Publications by authors named "Willard E Fee"

27 Publications

  • Page 1 of 1

Faster Triage of Veterans With Head and Neck Cancer.

Fed Pract 2016 Aug;33(Suppl 5):24S-29S

is a resident, is a research assistant, and are professors, and is a professor emeritus, all in the department of otolaryngology/head and neck surgery; all at Stanford University School of Medicine in Palo Alto, California. is a medical student at Stanford University School of Medicine. At the time of this study, was a medical student at University of Dammam School of Medicine in Saudi Arabia. is a nurse practitioner, and are nurses, and Dr. Sirjani is the chief, all in the department of otolaryngology/head and neck surgery at VA Palo Alto Health Care System.

High-risk patients with a growing mass require proper assessment, including a thorough history, physical examination, and fine-needle aspiration for diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375521PMC
August 2016

Impact of positron emission tomography/computed tomography surveillance at 12 and 24 months for detecting head and neck cancer recurrence.

Cancer 2013 Apr 7;119(7):1349-56. Epub 2012 Dec 7.

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.

Background: In head and neck cancer (HNC), 3-month post-treatment positron emission tomography (PET)/computed tomography (CT) reliably identifies persistent/recurrent disease. However, further PET/CT surveillance has unclear benefit. The impact of post-treatment PET/CT surveillance on outcomes is assessed at 12 and 24 months.

Methods: A 10-year retrospective analysis of HNC patients was carried out with long-term serial imaging. Imaging at 3 months included either PET/CT or magnetic resonance imaging, with all subsequent imaging comprised of PET/CT. PET/CT scans at 12 and 24 months were evaluated only if preceding interval scans were negative. Of 1114 identified patients, 284 had 3-month scans, 175 had 3- and 12-month scans, and 77 had 3-, 12-, and 24-month scans.

Results: PET/CT detection rates in clinically occult patients were 9% (15 of 175) at 12 months, and 4% (3 of 77) at 24 months. No difference in outcomes was identified between PET/CT-detected and clinically detected recurrences, with similar 3-year disease-free survival (41% vs 46%, P = .91) and 3-year overall survival (60% vs 54%, P = .70) rates. Compared with 3-month PET/CT, 12-month PET/CT demonstrated fewer equivocal reads (26% vs 10%, P < .001). Of scans deemed equivocal, 6% (5 of 89) were ultimately found to be positive.

Conclusions: HNC patients with negative 3-month imaging appear to derive limited benefit from subsequent PET/CT surveillance. No survival differences were observed between PET/CT-detected and clinically detected recurrences, although larger prospective studies are needed for further investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.27892DOI Listing
April 2013

Nasopharyngeal carcinoma: salvage of local recurrence.

Oral Oncol 2012 Sep 14;48(9):768-74. Epub 2012 Mar 14.

Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong.

Local control of nasopharyngeal carcinoma has substantially improved with advancing radiotherapy technology and appropriate combination with chemotherapy. However, when local recurrence occurs, this is one of the most difficult challenges. Aggressive treatment is indicated because long term salvage is achievable particularly for early recurrence, but high risk of complications is a serious concern. Treatment options include different methods of surgery and/or re-irradiation with/without chemotherapy. Available information in the literature is grossly inadequate; most reports compose of small series of highly selected patients with heterogeneous characteristics and treatment. No randomized trials have been performed to evaluate the therapeutic ratio of different treatment methods. This article reviews available treatment options, their therapeutic benefits and risks of complications; the objective is to provide information for developing treatment recommendations and suggestions for future improvement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.oraloncology.2012.02.017DOI Listing
September 2012

Targeted endoscopic salvage nasopharyngectomy for recurrent nasopharyngeal carcinoma.

Int Forum Allergy Rhinol 2012 Mar-Apr;2(2):166-73. Epub 2011 Dec 13.

Division of Rhinology, Stanford University School of Medicine, Stanford, CA 94305, USA.

Background: Despite modern radiotherapy and open surgical techniques, treatment of recurrent nasopharyngeal carcinoma (NPC) remains challenging, with substantial morbidity involved. Targeted endoscopic nasopharyngectomy was evaluated as a viable oncologic alternative to open nasopharyngectomy or radiation for recurrent NPC.

Methods: Thirteen patients who underwent endoscopic nasopharyngectomy for recurrent NPC between August 2005 and August 2010 were retrospectively reviewed. Average age at surgery was 55.7 years, with mean follow-up period 24.2 months. Two-year disease-free survival, 2-year overall survival, margin status, and complication rate were measured.

Results: Including resections for subsequent recurrences, 19 endoscopic procedures were performed with curative intent. Mean operating room (OR) time was 278 minutes, mean estimated blood loss was 197 mL, and mean length of hospitalization was 1.0 days. Negative margins were obtained in 78.9% of procedures: positive margins involved the parapharyngeal space, oropharynx, fossa of Rosenmuller, and infratemporal fossa. Stereotactic radiation was given postoperatively for localized positive margins. Four patients required repeat endoscopic nasopharyngectomy for re-recurrence, despite having their margins cleared or controlled with adjuvant treatment. Two-year local disease-free and overall survival rates were 69.2% and 100.0%, respectively. The overall minor complication rate was 52.6%, with no major complications.

Conclusion: Targeted endoscopic nasopharyngectomy is beneficial in locally recurrent NPC, with favorable morbidity and complication rates. Endoscopic surveillance and serial imaging together facilitate the early identification of re-recurrences, which often may be treated with additional directed resection. Postoperative stereotactic radiation may serve as an appropriate adjunct modality for disease control at positive margins.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/alr.20111DOI Listing
August 2012

A planned neck dissection is not necessary in all patients with N2-3 head-and-neck cancer after sequential chemoradiotherapy.

Int J Radiat Oncol Biol Phys 2012 Jul 2;83(3):994-9. Epub 2011 Dec 2.

Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA 94305-5847, USA.

Purpose: To assess the role of a planned neck dissection (PND) after sequential chemoradiotherapy for patients with head-and-neck cancer with N2-N3 nodal disease.

Methods And Materials: We reviewed 90 patients with N2-N3 head-and-neck squamous cell carcinoma treated between 1991 and 2001 on two sequential chemoradiotherapy protocols. All patients received induction and concurrent chemotherapy with cisplatin and 5-fluorocuracil, with or without tirapazamine. Patients with less than a clinical complete response (cCR) in the neck proceeded to a PND after chemoradiation. The primary endpoint was nodal response. Clinical outcomes and patterns of failure were analyzed.

Results: The median follow-up durations for living and all patients were 8.3 years (range, 1.5-16.3 year) and 5.4 years (range, 0.6-16.3 years), respectively. Of the 48 patients with nodal cCR whose necks were observed, 5 patients had neck failures as a component of their recurrence [neck and primary (n = 2); neck, primary, and distant (n = 1); neck only (n = 1); neck and distant (n = 1)]. Therefore, PND may have benefited only 2 patients (4%) [neck only failure (n = 1); neck and distant failure (n = 1)]. The pathologic complete response (pCR) rate for those with a clinical partial response (cPR) undergoing PND (n = 30) was 53%. The 5-year neck control rates after cCR, cPR→pCR, and cPR→pPR were 90%, 93%, and 78%, respectively (p = 0.36). The 5-year disease-free survival rates for the cCR, cPR→pCR, and cPR→pPR groups were 53%, 75%, and 42%, respectively (p = 0.04).

Conclusion: In our series, patients with N2-N3 neck disease achieving a cCR in the neck, PND would have benefited only 4% and, therefore, is not recommended. Patients with a cPR should be treated with PND. Residual tumor in the PND specimens was associated with poor outcomes; therefore, aggressive therapy is recommended. Studies using novel imaging modalities are needed to better assess treatment response.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijrobp.2011.07.042DOI Listing
July 2012

Novel neoadjuvant immunotherapy regimen safety and survival in head and neck squamous cell cancer.

Head Neck 2011 Dec 31;33(12):1666-74. Epub 2011 Jan 31.

Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Background: Cellular immune suppression is observed in head and neck squamous cell cancer (HNSCC) and contributes to poor prognosis. Restoration of immune homeostasis may require primary cell-derived cytokines at physiologic doses. An immunotherapy regimen containing a biologic, with multiple-active cytokine components, and administered with cytoxan, zinc, and indomethacin was developed to modulate cellular immunity.

Methods: Study methods were designed to determine the safety and efficacy of a 21-day neoadjuvant immunotherapy regimen in a phase 2 trial that enrolled 27 therapy-naïve patients with stage II to IVa HNSCC. Methods included safety, clinical and radiologic tumor response, disease-free survival (DFS), overall survival (OS), and tumor lymphocytic infiltrate (LI) data collection.

Results: Acute toxicity was minimal. Patients completed neoadjuvant treatment without surgical delay. By independent radiographic review, 83% had stable disease during treatment. OS was 92%, 73%, and 69% at 12, 24, and 36 months, respectively. Histologic analysis suggested correlation between survival and tumor LI.

Conclusion: Immunotherapy regimen was tolerated. Survival results are encouraging.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.21660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062188PMC
December 2011

Long-term great auricular nerve morbidity after sacrifice during parotidectomy.

Laryngoscope 2009 Jun;119(6):1140-6

Department of Otolaryngology/Head and Neck Surgery, Stanford University School of Medicine, Stanford, California 94305, USA.

Objectives/hypothesis: To clarify the extent and patient perspectives of great auricular nerve (GAN) morbidity and recovery after nerve sacrifice during parotidectomy 4 to 5 years after surgery.

Study Design: Prospective series.

Methods: Twenty-two patients who underwent parotidectomy with GAN sacrifice and were previously studied for GAN sensory outcome during the first postoperative year. We performed light touch sensation tests on each patient to develop an ink map representing anesthesia and paresthesia in the GAN sensory territory; patients also completed an outcomes questionnaire.

Results: Nineteen (86%) of 22 patients completed follow-up. One patient completed the questionnaire over the phone. The prevalence and average areas of anesthesia and paresthesia decreased since the first postoperative year according to sensory testing and patient scoring. At 4 to 5 years, 47% (9 of 19) of the patients had anesthesia, 58% (11 of 19) had paresthesia, and 26% (5 of 19) had neither anesthesia nor paresthesia during sensory testing. Patients reported that the GAN dysfunction brought them no to mild inference with their daily activities. At a mean point of 2 years, 70% (14 of 20) patients felt that their sensory symptoms had either completely abated or stabilized.

Conclusions: The posterior branch of the GAN should be preserved if it does not compromise tumor resection. If this is not possible, the patient and surgeon should be comforted in that only minor, if any, long-term disability will ensue. Laryngoscope, 2009.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.20246DOI Listing
June 2009

Excellent local control with stereotactic radiotherapy boost after external beam radiotherapy in patients with nasopharyngeal carcinoma.

Int J Radiat Oncol Biol Phys 2008 Jun 31;71(2):393-400. Epub 2007 Dec 31.

Department of Radiation Oncology, Stanford University, Stanford, CA 94305-5847, USA.

Purpose: To determine long-term outcomes in patients receiving stereotactic radiotherapy (SRT) as a boost after external beam radiotherapy (EBRT) for locally advanced nasopharyngeal carcinoma (NPC).

Methods And Materials: Eight-two patients received an SRT boost after EBRT between September 1992 and July 2006. Nine patients had T1, 30 had T2, 12 had T3, and 31 had T4 tumors. Sixteen patients had Stage II, 19 had Stage III, and 47 had Stage IV disease. Patients received 66 Gy of EBRT followed by a single-fraction SRT boost of 7-15 Gy, delivered 2-6 weeks after EBRT. Seventy patients also received cisplatin-based chemotherapy delivered concurrently with and adjuvant to radiotherapy.

Results: At a median follow-up of 40.7 months (range, 6.5-144.2 months) for living patients, there was only 1 local failure in a patient with a T4 tumor. At 5 years, the freedom from local relapse rate was 98%, freedom from nodal relapse 83%, freedom from distant metastasis 68%, freedom from any relapse 67%, and overall survival 69%. Late toxicity included radiation-related retinopathy in 3, carotid aneurysm in 1, and radiographic temporal lobe necrosis in 10 patients, of whom 2 patients were symptomatic with seizures. Of 10 patients with temporal lobe necrosis, 9 had T4 tumors.

Conclusion: Stereotactic radiotherapy boost after EBRT provides excellent local control for patients with NPC. Improved target delineation and dose homogeneity of radiation delivery for both EBRT and SRT is important to avoid long-term complications. Better systemic therapies for distant control are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijrobp.2007.10.027DOI Listing
June 2008

Quality of life 17 to 20 years after uvulopalatopharyngoplasty.

Laryngoscope 2007 Mar;117(3):503-6

YH Goh Ear Nose Throat, Head and Neck Surgery, Mount Elizabeth Medical Centre, Republic of Singapore.

Objectives: To study the long-term quality of life outcomes of a group of unselected patients for the long-term effects of uvulopalatopharyngoplasty (UPPP).

Study Design: Retrospective chart review and telephone survey.

Methods: Forty-nine patients who underwent UPPP between July 1980 and July 1983 and who had their medical records were reviewed and were asked to grade on a visual analogue scale (VAS) the clinical benefits and complications of UPPP after the surgery.

Results: Forty-three (87.8%) males and six (12.2%) female patients were studied. Improvement in snoring, excessive daytime somnolence, and nocturnal arousals were seen after UPPP with decreased effectiveness after time. The most common complication of UPPP was velopharyngeal insufficiency (VPI) (28.5%); however, dry throat and swallowing difficulty tended to be more severe in those patients who had them. No correlation between the snoring and VPI VAS grades was observed. Forty-three patients had a preoperative sleep study and 22 patients a postoperative sleep study. There was lack of correlation between the significant subjective clinical improvement and their postoperative polysomnography.

Conclusion: When undertaking UPPP, both subjective and objective benefits should be weighed against the risk of long-term ill effects. Patients should also be warned that the long-term side effects such as VPI, dry throat, and abnormal swallowing sensation might be more common than previously expected.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MLG.0b013e31802d83bdDOI Listing
March 2007

Evaluation of patterns of failure and subjective salivary function in patients treated with intensity modulated radiotherapy for head and neck squamous cell carcinoma.

Head Neck 2007 Mar;29(3):211-20

Department of Radiation Oncology, Stanford University Medical Center, Stanford, California 94305, USA.

Background: Our aim was to correlate patterns of failure with target volume delineations in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiation therapy (IMRT) and to report subjective xerostomia outcomes after IMRT as compared with conventional radiation therapy (CRT).

Methods: Between January 2000 and April 2005, 69 patients with newly diagnosed nonmetastatic HNSCC underwent curative parotid-sparing IMRT at Stanford University. Sites included were oropharynx (n = 39), oral cavity (n = 8), larynx (n = 8), hypopharynx (n = 8), and unknown primary (n = 6). Forty-six patients received definitive IMRT (66 Gy, 2.2 Gy/fraction), and 23 patients received postoperative IMRT (60.2 Gy, 2.15 Gy/fraction). Fifty-one patients also received concomitant chemotherapy. Posttreatment salivary gland function was evaluated by a validated xerostomia questionnaire in 29 IMRT and 75 matched CRT patients >6 months after completing radiation treatment.

Results: At a median follow-up of 25 months for living patients (range, 10-60), 7 locoregional failures were observed, 5 in the gross target or high-risk postoperative volume, 1 in the clinical target volume, and 1 at the junction of the IMRT and supraclavicular fields. The 2-year Kaplan-Meier estimates for locoregional control and overall survival were 92% and 74% for definitive IMRT and 87% and 87% for postoperative IMRT patients, respectively. The mean total xerostomia questionnaire score was significantly better for IMRT than for CRT patients (p = .006).

Conclusions: The predominant pattern of failure in IMRT-treated patients is in the gross tumor volume. Parotid sparing with IMRT resulted in less subjective xerostomia and may improve quality of life in irradiated HNSCC patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.20505DOI Listing
March 2007

Cyclin D1 and p16 expression in recurrent nasopharyngeal carcinoma.

World J Surg Oncol 2006 Sep 5;4:62. Epub 2006 Sep 5.

Department of Surgery, John D, Dingell VA Medical Center, 4646 John R, Street, Detroit, MI 48201, USA.

Background: Cyclin D1 and p16 are involved in the regulation of G1 checkpoint and may play an important role in the tumorigenesis of nasopharyngeal carcinoma (NPC). Previous studies have examined the level of expression of cyclin D1 and p16 in primary untreated NPC but no such information is available for recurrent NPC. We set out in this study to examine the expression level of cyclin D1 and p16 in recurrent NPC that have failed previous treatment with radiation +/- chemotherapy.

Patients And Methods: A total of 42 patients underwent salvage nasopharyngectomy from 1984 to 2001 for recurrent NPC after treatment failure with radiation +/- chemotherapy. Twenty-seven pathologic specimens were available for immunohistochemical study using antibodies against cyclin D1 and p16.

Results: Positive expression of cyclin D1 was observed in 7 of 27 recurrent NPC specimens (26%) while positive p16 expression was seen in only 1 of 27 recurrent NPC (4%).

Conclusion: While the level of expression of cyclin D1 in recurrent NPC was similar to that of previously untreated head and neck cancer, the level of p16 expression in recurrent NPC samples was much lower than that reported for previously untreated cancer. The finding that almost all (96%) of the recurrent NPC lack expression of p16 suggested that loss of p16 may confer a survival advantage by making cancer cells more resistant to conventional treatment with radiation +/- chemotherapy. Further research is warranted to investigate the clinical use of p16 both as a prognostic marker and as a potential therapeutic target.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/1477-7819-4-62DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1569377PMC
September 2006

Great auricular nerve morbidity after nerve sacrifice during parotidectomy.

Arch Otolaryngol Head Neck Surg 2006 Jun;132(6):642-9

Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, Calif, USA.

Objective: To clarify the extent, timing, and patient perspectives of great auricular nerve (GAN) morbidity and recovery after nerve sacrifice during parotidectomy during the first postoperative year.

Design: Prospective series.

Setting: Tertiary care academic medical center. Patients Twenty-seven consecutive patients who underwent parotidectomy with GAN sacrifice.

Main Outcome Measures: Preoperatively and at 3, 6, 9, and 12 months postoperatively, we performed light touch sensation tests on each patient to develop an ink map representing anesthesia and paresthesia in the GAN sensory territory; patients also completed an outcomes questionnaire.

Results: Twenty-two (81%) of 27 patients completed follow-up. The prevalence and average area of anesthesia decreased continually during the first year according to sensory testing and patient scoring. Half of the patients had no anesthesia at 12 months. The prevalence and average area of paresthesia increased during the first year according to sensory testing; however, the contiguity and subjective scoring of paresthesia peaked at 6 months and decreased in subsequent follow-up points. Throughout the first year, patients had difficulty using the telephone, shaving, combing their hair, wearing earrings, and sleeping on the operative side because of both anesthesia and paresthesia.

Conclusions: The impact of GAN sacrifice morbidity on patient quality of life is tolerable and improves during the first postoperative year. However, we feel that GAN morbidity may be bothersome enough to warrant efforts to preserve the posterior branch of the GAN when possible and appropriate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.132.6.642DOI Listing
June 2006

Readers' responses to "are 80 hours a week enough to train a surgeon?".

Authors:
Willard E Fee

MedGenMed 2005 ;7(4):43; author reply 44

View Article and Find Full Text PDF

Download full-text PDF

Source
June 2006

Mature results from a randomized Phase II trial of cisplatin plus 5-fluorouracil and radiotherapy with or without tirapazamine in patients with resectable Stage IV head and neck squamous cell carcinomas.

Cancer 2006 May;106(9):1940-9

Department of Radiation Oncology, Stanford University, Stanford, California 94305, USA.

Background: The objective of this article was to report the results from a randomized trial that evaluated the efficacy and toxicity of adding tirapazamine (TPZ) to chemoradiotherapy in the treatment of patients with head and neck squamous cell carcinomas (HNSCC).

Methods: Sixty-two patients with lymph node-positive, resectable, TNM Stage IV HNSCC were randomized to receive either 2 cycles of induction chemotherapy (TPZ, cisplatin, and 5-fluorouracil [5-FU]) followed by simultaneous chemoradiotherapy (TPZ, cisplatin, and 5-FU) or to receive the same regimen without TPZ. Patients who did not achieve a complete response at 50 Grays underwent surgical treatment. Stratification factors for randomization included tumor site, TNM stage, and median tumor oxygen tension. The primary endpoint was complete lymph node response.

Results: The addition of TPZ resulted in increased hematologic toxicity. There was 1 treatment-related death from induction chemotherapy. The complete clinical and pathologic response rate in the lymph nodes was 90% and 74% for the standard treatment arm and the TPZ arm, respectively (P = .08) and 89% and 90% at the primary site in the respective treatment arms (P = .71). The 5-year overall survival rate was 59%, the cause-specific survival rate was 68%, the rate of freedom from recurrence was 69%, and the locoregional control rate was 77% for the entire group. There was no difference with regard to any of the outcome parameters between the 2 treatment arms. The significant long-term toxicity rate also was found to be similar between the 2 arms.

Conclusions: The addition of TPZ increased hematologic toxicity but did not improve outcomes in patients with resectable, Stage IV HNSCC using the protocol administered this small randomized study. The combination of induction and simultaneous chemoradiotherapy resulted in excellent survival in these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.21785DOI Listing
May 2006

Advanced-staged tonsillar squamous carcinoma: organ preservation versus surgical management of the primary site.

Head Neck 2006 Jul;28(7):587-94

Department of Radiation Oncology, 875 Blake Wilbur Dr, R. CC-G228, Stanford University, Stanford, CA 94305, USA.

Background: Our aim was to review our experience in the management of advanced tonsillar squamous cell carcinoma (SCC) and to compare treatment outcomes between patients treated with and without surgery to the primary site.

Methods: The records of 74 patients with advanced-stage tonsillar SCC were reviewed. The median age at diagnosis was 58 years. Thirty-eight patients received definitive surgery to the primary site, and 36 were treated with an organ-preservation approach (OP) using radiotherapy +/- chemotherapy.

Results: No significant difference in overall survival (OS) or freedom from relapse (FFR) by treatment was found. T classification and N status were significant independent predictors on multivariate analysis for OS and FFR. Major late toxicity was noted in 10 patients in the surgical group and nine in the OP group.

Conclusion: Patients treated with OP and primary surgery had comparable OS and FFR. T classification and N status were significant independent predictors for tumor relapse and survival. On the basis of these results, we favor organ-preservation therapy for patients with advanced-stage tonsillar SCC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.20372DOI Listing
July 2006

Positron-emission tomography for surveillance of head and neck cancer.

Laryngoscope 2005 Apr;115(4):645-50

Department of Otolaryngology--Head and Neck Surgery, Stanford University School of Medicine, Stanford, California 94305, USA.

Objectives/hypothesis: To determine the diagnostic accuracy and the ideal timing of fluoro-fluorodeoxyglucose positron-emission tomography (PET) in the posttreatment surveillance of head and neck mucosal squamous cell carcinoma (HNSCC).

Study Design: Retrospective chart review.

Methods: Our sample includes 103 adult patients with 118 posttreatment PET scans who had undergone treatment for HNSCC. We correlated PET results with surgical pathology and clinical outcome in the subsequent 6 months.

Results: For the detection of locoregional persistent or recurrent HNSCC, PET scans had a sensitivity of 82%, specificity of 92%, positive predictive value (PPV) of 64%, negative predictive value (NPV) of 97%, and overall accuracy of 90%. For the detection of distant metastases, PET scans had a sensitivity of 89%, specificity of 97%, PPV of 85%, NPV of 98%, and overall accuracy of 96%. PET scans of the head and neck region performed greater than 1 month after the completion of radiation compared with scans performed within 1 month had a significantly higher sensitivity of 95% versus 55% (P < .01) and NPV of 99% versus 90% (P < .01).

Conclusion: PET is effective in detecting distant metastases in the posttreatment surveillance for HNSCC patients. A negative PET is highly reliable for all sites. However, a positive PET in the head and neck region is unreliable because of a high false-positivity rate. PET of the head and neck region has a statistically significant risk of a false-negative reading when performed within 1 month of radiation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/01.mlg.0000161345.23128.d4DOI Listing
April 2005

Split-thickness skin graft attachment to bone lacking periosteum.

Arch Otolaryngol Head Neck Surg 2005 Feb;131(2):124-8

Departments of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA 94305-5328, USA.

Objectives: To develop an animal model to investigate the survival of split-thickness skin grafts (STSGs) on bone without periosteum, to compare STSG attachment to bone with and without periosteum, and to determine the effect of fibrin glue on STSG attachment to bone.

Design: Prospective laboratory study.

Setting: University laboratory.

Subjects: Sprague-Dawley rats.

Main Outcome Measure: Percentage of survival of the STSGs at 2 weeks determined independently by the authors and a third, blinded head and neck surgeon.

Results: In experiment 1, which included 40 rats, the sutured STSGs showed an average survival rate of 38% when attached to bone with periosteum, 6% when attached to bare bone, and 10% when attached to bare bone using fibrin glue. The poor survival rate was thought to be attributable to the animals scratching at their bolster dressings. In experiment 2, 18 animals underwent a posteriorly based U-shaped flap of skin and subcutaneous tissue. The grafts were placed and isolated from the overlying flap with a biosynthetic wound dressing. The sutured STSG survival rates were as follows: 87% when attached to bone with periosteum, 94% when attached to bare bone, and 74% when attached to bare bone using fibrin glue.

Conclusions: The survival of STSGs attached to bare bone was comparable to that of STSGs attached to bone with periosteum when grafts were protected with the skin-subcutaneous flap. The STSGs that were fixed with 0.1 cc of fibrin glue demonstrated poorer survival rates than those attached with sutures and were associated with more seromas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.131.2.124DOI Listing
February 2005

Long-term results of 100 consecutive comprehensive neck dissections: implications for selective neck dissections.

Arch Otolaryngol Head Neck Surg 2004 Dec;130(12):1369-73

Department of Otolaryngology-Head and Neck Surgery, Stanford University Hospital, and Stanford University School of Medicine, Stanford, Calif, USA.

Objective: The optimal surgical procedure for the neck in patients with squamous head and neck cancers is controversial. Selective neck dissections have replaced modified radical neck dissections as the procedure of choice for the clinically negative (N0) neck and are now being considered for patients with early-stage neck disease. We report the long-term local recurrence rates in 100 consecutive patients undergoing a radical or modified radical neck dissection for clinically positive (N+) and N0 neck disease and review comprehensively the literature reporting and comparing regional control rates for both neck dissection types.

Patients: The clinical records of 100 consecutive patients who underwent a comprehensive neck dissection (levels I-V) for squamous head and neck cancers with a minimum of a 2-year follow-up were retrospectively reviewed for primary site of disease, clinical and pathologic neck status, histopathologic grade, neck dissection type, and the site and time of recurrence.

Results: Complete data were available for 97 patients on whom 99 neck dissections were performed. Three patients died from unknown causes. Seventy-six patients with N+ disease underwent a therapeutic neck dissection, while 24 patients with clinically N0 disease underwent an elective dissection. The overall neck recurrence rate in patients with controlled primary disease was 7%. The neck or regional failure rate for patients completing the recommended adjuvant radiotherapy was 4%. Six (25%) of 24 patients with clinically N0 disease had occult metastases. The recurrence rate for this group was 4%.

Conclusion: Further study is needed to determine the optimal surgical management of the N0 and limited N+ neck.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.130.12.1369DOI Listing
December 2004

Laryngeal embryonal rhabdomyosarcoma: a case of cervical metastases 13 years after treatment and a 25-year review of existing literature.

Arch Otolaryngol Head Neck Surg 2004 Oct;130(10):1217-22

Department of Otolaryngology-Head & Neck Surgery, Stanford University Hospital, 300 Pasteur Drive, Edwards R-135, Stanford, CA 94305, USA.

Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood, the majority of which are of the embryonal rhabdomyosarcoma (ER) variety. Present day treatment protocols involve a combination of aggressive surgery, chemotherapy, and radiation therapy. Embryonal rhabdomyosarcoma of the larynx is rare and unlike ER of other regions exhibits excellent response to multimodality treatment without the need for extensive surgery. We report a case of cervical metastases in a 29-year-old man 13 years after treatment of his laryngeal ER. To our knowledge, this is the first reported case of late neck metastases in ER of the larynx and the second reported case of delayed presentation of recurrent disease. A 25-year review of all published reports of ER of the larynx was conducted that highlights the move toward organ preservation with the multimodality treatment protocols. Embryonal rhabdomyosarcoma of the larynx is highly responsive to combination chemoradiotherapy, allowing for excellent cure rates without the need for extensive surgery. Late relapses warrant long-term follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.130.10.1217DOI Listing
October 2004

Identification of tyrosine kinases overexpressed in head and neck cancer.

Arch Otolaryngol Head Neck Surg 2004 Mar;130(3):311-6

Department of Otolaryngology/Head and Neck Surgery, Wayne State University, Detroit, MI 48201, USA.

Objective: To identify protein-tyrosine kinases (PTKs) that may be involved in the development and progression of head and neck squamous cell carcinoma (HNSCC).

Design: Messenger RNA from 7 HNSCC specimens was reverse transcribed to complementary DNA, and selective amplification of PTK complementary DNA was achieved using polymerase chain reaction (PCR) with degenerate PTK primers. The resulting PTK PCR products from these 7 HNSCC specimens were then cloned and randomly selected for sequencing. The PTKs that were represented multiple times in these randomly selected clones were selected as candidate PTKs that may be overexpressed in HNSCC. Antibodies against these candidate PTKs were then used for immunohistochemical studies on 8 other HNSCC specimens not used in the original selection of the candidate PTKs.

Results: Three known (EphA1, Brk, and Ron) and 2 novel (KIAA0728 and KIAA0279) PTKs were found to be highly expressed in the 7 HNSCC samples studied, based on the technique of reverse transcriptase-PCR with degenerate primers. Immunohistochemical studies with antibodies against the 3 known PTKs in 8 other HNSCC specimens not used in the previous reverse transcriptase-PCR reaction demonstrated overexpression of EphA1, Brk, and Ron in 12.5%, 37.5%, and 75% of these specimens.

Conclusions: In this study, we identified 5 PTKs that were overexpressed in HNSCC using a reverse transcriptase-PCR technique and confirmed the overexpression of 3 known PTKs in some of the 8 archival HNSCC specimens studied. Our finding suggests that the signaling pathways mediated through EphA1, Brk, and Ron may be involved in the development and progression of HNSCC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.130.3.311DOI Listing
March 2004

Functional outcome after total parotidectomy reconstruction.

Laryngoscope 2004 Feb;114(2):223-6

Division of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA.

Objectives/hypothesis: The objective was to compare and contrast the functional and cosmetic outcomes of patients who underwent total parotidectomy with and without reconstruction using an inferiorly based sternocleidomastoid muscle flap.

Study Design: Retrospective review in the setting of a university medical center.

Methods: Twenty-four patients underwent a total parotidectomy. Fifteen patients had reconstruction with an inferiorly based sternocleidomastoid muscle flap, and nine patients had no reconstruction. Clinical examination was performed independently by two head and neck surgeons and one aesthetician to evaluate cosmetic outcome, presence of gustatory flushing or sweating, and return of facial nerve and greater auricular nerve function.

Results: With the mean follow-up of 22 months, the group having reconstruction showed a better cosmetic outcome compared with the group without reconstruction. Objective testing for Frey syndrome demonstrated gustatory sweating in 20% of the group having reconstruction group versus 22% in the group without reconstruction. There was no difference in length of operation, hospital stay, or facial nerve function. Objective testing of facial sensation revealed that only 40% in the group having reconstruction had normal sensation to light touch compared with 78% in the group without reconstruction.

Conclusion: The inferiorly based sternocleidomastoid muscle flap offers improved cosmetic results in patients undergoing total parotidectomy. However, there is a decreased return of greater auricular nerve function, probably attributable to relocation of the nerve stump anteriorly. Benefit was not seen in prevention of Frey syndrome measured objectively; however, the group having reconstruction had fewer clinical symptoms of gustatory sweating or flushing.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/00005537-200402000-00009DOI Listing
February 2004

Evaluation of a patient with a parotid tumor.

Arch Otolaryngol Head Neck Surg 2003 Sep;129(9):937-8

Division of Otolaryngology, Stanford University Medical Center, R-135, Stanford, CA 94305-5328, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.129.9.937DOI Listing
September 2003

Long-term outcomes after external beam irradiation and brachytherapy boost for base-of-tongue cancers.

Int J Radiat Oncol Biol Phys 2003 Oct;57(2):489-94

Department of Radiation Oncology, Stanford University, Stanford, CA 94305-5302, USA.

Purpose: To assess long-term efficacy and toxicity associated with external beam irradiation (EBRT) and interstitial (192)Ir implantation for the treatment of squamous carcinoma of the base of tongue.

Methods And Materials: Between April 1975 and December 1993, 41 patients with base-of-tongue carcinomas were treated with (192)Ir interstitial implants after EBRT at Stanford University. One patient had Stage I, 6 had Stage II, 7 had Stage III, and 27 had Stage IV tumors. Twenty-eight patients had cervical lymph node involvement at diagnosis. All received EBRT to a median dose of 50 Gy (range 48.9-68 Gy) to the primary tumor and regional lymph nodes before brachytherapy. Interstitial implant was performed 2-4 weeks after EBRT. Intraoperatively, nylon catheters were placed via steel trocars into the base of tongue, glossotonsillar groove, and pharyngo-epiglottic fold using a catheter looping technique. Twenty-three of 28 node-positive patients also underwent simultaneous neck dissections. Postoperatively, the (192)Ir seeds were inserted and allowed to remain in place for approximately 35 h to achieve a median tumor dose of 26 Gy (range 20-34 Gy) to a median volume of 73 cc. Survival, local control, and complications were assessed.

Results: With a median follow-up of 62 months (range 9-215) for all patients and 90 months for alive patients, the 5-year Kaplan-Meier survival estimate was 66%. The 5-year local control rate was 82%, with 7 patients recurring locally, 2 of whom were salvaged with surgery. Nodal control was achieved in 93% of patients with either EBRT alone or in combination with neck dissection. The 5-year freedom from distant metastasis rate was 83%. Acute complications included transient bleeding (5%) and infection (8%). Late complication included soft-tissue necrosis/ulceration (7%), osteoradionecrosis (5%), and xerostomia.

Conclusion: Base-of-tongue carcinoma can be effectively treated with EBRT and (192)Ir implant boost. Local control is excellent and complication rates are acceptable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/s0360-3016(03)00597-2DOI Listing
October 2003

Improved local control with stereotactic radiosurgical boost in patients with nasopharyngeal carcinoma.

Int J Radiat Oncol Biol Phys 2003 Jul;56(4):1046-54

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305-5302, USA.

Purpose: Treatment of nasopharyngeal carcinoma using conventional external beam radiotherapy (EBRT) alone is associated with a significant risk of local recurrence. Stereotactic radiosurgery (STR) was used to boost the tumor site after EBRT to improve local control.

Methods And Materials: Forty-five nasopharyngeal carcinoma patients received a STR boost after EBRT at Stanford University. Seven had T1, 16 had T2, 4 had T3, and 18 had T4 tumors (1997 American Joint Commission on Cancer staging). Ten had Stage II, 8 had Stage III, and 27 had Stage IV neoplasms. Most patients received 66 Gy of EBRT delivered at 2 Gy/fraction. Thirty-six received concurrent cisplatin-based chemotherapy. STR was delivered to the primary site 4-6 weeks after EBRT in one fraction of 7-15 Gy.

Results: At a medium follow-up of 31 months, no local failures had occurred. The 3-year local control rate was 100%, the freedom from distant metastasis rate was 69%, the progression-free survival rate was 71%, and the overall survival rate was 75%. Univariate and multivariate analyses revealed N stage (favoring N0-N1, p = 0.02, hazard ratio HR 4.2) and World Health Organization histologic type (favoring type III, p = 0.002, HR 13) as significant factors for freedom from distant metastasis. World Health Organization histologic type (p = 0.004, HR 10.5) and age (p = 0.01, HR 1.07/y) were significant factors for survival. Late toxicity included transient cranial nerve weakness in 4, radiation-related retinopathy in 1, and asymptomatic temporal lobe necrosis in 3 patients who originally had intracranial tumor extension.

Conclusion: STR boost after EBRT provided excellent local control in nasopharyngeal carcinoma patients. The incidence of late toxicity was acceptable. More effective systemic treatment is needed to achieve improved survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/s0360-3016(03)00117-2DOI Listing
July 2003

Airway management after maxillectomy: routine tracheostomy is unnecessary.

Laryngoscope 2003 Jun;113(6):929-32

Department of Otolaryngology, Wayne State University, School of Medicine, Detroit, Michigan 48201, USA.

Objectives/hypothesis: There is a paucity of data to guide the optimal management of the airway in patients after maxillectomy. The decision on whether a concomitant tracheostomy is needed is often dictated by the surgeon's training and experience. We reviewed our experience with maxillectomy to assess the need for tracheostomy in postoperative airway management.

Study Design: Retrospective analysis at a university hospital.

Methods: We identified 121 patients who underwent 130 maxillectomies between October 1990 and September 2001. Twenty-four of these were total (all six walls removed), 45 were subtotal (two or more walls removed), and 61 were limited (only one wall removed). Reconstruction ranged from none to microvascular free flap, with split-thickness skin graft being the most common reconstructive option.

Results: Only 10 tracheostomies (7.7%) were performed at the time of maxillectomy. These included four tracheostomies in patients who underwent bulky flap reconstruction, two tracheostomies in patients who underwent both flap reconstruction and mandibulectomy, one tracheostomy in a patient who underwent mandibulectomy, one tracheostomy in a patient with mucormycosis in anticipation of prolonged ventilatory support postoperatively, and two tracheostomies at the surgeons' discretion because of concern for upper airway edema. Among the 111 patients who underwent 120 maxillectomies without concomitant tracheostomy, 1 patient (0.9%), a 74 year-old man with oxygen-dependent chronic obstructive pulmonary disease, required repeat intubation on day 3 and again on day 10 after the surgery, because of respiratory failure; fiberoptic examination confirmed the absence of upper airway compromise.

Conclusions: The routine performance of tracheostomy in patients undergoing maxillectomy is unnecessary. Selective use of tracheostomy may be indicated in situations in which mandibulectomy or bulky flap reconstruction is performed or a concern for postoperative oropharyngeal airway obstruction because of edema or packing exists.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/00005537-200306000-00002DOI Listing
June 2003

The efficacy of corticosteroids in postparotidectomy facial nerve paresis.

Laryngoscope 2002 Nov;112(11):1958-63

Division of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, California, USA.

Objective: To determine whether the administration of perioperative corticosteroids is effective in ameliorating facial nerve paresis after parotidectomy.

Study Design: Prospective, randomized, double-blinded, placebo-controlled clinical trial at a university medical center.

Methods: Patients scheduled for parotidectomy and who met inclusion criteria were invited to enroll in the protocol. They were stratified according to the anticipated surgery (superficial or total parotidectomy) and then received one of two doses of dexamethasone (0.51 or 1.41 mg/kg divided into three doses) or placebo solution immediately preoperatively and then every 8 hours for 16 hours postoperatively. The facial nerve was graded for proportion (percentage) of function at each of the four major regions (frontal, orbital, midface and upper lip, and lower lip). The early postoperative function and rate of return of function were compared among the treatment groups.

Results: Forty-nine patients were enrolled and evaluated (18 in the control group, 16 receiving low-dose dexamethasone, and 15 receiving high-dose dexamethasone). No therapeutic advantage of dexamethasone treatment could be appreciated with respect to the degree of early postoperative nerve function (81.3% for control patients vs. 69.5% for dexamethasone-treated patients [ =.239]). Similarly, the median time to recovery of complete facial nerve function was 60 days in the control group and was 150 days in the dexamethasone-treated patients.

Conclusions: Dexamethasone administration in patients undergoing parotidectomy is not justified. Despite the relatively modest risk profile of dexamethasone, we were unable to demonstrate any benefit in patients who were treated with either low-dose or high-dose steroids compared with placebo-treated patients in a randomized, controlled trial.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/00005537-200211000-00009DOI Listing
November 2002

Nasopharyngectomy for recurrent nasopharyngeal cancer: a 2- to 17-year follow-up.

Arch Otolaryngol Head Neck Surg 2002 Mar;128(3):280-4

Stanford University Medical School, Stanford, CA 94305-5328, USA.

Objective: To review the 2- to 17-year outcome of nasopharyngectomy following local recurrence of nasopharyngeal carcinoma.

Design: Retrospective review.

Setting: University medical center.

Patients: Thirty-seven patients with biopsy-proven recurrent nasopharyngeal cancer followed up for a minimum of 2 years after transpalatal, transmaxillary, and/or transcervical resection with and without neck dissection.

Outcome: Clinical examination, magnetic resonance imaging, chest x-ray examination, and liver function tests to determine re-recurrence; unlimited follow-up.

Results: With a mean follow-up of 5.4 years, the crude, 5-year, overall, free-of-disease survival rate was 52%, local control at 5 years was 67%, and the 5-year actuarial survival rate was 60%. Survival by recurrent T stage (rT) was as follows: rT1, 73%; rT2, 40%; rT3, 14%; and rT4, 0%. Complications occurred in 54% and included 1 death from carotid artery injury and 1 patient with permanent pharyngeal plexus paralysis with resultant dysphagia. The remaining patients had transitory complications that spontaneously resolved, required further surgery (closure of palate fistula, debridement, and reapplication of skin graft), or required further medical therapy.

Conclusions: The results of this study are better than most published reports of additional irradiation for rT1 and rT2 lesions. More recent radiation studies that use radiosurgery or implants suggest promising early results. A randomized prospective study comparing surgery with additional irradiation for recurrent disease at the primary site is warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archotol.128.3.280DOI Listing
March 2002