Laryngeal function preservation following supracricoid partial laryngectomy.

BACKGROUND: Supracricoid partial laryngectomy is a surgical technique that preserves laryngeal function. METHODS: A retrospective review of clinical records identified 41 patients that underwent supracricoid partial laryngectomy at our institution since 1998. In all, 26 patients with a minimum follow-up of 3 months were alive with a functioning larynx. All of them accepted participation in a functional evaluation. RESULTS: Ninety-seven percent of the patients were decannulated, and every patient achieved oral intake. The 5-year actuarial laryngoesophageal dysfunction-free survival was 66.5%. Median Voice Handicap Index (VHI) score was 26, with 75% of patients scoring <40. The Median MD Anderson Dysphagia Inventory (MDADI) score was 92, with 75% of patients scoring ≥80. Median maximum phonation time (MPT) was 12 seconds. Median maximum intensity (Imax) was 99 dB. CONCLUSIONS: Supracricoid partial laryngectomy allows laryngeal function preservation at a rate similar to that of chemoradiation protocols. When a careful preoperative patient selection is performed, long-term functional results are outstanding. © 2011 Wiley Periodicals, Inc. Head Neck, 2012.

Valor predictivo de la paratohormona en la hipocalcemia postiroidectomía / Parathyroid hormone as a predictor of post-thyroidectomy hypocalcemia

Introducción y objetivos: El riesgo de hipocalcemia es el motivo para prolongar la hospitalización de los pacientes intervenidos de tiroidectomía. Nos planteamos validar la determinación de paratohormona intacta para predecir el desarrollo de hipocalcemia. Material y métodos: Se realizó un estudio prospectivo en 82 pacientes intervenidos de tiroidectomía total entre febrero de 2009 y marzo de 2010 para establecer el momento de la determinación y el punto de corte de paratohormona más predictivos de hipocalcemia. Los pacientes con condiciones que pudieran interferir con la homeostasis del calcio fueron excluidos. Se determinaron la paratohormona y los niveles de calcio séricos preoperatoriamente, en el postoperatorio inmediato y en el tardío. Resultados: El 16,7% de los pacientes presentaron hipocalcemia. La disminución tardía de paratohormona demostró ser la prueba más precisa para detectar hipocalcemia. El punto de corte para seleccionar candidatos al alta precoz se estableció en una disminución del 80%, con una sensibilidad del 100% (IC95%: 77,2-100%) y una especificidad del 87% (IC95%: 77-93%). Empleando esta prueba, el 73,2% de los pacientes podrían haber recibido el alta a las 24 h de la cirugía. Se tomó como punto de corte para establecer candidatos a tratamiento precoz con calcio una disminución de la paratohormona del 98%, la especificidad fue del 98,6% (IC95%: 92,2-99,7%). Conclusiones: La disminución tardía de paratohormona es un buen predictor de hipocalcemiapostiroidectomía, que permite estratificar a los pacientes en tres grupos según su riesgo de hipocalcemia usando dos puntos de corte. El punto de corte del 80% presenta una sensibilidad y especificidad excelentes para seleccionar candidatos al alta hospitalaria precoz. El punto de corte del 98% presenta una alta especificidad para seleccionar candidatos a tratamiento precoz con calcio (AU)

Introduction and objective: The risk of developing hypocalcemia is the reason for prolonged hospitalisation after total thyroidectomy. The objective of this study was to validate parathyroid hormone measurement for predicting post-thyroidectomy hypocalcemia. Material and methods: Eighty-two patients who underwent total or completion thyroidectomy from February 2009 to March 2010 were enrolled in this prospective study to determine the best timing and cutoff point of parathyroid hormone to predict hypocalcemia. Patients with any condition that could interfere with calcium homeostasis were excluded from the survey. Parathyroid hormone and serum calcium levels were determined preoperatively, immediately after surgery and a number of hours later. Results: Treatment for hypocalcemia was required in 16.7% of patients. A percent of delayed decrease in parathyroid hormone was chosen as the best measurement to predict hypocalcemia. An 80% or higher decrease in delayed parathyroid hormone levels had 100% sensitivity (95% CI: 77.2-100%) and 87% specificity (95% CI: 77-93%) for selecting patients for early discharge. Using this test, 73.2% of the patients could have been discharged 24 hours after surgery. A 98% decrease in delayed parathyroid hormone levels could select candidates for early calcium replacement with 98.6% specificity (95% CI: 92.2-99.7%). Conclusions: The decrease in postoperative delayed parathyroid hormone levels is a good predictor of post-thyroidectomy hypocalcemia. A decrease of 80% or more in delayed parathyroid hormone level is a test with excellent sensibility and specificity for selecting candidates for early discharge. The 98% cutoff point has high specificity for selecting patients for early calcium replacement (AU)

Oncologic outcomes after supracricoid partial laryngectomy.

OBJECTIVE: To review the oncologic outcomes of a series of supracricoid partial laryngectomy. DESIGN: Case series with chart review. SETTING: La Paz University Hospital, Madrid, Spain. PATIENTS: Forty-one patients with glottic or supraglottic squamous cell carcinoma who underwent supracricoid partial laryngectomy between 1998 and 2008 at the authors' institution. MAIN OUTCOME MEASURE: Local control rate, specific-disease survival rate, and overall survival rate. RESULTS: All patients were male, with a mean age of 56 years (range, 38-71 years). Forty-one percent of tumors were classified as locally advanced carcinomas (T3-T4). Thirty-three patients (80%) underwent supracricoid laryngectomy with cricohyoidoepiglottopexy. Epiglottis was resected in the remaining 8 patients. One patient died in the immediate postoperative period because of cardiac tamponade, 6 developed pneumonia, 2 had a postoperative bleeding that required reintervention, and 2 developed pharyngocutaneous fistula. The median follow-up period was 43 months. More than 85% of the patients completed more than 2 years of follow-up. Five-year actuarial local control rate was 80%, being 92% for T1-T2 tumors and 67% for locally advanced tumors. Thirty-five patients (85%) preserved their larynx. The 6 patients who underwent total laryngectomy had a local recurrence or a regional recurrence that infiltrated the larynx. No laryngectomy was performed for functional reasons. CONCLUSION: Supracricoid partial laryngectomy is an oncologically safe procedure to preserve laryngeal functions in selected patients with glottic and supraglottic carcinomas.

[Parathyroid hormone as a predictor of post-thyroidectomy hypocalcemia]. / Valor predictivo de la paratohormona en la hipocalcemia postiroidectomía.

INTRODUCTION AND OBJECTIVE: The risk of developing hypocalcemia is the reason for prolonged hospitalisation after total thyroidectomy. The objective of this study was to validate parathyroid hormone measurement for predicting post-thyroidectomy hypocalcemia. MATERIAL AND METHODS: Eighty-two patients who underwent total or completion thyroidectomy from February 2009 to March 2010 were enrolled in this prospective study to determine the best timing and cutoff point of parathyroid hormone to predict hypocalcemia. Patients with any condition that could interfere with calcium homeostasis were excluded from the survey. Parathyroid hormone and serum calcium levels were determined preoperatively, immediately after surgery and a number of hours later. RESULTS: Treatment for hypocalcemia was required in 16.7% of patients. A percent of delayed decrease in parathyroid hormone was chosen as the best measurement to predict hypocalcemia. An 80% or higher decrease in delayed parathyroid hormone levels had 100% sensitivity (95% CI: 77.2-100%) and 87% specificity (95% CI: 77-93%) for selecting patients for early discharge. Using this test, 73.2% of the patients could have been discharged 24 hours after surgery. A 98% decrease in delayed parathyroid hormone levels could select candidates for early calcium replacement with 98.6% specificity (95% CI: 92.2-99.7%). CONCLUSIONS: The decrease in postoperative delayed parathyroid hormone levels is a good predictor of post-thyroidectomy hypocalcemia. A decrease of 80% or more in delayed parathyroid hormone level is a test with excellent sensibility and specificity for selecting candidates for early discharge. The 98% cutoff point has high specificity for selecting patients for early calcium replacement.

Large cell neuroendocrine carcinoma of the parotid gland: case report and literature review.

A 74-year-old male presented with a large polinodular mass in the neck. Fine needle aspiration cytology (FNAC) showed an undifferentiated large cell carcinoma. Computed tomography (CT) showed a large parotid mass with multiple satelite nodules. The remaining radiological studies were normal. Radical parotidectomy was performed. The tumor was a large cell carcinoma with neuroendocrine features and positive immunostain for neuroendocrine markers. The patient received postoperative radiotherapy and was free of tumor eight months later. Only four cases of large cell neuroendocrine carcinoma (LCNEC) of the salivary gland have been communicated. All of them have involved the parotid gland. This tumor presents in elderly patients as a large infiltrating parotid mass. Fine needle aspiration cytology serves to recognize the carcinoma, but it fails in recognizing the neuroendocrine features of the tumor. The histopathological features of this tumor are the same as in other organs. Chromogranin and synaptophysin are useful immunohistochemical markers. A primary location of the tumor in another organ, specially the lung, should be ruled out. Surgery is the main treatment modality and can be complemented with postoperative radiotherapy. The prognosis seems to be poor. More studies are needed to better define the therapeutical alternatives and prognostic factors of these rare tumors.

Malignant mixed tumor of the larynx.

BACKGROUND: Malignant mixed tumor of the larynx is a very rare neoplasm; only five cases have been reported, three in the English-language literature. METHODS: We report the case of a 69-year-old man with a 2-month history of hoarseness and a left laterocervical palpable mass. RESULTS: Total laryngectomy and bilateral radical neck dissection were performed. The tumor involved the glottic and subglottic regions and thyroid cartilage and extended to the anterior side of the larynx. Microscopically, the tumor was composed of three cellular types: epithelial cells, chondrocytes, and spindle cells. The epithelial cells resembled a moderately differentiated adenocarcinoma, the mesenchymal cells resembled a high-grade chondrosarcoma, and the spindle cells had immunohistochemical features of myoepithelial cells. The tumor metastasized to a cervical lymph node, with the three described components. The patient died 11 months after surgery. CONCLUSIONS: The lesion in this case was considered to be a malignant mixed tumor. Differences between this tumor and that of laryngeal chondrosarcoma are discussed.

Efficacy of piperacillin-tazobactam in the treatment of surgical wound infection after clean-contaminated head and neck oncologic surgery.

BACKGROUND: Although perioperative antibiotic prophylaxis has significantly reduced surgical wound infection rates, this complication is still a frequent complication of head and neck cancer surgery. Because these infections are typically polymicrobial, our study evaluated the safety and efficacy of piperacillin-tazobactam in the treatment of surgical wound infection after clean-contaminated head and neck oncologic surgery. METHODS: In this multicenter, prospective clinical trial, 70 patients with surgical wound infection received piperacillin-tazobactam. RESULTS: Of patients who were evaluable, 92.4% were also clinically cured or improved, and the bacteriologic eradication rate was 80.3%. Of the 70 patients enrolled in the study, six (8.5%) experienced six adverse events: two cases of moderate diarrhea, one allergic skin reaction, and three cases of phlebitis. No deaths were attributable to the study drug. CONCLUSIONS: Piperacillin-tazobactam is a good choice of treatment as monotherapy for surgical wound infection after clean-contaminated head and neck oncologic surgery.

Oncologic and functional results of near-total laryngectomy.

OBJECTIVE: To report the oncologic and functional outcome of patients undergoing near-total laryngectomy. STUDY DESIGN AND SETTING: A retrospective analysis was carried out from 1991 through 1998. RESULTS: Eighty-seven patients underwent near-total laryngectomy. The Kaplan-Meier overall survival, cause-specific survival, and relapse-free survival estimates at 5 years were 48.2%, 75.8%, and 72.4%, respectively. Univariate analysis revealed prognosis significance for location, stage, and pathologic cervical lymph node status. Five percent of the patients developed local recurrence, 16% recurrence in cervical lymph nodes, and 10% distant metastasis. Pharyngocutaneous fistula was the most frequent complication (48%). Seventy-seven percent of cases achieved voice preservation. Symptomatic aspiration was noted in 12.3% of cases. CONCLUSION: Near-total laryngectomy can be a successful surgical procedure for selected patients; it does not replace total laryngectomy but reduces its indications. Voice preservation can be achieved in most cases. SIGNIFICANCE: Near-total laryngectomy enhances the speech rehabilitation options for the laryngectomy patient by adding a physiologic, nonprosthetic tissue technique.

Prognostic significance of p16INK4a alterations and 9p21 loss of heterozygosity in locally advanced laryngeal squamous cell carcinoma.

The p16INK4a gene, localized within chromosome 9p21, has been identified as a cyclin-dependent kinase inhibitor and may negatively regulate the cell cycle acting as a tumor suppressor. Genetic alterations involving the 9p21 region are common in human cancers. A consecutive series of 64 untreated patients (median of follow up 53 months) undergoing surgical resection for locally advanced laryngeal squamous-cell carcinomas (LSCCs) has been studied prospectively. Our purpose was to investigate p16 alterations (9p21 allelic loss, hypermethylation and point mutations) and their possible association with clinico-pathological data and flow cytometric variables (DNA-ploidy and S-phase fraction (SPF)), and to determine the possible prognostic role of this gene in these tumors. PCR-based techniques were used for investigating 9p21 loss of heterozygosity (LOH) and methylation promoter status of the p16 gene. p16 mutations were detected by PCR-SSCP (single strand conformation polymorphism) and sequencing. 9p21 LOH was detected in 16/62 (26%) informative tumors, point mutations in 5% (3/64) and hypermethylation in 9% (6/64) of the cases. p16 alterations were significantly associated with high SPF and DNA-aneuploidy. By univariate analysis, poor histologic differentiation, stage IV, DNA-aneuploidy and p16 point mutations proved to be significantly related to quicker relapse, whereas these same factors, and in addition high SPF, 9p21 LOH and any p16 alterations were significantly related to shorter overall survival. By Cox proportional hazards analysis only histologic grade (G3) and p16 point mutations were independently related to both disease relapse and death. Our study has identified p16 point mutations as important biomolecular indicators in LSCCs.

Functional neck dissection for the clinically negative neck: effectiveness and controversies.

This study was performed to evaluate the effectiveness of functional neck dissection in controlling metastasis to the clinically negative (cN0) neck, focusing on recurrences in the pathologically negative (pN0) neck and the role of extracapsular spread in the cN0 neck. A series of 172 patients (253 dissected fields) treated for cN0 laryngeal or hypopharyngeal cancer with a 5-year minimum follow-up is presented. Occult metastasis was observed in 30% of the patients. Extracapsular spread was present in 39% of the positive nodes. The neck recurrence rate was 5.2%. Surgical specimens from cases of neck recurrence in pN0 necks were reevaluated for micrometastasis by immunostaining with antibody for cytokeratins. The immunohistochemical findings were positive in 1 of 4 cases. Functional neck dissection provides good neck control and survival rates for the cN0 neck. The accurate prognostic significance of extracapsular spread in cN0 necks is still unknown. Micrometastasis alone may be insufficient to explain recurrences in pN0 necks.

Surgical management of recurrent parathyroid cyst.

Parathyroid cysts are rare lesions of uncertain embryological origin, usually presenting as a painless mass in the lower part of the neck. Clinical presentation usually mimics a thyroid nodule, and fine needle aspiration with demonstration of high parathyroid hormone levels in fluid is often required to establish the diagnosis. In addition to difficulty in diagnosis, the best treatment for these uncommon lesions remains controversial. We present a case of recurrent parathyroid cyst after several fine needle aspirations managed by surgery, and discuss the relevant associated literature.