Localization of sentinel nodes in head and neck tumours by combined lymphoscintigraphy and bone scintigraphy.

Sentinel node scintigraphy in tumours of the head and neck region was combined with bone scintigraphy to provide anatomical landmarks in order to better locate the lymph node uptake. 99Tc(m)-nanocolloid (40 MBq) was injected in the peritumour region 1 h after the administration of bone-seeking 99Tc(m)-methylene diphosphonate (200 MBq). After 5 min, A-P and lateral projections of the head and neck region were acquired. In all the 26 patients examined, the surrounding anatomy was clearly depicted. In 23 patients, the lymphatic drainage was identified within 30 min. In these patients, all hot spots appearing outside the deposited activity could be located according to the neck region classification system of the Memorial Sloan-Kettering Hospital. No lymphatic drainage was visualized in the remaining three patients. The injection of bone-seeking activity 1 h before deposition of the radiocolloid provided images visualizing soft tissues as well as skeletal structures, thus improving the topical diagnosis. Correlation with the results of surgery was not performed. The administration of a small amount of bone-seeking activity prior to sentinel node scintigraphy of head and neck tumours improves the anatomical localization of the lymph node activity.

Outcome of ipsilateral treatment for patients with metastases to neck nodes of unknown origin.

It is not uncommon for head and neck cancer patients to present with neck node metastases. Standard treatment for patients in whom no primary tumor is found include surgery and radiotherapy but there is still controversy about the type and extent of treatment. A retrospective review was carried out on 51 consecutive patients with cervical lymph node metastases of unknown origin, treated between 1980 and 1994 at Radiumhemmet, Karolinska Hospital. All patients received radiotherapy to the ipsilateral neck and the corresponding mucosa and surgery was performed in 55% of cases. The 5-year overall survival rate was 41%. A primary tumor was later found in 6 cases (12%). Two cases of cancer were detected after 5 years and classified as 'second primaries'. Results from this small retrospective material have to be interpreted with caution but indicate that limited, ipsilateral radiotherapy to mucosa and lymph nodes combined with surgery, when possible, may be justified.

Deterioration of intraoral hole size identification after treatment of oral and pharyngeal cancer.

Thirty-one patients with a diagnosed malignant tumour of the oral cavity or pharynx were tested in hole size identification on four test occasions: before all treatment, after radiotherapy and 6 months and 1 year after surgical treatment. They were compared within groups as well as with a group of healthy reference individuals of the same age who underwent the same test procedure at a 2 months' interval. The oral group did not decline in hole size identification after radiotherapy, but did after surgery. The deterioration was persistent 1 year after surgery. The pharyngeal group did not change performance in hole size identification after radiotherapy, nor after surgery. It is obvious that surgery of the oral structures causes the deterioration. No correlation with damage to the lingual nerve could be registered. The oral cavity reacts as one unit, despite sensory input from two sides. The non-operated side does not compensate for the operated side. It is plausible that decreased oral sensory acuity, in recognizing hole size of the bolus, contributes to postoperative swallowing problems.

Hyperbaric oxygen therapy for wound complications after surgery in the irradiated head and neck: a review of the literature and a report of 15 consecutive patients.

BACKGROUND: Radiotherapy, which is often used for cancer in the head and neck, leads to damage of tissue cells and vasculature. Surgery in such tissues has an increased complication rate, because wound healing requires angiogenesis and fibroplasia as well as white blood cell activity, all of which are jeopardized. Hyperbaric oxygen therapy (HBO) raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasia, and has antibacterial effects. METHODS: In this consecutive retrospective study, 15 patients with soft-tissue wounds without signs of healing after surgery in full-dose (64 Gy) irradiated head and neck regions were treated with HBO and adjuvant therapy. The patients in this study were also compared with patients examined in an earlier study, with corresponding wounds treated without HBO. RESULTS: The healing processes seemed to be initiated and accelerated by HBO. In the HBO group, 12 of 15 patients healed completely, 2 patients healed partially, and only 1 patient did not heal at all. There were no life-threatening complications. In the reference group, only 7 of 15 patients with corresponding wounds without signs of healing eventually healed without surgical intervention, and 2 patients had severe postoperative hemorrhage, which in one case was fatal. CONCLUSION: Evaluation of obtained results supports the hypothesis that HBO therapy has a clinically significant effect on initiation and acceleration of healing processes in irradiated soft tissues.

Well-being and coping in oral and pharyngeal cancer patients.

Patients with oral and pharyngeal cancer often suffer serious functional impairments. To achieve a broader understanding of the patients' situation it is important to include their appraisal of present functioning. There may also be other factors of importance in the evaluation of well-being such as personality and coping. 42 patients with oral and pharyngeal cancer answered the Oral and Pharyngeal Nursing Care Questionnaires 12 months after treatment. The questionnaires contain 25 conditions (grouped as Therapy- or Psychosocial-related Conditions) from three perspectives: perceived severity, received support and received information. Other questionnaires included in the study were the Sense of Coherence Scale, Somatic Anxiety Scale (from the Karolinska Scale of Personality) and Health Index. The patients were classified with regard to the extensiveness of their surgery. Severe disturbances related to therapy were significantly correlated to weaker sense of coherence (r = -0.34), more anxiety (r = 0.31) and to worse feelings about general health (r = -0.37). The corresponding data with regard to severe disturbances related to psychosocial situation were r = -0.44, 0.52 and -0.65, respectively. There was no significant correlation between perceived severity and surgical extensiveness. The support and information concerning Psychosocial-related Conditions were evaluated as less than those concerning Therapy-related Conditions. The level of support and information was not significantly correlated to sense of coherence, anxiety, general health or surgical procedure. The patient's subjective appraisal of the seriousness of the circumstances connected with oral and pharyngeal cancer and its treatment is an important parameter in the care of these patients.

Functional status and coping in patients with oral and pharyngeal cancer before and after surgery.

BACKGROUND: Few studies, prospective or retrospective, exist that describe the quality of life of patients with oral or pharyngeal cancer. This study describes functional status, measured by the sickness impact profile (SIP), and coping, measured by the sense of coherence (SOC) scale, in a group of patients treated by surgery for oral or pharyngeal cancer. METHODS: Forty-two patients, divided into two groups, participated in the study. Twenty-seven patients completed SIP and SOC scale 12 months after treatment (the 12-month follow-up group), and 15 patients completed SIP and SOC scale before surgery and SIP 2-4 months and 12 months after treatment (the prospective group). The patients were also classified according to the extensiveness of their surgery: minor, moderate, or major. RESULTS: The psychosocial and physical functioning as well as the functions of recreation/pastimes, sleep/rest, home management, work, and eating were rated as being impaired 2-4 months and also 12 months after treatment. However, the obtained values were spread over a wide range, with large individual differences. Functional limitations were related to more extensive surgery and also to less successful coping. CONCLUSION: This study reveals the need of individualized rehabilitation for these patients, and that the SIP and the SOC scale may serve as evaluation tools in a rehabilitation program.

Influence on rabbit submandibular gland injury by stimulation or inhibition of gland function during irradiation. Histology and morphometry after 15 gray.

The loss of salivary gland function after a single dose of 15 Gy was correlated to loss of gland weight and degeneration of seromucous acini and serous tubules at 10 months postirradiation. The serous tubules were degranulated rather early, but regenerated after some months in an abnormal way as adenomatous structures. Striated ducts were mainly unaffected by irradiation. Arterioles showed slight to moderate narrowing of the lumina. There was an increased amount of plasma cells in the gland lobules at 10 months postirradiation. Histologic and morphometric criteria and changes in gland weight showed less pronounced radiation injury in glands irradiated during inhibition of the gland function by biperiden (Akineton) compared to glands irradiated during stimulation of the gland function by pilocarpine. This finding may offer a clinically important means to reduce salivary gland dysfunction after radiation treatment of tumors in the head and neck regions.

Free radial forearm flap reconstruction in surgery of the oral cavity and pharynx: surgical complications, impairment of speech and swallowing.

The first 100 consecutive free radial forearm flaps used in reconstruction for oral and pharyngeal cancer were investigated. Seven re-operations took place due to circulatory impairment of the flap. Two flaps underwent partial, and four total necrosis, one of those patients died of massive haemorrhage. Post-operative infection was significantly correlated to increased time between the last radiotherapy session and surgery. All but eight patients had post-operative impairment of swallowing and all but five patients had impairment of speech articulation or hypernasality. Post-operative time spent in hospital was a range of 12-122 days (mean 37 days). The 2-year survival rate was 70% and the 5-year survival rate was 45%.

The effect of irradiation on blood flow through rabbit submandibular glands.

Microspheres labelled with radioactive isotopes were used to study blood flow through irradiated rabbit submandibular glands before and after injection of pilocarpine. The blood flow through the submandibular glands was measured by the microsphere technique with satisfactory accuracy. A single radiation dose of 13.1 Gy at 3 months of age reduced blood flow through the whole gland significantly 4 months later, and even more at 10 months after irradiation. However, the relative blood flow (per gram of gland tissue) was almost unaffected at both 4 and 10 months post-irradiation with 13.1 Gy because of the simultaneous reduction of gland parenchyma.

Oral- and pharyngeal-cancer patients' perceived symptoms and health.

The purpose of this study was to describe the perceived eating problems, general symptoms, and general health of a group of oral- and pharyngeal- cancer patients before surgery in order to facilitate nursing care planning. A total of 29 patients (20 men and nine women) participated. Two groups were formed: in group 1, 13 patients participated before and, in group 2, 16 patients participated after the presurgical radiotherapy. Questionnaires were used to collect data. Eating disabilities were evident in both groups. The patients who had had their radiation therapy experienced problems such as bad taste function, mouth dryness, difficulties in chewing, and mouth pain more frequently than those who had not been treated. Only five patients in group 2 ate solid food, compared with 10 in group 1. Shoulder and back pain and feelings of worry and anxiety were perceived as the most frequent general symptoms. Most of the patients perceived their general health as being rather good, but some indicated poor health, several symptoms, poor appetite, and/or severe eating problems. Patients with oral and pharyngeal cancer should be carefully assessed before surgery because of their disparity of symptoms and disabilities so as to identify those who need specific nursing interventions.

Irradiation of rabbit submandibular glands. Histology and morphometry after 15 Gy.

Irradiation of rabbit submandibular glands with a single absorbed dose of 15 Gy caused tissue damage which persisted 4 and 10 months later. The injuries were studied by histology, measurement of gland weights and histomorphometry. Reduction of gland weight due to hypoplasia and missed weight gain were seen and the proportions of the three major intralobular compartments of the glands were altered being dependent on the interval between radiation exposure and observation time. The size of the lobules was reduced and extralobular fibrosis in the hilar region increased. The seromucous acini were partly atrophied, with successively changed architecture and reduced size of the granules. The serous tubules showed pronounced reduction of the granules at 4 months and a remarkable adenomatous regeneration at 10 months post irradiation. The striated ducts were almost unaffected during the observation time. Arteriolar changes were slight to moderate, and there was scarcely any capillary damage. The numbers of intra- and extralobular plasma cells were increased.

Blood flow through irradiated rabbit submandibular glands measured with fluorescein angiography.

Microvascular injury has been regarded as a contributing factor in irradiation damage of biologic tissues, including morphologic changes and increased permeability of the vascular network. The late irradiation effect on the capillary circulation of salivary glands was studied with dynamic fluorescein angiography. In 31 rabbits one side of the head was exposed to a single radiation dose of 15 Gy. At 4 and 10 months thereafter no significant difference was detectable in the microcirculation between the unshielded and shielded glands.

The capacity of irradiated rabbit submandibular glands to concentrate 99mTcO4 pertechnetate.

The capacity of irradiated rabbit salivary glands to accumulate 99mTcO4 pertechnetate offers a means for functional evaluation of radiation injury. In 50 rabbits one side of the head was exposed to 15 Gy irradiation in a single dose. Measurements of isotope were made 4 and 10 months thereafter. The seromucous acini (80% of the intralobular tissue) were radiosensitive and showed a weight reduction. The striated ducts (8% of the intralobular tissue) were not radiosensitive and their weights did not change. The 99mTcO4 accumulation capacity of the glands was reduced by the irradiation, but by less than the total gland weight. Consequently the parenchymal concentration of 99mTcO4 was increased after irradiation. These findings suggest that 99mTcO4 is more concentrated in non-radiosensitive striated ducts than in radiosensitive seromucous acini.

Morphology and histochemistry of rabbit submandibular glands.

The rabbit submandibular glands are of the heterocrine type. The most distal part of the ductal system consists of secretory endpieces, which are constructed mainly of two morphologically and histochemically different and distinct structures: distally the seromucous acini and proximally the serous tubuli. The cells of the seromucous acini are strongly AB pH 2.5 positive, AB pH 1.0 negative and PAS negative, indicating production of acid glycoproteins--mainly sialomucin. The cells of the serous tubuli are AB pH 2.5 negative and strongly PAS positive, indicating the presence of neutral glycoproteins. Glycol methacrylate embedded sections (Historesin) stained with a modified Trichrome stain were superior to standard paraffin sections regarding resolution and clarity of morphological details. Quantitative studies of intralobular structures on AB-PAS-stained paraffin sections compared with Trichrome-stained glycol methacrylate sections gave corresponding results. The latter method is well suited for study of structural changes in submandibular glands, as in assessing the effect of ionizing irradiation.

Evaluation of some prognostic factors in small squamous cell carcinoma of the mobile tongue: a multicenter study in Sweden.

In a retrospective study of 58 patients from all over Sweden, treated for small squamous cell carcinoma of the mobile tongue (T1N0M0), different prognostic factors were evaluated. A partial glossectomy was performed as primary treatment in all patients. The cancer recurred in 28 (38%) of 58 patients. One of 7 patients with only local recurrence, and 9 of 14 with recurrence in the neck died of their disease. The relative survival rate was 77%. Of the prognostic factors tested, tumor thickness was found to be the most significant. In patients with tumor thickness was found to be the most significant. In patients with tumor thickness exceeding 10 mm, recurrences occurred in 58% (P less than 0.0048), and 87% (P less than 0.0164) died of their cancer. This represents a statistically significant higher degree when compared with tumor thickness of less than 10 mm. Elective treatment of the neck nodes is recommended in epidermoid cancer of the mobile tongue when tumor thickness exceeds 10 mm, even in stage I tumors (i.e., the surface extension diameter is smaller than 20 mm at most).

Reconstruction in the head and neck regions with free radial forearm flaps and split-rib bone grafts.

Fifty patients with wound defects in the head and neck region underwent reconstruction with the free radial forearm flap. Mandible defects in 17 patients were reconstructed by split-rib bone grafts. Radiotherapy was administered to 44 patients preoperatively. The free flap was successful in 49 patients, and there was one case of partial flap necrosis. The free flap is soft, thin, and movable. The split-rib bone graft was successful in 15 patients, and there was one case of partial graft necrosis and one case of complete necrosis. Postoperative complications were decreased by 50 percent when compared with the complication rate when split ribs were covered by forehead flaps, deltopectoral flaps, or oral mucosa. Finally, the functional and cosmetic results were excellent.

Bicycle accidents.

Information concerning 520 bicycle accidents and their victims was obtained from medical records and the victims' replies to questionnaires. The analyzed aspects included risk of injury, completeness of accident registrations by police and in hospitals, types of injuries and influence of the cyclists' age and sex, alcohol, fatigue, hunger, haste, physical disability, purpose of cycling, wearing of protective helmet and other clothing, type and quality of road surface, site of accident (road junctions, separate cycle paths, etc.) and turning manoeuvres.