Background: The aim of this study was to investigate predictability of occult lymph node metastasis using maximum standardized uptake value (SUVmax) in the primary tumor on pre-treatment 18-fluorodeoxyglucose positron emission tomography FDG-PET in oral squamous cell carcinoma (OSCC) patients who were clinically node negative (cN0) before surgery.
Materials and Methods: A retrospective analysis of all patients treated at the University Hospital Zurich from 2007 to 2016 for OSCC with available pre-therapeutic FDG-PET was performed. We assessed the correlation of SUVmax of the primary tumors with the presence of occult nodal disease in the neck dissection specimen (pN+).
Results: The study included a total of 71 patients. In the nodal negative group (cN0/pN0), the median SUVmax of primary tumors was 9.0 (interquartile range (IQR) 7.4-13.9), while it was 11.4 (IQR 9.9-15.7) in the occult metastatic group (cN0/pN+). The difference was statistically significant (independent samples median test, P=0.037). In a multivariable model, the only independent predictor of occult metastatic disease for cN0 patients was a SUVmax > 9.5 (P=0.028). Further, primary tumors with SUVmax > 9.5 had a significantly higher risk of local recurrence (Log rank test, P=0.020)
Conclusion: Higher SUVmax (>9.5) of the primary tumor is associated with higher occurrence of occult metastatic nodal disease and worse local survival. High SUVmax of the primary tumor may encourage clinicians towards more aggressive treatment.

Objective: The essential prerequisite for focused parathyroidectomy in patients with pHPT is proper localization of all autonomic tissue. Sensitivity of conventional imaging modalities is influenced by different factors and decreases in the presence of a multinodular goiter. Therefore, a considerable percentage of pHPT patients have negative or equivocal localization studies before surgery. The aim of this study is to evaluate the utility of FCH-PET/CT for preoperative localization in patients with pHPT and negative/equivocal 99mTc-sestamibi scintigraphy/SPECT/CT and/or ultrasound.

Methods and measurements: Between 2014 and 2017, a total of 39 patients with pHPT and negative/equivocal conventional imaging were referred for FCH-PET/CT. In the analysis, we included those (n=23) who had surgery and a histopathologic workup of the lesions.

Results: 19 of 23 patients demonstrated no tracer uptake with 99mTc-sestamibi scintigraphy/SPECT/CT, 6 patients had an equivocal sonographic lesion, and multinodular goiter was present in 43%. In 21 of 23 patients, hyperfunctioning parathyroid tissue was identified correctly by FCH-PET/CT. 29 lesions were resected. All patients were classified as having surgical success according to a decrease of intraoperative parathyroid hormone of ≥50% and normalization of postoperative serum calcium levels.

Conclusion: Despite a high prevalence of multinodular goiter, diagnostic accuracy of FCH-PET/CT in our patient group was excellent. Therefore, FCH-PET/CT is a promising new imaging tool in patients with pHPT and negative/equivocal results by conventional imaging techniques.

Content
a) Aims
CNPase is part of an alternative, extracellular 2’,3’cAMP-adenosine pathway, degrading RNA to adenosine. The significance of this pathway in general and with special focus on tumor cells of head and neck squamous cell carcinomas will be analysed.

b) Materials and methods
CNPase will directly be detected on the surface and in the cytoplasma by flow cytometry. Furthermore Western Blot will be used to detect CNPase in immune cells, tumor cells and tumor derived exosomes. Finally immunohistochemistry will be performed to analyse CNPase on tissue of healthy donors as well as cancer tissue obtained by biopsies from operations. Tumor cells will be obtained from PCI HNSCC cultures and exosomes will be isolated by differential centrifugation as well as mini-column separation. Immune cells will be isolated from healthy donors from the blood bank.

c) Results
CNPase is expressed in the epithelial basal layer of healthy tissue. Overall expression is low compared to cancer tissue. Its expression is clearly increased in the front of invasion and present in all samples of HNSCC cancer cells. Lymphocytes and endothelial cells express CNPase. Further this enzyme shows up in tumor-derived exosomes isolated from culture of HNSCC cells and plasma of HNSCC patients. Not only the presence was detected but adding 2’3’cAMP as a substrate lead to production of down-stream metabolites, as such showing its enzymatic function.

d) Conclusion
Adenosine is a key agent in HNSCC that leads to immunosuppression. The study of alternative pathways in the era of increasing immunotherapy is of outmost importance. CNPase has potential to be a biomarker and therapeutic target.

PURPOSE
There have been few recent advances in the preoperative identification of occult lymph node metastases (OLNM) in oral squamous cell carcinoma (OSCC) . This study aimed to develop, compare and validate several machine learning models based on immunohistochemical and clinicopathological parameters to predict occult lymph node metastasis (OLNM) and propose a new clinical decision model aiming to reduce overtreatment of cN0 patients.
METHODS
The biomarkers Cluster of Differentiation-31 (CD31) and Prospero homeobox protein-1 (PROX1), previously reported as predictive of OLNM in OSCC, were re-evaluated on a training cohort (n=56) using four different state-of-the-art machine learning models. Next, the optimized models were tested on an external validation cohort (n=112) of early-stage (T1-2 N0) OSCC. Diagnostic performances were determined before and after negative predictive values (NPV) optimization.
RESULTS
The Random Forest (RF) model gave the best overall performance (area under the curve = 0.89 [95% CI = 0.8, 0.98]) and accuracy (0.88 [95% CI = 0.8, 0.93]) whilst maintaining a negative predictive value > 95%. The RF model decreases the rate of undiagnosed OLNM from 30% to less than 5% in early-stage OSCC while reducing the overtreatment of cN0 patients from 82% to only 9% with the proposed approach.
CONCLUSION
We provide a new clinical decision algorithm that incorporates risk stratification by a RF model and believe that its application could significantly improve the management of patients with early-stage OSCC.

Métastases ganglionnaires rétropharyngées dans les carcinomes épidermoïdes de l’oropharynx : étude de 50 patients

Auteurs : Avagnina A. , Bouayed S. , Boselie F, Rahban C., Von Wihl S., Arnoux A., Hallak B.



Objectif : le but de cette étude est d’investiguer l’incidence des adénopathies retro pharyngées chez les patients atteints d’un carcinome épidermoïde de l’oropharynx.

Matériel et Méthode : c’est une étude rétrospective englobant 50 patients avec carcinome épidermoïde de l’oropharynx diagnostiqués et traités dans le service ORL de l’hôpital de Sion entre le 2010 et le 2016.
L’atteinte ganglionnaire cervicale et plus particulièrement les ganglions retro pharyngées ont été évalués par un radiologue spécialisé. Elle s’est faite sur la base de tomodensitométrie, d’IRM ou de PETScan.

Résultats : Les ganglions retro pharyngés ont été retrouvés dans le 46% des cas ( 23 patients ). En appliquant des critères stricts radiologiques, on retrouve 12 cas de patients (24%) des cas avec ganglions retro pharyngés suspects. L’analyse de ces cas met en évidence une plus grande fréquence de l’origine amygdalienne, de stade avancé et de présence d’adénopathies multiples cervicales ipsi et controlatérales.


Conclusion : vu le taux d’incidence élevée des ganglions retro pharyngés dans les tumeurs de l’oropharynx, leur évaluation minutieuse devra être systématique pour optimiser le traitement par radiothérapie ou parfois même par chirurgie.

Objective: Preoperative malnutrition is an independent risk factor for complications in head and neck cancer (HNC) surgery. Patients undergoing salvage surgery are at highest risk due to negative effects of chemo-/radiotherapy on wound healing. We tested the hypothesis that preoperative administration of immunonutrition (IN) would decrease complications after salvage surgery in patients for recurrent HNC.

Subjects and Methods: Single armed study with historical control in a tertiary referral hospital. We included consecutive patients undergoing salvage surgery for recurrent HNC. We compared outcomes before and after implementation of preoperative IN and adjusted the regression analysis for gender, age, body mass index, Nutritional Risk Screening (NRS 2002), tobacco and alcohol consumption, tumor localization, tumor stage, and type of surgery. The primary endpoint was overall complications from surgery within a follow-up of 30 days.

Results: We included ninety-six patients (intervention group: 51, control group: 45). Use of preoperative IN was associated with significant reduction in overall complications (35% vs. 58%, fully-adjusted odds ratio 0.30 (95%CI 0.10 - 0.91, p=0.034). We also found a significant reduction in length of hospital stay. No differences in mortality and hospital readmission were found.

Conclusions: In patients undergoing salvage surgery for recurrent HNC, preoperative IN showed favorable effects on the risk for complications with also a reduction in length of hospital stay. By improving both, tissue regeneration and immune response, IN may help to ameliorate surgical outcomes in this high-risk population.

INTRODUCTION
Vestibular symptoms are common complaints in the general population with prevalences of up to 60%. In emergency departments (ED) dizziness has been reported in 3.3% of all patients. We assessed frequency and aetiology of vestibular symptoms in a large interdisciplinary tertiary ED.

METHODS
We included all 23.608 patients admitted to the ED in 2013 with vestibular symptoms either as a chief or as accompanying complaint. Clinical, radiological and laboratory findings as well as presumed aetiologies from ED medical records were manually extracted.

RESULTS
2473 patients (11%; mean age/SD 51.9/20.2 years; 50.7% females) complained about any vestibular symptom with 64.5% as a chief complaint. Vestibular symptoms were classified as vertigo (44.8%), dizziness (55%), postural symptoms (15.8%) and unknown vestibular symptoms (0.6%). Most frequent aetiologies were strokes (12.4%), orthostatic (12.1%), infections (10.3%), cardiovascular (9.8%), other central vestibular disorders (9.3%), peripheral vestibular disorders (8.8%). All other causes including trauma and somotoform dizziness were < 5% each. In 13.8%, no diagnosis was assigned. 23% of underlying causes were potentially life threatening.

DISCUSSION
Reported one-year prevalence of vestibular symptoms was 11% in a tertiary ED setting, which is higher than previously described. Every 8th patient with vestibular symptoms suffers from a stroke and/or any other potentially life threatening condition. Every 7th patient was sent home with a diagnosis of dizziness “not further specified”. Improvement of diagnostic accuracy should be pursued to reduce the risk of missing severe pathologies.

Objectifs :
Evaluation de la fonction vestibulaire avant et après implantation cochléaire (IC). Les IC bilatérales étant de plus en plus fréquentes, la préservation de la fonction vestibulaire est un enjeu important.
Matériel et méthode :
La fonction vestibulaire a été testée de façon prospective avant et après l’IC chez les patients implantés au Centre Hospitalo-Universitaire Romand d'Implants Cochléaires (CHURIC) entre 2013-2016. L’insertion s’est toujours faite par la membrane de la fenêtre ronde. La fonction vestibulaire a été évaluée avec les tests caloriques, le test pendulaire, le « video Head Impulse Test » et les potentiels évoqués myogéniques vestibulaires cervicaux et oculaires (c-/o-VEMPS).
Résultats :
54 IC. Données complètes pour 44 IC. La fonction vestibulaire est altérée dans 22% avant l’IC. Après l’IC, la préservation de la fonction vestibulaire est possible dans 68% des cas. Dans 28% des cas la fonction vestibulaire est altérée avec une atteinte hétérogène des sous-unités fonctionnelles vestibulaires. Dans 4% des cas l’atteinte est sévère ou totale.
Conclusion :
L’IC engendre une atteinte vestibulaire sévère dans 4% des cas. Même si le risque de déficit vestibulaire bilatéral sévère est faible, la fonction vestibulaire devrait être testée de façon complète et systématique.

OBJECTIVES
Evaluate the reproducibility of magnetic resonance imaging (MRI) for the diagnosis of endolymphatic hydrops in patients with Meniere's disease (MD) symptoms and assess its correlation with clinical diagnosis of MD.

METHODS
This retrospective analysis included 3T MRI examinations of 50 patients with MD symptoms (21 men, 29 women, mean age = 53+/-12). 3DT2 and 3D FLAIR were performed 4 hours after iv. injection of gadolinium and a « hydrops sequence » was obtained by subtracting the first two sequences. Two experienced readers assessed blindly and independently the presence and location of hydrops. Interobserver agreement was evaluated per patient, per ear and whether the hydrops was vestibular, cochlear or vestibulo-cochlear. According to the 2013 Barany Society’s criteria for MD, 16 patients had definite MD, 6 probable MD and 28 didn't match criteria. Correlation between clinical and MRI findings was based on the most experienced reader’s findings.

RESULTS
Inter-observer agreement was substantial for the MRI diagnosis of hydrops per patient (ϰ=0.82) and moderate for hydrops diagnosis per ear (ϰ=0.76), moderate for vestibular hydrops per ear (ϰ=0.78) and fair for cochlear hydrops per ear (ϰ=0.40). MRI hydrops was found in 93% of definite MD, in 83% of probable MD and in 75% of non-MD patients. 76% of MRI hydrops were bilateral.

CONCLUSIONS
Although overall MRI diagnosis of hydrops is well reproducible, the diagnosis of cochlear hydrops should be made with caution due to substantial interobserver variability. Despite strong correlation between clinical MD and MRI-hydrops, MRI-hydrops is also found in many patients not matching the strict MD criteria.

Cognitive-behavioural therapy (CBT) in combination with vestibular rehabilitation and psychoeducation could possibly improve the well-being of patients with dizziness only (DO) and those with dizziness and a quantified balance disorder (QBD). We examined whether both groups of patients responded similarly to the therapy combination.
Methods: Based on stance and gait balance tests 32 patients (23 female, 9 male) with persistent dizziness were split into 2 groups: those with QBD (pathological balance) or DO (normal balance). Pre- and post-therapy Dizziness Handicap Inventory (DHI) and Brief Symptom Inventory (BSI) questionnaires were used to assess psychometric measures. All patients received the same combination therapy in a group setting.
Results: Mean age of the QBD and DO groups was 60.6 and 44.8, respectively. Pre-therapy, questionnaire scores were pathological but did not differ between groups. Balance improved significantly for the QBD group (p= 0.003) but not for the DO group. DHI and BSI scores improved significantly in the DO group (0.001 < p < 0.045), some BSI sub-scores reaching normal levels while they remained unchanged for the QBD group. Phobic anxiety scores changed most for both groups, being significantly correlated with DHI scores, higher (R= 0.71 vs. 0.57) for the DO group.
Conclusions: Psychological measures in DO patients can be significantly improved by a combination therapy. Even though balance control improves to almost normal in QBD patients, their psychological measures do not improve accordingly. Addressing phobic anxiety more extensively during the group therapy program might help QBD patients to improve psychological measures.

Titre : Souriez, vous êtes filmés !
Objectifs : Si le transfert du muscle gracilis reste la technique la plus souvent utilisée pour le traitement de la paralysie faciale de longue durée, le choix de la source de réinnervation entre le nerf masséter et une greffe nerveuse transfaciale est un sujet à controverse. Nous avons voulu évaluer quelle technique apportait le meilleur résultat en terme de symétrie et de spontanéité du sourire.
Matériel et méthode : Nous avons évalué 5 patients avec une paralysie faciale unilatérale de longue durée qui ont bénéficié d’une réanimation faciale avec une reconstruction par muscle gracilis. 2 gracilis ont été innervés par le n. masseter homolatéral et 3 par une greffe transfaciale sur le nerf facial controlatéral. Ils ont été évalués au moyen d’outils validés dans la littérature (Sunnybrook, eFACE, Emotrics) afin de comparer les deux méthodes chirurgicales de réanimation faciale de manière objective, y compris la spontanéité des mouvements.
Résultats :Cette étude nous a permis d’utiliser et de comparer différents scores d’évaluation de paralysie faciale validés dans la littérature, en particulier eFACE et Emotrics qui sont de nouveaux outils permettant de comparer les résultats des deux méthodes chirurgicales de réanimation faciale de manière objective, plus précise et en tenant compte du sourire spontané. Ces résultats seront présentés en détail.
Conclusion : Les deux méthodes d’innervation sont fiables mais avec pour chacune d’elles des avantages et des inconvénients. Le choix réside dans les priorités à définir avec le patient : nombre d’opérations, amplitude et spontanéité des mouvements.
Auteurs De Sandre C, Gereige RJ, Pasche P

An der letzten Frühjahrsversammlung stellten wir die Vestibular Prehab mittels präoperativer ipsilateraler Gentamicinablation bei Patienten mit Vestibularisschwannom (VS) vor. Wir zeigen nun auf, ob diese Massnahme einen Einfluss auf die Gleichgewichts-Rehabilitation hat.

Bei Patienten mit einem VS wurde präoperativ anhand verschiedener Kriterien die Indikation für oder gegen ein Vestibular Prehab gestellt. Vor der Intervention, bei Eintritt zur VS-Operation, sowie 6 Wochen und später im Langzeitverlauf postoperativ wurden unter anderem folgende Untersuchungen zur Erfassung der Gleichgewichtsfunktion erhoben: Video-Kopfimpulstest, Dynamic Visual Acuity (DVA)-Test, Dizziness Handicap Inventory (DHI) und Functional Gait Assessment (FGA). Wir verglichen die Daten der Patienten mit und ohne Vestibular Prehab.

Zwischen 2011 und 2017 wurden 135 Patienten mit einem unilateralen Vestibularisschwannom erstoperiert. Rund ein Drittel (49) erhielten ein Vestibular Prehab. Diese Patienten waren im Schnitt einen Tag kürzer hospitalisiert und erzielten beim FGA sowohl 6 Wochen postoperativ als auch im Langzeitverlauf bessere Resultate als die Patienten ohne Vestibular Prehab. Bei der Erfragung der subjektiven Schwindelbeschwerden im DHI zeigte sich unabhängig von der Prehab eine Verschlechterung im Langzeitverlauf.

Das Vestibular Prehab eignet sich bei ausgewählten Patienten zur Optimierung der postoperativen Rehabilitationsphase, in dem es die Hospitalisationsdauer verkürzt und die Gangstabilität durch gezielte vestibuläre Physiotherapie verbessert.

Objective: International consensus on best practices for calculating and reporting vestibular function is lacking. Quantitative vestibulo-ocular reflex (VOR) gain using a video head impulse test (HIT) device can be calculated by various methods. Methods: We compared different VOR gain calculation methods using 1300 horizontal HIT traces from 26 patients with acute vestibular syndrome. We analyzed the ratio between eye and head velocity at specific time points (40ms and 60ms) after HIT onset (‘velocity gain’), ratio of velocity slopes (‘acceleration gain’), and ratio of area under the curves after de-saccading (‘position gain’). We also analyzed interactions between artifacts and calculation method. Results: There was no mean difference between VOR gain at 60ms and position gain, both showing a significant correlation (ρ=0.63, p=0.01) for artifact-free recordings. Other calculation methods showed statistically significant mean gain differences (range 0.02-0.19), but with gains still remaining within the expected normal or abnormal range. Artifacts affected normal gains more than abnormal gains, independent of calculation method. Conclusions: There is no clear superiority of a single gain calculation method for video HIT testing. Artifacts cause small but significant reductions of measured VOR gains in normal HITs, regardless of calculation method. Specific artifacts interact differently with calculation method in abnormal HITs, increasing measurement noise. This suggests a larger number of HITS should be performed to confirm abnormal results, regardless of calculation method.

Ziele
In der Diagnostik des Morbus Menière wird das Hydrops-MRT zunehmend eingesetzt. In der Literatur wird die Erkennungsrate des Hydrops bei wahrscheinlichem und sicherem Morbus Menière bei 95-100% angegeben. Bei am Luzerner Kantonsspital beurteilten Hydrops-MRT haben wir die Korrelation von Klinik und MRT-Befund untersucht.

Material und Methoden
Von 1/2015 bis 12/2017 wurden 197 Patienten mit der Frage nach endolymphatischem Hydrops mittels eines MRT mit speziellen Hydropssequenzen 4 Stunden nach i.v. Gadolinumgabe untersucht. Die Bilder wurden unabhängig von zwei Neuroradiologen betreffend Hydropsgrad (I, II) und Lokalisation des Hydrops (cochleär, vestibulär) beurteilt. Die Klinik wurde nach Menière-Diagnosekriterien (Barany, AAO-HNS) klassifiziert und dem radiologischen Befund gegenübergestellt.

Resultate
Unsere präliminäre Datenanalyse zeigt bei 84/197 Patienten mit Hydrops-MRT einen radiologisch nachweisbaren endolymphatischen Hydrops. Bei 47 % (57/121) der Patienten mit Morbus Menière nach AAO-HNS fand sich ein endolymphatischer Hydrops (definite 36/52, probable 2/11, possible 19/58). Bei 53% konnte trotz klinischer Diagnose eines Morbus Menière kein Hydrops nachgewiesen werden. Zusätzlich wurde ein Hydrops nachgewiesen bei 27 Patienten mit Innenohrproblematik die die Kriterien des Morbus Menière nicht erfüllten oder bei denen klinische Angaben fehlten.

Schlussfolgerungen
Die Korrelation zwischen Klinik und MRT Befund bei der Diagnose des Morbus Menière liegt mit 47% unter der in der Literatur beschriebenen Rate. Aufgrund der typischerweise fluktuierenden Symptomatik bei Morbus Menière ist möglicherweise der Zeitpunkt der Durchführung des MRT relevant.