Non-invasive imaging of freshly excised parathyroid glands using confocal reflectance microscopy

Background

Successful surgical management of primary hyperparathyroidism requires an understanding of the underlying pathological diagnosis. Various methods have been employed to distinguish normal from hyperfunctional diseased glands. Confocal reflectance microscopy (CRM) is a novel optical method of imaging tissue non-invasively without the need for fixation, sectioning and staining as in standard histopathology. Gray-scale images are displayed in real time on a monitor, and represent horizontal (en face) optical sections through the tissue. Using CRM, the goal of this study was to delineate histological features characteristic of the parathyroid gland, and to determine if confocal imaging could distinguish normal from adenomatous parathyroid tissue.

Methods

In this pilot observational cohort study, a total of 18 parathyroid glands was imaged using CRM immediately after excision in eight patients undergoing surgery for primary hyperparathyroidism. Confocal images were compared with corresponding permanent, haematoxylin and eosin-stained sections obtained from the same gland. For each patient, the percentage area occupied by fat cells was calculated in ten independent images (593 μm × 509 μm) of both normal and diseased glands.

Results

Characteristic histological features of the parathyroid gland were readily discernible by CRM and correlated well with permanent, haematoxylin and eosin-stained sections. The fat content of both normal and diseased glands could be determined easily. The percentage area occupied by fat cells was distinctly different in normal (mean(s.d.) 21·8(5·3) per cent) and diseased (0·9(2·4) per cent) parathyroid glands.

Conclusion

CRM rapidly revealed histological features of the parathyroid gland without histological processing. This new, simple, rapid and non-invasive technique has the potential for use as an adjunct to frozen-section analysis in intraoperative consultation during parathyroidectomy. This may provide a technique for in situ histological diagnosis of endocrine or other tissues without an excisional biopsy. Work is currently under way to develop an intraoperative probe for in vivo use.

A novel, noninvasive imaging technique for intraoperative assessment of parathyroid glands: confocal reflectance microscopy

BACKGROUND

Successful surgical management of primary hyperparathyroidism requires the ability to identify and distinguish normal from abnormal parathyroid tissue. Microscopic pathologic confirmation often helps with the diagnoses and decisions regarding the extent of parathyroid resection. Confocal reflectance microscopy (CRM) is an optical method of noninvasively imaging tissue without fixation, sectioning, and staining as in standard histopathology. The goal of this study was to determine if CRM imaging could be used to distinguish normal from diseased parathyroid tissue intraoperatively.

METHODS

In this study, 44 parathyroid glands from 21 patients undergoing operations for primary hyperparathyroidism were imaged immediately after excision. CRM images were compared with conventional hematoxylin-and-eosin stained sections obtained from the same gland. The percentage area occupied by fat cells was calculated in images of both normal and diseased glands.

RESULTS

Characteristic microscopic features of parathyroid glands were distinguishable by CRM and correlated well with histopathology. The stromal fat content of normal and diseased glands could easily be determined. The percentage area occupied by fat cells differed significantly (P <.00001) in normal glands (average, 23.0% +/- 10.9%) and adenomatous glands (average, 0.4% +/- 0.7%).

CONCLUSIONS

CRM imaging rapidly revealed microscopic features that reliably differentiated normal and diseased parathyroid glands. The success of this preliminary ex vivo study promotes interest in further development of an in situ probe for in vivo clinical diagnostic use.

Dedifferentiated chondrosarcoma of the larynx

A 74-year-old man with a history of a chondroid lesion of the larynx noted an enlarging neck mass. Axial CT showed a large expansile lesion arising from the left thyroid cartilage. Multiple rings and arcs with relatively intact cortex indicated a chondroid lesion. Irregularity of the anterolateral margin abutted a prominent soft-tissue component. The specimen obtained from fine needle aspiration was suggestive of a malignant fibrous histiocytoma. After further resection, the final diagnosis was dedifferentiated chondrosarcoma. A new soft-tissue component or rapid growth of the mass can be indicative of a diagnosis of dedifferentiated chondrosarcoma.

Optical integrating balloon device for photodynamic therapy

BACKGROUND AND OBJECTIVES

It is difficult to deliver light uniformly and efficiently over the complex shapes presented by various organs for photodynamic therapy (PDT). A balloon delivery device for photodynamic therapy was designed and tested for treatment of various anatomic tissues. The device uses the principle of optical integration by multiple internal diffuse reflections to achieve uniform output illumination.

STUDY DESIGN/MATERIALS AND METHODS

Soft, white, medical-grade silicone balloons were made in various shapes and tested for optical output, uniformity, efficiency, and power capabilities. Balloons were cast to be approximately the shape of the target tissue surface, organ, or cavity. Laser power was introduced into the saline-filled balloon by one or more fiber optics. Devices were constructed and used to illuminate oral mucosa and uterine endometrium for PDT.

RESULTS

The balloon walls had low optical absorption, high diffuse reflectivity (80-95%), and low diffuse transmittance (5-20%) in the 500- to 900-nm wavelength region. Optical efficiencies of 65% were typical with emitted light over complex, nonspherical surfaces. Efficiency increased with inflation of the device, such that irradiance (power/area) at the balloon surface was nearly constant with inflation.

CONCLUSION

Optically integrating balloons can provide highly uniform, efficient light exposure over complex tissue surfaces. Uniformity and irradiance were not strongly affected by balloon inflation, and these robust devices are easy to produce in essentially any shape.

Noninvasive imaging of human oral mucosa in vivo by confocal reflectance microscopy

OBJECTIVES/HYPOTHESIS

To study the microscopic anatomy of normal oral tissues in vivo using confocal reflectance microscopy (CRM). This novel and noninvasive imaging modality can define and characterize healthy oral mucosa and thus this work serves as the foundation for studying oral diseases in vivo.

STUDY DESIGN

This was a pilot observational cohort study comparing noninvasive CRM images with histology.

MATERIALS AND METHODS

Lip and tongue mucosa were imaged by CRM in six healthy human subjects. In CRM living tissue is illuminated by a laser source and backscattered (or reflected) light is collected by a detector. Image contrast is determined by natural differences in refractive indices of organelles and other subcellular structures within the tissues. Gray-scale images were displayed in real-time on a video monitor and represented horizontal (en face) optical sections through the tissue. Motion of the oral tissue relative to the objective lens was minimized with a tissue stabilizer. After imaging, biopsies were taken from the same site of lip mucosa to correlate noninvasive confocal images with conventional histology.

RESULTS

Confocal images correlated well with conventional histology, both qualitatively (visual analysis) and quantitatively (stereology). Imaging was possible up to depths of 490 and 250 microm in the lip and tongue, respectively. Cells and organelles including nuclei, circulating blood cells, and extracellular matrix were clearly observed.

CONCLUSION

CRM provides details of normal human oral mucosa at the cellular level without the artifacts of histological processing, and thus has the potential for further development and use in clinical practice as a diagnostic tool for the early detection of oral cancer and precancer.

Extent of lymphadenectomy achieved by various modifications of neck dissection: a pathologic analysis

OBJECTIVES

Quantify the extent of lymphadenectomy achieved by the various modifications of neck dissection based on microscopic pathologic analysis.

STUDY DESIGN

Retrospective review of neck specimens of patients who underwent neck dissection for head and neck malignancies at our institution over a 5-year period.

METHODS

Charts and pathology report findings on patients who underwent neck dissection were reviewed. Patients who received preoperative chemotherapy or radiation therapy to the neck were excluded. The number of lymph nodes documented by pathologic microscopic examination for each specimen was recorded.

RESULTS

There were 164 neck specimens on 135 patients (29 patient had simultaneous bilateral neck dissection). Those were divided into four groups based on the nonlymphatic structures preserved. There were 58 radical neck dissections (radical neck dissections) (group 1), 50 modified radical neck dissections sparing the eleventh cranial nerve (group 2), 15 modified radical neck dissections sparing the eleventh cranial nerve and internal jugular vein (group 3), and 33 modified radical neck dissections sparing the eleventh cranial nerve, internal jugular vein, and sternocleidomastoid muscle (group 4). The remaining 8 had other modifications of radical neck dissection. The mean number of lymph nodes found per specimen was 34 in group 1, 27 in group 2, 31 in group 3, and 22 in group 4. We performed one-way between-group analysis of variance (ANOVA). Pair-wise comparisons of means were carried out subsequent to ANOVA utilizing the Fisher Exact Test. Group 4 was significantly different from all other groups. Additionally, group 2 significantly differed from group 1.

CONCLUSIONS

The extent of lymphadenectomy achieved by neck dissection decreases as the number of nonlymphatic structures preserved in the neck increases. The impact of this finding on the pathologic staging or prognosis needs further analysis.

Manometric study of paranasal sinus mucoceles

A paranasal sinus mucocele is a chronic cystlike lesion characterized by slowly progressive remodeling and expansion of the surrounding osseous walls. If left untreated, it may cause significant facial deformity, ophthalmic disturbances, and, in the worst instance, intracranial complications. According to a review of the literature, there is a long-held view that positive pressure exists within paranasal sinus mucoceles; however, to our knowledge, pressure measurements have not been recorded in humans. In this study, pressure measurements were taken of 4 paranasal sinus mucoceles by means of an 18-gauge needle probe and an amplified pressure transducer. The average value was +15 cm H2O with a range of +4 to +39 cm H2O. This study confirms the long-standing assumption that positive pressure exists within paranasal sinus mucoceles. The magnitude of the pressure was comparable to that which was found to be associated with bone resorption in several previously published studies. Further studies are needed to determine whether positive pressure and osseous remodeling are causally related in this condition.

Induction chemotherapy with docetaxel, cisplatin, fluorouracil, and leucovorin for squamous cell carcinoma of the head and neck: a phase I/II trial

PURPOSE

A phase I/II trial of docetaxel, cisplatin, fluorouracil (5-FU), and leucovorin (TPFL5) induction chemotherapy for patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

Twenty-three previously untreated patients with stage III or IV SCCHN and Eastern Cooperative Oncology Group functional status less than or equal to 2 were treated with TPFL5. Postchemotherapy home support included intravenous fluids, prophylactic antibiotics, and granulocyte colony-stimulating factor (G-CSF). Docetaxel dose was escalated to determine the maximum-tolerated dose (MTD). Fifteen patients were treated with three cycles of TPFL5 at MTD. Patients who achieved either a partial response (PR) or complete response (CR) to three cycles of TPFL5 then received definitive twice-daily radiation therapy. Toxicity and clinical and pathologic response to TPFL5 were assessed.

RESULTS

Twenty-three patients received a total of 69 cycles of TPFL5. The MTD was determined to be docetaxel 60 mg/m2. Dose-limiting toxicity (DLT) was neutropenia. Additional significant toxicities at MTD were nausea, mucositis, diarrhea, peripheral neuropathy, and sodium-wasting nephropathy. The overall response rate to TPFL5 was 100%, which included 14 of 23 (61%) clinical CRs and nine of 23 (39%) clinical PRs. Primary-site clinical and pathologic CR rates were 19 of 22 (86%) CRs and 20 of 22 (91%) CRs, respectively. Eight patients had less than a CR in the neck to chemotherapy and, therefore, had postradiation neck dissections, four of which were positive for residual tumor.

CONCLUSION

TPFL5 is a tolerable induction regimen in patients with good performance status. The DLT is neutropenia with significant mucositis, diarrhea, peripheral neuropathy, and sodium-wasting nephropathy. The high response rates to TPFL5 justify further evaluation of this combination of agents in the context of formal clinical trials.

Treatment of recurrent head and neck cancer with cisplatin and 5-fluorouracil vs. the same plus bleomycin and methotrexate

A prospective randomized trial of 62 patients with recurrent squamous cell carcinoma of the head and neck was conducted to compare the effectiveness of our standard chemotherapy program with that of our test regimen. The standard chemotherapy regimen consisted of cisplatin 80 mg/M2 on day 1 followed by 5-fluorouracil 800 mg/M2 days 2 through 6. Our test regimen consisted of the same two drugs plus 15 U bleomycin on day 1 and methotrexate 100 mg/M2 on day 16 followed in 24 hours with 15 mg leucovorin every 6 hours for six doses. One patient in each arm of the study was not evaluated. Among 29 patients receiving the two-drug regimen, there was 1 complete response and 10 partial responses (38% response rate). Among 31 patients receiving the four-drug regimen, there were 3 complete responses and 16 partial responses (61% response rate; two vs. four-drug regimen, P = .06). The failure-free survival in the four-drug group was better than the two-drug group, median 4.5 vs. 2.3 months (P = .02). The overall survival for both groups was the same (median of 7.8 months). A detailed analysis of toxicity did not reveal any important differences between the two regimens. The addition of bleomycin and methotrexate to our cisplatin and 5-fluorouracil regimen resulted in an increase in effectiveness without adding toxicity.

The current surgical management of carotid body paragangliomas

To determine if recent trends in evaluation and therapy have contributed to the successful surgical management of carotid body paragangliomas, we reviewed our experience over the past decade. Nineteen carotid body paragangliomas were identified in 17 patients. Eleven patients underwent complete, preoperative embolization of their afferent arteries with one complication. Calculated carotid body paragangliomas surface areas did not differ between the embolized 64.6 +/- 43.3 cm2 and nonembolized 63.0 +/- 57.9 cm2 lesions. Intraoperative blood loss was lower (p = 0.02) in the patients treated with embolization (372 +/- 213 ml) compared with their cohorts (609 +/- 564 ml). However, the operative times were equivalent 4.1 hours versus 4.5 hours in both groups. Intraoperative electroencephalographic (EEG) monitoring was used in 10 patients; in one patient the EEG indicated intraoperative thrombosis of the carotid artery, which was successfully treated by thrombectomy without complications. Two patients required carotid bifurcation resection and vascular reconstruction to remove the entire tumor; a late stroke manifested by contralateral hand weakness developed in one of these patients. The incidence of cranial nerve injury was low at 16%, with one transient ramus mandibularis paresis and two instances of vocal cord dysfunction. Two additional patients had a postoperative Horner's syndrome. We conclude that by diminishing intraoperative blood loss through complete and careful preoperative embolization and use of intraoperative EEG monitoring along with careful surgical technique, the complications associated with this challenging operation are facilitated and diminished.

Acute and chronic effects of bone ablation with a pulsed holmium laser

A pulsed holmium laser transmitted through a quartz fiber was used to create osteotomies in the facial bones and sinuses of rabbits. The ablation process was quantified and residual thermal injury was assessed by light microscopy. Adjacent thermal damage was determined to vary between 130 and 220 microns and was independent of radiant exposure and pulse repetition rate. In other studies, large osteotomies were made to examine the biological response and to assess the technical feasibility of using fiber-delivered laser pulses in an operative setting. The animals tolerated the procedure without obvious problems and postoperative follow-up revealed a vigorous healing response. Because it can ablate both bone and soft tissue and can be transmitted through readily available, flexible quartz fibers, the holmium laser may prove to be a useful adjunct to endoscopic sinus surgical procedures.

Adaptation to surgery for head and neck cancer

We examined the postoperative adjustment of 45 patients who underwent surgery for cancers of the head and neck: 23 who had laryngeal cancer, 18 who had oral cavity/oropharyngeal cancers, and 4 who had cancers of other sites. Patients were assessed preoperatively, and at 3 months and 9 to 12 months postsurgery. Interviews and questionnaires were used to assess depression, body image, limitations, pain, financial problems, need for help at home, and social interaction. Results revealed that pain, fatigue, weakness, and loss of speech were major concerns. Pain and financial concerns were worst at 3 months and then improved. Physical limitations increased steadily with time. Depression was a major factor in patients with oral cavity and oropharyngeal cancers. Of note, patients who underwent postoperative radiation therapy had the most difficulty adapting to their illness and treatment, with persistent limitations in function and social isolation. The implications of these findings are discussed.

Plasma-mediated excimer laser ablation of bone: a potential microsurgical tool

A pulsed ultraviolet excimer laser was used to ablate bone in vitro at 193, 248, 308, and 351 nm and in vivo at 193 nm. Ablation was dependent on sufficient fluence (energy delivered per unit area per pulse) for plasma formation at the target site at all wavelengths. Adjacent tissue damage at various fluences for each wavelength was examined using a light microscope. Damage was minimal at 193 nm (1 to 3 microns) and most extensive at 351 nm (60 to 75 microns). This is in sharp contrast to the 1 to 3 mm of adjacent thermal damage produced when carbon dioxide lasers are used to ablate bone. Differences in the degree and type of damage to adjacent tissues among the wavelengths studied indicated that other ablation mechanisms and tissue interactions are involved in addition to simple plasma vaporization of bone. Bleeding during and after ablation demonstrated that the use of this laser does not cause thermal damage, which would cauterize adjacent vessels. Pre- and post-mortem lesions made at identical power and pulse settings were of equal depth, indicating that bleeding does not affect the ablation rate. The excimer laser has potential as a microsurgical instrument for the precise removal of bone with minimal damage to adjacent structures.

Sports Injury to the Larynx and Trachea

In brief: Athletes in contact sports frequently sustain trauma to the upper aerodigestive system. However, because of the slow progression and/or lack of symptoms relating to injuries of the larynx and associated structures, an early diagnosis is often not made. Complications may follow shortly after such injuries or later, so athletes, coaches, and team physicians should have a working knowledge of the pathophysiology of these injuries. This article discusses the anatomy of this part of the body, as well as the diagnosis and treatment of injuries to the larynx and upper aerodigestive system. Principles of treatment of upper airway trauma in general and of specific injuries are also addressed.

Preliminary clinical results with low flip angle spin-echo MR imaging of the head and neck

A new approach for producing primarily T2- and proton-density-weighted MR images in less time than the conventional long TR, long TE imaging is to reduce the TR of a double spin-echo pulse sequence and to also reduce the RF excitation flip angle to minimize the resulting T1 sensitivity. In preliminary studies with a human volunteer and five patients with various diseases of the head and neck, conventional long TR, long TE and short TR, short TE images were compared with short TR, long TE images with reduced flip angles (45 degrees, 30 degrees), which required only 40% of the imaging time of the long TR images. The latter images showed a similar contrast pattern to the conventional T2-weighted image, and contrast-to-noise measurements indicated an increase in contrast between the lesion and nearby tissue when the flip angle was reduced. Furthermore, the maximum contrast/noise per unit imaging time on the short TR, long TE image was comparable to that on the long TR, long TE image. Optimization of the flip angle with short TR allows a substantial reduction in imaging time but with a reduction in multislice capability. This technique will be most useful in areas of complex anatomy where two or more orthogonal imaging planes are required, such as the head and neck.

Pectoralis major myocutaneous flap reconstruction of the laryngopharynx and cervical esophagus

Advanced carcinoma of the hypopharynx and cervical esophagus is a formidable challenge to the skills of the head and neck surgeon. Radiation therapy is valuable as adjunctive therapy when combined with curative surgery, which is the primary treatment modality. The extent of anatomical disease associated with extensive neoplasia of the hypopharynx and cervical esophagus is frequently not amenable to total laryngectomy with local tissue repair. Surgical ablation usually requires an extended laryngectomy, which does not permit primary local repair. A previous report by this author, comparing all techniques historically and chronologically, indicated that the present impetus is toward procedures characterized by a one-stage primary repair with shorter completion times. Presently, the three most promising procedures that meet these criteria are the gastric transposition, free microvascular bowel transfer, and regional myocutaneous flap repair. Theogaraj, et al. reported the use of a partially tubulated pectoralis muscle flap over preserved posterior wall cervical esophageal mucosa in cases of short segment stenosis. Encouraged by these results, a technique using partial tubulation for long-segment stenosis was reported. The use of this technique was expanded to include the repair of the defect left after total ablation of the laryngopharynx and cervical esophagus. Over the past 40 months, 22 patients have undergone repair using partial tubulation of the pectoralis myocutaneous flap. This paper will discuss the technical aspects of the procedure and analyze the procedure as it relates to mortality, morbidity, and completion time. Low morbidity and a completion time of 18 days competes favorably with gastric transposition and free jejunal transfer. A rational approach to reconstruction using all procedures will be discussed.

Infrared laser bone ablation

The bone ablation characteristics of five infrared lasers, including three pulsed lasers (Nd:YAG, lambda = 1,064 micron; Hol:YSGG, lambda = 2.10 micron; and Erb:YAG, lambda = 2.94 micron) and two continuous-wave lasers (Nd:YAG, lambda = 1.064 micron; and CO2, lambda = 10.6 micron), were studied. All laser ablations were performed in vitro, using moist, freshly dissected calvarium of guinea pig skulls. Quantitative etch rates of the three pulsed lasers were calculated. Light microscopy of histologic sections of ablated bone revealed a zone of tissue damage of 10 to 15 micron adjacent to the lesion edge in the case of the pulsed Nd:YAG and the Erb:YAG lasers, from 20 to 90 micron zone of tissue damage for bone ablated by the Hol:YSGG laser, and 60 to 135 micron zone of tissue damage in the case of the two continuous-wave lasers. Possible mechanisms of bone ablation and tissue damage are discussed.

Giant cell reparative granuloma of the ethmoid sinus

This article represents the fourth and fifth reported cases of GCRG that involve the ethmoid sinus. The problems encountered in establishing the diagnosis are emphasized, as are the features that differentiate it from the giant cell tumor, aneurysmal bone cyst, and hyperparathyroidism, the conditions with which it is most commonly confused. The unusually aggressive behavior, as demonstrated by these two cases, is highlighted.

An analysis of induction and adjuvant chemotherapy in the multidisciplinary treatment of squamous-cell carcinoma of the head and neck

This study examines the role of combination chemotherapy with surgery and/or radiotherapy in the initial treatment of patients with advanced stage III and IV squamous-cell carcinoma of the head and neck (SCCHN). Two courses of initial (induction) cisplatin, bleomycin, and methotrexate with oral calcium leucovorin (PBM) were used with the principal intent of increasing the effectiveness of subsequent surgery and/or radiotherapy. Following induction chemotherapy and local treatment, disease-free patients who had responded to initial chemotherapy were entered into a randomized trial of adjuvant PBM. The response rates to induction PBM chemotherapy were a complete response (CR) rate of 26% and a partial response (PR) rate of 52%, for an overall response rate of 78%. A response to induction PBM was highly correlated with failure-free survival (P less than .0001). A Cox multistep regression analysis of potential prognostic factors was performed. After adjusting for the significant prognostic factors of performance status, initial tumor size, and primary tumor site, a response to induction chemotherapy remained independently associated with improved survival (P = .0002). The randomized trial of adjuvant chemotherapy demonstrated that such treatment significantly improved failure-free survival by decreasing local-regional failures. The benefit of adjuvant chemotherapy was particularly evident in patients who had a PR to induction chemotherapy (P = .01). The toxicity of this multidisciplinary approach was predictable and acceptable. Surgery and radiotherapy were not compromised by induction or adjuvant chemotherapy. Definitive evidence that chemotherapy can favorably influence survival awaits confirmation of these results by a randomized trial using a control arm of patients treated with conventional surgery and/or radiotherapy alone.

Pathology of surgery after induction chemotherapy: an analysis of resectability and locoregional control

At the Dana-Farber Cancer Institute Head and Neck Cancer Clinic, 114 previously untreated patients with advanced squamous cell carcinoma of the head and neck (17% stage III; 83% stage IV) were managed with induction chemotherapy using cis-platinum, bleomycin, and methotrexate, followed by definitive extirpative surgery and/or radiation therapy. The present report evaluates this group from a surgical and surgical pathology standpoint. The following aspects are evaluated: predictability of, and conversion to, resectability during induction chemotherapy; ease of surgical technique and intraoperative assessment; patterns of pre-op and post-op risks and complications; gross and histopathologic observations of the extent and character of residual primary and nodal disease, particularly after a response to chemotherapy; patterns of locoregional control or failure related to treatment variables. The issues subsequently addressed include: how does chemotherapy affect the operative candidacy and resectability of proposed surgical patients? Could, or should surgery be eliminated in the management of some patients treated with induction chemotherapy? Can less radical surgery be contemplated in patients significantly "downstaged" by prior chemotherapy treatment? Is increased locoregional or distant metastatic control observed in these patients? What is the role of surgery in the responder to chemotherapy?

Osteomyelitis of the orbit. A case report

With the advent of the antibiotic era, the incidence of osteomyelitis has decreased remarkably. However, cases of trauma-induced orbital cellulitis, abscess, fistula formation, and osteomyelitis may still occur. The following case is illustrative of the chronicity of problems (8-year course) caused by retained orbital wooden foreign bodies.

Treatment complications after sequential combination chemotherapy and radiotherapy with or without surgery in previously untreated squamous cell carcinoma of the head and neck

One hundred consecutive patients with previously untreated advanced squamous cell carcinoma of the head and neck were treated with induction combination chemotherapy followed by definitive surgery and/or radiotherapy, and were evaluated for radiotherapy related toxicity. The induction regimen consisted of cisplatin, bleomycin and methotrexate/leucovorin. Acute toxicity consisted predominantly of mucositis and weight loss, and was mild or moderate by degree in 94% of patients. Six percent of patients experienced severe or life threatening acute toxicities. Two acute toxic deaths were noted in this series, one from a combination of mucositis, weight loss and infection and one from hypoglycemia of unknown origin. Thirty-five percent of patients had radiation treatment interrupted briefly because of acute toxicity. Toxicity was greatest in patients who were nonresponders to induction chemotherapy and such may have been related to the continued presence of advanced tumor. Radiotherapy dose, surgical intervention and age did not have an impact on the presence or degree of acute toxicity. Late toxicities included: hypothyroidism in 32% of patients tested: osteoradionecrosis in 5% of patients, associated primarily with a composite resection (4 of 5 cases); and soft tissue ulcerations in 3%. Taken together, these data indicate that induction combination chemotherapy did not significantly increase the toxicity of subsequent radiotherapy with or without surgery.

Reconstruction of the laryngopharynx and cervical esophagus

The historical evolution of reconstruction of the cervical esophagus and laryngopharynx over the past 100 years is documented. The impact of these technical achievements is contrasted to the failure to improve the 5-year survival rate of 24%. While the clinician awaits new protocols of treatment to improve survival statistics, the thrust of the surgical oncologist is to develop a reliable method of reconstruction which meets specific minimal criteria. The following objectives should be achieved: Reconstruction should not limit the effectiveness of the ablative technique. Short hospitalization and one stage techniques are superior. Technique mortality and morbidity must be low. A 10-year institutional study using the Montgomery 2-stage technique is presented. In contrast, comparative literature data analysis of all methods of laryngopharyngocervical reconstruction indicates that single stage techniques offer a greater advantage. This study suggests that visceroplasty (stomach), free jejunal transfer, and single stage reconstruction, using the pectoralis myocutaneous flap, approach the previously established criteria more effectively than others. A new technique (1-stage), using partial tubulation of the pectoralis major myocutaneous flap, is recommended for regional reconstruction of the cervical esophagus and pharynx. In order to decrease the pressure and torsion on the vascular pedicle of the pectoralis major myocutaneous flap and increase its predicted length, partial resection of the ipsilateral clavicle is proposed.

Advanced squamous carcinoma of the head and neck. A preliminary report of neoadjuvant chemotherapy with cisplatin, bleomycin, and methotrexate

Between Oct 1, 1979 and Aug 1, 1982, 93 patients with advanced squamous carcinoma of the head and neck were given neoadjuvant treatment with cisplatin, bleomycin sulfate, and methotrexate before standard local treatment. Ninety-three patients were evaluable for response. The response rates were as follows: complete response, 24%; partial response, 64%; and no response, 12%. Differences in primary tumor site, performance status at presentation, histologic grade, and tumor size did not correlate with response to this chemotherapy. For patients achieving notable tumor reduction to 2 cm or less, standard local treatment with either surgery plus radiotherapy or high-dose radiotherapy alone was effective in controlling local disease. For patients with larger tumor masses following neoadjuvant chemotherapy, surgical resectability appeared to improve local control rates. In our series, patients not receiving maximal standard local treatment often had relapse of local disease despite favorable responses to chemotherapy.

Incidence of hypothyroidism following multimodality treatment for advanced squamous cell cancer of the head and neck

The incidence of chemical hypothyroidism, as manifested by elevated thyroid stimulating hormone (TSH) levels, has been estimated to be as high as 25% after radiation therapy and 45% after radiation therapy and surgery to the neck for treatment of nodal metastases from squamous carcinoma of the head and neck. We prospectively evaluated 43 previously untreated patients seen in the Dana Farber Cancer Institute Interdisciplinary Head and Neck Service who were treated with aggressive combination chemotherapy in addition to standard surgery and/or radiotherapy. All patients were serially monitored for serum TSH, serum T4, and clinical evidence of hypothyroidism. Following cis-platinum, bleomycin, and methotrexate chemotherapy and subsequent surgery and/or radiotherapy, decreased thyroid reserve appeared in 37% of patients at a median follow-up of 9 months. Thirty percent of patients receiving radiotherapy alone and 43% of patients receiving surgery and radiotherapy developed elevated TSH levels. Only one patient developed clinical symptoms. Other patients were asymptomatic despite persistently elevated TSH levels. Abnormalities appeared within the first 4 months after completion of all therapy and were slowly progressive. The addition of combination chemotherapy does not appear to increase the incidence or severity of thyroid dysfunction following radiation therapy and surgery to the neck. In view of the extended survival seen in patients treated with interdisciplinary regimens, we recommend that all patients receiving irradiation to the neck--particularly those patients having neck dissections or total laryngectomies--have routine thyroid function studies performed following the cessation of treatment.

Small cell carcinomas of the larynx: results of combined modality treatments

Four cases of primary small cell carcinoma of the larynx are described. Two patients presented with extensive metastatic disease and two with tumor limited to the larynx. All four cases responded (3PR, 1CR) to systemic combination chemotherapy. Long-term remission was achieved in one patient with limited disease who underwent chemotherapy with a complete response followed by definitive radiotherapy. Treatment results are compared with previously reported cases. The importance of early diagnosis through staging, and combined treatment in small cell carcinoma of the larynx is discussed.

Central island myomucosal tongue flap

Resection of intermediate-sized (T2 and T3) lesions of the anterior floor of the mouth is often associated with defects in speech, glutition, and cosmesis despite reconstructive efforts. This paper describes the use of the central island myomucosal tongue flap to reconstruct defects of this size. Since this flap possesses the same vascular characteristics as the myocutaneous flap it offers similar advantages. Experience with seven patients in whom this flap was used suggested that this is a dependable method of anterior floor of mouth reconstruction since there was no evidence of nonviability, delayed healing, or wound breakdown. The advantages of this flap are: (a) it is rapidly developed from easily accessible local tissue, (b) it offers the same reliability as myocutaneous flaps, (c) it causes less disability of articulation and deglutition than other tongue flaps, and (d) it results in no cosmetic deformity.

Chemotherapy of advanced salivary gland neoplasms

Fourteen patients with advanced salivary gland malignancies were treated with combination chemotherapy. Five of 13 patients responded to cyclophosphamide and adriamycin and two patients in the responding groups underwent further potentially curable treatment, rendering them disease-free. Three patients with mucoepidermoid carcinoma failed to respond to this regimen, but two of three patients treated with a combination of cisplatinum, bleomycin and methotrexate responded. The potential role for chemotherapy in the treatment of salivary gland malignancies is discussed.

Toxicity of aggressive multimodality therapy including cisplatinum, bleomycin and methotrexate with radiation and/or surgery for advanced head and neck cancer

A combined modality regimen employing induction chemotherapy with cisplatinum, bleomycin and methotrexate followed by surgery and/or radiation therapy was initiated in patients with advanced squamous cell carcinoma of the head and neck. In the first 23 patients treated with this program there was a 90% response rate to induction chemotherapy (9% CR and 81% PR). Toxicity associated with radiotherapy, but not surgery, was increased with 11 of 23 patients (48%) who experienced some toxicity during or immediately after radiotherapy. Mucositis was worse than expected and severe delayed mucositis was seen in 2 patients, one or whom required hospitalization. Late complications, possibly related to therapy included one myocardial infarction and one episode of hypoglycemia, both of which were fatal. One other patient voluntarily failed to take prescribed oral leucovorin, dying of unrescued methotrexate toxicity during adjuvant therapy, a questionable suicide. Further follow-up and analysis of failure will be necessary to determine if the value of a combined modality regimen in producing an increased cure rate and long term survival will out weight increased toxicity.

Florid dermal cylindroma (turban tumor)

A florid case of dermal cylindroma is presented as representative of the natural history and usual clinical findings in a patient afflicted by this tumorous growth. Although histologically and clinically benign, dermal cylindroma can result in considerable disfigurement of the patient. Treatment varies from isolated primary resection to serial resections with subsequent electrocautery or cryosurgery for small recurrences. Total scalping with skin grafting is reserved for only the most severe cases where normal integument has been completely involved by the disease process.

Role of chemotherapy in the multidisciplinary approach to advanced head and neck cancer: potentials and problems

Chemotherapy as initial treatment for advanced squamous carcinoma has received much recent attention. Despite sparse experimental data supporting its usefulness, such chemotherapy is now used for a variety of advanced malignancies. This experience is conceptually reviewed, with special emphasis on squamous carcinoma of the head and neck. Factors which influence treatment results, such as drug dosage, radiation treatment planning, and surgical resection, will require careful analysis in the evolution of the multidisciplinary approach to advanced head and neck cancer.

Chemotherapy for advanced carcinoma of the head and neck. A clinical update

Optimal therapy for stage III and stage IV squamous carcinoma arising in the head and neck requires a multidisciplinary approach, including chemotherapy. Advances have identified several chemotherapeutic agents and combinations of agents that show substantial antitumor activity in this disease. While antitumor activity can be documented, experience indicates the duration of antitumor effect is short, and the toxicity may limit further therapy. To date, studies have not shown an advantage of combination chemotherapy over single agents. Theoretically, combination chemotherapy should increase patient survival through regression of the primary tumor as well as ablation of distant metastases. An analysis of recent trials with patients who received induction chemotherapy before definitive local treatment suggests that regression of tumor in stage III and stage IV lesions before definitive therapy may increase local treatment for regional disease. Randomized trials are needed to confirm or disprove the efficacy of combination chemotherapy for advanced squamous carcinoma of the head and neck.

The differential diagnosis of the mass in the neck. A fresh look

A diagnosis of undifferentiated carcinoma by light microscopy in a neck node biopsy is insufficient to come to a conclusive answer as to the type of tumor with which one is dealing. The fact that undifferentiated carcinoma by light microscopy may very well be a histiocytic lymphoma with a different mode of treatment and an increasingly improved cure rate has changed the mode of evaluation in arriving at a diagnosis of the node in the neck with no visible primary in the upper aerodigestive tract.

Traumatic carotid-cavernous sinus fistula

Seventy-five percent of carotid-cavernous sinus fistulae result from high velocity head trauma. The most common symptom is a pulse synchronous bruit which usually becomes apparent when the patient regains his sensorium. The objective manifestations of such an arteriovenous fistula are characteristically localized to the ipsilateral orbit. A periorbital bruit and venous engorgement of the palpebral and bulbar conjunctivae are pathognomonic features. Bilateral carotid angiography confirms the diagnosis and determines which of several techniques might be used to obliterate the fistula. Occasionally the classic signs and symptoms may be delayed for days or weeks. Thus, the maxillofacial surgeon must be aware of this clinical entity to avoid untimely repair of facial fractures with potentially disastrous consequences.