Cervical metastases in upper aerodigestive tract squamous cell carcinoma: histopathologic analysis and reporting

BACKGROUND: Accurate histopathologic assessment of neck dissections is of paramount importance. Retrospective analyses of the distribution of lymph node metastases have formed the rationale for elective neck dissection. However, standard techniques for examination of neck dissection specimens may have difficulty in correctly recognizing node levels and may also miss micrometastases, microscopic extracapsular spread, and soft tissue deposits. METHODS: Two hundred thirty-seven neck dissections were performed in 173 patients with squamous cell carcinoma of the upper aerodigestive tract between August 1995 and November 2000. The neck dissections were separated into node levels peroperatively, sectioned at 6 microm thickness, and stained with hematoxylin and eosin. RESULTS: Eleven thousand three hundred forty-nine lymph nodes were identified and examined. The mean yield per neck dissection was 50.4 (range, 12-131); 21.4% had extracapsular spread, 11.0% had soft tissue deposits, and 13.3% had both. A third of the metastatic nodes were 3 mm or less in diameter. CONCLUSIONS: The accurate pathologic staging of the neck in patients with upper aerodigestive tract squamous cell cancer is important for providing prognostic information and optimizing the treatment plan for the patient. Accurate staging also allows the changing patterns of disease to be monitored and allows equitable comparison of patients in clinical trials and among surgical units.     

Squamous cell carcinoma of the upper aerodigestive tract: the prevalence of microscopic extracapsular spread and soft tissue deposits in the clinically N0 neck

BACKGROUND: With squamous cell carcinoma of the upper aerodigestive tract the presence or absence of neck metastases is the most important prognostic factor. This makes the histopathologic assessment of neck dissections of paramount importance. With the clinically N0 neck the prevalence of microscopic extracapsular spread and soft tissue deposits has not previously been described. METHODS: We have prospectively analyzed 96 elective neck dissections in 63 patients with upper aerodigestive tract squamous cell carcinoma and clinically N0 necks to assess the prevalence of microscopic extracapsular spread and soft tissue deposits. The dissections were separated peroperatively into nodal levels; these were sectioned at 6-microm sections and stained with H & E. RESULTS: Nineteen patients (30.2%) were upstaged to pN+ve. Twelve of these had microscopic extracapsular spread, which was 19.0% of the clinically N0 necks and 63.2% of the pN+ve. Five had soft tissue deposits, which was 7.9% of the clinically N0 necks. Fourteen patients had microscopic extracapsular spread and/or soft tissue deposits, which represented 22.2% of all necks examined and 73.7% of the pN+ve necks. CONCLUSIONS: Microscopic extracapsular spread and soft tissue deposits have a high prevalence in patients with clinically N0 necks. Extracapsular spread can occur at an early stage in metastasis from upper aerodigestive tract squamous cell carcinoma. Soft tissue deposits can also occur at an early stage. Soft tissue deposits may occur by the same process as lymph node metastasis with total effacement of the lymph node or may occur by some other process such as lymphatic tumor embolization.     

Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy tube placement

Background: Percutaneous endoscopic gastrostomy (PEG) tubes have replaced nasogastric tubes and Stamm gastrostomy tubes as a preferred means of feeding for patients with head and neck cancers, as recommended by the results of large series. A patient with stomal seeding of squamous cell carcinoma of the upper aerodigestive tract by PEG placement was reported. A review of literature was performed. Methods: A Medline search of implantation of squamous cell carcinoma from the upper aerodigestive tract to PEG exit site since the introduction of PEG was performed. Results: Two reports of implantation of squamous cell carcinoma of the upper aerodigestive tract to PEG exit site were found. Both patients and our patient were staged T4. Conclusions: Implantation of squamous cell carcinoma from the upper aerodigestive tract to the PEG exit site is a rare and late complication. Its prevalence is not known. For patients with a significant amount of squamous cell carcinoma in the upper aerodigestive tract, we recommend Stamm gastrostomy over PEG insertion by the pull technique. There is no report of such late complication by the push technique.     

Cervical node metastases in squamous cell carcinoma of the upper aerodigestive tract: the significance of extracapsular spread and soft tissue deposits

BACKGROUND: Literature regarding the prognostic significance of extracapsular spread and soft tissue deposits in cervical lymph node metastases of squamous cell carcinoma of the upper aerodigestive tract shows variable results. METHODS: We analyzed 215 prospectively collected neck dissections from 155 patients with upper aerodigestive tract squamous cell carcinoma to assess the prevalence of extracapsular spread and soft tissue deposits and to assess their effect on survival. RESULTS: Both extracapsular spread and soft tissue deposits significantly reduced survival (actuarial and recurrence free) compared with pN0 necks (p <.001) and pN+ve necks without extracapsular spread (p <.0025). There was no statistically significant difference between pN+ve necks without soft tissue deposits or extracapsular spread compared with those with pN0 necks (p =.24). Multivariate analysis revealed comparable results. CONCLUSIONS: Microscopic and macroscopic extracapsular spread and soft tissue deposits are of prognostic significance for survival and recurrence-free survival in patients with upper aerodigestive tract squamous cell carcinoma.     

Axillary nodal metastases in head and neck cancer

BACKGROUND: Axillary node metastasis is an uncommon occurrence in squamous carcinoma of the upper aerodigestive tract. METHODS: The tumor registry of The Johns Hopkins University Department of Otolaryngology-Head and Neck Surgery contained four cases of metastasis to the axilla from head and neck primary sites. A retrospective review of these cases was performed. RESULTS: Each patient had been initially treated for cancer years earlier including surgery and radiation to the neck. A recurrent cancer or a new primary then developed in the upper aerodigestive tract prior to the development of the axillary metastases. CONCLUSIONS: The common course of disease in these patients suggests that alteration of the lymphatic anatomy by previous treatment may have caused a new pattern of metastatic spread upon reseeding from the mucosa, resulting in the axillary metastases. Routine surveillance of the axillae by physical examination and/or computerized imaging in at risk patients may permit the early diagnosis of axillary metastases.     

Current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence‐based approach. © 2014 Wiley Periodicals, Inc. Head Neck 37: 915–926, 2015     

The effects of topical oral clindamycin antibiotic rinses on the bacterial content of saliva on healthy human subjects.

The use of systemic antibiotics for major head and neck surgical procedures involving the upper aerodigestive tract is now accepted as an important part of perioperative patient care. Despite knowledge of the high counts of bacteria present in saliva, no preoperative regimen for preparing the mouth has been standardized. Surgical wounds come in contact with saliva during the course of many head and neck procedures. While wound infection rates have been decreased with the use of prophylactic systemic antibiotics, serious morbidity still exists from postoperative wound infections. Reducing the bacterial counts in saliva preoperatively may further decrease wound infection rates. A prospective randomized pilot study of twenty healthy human subjects compared the effects of an oral rinse with clindamycin vs. a placebo rinse of normal saline. There was a statistically significant reduction in both aerobic and anaerobic colony counts in the clindamycin group at 4 hours after treatment. For the group that rinsed with placebo, there was an actual increase in counts 4 hours after treatment. It is concluded that oral rinses with clindamycin can reduce the bacterial content of saliva for a sufficient length of time to be effective as a preoperative prophylactic measure for head and neck surgery involving the upper aerodigestive tract. Future studies are planned to evaluate other potentially effective agents. A logical continuation is a clinical study of preoperative and postoperative rinses.     

The anatomic location of neck metastasis from occult squamous cell carcinoma

It has been axiomatic among head and neck surgeons that open biopsy of cervical nodes will jeopardize patients having squamous cell carcinoma. The inappropriate biopsy of a squamous cell carcinoma metastatic to a cervical node will statistically double both the subsequent rates of local recurrence and distant metastasis. There is no reliable method to clearly distinguish a cervical node involved with squamous cell carcinoma from adenopathy of other sources. Because of this, all patients with cervical adenopathy are evaluated with the time honored approach of careful visualization and palpation of the upper aerodigestive tract prior to open biopsy. The extent of this evaluation is often judgmental. A review of patients with cervical adenopathy of unknown origin and who had a tissue diagnosis, shows that node location is the most helpful parameter for predicting eventual histopathology. Nodes in the jugulodigastric, digestive, and anterior cervical regions have a probability of 19% and 12%, respectively, of being a squamous cell carcinoma. Multiple adenopathies in the supraclavicular and posterior cervical areas are frequently malignant (84% and 61% respectively), however, these are usually either lymphoma or infraclavicular metastasis.     

THE RELATIONSHIP OF CERVICAL LYMPH NODE METASTASES TO PRIMARY SITES OF CARCINOMA OF THE UPPER AERODIGESTIVE TRACT: A PATHOLOGICAL STUDY

Background: Therapeutic and elective dissection of the neck is accepted management in the treatment of squamous cell carcinoma (SCC) of the upper aerodigestive tract (UADT). Accurate histological assessment of the levels of involvement of cervical metastatic spread from different sites within the UADT has allowed the increasing use of less than radical procedures, with associated reduced morbidity. Methods : A total of 168 necks in 126 patients were examined pathologically. All levels were identified at surgery, marked and orientated by pinning the specimen to a cork board, and examined histologically. A total of 114 necks had a comprehensive neck dissection (CND) in which all levels were dissected. The number and level of involvement and the occult rate (114 necks) for each primary site was assessed. Of the total of 168 necks, 80 had pathologically involved nodes, and the number with greater than one node involved (N_2b)was compared for each primary site. The number with extracapsular spread for each nodal staging was also examined. Results: The sites of primary SCC were the oral cavity, oropharynx, hypopharynx, supraglottic and glottic larynx. In those patients with a primary in the oral cavity, no patient had level 5 involvement, but in two patients (7%) level 4 was involved. In the oropharynx, level 1 and 5 were involved in two patients (11%) each. In the hypopharynx, level 1 was not involved in any patient, however, level 5 contained metastasis in 7 (23%). In the supraglottic larynx, level 1 was involved in one (4%) patient and level 5 was involved in three (11%). In the glottis only one patient had bilateral multiple nodes which included level 5. In no case was level 5 involved without positive nodes in other levels. The occult rate for each primary site was 45%, 22%, 77%, 54% and 29%, respectively. The multiple node rate in the 80 necks with positive nodes was, respectively, 31%, 54%, 66%, 45% and 40%. All patients with a node larger than 3 cm had extracapsular spread of tumour. Conclusions : The level of nodal involvement and therefore the type of neck dissection should be determined by the site of the primary within the UADT and the presence or absence of nodes at surgery. There is a high number (39–66%) of pathologically involved necks which have multiple nodes and also nodes with extracapsular spread of tumour, which may influence the decision for postoperative radiotherapy.     

Metastatic head and neck carcinoma to a percutaneous endoscopic gastrostomy site

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement is a safe and widely accepted alternate route for enteral alimentation in the head and neck cancer patient population. Cancer metastatic to a PEG tube exit site is a rare but serious complication of this procedure. We sought to determine the route of spread responsible for PEG site metastases such that we may prevent further occurrences of this highly morbid condition. We also report a case of PEG site metastasis at our institution. METHODS: We performed a MEDLINE search for the years 1962 to 2002 and conducted a review of the literature. In the case at our institution, a 63-year-old man was referred to our institution with recurrent squamous cell carcinoma of the right base of tongue; he also had a 1.5-cm left apical lung nodule. He underwent PEG tube placement at the time of staging panendoscopy. Six months after the original tube placement, he had an ulcerated mass develop at the PEG site; biopsy of the mass revealed squamous cell carcinoma histologically identical to the base of tongue tumor. He also had recurrent lung cancer and four hepatic lesions develop. RESULTS: In our MEDLINE search, of the five patients diagnosed with PEG site disease >10 months after PEG placement, all five (100%) had synchronous distant metastatic disease. In the group of patients diagnosed with PEG site metastases < or =10 months after PEG placement, only four (24%) of 17 had synchronous distant metastatic disease. All patients underwent PEG placement by means of the "pull" technique. Direct implantation with a variable-sized initial tumor burden can explain all cases of PEG site metastasis. The presence of distant metastases is representative of the natural history of advanced head and neck malignancies. Smaller initial tumor implants present later than would larger initial tumor burdens, when the patient is more likely to have distant metastatic disease. In the case at our institution, the patient did not respond to treatment for his hepatic and PEG site metastases and his lung cancer, and he died 4 months after detection of the PEG site metastasis. CONCLUSIONS: PEG site metastases are iatrogenic complications of PEG tube placement in patients with squamous cell carcinoma of the upper aerodigestive tract. The use of laparoscopic, open, or the "push" technique of PEG tube placement in patients with head and neck cancer may prevent direct implantation of malignant cells into an enteral access site.     

Hypopharynxperforation nach endotrachealer Intubation

A case of perforating injury to the hypopharynx following uneventful intubation is reported. As symptoms are relatively unspecific, perforating trauma of the pharynx, larynx, esophagus or trachea may temporarily remain undetected. Consecutive development of an abscess or mediastinitis can cause a potential vital threat to the patient. Depending on the defect size and the overall situation a conservative or surgical management should be followed. Persistent complaints of neck or thorax pain after endotracheal intubation should always raise suspicion of injury to the upper aerodigestive tract, even after uncomplicated intubation.     

The management of a neck mass: presenting feature of an asymptomatic head and neck primary malignancy?

Malignancy of the upper aerodigestive tract is not always associated with obvious localizing symptoms. Presentation may then only be prompted by the appearance of a hard mass in the neck, a metastasis to a cervical lymph node. Neck exploration without a prior diligent search for an occult head and neck primary tumour is to be avoided as it compromises subsequent treatment. The diagnostic investigation of 112 patients complaining solely of a painless and enlarging neck swelling is reviewed. An otolaryngologic examination identified an asymptomatic malignancy of the head and neck in 72 patients (64%). Excision biopsy of the neck mass was required to achieve a diagnosis in only 29 (29%) of those patients who had not already undergone surgery. These results are presented to emphasize the need for a specialist examination of the head and neck prior to embarking on excision of any suspicious neck mass.     

Risk factors for wound infection in head and neck cancer surgery: a prospective study

BACKGROUND: The goal of this prospective study is to determine risk factors for wound infections (WI) for patients with head and neck cancer who underwent surgical procedure with opening of upper aerodigestive tract mucosa. METHODS: One hundred sixty-five consecutive surgical procedures were studied at Oscar Lambret Cancer Center within a 24-month interval. Twenty-five variables were recorded for each patient. Statistical evaluation used Chi2 test analysis (categorical data) and Mann-Whitney test (continuous variables). RESULTS: The overall rate of WI was 41.8%. Univariate analysis indicated that five variables were significantly related to the likelihood of WI: tumor stage (p =.044), previous chemotherapy (p =.008), duration of preoperative hospital stay (p = 022), permanent tracheostomy (p =.00008), and hypopharyngeal and laryngeal cancers (p =.008). CONCLUSIONS: Despite antibiotic prophylaxis, WI occurrence is high. These data inform the head and neck surgeon, when a patient is at risk for WI and may help to design future prospective studies.     

Management of the unknown primary carcinoma: long-term follow-up on a negative PET scan and negative panendoscopy

BACKGROUND: The unknown primary carcinoma in the head and neck has been estimated to represent up to 7% of all head and neck carcinomas. In an attempt to identify the occult primary tumor the evaluation of this patient population has included a complete head and neck examination, flexible fiberoptic endoscopy, and imaging with CT/MRI. More recently, positron emission tomography (PET) has been advocated as a tool to detect primary tumors. METHODS: A cohort of 31 patients with fine-needle aspiration biopsy-confirmed squamous cell carcinoma were prospectively entered into a diagnostic protocol to identify the occult primary tumor. The diagnostic protocol included a comprehensive head and neck examination (including flexible endoscopy) and CT and/or MRI. If the initial diagnostic evaluation failed to identify a primary tumor, the patients then underwent whole body PET imaging followed by staging endoscopy with biopsy of the at-risk occult tumor sites. The outcome measures included the accuracy of the PET to predict the presence of occult tumor at staging endoscopy and the accuracy of the negative PET and negative panendoscopy in predicting the subsequent development of a primary tumor in the upper aerodigestive tract during follow-up. RESULTS: The PET detected 9 occult primary tumors in the 31 patients (detection rate, 29%). Five occult primary tumors (2 base of tongue and 3 palatine tonsil) were detected during panendoscopy despite a negative PET. The combination of PET and panendoscopy detected 45.2% of the unknown primary tumors. Seventeen patients (N1, n = 7; N2a, n = 4; N2b, n = 2; N3, n = 4) had no primary tumor detected and were treated as an unknown primary carcinoma with primary neck dissection +/- radiation therapy +/- chemotherapy. In this series of 17 patients, there were 3 neck recurrences (17.6%). In addition, only 1 patient (5.8%) developed a primary tumor of the upper aerodigestive tract with a mean follow-up of 31.1 months (range, 21-60 months). CONCLUSION: A negative PET study in patients with an occult primary head and neck carcinoma does not preclude the need for panendoscopy with biopsy to detect the occult primary tumor. The risk of subsequent primary tumor appears to be low in the patients with a negative PET and a negative panendoscopy (<6%).     

Prostatic adenocarcinoma metastatic to the head and neck and the workup of an unknown epithelioid neoplasm

BACKGROUND: Epithelioid tumors in the head and neck are common and include both primary and metastatic lesions. For metastatic lesions, clinical factors, tumor location, and ancillary immunohistochemical studies must be taken into consideration to help the clinician and the pathologist determine the site of origin. One unusual, but important, primary tumor that can metastasize to the head and neck is carcinoma of the prostate (CAP). METHODS: The files of the University of Pennsylvania Department of Pathology were searched for cases of metastatic CAP. All slides were examined, and clinical information was obtained from the referring physician's patient charts. RESULTS: We describe 14 cases of metastatic CAP to the head and neck. Six patients had no history of CAP at the time of biopsy of the head and neck metastasis, and only eight patients had other widespread metastatic disease. Histologically, most of the tumors had epithelioid cells with prominent nucleoli and cribriform, solid, or infiltrating single cell growth patterns. PSA and PSAP immunohistochemical stains were positive in all cases. Seven of 12 patients with known follow-up are alive after radiation or hormonal therapy. CONCLUSIONS: These results demonstrate a fair prognosis with possible prolonged survival with metastatic CAP to the head and neck after appropriate diagnosis and subsequent hormone and radiation therapy. Given this survival advantage with treatment, it is critical to consider the diagnosis of metastatic CAP when evaluating a metastatic malignant epithelioid tumor in the head and neck of an elderly man.     

Pneumomediastinum secondary to a mandible fracture

Pneumomediastinum may be produced by a simple facial fracture. It may also be a sign of other aerodigestive tract injuries, and this possibility should be ruled out. A minimal patient workup should include panendoscopy and soft tissue neck x-ray films in all cases. If no other injuries are found, resolution of the pneumomediastinum may be expected without further treatment.     

Role of transoral robotic surgery in current head & neck practice

Morbidity and mortality associated with increasingly radical doses of chemoradiotherapy have led many to question the current standard of care in head and neck cancer. Recently, surgeons have developed minimally invasive, transoral techniques which have demonstrated excellent survival and favourable functional outcomes. Transoral robotic surgery (TORS) is the most recent, cutting edge in the evolution of transoral techniques; TORS allows surgeons unprecedented access to and visualisation of the upper aerodigestive tract. Early reports of TORS in the head and neck are favourable in both primary and recurrent disease. TORS has a role in the assessment of the patient with unknown primary and in the de-intensification of therapy in patients with cancers secondary to human papilloma virus. In this review we discuss the practical set up and technical features of TORS surgery and the application of TORS in primary and recurrent disease, and carcinoma of unknown primary. We outline the current ongoing research into the use of this technique and set out the vision for the future of this surgical modality.Surgical care for upper aerodigestive tract cancers has changed dramatically over the last three decades with technological advances in tumour imaging and resection. Recent advances in mechanical instrumentation and energy devices allow surgeons to remove head and neck cancers transorally; it is only rarely that the extrinsic muscles of the neck and the tongue are involved and the transoral route leads to reduced disruption of the external musculature, quicker recovery and a better functional outcome. In this review we will focus exclusively on the advances in transoral robotic surgery which have transformed the shape of resective head and neck cancer surgery.     

There is no routine head and neck exam during the COVID‐19 pandemic

Head and neck examinations are commonly performed by all physicians. In the era of the COVID‐19 pandemic caused by the SARS‐CoV‐2 virus, which has a high viral load in the upper airways, these examinations and procedures of the upper aerodigestive tract must be approached with caution. Based on experience and evidence from SARS‐CoV‐1 and early experience with SARS‐CoV‐2, we provide our perspective and guidance on mitigating transmission risk during head and neck examination, upper airway endoscopy, and head and neck mucosal surgery including tracheostomy.     

Ethical framework for head and neck cancer care impacted by COVID‐19

The COVID‐19 pandemic has upended head and neck cancer care delivery in ways unforeseen and unprecedented. The impact of these changes parallels other fields in oncology, but is disproportionate due to protective measures and limitations on potentially aerosolizing procedures and related interventions specific to the upper aerodigestive tract. The moral and professional dimensions of providing ethically appropriate and consistent care for our patients in the COVID‐19 crisis are considered herein for head and neck oncology providers.     

Is routine triple endoscopy cost-effective in head and neck cancer?

The multicentric occurrence of tumors of the upper aerodigestive tract has been well described, with an incidence ranging from 5 to 16 percent. Detection of a synchronous primary tumor at the time of initial work-up is crucial both for management and final outcome. However, there is a diversity of opinions regarding the extent of the work-up to search for a second primary tumor. Some investigators consider routine panendoscopy to be essential for every patient with a head and neck primary tumor. Routine esophagoscopy and bronchoscopy with bronchial washings in the absence of specific symptoms appear to have minimal benefit and high cost. In our study of 140 consecutive patients with primary squamous cell carcinoma of the head and neck seen over a period of 3 years, detailed history, thorough head and neck examination, routine chest radiograph, and barium swallow when indicated were sufficient to identify 18 patients (13 percent) with a second primary tumor in the upper aerodigestive tract. The synchronous tumors of eight patients were in the head and neck area, seven patients had carcinoma of the lung, and three patients had a second primary in the esophagus. Two patients had three synchronous primaries. Follow-up of these patients ranged from 1 to 4 years. Panendoscopy with cytologic washings was performed routinely. We questioned the cost-effectiveness of routine triscopy in every patient with head and neck cancer.