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BACKGROUND: In the frame of a nationwide study of oropharyngeal carcinoma in the Netherlands (1986-1990), the current International Union Against Cancer 1992/American Joint Committee on Cancer 1988 staging system was evaluated with respect to patient distribution and prognostic value. METHODS: Data related to epidemiology, treatment and survival from 640 patients referred for primary treatment were analyzed. Staging was first evaluated in a proportional-hazard regression analysis controlled for these data. Next, all possible combinations of T, N, and M were tested in a stepwise backward elimination model until all remaining indicator variables had a P value of less than 0.05. New stages were defined, based on the coefficients of the remaining indicator variables. RESULTS: The revised stages revealed two advantages compared with the UICC 1992/AJCC 1988 version: a more balanced distribution of patients (31% in Stage I, 31% in Stage II, 18% in Stage III, 14% in Stage IV, and 5% unknown in the revised staging system versus 7% in Stage I, 17% in Stage II, 24% in Stage III, 50% in Stage IV, and 2% unknown in the UICC 1992/AJCC 1988 staging system), and an improved prognostic discrimination for the disease specific survival (5-year results in the revised staging were 67% in Stage I, 42% in Stage II, 28% in Stage III, and 11% in Stage IV, versus 68% in Stage I, 64% in Stage II, 44% in Stage III and 27% in Stage IV in UICC 1992/AJCC 1988). CONCLUSION: Improvements in the current staging system in patient distribution in the stages in prognostic discrimination is feasible by regrouping the T, N, and M but without redefining the categories themselves.

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OBJECTIVE: Presently, widely employed treatment modalities for early glottic carcinoma include radiation therapy, surgical excision, and carbon dioxide laser excision. All these treatments have good oncological results, but poor or questionable functional results in terms of quality of voice and mucosal wave patterns as seen via a laryngostroboscope. We assessed the oncological and functional results of carbon dioxide laser vaporization of the diseased mucosa as a more conservative treatment alternative. DESIGN: Case series. SETTING: Department of Otolaryngology-Head and Neck Surgery in a tertiary care center. PATIENTS: Thirty-three patients with early glottic carcinoma (carcinoma in situ and Tla squamous cell carcinoma) who were referred to our center in the period from 1986 through 1990 were selected for carbon dioxide laser vaporization treatment on the criterion of a still recognizable mucosal wave pattern of the affected vocal fold via a laryngostroboscope. MAIN OUTCOME MEASURES: Local tumor control, voice quality, and a good appearance via a laryngostroboscope. RESULTS: Two patients were excluded from evaluation because a simultaneously diagnosed, incurable second primary tumor precluded frequent follow-up. Of the remaining 31 patients seen during a median follow-up period of 58 months, seven patients died of unrelated causes. A local recurrence of disease developed in two patients and was treated by radiation therapy. A recurrence of disease developed again in one of these patients but was successfully treated by total laryngectomy. Overall, local control of disease was achieved in all patients, with a 97% laryngeal preservation rate. Functional results in terms of voice quality were good in 97% of the patients, 75% of whom even retained a normal voice. Normal or near normal laryngostroboscopic appearance was achieved in 68% of all patients. CONCLUSION: Carbon dioxide laser vaporization is a good treatment alternative for early glottic carcinoma in terms of oncological as well as functional results.

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In 511 patients with T3N0-3M0 laryngeal carcinoma, 24 possible prognostic factors were analysed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnoea, and dysphagia, previous tracheotomy, tumour extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumour and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension were also evaluated. Univariate analysis revealed prognostic significance on survival for tumour extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy). In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumour, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.

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Magnetic resonance (MR) imaging was performed in 116 patients in whom a parotid mass lesion was clinically suspected. Eighty-six patients had benign disease. The 30 patients in whom a malignant tumor was found were further evaluated. To determine which features are characteristic of malignant parotid tumors, spin-echo T1- and T2-weighted images of malignant lesions in the parotid gland were compared with those of benign disease. In our series, tumor margins, homogeneity, or signal intensity were not discriminative factors to correctly predict benign or malignant disease. Infiltration into deep structures (eg, the parapharyngeal space, muscles, and bone) was observed only in malignant tumors. Infiltration into subcutaneous fat was noticed in malignant as well as in inflammatory disease. No statistically significant correlation was found between tumor grade and MR imaging features in malignant disease. MR imaging is useful in delineating malignant tumors but is unreliable in correctly predicting the histologic nature of a mass lesion in the parotid gland.

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In a total of 511 patients with T3,N0-3,M0 laryngeal carcinoma, 24 possible prognostic factors were analyzed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnea, and dysphagia, previous tracheotomy, tumor extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumor and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension ware also evaluated. In a univariate analysis for the whole group, tumor extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy) were considered to be prognostic factors of corrected actuarial survival. In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumor, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.

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The long term results of implantation of the 'Groningen button' after total laryngectomy were determined retrospectively in the ENT Department of the University Hospital Groningen, after follow-up periods of 6 months to 5 years. The study group consisted of 86 patients who received a Groningen button between 1981 and 1985, 79 men and 7 women with an average age of 60.5 years at the time of the total laryngectomy. The Groningen button is a silicon valve, which is introduced into a tracheo-oesophageal shunt, thus preventing aspiration of oesophageal contents and keeping the shunt open. The valve can be placed primarily during the laryngectomy or secondarily after the laryngectomy. The results of the voice restoration with the Groningen button were better than the results achieved with the injection oesophageal speech only. The results of a primarily constructed shunt with placement of the button were better than those of a button placed secondarily more than one year after the laryngectomy. The average lifetime of a button was about 3 months. The buttons of one-third of all patients were removed permanently after some time. In our study the complications were few. In our opinion a Groningen button can be placed during a laryngectomy to achieve a better voice restoration.

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The results of 16 cases of temporal bone resection were evaluated. The resections, 12 of which were total and 4 partial, had mostly been performed for squamous cell carcinoma invading the temporal bone. Five patients in whom the intervention was considered radical and not followed by irradiation, were alive and well 9 years or more later. The significance of postoperative radiotherapy was demonstrated in 3 patients who were alive and in good health 9 years or more later, although histological examination of resection margins showed residual tumour. Eight patients died 10 months to 5 1/3 years after operation, 6 of whom from recurrence, one from radiation necrosis of the temporal lobe of the brain, and one from cerebrovascular occlusion. Histologically, squamous cell carcinoma was found significantly more among the patients who died from recurrence than among those still living.

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Pharyngoesophageal myotomy, performed in 16 laryngectomees to improve vocal rehabilitation, proved to have some negative side effects. Although no failures of speech rehabilitation using a button were consequently found, a considerable number of button assisted esophageal speakers had a breathy voice. Also, the number of poor injection-esophageal speakers was much higher than in the group of nonmyotomized laryngectomees. A "normal" pseudoglottis could only rarely be identified by fluoroscopy in the myotomized group. A significantly lower intratracheal pressure appeared to be required for tracheo-esophageal phonation after myotomy. To improve the slightly disappointing voice rehabilitation results of the myotomized laryngectomees, a modified myotomy is proposed.

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The CO2 laser is being used in several otolaryngology departments around the world. Clinical experience has shown that it is a unique surgical tool in the management of benign and in some malignant lesions of the larynx. Until now, little has been written about its indications in patients with carcinomas of the larynx. The purpose of this paper is to present our experience with 58 patients with various premalignant and malignant lesions of the larynx in which the CO2 laser was employed as a curative or palliative debulking procedure.

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Inverted papilloma is an infrequent tumour of the nasal cavity and paranasal sinuses associated with controversy. The incidence of carcinoma in situ associated with inverted papilloma, has not been very well documented until now. Therefore, we present a case report characterized by an aggressive clinical behaviour, treated by extensive surgery and ultimately controlled by radiotherapy.

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In order to evaluate the quality of an informed consent procedure (I.C.P.) 48 patients with advanced cancer were offered participation in a phase I clinical trial and entered an I.C.P. consisting of three separate conversations. In the first session, the possible risks and benefits of a phase I study were informally explained by the patient's personal physician. The second session was attended by the patient, a relative, a registered nurse and a physician; the third session was held at least 5 days after the second. Forty-one patients gave their consent motivated by hope for improvement of their conditions, pressure exerted by relatives and friends, the desire to contribute to the progress of medicine or simply because they felt they had 'no choice'. Encouragement by relatives or friends seems to be a powerful incentive to participate. A period of a few days to consult relatives, friends or trusted physicians as a part of the procedure seems helpful in arriving at a well-considered decision.

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Singer and Blom's endoscopic technique, using a single valved silicone prosthesis, constituted a dramatic advance in speech rehabilitation following total laryngectomy. Since 1980, we have developed a silicone biflanged prosthesis that overcomes some of the inconveniences of previous prostheses. Insertion via the mouth and the oesophagus, or as a primary procedure during total laryngectomy is easily done with the use of specially developed instruments. The success rate in 36 patients in which the voice button was inserted at the time of total laryngectomy was 86.2%.

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The uncertainty and anxiety experienced by cancer patients and their ways of coping with uncertainty and anxiety were studied on the basis of a questionnaire completed by 418 patients. The study shows that 28.2% of the patients had a low and 33.5% had a high uncertainty score, while 50% had a low and 9% had a high anxiety score. Four ways of coping with uncertainty and anxiety can be distinguished, of which the use of self-instruction means was most common. Expert help proved to be important for reduction of uncertainty. For reduction of anxiety the support of the home environment and of fellow-patients was also of importance. The implications of these findings for the doctor's performance and for the care of cancer patients are discussed.

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A retrospective clinico-pathological study has been carried out in a series of 405 patients with squamous cell carcinoma of the head and neck who underwent a total of 484 radical neck dissections. The recurrence rate in the neck in 327 patients who had histological positive nodes was 21.1%. Recurrence in the neck after a standard radical neck dissection almost invariably proved fatal. A statistical analysis has been carried out to evaluate the clinical and pathological factors which are of importance in regards to recurrence in the neck. Histological factors such as extra-nodal spread and the number of histological positive nodes have been shown to be of much more prognostic importance than clinical parameters. When corrections are made for interdependencies between variables, histological extra-nodal spread proved to be the most important single prognostic factor (P less than 10(-7)).

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A patient with a solitary IgG-lambda plasmacytoma of the nasal cavity is described. Immunoelectrophoresis of the nasal washing fluid showed the presence of the same paraprotein. After radiotherapy the tumour and the paraprotein disappeared. Recurrence of the tumour after 6 months was again associated with the presence of the paraprotein in the nasal washing fluid. Immunoelectrophoresis of nasal washings may offer an easy method in detection and follow-up of localized plasmacytomas of the upper respiratory tract.

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