Joseph E. Harvey

Meta-analysis of second malignant tumors in head and neck cancer: The case for an endoscopic screening protocol

A meta-analysis was performed on data from the Washington University Department of Otolaryngology Head and Neck Tumor Registry and 24 studies reporting synchronous and metachronous malignancies in head and neck cancer patients. The overall second malignant tumor (second primary) prevalence was 14.2% in 40,287 patients, the majority of tumors being metachronous. Site relationships between index tumors and second primaries revealed significantly high risks along the digestive tract axis or the respiratory tract axis, although lung second primaries were prevalent in all groups. Head and neck second primaries were the largest group, being significantly more common in the oral cavity, oropharynx, and hypopharynx than in the larynx. Oral cavity index tumors showed the highest overall rate of second primary formation. Half of all aerodigestive tract second primaries are detected by 2 years from index tumor presentation, but non-aerodigestive tract tumors are common beyond 5 years. A significantly higher detection rate was proven for the prospective panendoscopy studies. We recommend routine interval endoscopic intervention within 2 years of treatment for optimum detection of second primaries in head and neck cancer patients. Also, a lifetime of clinical surveillance is suggested for aerodigestive tract second neoplasms in oral cavity, oropharynx, and hypopharynx cancer patients and for lung and non-aerodigestive tract neoplasms in larynx cancer patients.

Squamous cell carcinoma of the pyriform sinus: A nonrandomized comparison of therapeutic modalities and long‐term results

From January 1964 through December 1991, 408 patients with squamous cell carcinomas involving the pyriform sinus were treated at Washington University Medical Center. Their ages ranged from 29 to 83 years (mean, 62.3; median 59) and the male to female ratio was 5:1. The mean duration of symptoms prior to diagnosis was 3.9 months (range 1 to 32 months) and 89% had a smoking or ethanol history. Sixty‐seven percent had T3 or T4 lesions and 87% were stage III or IV at presentation. Sixty‐nine percent had neck metastases. The treatment strategy varied with respect to radiation and reconstruction. Prior to 1978, preoperative radiation (3.5 to 5000 cGy) was used. Postoperative radiation was given thereafter (600+ Gy). Since 1982, flap reconstruction (usually pectoralis major myocutaneous) has been used to close the partial laryngopharyngectomy (PLP) defect. Almost all N0 necks were treated by radiation or surgery and all N1‐N3 lesions were treated by combined therapy. Pyriform tumors were subdivided into three groups: 1. one‐wall lesions (n = 48), 2. medial‐wall lesions which involved the aryepiglottic fold or supraglottis (N = 267), and 3. two‐ or three‐wall lesions which extended to the pyriform apex or post‐cricoid region (N = 93). Ninety‐five patients had single‐modality therapy and 302 had combined treatment. Two hundred seven patients had conservation surgery (PLP) and 157 had total laryngopharyngectomy alone or in combination with radiation. Thirty‐three patients were treated by radiation alone. Eleven patients were excluded from the study because of distant metastases (TxNxM1) at presentation. The cumulative survival (NED) at 5, 10, 15, and 20 years was 56%, 35%, 31%, and 20%, respectively. The cumulative locoregional control rate was 71%. At 5 years (NED), the cure rates for one‐wall lesions (73%) were better than for medial‐wall lesions (63%) or 2‐ and 3‐wall lesions (49%).

Nasopulmonary Mechanics-Experimental Evidence of the Influence of the Upper Airway Upon the Lower

Nasal obstruction from whatever source, anatomic or infectious, causes measurably increased lower airway resistance. This has been verified by, (1) establishment of control groups of normal subjects for each of our successive studies, (2) oral and nasal measurements of pulmonary function in subjects with nasal and laryngeal obstruction, with postoperative observation, in some cases, for evaluation of changes in respiratory mechanics following corrective surgery, (3) establishment of baseline measurements of normal and abnormal pulmonary function in the human, (4) partitioning of total pulmonary resistance in the human and dog, and (5) long term observation of various types of surgically created nasal obstruction, as well as induced inflammation of the nasal cavities and paranasal sinuses in dogs, in order to study the effect of these conditions upon the function or mechanics of the lower airway.

Comparison of clinical evaluation and computed tomographic diagnostic accuracy for tumors of the larynx and hypopharynx.

Ninety‐five patients with laryngeal and hypopharyngeal cancer were examined and staged preoperatively by clinical evaluation (CE) and computed tomography(CT). The CE and CT staging were compared to each other and to the pathologic(PT) staging of the tumors. The CT staging showed high accuracy in staging transglottic (88%), supraglottic (68%), and oropharyngeal tumors invading the larynx (68%) when compared to the PT findings. The CT staging was less effective in evaluating glottic tumors (46%), both overstaging (12%) and understaging (20%) cases. Combined CE‐CT evaluation showed higher accuracy in staging all tumors (84%) compared to CE alone (52%) or CT alone (68%). The findings suggest that combined CE‐CT should be used to evaluate laryngeal and hypopharyngeal tumors.

Primary subglottic cancer

This retrospective study reviews 39 patients with primary subglottic cancer seen between 1955 and 1988 by the Department of Otolaryngology at Washington University. This number constitutes 1.8% of laryngeal cancer cases diagnosed during this period. Twenty‐eight patients (71.8%) had epidermoid cancer, of which 19 (67.9%) had “early” disease (stages I and II), and nine (32.1%) had “advanced” (stages III and IV). Overall 5‐year survival was 57.7%. Disease‐free survival was 46.2%. Patients treated with radiotherapy alone, surgery alone, or both had disease‐free 5‐year survivals of 22.2%, 41.7%, and 100%, respectively. Combination therapy showed a significantly higher (P < .01) disease‐free survival than radiotherapy alone.

The Risk of Contralateral Lymphatic Metastases for Cancers of the Larynx and Pharynx

PURPOSE This study was undertaken to determine the risk of cervical metastases to the contralateral side in patients treated for carcinoma of the larynx and pharynx. PATIENTS AND METHOD Retrospective evaluation of 846 patients treated between 1962 and 1981 with carcinoma of the supraglottis, transglottis, and pyriform sinus were reviewed. Lesions were classified as either transglottic with fixed vocal cord (TG-F), transglottic with mobile vocal cords (TG-M), central supraglottic (SG-C), marginal supraglottic (SG-M), glossoepiglottic cancers of the suprahyoid epiglottic, vallecula, and tongue base (SG-GE), and cancers of the pyriform sinus (PS). RESULTS Contralateral lymph node metastases were identified at presentation or later developed in SG-GE 26%, SG-M 14%, PS 13%, SG-C 7%, TG 4%. Contralateral metastases were significantly higher in patients with ipsilateral metastasis. The risk of contralateral metastasis was unrelated to the primary tumor size. CONCLUSIONS All but 79 patients received variable doses of irradiation to the contralateral neck. Therefore, the risk of metastatic disease is probably higher than reported. Parotid-sparing radiation technique is suggested for centrally located cancers of the supraglottis and transglottis when ipsilateral nodes are not involved because the risk of contralateral neck involvement is sufficiently low that opposite neck irradiation may be safely avoided.

Surgical pathology of cancer of the oral cavity and oropharynx

A study was designed to determine the influence of certain surgical pathologic findings on tumor spread and survival in patients with cancer of the oral cavity and oropharynx. All patients with the histopathological diagnosis of carcinoma of the oral cavity or oropharynx from 1955 to 1983 were included in the study. Using the Head and Neck Tumor Registry of the department of otolaryngology of the Washington University School of Medicine, information was obtained regarding preoperative evaluation, staging, classification, diagnosis, treatment, surgical pathology parameters, and outcome results. The patient populations consisted of 545 patients with oral cavity cancer and 224 patients with oropharynx cancer, all of whom were eligible for 3‐year follow‐up.

Prediction of occult neck disease in laryngeal cancer by means of a logistic regression statistical model

The ability to accurately predict the presence of subclinical metastatic neck disease in clinically N0 patients with primary epidermoid cancer of the larynx would be of great value in determining whether to perform an elective neck dissection. We describe a statistical approach to estimating the probability of occult neck disease given pretreatment clinical parameters. A retrospective study was performed involving 736 clinically N0 patients with primary laryngeal cancer who were treated surgically with primary resection and ipsilateral neck dissection. Nodal involvement was determined histologically after surgical lymphadenectomy. A logistic regression model was used to derive an equation that calculated the probability of occult neck metastasis based on pretreatment T stage, tumor location, and histologic grade. The model has a sensitivity of 74%, a specificity of 87%, and can be entered into a programmable calculator.

Natural history of treated T1N0 squamous carcinoma of the glottis.

The records of 373 patients with T1N0 squamous carcinoma of the glottis were examined. Of these, 271 underwent initial hemilaryngectomy; 102 had full-course irradiation for cure. While the overall survival rates of the two initial therapies were similar, failure of the initial treatment modality was approximately twice as frequent in the irradiated patients (34.4%) as in the patients undergoing hemilaryngectomy (16.9%). The effect of this difference in initial failure rate on quality of life and on cost of overall therapy will be discussed.

Impairment of function of the intrinsic laryngeal muscles after regeneration of the recurrent laryngeal nerve

Complete return of laryngeal function, as evidenced by normal excursion of the vocal folds during respiration and phonation, seldom follows division and repair of the laryngeal nerves. In order to investigate this phenomenon further the recurrent laryngeal nerve was sectioned and repaired in five dogs. Some functions of the intrinsic laryngeal muscles in these dogs were observed at intervals following repair of the nerve and compared to other dogs in which the nerve had been crushed or subjected to sustained pressure.