Carotid blowout syndrome in patients with head-and-neck cancers: reconstructive management by self-expandable stent-grafts.

BACKGROUND AND PURPOSE: Some reports of reconstructive management of carotid blowout syndrome (CBS) with stent-grafts are promising, but some are unfavorable. This study sought to evaluate the hemostatic efficacy, safety, and outcome of reconstructive, endovascular stent-graft placement in patients with head-and-neck cancers in association with CBS. METHODS: Eight patients with head-and-neck cancers with CBS were treated with self-expandable stent-grafts. We evaluated the initial hemostatic results, complications, and outcomes by assessing the clinical and imaging findings. RESULTS: Immediate hemostasis was achieved in all patients. Initial complications included stroke in 1 patient and asymptomatic thrombosis of the carotid artery in 2 patients. Delayed complications included rebleeding, delayed carotid thrombosis, and brain abscess formation. Rebleeding was noted in 4 patients and was successfully managed with a second stent-graft and embolization in 2 of them. Delayed carotid thrombosis with follow-up after 3 months was found in 3 patients, 1 of whom had associated brain abscesses. CONCLUSION: Although stent-grafts achieved immediate and initial hemostasis in patients with head-and-neck cancers and CBS, long-term safety, stent patency, and permanency of hemostasis appeared unfavorable. This treatment may be for temporary or emergency purposes rather than serving as a permanent measure. We suggest its applications in patients with acute CBS that precludes performance of an occlusion test, as well as when carotid occlusion poses an unusually high risk of neurologic morbidity. We also propose prophylactic antibiotic treatment and combined embolization of pathologic vascular feeders to improve outcomes.

Brain abscess formation: a delayed complication of carotid blowout syndrome treated by self-expandable stent-graft.

A patient with hypopharyngeal cancer developed carotid blowout syndrome (CBS) treated by self-expandable stent-graft in the left carotid artery. CT scan for progressive right hemiparesis 4 months later showed multiple left cerebral abscesses and left carotid thrombosis. Although deployment of stent-grafts for CBS can achieve initial hemostasis in patients with head-and-neck cancer, the placement of a stent-graft in a field of necrosis and infection is associated with poor long-term outcome. We recommend the use of prophylactic antibiotics if endovascular foreign materials are placed in a contaminated field.

Prognostic significance of nm23-H1 expression in oral squamous cell carcinoma.

Recent studies indicated nm23-H1 played a role in cancer progression. Therefore, we investigated clinical significance of nm23-H1 expression in oral squamous cell carcinoma (OSCC). In total, 86 OSCC specimens were immunohistochemically stained with nm23-H1-specific monoclonal antibodies. Immunohistochemical staining of nm23-H1 was confirmed by immunoblotting. The relations between nm23-H1 expression and clinicopathologic variables were evaluated by chi(2) analysis. As increased size of primary tumour could escalate metastatic potential and the data of patients at the late T stage might confound statistical analyses, we thus paid special attention to 54 patients at the early T stage of OSCC. Statistical difference of survival was compared by a log-rank test. Immunohistochemically, nm23-H1 expression was detected in 48.8% (42 out of 86) of tumorous specimens. It positively correlated with larger primary tumour size (P=0.03) and inversely with cigarette-smoking habit (P=0.042). In patients at the early T stage, decreased nm23 expression was associated with increased incidence of lymph node metastasis (P=0.004) and indicated poor survival (P=0.014). Tumour nm23-H1 expression is a prognostic factor for predicting better survival in OSCC patients at the early T stage, which may reflect antimetastatic potential of nm23. Therefore, modulation of nm23-H1 expression in cancer cells can provide a novel possibility of improving therapeutic strategy at this stage. In addition, our results further indicated cigarette smoking could aggravate the extent of nm23-H1 expression and possibly disease progression of OSCC patients.

Carbon dioxide laser microsurgery for tongue cancer: surgical techniques and long-term results.

Thirty-seven consecutive patients with cancer of the anterior two-thirds of the tongue without clinical neck lymph nodes or distant metastasis were treated with transoral carbon dioxide (CO2) laser microsurgery. During the operation, a monopolar coagulation-suction device was applied to achieve a clear surgical field. Under a surgical microscope, we repeatedly palpated the soft tissue to identify the tumour margins, in particular the deep margin, to maintain adequate safe margins in three dimensions. We resected the tumour by en bloc procedures rather than by vaporization or debulking. Of the 28 patients in the T1 and T2 groups, 26 patients did not receive postoperative radiotherapy. The local control rate calculated by the methods of Kaplan and Meier in all 37 patients at 5 years was 93.6%. No local recurrence occurred in the T1 or T2 cases. Nine patients suffered from neck recurrence and the neck control rate at 5 years was 74.6%. Eight of these nine patients were salvaged by surgery with adjuvant radiotherapy, and six of them finally achieved disease-free status. The 5-year disease-free survival rate for our series was 88%. Our surgical techniques using CO2 laser microsurgery are effective and advantageous methods for excision of oral tongue cancer, especially stage I and II lesions.

Contralateral hemilaryngotracheal flap reconstruction of the hypopharynx in pyriform carcinoma resection.

OBJECTIVES: To simplify the approach and reconstruction for advanced hypopharyngeal cancer, a modified technique-laryngotracheal fissure approach and laryngotracheal flap reconstruction--is presented. STUDY DESIGN: Prospective. METHODS: From August 1991 to December 1995, 44 consecutive patients with advanced hypopharyngeal cancer, mostly involving pyriform sinus, were operated on with this technique. The functional and oncologic results and complications were evaluated. RESULTS: Reconstruction was completed by using the laryngotracheal flap in 75% of patients, while the other 25% required additional patch-on pectoralis major myocutaneous flaps. Pharyngoesophageal stenosis occurred in one patient after radiotherapy and pharyngocutaneous fistula was noted in two. No local recurrence was noted. Seven cervical metastases developed in the follow-up period and six over the contralateral neck not treated surgically. The 5-year Kaplan-Meier disease-free survival was 46.8%. CONCLUSIONS: The authors' experience indicates that this is a simplified, radical treatment for most advanced hypopharyngeal cancer, with high applicability, good oncologic results, and low complication.

Transoral laryngeal surgery under flexible laryngovideostroboscopy.

Although direct microlaryngoscopic surgery is universally accepted as the standard procedure for endolaryngeal surgery, general anesthesia and direct laryngoscopy are necessary during the procedure. Suspended laryngeal position also impedes intraoperative functional monitoring. Transoral laryngeal surgery under indirect laryngeal mirror or telescope has the advantage of sparing general anesthesia and direct laryngoscopy, but lower precision, difficult manipulation, and a high patient cooperation requirement make the procedure of limited application. Trying to overcome the above shortcomings, transoral laryngeal surgery under flexible laryngovideostroboscopy (FLVS) is undertaken at our institute. The surgery is performed at an outpatient office under topical anesthesia, with the help of high-resolution fiberoptic stroboscopy, high-quality CCD videocamera, and monitor. From October, 1993 to March, 1996, 157 patients with selected laryngeal problems were operated upon using this technique, and 150 patients smoothly completed the procedure with satisfactory results. The technique is highly effective, especially for limited-manipulation, lower precision procedures and for patients who are not candidates for general anesthesia. With proper patient selection, this is a cost-effective surgery of low invasiveness and high applicability.

Wide opening method for vocal fold retention cyst.

BACKGROUND: Vocal fold cyst is a common cause of dysphonia. In our reported series, most cases were retention cysts. Enucleation of the cyst under microlaryngoscopy is usually considered to be an ideal treatment despite the fact that cyst rupture is frequently encountered with this procedure. In this report, we present a wide opening method for vocal fold retention cyst. METHODS: Twenty consecutive patients with vocal fold retention cysts larger than 2 mm in diameter were operated upon using the wide opening method (marsupialization). The medial cyst wall was excised along with the overlying mucosa, while the lateral cyst wall was preserved on the vocal fold. The cyst was widely opened following this procedure. RESULTS: Perceptual voice improvement was noted postoperatively. Videostroboscopy and acoustic analysis were also applied to confirm the perceptual results. CONCLUSIONS: The wide opening method has the advantages of simplicity, minimal tissue injury, rapid functional recovery and low recurrence. This technique can be considered another standard treatment of choice for medium- or large-sized vocal fold retention cysts.