Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

Delphian node metastasis in head and neck cancers--oracle or myth?

Delphian node (DN) refers to the pre-laryngeal or pre-cricoid nodal tissue often identified during laryngeal or thyroid surgery. The original nomenclature is based on the assumption that metastasis to this node was predictive of aggressive disease and poor outcome for patients. In this article, we review the existing literature on the topic to determine the significance of DN metastasis in laryngeal, hypopharyngeal and thyroid cancers.

Effects of heterogeneity in synaptic conductance between weakly coupled identical neurons

A significant degree of heterogeneity in synaptic conductance is present in neuron to neuron connections. We study the dynamics of weakly coupled pairs of neurons with heterogeneities in synaptic conductance using Wang-Buzsaki and Hodgkin-Huxley model neurons which have Types I and II excitability, respectively. This type of heterogeneity breaks a symmetry in the bifurcation diagrams of equilibrium phase difference versus the synaptic rate constant when compared to the identical case. For weakly coupled neurons coupled with identical values of synaptic conductance a phase locked solution exists for all values of the synaptic rate constant, α. In particular, in-phase and anti-phase solutions are guaranteed to exist for all α. Heterogeneity in synaptic conductance results in regions where no phase locked solution exists and the general loss of the ubiquitous in-phase and anti-phase solutions of the identically coupled case. We explain these results through examination of interaction functions using the weak coupling approximation and an in-depth analysis of the underlying multiple cusp bifurcation structure of the systems of coupled neurons.

Management of Thyroid nodules in adult patients

Thyroid nodule is a common presentation and requires a structured diagnostic approach to ascertain the risk of malignancy and determine appropriate management. This review article highlights the key points in the history and examination which can help with risk stratification. It also discussed the application of fine needle aspiration cytology findings and the British Thyroid Association Guidelines in clinical practice.

Recent changes in the treatment of patients with advanced laryngeal cancer

Since the original data from the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrated that nonsurgical therapy could achieve survival rates comparable to total laryngectomy in selected cases, there has been a progressive increase in employment of nonsurgical therapy for the management of advanced laryngeal cancer. Both neoadjuvant chemotherapy followed by conventionally fractionated or hyperfractioned radiotherapy for chemotherapy responders, or simultaneously administered chemoradiation has resulted in a significant number of patients who achieved cure while preserving their larynges. Nevertheless, combined chemotherapy and external beam radiation is associated with a variety of acute and chronic sequelae that can have a debilitating impact on function and quality of life. Although no therapeutic option is without risk, the decision regarding the modality of therapy for a patient with advanced laryngeal cancer should prompt a careful review of the current surgical techniques available for treatment. Data on quality of life and aging, as well as advances in minimally invasive surgical techniques, are available today that were not available at the time of the Veterans study. Selection of optimal therapy is often complex and raises the question whether the pendulum may have swung too far in the direction of nonsurgical therapy for advanced laryngeal cancer. This article reviews the current options available for a patient with advanced laryngeal cancer and discusses the impact of therapy.

Role of limited parotidectomy in management of pleomorphic adenoma

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed.

As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

Pleomorphic adenoma of the submandibular gland: an evolving change in practice following review of a personal case series

We reviewed patients with submandibular gland pleomorphic adenoma treated at a tertiary referral centre in the United Kingdom (1988-2004). Thirty-seven patients were identified, 32 newly diagnosed cases and 5 cases of recurrent disease previously treated elsewhere. The exact pre-operative diagnosis was "unknown" in 76% of the new cases. All cases were surgically excised (41% with extracapsular gland excision and 59% by selective level Ib, IIa and III neck dissection). Temporary marginal mandibular nerve neuropraxia was documented in 25% of cases. All 32 new cases remain clinically tumour free at the time of writing. In patients with recurrent disease, complete microscopic tumour clearance was achieved in three of the five cases, however all remain clinically tumour free. Pleomorphic adenomas of the submandibular gland are uncommon, with good prognosis following complete tumour excision. Recurrent tumours, however, are frequently multi-focal and difficult to excise completely. The adequacy of primary surgery is crucial and supports an approach for a more radical excision primarily by a selective level lb, IIa and III neck dissection; ensuring complete disease clearance for pleomorphic adenoma, avoiding the risks of tumour spillage associated with a limited excision and tumour handling; and removing the primary echelon of lymph nodes at risk of metastasis if the pathology turns out to be malignant.

Status of primary tumour surgical margins in squamous head and neck cancer: prognostic implications

PURPOSE OF REVIEW

To look at the current published literature on squamous-cell carcinoma of the head and neck, at the microscopic level, and the implications of molecular and genetic research.

RECENT FINDINGS

The goal of surgical treatment is still complete eradication of the primary tumour with a 'safe margin'. To achieve this 'safe margin' is not always possible, however. Currently, there is no agreed consensus as to how to submit tissue for frozen section, or how to define a 'clear margin'. Histopathologically, there are two margins requiring analysis, the mucosal margin and the 'deep margin'. Margins declared histopathologically 'tumour free' can be found to be positive for malignant/premalignant cells when molecular markers are applied. When the presence of genetically altered cells is suggested in the margins, there is an increased risk of a recurrent or new tumour. There is limited application of such knowledge and further trials are awaited.

SUMMARY

Standard histopathology has limitations for examining surgical margins. The probability of recurrent malignant disease is explained and this is much increased when molecular markers are identified in the resected margins. Further studies are required.

European Surgeons Were the First to Perform Neck Dissection

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdyński, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.

Risks of malignancy in inverted papilloma of the nose and paranasal sinuses

PURPOSE OF REVIEW

The majority of inverted nasal papilloma are benign and treatment is by complete local surgical removal. There is an associated real, but small risk of malignancy, which may coexist at the time of presentation or develop at a later time. This article reviews some of the recent publications addressing the association of inverted papilloma with malignancy.

RECENT FINDINGS

Neither the etiology of inverted papilloma nor the factors responsible for malignant transformation are fully elucidated to date. Inverted papilloma is associated with squamous cell carcinoma in approximately 10% of the cases. Malignancy may occur synchronously or metachronously.

SUMMARY

Based on the literature, the rates of synchronous and metachronous carcinoma are 7.1 and 3.6%, respectively, although rates may be exaggerated due to a referral bias to tertiary centres. A thorough removal of all diseased mucosa is curative and a meticulous histological examination of the entire specimen is necessary. The working risk is approximately 10%. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. As most recurrences are due to incomplete resection, it is mandatory to perform a close follow-up, with biopsies performed when indicated. Life-long follow-up is recommended.

Should all head and neck cancer patients be nursed in intensive therapy units following major surgery?

PURPOSE OF REVIEW

Surgery remains a mainstay of treatment for head and neck cancer. Patients have significant comorbidities, and protracted surgery is associated with complications and may require a high-dependency nursing environment such as an intensive care or high-dependency unit postoperatively. The literature is reviewed to document the current evidence for early postoperative nursing care.

RECENT FINDINGS

The mortality associated with major head and neck oncologic surgery is low, less than 3%, most frequently being myocardial infarction and pneumonia. The majority of patients can be nursed in a step-down (high-dependency unit) environment, which has one-to-one nursing, with experience and expertise, supported by medical staff. The decision where care is provided needs to be made locally, however, depending on staffing skill and levels, resources, and volume of workload.

SUMMARY

The majority do not require the routine use of the intensive therapy unit in the immediate postoperative period. The use of a 'specialist care', high-dependency unit or ward is cost effective, without reducing quality of care. Appropriate and adequate nursing staff with experience and expertise, and sustained resourcing, is paramount to the implementation of such a care facility.

Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancy

INTRODUCTION

Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy.

AIMS

To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional.

METHODS

We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature.

RESULTS

We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell-Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent.

CONCLUSION

Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.

Evolution of the management of laryngeal cancer

The treatment of laryngeal cancer has evolved through several phases, starting with wide extirpative surgical resection, and evolving through an era of conservation surgery and, finally, planned treatment using modalities of irradiation, chemotherapy and surgery in various combinations. Attempts to extirpate laryngeal cancer date to the nineteenth century, but only by the mid-twentieth century did advances in anesthesia, blood transfusion and antibiotics, make this surgery safe and reliable. Techniques of partial laryngectomy by external approach developed in the second half of the twentieth century, and endoscopic use of the laser refined the concept and provided a new paradigm for surgical treatment, particularly for early lesions. During most of this era, radiation was employed as an alternative method of treatment, with surgery reserved for salvage of radiation failure. By the last decade of the twentieth century, and to the present time, the value of combined modality therapy, using planned combinations of irradiation, chemotherapy and surgery became the standard of care for advanced laryngeal cancer, permitting maximal laryngeal preservation with the highest attainable cure rates.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Management Dilemmas in the Treatment and Follow-Up of Advanced Juvenile Nasopharyngeal Angiofibroma

Advanced juvenile nasopharyngeal angiofibroma (JNA) (i.e. disease with intracranial extension) is reportedly uncommon. The optimum management form of such a clinical situation currently remains controversial. This review, of the recent English published literature, discusses the common JNA classification systems advocated, shows the advantages and disadvantages of surgical approaches used (both open, endoscopic or combined), and re-evaluates the current role of radiotherapy (for initial management or treatment of residual/recurrent disease). We also discuss the typical presentation of these patients, the role of pre-operative embolization, as well as surgical techniques to minimize recurrence, and advocate a post-treatment follow-up protocol.