Preservation of the eye in the treatment of sinonasal malignant neoplasms with orbital involvement. A confirmation of the original treatise.

OBJECTIVE: To continue the retrospective analysis reported in 1988 that supported preservation of the eye in the treatment of sinonasal cancers when bony erosion of the orbit was noted on pretreatment radiographic analysis. DESIGN: Using the eye-sparing protocol previously reported, which included preoperative radiotherapy (with or without chemotherapy, depending on tumor size, involvement, or other characteristic) for malignant neoplasms of the superior nasal vault that had eroded the bony orbit, retrospective analysis of the results of therapy for the additional 33 patients treated between 1986 and 1993 was performed. These data were added to those from the original series to provide a total of 74 patients. Forty-one patients (55%) showed bony erosion at initial evaluation and 14 (19%) had periorbital involvement. During surgery, the periorbita was evaluated by frozen section control. If tumor was found, that region of periorbita was resected and, if necessary, replaced with fascia or split-thickness graft. RESULTS: Five patients from the original series had orbital sacrifice. Of the remaining 36 patients, 4 (11%) had recurrent disease involving the orbit, but not at the primary site. Twenty (55%) of the 36 patients had no orbital complications, and only 1 (3%) had a permanent motility disturbance and 4 (13%) developed cataracts after radiotherapy. CONCLUSION: With the use of preoperative radiotherapy in resection of involved periorbita with frozen section control in tumors of the sinonasal vault that involve the bony orbit, the eye can be spared in most instances without compromising oncologic safety.

Management of the eye in the treatment of sinonasal cancers.

Malignant neoplasms of the nose and paranasal sinuses typically manifest at a late stage and commonly abut or invade the orbit. Careful ophthalmologic examination and fine-cut CT provide the most accurate preoperative assessment of orbital involvement, providing guidance for treatment with a combination of radiation therapy and surgical resection. Although some surgeons still aggressively remove the eye when tumor abuts or involves limited periorbita, we have shown that this approach is unnecessarily ablative. The cosmetic, functional, and psychologic consequences of the loss of an eye mandate that every effort should be made to preserve the eye as long as oncologic safety is not compromised. The evidence is mounting that this is safe and organ sparing, and leaves functioning eyes. With the use of preoperative radiation therapy and frozen-section control of the periorbita, the eye can often be spared without increasing local recurrences or survival, and adequate postoperative function can be maintained.

Application of split-thickness skin grafts for acquired diseases of the external auditory canal.

Over the past 10 years a variety of acquired external auditory canal pathologies have been treated at the University of Virginia. Surgical intervention has been required in 16 patients (18 ears). The most common diagnosis in this group was canal stenosis. Split-thickness skin grafts have been used for epithelial coverage. Depending on the size and location of the canal defect, one of three graft types was used: island, segmental, or circumferential. Surgical techniques are discussed and illustrative cases presented. Long-term graft results have been excellent, with no patient requiring a second graft for coverage. In those patients with preoperative conductive losses, the average improvement in hearing threshold was 27 decibels.

Cytokeratin in anaplastic large cell lymphoma.

A B-cell anaplastic large cell lymphoma, confirmed by immunohistochemistry and Southern blot immunoglobulin gene rearrangement analysis, contained neoplastic cells that were immunoreactive for cytokeratin using antibodies CAM 5.2, M20, MAK 6, and KS-B17.2. Bands corresponding to cytokeratin 18 and cytokeratins 18 and 8 were seen on Western blot immunoanalysis using antibodies KS-B17.2 and CAM 5.2. The lymph node also contained cytokeratin-positive extrafollicular fibroblastic reticulum cells. Although it is possible that the presence of cytokeratin in the cells of anaplastic large cell lymphoma represented phagocytosed filaments from the reticulum cells, it is more likely that the cytokeratins were synthesized by the malignant cells. The finding of cytokeratin in anaplastic large cell lymphoma, although infrequent, adds to the confusion in the diagnosis of this pleomorphic neoplasm.

Preliminary report: endoscopic versus external surgery in the management of inverting papilloma.

Since January 1977, twenty-four patients with inverting papilloma of the nose and paranasal sinuses have been treated at the University of Virginia. Two patients had bilateral disease, for a total of 26 surgically treated sides. Patients were aged from 10 to 83 years, and 71% were male. Most tumors originated on the lateral nasal wall, with 62% involving the adjacent sinuses. Nineteen sides were treated by external approach and 7 were treated intranasally. There was a total of 5 recurrences in 4 patients and no associated squamous cell carcinomas. Seven patients were treated with endoscopic excision (4 primary tumors and 3 recurrences). There have been no recurrences since endoscopic treatment. These preliminary data give further evidence that endoscopic excision is a viable surgical option for many inverting papillomas.