Objectives/Hypothesis: To determine the diagnostic accuracy and the ideal timing of 18fluoro‐fluorodeoxyglucose positron‐emission tomography (PET) in the posttreatment surveillance of head and neck ...mucosal squamous cell carcinoma (HNSCC).
Study Design: Retrospective chart review.
Methods: Our sample includes 103 adult patients with 118 posttreatment PET scans who had undergone treatment for HNSCC. We correlated PET results with surgical pathology and clinical outcome in the subsequent 6 months.
Results: For the detection of locoregional persistent or recurrent HNSCC, PET scans had a sensitivity of 82%, specificity of 92%, positive predictive value (PPV) of 64%, negative predictive value (NPV) of 97%, and overall accuracy of 90%. For the detection of distant metastases, PET scans had a sensitivity of 89%, specificity of 97%, PPV of 85%, NPV of 98%, and overall accuracy of 96%. PET scans of the head and neck region performed greater than 1 month after the completion of radiation compared with scans performed within 1 month had a significantly higher sensitivity of 95% versus 55% (P < .01) and NPV of 99% versus 90% (P < .01).
Conclusion: PET is effective in detecting distant metastases in the posttreatment surveillance for HNSCC patients. A negative PET is highly reliable for all sites. However, a positive PET in the head and neck region is unreliable because of a high false‐positivity rate. PET of the head and neck region has a statistically significant risk of a false‐negative reading when performed within 1 month of radiation.
Summary Local control of nasopharyngeal carcinoma has substantially improved with advancing radiotherapy technology and appropriate combination with chemotherapy. However, when local recurrence ...occurs, this is one of the most difficult challenges. Aggressive treatment is indicated because long term salvage is achievable particularly for early recurrence, but high risk of complications is a serious concern. Treatment options include different methods of surgery and/or re-irradiation with/without chemotherapy. Available information in the literature is grossly inadequate; most reports compose of small series of highly selected patients with heterogeneous characteristics and treatment. No randomized trials have been performed to evaluate the therapeutic ratio of different treatment methods. This article reviews available treatment options, their therapeutic benefits and risks of complications; the objective is to provide information for developing treatment recommendations and suggestions for future improvement.
Despite modern radiotherapy and open surgical techniques, treatment of recurrent nasopharyngeal carcinoma (NPC) remains challenging, with substantial morbidity involved. Targeted endoscopic ...nasopharyngectomy was evaluated as a viable oncologic alternative to open nasopharyngectomy or radiation for recurrent NPC.
Thirteen patients who underwent endoscopic nasopharyngectomy for recurrent NPC between August 2005 and August 2010 were retrospectively reviewed. Average age at surgery was 55.7 years, with mean follow-up period 24.2 months. Two-year disease-free survival, 2-year overall survival, margin status, and complication rate were measured.
Including resections for subsequent recurrences, 19 endoscopic procedures were performed with curative intent. Mean operating room (OR) time was 278 minutes, mean estimated blood loss was 197 mL, and mean length of hospitalization was 1.0 days. Negative margins were obtained in 78.9% of procedures: positive margins involved the parapharyngeal space, oropharynx, fossa of Rosenmuller, and infratemporal fossa. Stereotactic radiation was given postoperatively for localized positive margins. Four patients required repeat endoscopic nasopharyngectomy for re-recurrence, despite having their margins cleared or controlled with adjuvant treatment. Two-year local disease-free and overall survival rates were 69.2% and 100.0%, respectively. The overall minor complication rate was 52.6%, with no major complications.
Targeted endoscopic nasopharyngectomy is beneficial in locally recurrent NPC, with favorable morbidity and complication rates. Endoscopic surveillance and serial imaging together facilitate the early identification of re-recurrences, which often may be treated with additional directed resection. Postoperative stereotactic radiation may serve as an appropriate adjunct modality for disease control at positive margins.
Objectives: To study the long‐term quality of life outcomes of a group of unselected patients for the long‐term effects of uvulopalatopharyngoplasty (UPPP).
Study Design: Retrospective chart review ...and telephone survey.
Methods: Forty‐nine patients who underwent UPPP between July 1980 and July 1983 and who had their medical records were reviewed and were asked to grade on a visual analogue scale (VAS) the clinical benefits and complications of UPPP after the surgery.
Results: Forty‐three (87.8%) males and six (12.2%) female patients were studied. Improvement in snoring, excessive daytime somnolence, and nocturnal arousals were seen after UPPP with decreased effectiveness after time. The most common complication of UPPP was velopharyngeal insufficiency (VPI) (28.5%); however, dry throat and swallowing difficulty tended to be more severe in those patients who had them. No correlation between the snoring and VPI VAS grades was observed. Forty‐three patients had a preoperative sleep study and 22 patients a postoperative sleep study. There was lack of correlation between the significant subjective clinical improvement and their postoperative polysomnography.
Conclusion: When undertaking UPPP, both subjective and objective benefits should be weighed against the risk of long‐term ill effects. Patients should also be warned that the long‐term side effects such as VPI, dry throat, and abnormal swallowing sensation might be more common than previously expected.
To determine long-term outcomes in patients receiving stereotactic radiotherapy (SRT) as a boost after external beam radiotherapy (EBRT) for locally advanced nasopharyngeal carcinoma (NPC).
Eight-two ...patients received an SRT boost after EBRT between September 1992 and July 2006. Nine patients had T1, 30 had T2, 12 had T3, and 31 had T4 tumors. Sixteen patients had Stage II, 19 had Stage III, and 47 had Stage IV disease. Patients received 66 Gy of EBRT followed by a single-fraction SRT boost of 7-15 Gy, delivered 2-6 weeks after EBRT. Seventy patients also received cisplatin-based chemotherapy delivered concurrently with and adjuvant to radiotherapy.
At a median follow-up of 40.7 months (range, 6.5-144.2 months) for living patients, there was only 1 local failure in a patient with a T4 tumor. At 5 years, the freedom from local relapse rate was 98%, freedom from nodal relapse 83%, freedom from distant metastasis 68%, freedom from any relapse 67%, and overall survival 69%. Late toxicity included radiation-related retinopathy in 3, carotid aneurysm in 1, and radiographic temporal lobe necrosis in 10 patients, of whom 2 patients were symptomatic with seizures. Of 10 patients with temporal lobe necrosis, 9 had T4 tumors.
Stereotactic radiotherapy boost after EBRT provides excellent local control for patients with NPC. Improved target delineation and dose homogeneity of radiation delivery for both EBRT and SRT is important to avoid long-term complications. Better systemic therapies for distant control are needed.
Objectives/Hypothesis:
To clarify the extent and patient perspectives of great auricular nerve (GAN) morbidity and recovery after nerve sacrifice during parotidectomy 4 to 5 years after surgery.
...Study Design:
Prospective series.
Methods:
Twenty‐two patients who underwent parotidectomy with GAN sacrifice and were previously studied for GAN sensory outcome during the first postoperative year. We performed light touch sensation tests on each patient to develop an ink map representing anesthesia and paresthesia in the GAN sensory territory; patients also completed an outcomes questionnaire.
Results:
Nineteen (86%) of 22 patients completed follow‐up. One patient completed the questionnaire over the phone. The prevalence and average areas of anesthesia and paresthesia decreased since the first postoperative year according to sensory testing and patient scoring. At 4 to 5 years, 47% (9 of 19) of the patients had anesthesia, 58% (11 of 19) had paresthesia, and 26% (5 of 19) had neither anesthesia nor paresthesia during sensory testing. Patients reported that the GAN dysfunction brought them no to mild inference with their daily activities. At a mean point of 2 years, 70% (14 of 20) patients felt that their sensory symptoms had either completely abated or stabilized.
Conclusions:
The posterior branch of the GAN should be preserved if it does not compromise tumor resection. If this is not possible, the patient and surgeon should be comforted in that only minor, if any, long‐term disability will ensue. Laryngoscope, 2009
To assess the role of a planned neck dissection (PND) after sequential chemoradiotherapy for patients with head-and-neck cancer with N2-N3 nodal disease.
We reviewed 90 patients with N2-N3 ...head-and-neck squamous cell carcinoma treated between 1991 and 2001 on two sequential chemoradiotherapy protocols. All patients received induction and concurrent chemotherapy with cisplatin and 5-fluorocuracil, with or without tirapazamine. Patients with less than a clinical complete response (cCR) in the neck proceeded to a PND after chemoradiation. The primary endpoint was nodal response. Clinical outcomes and patterns of failure were analyzed.
The median follow-up durations for living and all patients were 8.3 years (range, 1.5-16.3 year) and 5.4 years (range, 0.6-16.3 years), respectively. Of the 48 patients with nodal cCR whose necks were observed, 5 patients had neck failures as a component of their recurrence neck and primary (n = 2); neck, primary, and distant (n = 1); neck only (n = 1); neck and distant (n = 1). Therefore, PND may have benefited only 2 patients (4%) neck only failure (n = 1); neck and distant failure (n = 1). The pathologic complete response (pCR) rate for those with a clinical partial response (cPR) undergoing PND (n = 30) was 53%. The 5-year neck control rates after cCR, cPR→pCR, and cPR→pPR were 90%, 93%, and 78%, respectively (p = 0.36). The 5-year disease-free survival rates for the cCR, cPR→pCR, and cPR→pPR groups were 53%, 75%, and 42%, respectively (p = 0.04).
In our series, patients with N2-N3 neck disease achieving a cCR in the neck, PND would have benefited only 4% and, therefore, is not recommended. Patients with a cPR should be treated with PND. Residual tumor in the PND specimens was associated with poor outcomes; therefore, aggressive therapy is recommended. Studies using novel imaging modalities are needed to better assess treatment response.
Objectives/Hypothesis: The objective was to compare and contrast the functional and cosmetic outcomes of patients who underwent total parotidectomy with and without reconstruction using an inferiorly ...based sternocleidomastoid muscle flap.
Study Design: Retrospective review in the setting of a university medical center.
Methods: Twenty‐four patients underwent a total parotidectomy. Fifteen patients had reconstruction with an inferiorly based sternocleidomastoid muscle flap, and nine patients had no reconstruction. Clinical examination was performed independently by two head and neck surgeons and one aesthetician to evaluate cosmetic outcome, presence of gustatory flushing or sweating, and return of facial nerve and greater auricular nerve function.
Results: With the mean follow‐up of 22 months, the group having reconstruction showed a better cosmetic outcome compared with the group without reconstruction. Objective testing for Frey syndrome demonstrated gustatory sweating in 20% of the group having reconstruction group versus 22% in the group without reconstruction. There was no difference in length of operation, hospital stay, or facial nerve function. Objective testing of facial sensation revealed that only 40% in the group having reconstruction had normal sensation to light touch compared with 78% in the group without reconstruction.
Conclusion: The inferiorly based sternocleidomastoid muscle flap offers improved cosmetic results in patients undergoing total parotidectomy. However, there is a decreased return of greater auricular nerve function, probably attributable to relocation of the nerve stump anteriorly. Benefit was not seen in prevention of Frey syndrome measured objectively; however, the group having reconstruction had fewer clinical symptoms of gustatory sweating or flushing.
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