An approach to malignant parotid tumours.

A series of 30 patients with malignant parotid tumours selected for surgical treatment is presented. There were 18 males and 12 females, with an age range of 12-80 years. All presented with a parotid lump, one had an associated painful facial nerve palsy and one had clinically involved neck nodes. Four had previous surgery, surgical biopsy or radiotherapy. Pre-operative fine needle aspiration was performed on one patient. Postoperative radiotherapy was administered to 14 patients. Follow-up was for a mean of 5.5 years. The primary tumour was controlled by surgery alone in 15 of the 16 patients. There was one local recurrence and two patients in this group died from distant metastases. Of the group receiving postoperative radiotherapy, there was one local recurrence, one local and neck recurrence and one death from distant metastases. Mobile, discrete tumours can be treated by parotidectomy with preservation of the facial nerve and the selective use of radiotherapy. The malignant tumour with restricted mobility but no facial palsy is treated by parotidectomy, sacrificing only involved branches and postoperative radiotherapy. The clinically fixed lesions with facial palsy demand total parotidectomy in operable cases, nerve sacrifice and postoperative radiotherapy.

Infection in branchial cysts.

A series of 26 branchial cysts is reported. Seventeen patients presented with no history of infection, three with mild infection and six patients were referred with chronic or recurrent infection. The diagnosis of branchial cyst was confirmed histologically in each. Infection did not appear to be an important feature in the presentation of the 17 larger, visible cysts in the lateral neck diagnosed pre-operatively. Overt infection may have been prevented by antibiotics and aspiration of the cyst in three of these patients who had rapidly enlarging, uncomfortable, tense cysts. It is emphasized that a branchial cyst should be considered in explanation of any collar stud abscess or inflammatory mass in the lateral neck.

Cancer of the oral cavity: management of the clinically negative neck.

The management of the clinically uninvolved (No) neck in patients with cancers of the oral tongue, or floor of the mouth, including the gum, and treated by intra-oral resection remains contentious. The high incidence of metastasis to the neck found in patients selected for composite resection of tumours of these sites (30-59%) might suggest that elective treatment of the neck, either by neck dissection or irradiation, should be performed in all patients. To the contrary, it is shown that the incidence of late metastasis from T1 tumours, treated by intra-oral resection alone, is low (less than 20%), and although the incidence of late neck metastasis from T2 tumours which have been similarly treated, is 42.7%, death from uncontrolled disease in the neck, with the primary controlled, occurs in only 4%. Intra-oral resection of superficial T1 cancers without elective treatment of the neck appears justified, but the management of the No neck in patients with T2 tumours remains controversial.

Marginal resection of the mandible in treatment of cancer of the floor of the mouth.

In a series of 253 excisions of cancer of the floor of the mouth, 57 marginal resections of the mandible retaining mandibular continuity were performed. Tumour recurred at the primary site in six of the 47 patients available for review at three years; three within the mandible itself. Three patients died with uncontrolled primary disease, but the other three survived after additional surgery and/or radiation therapy. Although this recurrence rate might appear high, the outcome of the total series is comparable with other reported series. The results do not finally demonstrate that marginal resection can be used freely, but the low morbidity and good functional results make the technique attractive. Further prospective study is needed to refine the indications for both conservation and ablation of the mandible.

Surgical resection of oral and oropharyngeal cancer with pedicle flap reconstruction.

Seventy patients with squamous cell cancer of the oral cavity or oropharynx, because of advanced disease, or excision of residual or recurrent disease after radiotherapy required pedicle flap reconstruction. All were treated before 1 January 1976. Analysis of the outcome of these patients, some of whom were elderly, and most heavy smokers, showed that 17 (24.3%) survived 10 years or more. Age, metastatic neck nodes, and prior failure of radiation therapy to control the cancer did not seem to influence the prognosis significantly. It is concluded that, if patients are fit, and a reasonable quality of life can be assured with either a pedicle or vascularized free flap reconstruction, major resection is justified when technically feasible.

'Benign' pleomorphic adenoma of the parotid.

A personal series of 141 surgically treated parotid tumours is reviewed. Of 112 parotid tumours in which a diagnosis of 'benign' pleomorphic adenoma or other benign tumour was made, 8% proved to be malignant on histological examination. Three patients were thought to demonstrate malignant change in long standing 'benign' parotid tumours. It is concluded that in otherwise healthy patients, discrete, mobile parotid tumours should be removed without undue delay because of the risk of misdiagnosis and the chance of late development of malignancy in pleomorphic adenomata. Malignant tumours simulate benign tumours often enough to warrant treating all as potentially malignant.

Recurrent pleomorphic adenoma of the parotid.

Nineteen patients with recurrent pleomorphic adenoma of the parotid are reported. The aetiology of recurrence is discussed and capsule rupture is emphasized as a major cause, especially of multinodular recurrence. Further surgical attempts to remove recurrences are justified by the possibility of misdiagnosis of the original tumour and the late development of malignancy in recurrent nodules. Tumour clearance was achieved in all but two of 19 patients with recurrence or incomplete primary excision in those in whom it was attempted. Radiotherapy does not seem to be an appropriate alternative to repeated surgical excision.

Results of treatment of head and neck carcinoma with high dose methotrexate.

Forty four patients with squamous cell carcinoma of the head and neck from a variety of primary sites were treated with high dose methotrexate with folinic acid rescue from 1975 to 1977. The overall response rate was 66%. Response duration was short with a mean of 16 weeks. The usefulness of this technique in the treatment of head and neck cancer is discussed.

The management of squamous cell cancer of the mouth and throat.

Until chemotherapy is proved more effective in the initial management of squamous cell cancer of the mouth and throat, radiation and surgery will remain the principal treatment modalities. This paper documents a treatment selection process which is used in the Head and Neck Clinic of the Peter MacCallum Hospital. Anatomical resectability, potential of control by radiation, disability and deformity produced by surgery, presence of metastases, psychological factors, and concurrent disease, as well as tumour behaviour, are all factors which influence the choice of radiation or surgery, alone, or in combination, in the treatment of each patient.

Results of the surgical treatment of selected patients with squamous cell cancer of the mouth and throat.

The five year results of excision of cancer of the oral cavity and oropharynx in 172 patients selected for surgical treatment are reported. The overall survival rate was 48.8%, with 39.5% of patients dying with persistent or recurrent disease. An unexpectedly high survival rate of 42.2% was achieved in 45 patients with residual or recurrent tumour resected after failed initial radiation therapy.