Multicentricity in papillary thyroid carcinoma: analysis of predictive factors

OBJECTIVES

Multicentricity has been cited as a rationale for total thyroidectomy in patients with papillary thyroid carcinoma (PTC) confined to one lobe. The purpose of this study was to examine the incidence of multicentricity of PTC in a cohort of 165 patients with PTC confined to one lobe and to examine clinical and pathologic features that may help predict for the presence of contralateral disease.

DESIGN

Retrospective review.

SETTING

Tertiary care hospital.

METHOD

A retrospective review of 165 patients with PTC confined to one lobe treated at the Toronto General Hospital from 1992 to 1997 was performed.

MAIN OUTCOME MEASURE

The predictive factors affecting the presence of multicentricity of PTC were analyzed.

RESULTS

The incidence of PTC present in the contralateral lobe was 56.3%. We were unable to find any correlation of multicentricity with age, sex, tumour size, extrathyroidal spread, thyroiditis, or tall cell variant of PTC. There were trends toward higher incidence of contralateral disease in those patients with a prior history of irradiation and those with lymphatic metastases, but these trends did not reach statistical significance.

CONCLUSIONS

The incidence of contralateral disease in papillary thyroid cancer treated at the Toronto Hospital was 56.3%. There was a higher incidence of contralaterality in those patients with a previous history of irradiation and in those with lymphatogenous metastases, but this did not reach statistical significance.

Survival results of neoadjuvant chemotherapy for advanced squamous cell carcinoma of the head and neck

BACKGROUND

We carried out an open, randomized multi-center clinical trial for advanced head and neck cancer between April 1991 and December 1992. In this report, we update the results and analyze the 5-year survival results.

METHODS

Thirty-two patients with previously untreated stage III and IV resectable squamous cell carcinoma of the oral cavity and pharynx were entered into the study. The PEM regimen consisted of cisplatin 60 mg/m2 2 h infusion on day 1, etoposide 40 mg/m2 1 h infusion on days 1, 2 and 3 and mitomycin-C 7 mg/m2 i.v. bolus on day 1.

RESULTS

Among the 32 patients entered into this trial, eight were disqualified from the analysis. Of the remaining 24 patients, 13 were given neoadjuvant chemotherapy (NAC) and 11 underwent surgery alone. Among the 13 patients who received NAC, four achieved a complete response (31%) and three a partial response (23%), with an overall response rate of 54%. Myelosuppression was a major side effect. Thrombocytopenia and anemia were dose-limiting toxicities. Other adverse reactions, including mucositis, were all mild and transient. The overall 5-year survival after NAC and without NAC were 83 and 62%, respectively. The survival difference was not statistically significant (p = 0.33).

CONCLUSIONS

NAC does not appear to play a role in the treatment of cancer of the oral cavity and pharynx with our PEM regimen. However, the degree of toxicity was limited in our trial and therefore attempts to increase the dosage and/or revise the administration schedule for cancer of the pharynx and T1 to T3 tumor disease appear warranted.

Use of vertical median forehead flap in the reconstruction of the anterior skull base: report of two cases

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.

[Head and neck cancer]

Before CDDP was clinically used, combination chemotherapy regimens like BLM + MMC, VCR + MTX-LV + BLM, VCR + MTX-LV + BLM + MMC had been used for recurrent tumors of the head and neck. In a phase II study with CDDP, we experienced two patients with long-term survival (12, 15+) who were treated with CDDP as a second-line chemotherapy for recurrent tumors. Cisplatin was evaluated as a potentially curative agent. After that, CDDP based regimens have been used as neo-adjuvant setting (first-line chemotherapy). So it became quite difficult to make up a second-line chemotherapy since CDDP based regimens have been used as the first-line chemotherapy. We conducted basic research on second-line chemotherapy for recurrent head and neck cancer: (1) cross-resistance studies on head and neck cancer cell lines resistant to CDDP, 5-FU, MTX and BLM; (2) second line chemotherapy for CDDP + PEP combination chemotherapy, which was developed by us, in human KB cell line; and (3) effects of etoposide plus mitomycin C on head and neck squamous cell carcinoma in monolayer and multicellular tumor spheroid. Based on our long-term experience with chemotherapy for head and neck cancer, and the results of the above-mentioned basic research, we established a policy to select second-line chemotherapy for recurrent head and neck cancer, especially in cases previously treated with chemotherapy.

Papillary adenocarcinoma possibly arising from an intraductal papilloma of the parotid gland

We report a case of a 70-year-old female with a papillary adenocarcinoma which we believe to have originated from an intraductal papilloma of the parotid gland. A few cases of intraductal papilloma of a minor salivary gland have been reported; however, to our knowledge, intraductal papilloma and, hence, adenocarcinoma originating from an intraductal papilloma of the parotid gland, have never been described.

Primary small cell carcinoma of the larynx

Small cell carcinoma is a rare tumor of the larynx. We present such a case in a 78-year-old female. The histopathological diagnosis at the time of laryngomicroscopic biopsy was squamous cell carcinoma, upon which basis we initially chose surgical treatment. The surgical specimen, however, revealed small cell carcinoma. Despite the administration of radiotherapy and chemotherapy, the patient died 9 months after initial presentation. We believe that this case illustrates the need for a sufficiently large biopsy specimen in order to arrive at the correct histopathological diagnosis when small cell carcinoma of the larynx is present, and that immunohistochemistry and electron microscopy should be performed to aid the diagnosis.

[Intra-arterial chemotherapy of maxillary sinus carcinoma]

The long-term results and the preservation rate of maxillo-facial functions and structures were reviewed in 250 cases of maxillary sinus carcinoma which were treated at the Department of Otolaryngology of Keio University Hospital from 1957 to 1987, dividing them into 4 groups according to treatment modalities. The major treatment modalities of each group are as follows. I (1957-1966): Half of the cases underwent radical resection of the maxillo-facial region with or without postoperative irradiation. Preoperative intra-arterial chemotherapy was first introduced in 1963. II (1967-1973): Half of the cases received preoperative intra-arterial chemotherapy with bleomycin (BLM). III (1974-1981): The major treatment modalities consist of BLM ia + radiation----surgery and 5-FU ia + radiation. IV (1982-1987): Multidisciplinary treatment incorporating intra-arterial neoadjuvant chemotherapy mainly with cisplatin and peplomycin was performed. The 5-year survival rates of each group are as follows. I: 22%, II: 40%, III: 42%, IV: 55%. The 5-year survival rate was as high as 52% in cases treated with BLM ia followed by surgery in group II, but all cases underwent total maxillectomy. Meanwhile, in group IV, the 5-year survival rate was not only as high as 55%, but also the rate of total maxillectomy was quite low (18%). From these results, we realized that intra-arterial chemotherapy played an important role for improving the long-term results and preserving the functions and structures in the treatment of maxillary sinus carcinoma.

[Multidisciplinary treatment of head and neck cancer]

This presentation deals with multidisciplinary treatment of head and neck cancer, especially focusing on maxillary sinus carcinoma (MSC) and nasopharyngeal carcinoma (NPC). Since 1982, a new multidisciplinary treatment incorporating neo-adjuvant chemotherapy has been introduced in the treatment of MSC. The Neo-adjuvant chemotherapy includes cisplatin (CDDP) + peplomycin (PEP), adriamycin (ADR) analogs + CDDP + PEP, and CDDP +5-FU. Two courses of chemotherapy were given intraarterially with the interval of 2 weeks. Routinely, radiotherapy of 40 Gy by Linac was given to the primary tumor site, concomitantly combined with 5-FU intraarterial injections only during the first 10 days, 2 weeks after the end of chemotherapy. Additional treatment was performed according to the extent of the residual tumors. The 5-year survival rate for the 28 patients treated with this therapy was 55%. The 5-year survival rate by T classification was 100% for T2, 76% for T3 and 0% for T4 cases. The preservation rate of maxillo-facial structures and functions was 82%. Concerning NPC, neo-adjuvant chemotherapy included CDDP + PEP, ADR + CDDP + PEP and ADR + cyclophosphamide + PEP. Two courses of chemotherapy were performed, followed by radiotherapy of 60 Gy by Linac. Then intracavitary 60Co therapy was performed, followed by adjuvant chemoimmunotherapy. The 5-year survival rate for 21 patients treated with this therapy was 44%.

CONCLUSIONS

(1) The 5-year survival rate was better for patients with MSC who were treated with multidisciplinary treatment incorporating intraarterial neo-adjuvant chemotherapy than that for patients who received other treatment so far. Furthermore, the highest preservation rate of maxillo-facial structures and functions was achieved in the neo-adjuvant chemotherapy group. However, survival rates for T4 cases were very poor, so another approach should be taken. (2) The 5-year survival rate was also better for patients with NPC who were given multidisciplinary treatment than for patients who received other treatment to date. However, there was no decrease of distant metastases, which we aimed initially, despite the introduction of neo-adjuvant chemotherapy.

[Combined radiotherapy and chemotherapy for head and neck cancer]

There are 4 modalities of combined radiotherapy and chemotherapy which include (1) concurrent radiotherapy and chemotherapy, (2) sequential use of radiotherapy and chemotherapy (pre-radiation chemotherapy), (3) pre-radiation chemotherapy followed by concurrent radiation and chemotherapy, and (4) alternating use of radiotherapy and chemotherapy based upon Looney's hypothesis. We studied concurrent use of radiotherapy and UFT by means of animal experimentation and clinical trials. The results obtained revealed that UFT was a most suitable agent together with 5-fluorouracil for concurrent application of radiotherapy and chemotherapy. Neoadjuvant chemotherapy including pre-radiation chemotherapy was also studied in cases of maxillary sinus carcinoma and nasopharyngeal carcinoma. From the results, it seemed desirable to use cisplatin and bleomycin analogs sequentially in combined chemotherapy and radiotherapy. Neo-adjuvant chemotherapy should be studied successively to improve local tumor control rates and prevent distant metastases. For future perspectives, new trials of alternating radiotherapy and chemotherapy based upon Looney's hypothesis seem necessary.

[Radical excision followed by reconstruction of recurrent cancers of the head and neck]

Various modalities of treatment for recurrent cancers of the head and neck were studied and discussed, focusing especially on radical excision followed by reconstruction. Thirty-two patients with recurrent cancer of the head and neck were given this treatment over a 12-year period. Pectoralis major myocutaneous flap was most commonly used for reconstruction, while free latissimus dorsi myocutaneous flap with microneurovascular anastomosis was used for total cheek defect after surgery for cancer of the maxillary sinus. Five-year survival was 62% in cases of radical excision followed by reconstruction. Simple resection of recurrent lesions was conducted in 36 cases and the 5-year survival was also 62%. Radical neck dissection was performed in 22 cases in which cervical node metastases developed after control of the primary tumor, and the 5-year survival was 52%. On the other hand, the 5-year survival was not obtained in cases treated with radiotherapy alone in this series, while the 5-year survival was only 1% in cases treated with chemotherapy alone. It was concluded that surgery was the most reliable treatment for recurrent cancers of the head and neck, and that radical excision followed by reconstruction played an important role as salvage surgery.