Feasibility and safety of neck level IB-sparing radiotherapy in nasopharyngeal cancer: a long-term single institution analysis

Purpose@#Nasopharyngeal cancer (NPC) has a higher prevalence of regional nodal metastasis than other head and neck cancers; however, level IB lymph node involvement is rare. We evaluated the safety and feasibility of level IB-sparing radiotherapy (RT) for NPC patients. @*Materials and Methods@#We retrospectively reviewed 236 patients with NPC who underwent definitive intensity-modulated RT with or without chemotherapy between 2004 and 2018. Of them, 212 received IB-sparing RT, and 24 received non-IB-sparing RT. We conducted a propensity score matching analysis to compare treatment outcomes according to IB-sparing status. In addition, dosimetric analysis of the salivary glands was performed to identify the relationship between xerostomia and the IB-sparing RT. @*Results@#The median follow-up duration was 78 months (range, 7 to 194 months). Local, regional, and distant recurrences were observed in 11.9%, 6.8%, and 16.1% of patients, respectively. Of the 16 patients with regional recurrence, 14 underwent IB-sparing RT. The most common site categorization of regional recurrence was level II (75%), followed by retropharyngeal lymph nodes (43.8%); however, there was no recurrence at level IB. In the matched cohorts, IB-sparing RT was not significantly related to treatment outcomes. However, IB-sparing RT patients received a significantly lower mean ipsilateral and contralateral submandibular glands doses (all, p < 0.001) and had a lower incidence of chronic xerostomia compared with non-IB-sparing RT patients (p = 0.006). @*Conclusion@#Our results demonstrated that IB-sparing RT is sufficiently safe and feasible for treating NPC. To reduce the occurrence of xerostomia, IB-sparing RT should be considered without compromising target coverage.

Radiotherapy versus Surgery in Early-Stage HPV-Positive Oropharyngeal Cancer / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This study aimed to compare the outcomes of primary radiotherapy (RT) versus surgery in early-stage human papilloma virus–positive oropharyngeal squamous cell carcinoma (hpv+OPC), and investigate the preoperative clinical factors that can predict the requirement for postoperative adjuvant treatment. @*Materials and Methods@#This multicenter study included 166 patients with American Joint Committee on Cancer 8th edition-Stages I-II hpv+OPC. Sixty (36.1%) and 106 (63.9%) patients underwent primary (concurrent chemo)radiotherapy [(CC)RT] and surgery, respectively. Seventy-eight patients (73.6%) in the surgery group received postoperative (CC)RT. @*Results@#With a median follow-up of 45.6 months for survivors, the 2-year overall survival (OS), progression-free survival (PFS), and locoregional control (LC) for RT/surgery were 97.8%/96.4%, 91.1%/92.0%, and 92.9%/93.3%, respectively. In multivariate analyses, patients with synchronous radiologic extranodal extension and conglomeration (ENEcong) of metastatic lymph nodes (LNs) showed significantly poorer OS (p=0.047), PFS (p=0.001), and LC (p=0.003). In patients undergoing primary surgery, two or more clinically positive LN metastases (odds ratio [OR], 5.15; p=0.004) and LN metastases with ENEcong (OR, 3.75; p=0.009) were predictors of postoperative chemoradiotherapy. No patient in the primary RT group demonstrated late severe toxicity whereas three (2.8%), one (0.9%), and one (0.9%) patient in the surgery group showed grade 3 dysphagia, grade 3 xerostomia, and fatal oral cavity bleeding. @*Conclusion@#We found no differences in OS, PFS, and LC between upfront RT and surgery in stage I-II hpv+OPC which warrants comparison through a prospective trial in the treatment de-escalation era. However, most early-stage hpv+OPC patients undergoing surgery received adjuvant (CC)RT. Pretreatment LN findings were prognostic and predictive for adjuvant treatment.

Survival Benefits From Surgery for Stage IVa Head and Neck Squamous Cell Carcinoma: A Multi-Institutional Analysis of 1,033 Cases

Objectives@#. Head and neck squamous cell carcinomas (HNSCs) are frequently diagnosed at the locoregional advanced stage (stage IVa), but controversy remains regarding whether stage IVa HSNCs should be treated with upfront surgery or definitive chemoradiation therapy (CRT). The purpose of this study was to compare overall survival (OS) and disease-free survival (DFS) in patients with stage IVa HNSC treated primarily by surgery with curative intent with/without (neo)adjuvant treatment (surgery group) versus those treated primarily with CRT (CRT group). @*Methods@#. We reviewed data of 1,033 patients with stage IVa HNSC treated with curative intent at 17 cancer centers between 2010 and 2016. @*Results@#. Among 1,033 patients, 765 (74.1%) received upfront surgery and 268 (25.9%) received CRT. The 5-year OS and DFS rates were 64.4% and 62.0% in the surgery group and 49.5% and 45.4% in the CRT group, respectively. In multivariate analyses, OS and DFS were better in the surgery group than in the CRT group (odds ratio [OR] for death, 0.762; 95% confidence interval [CI], 0.592–0.981; OR for recurrence, 0.628; 95% CI, 0.492–0.802). In subgroup analyses, the OS and DFS of patients with oropharyngeal cancer were better in the surgery group (OR for death, 0.548; 95% CI, 0.341–0.879; OR for recurrence, 0.598; 95% CI, 0.377–0.948). In the surgery group, patients with laryngeal cancer showed better OS (OR for death, 0.432; 95% CI, 0.211–0.882), while those with hypopharyngeal cancer DFS was improved (OR for recurrence, 0.506; 95% CI, 0.328–0.780). @*Conclusion@#. A survival benefit from surgery may be achieved even in patients with stage IVa HNSC, particularly those with oropharyngeal and laryngeal cancer. Surgery led to a reduction in the recurrence rate in patients with hypopharyngeal cancer.

Role of concurrent chemoradiation on locally advanced unresectable adenoid cystic carcinoma

Background/Aims@#Adenoid cystic carcinoma (ACC) is a rare salivary gland tumor characterized by indolence, with a high rate of local recurrence and distant metastasis. This study aimed to investigate the effect of concurrent chemoradiation (CCRT) on locally advanced unresectable ACC. @*Methods@#We retrospectively analyzed clinical data from 10 patients with pathologically confirmed ACC of the head and neck who received CCRT with cisplatin in Seoul National University Hospital between 2013 and 2018. @*Results@#Ten patients with unresectable disease at the time of diagnosis or with positive margins after surgical resection received CCRT with weekly cisplatin. Eight patients (80%) achieved complete remission, of which three later developed distant metastases without local relapse; one patient developed distant metastasis and local relapse. Two patient achieved partial remission without progression. Patients experienced several toxicities, including dry mouth, radiation dermatitis, nausea, and salivary gland inflammation of mostly grade 1 to 2. Only one patient showed grade 3 oral mucositis. Median relapse-free survival was 34.5 months (95% confidence interval, 22.8 months to not reached). @*Conclusions@#CCRT with cisplatin is effective for local control of ACC with manageable toxicity and may be an effective treatment option for locally advanced unresectable ACC.

Usage and Diagnostic Yield of Fine-Needle Aspiration Cytology and Core Needle Biopsy in Thyroid Nodules: A Systematic Review and Meta-Analysis of Literature Published by Korean Authors

Objectives@#. The usefulness of core needle biopsy (CNB) for the diagnosis of thyroid nodules remains controversial, and preferences vary across hospitals. The purpose of this study was to assess the actual use of CNB in Korea and to analyze the advantages and disadvantages of CNB through a systematic review and meta-analysis of papers published by Korean authors. @*Methods@#. A meta-analysis of full-text publications published in English presenting data from Korea retrieved from the Embase literature database was performed. @*Results@#. CNB led to a significantly lower proportion of non-diagnostic results than fine-needle aspiration (FNA). However, the frequency of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) did not decrease as a result of performing CNB in nodules with initial AUS/FLUS results, while it increased in consecutive cases. A subcategory analysis of AUS/FLUS showed that the increased frequency of AUS/FLUS findings on CNB was due to more frequent diagnoses of architectural atypia and follicular neoplasm, which resulted in a higher frequency of inconclusive findings in consecutive cases compared to FNA. Hospitals favoring CNB had a higher proportion of AUS/FLUS diagnoses. Although the complication rate did not differ significantly between CNB and FNA, serious complications of CNB did occur. @*Conclusion@#. A reduced frequency of non-diagnostic results may be a definite advantage of CNB over FNA. However, the increased frequency of diagnoses of architectural atypia and follicular neoplasm should be considered when selecting CNB as a diagnostic tool.

Survival Benefits From Surgery for Stage IVa Head and Neck Squamous Cell Carcinoma: A Multi-Institutional Analysis of 1,033 Cases

Objectives@#. Head and neck squamous cell carcinomas (HNSCs) are frequently diagnosed at the locoregional advanced stage (stage IVa), but controversy remains regarding whether stage IVa HSNCs should be treated with upfront surgery or definitive chemoradiation therapy (CRT). The purpose of this study was to compare overall survival (OS) and disease-free survival (DFS) in patients with stage IVa HNSC treated primarily by surgery with curative intent with/without (neo)adjuvant treatment (surgery group) versus those treated primarily with CRT (CRT group). @*Methods@#. We reviewed data of 1,033 patients with stage IVa HNSC treated with curative intent at 17 cancer centers between 2010 and 2016. @*Results@#. Among 1,033 patients, 765 (74.1%) received upfront surgery and 268 (25.9%) received CRT. The 5-year OS and DFS rates were 64.4% and 62.0% in the surgery group and 49.5% and 45.4% in the CRT group, respectively. In multivariate analyses, OS and DFS were better in the surgery group than in the CRT group (odds ratio [OR] for death, 0.762; 95% confidence interval [CI], 0.592–0.981; OR for recurrence, 0.628; 95% CI, 0.492–0.802). In subgroup analyses, the OS and DFS of patients with oropharyngeal cancer were better in the surgery group (OR for death, 0.548; 95% CI, 0.341–0.879; OR for recurrence, 0.598; 95% CI, 0.377–0.948). In the surgery group, patients with laryngeal cancer showed better OS (OR for death, 0.432; 95% CI, 0.211–0.882), while those with hypopharyngeal cancer DFS was improved (OR for recurrence, 0.506; 95% CI, 0.328–0.780). @*Conclusion@#. A survival benefit from surgery may be achieved even in patients with stage IVa HNSC, particularly those with oropharyngeal and laryngeal cancer. Surgery led to a reduction in the recurrence rate in patients with hypopharyngeal cancer.

Risk of Microvascular Anastomosis Performed in Previous Treated Neck / 대한이비인후과학회지

Background and Objectives@#This study aimed to determine if a microvascular anastomosis on the neck, which had previously been treated, increases the risk of early complications, such as flap failure or hemorrhage and venous congestion that necessitates re-exploration.Subjects and Method A retrospective review was conducted on 274 cases of tumor resection with simultaneous free flap reconstruction from 2005 to 2019. Flap failure and re-exploration rate was evaluated according to the clinical variables including treatment history of recipient vessels. @*Results@#Twenty-one (7.7%) cases of flap failure were identified and re-exploration was conducted in 51 (18.6%) cases. Although the failure rate appeared to be high when micro-anastomosis was performed in the neck, where neck dissection with radiotherapy was previously performed (22.7%), there was no statistical significance compared with no previous treatment group. Previous neck dissection with irradiation was found to influence re-exploration {odds ratio (OR)=3.674 [95% confidence interval (CI) 1.348–10.014, p=0.011]} compared to no treatment. However, previous radiotherapy or surgery only did not show any significant difference compared to the untreated group. Venous congestion was the most common cause of re-exploration (50.1%), followed by hematoma (33.3%), and previous neck dissection with radiotherapy increased the risk of both [OR for venous congestion=3.056 (95% CI 1.009–9.255)], p=0.048, OR for hematoma=6.286 (95% CI 1.679–23.526), p=0.006] compared with no previous treatment. Radiotherapy alone did not change the risk of early complication. @*Conclusion@#Micro-anastomosis in a previously treated neck is feasible in terms of flap failure. However, micro-anastomosis in a neck, where neck dissection with radiotherapy were performed, may be more likely to cause complications such as venous congestion and hematoma that necessitate re-exploration.

The Usefulness of Medial Sural Artery Perforator Free Flap for Head and Neck Reconstruction / 대한이비인후과학회지

Background and Objectives@# The ideal flap for head and neck reconstruction should be pliable, have sufficiently long pedicle and minimize donor defects. Anterolateral thigh free flap (ALTFF) and radial forearm free flap (RFFF) have been the workhorse flaps for head and neck reconstruction. However, ALTFF is too bulky and RFFF leaves a conspicuous scar on the donner site. Medial sural artery perforator free flap (MSAPFF) is a possible alternative, which has the benefit of thin RFFF and low donor site morbidity of ALTFF. Here, we evaluated for the first time the usefulness of MSAPF for head and neck reconstruction in Korean patients. Subjects and Method We carried out a retrospective study of patients who underwent MSAPFF for head and neck reconstruction from October 2018 to July 2019 by retrieving their data from electronic medical records. Patient characteristics, flap characteristics, surgical outcomes, and complications of donor sites were analyzed. @*Results@# Eight patients underwent MSAPFF reconstruction after head and neck surgery. The recipient sites were the following: the floor of the mouth, palate, tongue, the base of the tongue and nasolabial fold. The average median flap size was 34.1 cm2 (range 17.5-50 cm2), length 7.1 cm (5.0-10.0 cm), width 4.7 cm (range 3.5-5.0 cm), and pedicle length 9.2 cm (range 8-10 cm). There was one flap failure because of pedicle arterial insufficiency. All donor sites were closed primarily without any complication. @*Conclusion@# Based on the findings of this study, MSAPFF may be a new workhorse flap because it has thin, pliable tissue with low donor-site morbidity for head and neck reconstruction.

Re-irradiation for recurrent or second primary head and neck cancer

Purpose@#To investigate the efficacy and safety of intensity-modulated radiotherapy (IMRT)-based re-irradiation (reRT) for recurrent or second primary head and neck cancer (HNC). @*Materials and Methods@#Patients who underwent IMRT-based reRT for recurrent or second primary HNC between 2007 and 2019 at two institutions were included. Medical records and dosimetric data were retrospectively reviewed. Overall survival (OS), progression-free survival (PFS), severe late toxicities, and clinicopathological prognostic factors were analyzed. @*Results@#A total of 42 patients were analyzed. With a median follow-up of 15.1 months (range, 3.7 to 85.8 months), the median OS was 28.9 months with a 2-year OS rate of 54.6%. The median PFS and 2-year PFS rates were 10.0 months and 30.9%, respectively. Multivariate analysis showed that good performance (Eastern Cooperative Oncology Group [ECOG] 0 or 1), a longer time interval (≥24 months) between radiotherapy courses, and higher reRT dose (>60 Gy) were significantly favorable factors for OS (all p < 0.05). Higher reRT dose and salvage surgery were significantly associated with improved PFS (all p < 0.05). Regarding the Multi‐Institution Reirradiation (MIRI) Collaborative RPA classification, the 2-year OS rates of each class were 87.5% in class I, 51.8% in class II, and 0% in class III (p = 0.008). Grade ≥3 late toxicity was reported in 10 (23.8%) patients. There was no significant factor associated with increased late toxicities. @*Conclusion@#IMRT-based reRT should be considered as a treatment option for patients with recurrent or second primary HNC. Further trials are needed to establish a subset of patients who may benefit from reRT without severe late toxicity.

Failure patterns of cervical lymph nodes in metastases of unknown origin according to target volume

Purpose@#This study was aim to evaluate the patterns of failure according to radiotherapy (RT) target volume for cervical lymph nodes in metastases of unknown primary origin in head and neck region (HNMUO). @*Materials and Methods@#Sixty-two patients with HNMUO between 1998 and 2016 were retrospectively reviewed. We analyzed the clinical outcomes and primary site failure depending on the radiation target volume. The target volume was classified according to whether the potential head and neck mucosal sites were included and whether the neck node was treated involved side only or bilaterally. @*Results@#Potential mucosal site RT (mucosal RT) was done to 23 patients and 39 patients did not receive mucosal RT. Mucosal RT showed no significant effect on overall survival (OS) and locoregional recurrence (LRR). The location of primary site failure encountered during follow-up period was found to be unpredictable and 75% of patients with recurrence received successful salvage therapies. No significant differences in OS and LRR were found between patients treated to unilateral (n = 35) and bilateral neck irradiation (n = 21). Treatment of both necks resulted in significantly higher mucositis. @*Conclusions@#We found no advantages in OS and LRR of patients with HNMUO when mucosal sites and bilateral neck node were included in the radiation target volume.

The Effect of Prophylactic Central Neck Dissection During Hemithyroidectomy on Locoregional Recurrence in Patients With Papillary Thyroid Carcinoma: A Meta-Analysis

Objectives@#. Hemithyroidectomy is commonly performed in patients with low- to intermediate-risk papillary thyroid carcinoma. The purpose of this meta-analysis was to evaluate the effect of prophylactic central neck dissection on locoregional recurrence in patients undergoing hemithyroidectomy. @*Methods@#. A meta-analysis was performed of full-text publications published in English retrieved from the Embase database. @*Results@#. The rate of regional recurrence in the central compartment after hemithyroidectomy, with or without prophylactic central neck dissection, was 0.17% and 1.78%, respectively. This difference was statistically significant. Recurrence in the lateral compartment or contralateral thyroid was not affected by prophylactic central neck dissection; the overall rate of recurrence was 1.3% and 5.4%, respectively. @*Conclusion@#. Prophylactic central neck dissection significantly reduced the risk of recurrence in the central compartment in patients undergoing hemithyroidectomy.

Primary Treatment and Survival Outcomes in Oropharyngeal Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Oropharyngeal cancer is one of those cancers with increasing incidence, and the therapeutic choices remain controversial. This study aims to evaluate the influence of changes in the primary treatment on the prognosis of oropharyngeal cancer patients. SUBJECTS AND METHOD: A total of 135 patients treated for oropharyngeal cancer in a single institution from 2004 to 2017 were analyzed in this study. Disease-free survival rate and the 3-, 5-year survival rates were calculated according to various radical primary treatments, which included concurrent chemo-radiation or radiation therapy, and surgery. Other outcomes including functional outcomes and treatment duration were also reported. RESULTS: The proportion of patients who were no-evidence-of-disease state at the last follow up was 97.8% for the group who underwent surgery as radical primary treatment, followed by concurrent chemo-radiation or radiation therapy (84.1%). The five-year survival rate was 0.7963 [95% confidence interval (CI): 0.6746–0.8765] for the concurrent chemo-radiation or radiation therapy group and 0.9488 (95% CI: 0.8093–0.9870) for the surgery group. When surgery was chosen as radical primary treatment for appropriately selected patients, approximately 30% of the patients could avoid radiation therapy. Gastrostomy or admission for supportive care as functional outcome showed no significant difference between treatment groups. CONCLUSION: Our results show various treatment outcomes depending on the radical primary treatment. These results can be used in clinical decisions and patient counselling.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient's treatment goals.

Role of Immunohistochemistry in Fine Needle Aspiration and Core Needle Biopsy of Thyroid Nodules

OBJECTIVES: Immunohistochemistry (IHC) has been used for the diagnosis of indeterminate results in fine needle aspiration (FNA) of thyroid nodules. However, the role of IHC in core needle biopsy (CNB) is not clear and the efficacy of testing for molecular markers following CNB has not been evaluated. The aim of this study is to compare the role of IHC staining in CNB with that in FNA when examining thyroid nodules and to compare the sensitivity and usefulness of different molecular markers. METHODS: Consecutive cases of thyroid FNA and CNB accompanied by IHC from 2004 to 2014 were included in this study with retrospective review of medical record. The rate of remaining nondiagnostic result (unsatisfactory, atypia of undetermined significance or follicular lesion of undetermined significance [AUS/FLUS]) and rate of strong expression of each molecular marker according to the diagnosis were evaluated. RESULTS: IHC was more frequently performed in CNB with multiple molecular markers compared to FNA (38.1% vs. 2.8%, 3 or 4 markers [Gal-3, HBME-1, CK19, and CD56] vs. 1 marker [Gal-3]). In the CNB group, 11.3% remained as AUS/FLUS after IHC, and the rate remaining nondiagnostic was significantly less than in the FNA group (42.9%). Gal-3 and CK19 showed higher specificity and expressed mainly in conventional type of papillary carcinoma and HBME-1 showed higher sensitivity for the diagnosis of carcinoma with expression in both conventional type and follicular variant papillary thyroid carcinoma. CONCLUSION: With these data, we could conclude that IHC was more effective following CNB than following FNA.

Comparison of Treatment Outcomes for T3 Glottic Squamous Cell Carcinoma: A Meta-Analysis

OBJECTIVES: This study compared the survival outcomes, local control rate, and laryngeal preservation rate of various treatment strategies in the treatment of T3 squamous cell carcinoma of the glottis using proportional meta-analyses. METHODS: Twenty-five retrospective case-series studies were included in these analyses. Treatment strategies were classified as total laryngectomy (TL), open partial laryngectomy (PL), transoral laser microsurgery (TLM), chemo-radiation therapy (CRT), and radiation therapy (RT) alone. RESULTS: The overall survival rate and disease-specific survival rate among laryngeal preservation treatments did not differ from the overall survival rate of TL. However, the local control rate was lower with RT than TL and PL, and laryngeal preservation rates of TLM and CRT were higher than RT alone. CONCLUSION: Consideration of preservation of laryngeal function is necessary when treating T3 glottic squamous cell carcinoma. PL, TLM, and, CRT are considered more appropriate initial laryngeal preservation strategies if available.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Results of Free Flap Reconstruction After Ablative Surgery in the Head and Neck

OBJECTIVES: Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap donor site, recipient site, and learning curve. METHODS: The medical records of patients who underwent free flap reconstruction from 2004-2012 were reviewed retrospectively. One hundred and fifty free flaps were used in 134 patients, who had an average age of 57.7 years. The types of flaps applied, primary defect sites, success rates, results of salvage operations for compromised flap, and the learning curve were analyzed. RESULTS: The anterolateral thigh flap was preferred for the reconstruction of head and neck defects. The overall success rate was 90.7%, with 14 cases of failure. A total of 19 salvage operations (12.7%) for compromised flap were performed, and 12 flaps (63.2%) were salvaged successfully. Dependency on the facial vessels as recipient vessels was statistically different when oral and oropharyngeal defects were compared to hypopharyngeal and laryngeal defects. The learning curve for microvascular surgery showed decrease in the failure rate after 50 cases. CONCLUSION: The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.

Multiple Symmetric Lipomatosis (Madelung's Disease) of the Neck and Pharynx / 대한이비인후과학회지

Multiple symmetric lipomatosis (Madelung's disease) is an infrequent disease of unknown etiology. The typical characteristic of the disease is bulging, symmetric masses of fat tissue on the neck, upper extremities, and upper parts of the trunk. The disease strongly affects middle-aged men, people from Mediterranean regions and with alcohol abuse history. We report three cases of middle to old age males with long-standing multi-lobulated bulging of the neck, which gradually enlarged over many years. Of peculiar interest is one patient who presented with snoring and apnea together with typical findings of Madelung's disease. The case had involvement of the hypopharynx, which was successfully managed with microscopic laryngeal surgery with CO2 laser. The authors elucidate three cases of Madelung's disease found in the pharynx and neck, and report a review of the literature.

A Convenient and Less Invasive Technique of Labial Minor Salivary Gland Biopsy Using a Minimal Incision With a Needle Tip

OBJECTIVES: This study was to show the technique and to compare the usefulness and complications of biopsy using a minimal incision with a needle tip of the labial minor salivary glands with those of conventional incisional lip biopsy in the diagnosis of Sjogren's syndrome. METHODS: We retrospectively reviewed the medical records of the patients who had the labial minor salivary gland biopsy for the diagnosis of Sjogren's syndrome between January 2005 and December 2008. One hundred forty-three patients were enrolled in this study. The yields of diagnostic salivary tissues and complications of the biopsy using a minimal incision with a needle tip and the conventional incisional lip biopsy were compared. RESULTS: Out of 143 patients, 56 patients underwent the conventional incisional lip biopsy and 87 patients received the biopsy using a minimal incision with a needle tip. In the biopsy using a minimal incision with a needle tip group, adequate salivary gland tissues were obtained in 85 patients out of 87 patients (97.7%). In the conventional incisional lip biopsy group, adequate specimens were acquired in 44 patients out of 56 patients (78.6%). There was no complication after the biopsy using a minimal incision with a needle tip, whereas there was one patient complained transient numbness of the lip after the conventional incisional lip biopsy. CONCLUSION: The less invasive labial minor salivary gland biopsy using a minimal incision with a needle tip was easy to perform and safe and showed the better result than the conventional incisional lip biopsy in terms of the adequate specimen in the diagnosis of Sjogren's syndrome. So it might be a good alternative to the conventional incisional lip biopsy.

Analysis of Relationship between Burning Mouth Syndrome and Abnormality of Serum Examination / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The objective of this study was to determine whether the serum levels of zinc, vitamin B12, folic acid, iron, and fungus were correlated with symptoms of burning mouth syndrome (BMS) and to analyze the relationship between treatment responses and the results from serum examination. SUBJECTS AND METHOD: We analyzed data from 284 patients whose serum examination results recorded responses to treatment were available from June 2004 to November 2011. A total of 219 patients experienced burning sensation, while 65 patients experienced only globus symptoms or voice changes. RESULTS: Of the patients who experienced burning sensations, 5 (2.3%) had vitamin B12 deficiency, 23 (10.5%) had iron deficiency, 40 (24%) had zinc deficiency, but no patients had folic acid concentrations below the reference range. A total of 44 patients (25%) were fungus-positive. The comparison of the experimental and control treatment groups revealed that iron-deficient patients and fungal-positive patients were more frequently found in the experimental group (p=0.023 and p=0.010, respectively). Abnormalities in the serum or physical examinations were observed in 126 patients (57.5%). Symptomatic treatments were performed for both groups, which corrected abnormalities in serum examinations. CONCLUSION: The rates of fungus positivity and iron deficiency were higher in the BMS group. However, we did not identify a correlation between the response to treatment and serum examination of the analyzed elements or fungus examination. The total secondary oral burning rate was found to affect treatment modality.