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PubMed1997

Prognostic significance of lymph node reactivity in the control of pathologic negative node squamous cell carcinomas of the oral cavity.

BACKGROUND: Identification of high-risk patients and defining prognostic factors may be useful in the treatment of head and neck cancer. The role of the lymph node reactivity is still obscure. The value of the node reactivity pattern as a predictor of tumor control in oral cavity cancer was analyzed. METHODS: Retrospective analysis of patients with oral cavity squamous cell carcinoma (OCSCC), submitted to tumor resection and neck dissection, with pathologic negative lymph nodes (pN0). Dominant node reactivity pattern was defined as lymphocytic predominance (LP), germinal centers (GC), normal (NL), sinus hystiocytosis (SH), and lymphocytic depletion (LD). Clinical and pathological characteristics of patients free of disease (DF) were compared with those of patients with control failure (CF), which included local, regional, and distant recurrences. RESULTS: Of the 26 patients with pN0 OCSCC, prevalence of SH was found in 10 cases, GC in 13, and LD, NL and PL in 1 case each. Comparing CF and DF groups, there was no significant statistical difference regarding: age, gender, performance status index, weight loss, smoking and drinking habits, complementary treatment, average follow-up, tumor grade or thickness, margins, or tumor inflammatory and desmoplastic reaction. Although there was a higher proportion of perineural invasion and larger tumors in the CF group, the difference was not statistically significant either. Germinal centers or LP were noted in only 27% of the CF group and in 73% of the DF group. Collectively, NL, SH, or LD patterns were observed in 73% of CF. This incidence was statistically different from 27% of the DF group (P <0.05). CONCLUSIONS: Lymph node reactivity pattern seems to be a prognostic index in pN0 OCSCC patients. Prospective analysis is advised to confirm these results. Prophylactic neck dissection as a staging procedure could select high-risk patients even when no metastasis is found.

Carcinoma, Squamous Cell↗
PubMed1997

[Lymphoscintigraphy with double tracer technique in carcinomas of the head-neck region].

BACKGROUND: Lymphoscintigraphy has been used since the early 1960s to demonstrate lymphatic drainage of head and neck tumors, but did not prove satisfactory. With the increasing importance of highly sophisticated neck dissection procedures, lymphoscintigraphy may have greater diagnostic impact. This assumes that lymphoscintigraphy will allow an accurate correlation of lymphatic drainage with anatomic structures. In this paper, we report on a method of lymphoscintigraphy with simultaneous body contouring. METHODS: Double-tracer lymphoscintigraphy was performed in 78 patients with squamous cell carcinoma. Patients received 100 MBq 99mTc-colloid in 0.1-0.2 ml in 3-4 peritumoral localizations. Ten patients were injected during surgery. Two milliliters of perchlorate solution were given orally in order to block the thyroid. Twenty minutes later patients received 50 MBq 99mTc-pertechnetate i.v. for body contouring. Planar images were obtained over 5 min each at 30 min and 4-6 h after injection from anterior, right lateral and left lateral using a LFOV-gamma camera. RESULTS: The thyroid was not visualized in any of the patients. In 28 of 78 patients (36%), the injection site was the only focal activity seen. In 50 of 78 patients (64%), lymph drainage was observed. Thirty-six of 78 patients (46%) showed unilateral lymphatic drainage, and 14 of 78 (18%) showed bilateral drainage. In all 50 patients showing lymphatic drainage, lymph nodes could be easily assigned to the six cervical lymph node compartments described. CONCLUSIONS: Double-tracer lymphoscintigraphy enables an accurate correlation of cervical lymph nodes and anatomic structures of the head and neck region. These findings suggest that the impact of these studies on the preoperative planning for neck dissection should be reevaluated.

Adult↗
PubMed1998

Management of the neck in patients with head and neck cancer treated by concurrent chemotherapy and radiation.

The current high level of interest in organ preservation strategies for patients with advanced squamous cell carcinoma of the head and neck undoubtedly will result in increasing numbers of patients managed initially with chemotherapy and radiation, either sequentially or concurrently. In some protocols, surgery, and neck dissection in particular, will either be mandatory or offered based on the degree of response to treatment and initial stage of neck disease. Head and neck oncologic surgeons need to be involved and at the forefront of such trials, to allow meaningful data regarding pathologic response to treatment to be obtained, as well as to define the role of surgery in such patients. Although present data is limited, it would appear that in patients achieving a complete response to chemoradiation, the role of neck dissection may be more limited than in the past, even for patients with N2 to N3 neck disease at presentation. Surgical complications may be increased in this heavily treated patient population, and subsequent surgery should be designed to minimize the risk of wound complications, especially if performed before the patient has made a full recovery from the metabolic and immunologic derangements associated with chemoradiation. Head and neck surgeons need to play an active role in the design and conduct of chemoradiation trials so that these and other relevant questions will be answered by the data generated.

Antineoplastic Agents↗
PubMed2003

T1-T2 NO oropharyngeal cancers treated with surgery alone. A GETTEC study.

The aim of this study is to show that surgical treatment of early-stage squamous cell carcinomas of the oropharynx gives identical, if not better, oncological results than the classic radiotherapy treatment in terms of locoregional control and survival. Fifty-three patients (32 T1, 21 T2, all N0) were operated on during the years 1995-2000. Surgical treatment consisted in a resection by the transoral approach in 43 patients (81.13%); ten patients (18.87%) benefited from a pharyngectomy with (seven) or without (three) mandibular resection. A level I to V selective neck dissection was performed on 35 patients, and 5 patients underwent a level II to V selective neck dissection. The 1-, 3- and 5-year overall survival rates were 100, 94.6 and 73%, respectively. There was no significant difference concerning the tumor stage ( P=0.69), the initial localization ( P=0.64), the macroscopic aspect ( P=0.65) and the management undertaken in the different centers ( P=0.19). The 5-year rate of specific survival was 100%. The 1-, 3- and 5-year locoregional control rates were 96.22, 92.45 and 88.68, respectively. The oncological occurrences observed were 2 persistent diseases, 5 local recurrences, 11 second primary cancers and 0 nodal recurrences. Seven local failures were observed, all of which were controlled after a second treatment. Eleven patients presented second primary cancers; three died, two are alive with an extension of this second localization, and six are alive and free of disease. The locoregional control provided by surgery alone on T1-T2 N0 oropharyngeal cancers is as good as radiotherapy. Moreover surgery alone makes it possible to spare patients the complications and aftereffects of radiotherapy. It also makes it possible during the recurrences to operate on patients in non-irradiated areas with lower morbidity and mortality. It is all the more beneficial since it will be possible to resort to radiotherapy after surgery if need be.

Carcinoma, Squamous Cell↗
PubMed1989

Chondrosarcoma of the epiglottis with regional and distant metastasis.

Chondrosarcoma of the epiglottis is extremely rare and there are no previously reported cases of this neoplasm with regional or distant metastases. The first case of this entity and its histopathologic considerations are presented. Accurate grading of this malignancy is essential, since a more poorly differentiated pathologic condition in these tumors indicates aggressive biologic properties consequently leading to frequent local recurrences and metastasis. This is evident in the present case in which, despite being free of local or regional recurrence for 3 years following a supraglottic laryngectomy and bilateral neck dissections, the patient developed pulmonary metastases. We support the use of conservative laryngeal surgery and modified neck dissections for this disease rather than partial resections or debulking procedures, since the histopathologic condition may not be fully recognized without microscopic analysis.

Chondrosarcoma↗
PubMed1975

Specific features of laryngeal carcinoma involving the anterior commissure and the subglottic region.

The anterior commissure may be a line or an area with the same vertical extension as the vocal cords anteriorly. If it is an area it may laterally be bounded by the "maculae flavae". The subglottic region includes the under surface of the vocal cords corresponding to the mucosa covering the conus elasticus and the mucosa inferiorly to the lower border of the cricoid cartilage. Serial sectioning has proved that the weak spot of the laryngeal framework is the anterior midline as far as early tumor invasion of cartilage and extension of tumor outside the larynx through the cricothyroid membrane is concerned. Despite many unfavorable anatomico-pathological points at this site, radiotherapy gives at least as good results as those reported with conservative (voice conservation) surgery. Primary subglottic carcinomas are rare. In a series of 110 serially sectioned laryngectomy specimens only four were classified as subglottic. These tumors possess specific characteristics: an extensive circumferential growth, cartilage invasion, and spread outside the larynx through the cricothyroid membrane, to trachea or to the hypopharynx. Twenty-four tumors were classified as glottic-subglottic. Three of these invaded the thyroid cartilage and seven spread outside the larynx through the cricothyroid membrane. Vocal cord fixation occurred in all four subglottic and in six of the glottic-subglottic tumors. The thyroarytenoid muscle was most freqeuntly invaded. Thyroid gland invasion did not occur in any of the subglottic tumors. A metastatic focus of tumor was observed in one lobe of the thyroid in the glottic-subglottic group. Two neck dissections were performed in the subglottic group and one of these contained a metastatic carcinoma. Eleven neck dissections were performed in the glottic-subglottic group and three contained metastatic tumor.

Follow-Up Studies↗
PubMed1987

[Cervical adenopathies of unknown primary site. Apropos of 190 cases].

From 1974 to 1983 a total of 190 patients with metastatic cervical adenopathy from an undetected epidermoid cancer were treated, this group representing 3% of total cervicofacial tumors seen. In half the cases the lymph node had evolved over more than 3 months and measured 6 cm or more. Prognosis was poor (27% survival at 3 years and 19% at 5 years). The presumed primary tumor was detected in 16% of cases and 27% of patients developed distant metastases, whereas the 86 patients treated by neck dissection and irradiation showed cervical evolution in only 23% of cases. The therapy proposed includes total radical neck dissection followed by pharyngeal and bilateral cervical irradiation, the value of chemotherapy remaining to be determined during controlled trials.

Aged↗
PubMed1998

[Marginal branch of the facial nerve in submandibular dissection for T2 lingual carcinomas].

Lingual carcinomas were found in the early stages. However, even with early detection carcinomas may show lymph node metastasis in the neck, and this may play an important role in their outcome. For this reason, neck dissection is the treatment of choice for T2 lingual carcinomas. A surgical technique of submandibular dissection preserving the mandibular branch of the facial nerve has been done in our department for the past 3 years. The effectiveness of this technique was studied by means of histopathological investigations of superficial nodes that were included in fatty tissues together with the mandibular branch. The conclusions are as follows; 1. No lymph node metastasis was observed histopathologically in superficial fatty tissues that contained the mandibular branch in any of the 26 cases of T2 lingual carcinomas. 2. In 8 cases of those 26, lymph node metastasis was found histopathologically in deep submandibular tissues resected during neck dissection. Even in these 8 cases, however, no metastasis was ditected in the superficial lymph nodes. 3. CH40(activated carbon particle) was injected into the lateral surface of the mobile tongue and its uptake into the submandibular lymph nodes were investigated in 10 cases of N(-) head and neck carcinomas. CH40 was detected in none of the superficial lymph node. 4. These results indicate that early lingual carcinomas localizing in the lateral surface of the tongue do not metastasize into the superficial lymph nodes of the submandibular region, and that our surgical technique of submandibular dissection is useful for T2 lingual carcinomas.

Facial Nerve↗
PubMed1988

Recurrence and morbidity in differentiated thyroid carcinoma in children.

The management of differentiated thyroid cancer in childhood is controversial. In particular, the role of aggressive surgical treatment has been questioned. This study was performed to identify those factors that are predictive of recurrence and morbidity following treatment through use of a multivariate model. The records of all patients 17 years of age or less admitted in the last 35 years with histologically confirmed differentiated thyroid carcinoma were reviewed. Data were sufficient for multivariate analysis in 93. The mean age at diagnosis was 13.3 years, and the median period of follow-up was 20 years. Seventy-one percent of the patients had nodal metastases. There were no deaths from thyroid carcinoma in this series, and the overall recurrence rate after initial treatment was 34%. Multivariate analysis demonstrated that only age (p less than or equal to 0.07) and histologic subtype (p less than or equal to 0.01) were predictive of time to recurrence. Major morbidity was a function of age (p less than or equal to 0.007) and extent of thyroid surgery (p less than or equal to 0.01). Probability of minor complications was predicted by use of radical neck dissection (p less than or equal to 0.02). Use of total or subtotal thyroidectomy or of radical neck dissection in children does not prevent recurrence and is associated with an increased risk of complications. We conclude that these procedures should be avoided in pediatric patients.

Adolescent↗
PubMed1993

Carcinoma of buccal mucosa: incidence of regional lymph node involvement.

Histopathological findings in 57 surgical specimens of T3 and T4 buccal mucosa cancers are reviewed. The incidence of the well-differentiated tumours (including verrucous carcinoma) was 61%. A moderate degree of lymphocytic infiltration of the tumour was present in 37% of patients. Histologically proven cervical lymph node deposits were present in only 16% of the patients. Amongst the group of patients with clinically enlarged lymph nodes, metastatic disease was histologically demonstrated in 17.5% at level I and 14% at level II of neck nodes. Amongst group of patients with no palpable nodes in the neck, metastatic disease was histologically demonstrated in 11.7% at level I and 9% at level II of neck nodes. These findings contra-indicate an elective neck dissection and indicate the need to confirm histologically the presence of lymph node deposits doing a radical neck dissection in patients with buccal mucosa cancer. This well-differentiated tumour has a much lower tendency to metastasize than cancers in other sites of the oral cavity.

Cheek↗
PubMed1990

Cervical lymph node metastases--diagnostic, therapeutic, and prognostic implications.

Patients with carcinoma of the upper aerodigestive tract presenting with cervical lymph node metastasis carry a poorer prognosis compared to those in whom the regional lymph nodes are uninvolved. Prognosis worsens as the volume of metastatic cancer in the cervical lymph nodes increases. While the classical treatment for these metastases has been a radical neck dissection, this operation produces significant esthetic and functional morbidity. Radiation therapy alone offers poor results when bulky disease in the neck is present. Fortunately, the combination of surgery and radiation therapy offers significant advantages, not only in terms of reduction of morbidity, but improvement of disease control. The author discusses the current debate over the extent of neck dissection and the advantages of pre- and post-operative radiation.

Humans↗
PubMedDate not supplied

Large visible gas bubbles in the internal jugular vein: a common occurrence during supine radical neck surgery?

STUDY OBJECTIVE: To establish the frequency of large visible bubbles or collections of bubbles in the jugular vein during radical neck dissection in the supine position. DESIGN: Prospective observation by at least two investigators of random consecutive patients scheduled for radical neck surgery. SETTING: Operating room suite in a university hospital specializing in head and neck cancer surgery. PATIENTS: Twelve consecutive ASA physical status II and III patients undergoing modified radical dissection for cancer. INTERVENTIONS: General anesthesia with fentanyl, oxygen (O2) 30% to 40%, nitrous oxide (N2O) 60% to 70%, and isoflurane 0.5% to 1.5%, with mechanical ventilation. Table position horizontal. Modified radical neck dissections performed by attending surgeons. Surgical field (jugular vein) carefully observed by the surgeons and an independent anesthesiologist investigator for the presence of bubbles during the dissection. MEASUREMENTS AND MAIN RESULTS: Easily visible bubbles were observed in the jugular veins of 42% (5 of 12) of the consecutive radical neck dissection patients studied. Some of the collections of bubbles were large (greater than 2.5 cm in diameter). In one case, the appearance and subsequent disappearance of bubbles was followed by a transient drop in arterial blood pressure (BP) and in end-tidal carbon dioxide (PETCO2), which was suggestive of a diagnosis of central venous air embolization. CONCLUSIONS: We theorize that some unexplained, undesirable intraoperative events (hypotension, arrhythmia, and hypoxemia) during radical neck dissection could be a result of venous air embolus or paradoxical air embolus. The anesthesia community should be aware of the high frequency of these visible bubbles in the jugular veins during radical neck surgery, even in the supine position. At minimum, this phenomenon is a frequent event of intellectual interest. At worst, these bubbles may be harbingers of significant central air embolism.

Adult↗
PubMed1991

A model for multidisciplinary data collection for cervical metastasis.

A system for multidisciplinary data collection for metastatic neck disease is discussed. Information from 87 neck dissections and 3218 lymph nodes is reported to illustrate the strength of the model. Clinical (endoscopic) assessment under general anesthesia, surgical assessment during the neck dissection, and radiographic (computed tomographic scan) assessment were compared with the pathological evaluation. All disciplines stratified the necks by region and node size. This model provides an effective stratagem for multi-institutional studies.

Data Collection↗
PubMed2003

Salvage of recurrent head and neck squamous cell carcinoma after primary curative surgery.

PURPOSE: The efficacy of salvage treatment of recurrent head and neck squamous cell carcinomas (HNSCC) after primary curative surgery was evaluated. METHODS: The management outcome of 377 patients who had recurrent squamous cell carcinoma of oral cavity, oropharynx, hypopharynx, and larynx after primary curative surgery was reviewed. RESULTS: The surgical salvage rates of recurrence were 29% local, 30% tracheostomal, 56% unilateral nodal recurrence of previously undissected neck, 32% of unilateral neck recurrence after prior neck dissection, and 11% lung metastasis. The 5-year tumor-free actuarial survival rates of those patients who received surgical salvage was 35% for local recurrence, 32% for unilateral nodal recurrence of the previously undissected neck, and 18% for nodal recurrence of the previously dissected neck. One patient of six with tracheostomal recurrence salvaged with surgery and one patient of six with lung metastasis salvaged with lobectomy survived without tumor at 5 years. There was no 5-year survivor of all patients salvaged with other nonsurgical methods. The mean survival of patients without surgical salvage was 6 months. CONCLUSIONS: There was a moderate chance of cure after surgical salvage of locoregional recurrent HNSCC. Surgical salvage was, however, only feasible for early recurrent tumor. Close follow-up surveillance of early recurrence is essential after primary treatment of patients.

Adolescent↗
PubMed2006

Complications in head and neck surgery: a meta-analysis of postlaryngectomy pharyngocutaneous fistula.

OBJECTIVE: To summarize the potential risk factors for postlaryngectomy pharyngocutaneous fistula. DATA SOURCES: Observational studies in the English-language literature about postlaryngectomy pharyngocutaneous fistula from January 1, 1970, to March 31, 2003. Studies were identified through a MEDLINE search with relevant key words; additional studies were identified through references. STUDY SELECTION: We included studies about the site of primary malignancy, type of procedure, and type of closure; studies had to have been based on individual-level data, with a comparison group for each risk factor evaluated. DATA EXTRACTION: Data required to calculate the relative risk of fistula associated with commonly reported risk factors were abstracted from the studies, and a meta-analysis using a random-effects approach was performed to estimate a summary relative risk of fistula for each risk factor. The statistical significance of heterogeneity of effects among studies was assessed. DATA SYNTHESIS: Of 65 studies identified, 26 met the inclusion criteria. Significant risk factors identified in the pooled analysis included postoperative hemoglobin level less than 12.5 g/dL, prior tracheotomy, preoperative radiotherapy, and preoperative radiotherapy and concurrent neck dissection. The degree of heterogeneity of effects among studies was significant for postoperative hemoglobin level, preoperative radiotherapy, concurrent neck dissection, and comorbid illness. The severity of fistula was greater in patients with a history of radiotherapy. CONCLUSIONS: This meta-analysis identified several significant risk factors for postlaryngectomy pharyngocutaneous fistula. The clinical implications of these findings and the potential sources of heterogeneity of effects among studies are discussed.

Cutaneous Fistula↗
PubMed1995

Outpatient thyroid and parathyroid surgery: a prospective study of feasibility, safety, and costs.

BACKGROUND: The purpose of this study was to determine feasibility, safety, and cost savings of outpatient thyroid and parathyroid surgery. METHODS: Consecutive unselected patients undergoing thyroid and parathyroid operations by two surgeons with a special interest in endocrine surgery were studied prospectively. RESULTS: One-hundred patients underwent operation, 61 as outpatients and 39 as inpatients. Outpatients included those undergoing thyroid lobectomy (39), total thyroidectomy (10), total thyroidectomy with parathyroidectomy (1), total thyroidectomy with modified neck dissection (1), and parathyroidectomy (10). Inpatients included those undergoing thyroid lobectomy (15), total thyroidectomy (8), total thyroidectomy with neck dissection (4), removal of substernal goiter (2), and parathyroidectomy (10). The average age of inpatients was slightly higher than that of outpatients (p < 0.05). Average hospital cost for outpatients was $1991 +/- $279 (range, $1594 to $2783) and for inpatients it was $2875 +/- 615 (range, $2031 to $4216), p < 0.001. Reasons for admission included extent of surgery (6), nausea (5), oversedation (4), urinary retention (2), inadequate home help (6), long travel time (2), patient preference (9), and medical reasons (5). No outpatients subsequently required admission. CONCLUSIONS: Outpatient thyroid and parathyroid surgery can be feasible and safe and resulted in a 30% savings in hospital costs. After extensive operations patients continue to require admission for postanesthetic complications, social reasons, or presence of serious comorbid disease.

Adult↗
PubMed2002

[Recurrent benign tumors of parotid gland: the role of the surgery].

Parotid gland tumor recurrences can prove problematic both in terms of facial nerve trauma during surgery and for the possible transformation into malignancy. Between 1981 and 2001 a total of 40 patients (23 women, 17 men; average age 48; age range 20-79 years) underwent surgery for recurrent parotid gland tumors. The average time between the first and the second surgical procedures was approximately 10 years. Five subjects underwent surgery several times for the same pathology. The Authors feel that MRI imaging is an essential tool for the evaluation of infiltrations into the soft tissues. The following surgical procedures were performed: enucleation in 2 cases; exofacial partial parotidectomy (PP) in 1; lower polar PP with functional neck dissection in 1; total parotidectomy (TP) with preservation of the facial nerve in 31 cases; TP with functional neck dissection in 2; TP with sectioning of the facial nerve in 2 and TP with transmandibular buccopharyngectomy and myocutaneous gran dorsal muscle flap in 1 case. Histology proved positive for the following: pleomorphous adenoma in 21 cases, adenocarcinoma in 11, aggressive fibromatosis in 2, cystadenolymphoma in 1, parotiditis in 1, lipoma in 1, cystic lymphoid hyperplasia in 1, histiofibrosarcoma in 1 and neurofibrosarcoma in 1. The surgical technique used was retrograde dissection of the facial nerve starting from one of the peripheral branches. Post-operatively, whenever a facial paralysis was encountered it proved difficult to recover. Paralysis of the nerve was permanent only in the 2 subjects where sectioning proved necessary because of infiltration by carcinoma. In 6 subjects recovery of the paralysis took one year, in 4 it took 6 months and in 2 other cases 3 months. In 22 cases there was only a slight paralysis of some branches which recovered during the post-operative period. We do not have definitive data on 4 subjects either because the period of time since surgery is still too short or because they did not come in for subsequent check-ups. The results of our study show that total parotidectomy should be the treatment of choice in case of benign parotid gland tumors and in particular for pleomorphic adenoma.

Adult↗
PubMed1998

Can we detect or predict the presence of occult nodal metastases in patients with squamous carcinoma of the oral tongue?

BACKGROUND: When to do a neck dissection as part of the surgical treatment for a patient with squamous carcinoma of the oral tongue is controversial, particularly when the primary can be resected without entering the neck. If the patient who is at high risk for having occult nodal disease in the neck can be identified, node dissection with the glossectomy could be justified. To better identify patients for this procedure, we correlated various tumor and patient factors along with preoperative diagnostic studies with the presence or absence of pathologically positive nodes in a group of patients who underwent node dissection. METHODS: Ninety-one previously untreated patients with biopsy-proved squamous carcinoma of the oral tongue were prospectively studied. All patients had a glossectomy and neck dissection as their initial treatment. The pathology findings (ie, lymph nodes with squamous cancer) were correlated with many preoperative and intraoperative factors, and a statistical analysis was made. RESULTS: The use of computed tomography and ultrasound was not better than the clinical examination in determining the presence or absence of nodal metastases. The best predictors were depth of muscle invasion, double DNA aneuploidy, and histologic differentiation of the tumor. CONCLUSIONS: All patients with stage T2-T4 squamous cancers of the oral tongue should have an elective dissection of the neck. Patients with T1N0 cancer who have a double DNA-aneuploid tumor, depth of muscle invasion > 4 mm, or have a poorly differentiated cancer should definitely undergo elective neck dissection. Ultrasound and computed tomography are of little value in predicting which patients have positive nodes.

Adult↗