Elective neck dissection during salvage total laryngectomy--a beneficial prognostic effect in locally advanced recurrent tumours.

OBJECTIVES: Elective neck dissection during salvage laryngectomy is controversial. The goal of our study was to evaluate the effect of elective neck dissection during salvage laryngectomy in patients with locally advanced disease at recurrence. DESIGN: Multicentre, retrospective study. SETTINGS: Two tertiary medical centres. PARTICIPANTS: Eighty-seven patients treated by salvage laryngectomy. MAIN OUTCOME MEASURES: Disease-Free and Overall Survival. RESULTS: Fifty-seven patients underwent salvage total laryngectomy for locally advanced recurrent squamous cell carcinoma of the larynx, and 30 patients underwent salvage laryngectomy for limited recurrent disease. Elective lateral neck dissection was performed in 48 patients. The groups were similar in age, sex, initial TNM stage and pre-operative treatment. Survival analysis showed that both disease-free survival and overall survival were improved in patients with locally advanced disease who underwent elective neck dissection. This beneficial effect was not demonstrated in patients with limited disease at recurrence. Multivariate analysis showed that the extent of the recurrent disease as well as elective neck dissection was associated with improved disease-free survival and overall survival. CONCLUSIONS: Elective neck dissection during salvage total laryngectomy seems to improve survival in patients with advanced local disease at recurrence. The role of neck dissection in the treatment of smaller tumours awaits further studies.

The impact of positive resection margins in partial laryngectomy for advanced laryngeal carcinomas and radiation failures.

OBJECTIVES: To investigate the prognostic significance of positive margin and disease course in partial laryngectomy for advanced laryngeal carcinoma and radiation failure. DESIGN: Retrospective case control study. SETTING: A major tertiary referral centre. PARTICIPANTS: Patients who underwent partial laryngectomy for advanced laryngeal carcinoma or for radiation failure with at least 2 years of follow-up. MAIN OUTCOME MEASURES: Margin status versus primary treatment and salvage treatment versus disease-free survival and overall survival. RESULTS: Twenty nine patients with sufficient follow-up data were found. Twelve patients had histological positive margin. Five of the 12 patients with a histological positive margin failed surgery as did four patients with clear margins. A positive margin had no effect on disease-free survival (P = 0.287) but was associated with poorer overall survival (P = 0.051). Of 11 patients treated primarily with surgery, recurrence was documented in one of eight with a positive margin and none of three with clear margins. Of 18 patients who underwent surgery secondary to radiation failure, recurrence was documented in all four with a positive margin and 4 of 14 with negative margins. Extended frontolateral resection, performed only in radiation failures, was associated with worse disease-free survival. CONCLUSIONS: Non-irradiated patients with involvement of a single margin after partial laryngectomy may be spared total laryngectomy if adjuvant radiation is administered. Patients who fail radiation should undergo radical partial laryngectomy, with conversion to total laryngectomy in those with a positive margin.

Prognostic factors for local control of early glottic cancer: the Rabin Medical Center retrospective study on 207 patients.

PURPOSE: Different radiation therapy schedules and devices have been used over the last 20 years at Rabin Medical Center in patients with early glottic cancer. The aim of the present retrospective analysis was to identify the subgroup of patients at high risk of failure of radiation treatment. MATERIALS AND METHODS: Between 1974 and 1994, 207 patients with squamous cell carcinoma of the glottis, 182 Stage T1 and 25 Stage T2, underwent definitive radiation therapy. During this period, treatment was administered with different radiation devices (60Co or 6-MV X ray), using different dose/fraction protocols (1.8 or 2 Gy per day, 5 or 6 fractions per week), total doses (42-77.4 Gy), overall radiation times, and delays. These treatment variables, in addition to certain patient and tumor characteristics, were correlated with local control at a median follow-up of 57 months (range 18-265 months). RESULTS: The 5-year local control rates for T1 and T2 tumors were 88% and 73%, respectively. Univariate analysis showed that smoking, diabetes mellitus, anterior commissure involvement, T stage, and extension of tumor to one third or more of the vocal cord were highly significantly correlated with decreased local control. None of the treatment variables, including dosage at which complete tumor regression was noted, were found to be predictive. By multivariate analysis, only anterior commissure involvement was found to be highly significant (risk ratio 1.9, 95% CI 1.2-3.0, p = 0.027), and T stage was borderline significant (risk ratio 1.6, 95% CI 1.0-2.5, p = 0.054). CONCLUSION: This study suggests that only two tumor characteristics are predictive of local failure of early glottic cancer: anterior commissure involvement and T stage. Treatment variables apparently do not influence local control.

Clear cell carcinoma of the thyroid gland.

Clear cell carcinoma is a rare variant of thyroid cancer, histologically related to the well-differentiated thyroid malignancies. The purpose of this paper is to discuss data collected from the English literature and to present three additional cases. In two of the three cases presented, thyroglobulin levels were extremely high after thyroid ablation. Both cases presented metastasis to lung and bone with significant I131 uptake. It seems that, when compared to the well-differentiated carcinomas of the thyroid gland, clear cell carcinoma has a more aggressive clinical course. Initial radical surgery is the treatment of choice for this kind of neoplasm and I131 should always be considered for the treatment of its metastasis.

Laryngeal carcinoma--epidemiological and clinical features: experience of the Rabin Medical Center in Israel.

We sought to compare the epidemiological and clinical features of patients with carcinoma of the larynx treated at a major Israeli tertiary facility with other series in the literature. The charts of 361 consecutive patients from 1974 to 1995 were reviewed. Our population was distinguished from other series by a low rate of alcohol abuse (12%), high incidence of second malignancies in sites other than the upper aerodigestive tract (53%) and high rate of early-stage tumors (82%). Overall 5-year survival and local control rates were 88% and 85%, respectively. Our study suggests that the low alcohol consumption and high proportion of early-stage tumors at diagnosis, characteristic of the Israeli population of patients with laryngeal carcinoma, may explain, in part, the relatively high survival and local control rates.

Histological changes in the cervical lymph nodes after radiotherapy.

Radiotherapy to the neck is frequently employed in the treatment of malignancies, sometimes alone and sometimes before or after surgery or with or without chemotherapy. We checked the histopathological changes in the neck after radiotherapy, dividing the changes into two groups. One with short-term changes between six months to one year, and the second group with long-term changes after more than six years. We compared these two groups with a control group without radiotherapy. The changes in the long-term group were more pronounced than in the short-term group, with more stromal fibrosis, vascular changes, and specially lymph nodes smaller than one centimeter. Thus, bigger lymph nodes (more then one centimeter) are more radiosensitive and become smaller after six years.

Anaplastic carcinoma of the thyroid.

A review of 48 cases of anaplastic cell carcinoma of the thyroid gland treated in the Department of E.N.T. of Beilinson Medical Center revealed more than 90% of the patients to be over 50 years of age. Twenty-five percent of the patients showed, histologically, areas of transition from differentiated carcinoma (either papillary or follicular) into anaplastic carcinoma. The patients were treated by surgery and/or irradiation and/or chemotherapy. Twenty-seven patients underwent subtotal or total thyroidectomy and 21 patients underwent biopsy or partial thyroidectomy. The survival rate was very poor, two-year survival rate was 28%. Twenty-eight of the patients (58%) died within one year of diagnosis.

Squamous cell carcinoma of the oral tongue.

Between 1958 and 1983 at Beilinson Medical Center, Petah Tiqva, Israel, 75 patients were diagnosed as having squamous cell carcinoma of the body of the tongue. Of these, 42 were male and 33 female and the average age at the time of diagnosis was 61.6 years. 29.33% were in clinical stage I, 36% in stage II, 26.67% in stage III and 8% in stage IV. Fifteen patients underwent only surgery, nine received only irradiation and 51 received combined treatment. The 5-year survival rate was 68.3% with a significant difference between that for stage I (90%) and stage II (83.7%) and that for stages III and IV (43.07% and 0%, respectively) (P less than 0.001). Among the 24 with recurrence of the malignancy, 20 died despite treatment and four patients died of causes unrelated to the malignancy. From this experience it was concluded that local excision of the tumor should be performed only in stage I patients and that in stage II patients prophylactic treatment of the neck (neck dissection and irradiation) should be undertaken because of the high incidence of occult metastases.

T1 glottic carcinoma involving the anterior commissure.

This study reviews the records of 56 patients with early glottic carcinoma involving the anterior commissure (T1N0M0) who were treated between 1958 and 1988 at Beilinson Medical Center. Five- and 10-year survival rates were 82% and 60%, respectively. Most failures were local (15 patients). In addition, three patients who were treatment failures had neck lesions (regional failure) and one had lung lesions (distant metastases). All 56 patients received irradiation as the only mode of initial treatment. The effectiveness of irradiation for anterior commissure lesions is therefore evaluated. The study supports previous reports suggesting that glottic carcinoma involving the anterior commissure is associated with a high rate of treatment failure.

Supraglottic carcinoma: a retrospective study of 114 patients.

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T1 and T2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T1 carcinoma (stage I) and 67 (58.8%) T2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T1: 11 T2), three of whom also had neck metastases. All except one T2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T1 disease as combined therapy did for T2. Five-year recurrence rates for T1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T2 patients were 39% and 28%. We suggest that patients with T1 supraglottic carcinoma be managed with radiotherapy and patients with T2 with combined therapy. We believe there is no need for elective neck dissection, especially in T1.

Laryngeal carcinoma in females.

Between 1950 and 1992, 96 women with squamous cell carcinoma of the larynx were diagnosed and treated in the Department of Otolaryngology and Oncology at Beilinson Medical Center, Israel, and Long Island College Hospital, Brooklyn, New York. Fifty-seven female patients (59%) had glottic carcinoma, 72% of them in stage I. Thirty-eight had supraglottic carcinoma, 68% of them in stages II and III. One patient had stage I subglottic carcinoma. Treatment varied between radiotherapy, surgery, or combined surgery with radiation and/or chemotherapy. The 5-year survival rate was 87%. Although most of the patients had glottic carcinoma in stage I, there was also a high percentage with supraglottic carcinoma, most in advanced stages and with metastases to other regions. The prognosis is not different from that in men. Smoking is an important factor in glottic carcinoma, but not as important as in males.

Stapedotomy technique and results: ten years' experience and comparative study with stapedectomy.

Fifty of the 810 patients who underwent stapedotomy for otosclerosis from 1969 through 1988 were randomly chosen for follow-up of at least 5 years. Most of the patients (65%) had follow-up of 10 years after stapedotomy, but another 50 patients who underwent stapedectomy had follow-ups of longer than 10 years. In 50 patients, stapedectomy under local anesthesia was performed by removal of the footplate of the stapes, using an endaural incision, and covering the oval window with Gelfoam. In the other 50 patients, stapedotomy was performed under general anesthesia, using an endopreauricular incision, making a small hole in the footplate, and covering the hole only with blood from the surgical area. Although both groups showed improvement in hearing after the operation, the air-bone gap in the stapedotomy group was significantly better than that in the stapedectomy group. The use of the endopreauricular incision under general anesthesia was preferable to endaural incision under local anesthesia because the operative field was wider, more convenient for the surgeon, and conducive to patient safety. There were no significant complications in either group.

Oral ofloxacin as treatment of malignant external otitis: a study of 17 cases.

Seventeen patients with malignant external otitis were treated with oral ofloxacin. Their mean age was 69 years. Seven of the patients were diabetic. Pseudomonas aeruginosa, sensitive to ofloxacin (Kirby-Bauer method, inhibition zone greater than or equal to 22 mm), was isolated from the external auditory canal in all patients. Ofloxacin (200 mg b.i.d.) was given to the patients for 12 to 39 days. Two patients also received additional parenteral antibiotic therapy. Subjective and objective improvement occurred in all patients during treatment, and complete resolution was documented in all patients, with one exception. Only one patient suffered recurrence 2 weeks after discontinuation of antimicrobial therapy. The results of our study suggest that oral ofloxacin is an effective treatment for malignant external otitis caused by Pseudomonas aeruginosa.

Clinicopathologic study and classification of vocal cord cysts.

Cysts of the true vocal cords are less common than other laryngeal cysts. They are usually easily recognized and managed. Patients present with complaints of hoarseness and/or dyspnea. We report our experience with 41 cases of cysts located in the true vocal cords. Clinical and histological aspects are reviewed and discussed. A new histological classification is proposed: A: cysts lined by columnar epithelium with mucous content; B: lined by columnar epithelium with cilia; C: lined b squamous epithelium without keratinization; D: lined by squamous epithelium with keratinization.

Papillary carcinoma of the thyroid.

Between 1954 and 1993 503 patients with papillary carcinoma of the thyroid were treated at the Department of Otolaryngology-Head and Neck Surgery of the Beilinson Medical Center. Two thirds of these patients were women. The median follow-up period was 10.3 years. In more than 30% of cases the tumor was discovered because of the presence of an enlarged lymph node and/or invasion to adjacent structures. Total or near-total thyroidectomy was performed in 381 patients. The 48 patients in whom it was necessary to perform a reoperation had a significantly higher complication rate. Multicentricity was found in 65% of those cases in which both thyroid lobes were available for histologic examination. Nineteen patients were found to have a "tail" cell variant, 223 had a pure papillary variant, and 261 a follicular variant. The mortality rate was 6.2% 15 years after initial therapy. A number of factors-age, size of tumor, presence of distant metastases, "tall" cell variant, and type of surgery-were found to be significant predictors of survival. After almost 40 years of experience in treating more than 500 cases of papillary cancer, we have come to the conclusion that the surgical approach should be aggressive.

Neck-dissection surgical specimens treated by lymph node revealing solution.

The detection of metastatic lymph nodes in cancer patients is essential for determining the cancer stage, and thus, the therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. We described a "Lymph Node Revealing Solution" (LNRS) that helps to detect tiny lymph nodes in neck dissection specimens. Twenty-one consecutive specimens of neck-dissection were investigated. The entire surgical specimen, fixed at first in formalin, was searched for lymph nodes by the traditional method. These were excised and sent for processing. The remaining tissue was immersed for 24 hours in LNRS. The lymph nodes stood out as white chalky nodules on the background of the yellow fat. They were then excised, and examined. A total of 227 lymph nodes were detected by the traditional method; 38 (17%) were positive for metastasis. Using the LNRS method, an additional 72 nodes were identified, among them 8 (11%) were positive for metastases and 2 cases were upstaged. LNRS is an inexpensive and easy method of detecting tiny lymph nodes; it enhances significantly the yield of normal and metastatic nodes of neck-dissection specimens and helps to establish a more accurate staging.

Capsular collagen staining of follicular thyroid neoplasms by picrosirius red: role in differential diagnosis.

A key criterion in the diagnosis of thyroid follicular carcinoma is capsular invasion, but invasion cannot always be demonstrated histologically. Since invasion is likely to evoke reactions in the capsular collagen, we examined the effects of invasion on capsular collagen with the picrosirius orange-red (PSR) staining technique for collagen. Under polarized light, the color of PSR-stained collagen varies as a function of the structural and biochemical properties of the collagen fibers. Capsules of widely invasive carcinomas (n = 10), minimally invasive carcinomas (n = 10), and adenomas (n = 28) were stained with the PSR method. Carcinomas were assessed along the thickened capsule for sites of definite invasion, minimal invasion, and no evidence of invasion. In adenomas, sites of thickened capsules (similar to carcinomas) were compared to sites of thin capsules. All foci were evaluated for the color and color intensity of collagen fibers. We found a significantly higher frequency of yellow-green collagen fibers than of orange-red fibers at sites of invasion, whereas orange-red fibers significantly predominated at non-invaded sites. In a minority of cases both colors occurred but the non-dominant color was of lesser intensity in all but 1 case. There were no significant differences in staining between minimally and widely invasive carcinomas. Thick capsules of adenomas consistently stained with an intense orange-red color, although weakly stained yellow-green fibers were also observed in some of these cases. We conclude that PSR staining can provide diagnostically useful information in capsular samples of carcinomas, when both color and color intensity of PSR staining are evaluated at the same site. Specifically, intense yellow-green birefringence of collagen in a thickened capsule is additional evidence for capsular invasion.

Respiratory distress due to diffuse cervical hyperostosis.

Cervical spondylosis and ankylosing hyperostosis of the cervical vertebrae are common findings. Although these hypertrophic changes can be completely asymptomatic, it is known that dysphagia may occur occasionally in the presence of massive cervical hyperostosis. Laryngotracheal symptoms due to cervical hyperostosis are less frequent and may be managed initially as tumors of the esophagus, trachea, or thyroid gland. The management of two severe cases of dyspnea due to cervical ankylosing hyperostosis are discussed.

Granulocytic sarcoma (chloroma) of the temporal bone.

A case of granulocytic sarcoma (chloroma) of the temporal bone in a male child is presented. The diagnosis was confirmed by electron microscopic and histologic findings. The patient presented with otologic and neurological manifestations. CAT scan was at first normal but after some months a mass was apparent in the apex of the petrous bone and a manifestation of preleukemia appeared.