Marion B. Ridley

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.

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.

Arytenoid Subluxation From Blunt Laryngeal Trauma

Isolated arytenoid dislocation and subluxation are uncommon laryngeal injuries most often resulting from endotracheal intubation. However, these diagnoses must be entertained in all patients having sustained laryngeal trauma. Complaints of dysphonia, pain with phonation, or odynophagia in the setting of laryngeal trauma should include evaluation for possible arytenoid displacement after an airway is secured. Prolonged hoarseness or odynophagia after endotracheal intubation should alert the physician to the possibility of a cricoarytenoid joint injury. This represents the first reported case of isolated arytenoid injury resulting from blunt external trauma to the larynx. The patient had a stable airway without intervention, and the displaced joint spontaneously relocated with resolution of the cricoarytenoid edema and hemarthrosis. We propose that the cricoarytenoid joint was subluxed probably due to edema, hematoma, and/or cricoarytenoid hemarthrosis sustained from blunt laryngeal trauma. We furthermore propose that some cases of cricoarytenoid subluxation may be treated without operative intervention.

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.

Signal averaging and waveform analysis of laser Doppler flowmetry monitoring of porcine myocutaneous flaps: I. Acute assessment of flap viability

Postoperative monitoring of microvascular free-tissue transfer is essential to the early identification and correction of vascular compromise. Laser Doppler flowmetry is a noninvasive monitor of capillary bed perfusion. Its current clinical use requires continuous monitoring and trend analysis to detect changes in capillary perfusion. This study investigated the hypothesis that signal averaging of laser Doppler flowmetry output triggered by a fixed point in the cardiac cycle would provide accurate information about the microvascular flow patterns not dependent on trend analysis. These results indicate that averaged waveform analysis allowed for a rapid, objective, and statistically significant distinction between a viable myocutaneous flap and one with vascular compromise in a porcine model. Moreover, this technique allows for distinction between venous and arterial insufficiency.

Renal cell carcinoma presenting as a masseteric space mass

Abstract We present an unusual case of renal cell carcinoma metastatic to the masseter muscle. Whereas metastasis of renal cell carcinoma to the head and neck in itself is common, metastasis to skeletal muscle is quite infrequent. Although the presence of metastasis in renal cell carcinoma implies an overall worse prognosis, surgical extirpation as well as management of the primary lesion is still advisable in the hope of achieving long-term survival. Renal cell carcinoma metastasis must always be included in the differential diagnosis of clear cell neoplasms of the head and neck.

First Place — Resident Clinical Science Award 1995: Signal Averaging and Waveform Analysis of Laser Doppler Flowmetry Monitoring of Porcine Myocutaneous Flaps: I. Acute Assessment of Flap Viability

Postoperative monitoring of microvascular free-tissue transfer is essential to the early identification and correction of vascular compromise. Laser Doppler flowmetry is a noninvasive monitor of capillary bed perfusion. Its current clinical use requires continuous monitoring and trend analysis to detect changes in capillary perfusion. This study investigated the hypothesis that signal averaging of laser Doppler flowmetry output triggered by a fixed point in the cardiac cycle would provide accurate information about the microvascular flow patterns not dependent on trend analysis. These results indicate that averaged waveform analysis allowed for a rapid, objective, and statistically significant distinction between a viable myocutaneous flap and one with vascular compromise in a porcine model. Moreover, this technique allows for distinction between venous and arterial insufficiency.

Hypocalcemia following Pharyngoesophageal Ablation and Gastric Pull-up Reconstruction: Pathophysiology and Management

Profound hypocalcemia has been observed following surgical ablation of malignancies in the hypopharynx, larynx, cervical trachea, and esophagus. Adequate control of these tumors may require extirpation of the visceral compartment of the neck and upper mediastinum. Preservation of parathyroid glands is sometimes inconsistent with good oncologic principles. Postoperative hypocalcemia develops rapidly, and high-dose intravenous calcium supplementation is required. Clinical observations indicated that requirements for calcium supplementation were reduced dramatically once oral feeding was instituted. It is postulated that dysfunction arising from surgical manipulation of the duodenum, the primary site for active calcium absorption, and bypass of that bowel segment by the feeding jejunostomy are primary contributors to the severity of hypocalcemia. A plan of management is proposed that includes early postoperative administration of 1,25-dihydroxyvitamin D or dihydrotachysterol, active vitamin D metabolites that promote the absorption of calcium. Early oral feeding is encouraged. Other mechanisms of calcium loss, appropriate calcium management, and parathyroid autotransplantation are discussed.