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Surgery for hypopharynx carcinoma: Feasibility and outcome
P176
OtolaryngologyHead and NeckSurgery August T999
Scientific Sessions--Wednesday
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-
OtolaryngologyHead and Neck Surgery Volume 121 Number 2
resectable lymph node metastases, 16 had unresectable primaries, 13 refused surgery, 13 had distant metastases, 8 had coexisting primaries, 12 had severe cardiopulmonary disorders, 9 had multiple risks, and 3 died prior to the initiation of any kind of therapy. Five-year overall survival was 26.6% for all 228 patients, 35.9% for the 136 patients with surgical treatment, 59.3% for the 46 patients who were treated with larynxsparing procedures, and 12.9% for those not treated surgically. Conclusion: Only 59.6% of 228 unselected, consecutive patients were suitable for surgical treatment. For these, no postoperative fatalities were observed. Five-year overall survival was significantly better for patients who qualified for surgery (35.9% vs 12,9%), but only 27.5% of them had their larynx preserved after 5 years. 9:16 AM
Supracricoid Laryngectomy (CHEP) Functional Results ROBERTOA LIMA MD (presenter); EMILSON DEQUEIROZFREITAS MD; JACOB KLIGERMAN MD; FERNANDO LUIS DIAS MD; MAURO M BARBOSA MD; JOSE SILVEIRA SOARES MD; GERAD DO MAI-rOS DE SA MD; Rio de Janeiro Brazil; Rio de Janeiro Brazit; Rio de Janeiro Brazil; Rio de Janeiro Brazil; Rio de Janeiro Brazil; Ponta Delgada Portugal; Rio de Janeiro Brazil
Objectives: The supracricoid laryngectomy is an alternative surgical technique that removes all thyroid cartilage, sparing at least one arytenoid cartilage. In order to assess whether supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) could successfully reach the cure and preserve the voice in T2/T3 glottic cancer, we studied 21 patients with
Scientific Sessions--Wednesday
P177
T2/T3 squamous cell carcinoma of the larynx treated in our institution with CHEE Methods: A retrospective analysis of 21 patients with T2/T3 glottic carcinoma was carried out between 1996 and 1997. The mean age was 58 years (range 41 to 79 years), 86% were male, and all had a smoking habit. All patients were evaluated with direct laryngoscopy and CT scan. Using the TNM classification (UICC-1987) we classified 11 (52%) patients as T3NOM0 and 10 patient as T2NOM0. Survival was analyzed under the Kaplan-Meyer actuarial method. Results: All 21 patients achieved the voice with this procedure, but 1 patient had severe aspiration and was treated with completion laryngectomy. Two patients had problems breathing without tracheostomy because of redundant mucosa and were treated with laser resection. One patient had fistula and infection after the surgery, causing stenosis of the airway, and is using the tracheostomy to breathe. The remaining 17 patients reached the voice without tracheostomy after a mean of 35 days (range 8-60 days). One patient had local recurrence and was treated with completion laryngectomy, and 1 patient had a second cancer in the oropharynx treated with palliative radiotherapy. Conclusion: This technique is useful for the treatment of selected cases of T2/T3 laryngeal cancer that otherwise would be treated surgically with total or near-total laryngectomy. It preserves the speech and the physiologic airway. The complications do not compromise the functionality of this technique. A larger follow-up time is needed to permit the analysis of the survival.
OtolaryngologyHead and NeckSurgery August T999
Scientific Sessions--Wednesday
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-
OtolaryngologyHead and Neck Surgery Volume 121 Number 2
resectable lymph node metastases, 16 had unresectable primaries, 13 refused surgery, 13 had distant metastases, 8 had coexisting primaries, 12 had severe cardiopulmonary disorders, 9 had multiple risks, and 3 died prior to the initiation of any kind of therapy. Five-year overall survival was 26.6% for all 228 patients, 35.9% for the 136 patients with surgical treatment, 59.3% for the 46 patients who were treated with larynxsparing procedures, and 12.9% for those not treated surgically. Conclusion: Only 59.6% of 228 unselected, consecutive patients were suitable for surgical treatment. For these, no postoperative fatalities were observed. Five-year overall survival was significantly better for patients who qualified for surgery (35.9% vs 12,9%), but only 27.5% of them had their larynx preserved after 5 years. 9:16 AM
Supracricoid Laryngectomy (CHEP) Functional Results ROBERTOA LIMA MD (presenter); EMILSON DEQUEIROZFREITAS MD; JACOB KLIGERMAN MD; FERNANDO LUIS DIAS MD; MAURO M BARBOSA MD; JOSE SILVEIRA SOARES MD; GERAD DO MAI-rOS DE SA MD; Rio de Janeiro Brazil; Rio de Janeiro Brazit; Rio de Janeiro Brazil; Rio de Janeiro Brazil; Rio de Janeiro Brazil; Ponta Delgada Portugal; Rio de Janeiro Brazil
Objectives: The supracricoid laryngectomy is an alternative surgical technique that removes all thyroid cartilage, sparing at least one arytenoid cartilage. In order to assess whether supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) could successfully reach the cure and preserve the voice in T2/T3 glottic cancer, we studied 21 patients with
Scientific Sessions--Wednesday
P177
T2/T3 squamous cell carcinoma of the larynx treated in our institution with CHEE Methods: A retrospective analysis of 21 patients with T2/T3 glottic carcinoma was carried out between 1996 and 1997. The mean age was 58 years (range 41 to 79 years), 86% were male, and all had a smoking habit. All patients were evaluated with direct laryngoscopy and CT scan. Using the TNM classification (UICC-1987) we classified 11 (52%) patients as T3NOM0 and 10 patient as T2NOM0. Survival was analyzed under the Kaplan-Meyer actuarial method. Results: All 21 patients achieved the voice with this procedure, but 1 patient had severe aspiration and was treated with completion laryngectomy. Two patients had problems breathing without tracheostomy because of redundant mucosa and were treated with laser resection. One patient had fistula and infection after the surgery, causing stenosis of the airway, and is using the tracheostomy to breathe. The remaining 17 patients reached the voice without tracheostomy after a mean of 35 days (range 8-60 days). One patient had local recurrence and was treated with completion laryngectomy, and 1 patient had a second cancer in the oropharynx treated with palliative radiotherapy. Conclusion: This technique is useful for the treatment of selected cases of T2/T3 laryngeal cancer that otherwise would be treated surgically with total or near-total laryngectomy. It preserves the speech and the physiologic airway. The complications do not compromise the functionality of this technique. A larger follow-up time is needed to permit the analysis of the survival.