Frans Ostyn

The significance of perineural spread in adenoid cystic carcinoma of the major and minor salivary glands.

Patient survival, local recurrence and distant metastasis were studied in relation to the pathological finding of perineural spread in 37 patients with adenoid cystic carcinoma of the major and minor salivary glands. All patients underwent a combined surgical and radiotherapeutical treatment. The overall incidence of perineural invasion in primary resection specimens was 52.6%. The 5-year actuarial survival rate for patients with perineural invasion was significantly lower (p less than 0.001) than for those without (36.9% versus 93.8%). In 26 patients with resection margins free of tumour, recurrences developed in 9/11 (81.8%) of the patients with perineural invasion as opposed to 4/15 (26.7%) of the patients without perineural invasion (p = 0.005). In the same group with resection margins free of tumour, distant metastasis developed after the primary treatment in 4/10 (40.0%) of the patients with perineural invasion, while none of the 14 patients without perineural invasion experienced distant metastasis (p less than 0.0002). The incidence of perineural invasion increased with a higher stage of the primary tumour.

Acoustic analysis of the speaking voice after thyroidectomy

Voices of 47 female patients were analyzed before and after thyroidectomy, with preservation of the recurrent and superior laryngeal nerves and normal vocal fold motility during the observation period. A mean decrease of the speaking fundamental frequency (SFF) of 12 Hz was found on day 4; in 8 patients the postoperative vocal pitch was more than 2 semitones lower. The distance between the highest and lowest F0 during speaking was diminished (speech was more monotone) and the vocal jitter was elevated. In the frequency spectrum, there was a diminished prominence of the harmonics. The other spectral parameters (as the slope of the spectrum and the H1/H2 ratio) were unchanged. All changes had disappeared the fifteenth day, except for a lower SFF (> 2 semitones) in 2 cases. It is concluded that after normal dissection of the laryngeal nerves, and in the absence of vocal fold paresis, other reasons for voice changes immediately after thyroidectomy remain: alterations in the neck muscles, in the laryngeal mucosa, and in the patients general condition. Although the effects seem limited and of short duration, knowledge of them is helpful when informing the patient before thyroid surgery.

The significance of extension and impaired mobility in cancer of the vocal cord

The criteria for T2 glottic cancer staging in the UICC classification are extension to the supra- or subglottic region combined or not with impaired mobility of the vocal cord. The prognostic significance of these factors is examined in this study. Patients with T2A lesions (normal mobility, 33 patients) have an uncorrected actuarial 5 year survival of 54%, and a local control rate with radiotherapy alone of 62%. Patients with T2B lesions (impaired mobility, 28 patients) have a survival of 40% and a local control rate of 65% with radiation only. After rescue surgery, local control is obtained in 81% of T2A patients and 68% of T2B patients. While local control rates with radiotherapy alone were the same in T2A and T2B patients, final survival was lower for T2B patients because of less successful salvage surgery. While no significant differences in local control were found for different mucosal spread patterns, local control was excellent (87%) with radiotherapy alone in eight patients with mobility impairment without extension beyond the true cord, indicating that impaired mobility by itself is not a bad prognostic factor, but only when it is combined with tumor extension. In 9 patients with T2B tumors, a laryngectomy was performed immediately after initial radiotherapy (40 or 50 Gy) when the tumor persisted or the vocal cord mobility did not return to normal. None of these patients had a local recurrence after surgery. The total local control in all 37 T2B patients together was 78% (compared with 81% in T2A patients). The adverse prognostic influence of impaired mobility seems to have been eliminated by the treatment policy of surgery for those patients with poor regressions after radiotherapy. A dose-response relation can not be demonstrated in T2 glottic cancer for the dose range between 50 and 70 Gy.

The different clinical presentation, behaviour and prognosis of carcinomas originating in the epilarynx and the lower supraglottis

Within the supraglottic larynx, two subregions can be distinguished: the epilarynx and the lower supraglottis. Tumours arising in these structures have very different clinical presentations and prognosis. Management should be adjusted accordingly. Between 1962 and 1977, 325 patients with supraglottic cancer were seen, of whom 317 presented as untreated cases. In 171 patients (54%) the tumour originated in the lower part of the supraglottis. In this group 61% had T1 or T2 lesions, 23% had palpable neck nodes. In 130 of these patients, the initial treatment was irradiation. At 5 years, actuarial survival was 55% (uncorrected) and local control was 77%. The larynx was preserved in 61% of patients. Tumour stage had only limited influence on treatment results, but the presence of neck nodes was very important for prognosis. The best survival rate was observed in patients with T1 or T2, N0 lesions. Epilaryngeal tumours were seen in 146 patients (46% of all supraglottic tumours). In this group, only 40% had T1 or T2 lesions and 47% had palpable nodes. In the 110 patients primarily treated with radiotherapy, uncorrected actuarial survival was 36%, local control was 56% at 5 years. The voice was preserved in 45% of patients. Tumour stage had no influence on prognosis, but the presence of lymph nodes was a very important prognostic discriminant. A dose-response relation was observed in the range between 40 Gy in 4 weeks and 65 Gy in 6.5 weeks, above this dose level no further improvement was observed. It is remarkable that, although the presence of palpable neck nodes at diagnosis is the most important factor determining local control and survival, only in 23 out of 104 local or regional recurrences was the relapse found in the neck nodes. In 75 patients, the primary treatment was a combination of radiotherapy and surgery (40 lower supraglottic and 35 epilaryngeal tumours). Survival at 5 years was 62%, local control 77%. While these results were about equal in both subsites, both survival and local control were higher than in patients treated with radiotherapy alone. In our institute, the complication rate of surgery after preoperative irradiation was low. From our data, it appears that a laryngectomy is to be preferred for all patients with palpable neck nodes and also for all T3 and T4 lesions of the lower supraglottis. Radiotherapy should probably be reserved for small (T1 and T2) tumours of the lower supraglottis and for epilaryngeal cancer without neck nodes.(ABSTRACT TRUNCATED AT 400 WORDS)

The primary treatment of advanced vocal cord cancer: laryngectomy or radiotherapy?

When different treatment modalities yield equal results in cancer treatment, the least mutilating is preferred. If results are different, however, the survival rate after treatment must be weighed against the quality of life. Considerable controversy exists concerning the primary treatment modality for advanced glottic cancer, with some authors defending surgery (with or without radiotherapy) and others defending radiotherapy as sole treatment, with laryngectomy reversed for local failures. From a group of 102 patients with T3 and T4 tumors, 65 were treated with a laryngectomy. Uncorrected survival at 5 years was 48%, local control was 75%. A group of 35 patients was treated with radiotherapy. Survival was 22% at 5 years, local control 23%, with rescue surgery 37%. These unfavorable results are related to the negative selection of patients for radiotherapy (inoperable, bad cooperation). In 14 patients who were operable but refused laryngectomy the final local control was 53%, with voice preservation in 34%; survival, however, remained low (27% at 5 years). Primary surgery seems to provide better chances for ultimate survival than radiotherapy alone. At the moment, it is not yet clear if a proportion of patients can be selected for whom a more conservative attitude can be allowed, with laryngectomy reserved for poor regression or recurrences after radiotherapy.

Hypopharyngeal cancer: Results of treatment with radiotherapy alone and combinations of surgery and radiotherapy

From 1962 to 1977, 90 patients with hypopharyngeal cancer were seen in the Academic Hospital in Leuven. Radiotherapy was the primary treatment in 66 patients, actuarial survival was 18% at 5 years and local control 22%. In 22 patients treated with a laryngopharyngectomy and pre- or postoperative radiotherapy, survival was also 18%, but local control was obtained in 51%. No differences in prognosis were demonstrated according to the tumoral stage or nodal status. Metastases were found in 10.5% of irradiated patients and in 14% of patients treated with combined therapy. The frequency of postoperative complications was not increased after surgery for preoperatively irradiated patients. Treatment results in hypopharyngeal cancer remain unfavorable, even with a combination of surgery and radiotherapy. Alternative approaches should be actively investigated to improve local control rates such as the modalities currently under study (high LET, new fractionations, combinations with drugs).

Glottic Carcinoma Limited to the Vocal Cords

Radiation therapy is generally considered to be the best primary treatment for early glottic carcinoma, with surgery reserved for local failure. In a series of 150 cases of T1 glottic carcinoma 138 were given radiation alone. In these patients the survival was 88 per cent at 3 years and 77 per cent at 5 years. Local control remained unchanged at 82 per cent after 6 years. When the results of surgery are included, local control was raised to 93 per cent. Preservation of the larynx was obtained in 92 per cent of survivors. Local extension or radiation dose levels had no influence on local control. The optimum dose could be lower than generally recommended. Voice quality after radiation therapy is superior to postsurgical laryngeal function. Since survival rates are identical, radiation therapy alone is the treatment of choice in all early glottic carcinomas.

Are postoperative complications more frequent and more serious after irradiation for laryngeal and hypopharyngeal cancer

In order to improve local cure rates and survival in patients with head and neck cancer, combinations of radiotherapy and surgery are used. Most reports on such treatment results indicate an improvement with combined therapy. However, it is not clear whether it is best to irradiate before or after surgery. There is disagreement in the literature, whether postoperative complications are more frequent when the irradiation is given prior to surgery. The incidence of postoperative complications was studied in 213 patients who had a laryngectomy for laryngeal or hypopharyngeal cancer. The incidence of major complications was 8.5% after a preoperative dose of 40 or 50 Gy. After rescue surgery for radiation failure this percentage was 32%. In our experience, the incidence of postoperative complications after doses up to 50 Gy/5 weeks is comparable to what can be expected after surgery alone. When higher doses are given, these complications are more frequent. In designing treatment plans, such considerations should be kept in mind.

Perichondrial microvascular free transfer: creation of a compound flap for laryngeal reconstruction in rabbits.

A free revascularized compound perichondrial flap was used over an intralaryngeally placed stent for reconstruction of a frontal laryngeal defect. The microvascular flap replaced the cartilaginous and mucosal defect. Short-term results showed successful reconstruction with a patent airway and viable mucosa. The vascularized sheet of perichondrium was not chosen for its neochondrogenetic effect, but it served as a vascular bed, nourishing the mucous and cartilaginous components in the compound flap. It is suggested that for clinical purposes the reliable fascia forearm flap, which is available in large amounts, can be used as a transferable vascularized bed with a thickness comparable to that of the perichondrial flap.

Weight characteristics of the parathyroid glands in renal hyperparathyroidism

Although the mean weight of normal parathyroid glands is known, reports concerning the weight of hyperplastic glands in renal hyperparathyroidism are rare. The aim was to collect data about the weight of such glands and also to study the intraindividual distribution.