Tumor growth inhibition and regression induced by photothermal vascular targeting and angiogenesis inhibitor retinoic acid.

The effect of photothermal vascular targeting, alone and in combination with antiangiogenic therapy, was evaluated using tumors produced in mice by transplantation of KB cells. Tumor growth inhibition and regression followed vascular damage produced by pulsed dye laser (PDL) radiation. Administration of the antiangiogenic agent all-trans-retinoic acid (RA) was associated with smaller average tumor volumes in the presence and absence of PDL irradiation, but this effect was not statistically significant. The ability of PDL photothermal vascular targeting to cause regression of tumors without harming normal tissue may be a consequence of preferential damage to supplying vessels at the tumor periphery.

Teaching models for Nd:YAG laser bronchoscopy.

A number of groups have demonstrated the efficacy of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser bronchoscopy for treatment of patients with selected tracheobronchial disorders. This therapy involves a new technology, the laser, and new adaptations of conventional rigid and flexible bronchoscopy that are unfamiliar to many bronchoscopists. We describe two teaching models for laser bronchoscopy that have been employed successfully in our laser courses. Using these models, bronchoscopists can become familiar with laser bronchoscopic equipment and appreciate the interaction of laser and soft tissue in a controlled setting in the laboratory before applying this therapy to patients.

Aspiration biopsy cytology of the salivary gland.

Aspiration biopsy by fine needle from the major salivary glands has been an under-utilized technic in the United States. To evaluate this form of biopsy, 69 patients with salivary gland enlargement were examined by this technic; 47 had confirmative histology. Characteristic ABC patterns were seen in the benign mixed tumor, the papillary cystadenoma lymphomatosum, the mucoepidermoid carcinoma, and malignancy metastatic to the salivary gland. These findings are described. The method proved complication-free and accurate and is recommended for all tumors of the salivary gland.

Diagnosis of infratemporal fossa tumors using percutaneous core needle biopsy.

Three patients with infratemporal fossa carcinomas presented with severe, unrelenting facial pain, weight loss, and 5th cranial nerve deficit. Erosion of the base of the skull at the foramen ovale was present in two of these patients. Histologic diagnosis of infratemporal fossa malignancy was obtained by needle biopsy of the foramen ovale region; the technique is described. This approach to the infratemporal fossa is preferred to the more complicated external surgical approach with its greater risk of morbidity. Surgical approaches to the infratemporal fossa are also reviewed. Two of the patients were treated with radiotherapy; the third refused further therapy. Supravoltage radiotherapy with curative intent is the recommended treatment because of the difficulty of an en bloc tumor resection in the infratemporal fossa. Radioactive gold seeds may be implanted through an external surgical approach to boost the local dose.

Diagnosis of salivary gland tumors by fine needle aspiration biopsy.

The cytologic findings of 51 smears obtained by fine needle aspiration biopsy from salivary gland masses were compared with the histologic findings of permanent sections. The overall concurrence rate between cytologic and histologic findings for being and malignant lesions was 91%. The diagnostic accuracy (exact histologic diagnosis) for the benign lesions was 87% and for the malignant tumors 60%. One case showed false-positive results and 1 case false-negative results. Fine needle aspiration biopsy has been found to be safe, free of complications, and helpful in the planning of treatment.

Histopathologic findings after cis-platinum bleomycin therapy in advanced previously untreated head and neck carcinoma.

Eleven patients with unresectable or marginally resectable (stage III and IV) cancer of the head and neck were treated according to protocol with preoperative chemotherapy, surgical resection, and postoperative radiotherapy. Chemotherapy consisted of a combination of cis-diamminedichloroplatinum (II) (cis-DDP), 120 mg/M2, and bleomycin, 15 mg/M2, given sequentially during a three week treatment period. Seven patients initially had unresectable lesions which became amenable to surgical resection after chemotherapy. All eleven patients had approximately a 25 to 100 per cent reduction in tumor size. Histopathologic examination after chemotherapy showed a marked tendency towards cellular differentiation and keratin formation. Tumor necrosis was conspicuous by its absence. These histologic changes appear to be different from those seen after the use of other chemotherapeutic agents and radiotherapy. The histopathologic results closely resemble those found after the administration of bleomycin alone, although considerably accentuated.

Prognostic indicators in induction cis-platinum bleomycin chemotherapy for advanced head and neck cancer.

A complete response to induction cis-platinum bleomycin chemotherapy significantly increases the probability of local tumor control and overall disease-free survival. Factors that favor a good response to chemotherapy are tumor histology (well differentiated), location of the primary site (oral cavity and oropharynx), nodal status (N0) and size of the primary lesion (t3 better than T4). Increased cellular maturation after chemotherapy correlates with an improved clinical response. The importance of induction and maintenance chemotherapy in the treatment of advanced head and neck cancer still needs to be determined with larger randomized series. Reliable predictors of therapy outcome are needed for realistic treatment planning, especially when the potential morbidity is considered.

Airway injury after tracheotomy and endotracheal intubation.

Iatrogenic airway injury after tracheotomy and endotracheal intubation continues to be a serious clinical problem. Endotracheal tubes cause pressure injury to the glottis and may result in severe commissural scarring that is difficult to treat. Tracheotomy tubes may result in severe stomal stenosis in the trachea or subglottic region, which is more amenable to surgical treatment. Both methods of airway intubation may result in pressure necrosis from the tube cuff that can be prevented by careful monitoring of inflation pressures. The technique of laryngotracheal resection and reconstruction has been well developed and may be applied successfully to most patients with subglottic and tracheal stenosis. The surgical treatment of glottic stenosis remains a challenge.

Laser applications in the trachea and bronchi: a comparative study of the soft tissue effects using contact and noncontact delivery systems.

A comparative study of laser soft tissue effects using carbon dioxide (CO2) and neodymium-yttrium aluminum garnet (Nd-YAG) lasers in contact and noncontact endoscopic delivery systems was done in the canine tracheobronchial tree to determine the best laser system for the specific disease. The CO2 laser bronchoscopic coupler, CO2 laser waveguide, Nd-YAG laser fiber, and Nd-YAG laser contact probe were used. A 5 mm diameter soft tissue injury exposing tracheal cartilage was made, and the power density for each laser modality was measured. Soft tissue effects were documented histologically using routine techniques and scanning electron microscopy acutely and at 1 week and 2 weeks after injury. The effects were similar with the CO2 laser coupler and the CO2 laser waveguide with comparable power densities. Compared with the CO2 laser, the Nd-YAG laser fiber caused more extensive and more difficult to control thermal damage in tissue. The Nd-YAG laser contact probe was capable of precise soft tissue ablation with minimal surrounding tissue damage and was associated with the most rapid healing. This study concluded that high power density with short exposures is desirable when treating benign disorders, such as tracheal stenosis, making the CO2 laser or Nd-YAG laser contact probe application a good choice. On the other hand, malignant tumors with a potential for hemorrhage are best treated with the Nd-YAG laser noncontact fiber system because of its superior coagulative effects.

Treatment of hereditary hemorrhagic telangiectasia by Nd-YAG laser photocoagulation.

Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) is an inherited abnormality of the vasculature characterized by abnormal subepidermal vessels. Frequent, sometimes severe, epistaxis often requiring blood transfusions is present in most patients. Septal dermatoplasty and estrogen have proved to be the most successful therapies. However, the frequency of failure in treatment has stimulated a search for an alternative therapy. The Nd-YAG laser was used at low-power settings (20-25 W) to treat 6 patients with hereditary hemorrhagic telangiectasia, all of whom had been treated previously using other modalities. Laser photocoagulation diminished the frequency and severity of hemorrhage in 5 of 6 patients without complications (6 to 9 month follow-up period). The Nd-YAG laser may be used repeatedly when new accessible lesions arise, and it appears to be a useful therapeutic option for this disease that is difficult to treat.

Neodymium-YAG laser photocoagulation of hemangiomas of the head and neck.

Hemangiomas of the head and neck region can be a therapeutic challenge depending on their size, flow rate, and location. The neodymium-yttrium aluminum garnet (Nd-YAG) laser was used to treat 16 pediatric and adult patients with cavernous, capillary, and mixed hemangiomas as well as hypertrophic port-wine stains of the head and neck. Low-power energy and intermittent short exposure accomplished photocoagulation with minimal damage to surrounding tissue. Follow-up study in these patients has ranged from 1 to 3 years with excellent results in 14 of 16 patients. Few complications and no major morbidity or mortality occurred. Photocoagulation of hemangiomas of the head and neck using the Nd-YAG laser appears to be an exciting new therapeutic option for this difficult problem. Further clinical study and follow-up appear to be warranted.

Fibrous histiocytoma of the parotid gland.

Fibrous histiocytomas are not uncommonly found in the head and neck region. These tumors, arising from the tissue histiocyte, generally behave in a benign fashion. An unusual case of a fibrous histiocytoma arising in the parotid gland is presented. The histopathology of these lesions as well as parotid neoplasms in children is reviewed. Wide local excision without sacrifice of important structures is the treatment of choice.

Pulsed-dye laser and retinoic acid delay progression of oral squamous cell carcinoma: a murine model.

OBJECTIVES/HYPOTHESIS: This study examined the role of the pulsed-dye laser (PDL) at 585 nm coupled with retinoic acid at therapeutic (5.0 mg/kg) and nontherapeutic (0.5 mg/kg) doses to delay the progression of cancer with a two-hit approach. The existing vasculature is selectively targeted by the laser, whereas retinoic acid inhibits future angiogenesis. STUDY DESIGN: Randomized, prospective study in a murine model. METHODS: Twenty-five athymic nude mice were inoculated with oral squamous cell cancers on six flank sites and randomly divided into five groups: 1) control subjects, 2) treatment with 0.5 mg/kg retinoic acid (RA 0.5), 3) treatment with 5.0 mg/kg retinoic acid (RA 5.0), 4) treatment with RA 0.5 + PDL, and 5) treatment with RA 5.0 + PDL. The PDL groups received irradiation after inoculation. The retinoic acid was administered daily. The tumors were counted and measured for 14 days. RESULTS: The control group developed visible tumors in 50% of the inoculation sites at 3 days compared with 3 days (RA 0.5) and 4 days (RA 5.0) for the retinoic acid groups and 9 days (RA 0.5 + PDL) and 10 days (RA 5.0 + PDL) for the laser treatment groups. There was no tumor growth until day 7 in the RA 5.0 + PDL group. The tumor volume was statistically different between the treatment groups. CONCLUSION: This study demonstrated the superiority of a single treatment with the PDL coupled with retinoic acid to delay the progression of cancer when compared with treatment with retinoic acid alone, thus introducing a novel strategy in cancer control.

Excisional biopsy in the selective management of T1 glottic cancer: a three-year follow-up study.

Transoral excisional biopsy has been used in the evaluation and management of 103 T1 glottic cancers. A 3-year follow-up on these patients indicates that excisional biopsy unequivocally established the diagnosis and stage of the disease and that it is adequate treatment for micro and mini squamous cell cancers of the glottis in which the margins of excision are clear. Excisional biopsy with positive margins and larger T1 tumors establishes the absolute need for radiotherapy. Excisional biopsy is ideal for the diagnosis and management of verrucous carcinoma and spindle cell carcinoma. Recurrent/residual squamous cell carcinoma after radiotherapy should be explored by excisional biopsy which may be curative or will establish the need for partial or total laryngectomy. The appropriate use of excisional biopsy in the selective management of early T1 glottic cancers requires attention to detail by the surgeon and the pathologist and sound clinical judgment.

Transtympanic endoscopy of the middle ear.

Modern optical technology has made available fiberoptic and rigid endoscopes with diameters of 2 mm and less with acceptable resolution. Endoscopes of small caliber were introduced through a strategically placed myringotomy or an existing perforation to perform exploration of the middle ear as an in-the-office procedure. This technique is now routinely used as an adjunct in the diagnostic evaluation of patients with suspected middle ear conditions. Exploratory surgery of the middle ear may be avoided or definitive procedures may be planned better based on endoscopic findings.

Tracheal anastomosis with the diode laser and fibrin tissue adhesive: an in vitro and in vivo investigation.

Absorbable sutures have been advocated for tracheal anastomosis to reduce fibrosis and foreign body reaction leading to recurrent stenosis. Fibrin tissue adhesive (FTA) and diode laser welding with indocyanine green-dyed fibrinogen were evaluated in tracheal anastomosis to reduce the number of sutures and to improve healing. In vitro studies demonstrated strong anastomoses with a combination of laser welding and FTA with minimal tissue damage. In a controlled in vivo study, circumferential resections of canine tracheas were repaired with laser welding and FTA augmented with a few stay sutures. These anastomoses had less fibrosis and tissue damage than anastomoses in control animals repaired with sutures alone. This study supports investigation of laser welding and FTA in human beings for tracheal anastomosis and other procedures in which suturing may be difficult.

Transoral management of localized carcinoma of the oral cavity using the CO2 laser.

Since 1972 we have been cautiously exploring the use of CO2 laser in the management of carefully selected cases of localized carcinoma of the oral cavity. At the present time our experience is based on the treatment of 57 patients with cancer of the oral cavity. The CO2 laser has been found to be an indispensable tool in the transoral management of T1 carcinomas, multiple superficial carcinoma, extensive leukoplakia and verrucous carcinoma. The laser allows precise excision of the lesion and involved mucosa and provides and excellent specimen for histologic verification of the margins. The morbidity of laser excision is minimal, so that a tracheotomy is not needed and patients can almost always be discharged on the following day. (Follow-up data on those patients at risk for 30 months indicate excellent control rates).

Neodymium-YAG laser intranasal photocoagulation in hereditary hemorrhagic telangiectasia: an update report.

Hereditary hemorrhagic telangiectasia is a challenging problem for the otolaryngologist since frequent, often severe epistaxis is the major symptom. Options for therapy in the past have included nasal packing, electrocautery, systemic estrogens, septal dermatoplasty, arterial embolization, and arterial ligation. Although successful treatment has been achieved with some of these methods, particularly septal dermatoplasty, other forms of therapy are needed prompting the use of laser photocoagulation. The neodymium yttrium-aluminum-garnet (Nd-YAG) laser was used to treat a group of 19 patients with hereditary hemorrhagic telangiectasia over a 4-year period without complications. Endonasal laser photocoagulation was effective in decreasing epistaxis in patients not requiring frequent transfusions prior to laser therapy. Three patients with the most severe epistaxis received minimal or no benefit from Nd-YAG laser photocoagulation. In most patients Nd-YAG photocoagulation is successful in treating epistaxis associated with hereditary hemorrhagic telangiectasia and should be a therapeutic option for this chronic disease having no available cure.

Echo-planar magnetic resonance imaging of deglutitive vocal fold closure: normal and pathologic patterns of displacement.

Abnormalities of vocal fold closure during deglutition predispose to aspiration due to impairment of airway protection. Conventional assessment of deglutitive vocal fold motion with laryngoscopy does not permit visualization through a complete adduction-abduction cycle. We determined spatiotemporal patterns of deglutitive vocal fold adduction through echo-planar magnetic resonance imaging in 15 normal volunteers and 6 patients with vocal fold paralysis. In normal volunteers, deglutitive vocal fold adduction was synchronized with laryngeal elevation, with complete vocal fold closure at the apex. Patients with unilateral vocal fold paralysis demonstrated reduced elevation and medial movement of the involved vocal fold. At maximal laryngeal elevation the uninvolved vocal fold attained a position superior to the paralyzed fold, resulting in level differences and an interglottic gap. Patients with bilateral vocal fold paralysis demonstrated reduced elevation and medial movement of both vocal folds. These findings indicate that normal and abnormal patterns of vocal fold displacement can be distinguished noninvasively through the use of echo-planar imaging.

A sliding chest wall flap for the management of advanced laryngeal carcinoma with anterior cervical skin invasion.

A reliable sliding chest wall flap, allowing extensive resection of tumors invading the anterior cervical skin is described. There has been no instance of failure or significant complication in the use of this flap in this small series of cases presented. It is believed that its use has allowed more extensive resection of tumor without any increase in morbidity, and may account for the prolonged survival seen in four out of six patients.