More aggressive behavior of squamous cell carcinoma of the anterior tongue in young women.

OBJECTIVE: To review the combined experience from two large medical centers in treating young female patients with anterior tongue cancer to determine the clinical course of this unique subset of patients. STUDY DESIGN: Retrospective study. METHODS: Seventeen female patients less than 40 years of age (group A) and 17 older patients, both male and female, greater than 40 years of age (group B) who had treatment for invasive squamous cell carcinoma of the anterior tongue were studied. The charts were reviewed for the clinical staging, treatment, and outcome of each patient. The disease-free survival and recurrence rates were compared between the two cohorts. RESULTS: The mean disease stage between the groups was II. The survival analysis showed a significant difference between the two groups in recurrences (group A = 65%, group B = 41%; P = .02). Further, of the patients who had recurrence, the young women did so significantly earlier in their disease course than the older patients (group A = 14 mo, group B = 40 mo; P < .05). Although the survival differences did not reach statistical significance (P = .15), the power of the study was low (power = 0.26) resulting in a high-level type II error. CONCLUSION: These data suggest that young women with squamous cell carcinoma of the anterior tongue have significantly higher rates of recurrent disease and the interval to recurrence is significantly shorter than in older patients. Further investigation is warranted until a statistically significant cohort is accrued; until that time, these patients warrant an aggressive initial treatment and close surveillance for recurrence.

Cancer of the tongue in patients less than forty.

INTRODUCTION: It is the opinion of many surgeons that the biologic potential of cancer that develops in young people is different compared with older patients. Prior reports on small series of patients addressing this issue have inadequate statistical power to resolve the question. METHODS: By use of the techniques of meta-analysis, patients less than 40 years old who had undergone treatment of squamous cell carcinoma (SCC) of the oral tongue were examined. Twenty-eight patients who were encountered in the Department of Otolaryngology, University of Pittsburgh School of Medicine, and 94 patients were identified in the literature for a total of 122 patients <40 years old. A control group of 150 patients, aged 40 years and older treated for SCC of the oral tongue between 1982 and 1994 was identified. RESULTS: Three-year disease-free survival in the group of patients aged less than 40 was 53.3% compared with 3-year disease free survivorship of 55.0% in the older cohort of patients. CONCLUSION: These data strongly suggest that the outcomes of treatment for SCC of the oral tongue in young patients are similar compared with patients older than 40 with similar extent of disease.

Skin metastases from head and neck squamous cell carcinoma: incidence and impact.

BACKGROUND: Squamous cell carcinoma (SCC) of the upper aerodigestive tract rarely metastasizes to the skin. This study was designed to review the incidence of skin metastases, to identify associated risk factors, and to investigate the prognostic significance of skin metastases. METHODS: A cohort of 2491 patients treated for SCC originating in the upper aerodigestive tract were evaluated retrospectively. Patients who developed skin metastases were evaluated with respect to tumor stage, treatment, and outcome. Patients with skin metastases were compared with patients who developed distant metastases at other sites and with those who did not develop distant metastases. RESULTS: Skin metastases developed in 19 (0.763%) patients. The median time to occurrence was 6 months. Ninety percent of patients died of disease within a median of 3 months (1 to 16 months) following diagnosis. The development of skin metastasis is most closely related to the presence of two or more cervical metastases and/or extracapsular spread of tumor in the cervical metastases. Similar risk factors were identified for the development of distant metastases to other sites. CONCLUSION: Metastasis to skin is a rare occurrence which has prognostic significance similar to distant metastasis to other areas.

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract.

BACKGROUND: Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated. METHODS: A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome. RESULTS: Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months. CONCLUSIONS: ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Oral and oropharyngeal squamous cell carcinoma in young adults: a report on 13 cases and review of the literature.

OBJECTIVE: Squamous cell carcinoma (SCC) of the head and neck is rare in patients younger than 45 years. Patients aged 18 to 45 years with SCC of the oral cavity (OC) and oropharynx (OP) were retrospectively compared with older control subjects. METHODS: Twenty of 127 patients with OC/OP SCC were young adults. Thirteen patients (10 men) comprise the present series; 9 had OC lesions. Seven case controls were identified. RESULTS: Overall, 15.75% of patients with OC/OP SCC were 18 to 45 years old. Seven OC lesions were early stage, and 2 were late stage; OP lesions were evenly divided. Eleven of 13 patients were disease free at the time of their last visit; 2 died of disease. Thirty-one percent of young patients were heavy drinkers; 77% of them smoked. CONCLUSIONS: Young adults' survival rate resembles that reported for all patients with head and neck cancer stage for stage. Tobacco and alcohol abuse prevention among young people is imperative. Health care providers who encounter a young patient with a suspicious head or neck lesion must include malignancy in their differential diagnosis.

Lymphatic mapping with isosulfan blue dye in squamous cell carcinoma of the head and neck.

OBJECTIVE: To determine whether intraoperative lymphatic mapping with isosulfan blue dye and sentinel lymph node biopsy accurately demonstrates the pathway of regional metastases from mucosal sites in squamous cell carcinoma of the head and neck. DESIGN: A prospective clinical study of intraoperative lymphatic mapping. SETTING: An academic tertiary referral center. PATIENTS: Patients with previously untreated squamous cell carcinoma of the head and neck whose surgical treatment included neck dissection. INTERVENTION: Injection of isosulfan blue dye into the mucosa surrounding squamous cell carcinomas of the upper aerodigestive tract during cervical lymphadenectomy. OUTCOME MEASURES: Correlation of the pathologic findings in the blue sentinel lymph node with those in the remaining cervical lymphatics. RESULTS: No blue-stained cervical lymphatics were identified after injection of the mucosa surrounding the primary squamous cell carcinoma with isosulfan dye. CONCLUSION: The technique of intraoperative lymphatic mapping with isosulfan blue dye requires further study before it can be used for the detection of occult cervical metastases in squamous cell carcinoma of the head and neck.

Fibrous dysplasia of the clivus and sphenoid sinus.

Fibrous dysplasia is a primary disease of bone that may lead to bony distortion, expansion, and weakness. Craniofacial involvement is an important entity for physicians to be aware of because of the potential for impingement on neurovascular structures, intracranial extension, and cosmetic deformity. We report two cases of craniofacial fibrous dysplasia and discuss the clinical presentation, radiographic and histologic findings, and the management of affected patients.

Effectiveness of selective neck dissection for management of the clinically negative neck.

OBJECTIVE: To determine the effectiveness of selective neck dissection for management of the clinically negative neck in head and neck squamous cell carcinoma. DESIGN: A retrospective comparison of patients treated electively with selective neck dissection and comprehensive neck dissection. SETTING: Academic tertiary referral center. PATIENTS: Patients with clinically negative necks and previously untreated head and neck squamous cell carcinoma. INTERVENTION: Elective neck dissection, surgical treatment of the primary lesion, and postoperative radiotherapy as indicated. OUTCOME MEASURES: Regional recurrence, distant metastasis, and disease-free survival. RESULTS: Selective neck dissection was as effective as comprehensive procedures for staging the clinically negative neck. Occult metastases had a statistically significant effect on patient outcome as measured by distant metastasis. CONCLUSION: Elective neck dissection provides invaluable staging information, which guides the decision for adjuvant therapy.

Primary extracranial meningioma of the maxillary antrum.

A case of primary extracranial meningioma of the maxillary antrum is reported. A 45-year-old male presented with symptoms of chronic sinusitis. Imaging studies showed a soft tissue mass with calcification, filling the maxillary antrum. The mass was removed surgically, and pathological studies revealed a ribroblastic meningioma. The maxillary antrum is an uncommon location of primary extracranial meningioma, and our case is the sixth to be reported in that location.

Papillary thyroid carcinoma associated with squamous cell carcinoma of the head and neck: significance and treatment.

Several studies in the recent literature would suggest that PTC found incidentally in the cervical lymphatics may be significant. By age alone, most of our head and neck cancer patients will fall into an intermediate risk group. There are also data to suggest that cervical metastasis from PTC may portend higher recurrence and mortality and that occult PTC may be a biologically significant situation. Many patients with cancer of the head and neck either have a good prognosis or don't follow the rules of their predicted prognosis, and for these patients living with the knowledge of an untreated thyroid, cancer may be an unnecessary concern. Other factors to be considered are that early PTC is probably curable disease and that there is real risk of transformation to higher grade or anaplastic cancer. Finally, there is no way to accurately predict the behavior of PTC. The decision to treat these cancers is ultimately made by the patient and the physician, and if there is a treatment with low morbidity that will alleviate concern of PTC recurrence, then this may outweigh the risk of treatment. Situations may exist when treating incidental PTC could be deferred. These include: a dismal prognosis for the head and neck primary when quality time outside of the hospital is the goal of the patient and the physician; or if the head and neck primary tumor requires external beam radiation therapy, because this may be adequate therapy for occult PTC. In summary, the scenario of PTC found incidentally in the neck treated for a head and neck SCC is unusual. Each patient will have a unique clinical situation based on the site and stage of the SCC, the age of the patient, and the treatment required for the SCC. Treatment options include total thyroidectomy, thyroid lobectomy, the administration of I131, and/or the use of external beam radiation, which must be weighed against the option of close clinical follow-up. In general, we recommend total thyroidectomy for PTC found incidentally in the cervical LNs for the reasons that have emerged from a recent review of the medical literature. We report 7 patients with synchronous head nad neck SCC and PTC who have all received surgical treatment for PTC (Table 1). In addition, we advocate postoperative radioiodine scanning with radioablation of metastatic or persistent PTC, or remnant ablation if uptake is greater than 2%. Our goal as head and neck surgeons should be to avoid inadequate therapy for incidental PTC.

Sinonasal undifferentiated carcinoma: current trends in treatment.

Sinonasal undifferentiated carcinoma (SNUC) is a rare and highly aggressive neoplasm of the paranasal sinuses, which has recently been characterized as a distinct pathologic entity. The prognosis for patients with SNUC is poor. Early case reports describe patients with lesions that were clinically advanced at initial presentation and surgically unresectable. Survival was reported in months after treatment with chemotherapy and radiation. As more experience was gained with treatment of SNUC, it was found that aggressive, combined surgical therapy of lesions previously considered unresectable has shown increased survival. We report a case of a 38-year-old man with SNUC originating in the posterior ethmoid, extending into the anterior cranial fossa and orbit, who was treated with preoperative hyperfractionated radiation therapy, chemotherapy, and craniofacial resection.

Hypophysectomy reduces the haloperidol-induced changes in striatal dopamine receptor density.

The ability of haloperidol (HAL) at doses of 1, 2 and 4 mg/kg to increase the density of the striatal dopamine (DA) receptors was measured in normal and hypophysectomized (Hypox) male rats. In intact rats HAL significantly increased the receptor density at all three doses. In Hypox rats HAL produced significantly less of an increase, with only the 4 mg/kg dose producing a statistically significant increase. Therefore, Hypox appears to reduce the ability of HAL to increase striatal DA receptor density.

Distribution and localization of estrogen-sensitive dopamine receptors in the rat brain.

Administration of estrogen to adult male rats increases the density of striatal dopamine receptors. The densities of the dopamine receptors in the nucleus accumbens and cortex are not altered, while the density of those in the hippocampus is decreased. In the pituitary the density, on a whole pituitary basis, is not changed. The increased density of striatal dopamine receptors normally observed after estrogen treatment is prevented by prior injection into the striatum of kainic acid, which destroys the intrinsic neurons in the striatum. In addition, the benzodiazepine receptors in the striatum, cortex, hippocampus, and cerebellum are not altered by estrogen treatment, showing the specificity of the estrogen treatment and suggesting that the effects of estrogen are not mediated through benzodiazepine receptors.

Effects of Estrogen on Striatal Dopamine receptor function in male and female rats.

The present study compares, biochemically and behaviorally, the effect of estrogen on central dopamine (DA) function in male and female rats. Estrogen has no direct effect in vitro on DA receptors from striatal tissue of male or female rats. In vivo administration of 17 beta-estradiol valerate to male or long-term ovariectomized female rats significantly increased the density of the striatal Da receptors by about 20 percent. Behaviorally, normal female rats have more intense stereotypy produced by apomorphine (APO stereotypy), regardless of the phase of their estrous cycle, than normal male rats, while the density of striatal DA receptors is equal. Estrogen administration to male rats increases their APO stereotypy. Normal intact female rats have no changes in APO stereotypy after the administration of estrogen. However, ovariectomy of female rats increases APO stereotypy, and estrogen administration decreases APO stereotypy back to the levels observed in the normal intact female rats. In the male rat there is a good correlation between the increased striatal Da receptor density and the increased APO stereotypy, but in the female rat factors other than striatal DA receptor density density appear to be important in the regulation of APO stereotypy.

Prolactin increases the density of striatal dopamine receptors in normal and hypophysectomized male rats.

Administration of prolactin to adult male rats, by S.C. injection, significantly increases the density of the striatal dopamine (DA) receptors, without altering the apparent affinity of the receptors for [3H]spiroperidol. Larger doses of prolactin are required to increase the density of the striatal DA receptors in hypophysectomized rats compared to normal rats. These results suggest that prolactin might be the common mediator of the increase in striatal DA receptor density produced by either estrogen or haloperidol administration. Monitoring and/or altering prolactin levels might be informative in neurologic or psychiatric disorders involving striatal DA neurotransmission.