Robert P. Zitsch

Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial.

PURPOSE The validity of sentinel lymph node biopsy (SLNB) for T1 or T2, clinically N0, oral cancer was tested by correlation of sentinel node pathologic status with that of nodes within the completion neck dissection. METHODS This prospective, cooperative group trial involved 25 institutions over a 3-year period. One hundred forty patients with invasive oral cancers, stage T1 and T2, N0 including 95 cancers of the tongue, 26 of the floor of mouth, and 19 other oral cancers were studied. The study excluded lesions with diameter smaller than 6 mm or minimal invasion. Imaging was used to exclude nonpalpable gross nodal disease. Patients underwent injection of the lesion with (99m)Tc-sulfur colloid, nuclear imaging, narrow-exposure SLNB, and completion selective neck dissection. The major end point was the negative-predictive value (NPV) of SLNB. RESULTS In the 106 SLNBs, which were found to be pathologically and clinically node-negative by routine hematoxylin and eosin stain, 100 patients were found to have no other pathologically positive nodes, corresponding to a NPV of 94%. With additional sectioning and immunohistochemistry, NPV was improved to 96%. In the forty patients with proven cervical metastases, the true-positive rate was 90.2% and was superior for tongue tumors relative to floor of mouth. For T1 lesions, metastases were correctly identified in 100%. CONCLUSION For T1 or T2 N0 oral squamous cell carcinoma, SLNB with step sectioning and immunohistochemistry, performed by surgeons of mixed experience levels, correctly predicted a pathologically negative neck in 96% of patients (NPV, 96%).

Outcome analysis for lip carcinoma

Carcinoma of the lip is a relatively common malignancy of the head and neck region, accounting for approximately one quarter of oral cavity cancers. Although this form of cancer is generally readily curable compared with malignancies at other head and neck sites, regional metastases, local recurrence, and even death from this disease may occasionally occur. A review of 1252 patients who were diagnosed with lip cancer from 1940 to 1987 was undertaken to identify and rank prognostic variables, clarify differential incidences of site predilection between male and female patients, and examine the correlation between tumor site and histopathologic diagnoses. Large tumor size, high tumor grade, the presence of adenopathy, a subsite other than the lower lip, and inadequate surgical margins were found to have a negative impact on determinate survival of patients with lip carcinoma. Twenty-one percent of lip cancers in female patients arose on the upper Up, whereas only 3% of lip cancers in male patients developed on the upper lip. Basal cell carcinomas comprised 13% of upper lip cancers and only less than 1% of lower lip cancers. Recurrence developed in 15.1% of the patients reviewed and was strongly associated with large tumor size and poor differentiation. Local recurrence was associated with a determinate survival of 78%, whereas patients having regional recurrences had a survival rate of 52%. These data support aggressive treatment of lip cancers greater than 3 cm in diameter, high-grade tumors, tumors associated with cervical lymphadenopathy, and upper lip and commissure tumors. Lip cancer in women seems to be slightly more aggressive than in men.

Intraoperative radiolymphoscintigraphy for detection of occult nodal metastasis in patients with head and neck squamous cell carcinoma.

OBJECTIVES: We sought to determine the feasibility and utility of intraoperative radiolymphoscintigraphy as a screening procedure for the detection of occult metastatic disease in selected cases of head and neck squamous cell carcinoma (HNSCC). METHODS: Patients with accessible primary HNSCC and no evidence of metastatic disease who were already undergoing planned surgical resection of the primary tumor and elective neck dissection met the inclusion criteria. Before resection, a handheld gamma probe was used to find the radiolabeled sentinel lymph node (SLN). The neck specimen was examined ex vivo by using the gamma probe; the SLN or SLNs were dissected free from the specimen and sent separately for histopathologic examination. RESULTS: At least one SLN was identified in all patients enrolled thus far. Four patients had microscopic carcinoma found in the SLN. Two of these had cancer only in the SLN, and two had disease both in the SLN and the remaining specimen. CONCLUSIONS: Intraoperative radiolymphoscintigraphy appears to be a feasible and promising procedure to aid the surgeon in more accurately detecting occult metastatic HNSCC.

Cervical lymph node metastases and squamous cell carcinoma of the lip

Squamous cell carcinoma of the lip generally has a favorable outcome. The chance of long‐term survival is significantly reduced if lymph node metastases develop. Any features that could identify patients having increased risks of occult lymph node metastases would allow more aggressive treatment and, possibly, a better outcome.

Sentinel node biopsy for squamous cell carcinoma of the head and neck

The clinical utility of sentinel node biopsy for melanoma has led multiple investigators to apply this approach to other cutaneous malignancies as well as to early cancers of the upper aerodigestive tract. Data are most extensive for oral cancer. A multi‐institutional pathologic validation trial for selected oral cancers provided negative predictive values of 96%. Subsequent trials should document clinical follow‐up. This technique may ultimately play a wider role in the management of mucosal cancers. J. Surg. Oncol. 2008;97:683–690.

Chondrosarcoma of the temporomandibular joint.

Chondrosarcomas arise most commonly in the pelvis, femur, and humerus. 1 The occurrence of this malignant osseous tumor in the head and neck region, especially the mandible, is rare. In 1986 Weiss and Bennett 2 r viewed the literature of chondrosarcoma involving the head and neck region and documented 161 cases, of which 56 involved the mandible. Even more rare is the occurrence of chondrosarcoma arising from the temporomandibular joint (TMJ). A current review of American and European literature revealed only 6 cases originating at the TMJ, the most recent of which was reported by Nitzan et al 3 in 1993. In this article an additional case of chondrosarcoma of the TMJ is presented. Pertinent clinical aspects, including presenting features, radiographic findings, histopathology, and treatment of chondrosarcoma of the mandible are discussed. Chondrosarcoma arising in the TMJ is emphasized because tumors at this site present a special management challenge because of the involvement of the cranial base and the temporal bone.

Schwannoma of the hard palate

Schwannomas are rare, benign neoplasms that can arise from any cranial, peripheral, or autonomic nerve that contains Schwann cells. Approximately 25% to 45% of all schwannomas occur in the head and neck. They occur most commonly in the eighth cranial nerve, but it has been reported that 20% to 58% arise in the oral cavity, with approximately 10% of these located on the hard palate. We report a case of schwannoma of the hard palate, present important pathologic considerations for diagnosis, and provide a review of the literature regarding extracranial schwannomas.

Management of inflammatory pseudotumor of the larynx.

A 33-year-old woman presented to Otolaryngology clinic with a 2to 3-month history of globus sensation, and progressive shortness of breath that evolved into stridor. Direct laryngoscopy and tracheoscopy was carried out, showing a large left subglottic polypoid lesion extending 2 cm below the true vocal cords that occluded 80% of the subglottic airway, and which exerted a “ball and valve” effect. A computed tomography (CT) showed a 12 13 mm mass in the subglottis (Fig 1). Tracheostomy as well as biopsy was carried out. The patient was started on 60 mg of prednisone daily for 6 weeks. The patient’s symptoms recurred and follow-up CT showed 11 6 12 mm subglottic mass. Radiation therapy was commenced 3 months after initial presentation. 20 Gy in 10 fractions was administered. Three months later, patient returned with stridor and direct laryngoscopy and tracheoscopy showed a persistent 1 cm mass in the subglottis. Biopsy of this mass was consistent with inflammatory pseudotumor. Open exci-

Bilateral Oncocytic Cysts of the Nasopharynx

We describe a 59-year-old male patient noted to have bilateral oncocytic cysts of the nasopharynx. These cysts appear to represent retention cysts of peritubal mucoserous glands that have undergone oncocytic metaplasia and would be classified as lateral acquired cysts of the nasopharynx. These cysts are benign but may cause symptoms related to their location in the airway and proximity to the eustachian tube. Endoscopic surgical removal is the treatment of choice.

Extranodal nasal-type natural killer/T-cell lymphoma masquerading as recalcitrant sinusitis.

Extranodal nasal‐type natural killer (NK)/T‐cell lymphoma is a very uncommon disease process often mimicking refractory sinusitis. The diagnosis may be discovered after an extensive exclusion process. Careful immunohistochemical evaluation is crucial to differentiate NK/T‐cell lymphoma from other malignancies.