Level V in therapeutic neck dissections for papillary thyroid carcinoma

Neck dissection for papillary thyroid carcinoma (PTC) is the standard of care for patients with clinical evidence of regional metastases. However, the extent of neck dissection is debatable. The purpose of the current study was to develop evidence‐based recommendations for when to include level V, or 1 of its sublevels, among patients with PTC undergoing neck dissection. A literature review of all studies evaluating the occurrence of metastases in level V in patients with regional metastases from PTC undergoing neck dissection was performed. Occurrence of metastases at level V is low in most series (5% to 10%), although a wide range was noticed. In cases in which metastases were found at level V, they occurred almost exclusively at sublevel VB. Sublevel VA was rarely, if ever, involved with metastatic lymph nodes. However, only recently have investigators begun to specify which sublevels of level V are at risk. Therapeutic dissection of level V is indicated when there is clinical evidence of disease involving this zone. Elective dissection of sublevel VB is indicated when there is involvement of level IV, or possibly multiple nodes at levels II and III. Under these circumstances, dissection of sublevel VB is indicated but sublevel VA may be spared. © 2012 Wiley Periodicals, Inc. Head Neck, 2013     

Elective paratracheal neck dissection for lateral metastases from papillary carcinoma of the thyroid: Is it indicated?

BACKGROUND: Therapeutic paratracheal neck dissection for patients with papillary carcinoma of the thyroid is standard treatment. Its use as an elective procedure is controversial. METHODS: Thirty-seven patients with papillary carcinoma of the thyroid and evidence of positive adenopathy at levels II-V underwent selective neck dissection and elective/therapeutic paratracheal neck dissection. Results of preoperative ultrasonography of the neck were compared with the dissection specimens. RESULTS: Morbidity of the surgical procedure was minimal (1 permanent hypocalcemia). All specimens showed metastases from papillary thyroid carcinoma: 100% (37/37) in the jugular chain of lymphatics and 83.7% (31/37) in the paratracheal region. The rate of occult (negative physical examination and ultrasonography) metastases in the paratracheal region in the presence of metastases in the ipsilateral jugular chain was 83.3% (20/24). CONCLUSION: The high rate of occult metastases in the paratracheal region and the low rate of surgical morbidity speak in favor of elective paratracheal neck dissection in patients with metastatic papillary carcinoma of the thyroid.     

Surgical management of parapharyngeal space tumors: a 10-year review.

OBJECTIVE: The purpose of this article is to describe the diagnostic evaluation and surgical approaches to parapharyngeal space tumors in a tertiary referral center. STUDY DESIGN AND SETTING: The study is a retrospective review of 47 patients diagnosed with tumors of the parapharyngeal space (12 with malignant diseases and 35 with benign lesions) and surgically treated during a 10-year period. The transcervical (40%) and the transcervical-transparotid approaches (46%) were the most commonly performed surgical procedures followed by the orbitozygomatic-middle fossa approach (12%) and the transmandibular approach (2%). RESULTS: The surgical procedures were uneventful and there were no postoperative mortalities. Complications were rare; the most common was transient facial nerve paralysis (5 patients). After an average follow-up of 35 months, only 1 of 35 patients with benign diseases had a recurrence 5 years following transcervical resection of a pleomorphic adenoma. Of 12 patients with malignant tumors, 5 (42%) are alive with no evidence of disease. The sensitivity of preoperative fine needle aspiration biopsy (n = 23 patients) was 87% for detection of malignant disease and specificity was 100%. CONCLUSIONS: Most benign parapharyngeal space tumors can be removed surgically with a low rate of complications and recurrence. Malignant neoplasms, however, carry an ominous prognosis and a low rate of disease-free survival. Fine needle aspiration may be helpful in preoperative diagnostic evaluation of patients with parapharyngeal space tumors.     

Tracheal mucormycosis presented as an intraluminal soft tissue mass

BACKGROUND: Mucormycosis is a potentially lethal disease caused by an opportunistic fungal infection. It occurs mostly in diabetic or immunosuppressed patients and usually involves the lungs or paranasal sinuses. METHODS: We report a rare case of a patient with diabetic ketoacidosis who presented with progressive cough and dyspnea. CT of the neck and chest showed an intraluminal soft-tissue mass extending from the first tracheal ring to the thoracic inlet, causing severe destruction of the trachea. Direct laryngoscopy and biopsy demonstrated hyphal invasion with architecture typical of invasive mucormycosis. RESULTS: The patient underwent resection of the upper trachea and prolonged amphotericin B therapy and is disease free at 24 months after surgery. CONCLUSIONS: In patients with diabetes presenting with progressive hoarseness, dyspnea, and endobronchial mass, a fungal infection should be considered. In case of invasive tracheal mucormycosis, prompt diagnosis and early surgical resection may help improve survival.     

Routine inclusion of level IV in neck dissection for squamous cell carcinoma of the larynx: Is it justified?

BACKGROUND: Dissection of levels II-IV as part of an elective or therapeutic neck dissection is common practice during laryngectomy for laryngeal squamous cell carcinoma (SCC). The necessity of routine dissection at level IV has recently been questioned. The purpose of this study was to find the incidence of level IV metastases in patients with transglottic and supraglottic SCC who underwent neck dissections. METHODS: The charts of 71 suitable patients were reviewed. Forty-two had supraglottic primary cancers, and 29 had transglottic primary tumors. Levels II-IV had been removed in them all, and their neck specimens were marked according to the levels of the neck. The surgical specimens were pathologically diagnosed. RESULTS: Of 43 patients who underwent elective lateral neck dissection, the only one (2.3%) with level IV metastases also showed metastases at level II. Nine (32%) of the other 28 patients with clinical adenopathy had level IV metastases. CONCLUSIONS: Dissection of level IV as part of a therapeutic neck dissection for supraglottic and transglottic SCC is recommended for patients with clinically enlarged lymph nodes, but its necessity in the absence of detectable adenopathy is challenged.     

Results of phase I-II trial of concomitant hyperfractionated radiation and oral etoposide (VP-16) in patients with unresectable squamous cell carcinoma of the head and neck

PURPOSE: The purpose of the current study was to investigate the efficacy of concomitant oral etoposide and hyperfractionated radiation for patients with unresectable head and neck squamous cell carcinoma. METHODS: A prospective nonrandomized phase I-II study was conducted using concomitant oral etoposide (50 mg/d for 13-27 days) and hyperfractionated radiotherapy (1.2 Gy twice daily to a total of 7440 rads) for patients with unresectable squamous cell carcinoma of the head and neck. Toxicity was graded according to the NCI common toxicity criteria. Patients were followed for a minimal period of 2 years. Endpoints for follow-up were recurrence or death. RESULTS: Seventeen patients were enrolled in the study. Grade III hematological toxicity occurred in 1 patient and moderate to severe mucositis occurred in all but 2 patients requiring a gastrostomy tube (n = 13) or intravenous fluids hydration (n = 2). One patient died of cardiac arrest unrelated to the treatment regimen. The overall response rates in patients that finished the protocol were 80% for the primary site and 100% for the neck. A complete response was observed in 47% at the primary site and 33% in the neck. Local control and disease-free survival (DFS) at an average follow-up of 3.7 years were 47% and 29%, respectively. CONCLUSIONS: Concomitant etoposide and hyperfractionated radiation is well tolerated and seems to be effective in the treatment of unresectable HNSCC with acceptable mucosal toxicity.     

Quality of life following surgery for anterior skull base tumors

OBJECTIVES: To evaluate patients' quality of life (QOL) after surgical extirpation of anterior skull base tumors, to elucidate different QOL domains, and to define possible predictors of functional outcome postoperatively. DESIGN: Retrospective survey. SETTING: University-affiliated medical center. PARTICIPANTS: Sixty-nine patients (76 consecutive cases) who underwent subcranial surgery between 1994 and 2002 for extirpation of anterior skull base tumors. MAIN OUTCOME MEASURE: A multidimensional, disease-specific questionnaire with 39 items was used. Six relevant domains of QOL were assessed: role of performance, physical functioning, vitality, pain, specific symptoms, and impact on emotions. RESULTS: The response rate for completing the questionnaire was 98% (40/41) after excluding patients who died (n = 13), were lost to follow-up (n = 10), and were operated on within 3 months of commencement of the study (n = 5). Thirty patients (74%) reported a significant improvement or no change in overall QOL within 6 months after surgery. The worst impact of surgery on the patients' QOL was on their financial status and emotional state. The most influential factor on QOL was malignancy leading to a significant decrease in the overall score. Radiotherapy, old age, comorbidity, and wide resection also significantly worsened QOL scores of specific domains. CONCLUSION: After subcranial extirpation of anterior skull base tumors, the overall outcome of the patients is good. Old age, malignancy, comorbidity, wide resection, and radiotherapy are negative prognostic factors for these patients' QOL.     

Is Dissection of Level IV Necessary in Patients With T1‐T3 N0 Tongue Cancer?

OBJECTIVE: Dissection of the lower jugular level of lymph nodes (level IV), as part of an elective neck dissection, has been advocated recently for all patients with oral tongue cancer because of the possibility of "skip metastases" to levels III and IV. The current study was undertaken to evaluate the need to perform a dissection of level IV in patients with oral tongue cancer with no clinical evidence of nodal metastases. METHODS: Fifty-one patients with T1-3, N0 squamous cell carcinoma of the oral tongue were treated with a partial glossectomy and a selective neck dissection of levels I, II, and III. When enlarged nodes were encountered during surgery in level II or III, the dissection was extended to include the nodes in level IV. Involvement of level IV was determined either by the presence of carcinoma on pathological examination or by the development of recurrence in the untreated level IV during a follow-up period of at least 2 years. RESULTS: Level IV was resected as part of the specimen in 17 of the 51 patients and metastatic tumor was found in this level in only one patient. At an average follow-up of 4.1 years, only one patient recurred at level IV, which had been addressed at the initial neck dissection. Consequently, the rate of metastases to undissected level IV was 2%. CONCLUSIONS: Metastases to level IV lymph nodes is rare in patients with T1-T3, N0 oral tongue cancer. Dissection of these nodes only when there is intraoperative suspicion of metastases in levels II or III does not increase the risk or recurrence of tumor in the neck.     

Curcumin: a new radio-sensitizer of squamous cell carcinoma cells.

PURPOSE: Curcumin, a potential chemopreventive agent, was found to inhibit cancer cells in S/G2M phases of the cell cycle, when radiation is more effective. The purpose of the current study was to investigate whether curcumin can sensitize squamous cell carcinoma (SCC) cells to the ionizing effects of irradiation. METHODS: Curcumin (3.5 microM) was added for 48 hours to an SCC cell line prior to irradiation. Cell growth (counts) and colony-formation (colonogenic assay) were examined after radiation. RESULTS: Incubation with curcumin only (3.75 microM) for 48 hours did not decrease the number of cells or the ability to form colonies in the absence of radiation. However, in plates that were exposed to 1-5 Gy of radiation, cell counts dropped significantly if pretreated with curcumin with a maximal effect at 2.5 Gy (where the cell counts dropped from 1240 to 1017, P < 0.001). The colonogenic assay revealed a significant decrease in the ability to form colonies following pretreatment with curcumin in all radiation doses ( P < 0.05). CONCLUSIONS: Given the appropriate doses, curcumin exhibits radio-sensitizing effects on SCC cells in vitro.     

Lymphoscintigraphy for sentinel node mapping using a hybrid SPECT/CT system.

Lymphoscintigraphy is performed before sentinel node (SN) biopsy for SN mapping. It is of clinical importance mainly if the tumor is located in body parts with ambiguous lymph node drainage. The purpose of this study was to assess the clinical benefit of fused SPECT/CT images to planar images for SN mapping. METHODS: Thirty-four consecutive patients with cutaneous malignant melanoma (n = 28) and squamous cell carcinoma (n = 6) and scheduled for SN biopsy were enrolled. Primary tumors were located in the trunk (n = 12), in the extremities (n = 12), in the head and neck (n = 9), and in the penis (n = 1). Scintigraphy was performed using a hybrid gamma-camera/low-dose CT system. Planar images and fused SPECT/CT images were interpreted separately. RESULTS: SPECT/CT identified multiple draining basins in 6 of 12 patients (50%) with trunk melanoma and in 3 of 9 patients (33%) with head and neck melanoma or mucosal tumor. In 9 of 21 patients (43%) with a primary tumor located in the head and neck or trunk region, SPECT/CT-fused images identified SNs that were missed on planar images, 2 of which were involved with tumor. Three of the 9 nodes were located close to the injection site and were hidden by its scattered radiation, and 2 were in-transit nodes. Another 4 nodes, identified on fused images only, were located in an additional basin to those identified on planar images. Fused images were of no added value either in patients with limb melanoma or in a patient with a penile melanoma. CONCLUSION: SPECT/CT SN mapping provides additional data that are of clinical relevance to SN biopsy in patients with trunk or head and neck melanoma and in patients with mucosal head and neck tumor.