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     

Intraosseous carcinoma of the jaws—A clinicopathologic review. Part I: Metastatic and salivary‐type carcinomas

This is the first part of a 3‐part comprehensive review of intraosseous carcinoma of the jaws. We have outlined 4 groups of intraosseous carcinoma of the jaws (metastatic, salivary‐type, odontogenic, and primary intraosseous carcinoma), emphasizing the need for accurate diagnosis and the problems associated with changing classification systems, standardization of diagnostic criteria and nomenclature, and the accuracy of existing literature. In this first part, the features of metastatic and the very rare salivary‐type carcinomas of the jaws are examined with particular emphasis on histologic and immunohistochemical characteristics, diagnostic difficulties, and uncertainties. © 2012 Wiley Periodicals, Inc. Head Neck, 2012     

Aggressive variants of papillary thyroid carcinoma

A number of histologic variants of well‐differentiated papillary carcinoma have been found to be associated with more aggressive tumor behavior. Tall cell, columnar cell, diffuse sclerosing, solid/trabecular, and insular variants of well‐differentiated papillary thyroid cancer are all potentially more aggressive than conventional papillary thyroid cancer. When subjected to multivariate analysis, however, evidence that the histologic subtype of tumor is an independent predictor of outcome is weak. Rather, the aggressive variants tend to present with features recognized by other staging systems as associated with a worse prognosis, including higher histologic grade, extracapsular spread, large tumor size, and the presence of distant metastases. Prognosis is directly related to the presence of these features. The state of our knowledge is limited by the relatively small number of cases that have been studied. The presence of an aggressive variant of papillary carcinoma should alert the surgeon that he is dealing with a potentially aggressive tumor. Clinical treatment decisions should be based on the stage of the disease, influenced by the knowledge that the aggressive variants tend to be associated with higher risk factors. The surgeon must be prepared to perform at the first, or second stage, a total thyroidectomy, central compartment neck dissection, additional lymphadenectomy, and/or resection of invaded surrounding structures, and search for distant metastasis. Postoperative radioactive iodine should generally be administered for these variants as they will generally be intermediate to advanced tumors. The tall cell variant is often refractory to such treatment but may be susceptible to treatment targeted against BRAF mutation. External beam irradiation may be used in cases of incomplete resection. © 2010 Wiley Periodicals, Inc. Head Neck, 2011     

Central compartment dissection in laryngeal cancer

We report here a review of the literature intended to clarify the nomenclature and boundaries of the nodes in the “central compartment” of the neck, the frequency with which tumors from the different laryngeal sites metastasize to these nodes, and the indications for central compartment node dissection in the treatment of cancers of the larynx. From this review, we conclude that, until consensus is reached about grouping of the lymph nodes in this area, it is best to refer to these nodes by their anatomic location, ie, prelaryngeal, pretracheal, or paratracheal lymph nodes. It is also advisable to describe dissection of these nodes as selective neck dissection (SND) with an annotation about the specific lymph node groups removed. Metastases in prelaryngeal and paratracheal lymph nodes in patients with squamous cell carcinoma of the larynx are associated with increased tumor recurrence, more frequent metastases in lymph nodes of the lateral compartment of the neck, and decreased survival. If untreated, they may lead to the development of peristomal recurrence. Therefore, elective treatment of level VI nodes is recommended in patients with squamous cell carcinomas of the subglottic region, advanced glottis carcinomas with subglottic extension, and in certain advanced carcinomas of the supraglottic region. © 2010 Wiley Periodicals, Inc. Head Neck, 2011     

Neuroendocrine neoplasms of the larynx: An overview

Neuroendocrine neoplasms of the larynx are rare but are the most common nonsquamous tumors of this organ. In the past, there has been considerable confusion about the nature and classification of these neoplasms, but the current consensus is that there are 4 different types of laryngeal neuroendocrine tumors composed of paraganglioma, typical carcinoid, atypical carcinoid tumor, and small cell neuroendocrine carcinoma. Carcinoids and small cell neuroendocrine carcinomas are epithelial neoplasms, whereas paragangliomas are of neural origin. Diagnosis is based primarily on light microscopy and confirmed by immunohistochemistry and electron microscopy. Precise diagnosis is essential because the natural history, treatment, and prognosis vary widely for the different neoplastic categories. Typical carcinoids are very rare and are treated by wide local excision, usually partial laryngectomy, without elective neck dissection. Atypical carcinoid tumors are more common and more aggressive. They are treated by partial or total laryngectomy with elective or therapeutic neck dissection. Adjuvant chemo/radiotherapy may be of benefit in some cases. Small cell neuroendocrine carcinomas are highly aggressive and should be considered disseminated at initial diagnosis. The treatment is by irradiation and chemotherapy as surgery has proven to be of a little benefit. Paragangliomas are treated by local excision or partial laryngectomy. It is difficult to determine the valid survival statistics for typical carcinoids because of their rarity and confusion in the literature with their atypical counterparts. They have a greater tendency to metastasize, and thus a worse prognosis than was previously believed. Atypical carcinoid tumors have a 5‐year survival rate of approximately 50%, which decreases with time. The prognosis of small cell neuroendocrine carcinoma of the larynx is dismal, with 5‐year survival rates of 5%. The biological behavior of laryngeal paraganglioma is generally benign and the prognosis is excellent. © 2009 Wiley Periodicals, Inc. Head Neck, 2009     

Surgical margins in head and neck cancer: A contemporary review

Adequate resection margins are critical to the treatment decisions and prognosis of patients with head and neck squamous cell carcinoma (HNSCC). However, there are numerous controversies regarding reporting and interpretation of the status of resection margins. Fundamental issues relating to the basic definition of margin adequacy, uniform reporting standards for margins, optimal method of specimen dissection, and the role of intraoperative frozen section evaluation, all require further clarification and standardization. Future horizons for margin surveillance offer the possible use of novel methods such as “molecular margins” and contact microscopic endoscopy, However, the limitations of these approaches need to be understood. The goal of this review was to evaluate these issues to define a more rational, standardized approach for achieving resection margin adequacy for patients with HNSCC undergoing curative resection. © 2012 Wiley Periodicals, Inc. Head Neck, 2013     

Chemotherapy and targeted therapy in adenoid cystic carcinoma of the head and neck: A review

Adenoid cystic carcinoma (ACC) is an uncommon tumor usually arising in the head and neck region, mainly in the salivary glands. It demonstrates an indolent prolonged course and is characterized by perineural invasion. Primary treatment of local and locoregional disease consists mainly of surgery and/or irradiation. During follow‐up these patients frequently develop local recurrences and distant metastases, especially in the lung, although long‐term survival is possible. The role of chemotherapy in ACC is limited, and studies with only a limited number of patients are performed. In this article we review the literature on chemotherapy regimens, including monotherapy and combination chemotherapy schedules, as well as the new targeted therapies. © 2010 Wiley Periodicals, Inc. Head Neck, 2011