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PubMed1991

Surgical treatment in head and neck cancer.

Three topics currently important in head and neck surgery are voice-conserving surgical treatment of laryngeal cancer, the role of modified radical neck dissection in the treatment of cervical metastases, and reconstruction and rehabilitation of the head and neck cancer patient. The laser has become an accepted modality for the treatment of early vocal cord cancer and has local control rates comparable to other treatment methods. Partial laryngectomy can conserve voice and yield excellent local control rates. The modified radical neck dissection has been shown to yield rates of local recurrence no greater than radical neck dissection for N0 and N1 neck disease associated with laryngeal cancer. Vocal rehabilitation following total laryngectomy has been revolutionized by the tracheoesophageal puncture procedure. Most patients can be expected to acquire voice using tracheoesophageal puncture following total laryngectomy. Free flaps have improved the functional results of many major head and neck surgical procedures and offer the possibility of better results in the future. However, more conventional reconstructive techniques, including local flaps, continue to have a role in head and neck surgery.

Head and Neck Neoplasms↗
PubMed2002

Histopathological features of occult metastasis detected by sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma.

OBJECTIVES: Sentinel lymph node biopsy has been introduced for head and neck cancer with promising results. Research in breast cancer has revealed different histopathological features of occult lymph node metastasis with possibly different clinical and prognostic implications. The aim of the study was to evaluate the histopathological features of occult metastasis detected by sentinel lymph node in oral and oropharyngeal squamous cell carcinoma. STUDY DESIGN: Prospective. METHODS: According to Hermanek (5), occult metastasis was differentiated into isolated tumor cells and infiltration of lymph node parenchyma smaller than 2 mm in diameter (micrometastasis) and larger than 2 mm in diameter (metastasis). RESULTS: Occult metastases were found in 6 of 19 (32%) sentinel lymph nodes. Three patients showed micrometastasis with a mean size of 1.4 mm (range, 1.2-1.5 mm), the first with three separate micrometastases within the same sentinel lymph node, the second with an additional cluster of isolated tumor cells within the same sentinel lymph node, and the third with an additional micrometastasis in one lymph node of the elective neck dissection. Two patients had macrometastasis (3.4 and 8 mm), both with multiple metastases in the elective neck dissection. One patient had two clusters of isolated tumor cells in the sentinel lymph node and an additional cluster of isolated tumor cells in one lymph node of the elective neck dissection. CONCLUSIONS: Occult metastasis can be subdivided histopathologically in isolated tumor cells, micrometastasis, and macrometastasis. We present the first study describing a great variety of these subtypes in sentinel lymph nodes from head and neck squamous cell carcinoma. Because the independent prognostic factor and clinical relevance of these subtypes is still unclear, we emphasize the importance of reporting these findings uniformly and according to well-established criteria.

Adult↗
PubMed1999

[Cervical lymph node metastasis and recurrence in supraglottic carcinoma after operation].

OBJECTIVE: To evaluate the regional control efficacy of elective neck dissection (END) in patients with supraglottic carcinoma. METHODS: The incidence of cervical recurrences of 582 patients with supraglottic carcinoma treated in this hospital from 1981 to 1993 were retrospectively reviewed. RESULTS: Three hundred and ninety-two cases (67.35%) of this group had T3 and T4 primary lesions. Among them, 147 cases (37.50%) had positive nodes(N+) and this accounted for 86.47% (147/170) of all N+ patients. Ipsilateral or bilateral cervical recurrence occurred in 33 of 126 (26.19%) node negative (N0) cases who had not had neck dissection and 30 of them (90.90%) were among T3 and T4 groups. However, Contralateral lymph node recurrence occurred only in 40 of 286(13.99%) N0 cases who had had END and 30 of them (75%) were among T3 and T4 groups. There were 163 cases who were readmitted and received surgery again for different purposes. The three and five year survival rates in the second stage END group were 86.67% and 77.78%, in metastasis group 64.81% and 32.50%, in recurrent group 33.33% and 30.77% respectively. There were significant differences in survival rates among these groups. CONCLUSION: Patients underwent elective neck dissection achieved better survival than those on "wait and watch" policy and salvage surgery. Elective neck dissection is recommended for the treatment of supraglottic carcinoma, especially for the T3 and T4 diseases.

Adult↗
PubMed2001

Is dissection of level IV necessary in patients with T1-T3 N0 tongue cancer?

OBJECTIVE: Dissection of the lower jugular level of lymph nodes (level IV), as part of an elective neck dissection, has been advocated recently for all patients with oral tongue cancer because of the possibility of "skip metastases" to levels III and IV. The current study was undertaken to evaluate the need to perform a dissection of level IV in patients with oral tongue cancer with no clinical evidence of nodal metastases. METHODS: Fifty-one patients with T1-3, N0 squamous cell carcinoma of the oral tongue were treated with a partial glossectomy and a selective neck dissection of levels I, II, and III. When enlarged nodes were encountered during surgery in level II or III, the dissection was extended to include the nodes in level IV. Involvement of level IV was determined either by the presence of carcinoma on pathological examination or by the development of recurrence in the untreated level IV during a follow-up period of at least 2 years. RESULTS: Level IV was resected as part of the specimen in 17 of the 51 patients and metastatic tumor was found in this level in only one patient. At an average follow-up of 4.1 years, only one patient recurred at level IV, which had been addressed at the initial neck dissection. Consequently, the rate of metastases to undissected level IV was 2%. CONCLUSIONS: Metastases to level IV lymph nodes is rare in patients with T1-T3, N0 oral tongue cancer. Dissection of these nodes only when there is intraoperative suspicion of metastases in levels II or III does not increase the risk or recurrence of tumor in the neck.

Adult↗
PubMed1985

[Choice of appropriate surgical treatment of thyroid cancer: review of 2,244 malignant thyroid tumors].

The aim of this study was to determine the appropriate surgical treatment of thyroid cancer. Follow-up results of 2,244 patients with malignant thyroid tumors were analyzed. As factors affecting the prognosis of thyroid cancer, histological type, sex, age, size of the primary tumors, extention of the primary tumor and the incidence of metastasis in excised lymphnodes were analyzed. Eight hundred and twenty-eight patients with papillary cancer were divided into 3 groups according to the combinations of the factors. Low-risk group (L group): Male under 30 years of age or female under 50 years of age, primary tumor less than 20 mm in maximum diameter, confined to one lobe and metastasis to the cervical lymphnodes less than 40%. High-risk group (H group): Male over 30 years of age or female over TP years of age, tumor more than 30 mm, primary lesion extended beyond isthmus and 40% or more metastasis to lymph nodes. Intermediate-ris group (I group): Other than the L and H groups. From the results of studies in each group on recurrence sites and recurrence rates, it was suggested that appropriate surgical treatment for L group was partial thyroidectomy or total lobectomy with local neck dissection, that for I group was total lobectomy with ipsilateral modified radical neck dissection and that for H group was subtotal thyroidectomy with bilateral modified radical neck dissections.

Adenocarcinoma↗
PubMed2000

Efficacy of surgical salvage for advanced neck metastases after radiotherapy failure.

OBJECTIVE: To analyze the efficacy of surgical salvage in patients with metastatic squamous cell carcinoma to the neck of stage N2 or N3 initially treated with radiotherapy. DESIGN: Retrospective review. SETTING: Tertiary care institution. METHODS: Four hundred and twenty-five patients received neck dissection at Sunnybrook Health Sciences Centre between 1990 and 1996. Sixty-one patients had neck dissection for salvage after radical radiotherapy for advanced neck disease of stage N2 or N3. These patients were selected from the Sunnybrook Head and Neck Database and reviewed. OUTCOME MEASURES: Survival and recurrence. RESULTS: Sixty-one patients underwent neck dissection for salvage after radiotherapy. Five-year overall survival was 30%. The majority (72%) failed locoregionally after surgical salvage. CONCLUSIONS: Surgical salvage after radiotherapy for advanced neck disease has a 30% 5-year survival rate. Surgical salvage after radiotherapy for advanced neck disease is effective in a minority of patients.

Combined Modality Therapy↗
PubMed1975

[Surgery of the tongue and floor of the mouth (author's transl)].

Most carcinomas of the oral tongue and floor of the mouth are presently treated surgically, often combined with pre- or postopervative irradiation. The treatment plan is mainly determined by the primary site and the local and regional extension, desirable are general rules on the basis of the TNM classification. The indications and principles of the most important operative procedures are discussed: Local excision, partial glossectomy, excision of the floor of the mouth with marginal mandibulectomy, composite resection. Operations for removal of the primary and radical neck dissection with preservation of the mandible (e.g. the pull-through procedure) are rarely advised. A radical neck dissection is indicated in each carcinoma of the oral tongue or floor of the mouth with palpable lymph nodes. If no nodes are palpable, an elective neck dissection is advised in view of the high frequency of clinically occult lymph node metastases (between 23 and 43%). Reconstructive measures following radical tongue and floor of the mouth operations are required for regaining a motility of the remaining tongue, for reconstruction of the floor of the mouth and for replacement of the mandible.

Carcinoma, Squamous Cell↗
PubMed2006

Deep plane cervicofacial flap: a useful and versatile technique in head and neck surgery.

BACKGROUND: Large oncosurgical defects of the cheek present a challenging reconstructive problem, especially when skin resections are combined with other procedures such as parotidectomy and/or neck dissection. METHODS: We present our experience with the deep plane cervicofacial flap (DPCFF) for reconstructing zone 1 (n=7), zone 2 (n=6), and zone 3 (n=5) cheek defects resulting from excision of primary cutaneous malignancies (n=13) and metastatic parotid (n=6) and/or neck (n=4) disease with skin involvement. The patients were between 65 and 88 years of age (mean, 76.7 years). The design of the flap was determined by the location of the defect and the need for simultaneous parotidectomy and/or neck dissection. Sixteen flaps were anteriorly based, whereas two were posteriorly based. RESULTS: Twelve patients underwent simultaneous parotidectomy (n=11) and/or neck dissection (n=10) and/or facial reanimation procedures (n=6). The size of the cutaneous defects ranged from 4 x 4 to 10 x 10 (mean, 5.6 x 5.3) cm. Eight patients received postoperative adjuvant radiotherapy to the primary site and/or parotid bed and neck. Superficial marginal flap necrosis occurred in one of the three patients who received definitive radiotherapy before salvage surgery and repair with DPCFF. Other complications included one hematoma, one ectropion, and one retraction of the lower eyelid. Apart from mild facial contour deficiency in two patients, excellent functional and cosmetic outcome with good skin color and texture match were achieved in all patients. CONCLUSIONS: The DPCFF is a versatile reconstructive technique in head and neck surgery. It provides a simple solution for a variety of cheek defects as an excellent alternative to regional or free tissue transfer. It can be used when simultaneous parotidectomy and/or neck dissection and/or facial reanimation procedures are required. This composite musculo-fascio-cutaneous unit is reliable with excellent vascularity, because it has an axial blood supply. Division of the facial suspensory ligaments during elevation of the flap in the sub-superficial musculo-aponeurotic system (SMAS) plane increases the mobility of this flap, which facilitates transfer.

Aged↗
PubMed1999

Surgical management of the neck in squamous cell carcinoma of the tongue.

If the nodes are involved, survival of patients with squamous cell carcinoma of the tongue is considerably reduced. Surgery remains the treatment of choice and, to define its role, we have reviewed 82 consecutive cases. Sixty-two cases (76%) were T1-2, and 46 patients (56%) had involved nodes. The cervical region II was the most often involved (n=26). Occult nodal metastases were present in 12 cases. The extent of nodal spread and prognosis varies according to whether the body or the base of the tongue is involved. Lesions of the base with involved node should be treated by a selective posterolateral neck dissection, whilst in the case of a lesion of the body of the tongue, the dissection should be selective anterolateral. In lesions of the base, when there are no nodes involved, a prophylactic selective posterolateral neck dissection is recommended, whilst in the case of the lesions of the body, selective supraomohyoid neck dissection in T2-4 lesions is recommended.

Adult↗
PubMed2002

Importance of lymph node metastases in follicular thyroid cancer.

There are many concepts of risk and prognostic factor analysis for differentiated thyroid cancer. The prognostic role of lymph node metastases in follicular thyroid cancer (FTC), however, is still controversial. We performed a retrospective trial in 186 patients with FTC (124 women, 62 men; mean follow-up 5.5 years) questioning whether lymph node metastases and radical thyroid surgery with neck dissection contribute to the prognosis of FTC. Univariate analysis demonstrated that lymph node metastasesp <0.005), tumor size (p <0.005), tumor stage (p <0.005), distant metastases p = 0.0063), and gender (p = 0.003) are significant prognostic factors for recurrence (Kaplan-Meier). Tumor size (p = 0.004), lymph node metastases p = 0.0478), and distant metastases p = 0.0064) influenced mortality. Age and extent of surgery were not significant for recurrence nor was gender for mortality. Multivariate analysis (Cox regression test) characterized tumor size (p <0.005) and lymph node metastases p = 0.004) as prognostic factors for recurrence of FTC. No significant difference was detected between patients being treated by thyroidectomy when compared to patients treated by thyroidectomy plus neck dissection in relation to recurrence. Our data demonstrate lymph node metastases to be a significant prognostic factor for recurrence of FTC and the patient's survival. We advocate thyroidectomy plus central lymph node dissection as the basic surgical strategy. For T3 and T4 tumors, unilateral modified neck dissection is an all but optional procedure. Whether radical surgery with thyroidectomy plus neck dissection has an impact on survival remains questionable.

Adenocarcinoma, Follicular↗
PubMed2001

[The clinical and pathological research of supraglottic carcinoma with bilateral cervical nodal metastasis].

OBJECTIVE: To evaluate clinical and pathological characteristics in patients with supraglottic carcinoma and bilateral cervical nodal metastasis. METHOD: 60 patients with supraglottic carcinoma treated in this hospital from 1985 to 1994 were retrospectively reviewed, including 30 cases with bilateral metastasis (experiment group) and 30 cases with unilateral metastasis (control group). The two groups were contrasted according to site of tumor, tumor diameter, surface morphology, clinical staging, the degree of invading the contralateral semilarynx, Border's grading, growth mode of tumor edge, the degree of invading preepiglottic space. RESULT: In stage T4 cases with low grading of cell differentiation made up 63.6% (7/11) in the bilateral metastasis group, while 10% in the ipsilateral metastasis group (P < 0.05). Significant differences lied between N0 group and N2 group (P < 0.05). Moderate and severe invasion of contralateral semilarynx in the bilateral group made up 87.5% (14/16), significantly higher than that in ipsilateral group 53.3% (16/30). CONCLUSION: Bilateral neck dissection should be used in T4 cases with low grading of cell differentiation in which the contralateral semilarynx was invaded. Bilateral neck dissection should be taken for the treatment of supraglottic carcinoma with N2.3 diseases. Bilateral neck dissection is recommended for the patients with moderate and severe invasion of the contralateral semilarynx.

Adult↗
PubMed1985

Transcapsular spread of metastatic squamous cell carcinoma from cervical lymph nodes.

The incidence, extent, and selected clinicopathologic correlations of transcapsular spread from metastatic tumor in the cervical lymph nodes have been investigated in 210 specimens obtained by radical neck dissection from 203 patients with squamous cell carcinomas of the head and neck. Transcapsular spread was detected in 137 of 159 (86 percent) positive specimens, and classified as macroscopic in 74 (54 percent) and microscopic in 63 (46 percent). Macroscopic transcapsular spread was seen most frequently in association with large nodal masses more than 3 cm in diameter (48 of 70 specimens, 69 percent), but also occurred in some specimens with smaller lymph nodes less than 3 cm in diameter (26 of 67 specimens, 39 percent). Anatomic structures most commonly invaded in areas of neck dissection with macroscopic spread from nodal metastases were skeletal muscle (39 dissections) and the adventitial coat of the internal jugular vein (27 dissections). Macroscopic transcapsular infiltration was associated with a high incidence (44 percent) of recurrent tumor in the ipsilateral neck, particularly within 12 months of surgery. Microscopic transcapsular growth was associated with a lower incidence (25 percent) of recurrent tumor in the ipsilateral neck but the difference did not reach statistical significance. Similar recurrence figures (32 percent) were found in the minority of patients whose nodal disease was intracapsular at the time of neck dissection. More precise definition of the morphologic extent of transcapsular spread could be important in clarifying its clinicopathologic correlations.

Adult↗
PubMedDate not supplied

Resection of advanced cervical metastasis prior to definitive radiotherapy for primary squamous carcinomas of the upper aerodigestive tract.

Thirty-five previously untreated patients with stage IV squamous cell carcinoma of the upper aerodigestive tract with advanced neck disease (mass greater than 3 cm) but with primary lesions thought to be locally controllable with radiotherapy were selected between 1972 and 1988 for treatment by neck dissection followed by radiotherapy; postoperative to the neck and definitive to the primary. Limited neck dissections spared muscles, nerves, and vasculature structures unless clinically involved with cancer. All patients received at least 50 Gy, postoperatively, to the entire neck with doses of up to 75 Gy being delivered to the primary treatment portals. Regional (neck) failure occurred in 11% (4 of 35) patients. Overall, 5-year survival from cancer was 55%. Multiple levels of neck involvement were associated with poorer survival than a single large node; however, the difference was not statistically significant. Delay in the institution of radiotherapy following surgery adversely affected survival (p = 0.01). This study demonstrates that in selected patients it is possible to resect advanced nodal metastasis prior to treating the primary with radiotherapy without compromising cancer control.

Adult↗
PubMed1986

Adjunctive liposurgical debulking and flap dissection in neck reconstruction.

Closing the defect resulting from excision of a 50 X 55 mm malignant lesion on the posterior aspect of the lateral neck was accomplished by mobilization of the entire submental and submandibular neck skin utilizing liposuction surgery dissecting techniques. This is the first reported case using this relatively atraumatic surgical modality to dissect redundant skin for use in flap reconstruction.

Adipose Tissue↗
PubMed2003

The role of positron emission tomography in the evaluation of the N-positive neck.

BACKGROUND: A major prognostic indicator in patients with squamous cell carcinoma of the upper aerodigestive tract is the presence or absence of cervical metastasis. Nodal involvement at different levels affects treatment. Thus identification of the degree of nodal involvement is important. Evaluation of the neck by conventional imaging modalities (computed tomography or magnetic resonance imaging) is not completely accurate. Positron emission tomography (PET) scanning as a dynamic functional assessment may allow detection of multiple metastatic nodes at different levels. PURPOSE: We sought to compare the effectiveness of PET with pathologic examination for: presence, location, and number of cervical metastases in the clinically N-positive neck. SETTING: Tertiary care academic facility. Materials and methods From 1994 to 1997, 15 patients with clinically N-positive necks who had preoperative PET scans underwent 23 neck dissections. PET scans were correlated with the pathologic findings of the neck dissections in determining the ability to correctly identify the number and level(s) of nodal disease. RESULTS: When determining identification of the level of disease, PET demonstrated sensitivity of 81%; specificity, 99%; positive predictive value, 97%; negative predictive value, 90%; and accuracy, 92%. When evaluating the ability to correctly predict neck stage, PET demonstrated sensitivity of 86%, positive predictive value of 100%, and accuracy of 80% compared with clinical examination with sensitivity of 53% and accuracy of 53%. CONCLUSION: PET accurately identified disease in the N-positive neck. Its ability to identify multiple level disease may allow it to help predict the selectivity of neck dissection in the therapeutic protocol.

Adult↗
PubMed1992

Comprehensive treatment strategy for oral and oropharyngeal cancer.

This prospective nonrandomized study analyzes the effectiveness of the following treatment protocol for oral and oropharyngeal cancers: (1) radical initial surgery; (2) elective modified or selective neck dissection for NO necks; (3) jaw preservation unless gross invasion is present; (4) radial forearm freeflap reconstruction; (5) elective tracheotomy; (6) postoperative radiotherapy unless previously given; and (7) active oral rehabilitation. Between 1987 and 1992, 75 patients (55 men and 20 women) with a median age of 58 years had this treatment. Fifteen had been previously treated with radiotherapy. Clinical stages of untreated patients were as follows: 4 patients, stage I; 25 patients, stage II; 12 patients, stage III; and 19 patients, stage IV. Ten patients had segmental jaw resection, 26 had a marginal mandibulectomy, and 26 had a jaw swing. There were no operative deaths, and only one flap (1.2%) failed. Median times for oral feeds and hospital stay were 8 and 17 days, respectively. Forty-four patients had postoperative radiotherapy. Median follow-up time is 30 months, and locoregional control is 95% for previously untreated patients and 54% for previously treated patients. Thirteen patients have died of disease, 8 with locoregional recurrence and 5 with distant metastases alone. We conclude that this treatment strategy is highly effective in previously untreated patients but less effective in salvaging patients in whom radiotherapy has failed.

Adult↗
PubMed2003

Diagnosis and management of carcinoma of unknown primary in the head and neck.

Carcinoma of unknown primary is defined as the histological diagnosis of metastasis without the detection of a primary tumor. In the literature, the incidence of CUP in all patients with a malignant disease is said to be between 3% and 15%. The most frequent histopathological results of CUP metastases are adenocarcinoma, followed by undifferentiated carcinoma and squamous cell carcinoma. In this retrospective investigation the clinical records of 167 patients were studied. All patients had been admitted and treated for cervical CUP at the Department of Otorhinolaryngology of the Grosshadern Clinic from 1979 to 1998. Cervical swelling was the first noted symptom in all cases, followed by pain and dysphagia. The study group comprised 134 men and 33 women with an average age of 55 years at admission. Squamous cell carcinoma (n=123) was the predominant histopathological finding of the cervical lymph nodes. During the 10-year follow-up, a primary tumor was detected in 36 (21.5%) of the 167 initially diagnosed CUP patients. In over 90% of these cases the tumor was localized in the head and neck region. The most frequent origin of the tumor was the tonsilla palatina (n=7). Neck dissection and additional postoperative radiotherapy was performed in 118 (70.7%) of the 167 CUP patients. Primary radiotherapy was the treatment of choice in 28 patients; eight patients received combined radio-chemotherapy as the primary treatment and seven patients were treated with chemotherapy alone. Six patients had no treatment. Comparison of different treatment protocols revealed a significant difference in patient survival: in comparison with primary radiotherapy alone or neck dissection and postoperative radiotherapy, the survival rate improved significantly in patients that received a bilateral tonsillectomy in addition to neck dissection and postoperative radiotherapy. The treatment of choice in patients with cervical CUP should be a surgical procedure including (radical) neck dissection and diagnostic bilateral tonsillectomy followed by postoperative radiation of the cervical lymph drainage. Bilateral tonsillectomy is especially important and is correlated with a significant improvement of the survival rate in CUP patients. Additional postoperative radiation of the entire pharyngeal and laryngeal mucosa should also be considered in order to treat a possible small primary tumor in this region.

Adolescent↗