis.

Results: Of the 72 articles identified, 24 met the inclusion criteria resulting in the inclusion of 357 patients. The overall perioperative 30-day mortality was 3.6% (13/357). Permanent cerebrovascular complications occurred in 3.6% (13/357). Carotid blowout episodes were encountered in 1.4% (5/357). The meta-regression analysis showed a significant difference in 1-year overall survival between reports published from 1981-1999 (37.0%) and 2001-2016 (65.4%; P = .02).

Conclusion: This review provides evidence that sacrifice with extracranial reconstruction of common or internal carotid artery in selected patients with head and neck carcinoma may improve survival with acceptable complication rates. However, all of the published literature is retrospective involving selected series and, therefore, precludes determining the absolute effectiveness of the surgery.
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http://dx.doi.org/10.1002/hed.25093DOI Listing
June 2018

Targeted Treatment With Radio Frequency Ablation for Lingual Tonsil.

Clin Med Insights Ear Nose Throat 2018 8;11:1179550617749857. Epub 2018 Jan 8.

Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.

Objectives: Benign enlargement of the lingual tonsils due to various causes may cause symptoms that warrant treatment. Conventional lingual tonsillectomy remains a challenging procedure, and there is no established standard procedure. We aimed to review the patients receiving different methods of lingual tonsil surgery for various indications at our institute.

Methods: Retrospective clinical data on all patients with an ablative operation of the tongue base during the 8-year period between 2007 and 2014 at the Helsinki University Hospital, Helsinki, Finland, were reviewed. The larger cohort comprised 35 patients, of whom 26 were men (74%). Ten patients had undergone solely lingual tonsil radio frequency ablation (LTRFA). The minimum follow-up time for all patients was 2 years.

Results: Of the 10 patients, 5 patients with LTRFA had been operated on because of symptomatic lingual tonsil hypertrophy and 5 because of periodic fever associated with possible lingual tonsil involvement. In 2 of the 5 patients with periodic fever, the fever cycles ended after the operation. Of the 5 patients, 3 patients with symptomatic lingual tonsil hypertrophy have been non-symptomatic after 1 to 3 treatment sessions. The last 2 patients continue to have persistent symptoms. There were no major complications.

Conclusions: Development of new approaches for the management of various lingual tonsil conditions is warranted. Lingual tonsil volume reduction by LTRFA seems to be a treatment alternative with low morbidity but with limited curative effect only.
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http://dx.doi.org/10.1177/1179550617749857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761902PMC
January 2018

The Helsinki Face Transplantation: Surgical aspects and 1-year outcome.

J Plast Reconstr Aesthet Surg 2018 02 15;71(2):132-139. Epub 2017 Nov 15.

Oral and Maxillofacial Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.

Background: Since 2005, at least 38 facial transplantations have been performed worldwide. We herein describe the surgical technique and 1-year clinical outcome in Finland's first face transplant case.

Methods: A 34-year-old male who had a severe facial deformity following ballistic trauma in 1999 underwent facial transplantation at the Helsinki University Hospital on 8th February 2016. Three-dimensional (3D) technology was used to manufacture donor and recipient patient-specific osteotomy guides and a donor face mask. The facial transplant consisted of a Le Fort II maxilla, central mandible, lower ⅔ of the midface muscles, facial and neck skin, oral mucosa, anterior tongue and floor of mouth muscles, facial nerve (three bilateral branches), and bilateral hypoglossal and buccal nerves.

Results: At 1-year follow-up, there have thus far been no clinical or histological signs of rejection. The patient has a good aesthetic outcome with symmetrical restoration of the mobile central part of the face, with recovery of pain and light touch sensation to almost the entire facial skin and intraoral mucosa. Electromyography at 1 year has confirmed symmetrical muscle activity in the floor of the mouth and facial musculature, and the patient is able to produce spontaneous smile. Successful social and psychological outcome has also been observed. Postoperative complications requiring intervention included early (nasopalatinal fistula, submandibular sialocele, temporomandibular joint pain and transient type 2 diabetes) and late (intraoral wound and fungal infection, renal impairment and hypertension) complications.

Conclusion: At 1 year, we report an overall good functional outcome in Finland's first face transplant.
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http://dx.doi.org/10.1016/j.bjps.2017.10.007DOI Listing
February 2018

Total or subtotal glossectomy with laryngeal preservation: a national study of 29 patients.

Eur Arch Otorhinolaryngol 2018 Jan 8;275(1):191-197. Epub 2017 Nov 8.

Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, P.O.Box 263, 00029 HUS, Helsinki, Finland.

Total glossectomy remains a controversial procedure as it often leads to notorious sequalae in swallowing and speaking functions. Disease entities indicating total glossectomy tend to have poor prognosis. We evaluated whether this type of surgery can be concidered justified based on our national series. We reviewed all total and subtotal glossectomies with laryngeal preservation performed in Finland between 2005 and 2014 in terms of overall survival (OS), disease-specific survival (DSS), locoregional control (LRC), and functional outcome as assessed by gastric tube or tracheostomy dependence and ability to produce intelligible speech. Of the 29 eligible patients, 15 had undergone total and 14 subtotal glossectomy with curative intent. In eight patients, total/subtotal glossectomy was performed as salvage procedure after the previous treatment. One-year estimates for OS, DSS, and LRC were 48, 59, and 66%, and corresponding 3-year estimates were 31, 46, and 46%, respectively. The gastrostomy and tracheostomy dependence rates at 1 year after operation were 77 and 15%, respectively. Fifty-nine percent of the patients were assessed to be able to communicate verbally. As in most other published studies, we found unsatisfactory survival figures after subtotal or total glossectomy and most patients remained dependent on gastrostomy tube. This surgery is, however, presumably the best and often only chance for cure in a selective patient population, and according to our opinion, it is indicated as a primary or salvage treatment provided that the reconstruction is planned optimally to guarantee a reasonable quality of life after surgery.
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http://dx.doi.org/10.1007/s00405-017-4789-zDOI Listing
January 2018

Accuracy of preoperative MRI to assess lateral neck metastases in papillary thyroid carcinoma.

Eur Arch Otorhinolaryngol 2017 Nov 2;274(11):3977-3983. Epub 2017 Sep 2.

Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland.

Primary treatment of papillary thyroid carcinoma (PTC) with lateral lymph node metastasis is surgery, but the extent of lateral neck dissection remains undefined. Preoperative imaging is used to guide the extent of surgery, although its sensitivity and specificity for defining the number and level of affected lymph nodes on the lateral neck is relatively modest. Our aim was to assess the role of preoperative magnetic resonance imaging (MRI) in predicting the requisite levels of neck dissection in patients with regionally metastatic PTC, with a focus on Levels II and V. All patients with PTC and lateral neck metastasis who had undergone neck dissection at the Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland from 2013 to 2016 and had a preoperative MRI available were retrospectively reviewed. A head and neck radiologist re-evaluated all MRIs, and the imaging findings were compared with histopathology after neck dissection. In the cohort of 39 patients, preoperative MRI showed concordance with histopathology for Levels II and V as follows: sensitivity of 94 and 67%, specificity of 20 and 91%, positive predictive value of 56 and 75%, and negative predictive value of 75 and 87%, respectively. In PTC, MRI demonstrated fairly high specificity and negative predictive value for Level V metastasis, and future studies are needed to verify our results to omit prophylactic dissection of this level. Routine dissection of Level II in patients with regionally metastatic PTC needs to be considered, as MRI showed low specificity.
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http://dx.doi.org/10.1007/s00405-017-4728-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633621PMC
November 2017

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

Eur Arch Otorhinolaryngol 2017 Nov 1;274(11):3971-3976. Epub 2017 Sep 1.

Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland.

Percutaneous endoscopic gastrostomy (PEG) is often the treatment of choice in head and neck cancer (HNC) patients needing long-term nutritional support. Prospective studies on PEG tube placement in an otorhinolaryngologist service are lacking. At our hospital, otolaryngologist-head and neck (ORL-HN) surgeons-have performed PEG insertions for HNC patients since 2008. We prospectively analyzed 127 consecutive HNC patients who received their PEG tubes at the Department of Otorhinolaryngology-head and neck surgery, and evaluated the outcome of PEG tube insertions performed by ORL-HN surgeons. To compare time delays before and after, PEG placement service was transferred from gastrointestinal surgeons to ORL-HN surgeons, and we retrospectively analyzed a separate group of 110 HNC patients who had earlier received PEG tubes at the Department of Gastrointestinal Surgery. ORL-HN surgeons' success rate in PEG insertion was 97.6%, leading to a final prospective study group of 124 patients. Major complications occurred in four (3.2%): two buried bumper syndromes, one subcutaneous hemorrhage leading to an abscess in the abdominal wall, and one metastasis at the PEG site. The most common minor complication was peristomal granulomatous tissue affecting 23 (18.5%) patients. After the change in practice, median time delay before PEG insertion decreased from 13 to 10 days (P < 0.005). The proportion of early PEG placements within 0-3 days increased from 3.6 to 14.6% (P < 0.005). PEG tube insertion seems to be a safe procedure in the hands of an ORL-HN surgeon. Independence from gastrointestinal surgeons' services reduced the time delay and improved the availability of urgent PEG insertions.
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http://dx.doi.org/10.1007/s00405-017-4732-3DOI Listing
November 2017

Comparison of intubation and tracheotomy in patients with deep neck infection.

Eur Arch Otorhinolaryngol 2017 Oct 5;274(10):3767-3772. Epub 2017 Aug 5.

Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, PO Box 263, 00029, Helsinki, Finland.

Possible airway compromise further complicates treatment of deep neck infections (DNI). Airway management is crucial, but factors affecting the method of choice are unclear. We retrospectively evaluated adult DNIs in a single tertiary center covering 10 years, with special attention on airway management. Patient data were retrieved from electronic data files from 2007 to 2016, and included adult patients with DNI operated through the neck. Of the 202 patients, 127 (63%) were male, with a median age of 47 years. Odontogenic (n = 74; 35%) infection was the most common etiology. Intubation was the most common method of airway management (n = 165; 82%), and most patients (n = 102; 50%) were extubated immediately after surgery. Tracheotomy was performed primarily for 35 (17%) patients, and secondarily for 25 (15%). Two patients were managed in local anesthesia. Altogether 80 (40%) patients required care in the intensive care unit for a median of 7 days. Median hospital stay was 6 days for intubated patients and 10 days for primarily tracheotomized (p = 0.036). DNI extended to the mediastinal space in 25 (12%) patients, most of whom with odontogenic infection (48%), and necrotizing fasciitis (32%). Odontogenic infection was the most common etiology for DNI with increased risk for mediastinal involvement. Intubation was most common type of airway management with high success in immediate extubation after surgery. The need for tracheotomy seemed to lead to a longer hospital care and was associated with a more severe clinical course.
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http://dx.doi.org/10.1007/s00405-017-4694-5DOI Listing
October 2017

Early stage minor salivary gland adenoid cystic carcinoma has favourable prognosis.

Virchows Arch 2017 Dec 10;471(6):785-792. Epub 2017 Jun 10.

Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

The purpose of the study was to evaluate the long-term outcome of minor salivary and mucous gland (MiSG) adenoid cystic carcinoma (ACC) of the head and neck and to compare the results with earlier reports including our recently published series on major salivary gland (MaSG) ACC. The study comprised 68 MiSG ACCs operated during 1974-2012 at the Helsinki University Hospital, Helsinki, Finland. Medical records and histological samples were reviewed. Our previously published cohort comprising 54 MaSG ACCs during the years from 1974 to 2009 was used for comparison. The most common locations were the oral cavity and sinonasal cavities. Most patients presented stages IV (33.8%) and I (23.5%) disease. Primary treatment with curative intent, mainly surgery, was offered for 64 patients. Thirty-three (51.6%) of these patients developed a disease recurrence and 22 (66.7%) patients in less than 5 years. The difference in the length of recurrence-free time (<5 vs. >5 years) had an impact on OS and DSS (p < 0.001) showing worse prognosis for the earlier recurring group. T classes 2-4 (p = 0.005, p < 0.001, and p = 0.001, respectively) and stages II-IV (p = 0.019, p < 0.001, and p = 0.002, respectively) were associated with worse OS, DSS, and DFS. MiSG ACC had a similar long-term survival compared to MaSG ACC. Patients with stage I MiSG ACC seem to carry a favourable prognosis compared with those with stages II, III, and IV tumours. It is thus noteworthy that stage II tumours represent a truly advanced disease entity warranting a more aggressive treatment approach.
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http://dx.doi.org/10.1007/s00428-017-2163-6DOI Listing
December 2017