Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group

BACKGROUND

As a general rule, surgery whenever possible, followed by irradiation is considered to be the standard treatment for cancer of the hypopharynx, thus sacrificing natural speech. In most patients, surgery includes removal of the larynx.

PURPOSE

A prospective, randomized phase III study was conducted by the European Organization for Research and Treatment of Cancer (EORTC) starting in 1990 to compare a larynx-preserving treatment (induction chemotherapy plus definitive, radiation therapy in patients who showed a complete response or surgery in those who did not respond) with conventional treatment (total laryngectomy with partial pharyngectomy, radical neck dissection, and postoperative irradiation) in previously untreated and operable patients with histologically proven squamous cell carcinomas of the pyriform sinus or aryepiglottic fold, but free of other cancers.

METHODS

Patients were randomly assigned to one of two treatment arms: 1) immediate surgery with postoperative radiotherapy (50-70 Gy) or 2) induction chemotherapy (cisplatin [100 mg/m2] given as a bolus intravenous injection on day 1, followed by infusion of fluorouracil [1000 mg/m2 per day] on days 1-5). An endoscopic evaluation was performed after each cycle of chemotherapy. After two cycles, only partial and complete responders received a third cycle. Patients with a complete response after two or three cycles of chemotherapy were treated thereafter by irradiation (70 Gy); nonresponding patients underwent conventional surgery with postoperative radiation (50-70 Gy). Salvage surgery was also performed when patients relapsed after chemotherapy and irradiation. The trial was designed to test the equivalence of the two treatment arms; i.e., the induction chemotherapy treatment would be judged equivalent to immediate surgery if the relative risk of death for induction chemotherapy compared with immediate surgery was significantly less than 1.43 using a one-sided hypothesis test at the .05 level of significance.

RESULTS

Two hundred two patients entered the trial and were randomly assigned; only 194 were eligible for treatment (94 in the immediate-surgery arm and 100 in the induction-chemotherapy arm). In the induction-chemotherapy arm, complete response was seen in 52 (54%) of 97 patients with local disease (primary tumor) and in 31 (51%) of 61 patients with regional disease (involvement of the neck). Treatment failures at local, regional, and second primary sites occurred at approximately the same frequencies in the immediate-surgery arm (12%, 19%, and 16%, respectively) and in the induction-chemotherapy arm (17%, 23%, and 13%, respectively). In contrast, there were fewer failures at distant sites in the induction-chemotherapy arm than in the immediate-surgery arm (25% versus 36%, respectively; P = .041). The median duration of survival was 25 months in the immediate-surgery arm and 44 months in the induction-chemotherapy arm and, since the observed hazard ratio was 0.86 (logrank test, P = .006), which was significantly less than 1.43, the two treatments were judged to be equivalent. The 3- and 5-year estimates of retaining a functional larynx in patients treated in the induction-chemotherapy arm were 42% (95% confidence interval = 31%-53%) and 35% (95% confidence interval = 22%-48%), respectively.

CONCLUSIONS AND IMPLICATIONS

Larynx preservation without jeopardizing survival appears feasible in patients with cancer of the hypopharynx. On the basis of these observations, the EORTC has now accepted the use of induction chemotherapy followed by radiation as the new standard treatment in its future phase III larynx preservation trials.

Prognostic value of a microRNA signature in nasopharyngeal carcinoma: a microRNA expression analysis

BACKGROUND

MicroRNAs (miRNAs) can be used as prognostic biomarkers in many types of cancer. We aimed to identify miRNAs that were prognostic in patients with nasopharyngeal carcinoma.

METHODS

We retrospectively analysed miRNA expression profiles in 312 paraffin-embedded specimens of nasopharyngeal carcinoma from Sun Yat-sen University Cancer Center (Guangzhou, China) and 18 specimens of non-cancer nasopharyngitis. Using an 873 probe microarray, we assessed associations between miRNA signatures and clinical outcome in a randomly selected 156 samples (training set) and validated findings in the remaining 156 samples (internal validation set). We confirmed the miRNAs signature using quantitative RT-PCR analysis in 156 samples from a second randomisation of the 312 samples, and validated the miRNA signature in 153 samples from the West China Hospital of Sichuan University in Chengdu, China (independent set). We used the Kaplan-Meier method and log-rank tests to estimate correlations of the miRNA signature with disease-free survival (DFS), distant metastasis-free survival (DMFS), and overall survival.

FINDINGS

41 miRNAs were differentially expressed between nasopharyngeal carcinoma and non-cancer nasopharyngitis tissues. A signature of five miRNAs, each significantly associated with DFS, was identified in the training set. We calculated a risk score from the signature and classified patients as high risk or low risk. Compared with patients with low-risk scores, patients with high risk scores in the training set had shorter DFS (hazard ratio [HR] 2·73, 95% CI 1·46-5·11; p=0·0019), DMFS (3·48, 1·57-7·75; p=0·0020), and overall survival (2·48, 1·24-4·96; p=0·010). We noted equivalent findings in the internal validation set for DFS (2·47, 1·32-4·61; p=0·0052), DMFS (2·28, 1·09-4·80; p=0·030), and overall survival (2·87, 1·38-5·96; p=0·0051) and in the independent set for DFS (3·16, 1·65-6·04; p=0·0011), DMFS (2·39, 1·05-5·42; p=0·037), and overall survival (3·07, 1·34-7·01; p=0·0082). The five-miRNA signature was an independent prognostic factor. A combination of this signature and TNM stage had better prognostic value than did TNM stage alone in the training set (area under receiver operating characteristics 0·68 [95% CI 0·60-0·76] vs 0·60 [0·52-0·67]; p=0·013), the internal validation set (0·70 [0·61-0·78] vs 0·61 [0·54-0·68]; p=0·012), and the independent set (0·70 [0·62-0·78] vs 0·63 [0·56-0·69]; p=0·032).

INTERPRETATION

Identification of patients with the five-miRNA signature might add prognostic value to the TNM staging system and inform treatment decisions for patients at high risk of progression.

FUNDING

Science Foundation of Chinese Ministry of Health, National Natural Science Foundation of China, Pearl River Scholar Funded Scheme, Guangdong Key Scientific and Technological Innovation Program, Guangdong Natural Science Foundation, Fundamental Research Funds for the Central Universities.

Nasopharyngectomy in the treatment of recurrent nasopharyngeal carcinoma: a twelve-year experience

BACKGROUND

The incidence of recurrent nasopharyngeal carcinoma (NPC) after primary radiotherapy is considerable. The result of re-irradiation to the recurrent tumor is not satisfactory.

METHODS

Thirty-one patients who received nasopharyngectomy for treatment of their recurrent nasopharyngeal carcinoma (NPC) (rT1 to rT3) at the Prince of Wales Hospital during the period 1986 to 1997 were reviewed retrospectively. Eleven patients had nasopharyngectomy performed by the transoropalatal approach, 9 patients by the maxillary swing approach, and 11 patients by the mandibular approach.

RESULTS

Most recurrences (29 of 31) were rT1 and rT2 tumors. No hospital mortality occurred. The common complications of nasopharyngectomy were palatal defect (17 of 31), trismus (15 of 31), otitis media with effusion (20 of 31), dysphagia (12 of 31), and nasal regurgitation (8 of 31). Nine surgical specimens had microscopic invasion of the resection margins. The 5-year actuarial overall survival, actuarial disease-free survival, and tumor control were 47%, 42%, and 43%, respectively. The administration of postoperative radiotherapy significantly enhanced survival and tumor control after nasopharyngectomy.

CONCLUSIONS

Nasopharyngectomy supplemented by postoperative radiotherapy achieved significant survival and tumor control with acceptable complications in selected recurrent NPC. It appears to be a better salvage treatment than re-irradiation alone for selected recurrent NPC.

Total Pharyngolaryngectomy for Squamous Cell Carcinoma of the Hypopharynx: A Review

OBJECTIVES

To evaluate our experience with total pharyngolaryngectomy in the treatment of hypopharyngeal squamous cell carcinoma.

STUDY DESIGN

Retrospective analysis of consecutively treated patients in an academic otolaryngology, head and neck department.

METHODS

One hundred eighty patients who had total pharyngolaryngectomy performed for hypopharyngeal carcinoma were included in this study. Patients with a history of previous head and neck cancer were excluded. Clinicopathologic parameters were recorded and survival calculated using the Kaplan-Meier method.

RESULTS

One hundred sixty-two (90%) of the patients were male, and the patients had a mean age of 62 years. The majority (91%) of patients had advanced overall clinical stage disease (stage 3,4). Thirty-one (17.8%) and 43 (24%) patients developed locoregional and metastatic disease recurrence, respectively. The 2- and 5-year disease-specific survival rates were 72% and 52%, respectively. Advanced nodal stage, perineural invasion, lymphovascular invasion, and positive margins were predictors of poor survival on univariate analysis, and lymphovascular invasion was an independent prognostic factor on multivariate analysis.

CONCLUSION

Surgery and postoperative radiotherapy remains the treatment against which other modalities should be compared for advanced stage hypopharyngeal squamous cell carcinoma.

Reconstruction with free jejunal autograft after circumferential pharyngolaryngectomy: eighty-three cases

The free jejunal autograft (FJA) has become a common procedure for pharyngeal reconstruction after circumferential pharyngolaryngectomy. In order to evaluate the postoperative outcome and the functional and carcinologic results, we retrospectively reviewed 83 cases of reconstruction with FJA. Fifty-one patients had received no prior radiotherapy, and 25 had received prior radiotherapy for their hypopharyngeal tumor or for another previous primary. Seven patients underwent a secondary reconstruction. In the postoperative course, there were 2 postoperative deaths, 4 graft failures (5%), and 11 salivary fistulas. The median time to removal of the nasogastric tube was 16 days, and to discharge, 23 days. Forty-eight patients received postoperative radiotherapy, with good tolerance. At 1 year postoperatively, 98% of the patients were able to eat a solid or soft diet. The postoperative radiotherapy did not impair the quality of the functional results in a long-term assessment. The vocal results were disappointing. The 3-year survival rate was 40%. The main carcinologic failures (45 patients) were locoregional recurrences (20 patients) and metastasis, which was the cause of death in 34% of the cases. It seems clear that FJA allows one-stage reconstruction and good swallowing rehabilitation, tolerates postoperative radiotherapy, and increases the quality of life in these patients with a poor prognosis.

Squamous cell carcinoma of the hypopharynx--analysis of treatment results

The results of surgical treatment and causes of failure in 109 patients with squamous cell carcinoma of the hypopharynx were analyzed. The 5-year survival was significantly related to the stage of the disease (stage I, 74%; stage II, 63%; stage III, 32%; and stage IV, 14%) and the preoperative nodal staging (N0, 57%; N1, 28%; N2, 6%; and N3, 0%), but not related to the extent of tumor resection. The local control rate was 86% and the majority of the local recurrences occurred at the upper resection margin. There was no significant difference in the local recurrence rate between those patients who had pharyngolaryngoesophagectomy and those who had pharyngolaryngectomy. However, the resection-associated complications (bleeding, cardiac arrhythmia, pulmonary complications) were more frequent when total esophagectomy was performed. Reconstruction-associated complications such as wound infection and anastomotic leakage occurred less often after gastric pull-up reconstruction as compared with the use of myocutaneous flap, but was associated with more serious outcome after pharyngo-gastric anastomosis. Thirty-seven patients (34%) had neck node recurrences and these were significantly related to the preoperative nodal staging (N0, 20%; N1, 37%; N2, 48%; and N3, 83%). Additional primary cancers occurred in 17% of the patients and was a significant cause of death in those patients who survived more than 2 years.

Minimally Invasive Endoscopic Nasopharyngectomy in the Treatment of Recurrent T1-2a Nasopharyngeal Carcinoma

OBJECTIVE

To study the efficacy of endoscopic nasopharyngectomy in salvaging recurrent T1 to 2a nasopharyngeal carcinoma (NPC).

STUDY DESIGN

An investigation of the outcome of endoscopic nasopharyngectomy.

METHODS

Six nasopharyngectomies for patients presenting with locally recurrent T1 to 2a NPC were performed exclusively by way of endoscopic resection by a single surgeon (m.-k.c.) during the period 2001 to 2005. All patients were operated on with curative intent without postoperative radiotherapy.

RESULTS

All six operations were successfully performed endoscopically, and no conversions to conventional open resection were necessary. Of the patients who underwent endoscopic excision, three of them had rT1 disease, and the others had rT2a disease. No surgical specimens had microscopic invasion of the resection margins. No complications associated with the operation occurred. The patients were followed up for 16 to 59 (average, 29) months. One local recurrence was noted in this series to date, and the patient was treated with intensity-modulated radiotherapy and chemotherapy.

CONCLUSIONS

Exclusively endoscopic nasopharyngectomy is a feasible method for treatment of locally recurrent T1- to 2a-staged NPC.

Primary and salvage (hypo)pharyngectomy: Analysis and outcome

BACKGROUND

Surgery for squamous cell carcinoma (SCC) arising or extending to the hypopharynx is generally reserved for advanced disease or salvage. The prognosis of patients requiring pharyngectomy is poor, and the perioperative morbidity is significant. The aim of the present study is to describe the disease-related and treatment-related outcomes of patients undergoing primary and salvage pharyngectomy for cancer of the hypopharynx and larynx over a 10-year period from a single institution.

METHODS

We retrospectively reviewed 138 partial and circumferential pharyngectomies performed at a tertiary referral center between 1992 and 2002. There were 31 females and 107 males. The median age was 62 years (range, 27-81 years), and mean follow-up was 3.6 years. Salvage pharyngectomy for radiation failure was performed in 72 patients (52%), and in 66 patients (48%) pharyngectomy was performed as the primary treatment.

RESULTS

The 5-year overall survival rate after salvage pharyngectomy was 31% and after primary pharyngectomy was 38%. The 5-year disease-specific survival (DSS) for salvage was 40% and after primary surgery was 45%. The 5-year local and regional control rates for salvage pharyngectomy were 71% and 70%, respectively, and for primary pharyngectomy were 79% and 67%, respectively. The perioperative mortality rate was 3.6%, and the combined morbidity rate was 70%. Postoperative hypocalcemia developed in 44% of patients, a pharyngocutaneous fistula developed in 31% of patients, and the long-term stricture rate was 15%. Variables adversely affecting DSS on univariate analysis were nodal metastases (p = .044), extracapsular spread (ECS) (p = .006), poorly differentiated tumors (p = .015), lymphovascular invasion (p = .042), and positive tumor margins (p = .026). ECS (p = .023) was the only independent prognostic variable on multivariable analysis; however, there was a trend toward significance for nodal metastases (p = .064) and tumor differentiation (p = .079).

CONCLUSION

This study demonstrates that both salvage pharyngectomy and primary surgery for advanced disease are viable options with high locoregional control. However, this represents a high-risk group in terms of both operative morbidity and survival. Patients with nodal metastases, ECS, and poorly differentiated tumors are likely to succumb to their disease and should be selected for adjuvant therapy when possible.

Transoral carbon-dioxide laser resection of hypopharyngeal carcinoma

In hypopharyngeal carcinoma, open partial resection is rarely feasible because of the high rate of chronic aspiration. Transoral laser surgery, however, is not associated with major swallowing problems. Between 1991 and 1995, a total of 29 patients with cancer of the hypopharynx were treated using laser surgical resection. In 25 patients, a neck dissection was performed, and 26 patients were radiated postoperatively. The 5-year overall survival was 48% and tumor-related survival 58%. The outcome was significantly ( P<0.048) dependent on the preoperative lymph node status (N(0)=74%, N(+)=34% overall survival). Accordingly, the 5-year survival in stage I and stage II tumors was 71% and in stage III and IV tumors 47%. The highest local control rate was achieved in patients with carcinoma of the hypopharyngeal walls. A major advantage of laser surgery is that resurfacing of the wounds takes place per secundam. No reconstructions with free vascularized grafts have to be performed. There were no functional deficits regarding speech and swallowing in 94%, 100% and 100% of the surviving patients without local recurrence after 3, 4 and 5 years, respectively. No patient had to have a tracheostomy intraoperatively. Laser surgical treatment in combination with neck dissection and postoperative radiotherapy of selected patients with early cancer of the hypopharynx shows comparable results with open surgical procedures and is superior to radiotherapy alone. Given the low postoperative morbidity, transoral laser surgery with the goal of preserving the larynx should gain more importance in the future.

Supracricoid hemilaryngopharyngectomy. Analysis of 240 cases

The supracricoid hemilaryngopharyngectomy consists of resection of the supracricoid hemilarynx and ipsilateral pyriform sinus. Two hundred forty patients underwent this procedure from 1964 through 1983. Two hundred twenty-two patients had no airway impairment, and 204 recovered normal deglutition. The local recurrence rate was 5.2%. Indications for the procedure are carcinoma of the supracricoid upper part of the pyriform sinus and carcinoma of the lateral laryngeal margin with normal vocal cord mobility.

Supracricoid hemilaryngopharyngectomy in selected pyriform sinus carcinoma staged as T2

From 1964 to 1985 supracricoid hemilaryngopharyngectomy (SCHLP) was performed at the authors' institution for 34 selected pyriform sinus carcinomas staged as T2. Tumors involved the anterior part of the pyriform sinus, the lateral wall, the medial wall, and the whole aryepiglottic fold in all cases. Tumors with invasion of the apex of the pyriform sinus, of the retrocricoid region, of the posterior pharyngeal wall, or with fixation of the true vocal cord were excluded from the study. Such a technique was aimed at preserving physiologic phonation, respiration, and swallowing while achieving the same local control rate as pharyngolaryngectomy. Patients were monitored for at least 6 years or until death. No patients were lost to follow-up. The 5-year cause-specific survival rate was 55.8%. The main cause of death was second primary tumor. The 5-year actuarial local recurrence rate was 3.4%. The authors' experience with the SCHLP technique challenges the traditional teaching of pharyngolaryngectomy and establishes this technique as a safe method of voice preservation in selected cases of pyriform sinus carcinomas.

Functional evaluation of pharyngoesophageal reconstructive techniques

This work represents a 12-year experience from the Eastern Virginia Medical School, Norfolk, with 115 patients who had pharyngoesophageal resections for cancer treatment. Each patient received reconstruction by one of four major techniques: deltopectoral flaps (n = 43), pectoralis myocutaneous flaps (n = 36), gastric pull-ups (n = 19), and free jejunal autografts (n = 17). An analysis of the procedures with emphasis on the functional results indicates that each technique has advantages in specific circumstances. Guidelines for the application of these techniques are presented.

Primary Parapharyngeal Space Tumors in a Mexican Cancer Center

OBJECTIVE: To describe clinical and demographic characteristics of the parapharyngeal space tumors and assess surgical approaches used to treat them at our institution.

METHODS: A retrospective and descriptive study of the parapharyngeal space tumors, excluding paragangliomas, treated from June 1991 to October 2002 in a cancer center. The study population included 21 patients, 8 men and 13 women, average age of 41 years (range, 20 to 70 years). Fine needle biopsy was done in 5 (24%) patients. Computed tomography (CT) was performed in all patients, and only a few required magnetic resonance image (MRI).

RESULTS: Surgical approaches included transcervical alone or in combination with parotidectomy, transoral, or transmandibular (mandibular swing) approach. Laminectomy and segmentary approaches were also performed in 1 patient each. Sixteen (76%) patients had benign lesions and 5 (24%) had malignant tumors. Neurogenic tumors represented 57% of all tumors. Mean tumor size was of 6.7 cm (range, 3 to 11 cm). Six (29%) patients received adjuvant radiotherapy. Complications occurred in 6 (29%) patients, 4 (19%) of which were nervous injuries associated with peripheral nerve sheath tumors. Median disease-free follow-up survival was 33 months (range, 2 to 184 months) despite being an heterogeneous group of histologies.

CONCLUSION: Parapharyngeal space is a rare location for head and neck tumors. Cervical approach should be the first choice for large tumors; transoral approach is reserved for tumors less than 3 cm. Conversion to mandibular swing approach when the cervical approach is not offering proper exposure for tumor resection is indicated. Preoperative histologic diagnosis is not required. Nevertheless, CT scan should always be performed in order to exclude paragangliomas, distinguish prestyloid from poststyloid lesions, and to assess the extension of the tumor as well as its relationship with adjacent structures.

Primary closure of pharyngeal remnant after total laryngectomy and partial pharyngectomy: how much residual mucosa is sufficient?

After total laryngectomy with or without partial pharyngectomy, the remaining pharyngeal defect can be repaired either by primary closure or with additional tissue, depending on the amount of pharyngeal tissue remnant available. The aim of this study was to determine the minimum width of the pharyngeal remnant that could be safely closed primarily without causing difficulty in swallowing. A total of 52 consecutive patients who underwent total laryngectomy were entered into the study. The relaxed and stretched widths of the pharyngeal remnant were measured after removal of the specimen. The widths of the pharyngeal mucosa ranged from 1.5 to 5.0 cm relaxed (mean, 3.24 cm) and from 2.5 to 8.0 cm stretched (mean, 4.83 cm). All neopharynx was reconstructed by closing the pharynx primarily. Seven of the 52 patients developed recurrent tumor with concomitant dysphagia. Two of the 45 patients without recurrence presented with acute dysphagia from food bolus obstruction, and 1 patient developed benign inflammatory stricture following an episode of fish-bone impaction. The narrowest widths of the pharyngeal remnant in this group of 45 were 1.5 cm relaxed and 2.5 cm stretched. As these patients do not have swallowing difficulty, we conclude that in the absence of tumor recurrence, this amount of residual pharyngeal tissue is sufficient both for primary closure of the pharynx and in restoring swallowing function.

Current treatment options for local residual nasopharyngeal carcinoma

OPINION STATEMENT

Local residual disease occurs in 7-13 % after primary treatment for nasopharyngeal carcinoma (NPC). To prevent tumor progression and/or distant metastasis, treatment is indicated. Biopsy is the "gold standard" for diagnosing residual disease. Because late histological regression frequently is seen after primary treatment for NPC, biopsy should be performed when imaging or endoscopy is suspicious at 10 weeks. Different modalities can be used in the treatment of local residual disease. Interestingly, the treatment of residual disease has better outcomes than treatment of recurrent disease. For early-stage disease (rT1-2), treatment results and survival rates are very good and comparable to patients who had a complete response after the first treatment. Surgery (endoscopic or open), brachytherapy (interstitial or intracavitary), external or stereotactic beam radiotherapy, or photodynamic therapy all have very good and comparable response rates. Choice should depend on the extension of disease, feasibility of the treatment, and doctor's and patient's preferences and experience, as well as the risks of the adverse events. For the more extended tumors, choice of treatment is more difficult, because complete response rates are poorer and severe side effects are not uncommon. The results of external beam reirradiation and stereotactic radiotherapy are better than brachytherapy for T3-4 tumors. Photodynamic therapy resulted in good palliative responses in a few patients with extensive disease. Also, chemotherapeutics or the Epstein-Barr virus targeted therapies can be used when curative intent treatment is not feasible anymore. However, their advantage in isolated local failure has not been well described yet. Because residual disease often is a problem in countries with a high incidence of NPC and limited radiotherapeutic and surgical facilities, it should be understood that most of the above mentioned therapeutic modalities (radiotherapy and surgery) will not be readily available. More research with controlled, randomized trials are needed to find realistic treatment options for residual disease.

A reappraisal of surgical management for squamous cell carcinoma in the pharyngoesophageal junction

BACKGROUND

Squamous cell carcinoma (SCC) in the pharyngoesophageal junction (PEJ) with concomitant involvement of both the hypopharynx and cervical esophagus occurs rarely and poses a challenge in treatment. Data regarding the long-term result of aggressive surgical management was lacking.

METHODS

Forty-one consecutive patients were treated with total pharyngolaryngo-esophagectomy (PLE) and reconstruction between 1984 and 2002. The clinicopathological parameters and prognostic data were analyzed.

RESULTS

The surgery carried a postoperative mortality rate of 9.8%. The overall median survival was 18.5 months, with a 31.5% 5-year survival rate. By multivariate analysis, patients with major tumor localization in the hypopharynx had significantly favorable prognosis (median survivals for hypopharyngeal versus esophageal localization, 37.2 versus 7.1 months, P = 0.043). The administration of adjuvant radiotherapy and tumor size less than 5 cm also contributed to a better outcome (P = 0.001 and P = 0.037, respectively).

CONCLUSIONS

An aggressive surgical approach with total PLE in conjunction with adjuvant radiotherapy represents a feasible option for treatment of advanced SCC simultaneously involving the hypopharynx and cervical esophagus, given the major tumor localization in the hypopharynx. On the other hand, radical surgery for those with major esophageal localization or with tumor size larger than 5 cm yielded ominous results and warrants further justification.

Supraglottic hemilaryngopharyngectomy plus radiation for the treatment of early lateral margin and pyriform sinus carcinoma

BACKGROUND

Supraglottic hemilaryngopharyngectomy is a functional procedure suitable for the treatment of carcinoma of the upper part of the pyriform sinus and carcinoma of the lateral laryngeal margin. It consists of resection of the supraglottic hemilarynx and ipsilateral pyriform sinus.

METHODS

Forty-nine patients underwent this procedure from 1979 through 1994. The median age was 51 (40-72). The data were collected by a review of patients' records.

RESULTS

Two patients died in the postoperative period. The average time of removal of the nasogastric tube was 14 days. The survival rate at 3 years was 52% and at 5 years, 47%. The local recurrence rate was 2%, the overall neck recurrence was 15%, metastasis occurred in 15% of cases.

CONCLUSIONS

Indications for this procedure are carcinoma of the upper part of the pyriform sinus and carcinoma of the laryngeal margin with normal vocal cord mobility.

Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy

BACKGROUND

Enlarged tracheoesophageal puncture (TEP) is a challenging complication of surgical prosthetic voice restoration. Prevention of this complication requires identification of high-risk individuals, and surgical and prosthetic correlates of TEP enlargement.

METHODS

Multivariable logistic regression methods were used to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP in a 5-year retrospective cohort.

RESULTS

Enlarged TEP only occurred in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced (N2 or N3) nodal disease (odds ratio [OR](adjusted) , 4.3; 95% confidence interval [CI], 1.0-19.1), postoperative stricture (OR(adjusted) , 3.2; 95% CI, 1.2-8.6), and diagnosis of locoregional recurrence or distant metastasis after laryngectomy (OR(adjusted) , 6.2; 95% CI, 2.3-16.4) increased risk of enlarged TEP. Extended resection and preoperative nutritional status were also significantly associated with enlarged TEP. Prosthetic parameters did not significantly correlate with enlargement.

CONCLUSION

Development of enlarged TEP is a multifactorial process related to both baseline and postoperative factors.

Supracricoid Hemilaryngopharyngectomy in Patients with Invasive Squamous Cell Carcinoma of the Pyriform Sinus

On the basis of a retrospective review of an inception cohort of 135 patients, with an isolated, previously untreated, moderately differentiated to well-differentiated invasive squamous cell carcinoma of the pyriform sinus and a minimum of 3 years of follow-up, consecutively managed with a supracricoid hemilaryngopharyngectomy (SCHLP) at a single tertiary referral care center and locally controlled, the authors review in detail the surgical technique, highlight the potential technical pitfalls, and document the complications and long-term functional outcome. The overall postoperative mortality rate was 3.7%. The overall mortality rate directly related to the SCHLP was 1.5%. A significant surgical complication directly related to SCHLP completion was noted in 9.6% of cases. The mean lengths of time to removal of the tracheotomy and feeding tubes were 9 and 19 days, respectively. The mean duration of hospitalization was 25 days. Normal swallowing without aspiration by the first postoperative month was noted in 64.6% of patients. Temporary grade 1–2 aspiration and grade 3 aspiration were noted in 26.9% and 8.5% of patients, respectively. Overall, in our series, successful oral alimentation without gastrostomy or completion total laryngectomy was achieved in 91.9% of patients by the first postoperative year, and the incidences of permanent gastrostomy, completion total laryngectomy, and aspiration-related death were 0.7%, 1.5%, and 0.7%, respectively. A significant late complication related to the use of postoperative radiotherapy was noted in 26.5% of cases. From a functional point of view, such results suggest that SCHLP should be integrated among the various conservation treatment options available to patients with selected invasive squamous cell carcinoma of the pyriform sinus.

Salvage surgery for recurrent nasopharyngeal carcinoma

OBJECTIVE

To evaluate the results of salvage surgery for patients with primary recurrence of nasopharyngeal carcinoma after radiotherapy.

DESIGN

Cohort study.

SETTING

Academic tertiary referral center.

PATIENTS

Eighteen consecutive patients with primary recurrence of nasopharyngeal carcinoma after radiation failure underwent nasopharyngectomy for cure via a facial translocation approach from July 1, 1993, to December 31, 1999. Follow-up ranged from 3 to 71 months. Five patients with skull base invasion required a combined neurosurgical approach to treatment. Seven patients had additional postoperative radiotherapy.

RESULTS

The actuarial 3-year survival was 57%, while the local control was 78%. Four of 5 patients who had skull base invasion achieved local control. There was no surgical mortality, and the morbidity was 22%.

CONCLUSION

Advances in skull base surgery make possible the effective control of primary recurrence of nasopharyngeal carcinoma, with acceptable mortality and morbidity.

Reconstruction with free bowel autografts after pharyngoesophageal or laryngopharyngoesophageal resection

Reliability has become a foremost requirement in pharyngoesophageal reconstruction because of the disastrous consequences after a failure. Our institution has achieved a 97 percent success rate using the free bowel autograft. We believe that this represents a significant accomplishment and designates the free bowel autograft as the reconstructive method of choice after pharyngoesophageal resection.

Quantitative analysis of plasma cell-free Epstein-Barr virus DNA in nasopharyngeal carcinoma after salvage nasopharyngectomy: A prospective study

BACKGROUND

The quantity of circulating cell-free Epstein-Barr virus (EBV) DNA in patients with nasopharyngeal carcinoma (NPC) managed by radiotherapy has prognostic relevance. We measured the copy number of EBV DNA in patients with early recurrent NPC before and after salvage nasopharyngectomy.

METHODS

Nasopharyngectomy with the maxillary swing approach was performed for 28 patients. Serum blood samples were taken prospectively before nasopharyngectomy and on postoperative day 7. Plasma cell-free EBV DNA copies were measured with a real-time quantitative polymerase chain reaction for the BamHI-W fragment of the EBV genome.

RESULTS

Cell-free EBV DNA was detected in 17 patients before nasopharyngectomy. Surgical resection reduced the copy number of EBV DNA significantly (p = .016). Negative surgical margins achieved during nasopharyngectomy is associated with a zero EBV DNA copy postoperatively (p = .022).

CONCLUSION

Cell-free EBV DNA was detected in 61% of patients with recurrent NPC, and its quantity postoperatively reflects whether the salvage nasopharyngectomy has achieved a negative surgical margin.

Montgomery salivary bypass tube in the reconstruction of the hypopharynx. Cost-benefit study

This study analyzes the postoperative complications and the functional results in 61 patients who underwent total laryngectomy with partial or total (circumferential) pharyngectomy reconstructed with a pectoralis major myocutaneous flap, in relation to the use of the Montgomery Salivary Bypass Tube (MSBPT). There were no significant differences regarding frequency of postoperative cervical complications in relation to the use of the MSBPT. The median hospital stay for patients without the MSBPT (36 days) was significantly higher than that for patients with the MSBPT (25 days). Although the MSBPT did not modify the rate of complications at the cervical level, it did reduce their severity. A financial study showed the cost-effectiveness of using the MSBPT. Systematic use of the MSBPT is recommended after total laryngectomy with partial or total pharyngectomy reconstructed with a pectoralis major myocutaneous flap.