Reconstruction of sternal and abdominal wall defects in a case of desmoid tumor.

A case of desmoid tumor of the anterior chest and abdominal wall is presented. The entire body of the sternum along with the upper abdominal wall and inner parts of both breasts was resected. The resulting defect over the pericardium and abdomen was reconstructed by the omentum and Marlex mesh. The large skin defect was covered by bilateral thoracoabdominal tube pedicles. The patient had a stable chest wall with uncompromised respiratory function 1 week after the operation. Prevention of local recurrences of desmoid tumors requires wide excision of the involved soft tissues and bony structures. The principles of wide resection of soft tissue tumors, reconstruction of the anterior chest and abdominal wall defects, and planning the skin coverage over the resulting defect are discussed.

Transaxillary latissimus dorsi flap reconstruction in head and neck cancer. Limitations and refinements in 56 cases.

The transaxillary latissimus dorsi musculocutaneous flap is suitable whenever a large volume of tissue is required for head and neck reconstruction. Fifty-six transaxillary latissimus dorsi musculocutaneous flap reconstructions were performed in 55 patients. There were two cases of complete flap necrosis and eight cases of partial flap necrosis. The latissimus dorsi vascular pedicle is separate from the irradiated field. The pedicled latissimus dorsi flap provides coverage of the orbitocranium, including the supraorbital region and central portion of the upper face. In the event that the pedicled latissimus dorsi flap does not reach far enough cephalad, the nutrient vessels may be separated from the axillary artery and anastomosed to vessels in the neck. Combined defects of the esophagus, mandibulofacial region, and neck may be reconstructed with a single large latissimus dorsi flap. Hairless skin particularly suitable for oral cavity reconstruction is usually available. Aesthetic and functional deficits are minimal after latissimus dorsi reconstruction. Disadvantages of this technique include repositioning of the patient, increased blood loss, and longer operating time. Permanent brachial plexus injury may occur. The latissimus dorsi musculocutaneous flap should not be used when defects can be reconstructed by simpler methods.

Total glossectomy.

Forty-five patients had a "total" glossectomy for initial advanced tongue carcinoma or for recurrent carcinoma. Forty percent of the patients (18) had a total laryngectomy at the time of glossectomy. Forty-nine percent of the patients (22) had either a lateral or anterior mandibulectomy at the time of glossectomy. Seventy-one percent of the patients (15 of 21) who had an intact larynx and 12.5 percent who had laryngectomy (3 of 24) had some degree of useful speech. Thirty-one percent of the patients (14 of 45) had no problems in deglutition whereas 53 percent of the patients (24) needed a nasogastric tube, 4 patients inserted the feeding tube themselves, 2 had a cervical esophagostomy, and 1 had a special prosthesis for feeding purposes. Thirty-seven percent of the patients (10 of 27) had considerable aspiration problems. Twenty-two percent (6 patients) needed a laryngectomy, and 7.5 percent (2 patients) needed a cervical esophagostomy to prevent further problems. Seven and one-half percent of the patients (2) succumbed to serious pulmonary infection. In this study, total glossectomy had a salvage rate of 65 percent at 6 months postoperatively, 27.5 percent at 1 year, 25 percent at 2 years, 25 percent at 3 years, 20 percent at 5 years, and 10 percent at 10 years.

Management of advanced glottic carcinomas.

One hundred twenty-eight patients with T3 or T4 glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent (12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.

Advanced and recurrent squamous carcinoma of the lower lip.

The results of aggressive surgical treatment of primary lip cancer and advanced and recurrent carcinoma of the lip are illustrated and discussed. Early detection of involved lymph nodes before capsular penetration occurs and careful and complete dissection of the submental and submandibular regions are advocated as possible ways to prevent persistent upper neck disease, the main killer of these patients.

Metastatic patterns in squamous cell cancer of the head and neck.

This retrospective study on 832 head and neck cancer patients who died between 1961 and 1985 was carried out to determine the incidence and sites of distant metastases. All patients were staged prior to definitive treatment and were autopsied. The overall incidence of distant metastases was 47 percent. The hypopharynx had the highest incidence of distant metastases (60 percent), followed by the base of the tongue (53 percent) and the anterior tongue (50 percent). Of the 387 patients with distant metastases, 91 percent died with uncontrolled tumor either at the primary site or in the neck. The lung was the most common site of distant metastases (80 percent), followed by the mediastinal nodes (34 percent), the liver (31 percent), and bone (31 percent). Overall, 6 percent of the patients had stage I disease, 20 percent had stage II disease, 32 percent had stage III disease, and 43 percent had stage IV disease. The highest incidence of distant metastases was found in those patients with stage IV disease (193 of 350 patients, 55 percent). We believe that the initial stage of disease does appear to be related to the ultimate development of the distant metastases.

Major head and neck reconstruction using the deltopectoral flap. A 20 year experience.

Six hundred seventy-eight deltopectoral flaps were raised in 604 patients, 125 of which were delayed and 215 of which were used in previously irradiated beds. The rate of major flap necrosis was 16.9 percent and the overall rate of complications, 51.4 percent. Delay in creating the deltopectoral flap had no influence on the risk of complications and necrosis, whereas the use of the flap in a previously irradiated bed was associated with a significantly increased risk of major flap necrosis. The least flap loss occurred when the deltopectoral flap was used without tubulation for skin coverage only. Complications and flap necrosis occurred most frequently when flaps were tubulated in a reversed manner or used for lining of major portions of or for total oropharyngeal and hypopharyngeal reconstruction. The deltopectoral flap remains a useful, reliable, and versatile regional flap that can be used alone or in combination with other flaps in selected circumstances for major head and neck reconstruction.

Surgical management of squamous cell carcinoma of the floor of the mouth.

Treatment failure and survival in 209 patients with squamous cell carcinoma of the floor of the mouth treated with surgery as the single curative modality are reported. Fifty percent of the patients had stage III and IV disease. The primary tumor was excised with 1 to 2 cm margins and the mandible was resected in 73 percent of the patients; 77 percent underwent radical neck dissection. No cures were observed in 11 patients with involved surgical margins on permanent section. For 198 patients with uninvolved margins, determinate survival at 5 years for all stages was 49 percent and 69, 64, 46, and 26 percent for stages I through IV (p less than 0.01). The most common sites of initial and ultimate treatment failure were the neck (42 of 72 patients) and distant metastases (33 of 53 patients), respectively. Treatment of the neck is identified as an unresolved problem in the management of early stage disease. Recent improvements in survival for stage III and IV disease are accounted for, in part, by adequate surgical resection.

Results of surgical resection of pulmonary metastases of squamous cell carcinoma of the head and neck.

In this retrospective review of 58 patients (12 females and 46 males) with pulmonary metastases of squamous cell carcinoma of the head and neck treated between January 1, 1970, and December 31, 1989, we evaluated their clinical courses and analyzed the outcomes of those who underwent pulmonary resection. For the entire group of patients, factors predictive of survival in those patients with a diagnosis of pulmonary metastases included pulmonary resection of metastases (p = 0.0001), locoregional control of the head and neck primary tumor at the time of diagnosis of pulmonary metastases (p = 0.007), TNM stage of the head and neck primary tumor (p = 0.02), a single nodule seen on the chest radiograph (p = 0.02), and disease-free interval (DFI) from the primary tumor of the head and neck of 2 years or more (p = 0.05). Twenty-four of 58 patients underwent thoracotomy for resection of metastases. Four (17%) were found to have a second primary tumor of the lung. Of the 20 remaining patients who underwent explorative surgery for possible pulmonary resection, 18 (90%) underwent complete resection of all malignant disease with an estimated 5-year survival of 29%. In these patients, a DFI of less than 1 year was associated with a 5-year survival rate of 0%, whereas a DFI of 1 to 2 years was associated with a 5-year survival rate of 43% and a DFI of 2 years or longer had a 5-year survival rate of 33%. The number of malignant pulmonary nodules that were resected ranged from one to five and was not significant in predicting survival (p = 0.19). Of eight patients who underwent the resection of more than one malignant pulmonary nodule, 50% survived 2 years, but none survived 5 years. Resection of a solitary pulmonary metastasis from squamous cell carcinoma of the head and neck resulted in long-term survival in selected patients. Important prognostic factors included locoregional control of the head and neck primary tumor, the number of nodules seen on chest radiograph, the TNM stage of the primary tumor, and the DFI from the head and neck primary tumor. The value of resection in patients with more than one malignant pulmonary nodule remains to be defined for this group of patients.

Surgery versus radiation therapy as single-modality treatment of tonsillar fossa carcinoma: the Roswell Park Cancer Institute experience (1971-1991).

OBJECTIVE: To compare the efficacy and treatment outcomes in patients with tonsillar fossa cancer using surgery or radiation as a single modality therapy. METHODS: From 1971 to 1991 239 patients with oral pharyngeal cancer were treated at Roswell Park Cancer Institute. Of these patients 90 had tonsillar carcinoma. Seventy-six of these patients received either surgery (SA) (n = 56) or radiation therapy (RA) (n = 20) as single-modality therapy and are the subject of this review. All patients in the radiation arm of this review were surgical candidates who declined primary surgical therapy. RESULTS: Sixty-three percent of the SA and 80% of the RA treatment groups presented with either stage III or stage IV disease (P < or = .05). Forty-seven percent of the SA group and 52% of the RA patients had clinically positive regional disease at initial presentation. There was a predictable pattern of nodal presentation, with level II the most frequently involved region. The rate of occult metastasis was 27% and was evenly distributed between T1 and T4 disease. The overall local control rate in the SA group was 75%, compared with 60% in the RA group (P value was not significant). The disease-specific survival (all stages) was 61% in the SA group and 37% in the RA group (P < or = .05). The disease-free survival for stage III and stage IV disease in the SA group was 47% and in the RA group 27% (P < or = .05). Survival measured against clinical response to radiation therapy, in complete responders (all stages) was 83%; by contrast there were no survivors past 24 months in the partial response group (P < or = .001). CONCLUSION: The results from this study suggest that for early disease (stage I/II), surgery or radiation therapy as single-modality treatment is equally effective. For advanced disease radiation therapy is inferior to surgery as a single-modality treatment, as measured by ultimate survival and the local control of disease. There is, however, a subset of patients with advanced disease who respond to radiation therapy and whose survival is equivalent to our surgical cohort of patients.

Problems in resection of chest wall sarcomas.

To illustrate the problems of reconstruction in major chest wall resection, five patients with a variety of soft tissue tumors of the chest wall, located at different sites, are presented. Patients, who underwent a lateral or posterolateral chest wall resection required removal of two to five ribs sequentially as well as the adjacent soft tissue. Those who underwent an anterior chest wall resection required resection of the manubrium or the body of sternum as well as of adjacent costal cartilages. To prevent instability of the chest, herniation, and to minimize flailing, the chest defect was bridged with the use of Marlex mesh. Whenever possible, the omentum was brought into the chest cavity to increase the vascularity of the reconstruction. Since, in most instances, the tumors involved the skin because of previous damage from radiation therapy, extensive skin coverage was planned well in advance of resection. Pedicle skin flaps or rotation flaps were used to cover the skin defect. Ventilatory support by volume respirator, was required for three to four days. In all patients, the chest wall was completeley stable after three to six weeks.

Patterns of nodal metastasis and surgical management of the neck in supraglottic laryngeal carcinoma.

BACKGROUND: Appropriate management of the clinically negative (N0) neck in supraglottic laryngeal cancer continues to be an area of controversy in head and neck surgery. Our treatment policy has been aggressive surgical management even in the clinically N0 neck. METHODS: Between 1971 and 1991, 104 patients had the primary diagnosis of supraglottic laryngeal cancer. Ninety of these patients received their treatment at Roswell Park Cancer Institute and are the subject of this retrospective review. RESULTS: All neoplasms included in this study were squamous cell cancers. The most common subsite involved with tumor in our series was the epiglottis, followed by the aryepiglottic folds and false cords. Supraglottic laryngectomy was performed of 29% of the cases; the remainder received total laryngectomy. Thirty-six percent of the patients had pathologic stage I/II disease, and 64% had stage III/IV. The 5-year survival rates were 100%, 81%, 73%, and 63% for stages I through IV, respectively. Fifty-seven patients had clinically N0 disease at presentation; of these 34 underwent elective neck dissection, and the remaining 23 patients were observed. Of those patients receiving neck dissection, 30% (n = 10) were found to have histologically positive disease, and of the 23 patients observed, 30% (n = 7) had histologically positive regional (neck) disease. Of the 17 clinically N0 and pathologically N+ patients, 82% (14 of 17) had involvement of level I (submandibular triangle), and 100% had involvement of level II. The incidence of bilateral disease in the clinically N0 patient was 44%. There were no local failures. CONCLUSIONS: There is a high incidence of occult regional disease even in early-stage supraglottic squamous cell carcinoma of the larynx. In the surgical management the clinically N0 neck, we presently recommend bilateral neck dissection of levels I through IV to adequately address those regions at highest risk for occult disease.

Bone dust cranioplasty: case report.

The use of the bone dust technique of cranioplasty, in a case of neglected basal cell carcinoma of the scalp, is described. A minor modification of the technique was the covering of the bone paste with a layer of oxycellulose, to protect it from disruption and to provide a matrix for new bone growth. A rapid restoration of a sizeable portion of the bony cranial vault was achieved.

Comparison of the operating microscope and loupes for free microvascular tissue transfer.

A retrospective study of 200 consecutive free microvascular tissue transfers over a 3-year period was done to compare the performance of free-tissue transfers with loupes and with the operating microscope. One-hundred and nineteen flaps (59.5 percent) were performed under 3.5 x loupe magnification and 81 under the operating microscope (40.5 percent). The magnification selection process was based on cumulative past experience, with all early anastomoses performed with the microscope and the vast majority of the more recent operations performed with loupe magnification. Loupes were used preferentially for head and neck reconstruction and breast reconstruction. The microscope was required for performing vascular anastomoses on children and on vessels less than or equal to 1.5 mm in diameter. Results were compared with respect to etiology of defect, type of flap, age of patient, free-flap success, complications, and overall success of the reconstruction. There was no difference in outcome between the two groups, with free-flap success rates of 99 percent for both the loupe and the microscope groups. We believe that our success with loupe-only free-tissue transfers is attributable to our prior considerable experience with the microscope. We would caution that comfort and experience with microanastomoses under the operating microscope should be obtained prior to beginning a loupe-only experience.

Craniofacial and head and neck applications of the transaxillary latissimus dorsi flap.

The use of a transaxillary latissimus dorsi musculocutaneous flap is suitable whenever a large volume of tissue is required for head and neck reconstruction. Our series of 63 transaxillary latissimus dorsi musculocutaneous flap reconstructions included three cases of complete flap necrosis and ten cases of partial flap necrosis. When used in reconstructive head and neck surgery, the latissimus dorsi vascular pedicle is separate from the radiated field. The pedicled latissimus dorsi flap provides coverage of the orbitocranium, including the supraorbital region and central portion of the upper face. In the event that the pedicle muscle flap does not reach far enough cephalad, the nutrient vessels can be separated from the axillary artery and anastomosed to vessels in the neck. Combined defects of the esophagus, the mandibulofacial region, and the neck may be reconstructed with a single large latissimus dorsi flap. In our experience, aesthetic and functional deficits have been well tolerated by patients after latissimus dorsi reconstruction. Disadvantages of the latissimus dorsi flap include repositioning of the patient, increased blood loss, and longer operating time. Permanent brachial plexus injury can also occur. In general, the transaxillary latissimus dorsi musculocutaneous flap should not be used when defects can be reconstructed using simpler methods.