Search

Radiation-induced skin cancers can be difficult to diagnose and treat. Typically, a patient who has received orthovoltage radiotherapy for disorders such as acne, eczema, tinea capitis, skin tuberculosis, and skin cancer can expect that aggressive skin cancers and chronic radiodermatitis may develop subsequently. Cryptic facial cancers can lead to metastases and death. Prophylactic widefield excision of previously irradiated facial skin that has been subject to multiple recurrent skin cancers is suggested as a method of deterring future cutaneous malignancy and metastases. The use of tissue expanders and full-thickness skin grafts offers an expedient and successful method of subsequent reconstruction.

Both cisplatin and leucovorin (LV) interact with fluorouracil (5-FU) by increasing intracellular reduced folate levels and thereby the inhibition of thymidylate synthase. Therefore, the addition of LV to cisplatin and 5-FU (PFL) may increase the activity of that combination in head and neck cancer. We treated 31 patients with locally advanced head and neck cancer with two cycles of neoadjuvant PFL consisting of 100 mg/m2 of cisplatin on day 1 followed by a 5-day continuous infusion of 5-FU at 1,000 mg/m2/day and oral LV at 100 mg administered every 4 hours during the entire duration of chemotherapy infusion. Two patients died during neoadjuvant chemotherapy of sudden death and sepsis, respectively, and were not evaluated for response. Of 29 evaluable patients, nine had a complete response (CR), 17 had a partial response (PR), and three had stable disease. Toxicities consisted of mild to moderate myelosuppression and moderate to severe mucositis, necessitating reduction of 5-FU on cycle 2 to less than or equal to 80% of the intended dose in 22 of 29 patients. Administration of LV by repeated oral dosing resulted in total reduced folate plasma concentrations of 5.3 (+/- 2.9) and 6.7 (+/- 3.4) mumol on days 2 and 4 of the 5-FU infusion. The sum of 1-LV and its metabolite 5-CH3-tetrahydrofolate exceeded the concentration of d-LV, consistent with selective absorption of the biologically active 1-stereoisomer from the gastrointestinal tract.

Blindness following facial trauma may occur with what appears to be a minor insult to the periorbital area. This report deals with our experience in treating five patients who had sudden blindness following frontal head trauma. Unselected optic nerve decompression was in general unrewarding in reversing blindness. However, the early administration of pharmacologic doses of corticosteroids does appear effective in reversing blindness in this select patient population and may indicate which patient is a good candidate for decompression. Examination of holographic experiments performed on dried skulls, in addition to clinical findings, appears to suggest that the cause of blindness associated with frontal head trauma may be related to stretching of the optic nerve and not necessarily to compression.

The authors present a case of a 33-year-old white man with a 4-month history of a rapidly enlarging, tender, painful, circumscribed facial mass located in the masseter muscle. CT scan and fine needle aspiration cytology, coupled with clinical assessment, suggested the diagnosis of proliferative myositis. Curative intraoral excisional biopsy was done, thereby avoiding a parotidectomy incision and approach to the lesion. The pathology showed proliferative myositis. A review of the literature revealed 36 cases which indicated that proliferative myositis is a relatively rare etiology of a head and neck mass. Careful clinical, radiologic, and pathologic evaluations were required to make this unusual diagnosis and avoid any unnecessary facial mutilation in its treatment.

The principles and practice of local anesthesia on the face are discussed in terms of preoperative preparation of the patient, effective topical and injectable local anesthetics, innervation of the face, and techniques of topical application and injection of local anesthetics.

A prospective study of 71 auricular malignant neoplasms was performed to identify lesions with a high risk of recurrence. Previously recommended margins for conventional surgical excision were marked. Then, all lesions were excised by the Mohs' technique. The Mohs' defect was compared with previously marked margins for conventional excision. Conventional excision would have been inadequate in 13% of primary and initially recurrent lesions smaller than 1 cm (clinical examination) and in 27% of primary lesions and 33% of recurrent lesions larger than 1 cm. All cases successfully excised by conventional excision would have resulted in a larger defect than the actual Mohs' defect. Morpheaform basal cell carcinoma was the most common lesion inadequately excised. Either cases of this histologic type or lesions larger than 1 cm or both require consideration for the use of the Mohs' technique.

The transfacial approach to the anterior cranial fossa for tumor removal provides for excellent surgical exposure, improved postoperative appearance, and a minimum of complications. The technique is different from previously reported combined craniofacial ablative procedures in that the head and neck surgeon and the neurosurgeon approach the anterior fossa mass through the same facial incision, thus avoiding the need for a separate craniotomy incision. The formation of a vascularized nasofrontal bone flap allows for better wound healing regardless of preoperative and postoperative radiotherapy and/or chemotherapy. This report presents 42 cases in which the transfacial approach was exclusively used in a combined manner to remove nasal, paranasal sinus, and nasopharyngeal neoplasms. The transfacial technique offers a significant advantage over previously described approaches to the anterior skull base.

Facial skin cancer has a high incidence during later life. The majority of our patients had been previously treated by a number of different modalities. The recurrence of persistance of their cutaneous neoplasm was often quite extensive and thus required a rather large excision to eradicate the disease. Employment of a number of small operations under local anesthesia in which the patients could return to their home environment provided for a potential reduction in psychological and physical morbidity. The use of delayed healing often allowed reconstruction with a local flap or skin graft that if reconstructed primarily would have necessitated a more extensive operative procedure. Use of local flaps and/or skin grafts avoided excessive blood loss and long periods of immobilization associated with larger regional and distant flaps. Finally the denial of reconstructive surgery because of age should be condemned since fairly small operations in conjunction with delayed wound healing can provide acceptable cosmetic and functional results.

Forty laryngectomy patients in Iowa have received a tracheoesophageal fistula and voice button prosthesis. The fistula was successfully completed in all patients using local anesthesia. Delayed insertion of the voice prosthesis, approximately a month after the fistula is created, appears to be helpful in establishing the respiratory muscle control needed to achieve tracheoesophageal speech. In addition, delayed insertion allows for longer fistula maturation, recognition by the patient that speech is formed by vibrations within the pharyngoesophageal segment, and improved ability to manage the fistula site by proper insertion of the stent. The tracheoesophageal fistula-voice button prosthesis technique has proved to be a relatively simple, uncomplicated, reproducible and inexpensive method of achieving effective speech in a majority of laryngectomy patients.

This study was designed to evaluate the safety, reliability, and patient acceptance of outpatient continuous intravenous infusion (CVI) chemotherapy. Twenty-two patients with locally advanced head and neck cancer received induction chemotherapy with methotrexate, cisplatin and a 5-day CVI of 5-fluorouracil (5-FU). Patients were randomized to receive the 5-FU portion of cycle 1 either by a standard inpatient CVI chemotherapy delivery device (standard pump) or by the Infusor (Baxter Healthcare Corporation, Deerfield, IL), a portable chemotherapy delivery system that provides a constant flow of drug over a period of 24 hours. For cycle 2, patients crossed over to the alternative drug delivery method. Patients receiving chemotherapy via the Infusor could choose to be either inpatients or outpatients. Daily plasma concentrations of 5-FU were determined during the first two cycles of chemotherapy. There was no significant difference in the mean steady state plasma 5-FU levels achieved with either drug delivery method (329.7 +/- 95.8 ng/ml for infusor cycles vs. 352.8 +/- 114.9 ng/ml for standard pump cycles). Clinical toxicities consisted primarily of mucositis for both methods of drug delivery. Eight patients declined to receive CVI chemotherapy as outpatients citing as reasons fear of malfunction of the device, inconvenience of the frequent clinic visits necessitated by daily monitoring of plasma 5-FU concentrations, and restrictions in daily home activities. Eleven patients underwent CVI chemotherapy via Infusor as outpatients. All reported outpatient CVI chemotherapy as convenient and effective and, when eligible, chose it again in subsequent cycles. A comparison of estimated costs revealed reductions in daily costs of +366.00 (+2,200.00 per cycle) for outpatient chemotherapy. Outpatient CVI chemotherapy is a reliable drug delivery method that was accepted by a majority of patients in this study. These factors may help to establish outpatient CVI chemotherapy as a viable alternative to hospitalization.

The use of skin grafts on granulating wounds is an established practice. Delaying the application of a full- or split-thickness skin graft may be an advantageous alternative method of surgical reconstruction in selected cases. Partial healing by secondary intention is useful for filling in deeper defects and usually produces a wound that is much smaller and of more normal contour than the original defect. Contraction of the graft bed is markedly influenced by location, tissue laxity, surface tension lines, motion, and wound geometry. Proper wound care, correct surgical preparation of the defect, and timing of the graft procedure are all important considerations in maximizing the overall result. Through-and-through defects and wounds produced over areas with little underlying support (eyelids and lip) often need flap reconstruction or immediate grafting to prevent undesirable functional and cosmetic results. By combining delayed healing and conventional reconstructive techniques, major tissue loss can often be restored while minimizing patient morbidity.

Many reports of the trapezius myocutaneous flap have centered on a single form of the flap. However, three distinct myocutaneous segments, the superior, the lateral island, and the extended island flaps, can be harvested from the trapezius muscle and its overlying skin. Fifty-five patients underwent reconstruction for head and neck defects using 56 trapezius myocutaneous flaps consisting of 28 superior, 24 lateral island, and four extended island flaps. The four vascular supplies of the trapezius muscle are discussed, with emphasis on the variable nature of the transverse cervical and dorsal scapular arteries. Major complications developed in two of 28 superior, five of 24 lateral island, and one of four extended island flaps. The superior flap, although the most dependable, has the most limited range of application. Both the lateral and extended island flaps have a broader range of clinical application, but their usefulness may be limited by previous neck surgery or occult neoplasm in the neck, as well as by the variable vascular supply. Due to the above limitations, 30% of our attempts to utilize the lateral island flap had to be aborted at the time of surgery and an alternate means of reconstruction used. The trapezius myocutaneous flaps are excellent reconstructive tools for selected defects.

The effects of the addition of indomethacin to PHA or Con A stimulated lymphocytes from patients with untreated squamous cell carcinoma of the head and neck or from patients with the disease who have just finished irradiation therapy from the disease was quantitated and compared to those of the control group. Lymphocytes from eight of 26 patients with untreated carcinoma were significantly augmented by the addition of indomethacin. The remaining eighteen patients were equal to the controls. For all 17 patients who had just finished extensive field irradiation therapy, significant enhancement of PHA and Con A reactivity by indomethacin was found, which did not appear to be solely a function of low baseline mitogen reactivity. In additional studies, stimulated lymphocytes of irradiated patients were tested for their sensitivity to the inhibitory effect of PGE2. The mitogen treated lymphocytes from all patients that had just finished irradiation therapy were found to be significantly more sensitive to the inhibition by PGE2 as compared to the normal lymphocyte response. This effect was also found not to be related merely to a low PHA or Con A reactivity of the lymphocytes. In both patient groups there was a striking correlation between the percent augmentation of indomethacin and the percent inhibition of PGE2 in that when the percent augmentation values were low so were percent inhibition values and when the degree of augmentation by indomethacin was elevated so was the inhibition by PGE2. This data suggests that increase sensitivity of stimulated lymphocytes to PGE2 may be responsible, at least in part, for the depressed mitogen response and the significant augmentation of this immune response by indomethacin in about 1/3 of the untreated patients with advanced head and neck carcinoma and in those patients who have just finished irradiation therapy. The results of this study support the hypothesis that perhaps patients receiving irradiation therapy may benefit by the oral administration of indomethacin, an approach that needs further consideration.

This study was designed to test whether previously untreated patients with head and neck cancer could effectively manage home continuous infusion chemotherapy, and to compare their acceptance and adjustment to home versus inpatient treatment. Twenty-two patients received 3-4 cycles of induction chemotherapy and a 5-day continuous intravenous infusion (CVI). Patients were randomized to receive the CVI portion of cycle 1 either in the hospital via a standard chemotherapy delivery device or at home via the Travenol Infusor, a portable and disposable drug delivery system. For their second cycle of chemotherapy, patients crossed over to the alternate drug delivery method. Patients who did not want to receive their treatment at home received their chemotherapy as inpatients via the Infusor. Therefore, all patients received treatment with both drug delivery methods. Nineteen patients were evaluable for this study. Eleven patients received at least one cycle of home CVI chemotherapy, and adjusted well to this method of drug delivery. Levels of psychological distress decreased for this group of patients when receiving outpatient chemotherapy compared to their inpatient cycles. The eight patients who received all chemotherapy cycles as inpatients (refused home treatment) were found to be less educated and reported greater physical impairment prior to study entry than future home CVI acceptors. Levels of psychological distress in this group increased with each inpatient chemotherapy cycle. We conclude that home CVI chemotherapy may be an alternative to inpatient treatment for patients who have had at least one cycle of inpatient chemotherapy. The best candidates for home treatment are patients with unimpaired daily functioning and a minimum high school education.

The fluorescein test is widely used in clinical and experimental studies for prediction of the viability of skin flaps. A thorough search of the literature revealed that the accuracy of this test had never been studied. Therefore, this study was designed to evaluate the accuracy of the fluorescein test in predicting the viability of skin flaps. A total of 212 unipedicle porcine skin flaps were used in this study. Statistical analysis demonstrated that the surviving area of the flap was significant greater than the staining area of the flap. We suggest that caution be exercised when the fluorescein dye test is used to assess skin flap viability and that the test be used for an approximate indication and not for an accurate prediction of the surviving flap area.

To increase the complete response (CR) rate of patients with locally advanced head and neck cancer after three cycles of neoadjuvant chemotherapy, we added sequential methotrexate to the combination of cisplatin and continuous infusion fluorouracil (5-FU). We also evaluated the feasibility of administering three additional cycles of the same regimen as adjuvant chemotherapy. Thirty-eight patients were treated; the median age was 53 years and 36 patients had stage IV disease. Chemotherapy consisted of methotrexate 120 mg/m2 followed 24 hours later by cisplatin 100 mg/m2 and a five-day continuous infusion of 5-FU at 1,000 mg/m2/d. Of 34 patients evaluable for response to neoadjuvant chemotherapy, nine had a CR, 21 a partial response (PR), two a minimal response (MR), and one patient each stable disease (SD) and no response (NR). Of 31 patients who received local therapy, 15 were treated with surgery and radiotherapy and 16 with radiotherapy alone. Of 25 patients eligible to receive adjuvant chemotherapy only ten received all three intended cycles, while 15 received less or no adjuvant chemotherapy because of patient refusal, cumulative toxicity, or early disease progression. With a median follow-up time of 39 months, the median survival is estimated to be 20 months. Of eight patients with nasopharyngeal or paranasal sinus cancer, none has had disease recurrence. Patients with good initial performance status and low N-stage also had a significant survival advantage. Chemotherapy-related toxicities consisted mainly of mucositis, requiring 5-FU dose reduction in the majority of patients; similar toxicities were exacerbated in the adjuvant setting. The addition of methotrexate did not increase the CR rate over what has been reported for the combination of cisplatin and 5-FU alone. Certain subsets of patients appear to have a good prognosis when treated in this fashion. The administration of adequate adjuvant chemotherapy in patients with head and neck cancer remains difficult due to toxicity and poor patient compliance.

Transposition of the spinal accessory (XI) and facial (VII) nerves has been used successfully in reanimation of facial paralysis, but because of the severity of symptoms associated with denervation of the trapezius muscle, this technique has largely been abandoned. Hypoglossal-facial (XII-VII) nerve anastomosis has now become a more favored procedure; however, the resultant hemiglossal atrophy carries some morbidity. Transposition of the sternocleidomastoid (SCM) branch of the accessory nerve as a way to avoid shoulder paralysis was reported more than 20 years ago with initially excellent results, yet few follow-up studies have been done. Twenty-one fresh cadaver dissections of the accessory nerve-SCM branch and facial nerve were performed to determine if adequate numbers of fascicle groups and sufficient proximal nerve length are available for an adequate end-to-end anastomosis without nerve interposition grafting. This paper presents our anatomic and histologic findings to support the use of proximal SCM nerve anastomosis to distal facial nerve in facial reanimation. When feasible, the use of this technique to correct facial paralysis is encouraged rather than hypoglossal-to-facial nerve anastomotic repair.

Surgical reconstruction of the total rhinectomy defect presents unique difficulties for both the surgeon and the patient. The forehead flap provides an excellent color match and two-stage reconstruction. However, frequently, flap delay is needed, there may be insufficient cutaneous tissue available, and, most important, a secondary residual facial deformity is created. The tube abdominal flap technique of total nasal reconstruction provides adequate tissue and a hidden scar but gives a poor facial color match, offers multiple operative stages, and can severely debilitate the patient's shoulder from prolonged immobilization. This article outlines a new method of total nasal reconstruction using a trapezius myocutaneous island "paddle" flap. This flap provides abundant cutaneous tissue without need for delay, offers an excellent color match, requires a two-stage operation, and uses a hidden donor site. No immobilization is needed in the transfer of this regional flap to the face and, thus, would be of particular usefulness in the geriatric patient.

The purpose of this article is to familiarize th surgeon with the latissimus dorsi flap and some particularly useful applications of it. This flap has proved extremely versatile, with many uses, among them immediate coverage for extensive head and neck wounds. It has been equally successful in repairing defects in both normal and irradiated tissue. The range of the arc of utilization has been exceptional, easily reaching the skull vertex from the chest wall. However, to be able to extend this flap so far requires careful dissection of the neurovascular pedicle and intimate anatomic knowledge of the posterior axilla region. This flap's muscle bulk is quite acceptable and the donor site may almost always be closed primarily. There appears to be less functional disability from sacrifice of this muscle than with pectoralis or trapezius myocutaneous flaps. Accordingly, it is ideal when much tissue is needed for single-stage coverage. Additional uses are available when flaps from other sites have failed.

As a result of prolonged hospitalizations and the frequent administration of sclerosing antibiotics and/or chemotherapeutic agents, vascular access frequently becomes difficult in patients with advanced head and neck carcinoma. Eighty-six totally implantable venous access devices were placed in 83 patients with advanced head and neck cancer to facilitate the administration of continuous intravenous infusion chemotherapy. Complications relating to surgical placement or usage of the device occurred in 29 of 86 ports (34%), leading to the removal of eight devices (9%). The implantation of two devices required revision. There were no serious sequelae from any of the complications. The port facilitated the administration of home chemotherapy in 11 patients. Because of our favorable experience, we now routinely recommend placement of these devices to all patients with advanced head and neck cancer at our institution.

Giant cervical lymph node metastasis originating from head and neck epidermoid carcinoma has traditionally indicated a poor prognosis. However, some patients with stage IV disease may live many years. In order to identify factors which might contribute to long-term survival, a retrospective analysis of 94 patients with head and neck squamous cell carcinoma and metastatic cervical lymph nodes greater than 4 cm was performed. At the time of study, 15 patients were alive; 62 of the remaining 79 patients had died due to related causes. Of the 15 survivors, mean survival time was 10.3 years, and the determinate five-year or greater survival rate was 20%. In contrast, mean survival of the 62 determinate nonsurvivors was 1.4 years. Recommended treatment for stage IV head and neck cancer patients with giant cervical lymph nodes consists of preoperative radiation therapy followed by wide-field en bloc resection.

Osteochondromas are benign bone tumors which rarely present as neck masses. This report reviews the literature and presents the case of a 10-year-old girl with a neck mass and hoarseness due to an osteochondroma of the cervical spine. An extensive diagnostic evaluation and partial surgical excision were necessary. Although rare, osteochondromas should be considered in the differential diagnosis of a firm neck mass. Surgical excision of these lesions is recommended.

Traction injury to the optic nerve and vasa nervorum is the suggested etiology for monocular blindness following trivial frontal trauma. Holographic interferometry was used on human skulls to demonstrate orbital deformation in response to nondestructive frontal loading. The findings suggest an additional mechanism for energy dissipation and therefore for optic nerve injury following frontal impact.

The free compound groin flap has been used to reconstruct anterior mandibular defects in four patients. The bone grafts have remained viable despite being placed in irradiated and contaminated fields. Partial intraoral exposure of two of the bone grafts did not interfere with their viability. Positive technetium Tc 99m pyrophosphate scanning, histology, and tetracycline labeling of the bony part of the composite flap indicate the maintenance of osseous viability without a transitory substitution phase for bone remodeling as seen in conventional bone grafts. Bone viability as it relates to blood supply of the free osteocutaneous groin flap is discussed.

Squamous-cell carcinoma involving the upper lip grows more rapidly and is more difficult to control than squamous-cell carcinoma of the lower lip. The lesion usually is histologically more undifferentiated than squamous-cell carcinoma of the lower lip and metastases develop earlier. A case report of a patient with a squamous-cell carcinoma in an upper lip with regional metastases is presented and illustrated.

Three groups of rats were studied. Group 1 rats received 6,000 R of irradiation, group 2 rats received 4,000 R, and group 3 rats acted as a control. Four weeks following irradiation, the femoral artery of each rat was cut and reapproximated using microvascular surgical techniques. Four weeks after surgery, the same femoral artery was evaluated for patency. There was no notable effect of irradiation on the patency of subsequently performed anastomosis of these small (1 mm in diameter) muscular arteries. Radiation effects were obvious on histological examination, but the anatomical and physiological alterations apparently were not severe enough to cause early thrombosis after microsurgical manipulation of these vessels.

Free groin flaps were used successfully within the oral cavity in 4 patients after ablative operations for cancer. Preoperative or postoperative radiation (cobalt therapy) had no apparent detrimental effect on the survival of these free flaps.

A free flap has been defined as an island flap that has been completely detached from the body and transferred to a distant recipient site, where microvascular anastomoses are done to reestablish its essential intravascular circulation. The groin flap, based on its superficial circumflex iliac artery and venae comitantes, was utilized as a free flap to close large intraoral defects in six patients following ablative cancer operations. All patients received preoperative or postoperative irradiation therapy. Four of the six free groin flap operations were clinically successful. One flap became necrotic unexpectedly after 3 1/2 weeks. Infection played a major part in necrosis of the other flap. The use of the free flap in oral cavity reconstruction offers certain advantages over regional vascular flaps but definite limitations exist.

A random pattern flap, such as the nape-of-the-neck flap, is a delayed cutaneous flap that relies on collateral circulation based on the skin pedicle. The myocutaneous trapezius flap, however, is a cervical flap that does not need to be delayed since it receives its blood supply from a musculocutaneous artery. The author has radiographic and clinical evidence that demonstrates that the upper one-half of the trapezius muscle is primarily, and abundantly, supplied by the transverse cervical artery. If this artery is kept intact during resection and reconstruction, a flap as large as 12 x 42 cm may be maintained. This flap has been used in various types of reconstruction on 23 patients, and it has been successful in terms of viability, versatility, safety, and cosmesis.

Pressure receptors exist within the walls of the carotid bulb which are responsible for maintaining the balance between blood volume, vascular tone, and cardiac output. When these receptors are manipulated during neck surgery the result may be bradycardia, hypotension or cardiac arrythmia. Such events occur sporatically during head and neck surgery and occasionally may prove fatal. While many surgeons advocate anesthetizing the carotid bulb prophylactically, this practice is not universally accepted. A retrospective appraisal of 76 radical neck dissections demonstrated an incidence of clear cut vasovagal reflex activity of 10%. Thirty-one radical neck procedures were then randomized into treatment and control groups in a prospective fashion. The treatment group (12 patients) had 5 cc. of 2% lidocaine applied topically to the carotid bifurcation. Nineteen controls had normal saline applied to the same site. The incidence of vasovagal reflexes in the control group was 10% and 16% in the treatment group. The similarity of these treatment groups is highly significant. It is concluded that topical 2% lidocaine is not an adequate prophylaxis for vasovagal reflexes during radical neck dissection.

A 49-year-old man had a recurring intranasal mass accompanied by erythematous plaques on the forehead. Biopsy specimens of the skin and intranasal mass led to a diagnosis of granuloma faciale, a rare benign skin disorder. Lateral intranasal location and associated facial lesions help to clinically differentiate this lesion from more ominous midline granulomatous diseases. The lesions were treated with intralesional steroid injections. This may be the first reported intranasal occurrence of granuloma faciale.

Free flap reconstruction is discussed with emphasis on microsurgical technique utilized in union of blood vessels 1 mm in external diameter. Proper microsurgical instrumentation, magnification and small vessel suture technique are all of importance in achieving a successful microvascular anastomosis. Technical maneuvers employed in identifying and avoiding small vessel thrombosis are presented. Surgical techniques, as presented here, have allowed us to successfully use free flaps to reconstruct large oral cavity defects following ablative cancer operations.

If chemotherapy is to be used with the greatest efficacy in head and neck cancer, a predictive test that will indicate tumor sensitivity or resistance in individual patients may be desirable. This report demonstrates that the in vivo murine subrenal capsule assay was an efficient, sensitive method for retrospectively predicting the clinical response of squamous cell carcinomas of the head and neck to chemotherapy. Twenty-five courses of chemotherapy in 22 patients were compared to responses in the in vivo assay. The assay correctly identified sensitivity to chemotherapy in 86% of clinically responding patients. The specificity of the assay was 78%. A 60% efficiency for predicting clinical response and a 93% efficiency for predicting clinical resistance were demonstrated. Eighty percent of the results were correctly classified. The murine subrenal capsule assay has potential in planning of chemotherapy for selected patients.

Hydroxyurea and fluorouracil (5-FU) are active cytotoxic drugs in head and neck cancer and have shown synergistic activity in vitro. Both drugs also act as radiosensitizers. Therefore, we administered radiotherapy at daily fractions of 180 to 200 cGy with simultaneous continuous infusion 5-FU at 800 mg/m2/d and escalating daily doses of hydroxyurea for five days. Cycles were repeated every other week until completion of radiotherapy. Thirty-nine inoperable patients were treated at six dose levels of hydroxyurea ranging from 500 mg to 3,000 mg orally daily. Little effect of hydroxyurea on the WBC or platelet count was noted in patients receiving less than 2,000 mg daily, whereas both parameters decreased progressively in patients receiving 2,000 mg daily or more. Mucositis occurred at all dose levels, requiring frequent dose reduction of 5-FU; however, in patients receiving a daily hydroxyurea dose of 2,000 mg or less, the median weekly 5-FU dose administered was 1,725 mg/m2 (86% of the intended 5-FU dose), whereas at daily hydroxyurea doses exceeding 2,000 mg, the median weekly 5-FU dose decreased to 1,133 mg/m2 (57%) (P = .001). Of 15 evaluable patients with recurrent disease after prior local therapy only one failed to respond; six had a complete response (CR), and eight a partial response (PR). Of 17 evaluable patients without prior local therapy, 12 had a CR, with no patient developing recurrence in the irradiated field to date; five patients had a PR. We conclude that the recommended dose of hydroxyurea in this regimen is 2,000 mg daily. That dose will cause mild to moderate myelosuppression and will allow for delivery of greater than 80% of the intended 5-FU dose. The activity of this regimen in poor-prognosis head and neck cancer exceeds 90%; its further investigation in previously untreated patients is warranted.

Complicated wounds of the head and neck involve a severe deficiency of tissue in a contaminated or irradiated area that is predisposed to infection and necrosis. Reconstruction of these wound areas frequently requires multiple operations and prolonged hospitalization. We have successfully reconstructed complicated head and neck wounds in thirteen patients by means of a single-stage microvascular tissue transfer of the greater omentum with or without an attached segment of the stomach wall. There were 11 complete successes, two partial failures, and no complete failures. We describe four cases to illustrate the basic fundamentals of this reconstructive technique.

A portion of the greater curve of the stomach with its attached omentum was transplanted to reconstruct the pharynx and oral cavity after ablation of upper aerodigestive tract cancer. The tissue characteristics of the transplanted material were similar to those of the removed oropharyngeal tissue. The gastro-omental free flap produced a moist mucosal surface that was self-cleaning and distensible. The free gastro-omental flap was successful in five of seven patients. Because of excessive flap secretions during the early postoperative period, all patients had tracheotomies to protect the lower airway from aspiration.

This study was performed to evaluate the free gastroomental flap for the reconstruction of mucosal and soft tissue defects after ablative surgery for head and neck cancer. Its use in a dog model was assessed in terms of the feasability of the surgical technique, acid secretion by the gastric mucosa, changes in the cell population of the graft, and the possibility that the omentum may augment lymphatic drainage after cervical node dissection. Gastroomental flaps were harvested, based on the gastroepiploic artery, and transplanted to the neck in ten dogs. Neck dissection and creation of a defect in the floor of the mouth were followed by microvascular anastamosis of the gastroepiploic vessels to suitable recipient vessels in the neck. Following this, the flap was sutured into place, reconstructing the defect in the floor of the mouth. The omentum was draped over the carotid artery and into the upper mediastinum. Intraoral pH remained stable during a 6-month follow-up period and there was no stomatitis noted. Radionuclide images suggested that the omental lymphatics contributed to regional lymphatic drainage. Histologic examination following sacrifice at 6 months showed atrophy of gastric glands but no epithelial metaplasia. We conclude that the free gastroomental flap is feasible, provides immediate restoration of soft tissue bulk, supplies a mucosal surface that adapts to the oral environment, and may augment regional lymphatic drainage.

A retrospective analysis of 103 selected patients with floor-of-mouth epidermoid carcinoma compared the effectiveness of surgical therapy alone vs planned preoperative radiation combined therapy vs irradiation therapy. All three treatment methods appeared equally effective in irradicating stage I and II disease. Stage III floor-of-mouth epidermoid carcinoma was similarly controlled by either surgical therapy or combined therapy. Irradiation therapy alone was markedly inferior in treatment of stage III disease. Stage IV disease was poorly handled by any of the treatment methods. Histologic factors, tumor characteristics, tumor spread, nodal status, and staging did not appear in the majority of cases to significantly influence treatment selection or survival or both.

The nose is one of the most common sites of malignancy on the face, probably because of its unique position of exposure to environmental damage. By far the most common type of nasal tumor is basal cell carcinoma. Squamous cell carcinoma is less common but considerably more aggressive, with a tendency to fast growth and metastasis. Tumors of either type are more likely to invade easily and resist treatment if they are in certain "danger zones." Nasal skin cancer in general has a relatively good prognosis, regardless of the type of treatment selected, ie, surgery, radiotherapy, cryotherapy, or electrodesiccation and curretage. However, tumors that are not eradicated have a long history of recurrences before proving fatal. When ablative surgery is performed, some type of reconstructive procedure is usually necessary.

We studied epidermal growth factor receptor (EGFR) gene amplification and expression in 11 early passage human head and neck carcinoma cell lines. Three cell lines demonstrated EGFR gene amplification and 10 lines showed an increase in EGFR mRNA when compared with normal keratinocytes, placenta, and a human skin carcinoma cell line. The effects of EGF on growth in 6 head and neck carcinoma cell lines was also studied. Growth inhibition at a concentration of 20 ng/mL was observed in one cell line but had no effect on growth in 5 cell lines. An increase in EGFR may be important in the etiology of, or progression of, head and neck carcinoma although the mechanisms need to be elucidated by further study.