Evaluation of advanced directives in head and neck oncology patients

OtolaryngologyHead and Neck Surgery Volume 121 N u m b e r 2

11% (19/166). Minor complications occurred in 8.5% of patients. Conclusion: USFNA is a safe and effective diagnostic modality in the management of thyroid disease, especially for nodules that are difficult to palpate. 8:30 AM

Cancer without Surface Atypia: Why Surface Markers Are Not Reliable PAUL W BAUER MD (presenter); CHARLES W VAUGHAN MD FACS; GERARD F DOMANOWSKI MD; ERROL BAKER PHD; Waltham MA; Boston MA; Boston MA; Boston MA

Objective: Techniques of mucosal epithelial observation require that atypia develop into a full-thickness process upward from the basement membrane prior to invading the submucosal connective tissue. We raised the following questions: Is full-thickness atypia a necessary precondition for invasion? Does the lack of surface atypia preclude invasion? Methods: A retrospective, randomized review of histologic specimens of head and neck squamous cell carcinoma. Ninety patients were selected randomly from the tumor registry of the past 17 years of patients who have undergone surgical excision. All slides with mucosal epithelium present were reviewed for each patient. Observations from each slide selected were analyzed by calculating ~2 against a priori expected values for atypical surface epithelium with invasion, atypical surface epithelium without invasion, normal surface epithelium with invasion, and normal surface epithelium without invasion. Results: Generated a study population of 77 patients, represented by 371 pathology slides, and 730 data points. There were 69 instances of normal surface epithelium with underlying invasion. The observed frequency of invasion given a normal surface was significantly (P < 0.00001) greater than what would have been predicted. Conclusion: The hypothesis that normal surface precludes invasion was not supported by these data. Full-thickness atypia is not a necessary precondition for invasion. Techniques that rely on surface observation of atypia are not reliable guides to predicting invasion. 8:38 AM

Risk Factors Associated with Hypothyroidism Following Laryngectomy THOMAS T GAL JR MD (presenter); ROBIN L GAL MSPH; DOUGLAS W KLOTCH MD FACS; ALAN B CANTOR PHD; Tampa FL

Objectives: Hypothyroidism is a well-documented complication following treatment of head and neck cancer, and it is particularly significant in patients undergoing laryngectomy. The objective of this study was the identification of factors associated with the development of hypothyroidism in this population. Methods: Records of 136 patients treated with laryngectomy were retrospectively reviewed in an attempt to define a risk

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factor profile for patients who are most likely to develop hypothyroidism following laryngectomy. The Cox proportional hazards model was used to identify factors significantly related to an increased risk for development of hypothyroidism. The actuarial method was used to estimate the period of greatest risk for the development of hypothyroidism. Results: Increased risks were found for patients who were female (P = 0.0049), received preoperative radiation therapy (P = 0.0022), had invasion of the thyroid gland by tumor (P = 0.0003), had presence of cervical metastases (P = 0.0022), and developed postoperative fistula (P = 0.0095). From the actuarial method, we estimate that the period of time when patients are at greatest risk for development of hypothyroidism is between 0 and 14 months after surgical intervention. Wound complications were twice as frequent in hypothyroid patients. Conclusion: Perioperative awareness of risk factors associated with the development of hypothyroidism in patients undergoing laryngectomy allows for early recognition and management of hypothyroidism and may reduce the number of complications related to wound healing and fistula. 8:46 AM

Evaluation of Advanced Directives in Head and Neck Oncology Patients WAYNE E BERRYHtLL MD (presenter); GEORGE L ADAMS MD; Saint Paul MN; Minneapolis MN

Objectives: Advanced directives (ADs) are means by which patients can express their desires concerning treatment and care. In order for these directives to be effective, the patient must fully understand the individual components of the directive. Most ADs do specifically address issues effecting head and neck (H&N) patients and are therefore ineffective. This study queries H&N oncology patients concerning AD issues, evaluates their understanding, and implements an AD specific to H&N patients that addresses unique issues such as carotid rupture and airway obstruction. Methods: Thirty-eight H&N oncology patients, at various stages of disease course and treatment, were interviewed and given a 10-question survey evaluating their understanding of ADs, components of CPR, ventilation, intubation, artificial nutrition, tracheostomy, management of carotid blowout, and other methods of support. The survey also evaluated the efficacy of the provider's ability to communicate these issues. Patients were given the opportunity to complete a specific H&N AD. Results: Twenty-three of the patients surveyed had an AD on the patient record. Patients with advanced stages and longer courses were more likely to have an AD in place. All patients had some misconception regarding the performance of CPR and its components. Eighty-three percent of patients did not understand principles of intubation, ventilation, and the use of a ventilator. Development of a life-threatening con-

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dition and worsening of disease were the most common events leading to an AD discussion. All patients were open to the subject of AD. Those patients with an AD stated that discussion regarding AD should begin at diagnosis of disease and should be a regular part of follow-up. Seven of the 15 patients without ADs were not prepared to have an AD in place. All patients with ADs found the H&N-specific AD informative and useful. Conclusion: AD is an effective means by which patients maintain control over their care and treatment. The presence of an AD does not ensure that patients understand all aspects of their choices. Time and explanation of management issues were found to correct most misconceptions. AD discussions should be an integral part of follow-up for patients and should begin early in the course of treatment. The H&N-specific AD addresses issues unique to H&N patients (carotid rupture, airway obstruction). This AD was well received by patients and was able to clearly document their wishes regarding management of carotid rupture, airway distress, tracheostomy, and nutrition issues. AD issues must be continually addressed and revisited to keep patients well informed so that they may maintain effective control over their care. 9:00 AM

Distant Metastases in Advanced Head and Neck Cancer ERIK G COHEN MD (presenter); AIJAZ ALVI MD FACS; Philadelphia PA

Objectives: Treatment of squamous cell carcinoma of the head and neck has evolved during the past several decades. As local and regional control has improved, overall survival has not, despite refinement of treatment techniques. Distant metastases (DM) in the face of locoregional control may be the factor preventing high survival rates in advanced head and neck cancer patients. This study aims to identify risk factors for DM in surgically treated patients with advanced stage cancer of the oropharynx, hypopharynx, and supraglottic larynx. Methods: Patients were identified from a computer-based tumor registry at an academic, tertiary-care university hospital. Only patients with advanced-stage squamous cell carcinoma treated with curative intent by the department of otolaryngology-head and neck surgery at this institution were considered. Inclusion criteria for this retrospective chart review study included advanced TNM stage, primary surgical management, no DM at presentation, and minimum of 2 years' follow-up. Occurrence of DM with locoregional control was used as the endpoint. Clinical and pathologic staging data were obtained from medical records. Histopathologic data were obtained from surgical pathology reports. Data were tabulated and analyzed using Z 2 and Fisher's exact test when appropriate. Results: Locoregional control was achieved i n 4 0 of 51 patients (78%). Twelve patients (24%) developed DM despite locoregional control. Preliminary data revealed that neither

clinical nor pathologic T, N, or overall stage predicted DM. There was a trend toward patients with extranodal spread developing DM (P = 0.16). The presence of 4 or more positive nodes predicted DM (P = 0.008), while the presence of 3 or more positive nodes did not (P = 0.16). Positive level V nodes (P = 0.001) and positive nodes in levels II1-V (P = 0.002) predicted DM. Association of bilateral positive nodes with DM approached statistical significance (P = 0.066). Conclusion: DM were a significant cause of mortality in this study despite a high locoregional control rate among patients with advanced-stage head and neck cancer. TNM staging criteria did not predict patients who would go on to develop DM. Preliminary data indicate that the presence of 4 or more positive nodes, positive nodes in the low neck, and possibly bilateral positive nodes are risk factors for DM. 9:08 AM

Surgery for Hypopharynx Carcinoma: Feasibility and Outcome HANS EDMUND ECKEL MD (presenter); MICHAEL DAMM MD; MARKUS JUNGEHUELSING MD; CHRISTIAN SITTELMD; Cologne Germany

Objectives: Surgery, usually in combination with postoperative radiotherapy, is believed to provide the highest cure rates in patients with hypopharynx carcinoma. However, the percentage of patients suitable for primary surgery, surgical mortality rates, and organ preservation rates for this routinely used therapeutic approach have not been studied in detail. This study seeks to evaluate treatment modalities, mortality following surgery, survival, and organ preservation for a consecutive cohort of hypopharynx cancer patients treated according to a prospective protocol that favors surgery as the initial approach to the disease whenever possible and ethically justifiable. Methods: The charts of 228 consecutive patients with previously untreated hypopharyngeal squamous cell carcinoma seen from 1986 to 1997 were reviewed. No patient was excluded from data analysis. Outcome measures were calculated using the Kaplan-Meier estimator. Surgery was offered as initial treatment if the primary tumor and regional metastases seemed completely resectable, distant metastases were not detected during preoperative workup, coexisting malignancies did not preclude a curative approach, general health status of the patient was considered sufficient to withstand the operative trauma, patients were willing to undergo surgery, and patients were judged to be capable of dealing with the consequences of such treatment. Results: Of 228 patients, 136 were found suitable for initial surgical treatment: 46 had larynx-sparing procedures, 54 had total laryngectomy, and 36 had total laryngopharyngectomy. Microvascular jejunum loops for pharynx reconstruction were used in 22 patients, and gastric pull-up was used in 14. No patient died postoperatively. Of the remaining 92, 18 had non-