- Email: [email protected]
Computer assisted navigation in head and neck oncologic surgery
s6-
Symposia/Proffered Papers Nijmegen, TheNetherlands, SRADROUDUNIVERSITYNIJMEGENMEDICALCENTRE,Otorhinolaryngology and
Head& NeckSurgery,Nijmegen,TheNetherlands, 4RADBOUDUNIVERSITYNIJMEGENMEDICALCENTRE,Oral and Maxillofacial Sur-
gery, Nijmegen,TheNetherlands Positron emission tomography has emerged as promising technique for molecular imaging of cancer. F-18-fluordeoxyglucose (FDG-PET) is the most widely used radiopharmaceutical, depicting the increased metabolism of cancer cells, Application of other PETradiopharmaceuticals such as the proliferation marker F-18-deoxyfluorothymidine (FLT) and hypoxia markers (e.g. F-18-misonidazol, FMISO) is receiving increasing interest. In potentially resectable head and neck cancer, FDG-PET is mainly used as an additional tool for staging. FDG-PET is particularly suitable to detect distant metastases or secondary primary tumors in high-risk patients. For assessment of micrometastatic involvement of lymph nodes, the diagnostic yield of FDG-PET does not replace surgical staging procedures. Of particular interest is the utility of FDG-PET in patients with cervical lymph node metastases of unknown primaries, in whom an added value of FDG-PET of up to 50% is reported. FDG-PET may also play a role in restaging patients, suspected of relapse. In radiation oncology, PET provides insight in tumor characteristics and can be complementary to the anatomical data of CT and MRI for target volume delineation beyond anatomical localization. Incorporation of information derived by PET (FDG, FLT, FMISO) into target volume delineation is being investigated and validated. To appreciate the added value of PET, several issues need to be addressed: accuracy of tumor delineation and the adequacy of the visualization of biological tumor characteristics and intratumoral heterogeneity. Of particular interest is the potential utility of PET to evaluate tumor biology during radiation treatment. However, at present robust data that support early adaptation of the radiation treatment plan are still lacking. In conclusion, molecular imaging with positron emission tomography has a role in the diagnostic work-up of patients with head and neck cancer, especially for staging. New indications are being pursued and the utility to incorporate positron emission tomography into radiation treatment planning is under investigation. 23speaker EVALUATION OF TUMOUR RESPONSE M. Lonneux UCL CLINIQUESUNIVERSITAIRESST. LUC,dept, Brussels,Belgium The lecture will cover the use of functional imaging, i.e. PET and PET-CT, for the evaluation of the tumor response to therapy. Beyond the wide use of PET in routine diagnosis and staging of cancer, the evaluation of tumor response is a more recent application of the technique. In the light of the recent literature, several aspects will be addressed. First is the clinical question. Usually the tumor response is evaluated at the end of a planned treatment course, e.g. several courses of chemotherapy or a complete dose of radiotherapy. This allows for selecting patients with a progressive disease for a salvage therapy, e.g. laryngectomy. PET-FDG has been shown more accurate than CT/MR to estimate the actual response of the primary tumor, especially to detect patients with progressive disease. Evaluation of early or very early response (after I cycle of treatment for example) is another potential application of metabolic imaging. Indeed, in several tumor types, the extent of the early tumor response measured by PET is a good predictor of the final outcome of the patient. The second issue relates to the methodology of PET procedures performed to measure tumor response. In particular, the tracer uptake has to be quantified with the highest precision. Standardized uptakes values (SUV) are the most common quantitative index used in PET imaging. We will briefly detail all the factors that influence
Friday, February 23, 2007 this index. One of the most important is certainly the time interval between the injection of the tracer and the acquisition of images. In one wants to quantitatively compare pre- and post-treatment scans, the time interval has to be identical for both procedures. The final part of the lecture will focus on the research work that is presently conducted to discriminate tumoral metabolic activity from the inflammation induced by radiotherapy. 24 oral FDG-PET COMBINED WITH CT CONSIDERABLY ALTERS TUMOUR DELINEATION FOR RADIOTHERAPY FOR H&N CANCER COMPARED TO CT ONLY C. Terhaard ~, B. de Keizer2,M. Hobbelink2 1UNIVERSITYMEDICALCENTERUTRECHT,Radiotherapy, Utrecht, The Nether-
lands, 2UNIVERSITYMEDICALCENTERUTRECHT,NuclearMedicine, Utrecht, The Neth-
erlands Purpose/Objective: In our institute parotid sparing intensity modulated radiotherapy has been the treatment of choice for squamous cell carcinoma of the head and neck since 2002. Image guided radiotherapy (IGRT) has become of utter importance for exact delineation of the gross tumour volume (GTV) of the primary tumour and possible neck nodes. In this study we investigate the importance of FDG-PET, combined with a planning CT for the delineation of GTV. Materials/Methods: From 2003 until 2006 109 patients treated primarily (95%) or for recurrent disease (5%) by (chemo) radiotherapy received a planning CT and FDG-PET in the same mould. Matching of the images was performed using mutual information matching. FDG-PET scans were analysed by an experienced radiation oncologist and Nuclear Medicine physician. Alteration of the GTV and/or change of treatment preference based on FDG-PET -CT compared to CT only was evaluated. The tumour was located in the pharynx in 76%, the larynx in 11%, and the oral cavity in 13%. Advanced T-stage (T3-4) was noted in 46%. Neck nodes were positive in 61%. Results:Based on the FDG-PET - CT compared to CT only, the radiation field was adapted in 45%; due to change on local extension in 16%, N-stage in 22%, combined T-N extension in 3%. In 6% a second primary was diagnosed on FDG-PET, cause for change of treatment modality in 4 out of 6. In 3% N-stage was down-staged, and in 17% up-staged, based on findings of the combined FDG-PET-CT scan. For determination of local extension CT only was incapable to show the entire local extension in 20%, mostly based on scatter from lead inlays. In 7%, also on FDG-PET local turnout extension was not clearly visible. In general CT showed larger tumour volumes compared to FDG-PET. Conclusions:FDG-PET combined with CT, performed in the same mould, results in alteration of the determination of the GTV in a significant number of patients, compared to CT only. Diagnosis of a second primary tumour influenced choice of treatment. For head and neck tumours treated with primary (chemo) radiotherapy combined FDG-PET-CT scanning should be the standard for IGRT. 25 oral COMPUTER ASSISTED NAVIGATION IN HEAD AND NECK ONCOLOGIC SURGERY G. Dolivet ~ F. MarchaP, P. Henrot3,J. Stines3, H. Gisquet~, JP. Barberot4, P.Ganglo~, B. Phulpin ~,F. Guillemin2,J.L. Verhaeghe2 ICENTREALEXISVAUTRIN,Head and Neck Surgery Unit, VandoeuvreLes
Nancy, France, 2CENTREALEXISVAUTRIN,Oncologic SurgeryDepartment, VandoeuvreLes
Nancy, France, SCENTREALEXISVAUTRIN,Radiology Department, VandoeuvreLes Nancy,
France, 4HIA LEGOUEST,Headand NeckSurgery,Metz, France
Friday, February 23, 2007 Purpose/Objective: Cranio facial oncologic surgery have always had to face to the double difficulties of sparing vital structures and evaluating the quality of the resection in bone. The computer assisted navigation could allow to avoid those problems. Goal of our study : the first height cases of our faisability study were used to evaluate difficulties of instalation, time increase in the surgical procedure, real possibility of evaluating surgical virtual margin, precision of the device and detection of vital structures. Materials/Methods: Heigth patient with tumor closed to the facial bone structure were treated by surgery. We use a Praxim (Surgetic Station) system with infra red and stereo camera. Pre op imaging were CT Scan or CT Scan/MRI fusion. Patients had different deseases as : lacrymal tumor relapse in irradiated area, SCC of the facial skin invading the infra orbital area, latero fronto-facial SCC invading the pterygo-maxillar fossa, atypical image in the two maxillar sinus with history an history of oral pharynx SCC relapse of a rhino pharyngeal indifferentied carcinoma or adenocarcinoma, relapse of mid face carcinoma and latero basocranial tumoral relapse Results: All procedure were done without difficulty. The average increase of time were 15 minute of the surgical procedure. We were abble to define surgical margin in seven cases,the last were a sinusal exploration. The infra orbital nerve could be finded easily as well as the optical nerve and all were respected. The carotidian and the vertebral artery were detected at the base of the skull. If soft tissue can have modification and cannot be use as precise landmarks, bone and linked structure give a precision of 1 to 2 mm. Conclusions: The computer assisted device seems to be very promising in oncological cranio facial surgery and the principle could be extended to other as vertebral, pelvic and probably liver oncologic surgery 26 oral DIFFUSION WEIGHTED (DW) MRI TO EVALUATESALIVARY GLAND FUNCTION BEFOREAND AFTER RADIOTHERAPY. S. Nuyts ~, R Dirixl,V. Vandecaveye2,F. De Keyzer2,W.Van den Bogaert1, R. Hermans 2 IUNIVERSITYHOSPITALGASTHUISBERGIRadiation Oncology, Leuven CancerIn-
stitute, Leuven,Belgium, 2UNIVERSITYHOSPITAL GASTHUISBERGrRadiology, Leuven Cancer Institute,
Leuven, Belgium Purpose/Objective: To evaluate the use of Diffusion Weighted (DW) MRI as a non-invasive tool to investigate three-dimensional (3D) salivary gland function and advance our understanding of dose-volume factors in radiation-induced xerostomia. Materials/Methods: Echo-planar DW MRI was performed on a 1.S T unit in 23 HNC patients before and at 6 months after parotid-sparing 3D-conformal RT (mean dose to the contralateral parotid gland was kept ~26 Gy) and in 7 healthy volunteers. A sequence was performed once at rest and then continuously repeated over a mean period of 26 minutes (range: 24 - 28 minutes) during salivary stimulation with a tablet of ascorbic acid given orally. Apparent diffusion coefficient (ADC) maps for both parotid and submandibular glands could be obtained in all volunteers and patients. Results: In patients before RT and in volunteers, the mean ADC value at rest was significantly lower in the parotid (0.93 (_+0.13) x 10-3) than in the submandibular (1.19 (_+ 0.12) x 10-3) gland (p = 0.004). No significant difference was observed between left and right parotid (p = 0.07) or submandibular (p = 0.42) glands. During the first S minutes of stimulation, the ADC value of the parotid showed a decrease to a lower value (p = 0.13), followed in the next 1S minutes by a steady increase (p <0.0001) until a peak ADC, significantly higher than the baseline value (p = 0.0002), was reached after a median of 21 minutes. In the submandibular glands, a significant decrease was seen (p = 0.0005) followed by a significant increase to a maximum (p
Symposia/Proffered Papers <0.0001), significantly higher than the baseline value (p = 0.049). In patients, the baseline ADC value at rest was significantly higher after RT (1.12 (+ 0.14) x 10-3) than before RT (0.91 (_+ 0.04) x 10-3) in the irradiated parotid glands (p = 0.004), but not in the spared glands (p = 0.16). In the spared parotids, the same response to stimulation was seen as before RT: a decrease to a lower ADC value (p = 0.14), followed by a significant increase to a maximum (p = 0.01), significantly higher than the baseline value (p = 0.02). This pattern was completely lost in the parotids that received a mean dose ~26 Gy, where no significant differences were observed in ADC values during stimulation. No attempt was made to spare the submandibufar glands. Consequently, the baseline ADC value at rest was significantly higher after RT compared to before RT in both the ipsilateral (p = 0.02) and the contralateral submandibular gland (p = 0.04). No significant differences were observed in ADC values during stimulation in the irradiated submandibular glands. Conclusions: DW MRI allows to non-invasively demonstrate functional changes in the salivary glands after RT. Since ADC values can be calculated for each pixel, functional 3D maps of the parotid and submandibular glands before and after radiotherapy will be compared with the isodoses to evaluate dose-response relationships within the salivary glands and between patients. These data will be presented at the time of the meeting.
OptimizingTreatmentfor LocallyAdvancedPharyng0LaryngealSCC:State of the Art 27 speaker VOICE SPARING SURGERY FOR ADVANCED PHARYNGO-LARYNGEAL CANCER G. Spriano.V. Manciocco, R. Pellini NATIONALCANCERINSTITUTE- REGINAELENA,Dept. Otolaryngology Head and Neck Surgery, Rome, Italy Regarding quality of life, Weinstein definitively assessed the superiority of partial laryngectomy versus total laryngectomy with tracheo-esophageal puncture. Randomized controlled studies have shown that preservation of the larynx function in selected patients with advanced resectable laryngeal and hypopharyngeal cancer is possible without compromising survival compared to total laryngectomy, in the United States, the treatment of advanced laryngeal cancer has moved from radical surgery toward a more conservative approach involving definitive radiotherapy and chemotherapy, with extirpative surgery held in reserve for salvage. In Europe, there has been increasing reliance on the use of "function-preserving" surgical approaches even for selected advanced laryngeal lesions and for selected recurrence in radiotherapy failure. Various surgical procedures are available for management of advanced laryngeal cancer to address according to the site and extent of the tumor: supracricoid} partial laryngectomy with cricohyoidopexy or with cricohyoidoepiglottopexy, extended supraglottic laryngectomy, and recently, tracheohyoidopexy or tracheohyoidoepiglottopexy.These procedures may be effectively employed in combination with neck dissection and postoperative radiotherapy when necessary. Failures are usually due to a technical mistake or to an inadequate evaluation of the local extension. Careful monitoring of the conservatively treated patient is mandatory to allow for early salvage of failures to the original therapy. Clearly a multidisciplinary approach is, at the moment, the best strategy to individualise treatment for every patient and improve design of future clinical trial.
-$7
Symposia/Proffered Papers Nijmegen, TheNetherlands, SRADROUDUNIVERSITYNIJMEGENMEDICALCENTRE,Otorhinolaryngology and
Head& NeckSurgery,Nijmegen,TheNetherlands, 4RADBOUDUNIVERSITYNIJMEGENMEDICALCENTRE,Oral and Maxillofacial Sur-
gery, Nijmegen,TheNetherlands Positron emission tomography has emerged as promising technique for molecular imaging of cancer. F-18-fluordeoxyglucose (FDG-PET) is the most widely used radiopharmaceutical, depicting the increased metabolism of cancer cells, Application of other PETradiopharmaceuticals such as the proliferation marker F-18-deoxyfluorothymidine (FLT) and hypoxia markers (e.g. F-18-misonidazol, FMISO) is receiving increasing interest. In potentially resectable head and neck cancer, FDG-PET is mainly used as an additional tool for staging. FDG-PET is particularly suitable to detect distant metastases or secondary primary tumors in high-risk patients. For assessment of micrometastatic involvement of lymph nodes, the diagnostic yield of FDG-PET does not replace surgical staging procedures. Of particular interest is the utility of FDG-PET in patients with cervical lymph node metastases of unknown primaries, in whom an added value of FDG-PET of up to 50% is reported. FDG-PET may also play a role in restaging patients, suspected of relapse. In radiation oncology, PET provides insight in tumor characteristics and can be complementary to the anatomical data of CT and MRI for target volume delineation beyond anatomical localization. Incorporation of information derived by PET (FDG, FLT, FMISO) into target volume delineation is being investigated and validated. To appreciate the added value of PET, several issues need to be addressed: accuracy of tumor delineation and the adequacy of the visualization of biological tumor characteristics and intratumoral heterogeneity. Of particular interest is the potential utility of PET to evaluate tumor biology during radiation treatment. However, at present robust data that support early adaptation of the radiation treatment plan are still lacking. In conclusion, molecular imaging with positron emission tomography has a role in the diagnostic work-up of patients with head and neck cancer, especially for staging. New indications are being pursued and the utility to incorporate positron emission tomography into radiation treatment planning is under investigation. 23speaker EVALUATION OF TUMOUR RESPONSE M. Lonneux UCL CLINIQUESUNIVERSITAIRESST. LUC,dept, Brussels,Belgium The lecture will cover the use of functional imaging, i.e. PET and PET-CT, for the evaluation of the tumor response to therapy. Beyond the wide use of PET in routine diagnosis and staging of cancer, the evaluation of tumor response is a more recent application of the technique. In the light of the recent literature, several aspects will be addressed. First is the clinical question. Usually the tumor response is evaluated at the end of a planned treatment course, e.g. several courses of chemotherapy or a complete dose of radiotherapy. This allows for selecting patients with a progressive disease for a salvage therapy, e.g. laryngectomy. PET-FDG has been shown more accurate than CT/MR to estimate the actual response of the primary tumor, especially to detect patients with progressive disease. Evaluation of early or very early response (after I cycle of treatment for example) is another potential application of metabolic imaging. Indeed, in several tumor types, the extent of the early tumor response measured by PET is a good predictor of the final outcome of the patient. The second issue relates to the methodology of PET procedures performed to measure tumor response. In particular, the tracer uptake has to be quantified with the highest precision. Standardized uptakes values (SUV) are the most common quantitative index used in PET imaging. We will briefly detail all the factors that influence
Friday, February 23, 2007 this index. One of the most important is certainly the time interval between the injection of the tracer and the acquisition of images. In one wants to quantitatively compare pre- and post-treatment scans, the time interval has to be identical for both procedures. The final part of the lecture will focus on the research work that is presently conducted to discriminate tumoral metabolic activity from the inflammation induced by radiotherapy. 24 oral FDG-PET COMBINED WITH CT CONSIDERABLY ALTERS TUMOUR DELINEATION FOR RADIOTHERAPY FOR H&N CANCER COMPARED TO CT ONLY C. Terhaard ~, B. de Keizer2,M. Hobbelink2 1UNIVERSITYMEDICALCENTERUTRECHT,Radiotherapy, Utrecht, The Nether-
lands, 2UNIVERSITYMEDICALCENTERUTRECHT,NuclearMedicine, Utrecht, The Neth-
erlands Purpose/Objective: In our institute parotid sparing intensity modulated radiotherapy has been the treatment of choice for squamous cell carcinoma of the head and neck since 2002. Image guided radiotherapy (IGRT) has become of utter importance for exact delineation of the gross tumour volume (GTV) of the primary tumour and possible neck nodes. In this study we investigate the importance of FDG-PET, combined with a planning CT for the delineation of GTV. Materials/Methods: From 2003 until 2006 109 patients treated primarily (95%) or for recurrent disease (5%) by (chemo) radiotherapy received a planning CT and FDG-PET in the same mould. Matching of the images was performed using mutual information matching. FDG-PET scans were analysed by an experienced radiation oncologist and Nuclear Medicine physician. Alteration of the GTV and/or change of treatment preference based on FDG-PET -CT compared to CT only was evaluated. The tumour was located in the pharynx in 76%, the larynx in 11%, and the oral cavity in 13%. Advanced T-stage (T3-4) was noted in 46%. Neck nodes were positive in 61%. Results:Based on the FDG-PET - CT compared to CT only, the radiation field was adapted in 45%; due to change on local extension in 16%, N-stage in 22%, combined T-N extension in 3%. In 6% a second primary was diagnosed on FDG-PET, cause for change of treatment modality in 4 out of 6. In 3% N-stage was down-staged, and in 17% up-staged, based on findings of the combined FDG-PET-CT scan. For determination of local extension CT only was incapable to show the entire local extension in 20%, mostly based on scatter from lead inlays. In 7%, also on FDG-PET local turnout extension was not clearly visible. In general CT showed larger tumour volumes compared to FDG-PET. Conclusions:FDG-PET combined with CT, performed in the same mould, results in alteration of the determination of the GTV in a significant number of patients, compared to CT only. Diagnosis of a second primary tumour influenced choice of treatment. For head and neck tumours treated with primary (chemo) radiotherapy combined FDG-PET-CT scanning should be the standard for IGRT. 25 oral COMPUTER ASSISTED NAVIGATION IN HEAD AND NECK ONCOLOGIC SURGERY G. Dolivet ~ F. MarchaP, P. Henrot3,J. Stines3, H. Gisquet~, JP. Barberot4, P.Ganglo~, B. Phulpin ~,F. Guillemin2,J.L. Verhaeghe2 ICENTREALEXISVAUTRIN,Head and Neck Surgery Unit, VandoeuvreLes
Nancy, France, 2CENTREALEXISVAUTRIN,Oncologic SurgeryDepartment, VandoeuvreLes
Nancy, France, SCENTREALEXISVAUTRIN,Radiology Department, VandoeuvreLes Nancy,
France, 4HIA LEGOUEST,Headand NeckSurgery,Metz, France
Friday, February 23, 2007 Purpose/Objective: Cranio facial oncologic surgery have always had to face to the double difficulties of sparing vital structures and evaluating the quality of the resection in bone. The computer assisted navigation could allow to avoid those problems. Goal of our study : the first height cases of our faisability study were used to evaluate difficulties of instalation, time increase in the surgical procedure, real possibility of evaluating surgical virtual margin, precision of the device and detection of vital structures. Materials/Methods: Heigth patient with tumor closed to the facial bone structure were treated by surgery. We use a Praxim (Surgetic Station) system with infra red and stereo camera. Pre op imaging were CT Scan or CT Scan/MRI fusion. Patients had different deseases as : lacrymal tumor relapse in irradiated area, SCC of the facial skin invading the infra orbital area, latero fronto-facial SCC invading the pterygo-maxillar fossa, atypical image in the two maxillar sinus with history an history of oral pharynx SCC relapse of a rhino pharyngeal indifferentied carcinoma or adenocarcinoma, relapse of mid face carcinoma and latero basocranial tumoral relapse Results: All procedure were done without difficulty. The average increase of time were 15 minute of the surgical procedure. We were abble to define surgical margin in seven cases,the last were a sinusal exploration. The infra orbital nerve could be finded easily as well as the optical nerve and all were respected. The carotidian and the vertebral artery were detected at the base of the skull. If soft tissue can have modification and cannot be use as precise landmarks, bone and linked structure give a precision of 1 to 2 mm. Conclusions: The computer assisted device seems to be very promising in oncological cranio facial surgery and the principle could be extended to other as vertebral, pelvic and probably liver oncologic surgery 26 oral DIFFUSION WEIGHTED (DW) MRI TO EVALUATESALIVARY GLAND FUNCTION BEFOREAND AFTER RADIOTHERAPY. S. Nuyts ~, R Dirixl,V. Vandecaveye2,F. De Keyzer2,W.Van den Bogaert1, R. Hermans 2 IUNIVERSITYHOSPITALGASTHUISBERGIRadiation Oncology, Leuven CancerIn-
stitute, Leuven,Belgium, 2UNIVERSITYHOSPITAL GASTHUISBERGrRadiology, Leuven Cancer Institute,
Leuven, Belgium Purpose/Objective: To evaluate the use of Diffusion Weighted (DW) MRI as a non-invasive tool to investigate three-dimensional (3D) salivary gland function and advance our understanding of dose-volume factors in radiation-induced xerostomia. Materials/Methods: Echo-planar DW MRI was performed on a 1.S T unit in 23 HNC patients before and at 6 months after parotid-sparing 3D-conformal RT (mean dose to the contralateral parotid gland was kept ~26 Gy) and in 7 healthy volunteers. A sequence was performed once at rest and then continuously repeated over a mean period of 26 minutes (range: 24 - 28 minutes) during salivary stimulation with a tablet of ascorbic acid given orally. Apparent diffusion coefficient (ADC) maps for both parotid and submandibular glands could be obtained in all volunteers and patients. Results: In patients before RT and in volunteers, the mean ADC value at rest was significantly lower in the parotid (0.93 (_+0.13) x 10-3) than in the submandibular (1.19 (_+ 0.12) x 10-3) gland (p = 0.004). No significant difference was observed between left and right parotid (p = 0.07) or submandibular (p = 0.42) glands. During the first S minutes of stimulation, the ADC value of the parotid showed a decrease to a lower value (p = 0.13), followed in the next 1S minutes by a steady increase (p <0.0001) until a peak ADC, significantly higher than the baseline value (p = 0.0002), was reached after a median of 21 minutes. In the submandibular glands, a significant decrease was seen (p = 0.0005) followed by a significant increase to a maximum (p
Symposia/Proffered Papers <0.0001), significantly higher than the baseline value (p = 0.049). In patients, the baseline ADC value at rest was significantly higher after RT (1.12 (+ 0.14) x 10-3) than before RT (0.91 (_+ 0.04) x 10-3) in the irradiated parotid glands (p = 0.004), but not in the spared glands (p = 0.16). In the spared parotids, the same response to stimulation was seen as before RT: a decrease to a lower ADC value (p = 0.14), followed by a significant increase to a maximum (p = 0.01), significantly higher than the baseline value (p = 0.02). This pattern was completely lost in the parotids that received a mean dose ~26 Gy, where no significant differences were observed in ADC values during stimulation. No attempt was made to spare the submandibufar glands. Consequently, the baseline ADC value at rest was significantly higher after RT compared to before RT in both the ipsilateral (p = 0.02) and the contralateral submandibular gland (p = 0.04). No significant differences were observed in ADC values during stimulation in the irradiated submandibular glands. Conclusions: DW MRI allows to non-invasively demonstrate functional changes in the salivary glands after RT. Since ADC values can be calculated for each pixel, functional 3D maps of the parotid and submandibular glands before and after radiotherapy will be compared with the isodoses to evaluate dose-response relationships within the salivary glands and between patients. These data will be presented at the time of the meeting.
OptimizingTreatmentfor LocallyAdvancedPharyng0LaryngealSCC:State of the Art 27 speaker VOICE SPARING SURGERY FOR ADVANCED PHARYNGO-LARYNGEAL CANCER G. Spriano.V. Manciocco, R. Pellini NATIONALCANCERINSTITUTE- REGINAELENA,Dept. Otolaryngology Head and Neck Surgery, Rome, Italy Regarding quality of life, Weinstein definitively assessed the superiority of partial laryngectomy versus total laryngectomy with tracheo-esophageal puncture. Randomized controlled studies have shown that preservation of the larynx function in selected patients with advanced resectable laryngeal and hypopharyngeal cancer is possible without compromising survival compared to total laryngectomy, in the United States, the treatment of advanced laryngeal cancer has moved from radical surgery toward a more conservative approach involving definitive radiotherapy and chemotherapy, with extirpative surgery held in reserve for salvage. In Europe, there has been increasing reliance on the use of "function-preserving" surgical approaches even for selected advanced laryngeal lesions and for selected recurrence in radiotherapy failure. Various surgical procedures are available for management of advanced laryngeal cancer to address according to the site and extent of the tumor: supracricoid} partial laryngectomy with cricohyoidopexy or with cricohyoidoepiglottopexy, extended supraglottic laryngectomy, and recently, tracheohyoidopexy or tracheohyoidoepiglottopexy.These procedures may be effectively employed in combination with neck dissection and postoperative radiotherapy when necessary. Failures are usually due to a technical mistake or to an inadequate evaluation of the local extension. Careful monitoring of the conservatively treated patient is mandatory to allow for early salvage of failures to the original therapy. Clearly a multidisciplinary approach is, at the moment, the best strategy to individualise treatment for every patient and improve design of future clinical trial.
-$7