Dual thyroid ectopia with submental thyroid excision using Sistrunk procedure: A case report.

INTRODUCTION AND IMPORTANCE: Having two or more sites of simultaneous ectopic thyroid tissue is a rare phenomenon. Thyroid ectopia should be considered in congenital hypothyroidism where no eutopic thyroid gland is found. CASE PRESENTATION: This case describes an incidental finding of dual ectopic thyroid tissue on computer tomography scan in an adult with known congenital hypothyroidism that was previously attributed to thyroid agenesis. The decision was made to proceed with a Sistrunk procedure to excise the ectopic submental thyroid as it became more noticeable after weight loss following bariatric surgery, and to monitor the remaining lingual thyroid with a combination of clinical symptomology, imaging and thyroid function studies given its challenging location. CLINICAL DISCUSSION: The literature on pathophysiology, imaging modalities, and common considerations for surgical extirpation is reviewed. CONCLUSION: The utility of thyroid scintigraphy may be limited in patients with known thyroid ectopia; other investigative modalities are helpful. The Sistrunk procedure was used to excise an ectopic thyroid, based on its embryological migration from the foramen caecum to the usual pretracheal position along the thyroglossal tract, and is a suitable technique for excision of submental thyroid tissue causing an unsightly mass and where thorough histopathological examination is required to exclude malignancy.

Important prognostic significance of lymph node density in patients with node positive oral tongue cancer.

BACKGROUND: Lymph node density (LND) has been described as a prognostic factor for survival in patients with head and neck squamous cell carcinoma, particularly of the oral cavity. The aim of this study was to determine the prognostic significance of LND in patients with node positive oral tongue squamous cell carcinoma (OTSCC). METHODS: Patients with pathological node positive OTSCC were identified in a retrospective review of prospectively collected data. The optimal cut-point for LND was determined using the minimum P-value method and the log-rank test. The impact of this LND cut-point on time to disease progression and overall survival was determined. RESULTS: In 72 patients with OTSCC, an LND of 14.3% was found to have the greatest separation using the log-rank test (P < 0.001). LND ≤14.3% was predicted for longer time to disease progression with a median time of 73 months compared to 9.4 months in patients with an LND >14.3% (hazard ratio: 3.43; 95% confidence interval: 1.76-6.70; P < 0.001). LND was also a significant predictor of overall survival with a median overall survival with LND ≤14.3% of 82.3 months, compared with 14.7 months in patients with an LND >14.3% (hazard ratio: 3.28; 95% confidence interval: 1.61-6.68; P = 0.001). Patients with an LND >14.3% experienced a higher rate of regional recurrence. CONCLUSION: Our findings confirm the prognostic significance of LND in patients with node positive OTSCC, with a similar LND cut-point value to other published series. Improving regional control in these high-risk patients may improve outcome.

Prognostic Significance of Lymph Node Ratio in Metastatic Cutaneous Squamous Cell Carcinoma of the Head and Neck.

BACKGROUND: The prognostic variables in patients with metastatic cutaneous nodal squamous cell carcinoma (SCC) are well documented; however, the relationship between lymph node ratio (LNR) and outcome is not well researched. LNR represents the ratio of positive lymph nodes to total excised lymph nodes. We analyzed the correlation between LNR and outcome in patients who have undergone surgery for metastatic cutaneous nodal SCC of the head and neck. METHODS: Analysis was performed on retrospectively collected data, identifying patients who underwent surgery at Westmead Hospital, Sydney. Pathology reports were reviewed to ascertain LNR. A log-rank test identified a specific LNR value to compare time to disease progression (TTDP) and overall survival (OS). Multivariate proportional hazard regression models were used to review outcome. RESULTS: In total, 193 males and 45 females with a median of age 68 years were identified, with a mean recorded LNR of 0.15. On multivariate analysis, an LNR cutpoint of 0.21 was a significant predictor of decreased TTDP [hazard ratio (HR) 2.34, 95 % confidence interval (CI) 4.40-0.49; p = 0.009] and OS (HR 2.75, 95 % CI 1.57-4.82; p < 0.001). Forty-nine of 238 patients (21 %) developed recurrence, with most recurrences being regional (29 of 49; 59 %). A total of 17 % of patients with an LNR ≤0.21 recurred compared with 40 % for patients with an LNR >0.21. CONCLUSIONS: LNR is potentially an independent predictor of outcome in patients with metastatic cutaneous nodal SCC. The clinical relevance of this finding requires further validation.

Ameloblastic Carcinoma.

BACKGROUND: Ameloblastic carcinoma secondary type is an extremely rare and aggressive odontogenic neoplasm that exhibits histological features of malignancy in primary and metastatic sites. It arises through carcinomatous de-differentiation of a pre-existing ameloblastoma or odontogenic cyst, typically following repeated treatments and recurrences of the benign precursor neoplasm. Identification of an ameloblastic carcinoma, secondary type presenting with histologic features of malignant transformation from an earlier untreated benign lesion remains a rarity. Herein, we report 1 such case. CASE REPORT: A 66-year-old man was referred for management of a newly diagnosed ameloblastic carcinoma. He underwent radical surgical intervention comprising hemimandibulectomy, supraomohyoid neck dissection, and free-flap reconstruction. Final histologic analysis demonstrated features suggestive of carcinomatous de-differentiation for a consensus diagnosis of ameloblastic carcinoma, secondary type (de-differentiated) intraosseous. CONCLUSIONS: Ameloblastic carcinoma, secondary type represents a rare and challenging histologic diagnosis. Radical surgical resection with adequate hard and soft tissue margins is essential for curative management of localized disease.

Desmoplastic fibroblastoma presenting as a parotid tumour: a case report and review of the literature.

Desmoplastic fibroblastomas (DFs) are rare fibrous soft tissue tumours that usually arise in subcutaneous tissue or skeletal muscle in a variety of anatomical sites. These lesions most frequently present as painless, slow-growing mobile masses. A case of DF is described in a 47-year-old man who presented with a painless right parotid mass of 2 months duration. At surgery, the lesion was attached to the tail of the right parotid gland. Histopathological examination demonstrated a fibrous lesion comprising spindled and stellate shaped fibroblasts with focal myxoid stromal change. The features were consistent with a DF. This report documents a rare parotid lesion which may mimic other more common parotid gland neoplasms.

Relevance of the primary lesion in the prognosis of metastatic cutaneous squamous cell carcinoma.

BACKGROUND: It remains unclear how primary tumor factors impact on prognosis in patients with nodal metastasis in head and neck cutaneous squamous cell carcinoma (SCC). The purpose of this study was to assess whether primary tumor characteristics are independent prognostic factors. METHODS: Patients treated for metastatic cutaneous SCC from 1978 to 2010 were identified (n = 239). A proportional hazards model was used to assess the effect of primary tumor variables. RESULTS: On multivariable analysis, tumor differentiation (hazard ratio [HR], 0.2; 95% confidence interval [CI], 0.1-0.8; p = .03) was found to be significantly associated with disease-specific survival (DSS), unlike margin status (p = .23), tumor size (p = .21), and thickness (p = .11). Patient, treatment, and nodal factors were confirmed to be important predictors of survival. CONCLUSION: This article suggests that pathological features of the primary lesion bear little importance in the presence of established nodal metastasis, other than tumor differentiation. It validates the grouping of T1-3N1 as stage III under the current American Joint Committee on Cancer (AJCC) TNM staging system.

Prognostic significance of disease-free interval in head and neck cutaneous squamous cell carcinoma with nodal metastases.

BACKGROUND: The purpose of this study was to determine whether the disease-free interval (DFI) between treatment of primary head and neck cutaneous squamous cell carcinoma (SCC) and the development of regional metastases is an independent prognostic factor. METHODS: A retrospective analysis of 229 patients with metastatic nodal head and neck cutaneous SCC, treated with curative intent by surgery ± adjuvant radiotherapy was conducted. RESULTS: After adjusting for the effect of nodal staging, extracapsular spread, involved margins, adjuvant radiotherapy, and immunosuppression, a short DFI (≤9 months vs >9 months) was a significant predictor of disease-related mortality (hazard ratio [HR], 3.0; 95% confidence interval [CI], 1.4-6.5; p = .004) and locoregional relapse (HR, 2.0; 95% CI, 1.1-4.0; p = .044). CONCLUSION: The DFI is a potentially powerful independent prognostic factor in patients with regional metastases secondary to head and neck cutaneous SCC. It provides information before definitive treatment that may ultimately assist clinicians in applying a risk-adapted management paradigm.

Early-stage squamous cell carcinoma of the lip: the Australian experience and the benefits of radiotherapy in improving outcome in high-risk patients after resection.

BACKGROUND: The purpose of this study was to analyze the outcome of Australian patients treated for early lip cancer. METHODS: Data on 217 patients with T1 to T2 squamous cell carcinoma (SCC) of the lip and treated with radical intent were analyzed. RESULTS: The addition of local adjuvant radiotherapy in patients with a close/positive margin was associated with a significant improvement in relapse-free survival (RFS; p = .008). Tumor thickness (≤4 mm vs >4 mm) was also significantly associated with RFS (p = .01). The 5-year RFS was 51% after surgery, 87% after radiotherapy, and 92% after adjuvant radiotherapy. CONCLUSIONS: Patients with a tumor thickness >4 mm experienced an increased risk of recurrence, especially nodal. Compared with patients having any radiotherapy, those undergoing surgery experienced a higher rate of locoregional recurrence. The addition of adjuvant radiotherapy in patients with inadequate excision significantly decreased the risk of recurrence.

Predictors of outcome in patients with metastatic cutaneous head and neck squamous cell carcinoma involving cervical lymph nodes: Improved survival with the addition of adjuvant radiotherapy.

BACKGROUND: The purpose of this study was to compare the outcome of surgery against surgery plus radiotherapy in patients with metastatic cutaneous head and neck squamous cell carcinoma (HNSCC) to cervical nodes. METHODS: We conducted a 28-year retrospective analysis of 122 patients whom were treated for metastatic cutaneous HNSCC involving the cervical nodes (levels I-V). RESULTS: After surgery alone, 11 patients (55%) developed recurrence compared with 23 patients (23%) after surgery plus radiotherapy. On multivariate analysis, the following variables were significantly associated with disease-free survival (DFS): immunosuppression (p = .002), treatment modality (p < .001), extracapsular spread (p = .009), and pathological nodal stage (p = .04). Patients undergoing surgery plus radiotherapy had a significantly better 5-year DFS (74% vs 34%; p = .001) and 5-year overall survival (OS; 66% vs 27%; p = .003) compared with surgery alone. CONCLUSION: In patients with metastatic cutaneous HNSCC involving cervical nodes, survival was significantly improved with the addition of radiotherapy.

Metastatic cutaneous squamous cell carcinoma of the head and neck: the Immunosuppression, Treatment, Extranodal spread, and Margin status (ITEM) prognostic score to predict outcome and the need to improve survival.

BACKGROUND: : The authors propose a prognostic score model using a prospective study of patients with regional metastatic cutaneous squamous cell carcinoma of the head and neck. METHODS: : Two-hundred fifty patients were analyzed using a competing risks model to identify risk factors for survival. A risk score was obtained using the significant coefficients from the regression model, and cutoff points were determined that separated the score into 3 risk groups (low risk, moderate risk, and high risk). RESULTS: : At a median follow-up of 54 months (range, 1.3-212 months) 70 of 250 patients (28%) developed recurrent disease: Most were regional recurrences (51 of 70 patients; 73%) in the treated lymph node basin. After regional recurrence, a majority (73%) died of disease. The following 4 variables were associated significantly with survival: immunosuppression (hazard ratio [HR], 3.13; 95% confidence interval [CI], 1.39-7.05), treatment (HR, 0.32; 95% CI, 0.16-0.66), extranodal spread (HR, 9.92; 95% CI, 1.28-77.09), and margin status (HR, 1.85; 95% CI, 1.85-3.369); and those 4 variables (immuosuppression, treatment, extranodal spread, and margin status) were used to calculate the ITEM score. The 5-year risk of dying from disease for patients with high-risk (>3.0), moderate-risk (>2.6-3.0), and low-risk (< or =2.6) ITEM scores were 56%, 24%, and 6%, respectively. Fifty-six of 250 patients (22%) died from another cause. CONCLUSIONS: : Patients who underwent surgery and received adjuvant radiotherapy had a better outcome compared with patients who underwent surgery alone. Patients who had moderate- or high-risk ITEM scores, usually because of extranodal spread and involved excision margins, had a poor outcome. The authors recommend considering these patients for inclusion in adjuvant chemoradiotherapy trials. Cancer 2009. (c) 2009 American Cancer Society.

Metastatic cutaneous squamous cell carcinoma of the scalp.

BACKGROUND: Metastatic cutaneous squamous cell carcinoma arising from the scalp, although relatively uncommon, is associated with a poor outcome. Older men with a history of baldness and actinic scalp lesions are particularly at risk. METHODS: Between 1980 and 2005, 27 patients with metastatic cutaneous squamous cell carcinoma of the scalp were referred to the Head and Neck Cancer Service at Westmead Hospital, Sydney. Relevant data were extracted from a prospectively maintained database. Patterns of recurrence and outcome were analysed. RESULTS: Median age at diagnosis was 70 years and median follow up was 45 months in 26 men and one woman. Ten primary (index) lesions were located on the midline scalp, 14 left sided and 3 right sided. Median lesion size was 18 mm and median thickness was 5.5 mm. The median time between treatment of the scalp primary and the development of nodal metastases was 8 months. In 10 patients, nodal metastases were present at the time of primary treatment. Fifteen patients developed parotid metastases (+cervical nodes in 7 of 15) and 12 developed cervical only metastases (5 of 12 level V). All patients underwent nodal surgery and most (75%) also received adjuvant radiotherapy. At the last follow up, 41% of patients had died from their disease. Median survival after relapse was 9 months and all patients experiencing relapse died with most (11 of 13) dying from metastatic disease. CONCLUSION: Patients with metastatic cutaneous squamous cell carcinoma of the scalp have a poor prognosis with most dying from regional relapse. Those treated with surgery and adjuvant radiotherapy had a better outcome.

Merkel cell carcinoma: a review of management.

PURPOSE OF REVIEW: Merkel cell carcinoma is an uncommon but aggressive primary cutaneous neuroendocrine (small cell) carcinoma. The head and neck is a frequent site (50-60%) for presentation. The optimal treatment of patients with Merkel cell carcinoma remains debated with recent evidence adding support for a multimodality approach. Despite this the outcome for patients with unfavourable disease remains poor and in many series 25-50% of patients die as a direct result of Merkel cell carcinoma. RECENT FINDINGS: Wide excision (2-3 cm) of the primary lesion has been recommended, although achieving this is often impossible within the functional and cosmetic constraints of the head and neck. The well-documented responsiveness of this disease to radiotherapy and chemotherapy has strengthened the case for less radical surgery. Current best practice, as presented in recent publications, would support adjuvant wide-field radiotherapy, delivered after wide excision with negative microscopic margins, as best practice. The role of platinum-based chemotherapy remains under investigation. SUMMARY: Most patients with a Merkel cell carcinoma should be recommended wide-field adjuvant radiotherapy to encompass the primary site, in-transit tissue and first echelon lymph nodes following surgery. The benefit of adding chemotherapy is currently unproven and should be considered on an individual basis.

The need for a better prognostic staging system in patients with metastatic cutaneous squamous cell carcinoma of the head and neck.

PURPOSE OF REVIEW: A validated and universal staging system for metastatic cutaneous head and neck squamous cell carcinoma that accurately describes its clinical behaviour is vital for prognostication and management. The current clinical staging system is not specific for the head and neck and makes no allowances for disease extent. The lack of an improved staging system prevents any meaningful research into improved treatment strategies in patients with head and neck cutaneous squamous cell carcinoma. RECENT FINDINGS: Contemporary evidence supports surgery and adjuvant radiotherapy as current best practice for patients with operable metastatic head and neck cutaneous squamous cell carcinoma. Despite this, patients with poor-prognosis disease are still at risk of locoregional relapse and may benefit from collaborative research. The modified staging system proposed by O'Brien is an important aspect of any further research and is discussed in this article. SUMMARY: The present clinical staging for head and neck cutaneous squamous cell carcinoma is inadequate and the evidence to date supports a recommendation for changing the current system to reflect the heterogeneity and complexity of this disease.

Giant functioning parathyroid cyst presenting as a retrosternal goitre.

Parathyroid cysts are rare and even more rarely cause a neck mass resembling a goitre. Such large parathyroid cysts may involve the mediastinum, growing to a sufficient size to produce symptoms related to obstruction, and if functioning, primary hyperparathyroidism. Parathyroid cysts should be considered in the list of differential diagnoses of anterior neck masses to allow for appropriate preoperative investigation to avoid unnecessary confusion at the time of operation. We report a case where a functioning parathyroid cyst presented as a retrosternal goitre to emphasize the potential pitfalls associated with their diagnosis and management.

Cutaneous head and neck squamous cell carcinoma metastatic to parotid and cervical lymph nodes.

Nonmelanoma skin cancers occur at an epidemic rate in Australia and are increasing in incidence worldwide. In most patients, local treatment is curative. However, a subset of patients will be diagnosed with a high-risk cutaneous squamous cell carcinoma (SCC) and are defined as patients at increased risk of developing metastases to regional lymph nodes. Patients with high-risk SCC may be identified based on primary lesion and patient factors. Most cutaneous SCC arises on the sun-exposed head and neck. The parotid and upper cervical nodes are common sites for the development of metastases arising from ear, anterior scalp, temple/forehead, or scalp SCC. The mortality and morbidity associated with high-risk cutaneous SCC is usually a consequence of uncontrolled metastatic nodal disease and, to a lesser extent, distant metastases. Patients with operable nodal disease have traditionally been recommended for surgery. The efficacy of adjuvant radiotherapy has previously been questioned based on weak evidence in the early literature. Recent evidence from larger studies has, however, strengthened the case for adjuvant radiotherapy as a means to improve locoregional control and survival. Despite this, many patients still experience relapse and die. Research aimed at improving outcome such as a randomized trial incorporating the addition of chemotherapy to adjuvant radiotherapy is currently in progress in Australia and New Zealand. Ongoing research also includes the development of a proposed new staging system and investigating the role of molecular factors such as the epidermal growth factor receptor.

High-risk cutaneous squamous cell carcinoma of the head and neck: results from 266 treated patients with metastatic lymph node disease.

BACKGROUND: Most patients with cutaneous squamous cell carcinoma (cSCC) of the head and neck (HN) are at low-risk (<5%) of developing metastatic SCC to regional lymph nodes. However, patients with unfavorable clinicopathologic factors often are under appreciated by clinicians but remain at higher risk for developing metastatic lymph node disease and dying. METHODS: Patients were identified who had metastatic cSCC to lymph nodes (parotid and cervical) of the HN and who were treated within the context of a multidisciplinary HN cancer service between 1980 and 2005 at Westmead Hospital (Sydney, Australia). Relevant patient details and data from primary lesions were analyzed and reported. RESULTS: In total, 266 patients were treated with curative intent. The median patient age was 69 years among 219 males and 47 females. The majority of metastatic lymph nodes (162 of 266 lymph nodes; 61%) were located in the parotid with or without cervical lymph node involvement. The median tumor thickness was 6 mm (range, 0.5-28 mm), and the median tumor size was 15 mm (range, 3-70 mm). Most tumors (65%) that measured >or=5 mm in thickness, and 30% of patients had lesions that measured >or=2 cm in greatest dimension. Recurrent cSCC was present in 15% of patients, and most lesions were located within the lymphatic drainage of the parotid on the temple/forehead (28%), on or around the ear (20%), or on the cheek (12%). Forty-six percent of patients had moderately or poorly differentiated cSCC, and 5% of patients were immunosuppressed. A minority of patients (27%) did not have an identifiable index lesion. CONCLUSIONS: Data from this large, prospective data base, in concordance with other series, suggested that a patient with thick cSCC (>4-5 mm) located in proximity to the parotid gland can be considered at high-risk. Increasing lesion size and recurrence contribute to this risk.

Implications for clinical staging of metastatic cutaneous squamous carcinoma of the head and neck based on a multicenter study of treatment outcomes.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) of the head and neck is a common cancer that has the potential to metastasize to lymph nodes in the parotid gland and neck. Previous studies have highlighted limitations with the current TNM staging system for metastatic skin carcinoma. The aim of this study was to test a new staging system that may provide better discrimination between patient groups. METHODS: A retrospective multicenter study was conducted on 322 patients from three Australian and three North American institutions. All had metastatic cutaneous SCC involving the parotid gland and/or neck and all were treated for cure with a minimum followup time of 2 years. These patients were restaged using a newly proposed system that separated parotid disease (P stage) from neck disease (N stage) and included subgroups of P and N stage. Metastases involved the parotid in 260 patients (149 P1; 78 P2; 33 P3) and 43 of these had clinical neck disease also (22 N1; 21 N2). Neck metastases alone occurred in 62 patients (26 N1; 36 N2). Ninety percent of patients were treated surgically and 267 of 322 received radiotherapy. RESULTS: Neck nodes were pathologically involved in 32% of patients with parotid metastases. Disease recurred in 105 (33%) of the 322 patients, involving the parotid in 42, neck in 33, and distant sites in 30. Parotid recurrence did not vary significantly with P stage. Disease-specific survival was 74% at 5 years. Survival was significantly worse for patients with advanced P stage: 69% survival at 5 years compared with 82% for those with early P stage (P = 0.02) and for those with both parotid and neck node involvement pathologically: 61% survival compared with 79% for those with parotid disease alone (P = 0.027). Both univariate and multivariate analysis confirmed these findings. Clinical neck involvement among patients with parotid metastases did not significantly worsen survival (P = 0.1). CONCLUSIONS: This study, which included a mixed cohort of patients from six different institutions, provides further information about the clinical behavior of metastatic cutaneous SCC of the head and neck. The hypothesis that separation of parotid and neck disease in a new staging system is supported by the results. The benefit of having subgroups of P and N stage is uncertain, but it is likely to identify patients with unfavorable characteristics that may benefit from further research.

Merkel cell carcinoma: improved outcome with adjuvant radiotherapy.

BACKGROUND: Merkel cell carcinoma is an aggressive primary cutaneous neuroendocrine carcinoma. Patients remain at high risk of locoregional and distant relapse despite treatment. Most studies support the incorporation of locoregional adjuvant radiotherapy in reducing the risk of relapse. METHODS: Between 1980 and 2002, 86 patients diagnosed with Merkel cell carcinoma were treated with curative intent at Westmead Hospital, Sydney. Multivariate analysis was performed using Cox regression analysis. Disease-free survival and overall survival was calculated using Kaplan-Meier survival curves. RESULTS: Median age at diagnosis was 75 years (range 46-89 years) in 49 men and 37 women. Median duration of follow up was 31 months (range 6-153 months). Fifty-one (59%) patients presented with a primary lesion, 19 (22%) with a primary lesion and clinical nodal disease and 16 (19%) with lymph node metastases from an unknown primary. A total of 47 of 86 (55%) relapsed with regional nodal relapse, the commonest site of first relapse. Local relapse was similar for patients undergoing surgery (5/37; 14%) compared with surgery and adjuvant radiotherapy (3/25; 12%). Nodal relapse occurred in 14 of 36 (37%) treated with surgery compared with 7 of 38 (18%) patients treated with surgery and adjuvant radiotherapy. Patients treated with surgery and adjuvant radiotherapy experienced a better median disease free survival compared to those undergoing surgery alone (10.5 months vs 4 months; P < 0.01). The 5-year overall and disease-free survival rate for the entire study population was 47% and 25%, respectively. Twenty-six patients (30%) died as a result of Merkel cell carcinoma. CONCLUSION: Merkel cell carcinoma is an aggressive skin cancer. The addition of adjuvant radiotherapy markedly improves regional control rates and should be considered best practice.

Surgery and adjuvant radiotherapy in patients with cutaneous head and neck squamous cell carcinoma metastatic to lymph nodes: combined treatment should be considered best practice.

OBJECTIVE: Patients with cutaneous squamous cell carcinoma (SCC) may develop metastatic SCC to nodes in the head and neck. Recent data support best outcome with the addition of adjuvant radiotherapy. This study aims to present further supportive evidence. STUDY DESIGN: Retrospective chart review. METHODS: Patients were identified with metastatic cutaneous SCC to nodes of the head and neck treated with surgery or surgery and adjuvant radiotherapy. Relapse and outcome were analyzed using Cox regression analysis. Disease-free survival and overall survival rates were calculated using Kaplan-Meier survival curves. RESULTS: Between 1980 to 2000, 167 patients were treated with curative intent at Westmead Hospital, Sydney. Median age was 67 years (range, 34-95) in 143 men and 24 women with a minimum follow-up of 24 months. Patients underwent surgery (21/167; 13%), or surgery and adjuvant radiotherapy (146/167; 87%). The majority (98/167; 59%) of metastatic nodes were located in the parotid and/or cervical nodes. The remaining 69 (41%) had metastatic cervical nodes (levels I-V). Forty-seven patients (28%) had recurrences, with the majority (35/47; 74%) as locoregional failures. On multivariate analysis, spread to multiple nodes and single-modality treatment significantly predicted worse survival. Patients undergoing combined treatment had a lower rate of locoregional recurrence (20% vs. 43%) and a significantly better 5-year disease-free survival rate (73% vs. 54%; P = .004) compared to surgery alone. CONCLUSIONS: In patients with metastatic cutaneous head and neck SCC, surgery and adjuvant radiotherapy provide the best chance of achieving locoregional control and should be considered best practice.

Anterior tongue cancer and the incidence of cervical lymph node metastases with increasing tumour thickness: should elective treatment to the neck be standard practice in all patients?

BACKGROUND: There is an increasing risk of cervical lymph node metastases as tumour thickness increases in patients with anterior tongue squamous cell carcinoma (SCC). The role of elective neck treatment in early anterior tongue cancer in unclear. METHODS: Patients diagnosed with anterior tongue cancer and treated with glossectomy +/- neck dissection were identified. The aim was to document the incidence of pathological lymph node metastases and outcome with increasing tumour thickness. The Cox proportional hazards model was used to identify prognostic factors. Survival curves were calculated using the Kaplan-Meier method. RESULTS: Between 1980 and 2002 99 patients (63 male and 36 female) with anterior tongue SCC were treated at Westmead Hospital, Sydney, and had a documented tumour thickness. Median age at diagnosis was 63 years (23-89 years). Median follow up was 37 months (6-205 months). Sixty-three patients underwent partial glossectomy and neck dissection. Thirty-six underwent partial glossectomy only. At the time of presentation 45/63 (71%) were clinically node negative. Using tumour thickness < or = 5 mm versus > 5 mm the incidence of nodal metastases was 8% versus 51% (P = 0.007). On multivariate analysis pathological nodal involvement and advanced stage both significantly predicted survival. The 2-year disease-free survival difference based on tumour thickness (< or = 5 mm vs > 5 mm) was 76% versus 65% (P = 0.47). CONCLUSIONS: Elective treatment to the ipsilateral neck is not indicated in all patients with anterior tongue cancer. However, for patients with a tumour thickness > 5 mm it is recommended that they undergo treatment to the ipsilateral neck in the form of a supraomohyoid neck dissection.