Ansa Cervicalis-to-Recurrent Laryngeal Nerve Anastomosis for Unilateral Vocal Fold Paralysis: Experience of a Single Institution

Objectives:

One treatment option for unilateral vocal fold paralysis (UVFP) is ansa cervicalis-to-recurrent laryngeal nerve (ansa-RLN) anastomosis to provide reinnervation to the affected vocal fold. The advantages of this treatment approach are that it 1) provides vocal fold tone, bulk, and tension, 2) is technically simple, and 3) does not preclude other medialization procedures. We present all patients who have undergone ansa-RLN anastomosis for UVFP at our institution.

Methods:

An Institutional Review Board-approved retrospective chart review was performed to include all patients who had undergone an ansa-RLN anastomosis procedure for UVFP at our institution. Data from clinical and endoscopic laryngoscopy with stroboscopy were recorded. Statistical analysis was performed on visual and perceptual vocal data.

Results:

A total of 46 patients were included in the study. Stroboscopic analysis and perceptual vocal evaluation was performed in a blinded fashion on the 21 patients who had preoperative and postoperative stroboscopy. Severity, roughness, breathiness, and strain all improved significantly over time. Glottic closure, vocal fold edge, and supraglottic effort all significantly improved after operation. Of the 38 patients with at least 3 months of follow-up, all except 1 demonstrated evidence of reinnervation.

Conclusions:

This technique for treating UVFP results in significant improvements in patients' voice and on visual examination.

Postallograft donor and recipient dendritic cell trafficking in the rat larynx

OBJECTIVES/HYPOTHESIS

Dendritic cells (DC) are potent antigen-presenting cells that instigate allograft rejection. Their migration kinetics vary depending on the type of organ transplanted. The timing of donor and recipient DC trafficking in laryngeal transplants is unknown.

STUDY DESIGN

Prospective animal model.

METHODS

Lewis to Brown Norway (BN) rat laryngeal allografts and BN to BN isografts were performed without immunosuppression. Recipient animals were sacrificed at seven posttransplant time points. Total DC, as well as recipient and donor DC (in allograft recipients), were enumerated in situ in the airway epithelium and subepithelium using monoclonal antibodies, immunofluorescence, confocal microscopy, and image analysis software.

RESULTS

Total DC densities in both laryngeal allografts and isografts decreased to approximately 10% of their initial values in the first 3 days and then rose beyond their starting values. In allografts, there was a net efflux of donor DC, reaching a nadir by 3 to 5 days; they were identified in recipient cervical lymph nodes from 12 hours to 5 days. Recipient DC infiltrated the laryngeal allograft, reaching a maximal density by day 7.

CONCLUSION

The paradigm of donor DC efflux and recipient DC influx has been confirmed in a rat laryngeal transplant model, and the allograft-specific timing of these events has been elucidated. Similarities in total DC migration between allografts and isografts suggest that this phenomenon may not be driven entirely by major histocompatibility mismatch. Further understanding of trafficking may help with the goal of manipulating DC to induce allograft tolerance in the absence of generalized immunosuppression.

RAD inhibition of sarcoma growth: implications for laryngeal transplantation

PURPOSE

Laryngeal transplantation has not been widely accepted because of concerns regarding accelerated tumor recurrences in the setting of nonspecific immunosuppression. Allotransplantation could potentially be offered to patients if immunosuppressive therapy could be demonstrated to exert tumor suppressive properties. Preliminary reports have demonstrated an antiproliferative effect of everolimus (RAD), a derivative of the immunosuppressant rapamycin.

MATERIALS AND METHODS

Forty-five 10-week-old inbred C57BL/6N (B6) mice were injected subcutaneously with 1 x 10(6) MCA205 sarcoma cells. On the third postinoculation day, the mice were divided into 4 treatment groups, undergoing daily gavage with RAD at 0, 0.2, 1.0, and 5.0 mg/kg per day for 10 consecutive days. Thereafter, treatment with RAD was discontinued and tumor size was measured every 2 days during treatment and biweekly until sacrifice on the 31st postinoculation day. Whole-blood trough levels (C(min)) were measured for each group.

RESULTS

Mean tumor diameter among the control animals and the mice treated with RAD 0.2 mg/kg per day demonstrated no significant difference (P > .07). Groups treated with RAD 1 and 5 mg/kg per day demonstrated significant growth inhibition between the 7th and the 23rd postinoculation days (P < .0001), with no significant differences being noted between these two groups (P > .09). Mean tumor suppressive whole-blood C(min)'s for the 1 and 5 mg/kg per day groups were 75.6 and 368.9 pg/microL, respectively.

CONCLUSIONS

RAD delivered at immunosuppressive doses of 1 and 5 mg/kg per day resulted in significant growth restriction of a fibrosarcoma in a murine model.

Laryngeal transplantation: research, clinical experience, and future goals

The loss of a functional voice because of trauma or laryngectomy can have a devastating impact on a patient's self-esteem and overall quality of life. Unfortunately, even with advances in organ preservation therapy, total laryngectomy is frequently necessary in the treatment of laryngeal carcinoma. Over the past several years, the senior author initiated research into laryngeal transplantation with the goal of restoring lung-powered speech for these patients. The research led to the development of an animal model and several groundbreaking studies in this area. Investigations into the use of irradiation, single-drug and multidrug immunosuppression, and the effects of mammalian target of rapamycin (mTOR) inhibitors have produced significant insight into laryngeal allograft preservation. The laboratory research culminated in the first successful total laryngeal transplant in 1998. The patient had suffered significant laryngeal trauma and strongly desired return of laryngeal phonation. The patient has been maintained on multidrug immunosuppression with minimal difficulties. Now more than 8 years after the procedure, the patient continues to have an excellent voice and dramatically improved quality of life. Recent data suggest that altered immunosuppression schedules and the use of mTOR inhibitors may allow patients to minimize immunosuppression-related adverse effects and ameliorate the risk of developing recurrent or de novo carcinoma. These data, when considered in combination with the progress made over the past 14 years, lead us to believe that the future of laryngeal transplantation is bright.

Swallowing Outcomes After Microvascular Head and Neck Reconstruction: A Prospective Review of 191 Cases

BACKGROUND

The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic.

METHODS

The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect.

RESULTS

The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet.

CONCLUSIONS

In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.

Ability of positron emission tomography to detect residual neck node disease in patients with head and neck squamous cell carcinoma after definitive chemoradiotherapy

OBJECTIVE

To report our experience using the neck examination, computed tomography (CT), and positron emission tomography (PET) to clinically evaluate node-positive patients with head and neck squamous cell cancer for residual neck node disease after definitive chemoradiotherapy.

DESIGN

Retrospective review of all Cleveland Clinic patients with head and neck squamous cell cancer and N2 or N3 neck node involvement at presentation who were treated with definitive concurrent chemoradiotherapy and who underwent clinical restaging after treatment using the neck examination, CT, and PET.

SETTING

Tertiary care referral institution.

PATIENTS

Forty-eight patients with 72 positive necks at diagnosis were followed up for a median of 20 months.

MAIN OUTCOME MEASURES

Palpable nodes on examination, nodes larger than 1 cm, nodes with central necrosis on CT, or any hypermetabolic lymph nodes on PET were considered clinical evidence of residual nodal disease. The true rate of pathologic involvement was determined by histologic examination after planned neck dissection or if regional recurrence developed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for all 3 clinical assessment tools.

RESULTS

Planned neck dissection was performed in 33 necks and was positive for residual neck node disease in 5 necks. A delayed neck dissection was performed in 5 necks and was positive in 3 necks. The positive predictive value was low for all 3 clinical assessment tools. The addition of PET did not significantly improve the negative predictive value or positive predictive value of CT and the clinical examination.

CONCLUSIONS

Residual neck node disease after definitive chemoradiotherapy was infrequent and was not well predicted by PET. A positive PET finding in this setting is of little utility. Although a negative PET finding was highly predictive for control of neck disease after chemoradiotherapy, it added little to the clinical neck examination and CT.

Clinical predictors of larynx preservation (LP) after multiagent concurrent chemoradiotherapy (MCCRT)

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Background: Identification of patients (pts) with larynx and hypopharynx (HP) squamous cell cancer (SCC) most likely to benefit from a LP strategy remains problematic. We retrospectively reviewed the Cleveland Clinic experience using MCCRT to identify potential clinical predictors for success. Methods: Definitive CCRT was considered appropriate for pts with locoregionally confined larynx or HP SCC except for those with cartilage invasion or laryngeal destruction. Cisplatin (20 mg/m2/day) and 5-FU (1,000 mg/m2/day) were given as continuous intravenous infusions on days 1–4 during the first and fourth weeks of either once or twice daily radiation. Laryngectomy was only performed for locally persistent or recurrent disease. Results: Between 1989 and 2006, 115 pts were treated; 87 (76%) were male, and 102 (89%) were white. The median age was 59 (range 31–77) years. The primary site was the HP in 46 pts (40%) , supraglottis in 50 (43%) and glottis in 19 (17%). Tumor was T1 in 4 (3%), T2 in 31 (27%), T3 in 42 (37%), T4 in 37 (32%), and TX in 1 (1%). Disease was stage II in 8 (7%), III in 34 (30%), and IV in 73 (63%). With a median follow up of 62 (range 5–195) months, the 5-year Kaplan-Meier projected local control rate without surgery is 82%. Residual primary site disease was found in only 5 pts after MCCRT. Primary site recurrence developed in 14 more pts. Surgical salvage was successful in 13 of these 19 pts (68%). The 5-year projected local control rate (including surgical salvage) is 94%. Late complications after successful LP included permanent tracheotomy in 3, and feeding tube dependence in 7 pts. For all 115 pts, the 5-year projected freedom from recurrence is 64%, overall survival 58% and laryngectomy-free survival 52%. Local control without surgery was more likely in pts with T1–2 compared to T3–4 tumors (97% vs. 75%, P=0.01), but was not predicted by age, race, tumor differentiation, primary site, nodal status, stage, radiation schedule (daily vs. twice daily), baseline hemoglobin, or continued smoking. Conclusions: This MCCRT regimen can be expected to result in successful LP in all clinical subsets of appropriately selected pts with larynx and HP SCC. Although local failure was more likely in pts with T3 or T4 tumors, it was infrequent, and subsequent surgical salvage was highly effective.

No significant financial relationships to disclose.

Transoral Robot-Assisted CO2 Laser Supraglottic Laryngectomy: Experimental and Clinical Data

BACKGROUND

Transoral CO2 laser surgery for selected supraglottic tumors results in improved postoperative function and decreased morbidity, with comparable survival to open surgery. Recently, robot-assisted techniques have been reported for the management of supraglottic lesions. There are no reports in the English literature of robotic technology coupled with CO2 laser technology. Our objective was to report the use of such technology.

STUDY DESIGN

Experimental resection of the supraglottis in a cadaver and a dog model using a commercially available surgical robot coupled with CO2 laser technology. Initial human experience with such technology is reported.

METHODS

With use of a hollow core fiber that allows the transmission of CO2 laser energy linked to the daVinci Surgical Robot, a supraglottic laryngectomy was performed in an edentulous female cadaver. The FK Laryngo-Pharyngoscope was used for exposure. In a second experiment, a supraglottic partial laryngectomy was performed in an 80 pound dog. On the basis of our experimental experience, a CO2 laser robotic-assisted supraglottic laryngectomy was attempted in three patients.

RESULTS

Removal of the supraglottic larynx in both a cadaver and canine experimental models was believed to be satisfactory using this technology. Bleeding was easily controlled in the live canine model. A 74-year-old woman with a large supraglottic mass for which she had been offered a total laryngectomy was resected successfully with this technology. The FK Laryngo-Pharyngoscope provided excellent exposure. The patient was able to swallow without difficulty on postoperative day 5. Follow-up endoscopic examination at 1 month showed no evidence of residual laryngeal tumor. Robot-assisted procedures were attempted in two additional patients, but adequate exposure could not be achieved, and more traditional techniques were performed.

CONCLUSIONS

The use of the daVinci Surgical robot coupled with CO2 laser technology is feasible, as demonstrated by our experimental and clinical data. Although further development of the robotic technology is required at present, the use of robotics coupled with CO2 laser technology may have important implications in the management of supraglottic laryngeal cancer in the future.

Risk factors for hypopharyngeal/upper esophageal stricture formation after concurrent chemoradiation

BACKGROUND

Concurrent chemoradiation therapy has been demonstrated to be effective as an organ-sparing treatment for select advanced head and neck squamous cell carcinoma (HNSCC). However, this treatment modality is not without side effects. One side effect is the formation of upper esophageal strictures. As concurrent chemoradiation treatment is used more frequently, it is important to identify risk factors associated with stricture formation.

METHODS

A retrospective chart review of all patients who had undergone definitive concurrent chemoradiation treatment between 1989 and 2002 was performed. Exclusion criteria included death within 1 year or persistent/recurrent disease that required surgical salvage at the primary site. The outcome measure was stricture formation as determined by both objective findings (barium swallow or endoscopy) and the need for dilation after treatment.

RESULTS

Of the 222 patients in this cohort, there were enough data for 199 patients to assess for stricture formation. Strictures developed in a total of 41 patients (21%). Significant predictive factors were a twice-daily (BID) radiation fractionation (p = .007), female sex (p = .015), and a hypopharyngeal primary site (p = .01). Age and tumor extent were not significant factors in stricture formation (p = .15 and p = .23, respectively).

CONCLUSIONS

Symptomatic strictures occur in 21% of patients undergoing concurrent chemoradiation for HNSCC. Female sex, BID radiation fractionation, and a hypopharyngeal primary site are significant predictive factors for stricture formation.

Association between development of hypothyroidism and improved survival in patients with head and neck cancer

OBJECTIVE

To determine if the development of hypothyroidism has an effect on the outcome of advanced-stage head and neck squamous cell carcinoma.

DESIGN

Retrospective database analysis.

SETTING

Tertiary care center.

PATIENTS

The study population comprised 155 patients with advanced-stage head and neck squamous cell carcinoma.

INTERVENTIONS

Patients underwent radiation therapy alone or in combination with chemotherapy and surgery when indicated.

MAIN OUTCOME MEASURES

Kaplan-Meier analysis was used to assess survival, not adjusting for timing of the detection of hypothyroidism. The following 2 analyses were then performed to adjust for the timing of detection: (1) hypothyroidism was assessed as a time-varying covariate in a Cox proportional hazards model and (2) a landmark analysis was conducted at 9, 12, 15, 18, 21, and 24 months using the Kaplan-Meier method.

RESULTS

Of the 155 patients, 59 developed hypothyroidism, defined as a thyrotropin level greater than 5.5 mIU/L (institutional value). An unadjusted Kaplan-Meier analysis indicated that patients who develop hypothyroidism have significantly better survival than patients who do not (P<.001, log-rank test). After adjusting for the timing of hypothyroidism, a Cox proportional hazards analysis indicated that survival was better, but not statistically significant, for patients who developed hypothyroidism (hazard ratio, 0.62; P=.12); results from a landmark analysis supported this finding (P values ranged from .11 to .19).

CONCLUSIONS

Development of hypothyroidism may be associated with improved survival and increased recurrence-free survival. Larger, prospective studies appear warranted to test the beneficial effect of hypothyroidism.

Vocal Outcomes After Laser Resection of Early-Stage Glottic Cancer With Adjuvant Cryotherapy

OBJECTIVE

To evaluate the vocal outcomes of patients with early-stage glottic carcinoma undergoing laser resection with adjuvant cryoablative therapy.

DESIGN

Retrospective review.

SETTING

Tertiary care center. Patients Twenty patients with early-stage glottic carcinoma. Intervention Treatment of early-stage glottic carcinoma with endoscopic carbon dioxide laser resection in conjunction with cryoablation.

MAIN OUTCOME MEASURES

Disease-free survival and subjective and objective measures of posttreatment voice quality, based on serial videolaryngostroboscopy.

RESULTS

There was 1 local treatment failure, with an overall mean disease-free follow-up of 32.6 months (range, 3-93 months). Carbon dioxide laser resection and cryoablative therapy were associated with a significant improvement in subjective voice quality (P<.001). Long-term dysphonia was uniformly improved vis-à-vis the pretreatment condition, even among patients with the most advanced disease undergoing the widest resections. Posttreatment web formation was not noted among 4 patients with anterior commissure involvement.

CONCLUSIONS

Endoscopic laser laryngeal surgery performed in conjunction with cryotherapy for early-stage glottic carcinoma yielded excellent primary site control, while improving subjective and objective measures of voice quality. Combined laser surgery and cryotherapy is a possible alternative to radiotherapy for selected patients with early-stage glottic carcinoma who desire curative therapy, while optimizing vocal outcomes.

Vocal Fold Healing after Laser Cordectomy with Adjuvant Cryotherapy

OBJECTIVES

To understand the effect of adjuvant cryotherapy on glottic wound healing after endoscopic CO2 laser cordectomy.

STUDY DESIGN

Canine acute injury model with videolaryngostroboscopic and histopathologic outcomes analysis.

METHODS

Twelve adult male dogs underwent bilateral endoscopic CO2 laser transmuscular cordectomy followed by randomized unilateral endoscopic glottic cryotherapy. The animals were randomly divided into four groups and underwent videolaryngostroboscopy followed by sacrifice at 0, 2, 6, and 12 weeks postoperatively. Three untreated male dogs served as controls. Histopathologic sections were prepared with Alcian blue, Giemsa, hematoxylin-eosin, movat's, Masson's trichrome, and picrosirius stains.

RESULTS

Videostroboscopy demonstrated an earlier restoration of glottic volume and a return of mucosal waves among vocal folds treated with combined therapy by 6 weeks posttreatment. The mean depth of inflammatory reaction in the vocal cords treated with combined therapy was 1.07 mm versus 1.15 mm in vocal cords treated with CO2 laser therapy alone. At 2 and 6 weeks postoperatively, combined treatment was associated with a decreased volume of collagen. At 12 weeks postoperatively, combined treatment was associated with greater collagen organization, normalized collagen histoarchitecture, and decreased keratinization.

CONCLUSIONS

Adjuvant cryotherapy appears to alter glottis-specific wound healing, leading to decreased and more organized collagen formation and decreased keratinization with a resultant improvement in glottic function, when compared with CO2 laser surgery alone, in an acute canine injury model. Studies in humans are ongoing to further evaluate the clinical potential of cryotherapy on glottic wound healing.

Neck dissection: then and now

The significance of metastatic disease in the lymph nodes of the neck as a critical independent prognostic factor in head and neck cancer has long been appreciated. Although 19th century surgeons attempted to remove involved cervical lymph nodes at the time of resection of the primary cancer, a systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdyński in 1888 and popularized and illustrated by Crile in the early 20th century, provided consistent and more effective treatment, and forms the basis of our current techniques. During the first half of the 20th century, developments included preservation of the accessory nerve in selected cases, elective neck dissection performed in association with resection of various primary tumors, bilateral neck dissection and limited neck dissection. The greatest impetus to the status of radical neck dissection came from Martin, whose technique consisted of resection of all lymph nodes from level I-V together with the accessory nerve, internal jugular vein, sternocleidomastoid muscle and various other structures in a single block of resected tissue. Martin's technical precepts were followed until the latter part of the 20th century when modifications in technique began to find general acceptance. The first description of an effective technique of modified radical neck dissection was published in Spanish by Suárez, in 1963. This technique, which preserves important structures, such as the internal jugular vein, sternocleidomastoid muscle and accessory nerve, was refined and popularized by various authors who published their results in the English language literature during the period from 1964 through 1990 and beyond. Modified or "functional" neck dissection avoids much of the morbidity of radical neck dissection while achieving equivalent degrees of control of regional disease in properly selected cases. By the late 20th century, the concept of selective neck dissection, consisting of resection of only the nodal groups at greatest risk for metastasis from a given primary site, was studied and developed. These limited dissections are now widely employed for elective, and in properly selected cases, therapeutic treatment and staging of the neck, and have been proposed for limited cervical recurrences after various chemoradiation protocols. Prospective studies have demonstrated similar rates of neck recurrence and survival after elective selective neck dissection compared to elective modified radical neck dissection. Other modifications and factors applied to treatment of cervical lymph node disease include the use of adjuvant and neo-adjuvant radiation and chemotherapy, a revised system for classification of neck dissections, the identification of various adverse prognostic factors such as extracapsular spread and extranodal soft tissue deposits, application of sentinel lymph node biopsy to staging of the neck, the use of immunohistochemical and molecular techniques for identification of lymph node metastases not detectable by light microscopy, and the possibility of endoscopic neck dissection. The authors conclude that neck dissection, as evolved over the past century, is a fundamental tool in management of patients with head and neck cancer, but is still a work in progress.

Everolimus (RAD) inhibits in vivo growth of murine squamous cell carcinoma (SCC VII)

OBJECTIVE

Everolimus (RAD) is an mTOR inhibitor closely related to rapamycin. A potent immunosuppressive agent, it has also shown evidence of antineoplastic properties. SCC VII is a spontaneously arising murine squamous cell carcinoma line. This study examines the effect of everolimus on SCC VII proliferation. The data may provide support for the use of everolimus in transplant recipients with a history of malignancy.

METHODS

A dose efficacy study was conducted that used a murine model of intradermal tumor growth and pulmonary metastases. The development of intradermal tumors and pulmonary metastases were studied. Of 80 total mice, 40 received intradermal injection of 1 x 10 SCC VII cells and 40 received intravenous injection of 1 x 10 cells to establish pulmonary metastases. Within each group, animals were subdivided into four subgroups that received 1) 1 mg/kg everolimus twice a day, 2) 0.5 mg/kg everolimus twice a day, 3) 7.5 mg/kg cyclosporine per day, and 4) no treatment. Intradermal tumors were measured three times per week. Animals receiving an intravenous tumor injection were killed after 17 days and pulmonary metastases were quantified. Medication trough levels were measured in all treated animals.

RESULTS

Everolimus showed statistically significant tumor inhibition at 1.0 mg/kg twice a day and 0.5 mg/kg twice a day when compared with animals treated with cyclosporine and with untreated animals (P < .0001). Tumor inhibition was evident in both models studied (intradermal tumors and pulmonary metastasis generation).

CONCLUSIONS

Everolimus provides potent tumor inhibition in animals inoculated with SCC VII cells. Inhibition of both local and distant spread of disease is evident. Although most immunosuppressives are known to potentiate neoplastic disease, this study supports the use of everolimus immunosuppression in the face of prior malignancy. This data has significant implication for laryngeal transplantation after laryngectomy.

Does positron emission tomography (PET) improve our ability to detect residual neck node (NN) disease in patients with squamous cell head and neck cancer (SCHNC) after definitive chemoradiotherapy?

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Background: Management of the neck in patients undergoing non-operative treatment for SCHNC is controversial. This study details our experience using the neck exam, computerized tomography (CT), and PET to clinically evaluate patients for residual NN disease after definitive chemoradiotherapy. Methods: We retrospectively reviewed all patients with SCHNC with NN involvement at presentation, who were treated with definitive concurrent chemoradiotherapy using fluorouracil and cisplatin. Clinical restaging by neck exam, CT, and PET was accomplished 8–12 weeks after completion of treatment. Residual palpable nodes on exam, residual nodes larger than 1 centimeter, or with central necrosis on CT, or any residual hypermetabolic lymph nodes on PET were considered to be clinical evidence of residual NN disease. Persistent NN disease was confirmed only if pathologic involvement was identified at the time of neck dissection, or if regional recurrence developed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy (Acc) were calculated for all three clinical assessment tools. Results: The study included 43 patients with 64 positive necks at diagnosis, followed for a median of 11.5 (range 3.9–43.3) months. All but two patients are alive. Planned neck dissection was performed in 26 necks after chemoradiotherapy, and was positive in four. Recurrent primary site or NN disease prompted a delayed neck dissection in eight necks, which was positive in three. The utility of these clinical assessment tools and combinations thereof are detailed in the table . Conclusions: Residual NN disease after definitive chemoradiotherapy was infrequent and not well predicted by PET. A positive PET in this setting is of little utility. Although a negative PET was highly predictive for control of neck disease after chemoradiotherapy, it added little to the clinical neck exam and the CT.

[Table: see text]

No significant financial relationships to disclose.

Multiagent Concurrent Chemoradiotherapy for Locoregionally Advanced Squamous Cell Head and Neck Cancer: Mature Results From a Single Institution

Purpose

A retrospective review with long-term follow-up is reported from the Cleveland Clinic Foundation studying radiation and concurrent multiagent chemotherapy in patients with locoregionally advanced squamous cell head and neck cancer.

Patients and Methods

Between 1989 and 2002, 222 patients were treated with 4-day continuous infusions of fluorouracil (1,000 mg/m2/d) and cisplatin (20 mg/m2/d) during weeks 1 and 4 of either once daily or twice daily radiation therapy. Primary site resection was reserved for patients with residual or recurrent primary site disease after chemoradiotherapy. Neck dissection was considered for patients with N2 or greater disease, irrespective of clinical response, and for patients with residual or recurrent neck disease.

Results

With a median follow-up of 73 months, the Kaplan-Meier 5-year projected overall survival rate is 65.7%, freedom from recurrence rate is 74.0%, local control without the need for surgical resection rate is 86.7%, and overall survival rate with organ preservation is 62.2%. Including patients undergoing primary site resection as salvage therapy, the overall local control rate is 92.4%. Regional control rate at 5 years is 92.4%. Among patients with N2-3 disease, regional control was significantly better if a planned neck dissection was performed. Distant control at 5 years was achieved in 85.4% of patients and was significantly worse in patients with hypopharyngeal primary sites and patients with poorly differentiated tumors.

Conclusion

Concurrent multiagent chemoradiotherapy can result in organ preservation and cure in the majority of appropriately selected patients with locoregionally advanced, nonmetastatic, squamous cell head and neck cancer. Distant metastatic disease was the most common cause of treatment failure. Late functional outcomes will require further investigation.

Gastroesophageal reflux and laryngeal cancer: causation or association? A critical review

Gastroesophageal reflux disease has been implicated as a causative factor in several laryngeal disorders. Its involvement in laryngeal cancer is of interest not only from a clinicopathologic aspect, but also from a public health perspective. However, despite a number of studies, a causal relationship with laryngeal cancer is uncertain. In this article, we address the current literature in a critical manner to facilitate the understanding of this subject and evaluate the relationship between gastroesophageal reflux disease and laryngeal carcinoma.

Pulsed immunosuppression with everolimus and anti-alphabeta T-cell receptor: laryngeal allograft preservation at six months

OBJECTIVES

Laryngeal transplantation can restore the voice in patients who have undergone laryngectomy. However, the prospect of lifelong immunosuppression is a drawback to this procedure. We present data from a study aimed at minimizing the need for immunosuppression while maintaining graft viability through a novel pulsed-dosing protocol.

METHODS

Larynges were transplanted from Lewis-brown Norway (RT1(l+n, F1) rats to Lewis (RT1(l)) recipients. All recipients received 7 days of treatment with everolimus and mouse anti-rat alphabeta T-cell receptor (anti-TCR) monoclonal antibodies beginning the day before transplantation. At 90 days after transplantation, all recipients received a pulse of the same treatment combination for 5 days. From 90 to 180 days after transplantation, the rats received no treatment (group 1, n = 5), 2.5 mg/kg everolimus per day (group 2, n = 5), or 1.0 mg/kg everolimus per day (group 3, n = 5).

RESULTS

Histologic analysis of rats that received everolimus as pulse therapy evidenced no signs of rejection, whereas animals that were untreated after 90 days had normal to mild chronic rejection. T-cell reconstitution occurred 65 days after perioperative immunosuppressive treatment, but less rapidly after pulse therapy. Also, peripheral chimerism was generated in all 3 groups.

CONCLUSIONS

In the rat laryngeal transplantation model, short-term perioperative therapy with everolimus and anti-TCR followed by pulsing is a viable alternative to the concerns associated with continuous, lifelong immunosuppression.

The effect of donor-specific transfusion upon rejection in a rat model of laryngeal transplantation

Lifelong immunosuppression carries significant morbidity, and techniques to reduce or eliminate such immunosuppression might expand laryngeal transplantation. This study investigates the ability of donor-specific transfusion to establish tolerance in a rat model of laryngeal transplantation. A total of 289 transplants were performed from Lewis-Brown-Norway donors to Lewis recipients. Donor-specific transfusion was provided as single intravenous injections of donor splenocytes 1 hour before transplantation. Different combinations of in vitro irradiation of donor larynges and postoperative cyclosporine doses provided additional immunomodulation. Allograft rejection was scored histologically at sacrifice 15 or 30 days posttransplant. Multivariate analysis was performed across all groups, and paired analyses compared groups with and without donor-specific transfusion. Donor-specific transfusion did not improve rejection score, although increased cyclosporine dose did (P < .001). Donor splenocyte injection on the day of transplantation does not establish tolerance to laryngeal allografts or permit reduction of other immunosuppression. Other immunomodulatory strategies to establish tolerance in rat laryngeal transplantation require further investigation.

Immunomodulation with anti-αβ T-cell receptor monoclonal antibodies in combination with cyclosporine a improves regeneration in nerve allografts

OBJECTIVES

To investigate the use of nerve allografts in animals treated with a short-term combined protocol of anti-alpha/beta T-cell receptor monoclonal antibodies and Cyclosporine A (CsA) to induce tolerance and allow for nerve regeneration.

STUDY DESIGN

An established rat sciatic nerve model was used. A total of 76 rats were used in this experiment (Lew RT1L n=44, Lewis-Brown-Norway (LBN RT1L+N, n=22), Brown-Norway (BN RT1N, n=10). Sciatic nerve (1.5 cm) deficits were created in the Lewis rats and the animals were randomized to seven treatment groups to allow for repair with isograft controls (LEW-LEW) and with both semiallogeneic (LBN-LEW) and full major histocompatability (MHC) mismatched (BN-Lew) allografts.

METHODS

Nerve regeneration was evaluated at 6 and 12 weeks by somatosensory evoked potentials (SSEP) and standardized pin-prick and toe-spread tests. Nerve samples were harvested at 12 weeks and stained with toluidine blue to assess the total number of myelinated axons, axon area, and myelin sheath thickness. Muscle denervation atrophy was evaluated by gastrocnemius weights. Immunocompetence was investigated through skin grafting and fluorescent activated cell sorting (FACS) analysis.

RESULTS

Improved functional, electrophysiologic, and histomorphometric outcomes were observed in animals treated with anti-alpha/betaTCR mAbs and CsA after nerve allograft transplantation when compared to animals receiving no treatment and CsA alone.

CONCLUSIONS

The immunomodulating protocol of combination anti-alpha/beta TCR mAbs and CsA for a 5 week period altered the rejection process, affording nerve regeneration. It may provide for an expanded source of nerve tissue to alleviate the morbidity of harvesting peripheral nerves from multiple sites for those afflicted with extensive peripheral nerve injuries.

Laryngeal transplantation in 2005: a review

There is no good surgical, medical or prosthetic solution to the problems faced by those with a larynx whose function is irreversibly damaged by tumor or trauma. Over the past 10 years, the pace of research designed to establish laryngeal transplantation as a therapeutic option for these persons has increased steadily. The biggest milestone in this field was the world's first true laryngeal transplant performed in Cleveland, Ohio in 1998. The recipient's graft continues to function well, in many respects, even after 7 years. However, it has also highlighted the remaining barriers to full-scale clinical trials. Stimulated by these observations, several groups have accumulated data which point to answers to some of the outstanding questions surrounding functional reinnervation and immunomodulation. This review seeks to outline the progress achieved in this field by 2005 and to point the way forward for laryngeal transplantation research in the 21st century.