Differentiated thyroid cancer presenting initially with distant metastasis

BACKGROUND

The initial presentation of distant metastases in patients with differentiated thyroid cancer is a rare event. Interestingly, if managed appropriately, the long-term survival in this group of patients is approximately 43%. We intend to review our experience of patients presenting initially with distant metastatic disease in a large series of differentiated thyroid cancer patients.

METHODS

In the entire series of 1,038 consecutive patients treated at Memorial Sloan-Kettering Cancer Center from 1930 to 1985, 44 patients presented initially with distant metastases (4%). There were 22 male and 22 female patients ranging in age from 7 to 75 years with a mean age of 51 years. Patients were analyzed for their prognostic factors, and the survival curves were drawn by the Kaplan-Meier method. Univariate and multivariate analyses were performed by the Cox regression model.

RESULTS

There were 19 patients presenting with distant metastases in 810 patients presenting with papillary thyroid cancer (2.3%). The incidence was high in patients with follicular thyroid cancer (11%). It is interesting to note that the highest incidence of presentation with distant metastatic disease was in patients above the age of 45 and with follicular thyroid carcinoma. The long-term survival in this group is 43% compared with 86% in patients presenting without distant metastasis (P < 0.001). There was no statistical difference in survival of patients below or above the age of 45.

CONCLUSION

Even though the presence of distant metastasis at the time of initial presentation in other cancers is considered to be of grave prognosis, for patients with differentiated thyroid cancer, the long-term survival is still 43%. The incidence of distant metastasis is highest in patients with follicular thyroid cancer. Appropriate initial evaluation and treatment will lead to satisfactory long-term survival.

Extended anterior craniofacial resection for intracranial extension of malignant tumors

OBJECTIVE

To review our experience with anterior craniofacial resection for malignant neoplasms with intracranial extension. Survival was analyzed in terms of presence of intracranial extension, extent of intradural disease, tumor histology, and histological status of margins.

PATIENTS

In a retrospective review made at a tertiary cancer facility, 26 of the 115 consecutive patients undergoing craniofacial resection for malignant lesions of the anterior skull base had intracranial extension, defined as dural and/or brain extension. Survival was evaluated with the Kaplan-Meier product limit method, and comparisons between individual subgroups were performed using the log-rank test.

RESULTS

Patients with intradural extension have a statistically worse disease-specific survival than patients without intracranial extension (P = 0.05). Surgical margins and tumor histology impact on survival. The incidence of local complications was 42% and of systemic complications, 8%.

CONCLUSION

Anterior craniofacial resection is indicated for patients with resectable disease. The complication rate is comparable with that of patients without intracranial extension. Gross total resection with histologically negative margins portends a better prognosis. Esthesioneuroblastoma has a better prognosis than other tumor types.

Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible

BACKGROUND

Management of osteoradionecrosis (ORN) remains a difficult and challenging problem. The traditional approach using debridement, antibiotics, and occasionally hyperbaric oxygen is usually successful in treating minimal ORN. However, when bone and soft-tissue necrosis is extensive, the conservative approach usually requires intensive care over a long period of time and often yields unsatisfactory functional and cosmetic results.

METHODS

Within the past 5 years, we have used radical resection of the mandible with immediate microvascular reconstruction in the treatment of extensive ORN of the mandible. This aggressive surgical approach was used in six patients with advanced ORN of the mandible, all of whom had failed initial conservative treatment, including hyperbaric oxygen therapy in three. A fibular free graft with microvascular anastomosis was used in all patients.

RESULTS

All the patients healed primarily with minimal postoperative morbidity and excellent cosmetic results. Two patients subsequently required removal of some of their hardware. One patient had placement of osseointegrated implants with an excellent cosmetic and functional result.

CONCLUSION

Microvascular reconstruction with its own blood supply seems to expedite bone healing and limit further osteoradionecrosis of the remaining mandible. Although prevention is the primary goal in radiation injury, our experience suggests that radical resection with free microvascular reconstruction offers significant advantages to selected patients with extensive ORN of the mandible.

Hypopharyngeal cancer patient care evaluation

A survey was conducted to identify demographics and standards of care for treatment of hypopharyngeal squamous cell carcinoma in the United States. Data were accrued from voluntary submission of cancer registry and medical chart information from 769 hospitals representing 2939 cases diagnosed from 1980 to 1985 and 1990 to 1992. Clinical findings, diagnostic procedures employed, treatment practices, and outcome are presented. Overall, 5-year disease-specific survival was 33.4%, which segregated to 63.1% (stage I), 57.5% (stage II), 41.8% (stage III), and 22% (stage IV). Survival was best for patients treated with surgery only (50.4%), similar with combined surgery and irradiation (48%), and worse with irradiation only (25.8%). This analysis provides a standard to which current treatment practice and future clinical trials may be compared.

Long-term regional control after radiation therapy and neck dissection for base of tongue carcinoma

PURPOSE

Minimal literature exists with 10-year data on neck control in advanced head and neck cancer. The purpose of this study is to determine long-term regional control for base of tongue carcinoma patients treated with primary radiation therapy plus neck dissection.

METHODS AND MATERIALS

Between 1981-1996, primary radiation therapy was used to treat 68 patients with squamous cell carcinoma of the base of tongue. Neck dissection was added for those who presented with palpable lymph node metastases. The T-stage distribution was T1, 17; T2, 32; T3, 17; and T4, 2. The N-stage distribution was N0, 10; N1, 24; N2a, 6; N2b, 11, N2c, 8; N3, 7; and Nx, 2. Ages ranged from 35 to 77 (median 55 years) among the 59 males and nine females. Therapy generally consisted of initial external beam irradiation to the primary site (54 Gy) and neck (50 Gy). Clinically positive necks were boosted to 60 Gy with external beam irradiation. Three weeks later, the base of tongue was boosted with an Ir-192 interstitial implant (20-30 Gy). A neck dissection was done at the same anesthesia for those who presented with clinically positive necks, even if a complete clinical neck response was achieved with external beam irradiation. Neoadjuvant cisplatin-based chemotherapy was administered to nine patients who would have required a total laryngectomy if their primary tumors had been surgically managed. The median follow-up was 36 months with a range from 1 to 151 months. Eleven patients were followed for over 8 years. No patients were lost to follow-up.

RESULTS

Actuarial 5- and 10-year neck control was 96% overall, 86% after radiation alone, and 100% after radiation plus neck dissection. Pathologically negative neck specimens were observed in 70% of necks dissected after external beam irradiation. The remaining 30% of dissected necks were pathologically positive. These specimens contained multiple positive nodes in 83% despite a 56% overall complete clinical neck response rate to irradiation. Regional failure occurred in only two patients, neither of whom underwent adjuvant neck dissection. Symptomatic neck fibrosis (RTOG grade 3) was not observed. Actuarial 5- and 10-year local control was 88% and 88%, disease-free survival was 80% and 67%, and overall survival was 86% and 52%.

CONCLUSION

For base of tongue cancer, most patients can obtain long-term regional control with no severe complications after definitive radiation therapy, plus neck dissection for those who present with lymphadenopathy. Complete clinical regression of palpable neck metastases after irradiation poorly correlates with pathologic outcome. Our current policy is to include neck dissection at the time of implantation for patients who present with palpable neck metastases. We realize that this therapeutic approach may overtreat some patients, but we are reluctant to change our policy in light of these excellent outcomes.

Maxillectomy and its classification

BACKGROUND

Many adjectives are used to describe maxillectomy procedures, such as radical, total, extended, subtotal, medial, partial, and limited. The variety of nomenclature in our own Service database testifies that much confusion exists.

METHODS

We have reviewed a 10-year experience with 403 maxillectomies performed between 1984 and 1993. Based on our retrospective reassessment, the operations were grouped into one of three categories. The term "limited" (LM) was applied to any maxillectomy which primarily removed one wall of the antrum. Designated "subtotal" (SM) was any procedure which removed at least two walls, including the palate. We listed as "total" (TM) only those who had a complete resection of the maxilla. Hospital charts were selectively reviewed, and each of the three types of maxillectomy was analyzed to determine the histology and site of the index cancers and the incidence of complex reconstruction.

RESULTS

We determined that the maxillectomy performed in 230 patients (57%) was a LM. Tumor site and extent defined five different approaches in this cohort: peroral, 73; medial maxillectomy, 53; anterior craniofacial, 43; upper cheek flap, 42; and transfacial, 19. Subtotal maxillectomy or TM was performed in 135 and 38 (34% and 9%, respectively), almost 90% of whom had a cheek flap approach. Only 51 patients had an orbital exenteration, including 27 of the 38 (71%) of those who had a TM. Complex repair was employed in a total of 63 patients (16%), most often in those having TM (14 of 38, 37%).

CONCLUSIONS

Classification of maxillectomy either as LM, SM, or TM is useful and feasible. To define a LM, the portion of the maxilla removed (ie, palate, anterior wall, medial wall) must be specified. For any maxillectomy, the access used should be listed, and the surgeon should indicate whether the maxillectomy has been extended to include adjacent structures.

Low-risk differentiated thyroid cancer: the need for selective treatment

BACKGROUND

The well recognized prognostic factors in differentiated carcinoma of the thyroid are age, grade, extracapsular extension, distant metastasis, and size of the tumor. Based on these prognostic factors, we have divided patients into low-, intermediate-, and high-risk categories. Clearly, there are significant differences in these three groups. This article analyzes in depth our data on low-risk thyroid cancer patients.

METHODS

A retrospective review of 1,038 patients with differentiated carcinoma of the thyroid was undertaken. Various prognostic factors and risk groups were analyzed. Univariate and multivariate analyses were performed, and the survival curves were plotted by the Kaplan-Meier method. The inclusion criteria for the low-risk group were age younger than 45 years, tumors < 4 cm in size, low-grade histology, absence of distant metastasis, and absence of extrathyroidal extension. There were 465 patients in the low-risk group. Four hundred three patients had papillary and 62 patients had follicular thyroid cancer. There were 120 male and 354 female patients. Two hundred seventy-eight patients (60%) presented with clinically apparent lymph node metastasis.

RESULTS

With a median follow-up of 20 years, the 10- and 20-year survival in this select group was 99%. The local, regional, and distant recurrence rates were 5, 9, and 2% in this series. The analysis of the data showed statistical difference in local recurrence rate between partial lobectomy and total lobectomy (27 vs. 4%; p = 0.005). There was no statistical difference in local recurrence rate between total lobectomy compared with total thyroidectomy (4 vs. 1%; p = 0.10). The overall failure rate between partial lobectomy and total thyroidectomy (27 vs. 8%) was statistically significant (p = 0.04). There was no statistical difference in the overall failure rate between total lobectomy and total thyroidectomy (13 vs. 8%; p = 0.06). There was no survival difference between various histologies or nodal status.

CONCLUSIONS

Patients with low-risk tumors have excellent long-term survival. Nodulectomy or partial lobectomy should be avoided. The intraoperative decisions regarding the extent of thyroidectomy should be based on gross clinical findings and risk group analysis.

Combined surgery and radiation therapy for squamous cell carcinoma of the hypopharynx

Squamous cell carcinoma of the hypopharynx remains a highly lethal disease. This article documents our experience with 132 patients undergoing surgical management of squamous cell carcinoma of the hypopharynx, of whom 80% received postoperative radiation therapy. Local-regional control was obtained in 61% of the patients. Five-year overall and disease-free survival rates were 30% and 41%, respectively. Prognosis was better in patients with limited disease: local disease permitting larynx-sparing surgery, N0/N1 clinical neck, and stage I/II/III disease. Cancer of the hypopharynx remains an aggressive entity associated with poor prognosis. Novel strategies stressing improved local-regional control with prevention of distant metastasis are warranted.

Patterns of care for cancer of the larynx in the United States

OBJECTIVE

To assess case-mix characteristics, treatment patterns, and outcomes for laryngeal cancer using the largest series of patients to date.

DESIGN

Analyses performed on retrospectively collected survey data submitted by hospitals for diagnostic periods 1980 through 1985 and 1990 through 1992 (with a 9-year follow-up for the long-term group).

SETTING

Broad spectrum of US hospitals (N = 769).

PATIENTS

Consecutively accrued series of patients with laryngeal cancer (N = 16,936), with only squamous cell carcinomas (N = 16,213) analyzed.

INTERVENTIONS

Surgery, radiation therapy, and chemotherapy.

MAIN OUTCOME MEASURES

Descriptive analyses of case-mix, diagnostic, and treatment characteristics plus recurrence and 5-year, disease-specific survival outcomes.

RESULTS

There was a slight increase across these years in stage IV disease and in radiation therapy (with or without surgery and/or chemotherapy). Overall diversity of management of this disease (by site and stage) was apparent. Five-year survival rates indicated a large difference between modified groupings of the T and N classifications, separating stages III and IV cases into localized disease (87.5% for T1-T2; 76.0% for T3-T4 cases) and regional metastasis (46.2%).

CONCLUSIONS

Regardless of improvements in entering data in hospital records (most commendably, staging), more rigorous standards are needed. Also, the small increase in advanced-stage patients indicates that efforts toward early detection have not been successful. The rise in radiation therapy perhaps reflected an increased use of nonsurgical treatment for early-stage patients and organ-sparing radiochemotherapy protocols for advanced-stage patients. Regrouping stages III and IV cases into localized disease vs regional metastasis appears to predict survival better. Ongoing refinements of the American Joint Committee on Cancer staging scheme will hopefully improve this cancer's classification.

Current role of the radial forearm free flap in mandibular reconstruction

The radial forearm free flap was selected as a donor site in only 17 (11 percent) of 155 consecutive free flap mandible reconstructions performed over a 9-year period. It was used either as an osteocutaneous flap (58 percent), as a soft-tissue flap alone for coverage of a reconstruction plate (18 percent), to supplement another free flap (12 percent), or to salvage a previous reconstruction (12 percent). The most common underlying disease was epidermoid carcinoma (82 percent), the average patient age was 55 years, and the average length of follow-up was 13.5 months. Although there was one patient death, there were no anastomotic failures. Postoperatively, two patients experienced fracture at the donor site (12 percent), and three patients (18 percent) had hardware related problems such as exposure, infection, or both. Although early studies advocated using the osteocutaneous radial forearm flap as a preferred method in mandible reconstruction, superior donor site options such as the fibula have now relegated it to a minor role. The best remaining indication for its use today is for a limited posterior bone defect associated with a large adjacent mucosal loss. Osseointegrated implant capability is not important in this setting, and the short bone length needed for this application minimizes the potential for fracture at the donor site, a serious complication. Otherwise, the osteocutaneous radial forearm flap is not recommended for the majority of segmental mandibular defects. The radial forearm flap without bone continues to have an important supportive role in mandibular reconstruction. It is an excellent choice in this regard when used to cover a reconstruction plate, as a second free flap when soft-tissue requirements are exceptionally large, or for salvage of a previous mandible reconstruction.

Supraspinal accessory lymph node metastases in supraomohyoid neck dissection

BACKGROUND

Some patients undergoing surgical resection of primary squamous cell carcinoma of the oral cavity and oropharynx also undergo supraomohyoid neck dissection for staging of the negative (N(o)) neck. Dissection of the supraspinal accessory lymph node pad requires significant traction of the spinal accessory nerve. There are currently no data to indicate the incidence of metastases to this site and thus the necessity of performing dissection of these nodes.

METHODS

A prospective analysis of a consecutive series of 44 patients with newly diagnosed squamous carcinoma of the oral cavity or oropharynx undergoing surgical management of the primary lesion with staging neck dissection was performed. Patients underwent unilateral (41) or bilateral (3) supraomohyoid neck dissection with separate submission of the supraspinal accessory lymph node pad for pathologic evaluation to determine the incidence of nodal metastases.

RESULTS

A total of 15 patients (32%) had microscopic metastatic squamous cell carcinoma involving the supraomohyoid neck dissection specimen. Only 1 patient had a metastatic deposit involving the supraspinal accessory lymph node pad. This patient also had metastases in additional lymph nodes at level II. There was an equal incidence of metastases for all patients when stratifying by T stage.

CONCLUSION

This preliminary report reveals a small incidence of supraspinal accessory lymph node metastases in patients with T + NO squamous cell carcinoma of the oral cavity and oropharynx. We continue to accrue patients to determine if the incidence of supraspinal accessory lymph node metastases varies with an increased number of patients.

Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid

BACKGROUND

Understanding of differentiated carcinoma of the thyroid has improved in recent years with the definition of prognostic factors and risk group analysis. We intend to review our experience of differentiated thyroid cancer in relation to the risk of nodal and distant metastasis based on various histologic subgroups.

METHODS

This is a retrospective review of a consecutive series of 1,038 previously untreated patients with differentiated carcinoma of the thyroid treated over a period of 55 years. Univariate and multivariate analysis of various prognostic factors was performed. The incidence of nodal and distant metastasis was analyzed based on various histologic varieties of differentiated thyroid cancer.

RESULTS

There were 337 male and 701 female patients. The various histologic subgroups included papillary (810), follicular (169), and Hurthle cell cancer (59). The cumulative risk of nodal metastasis based on histological group was 61%, 30%, and 21% for papillary, follicular, and Hurthle cell variety, respectively. The risk of distant metastasis for the same histologic varieties was 10%, 22%, and 33%, respectively. The 5- and 20-year survival for these histologic subgroups was papillary (94% and 87%, respectively), follicular (87% and 81%), and Hurthle cell tumors (81% and 65%; P < 0.001).

CONCLUSIONS

The incidence of nodal metastasis is highest in the papillary subgroup; however, the incidence of distant metastasis was 33% in the Hurthle cell variety. The risk of nodal and distant metastasis varies considerably based on individual histologic variety.

The extent of neck disease after regional failure during observation of the N0 neck

BACKGROUND

The optimum management of the N0 neck remains controversial. When the neck is observed it is hoped that close follow-up will detect regional failure at an early stage. To test this hypothesis we examined patients undergoing therapeutic neck dissection for newly developed neck metastases during observation after treatment of the primary tumor.

METHODS

A retrospective chart review of 47 patients undergoing neck dissection for regional failure after surgical treatment of the primary tumor and observation of the neck from 1987 to 1992 was performed. The median time to failure in the neck was 13 months.

RESULTS

The clinical neck stage at the time of neck dissection was N1 in 37, N2A in 6, N2B in 1, and N3 in 3. However, pathologic staging revealed stages of N1 in 19, N2A in 5, N2B in 20, and N3 in 3. Extracapsular spread (ECS) was present in 23 patients (49%). Overall 36 patients (77%) had adverse pathologic findings (N greater than 1 or ECS).

CONCLUSIONS

These data indicate that when observation is used for the neck at risk for metastasis, patients tend to fail with high stage disease in the neck. This supports the philosophy of elective treatment of the neck but cannot show whether elective treatment will improve survival.

Management of the orbit during anterior fossa craniofacial resection

OBJECTIVE

To determine the postoperative ocular function in patients undergoing anterior fossa craniofacial resection with preservation of the orbit.

DESIGN

Retrospective medical chart review of patients treated from January 1, 1973, to July 31, 1994. Median follow-up was 38 months (range, 1-210 months).

SETTING

Tertiary referral center.

PATIENTS

Fifty-eight consecutive patients undergoing anterior fossa craniofacial resection with orbital preservation for tumors involving the anterior skull base.

MAIN OUTCOME MEASURES

Assessment of orbital complications of treatment, need for further surgical intervention to correct these complications, and determination whether functional vision was retained at last follow-up examination, and tumor recurrence within preserved orbits.

INTERVENTIONS

Anterior craniofacial resection with orbital preservation. Postoperative radiation therapy was administered to selected patients.

RESULTS

Overall, 25 patients (43%) had some ocular sequelae of their treatment. This consisted of epiphora in 21 patients, diplopia in 8, vision loss in 6, and pain and enophthalmos in 2. Twelve patients required revision surgery consisting of dacryocystorhinostomy in 8, ectropion repair in 3, drainage of orbital mucocele in 1, and corneal transplant in 1. Ocular complications were more common and vision loss occurred only in patients treated with postoperative radiation therapy. Functional vision in the ipsilateral eye was retained in 50 of the 58 patients.

CONCLUSIONS

When the orbit is preserved during anterior fossa craniofacial resection, ocular sequelae are frequent and may require revision surgery. Functional vision can be preserved in most patients.

Supraomohyoid neck dissection

BACKGROUND

Supraomohyoid neck dissection (SOHND) has assumed increasing importance as a staging lymphadenectomy in patients with N(o) oral and oropharyngeal squamous cell carcinoma (SCC), as well as a potentially curative procedure in selected patients with limited metastatic disease in the neck.

METHODS

Retrospective chart review of 287 patients who had a total of 320 SOHND for SCC between 1986 and 1993 as a follow-up to an earlier report that covered our experience between 1980 and 1985. After excluding 24 patients who also had local recurrence, or a new primary, the remaining 296 SOHND were assessed for the effectiveness of tumor control in the neck.

RESULTS

Of 248 elective SOHND, clinically negative nodes proved histologically positive in 60 patients (25%), only 4 of whom failed in the neck (7%). A total of 48 patients (16%) had a therapeutic SOHND for limited N+ disease, confirmed pathologically in 31, with neck recurrence documented in 2 (6%). Nodes proved negative histologically in 205 patients, 10 of whom failed in the neck (5%). Nine of the 16 patients with neck recurrence had received postoperative radiation therapy and 9 recurred within the field of the SOHND.

CONCLUSIONS

SOHND is a reliable staging procedure in patients with N(o) oral or oropharyngeal SCC. Therapeutic SOHND, in conjunction with postoperative radiation therapy, was highly effective in controlling neck metastases in carefully selected patients with limited disease in the upper neck.

Conservation surgery for recurrent carcinoma of the glottic larynx

BACKGROUND

Partial laryngectomy following previous irradiation is an oncologically sound procedure with excellent local control and survival rates. Several reports suggest an increased complication rate in previously irradiated patients.

METHODS

To analyze whether previous irradiation affected complications, disease control, or survival we performed a retrospective analysis of all patients who underwent vertical partial laryngectomy (VPL) for squamous cell carcinoma of the glottic larynx between January 1984 and August 1993.

RESULTS

Sixty-eight patients had adequate followup. The overall 5-year survival rates were 79% for previously treated patients and 95% for primary VPL patients (P = NS). The local control rates with surgical salvage were 93% and 98%, respectively. No increase in wound complications, time to decannulation, length of hospitalization, or ability to swallow were found.

CONCLUSIONS

VPL can be performed safely in selected patients following previous radiotherapy without a significant increase in complications or cost.

Posterior pharyngeal carcinoma resection with larynx preservation and radial forearm free flap reconstruction: a preliminary report

BACKGROUND

Surgical management of selected posterior pharyngeal wall lesions can be performed with pharyngectomy, allowing for larynx preservation, with radial forearm free flap (RFFF) reconstruction.

METHODS

Retrospective review of our experience using RFFF reconstruction in 9 patients.

RESULTS

All 9 patients had a posterior pharyngectomy with larynx preservation, neck dissection (3 bilateral, 6 unilateral), and RFFF reconstruction. Six patients experienced 8 postoperative complications including one postoperative death. Only 3 patients were able to obtain all nutrition orally. Tracheotomy decannulation occurred in 4 patients and voice was maintained in all patients. American Society of Anesthesiologists score (ASA) was an accurate predictor of postoperative medical complications.

CONCLUSIONS

Posterior pharyngeal resections with larynx preservation and RFFF reconstruction can be accomplished with acceptable morbidity in healthy patients with carefully selected lesions of the posterior pharyngeal wall. However, in patients with significant co-morbidities as reflected by an ASA of 3 or more, larynx preservation and RFFF reconstruction was fraught with significant morbidity and is not recommended.

Risk group stratification and prognostic factors in papillary carcinoma of thyroid

BACKGROUND

Our understanding of the natural history of differentiated thyroid carcinoma has improved with the definition of prognostic factors. These prognostic factors have helped us identify patients in various risk groups.

METHODS

A retrospective review of a consecutive series of 810 previously untreated patients with papillary carcinoma of the thyroid was undertaken to analyze the prognostic factors and risk groups. There were 403 patients in the low-risk group, 313 in the intermediate group, and 94 classified in the high-risk group.

RESULTS

With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 43% survived in the high-risk group. The intermediate-risk group had a 20-year survival of 83%. The favorable prognostic factors included female sex, young age, absence of distant metastases and extrathyroidal extension of the disease, size < 4 cm, and low-grade histology. Focality, presence of lymph node metastasis, and pure papillary or mixed variant had no statistical significance on prognosis.

CONCLUSIONS

Based on various prognostic factors, low-, intermediate-, and high-risk groups are identified. Patients in the low-risk group have excellent survival (99%). Appropriate selection of surgical and adjuvant treatment should therefore be used based on prognostic factors and risk group stratification.

Combined chemotherapy and radiotherapy versus surgery and postoperative radiotherapy for advanced hypopharyngeal cancer

BACKGROUND

Although the standard therapy for locally advanced hypopharyngeal cancer remains surgery and postoperative radiotherapy (RT), alternative treatment approaches include induction chemotherapy and RT. The purpose of this retrospective study was to compare the long-term outcome of these treatments performed in a single institution.

METHODS

Twenty-six patients with advanced, resectable, squamous cell carcinoma of the hypopharynx were treated with induction chemotherapy and definitive RT (group I), reserving laryngectomy for salvage. The induction phase of therapy consisted of 2-3 cycles of cisplatin-based chemotherapy followed by conventional fractionated RT to doses of 66-70 Gy. The outcomes of this group of patients were compared with the outcomes of 30 patients with hypopharyngeal cancer who were treated at our institution with surgery and postoperative RT (group II). The median follow-up times of the surviving patients in groups I and II were 5 and 9 years, respectively.

RESULTS

The local recurrence-free survival at 5 years from the completion of therapy for group I was 50%, compared with 69% for group II (p = .41). Among patients with T3-T4 primary tumors, the 5-year local control rates were 58% and 59% for groups I and II, respectively (p = .78). The likelihood of larynx preservation, free of local disease at 5 years for group I, was 52%. The 5-year neck recurrence-free survival for groups I and II were 47% and 69%, respectively (p = .66). Among patients with N2-N3 stage disease, the 5-year incidence of neck failure for groups I and II were 73% and 68%, respectively (p = .74). The 5-year distant metastases-free survival for groups I and II were 67% and 57%, respectively (p = .19). The 5-year disease-free survival rates for groups I and II were 30% and 42%, respectively (p = .9). The 5-year overall survival rates for groups I and II were 15% and 22%, respectively (p = .65).

CONCLUSIONS

Nonsurgical therapy for advanced stage hypopharyngeal cancer provides survivorship comparable with that achieved with standard approaches of surgery and postoperative RT. However, despite the therapy, the outcome is poor. Future studies will need to explore new treatment strategies in an effort to improve upon the outcome for this group of patients.

Quality of life of maxillectomy patients using an obturator prosthesis

BACKGROUND

The psychosocial adaptation of patients who had undergone a resection of the maxilla for cancer of the maxillary antrum and/or hard palate with the placement of an obturator prosthesis to restore speech and eating function was studied.

METHODS

Forty-seven patients were interviewed who had a maxillectomy with an obturator prosthesis at Memorial Sloan-Kettering Cancer Center, an average of 5.2 years (SD = 2.4 years) ago, 94% of whom had some of their soft palate resected. Interviews were conducted by telephone by a trained research interviewer, using a series of questionnaires to assess their satisfaction with the functioning of their obturator, and the psychological, vocational, family, social, and sexual adjustment. Measures included the Obturator Functioning Scale (OFS). Psychosocial Adjustment to Illness Scale (PAIS), Mental Health Inventory (MHI), Impact of Event Scale, and Family Functioning Scale.

RESULTS

Using multiple regression and discriminant function analyses, satisfactory functioning of the obturator prosthesis, as measured by the OFS, was found to be (1) the most highly significant predictor of adjustment, as measured by the PAIS (p < .0001) and the MHI Global Psychological Distress Subscale (MHI-GPD) (p < .001), and (2) significantly related to their perception of the negative socioeconomic impact of cancer upon their lives. The most significant predictor of better obturator functioning were the extent of resection of their soft palate (one third or less, p < .001), and hard palate (one fourth or less, p < .01). Specific aspects of obturator functioning that most significantly correlated with better adjustment (PAIS, MHI-GPD) were: less difficulty in pronouncing words (r = .40 and r = .51, respectively, p < .01), chewing and swallowing food (r = .27-.46, p < .05), and less change in their voice quality after surgery (r = .52 and r = .56, respectively, p < .001).

CONCLUSIONS

These findings suggest that a well-functioning obturator significantly contributes to improving the quality of life of maxillectomy patients.

Impact of lymph node metastasis in differentiated carcinoma of the thyroid: a matched-pair analysis

BACKGROUND

Cervical lymph node metastasis in differentiated thyroid carcinoma has mostly been found to have little relationship to prognosis. However, some studies report nodal involvement to be an adverse factor, while others have found it to be favorable. We have undertaken a matched-pair analysis of previously untreated patients, with and without ipsilateral neck metastasis, to examine the significance of nodal spread in patients with otherwise equivalent prognostic factors for differentiated thyroid cancer.

METHOD

From a database of 931 patients, treated from 1930 to 1980, we used a computer to match patients with confirmed lateral neck metastasis (N1) to those who were stage NO, and had the following identical prognostic factors: no distant metastasis, age (within 4 years), and tumor size, histology, and intrathyroidal extent. When possible, matches were also made for gender, multifocality, and extent of thyroid surgery. Survival and treatment failures were analyzed, with and without stratification for age.

RESULTS

We were able to select 100 N1 patients with corresponding NO patients, sharing the major prognostic risk factors as listed. Overall, there was no difference in survival, although N1 patients more often had recurrence. Mortality increased with age. Analysis at high-risk age (45 years and older) showed significantly more recurrences in N1 patients (p = .008). Twenty-year survival in N1 patients over the age of 45 was lower than that of NO patients. On the other hand, under the age of 45, N1 patients had better survival. These differences, however, did not reach statistical significance.

CONCLUSION

Nodal involvement in older patients with thyroid cancer increases the risk of recurrence, although no significant difference in survival is observed in relation to age.