The role of radioactive iodine in the management of patients with differentiated thyroid cancer - An oncologic surgical perspective.

With improved understanding of the biology of differentiated thyroid carcinoma its management is evolving. The approach to surgery for the primary tumour and elective nodal surgery is moving from a "one-size-fits-all" recommendation to a more personalised approach based on risk group stratification. With this selective approach to initial surgery, the indications for adjuvant radioactive iodine (RAI) therapy are also changing. This selective approach to adjuvant therapy requires understanding by the entire treatment team of the rationale for RAI, the potential for benefit, the limitations of the evidence, and the potential for side-effects. This review considers the evidence base for the benefits of using RAI in the primary and recurrent setting as well as the side-effects and risks from RAI treatment. By considering the pros and cons of adjuvant therapy we present an oncologic surgical perspective on selection of treatment for patients, both following pre-operative diagnostic biopsy and in the setting of a post-operative diagnosis of malignancy.

Elective neck dissection versus observation in primary parotid carcinoma.

OBJECTIVE: To evaluate the efficacy of elective neck dissection in the clinically negative neck of patients with primary carcinoma of the parotid gland. Study design and setting A retrospective analysis was undertaken at a university Department of Otorhinolaryngology-Head and Neck Surgery on 83 previously untreated patients with primary carcinoma of the parotid gland and a clinically negative neck. The reliability of fine needle aspiration cytology, frozen section, and the clinico-pathologic findings of patients with occult neck metastases were analyzed. The regional recurrence rate and the outcome were compared among 2 groups; one with elective neck dissection (N = 41) and one without elective neck dissection (N = 42). RESULTS: The diagnosis of malignancy was known preoperatively in 59 (71%) cases, the exact histologic tumor type in 36 (43%) and the grade in 37 (44%) of 83 cases. Occult metastases were detected in 8 (20%) of 41 cNO patients, in 5 cases associated with a high-grade and in 3 cases with a low-grade carcinoma. Recurrence of disease developed in 5 (12%) patients in the elective neck dissection group and in 11 (26%) patients in the observation group. All of the 7 neck recurrences occurred in the observation group. The 5-year actuarial and disease-free survival rate was 80% and 86% for patients with elective neck dissection and 83% and 69% for patients without neck dissection. Conclusion and significance A routine elective neck dissection is suggested in all patients with primary carcinoma of the parotid gland. The efficacy of elective neck dissection, nevertheless, has never been evaluated prospectively.

Descending necrotizing mediastinitis: surgical treatment via clamshell approach.

BACKGROUND: Descending necrotizing mediastinitis requires an early and aggressive surgical approach to reduce the high morbidity and mortality associated with this disease. The clamshell incision has provided excellent exposure of the entire mediastinum and both pleural cavities and was assessed in patients suffering from descending necrotizing mediastinitis. METHODS: Three patients with descending necrotizing mediastinitis and bilateral pleural empyema due to invasive streptococcal infections were operated on with this method. Radical debridement of the mediastinum and bilateral decortication was performed through a clamshell incision, including pericardiectomy in 2 patients. All patients received initially a high dose of antibiotic regimen, 2 had bilateral chest tube drainage, and 1 had mediastinal drainage and pleural debridement via cervical mediastinotomy and thoracoscopy, respectively. All these measures alone, however, failed to control the disease. RESULTS: The clamshell incision offered an excellent exposure for bilateral decortication and debridement of the entire mediastinum including pericardiectomy. One patient, who was referred in critically ill condition, died of multiorgan failure in the postoperative period. The remaining 2 patients recovered without further interventions and without evidence of phrenic nerve palsy, sternum osteomyelitis, or sternal override. CONCLUSIONS: The clamshell approach offers an excellent exposure for a complete one-stage surgical treatment with mediastinal debridement and bilateral decortication in patients suffering from descending necrotizing mediastinitis in the absence of profound septic shock.

Growth patterns of piriform sinus carcinomas.

Advances in functional surgery have encouraged many head and neck surgeons to treat piriform sinus carcinomas, whenever possible, by conservation surgery. An increased understanding of the histopathologic growth pattern and spread of piriform sinus carcionomas is needed to define criteria for appropriate application of voice preservation surgery. The purpose of this study was to analyze the patterns of tumor spread to laryngeal and parapharyngeal structures. A total of 42 specimens obtained by laryngopharyngectomy were subjected to a whole-organ section study. Carcinomas confined to the lateral wall tended to extend laterally beyond the thyroid ala and rarely infiltrated the intrinsic laryngeal muscles. As a result, conservation surgery could be possible in many cases, including T4 carcinomas. Carcinomas confined to the medial wall or occupying the whole piriform sinus tended to infiltrate laryngeal structures early, and hemilaryngeal fixation was observed in 61% of these cases; tumor spread to the contralateral side in 64%. The hemilarynx fixation was due to an invasion of intrinsic laryngeal muscles. An isolated perineural or cricoarytenoid joint involvement was never observed. For these tumors, conservation surgery would be inadequate in most cases, as they often present extensive laryngeal involvement with spread to the contralateral side.

Carotid body paraganglioma with metastases.

The diagnosis of a carotid body paraganglioma with metastases led us to a critical review of the literature of 106 cases with metastasis reported between 1893 and 1980. The percentage of tumors with metastasis is in the order of 11.5% to 13%. There is no proven histological criterion from which to assert or infer their malignancy.

Facial nerve function after petrosectomy.

OBJECTIVES: Evaluation of facial nerve function after petrosectomy in a patient series with facial nerve denudation-decompression, forward or backward rerouting, and facial nerve suture and grafting. STUDY DESIGN: Fifty-six patients with petrosectomies performed for 24 benign and 9 malignant tumors of the petrous bone, 13 malignant tumors of the parotid gland or of the infratemporal spaces with infiltration of the petrous bone, 8 traumatic facial nerve disruptions, and 2 osteoradionecroses were retrospectively evaluated with respect to facial nerve function. Sixteen cases involved a partial, 25 a subtotal, and 15 an extended subtotal petrosectomy. METHODS: The treatment of the facial nerve included 15 denudation-compressions, 23 denudation-compressions with rerouting, 4 primary sutures, and 14 nerve grafts. The House-Brackmann grading system was used for facial nerve evaluation. RESULTS: Normal or nearly normal facial nerve function was obtained in facial nerve denudation-decompression with and without rerouting (House-Brackmann Grade I or II) except in cases of malignant tumors and osteoradionecrosis, where preoperative impaired function remained. Satisfactory results were obtained with nerve suturing and nerve grafting after petrous bone fracture (Grade III or IV, in one case practically Grade II) except in a case of late repair 3 years after the trauma (Grade V). Variable results were obtained with nerve grafting in cases with tumor infiltration: Satisfactory results (5 of Grade III or IV) were obtained when the tumor was healed and also when postoperative radiotherapy was applied; poor results were obtained in the case of tumor recurrence (6 of Grade V or VI). CONCLUSIONS: Our results show that petrosectomy with denudation-decompression of the facial nerve with or without rerouting usually results in a normal mimic of the face. When the facial nerve is disrupted by trauma or when the nerve is infiltrated by tumor, early reconstruction with nerve suture or grafting mostly leads to a partial and quite acceptable reinnervation of the face.

Value of fine-needle aspiration cytology of parotid gland masses.

OBJECTIVE: To evaluate the usefulness and accuracy of fine-needle aspiration cytology (FNAC) in the diagnosis of parotid gland masses. STUDY DESIGN: Retrospective chart review of patients undergoing FNAC. METHODS: Between January 1990 and December 1998, 410 parotid glands were resected at the Department of Otorhinolaryngology-Head and Neck Surgery at the University of Berne, Inselpital (Berne, Switzerland). Included in the study were 228 cases with preoperative FNAC. In a retrospective study the results of FNAC were analyzed and compared with the corresponding histopathological diagnosis. RESULTS: Histological evaluation revealed 65 malignant tumors and 163 benign lesions (150 neoplasms and 13 nonneoplastic lesions). The cytological findings were nondiagnostic in 13 (5.7%), true-negative in 146 (64%), true-positive in 39 (17%), false-negative in 22 (9.8%) and false-positive in 8 (4.5%) cases in detecting malignant tumors. Nineteen of 39 (49%) malignant tumors (true-positive) and 123 of 146 (84%) benign lesions (true-negative) were classified accurately. The accuracy, sensitivity, and specificity were 86%, 64%, and 95% respectively. CONCLUSIONS: Fine-needle aspiration cytology is a valuable adjunct to preoperative assessment of parotid masses. Preoperative recognition of malignant tumors may help prepare both the surgeon and patient for an appropriate surgical procedure.

Frequency and sites of distant metastases in head and neck squamous cell carcinoma. An analysis of 101 cases at autopsy.

One hundred one cases of squamous cell carcinoma of the upper respiratory and digestive tracts were analyzed for distant metastases. In all cases, autopsies were performed. Forty (40%) of the 101 patients had presented with one or more distant metastases. The most common sites of distant metastases were the lungs (70%), the liver (42%), and the bones (15%). There was a correlation between initial cervical lymph node involvement and development of distant metastases. In five cases of distant metastases, no tumor was found in the site of the primary lesion or in the cervical lymph nodes.

Pretherapeutic staging of hypopharyngeal carcinoma. Clinical findings, computed tomography, and magnetic resonance imaging compared with histopathologic evaluation.

OBJECTIVES: To assess the accuracy of preoperative computed tomography (CT), magnetic resonance imaging (MRI), and clinical and endoscopic tumor evaluation and to analyze the impact of these diagnostic modalities on pretherapeutic staging of hypopharyngeal carcinoma. DESIGNS: Prospective study of 44 consecutive patients with hypopharyngeal carcinoma undergoing surgical resection. SETTING: Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Bern, Switzerland. METHODS: All patients underwent contrast-enhanced CT, MRI at 1.5 T, indirect laryngoscopy, and direct laryngoscopy. The surgical specimens were cut in whole-organ slices parallel to the plane of the axial CT and MRI scans. The histologic findings were compared with the findings of the different diagnostic modalities. RESULTS: The main tumor site was misdiagnosed by endoscopy in 7 (16%) of 44 patients and by CT and MRI in 16 (36%) of 44 patients. Neoplastic invasion of cartilage was present in 21 (48%) of 44 laryngectomy specimens. Magnetic resonance imaging was more sensitive in detecting neoplastic invasion of cartilage than CT (97% vs 68%; P = .002). Magnetic resonance imaging was less specific than CT (62% vs 84%; P = .02), taking into account the thyroid and cricoid cartilages. There was no difference between the overall accuracy of CT and MRI in detecting neoplastic invasion of cartilage (78% vs 75%). Clinical and endoscopic evaluation failed to correctly stage 16 (36%) of 44 patients. Combined clinical and CT evaluation and combined clinical and MRI evaluation failed to correctly stage 12 and 13 of 44 patients, respectively. CONCLUSIONS: The assessment of tumor site is more accurate using endoscopic evaluation than CT or MRI. Magnetic resonance imaging is more sensitive in detecting neoplastic cartilage invasion than CT, whereas CT is more specific. Clinical and endoscopic evaluation of tumor stage alone fails to identify invasion of the laryngeal framework. Therefore, many tumors staged pT4 are clinically understaged. The preoperative staging accuracy was improved by combining the information gained using both clinical evaluation and CT or MRI. However, there was no difference in the staging accuracy between CT and MRI.

Endovascular treatment of acute and subacute hemorrhage in the head and neck.

OBJECTIVE: Acute and subacute hemorrhage in the head and neck often represent a life-threatening situation. The goal of this study is to evaluate the indications for and contributions of endovascular techniques in the diagnosis and management of such severe cases. DESIGN: Seventy-two patients with acute or subacute intractable hemorrhage of the head and neck were treated over a period of 5 years: 2 patients had experienced trauma; in 6 cases the cause of bleeding was iatrogenic; and in 2 patients intraosseous arteriovenous malformations were manifested. Fifteen patients had tumors, 9 of whom had prior radiotherapy. Forty-seven patients presented with epistaxis (41 idiopathic and 6 during anticoagulation therapy). The endovascular therapy was performed using polyvinyl alcohol particles, fibered platinum or electrolytically detachable coils (Guglielmi detachable coils; Target Therapeutics, Fremont, Calif), a stent, glue (Ethibloc; Ethicon GmbH, Norderstedt, Germany, and Histoacryl; B. Braun Melsungen AG, Melsungen, Germany), or with a combination of these different embolic materials. RESULTS: The acute bleeding was successfully controlled in all cases. Fourteen patients (7 with epistaxis, 5 with tumors, and 2 with arteriovenous malformations) had to be embolized more than once before the bleeding could be controlled. The idiopathic, traumatic, iatrogenic, and remaining tumoral cases were treated only once. The long-term morbidity was 1.9%. CONCLUSIONS: Owing to the recent continuous advances in interventional radiologic techniques, it is possible to treat both acute and subacute life-threatening head and neck hemorrhage most efficiently. In many cases the endovascular therapy complements surgery.

Establishing radiological percutaneous gastrostomy with balloon-retained tubes as an alternative to endoscopic and surgical gastrostomy in patients with tumours of the head and neck or oesophagus.

The purpose of this study was to report our experience introducing radiological percutaneous gastrostomy (RPG) catheters at a hospital where hitherto only endoscopic and surgical methods have been used. The feasibility, success, time requirements, and complications of RPG were prospectively evaluated during a 12-month period. 26 consecutive patients (median age 63 years, range 41-91 years) underwent gastropexy with T-fasteners followed by insertion of a 12-18 F balloon tube through a peel-away introducer and were followed-up clinically and radiologically. Success and complications occurring within 30 days were assessed. RPG was technically successful in all cases. Median procedure time was 34 min (range 20-90 min), median fluoroscopy time 6.9 min (range 2.3-30 min). 13 surgical gastrostomies were avoided. One minor complication (peristomal leakage) occurred in a patient with gastric reflux and atony. Another patient destroyed the balloon of his tube by injecting food into the balloon port, which led to tube dislocation and peritonitis. In conclusion, radiological gastrostomy can be quickly learned by radiologists and is readily accepted by clinicians. It is an alternative to surgical gastrostomy when percutaneous endoscopic gastrostomy is not feasible, but can also be used as the primary method instead of the endoscopic method.

[Virtual laryngoscopy and multiplanar reformats with multirow detector CT for detection and grading of upper airway stenosis]. / Virtuelle Laryngoskopie und multiplanare Reformationen mit Mehrzeilen-Spiral-CT zur Detektion und Graduierung von Stenosen der oberen Luftwege.

PURPOSE: A controlled trial was performed to compare non-invasive multislice CT (virtual laryngoscopy, axial CT slices, coronal and sagittal reformats) in the detection and grading of upper airway stenosis with fiberoptic laryngoscopy. MATERIAL AND METHODS: Multislice CT and fiberoptic laryngoscopy were used to examine 111 upper airway sections (supraglottis, glottis, subglottis, trachea) in 29 patients. CT data were acquired on a multirow detector CT (collimation 4 x 1 mm, reconstruction interval 1 mm, IV contrast) and postprocessing was performed using multiplanar reformatted images (MPR) and virtual laryngoscopy. RESULTS: All CT methods accurately detected upper airway stenosis (accuracy was 96 % for virtual laryngoscopy and MPR and 94 % for axial CT-slices). Correlation of fiberoptic and virtual laryngoscopy (r = 0.94) for grading of stenosis was closer than with sagittal reformats (r = 0.80), coronal reformats (r = 0.72), and axial CT slices (r = 0.57). Even high grade stenosis could be passed with virtual laryngoscopy that was impassable for fiberoptic laryngoscopy. CONCLUSIONS: Virtual laryngoscopy enabled better assessment of stenosis as compared to reading of axial CT slices or MPR. Virtual laryngoscopy is complementary to fiberoptic laryngoscopy and should be combined with axial CT slices and MPR readings for evaluation of the surrounding structures.

Stoma recurrence after laryngectomy: an analysis of risk factors.

Data from 130 patients who underwent total laryngectomy for squamous cell carcinoma of the larynx were reviewed. Patients were treated either by primary laryngectomy and planned postoperative radiotherapy or by primary radiotherapy and subsequent salvage laryngectomy. Patients with other treatment modalities and patients with positive margins of resection and laryngectomies for hypopharyngeal cancers were excluded from the study. The stomal recurrence rate with reference to several risk factors, such as primary tumor stage, location of tumor, lymph node metastases, timing of tracheotomy, and presence of a postoperative pharyngoperistomal fistula, was analyzed. The overall incidence of stomal recurrence was 10%. The treatment modality appeared to have an impact on subsequent stomal recurrence: stomal recurrence developed more often after salvage laryngectomy (18.4%) than after primary laryngectomy with planned postoperative radiation (4.8%). Advanced T stage, N stage, subglottic involvement, and preoperative tracheotomy are risk factors for stomal recurrence only in patients with a primary laryngectomy. Stomal recurrence developed in only four patients after primary laryngectomy with planned radiation. All four patients had more than one risk factor: primary tumor stage T4 (four times), subglottic involvement (three times), and preoperative tracheotomy (three times). The presence of a postoperative pharyngoperistomal fistula likewise may represent a risk factor for the development of a stomal recurrence.

Undifferentiated carcinoma of nasopharyngeal type of the laryngopharyngeal region.

Undifferentiated carcinoma of nasopharyngeal type (lymphoepithelioma) is an extremely rare malignancy in the laryngohypopharyngeal region. We found reports of only 13 such tumors in the English language literature. We present the findings of four additional cases, one hypopharyngeal and three laryngeal in origin. The three laryngeal tumors were characterized by submucosal spread. The tumors were classified T3 (2x) and T4 (2x) with cervical lymph node metastases at initial presentation in all cases. In three of our four cases the Epstein-Barr virus was demonstrated by the Epstein-Barr virus-encoded RNAs in situ hybridization.

Surgical treatment of Zenker's diverticulum: transcutaneous diverticulectomy versus microendoscopic myotomy of the cricopharyngeal muscle with CO2 laser.

In a retrospective study, we analyzed 97 patients who were treated by either transcutaneous diverticulectomy (n = 66) or microendoscopic myotomy of the cricopharyngeal muscle with CO(2) laser (n = 31). Two (6.4%) of 31 patients in the microendoscopic myotomy group had complications, compared with 10 (15%) of 66 patients in the diverticulectomy group. In addition, the complications observed in the microendoscopic myotomy group were less severe than those observed in the transcutaneous diverticulectomy group. The average length of hospitalization was shorter in the microendoscopic myotomy group than in the diverticulectomy group (8 days versus 11.4 days). We conclude that microendoscopic CO(2)-laser myotomy is a less invasive, more precise, and safer procedure, which results in a shortened period of hospitalization and complete relief of symptoms in the vast majority of cases.

Leiomyosarcoma of the middle ear and temporal bone.

Leiomyosarcoma is a malignant tumor of smooth muscle origin. It is rarely encountered in the head and neck area. A patient with leiomyosarcoma of the middle ear and the temporal bone with unusual bone destruction is presented. To our knowledge it is the first report of a middle ear and temporal bone leiomyosarcoma.

Plasma cell granuloma of the supraglottic larynx.

The occurrence of plasma cell granuloma of the larynx appears to be unusual. Review of the literature revealed only two previously reported cases. We present an additional case of plasma cell granuloma of the larynx. The diagnosis was made by histological and immunohistochemical examinations. The tumour was successfully treated by radiation therapy.

[Cancers of the upper face. The experience of the Gustave Roussy Institute. Apropos of 162 cases (1965-1980)]. / Les cancers du massif facial supérieur. Expérience de l'Institut Gustave-Roussy. A propos de 162 cas (1965-1980).

Cancer of para-nasal cavities represented only a small group among cancers of upper aero-digestive tract; 3 to 4% of 1,200 admissions yearly with cancer of head and neck. These cancers may arise from bone or cartilage but originated mainly in the mucosal lining of nasal and sinus cavities. In the latter case these were carcinomas representing approximately 75% of nasosinusal cancers treated. Carcinomas are reviewed, with a distinction between epidermoid and glandular types due to their particular evolutive courses, this retrospective study involving 162 case-reports of patients over 16 years of age treated entirely in the Institut Gustave-Roussy between 1965 and 1980.

[Malignancies of the mouth cavity, pharynx and larynx--symptoms, diagnosis and therapy]. / Malignome der Mundhöhle, des Rachens und des Kehlkopfes--Symptome, Diagnose und Therapie.

In Switzerland, 7.1% of all malignancies are localized in the oral cavity, pharynx or larynx. These malignancies are diagnosed too often in an advanced stage with a subsequent relatively poor prognosis. To achieve a better survival rate, these malignancies have to be diagnosed in an earlier stage. Therefore, it is important to know the main symptoms, the diagnostic procedure and the treatment possibilities of these cancers, which are described in the following text.

[Rare neck tumors: neurogenic tumors and carotid glomus tumors]. / Seltene Halstumoren: neurogene Tumoren und Tumoren des Glomus caroticum.

Among the rare tumors of the neck, neurogenic tumors and paraganglioma of the carotid body are discussed. Special emphasis is placed on a preoperative diagnosis of the carotid paraganglioma.