Influence of condition of surgical margins on local recurrence and disease-specific survival in oral and oropharyngeal cancer.

BACKGROUND: The clearance of surgical margins at the primary site is widely thought to influence the subsequent course of the disease in patients operated on for oral and oropharyngeal carcinoma. In some reports the adverse impact of close or involved margins was not negated by postoperative radiotherapy. These findings, in addition to descriptive histopathological studies, have led some authors to recommend margins of more than a macroscopic clearance of 1cm at certain subsites. We have therefore examined the relation between the condition of surgical margins and local recurrence and disease-specific survival. METHODS: Identical treatment protocols were used to treat two independent groups of patients (Sydney, Australia, n=237; Lanarkshire, n=95) who presented with previously untreated carcinoma of the mouth or oropharynx. All patients were operated on with the primary objective of achieving a macroscopic clearance of 1cm. Postoperative radiotherapy was used according to a protocol. Data about patients were entered into comprehensive computerised databases prospectively. Known clinical and pathological prognostic indicators, in addition to the condition of surgical margins, were analysed to find out if they were predictive of local recurrence and disease-specific survival using the Cox proportional hazard model. RESULTS: Local recurrence was predicted by the presence of perineural invasion at the primary site in both groups. Disease-specific survival was predicted by the presence and extent of regional lymph node metastases in both groups. The condition of surgical margins (clear, close, or involved) did not predict local recurrence, or disease-specific survival on multivariate analysis. CONCLUSIONS: A macroscopic margin of 1cm seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have close or involved margins the biology of the disease influences the subsequent course irrespective of the width of clearance of tumour.

Incidence of cervical node involvement in metastatic cutaneous malignancy involving the parotid gland.

BACKGROUND: The parotid lymph nodes represent an important group of nodes at risk for metastatic involvement from cutaneous malignancies of the head and neck. When treating patients with metastatic disease in the parotid gland it has been our custom to also remove the lymph nodes of the neck on the basis that these nodes represent other nodal groups at risk for metastatic involvement. The aim of this study is to determine the incidence of cervical node involvement among patients with clinical metastatic SCC or melanoma of the parotid to determine whether treatment of the clinically negative neck is warranted. METHODS: The study group consists of 123 prospectively accessioned patients with clinical metastatic cutaneous squamous cell carcinoma (SCC) (n = 73) or melanoma (n = 50) involving the parotid gland and a minimum of 2 years of follow up, irrespective of the clinical status of the neck. RESULTS: Among 73 patients with metastatic SCC in the parotid, 19 (26%) had clinical neck involvement, and 16 of these were pathologically positive (84%). A total of 37 patients had elective neck dissections, and 13 were pathologically positive, which is an overall rate of 52% neck involvement among patients having neck dissection. Among 50 patients with metastatic melanoma in the parotid, 19 (38%) patients were initially seen with clinical neck disease, and all were pathologically positive. Among 31 patients with clinically negative necks, 26 had neck dissections and seven had positive nodes (27%). Overall, 58% of patients with melanoma who had a neck dissection had positive nodes. CONCLUSION: Patients with metastatic cutaneous SCC and melanoma involving the parotid gland had a high incidence of clinical (26% and 38%, respectively) and occult neck disease (35% and 27%). Treatment of the clinically negative neck in the presence of clinical metastatic parotid cancer should be considered to reduce the likelihood of failure in cervical nodes, to define the extent of disease, and to assist with patient selection for adjuvant therapy.

Do nodal metastases from cutaneous melanoma of the head and neck follow a clinically predictable pattern?

BACKGROUND: Potential lymphatic drainage patterns from cutaneous melanomas of the head and neck are said to be variable and frequently unpredictable. The aim of this article is to correlate the anatomic distribution of pathologically involved lymph nodes with primary melanoma sites and to compare these findings with clinically predicted patterns of metastatic spread. METHODS: A prospectively documented series of 169 patients with pathologically proven metastatic melanoma was reviewed by analyzing the clinical, operative, and pathologic records. Clinically, it was predicted that melanomas of the anterior scalp, forehead, and face could metastasize to the parotid and neck levels I-III; the coronal scalp, ear, and neck to the parotid and levels I-V; the posterior scalp to occipital nodes and levels II-V; and the lower neck to levels III-V. Minimum follow up was 2 years. RESULTS: There were 141 therapeutic (97 comprehensive, 44 selective) and 28 elective lymphadenectomies (4 comprehensive dissections, 21 selective neck dissections, and 3 cases in which parotidectomy alone was performed). Overall, there were 112 parotidectomies, 44 of which were therapeutic and 68 elective. Pathologically positive nodes involved clinically predicted nodal groups in 156 of 169 cases (92.3%). The incidence of postauricular node involvement was only 1.5% (3 cases). No patient was initially seen with contralateral metastatic disease; however, 5 patients (2.9%) failed in the contralateral neck after therapeutic dissection. In 68% of patients, metastatic disease involved the nearest nodal group, and in 59% only a single node was involved. CONCLUSIONS: Cutaneous malignant melanomas of the head and neck metastasized to clinically predicted nodal groups in 92% of patients in this series. Postauricular and contralateral metastatic node involvement was uncommon.

Multicentricity in papillary thyroid carcinoma: analysis of predictive factors.

OBJECTIVES: Multicentricity has been cited as a rationale for total thyroidectomy in patients with papillary thyroid carcinoma (PTC) confined to one lobe. The purpose of this study was to examine the incidence of multicentricity of PTC in a cohort of 165 patients with PTC confined to one lobe and to examine clinical and pathologic features that may help predict for the presence of contralateral disease. DESIGN: Retrospective review. SETTING: Tertiary care hospital. METHOD: A retrospective review of 165 patients with PTC confined to one lobe treated at the Toronto General Hospital from 1992 to 1997 was performed. MAIN OUTCOME MEASURE: The predictive factors affecting the presence of multicentricity of PTC were analyzed. RESULTS: The incidence of PTC present in the contralateral lobe was 56.3%. We were unable to find any correlation of multicentricity with age, sex, tumour size, extrathyroidal spread, thyroiditis, or tall cell variant of PTC. There were trends toward higher incidence of contralateral disease in those patients with a prior history of irradiation and those with lymphatic metastases, but these trends did not reach statistical significance. CONCLUSIONS: The incidence of contralateral disease in papillary thyroid cancer treated at the Toronto Hospital was 56.3%. There was a higher incidence of contralaterality in those patients with a previous history of irradiation and in those with lymphatogenous metastases, but this did not reach statistical significance.

Temporal bone necrosis: diagnosis, classification, and management.

OBJECTIVE: The goal of this study was to analyze temporal bone necrosis and classify its diagnosis and treatment according to extent of necrosis and cause. METHODS AND MATERIAL: Twenty-six cases of temporal bone necrosis were retrospectively reviewed between 1988 and 1997 at the University of British Columbia. RESULTS: Patients were classified on the basis of disease extent restricted to the tympanic bone or extension beyond the tympanic bone, as well as on the basis of the cause of disease; treatment based on classification. Patients with localized disease of the tympanic bone had minimal symptoms. Those with radiation-induced localized necrosis were less likely to respond to conservative medical management. Patients with diffuse disease were more likely to require surgical intervention. CONCLUSIONS: Temporal bone necrosis comprises a spectrum of disease from idiopathic tympanic bone necrosis, which rarely requires surgery, to the more severe forms of radiation-induced diffuse temporal bone necrosis that may cause life-threatening complications requiring surgical intervention.

Reconstruction of total lower lip and chin defects using the composite radial forearm--palmaris longus tendon free flap.

BACKGROUND: Functional and aesthetic restoration of total lip and chin defects can be achieved using the composite radial forearm-palmaris longus tendon free flap. OBJECTIVE: To present the technique we use and our experience with this form of reconstruction in 10 consecutive patients with total lip and chin defects who were surgically treated between 1992 and 1998. METHODS: The palmaris longus tendon acting as a sling over which the flap is draped is responsible for long-term maintenance of vertical lip height and lip support. The factors responsible for this are the long-term maintenance of vertical lip height and lip support and the transfer of facial muscle activity to the neolip. RESULTS: All patients were satisfied with their final reconstructive result. Oral competence for deglutition and speech was achieved in all patients in our case series, with no incidence of drooling. CONCLUSION: We recommend the use of the composite radial forearm-palmaris longus tendon free flap for this type of reconstructive surgery. Arch Facial Plast Surg. 2000;2:53-56

Efficacy of surgical salvage for advanced neck metastases after radiotherapy failure.

OBJECTIVE: To analyze the efficacy of surgical salvage in patients with metastatic squamous cell carcinoma to the neck of stage N2 or N3 initially treated with radiotherapy. DESIGN: Retrospective review. SETTING: Tertiary care institution. METHODS: Four hundred and twenty-five patients received neck dissection at Sunnybrook Health Sciences Centre between 1990 and 1996. Sixty-one patients had neck dissection for salvage after radical radiotherapy for advanced neck disease of stage N2 or N3. These patients were selected from the Sunnybrook Head and Neck Database and reviewed. OUTCOME MEASURES: Survival and recurrence. RESULTS: Sixty-one patients underwent neck dissection for salvage after radiotherapy. Five-year overall survival was 30%. The majority (72%) failed locoregionally after surgical salvage. CONCLUSIONS: Surgical salvage after radiotherapy for advanced neck disease has a 30% 5-year survival rate. Surgical salvage after radiotherapy for advanced neck disease is effective in a minority of patients.

Detection of squamous neoplasia by fluorescence imaging comparing porfimer sodium fluorescence to tissue autofluorescence in the hamster cheek-pouch model.

BACKGROUND: Early neoplastic changes in the oral cavity may be difficult to detect. Fluorescence imaging using porphyrin-derived drugs has been used to enhance detection of neoplasia. Autofluorescence has also been used for this purpose. This paper compares autofluorescence to porfimer sodium-induced fluorescence in the detection of neoplasia in the hamster cheek-pouch model. MATERIALS AND METHODS: Neoplasia was induced in the hamster cheek pouch by the application of 9,10-dimethyl-1,2-benzanthracene. Animals were imaged either with injection of drug (porfimer sodium) or without drug (autofluorescence). Imaging was carried out using a laser-induced fluorescence detection system. Biopsies were performed on imaged sections and histologic grades were assigned. RESULTS: Porfimer sodium fluorescence provided 100% sensitivity and specificity in detection of neoplasia. The sensitivity and specificity with autofluorescence was 76% and 83%, respectively. CONCLUSIONS: Autofluorescence provides an accurate means of detecting early neoplastic changes in the hamster cheek-pouch model; however, porfimer sodium imaging does improve detection rates.

Antenatal appendicular perforation.

Antenatal appendicular perforation leading to localized meconium peritonitis and intestinal obstruction is reported in a premature neonate. The baby was successfully treated by a limited ileocaecal resection.

Burkitt-type lymphoma. Diagnosis by fine needle aspiration cytology.

Forty cases of lymphoma were categorized as Burkitt-type lymphoma in a study of fine needle aspiration (FNA) smears. These constituted 14.3% of all cases of non-Hodgkin's lymphoma diagnosed between 1974 and 1982. The median age was 22 years in these cases, 81.8% of which had extranodal tumors. The majority of the cells in the smears (59.8% +/- 8.32%) were in the 11 micron to 15 micron size range and 60.3% +/- 10.3% had noncleaved nuclei. An average 71% of the cells contained cytoplasmic and/or nuclear vacuolizations. Nonneoplastic macrophages were present in the smears in 87.5% of the cases. A study of paraffin-embedded sections in 17 cases revealed the characteristic "starry-sky" appearance in 11; in 5 it was not clearly appreciated and in 1 the nonneoplastic macrophages were absent. FNA cytology was found to be quite reliable for arriving at a diagnosis of Burkitt-type lymphoma. More than 50% of the cases were managed without resort to subsequent surgical biopsy. Exploratory laparotomy was avoided in 69% of the cases having abdominal tumors.

Multilocular cyst of kidney.

We describe a child with a multilocular renal cyst who presented with a renal mass and pain due to haemorrhage into the cyst. This type of presentation has not been reported previously.