Abrasive esophageal cytology for the oncological follow-up of patients with head and neck cancer.

OBJECTIVES: The occurrence of a second primary cancer in the esophagus in patients with head and neck squamous cell carcinoma is frequent and is associated with a poor prognosis. The aim of this study was to evaluate the yield of abrasive esophageal cytology as a means of screening for metachronous cancer of the upper aerodigestive tract. STUDY DESIGN: We retrospectively reviewed the results of abrasive esophageal cytology performed twice yearly for the screening of patients with prior head and neck cancer. METHODS: From 1987 to 1996, 320 patients treated for head and neck cancer underwent 1,673 abrasive cytology examinations of the esophagus during a mean follow-up period of 4 years. Cytological results were classified as negative, suspect, or positive for malignancy. RESULTS: Twenty-five patients without symptoms had one or more suspect or positive cytologic findings, leading to 29 endoscopic examinations. These revealed 20 premalignant or early malignant lesions of the esophagus (2 dysplasias, 18 squamous cell carcinomas), 2 glandular carcinomas, and 10 clinically unsuspected oral or pharyngeal carcinomas. In seven patients, positive cytological results were associated with clinically visible head and neck cancer. Of the 34 patients with suspect cytological results for malignancy, 10 had no evidence of tumor at endoscopy and 24 had no endoscopic examination because of refusal or because suspected cells were not found in additional examinations. Negative results on cytological examination were found for 254 patients throughout their follow-up, and none of them developed esophageal cancer during a mean follow-up period of 3 years. CONCLUSIONS: For patients with head and neck cancer, abrasive sponge cytology is useful for detecting esophageal cancer at an early stage. In addition, it may reveal unsuspected second primaries or recurrences in the head and neck region.     

Squamous-cell carcinoma of the tongue: treatment results and prognosis

OBJECTIVE: The aim of the study was to assess the results of curative treatment of patients with squamous cell carcinoma of the tongue and to evaluate survival and predictive factors of recurrence. PATIENTS AND METHODS: A series of 309 patients with squamous cell carcinoma of the tongue treated with curative intent was studied from January 1988 to December 1999. The percentage of oral tongue cancer was 82.2 and the percentage of cancer of base of the tongue was 17.8. Most patients underwent surgical procedure alone or combined with radiotherapy (92%). We performed 252 neck dissections. Bilateral dissections were performed for cancer of the apex linguae, cancer of the base of the tongue, for patients with N2c neck disease and whenever the primary tumor site crossed the median line. Twenty-five patients (8%) were treated with radiation therapy alone. Mean follow-up was 55 months. The functional results were assessed within a minimum of 10 months postoperative follow-up. RESULTS: In 45.2%, there was histological evidence of node invasion with 53.5% of extracapsular node spread in the neck specimens. Extracapsular node spread did not influence survival or recurrences. Occult cervical metastasis in an elective neck dissection in clinically negative necks was found in about 20% of patients with 47% of extracapsular node spread (41% for cancer of mobile tongue and 80% for those of base of the tongue). About 23% of patients with cancer of base of the tongue staged N0 had histological node invasion in controlateral neck nodes. The postoperative mortality rate was 0.9%. The rate of complications was 17%. The cancer recurred in 41.7% of all cases. Twelve percent of all patients had second primary cancers of the upper aerodigestive tract. The overall survival and non-recurrence rates at 2 and 5 years were higher in cancer of oral tongue than in cancer of base of the tongue. Survival rates were better when neck nodes were clinically or histologically negatives and in early-stage carcinomas. Non-recurrence rates were better when nodes were clinically or histologically negatives and when margins of exeresis were not involved. The functional results were better in oral tongue cancer than in base of the tongue cancer. DISCUSSION: Prognosis (survival and non-recurrence rates and functional results) of squamous cell carcinomas of oral tongue was better than prognosis of those of base of tongue. We recommend an aggressive surgical procedure even in patients with neck classed N0 (with reservations for T1 lesions with small depth of invasion): an ipsilateral supraomohyoid neck dissection for cancer of oral tongue and a bilateral supraomohyoid neck dissection for cancer of base of the tongue, cancer of oral tongue which crosses the median line of the oral cavity and cancer of the apex linguae. Postoperative radiotherapy must be performed when margins are positives and/or when nodes are involved with or without extracapsular spread.     

Advances in the diagnosis of unknown primary carcinoma of the neck

The diagnosis of carcinoma of unknown primary is set, when histologically the neck metastases are confirmed but the primary focus is not possible to be found or occurs during the follow-up. The CUP-nodes constitute 2-20% of all neck metastases in laryngological entities. The squamous cell carcinoma or anaplastic carcinoma recognized in the neck nodes suggest, that the primary focus is localised in the head and neck region. AIM: The schedule of diagnostic procedure aiming at finding the primary focus in CUP-syndrome is presented. The knowledge of carcinoma cells spreading paths between particular neck regions is crucial for effective diagnostics of tumor localization in upper aerodigestive tract. RESULTS: Among 3320 oncological patients treated between 1993-2003 in Department of Otolaryngology, Head Neck Oncological Surgery 32 were diagnosed as CUP syndrome. In 17 patients the primary localisation was revealed during the follow-up period in: nasopharynx, palatine tonsil, hypopharynx, testis and breast. In 15 patients the primary focus was never found. The radical neck dissection followed by radiotherapy or chemotherapy was performed in patients with CUP. In cases when primary tumor was found, the radical surgery or radiotherapy was additionally applied.     

Analysis of nodal metastasis in malignancies of upper aerodigestive tract

A mass appearing in the neck can be a diagnostic challenge. The malignancies of upper aerodigestive tract are mostly squamous cell carcinoma and their metastasis remain largely confined to accessible neck areas permitting useful surgical management. In this study 30 patients were taken up with neck node metastasis. It was found that in supraglottic carcinoma even in no neck incidence of nodal metastasis was high. Even the retropharyngeal lymphnodes not involved in routine radical neck dissection were found to be involved in a few cases, which justifies the search for nodes in retropharyngeal area in routine radical neck dissection.     

Incidence and significance of clinically unsuspected thyroid tissue in lymph nodes found during neck dissection in head and neck carcinoma patients

OBJECTIVES/HYPOTHESIS: The objectives were to quantify the incidence of clinically unsuspected thyroid tissue in cervical lymph nodes encountered during neck dissection in patients with head and neck carcinoma, to describe the location and histological aspect of these inclusions, and to assess their clinical significance. STUDY DESIGN: Retrospective study. METHODS: The histological records of 1123 neck dissections in 752 patients with head and neck carcinoma were reviewed. In cases with thyroid inclusions, the pathological diagnosis was reviewed and an immunohistochemical study against thyroglobulin and calcitonin was carried out. RESULTS: Clinically unsuspected thyroid tissue was found in lymph nodes in 11 of the 752 patients with head and neck carcinoma treated with neck dissection. In five cases, the thyroid inclusion was compatible with a metastases of an occult papillary thyroid carcinoma. In the other six cases, a collection of thyroid follicles without malignant characteristics was found beneath the lymph node capsule. These latter cases were considered benign thyroid inclusions. A thyroidectomy was performed in three of the patients with lymph node metastases of the papillary carcinoma. An occult papillary carcinoma was found in only one case. The other two patients had been treated previously with radiotherapy for an early-stage glottic carcinoma. Immunohistochemical study did not find calcitonin-positive cells within the benign thyroid inclusions. After a follow-up period ranging from 1.2 to 8.2 years, no patient had any kind of local, regional, or distant relapse related to the thyroid disease. CONCLUSION: The incidence of unsuspected thyroid tissue in lymph nodes of patients with head and neck carcinoma treated with neck dissection was 1.5%. Both lymph node metastases of a papillary carcinoma and benign thyroid inclusions were found. The study results suggest that the incidental finding of thyroid tissue in the lymph nodes during a neck dissection in patients with head and neck carcinoma does not necessarily indicate the need for aggressive therapy.     

Management of thyroid carcinoma invading the aerodigestive tract

Objectives: To evaluate approaches to thyroid carcinoma invading the aerodigestive tract, with particular attention to well-differentiated carcinomas. Study Design: Retrospective review of experience with thyroid carcinoma invading the aerodigestive tract over a 20-year period at a tertiary referral hospital. Methods: The medical records of all patients with a diagnosis of thyroid cancer treated at Emory University Hospital, Atlanta, Georgia, from 1977 through 1997 were reviewed. Multiple clinical variables were analyzed including treatment, development of recurrence, and survival. Survival and time to local recurrence were determined by Kaplan-Meier analysis, and statistical comparisons were made using log-rank analysis. Results: Five hundred thirty-six cases were identified; 28 patients (5.2%) were identified with invasive disease involving the aerodigestive tract. Histologic findings at the time of invasion included 15 well-differentiated (WD) carcinomas and 13 poorly differentiated (PD) carcinomas. Eight of the 28 patients (5 WD, 3 PD) underwent surgical resection of some portion of the aerodigestive tract with curative intent. Ten patients (8 WD, 2 PD) underwent incomplete resection with tumor left adjacent to aerodigestive tract structures. All patients undergoing incomplete resection developed local recurrence. Six required salvage resection, as opposed to no recurrences in WD carcinomas following complete resection (P = .01). Survival at 5 years for WD carcinomas undergoing complete resection versus initial incomplete resection was 100% versus 50%, respectively (P = .27). Conclusion: Review of our experience shows that complete resection of thyroid carcinoma invading the aerodigestive tract can offer prolonged palliation, improved local control, and the opportunity for cure in selected patients.     

Impfmetastasen nach translaryngealer Tracheotomie nach Fantoni

The translaryngeal tracheotomy (TLT) according to Fantoni with rigid endoscopy is well known and easy to execute. In our department we have used this method since 2002. In 17 patients suffering from carcinomas of the upper aerodigestive tract, we performed a TLT. Peri- and postoperative complications were examined. In 17 patients there were no intraoperative complications. As an early complication we found in one case a dislocation of the tracheostomy tube postoperatively. In one patient we observed metastases in the prior TLT stoma as a major late complication. Another patient also probably suffered from metastases in the prior TLT stoma. We did not find tracheoesophageal fistulas or stenosis of the trachea. Iatrogenic neoplastic seeding of squamous cell carcinomas of the upper aerodigestive tract is a serious complication. Our experience with these two cases and a review of the literature indicates that in patients with head and neck cancer, pull procedures for placement of TLT tubes may induce metastases by direct implantation of tumor cells because of contact between the TLT tube and the primary tumor cells. TLT according to Fantoni cannot be recommended for the treatment of cancer of the upper aerodigestive tract. Methods of tube insertion that avoid such contact, e.g., Ciaglia, surgical tracheostomy, should be preferred.     

Multiple synchronous carcinoma of the aero-digestive tract

Multiple carcinoma of the upper aerodigestive tract is an increasingly recognized problem, and a concept of 'field cancerization' has been proposed to explain this phenomena. The initial assessment of a patient with an isolated aerodigestive carcinoma must be extensive so as not to miss any synchronous lesions, and may include radiography and endoscopy. Treatment cannot be standardised but must be tailored to suit individual problems and because of the high incidence of metachronous tumours, follow-up must be both thorough and 'lifelong'. A case of three primary synchronous squamous carcinomas of the upper aerodigestive tract is presented. The relevant literature is reviewed.     

Role of [18]-FDG PET/CT in the initial staging of head and neck cancers

OBJECTIVE: To evaluate the impact of fusion of positron emission tomography with computed tomography (FDG-PET/CT) in the initial staging of head and neck carcinomas. METHODS: This retrospective study included 44 patients with squamous cell carcinoma of the upper aerodigestive tract. Patients underwent a standard workup and a PET/CT image fusion during the initial staging. The standard workup included CT scan of the head, neck and chest, panendoscopy under general anaesthesia, oesophageal endoscopy and abdominal echography. Potential additional diagnostic value of PET/CT was evaluated. RESULTS: Findings between PET/CT and standard workup were concordant in 41/44 cases for primary tumour in 79/88 cases for lymph node staging, in 36/44 cases for distant metastases (or distant second primary) and in 41/44 cases for synchronous second primaries of the upper aero-digestive tract. PET/CT leads to a change of treatment for 6.8% of patients (1 for lymph node staging and 2 for distant metastases). 17.2% of pathological FDG uptake foci found by PET/CT were false-positives results. CONCLUSION: PET/CT enables to realise a whole body check-up in a single time. However, it cannot be used alone, due to its lack of spatial resolution: It must be used in complement of the standard workup. This high rate of false-positive findings, asking for further expensive diagnostic procedures, limits its usefulness.     

Pharyngo-laryngeal examination with the narrow band imaging technology: early experience

The prognosis of cancer patients is highly dependent on the time of diagnosis. Early, stage 1 disease is often curable whereas late stage diseases are usually beyond curable treatments. Therefore, new diagnostic tools for malignancies of the upper aerodigestive tract are developed all the time and narrow band imaging (NBI) is one of these new options for early diagnostics. In this paper, we describe the implementation of NBI technique in our institution. During the first 6 weeks we used NBI to examine 73 patients with different types of pharyngeal or laryngeal problems. Most of the patients (77%) were on follow-up visits after earlier malignant disease. In our series we had 11 NBI-positive patients and the histological diagnosis was carcinoma or dysplasia among 10 of these. Among the NBI negative patients we found four carcinomas. It is notable that NBI affected the decision of a biopsy procedure in three patients, with final diagnosis of dysplasia or carcinoma. In conclusion, we find NBI useful in the diagnostics of malignancies of the upper aerodigestive tract. This is a useful tool in improving the accuracy of the diagnostics. However, it still takes an experienced clinician and a learning curve can be expected.     

Treatment of a thyroid neoplasm infiltrating the respiratory-digestive tracts

From 1992 to 1999, 58 thyroid gland operations (41 female and 17 male) were performed in ENT Department of the District Hospital in Rzeszów. In 14 (21.4%) cases (9 female and 5 male) thyroid surgery was done for malignant disorders: papillary carcinoma in 11 (79%) patients, follicular carcinoma in 2 patients and medullary carcinoma in 1 patient. There were neck metastases in 9/14 (64.4%) patients. In 3 cases with papillary carcinoma (all with neck metastases) aerodigestive tract was invaded. One patient had neoplasmatic invasion of the larynx and trachea, one patient had invasion of larynx et pharynx and in one patient tumour invaded the esophageal wall. In those patients radical surgery was done: total thyroidectomy with total laryngectomy and radical neck dissection (2 patients) and subtotal thyroidectomy with conservative neck dissection (1 patient). External beam irradiation and radioactive iodine 131 treatment followed surgery. Two patients are still alive 6 years after the treatment free of disease, and 1 patient died of unrelated causes 3 months after the surgery. Symptoms, diagnostic evaluation and treatment of thyroid papillary carcinoma invading the aerodigestive tract are detailed in paper.     

Differentiated thyroid cancer invading the hypopharynx: A case report

Most thyroid cancers (90–95%) are well differentiated. Well differentiated cancers of the thyroid are usually confined to the thyroid capsule, making them amenable to isolated thyroid resection. Invasion of the upper aerodigestive tract by these cancers is infrequent and hypopharyngeal invasion is still rare. We report a 51 year old man with thyroid cancer invading the hypopharynx, who was successfully managed with complete resection along with a partial pharyngectomy. He is asymptomatic and disease free eighteen months after surgery. We advocate aggressive surgical extirpation of thyroid carcinoma invading the upper aerodigestive tract.     

Incidental metastases of well-differentiated thyroid carcinoma in lymph nodes of patients with squamous cell head and neck cancer: eight cases with a review of the literature

The examination of a large series of cervical lymph nodes in patients with head and neck cancer revealed the presence of incidental metastases of occult thyroid carcinoma in eight patients, of which six cases were squamous cell carcinoma of glottic and supraglottic sites of the larynx and two cases were pyriform sinus and tongue carcinomas. Three patients had two lymph nodes and the remaining patients had one lymph node each involved. The nodal chains affected were the jugular (n=5; level IV), Kuttner (level II), supraomohyoid (level III) and supraclavicular (level VI). In four cases, a subtotal thyroidectomy or unilateral lobectomy was performed during laryngectomy (for surgical reasons) or after histologic nodal examination; a minimal focus of thyroid papillary carcinoma was detected in one patient. Three of eight patients died from recurrence of the squamous cell carcinoma; no case presented clinical evidence of thyroid malignancy. The differential diagnosis from benign thyroid heterotopia was based on the presence of minimal nuclear atypia. The choice of treatment of patients with a coexisting neoplasm characterized by poor prognosis is difficult, and contrasting opinions exist regarding the use of radical thyroidectomy and the subsequent management. As reported in the literature (66 cases), the more aggressive squamous cell carcinoma will determine the prognosis of these patients; in fact, only one of the referred cases died of cerebellar metastases of the thyroid cancer. Our results emphasize the importance of an accurate re-evaluation and follow-up of patients with incidental occult metastases for detection of a primary thyroid tumor. In the general population, this incidental nodal involvement may be related to a minimal occult thyroid carcinoma.An erratum to this article can be found at     

The differential diagnosis of the mass in the neck. A fresh look

A diagnosis of undifferentiated carcinoma by light microscopy in a neck node biopsy is insufficient to come to a conclusive answer as to the type of tumor with which one is dealing. The fact that undifferentiated carcinoma by light microscopy may very well be a histiocytic lymphoma with a different mode of treatment and an increasingly improved cure rate has changed the mode of evaluation in arriving at a diagnosis of the node in the neck with no visible primary in the upper aerodigestive tract.     

Follow-up strategies in head and neck cancer other than upper aerodigestive tract squamous cell carcinoma

Post-therapy follow-up for patients with head and neck cancer other than upper aerodigestive tract squamous cell carcinoma should meet several objectives: to detect both local, regional or distant recurrences, to evaluate acute and long-term treatment-related side effects, to guide the rehabilitation process, and to provide psychosocial support when needed. To our knowledge, there are no published reports in the literature dedicated to the follow-up of patients with these tumours. A comprehensive literature search for post-treatment follow-up strategies spanning from 1980 to 2012 was performed on several databases. This review focuses on malignant salivary gland tumors, soft tissue sarcomas, cutaneous squamous cell carcinomas, and sinonasal adenocarcinomas. Given the varying biological behavior and treatment-related factors and based on the literature, different recommendations are made on the follow-up of patients with the above-mentioned tumors.     

Paratracheal lymph node involvement in advanced cancer of the larynx,hypopharynx, and cervical esophagus

OBJECTIVES/HYPOTHESIS: The presence of nodal metastatic disease in head and neck cancer is the foremost prognostic factor. Although neck dissection is the surgical gold standard for the treatment of cervical lymphatic spread, the paratracheal nodal group is not routinely included in the dissection. The study determined the nodal yield, presence of metastases, and prognostic importance of paratracheal nodes in patients with advanced carcinoma of the upper aerodigestive tract. STUDY DESIGN: Prospective histological and survival analysis. METHODS: Over a 4-year period (October 1994-June 1998), consecutive patients undergoing laryngectomy with or without pharyngectomy or cervical esophagectomy underwent paratracheal node dissection on a prospective basis. Nodal tissue was examined for the presence of metastases. Statistical comparison of survival probability was determined by use of log-rank/chi2 test. RESULTS: Fifty patients have been included in the study to date, with a minimal follow-up of 3 years. The average number of paratracheal nodes dissected was three per side (range, 1-5). Thirteen (26%) patients demonstrated histological evidence of paratracheal nodal metastases (larynx, 20%; postcricoid/cervical esophageal region, 43%). Five patients (10%) had positive paratracheal nodes alone in a histologically negative cervical neck dissection. The majority of positive paratracheal nodes were less than 1 cm in diameter and appeared negative preoperatively. The absence of positive paratracheal nodes may have a survival benefit. CONCLUSION: The study highlighted the propensity of advanced carcinoma of the upper aerodigestive tract to involve the paratracheal nodes. This area should be routinely dissected in the surgical management of these tumors.     

Second primary carcinomas in the upper aerodigestive tract in different locations and age groups

BACKGROUND: Second primary tumors are of great importance for diagnostics, therapy and prognosis in patients suffering from squamous cell carcinomas of the upper aerodigestive tract. The clinical observation of an increase of second primaries was the reason for analyzing all patients with head and neck cancer treated for a certain period of time at our institution. METHODS: The hospital charts of 576 patients treated for squamous cell carcinoma of the oral cavity, the oropharynx, the hypopharynx and larynx treated from 1993 till 1996 at the Department of Otolaryngology, Head and Neck Surgery of the University of Würzburg were reviewed retrospectively. RESULTS: 10.1% of all patients developed a second primary tumor. The rate was highest for patients with carcinoma of the oral cavity (17.5%), followed by tumors of the hypo- and oropharynx (11.7% and 11.5%) and the larynx (6.4%). Besides the location, younger age was detected as a risk factor for the formation of second malignancies. The latency between first and second primary tumor was 2.9 years in average. 31% of the second primaries were detected synchronous, 39% metachronous. CONCLUSION: The results demonstrate that younger patients and patients with carcinomas of the upper digestive tract need a consequent follow-up. The development of second primaries even years after the first malignoma demonstrates the necessity of lifelong follow-up and oncological care.     

Low incidence of point mutation at codon 12 of K-ras proto-oncogene in squamous cell carcinoma of the upper aerodigestive tract

Forty-two cases of squamous cell carcinoma arising in the upper aerodigestive tract were examined to determine the incidence and type of point mutation in codon 12 of the c-K-ras gene by using the polymerase chain reaction and oligonucleotide hybridization techniques on DNA extracted from paraffin blocks. DNA sequencing, in addition, was performed in 4 cases. No point mutation was detected in codon 12 of c-K-ras in the 42 squamous cell carcinomas we examined. According to the results of DNA sequencing of 4 cases, codon 13 also revealed no point mutation. Thus, point mutational activation of codon 12 of c-K-ras oncogene is an uncommon event in human upper aerodigestive tract squamous cell carcinoma.     

Toluidine blue staining of the esophagus. A useful adjunct in the panendoscopic evaluation of patients with squamous cell carcinoma of the head and neck

Carcinoma of the esophagus has a much higher incidence among patients with squamous cell carcinoma of the head and neck than among the population at large. Esophageal cancer has a low cure rate, and the possibility for increased survival can be enhanced primarily through early detection. Toluidine blue has proved to be effective in demonstrating early malignant lesions that would not be detectable otherwise. A technique has been developed for toluidine blue staining of the esophagus during panendoscopy. In this initial series of 18 patients with squamous cell carcinoma of the upper aerodigestive tract, we found a 17% incidence of early carcinoma of the esophagus. We believe this technique to be an important adjunct to the evaluation of these patients at high risk for esophageal carcinoma.     

Simultaneous squamous cell carcinomas of the oral cavity and oropharynx

INTRODUCTION: Squamous cell carcinoma of the oral cavity is often a single localization, but the discovery of another or several associated lesions is not exceptional. The goal of our study was a retrospective analysis of patients having 2 simultaneous squamous cell carcinomas of the upper aerodigestive tract (UADT), i.e. diagnosed during the same panendoscopy by excluding the esophagus and the lung. PATIENTS AND METHODS: Between 1995 and 2001, 1,129 patients were treated for squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx in the Bordeaux Maxillo-facial Surgery Unit. 1% of these patients presented 2 simultaneous squamous cell carcinomas of UADT. RESULTS: Our series was divided in 9 men (75%) and 3 women (25%) with an average age of 61.3 years (48-86). At the end of the study 2 patients were lost to follow-up, 3 patients were alive without recurrence, and 1 patient was alive with recurrence. The average follow-up time was 17.6 months. DISCUSSION: A review of the literature gave an incidence of simultaneous squamous cell carcinomas of UADT varying from 1.3 to 12.8% according to authors. Thus, any patient having squamous cell carcinoma of the UADT must be considered as having an important potential risk to present another simultaneous cancer and to benefit from a systematic panendoscopy. In spite of an early diagnosis, the prognostic of these lesions remains bad.