Prognosis of patients with recurrent laryngeal carcinoma.

BACKGROUND: Although recurrent laryngeal carcinoma is a common clinical problem, the data regarding its natural history and prognostic factors are limited. The aim of the study was to describe the clinical course of patients with recurrent laryngeal carcinoma and determine the impact of various factors on their survival. METHODS: The medical files of 65 patients with recurrent laryngeal cancer treated at the Rabin Medical Center between 1975 and 1996 were reviewed. The possible risk factors for survival were analyzed using univariate and multivariate models. RESULTS: The estimated 2- and 5-year survival rates of the patient population were 67% and 56%, respectively. On univariate analysis, primary tumor site, T stage and nodal status, duration of disease-free interval, site of recurrence, and operability of recurrent tumor were all powerful prognostic factors for survival. On multivariate analysis, three variables retained statistical significance: primary tumor site (p < .001), site of recurrence (p < .001), and its operability (p = .005). CONCLUSIONS: We found several disease-related factors to be predictive of poor outcome in patients with recurrent laryngeal cancer. Our data emphasize the need for early detection not only of primary tumors but also of their recurrences.

Histological changes in the cervical lymph nodes after radiotherapy.

Radiotherapy to the neck is frequently employed in the treatment of malignancies, sometimes alone and sometimes before or after surgery or with or without chemotherapy. We checked the histopathological changes in the neck after radiotherapy, dividing the changes into two groups. One with short-term changes between six months to one year, and the second group with long-term changes after more than six years. We compared these two groups with a control group without radiotherapy. The changes in the long-term group were more pronounced than in the short-term group, with more stromal fibrosis, vascular changes, and specially lymph nodes smaller than one centimeter. Thus, bigger lymph nodes (more then one centimeter) are more radiosensitive and become smaller after six years.

Laryngeal carcinoma--epidemiological and clinical features: experience of the Rabin Medical Center in Israel.

We sought to compare the epidemiological and clinical features of patients with carcinoma of the larynx treated at a major Israeli tertiary facility with other series in the literature. The charts of 361 consecutive patients from 1974 to 1995 were reviewed. Our population was distinguished from other series by a low rate of alcohol abuse (12%), high incidence of second malignancies in sites other than the upper aerodigestive tract (53%) and high rate of early-stage tumors (82%). Overall 5-year survival and local control rates were 88% and 85%, respectively. Our study suggests that the low alcohol consumption and high proportion of early-stage tumors at diagnosis, characteristic of the Israeli population of patients with laryngeal carcinoma, may explain, in part, the relatively high survival and local control rates.

[Breast cancer after mantle field irradiation for Hodgkin's disease].

Effective use of modern therapeutic modalities results in the cure of 75%-80% of Hodgkin's disease patients, regardless of stage. The major threat to continued survival is, therefore, not recurrent disease but development of second malignancies. Recent reports have firmly established the increased risk of breast cancer developing in women treated with mantle field irradiation. We describe 3 women who developed breast carcinoma following mantle field irradiation for Hodgkin's disease. Their clinical course was consistent with that reported in larger series. They were relatively young when irradiated and there was a long interval between radiation therapy and the diagnosis of breast cancer. Review of the literature shows that there may be a role for prophylactic mastectomy after irradiation for Hodgkin's disease.

Toxicity of adjuvant high-dose interferon-alpha-2b in patients with cutaneous melanoma at high risk of recurrence.

Interferon-alpha-2b (INF-alpha-2b) has been approved by the FDA as adjuvant treatment for patients with melanoma at high risk of recurrence. INF-alpha-2b is administered at 20 MU/m2/day IV, 5 days per week for 4 weeks, and then 10 MU/m2/day SC, three times weekly for 48 weeks. We investigated the toxicity of this protocol in 30 patients between June 1996 and February 1998. An intensive toxicity evaluation program was developed to monitor side effects. During both induction and maintenance phases, 60% of patients required a dose delay and/or reduction. Twenty percent were unable to complete the treatment plan, and 53% tolerated at least 80% of the scheduled dose. The frequently reported toxicity during induction included constitutional symptoms, myelosuppression, and hepatotoxicity. All were reversible on cessation of treatment or dose modification. During maintenance, toxicity included thyroid dysfunction, hypertriglyceridemia, retinopathy and a combination of mood disturbances, memory loss, cognitive slowing and impaired executive function. Administration of high-dose INF-alpha-2b is feasible, with close patient monitoring.

Prognostic factors for local control of early glottic cancer: the Rabin Medical Center retrospective study on 207 patients.

PURPOSE: Different radiation therapy schedules and devices have been used over the last 20 years at Rabin Medical Center in patients with early glottic cancer. The aim of the present retrospective analysis was to identify the subgroup of patients at high risk of failure of radiation treatment. MATERIALS AND METHODS: Between 1974 and 1994, 207 patients with squamous cell carcinoma of the glottis, 182 Stage T1 and 25 Stage T2, underwent definitive radiation therapy. During this period, treatment was administered with different radiation devices (60Co or 6-MV X ray), using different dose/fraction protocols (1.8 or 2 Gy per day, 5 or 6 fractions per week), total doses (42-77.4 Gy), overall radiation times, and delays. These treatment variables, in addition to certain patient and tumor characteristics, were correlated with local control at a median follow-up of 57 months (range 18-265 months). RESULTS: The 5-year local control rates for T1 and T2 tumors were 88% and 73%, respectively. Univariate analysis showed that smoking, diabetes mellitus, anterior commissure involvement, T stage, and extension of tumor to one third or more of the vocal cord were highly significantly correlated with decreased local control. None of the treatment variables, including dosage at which complete tumor regression was noted, were found to be predictive. By multivariate analysis, only anterior commissure involvement was found to be highly significant (risk ratio 1.9, 95% CI 1.2-3.0, p = 0.027), and T stage was borderline significant (risk ratio 1.6, 95% CI 1.0-2.5, p = 0.054). CONCLUSION: This study suggests that only two tumor characteristics are predictive of local failure of early glottic cancer: anterior commissure involvement and T stage. Treatment variables apparently do not influence local control.

Ethanol injection to parathyroid tissue: indications and limitations.

Hyperparathyroidism is a potentially life-threatening disease, caused primarily by parathyroid adenoma. Surgical excision of the tumor, with consequent return of calcium levels to the normal range, is considered the treatment of choice. Within the last few years, several reports have described the destruction of parathyroid tissue using ultrasonically guided injection of 96% ethanol into pathologic parathyroid glands, resulting in successful regulation of both primary and secondary hyperparathyroidism. The procedure was reported as an alternative to operative treatment for patients as high surgical risk, such as the elderly and the critically ill. We report the occurrence of transient Horner's syndrome and vocal fold paralysis after successful injections of ethanol into a parathyroid adenoma, and discuss the implications and restrictions of the procedure in view of the medical literature.

Acute mastoiditis: a 10-year review.

PURPOSE: To study how antibiotic treatment and an early decision to aspirate subperiosteal abscesses can reduce hospitalization periods and costs in patients with acute mastoiditis. PATIENTS AND METHODS: During a 10-year period, 134 patients were diagnosed with acute mastoiditis at the Department of Ear, Nose, and Throat and Head and Neck Surgery (Kaplan Medical Center, Rehovot, Israel). The diagnoses was based on physical findings of retroauricular swelling and erythema and tenderness, with protrusion of the auricle forward and downward. The majority of patients (77) reached medical treatment during the first 3 days of their disease. Wide myringotomy and intravenous antibiotic treatment, aspiration, and complete cortical mastoidectomy were the treatment options. RESULTS: With the administration of wide myringotomy and intravenous antibiotic treatment, 115 patients recovered; nine received aspiration and did not need surgery; and only 15 patients who received the antibiotic treatment needed a complete cortical mastoidectomy. CONCLUSION: With the wise use of antibiotics and early decision to aspirate subperiosteal abscesses, the hospitalization period, the cost, and the need for surgery can be reduced.

Supraglottic carcinoma: a retrospective study of 114 patients.

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T1 and T2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T1 carcinoma (stage I) and 67 (58.8%) T2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T1: 11 T2), three of whom also had neck metastases. All except one T2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T1 disease as combined therapy did for T2. Five-year recurrence rates for T1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T2 patients were 39% and 28%. We suggest that patients with T1 supraglottic carcinoma be managed with radiotherapy and patients with T2 with combined therapy. We believe there is no need for elective neck dissection, especially in T1.

Laryngeal carcinoma in females.

Between 1950 and 1992, 96 women with squamous cell carcinoma of the larynx were diagnosed and treated in the Department of Otolaryngology and Oncology at Beilinson Medical Center, Israel, and Long Island College Hospital, Brooklyn, New York. Fifty-seven female patients (59%) had glottic carcinoma, 72% of them in stage I. Thirty-eight had supraglottic carcinoma, 68% of them in stages II and III. One patient had stage I subglottic carcinoma. Treatment varied between radiotherapy, surgery, or combined surgery with radiation and/or chemotherapy. The 5-year survival rate was 87%. Although most of the patients had glottic carcinoma in stage I, there was also a high percentage with supraglottic carcinoma, most in advanced stages and with metastases to other regions. The prognosis is not different from that in men. Smoking is an important factor in glottic carcinoma, but not as important as in males.

Vocal cord palsy: possible late complication of radiotherapy for head and neck cancer.

Cranial nerve palsies are uncommon complications of radiotherapy for head and neck cancer. A review of the literature reveals that cranial nerve damage after radiotherapy has been reported for the optic, oculomotor, trigeminal, abducens, cochlear, vagus, spinal accessory, and hypoglossal nerves. The hypoglossal nerve appears to be the most commonly affected, and the recurrent laryngeal nerve is seldom involved. The case histories of three patients who developed vocal cord palsy from 21 to 34 years after a course of curative or postoperative radiotherapy for carcinoma of the head and neck are presented. Two patients had bilateral palsy, and in the third patient, bilateral damage cannot be excluded. Physical examination and radiographic investigations on admission and on follow-up did not demonstrate any evidence of tumor recurrence, cervical or distant metastases, or second primary tumors. The distinction between irradiation-induced palsy and that due to malignancies is emphasized.

T1 glottic carcinoma involving the anterior commissure.

This study reviews the records of 56 patients with early glottic carcinoma involving the anterior commissure (T1N0M0) who were treated between 1958 and 1988 at Beilinson Medical Center. Five- and 10-year survival rates were 82% and 60%, respectively. Most failures were local (15 patients). In addition, three patients who were treatment failures had neck lesions (regional failure) and one had lung lesions (distant metastases). All 56 patients received irradiation as the only mode of initial treatment. The effectiveness of irradiation for anterior commissure lesions is therefore evaluated. The study supports previous reports suggesting that glottic carcinoma involving the anterior commissure is associated with a high rate of treatment failure.

Obstructing adenoids in adolescents: changing trends?

The number of adolescents undergoing surgery for obstructing adenoids has increased significantly in our practice in recent years. Over an 11-year period during which 539 adenoidectomies were performed, the mean age of patients increased progressively from 4.6 years in 1980 to 7.88 years in 1990. The median age gradually increased over the same period from 4 to 7 years, and the standard deviation from 4.95 to 19.38. Enlarged adenoids should be considered in the differential diagnosis of adolescents suffering from nasal obstruction, snoring or obstructive sleep apnea.

Long-term follow-up of the effectiveness and safety of inferior turbinectomy.

The long-term effectiveness and safety of inferior turbinectomy were assessed in 186 patients who were interviewed and examined 10 to 15 years after surgery (mean 12.3 years). Relief of nasal obstruction was reported by 82 percent of the patients; rhinoscopy showed wide, clean nasal airways in 88 percent. Rhinorrhea was still a problem for 34 percent of patients, and 19 percent were receiving medical treatment for this symptom. Smell acuity had improved in 52 percent of the patients. Before turbinectomy, 32 patients had suffered from bronchial asthma; postoperatively, there was an improvement in 16, and no change in 13; 3 patients reported exacerbation of asthmatic attacks. Atrophic changes of the nasal mucosa and chronic purulent infection were not observed in any of the patients.

Needle aspiration and pressure sutures for auricular pseudocyst.

Auricular pseudocyst is an asymptomatic cystic swelling of the upper portion of the auricle. Various therapeutic approaches have been employed with variable success. We report our results with nine patients treated by needle aspiration and bolstered pressure sutures applied over both aspects of the cyst for 1 week. Treatment resulted in complete resolution with no recurrence of the lesion in any of the patients. This procedure is simple, does not require an operating room setting, and is more comfortable and more acceptable aesthetically by the patient.

Experience with the Wilkie procedure for sialorrhea.

Sialorrhea (drooling) is most commonly seen in children with cerebral palsy or mental retardation. Surgical procedures for the control of sialorrhea include salivary gland excision, parasympathetic nerve section, and salivary duct ligation and/or rerouting. Eighteen children between the ages of 5 and 17 years underwent bilateral submandibular gland excision and rerouting of Stensen's duct (Wilkie procedure). All children had severe drooling associated with cerebral palsy or mental retardation. Follow-up at 7 years showed satisfactory control of sialorrhea in 16 of 18 patients (89%). There was one major complication: xerostomia. Our results indicate that submandibular gland excision together with parotid duct retropositioning provides effective control of sialorrhea in most cases. Unfavorable head and mandibular posturing seemed to cause persistent sialorrhea in one case.

Olfactory function following late repair of choanal atresia.

Results of olfactory function tests (threshold determination and odor identification) in three cases of bilateral and one case of unilateral choanal atresia are reported. All four patients underwent successful repair of choanal atresia at relatively advanced ages (8 to 31 years). Test results showed that patients who had suffered from bilateral atresia had permanent olfactory deficits, while the patient who had suffered from unilateral atresia appeared to have normal olfactory acuity. Although these results should be interpreted with caution due to the small number of cases examined, they suggest the possibility that early sensory exposure might be needed for the normal development of central olfactory functions in analogy to the visual system.

Clinical and pathological features of non-Hodgkin's lymphoma of the tonsil. Review of the literature and report of 10 cases.

Ten patients with tonsillar lymphomas diagnosed and treated in our hematology unit from 1979 to 1986 are reported. The heterogeneous histology at presentation, the aggressiveness of the histologic types during relapse, and the relatively low incidence of gastrointestinal tract involvement are discussed. A review of the literature is presented. In view of the better survival rate obtained with chemotherapy or combined chemo- and radiotherapy, we confirm that lymphomas of the tonsil should be aggressively treated, regardless of the staging. Among our 10 cases, 2 are of special interest since they progressed into highly malignant disorders: B-acute lymphoblastic leukemia and Burkitt's lymphoma.

Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration.

Outpatient management of peritonsillar abscess by needle aspiration and oral antibiotic therapy was evaluated for its effectiveness in providing rapid symptom relief and cure and in preventing recurrence. Between 1984 and 1987, 124 patients with peritonsillar infection were treated in our department, and 115 were included in this prospective study. Needle aspiration was not carried out in 11 patients because of young age, noncooperation, or severe trismus. The other 104 patients underwent permucosal aspiration and were followed up for periods of four months to three years. Of these, findings of aspiration were positive in 75 (72%). Only nine (12%) of the 75 patients with positive aspirates had to be hospitalized. In 64 (85%) of the 75 patients, the abscess resolved without further therapy. Aspiration of pus, along with oral administration of antibiotics, thus appears to be a reasonable alternative to incision and drainage or "hot" tonsillectomy in patients with peritonsillar abscess. This conservative approach obviates the need for hospital admission in most patients, thus enabling a significant cost reduction.

Effects of elevated intranasal temperature on subjective and objective findings in perennial rhinitis.

The effects of elevated intranasal temperature on symptoms and signs of perennial rhinitis were studied in 78 patients by a double-blind, randomized, placebo-controlled clinical trial. Patients were subjected to two treatments separated by a 1-week interval. Each treatment consisted of three 30-minute sessions, during which the patient's intranasal temperature was raised by inhalation of saturated hot air (42 degrees C to 44 degrees C). Subjective response was recorded on a daily symptom score card during the week following treatment. Nasal patency was determined before and after treatment by measuring maximal nasal expiratory and inspiratory airflow and by measuring the area covered with vapor formed by the exhaled air on a plate. Highly reproducible results were obtained by using these three objective methods. Elevation of intranasal temperature resulted in amelioration of rhinitis symptoms and in objective evidence of increased nasal patency in a significant percentage of patients compared to the placebo-treated group.