Comparison of Intraoperative Sonography and Histopathologic Evaluation of Tumor Thickness and Depth of Invasion in Oral Tongue Cancer: A Pilot Study.

BACKGROUND AND PURPOSE: For primary squamous cell carcinoma of the oral tongue, accurate assessment of tumor thickness and depth of invasion is critical for staging and operative management. Currently, typical imaging modalities used for preoperative staging are CT and MR imaging. Intraoperatively, CT or MR imaging cannot provide real-time guidance, and assessment by manual palpation is limited in precision. We investigated whether intraoperative sonography is a feasible technique for assessment of tumor thickness and depth of invasion and validated its accuracy by comparing it with histopathologic evaluation of the resected specimen. MATERIALS AND METHODS: Twenty-six patients with squamous cell carcinoma of the oral tongue who underwent tumor resection by a single surgeon between March 31, 2016, and April 26, 2019, were prospectively identified. Intraoperative sonography was obtained in planes longitudinal and transverse to the long axis of the tumor. Twenty-two patients had archived images that allowed measurements of tumor thickness and depth of invasion sonographically. Two patients had dysplasia and were excluded. The remaining 20 patients had histologic tumor thickness and histologic depth of invasion measured by a single pathologist. RESULTS: The mean sonographic tumor thickness was 7.5 ± 3.5 mm, and the mean histologic tumor thickness was 7.0 ± 4.2 mm. Mean sonographic depth of invasion and histologic depth of invasion were 6.6 ± 3.4 and 6.4 ± 4.4 mm, respectively. There was excellent correlation between sonographic and histologic measurements for both tumor thickness and depth of invasion with Pearson correlation coefficients of 0.95 (95% CI, 0.87-0.98) and 0.95 (95% CI, 0.87-0.98), respectively. CONCLUSIONS: Intraoperative sonography can provide reliable, real-time assessment of the extent of tongue tumors.

Oral cancer in vivo gene expression profiling assisted by laser capture microdissection and microarray analysis.

Large scale gene expression profiling was carried out on laser capture microdissected (LCM) tumor and normal oral epithelial cells and analysed on high-density oligonucleotide microarrays. About 600 genes were found to be oral cancer associated. These oral cancer associated genes include oncogenes, tumor suppressors, transcription factors, xenobiotic enzymes, metastatic proteins, differentiation markers, and genes that have not been implicated in oral cancer. The database created provides a verifiable global profile of gene expression during oral carcinogenesis, revealing the potential role of known genes as well as genes that have not been previously implicated in oral cancer.

Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects.

BACKGROUND: The temporoparietal fascial flap has proven to be a versatile flap for a broad spectrum of reconstructive problems in the head and neck. The temporoparietal fascial flap is a thin, pliable layer of richly vascularized tissue that may be transferred either pedicled or free and alone or as a carrier of subjacent bone or overlying skin and scalp. OBJECTIVE: To report our experience using a hair-bearing temporoparietal fascial flap for reconstruction in 6 male patients with extensive upper lip and scalp defects, including a discussion of the surgical anatomy and technique. METHODS: Temporoparietal fascial flaps with overlying scalp were used as pedicled and free flaps for the reconstruction of upper lip and scalp defects. RESULTS: All reconstructive results were satisfactory. Oral competence, measured by both speech and mastication performance, was achieved in patients with upper lip defects. Healthy scalp coverage was obtained in patients with local defects. The cosmetic appearance was satisfactory to all patients. CONCLUSIONS: Ideal reconstruction of large upper lip and scalp defects is achieved with local tissue that best mimics the normal face color, texture, and hair-bearing qualities. Hair-bearing temporoparietal fascial flaps possess these characteristics and are an excellent choice for the restoration of function and aesthetics.

Pedicled rhinotomy for clival chordomas invaginating the brainstem.

OBJECT: Clival chordomas are frequently midline lesions whose posterior growth may breach the dura and invaginate the brainstem. This precludes safe delivery of potentially curative high-dose fractionated proton radiotherapy. To avoid this problem, the authors performed pedicled rhinotomy to resect chordomas in 10 patients. METHODS: Pedicled rhinotomy is a midface transnasal route to the intercarotid sella and clivus from the tuberculum sellae to the mid-C-2 level. It involves a lateral rhinotomy incision, osteotomies of nasal bones and cartilage, lateral rotation of the nose, removal of the nasal septum and medial maxillary walls, opening of ethmoid and sphenoid sinuses, and dissection of nasopharynx and oropharynx to expose the clivus and craniovertebral junction. Tumors involving the sella, medial cavernous sinuses, middle and lower clivus, and C-1 arch and dens can be removed even if they traverse the dura. Closure involves dural repair, grafting of fat and split-thickness skin, rotation of a vascularized mucosal pedicle, and reattachment of nasal cartilage. Ten clival chordomas in adult patients were surgically removed via a pedicled rhinotomy approach. Seven patients had previously undergone a total of nine skull base procedures. In eight of the 10 patients, tumors compressing the brainstem were completely removed using this technique. One patient required an additional subtemporal resection of a suprasellar tumor before definitive radiotherapy could be undertaken. No patient sustained any new neurological deficit; in eight patients headache, diplopia, or hemiparesis improved. One patient developed postoperative cerebrospinal fluid leakage and meningitis that were successfully treated with antibiotic agents and shunt placement. CONCLUSIONS: Pedicled rhinotomy provides excellent shallow-field exposure of midline clival chordomas and permits relief of brainstem compression and the postoperative administration of potentially curative proton beam irradiation.

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction.

BACKGROUND: Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. METHODS: A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. RESULTS: The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. CONCLUSIONS: The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.

Montgomery Thyroplasty Implant for vocal fold immobility: phonatory outcomes.

Forty-three patients with a diagnosis of unilateral vocal fold immobility underwent thyroplasty type I with the Montgomery Thyroplasty Implant System. Preoperative and postoperative evaluations were completed by means of videostroboscopic, acoustic, and aerodynamic measures. Clinicians' perceptions of vocal quality and patients' satisfaction with the surgery and vocal quality were determined. Improvements after surgery were observed for glottal closure, vocal fold amplitude, mucosal wave activity, average intensity, maximum intensity range, maximum phonation time, glottal airflow, average sound pressure, and subglottal pressure. Average postsurgical fundamental frequency values fell within normal limits and did not display significant changes relative to presurgical values. The clinicians' perceptual evaluations indicated an improvement in voice quality for most patients. A majority of patients expressed satisfaction with the surgery and resulting voice quality. The results of the present study, in combination with the surgical advantages that have been described for the Montgomery Thyroplasty Implant System, support the view that this approach offers an attractive alternative for treating unilateral vocal fold immobility.

Histological pattern of mandibular invasion by oral squamous cell carcinoma.

OBJECTIVE: Mandibular invasion by oral squamous cell carcinoma may progress by either an infiltrative or an erosive histological pattern. The infiltrative pattern is marked by nests and cords of tumor cells along an irregular tumor front, and the erosive pattern exhibits a broad, pushing tumor front. The objectives of this study were 1) to define the characteristics associated with each histological pattern of mandibular invasion, 2) to assess the relationship between pattern of invasion and clinical outcome as measured by death with disease and disease presence at last follow-up, and 3) to determine whether the cell cycle markers cyclin D1 and Ki-67 are associated with the histological pattern of invasion or are predictive of outcome. STUDY DESIGN: Retrospective study of 68 patients with mandibular invasion by oral cavity squamous cell carcinoma treated by mandibulectomy. METHODS: The clinical records, pathology reports, and original H&E-stained slides were reviewed for each patient. Immunohistochemical staining of cyclin D1 and Ki-67 was performed on slides cut from the paraffin blocks of these patients' specimens. RESULTS: The parameters found to be significantly associated with the infiltrative pattern of mandibular invasion included higher tumor grade, medullary space invasion, positive bone or soft tissue margins, history of previously failed treatment, and postoperative tumor recurrence. The infiltrative pattern had a positive bone margin rate of 47.6% and a primary site recurrence rate of 52.6%. In contrast, the erosive pattern had a positive bone margin rate of 4.9% and a primary site recurrence rate of 16.7%. The infiltrative pattern of invasion gave a fourfold increased risk of death with disease and disease presence at last follow-up in univariate and multivariate analyses when compared with the erosive pattern of invasion. The 3-year disease-free survival was 30% for the infiltrative pattern and 73% for the erosive pattern. The median disease-free survival was 1.5 years for the infiltrative pattern and 5.5 years for the erosive pattern. There was no correlation between cyclin D1 or Ki-67 staining and invasion pattern or clinical outcome. CONCLUSIONS: The infiltrative pattern of mandibular invasion by oral squamous cell carcinoma is correlated with a significantly worse prognosis when compared with the erosive pattern of invasion. The infiltrative pattern clearly exhibits a more aggressive behavior with an increased likelihood of positive margins, recurrence, death with disease, and shorter disease-free survival. We recommend that pathologists routinely comment on the histological pattern of invasion when reviewing oral squamous cell carcinoma with mandibular invasion.

Combining free flap reconstruction and craniofacial prosthetic technique for orbit, scalp, and temporal defects.

OBJECTIVES: To identify factors leading to successful application of prosthetic techniques following free flap reconstruction of the orbit, scalp, and temporal region. STUDY DESIGN: Retrospective review. METHODS: Twenty-eight patients who underwent free flap reconstruction for defects of these regions between 1989 and 1996 were reviewed for clinical parameters, flap loss, patient survival, and implant loss rate. Prosthetic usage rates were compared before and after introduction of a site-specific reconstructive algorithm. RESULTS: Free flap success rate was 93%, whereas osseointegrated implant loss rate was 11%. In addition to implants, a reconstructive strategy that provided thin, vascular tissue between bone and skin, a flat platform in the temporal region, and preservation of orbital cavity depth led to increased prosthetic usage. CONCLUSIONS: Craniofacial prosthetic techniques can significantly augment the results of free flap surgery for the orbit, scalp, and temporal region. Successful combination of these techniques requires a site-specific surgical approach.

Evaluation of chemotherapy response in patients with advanced head and neck cancer using [F-18]fluorodeoxyglucose positron emission tomography.

BACKGROUND: [F-18]Fluorodeoxyglucose (FDG)-positron emission tomography (PET) can measure the metabolic activity of tissues; FDG-PET may be able to predict response to chemotherapy by identifying changes in tumor metabolism. Measurement of response to treatment may help improve survival in the management of advanced head and neck cancer. We evaluated this particular use of FDG-PET in patients participating in a neoadjuvant organ-preservation protocol using taxol and carboplatin and compared pathologic response after chemotherapy with changes in tumor metabolism measured by FDG-PET. METHODS: Serial FDG-PET studies (n = 56) were performed in patients (n = 28) with stage III/IV head and neck cancer participating in a neoadjuvant organ-preservation protocol. The FDG-PET studies were performed before and after chemotherapy. All patients had tissue biopsies before and after chemotherapy. Patients were classified as pathologic complete response (PCR) or residual disease (RD) based on tissue biopsies. Visual analysis of PET scans was performed to identify patients with complete response by PET, and these findings were compared with pathology results. Metabolic changes were also evaluated using standardized uptake ratios (SUR) of FDG. RESULTS: The sensitivity and specificity of PET for residual cancer after therapy was 90% (19/21) and 83% (5/6), respectively. Two patients had initially negative biopsies and positive PET studies for persistent disease. Pathology review and rebiospy led to confirmation of the PET results in these cases, giving a sensitivity of 90% for initial tissue biopsy. CONCLUSIONS: In this preliminary analysis, FDG-PET was accurate in classifying response to chemotherapy in most patients. Fluorodeoxyglucose-PET may identify residual viable tumor when it is otherwise undetectable.

Expression of p53 protein in advanced head and neck squamous cell carcinoma before and after chemotherapy.

BACKGROUND: The expression of p53 protein has been reported to be in the range of 35% to 67% in head and neck squamous cell carcinoma (HNSCC). Mutations of the gene for p53 protein have been associated with rapidly proliferating tumors, and p53 protein expression has been shown to be a significant predictor of worse survival in surgically resected HNSCC. To determine whether p53 protein expression in advanced (stages III and IV) HNSCC has any impact on tumor response to 2 to 3 courses of paclitaxel (Taxol) and carboplatin, we prospectively studied prechemotherapy specimens from patients with previously untreated, advanced-stage HNSCC. We also attempted to study residual tumors after chemotherapy to determine if the p53 status of the tumor changed. DESIGN: The expression of p53 protein was evaluated by immunohistochemical analysis (clone BP53-12-1; Bio-Genex, San Ramon, Calif). SETTING: Tertiary university medical center. INTERVENTION: Two to 3 courses of chemotherapy with paclitaxel and carboplatin. MAIN OUTCOME MEASURES: Pathologic complete remission or residual tumor. RESULTS: The results of p53 immunostaining were positive in 24 (67%) of 36 HNSCC specimens before chemotherapy. After chemotherapy, 8 patients achieved pathologic complete remission. Before chemotherapy, the tumor was p53 negative in 2 patients and positive in 6 patients. CONCLUSIONS: No correlation of p53 protein expression with response to chemotherapy was noted. The expression of p53 protein converted from positive to negative in 5 (42%) of 12 specimens from patients with residual tumor after chemotherapy, with no impact on clinical outcome.

Erythropoietin reduces anemia and transfusions after chemotherapy with paclitaxel and carboplatin.

BACKGROUND: The authors report on anemia observed during preoperative paclitaxel and carboplatin chemotherapy in patients with advanced head and neck carcinoma and discuss how the use of recombinant human erythropoietin (r-HuEPO) ameliorates this anemia, reducing the need for subsequent packed red blood cell (PRBC) transfusions. METHODS: Response to r-HuEPO was defined as reduced hemoglobin fall during preoperative chemotherapy and reduced transfusion requirements during surgery. Thirty-six patients with advanced head and neck carcinoma were evaluable after treatment with preoperative chemotherapy using paclitaxel and carboplatin. Group 1 was comprised of 14 patients who empirically received r-HuEPO at a dose of 150 U/kg 3 times per week for 3 weeks; in patients deemed nonresponders, the dose was increased to 300 U/kg and 450 U/kg in the subsequent courses. Group 2 was comprised of 22 patients who did not receive r-HuEPO. RESULTS: During preoperative chemotherapy, the mean hemoglobin fall was 0.5 g/dL in Group 1 (P = 0.40). In Group 2 there was a statistically significant mean hemoglobin fall of 3.3 g/dL (P < 0.0001). There was also a nonstatistically significant trend toward fewer PRBC transfusions: none of 14 patients (0%) in Group 1 versus 4 of 22 patients (18%) in Group 2 (P = 0.141). CONCLUSIONS: A significant fall in hemoglobin and an increase in the need for transfusions were observed in head and neck carcinoma patients receiving carboplatin and paclitaxel chemotherapy prior to surgery. Empiric r-HuEPO therapy appeared to prevent anemia and reduced the need for PRBC transfusions.

Changes in quality-of-life scores in a population of patients treated for squamous cell carcinoma of the head and neck.

BACKGROUND: Quality of life levels fluctuate depending on treatment type and at various points throughout treatment. In patients with advanced head and neck cancer, quality of life is thought to be treatment dependent. The purpose of this study is to compare levels of patients self-reported quality of life across treatment. PATIENTS AND METHODS: Preliminary data presented here are based on 24 patients enrolled so far in an experimental organ-preservation protocol. The two treatment groups consist of one group treated with chemotherapy (paclitaxel and carboplatin) followed by radiation therapy and the second group which is treated with chemotherapy (paclitaxel and carboplatin) followed by surgery and postoperative radiation. Data is collected pretreatment and at uniform points throughout the course of treatment. RESULTS: Preliminary results suggest that quality of life is significantly higher in the nonsurgical group than in the surgical group at the last treatment point reported. Social distress/avoidance is also lower in the nonsurgical group. Because of the small number of patients represented in this study, results should be interpreted with caution and should be viewed as descriptive at this juncture. CONCLUSION: Quality of life seems to be preserved in patients who experience less invasive and disfiguring treatment, and who also have compromised eating and communication abilities. Data collection in this study is ongoing.

Assessment of functional morbidity in the radial forearm free flap donor site.

OBJECTIVE: To quantitate the functional morbidity to the hand and wrist due to the harvest of a radial forearm free fasciocutaneous flap. DESIGN: Case-control study with age-matched control groups. SETTING: Tertiary care hospital. PATIENTS: A consecutive sample of 21 patients who underwent a radial forearm free flap reconstruction of the head and neck from June 1993 to February 1995 constitute the experimental group. Thirteen of those eligible patients participated in the study. Two control groups were identified. One cohort included 13 patients with head and neck cancer who underwent free tissue transfer other than the radial forearm flap. The other cohort consisted of 16 subjects who were healthy volunteers, patients without cancer, or patients who were considered to be cured of cancer. OUTCOME-MEASURES: Wrist range of motion, grip strength, and sensation in the radial, ulnar, and median nerve distributions on the hands, bilaterally. RESULTS: No significant differences (P > .05) were detected between the groups for the modalities that were tested. CONCLUSION: There is minimal functional morbidity associated with the harvest of the radial forearm free fasciocutaneous flap.

Management of airway obstruction in cicatricial pemphigoid.

Cicatricial pemphigoid is a chronic vesiculobullous disease of the mucosal epithelium that primarily involves the oral cavity and the eyes. The clinical and histologic features are identical to those of bullous pemphigoid, and these features often can be nonspecific for other disease processes. It is not unusual for a period of 1 year or more to elapse before a diagnosis is made. The diagnosis of cicatricial pemphigoid requires characteristic lesions and histopathologic evidence of immunoglobulin deposition along the basement membrane, as well as a high index of suspicion. The authors detail a case of cicatricial pemphigoid resulting in airway obstruction and present the treatment required for both stabilization of the airway and resolution of the disease process.

Relationship between psychological status and compliance in a sample of patients treated for cancer of the head and neck.

BACKGROUND: the psychological status of patients treated for advanced head and neck cancer is an area of patient care that has not received sufficient attention from caregivers and can be influential in terms of patient outcomes. METHODS: Thirty patients participated in this study designed to evaluate areas of psychological distress associated with treatment of advanced head and neck cancer. Patients completed a set of questionnaires related to various psychosocial variables including anxiety, depression, social support, health locus of control, adjustment to illness, illness-related behaviors, and compliance. RESULTS: Moderate levels of depression and anxiety, disability, and psychological distress characterize this sample of patients. Additionally, patient self-report of compliance reveals different variable combinations to be related to overall diet and medication compliance, and different levels of each compliance type were observed. CONCLUSION: Head and neck cancer therapy presents a unique set of challenges for patients. Awareness of the impact of the illness and the psychological distress that are experienced should improve patient compliance and medical outcome.

Hodgkin's disease primarily involving Waldeyer's ring. Case report and review of the literature.

We report a rare case of mixed cellularity Hodgkin's disease primarily involving Waldeyer's ring, which was confirmed by immunohistochemistry and gene rearrangement studies. Our literature search revealed only 14 cases of this entity; six of these represented lymphocyte-predominant Hodgkin's disease not confirmed by immunohistochemistry and, thus, were possibly not truly Hodgkin's disease. Our case demonstrates the diagnostic difficulties in this rare entity and we recommend appropriate immunoperoxidase staining in atypical lymphoid proliferations involving otolaryngic mucosa-associated lymphoid tissue.