Neoplastic fixation to the prevertebral compartment by squamous cell carcinoma of the head and neck

OBJECTIVE

The purpose of this study was to determine the accuracy of MR imaging in determining fixation of squamous cell carcinomas to the prevertebral space.

MATERIALS AND METHODS

MR images of 15 patients with large pharyngeal carcinoma (n = 13) or laryngeal carcinomas with pharyngeal extension (n = 2) were retrospectively reviewed independently by two head and neck radiologists who were unaware of the surgical findings. MR images were evaluated for four criteria in the prevertebral longus muscle complex: muscle concavity, irregular tumor-muscle interface, T2 hyperintensity, and enhancement. All patients underwent panendoscopy where fixation or mobility of the tumor relative to the prevertebral fascia was assessed by manual manipulation. Tumors in six patients were fixed to the prevertebral space and inoperable. In nine patients whose tumors were not fixed, open neck explorations were performed and tumors were resected in seven patients. MR findings were compared with panendoscopy in all patients and with intraoperative assessment in nine patients.

RESULTS

Eleven of 15 patients had at least two of the MR imaging criteria present. None of the MR findings were both sensitive and specific for tumor fixation. Although muscle concavity and enhancement each had a sensitivity of 88%, both criteria suffered from low specificity (14% and 29%, respectively). An irregular tumor-muscle interface and muscle T2 hyperintensity were criteria that suffered from both low sensitivity and specificity. Accuracy of the imaging criteria independently ranged from 53% to 60%.

CONCLUSION

Although abnormal muscle contour, T2 hyperintensity, and enhancement are frequently present in neck carcinomas that are fixed to the prevertebral space, these findings may also be present in patients in whom the tumor is mobile and resectable. MR imaging may not be able to differentiate between neoplastic fixation and nonneoplastic changes in the prevertebral space.

Can radiologists accurately predict preepiglottic space invasion with MR imaging?

OBJECTIVE

The purpose of this study was to evaluate whether observers of MR imaging can accurately predict invasion of the preepiglottic fat (PEF) in patients with oropharyngeal and supraglottic laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

For 41 patients with pathologically proven squamous cell carcinoma of the oropharynx and supraglottic larynx, we retrospectively analyzed their MR images for the presence or absence of PEF neoplastic invasion. Unenhanced T1-weighted, fat-suppressed T2-weighted, and contrast-enhanced fat-suppressed T1-weighted scans were analyzed independently by two neuroradiologists who were unaware of the surgical findings. Proof of diagnosis was determined by pathologic analysis, intraoperative assessment, or both.

RESULTS

Sixteen patients had neoplastic infiltration of the PEF. All infiltration was correctly predicted by the two observers of MR imaging, resulting in a sensitivity of 100%. Twenty-five patients had no invasion of the PEF by pathologic or surgical evaluation or both. Of these patients, negative findings were correctly predicted on MR imaging in 21 patients, whereas positive findings were incorrectly predicted on MR imaging in the remaining four patients, resulting in a specificity of 84% and an accuracy of 90%. In two of the four false-positive cases, effacement of the fat in the preepiglottic space by large tumors was mistaken for invasion. In a third patient, spread to the paraglottic space was mistaken for PEF extension. In the fourth false-positive case, glandular tissue along the ventral epiglottis may have been mistaken for tumor. The observers believed that unenhanced sagittal and axial T1-weighted scans were particularly useful because fat saturation artifacts may degrade T2-weighted and contrast-enhanced T1-weighted scans.

CONCLUSION

Unenhanced T1-weighted MR images are highly sensitive for neoplastic infiltration of the preepiglottic space in patients with oropharyngeal and supraglottic laryngeal carcinoma who are at risk for such spread. Identification of PEF invasion is important because it affects prognosis and may affect surgical management.

Synovial sarcomas of the head and neck: MR findings

OBJECTIVE

MR images of six synovial sarcomas of the head and neck were evaluated to determine their characteristic sites of origin, size, extent, intensity, and contrast enhancement. It was hoped that specific MR characteristics could be defined to suggest this entity.

CONCLUSION

A nonmucosal head and neck mass that is isointense to gray matter on T1-weighted images and is well defined yet heterogeneous, with septations, hemorrhage, cysts, calcification, or multilocularity, should raise suspicion of a synovial sarcoma. Because the appearance of synovial sarcomas varies and other masses may appear similar, no specific imaging characteristics define the entity.

Computer-assisted resection of benign sinonasal tumors with skull base and orbital extension

OBJECTIVE

To use freehand, real-time, intraoperative, 3-dimensional computed tomography (3-D CT) localization to assist with resection of sinonasal lesions with skull-base and/or orbital extension.

DESIGN

The 3-D CT is computer-assisted technology using the preoperative CT scan as a road map for resection of lesions. Previous technology, while resulting in little intraoperative error, required use of a somewhat cumbersome rigid articulated arm and attached probe, limiting mobility and requiring rigid fixation of the head to maintain system reference. A new freehand version of this technology, eliminating these limitations, has been used for resection of benign sinonasal lesions with skull-base and/or orbital extension.

SETTING

Tertiary care, university-based practice.

PATIENTS

Seven patients prospectively selected with benign lesions involving the sinonasal cavity and orbit and/or skull base.

INTERVENTION

All patients underwent surgical resection of their tumors using endoscopic, open, or combined procedures with the assistance of freehand 3-D CT localization. MAIN OUTCOME ASSESSMENTS: Surgeon assessment of usefulness.

RESULTS

In several cases, the device assisted the operator in determining the exact location of a displaced optic nerve, ensuring vision preservation, while in other cases, the location and depth of skull-base penetration was clearly determined, allowing resection via a transnasal endoscopic approach. In addition, the device was useful for determining the depth of necessary resection for optimal cosmetic result. In all cases, system accuracy was within less than 2 mm at the operative site. System limitations included need for an additional preoperative CT and time required at the beginning of the case for system setup and registration.

CONCLUSIONS

Freehand 3-D CT, while still with limitations, offers the advantage of increased surgical safety, aiding anatomic understanding in distorted surgical fields for resection of benign sinonasal tumors with orbital and skull-base extension.

Capnography during jet ventilation for laryngoscopy

Jet ventilation is often used during laryngoscopy to permit improved visualization of the larynx and to eliminate a potentially flammable endotracheal tube when laser surgery of the airway is performed. Observation of chest wall movement and blood gas analysis are the usual standards for assessing the adequacy of ventilation during jet ventilation. It is reasonable to hypothesize that measurement of end-tidal CO2 concentrations during jet ventilation can be used to assess the adequacy of ventilation during jet ventilation. To test this hypothesis, end-tidal CO2 concentrations were determined during mechanical ventilation through an endotracheal tube and during jet ventilation. At the time that each end-tidal measurement was obtained, a sample of arterial blood was also obtained for later blood gas analysis. For both mechanical ventilation and jet ventilation, well defined relationships between end-tidal CO2 and arterial CO2 tensions were obtained. However, the relationships are distinct: the difference in arterial to end-tidal CO2 tension during supraglottic jet ventilation at a conventional respiratory rate was found to be 13.4 +/- 6.8 mm Hg (mean +/- SD) compared with 5.7 +/- 5.2 mm Hg obtained during conventional ventilation through an endotracheal tube.

Supracricoid hemilaryngopharyngectomy conversion to Pearson's near-total laryngectomy: a case report

BACKGROUND

Pearson's near-total laryngectomy was initially advocated in patients with extended glottic carcinoma and hypopharyngeal carcinoma. More recently, the utility of near-total laryngectomy for supraglottic pharyngeal, base of tongue, and other cancers such as thyroid cancer with anterior tracheal wall invasion has also been reported.

METHODS

The purpose of this case report was to demonstrate the feasibility of this procedure in the setting of severe aspiration after supracricoid hemilaryngopharyngectomy.

RESULTS

The first case of successful conversion from supracricoid hemilaryngopharyngectomy to Pearson's near-total laryngectomy in a patient with severe and recurrent aspiration is presented.

CONCLUSIONS

This case report suggests that when partial laryngopharyngectomy results in severe and recurrent aspiration, rather than having to convert the patient to a total laryngectomy with tracheoesophageal puncture, a near-total laryngectomy is a reasonable option with acceptable functional results.

Delphian lymph node in laryngeal carcinoma: a whole organ study

The incidence of Delphian or cricothyroid lymph node involvement in laryngeal carcinoma was studied in whole organ sections of 92 laryngectomy specimens. Histologic examination revealed that of the 92 whole organ sections, 8 were noted to have cricothyroid node involvement (8.7%). All 8 patients had submucosal involvement of the conus elasticus, 7 had involvement of the subglottic mucosa, and 6 had invasion of the cricoid cartilage. Four of the 8 patients with cricothyroid node involvement died of the disease, 3 of whom had stomal recurrence. None of the patients who died of disease had surgical management of the paratracheal lymph nodes or postoperative radiation therapy. The benefit of surgical margins of the paratracheal lymph node bed as well as the role of radiation therapy are discussed.

Pilot study of the oral omeprazole test for reflux laryngitis

BACKGROUND

Gastroesophageal reflux disease occasionally presents with laryngeal symptoms. Such patients are often referred for a gastroenterology evaluation. This study was designed to determine whether an empiric trial of high-dose omeprazole therapy could reliably identify patients with reflux laryngitis and thus obviate the need for a gastroenterology workup.

METHODS

Patients were evaluated with a history, physical examination, esophageal manometry, upper endoscopy, and 24-hour pH-metry for determination of the presence of absence of underlying gastroesophageal reflux disease and then received an empiric trial of oral omeprazole therapy (20 mg twice daily for 1 month). A positive omeprazole test result was defined as resolution of all laryngeal symptoms on completion of the empiric trial of therapy.

RESULTS

Two patients were classified as having no reflux, and eight were classified as having reflux. Omeprazole test results were positive in six patients. Five of six had reflux, but one patient had no evidence for reflux. Omeprazole test results were negative in four patients. Three of four had reflux, and one did not. Despite the absence of antisecretory therapy, laryngeal symptoms did not recur in either patient without reflux during follow-up. Laryngeal symptoms were managed in two of the three patients with reflux who had negative omeprazole test results and who were using inhalers in combination with histamine H2 receptor antagonist therapy for their reflux disease. One patient with reflux who had a negative omeprazole test result responded to higher doses of omeprazole, and the five patients with reflux who had positive omeprazole test results all responded to continuation of omeprazole.

CONCLUSIONS

The omeprazole test may be useful in confirming the suspicion of reflux laryngitis in patients suspected of having this disease after an otolaryngology evaluation. However, there is a potential for false-positive and false-negative test results. A gastroenterology evaluation may aid in the identification of false-positive test results by documenting the absence of reflux in certain responders.

Granular cell myoblastoma of the cervical esophagus: MR findings

Granular cell myoblastomas are uncommon, typically benign tumors. Involvement of the esophagus is rare, and frequently they are asymptomatic. We report a granular cell myoblastoma involving the cervical esophagus in a patient who had paralysis of the true vocal cord and progressive dysphagia. At MR imaging, the circumscribed mass was hypointense on T1-weighted images and mildly hyperintense on T2-weighted images, with homogeneous contrast enhancement.

Primary malignant melanoma of the sinonasal cavity: MR imaging evaluation

To evaluate the magnetic resonance (MR) imaging characteristics of primary malignant melanoma of the sinonasal cavity, T1- and T2-weighted MR images of 12 patients with primary sinonasal melanoma were retrospectively reviewed. Gadolinium-enhanced imaging was performed in seven cases. The MR images were compared with histopathologic results. There were seven melanotic melanomas and five amelanotic melanomas; hemorrhage was present in three melanotic and two amelanotic melanomas. The seven melanotic melanomas were hyperintense to gray matter on T1-weighted images (whether hemorrhage was present or not), consistent with the paramagnetic effect of melanin. Four of the five amelanotic melanomas had intermediate signal intensity on T1-weighted images; one was not detected. On T2-weighted images, all of the melanomas detected had intermediate though variable signal intensity compared with that of gray matter. On gadolinium-enhanced images, all cases demonstrated mild to moderate enhancement. The signal intensity of sinonasal melanoma appears to vary according to the histopathologic components of the tumor. High signal intensity within the lesion on T1-weighted images suggests the presence of melanin.

The role of computed tomography and magnetic resonance imaging in planning for conservation laryngeal surgery

Refined laryngeal conservation surgeries have been devised to maintain the voice while eradicating even extensive glottic and hypopharyngeal tumors. The role of diagnostic imaging is to adequately define the extent of disease in conjunction with endoscopy. Critical areas to be evaluated are the tongue base, vallecula, pre-epiglottic space, arytenoid cartilages, postcricoid region, hypopharynx, thyroid cartilage, and subglottis.

Evaluation of HER-2/neu (c-erbB-2) oncogene expression in whole organ sections of supraglottic squamous cell carcinoma

Adequate pathologic material and careful clinical follow-up are prerequisites for the analysis of the expression of particular oncogenic proteins that are prognostically important in squamous cell carcinoma of the larynx. The Gabriel Tucker, Jr, Collection of 150 whole organ specimens allows for the potential immunohistochemical study of the entire tumor. Sections from 32 supraglottic carcinomas were studied immunohistochemically for the presence of HER-2/neu (c-erbB-2) oncogene expression. Long-term follow-up data were available in all cases to assist in determining the prognostic significance of the specified oncogene in supraglottic squamous cell carcinoma. Our study revealed that joint presentation of immune staining for c-erbB-2 and positive lymph node status was significantly associated with distant metastasis (p=.00760).

Glottic carcinoma with a fixed true vocal cord: outcomes after neoadjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidoepiglottopexy

Twenty patients with glottic squamous cell carcinoma and a fixed true vocal cord underwent neoadjuvant chemotherapy followed by supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Phonation, respiration, and deglutition were preserved. Local control was better than has been previously reported for either extended vertical partial laryngectomy or radiation therapy. All patients were monitored for at least 3 years or until death. The Kaplan-Meier 3-year survival, local recurrence, nodal recurrence, distant metastasis, and second primary rates were 75%, 10.8%, 5%, 10.8%, and 10.8%, respectively. Overall local control was achieved in all cases, and laryngeal preservation in 90%. Our experience suggested that neoadjuvant chemotherapy with supracricoid partial laryngectomy with cricohyoidoepiglottopexy deserves further consideration in the treatment of glottic tumors with a fixed true vocal cord.

Glottic Carcinoma with a Fixed True Vocal Cord: Outcomes after Neoadjuvant Chemotherapy and Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

Twenty patients with glottic squamous cell carcinoma and a fixed true vocal cord underwent neoadjuvant chemotherapy followed by supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Phonation, respiration, and deglutition were preserved. Local control was better than has been previously reported for either extended vertical partial laryngectomy or radiation therapy. All patients were monitored for at least 3 years or until death. The Kaplan-Meier 3-year survival, local recurrence, nodal recurrence, distant metastasis, and second primary rates were 75%, 10.8%, 5%, 10.8%, and 10.8%, respectively. Overall local control was achieved in all cases, and laryngeal preservation in 90%. Our experience suggested that neoadjuvant chemotherapy with supracricoid partial laryngectomy with cricohyoidoepiglottopexy deserves further consideration in the treatment of glottic tumors with a fixed true vocal cord.

Reconsidering a paradigm: the spread of supraglottic carcinoma to the glottis

This study was performed to evaluate the spread of supraglottic carcinoma to the glottic level. Whole organ sections of total laryngectomy specimens from 37 patients with previously untreated supraglottic carcinomas were reviewed retrospectively. Of the 37 specimens, 20 (54%) were noted to have extension of cancer to the glottic level. A significant relationship was noted between glottic extension and abnormal cord motion (P = .0002). A statistically significant trend was noted for the relationship between inferior extension along the supraglottic mucosa and glottic level extension (P < .0001). Contrary to the prevailing model of the spread of supraglottic carcinoma, in which there is a distinct barrier to spread at the ventricle, this analysis of selected supraglottic carcinomas revealed a continuum of spread from the supraglottic to the glottis.

Evaluation of osseointegration of endosseous implants in radiated, vascularized fibula flaps to the mandible: a pilot study

PURPOSE

This study clinically evaluated the osseointegration of implants placed into vascularized fibula flaps used in mandibular reconstruction of cancer patients following radiation treatment and subsequent hyperbaric oxygen (HBO) therapy.

MATERIALS AND METHODS

Five head and neck cancer patients had mandibular resection and immediate reconstruction with a vascularized fibula flap. Subsequent therapy included greater than 50 Gy of radiation to the fibula flap over a 6 to 8-week period. Two to 6 weeks following radiation therapy each patient received 20 90-minute daily sessions of HBO at 2.4 atmosphere pressure. Stage 1 implant surgery was performed placing two to six implants (15 mm in length and 3.75 to 4.0 mm in width) into each fibula flap. This was followed by 10 postoperative HBO sessions using the previously mentioned protocol. The stage 2 procedure was performed 6 months after the stage 1 procedure. Osseointegration was assessed clinically using manual force and an electronic device at the time the implants were uncovered and monthly over a 6-month period.

RESULTS

All 20 implants placed in the fibula flaps were osseointegrated clinically at the time the implants were uncovered and during the 6-month follow-up.

CONCLUSION

In this pilot study, mandibular reconstruction with a vascularized fibula flap and endosseous osseointegrated implants, following radiation of the fibula, was successful. It was concluded that factors such as the graft having its own blood supply and the use of HBO contributed to the successful osseointegration of these implants.

Carotid artery invasion by head and neck masses: prediction with MR imaging

PURPOSE

To determine the value of magnetic resonance (MR) imaging in predicting resectability of head and neck neoplasms around the carotid arteries.

MATERIALS AND METHODS

Forty-nine patients (28 male patients and 21 female patients aged 17-79 years; mean, 57.3 years) with head and neck masses and clinical evidence of carotid wall invasion underwent MR imaging. T1-weighted, T2-weighted, and gadolinium-enhanced T1-weighted images were analyzed to determine circumferential involvement of 53 arteries by tumor.

RESULTS

More than 270 degrees of circumferential involvement was considered suggestive of unresectability of the malignant neoplasm; 270 degrees or less was considered lack of invasion. The sensitivity of MR imaging for determination of unresectable disease was 100% (12 of 12 cases), specificity was 88% (36 of 41), and accuracy was 91% (48 of 53). Accuracy was 100% for squamous cell carcinoma (n = 29).

CONCLUSION

Tumor that encompasses more than 270 degrees of the carotid artery probably cannot be removed from the artery. Tumor that involves 270 degrees or less of the artery can be removed.

MR of mandibular invasion in patients with oral and oropharyngeal malignant neoplasms

PURPOSE

To investigate whether MR imaging is an accurate means of assessing mandibular invasion in patients with carcinoma.

METHODS

We retrospectively studied the MR scans of 22 patients with pathologic or surgical confirmation of mandibular invasion from oral and oropharyngeal cancers. The MR images were blindly analyzed using primary criteria of: (a) cortical breakdown, (b) replacement of bone marrow fat, or (c) gadopentetate dimeglumine enhancement of a mass at the bone marrow defect. Secondary criteria of: (a) contiguous soft-tissue mass, and (b) mass on both sides of the mandibular cortex were also examined. Mandibular invasion was graded as periosteal/cortical, medullary, or no invasion.

RESULTS

Primary positive findings of cortical breakdown and abnormal bone marrow signal were highly sensitive (100%) for periosteal/cortical invasion and medullary involvement, respectively. However, a high rate of false-positive studies hampered the MR accuracy, which fell into the 73% to 77% range. A negative MR study was highly predictive, but a positive study was less valuable. Gadolinium enhancement added little to the MR study's accuracy. False-positive studies mainly occurred in the setting of prior irradiation, osteoradionecrosis, and odontogenic infections.

CONCLUSIONS

MR imaging is a sensitive method for detecting mandibular invasion but has a low positive predictive value. A negative study virtually excludes cortical/periosteal or bone marrow invasion.