Transnasal, transfacial, anterior skull base resection of olfactory neuroblastoma.

PURPOSE: Using a transnasal, transfacial, anterior skull base approach, we have removed olfactory neuroblastomas (OFN) obviating the need for a frontal craniotomy. The objectives were to present our surgical approach in achieving clear margins, to assess patient survival, and to recommend eligibility criteria. MATERIALS AND METHODS: A retrospective chart review was done to identify patients diagnosed with OFN who underwent this surgical approach. Thirteen patients were identified who underwent our pictorially described approach. Postoperative assessment of pathologic margins, patient survival, and limitations of surgical approach was determined. RESULTS: Of the 13 patients, 12 (92%) had clear postsurgical margins. One patient had residual intracranial disease due to coagulopathy preventing further resection. Twelve patients remain alive with 10 patients remaining disease-free (follow-up ranging from 11 to 64 months). Three patients presented with recurrent disease initially, with 2 having had subsequent repeat local and regional recurrences, respectively; one of whom died recently of the re-recurrent disease. One patient had a postoperative cerebrospinal fluid leak repaired via the original surgical approach. CONCLUSIONS: Although craniofacial resection remains an accepted approach for surgical treatment of OFN, we have adopted a transnasal, transfacial approach eliminating the need for a frontal craniotomy. This approach allows for adequate exposure of the cribriform plate, dura, and anterior skull base. Our technique minimizes dural defects and prevents many craniotomy-associated complications, including frontal lobe retraction. Long-term follow-up is needed to compare survival using this approach; however, our results to date are quite promising.

Parapharyngeal space pleomorphic adenoma: a 30-year review.

OBJECTIVES/HYPOTHESIS: To evaluate the treatment results of pleomorphic adenoma (PA) of the parapharyngeal space at a single institution during a 30-year period. STUDY DESIGN: A retrospective review. METHODS: This study was performed by examining the records and reviewing the pathology of 44 patients with PA of the parapharyngeal space treated at a single medical center from January 1975 to November 2005. RESULTS: Of the 44 patients with PA, 35 patients underwent 38 excisions. Eleven men and 27 women were treated surgically. Follow-up varied from 24 months to 180 months. There were three recurrences in two patients. Recurrence rates at 5 and 10 years were equal at 7.9%. Gender, age, tumor volume, surgical approach, pathologic surgical margin status, and prior resections were evaluated for significant prognostic factors. Advanced age proved a poor prognostic indicator (P < .05). History of prior resection (P < .01) was significant for recurrence. Positive surgical margins (P = .69) proved a negative association. CONCLUSIONS: We report low recurrence rates in this patient population with two important prognostic indicators. History of prior resection is significant to predict recurrence. Interestingly, positive surgical margins are actually shown not to effect risk of recurrence. Local recurrence of the tumor is associated with further recurrence and less favorable prognosis.

Acellular dermal matrix grafts for prevention of microarterial thrombophlebitis.

OBJECTIVE: To examine the role of acellular dermal matrix grafts for prevention of microarterial anastomotic thrombophlebitis. DESIGN: Bilateral femoral artery microvascular anastomoses were created in the field of established wounds infected with Staphylococcus aureus in 12 rats. In each animal, 1 femoral microarterial anastomosis was wrapped with an acellular dermal matrix graft, and the contralateral femoral anastomosis was left unprotected. The incidence of femoral artery thrombosis was determined after 4 days by wound reexploration. SETTING: David Geffen School of Medicine, University of California, Los Angeles. MAIN OUTCOME MEASURE: The patency of femoral artery anastomoses was determined after 4 days by wound reexploration. RESULTS: The incidence of femoral artery thrombosis in vessels wrapped with acellular dermal matrix grafts was 17%. The incidence of femoral artery thrombosis in unprotected vessels was 100%. This difference was statistically significant (P<.05). CONCLUSION: Acellular dermal matrix grafts seem to have a protective effect in the prevention of acute thrombophlebitis when arterial microvascular anastomoses are performed in infected surgical fields.

Adenoid cystic carcinoma of the submandibular gland: a 35-year review.

OBJECTIVES: To evaluate the treatment results of adenoid cystic carcinoma (ACC) of the submandibular gland at a single institution during a 35-year period. STUDY DESIGN & SETTING: A retrospective review was performed by examining the records and reviewing the pathology of 22 patients with ACC of the submandibular gland treated at UCLA Medical Center from June 1963 to December 1997. RESULTS: Seven men and 15 women with an age range of 23 to 85 years (median, 48 years) were treated. Surgical intervention was performed in 21 patients. All patients with advanced tumor size, perineural invasion, microscopically positive surgical margins, or regional neck metastases received postoperative adjunctive therapy, primarily radiotherapy. Follow-up varied from 6 months to 181 months (median, 67 months). Disease-free survival at 3, 5, and 10 years was 66%, 57%, and 41% respectively, whereas overall survival was 76%, 70%, and 37%, respectively (note: 5- and 10-year survival rates are not statistically conclusive due to the small sample size). CONCLUSIONS: We report fairly high disease-free survival rates in this patient population and a number of prognostic trends are evident. Early diagnosis, wide surgical intervention, and postoperative radiation are associated with a favorable prognosis. Advanced tumor size, positive surgical margins, perineural invasion, and local recurrence of the tumor are associated with an unfavorable prognosis. EBM RATING: C.

Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction.

OBJECTIVE: To determine the incidence and causes of perioperative complications in patients who undergo microvascular free flap procedures for reconstruction of the head and neck. SETTING: Academic tertiary care medical center. PATIENTS AND METHODS: A total of 400 consecutive microvascular free flap procedures were performed for reconstruction of the head and neck, with 95% of the defects arising after the treatment of malignancies. Flap donor sites included radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n = 28), iliac crest (n = 5), and a jejunal flap. Patient-related characteristics (age; sex; diagnosis; comorbidity level; tumor stage; defect site; primary vs secondary reconstruction; and history of surgery, radiation therapy, or chemotherapy) and the incidence of perioperative complications were recorded prospectively over a 7-year period. RESULTS: The perioperative mortality was 1.3%. Overall, perioperative complications occurred in 36.1% of all cases. Free flaps proved to be extremely reliable, with a 0.8% incidence of free flap failure and a 3% incidence of partial flap necrosis. Perioperative medical complications occurred in 20.5% of cases, with pulmonary, cardiac, and infectious complications predominating. Multivariate statistical analysis showed significant relationships between the incidence of perioperative complications and preoperative comorbidity level as indicated by American Society of Anesthesiologists (ASA) status (P =.02). CONCLUSIONS: The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of perioperative complications is related to preoperative comorbidity level.

Efficacy of radiation therapy in the local control of desmoplastic malignant melanoma.

BACKGROUND: Desmoplastic malignant melanoma (DMM) is a rare variant of malignant melanoma with high local recurrence rate after surgical excision. We performed a retrospective review to address the role of radiation therapy in local control of this tumor. METHODS: Between 1976 and 1997, 44 patients with the pathologic diagnosis of DMM were registered at our tumor registry. Fourteen patients received postoperative RT, and one patient received preoperative RT. Three of the irradiated lesions had gross residual or positive surgical margins. Doses ranged from 44 to 66 Gy. RESULTS: Sixty-eight percent of DMM lesions occurred in the head and neck region. Forty-eight percent (21 of 44) of patients experienced a local recurrence after initial excision (mean time to recurrence, 12 months). Local failure in head and neck was 46% (14 of 30). Clark level, primary site, and neurotropism did not predict local recurrence; the Clark level predicted distant metastasis. No viable tumor was found in the surgical specimen of the patient who received preoperative RT. None of 15 patients who received adjuvant irradiation had any additional recurrences (mean follow-up, 64.7 months). By contrast, four of seven patients with history of recurrence who did not receive RT had local relapse (p =.005). The incidence of distant metastasis did not reach statistical significance between the irradiated and nonirradiated groups. CONCLUSIONS: The high rate of local recurrence of DMM after surgical resection is dramatically reduced by adjuvant radiation therapy. We recommend adjuvant postoperative radiation therapy as a part of treatment of DMM.

Local administration of nitric oxide donor significantly impacts microvascular thrombosis.

OBJECTIVES/HYPOTHESIS: Clinical pharmacotherapy has demonstrated a role in preventing microvascular thrombosis in both experimental and clinical settings. Previous studies in the rabbit model have noted an increased rate of thrombosis with intravenous infusion of nitric oxide antagonists. The study assessed the effects of local application of nitric oxide agonists and antagonists on microvascular anastomotic patency rates. STUDY DESIGN: A randomized, prospective analysis. METHODS: An arterial inversion graft microvascular thrombosis model was used in New Zealand white rabbits. The rabbits were randomly assigned to nitric oxide agonist, antagonist, and control groups. In each rabbit, the common femoral artery was surgically exposed and a 2-mm arterial inversion graft was harvested. The anastomosis of the graft to the common femoral artery was performed in solutions of either 100 micromol/L spermine NONOate (nitric oxide donor), 100 micromol/L nitro-L-arginine-methyl ester (L-NAME) (nitric oxide synthase inhibitor), or 0.9% sodium chloride (control) solution. The contralateral common femoral artery also underwent arterial inversion graft testing with the use of the same solution. Arterial patency was assessed 1 hour after anastomosis. RESULTS: Sixteen of 22 arterial inversion grafts performed in the spermine NONOate solution remained patent, and 6 of 22 clotted. Eleven of 21 arterial inversion grafts performed in the control solution remained patent, and 10 clotted. Seven of 21 arterial inversion grafts performed in the L-NAME solution remained patent, and 14 clotted. These results were found to be statistically significant using the chi test with a value of less than.05. CONCLUSIONS: In the rabbit model, local application of nitric oxide agonists and antagonists can significantly impact anastomotic patency rates. Further studies may demonstrate a role for the clinical use of nitric oxide in microvascular surgery.

Fluorescence in situ hybridization for detecting TP16 MTS1/CDK41 gene deletions in squamous cell carcinoma of the head and neck.

We have previously shown TP16 MTS1/CDK41 gene deletion in more than 50% of a cohort of squamous cell carcinoma of the head and neck (SCCHN) patients using polymerase chain reaction (PCR). We have performed fluorescence in situ hybridization (FISH) on paraffin-embedded SCCHN specimens from the same cohort to identify the deletion of TP16 MTS1/CDK41CDK41gene. Twenty normal and 19 SCCHN specimens were studied. An alpha-satellite DNA probe specific for chromosome 9 and a cosmid probe for the TP16 MTS1/CDK41CDK41gene were used. Of the 19 tumors examined by FISH, 6 had homozygous deletions, 7 were hemizygously deleted, and the remaining 6 showed no evidence of deletion of the TP16 MTS1/CDK41 gene. None of the normal specimens showed TP16 gene deletion. Data obtained from FISH highly correlated with the PCR results for the identification of TP16 MTS1/CDK41 gene deletions. Patients with deletion of the TP16 MTS1/CDK41 gene show a greater tendency toward the development of recurrence and metastasis.

Long-term survival outcome in transhyoid resection of base of tongue squamous cell carcinoma.

BACKGROUND: The transhyoid approach for the resection of squamous cell carcinoma (SCC) of the base of the tongue continues to evolve and remains controversial. We previously reported that the functional outcome of this operation is superior to that of the traditional transmandibular approaches. OBJECTIVE: To report our long-term survival rates for T1, T2, and select T3 SCCs of the base of the tongue using the transhyoid approach. PATIENTS AND METHODS: Twenty-eight patients with SCC of the base of the tongue were treated using a transhyoid approach at the University of California, Los Angeles, Medical Center between 1981 and 1998. RESULTS: All 28 patients underwent simultaneous neck dissection, and 27 patients underwent postoperative radiation therapy. The majority of the patients had advanced stage III or IV SCC. Twenty-five of the 28 patients had clear margins in the final pathologic specimen. The overall 3- and 5-year patient survival rates were 88.5% and 80.0%, respectively. Tumor-specific 5-year survival rates were 80.0%, 84.6%, and 50.0% for T1, T2, and T3 tumors, respectively. Stage-specific 5-year survival rates were 60.0%, 100.0%, and 80.0% for stages II, III, and IV, respectively. CONCLUSIONS: The advantages of the transhyoid approach to SCC of the base of the tongue in conjunction with neck dissection and postoperative radiation therapy include excellent long-term patient survival, improved swallowing and speech function, outstanding tumor exposure, and minimal cosmetic deformity.

Cyclin D1 amplification and p16(MTS1/CDK4I) deletion correlate with poor prognosis in head and neck tumors.

OBJECTIVES/HYPOTHESIS: Cyclin D1, a cell cycle regulator localized to chromosome 11q13, is amplified in several human tumors including head and neck squamous cell carcinoma (HNSCC). Amplification and/or overexpression of cyclin D1 have been correlated to a poor prognosis. Deletion of the p16 gene, localized to 9p21, has also been observed in a significant proportion of HNSCC. The p16 gene regulates cyclin D1-CDK4 activity and prevents retinoblastoma tumor suppressor gene phosphorylation, thereby downregulating cellular proliferation. Detection of cyclin D1 amplification and p16 deletion using a simple and sensitive method will be valuable for the development of effective treatment modalities for head and neck cancer. STUDY DESIGN: We have used fluorescence in situ hybridization (FISH) to study cyclin D1 amplification and p16 gene deletion in head and neck tumors. Both single- and dual-color FISH were performed. METHODS: Paraffin-embedded tissues from 103 patients with HNSCC were analyzed using genomic DNA probes for cyclin D1 and p16. Dual-color FISH was performed with chromosome 11 or 9 centromeric probes as a control. Twenty-eight of these samples were analyzed for p16 expression by immunohistochemistry. RESULTS: Cyclin D1 amplification was observed in 30% (31/103) of patients, and p16 deletion in 52% (54/103). Lack of p16 expression was observed in 64% (18/28) of patients. There was a good correlation between the deletion of p16 sequences and the loss of p16 expression (P = .008). Amplification of cyclin D1 had a statistically significant association with recurrence, distant metastasis, and survival at 36 months. There was a significant association between p16 deletion and the development of distant metastases. Cyclin D1 amplification and p16 deletion together correlated with recurrence, distant metastasis, and survival. CONCLUSIONS: We demonstrate that FISH is a simple and sensitive method for detecting cyclin D1 amplification and p16 deletion in head and neck cancer. Our results suggest that these two genetic aberrations together portend a poorer outcome than either of the abnormalities alone in head and neck cancer.

The role of radiation in the treatment of advanced juvenile angiofibroma.

OBJECTIVES/HYPOTHESIS: To demonstrate the efficacy of external beam radiation therapy as a primary treatment modality for the management of patients with advanced juvenile nasopharyngeal angiofibroma (JNA). STUDY DESIGN: Retrospective chart review. METHODS: The medical records of 130 patients with the diagnosis of JNA seen at UCLA Medical Center over a 41-year period (1960-2000) were retrospectively reviewed. RESULTS: One hundred thirty cases of JNA have been seen at UCLA Medical Center from 1960 to 2000. One hundred two were treated with surgical resection, 1 refused therapy, and the remaining 27 received radiation (3000-5500 cGy) as their primary mode of treatment. Fifteen percent (4 of 27) of the irradiated patients developed recurrent tumor 2 to 5 years later. Long-term complications occurred in 4 patients (15%) and consisted of growth retardation, panhypopituitarism, temporal lobe necrosis, cataracts, and radiation keratopathy. CONCLUSIONS: External beam radiation therapy represents an effective mode of treatment for patients with advanced JNA. Although the latency period may be long, we think the likelihood of potentially fatal complications developing at the radiation dosages we recommend is less than the risk of significant morbidity and mortality associated with surgical intervention in these cases.

Fungal mucoceles of the sphenoid sinus.

OBJECTIVE: The purpose of this study was to demonstrate that fungal mucoceles of the sphenoid sinus do not necessarily require an external approach for eradication of disease. We report 6 cases of fungal mucoceles of the sphenoid sinus seen at UCLA Medical Center from 1980-1999, 4 of which were successfully treated with endoscopic intranasal sphenoidotomy and the other 2 through either a transseptal or transantral approach. STUDY DESIGN AND METHODS: Case series. The medical records of 6 patients with fungal mucoceles of the sphenoid sinus treated at UCLA Medical Center over a 20-year period (1980-1999) were retrospectively reviewed. RESULTS: Six patients diagnosed with fungal mucoceles of the sphenoid sinus were seen at UCLA Medical Center from 1980-1999. Endoscopic intranasal sphenoid sinusotomy was performed on 4 patients and a transseptal or transantral approach to the sphenoid sinus was used on the remaining 2 patients. No evidence of recurrent disease has been seen after up to 15 years of follow-up. CONCLUSIONS: When diagnosed early, functional endoscopic intranasal sphenoidotomy represents an effective mode of treatment for patients with fungal mucoceles of the sphenoid sinus, obviating the need for more aggressive surgical approaches.

Nd:YAG laser therapy for palliation of recurrent squamous cell carcinomas in the oral cavity.

BACKGROUND AND OBJECTIVES: The objective of this study was to evaluate the outcome of laser photo-thermoablation for palliation of recurrent squamous cell tumors of the oral cavity. STUDY DESIGN/PATIENTS AND METHODS: Seventeen patients were treated with the Nd:YAG laser (power output was 50 W) delivered through a curved oral handpiece. RESULTS: Ten patients are alive, 7 with tumor remission, and 3 with persistent disease with an average follow-up of 16 months (range = 2-36). A total of 29 tumor sites received laser treatment with 17 (58%) completely ablated. Stratified by tumor site Nd:YAG treatment led to complete local response in 8/10 buccal mucosa, 2/5 retromolar trigone, 2/2 tongue, 2/5 gingiva, 1/2 floor of mouth, 2/4 hard palate. CONCLUSIONS: Nd:YAG laser treatment of recurrent oral cavity squamous cell carcinoma can be performed safely and repeated as needed to achieve tumor palliation. However, extended follow-up may be needed before convincing evidence of long-term therapeutic benefits is obtained.

Microvascular reconstruction after previous neck dissection.

BACKGROUND: Microvascular reconstruction of defects in the head and neck is more challenging in patients who have undergone a previous neck dissection, owing to prior resection of potential cervical recipient blood vessels used for free flap perfusion. OBJECTIVE: To evaluate the reliability and safety of free flap reconstruction in patients with previous neck dissection. PATIENTS AND METHODS: Sixty free flaps were performed in 59 patients with a medical history of neck dissection for head and neck cancer. This included patients undergoing salvage surgery for recurrent cancer as well as patients undergoing secondary reconstruction of cancer surgery-related defects. Flap selection included 25 radial forearm flaps, 20 fibula flaps, 7 rectus abdominis flaps, 7 subscapular system flaps, and 1 iliac crest flap. RESULTS: Recipient vessels were used in the field of previous neck dissection in approximately half the patients with previous selective neck dissection, while contralateral recipient vessels were always used in patients with a history of modified radical or radical neck dissection. Vein grafts were not necessary in any cases. One arterial anastomosis that was created under excessive tension required urgent reoperation and revision, but there were no cases of free flap failure. CONCLUSIONS: Free flap reconstruction of the head and neck is highly successful in patients with a history of neck dissection, despite a relative paucity of potential cervical recipient blood vessels. Heavy reliance on free flaps with long vascular pedicles obviated the need to perform vein grafts in the present series, probably contributing to the absence of free flap failure. Previous neck dissection should not be considered a contraindication to microvascular reconstruction of the head and neck.