Reconstruction of total maxillectomy defects with preservation of the orbital contents.

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.

Long term results of primary radiotherapy with/without neck dissection for squamous cell cancer of the base of tongue.

BACKGROUND: There are several management options for patients with squamous cell cancer of the base of tongue. We have had an interest in using primary radiotherapy with or without neck dissection, in an effort to provide optimal oncologic as well as functional outcomes. METHODS: From 1981 to 1995, 68 patients with primary squamous cell cancer of the base of tongue were managed with primary radiotherapy, with neck dissection added for those who were initially seen with palpable lymph node metastases. Ages ranged from 35 to 77 years (median age, 55 years). There were 59 men and 9 women. T Stage distribution was: T1, 17; T2, 32; T3, 17; T4, 2. Fifty-eight patients (85%) were initially seen with nodal metastases. Initial treatment generally involved external-beam radiotherapy (EBRT) to the primary site and upper neck (54 Gy) and to the low neck (50 Gy). A 192-Ir brachytherapy boost (20-30 Gy) to the base of tongue was done about 3 weeks later, at the same anesthesia used for the neck dissection. All patients had temporary tracheostomy. Follow-up ranged from 1 month to 151 months (median, 36 months). Nine patients received neoadjuvant chemotherapy as part of a larynx-preservation protocol. RESULTS: Actuarial 5- and 10-year local control is 89% and 89%, distant metastasis free survival is 91% and 76%, disease-free survival is 80% and 67%, and overall survival is 86% and 52%, respectively. Complications occurred in 16%. CONCLUSIONS: Our long term data clearly demonstrate that primary radiotherapy produces excellent oncologic outcomes.

Outcome of patients with a history of bilateral retinoblastoma treated for a second malignancy: the Memorial Sloan-Kettering experience.

BACKGROUND: Patients with bilateral retinoblastoma are well recognized to have a high risk of developing a second malignancy, but there are little published data regarding the outcome of these patients following treatment. PATIENTS AND METHODS: We identified 15 patients with a history of bilateral retinoblastoma who received treatment at Memorial Sloan-Kettering Cancer Center for a newly diagnosed second malignancy. The median age of second tumor occurrence was 18 years (range 10-32 years). Three patients later had a third tumor (18 tumors total). Tumor sites included facial structures in 14 cases and extremities in 4. Histologies included osteosarcoma (5), leiomyosarcoma (5), high-grade spindle cell sarcoma (3), malignant fibrous histiocytoma (3), malignant mesenchymoma (1), and angiosarcoma (1). RESULTS: Nine patients are alive: 7 disease free at a median of 29 months (range 6-214 months) and 2 with residual disease 59 and 148 months post-diagnosis of the second malignancy. Six patients have died at a median of 31 months (range 16-98 months) after diagnosis of the second malignancy. CONCLUSIONS: Patients with a history of bilateral retinoblastoma who develop a second malignancy may enjoy extended periods of survival. Aggressive therapy appropriate to the tumor histology and site is indicated.

Craniofacial resection for malignant tumors involving the anterior skull base.

OBJECTIVES: To review our experience with craniofacial resection for malignant neoplasms of the anterior skull base and report long-term results, and to analyze survival in terms of the overall experience, tumor histological diagnoses, and tumor extent. Also, to report complications of this surgical procedure. DESIGN: Retrospective review. SETTING: Tertiary cancer facility. PATIENTS: We evaluated 115 consecutive patients undergoing craniofacial resection for malignant neoplasms involving the anterior skull base. Forty-five (39%) presented with recurrent or persistent disease after prior therapy. MAIN OUTCOME MEASURES: Survival was evaluated with the Kaplan-Meier product limit method and comparisons between individual subgroups were performed using the log-rank test. RESULTS: The operative mortality rate was 3.5%. Major complications occurred in 40 patients (35%). For the entire group, disease-specific survival rates were 58% and 48% at 5 and 10 years, respectively. The highest survival rate was observed in patients with esthesioneuroblastoma and lowest in those with mucosal melanoma. Survival was significantly better for those whose tumors could be excised with a limited resection in comparison with those requiring an extended procedure (P = .009). CONCLUSIONS: A 23-year experience with craniofacial resection performed for malignant tumors involving the anterior skull base confirms the durable results obtained with this intervention. The diversity of histological diagnoses, site of origin, extent of tumor invasion, and impact of prior therapy hampers any attempt at reporting meaningful survival statistics for comparison with other series or other means of treatment.

Extended anterior craniofacial resection for intracranial extension of malignant tumors.

OBJECTIVE: To review our experience with anterior craniofacial resection for malignant neoplasms with intracranial extension. Survival was analyzed in terms of presence of intracranial extension, extent of intradural disease, tumor histology, and histological status of margins. PATIENTS: In a retrospective review made at a tertiary cancer facility, 26 of the 115 consecutive patients undergoing craniofacial resection for malignant lesions of the anterior skull base had intracranial extension, defined as dural and/or brain extension. Survival was evaluated with the Kaplan-Meier product limit method, and comparisons between individual subgroups were performed using the log-rank test. RESULTS: Patients with intradural extension have a statistically worse disease-specific survival than patients without intracranial extension (P = 0.05). Surgical margins and tumor histology impact on survival. The incidence of local complications was 42% and of systemic complications, 8%. CONCLUSION: Anterior craniofacial resection is indicated for patients with resectable disease. The complication rate is comparable with that of patients without intracranial extension. Gross total resection with histologically negative margins portends a better prognosis. Esthesioneuroblastoma has a better prognosis than other tumor types.

Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible.

BACKGROUND: Management of osteoradionecrosis (ORN) remains a difficult and challenging problem. The traditional approach using debridement, antibiotics, and occasionally hyperbaric oxygen is usually successful in treating minimal ORN. However, when bone and soft-tissue necrosis is extensive, the conservative approach usually requires intensive care over a long period of time and often yields unsatisfactory functional and cosmetic results. METHODS: Within the past 5 years, we have used radical resection of the mandible with immediate microvascular reconstruction in the treatment of extensive ORN of the mandible. This aggressive surgical approach was used in six patients with advanced ORN of the mandible, all of whom had failed initial conservative treatment, including hyperbaric oxygen therapy in three. A fibular free graft with microvascular anastomosis was used in all patients. RESULTS: All the patients healed primarily with minimal postoperative morbidity and excellent cosmetic results. Two patients subsequently required removal of some of their hardware. One patient had placement of osseointegrated implants with an excellent cosmetic and functional result. CONCLUSION: Microvascular reconstruction with its own blood supply seems to expedite bone healing and limit further osteoradionecrosis of the remaining mandible. Although prevention is the primary goal in radiation injury, our experience suggests that radical resection with free microvascular reconstruction offers significant advantages to selected patients with extensive ORN of the mandible.

Maxillectomy and its classification.

BACKGROUND: Many adjectives are used to describe maxillectomy procedures, such as radical, total, extended, subtotal, medial, partial, and limited. The variety of nomenclature in our own Service database testifies that much confusion exists. METHODS: We have reviewed a 10-year experience with 403 maxillectomies performed between 1984 and 1993. Based on our retrospective reassessment, the operations were grouped into one of three categories. The term "limited" (LM) was applied to any maxillectomy which primarily removed one wall of the antrum. Designated "subtotal" (SM) was any procedure which removed at least two walls, including the palate. We listed as "total" (TM) only those who had a complete resection of the maxilla. Hospital charts were selectively reviewed, and each of the three types of maxillectomy was analyzed to determine the histology and site of the index cancers and the incidence of complex reconstruction. RESULTS: We determined that the maxillectomy performed in 230 patients (57%) was a LM. Tumor site and extent defined five different approaches in this cohort: peroral, 73; medial maxillectomy, 53; anterior craniofacial, 43; upper cheek flap, 42; and transfacial, 19. Subtotal maxillectomy or TM was performed in 135 and 38 (34% and 9%, respectively), almost 90% of whom had a cheek flap approach. Only 51 patients had an orbital exenteration, including 27 of the 38 (71%) of those who had a TM. Complex repair was employed in a total of 63 patients (16%), most often in those having TM (14 of 38, 37%). CONCLUSIONS: Classification of maxillectomy either as LM, SM, or TM is useful and feasible. To define a LM, the portion of the maxilla removed (ie, palate, anterior wall, medial wall) must be specified. For any maxillectomy, the access used should be listed, and the surgeon should indicate whether the maxillectomy has been extended to include adjacent structures.

Long-term regional control after radiation therapy and neck dissection for base of tongue carcinoma.

PURPOSE: Minimal literature exists with 10-year data on neck control in advanced head and neck cancer. The purpose of this study is to determine long-term regional control for base of tongue carcinoma patients treated with primary radiation therapy plus neck dissection. METHODS AND MATERIALS: Between 1981-1996, primary radiation therapy was used to treat 68 patients with squamous cell carcinoma of the base of tongue. Neck dissection was added for those who presented with palpable lymph node metastases. The T-stage distribution was T1, 17; T2, 32; T3, 17; and T4, 2. The N-stage distribution was N0, 10; N1, 24; N2a, 6; N2b, 11, N2c, 8; N3, 7; and Nx, 2. Ages ranged from 35 to 77 (median 55 years) among the 59 males and nine females. Therapy generally consisted of initial external beam irradiation to the primary site (54 Gy) and neck (50 Gy). Clinically positive necks were boosted to 60 Gy with external beam irradiation. Three weeks later, the base of tongue was boosted with an Ir-192 interstitial implant (20-30 Gy). A neck dissection was done at the same anesthesia for those who presented with clinically positive necks, even if a complete clinical neck response was achieved with external beam irradiation. Neoadjuvant cisplatin-based chemotherapy was administered to nine patients who would have required a total laryngectomy if their primary tumors had been surgically managed. The median follow-up was 36 months with a range from 1 to 151 months. Eleven patients were followed for over 8 years. No patients were lost to follow-up. RESULTS: Actuarial 5- and 10-year neck control was 96% overall, 86% after radiation alone, and 100% after radiation plus neck dissection. Pathologically negative neck specimens were observed in 70% of necks dissected after external beam irradiation. The remaining 30% of dissected necks were pathologically positive. These specimens contained multiple positive nodes in 83% despite a 56% overall complete clinical neck response rate to irradiation. Regional failure occurred in only two patients, neither of whom underwent adjuvant neck dissection. Symptomatic neck fibrosis (RTOG grade 3) was not observed. Actuarial 5- and 10-year local control was 88% and 88%, disease-free survival was 80% and 67%, and overall survival was 86% and 52%. CONCLUSION: For base of tongue cancer, most patients can obtain long-term regional control with no severe complications after definitive radiation therapy, plus neck dissection for those who present with lymphadenopathy. Complete clinical regression of palpable neck metastases after irradiation poorly correlates with pathologic outcome. Our current policy is to include neck dissection at the time of implantation for patients who present with palpable neck metastases. We realize that this therapeutic approach may overtreat some patients, but we are reluctant to change our policy in light of these excellent outcomes.

Detailed quality of life assessment in patients treated with primary radiotherapy for squamous cell cancer of the base of the tongue.

BACKGROUND: This study was conducted to evaluate quality of life in patients treated with primary radiotherapy (RT) for cancer of the base of tongue. METHODS: From 1981 to 1990, 36 patients with primary squamous cell cancer of the base of tongue were managed with primary radiotherapy. Ages ranged from 35 to 71 years (median, 58 years), T Stage was: T1, n = 11; T2, n = 14; T3, n = 10; T4, n = 1. Thirty-one patients (86%) had palpable cervical lymph node metastases at initial examination (N1, n = 16; N2, n = 11; N3, n = 4). Patients received external beam RT to their primary site and necks, followed by a brachytherapy boost to the tongue. Those with neck nodes also had a neck dissection. The median follow-up is 5 years (minimum, 3 years). Actuarial 5-year local control was 85%; regional control was 96%; distant metastases-free survival was 87.5%; and overall survival, 85%. Twenty-nine of the 30 long-term survivors completed (1) Memorial Symptom Assessment Scale (MSAS), (2) Functional Assessment of Cancer Therapy (FACT), (3) Performance Status Scale for Head and Neck Cancer (PSS), and (4) a sociodemographic and economic questionnaire. At the time of cancer diagnosis, 62% were employed full-time, and 21% were employed part-time; 83% were earning > $20,000/year, and 59% were earning > $60,000/year. RESULTS: At follow-up, annual incomes were similar to those at initial examination. Of those who had been working full-time, 72% were still in full-time work, and of those who had been working part-time, 83% were still in part-time work. Average PSS scores were 90 for eating in public, 96 for understandability of speech, and 68 for normalcy of diet. On the MSAS, the following symptoms had prevalence: > 30% xerostomia, difficulty swallowing, decreased energy, pain, worrying, insomnia, cough, drowsy, change in taste, and irritability. Scores on the FACT exceeded published values collected for a mixed cancer population. CONCLUSIONS: The overwhelming majority of patients achieved excellent functional status and quality of life and could maintain their prediagnosis earning potential and employment status after primary radiation for advanced base of tongue cancer.

Current role of the radial forearm free flap in mandibular reconstruction.

The radial forearm free flap was selected as a donor site in only 17 (11 percent) of 155 consecutive free flap mandible reconstructions performed over a 9-year period. It was used either as an osteocutaneous flap (58 percent), as a soft-tissue flap alone for coverage of a reconstruction plate (18 percent), to supplement another free flap (12 percent), or to salvage a previous reconstruction (12 percent). The most common underlying disease was epidermoid carcinoma (82 percent), the average patient age was 55 years, and the average length of follow-up was 13.5 months. Although there was one patient death, there were no anastomotic failures. Postoperatively, two patients experienced fracture at the donor site (12 percent), and three patients (18 percent) had hardware related problems such as exposure, infection, or both. Although early studies advocated using the osteocutaneous radial forearm flap as a preferred method in mandible reconstruction, superior donor site options such as the fibula have now relegated it to a minor role. The best remaining indication for its use today is for a limited posterior bone defect associated with a large adjacent mucosal loss. Osseointegrated implant capability is not important in this setting, and the short bone length needed for this application minimizes the potential for fracture at the donor site, a serious complication. Otherwise, the osteocutaneous radial forearm flap is not recommended for the majority of segmental mandibular defects. The radial forearm flap without bone continues to have an important supportive role in mandibular reconstruction. It is an excellent choice in this regard when used to cover a reconstruction plate, as a second free flap when soft-tissue requirements are exceptionally large, or for salvage of a previous mandible reconstruction.

Utilization of intraoperative electroneurography to understand the innervation of the trapezius muscle.

The radical neck dissection is an operation for the management of lymph node metastases from primary sites involving the oral cavity, larynx, and other areas of the head and neck. In this procedure, the spinal accessory nerve is removed along with other structures. In modified neck dissection the spinal accessory nerve is preserved. Patients undergoing the modified neck dissection have had variable functional outcomes from little or no pain or disability, to significant muscle dysfunction. Our group hypothesized that patients with good functional outcomes following modified neck dissection may have had motor contributions from C2, C3, or C4 branches, while those with less favorable outcomes did not. To demonstrate the presence of motor input and its significance both from the spinal accessory nerve and the branches of the cervical plexus, we utilized intraoperative electroneurography. We find that although there is motor contribution from C2, C3, and C4 to the trapezius muscle, it was not consistent or significant.

Supraomohyoid neck dissection.

BACKGROUND: Supraomohyoid neck dissection (SOHND) has assumed increasing importance as a staging lymphadenectomy in patients with N(o) oral and oropharyngeal squamous cell carcinoma (SCC), as well as a potentially curative procedure in selected patients with limited metastatic disease in the neck. METHODS: Retrospective chart review of 287 patients who had a total of 320 SOHND for SCC between 1986 and 1993 as a follow-up to an earlier report that covered our experience between 1980 and 1985. After excluding 24 patients who also had local recurrence, or a new primary, the remaining 296 SOHND were assessed for the effectiveness of tumor control in the neck. RESULTS: Of 248 elective SOHND, clinically negative nodes proved histologically positive in 60 patients (25%), only 4 of whom failed in the neck (7%). A total of 48 patients (16%) had a therapeutic SOHND for limited N+ disease, confirmed pathologically in 31, with neck recurrence documented in 2 (6%). Nodes proved negative histologically in 205 patients, 10 of whom failed in the neck (5%). Nine of the 16 patients with neck recurrence had received postoperative radiation therapy and 9 recurred within the field of the SOHND. CONCLUSIONS: SOHND is a reliable staging procedure in patients with N(o) oral or oropharyngeal SCC. Therapeutic SOHND, in conjunction with postoperative radiation therapy, was highly effective in controlling neck metastases in carefully selected patients with limited disease in the upper neck.

Supraspinal accessory lymph node metastases in supraomohyoid neck dissection.

BACKGROUND: Some patients undergoing surgical resection of primary squamous cell carcinoma of the oral cavity and oropharynx also undergo supraomohyoid neck dissection for staging of the negative (N(o)) neck. Dissection of the supraspinal accessory lymph node pad requires significant traction of the spinal accessory nerve. There are currently no data to indicate the incidence of metastases to this site and thus the necessity of performing dissection of these nodes. METHODS: A prospective analysis of a consecutive series of 44 patients with newly diagnosed squamous carcinoma of the oral cavity or oropharynx undergoing surgical management of the primary lesion with staging neck dissection was performed. Patients underwent unilateral (41) or bilateral (3) supraomohyoid neck dissection with separate submission of the supraspinal accessory lymph node pad for pathologic evaluation to determine the incidence of nodal metastases. RESULTS: A total of 15 patients (32%) had microscopic metastatic squamous cell carcinoma involving the supraomohyoid neck dissection specimen. Only 1 patient had a metastatic deposit involving the supraspinal accessory lymph node pad. This patient also had metastases in additional lymph nodes at level II. There was an equal incidence of metastases for all patients when stratifying by T stage. CONCLUSION: This preliminary report reveals a small incidence of supraspinal accessory lymph node metastases in patients with T + NO squamous cell carcinoma of the oral cavity and oropharynx. We continue to accrue patients to determine if the incidence of supraspinal accessory lymph node metastases varies with an increased number of patients.

Combined chemotherapy and radiotherapy versus surgery and postoperative radiotherapy for advanced hypopharyngeal cancer.

BACKGROUND: Although the standard therapy for locally advanced hypopharyngeal cancer remains surgery and postoperative radiotherapy (RT), alternative treatment approaches include induction chemotherapy and RT. The purpose of this retrospective study was to compare the long-term outcome of these treatments performed in a single institution. METHODS: Twenty-six patients with advanced, resectable, squamous cell carcinoma of the hypopharynx were treated with induction chemotherapy and definitive RT (group I), reserving laryngectomy for salvage. The induction phase of therapy consisted of 2-3 cycles of cisplatin-based chemotherapy followed by conventional fractionated RT to doses of 66-70 Gy. The outcomes of this group of patients were compared with the outcomes of 30 patients with hypopharyngeal cancer who were treated at our institution with surgery and postoperative RT (group II). The median follow-up times of the surviving patients in groups I and II were 5 and 9 years, respectively. RESULTS: The local recurrence-free survival at 5 years from the completion of therapy for group I was 50%, compared with 69% for group II (p = .41). Among patients with T3-T4 primary tumors, the 5-year local control rates were 58% and 59% for groups I and II, respectively (p = .78). The likelihood of larynx preservation, free of local disease at 5 years for group I, was 52%. The 5-year neck recurrence-free survival for groups I and II were 47% and 69%, respectively (p = .66). Among patients with N2-N3 stage disease, the 5-year incidence of neck failure for groups I and II were 73% and 68%, respectively (p = .74). The 5-year distant metastases-free survival for groups I and II were 67% and 57%, respectively (p = .19). The 5-year disease-free survival rates for groups I and II were 30% and 42%, respectively (p = .9). The 5-year overall survival rates for groups I and II were 15% and 22%, respectively (p = .65). CONCLUSIONS: Nonsurgical therapy for advanced stage hypopharyngeal cancer provides survivorship comparable with that achieved with standard approaches of surgery and postoperative RT. However, despite the therapy, the outcome is poor. Future studies will need to explore new treatment strategies in an effort to improve upon the outcome for this group of patients.

Quality of life of maxillectomy patients using an obturator prosthesis.

BACKGROUND: The psychosocial adaptation of patients who had undergone a resection of the maxilla for cancer of the maxillary antrum and/or hard palate with the placement of an obturator prosthesis to restore speech and eating function was studied. METHODS: Forty-seven patients were interviewed who had a maxillectomy with an obturator prosthesis at Memorial Sloan-Kettering Cancer Center, an average of 5.2 years (SD = 2.4 years) ago, 94% of whom had some of their soft palate resected. Interviews were conducted by telephone by a trained research interviewer, using a series of questionnaires to assess their satisfaction with the functioning of their obturator, and the psychological, vocational, family, social, and sexual adjustment. Measures included the Obturator Functioning Scale (OFS). Psychosocial Adjustment to Illness Scale (PAIS), Mental Health Inventory (MHI), Impact of Event Scale, and Family Functioning Scale. RESULTS: Using multiple regression and discriminant function analyses, satisfactory functioning of the obturator prosthesis, as measured by the OFS, was found to be (1) the most highly significant predictor of adjustment, as measured by the PAIS (p < .0001) and the MHI Global Psychological Distress Subscale (MHI-GPD) (p < .001), and (2) significantly related to their perception of the negative socioeconomic impact of cancer upon their lives. The most significant predictor of better obturator functioning were the extent of resection of their soft palate (one third or less, p < .001), and hard palate (one fourth or less, p < .01). Specific aspects of obturator functioning that most significantly correlated with better adjustment (PAIS, MHI-GPD) were: less difficulty in pronouncing words (r = .40 and r = .51, respectively, p < .01), chewing and swallowing food (r = .27-.46, p < .05), and less change in their voice quality after surgery (r = .52 and r = .56, respectively, p < .001). CONCLUSIONS: These findings suggest that a well-functioning obturator significantly contributes to improving the quality of life of maxillectomy patients.

Long-term subjective functional outcome of surgery plus postoperative radiotheraphy for advanced stage oral cavity and oropharyngeal carcinoma.

BACKGROUND: Although long-term cures have been achieved for locally advanced squamous cell carcinomas of the head and neck, there is a paucity of information available regarding patients' perspectives of their functional outcome. PATIENTS AND METHODS: Thirty-five long-term survivors free of disease following surgery and postoperative radiotherapy for advanced cancers of the oral cavity and oropharynx were sent questionnaires to evaluate their long-term functional outcome after therapy. The questionnaires included a subjective performance status scale that assessed the patient perceived (1) ability to eat in public, (2) understandability of speech, and (3) normalcy of diet. Twenty-nine of 35 patients participated in this function assessment and are the subjects of this report. RESULTS: The mean function scores for all patients were as follows: 72 for eating in public, 69 for understandability of speech, and 58 for normalcy of diet. Functional results were further analyzed by T stage and anatomic subsite. Inferior results were noted with increasing T stage. A two-way analysis of variance showed that this difference was significant even after adjusting for the effect of anatomic subsite (P = 0.0002, P = 0.018, and P = 0.0018 for the three outcome variables). In addition, patients with base of tongue lesions had a worse functional outcome for both early T state (T1/T2) and advanced T stage (T3/T4) when compared to other subsites. This difference averaged across T stage was statistically significant for understandability of speech (P = 0.0019) and normalcy of diet (P = 0.013), but was not significant for eating in public (P = 0.16). CONCLUSIONS: This performance status scale was found to be a useful tool for functional assessment following definitive therapy for advanced stage head and neck carcinomas. These subjective functional scores deteriorated with increasing T stage. In addition, functional scores for oral tongue, floor of mouth, and tonsillar primaries were superior to those for base of tongue lesions. These functional outcome scores are consistent with the extent of surgery required for the base of tongue subsite and are in direct relation to the patients' T stage in this study population.

Salvage laryngectomy for unsuccessful larynx preservation therapy.

From 1983 to 1991, 31 patients underwent salvage laryngectomy for persistent or recurrent squamous carcinoma of the larynx (14), hypopharynx (15), or oropharynx (2) as part of a larynx preservation protocol. Laryngectomy was performed as a consequence of poor response to induction chemotherapy in 13 and for recurrent disease after completion of chemotherapy and irradiation in 18. Postoperative pharyngocutaneous fistula occurred in 39%, resulting in prolonged hospitalization. Local control was achieved in 68%, more often in patients with laryngeal as opposed to nonlaryngeal primaries (86% versus 53%; p = .05). The overall actuarial survival and disease-specific survival at 2 years were 32% and 38%, respectively. Disease-specific survival at 2 years was better in patients with laryngeal as compared to nonlaryngeal primaries (56% versus 24%; p = .02). There were no long-term survivors among the nonlaryngeal primary patients. In selected patients in whom larynx preservation failed, salvage laryngectomy was associated with acceptable local control and survival. Palliation was obtained in patients who were not cured by their laryngectomy. Future investigation will focus on identification of factors predicting complications and strategies to reduce the incidence and severity.

Organ-function preservation in advanced oropharynx cancer: results with induction chemotherapy and radiation.

PURPOSE: To evaluate the feasibility and efficacy of a strategy using induction chemotherapy followed by radiation therapy (RT) as a means of organ-function preservation in patients with advanced oropharynx cancer. PATIENTS AND METHODS: From January 1983 to December 1990, 33 patients with advanced squamous cell oropharynx cancer whose appropriate surgical management would have required a tongue procedure and potential total laryngectomy were treated with one to three cycles of cisplatin (CDDP)-based induction chemotherapy. Patients with a complete response (CR) or partial response (PR) at the primary site then received definitive external-beam RT with or without interstitial implant with or without neck dissection with surgery to the primary tumor site reserved for disease persistence or relapse; patients with less than a PR after chemotherapy had appropriate surgery and postoperative RT recommended. RESULTS: With a median follow-up period of 6.2 years, actuarial overall and failure-free survival rates at 5 years are 41% and 42%, respectively. Chemotherapy toxicity contributed to the death of two patients and was possibly a factor in two others. Local control was achieved in 14 patients (42%) without any surgery to the larynx or tongue. Among 13 patients currently alive, all had a preserved larynx and only one required tongue surgery; 12 of 13 have speech subjectively described as always understandable; and nine of 13 have no significant restrictions in their diet. CONCLUSION: This treatment program is feasible and effective in patients with advanced oropharynx cancer and produces an excellent functional outcome in most long-term survivors. Modifications to optimize patient selection, minimize toxicity, and improve local control are indicated. The relative toxicity, efficacy, and functional outcome provided by this and other chemotherapy and RT programs versus either standard surgery and/or RT options can only be addressed in a randomized comparison of these therapies.

Prevalence and predictors of continued tobacco use after treatment of patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer who continue to smoke after diagnosis and treatment are more likely than patients who quit to experience tumor recurrence and second primary malignancies. Therefore, information about patients' smoking status and the factors associated with continued tobacco use are important considerations in the comprehensive care patients with head and neck cancer. METHODS: Study participants were 144 patients with newly diagnosed squamous cell carcinomas of the upper aerodigestive tract who underwent surgical treatment, with or without postoperative radiotherapy or chemotherapy, 3-15 months before assessment of their postoperative tobacco use. RESULTS: Among the 74 patients who had smoked in the year before diagnosis, 35% reported continued tobacco use after surgery. Compared with patients who abstained from smoking, patients who continued to use tobacco were less likely to have received postoperative radiotherapy, to have had less extensive disease, to have had oral cavity disease, and to have had higher levels of education. Hierarchical regression analysis indicated that most of the explained variance in smoking status could be accounted for on the first step of analysis by disease site. Interest in smoking cessation was high, and most patients made multiple attempts to quit. CONCLUSIONS: Although the diagnosis of a tobacco-related malignancy clearly represents a strong catalyst for smoking cessation, a sizable subgroup of patients continue to smoke. Patients with less severe disease who undergo less extensive treatment are particularly at risk for continued tobacco use. These data highlight the importance of developing smoking cessation interventions designed to meet the demographic, disease, treatment, and tobacco-use characteristics of this patient population.