Phase 1 study of EGFR-antisense DNA, cetuximab, and radiotherapy in head and neck cancer with preclinical correlatives.

BACKGROUND: Cetuximab combined with radiation therapy (RT) is an evidence-based treatment for locally advanced head and neck squamous cell carcinoma (HNSCC); however, locoregional failure remains the primary cause of cancer-related death in this disease. Intratumoral injection of epidermal growth factor receptor (EGFR)-antisense plasmid DNA (EGFR-AS) is safe and has been associated with promising lesional responses in patients who have recurrent/metastatic HNSCC. For the current study, the authors investigated the antitumor effects of cetuximab and EGFR-AS in preclinical HNSCC models and reported their phase 1 experience adding intratumoral EGFR-AS to cetuximab RT. METHODS: Antitumor mechanisms were investigated in cell line and xenograft models. Phase 1 trial eligibility required stage IVA through IVC HNSCC and a measurable lesion accessible for repeat injections. Patients received standard cetuximab was for 9 weeks. EGFR-AS was injected weekly until they achieved a lesional complete response. RT was delivered by conventional fractionation for 7 weeks, starting at week 3. Research biopsies were obtained at baseline and week 2. RESULTS: When added to cetuximab, EGFR-AS decreased cell viability and xenograft growth compared with EGFR-sense control, partially mediated by reduced EGFR expression. Six patients were enrolled in the phase 1 cohort. No grade 2 or greater EGFR-AS-related adverse events occurred. The best lesional response was a complete response (4 patients), and 1 patient each had a partial response and disease progression. EGFR expression decreased in 4 patients who had available paired specimens. CONCLUSIONS: In preclinical models, dual EGFR inhibition with cetuximab and EGFR-AS enhanced antitumor effects. In a phase 1 cohort, intratumoral EGFR-AS injections, cetuximab, and RT were well tolerated. A phase 2 trial is needed to conduct an extended evaluation of safety and to establish efficacy.

Dysplastic follicular dendritic cells in hyaline-vascular Castleman disease: a rare occurrence creating diagnostic difficulty.

Follicular dendritic cell (FDC) proliferations and dysplastic FDCs can be seen in Hyaline-vascular Castleman disease (HVCD). The association between HVCD and FDC sarcoma is well-documented; dysplastic FDCs may be precursors to FDC sarcoma. Herein, we describe a case of HVCD with strikingly large and dysplastic FDCs, which raised the differential of Hodgkin lymphoma and other neoplasms. Scattered dysplastic FDCs were predominantly in germinal centers and mantle zones, and rarely in interfollicular areas. Although occasional germinal centers contained increased FDCs, no mass forming proliferations were present to suggest FDC sarcoma. Immunostaining demonstrated that the atypical FDCs expressed CD21, clusterin and CXCL13, but not CD23, S100, pankeratin or CD30; they aberrantly expressed epidermal growth factor receptor (EGFR). The present case demonstrates that dysplastic FDCs may be present as isolated cells that require immunophenotyping to distinguish them from malignant entities with similar morphologic features. A variety of FDC markers is required to confirm their origin as the expression of any single marker is not assured, as occurred in this case. Pathologists need be aware of FDC proliferations in HVCD because of their association with FDC sarcoma. Aberrant EGFR expression by dysplastic FDCs may indicate that they are pre-neoplastic and necessitate long-term patient follow-up.

Review of accessory parotid gland tumors: pathologic incidence and surgical management.

OBJECTIVE: The current study presents our experience with accessory parotid gland masses and reviews the literature on accessory parotid tumor incidence and surgical management. Based on our results, we advocate a standard parotidectomy approach with routine facial nerve dissection at the time of excision. STUDY DESIGN: We performed a retrospective chart review and comprehensive literature review on incidence of accessory parotid gland neoplasms. METHODS: A retrospective chart review of all patients with mid-cheek masses treated by the senior author was conducted from January 2003 to January 2009. The tumor size at presentation, FNA biopsy, pathologic diagnosis, and surgical treatment were recorded for 13 patients. RESULTS: In the case series, 54% of lesions were benign (n=7) and 46% were malignant (n=6) including benign pathologies of 4 pleomorphic adenomas, 2 lymphadenitis, 1 monomorphic adenoma and malignant pathologies of 2 mucoepidermoid carcinoma, 2 B-cell lymphomas, 1 adenocarcinoma, and 1 myofibrosarcoma. Surgical intervention was performed on all patients with standard parotidectomy incision for accessory parotid mass excision after identification and tracing of facial nerve and its branches. CONCLUSION: The present study provides support for a standard parotid incision with identification of the facial nerve at the time of surgical incision as this resulted in successful excision of accessory parotid tumors with favorable cosmetic results and without facial paralysis or tumor recurrence. Literature review of 152 cases of accessory parotid gland lesions, revealed a pooled incidence of 70% benign and 30% malignant.

Prevalence of HPV associated oropharyngeal cancer among south Texans.

The goal of this study was to begin to assess the prevalence of oropharyngeal cancer among all oral cancers and thus the potential role of human papillomavirus (HPV) in this disease in the south Texas Region served by the University of Texas Health Science Center at San Antonio (UTHSCSA), and University Health System (UHS) in San Antonio, Texas. This health system represents the largest catchment area for oral cancer serving the south Texas populations, extending from the U.S.-Mexico border, north to Williamson County, west to Eagle Pass, and east to Gonzales County. With the move towards electronic medical records (EMR) nationwide, our team conducted a feasibility study to answer this question utilizing electronic record coding data across both local networks.

Hypopharyngeal diverticulum after cervical spine surgery; the role of endoscopic management.

PURPOSE: The purpose of this study was to assess the role of minimally invasive endoscopic diverticulostomy in patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation. MATERIALS AND METHODS: This is a retrospective case series of seven patients who underwent endoscopic management of a symptomatic hypopharyngeal diverticulum. The patients were analyzed for diverticulum size, pre-operative and post-operative dysphagia and regurgitation scores, and complications. The overall success with the endoscopic approach was compared to the prior experience with traditional Zenker's diverticulum. RESULTS: Of the seven patients with hypopharyngeal diverticulum, four were successfully managed with minimally invasive endoscopic diverticulostomy (57%). These four patients all demonstrated clinically significant improvement in both dysphagia and regurgitation scores at a minimum of 6 months postoperatively. Complications were minimal and consisted of one case with postoperative subcutaneous air. There were no cases of fistula, mediastinitis, or nerve injury. CONCLUSIONS: Minimally invasive endoscopic diverticulotomy can be successfully applied to patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation.

Intraoperative relationship of the spinal accessory nerve to the internal jugular vein: variation from cadaver studies.

PURPOSE: Conflicting locations of the spinal accessory nerve (SAN) with respect to the internal jugular vein (IJV) are reported in the literature and anatomy texts. The objective of this study is to analyze this anatomic relationship specifically at the level of the posterior belly of the digastric muscle where it is encountered most often during surgery. MATERIAL AND METHODS: This study is a case series with planned chart review of all operative reports for neck dissections/explorations performed between June 2002 to June 2008 at an academic tertiary care referral center. Inclusion criteria required intraoperative identification of the SAN at the level of the posterior belly of the digastric muscle. Patients undergoing revision neck dissection were excluded. Data is presented using descriptive statistics. RESULTS: One hundred ninety-seven patients were identified; 175 met inclusion criteria. Thirty-two patients received bilateral neck dissections/explorations, resulting in a total of 207 SANs for analysis. The most common location of the SAN was lateral to the IJV (198; 95%). In 6 (2.8%) cases the SAN was identified medial to the IJV and 2 nerves pierced the IJV. A new variant of the SAN splitting around the SAN was identified. CONCLUSION: The majority of SANs course lateral to the IJV at the level of the posterior belly of the digastrics muscle (95%). This intraoperative finding differs from cadaveric studies. Discrepancies may reflect variation in the level at which the nerve was identified, as well as tissue changes related to cadaver versus in vivo studies.

Intraoperative 186Re-liposome radionuclide therapy in a head and neck squamous cell carcinoma xenograft positive surgical margin model.

PURPOSE: Positive surgical margins in advanced head and neck squamous cell carcinoma (HNSCC) have a well-documented association with an increased risk of locoregional recurrence and significantly poorer survival. Traditionally, unresectable tumor is treated with postoperative radiotherapy and/or chemotherapy. However, these therapeutic options can delay treatment and increase toxicity. The potential value of intraoperative injection of liposomal therapeutic radionuclides as a locoregional, targeted therapy in unresectable advanced HNSCC was assessed in a nude rat xenograft positive surgical margin model. EXPERIMENTAL DESIGN: The therapeutic effects of beta-emission rhenium-186 (186Re) carried by liposomes into the tumor remnants in a nude rat squamous cell carcinoma xenograft model were studied. Following the partial resection of tumor xenografts, the animals were intratumorally injected with 186Re-labeled or unlabeled (control) neutrally charged or positively charged 100-nm-diameter liposomes. Tumor size, body weight, hematology, and toxicity were monitored for 35 days posttherapy. RESULTS: The neutral (n = 4) and cationic (n = 4) liposome control groups showed an increase in tumor growth of 288.0 +/- 37.3% and 292.2 +/- 133.7%, respectively, by day 15. The 186Re-neutral-liposome group (n = 8) and the 186Re-cationic-liposome group (n = 8) presented with an average final tumor volume of 25.6 +/- 21.8% and 28.5 +/- 32.2%, respectively, at the end of the study (day 35). All groups showed consistent increases in body weight. No significant systemic toxicity was observed in any of the animals. CONCLUSIONS: With excellent tumor suppression and minimal side-effect profile, the intraoperative use of liposomal therapeutic radionuclides may play a role in the management of positive surgical margins in advanced HNSCC.

Accuracy of cone beam computed tomography in determining the location of the genial tubercle.

OBJECTIVE: To determine the accuracy of cone beam computed tomography (CT) to predict the location of the genial tubercle. STUDY DESIGN AND SETTING: Cadaver study for anatomic analysis of 17 adult human cadaver heads. Each skull/cadaver head underwent radiographic imaging with cone beam CT and cadaver dissection. Measurements, including mandibular height (MH), genial tubercle width (GTW), genial tubercle height (GTH), distance from inferior border of mandible to genial tubercle (IBM/GT), and mandibular thickness (MT) were recorded. RESULTS: Statistical analysis with paired t test showed no significant difference between cadaver dissections versus cone beam measurements. Ninety-five percent confidence intervals (CI) were as follows: GTW (-0.2 to 1.0), GTH (-0.1 to 0.9), distance IBM/GT (-0.8 to 5.0), MH (-1.3 to -2.6), and MT (-0.1 to 0.3). CONCLUSION: These results show the accuracy of the 3D cone beam CT in the anatomic location of the genial tubercle. SIGNIFICANCE: This radiographic technique may prove useful in pre-operative planning for the mandibular osteotomy in genioglossus advancement procedures.

The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling.

OBJECTIVE: The purpose of this project was to analyze the endoscopic management of Zenker diverticulum (ZD) using both the CO2 laser and endoscopic stapling techniques. This study compares the two techniques in terms of diverticulum size, onset to oral intake, hospital stay, resolution of symptoms (dysphagia and regurgitation), and complications. STUDY DESIGN: A retrospective consecutive case series was performed at an academic medical center. METHODS: Forty patients underwent an attempted endoscopic resection of the ZD using either the CO2 laser or the endoscopic stapling technique. The two techniques were compared on a variety of parameters, including diverticulum size, hospital stay, onset to oral intake, resolution of symptoms, and complications. Symptom scores were obtained before and after surgery with a patient self-reported scoring report (scale 0-3 for both dysphagia and regurgitation with 0 indicating asymptomatic and 3 severe symptoms). RESULTS: Forty patients underwent an attempted endoscopic management of ZD. Five patients (12.5%) failed endoscopic exposure (four converted to open, one observed). Sixteen patients underwent CO2 laser management and 19 underwent endoscopic stapling. The mean diverticulum size (3.8 cm CO2 laser versus 4.4 cm stapling) was not significantly different for the two groups. Both groups demonstrated a significant decrease in preoperative versus postoperative dysphagia and regurgitation symptoms scores, respectively, CO2 laser dysphagia scores decreasing from 2.75 to 1.38 and the regurgitation score dropping from 1.51 to 0.68, whereas endoscopic stapling dysphagia score decreased from 2.74 to 1.21 and the regurgitation score dropped from 1.37 to 0.53. Overall, 86% of patients demonstrated an onset of liquid intake on postoperative day 1 and the average length of stay was 3.4 days in the CO2 laser group and 1.5 days in the endoscopic stapling (P < .0015). Complications included dental trauma in four patients (two CO2 laser and two stapling) and subcutaneous air in three patients (all three CO2 laser). There were no cases of mediastinitis, recurrent laryngeal nerve injury, fistula, or perioperative death. CONCLUSIONS: The endoscopic management of ZD is a safe and effective technique. The endoscopic stapling technique appears to have an improved efficacy and safety when compared with the CO2 laser technique. The two techniques are compared and contrasted.

The role of positron emission tomography scans in the management of the N-positive neck in head and neck squamous cell carcinoma after chemoradiotherapy.

OBJECTIVE: The objective of this study was to determine the sensitivity, specificity, and predictive value of 18-fluorodeoxyglucose positron emission tomography (PET) in predicting residual cervical metastatic disease in patients with N-positive necks undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract. METHODS: The authors studied a prospective case series of patients (2003-2005) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SSC. Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment PET scan (8-12 weeks after completion of treatment), followed by salvage neck dissection. The posttreatment PET scan neck findings were correlated to the salvage neck dissection pathology report. The sensitivity, specificity, and predictive values of the PET scan to predict residual cervical metastatic disease after curative chemoradiotherapy were calculated. RESULTS: Twenty-one neck dissections (pretreatment N1 = 5, N2a = 2, N2b = 8, N3 = 6) were entered into the protocol. Four (19.0%) of the 21 neck specimens were positive for residual cervical metastatic disease, whereas the remaining 17 (80.9%) specimens demonstrated no residual carcinoma. The overall sensitivity and specificity were 75.0% and 64.7%, respectively. The positive predictive value was 33% and the negative predictive value was 91.7%. CONCLUSIONS: Although the role of posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2 and N3 necks, as well as N1 necks with an incomplete response to treatment. Based on this small prospective study, it appears that PET imaging lacks adequate sensitivity and specificity to reliably predict the presence of residual cervical metastatic disease after completion of chemoradiotherapy. With a negative predictive value of 91.7%, however, a negative PET scan appears to be a reliable predictor of the absence of residual tumor.

Risk factors for the development of hypothyroidism after hemithyroidectomy.

OBJECTIVES: To assess the incidence of hypothyroidism after hemithyroidectomy and to identify risk factors for the development of hypothyroidism. DESIGN: Retrospective analysis. SETTING: A tertiary care academic medical center. PATIENTS: The study included 90 patients who underwent a hemithyroidectomy from 1999 to 2004. MAIN OUTCOME MEASURES: Hypothyroidism was defined as a serum thyrotropin level greater than 6.0 mIU/L at least 8 weeks after hemithyroidectomy. All patients were analyzed for age, sex, surgical indications, preoperative and postoperative thyrotropin levels, weight of resected specimen, final pathologic analysis, and length of follow-up. Multivariate analysis was performed to identify multiple risk factors for the development of hypothyroidism. RESULTS: The final pathologic analysis demonstrated 49 follicular adenomas, 17 cases of Hashimoto thyroiditis, 10 multinodular goiters, and 14 other abnormalities. The overall incidence of the development of hypothyroidism after hemithyroidectomy was 27% (24 of 90 patients). When the groups were broken down by pathologic diagnosis, the incidence of hypothyroidism developing during follow-up among the Hashimoto thyroiditis and multinodular goiter groups was 59% and 50%, respectively. Also, the patients who developed hypothyroidism were noted to have statistically significant higher preoperative serum thyrotropin levels (3.15 mIU/L vs 1.95 mIU/L; P<.001) than those who remained euthyroid. There was no relationship between age, sex, or weight of the resected tissue and the subsequent risk of hypothyroidism. CONCLUSIONS: The overall incidence of posthemithyroidectomy hypothyroidism was 27%, and the majority of cases developed in the first 6 to 12 months after surgery. Risk factors for the development of hypothyroidism include pathologic diagnosis (Hashimoto thyroiditis and multinodular goiter) as well as a high-normal serum thyrotropin level. Routine monitoring of serum thyrotropin levels should be performed in all patients who undergo a hemithyroidectomy.

Setup and characterization of a human head and neck squamous cell carcinoma xenograft model in nude rats.

OBJECTIVE: To develop and characterize a new head and neck cancer animal model. STUDY DESIGN: A human head and neck squamous cell carcinoma (HNSCC) xenograft model in nude rats was established via subcutaneous inoculation of a human-origin HNSCC cell line, SCC-4. The tumor was evaluated for growth characteristics, pathologic features by hematoxylin-eosin (HE) staining, and immunohistochemistry of epidermal growth factor receptor (EGFR). 2-[18F] fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography (PET) imaging characteristics were studied too. RESULTS: A new HNSCC animal model was successfully established. Tumor sizes reached about 1 cm3 on day 15 after tumor cell inoculation. HE staining pathology has confirmed that this tumor is a typical SCC. EGFR immunohistochemistry demonstrated this tumor model to be strongly EGFR positive. 18F-FDG PET study has shown that 18F-FDG accumulated in tumors. CONCLUSIONS: This study has demonstrated that this tumor model is an appropriate HNSCC tumor model for animal studies on HNSCC.

'Cytology-on-a-chip' based sensors for monitoring of potentially malignant oral lesions.

UNLABELLED: Despite significant advances in surgical procedures and treatment, long-term prognosis for patients with oral cancer remains poor, with survival rates among the lowest of major cancers. Better methods are desperately needed to identify potential malignancies early when treatments are more effective. OBJECTIVE: To develop robust classification models from cytology-on-a-chip measurements that mirror diagnostic performance of gold standard approach involving tissue biopsy. MATERIALS AND METHODS: Measurements were recorded from 714 prospectively recruited patients with suspicious lesions across 6 diagnostic categories (each confirmed by tissue biopsy -histopathology) using a powerful new 'cytology-on-a-chip' approach capable of executing high content analysis at a single cell level. Over 200 cellular features related to biomarker expression, nuclear parameters and cellular morphology were recorded per cell. By cataloging an average of 2000 cells per patient, these efforts resulted in nearly 13 million indexed objects. RESULTS: Binary "low-risk"/"high-risk" models yielded AUC values of 0.88 and 0.84 for training and validation models, respectively, with an accompanying difference in sensitivity+specificity of 6.2%. In terms of accuracy, this model accurately predicted the correct diagnosis approximately 70% of the time, compared to the 69% initial agreement rate of the pool of expert pathologists. Key parameters identified in these models included cell circularity, Ki67 and EGFR expression, nuclear-cytoplasmic ratio, nuclear area, and cell area. CONCLUSIONS: This chip-based approach yields objective data that can be leveraged for diagnosis and management of patients with PMOL as well as uncovering new molecular-level insights behind cytological differences across the OED spectrum.

Positron emission tomography in the management of unknown primary head and neck carcinoma.

OBJECTIVE: To assess the role of positron emission tomography (PET) in the management of unknown primary carcinoma of the head and neck region. DESIGN AND SETTING: Prospective case series at an academic medical center. PATIENTS: Twenty-six patients with an open excisional biopsy or a fine-needle aspiration biopsy finding that confirmed squamous cell carcinoma of the cervical lymph nodes and no visible primary tumor (as determined by results of a comprehensive physical examination and computed tomography and/or magnetic resonance imaging) underwent PET. The standard evaluation consisted of a comprehensive head and neck examination that included fiberoptic laryngoscopy/nasopharyngoscopy, computed tomography and/or magnetic resonance imaging, and PET followed by panendoscopy with selected biopsies and tonsillectomy. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of PET to detect an occult primary tumor. RESULTS: The PET detected 8 occult primary tumors in 26 patients (detection rate, 30.8%). Four occult primary tumors (2 at the base of the tongue and 2 in the tonsil) were detected during routine panendoscopy with negative PET findings. The sensitivity of PET was 66.0%, with a specificity of 92.9%. The positive predictive value was 88.8%, and the negative predictive value was 76.5%. CONCLUSIONS: Positron emission tomography can be a valuable tool to identify a subset of patients with an occult primary tumor in the head and neck region. In addition, it can be used to screen for primary tumors below the clavicle. Early identification of the primary tumor may allow for more accurate tumor staging and targeted radiotherapy to minimize adverse effects and complications. A normal PET finding, however, does not eliminate the need for a careful panendoscopy with directed biopsies and tonsillectomy.

Anatomic analysis of the Genial Bone Advancement Trephine System's effectiveness at capturing the genial tubercle and its muscular attachments.

OBJECTIVE: The Genial Bone Advancement Trephine (GBAT) System (Stryker Leibinger Inc, Kalamazoo, MI) is a 1-step system that advances the genial tubercle for treatment of retrolingual obstruction in obstructive sleep apnea. The purpose of this project was to anatomically analyze the effectiveness of the GBAT System to capture the genial tubercle and its muscular attachments in the circular trephine. METHODS: Eight cadaveric heads (ages 54-89 years; 3 female and 5 male) were examined, and Panorex radiographs (Stryker Leibinger Inc, Kalamazoo, MI) were obtained. Seven specimens were selected on the basis of mandibular height and dentition to undergo the procedure. The procedure was performed using the GBAT system with the 14-mm trephine according to the stepwise instructions. The mandibles were dissected, and analysis of the location of the osteotomy with respect to the genial tubercle, genioglossus muscles, geniohyoid muscles, and mandibular dentition was performed. RESULTS: All 7 of the specimens had complete capture of the genial tubercle. The mean percentage of the genioglossus muscle captured in the circular trephine was 85% (50%-100%). All specimens had preservation of the posterior muscle fibers. The mean percentage of the geniohyoid muscle captured was 78% (15%-100%). No tooth roots were transected or contained in the bone plug. CONCLUSIONS: The GBAT System is an effective 1-step system for capturing and advancing the genial tubercle and its muscular attachments in the treatment of OSA.

Interobserver agreement in dysplasia grading: toward an enhanced gold standard for clinical pathology trials.

OBJECTIVE: Interobserver agreement in the context of oral epithelial dysplasia (OED) grading has been notoriously unreliable and can impose barriers for developing new molecular markers and diagnostic technologies. This paper aimed to report the details of a 3-stage histopathology review and adjudication process with the goal of achieving a consensus histopathologic diagnosis of each biopsy. STUDY DESIGN: Two adjacent serial histologic sections of oral lesions from 846 patients were independently scored by 2 different pathologists from a pool of 4. In instances where the original 2 pathologists disagreed, a third, independent adjudicating pathologist conducted a review of both sections. If a majority agreement was not achieved, the third stage involved a face-to-face consensus review. RESULTS: Individual pathologist pair κ values ranged from 0.251 to 0.706 (fair-good) before the 3-stage review process. During the initial review phase, the 2 pathologists agreed on a diagnosis for 69.9% of the cases. After the adjudication review by a third pathologist, an additional 22.8% of cases were given a consensus diagnosis (agreement of 2 out of 3 pathologists). After the face-to-face review, the remaining 7.3% of cases had a consensus diagnosis. CONCLUSIONS: The use of the defined protocol resulted in a substantial increase (30%) in diagnostic agreement and has the potential to improve the level of agreement for establishing gold standards for studies based on histopathologic diagnosis.

The role of computed tomographic scans in the management of the N-positive neck in head and neck squamous cell carcinoma after chemoradiotherapy.

OBJECTIVE: To determine the sensitivity and specificity of computed tomographic (CT) scanning in predicting residual cervical metastatic disease (N-positive neck) in patients undergoing curative radiotherapy and chemoradiotherapy for squamous cell carcinoma (SCC) of the upper aerodigestive tract. DESIGN: Retrospective case series (1995-2002) of patients undergoing radiotherapy and chemoradiotherapy for advanced head and neck SCC. METHODS: Study entry criteria included N-positive neck disease, a complete response to treatment at the primary tumor site, posttreatment CT scan, posttreatment neck dissection, and correlation of posttreatment CT scan with pathologic neck specimen. We calculated the sensitivity and specificity of the CT scan to predict the presence of residual cervical metastatic disease after curative radiotherapy and chemoradiotherapy. RESULTS: Forty-three patients (including 10 with bilateral N-positive necks) met the study criteria for analysis. Twenty (38%) of the 53 neck dissection specimens were positive for residual cervical metastatic disease. The sensitivity of the CT scan was 85%, while the specificity was only 24%. The positive predictive value of the CT scan was 40%. CONCLUSIONS: While the role of the posttreatment neck dissection remains controversial, the surgeon must rely on clinical examination and imaging studies. Our practice has been to perform planned staged neck dissections on all N2/N3 necks as well as N1 necks with an incomplete response to treatment. Based on our results, it appears that the CT scan technique lacks adequate sensitivity and specificity to reliably predict the presence of residual metastatic disease.

The role of the Genial Bone Advancement Trephine system in conjunction with uvulopalatopharyngoplasty in the multilevel management of obstructive sleep apnea.

OBJECTIVES: The successful surgical management of obstructive sleep apnea (OSA) requires surgical procedures that address both retropalatal and retrolingual airway obstruction. The Genial Bone Advancement Trephine (GBAT) system is a new, 1-step system that allows for isolation and advancement of the genioglossus muscle via a guided trephine system. The purpose of this project was to describe our experience using the GBAT system to perform genioglossus advancement (GGA) in conjunction with uvulopalatopharyngoplasty (UPPP) in the surgical management of OSA. STUDY DESIGN: Retrospective analysis of 35 consecutive patients undergoing GGA using the GBAT system in conjunction with UPPP for the management of OSA during a 3-year period (1999 to 2002). RESULTS: Twenty-four patients had complete preoperative and postoperative polysomnographic data. A 70% reduction in the Respiratory Disturbance Index (RDI) and Apnea Index (AI) in the preoperative versus postoperative PSG (RDI, 52.9 +/- 17.1 versus 15.9 +/- 7.5; AI, 20.1 +/- 6.7 versus 6.1 +/- 4.5; P < or = 0.0001). The lowest oxygen desaturation increased from 80% to 88% (P = 0.0002), and the posterior airway increased from 7.9 to 12.6 mm (P < 0.0001). With a surgical cure defined as a greater than 50% reduction in the RDI and a final postoperative RDI of less than 20 events per hour, the true surgical cure rate was 67% (16 of 24 patients). CONCLUSIONS: The GBAT system performed in conjunction with UPPP can produce significant reductions in RDI and AI while improving the oxygen desaturation and enlarging the posterior airway space. The effective cure rates using the GBAT system are in agreement with previous reports in the literature using various GGA techniques. The GBAT may have some advantages in terms of simplicity and safety.

Role of the tongue base suspension suture with The Repose System bone screw in the multilevel surgical management of obstructive sleep apnea.

OBJECTIVE: The Repose System (tongue base suspension) is a new, minimally invasive technique for tongue base suspension in the treatment of obstructive sleep apnea. The purpose of this project was to describe our preliminary experience using this tongue base suspension system in conjunction with uvulopalatopharyngoplasty (UPPP) in the multilevel surgical approach to the management of obstructive sleep apnea (OSA). STUDY DESIGN: We conducted a retrospective analysis of 19 consecutive patients undergoing UPPP and The Repose System tongue base suspension for the management of obstructive sleep apnea during a 1-year period (1998 through 1999). RESULTS: Fifteen patients (11 men and 4 women) had complete preoperative and postoperative polysomnographic data. A 46% reduction in the preoperative respiratory disturbance index (RDI) (38.7 +/- 12.3) versus the postoperative RDI (21.0 +/- 7.4, P < 0.05) was demonstrated at a mean of 3.8 months after surgery. The apnea index demonstrated a 39% reduction. The surgical cure rate was 20% (3 of 15 patients). CONCLUSIONS: The Repose System in conjunction with UPPP has been shown to produce significant reductions in the RDI and apnea index as well as a significant increase in O2 saturation. Despite the improvement in these objective parameters, the overall surgical cure rate was only 20% (3 of 15 patients) in this retrospective series. Further research is warranted to define the role of The Repose System in the management of obstructive sleep apnea patients with multilevel airway obstruction.

Surgical anatomy of the thyroid and parathyroid glands.

From a surgical viewpoint there are several critical anatomic structures that lie in close proximity to the thyroid gland. These critical structures include the recurrent laryngeal nerves, the superior laryngeal nerves, and the parathyroid glands. Successful thyroid surgery depends on the technical skill of the surgeon to identify and preserve these vital structures.