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ABSTRACT: Radiation is a known risk factor for poor wound healing. Patients undergoing intraoperative radiation therapy (IORT) typically receive higher cumulative doses to their wound beds than patients treated with conventional radiation therapy. We review our experience with IORT in patients undergoing resection of head and neck cancer and flap reconstruction. Logistics of delivery and outcomes are discussed.
A retrospective chart review was performed on all patients at Beth Israel Medical Center who underwent IORT for head and neck cancer between 2000 and 2007. Twenty-one patients receiving 22 treatments involving flap reconstruction were identified. The results of these reconstructions were evaluated for complications and functional outcome.
All patients had complex surgical wounds of the face, upper aerodigestive tract, or neck who received IORT in conjunction with pedicled or free flap closure. Twenty-five flaps in 21 patients were performed in the setting of IORT. All patients received between 10 and 15 Gy of IORT administered directly to the wound bed. There were no perioperative mortalities. Wound breakdown occurred in three cases, all of which were treated successfully by operative revision. Functionally, most patients did well and performed similarly to historic controls for their type of reconstruction.
Reconstruction using flaps in the context of IORT can be achieved with expectation of good wound healing in the majority of cases despite heavy cumulative doses of radiation to recipient wound beds.
The Laryngoscope 02/2008; 118(1):69-74. · 1.75 Impact Factor
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ABSTRACT: This study was performed to assess the overall incidence and duration of alterations in tongue sensation and taste after operative microlaryngoscopy, and the relation of these symptoms to operative time.
We performed a retrospective review of information regarding tongue symptoms in patients who completed standard post-microlaryngoscopy follow-up at 1 week, 1 month, and 3 months.
One hundred patients (54 male and 46 female; mean age, 46 years; age range, 14 to 83 years) met the inclusion criteria. Eighteen patients had positive findings at 1 week: 15 complained of paresthesia and 3 of dysgeusia. The symptoms decreased over time without treatment (4% of patients at 1 month and 1% of patients at 3 months). Only 1 case of dysgeusia persisted past 3 months. Gender was found to be a significant independent risk factor for the development of symptoms (odds ratio, 5.63; 95% confidence interval, 1.36 to 31.29; p = .013). Patients whose operations lasted longer than 1 hour were almost 4 times more likely to develop tongue-related symptoms than those with an operative time less than 30 minutes, although these findings did not achieve statistical significance (odds ratio, 3.91; 95% confidence interval, 0.62 to 30.95; p = .182).
Alterations in tongue sensation and taste, most likely due to lingual nerve injury, are common after microlaryngoscopy, especially in female patients. They also tend to be associated with longer operative times. Although transient in nearly every case, lingual paresthesia and dysgeusia should form part of the preoperative discussion with the patient.
The Annals of otology, rhinology, and laryngology 02/2006; 115(1):18-22. · 1.05 Impact Factor
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Douglas K Frank,
Kenneth S Hu,
Bruce E Culliney,
Mark S Persky,
Moses Nussbaum,
Stimson P Schantz,
Stephen C Malamud,
Roy A Holliday,
Azita S Khorsandi, Roy B Sessions,
Louis B Harrison
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ABSTRACT: Since 1998, at our academic, multidisciplinary head and neck cancer treatment center, it has been our policy to treat appropriate patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) with concomitant radiochemotherapy followed within 6 weeks by planned neck dissection(s). Our objective was to investigate the oncologic efficacy of planned neck dissection, to date, in this patient population with a focus on outcomes in the neck.
Retrospective analysis of a cumulative patient database.
The medical records of all patients who underwent planned neck dissection(s) after concomitant radiochemotherapy for locoregionally advanced SCCHN at Beth Israel Medical Center and The Institute for Head and Neck Cancer in New York City were reviewed. For each patient, preradiochemotherapy primary and neck stage, postradiochemotherapy/preneck dissection clinical and radiographic neck status, type of neck dissection(s) performed, pathologic status of the neck dissection specimen(s), length of follow-up (after planned neck dissection), disease status at last follow-up, and site(s) of recurrence were recorded. Local, regional, and distant disease control rates were calculated by the Kaplan-Meier method.
Fifty-one planned neck dissections were performed on 39 radiochemotherapy patients (12 patients had bilateral operations) between early 1998 and October, 2003. Thirty-two (82%) patients had N2 or greater neck disease, with 29 (74%) having T3/T4 disease at various upper aerodigestive tract primary sites. Patients received an average of 6,700 cGy and 6,000 cGy external beam radiation therapy to primary disease sites and involved cervical lymphatics respectively, concomitant with one of three platinum-based chemotherapy schedules. At a mean follow-up time of 24 (range 8-57) months for the entire study population, there has been only one neck recurrence (N2A neck). No patient with N2B (n = 11), N2C (n = 13, with majority of heminecks staged N2B), or N3 (n = 5) disease has recurred in the neck. No recurrences have occurred in the 41 heminecks (in 33 patients) where modified neck dissection (including 24 selective procedures) was performed despite the presence of residual carcinoma in 13 (32%) of these heminecks on pathologic review. Among all heminecks with residual carcinoma present (n = 18) in the neck dissection specimen, there has been only one neck recurrence. There have been no recurrences in the 26 heminecks (in 19 patients) with incomplete clinical response after radiochemotherapy despite the presence of residual carcinoma in 14 (54%) of these necks on pathologic review. The clinical and radiographic absence of residual disease after radiochemotherapy did not always predict a complete pathologic response. Surgical complications have been limited (1 chyle leak, 1 wound breakdown).
The integration of planned neck dissection into the multidisciplinary management of patients with locoregionally advanced SCCHN is highly effective in controlling cervical metastatic disease. Modified and selective neck dissection procedures can be performed in the majority of patients, regardless of the response in the neck subsequent to concomitant radiochemotherapy. We recommend a planned neck dissection(s) in all patients staged (pretreatment) with N2 or greater neck disease and in select N1 cases.
The Laryngoscope 07/2005; 115(6):1015-20. · 1.75 Impact Factor
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ABSTRACT: Kaposi's sarcoma is a common malignancy in patients infected with HIV but is rarely seen in the major salivary glands. If a patient is known to be HIV-positive, however, Kaposi's sarcoma must be considered in the differential diagnosis of salivary gland masses in addition to the benign and malignant neoplasms that occur in immunocompetent patients. We present a unique case in which an otherwise healthy patient was diagnosed with HIV after resection of his enlarged parotid gland revealed Kaposi's sarcoma.
Case report.
A 58-year-old man presented with slowly enlarging bilateral parotid masses of approximately 3 years' duration. The patient's presentation, workup, and final diagnosis of Kaposi's sarcoma are discussed.
A magnetic resonance imaging scan of the neck showed two right parotid lesions and one left parotid mass. The patient underwent a right superficial parotidectomy for a suspected diagnosis of Warthin's tumor, given the bilaterality of the lesions. Histologic evaluation of the surgical specimen revealed spindle-shaped cells with extravasated erythrocytes typical of Kaposi's sarcoma. After discussion of the results with the patient, HIV risk factors were elucidated, and subsequent testing revealed the patient to be HIV-positive.
Although Kaposi's sarcoma is common in AIDS patients, there are few case reports of this malignancy arising in the salivary glands. Previously reported cases include salivary gland Kaposi's sarcoma in known HIV-positive patients and a handful of reports in patients without confirmed immunocompromise. The patient presented here is unique because the diagnosis of parotid gland Kaposi's sarcoma led to a new diagnosis of HIV. This interesting case reiterates the need for complete history taking and the inclusion of Kaposi's sarcoma in the differential diagnosis of salivary gland masses in the appropriate patient population.
The Laryngoscope 06/2005; 115(5):861-3. · 1.75 Impact Factor
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ABSTRACT: The management of base of tongue cancer has evolved steadily over time. Organ preservation with primary radiation therapy has produced excellent oncologic and functional outcomes. Concomitant chemotherapy has become important in patients with locoregionally advanced disease. Planned neck dissection after organ preservation therapy continues to be an integral step for regional control. This article reports the results of a literature review of base of tongue cancer emphasizing a multidisciplinary approach to obtain optimal results in terms of cure and quality of life.
Otolaryngologic Clinics of North America 03/2005; 38(1):75-85, viii. · 1.65 Impact Factor
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ABSTRACT: Pleomorphic adenomas are the most common salivary gland tumors and are typically cured with complete surgical excision. There are rare reports, however, in which these histologically benign tumors have inexplicably metastasized to distant sites. We present a case of a patient who presented, 27 years after excision of a parotid pleomorphic adenoma, with a recurrence in the parotid bed and a mediastinal metastasis.
Case report.
A 43-year-old woman presented with a mass in the right parotid bed 27 years after excision of a pleomorphic adenoma of the parotid. The patient's presentation, workup, and final diagnosis of benign metastasizing pleomorphic adenoma will be discussed, along with a pertinent review of the literature.
A diagnosis of recurrent pleomorphic adenoma was made from a fine needle aspiration biopsy of the right parotid mass. On subsequent computed tomographic scan, chest images revealed an incidental left mediastinal mass, which also proved to be a pleomorphic adenoma on computed tomography-guided fine needle aspiration biopsy. The patient underwent a completion parotidectomy and sternotomy with excision of the mediastinal mass. Examination of the pathology specimens confirmed a diagnosis of pleomorphic adenoma in both the parotid bed and the mediastinum. No histologic characteristics of malignancy were seen in either specimen; therefore, a diagnosis of benign metastasizing mixed tumor was rendered.
Benign metastasizing pleomorphic adenoma is a rare and controversial but distinct clinical entity. Although the definition of the term benign precludes metastatic disease, these tumors do not demonstrate any malignant features yet metastasize to distant sites. It remains to be determined whether these benign metastasizing pleomorphic adenomas are really low-grade salivary malignancies.
American Journal of Otolaryngology 28(2):130-3. · 0.87 Impact Factor
