Malignant melanoma of the head and neck: effect of treatment on survival.

This study compared outcomes for intermediate-thickness (1.5 to 3.99 mm) head and neck melanomas treated with or without elective lymph node dissection (ELND). The records of all head and neck melanomas treated at Virginia Mason Medical Center from 1974 through 1995 were reviewed and analyzed for outcome by stage and elective or therapeutic lymph node dissection. One hundred seventy-four patients with head and neck melanomas were treated in the study period, of which only 25% had intermediate-thickness lesions. Of 38 clinically node-negative patients with intermediate-thickness lesions followed more than 3 years, 10 underwent ELND, yielding two positive dissections (20%). The rate of distant metastases and the mortality rate were 44% and 35% lower in patients undergoing ELND compared with stage II patients who did not undergo ELND, but the difference did not achieve statistical significance (P = 0.12 and 0.21, respectively). The role of ELND in head and neck melanoma is uncertain. This retrospective study is limited by the small number of intermediate-thickness lesions, yet there appears to be a survival advantage to ELND in head and neck melanoma, even in negative dissections. Conventional histologic stains miss micrometastases detected by immunohistological and polymerase chain techniques. Removal of such micrometastases may explain the improved outcome. A multicenter prospective trial in head and neck melanomas, incorporating the latest techniques of sentinel node biopsy and immunohistological staining of node specimens, is needed to clarify definitive therapy for this increasingly common diagnosis.

Head and neck manifestations of Maffucci's syndrome: chondrosarcoma of the nasal septum.

The possibility of a dyschondroplastic syndrome should be considered in any patient presenting with a cartilagenous tumor in the head and neck. Classification of the patient as Maffucci's syndrome or Ollier's disease increases the need for vigilant observation for the development of sarcomatous lesions and can help differentiate between low-grade chondrosarcoma and atypical enchondroma.

What's wrong with total quality management?

There is nothing inherently wrong with TQM, says author C. Thomas Yarington, Jr., M.D. The problems come when management does not fully support the total integration of the practice into the quality improvement effort.

Parotid cancer: treatment and results.

The records of 74 consecutive patients with primary parotid malignancy were reviewed. The age and sex incidence was comparable to that described in previous studies; we observed a high incidence of adenocarcinoma not reported by other investigators. Stage at the time of examination and histologic grade of tumor were independent statistically significant predictors of clinical outcome. Long survival with low grade disease and late recurrence were common. Radiation therapy has been shown to increase survival in a number of studies; however, it had no demonstrable benefit in our series. Parotid cancer should be managed aggressively and early surgery is indicated for all parotid neoplasms. Neck dissection is indicated for clinically positive nodes and high grade cancers; radiation therapy is indicated for high grade cancers and residual disease.

The tracheoesophageal diversion and laryngotracheal separation procedures for treatment of intractable aspiration.

Intractable aspiration is a severe and often fatal complication in patients with impaired protective function of the larynx. This problem is usually a result of central nervous system disorders such as cerebrovascular accident, trauma, neoplasms, or degenerative disease. Surgical separation of the upper respiratory tract from the digestive tract can prevent recurrent contamination of the respiratory system in these patients. Two such procedures are the tracheoesophageal diversion procedure and a modification of this operation, the laryngotracheal separation procedure. The Virginia Mason Medical Center experience with these procedures, their indications, technique, and outcome are presented. In addition, cases of successful surgical reversal of the diversion procedures are discussed.

Submandibular gland excision.

A review of 107 submandibular gland excisions was made to determine the relative frequency of neoplastic versus non-neoplastic disease. The results show a preponderance of non-neoplastic pathology. Benign tumors were found in 6% of glands, primary glandular and metastatic carcinoma in 3%. Timely treatment of a submandibular gland mass is indicated due to the relatively aggressive behavior of malignancies originating in this location.

Indications for the tracheoesophageal diversion procedure and the laryngotracheal separation procedure.

Impaired protective function of the larynx can lead to intractable aspiration, a severe and potentially fatal disorder. If medical therapy fails to prevent intractable aspiration, surgical separation of the upper respiratory tract from the digestive tract is necessary to prevent recurrent contamination of the respiratory system in these patients. Two such surgical procedures are the tracheoesophageal diversion procedure and the laryngotracheal separation procedure. Our approach to patients with intractable aspiration and the indications for the use of these surgical procedures for the prevention of aspiration are discussed.

Extrameningeal meningiomas of the infratemporal fossa: diagnosis and treatment.

A presentation of two recently treated extrameningeal meningiomas of the infratemporal fossa will be augmented by a review of the literature on this subject. These tumors are quite rare, insidious in their presentation, and, as a benign tumor, require consideration of surgical treatment which causes the least possible functional disability. The natural history of these lesions and the surgical approach which has proved most successful in our hands will be discussed in some detail.

Carcinoid tumor of the larynx: the role of conservative therapy.

Carcinoid tumors of the larynx are an extremely rare condition, universally malignant, and unresponsive to radiation and chemotherapy. Just over 20 cases have been reported in the literature to date. Treatment is adequate surgical excision. The number of these tumors reported should increase due to the use of electron microscopy and immunohistologic techniques in making the diagnosis. This paper illustrates the role of conservative laryngeal surgery, when appropriate, as an effective form of therapy. The basic pathologic diagnostic criteria are illustrated.

Vagal body tumors: diagnosis and treatment.

This presentation includes a report of four vagal body tumors bringing the total number in the English literature to approximately 80. The diagnosis and treatment of this lesion, its familial incidence and the propensity for multiple secreting or nonsecreting chemodectomas, and appropriate clinical and pathologic studies required will be reviewed in some detail. Appropriate differential diagnostic features will be illustrated by comparison of these tumors with other primary vagal tumors from our experience such as neurofibromas, neurilemmomas, and cystic degeneration of neurilemmomas.

Synchronous parotid tumors of different histological types in association with metastasizing hypopharyngeal carcinoma.

At operation for metastasizing carcinoma of the piriform sinus a patient was found to have two separate parotid tumors, one a pleomorphic adenoma and the other a papillary cystadenoma lymphomatosum (Warthin's tumor). These tumors presented as palpable masses on the same side as a lymph node involved with carcinoma. Synchronous parotid tumors of different types are rare; previous reports in the literature show that this combination of pleomorphic adenoma and Warthin's tumor is the most common. We have found no previous report of multiple parotid neoplasms in a patient with coexistent squamous carcinoma of the head and neck.

Aspergillosis of the maxillary sinuses in otherwise healthy patients.

There is an increasing number of reports of fungal infections of the nose and paranasal sinuses, due in part to increasing recognition of this condition in both healthy and immunologically depressed patients. Three cases of aspergillosis of the maxillary sinus are presented, one of which demonstrates bone destruction in an otherwise healthy individual. In diagnosing aspergillosis sinusitis it is important to submit material for microscopic examination, as cultures are often negative for fungus. Treatment consists of surgery to establish good aeration and drainage with the addition of antifungal drugs in selected cases.

Olfactory neuroblastoma. Chemotherapy and radiotherapy for extensive disease.

A patient with olfactory neuroblastoma had extensive involvement of the nasopharynx, sinuses and orbit, and cervical metastasis. After surgical biopsy and excision of metastatic disease, she was treated with chemotherapy: three cycles of high-dose cisplatin (100 mg/sq m) and infusion of fluorouracil (1 g/sq m/day for five days). Subsequent treatment included definitive radiation therapy followed by three additional cycles of chemotherapy. The patient is free of disease three years after initiating therapy. This case report demonstrates the potential efficacy of planned combined modality therapy, including early chemotherapy in the control of locally advanced, unresectable olfactory neuroblastoma.