Quality of life and recurrence concern in survivors of head and neck cancer.

OBJECTIVES/HYPOTHESIS: A cohort of 3-year survivors of head and neck cancer was evaluated for persistent quality of life (QOL) concerns and long-term treatment effects. STUDY DESIGN: Mailed questionnaire. METHODS: The questionnaire with the University of Washington Quality of Life (UWQOL) scale, the Performance Status Scale for Head and Neck Cancer (PSS-HN), the Functional Assessment of Cancer Therapy (FACT) scale, and the Functional Assessment of Cancer Therapy Head and Neck (FACT-HN) scale and locally prepared questions was sent to 111 3-year disease-free survivors. Analysis was performed to statistically evaluate the effect of stage, site, treatment type, surgery, and cancer concern on QOL. Current smoking information was gathered. RESULTS: Seventy-two survivors completed the questionnaire. Advanced stage was correlated with lower QOL scores in the domains of disfigurement, chewing ability, speech, and eating in public. QOL scores did not vary by initial tumor site. Patients treated with irradiation alone had statistically better QOL scores than those treated with combined surgery/radiation therapy in the pain, disfigurement, chewing, and speech domains. Laryngectomy and composite resection survivors reported lower QOL scores than patients treated with irradiation alone. A low level of cancer concern persisted in about half of the long-term survivors. Cancer concern was associated with continued pain, disfigurement, and limitations on eating in public. Three-quarters of the tobacco users had quit by the time of the questionnaire. Nevertheless, the patients were not thoroughly convinced that tobacco had caused their cancer. CONCLUSIONS: Long-term survivors of head and neck cancer experience QOL effects well after completion of treatment. Effects are most pronounced in survivors who required combined surgery/radiation therapy. Continuing low levels of cancer concern persist in about half of the survivors. Many cancer survivors successfully quit smoking.

Tongue reconstruction with a combined brachioradialis-radial forearm flap.

Total glossectomy adversely affects speech and swallowing, and subsequent reconstruction results in limited functional return. The radial forearm flap has been reliably used to resurface glossectomy defects, but has limited bulk with which to aid in palatoglossal contact for speech. The authors have modified the forearm flap by incorporating a segment of brachioradialis muscle, to increase bulk posteriorly and to aid in speech. Sufficient muscle perforators arise from the proximal brachial artery and enter the brachioradialis to permit transfer of the muscle with the fasciocutaneous forearm flap as a single free-flap unit. The muscle is folded onto itself and enclosed within the forearm flap skin to create a neotongue. Coaptation of the antebrachial cutaneous nerves can provide a senate flap. Successful transfer of the combined brachioradialis/forearm flap in a patient who had undergone total glossectomy resulted in a neotongue good shape. Speech was rated good by a speech pathologist, and palatoglossal contact was observed on cineoradiograph. No functional loss at the donor site occurred. Inclusion of the brachioradialis muscle with the radial forearm flap as a combined unit results in a neotongue with good form and increased bulk posteriorly at the base, compared to a standard fasciocutaneous flap alone. This is a useful variation of the forearm flap. Sensory return is possible if the medial and/or lateral antebrachial cutaneous nerves of the flap are coapted to the lingual nerve.

Screening for cancers of the head and neck: addressing the problem.

More than 90% of upper aerodigestive tract (UADT) cancers occur in people with specific lifestyle risks, including tobacco and alcohol use. More than 90% of tumors occur in easily examined parts of the head and neck, therefore, there is the possibility of identifying the vast majority of patients through selective screening. Physicians should keep in mind that the mucosa's sojourn from visually suspicious (and possibly malignant) tissue is most likely less than two years, and frequent examination of asymptomatic patients is necessary. When patients wait to bring symptoms to medical attention, their cancers will be advanced 60% of the time when the chance of cure is less than 30%. Given the difficulty of implementing regular examinations in a poorly compliant, high risk population, genetic and molecular screening tools may allow very high risk individuals to be identified.

The innervated gracilis musculocutaneous flap for total tongue reconstruction.

A functional neotongue following total glossectomy requires both soft-tissue bulk and reconstruction of muscle function. We used innervated transverse gracilis musculocutaneous flaps to reconstruct total glossectomy defects in eight patients. The obturator nerve to the gracilis muscle was approximated to the hypoglossal nerve to reinnervate the gracilis muscle by using microsurgical technique. The cutaneous paddle of the gracilis flap easily supplies sufficient bulk to replace the total glossectomy defect. Follow-up of patients ranged from 3 to 47 months. All patients were able to resume oral feeding. Electromyographic studies performed on one patient showed reinnervation of the flap with active elevation of the posterior pharynx. Ultimately, seven patients died because of recurrence of their disease. The innervated gracilis musculocutaneous flap may benefit patients who have a total glossectomy by allowing them to achieve a more functional recovery.

Report of the first case of invasive fungal sinusitis caused by Scopulariopsis acremonium: review of scopulariopsis infections.

Scopulariopsis acremonium is a species of saprophytic fungus not previously reported to cause invasive disease in humans, although invasive infections from other species of Scopulariopsis have been reported and are reviewed. Deep infection with this fungus is associated with a high mortality rate. Invasive fungal sinusitis, in general, is a potentially fatal disease that typically affects immunocompromised patients, such as those receiving intensive chemotherapy or undergoing bone marrow transplantation. We report a case of invasive fungal sinusitis caused by Scopulariopsis acremonium in a patient with leukemia, who was successfully treated with amphotericin B, itraconazole, endoscopic sinus surgery, and granulocyte colony-stimulating factor.

Malignant melanoma of the external auditory canal.

Malignant melanoma of the ear, other than the pinna, rarely occurs. This is the first report of a melanoma confined to the external auditory canal. The case presented is of a 75-year-old man with a malignant melanoma confined to the external auditory canal. Excision of the tumor and surrounding lymphatics was accomplished with a lateral temporal bone resection, superficial parotidectomy, and selective neck dissection. The patient initially refused postoperative radiation therapy. Histologic evaluation documented a 17-mm thick malignant melanoma. All margins were clear and none of the nodes was positive. Eight months later, he returned with local, regional, and distant recurrence. Despite attempts at salvage with external radiation, brachytherapy, and chemotherapy, he died 13 months postoperatively with widespread disease. Melanoma confined to the external auditory canal has not been previously reported. A 17-mm thick melanoma carries a dismal prognosis. Despite initial negative surgical margins and lack of regional metastases, this patient developed a rapid, widespread pattern of recurrence.

Planned postradiotherapy neck dissection in patients with advanced head and neck cancer.

BACKGROUND: Metastatic neck nodes in patients with squamous cell carcinoma of the head and neck are most commonly managed by surgery, radiotherapy, or combined-modality therapy. For combined-modality cases, the sequencing of surgery and radiotherapy is generally guided by which modality is considered preferable for treatment of the primary tumor. A postradiotherapy neck dissection is often considered for those patients with > N1 disease in which the primary is treated with radiotherapy alone. METHODS: Between February 1991 and October 1995, 25 patients with node-positive squamous cell carcinoma of the head and neck were treated with planned unilateral (n = 22) or bilateral (n = 3) neck dissection following high-dose radiotherapy. The primary tumor sites included: tongue base (n = 11), tonsil (n = 6), nasopharynx (n = 3), pyriform sinus (n = 2), supraglottic larynx, (n = 1), soft palate (n = 1), and unknown head and neck primary (n = 1). The specific nodal stage breakdown of the 28 individual neck dissections (25 patients) was N1 (n = 1), N2A (n = 5), N2B (n = 15), N3 (n = 7). RESULTS: Nineteen of the 28 neck dissections (68%) demonstrated no evidence of residual carcinoma. Of the nine positive neck dissections, six revealed malignant cells in a single nodal echelon. The 1- and 2-year rate of neck control in all 25 patients was 100% and 93%, respectively. The 1- and 2-year disease-specific survival for all 25 patients was 83% and 60%, respectively. With a minimum follow-up of 2 years, 64% of the 25 patients remain alive with no evidence of disease or dead of non-cancer causes. CONCLUSION: In this series of postradiotherapy neck dissections, two thirds of the dissections demonstrated no evidence of residual tumor (19/28, or 68%). However, there was not a direct correlation between pretreatment nodal size (neck staging), radiation dose delivered, and the likelihood of achieving a cancer-free neck dissection. Only one of 28 postradiotherapy neck dissections identified tumor outside of nodal stations II-IV. The predictable pattern of residual disease in pathologically positive cases suggests that a selective neck dissection encompassing levels II-IV may be appropriate in a majority of patients.

The role of dental prostheses in alveolar ridge squamous carcinomas.

BACKGROUND: Alveolar ridge squamous carcinomas develop in patients outside the usual constellation of risk factors. OBJECTIVE: To determine whether the use of dentures was a risk factor specific to patients with alveolar ridge carcinoma. DESIGN: Case-control method with a unique control group-a concurrent cohort of patients with head and neck cancer with primaries in the oropharynx, hypopharynx, and larynx. SETTING: Tertiary care hospital-based clinic. PATIENTS: Forty-one patients with squamous carcinomas centered on the maxillary or mandibular alveolar ridges. The control group was 175 concurrently seen patients with squamous carcinomas of the laryngopharynx for whom dental status was known. MAIN OUTCOME MEASURES: Age at diagnosis, sex, tobacco use, alcohol use, and denture use. RESULTS: Patients with alveolar ridge were more likely to be female, older, nonsmokers, and nondrinkers. The crude odds ratio of denture use in patients with alveolar ridge cancer was 2.28 (P=.03). Eliminating other confounding factors with logistic regression, the adjusted odds ratio dropped to 1.30 (P=.59). Among patients with alveolar ridge, smoking status correlated with age and gender: current smokers were on average 64.4 years old and 9 of 16 were men. Nonsmokers' average age was 79.1 years and 1 of 11 was a man. CONCLUSIONS: In this study, denture use was not an independent risk factor for alveolar ridge carcinomas. Among patients with little to no tobacco or alcohol exposure, the alveolar ridge carcinomas tended to occur in the elderly and in women.

Tracheal advancement flap for postlaryngectomy stomal stenosis.

BACKGROUND: Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP). METHODS: A revision technique which advances the trachea out of the stoma, divides the anterior tracheal wall, and leaves the posterior tracheal wall undisturbed was designed. The paper describes the technique in detail. "Success" was defined as producing a stable, trouble-free stoma requiring no stenting; "partial success" as an improved stoma requiring some stenting; and "failure" as no improvement and continuous stenting. RESULTS: Fifteen patients underwent the procedure. Median time from laryngectomy to revision was 10 months. Preoperative to postoperative median stoma size increased from 63 mm2 to 135 mm2. Seven patients were classified as successful, six patients were partially successful, and two patients had no improvement. CONCLUSION: The tracheal advancement flap is a safe technique for the laryngectomy patient who has undergone or might undergo voice restoration.

The risk and complications of aspiration following cricopharyngeal myotomy.

This article reviews a series of patients undergoing cricopharyngeal myotomy and determines whether clinically dangerous aspiration is seen postoperatively. A total of 23 patients underwent myotomy. Indications included Zenker's diverticulum (14), anticipated or real dysphagia from skull base lesions (5), dysphagia from stroke (2), and dysphagia from glossectomy and radiation therapy (2). Surgical procedures, complications, and effectiveness were reviewed. Of patients with Zenker's diverticula, 13 of 14 had clinically useful improvement in dysphagia. Of patients with skull base lesions, all 5 had improvement (4 of these also had thyroplasites and cervical plexus-to-superior laryngeal nerve anastomoses). Of the patients with strokes, neither had significant improvement. Of the patients with glossectomy and radiation, 1 had useful improvement. Complications were seen in 5 patients: 2 had self-limiting pharyngeal leaks, and 3 had pneumonia 1-4 months postoperatively. One patient also had a postoperative ipsilateral recurrent laryngeal nerve injury. There were no postoperative deaths. In conclusion, cricopharyngeal myotomy has definite utility in the management of cervical dysphagia, even though the etiology of the dysphagia can be multifactorial. Risks directly attributable to the procedure are usually self-limiting; serious complications are usually associated with the underlying disease. The addition of adjunctive procedures, such as thyroplasty and superior laryngeal nerve reinnervation, may be of additional benefit to patients with high extracranial vagal injuries.

Carcinoma of the larynx in patients with gastroesophageal reflux.

PURPOSE: To study the relationship between gastroesophageal reflux disease (GERD) and the development of laryngeal cancer in patients who lack other accepted risk factors for the development of squamous cell carcinoma of the larynx. PATIENTS AND METHODS: A retrospective review of patients either treated surgically or with radiation therapy for stage 1 or stage 2 laryngeal carcinoma with specific reference to smoking history and the presence of GERD. RESULTS: We present 9 lifetime nonsmoking patients with stage 1 or 2 laryngeal carcinoma in whom GERD was clinically and/or radiographically shown. Also, 14 patients are identified who quit smoking more than 15 years before the development of laryngeal cancer and who also had evidence of GERD. CONCLUSION: We propose that the development of laryngeal carcinoma in this cohort of patients who lack typical risk factors supports the notion that GERD plays a role in the etiology of carcinoma of the larynx. Because the accepted risk factors for laryngeal carcinoma such as smoking and alcohol use increase the likelihood of reflux, GERD may act as a cocarcinogen in smokers and drinkers. Of interest, the treatment of GERD can reverse the signs of chronic laryngitis and should be instituted in patients with laryngeal pathology who have GERD.

Caustic and thermal epiglottitis in the adult.

The presence of dysphagia, drooling, and stridor in an adult subsequent to thermal or caustic injury should alert the treating physician to the possibility of injury to the supraglottic structures with resultant epiglottitis. These adults possess many of the features seen in acute infectious epiglottitis and should be handled with the same consideration for potential upper airway obstruction. Epiglottic injuries of this type should be suspected in adults with mental disorders or communication difficulties.

Risk factors which predict persistent cancer in the abnormal larynx following definitive irradiation.

Laryngeal abnormalities following definitive irradiation for carcinoma of the larynx are common. The objective of this study was to identify risk factors for persistent cancer in such patients who were found to have abnormal larynges following definitive irradiation. A retrospective evaluation of 185 consecutive patients undergoing primary irradiation for a glottic or supraglottic laryngeal squamous carcinoma treated between 1976 and 1990 at the Affiliated Hospitals of the Medical College of Wisconsin was performed. From chart review, data concerning site, stage, intent of treatment, smoking history, treatment dose, fraction size, failure patterns, and outcome were obtained. In addition, worrisome signs and symptoms including ulceration, dysphasia, odynophagia, airway distress, aphonia, blood, pain, oedema, aspiration, and pneumonia were recorded. Univariate association with failure and a persistently abnormal laryngeal examination was assessed using the Mantel-Haenszel test. The odds ratio was used to estimate relative risk associated with dichotomous risk factors. Disease-free and overall survival were estimated using Kaplan-Meier methodology. The log rank test was used to compare survival as defined by the levels of various risk factors. Two-year disease-free survival was 83% (T1 = 93%, T2 = 72%, T3/T4 = 66%). Primary failure was associated with the presence of an abnormal examination (P = 0.001), tracheotomy (P = 0.001), symptom index (P = 0.002), aphonia (P = 0.003), advanced T stage (P = 0.03), and lower total dose (P = 0.03). Of 151 patients who survived 6 months disease-free with an intact larynx, an abnormal examination was seen in those with advanced T stage (P = 0.002), supraglottic primary (P = 0.003), symptom index (P = 0.008), eventual failure at the primary site (P = 0.008), continued smoking (P = 0.01), and higher total dose (P = 0.01). The symptom index (total signs and symptoms of airway distress, aphonia, ulceration, pain, oedema, dysphagia, blood production, aspiration, pneumonia, and odynophagia) was correlated with primary failure and continued smoking. Of 37 patients with continually normal examinations, only 1 (3%) failed at the primary site. Of 102 who survived 6 months but with an abnormal examination, 22 (22%) eventually developed a primary failure. Persistently abnormal larynges are common after radiation therapy, yet not all harbour cancer. Risk factors for persistent cancer include stage, airway, total dose, and symptom index. Patients whose larynges return to normal after radiation rarely fail at the primary site.

Kaposi's sarcoma of the oral cavity in a non-AIDS patient: case report and review of the literature.

BACKGROUND: Not every patient with Kaposi's sarcoma (KS) has acquired immunodeficiency syndrome (AIDS). The "classic" form of KS is rare, and is associated with an indolent course. It is very distinct from AIDS-associated KS in which oral involvement is common and may be the initial presenting feature of this disease. Two other types of KS are recognized, the African and renal transplant-associated, which also are rarely associated with oral involvement. METHODS: We present the case of a 76-year-old man of Mediterranean ancestry who was found to have a biopsy-proven classical KS lesion of the hard palate. The patient was followed by the Radiation Therapy and Otolaryngology Services during and after his treatment. A review of the literature was also conducted. RESULTS: Radiotherapy was ineffective at a dose considered "standard" for KS in AIDS patients (1,500 cGy), but was effective when continued to 4,800 cGy. A 24-month follow-up showed no evidence of recurrence in the oral cavity. CONCLUSIONS: KS of the oral cavity, is almost always associated with AIDS in the United States, However, it can occur in any of the four types of KS. Although this neoplasm is typically highly radiosensitive, the treatment for each patient needs to be individualized.

Hyperbaric oxygen therapy and squamous cell carcinoma cell line growth.

Hyperbaric oxygen (HBO) promotes tissue healing by increasing oxygenation. Therefore, HBO therapy is clinically useful for some patients who have undergone major cancer resection and/or radiotherapy to the head and neck. For individual patients, however, there might be undetected viable tumor present at the time of therapy. This study was performed to determine if increased tissue oxygen had a measurable effect on the growth of squamous carcinoma xenotransplants which had been derived from head and neck cancers. After the successful growth of two well-established human squamous cell carcinoma cell lines (183 and 1483), each tumor was transplanted into 20 mice. Every mouse received four transplants of 10(6) cells. Ten mice with 40 xenotransplants in each group were treated with HBO daily for 90 minutes at a pressure of 2 atm, whereas the other 10 formed the control group. The mice transplanted with cell line 1483 were treated for 21 days; mice transplanted with cell line 183 were treated for 28 days. The tumor weight, volume, and histology were evaluated. No significant difference was found between experimental groups. This study suggests that increased tissue oxygen neither significantly increases nor decreases the growth of squamous cell carcinoma.

DNA content in nasopharyngeal carcinoma.

DNA analysis by flow cytometry was performed on tissue blocks from 41 patients with nasopharyngeal carcinoma. The histologic slides were reviewed by a pathologist and blindly classified according to the World Health Organization classification. The paraffin-embedded blocks were processed to obtain individual nuclei, which were then stained with propidium iodide. The nuclei were analyzed on a flow cytometer. Excluding 10 uninterpretable histograms, the remainder were interpreted blindly and classified as diploid or aneuploid. The Cox proportional hazards survival model was used to analyze stage, histology, radiation dose, and ploidy. We observed more diploids (23 of 31; 74%) than aneuploids (eight of 31; 26%). The 2-year survival rate of diploids was 55%, compared with 25% of aneuploids (P less than .05). We conclude that ploidy status is an independent prognostic factor in nasopharyngeal carcinoma.

Flow cytometric evaluation of chemosensitive and chemoresistant head and neck tumors.

For patients with head and neck squamous carcinoma, a clinical response to induction chemotherapy has correlated with a survival advantage. Similarly, patients with diploid tumors have displayed a survival advantage when compared with patients with aneuploid tumors. This study examined DNA content in 33 patients who had undergone induction chemotherapy as part of two clinical protocols to determine if there was a correlation between the patients with diploid tumors and the patients with a clinical response to chemotherapy. Although patients with stage III tumors had a longer disease-free survival than stage IV patients (p less than 0.0002), the addition of DNA content information did not improve the ability to predict response. Specifically, there was no correlation between DNA content and the response to chemotherapy. In addition, for this group of patients, a diploid DNA content was not correlated with a survival advantage. We conclude that DNA content information did not add significantly to the prediction of clinical outcome in these patients who received induction chemotherapy.