Adjuvant chemotherapy for high-risk squamous-cell carcinoma of the head and neck.

A prospective clinical trial was developed to evaluate efficacy, toxicity, and patient compliance to adjuvant chemotherapy following surgery and postoperative radiation therapy in patients with squamous-cell carcinoma of the head and neck with extracapsular spread of tumor in cervical metastases. Following postoperative radiation therapy, 18 courses of methotrexate (MTX) and 5-fluorouracil (5-FU) were administered over 6 months. Fifty patients were registered. A total of 771 doses were administered. Dose reduction was required 72 times. Therapy was stopped in one patient (2%) because of toxicity. Three patients (6%) refused to complete the adjuvant therapy. Adjusted 2-year no evidence of disease (NED) survival is 66%. This study demonstrates that patients with advanced squamous-cell carcinoma of the head and neck can undertake an aggressive program of adjuvant MTX/5-FU with acceptable compliance and toxicities. Preliminary data generated in this nonrandomized study support the call for a prospective randomized multiinstitutional trial of this program.

Nursing care of the head and neck cancer patient.

Because head and neck cancer and its treatment cause such severe morbidity, very specialized nursing care is required before, during, and after therapy and rehabilitation. All aspects of nursing, especially physical care, health teaching, and psychosocial counseling, are crucial in helping the patient and his family deal with his illness, its treatment, and the consequences.

Surgical management of early epidermoid carcinoma of the anterior floor of the mouth.

Therapy for early carcinoma of the floor of the mouth is difficult because of the tendency for local invasion of muscle and extension onto the mandible and alveolus. Nearly 100% local control of disease without mandibular complication has been possible with a wide local three-dimensional resection including marginal mandibulectomy with split thickness skin grafting. The operative technique and special considerations including management of the mandible, submandibular ducts, and airway are detailed. Lymph node metastases habe been uncommon. The primary disease and pathology are correlated with regional metastasis, and based on this a treatment plan is recommended.

Antimicrobial prophylaxis for contaminated head and neck surgery.

The use of antibiotic prophylaxis in head and neck surgery is controversial. Most surgeons agree that when surgery requires entry into the aerodigestive tract through the skin the wound is by definition contaminated and antibiotic prophylaxis is indicated as it is in other contaminated wounds. There is no general agreement as to which antibiotic or combination of antibiotics to use or what the schedule of dosage administration should be. In order to obtain a meaningful data to help in decision making, a double blind, randomized study was performed to investigate whether cefazolin alone or a combination of gentamicin and clindamycin was more effective in prophylaxis. All patients entered into the study underwent major oncologic head and neck surgery requiring entry into the upper aerodigestive tract through the skin. Patients were stratified at entry according to the stage of disease, surgical procedure, and the existence of a prior tracheotomy or prior radiation therapy. Subsequently, patients were randomly assigned to 1 of 4 treatment groups. Group I: Cefazolin 1 day, placebo day 2 to 5. Group II: Cefazolin days 1 to 5, Group III: Gentamicin and clindamycin 1 day, placebo days 2 to 5. Group IV: Gentamicin and clindamycin days 1 to 5. Drugs were given intravenously beginning 3 hours preoperatively and continued postoperatively every 8 hours, according to the assigned schedule. All wounds were observed daily following surgery and were graded on a predetermined scale by 3 unbiased observers. Significantly wound infections occurred in 15% of all patients. Group I, 33%; Group II, 20%; Group III, 7%; Group IV, 4%. In Group III and Group IV there was a statistically significant (P less than .05) reduction in the rate of postoperative wound infection. Multifactorial analysis demonstrated that patients whose surgery included repair with a regional pectoral flap had a statistically significant increased chance of developing postoperative wound infection (P less than .05). Patients undergoing laryngectomy, with or without neck dissection, were at less risk of postoperative infection tham patients undergoing oropharyngeal resection (P less than .05). The preoperative existence of tracheotomy or prior radiation therapy had no demonstrable effect on the incidence of wound infection postoperatively in this study.

Adjuvant methotrexate-5-fluorouracil for extracapsular squamous cell carcinoma in cervical metastasis.

A trial of surgery, irradiation, and adjuvant chemotherapy was offered to patients with extracapsular spread of squamous cell carcinoma in cervical metastases. Following surgery and irradiation, methotrexate, 5-fluorouracil, and leucovorin were administered 18 times over 6 months. Fifty patients undertook chemotherapy, while 47 patients declined further therapy. Comparison of the two groups according to stage, site, and Karnofsky performance status demonstrated no significant differences. The number of nodes encountered and the number and percentage of nodes with extracapsular spread were similar in the two groups. The minimum 5-year adjusted survival for patients undergoing adjuvant chemotherapy is 54% (20 of 37 patients), while survival of patients who failed to undertake adjuvant chemotherapy was 17% (5 of 30 patients). These data suggest the efficacy of methotrexate-5-fluorouracil adjuvant chemotherapy and support the need for a prospective randomized clinical trial.

Cefazolin vs moxalactam? A double-blind randomized trial of cephalosporins in head and neck surgery.

Cefazolin and moxalactam were compared in a prospective randomized double-blind trial of 118 patients undergoing oncologic head and neck surgery. Both antibiotics were given 2 g every four hours for four doses. Five infections were encountered in the cefazolin group (8.5%) and two infections in the moxalactam group (3.4%); this difference was not statistically significant. This assessment does not indicate, however, that the two regimens are equally efficacious.

Prophylactic perioperative antibiotics in contaminated head and neck surgery.

Controversy remains regarding the use of prophylactic antibiotic therapy in contaminated head and neck surgery. In an attempt to clarify this issue, a prospective double-blind randomized study has been undertaken in patients who were to undergo major contaminated (skin to mucosa) oncologic surgery. The drug combination gentamicin plus clindamycin was compared with cefazolin. One day of therapy was compared with five days. Results showed a statistically significant higher rate of infection with the use of cefazolin. In addition, preliminary results indicate that the longer duration of therapy decreases infection rates.

Effect of certain head and neck tumors and their management on the ventilatory function of the eustachian tube.

A prospective study was carried out which tested three hypotheses: 1) certain tumors of the head and neck that originate in sites other than the nasopharynx may cause middle ear effusion; 2) middle ear effusion is a predictable sequela of radical maxillectomy as well as total or partial resection of the soft palate; and 3) middle ear effusions that follow surgery to remove head and neck lesions are due to disturbances in palatal function, specifically to tensor veli palatini muscle dysfunction. Our results indicate that one fourth of all subjects had some evidence of middle ear abnormality prior to entering into treatment although they were asymptomatic. The treatment process influenced the function of the middle ear, as 79% of the subjects experienced middle ear-eustachian tube dysfunction following treatment, and 23% were found to have developed a perforation of the tympanic membrane or required myringotomy and tube insertion to relieve middle ear effusion. The results of these studies indicate that surgery that is adequate to remove cancer of the maxilla, tonsil, or palate in most cases interferes with the function of the tensor veli palatini muscle, resulting in functional eustachian tube obstruction. The need for attention to and the treatment of middle ear effusion in such patients is emphasized in light of other sensory deficits in this patient population.

Nursing care of patients with laryngeal carcinoma.

The patient with cancer of the larynx can provide a challenge to the nursing staff. All aspects of nursing management are encompassed in providing care to this unique group of patients. Prevention and early detection are mandatory in the treatment of the patient with cancer of the larynx. Acute care/intensive care nursing, teaching, general medical surgical nursing, rehabilitative nursing, and psychological counseling are all required for any patient undergoing treatment for a cancer of the larynx. The nurse is in a key position to coordinate the care received by these patients and their family members in order for the patient to resume a reasonable quality of life.

Writing for publication: Part III--References.

Although a literature search is performed when first identifying your subject, the reference list is not generated until you are actually doing your research for the article. This part of "Writing for Publication" will address references and citations within the text.

The extracapsular spread of tumors in cervical node metastasis.

Extracapsular spread (ECS) of lymph node metastases is believed to be an indicator of poor prognosis. In general, it has been thought that ECS was limited to large "fixed" nodes. To test the validity of the assumption that nodes less than 3 cm in diameter do not have ECS, the specimens from 177 radical neck dissections were reviewed retrospectively with regard to ECS. Sixty-five percent of the nodes that were 2.9 cm or less in diameter were found to demonstrate ECS. We found no substantial difference in the number of patients who had no histologic disease in their necks when compared with a second group of patients who had metastasis confined to the lymph node. The patients whose lesions had ECS had statistically significantly reduced numbers of survivors. Other factors, eg, tumor differentiation and the number of malignant nodes, had no prognostic importance. The impact of ECS on staging, the reporting of retrospective reviews, and therapy are discussed.

Maintenance chemotherapy for high-risk patients. A preliminary report.

A prospectively designed program employing surgery, radiotherapy, and maintenance chemotherapy was initiated for patients with histologic evidence of extracapsular spread of tumor in cervical metastases. Postoperative radiotherapy consisted of 6,000 rad of cobalt 60 administered in 180- to 200-rad fractions. Chemotherapy was initiated two to four weeks following radiotherapy. Methotrexate sodium (250 mg/sq m), fluorouracil (600 mg/sq m), and leucovorin calcium were administered one day per week, two weeks of three, for a total of 18 treatments in six months. Thirty-two patients have been in the therapeutic program. Toxic reaction has been minimal and self-limiting. One patient stopped chemotherapy because of toxic reaction. One patient (3%) was noncompliant. All patients have been followed up for 18 to 33 months. Twenty-one patients remain alive and free of disease (81% determinate survival). This compares with a 36% (9/25) disease-free survival for concurrent controls and 39% survival for historic controls.