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Background: Recent data suggest that tamoxifen may act by altering serum levels of insulin-like growth factors (IGFs) and their binding proteins (BPs). This prospective paired cohort study evaluated the influence of tamoxifen on serum levels of IGFs and BPs in postmenopausal patients with breast cancer., Methods: Blood was collected from 32 postmenopausal patients with breast cancer before and during tamoxifen therapy for at least 6 months. All patients had undergone primary surgery. Serum concentrations of IGF-I, IGF-II, BP-1, and BP-3 were determined by immunoradiometric assays, and Western ligand blots provided a semiquantitative measurement of BP-2, BP-3, and BP-4. Statistical analysis was performed by paired Student's t-test., Results: Mean serum IGF-1 level was significantly lower after tamoxifen treatment (pretreatment: 116.2 ng/mL+/-13.6 [SEM] vs. posttreatment: 77.5 ng/mL+/-7.8; P=.003). In contrast, mean IGF-II levels increased from 651.5+/-62.2 ng/mL to 812.5+/-35.1 ng/mL during treatment (P=.006). Posttreatment levels of BP-1 (92.9 ng/mL+/-7.5) were significantly higher compared to the pretreatment values (28.1 ng/mL+/-4.7; P <.001). Serum concentration of BP-3 also was elevated (pretreatment: 2228.1 ng/mL+/-145.2 vs. posttreatment: 3539.1 ng/mL+/-172.3; P <.001). Densitometric measurements showed a similar significant increase in BP-3 (P <.001) as well as BP-4 (P=.017) after hormonal therapy. Levels of BP-2 were not influenced by tamoxifen treatment., Conclusions: These significant alterations in serum concentrations of IGFs and BPs with tamoxifen therapy suggest that the IGF system is a potential mechanism by which tamoxifen exerts its growth inhibitory effect on breast carcinomas.

Background: Insulin-like growth factor 1 (IGF-1) has mitogenic properties for breast cancer cell lines and has been proposed to be an important factor in breast carcinogenesis. We hypothesized that differences in IGF-1 or its binding proteins might increase susceptibility to breast cancer. This case-control study was designed to investigate whether patients with breast cancer have altered levels of either IGF-1 or its intermediary modulatory proteins, the IGF binding proteins (BP)., Methods: Serum was collected from 90 patients (63 with breast cancer and 27 with benign breast disease) after an overnight fast and before surgery. IGF-1, BP1, and BP3 levels were determined by immunoradiometric assays. In a subset of 66 patients, Western ligand blots were also performed for a semiquantitative measurement of functioning BP levels. A forward stepwise logistic regression model to adjust for other confounding variables (age, menopausal status, parity, age at menarche, use of oral contraceptives, history of breast biopsy, family history of breast cancer, hormone replacement therapy, and body-mass index) was used in the multivariate analysis., Results: Serum IGF-1 levels were similar in cases and controls. However, levels of BP3 (p < 0.001), BP4 (p < 0.01), and BP1 (p < 0.05) were significantly associated with risk of breast cancer. The level of BP3 was the most significant factor predictive of breast cancer. The odds ratio for breast cancer in women with BP3 levels >2066 ng/ml was 0.18 (95% CI, 0.05-0.55). Correspondingly, women with BP1 levels higher than 39 ng/ml had an odds ratio of 0.21 (95% CI, 0.07-0.68) for breast cancer. When considering only cancer patients (n = 63), decreasing levels of BP4 (p < 0.01) and increasing levels of BP1 (p < 0.02) were significantly associated with progesterone receptor positivity (PR+) in the tumor. The odds ratio of PR+ in patients with BP1 levels higher than 34 ng/ml was 7.49 (95% CI, 1.5-37.4). Better grade of tumor (well and moderately differentiated) was observed in patients with higher levels of BP3 (p < 0.03)., Conclusions: Distinct differences in BP profiles exist among patients with breast cancer and also among those with high-grade, hormonal receptor-negative tumors. These findings suggest that the bioavailability of IGF-1 as mediated by its binding proteins may participate in both breast carcinogenesis and selection of more aggressive breast carcinomas.

Preoperative localisation procedures in primary hyperparathyroidism have been associated with advantages like decreased operative dissection, shorter operating time and in some series, lower morbidity and mortality. However, successful identification of parathyroid glands exceeding 90% is achievable at surgery without preoperative localisation studies. Sixty-nine patients who underwent parathyroidectomy at the Department of Surgery, Singapore General Hospital, between March 1990 and July 1996 were analysed to determine the role of preoperative localisation techniques. Preoperative localisation of parathyroid glands consisted of computed tomographic (CT) scan in 66.7% of patients, technetium99 sestamibi scan in 23.2%, ultrasound in 15.9% and angiographic localisation in 4.3% of the patients. In the 28 end stage renal failure patients who were operated for progressive renal osteodystrophy, 6 had preceding renal transplants. The success of identifying parathyroid glands at operation in these 28 patients was independent of CT scan findings. CT scan was correct in only 6% of patients while surgical exploration had a success rate of 100%. Of the 41 patients with primary hyperparathyroidism, the success of CT scan in identifying enlarged parathyroid glands was 41.4% compared to 91.6% via surgical exploration. Furthermore, CT scan was not able to discriminate between superior and inferior parathyroid glands. Preoperative Tc-99m sestamibi scan and ultrasound correctly localised pathologic parathyroid gland in 40% and 18.2% of the patients, respectively. Therefore, the use of preoperative imaging to localise parathyroid glands before the intended exploration was found not to be useful in our series.

Background: It has been proposed that clones of tumor cells acquire higher metastatic potential as a result of specific genetic alterations. This study was designed to determine the role of the c-met protooncogene in systemic spread by comparing the loss of the c-met protooncogene between primary and metastatic breast carcinomas., Methods: Only patients who had not received chemotherapy or radiotherapy in the preceding 6 months were included in this study. Histologically proven malignant tissue was obtained from the primary tumor, involved nodes, and distant metastatic and recurrent tumors of patients with breast carcinomas. Allelic loss of the c-met protooncogene in tumor tissue was determined by Southern blotting using a polymerase chain reaction-generated 347-bp human met-H probe. Restriction digestion was performed using Taq I and Msp I, with the patient's lymphocyte DNA as controls., Results: Of 52 patients, lymphocyte DNA from 36 patients was heterozygous for the c-met protooncogene (69% informative). Forty-six tumors from these 36 patients were analyzed. Four of 30 primary tumors (13%) showed allelic loss of c-met. Of the nine nodal metastases examined, three (33%) showed allelic loss of the c-met protooncogene. Of seven distant metastatic breast tumors or recurrent disease, two (29%) showed allelic loss (both in patients with skin metastasis in the chest wall)., Conclusions: Allelic loss of the c-met protooncogene was detected in both primary (13%) and metastatic sites (31%) of breast cancer. Although a higher proportion of allelic loss of c-met was noted in nodal and distant/recurrent disease, the difference when compared with the primary tumor was not statistically significant. These findings indicate a limited role of the c-met protooncogene in breast cancer metastases.

Unlabelled: Studies on liver regeneration are often carried out on small animal models such as the rat. The use of large animal models however has many advantages. Repeated biopsies of the liver may be carried out and the animal can thus serve as its own control. Sequential changes in the regenerative response to various putative hepatotrophic factors can therefore be studied. Ultrasound-guided percutaneous biopsy (USGPB) of the liver, a technique widely used in clinical practice to obtain liver samples, offers a means for repeated liver biopsies. This study was carried out to validate the use of serial USGPB of the liver as a research technique in the study of liver regeneration in a porcine hepatectomy model., Material and Method: Left hepatectomy was carried out in nine Yorkshire pigs (20-30 kg). Bromodeoxyuridine (BrdU) at 50 mg/ kg BW was administered daily for the first 5 days after surgery. USGPB was carried out 1 hr later using 16F biopsy needles in a Biopty device. Ultrasonography was carried out using an Acuson XP10 color doppler ultrasound machine. Immunoperoxidase staining of the biopsy specimens was performed using mouse monoclonal antibody to BrdU. Regenerating cells were identified and labeling indices constructed for each day after hepatectomy. All animals were sacrificed at the end of the study and postmortem was performed., Results and Conclusion: USGPB was successful at every attempt and no animal suffered complications following the procedure. Median cumulative labeling indices increased rapidly after hepatectomy and the steepest rise occurred between the third and fourth day after surgery when it increased from 2.25 to 3.40% before leveling off. These results are consistent with those obtained by other reported techniques. USGPB of the liver overcomes the need for repeated laparotomies to obtain biopsy samples in a large animal model and has no morbidity and mortality that could lead to animal wastage.

The radical neck dissection is an operation for the management of lymph node metastases from primary sites involving the oral cavity, larynx, and other areas of the head and neck. In this procedure, the spinal accessory nerve is removed along with other structures. In modified neck dissection the spinal accessory nerve is preserved. Patients undergoing the modified neck dissection have had variable functional outcomes from little or no pain or disability, to significant muscle dysfunction. Our group hypothesized that patients with good functional outcomes following modified neck dissection may have had motor contributions from C2, C3, or C4 branches, while those with less favorable outcomes did not. To demonstrate the presence of motor input and its significance both from the spinal accessory nerve and the branches of the cervical plexus, we utilized intraoperative electroneurography. We find that although there is motor contribution from C2, C3, and C4 to the trapezius muscle, it was not consistent or significant.

This 50-year-old man was on enteral full-strength Ensure through the jejunostomy tube. The enteral feed was accidentally infused through the peripheral intravenous line. He went into a septic state with hypotension, hypoxemia, and increased pulmonary shunting requiring ventilatory and inotropic support. We instituted two cycles of plasmapheresis in an attempt to remove any foreign antigen and toxins present. This resulted in improved oxygenation, rapid recovery, and discharge from intensive care. His blood culture grew Klebsiella species that was consistent with the organism grown from the culture of the Ensure feeds.

Background: Controversy exists as to the significance of the cervical plexus as efferent to the trapezius muscle. We have sought to further study this question and to add to anatomic and electrophysiologic evidence of a histochemical perspective., Method: The accessory nerve and the cervical plexus branches from 18 neck dissections were studied by histochemical staining for acetylcholinesterase (motor nerve) and carbonic anhydrase (sensory nerve) activity. The motor controls were either accessory nerve, ansa hypoglossi or hypoglossal nerve, and for sensory controls the greater auricular nerve., Results: Eleven of 18 necks (61%) contained evidence of motor axons in the branches of the cervical plexus. Motor axons were noted mainly in C3 and or C4., Conclusion: There is confirmatory histochemical evidence that a significant proportion of cervical spinal nerves to the accessory nerve or trapezius contain motor nerves.

This prospective study sought to determine the width of tumour to fascial margins attainable after mastectomy in Asian women with breast cancers. The narrowest perpendicular distance from tumour to the deep fascia was measured in the mastectomy specimens of 177 consecutive Singaporean women with primary breast carcinomas. A highly significant linear correlation was present between the tumour size (P < 0.001, Pearson's R = -0.34) and the width of deep margins. Furthermore, T staging (P < 0.01, ANOVA) was inversely correlated with the width of deep margins and significant differences were observed between early (T0 to T2) and late (T3 to T4) lesions. In patients with ductal carcinoma in situ (DCIS) and T1 lesions, deep margins greater than 10 mm were achieved in only 23% and 33% of the women respectively. For patients with DCIS, 33% had either positive margins or margins less than 2 mm. The corresponding figures for women with T1 and T2 lesions were 11% and 26%, respectively. The inability to obtain negative deep margins were considerable with large tumours as 10% of the women with T3 tumours and 33% with T4 tumours had positive margins. Thus the proportion of positive or narrow deep margins following mastectomy is appreciable in Asian women and even in those with early tumours. The implications of these findings on the risk of locoregional recurrence or the need for more radical surgery or adjuvant radiotherapy remain uncertain, and will require further elucidation.

Blom-Singer valve prosthesis is an increasingly popular technique for voice rehabilitation in alaryngeal patients. Although primary voice puncture is being practised, the creation of the tracheo-oesophageal fistula is performed in the majority of patients as a secondary procedure. We describe a technique of secondary tracheo-oesophageal puncture using the flexible endoscope which can be performed under local anaesthetic and sedation. The technique overcomes the difficulty of passing a rigid oesophagoscope or forceps to the level of the tracheostome in a scarred and irradiated neck. The new technique also obviates the need for general anaesthesia. We have successfully used the technique in three patients.

Changes in sexual functioning, attitudes and sexual behaviour in local women after mastectomy and conservative breast surgery for breast cancer were assessed in this study. Given the social bearing, only married women agreed to be entered into the study. The complexities of variables other than breast loss, contributing to sexual difficulties were recognized and assessed. Through questionnaires designed for local women, a significant proportion of mastectomy women were found to have disturbances in at least one area in their sexual functioning after surgery. A significant number experienced changes in their sexual habits as well.

The surgical defect after radical resection in the head and neck region is extensive and often involves skin, oral mucosa and bone. Primary reconstruction allows for rapid restoration of function and rehabilitation of the patient. We report a series of 93 patients with oropharyngeal reconstruction after ablative surgery in the head and neck. For reconstruction, there were 41 pedicled myocutaneous flaps, 18 random flaps and 7 vascularised free flaps. There were 3 partial and 1 complete flap failures together with 5 persistent fistulas. The factors considered in the choice of reconstruction and our philosophy in this regard are discussed.

Background: Nonsquamous cell malignant tumors of the nasal cavity and paranasal sinuses are an uncommon and diverse group of neoplasms. Our goal was to define the relative frequency and distribution of these neoplasms, as well as treatment and outcome., Methods: This retrospective study analyzed 106 patients with nonsquamous cell malignant neoplasms of the nasal cavity and paranasal sinuses treated at our institution between 1966 and 1982., Results: Pathology included: salivary type carcinoma (33 patients); sarcoma (25 patients); melanoma (18 patients); esthesioneuroblastoma (11 patients); lymphoma (11 patients); and anaplastic cancer (9 patients). Most tumors arose in the nasal cavity (50%), followed by the antrum (39%), ethmoid sinus (9%), and frontal sinus (2%). Fifty-four percent of all patients were treated with surgery alone. Determinate 5-year and 10-year cure rates were: esthesioneuroblastoma, 70% and 50%; lymphoma, 45% and 30%; anaplastic, 33% and 25%; salivary, 31% and 18%; sarcoma, 25% and 21%; and melanoma, 19% and 0%., Conclusions: Overall survival for patients with nonsquamous cell malignant neoplasms of the nasal cavity and paranasal sinuses is poor, particularly with follow-up extended to 10 years. Local recurrence is the major source of treatment failure. We were unable to demonstrate any survival advantage in the group of patients who received surgery and radiotherapy in combination.

Background: Conventional techniques of laryngoscopy for vocal cord palsy can sometimes be difficult or impossible to perform, and B-mode real-time ultrasonography has been previously reported by the authors to be helpful in these situations. In some cases, however, B-mode ultrasonography can be inconclusive. We investigated whether color Doppler imaging can significantly improve vocal cord examination in these cases., Method: Ten normal volunteers were examined using the Acuson 128XP/5 with a 7-MHz L7384 linear transducer. The thyroid cartilage was used as an acoustic window. Several distinct color flow patterns were observed with the subjects breathing quietly at rest, at the start of vocalization, and in prolonged phonation. Eight patients with hoarseness of voice were then examined by two separate observers in a double-blinded fashion. The first observer performed B-mode ultrasonography and color Doppler imaging, while the second observer performed indirect laryngoscopy and direct fiberoptic laryngoscopy., Results: Laryngoscopy was used as the standard for comparison. B-mode real-time ultrasonography correctly identified vocal cord palsy in three patients and normal vocal cords in one. The remaining four patients were reported as equivocal or normal. Color Doppler imaging correctly identified the problem in all eight patients., Conclusion: Color Doppler imaging for vocal cord examination is more sensitive than B-mode real-time ultrasonography, and seems to be as accurate as laryngoscopy in determining vocal cord palsy or paresis.

The nasolabial flap was used in 11 patients for reconstruction of moderate sized intra-oral defects. There was minimal morbidity of donor and recipient sites in terms of function and cosmesis. The flap was easily harvested, with a reduction in operating time. The superb vascularity and reliability of the flap was demonstrated by the fact that it was possible to use this flap even after a radical neck dissection had been performed on the same side or after radiotherapy. This article describes the authors' experience with the use of the subcutaneously-pedicled, inferiorly-based, double-staged nasolabial flap for intra-oral reconstruction.

Although the surgical anatomy of the spinal accessory nerve and the cervical plexus has been extensively described, the exact motor innervation of the trapezius has been controversial. Attempts to resolve this question have involved anatomic or electrophysiologic studies in human embryos and animals. Extrapolation of the results to adult humans may not be correct. Accurate identification of muscle innervation is obtainable by intra-operative measurement of motor action potentials produced by direct stimulation of the accessory nerve and the cervical plexus. The study involved 14 patients undergoing supraomohyoid or modified neck dissections. Under direct vision, stimulating electrodes were placed on the identified nerves and motor action potentials, and latencies were recorded by surface electrodes placed over the three portions of the trapezius. In 13 patients, when the accessory nerve was stimulated, motor action potentials were obtained in 13 of 13 in the first portion, 11 of 13 in the second portion, and 10 of 13 in the third portion of the trapezius. In the last patient, the accessory nerve ended in the sternocleidomastoid muscle, and innervation of the trapezius was via C3 as demonstrated by motor action potentials. Responses when the roots of the cervical plexus were stimulated varied. Three patterns were seen: In the first group (seven patients), motor action potentials were distinct from those recorded when the accessory nerve was stimulated. Additionally, latencies were different from those of the accessory nerve. The second group (four patients) had motor action potentials that were similar to those obtained from stimulation of the accessory nerve, although their corresponding latencies were different.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast cancer patients with chest wall recurrence or patients with advanced breast cancer pose a difficult challenge to surgeons. Surgical ablation results in not only a large soft tissue defect that needs cover but often, in addition, a significant bony chest wall defect. The majority of these patients would have already received irradiation or chemotherapy or both. Thus, wound healing is significantly impaired. For these reasons, surgery was previously not attractive as an alternative in the palliation of these patients. Over a one-year period, seven breast cancer patients had chest wall resection. Six patients had recurrent tumours and one had advanced primary breast cancer. Two of these patients required only extensive resection of soft tissue of the anterior chest wall. The other five patients required, in addition, resection of the bony chest wall. Myocutaneous flaps were used to repair the surgical defects in six of these patients. Five were rectus abdominis myocutaneous flaps and one a pectoralis major myocutaneous flap. In one patient, a deltovertebral skin flap, which is an axial pattern skin flap was used. Primary wound healing was achieved in five of six patients (83%). One patient died immediately post-operatively, the cause of which is unknown. One of the rectus abdominis flap needed an exploration but was ultimately salvaged. This paper demonstrates the usefulness of the myocutaneous flap in enabling surgery to become a modality for palliation of patients with recurrent and advanced breast cancer.

Papillary carcinoma of the thyroid has a propensity for spread to the regional lymph nodes, in particular those along the recurrent laryngeal nerve. Twenty cases of papillary carcinoma of the thyroid had prophylactic clearance of the lymph nodes along the tracheo-oesophageal groove, and one patient had removal of recurrent disease in the groove. Eleven of the twenty patients had, in addition, some form of cervical lymph node clearance for clinically palpable ipsilateral cervical lymph nodes. Metastases to the tracheo-oesophageal groove lymph nodes was seen in seven of the twenty patients (35%). Tumour size, age, sex, race and cervical lymph node involvement did not appear to predict involvement of the tracheo-oesophageal groove lymph nodes. Clearance of the lymph nodes along the tracheo-oesophageal groove at the time of resection of primary disease is worthwhile for thyroid papillary carcinoma, because of the high incidence rate (35%) and also clearance for subsequent recurrence will be more difficult with a higher risk of damage to the recurrent laryngeal nerve and parathyroids.

Breast carcinoma-in-situ constitutes 4.1% of 707 breast cancers diagnosed between 1988 and 1990. Among these 30 patients, intraductal carcinoma-in-situ (DCIS) outnumbers lobular carcinoma-in-situ (LCIS) by 9-fold. They are mostly symptomatic - 87% present as breast lumps and/or nipple discharge, with 52% of lumps exceeding 2cm size. Three patients were detected by screening mammography and it is expected that more breast carcinoma-in-situ will be detected through mammographic screening. Two-thirds of the patients had mastectomy while the rest had lesser procedures. The different surgical procedures and adjuvant therapy instituted for the patients are reflections of the differing opinions regarding optimum therapy for carcinoma-in-situ and the differing rationale for DCIS and LCIS lesions.

Calcifying epithelioma of Malherbe (pilomatrixoma) is a relatively uncommon benign skin tumour of hair follicle origin. It usually presents in the face and upper extremities of young adults as an asymptomatic subcutaneous or dermal tumour. Treatment is surgical excision. This paper presents a case of a large tumour in the preauricular region with difficulty in diagnosis preoperatively and required a superficial parotidectomy to clear the tumour from the facial nerve.

Oestrogen receptor (ER) monoclonal antibody, H222 was used to study ER expression in forty-seven paraffin embedded blocks of well differentiated thyroid cancers. Trypsinisation, DNase I digestion, together with the use of labelled streptavidin biotin immuno-histochemical staining kit were adopted to increase the sensitivity of the immunoreaction. One out of twenty-seven papillary carcinomas and one out of twenty follicular carcinomas were immunoreactive. Thus, 4.3% of the well differentiated thyroid cancers were noted to express ER. The increased incidence and the better prognosis in females with well differentiated thyroid cancers is unlikely to be explained on the presence or absence of ER.

A consecutive series of 78 patients who underwent conservation surgery for squamous cell carcinoma of the supraglottic larynx is analyzed. The majority of the patients were middle-aged men who had early-stage disease, with only 18 patients in stage III and 6 in stage IV. The epiglottis was the most frequent site, followed by the aryepiglottic fold and other sites in the supraglottic larynx. There was no operative mortality and the complication rate was low. Univariate analysis showed no influence of tumor stage, tumor differentiation, or involved surgical margins on survival. Determinate survival rates of 85 percent at 3 years and 72 percent at 5 years were observed. Local recurrences took place in 12 patients, 4 of whom were salvaged by total laryngectomy; neck failure occurred in 13 patients, 7 of whom were salvaged after further treatment; and 1 of the 2 patients with distant metastasis was salvaged after further treatment. We believe that every patient with a favorable lesion of the supraglottic larynx should be considered for conservation surgery, specifically, supraglottic partial laryngectomy, adhering to the criteria mentioned. Initial surgical treatment offers excellent local control and 5 year survival. Adjuvant postoperative radiotherapy may be considered in those patients with bulky primary tumors, positive surgical margins, and histologically confirmed cervical lymph node metastases.

Two hundred fifty radical neck dissections, undertaken for mucosal squamous carcinomas of the head and neck, were reviewed with reference to pathological findings and their clinical implications. No major differences in descriptive surgical pathology were established between irradiated and non-irradiated resections. In general, irradiated dissections had lower total node counts and somewhat fewer nodal metastases involving a smaller number of different nodal groups. The topography of nodal deposits was similar in irradiated and non-irradiated resections. Palpable keratin granulomas (without intact tumor) were almost confined to irradiated patients. Transcapsular spread of tumor from involved lymph nodes was common: it was demonstrated in 160/188 'positive' dissections (85%) and was subclassified as 'macroscopic' in 90 and 'microscopic' in 70. The incidence and extent of transcapsular spread was similar in irradiated and nonirradiated resections. It was more frequently observed in association with large nodal masses but it was also regularly found with small nodal deposits less than 3 cm in diameter. Statistical analyses showed strong associations (p less than 0.0005) between the presence and/or extent of transcapsular spread and subsequent recurrence in the operated neck and overall survival. The predictive value of other clinical and pathological features vis-a-vis local neck recurrence such as numbers of involved nodal groups was weaker. Macroscopic transcapsulr spread emerges as the major prognostic factor for recurrent disease in the neck (p less than 0.0001). Attention is drawn to the advantages of accurate descriptive categories ('macroscopic', 'microscopic') for this critical prognostic feature.

This study retrospectively analyzed 105 patients with squamous carcinoma of the nasal cavity and paranasal sinuses. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 (10 percent), and the sphenoid sinus in 2 (2 percent). Over half of the patients with antral cancer were treated with surgery and radiotherapy, whereas one-third of the remaining patients received combination therapy. Most procedures were radical, including sacrifice of the orbital contents in half of the surgically treated patients. The 5-year determinate cure rate was 45 percent for patients with nasal cavity tumors, 38 percent for those with maxillary sinus lesions, and 13 percent for those with ethmoid tumors. Local recurrence remains a major problem despite aggressive surgery and increased use of adjunctive radiotherapy.

The radiologic and histologic features of mandibular invasion, and its clinical implications, are considered in a retrospective series of 111 patients with squamous carcinomas of the oral cavity and oropharynx treated by composite resection. Eighty percent of the entire group had either recurrent or advanced (T3, T4) local disease, and 33 patients (30%) had histologic evidence of mandibular invasion by tumor. Preoperative radiologic assessment was unreliable in cases in which infiltrating tumor was confined to the periosteum and superficial cortex-44% false negatives. The extent of bone invasion was found to correlate with the size of the tumor, but not with its histologic grade. The mandibular periosteum was not seen as a morphologically discrete "barrier" and infiltration occurred at various points along the mandibular body, mainly related to the course of the inferior dental canal. The gross and microscopic patterns of bone invasion appeared to be similar in irradiated and nonirradiated resections. The incidence and pattern of recurrent disease following composite resection was the same in the groups with and without mandibular invasion: in each group half the patients were dead from disease and one third alive and free of disease at 2 years. Mandibular invasion alone did not appear to influence prognosis in this series.

The incidence, extent, and selected clinicopathologic correlations of transcapsular spread from metastatic tumor in the cervical lymph nodes have been investigated in 210 specimens obtained by radical neck dissection from 203 patients with squamous cell carcinomas of the head and neck. Transcapsular spread was detected in 137 of 159 (86 percent) positive specimens, and classified as macroscopic in 74 (54 percent) and microscopic in 63 (46 percent). Macroscopic transcapsular spread was seen most frequently in association with large nodal masses more than 3 cm in diameter (48 of 70 specimens, 69 percent), but also occurred in some specimens with smaller lymph nodes less than 3 cm in diameter (26 of 67 specimens, 39 percent). Anatomic structures most commonly invaded in areas of neck dissection with macroscopic spread from nodal metastases were skeletal muscle (39 dissections) and the adventitial coat of the internal jugular vein (27 dissections). Macroscopic transcapsular infiltration was associated with a high incidence (44 percent) of recurrent tumor in the ipsilateral neck, particularly within 12 months of surgery. Microscopic transcapsular growth was associated with a lower incidence (25 percent) of recurrent tumor in the ipsilateral neck but the difference did not reach statistical significance. Similar recurrence figures (32 percent) were found in the minority of patients whose nodal disease was intracapsular at the time of neck dissection. More precise definition of the morphologic extent of transcapsular spread could be important in clarifying its clinicopathologic correlations.

We reviewed a 20-year experience with squamous carcinoma of the gums in 347 patients who received definitive therapy. More than three-quarters of the lesions involved the lower gum and all but 37 patients were previously untreated. The proportion of patients with localized tumors (N0) remained the same (64 percent). Surgery continued to be the treatment of choice in 97 percent of patients, but proportionately more patients had a more conservative procedure which preserved lower jaw continuity. The 5-year determinate survival rate was little changed (54 percent). Advanced clinical stage (stages III and IV), prior dental extraction, bone invasion, and involvement of surgical margins were predictive of a lower survival rate on univariate analysis. Clinical stage was the only significant predictor of survival on multivariate analysis. The impact of adjunctive radiotherapy could not be assessed.

Significant advances in head and neck oncology are reviewed in this article. Tumour biology and pathology are outlined in some detail. Multidisciplinary management is emphasised. Conservatism in surgical treatment and the roles of radiotherapy, chemotherapy and other modalities are discussed. The alteration in the natural history of head and neck cancers with effective local and regional control is mentioned.

Bowel obstruction developing in patients with gynaecological malignancies may present as a therapeutic dilemma. The causes, and results of surgical and conservative management of 92 patients are analysed. The causes of obstruction in the 64 patients who were treated surgically were: tumour recurrence in 42, adhesions in 12, radiation stricture in 9 and pelvic abscess in 1. Surgical palliation was effective in 45 patients in this group, with another 12 patients being palliated initially but subsequently developing further obstructive symptoms. Surgical palliation was ineffective in 7. Conservative management was effective only in 12 of the 41 patients, and even in this group 8 developed further obstructive episodes within the first month of discharge. The median survival in the surgically treated group for benign and malignant causes is 57 and 10 weeks respectively; while it is 4 weeks for those treated conservatively.

Total glossectomy is a procedure based on sound oncologic principles, and its usefulness may not be fully appreciated. Given the dimensions of the tongue and the need to obtain a wide margin of resection, this procedure may be indicated in selected T3 lesions and recurrences after irradiation. The procedure offers excellent palliation of pain, and form and function may be preserved by rim mandibulectomy when indicated. New reconstructive techniques allow for speedier recovery. Aspiration need not be a complication of total glossectomy if care is taken to preserve the superior laryngeal nerve. Speech rehabilitation plays an important role in returning these patients to their normal environment. Overall 1 and 3 year disease-free survival rates have been encouraging.

Details of the course of the accessory nerve and the pattern of the cervical contributions to the nerve are essential for planning neck dissection. Based on a recent anatomic description, a technique was devised to preserve the distal accessory nerve; the theory advanced was that the trapezius was supplied by motor fibers from the cervical plexus, which join the accessory nerve in the posterior triangle. Dissections were performed on 23 cadavers to test such a theory. The course of the accessory nerve in the neck was mapped in each dissection, and landmarks for use during surgery determined. Cervical contributions to the nerve usually joined deep to the sternocleidomastoid, and not in the posterior triangle. Branches from the cervical plexus, independent of the accessory nerve, entered the trapezius in the posterior triangle. None of the bilateral dissections showed symmetry of the cervical contributions.

A consecutive series of 197 patients who underwent conservation surgery for squamous cell carcinoma of the glottic larynx was analyzed. The majority of patients were male. One hundred forty-one had stage I disease, 44 had stage II, and 12 had stage III disease at the time of treatment. Partial laryngectomy was performed in 25 patients who had recurrent cancer after previous definitive radiotherapy and in 5 patients who had previously undergone cordectomy. There was no operative mortality and postoperative morbidity was low. Local recurrence developed in 32 patients (17 percent); cervical metastasis developed in 8 patients. The determinate survival rates at 3 and 5 years were 92 percent and 87 percent, respectively. Multivariate analysis showed soft-tissue margins and tumor differentiation as the two significant covariates in predicting survival. Positive surgical margins were also significant covariates affecting local recurrence. These data suggest that conservation surgery is an effective treatment for early vocal cord carcinoma. Adequate surgical margins are essential. Postoperative irradiation should be considered in patients with inadequate margins.

To facilitate long-term venous access in patients receiving chemotherapy, a subcutaneous totally implantable system (Port-a-Cath, Phamacia) has been used in 14 patients. The method of implantation and the advantages over conventional central venous catheters are discussed. The expense of the system necessitates careful patient selection.