Adenoid cystic carcinoma of the head and neck.

PURPOSE: To report our experience using radiotherapy alone or combined with surgery to treat adenoid cystic carcinoma of the head and neck. MATERIALS AND METHODS: Radiotherapy alone or combined with surgery was used to treat 120 previously untreated patients with adenoid cystic carcinoma (ACC) of the head and neck from August 1966 to March 2008. Patients were treated with curative intent. American Joint Committee on Cancer stage distribution was,T0 (n = 1), T1 (n = 26), T2 (n = 25), T3 (n = 14), T4 (n = 54), N0 (n = 113), N1 (n = 2), N2a (n = 1), N2b (n = 2), and N2c (n = 2). Treatment included surgery with postoperative radiotherapy (n = 71), radiotherapy alone (n = 46), and preoperative radiotherapy and surgery (n = 3). Incidental and clinical perineural invasion was found in 41 (34%) and 35 (29%) patients, respectively. Median follow-up was 8.6 and 11.6 years overall and among living patients, respectively. RESULTS: The 10-year overall, cause-specific, and distant metastasis-free survival rates, respectively, were as follows: radiotherapy alone, 37%, 46%, and 76%; surgery and radiotherapy, 57%, 71%, and 62%; and overall, 50%. The 10-year local control rates were as follows: radiotherapy alone, 36%; surgery and radiotherapy, 84%; and overall, 65%. The 10-year neck control rates were as follows: elective nodal irradiation (ENI), 98%; no ENI, 89%; and overall, 95%. CONCLUSIONS: Surgery and adjuvant radiotherapy offer the best chance for cure for patients with resectable adenoid cystic carcinomas of the head and neck. Some patients with advanced, incompletely resectable disease can be cured with radiotherapy alone. ENI should be considered for primary sites located in lymphatic-rich regions.

Head and neck osteosarcoma.

OBJECTIVE: The objective of the study was to discuss the optimal management and treatment outcomes for patients with head and neck osteosarcomas. STUDY DESIGN: Review article. METHODS: Review of the pertinent literature. RESULTS: Osteosarcomas account for approximately 1% or less of all head and neck cancers. The vast majority occur in the mandible and maxilla. The median age is in the fourth decade, with a wide range. They are more likely to recur locally after treatment and distant metastases are observed less often than with the more common osteosarcomas arising in the long bones. The optimal treatment is complete resection. The role of adjuvant chemotherapy is ill-defined. The vast majority of recurrences are observed within 5 years. The 5-year disease-specific and overall survival rates are approximately 60% to 70%. CONCLUSIONS: Osteosarcoma of the head and neck is a rare entity that occurs primarily in the mandible and maxilla. The optimal treatment is surgery. Adjuvant radiotherapy should be considered for those with close or positive margins. The role of adjuvant chemotherapy is ill-defined. The likelihood of cure is approximately 60% to 70%.

Minimally invasive video-assisted thyroidectomy.

BACKGROUND: Minimally invasive video-assisted thyroidectomy (MIVAT) has been developed and successfully used in Italy to perform thyroidectomy and central node dissection through an incision of 2 to 3 cm. OBJECTIVES: Determine the safety, utility, and complication rates of MIVAT in a university setting within the United States. STUDY DESIGN: Single surgeon series of MIVAT performed during an 18-month period. RESULTS: Two hundred fifty thyroidectomies were performed between January 2006 and June 2007. Ninety-two (37%) met eligibility criteria for MIVAT. Six (7%) procedures were converted to open thyroidectomy (incision 4-5 cm) because of extent of the disease (3 strap muscle invasions, 1 thyroiditis, and 2 excessive size goiters). Eighty-six (93%) procedures were completed via the MIVAT technique. There was one case of transient and no cases of permanent recurrent laryngeal nerve paralysis (0.7% of nerves at risk). There were two cases of transient hypocalcemia (3.6% of total/completion cases). There were no hematomas or seromas. There were five (5.8%) cases of minor superficial skin burn. Mean operative times were significantly reduced during the study period (67 to 42 min for hemithyroidectomy, P = .0005; 110 to 77 min for total thyroidectomy, P = .02). Mean incision length measured after wound closure was 2.5 cm. CONCLUSION: We found implantation of MIVAT to be safe, with rates of hypocalcemia, vocal cord paresis, and hematoma comparable with those reported for the traditional open approach. Procedure times varied based on extent of thyroidectomy, patient factors, and experience of the operator and were significantly reduced during the study period.

Esthesioneuroblastoma of the nasal cavity.

OBJECTIVES: Esthesioneuroblastoma is an uncommon cancer of the nasal cavity. We describe the outcomes for 26 patients treated with curative intent with photon radiotherapy (RT) at the University of Florida. METHODS: Between May 1972 and June 2007, 26 patients received RT for previously untreated esthesioneuroblastoma of the nasal cavity. Sixteen patients were males and 10 were females with a median age of 55 years (range, 3 to 82 y). The modified Kadish stage distribution was: B, 7 patients; C, 17 patients; and D, 2 patients. Treatment modalities included the following: definitive RT, 5 patients; preoperative RT, 2 patients; and postoperative RT after resection, 19 patients. Elective neck irradiation (ENI) was performed in 17 (71%) of 24 N0 patients. RESULTS: Rates of local control, cause-specific survival, and absolute overall survival at 5 years were 79%, 72%, and 69%, respectively. Overall survival among patients treated with definitive RT was 20% at 5 years, compared with 81% among those who underwent surgery and adjuvant RT (P=0.01). One (6%) of 17 patients who received ENI developed a recurrence in the neck and was successfully salvaged. Ultimate neck control was 100% at 5 years for patients who received ENI versus 69% among those not receiving ENI (P=0.0173). CONCLUSIONS: Resection combined with adjuvant RT is more effective than surgery or RT alone in the treatment of esthesioneuroblastoma. ENI reduces the risk of regional relapse in patients with Kadish stage B and C cancers.

Postoperative radiotherapy for patients at high risk of recurrence of oral cavity squamous cell carcinoma.

OBJECTIVES: To evaluate the efficacy of postoperative radiotherapy for oral cavity squamous cell carcinoma (OCSCC) by comparing outcomes of high-risk subgroups. STUDY DESIGN: Retrospective review. METHODS: Outcome study of 139 patients with OCSCC treated with gross total resection and postoperative radiotherapy ± chemotherapy and at least one high-risk pathologic finding: positive margin (52%), close (0.1-5 mm) margin (27%), or extracapsular nodal extension (ECE; 45%). RESULTS: Median follow-up was 2.3 years. Local-regional control (LRC), freedom from distant metastases, cause-specific survival, and overall survival (OS) rates at 5 years were 64%, 85%, 51%, and 36%, respectively. Five-year LRC for negative (>5 mm), close (0.1-5 mm), and positive (carcinoma in situ or tumor at ink) margins were 73%, 83%, and 63%, respectively (P = not significant). Five-year neck control was 100% for node-negative patients, 88% for node-positive patients with no ECE, and 86% for node-positive patients with ECE (P = not significant). The combination of close/positive margin and ECE resulted in worse 5-year LRC (37% vs. 70%, P < 0.001), progression-free survival (26% vs. 60%, P < 0.001), and OS (13 vs. 43%, P < 0.001) compared with a single high-risk indication. CONCLUSIONS: Local-regional control was the predominant mode of treatment failure. Outcome in our series was not statistically different based on margin status or nodal ECE. This finding is indirect evidence of the efficacy of adjuvant radiotherapy in this setting.

Intrathyroidal parathyroid carcinoma: report of an unusual case and review of the literature.

Intrathyroidal parathyroid carcinoma is an exceedingly rare cause of primary hyperparathyroidism. A 51-year-old African American female presented with goiter, hyperparathyroidism, and symptomatic hypercalcemia. Sestamibi scan revealed diffuse activity within an enlarged thyroid gland with uptake in the right thyroid lobe suggestive of hyperfunctioning parathyroid tissue. The patient underwent thyroidectomy and parathyroidectomy. At exploration, a 2.0 cm nodule in the usual location of the right inferior parathyroid was sent for intraoperative frozen consultation, which revealed only ectopic thyroid tissue. No parathyroid glands were identified grossly on the external aspect of the thyroid. Interestingly, postoperative parathyroid hormone levels normalized after removal of the thyroid gland. Examination of the thyroidectomy specimen revealed a 1.4 cm parathyroid nodule located within the parenchyma of the right superior thyroid, with capsular and vascular invasion and local infiltration into surrounding thyroid tissue. We present only the eighth reported case of intrathyroidal parathyroid carcinoma and review the literature.

Locally destructive skull base lesion: IgG4-related sclerosing disease.

A unique case of IgG4(+) sclerosing disease was diagnosed in the sphenoid sinus, a previously unreported location, and was treated in a novel manner. This study describes the clinical presentation and management of IgG4 sclerosing disease in the paranasal sinuses. A retrospective case review and review of the medical literature were performed. A 38-year-old woman with a 2-year history of constant frontal headaches presented to our clinic. Imaging showed bony destruction of the sphenoid sinus and sellar floor. The patient underwent a right-sided sphenoidotomy with debridement and biopsy. Pathological evaluation showed a dense plasmacytic infiltrate with >150 IgG4(+) cells/high-power field. She was subsequently started on a nasal corticosteroid with improved patency of the sphenoid antrostomy. We report an unusual case of a middle-aged woman who presented with IgG4-sclerosing disease (IGSD) isolated to the sphenoid sinus. Although our knowledge concerning treatment in extrapancreatic organs is lacking, there is evidence that glucocorticoid treatment improves nasal sinus opacification on CT findings (Sato Y, Ohshima K, Ichimura K, et al., Ocular adnexal IgG4-related disease has uniform clinicopathology, Pathol Int 58:465-470, 2008). This case study and literature review adds to the growing literature describing IGSD in the head and neck and more specifically isolated to the sphenoid sinus with preliminary data concerning local control with topical steroids.

Definitive radiation therapy for squamous cell carcinoma of the pharyngeal wall.

PURPOSE: To analyze the results of definitive radiation therapy (RT) for squamous cell carcinoma of the pharyngeal wall. METHODS AND MATERIALS: Between 1964 and 2009, 170 patients were treated with definitive RT; all living patients had a 1.7-year minimum follow-up. RESULTS: The 5-year rates of local control and ultimate local control were the following: T1, 93% and 93%; T2, 84% and 91%; T3, 60% and 62%; and T4, 44% and 44%. Multivariate analysis revealed stage I-II tumors, female gender, and altered fractionation were associated with improved local-regional control. The 5-year cause-specific and overall survival rates were the following: I, 88% and 50%; II, 89% and 57%; III, 49% and 31%; IV, 35% and 21%; and overall, 50% and 31%, respectively. Fatal complications occurred in 9 patients (5%). CONCLUSIONS: Local-regional control and survival are related to extent of disease and treatment technique. Although outcomes have improved in recent years, the morbidity of treatment is significant and a substantial proportion of patients die due to cancer.

Radiotherapy with or without surgery for maxillary sinus squamous cell carcinoma: should the clinical N0 neck be treated?

OBJECTIVES: Maxillary sinus squamous cell carcinoma is commonly diagnosed at an advanced stage and treated using radiotherapy, with or without surgical resection. METHODS: Fifty-four patients with maxillary sinus squamous cell carcinoma were treated from 1969 to 2006, using radiotherapy, with or without surgical resection. Fifty-two (96%) patients had American Joint Committee on Cancer stages III to IV disease, and 45 (83%) patients had N0 neck disease. RESULTS: Five-year local control (LC) rates by T-stage were 63% for T2/T3; and 43% for T4. Five-year LC rates for patients treated with radiotherapy preoperatively, postoperatively, and definitively were 61%, 65%, and 37%, respectively. Initially, overall 5-year LC, neck control, and local-regional control were 49%, 82%, and 45%, respectively. The ultimate 5-year LC, neck control, and local regional control after salvage of failures were 51%, 87%, and 50%, respectively. The overall 5-year cause-specific survival was 41%. Thirty-three percent of patients had a severe complication. CONCLUSIONS: Radiotherapy, with or without surgical resection, remains an effective tool in treating patients with this disease. LC, cause-specific survival, and complication rates need significant improvement. Treatment details and recommendations are discussed herein.

Head and neck paragangliomas.

BACKGROUND: The purpose of this study was to describe the natural history and optimal treatment for head and neck paragangliomas (PGs). METHODS: Our methods were the review of the pertinent literature. RESULTS: PGs are rare tumors seen most commonly in the head and neck. Approximately 90% are sporadic; the remainder are familial and related to mutations of the succinate dehydrogenase (SDH) gene complex. Most PGs are benign and slow growing; 6% to 19% are malignant, as evidenced by the development of metastases. PGs may be treated by complete resection or moderate-dose radiotherapy with a ≥90% likelihood of cure. The optimal radiotherapy dose is approximately 45 Gy/25 fractions/5 weeks. The treatment modality selected depends on the risk of complications. Due to their rarity, the optimal treatment for malignant PGs is unclear. CONCLUSION: PGs may be treated by either complete resection or radiotherapy with a high likelihood of success. Treatment depends on the location and extent of the PG and the morbidity associated with treatment.

Tracheocele: an unusual cause of dysphonia.

EDUCATIONAL OBJECTIVES: Describe the clinical presentation and management of tracheoceles. STUDY DESIGN: Retrospective case review and review of the medical literature. RESULTS: A 56 year old female patient presented with progressive dysphonia and history of benign thyroid nodules. Flexible laryngoscopy revealed a severely paretic right true vocal cord. Computed tomography revealed a right sided air filled sac in the tracheoesophageal groove suspicious for causing compression of the right recurrent laryngeal nerve. The patient underwent an elective right hemithyroidectomy and resection of the air filled sac. Post operative pathology of the air filled sax was consistent with a tracheocele. A laryngoscopy performed 6 months postoperatively demonstrated recovery of right cord function. CONCLUSIONS: Tracheoceles are an uncommon entity first described in 1846 by Rokitansky (1) with only a paucity of case reports in the literature describing the surgical management and treatment of this disease. Herein, we report a patient who presented with dysphonia from a tracheocele in the right tracheoesophageal groove who subsequently underwent surgical resection ultimately improving vocal cord function.

Altered fractionation and adjuvant chemotherapy for head and neck squamous cell carcinoma.

BACKGROUND: The aim of this review was to discuss the role of altered fractionation and adjuvant chemotherapy for patients treated with definitive radiotherapy (RT) for head and neck squamous cell carcinoma (HNSCC). METHODS: This review explores the pertinent literature and discusses the optimal management of previously untreated patients with stage III-stage IVA and/or -B HNSCCs. RESULTS: Depending on the schedule, altered fractionation improves locoregional control and survival. Both hyperfractionation and concomitant boost RT improve locoregional control and are associated with improved overall survival (OS). Adjuvant chemotherapy improves OS; the greatest impact is observed after concomitant versus induction or maintenance chemotherapy. Monochemotherapy appears to be equivalent to polychemotherapy. Drugs associated with the greatest survival benefit include fluorouracil and cisplatin. Intraarterial chemotherapy offers no advantage over intravenous chemotherapy. Concomitant cetuximab and RT results in improved outcomes similar to those observed after concomitant cisplatin-based chemotherapy and RT. CONCLUSIONS: Altered fractionation and/or concomitant chemotherapy result in improved outcomes compared with conventionally fractionated definitive RT alone for stage III-stage IV HNSCC. The optimal combination of RT fractionation and chemotherapy remains unclear.

Elective neck dissection during salvage surgery for locally recurrent head and neck squamous cell carcinoma after radiotherapy with elective nodal irradiation.

OBJECTIVES/HYPOTHESIS: To define the role of elective neck dissection during salvage surgery for locally recurrent head and neck squamous cell carcinoma (SCCA) initially treated with elective nodal irradiation (ENI). STUDY DESIGN: Retrospective chart review. METHODS: We reviewed the medical records of patients treated with ENI at our institution from 1965 to 2006 for T1-4 N0 M0 SCCA of the oropharynx, hypopharynx, or larynx who developed an isolated local recurrence and remained N0. Fifty-seven patients were salvaged, 40 with neck dissection and 17 with neck observation. We then compared toxicity and actuarial outcomes between the two groups. Results were compared to the pertinent literature in a pooled analysis. RESULTS: Four of 46 (9%) heminecks were found to have occult metastases in dissected specimens. The 5-year local-regional control rate was 75% for all patients. Neck dissection resulted in poorer outcomes compared with observation. In the dissected group, the 5-year local control, regional control, cause-specific survival, and overall survival rates were 71%, 87%, 60%, and 45%, respectively, compared to 82%, 94%, 92%, and 56%, respectively, for the observed group. Toxicity was more likely with dissection. In the pooled analysis totaling 230 patients, the overall pathologic positive rate of neck-dissection specimens was 9.6%; the compiled data showed no improvement in outcomes when salvage included neck dissection. CONCLUSIONS: Routine elective neck dissection should not be included during salvage surgery for locally recurrent head and neck SCCA if initial radiotherapy includes ENI. The risk of occult neck disease is low, outcomes do not improve, and the likelihood of toxicity increases. Laryngoscope, 2010.

Squamous cell carcinoma of the external auditory canal: long-term clinical outcomes using surgery and external-beam radiotherapy.

OBJECTIVE: Squamous cell carcinoma (SCCA) of the external auditory canal (EAC) is often treated with a combination of surgery and radiotherapy (RT) to optimize the chance of achieving locoregional control. This retrospective review describes a 27-year experience of treating these tumors at the University of Florida. METHODS: Thirty patients with histologically confirmed SCCA of the EAC received external-beam radiation (RT) alone or combined with surgical resection between 1976 and 2003. Seven patients were treated with RT alone, 22 with postoperative RT, and 1with preoperative RT. Patients were grouped according to nodal status (N0/N1) and the Stell staging system for tumors of the EAC and middle ear. Early stage was defined as T1/T2 (n = 12) and advanced stage as T3 (n = 18). Median follow-up was 2 years (range, 0.1-19.4 years) with no patients lost to follow-up. RESULTS: The 5-year actuarial probabilities for local control, locoregional control, and cause-specific survival for patients with early stage (T1/T2) versus advanced-stage (T3) tumors were 74% and 55% (P = 0.27), 63% and 38% (P = 0.16), and 70% and 41% (P = 0.04), respectively. The regional control rate was 83% (P = 0.6). There were 12 local recurrences and 4 neck recurrences as the first site of failure. One failure was successfully salvaged with surgery. Five of 23 (21%) patients undergoing surgery had significant complications (grade 3 or 4), whereas 2 of 30 (7%) patients receiving RT experienced grade 3 complications. CONCLUSION: Patients with early stage disease achieved better local control, locoregional control, and cause-specific survival than those with advanced tumors. Less than half of the patients (13 of 30; 43%) were cured without significant complications, suggesting a suboptimal therapeutic ratio, using current treatment methods.

Carcinoma of the nasal cavity and paranasal sinuses.

OBJECTIVES/HYPOTHESIS: To determine the outcomes after radiotherapy (RT) alone or combined with surgery at the University of Florida for patients with carcinomas of the nasal cavity and paranasal sinuses. METHODS: Between November 1964 and June 2005, 109 patients were treated with curative intent. Patients with maxillary sinus carcinomas were excluded. Fifty-six patients were treated with definitive RT, and 53 patients received surgery and preoperative (eight patients) or postoperative (45 patients) RT. Median follow-up was 4.3 years (range, 0.2-35.9 years). Median follow-up on living patients was 9.4 years (range, 2.0-35.9 years). RESULTS: The 5-year local control rates were: T1-T3, 82%; T4, 50%; and overall, 63%. Local control at 5 years was 43% after definitive RT versus 84% after surgery and adjuvant RT (P < .0001). Multivariate analysis of local control revealed that both overall stage and treatment group (definitive RT versus surgery and adjuvant RT) significantly impacted this endpoint. Cause-specific survival rates were: stages I to III, 81%; stage IV, 54%; and overall, 62%. Multivariate analysis revealed that T-stage, N-stage, and treatment group significantly influenced this endpoint. Thirty-one (20%) of 109 patients sustained severe complications; 17 of 56 patients (16%) after definitive RT and 14 of 53 patients (25%) after surgery and adjuvant RT. CONCLUSIONS: The probability of local control and cause-specific survival is better after surgery and RT compared with definitive RT. There is a modest increase in the risk of complications after surgery and RT. Thus, the preferred treatment is surgery combined with preoperative or postoperative RT.

Cutaneous squamous cell carcinoma metastatic to parotid-area lymph nodes.

INTRODUCTION: Metastatic spread to parotid-area lymph nodes (PALN) occurs in 1% to 3% of patients with cutaneous squamous cell carcinoma of the head and neck. Presented herein is the University of Florida experience using radiation therapy (RT) to treat patients with PALN metastases from a skin primary. METHODS AND MATERIALS: From November 1969 to February 2005, 121 parotids in 117 patients received irradiation for nonmelanotic skin carcinoma metastatic to PALN. Patients were staged by the O'Brien staging system. Of the 121 parotids receiving RT, 17 (14%) were treated preoperatively, 87 (72%) postoperatively, and 17 with RT alone. RESULTS: Five-year actuarial probabilities of local (parotid) control, local-regional control, disease-free survival and overall survival were 78%, 74%, 70%, and 54%, respectively. When patients were separated by O'Brien P-stage, statistically significant differences were seen among the groups for local (parotid) control, local-regional control, and disease-free survival. A statistically significant decrease in local control was seen in patients treated with positive surgical margins (92% vs. 76%) and in local-regional control for patients treated with preoperative RT or RT alone when compared with postoperative RT (59% and 47% vs. 83%, respectively). The 5-year actuarial probability of freedom from distant metastases was 92%. Three (2.6%) patients suffered severe complications. CONCLUSIONS: PALN metastases from a cutaneous head and neck primary site are best treated with surgery and postoperative RT. Our data support the hypothesis that the O'Brien staging system is superior to the American Joint Committee on Cancer system for the staging of cutaneous metastases to PALN. Positive surgical margins confer a worse prognosis in terms of local-regional control and disease-free survival. Patients treated with preoperative RT seem to have a worse prognosis than those treated postoperatively, likely a result of patient selection and the surgeon's inability to accurately assess viable tumor extent after preoperative RT. Severe complications are uncommon after surgery and RT for PALN metastases.