Christian Sittel

Transoral laser surgery for early glottic carcinoma

Abstract This prospective study evaluates the oncological results of transoral laser surgery (TLS) for glottic carcinoma categorized Tis, T1 and T2 in a large, unselected group of 285 consecutive patients from a university-based referral center that uses transoral laser surgery as the standard approach to these tumors. Patients were treated between 1 January 1987 and 31 December 1996. Thirty-three patients had Tis disease, 174 T1 tumors and 113 T2. Main outcome measures were local control with initial therapy, ultimate local control, regional control, organ preservation, overall survival and cause-specific survival. The 5-year uncorrected actuarial survival for all 285 patients was 71.1%, and cause-specific actuarial survival was 98.7%. Local control with initial treatment was 85.9%, ultimate local control with salvage for local treatment failures 98.5%, and regional control 98.4%. In all, 94.3% had their larynges preserved after 5 years. Although favorable oncological results for early laryngeal carcinoma treated with laser surgery are supported this study, no definitive recommendations can be given for the best single treatment. Partial laryngectomies lead to the highest local control rates reported so far, radiotherapy is believed to preserve voice best and laser surgery is associated with time- and cost-effectiveness, low morbidity, fair local control rates and excellent re-treatment options in case of local failure. All specialists dealing with the treatment of early glottic carcinoma should be able to offer these different treatment modalities to their patients and to deal specifically with each patient’s individual needs and preferences.

Surgical treatment for hypopharynx carcinoma : feasibility, mortality, and results

This study seeks to evaluate treatment modalities, mortality after surgery, survival, and local control rates for a consecutive cohort of patients with cancer of the hypopharynx treated according to a prospective protocol that favors surgery as an initial approach to the disease. The charts of 228 consecutive patients with previously untreated hypopharyngeal squamous cell carcinoma were reviewed. Outcome measures (overall survival, disease specific survival, and local control) were calculated using the Kaplan-Meier estimator. Of 228 consecutive patients, 136 (59.6%) were found suitable for initial surgical treatment. Of the remaining 92 patients, 18 (7.9%) had nonresectable lymph node metastases, 16 (7.0%) had unresectable primary tumors, 13 (5.7%) refused surgery, and 13 (5.7%) presented distant metastases during initial diagnostic evaluation. Of those who had surgery, 46 had larynx-sparing procedures, 54 had total laryngectomy, and 36 had total laryngo-pharyngectomy. None of the patients who had surgery died postoperatively. Actuarial 5-year overall survival was 27.2% for all 228 patients, 39.5% for the 136 patients with surgical treatment, and 61.1% for the 46 patients who were treated with larynx-sparing procedures.

Prognostic significance of Ki-67 (MIB1), PCNA and p53 in cancer of the oropharynx and oral cavity

Up to now results concerning the prognostic value of tumor proliferation markers in squamous cell head and neck carcinoma have been equivocal. Beside biological reasons, different treatment modalities are hypothetically responsible for contradictory findings. The aim of this study was to investigate the relationship between proliferative capacity, represented by the immunohistochemical labeling index of proliferation markers Ki-67, PCNA and p53 status, and treatment failure in a matched-pair study design of recurrent and non-recurrent carcinoma initially treated with primary surgery combined with curative post-operative radiation. From a group of 239 patients with T1-T3 carcinoma of the oropharynx or oral cavity, 28 patients with recurrent disease were selected and matched with 28 patients with non-recurrent disease regarding stage and location of tumor as well as age and therapy. All patients received primary surgery combined with post-operative radiation. Immunohistochemistry determined the p53 status and the PCNA and MIB1 (Ki-67) labeling index. The Ki-67 labeling index was significantly (p=0.032) higher in tumors from patients suffering from treatment failure (mean=59. 1%) than in non-failures (mean=50.5%). Carcinoma with a Ki-67 (MIB1) labeling index above the median (53.7%) of the general study population showed a mean time to relapse of 45 months (n=25), whereas mean time-to-relapse was 61.7 months for those cases (n=31) below the median of the general study population (p=0.029). The PCNA labeling index did not correlate significantly with tumor recurrence (mean=50.2% for treatment failures, 45% for non-failures, p=0.31), nor with time-to-relapse (p=0.26). Forty-six percent of tumors showed p53 over-expression. However, there was no significant correlation between p53 over-expression and tumor recurrence or time-to-relapse. We present the largest series of oropharyngeal and oral cavity carcinoma investigated by immunohistochemistry in a controlled study. We conclude that a high Ki-67 labeling index is an indicator for treatment failure in these patients. Like other investigations for different head and neck subsites, we found no relationship between p53 or PCNA status and tumor prognosis. Our data, obtained from a group of patients treated with a combination of surgery and post-operative irradiation, show that for squamous cell carcinoma of the oropharynx and oral cavity the detection of Ki-67 is an unfavorable prognostic factor.

Morphometry of the larynx in horizontal sections

PURPOSE Until recently, only few studies on laryngeal morphometry in the horizontal plane, which used unreliable techniques, have been reported. The established methods of whole-organ serial sectioning of the larynx serve the purpose of histological investigation very well. Because they cause major tissue shrinkage, these techniques are not useful for morphometry. Nevertheless, normal data of laryngeal horizontal anatomy are of great surgical and diagnostic interest. Data on endolaryngeal angles, airway lumina, and the thickness of parts of the laryngeal skeleton can be helpful in the planning of endolaryngeal surgical intervention or the transcutaneous placement of electrodes for laryngeal electromyography. The aim of this study was to establish a method for the production of whole-organ serial sections that allows for the collection of exact and reliable morphometrical data. MATERIALS AND METHODS A total of 20 fresh human cadaver larynges were investigated in this study. Nineteen measurements on three different planes were obtained in each larynx. The larynges were shock-frosted using liquid propane and nitrogen and then cut with a slicing machine. Measurements were obtained using a computer-aided analyzing system. RESULTS The collected data give an exact and extensive description of the morphometrics of laryngeal structures such as thyroid and cricoid cartilage, arytenoid cartilages, vocal cords, and endolaryngeal airways at different section levels. CONCLUSION This study is the first to provide detailed anthropometric data on whole-organ sections of the larynx following a new method. This technique of using serial sections of the investigated specimen avoids artifacts caused by tissue fixation. Thus, it may be considered being particularly suited to the conduction of anthropometric studies on human larynges.

Phonatory results after laser surgery for glottic carcinoma

OBJECTIVE: To identify the influence of type and extent of surgery on postoperative voice parameters after endoscopic laser resection for glottic carcinoma. SETTING AND DESIGN: A multidisciplinary university-based head and neck cancer center. Objective and subjective measures of voice were correlated with type and extent of surgery following a standardized classification in a prospective study including 80 patients. SUBJECTS AND METHOD: The postoperative mechanism of phonation was assessed by videostroboscopy 6 months after surgery at the earliest. A phonetogram was produced, and its area was calculated (relative phonetogram [RP]) in relation to a gender-different normal phonetogram. Two speech therapists (ST) and a trained otolaryngologist (TO) rated each voice independently for communication ability in a grade from 1 (poor) to 5 (near normal). RESULTS: After simple cordectomy the means were as follows: RP = 24.8%, TO = 3.26, and ST = 3.33. When the anterior commissure was completely preserved, mean results were better (RP = 34%, TO = 3.92, ST = 3.83). Results were worse after extended cordectomy (RP = 14.7%, TO = 2.82, ST = 3.00) and transglottic resection (RP = 13.7%, TO = 2.30, ST = 2.86) but were similar within these two groups. The parameters RP, TO, and ST do not differ significantly between the group who had speech therapy after surgery (n = 33) and the group who did not (n = 47). Voice production at glottic level yields better results for every parameter than supraglottic substitute phonation. The amount of tissue removed was less significant. CONCLUSION: Postoperative phonatory results correlate with the postoperative mechanism of phonation. There is no linear correlation with the amount of tissue removed. Comparison of similar types of resection preservation of the anterior commissure plays a key role. From the data in this study, there is no evidence for a significant benefit from speech therapy. The parameter RP is an effective and relatively simple parameter to complete auditory voice assessment.

Textured polydimethylsiloxane elastomers in the human larynx : Safety and efficiency of use

For the treatment of unilateral laryngeal paralysis with glottic insufficiency injection laryngoplasty is a popular modality of treatment. This procedure augments the volume of the paralyzed vocal fold by endoscopic injection. However, the ideal substance has not yet been found for that purpose. We report for the first time the systematic application and long-term results of vulcanized polydimethylsiloxane (PDMS) particles in the treatment of glottic insufficiency in the human larynx. Of 10 patients treated with PDMS in the early 1990s, 7 patients could be retrieved for reevaluation. Laryngeal function was assessed by videostroboscopy, expert rating, and further characterized by the objective parameters of voice profile and maximum phonation time. In a standardized questionnaire, all patients were asked for their personal impression of the results. Mean follow-up time was 88.4 months (range 69-102 months). Glottic closure was complete in 5 of 7 patients. There were no signs of granuloma formation or other pathologic changes of the injected vocal folds. In 4 cases, voices were rated normal or near-normal; 2 voices were rated as fair; 1 usable. All the patients reported significant and lasting voice improvement. None of the patients reported any problems related to PDMS. PDMS particles provide permanent augmentation of human vocal fold volume without complications. Their use is a valuable and safe alternative when a definitive one-step procedure seems advantageous. However, further studies are needed to assess voice improvement in comparison to other materials.

Transoral CO2 laser for surgical management of glottic carcinoma in situ.

Objectives/Hypothesis In carcinoma in situ (CIS) tumors malignant cells have not penetrated the basement membrane and therefore have no metastatic potential. Treatment strategies of CIS are topics of ongoing discussion. The aim of this study was to evaluate long‐term results of CO2 laser therapy in laryngeal CIS.

Ki‐67 (MIB1), p53, and Lewis‐X (LeuM1) as Prognostic Factors of Recurrence in T1 and T2 Laryngeal Carcinoma

Objectives Recently published data suggest a prognostic value of immunohistochemical proliferation markers for limited laryngeal carcinoma. Previous studies have reported contrasting findings on this issue. In this context, different treatment modalities may be responsible for contradictory findings. To study the relationship between proliferative activity—expressed by the immunohistochemical labeling index of proliferation‐associated markers Ki‐67 (MIB1), Lewis‐X (LeuM1), and proliferating cell nuclear antigen (PCNA) and by p53 status—and treatment failure in a matched‐pair study on recurrent and nonrecurrent T1 and T2 glottic carcinoma having received primary transoral laser surgery.

Treatment of postparotidectomy salivary fistula with botulinum toxin.

We report on the successful treatment with botulinum toxin type A local injections of a salivary fistula that occurred after superficial parotidectomy. In a 58-year-old woman, transcutaneous discharge of saliva in the preauricular region had persisted in spite of 2 surgical revisions. Moreover, facial weakness and synkinesis had developed as a result of an iatrogenic lesion that had occurred at the time of primary surgery and required immediate reanastomosis of the main nerve trunk. Botulinum toxin A was injected into the deep lobe of the remaining parotid gland under ultrasonographic guidance. Additionally, botulinum toxin A was injected into the left orbicularis oculi muscle in order to improve the synkinesis. No adverse effects were observed. The sialorrhea was stopped for 11 months, and the synkinesis of the facial muscles was reduced significantly for 4 months. We conclude that botulinum toxin A injection is a successful alternative for the treatment of chronic salivary fistula.

Nasal cocaine abuse presenting as a central facial destructive granuloma

Abstract We describe a 36-year-old patient with an aggressive, midline intranasal and naso-and oropharyngeal destructive process. For months the patient denied heavy abuse of nasal cocaine, but finally admitted it. Necrosis and atrophy of the inferior and middle nasal turbinates bilaterally, prominent naso and oropharyngeal ulcers, nasal septal as well as hard palate perforation were observed clinically. Repeated biopsies revealed focal areas of chronic inflammation and necrosis, but there was no evidence of vasculitis or granuloma formation. Since serum was slightly positive for antineutrophil cytoplasmic antibody, the initial diagnosis was Wegener’s granulomatosis. In the United States there have been a few reports on a new cocaine-associated syndrome presenting as an aggressive, midline, intranasal and intrapharyngeal destructive process mimicking limited Wegener’s granulomatosis and midline reticulosis. We report the first such case in Europe and offer guidelines for the diagnostic work-up of such cases.