Poor functional performance following bidirectional dilatation of severe post radiation oesophageal stricture.

CONCLUSION: Bidirectional oesophageal dilatation for severe chemoradiation-induced oesophageal strictures is efficacious in improving luminal patency but ineffective in relieving functional dysphagia. OBJECTIVE: To assess the efficacy of bidirectional oesophageal dilatation in the severely strictured oesophagus induced by radiation therapy following the treatment of head and neck malignancies. METHODS: The study design was a case series in the setting of a tertiary cancer centre. We carried out a retrospective analysis of patients who underwent bidirectional oesophageal dilatation for oesophageal stricture secondary to radiation therapy for head and neck malignancies over a 5-year period. The parameters of the primary tumour, evaluation of preoperative and postoperative oesophageal dysfunction and complications of the procedure were evaluated. RESULTS: There were nine episodes of bidirectional oesophageal dilatation among five patients with complete or severe oesophageal obstruction. Mean age was 63 years. The procedure was uneventful in all but one patient who was found to have postoperative mediastinitis, and healed completely. Four patients had persistent dysphagic symptoms despite post dilatation video fluoroscopy failing to reveal any significant narrowing of the oesophageal lumen.

Managing regional metastasis in patients with cutaneous head and neck melanoma - is selective neck dissection appropriate?

BACKGROUND: Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection. METHODS: Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND). RESULTS: There was no difference in LR, OS and PFS between CND (n=18) and SND groups (n=79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR. CONCLUSION: Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.

Use of positron emission tomography scanning in metastatic head and neck cutaneous squamous cell cancer: does it add to patient management?

PURPOSE: To evaluate the impact of whole-body positron emission tomography in comparison to staging by conventional methods alone in management of patients with head and neck cutaneous squamous cell cancer (cSCC) with confirmed regional nodal metastasis. MATERIALS AND METHODS: This is a retrospective case cohort study carried out at a tertiary referral cancer centre. The participants were thirty-one adults with head and neck cSCC and regional nodal metastasis. The original treatment plan based on conventional cross-sectional imaging and clinical examination was compared to the final treatment plan after additional PET staging to evaluate the impact of 18F-FDG PET-CT on patient management. RESULTS: Addition of 18F-FDG PET-CT did not change the management in 24/31 (77%) of patients. In four cases the 18F-FDG PET-CT failed to pick up biopsy proven metastatic disease. Two patients who had reduced extent of surgery have shown no features of regional failure after one year of follow-up. CONCLUSION: Overall the management in majority of head and neck cSCC patients with regional metastasis does not change by addition of 18F-FDG PET-CT over conventional imaging.

Aggressive behavior of cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia.

OBJECTIVES/HYPOTHESIS: Immunosuppression in organ transplant recipients increases the incidence and aggressiveness of cutaneous squamous cell carcinoma. However, there are little clinical data on cutaneous squamous cell carcinoma in patients with immunosuppression due to chronic lymphocytic leukemia. In this study we evaluated the clinical features, patterns of recurrence, and outcomes of cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia. STUDY DESIGN: Retrospective cohort study. METHODS: A review was performed of 42 consecutive patients with cutaneous squamous cell carcinoma and chronic lymphocytic leukemia presenting to our institution between July 2000 and July 2010. Baseline characteristics, treatment details, and outcomes were analyzed. RESULTS: Thirty-four patients presented with primary cutaneous squamous cell carcinoma (33 node negative, 1 node positive), and eight patients presented with nodal disease without a simultaneous index primary. The 2-year cumulative incidence of local recurrence for primary cutaneous squamous cell carcinoma was 15%. Nodal recurrence occurred in 36% of node-negative patients. The 3-year overall and cause-specific survival rate for all patients was 37% and 65%, respectively. In patients managed curatively for nodal disease at presentation or relapse (n = 17), the 3-year overall and cause-specific survival rate was 21% and 53%, respectively. CONCLUSIONS: Patients with cutaneous squamous cell carcinoma and chronic lymphocytic leukemia experience higher rates of skin cancer recurrence and death than expected in an immunocompetent population. Novel strategies are needed to improve outcomes.

The cervico-submental keystone island flap for locoregional head and neck reconstruction.

BACKGROUND: Locally advanced head and neck cancer often requires wide resections of the cheek and parotid gland, and in an ageing population preferred reconstructive options aim to avoid lengthy operating times or high risk surgery. While most large parotid defects traditionally require free flap reconstruction, we describe a new and versatile locoregional flap that has been shown to be reliable, simple and safe. METHODS: We describe the cervico-submental (CSM) keystone-design perforator island flap for head and neck reconstruction, including an analysis of 33 consecutive patients with a range of head and neck defects. The flap was raised based on perforators of the external carotid artery and its branches, and designed to overlay the C2/C3 dermatomes (an aide memoire for flap design). The indications, and surgical technique are described. RESULTS: In 33 consecutive patients, no major complications were encountered. Five patients developed superficial infections, one developed post-operative bleeding and one patient developed partial tip necrosis. Theatre time was considerably shorter than our alternative reconstructive options. CONCLUSION: The CSM keystone-design perforator island flap is a novel and versatile flap, which can be used in a range of advanced cheek and parotidectomy defects, and may enable improved surgical management in an increasingly elderly and high-risk population.

Bidirectional esophageal dilatation in pharyngoesophageal stenosis postradiotherapy.

Severely stenosed radiation-induced benign strictures around the level of cricopharyngeus post-radical chemoradiation for head and neck or upper esophageal cancers pose significant management problems. We report our technique of bidirectional assessment and dilatation of pharyngoesophageal strictures in patients with an in situ percutaneous endoscopic gastrostomy (PEG) tube. The upper gastrointestinal surgeon approached the area of stenosis in a retrograde manner through the PEG tube to guide the otolaryngeal surgeon who performed anterograde dilatation via a rigid laryngoscope. Between 2005 and 2009, bidirectional esophageal dilatation was performed on 5 patients at our institution. Video fluoroscopy confirmed improved patency of stenosed esophagus in all cases and good improvement in swallowing ability in 4 patients. The ability to accurately assess pharyngoesophageal strictures using bidirectional visualization and transillumination is the key modification of our technique. We suggest using bidirectional esophageal dilatation on difficult cases with severe pharyngoesophageal stenoses although extreme care is required.

Safety of thromboprophylaxis after oncologic head and neck surgery. Study of 1018 patients.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are significantly reduced with appropriate use of thromboprophylaxis and scarcely evaluated in patients undergoing oncologic head and neck surgery (OHNS). METHODS: A retrospective study on 1018 patients who underwent oncologic head and neck surgery. The records of patients with venous thromboembolism (VTE) or postoperative bleeding were reviewed for the cancer grading, management, previous known coagulopathy, anticoagulation, and general demographics. RESULTS: Of a total of 1018 patients undergoing oncologic head and neck surgery, 450 patients had no chemoprophylaxis and 568 received it. The rate of a VTE event in our cohort was 0%. Twelve patients presented with hematoma or bleeding from the surgical site, 11 in the group that received chemoprophylaxis (p = .006). CONCLUSIONS: Our analysis shows no benefit from chemoprophylaxis in oncologic head and neck surgery patients, with no VTE events. Our analysis shows higher rates of morbid side effects from using chemoprophylaxis, and we therefore conclude that chemoprophylaxis should not be routinely used.

Keystone island flap reconstruction of parotid defects.

BACKGROUND: Skin cancers of the face and scalp have a propensity to metastasize to the parotid group of lymph nodes. The resection of these secondary tumors and other primary tumors in the parotid region often results in defects requiring flap reconstruction. Pectoralis major flaps are reliable and free flaps are arguably the criterion standard. However, we have found keystone island flaps to be a simple and robust alternative, with low donor-site and patient morbidity. The aim of this article is to share our surgical technique, experience, and outcomes of reconstructing parotid defects with keystone island flaps. METHODS: The authors retrospectively reviewed 62 patients who had 63 parotid defect reconstructions at a single institution from 2004 to 2009 (5-year period). RESULTS: The diseases involved were squamous cell carcinoma (52 cases), melanoma (five cases), basal cell carcinoma (four cases), and others (two cases). Nine patients presented with a previous history of radiotherapy and 33 patients required adjuvant radiotherapy. Seven patients (11 percent) suffered postoperative complications necessitating a return to the operating room. CONCLUSIONS: Keystone island perforator-based flaps present an alternative to free tissue transfer. From the series presented, it can be seen that reliable and reproducible results are achievable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Review: mucosal melanoma of the head and neck.

Head and neck mucosal melanoma (MM) is a rare and aggressive neoplasm, with high rates of local, regional, and distant failure. Owing to the small size of most reported series and their retrospective nature, and the lack of uniform comprehensive staging system, the effect of various treatment strategies on disease control and survival has been difficult to assess. The optimal management of head and neck MM is not well defined. Surgical treatment has being advocated as the primary treatment modality, with growing consideration for postoperative radiotherapy, as wide surgical resection in the head and neck region is often difficult. Radiotherapy is recently reported as a beneficial management modality, regardless of the fact that MM has been considered to be radioresistant. As significant morbidity is expected in high doses of radiotherapy to the head and neck region, new radiographic modalities with better precision are required. Furthermore, high-energy radiotherapy was suggested as a better therapy to mucosal MM due to the suggested biology of the tumor. The high rates of locoregional recurrence and distant metastasis also suggest that a systemic treatment is needed. Currently, there is no role for adjuvant systemic therapy for patients who have been successfully resected, but recent developments in the understanding of the biology of melanoma and, in particular, specific growth pathways holds promise for the future. We strongly recommend further evaluation of the role of chemotherapy and immunotherapy to decrease the rates of distant metastasis and improve survival.

Larynx preservation with primary non-surgical treatment for loco-regionally advanced larynx cancer.

INTRODUCTION: The objective of this paper was to review the results of primary non-surgical treatment with the aim of larynx preservation for loco-regionally advanced larynx cancer (LALC). METHODS: All patients with LALC presenting between January 2002 and December 2006 who were selected for primary non-surgical treatment were included in this study. RESULTS: There were 60 patients, 48% with stage III and 52% with stage IV disease. The median follow-up of living patients was 41 months. Larynx preservation with local disease control was achieved in 83% and 77% of patients at 3 and 5 years, respectively. Failure-free survival at 3 and 5 years was 66% and 59%, respectively, and overall survival was 67% and 45%, respectively. All patients with larynx preservation had a functional voice. Two patients became feeding tube dependant. Thirty-nine percent of all deaths were unrelated to LALC. CONCLUSIONS: Primary non-surgical treatment achieves high rates of larynx preservation with a low rate of severe complications but overall survival remains disappointing.

Use of the keystone island flap for advanced head and neck cancer in the elderly--a principle of amelioration.

Traditional management strategies of advanced head and neck cancer in the elderly include palliation and radical resection with microsurgical reconstruction. The keystone flap approach is an alternate reconstructive technique with a range of benefits for the aging population. This publication presents a series of elderly patients with head and neck cancer who underwent resection and reconstruction using the keystone flap principles. The aim is to demonstrate the value of this reconstructive technique in the various anatomical regions of the head and neck. Various operative sequences are accompanied by illustrations and discussions of the underlying principles.

Keystone island flap: an alternative reconstructive option to free flaps in irradiated tissue.

BACKGROUND: The Keystone Flap is an island flap that is very useful for repairing skin defects of the integument. Described as a keystone, this arc-shaped flap in fact consists of a schematically designed, perforator-based reconstructive unit which serendipitously resembles two conjoined VY flaps. This facilitates closure because of the multiple VY points at the extremes, where the surrounding tissue is advanced to close the defect while the flap size remains basically static. METHODS: A consecutive series of nine cases involving the head and neck and inguinal regions were examined to show the use of the Keystone Flap in irradiated tissue for recurrent disease. They are described by using a combination of clinical illustrations and diagrams to explain the surgical technique. RESULTS: The average age of the patients in the series is 74 years. A low complication rate and rapid wound healing with no significant flap necrosis was shown in this series. Additionally the short operation time is quite beneficial, particularly for the elderly. CONCLUSION: There is a low complication rate using Keystone flaps (this double VY is a clinical development from Diffenbach's original work of 1848(1)) and this technique is particularly useful in achieving wound healing especially after irradiation treatment. This surgical technique once mastered is easy to perform. Another bonus is that there is minimal use of postoperative analgesia. Additional XRT is well tolerated by the patients with minimal evidence of wound complications, while achieving an acceptable aesthetic appearance.

Audit of the use of antimicrobial prophylaxis in nasal surgery at a specialist Australian hospital.

BACKGROUND: In 2002-03 a retrospective audit of the use of surgical antimicrobial prophylaxis (AMP) for elective nasal surgery was undertaken at the Royal Victorian Eye and Ear Hospital (RVEEH). The RVEEH is a publicly funded teaching hospital that provides specialist eye, nose and throat medicine in Victoria, Australia. The aim of the audit was to determine the extent to which the use of antimicrobial prophylaxis in the hospital was consistent with Australian and international evidence-based guidelines and if there was a need for the hospital to develop internal guidelines for the use of AMP. METHODS: The histories of 500 consecutive patients who had undergone nasal surgery within the study period of August 2001 and July 2002 were examined. The data collected from these histories included information such as the patients' age, gender, diagnosis, surgical procedure performed, antimicrobial agents used, and the length of follow up and a range of factors shown in previous studies to increase the risk of surgical site infection. RESULTS: A total of 306 (72.86%) patients were found to have received antimicrobial agents either prior to admission, during admission or on discharge. Only 24 patients (5.71%) were administered antimicrobials immediately prior to surgery and at no other time. CONCLUSIONS: The findings of this study support the need for further research to examine the appropriateness of the use of AMP at the RVEEH and the need for internal guidelines for its use.

The humoral immune response to head and neck cancer antigens as defined by the serological analysis of tumor antigens by recombinant cDNA expression cloning.

Learning to identify tumor and tumor-associated antigens in patients with squamous cell carcinoma of the head and neck (HNSCC) may bring about better diagnostic and prognostic evaluations of the disease, innovative therapies based on immunological approaches, and a better understanding of the biology of tumorigenesis. Serological analysis of tumor antigens by recombinant cDNA expression cloning (SEREX) has been used to identify antigens in head and neck cancer to which patients have produced high-titered IgG antibodies. Four cDNA expression libraries have been screened with sera from 6 head and neck cancer patients. Thirty-seven individual gene products were identified. Thirty-one previously characterized proteins and 6 genes coding for molecules that are only partially characterized or novel were isolated. Tissue expression was evaluated by Northern blot analysis, RT-PCR, and in one case, quantitative real-time PCR (qPCR) using Taqman technology. Clone AU-HN-15 encoded a protein highly expressed in HNSCC tissues and cell lines. Tissue adjacent to the tumor had negligible expression. There was low or negligible expression in normal tissues, except for the brain and thymus. AU-HN-15 is identical to KIAA0530; it is an uncharacterized protein previously cloned from brain tissue and has a zinc finger domain. The cDNA encoding this protein has also been isolated in SEREX screens of testicular cancer, breast cancer, and colorectal cancer. Whether AU-HN-15 represents a tumor-antigen target suitable for prognostic or therapeutic purposes is still being analyzed.

Treatment outcome of N3 nodal head and neck squamous cell carcinoma.

OBJECTIVE: The aim of this study was to investigate the treatment outcome of N3 nodal disease. Study design A single institution retrospective nonrandomized study was conducted. A total of 53 patients with primary presentation of squamous cell carcinomas from various head and neck sites from 1980 to 1994 were recruited for this study. Eight patients with nasopharyngeal cancers who underwent treatment with palliative intent were excluded from the study. Treatment options were broadly divided into 4 treatment categories; postoperative radiotherapy; preoperative radiotherapy; surgery alone; and chemotherapy pre- or postoperatively with or without radiotherapy. RESULTS: Mean age of the participants was 63 years (SD = 8.2); 93% were men. Median follow-up period was 12 months (range, 5 to 184 months). Of the 45 N3 patients, 21 patients had a recurrence in the neck after treatment, with 1 in the contralateral neck. The overall rates of control in the neck at 1, 3, and 5 years were 73.1%, 34.6%, and 26.9%, respectively. The 1, 3, and 5-year neck control rates for each main group were 92.3%, 46.1%, and 46.1% with postoperative radiotherapy; 66.7%, 33.3%, and 11.1% with preoperative radiotherapy and 33.3%, 0%, and 0% with surgery alone. Overall survival rates at 1, 3, and 5-years were 52.8%, 25%, and 22.2%. Survival rates in those who received radiotherapy were better than those who only had surgery. The 5-year survival rate was significantly higher for those who had postoperative radiotherapy (38.9%) compared with patients who had preoperative radiotherapy (9.1%) and surgery alone (0%). CONCLUSION: Our treatment outcomes, particularly those in the group receiving postoperative radiotherapy, were similar to other studies. The prognosis of N3 neck disease was poor but improved with radiotherapy, particularly postoperative radiotherapy. The role of definitive chemotherapy and/or radiotherapy and salvage surgery is difficult to evaluate as the results are inconsistent and the available data are limited. Future studies in particular with quality of life assessment are needed to evaluate the management of N3 head and neck cancer.

Heart and liver defects and reduced transforming growth factor beta2 sensitivity in transforming growth factor beta type III receptor-deficient embryos.

The type III transforming growth factor beta (TGFbeta) receptor (TbetaRIII) binds both TGFbeta and inhibin with high affinity and modulates the association of these ligands with their signaling receptors. However, the significance of TbetaRIII signaling in vivo is not known. In this study, we have sought to determine the role of TbetaRIII during development. We identified the predominant expression sites of TbetaRIII mRNA as liver and heart during midgestation and have disrupted the murine TbetaRIII gene by homologous recombination. Beginning at embryonic day 13.5, mice with mutations in TbetaRIII developed lethal proliferative defects in heart and apoptosis in liver, indicating that TbetaRIII is required during murine somatic development. To assess the effects of the absence of TbetaRIII on the function of its ligands, primary fibroblasts were generated from TbetaRIII-null and wild-type embryos. Our results indicate that TbetaRIII deficiency differentially affects the activities of TGFbeta ligands. Notably, TbetaRIII-null cells exhibited significantly reduced sensitivity to TGFbeta2 in terms of growth inhibition, reporter gene activation, and Smad2 nuclear localization, effects not observed with other ligands. These data indicate that TbetaRIII is an important modulator of TGFbeta2 function in embryonic fibroblasts and that reduced sensitivity to TGFbeta2 may underlie aspects of the TbetaRIII mutant phenotype.

Evaluation of 18 F-fluorodeoxyglucose positron emission tomography and computed tomography with histopathologic correlation in the initial staging of head and neck cancer.

OBJECTIVE: To prospectively evaluate the use of 18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) in the initial staging of squamous cell head and neck carcinoma. SUMMARY BACKGROUND DATA: The status of cervical lymph nodes is an important prognostic factor and determinant of management approach in squamous cell head and neck cancer. METHODS: FDG-PET findings were compared with those of computed tomography (CT) before removal of the primary tumor and/or neck dissection. Histopathologic analysis was used as the gold standard for assessment of the sensitivity and specificity of these modalities. RESULTS: FDG-PET correctly identified the primary tumor in 35 of 40 patients in whom the site of the primary was known clinically and still present (sensitivity 88%). None of four unknown primaries were detected. Tumors not detected by FDG-PET were generally superficial, with depths of less than 4 mm. CT correctly identified 18 of the 35 primary tumors (sensitivity 51%). Eleven of 17 CT false-negative tumors were detected by FDG-PET. The sensitivity and specificity for the presence of metastatic neck disease on FDG-PET were 82% and 100%, respectively; those for CT were 81% and 81%, respectively. FDG-PET was true positive for metastatic neck disease in two of the three CT false-negative patients. CONCLUSIONS: FDG-PET shows promise in the initial staging of head and neck cancer and provides additional accuracy to a conventional staging process using CT.