Search

Operations for intraoral carcinoma do produce deformities and loss of function. Historically, surgeons have constantly tried to correct or improve these deficiencies. The tendency on the part of the surgeon is to replace each bit of tissue removed, hoping that if the site appears normal the patient will be normal. The appearance of the patient has as a rule been given more attention than the functional result. Dysfunction is related to the alteration of certain anatomic and physiologic conditions identified as: (1) inability to obliterate the anterior oral cavity, (2) defects in the palate, (3) inability to close off the oropharyngeal space, and (4) disturbance of normal channels to bypass the larynx. Lateral mandibulectomy and radical neck dissection performed for cancer of the retromolar area, lower gum, lateral tongue, or floor of the mouth will in most instances result in very acceptable cosmetic and functional results. These patients look well, speak well, eat and swallow well, and can assume their usual role in society. Further surgical attempts to improve any deficiencies are discouraged. Patients sometimes ask about bone grafting or devices to replace the resected mandible and our recommendations are very emphatic on the negative side.

Multiple malignancies occurred in 7.5 per cent of 1,919 patients with head and neck cancer. In 64 per cent of patients the two cancers were diagnosed within twenty-four months of each other. Multiple malignancies occurred most frequently in patients with head and neck skin cancer. The most commonly encountered additional malignancy was another cancer of the head and neck. The three year survival of patients after treatment of a second primary malignancy was 21 per cent and the five year survival 9 per cent.

Over 90% of malignant tumors of the head and neck are squamous cell cancers. These originate in the epithelium of the upper respiratory and alimentary tracts. Some thirty or more primary sites are recognized. Though there are specific therapeutic problems relative to each of these sites, there are general principles which apply to many. I have attempted to present a general outline of therapy for squamous cell carcinoma of the head and neck. It is hoped that this will help the physician who is not intimately involved with the details of therapy to understand why some patients with malignancy are treated one way while others are directed along other avenues of therapy.

Four different techniques of parathyroid gland reimplantation into muscle were studied in 38 dogs following total parathyroidectomy. The types of autotransplants were whole gland, minced glandular tissue, thin slices 0.3 mm or less, and thick slices 0.4 mm to 0.5 mm. The animals were followed for four months. Parathyroid function was evaluated by serum calcium and phosphorus determinations. Graft sites were extirpated two months after re-implantation and studied histologically. The thin slice technique was found to be most successful of the four techniques studied.

Cervical carcinoma, primary undetermined, is a clinical entity which occasionally confronts the head and neck surgeon. Most regard the neck mass as a metastatic rather than as a primary lesion. In the present series, 82 per cent of the neck tumors were histologically anaplastic carcinoma. Reticulum cell sarcoma and anaplastic carcinoma of the breast, pancreas and lung should be considered in the differential diagnosis. Eighty per cent of the neck masses were clinically inoperable by radical neck dissection. The primary was subsequently located in 45 per cent of patients. Half of these primaries were located in the head and neck, and the most frequent site was the nasopharynx. The other half were located below the level of the clavicles, but in each instance the presenting mass was in the supraclavicular area or lower spinal accessory area. All patients were treated with radiation. The four year survival of the entire group was 39 per cent. The four year survival clinically free of disease was 30 per cent. Since the eight year period included in this report, the Head and Neck A Service has embarked on a surgical approach in selected patients with this entity. Surgery is indicated if the neck mass is (1) clinically operable (not fixed to skin or deep structures), (2) located in the cervical area, and (3) histologically Grade I or Grade II. Contraindications to surgery are as follows: (1) a large, fixed mass, (2) a. supraclavicular mass, (3) a mass located over the mastoid area, and (4) anaplastic carcinoma. Adherence to these surgical criteria excludes approximately 80 per cent of patients, and these are treated with radiation.

Summary o 1. A modified neck operation for carcinoma of the thyroid gland is described in which the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve are preserved. 2. Histologic studies and clinical follow-up data suggest that the operation is as effective as standard radical neck dissection. 3. The operation has the advantage of reducing cosmetic disfigurement and preserving function.

In recent years, the indication for tracheotomy has been recognized more frequently. Severe accident cases, chest injuries, postoperative neurosurgical cases, and head and neck cases often require tracheotomy, not only to prevent immediate asphyxiation but also to promote a smoother post-traumatic or postoperative convalescence. The successful outcome of many of these cases is partially dependent on a systematic and efficient system of tracheotomy care. Experience has proved that this is often lacking on some surgical floors. Many of the patients admitted to the Head and Neck Service of the Roswell Park Memorial Institute require tracheotomy. It is the purpose of this paper to describe a simple and adequate method of tracheotomy care now in use on this Service. The method of care must take into consideration the alterations in physiology of the patient. First, the freshly tracheotomized patient is unable to cough efficiently and rid the tracheobronchial tree of secretions.

1. 1. When 106 patients with carcinoma of the oral cavity, pharynx or larynx were interviewed concerning their use of alcoholic beverages and tobacco, 92 per cent reported that they drank significant amounts of alcohol daily. A history of heavy consumption of alcohol was given by 62 per cent of the patients, and 85 per cent smoked the equivalent of one or more packs of cigarettes a day. 2. 2. Of the 106 patients interviewed, eightynine were men and seventeen were women, a ratio of 5.2:1. The median age of diagnosis for the entire series was sixty-two years. 3. 3. Of all of the patients with oral carcinoma in this study, a second primary malignant lesion developed in 7.5 per cent. 4. 4. Additional supporting evidence is presented that the habitual use of tobacco and alcohol plays an important role in the cause of oral carcinoma. The etiologic mechanism is not understood, but possible related factors are discussed.

From January 1957 to December 1971, 141 patients were treated for hypopharyngeal carcinoma. Twenty-one patients who died within three years of treatment with unrelated cause are excluded, leaving 120 patients for the present study with a minimum of five years follow-up. Nine patients were classified stage I, eight stage II, eighty-four stage III, and nineteen stage IV. Eighty-one patients were treated primarily by radical surgery with (27) or without (54) deltopectoral flap reconstruction. Twenty of these eighty-one patients (24 per cent) survived for five years. Four patients had microscopic tumor at margin of resection and received a full course of radiation therapy in the immediate postoperative period. Two of four (50 per cent) survived for five years. Fiftyseven other patients developed recurrences; of these, forty patients could be treated with radiation therapy. Eight of forty patients (20 per cent) with postoperative local recurrences and treated with radiation therapy survived five years. The overall total five year survival by surgery, surgery and immediate postoperative radiation therapy for microscopic residual disease, and surgery and radiation therapy for postsurgical local recurrence is 37.3 per cent (30/81). Eleven patients were seen here with radiation therapy failures elsewhere that were treated with surgery. Five year survival in this group is 27.27 per cent (3/11). Twenty-eight patients were treated here with radiation therapy alone. These patients were in very poor general condition or had far advanced disease (fixed neck masses). Only one of twenty-eight (3.5 per cent) was alive after five years. Total five year survivorship was 34 of 120 (28.3 per cent). Seven patients had stage I, five stage II, twenty-one stage III, and one stage IV disease. From this study it appears that radiation therapy for local postoperative recurrence and in the immediate postoperative period for microscopic residual disease is worthwhile and can significantly increase the five year salvage rate.

From January 1958 through December 1983, 56 modified radical neck dissections were performed on 47 patients with metastases to the cervical nodes from differentiated carcinomas of the thyroid. In nine patients, a second modified radical neck dissection was performed either simultaneously or at a later date. Lymph node clearance was performed on all but one surgical specimen. The number of nodes in each specimen ranged from 10 to 96, and the number of involved nodes ranged from 1 to 20. Thirty-eight of the 56 neck specimens contained four or more positive nodes. Seventeen patients were followed for 10 to 26 years, 18 patients for 5 to 9 years, and 5 patients for less than 5 years. Seven other patients died, three from other causes and four from lung metastases. There were no recurrences in the neck sides that would have been cleared if standard radical neck dissection had been performed. This reappraisal with long-term follow-up supports our initial impression that a modified radical neck dissection sparing the spinal accessory nerve, the sternocleidomastoid muscle, the internal jugular vein, or any combination thereof is an effective procedure for differentiated cancer of the thyroid, with preservation of good shoulder function and improvement in the cosmetic appearance of the neck.

1. 1. Squamous cell carcinoma of the pyriform sinus is a rare tumor. 2. 2. Eighty per cent or more of patients with this lesion have metastases in the cervical nodes at the time of treatment. 3. 3. Radiation administered to the patients treated between 1940 and 1954 controlled the lesion in 3 per cent of patients. 4. 4. The introduction of radical surgery during a later period (1954 to 1961) increased the absolute five year survival rate to 10 per cent. 5. 5. The resectability rate of lesions in patients treated between 1954 and 1961 was 50 per cent. 6. 6. The five year survival among the surgically treated patients was 20 per cent. 7. 7. Earlier diagnosis and an improved rate of resectability would theoretically improve the absolute survival figures.

In an investigative study sixty patients with single and multiple areas of leukoplakia were treated by cryotherapy. The acceptability of this modality by patients was excellent. Recurrence developed in twelve patients during a follow-up period which ranged from two and a half to four and a half years. In four patients squamous cell carcinomas developed which were relatively small primary lesions in or adjacent to the area of the treated leukoplakia. Although the incidence of malignancy of 6.6 per cent is well within the reported range of malignant change in intraoral leukoplakia, this finding considerably diminishes our initial enthusiasm regarding this modality as routine treatment for leukoplakia and certainly emphasizes the need for further study before it can be completely acceptable as a routine form of treatment.

We have outlined the clinical manifestations of “localized” malignant lesions of the intraoral cavity, their clinical behavior after intraoral excision, and their control rate employing intraoral excision as primary therapy. We must keep in mind that these small “localized” cancers are potential “killers” and the five year mortality from disease in our series was 25 per cent. This mortality may decrease with (1) more careful selection when patients are included in the “localized” lesion group and (2) earlier use of composite procedures in questionable cases.

Serum antibody titers to Epstein-Barr virus were significantly elevated in a group of twenty-three patients with nasopharyngeal carcinoma as compared with eighty-six patients with cancer of other sites in the head and neck and 222 age-matched controls. Our findings in this group of patients support the suggestion of an association between the Epstein-Barr virus and nasopharyngeal carcinoma.

One hundred and five deltopectoral flaps were raised in 100 patients. Fifty-four were delayed prior to use and 51 flaps were used immediately without delay. Delay was used whenever there was a high probability of impaired healing or a modification of a portion of the flap was necessary. In patients with delayed flaps there was major loss in 16.6 per cent and minor loss in 9.2 per cent. In immediate reconstruction of the flap, major loss occurred in 15.7 per cent and minor loss in 17.6 per cent. The most frequent major flap losses occurred during attempts to reconstruct the palate. Placement of the flap into a previously radiated tissue bed, diabetes, and wound infections were the major contributing factors to major flap loss in both groups of patients.

A 62-year-old Caucasian man presented with a slow-growing 3 by 3 cm. mass in the left preauricular region. The pathologist's report on the surgical specimen favored a diagnosis of acinic cell carcinoma but recommended evaluation of the patient for possible metastatic renal cell carcinoma. A subsequent intravenous pyelogram and arteriogram revealed the presence of a mass in the right kidney. The lesion proved to be a renal cell carcinoma which was microscopically indistinguishable from the parotid tumor.

In clinical practice, small or localized thyroid cancer is often missed at the time of surgery and is diagnosed only later after the pathologist has been able to study multiple sections. Our data suggest that patients with early or localized thyroid cancer can be controlled with less than total thyroidectomy. If the nodule is completely excised without fracture (preferably lobectomy) or not cut into, if there is no evidence of metastatic disease either by palpation or frozen section, and if gross examination of the surgical specimen and frozen sections is negative for carcinoma, it is our policy to place these individuals on a regimen of observation only. Additional surgery is performed only if clinical evidence of recurrent cancer develops. Long-term follow-up of forty-four patients supports this treatment policy. Of these, seven had clinical recurrences: three benign; four (9 per cent) malignant. (The 2 patients with metastatic periglandular lymph nodes in the surgical specimen would not meet our present criteria.) We have in our files several additional patients who seem to support the same conclusions but will be reported on only after longer follow-up.

The surgical oncologist is sometimes confronted with a patient who was surgically treated for cancer of the thyroid gland and now has recurrent disease. In most instances, additional surgical treatment is indicated. The magnitude of surgery is primarily determined by the amount of tissue removed at the original operation. Surgery for recurrent disease may include completion of total thyroidectomy with dissection of lymphatic tissues in the thyroid compartment or/and neck dissection, preferably modified. Several clinical situations are outlined and discussed.

Sequential radiofluoride photoscans were used to follow experimental bone autografts in the tibia of dogs. They were more sensitive than roentgenograms and were found to correlate quite well with the histologic progress of the grafts in incorporation and remodeling.

Animal experiments demonstrated that full thickness flaps of esophagus and pharynx can be rotated to reconstruct surgical defects of the cervical esophagus. Because of the blood supply of the esophagus success can be expected only when the flaps are kept relatively short. The procedure has been carried out successfully in two human subjects.

1. 1. Forty-eight operative dental procedures, which in most instances included multiple extractions, were performed on thirty-two patients previously treated with cancericidal doses of radiotherapy. 2. 2. In no patient did osteoradionecrosis of the mandible develop.

1.1. Cancer cells were found in washings from sixteen of 279 radical operative wounds for head and neck cancer. In five washings, atypical cells were seen. No false positive or suspicious cells were found in washings from fifty-one benign head and neck lesions. 2.2. Our recurrence rate in 178 operative sites with negative washings and a follow-up of one year or more has been 25 per cent. 3.3. In fifty-eight cases selected at random with negative washings, 0.5 per cent Clorpactin XCB has been used as a wound irrigant. In forty-seven cases which have been followed up one year or more, the local recurrence rate has been 25.5 per cent. 4.4. Local recurrence has been found in eight of the ten patients who have had positive washings and have been followed up for one year or longer. 5.5. In one of two patients who had positive wound washings and received 0.5 per cent Clorpactin XCB irrigation has developed local recurrence during a follow-up of one year or longer.

The incidence of carcinoma of the nasopharynx is high among Indonesian natives. The data for this paper were compiled from the histological material in the Department of Pathology, Surabaja Medical School. The material included biopsy and surgical specimens from 160 patients with malignancy of the nasopharynx examined during the years 1952-1955. Some of this material was obtained from patients in hospitals in East Java, the eastern part of Indonesia, but most of it from the Central Hospital in Surabaja. Of the 107 Indonesian patients with malignancy of the nasopharynx, 75 were men and 32 were women, resulting in a ratio of 2:1. Teoh 1 stated that the incidence of nasopharyngeal carcinoma in men was at least twice as much as in women. The findings of Mekie 4 and Digby 3 showed an incidence of 3:1 and 2:1 respectively. Table 1 lists the relative frequency of malignant tumors affecting various organs

Postoperative wound drainage fluid from sixty patients who had undergone clinically curative resections for squamous cell carcinomas of the head and neck region was collected during a seventy-two hour postoperative period, processed and examined for the presence of tumor cells. Operative washings from each of the cases were also examined. Wound drainage fluids from nine patients (15 per cent) were found to contain tumor cells as late as forty-eight to seventy-two hours after surgery, even though wound irrigations at the time of surgery were negative. In a relatively short follow-up period in two of these patients, seeding under the skin flaps has developed. These observations indicate that seeding of the surgical wound may occur during the early postoperative period, and may be a contributory factor in local recurrence.

Eighty-five patients underwent total laryngectomy or total laryngectomy in continuity with a radical neck dissection during the five year period 1964 through 1968. Forty-eight patients (56.4%) were able to learn esophageal speech; six were rated as excellent, 25 as good, eight as fair, and nine as poor. Nineteen patients (22.4%) who either could not learn esophageal speech or had no desire to learn were able to communicate with the aid of an electronic speaking device. Of the 53 patients gainfully employed outside the home prior to surgery, only 22 were able to return to work. Forty of the 48 patients who learned esophageal speech were gainfully employed outside the home before surgery, but only 19 (47%) were able to return to work.

The period 1950 to 1962 has seen improved results for both radiation and surgery. Radiation will provide good survival results in patients with mobile cord lesions without involvement of the anterior commissure. Laryngectomy is the treatment of choice for anterior commissure involvement even when cord motion is normal. Surgery, however, is the treatment of choice for fixed cord, extrinsic endolaryngeal, and extrinsic exolaryngeal lesions. The absolute five year survival with no evidence of disease showed an improvement of 40, 40, and 30 per cent, respectively, over radiation in these categories.

Autogenous parathyroid tissue was reimplanted by a thin slice technic in five patients undergoing unilateral thyroid lobectomy and removal of two adjacent parathyroid glands as part of en bloc surgical resection for squamous cell carcinoma of the extrinsic larynx. An implant site was excised at varying periods of one to six months in different patients and all revealed histologically viable parathyroid tissue. This technic of implantation is advocated for reimplantation of parathyroid tissue present in the surgical specimen in cases of total thyroidectomy for cancer of the thyroid.

Previous studies have indicated that the interposition of a short reversed small bowel segment after massive small bowel resection in dogs will prolong transit time and maintain better nutritional status. 1-5 Using triolein 1131, Singleton et al 3 found that fat absorption rose temporarily after interposition of a nine- to ten-inch reversed segment of ileum, but was unable to explain why the animals became cachectic and died after a three- to four-month period, with a gradual decrease of absorption levels. Stahlgren et al 5 found that losses of water, fat, and nitrogen were decreased by the effects of a short antiperistaltic segment. Recently, Gibson et al 6 reported the successful use of a short reversed small bowel segment in an 80-year-old female patient who underwent resection of more than 90% of the intestine for occlusion of the superior mesenteric artery with gangrene of the bowel. The present study of fat

1. 1. Data have been presented indicating that the mandible may be preserved in a higher percentage of patients. 2. 2. Clinical application in a small number of patients has provided good results. 3. 3. Clinical criteria for the selection of patients have been outlined.

1. 1. Cancericidal doses of x-rays will produce tissue changes which interfere with normal healing of surgical wounds in the neck. 2. 2. Evaluation of tissue changes and judgment in selection of patients for surgery will lessen postoperative complications. 3. 3. The resulting complications, in most instances, can be satisfactorily handled. 4. 4. The most serious complication is wound slough and perforation of the carotid artery, which may result in death.

• A painless lateral neck mass in an otherwise healthy 58-year-old man is a frequent diagnostic problem. We have recently seen such a patient with a cervical neck mass whose preoperative evaluation findings were normal. Excisional biopsy revealed a lymph node exhibiting changes compatible with extramedullary hematopoiesis. This becomes an additional unusual cause of enlarged lateral neck nodes. (Arch Otolaryngol1982;108:523-524)

1. 1. A well defined group of patients have been studied. 2. 2. Composite operation resulted in a 56 per cent five year disease-free survival rate. 3. 3. Treatment of recurrent disease with irradiation increased the five year survival to 61 per cent. 4. 4. Preoperative irradiation for squamous cell carcinoma of the intraoral cavity, stage III, is unwarranted unless this treatment plan can produce five year end results better than 61 per cent.

Administration of 75 μg of sodium liothyronine per day for 12 weeks resulted in a measurable decrease in the size of nontoxic goiters in about half of 46 patients. No nodules disappeared during these short courses of thyroid-suppressive therapy; in most cases, decrease in goiter size was relatively slow, and measurable changes were often not observed until after 8 weeks of therapy. Suppression of thyroidal iodine uptake or of endogenous hormone secretion was not necessary in order to obtain reductions in goiter size. This suggests the possibility that treatment of goiter with thyroid hormones could be reduced to a simple routine by using moderate doses for all patients and by omitting iodine uptake studies and determinations of protein-bound iodine.

THE LITERATURE on bone transplantation in animals is quite voluminous and contains numerous conflicting opinions. 1,2,31,2,3 Chase and Herndon 1 found that our present-day knowledge of the histological fate of bone following transplantation is but little changed from the views presented by Auxhausen in 1907 and 1909. His fundamental principles were that periosteum has in high degree the property of survival and osteogenic activity in autografts, has markedly less in homografts, and practically none in heterografts. Most of the investigations in recent bone transplants have dealt with the relative merits of different types of donor material. There is general agreement that autogenous bone is the best graft to use because healing is more rapid; that cancellous bone is more rapidly revascularized than cortical bone; and that osteocytes, the mature elements of bone in both cortical and cancellous grafts, survive transplantation infrequently. A number of investigators have studied the effects of

JUVENILE nasopharyngeal fibromas are rare lesions, histologically benign, but in some instances they produce clinical manifestations which justify radical surgical excision. Some, because of their small size, lack disturbing symptoms and pass into the "fibrotic burnt out" postadolescent stage almost unnoticed. At the other extreme are cases in which the tumor continues to grow and results in deformity in a young person. In this latter group are lesions which produce recurrent episodes of severe epistaxis and sepsis and fail to respond to conventional forms of radiological, hormonal, and surgical therapy. The infrequent occurrence of this lesion is self-evident when one reviews the literature. The largest series is that of Figi and Davis, who reported 114 cases from the Mayo Clinic in 1950. Martin and coworkers reported 29 cases from the files of the Memorial Hospital, where some 2000 head and neck neoplasms are seen yearly, and, of these, 2 per

Cysts, sinuses, and fistulas are the commonest forms of clinical lesions which occur in the thyroglossal duct tract. Malignant tumors are considered a rare entity. Embryologically, this tract begins as a midline hollow, stalk-like evagination of the floor of the pharynx between the ventral ends of the first and second bronchial arches. This descends in the midline of the neck, prior to fusion of the arches which will form the tongue substance, and proceeds through tissue which will later form the hyoid bone. It terminates and gives origin to pyramidal lobe and a portion of the isthmus of the thyroid gland. The high columnar epithelial lining degenerates and disappears. Persistent tracts may show a variety of cellular lining anywhere from a high columnar to a squamous pattern. It is not uncommon to find microscopically identifiable bits of thyroid tissue in the walls of persistent tracts. Any one of the above

The ability of skilled physicians to estimate cancer risk in nontoxic goiter was determined by reviewing 235 evaluations of patients referred as thyroid cancer suspects and comparing the diagnostic impressions with the subsequent clinical and histological findings. Of 202 patients classified as "benign" on clinical evaluation, 2% proved to have thyroid cancer. In contrast, 28% of those classified as "suspected of cancer" and 53% of those classified as "probably cancer" did indeed have malignant goiters. Furthermore, although only 63 patients with "benign" goiters were subjected to early thyroidectomy, these included all 4 with thyroid cancer so far identified in this group. These figures indicate that patients with goiter can be divided quite successfully into low and high cancer-risk groups and that preoperative selection is justified.