Relationship between quality of life and depression in patients with head and neck cancer.

OBJECTIVE: This study describes the relationship between health-related quality of life (HRQOL) and depression in patients following major surgery for head and neck cancer. DESIGN: Cross-sectional study using medical chart review, patient interview, and test administration. METHOD: Fifty patients were evaluated 6 months to 6 years following surgery using one global HRQOL measure (The Functional Assessment of Cancer Therapy-General [FACT-G]); three disease-specific measures of HRQOL (the HN module of the FACT [FACT-HNS], The University of Washington Quality of Life Scale [UWQOL], and The Performance Status Scale for Head and Neck Cancer); and one measure of depression (The Beck Depression Inventory [BDI]). RESULTS: The study population showed a high occurrence of depressive symptoms (22%). A negative correlation existed between the BDI and HRQOL as measured by the FACT-G (r = -0.49, P < .001) and the UWQOL (r = -0.44, P = .003). When somatic symptoms of depression were removed, the BDI remained correlated with HRQOL and was most highly correlated with the Emotional Well-Being (EWB) subscale of the FACT-G (r = -0.42, P = .003). There was no correlation between clinician judgments of EWB and any patient-rated measures of HRQOL or depression. CONCLUSIONS: Results demonstrate an inverse relationship between patient-reported HRQOL and depression. The lack of correlation between physician and patient ratings of HRQOL and EWB stresses the importance of obtaining patient ratings in addition to traditional clinician ratings when assessing outcomes. Finally, the multidimensional construction of the FACT with its specific subscales may make it a useful clinical tool for assessing patient status and augmenting patient interviews.

Unilateral parathyroidectomy: the value of the localizing scan.

Surgery for correction of primary hyperparathyroidism utilizing a standard bilateral neck exploration has a success rate of approximately 90 to 95%. With the inception of pre-operative localization studies that were 90% accurate in localizing the diseased gland, the concept arose that a unilateral exploration could be as successful as a bilateral exploration. Bilateral exploration of the neck for hyperparathyroidism exposes the patient to a greater potential of morbidity for hypoparathyroidism and recurrent laryngeal nerve injury. It is our feeling based on personal experience that unilateral parathyroidectomy in selective cases can be as successful as the bilateral operation and be more cost effective, saving over $1,100 (U.S.) per case.

Merkel cell tumor of the head and neck. Five new cases with literature review.

Merkel cell carcinoma (MCC) of the skin is an uncommon, but highly aggressive neoplasm with a marked propensity for local and distant metastasis. Despite the fact that more than half of the 600 cases of MCC reported in the literature involved primary sites in the head and neck, MCC has rarely been discussed in otolaryngology publications. We present five new cases of MCC of the head and neck and summarize 89 additional cases from the literature in which detailed treatment and survival data were given. Our findings again emphasize the difficulty in making the initial histopathologic diagnosis of MCC and demonstrate the necessity of early diagnosis and multimodality treatment.

Transantral sphenoethmoidectomy: a procedure for the 1990s?

Currently, among otolaryngologists, much attention is focused on the surgical management of paranasal sinus disease. However, transantral sphenoethmoidectomy is rarely mentioned in the literature of the past several decades. We reviewed a consecutive series of 98 patients over a 12-year period who underwent transantral sphenoethmoidectomy in the treatment of severe chronic hyperplastic pansinusitis. The major and minor complications encountered are tabulated, as are the clinical outcomes. A description of the operative technique is followed by a discussion of the indications for this approach. We believe transantral sphenoethmoidectomy has a useful place in modern paranasal sinus surgery.

Riedel's thyroiditis.

Invasive fibrous (Riedel's) thyroiditis is a rare thyroid condition of unknown origin that may be associated with inflammatory fibrosclerosing processes elsewhere in the body. Although the condition is benign and self-limiting, its importance lies in its ability to clinically mimic carcinoma almost completely, necessitating performing an open biopsy to establish the correct diagnosis. In a review of over 700 thyroid operations performed at Loma Linda (Calif) University Medical Center in the past 15 years, we encountered only one documented case of Riedel's thyroiditis. Our patient presented with a firm thyroid mass, vocal cord paralysis, and symptoms of esophageal compression. Surgery was performed to obtain a definitive diagnosis and prevent the possibility of subsequent additional tracheal compression with airway compromise. The pathologic findings, as well as the medical and surgical treatment of this condition, are reviewed.

The pitfalls of technetium Tc 99m/thallium 201 parathyroid scanning.

Technetium Tc 99m/thallium 201 parathyroid scanning has been proved to be effective by multiple researchers. A review of 54 patients who underwent scanning and operations at an institution showed the scans to be accurate in 83%. There were 15% false-negative and 2% false-positive scans. The pitfalls of parathyroid scanning can be related to false-positives and false-negatives.

Total thyroidectomy in the treatment of thyroid disease.

In a review of thyroid surgery during the past 12 years, total thyroidectomy was performed in 20% of the cases. Forty percent were done for malignant disease and 60% for benign disease. Our indications for using this operation in benign thyroid disease include bilateral nodular goiter, Graves' disease, chronic thyroiditis, and cases in which the rapid frozen diagnosis is equivocal for carcinoma. We feel that the risks of reoperation for recurrent thyroid disease are greater than the risks of a total thyroidectomy as the initial surgical procedure. With the increased use of total thyroidectomy the incidence of permanent hypoparathyroidism can be decreased. We reviewed our preoperative work-up, indications for total thyroidectomy, surgical technique, diagnostic accuracy of needle biopsy, accuracy of rapid frozen section reports, and postoperative complications.

Adjuvant methotrexate escalated to toxicity for resectable stage III and IV squamous head and neck carcinomas--a prospective, randomized study.

To determine if adjuvant methotrexate (MTX), escalated weekly to toxicity, could improve disease-free survival (DFS) and overall survival by preventing recurrent disease, 60 patients with potentially resectable stage III or IV squamous head and neck carcinomas were stratified by primary site, stage, and nutritional status, then randomized by pairs to receive or not receive adjuvant MTX. All received standard surgery and postoperative radiation therapy. Five patients were taken off study because of unresectability at the time of surgery, leaving 55 evaluable patients. There were no statistically significant imbalances in known prognostic factors between the two treatment arms. MTX was begun at 40 mg/m2 and escalated 10 mg/m2 weekly (four doses preoperatively; four doses postoperatively, preradiation therapy; eight doses postradiation therapy) to mucosal or hematologic toxicity. The median peak MTX dose achieved was 80 mg/m2. Although three patients were hospitalized with MTX toxicity, none died of MTX toxicity. No patient receiving MTX had disease progression during treatment, and there was no increase in postoperative complications. Thirty-two patients died (median survival, 19 months); 23 patients are alive with median follow-up of 43 months. There was no statistically significant difference in actuarial DFS (P = 1.0) or overall survival (P = .61). Although patients on the MTX arm appeared to have less local and regional recurrences at first recurrence (thus more distant metastases), this did not reach statistical significance (P = .06). There was no significant difference between the sites of recurrence at death or last follow-up (P = .38).

Parathyroid carcinoma: two new cases--diagnosis, therapy, and treatment.

Carcinoma of the parathyroid gland is a disease only rarely encountered in clinical practice. As most of these tumors retain the ability to manufacture active parathyroid hormone, most patients with the disease present with hypercalcemia, many times symptomatic. Since the tumor accounts for only 0.5% to 4.0% of cases of primary hyperparathyroidism, the diagnosis of parathyroid carcinoma may be unsuspected and delayed. The clinical index of suspicion should be elevated if there is a palpable neck mass, an exceptionally high serum calcium level, and/or recurrence of hypercalcemia following surgery. We review two patients with parathyroid carcinoma who presented with hypercalcemia. In both, the diagnosis of malignancy was made only after microscopic examination of the operative specimen. Surgery consisted of wide local excision in both cases; radiation therapy was administered in one. Postoperative disease-free status is now 23 and 37 months. One of the patients had a history of radiation therapy to the larynx 20 years prior to the development of parathyroid carcinoma. Also reviewed in this paper are the clinical and histopathologic criteria for making the diagnosis of parathyroid carcinoma and the therapeutic approaches and prognosis of this unusual tumor.

Meibomian gland adenocarcinoma of the eyelid with preauricular lymph node metastasis.

Meibomian gland carcinomas of the eyelid are rare neoplasms, accounting for less than 1% of all eyelid tumors. They usually mimic chalazia and undergo repeated curettage before a definitive diagnosis is made. Although they are relatively slow growing tumors they behave in an aggressive manner, frequently metastasizing to regional lymph nodes. Approximately 50% of the patients who develop metastasis to lymph nodes of the neck will survive five years. We present a case of meibomian gland carcinoma with preauricular lymph node metastasis, treated with orbital exenteration, superficial parotidectomy, and radical neck dissection.