Role of surgery in treatment of advanced differentiated thyroid carcinomas.

Well-differentiated thyroid carcinomas are characterized by a long natural history. The evolution of the reconstructive techniques and the improvement of the peri-operative anaestesiologist management of the patient have contributed, over the last few years, to a progressive widening of demolitive surgery. The aims of enlarged surgical treatment in differentiated advanced thyroid carcinomas are to guarantee respiratory and alimentary functions as well as symptomatic benefits, to obtain local control of the disease and the recovery of adjuvant therapeutic options, such as metabolic and conventional radiation. In the present study, 27 patients who underwent enlarged surgery for differentiated thyroid carcinoma involving the superior digestive-aerial ways (SDAW) were treated between January 1992 and December 2002. The following results were achieved: Group 1 (7 patients): partial resection of the trachea and larynx: 57% of patients are Not Evidence Disease (NED) at a mean follow-up of 7 years; the other 43% are Alive With Disease (AWD). Group 2 (4 patients): total laryngectomy associated with emi-pharyngectomy or oesophagectomy of whom 50% are NED at a mean follow-up of 6 years. Group 3 (4 patients): mediastinum dissection in sternotomy of whom 3 patients NED at 7, 8 and 12 years of follow-up, respectively (75%). Group 4 (12 patients): latero-cervical, retro-clavear and subclavear dissection, of whom 75% of cases are NED at a mean follow-up of 5.1 years. Enlarged surgery is justified by the long natural history of the differentiated histotypes and the advantages it offers to adjuvant therapies. An essential principle, in the case of enlarged thyroid resections, is the modularity. With respect to the loco-regional spread of the disease, the surgeon has to study a treatment plan with a surgical procedure that involves the various elective districts of spreading, planning each surgical step with the entity of demolition and reconstruction being modulated according to the demand.

Bleeding/bruising symptomatology in children with and without bleeding disorders.

A questionnaire, designed to assess bleeding/bruising tendencies, was administered to 251 otherwise healthy children undergoing a tonsillectomy and/or adenoidectomy. 23 children with excessive bleeding during or after the operation, with a long bleeding time or who reported taking aspirin recently were excluded, to give a population of 228 non-bleeders. For comparative purposes, 31 patients with bleeding disorders (von Willebrand's disease and/or platelet function defects) were studied. A considerable proportion of "non-bleeding" children reported easy bruising (24%), had bruises at least once a week (36%) and suffered from nosebleeds (39%). The respective frequencies (67%, 68% and 69%) for children with bleeding disorders were significantly higher. Occurrence of bruises usually on more than one part of the body, frequent large bruises or hematomas were rare in "non-bleeders" (4.9%, 3.5% and 2.7% respectively), but more common in "bleeders" (38.5%, 29.6% and 21.7% respectively).

Squamous-cell carcinoma of the upper lip - analysis of 123 cases.

Squamous cell carcinoma of the upper lip is rare and poorly described in the literature. We analysed retrospectively 123 cases occurring from 1929 to 1987. Greatest incidence was in the seventh decade and the M/F ratio was 2:1. Treatment was radiotherapy (36) or surgery (87). In early disease stages radiotherapy and surgery were equally effective, but in advanced disease surgery provided better results. Involved nodes indicate mandatory laterocervical submandibular lymph node dissection (bilateral for central lesions) but prophylactic dissection is inappropriate. The high frequency of relapse, tendency to plurifocality (as with all cercicofacial tumors) and risk of lymph node involvement underline the importance of regular and careful follow-up.

Combined anterior craniofacial resection for tumors involving the cribriform plate: early postoperative complications and technical considerations.

OBJECTIVE: Combined craniofacial resection has become the standard approach for malignant tumors involving the cribriform plate and anterior cranial fossa. Despite its widespread application, however, many surgeons agree that the procedure carries a risk of significant morbidity and even mortality. The purpose of this study was to analyze the experience at a single institution to determine the incidence of early postoperative complications encountered after combined craniofacial resection of tumors involving the cribriform plate and to provide information to improve management. METHODS: Between 1987 and 1997, 168 patients underwent combined craniofacial resection at the National Cancer Institute of Milan for tumors involving the cribriform plate. Patient charts, operative notes, follow-up clinic notes, radiographic studies, and pathology reports were analyzed. Morbidity encountered in the first 30 cases was compared with that encountered in the subsequent 138 cases. RESULTS: The most frequently encountered pathological findings were adenocarcinoma (53.6%), squamous cell carcinoma (17%), and esthesioneuroblastoma (9.8%). Eight patients (4.7%) died, 6 of whom were among the first 30 patients to undergo resection. Among patients with fatal complications were three with meningoencephalitis, three with intracranial hemorrhage, and one with myocardial infarction. Fifty patients (29.7%) had nonfatal morbidity; 16 of these patients were among the first 30 patients operated. Transient cerebrospinal fluid leakage was the most frequent adverse effect (9.5%); 12 patients (7.1%) had pneumocephalus, 3 (1.8%) had meningitis, 4 (2.4%) had wound infections, 3 (1.8%) experienced transient impairment of mental status, 3 (1.8%) had transient diplopia, 2 (1.2%) had diabetes insipidus, and 1 (0.6%) had bone flap necrosis. CONCLUSION: We observed a dramatic decrease in mortality and morbidity in patients who underwent combined craniofacial resection after the first 30 cases in our series. Improvement of specific aspects of surgical technique, such as more refined reconstructive methods and improved prophylactic antibiotic therapy, is at least partly responsible for this favorable trend.

Primary high-grade mucoepidermoid carcinoma of the minor salivary glands with cutaneous metastases at diagnosis.

Mucoepidermoid carcinoma (MEC) represents 15% of all salivary glands malignancies. Metastatic disease at diagnosis is observed in less than 5% of the cases. The lung is the most commonly involved site. This is the first reported case of high-grade MEC of the salivary gland with skin metastases at diagnosis. This feature was associated with a chemoresistant and aggressive behaviour. Differential diagnosis between metastatic MEC and primary skin MEC is essential for therapeutic management and prognosis.

A new classification for malignant tumors involving the anterior skull base.

OBJECTIVES: To propose our clinical classification of malignant ethmoid tumors and to compare it with the last American Joint Committee on Cancer (AJCC)-Union Internationale Contre le Cancer (UICC) classification, published in 1997. DESIGN: Retrospective review. SETTING: Tertiary cancer facility. PATIENTS: We evaluated 123 consecutive patients undergoing craniofacial resection for malignant ethmoid tumors involving the anterior skull base. The mean follow-up was 60 months. Fifty-nine patients (48%) presented with recurrent disease after prior therapy. We classified them with a new classification system (Istituto Nazionale per lo Studio e la Cura dei Tumori) based on the most commonly accepted unfavorable prognostic factors (involvement of dura mater; intradural extension; involvement of the orbit and, in particular, of its apex; invasion of maxillary, frontal, and/or sphenoid sinuses; and invasion of the infratemporal fossa and skin. We also classified patients with the AJCC classification published in 1997. MAIN OUTCOME MEASURES: Disease-free status and overall survival rate. To study a possible association with tumor stage, the Cox regression model was adopted. RESULTS: According to our classification, patient distribution by tumor type was T2, n = 46; T3, n = 29; and T4, n = 48 (no T1 tumors were present in the series). For previously untreated patients, 5-year disease-free survival estimates were T2, 57%; T3, 50%; and T4, 13%. For relapses, corresponding figures were T2, 31%; T3, 23%; and T4, 1%. The prognostic difference among stages was statistically significant (P<.001). Similar results were obtained for overall survival. In contrast, patient distribution among different AJCC stages was less balanced, and we failed to detect a significant association with the clinical outcome using this classification. CONCLUSION: We propose the use of our staging system by all those specialists in the field willing to validate the classification and possibly apply it for clinical and investigational purposes.

Fuzzy pre-processing of gold standards as applied to biomedical spectra classification.

Fuzzy gold standard adjustment is a novel fuzzy set theoretic pre-processing strategy that compensates for the possible imprecision of a well-established gold standard (reference test) by adjusting, if necessary, the class labels in the design set while maintaining the gold standard's discriminatory power. The adjusted gold standard incorporates robust within-class centroid information. This strategy was applied to biomedical data acquired from a MR spectrometer for the purpose of classifying human brain neoplasms. It is shown that consistent improvement (10-13%) to the discriminatory power of the underlying classifier is obtained when using this pre-processing strategy.

Bleeding predisposition assessments in tonsillectomy/adenoidectomy patients using fuzzy interquartile encoded neural networks.

A fuzzy set theoretic methodology is described that serves as a classification preprocessing strategy for supervised feed-forward neural networks. This methodology, fuzzy interquartile encoding, determines the respective degrees to which a feature belongs to a collection of fuzzy sets that overlap at the respective quartile boundaries of the feature. These membership values are subsequently used in place of the original feature. This transformation has a normalizing effect on the feature space and is more robust to feature outliers. Its effectiveness is scrutinized using several synthetic data sets with various underlying distributions. Fuzzy interquartile encoding is shown to consistently improve the discriminatory power of the underlying classifiers. The methodology is also applied to two biomedical data sets relating to tonsillectomy and/or adenoidectomy patients who may or may not have had a predisposition to excessive bleeding during their operation. The features of the first data set are blood sample test results acquired from a coagulation laboratory and the class labels are one of three hemostatic defects as identified by the reference tests. The second data set consists of patient responses to queries from a bleeding tendency questionnaire. Normal and abnormal class labels were derived from a hematology expert system designed in consultation with a pediatric hematologist. Fuzzy interquartile encoding effected an 11% improvement in the classification accuracy of the underlying neural network classifier with the former data set and 18% with the latter.

A novel, direct spatio-temporal approach for analyzing fMRI experiments.

We introduce a novel approach to couple temporal similarity with spatial neighborhood information. This is achieved by concatenating the K nearest, spatially contiguous neighbors of a pixel time-course (TC) of T time-instances. This produces a new TC of (K+1)T time instances. Depending on how "nearest" is defined, we have various options. Strictly spatial nearness means augmenting a given TC by its K nearest neighbors in some canonical spatial order. A more powerful and flexible option is to order the TCs to be concatenated according to their temporal similarity to the central voxel TC. For this study, we have chosen Pearson's cross-correlation coefficient as the measure of similarity. For more than a single neighbor, two concatenation options are possible. The direct ordering option requires that the TCs to be concatenated be spatially contiguous to the central pixel. The more flexible indirect option merely demands that one of a chain of temporally similar TCs be spatially connected to the central pixel. We also apply the temporal similarity criterion to the more conventional spatial (median) filtering, and show that it gives superior result to a strict spatial filtering. The method is tested and verified on a null fMRI dataset onto which we superposed two types of "activations" with known temporal behavior and spatial location. It is also applied to a real dataset containing visual activation. We also propose a strategy, based on the flexibility of the method, to determine a consensus, "core" set of activations.

EvIdent: a functional magnetic resonance image analysis system.

EvIdent (EVent IDENTification) is a user-friendly, algorithm-rich, exploratory data analysis software for quickly detecting, investigating, and visualizing novel events in a set of images as they evolve in time and/or frequency. For instance, in a series of functional magnetic resonance neuroimages, novelty may manifest itself as neural activations in a time course. The core of the system is an enhanced variant of the fuzzy c-means clustering algorithm. Fuzzy clustering obviates the need for models of the underlying requisite biological function, models that are often statistically suspect.

Neural network classification of infrared spectra of control and Alzheimer's diseased tissue.

Artificial neural network classification methods were applied to infrared spectra of histopathologically confirmed Alzheimer's diseased and control brain tissue. Principal component analysis was used as a preprocessing technique for some of these artificial neural networks while others were trained using the original spectra. The leave-one-out method was used for cross-validation and linear discriminant analysis was used as a performance benchmark. In the cases where principal components were used, the artificial neural networks consistently outperformed their linear discriminant counterparts; 100% versus 98% correct classifications, respectively, for the two class problem, and 90% versus 81% for a more complex five class problem. Using the original spectra, only one of the three selected artificial neural network architectures (a variation of the back-propagation algorithm using fuzzy encoding) produced results comparable to the best corresponding principal component cases: 98% and 85% correct classifications for the two and five class problems, respectively.

Skull base reconstruction after anterior craniofacial resection.

Anterior craniofacial resection has become a popular operation for nasoethmoid tumours involving the skull base. Many papers have been published since the first by Ketcham et al. in 1963. However, there is still controversy about the method for reconstruction of an anterior skull base defect after resection. The simple reconstruction of Ketcham has been followed by more sophisticated procedures using galeal-pericranial flaps, free flaps with microvascular anastomosis and bony or alloplastic augmentation. The main purposes of the reconstructions are to prevent brain herniation, to avoid intracranial infections, to diminish the risk of CSF leakage and to avoid pneumocephalus. From the relevant literature and our own experience of 168 anterior craniofacial resections, we conclude that a pedicled pericranial flap is the best choice for closing a cranial base defect.

[Combined transfacial and infratemporal approaches for T3-T4 malignant maxillary tumors]. / Maxillectomia per via combinata transfacciale ed infratemporale per i tumori maligni T3-T4 del massiccio facciale.

The technique of maxillectomy employing an anterior transfacial approach has practically remained unaltered since historical and suggestive descriptions of Lizars reported in 1829 and those of Fergusson reported in 1842. This procedure is suitable and efficacious for benign tumors as well as for malignant tumors which involve the inferior, anterior, medial or lateral wall of the maxillary sinus. However, when the tumor erodes the posterior wall, surrounding and destroying the pterygoid and invading the pterygo-maxillary and the infratemporal fossae, sometimes causing thrismus as a result of infiltration of the pterygoid muscles, surgical control of the posterior extension through an anterior approach is impossible. Many authors maintain that in these cases surgery is useless if not detrimental in light of the low survival rates reported. We propose a new surgical technique (a double approach--transfacial and infratemporal preauricolar) to be followed in these patients. These approaches allow us to completely surround the extension of the tumor as well as to achieve surgical radicality in T4. Moreover, with this technique it is possible to use the temporalis muscle to repair the resulting post-maxillectomy cavity thus eliminating the necessity of the obturator. From 1992 to 1994 we operated 46 patients with T3 and T4 malignant tumors of the maxillary sinus following this procedure. We had 1 death due to heart infarction 3 days after surgery. On the other hand no serious local complications were observed. There were only 7 suppurations in the temporal region, either resolved quickly and spontaneously or through simple surgical drainage. The follow-up is still too brief to allow us to draw definite conclusions. At any rate, presently 30 of our 46 patients are alive and disease free.

[Malignant maxillary tumors involving the pterygo-maxillary and infratemporal fossae: a series of 200 cases]. / Resezione cranio-facciale anteriore per tumori maligni: esperienza di 200 casi.

At the Cranio-Maxillo-Facial Surgery Unit of the Istituto Nazionale per lo Studio e la Cura dei Tumori in Milan, Italy between 1987 and 1999 200 anterior cranio-facial resections were performed on malignant ethmoid tumors involving the anterior cranial base and extending to the nasal fossae and, at times to the orbit and maxillary and sphenoid sinuses. In the second portion of this case study the authors simplified their surgical technique. The frontal craniotomy was made rectangular and low, performed with an oscillating saw and scalpel, without drilling holes. The osteotomy of the cranial base was modulated according to tumor extension. Typically a paralateronasal facial incision was performed without opening the upper lip. Whenever the maxillary sinus and/or orbit were involved, the skin incision and osteotomy was consequently modified. Repair of the cranial base was performed with a pedicled pericranial flap. In this case study there were 6 post-operative deaths in the first 30 patients and only 2 in the remaining 170. The male/female ratio was 145/55, mean age 55 years (12-80) and average follow-up 38 months (2-117). There were 120 primary tumors while the remaining 80 patients presented recurrences from prior treatments. There were 96 adenocarcinomas, 42 spinocellular carcinomas, 21 esthesioneuroblastoma 15 adenoid-cystic carcinomas, 9 melanomas and 17 rare tumors. Our classification identified the following stages: 69 T2, 54 T3 and 77 T4 while the UICC-AJCC staging system indicated: 25 T1, 16 T2, 68 T3 and 91 T4. The NED survival according to tumor stage (INT classification) was: T262.3%, T3 44.4% and T4 29.9%. The NED survival for patients who had not previously undergone treatment was: T2 71.7%, T3 58.8% and T4 42.5%. On the other hand the NED survival for the cases of recurrence was: T2 43.5%, T3 20% and T4 16.2%. These results lead to the conclusion that the surgical technique currently used is valid and that the anterior cranio-facial resection should always be performed in patients with ethmoid tumors coming into contact with, or eroding, the cribriform plate. For all staging classes, the prognosis for those patients undergoing surgery for recurrence from prior, inadequate treatment was significantly worse than that for the primary tumors.

[Anterior cranio-facial resection for malignant tumors: report of 91 cases]. / Resezione cranio-facciale anteriore per tumori maligni: esperienza di 91 casi.

Between 1987 and 1994 we performed 103 anterior cranio-facial resections in patients affected by tumors involving the ethmoid, the nasal cavities and, sometimes, the orbit, the maxillary and sphenoid sinuses. The cibriform plate was always involved. The tumor invaded the frontal dura in 20 patients without intradural neoplastic vegetations. These were present in 6 cases. Ninety-one of these patients had a malignant tumor; from the histologic point of view we had 50 adenocarcinomas, 16 epidermoid carcinomas, 8 estesioneuroblastomas, 6 adenoid cystic carcinomas, 5 melanomas and 6 infrequent types. The surgical technique became simplier in the second half of our patients. Now we perform a coronal skin incision and prepare a pericranial flap without the galea and use it to reconstruct the cranial base defect without bone or alloplastic material. The frontal craniotomy is rectangular, low and made by an oscillating saw without trephine holes. The posterior section of the skull base for a typical ethmoid tumor is always on the sphenoid roof and the lateral ones on the medial third of the orbital roof, al least in the more interested side. The anterior section is on the frontal sinus floor. The osteotomies may be enlarged according to tumor extension. Our facial incision is paranasal without splitting of the upper lip, but sometimes we used wider skin incisions and osteotomies for tumors involving the maxillary sinus and palate. We had many important complications in the first half of out patients with 7 postoperative deaths but none in the second half. Fifty-five percent of the adenocarcinomas, 7% of the epidermoid carcinomas, 75% of the estesioneuroblastomas, 100% of the adenoid cystic carcinomas and 0% of the melanomas are alive and well. Forty-six patients were previously treated elsewhere and 45 were untreated. The cure rate of these two groups of patients is very different: 38.1% of the first versus 61.9% of the second ones are alive and free of disease. Our experience proves that every transfacial or transnasal resection of an ethmoidal tumor involving the cribriform plate must be avoided.

[Classification of ethmoid malignancies]. / Classificazione dei tumori maligni dell'etmoide.

The UICC and AJCC never classified ethmoid malignancies prior to the latest edition (1997). Most classifications in the literature refer to a single histological type (estensioneuroblastoma or carcinoma) while others basically consider the intracranial extension, without distinguishing between intra or extradural. Still others consider invasion of the orbit. There is as yet no classification which considers all the prognostic factors associated with the extension of this neoplasm. The authors reviewed 84 patients with ethmoid malignancy who had undergone anterior cranio-facial resection between 1987 and 1994 and had been followed up for a minimum of 36 months. Of these patients, 43 were recurrences of previous treatment while 42 had not previously been treated. The breakdown was as follows: 45 adenocarcinoma, 14 squamous cell carcinoma (more or less differentiated), 8 etesioneuroblastoma, 6 adenoidocistic carcinoma, 5 melanoma and 6 rare forms. These cases were staged according to a new classification identifying the worst prognostic factors: invasion into the dura and, above all, intradural extension; invasion of the sphenoid sinus, orbit, and in particular the orbit apex, the frontal sinus, the maxillary sinus, the pterygoid, infratemporal fossa and the skin. Until 1994 we used this classification which is similar to the one proposed by the UICC in 1997. On the basis of this classification our case breakdown is as follows: T2 35, T3 24, T4 25 (there were no cases of T1). Since a patient can live as much as 4-5 years with a recurrence but the recurrences all appeared within 2 years after surgery, we used a NED survival at 36 months as index of healing. The NED survival at 36 months was: T2 54%, T3 41%, T4 8%. In patients which had not received prior treatment the NED survival was: T2 63%, T3 45%, T4 9%. The progressive worsening of prognosis from T2 to T4, particularly in patients which had not been pretreated, leads us to assume that the true prognostic factors for malignant ethmoid tumors have been identified.

[Lymph node metastases in paranasal sinus carcinoma: prognostic value and treatment]. / Metastasi linfonodali nei carcinomi dei seni paranasali: valore prognostico e trattamento.

The purpose of this report is to assess, on the basis of a sizeable study, the prognostic value of lymph node metastases in paranasal sinus carcinoma and, in particular, in squamous cell carcinoma of the maxillary sinus. We have reviewed the charts of 601 cases of paranasal sinus carcinoma between 1970 and 1999. All of the patients were treated surgically, alone or associated with chemotherapy and/or radiotherapy. The maxillary sinus tumors numbered 379 (153 squamous cell carcinomas, 15 undifferentiated carcinomas, 94 adenoid cystic carcinomas, 19 adenocarcinomas, 98 mesenchymal tumors and rare forms) and the ethmoidal tumors were 222 (117 adenocarcinomas, 27 squamous cell carcinomas, 16 adenoid cystic carcinomas, 13 undifferentiated carcinomas, 49 other histological forms). Lymph node metastases in ethmoidal tumors were rare, with the exception of undifferentiated carcinoma (46.1%). The percentages of metastatic squamous cell carcinoma of the maxillary sinus upon presentation were: T2 15.5%, T3 7%, and T4 4%. All these patients underwent lymph node excision. The metastases successive to treatment of the primary tumor were: T2 16.9%, T3 8.8%, and T4 12%. 75% of these late metastases occurred contemporaneously with a recurrence of T and only 5 (25%) constituted the single reawakening of disease; four of these patients underwent neck surgery and were cured operatively. One had fixed, inoperable metastases. The NED survival rate at least two years after T therapy in patients free from metastases was 50.4%, against 25% in those with initial or distant metastases (T2 72.9% vs. 30.4%, T3 37.5% vs. 22.2%, and T4 28.6% vs. 0%). In conclusion, squamous cell carcinomas of the maxillary sinus which have extended to the oral cavity (T2) show greater lymph node propagation than those of the superoposterior portion (T3-T4). The presence or successive appearance of lymph node metastases indicates elevated malignancy of the tumor, with a very negative prognosis. N, however, is rarely the cause of death for these patients. Prophylactic lymph node excision in N0 patients is therefore not indicated.

[Malignant maxillary tumors involving the pterygo-maxillary and infratemporal fossae: a series of 65 patients and a comparison of the 1997 and 1977 UICC-AJCC staging systems]. / Tumori maligni del mascellare estesi alla fossa pterigo-mascellare ed infratemporale. Risultati su 65 pazienti e confronto fra la classificazione TNM UICC-AJCC 1987 e 1997.

The prognosis for maxillary malignancies with posterior extension to the pterygo-maxillary and infratemporal fossae is worse than for those with anterior-inferior extrinsication. Maxillectomy using only an anterior approach does not enable enblock, radical resection of such tumors. Many different approaches to the infratemporal fossae have been described in the literature. The authors use a double infratemporal and transfacial approach. Between 1990 and 1998 this approach was used on 65 patients with malignant maxillary tumors. There was one post-operative death due to myocardial infarction. There were only 9 cases of temporal infection, and all were resolved. There were no cases of necrosis of either the temporal muscle or the revascularized flaps. The cases included the following tumors: spinocellular and anaplastic carcinoma (21 cases); adenoid-cystic carcinoma (16); adenocarcinoma (4); sarcoma (18); other malignant tumors (6). There were 29 primary tumors while the remaining 36 were recurrences from prior treatment. Using the UICC-AICC 1987-92 staging system there were 22 cases of T3 and 43 T4. Using the 1997 system there were 35 T3s and 30 T4s. Resection was radical in 54 cases while in the remaining 11 there were micro or macroscopic limitations at the rhinopharyngeal level and/or at the orbit apex. The NED survival percentages were: T3 59.2%; T4 28% (using the 1987-92 system) while they were T3 45.7% and T4 26.7% (using the 1997 system). In the 41 patients with carcinoma (spinocellular, anaplastic, adeno and adenoid-cystic) the NED survival percentages were: T3 54.5%; T4 23.4% (using the 1987-92 system) while they were T3 45% and T4 19% (using the 1997 system). The NED survival percentage was 41.4% for primary tumors and 36.1% for recurrences. These results lead one to conclude that this surgical technique permits good results with T3-T4 maxillary malignancies. The prognosis for recurrences is worse than for primary tumors and the prognosis for sarcoma is better than for carcinoma. The UICC-AICC staging systems are valid for prognostic purposes. The current analyses indicate that the 1987-92 system is slightly more suitable than the 1997 system. In fact, there were 13 patients which the 1987-92 system had classified as T4 and which the 1997 system had reclassified as T3. In all these cases the prognosis was more similar to that of T4 than T3.

Esthesioneuroblastoma metastatic to the trachea.

Esthesioneuroblastoma is a rare tumour, for which a multimodal approach, including a combination of surgery and radiation, appears to provide the best disease-free and overall survival. Well-known for its tendency for local recurrence and distant spreading by both lymphatic and haematogenous routes, the most common sites of metastases are lungs and bones, followed by liver, spleen, scalp, breast, adrenals and ovary. One single case of metastasis to the trachea has been reported in the literature. The case is reported here of a patient who developed metastatic esthesioneuroblastoma to the trachea 18 months after primary surgery and radiation therapy. The patient was treated by two subsequent N-YAG laser endoscopic resections and chemotherapy.