Anlotinib in Locally Advanced or Metastatic Radioiodine-Refractory Differentiated Thyroid Carcinoma: A Randomized, Double-Blind, Multicenter Phase II Trial

PURPOSE

Alhough antiangiogenic agents are the bedrock of treatment for radioiodine-refractory differentiated thyroid carcinoma (RAIR-DTC), novel antiangiogenic agents with optimized features like greater target-binding affinities and more favorable pharmacokinetics profile are needed. This phase II randomized, double-blind, placebo-controlled trial investigated the efficacy and safety of anlotinib, a multikinase inhibitor, for RAIR-DTC.

PATIENTS AND METHODS

Patients (ages between 18 and 70 years) with pathologically confirmed locally advanced or metastatic RAIR-DTC were enrolled and randomly received 12 mg anlotinib once daily or placebo on day 1 to 14 every 3 weeks. Patients on placebo were allowed to receive open-label anlotinib after disease progression. The primary endpoint was progression-free survival (PFS). The secondary endpoints included overall survival (OS) and safety.

RESULTS

Between September 2015 and August 2018, 76 and 37 patients randomly received anlotinib and placebo, respectively. Patients receiving anlotinib had a significantly longer median PFS [40.5 months, 95% confidence interval (CI), 28.3-not estimable (NE) versus placebo 8.4 months, 95% CI, 5.6-13.8; HR = 0.21, 95% CI, 0.12-0.37, P < 0.001], meeting the primary endpoint. OS was still immature, with a trend of benefit with anlotinib (HR = 0.57, 95% CI, 0.29-1.12). All patients in the anlotinib group experienced adverse events (AE); 8 (10.5%) discontinued treatment due to AEs.

CONCLUSIONS

Anlotinib demonstrated promising efficacy and favorable tolerance in the treatment of locally advanced or metastatic RAIR-DTC, supporting further research to establish its role in the treatment of this serious disease.

Anlotinib in patients with medullary thyroid carcinoma with negative prognostic factors: A sub-analysis based on the ALTER01031 study

BACKGROUND

Medullary thyroid carcinoma (MTC) is a rare type of thyroid cancer; however, it accounted for 13.4% of the disease-specific mortalities. ALTER01031 (NCT02586350) was a randomised, placebo-controlled phase 2b trial that evaluated the efficacy and safety of anlotinib in locally advanced or metastatic MTC. This post hoc analysis aimed to evaluate the efficacy and safety of anlotinib in older patients and those with bone metastases using ALTER01031.

METHODS

In ALTER01031, anlotinib significantly prolonged the median progression-free survival (PFS) from 11.1 months to 20.7 months compared with placebo in the whole population. Patients who were older (≥ 50 years) or had bone metastases were selected. PFS and overall survival (OS) were estimated and compared between patients receiving anlotinib or placebo in each subgroup. A sub-analysis of tumour response and safety was also performed.

RESULTS

Patients with older age or bone metastases experienced rapid disease progression as the median PFS was 6.8 months and 7.0 months respectively in the placebo group. Anlotinib significantly improved the median PFS to 17.5 months (P = 0.002) and 20.7 months (P = 0.029) with hazard ratio (HR) of 0.31 (95% CI, 0.15-0.68) and 0.44 (95% CI, 0.20-0.94) compared with placebo. Significant benefit in OS was observed in patients with older age after a longer follow-up (HR = 0.47 [95% CI, 0.22-0.99], P = 0.041). The safety profile of these subgroups was similar to that of the entire population.

CONCLUSION

This sub-analysis demonstrated significant survival benefits and favourable safety of anlotinib in patients with MTC who had old age or bone metastases, supporting the feasibility of anlotinib in these patients.

Anlotinib in radioiodine-refractory differentiated thyroid carcinoma: A subanalysis based on ALTER01032 study for patients with poor baseline characteristics

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Background: Anlotinib (anlo), a multikinase inhibitor, has demonstrated a significant survival benefit in treating locally advanced or metastatic radioiodine-refractory differentiated thyroid carcinoma (RAIR-DTC) with a nearly 4 folds prolongation in median progression-free survival (mPFS) (HR = 0.21, p < 0.0001) compared with placebo in a randomized, placebo-controlled phase 2 study (ALTER01032, NCT02586337). Older age, bone metastasis, structural progression within a short time are generally indicated as negative prognostic factors for thyroid cancer. This subanalysis explored the outcomes of patients (pts) enrolled in ALTER01032 study with these poor baseline characteristics. Methods: 113 pts were enrolled, 76 in anlo arm and 37 in placbo arm. The primary endpoint is PFS. Pts with older age (≥ 55), bone metastasis or radiographic documented disease progression within 3 months (mo) before enrollment were selected. The PFS and overall survival (OS) for these pts were estimated and compared. Since 64.9% pts in placebo arm received crossover treatment with open label anlo after progression while only 3 pts in anlo arm received post-study treatment, the penitential bias for OS from imbalance of subsequent treatment was adjusted by a two-stage estimation method. Results: The results of subanalysis were summarized in the table below. Pts with poor baseline characteristics showed higher risk of progression and death. Significant PFS prolongation was shown across all subgroups in pts received anlo compared with their counterparts who received placebo ( P < 0.05). In pts with bone metastasis or structural progression within 3 mo, anlo treatment achieved significant OS benefit ( P < 0.05). Also, in older pts, a trend of OS improvement was observed (HR = 0.85 (95% CI 0.37, 1.97)). Most pts in placebo arm received crossover anlo. After adjustment, a near-significant decrease of death risk was observed in older pts received anlo compared with those received placebo (HR = 0.48 (95% CI 0.20, 1.13)). Conclusions: This subanalysis showed anlo effectively improved both PFS and OS of pts with RAIR-DTC who have poor baseline characteristics above. Interestingly, although most pts in placebo arm received crossover anlo, they still have higher risk of death, indicating the importance of earlier treatment for these pts. Clinical trial information: NCT02586337. [Table: see text]

Anlotinib in Locally Advanced or Metastatic Medullary Thyroid Carcinoma: A Randomized, Double-Blind Phase IIB Trial

PURPOSE

Medullary thyroid cancer (MTC) accounts for about 2% of all thyroid cancer, but has a relatively poor prognosis compared with differentiated thyroid cancer. Anlotinib is a novel multitarget tyrosine kinase inhibitor targeting VEGFR, PDGFR, FGFR, and c-Kit. This multicenter, randomized, double-blind, placebo-controlled phase IIB study (ALTER 01031 and NCT02586350) was conducted to investigate the efficacy and safety of anlotinib in MTC.

PATIENTS AND METHODS

Patients with histopathologically confirmed, unresectable locally advanced or metastatic MTC were enrolled and randomly assigned in a 2:1 ratio to receive anlotinib (12 mg once daily from day 1 to 14 every 3 weeks) or placebo. Patients in placebo group were allowed to receive open-label anlotinib after disease progression. The primary endpoint was progression-free survival (PFS); secondary endpoints included objective response rate (ORR), disease control rate (DCR), and overall survival (OS).

RESULTS

Ninety-one patients were enrolled. At data cutoff date, the median PFS was significantly prolonged in the anlotinib group than in the placebo group (20.7 months vs. 11.1 months, P = 0.029; HR, 0.53; 95% confidence interval, 0.30-0.95). The ORR of anlotinib treatment was 48.4%. The incidence of treatment-related adverse events (TRAE) was 100% and 89.7% in the anlotinib and placebo groups, respectively. The most common TRAEs of all grades in the anlotinib group were palmar-plantar erythrodysesthesia syndrome (62.9%), proteinuria (61.3%), and hypertriglyceridemia (48.4%).

CONCLUSIONS

Anlotinib demonstrates its efficacy and safety in this phase IIB trial for the treatment of MTC and may become a new choice for this rare disease, especially for Chinese patients.

Surufatinib in Chinese Patients with Locally Advanced or Metastatic Differentiated Thyroid Cancer and Medullary Thyroid Cancer: A Multicenter, Open-Label, Phase II Trial

Background: Thyroid cancer is the most common endocrine tumor with an increasing incidence. Limited treatment options are available for patients with advanced or recurrent metastatic disease, resulting in a poor prognosis. Surufatinib targets multiple kinases (vascular endothelial growth factor receptors, fibroblast growth factor receptor-1, and colony-stimulating factor-1 receptor) involved in tumor angiogenesis and tumor immune evasion. Surufatinib has demonstrated promising antitumor activity in various advanced solid tumors. This study aimed to determine the objective response rate (ORR) of surufatinib in patients with locally advanced or distant metastatic differentiated thyroid cancer (DTC) or medullary thyroid cancer (MTC). Methods: This Phase II open-label study by Simon's two-stage design was conducted at 10 sites across China. Patients with radioiodine (RAI)-refractory DTC with locally advanced disease or distant metastasis (DTC1 group); patients who received limited initial surgery and then developed locally advanced unresectable recurrences and were not considered candidates for RAI therapy due to residual normal thyroid tissue (DTC2 group); or patients with MTC with locally advanced disease or distant metastasis (MTC group) were enrolled. A total of 59 patients were enrolled (26 in DTC1, 6 in DTC2, and 27 in MTC) and received 300 mg surufatinib daily in 28-day cycles. The primary endpoint was ORR as determined by the investigators. Results: Overall ORR was 23.2% [95% confidence interval, CI 12.98-36.42]: 21.7% in the DTC1 cohort, 33.3% in the DTC2 cohort, and 22.2% in the MTC cohort. Forty-nine patients achieved disease control (87.5% [CI 75.93-94.82]): 87.0% in the DTC1 cohort, 83.3% in the DTC2 cohort, and 88.9% in the MTC cohort. Median time to response was 59.0 days, and 59.0, 85.5, and 59.0 days in the DTC1, DTC2, and MTC cohorts. Overall median progression-free survival was 11.1 months [CI 5.98-16.69]; 11.1 months in DTC1 and MTC cohorts, while the DTC2 cohort had not reached the median at the data cutoff. The most common treatment-emergent adverse events grade ≥3 were hypertension (20.3%), proteinuria (11.9%), and then elevated blood pressure, hypertriglyceridemia, and pulmonary inflammation (5.1% each). Conclusions: Surufatinib demonstrated promising efficacy with a tolerable and manageable safety profile for patients with locally advanced or metastatic MTC, RAI-refractory DTC, or locally advanced unresectable recurrences unable to receive RAI.

Association between calcitonin and efficacy of anlotinib in medullary thyroid carcinoma: An analysis based on the ALTER01031 trial

6526

Background: Calcitonin (Ct) is the most important biomarker for medullary thyroid carcinoma (MTC). In a randomized, placebo-controlled phase IIb trial (ALTER01031, NCT02586350) for MTC, anlotinib exhibited a strong capability not only in PFS prolongation but also in decreasing Ct level. This subanalysis explored the relationship between Ct level and anlotinib efficacy in this trial. Methods: Serum Ct of patients (pts) were tested at baseline and on week 6 (after 2 treatment cycles). Correlation between changes in Ct level and changes in target lesion diameters was explored. The influence of baseline Ct level on median PFS for anlotinib treated pts was estimated. Finally, pts in anlotinib arm were divided into two subgroups based on the percentage decline of Ct levels (> 50% vs. ≤50%) at week 6. Median PFS (mPFS), median OS (mOS) and objective response rate (ORR) of two groups were compared. Results: 86 of 91 enrolled pts (58 in anlotinib arm and 28 in placebo arm) were recorded their serum Ct levels at baseline and no significant difference was observed between two arms (7990.0 ng/L vs. 10891.5 ng/L, P = 0.192). After 2 treatment cycles, the Ct level decreased to 4597.5 ng/L in anlotinib arm (n = 50) while increased slightly in placebo arm (12640.0 ng/L, n = 24, P = 0.006). For 49 pts in anlotinib arm who had complete assessments at baseline and week 6, roughly linear relationship was observed between Ct levels (X-axis) and target lesion diameters (Y-axis) in percent changes from baseline to week 6 (y = 0.175x – 0.049; r = 0.352, P = 0.016, excluding 3 outliers). Pts with less baseline Ct level (≤ median value vs. > median value) did not show more PFS benefit (17.7 vs. 22.4 months, P = 0.802). However, after 2 treatment cycles, a trend of better survival and higher response was observed in pts with high percentage decline of Ct level (> 50%, n = 25) than those with low percentage decline (≤50%, n =25) although without statistical difference (data presented in the table below). Conclusions: In ALTER01031, anlotinib showed a strong capability in rapidly decreasing serum Ct. Lower baseline Ct level does not mean better prognosis while a rapid Ct decrease may predict improved survival and treatment response to MTC pts received anlotinib. Clinical trial information: NCT02586350 . [Table: see text]

Influence of Eastern Cooperative Oncology Group performance status (ECOG PS), tumor size and age on patient outcomes after anlotinib treatment: A subgroup analysis based on ALTER01031 trial for medullary thyroid carcinoma (MTC)

6527

Background: Anlotinib is a newly developed TKI achieved a nearly 2-fold PFS prolongation in a randomized, placebo-controlled phase 2b trial (NCT02586350) for MTC, the results of which were firstly published in 2019 ASCO annual meeting. This subanalysis examined the influence of baseline demographic (ECOG PS score, age) and tumor size on efficacy in this study. Methods: Kaplan-Meier method was applied to estimate the median PFS (mPFS) for subgroups of patients (pts) received anlotinib or placebo based on ECOG PS score (0 vs. 1), median tumor lesion diameter ( < 67 vs. ≥67mm) and age ( < 55 vs. ≥55 years old). Results: 91 eligible pts were randomly assigned in a 2:1 ratio to receive anlotinib or placebo. The numbers of pts in each subgroup were summarized in the table below. In placebo arm, mPFS did not differ significantly between pts with ECOG PS 0 and 1 (11.3 vs. 11.1months; HR = 0.895 [95% CI 0.347, 2.312], P = 0.821) or between pts with tumor lesion diameter < 67mm and ≥ 67mm (7.0 vs. 11.1 months; HR = 1.168 [95% CI 0.463, 2.945], P = 0.737). Conversely, pts in anlotinib arm with ECOG PS 0 obtained more PFS benefits (34.6 vs. 14.0 months; HR = 0.331 [95% CI 0.163, 0.671], P = 0.002). Similarly, anlotinib treated pts with tumor lesion diameters < 67mm achieved a longer mPFS (Not reached vs. 14.0 months, HR = 0.567 [95% CI 0.280, 1.147], P = 0.111). Consistent with that has been verified in differentiated thyroid cancer, high age predicted poor prognosis as mPFS were 14.3 months and 6.8 months in pts < 55 and ≥ 55 years old respectively in placebo arm (HR = 0.322 [95% CI 0.116, 0.893], P = 0.007).). Anlotinib treatment exhibited PFS improvement to pts in both age groups but higher PFS prolongation was observed in pts < 55 years old (22.4 vs. 14.0 months; HR = 0.720 [95% CI 0.321, 1.614], P = 0.381). Conclusions: This analysis showed that for pts in placebo arm, PFS was similar regardless of functional status (ECOG PS) or tumor size while older pts had higher progression risk. Treatment with anlotinib exhibited greater PFS benefits for pts with better functional status (ECOG PS = 0), younger age or lower tumor burden. These results indicated that it is reasonable to start anlotinib treatment at a relative earlier disease stage before the worsen of ECOG PS, increase of tumor size or ageing. Clinical trial information: NCT02586350 . [Table: see text]

Exploration of associations between adverse drug reactions and clinical outcomes in anlotinib treatment against medullary thyroid carcinoma (MTC): A subgroup analysis based on the ALTER01031 trial

e18518

Background: Anlotinib demonstrated favorable efficacy in a randomized, placebo-controlled phase 2b trial (ALTER01031, NCT02586350) for MTC which was published in 2019 ASCO annual meeting. Similar with other anti-angiogenesis drugs, hand-foot syndrome (HFS), hypertension and proteinuria were the major adverse drug reactions (ADRs) observed in this trial. We explored the association between common ADRs and the clinical outcomes with anlotinib in this subanalysis. Methods: Patients in the anlotinib group of ALTER01031 were divided into different groups according to the development of ADRs including HFS, hypertension or proteinuria. Kaplan-Meier method was used to estimate median PFS (mPFS) for patients in different groups. The mPFS for patients with or without dose reduction were also evaluated. Results: A total of 62 patients received anlotinib in ALTER 01031. HFS of any grade was observed in 39 patients with a mPFS of 28.5 months, which was longer than in those without HFS (14.0 months, P = 0.079). The hazard ratio for progression was 0.540 (95% CI 0.252, 1.158) although statistical difference was not reached. Similarly, more survival benefit was also observed in 29 and 38 patients who experienced hypertension and proteinuria, with mPFS of 28.5 months and 22.4 months respectively. While the mPFS for patients without corresponding ADRs were only 17.0 months (HR = 0.648 [95% CI 0.320, 1.314], P = 0.237) and 14.0 months (HR = 0.738 [95% CI 0.331, 1.65], P = 0.421). Median PFS had not been reached in 20 patients with dose reduction while was recorded as 17.0 months in those without (HR = 0.707 [95% CI 0.335, 1.496], P = 0.392). Conclusions: This analysis indicated a trend of greater PFS benefit for MTC patients treated with anlotinib who experienced HFS, hypertension or proteinuria although no statistical differences were observed. A possible positive association was also observed between dose reductions and better clinical outcomes. Clinical trial information: NCT02586350.

Afatinib versus methotrexate as second-line treatment in Asian patients with recurrent or metastatic squamous cell carcinoma of the head and neck progressing on or after platinum-based therapy (LUX-Head & Neck 3): an open-label, randomised phase III trial

BACKGROUND

Treatment options are limited for patients with recurrent or metastatic squamous cell carcinoma of the head and neck (HNSCC) following progression after first-line platinum-based therapy, particularly in Asian countries.

PATIENTS AND METHODS

In this randomised, open-label, phase III trial, we enrolled Asian patients aged ≥18 years, with histologically or cytologically confirmed recurrent/metastatic HNSCC following first-line platinum-based therapy who were not amenable for salvage surgery or radiotherapy, and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0/1. Patients were randomised (2 : 1) to receive oral afatinib (40 mg/day) or intravenous methotrexate (40 mg/m2/week), stratified by ECOG performance status and prior EGFR-targeted antibody therapy. The primary end point was progression-free survival (PFS) assessed by an independent central review committee blinded to treatment allocation.

RESULTS

A total of 340 patients were randomised (228 afatinib; 112 methotrexate). After a median follow-up of 6.4 months, afatinib significantly decreased the risk of progression/death by 37% versus methotrexate (hazard ratio 0.63; 95% confidence interval 0.48-0.82; P = 0.0005; median 2.9 versus 2.6 months; landmark analysis at 12 and 24 weeks, 58% versus 41%, 21% versus 9%). Improved PFS was complemented by quality of life benefits. Objective response rate was 28% with afatinib and 13% with methotrexate. There was no significant difference in overall survival. The most common grade ≥3 drug-related adverse events were rash/acne (4% with afatinib versus 0% with methotrexate), diarrhoea (4% versus 0%), fatigue (1% versus 5%), anaemia (<1% versus 5%) and leukopenia (0% versus 5%).

CONCLUSIONS

Consistent with the phase III LUX-Head & Neck 1 trial, afatinib significantly improved PFS versus methotrexate, with a manageable safety profile. These results demonstrate the efficacy and feasibility of afatinib as a second-line treatment option for certain patients with recurrent or metastatic HNSCC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01856478.

Three-dimensional character of the deformation twin in magnesium

Deformation twins are three-dimensional domains, traditionally viewed as ellipsoids because of their two-dimensional lenticular sections. In this work, we performed statistical analysis of twin shapes viewing along three orthogonal directions: the 'dark side' (DS) view along the twin shear direction (η₁), the twinning plane normal (TPN) view (k₁) and the 'bright side' (BS) view along the direction λ(=k₁ × η₁). Our electron back-scatter diffraction results show that twins in the DS and BS views normally exhibit a lenticular shape, whereas they show an irregular shape in the TPN view. Moreover, the findings in the TPN view revealed that twins grow faster along λ the lateral direction than along η₁ the forward propagation direction at the initial stages of twin growth. These twin sections are irregular, indicating that growth is locally controlled and the overall shape is not perfectly ellipsoidal. We explain these findings using atomistic models, and ascribe them to differences in the mobility of the edge and screw components of the twinning dislocations.

[Efficacy and safety of vandetanib on advanced medullary thyroid carcinoma: single center result from a phase Ⅲ study]

Objective: There is no effective therapy for patients with advanced medullary thyroid carcinoma (MTC). Vandetanib,a novel multitargeted receptor tyrosine kinase inhibitor, has previously shown antitumor activity in phase Ⅱ studies of patients with advanced MTC. This study was to evaluate the efficacy and the safety of vandetanib on advanced MTC. Methods: This study was an open, international multi-center phase Ⅲ clinical trial and the study number was NCT01298323. The single-center study was a sub-group analysis of the international study, which was conducted on 9 pathologically confirmed advanced MTC patients by Cancer Hospital Chinese Academy of Medical Sciences between March 2012 and October 2017. Vandetanib (300 mg) was orally administered daily till death or withdrawal. The efficacy was evaluated according to RECIST criteria and the adverse events were evaluated according to NCI criteria. Results: The objective response rate was 3/9,and the disease control rate was 4/9. The median progression-free survival was 44 months. All patients who had the elevated levels of calcitonin (CTN) and carcino-embryonic antigen (CEA) before treatment began to show the decreases in the level of CTN and CEA after 3 months and later showed again the increases in the levels of both tumor markers with tumor progression. By ROC curve analysis, CTN was of statistically significance(P<0.05, 95%CI 0.558-0.834), but CEA was not(P>0.05). Adverse events were generally mild (grade 1 or 2),including hypertension (9 cases),skin rash (9 cases), and diarrhea (6 cases). Two patients developed grade 3 elevation of serum glutamate pyruvate transaminase and one patient developed grade 3 elevation of drug-related bowel disease. No grade 4 drug-related adverse event occurred. Conclusions: Vandetanib is effective and well tolerated for patients with locally advanced or metastatic MTC who have no chance for surgery. This indicates the increase of CTN is clinically relevant to disease progression, but the number of patients are extremely low, and, therefore further research is needed. Long-term use of vandetanib may cause resistance.

Anlotinib for the Treatment of Patients with Locally Advanced or Metastatic Medullary Thyroid Cancer

BACKGROUND

The prognosis of advanced or metastatic medullary thyroid carcinoma (MTC) is poor, and there are few therapeutic options. Anlotinib has previously shown promising antitumor activity on MTC in preclinical models and a Phase I study. This Phase II clinical trial was devised to confirm the antitumor activity of anlotinib in patients with advanced or metastatic MTC.

METHODS

Patients with unresectable locally advanced or metastatic MTC received once daily oral anlotinib 12 mg, two weeks on/one week off, until disease progression, death, unacceptable toxicity, or withdrawal of consent for any reason. The dose was adjusted on the basis of observed toxicity. The primary endpoint was progression-free survival (PFS).

RESULTS

Fifty-eight patients received anlotinib treatment. The primary endpoint PFS has not yet been reached at the time of analysis. On the basis of investigator assessments, 56.9% of patients experienced a partial response. PFS rate at 48 weeks was 85.5%. Forty-five patients had a ≥50% decrease in serum calcitonin concentration from baseline. The most common adverse events were hand-foot syndrome, hypertriglyceridemia, cholesterol elevation, fatigue, and proteinuria.

CONCLUSIONS

Anlotinib demonstrated a durable antitumor activity with a manageable adverse event profile in locally advanced or metastatic MTC.

[Dye-tattooing under ultrasound guidance in preoperative localization of neck recurrences from thyroid cancer]

Objective: To evaluate the efficacy and safety of the application of dye-tattooing under ultrasound guidance in preoperative localization of neck recurrences from thyroid cancer. Methods: Between October 2014 to September 2016, 25 patients with 34 lesions were enrolled. There were 22 cases of papillary thyroid carcinoma and three cases of medullary thyroid carcinoma, all of which could not be detected by computed tomography. Surgeons located the recurrent lesions using dye-tattooing under ultrasound guidance along with radiologist three days before the operation. Results: All lesions were successfully located (100%), 32 of which were located directly and two of which were located indirectly. Postoperative pathological examination confirmed 25 metastases of papillary thyroid carcinoma, two metastases of medullary thyroid carcinoma, and seven cases of false positives. The accuracy of ultrasound diagnosis was 79.4%. After 15 months of follow-up, neither tumor residual nor recurrences was detected according to imaging tests. Conclusions: Dye-tattooing under ultrasound guidance represents a reliable and safe method for localization of neck recurrences from thyroid cancer. The cooperation between experienced surgeons and radiologists will be crucial to successful location.

[Management of T3 supraglottic carcinoma: a retrospective study]

Objective: To discuss the strategy of therapeutic management of T3 supraglottic carcinoma. Methods: A retrospective analysis of 459 patients with T3 supraglottic carcinoma treated in our hospital was performed. We evaluated the results of different managements, including surgery alone, preoperative radiotherapy, postoperative radiotherapy and radiotherapy alone. The extent of the lesion was also put into analysis. Statistical analysis of the overall survival (OS), cause-specific survival (CSS), local control (LC), regional control(RC), function-conservation (FC) were performed with the statistical package from SPSS. Results: In all patients, the rates of 5-year OS, CSS, LC, RC and FC were 64.2%, 71.2%, 87.8%, 78.8% and 64.5% respectively. The OS, LC and FC of the patients treated by surgery alone, preoperative radiotherapy and postoperative radiotherapy had no significant difference, and were remarkably better than that of patients treated by radiotherapy alone (P<0.001). In 412 patients treated by surgery, 300 patients received function-conservation laryngectomy. 209 patients (50.7%, 209/412) survived and maintained well-function of larynx for 5 years, which was significantly better than those in the radiotherapy alone group (27.7%, 13/47). The patients with the lesion invading the pre-epiglottic space but limited in supraglottic area had better OS (70.2%), LC (93.5%) and FC (85.1%). The rate of 5-year neck lymphatic metastasis was 56.2%(258/459), and the 5-year OS of patients with N0, N1, N2 and N3 stage were 76.0%, 66.2%, 50.5% and 13.0% respectively. Conclusions: Surgical treatment was the best therapeutic approach for T3 supraglottic laryngeal carcinoma. Most patients with T3 lesions are suitable for function-conservation laryngectomy. Surgical procedure was determined by tumor invaded location and extension. The combined therapy of surgery and radiotherapy had no significant advantage.

[Clinical analysis of secondary cervical lymph node dissection in papillary thyroid carcinoma]

Objective: To investigate the value of secondary cervical lymph node dissection in papillary thyroid carcinoma (PTC). Methods: PTC patients with recurrence re-operated in a previously dissected area at our hospital during 2000-2016 were included in this analysis. Patients were divided according to the operative interval of 6 months. The level and number of lymph node metastasis and the number of lymph node dissection were analyzed to calculate the ratio of lymph node metastasis. Results: A total of 336 PTC patients received 360 side lateral cervical lymph nodes dissection. The ratio of recurrence in unilateral lateral neck is 92.9%(312/336). The ratio of recurrence in multiple levels (more than two regions) were 47.5% (171/360). The recurrence ratio of level Ⅱ, Ⅲ, Ⅳ and Ⅴ were 55.6%(200/360), 44.2%(159/360), 59.7%(215/360) and 10.3%(37/360), respectively. Lymph node metastases were inclined to level Ⅱ (33.6%) and Ⅳ (35.8%). The mean number of lymph node dissection and metastasis in the group of operative interval ≤ 6 months was 26.56 per case and 4.37 per case, respectively. The mean number of lymph node dissection and metastasis in the group of operative interval >6 months was 16.80 per case and 3.20 per case, respectively. The number of lymph node dissection and metastasis between these two groups were significantly different (P=0.001, P<0.001). Conclusions: Lymph node metastasis of PTC patients with secondary cervical lymph node dissection are inclined to level Ⅱ and level Ⅳ. Moreover, multi-level metastasis is not rare. Level Ⅱ and level Ⅳ require more attention in the first operation. Most of the patients undergo reoperation because of residual lymph nodes from the previous treatment. Normalization and completeness of the initial dissection are particularly important to PTC patients.

[Clinical features of postoperative cervical lymph nodes recurrence in papillary thyroid carcinoma]

Objective: To analyse the postoperative metastasis or recurrence of cervical lymph nodes in individual neck levels for papillary thyroid carcinoma and to evaluate the outcomes and complications of re-surgery. Methods: A retrospective cohort study of 259 patients who underwent lymph node dissection for PTC relapse from January 2010 to June 2011. Lymph node metastases in each of neck levels were detected, postoperative complications were evaluated, and the patients were followed up with examining thyroglobulin levels to assess the therapeutic effect.Continuous variables were compared with t test.Categorical variables were compared with Fisher's exact test. Results: Lymph node metastasis was found in 259 cases and lymph node metastasis rates in levels Ⅱ, Ⅲ, Ⅳ, Ⅴ and Ⅵ were 43.2%, 50.2%, 45.6%, 8.1% and 59.1% respectively. In 44 cases received the neck dissection of level Ⅱ, the metastasis rates in the levels Ⅱa and Ⅱb were respectively (52.3% vs 18.2%, P=0.887). Recurrence in unilateral lateral neck was more common than that in bilateral lateral neck (73.1% vs 20.6%, P<0.001). The lymph nodes in lateral neck were more likely to metastasize than those in central region (80.7% vs 59.1%, P<0.001). There were 47 cases (18.1%) had postoperative complications, including 10 cases with permanent hypocalcemia. Conclusions: The scope of re-operation for neck metastasis or recurrence in papillary thyroid carcinoma should include the dissection of levels Ⅱ-Ⅳ and Ⅵ. The incidence of postoperative complications for re-surgery is high, and re-surgery should be performed by experienced surgeon.

Efficacy of Superselective Neck Dissection in Detecting Metastasis in Patients with cN0 Papillary Thyroid Carcinoma at High Risk of Lateral Neck Metastasis

Background

This study aimed to evaluate superselective neck dissection (SSND) in patients with cN0 papillary thyroid carcinoma (PTC) at high risk of lateral cervical lymph node (LN) metastasis.

Material/Methods

This study enrolled 138 patients with PTC who underwent SSND. These patients were at high risk for LN metastasis and the rate of cervical LN metastasis was recorded.

Results

In all, 146 lateral neck dissections were performed in 138 patients. Intraoperative pathological data revealed LN metastasis from 55 cases, for which Level II and V dissection were performed. Ninety SSNDs were performed in the other 83 patients without metastasis identified in frozen sections. Occult lymph node metastasis (OLNM) rates were 56.8% and 43.5% in the central compartment and lateral neck, respectively. OLNM rates of Level II–VI were 17.8%, 31.5%, 36.3%, 1.4%, and 56.8%, respectively. Level VI metastasis (p<0.001), extra thyroidal extension (p=0.003), and tumor size (p=0.011) were significant factors for lateral neck LN metastasis.

Conclusions

SSND might be effective for early diagnosis of lateral neck metastases of PTC. Patients with OLNM should receive level II, III, and IV dissection, but level V dissection could be omitted.

[Central compartment reoperation for recurrent/persistent differentiated thyroid cancer]

Objective: To analyze the incidences of complications after central compartment reoperation for recurrent/persistent differentiated thyroid cancer, and to investigate the safety and feasiblity of central compartment reoperation. Methord: A total of 109 patients who underwent central compartment reoperation for recurrent/persistent differentiated thyroid cancer from January 1, 2011 to March 31, 2016 in Cancer Hospital, Chinese Academy of Medical Sciences was analysed retrospectively, and the incidences of reoperation-related complications were evaluated. Results: Among 109 patients, only 10 (9.2%) patients were treated initially in our hospital and remaining patients (90.8%) treated initially in the other hospitals. Surgical approaches for thyroid beds: 61 patients (56.0%) underwent supplemented total thyroidectomy, 3 patients (2.8%) for removal of recurrent thyroid cancer, 2 patients (1.8%) with supplemented total thyroidectomy and removal of recurrent thyroid cancer, and 12 cases (11.0%) had bilateral thyroid lobectomy. Central compartment lymph node dissection: 66 patients (60.6%) underwent bilateral central neck dissection, 40 patients (36.7%) with unilateral central neck dissection. A total of 16 patients (14.7%) had complications. Transient and permanent vocal fold paralysis developed in 9(8.3%) and 2(1.8 %) patients, respectively. Transient and permanent hypoparathyroidism occurred in 2(1.8%) patients and 11 patients (10.1%), respectively. Postoperative bleeding happened in 1 patient (0.9%). with follow-up from 7 to 61 month, median follow-up was 17.2 months. All patients survived, with recurrence in 3 (2.8%) patients. Conclusions: It seems the incidences of complications for thyroid carcinoma reoperation in central compartment is low for the experienced surgeon. The reoperation was safe and feasible.

[Gastric pull-up reconstruction after pharyngoesphagectomy for advanced hypopharyngeal or cervical esophageal squamous cell carcinoma]

Objective: To analyze the clinical results of gastric pull-up reconstruction following total pharyngoesophagectomy. Methods: A total of 90 patients with hypopharyngeal or cervical esophageal cancinoma who underwent gatric pull-up reconstruction after pharyngoesophagectomy between June 2006 and June 2015 were reviewed retrospectively. Clinical data were analyzed. Rates of survival, recurrence and complicates were calculated with SPSS software. Results: Of 90 patients, 8 patients had hypopharyngeal cancinoma invading cervical esophagus, 51 patients had cervical esophageal carcinoma, and 31 patients had hypophageal and esophageal multiple parimary carcinomas. Forty patients were treated with surgery alone, 29 patients with planned surgery, and 21 patients with salvage surgery. After follow up of 6-104 months with a median of 22 months, 54 patients died and the total 3-year survival rate was 36.3%. Seventeen patients developed local recurrences and 10 patients cervical or mediastinal lymph node metastasis (LNM). The 3-year survival rates of patients with and without recurrence or LNM were respectively 5.9%, and 45.7% (χ²=11.564, P=0.001). Twenty-three patients developed distant metastasis. The 3-year survival rate of patients with and without distant metastasis were respectively 22.9% and 41.8% (χ²=4.534, P=0.033). Multivariate analysis showed local recurrence and distant metastasis as predictors for poor survival. The rates of perioperative mortality and anastomotic fistula were 3.3% (3/90) and 13.3%(12/90), respectively. Conclusions: Gastric pull-up reconstruction is a relatively safe and effective method for esophageal reconstruction after removal of hypopharyngeal or cervical esophageal carcinoma. Some patients could achieve good survival with low mortality and acceptable morbidity after multidisciplinary treatments.

Inactivated Pseudomonas aeruginosa inhibits hypoxia-induced pulmonary hypertension by preventing TGF-β1/Smad signaling

Pseudomonas aeruginosa is one of the common colonizing bacteria of the human body and is an opportunistic pathogen frequently associated with respiratory infections. Inactivated P. aeruginosa (IPA) have a variety of biological effects against inflammation and allergy. Transforming growth factor-β (TGF-β) signaling plays a critical role in the regulation of cell growth, differentiation, and development in a wide range of biological systems. The present study was designed to investigate the effects of IPA on TGF-β/Smad signaling in vivo, using a hypoxia-induced pulmonary hypertension (PH) rat model. Sprague Dawley rats (n=40) were exposed to 10% oxygen for 21 days to induce PH. At the same time, IPA was administered intravenously from day 1 to day 14. Mean pulmonary artery pressure (mPAP) and the right ventricle (RV) to left ventricle plus the interventricular septum (LV+S) mass ratio were used to evaluate the development of PH. Vessel thickness and density were measured using immunohistochemistry. Primary arterial smooth muscle cells (PASMCs) were isolated and the proliferation of PASMCs was assayed by flow cytometry. The production of TGF-β1 in cultured supernatant of PASMCs was assayed by ELISA. The expression levels of α-smooth muscle actin (α-SMA), TGF-β1 and phospho-Smad 2/3 in PASMCs were assayed by western blot. Our data indicated that IPA attenuated PH, RV hypertrophy and pulmonary vascular remodeling in rats, which was probably mediated by restraining the hypoxia-induced overactive TGF-β1/Smad signaling. In conclusion, IPA is a promising protective treatment in PH due to the inhibiting effects on TGF-β1/Smad 2/3 signaling.

[Clinical analysis of lymphocytic thyroiditis coexistent with papillary thyroid carcinoma]

OBJECTIVE

To analyse the clinical features and treatment strategies of papillary thyroid carcinoma(PTC) coexistent with lymphocytic thyroiditis (LT).

METHODS

A total of 292 patients including 25 males and 267 females with LT and thyroid nodules treated in the department of head and neck surgery between Sep 2011 and Sep 2014 was analysed retrospectively and divided into two groups according to pathological results, of them 262 patients, with a median age of 47 years old, were LT with PTC and 30 patients, with a median age of 54 years old, were LT with benign nodules. Among 262 patients having LT with PTC, 259 were diagnosed as having malignant or suspicious malignant nodules and 3 having benign nodules with ultrasound before surgery, 98 cases were considered multifocal malignant nodules by preoperative ultrasound, and 112 cases were positive in cervical lymph nodes, including bilateral positive in 37 cases. Of 30 patients having LT with benign nodules, 14 were diagnosed malignant or suspicious malignant nodules and 16 benign nodules.

RESULTS

The mean age in 262 patients with PTC was less significantly than that in 30 patients with benign nodules (P<0.05). Ultrasound showed a high proportion of calcification and microcalcification in patients with PTC (34%) compared to patients with benign nodules(13%)(P<0.05). There were not significant differences in the mean levels of serum thyroid stimulating hormone(TSH) (2.80 vs 2.99 mU/L, P=0.233), thyroglobulin(TG) (27.14 vs 18.60 μg/L, P=0.747), and anti-thyroglobulin antibodies(ATG)(417.3 vs 378.7 U/ml, P=0.834) between patients with PTC and those with benign nodules. In patients with PTC, multifocal tumor accounted for 42%. The central and lateral lymph node metastasis rates were respectively 50% and 24%, and the occult metastasis rate of lateral neck lymph node was 16%. Univariate analysis showed that age less than 45 years old, multifocal tumor, tumor diameter more than or equal to 2cm and extrathyroidal extension were associated with central lymph node metastasis (P<0.05), but not with lateral neck metastasis. Multivariate analysis showed a closed correlation only between the lymph node metastases in central and lateral neck levels (P<0.05).

CONCLUSIONS

Calcification and microcalcification have the same importance in the ultrasonic diagnosis for PTC in patients with LT. Total thyroidectomy and prophylactic central lymph node should be a choice for LT with PTC. Lymph node metastasis in level Ⅵ indicates the possibility of lateral cervical lymph node metastasis in the patients having LT with PTC.

[Analysis of risk factors for bleeding after thyroid surgery]

OBJECTIVE

To identify risk factors for bleeding after thyroid surgery, and discuss the potential relevance between the bleeding timing and sources.

METHODS

A total of 2568 cases that underwent thyroid operation from June 2012 to June 2013 were collected and analysed retrospectively the risk factors for postoperative bleeding by Cox and the potential relevance between the bleeding timing and sources.

RESULTS

Among 2568 patients, 40 patients occurred postoperative bleeding Indentified risk factors were extent resection (P=0.0435) and surgeon (P=0.0071). Thyroid bed and strap muscles/sternocleidomastoid were the most common sources of bleeding after surgery within 6 hours; while thyroid bed was the most common source of bleeding after surgery between 6 and 8 h; wound errhysis was the most common source during 8-24 h after the operation; thyroid bed and strap muscles/sternocleidomastoid were the most common sources within 24 h after thgroid surgery.

CONCLUSIONS

Bleeding after thyroid surgery is a rare but potentially life-threatening complication, and the extent of resection and the surgeon are risk factors. Thyroid bed and strap muscles/sternocleidomastoid are the most common sources of bleeding after surgery within 24 hours.

Prevention and Treatment of Life-Threatening Bleeding After Thyroid Surgery

BACKGROUND Few reports have discussed life- threatening bleeding that occurs postoperatively in patients who have undergone thyroid surgery. In this article, we discuss the causes, treatment measures, and possible ways of preventing this severe complication. MATERIAL AND METHODS From Jan 2002 to Dec 2014 we retrospectively analyzed 7 patients who developed life-threatening bleeding after undergoing thyroid surgery at our center. RESULTS Among the group of 7 patients, there was 1 case of superior thyroid artery hemorrhage (STAH), 5 cases of carotid blowout syndrome (CBS), and 1 case of tracheo-innominate fistula (TIF). The STAH was caused by unreliable ligation. All the cases of CBS and TIF were caused by surgical wound infection. Six patients were transferred to the operating room immediately; open surgical treatment was performed on these 6 patients. Out of these 6 patients, 1 patient did not survive the operation, and hemorrhage was successfully controlled in 3 patients. The remaining 2 patients again experienced bleeding even after undergoing open surgery. Only 1 patient developed long-term neurological complications. CONCLUSIONS Infection is the most common cause of life-threatening bleeding that occurs postoperatively in some patients who have undergone thyroid surgery. Early surgical intervention can save the lives of these patients without causing any severe neurological complications.

Risk factors for and occurrence of postoperative cervical hematoma after thyroid surgery: A single-institution study based on 5156 cases from the past 2 years

BACKGROUND

The occurrence of and risk factors for postoperative cervical hematoma remain unclear.

METHODS

We conducted a retrospective analysis of 5156 patients treated at a single institution.

RESULTS

The occurrence of postoperative cervical hematoma was 0.85% (44 of 5156 patients). The multivariate analysis showed that male sex, benign pathology, hypertension, and previous thyroid surgery are individual risk factors with odds ratios of 1.906, 2.004, 7.962, and 4.407, respectively. The majority (88.7%) of hematomas occurred within 12 hours after surgery. Obvious bleeding points were detected in 28 cases (73.6%) during reexploration, surface of the strap muscle, superior thyroid vessel, and end of the recurrent laryngeal nerve were the most frequent bleeding sources.

CONCLUSION

Hematoma often occurs within 12 hours after thyroid surgery. Hypertension, previous thyroid surgery, male sex, and benign pathology may increase the risk of hematoma.

[Cervical lymph node metastasis in medullary thyroid carcinoma]

OBJECTIVE

To study the patterns of cervical lymph node metastasis of medullary thyroid carcinoma.

METHODS

Ninety-one patients with medullary thyroid carcinoma first treated between January 1999 and October 2014 were analyzed retrospectively. Of 91 patients, 39 cases presented with clinical negative node (cN0) and 52 cases with clinical positive node (cN+). Central compartment dissection was performed in all cases. Lateral neck dissection was performed in 52 cN+ cases (71 sides). All neck dissection specimens were obtained and analyzed for lymph node (LN) involvement with respect to neck levels. The distribution of LN with metastasis was studied in cN+ patients and the following factors were used to study the predictive value of central compartment LN metastasis: sex, age, family history, tumor size, bilateral tumor, multifocality of the tumor, extracapsular spread, and remote metastasis. Univariate analysis with the χ(2) test was used to analyze the statistical correlation between central compartment LN metastasis and other clinical factors. Multiple logistic regression analysis was used to identify the factors related to central compartment metastasis.

RESULTS

Neck and bilateral neck metastasis rates were 73.6%, 19.8% respectively. Metastasis rates in central compartment and superior mediastinal region were 68.1% and 27.5% respectively. The central compartment metastasis rate was 33.3% in cN0 patients and 94.2% in cN+ patients. The superior mediastinal metastasis rate was 2.6% in cN0 patients and 46.2% in cN+ patients. Extracapsular spread was an independent predictive factor for central compartment metastasis (χ(2)=15.592, P=0.000, OR=12.876). The incidences of LN metastases at level II, III, IV, V were 62.9%,84.5%,83.1%,50.0% in cN+ patient, respectively. Multi-sites were involved. The possibility of lateral neck metastasis was higher when preoperative value of calcitonin was higher than 300 ng/L (66.7% vs 28.6%, χ(2)=5.771, P=0.016).

CONCLUSIONS

Cervical lymph node metastasis of medullary thyroid carcinoma is higher. Central compartment dissection is necessary in cN0 patients with extracapsular spread. Neck dissection from level II to level VII was necessary in cN+ patients. Preoperative value of calcitonin maybe can predict the lateral neck metastasis incidence.

Long-term outcomes of observation for clinically negative central compartment lymph nodes in papillary thyroid carcinoma

The treatment strategy for clinically negative lymph nodes of papillary thyroid carcinoma is controversial. We report the long-term outcomes of a series of cases treated with thyroidectomy without prophylactic central neck dissection. We reviewed 1,397 cases with papillary thyroid carcinoma treated at our institution between 1991 and 2000. One hundred and seventy-two newly diagnosed cases underwent observation for cN0 central neck lymph nodes. Regional recurrence of the ipsilateral side including central compartment and the lateral neck which needs reoperation was considered as key point for analysis. With a mean follow-up of 96.4 months (34-204 months), the overall 10-year disease-specific and recurrence-free survival rates were 99 and 86 %, respectively. The recurrence and reoperation rates of the central compartment were 3 % (5/172) and 4 % (7/172), respectively. Univariate analysis showed that extrathyroidal extension was associated with regional recurrence (99 vs. 82 %; p = 0.002). Central compartment observation is safe in cN0 cases with papillary thyroid carcinoma, particularly in those without extrathyroidal extension.

[Factors related to central lymph node metastasis in different subregions for unilateral papillary thyroid carcinoma with clinical N0 stage]

OBJECTIVE

To study clinicopathologic factors related to central lymph node (CLN) metastasis in different subregions for unilateral papillary thyroid carcinoma (PTC) with clinical N0.

METHODS

A total of 145 PTC cases with clinical N0 treated in the same group of the department of head and neck surgery, Cancer Hospital, Chinese Academy of Medical Science between Jan. 2011 and Jan. 2014 was analysed retrospectively. Clinicopathologic factors related to CLN metastasis in different subregions were analyzed, including sex, age, tumor size, extrathyroidal extension, and multifocal tumor.

RESULTS

CLN metastases existed in 57.9% (84/145) cases and the incidences of ipsilateral paratracheal, pretracheal, and prelaryngeal metastasis were 53.8%, 24.1% and 11.3% respectively. Right paratracheal lymph node metastasis occurred in anterior (17/38, 44.7%) and posterior (12/38, 31.6%) to the recurrent laryngeal nerve. Multivariate analysis indicated that extrathyroidal extension (OR = 4.49, 95%CI 1.80-11.20, P = 0.001) and tumor size (OR = 2.17, 95%CI 1.06-4.45, P = 0.034) were independent risk factors for ipsilateral paratracheal CLN metastasis; ipsilateral paratracheal CLN metastasis (OR = 2.12, 95%CI 0.08-4.60, P = 0.003) was an independent risk factor for pretracheal CLN metastasis.

CONCLUSIONS

A high risk of CLN metastasis especially ipsilateral paratracheal metastasis exists in DTC with clinical N0. Ipsilateral paratracheal, pretracheal and prelaryngeal CLN dissection should be conducted when maximum tumor diameter more than 1 cm or extrathyroidal extension. CLN anterior and posterior to the recurrent larygeal nerve should be removed simultaneously when the ipsilateral paratracheal CLN metastasis at right side. Total thyroidectomy and contralateral paratracheal CLN dissection should be conciderded in multifocal tumor.

Minimally-invasive endoscopically-assisted neck dissection for lateral cervical metastases of thyroid papillary carcinoma

Traditional open operations for lateral neck dissection in patients with papillary thyroid carcinoma leave an unsightly scar. We report complete lateral neck dissection and thyroidectomy for papillary thyroid carcinoma using an endoscopically-assisted approach through a small incision, and evaluate its feasibility and safety. Between March 2010 and January 2013, 6 patients with no definite metastases to the lymph nodes at levels II-IV, and 20 with definite metastases to the lymph nodes at levels II-V were selected. Thyroidectomy, dissection of the central compartment (level VI), and ipsilateral level II-IV and II-V neck dissections were done through a small incision in the neck. The steps of endoscopic lateral neck dissection were similar to those of conventional operations. The mean operating time for the whole procedure was 3.57 hours (range 2.5 - 5.0). It was successful in all patients and there were no serious complications or serious blood loss. A total of 21 patients had lymph node metastases in the central and lateral zones. The mean yield of lymph nodes was 38.6 (range 16-61). There was no evidence of residual or recurrent disease at follow-up, and the cosmetic result was excellent. Minimally invasive, video-assisted comprehensive neck dissection for metastatic papillary thyroid carcinoma is feasible and safe, and has excellent cosmetic results. Further studies with a larger number of patients and long-term follow-up are needed to verify its oncological validity.

[Clinical role of BRAF V600E mutation testing in thyroid nodules]

OBJECTIVE

To evaluate the clinical role of BRAF V600E mutation testing in fine-needle aspirates (FNA) of thyroid nodules.

METHODS

This study included 83 nodules in 80 patients who underwent FNA from March 2013 to September 2013. Cytological specimens were collected and BRAF exon 15 was examined by polymerase chain reaction (PCR). DNA sequencing and analysis were performed. Diagnostic performances of cytology and cytology with BRAF V600E mutation analysis were compared according to postoperative pathological diagnosis. The relation of BRAF V600E mutation with clinical factors including sex and age of patients, tumor size, lymph node metastasis, multifocality, and AJCC stage were analyzed.

RESULTS

Of 83 nodules, 33 nodules were clinically observed, and 48 nodules underwent surgery, and suggestions of surgery were refused in 2 nodules. Among 48 nodules with surgery, BRAF V600E mutation was found in 25 nodules with histologic confirmation of papillary thyroid carcinoma after thyroidectomy, 13 of the 25 nodules were cytologically diagnosed as carcinoma and 12 were indeterminate. Among the 23 BRAF V600E negative noodles, 5 were cytologically diagnosed as carcinoma, 2 were benign, and 16 were indeterminate; 15 nodules were histologic confirmation of papillary thyroid carcinoma after thyroidectomy, 1 nodule was medullary thyroid carcinoma, and 7 nodules were benign. Biomolecular analysis significantly increased cytology sensitivity for papillary thyroid carcinoma from 43.9% to 73.2% (P < 0.05). Direct DNA sequencing showed that the presence of BRAF V600E mutation was 62.5% in 40 thyroid papillary nodules. There were 16 BRAF-positive nodules (80.0%) among 20 papillary thyroid nodules with extrathyroidal extension, however there were 9 BRAF-negative nodules (45.0%) among 20 papillary thyroid nodules without extrathyroidal extension. Univariate analysis indicated the BRAF V600E mutation was associated with extrathyroidal extension (χ² = 5.227, P = 0.022), but not with sex, age, tumor size, lymph node metastasis, multifocality and AJCC stage.

CONCLUSION

BRAF V600E mutation analysis can significantly improve FNA diagnostic accuracy and maybe useful for prediction of high-risk of thyroid carcinoma.

[Clinical features of familial non-medullary thyroid cancer patients]

OBJECTIVE

To analyze the clinical features of familial non-medullary thyroid cancers, and to discuss their management.

METHODS

Sixty thyroid cancer patients with familial non-medullary thyroid cancer (FNMTC) history during Sep. 2003 to Sep. 2012 were collected as study group, and another 60 sporadic thyroid cancer patients were randomly chosen as control. We compared the differences of their clinical features.

RESULTS

All the patients were diagnosed as thyroid papillary carcinoma. The study group included 40 female and 20 male patients. There were 16 cases in stage T1, 37 in stage T3, and 7 in stage T4. The patients were 21-66-year old ( median age 42-years). The control group included 49 female and 11 male patients. The patients were 24- to 78-year old, and the median age was 45.5 years. 43.3% of the patients in the study group and 18.3% of the patients in the control group had bilateral carcinomas (P = 0.003). There were multifocal lesions in 53.3% of the patients in the study group and 35.0% of the control group, local invasion in 73.3% of the patients in the study group and 55.0% of the control group, and coexisting benign thyroid diseases in 81.7% of the patients of the study group and 50.0% of the control group (P < 0.05 for all). There were cervical lymph node metastases in 60.0% of the patients in the study group and 38.3% in the control group (P = 0.018). In the study group, 32 cases were of parent-offspring type and 28 cases of sibling type. Among the parent-offspring type patients, the median onset age of the first generation offsprings was 58 years, and that of the second generation offsprings was 32 years (P < 0.001).

CONCLUSIONS

Familial nonmedullary thyroid cancer, especially in parent-offspring type patients, is more aggressive than sporadic nonmedullary thyroid cancer, and often involves bilateral lobes, has multifocality, and combines with benign thyroid diseases. We recommend a total thyroidectomy for treatment, and to screen all the family members >20 years old, with ultrasonography for early diagnosis and treatment.

[Preliminary study of patterns of level IIb lymph node metastasis in papillary thyroid carcinoma]

OBJECTIVE

To evaluate the factors related to level IIb lymph node(LN) metastasis in papillary thyroid carcinoma (PTC). Method The medical records of 63 PTC patients were reviewed. The patients underwent neck dissection (ND) between January 2011 and December 2012, who were determined with pathologically lateral cervical LN metastasis. A total of 67 ND specimens were obtained and analyzed for LN involvement with respect to neck levels. The relation of level IIb LN metastasis with clinical factors, including age and sex of patients, tumor size, location, multifocality, extracapsular spread (ECS) and stage of primary PTC, coexistence of lymphocytic thyroiditis, distribution of metastasis LN in different levels, fusion and extracapsular invasion of LN were analyzed with univariate analysis and χ(2) test. SPSS 14.0 software was used to analyze the data.

RESULTS

Of 63 patients, 41 patients revealed thyroid tumor maximum diameter more than 1 centimeter, 26 patients with tumor located in the upper 1/3 thyroid lobe, 39 patients with multiplicity of thyroid tumor and 54 patients with ECS, 54 patients with pathological T3/T4a stage, 15 patients with coexisting lymphocytic thyroiditis. Among the 67 ND specimens, 12 specimens (17.9%) showed level IIb LN metastasis and the incidences of LN metastasis at level IIa, III, IV, V, VI, IIa+III, III+IV, and IIa+III+IV were 56.7%, 86.6%, 68.7%, 22.4%, 86.6%, 52.2%, 55.2%, 37.3%, respectively. Of the 38 ND specimens with level IIa LN metastases, 10 were positive in level IIb(26.3%). But of 29 ND specimens without level IIa LN metastases, only 2 were positive in level IIb. A univariate analysis revealed that level IIa LN metastasis was a significant predictive factor for level IIb LN metastasis (χ(2) = 4.219, P = 0.040).

CONCLUSION

The incidence of LN metastasis to level IIb is low in PTC, which is less when level IIa is not involved.

[Significance of selective neck dissection in patients with cN0 thyroid carcinoma]

OBJECTIVE

To investigate the significance of selective neck dissection in patients with cN0 thyroid carcinoma who have a high-risk of lateral neck lymph node metastasis.

METHODS

Sixty three patients with cN0 thyroid carcinoma who have a high-risk of lateral neck lymph node metastasis were prospectively studied at the Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between August 2006 and June 2011. The patients with cN0 thyroid carcinoma easy to occur neck lymph node metastasis include: The maximum diameter of primary tumor is ≥ 2 cm; The primary tumor invaded the thyroid capsule; Lymph node metastasis in level VI is found; Lymph node enlargement in level III or/and IV were detected preoperatively by ultrasonography, but not considered as metastasis. The surgical procedure is that the selective neck dissection in level III and IV is performed depending on the collar incision of thyroid surgery. The lymph node chosen from the specimen has a frozen section. If lymph node metastasis is found in the frozen section, a functional neck dissection should be performed through prolonging the collar incision.

RESULTS

All cases were pathologically confirmed as thyroid papillary carcinoma. The occult metastasis rate of lateral neck lymph nodes was 39.7%. According to the univariate analysis, the patients with thyroid capsule invasion and lymph node metastasis in level VI were more likely to have lateral neck lymph node metastasis, and the occult metastasis rate was 46.9% and 54.3%, respectively (P = 0.028, P = 0.008), and there were statistically no significant difference in the primary tumor size and the preoperative neck lymph node status by ultrasonography with occult metastasis of lateral neck lymph nodes (P = 0.803 and P = 0.072). According to the multivariate analysis, there was a significant correlation only between the lymph node metastasis in level VI and occult metastasis of lateral neck lymph nodes (P = 0.017), but there was no significant correlation with the thyroid capsule invasion, primary tumor size and neck lymph node status by preoperative ultrasonography in prediction of occult metastasis of lateral neck lymph nodes (all P > 0.05).

CONCLUSIONS

Selective neck dissection is feasible for the patients with cN0 thyroid carcinoma who have a high-risk lateral neck lymph node metastasis and the lateral occult metastatic lymph node can be promptly found and removed. We suggest that the selective neck dissection for level III and IV should be routinely performed in cN0 thyroid carcinoma patients with thyroid capsule invasion and lymph node metastasis in level VI.

Superior mediastinal dissection for papillary thyroid carcinoma: approaches and outcomes

BACKGROUND

Superior mediastinal surgery for thyroid carcinoma is not a standardized procedure like the neck dissection. The objective of this study was to evaluate the effectiveness of superior mediastinal dissection for mediastinal metastasis of papillary thyroid carcinoma (PTC).

METHODS

We conducted a retrospective review of 119 patients who underwent superior mediastinal dissection for the treatment of PTC. The postoperative characteristics and follow-up data were analyzed. Cox regression was performed to identify the factors related to the mediastinal control.

RESULTS

No severe complications occurred in this series. The five-year local (mediastinum) disease-free survival rates of comprehensive (n = 29) and partial (n = 90) superior mediastinal dissection were 86.3 and 84.0%, respectively (log-rank = 0.562; p = 0.452). Different patterns of superior mediastinal dissection did not turn out to be related to mediastinal recurrence in the cox regression. Bilateral paratracheal metastasis was identified as an individual risk factor of mediastinal recurrence with a relative risk value of 4.635 (95% CI: 1.399-15.355; p = 0.012).

CONCLUSIONS

Both partial and comprehensive superior mediastinal dissections are effective and safe for the treatment of mediastinal metastasis of PTC if appropriately designed.

[Clinical analysis of 318 cases of oropharyngeal squamous cell carcinoma]

OBJECTIVE

To investigate the clinicopathological features, treatment outcomes and prognosis of patients with oropharyngeal squamous cell carcinoma (OSCC).

METHODS

Retrospective review of 318 consecutive cases with OSCC treated from January 1999 to December 2011. Survival rates and prognostic factors were calculated using the Kaplan-Meier method and multivariate Cox model survival analysis respectively. There were 281 males and 37 females, with a median age of 56 years. Of the 318 cases, 163 carcinomas were from tonsil, 108 from tongue base and 47 from soft palate-uvula. The presenting symptoms were pharyngalgia (128 cases, 40.3%), neck masses (71 cases, 22.3%), foreign body sensation in the pharynx (63 cases, 19.8%) and dental ulcer (44 cases, 13.8%). The median time from onset of the first symptoms until diagnosis of OSCC was 3 months. Of the 318 OSCC, 75 were with high grade, 110 with intermediate grade and 133 with low grade, including 10 patients at stageI, 39 at stage II, 68 at stage III and 201 at stage IV.

RESULTS

The rates of lymph node metastasis, distant metastasis and second primary carcinoma were 72.3%, 13.2% and 7.9%, respectively. Of 318 patients, 117 received radiotherapy alone, 66 underwent surgery plus postoperative radiotherapy, 59 underwent preoperative radiotherapy plus surgery, 33 received concomitant chemotherapy and radiotherapy, 20 received concomitant molecular targeted therapy and radiotherapy, 16 underwent surgery alone and 7 received induction chemotherapy plus radiotherapy. The 3-, 5-year overall survival (OS) rates were 58.4%, 50.7%, respectively, and the median overall survival time was 60.1 months. Ages (P = 0.034), gender(P = 0.024), smoking and alcohol consumptions(P = 0.008), doses of radiotherapy(P = 0.046) and clinic stages(P = 0.001) were independent factors for OS.

CONCLUSIONS

OSCC is poor in prognosis, with a high incidence of cervical lymph node metastasis. Radiotherapy and salvage surgery are the main treatments for OSCC.

[Primary squamous cell carcinoma of the thyroid: retrospective analysis of 28 cases]

OBJECTIVE

To investigate the clinicopathological features, treatment outcomes and prognosis of patients with squamous cell carcinoma of the thyroid (SCCT).

METHODS

Retrospective review of SCCT cases in our hospital from January 1999 to May 2012. Demographic data and clinical charts, including presenting symptoms, histologic grade of tumor, treatment, and outcome of 28 consecutive patients were obtained. Survival rates and prognostic factors were calculated with SPSS 13.0 software using the Kaplan-Meier method and multivariate Cox model survival analysis.

RESULTS

SCCT accounted for only 0.36% of all types of thyroid malignancy. There were 15 males and 13 females, and the median age was 63 years. The presenting symptoms were neck masses (26/28) and hoarse voice (18/28). The 28 SCCTs included 15 high grade tumors, eight intermediate grade tumors and five low grade tumors. According to the UICC 2002 staging criteria, 16 patients were stage IVa, and 12 were stage IVb. Of the 28 patients, 19 underwent surgery plus postoperative radiotherapy, seven underwent surgery alone, and two received radiotherapy alone. The rates of lymph node metastasis and distant metastasis were 60.7% and 25.0%, respectively. The 1-year, 2-year and 5-year overall survival (OS) rate were 50.4%, 25.8% and 19.3%, respectively, and the median overall survival time was 12.2 months. Kaplan-Meier univariate survival analyses indicated that the sizes of the tumors, esophageal invasions and treatment policies are prognostic factors, and multivariate Cox model survival analyses confirmed that the sizes of the tumors and treatment policies were independent factors for OS. Multivariate survival analyses confirmed that the sizes of the tumors and treatment policies were independent factors for OS.

CONCLUSIONS

SCCT is a rare malignant tumor with strong invasive ability, high malignancy and poor prognosis. Combined modality therapy was strongly recommended, and surgical resection plus postoperative radiotherapy may be the main treatment protocol for patients with SCCT.

Tracheo-innominate artery fistula: Diagnosis and surgical management

BACKGROUND

Tracheo-innominate artery fistula (TIF) is a rare and fatal complication after tracheostomy. The diagnosis, treatment, and possible prevention of this disease are discussed in this study.

METHODS

From 1976 to 2008, 14 patients with TIF were studied retrospectively.

RESULTS

All patients underwent open surgical tracheostomy. Before TIF, herald events occurred in 10 patients (8 had slight hemoptysis and 2 had innominate artery exposure). When TIF occurred, bedside aid was administered, and 5 patients lived long enough to reach the operating room. Four patients accepted median sternotomy and ligation of innominate arteries. After surgery, mediastinal infection caused the rebleeding and death of 3 patients. In conducting follow-up for 11 months, the last patient was still alive without neurological complications. The survival rate was only 7.1%.

CONCLUSION

Prompt diagnosis and surgical intervention can save the life of a patient with TIF. Prevention is vital because of the high mortality of this disease.

[Effects of sorafenib and liposome doxorubicin on human poorly differentiated thyroid carcinoma xenografts in nude mice]

OBJECTIVE

To evaluate the therapeutic effects of sorafenib and liposome doxorubicin on poorly differentiated thyroid carcinoma (PDTC) xenografts in nude mice.

METHODS

Sorafenib and liposome doxorubicin were applied to PDTC xenografts in nude mice. The mice were randomized into seven groups: blank control (A), vehicle control (B), single liposome doxorubicin (C), single sorafenib group (D), liposome doxorubicin combined with low dose sorafenib group (E), combined group with medium dosage of sorafenib (F), combined group with high-dose of sorafenib(G). The volume, weight and growth inhibition rate of tumours were measured to evaluate the therapeutic effects of drugs.

RESULTS

Sorafenib and liposome doxorubicin showed significant antitumor activity in the PDTC xenografts. The mean tumor volumes of seven groups were (1274.13 ± 393.76) mm(3), (1060.00 ± 469.05) mm(3), (726.76 ± 488.22) mm(3), (451.54 ± 97.75) mm(3), (518.37 ± 164.44) mm(3), (310.51 ± 210.53) mm(3), and (228.44 ± 129.21) mm(3), respectively. The mean tumor weights of the seven groups were (1.13 ± 0.42)g, (0.91 ± 0.39)g, (0.78 ± 0.45)g, (0.55 ± 0.17) g, (0.52 ± 0.19) g, (0.34 ± 0.21) g, and (0.19 ± 0.09) g separately. The tumor inhibition rates of group C to G were 30.8%, 40.8%, 42.3%, 62.9%, 72.6% separately.

CONCLUSIONS

Sorafenib and liposome doxorubicin, no matter for single agent or in combination, showed significant antitumor activity in the PDTC PDTC xenografts in vivo. The tumour-inhibited effect of single sorafenib is better than that of single liposome doxorubicin. Liposome doxorubicin combined with medium dosage of sorafenib had a better therapeutic effect and less side effects.

[Human papillomavirus infection in oropharyngeal squamous cell carcinoma and prognosis: a preliminary analysis of 66 cases]

OBJECTIVE

To analyze the relationship between the prognosis of patients with oropharyngeal squamous cell carcinoma (OSCC) and human papillomavirus (HPV) infection in OSCC.

METHODS

Sixty-six patients with oropharyngeal carcinoma who met the enrollment criteria during the period from January 1999 to December 2009 were retrospectively reviewed. The presence or absence of HPV oncogenic types in OSCC specimen was determined by multiplex polymerase chain reaction (PCR). Overall survival (OS) and disease specific survival (DSS) for HPV-positive and HPV-negative patients were estimated by Kaplan-Meier analysis. Cox regression model was used for multivariate analysis.

RESULTS

HPV-DNA was detected in 11(16.7%) of all specimens. Among them, 7 were positive for HPV-16, 1 for HPV-16/11, 1 for HPV-35, 1 for HPV-58/52, and 1 for HPV-33/52/54. With the follow-up of 3-78 months (a median of 24.5 months), patients with HPV-positive tumors had significantly better overall survival (χ2=5.792, P=0.016) and disease specific survival (χ2=4.721, P=0.030), the 3-year OS and DSS were 90.0% vs 52.4% and 90.0% vs 56.4%, respectively. Multivariate analysis by Cox regression model showed that HPV infection and nodal status were both independent prognostic factors for patients with OSCC (P<0.05).

CONCLUSIONS

Patients with HPV-positive OSCC have significantly better prognosis than patients with HPV-negative tumors. HPV infection is an independent prognostic factor.

[Association of antigen processing machinery and HLA class I defects with clinicopathological outcome in laryngeal squamous cell carcinoma]

OBJECTIVE

To investigate the role of antigen-processing machinery (APM) component defects in HLA class I antigen down-regulation in laryngeal squamous cell carcinoma (SCC) and to assess the clinical significance of these defects.

METHODS

Fifty-one formalin-fixed, paraffin-embedded SCC specimens were examined for the expressions of APM component transporter associated with antigen processing (TAP1) and low molecular weight polypeptide (LMP-7) and HLA class I antigen by immunohistochemistry.

RESULTS

HLA class I antigens, TAP-1 and LMP-7 expressions were down-regulated in 56.9% (29/51), 39.2% (20/51) and 45.1% (23/51) of the tested specimens respectively, whereas HLA class I antigens, TAP-1 and LMP-7 expressions lost in 21.6% (11/51), 33.3% (17/51) and 27.5% (14/51) of the tested specimens respectively. TAP-1 and LMP-7 expressions were significantly correlated with HLA class I antigen expression (r=0.460, P<0.05 and r=0.685, P<0.05, respectively). HLA class I antigens down-regulation was significantly correlated with T stage (χ2=8.61, P<0.05). Both TAP-1 and LMP-7 down-regulations were significantly correlated with T stage (χ2 values were 9.72 and 8.97 respectively, P<0.05) and TNM stage (χ2 values were 9.18 and 7.70 respectively, P<0.05). TAP-1, LMP-7 and HLA class I antigen down-regulations were significantly associated with reduced patients' overall survival (P<0.05) and disease-free survival (P<0.05). Multivariate analysis showed lymph node metastasis, recurrence and HLA class I antigen down-regulation were unfavorable prognostic factors (P<0.05).

CONCLUSIONS

Down-regulated expressions of HLA class I antigen and APM component TAP-1 and LMP-7 occur frequently in laryngeal squamous cell carcinoma, by which cancer cells could avoid immune surveillance, while HLA class I antigen down-regulation is a major contributing factor to tumour progression and mortality.

[Cervical lymph node metastasis in clinical N0 papillary thyroid carcinoma]

OBJECTIVE

To study the patterns of cervical lymph nodes metastasis and the surgical managements of cervical lymph nodes in clinical N0 (cN0) papillary thyroid carcinoma.

METHODS

Fifty-one consecutive patients with papillary carcinomas without clinical evidence of cervical lymph node involvement were included in the study between August 2007 and September 2010, in which 53 sides underwent neck lymph node dissection. Preoperative lymphoscintigraphy intra-operative hand-held gamma probe detecting and blue dye technique were used to detect the sentinel lymph node (SLN). SLNs were sent to frozen-section and the results were compared with specimen of routine selective neck dissection. All the pathologic specimens were reviewed by pathologists, counting the numbers of pathologic positive nodes and mapping the localization of positive nodes in level II, III, IV, V and VI respectively. The following criteria were used to study the predictive value of lateral neck compartment lymph node metastasis: age, multifocality of the tumor, extracapsular spread (ECS), tumor size, and the number of central compartment metastasis nodes. Univariate analysis with the χ2 test was used to analyze the statistical correlation between lateral neck compartment lymph node metastasis and the other clinical factors. Multiple logistic regression analysis was used to identify the multivariate correlates of lateral neck compartment metastasis.

RESULTS

The occult lymph node metastasis and lateral neck metastasis rates were 77.4% and 58.5% respectively, central compartment metastasis ≥3 nodes was the only independent predictive factor for the metastasis in lateral neck. Twelve sides were pN0 and other 41 sides were pN+ in all 53 side specimens. Of 41 sides with pN+, 17 sides (41.5%) involved single site and 24 sides (58.5%) involved multi-sites. The distribution of metastasis lymph nodes:level VI 62.3%, level III 52.8%, level IV 30.2%, level II 18.9%, and level V 0%.

CONCLUSIONS

Cervical occult lymph node metastasis in cN0 papillary thyroid carcinoma mainly localizes in level VI, level III, level IV and level II.Selective neck dissection including level VI, III, IV, II is enough for papillary carcinoma without clinical evidence of cervical lymph node involvement.

[Fine-needle aspiration cytology of thyroid nodules: a clinical evaluation]

OBJECTIVE

To investigate the clinical application of fine needle aspiration (FNA) cytology of thyroid nodules.

METHODS

A retrospective review was performed of 474 consecutive cases of FNA cytology of thyroid nodules from October 2005 to January 2011. Two hundred and eighteen patients underwent ultrasound-guided FNA, and 256 patients experienced palpation-guided FNA. Cytologic diagnoses were classified as unsatisfactory, benign, atypical cellular lesion, follicular neoplasm, suspicious for malignancy, and positive for malignancy. The discrepancies between initial cytologic diagnoses and histologic diagnoses were evaluated in 157 surgical specimens.

RESULTS

According to the cytological categories, the rates for histologically confirmed malignancy in the 157 patients were as follows: 2/7 of unsatisfactory results, 16.7% (9/54) of benign lesion, 3/9 of atypical cellular lesion, 1/3 of follicular neoplasm, 83.3% (35/42) of suspicious for malignancies, and 97.6% (41/42) of positive for malignancies. The sensitivity, specificity and positive predictive value of thyroid FNA for the diagnosis of malignancy were 85.4%, 86.9% and 90.5%, respectively.

CONCLUSIONS

FNA can provide an accurate diagnosis of thyroid malignancy preoperatively. The 6 diagnostic categories were beneficial for either clinical follow-up or surgical management of the patients with thyroid nodules.

[Analysis of surgical treatment of papillary thyroid carcinoma]

OBJECTIVE

To present the treatment results and to analyze the causes of recurrence in patients with papillary thyroid carcinoma.

METHODS

A retrospective review of 600 patients with papillary thyroid carcinoma treated between 1994 and 1999 was conducted. The primary lesions were originated from the left lobe in 188 cases, the right lobe in 290 cases, the isthmus in 8 cases, and multicentric in 114 cases. From the 600 cases, 584 were well-differentiated and 16 poorly differentiated. TNM stage:385 cases of stage I, 37 cases of stage II, 17 cases of stage III, and 161 cases of stage IV. Three hundred and one patients was N1b stage. All patients received surgical treatment. Among them, 19 cases received radiotherapy, 71 received (131)I-therapy and one case received concomitant radiotherapy and (131)I-therapy.

RESULTS

There were 94 recurrent cases. Twenty-seven cases died of recurrence, metastasis and other diseases. The overall 10-year survival rate was 93.2%. The overall 10 year survival rates of stage I, II, III, and IV patients were 99.1%, 94.7%, 93.8%, and 78.5%, respectively (P < 0.01). The 10-year survival rate of lower-age group (< 45 years) was 99.4% and higher-age group (≥ 45 years) 82.1% (P < 0.01). The 10-year survival rate of patients with trachea invasion was 66.5%, significantly lower than the 95.1% in patients without trachea invasion (P < 0.01). The 10-year survival rate of well-differentiated cases was 94.9%, significantly higher than the 38.9% in the poorly differentiated cases (P < 0.01). Multivariate analysis showed that the TNM stage, differentiation degree and the thorough going surgical operation were independent risk factors for the prognosis of papillary thyroid carcinoma.

CONCLUSIONS

The TNM stage, differentiation degree and the thorough going surgical operation are independent risk factors for the prognosis of papillary thyroid carcinoma.

[Functional reconstruction after total or near total glossectomy]

OBJECTIVE

To evaluate the functional outcomes of patients who underwent total or near total glossectomy with pectoralis major myocutaneous flap (PMMF) or free flap (FF) reconstruction.

METHODS

Retrospective study of 38 consecutive patients undergoing total or near total glossectomy with PMMF or FF reconstruction. The outcomes of decannulation, feeding and speech function recovery were compared.

RESULTS

Near total glossectomy was performed in 33 patients and total glossectomy was performed in 5 patients. Twenty five patients underwent reconstruction with PMMF including 2 salvage reconstructions after free flaps failure. All PMMFs survived except one complete necrosis. The success rate of PMMF was 96.0% (24/25). Fifteen patients underwent reconstruction with FF. Two flaps developed complete necrosis and the success rate of FF was 86.7% (13/15). The difference in the rates between the two groups was not significant (P=0.545). In the PMMF and FF groups, the renewal of oral feeding were 65.2% (15/23) and 100% (13/13), P<0.05, and the tracheostomy decannulation were 52.2% (12/23) and 100% (12/12), P<0.05, respectively. Postoperative feeding function recovery was better in FF group than that in PMMF group (P=0.011). Single factor analysis showed that using FF and maintaining the continuity of the mandible were related to successful rate of renewal of oral feeding. Multivariate Logistic regression analysis showed that the continuity of the mandible was the only independent predictor for renewal of oral feeding. There was no significant difference in the postoperative speech functions between the two groups.

CONCLUSIONS

The continuity of the mandible is the major factor to restore the functional outcomes in feeding after total or near total glossectomy. Compared with PMMF, using FF is more beneficial to retain or rebuild the continuity of the mandible.

Expression and clinical significance of cathepsin B and stefin A in laryngeal cancer

The aim of this study was to investigate the roles of the cathepsin B cysteine protease and its endogenous inhibitor stefin A in laryngeal cancer. Immunohistochemistry was employed to detect the expression of cathepsin B and stefin A in 84 patients with laryngeal cancer, respectively. The protein expression of stefin A was negatively associated with lymphatic metastasis, recurrence of laryngeal cancer and the survival rate, which was not observed with cathepsin B protein expression. Both down-regulation of cathepsin B and up-regulation of stefin A in vitro significantly inhibited the migration, invasion and proliferation of laryngeal cancer cells, respectively. Our results strongly suggest that stefin A may be a potential predictor of laryngeal cancer and may be used in the molecular diagnosis and gene therapy of laryngeal cancer. Cathepsin B may be used as a promising therapeutic target in the treatment of laryngeal cancer.

[Clinical analysis of 42 cases with adenoid cystic carcinoma of the nasal cavity]

OBJECTIVE

To study the clinical characters, treatment, outcome and the factors affecting long-term treatment results of adenoid cystic carcinoma (ACC) of the nasal cavity.

METHOD

The clinical data were analyzed retrospectively in 42 patients with ACC of the nasal cavity treated initially. The characters of survival rate, local recurrence and distant metastasis were analyzed using Kaplan-Meier method. Factors that might be related to the prognosis were analyzed by Log-rank test.

RESULT

The 5-,10-,15-,20-year cumulative overall survival and disease-free survival rate were 88.1%, 54.4%, 35.4%, 35.4% and 60.0%, 53.1%, 30.2%, 30.2% respectively. The 5-,10-,15-,20-year cumulative local control rate were 69.5%, 62.3%, 49.8%, 49.8% respectively and the cumulative distant metastasis rate were 22.2%, 25.9%, 34.2%, 34.2% respectively. Clinical T stage was the factor affecting local control and survival (P<0.05). There was no difference in survival for patients treated by surgery along with sufficient margins, compared with patients treated by surgery combined with postoperative radiation. Patients treated with preoperative radiation had poorer local control and survival than patients treated with postoperative radiation, but there was no statistical significance (P>0.05). The most of patients (75%) died of local recurrence at the primary site.

CONCLUSION

The most frequent site of failure was local recurrence at the primary site. Patients with early stage disease are amenable to surgery alone with sufficient margins. Surgery combined with high-dose postoperative radiation improves the local control and survival in patients with positive margins, no sufficient margins or advanced disease (T3 + T4). The most of tumors could be reduced remarkably and the radical operation may be performed for the patients with unresectable advanced tumors after preoperative radiation.

[Salvage surgery after failure of partial laryngectomy for laryngeal carcinoma]

OBJECTIVE

To study surgical managements, outcomes and the factors affecting prognosis of the primary recurrence following partial laryngectomy for laryngeal carcinoma.

METHODS

The clinical data of 77 patients with salvage surgery for primary recurrence following partial laryngectomy for laryngeal carcinoma were analyzed retrospectively. Fifty-one patients underwent salvage total laryngectomy and other 26 patients with salvage partial laryngectomy. Of them, 19 patients without previous radiotherapy received a combined therapy of surgery and radiotherapy. Survival rates were analyzed using Kaplan-Meier method. Prognosis factors were analyzed by Log-rank test and Cox regression.

RESULTS

After salvage surgery, the 3-and 5-year cumulative overall survival rates were 59.1% and 52.7% respectively, and both the 3- and 5-year local recurrence rates were 30.7%. Most patients (48.4%) died of the failure at the primary sites. Multivariate analysis revealed the advanced T stage at initial presentation and the extra-laryngeal invasion of recurrent tumor were adverse prognostic factors for survival rate and also the advanced T stage at initial presentation influenced local recurrence rate.

CONCLUSIONS

Salvage surgery for the primary recurrence following conservation treatment for laryngeal carcinoma can achieve promising results. Salvage total laryngectomy is the main therapeutic management in most recurrent patients. Salvage partial laryngectomy can achieve sound results in the patients selected carefully.

[Adenoid cystic carcinoma of maxillary sinus: diagnosis, treatment and prognostic factors]

OBJECTIVE

To study the clinical characters, the outcomes of treatments and the factors affecting long-term treatment results of adenoid cystic carcinoma (ACC) of the maxillary sinus.

METHODS

The clinical data of 80 patients with ACC of the maxillary sinus treated initially were analyzed retrospectively. Survival rate, local recurrence and distant metastasis were analyzed using Kaplan-Meier method. Prognosis factors were analyzed by Log-rank test and Cox regression.

RESULTS

The 5-, 10- and 15-year cumulative overall survival rates were 65.2%, 37.1%, 26.3% respectively and 5-, 10-, and 15-year disease-free survival rates 50.7%, 30.7% and 24.5% respectively. The 5-, 10- and 15-year cumulative local control rates were 68.5%, 47.3% and 47.3% respectively and the cumulative distant metastasis rate were 32.8%, 48.8% and 48.8% respectively. Prognostic factors affecting survival included T stage, pathologic grade and the modes of treatment (P < 0.05). Patients with combined therapy composed of surgery and radiation had a better local control, compared with surgery or radiation alone (χ(2) = 18.33, P < 0.01), and surgery combined with postoperative radiation was prior to preoperative radiation combined with surgery (χ(2) = 6.64, P < 0.05). Patients treated with surgery combined with preoperative radiation, either with doses of ≥ 60 Gy or with negative margins, had a better local control, compared with doses < 60 Gy and with positive margins (χ(2) = 5.06, P < 0.05). The most of patients (62.8%) died of local recurrence.

CONCLUSIONS

The most of failure was due to recurrence. Combined therapy composed of surgery and radiation improves the local control and survival in patients with ACC of the maxillary sinus, compared with surgery or radiation alone. Surgery combined with postoperative radiation provides the best overall survival and local control and should be the first choice of treatments.