The treatment of distant metastases in head and neck cancer--present and future

At the present time the occurrence of distant metastases in patients with head and neck squamous cell carcinoma means that lifespan is measured in months. In most instances treatment is purely palliative. Isolated lung metastasis can be successfully removed with long-term disease control in selected patients. Radiotherapy can be useful for palliation of bone metastases and occasionally lung or brain metastases. Chemotherapy does not have a major impact at the present time except for the treatment of metastases from nasopharyngeal cancer. Palliative symptomatic care, along with appropriate pain control, is essential since pain management is very important in these patients. A significant change in the survival of patients with head and neck cancer is only likely to occur by the development of new approaches to treatment. Blocking tumor angiogenesis and treatment based on genetic abnormalities or cell surface receptors offer the two strategies that are most likely to be successful.

Distant metastases from thyroid and parathyroid cancer

Thyroid cancer represents a unique biological tumor where even with the high incidence of distant metastases, the overall prognosis is not as poor as many other human cancers. The overall long-term survival in patients presenting initially with distant metastasis is approximately 50%. The overall incidence of distant metastases varies between 10 and 35%, depending upon the histology. The overall incidence is directly related to various histologies - being least in papillary thyroid carcinoma (10%) and highest in Hürthle cell tumor (33%). The incidence of distant metastases is also very high in patients with medullary and anaplastic thyroid cancer. The incidence of distant metastases at the time of initial presentation in differentiated thyroid cancer is approximately 4%. In high-risk patients - especially in patients with extrathyroidal extension or massive nodal metastasis - the distant metastases can be evaluated after total thyroidectomy with radioactive iodine ablation. Pulmonary metastases are very common in young individuals, but they are extremely well treated and the mortality from distant metastases in this group is very low. However, distant metastases in patients with poorly-differentiated carcinoma have a poor prognosis. In high-risk patients, generally a total thyroidectomy should be undertaken so that the patient can undergo radioactive iodine dosimetry and ablation as indicated. The surveillance in patients with thyroid cancer includes: close clinical follow-up, chest X-ray, and radioactive iodine dosimetry. Thyroglobulin is commonly used as a prognostic marker in patients having undergone total thyroidectomy. The incidence of distant metastases in medullary thyroid cancer is high, mainly to the lung and liver. Persistent hypercalcitonemia is an indication of regional or distant metastases. A variety of diagnostic tests are helpful, such as octreotide scanning, computed tomography scan, magnetic resonance imaging and positron emission tomography scan. Laparoscopy to evaluate the surface of the liver is also an important investigation to detect distant metastases. The incidence of distant metastases is very high in patients with anaplastic thyroid cancer, but most of the time the outcome depends on the locoregional recurrence and massive disease in the central compartment. The parathyroid cancer is quite rare, less than 1%, in patients undergoing parathyroidectomy. The diagnosis of parathyroid cancer is made by pathological features but the most certain method of diagnosis of a malignant tumor of the parathyroid is the identification of secondary deposits. The incidence of distant metastasis is difficult to determine due to the rarity of this condition, but the most common site is the lung. Patients with distant metastasis have recurrent progressive hypercalcemia along with high parathormone level.

General considerations on distant metastases from head and neck cancer

Mortality in head and neck cancer is due to locoregional disease, distant metastases or intercurrent disease. As treatment of the primary tumor and cervical metastases has improved, the proportion of deaths from co-morbidity and from distant metastases has increased. Distant metastases almost invariably herald a poor prognosis in head and neck cancer with an average survival of 4.3-7.3 months and treatment is usually palliative. Reliable detection is important to prevent inappropriate treatment. The risk is related to the site, stage and histology of the primary tumor and the presence of cervical metastases. Early detection and treatment of cervical metastases may prevent distant metastases. Accurate staging of tumors helps to identify high-risk tumors that should be specifically investigated for distant metastases.

Screening tests to evaluate distant metastases in head and neck cancer

Investigation for distant metastases is part of the staging process of a primary tumor or recurrent disease before treatment. The lung is the most frequent site followed by bone and liver. Advanced stage and cervical metastases are the most important predictors of metastases. Almost all distant metastases are associated with lung metastases. Computed tomography scan of the chest is the single most effective investigation. The value of routine screening tests is questionable and merits further investigation.

Incidence and sites of distant metastases from head and neck cancer

The incidence of distant metastases in head and neck squamous cell carcinoma (SCC) is relatively small in comparison to other malignancies. Distant metastases adversely impact survival and may significantly affect treatment planning. The incidence of distant metastases is influenced by location of the primary tumor, initial T and N stage of the neoplasm, and the presence or absence of regional control above the clavicle. Patients with advanced nodal disease have a high incidence of distant metastases, particularly in the presence of jugular vein invasion or extensive soft tissue disease in the neck. Primary tumors of advanced T stages in the hypopharynx, oropharynx and oral cavity are associated with the highest incidence of distant metastases. Pulmonary metastases are the most frequent in SCC, accounting for 66% of distant metastases. It may be difficult to distinguish pulmonary metastasis from a new primary tumor, particularly if solitary. Other metastatic sites include bone (22%), liver (10%), skin, mediastinum and bone marrow. An important question remains as to how intensely pre- and postoperative screening for distant metastases should be performed. Preoperative chest X-ray is warranted in all cases. If the primary tumor and nodal status place the patient at high risk for pulmonary metastasis, then preoperative computed tomography scan of the chest should be done. Screening for distant metastases at other sites is usually not indicated in SCC of the upper aerodigestive tract. Postoperatively, annual X-rays of the chest are usually sufficient, but in high-risk situations a chest X-ray performed every 3-6 months may be beneficial. Certain histologic types of primary tumor have greater or lesser propensity to metastasize distantly, and have a different natural history. Adenoid cystic carcinoma metastasizes frequently, even in the absence of extensive local or regional disease. Basaloid squamous cell carcinoma and neuroendocrine carcinomas also metastasize widely. Extensive evaluation for distant metastases is justified for these tumors. Knowledge of the natural history of various neoplasms and the factors that contribute to distant metastases as well as good judgement are essential for cost-effective treatment planning and decision-making with regard to pre- and postoperative evaluation for distant metastases in cancer of the head and neck.

The sentinel node procedure with Patent Blue V dye in the surgical treatment of papillary thyroid carcinoma

How far to extend the surgical treatment of papillary thyroid carcinoma (PTC) is still an open question. A contribution may come from intra-operative lymphatic mapping because, in other malignancies, the procedure has become an important aid in defining lymph node status. To assess the feasibility of using the sentinel lymph node (SLN) technique with the intratumoral injection of Patent Blue V dye to guide nodal dissection in PTC, 29 patients with a preoperative diagnosis of PTC and no clinical or ultrasonographic evidence of nodal involvement underwent cervicotomy and exposure of the thyroid gland, followed by Patent Blue V dye injection into the thyroid nodule. Total thyroidectomy was subsequently performed, resecting the lymph nodes at levels III, IV, VI and VII. The thyroid, SLN and the other lymph nodes were snap-frozen and submitted for both intra-operative and subsequent definitive pathological evaluation. Intra-operative lymphatic mapping located the SLN in 22/29 patients (75.9%) and the SLN revealed neoplastic involvement in 4/22 (18.2%); other lymph nodes were also positive in 2 cases. In the 18 patients whose SLNs were not metastatic, the other nodes were also disease-free. The SLN technique thus seems helpful in avoiding unnecessary lymph node dissection in PTC without spread to the SLN.

Surgical management of the neck in thyroid cancer

Thyroid cancer is a relatively common clinical problem. The American Cancer Society has estimated 1,050,000 newly diagnosed cancers in 1999 in the United States, of which 16,000 are expected to be of thyroid origin. Although most thyroid cancers have an excellent prognosis as compared with other malignant tumors, it is estimated that approximately 1,225 deaths will be attributed to the disease [1].

The pathology and clinical features of "glue ear": a review

The clinical entity known as "glue ear" is synonymous with mucoid otitis media and represents the most common cause of hearing loss in children. This review considers the current state of our knowledge of mucoid otitis media, discussing definition and terminology, pathology, etiology and microbiology, clinical features, differential diagnosis and treatment.

What is the incidence of occult metastasis in patients with stage N(0) cancers of the head and neck?

There is a large body of evidence in the European and US literature which argues forcefully that the presence of metastatic deposits within cervical lymph nodes is the single most significant independent adverse prognostic factor in patients with squamous-cell carcinomas of the head and neck. When all head and neck cancers are considered, ipsilateral lymph node metastases appear to decrease patient survival by as much as 50%; moreover, the presence of contralateral or bilateral cervical metastases reduces prognosis by an additional 50%. Patients with cervical metastases seem to be more likely to develop both distant metastases and local recurrences at the primary site.

The pathology and management of subglottic cancer

Because there is still considerable controversy concerning the anatomical boundaries separating the three regions of the larynx, cancer of the subglottis remains difficult to manage. We have reviewed the numerous differences in the anatomical definitions used in the literature and the consequent differences in reported findings on the incidence of subglottic cancer and its classification. We have also summarized the pathology of subglottic malignant neoplastic lesions, their presenting symptoms and tendency for spread, and the use of imaging methods in its diagnosis. Suitable forms of treatment are discussed, as are considerations on prognosis.

Is extended selective supraomohyoid neck dissection indicated for treatment of oral cancer with clinically negative neck?

Oral cavity tumors may develop occult metastases to the cervical lymph nodes. Current imaging techniques and routine histopathologic methods may fail to detect lymph node micrometastases, but the surgeon has to electively dissect a neck at risk of developing clinical disease. Supraomohyoid neck dissection has been the elective surgery for treating a clinically negative neck in patients with oral cavity primaries. A literature review revealed that level IV nodes can be significantly affected by occult disease with and without metastases in level I-III lymph nodes. This means that level IV nodes have to be included in the supraomohyoid neck dissection, resulting in a more extensive surgical procedure to ensure a margin of oncological safety.