The role of neck dissection in the treatment of supraglottic laryngeal cancer.
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Carcinoma, Squamous Cell↗
Biomedical subjects
C E Silver
Publications and source records attributed to C E Silver.
The role of partial laryngeal resection in current management of laryngeal cancer: a collective review.
A spectrum of treatment plans and surgical procedures is available for management of early and moderately advanced laryngeal cancer. While the approach of chemotherapy and irradiation, or irradiation alone, followed by total laryngectomy for failure is often employed in practice by present day clinicians, the options of conventional conservation surgery (CCS), transoral endoscopic laser surgery (TLS) and supracricoid partial laryngectomy (SCPL) provide a wide choice of treatments that may help attain the goal of cure with preservation of laryngeal function and integrity of the airway. While CCS has been supplanted for many early-stage lesions by TLS and for more advanced stages by SCPL, centres throughout the world have reported favourable results with CCS, which is often modified to include resection of more extensive tumours than was previously possible. During the past decade a number of extended CCS procedures have been developed for management of glottic tumours involving both vocal cords and the anterior commissure, the paraglottic space and with vocal cord fixation, and for supraglottic tumours involving the glottis or hypopharynx. TLS has proved an effective, minimally invasive and functionally satisfactory procedure for management of suitable T1 and T2 glottic cancers, and stage I-III supraglottic cancers. The procedure may be effectively employed in combination with neck dissection and postoperative radiotherapy when necessary, particularly for moderately advanced supraglottic carcinomas. SCPL has proven effective in management of glottic and supraglottic cancers of all stages, even with involvement of paraglottic space and thyroid cartilage, provided at least one arytenoid unit can be preserved with clear margins. Invasion of cricoid cartilage is the most significant limitation for this procedure. All three surgical approaches have been employed for irradiation failure, but with greatly increased failure and complication rates compared with the results of treatment of non-irradiated patients. Thus a decision to treat laryngeal cancer initially with irradiation may preclude a satisfactory result from partial laryngectomy should radiation fail. The treatment of laryngeal cancer should be individualized according to the size and extent of the tumour, the age and physical condition of the patient, and the skill and experience of the surgeon with various treatment modalities and surgical procedures.
Combined Modality Therapy↗
Recurrent acute suppurative thyroiditis in an adult due to a fourth branchial pouch fistula.
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Acute Disease↗
Benign parotid hypertrophy on +HIV patients: limited late failures after external radiation.
PURPOSE: Although 8-10 Gy of external radiation therapy for +HIV associated parotid hypertrophy has achieved high response rates, the responses were transient with only 1/12 of patients retaining cosmetic control at median follow-up procedures of 9.5 months. Retreatment for failures after 8-10 Gy has also been unsatisfactory. Having shown that 24 Gy of external radiation therapy for benign parotid hypertrophy produced more durable cosmetic control than 8-10 Gy, we now report on longer follow-up periods on a group of patients receiving 24 Gy. MATERIALS AND METHODS: Twenty +HIV patients with clinical and radiographic evidence of lymphoepithelial lesions of the parotid were treated with 24 Gy of external radiation therapy using daily 1.5 Gy fractions; parallel opposed technique and 6 MV photons were used in 19 patients, and unilateral electron treatment was performed for one patient. RESULTS: With a mean follow-up period of 24 months, the cosmetic control appears durable. We have had no late failures past 24 months. Two patients have complained of modest xerostomia. There was no correlation with size of the cyst and eventual cosmetic result. CONCLUSIONS: Twenty-four Gy produces durable parotid control for HIV associated lymphoepithelial lesions of the parotid glands in +HIV patients. Failures after 2 years are uncommon and the side effects have been tolerable.
Female↗
Close or positive margins after surgical resection for the head and neck cancer patient: the addition of brachytherapy improves local control.
PURPOSE: Microscopically positive or close margins after surgical resection results in an approximately 21-26% local failure rate despite excellent postoperative external radiation therapy. We sought to demonstrate improved local control in head and neck cancer patients who had a resection with curative intent, and had unexpected, microscopically positive or close surgical margins. METHODS AND MATERIALS: Twenty-nine patients with microscopically close or positive margins after curative surgery were given definitive, adjuvant external radiation therapy and 125I brachytherapy. All 29 patients had squamous cell cancer and tonsil was the most common subsite within the head and neck region. After external radiation therapy and thorough discussions with the attending surgeon and pathologists, the slides, gross specimens, and appropriate radiographs were reviewed and a target volume was determined. The target volume was the region of the margin in question and varied in size based on the surgery and pathologic results. Once the target volume was identified the patient was taken back to the operating room for insertion of 125I seeds. Activity implanted (range 2.9-21.5 millicuries) was designed to administer a cumulative lifetime dose of 120-160 Gy. RESULTS: Twenty-nine patients were followed for a median of 26 months (range 5-86 months). Two-year actuarial local control was 92%. CONCLUSION: 125I, after external radiation therapy, is an excellent method to improve local control in the subset of patients with unexpectedly unsatisfactory margins.
Brachytherapy↗
A phase I clinical trial of prolonged infusion of hydroxyurea in combination with hyperfractionated, accelerated, external radiation therapy in patients with advanced squamous cell cancer of the head and neck.
BACKGROUND: Preclinical data suggested that sustained inhibition of the anabolic enzyme, ribonucleotide reductase (RR), by hydroxyurea (HU) may be critical for the anticancer effects of the drug. A phase I trial of continuous infusion HU with concomitant hyperfractionated, accelerated radiation therapy (CHU-CHRT) was initiated to determine the maximum tolerated dose (MTD) and dose limiting toxicities (DLT) of HU in patients with locally advanced squamous cell carcinoma (SCC) of the head and neck. METHODS: Patients were required to have histologically-documented and radiographically-staged locally advanced SCC of the hypopharynx (AJC stages II, III or IV), oropharynx (AJC stage IV), or oral cavity (AJC stage IV) not amenable to reasonable surgical resection. Eligible patients had adequate bone marrow, hepatic, and renal function and had to give informed consent. Concomitant, hyperfractionated, accelerated radiation therapy (CHRT) consisted of 1.2 Gy BID (6 hour minimum interfraction interval) on weekdays and 1.2 Gy delivered daily on the weekends to a total tumor dose of 74.4 Gy. Continuous infusion hydroxyurea (CHU) was administered at 0.25-0.375 mg/m2/min as a continuous intravenous infusion daily for 5 days with weekends days off for the duration of the radiation therapy. The dose of HU was increased by 0.125 mg/m2/min between dose levels until DLT was reached in 2/6 patients. If the primary had a complete clinical response and biopsies were negative, planned neck dissections were performed. RESULTS: Fifteen patients were enrolled and are evaluable. The initial dose level, 0.25 mg/m2/min was tolerated by 3/3 patients. At 0.375 mg/m2/min, 3/6 patients experienced grade 3-4 infections, with one patient having a non-fatal, subendocardial infarction. At 0.313 mg/m2/min, no patient experienced DLT. CONCLUSION: The MTD for CHU-CHRT was 0.313 mg/m2/min. The toxicities were primarily mucosal and a phase II study is in progress.
Adult↗
Kaposi's sarcoma of the parotid gland in acquired immunodeficiency syndrome.
Parotid gland enlargement is common in patients infected with the human immunodeficiency virus. Although parotitis is the usual histopathological feature in such cases, patients with acquired immunodeficiency syndrome are at high risk of developing both lymphoma and Kaposi's sarcoma of the parotid gland. Human immunodeficiency virus, however, is not detected within the parotid parenchyma even in the presence of Kaposi's sarcoma. The pathway of the virus' entry into the saliva remains unknown.
Acquired Immunodeficiency Syndrome↗
Preoperative parathyroid localization with sestamibi.
PURPOSE: Results of noninvasive preoperative parathyroid localization with technetium99m-labeled sestamibi are reported in a series of 51 patients. PATIENTS AND METHODS: Forty-four patients had hyperparathyroidism surgically treated for the first time and seven patients underwent reexploration for recurrent or persistent hyperparathyroidism. Preoperative scintigraphy with sestamibi was performed in all patients before surgical exploration. Results of the radionuclide studies were compared with surgical and pathologic findings. RESULTS: Twenty-six patients had solitary adenomas. All 26 were localized preoperatively by the scans. Among 18 patients with multiglandular pathology, 69 pathological glands were found at surgery. Thirty-six of these glands, in 15 patients, were localized by the scans. Among the 7 patients evaluated after failed exploration or recurrent hyperparathyroidism, 7 pathologic glands were found, of which 6 were correctly localized by the scan. Ectopic lesions in 2 patients were correctly localized by the scan. CONCLUSIONS: The authors conclude that sestamibi parathyroid localization is an effective method for preoperative parathyroid localization, with accuracy exceeding that of other noninvasive studies.
Adenoma↗
Cosmetic control of parotid gland hypertrophy using radiation therapy.
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Adult↗
Laryngeal paraganglioma versus atypical carcinoid tumor.
Paraganglioma and atypical carcinoid tumor of the larynx are two neuroendocrine neoplasms that have often been confused in the past, and even in the present, in the literature. The clinicopathological profile of the two lesions is presented and the differential diagnosis is discussed. A correct diagnosis is of paramount importance, since treatment and prognosis depend on diagnostic accuracy and differ for the two lesions. Paraganglioma of the larynx is usually benign, whereas atypical carcinoid tumor is malignant and has an aggressive clinical course.
Adolescent↗
Cartilaginous tumors of the larynx.
Cartilaginous tumors of the larynx, while rare, will on occasion be encountered by the otolaryngologist in routine daily practice. True laryngeal chondromas are exceedingly rare, and as a consequence, a putative diagnosis of chondroma should be viewed with suspicion. On pathologic examination, laryngeal chondromas usually prove to be small lesions (less than 2 cm in maximum dimension) and may arise in children or adults. Laryngeal chondrosarcomas, by contrast, usually prove to be larger lesions (exceeding 3 cm in greatest dimension) and are typically found in adults. While high-grade chondrosarcomas are readily identifiable on light microscopic study, the distinction between a chondroma and a low-grade chondrosarcoma is often not so clear-cut. Some low-grade chondrosarcomas may show a slight increase in both cellularity and cytologic atypia when compared with chondromas, but the two patterns often overlap. When faced with a limited biopsy specimen of a laryngeal cartilaginous lesion in which neither increased cellularity nor recognizable cytologic atypia is found, a diagnosis of "cartilaginous tumor without obvious evidence of malignancy--further classification dependent on examination of the lesion in its entirety," or words to this effect, is recommended.
Chondroma↗
New barriers to ventricular invasion in paraglottic laryngeal cancer.
BACKGROUND: Anatomic barriers to the spread of laryngeal cancer include the conus elasticus, the quadrangular membrane, and the thyroid cartilage. It has been speculated that an elastic barrier surrounds and protects the ventricle. METHODS: The authors studied the microanatomic patterns of spread of 17 cases of patients who had laryngeal cancer with paraglottic disease and confirmed their findings by examining normal autopsy specimens. RESULTS: Five patients of the seventeen cases showed no ventricular mucosal involvement despite extensive paraglottic disease. Both an inner, central, subepithelial periventricular elastic membrane barrier were identified; the latter was in continuity with the conus elasticus and quadrangular membrane. CONCLUSIONS: Two weak fibroelastic barriers surround the ventricle. The outer, peripheral, fibroelastic membrane is contiguous with the conus elasticus and the quadrangular membrane. Therefore, ventricular involvement is not a sensitive indicator of paraglottic spread. Squamous cell cancer may grow around the periventricular barriers to involve both the true and false cords but may spare the ventricle. The prognostic significance of the violation or preservation of the periventricular elastic barriers is unknown.
Carcinoma, Squamous Cell↗
Parathyroid re-exploration.
The authors evaluated their experience with 27 patients who required parathyroid re-explorations. The initial exploration was unsuccessful in 20 patients: in 8 because of ectopic lesions, in 2 because of undetected supernumerary glands, and in 10 because of inadequate exploration of the neck. All of the patients with inadequate neck explorations were found to have eutopic disease. Seven patients required re-exploration because of recurrent disease. Localization studies were performed prior to re-explorative surgery in 26 of 27 patients, which resulted in successful placement in 21. Invasive procedures, selective vein catheterization, and/or arteriography were effective in 12 of 15 patients. Noninvasive procedures, including thallium-technetium scintigraphy, magnetic resonance imaging, computed tomography, and ultrasonography, were accurate in 14 of 21 patients. Twenty-three (85%) of 27 patients were cured, including 17 of 20 patients after an unsuccessful initial exploration and 6 of 7 patients with recurrent disease. Careful review of operative and pathology reports from the initial surgery was essential in determining the adequacy of the exploration, the presence of microscopic abnormalities, and the glands that were positively identified. Such analysis, in conjunction with noninvasive localization studies, will lead to successful re-exploration in the majority of cases.
Chronic Disease↗
Surgical approach to submucosal lesions of the supraglottic larynx: the supero-lateral thyrotomy.
The surgical approach to the hypopharynx by lateral pharyngotomy as described by Trotter has found widespread use in management of supraglottic carcinoma. A similar but more conservative approach may be employed for removal of cysts and benign or well-encapsulated neoplasms of the epiglottis and supraglottic space. We call this approach a supero-lateral thyrotomy, to differentiate it from the classic lateral pharyngotomy. Surgery consists of subperichondrial resection of the superior half of the ipsilateral thyroid cartilage with preservation of internal lining and superior laryngeal nerve. The lesion may then be enucleated or resected, and the defect, if any exists, closed with overlying mucosa and the flap of preserved perichondrium. The technique has been employed in cases of paraganglioma, haemangiopericytoma and saccular cysts.
Aged↗
Treatment of neuroendocrine neoplasms of the larynx.
The best treatment for carcinoid tumor is surgical excision. The mainstay of treatment for atypical carcinoid tumor is wide surgical resection, often with elective neck dissection. Although it is not effective in the management of paragangliomas and carcinoid tumors, primary radiation therapy with adjuvant chemotherapy is the treatment of choice for small cell neuroendocrine carcinoma of the larynx. Management of laryngeal paraganglioma is surgical and may often be accomplished by partial laryngectomy. Most tumors are supraglottic and may be resected via modified lateral pharyngotomy. Preoperative angiography and embolization are occasionally useful.
Carcinoid Tumor↗
Fine-needle aspiration of parotid tumors.
We evaluated the accuracy and usefulness of fine-needle aspiration cytologic evaluation of intraparotid masses in 64 patients who underwent subsequent surgery. Adequate specimens for cytologic evaluation were obtained in 46 of the 64 patients (72 percent). Thirty-three lesions in this group (72 percent) were benign and 13 (28 percent) were malignant. There was agreement of cytologic with final histologic diagnosis with regard to distinction of malignant from benign lesions in 43 of the 46 cases (93 percent). Eleven of 13 malignant tumors (sensitivity 85 percent) and 32 of 33 benign lesions (specificity 97 percent) were predicted. Exact tissue diagnosis was correctly determined in 34 of the 46 tumors (74 percent). There were no instances of hematoma, infection, facial nerve injury, implantation of tumor, or other complications as a result of 71 aspirations performed in 64 patients. Information gained by fine-needle aspiration was often valuable in assessing the suitability and extent of surgical treatment.
Biopsy, Needle↗
Replacement of upper esophagus: results with myocutaneous flap and with gastric transposition.
The authors reviewed 25 cases of pharyngoesophageal replacement. A tubed pectoralis major myocutaneous flap was employed in ten cases where an adequate distal resection margin could be obtained above the thoracic inlet. Total gastric transposition was used in 15 cases where resection extended into the mediastinum. The overall rates of complications (52%), postoperative mortality (20%), and satisfactory deglutition (80%) were similar for both operations and were superior to those achieved with reconstructive procedures previously used by the authors. The choice of method is influenced by the length of the pharyngoesophagus to be replaced and the general condition of the patient. Gastric transposition is a more versatile operation and is adaptable to replacement of the entire esophagus if necessary, while the tubed pectoralis major myocutaneous flap has proven particularly effective for the rehabilitation of elderly and severely debilitated patients.
Aged↗
Intraoperative histologic evaluation in exploration of the parathyroid glands.
In this review, 123 explorations for primary hyperparathyroidism were performed, at which at least three glands were identified and specimens were taken for biopsy. Gross operative and histologic findings were evaluated and correlated with follow-up data. A new classification for disease of the parathyroid glands is devised in which microhyperplasia occurring in grossly normal glands is subclassified into two groups. One (Class II), consisting of hypercellularity only, is thought not to produce clinical hyperparathyroidism. The second group (Class III), which includes glands with nodular hyperplasia, abnormal cytologic findings or oxyphilic nodules, is considered clinically significant. Evaluation and follow-up study revealed three instances of clinical hyperparathyroidism attributed to Class III histologic changes, while there were no instances of recurrent or persistent hyperparathyroidism attributable to Class II disease. Involvement of multiple glands, both gross and microscopic, occurred frequently (26 per cent) and was often bilateral and nonuniform. We concluded that optimal surgical management of primary hyperparathyroidism is achieved by selective removal of parathyroid glands guided by the histologic findings in each gland.
Adult↗