Supraglottic Larynx Research Articles

General Anesthesia in a Child with a Dynamic, Vascular Anterior Mediastinal Mass

THE patient with an anterior mediastinal mass presents the anesthesiologist with a formidable challenge. Severe respiratory and cardiovascular complications, including the inability to resuscitate, can ensue on induction of general anesthesia. We describe the anesthetic management of a child with a large dynamic vascular malformation located in the neck and mediastinum who underwent percutaneous sclerotherapy.

Pattern of Failure in Long-Term Survivors after Radio-Chemotherapy for Inoperable Head and Neck Cancer

Background: After conventionally fractionated radical radiotherapy for advanced unresectable squamous cell carcinoma of the tongue, the floor of mouth and the supraglottic larynx, oro- and hypopharynx loco-regional tumor control rates rarely exceed 30%. Therefore, cytotoxic chemotherapy has been added in an attempt to improve loco-regional tumor control rates and reduce the incidence of distant spread and ultimately long-term survival. Still, in these patients comorbidity may often compromise possible improvements achieved by treatment intensification. Patients and Methods: In a prospective phase II study from 1984 to 1989, patients with loco-regionally advanced head and neck carcinoma were treated with 3 courses of simultaneous radio-chemotherapy. Radiotherapy was administered in two fractions per day 1.8 Gy each. During one course from day 3 to day 11 23.4 Gy were delivered in 13 fractions. Chemotherapy consisted of cis-Platin 60 mg/m2, leucovorin 50 mg/m2 intravenous bolus and 5-FU 350 mg/m2 intravenous bolus on day 2 and leucovorin 100 mg/m2/24-hour continuous infusion and 5-FU 350 mg/m2/24 h from day 2 to 5. Treatment was repeated on days 22 and 44, total radiation dose was 70.2 Gy. From day 12 to 21 and 34 to 43 treatment breaks were scheduled. Results: 105 patients are evaluable with a follow-up from 36 to 105 months in surviving patients. The crude overall survival rate at 5 years is 29% the probability of progression-free survival is 39% (Kaplan-Meier estimations). Loco-regional recurrences were observed in 52 patients after a median interval of 11 (2-81) months. 16 patients developed distant metastases after a median interval of 21 (6-81) months. Conclusions: Compared with data from the literature the pattern of relapse is very similar to that observed after radical radiotherapy alone. Median interval to distant spread appears to be prolonged by simultaneous chemotherapy but this may be due to prolonged follow up. Three-year figures of loco-regional control and survival are valid parameters to apreciate long-term data. Since nearly a third of patients are long-term survivors chronic toxicity deserves special attention in future trials.

Radiothérapie exclusive de 250 cancers du larynx sus-glottique stade I–II

Two-hundred and fifty patients presenting with a stage I-II cancer of the supraglottic larynx were definitively treated with irradiation. The 5-year disease-free survival rate is 76%. Multivariate analysis reveals that the only statistically significant prognostic parameters are clinical stage (I versus II), and tumour site (epilarynx versus supraglottis).

Elective postoperative radiation therapy following supraglottic laryngectomy:A simple new technique

Preventing relapse in the neck is a major contemporary priority in cancers of the supraglottic larynx treated surgically. Previous studies have demonstrated that observing the clinically NO neck, or performing unilateral elective neck dissection, results in unacceptably high mortality. However, neither bilateral elective neck dissections nor postoperative bilateral elective neck irradiation have been uniformly embraced by head and neck oncologists because of fears that they would produce complications and damage the residual larynx. We undertook this study to evaluate the safety of postoperative neck radiotherapy, with the larynx shielded, after supraglottic laryngectomy. We treated 15 patients with T1–2, N0–3 disease by supraglottic laryngectomy followed by elective neck irradiation to a median dose of 56 Gy over 6 weeks. We shielded the residual larynx from irradiation because the primary margins were satisfactory in all of these patients. With follow-up periods ranging from 1.5 to 8.5 years (median 4.5 years), the incidence of complications was 0/15 (0%). The actuarial proportion of the patients who after 5 years remained free of relapse in the larynx was 100%, in the neck was 90%, and at distant sites was 80%. The cause-specific survival of the patients who initially presented with clinically N0–N1 necks was 100%, but with N2–N3 necks was only 20%. In conclusions, fears that postoperative irradiation would damage the residual larynx after supraglottic laryngectomy are quite unfounded when the larynx itself does not need to be irradiated and is shielded. Combining supraglottic laryngectomy with postoperative radiotherapy in this manner proved safe, with a cause-specific survival rate of 100% after 5 years in the patients without advanced neck disease. Better systemic therapy is necessary to help the patients with clinically advanced neck disease. Radiat. Oncol. Invest. 4:239–242, 1996. © 1997 Wiley-Liss, Inc.

Hyoepiglottic ligament in supraglottic cancer.

The hyoepiglottic ligament (HL) is a connective tissue structure that serves as the roof of both the paraglottic and the preepiglottic spaces and thereby anatomically separates the supraglottic larynx from the tongue base. Whole mount serially sectioned larynges with supraglottic cancer were reviewed to help clarify cephalad spread of cancer in this region. The whole mount slides were analyzed from 70 laryngectomy specimens that were resected for supraglottic cancer. The HL was breached by cancer in 13 specimens, and all of these displayed clinical and histopathologic invasion of the preepiglottic and paraglottic spaces. Invasion of the suprahyoid epiglottis was noted in 9 specimens, and invasion of the aryepiglottic fold in 4. There were no instances in which cancer escaped from the deep compartments of the supraglottic larynx to the tongue base without synchronous erosion of the suprahyoid epiglottis (insertion of the medial HL) or the pharyngoepiglottic fold (lateral HL). The HL is a resilient connective tissue barrier to the spread of cancer from the supraglottis to the tongue base. This investigation reinforced the concept that, typically, the HL acts as a deep cephalad surgical boundary in resecting supraglottic cancer that 1) is confined to the laryngeal membranes and 2) does not clinically invade the suprahyoid epiglottis.

Open Surgical Techniques for Laryngotracheal Stenosis

Adult subglottic and proximal tracheal stenoses are some of the most crippling complications of endotracheal intubation or other laryngotracheal trauma. Subglottic stenoses are a part of the broader category of laryngotracheal stenoses that comprises any lesion from supraglottic larynx to trachea. Patients with laryngotracheal or tracheal stenosis may present with stridor, shortness of breath, or exercise intolerance and may be tracheotomy dependent. The surgeon must have several choices of procedures available to correctly treat the variety of lesions that may occur. This article briefly outlines the pathophysiology of subglottic and tracheal stenosis and discusses in detail the open procedures available.

Results of an RTOG phase III trial (RTOG 85-27) comparing radiotherapy plus etanidazole with radiotherapy alone for locally advanced head and neck carcinomas

The objectives of this study were to determine the efficacy and toxicity of Etanidazole (ETA), a hypoxic cell sensitizer, when combined with conventional radiotherapy (RT) in the management of advanced head and neck carcinomas. From March 1988 to September 1991, 521 patients who had Stage III or IV head and neck carcinomas were randomized to receive conventional RT alone (66 Gy in 33 fractions to 74 Gy in 37 fractions, 5 fractions per week) or RT+ETA (2.0 g/m2 thrice weekly for 17 doses), of whom 504 were eligible and analyzable. Treatment assignments were stratified before randomization according to the primary site (oral cavity + hypopharynx vs. supraglottic larynx + oropharynx + nasopharynx), T-stage (T1-3 vs. T4), and N-stage (N0-2 vs. N3). Pretreatment characteristics were balanced. In the RT-alone arm, 39% of patients had T3 and 34% had T4 disease, whereas in the RT+ETA arm, 42% of patients had T3 and 33% had T4 disease. Thirty-eight percent of the RT-alone patients and 37% of the RT+ETA patients had N3 disease. The median follow-up of surviving patients was 3.38 years, with a range between 0.96 and 5.63 years. One hundred and ninety-four of the 252 (77%) RT+ETA patients received at least 14 doses of the drug. Overall RT protocol compliance rate was 82% in the RT-alone arm and 86% in the RT+ETA arm. No Grade 3 or 4 central nervous system or peripheral neuropathy was observed in the RT+ETA arm. Eighteen percent of the patients developed Grade 1 and 5% developed Grade 2 peripheral neuropathy. Other drug related toxicities included nausea/vomiting (27%), low blood counts (15%), and allergy (9%). Most of these toxicities were Grade 1 and 2. The incidence of severe acute and late radiation effects were similar between the two arms. The 2-year actuarial local-regional control rate (LCR) was 40% for the RT-alone arm and 40% for the RT+ETA arm. Two-year actuarial survival was 41% for the RT-alone arm and 43% for the RT+ETA arm (p = 0.65). Multivariate analyses were performed to investigate the influence of covariates on treatment effects. A strong treatment interaction with N-stage was revealed: LCR (50% vs. 40% at 2 years), RT+ETA improved for patients with N0-2 disease but not for N3 patients (22% for RT+ETA and 40% for RT). Further analyses showed that RT+ETA was more advantageous in N0-1 patients, with a 2-year LCR of 55% for RT+ETA vs. 37% for RT only (p = 0.03). A similar phenomenon was observed when using survival as the end point. The results showed that adding Etanidazole to conventional RT produced no global benefit for patients who had advanced head and neck carcinomas. There was a suggested benefit for patients who had N0-1 disease, and that needs to be confirmed by another study.

Salvage surgery following radiation failure in squamous cell carcinoma of the supraglottic larynx

We analyzed the clinical course of patients who developed local (primary) recurrence following high-dose irradiation of squamous cell carcinoma of the supraglottic larynx. Between October 1964 and July 1991, 206 patients with previously untreated squamous cell carcinoma of the supraglottic larynx underwent radiotherapy with curative intent. Local failure occurred in 46 (22%) patients. Successful surgical salvage was defined as no evidence of recurrent cancer for at least 2 years after salvage surgery and continuously thereafter. Sixteen patients did not undergo salvage surgery because of refusal (7 patients), severe medical illness (2 patients), concurrent distant metastasis (5 patients), or unresectable neck disease (2 patients). Twenty-six patients underwent total laryngectomy, and 4 patients had a voice-sparing procedure. Successful salvage was achieved in 50% of patients who underwent surgery. The rate of successful salvage did not correlate with preirradiation T-stage or time to failure after irradiation. Most of the failures after surgery were because of failure to control the primary cancer. The overall rate of postsurgical complications was 37%. No operative or perioperative deaths occurred. The 5-year survival rate for all 46 patients, calculated from the date of irradiation failure, was 20%, while the 5-year survival rate after salvage surgery for the 30 patients who underwent the procedure was 29%. There are few data in the literature regarding the clinical outcome in patients whose tumors are not controlled by initial radiotherapy. In the current and previous series, one-half to two-thirds of patients who developed primary failure underwent salvage surgery, which was successful in approximately half of the operated patients, leading to a 25-30% rate of long-term disease-free survival among the entire group of patients who developed failure.

Retropharyngeal adenopathy as a predictor of outcome in squamous cell carcinoma of the head and neck.

Little information about the incidence of retropharyngeal adenopathy and its impact on prognosis has been published. For 774 patients with squamous cell carcinoma of the nasopharynx, oropharynx, hypopharynx, or supraglottic larynx, pretreatment CT and, in selected cases, MRI scans were reviewed to determine the presence of retropharyngeal adenopathy. Results were analyzed in 619 patients treated with curative intent to determine the prognostic impact of retropharyngeal adenopathy. The highest incidence of retropharyngeal adenopathy was seen in patients with nasopharyngeal (74%) and pharyngeal wall (19%) cancers. The number of cervical nodal groups involved was the most significant factor (p < .0001) relating to the incidence of retropharyngeal adenopathy. The rates of neck relapse (40% at 5 years) and distant metastasis were significantly higher in patients with retropharyngeal adenopathy, and the rates of 5-year relapse-free survival and absolute survival were significantly lower. Retropharyngeal adenopathy is a strong predictor of poor prognosis, particularly for patients with advanced neck disease.

Management of cancer of the supraglottic larynx

Educational objectives: To understand the etiology and diagnostic and staging systems used in the management of patients with cancer of the supraglottic larynx and to understand the medical and surgical techniques used in the management of this disease, together with the risks and benefits.

Laryngeal mucosal malignant melanoma. A clinicopathologic, immunohistochemical, and ultrastructural study of four patients and a review of the literature.

Primary laryngeal mucosal malignant melanomas are uncommon tumors that morphologically are readily confused with more common types of laryngeal cancer. Four cases of primary laryngeal mucosal malignant melanoma were identified from the files of the Otolaryngic Tumor Registry-Armed Forces Institute of Pathology. Clinical records were available for all four cases. Paraffin blocks or unstained slides were available for three of the four cases. The light microscopic features were evaluated in all cases. Immunohistochemistry was performed in three cases; electron microscopic analysis was performed in two cases. Follow-up data was available in three of the four cases. The patients were all males and ranged in age from 35 to 84 years. The clinical presentations included hoarseness, hemoptysis, dysphagia, and airway obstruction, with complaints ranging from 1 to 8 months. The sites of involvement included the supraglottic larynx and the right true vocal cord. A history of cutaneous melanoma or of a melanoma of another site was not reported for any of the patients. Histologically, the tumors were invasive and composed of a pleomorphic epithelioid cell population of malignant cells. Malignant spindle-shaped cell could also be identified. The presence of melanin was identifiable by light microscopy in two cases; Fontana stains confirmed the presence of melanin in the other two. The immunohistochemical findings showed diffuse immunoreactivity with S-100 protein and HMB-45. There was no immunoreactivity with cytokeratin. The specimen of one patient demonstrated focal immunoreactivity with chromogranin. Electron microscopic features included the presence of premalonosomes or melanosomes. Total laryngectomy was the treatment of choice supplemented with radiotherapy. Follow-up information was available for three patients and all three died of metastatic disease within 36 months of diagnosis. Metastasis occurred to the brain, lungs, spine, and regional lymph nodes. The fourth patient was lost to follow-up. Laryngeal mucosal malignant melanoma is an uncommon neoplasm that clinically and pathologically simulates more conventional types of laryngeal cancers. The light microscopic, immunohistochemical, and electron microscopic findings confirm the diagnosis. Aggressive management is indicated, as these tumors disseminate widely and are rapidly fatal.

Lipomas of the larynx and hypopharynx: a review of the literature with the addition of three new cases

Lipomas of the larynx and hypopharynx are uncommon mesenchymal neoplasms. This report discusses the clinical and pathological features of three cases of laryngeal and hypopharyngeal lipomas. Two of the cases occurred in females and one in a male. The ages of the patients were 28, 51 and 51 years respectively. Two of the cases involved the supraglottic larynx (left arytenoid and left vestibular fold); the third involved the pyriform sinus. Symptoms included airway obstruction, dysphagia, throat discomfort, a sensation of excessive secretions in the throat and an increase in snoring. The complaints occurred over periods ranging from several months to one year in duration. Clinically, a polypoid lesion described as yellow in appearance was seen. Histologically, the tumours were composed of mature adipocytes without evidence of pleomorphism, lipoblasts or infiltrative growth. Surgery was the treatment of choice and included simple but complete excision in two of the cases. In these two cases, surgery proved curative with follow-up periods of 11 and seven years, respectively. In one case, the initial tumour was removed in pieces. This lesion recurred 15 years after the initial resection and was totally excised at that time. This patient has been free of tumour for more than five years.

Does pathologic node status affect local control in patients with carcinoma of the head and neck treated with radical surgery and postoperative radiotherapy?

To evaluate the effect of pathologic lymph node status and nodal stage on local control at the primary site in patients with advanced squamous cell carcinomas of the head and neck, treated with radical surgery and postoperative irradiation. Fifty-seven patients with advanced squamous cell carcinomas of the oral cavity, oropharynx, hypopharynx, larynx, and supraglottic larynx were analyzed. All patients underwent resection of the primary lesion, neck dissection, and postoperative radiotherapy. Minimum follow-up was 2 years. The median dose to the primary tumor bed was 60.4 Gray (range 39.7-72.0). Besides pathologic nodal status (pN0 vs. pN+) and nodal stage, the following factors were analyzed for their impact on local control: age, gender, T stage, tumor grade, resection margins, interval from surgery to irradiation, dose to the primary site, and overall treatment time. The 3-year actuarial local control rate was 78%. When all patients were analyzed, nodal status (pN0 vs. pN+) did not affect control at the primary site (71% vs. 82%, p = 0.42). Nodal stage (pN0-N2a va. pN2b-N2c) was also not a significant factor for local control (74% vs. 82%, p = 0.57). When only patients with negative margins were analyzed, nodal status again did not impact on local control (79% vs. 90% for pN0 vs. pN+, p = 0.39). On univariate analysis, only tumor grade, margin status, and elapsed days were significant factors for local control. Local control was 85% for patients with negative margins vs. 60% for those with positive margins (p = 0.016). For patients with moderately and poorly differentiated tumors, local control was 86% as compared to 50% for patients with well-differentiated tumors (p = 0.007). When radiotherapy was completed within 50 days, local control was 93% as opposed to 63% for > 50 days (p = 0.016). On multivariate analysis, only margin status (p = 0.002) and tumor grade (p = 0.007) remained significant. We conclude that neither the presence of pathologically positive nodes nor nodal stage is a prognostically significant factor for local control in patients who have undergone radical surgery and postoperative radiotherapy for advanced squamous cell carcinomas of the head and neck. We do not recommend a change in treatment philosophy, such as an increase in dose to the primary site, based on the pathologic status of the neck.

Hyperfractionated radiation in the treatment of squamous cell carcinomas of the head and neck: A comparison of two fractionation schedules

In 1984 we began treating patients with squamous cell carcinomas of the larynx and hypopharynx with hyperfractionated radiotherapy. Patients received 76.8 Gy in 1.2 Gy fractions twice daily, with a 4 h interfraction interval. In 1988, this schedule was modified in patients treated with shrinking field techniques. The dose per fraction was slightly reduced (while not changing the total dose), and the interfraction interval was increased to 6 h. The goal was to decrease toxicity while maintaining satisfactory local-regional control. This retrospective study analyzes the results of this schedule modification. Two hundred thirty-six patients were included in the analysis. Distribution of patients by primary site and T stage was as follows: supraglottic larynx, 120 patients; hypopharynx, 70; true vocal cord, 24; and oropharynx, 22; T1, 5 patients; T2, 118; T3, 93; T4, 19; and Tx, 1. Ninety-nine patients presented with cervical nodal disease. Seventy-eight patients (group A), including 16 treated with induction chemotherapy, were treated throughout with 1.2 Gy fractions twice daily and a 4-h interfraction interval. Subsequently, 158 patients (group B), 57 of whom received chemotherapy, received 1.1 Gy fractions to 55 Gy, and then 1.2 Gy fractions to their boost volumes to 76.6 Gy. The interfraction interval was 6 h. Median follow-up was 91 and 35 months for group A and B, respectively. Two-year actuarial survival, local control, and ultimate local rates were 70%, 75%, and 85%, respectively. Differences between survival rates for group A and group B were not statistically significant, with 2-year rates of 66% and 72%, respectively. Overall local control rates at 2 years were 77% and 74%, respectively, for groups A and B (p = 0.22). However, there was a trend toward inferior results in group B patients with T3 disease (67% at 2 years compared to 76% in group A, p = 0.13). Confluent mucositis and persistent mucositis developed in 52% and 14% of group A patients, but only 37% and 4% of group B patients (p = 0.02 and p < 0.01, respectively). There was a near significant trend toward fewer late complications in group B who developed an 8% complication rate at 3 years compared to 15% of group A patients (p = 0.07). The net effect of reducing the dose per fraction to 1.1 Gy twice daily for fields covering gross disease and subclinical sites, and increasing the interfraction interval to 6 h was to reduce the incidence of both acute and late complications. Excellent overall local control rates (85%) for T2 lesions were achieved with both hyperfractionation regimens and we, therefore, continue to treat patients with T2 tumors with the modified schedule. The overall results in selected patients with T3 lesions was also satisfactory (69%), but as there was a trend towards poorer local control in patients treated with 1.1 Gy fractions, we recommend using 1.2 Gy for the entire treatment of these patients, while maintaining the 6 h interfraction interval to reduce the risk of late complications.

Classification of neck dissection: Variations on a new theme

Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck dissection. We considered a neck dissection as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels. At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient. The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nonlymphatic structures sacrificed, we allow for the possibility that some procedures may be both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.

Identification, Classification, Treatment, and Prognosis of Laryngeal Paraganglioma

This study details the clinicopathologic features of 62 cases of laryngeal paraganglioma (LP), including 54 acceptable cases identified in the literature (although clinical information is lacking on 7 of these) and 8 previously unpublished cases identified from the Registry of Otolaryngic-Endocrine Pathology at the Armed Forces Institute of Pathology. Demographic findings show that the overwhelming majority of cases affect women (41:14), mainly in the fourth to sixth decades of life (age range, 14 to 83 years; median, 44 years), with a prevalence in the supraglottic larynx. These neoplasms are treated by surgical resection and are benign. Despite the characteristic pathologic features associated with LP, it is sometimes confused with other neoplasms, particularly neuroendocrine carcinomas of the larynx, and this confusion leads to unfortunate designations such as malignant paraganglioma and metastasizing paraganglioma of the larynx. Judging from the cases reported in this study and those identified in the literature, we conclude that malignant biologic behavior associated with LP is extraordinarily rare (< 2%). Because of the misdiagnoses of LP, the prognosis associated with this entity has been skewed to suggest that LP may behave aggressively. This has led to the inappropriate classification of LP among the malignant categories of laryngeal neuroendocrine neoplasms. The goal of this study is to detail the features diagnostic of LP and to discuss the appropriate treatment, prognosis, and classification of these neoplasms.

The Impact of Bilateral Neck Dissection on Pattern of Recurrence and Survival in Supraglottic Carcinoma

The findings of an initial evaluation of 202 patients treated for squamous cell carcinoma of the supraglottic larynx have been previously reported. Recurrent disease was observed at the primary site in four patients (2%), in the regional lymphatics in 39 patients (20%), and at distant sites in 24 patients (12%). Critical analysis of patients who demonstrated recurrent disease in the cervical lymphatics indicated that 38 of 39 recurrences developed in nonsurgically treated necks irrespective of the use of postoperative radiation therapy. Accordingly, all patients with supraglottic carcinoma have been treated with routine bilateral neck dissection since that time. We have reviewed our data to determine if bilateral neck dissections deter recurrence and improves survival. A retrospective review of the clinical course of 76 patients undergoing excision of supraglottic squamous carcinoma combined with bilateral neck dissection between 1980 and 1990 was performed to determine survival and recurrence rates. Surgery alone was used to treat 32 patients, while 44 patients were treated with surgery plus adjunctive therapy. Department of Otolaryngology--Head and Neck Surgery, The Eye and Ear Institute, University of Pittsburgh (Pa) School of Medicine. Distant metastatic spread was the most frequent site of failure, occurring in nine (11.8%) of 76 patients. Local recurrence was experienced by two patients (1%). The incidence of cervical recurrence (seven patients, 9.2%) following treatment for squamous cell carcinoma of the supraglottic larynx has been reduced from 20% to 9% through the use of bilateral neck dissection. The 2-year survival rate increased from 72% to 76%. Routine bilateral neck dissection is beneficial in the surgical management of squamous cell carcinoma of the supraglottic larynx.

Frequent loss of heterozygosity for Rb, TP53, and chromosome arm 3p, but not NME1 in squamous cell carcinomas of the supraglottic larynx

The inactivation of some tumor suppressor genes classically manifests itself through the loss of heterozygosity at nearby genetic mapping markers. Inactivation of these genes appears to have diagnostic/prognostic significance in some types of tumors. Molecular genetic tools based on suppressor inactivation might, therefore, have great utility in treatment planning. The polymerase chain reaction and highly informative microsatellite markers were used to compare DNA derived from matched sets of tumor and normal tissue samples from 37 supraglottic laryngeal squamous cell carcinomas. Tumor samples were microdissected free of contaminating normal tissue to maximize the detection of allelic loss. Polymerase chain reaction products were fractionated by denaturing gel electrophoresis and were visualized by autoradiography. Allelic losses were frequent at TP53 (56% of the tumors), the retinoblastoma gene (Rb, 59%), and the p13-14 region of chromosome 3 (64%). In contrast, the putative metastasis suppressor, NME1 (also known as NM23), was lost infrequently (7%). NME1 allelic loss did not correlate with the presence of lymph node metastases in these patients. The high frequencies of allelic loss at TP53, Rb, and 3p13-14 suggest that these suppressors play a major role in laryngeal carcinogenesis. In sharp contrast, the low frequency of loss at NME1 and its equal distribution in nodal metastasis-positive and -negative patients suggests that inactivation of this gene by allelic loss probably does not play a role in the development of regional metastases from these tumors. Allelic loss in 3p13-14 was found in tumors of all histopathologic grades.

Basaloid squamous cell carcinoma of the head and neck: A clinicopathologic and flow cytometric study of 10 new cases with review of the English literature

Introduction: We describe the clinicopathologic and flow cytometric features of 10 cases of basaloid squamous cell carcinoma (BSCC) of the head and neck to determine if DNA ploidy is a useful prognostic indicator. We also provide a review of 80 cases previously reported in the English language literature. Materials and Methods: The 10 cases were obtained from the surgical pathology files of Presbyterian University Hospital and The Eye and Ear Institute, Pittsburgh, PA (1987–1991). In all 10 cases, the microscopic slides and clinical data were reviewed. Flow cytometry was performed using the Hedley technique and formalin-fixed, paraffin-embedded tissue. Results: The mean age of patients with BSCC was 64 years (range, 49 to 75 years). Tumor involved the base of tongue (n = 5), hypopharynx-epiglottis (n = 3), and tonsil (n = 1). One case presented with cervical lymph node metastasis from an unknown primary site. Histologically, BSCC showed a biphasic pattern with basaloid-squamous elements, comedonecrosis, stromal hyalinization, surface dysplasia, and an in situ and/or invasive squamous cell carcinoma component. Flow cytometry revealed six diploid and four aneuploid tumors. Five of six patients with diploid and all four patients with aneuploid tumors developed early regional and/or distant metastases. Of the two patients who died of disease, one had a diploid and the other an aneuploid tumor. Conclusion: Our study reaffirms the predilection of BSCC for the base of tongue, pyriform sinus, and supraglottic larynx, and its aggressive biologic behavior with a high incidence of cervical lymph node metastasis (64%), distant spread (44%), and death from disease (38% mortality at 17 months median follow-up). However, in contrast to previous reports, tumor ploidy by flow cytometry provided no additional prognostic information beyond that supplied by routine histologic evaluation.

Carcinoma of the Larynx: Selective Approach to the Management of Cervical Lymphatics

Our experience with the surgical management of 472 patients with squamous cell carcinoma of the larynx suggests that more aggressive management of the N0 neck is effective in managing patients with laryngeal carcinoma. Only 3% of patients developed recurrence at the primary site. Patients with T3 and T4 carcinoma of the glottic larynx and all patients treated surgically for carcinoma of the supraglottic larynx should undergo routine elective neck dissection of the N0 neck. This is undertaken on the ipsilateral side for T3 and T4 glottic lesions. Selective neck dissection is undertaken bilaterally for patients with carcinoma of the supraglottic larynx irrespective of the side of the primary tumor. Distant metastasis develops as a sole site of recurrent disease in 9% of patients overall. Additionally, 14% of patients developed a second primary carcinoma sometime during the postoperative period. Strategies to prevent and manage these problems are the challenge for the future.