Relapse patterns after transoral laser microsurgery and postoperative irradiation for squamous cell carcinomas of the tonsil and tongue base.

OBJECTIVES: We evaluated relapse patterns after transoral laser microsurgery (TLM) in squamous cell carcinoma (SCC) of the tonsil and tongue base and evaluated the indications for adjuvant irradiation. METHODS: Between December 1, 1996, and December 31, 2005, 79 patients with previously untreated SCC of the tonsil or tongue base underwent TLM with or without neck dissection. Thirty-eight patients (48%) underwent postoperative irradiation (median, 62 Gy) to the primary site and the neck. Analysis of relapse patterns was performed on the basis of adverse risk factors and the presence or absence of adjuvant irradiation. RESULTS: The median follow-up for living patients was 47 months (range, 10 to 107 months), and patients were monitored for at least 2 years or until recurrence or death. Local, regional, and distant treatment failures numbered 4, 6, and 4 for surgery alone (n = 41) and 0, 2, and 6 for adjuvant irradiation (n = 38), respectively. Patients with high-risk features (extracapsular extension or at least 2 adverse factors) had locoregional control rates at 2 or more years of 66% and 94% for TLM alone and TLM plus adjuvant irradiation, respectively. CONCLUSIONS: Adjuvant irradiation after TLM resection of oropharyngeal SCC with intermediate- or high-risk features improves locoregional control compared with TLM alone.

Membrane-Induced Technique for the Management of Combined Soft Tissue and Osseous Defects.

The induced membrane technique is a simple, effective, and reproducible treatment method for segmental bone defects. It is a 2-stage approach that requires eventual autologous bone graft to manage the deficit. The first stage requires debridement of all nonviable tissue while preserving a healthy soft tissue envelope. A polymethylmethacrylate is implanted between the osseous segments to maintain length. The osseous defect can be stabilized internally or externally. During the second stage, a vascularized induced membrane is formed and produces multiple growth factors. The induced membrane technique is a valuable option for limb salvage in cases of segmental bone defects.

The Distally Based Posterior Tibial Artery Flap.

Soft tissue defects to the distal leg and hindfoot are challenging with only the smallest defects closed primarily without tissue transposition. These defects to the distal leg and hindfoot can lead to tendon desiccation, damaged neurovascular structures, and exposed joint surfaces. These wounds can be the result of postoperative dehiscence and exposed orthopedic hardware, with high susceptibility to infection. Pedicled fasciocutaneous flaps of the medial leg provide an excellent solution with good outcomes that do not require microanastomosis and have similar outcomes as compared with free flap reconstruction in the lower extremity.

Transoral laser microsurgery for recurrent laryngeal and pharyngeal cancer.

STUDY DESIGN AND SETTING: A two-center prospective case series analysis. PATIENTS: One hundred fourteen patients with previously treated laryngeal or pharyngeal squamous cell carcinoma who underwent salvage transoral laser microsurgery (TLM). INTERVENTIONS: TLM in 114 patients, neck dissection in 22 (19%) patients, adjuvant radiotherapy in 12 (11%) patients. RESULTS: Ninety-one (80%) patients had recurrent primary tumors whereas 23 (20%) patients had second primary tumors occur within a previously irradiated field. The minimum follow-up was 1 year (median, 3 years). The distribution of tumor location was oropharynx 52 (46%), glottic and subglottic larynx 44 (39%), supraglottic larynx 11 (10%), and pyriform/hypopharynx 7 (6%). Overall, three-year local and locoregional control estimates were 70 percent and 67 percent, respectively; and three-year survival and disease-free survival estimates were 62 percent and 64 percent, respectively. The average duration of hospitalization was 2.3 days. Four (3.5%) patients had significant postoperative bleeding. Two (<2%) patients had treatment-related deaths. CONCLUSIONS: Transoral laser microsurgery offers select patients an attractive alternative salvage surgical therapy to the recurrent and second primary tumor site.

Transoral laser microsurgery for untreated glottic carcinoma.

OBJECTIVES: To report the oncology and functional outcomes of transoral laser microsurgery (TLM) for untreated glottic carcinoma. STUDY DESIGN: A 2 center prospective case series analysis. SETTING: Academic, tertiary referral centers. RESULTS: Seventy-six patients underwent TLM. Pathologic T stages were: T1, 45 (59%); T2, 21 (28%); T3, 5 (7%); and T4, 5 (7%). Five (7%) patients had neck dissections. Five (7%) patients received adjuvant radiotherapy. Mean follow-up was 42 months. Respective T1 and T2 5-year Kaplan-Meier estimates were: local control, 90% and 93%; loco-regional control, 90% and 93%; disease specific survival, 90% and 93%; and overall survival, 94% and 93%. The average hospital stay was 2 days. Two (3%) patients experienced major complications. The overall laryngeal preservation rate was 95% (72 of 76). CONCLUSIONS: TLM is a safe and effective treatment in select carcinoma of the glottic larynx. Low morbidity and mortality and short periods of hospitalization make TLM an attractive therapeutic option. SIGNIFICANCE: TLM is an emerging strategy in the treatment of laryngeal cancer.

Transoral laser microsurgery for carcinoma of the supraglottic larynx.

OBJECTIVES: The study goal was to report the oncologic outcomes of transoral laser microsurgery (TLM) in the treatment of squamous cell carcinoma of the supraglottic larynx. STUDY DESIGN AND SETTING: A two-center prospective case series analysis. RESULTS: Thirty-eight patients underwent TLM for previously untreated carcinoma of the supraglottic larynx between 1997 and 2005. Pathological T stages were T1 in 8 (21%), T2 in 14 (37%), T3 in 8 (21%), and T4 in 8 (21%). Twenty-six patients (68%) had neck dissections. Thirteen patients (34%) received adjuvant radiotherapy. The mean follow-up for all patients was 31 months. The 2-year Kaplan-Meier estimates for local control were 97%; locoregional control, 94%; disease-specific survival, 80%; and overall survival, 85%. The overall functional laryngeal preservation rate was 79% (19 of 24). CONCLUSIONS: TLM is a safe and effective treatment for cancer of the supraglottic larynx. SIGNIFICANCE: TLM is an emerging strategy in the management of laryngeal cancer.

Carcinoma of the tongue base treated by transoral laser microsurgery, part one: Untreated tumors, a prospective analysis of oncologic and functional outcomes.

OBJECTIVES: To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the management of untreated primary carcinoma of the tongue base. STUDY DESIGN: A two center prospective case series analysis. METHODS: Fifty-nine patients with pathologically confirmed squamous cell carcinoma of the tongue base were treated with TLM between 1997 and 2005. The pathological T stage distribution was: T1, 16; T2, 23; T3, 12 and T4, 8. Thirty-six patients presented with stage IV disease, 12 with stage III, 7 with stage II and 4 with stage I disease. Neck dissections were performed in 49 patients (83%). Twenty-eight patients (47%) underwent adjuvant radiotherapy. End points analyzed were local control, loco regional control, disease specific survival, and overall survival. Organ function was assessed before and after treatment using a clinical Functional Outcome Swallowing Scale (FOSS) and Communication Scale (CS) staging system. RESULTS: The mean follow up for all patients was 31 months. The 2 and 5-year Kaplan-Meier estimates were: local control, both 90%; loco-regional control, both 88%; recurrence free survival, both 84% and overall survival 91% and 69% respectively. For all patients the median stay in hospital was 4 days. The median length of hospital visit for TLM alone was 2.5 days and 4 days for TLM with neck dissection. Three patients (5%) suffered minor post-operative hemorrhage. The median pre-operative FOSS stage was 0 (normal function.) The median post-operative FOSS stage was stage 1 (Normal function with episodic or daily symptoms of dysphagia.) There were no clinically significant changes in communication function after treatment. CONCLUSIONS: Transoral laser surgery is a safe and effective treatment for select early and advanced previously untreated squamous cell cancer of the tongue base. In addition, the low morbidity and mortality and shortened duration of hospitalization associated with TLM make it an attractive therapeutic alternative.

Carcinoma of the tongue base treated by transoral laser microsurgery, part two: Persistent, recurrent and second primary tumors.

OBJECTIVES: To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the treatment of persistent, recurrent, and second primary squamous cell carcinoma of the tongue base. STUDY DESIGN: A two-center prospective case series analysis. METHODS: Twenty-five patients with persistent, recurrent, or second primary squamous cell carcinoma of the tongue base were treated with TLM between 1997 and 2005. Four (16%) patients with persistent disease at the primary site were considered TX. Eleven (44%) patients with recurrent disease were pathologically staged rT1 3/11, rT2 2/11, rT3 4/11, T4 1/11, and TX 1/11. Ten (40%) patients with second primary tumors were staged pT1, 4/10; pT2, 3/10; pT3, 2/10; and pT4, 1/10. Eight (32%) patients underwent neck dissection. Three (12%) patients received adjuvant radiotherapy. Pre- and post-treatment organ function was assessed using a clinical Functional Outcome Swallowing Scale (FOSS) and Communication Scale. RESULTS: The mean follow-up period was 26 months. The 2-year Kaplan-Meier local control and locoregional control estimate was 69%. For those patients presenting with persistent/recurrent or second primary disease, the 2 year local control estimates were 75% and 68%, respectively. For all patients, the respective 2 and 5 year overall survival estimates were 54% and 26%. Two (8%) patients suffered postoperative hemorrhage. The average duration of hospitalization was 3.6 days. The median pretreatment and posttreatment FOSS stage was stage 2 and stage 3, respectively. CONCLUSIONS: Transoral laser surgery is a rational and effective treatment in appropriately selected patients with persistent, recurrent, or second primary tongue base cancer. The low morbidity and mortality and shortened duration of hospitalization associated with TLM make it an attractive therapeutic alternative.

Glucose tolerance and cardiovascular risk in young adult African Americans.

BACKGROUND: Patients with type 2 diabetes have higher rates of cardiovascular events. Among African Americans, there is a higher prevalence of both cardiovascular disease and type 2 diabetes. Few studies have examined longitudinally the change in glucose tolerance in younger adult African Americans. METHODS: To examine the longitudinal relationship of glucose tolerance with other cardiovascular risk factors, 30 African American men and women aged 20 to 43 years were examined twice at an interval of 4 to 5 years. Cardiovascular risk factors, glucose tolerance, and insulin sensitivity (determined from euglycemic hyperinsulinemic clamp procedure) were assessed at each examination. Known diabetics were excluded from initial enrollment. The relationship of glucose tolerance status (normal, impaired, or diabetic glucose tolerance) to body mass index, blood pressure, cholesterol, and insulin sensitivity were further investigated. RESULTS: Initial oral glucose tolerance test identified 24 of 130 (18.5%) subjects with impaired glucose tolerance and 2 of 130 (1.5%) subjects with diabetes. Of the remaining 104 subjects with normal glucose tolerance, subsequent 5-year examination detected 31 (29.8%) with impaired glucose tolerance and 5 (4.8%) with diabetes. Those who later developed diabetes had higher mean systolic blood pressure (133 versus 121, P = 0.037) at exam 1. By exam 2, those with abnormal glucose tolerance had worse cardiovascular risk profiles and increased insulin resistance (P < 0.001). CONCLUSION: Conversion to abnormal glucose tolerance is relatively frequent in young adult African Americans. Deterioration in glucose tolerance may be preceded by higher systolic blood pressure and is accompanied by worsening of other cardiovascular risk factors and insulin resistance.

The association between hypertension and other cardiovascular risk factors in young adult African Americans.

Hypertension is a major cause of cardiovascular disease in African Americans. The excess morbidity and mortality due to cardiovascular disease in African Americans compared to Caucasians is not well explained. The purpose of this study was to examine the association between hypertension and other cardiovascular risk factors in young adult African Americans. A risk factor scoring system was developed, based on national guidelines for obesity, smoking, cholesterol levels, glucose tolerance, and blood pressure. Data from a previously studied cohort of 206 women and 117 men were analyzed for the association of hypertension with other risk factors. Among women, risk factor intensification is due to impaired glucose tolerance and obesity. Among men, intensification appears to be related to all major risk factor categories. These findings indicate that among hypertensive African Americans there is an amplification of other risk factors. The data also support the clinical management of multiple risk factors as well as the achievement of blood pressure control.

Obesity, smoking, and multiple cardiovascular risk factors in young adult African Americans.

OBJECTIVES: To examine the associations between the combination of obesity and tobacco use and total cardiovascular risk score in young adult African Americans. DESIGN: A cross-sectional study of 323 African-American men (N = 117) and women (N = 206) aged 20-46 years. METHODS: Age, height, weight, and data on smoking behavior were obtained, as well as measurements of blood pressure, serum lipids, and measurements from an oral glucose tolerance test (OGTT). A cardiovascular risk score was calculated from the above data. RESULTS: Fasting insulin, fasting blood glucose, and blood glucose at 120 minutes of OGTT were significantly higher in obese (body mass index [BMI] > or = 30 kg/m2) men. Obese men also had significantly higher LDL cholesterol, lower HDL cholesterol and higher total risk scores. Obese women had significantly higher blood pressure, higher fasting insulin, lower LDL cholesterol, and higher total risk scores. Among the members of this cohort, 65% of men and 79% of women were obese and/or smoked. Of those who were obese and/or smoked, 68% of the men and 82% of the women had at least one other cardiovascular risk factor. CONCLUSIONS: The modifiable risk factors of obesity and smoking were present in a large majority of these young adult African Americans in association with other cardiovascular risk factors.

Oropharyngeal cancer: a case for single modality treatment with transoral laser microsurgery.

OBJECTIVE: To demonstrate the role of transoral laser microsurgery (TLM) in the treatment of oropharyngeal cancer. DESIGN: A 2-center retrospective case series analysis. SETTING: Two tertiary care medical centers. PATIENTS: The study population comprised 69 patients with previously untreated select T1 to T3, N0 to N2 squamous cell carcinoma of the oropharynx, of whom 44 (74%) had no indication for adjuvant RT and 25 (36%) had an indication for adjuvant RT to the neck alone but declined radiotherapy. The primary tumor sites were the tonsil (n = 28 [41%]), tongue base (n = 28 [41%]), pharyngeal wall (n = 8 [12%]), soft palate (n = 4 [6%]), and vallecula (n = 1 [1%]). INTERVENTIONS: Transoral laser microsurgery in 69 patients, with neck dissection in 59 patients (83%). MAIN OUTCOME MEASURES: Complications, local and regional control, overall and disease-specific survival, swallow function, and feeding tube dependence. RESULTS: Over the mean follow-up period of 44 months, 66 of 69 patients had no disease recurrence at the primary site. The 5-year local control estimate was 94%. The mean duration of hospitalization was 3 days. There were no major complications relating to TLM. No patient required a permanent feeding or tracheostomy tube. For stage I, II, and III disease, the 5-year Kaplan-Meier estimates of locoregional control were 90%, 73%, and 70%, respectively. The 5-year overall survival estimate was 86%. CONCLUSIONS: Transoral laser microsurgery alone with or without neck dissection is an effective approach for select T1 to T3, N0, or N1 oropharyngeal cancer. Low levels of morbidity, short treatment duration, and excellent disease control make it an attractive therapeutic strategy. The treatment option of endoscopic-assisted laser microsurgery should be discussed by the multidisciplinary team for patients presenting with tumors suitable for this approach.