Negative prognostic factors for head and neck cancer in the young.

PURPOSE: To evaluate the prognosis of head and neck (HN) squamous cell carcinoma (SCC) diagnosed in young people (≤40 years), and to compare it with the typical older patients. METHODS: The study population comprised 69 HN cancer patients below the age of 40 years. An equal-sized control group of older patients was pair-matched with the young cases. Cases and controls were compared for type and frequency of recurrence, in addition to survival. Tongue tumor specimens from 12 women of the study group (6 young and 6 old) were included in a pilot immunohistochemical analysis of estrogen receptors (ER) expression. RESULTS: Young patients with early (T1,T2) tongue cancer had shorter overall survival (OS) than their matched controls, but the finding was marginally non-significant (p=0.056). In the young population, late neck metastasis was a particularly aggravating factor for survival (p=0.004). In the case of tongue SCCs, young women were at the greatest risk of recurrence than any other gender-age combination (p=0.006). However, only 8.3% of tumors expressed ER. CONCLUSION: Early-stage tongue cancer, regional recurrence, and tongue SCCs in women are negative prognostic factors for young HN cancer patients. Treatment modifications targeting these subgroups might be beneficial.

Correlation of expression of cyclooxygenase-2, vascular endothelial growth factor, and peroxisome proliferator-activated receptor delta with head and neck squamous cell carcinoma.

Cyclooxygenase (COX) is the rate-limiting enzyme in the formation of prostaglandins from arachidonic acid. COX exists in 2 isoforms, COX-1 and COX-2. These isoforms are encoded by separate genes and demonstrate cell-specific expression and regulation. Peroxisome proliferator-activated receptor delta (PPARdelta) is a nuclear transcription factor that is activated by prostacyclin. Vascular endothelial growth factor (VEGF) is a proangiogenic factor that is up-regulated in various tumors. Vascular endothelial growth factor has been shown to interact with COX-derived prostaglandins in angiogenesis. To better understand the roles of these genes in head and neck squamous cell carcinoma (HNSCCA), we examined the differential expression of the COX1, COX2, VEGF, and PPARdelta genes in these tumors. Tissue samples from patients with HNSCCA were analyzed for COX-1, COX-2, VEGF, and PPARdelta messenger RNAs (mRNAs) by in situ hybridization. COX-1 and COX-2 mRNAs were also evaluated with Northern blot hybridization. Immunohistochemistry was used to analyze for COX-2 and PPARdelta proteins. Results showed focal areas of accumulation for COX-2, VEGF, and PPARdelta but not COX-1 in human HNSCCA. Northern blot hybridization showed higher levels of COX-2 mRNA in HNSCCA than in normal tissue. This suggests a supportive role of COX-2 in development and/or progression of HNSCCA. In addition, PPARdelta may be a receptor for COX-2-produced prostaglandins in HNSCCA. There is a potential role for selective COX-2 inhibitors in the treatment of these lesions.

Osteocutaneous radial forearm free flap: its use without significant donor site morbidity.

While the fasciocutaneous radial forearm free flap has gained increasing popularity, the osteocutaneous radial forearm free flap has been condemned because of a high rate of pathologic donor radius fracture. On the basis of studies that demonstrated increased strength in ostectomized radii after dynamic compression plating, we believed that internal fixation at the time of graft harvest would significantly reduce the incidence of donor radius fracture. This is a retrospective review of the first 54 patients undergoing osteocutaneous radial forearm free flap reconstruction of the head and neck at our institution; 52 underwent prophylactic plating of their donor radii. No clinically significant donor radius fractures have occurred in plated patients. Five asymptomatic fractures were discovered on routine radiographs and required no treatment. Objective evaluation of forearm range of motion and strength after graft harvest demonstrated excellent function compared with unoperated arms. Serial radiographs have shown remodeling and reconstitution of donor radii without localized osteopenia.

Efficacy of preoperative dual-phase sestamibi scanning in hyperparathyroidism.

PURPOSE: The objective of this article is to evaluate our experience with sestamibi scanning in patients with primary and secondary hyperparathyroidism. PATIENTS AND METHODS: A retrospective review of patients referred to the radiology department at the University of Kansas Medical Center for parathyroid studies between January 1, 1993, and August 1, 1998, was done. Patients included in the study were those who underwent both dual-phase technetium (Tc-99m) sestamibi scanning and subsequent parathyroidectomy at our institution (n = 34). Twenty-six patients had primary hyperparathyroidism and 8 patients had secondary hyperparathyroidism. Fifteen had previous history of neck exploration. RESULTS: Sensitivity of sestamibi scans in detection of all abnormal pathology in cases of primary hyperparathyroidism was 60% overall. Among the subset of adenoma cases, sensitivity was 82% (14/17). Among cases of primary parathyroid hyperplasia, no scan correctly localized all abnormal glands; however 60% (3/5) showed localization of at least one hyperplastic gland. Of the 2 patients with parathyroid carcinoma, in only one case was there evidence of sestamibi retention in the correct thyroid lobe. In patients with secondary hyperparathyroidism, sestamibi scanning was successful in identifying all hyperplastic tissue in only one case (sensitivity 13%). In 7 of the 8 cases of secondary hyperparathyroidism, the scan localized at least one hyperplastic gland. CONCLUSION: Sestamibi scanning is useful in the localization of abnormal pathology in cases of primary hyperparathyroidism, especially adenomas. In cases of hyperplasia, whether attributable to primary or secondary hyperparathyroidism, sestamibi imaging is less successful.

Preoperative evaluation of the radial forearm free flap patient with the objective Allen's test.

OBJECTIVE: The conventional subjective Allen's test (SAT) can be problematic because of its subjective nature. The objective Allen's test (OAT) was used before surgery to reliably and objectively assess forearm vascular flow in anticipation of harvesting a radial forearm free flap (RFFF) for use in head and neck reconstruction. STUDY DESIGN AND SETTING: Retrospective analysis of 65 patients undergoing both preoperative SAT and OAT was completed at the University of Kansas Medical Center between December 1994 and March 1998. RESULTS: The sensitivity and specificity of the SAT compared with the sensitivity and specificity of the OAT were only 65% and 76%, respectively. In 40 patients with at least 1 forearm with a positive SAT, only 1 (2.5%) patient was found by OAT to have vasculature that would not have allowed safe RFFF harvest in either forearm. In contrast, of the 25 patients with equivocal or negative SAT results in both arms, 18 (72%) were found by OAT to be safe candidates for RFFF harvests. CONCLUSIONS: The OAT is an objective measure of forearm vascular flow and is superior to conventional SAT in RFFF donor-site selection.

Salivary gland neoplasms with basaloid cell features: report of two cases diagnosed by fine-needle aspiration cytology.

Basal-cell adenoma and basal-cell adenocarcinoma of the salivary gland are rare tumors. Fine-needle aspiration cytology of these tumors, particularly those of basal-cell adenocarcinoma, has rarely been described in the literature. In this report, we describe the clinical, cytomorphologic, histopathologic, and immunohistochemical features of basal-cell adenoma and its malignant counterpart, basal-cell adenocarcinoma, in 2 patients. Fine-needle aspiration specimens from both tumors contained abundant cohesive groups of neoplastic cells. Basaloid cells were prominent in both tumors; however, there were significant cytologic atypia, hyperchromasia, and increased nuclear-to-cytoplasmic ratio in basal-cell adenocarcinoma. Review of the literature and cytomorphologic distinction between both tumors and others are discussed.

Odontogenic ghost cell carcinoma: a case report with immunohistochemical and ultrastructural characterization.

The odontogenic ghost cell tumor (OGCT) is the rare, neoplastic variant of the calcifying odontogenic cyst (COC). To date, there have been only four reports of malignant OGCTs, in five patients. We report an additional case of a malignant odontogenic ghost cell tumor that involved the right maxilla of a 20-year-old man. Our report includes its immunocytochemical and ultrastructural characterization.

Risk factors for pulmonary complications in the postoperative head and neck surgery patient.

BACKGROUND: Pulmonary complications are a primary source of increased cost and morbidity in surgically treated head and neck cancer patients. This study investigates potential risk factors related to postoperative pulmonary complications (pneumonia, adult respiratory distress syndrome (ARDS), and prolonged mechanical ventilation) in head and neck cancer patients. METHODS: Data from 144 major head and neck procedures performed at the University of Washington between 1985 and 1991 were retrospectively reviewed. Univariate and multivariate analysis were used to evaluate preoperative and perioperative variables identified as potential risk factors for postoperative pulmonary complications. RESULTS: Fifteen percent of patients had a postoperative pulmonary complication, (n = 21: 18 postoperative pneumonia; 2 ARDS; and 4 prolonged ventilation). The most common pneumonia pathogen was Staphylococcus aureus (62%). Univariate analysis identified smoking and weight loss as significant factors associated with pulmonary complications. The variables preoperative blood urea nitrogen, white blood cell count, and operative chest flap closure all approached but did not reach significance. Multivariate analysis of a subgroup of patients identified smoking history and perioperative antibiotic choice as the only independently significant variables. CONCLUSIONS: Patient smoking history was the primary variable related to postoperative pulmonary problems, with evidence of increasing risk with increased exposure. Other variables added only limited additional risk association information after multivariate analysis.

Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer.

OBJECTIVE: To compare the cost and functional results of free and pedicled soft tissue reconstruction after posterior oral cavity and oropharyngeal extirpation. DESIGN: Retrospective study of 53 consecutive patients undergoing extirpation with primary soft tissue reconstruction from January 1, 1991, to December 31, 1995. Median follow-up was 298 days. SETTING: Academic tertiary care medical center. INTERVENTION: Twenty-four patients underwent reconstruction with a pedicled pectoralis major myocutaneous flap (PMMF); 29 patients, with a fasciocutaneous free flap (FF) (27 radial forearm, 1 lateral arm, and 1 scapular). MAIN OUTCOME MEASURES: Direct (inpatient hospital resources used and monetary costs) and intangible (post-operative complications and function) costs. RESULTS: Operative time was longer for FF reconstructions (P = .003), but both patient groups had similar intensive care unit and hospital stays. Treatment cost for FF reconstructions was $41,122, compared with $37,160 for PMMF reconstructions (P = .003). This difference was due to increased professional fees for FF reconstruction (P < .001) which was offset by intangible cost differences. The PMMF group tended toward an increased rate of flap-related complications, compared with the FF group. At last follow-up, 4 patients in the FF group (15%) and 3 in the PMMF group (15%) had their tracheotomy. In contrast, 17 (85%) patients in the PMMF group and 11 (39%) patients in the FF group required enteral tube feedings (P = .002). Also, 18 (64%) patients in the FF group were eating at least a soft diet compared with 6 (30%) patients in the PMMF group (P = .02). CONCLUSIONS: Comparison of direct costs reveals only a modest difference in reconstruction costs that is outweighed by the intangible costs of PMMF reconstruction. The functional benefits of FF reconstruction appear to justify its slight increased expense and its use rather than PMMF reconstruction after extirpation in the posterior oral cavity and oropharynx.

Risk factors for complications in clean-contaminated head and neck surgical procedures.

BACKGROUND: Contamination of a head and neck surgical wound with oropharyngeal secretions has been shown to dramatically increase the incidence of wound complications. Appropriate perioperative antibiotic prophylaxis has significantly reduced contaminated wound infection rates in several previous reports. The current study examined multiple patient parameters to determine risk factors for all perioperative complications following clean-contaminated head and neck surgical procedures. METHODS: Retrospective review of medical records from 159 patients who underwent clean-contaminated major head and neck surgical procedures at the University of Washington between 1985 and 1991. More than 30 preoperative and operative parameters were evaluated, and all complications were recorded. The data were examined using a multivariate statistical analysis. RESULTS: An overall complication rate of 63% included 22% with wound infections (oro/pharyngocutaneous fistula or purulent drainage), 22% with other types of infections, and 51% with noninfectious complications. The overall perioperative mortality rate was 1.2% (two patients). Prior radiotherapy, operative time, perioperative transfusion, and flap reconstruction were all associated with a significantly higher overall complication rate (p < or = 0.05). Only prior radiotherapy therapy correlated with an increase in wound infection rate (p = 0.05). CONCLUSIONS: Prior radiotherapy significantly increases the risk of perioperative complications and wound infections following clean-contaminated head and neck surgical procedures. Other factors reflecting the complexity of the procedure also influence the overall complication rate.

Hair cell replacement in avian vestibular epithelium: supporting cell to type I hair cell.

Previous investigations have demonstrated that the sensory epithelium of the avian vestibular system possesses the capacity to replace hair cells both on an ongoing basis and following severe damage. Supporting cells, within the sensory epithelium, are believed to be the progenitors of the regenerated hair cells. In the present study we describe the series of events leading to the formation of a regenerated vestibular hair cell in post-hatched birds. Young chickens received injections of streptomycin sulfate in order to damage the sensory epithelium of the vestibular system. These injections were followed by injections of the cell proliferation marker tritiated-thymidine. At predetermined intervals, the animals were killed, and the vestibular organs were processed for tissue autoradiography. Our results confirm that hair cells originate from supporting cells. The data also indicate that postmitotic cells migrate towards the lumen of the epithelium where they differentiate into Type II hair cells. At a later time, some of the new Type II hair cells further differentiate into Type I hair cells. These results suggest that both types of avian vestibular hair cells have a common ancestor. The data also provide evidence in support of the hypothesis that calyx enclosed Type I hair cells, only present in birds and mammals, are a more differentiated stage of Type II hair cells.

Hair cell regeneration in the inner ear.

Hearing and balance disorders caused by the loss of inner ear hair cells is a common problem encountered in otolaryngology-head and neck surgery. The postembryonic production of hair cells in cold-blooded vertebrates has been known for several decades, and recent studies in the avian inner ear after ototoxic drug and noise damage have demonstrated a remarkable capacity for both anatomic and functional recovery. The regeneration of sensory hair cells has been shown to be integral to this repair process. Current work is focusing on the cellular progenitor source of new hair cells and the trigger mechanism responsible for inducing hair cell regeneration. Preliminary studies suggest that reparative proliferation may also occur in the mammalian inner ear. Work in this field is moving at a rapid pace. The results thus far have yielded optimism that direct stimulation of hair cell production or transplantation of living hair cells may eventually become treatment modalities for the damaged human inner ear. These proposals would have been considered unrealistic less than 10 years ago, but they now have caught the full attention of both clinician and researcher.