Jesus E. Medina

Perineural invasion in squamous cell skin carcinoma of the head and neck

On review of 520 patients with 967 squamous cell carcinomas of the skin of the face treated at The University of Texas M.D. Anderson Hospital and Tumor Institute at Houston during a 10 year period, 14 percent of the patients were noted to have perineural extension of tumor. Study of the patients with perineural tumor demonstrated an increased incidence of spindle cell and adenosquamous cell types, an increased incidence of cervical lymphadenopathy and distant metastasis, and significantly reduced survival curves compared with those of patients with squamous cell skin carcinoma without perineural invasion. Tabulation confirmed that the maxillary and mandibular branches of the trigeminal nerve and the facial nerve were most commonly involved. For patients with squamous cell skin carcinomas with perineural invasion, aggressive therapy is recommended, specifically, resection of involved tissues and nerves and appropriate regional lymphadenectomy followed by postoperative radiotherapy. This plan affords the best opportunity for tumor control. The indications for exploration of the middle fossa of the intracranial portion of the trigeminal nerve deserve further study.

Consensus Statement on the Classification and Terminology of Neck Dissection

OBJECTIVE To update the guidelines for neck dissection terminology, as previously recommended by the American Head and Neck Society. PARTICIPANTS Committee for Neck Dissection Classification, American Head and Neck Society; representation from the Committee for Head and Neck Surgery and Oncology, American Academy of Otolaryngology-Head and Neck Surgery (T.A.D.). EVIDENCE Review of current literature on neck dissection classification. CONSENSUS PROCESS Semiannual face-to-face meetings of the Committee for Neck Dissection Terminology and e-mail correspondence. CONCLUSIONS Standardization of terminology for neck dissection is important for communication among clinicians and researchers. New recommendations have been made regarding the following: boundaries between levels I and II and between levels III/IV and VI; terminology of the superior mediastinal nodes; and the method of submitting surgical specimens for pathologic analysis.

NODAL METASTASES: Predictive Factors

Squamous cell carcinoma of the upper respiratory and digestive tract has a high risk for neck metastasis, which reduces the probability of regional control and survival. We analyzed the literature and our own experience to review the possible risk factors for the occurrence of metastasis. The most significant risk factors were: tumor site and size, grade of histologic differentiation, tumor thickness (tongue and floor of mouth carcinoma), vascular embolization, and perineural infiltration. A series of biomarkers has been studied over the last 10 years, but no one has proved to be significant enough for clinical use. Based on several multivariate analysis, it is recommended elective treatment of the neck for high-risk patients.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine‐needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein–Barr virus (EBV) is important. Head Neck, 2013

Management of stage T3 and T4 glottic carcinomas.

Between 1959 and 1979, 242 patients with T3 and T4 lesions of the vocal cords were treated at our institution. Treatment consisted of total laryngectomy in all patients. Different modalities of regional node dissections were performed on 187 patients. In addition, 50 patients received irradiation with cobalt-60 postoperatively for specific features of the disease. In the group of 192 patients whose treatment consisted of surgery alone, 28 (14 percent) had recurrence in the neck and 10 (5 percent) had stomal recurrence. Of the patients treated with combined therapy, three (6 percent) had ipsilateral neck recurrences and one (2 percent) had stomal recurrence. For lesions staged N0, failure rates above the clavicles were 16 percent and 31 percent for patients with T3 and T4 lesions, respectively, in the group treated by surgery alone, 9 percent and 6 percent for patients with T3 and T4 lesions, respectively, in the combined therapy group. The rate of failure above the clavicles for lesions staged N+ was 32 percent in the group treated with surgery alone and 8 percent in the combined therapy group. In this study, a correlation was made between the failure rates above the clavicles and different clinical and histologic characteristics of the tumor, surgical findings, and the different modalities of cervical node dissection used. From analysis of the data, recommendations have been made for the selective treatment of patients with advanced glottic carcinomas.

Neck dissection in the treatment of cancer of major salivary glands.

The treatment of the neck nodes in salivary gland tumors has changed considerably in the last two decades. The current thinking and the rationale for it are discussed in detail in this article.

Planned neck dissection following chemoradiotherapy for advanced head and neck cancer: Is it necessary for all?

In the absence of large‐scale randomized trials evaluating dissection versus observation of the involved neck after neoadjuvant chemoradiotherapy, there is a need to collect data that will either support or ultimately refute a role for planned posttreatment neck dissection. A significant percentage of patients with extensive (N2 or N3) neck disease who demonstrate a complete response to chemoradiation therapy may harbor residual occult metastases, and identification of this subset of patients remains a clinical challenge. Because surgical salvage rates are greatly diminished when occult nodal disease becomes clinically manifest, planned posttreatment neck dissection is advocated but may not be necessary in all patients. The role of positron emission tomography chemoradiotherapy (PET‐CT) in this scenario remains unproven but holds promise in being able to identify which patients may be harboring residual disease in the neck after chemoradiotherapy. The implementation of as yet unidentified molecular tumor markers in combination with PET‐CT may ultimately prove to be effective in identifying patients who will best benefit from posttherapy neck dissection. Correlation of imaging results and pathologic node status will be important in determining the accuracy and, therefore, the value of this imaging modality for predicting the presence or absence of residual disease.

Squamous carcinoma of the external ear

The medical records of 486 patients with pathologically proved squamous carcinoma of the skin of the external ear were analyzed. It is a disease of elderly white men, and the helix is the most common site of origin. Well-differentiated squamous carcinoma is the most frequent histologic variant. Ninety-five percent of our patients were treated surgically with above-clavical control in 87 percent and 28 percent survival. The low survival rate was related to the old age of the patients who frequently died of intercurrent disease and second cancers. A 12 percent incidence of nodal metastases is comparable with the incidence reported in other series. Aggressive surgical ablation and the selected use of adjunctive postoperative irradiation appear justified in those patients with locally invasive tumors, multiple nodal metastases, and extracapsular invasion.

Curcumin: A new radio-sensitizer of squamous cell carcinoma cells

PURPOSE: Curcumin, a potential chemopreventive agent, was found to inhibit cancer cells in S/G2M phases of the cell cycle, when radiation is more effective. The purpose of the current study was to investigate whether curcumin can sensitize squamous cell carcinoma (SCC) cells to the ionizing effects of irradiation. METHODS: Curcumin (3.5 μM) was added for 48 hours to an SCC cell line prior to irradiation. Cell growth (counts) and colony-formation (colonogenic assay) were examined after radiation. RESULTS: Incubation with curcumin only (3.75 μM) for 48 hours did not decrease the number of cells or the ability to form colonies in the absence of radiation. However, in plates that were exposed to 1–5 Gy of radiation, cell counts dropped significantly if pretreated with curcumin with a maximal effect at 2.5 Gy (where the cell counts dropped from 1240 to 1017, P < 0.001). The colonogenic assay revealed a significant decrease in the ability to form colonies following pretreatment with curcumin in all radiation doses (P < 0.05). CONCLUSIONS: Given the appropriate doses, curcumin exhibits radio-sensitizing effects on SCC cells in vitro.

Early Oral Feeding Following Total Laryngectomy

Objectives The time to begin oral feeding after total laryngectomy remains a subject of debate among head and neck surgeons. The prevailing assumption is that early initiation of oral feeding may cause pharyngocutaneous fistula; thus, the common practice of initiating oral feeding after a period of 7 to 10 days. The objective of the study was to demonstrate the feasibility and safety of oral feeding 48 hours after total laryngectomy.