Carl E. Silver

Carotid body paragangliomas: a systematic study on management with surgery and radiotherapy

The definitive universally accepted treatment for carotid body tumors (CBT) is surgery. The impact of surgery on cranial nerves and the carotid artery has often been underestimated. Alternatively, a few CBTs have been followed without treatment or irradiation. The goal of this study is to summarize the existing evidence concerning the efficacy and safety of surgery and external beam radiotherapy (EBRT) for CBT. Relevant articles were identified using strict criteria for systematic searches. Sixty-seven articles met the criteria which included 2,175 surgically treated patients. On the other hand, 17 articles including 127 patients treated with EBRT were found. Long-term control of the disease was obtained in 93.8xa0% of patients who received surgical treatment and in 94.5xa0% of the radiotherapy group. Surgery resulted in 483 (483/2,175xa0=xa022.2xa0%) new cranial nerve permanent deficits, whereas in the EBRT group, no new deficits were recorded (pxa0=xa00.004). The common/internal carotid artery was resected in 271 (12.5xa0%) patients because of injury or tumor encasement, with immediate reconstruction in 212 (9.7xa0%) patients. Three percent (60) of patients developed a permanent stroke and 1.3xa0% (26) died due to postoperative complications. The major complications rates and the mortality after completion of the treatment also were significantly higher in surgical series compared to EBRT series. This systematic analysis highlights evidence that EBRT offers a similar chance of tumor control with lower risk of morbidity as compared to surgery in patients with CBT. This questions the traditional notion that surgery should be the mainstay of treatment.

What is the role of sentinel lymph node biopsy in the management of oral cancer in 2010

This paper was written by members and invitees of the International Head and Neck Scientific Group ( http://www.IHNSG.com ).

Current considerations in neck dissection

(2002). Current Considerations in Neck Dissection. Acta Oto-Laryngologica: Vol. 122, No. 3, pp. 323-329.

Benign parotid hypertrophy in +HIV patients: limited late failures after external radiation

PURPOSEnAlthough 8-10 Gy of external radiation therapy for +HIV associated parotid hypertrophy has achieved high response rates, the responses were transient with only 1/12 of patients retaining cosmetic control at median follow-up procedures of 9.5 months. Retreatment for failures after 8-10 Gy has also been unsatisfactory. Having shown that 24 Gy of external radiation therapy for benign parotid hypertrophy produced more durable cosmetic control than 8-10 Gy, we now report on longer follow-up periods on a group of patients receiving 24 Gy.nnnMATERIALS AND METHODSnTwenty +HIV patients with clinical and radiographic evidence of lymphoepithelial lesions of the parotid were treated with 24 Gy of external radiation therapy using daily 1.5 Gy fractions; parallel opposed technique and 6 MV photons were used in 19 patients, and unilateral electron treatment was performed for one patient.nnnRESULTSnWith a mean follow-up period of 24 months, the cosmetic control appears durable. We have had no late failures past 24 months. Two patients have complained of modest xerostomia. There was no correlation with size of the cyst and eventual cosmetic result.nnnCONCLUSIONSnTwenty-four Gy produces durable parotid control for HIV associated lymphoepithelial lesions of the parotid glands in +HIV patients. Failures after 2 years are uncommon and the side effects have been tolerable.

The controversy in the management of the N0 neck for squamous cell carcinoma of the maxillary sinus

Squamous cell carcinoma (SCC) of the maxillary sinus is a relatively rare disease. As the reported incidence of regional metastasis varies widely, controversy exists as to whether or not the N0 classified neck should be treated electively. In this review, the data from published series are analyzed to decide on a recommendation of elective treatment of the neck in maxillary SCC. The published series consist of heterogeneous populations of different subsites of the paranasal sinuses, different histological types, different staging and treatment modalities used and different ways of reporting the results. These factors do not allow for recommendations based on high levels of evidence. Given this fact, the relatively high incidence rate of regional metastasis at presentation or in follow-up in the untreated N0 neck, and the relatively low toxicity of elective neck irradiation, such irradiation in SCC of the maxillary sinus should be considered.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

The Role of Neck Dissection in the Treatment of Supraglottic Laryngeal Cancer

ALFIO FERLITO, J. GRAHAM BUCKLEY, ASHOK R. SHAHA, CARL E. SILVER, ALESSANDRA RINALDO and LUIZ KOWALSKI From the Departments of Otolaryngology—Head and Neck Surgery, Uni×ersity of Udine, Udine, Italy and Leeds General Inx8e rmary, Leeds, UK, Head and Neck Ser×ice, Memorial Sloan–Kettering Cancer Center, New York, New York, USA, Department of Surgery, Albert Einstein College of Medicine, Montex8e ore Medical Center, New York, New York, USA and Head and Neck Surgery and Otorhinolaryngolog y Department, Centro de Tratamento e Pesquisa Hospital do Cancer A. C. Camargo, São Paulo, BrazilMuch discussion of supraglottic cancer centers on management of the primary tumor. Radiation treatment, conservation surgery and transoral laser surgery have been employed with success according to the skills and preferences of the therapist and the nature of the primary tumor. The absence of prospective clinical trials has provided a basis for dispute concerning the most effective treatment for tumors at any given stage. Comparison of survival rates between different treatment modalities is dife cult because of a tendency to select patients with favorable primary tumors for surgical treatment and those with favorable nodal status for radiation therapy. Control of the primary tumor is achieved in the majority of patients, as total laryngectomy is an effective procedure of last resort. Thus the choice of modality and procedure for primary tumor control impacts mainly on quality of life, rather than survival. Survival of patients with supraglottic carcinoma is largely determined by the high rate of cervical node metastases (1‐3). Nodal status has a greater ine uence on the curability of supraglottic cancer than the status of the primary tumor, as histologically identie ed regional metastases are associated with signie cantly increased risk of distant recurrence and decreased survival (4). Neck disease reduces survival by about 50%. Cervical failures often occur in the undissected neck. The proper management of the neck in patients with supraglottic cancer remains a subject of much debate. Cervical metastases are clinically apparent in : 40% of patients with supraglottic cancer when e rst seen, and 50% of neck dissection specimens are histologically positive (5‐10). The efe cacy of treatment depends on the likelihood of regional tumor control and the morbidity resulting from treatment. Improved regional control should, in theory, result in an increase in survival and a reduction in morbidity. Determination of optimal treatment may be based on pathological studies of the incidence and distribution of metastases within the cervical nodes and on clinical studies of the effectiveness of different treatment strategies for cancer control and functional outcome. PATHOLOGIC STUDIES Pre◊alence of nodal metastases There may be considerable variation in the way different studies classify supraglottic cancer. Some include tumors that extend to the glottis, while some class these as transglottic (11) or multiregional (10). Most are also likely to include tumors with hypopharyngeal extension. The majority of advanced laryngeal cancers that are considered for neck dissection extend to the supraglottic larynx. Treatment of the neck in these cases should be the same as for supraglottic cancer. The overall prevalence of occult metastases for all laryngeal cancers is 24% (92.4%) (5‐8, 10‐15). Thirty-nine (93.5%) percent of patients with supraglottic cancer have nodal metastases at presentation and 49% (93.7%) of neck dissections are histologically positive (5‐7, 9, 10). Pattern of metastasis Most supraglottic tumors metastasize to levels II, III and IV. The distribution of metastases in pathologically positive necks, determined from combined studies, is 31% (28.3‐33.7%) to level II, 27% (24‐29.2%) to level III and 12% (10.3‐14.1%) to level IV. The risk of metastases to either level I or level V is very low at 2.4% (1.5‐3.3%) and 2.6% (1.7‐3.5%), respectively (4, 7, 8, 10‐13, 15‐17). There is no doubt that some tumors do metastasize to level V. Kowalski et al. (18) observed that levels I and V were rarely involved, and always in association with clinical and histologic involvement of levels II, III and:or IV.

Is elective neck dissection indicated during salvage surgery for head and neck squamous cell carcinoma

Among patients with head and neck squamous cell carcinoma with a negative neck who are initially treated with (chemo)radiotherapy, a number of cases will recur locally without obvious neck recurrence. There is little information available as to the most efficacious management of the neck in these cases. We have reviewed the literature to see what conclusions can be drawn from previous reports. We conducted a bibliography search on MEDLINE and EMBASE databases. Studies published in the English language and those on squamous cell carcinoma of the oral cavity, nasopharynx, oropharynx, larynx and hypopharynx were included. Data related to neck management were extracted from the articles. Twelve studies satisfied the inclusion criteria. Five studies reported only one treatment plan (either neck dissection or observation), while the others compared neck dissection to observation. The rate of occult metastases ranged from 3.4 to 12xa0%. The studies included a variable distribution of primary sites and stages of the recurrent primary tumors. The risk of occult neck node metastasis in a clinically rN0 patient correlated with tumor site and T stage. Observation of the neck can be suggested for patients with T1-2 glottic tumors, who recurred with less advanced tumors (rT1-2). For patients with more advanced laryngeal recurrences or recurrence at other high-risk sites, neck dissection could be considered for the rN0 patient, particularly if the neck was not included in the previous radiation fields.

Extracervical approaches to endoscopic thyroid surgery

There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15xa0years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO2.

Reflux and aerodigestive tract diseases

Gastroesophageal reflux disease can present with a wide variety of extraesophageal symptoms. In particular, the type of disease characterized predominately by laryngopharyngeal reflux may be difficult to diagnose because of the absence of regurgitation or heartburn. The available battery of diagnostic tools is often insufficient to confirm a diagnosis of reflux, so the diagnosis is often made by elimination. In many cases, treatment with proton pump inhibitors will relieve symptoms and respiratory complications, despite the persistence of non-acidic reflux. Such treatment is often employed to “confirm” the diagnosis, as measured by patient response. Many diseases have been related to this condition in the literature. The authors review knowledge about these manifestations and their relationship with refluxed gastric content. Physiopathology, symptoms and treatment are reviewed in order to clarify our understanding of laryngopharyngeal reflux diseases and related manifestations.