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OBJECTIVE: To review our experience with anterior craniofacial resection for malignant neoplasms with intracranial extension. Survival was analyzed in terms of presence of intracranial extension, extent of intradural disease, tumor histology, and histological status of margins. PATIENTS: In a retrospective review made at a tertiary cancer facility, 26 of the 115 consecutive patients undergoing craniofacial resection for malignant lesions of the anterior skull base had intracranial extension, defined as dural and/or brain extension. Survival was evaluated with the Kaplan-Meier product limit method, and comparisons between individual subgroups were performed using the log-rank test RESULTS: Patients with intradural extension have a statistically worse disease-specific survival than patients without intracranial extension (P = 0.05). Surgical margins and tumor histology impact on survival. The incidence of local complications was 42% and of systemic complications, 8%. CONCLUSION: Anterior craniofacial resection is indicated for patients with resectable disease. The complication rate is comparable with that of patients without intracranial extension. Gross total resection with histologically negative margins portends a better prognosis. Esthesioneuroblastoma has a better prognosis than other tumor types.

BACKGROUND: Supraomohyoid neck dissection (SOHND) has assumed increasing importance as a staging lymphadenectomy in patients with ([N.sub.o]) oral and oropharyngeal squamous cell carcinoma (SCC), as well as a potentially curative procedure in selected patients with limited metastatic disease in the neck. METHODS: Retrospective chart review of 287 patients who had a total of 320 SOHND for SCC between 1986 and 1993 as a follow-up to an earlier report that covered our experience between 1980 and 1985. After excluding 24 patients who also had local recurrence, or a new primary, the remaining 296 SOHND were assessed for the effectiveness of tumor control in the neck. RESULTS: Of 248 elective SOHND, clinically negative nodes proved histologically positive in 60 patients (25%), only 4 of whom failed in the neck (7%). A total of 48 patients (16%) had a therapeutic SOHND for limited N+ disease, confirmed pathologically in 31, with neck recurrence documented in 2 (6%). Nodes proved negative histologically in 205 patients, 10 of whom failed in the neck (5%). Nine of the 16 patients with neck recurrence had received postoperative radiation therapy and 9 recurred within the field of the SOHND. CONCLUSIONS: SOHND is a reliable staging procedure in patients with [N.sub.o] oral or oropharyngeal SCC. Therapeutic SOHND, in conjunction with postoperative radiation therapy, was highly effective in controlling neck metastases in carefully selected patients with limited disease in the upper neck.

BACKGROUND: Some patients undergoing surgical resection of primary squamous cell carcinoma of the oral cavity and oropharynx also undergo supraomohyoid neck dissection for staging of the negative ([N.sub.o]) neck. Dissection of the supraspinal accessory lymph node pad requires significant traction of the spinal accessory nerve. There are currently no data to indicate the incidence of metastases to this site and thus the necessity of performing dissection of these nodes. METHODS: A prospective analysis of a consecutive series of 44 patients with newly diagnosed squamous carcinoma of the oral cavity or oropharynx undergoing surgical management of the primary lesion with staging neck dissection was performed. Patients underwent unilateral (41) or bilateral (3) supraomohyoid neck dissection with separate submission of the supraspinal accessory lymph node pad for pathologic evaluation to determine the incidence of nodal metastases. RESULTS: A total of 15 patients (32%) had microscopic metastatic squamous cell carcinoma involving the supraomohyoid neck dissection specimen. Only 1 patient had a metastatic deposit involving the supraspinal accessory lymph node pad. This patient also had metastases in additional lymph nodes at level II. There was an equal incidence of metastases for all patients when stratifying by T stage. CONCLUSION: This preliminary report reveals a small incidence of supraspinal accessory lymph node metastases in patients with T + N0 squamous cell carcinoma of the oral cavity and oropharynx. We continue to accrue patients to determine if the incidence of supraspinal accessory lymph node metastases varies with an increased number of patients.

BACKGROUND: Although long-term cures have been achieved for locally advanced squamous cell carcinomas of the head and neck, there is a paucity of information available regarding patients' perspectives of their functional outcome. PATIENTS AND METHODS: Thirty-five long-term survivors free of disease following surgery and postoperative radiotherapy for advanced cancers of the oral cavity and oropharynx were sent questionnaires to evaluate their long-term functional outcome after therapy. The questionnaires included a subjective performance status scale that assessed the patient's perceived (1) ability to eat in public, (2) understandability of speech, and (3) normalcy of diet. Twenty-nine of 35 patients participated in this function assessment and are the subjects of this report. RESULTS: The mean function scores for all patients were as follows: 72 for eating in public, 69 for understandability of speech, and 58 for normalcy of diet. Functional results were further analyzed by T stage and anatomic subsite. Inferior results were noted with increasing T stage. A two-way analysis of variance showed that this difference was significant even after adjusting for the effect of anatomic subsite (P = 0.0002, P = 0.018, and P = 0.0018 for the three outcome variables). in addition, patients with base of tongue lesions had a worse functional outcome for both early T stage (T1/T2) and advanced T stage (T3/T4) when compared to other subsites. This difference averaged across T stage was statistically significant for understandability of speech (P = 0.0019) and normalcy of diet (P = 0.013), but was not significant for eating in public (P = 0.16). CONCLUSIONS: This performance status scale was found to be a useful tool for functional assessment following definitive therapy for advanced stage head and neck carcinomas. These subjective functional scores deteriorated with increasing T stage. In addition, functional scores for oral tongue, floor of mouth, and tonsillar primaries were superior to those for base of tongue lesions. These functional outcome scores are consistent with the extent of surgery required for the base of tongue subsite and are in direct relation to the patients' T stage in this study population.

Background. Patients with head and neck cancer who continue to smoke after diagnosis and treatment are more likely than patients who quit to experience tumor recurrence and second primary malignancies. Therefore, information about patients' smoking status and the factors associated with continued tobacco use are important considerations in the comprehensive care patients with head and neck cancer. Methods. Study participants were 144 patients with newly diagnosed squamous cell carcinomas of the upper aerodigestive tract who underwent surgical treatment, with or without postoperative radiotherapy or chemotherapy, 3--15 months before assessment of their postoperative tobacco use. Results. Among the 74 patients who had smoked in the year before diagnosis, 35% reported continued tobacco use after surgery. Compared with patients who abstained from smoking, patients who continued to use tobacco were less likely to have received postoperative radiotherapy, to have had less extensive disease, to have had oral cavity disease, and to have had higher levels of education. Hierarchical regression analysis indicated that most of the explained variance in smoking status could be accounted for on the first step of analysis by disease site. Interest in smoking cessation was high, and most patients made multiple attempts to quit. Conclusions. Although the diagnosis of a tobacco-related malignancy clearly represents a strong catalyst for smoking cessation, a sizable subgroup of patients continue to smoke. Patients with less severe disease who undergo less extensive treatment are particularly at risk for continued tobacco use. These data highlight the importance of developing smoking cessation interventions designed to meet the demographic, disease, treatment, and tobacco-use characteristics of this patient population.

BACKGROUND: Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck section. METHODS: We considered a neck dissection' as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels. RESULTS: At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient. CONCLUSIONS: The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nordymphatic structures sacrificed, we allow for the possibility that some procedures may he both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.

Background. Soft tissue sarcomas of the head and neck represent uncommon malignant neoplasms. With the exception of orbital and parameningeal sites, the treatment of sarcomas in the head and neck has not been standardized. The authors used a prospectively collected database of adult soft tissue sarcomas to identify prognostic factors for local control and survival. Methods. A prospectively collected database of adult soft tissue sarcoma from 1982 to 1989 was analyzed for the impact of prognostic factors on local control and survival. Factors examined included histologic type, tumor grade, size, and resection margins. Results. The overall and disease free survival at 5 years was 71 and 60%, respectively. Local control was 70% at 5 years. On univariate analysis, grade and margin status were predictors for local control. Analysis based on the Cox proportional hazard model revealed that margin status was the only significant factor in predicting local control. Grade and margin status were significant prognostic indicators for survival both on univariate analysis and in the Cox proportional hazard model. Conclusion. Patients with head and neck sarcomas should undergo wide excision with the removal of all gross disease and the acquisition of negative, microscopic surgical margins. Patients with positive margins should receive adjuvant radiotherapy for local control. High grade lesions place patients at risk for local recurrence and distant dissemination. Investigational regimens designed to prevent metastatic disease should be performed. Cancer 1994; 74:697-702.

The extent of surgical resection for differentiated carinoma of the thyroid gland confined to one lobe remains controversial. Although primary tumor size and extrathyroid extension are associated with a poor prognosis, the presence of multifocal lesions is not associated with an adverse prognosis. Therefore, the role of lobectomy versus total thyroidectomy must be studied in a prospective, randomized trial. Due to the need for long-term follow-up, such a trial has not yet been undertaken. As an alternative to such a trial, we have identified 146 patients from a consecutive series of 931 previously untreated patients undergoing surgical treatment at 1 institution between 1930 and 1980. For this study of matched-pair analysis, 73 patients, aged 45 years or older, were matched in each arm for significant prognostic factors. One group underwent lobectomy, and the other group underwent total thyroidectomy. The 20-year survival rate in the lobectomy group was 82% compared with 73% in the total thyroidectomy group (p = not significant). The patterns of failure in these two groups of patients were examined. A comparison of the patients who underwent lobectomy with an unmatched group of patients who underwent lobectomy showed similar survival rates. On the other hand, unmatched patients undergoing total thyroidectomy had a poorer survival rate than the matched group. This signifies a more aggressive nature of disease in the unmatched group of patients undergoing total thyroidectomy. We therefore conclude that low-risk patients undergoing lobectomy are likely to do as well as those undergoing total thyroidectomy and without the increased risk of the morbidity of total thyroidectomy.

A retrospective review of a consecutive series of 931 previously untreated patients with differentiated thyroid carcinoma treated over a 5O-year period was undertaken to analyze prognostic factors. Dam permining to demographic status, clinical, operative, and pathologic findings, and survival were analyzed. Univariate statistical analysis was performed based on the Kaplan-Meier method and the log-rank test. Multivariate analysis was pedormed to assess the independent effect of these variables using the Cox model. There were 630 female and 301 male patients, with an average age of 43 years. A total of 532 patients were younger than 45 years. Seven hundred thirty-one patients had either pure or mixed papillary carcinoma, and 200 had follicular carcinoma. In 153 patients, lesions were larger than 4 cm. Extrathyroidal extension was noted in 71 patients. Multifocal lesions were present in 159 patients. Regional lymph node metastusis was present on admission in 451 patients, and distant metastases were noted on presentation in 45 patients. Deterurinate survival for all patients was 87% at 10 years. Favorable prognostic factors using univariate analysis included female gender, multifocal primary tumors, and regional lymph node metastases. Adverse prognostic factors included age over 45 years, fo11icular histology, extrathyroidal , tumor size exceeding 4 cm, and the presence of distant metastases. On muhivariate analysis, the only factors that affected the pragnosis were patient age, histology, tumor size, extrathyroidal extension, and distant metastases. These observations suppart findings of reports from the Mayo Clinic and Lahey Clinic regarding the significance of prognostic factors for differentiated carcinoma of the thyroid gland.

Carcinosarcomas of the salivary glands are rare lesions that generally have been associated with benign mixed tumors. The authors report a case of a submandibular gland lesion, which occurred in a 64-year-old man, that was composed of intermingled ductal type adenocarcinoma and osteogenic sarcoma with a large component of osteoclast-like giant cells. The local recurrence of the tumor was entirely sarcomatous with no epithelial component observed. There was no histologic evidence of a preexisting or coexisting pleomorphic adenoma. Immunohistochemical studies confirmed two separate populations of tumor cells, corresponding to the histologic growth pattern. The authors review the literature and discuss histogenetic implications of distinction between de novo carcinosarcoma and carcinosarcoma in association with pleomorphic adenoma. Cancer 1991; 69:2031-2035.

We reviewed our experience with 120 patients who had gastrointestinal (GI) continuity restored by gastric transposition after cervical esophagectomy or circumferential pharyngectomy. This included 62 patients with pharyngeal tumors, 43 with esophageal lesions, 7 with parastomal recurrences, and 8 with other primaries (including 4 with thyroid cancer). Operative mortality (11%) for this two-team procedure was significantly higher in patients 60 years of age or older, and there was a trend toward higher mortality in those who had resection of esophageal rather than pharyngeal primaries (14% versus 5%). A total of 105 intraoperative or perioperative complications occurred in 66 patients (55%), 81 of which were directly related to the surgery and 24 of which involved various organ systems. Aside from 15 anastomotic leaks (13%) and 3 instances of partial stomach necrosis (3%), most of the local complications were relatively minor. Our experience indicates that the transposed stomach is highly reliable for restoration of GI continuity, but complications are frequent and the mortality is high. Careful patient selection is essential to minimize morbidity., A reliable method of reconstructing the area between the pharynx (throat) or esophagus (muscular tube connecting the throat to the stomach) is stomach transposition, a procedure that pulls up the stomach to connect it with the remaining stump of esophagus or pharynx. There are other alternatives such as jejunal (intestinal) autograft, if the area requiring restoration located in the esophagopharyngeal area above the clavicle (collarbone). To permit future comparisons of various methods, an update is presented of experience with the stomach transposition procedure. A review was undertaken of 120 patients who underwent reconstruction using the transposed stomach from 1973 through September 1990. Patients underwent either excision of the esophagus at the level of the neck or circumferential excision of the pharynx. Before 1978, surgery was performed mainly for esophageal cancer; since 1979, most of the procedures were associated with hypopharyngeal tumors (tumors in the lowermost portion of the throat, leading to the larynx). There were 62 patients with pharyngeal tumors, 43 with esophageal tumors, seven with tumor recurrence, and eight patients with cancers of other primary sites, including four thyroid cancers. The mortality from complications of surgery 11 percent; it was significantly higher in patients over 60 . Patients who underwent esophageal resection had a 14 percent mortality compared with 5 percent mortality for those with pharyngeal cancer. Sixty-six patients (55 percent) experienced a total of 105 complications; most were directly related to the technical problems of the procedure. There were 24 complications involving other areas of the body, such as the lungs (pneumonitis respiratory failure), the heart, and the liver. Transposition of the stomach can successfully restore gastrointestinal continuity, but the procedure has a high risk of complications and mortality. (Consumer Summary produced by Reliance Medical Information, Inc.)

We reviewed a 45-year experience with 459 patients who had previously untreated minor salivary gland neoplasms, 378 (82%) of which were malignant. Data were adequate for retrospective clinical staging in 353 of the 378 patients with malignant tumors using criteria identical to those for squamous carcinoma in the same sites. Five-, 10-, and 15-year survival rates for the patients with malignant tumors treated after 1966 were 75%, 62%, and 56%, respectively, a significant improvement compared with results reported previously. Multivariate analysis confirms that survival was significantly influenced by the clinical stage and the histologic grade, but the applicability of grading was limited to patients with mucoepidermoid carcinoma or adenocarcinoma. Ten-year overall survival was 83%, 53%, 35%, and 24% for patients with stage I through stage IV, respectively. Results in these patients are similar to those we have recently reported in patients with major salivary gland carcinomas, but we are unable to demonstrate that postoperative radiotherapy improved survival., There are tremendous variations in the size, form, and presentation of tumors of the minor salivary glands (mucus-secreting, submucosal glands) of the head and neck. It has been reported that anatomic site and extent of tumor are the most significant prognostic indicators for survival. No staging system (a method for describing the extent of cancer and metastasis) currently exists for tumors of the minor salivary glands. To establish criteria for such a staging, a review was undertaken of patients with minor salivary gland cancer treated over a 45-year period. There were 459 patients with tumors of the minor salivary glands; 378 (78 percent) of these patients had cancer; and adequate data were available for 353 of these subjects. The average age of patients with cancer was 56 years, compared with 48 years for patients with benign tumors. The most common site for the tumor was the palate (37 percent), followed by the tongue (14 percent), and the cheek (10 percent). The criteria used to stage the cancer was similar to that used for squamous cell cancer of the same sites. For patients treated after 1966, survival was 75, 62, and 56 percent at 5, 10, and 15 years, respectively. This was a significant improvement over the survival rates of patients treated earlier. Survival was significantly influenced by clinical stage and tissue grade. Grading was limited to patients with mucoepidermoid cancer or adenocarcinoma. Using the staging system, the 10-year survival for stage I was 83 percent; stage II, 53 percent; stage III, 35 percent; and stage IV, 24 percent. Radiotherapy did not appear to improve survival. Patients with minor salivary gland cancer require surgical removal of all gross and microscopic cancer tissue. Patients with high-stage tumors, or those with surgical margins that are questionable may benefit from radiotherapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Three hundred ninety-eight consecutive, previously untreated patients undergoing surgery for epidermoid carcinoma of the oral cavity from 1979 to 1983 were reviewed. One hundred twenty-nine patients were classified as having positive surgical margins. Of these, 83 patients had tumor within 0.5 mm of the surgical margin, 9 had premalignant changes at the margin, 9 had in situ carcinoma at the margin, and 28 had invasive cancer at the margin. The remaining 269 patients had uninvolved margins. The significance of positive margins relating to survival, subsequent clinical course, local recurrence, and patterns of treatment failure was examined, along with the impact of adjuvant postoperative radiotherapy on positive margins. The percentage of patients having positive margins progressively increased with increasing T stage: 21% in TI versus 55% in T4 primary cancers. The overall 5-year survival for patients with negative margins was 60%. For patients with positive margins, 5-year survival was 52%. This difference was statistically significant. The incidence of local recurrence in patients having positive surgical margins was twice as much as in those with negative margins (36% versus 18%). Metastasis rates in the neck and at distant sites were not significantly influenced by the status of the surgical margin. Of the 129 patients with positive margins, 49 received postoperative radiotherapy. In those patients so treated, a trend toward lower recurrence rates was noted. Differences were not statistically significant. This retrospective review confiriins the importance of adequate resection of the primary tumor as well as the relative ineffectiveness of adjuvant postoperative radiotherapy in the improvement of local control in patients with positive surgical margins., There is an implication of significantly higher risk of recurrence and poor prognosis when the final pathology report indicates the presence of cancer in the surgical margin of the removed tumorous tissue. In patients with squamous cell carcinoma of the head and neck, it is difficult to quantify the risk of recurrence related to a cancerous (involved) margin, because reports deal with small numbers of patients. The value of adjuvant (additional) postoperative radiotherapy when the surgical margin is positive has also not been determined. A retrospective review of 389 patients undergoing surgery for cancer of the oral cavity were reviewed. Surgery was performed between 1979 and 1983. Positive margins were identified in 129 patients. Five-year survival for all patients was 57 percent; for patients with negative surgical margins it was 60 percent, and for patients with positive surgical margins it was 52 percent. This difference was statistically significant. Patients with positive surgical margins had an incidence of local recurrence that was twice that of patients with negative margins. Metastasis (spread) to the neck or other areas of the body was not significantly influenced by the status of surgical margins. Of the 129 surgical patients, 49 had postoperative radiotherapy; these patients showed a trend toward lower recurrence rates, but this was not statistically significant. It is concluded that it is important that the primary tumor be adequately resected to provide negative surgical margins. Postoperative radiotherapy appears to be ineffective in controlling cancer recurrence in patients with positive surgical margins. (Consumer Summary produced by Reliance Medical Information, Inc.)

We reviewed the clinical records and pathologic material of 176 adults with primary soft tissue sarcomas treated at Memorial Sloan-Kettering Cancer Center between 1950 and 1985. Seventy-two patients (41%) had low-grade sarcomas and 104 (59%) had high-grade sarcomas. All but 18 patients underwent some form of excision as initial therapy. Adjuvant radiotherapy and chemotherapy combined with surgical excision showed no significant effect. A significantly increased risk of treatment failure was associated with large tumor size, positive surgical margins, bone involvement, local recurrence, metastatic spread, and high histologic grade. Except for recurrence, the p value by univariate analysis in the log-rank test for comparison of survival according to these clinical and pathologic characteristics was p, Sarcoma, cancer of the soft tissue that tends to be vascular and usually highly invasive, is frequently encountered as a painless swelling. Sarcomas of the head and neck represent less than 10 percent of all sarcomas. They carry a low survival rate for adults, although promising results have been achieved for children with the use of multi-agent chemotherapy. A review of 176 adult patients with head and neck sarcoma was undertaken in an attempt to identify factors that might predict prognosis and identify patients at high risk for non-response to treatment. These patients were treated between 1950 and 1985, and the minimum follow-up was two years. The average age was 48. Low-grade sarcoma was found in 72 patients (41 percent) and 104 patients had high-grade sarcoma. Surgical excision was the initial therapy for most patients; 18 patients had inoperable cancer. No significant benefit was obtained by the addition of radiotherapy or chemotherapy to the treatment regimen. Treatment failure was associated with large tumor size, excised tissue margins showing cancer, cancer involving the bone, local recurrence of disease, metastasis (spread outside the original site), and high histologic (tissue study) grade. The overall survival after two years was 75 percent; after five years, was 55 percent; and after 10 years, 46 percent. Patients who had high-grade sarcoma had 10-year survival of less than 20 percent, and only five patients who had high-grade metastatic sarcoma have survived (range 2 to 7 years). The histologic grade of sarcomas was a significant factor influencing overall survival. (Consumer Summary produced by Reliance Medical Information, Inc.)