James N. Endicott

Postoperative accelerated radiotherapy in high-risk squamous cell carcinoma of the head and neck: Long-term results of a prospective trial

For patients treated with combination resection and postoperative radiotherapy, the interval between surgery and completion of radiotherapy represents an opportunity for tumor repopulation and treatment failure. A prospective trial to test the feasibility and efficacy of accelerated postoperative radiotherapy was concluded in August of 1990.

Diagnosis and management decisions in infections of the deep fascial spaces of the head and neck utilizing computerized tomography

Infections of the deep spaces of the head and neck may still result in major consequences despite the advent of antibiotics. Abscesses in these areas merit special consideration by todays head and neck surgeon because of their relative rarity and the life-threatening complications that may follow inadequate treatment. Diagnosis and management decisions are enhanced by use of computerized tomography (CT) as an adjunctive study. The EMI scan may demonstrate either cellulitis of the neck requiring no surgery or a space abscess displacing the adjacent structures thus requiring surgical drainage. Anatomy of the significant fascial planes and spaces of the neck will reviewed employing CT utilizing 3 mm cuts. Specific case presentations feature early diagnosis and management.

A prospective trial of accelerated radiotherapy in the postoperative treatment of high-risk squamous cell carcinoma of the head and neck☆

PURPOSE To evaluate the feasibility and toxicity of accelerated fractionation in the postoperative setting in high risk squamous cell carcinoma of the head and neck. METHODS AND MATERIALS Thirty-two patients with high risk pathologic features (e.g., extracapsular extension, positive margins, > or = 4 nodes positive, perineural invasion) were enrolled in an accelerated fractionation schedule, using a modification of the M.D. Anderson concomitant boost technique delivering 63 Gy in 5.3 weeks at 1.8 Gy per fraction. RESULTS Thirty patients (94%) completed treatment per protocol. Confluent mucositis was seen in 22 (69%) and five patients (22%) required 2 to 4 months for complete healing. Only five patients (16%) lost more than 10% of body weight. At a median follow-up of 32 months (range 22-42 months), the crude infield failure rate is 8/32 (25%). Infield recurrence was significantly associated with the interval from surgery to commencement of radiotherapy; 0/10 (0%) patients beginning radiotherapy within 4 weeks of surgery had infield failures compared to 8/22 (36%) for patients beginning radiotherapy more than 4 weeks after surgery (p = 0.035). CONCLUSION While acute side effects appear to be increased compared to conventional radiotherapy, we conclude that postoperative accelerated radiotherapy is feasible and has acceptable toxicity in this population. These results support the concept of rapid tumor repopulation after resection. A randomized multi-institutional trial is currently underway to compare conventional and accelerated fractionation in the postoperative setting.

Reconstruction After Temporal Bone Resection

Reconstruction of soft tissue defects after temporal bone resection can vary from simple closure of the external auditory canal to complex flap coverage of extensive defects. Between 1987 and 1996, 34 patients underwent lateral skull base resections and reconstruction for invasive carcinoma of the temporal bone. Seven underwent sleeve resection and/or radical mastoidectomy. Sleeve resection was managed with tympanoplasty, canalplasty, or obliteration of the external auditory canal (10). There were 24 lateral temporal bone resections and four subtotal temporal bone resections. Larger defects created by lateral and subtotal temporal bone resections required closure with a combination of temporalis flaps and local rotational cutaneous flaps (13). Lower island trapezius flaps (five), free flaps (four), and pectoralis major flaps (two) were also used. Indications and efficacy of each method are discussed, and treatment outcomes are presented.

Marijuana and Head and Neck Cancer

Although head and neck cancer comprises only 5 to 7% (1) of human cancer, the devastating functional, psychosocial, and cosmetic affects as a result of standard therapy has delegated special importance to these tumors. Eighty-five percent of head and neck tumors have a squamous cell carcinoma histology and characteristically grow slowly with eventual regional lymphatic spread to cervical lymph nodes. Distant metastasis (below the clavicles) occurs in a late or more advanced stage and is generally considered incurable. Squamous cell carcinoma occurs in the mucosal lining of the upper aerodigestive tract including larynx, hypopharynx, oropharynx, oral cavity, nasopharynx and nose. Early cancers may be cured with radiation therapy or conservative surgical procedures. Advanced cancers without distant metastasis may require wide-field resection with post-operative radiation for cure.

Esophageal perforations: the role of computerized tomography in diagnosis and management decisions.

External drainage is indicated when a neck abscess results from esophageal or hypopharyngeal perforation.

Simultaneous squamous cell carcinoma of the head and neck and reticuloendothelial malignancies

BACKGROUND Multiple primary neoplasms have been reported 4% to 26% of patients with a squamous cell carcinoma (SCC) of the head and neck. The vast majority of these second primaries are SCC and occur in the upper aerodigestive tract; however, head and neck SCC patients are also at higher risk for nonepidermoid neoplasms at any site. Reticuloendothelial malignancies (REM) have been reported in many patients that have SCC of the head and neck as well. METHODS Retrospective case series of 5 advanced cases of SCC of the head and neck with synchronous REM. RESULTS There was 40% mortality with 19.4 months mean follow-up. Fifty percent of the case had simultaneous cervical involvement with both processes. CONCLUSION REM can occur simultaneously with SCC of the head and neck and confound staging of nodal status. Head and neck SCC patients are at increased risk for REM secondary to age and treatment factors.

Anterior approach for CT-guided biopsy of skull base and parapharyngeal space lesions

At our institution we use an anterior approach to biopsy of the parapharyngeal space or skull base lesions because it provides more direct access than the traditional lateral approach through the mandibular notch. The anterior approach follows a course lateral to the alveolar ridge of the maxilla and lateral pterygoid plate, and inferior to the zygomatic process of the maxilla. Biopsy was performed on 15 patients with either a skull base or a parapharyngeal space mass, none of which could be palpated externally or through the oral cavity by the ear, nose, and throat surgeon. In 12 patients the needle biopsy correlated with the surgical pathology. Three needle biopsies were nondiagnostic.

Prebiopsy assessment of patients with suspected head and neck cancer

Sixty-three patients waiting for a diagnostic evaluation for suspected head and neck cancer were evaluated using standardized psychometric instruments and a clinical interview. Patients with both malignant and benign lesions were found to have significant anxiety and depression. Compared with patients who had benign lesions, those with carcinomas reported less concomitant stress; however, alcohol use was equally prevalent in both groups. The authors discuss the results in the context of theories about cancerprone personalities, the characteristics of the patient population, and psychometric testing. The authors recommend early screening of patients with head and neck cancer for psychopathology.

Amyloidosis presenting as a mass in the neck.

A 54‐year‐old white male presented with a large suprahyoid midline mass. On thorough history and physical examination, he had features which characterize amyloidosis, including congestive heart failure and carpal tunnel syndrome. The classification, clinical findings, and associated syndromes are reviewed. A striking feature of the amyloid deposit is its rapid growth. Amyloidosis should now be considered in a differential diagnosis of a neck mass.