Safety and Efficacy of Primary Tracheoesophageal Puncture and Prosthesis Fit

Objectives:

Compare the safety and efficacy of primary tracheoesophageal puncture (TEP) and prosthesis fit with traditional methods, such as secondary TEP or primary TEP with catheter stenting (secondary fit).

Methods:

Retrospective cohort study of patients who underwent total laryngectomy with TEP between 2009 and 2013. Voice outcome was assessed as voice production at the first postoperative appointment and TEP usage at 6 months and 1 year following puncture. Perioperative emergency department visits, pharyngocutaneous fistula (PCF), and stomal breakdown were analyzed.

Results:

Ninety patients were included. Seventy-three had primary TEPs, of which 32 were catheter stented and 41 were fitted primarily. The remainder (17) had secondary TEPs, of which 8 were primarily fit. Patients with primary fittings were less likely to come to the emergency department postoperatively (14% vs 39%, P < .01). PCF rate (9.3% vs 9.7%, P = .95) and stomal breakdown rate (12.2% vs 9.3%, P = .7) were similar between primary vs secondary fit. There was no difference in PCF or stomal breakdown rates between primary and secondary punctures. Among patients with primary punctures, primary fit patients trended toward higher initial voice success compared with secondary fit patients (87% vs 78%, P = .3). At 6 months and 12 months after surgery, primary fit patients also tended toward higher rates of TEP usage (6 m: 83% vs 61%, P = .1; 12 m: 92% vs 73%, P = .17).

Conclusions:

Primary TEP with primary fit represents a safe and effective approach to vocal rehabilitation following total laryngectomy.

Outcomes and Complications of Locally Advanced Sinonasal Malignancies Treated with Open and Endoscopic Resections

Objectives:

(1) Compare outcomes of patients with sinonasal malignancies (SNM) treated with an open resection to patients treated with an exclusively endoscopic or endoscopic-assisted approach. (2) Analyze the differences in surgical complications, length of hospital stay, and margin status between open and endoscopic approaches.

Methods:

A retrospective review was performed on 102 patients with a pathologically diagnosed T3 or T4 SNM treated definitively at a tertiary care academic center from 1995 to 2012. Oncologic outcomes were determined.

Results:

Of the 102 patients, 29 presented with T3 disease while 73 presented with T4 disease. The most common histologic subtype was squamous cell carcinoma (56.9%). Fifty-three patients (52.0%) underwent open resection while 26 (25.5%) underwent an endoscopic or endoscopic-assisted resection. The 5- and 10-year disease-specific survival (DSS) for the 2 surgically treated groups was 67.6% and 65.2%, respectively. There was no significant difference between patients treated with open resection and patients treated with endoscopic resection in overall survival ( P = .98) or DSS ( P = .15). There was no significant difference between the groups with regard to length of stay (median for both = 5 days, P = .39) or margin status ( P = .42). The endoscopic surgery group had significantly more cerebrospinal fluid (CSF) leaks than the open surgery group (42% vs 6%, P < .001).

Conclusions:

Endoscopic and endoscopic-assisted resection of locally advanced SNM in the appropriately selected patient results in similar long-term oncologic control as open resection. There may be a higher rate of CSF leaks during endoscopic resections that contributes to hospital stays similar to those after open resections.

Solitary dural metastasis at presentation in a patient with untreated human papillomavirus-associated squamous cell carcinoma of the oropharynx

BACKGROUND

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (SCC) is associated with high cure rates and distant metastases are rare.

METHODS AND RESULTS

We report a case of a 61-year-old man presenting with acute left-sided weakness. An enhancing dural mass was noted and resected. Histology revealed p16-positive SCC. Further workup revealed a p16-positive right tonsillar primary with ipsilateral nodal disease and was classified as T2N2bM1. The patient underwent whole brain irradiation and definitive chemoradiation with curative intent. Complete clinical response was achieved and the patient continues to be disease-free 6 months posttreatment.

CONCLUSION

HPV-associated oligometastatic oropharyngeal SCC is a rare entity that may have a unique natural history and behavior. Given the excellent treatment response and prognosis of HPV-positive disease in general, these patients may be appropriate for definitive treatment approaches.

Anaplastic thyroid cancer in young patients: a contemporary review

PURPOSE

Little is known about prognostic factors and treatment outcomes in young patients with anaplastic thyroid cancer (ATC). The goal of this study is to define the clinical features of this subgroup.

MATERIAL AND METHODS

Patients age 55 or younger with either ATC or well-differentiated thyroid cancer (WDTC) with anaplastic changes were identified using electronic medical record at the Cleveland Clinic. The same number of patients older than 55 was randomly selected to serve as control. Progression-free survival (PFS), overall survival time (OST) and cause-specific mortality (CSM) were measured against age, tumor histology, extent of disease, and treatment modalities.

RESULTS

Twelve patients age 55 or younger were identified. The median age was 51 years. Four patients had WDTC with anaplastic components--mixed tumor group (MTG). Their median PFS, OST, and CSM at 24 months were 21.5 months, 51 months, and 25%, respectively. For the other 8 patients who had pure ATC, their median PFS, OST, and CSM were 3.5 months, 6 months, and 100%, respectively. Patients in the MTG had better survival compared to the pure ATC and control group in terms of PFS (p = 0.0047 and p = 0.0053), OST (p = 0.0028 and p = 0.0029) and the CSM at 24 months (p = 0.0339 and p = 0.0096). In the pure ATC group, patients with positive cervical lymph node and distant metastases had similar overall survival outcomes (6 vs. 8 months, p = 0.4995).

CONCLUSION

Prognostic factors favoring survival in young patients with ATC include ATC arising within WDTC. Once full anaplastic transformation occurs, age was not a significant factor in survival.

Salvage laryngectomy in patients with recurrent laryngeal cancer in the setting of nonoperative treatment failure

OBJECTIVE

To investigate the effectiveness of salvage partial and total laryngectomy in the treatment of recurrent laryngeal cancer in the setting of initial nonoperative treatment failure and to identify factors influencing long-term survival.

STUDY DESIGN

Case series with planned chart review.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Patients with recurrent squamous cell carcinoma of the larynx initially treated with either radiation or chemoradiation, who underwent salvage laryngectomy at the Cleveland Clinic Foundation from 1997 to 2011, were identified. The cohort was divided into an early-stage group and an advanced-stage group based on initial tumor staging. Survival outcome was evaluated separately in each group against tumor staging, methods of treatment, and nodal status. Secondary endpoints of speech and swallowing were also evaluated.

RESULTS

A total of 100 patients were identified, with 72 patients in the early-stage group and 28 patients in the advanced-stage group. The overall postsalvage locoregional control rate was 70%, and the 5-year disease-specific survival was 70% and 55.2% in the early and advanced group, respectively (P = .39). The 5-year disease-specific survival was not significant in either group when compared with recurrent staging, initial treatment, salvage treatment, or nodal disease (P = ns). Using voice prostheses, good to excellent speech function was achieved postoperatively in most patients.

CONCLUSION

Tumor staging, methods of initial and salvage treatment, and nodal disease were not significant predictors of survival. Both salvage partial and total laryngectomy were effective methods in the treatment of recurrent laryngeal cancer in carefully selected patients.

Salvage Laryngectomy Outcomes in Recurrent Laryngeal Cancer

Objective: To investigate the effectiveness of salvage partial laryngectomy (PL) and total laryngectomy (TL) in the treatment of recurrent laryngeal cancer in terms of disease control, postoperative course, survival, and functional outcomes, and to identify additional factors influencing the long-term survival and disease recurrence in patients receiving salvage laryngectomy.

Method: Retrospective chart review of patients with recurrent squamous cell carcinoma (SCC) of the larynx receiving salvage laryngectomy at Cleveland Clinic from 1997 to 2011. Disease-specific survival (DSS), overall survival (OS), functional outcomes, recurrence rate, and postoperative course were evaluated against the methods of primary site and neck treatment.

Results: The series is composed of 109 patients. The 5-year DSS and 5-year OS rates were 70.2% and 62.9%, respectively. Laryngeal preservation rate after PL was 80%, with 34% overall complication rate for all patients. No significant differences were noted in 5-year OS ( P = .3241), postsalvage recurrence rate ( P = .3374), postoperative course, or functional outcomes between salvage TL and PL. Five-year DSS was higher in the PL group ( P = .0309). Primary tumor location, presalvage treatment, initial/recurrent T-staging, and neck dissection were not significant predictors of survival or recurrence ( P = NS), but positive nodal disease ( P = .0320), rN-staging ( P = .0474), and postsalvage recurrence ( P < .0001) were predictors of worse prognosis.

Conclusion: Salvage PL and TL are both effective procedures in treatment of recurrent laryngeal cancer after treatment failure, with similar efficacy in disease control, survival, functional outcomes, and complication rate in highly selected patients.

Improved Outcomes in Primary Prosthesis Placement during Tracheoesophageal Puncture

Objective: Tracheoesophageal prosthesis facilitates esophageal speech in postlaryngectomy patients. The vocal prosthesis can be placed either during tracheoesophageal puncture (TEP) or, more commonly, in a delayed fashion. Our objectives were to: 1) analyze the voice outcomes and 2) compare the pain and emergency care, following primary versus delayed prosthesis placement.

Method: A 2011 cohort study. A tracheoesophageal puncture occurred in conjunction with, or within 3 months of, total laryngectomy. Nine patients underwent primary and 11 patients underwent delayed prosthesis placement. The primary outcome was voice production at the first postoperative appointment. Secondary outcomes included pain and perioperative emergency room visits.

Results: All patients (100%) with prostheses placed at the time of the TEP had voice production at the first postoperative clinic visit, in comparison to only 45% (5/11) of patients with prostheses placed in delayed fashion. Significant pain with vocalization occurred in zero primary placement prosthesis patients, but in 55% (6/11) of delayed placement prosthesis patients. Only one primary placement prosthesis patient (11%) sought emergency medical care related to their stoma or voice prosthesis versus 7 (64%) delayed placement prosthesis patients.

Conclusion: Primary prosthesis placement during TEP has significantly improved voice and quality of life outcomes with earlier voice production, reduced postoperative pain and the virtual elimination of perioperative emergency room visits. This significant modification of the standard technique represents a highly successful and cost-effective approach to vocal rehabilitation in post-laryngectomy patients.

Preoperative Testing for Radial Forearm Free Flaps

Objective: Determine whether Doppler ultrasound (DUS) is a necessary preoperative test for all patients undergoing radial forearm free flaps (RFFF) or if it can safely be omitted in patients with a normal clinical Allen test (CAT).

Method: Retrospective analysis of 143 consecutive patients who underwent RFFF at Vanderbilt University Medical Center between 1992 and 2006. Charts were reviewed for the Allen test, Doppler ultrasound, intraoperative vascular findings, and clinical outcomes. Data were recorded in a Redcap Database and statistical analysis performed by the Vanderbilt Department of Biostatistics.

Results: Ninety percent of DUS and 92% of CAT were normal. The relationship between DUS and CAT was statistically significant. For patients with sufficient flow on CAT, 98% were in agreement with the SAT. Of the 3 patients with insufficient flow intraoperatively, 2 had documented normal CAT and DUS. Two patients developed hand ischemia. Both had normal CAT and no preoperative DUS. One hundred percent of abnormal DUS were abnormal by CAT.

Conclusion: Postoperative RFFF hand ischemia is an extremely rare condition, but it does cause significant postoperative morbidity. DUS testing highly correlates with the findings of CAT and does not appear to be superior in predicting intraoperative findings or postoperative complications. DUS should be limited to patients who have an abnormal CAT.

Economic Aspects of Head and Neck Oncologic Surgery: Implications for the Head and Neck Surgeon Now and in the Future

Program Description: Although head and neck oncologic surgery (HNOS) is time consuming, requires an effective team, and needs allotment of precious resources, financial compensation for the surgeon is relatively low so that financial inducements for a surgeon to do HNOS are diminishing. However, HNOS can generate significant revenue for a hospital. This miniseminar provides information about costs, revenue, profit/ loss analysis of many aspects of HNOS. Parameters pertaining to HNOS that will be defined and discussed include the following: relative value units (RVU’s) contribution margins, case mix index, allocated expenses, opportunity costs, comparative profitability of various different treatment modalities, and the impact of diminishing reimbursements. In addition we will explain the ways that an otolaryngology department can utilize hospital financial data to justify the commitment of the varied resources that are needed to do major HNOS cases and to safely take care of the patients following surgery. In addition, we will discuss the mandate from the Residency Review Committee that requires residency programs to provide experience for residents with HNOS index cases. We will discuss how to prepare financial data, economic projections, and a business plan in a way that is both comprehensible to hospital financial planners and sufficiently compelling to warrant the commitment of resources that is likely to enable a HNOS program to become vibrant and grow. Examples of successful efforts to garner hospital resources for HNOS will be provided. Risk management will be considered in an analysis of safety issues inherent in doing HNOS and providing postoperative care for patients with advanced disease. We will discuss the need to report outcome data to such external data repositories and agencies such as University Healthsystems Consortium (UHC), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the US Department of Health and Human Services. Finally, we will discuss how imminent health care reform measures are likely to impact financial aspects of doing HNOS within the next few years including Accountable Care organizations and Health Innovation Zones.

Educational Objectives: 1) Understand how to obtain and interpret hospital financial data that is pertinent for HNOS. 2) Discuss how imminent health care reform measures may impact financial aspects of doing HNOS. 3) Understand the constraints for academic success for a head and neck oncologic surgeon.

Insulin-like growth factor-1 receptor inhibitor, AMG-479, in cetuximab-refractory head and neck squamous cell carcinoma

BACKGROUND

Recurrent head and neck squamous cell carcinoma (HNSCC) remains a difficult cancer to treat. Here, we describe a patient with HNSCC who had complete response to methotrexate (MTX) after progressing on multiple cytotoxic agents, cetuximab, and AMG-479 (monoclonal antibody against insulin-like growth factor-1 receptor [IGF-1R]).

METHODS

The clinical information was collected by a retrospective medical record review under an Institutional Review Board-approved protocol. From 4 tumors and 2 normal mucosal epithelia, global gene expression, and IGF-1R and dihydrofolate reductase (DHFR) protein levels were determined.

RESULTS

Effective target inhibition in the tumor was confirmed by the decreased protein levels of total and phospho-IGF-1R after treatment with AMG-479. Decreased level of DHFR and conversion of a gene expression profile associated with cetuximab-resistance to cetuximab-sensitivity were also observed.

CONCLUSION

This suggests that the combination of AMG-479 and MTX or cetuximab may be a promising therapeutic approach in refractory HNSCC.

Synovial sarcoma of the head and neck: a review of its diagnosis and management and a report of a rare case of orbital involvement

Synovial sarcoma is typically an aggressive malignant tumor of the soft tissues, usually in the extremities, that affects young adults. Tumors of the head and neck are rare. Reported head and neck sites have included the hypopharynx (the most common site), the oropharynx, the larynx, and the soft tissues of the neck; only 4 cases of orbital involvement have been previously reported. We describe a case of synovial sarcoma of the medial canthus, which we discovered during a review of a tumor registry. The patient, an 18-year-old woman, underwent conservative excision and postoperative radiation therapy. Long-term follow-up detected no evidence of recurrence. Because there is no established, consistent approach to the treatment of synovial sarcoma of the head and neck, we also present a consensus management plan based on our review of the literature.

Synovial Sarcoma of the Head and Neck: A Review of its Diagnosis and Management and a Report of a Rare Case of Orbital Involvement

Synovial sarcoma is typically an aggressive malignant tumor of the soft tissues, usually in the extremities, that affects young adults. Tumors of the head and neck are rare. Reported head and neck sites have included the hypopharynx (the most common site), the oropharynx, the larynx, and the soft tissues of the neck; only 4 cases of orbital involvement have been previously reported. We describe a case of synovial sarcoma of the medial canthus, which we discovered during a review of a tumor registry. The patient, an 18-year-old woman, underwent conservative excision and postoperative radiation therapy. Long-term follow-up detected no evidence of recurrence. Because there is no established, consistent approach to the treatment of synovial sarcoma of the head and neck, we also present a consensus management plan based on our review of the literature.

Short-Term Culture and In-Vivo Modeling of Primary HNSCC

Problem

Head and neck squamous cell carcinoma (HNSCC) accounts for 4% of annual U.S. cancer deaths. In-vivo models exist using established HNSCC lines, but currently there is no such model that allows consistent growth of HNSCC from primary tumors.

Methods

Primary HNSCC tissue was obtained from 103 patients at biopsy/resection, disaggregated and seeded onto collagen-coated plates in keratinocyte growth media with 10% FBS, additives and antibiotics. After short-term growth in culture, cells were transferred to denuded rat tracheas and implanted subcutaneously in nude mice. Indirect immunofluorescent staining using antibodies specific to cytokeratin, vimentin and nuclear Ku was performed to determine cell lineage and origin.

Results

Cultured cells exhibited morphology consistent with epithelial or stromal derivation. 80% of cultures had viable cells present at 10 days and 24% were maintained 30 days or longer. 5 cultures (5%) proliferated after multiple passages and thrived on uncoated plates in the absence of mesenchymal cells. The xenograft model was able to successfully establish tumors in vivo from 59% of primary tumors. Immunostaining for nuclear Ku and cytokeratin confirmed human origin and epithelial cell lineage, respectively.

Conclusion

The high success rate indicates that selective growth and survival pressures for short-term culture of primary HNSCC may be considerably less than for establishment of cell lines. Additionally, the techniques permit tumor-derived epithelial and mesenchymal cells to be cultured simultaneously. Preliminary data for the in-vivo trachea xenograft model is promising. A luciferase lentiviral system has been created to allow monitoring of tumor growth in vivo with serial live animal imaging.

Significance

These short-term culture techniques may more accurately characterize both the biological diversity of HNSCC and tumor-stromal cell interactions. Once optimized, the trachea xenograft model can be used to determine the in-vivo response of a heterogeneous group of HNSCC to standard and novel therapies.

Support

Funds provided by an endowment for the Barry Baker Laboratory for Head and Neck Oncology, the Vanderbilt Ingram Cancer Center Endowed Professorship Fund, and the Robert J. Kleberg, Jr. and Helen C. Kleberg Foundation.

Antegrade and Retrograde Endoscopy for Treatment of Esophageal Stricture

Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.

Antegrade and retrograde endoscopy for treatment of esophageal stricture

Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.

Phase II trial of irinotecan plus cisplatin in patients with recurrent or metastatic squamous carcinoma of the head and neck

BACKGROUND

Patients with recurrent or metastatic HNC have a poor response and survival with currently available chemotherapy agents. Thus, new agents are needed. The authors report the results of a phase II trial of irinotecan and cisplatin in patients with metastatic or recurrent HNC.

METHODS

Patients were treated with irinotecan 65 mg/m2 IV over 90 minutes and cisplatin 30 mg/m2 were administered intravenously weekly for four weeks, followed by a two week rest. However, after 17 patients were treated with weekly irinotecan at a dose of 65 mg/m2, toxicity analysis demonstrated the poor tolerance of that dose in this patient population. Thus, the protocol was amended, and irinotecan was dose reduced to a starting dose of 50 mg/m2. Twenty-three additional patients were treated with this dose.

RESULTS

Forty patients were enrolled on study between February 2002 and April 2006, 17 patients at the first dose level and 23 patients at the amended dose level. Overall, 12 of 17 patients (71%) treated with irinotecan 65 mg/m2 experienced clinically significant grade 3 or 4 toxicity. Twelve patients required dose reductions. Toxicity was reduced but 17% of patients still experienced grade 3 or 4 toxicity on the lower irinotecan dose. The response rate was 35% for patients treated at irinotecan 65 mg/m2 and 22% for patients treated at 50 mg/m2. No complete responses were noted.

CONCLUSIONS

The combination of irinotecan and cisplatin is efficacious in a poor prognosis group of patients but toxicity is substantial.

Surgical management of minor salivary gland neoplasms of the palate

OBJECTIVE

Minor salivary gland tumors are uncommon, accounting for up to 15% of salivary gland neoplasms. We describe our experience with both benign and malignant tumors of the palatal minor salivary glands, focusing on the extent of resection and options for defect reconstruction.

STUDY DESIGN

Retrospective review of medical records.

RESULTS

From 1994 to 2002, 37 patients with primary neoplasms originating in the palatal minor salivary glands were treated at a single institution. Patients ranged in age from the second to the seventh decades, with a female preponderance. Twenty-four percent of the lesions were benign. The most common malignant tumor encountered was low grade polymorphous adenocarcinoma, followed by mucoepidermoid carcinoma, and adenoid cystic carcinoma. The extent of surgical resection was dictated by tumor pathology and evidence of perineural spread, and defects were reconstructed with a variety of techniques. Postoperative complications included velopharyngeal insufficiency, flap fistulization or loss, and trismus. After 1 month to 8 years of follow-up, 1 patient has died with regional and systemic metastases.

CONCLUSIONS

Neoplasms of the minor salivary glands in the palate may be excised, with limits dictated by tumor histopathology and perineural invasion. Improved functional results may be achieved by immediately reconstructing the defects with rotational flaps, reserving free flaps for more extensive defects of the maxilla and infratemporal fossa.

Sphenoid sinus myxoma: case report and literature review

OBJECTIVES

We present the first known case in the English-language literature of a myxoma arising in the sphenoid sinus. By describing the patient's clinical course and the salient features of this rare neoplasm, we seek to increase the awareness of the presentation, histological features, and treatment considerations for myxomas of the head and neck. In the process, we intend to describe the work-up of isolated sphenoid sinus lesions and focus on the varying and evolving techniques for surgical access to the sphenoid sinus.

STUDY DESIGN AND METHODS

Case report and literature review.

RESULTS

We describe the clinical course of a patient with a myxoma of the sphenoid sinus. The patient underwent an external sphenoethmoidectomy through a lateral rhinotomy approach with medial maxillectomy under MRI-guidance. He remains without evidence of recurrent disease after 8 months.

CONCLUSIONS

Myxomas of the head and neck are rare neoplasms. Their infiltrative nature and tendency to recur demand an aggressive surgical approach that may be accomplished with minimal morbidity using currently available image-guided techniques.

A Phase II multi-institutional trial of chemoradiation using weekly docetaxel and erythropoietin for high-risk postoperative head and neck cancer patients

PURPOSE

To determine efficacy and toxicities of postoperative concurrent chemoradiation using docetaxel in high-risk head and neck cancer.

METHODS AND MATERIALS

High-risk patients were enrolled 2-8 weeks after surgery. Treatment included 60 Gy for 6 weeks with weekly docetaxel 25 mg/m(2) and erythropoietin alpha 40,000 U for hemoglobin < or =12 g/dL. Primary endpoints included locoregional control (LC), disease-free survival (DFS), and patterns of failure (POF). Secondary endpoints were toxicity and quality of life.

RESULTS

Eighteen patients were enrolled (14 male, 4 female), aged 24-70 years (median, 55 years). Primary site included oropharynx = 7, oral cavity = 8, hypopharynx = 1, and larynx = 2. Pathologic American Joint Committee on Cancer Stage was III = 3 patients, IV = 15 patients. High-risk eligibility included > or =2 positive lymph nodes = 13, extracapsular extension = 10, positive margins = 8 (11 patients with two or more risk factors). Docetaxel was reduced to 20 mg/m(2)/week after 5 patients had prolonged Grade 3 or higher mucositis. Overall, number of doses delivered was 2 of 6 = 1, 3 of 6 = 2, 4 of 6 = 2, 5 of 6 = 4, 6 of 6 = 9 patients. With median follow-up of 30 months (range, 5-66), 10 (56%) patients are alive and have no evidence of disease (NED); POF: three local recurrences (two with distant) and 1 distant only. One-year survival was 76%, median PFS and DFS had not been reached. Three-year LC was 82%. No Grade 3 or higher late toxicities were observed, although a few cases of prolonged mucositis and taste loss (>3 months) were seen, particularly at 25 mg/m(2)/week.

CONCLUSION

Postoperative radiation therapy with weekly docetaxel 20 or 25 mg/m(2)/week for high-risk postoperative head and neck cancer caused intolerable mucosal toxicity, prompting early study termination. Further studies should consider 15 mg/m(2). Actuarial 3-year LC is 82%, similar to cisplatin-based chemoradiation regimens. Distant metastasis remains an important issue requiring additional systemic interventions.

Increased epidermal growth factor receptor gene copy number is associated with poor prognosis in head and neck squamous cell carcinomas

PURPOSE

High epidermal growth factor receptor (EGFR) gene copy number is associated with poor prognosis in lung cancer, but such findings have not been reported for HNSCC. A better understanding of the EGFR pathway may improve the use of EGFR inhibitors in HNSCC.

PATIENTS AND METHODS

EGFR status was analyzed in 86 tumor samples from 82 HNSCC patients by fluorescent in situ hybridization (FISH) to determine EGFR gene copy number, by polymerase chain reaction and direct sequencing for activating mutations, and by DNA microarray and immunohistochemistry for RNA and protein expression. The results were associated with patient characteristics and clinical end points.

RESULTS

Forty-three (58%) of 75 samples with FISH results demonstrated EGFR high polysomy and/or gene amplification (FISH positive). The FISH-positive group did not differ from the FISH-negative group with respect to age, sex, race, tumor grade, subsites and stage, or EGFR expression by analyses of RNA or protein. No activating EGFR mutations were found. However, the FISH-positive group was associated with worse progression-free and overall survival (P < .05 and P < .01, respectively; log-rank test). When microarray data were interrogated using the FISH results as a supervising parameter, ECop (which is known to coamplify with EGFR and regulate nuclear factor-kappa B transcriptional activity) had higher expression in FISH-positive tumors.

CONCLUSION

High EGFR gene copy number by FISH is frequent in HNSCC and is a poor prognostic indicator. Additional investigation is indicated to determine the biologic significance and implications for EGFR inhibitor therapies in HNSCC.

Gene expression differences associated with human papillomavirus status in head and neck squamous cell carcinoma

Human papillomavirus (HPV) is associated with a subset of head and neck squamous cell carcinoma (HNSCC). Between 15% and 35% of HNSCCs harbor HPV DNA. Demographic and exposure differences between HPV-positive (HPV+) and negative (HPV-) HNSCCs suggest that HPV+ tumors may constitute a subclass with different biology, whereas clinical differences have also been observed. Gene expression profiles of HPV+ and HPV- tumors were compared with further exploration of the biological effect of HPV in HNSCC. Thirty-six HNSCC tumors were analyzed using Affymetrix Human 133U Plus 2.0 GeneChip and for HPV by PCR and real-time PCR. Eight of 36 (22%) tumors were positive for HPV subtype 16. Statistical analysis using Significance Analysis of Microarrays based on HPV status as a supervising variable resulted in a list of 91 genes that were differentially expressed with statistical significance. Results for a subset of these genes were verified by real-time PCR. Genes highly expressed in HPV+ samples included cell cycle regulators (p16(INK4A), p18, and CDC7) and transcription factors (TAF7L, RFC4, RPA2, and TFDP2). The microarray data were also investigated by mapping genes by chromosomal location (DIGMAP). A large number of genes on chromosome 3q24-qter had high levels of expression in HPV+ tumors. Further investigation of differentially expressed genes may reveal the unique pathways in HPV+ tumors that may explain the different natural history and biological properties of these tumors. These properties may be exploited as a target of novel therapeutic agents in HNSCC treatment.

Squamous cell carcinoma of the oropharynx and hypopharynx

Oropharyngeal and hypopharyngeal squamous cell carcinomas require an interdisciplinary approach to manage patients appropriately. Tumor stage and histology, functional outcome, and patient comorbidities are important factors to consider. Various surgical approaches as well as chemotherapy and radiation therapy alone or in combination remain the mainstay of therapy.

Surgical management of parapharyngeal space masses

BACKGROUND

We sought to examine surgical techniques used to remove parapharyngeal space (PPS) masses.

METHODS

This retrospective search was conducted from 1980 to 2003. Age, sex, diagnosis, surgical approach, complications, and outcome were collected.

RESULTS

One hundred sixty-six PPS masses were identified: 21 (12.7%) were malignant, 145 (87.3%) were benign, 76 (45.8%) were vascular, and 69 (41.6 %) involved the skull base. Transcervical techniques were used in all cases. Removing the styloid and its musculature and level II lymphadenectomies enhanced exposure for vascular and skull base tumors. Thirty transcervical-transmastoid dissections (20.4%) facilitated removal of vascular skull base tumors. To identify the facial nerve, 20 transparotid-transcervical approaches (13.6%) were performed. Three mandibulotomies (2.0%) were required for internal carotid artery involvement. Expected neurologic sequelae resulted from cranial nerve involvement by tumor. Three patients (2.0%), all presenting with recurrent cancer, had local recurrences.

CONCLUSION

Careful patient assessment and surgical techniques allow the oncologically safe removal of benign, vascular, and skull base PPS tumors.

Current concepts in lip reconstruction

PURPOSE OF REVIEW

Approximately 25% of all oral cavity carcinomas involve the lips, and the primary management of these lesions is complete surgical resection. The management of the resulting lip defect remains a significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimize the functional and cosmetic outcome. Reviewed here are the accepted techniques of lip reconstruction, as well newer techniques that have been reported.

RECENT FINDINGS

There have been no major advances in lip reconstruction; rather, continued improvement on accepted techniques. The main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening, and the restoration of normal anatomic relations such that both the active (smile) and passive (form) cosmetic outcome is acceptable. The reconstruction should be tailored to the individual needs of the patient and should take into account the patient's condition, local tissue characteristics, previous treatment(s), and functional needs (eg, denture use), in addition to the size and location of the defect.

SUMMARY

The lips play a key role in facial expression, speech, and eating. This requires meticulous attention to preoperative planning and surgical technique to maximize the functional and cosmetic outcome. It is important to assess local tissue characteristics (skin laxity) and previous treatment (surgery and/or irradiation) before the surgical plan is made final. Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match. Whenever possible, dynamic reconstruction should be attempted. Careful preoperative assessment and planning will allow the surgeon to reach an acceptable balance between form and function with the reconstruction.

Tumors of the Accessory Lobe of the Parotid Gland: A 10-Year Experience

OBJECTIVES/HYPOTHESIS

The differential diagnosis of midcheek masses include pathology arising from normal anatomic structures or from variations of normal accessory parotid gland tissue. Accessory parotid gland tissue has been described as salivary tissue adjacent to Stenson's duct that is separate from the main body of the parotid gland. We report our 10-year experience with the diagnosis and treatment of eight accessory parotid gland neoplasms that have been followed by the senior authors.

STUDY DESIGN

This is a retrospective review of our experience with eight accessory parotid gland neoplasms.

METHODS

A literature review and retrospective chart review of our experience with accessory parotid gland tumors over the past 10 years. The presentation, evaluation, management, treatment, and outcome were recorded.

RESULTS

Eight cases of accessory lobe parotid tumors were identified, which have been followed since the date of initial treatment. All of the patients presented with a slowly growing cheek mass. There was one case of carcinoma expleomorphic adenoma, one case of undifferentiated carcinoma (small cell carcinoma), one case of basal cell adenocarcinoma, one case of benign salivary cyst, two cases of pleomorphic adenoma, and two cases of monomorphic adenoma. A standard facelift approach or modified Blair incision was used to excise these tumors.

CONCLUSIONS

Neoplasms of the accessory parotid gland are rare. Management of these tumors include a high index of suspicion, good understanding of the anatomy, and meticulous surgical approach.

Use of the anterolateral thigh flap for reconstruction of the head and neck

PURPOSE OF REVIEW

The anterolateral thigh free flap has achieved recent popularity in North America for the reconstruction of head and neck defects after ablative surgery. The flap is most often based on either the septocutaneous or musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery. Its versatility allows for a subcutaneous, fasciocutaneous, myocutaneous, or adipofascial flap to be obtained.

RECENT FINDINGS

Recent publications have described the utility of the anterolateral thigh flap for reconstruction of head and neck defects. It has been used successfully in the reconstruction of the laryngopharynx, oral cavity, oropharynx, external skin, and maxilla. Furthermore, when a thinner flap is needed, a suprafascial anterolateral thigh flap may be raised or the flap may be thinned after it is obtained.

SUMMARY

The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft tissue defects of the head and neck. This flap has gained great popularity in mainland China, Taiwan, and Japan given its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in Europe and North America because of the relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue in the Western population in comparison with the patient population of the Far East. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafascial flap or thinning the flap after it has been obtained.

Functional outcomes after free flap reconstruction of the upper aerodigestive tract

PURPOSE OF REVIEW

When the complex structures of the upper aerodigestive tract are disrupted after resection of head and neck tumors, an appropriate reconstructive option should be chosen in an attempt to regain maximum function. Reconstructions using microvascular free tissue transfer offer unparalleled flexibility, both in tissue composition and in placement. This article will examine functional outcomes after free flap reconstruction of the upper aerodigestive tract.

RECENT FINDINGS

With the maturation of free tissue transfer techniques, functional outcomes are being analyzed with increasing frequency. Recent reports show promising results for free flap reconstruction of oral cavity, oropharyngeal, and hypopharyngeal soft tissue defects, as well as for bony mandibular and maxillary defects.

SUMMARY

For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes. In the future, randomized studies are needed to compare the functional outcomes of microvascular free flaps with those of other reconstructive options.

The role of free tissue transfer in the reconstruction of massive neglected skin cancers of the head and neck

BACKGROUND

Most skin cancers involving the head and neck region are easily managed with surgical resection and local flap rotation. Occasional patients present with massive neglected skin cancers or skin cancers that have recurred after multiple treatments. Management of these massive tumors may involve craniofacial resection, maxillectomy, or mandibulectomy to obtain clear margins. Reconstruction requires massive composite soft tissue replacement. We presented our experience with, to our knowledge, the largest series reported to date.

DESIGN

A retrospective chart review of 43 patients with massive neglected skin cancer of the head and neck reconstructed by means of free tissue transfer from January 1, 1992, through October 1, 2001.

SETTING

Academic tertiary referral medical center.

RESULTS

Seventeen patients with squamous cell carcinoma and 26 patients with basal cell carcinoma were treated. Primary sites included the cheek (n = 15), ear (n = 8), forehead (n = 5), neck (n = 4), scalp (n = 5), and nose (n = 6). Treatment involved a combination of orbital exenteration (n = 16), maxillectomy (n = 12), mandibulectomy (n = 6), auriculectomy (n = 5), craniofacial resection (n = 10), rhinectomy (n = 6), and lateral temporal bone excision (n = 5). Flaps used for reconstruction included the rectus abdominis (n = 22), latissimus dorsi (n = 11), radial forearm (n = 8), and lateral arm (n = 2). Radiotherapeutic exposure included pretreatment in 21 patients and posttreatment in 15. Twelve patients had undergone no previous surgeries; 15 patients, 1 to 5; and 16 patients, more than 5. Follow-up revealed evidence of local recurrence (n = 12), locoregional recurrence (n = 3), distant metastasis (n = 3), and no evidence of disease (n = 25).

CONCLUSIONS

Massive skin cancers are generally associated with disfiguring, debilitating surgery and high mortality rates. We demonstrate that free tissue transfer yields acceptable survival with functional and cosmetic outcomes.

Carbon Dioxide Laser Endoscopic Diverticulotomy Versus Open Diverticulectomy for Zenker???s Diverticulum

OBJECTIVES/HYPOTHESIS

To compare open and CO2 laser-assisted endoscopic surgical management of Zenker's diverticulum.

STUDY DESIGN

A retrospective review of 49 consecutive surgically treated patients with Zenker's diverticulum was conducted.

METHODS

Patients' records were reviewed and analyzed for patient age and sex, size of diverticulum, incision time (time recorded from start of incision to surgical completion of case), length of hospital stay, complications, and follow-up management. A postoperative questionnaire inquiring about swallow function was conducted by mail or telephone. Swallow function was assessed on a four-point scale.

RESULTS

Various procedures performed included endoscopic CO2 laser-assisted diverticulotomy (n = 24) and open diverticulectomy with cricopharyngeal myotomy (n = 28). The average incision time of laser endoscopic cases (47 min) was significantly shorter (P <.001) than that of open diverticulectomy cases (170 min). Length of hospital stay did not significantly vary between the two groups. Five patients (21%) initially treated with laser endoscopic diverticulotomy demonstrated symptomatic persistent Zenker's diverticulum; three underwent repeat operation. No open cases required repeat operation. One endoscopic case was aborted secondary to esophageal injury from placement of the endoscope. Postoperative fever was seen in two (8%) endoscopic cases and four (14%) open approach cases. No major complications (recurrent laryngeal nerve paralysis, mediastinitis, or death) were encountered. More than 90% of respondents in each treatment group reported normal or near-normal swallow function.

CONCLUSION

Laser endoscopic management is a reasonable and safe method for surgical treatment of Zenker's diverticulum in comparison with the open technique. Employment of the endoscopic approach reduces operative time and the complexity of postoperative care. Practitioners should be aware that the endoscopic approach may result in a higher failure rate.

Palatal reconstruction with the palatal island flap

OBJECTIVES/HYPOTHESIS

The management of palatal defects resulting from the extirpation of benign and malignant lesions uses a variety of methods, with the optimal techniques allowing maximal postoperative function with minimal morbidity. The palatal island flap is an effective, reliable technique for reconstructing postablative oral cavity defects.

METHODS

All patients who underwent palatal resections for benign or malignant lesions at a tertiary care, referral-based head and neck cancer center since 1995 were eligible. Ten patients were identified whose surgical defects were reconstructed with palatal island flaps. The cases were reviewed for the symptomatology, tumor features, defect size, perioperative and postoperative management, complications, and impact on palatal function.

RESULTS

Ten patients ranging in age from 18 to 81 years underwent palatal island mucoperiosteal flaps after resection of a variety of benign and malignant tumors, most arising from minor salivary glands. The defects ranged in size from 5 to 15 cm2, with extension into the floor of the nose in four cases and to the skull base in two. Nine patients were discharged on a regimen of oral diet, and no patient manifested permanent velopharyngeal insufficiency, speech impairment, or airway compromise. Follow-up ranged from 3 months to 6 years, with an average follow-up of 18.5 months. Delayed donor site re-epithelialization required debridement in one case, and two patients required obturation of small oronasal fistulae.

CONCLUSION

The palatal island mucoperiosteal flap provides an effective means of reconstructing hard and soft palate defects with few complications and low morbidity.

Lateral approach to a neurenteric cyst of the cervical spine: case presentation and review of surgical technique

STUDY DESIGN

The lateral cervical spinal approach is illustrated by a case of neurenteric cyst.

OBJECTIVES

To present a case of a neurenteric cyst resected the lateral cervical approach, and to review the approach in detail.

SUMMARY OF BACKGROUND DATA

Intradural lesions located anterior to the high cervical spinal cord may present a difficult surgical problem. Neurenteric cysts are unusual lesions found in the brain and spinal cord. This report presents a case of cervical neurenteric cyst causing anterior cord compression that was resected using the lateral cervical approach.

METHODS

A 32-year-old woman presented with chronic headaches and worsening nausea, tinnitus, dizziness, and hyperreflexia and clonus in her lower extremities. Magnetic resonance imaging of the cervical spine showed a mass compressing the anterior spinal cord at C3. Pathology showed that this lesion was a neurenteric cyst. The lesion was resected using the lateral cervical approach.

RESULTS

At this writing, 36 months after surgery, the patient has continued resolution of her symptoms, and no cyst recurrence has been shown on repeat MRI imaging. She has no evidence of postlaminectomy kyphosis.

CONCLUSIONS

The lateral cervical approach is useful for surgeons attempting to resect lateral and anterior intradural lesions of the cervical spine. It also gives excellent cranial-to-caudal access to the thecal sac, spinal cord, and the lesion to be resected. The neck incision preserves cosmesis, and neuromuscular function is maintained. Spinal fusion was avoided in the reported case.

Incidental metastatic papillary thyroid carcinoma in microvascular reconstruction

OBJECTIVES/HYPOTHESIS

Occult papillary thyroid carcinoma has a reported prevalence of 1% to 35% based on autopsy studies. Cervical lymphatic metastases from papillary thyroid carcinoma have been associated with a higher likelihood of recurrence with a questionable impact on survival. Without clinically evident disease in the thyroid or cervical nodes, management of these patients presents a treatment dilemma. We propose an individualized treatment plan for patients in whom metastatic papillary thyroid carcinoma is incidentally detected during neck exploration for other purposes.

STUDY DESIGN

Retrospective review and discussion of the literature.

METHODS

The clinical course of two patients with incidentally discovered metastatic papillary thyroid carcinoma to the cervical lymph nodes is described. Both patients had previously received head and neck irradiation in childhood and required free flap reconstruction of extensive skull base defects following extirpation of meningiomas.

RESULTS

Neck dissection specimens from levels I and II obtained during exposure of recipient vessels for microvascular tissue transfer revealed papillary thyroid carcinoma in both cases. The patients subsequently underwent total thyroidectomy, neck dissection, and postoperative radioactive iodine ablation of residual thyroid tissue. After 1 year of follow-up, both patients were without evidence of recurrent disease.

CONCLUSIONS

An individualized approach is justified to treat metastatic papillary thyroid carcinoma incidentally discovered during other procedures. The case reports underscore the importance of pathological analysis of surgical specimens obtained during head and neck reconstruction.

Microvascular free tissue transfer in reconstructing skull base defects: lessons learned

OBJECTIVE

To demonstrate the effectiveness of microvascular free tissue transfer in reconstructing complex skull base defects.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was conducted identifying patients with anterior or lateral skull base defects, or both, who underwent microvascular free flap reconstruction. Appropriate demographic, pathological, and preoperative and postoperative clinical data were collected and analyzed.

RESULTS

Thirty-five patients with skull base defects were identified, including 8 women (Mean age, 43.9 y; age range, 28-75 y) and 27 men (mean age, 57.9 y; age range, 19-85 y). Defects were secondary to trauma in two cases, whereas the remaining 33 cases were secondary to ablative procedures for a variety of malignant tumors, of which squamous cell carcinoma was the most common (n = 18). The average defect surface area was 89.3 cm(2), and 36 free flaps were used. The most commonly used flap was the rectus myocutaneous (n = 20); however, six different flap types were employed, including three radial forearm fascial flaps. In all, there were seven flap-related complications and there was one total flap loss. A total of 43 postoperative complications occurred in 23 patients, with the most common complications being grouped as intracranial (n = 10), orbital (n = 9), and cardiac (n = 9). The perioperative mortality rate was 5.7%, and the average hospital stay was 13.5 days (range, 7-37 d).

CONCLUSIONS

The use of microvascular free tissue transfer for reconstruction of complex skull base defects has proven highly successful in the large series presented in the current study. The versatility and reliability of free flaps for such reconstruction are discussed, and helpful hints are given to minimize the complication rate.

Expression of p63 and 14-3-3sigma in normal and hyperdifferentiated mucosa of the upper aerodigestive tract

OBJECTIVE

Our goal was to analyze p63 and 14-3-3sigma expression in normal and hyperdifferentiated head and neck mucosa.

STUDY DESIGN

Compare the in vivo expression of p63 and 14-3-3sigma by immunohistochemistry in normal mucosa and oral lichen planus, a benign mucosal lesion marked by hyperdifferentiation and apoptosis.

RESULTS AND CONCLUSION

p63 is underexpressed and 14-3-3sigma is overexpressed in lichen planus on immunohistochemical analysis.

SIGNIFICANCE

The findings support the hypothesis that p63 plays an antidifferentiation role, whereas 14-3-3sigma plays a prodifferentiation role in the upper aerodigestive tract epithelium. Lichen planus is a valuable model for the study of p63, 14-3-3sigma, and mucosal differentiation. p63 and 14-3-3sigma may be molecular markers for oral lichen planus.

Analysis of cell-cycle checkpoint pathways in head and neck cancer cell lines: implications for therapeutic strategies

OBJECTIVE

To determine the mechanism of action of paclitaxel (Taxol) and carboplatin in cell lines of head and neck squamous cell carcinoma (HNSCC).

DESIGN

Four HNSCC cell lines were treated with paclitaxel and carboplatin, alone or in combination, and evaluated for cell-cycle position by means of flow cytometry, for molecular determinants of cell cycle by means of Western blotting and kinase analysis, and for anchorage-independent growth by means of soft-agar assays.

RESULTS

Paclitaxel was more effective at inducing apoptosis and inhibiting anchorage-independent cell growth, compared with carboplatin. The activity of paclitaxel was correlated with an elevation of cyclin B1/CDC2 activity, prolonged mitotic arrest, and Bcl-2 phosphorylation. In contrast, carboplatin arrested cells before mitosis. Combination treatment with both agents, simultaneously or sequentially, was more effective at inhibiting cell growth than either single agent. Cellular outcome was the same regardless of which drug was used first. The order of addition of these 2 drugs differentially affected cell-cycle position. Paclitaxel pretreatment arrested cells in mitosis, whereas carboplatin pretreatment or cotreatment resulted in premitotic arrest.

CONCLUSIONS

To our knowledge, this study is the first to explore how paclitaxel and carboplatin, alone or in combination, differentially affect cell-cycle checkpoint response and HNSCC cell growth. These results provide molecular validation for the current clinical use of both drugs in combination and set the stage for analyses of patient tumor specimens.

Increasing use of the scapula osteocutaneous free flap

OBJECTIVES

To determine the appropriate use of the scapula osteocutaneous free flap (SOFF) and to document donor site morbidity.

STUDY DESIGN

Retrospective review and prospective physical therapy evaluation.

METHODS

A computer database of all free flap procedures performed at a single institution was created. Specific clinical and operative details from cases involving a bone flap were extracted from the database. Rates of usage of the various osteocutaneous flaps were compared over four successive 2-year intervals (1992-1999). A single physical therapist performed a structured evaluation of the donor site.

RESULTS

Overall, 64 bone flap procedures were performed, of which 24 (37.5%) were SOFF procedures. The SOFF utilization has increased from 6.6% to 63.6%, while fibula and iliac crest utilization has fallen significantly. This is in part because of the greater versatility of the SOFF, with the possibility of separate skin paddles and adequate bone length. The mean cutaneous area harvested with the SOFF was 110 cm2 (range, 48-200 cm2) compared with 55.4 cm2 (range, 25-102 cm2) and 77.6 cm2 (range, 50-120 cm2) for the fibula and iliac crest, respectively. Mean bone flap lengths were 8.37, 7.65, and 10.1 cm, respectively, for the SOFF, fibula, and iliac crest. Dual skin paddles were used in 50% of the SOFF procedures versus 2.8% for the fibula flap procedures. There were no significant complications of the donor site in any patient, and there was only one flap failure (4.1%). Related to the SOFF, donor site morbidity was subjectively judged as "mild," for pain, mobility, and strength. There were no complaints of poor appearance of the donor site. Activities of daily living were judged as "not limited" or 'limited a little" in the majority of patients. Objective measurements of range of motion revealed an average reduction of 1 degree to 12 degrees in five different shoulder functions. Elbow and arm ranges of motion were not limited. Strength was minimally reduced in the shoulder, while the arm and forearm showed no reduction in strength.

CONCLUSIONS

The SOFF is a versatile osteocutaneous free flap that can be used for a multitude of reconstructive problems. This and its relative lack of significant donor site morbidity have caused its use to increase significantly.

Tongue replantation in an animal model

Although the tongue is not a vital organ in sustaining life, it may be a vital organ in sustaining the will to live in many people. As carcinoma of the tongue represents the majority of the 30,000 oral cavity cancers diagnosed per year in the United States, many patients face the potential consequences of resection of part or all of the tongue for cure. To date, reconstructive options do not restore optimal tongue function including articulation, swallowing, taste, or sensation. With the ultimate goal of improving tongue reconstruction, we report on a successfully performed autograft transplantation of the tongue in an animal model. Before undertaking allograft transplantation of the tongue, an autograft tongue transplant would be attempted to identify the feasibility of such a procedure and to determine the similarity of an animal model with human techniques. The dog's neck, tongue, and oral anatomy represent an excellent animal model for tongue reconstruction. This procedure can be performed successfully in an animal model. The only previously published replantation of the tongue involved the reattachment of the anterior portion of a human tongue after physical trauma. To our knowledge, the enclosed report represents the first successful total excision and replantation of the tongue in either a human or animal model.

Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma

OBJECTIVE

To analyze the presentation, evaluation, and treatment of a subset of patients with well-differentiated thyroid carcinoma who present with a lateral neck mass and no palpable disease in the thyroid gland.

STUDY DESIGN

A retrospective review of all patients undergoing thyroidectomy for malignancy.

METHODS

A database of all thyroidectomies performed for malignancy by the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery from 1992 to 1997 was created. Patients who presented with an isolated neck mass without evidence of palpable disease in the thyroid were selected for the study population.

RESULTS

There were 60 cases of thyroid malignancy, with 14 cases (23.3%) that presented as isolated lateral neck mass. The characteristics of this group (compared with the population of all thyroid malignancies) include younger age at presentation (37.7 +/- 15.2 y vs. 49.8 +/- 15.6 y; Student t test: P = .019) and long-standing presence of symptoms (27.4 +/- 39.6 mo vs. 3.6 +/- 3.9 mo; P = .023). These patients generally presented from a referring facility after having an excisional biopsy, which was 100% accurate. Fine-needle aspiration is becoming more useful and was 66.7% accurate. Histological examination revealed cancer in the thyroid gland in all patients, 11 cases of papillary carcinoma, 2 follicular carcinomas, and one medullary carcinoma The mean size of the primary focus was 10.9 +/- 8.7 mm, with 29% demonstrating bilateral disease and 14% demonstrating multifocal disease in the ipsilateral gland. The neck specimens revealed an average of 5.3 +/- 3.2 metastatic nodes in levels II-IV and 3.9 +/- 4.6 metastatic nodes in the paratracheal region.

CONCLUSION

Based on this patient population, the long-standing lateral neck mass in the young patient should raise the physician's index of suspicion for thyroid carcinoma Fine-needle aspiration should be used in conjunction with judicious excisional biopsy. The bilateral and multifocal nature of otherwise occult primary disease argues for total thyroidectomy in this setting.

Current options in management of head and neck cancer patients

Head and neck cancer, particularly squamous cell carcinoma (SCC) of the upper aerodigestive tract, poses difficult diagnostic and therapeutic challenges to the clinician. A methodical approach, including complete visualization of mucosal surfaces, appropriate imaging, and tissue diagnosis whenever possible, gives patients the best opportunity for early intervention. A treatment program of surgery, radiation, or chemotherapy is best developed by a devoted head and neck oncologic team, involving surgeons, radiation and medical oncologists, and rehabilitative specialists with significant experience in the care of head and neck oncologic patients. Despite new advancements in the treatment of patients with advanced stage SCC of the head and neck, little progress has been made in overall survival. Several new avenues of investigation are currently being explored, one of which may ultimately provide the answer for this devastating disease.

Management of substernal goiter

OBJECTIVE

To analyze the presentation, evaluation and treatment of patients with large substernal goiters, with emphasis on the radiographic evaluation and the results of treatment.

STUDY DESIGN

A retrospective chart review of 150 patients undergoing thyroidectomy at the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery.

METHODS

Charts of patients undergoing thyroidectomy were reviewed. Those with substernal goiter, defined as a major portion of the goiter within the mediastinum, were included in the study. When available, the radiographic studies were reviewed by a staff neuroradiologist.

RESULTS

Twenty-three patients (15.3%) presented with substernal extension of the goiter. Characteristics of these patients included mean age of 59 years, 78% female, symptoms of compression such as dyspnea, choking, and dysphagia (65%), hoarseness (43%), and previous thyroid surgery (30%). Seventeen percent were asymptomatic. Preoperative radiographs demonstrated tracheal compression (73%), tracheal deviation (77%), esophageal compression (27%), and major vessel displacement (50%). Histology revealed multinodular goiter (16/23, 70%), thyroiditis (3/23, 13%), and malignancy (4/23, 17%). The average size of the resected specimen in greatest dimension was 8.0 cm (range, 3.0-14.0 cm) and weighed 148 g (range, 39-426 g). All were successfully approached through a transcervical incision without the need for sternotomy, and total thyroidectomy was performed in 83% of the cases. No major complications have been documented, and no evidence of tracheomalacia was encountered.

CONCLUSION

Despite the large size of these goiters and the significant involvement of the major mediastinal structures, all were approached through the transcervical incision. Further, despite significant tracheal involvement, there were no cases of tracheomalacia or major complications. For intraoperative planning, the authors advocate the routine use of preoperative computed tomography scanning.

Delayed regional metastasis from midfacial squamous carcinomas

BACKGROUND

Metastases from mucosal and cutaneous carcinomas can present in a delayed fashion, and this late presentation may confer a different prognosis after conventional treatment.

METHODS

We present a series of patients in which there was a significant time delay between the treatment of a squamous carcinoma of the skin or mucosa of the midface and the detection of regional metastases in 12 of the 13 cases. Primary tumors were located on the lower lip and commissure (n = 3), nasal tip (n = 2), nasal ala (n = 1), columella (n = 1), nasofacial crease (n = 2), maxillary alveolus (n = 3), and mandibular alveolus (n = 1). Metastatic spread manifested by palpable perifacial or submandibular lymph nodes was not evident until greater than 11 months after the treatment of the primary site in 12 of 13 patients (range, 3-45 months). Nine of the patients were clinically staged as N1, whereas there was one each in the N2a, N2b, N2c, and N3 categories. Eleven of the 13 patients were initially seen with palpable disease involving the perifacial nodes within or around the submandibular gland. All patients were treated with neck dissection except one, who refused surgical treatment and underwent a second course of radiotherapy to the cervical region. The nine patients initially seen with clinical stage N1 disease underwent neck dissection with preservation of the sternocleidomastoid, internal jugular vein, and accessory nerve.

RESULTS

Of 10 patients with perifacial node metastases who underwent neck dissection, 8 required sacrifice of the marginal mandibular nerve and overlying platysma to gain adequate margin. Extracapsular spread was present in 11 patients, (8 of 9 who were clinically N1). Postoperative radiotherapy was recommended to all patients with extracapsular spread, although only 7 of the 11 received radiotherapy. There were no regional recurrences after a minimum follow-up of 1 year (range, 12-65 months; mean, 31.4 months). Histologic grade appeared to have no influence on prognosis.

CONCLUSIONS

This cohort demonstrates the ability of midfacial squamous cell carcinoma to manifest regional metastatic disease over a delayed time. This delayed presentation appears to confer a more favorable response to treatment. For midfacial cancers, the perifacial nodes are at greatest risk for metastatic spread. For tumors in this region, primary treatment of the neck is probably not warranted, but careful extended follow-up for the potential of delayed cervical metastasis is prudent.