Computed tomography-guided aspirations of parapharyngeal and skull base masses

Computed tomography (CT)-guided aspirations of 22 parapharyngeal and skull base masses were performed via an oblique approach between the ascending ramus of the mandible and the pterygoid plates. A 22 g spinal needle was inserted through an 18 g introducer needle for sampling. Diagnostic specimens were obtained in 20 cases including six salivary gland neoplasms, five squamous cell carcinomas, five infections, and two cysts. On average, 2.8 passes into the mass were required although fewer were necessary to diagnose neoplasms (2.0 passes). No complications occurred. In this series, 100% of neoplasms were detected cytologically and there were no false-negative results. In two cases (9.1%) there was a discrepancy between the initial aspiration report and the final histologic diagnosis. CT-guided aspirations of skull base masses are a viable alternative to what would otherwise be a difficult surgical approach for biopsy. Diagnostic samples are obtained in 90.9% (20 of 22) with an accuracy of 90% (18 of 20).

Feasibility and outcome of endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum

OBJECTIVES/HYPOTHESIS

Endoscopic staple-assisted esophagodiverticulostomy (ESED) is a newly described method of surgically correcting Zenker's diverticulum. Initial reports on the ease and success of the surgery have been quite enthusiastic, making it seem the procedure of choice. We initiated the procedure in an algorithm of treatment of Zenker's diverticulum, to further explore the feasibility and outcome of this new technique.

STUDY DESIGN

This is a case series of 23 patients with Zenker's diverticulum who have undergone surgical repair. For each patient, an attempt at ESED was made. If unsuccessful, an open approach was then taken.

RESULTS

Seven of 23 patients (30%) were unable to be treated with ESED because of inability to expose the diverticulum or unfavorable anatomy of the diverticulum itself. Of the remaining 16 patients, ESED was successful in resolving the symptoms of diverticulum in 14 (87%). Two patients (13%) were somewhat improved but had persistent dysphagia. No significant complications occurred. All patients resumed oral diet within the first 24 hours after surgery.

CONCLUSION

Esophagodiverticulostomy is an excellent method of surgically correcting Zenker's diverticulum in many patients, but anatomical considerations may prevent its use, making open approaches of continued importance in a surgeon's armamentarium.

Advanced oropharyngeal carcinoma treated with surgery and radiotherapy: oncologic outcome and functional assessment

INTRODUCTION/PURPOSE

Surgery and postoperative radiotherapy (XRT) is a standard therapy for locally advanced resectable oropharyngeal carcinoma. This maximizes local-regional control, but does not address the potential for occult distant metastases. Additionally, some patients may suffer poor functional outcome after this intensive local therapy. This report reviews our institutional experience with modern radical surgery and XRT for this disease.

METHODS

A retrospective chart review was performed on 51 consecutive patients treated from 1991 to 1997 at the University of Pennsylvania with radical surgery and postoperative XRT. This study included patients with locally advanced, stage III/IV (exclusive of T1-2N1) squamous carcinoma of the oropharynx. All patients had a good performance status (ECOG 0-1). Patients who received adjuvant chemotherapy were excluded. No patient had gross residual disease after surgery; the median XRT dose was 63.7 Gy. Survival, local-regional control (LRC), and freedom from distant metastases (DM) were calculated actuarially. In patients who remained free of disease, functional status was determined using the List Performance Status Scale (PSS).

RESULTS

With a median follow-up in surviving patients of 34 months, the 3-year actuarial overall survival was 51%. The 3-year LRC was 73%, and the freedom from DM was 69%. The most significant factor predicting for failure was the number of pathologically positive nodes (P <.001 for survival and DM; P =.003 for LRC). In 29 patients who were evaluable for the List PSS, the mean normalcy-of-diet score was 48; the mean eating-in-public score was 53; and the mean understandability-of-speech score was 75. There was a trend toward better PSS scores in patients with T1-2 tumors versus T3-4 tumors, although this did not reach statistical significance.

CONCLUSIONS

Surgery and postoperative XRT offer relatively good LRC and moderate overall survival rates. Results, however, remain suboptimal, particularly with respect to the risk of DM and the functional outcome. These data provide a baseline for comparison with maturing results from multimodality trials in which radical surgery is not used in all patients with locally advanced oropharyngeal carcinoma.

Surgical approach to organ preservation in the treatment of cancer of the larynx

Nonsurgical approaches to preservation of the larynx in the treatment of laryngeal carcinoma include either radiation alone or chemotherapy and radiation in combination. In light of the common use of total laryngectomy, these nonsurgical approaches have often been referred to as "organ-preservation" strategies. Within the context of this old paradigm, clinicians viewed surgery as offering the patient local control, with the caveat that the price would either be the loss of the larynx or the creation of a disability in swallowing or speech. Over the last 10 years, there has been a renaissance in the surgical approaches to laryngeal preservation, as evident in the surgical literature. A new paradigm has emerged in which both the surgical and nonsurgical approaches have equal value in laryngeal organ preservation. Today, a broad spectrum of surgical organ-preservation techniques are available that result in excellent oncologic outcomes as well as excellent and consistent functional outcomes in terms of speech and swallowing. The aim of this article is to present the options for organ-preservation surgery for laryngeal cancer.

Phase I study of paclitaxel given by seven-week continuous infusion concurrent with radiation therapy for locally advanced squamous cell carcinoma of the head and neck

PURPOSE

Paclitaxel is one of the most active agents for squamous cell carcinoma of the head and neck (SCCHN) and an in vitro radiosensitizer. The dose-response relationship for paclitaxel may depend more on exposure duration than on peak concentration. This National Cancer Institute-sponsored phase I trial was designed to determine the feasibility of combining continuous-infusion (CI) paclitaxel with concurrent radiation therapy (RT).

PATIENTS AND METHODS

Patients with previously untreated stage IVA/B SCCHN were eligible. Primary end points were determination of the maximum-tolerated dose, dose-limiting toxicity, and pharmacokinetics for paclitaxel given by CI (24 hours a day, 7 days a week for 7 weeks) during RT (70 Gy/7 weeks).

RESULTS

Twenty-seven patients were enrolled and assessable for toxicity. Nineteen of the patients who completed > or = 70 Gy were assessable for response. Grade 3 skin and mucosal acute reactions occurred at 10.5 mg/m(2)/d, but uninterrupted treatment was possible in five of six patients. At 17 mg/m(2)/d, skin toxicity required a 2-week treatment break for all three patients. The mean paclitaxel serum concentration at dose levels > or = 6.5 mg/m(2)/d exceeded that reported to achieve in vitro radiosensitization. Initial locoregional control was achieved in 14 (58%) of 24 of patients treated to 70 Gy, and control persisted in nine (38%).

CONCLUSION

CI paclitaxel with concurrent RT is a feasible and tolerable regimen for patients with advanced SCCHN and good performance status. Preliminary response and survival data are encouraging and suggest that further study is indicated. The recommended phase II dose of paclitaxel by CI is 10.5 mg/m(2)/d with RT for SCCHN.

Laryngeal preservation with supracricoid partial laryngectomy results in improved quality of life when compared with total laryngectomy

OBJECTIVES/HYPOTHESES

Study 1: To assess the oncologic outcome following supracricoid partial laryngectomy (SCPL). Study 2: To compare the quality of life (QOL) following SCPL to total laryngectomy (TL) with tracheoesophageal puncture (TEP). Study 3: To analyze whole organ TL sections to determine the percentage of lesions amenable to SCPL STUDY DESIGN: Study 1: A retrospective review of patients who underwent SCPL. Study 2: A non-randomized, prospective study using QOL instruments to compare patients who underwent either SCPL or TL Study 3: A retrospective histopathologic study of TL specimens assessed for the possibility of performing an SCPL.

METHODS

Study 1: Twenty-five patients with carcinoma of the larynx underwent SCPL between June 1992 and June 1999. Various rates of oncologic outcome were calculated. Study 2: Thirty-one patients participated in the QOL assessment. This included the SF-36 general health status measure, the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, and the University of Michigan Voice-Related Quality of Life (VRQOL) instrument. Study 3: Ninety surgical specimens were obtained and studied from the total laryngectomy cases in the Tucker Collection. Multiple sites were evaluated for the presence of carcinoma A computer program was written to classify whether the patient was amenable to SCPL.

RESULTS

Study 1: The overall local control rate was 96% (24/25). The local control rate following SCPL with cricohyoidoepiglottopexy (CHEP) was 95% (20/21). The local control rate following SCPL with cricohyoidopexy (CHP) was 100% (4/4). Study 2: The SCPL had significantly higher domain scores than TL and TEP in the following categories for the SF-36: physical function, physical limitations, general health, vitality, social functioning, emotional limitations, and physical health summary. The significantly higher domains for the SCPL when compared with the TL and TEP for the HNQOL were eating and pain. Finally, when voice-related QOL was assessed with the V-RQOL, the domains of physical functioning and the total score were significantly better with SCPL when compared with TL and TEP. Study 3: Forty of 90 (44%) laryngeal whole organ specimens were determined to be resectable by SCPL. In 16 (18%) specimens, the patients could have undergone SCPL with CHEP and in 24 (27%) specimens the patients could have undergone SCPL with CHP. Among the 40 (44%) specimens determined to be able to have undergone SCPL, 19 were glottic (1 T1, 15 T2, 3 T3) and 21 were supraglottic (9 T2, 12 T3).

CONCLUSIONS

1) A review of the literature and an analysis of the data in this study indicate that excellent local control may be expected following SCPL. 2) The QOL following SCPL, as measured by three validated QOL instruments, is superior to TL with TEP. 3) A histologic assessment of whole organ sections of TL specimens indicates that many patients who have been subjected to TL may have been candidates for SCPL. 4) If the indications and contraindications are rigorously adhered to, SCPLs are reasonable alternatives to TL in selected cases.

Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer

BACKGROUND

Microvascular free flaps are becoming the reconstructive option of choice for many head and neck defects. Many previous studies have examined factors predicting free flap survival. No study has compared differences in free flap survival when anastomosed to the internal or external jugular systems.

METHODS

Retrospective review of all free flaps performed at an academic medical center by a single head and neck microvascular surgeon during the period July 1995 to December 1999. Flaps were closely monitored postoperatively and taken back to the operating room urgently for arterial insufficiency or venous congestion.

RESULTS

On hundred fifty-six free flaps were performed during this time period. Sixty-five free flaps were anastomosed to the external jugular (EJ) vein and 86 to the IJ system (62 to the proximal common facial vein, 17 end-side on the IJ, and 7 to other branches). Five had either two venous anastomoses or were anastomosed to other veins and were excluded from statistical analysis. Six (4%) vascular thromboses occurred; 5 were venous and 1 arterial. Success by group was 99% for IJ anastomosis (1 arterial thrombosis) and 92% for EJ anastomosis (5 venous thromboses, p =.03). Urgent anastomotic revision and reperfusion salvaged 5 of the 6 flaps (overall success 99%).

CONCLUSIONS

Although the overall success rate (96% success with 99% success with salvage) is comparable to other large series, microvascular free flaps anastomosed to the external jugular vein failed at a significantly higher rate than those anastomosed to the IJ system. This suggests that the IJ system should be used as a recipient vessel when feasible.

Left hemispheric strokes in coronary surgery: implications for end-hole aortic cannulas

BACKGROUND

Perioperative stroke (POS) is a devastating complication of coronary artery bypass grafting (CABG). Many studies have been published concerning risk factors and possible causes of POS but none have studied which side of the brain is more frequently involved. The finding of a strong preponderance of left-sided strokes calls into question some widely held theories as to the cause of POS and implicates end-hole aortic perfusion catheters as a major factor.

METHODS

During a 3-year period (1996 to 1998), prospective data were collected on all 2,217 consecutive CABG patients at one hospital (with surgery by different surgeons in different groups). Strokes were classified as perioperative (within 3 days of surgery) or late (beyond 3 days but during hospitalization).

RESULTS

There were a total of 51 strokes (2.3%): 21 left, 10 right, 7 bilateral, 7 lacunar, 1 brainstem, and 5 indeterminate. There were 18 major territorial perioperative strokes on the left side and 6 on the right side. Thus, 75% (18 of 24) of POS were left-sided. Stroke patients were significantly younger than nonstroke patients (66.3 +/- 10.52 versus 71.4 +/- 8.47 years, p = 0.009). Other demographic data did not differ significantly.

CONCLUSIONS

If aortic clamping, cannulation, or manipulation were responsible for most strokes, then right-sided strokes should predominate, as the innominate artery is closest to the source of such emboli. In contrast, end-hole aortic cannulas direct a high-velocity jet at the left carotid orifice and may be responsible for a large proportion of POS. Side-hole aortic cannulas may reduce the incidence of this complication.

Radiotherapy with 6-megavolt photons for early glottic carcinoma: potential impact of extension to the posterior vocal cord

PURPOSE

Radiation therapy has a high success rate in the treatment of early glottic carcinoma. Excellent outcomes have been reported from centers using cobalt-60 or relatively low-energy (< or = 4 MV) radiation therapy to achieve these results. Whether similar outcomes can be achieved with a 6 MV linear accelerator has been less rigorously evaluated. This study assesses the efficacy of 6 MV radiation therapy for early stage glottic cancer and identifies prognostic factors for local control and overall survival in this common disease.

MATERIALS AND METHODS

One hundred twenty-eight consecutive cases of Tis, T1, and T2 squamous cell carcinomas of the glottis from 1982 to 1996 were retrospectively analyzed with regard to local control and survival. All patients were treated with definitive radiation therapy with a 6-MV linear accelerator. Potential prognostic factors for local control and survival were evaluated with univariate and multivariate models. Median follow-up of locally controlled patients was 65 months.

RESULTS

The overall 3-year actuarial local control rates for T1 and T2 carcinomas were 86% and 68%, respectively. Patients with lesions involving the posterior third of the vocal cord had significantly worse 3-year local control (76% vs. 86%, P =.038). Radiation therapy technique and overall treatment time did not significantly affect local control. For patients with Tis and T1 lesions, factors associated with significantly worse local control included cordectomy-ineligible disease (P =.024), dose less than 6,600 cGy (P =.024), and lesions limited to the posterior third of the vocal cord (P =.004). Three-year local control was 76%, with doses less than 6,600 cGy and 90% with higher doses. High rates of second primary malignancies were observed and represented the major cause of death. Five-year overall survival was 84%.

CONCLUSIONS

The use of 6-MV photons for treatment of early glottic cancer seems to achieve local control similar to that reported with lower-energy photons. However, patients with posterior third involvement had a poorer local control rate with standard radiation therapy, thereby suggesting that alternative approaches be considered.

Pilot study of organ preservation multimodality therapy for locally advanced resectable oropharyngeal carcinoma

The purpose of this study was to determine the early efficacy and toxicity of a new multimodality organ-preservation regimen for locally advanced, resectable oropharyngeal squamous cell carcinoma (SCC). Patients with T3-4N0-3M0 or T2N2-3M0 oropharyngeal SCC were eligible for this Phase II study. Patients needed the physiologic reserve for surgery and technically resectable tumors. Induction carboplatin (area under the curve = 6) and paclitaxel (200 mg/m2) x 2 cycles (q21 days) were given. Objective responders received definitive radiotherapy (XRT), 70 Gy/7 weeks with concurrent weekly paclitaxel. Initially, the dose of paclitaxel was 50 mg/m2/week; because of mucosal toxicity it was reduced to 30 mg/m2/week. Patients with N2-3 disease received post-XRT neck dissection and 2 more cycles of "adjuvant" chemotherapy. In the first 22 patients, the neutropenic fever rate was 27%. Although there has been no grade IV-V toxicity from induction therapy, grade II-III toxicity resulted in an unacceptable delay in starting XRT in 14% of patients. The response rate to induction chemotherapy was 91%. Grade III mucositis occurred in all patients during concurrent chemoradiotherapy. One patient died of pneumonia during concurrent chemoradiotherapy after receiving 26 Gy and 3 doses of paclitaxel 50 mg/m2. No dose-limiting toxicity occurred in 15 patients treated with concurrent paclitaxel 30 mg/m2/week. Actuarial overall survival at 18 months is 82%; local-regional control is 86%. To date, distant metastases have not developed in any patients. This regimen has intense but acceptable acute toxicity. The maximum tolerated dosage of weekly paclitaxel during standard continuous-course XRT is confirmed to be 30 mg/m2/week. The treatment efficacy of this regimen (response rate and short-term local-regional and distant control) is encouraging. Accrual continues to obtain long-term toxicity, efficacy, and quality-of-life data.

Morbidity after midline mandibulotomy and radiation therapy

PURPOSE

To assess the morbidity of mandibulotomy in patients treated for neoplasms of the oropharynx and oral cavity, and to determine if postoperative radiation therapy to the mandibulotomy site carries an increased risk of complications.

PATIENTS AND METHODS

The medical charts of 30 patients treated between 1992 and 1996 undergoing midline mandibulotomy for tumors of the oral cavity (7 patients) and oropharynx (23 patients) were retrospectively reviewed. Three patients presented with recurrent disease, 1 of whom was previously irradiated. Twenty-five patients received postoperative radiation after mandibulotomy to a median dose of 60 Gy to the primary tumor bed, whereas 5 patients were treated with surgery alone. The patients were separated into those whose mandibulotomy site was within the radiation treatment field (n = 9), and those whose site was shielded (n = 10). Median follow-up was 27.8 months (range 5-81 months). End points included significant pain involving the mandibulotomy site, trismus, malocclusion, wound infection, osteoradionecrosis, and time to oral intake.

RESULTS

There were no postoperative deaths. Minor wound infection or breakdown occurred in 4/30 patients (13%). All of these resolved with local care and parenteral antibiotics. More serious complications involving the mandibulotomy occurred in 2 patients (7%). One patient had chronic wound drainage at the mandibular osteotomy site, which healed after plate removal. Another patient developed osteoradionecrosis. No patient developed trismus or malocclusion. With a median follow-up of 27.8 months, 4 patients have recurred locally. The complication rate was 11% for patients whose mandibulotomy site was irradiated, and 30% for those whose site was shielded.

CONCLUSION

Mandibulotomy can be safely performed in patients who are likely to require postoperative external radiation.

Clinical care pathways: decreasing resource utilization in head and neck surgical patients

In this era of decreasing reimbursement, health systems have been forced to become more efficient and decrease resource utilization to remain financially viable. One of the methods of internal cost control has been the use of clinical pathways. Given the complexity of treatment of head and neck cancer patients, clinical pathways can help to standardize decision making and introduce uniformity in resource utilization. The objective of this study is to compare resource utilization and outcomes before and after implementation of a clinical pathway for head and neck surgical patients. We observed significant decreases in hospital costs as well as shorter lengths of stay after pathway implementation. It is our belief that a uniform management tool is beneficial in this complex disease.

Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy

Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.

Detection of recurrent head and neck squamous cell carcinomas after radiation therapy with 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography

OBJECTIVES/HYPOTHESIS

Fluorodeoxyglucose positron emission tomography (FDG-PET) has been proposed as a sensitive method to diagnose and stage various malignancies. We assessed the efficacy of FDG-PET imaging in distinguishing tumor persistence/recurrence from posttreatment changes following radiation therapy for squamous carcinomas of the head and neck

STUDY DESIGN

Retrospective analysis of FDG-PET results compared with biopsy results or outcome, or both.

METHODS

Twenty-eight patients who had undergone radiation therapy with or without surgery for treatment of squamous cell carcinoma were studied with FDG-PET imaging. There was clinical suspicion for recurrence in each patient, but no obvious mass or lesion to biopsy was found on physical examination or anatomic imaging. The results of FDG-PET imaging were compared with those of biopsy or clinical follow-up of at least 6 months, or both.

RESULTS

FDG-PET imaging was positive in 13 patients, and the presence of active disease was confirmed in 12. Two thirds of the 12 received further cancer treatment. There were 15 negative FDG-PET images. Thirteen of these were confirmed true-negative images, but two studies were false-negative images. The sensitivity and specificity of FDG-PET were 86% and 93%, respectively, with positive and negative predictive values of 92% and 87%, respectively. The overall accuracy was 89%.

CONCLUSION

FDG-PET imaging is a useful modality to distinguish tumor persistence/recurrence from radiation-induced tissue changes in the neck following treatment for head and neck cancer. FDG-PET can identify patients who may benefit from further treatment, and may lead to improved outcome for individual patients.

A phase I trial of 96-hour paclitaxel infusion plus accelerated radiotherapy of unrespectable head and neck cancer

PURPOSE

To determine the maximum tolerated dose (MTD) of paclitaxel given as a 96-hour continuous infusion during Weeks 1 and 5 of an accelerated radiotherapy schedule for the definitive treatment of advanced (nonmetastatic) unresectable squamous cell carcinoma of the head and neck (SCCHN).

METHODS AND MATERIALS

Thirteen patients with Stage IV SCCHN were enrolled. Radiotherapy consisted of 70-72 Gy over 6 weeks, with a fractionation scheme of 2 Gy q.d. for 4 weeks followed by 1.6 Gy b.i.d. for 2 weeks, with no planned interruptions. Paclitaxel was administered over a 96-hour continuous infusion during Weeks 1 and 5 of radiotherapy at the following dose levels: Dose Level 1: 40 mg/m(2)/96-hours (3 patients); Dose Level 2: 80 mg/m(2)/96-hrs (5 patients); Dose Level 3: 120 mg/m(2)/96-hours (2 patients); and Dose Level 2A: 100 mg/m(2)/96-hours (3 patients).

RESULTS

The MTD of Paclitaxel was 100 mg/m(2)/96-hours. All but one patient (who experienced progressive disease after receiving 61 Gy and both cycles of paclitaxel) completed therapy as planned. Dose-limiting toxicity occurred in both patients enrolled at Dose Level 3, with one patient experiencing Grade 4 diffuse moist desquamation and the other patient experiencing Grade 4 mucositis and febrile neutropenia. Thus, Dose Level 2A was opened and no dose limiting toxicity was noted. Grade 3 non-dose limiting mucositis and dermatitis occurred at all paclitaxel dose levels. There were no treatment-related deaths. All Grade 3 and 4 toxicities were reversible. Complete responses were seen in 8 of 13 patients, 4 patients achieved partial responses, and 1 patient had no response/progressive disease.

CONCLUSIONS

Infusional paclitaxel over 96 hours during Weeks 1 and 5 of this accelerated radiotherapy schedule is feasible. The MTD of paclitaxel in this protocol was 100 mg/m(2)/96-hours. Dose-limiting toxicities were primarily enhanced epithelial reactions, but febrile neutropenia also occurred. All patients develop non-dose limiting Grade 3 skin and mucosal reactions, reflecting the high treatment intensity. This regimen merits further investigation.

Nerve cell adhesion molecule expression in squamous cell carcinoma of the head and neck: a predictor of propensity toward perineural spread

OBJECTIVE

To evaluate head and neck squamous cell carcinomas (SCCAs) for the expression of nerve cell adhesion molecule (N-CAM). We propose that expression of N-CAM by tumor cells may be associated with perineural invasion in SCCA of the head and neck.

METHODS

Seventy-six archived specimens of histologically proven SCCA were analyzed by immunohistochemistry for the expression of N-CAM. Positive and negative controls were used to assess staining. Two sections of each specimen were reviewed for the presence of perineural invasion. A retrospective chart review was performed for each patient that corresponded to the above specimens.

RESULTS

Perineural invasion was present in 28 (37%) of the 76 patients evaluated for the expression of N-CAM. N-CAM expression was demonstrated in 38 (50%) of the 76 specimens. The incidence of N-CAM expression was significantly associated with perineural invasion (P = .002). There was no significant association between the presence of staining or the presence of perineural invasion and the incidence of locoregional recurrence, distant metastasis, or survival status; however, the mean follow-up was only 13.6 months (range, 1-49 mo).

CONCLUSION

There is a positive correlation between the presence of N-CAM expression and perineural invasion in SCCA of the head and neck. The expression of this adhesion molecule by tumor cells may facilitate both homophilic cell-to-cell and heterophilic cell-to-substrate adhesion, thereby enabling the tumor cells to use the perineural tissues or neural cells, or both as a conduit for perineural spread.

Seven-week continuous-infusion paclitaxel concurrent with radiation therapy for locally advanced non-small cell lung and head and neck cancers

The goal of these National Cancer Institute-sponsored phase I trials is to determine the feasibility, toxicity, and pharmacokinetics of continuous-infusion (24 hr/d, 7 d/wk, 7 weeks total) intravenous paclitaxel combined with standard, curative-intent thoracic radiation therapy (XRT) for previously untreated, locally advanced non-small cell lung cancer and squamous cell cancer of the head and neck (HNSCC). Eligible patients have locally advanced (T4NXM0 or TXN2-3M0) non-small cell lung cancer ineligible for potentially curative surgical resection or locally advanced HNSCC with an expected 5-year survival rate of less than 25%, as well as a good performance status, adequate hematologic, hepatic, and renal function, and no distant metastases. Non-small cell lung cancer patients receive a total tumor dose of 64.8 Gy megavoltage XRT in 7 weeks at 1.8 Gy once daily, 5 d/wk. Patients with HNSCC receive 70 Gy megavoltage XRT in 7 weeks at 2 Gy once daily, 5 d/wk. Paclitaxel is delivered by continuous intravenous infusion starting 48 hours before XRT and continuing for its duration. The dose of paclitaxel is escalated in cohorts of three patients in a standard phase I design. To date, 49 patients have been entered on both studies and 43 are evaluable for toxicity. Paclitaxel dose is currently at the 17 mg/m2/d dose level, with no dose-limiting toxicity thus far. Clinical outcomes suggest significant activity for this combination. This therapy is feasible and has been well-tolerated through current dose levels. Dose escalation is ongoing.

Malignant tumors of the nose and paranasal sinuses: hospital of the University of Pennsylvania experience 1990-1997

We reviewed our experience with sinonasal malignancies, which comprise less than 1% of all cancers, in order to determine the spectrum of disease and outcome after treatment. The medical records of 48 patients with sinonasal malignancies treated between 1990-1997 were reviewed for epidemiologic characteristics, tumor location and histology, treatment modalities, and tumor recurrence. Mean age was 58.5 years and 46% were male. Multiple sites of origin were common, including maxillary sinus (83%), ethmoid sinus (35%), and nasal cavity (40%). The histologic spectrum included squamous cell carcinoma (46%), adenoid cystic carcinoma (6%), and miscellaneous others (48%). Treatment included surgery and adjuvant radiotherapy (XRT) (58%), surgery alone (27%), XRT and chemotherapy (6%), surgery and chemotherapy (4%), and XRT alone (4%). Mean follow-up was 15 months (range 2-58). Recurrence was evident in nine patients (19%), 3 (33%) of whom had prior treatment before presenting to HUP. Of the six who recurred after initial treatment at HUP, five (83.3%) were treated with surgery and XRT and one (16.7%) was treated with surgery alone. Of the three that recurred after undergoing attempts at salvage (prior treatment and then treatment at HUP), one had received surgery alone followed by surgery and XRT, one had surgery and XRT followed by surgery and one had XRT followed by surgery alone. Our experience reveals surgery and XRT to be the modality of choice, particularly for advanced tumors, whereas surgery alone may be sufficient for small, well localized tumors. Neoadjuvant chemotherapy may offer improved local control; the future role of endoscopic surgery warrants further investigation.

Image-guided fine-needle aspiration of the head and neck: five years' experience

OBJECTIVE

To evaluate the diagnostic utility of image-guided fine-needle aspiration (FNA) in the head and neck.

DESIGN

All image-guided FNAs of the head and neck performed January 1992 through June 1997 were included. All cytohistopathologic data were reviewed and collated. A slide review was performed in all cases with cytohistologic discrepancies.

SETTING

The Department of Radiology, University of Pennsylvania Medical Center, Philadelphia.

PATIENTS

Patients with deep-seated or poorly localized masses in the head and neck, representing both primary or recurrent/metastatic lesions, were referred.

RESULTS

There were 111 computed tomography-guided FNAs performed in 109 patients. Sites sampled included parapharyngeal (n = 20), parotid or submandibular (n= 25), thyroid (34), and neck, paratracheal/paraesophageal, skull base, and paraspinal (n = 32). Diagnostic samples were obtained in 93 cases (83.8%). The procedures were well tolerated, without long-term complications. Cytologic examination detected a total of 39 malignancies, 24 of which were confirmed histologically. Eleven of the remaining malignant FNA cases reflected recurrent tumor; there were 3 false-positive FNA cases (2.7%), 2 in the setting of previous surgery and/or radiation therapy. There were 2 false-negative aspirates from sites deep in the neck (1.8%) among 7 of the 35 patients with benign aspirates who underwent surgery. Twenty six patients underwent ultrasound-guided FNA (thyroid gland only), revealing 1 papillary carcinoma and 1 intrathyroidal parathyroid gland, both of which were confirmed histologically. The findings in the aspirates from the rest of the patients were benign (n = 18), Hurthle cell neoplasm (n = 1), and nondiagnostic (n = 5).

CONCLUSIONS

(1) The cytologic findings were supported clinically and/or histologically in 86 (92%) of the 93 diagnostic computed tomography-guided FNA cases. (2) Unnecessary surgery was avoided in 37% of the patients with recurrent tumor or benign diagnoses by cytologic assessment. (3) Potential pitfalls include false-positive diagnoses after radiation therapy and procedural or sampling limitations for deep neck and paraspinal lesions.

Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck

BACKGROUND

Most patients receiving accelerated fractionation radiotherapy or chemoradiotherapy for head and neck cancer experience severe mucositis. This can lead to decreased oral intake, resulting in dehydration, severe malnutrition, hospitalization, and/or interruption of radiotherapy.

OBJECTIVE

To evaluate the effect of prophylactic gastrostomy tubes (PGTs) on the rates of weight loss, unplanned interruptions, and hospitalization during high-intensity head and neck radiotherapy.

METHODS

A retrospective review was performed on 88 patients treated for locally advanced head and neck cancer with accelerated twice-a-day radiation (n = 59) or concurrent chemoradiotherapy (n = 29). Prophylactic gastrostomy tubes were placed in 36 (41%) of patients in anticipation of increased acute toxic effects from treatment. The remaining patients without PGTs served as a control group.

RESULTS

Patients without PGTs lost an average 3.1 kg compared with 7.0 kg in the control group (P<.001). There were significantly fewer hospitalizations for nutritional or dehydration issues in those with PGTs than in the control group (13% vs 34%; P = .04, chi2 test). Among those with good performance status, no patient with a PGT required a treatment interruption, compared with 18% of patients without a PGT (P = .08). Sixteen patients (31%) in the control group underwent therapeutic gastrostomy tube placement during or after radiation therapy.

CONCLUSIONS

The use of PGTs significantly reduces weight loss and the rate of hospitalization for dehydration and complications of mucositis. Treatment interruptions may also be avoided by the use of PGTs in patients with good performance status. We encourage patients scheduled for intensive radiation therapy to receive a PGT.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Can radiologists accurately predict preepiglottic space invasion with MR imaging?

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Synovial sarcomas of the head and neck: MR findings

OBJECTIVE

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

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

SETTING

Tertiary care, university-based practice.

PATIENTS

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

INTERVENTION

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

RESULTS

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

CONCLUSIONS

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

Capnography during jet ventilation for laryngoscopy

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delphian lymph node in laryngeal carcinoma: a whole organ study

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

Pilot study of the oral omeprazole test for reflux laryngitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Granular cell myoblastoma of the cervical esophagus: MR findings

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

Primary malignant melanoma of the sinonasal cavity: MR imaging evaluation

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

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

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

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

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

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

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

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

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

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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