Use of apron flap incision for neck dissection.

Neck dissection is one of the most commonly performed surgical procedures in the management of head and neck cancer. Different skin incisions with various modifications have been described in the literature. Three commonly used but conceptually different incisions were compared with respect to the incidence of wound dehiscence in a retrospective review. There were 166 patients with 184 neck dissections carried out using a triradiate (n = 85), modified MacFee (n = 25), or an apron flap incision (n = 74). The incidence of wound dehiscence in the three groups was 11 percent, 8 percent, and 0 percent for the triradiate, modified MacFee, and apron flap incisions, respectively. There was a statistically significant difference in the incidence of wound dehiscence between the apron flap incision and the triradiate incision groups (p = 0.004). The difference in wound dehiscence was not statistically significant between the apron flap incision and the modified MacFee incision groups (p = 0.06). Overall, there was a significant increase in the incidence of wound dehiscence in previously irradiated necks (p = 0.02), but this was significant only for the triradiate incision (p = 0.005) when analyzed individually. Comparison of triradiate, apron, and MacFee incisions did not show a statistically significant difference between the incisions with regard to other postoperative complications in terms of seroma, hematoma, wound infection, and fistula formation. The apron flap incision is the recommended approach in the presence of previous neck irradiation as it gives easier access than the MacFee incision. The robustness of the flap is because of the absence of a trifurcate point as well as a good vascular supply arising from arterial territory of the external carotid artery.

Management of the N0 neck in early cancer of the oral tongue.

Elective treatment of the clinically negative neck in the management of early oral tongue cancers remains controversial. A retrospective review of 71 patients with T1, 2 N0M0 squamous cell carcinoma of the oral tongue treated at the Royal Marsden Hospital was carried out. Cervical nodal recurrence at 2 years was 17% in the group of patients who received elective neck treatment as compared to 43% in the group who had observation of the neck and the difference is statistically significant (P = 0.025). The difference in 5-year survival between the group who had elective neck treatment and the group who did not (75% versus 65%) was not statistically significant. Until future research allows us to be more selective on the basis of a reliable panel of histological and/or biological markers for propensity to nodal metastases, elective neck treatment should be considered in the initial management of the patients with early oral tongue cancer.

Development of ganglioneuroma following successful treatment for orbital rhabdomyosarcoma.

A female infant presented with a left orbital embryonal rhabdomyosarcoma at the age of 3 months. She was successfully treated for this tumour with chemo- and radiotherapy. Eight years later she developed a ganglioneuroma in the same area which was treated surgically, but recurred at the age of 19. Re-examination of all of the specimens using immunohistochemistry confirmed that the initial and successive diagnoses had been correct. Two further explanations for this rare sequence of events are considered: whether the initial biopsy had been unrepresentative of the whole tumour, or whether there had indeed been two separate tumours arising in the same area. The theories of this previously undocumented occurrence are discussed further.

Cisplatin and 5-fluorouracil for symptom control in advanced salivary adenoid cystic carcinoma.

Adenoid cystic carcinoma is a relatively rare tumour which arises in the parotid and submandibular salivary glands. Initial management is surgical, often with post-operative radiotherapy, but local relapse is common and distant metastasis not infrequent. Chemotherapy is generally reserved for cases where symptoms are not controlled by other means, since the tumour is slow growing and the response rate frequently disappointing. Cisplatin and 5-fluorouracil (5-FU) both show single agent activity in this disease but had not been previously investigated in combination. All patients referred for palliative chemotherapy of metastatic, symptomatic, histologically confirmed adenoid cystic carcinoma between November 1990 and February 1994 were considered for this study. The drugs were administered as follows: cisplatin 100 mg/m2 with appropriate pre- and post-hydration and 5-FU on a 4-day schedule of 1 g/m2/day. A total of 11 patients (7 male, 4 female) with median age 53 years (range 34-69) received 46 courses of chemotherapy (median four, range one to six). All patients had prior surgery and 8 had previously received radiotherapy. There were no objective responses of > 50% reduction in tumour size. 3 patients had a minor response and two progressed on treatment. The symptomatic response rate, however, was 64%, which compares favourably with other previously reported regimens. Toxicity was manageable. The median time to tumour progression was 9 months (range 0-38) and median survival was 12 months (range 1-65). This cisplatin/5-FU regimen would appear to produce a low rate of objective response but useful palliative benefits in advanced symptomatic adenoid cystic carcinoma. Prior series suggest that a higher objective response rate may be possible with a platinum/anthracycline/fluorouracil combination, and investigation of such a regimen is warranted.

Chemotherapy for symptom control in recurrent squamous cell carcinoma of the head and neck.

BACKGROUND: The role of chemotherapy in patients with recurrent squamous cell carcinomas of the head and neck (SCCHN) is unclear. The aim of this study was to assess the ability of combination chemotherapy to control symptoms in this setting. PATIENTS AND METHODS: Using a prospectively accrued database all patients referred for chemotherapy with symptomatic relapse following surgery were identified. Objective response was recorded using standard criteria and maximum symptom response was assessed retrospectively from case notes using a published scoring scale. RESULTS: A total of 57 (median age 56, range 37-85) patients were studied who had received mainly cisplatin/5-fluorouracil combinations. Thirty-seven had previously received radiotherapy. Fifty-two patients had evaluable disease; 18 (35%) had objective responses (14 PRs and 4 CRs). There were a total of 103 symptoms recorded with eight different individual symptoms. Forty-four (43%) symptoms improved on treatment, 52 (50%) were unchanged and 7 (7%) worsened. The number of patients with improvement in the most frequently recorded symptoms were as follows: pain 11/28 (39%), swelling 12/23 (52%) and dysphagia 6/18 (33%). Sixty-seven percent of patients with objective response also had an improvement in their symptoms but a significant proportion (33%) of non-responders had a symptomatic response. Lack of objective response was not correlated with worsening symptoms. Grade 3/4 toxicity was uncommon (6%-17%) and there were no toxic deaths. A majority of patients (82%) experienced either no change or an improvement in performance status. CONCLUSION: These results demonstrate that chemotherapy improves many of the symptoms associated with recurrent SCCHN, without deterioration in performance status. Symptomatic improvement is more likely if there is evidence of significant tumour shrinkage, but even non-responding patients can benefit.

Esophageal leiomyomatosis involving trachea: surgical resection and repair.

We report the case of a 26-year-old man with diffuse esophageal leiomyomatosis involving the trachea. The tumor was resected by total esophagectomy and partial resection of the trachea and the left main bronchus. The tracheobronchial defect was repaired with a free forearm skin graft with satisfactory outcome. This approach offers good long-term prospects.

Salvage treatment for inoperable neck nodes in head and neck cancer using combined iridium-192 brachytherapy and surgical reconstruction.

The results of debulking surgery and re-irradiation with radioactive implants (brachytherapy) are reported for 39 patients with inoperable metastatic neck nodes from primary head and neck cancers. For 13 patients conventional salvage by partial debulking surgery and brachytherapy proved effective, with 68 per cent control at 1 year, but six patients suffered severe radiation fibrosis, necrosis and contractures. Some 26 patients were treated by combined tumour debulking, skin resurfacing and brachytherapy implant. Initial tumour control and freedom from serious toxicity was achieved in 24 patients. Local control was achieved in 63 per cent of patients at 1 year, with a serious morbidity rate of 12 per cent.

Eusol: the plastic surgeon's choice?

Many products are currently promoted for use on wounds. Edinburgh University Solution of Lime (Eusol) has recently received adverse publicity regarding its use in wound management. One hundred and twenty-four consultant plastic surgeons were surveyed regarding their use of Eusol. Ninety-five replies were obtained (77%); of those who replied, 78 (82%) still use Eusol, while nine out of 17 who do not are prevented from using it as they are unable to obtain necessary supplies. In plastic surgery, Eusol is still being used by plastic surgeons in specific situations.

Aggressive cutaneous squamous cell carcinoma of the head and neck in patients with chronic lymphocytic leukaemia.

We describe multiple cutaneous squamous cell carcinomas of the head and neck in five patients with chronic lymphocytic leukaemia (CLL). When associated with CLL, cutaneous squamous cell carcinomata behave in a much more aggressive manner than otherwise expected. Four patients developed local recurrence after primary treatment. All five patients developed lymph node metastases containing squamous cell carcinoma. Three of five patients (60 per cent) had multiple primary lesions. Whereas the increased incidence of second cancers in CLL and notably of skin cancers is documented, little has been written to describe the aggressive behaviour of these tumours. It is important, when treating these patients, to be aware of the high tendency towards local recurrence and lymph node metastasis and to consider an aggressive management plan and careful follow-up.

Soft-tissue reconstruction in thoracic surgery.

BACKGROUND: Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. METHODS: We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 +/- 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. RESULTS: There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. CONCLUSIONS: The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Exenteration as palliation for patients with advanced pelvic malignancy.

OBJECTIVE: To examine the place of pelvic exenteration in the palliation of advanced and recurrent pelvic tumours. PATIENTS AND METHODS: The notes of patients referred for palliative exenteration were reviewed retrospectively. Fourteen patients (three men, mean age 52 years, and 11 women, mean age 61 years) with a variety of pelvic tumours associated with severe symptoms, had a laparotomy with a view to pelvic exenteration and 10 underwent total or anterior exenteration. RESULTS: Eight patients achieved excellent or good palliation based on survival and quality of life assessment, and two received no benefit. Four of eight patients were alive and apparently free of tumour at a mean of 17 months after surgery. Four were alive, symptom-free but with evidence of malignancy at a mean of 19 months. Two patients who received no benefit died at 2 and 7 months after surgery. The planned exenteration was abandoned in four patients; three of these four patients were dead at a mean of 13 months and one was alive at 12 months. CONCLUSION: Our results confirm that with careful selection and appropriate multi-specialty care, aggressive pelvic surgery is of value in the palliation of some tumours.

Seeding of a parotid pleomorphic adenoma.

Recurrent pleomorphic adenoma of the parotid usually occurs in the distribution of the primary procedure. There are numerous reports of widespread local recurrence and a few reported cases of distant metastases. Extensive seeding throughout the entire ipsilateral neck is rare. Treatment involves a combination of radical surgery and radiotherapy. The potential for malignant transformation demands close follow-up of younger patients particularly.

Reconstruction of the abdominal wall with a latissimus dorsi musculocutaneous flap: a case of a massive abdominal wall metastasis from a cervical cancer requiring palliative resection.

A 49-year-old woman presented with a huge abdominal mass. At laparotomy, a 36-cm diameter semisolid, semicystic mass from the abdominal wall was removed. The peritoneal defect was covered by a mesh and a free latissimus dorsi myocutaneous flap. Histology showed a poorly differentiated squamous cell carcinoma consistent with metastatic tumor from a cervical primary. Surgery has a finite palliative role to extirpate a tumor mass of this size if reconstruction and some form of closure can be achieved.

The latissimus dorsi flap in head and neck reconstructive surgery: a review of 121 procedures.

The results of a prospective study of 121 latissimus dorsi flaps performed during head and neck reconstructive surgery at the Royal Marsden Hospital are presented. Three-quarters of the flaps were pedicled and one-quarter were free. All the patients underwent surgery for malignant disease. The flap failure rate was 5%, other flap related complications occurred in 19% and the overall rate of complications was 26%. Previous radiotherapy, site of reconstruction, type of flap (free or pedicled) and age of the patient were not significant risk factors. Men were more likely to have a complication than women.

Treatment of desmoid tumours in Gardner's syndrome.

A 24 year old woman with Gardner's syndrome developed a massive chest wall desmoid tumour, which required radical excision and prosthetic reconstruction. In view of the local aggressiveness of this tumour and the fact that it does not metastasize a policy of radical surgery when possible is recommended.

Sternoclavicular joint swellings: diagnosis and management.

Five patients with sternoclavicular swellings are described. The group presents a variety of diagnoses which highlight the need for thorough investigation and appropriate management of swellings around the sternoclavicular joint. Although frequently assumed to be benign, this series demonstrates the potential occurrence of malignant disease, and the dangers of pursuing a simple conservative course. Conversely, a substantiated benign diagnosis may avoid the use of unnecessary surgical treatment.

Free flaps in head and neck reconstructive surgery: a review of 77 cases.

Recent advances in surgical technique and instrumentation have ensured that success rates for microvascular free transfer can now exceed 90%. This paper reviews a prospective study of 77 free flaps performed at the Royal Marsden Hospital under the care of one surgeon (NMB) over a 2-year period. 76 patients who underwent 77 free flaps were studied. 68 patients had malignant tumours and 8 had benign lesions. The flap success rate was 95% and the mortality rate 0%. The major complication rate was 20% and the most common complication was a salivary fistula (12%). Microvascular free transfer to the head and neck is not associated with increased morbidity and mortality. It offers single stage, reliable, effective reconstruction using a wide variety of donor sites and tissues.