Hürthle cell carcinoma: a critical histopathologic appraisal.

PURPOSE: Controversy exists over the ability of morphology to predict the biologic behavior of Hürthle cell carcinoma. The aim of this study was to conduct a critical histopathologic review of Hürthle cell carcinoma and to correlate morphologic parameters with clinical outcome. PATIENTS AND METHODS: Patients with histologically confirmed Hürthle cell carcinoma treated between 1940 and 2000 form the basis of this study. Adenomas were excluded. Tumors of unknown malignant behavior ([UMB] n = 17) had solid growth pattern, incomplete capsular invasion (Ci), or both but no vascular invasion (Vi). Minimally invasive carcinomas ([MIC] n = 23) had one focus of intra- or extracapsular Vi, one focus of complete Ci, or both. Widely invasive carcinomas ([WIC] n = 33) demonstrated more than one focus of Vi, more than one focus of Ci, or both. The primary end points were relapse-free survival (RFS) and disease-specific survival (DSS). Rates of recurrence/death were estimated by Kaplan-Meier method. The univariate influence of prognostic factors on end points was analyzed by log-rank test, and multivariate analysis was performed by Cox regression. RESULTS: Median follow-up was 8 years. No patients with UMB or MIC relapsed or died of disease. Of WIC, 73% relapsed and 55% died of disease. Age, size, and extent of resection did not influence outcome. Adverse predictors of RFS and DSS among WIC were extrathyroidal extension, nodal metastasis, positive margin, and solid growth pattern (P <.05). Both Ci and Vi were associated with worse DSS (P <.05). On multivariate analysis, extrathyroidal extension and nodal metastases were independent predictors of outcome (P <.05). CONCLUSION: Patients with Hürthle cell carcinoma have a prognosis that is predicted by well-defined histomorphologic characteristics. Unlike differentiated thyroid cancer, nodal metastases predict a worse outcome in widely invasive Hürthle cell carcinoma, as does extrathyroidal extension.

Dermatofibrosarcoma protuberans of the head and neck.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) of the head and neck is a rare, locally infiltrative, low-grade sarcoma. This study defines the clinical behavior of DFSP, evaluates the role of frozen section analysis, and identifies factors that predict local control. METHODS: Hospital records and pathological slides were reviewed for 33 patients with pathologically confirmed head and neck DFSP treated at Memorial Sloan-Kettering Cancer Center between 1964 and 1999. Factors were analyzed by using Fisher's exact or chi2 tests. RESULTS: For 21 primary and 12 recurrent patients, median age and tumor size at presentation was 39 years and 2.0 cm, respectively. Thirty-two (97%) patients were alive at a median follow-up of 82 months. Three patients recurred locally, all with smaller than 2-cm resection margins. Deep tumors were more likely to have a margin-positive resection than superficial lesions (P = .03). Gross margin 2 cm or more was a significant predictor of a negative histological margin (P<.001). There was a trend toward improved recurrence-free survival for tumors treated with wide (> or =2 cm) margin resection (P = .059). Accuracy, sensitivity, specificity, and false negative rates of frozen section were 80%, 43%, 100%, and 57%, respectively. CONCLUSIONS: Wide margin resection of head and neck DFSP predicts negative histological margins and impacts favorably on local recurrence-free survival. Frozen section analysis does not assess resection margins accurately.

Treatment of recurrent pleomorphic adenomas of the parotid gland.

Recurrent pleomorphic adenomas (RPAs) of the parotid gland are an uncommon but challenging problem. The records of 31 patients with RPAs were reviewed to assess the clinical presentation and treatment results. More than half of these patients underwent total parotidectomy. Local control was achieved in 94% of patients at 7 years (median follow-up 7.3 years). Patients who had surgery for recurrence after a formal parotidectomy were more likely to have another recurrence (63% local control at 7 years) than patients whose initial procedure was a limited excision (100% local control at 7 years; P < 0.01). Better local control was seen in 11 patients who received postoperative irradiation (100% at 10 years) than in 20 patients who did not (71% at 10 years; P < 0.28). Adequate surgical resection yields an acceptable local control rate in patients with RPAs. Postoperative radiation therapy may improve control in patients at high risk for another recurrence.

Pattern of invasion and margin assessment in patients with oral tongue cancer.

BACKGROUND: Involvement of resection margins and the pattern of tumor invasion are reported to be important predictors of local recurrence and survival in surgically treated patients. In this study we have retrospectively assessed the significance of these two prognostic factors in a relatively homogeneous patient population. Patients and Methods This study was confined to 150 previously untreated patients who had surgery for squamous carcinoma of the oral tongue between 1987 and 1993. There were 82 men and 68 women who ranged in age from 25 to 89 years (median 60 years). Glossectomy was peroral in 129, whereas 8 and 13, respectively, had a cheek flap or mandibulotomy approach. Some form of lymphadenectomy was performed in 109 (73%), and 51 patients (34%) received postoperative radiotherapy. Histologic slides from each primary tumor were reviewed to verify the margin status. In addition, the pattern of invasion was evaluated and graded from 1 to 4, varying from a consistently well-defined, "pushing" border (Grade 1) to diffuse infiltration and cellular dissociation (Grade 4). RESULTS: Intraoperative frozen section assessment of margins was accurate, whether positive or negative, in 118 of 133 patients (89%). Positive or close margins (within one high-power field) and an endophytic growth pattern were associated with a significant increase in local recurrence (p <0.003 and <0.04, respectively). With higher grades of infiltration (Grade 3 or 4; 82 patients), the tumors tended to be larger and the patients younger. Although the likelihood of nodal involvement and subsequent distant metastasis was significantly greater in those with Grade 3 or grade 4 patterns (p <0.0003 and <0. 01, respectively), there was no impact on local recurrence. Cumulative survival was similar whether or not the surgical margins were involved, but was significantly reduced when the pattern of tumor invasion was of higher grade (p <0.01). SUMMARY: Frozen section provided reasonably accurate information about margins in our patients, whether taken from the patient or the surgical specimen. Positive margins increased the likelihood of local recurrence, but did not impact on survival because subsequent surgery and/or irradiation controlled tumor recurrence in some patients. Grade 3 or 4 patterns at the tumor/host interface were associated with an increased incidence of nodal and distant metastasis, as well as a significant decrease in survival.

Giant cell tumour of the retropharynx.

AIMS: Giant cell tumours of soft tissues are usually of tenosynovial origin and are benign, slow growing neoplasms that have the capacity for local recurrence. They occur most frequently in the fingers and only rarely in the head and neck region. Their occurrence in the retropharynx has not been reported. The differential diagnoses of head and neck lesions containing giant cells are discussed. METHODS AND RESULTS: We describe a case of a retropharyngeal giant cell tumour of tenosynovial type in a 48-year-old man. The clinical, radiological and histological features are reviewed. Immunohistochemical studies point to a possible histiocytic origin based on reactivity for CD68. CONCLUSIONS: Tenosynovial giant cell tumour should be considered in the differential diagnosis of tumours arising in the retropharyngeal soft tissues.

A prospective phase II trial of concomitant chemotherapy and radiotherapy with delayed accelerated fractionation in unresectable tumors of the head and neck.

BACKGROUND: Our study is a prospective evaluation of unresectable malignant cancers of the head and neck treated with concomitant chemotherapy and radiotherapy (RT) using delayed accelerated fractionation (concomitant boost). METHODS: Between January 1988 and March 1995, 82 patients with unresectable cancers of the head and neck were enrolled in this phase II study. Of these, 52 patients were treated and followed for a minimum of 3 years and are the subject of this analysis. All patients had T4 lesions and were stage IV according to the American Joint Committee on Staging Criteria (AJCC). Patients received RT with accelerated fractionation to a total of 70 Gy in 6 weeks using a concomitant-boost technique. Concomitant cis platin (100 mg/M2) was given on days 1 and 22 of RT. Twenty-seven patients received mitomycin-C (7.5 mg/M2) on days 1 and 22, and 1 patient received mitomycin-C on day 1. In addition, 27 patients received adjuvant chemotherapy with cis platin and vinblastine. The mean follow-up was 45 months (range, 36-72 months). The minimum follow-up for surviving patients in 3 years. RESULTS: At 3 years, the local control rate was 58%. Three-year local control rates for paranasal sinus, nasopharynx, oropharynx, and larynx/hypopharynx were 78%, 78%, 64%, and 100%, respectively. For all patients, the distant-metastasis-free survival was 56%, and the overall survival rate was 36%. Patients with oral cavity cancers experienced worse overall survival versus other sites, 0% versus 47% (p = .03). Salivary cancers also showed worse survival versus other sites, 0% versus 47%, but was not statistically significant. Severe acute complications occurred in 34% of patients. Treatment-related toxicity also resulted in the death of 2 patients. Severe late complications occurred in 7% of patients. CONCLUSIONS: Treatment of this poor prognostic group of patients with aggressive chemotherapy and RT produced surprisingly good local control and survival.

Management of malignant tumors of the salivary glands.

Results of treatment for patients with salivary gland carcinoma have improved in recent years, most likely due to earlier diagnosis and the use of more effective locoregional therapy. Salivary gland tumors are treated surgically, often in conjunction with postoperative radiation therapy when the tumor is malignant. Good results rest strongly on the performance of an adequate, en bloc initial resection. Radical neck dissection in indicated in patients with obvious cervical metastasis, and limited neck dissection may be appropriate in patients with clinically negative nodes in whom occult nodal involvement is likely. Postoperative radiation therapy should be administered when the tumor is high stage or high grade, the adequacy of the resection is in question, or the tumor has ominous pathologic features. Neutron beam therapy shows promise in controlling locoregional disease but requires further study. No single chemotherapeutic agent or combination regimen has produced consistent results. At present, chemotherapy is clearly indicated only for palliation in symptomatic patients with recurrent and/or unresectable cancers. Patients with salivary gland carcinomas must be followed for long periods, as recurrence may occur a decade or more following therapy. Distant metastasis appears to occur in approximately 20% of patients.

Verrucous carcinoma, then and now.

The salient clinical and pathological features of verrucous carcinoma, as first described by Ackerman in 1948, are reviewed. Two case reports are presented. The first concerns a personal experience with a patient who had five surgical procedures for multifocal oral verrucous carcinoma and remains alive and well 28 years after her initial treatment. The second report highlights the remarkable story of President Grover Cleveland's secret surgery for verrucous carcinoma of the palate in 1893. Current concepts about the management of this uncommon tumor are reviewed, as well as some recent investigations that deal with its etiology.

Extended neck dissection.

BACKGROUND: This study defines the clinical settings in which extended radical neck dissection (ERND) was performed and determines its impact on control of disease in the neck and on survival. METHODS: We reviewed the records of 106 patients undergoing ERND between 1984 and 1993. Most (76) had metastatic squamous cell carcinoma (SCC) that had extended to extranodal structures in the upper neck. RESULTS: Five-year disease-free survival was 39%, and disease was controlled in the neck in 72 patients (68%) with a median follow-up of 5.5 years. A trend toward better survival was seen in patients with SCC (47% at 5 years), compared with those with other histologies (24% at 5 years; P <0.12). Patients with levels I, II, or III involved had better survival (46% at 5 years) than those with level IV, V, or multiple levels involved (14% at 5 years; P <0.0088). Finally, when prior radiation therapy precluded additional irradiation of the neck, survival was only 22% at 5 years, compared with 47% for those who received postoperative radiation (P <0.017). CONCLUSIONS: Although advanced neck disease invading adjacent structures remains an ominous sign, neck control and 5-year survival were achieved in nearly one half of these patients when multimodality therapy was possible.

Distant metastasis in adenoid cystic carcinoma of salivary origin.

BACKGROUND: Adenoid cystic carcinoma (ACC) is an aggressive, often indolent tumor, with a high incidence of distant metastasis (DM). Relatively little has been written about the factors that influence distant spread and subsequent survival because it is uncommon and more than a decade of observation may be required to appreciate the prolonged clinical course in some patients. METHODS: We have retrospectively studied 196 determinate patients who received definitive treatment in our hospital between 1939 and 1986 for ACC in all salivary sites. Inclusion criteria were no prior treatment elsewhere other than excisional biopsy and eligibility for follow-up of at least 10 years. Variables assessed for their impact on distant metastasis included age, gender, site, size, node status, stage, grade, and locoregional treatment failure. RESULTS: Treatment failure occurred in a total of 122 of 196 determinate patients (62%), 74 of whom had DM (38%). This was usually associated with locoregional recurrence (51 patients), but DM was the only indication of failure in 23 whose primary tumor was controlled. Of the 74 patients with known DM, the lung was recorded as the only involved site in 50 patients, lung was involved in addition to other sites in 17, bone metastases alone occured in 5, and the remaining 2 developed disseminated disease. Disease-free intervals varied from 1 month to 19 years (median 36 months) and exceeded 10 years in 9 of 113 patients (8%) with adequate information about treatment failure. Survival with DM was less than 3 years in 54%, but more than 10 yrs in 10% (maximum 16 years). The only significant factors influencing survival were the size of the primary tumor (P <0.0000), local or neck recurrence (P = 0.0006), and the presence of nodal involvement (P = 0.02). CONCLUSIONS: The high incidence of DM with locoregional failure confirms the importance of aggressive initial surgery, combined with irradiation, for high-stage tumors or involved surgical margins. Large tumor size and lymph node involvement, rather than microscopic appearance, were predictive of DM. Considering that lung metastases are usually multiple, and prolonged survival without treatment is not unusual, resection of pulmonary metastases may be hard to justify in ACC patients based on the limited experience thus far reported. Chemotherapy for metastatic ACC is probably best withheld until symptoms appear.

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

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

Maxillectomy and its classification.

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

Hyperparathyroidism associated with sarcoma of bone.

The objective of this paper is to report the uncommon association of hyperparathyroidism (one case resulting from an adenoma and the other from chief cell hyperplasia) and sarcoma of bone. The radiographic appearances of both cases were thought to be a little unusual and are discussed in detail. The possible relationship of the sarcomas to brown tumors is discussed.

Supraomohyoid neck dissection.

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

Supraspinal accessory lymph node metastases in supraomohyoid neck dissection.

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

Management of the neck in parotid carcinoma.

BACKGROUND: Management of the clinically negative neck remains a controversial issue in patients with carcinoma of the parotid gland. Our treatment policy has always been conservative, reserving lymphadenectomy for selected patients. METHODS: We retrospectively evaluated 121 patients with malignant tumors of the parotid gland who received their definitive treatment at the Memorial Sloan-Kettering Cancer Center between 1966 and 1988. RESULTS: A total of 35 neck dissections (ND) were performed, 14 of which involved removal of clinically positive nodes (radical in 10, modified in 2, and limited in 3). Twenty-one patients had an elective lymphadenectomy (radical in 14, modified in 2, and limited in 4), usually because of ominous histology or high T stage. In addition to histologically positive regional lymph nodes, facial nerve paralysis, gender, and advanced stage, the decision to perform a ND, whether elective or therapeutic, was significantly predictive of decreased survival (P < 0.001). In the majority of patients (86, or 65%), the neck was observed rather than treated electively, with no impact on overall survival. Only 4 of 121 patients developed neck recurrence following treatment, including 3 who had neck dissection as part of their initial management. CONCLUSIONS: These data support our policy of reserving elective ND only for those histologic diagnoses that carry the highest risk of nodal metastases, as well as for selected patients whose primary tumor resection might be facilitated by lymphadenectomy.

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

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

Quality of life of maxillectomy patients using an obturator prosthesis.

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

Salvage laryngectomy for unsuccessful larynx preservation therapy.

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

Impact of clinicopathologic parameters on patient survival in carcinoma of the cervical esophagus.

BACKGROUND: The survival of patients with carcinoma of the cervical esophagus remains poor in spite of multimodality treatment and technical improvements in surgical resection and reconstruction. This study was undertaken to update our experience with cervical esophageal carcinoma and to identify factors that had an impact on patient survival and quality of life. PATIENTS AND METHODS: Clinical data encompassing 132 variables were collected on 67 patients with cervical esophageal carcinoma from 1980 to 1993. Statistical analysis was performed: independent Student's t-tests, Cox regression, Kaplan-Meier curves, and log rank analyses were used in the statistical evaluation. The mean age of the patients was 63 years (range 31 to 88). Dysphagia was the primary symptom in 86% of patients; 80% had received no prior treatment. The most common abnormal finding (21%) on physical examination was a neck mass. RESULTS: Curative resection was performed in 22 patients, 7 had palliative procedures, and 7 were found to be inoperable at exploration and received palliative treatment. Radiation with or without chemotherapy was definitive treatment for 10 patients, whereas 4 patients were treated with chemotherapy alone for cure, and 17 patients received palliative treatment. The mean survival following diagnosis was 17 months (range 1 to 96). Cumulative 5-year survival was 12%. CONCLUSIONS: Persistent disease, chemotherapy prior to presentation, and chemotherapy for cure remained as statistically significant parameters associated with decreased survival by multivariate analysis. There was a trend toward improved survival in patients treated with surgical resection.