Bilateral chylothorax following left-sided radical neck dissection.

Chylothorax is an extremely rare but potentially life-threatening complication of radical neck dissection. Its rarity makes surgeons unfamiliar with its management. We report the case of a bilateral chylothorax occurring after a left radical neck dissection and discuss its management. A multi-disciplinary approach is advocated, involving surgical, respiratory and dietetic input, and this led to a favourable outcome for our patient.

Accuracy of tele-oncology compared with face-to-face consultation in head and neck cancer case conferences.

Telemedicine was introduced for weekly tumour case conferences between Sahlgrenska University Hospital and two district hospitals in Sweden. The accuracy of tele-oncology was determined using simulated telemedicine consultations, in which all the material relating to each case was presented but without the patient in person. The people attending the conference were asked to determine the tumour ('TNM') classification and treatment. The patient was then presented in person, to give the audience the opportunity to ask questions and perform a physical examination. Then a new discussion regarding the tumour classification and the treatment plan took place, and the consensus was recorded. Of the 98 consecutive patients studied in this way, 80 could be evaluated by both techniques. Of these 80, 73 (91%) had the same classification and treatment plan in the telemedicine simulation as in the subsequent face-to-face consultation. In four cases the TNM classification was changed and for three patients the treatment plan was altered. The specialists also had to state their degree of confidence in the tele-oncology decisions. When they recorded uncertainty about their decision, it was generally because they wanted to palpate the tumour. In five of the seven patients with a different outcome, the clinical evaluation was stated to be dubious or not possible. The results show that telemedicine can be used safely for the management of head and neck cancers.

A prospective study of quality of life in head and neck cancer patients. Part II: Longitudinal data.

OBJECTIVES: To evaluate the health-related quality of life (HRQL) of patients with head and neck cancer during and after treatment with radiotherapy, surgery, and chemotherapy. STUDY DESIGN: Prospective, descriptive study. METHODS: All new patients in four institutions in Norway and Sweden were asked to participate. Health-related quality of life was assessed at baseline and at 1, 2, 3, 6, and 12 months after start of treatment by means of the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and the EORTC head and neck cancer-specific questionnaire. Baseline results are described elsewhere; longitudinal results are presented in the current article. Three hundred fifty-seven patients with cancer in the oral cavity, pharynx, larynx, nose, sinuses, and salivary glands and neck node metastases from unknown primaries filled in the questionnaires at baseline. RESULTS: Seventy-eight percent of the patients who were alive after 12 months filled in all questionnaires (218/280). The general trend was that HRQL deteriorated significantly during treatment, followed by a slow recovery until the 12-month follow-up with few exceptions (senses, dry mouth, and sexuality). Patients who later died reported worse HRQL at each assessment point compared with patients who filled in all six questionnaires, whereas those who dropped out of the study for other reasons were quite similar to patients who filled in all questionnaires. The patients with pharyngeal cancer in general reported worse HRQL compared with the other groups and did not reach pretreatment values in several domains. Stage was also an important factor for HRQL in patients with head and neck cancer. CONCLUSION: Detailed knowledge about the differences between groups and changes over time may aid us in the communication with patients and in the design of intervention studies focusing on improvement of the support and rehabilitation of patients with head and neck cancer.

A prospective study of quality of life in head and neck cancer patients. Part I: at diagnosis.

PURPOSE: A Swedish and Norwegian study was designed to examine health-related quality of life (HQL) in patients with head and neck cancer (head and neck) at diagnosis and during treatment and rehabilitation. The overall aim was to examine the impact on HQL at diagnosis depending on tumor location, stage, sex, and age (part I) and to describe HQL longitudinally and determine for which patients and during which period HQL deteriorated most (part II). This article presents the results at diagnosis. METHOD: Patients with head and neck cancer at five hospitals in Sweden and Norway were consecutively requested to participate. They were asked to answer the EORTC QLQ-C30 and QLQ-H&N35 (the European Organization for Research and Treatment of Cancer, Core 30 questionnaire and head and neck cancer module) repeatedly during 1 year. A total of 357 patients (mean age, 63 y; 72% males) were included. RESULTS: Patients with different tumor locations all had their special problems at diagnosis, for example, those with tumors in the larynx with communication, those with oral tumors with pain, and those with pharyngeal tumors with nutrition and pain. The patients with hypopharyngeal cancer reported the worst HQL. Stage appeared to have the strongest impact on HQL. Patients with a more advanced tumor stage reported significantly worse HQL scores for 24 of 32 variables reflecting functioning or problems. The females scored worse than the males for some areas, in particular, emotional functioning. The older patients scored significantly better for emotional and social functioning than patients <65 years but worse for physical functioning and various symptoms. The traditional way of grouping the tumor locations into oral, pharyngeal, laryngeal, and "other" tumors (salivary gland, sinus and nose, and unknown primary) was tested from a HQL point of view and found to be consistent. CONCLUSIONS: The chosen questionnaires differentiated between different sites of head and neck cancer at diagnosis. Tumor stage had the most powerful impact on HQL score.

Haptic palpation of head and neck cancer patients--implication for education and telemedicine.

Malignancy in the head and neck area is a disease that often gives high morbidity in functions like speech, eating, breathing and cosmetics. To ensure a treatment of high clinical standard these patients are presented for a multidisciplinary tumor-team at Sahlgren University hospital. The team usually involves ENT-surgeons (Ear, Nose and Throat), oncologists, radiologists, pathologists, plastic surgeon, general surgeon and oral surgeons. The aim of the presentation is to classificate the tumor and suggests a treatment. The patients presented are from the whole western region of Sweden, and therefore some patients have to travel long distances. To minimize travel telemedicine was introduced 1998 with success [1]. One concern, when presenting a patient with telemedicine, has been the lack of possibility to palpate the tumor and the tissue surrounding it. To address this problem a 3D model of the tumor visualizes the region and possibly allows haptic palpation. Based on a series of high resolution CT/MR scans, a model of the region around the patients tumor is created. Haptic properties are added to the skin and subcutaneous structures (including the tumor) of the model. Initially, the haptic tuning is done by an examining physician, but in the final telemedical application, the aim is to develop a sensory device for this purpose (e.g. a position sensitive glove, such as Virtual Technologies, Inc. CyberGlove [2] and a graded system for setting firmness of the tissue). The model with its haptic properties can then be examined visually and haptically, the latter using a haptic device such as the SensAble PHANToM [3]. The present system uses a 3D model in VRML format based on reconstructed structures in the ROI (which includes the jawbones, the vertebra, the throat, major muscles and the skin) from high resolution CT. Haptic properties are added using MAGMA 2.5 (ReachIn Technologies AB, Sweden) [4]. Haptic force feedback is provided using a PHANToM Desktop (SensAble Technologies Inc) [3]. Visual feedback can be either monoscopic or stereoscopic (StereoGraphic CrystalEyes) [5]. The system will be used for concept testing and for evaluating possible limitations and/or the need for a modified examination protocol. Once a reliable set of parameters has been generated (using both professionals and medical students at various levels), the remote components will be added.

Overexpression of p53-related proteins predicts rapid growth rate of head and neck cancer.

OBJECTIVES/HYPOTHESIS: The p53 tumor suppressor gene plays an important role for cell cycle regulation and is the most frequent mutated gene in head and neck cancer. Controversy remains regarding the biological and clinical value of immunohistochemical identification of the proteins accumulated in association with inactivation of the p53 gene and increased tumor growth. Therefore, the objective of the present study was to perform a cell kinetic analysis of cases with untreated squamous cell carcinoma and to compare the result with immunostaining for p53-related proteins in the tumor cells. STUDY DESIGN: A prospective series of 32 patients presenting with various stages of untreated squamous cell carcinoma of the head and neck were included. Bromodeoxyuridine (BrdU) was injected as a tracer dose before tumor biopsy for cell kinetic analysis, and p53 protein accumulation was detected using two antibodies (DO7 and PAb 1801). RESULTS: Antibody DO7 showed the highest and the optimal immunoreactivity. Diploid tumors were found in 27 cases (84%), and the mean potential doubling time (Tpot) was 55 +/- 7 hours for these tumors. Positivity of DO7 (>1%) was demonstrated in 85% of the cases. However, a discrimination level exceeding 20% was required to obtain a significant negative relationship (Spearman's rank correlation coefficient test, P < or = .03) between Tpot and DO7 positivity. At that level, 33% of the tumors remained DO7-positive. The corresponding Tpot was not significantly different from the overall mean. The rates of metastatic disease and survival were not dependent on DO7 immunoreactivity or cancer cell kinetics. CONCLUSION: Accumulation of p53-related proteins is associated with an unrestrained growth of head and neck cancer.

Long-term study of quality and safety of osseointegration for the retention of auricular prostheses.

The aim of this article is to describe the safety and quality of the osseointegrated implant technique for the retention of craniofacial prostheses, to present a protocol for collection of clinical data, and to discuss the impact of the procedure on the patient quality of life. A protocol was designed and used to study patients who had received auricular prostheses consecutively since 1979 at our department. The patients were asked to answer a questionnaire designed to describe symptoms and problems specific for someone wearing an auricular prosthesis. In total, 99 patients received 107 prosthetic ears (8 patients had bilateral defects) retained on 309 implants (2 to 4 implants/ear). Patients of all ages were represented, and only 9 discontinuities were reported. Most patients (95%) wear their prosthesis every day, in most cases more than 10 hours/day. The follow-up period ranged from 1 to 12 years, giving a total of 2624 postoperative observations of implants, with a 3% incidence of significant skin reaction. We conclude that the surgical technique for auricular prostheses retained on osseointegrated implants is simple and associated with a low rate of peroperative and long-term complications. It offers a high degree of stability and aesthetic satisfaction.

Long-term sequelae after surgery for orbital floor fractures.

A surgical technique involving exact repositioning and rigid fixation is required for the reduction of fractures of the orbital floor. Even then, sequelae may be present long after the trauma. The aim of this study was to establish the frequency and type of sequelae after surgery for orbital floor fractures and to investigate the extent to which the method of surgery had any impact on the severity of the sequelae. A questionnaire was sent to all 107 patients (response rate 77%) 1 to 5 years after the injury. Further clinical data were obtained from the patients' charts. Eighty-three percent of the patients were affected by some kind of permanent sequelae in terms of sensibility, vision, and/or physical appearance. A high frequency of diplopia (36%) was related to the reconstruction of the orbital floor with a temporary "supporting" antral packing in the maxillary sinus, a technique which has now been abandoned at our department in favor of orbital restoration with sheets of porous polyethylene. Our conclusion is that, because long-term sequelae are common, the surgical technique must be subjected to continuous quality control to minimize future problems for this group of patients.

A prospective multicentre study in Sweden and Norway of mental distress and psychiatric morbidity in head and neck cancer patients.

A Swedish/Norwegian head and neck cancer study was designed to assess prospectively the levels of mental distress and psychiatric morbidity in a heterogeneous sample of newly diagnosed head and neck cancer patients. A total of 357 patients were included. The mean age was 63 years, and 72% were males. The patients were asked to answer the HAD scale (the Hospital Anxiety and Depression scale) six times during 1 year. The number of possible or probable cases of anxiety or depression disorder was calculated according to standardized cut-offs. Approximately one-third of the patients scored as a possible or probable case of a major mood disorder at each measurement point during the study year. There were new cases of anxiety or depression at each time point. The anxiety level was highest at diagnosis, while depression was most common during treatment. Females were more anxious than males at diagnosis, and patients under 65 years of age scored higher than those over 65. Patients with lower performance status and more advanced disease reported higher levels of mental distress and more often scored as a probable or possible cases of psychiatric disorder. Our psychometric analyses supported the two-dimensional structure and stability of the HAD scale. The HAD scale seems to be the method of choice for getting valid information about the probability of mood disorder in head and neck cancer populations. The prevalence of psychiatric morbidity found in this study emphasizes the importance of improved diagnosis and treatment.

Quality-of-life effects of psychosocial intervention in patients with head and neck cancer.

METHODS: Two studies of psychosocial interventions in head and neck cancer patients at different stages of their disease were performed. We explored the feasibility and effectiveness of different approaches, offered for the first time to this population. The first study concerned long-term group psychological therapy for patients with newly diagnosed head and neck cancer. Quality of life was measured longitudinally for 1 year and compared with that of a control group. The second study comprised a short-term psychoeducational program 1 year after treatment for head and neck cancer. Quality-of-life assessments were made repeatedly from diagnosis until 1 month after the intervention. RESULTS: Thirteen patients started the psychological group therapy, and 8 of them completed both the intervention and evaluation procedure. The quality of life of the therapy group improved more than that of a control group in most areas measured during the study year, in particular psychiatric morbidity, social functioning, emotional functioning, and global quality of life. The results indicate benefits from the therapy, although the therapy group scored worse than the control group at diagnosis. Most of the variables representing functioning and symptoms improved after the 1-week psychoeducational program, especially items reflecting "trouble eating" and "problems enjoying your meals." Patients' judgments of the intervention quality indicated satisfaction with all separate elements, mostly education, about cancer and the opportunity to socialize with the other guests. CONCLUSION: These pilot studies suggest that head and neck cancer patients can benefit from different psychosocial interventions. Quality-of-life questionnaires were well accepted and sensitive to changes during the studies. Thus our early findings seem promising and would justify confirmation in larger studies.

Quality of life in head and neck cancer patients: validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35.

PURPOSE: The aim of this study was to define the scales and test the validity, reliability, and sensitivity of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-H&N35, a questionnaire designed to assess the quality of life of head and neck (H&N) cancer patients in conjunction with the general cancer-specific EORTC QLQ-C30. PATIENTS AND METHODS: Questionnaires were given to 500 H&N cancer patients from Norway, Sweden, and the Netherlands as part of two prospective studies. The patients completed the questionnaires before, during (Norway and Sweden only), and after treatment, yielding a total of 2070 completed questionnaires. RESULTS: The compliance rate was high, and the questionnaires were well accepted by the patients. Seven scales were constructed (pain, swallowing, senses, speech, social eating, social contact, sexuality). Scales and single items were sensitive to differences between patient subgroups with relation to site, stage, or performance status. Most scales and single items were sensitive to changes, with differences of various magnitudes according to the site in question. The internal consistency, as assessed by Cronbach's alpha coefficient, varied according to assessment point and within subsamples of patients. A low overall alpha value was found for the speech and the senses scales, but values were higher in assessments of patients with laryngeal cancer and in patients with nose, sinus, and salivary gland tumors. Scales and single items in the QLQ-H&N35 seem to be more sensitive to differences between groups and changes over time than do the scales and single items in the core questionnaire. CONCLUSION: The QLQ-H&N35, in conjunction with the QLQ-C30, provides a valuable tool for the assessment of health-related quality of life in clinical studies of H&N cancer patients before, during, and after treatment with radiotherapy, surgery, or chemotherapy.

Quality of life and voice in patients with laryngeal carcinoma: a posttreatment comparison of laryngectomy (salvage surgery) versus radiotherapy.

OBJECTIVES: This study was designed to compare the voice and the quality of life (QOL) of laryngeal cancer patients receiving treatment with radical radiotherapy with or without laryngectomy as salvage surgery. We also compared the patients' own perceptual ratings of their voice to the perceptual ratings of a group of listeners. STUDY DESIGN: Two groups of laryngeal cancer patients were studied. METHODS: Fourteen irradiated laryngeal speakers with preserved larynx were matched with 14 salvage surgery laryngectomized patients speaking with tracheoesophageal prosthesis (TEP). To measure patients' QOL, we used the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck module (EORTC QLQ-H&N35), the Hospital Anxiety and Depression scale (HAD) and a study-specific questionnaire. For the perceptual speech evaluation we used visual analog scales. RESULTS: The perceptual ratings of speech intelligibility, voice quality, and speech acceptability showed a significant difference between the treatment groups. Both the patients who received treatment with radiotherapy and the listeners rated the irradiated laryngeal voices higher than the tracheoesophageal speech. The laryngectomized patients scored significantly better than the patients treated with radical radiotherapy on the question about hoarseness. No other significant difference was found for the QOL functions and symptoms. CONCLUSION: When patients treated with radiotherapy were compared with patients treated with laryngectomy as salvage surgery, QOL was similar, only small differences being found in the perceptual speech evaluation.

Malnutrition and food intake in relation to quality of life in head and neck cancer patients.

BACKGROUND: The quality of life (QL) of cancer patients has attracted an increasing interest in recent years. Patients with head and neck cancer often have troublesome symptoms due to the disease and to treatment side effects, which will have an impact on the patient's QL. The aim of this study was to evaluate the possibility of studying QL in relation to well-known clinical parameters. METHODS: Patient's QL was evaluated according to the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) combined with a diagnosis-specific questionnaire. Quality of life was measured in a cross section of head and neck cancer patients (n = 48) and related to nutritional status, energy intake, severity of disease, and 2-year survival. RESULTS: Fifty-one percent of the patients (mean age, 67 years) fulfilled the criteria proposed for malnutrition, and 55% had a negative energy balance. We did not find any correlation between the severity of the cancer disease and the patient's self-rated QL. However, we found significantly better QL ratings among the 2-year survivors (mean, 63; range 52-76 versus mean, 42; range, 31-54; p < .05). There were few correlations between the QL items and malnutrition. CONCLUSIONS: Quality of life measurements offer objective information on well-being, sometimes quite opposite that of other clinical parameters, such as tumor stage. Furthermore, QL measurements may be of prognostic value concerning the survival of head and neck cancer patients.

A prospective quality of life study of patients with laryngeal carcinoma by tumor stage and different radiation therapy schedules.

This study was designed to prospectively monitor the quality of life of laryngeal cancer patients, to compare the quality of life of patients with small tumors with that of patients with large tumors, and to test any quality of life difference in patients with small tumors treated with conventional versus hyperfractioned accelerated radiation therapy. Patients having had a laryngectomy within the study year were also analyzed separately. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30), the EORTC Head and Neck Module (H&N-37), and the Hospital Anxiety and Depression (HAD) scale were administered six times during 1 year. These questionnaires were found to be suitable for measuring laryngeal cancer patients' quality of life longitudinally. The questionnaires were sensitive to differences in quality of life for small versus large tumors and showed that hyperfractioned accelerated radiation therapy was advantageous compared with conventional radiation therapy with respect to quality of life at the 1-year follow-up.

Cell proliferative modulation of MCG 101 sarcoma from mice exposed to hyperbaric oxygenation.

Tumor cell kinetics were studied in C57 Bl/J mice with a transplantable sarcoma, MCG 101, exposed to hyperbaric oxygen (HBO2), 2.8 atm abs, 2 hours daily for 9 days or until spontaneous death. The isoenzymatic pattern of lactate dehydrogenase (LDH) confirmed that there was a significant shift toward aerobic metabolism in tumor tissue as well as in the liver and skeletal muscle. Recruitment of cells from the G0G1 state into DNA synthesis was associated with an increased mobilization of substrates for polyamine synthesis in terms of an elevated ornithine decarboxylase (ODC) activity. However, cell cycle turnover in terms of bivariate flow cytometric analysis after bromodeoxyuridine (BrdUrd) injection, final tumor weight, and survival time were not changed compared with the controls. Tumor cell metabolism demonstrated evidence of an unchanged net energy utilization, in that activities (V(max) of phosphofructokinase (PFK) and LDH were not significantly changed. When the tumor-bearing animals were exposed to advanced HBO2 pressure (3.7 atm abs) for 3 h as a single dose, the DNA distribution and growth rate were not changed immediately. However, 3.5 h later we observed a DNA pattern similar to that after repeated HBO2 treatments, 2.8 atm abs, concomitant with a preponderance of cells in the late S-phase, which is consistent with a block at the entry of G2M. We conclude that MCG 101 sarcoma recovers from HBO2 exposure by an accumulation of cells in the S-phase without significant changes of net tumor growth. This may have relevance to clinical radiocurability.

Prospective, longitudinal quality-of-life study of patients with head and neck cancer: a feasibility study including the EORTC QLQ-C30.

Despite modern advances in the treatment of head and neck cancer, the survival rate fails to improve. Considering the different treatment modalities involved, quality of life has been thought of as an additional end point criterion for use in clinical trials. A Nordic protocol to measure the quality of life of head and neck cancer patients before, during, and after treatment was established. Before the study, a pilot study was done with this protocol. The main purpose of this pilot study was to find out whether this cancer population would answer quality-of-life questionnaires repeatedly (six times) over a 1-year period and whether the chosen questionnaires-a core questionnaire (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30)), a tumor-specific questionnaire, and a psychological distress measure (Hospital Anxiety and Depression scale (HAD))-were sensitive for changes to functions and symptoms during the study year. The results presented in this article all refer to the pilot study. Forty-eight consecutive patients agreed to participate in the study. The most common tumor locations were the oral cavity (17) and the larynx (12). Almost all patients received combined treatment: 45 of 48 radiation therapy, 18 of 48 chemotherapy, and 17 of 48 surgery. After the primary treatment, 40 patients had complete tumor remission. Four of the 48 patients did not answer any questionnaires and were therefore excluded from the study. Of the remaining 44 patients, 3 died during the study year, and another 6 withdrew for various reasons. Thirty-five (85%) of the 41 patients alive at the 1-year follow-up answered all six questionnaires and thus completed the study. Mailed questionnaires were used throughout the study. All questionnaires were well accepted and found to be sensitive to changes during the study year. The greatest variability was found for symptoms and functions related specifically to head and neck cancer. The symptoms were swallowing difficulties, hoarse voice, sore mouth, dry mouth, and problems with taste. They all showed the same pattern, with an increase of symptoms during and just after finishing the treatment. The HAD scale revealed a high level of psychological distress, with 21% probable cases of psychiatric morbidity at diagnosis. In conclusion, it was shown that the study design and questionnaires were feasible for the forthcoming prospective quality-of-life assessment of Swedish and Norwegian head and neck cancer patients.

A prospective quality of life study of patients with oral or pharyngeal carcinoma treated with external beam irradiation with or without brachytherapy.

The aim of this longitudinal quality of life (QL) study, was to study tumour-related symptoms and treatment side-effects of patients with oral or oropharyngeal cancer and to determine whether an increased local dose of irradiation (brachytherapy affected QL. The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), a tumour-specific Head and Neck questionnaire and the Hospital Anxiety and Depression scale (HAD) were used repeatedly during 1 year. There were 105 patients, with a cumulative response rate of 89%. Most symptoms and problems were at their peak 2 or 3 months after the start of treatment. Nutrition and pain were found to be the major problems, and as many as 19-40% reported psychiatric distress. Patients having received additional brachytherapy did not report any increase in QL problems (except for pain) compared with those having had external radiation only. Quality of life does not seem to be affected by the increased irradiation local dose given when brachytherapy is included in the treatment regimen.

Tumour purine nucleotides and cell proliferation in response to exercise in rats.

Voluntary physical exercise can delay the onset of anorexia and cachexia in tumour-bearing rats. A substrate deviation in the host which has been hypothesised as tumour burden is reduced despite an increase in food intake. Therefore, we determined the levels of purine nucleotides, the energy charge and the cell division rate in tumours from exercising animals in the postexercise period. Tumour content of purine nucleotides was analysed by HPLC. Tumour cell kinetics was studied by flow cytometry after incorporation of bromodeoxyuridine (BrdU) into DNA. Exercising animals demonstrated a 34.4% reduction in tumour volume (P < 0.05) but a 1.31-fold increase in energy charge in tumour tissue (P < 0.05). Labelling index (LI), DNA synthesis time (Ts) and potential doubling time (Tpot) were not significantly altered. These results suggest that the influence on tumour growth is closely related to the exercise period.