Surgical treatment of squamous cell carcinoma of the base of tongue

INTRODUCTION

Squamous cell carcinoma (SSC) of the tongue base has historically been shown to be associated with a poor prognosis. We reviewed our experience with primary surgery followed by postoperative radiation therapy (XRT) to determine the impact of our treatment protocols on outcome.

METHODS

We retrospectively reviewed the records of all patients presenting to the University of Pittsburgh with previously untreated SSC of the tongue base between 1980-1997. Patients who were treated nonoperatively were excluded from analysis. Surgical excision of the primary was performed with ipsilateral neck dissection. The contralateral neck was dissected when the primary lesion was located in the midline or for clinically positive contralateral neck nodes. Postoperatively, most patients (93%) received XRT to the primary site and neck. Adjuvant chemotherapy was offered if histologic signs of aggressive behavior were identified (multiple nodes or extracapsular spread).

RESULTS

Of 87 patients identified, 39 (45%) were initially seen with T1 or T2 tumors. Seventy-nine patients (91%) were initially seen with stage III or IV disease. Contralateral neck dissection was performed in 36 patients (41%). Metastatic disease was demonstrated in 84% of ipsilateral neck nodes and in 47% of contralateral neck nodes. Occult metastases were found in 61% of clinically N0 necks. Local recurrence occurred in 5 patients, regional recurrence occurred in 12 patients, and distant metastases developed in 22 patients. Overall and disease-specific survival rates at 5 years for all patients were 49% and 56%, respectively. The 5 year disease-specific survival rates for stage I, stage II, stage III, and stage IV disease were 100%, 86%, 62%, and 48%. The 5-year disease-specific survival rate was 88% for T1 lesions, 64% for T2 lesions, 58% for T3 lesions, and 30% for T4 lesions (p <.05, log-rank test).

CONCLUSIONS

Surgical treatment of SCC of the tongue base is highly effective in achieving local disease control and disease-free survival for early lesions. Because both functional outcome and survival are poor after surgical treatment of advanced lesions, we now offer brachytherapy with XRT or participation in a combined chemoradiation protocol rather than primary surgical therapy to patients with advanced disease. Prospective studies are needed to compare the effect of these organ-preserving therapies with traditional combined surgery and XRT to determine the effect on functional outcome and quality of life.

Nasal T-cell lymphoma: case report and review of diagnostic features

A 73-year-old man was referred to us for evaluation of extensive nasal crusting and progressive erosion of the nasal midline structures. Clinical examination suggested that the patient had a T-cell lymphoma, a suspicion that was confirmed on immunohistochemical analysis. The patient was treated with combination chemo- and radiotherapy and exhibited a marked response. At the 14-month followup, he remained disease-free.

Proposal of standardization on screening tests for detection of distant metastases from head and neck cancer

A standardized approach to screening for distant metastases must be flexible. This reflects the fact that the issues involved have not been adequately studied to allow evidence-based recommendations. Effective and responsible application of screening for distant metastasis would improve our ability to council patients regarding important therapeutic decisions. It would also have important consequences on healthcare economics. Screening recommendations should reflect the stage of the primary tumor and the histologic cell type because these two parameters most clearly correlate with the risk for distant metastases. The most commonly encountered distant metastases are pulmonary. The most sensitive validated screening technique is just computed tomography (CT). Advanced technologies such as simultaneous positron emission tomography/CT may replace these prior technologies in the near future. Recommendations for routine screening following curative treatment are subjective at this time. Careful history and physical examination remains the basis for the follow-up evaluation. The sensitivity and cost effectiveness of imaging studies in this setting remains unstudied and contentious.

The role of topical antibiotic prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction

OBJECTIVES/HYPOTHESIS

Patients undergoing contaminated head and neck surgery with flap reconstruction have wound infection rates of 20% to 25% with parenteral antibiotic prophylaxis. Studies suggest that perioperative antimicrobial mouthwash reduces oropharyngeal flora and may prevent wound infections. We hypothesized that the addition of topical antibiotics to a parenteral prophylactic regimen would reduce the incidence of wound infection in these high-risk patients.

STUDY DESIGN

We performed a randomized, prospective clinical trial.

METHODS

Patients received either 1) parenteral piperacillin/tazobactam (3.375 g every 6 hours for 48 h) or 2) parenteral piperacillin/tazobactam plus topical piperacillin/tazobactam administered as a mouthwash immediately before surgery and once a day for 2 days postoperatively, with piperacillin/tazobactam added to the intraoperative irrigation solution. The wounds of all patients were evaluated daily using predefined objective criteria.

RESULTS

Sixty-two patients met inclusion criteria and were enrolled in the study. The overall wound infection rate was 8.1% (95% confidence interval [CI], 2.7%-17.8%). Two of 31 patients (6.4%) who received parenteral antibiotics alone developed a wound infection compared with 3 of 31 patients (9.7%) randomly assigned to receive topical plus parenteral antibiotics. This difference was not statistically significant (P = >.05). Infection rate was not associated with flap type (rotational vs. free tissue transfer), mandibular reconstruction, age, gender, tumor site, stage, surgical duration, or blood loss.

CONCLUSIONS

These results suggest that piperacillin/tazobactam is a highly effective antibiotic for prevention of wound infection in patients undergoing flap reconstruction following contaminated head and neck surgery. However, the addition of topical piperacillin/tazobactam does not appear to enhance the prophylactic benefit of parenteral antibiotics alone.

Prevention of radiation-induced mucositis

Radiation-induced mucositis is an important dose-limiting acute side effect associated with the treatment of tumors of the upper aerodigestive tract. The toxicity of radiation therapy increases with prior or concurrent administration of some chemotherapeutic agents. Pretreatment eradication of infection, maintenance of oral hygiene, and treatment breaks, as necessary, have been the mainstay of the therapeutic options for patients with radiation-induced mucositis. Recent research has begun to clarify the pathophysiology of radiation-induced mucositis. This suggests that new, more effective agents for both prevention and treatment may be forthcoming in the near future. Currently, no highly effective and widely accepted prevention or treatment exists.

Selective neck dissection in the management of the clinically node-negative neck

OBJECTIVE

To evaluate the efficacy of the selective neck dissection (SND) in the management of the clinically node-negative neck.

STUDY DESIGN

Case histories were evaluated retrospectively.

METHODS

The results of 300 neck dissections performed on 210 patients were studied.

RESULTS

The primary sites were oral cavity (91), oropharynx (30), hypopharynx (16), and larynx (73). Seventy-one necks (23%) were node positive on pathological examination. The number of positive nodes varied from 1 to 9 per side. Of necks with positive nodes, 17 (24%) had extracapsular spread. The median follow-up was 41 months. Recurrent disease developed in the dissected neck of 11 patients (4%). Two recurrences developed outside the dissected field. The incidence of regional recurrences was similar in patients in whom nodes were negative on histological examination (3%) when compared with patients with positive nodes without extracapsular spread (4%). In contrast, regional recurrence developed in 18% of necks with extracapsular spread. This observation was statistically significant. Patients having more than two metastatic lymph nodes had a higher incidence of recurrent disease than the patients with carcinoma limited to one or two nodes. Recurrence rate in the pathologically node positive (pN+) necks was comparable to recurrence in those pathologically node negative (pNO) necks in the patients who did not have irradiation.

CONCLUSION

SND is effective for controlling neck disease and serves to detect patients who require adjuvant therapy.

Process versus content in eyewitness metamemory monitoring

Three studies (Ns = 200, 135, and 187 college undergraduates) contrasted process versus content accounts of eyewitness metamemory monitoring. Subjective vividness, a cue related to memory content, was a better predictor of confidence and accuracy than were cues related to the retrieval process. Participants who were asked to recall, rather than recognize, event details displayed greater insight into accuracy, primarily because vividness was a more valid accuracy cue under recall conditions. Results reinforce the value of recall-based protocols for eliciting eyewitness testimony and suggest some specific conditions (e.g., yes-no recognition) under which investigators should be especially cautious in relying on confidence to infer accuracy. In addition, results point to a general framework for understanding moderating effects on eyewitness metamemory accuracy.

More aggressive behavior of squamous cell carcinoma of the anterior tongue in young women

OBJECTIVE

To review the combined experience from two large medical centers in treating young female patients with anterior tongue cancer to determine the clinical course of this unique subset of patients.

STUDY DESIGN

Retrospective study.

METHODS

Seventeen female patients less than 40 years of age (group A) and 17 older patients, both male and female, greater than 40 years of age (group B) who had treatment for invasive squamous cell carcinoma of the anterior tongue were studied. The charts were reviewed for the clinical staging, treatment, and outcome of each patient. The disease-free survival and recurrence rates were compared between the two cohorts.

RESULTS

The mean disease stage between the groups was II. The survival analysis showed a significant difference between the two groups in recurrences (group A = 65%, group B = 41%; P = .02). Further, of the patients who had recurrence, the young women did so significantly earlier in their disease course than the older patients (group A = 14 mo, group B = 40 mo; P < .05). Although the survival differences did not reach statistical significance (P = .15), the power of the study was low (power = 0.26) resulting in a high-level type II error.

CONCLUSION

These data suggest that young women with squamous cell carcinoma of the anterior tongue have significantly higher rates of recurrent disease and the interval to recurrence is significantly shorter than in older patients. Further investigation is warranted until a statistically significant cohort is accrued; until that time, these patients warrant an aggressive initial treatment and close surveillance for recurrence.

Incidence of unsuspected metastases in lateral cervical cysts

OBJECTIVE

Solitary cystic squamous cell carcinoma metastases may be difficult to distinguish clinically from a benign cervical cyst. We sought to identify the incidence of solitary cystic squamous cell carcinoma metastasis in patients presenting with apparently benign cervical cysts.

STUDY DESIGN

Retrospective review.

METHODS

The records of all patients who presented with isolated lateral cervical cysts between 1983 and 1999 were reviewed. Patients with a clinically apparent primary malignancy, a history of head and neck cancer, a history of irradiation, or age less than 18 years were excluded from analysis, as were patients with a histological diagnosis of nonsquamous cell malignancy or those without a final histological diagnosis.

RESULTS

One hundred twenty-one adult patients presented with an initial diagnosis of lateral cervical cyst. Metastatic squamous cell carcinoma was demonstrated histologically after surgical excision in 12 patients (9.9%). The incidence of malignancy was significantly greater in patients greater than 40 years of age (23.5%, P < .0001). Results of preoperative fine-needle aspiration (FNA) were negative for malignancy in five cases of metastatic squamous cell carcinoma. Panendoscopy with directed biopsies revealed an occult primary in the base of tongue in three patients, tonsil in one patient, and nasopharynx in one. No primary was found in six patients, despite repeated examinations and close follow-up.

CONCLUSIONS

Solitary cervical cysts in patients older than 40 years of age should be presumed to be carcinoma until proven otherwise. A negative FNA result may be misleading, because of hypocellularity of the cyst fluid. Excisional biopsy should be undertaken with provisions made for frozen-section analysis of the specimen and contingency panendoscopy with directed biopsies of Waldeyer's ring if frozen-section histological examination reveals malignancy.

Process versus content in eyewitness metamemory monitoring

Three studies (Ns = 200, 135, and 187 college undergraduates) contrasted process versus content accounts of eyewitness metamemory monitoring. Subjective vividness, a cue related to memory content, was a better predictor of confidence and accuracy than were cues related to the retrieval process. Participants who were asked to recall, rather than recognize, event details displayed greater insight into accuracy, primarily because vividness was a more valid accuracy cue under recall conditions. Results reinforce the value of recall-based protocols for eliciting eyewitness testimony and suggest some specific conditions (e.g., yes-no recognition) under which investigators should be especially cautious in relying on confidence to infer accuracy. In addition, results point to a general framework for understanding moderating effects on eyewitness metamemory accuracy.

Early detection and treatment of skin cancer

The incidence of skin cancer is increasing by epidemic proportions. Basal cell cancer remains the most common skin neoplasm, and simple excision is generally curative. Squamous cell cancers may be preceded by actinic keratoses-premalignant lesions that are treated with cryotherapy, excision, curettage or topical 5-fluorouracil. While squamous cell carcinoma is usually easily cured with local excision, it may invade deeper structures and metastasize. Aggressive local growth and metastasis are common features of malignant melanoma, which accounts for 75 percent of all deaths associated with skin cancer. Early detection greatly improves the prognosis of patients with malignant melanoma. The differential diagnosis of pigmented lesions is challenging, although the ABCD and seven-point checklists are helpful in determining which pigmented lesions require excision. Sun exposure remains the most important risk factor for all skin neoplasms. Thus, patients should be taught basic "safe sun" measures: sun avoidance during peak ultraviolet-B hours; proper use of sunscreen and protective clothing; and avoidance of suntanning.

Family planning services and programmes in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on the family planning services and programmes in the Region. Data were collected using a questionnaire which explored the following areas: the presence of population or family planning policies and family planning activities, the family planning services available, promotional and educational activities on family planning, quality assurance, family planning data collection, analysis and dissemination, and the use of such information. The results indicate that 13 of the countries have national policies on population and family planning but even in those that do not, family planning services are widely available. The scope of the services provided varied. There is still a need to implement or strengthen family planning programmes in the Region, a need which is recognized by the countries themselves.

Primary surgery as treatment for early squamous cell carcinoma of the tonsil

BACKGROUND

The management of tonsil carcinoma has gradually evolved such that the literature is replete with outcome summaries of this disease treated with primary RT and chemotherapy. Recently there have been no reports of patient outcomes with primary surgical therapy. Nonsurgical treatment is warranted when tumors are unresectable or if the patient refuses surgery. Our policy has been to treat operable squamous cell carcinoma (SCCA) of the tonsil with surgery. The decision to use adjuvant therapy is based on the surgical and histologic findings. We herein report our results with this treatment protocol.

METHODS

A retrospective review of 162 patients with SCCA of the tonsil was performed. Eighty-four patients were treated with surgery, which was followed by RT and/or chemotherapy if histologic signs of aggressive behavior were identified. Patients were followed 2 to 15 years after treatment.

RESULTS

Of the 9 patients with stage I disease, 89% are without evidence of recurrent disease and 91% of patients with stage II tonsil cancers are also disease free. The survival rates for stage III and stage IV cancer patients are 79 and 52%, respectively.

CONCLUSION

Our data suggest that patients with early tonsil cancer can be effectively treated with surgery. Surgery allows pathologic staging so that patients with advanced tumors can be treated with adjuvant therapy.

Cancer of the tongue in patients less than forty

INTRODUCTION

It is the opinion of many surgeons that the biologic potential of cancer that develops in young people is different compared with older patients. Prior reports on small series of patients addressing this issue have inadequate statistical power to resolve the question.

METHODS

By use of the techniques of meta-analysis, patients less than 40 years old who had undergone treatment of squamous cell carcinoma (SCC) of the oral tongue were examined. Twenty-eight patients who were encountered in the Department of Otolaryngology, University of Pittsburgh School of Medicine, and 94 patients were identified in the literature for a total of 122 patients <40 years old. A control group of 150 patients, aged 40 years and older treated for SCC of the oral tongue between 1982 and 1994 was identified.

RESULTS

Three-year disease-free survival in the group of patients aged less than 40 was 53.3% compared with 3-year disease free survivorship of 55.0% in the older cohort of patients.

CONCLUSION

These data strongly suggest that the outcomes of treatment for SCC of the oral tongue in young patients are similar compared with patients older than 40 with similar extent of disease.

Risk factors for local recurrence of adenoid cystic carcinoma: the role of postoperative radiation therapy

PURPOSE

Postoperative radiation therapy is often advocated in the treatment of patients with adenoid cystic carcinoma (ACC) of the head and neck. A retrospective analysis was performed to determine prognostic factors for local recurrence after surgery and to examine the role of postoperative radiation therapy.

MATERIALS AND METHODS

A retrospective analysis of 58 patients undergoing surgery for ACC of the head and neck at the University of Pittsburgh Medical Center from 1974 to 1994 was performed. Patients were followed up for a minimum of 24 months for the development of recurrent disease. The association of recurrence was correlated with clinical factors (age, sex, site, and stage); postoperative treatment (radiation therapy v no radiation); and pathologic variables (grade, margins of resection, and perineural invasion), and appropriate statistical analysis was performed.

RESULTS

Recurrent disease developed in 59% of patients, despite the addition of postoperative radiation therapy in 83% of patients. Tumor site was the single most important factor for the development of locally recurrent disease and was correlated with primary tumor stage and resection margins. Local recurrence rates were decreased (P = .07) in patients with negative surgical margins who were irradiated.

CONCLUSIONS

Larger perspective randomized trials are necessary to evaluate the efficacy of postoperative radiation, and new treatments need to be investigated to improve local control rates for ACC of the head and neck.

Skin metastases from head and neck squamous cell carcinoma: incidence and impact

BACKGROUND

Squamous cell carcinoma (SCC) of the upper aerodigestive tract rarely metastasizes to the skin. This study was designed to review the incidence of skin metastases, to identify associated risk factors, and to investigate the prognostic significance of skin metastases.

METHODS

A cohort of 2491 patients treated for SCC originating in the upper aerodigestive tract were evaluated retrospectively. Patients who developed skin metastases were evaluated with respect to tumor stage, treatment, and outcome. Patients with skin metastases were compared with patients who developed distant metastases at other sites and with those who did not develop distant metastases.

RESULTS

Skin metastases developed in 19 (0.763%) patients. The median time to occurrence was 6 months. Ninety percent of patients died of disease within a median of 3 months (1 to 16 months) following diagnosis. The development of skin metastasis is most closely related to the presence of two or more cervical metastases and/or extracapsular spread of tumor in the cervical metastases. Similar risk factors were identified for the development of distant metastases to other sites.

CONCLUSION

Metastasis to skin is a rare occurrence which has prognostic significance similar to distant metastasis to other areas.

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract

BACKGROUND

Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated.

METHODS

A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome.

RESULTS

Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months.

CONCLUSIONS

ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Spontaneous ex vivo apoptosis of peripheral blood mononuclear cells in patients with head and neck cancer

Proportions of apoptotic (TUNEL+) peripheral blood mononuclear cells (PBMCs) were measured by flow cytometry in patients with head and neck cancer and normal controls at the time of blood draws (0 time) and after 24-h incubation. PBMCs were incubated at 37 degrees C in medium (spontaneous apoptosis) and in the presence of CH-11 antibody (anti-Fas) or tumor necrosis factor (TNF)-alpha, both capable of inducing DNA fragmentation in activated T cells expressing the TNF family of receptors. PBMCs obtained from the patients had significantly higher (P < 0.0001) proportion of apoptotic cells than PBMCs of controls at 0 time as well as after 24-h incubation. Ex vivo apoptosis included all subsets of PBMCs: CD3+ T cells, CD16+ CD56+ natural killer cells, CD19+ B cells, and CD14+ monocytes, as determined by two-color flow cytometry. However, T cells represented the largest PBMC subset undergoing apoptosis, and lymphocytes rather than monocytes were the major TUNEL+ PBMC population. Among T cells, the level of spontaneous ex vivo apoptosis was nearly as high as that of CH-11 antibody-induced or TNF-alpha-induced apoptosis, indicating that activated Fas+ and TNFR1+ T cells were preprogrammed in vivo to die. Also, elevated levels of spontaneous apoptosis at time 0 in patients with head and neck cancer (P < 0.0001) indicated that a higher fraction of PBMCs was undergoing apoptosis in vivo in patients than controls. Together, the data suggest that an increased rate of turnover of lymphocytes is associated with cancer and may be responsible for functional lymphocyte imbalance, even in treated patients who have no evident disease.

Determination of olanzapine in human breast milk by high-performance liquid chromatography with electrochemical detection

A reversed-phase high-performance liquid chromatographic-electrochemical assay was developed and validated for the quantification of olanzapine in human breast milk. The assay involved a solid-phase extraction (SPE) of olanzapine and its internal standard on a Bond Elut Certify LRC mixed-mode cartridge. After conditioning of the SPE cartridge, human milk (1 ml) was passed through the cartridge. The cartridge was washed with five separate washing steps to remove endogenous compounds, and the analytes were eluted with ethyl acetate-ammonium hydroxide (98:2, v/v) solution. The eluate was evaporated to dryness (gentle stream of nitrogen at 40 degrees C), and the residue was dissolved in mobile phase. The extract was injected onto a YMC basic column (150 mmx4.6 mm I.D., 5 microm particle size) at a flow-rate of 1 ml/min. A mixture of 75 mM phosphate buffer, pH 7.0-acetonitrile-methanol (48:26:26, v/v/v) was used as the mobile phase. Standard curves with a lower limit of quantitation of 0.25 ng/ml of olanzapine were linear (r2> or =0.9992) over a range of 0.25-100 ng/ml. Based on the analysis of quality control (QC) samples, the average inter-day accuracy (RE) was 99.0% with an average precision (CV) of 6.64% over the entire range. The stability of olanzapine in human milk was established after three freeze-thaw-heat cycles and storage at -70 degrees C for 10 months. The validated method was used to measure olanzapine concentrations in human milk during a clinical trial.

Allergic rhinitis and rhinosinusitis. Is there a connection between allergy and infection?

Each year allergic rhinitis and rhinosinusitis account for millions of office visits and billions of dollars spent on prescription and nonprescription drugs. Although the causes and symptoms of these two ailments differ, there is evidence that they are linked. The authors explain how effective control of allergy symptoms can reduce the incidence and severity of rhinosinusitis.

Detection of intracellular tumor necrosis factor alpha in stimulated fetal cells

BACKGROUND

It is unknown if immature fetal cells produce tumor necrosis factor (TNF) alpha in the same manner that adult cells do. The aim of this study was to determine the feasibility of early detection of intracellular TNF produced by circulating human monocytes (Mo) and lymphocytes (Ly) using flow cytometry and to compare the stimulation profiles of mature and fetal cells.

MATERIAL AND METHODS

Fetal umbilical cord blood (n = 10) and adult volunteer blood (n = 10) were obtained. In vitro stimulation with endotoxin (LPS) and ionomycin-PMA was performed. Brefeldin A was added to prevent extracellular transport of TNF. Cell type was determined by using CD-14 marker separating monocyte and lymphocyte populations. Anti-human TNF monoclonal antibody was used to detect intracellular TNF by flow cytometry analysis.

RESULTS

Thirty to sixty thousand cells were analyzed per sample. Average TNF expression of stimulated fetal Mo was 28.2%, and that of fetal Ly was only 1.1%. Adult stimulated Ly had an average TNF expression of 31.9%, and adult Mo, 29.6% (P < 0.05 for adult Ly vs fetal Ly).

CONCLUSION

TNF flow cytometry analysis allows assessment of individual cell types and their ability to produce that cytokine. Fetal cells are able to produce TNF when stimulated, but the stimulation profile of Ly differs from that of adult samples. This observation may be of clinical importance in evaluating the response of immature cells to a septic stimulus. Flow cytometry is reliable, reproducible, quick, and easily obtained from a small sample of peripheral blood. Clinical use will be applicable once appropriate controls are developed, as reported in this study.

Squamous cell carcinoma of the sinonasal tract invading the orbit

OBJECTIVE/HYPOTHESIS

The treatment of squamous cell carcinoma (SCC) of the sinonasal tract has evolved from routine exenteration of the orbital contents to sparing of the orbit when the SCC does not transgress the periorbita. Nonetheless, the influence of this change in treatment over the rate of local recurrence or survival has not been clearly elucidated. The objective was to ascertain whether orbital sparing surgery for the treatment of SCC of the paranasal sinuses influences the rate of local recurrence or survival.

STUDY DESIGN

This is a retrospective study of patients presenting with SCC arising in the sinonasal tract, treated primarily at the University of Pittsburgh Medical Center from 1977 to 1990, including meta-analysis of the English literature regarding SCC of the sinonasal tract.

METHODS

Review of medical records regarding demographics, histology, extension of tumor, pathologic results, type of surgery, adjunctive therapy, and outcome. Articles for meta-analysis were identified by Medline search and cross-referencing.

RESULTS

Fifty-eight patients with orbital invasion, including bone and/or soft tissue invasion, were included in the study. Patients presenting with invasion of the bony orbit without soft tissue invasion were treated with maxillectomy and/or ethmoidectomy, sparing the orbital contents. Patients presenting with invasion of the orbital bones and soft tissues were treated with ethmoidectomy or maxillectomy, including orbital exenteration. At 3 years' follow-up, 52% of the patients whose orbit was exenterated were alive and without evidence of disease, compared with 59% of the patients whose orbit was spared. This difference was not statistically significant. Similarly, the rate of local recurrence was not statistically significant (P > .05). A meta-analysis of the literature revealed similar results.

CONCLUSIONS

Our data suggest that sparing of the soft tissues of the orbit when the periorbita has not been transgressed by SCC does not downgrade the rate of cure or local control.

Clinical significance of decreased zeta chain expression in peripheral blood lymphocytes of patients with head and neck cancer

Patients with squamous cell carcinoma of the head and neck (SCCHN) frequently have impaired immune responses. Alterations in T-cell receptor-associated signaling molecules in tumor-infiltrating as well as circulating lymphocytes have been reported in these patients. Using quantitative flow cytometry analysis, we have demonstrated that expression of the zeta chain is significantly decreased relative to normal controls in both CD8+ and CD4+ T cells as well as CD3- CD56+ CD16+ natural killer cells in the peripheral blood of patients with SCCHN who, as a result of previous therapies, have no evident disease. Patients with a more aggressive type of SCCHN and those who experienced a recurrence or had a second primary cancer within the last 2 years of the study had the lowest zeta chain expression. In addition, SCCHN patients showed a significantly greater spontaneous ex vivo apoptosis, as measured by a terminal deoxynucleotide transferase-mediated dUTP nick end labeling assay, in PBMCs, compared to normal controls. The observed decreased expression of zeta in T and natural killer cells coincided but did not directly correlate with significantly increased spontaneous apoptosis of lymphocytes obtained from treated patients with no evident disease. The results suggest that in patients with SCCHN, zeta chain defects and lymphocyte apoptosis are manifestations of long-lasting negative effects of tumor on the immune system.