Showing papers in "Head and Neck-journal for The Sciences and Specialties of The Head and Neck in 2005"

Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (# 9501).

Abstract: Background. In 2004, level I evidence was estab- lished for the postoperative adjuvant treatment of patients with selected high-risk locally advanced head and neck cancers, with the publication of the results of two trials conducted in Europe

Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy

Abstract: Background. We aimed to determine the effect of dietary counseling or oral supplements on outcome for patients with cancer, specifically, nutritional outcome, morbidity, and quality of life (QOL), during and 3 months after radiotherapy. Methods. Seventy-five patients with head and neck cancer who were referred for radiotherapy (RT) were randomized to the following groups: group 1 (n = 25), patients who received dietary counseling with regular foods; group 2 (n = 25), patients who maintained usual diet plus supplements; and group 3 (n = 25), patients who maintained intake ad lib. Nutritional intake (determined by diet history) and status (determined by Ottery's Subjective Global Assessment), and QOL (determined by the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire version 3.0 [EORTC QLQ-C30]) were evaluated at baseline, at the end of RT, and at 3 months. Results. Energy intake after RT increased in both groups 1 and 2 (p ≤ .05). Protein intake also increased in both groups 1 and 2 (p ≤ .006). Both energy and protein intake decreased significantly in group 3 (p 90% of patients experienced RT toxicity; this was not significantly different between groups, with a trend for reduced symptomatology in group 1 versus group 2/group 3 (p < .07). At 3 months, the reduction of incidence/severity of grade 1+2 anorexia, nausea/vomiting, xerostomia, and dysgeusia was different: 90% of the patients improved in group 1 versus 67% in group 2 versus 51% in group 3 (p < .0001). After RT, QOL function scores improved (p < .003) proportionally with improved nutritional intake and status in group 1/group 2 (p < .05) and worsened in group 3 (p < .05); at 3 months, patients in group 1 maintained or improved overall QOL, whereas patients in groups 2 and 3 maintained or worsened overall QOL. Conclusions. During RT, nutritional interventions positively influenced outcomes, and counseling was of similar/higher benefit; in the medium term, only counseling exerted a significant impact on patient outcomes. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Importance of tumor thickness and depth of invasion in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the literature.

Abstract: Background. Oral mucosa squamous cell carci- noma (OSCC) has locoregional evolution, with frequent neck involvement (the most important parameter for prognosis). There are still many doubts concerning the best way to approach N0 neck disease in early-stage lesions (T1 and T2). Many parameters have been studied to identify N0 patients with a high likelihood of harboring occult node metastases or of having them develop. Methods. A review of the studies analyzing ''tumor thick- ness''/''depth of invasion'' in predicting regional metastases and survival was undertaken. Results. The literature suggests that ''tumor thickness''/ ''depth of invasion'' is a reliable parameter for predicting regional nodal involvement and survival in OSCC. Conclusions. Authors are in substantial agreement regard- ing the reliability of tumor thickness. The lack of comparable study groups, measurement techniques, and cut-off values points to the need for further studies so as to reach a consensus and to develop therapy protocols that include tumor thickness. A 2005 Wiley Periodicals, Inc. Head Neck 27: 1080 - 1091, 2005

Complications of craniofacial resection for malignant tumors of the skull base: Report of an International Collaborative Study

Abstract: Background. Advances in imaging, surgical technique, and perioperative care have made craniofacial resection (CFR) an effective and safe option for treating malignant tumors involving the skull base. The procedure does, however, have complications. Because of the relative rarity of these tumors, most existing data on postoperative complications come from individual reports of relatively small series of patients. This international collaborative report examines a large cohort of patients accumulated from multiple institutions with the aim of identifying patient-related and tumor-related predictors of postoperative morbidity and mortality and set a benchmark for future studies. Methods. One thousand one hundred ninety-three patients from 17 institutions were analyzed for postoperative mortality and complications. Postoperative complications were classified into systemic, wound, central nervous system (CNS), and orbit. Statistical analyses were carried out in relation to patient characteristics, extent of disease, prior radiation treatment, and type of reconstruction to determine factors that predicted mortality or complications. Results. Postoperative mortality occurred in 56 patients (4.7%). The presence of medical comorbidity was the only independent predictor of mortality. Postoperative complications occurred in 433 patients (36.3%). Wound complications occurred in 237 (19.8%), CNS-related complications in 193 (16.2%), orbital complications in 20 (1.7%), and systemic complications in 57 (4.8%) patients. Medical comorbidity, prior radiation therapy, and the extent of intracranial tumour involvement were independent predictors of postoperative complications. Conclusions. CFR is a safe surgical treatment for malignant tumors of the skull base, with an overall mortality of 4.7% and complication rate of 36.3%. The impact of medical comorbidity and intracranial tumor extent should be carefully considered when planning therapy for patients whose tumors are amenable to CFR. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Utility of positron emission tomography for the detection of disease in residual neck nodes after (chemo)radiotherapy in head and neck cancer

Abstract: Background. This study evaluates the utility of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) in patients with a node-positive mucosal head and neck squamous cell carcinoma who achieved a complete response at the primary site but had a residual mass in the neck 8 weeks or more after definitive (chemo)radiotherapy.

Craniofacial resection for malignant paranasal sinus tumors: Report of an International Collaborative Study

Abstract: Background. Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient-related and tumor-related predictors of prognosis after craniofacial resection (CFR). Methods. Three hundred thirty-four patients from 17 institutions were analyzed for outcome. Patients with esthesioneuroblastoma were excluded and are being reported separately. The median age was 57 years (range, 3–98 years). One hundred eighty-eight patients (56.3%) had had prior single-modality or combined treatment, which included surgery in 120 (36%), radiation in 79 (23.7%), and chemotherapy in 56 (16.8%). The most common histologic findings were adenocarcinoma in 107 (32%) and squamous cell carcinoma in 101 (30.2%). The margins of resection were close or microscopically positive in 95 (30%). Adjuvant radiotherapy was given in 161 (48.2%) and chemotherapy in 16 (4.8%). Statistical analyses for outcomes were performed in relation to patient characteristics, tumor characteristics, including histologic findings and extent of disease, surgical resection margins, prior radiation, and prior chemotherapy to determine predictive factors. Results. Postoperative mortality occurred in 15 patients (4.5%). Postoperative complications occurred in 110 patients (32.9%). The 5-year overall, disease-specific, and recurrence-free survival rates were 48.3%, 53.3%, and 45.8%, respectively. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. Conclusions. CFR for malignant paranasal sinus tumors is a safe surgical treatment with an overall mortality of 4.5% and complication rate of 33%. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent are independent predictors of outcome. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Surgical margin determination in head and neck oncology: Current clinical practice. The results of an International American Head and Neck Society Member Survey†

Abstract: Background. Our aim was to investigate the ways in which surgeons who perform head and neck ablative pro- cedures on a regular basis define margins, how they use frozen sections to evaluate margins, and the effect of chemoradiation on determining tumor margins. Methods. A custom-designed questionnaire was mailed to members of the American Head and Neck Society asking mem- bers how they evaluate and define tumor margins. Results. Of 1500 surveys mailed, 476 completed surveys were received. The most common response for distance of a clear pathologic margin was >5 mm on microscopic evaluation. A margin containing carcinoma in situ was considered a posi- tive margin by most, but most did not consider a margin containing dysplasia a positive margin. When initial frozen section margins are positive for tumor and further resection re- sults in negative frozen section margins, 90% consider the patient's margin negative. Most surgeons sample the frozen section from the surgical bed rather than from the main specimen. Nearly half use wider margins when resecting tumors treated with neoadjuvant therapy. When resecting recurrent or residual tumors treated with previous chemoradiation therapy,

Major healing of refractory mandible osteoradionecrosis after treatment combining pentoxifylline and tocopherol: a phase II trial.

Abstract: Background. Osteoradionecrosis (ORN) is a non- healing wound of the bone that is difficult to manage. Is a treat- ment combining pentoxifylline (PTX) and tocopherol (vitamin E) boosted by clodronate effective in reversing this fibronecrot- ic process? Methods. Eighteen consecutive patients previously irradi- ated for head and neck cancer had exteriorized mandible ORN. Length of exposed bone (L) was 13.4 F 8 mm, and the mean subjective objective medical management and analytic evalu-

Hypoxia in head and neck cancer: how much, how important?

Abstract: BACKGROUND: Hypoxia develops in tumors because of a less ordered, often chaotic, and leaky vascular supply compared with that in normal tissues. In preclinical models, hypoxia has been shown to be associated with treatment resistance and increased malignant potential. In the clinic, several reports show the presence and extent of tumor hypoxia as a negative prognostic indicator. This article reviews the biology and importance of hypoxia in head and neck cancer. METHODS: A review of literature was carried out and combined with our own experience on hypoxia measurements using exogenous and endogenous markers. RESULTS: Hypoxia can increase resistance to radiation and cytotoxic drugs and lead to malignant progression, affecting all treatment modalities, including surgery. Hypoxia measurements using electrodes, exogenous bioreductive markers, or endogenous markers show the presence of hypoxia in most head and neck cancers, and correlations with outcome, although limited, consistently indicate hypoxia as an important negative factor. Each hypoxia measurement method has disadvantages, and no "gold standard" yet exists. Distinctions among chronic, acute, and intermediate hypoxia need to be made, because their biology and relevance to treatment resistance differ. Reliable methods for measuring these different forms in the clinic are still lacking. Several methods to overcome hypoxia have been tested clinically, with radiosensitizers (nimorazole), hypoxic cytotoxins (tirapazamine), and carbogen showing some success. New treatments such as hypoxia-mediated gene therapy await proper clinical testing. CONCLUSIONS: The hypoxia problem in head and neck cancer needs to be addressed if improvements in current treatments are to be made. Increased knowledge of the molecular biology of intermediate, severe, and intermittent hypoxia is needed to assess their relevance and indicate strategies for overcoming their negative influence.

Olfactory neuroblastoma: the 22-year experience at one comprehensive cancer center.

Abstract: Background. Olfactory neuroblastoma (ONB) is a rare tumor arising from the olfactory neuroepithelium. There is no universally accepted staging system, and treatment approaches lack uniformity. We present one institution's experience with this tumor and the results of therapy. Methods. Thirty patients treated for ONB at The University of Texas M. D. Anderson Cancer Center between 1979 and 2002 were retrospectively reviewed. The diagnosis of ONB was histologically confirmed for each patient. Results. The mean follow-up was 7.32 years. In 77% of cases, patients received treatment with surgery followed by postoperative radiation therapy. Sixteen percent received chemotherapy as part of their initial treatment. Overall 5-year and 10-year survival rates were 89% and 81%, respectively. Nine patients whose disease was initially stage C had a recurrence. The mean time for recurrence was 4.67 years. Conclusions. The M. D. Anderson Cancer Center approach to ONB is complete surgical resection, usually involving a craniofacial approach, with postoperative radiation therapy. This approach seems to be curative in early-stage disease. Late recurrence warrants long-term follow-up. © 2005 Wiley Periodicals, Inc. Head Neck27: 138–149, 2005

Relative accuracy of fine-needle aspiration and frozen section in the diagnosis of lesions of the parotid gland.

Abstract: Background. Both fine-needle aspiration (FNA) and frozen section (FS), although useful in preoperative and intraoperative management, have their advantages and pitfalls when used in the diagnosis of salivary gland lesions. The accuracy of each of these modalities has been assessed separately in many studies; a direct comparison of these techniques on a large cohort has not been well studied. Herein, we determine the relative accuracies of both FNA and FS in the diagnosis of salivary gland lesions. Methods. We reviewed a cohort of 220 cases of parotid gland FNA with histologic follow-up; FS was performed in 57 cases (26%). The sensitivity, specificity, and accuracy of FNA and FS were determined with respect to the final histologic diagnosis. For these calculations, benign diagnosis was considered negative, whereas a malignant diagnosis was considered positive. In addition, we re-reviewed the FNA and FS slides in cases that had conflicting FNA and FS results. Results. Of the 220 cases examined, the FNA diagnoses were as follows: benign (n = 142), malignant (n = 52), indeterminate (n = 14), and nondiagnostic (n = 12). Correlating these findings with the histologic findings, nine cases (4%) were false negative, whereas 12 (5%) were false positive. The sensitivity, specificity, and accuracy for FNA when diagnostic were 86%, 92%, and 90%, respectively. In 57 cases with FS, seven (12%) were false negative, whereas none were false positive. The FS was able to change to benign four diagnoses that were malignant by FNA and provide a diagnosis for five nondiagnostic FNAs. The sensitivity, specificity, and accuracy for FS were 77%, 100%, and 88%, respectively. The sensitivity, specificity, and accuracy for FNA and FS combined were 90%, 100%, and 95%, respectively. Conclusions. Both FNA and FS provide a similar accuracy. FS may be useful if FNA is nondiagnostic and may also be useful in confirming or refuting malignancy in some cases. Hence, both techniques are complementary to each other in the diagnosis of salivary gland lesions. © 2005 Wiley Periodicals, Inc. Head Neck27: 217–223, 2005

Survival outcome of patients with nasopharyngeal carcinoma with first local failure: A study by the Hong Kong nasopharyngeal carcinoma study group

Abstract: Background. The purpose of this article is to report the overall survival (OS) outcome of patients with naso- pharyngeal carcinoma (NPC) with local failure who received salvage treatment and to identify prognostic factors for OS. Methods. Between January 1996 and December 2000, 2915 patients received primary radiotherapy (RT) with or without che- motherapy for nonmetastatic NPC. At a median follow-up of 3.1 years, 319 patients had developed local failure as the first failure, with or without synchronous regional/distant failure. OS was calculated from the start of primary RT. Univariate and mul- tivariate analyses were performed to identify prognostic factors for OS in patients with isolated local failure. Results. The T classification distribution of the local failure (rT classification) was as follows: 68 (21%) rT1 to T2a, 92 (29%) rT2b, 82 (26%) rT3, and 77 (24%) rT4. The rT classification was the same as the initial T classification in 82% of patients. Two hundred seventy-five patients (86%) had isolated local failure, and 232 (84%) of them did not have any distant metastasis or regional failure develop during follow-up. Salvage treatment was given to 200 patients (73%) with isolated local failure. One hundred fifty-nine patients (80%) received reirradiation (108 external beam RT (EBRT), 44 brachytherapy, and seven EBRT plus brachytherapy), 22 patients (11%) underwent nasopha- ryngectomy with or without postoperative RT, and 19 patients (9%) were treated with chemotherapy alone. Four patients died of RT complications, and one died of chemotherapy toxicity in the absence of active NPC. The 3-year actuarial OS for patients with isolated local failure was 74%. On multivariate analysis, ad- vanced initial T classification (hazard ratio (HR), 1.44; p = .0006) and the use of salvage treatment (HR, 0.54; p = .0038) were independent prognostic factors. For the subgroups of patients who had the same recurrent and initial T classification, salvage treatment was associated with improved OS only in the sub- group with T1 to T2 local failure (n = 127; p = 0.0446), but not in the subgroups with T3 (n = 48) or T4 (n = 54) disease. Conclusions. Most patients with first local failure have localized disease. Salvage treatment is feasible in most of the

Sentinel node biopsy in squamous cell cancer of the oral cavity and oral pharynx: a diagnostic meta-analysis.

Abstract: Background. The sentinel node biopsy concept has been gaining support in the head and neck cancer literature during only the last few years, and several pilot studies have been published. This procedure aims to avoid unnecessary treatment to the clinically negative neck by identifying the patients with occult neck disease. Methods. We performed a systematic review and a diagnostic meta-analysis of all published literature regarding sentinel node biopsies in head and neck cancer until December 2003 using established guidelines. Using the pooled sensitivity rates obtained from the meta-analysis and treatment outcomes from published literature, we created a decision analysis model to identify the treatment arm with better payoffs. Results. A total of 301 patients with oral cavity primary tumors and 46 patients with oropharyngeal primary tumors from 19 articles were included for the meta-analysis. The pooled sensitivity result using the random effects model was 0.926 (95% confidence interval, 0.852–0.964). The cumulative payoff for the sentinel node biopsy arm was lower than that for the elective node dissection arm by about 1%. The payoffs were assigned for the recurrence and mortality rates only and did not take into account the morbidity caused by the procedures. Conclusions. The sentinel node biopsy procedure has shown high sensitivity rates in pilot studies for oral and oropharyngeal squamous cell cancer across the globe and is reliable and reproducible. This study provides a firm evidence base for forthcoming trials on the role of sentinel node biopsy in head and neck cancer. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Treatment results of 1070 patients with nasopharyngeal carcinoma: an analysis of survival and failure patterns.

Abstract: Background. The aim of this analysis was to evaluate the outcomes of patients with nasopharyngeal carcinoma (NPC) treated primarily by external beam irradiation (ERT) and to explore for possible ways to improve the treatment results. Methods. One thousand seventy patients with nonmetastatic NPC treated from 1990 to 1998 were retrospectively analyzed. The distribution according to the Union Internationale Contre le Cancer (UICC) (1997 edition) staging system at initial diagnosis was as follows: stage I, n = 113; stage IIA, n = 38; stage IIB, n = 360; stage III, n = 306; stage IVA, n = 136; stage IVB, n = 117; T1, n = 284; T2a, n = 88; T2b, n = 398; T3, n = 149; T4, n = 151; N0, n = 321; N1, n = 393; N2, n = 238; N3a, n = 29; N3b, n = 89. Two hundred eight patients were given neoadjuvant chemotherapy. Ninety-seven patients were diagnosed with locally persistent disease and were salvaged with high dose rate intracavitary brachytherapy. Multivariate analysis was performed with the Cox regression proportional hazards model. Results. The 5-year actuarial local failure–free survival, regional failure–free survival, distant metastasis–free survival, progression-free survival, cancer-specific survival, and overall survival rates were 80.9%, 93.3%, 77.2%, 62.7%, 71.4%, and 66.5%, respectively. Isolated distant metastasis occurred in 191 patients (18%). The distributions were as follow: stage I, 2.1% (two of 95); stage IIA, 5.7% (two of 35); stage IIB, 14.9% (45 of 302); stage III, 26.4% (62 of 235); stage IVA, 40% (40 of 100); stage IVB, 47.1% (40 of 85). Results of the multivariate analysis of various clinical endpoints were discussed. By studying these failure patterns, it is hoped that we could refine future treatments according to the failure patterns of patients with different risks of locoregional and distant failure. Conclusions. The 18% incidence of isolated distant metastasis is too high to be ignored. Maximizing the local control and minimizing the risk of distant metastasis and late complications should be the key objectives in designing future clinical trials. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Quality of life and illness perceptions in patients with recently diagnosed head and neck cancer

Abstract: Background. The purpose of this study was to investigate which illness perceptions of patients recently diagnosed with head and neck cancer explain variance in their quality of life (QOL) to identify potential targets for interventions aimed at improving QOL. Methods. Sixty-eight patients (mainly with stage III and IV disease) completed the Illness Perception Questionnaire-Revised (IPQ-R) and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Results. Pretreatment cross-sectional results from this prospective study show that, after controlling for age and comorbidity, illness perceptions were significantly related to the QLQ-C30 physical, role, emotional, cognitive, social functioning, and global health subscales. Patients with increased attention to symptoms, who believed in a greater likelihood of recurrence, who were more likely to engage in self-blame, and who had a stronger emotional reaction to the illness had lower QOL scores. Conclusion. Our results suggest that restructuring negative pretreatment illness perceptions may help patients to cope more adequately during and after treatment. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Oral rehabilitation after treatment for head and neck malignancy.

Abstract: \Background. Advances in the management of oral malignancy have resulted in significant improvements in survival and functional outcome. Ablation of oral tissues and radiotherapy render many patients unable to wear conventional prostheses, and these patients are, thus, candidates for oral rehabilitation with osseointegrated implants. We aim to present outcomes and complications of such treatment over a 14-year period in a single unit. Methods. Data were collected for 81 consecutive patients, most of whom had received microvascular free flap reconstruction after surgical ablation of oral squamous cell carcinoma. Three hundred eighty-six implants were placed after a delay of 12 months after surgery. Sixty-five percent of implants were placed in the anterior mandible. Radiotherapy was used in 47% of the patients, and hyperbaric oxygen treatment was routinely used in irradiated subjects during the latter half of the series. Retrospective analysis of implants and prostheses was made by use of case notes, radiographs, and a computerized database. Results. Data are presented for 364 of the 386 implants in 77 of the 81 patients after a median follow-up of 4 years. Two hundred sixty-five (73%) of the implants were in function supporting prostheses, 56 (15%) had been lost, and 43 (12%) were present but not loaded (ie, “sleepers”). Implant loss seemed patient specific and was also correlated with host bone type. Thirteen percent of patients in whom implants were placed in the mandible lost at least one implant, and the equivalent values for the maxilla was 40%. Thirty-six percent of patients in whom implants were placed in bone graft or flap lost at least one implant. The effects of implant manufacture, dimensions, radiotherapy, and hyperbaric oxygen did not reach statistical significance in this series. Cases of a second primary malignancy were noteworthy; however, the impact of recurrence was minimized by the delay between resection and rehabilitation. Of the 42 fixed and 29 removable prostheses fitted, 12 (17%) failed. Conclusions. Implants placed in mandible were reliable, but failure rates in vascularized bone graft and maxilla were higher. Radiotherapy did not seem to prejudice implant survival, and hyperbaric oxygen had no demonstrable benefit in this series. Despite some persistent soft tissue problems and implant loss, most patients reached a successful prosthetic and functional outcome

Quality of life, mucositis, and xerostomia from radiotherapy for head and neck cancers: a report from the NCIC CTG HN2 randomized trial of an antimicrobial lozenge to prevent mucositis.

Abstract: Background. The National Cancer Institute of Canada Clinical Trials Group undertook a multicenter, randomized, double-blind controlled trial of an oral antimicrobial versus placebo to prevent and treat mucositis. We present the quality of life (QOL) analysis for this trial. Methods. One hundred thirty-eight patients were randomly assigned. QOL data were collected every 2 weeks before, during, and after radiotherapy. The European Organization for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ-C30) and a Trial Specific Checklist (TSC) were used. Results. The antimicrobial lozenge did not impact QOL. The principal acute side effect of radiotherapy is oral pain, affecting more than 90% of patients. Role function is impacted during treatment, and patients experience fatigue. Appetite was reported to markedly increase during radiotherapy. There was a dramatic and persistent increase in dry mouth. Conclusions. This study highlights the benefits of combining the EORTC QLQ-30 with an “oral” TSC in a randomized controlled trial and provides valuable baseline data for their use with an objective mucositis scoring system. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Surgical management of parapharyngeal space masses

Abstract: Background. We sought to examine surgical tech- niques used to remove parapharyngeal space (PPS) masses. Methods. This retrospective search was conducted from 1980 to 2003. Age, sex, diagnosis, surgical approach, compli- cations, and outcome were collected. Results. One hundred sixty-six PPS masses were identi- fied: 21 (12.7%) were malignant, 145 (87.3%) were benign, 76 (45.8%) were vascular, and 69 (41.6 %) involved the skull base. Transcervical techniques were used in all cases. Removing the styloid and its musculature and level II lymphadenectomies enhanced exposure for vascular and skull base tumors. Thirty transcervical - transmastoid dissections (20.4%) facilitated removal of vascular skull base tumors. To identify the facial nerve, 20 transparotid- transcervical approaches (13.6%) were performed. Three mandibulotomies (2.0%) were required for internal carotid artery involvement. Expected neurologic se- quelae resulted from cranial nerve involvement by tumor. Three patients (2.0%), all presenting with recurrent cancer, had local recurrences. Conclusion. Careful patient assessment and surgical tech- niques allow the oncologically safe removal of benign, vascular, and skull base PPS tumors. A 2005 Wiley Periodicals, Inc. Head Neck 27: 669 - 675, 2005

FDG-PET/CT-guided intensity modulated head and neck radiotherapy: A pilot investigation

Abstract: Background. 2-deoxy-2[ 18 F]fluoro- D -glucose–positron emission tomography (FDG-PET) imaging can beregistered with CT images and can potentially improve neckstaging sensitivity and specificity in patients with head and necksquamous cell cancer. The intent of this study was to examinethe use of registered FDG-PET/CT imaging to guide head andneck intensity modulated radiotherapy (IMRT) planning.Methods. Twenty patients with squamous cell carcinoma ofthe oral cavity, oropharynx, larynx, or hypopharynx underwentFDG-PET and contrast-enhanced CT imaging of the head andneck before neck dissection surgery. Combined FDG-PET/CTimages were created by use of a nonrigid image registrationalgorithm. All IMRT plans were theoretical and were not used fortreatment. We prescribed 66 Gy in 30 fractions to FDG-avid CTabnormalities and nodal zones directly involved with disease,without prophylactic coverage of uninvolved neck levels.Matched CT-guided IMRT plans designed according to thespecifications of Radiation Therapy Oncology Group (RTOG)H-0022 were available for comparison. We investigated thefeasibility of FDG-PET/CT–directed IMRT dose escalation in fivepatients with FDG-avid disease located away from critical normalstructures. After 66 Gy, FDG-avid disease with 0.5-cm margins

F-18 FDG PET-CT fusion in radiotherapy treatment planning for head and neck cancer

Abstract: Background. The fusion of fluoro-2-deoxy-D- glucose - positron emission tomography (FDG-PET) with CT scans has been shown to improve diagnostic accuracy and staging in non-small cell lung cancer. We report on the influence of PET-CT fusion on the management of patients with head and neck cancer. Methods. Thirty-six patients with intact primary head and neck cancers treated with radiation therapy (RT) received PET- CT as part of treatment planning. Workup before PET-CT in- cluded a contrast-enhanced CT scan of the head and neck and chest X-ray; patients with nasopharyngeal and paranasal sinus primary tumors also underwent MRI. Results. Changes in TNM score and American Joint Com- mittee on Cancer stage occurred in 13 patients (36%) and five patients (14%), respectively, based on PET-CT. RT volume and dose were altered in five patients (14%) and four patients (11%), respectively. Five patients initially were seen with carcinoma of unknown primary, and PET-CT confirmed oropharyngeal primary tumors in two. PET-CT data also detected a synchronous lung cancer in one patient. Conclusion. PET-CT fusion may have a significant impact on staging and determination of RT treatment volume and dose. A 2005 Wiley Periodicals, Inc. Head Neck 27: 494 - 502, 2005

Second primary malignancy of the aerodigestive tract in patients treated for cancer of the oral cavity and larynx

Abstract: Background. We aimed to identify patterns and predictors of second primary malignancy (SPM) of the aerodigestive tract (SPMADT) in patients with squamous cell carcinoma of the oral cavity (SCCOC) and larynx (SCCL). Methods. One thousand two hundred fifty-seven patients from two existing databases were studied: 595 with SCCOC (1986–1995) and 662 with SCCL (1984–1998). The primary endpoint of interest was development of SPMADT, defined as a second primary neoplasm of the head and neck, esophagus, or lung. Results. The 5-year SPMADT rate was 8% in the SCCL versus 10% in the SCCOC subgroup. Lung SPM was more common in the SCCL group; head and neck SPM was more common in the SCCOC group. Smokers had a fivefold increased risk, whereas alcohol use was associated with a twofold increased risk of SPMADT. Conclusions. The rates of SPMADT after treatment of SCCOC and SCCL are comparable, but the patterns are different. Smoking and alcohol use are independent predictors of SPMADT development. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Same-day discharge after total thyroidectomy: The value of 6-hour serum parathyroid hormone and calcium levels

Abstract: Background. The purpose of this study was to determine whether patients who undergo total thyroidectomy will have postoperative hypocalcemia develop when they reach the critical 6-hour serum levels defined as parathyroid hormone (PTH) ≥28 ng/L and simultaneous corrected calcium ≥2.14 mmol/L. Methods. This was a prospective study involving 70 consecutive total thyroidectomy patients. There were 51 women and 19 men involved in the study. The mean age was 49.3 years (range, 21–76 years). Patients who had completion thyroidectomy or neck dissections were excluded. Patients undergoing parathyroidectomy at the time of thyroidectomy were also excluded. PTH and corrected calcium levels were measured postoperatively at 6, 12, and 20 hours. Results. Hypocalcemia developed in 24% (17 of 70) of the patients. Of the 53 patients who remained normocalcemic, 68% (36 of 53) reached the 6-hour critical level. None of the hypocalcemic patients (0 of 17) attained the 6-hour critical level (chi-square test p < .0001). This translates into a specificity of 100% (95% confidence interval [CI], 80.5% to 100%) and a positive predictive value of 100% (95% CI, 90.1% to 100%). Conclusions. The simultaneous evaluation of PTH and corrected calcium levels 6 hours after thyroidectomy allows for an accurate prediction of the trend of serum calcium. This study enables us to confidently consider same-day discharge for most of our thyroidectomy patients. © 2004 Wiley Periodicals, Inc. Head Neck27: 1–7, 2005

Adult head and neck soft tissue sarcomas

Abstract: Background. The purpose was to determine the optimal treatment for adult patients with head and neck soft tissue sarcomas. Methods. We conducted a review of the pertinent literature. Results. Local control after surgery alone or combined with radiotherapy was obtained in approximately 60% to 70% of the patients. The probability of local control is influenced by histologic grade, tumor size, and surgical margins. Patients with high-grade tumors and/or positive margins have improved local control if adjuvant radiotherapy is used. Distant metastases occurred in 10% to 30% of patients. The 5-year overall and cause-specific survival rates varied from approximately 60% to 70% and are affected by age, histologic grade, previous treatment of tumor, invasion of deep structures, and adequacy of surgery. Conclusions. The optimal treatment for adult head and neck soft tissue sarcomas is surgery. Adjuvant radiotherapy improves outcomes for those with high-grade tumors and/or positive margins. Radiotherapy alone will cure a small subset of patients with unresectable tumors. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005

Oral and pharyngeal cancer: analysis of patient delay at different tumor stages.

Abstract: Background. The aim of this study was to examine which factors are related to patient delay in a cohort of consecutive patients with pharyngeal cancer and oral cancer and to determine whether the different stages of patient delay (ie, appraisal, illness, behavioral, and scheduling) were related to different tumor stages. Methods. Before treatment, 55 patients with pharyngeal cancer and 134 patients with oral cancer were interviewed about their prediagnostic period. To verify the data, a questionnaire was sent to the general practitioner and/or dentist and a close relative, Results. Patients with a delay of more than 30 days were significantly more often diagnosed with late-stage (T3-T4) disease (pharynx, p = .01, odds ratio [OR] = 4.5; oral, p =.01, OR = 3.2). No sociodemographic characteristics were associated with patient delay. Conclusions. Prolonged patient delay was associated with late-stage disease for both patients with pharyngeal cancer and patients with oral cancer. Although for most patients the symptoms are vague or might look like a common cold or infection, the general public should be better informed about tumor symptoms. This may enhance earlier visits to a health care professional. (c) 2005 Wiley Periodicals, Inc.

CO2 laser surgery in the treatment of glottic cancer.

Abstract: Background. The aim of the study was to assess the effectiveness of CO2 laser endoscopic surgery in the treat- ment of glottic carcinoma limited to the true vocal cords or involving the adjacent regions. Methods. Seven hundred nineteen patients (687 men and 32 women; mean age, 60.4 years; range, 33-86 years) with glottic carcinoma (432 T1N0M0, 236 T2N0M0, 51 T3N0M0) underwent CO2 laser surgery (mean follow-up, 5 years; range, 2-17 years). Statistical comparison was carried out with Wilcoxon test, considering p .05); and no significant differences in the com- parison of unilateral and bilateral tumors (p > .05). Actuarial local control, actuarial nodal control, and actuarial distant metastasis control at 5 years were 85%, 98%, and 99%, respectively, in patients with T1 disease; and 66%, 82%, and 91% in patients with T2 disease; and 66%, 83%, and 95% in patients with T3 disease. The laryngeal preservation rate was 97.3% in the T1 group, 82.5% in the T2 group, and 80.5% in T3 group. Conclusions. CO2 laser endoscopic surgery is effective in the treatment of glottic carcinoma not infiltrating the cartilaginous skeleton; the results achieved are competitive with those of open conservative operations, if we take into account the possibilities afforded by salvage surgery and the rate of laryngeal preser- vation achieved in the study patients. A 2004 Wiley Periodicals, Inc. Head Neck 27: 566-574, 2005

A pilot study of longitudinal serum cytokine and angiogenesis factor levels as markers of therapeutic response and survival in patients with head and neck squamous cell carcinoma.

Abstract: Background. Head and neck squamous cell carcinomas (HNSCCs) were previously shown to express a repertoire of cytokines and angiogenesis factors that contribute to malignant pathogenesis and are detectable in serum. Pretreatment and posttreatment serum levels of cytokines and angiogenesis factors were evaluated as markers for outcome in patients with HNSCC. Methods. Baseline cytokine and factor levels of 29 patients with HNSCC were compared with those of 15 age-matched and sex-matched controls, and pretreatment and posttreatment levels of 22 of the patients eligible for treatment and followed for a median of 37 months were compared. Results. Mean serum concentrations of interleukin (IL)-6, IL- 8, hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), and growth regulated oncogene 1 (GRO-1) were increased in patients with HNSCC, but elevation of these factors was not associated with clinical outcome. However, changes in first posttreatment serum cytokine levels were observed for many of the patients consistent with response, progression, and survival. Later increases in IL-6 or HGF were observed in patients who had a relapse and inflammatory or infectious complications. A relationship between the change in the pretreatment and first posttreatment cytokine measurement with survival was detected for HGF, IL-8, IL-6, and VEGF using a

Safety of video-assisted thyroidectomy versus conventional surgery.

Abstract: Background. Thyroid gland manipulation, surgical stress response, and postoperative outcome in cases of video-assisted thyroidectomy (VAT) and conventional thyroidectomy were compared to verify the safety of VAT. Methods. Twenty consenting patients were randomly assigned to undergo VAT or conventional thyroidectomy. Serum thyroglobulin levels were monitored as indicators of thyroid manipulation, and C-reactive protein and white blood cell count were monitored to assess surgical stress response. Thyroid capsule integrity and the presence of spilled cells in the thyroid bed were verified. Results. No significant differences were found in the indicators of thyroid gland manipulation and surgical stress response between groups. No thyroid capsules ruptured, and no spilled thyroid cells were found. Patients who had VAT experienced less pain, required fewer analgesics, and were more satisfied with the cosmetic result and the surgical outcome. Conclusions. VAT is as safe as conventional thyroidectomy and is characterized by a less painful postoperative course and by better cosmetic results and postoperative outcome. © 2004 Wiley Periodicals, Inc. Head Neck27: 58–64, 2005

Quality of life as predictor of weight loss in patients with head and neck cancer.

Abstract: Background. The purpose of this prospective study was to evaluate whether a relationship exists between malnutrition (≥10% weight loss) and health-related quality of life (HRQL) in patients with head and neck cancer and whether weight loss can be predicted with HRQL questionnaires. Methods. Weight and HRQL were monitored in 49 patients. HRQL was assessed longitudinally, using the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck Cancer module (QLQ-H&N35), and the Hospital Anxiety and Depression Scale (HADS). Results. At diagnosis, those patients who had a weight loss greater than 10% (n = 20) after treatment scored significantly worse on 15 of 28 HRQL variables than did patients who lost less (n = 29). The largest difference (Δ ≥20) was found for role functioning, fatigue, loss of appetite, global quality of life, sticky saliva, and swallowing. Differences in HRQL persisted even after 3 years. The fatigue scale was the only significant predictor of weight loss (p = .005) at diagnosis. Conclusions. Patients with head and neck cancer who are at risk of severe weight loss developing during treatment may be detected with the aid of HRQL questionnaires at diagnosis. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX,2005

Advanced squamous cell carcinoma of lower gingivobuccal complex: Patterns of spread and failure†

Abstract: Background. Carcinoma of the gingivobuccal complex is commonly associated with the use of smokeless tobacco known as ''quid.'' Methods. We conducted a retrospective chart review of 511 patients with advanced cancer of gingivobuccal complex surgically treated during 1994 to 1995. We evaluated patterns of disease failure in these patients and correlated disease-free survival with various prognostic factors. Results. During a median follow-up of 46 months, 159 loco- regional recurrences and 11 distant metastases were detected in 148 patients. Seventy-nine percent of the recurrences ap- peared within 18 months of surgery, and the median survival for patients with recurrent disease was less than 4 months. Two-year and 5-year disease-free survival rates were 64% and 57%, respectively. On multivariate analysis, disease-free sur- vival showed significant correlation with skin involvement and extracapsular spread. Conclusions. Gingivobuccal cancers usually fail locoregion- ally. Soft tissue infiltration and extracapsular spread of nodal dis-

Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study

Abstract: Background. Past research has suggested that medical diagnosis and trach cuff conditions may contribute to swallow physiology changes in patients with tracheostomy. This study attempts to investigate the differences in swallow physiology between patients with trach cuff-inflated and trach cuff–deflated conditions with respect to four medical diagnostic categories: neuromuscular disorder, head and neck cancer, respiratory diseases, and general medical diagnosis. Methods. Retrospective database analysis of videofluoroscopic study results in 623 patients with tracheostomies with trach cuff-inflated or cuff–deflated conditions. Swallow disorders were examined for each patient. Results. The frequencies of reduced laryngeal elevation and silent aspiration were found to be significantly higher in the cuff-inflated condition than the cuff–deflated condition. Significant swallow physiology changes were also found to be significantly different among various medical diagnostic categories. Conclusions. It is important to evaluate changes in swallow physiology under both the trach cuff-inflated and cuff–deflated conditions to fully assess swallow function. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005