Functional voice quality assessment in curative microsurgery of laryngeal malignancies. Postoperative voice rehabilitation based on the "laryngeal double valve function"

According to Negus and Pressman the sphincter systems of the vocal folds and the ventricular folds form a respiratory "laryngeal double valve function". Correspondingly, we found a physiological phonation system of the glottis and a pathological-compensatory one of the supraglottis. They appear to be regulated through an automatic phonatory control system with the glottal phonatory function evidently acting as sensor level. In order to confirm this hypothesis, objective voice analyses with glottal-relevant parameters of 26 voice-rehabilitated patients after minimally invasive laser surgery of glottal carcinomas are presented and integrated into a "hoarseness diagram" with the coordinates roughness and breathiness. Using statistically deliminated acoustic dusters, our data show a qualitative hierarchy of different postoperative phonation mechanisms. They demonstrate the influence of the vibratory capacity of glottal and supraglottal structures on the quality of the vibratory closure. Both functional parameters evidently determine the resulting voice quality in the sense of our hypothesis.     

Post-radiation cervical myelopathy after radiotherapy of laryngeal carcinoma

The authors report a case of postradiotherapy cervical myelopathy after treatment of laryngeal cancer. The patient aged 61 was referred to a neurological hospital department with suspected metastasis of laryngeal cancer to the spine with symptoms indicating cervical cord lesion. During observation and after imaging examinations of the cervical spine cancer recurrence was excluded. History data and imaging methods served a basis for the diagnosis of postradiation myelopathy. The authors warn against too ready diagnosis of cancer in such cases and a repetition of radiotherapy.     

Assessment of postoperative pain after laryngeal surgery for cancer

OBJECTIVES: To assess the intensity of postoperative pain after laryngeal surgery for cancer and the efficacy of analgesic injections at fixed hours. DESIGN: A prospective clinical study performed during the 3 days following laryngeal cancer surgery. SETTING: A university medical center. PATIENTS: Fifteen men (age range, 38-74 years) having just undergone a partial or total laryngectomy for epidermoid carcinoma. INTERVENTIONS: The analgesic treatment consisted of intravenous administrations at fixed hours (propacetamol or nalbuphine hydrochloride), with the possibility of rescue doses on demand. Pain and anxiety were assessed by means of visual analog scales (graduated from 0-10) every 3 hours on postoperative day 1, then every 6 hours on postoperative days 2 and 3. Objective criteria, ie, heart and respiratory rates and mean blood pressure, were measured with the same schedule. MAIN OUTCOME MEASURES: Postoperative pain and anxiety intensities and their variations were analyzed. Correlations between postoperative pain and other criteria were researched. RESULTS: Postoperative pain had a high initial level (maximum median, 7), then decreased and reached a score of 3 at the 30th hour. Unpredictable individual peaks of pain were reported. Anxiety was never high (maximum median, 4). No individual correlation was found between pain and objective parameters. CONCLUSIONS: After laryngeal surgery for cancer, pain can reach high levels, particularly in the first hours following recovery. Analgesic administrations at fixed hours are not effective enough. Postoperative analgesic treatment should aim to prevent the high initial pain and be individually adapted.     

Salvage surgery after unsuccessful radiotherapy of laryngeal cancer]

The methods usually employed for reconstruction of total lower eyelid loss include (1) tarsoconjunctival flaps from the upper eyelid and skin-graft cover and (2) chondromucosal grafts and local skin-flap cover. We report a technique for coverage of these defects with an island flap involving the full thickness of the ipsilateral nasal wall based on the dorsal (external) nasal vessels, terminal branches of the ophthalmic vessels. The advantages of this method are (1) the main components of the eyelid (skin, tarsus, conjunctiva) are reconstructed in a single short operation, even under local anesthesia, (2) there is one donor area that can be closed primarily without significant deformity, (3) the upper lid remains intact, and ectropion is improbable, and (4) the procedure involves a short hospitalization. As disadvantages we might mention bulkiness of the new eyelid and difficult dissection of the (subcutaneous) pedicle.     

Disease-free survival and recurrence after resection of colorectal carcinoma

Recurrence data from a series of 1,315 colorectal cancer patients managed by one surgeon with potentially curative resection are presented. Complete follow-up information was available on 1,287 (98%) patients. At the time of the last recurrences, 164 and 232 months for rectal and colonic tumours respectively, the long-time recurrence rate was significantly (P = 0.001) higher for rectal tumours (42%) than for colonic (33%). Although local recurrences tended to be more common in rectal than in colonic tumours (18% compared to 15%), only those in contiguity with the operative area were significantly (P less than 0.005) more common in rectal tumours. Systemic recurrences were also significantly (P less than 0.025) commoner for rectal tumours. The greater recurrence rates in rectal tumours were associated with significantly (P less than 0.001) higher incidence of stage C tumours shorter recurrence-free survival in rectal stage C tumours (P = 0.001) and higher incidence of pulmonary metastases (P less than 0.001).     

Quality of life after treatment in patients with laryngeal carcinoma]

Today laryngeal cancer can be cured by means of a variety of treatments (nearly 60% of the patients in an unselected population are still alive after 5 years). Despite the low incidence, this form of cancer can present a significant social problem because the form of treatment can have an impact on the esthetic, functional and emotional aspects affecting the quality of life (QOL). In the present study 690 laryngeal cancer patients treated with 6 different forms of therapy (total laryngectomy, partial laryngectomy, cordectomy, radiotherapy alone, total laryngectomy plus post-operative radiotherapy, partial laryngectomy plus post-operative radiotherapy) were asked to fill out a specific EORTC CORE QOL Questionnaire (EORTC QLQ C-30) as well as a specific head and neck questionnaire. Six multi-item function scales, 3 symptom scales and 6 individual items assessing both symptoms and economic consequences of the disease were evaluated. A total of 517 patients (74.92%) filled out the questionnaire. For each form of therapy the patients were divided by age (under and over 65 years of age). The results indicate that the quality of life is better in those patients who underwent a single form of treatment (i.e. radiotherapy alone, partial laryngectomy, total laryngectomy) than in those who underwent combination treatments (i.e. surgery plus radiotherapy). Moreover, the results were better in the older patients. Quite often laryngeal cancer patients are subject to psychosocial problems although this did not show up in the present study where the patients tended to consider surgery as a liberation. The social-cultural level of the patient has a significant effect on the quality of life as it proved better in those social classes were physical strength is of prime importance as opposed to those dominated by social parameters such as socialization, communication and aesthetics.     

Long-term results of vocal rehabilitation after total laryngectomy with the low-resistance, indwelling Provox voice prosthesis system

A low-resistance indwelling prosthesis for vocal rehabilitation after total laryngectomy, Provox was developed in the Netherlands Cancer Institute 5 years ago. The long-term results in 132 patients using this prosthesis are now reported. The mean and median device life of the prosthesis in the 75 patients in long-term follow-up are 235 and 141 days respectively. Good to fair vocal rehabilitation was achieved in 92% of the patients. Statistical analysis revealed a significant relationship of the device life with the original tumour site (P = 0.0078). Radiotherapy had a borderline (P = 0.0652) negative influence on the device life but not on prosthesis-related complications. Increasing follow-up time has a positive influence on the device life of the prosthesis (P < 0.0001).     

Risk analysis of pancreatic fistula after pancreatic head resection

BACKGROUND: Secretory phospholipase A2 group II (sPLA2-II) has pro-inflammatory effects. The importance of tumor necrosis factor (TNF) for induction of plasma sPLA2-II in humans was studied in two groups of subjects. SUBJECTS: Six healthy volunteers received a single intravenous injection of recombinant human TNF or isotonic saline at random. Ten patients with active Crohn's disease received a single intravenous infusion of an anti-TNF chimeric monoclonal antibody, cA2. RESULTS: TNF infusion in healthy volunteers resulted in an increase of sPLA2-II at 3 h, with a maximal plasma level at 6 h (20.8+/-8.9 ng/ml; P < 0.05). In Crohn's disease base-line sPLA2-II levels were 33.9+/-13.4 ng/ml 24 h after infusion of cA2, 11.0+/-2.9 ng/ml (P < 0.005). Further decrease occurred in all except two patients at 2 weeks. The decrease in plasma sPLA2-II preceded all clinical signs of remission. CONCLUSION: TNF infusion in healthy humans can induce a rapid increase of circulating sPLA2-II, and selective blocking of TNF-alpha with cA2 results in a rapid decrease in sPLA2-II in peripheral blood. These data confirm that TNF has an important role in regulating the release of sPLA2-II in systemic and local inflammatory reactions.     

Long-term results after resection of hepatocellular carcinoma: experience of 480 cases

We have investigated the use of dU excision by uracil N-glycosylase (UDG) to create cohesive ends on PCR fragments "mimicking" those generated by restriction enzymes. The feasibility of this approach for directional and nondirectional cloning using cohesive ends mimicking SacI or PstI ends is demonstrated by the subcloning of a 383 to 388-bp fragment of bovine basic fibroblast growth factor into restriction enzyme-linearized pT7T318U. UDG-mediated cohesive ends imperfectly matched to PstI-generated vector ends gave reasonable cloning efficiency and accuracy, suggesting that the approach may be extended to mimicry of other restriction enzymes producing 3' overhangs. The rapid and specific excision of dU by UDG (within 30 min at 37 degrees C) has several potential advantages over the use of restriction site-modified primers, including the avoidance of restriction cleavage at internal sites within the PCR product. Also, following ligation, the approach described may be used to prevent subsequent cleavage of the joined DNA segments by the restriction enzyme, that is, by not recreating the restriction enzyme recognition sequence at the junction, which may find application in gene engineering. By adapting the approach to use dU-containing linkers or "vectorettes," the approach may be used for cloning unknown sequences (e.g., by cDNA or genomic library construction) or for mimicking 5' overhang cohesive ends on PCR fragments.     

Radioimmunoguided surgery benefits in carcinoembryonic antigen-directed second-look surgery in the asymptomatic patient after curative resection of colorectal cancer

A daily ingestion of 1000 to 1500 mg elemental calcium associated with vitamin D supplement is presently considered to be the adequate and least expensive therapy for senile osteoporosis. There exists only scarce data about calcium absorption with available calcium salts in elderly patients. We have compared the digestive absorption of calcium (Ca) citrate in soluble and solid form and calcium gluconolactate-carbonate in 15 young and 20 elderly, healthy women using the oral calcium loading test. The subjects were divided into two groups. In the first group, the absorption of solid Ca citrate (1000 mg Ca element) was compared to the absorption of Ca gluconolactate-carbonate (1000 mg Ca element) both in young (n = 7) and elderly women (n = 10). In the second group, the absorption of soluble Ca citrate (1000 mg Ca element) was compared to the absorption of Ca gluconolactate-carbonate (1000 mg Ca element) in young (n = 8) and elderly (n = 10) women. In the preload phase, basal calciuria was increased in elderly women (p < 0.01) although basal calcemia was similar in young and elderly women. After oral administration of the calcium salts, an increase in plasma Ca was observed in both groups which was greater for soluble Ca citrate and Ca gluconolactate than for solid Ca citrate. In young women, the increase in plasma calcium was significantly higher with soluble Ca citrate compared to Ca gluconolactate (p < 0.05). In elderly women, the postload calciuria was significantly higher for soluble Ca citrate (p < 0.05) and Ca gluconolactate (p < 0.05) compared to solid Ca citrate. A similar pattern was observed in young women, although it was not significant. In conclusion, an oral load of 1000 mg soluble Ca citrate and Ca gluconolactate-carbonate induces significant biochemical changes suggesting a better digestive absorption compared to Ca citrate in solid form, both in young and elderly women. We did not observe different response, between young and old patients.     

Home rehabilitation after stroke. Review of the literature

To find an answer to the question whether domiciliary rehabilitation after stroke is better or cheaper than alternative forms of rehabilitation, a systematic literature review of controlled trials was performed. Three large and two smaller, more preliminary studies of all together a thousand patients were found and regarded methodologically acceptable. Efficacy as regards functional, emotional and qualitative outcome of patients was equivalent for various modes of care. So was the degree of stress, social function and quality of life for the main carers. Home treatment costed less than regular day care but more than routine care including a mixture of outpatient and day care, as considered required. Domiciliary rehabilitation seems to be a good and cost effective alternative for stroke patients who need and cannot manage frequent out-patients visits without ambulance or other exhausting and expensive transports.     

Intestinal obstruction and peritoneal carcinomatosis after endoscopic resection of transitional carcinoma of urinary bladder

Gut involvement in bladder tumours is low, even exceptional in the presence of surface, low-grade neoplasia. The authors explain their experience in the diagnosis and management of a patient treated endoscopically for a vesical surface tumour which subsequently exhibited peritoneal and gut metastatic seeding. The various mechanisms for gut dissemination of vesical neoplasias and the repercussion of their endoscopic management are discussed.     

Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx

Although tracheoesophageal voice restoration is accepted after reconstruction of the neopharynx with the pectoralis major myocutaneous flap, the character of such voice is not well described. Six patients reconstructed with the pectoralis major flap after laryngopharyngectomy underwent successful voice restoration with the Blom-Singer prosthesis. Voice was evaluated by a standardized protocol and compared with voices of control subjects treated with total laryngectomy and similar voice restoration. The patients with pectoralis major flaps produced similar intensity levels for soft voice (53.7 dB vs. 55.6 dB) and loud voice (61.3 dB vs. 65.3 dB) when compared with controls (p > 0.05). No significant differences (p > 0.05) were noted for fundamental frequency (F0) between patients with pectoralis major flaps and controls for soft (62.3 Hz vs. 85.4 Hz) and loud (109.8 Hz vs. 133.8 Hz) voice. Jitter was also comparable. Trained and naive listeners completed qualitative analyses for 10 parameters and judged that control patients had significantly better voice for most parameters. This finding demonstrates that dependable voice is attainable after pectoralis major flap reconstruction of the neopharynx. Although this voice does not differ significantly from voice after standard laryngectomy for acoustic parameters, perceptual analysis does reveal significant differences.     

Clinicopathologic features of patients with hepatocellular carcinoma surviving >10 years after hepatic resection

BACKGROUND: This study was performed to clarify the clinicopathologic features of hepatocellular carcinoma (HCC) patients surviving >10 years after hepatic resection. METHODS: Between January 1971 and April 1987, 142 patients underwent hepatic resection. Thirty-nine patients who died of surgical morbidity (surgical mortality rate: 27.5%) were excluded from this study. Among the 103 patients who survived and were observed for >10 years after surgery, 12 patients (11.7%) survived >10 years after hepatectomy. The surviving patients were divided into 2 groups: 10-year survivors (n = 12) and nonsurvivors (n = 91). A comparative study between the two groups was made. RESULTS: Preoperative liver function tests such as the indocyanine green retention test at 15 minutes and albumin levels showed that 10-year survivors had better liver function than nonsurvivors. With regard to virus markers, 5 of 12 patients (41.7%) were positive for hepatitis B surface antigen (HBs-Ag) and the incidence of hepatitis B virus-related HCC was significantly higher than in nonsurvivors (P = 0.020). The results also showed that 4 of 12 long term survivors had hepatitis C virus (HCV) antibody and 1 patient did not have any HCV antibody or HBs-Ag. In two other patients, the HCV antibody was not measured and HBs-Ag was negative. Among four patients with the HCV antibody, the serum HCV RNA concentration, measured by branched DNA probe assay, was <0.5 in 3 patients and 1.72 in 1 patient. Therefore, the HCV RNA concentration tended to be lower in 10-year survivors. Tumor recurrence occurred in 8 of the 10-year survivors. Solitary recurrence was observed in five patients whereas multiple recurrence was observed in three patients. All five patients with solitary recurrence underwent a second resection. CONCLUSIONS: Based on the results of the current study, good liver function, HBs-Ag positivity, and a low concentration of serum HCV RNA in HCV-related HCC should be considered potentially good predictors of a long term survival.     

Significant prognostic factors for 5-year survival after curative resection of renal cell carcinoma

The aim of this study was, (1) to characterize the serum protein binding of lerisetron, a new 5-hydroxytryptamine (5-HT3) receptor antagonist under investigation as an antiemetic agent, and (2) to measure the percentage of unbound lerisetron in cancer patients. The binding parameters were determined in human serum albumin (HSA), alpha1-acid glycoprotein (AAG) and in pooled serum from six healthy volunteers. Concentrations of lerisetron ranging from 50 ng/ml to 2 microg/ml were used. The serum protein binding of 14C-lerisetron (2 microg/ml) was determined by ultrafiltration in three groups of individuals. Group I comprised healthy subjects (n = 11), group II comprised cancer patients undergoing radiotherapy (n = 9), and group III comprised cancer patients receiving chemotherapy (n = 18). The unbound concentration of lerisetron was measured in all samples by liquid scintillation counting. Concentrations of both AAG and HSA were also measured in all serum samples. The drug was extensively bound in pooled serum, involving a nonsaturated process. In HSA, lerisetron was also highly bound (4.04+/-0.8% unbound) and the protein binding was essentially unchanged within the studied concentration range of lerisetron. The extent of binding to AAG was high but significantly lower than in serum and in HSA and was also independent of lerisetron concentration. The unbound lerisetron was significantly decreased in group II cancer patients when compared with group I subjects (2.38+/-0.64% vs 3.70+/-0.70%; P < 0.001). No significant changes in lerisetron binding were observed in group III patients. HSA was diminished in both groups of patients and AAG was only significantly increased in group II. Unbound lerisetron was correlated with AAG in group II and with HSA in group III.     

A valid new approach in treating solitary new lesions after resection of hepatocellular carcinoma

Recent studies have suggested that the appearance of solitary new lesions after a curative resection of hepatocellular carcinoma (HCC) may be closely related to the metachronous multicentric development of HCC. It is therefore extremely important to investigate the histological characteristics of solitary new nodular lesions confirmed to be HCC by an ultrasound (US)-guided needle biopsy. Thirty-five patients with small HCC, < or = 3 cm in diameter, who underwent a curative hepatic resection between 1987 and 1992, were observed for possible recurrence over a period of > or = 1 year. Solitary new lesions confirmed to be HCC were noted in 7 (20.0%) out of 35 cases 10-65 months after operation. All solitary new lesions underwent US-guided needle biopsy, and a histological examination of the biopsy specimen was performed. All seven solitary new lesions were then classified into the following two groups according to the histologic differentiation of biopsy specimens and were found to consist of five well-differentiated HCCs (71.4%) and two moderately differentiated HCCs (28.6%). Three of the five well-differentiated HCCs were accompanied by varying degrees of fatty changes. These morphologic observations suggest that approximately 70% of the solitary new lesions confirmed to be HCC after a curative resection of small HCC may thus be related to the metachronous multicentric origin of HCC. However, it is difficult to estimate the exact incidence of such cases. As a result, curative treatment may sometimes be feasible, even when treating solitary new lesions after resection of HCC. Therefore, we can better evaluate such solitary new nodular lesions after a resection of HCC by means of a histologic evaluation using US-guided needle biopsy.