Emergency cricothyrotomy: long-term results.

In 1996 we reviewed the literature and reported on our own series of emergency cricothyrotomy (EC) patients. The success rate in obtaining an airway was very good. The survival rate was also acceptable. However, there have been no reports of long-term results of EC. We retrospectively reviewed the long-term results in 27 survivors of 65 original EC patients. The average length of follow-up was 37 months (1-77 months). In 13 patients no airway problems were found. The remaining 14 patients had only minor problems such as hoarse voice and mild untreated stenosis. Of these 27 patients, however, only seven were doing well. Five patients had relatively minor problems such as the need for a gastrostomy tube, minor shortness of breath, or minor neurological problems. Fifteen patients had major problems: cervical spine injuries, changes in mental status, need for permanent nursing home care, seizure disorders, or injuries that precluded their working. In most cases these problems were due to the underlying disease process. EC is effective in obtaining an airway with a low incidence of later severe airway problems. However, many of these patients do poorly overall.

Postoperative radiation of open head and neck wounds--updated.

BACKGROUND: Postoperative radiotherapy is commonly used in treating head and neck cancer. A concern is the possibility of an unhealed surgical wound delaying or disrupting the treatment schedule. Our institution previously reported our experience on the outcome of radiotherapy on unhealed wounds from 1977 to 1984. METHODS: In an effort to update and enlarge this series, we reviewed the charts of patients receiving postoperative radiotherapy from 1985 to 1990. Of 267 patients, 20 had unhealed wounds or fistulas at the beginning of treatment. The wounds healed spontaneously in 17 of these patients, 1 required surgical closure, and 2 never healed. Combining our current and previous series, 452 patients had onset of postoperative radiation therapy at our institution from 1977 through 1990, of whom 33 had unhealed wounds at the onset of irradiation. RESULTS: In 22 of 33 (67%) patients, the wounds healed spontaneously (mean: 98 days, range: 36 to 304 days). Five additional patients achieved successful wound healing following surgical closure (mean: 281 days, range; 112 to 608 days). The remaining 6 patients died before healing was complete (4 patients) or were lost to follow-up (2 patients) at 16 and 27 months before wound healing occurred. Nine patients in this study are alive with no evidence of disease, 19 died of cancer, and 5 died of other causes. CONCLUSIONS: When there are indications to deliver irradiation in the postoperative setting, it is desirable to initiate treatment within 6 weeks of the data of surgery. Although it is preferable to have completely closed operative wounds prior to irradiation, some consideration must be given to initiating irradiation in the face of incompletely closed wounds when it is anticipated that healing time will be prolonged. In some patients, the wounds continue to heal during the course of irradiation, or will stabilize, and can be surgically managed after irradiation is completed or may spontaneously heal after treatment. Excessive delays in initiating appropriate cancer therapy may lead to recurrence prior to irradiation; such recurrences are rarely successfully salvaged.

Emergency cricothyroidotomy.

The effectiveness and safety of cricothyroidotomy was reviewed at our institution and in the literature. The literature review yielded nine reports on emergent cricothyroidotomy. Out of 320 patients, there were 308 successful airways and 99 survivors. In 172 cases (eight reports), the patient was not in cardiac arrest, and this group accounted for 84 of 99 survivors. Acute complications were rare and included bleeding and misplacement of the airway. Long-term complications were difficult to evaluate because of the small number of survivors, many of whom were in a permanent vegetative state. At our institution, we had 65 patients who underwent emergent cricothyroidotomy with 62 successful airways and 27 survivors. In 33 patients, vital signs were present at the time of emergent cricothyroidotomy. This group accounted for 25 of 27 survivors. Acute complications were: misplacement or failure to obtain an airway (seven), no airway (three), chest tube required (two), and bleeding (one). In the 27 survivors long-term complications were: failure to decannulate (two), and vocal cord paralysis, granulation tissue and hoarseness, one case each. We conclude that emergent cricothyroidotomy is effective in establishing airways in emergency situations, although the survival rate is better if the patient is not in cardiac arrest (49 vs 31% in literature and 41 vs 76% in our study).

Cancer of the breast in pregnancy.

Contrary to common belief, pregnancy does not stimulate the growth of breast cancer. Thus, no justification exists for therapeutic abortion. Generally, treatment should not be altered or delayed because of pregnancy. If the patient so desires, she should be allowed to become pregnant but should be delayed for at least 2 years. The management of breast cancer in pregnancy should involve a team approach, including a breast surgeon, obstetrician, breast counselor, medical oncologist, and radiotherapist.

Benign tumors of the breast.

Most patients who consult their physician for "breast lesions" do not have a malignancy of the breast. The benign lesions of the breast include fibrocystic condition, macrocyst fibroadenomas, and intraductal papillomas. Nipple discharge is a common condition, and the diagnosis and treatment is discussed. Rarer benign tumors such as adenoid tumors, lipomas, neurofibromatosis, benign fibrous histiocytoma, and glandular cell tumors are briefly discussed.

The role of fine-needle aspiration in the diagnosis of breast lesions.

OBJECTIVE: To show that using a combination of clinical impression, mammogram, and fine-needle aspiration (FNA), an accurate diagnosis of breast lesions can be made in a gynecologic office setting. STUDY DESIGN: All patients requiring FNA between January 1987, to February 1990, had a clinical and mammographic impression recorded as to whether the lesion was benign or malignant. All lesions in which a FNA diagnosis was given were evaluated. RESULTS: One hundred one patients met the criteria for inclusion into the study. There were two false-positives and one false-negative aspiration for carcinoma in the study. However, in all three of these patients, the clinical impression, or the mammogram, did not agree with the aspiration results. There were no false-negative or positive results when all three criteria were used. CONCLUSIONS: Although a larger study is needed to confirm this study, FNA in combination with clinical impression and mammogram can be used reliably to diagnose a breast lesion.

Iodine-125 interstitial implants as salvage therapy for recurrent gynecologic malignancies.

Twenty-one patients with the diagnosis of recurrent gynecologic pelvic malignancy from various primary sites were treated with iodine-125 (I-125) interstitial implants. Eighteen of these patients had been treated with a combination of surgery and radiation therapy for their primary malignancies and 90% had responded. Seventy-five percent had complete local responses. The overall survival time, volume-response relationship, and complications are discussed and the radioresponse of various histologic types is presented.

Outcome of treatment of 160 patients with squamous cell carcinoma of the neck staged N3a.

One hundred sixty patients with N3a neck disease were studied to evaluate the overall treatment outcome. Of these, 54 received palliative radiotherapy and 106 patients were treated with treated with curative intent. Twenty patients (19%) died of intercurrent disease (13 at less than 2 years), and 13 of 93 patients followed for 2 or more years are alive with no evidence of disease. Thus, 73 patients died directly from cancer, with metastatic disease being the leading cause of death. Almost one third of the patients failed to complete treatment.

Cancer of the maxillary sinus treated with surgery and/or radiation therapy.

This is an analysis of 37 previously untreated patients with squamous cell carcinoma of the maxillary sinus treated with curative intent at the University of Florida from January 1966 through January 1984. All patients were followed for at least two years and 86 per cent (32/27) were followed for a minimum of five years. Patients were treated for cure with radiation therapy alone (25), surgery alone (1), or surgery and preoperative (6) or postoperative (5) radiation therapy. This study presents the results of treatment and the incidence of treatment-related complications in this group of patients.

Surgical treatment of the elderly patient with gynecologic cancer.

One hundred and one patients with gynecologic oncologic disease who were 70 years of age or more underwent 169 surgical procedures during an eight year period. The rate of major morbidity was 22.0 per cent, and the operative mortality rate was 1.3 per cent. The one year survival rate was 86 per cent. We were unable to predict morbidity or mortality based on age, past history, American Society of Anesthesiologists class, preoperative laboratory studies or type of operation. When the group of elderly patients was compared with a control group of patients with cancer who were 60 years of age or less, there was a significantly higher rate of major morbidity in the elderly (22 versus 9 per cent), but more one year survivors (86 versus 74 per cent). We conclude that age alone should not be a deterrent to surgical management of gynecologic malignant disease. With careful perioperative management and attention to the unique problems of the elderly, acceptable surgical rates can be achieved.

MR imaging of uterine carcinoma: correlation with clinical and pathologic findings.

Thirteen patients with clinical stages I and II endometrial carcinoma were examined with magnetic resonance (MR) imaging before surgery. Depth of invasion and stage of disease were assessed, and the results were compared with those from MR images of the surgical specimens and pathologic findings. Staging with MR imaging was accurate in 11 of 13 patients (85%). Our results agree with previous reports that MR imaging is an accurate, noninvasive method of assessing depth of myometrial invasion and cervical involvement. We anticipate that MR imaging will have an increasing role in treatment of patients with endometrial carcinoma.

Lack of effect of carbonic anhydrase inhibition on direct measurements of endolymph bicarbonate.

In the past, sodium, potassium, and chloride have been measured in endolymph directly, but bicarbonate has been measured only indirectly. We sampled endolymph directly while monitoring endocochlear potentials in normal and methazolamide-treated guinea pigs. Bicarbonate was determined in samples by use of a method that depends on reduction of NADH to NAD linked to malate formation from oxaloacetate. In 11 normal animals, the bicarbonate in endolymph was 20.2 mM +/- 4,4 mM (mean +/- standard deviation); in six of these, plasma bicarbonate was 23.1 mM +/- 3.5 mM. Nine animals treated with methazolamide (carbonic anhydrase inhibitor) had an endolymph bicarbonate of 19.5 mM +/- 3.9 mM; plasma bicarbonate in five of these was 25 mM +/- 3.2 mM. Carbonic anhydrase inhibition did not significantly affect endolymphatic bicarbonate levels.

GIA stapler in radical neck dissection.

I have used this procedure for over 7 years on approximately 150 radical neck dissections and have experienced no complications related to the use of this stapler, and operative time has been reduced. Approximately one third of these neck dissections have been done on patients who later received radiation therapy. In addition, approximately one third received preoperative radiation therapy. No problems with increased complications or recurrences in the area where the staples remain have been noted. This procedure has been discussed with radiation therapists at the University of Florida, where most of the patients received radiation therapy, and no increase in the complication rate or recurrence rate in this area of the neck was noted.

Deep spread patterns in CT staging of T2-4 squamous cell laryngeal carcinoma.

In addition to clinical examination and less sophisticated radiographic techniques, high-resolution computerized tomography (CT) can help to stage squamous cell carcinoma of the larynx. This study was undertaken to identify findings on CT scans that might predict the likelihood of radiation therapy (RT) alone, controlling the primary site disease without significant irradiation-related complications. Of 30 patients with T2-4 cancers of the larynx, 13 were classified as favorable and 17 were classified as unfavorable candidates for RT based on the CT criteria of transglottic spread, more than 25% pre-epiglottic space involvement, extensive paralaryngeal space spread, or cartilage involvement. Seven of 17 (41%) unfavorable patients had local recurrences, two are alive with cancer, three patients are dead of disease (DOD), and five had significant complication, but there was no evidence of recurrent cancer. In the favorable group, there were two local recurrences (15%), one distant metastasis, one patient is DOD, and one had a significant complication, but no recurrent cancer. These data may be used to more adequately select and inform patients with T2-4 squamous cell carcinoma of the larynx before RT.

Hyperfractionation for head and neck cancer.

Between March 1978 and April 1984, 144 patients with 148 moderately advanced to advanced primary squamous cell carcinomas of the head and neck received treatment with curative intent with twice-a-day irradiation (120 cGy/fraction, 4-6 hour interfraction interval). Eighty-eight percent of the patients had AJCC Stage III-IV cancers. One hundred and thirty-two patients received irradiation alone to the primary site with or without radical neck dissection, with surgery reserved for salvage. The total doses administered were 7440-7920 cGy in the majority of instances. In 19 patients with oropharyngeal lesions, a 1000-1500 cGy radium needle boost was added after the basic dose. Twelve patients received preoperative irradiation (5040-6000 cGy) followed by primary resection and radical neck dissection. Local control results following irradiation alone to total doses of greater than 7000 cGy with minimum 2-year follow-up were 25/31 (81%), 38/50 (76%), and 5/25 (20%) for T2, T3, and T4 cancers, respectively. Local control rates did not correlate well with total dose. Local control following preoperative irradiation plus primary resection was obtained in 4 of 5 T3 and 2 of 3 T4 primary lesions. The 5-year actuarial rates of neck control were 100% for N0 (45 patients), 90% for N1 (25 patients), 77% for N2 (23 patients), 50% for N3A (9 patients), and 70% for N3B (42 patients). The 5-year actuarial rates of continuous disease control above the clavicles were 73% for Stage III, 64% for Stage IVA, and 32% for Stage IVB. The actuarial 4-year rate of continuous disease control above the clavicles was 78% for Stage II. For patients whose disease was controlled above the clavicles, distant metastases developed in 4% of patients with Stage II-III disease and in 18% of patients with Stage IV disease. Radiation complications following irradiation alone to the primary site correlated with total dose. Complications of planned neck dissection(s) were acceptable. Complications of salvage surgery at the primary site were similar to those seen in patients treated once a day. The actuarial 5-year survival rates, according to modified AJCC stage, were 59% for Stage III, 37% for Stage IVA, and 23% for Stage IVB. The actuarial 4-year survival rate for Stage II was 69%. Compared to historical control groups treated with once-a-day, continuous-course irradiation at our institution, twice-a-day treatment has produced local control results that are higher by 10-15 percentage points.

Detection of localized breast cancer by prospective mammographic screening criteria.

From 1983 to 1986, 1110 gynecology office patients met our prospective mammographic screening criteria. Ninety-eight mammographically guided, needle-localized breast biopsies were performed on 89 patients (8.0%). Twenty-one nonpalpable breast cancers (22.0%) were diagnosed in 18 patients with these methods. Treatment alternatives chosen in patients with positive biopsy specimens are presented. The importance of establishing consistent criteria for mammography and breast biopsy in the early diagnosis of localized breast cancer is discussed. The unique opportunity of the gynecologist to change the morality rate of breast cancer is emphasized.

Breast biopsy and the surgical treatment of early carcinoma of the breast.

Biopsy techniques include aspiration for fluid, for cytology, or for histology. The indications for each method depend on the physical and/or mammographic findings. If a breast cancer is diagnosed, then treatment will depend on the size and location of the lesion and the patient's wishes. The surgical technique for lumpectomy and axillary node dissection is described.