Aerodigestive Tract Malignancies Research Articles

Neck masses: diagnostic analysis of 630 cases in Turkish population

Neck masses can be classified into three main categories: congenital, inflammatory and neoplastic. Our aim was to determine the distribution of diagnosis in patients who were followed-up for a neck mass and had undergone surgery for diagnostic indications. Six hundred and thirty cases referred to the Otorhinolaryngology and Head Neck Surgery Department of Haseki Research and Training Hospital between January 2005 and February 2012 with a neck mass who underwent excisional or incisional biopsy to establish a histopathologic diagnosis were retrospectively evaluated. Patients with a diagnosis of upper aerodigestive tract malignancy were excluded from the study. As well as the patients with thyroid masses were excluded. Only unknown primary neck masses were included in the study. The neck masses were categorized as inflammatory (33.49%), congenital (18.9%) or neoplastic (47.6%). Neoplastic masses were either benign (51%) or malignant (49%) tumors. The most common causes were tuberculous lymphadenitis (40.28%) among inflammatory masses, thyroglossal duct cysts (32.77%) among congenital masses, pleomorphic adenoma (22.33%) among benign neoplastic masses, and lymphoma (20%) among malignant neoplastic masses. The most common types of mass were congenital in the 0-20year age group, benign neoplastic in 21-40-year-old and malignant neoplastic in the >40-year group. Any neck mass, especially in an elderly patient, should be managed with caution as a considerable proportion may be malignant. In children and adolescents, a neck mass requiring surgery is most likely to be congenital. Tuberculosis should be considered as a cause of a neck mass due to a long-term inflammatory process in a developing country.

Cervicofacial and Cervicothoracic Rotation Flaps: An Update

Objective: 1) Understand the indications for use of the cervicofacial and cervicothoracic advancement flaps in head and neck reconstruction. 2) Learn the surgical technique for constructing cervicofacial and cervicothoracic advancement flaps in head and neck reconstruction. 3) Describe the varying defects that can be reconstructed with cervicofacial and cervicothoracic advancement flaps. Method: Retrospective review of medical records at a university-based head and neck cancer center. Patients were operated on between 2001 and 2012. Patients had varying lesions that were amenable to cervicofacial and/or cervicothroacic advancement flaps. After a thorough description of indications and defect locations, complications and flap viability were evaluated. Results: Sixty-nine patients were identified, with a mean age of 66 years. Primary or recurrent skin neoplasms made up the most common surgical indication, followed by primary parotid tumors and cervical metastases from aerodigestive tract malignancies. Defects of the cheek, orbit, periauricular region, and neck were reconstructed with cervicofacial or cervicothoracic flaps. Larger wounds required extension of the incision onto the chest wall. Other reconstructive modalities were used in 38 cases to increase tissue bulk or provide internal lining. Minor wound complications occurred in 15 patients. There was no statistically significant association between wound complications and smoking or previous radiation therapy. Conclusion: Compound cervicofacial and cervicothoracic rotation flaps provide a straightforward, reliable, and efficient means to reconstruct compledefects of the face, lateral skull.

Serum biomarker modulation following molecular targeting of epidermal growth factor and cyclooxygenase pathways: A pilot randomized trial in head and neck cancer

Targeting the epidermal growth factor receptor (EGFR) using the tyrosine kinase inhibitor (TKI) erlotinib has demonstrated activity in aerodigestive tract malignancies. Co-targeting of the G-protein-coupled receptor cyclooxygenase (COX) with EGFR inhibitors has shown promise in preclinical models and early phase clinical studies. We studied the modulation of serum proteins after neoadjuvant treatment with erlotinib with or without sulindac in head and neck cancer patients. In a prospective, randomized, double-blind clinical trial, paired serum samples were obtained before and after neoadjuvant treatment in three groups of patients (n = 23 total), who were randomized to receive 7-14 consecutive days of erlotinib alone, erlotinib plus sulindac, or placebo. Two separate multiplexed ELISA systems (SearchLight™ or Luminex™) were used to measure serum biomarkers. HGF and IL-6 levels were tested on both systems, and validated using single analyte ELISAs. Several analytes were significantly altered (generally decreased) post-treatment, in patients who received erlotinib (with or without sulindac) as well as in the placebo groups. No single analyte was differentially altered across the three treatment groups using either multiplex platform. Single HGF ELISA suggested a nonspecific decrease in all patients. These results demonstrate the importance of a placebo group when assessing changes in expression of serum biomarkers. While multiplex platforms can provide quantitative information on a large number of serum analytes, results should be cautiously compared across platforms due to their intrinsic features. Furthermore, the dynamic range of expression of a single analyte is constrained in multiplex versus standard ELISA.

Comprehensive approach to restoration of function in patients with radiation‐induced pharyngoesophageal stenosis: Report of 31 patients and proposal of new classification scheme

The treatment for upper aerodigestive tract malignancy with external beam radiation therapy and chemotherapy can result in a "cure," yet result in pharyngoesophageal (PE) stenosis. To improve communication, compare therapeutic results, and assist in treatment planning, we developed a new classification system to describe PE stenoses. Additionally, we analyzed our 6-year experience. The new classification system was defined and used to assess patient management. Thirty-one patients underwent treatment for PE stenoses using: 4 rendezvous dilations, 3 regional, and 24 free tissue transfers. Overall success was based on airway status, speech, and swallowing outcomes. Classification of posttreatment stenoses has been applied to this patient group. It is effective in defining the problem and considerations related to treatment planning and surgical access when augmentation pharyngoplasty is required. Patients with an intact larynx have many issues that make recovery of function less consistent, despite segment restoration.

The Utility of Frozen Section Margin Analysis in Transoral Robotic Surgery

Objective: Determine the benefit of frozen section margin analysis on oncologic specimens resected via Transoral Robotic Surgery (TORS). Method: A retrospective, single institution chart review of 150 consecutive patients with upper aerodigestive tract malignancies who underwent Transoral Robotic Surgery with intraoperative frozen section margin analysis between April 2007 and November 2010. Results: A total of 105 of the 150 cases were found to have negative tumor margins on initial tumor extripation. None of these patients were found to have delayed positive margins on permanent section analysis. Forty-five patients were found to have 1 or more positive margins on frozen section analysis following initial tumor, and/or tumor margin resection. These positive margins were all re-resected until frozen section pathology was consistent with tumor free margins (no evidence of CIS or invasive carcinoma). Of the 45 patients who underwent re-resection of initial tumor involved margins, 2 were found to have positive margin disease on permanent section pathology. Conclusion: Frozen section margin analysis is a critical intraoperative tool in Transoral Robotic Surgery that accurately accesses margin free tumor resection. This technique allows for a single operative encounter consisting of initial tumor biopsy with rapid diagnosis, followed by immediate complete primary tumor resection with synchronous neck dissection when oncologically indicated.

State‐of‐the‐Art Endoscopic Management of Larynx and Pharynx Cancer

Program Description: Transoral treatment of larynx and pharynx cancer has been done for over a century. Despite substantial technical innovations such as enhanced imaging, innovative laser technologies, and robotics guidance systems, radiotherapy and/or chemotherapy dominate the treatment strategy at many institutions. In part, this is due to limited familiarity with recent novel endoscopic surgical approaches. Outcomes data on transoral microsurgical management for advanced oropharynx and larynx cancer will be presented to illustrate the efficacy of surgical management of these diseases. Robotics and laser photoangiolysis of laryngeal cancer are two emerging technologies that can enhance endoscopic surgery. These novel and innovative treatment technologies can potentially be combined in the future to expand the indications for endoscopic surgery. This miniseminar will highlight advantages and disadvantages of endoscopic techniques and update the attendees on state-of-the-art procedural innovations. Educational Objectives: 1) Understand outcomes data on transoral laser microsurgery for advanced oropharyngeal and laryngeal cancer. 2) Understand the emerging role of robotics in endoscopic surgical management of larynx and pharynx cancer. 3) Understand concepts of photoangiolysis in treatment of aerodigestive tract malignancy.

Aktinomykose im Bereich von Pharynx und Larynx

Cervicofacial actinomycosis is an uncommon infection and in most cases odontogenic in origin. Pharyngeal and/or laryngeal lesions, usually occurring secondary to mucosal trauma, are very rare and may mimic a malignant tumor. In such cases, which represent less than 1% of all cases, the differential diagnosis with upper aerodigestive tract malignancy remains challenging. We report a case of actinomycosis in a 56-year-old male patient who presented with an extensive, centrally necrotic mass in the oropharynx, hypopharynx and larynx region suspected to be a tumor. The lesion was diagnosed 6 months following accidental ingestion of an ear of corn and ultimately proved to be cervicofacial actinomycosis. The clinical and pathological features and current aspects of the diagnosis and treatment of cervicofacial actinomycosis are discussed.

The Natural History of Globus Pharyngeus

Globus pharyngeus is a common disorder and accounts for 5% of all ENT referrals. Objectives. To evaluate the role of barium swallow and endoscopy in these patients, to ascertain the incidence, if any, of aerodigestive tract malignancy in this group and to assess the natural evolution of globus pharyngeus. Materials and Methods. Seventy-nine patients underwent barium swallow and rigid oesophagoscopy for globus pharyngeus between January 2005 and October 2008. Fifty-five patients were contacted by phone on average 5 years and 3 months after intervention and asked if their symptoms still persisted. Twenty-four patients were uncontactable or lost to followup, three patients were deceased, two of cardiac related disease and one of renal failure. Results. The majority of patients, 36 of 55 (65%), had a normal barium swallow. Forty-five of 55 (82%) of patients had normal rigid endoscopies. Thirty-one of 55 (56%) patients were at an average followup time of 5 years and 3 months. No patient developed a malignant lesion. Conclusion. Globus pharyngeus is a relatively common but benign condition of indeterminate origin. Our study demonstrates that many of these patients spontaneously improve with time.

The diagnosis and management of globus: a perspective from Belgium

There is no standard protocol for managing globus pharyngeus. Checking the recent developments in this field regularly is of paramount importance. The commonest symptoms for which proton pump inhibitors are prescribed are globus (73%), followed by choking episodes (66%) and chronic cough (62%). Opinions remain divided about the role of upper esophageal sphincter hypertonicity in globus sensation. Upper aerodigestive tract malignancy is rare and must be excluded. Hypertrophy of the base of the tongue, heterotopic gastric mucosa, curled epiglottis, thyroid enlargement, rare benign or malignant tumors of the pharynx, excessive tension and Eagle's syndrome are possible causes. Flexible endoscopy is a frequently used examination, but there is a 'blind zone' under any upper aerodigestive tract malignancy, requiring rigid endoscopy for some indications. Barium swallow pharyngoesophagography should not be requested systematically for cancer detection. Dual-probe 24 h pH monitoring can help in the diagnosis of reflux. Impedance recording can be useful for the detection of acidic and nonacidic liquid and mist reflux events. Manometric measurements are consistent. Laryngopharyngeal symptoms, such as throat clearing, hoarseness, cough, and globus pharyngeus, are slower to resolve than esophageal symptoms. Nocturnal recovery of gastric acid secretion was demonstrated even with proton pump inhibitors. The symptoms disappeared with an additional H2 receptor antagonist. More awareness is required for patients complaining of globus pharyngeus.

Radiofrequency coblation for the resection of head and neck malignancies

To review the safety and efficacy of the use of radiofrequency coblation for endoscopic resection of upper aerodigestive tract malignancies and to compare length of procedures using coblation with CO(2) laser surgery. A retrospective case-note review of 40 adult patients with endoscopically treated mucosal squamous cell carcinoma of the head and neck, 20 having undergone resection using radiofrequency coblation and being case-matched to 20 treated with CO(2) laser. Coblation proved to be an effective method for resection of selected head and neck malignancies. It allows for much faster resection times than the CO(2) laser (P = 0.017) especially in the oropharynx (P = 0.007), but the large probes currently available can cause problems in assessment of adequate resection margins. Although current probe design limits the potential for resection of some tumors, radiofrequency coblation appears to be an attractive evolving technique for the endoscopic resection of selected upper aerodigestive tract malignancies.

18F-Fluorodeoxyglucose-positron emission tomography and bone scintigraphy for detecting bone metastases in patients with malignancies of the upper aerodigestive tract

The role of 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) in identifying bone metastases in patients with head and neck cancer is not clear. We compared the ability of FDG-PET and bone scintigraphy (BS) to detect bone metastases in patients with upper aerodigestive tract (UADT) malignancies. Patients with histologically confirmed malignancies in the UADT underwent both FDG-PET and BS at initial staging or follow-up. The two methods were compared in patients and in seven skeletal regions. Maximum standard uptake value (SUVmax) on PET was calculated in each lesion and compared between true- and false-positive lesions. This study included 564 eligible patients, of whom 17 had bone metastases. The spine was the most frequently involved site, followed by the lungs and liver. Both FDG-PET and BS had high specificity, accuracy, and negative predictive values for detecting bone metastases (>95% each), and the two methods did not differ in sensitivity, specificity, and predictive values (P>0.05). Both FDG-PET (n=15) and BS (n=14) yielded a significant number of false-positive results, which could be corrected by further work-ups and follow-up imaging. Compared with true-positive lesions, the false-positive lesions on FDG-PET were usually single (86.7% vs. 12.5%, P<0.001) and had lower mean SUVmax (2.4 vs. 5.6, P<0.001). FDG-PET is not more accurate than BS for detecting bone metastasis in patients with UADT cancer. Positive findings on FDG-PET or BS require further confirmation.

2390: Gastrostomy Tube and Tracheostomy Dependence After Transoral Laser Microsurgery and Postoperative Radiation for Advanced Stage Base of Tongue Carcinoma

Transoral laser microsurgery (TLM) offers an attractive alternative organ sparing surgical therapy in the management of upper aerodigestive tract malignancies. We report the oncologic and functional outcomes of TLM and adjuvant external beam radiation from our experience in the treatment of advanced squamous cell carcinoma of the tongue base.

Case report of yerba maté drinking and persistent oral lesions

Yerba maté is a tea-like beverage (an infusion of Ilex paraguariensis) that is commonly consumed in many parts of South America. The drinking of maté is a social habit, and some research suggests that it is a risk factor for upper aerodigestive tract malignancies including the oral cavity, oropharynx, larynx and esophagus. Smoking and alcohol drinking are often strongly associated with maté consumption in most South American populations. In this case report, a patient that chronically consumed maté presented with various oral lesions requiring biopsy.

Does loss of heterozygosity in critical genome regions predict a local relapse in patients after laryngectomy?

Background Patients, who had an upper aerodigestive tract malignancy, have a high incidence of succeeding tumor development. This has been attributed to the role of “field cancerization” in carcinogenesis. The aim of this study was analysis of loss of heterozygosity (LOH) in the regions frequently lost during the course of head and neck squamous cell carcinomas (HNSCC), especially at early stages, which could answer the clinicians’ question, if LOH analysis has any “predictive” value in relation to tumor occurrence. Material and methods Sixty-five larynx cancer patients were examined for loss of heterozygosity on 3p, 7q, 8p, 9p and 18q chromosomal arms with the use of 12 microsatellite markers. The material from a single patient consisted of blood, tumor, safe margin and one or two clinically unchanged mucosal samples. During follow up, the material from brush specimens (14 patients) as well as laryngeal swabs (4 patients) was also examined. Results The highest frequency of LOH was detected for marker D3S1234 in tumor tissues (29%). Analysis of margin samples (b) revealed low LOH frequencies (2–5%) and complete retention of heterozygosity for markers: D3S1234, D7S486, D8S261, D8S264, D9S171 and D18S46. Similarly, for normal appearing mucosa from upper part of larynx (c) frequencies of LOH were low (2–6%), with the complete retention of heterozygosity for markers: D3S1284, D3S1304, D3S1234, D8S264 and D9S1870. We did not detect any LOH in the material of normal appearing mucosa from tracheostoma region (d). During follow up, LOH was detected for eight markers, with the highest incidence for markers D18S46 (six cases), D7S486 (four cases) and D3S1300 (three cases). Conclusions The data, obtained during this investigation, did not reveal the predictive value of LOH with respect to local relapse occurrence in laryngeal cancer patients. However, time of follow up did not reach 5 years, so that further clinical monitoring should be conducted.

The prosthodontist′s role in head and neck cancer and Introduction - Oncologic dentistry

A comprehensive oral and dental screening should be part of the pre-treatment workup of patients with cancer, especially those who have head and neck tumors. This screening needs to be performed by a Prosthodontist who is familiar with the pathologic process of disease and the type of treatment being rendered; and who comprehends the morbidities associated with eradicating malignancy. Oftentimes, this is a specially trained prosthodontist. According to WHO statistics, individuals living in the Indian subcontinent have the highest prevalence of oral and upper aero-digestive tract malignancies. The afflicted may develop oral complications of cancer treatment, especially from systemic chemotherapy and head and neck radiation therapy. The trend toward people maintaining their teeth longer, coupled with the rising age of the population, suggest that dentists may frequently be treating patients with cancer and should be informed about the aspects of care that will affect oral health. Unfortunately however, when the cancer curricula of dental schools was investigated, it was found that deficits in oncologic dentistry education included failure to provide practical clinical oncology experience in diagnosis, the decision-making process, referral procedures, management of oral complications of cancer therapy, maxillofacial rehabilitation; and psychosocial training in oncology. This article is intended as a primer for prosthodontists, most of whom undoubtedly will need to deal with cancer patients. It is suggested that the prosthodontic curriculum in India include all aspects of oncologic dentistry.

Cervicofacial and cervicothoracic rotation flaps in head and neck reconstruction

Compound cervicofacial and cervicothoracic rotation flaps are highly versatile flaps that may be applied to a variety of defects of the cheek, orbit, periauricular region, and neck. These rotation advancement flaps should be a staple of the head and neck surgeon's reconstructive armamentarium. This is a retrospective review of medical records at a university-based head and neck cancer center. Thirty-three patients were identified, with a mean age of 66 years. Primary or recurrent skin neoplasms made up the most common indication for surgery, followed by primary parotid tumors and cervical lymphatic metastases from upper aerodigestive tract malignancies. Defects of the cheek, orbit, periauricular region, and neck were reconstructed with cervicofacial or cervicothoracic flaps, with larger wounds requiring variable extension of the incision onto the chest wall. Other reconstructive modalities were used in 18 cases to increase tissue bulk or provide internal lining. Minor wound complications occurred in 13 patients. There was no statistically significant association between wound complications and smoking or previous radiation therapy. Compound cervicofacial and cervicothoracic rotation flaps provide a straightforward, reliable, and efficient means to reconstruct complex defects of the face, lateral skull base, and neck, with the potential for excellent cosmetic results.

Longitudinal study of smoking patterns in relation to the development of smoking-related secondary primary tumors in patients with upper aerodigestive tract malignancies.

The authors set out to assess the correlation between smoking-related second primary tumor (SPT) development and cigarette smoking habits after diagnosis and definitive treatment in patients with early-stage head and neck squamous cell carcinoma who were enrolled in a placebo-controlled randomized chemoprevention trial of 13-cis-retinoic acid. Longitudinal data collected for 10 years after the index diagnosis are presented for 1190 patients. Cox proportional hazards regression models were used to examine the effects of changes in smoking behavior on smoking-related SPT development. One-third of all patients who quit smoking within 12 months before randomization experienced recurrence, compared with 6.9% and 10.4% of all never-smokers and former smokers, respectively. Approximately 16% of all current smokers stopped smoking, and nearly 22% of current smokers developed SPTs, compared with 14.5%, 13.2%, and 8.8% of all recent smokers, former smokers, and never-smokers, respectively. The probability of developing a smoking-related SPT was highest among patients who were current smokers at randomization. These patients, regardless of whether they ceased smoking during follow-up, were nearly three times more likely than patients who had never smoked to develop a smoking-related SPT. In contrast, former smokers and recent quitters who continued to abstain from smoking during follow-up were approximately 1.5 times more likely to develop an SPT compared with patients who had never smoked. Patients who continue to smoke after the successful treatment of their index head and neck malignancies have a substantially higher risk of developing smoking-related SPTs.

Mohs micrographic surgery and the otolaryngologist

Objective The purpose of this study was to provide an update and overview of the current indications for Mohs micrographic surgery (MMS) for cutaneous and upper aerodigestive tract malignancies. Study design Literature review. Methods A comprehensive review of the literature from 1971 to present was completed by using the Medline data base. In addition, interviews were obtained with several otolaryngologists who had used the technique. Results MMS offers a superior alternative to standard excision in a variety of cutaneous malignancies. Overall, for the skin cancers likely to be encountered by the otolaryngologist, there is significant evidence that MMS offers increased rates of cure as well as tissue conservation. The role of MMS in upper aerodigestive tract malignancies continues to evolve and multiple issues must be addressed before its general application. Conclusions When confronted with a difficult cutaneous malignancy, the otolaryngologist should consider MMS to optimize treatment results.

Management of globus pharyngeus: review of 699 cases.

The principal reason for performing investigations in patients with globus pharyngeus is to detect a pharyngeal or upper oesophageal malignancy presenting this way. There is uncertainty regarding both the necessity for investigation in globus patients and the first line investigation of choice in the screening of such patients. The authors therefore undertook a retrospective study of 699 patients who presented with globus sensation. Of these, 451 patients (64.5 per cent) had a typical history and in these patients, outpatient examination, including fibre-optic nasendoscopy was able to detect all pathologies, except one insignificant pharyngeal pouch, which required no intervention and one patient with a distal peptic stricture. In patients with atypical symptoms the combination of fibre-optic nasendoscopy and barium swallow identified all pathologies (five aerodigestive tract malignancies) except one distal peptic stricture. The authors concluded that if out-patient examination is adequate, no further investigation of typical globus symptoms is required. Such a policy would produce significant savings for both out-patient and radiology services.

Outcomes research in head and neck reconstruction.

Modern management of advanced upper aerodigestive tract malignancy often results in profound effects on function and appearance. These functions include speech, deglutition, mastication, taste, oral hygiene, and airway maintenance. The most commonly studied site in the head and neck is the oromandibular complex. The primary goals of reconstruction are the preservation and restoration of these functions along with socially acceptable cosmesis. Achieving these objectives is not to be accomplished at the expense of acceptable oncologic principles. With the availability of microvascular free tissue techniques, single-stage oromandibular reconstruction is now commonly performed. Few studies, however, have critically examined the functional outcomes of these techniques. To date, these investigations have been limited and retrospective. Lack of a uniform system for reporting defect size and locations as well as patient function and quality of life has limited the utility of the available data. In this article, outcomes research in head and neck reconstruction is discussed with regard to objective study parameters using the oral cavity as a model. Pertinent current literature is cited.