[Extranodal Metastases of Renal Cell Carcinoma to the Head and Neck: A Diagnostic Challenge]. / Extranodale Metastasen von Nierenzellkarzinomen in der Kopf-Hals-Region.

BACKGROUND: Single case reports about extranodal renal cell carcinoma (RCC) metastasis to the head and neck (HN) often implicating unusual clinical follow-ups are well known. Subject of our investigation is to ascertain the true meaning of RCC for differential diagnostic of the head and neck surgion. METHODS: We retrospectively review the reports of 612 patients with RCC treated in a 13-years period in the department of urology. RESULTS: Of the 612 RCC 191 (31%) were metastatic, 3 female and 4 male (mean 66.8a, 56a-78a) presented with extranodal metastases within the HN. Extranodal locations were parotid and thyroid glands (2 ×), tongue, forehead scin, bone and paranasal sinus. Occurrence of metastases were observed in mean 40.8 months (5-87) after the primary. In one patient metastasis to the parotid gland was the only manifestation of RCC 78 month treated before, the others presented with further metastases to infraclavicular organs. DISCUSSION: According to our results extranodal metastases of RCC to the HN are uncommon (1.1%). Therefore and because of the unusual location extranodal metastases of RCC remain a diagnostic challenge for the ENT specialist and the pathologist with peculiar knowledge of the oncological history of the patient remaining an essential condition. We found exclusive metastasis to the HN in only one of 7 cases. Nevertheless surgical treatment has to be considered in curative and symptomatic treatment strategies.

Selective neck dissection as a therapeutic option in management of squamous cell carcinoma of unknown primary.

Carcinoma of unknown primary of the neck (CUP) is a metastasis presenting in one or more cervical lymph nodes, with no primary mucosal site identified. Retrospective case notes review of 25 consecutive patients (median age 55, 72% males) diagnosed as CUP who underwent neck dissection in a UK tertiary referral comprehensive cancer centre between 2000 and 2011. Median follow-up was 33 months. Nineteen patients underwent comprehensive neck dissections (six extended), six patients had selective neck dissection. Five year disease specific survival and regional recurrence free survival were 76 and 80% respectively. The overall rate of occult disease (disease not identified on preoperative evaluation, but found on histopathologic examination) was 8%, with rates of 0% in level I and 6% in level V. Our study suggests that in patients without preoperative evidence of disease in levels I or V selective neck dissection might be considered as an option, to facilitate preservation of the submandibular gland and accessory nerve without compromising oncological outcome. Larger studies should be performed before a change in practice can be advised.

PET/CT in the management of metastatic cervical lymphadenopathy from unknown primary site: a seven years retrospective study.

OBJECTIVES: To evaluate the accuracy of PET/CT for the diagnostic evaluation of patients presenting cervical node metastasis of suspected unknown primary; furthermore to understand its relative clinical utility and relevance when compared to classic endoscopic investigation approach. MATERIALS & METHODS: A retrospective study was pursued, collecting information from clinical files of all patients who presented to the Portuguese Institute of Oncology - Oporto, from January 2005 to December 2011, with cervical node metastases whose primary hadn't been found, despite clinical examination and standard imaging (CT scan or MRI) and therefore were submitted to a PET/CT. Among those presenting with non-supraclavicular metastasis patients were subsequently analyzed according to: histopathology; those who performed examination under anaesthesia (EUA) for biopsies either before of after PET/CT. RESULTS: Eighty nine patients were included in the study. Detection rate was 32.6% with no statistically difference between those with supraclavicular metastases and those with metastases in higher cervical levels (p = 0.24). In this last group (n = 76), 43% patients had had PET/CT and an endoscopy associated with biopsies of the upper aerodigestive tract in different orders, to complete diagnostic workup in cases where the first performed was inconclusive. No statistically difference was found between these two methods (p = 0.25). Most of noticed false negatives were microscopic lesions located deep in the palatine tonsils. CONCLUSIONS: PET/CT showed to be an useful tool when searching for primary tumours whether metastasis were supraclavicular or located in higher levels of the neck. Despite its good accuracy and detection of tumours previously undetected by EUA with biopsies (missed mainly due to sampling error), up-front negative scan shouldn't preclude performing endoscopies. Being evident that both tools are helpful. It was not possible in this study to find any evidence that could show which one of these two exams should be performed first.

Upper aerodigestive tract cancer and the lung: a tale of two aspirations.

Patients with upper aerodigestive epithelial cancers frequently develop second primary cancers due to common risk factors or develop distant metastases depending on the locoregional status of the primary tumor. In most instances, the organ affected is the lung. Pulmonary spread usually occurs due to hematogenous or lymphatic dissemination. The following is a report of two patients with upper aerodigestive tract squamous cell carcinomas who developed lung metastases due to aspiration, a route not well documented in recent literature.

Human papillomavirus in metastatic lymph nodes from unknown primary head and neck squamous cell carcinoma.

OBJECTIVE: Determine human papillomavirus (HPV) incidence in unknown primary squamous cell carcinomas (SCCa) of the head and neck and assess if HPV status influenced survival. STUDY DESIGN: Historical cohort study. SETTING: Tertiary care center. SUBJECTS: Patients with unknown primary SCCa despite a complete workup who underwent neck dissection or excisional biopsy and postoperative comprehensive ± chemoradiotherapy between 2002 and 2009. METHODS: HPV fluorescence in situ hybridization (FISH) and p16(INK4a) immunohistochemistry (p16 IHC) were performed. Results were compared with survival, age, race, gender, tobacco use, alcohol use, and nodal stage. RESULTS: Twenty-five patients met the inclusion criteria, of whom 88% were >10 pack year tobacco users. Twenty-eight percent were HPV-positive defined by both p16+ and FISH+. Five-year overall survival was 66.7% in HPV-positive and 48.5% in HPV-negative patients (P = .35). Similarly, 5-year disease-free survival rates were 66.7% in HPV-positive and 48.5% in HPV-negative patients (P = .54). All 3 HPV-positive nonsmokers were survivors, but this was not significant because of the small sample size (P > .05). No other characteristics were associated with survival (P > .05). CONCLUSION: Twenty-eight percent of metastatic lymph nodes from occult primary tumors were HPV positive. There was no survival difference associated with HPV status. Most of the HPV-positive patients in this study were tobacco users who had similar survival to HPV-negative patients, so caution should be used in interpreting HPV status in these patients.

When to manage level V in head and neck carcinoma?

OBJECTIVES/HYPOTHESIS: As superselective neck dissection strategy is gaining popularity to minimize postoperative morbidity and better life quality, we investigated the metastatic nodal status of level V neck lymph node group for head and neck squamous cell carcinoma in various primary sites. We have also aimed to display the impact of involvement of other nodal groups on level V. STUDY DESIGN: Retrospective review of histopathologic examination of case series at a comprehensive cancer center. METHODS: The study group was composed of 107 patients who underwent a type of neck dissection including level V among 243 patients. The impact of primary site and metastatic nodal status of other levels on metastasis to level V involvement were evaluated. RESULTS: The most common primary tumor site was oropharynx (n = 43), followed by oral cavity (n = 32), larynx (n = 16), carcinoma of unknown primary (n = 10), and hypopharynx (n = 6). General pathologic N positivity for all levels was 78.3% (76 of 97) when 10 carcinoma of unknown primary patients were excluded. Level V was involved in 13 of 107 (12.1%) patients. Level V was not involved in any patient when the other levels were not involved (0 of 21). Even when considering only N+ patients, the ratio of N positivity for level V is still <20% (13 of 86, 15.1%). CONCLUSIONS: Because level V was not involved in any patient when the other levels were not involved, it might be reasonable to preserve level V especially in clinically and intraoperatively N0 patients.

[Post-therapeutic imaging strategies and follow-up in head and neck malignant tumours]. / Aktuelle Aspekte der posttherapeutischen Bildgebung bei Kopf-Hals-Malignomen.

Post-therapeutic imaging is crucial for treatment planning and control in patients with malignant lesions in the head and neck. Focussed on CT, PET-CT and MRI, imaging strategies for post-therapeutic follow-up have been developed and investigated during the last few years. This review should help to interpret the results of these studies and make the reader familiar with the latest developments.

Fluorodeoxyglucose-positron-emission tomography imaging of head and neck squamous cell cancer.

The hybrid technique of PET/CT has significantly impacted the imaging and management of HNSCC since its introduction in 2001 and has become the technique of choice for imaging of this cancer. Diagnostic FDG-PET/CT is useful for identification of an unknown primary tumor, delineation of extent of primary tumor, detection of regional lymph node involvement even in a normal-sized node, detection of distant metastases and occasional synchronous primary tumor, assessment of therapy response, and long-term surveillance for recurrence and metastases. The role of PET/CT is evolving in radiation therapy planning. Combined diagnostic PET/CT provides the best anatomic and metabolic in vivo information for the comprehensive management of HNSCC.

[Simultaneous noninvasive monitoring for radial forearm and fibula flaps using laser Doppler flowmetry and tissue spectrophotometry]. / Simultanes nichtinvasives Monitoring mit Laser-Doppler-Flussmessung und Gewebespektrometrie bei fasziokutanen Radialislappen und osteokutanen Fibulatransplantaten.

AIM: In the literature currently available monitoring devices are usually divided into two major groups: those for monitoring perfusion and those for measuring tissue oxygenation. The O(2)C (oxygen to see) system combines these two ways of monitoring free flap viability. The aim of this prospective study was to determine the necessity of flap revision and when unnecessary revision can be avoided. Another point of interest was the question of whether critical values for the successful course of free flaps could be defined and in addition whether such values would differ for different flap types. PATIENTS AND METHODS: In a prospective study 82 free flaps (61 radial forearm flaps and 21 fibula flaps) were monitored with the O(2)C monitoring unit. Measurements were carried out intraoperatively and postoperatively up to 14 days. RESULTS: Perfusion compromise occurred in 12 (14.6%) of 82 monitored free flaps. Operative exploration was performed in seven cases, in five of them successfully. Five flaps (three radial forearm and two fibula flaps) were lost due to vascular compromise, which led to an overall success rate of 93.4%. Venous congestion was identified by a rapid increase in hemoglobin concentration of more than 30%. An abrupt decline of blood flow and hemoglobin oxygenation indicated arterial occlusion. Vascular complications were detected in all cases prior to clinical assessment with no false positive or negative results. For radial forearm flaps a hemoglobin oxygenation of 15%, a superficial flow of 10 AU, and a deep flow of 20 AU were identified as minimum values for flap viability. For fibula flaps a hemoglobin oxygenation of 10%, a superficial flow of 5 AU, and a deep flow of 15 AU were determined as minimum values. CONCLUSION: O(2)C combines laser Doppler flowmetry and tissue spectrophotometry and for the first time allows simultaneous measurement of the microcirculatory parameters including blood flow, flow velocity, hemoglobin concentration, and hemoglobin oxygenation. We found this new noninvasive technique to be a reliable and accurate method for evaluating flap viability and improving the success rate in free flap transfer.

[Sonographical differential diagnosis of cervical lumps]. / Knoten am Hals--Sonographische Differentialdiagnostik.

A brief synopsis for a practical approach in the clinical and sonographical evaluation of cervical lumps except for lymph node diseases is presented.

[PET/CT imaging in head and neck tumors]. / PET-CT-Bildgebung bei Kopf-Hals-Tumoren.

AIM: To evaluate the usefulness of combined PET/CT examinations for detection of malignant tumors and their metastases in head and neck oncology. METHODS: 51 patients received whole body scans on a dual modality PET/CT system. CT was performed without i.v. contrast. The results were compared concerning the diagnostic impact of native CT scan on FDG-PET images and the additional value of fused imaging. RESULTS: From 153 lesions were 97 classified as malignant on CT and 136 on FDG/PET images, as suspicious for malignancy in 33 on CT and 7 on FDG-PET and as benign in 23 on CT and 10 on FDG-PET. With combined PET/CT all primary and recurrent tumors could be found, the detection rate in patients with unknown primary tumors was 45%. Compared to PET or CT alone the sensitivity, specifity and accuracy could be significantly improved by means of combined PET/CT. CONCLUSION: Fused PET/CT imaging with [F18]-FDG and native CT-scanning enables accurate diagnosis in 93% of lesions and 90% of patients with head and neck oncology.

[Interdisciplinary interventional therapy for tracheobronchial stenosis with modern metal net stents]. / Interdisziplinäre interventionelle Therapie tracheobronchialer Stenosen mit modernen Metallmaschenstents.

STUDY OBJECTIVES: Assessment of the therapeutic potential of tracheobronchial stenting for obstructive tracheobronchial disease, in-vivo comparison of different stent types and development of helpful criteria for choosing the suitable stent type. MATERIAL AND METHODS: Prospective case analysis. Between 1993 and 1999 53 stents were implanted into the tracheobronchial system of 39 consecutive patients with benign or malignant airway obstruction. Every single stent (26 Strecker Stents, 18 Wallstents, 6 Accuflex Nitinolstents, 1 Dumon-, 1 Rüsch- and 1 Palmazstent) was recorded in an unified database. Analysis comprised clinical effectiveness, lung function if possible, relevant complications and radiologic follow-up parameters. The probability of their remaining within the tracheobronchial system, of their remaining undislocated and uncompressed was calculated using Kaplan-Meier analysis for three stent types. RESULTS: Stent placement proved itself to be an effective treatment in 86 % of the patients. Resistance could be normalized in 9/9 patients. Kaplan-Meier analysis clearly revealed a higher probability for the Wall- and Nitinolstent to remain within the tracheobronchial system and to remain uncompressed. Dislocation also occurred more rarely. Explantation of the Wallstent, however, if desired, was much more difficult compared to the Strecker stent. The Wallstent also occasionally led to the formation of granulation tissue especially at the proximal stent end and, as such, required reintervention. CONCLUSION: Any of the 3 stent types proved to be an effective therapeutic option in the management of obstructive tracheobronchial disease. Choise of the stent type should be determined through definition of the therapeutic intention. It is useful to distinguish between (a) benign stenosis, (b) malignant stenosis but curative therapeutic situation and (c) malignant stenosis in a palliative therapeutic situation with limited life expectancy. In spite of its superior mechanical properties the Wallstent is rather suited for a palliative situation because explantation may be difficult. The Strecker Stent requires more reinterventions but removal is easy to perform. The Nitinolstent possibly represents a reasonable compromise.

[Correlation of FDG-PET and MRI/CT with histopathology in primary diagnosis, lymph node staging and diagnosis of recurrency of head and neck cancer]. / Korrelation von FDG-PET und MRT/CT mit der Histopathologie in Primärdiagnostik, Lymphknotenstaging und Rezidivdiagnostik von Kopf-Hals-Tumoren.

AIM: Correct staging of head and neck cancer is important for the patient's prognosis and further therapeutic strategies. Aim of the present study was to investigate the diagnostic value of FDG-PET regarding the pre-surgical diagnosis of primary tumor and cervical lymph node metastases, the diagnosis of tumour recurrence, and the localisation of unknown primary, further to compare the results to those of morphological imaging modalities (CT/MRI) and to correlate the results of both methods with histopathological findings. PATIENTS/METHODS: 115 patients (pts) (72 x primary diagnosis, 37 x recurrence, and 6 x unknown primary) underwent FDG-PET (ECAT EXACT HR+) and CT or MRI. Results were correlated with histopathological findings in terms of detection of primary and recurrent tumors as well as lymph node metastases. RESULTS: Regarding the pre-surgical diagnosis, sensitivity and specificity for identifying primary tumors were 85 % and 100 % for PET and 88 % and 75 % for CT/MRI, respectively. Accuracy was 86 % for PET and 87 % for CT/MRI. Sensitivity and specificity for detecting primary lymph node involvement were 71 %/86 % for PET and 74 %/57 % for CT/MRI, resulting in an accuracy of 77 % with PET and 68 % with morphological imaging. In 23 pts histopathology revealed pT1 stages with tumor diameters < 12 mm. In 8 pts CT/MRI and in 10 pts PET failed to identify these small primary lesions. Detecting tumor recurrence (n = 37) PET showed a higher sensitivity (83 %), specificity (76 %) and accuracy (78 %) compared to CT/MRI (sensitivity: 67 %; specificity: 52 %; accuracy: 57 %). In 4/6 pts with unknown primary, imaging was able to identify a primary lesion (3/4 in FDG-PET, 2/4 in CT/MRI), in 2/6 patients even in the follow-up no primary tumor was found. CONCLUSIONS: FDG-PET provides only minor additional information to morphological imaging concerning diagnosis of primary tumors. At a similar level of sensitivity, however, it seems to be more specific regarding the lymph node involvement. PET seems to be superior to CT/MRI in detecting tumor recurrence as well as occult primary tumors in pts with known cervical lymph node metastases.

[Tissue sampling in the deep head-neck area with a new ultrasound-controlled, semi-automatic micro-punch biopsy device]. / Gewebeentnahmen aus dem tiefen Kopf-Hals-Bereich mit einer neuen sonographiegesteuerten, halbautomatischen Mikrostanze.

Fine needle aspiration biopsy (FNAB) under ultrasound control is an established diagnostic procedure for the head and neck region. Because of the disintegration of tissues, the diagnostic value of the method is limited resulting in only moderate specificity. In a prospective study, we performed a new, semi-automatic biopsy method in patients who had been diagnosed with sonographically confirmed pathologic masses in the head-neck region. This biopsy is carried out with a spring-loaded biopsy pistol which uses a disposable 20-gauge, specially designed cutting needle. Because this method combines the low invasiveness of FNAB with the high specificity of an excisional biopsy, a high tissue quality is obtained. Comparing these bioptic results with those of subsequent excisional biopsies proves that this new method yields a sensitivity of close to 100% for the detection of lymph node metastases of squamous cell carcinomas (SCC). The tissue cylinders have a reproducible size and allow ultrastructural investigations in the transmission electron microscope (TEM) on the ultrastructural level. Due to the excellent tissue preservation in the biopsy cylinders, ultrastructural studies, using transmission electron microscopy, may be carried out with the biopsy material. Furthermore, following paraffin embedding of biopsy cylinders, serial sections may be obtained for special staining techniques, and immunohistological investigations are possible which may serve as an adjunct in the diagnosis of, e.g., lymphoproliferative lesions with a sensitivity of 96%. Summarizing, the new semi-automatic biopsy technique obtains tissue probes of high quality with low invasiveness which enables highly sensitive diagnosis of head and neck lesions.

[Metastasis of systemic origin in otorhinolaryngology]. / Metástasis de origen sistémico en otorrinolaringología.

INTRODUCTION: In the upper respiratory-digestive tract cancer is always primary. Such cancer is very common, but other extremely rare secondary cancers may be found. DEVELOPMENT: We studied our own patients and some published in the literature: cancer of the kidney with metastases in the paranasal sinuses and cancer of the breast metastasizing to the temporal bone. We review the bibliography on these rare metastases. CONCLUSIONS: In all cases of otorhinolaryngological cancer a detailed history should be taken, with special reference to previous neoplasms. It is particularly important to study and review any history of renal, breast or prostate tumors with regard to the primary tumor and the receptor organs of metastases, the paranasal sinuses and temporal bones. The most difficult problem occurs when the primary tumor is present but undiagnosed. Therefore, in all cases of cancer of the paranasal sinuses and temporal bones, before treatment is started the kidney, prostate, breast and other organs above and below the diaphragm where tumor may be present should be examined. The prognosis of these metastases, which are almost always fatal, is very poor so that often treatment is only palliative rather than aggressive.

Fluorodeoxyglucose positron emission tomography, a new technique for increasing the detection rate of coincident thyroid cancer in head and neck oncology.

Clinically occult thyroid cancer is not uncommon and may occur in 1% to 10% of the population Since the first studies on the use of fluorodeoxyglucose positron emission tomography (FDG PET) in clinical oncology some reports have appeared on the detection of occult tumors using this imaging modality. According to these results, the number of patients with head and neck cancer and clinically occult coincident primary tumors at initial presentation may be expected to increase. In two of the four patients presented, the coincident tumor was detected with FDG PET. The possible role of this new imaging technique is discussed in correlation with treatment and clinical outcome.

[Primary small cell carcinomas and metastatic disease in the head and neck]. / Kleinzellige Karzinome. Primärtumoren und Metastasen im Kopf-Hals-Bereich.

Extrapulmonary small cell carcinomas are recognized as a clinicopathologic entity distinct from small cell lung cancer. Such carcinomas as primary tumors have been described in several locations in the head and neck although most cases of metastatic tumor in the neck originate from a pulmonary primary. In this report we present a small cell carcinoma of the larynx, metastasis in the parotid gland as the first manifestation of a small cell lung cancer and a small cell carcinoma of the Merkel cell type in a parotid lymph node. Our review of the current literature shows that most small cell carcinomas in the head and neck are extrapulmonary primary tumors. Since histological criteria are the same, a pulmonary neoplasm has to be excluded in every case. The differentiation between a primary head and neck tumor and metastatic disease as well as the location and staging are essential criteria for therapy and prognosis.

[Distant metastasis of squamous epithelial carcinomas of the upper aerodigestive tract. The effect of clinical tumor parameters and course of illness]. / Fernmetastasierung von Plattenepithelkarzinomen des oberen Aerodigestivtrakts. Der Einfluss klinischer Tumorparameter und des Krankheitsverlaufs.

Screening for distant metastases from head and neck tumors is still controversial. In the present study, the records of 1087 patients with newly diagnosed squamous cell carcinomas of the upper aerodigestive tract were reviewed retrospectively to determine clinical factors influencing the incidence and location of distant metastases. Overall, 130 patients (12.0%) developed clinical evidence of metastatic disease, 17 of whom (1.6%) had metastases at the time of initial presentation. The rate of distant metastases significantly increased with the initial stage of tumors (P < 0.00001) and the occurrence of local and/or regional recurrences (P < 0.00001) or of second primaries below the clavicles (P < 0.0005). The locations of primary cancers as well as histopathologic grading were not independent risk factors for the development of distant metastases. They mainly reflected different frequency distributions of stages. The lungs, liver and bones were the most common sites of metastatic disease, being involved in 68.5%, 23.8% and 20.0% of cases, respectively. Our findings show that at the time of initial presentation chest X-ray alone appears to be sufficient to exclude distant metastases from tumors classified as T1-3 NO. Further screening comprising abdominal ultrasound, bone scanning and/or CT scans of the thorax is particularly indicated for patients with advanced-stage disease, local and/or regional recurrences and second primaries below the clavicles. However, the individual decisions should consider whether the detection of distant metastases will significantly affect clinical management.

Carcinomas de células basales de la piel con metástasis / Basal cell carcinoma of the skin with metastases

Describimos un caso de carcinoma de células basales (CCB) con metástasis viscerales en un varón de 51 años que presentó dificultad respiratoria y derrame pleural. En la autopsia las metástasis de CCB infiltraban ambas pleuras y pulmones, pericardio, hueso, hígado y suprarrenales. La revisión del tumor cutáneo resecado 11 años antes mostró un CCB infiltrante con similares características histológicas a las metástasis