Chemoradiation tends to be effective in these patients, and if the patient has no disease afterward (as shown by radiological findings and PET scan), neck dissection won’t be needed.
Explore This IssueApril 2006
When neck dissections are performed, there is often a small amount of thickening remaining that is fibrosis. Dr. Shaha suggested that ultrasound-guided biopsy could be a useful tool to check on this vague fullness. But if there is cancer there, it needs to be removed quickly.
Malignant Hypopharynx Tumor and Thyroid Cancer
The case of a 78-year-old female patient presenting with shortness of breath, a hoarse voice, and considerable dysphagia, was discussed. A large malignant hypopharynx tumor was found, with extensive disease involving the entire right side of the pyriform sinus, and extending into the postcricoid area. Here, panelists agreed that the patient needed laryngectomy and adjuvant therapy—unless there are other comorbidities altering this course of action.
Some in the medical field argue that total laryngectomy is disfiguring. However, “it’s the disease that is mutilating and the total laryngectomy is the right operation,” and improves quality of life, Dr. Shaha said. An important point is to consider exactly which patients will benefit most from total laryngectomy along with chemoradiation.
The final case discussed was of a 43-year old male presenting with elevated carcinoembryonic antigen (CEA). A chest CT scan revealed a large 4 cm by 3 cm mass involving the right thyroid, and serum calcitonin was at 9,000. Fine needle biopsy was positive for medullary thyroid cancer.
Here, panelists agreed the patient needed a total thyroidectomy and modified neck dissection with follow-up studies to check for recurrence or metastatic spread. Follow-up should include imaging of the neck, brain, and abdomen.
Watch Calcitonin Levels
However, even if imaging reveals no disease spread, the patient isn’t necessarily cured. Indeed, Dr. Shaha described such a patient who had no evidence of spread detected, yet returned with calcitonin levels of 12,000. The patient had multiple metastases on the liver, “a common problem in patients who present with medullary carcinoma and high calcitonin,” Dr. Shaha said.
About the only thing that can be done for these patients is to refer them for experimental treatment. Dr. Shaha suggested that otolaryngologists should check the National Institutes of Health Web site to find lists of study groups and protocols.
Many of the conditions described at the session are now treated with chemoradiation as the primary modality, though patients still need to be appropriately chosen. “We still have a responsibility to find out who is not going to do well with this treatment, and treat those cases with surgery initially,” Dr. Shaha said.