Prospective randomized study of post-operative chemotherapy with levamisole and UFT for head and neck carcinoma

AIMS

A prospective randomized study was conducted to evaluate the benefit of adjuvant levamisole/UFT (futraful and uracil) chemotherapy in head and neck squamous cell carcinoma.

METHODS

Sixty-five patients with stage III and IV squamous cell carcinomas of oral cavity, oropharynx, hypopharynx and larynx with no distant metastasis were randomized for the chemotherapy study. Thirty-one patients were randomized for chemotherapy and two of them were subsequently excluded. In this study, a total of 29 patients on levamisole/UFT therapy and 34 patients on the control group were analysed. The main outcome was measured by the 5-year disease-free actuarial survival rate.

RESULTS

The rates of distant metastasis were 10% for chemotherapy group and 32% for control group (P=0.06). The 5-year disease-free actuarial survival rates for patients with and without adjuvant chemotherapy were 57% and 39% respectively (P=0.207).

CONCLUSIONS

A trend of better distant control in head and neck cancer patients with post-operative adjuvant oral chemotherapy was observed. The side effects were minimal. However, there was no statistically significant improvement in the overall long-term survival. It may be of value to conduct a large-scale multi-centre prospective randomized study to verify the efficacy of levamisole and UFT as post-operative adjuvant chemotherapy for the control of distant metastasis in high-risk population.

The clinicopathological significance of bcl-2 expression in the surgical treatment of laryngeal carcinoma

Bcl-2 expression was studied by immunohistochemistry on laryngectomy specimens from 176 patients. Of the 176 tumours, 11% had positive bcl-2 staining. Bcl-2 expression was significantly correlated with tumour grade: 5% of well-differentiated tumours, 12% of moderately-differentiated tumours and 23% of poorly-differentiated tumours had positive expression of bcl-2. Nodal metastases were also found to be significantly related to bcl-2 expression: 36% of nodal metastases for negative bcl-2 expression compared with 70% for positive expression. The risk of nodal metastases increased significantly with the presence of bcl-2 expression, moderate or poor differentiation and supraglottic involvement. The risk of nodal metastases increased significantly with the presence of increasing numbers of risk factors: 11% without risk factor, 21% with one risk factor, 49% with two risk factors and 77% with three risk factors. Bcl-2 expression in laryngeal carcinoma is significantly correlated with tumour grade and nodal metastases. It has added prognostic value for nodal metastases together with tumour grade and site of tumour involvement.

Prognostic significance of serum p53 protein and p53 antibody in patients with surgical treatment for head and neck squamous cell carcinoma

OBJECTIVES

This study aims at investigating the prognostic values of serum p53 protein and anti-p53 antibody in patients undergoing surgical treatment for head and neck squamous cell carcinoma (HNSCC).

METHODS

Serum p53 protein and anti-p53 antibody concentrations were determined by an enzyme-linked immunosorbent assay (ELISA) in 75 patients with HNSCC and 28 healthy controls. In 28 patients, formalin-fixed tumor tissues were also available for immunohistochemical staining by an anti-p53 DO7 monoclonal antibody. The results were correlated with the clinicopathologic parameters.

RESULTS

The mean preoperative serum concentration of p53 protein in patients with HNSCC was significantly higher than healthy controls (59.45 pg/mL vs 16.4 pg/mL, p =.007). Preoperative serum p53 antibody was present in 23 (31%) patients and was present in one healthy control. Eighteen (62%) tumor tissues showed p53 overexpression by immunohistochemistry. The presence of serum anti-p53 antibody before operation was associated with a significantly higher incidence (65%) of nodal metastasis compared with 27% nodal metastasis in patients with absence of serum anti-p53 antibody (p =.002).

CONCLUSION

Preoperative serum p53 antibody was a significant prognostic factor for nodal metastasis of HNSCC.

A comparative study of the clinicopathological significance of E-cadherin and catenins (alpha, beta, gamma) expression in the surgical management of oral tongue carcinoma

PURPOSE

E-cadherin and catenins are important epithelial adhesion molecules in normal epithelium. Loss of E-cadherin-catenin adhesion is an important step in the progression of many epithelial cancers. E-cadherin and catenins expression in carcinoma of the tongue were evaluated in relation to their clinicopathological features and prognostic values.

METHOD

Immunohistochemical staining was carried out with E-cadherin and (alpha, beta, gamma)-catenin monoclonal antibodies for 85 surgical specimens of oral tongue carcinoma, nine matched metastatic lymph nodes, and seven locally recurrent tumours.

RESULTS

There was under-expression in 85% of E-cadherin, 94% of alpha-catenin, 89% of beta-catenin, and 83% of gamma-catenin in the primary tumours. There was no correlation of E-cadherin/catenin expression with sex, age, cancer stage, and differentiation. Nodal metastasis was found in 68% of patients with weak expression of gamma-catenin compared with 9% with strong expression in primary tumours (chi-square, P = 0.02). E-cadherin was a significant prognostic factor for survival and recurrence; patients with weak E-cadherin expression had 53% 5-year survival compared with 85% with strong expression (Wilcoxon, P = 0.0159).

CONCLUSIONS

Both E-cadherin and catenins were highly under-expressed in oral tongue carcinoma, metastatic lymph node, and recurrent tumour. gamma-catenin had predictive value for nodal metastasis. E-cadherin was, however, a more important prognostic factor for recurrence and survival.

Effect of the external nasal dilator on nasal minimal cross-sectional area in orientals as assessed by acoustic rhinometry

OBJECTIVE

This study aimed to evaluate the effect of the external nasal dilator on the dimension of the nasal valve in Orientals.

DESIGN

A cohort study of normal subjects.

SETTING

Academic institution.

METHODS

The nasal fossae of normal subjects were assessed by acoustic rhinometry before and after application of the external nasal dilator.

MAIN OUTCOME MEASURES

The minimal cross-sectional area of the nasal fossae and the total cross-sectional area of the nose.

RESULTS

Nasal fossae of 25 normal subjects were evaluated. There was a significant increase of 0.10 cm2 (SD = 0.16) or a 17% increase in the minimal cross-sectional area of the 50 nasal cavities after application of the external nasal dilator (Wilcoxon's matched-pairs signed rank test, p = .0001). A significant increase in the total minimal cross-sectional area for the whole nose after application was also present (0.19 cm2, SD = .27, or 16%; Wilcoxon's matched-pairs signed rank test, p = .0032).

CONCLUSIONS

The external nasal dilator results in an increase in the minimal cross-sectional area of the nasal airway in Orientals.

A comparison of the prognostic significance of tumor diameter, length, width, thickness, area, volume, and clinicopathological features of oral tongue carcinoma

BACKGROUND

The present study aims at evaluation of the prognostic value of tumor size including diameter, length, thickness, width, area, and volume in the prediction of nodal metastasis, local recurrence, and survival of oral tongue carcinoma. The results will have important implications for the management of patients.

METHODS

Eighty-five glossectomy specimens of oral tongue carcinoma were serially sectioned in 3 mm thickness for the tumor size evaluation with computer image analyzer.

RESULTS

Among all the tumor size parameters being evaluated, tumor thickness was the only significant factor for the prediction of local recurrence, nodal metastasis, and survival. With the use of 3 mm and 9 mm division, tumor of up to 3 mm thickness has 10% nodal metastasis, 0% local recurrence, and 100% 5-year actuarial disease-free survival; tumor thickness of more than 3 mm and up to 9 mm has 50% nodal metastasis, 11% local recurrence, and 77% 5-year actuarial disease free survival; tumor of more than 9 mm has 65% nodal metastasis, 26% local recurrence, and 60% 5-year actuarial disease-free survival.

CONCLUSIONS

Tumor thickness should be considered in the management of patients with oral tongue carcinoma.

Cyclin D1 expression in oral squamous cell carcinomas: clinicopathological relevance and correlation with p53 expression

The aim of the present study is to study the relationship between cyclin D1 and the clinicopathological features of oral squamous cell carcinomas. The cyclin D1 and p53 expression in oral squamous cell carcinomas from 56 patients (45 men, 11 women) was studied by immunohistochemistry using monoclonal antibodies. The correlation between cyclin D1 and the clinicopathological features of the oral cancers was evaluated. Cyclin D1 expression was found in 63% of oral squamous cell carcinomas; it was often weak but was more frequently positive in high-grade lesions (P=0.019). The expression was positively correlated with p53 expression (P= 0.06). Radiation therapy did not alter the expression of either cyclin D1 or p53 proteins. Expression of these proteins was not related to the age, gender or survival of the patients, or to stages of the tumors. The cyclin D1 expression was more frequently seen in patients with squamous cell carcinomas of oropharynx, palate, floor of mouth and gingiva. To conclude, cyclin D1 was frequently expressed in oral squamous cell carcinomas. This expression was related to the grade of the tumors and was not similar in various regions in the oral cavity, which may indicate the different tumor biology of cancers from these regions.

Correlation of pure tone audiogram results and hearing benefit of tympanoplasty for chronic suppurative otitis media

The aim of this study was to evaluate the correlation between pure tone audiogram results and the subjective sensation of hearing benefit of patients who had tympanoplasty for chronic suppurative otitis media. This is a prospective study of 115 patients who had tympanoplasty between 1992 and 1994. The outcome, including a pure tone audiogram and the subjective sensation of hearing benefit, was evaluated at 1 year after operation. There were 63 (55%) patients with subjective hearing benefit after the tympanoplasty. The subjective sensation of hearing benefit correlated with the magnitude of the air conduction (AC) threshold reduction, and increased from 39% for an AC reduction of less than or equal to 10 dB to 100% for an AC reduction of more than 30 dB. The effect of the interaural AC threshold difference on the subjective sensation of hearing was not significant; improvement was felt by 92% of patients when the operated ear became the better hearing ear, and by 73% of patients when the operated ear remained the worse hearing ear. There was considerable discrepancy between the subjective hearing benefit and the pure tone audiogram results. A combination of parameters, including the air-bone gap, the AC threshold, and the subjective hearing change, is recommended in reporting the results of tympanoplasty.

Long-term sensorineural hearing deficit following radiotherapy in patients suffering from nasopharyngeal carcinoma: A prospective study

BACKGROUND

This was a prospective study to evaluate the effect of radical external irradiation on inner ear function after treatment of nasopharyngeal carcinoma.

METHODS

Pure tone audiograms were performed at regular intervals before, after, and up to 4.5 years following completion of radiotherapy.

RESULTS

Two hundred ninety-four patients (526 ears) were included. Within 3 months after radiotherapy, deterioration of bone conduction threshold at 4 kHz and pure tone average (average of 0.5 kHz, 1 kHz, and 2 kHz) were noted in 164 ears (31%) and 75 ears (14%), respectively. Patients older than 50 years and ears with threshold below 60 dB at 4 kHz before radiotherapy were significant factors (p < 0.01 and p < 0. 001) associated with a 4 kHz loss. In 40% of these ears, recovery was evident at 2 years. With follow-up for 4.5 years, the probability of significant threshold deterioration increased with time.

CONCLUSION

Sensorineural hearing loss started soon after radiotherapy. Early changes could be reversible while the probability of persistent hearing loss continued to increase.

Measurement of nasal geometry by acoustic rhinometry in normal-breathing Asian children

OBJECTIVE

The purpose of this study was to obtain normal values of nasal geometry in Asian children with no nasal problems using the acoustic rhinometry method.

METHOD

Acoustic rhinometric measurement of the nasal fossae was performed in pediatric patients coming for general surgical operations with no nasal problem.

RESULTS

A cohort study of 183 children in an acute care hospital with full elective and emergency surgical services was undertaken. The mean minimal cross-sectional area (MCA), which was functionally important for nasal breathing, was found to be 0.32 cm2 (SD = 0.13) and situated at 1.40 cm (SD = 0.26) from the anterior nare. Normal values for area, length, and volume of the nose in these children as a group and at different ages from 1 to 11 years old were obtained.

CONCLUSIONS

Acoustic rhinometry was found to be well tolerated by the children. The MCA was confirmed to be situated at the anterior part of the nose and had a positive correlation with an increase in age.

Clinicopathological analysis of elective neck dissection for N0 neck of early oral tongue carcinoma

BACKGROUND

The study aims at evaluation of the efficacy of elective neck dissection as a staging and therapeutic procedure for N0 neck of early carcinoma of the oral tongue by whole organ serial sectioning.

METHODS

There were 50 stage I and II patients. The neck dissection specimens were whole organ sectioned in 3-mm intervals for the evaluation of nodal metastasis.

RESULTS

There were 18 (36%) patients with subclinical nodal metastasis. The total number of metastatic nodes were 31 (1%) among all 2,826 nodes being examined. The metastatic foci had a median size of 3 mm and occupied a median of 6% of the cross sectional area of the involved nodes. The ipsilateral level II nodes were the commonest (26%) site of metastasis. Metastatic nodes were present in 34% patients who had negative preoperative radiological assessment and in 20% patients who had negative intraoperative frozen section sampling of neck nodes. Patients with subclinical nodal metastasis had a high incidence of regional recurrence (62%) and low survival (27%) when postoperative radiotherapy was not given after elective neck dissection.

CONCLUSIONS

Ipsilateral level I,II,III neck dissection is an adequate diagnostic procedure for staging of the N0 neck of early oral tongue carcinoma. Its diagnostic role cannot be replaced by the available pre-operative radiological screening and intra-operative frozen section sampling. However, elective selective neck dissection is an effective but not adequate therapeutic procedure, and post-operative adjuvant radiotherapy and chemotherapy have to be considered for all pathologically positive necks.

Otorrhea after grommet insertion for middle ear effusion in patients with nasopharyngeal carcinoma

PURPOSE

To document the incidence of complications after myringotomy and grommet insertion in patients with nasopharyngeal carcinoma. The focus is on the incidence of otorrhea and perforation. The possible risk factors for these conditions and treatment response were studied.

MATERIALS AND METHODS

We reviewed the records on 206 ears of 163 patients who suffered from nasopharyngeal carcinoma and underwent myringotomy and grommet insertion in a 7-year period. The follow-up period ranged from 4 weeks to 78 months (median, 9 months).

RESULTS

The overall incidence of otorrhea in these ears was 38%. Patients with nasopharyngeal carcinoma (NPC) had a significantly high incidence of postoperative discharge (chi2 test, P<.0001) compared with other patients who underwent myringotomy and grommet insertion. The mean interval between myringotomy and otorrhea was 19.8 weeks. Forty-seven per cent of the ears with a discharge developed otorrhea within 1 month. In 42%, the otorrhea responded to treatment and the ears became dry. After extrusion of the grommet, 29% of those ears with otorrhea ended with an eardrum perforation, and 24% of the ears showed recurrent effusion.

CONCLUSIONS

For patients with NPC who underwent myringotomy, there was a significant risk of otorrhea (49%) and persistent perforation (29%), and these complications were difficult to manage. We conclude that myringotomy and grommet insertion should not be routinely offered to NPC patients with middle ear effusion.

Local recurrence of carcinoma of the tongue after glossectomy: patient prognosis

We conducted a retrospective review of the prognosis for patients with local recurrence after surgical treatment of carcinoma of the tongue. Glossectomy for squamous cell carcinoma of the tongue was performed in 167 patients. Local recurrence developed in 32 patients including 21 with local recurrence alone, 10 with locoregional recurrence and one with locodistant recurrence. The incidence of local recurrence increased with tumor stage (from 16% of T1 tumors to 46% of T4 carcinomas). Eleven (34%) patients underwent surgical salvage for local recurrence, with only one (9%) patient surviving free of carcinoma at 43 months post-surgical salvage. All of the remaining 21 patients with local recurrence were treated palliatively and all died within one year. Patients who underwent surgical salvage had significantly higher survival rates compared to those treated palliatively. Close follow-up after glossectomy is important for early detection of local recurrence amenable to surgical salvage. However, the overall prognosis for patients with local recurrence was poor, with a three-year actuarial survival rate of only 3%. Therefore, prevention of local recurrence with adequate initial surgical treatment is essential.

Elective neck dissection versus observation in the treatment of early oral tongue carcinoma

BACKGROUND

The aim of the present review is to evaluate the results of elective neck dissection and "watchful waiting" in the surgical treatment of stages I and II squamous cell carcinoma of oral tongue.

METHODS

This is a retrospective study of patients with surgical treatment between January 1980 and December 1994.

RESULTS

There were 63 patients including those with 34 T1 and 29 T2 carcinoma. The first sites of tumor recurrence were 5 (8%) local, 17 (27%) regional, 2 (3%) distant, 1 (2%) locoregional, and 1 (2%) both regional and distant. Of the 30 NO neck patients who had no elective neck dissection, the regional recurrence rate was 47%, and eventually 23% died of tumor related to regional recurrence. Elective neck dissection significantly reduced the regional recurrence rate to 9% and also significantly reduced the regional recurrence related mortality to 3%. Elective neck dissection also increased the 5-year disease-free actuarial survival rate to 86% compared with 55% for "watchful waiting."

CONCLUSIONS

Regional recurrence was the most common cause of failure after surgical treatment of oral tongue carcinoma. Elective neck dissection significantly reduced mortality due to regional recurrence and also increased the overall survival. There was no significant difference between elective radical neck dissection and selective I, II, and III neck dissection in the improvement of treatment results. This retrospective study suggests that elective selective I, II, III neck dissection is a treatment strategy of choice for stages I and II carcinoma of the oral tongue. A prospective randomized study is worthwhile to further evaluate the benefit of elective neck dissection in the treatment of early carcinoma of the tongue.

Expression of p53 in recurrent nodal metastasis from nasopharyngeal carcinoma (NPC)

This study reports the incidence of p53 expression in 40 patients with recurrent nodal metastasis from nasopharyngeal carcinoma (NPC) and its prognostic value in this group of patients. Immunohistochemical staining using monoclonal antibody specific for human p53 protein was performed on the tumour-bearing nodes from 40 patients. The results were divided into four grades (I, negative; II, < 10% of cells positive; III, 10-50% of cells positive; and IV, > 50% of cells positive). The staining scores were correlated with histological tumour types, subsequent recurrence and survival. All patients had undergone neck irradiation. Lymph node specimens from six patients (15%) showed positive staining of nuclear p53 protein. The distribution among the different grades was: three (7.5%) for II, two (5%) for III and one (2.5%) for IV. Patients with p53-overexpressed tumours had a significantly higher number of tumour-bearing lymph nodes. There was no correlation of p53 expression with histological tumour types, second tumour recurrence and survival. Expression of p53 appears to be uncommon in patients with recurrent nodal metastases in NPC. It did not have prognostic value in this particular series of patients.

Submucosal tumor extension in hypopharyngeal cancer

OBJECTIVES

To study the incidence and extent of submucosal tumor extension in hypopharyngeal cancer and to evaluate the impact on the tumor recurrence and overall survival rates.

METHODS

Fifty-seven resected specimens of hypopharyngeal cancer were studied in detail from January 1986 to December 1989 by use of the whole-organ, step-serial sectioning technique.

RESULTS

Three types of submucosal tumor extension could be identified. Type I extension was characterized by a tumor with a smooth round contour that extended submucosally. The mucosa was thereby elevated and was detectable on gross inspection at operation. In type II extension, tongues and islands of tumor infiltrated within the submucosa, and these were not noticeable on gross examination. Skip metastasis in the submucosa where the submucosal tumor was completely separated from the main tumor bulk was classified as type III extension. Thirty-three patients (58%) had submucosal tumor extension. The frequencies (and extents of submucosal tumor extension) in the superior, medial, lateral, and inferior directions were 16% (3-10 mm), 37% (2-37 mm), 26% (2-37 mm), and 28% (3-35 mm), respectively. Two thirds of the submucosal extension was type I (22 of 33), and only 1 patient had a true skip lesion submucosally (type III extension). Type II submucosal extension was found in one third of the patients (11 of 33). This occurred significantly more often in the patients who had received radiotherapy before surgery (82% [9/11]; P < .001; 95% confidence interval, 1.28-4.44). The presence of submucosal tumor extension had no effect on the tumor recurrence and overall survival rates.

CONCLUSIONS

The incidence of submucosal tumor extensions in hypopharyngeal cancer is high (58%), but most (67%) of them can be detected grossly at operation. The presence of submucosal tumor extension does not adversely affect the survival and tumor recurrence rates.

Results of surgical salvage of locoregional recurrence of carcinoma of the tongue after radiotherapy failure

The aim of this study was to evaluate the efficacy of surgical salvage of local and nodal recurrence of carcinoma of the oral tongue after radiotherapy failure. Of the 47 patients in this retrospective review (between 1980 and 1992), there were 25 with local recurrence alone, 11 with locoregional recurrence, and 11 with nodal recurrence alone. There was no operative mortality, and 17% of patients had one or more surgical complications, including wound infection, flap necrosis, anastomotic leakage, and chest infection. Twenty-nine (62%) patients developed recurrences in the head and neck region after the salvage operation, and 9 of them had second surgical salvage operations. At the last follow-up, 53% of patients had died of carcinoma of the tongue and the overall 5-year actuarial survival rate was 43%. The 5-year actuarial survival rates were 39% for local recurrence alone, 27% for locoregional recurrence, and 68% for nodal recurrence alone. Surgical salvage had satisfactory results for patients with oral tongue carcinoma after radiotherapy failure. Close follow-up and early surgical intervention are essential for patients primarily treated with radiotherapy.

Long-term results of voice rehabilitation after total laryngectomy using primary tracheoesophageal puncture in Chinese patients

PURPOSE

Prosthetic voice restoration is an increasingly popular method of postlaryngectomy voice rehabilitation. Despite its success in non-tonal languages, the efficacy of tracheoesophageal speech in tonal languages was largely unknown. The aim of the present study was to evaluate the long-term results of voice rehabilitation using a Blom-Singer valve (BSV) in the tonal language of Cantonese.

PATIENTS AND METHODS

The records of 159 patients who underwent total laryngectomy and primary tracheoesophageal puncture (TEP) between May 1985 and December 1994 were retrospectively reviewed. Tracheoesophageal speech was regarded as functional if effective communication could be made during face-to-face conversation and telephone conversation. Any TEP-related complications were noted. Perioperative factors that might contribute to nonfunctional speech were subjected to statistical analysis.

RESULTS

Six hospital mortalities were excluded from speech analysis. Of the remaining 153 patients, the median follow-up was 25 months, ranging from 3 to 113 months. Seventy-three patients had closure of tracheosophageal fistulae (TEF), and the main causes were ineffective voice production, dislodgment, and tracheostomal stenosis. Only 15 of them acquired functional speech before closure. The other 80 patients used a BSV as the chief modality of voice rehabilitation, with functional results achieved in 64 patients. None of the perioperative factors were found to be statistically significant in relation to nonfunctional speech.

CONCLUSION

Primary TEP is an established method of voice rehabilitation after total laryngectomy. In our series, 52% patients achieved functional tracheoesophageal speech using a BSV.

Prospective Randomized Study of Thrice Weekly Six-Month and Nine-Month Chemotherapy for Cervical Tuberculous Lymphadenopathy

The aim of this study is to compare the efficacy of a thrice weekly 6-month regimen, 4S3H3R3Z3/2H3R3 (which consists of an initial 4 months of streptomycin ( S), isoniazid ( H), rifampicin ( R), and pyrazinamide ( Z) followed by 2 months of isoniazid and rifampicin), with a thrice weekly 9-month regimen, 4S3H3R3Z3/5H3R3 (which consists of an initial 4 months of streptomycin, isoniazid, rifampicin, and pyrazinamide followed by 5 months of isoniazid and rifampicin), in the treatment of cervical tuberculous lymphadenopathy. A total of 113 patients were recruited between August 1987 and December 1993. Twenty-two patients were excluded from the analysis because of defaulting treatment or modification of regimen. Ninety-one patients were included in the analysis. Forty-three patients were given the 6-month regimen, and 48 patients were given the 9-month regimen. Two (5%) patients of the 6-month regimen and one (2%) patient of the 9-month regimen had primary failure after completion of treatment (relative risk, 2.23; 95% confidence interval, 0.21 to 23.76). Of the 88 patients who had initial clinical remission after completion of treatment, the 5-year actuarial remission rates were 89% for the 6-month regimen and 90% for the 9-month regimen (Wilcoxon, p = 0.44). There were no significant differences of both primary failure rate and 5-year actuarial remission rate of the two regimens. The 6-month regimen is recommended as the initial treatment of tuberculous lymphadenopathy.

Prospective randomized study of thrice weekly six-month and nine-month chemotherapy for cervical tuberculous lymphadenopathy

The aim of this study is to compare the efficacy of a thrice weekly 6-month regimen, 4S3H3R3Z3/2H3R3 (which consists of an initial 4 months of streptomycin (S), isoniazid (H), rifampicin (R), and pyrazinamide (Z) followed by 2 months of isoniazid and rifampicin), with a thrice weekly 9-month regimen, 4S3H3R3Z3/5H3R3 (which consists of an initial 4 months of streptomycin, isoniazid, rifampicin, and pyrazinamide followed by 5 months of isoniazid and rifampicin), in the treatment of cervical tuberculous lymphadenopathy. A total of 113 patients were recruited between August 1987 and December 1993. Twenty-two patients were excluded from the analysis because of defaulting treatment or modification of regimen. Ninety-one patients were included in the analysis. Forty-three patients were given the 6-month regimen, and 48 patients were given the 9-month regimen. Two (5%) patients of the 6-month regimen and one (2%) patient of the 9-month regimen had primary failure after completion of treatment (relative risk, 2.23; 95% confidence interval, 0.21 to 23.76). Of the 88 patients who had initial clinical remission after completion of treatment, the 5-year actuarial remission rates were 89% for the 6-month regimen and 90% for the 9-month regimen (Wilcoxon, p = 0.44). There were no significant differences of both primary failure rate and 5-year actuarial remission rate of the two regimens. The 6-month regimen is recommended as the initial treatment of tuberculous lymphadenopathy.

Assessment of tracheoesophageal speech in a tonal language. A prospective study

BACKGROUND

Tracheoesophageal puncture followed by insertion of a voice prosthesis is an increasingly popular method for voice rehabilitation after total laryngectomy.

OBJECTIVE

To perform a functional assessment of voice produced by means of the Blom-Singer valve in a tonal language (Cantonese).

DESIGN

Prospective study.

SETTING

Hospital referral center.

MAIN OUTCOME MEASURE

A 5-point scoring scale was adopted for 15 test items of speech assessment grouped into 4 categories: phonatory skills, articulation, additional factors, and general judgment. The sum of the scores for the 15 items was the final speech score. The final speech score was rated as poor, satisfactory, or excellent if it was in the range of less than 30, 31 to 45, or 46 to 75, respectively.

RESULTS

Forty-four users of the Blom-Singer valve who had undergone total laryngectomy and primary tracheoesophageal puncture were available for functional assessment. The final speech score was poor in 2 patients (5%), satisfactory in 4 (9%), and excellent in 38 (86%).

CONCLUSION

Chinese patients can speak satisfactory tonal language with the Blom-Singer voice prosthesis.

Comprehensive analysis of pharyngeal recurrence of laryngeal carcinoma after total laryngectomy

PURPOSE

This study analyzes the incidence, risk factors, treatment results, and prognosis of local recurrence at the pharynx after total laryngectomy for laryngeal carcinoma.

PATIENTS AND METHODS

The records of 292 patients who underwent total laryngectomy for the treatment of laryngeal carcinoma between January 1978 and December 1990 were reviewed.

RESULTS

Of these 292 patients, there were 24 patients who developed local recurrence at the pharynx. The 5-year actuarial cumulative local recurrence rate was 10%. There were 17 cases of pharyngeal recurrence alone, five cases of pharyngeal and nodal recurrence, one case of pharyngeal and tracheostomal recurrence, and one case of pharyngeal and distant metastasis. Ten (42%) patients were salvaged surgically; the 5-year actuarial survival rate after surgical salvage was 53%. The other 14 patients were treated with palliative treatment, and all died of tumor, with the longest period of survival being 28 months.

CONCLUSION

Surgical salvage of pharyngeal recurrence has acceptable results. Close monitoring of patients is important to have an early diagnosis of salvageable recurrence.

Risk factors of tracheostomal recurrence after laryngectomy for laryngeal carcinoma

BACKGROUND

Tracheostomal recurrence after total laryngectomy for laryngeal carcinoma has a poor prognosis. The independent risk factors of tracheostomal recurrence are, however, not well documented.

METHODS

This is a multivariate analysis of the risk factors of tracheostomal recurrence after total laryngectomy for 322 laryngeal squamous cell carcinomas. The factors included in the analysis were sex, age, tumor stage, sites of tumor involvement, preoperative airway obstruction, preoperative tracheostomy, extent of surgical resection, radiotherapy, and pathological resection margin.

RESULTS

Seventeen (5%) patients developed tracheostomal recurrence. Univariate analysis showed that preoperative airway obstruction, subglottic involvement, and postcricoid extension were significant factors associated with tracheostomal recurrence. Multivariate analysis using logistic regression method showed that both subglottic and postcricoid involvement were independent predisposing factors for tracheostomal recurrence. The tracheostomal recurrence rates were 2% in patients without the risk factor and 10% in patients with the presence of one or both risk factors.

CONCLUSIONS

Subglottic and postcricoid involvement were independent risk factors for tracheostomal recurrence.

Comprehensive analysis of nodal recurrence of advanced laryngeal carcinoma following surgery

The problems of nodal recurrence after surgical treatment of T3-4 laryngeal carcinoma were analysed. There were 133 N0 and 66 N+ patients. The 5-year actuarial nodal recurrence rate of N0 patients was 18% and N+ patients was 31%. Nodal recurrence was the commonest site of recurrence. The sites of nodal recurrence of N0 patients were at the level II, III, and IV nodes. Both ipsilateral and contralateral nodal recurrences were common. Of those patients who developed nodal recurrence, 63% patients were feasible for surgical salvage. Surgical salvage with radical neck dissection was the preferred treatment for nodal recurrence with 38% 5-year survival rate. The 'watchful waiting policy' in the management of N0 neck is an acceptable option with eventual nodal failure rate of 10% after surgical salvage. Close follow-up of patients is mandatory for the early detection of surgically salvageable nodal recurrence.

Critical appraisal of watchful waiting policy in the management of N0 neck of advanced laryngeal carcinoma

OBJECTIVE

To analyze the problem of nodal recurrence of N0 neck advanced laryngeal carcinoma.

DESIGN

Retrospective analysis.

SETTING

Hospital referral center.

PATIENTS

One hundred thirty-three patients with cancer stages T3-T4, N0, M0 who had total laryngectomy between January 1981 and December 1990.

MAIN OUTCOME MEASURE

Nodal recurrence.

RESULTS

Of the 11 patients who had elective radical neck dissections, there was no nodal recurrence. Of the other 122 patients who had no elective neck dissection, 19 patients (16%) developed nodal recurrence and all nodal recurrence was at levels II, III, and IV. Twelve patients (63%) underwent salvage radical neck dissection for nodal recurrence and they had a 38% adjusted 5-year actuarial survival rate. Of these 122 patients who had no elective neck dissection for the N0 neck, 12 patients (10%) eventually died of nodal recurrence.

CONCLUSIONS

The watchful waiting policy is a satisfactory management option of N0 neck of advanced laryngeal carcinoma.

Cancer of the larynx in Hong Kong: a clinico-pathological study

Laryngeal cancer is a relatively common cancer in Hong Kong when compared with other cities over the world. The purpose of this study is to characterize and identify the clinico-pathological features of patients with laryngeal cancer being resected or autopsied in our hospital for the years 1973 to 1992. The peak age at presentation of 451 patients (408 males, 43 females) with primary laryngeal cancer resected was 62 years old and 1.6% of patients were under 40. The incidence increased with age in both sexes. The patients were noted to be ageing steadily in the 20-year study period. Most patients (30%) had tumours involving both the supra-glottis and glottis. Histological examination revealed that the cancers comprised squamous cell carcinomas (98.3%), spindle cell carcinoma (0.7%), adenoid cystic carcinoma (0.2%), mucoepidermoid carcinoma (0.2%), atypical carcinoid (0.2%) and chondrosarcoma (0.4%). Most cases of squamous cell carcinoma were moderately differentiated (67.3%). Poorly differentiated squamous cell carcinomas were more often noted in females. Forty-six laryngeal cancers were noted in the study period giving an autopsy incidence of laryngeal cancers of 0.46%. Distant metastases were found in 50% of these autopsied cases. The metastatic lesions were found in the lung (43%), liver (18%), diaphragm/pleura (18%), kidney (9%), bone (7%), heart (5%), spleen (2%), nostril (2%) and small intestine (2%). The results indicate that there are different histological subtypes of laryngeal cancer in Hong Kong Chinese and they share similar epidemiological characteristics with those reported in other studies.

Prognosis of recurrent laryngeal carcinoma after laryngectomy

BACKGROUND

Recurrence is common after total laryngectomy for advanced laryngeal carcinoma. The aim of the present study was to review the prognosis of recurrent laryngeal carcinoma after total laryngectomy.

METHODS

The records of 165 patients who developed recurrences after total laryngectomy for laryngeal squamous cell carcinoma between January 1971 and December 1990 were reviewed.

RESULTS

Of the 165 patients who developed recurrences, 34 (21%) patients had surgical salvage. The sites of recurrence of these 34 operable patients included 11 pharyngeal, 3 tracheostomal, 15 nodal, 2 pharyngeal with nodal, and 3 pulmonary metastasis. Pharyngeal recurrence had the highest salvage rate, followed by nodal and pulmonary recurrence. All patients with tracheostomal had recurrence after salvage surgery. After the surgical salvage, the tumor recurrence rate was 44% and the 5-year actuarial survival rate was 42%. Of the other 131 patients who had palliative treatment without surgical salvage, the 5-year actuarial survival rate was 2%.

CONCLUSIONS

The present study showed that patients who had surgical salvage for recurrent tumor after total laryngectomy had satisfactory prognosis. Close follow-up of patients after initial operation is essential to detect recurrence early, while surgical salvage is still feasible.

Analysis of recurrence after surgical treatment of advanced laryngeal carcinoma

The pattern of recurrences after surgical treatment of 276 patients with stage T3 and T4 laryngeal carcinoma was reviewed. Nodal recurrence was the commonest site and occurred mainly in patients with supraglottic and transglottic carcinoma. Distant metastasis was the second commonest site of recurrence, and the most distant metastases developed without locoregional recurrence. Local recurrence alone was uncommon in patients treated with primary surgery.

Clinics in diagnostic imaging

A 48-year-old Chinese woman presented with progressive right-sided sensorineural hearing loss. Computerised tomography showed asymmetrical widening of the right internal acoustic canal. Post-gadolinium magnetic resonance images demonstrated marked enhancement of an intracanalicular tumour. The diagnosis of acoustic neuroma was confirmed surgically. The approach to imaging of deafness, particularly of unilateral sensorineural hearing loss, is discussed. Magnetic resonance imaging is currently the definitive test for diagnosis of acoustic neuromas.

Bacteriology of chronic suppurative otitis media: ofloxacin susceptibility

Fifty-four patients with active chronic suppurative otitis media (CSOM) were prospectively studied for the bacteriology and their in vitro antibiotic susceptibility to ofloxacin. Thirty-nine patients (72%) had positive cultures. The commonest organism was Pseudomonas sp., which was found in 18 (33%) patients. The second commonest organism was Staphylococcus aureus, which was found in 15 (28%) patients. Bacteroides sp. was found only in 3 (6%) patients, and all were in association with the aerobes. Of all 42 aerobes found, 35 (83%) were susceptible to ofloxacin. The in vitro susceptibility results indicate that ofloxacin can be an effective antibiotic in the treatment of active CSOM.

Thyroidectomy during laryngectomy for advanced laryngeal carcinoma--whole organ section study with long-term functional evaluation

Whole organ step-serial section of laryngectomy specimens was carried out in 16 patients with a T3 and T4 laryngeal carcinoma to study the involvement of the thyroid gland. Three patients (19%) were found to have tumour invasion into the thyroid gland, and two patients (16%) were found to have tumour on the thyroid capsule. Of the 12 patients who had tumour involving the subglottic region, five patients were found to have involvement of the thyroid gland. Of the remaining four patients without subglottic tumour extension, none had tumour involvement of the thyroid gland. Of the five patients who had long-term survival of 10 years, two patients had subclinical hypothyroidism and one patient had clinical hypothyroidism. We recommend routine hemithyroidectomy when the subglottic region is involved by tumour. The whole thyroid gland should be preserved when the laryngeal tumour is confined to the supraglottic and glottic regions without clinical evidence of thyroid gland involvement.

Results of Surgical Salvage for Radiation Failures of Laryngeal Carcinoma

The results of surgical salvage of radiation failures of laryngeal carcinoma were reviewed. There were 167 stage T3 and T4 patients. The operative mortality was 7%. The complication rates were 8% wound infection, 13% chest complication, and 25% anastomotic leakage. After the first salvage operation, pharyngeal recurrence developed in 28 (48%) patients. Seven (25%| patients were feasible for second salvage operation, and none of them had further local recurrence. There were 9 (5%) tracheostomal recurrences. Of the 126 NO patients, 23(18%) had nodal recurrence, and only 5 of the nodal recurrences were feasible for salvage by radical neck dissection. All 41 node-positive patients underwent radical neck dissection, and 9 (23%) had nodal recurrence. Of the 126 node-negative patients, 19 (15%) had distant metastasis. Of the 41 node-positive patients, 18 (44%) had distant metastasis. The node-positive patients had a significantly high distant failure rate despite locoregional control of tumor. The adjusted 5-year survival rate of T3–4NOMO was 45%, and that of T3–4N + MO was 22%.

Results of surgical salvage for radiation failures of laryngeal carcinoma

The results of surgical salvage of radiation failures of laryngeal carcinoma were reviewed. There were 167 stage T3 and T4 patients. The operative mortality was 7%. The complication rates were 8% wound infection, 13% chest complication, and 25% anastomotic leakage. After the first salvage operation, pharyngeal recurrence developed in 28 (18%) patients. Seven (25%) patients were feasible for second salvage operation, and none of them had further local recurrence. There were 9 (5%) tracheostomal recurrences. Of the 126 N0 patients, 23 (18%) had nodal recurrence, and only 5 of the nodal recurrences were feasible for salvage by radical neck dissection. All 41 node-positive patients underwent radical neck dissection, and 9 (23%) had nodal recurrence. Of the 126 node-negative patients, 19 (15%) had distant metastasis. Of the 41 node-positive patients, 18 (44%) had distant metastasis. The node-positive patients had a significantly high distant failure rate despite locoregional control of tumor. The adjusted 5-year survival rate of T3-4N0M0 was 45%, and that of T3-4N + M0 was 22%.