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PubMed1961

Indications for operation in laryngeal cancer.

Improvements in the surgical treatment of laryngeal cancer by combined laryngectomy and radical neck dissection have given new importance to selection of the mode of treatment for various stages of disease at that site. To cast light on the subject, the cases of 63 patients with cancer of the larynx were reviewed. Twenty-one of them were operated on for recurrence after radiation therapy; and 42 were treated surgically at the outset, 36 of them having combined laryngectomy and radical neck dissection. In almost 80 per cent of the patients the lesion was extrinsic. In the entire series, 51 patients had combined operations, and in 41 of them the cervical lymph nodes were positive for metastasis. Reports in the literature also make note of a very high incidence of cervical node metastasis not only in cases of extrinsic cancer, but also in those in which the lesion is intrinsic. Because of the frequency of cervical node spread, and its occult nature, choice between radiation and surgical operation must be made after candid, critical appraisal of the individual condition in each patient.

Adult↗
PubMed1981

[Methodical aspects of intra-arterial chemotherapy of malignant head and neck tumors (author's transl)].

A new method of intra-arterial (i.a.) chemotherapy of malignant head and neck tumors based on a vascular-surgical procedure is described. In combination with radical neck dissection the external carotid artery is prolonged end-to-end by an autogeneic saphenal vein graft and anastomosed with the common carotid artery end-to-side more proximally. After wound healing the transplant is well palpable and can easily be cannulated percutaneously, thus facilitating continuous or repeated i. a. chemotherapy of the malignant tumor. During therapy intervals the cannula should be removed. In this way, it is possible to perform i. a. cytostatic therapy over several weeks or months. All the branches of the external carotid artery not directly contributing to the blood supply of the tumor region have to be ligated during the neck dissection, in order to maintain the necessary high concentration of the drugs at the tumor site. First clinical results obtained with this method demonstrate the safety of the procedure and suggest new aspects of chemotherapy in head and neck cancer.

Antineoplastic Agents↗
PubMed1989

Management of occult metastatic disease from salivary gland neoplasms.

Evaluating salivary gland neoplasms is difficult because of the relatively low incidence of these lesions, their variable locations, and their multiple histologic cell types. Little has been reported on nodal metastases, whether manifest or occult, from these neoplasms. Ninety cases of salivary gland neoplasm are analyzed to provide a clearer understanding of the appropriate approach to occult salivary gland cervical metastases. Manifest regional metastases at the original presentation were absent in 72% (65/90). Few nodal metastases occurred after the primary tumor was controlled (2% [1/56]). Local recurrence (38% [34/90]) and distant metastases (25% [14/56]) were more common. Stage I and II disease was treated by surgical resection of the primary tumor alone; resection was combined with postoperative radiation therapy for stage III disease. Whenever the neck was entered for stage III disease, a conservative neck dissection was incorporated with the resection to reduce the postoperative irradiation field once the neck had been proved N, O histologically. Delayed nodal metastasis was treated by neck dissection alone.

Adenocarcinoma↗
PubMedDate not supplied

Nasopharyngeal carcinoma: clinical course and results of therapy.

Ninety-nine patients with carcinoma of the nasopharynx were reviewed. No significant relationship was found between T classification and survival or between tumor cell type and survival. The presence of regional metastases, however, did influence the outcome of therapy. A 5-year survival of 34.4% was recorded for patients without nodal disease in contrast to 14% for patients with massive lymphadenopathy or bilateral cervical metastases. The significance of regional metastases is supported by the relationship between survival and disease stage. The 5-year survival for stage I was 67%, while the average survival for stages III and IV was 21%. The average 3- and 5-year survivals for the entire series of patients were 36.2% and 23.9%, respectively. Early lesions confined to the primary site have the greatest chance of cure, but even advanced disease with bone destruction or cranial nerve involvement may be controlled with radiotherapy in some cases. Patients who develop cervical metastases following successful control of nasopharyngeal tumor may be cured by radical neck dissection. Two (28.6%) of seven patients undergoing surgical treatment survived for 10 years following neck dissection.

Adolescent↗
PubMed2000

Familial nonmedullary thyroid cancer.

Familial nonmedullary thyroid cancer is more aggressive than sporadic nonmedullary thyroid cancer. It tends to affect younger patients, and the tumors are often multi-focal and bilateral. Histologically, 90% of these tumors are papillary cancers and the remaining are Hürthle cell cancers. We recommend total thyroidectomy to remove all the thyroid tissue, which harbors the genetic defect responsible for the disease (even in low-risk patients) due to the predisposition to develop thyroid cancer and the more aggressive nature of the disease. Careful exploration of the ipsilateral lymph nodes with ipsilateral central neck dissection is encouraged to decrease a high recurrence rate (44%). A complete modified radical neck dissection should be limited to a therapeutic role because there is no clear evidence that this procedure carries any survival benefit. We also recommend that patients receive radioactive iodine ablation post-operatively, including a prophylactic dose (30 mCi) for patients with no evidence of residual uptake on the postoperative iodine 131 whole body scan and in low-risk patients using any of the prognostic scoring systems. Patients should be placed on enough thyroid hormone to suppress thyroid-stimulating hormone (TSH) to approximately 0.1 mL/mL in low-risk patients and to less than 0.1 mL/mL in high-risk patients. Focal metastatic disease in patients with familial nonmedullary thyroid cancer is best dealt with by surgical excision followed by radioactive iodine ablation when appropriate. Redifferentiation therapy has a promising role in patients who have radioactive iodine-resistant tumors. The value of prevention, early detection, and targeted gene therapy once the gene or genes responsible for familial non-medullary thyroid cancer have been identified cannot be overemphasized.

Carcinoma↗
PubMedDate not supplied

Squamous cell carcinoma in a thyroglossal duct cyst (TGDC): clinical presentation, diagnosis, and management.

Squamous cell carcinoma arising in a TGDC is a rare event, and a high index of suspicion is therefore needed for reaching a correct preoperative diagnosis to plan adequate therapy. The work-up should include fine needle aspiration cytology and high-resolution CT scan. The recommended therapy is adequate wide resection with frozen section control of the surgical margins. For localized lesions within the TGDC (diagnosed as an incidental histological finding), the Sistrunk operation is adequate. If, however, the tumor invades surrounding structures, wider resections (which may include strap muscles, thyroid, larynx, or base of tongue) are recommended. Neck dissection is reserved for cases with nodal metastasis. There is no role for prophylactic neck dissections except perhaps for the paratracheal nodes. Postoperative radiation therapy is recommended for larger lesions, positive surgical margins, or extensive nodal disease. Strict follow-up is recommended for prolonged periods of time, because local recurrences are common and could occur many years after the initial treatment.

Adult↗
PubMedDate not supplied

[Use of CO2 laser in conservative surgery of glottic tumors].

The present work evaluates the results obtained in a group of 360 patients with laryngeal-glottic tumors (classification T1/T2-N0-M0) who, in the last 10 years, have undergone direct microlaryngoscopy surgery employing a CO2 Laser. In the T1 glottic carcinomas the neoplasm was limited to the vocal cord on one side or it involved the anterior commissure and, most likely, the vocal cord on the opposite side; in T2 glottic tumors the extension reached the hypoglottic region and/or the Morgagni ventricle and the false vocal cords on one or both sides but without compromising laryngeal motility. The five year healing rate for the T1 tumors proved to be 84.7% while it was 74% for the T2 forms. In 36 cases complications were found which can be broken down as follows: - limited local recurrences (13 patients) requiring subsequent direct microlaryngoscopy; - regional lymph node metastases (6 patients) without reproduction of the primary neoplasm; in general (5 of the 6 cases) these patients underwent lateral neck dissection; - spreading of the neoplastic process (17 cases) which made total laryngectomy with lateral neck dissection necessary; this procedure was performed in 15 cases. When these subsequent surgical procedures are also taken into account the percentage healing rises to 94.3% for T1 glottic tumors and to 84.9% for T2. Detailed analysis of the case study, comparison with the data found in the relative literature regarding patients treated with traditional techniques, a series of observations on the advantages and disadvantages inherent to the techniques employed have all led to the conclusion that the use of a CO2 laser in the treatment of laryngeal tumors gives excellent results in terms of prognosis. Moreover, this technique offers significant advantages over the traditional methods and constitutes a reliable technique for partial laryngectomies as long as the indications are accurately applied and the proper techniques used.

Adult↗
PubMed1988

[Distribution of recurrent lesions after radical resection of cancer of the thoracic esophagus].

In 150 patients who got cancer recurrence after curative resection for cancer of the thoracic esophagus, the sites where recurrent lesions were clinically detected for the first time were examined. The distribution of recurrent lesions in patients who did not undergo neck dissection at the operation (group A) differed from the distribution in those who underwent neck dissection (group B). Cervical and/or upper mediastinal recurrence occurred in 49% of cases in group A and in 11% of group B. On the contrary, middle or lower mediastinal recurrence was more often in group B. The distribution of recurrent lesions varied depending on the state of lymph node metastasis detected at surgery. Cervical and upper mediastinal recurrence was much more frequent than hematogenic recurrence in cases without lymph node involvement in group A, while hematogenic recurrence was more frequent in cases with both mediastinal and abdominal lymph node metastasis. In the upper mediastinum, recurrence along the recurrent laryngeal nerves was most frequent and it was supposed to have developed from residual lymphatic metastases. In the middle and lower mediastinum, recurrent lesions were located around the left main bronchus and descending aorta, and cancer infiltration of the neighboring organs was frequent. Recurrence at the abdominal paraaortic nodes was observed mainly in cases with perigastric lymph node involvement.

Esophageal Neoplasms↗
PubMed1994

Endoscopic treatment of supraglottic and hypopharynx cancer.

Transoral excision of supraglottic and hypopharynx cancer as a single modality is effective when lesions are selected for small size and endoscopic accessibility. Excisional biopsy with clear margins of larger supraglottic tumors in combination with postoperative radiotherapy provides an excellent treatment alternative for selected lesions in patients who are not candidates for open surgery. In this preliminary report, 45 cases using this minimally invasive approach are reviewed outlining oncologic rationale and functional advantages. A large bore tubed laryngoscope or the adjustable bivalve supraglottiscope was used along with a carbon dioxide laser in all cases. In 22 of the 45 patients (mostly T1), local en bloc excision of the primary cancer was performed as sole treatment on selected lesions of the supraglottis and hypopharynx. There were no local recurrences, however, 1 patient developed a neck recurrence and was salvaged by neck dissection. Twenty-three of the 45 patients had more extensive primaries (mostly T2, T3) and N0 necks. Transoral excisional biopsy was followed by full-course radiation therapy to the primary site and both necks. All 23 were followed a minimum of 2 years, and the median follow-up period was 58 months. Clear margins were obtained in 16 of 23, and there were no recurrences in the larynx. Two of 16 did fail in the neck and died despite neck dissection. Seven of 23 patients had positive margins and, despite full-course radiotherapy to the primary site and both necks, 5 of 7 failed locally or regionally. Two of the 7 died of their disease despite open salvage surgery. Therefore, 4 of 23 patients who underwent transoral excision of larger lesions followed by full-course radiotherapy died of recurrent cancer.

Combined Modality Therapy↗
PubMed2002

Prognostic indicators of occult metastases in oral cancer.

OBJECTIVE: We evaluated the importance of several tumor factors related to predicting the presence of occult metastases in the oral cavity. STUDY DESIGN: Retrospective case study. METHODS: The study comprises 29 patients treated at the Department of Otorhinolaryngology (University of Trieste, Cattinara Hospital, Trieste, Italy) between January 1990 and December 2000, who had T1-T2 carcinoma of the oral cavity that had or had not extended to the oropharynx and were clinically evaluated as N0 neck. The patients all underwent surgery with removal of tumor and neck dissection. Four tumor-related parameters were examined with the aim of evaluating their predictivity of metastasis tumor class, degree of keratinization, degree of differentiation according to Brooler's histopathological grading, and invasive cell grading (ICG). With the exception of tumor class, these parameters were evaluated both in the biopsy and in the surgical specimen and the findings were then compared. We evaluated existing correlations between each individual parameter and the histopathological presence of micrometastases (pN+) and extracapsular spread revealed when specimens from the neck were examined. RESULTS: There was a highly significant correlation between ICG equal to or greater than 13 (range, 5-20) and the presence of occult metastases (P = .0017). On the basis of our findings, the ICG parameter correctly identified 9 of 10 (pN+) patients and could have reduced overtreatment from 65.5% to 17.2% in histopathological necks (pN0). CONCLUSION: It would appear that with a delay in programming a neck dissection so as to consider ICG in combination with thickness, as in seven recent patients, identification of locoregional occult metastases (pN+) might be more precise.

Adult↗
PubMed2002

Prognostic indicators of occult metastases in oral cancer.

OBJECTIVE: We evaluated the importance of several tumor factors related to predicting the presence of occult metastases in the oral cavity. STUDY DESIGN: Retrospective case study. METHODS: The study comprises 29 patients treated at the Department of Otorhinolaryngology (University of Trieste, Cattinara Hospital, Trieste, Italy) between January 1990 and December 2000, who had T1-T2 carcinoma of the oral cavity that had or had not extended to the oropharynx and were clinically evaluated as N0 neck. The patients all underwent surgery with removal of tumor and neck dissection. Four tumor-related parameters were examined with the aim of evaluating their predictivity of metastasis: tumor class, degree of keratinization, degree of differentiation according to Brooler's histopathological grading, and invasive cell grading (ICG). With the exception of tumor class, these parameters were evaluated both in the biopsy and in the surgical specimen and the findings were then compared. We evaluated existing correlations between each individual parameter and the histopathological presence of micrometastases (pN+) and extracapsular spread revealed when specimens from the neck were examined. RESULTS: There was a highly significant correlation between ICG equal to or greater than 13 (range, 5-20) and the presence of occult metastases (P =.0017). On the basis of our findings, the ICG parameter correctly identified 9 of 10 (pN+) patients and could have reduced overtreatment from 65.5% to 17.2% in histopathologically negative necks (pN0). CONCLUSION: It would appear that with a delay in programming a neck dissection so as to consider ICG in combination with thickness, as in seven recent patients, identification of locoregional occult metastases (pN+) might be more precise.

Adult↗
PubMed1982

Unusual presentation of head and neck neoplasm.

We have a 67-year-old Caucasian male presenting with a (T4, N1b, Mo) Stage III squamous cell carcinoma of the larynx. He subsequently underwent a total laryngectomy and right radical neck dissection. It was only determined by the pathology report that the cervical nodes in the neck specimen obtained the associated disease, Hodgkin's (mixed cellular lymphoma), rather than the expected well differentiated squamous cell carcinoma found in the larynx. Metastatic work-up was unrevealing. Reviewing the English literature fails to reveal a similar case report of squamous cell carcinoma of the larynx with Hodgkin's disease in the associated neck dissection. It was unfortunate that this patient died of a third pathology, cerebral hemorrhage, in the immediate post-op period.

Aged↗
PubMed2004

Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes.

OBJECTIVE: To determine the incidence of clinically positive lateral cervical nodes at presentation and after initial treatment in patients with well-differentiated thyroid cancer. DESIGN: Retrospective chart review. SETTING: University-affiliated teaching hospitals. PATIENTS: A total of 508 patients who underwent a thyroidectomy as part of their initial treatment for well-differentiated thyroid carcinoma between January 1978 and December 1999. Neck dissections were performed only for clinically palpable cervical nodes. MAIN OUTCOME MEASURES: Recurrence in the neck and survival. RESULTS: Forty-four patients (9%) had palpable lateral cervical lymph nodes at the time of surgery. All 31 patients younger than 45 years presenting with palpable positive nodes are alive and free of disease; 4 of 13 patients 45 years or older have died of thyroid cancer. Only 16 (3%) of 464 patients who did not undergo initial neck dissection had recurrence in lateral cervical nodes. Recurrence is more likely when the initial tumor is larger than 4 cm. In 216 patients younger than 45 years, there were 5 (2%) recurrences in lateral cervical nodes; these patients remain alive and free of disease. In 248 patients 45 years or older, there were 11 (4%) with recurrent disease in the lateral neck; 4 of these patients have died of thyroid cancer. CONCLUSIONS: An aggressive approach to detecting and treating occult lateral cervical nodes by techniques such as jugular node sampling, sentinel node biopsy, or image-guided needle biopsy is not necessary in most patients. Attempts to detect and remove occult lateral cervical lymph node metastases might be considered in older patients with large primary tumors.

Adult↗
PubMedDate not supplied

Surgical experience in children with differentiated thyroid carcinoma.

BACKGROUND: The optimal surgical treatment in children with well-differentiated thyroid carcinoma remains an important point of discussion. In this study, we evaluated our surgical experience and reviewed the literature accordingly to identify the most adequate treatment. METHODS: We retrospectively analyzed 21 children, all under the age of 18 years at the time of diagnosis, with differentiated thyroid carcinoma (17 papillary, 3 follicular, and 1 Hürthle cell carcinoma). Total thyroidectomy was performed, followed by radioiodine therapy, as a part of the initial treatment in all patients. The results were compared with data from the literature. RESULTS: Eleven children (52%) who presented with cervical lymph node metastases were treated by a modified radical neck dissection. Pulmonary metastases were seen at diagnosis in three patients. Six patients developed temporary complications. During follow-up, with a median of 11 years (range, 2-26 years), two patients (10%) developed recurrences, and no patient died during this observation period. A literature search confirmed our experience of excellent results without an increase of complications in the more aggressively treated patients. CONCLUSIONS: In children with differentiated thyroid cancer, treatment should consist of total thyroidectomy, followed by a modified radical neck dissection (when indicated) and iodine-131 ablation treatment. This aggressive approach seems to be justified because of the high incidence of nodal involvement and the low complication and recurrence rate after surgery.

Adolescent↗
PubMed1999

[Pathologic feature of occult lymphatic metastasis in supraglottic carcinoma].

OBJECTIVE: To study the pathologic features of occult lymphatic metastasis in patients with supraglottic carcinoma and its implication in treatment. METHODS: Serial sections of 153 neck dissection specimens in 100 patients with supraglottic carcinoma were studied under microscope. RESULTS: Clinically negative nodes had been proved histologically positive in 58 specimens (38%) and 51 occult nodes, size ranged from 0.5 cm to 2.6 cm with average of 1.1 cm. The distribution of metastastic lymph nodes was 1 in level I (2%), 37 in level II (73%), 12 in level III(23%) and 1 in level IV(2%). Among the 51 nodes, 21(41%) were in early stage, 18 (35%) in growth stage, 7(14%) in full stage, 5(10%) were extracapsular. CONCLUSION: Occult metastasis rate of supraglottic carcinoma is as high as 38%, selective neck dissection is recommended for the surgical treatment of this disease.

Adult↗
PubMed2002

Intraoperative electromyography for identification of the trapezius muscle innervation: clinical proof of a new anatomical concept.

OBJECTIVE/HYPOTHESIS: There is still considerable controversy among surgeons on trapezius muscle innervation. In addition, the rate of unexpected postoperative trapezius pareses is unacceptably high. Recent anatomical findings might answer most of the questions. The objective of the present study was to clinically prove the recent anatomical findings, especially the concept of the innervation of the descending part of the trapezius muscle. STUDY DESIGN: Intraoperative electromyography of the spinal accessory nerve and its branches in the posterior triangle of the neck. SETTING: Intraoperative electromyography was performed during 17 modified radical neck dissections on 14 patients of both sexes ranging in age from 44 to 68 years (mean age, 56 y). Potentials were registered through pairs of needle electrodes placed in each of the three parts of the trapezius muscle. Intraoperatively, the spinal accessory nerve and its fine cranial branch passing toward the descending part of the muscle were identified and stimulated in the posterior triangle of the neck.RESULTS Stimulation of the fine cranial branch of the spinal accessory nerve led to a clearly visible and recordable contraction in the descending part of the trapezius muscle in all patients. Stimulation of the main trunk of the spinal accessory nerve in the posterior triangle of the neck distal to the above-mentioned branching led to a clearly visible and recordable contraction in the transverse and ascending parts of the muscle. CONCLUSIONS: The results strongly support recent anatomical findings showing that, functionally, the most important descending part of the trapezius muscle is innervated by a fine single branch arising from the spinal accessory nerve in the posterior triangle of the neck. This may help to prevent more patients undergoing modified radical neck dissections from shoulder-arm syndrome.

Accessory Nerve↗
PubMed2004

Cervical lymph node metastases of squamous cell carcinoma from an unknown primary.

Cervical lymph node metastases of squamous cell carcinoma from occult primary constitute about 2-5% of all patients with carcinoma of unknown primary site (CUP). Metastases in the upper and middle neck are generally attributed to head and neck cancers, whereas the lower neck (supraclavicular area) involvement is often associated with primary malignancies below the clavicles. The diagnostic procedures include physical examination with thorough evaluation of the head and neck mucosa using fiber-optic endoscopy, biopsies from all suspicious sites or blindly from the sites of possible origin of the primary, computer tomography and/or magnetic resonance. A systematic tonsillectomy in the absence of suspicious lesions is often recommended since up to 25% of primary tumors can be detected in this site. The thoracic primary (tracheal, bronchial, lung, esophagus) has to be excluded, especially in the case of lower neck involvement. Positron emission tomography (PET) with fluoro-2-deoxy-D-glucose allows detection of primary tumor in about 25% of cases, but this procedure is still considered investigational. Therapeutic approaches include surgery (lymph node excision or neck dissection), with or without postoperative radiotherapy, radiotherapy alone and radiotherapy followed by surgery. In early stages (N1), neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases (N2, N3) necessitate combined approaches. The extent of radiotherapy (irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy) remains debatable. A potential benefit from extensive radiotherapy should be weighted against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence. The role of other methods, such as chemotherapy and hyperthermia, remains to be determined.

Carcinoma, Squamous Cell↗
PubMed1990

New operative strategy in the treatment of metastasizing medullary carcinoma of the thyroid.

Medullary carcinoma of the thyroid (MTC) is exceptional in that the hormone calcitonin produced by the tumor cells represents a specific and sensitive tumor marker. Careful screening by serial calcitonin determinations following pentagastrin stimulation allows for the early detection of metastatic disease. We have adopted a method of meticulous modified radical neck dissection to eradicate persistent or recurrent MCT in 11 patients treated over a 15-month period. This surgical approach resulted in potentially curative treatment in two patients. Effective tumor reduction was achieved in another seven. Two patients have persistent or progressive disease despite maximum efforts to eradicate malignant tissue. Follow-up is presently incomplete in one patient. Postoperative complications included recurrent nerve paralysis (n = 3), hypoparathyroidism (n = 2), muscular weakness (n = 2) and Horner's syndrome (n = 3). The majority of nervous complications improved spontaneously. It is concluded that the adopted method of meticulous modified radical neck dissection offers the chance of cure to some patients and results in the removal of substantial tumor mass in the majority of others. Postoperative problems are mostly temporary and are deemed acceptable.

Adult↗