Recurrent pleomorphic adenoma: results of surgical treatment.

BACKGROUND: Recurrent parotid pleomorphic adenoma surgery increases the risk of facial nerve injury, and there is also a risk of ulterior recurrence. METHODS: Postoperative results from 62 consecutive patients operated for recurrent pleomorphic adenoma were analyzed. It was the first recurrence for 49 patients (79%), the second or more for 13 patients (21%). RESULTS: Total parotidectomy was performed in 69.4% of cases. Skin resection was performed in 47 patients (75.8%). Resection of a facial nerve branch was performed in seven patients (11.3%). Pathologic examination findings revealed carcinoma ex pleomorphic adenoma in 10/62 cases (16.1%) and microscopic multinodular disease in 39 patients (62.9%). Nine patients had preoperative facial palsy, 95% had postoperative facial paralysis ≥ grade II (House-Brackmann scale), and 11.3% still had ≥ grade III facial palsy after 1 year. Six patients developed another recurrence after our intervention (9.68%). Moreover, carcinoma was discovered after a new intervention in 40% of these patients. Initial partial parotid surgery [hazard ratio (HR) = 8.477, P = 0.008], microscopic multinodular recurrent disease (HR = 11.717, P = 0.005), and ≥ 1 recurrence number (HR = 10.608, P = 0.01) were associated with increased risk of ulterior recurrence. CONCLUSION: Surgery is recommended in pleomorphic adenoma recurrence because of the high rate of carcinoma ex pleomorphic adenoma (16.1%). Nevertheless, a definitive facial paralysis ≥ grade III rate of 11.3% is reported after multiple nerve dissection. New recurrence after surgery is less frequent if the initial treatment for pleomorphic adenoma is total parotidectomy.

Laryngeal dedifferentiated liposarcoma.

BACKGROUND: Soft tissue liposarcomas are quite common in the adult population, whereas liposarcoma of the larynx is exceedingly rare. METHODS: We describe an exceptional case of liposarcoma of the posterior aspect of the left arytenoid in a 62-year-old woman who was treated with two endoscopic excisions and adjuvant radiotherapy (RT). This is the 32nd case of laryngeal liposarcoma reported in the English literature. RESULTS: After a 20 months follow-up, no local, regional recurrences or distant metastases were detected, and no functional complications are described for the patient. CONCLUSION: This case report highlights that endoscopic surgical treatment enables excellent organ and functional preservation. However, recurrence of laryngeal liposarcoma is the principal risk, so extended follow-up is essential. RT has no defined role in treatment but can be discussed, especially considering the surgical margins and recurrence status.

The diagnostic accuracy of reverse transcription-PCR quantification of cytokeratin mRNA in the detection of sentinel lymph node invasion in oral and oropharyngeal squamous cell carcinoma: a comparison with immunohistochemistry.

PURPOSE: The main goal of sentinel lymph node (SLN) detection in head and neck squamous cell carcinomas is to limit neck dissections to pN+ cases only. However, intraoperative + diagnosis cannot be routinely done using the current gold standard, serial step sectioning with immunohistochemistry. Real-time quantitative reverse transcription-PCR (RT-PCR) is potentially compatible with intraoperative use, proving highly sensitive in detecting molecular markers. This study postoperatively assessed the accuracy of quantitative RT-PCR in staging patients from their SLN. EXPERIMENTAL DESIGN: A combined analysis on the same SLN by serial step sectioning with immunohistochemistry and quantitative RT-PCR targeting cytokeratins 5, 14, and 17 was done in 18 consecutive patients with oral or oropharyngeal squamous cell carcinoma and 10 control subjects. RESULTS: From 71 lymph nodes examined, mRNA levels (KRT) were linked to metastasis size for the three cytokeratins studied (Pearson correlation coefficient, r = 0.89, 0.73, and 0.77 for KRT 5, 14, and 17 respectively; P < 0.05). Histopathology-positive SLNs (macro- and micrometastases) showed higher mRNA values than negative SLNs for KRT 17 (P < 10(-4)) and KRT 14 (P < 10(-2)). KRT 5 showed nonsignificant results. KRT 17 seemed to be the most accurate marker for the diagnosis of micrometastases of a size >450 mum. Smaller micrometastases and isolated tumor cells did not provide results above the background level. Receiver operating characteristic curve analysis for KRT 17 identified a cutoff value where patient staging reached 100% specificity and sensitivity for macro- and micrometastases. CONCLUSION: Quantitative RT-PCR for SLN staging in cN(0) patients with oral and oropharyngeal squamous cell carcinoma seems to be a promising approach.

Laryngostroboscopic evaluation after supracricoid partial laryngectomy.

BACKGROUND: Supracricoid partial laryngectomy (SCPL) results in laryngeal preservation in more than 95% of patients with T2 glottic carcinoma. Postsurgical glottic function is characterized by an absence of vocal cords, and phonation quality is a key post-SCPL quality-of-life factor. OBJECTIVE: This investigation was designed to enhance post-SCPL vocal function, study anatomic function of the post-SCPL larynx, and correlate anatomic findings with perceptual and instrumented measurements of voice. METHOD: Twenty-five patients were included. All had undergone SCPL with cricoepiglottopexy for T2 glottic carcinoma. All patients were evaluated by laryngostroboscopic examination, voice sample recording, and instrumented voice analysis with the aim of gaining further insight into postoperative larynx function. Laryngostroboscopic parameters such as laryngeal occlusion, epiglottic length, arytenoid movement, and vibratory area were assessed. The perceptual evaluation was based on the GRBAS scale. Acoustic and aerodynamic parameters were recorded, including fundamental frequency (F0), intensity, jitter, shimmer, signal-to-noise ratio (SNR), oral airflow (OAF), maximum phonation time (MPT), and estimated subglottic pressure (ESGP). Nonparametric tests were used to compare laryngostroboscopic parameters with instrumented measurements and perceptual evaluations of voice quality. RESULTS: Correlations were established among occlusion, epiglottic length, and general grade of dysphonia. Oral air flow (P = 0.006) was found to be correlated with occlusion. Voice roughness was correlated with the presence of a clearly identifiable vibratory area (P = 0.003), whereas these vibratory areas were correlated with shimmer (P = 0.041), OAF (P = 0.001), and SNR (P = 0.001). The number of preserved arytenoids was not identified as a voice quality factor (P = 0.423). CONCLUSION: This study highlighted correlations between the laryngostroboscopic examination results and the perceptive and instrumented measurements of voice. Glottis occlusion and epiglottis length were found to be key factors for postoperative voice quality. These results should help to advance technical development on surgical techniques to enhance voice results.

Fourth branchial pouch sinus: from diagnosis to treatment.

BACKGROUND: Fourth branchial pouch sinus (FBPS) is rare and frequently unknown to clinicians. Misdiagnosis is common and definitive surgery is often made difficult by previous episodes of infection and failed attempts at excision. The purpose of this paper is to clarify the diagnostic criteria and the methods used for the surgical management of FBPS. MATERIALS AND METHOD: From a series of 265 head and neck cysts and fistulae, 7 cases of FBPS were retrospectively reviewed. The surgical technique is detailed. RESULTS: Six cases were located on the left side and one on the right. CT scanning showed an air-filled structure on both sides of the lesser horn of the thyroid cartilage in 2 cases out of 4, and barium swallow found a FBPS in 1 case out of 3. Direct pharyngoscopy allowed confirmation of the diagnosis in all cases and permitted catheterization of the tract with the spring guidewire of a vascular catheter which helped surgical location and subsequent dissection. The recurrent laryngeal nerve was systematically dissected to avoid inadvertent damage. A hemi-thyroidectomy was performed in one case. A transient laryngeal paralysis (lasting 9 months) was noted in a 3-week-old newborn operated on. None of the 7 cases had a recurrence after complete resection of the FBPS (3.7 years average follow-up). CONCLUSION: Symptoms on the right side do not exclude the diagnosis of a FBPS. Endoscopy is the key investigation. It allows confirmation of the diagnosis and catheterization of the tract, which aids the surgical dissection. Total removal of the sinus tract tissue with dissection and preservation of the recurrent laryngeal nerve is recommended. EBM RATING: A-1.

Acoustic and aerodynamic measurement of speech production after supracricoid partial laryngectomy.

BACKGROUND: Supracricoid partial laryngectomy (SCPL) results in laryngeal preservation in more than 95% of patients with T2 glottic carcinoma. After surgery, glottis function is characterized by an absence of vocal cords and poor glottis closure. Voice is an important postSCPL quality of life factor. OBJECTIVE: Enhance postSCPL vocal function. Obtain postsurgical acoustic and aerodynamic measurements and correlate multiple objective parameters with perceptual results. METHOD: Continuous speech voice samples from 61 patients who had undergone SCPL more than 1 year before were scored according to the global, roughness, breathiness, asthenia, and strain (GRBAS) scale by a jury of listeners. Acoustic and aerodynamic parameters were recorded: fundamental frequency (F0), intensity, jitter, shimmer, signal-to-noise ratio (SNR), signal-to-noise ratio greater than 1 kHz (SNR>1), oral airflow (OAF), maximum phonation time (MPT), and estimated subglottic pressure (ESGP). Nonparametric tests and logistic regression analysis were used to compare objective measurements and perceptual evaluations. RESULTS: All patients had various degrees of dysphonia: grade 1, 4.9%; grade 2, 55.7%; and grade 3, 39.4%. Correlations between perceptual grades and objective parameters were obtained for jitter, shimmer, SNR, SNR>1, ESGP, and OAF. No correlations were obtained between the different parameters and age, number of arytenoids, and time elapsed since surgery (TESS). Logistic regression analysis of jitter, SNR, ESGP, and OAF parameters revealed 92.6% agreement with the perceptual evaluation results.

Supracricoid partial laryngectomies after failure of radiation therapy.

BACKGROUND: Conservation of laryngeal function is a key surgical objective in cases of limited recurrence after previously irradiated T1b or T2 glottic carcinoma. Only a few articles have mentioned the use of supracricoid partial laryngectomies (SCPL) to treat recurrent T1/T2 tumors that cannot be managed with vertical partial laryngectomy. OBJECTIVES: To evaluate oncologic and functional results of SCPL in selected cases of T1/T2 glottic carcinoma recurrence after primary irradiation therapy. METHOD: Between 1986 and 2000, 23 selected patients (T1b, 12 cases; T2, 11 cases) underwent SCPL as salvage treatment: cricohyoidepiglottopexy (CHEP) in 18 cases and cricohyodopexy (CHP) in 5 cases. RESULTS: The mean cannulation time was 28 (14-90) days. The mean nasogastric feeding tube time for CHP and CHEP was 55 (28-96) days and 21 (9-45) days, respectively. Four (17.4%) patients had major swallowing recovery problems. Three patients died in the postoperative period, one of intercurrent disease and two because of aspiration pneumonia. Six (26.08%) patients relapsed and underwent total laryngectomy. Three were subsequently controlled. The T stage was correlated with the onset of a new recurrence (P = .0258). The surgical margins were not correlated with recurrence (P = .0741). At 3 and 5 years, the global survival rate was 82.9% and 69.04%. The success rate for oncologic control and oncologic control with organ preservation was 74% and 66.6%, respectively. CONCLUSION: In selected cases of limited recurrence after radiation therapy for T1/T2 vocal cord carcinomas, SCPL can be an alternative to total laryngectomy when partial vertical surgery appears unsuitable.

Continuous facial nerve monitoring during pleomorphic adenoma recurrence surgery.

OBJECTIVES: Surgery of recurrent pleomorphic adenoma (RPA) is known to lead to a high facial nerve complication rate. The efficacy of the continuous facial nerve monitoring (CFNM) technique remains to be proven in RPA surgery. The goal was thus to evaluate facial nerve palsy rates and the recovery period after parotidectomy for RPA using CFNM by way of continuous electromyography and to compare these rates and the operation time with those of patients who had undergone surgery without facial nerve monitoring. DESIGN: Cohort study. PATIENTS: Forty-seven patients were referred for RPA (1981-2003). Among them, 32 (18 unmonitored and 14 monitored) patients displayed no preoperative facial palsy, and histologic analyses revealed evidence of recurrence. The operation time and the extent and duration of postoperative facial nerve palsy were examined in both groups (monitored vs. unmonitored). Both groups had a similar clinical appearance distribution. RESULTS: Facial nerve paralysis was estimated using the House-Brackmann grading scale. CFNM reduced the intensity of facial nerve paralysis independently of the kind of surgery performed. The complete deficit rates were 0% for the monitored group and 5.6% for the unmonitored group. Postoperative facial nerve paralysis was significantly lower (P = .01) in the monitored group than in the unmonitored group. CFNM improved the duration of facial paralysis (P = .001) in the monitored group. The operation time was significantly lower in the monitored group than in the unmonitored group (P = .001). CONCLUSIONS: Routine use of CFNM during RPA surgery improves the surgical outcome. The facial nerve deficit can be reduced, and the recovery of facial nerve function is faster.

Management of descending necrotizing mediastinitis.

OBJECTIVE/HYPOTHESIS: Descending necrotizing mediastinitis is caused by downward spread of neck infections and constitutes a highly lethal complication of oropharyngeal lesions. This infection previously had a much worse prognosis. In recent years, more aggressive management has been recommended. The aim of this study is to evaluate the results with the association of thoracotomy and cervicotomy, medical care in an intensive care unit, and daily washing of drained cervical and thoracic tissues. STUDY DESIGN: Retrospective study of 17 patients treated from 1984 to 1998. METHOD: Descending necrotizing mediastinitis was consecutive to pharyngitis (6 cases), peritonsillar abscess (3 cases), dental abscess (6 cases), foreign body infection (1 case), and laryngitis (1 case). Corticotherapy was reported in seven cases. Twelve patients had no particular medical history. Mean age was 42 years. Mean duration of signs before diagnosis was 6 days. Thoracotomy was associated with the cervical approach in 14 cases, whereas 3 patients were treated by cervicotomy only. RESULTS: Fourteen patients of 17 (82.3%) were successfully treated. Three deaths occurred. The mean duration of hospitalization in the intensive care unit was 30 days, and the mean total duration of hospitalization was 45 days. CONCLUSION: Descending necrotizing mediastinitis must be detected as soon as possible by computed tomography (CT) scanning in patients with persistent symptomatologia after treatment for oropharyngeal infections. Prompt surgical drainage with thoracotomy and cervicotomy in all cases of mediastinal involvement below the tracheal carena, use of CT scanning to monitor the disease evolution, and medical management in an intensive care unit significantly reduces the mortality rate to less than 20%.

Prognostic value of a three-grade classification in primary epithelial parotid carcinoma: result of a histological review from a 20-year experience of total parotidectomy with neck dissection in a single institution.

BACKGROUND: The tumour grading of primary parotid cancers (PPCs) remains controversial. METHODS: A 20-year standardised single centre treatment has been assessed retrospectively. The histological review of 155 consecutively treated parotid malignancies identified 96 suitable cases for univariate and multivariate survival analyses. RESULTS: Treatment involved total parotidectomy, neck dissection and post-operative radiotherapy in, respectively, 91.7%, 83.3% and 70.4% of cases. The 5-year overall survival, disease-specific and recurrence-free survival rates were 79.4%, 83.5% and 70.8%, respectively. Univariate analysis confirmed the classical prognostic factors, i.e. age>60 years, male gender, facial palsy, hardness of the tumour, clinical stage, tumour grade, facial nerve invasion and lymph node metastases. Multivariate analysis identified a three-grade classification just after the clinical stage as the most important prognostic factor. CONCLUSION: This study identifies the prognostic significance of intermediate grade tumours.

Randomized phase III trial comparing induction chemotherapy followed by radiotherapy to concomitant chemoradiotherapy for laryngeal preservation in T3M0 pyriform sinus carcinoma.

CONCLUSIONS: Conventional radiotherapy with concurrent cisplatin is significantly superior to induction cisplatin fluorouracil chemotherapy followed by radiotherapy in terms of laryngeal preservation in patients with T3 hypopharyngeal carcinoma. Despite a high rate of laryngeal preservation no survival benefit was recorded in this selected population. OBJECTIVES: To compare conventional radiotherapy with concurrent cisplatin to induction chemotherapy with cisplatin fluorouracil followed by conventional radiotherapy. The primary end point was the preservation of the larynx. The secondary end points included toxicity, causes of death, and survival rates. PATIENTS AND METHODS: Seventy-one adult patients with previously untreated resectable T3 pyriform sinus squamous cell carcinoma were enrolled in the multicenter prospective randomized phase III trial. They were evaluated for organ preservation, survival rates, and toxic reactions. RESULTS: The rates of laryngeal preservation at 2 years were 68% for the induction chemotherapy (IC) group and 92% for the chemoradiotherapy (CR) group (p = 0.016). At 2 years, the event-free survival rates were 36% and 41% for the IC group and CR group, respectively.

Neck restaging with sentinel node biopsy in T1-T2N0 oral and oropharyngeal cancer: Why and how?

OBJECTIVE: To evaluate the lack of accuracy in neck staging with the classical technique (i.e., neck dissection and routine histopathology) with the sentinel node (SN) biopsy in oral and oropharyngeal T1-T2N0 cancer. STUDY DESIGN: Cross-sectional study with planned data collection. SETTING: Tertiary center care. SUBJECTS AND METHODS: In 50 consecutive patients, the pathological stage of sentinel node (pSN) was established after analyzing SN biopsies (n = 148) using serial sectioning and immunohistochemistry. Systematic selective neck dissection was performed. The pN stage was established with routine histopathologic analysis of both the non-SN (n = 1075) and the 148 SN biopsies. RESULTS: The sensitivity and negative predictive value of pSN staging were 100 percent. Conversely, if one considers pSN staging procedure as the reference test for micro- and macro-metastasis diagnosis, the sensitivity of the classical pN staging procedure was 50 percent (9/1; 95% CI 26.9-73.1) and its negative predictive value was 78 percent (95% CI 61.9-88.8). Fifteen patients (30%) were upstaged, including nine cases from pN0 to pSN >or= 1 and six cases from pN1 to pSN2. Two of the pN0-pSN1 upstaged patients died with relapsed neck disease. CONCLUSION: The SN biopsy technique appeared to be the best staging method in cN0 patients and provided evidence that routinely undiagnosed lymph node invasion may have clinical significance.

Supraglottic hemipharyngolaryngectomy for the treatment of T1 and T2 carcinomas of laryngeal margin and piriform sinus.

BACKGROUND: We evaluated the functional and oncologic results of supraglottic hemipharyngolaryngectomy as treatment for T1 and T2 lateral laryngeal margin and piriform sinus carcinomas. METHODS: Eighty-seven patients underwent this surgical treatment. The disease was classified T1 in 14 of these cases (16.1%) and T2 in 73 cases (83.9%). The nodal status indicated 39 cases of N0 (44.8%), 18 cases of N1 (20.7%), 28 cases of N2 (32.2%), and two cases of N3 (2.2%). With regard to the N0 cases, 15 (38.4%) were positive at the histologic examination. Within the N+ group, 52.1% involved capsular rupture. RESULTS: Two patients died of complications during the postoperative period. The mean duration of nasogastric tube feeding was 20 days. Six patients (7.27%) had feeding resumption problems. All patients were decanulated after a mean period of 16 days. All patients underwent postoperative radiation therapy, except two with T1N0N- disease and three who had previously undergone this treatment. The 5-year actuarial survival rate was 60.3% (T1, 83.3%; T2, 49.9%). The rates of local and regional recurrence, second primary cancer, and metastasis were 19.5%, 24.1%, and 28.1%, respectively. The infringement of the pharyngoepiglottic fold was significantly correlated with locoregional recurrence. The survival rate was significantly correlated with the nodal status and extracapsular spread. CONCLUSIONS: Initial staged cancers of the laryngeal margin and piriform sinus can be successfully managed with conservative surgery called supraglottic hemipharyngolaryngectomy combined with nodal neck dissection. Postoperative radiation therapy is still recommended in most cases because of the high recurrence potential and prevalence of secondary regional cancers. This combined treatment seems to be a suitable therapeutic choice in the treatment of patients with T1 and T2 carcinomas of the laryngeal margins and piriform sinus.