Transmandibular approach to total maxillectomy.

Total Maxillectomy through transfacial approach has been practiced in the treatment of Cancer for more than a decade. Its role in T(3) - T(4) tumors extending posteriorly through gthe bony wall is questionable, since an oncological radical procedure is often not possible. Recurrences in the infratemporal fossa are common. Despite the addition of radiotherapy five year survivals have not significantly improved. Transmandibular approach to Total Maxillectomy overcomes this shortcoming by including the pterygopalatine fossa enbloc with the maxilla. Early experience is presented.

Advanced squamous cell carcinoma of the base of the tongue treated with surgery and post-operative radiotherapy.

BACKGROUND: Early stage squamous cell carcinoma of the base of the tongue has been successfully treated with radiotherapy and brachytherapy. However, the vast majority of these tumours seen in Western Europe are already at an advanced stage. Medical records of 79 patients with squamous cell carcinoma of the base of the tongue treated between 1980 and 1994 were examined. METHODS: Eighty-three per cent of the primary tumours were stage T3 or T4. Fifty-nine patients were treated with surgery and post-operative radiotherapy. Quality of life assessment amongst the survivors was performed by means of a questionnaire. RESULTS: Five year disease free survival in patients undergoing excision for T3-T4 tumours was 59%. Patients with T2-T3 tumours undergoing partial excision of the tongue base had a 3 year recurrence free survival rate of 68%. Distant metastasis occurred in 16%. Seventy-eight per cent of the patients judged their quality of life to be near normal. CONCLUSION: Surgery and post-operative radiotherapy offer a reasonably good survival in advanced carcinoma of the base of the tongue with preservation of quality of life.

Assessment of tumour invasion into the mandible: the value of different imaging techniques.

In oral carcinomas close to the mandible, tumour invasion of the mandible is important in selecting segmental or marginal resection. Imaging may play a role in assessing tumour invasion. This study compares the accuracy of panoramic X-ray, CT and MR imaging in assessing invasion of the mandible in 29 patients. At histopathology, 6 patients had mandible erosion, 12 had invasion and 11 had an intact mandible. Magnetic resonance imaging had the highest sensitivity (94%), but a low specificity (73%), with 3 of 11 intact mandibles interpreted as positive. Furthermore, MR often overestimated the extent of tumour invasion. On the other hand, CT and panoramic X-ray had a lower sensitivity (64 and 63%, respectively) and a higher specificity (89 and 90%, respectively). Computed tomography (using 5-mm sections) and panoramic X-ray had a similar accuracy, and negative findings do not exclude invasion. Magnetic resonance imaging was the most sensitive technique but had more false positives and frequently overestimated the extent of tumour invasion. Because none of the radiological techniques are accurate enough, clinical examination seems at present to remain the most important modality in deciding between segmental and marginal resection. Tumour invasion at CT or panoramic X-ray is a strong argument for a segmental resection.

Malignant epithelial parotid gland tumours: analysis and results in 65 previously untreated patients.

BACKGROUND: Optimal management of malignant epithelial parotid tumours requires knowledge of the available therapeutic modalities and the different biological characteristics. The aim of the study was to review the characteristics of patients at presentation, histological classification, disease-free and overall survival rates, and the results of the applied treatment policy regarding the facial nerve and neck. METHODS: Between 1974 and 1995 a total of 65 patients was treated with curative intent for a previously untreated malignant epithelial parotid gland tumour. All patients underwent some type of parotidectomy, 20 of whom had an en bloc radical neck dissection. In selected cases the facial nerve or its branches were peeled off the tumour thus violating the objective of tumour-free margins and relying heavily on the efficacy of postoperative radiotherapy. In total 51 patients received postoperative radiotherapy. None of the patients was lost to follow-up. RESULTS: There were 12 locoregional failures (18 per cent). In only one of these 12 patients was salvage therapy successful; the remaining 11 patients died from the tumour. All but one of the eight patients with distant metastasis only died from the tumour. The estimated 5- and 10-year disease-free rates were 68 and 59 per cent respectively. The corresponding survival rates were 75 per cent and 67 per cent. A significant relationship could be observed between tumour stage and survival. The presence of lymph node metastases proved to be the strongest single prognostic factor. CONCLUSION: In selected cases a conservative approach towards the facial nerve is justified.

Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland.

BACKGROUND: Recent modifications of surgical technique may have influenced outcome following parotidectomy. This retrospective study compares the results of the different surgical methods with regard to recurrence rate and the effects on morbidity between 1974 and 1994. METHODS: A total of 246 primary surgical parotid procedures were performed on 245 patients for pleomorphic adenoma. These included 131 'partial' superficial parotidectomies, 61 'total' superficial parotidectomies, 30 partial superficial/deep lobe parotidectomies, eight total parotidectomies, and 16 'selective' deep lobe parotidectomies. In the recent past, the posterior branch of the greater auricular nerve was preserved in the majority of patients. Eleven patients received postoperative radiotherapy. Median follow-up was 95 months. Fourteen patients died without recurrent tumour. RESULTS: Two patients (0.8 per cent) developed local recurrence, both after total parotidectomy for a deep lobe tumour. No patient experienced permanent facial nerve palsy. The incidence of gustatory sweating for partial superficial parotidectomy was 6.9 per cent (nine of 131) compared with 13.1 per cent (eight of 61) for total superficial parotidectomy. CONCLUSION: Partial parotidectomy is an effective treatment for the majority of pleomorphic adenomas; local recurrence is rare and morbidity is low. Prolonged follow-up is unnecessary.

Treatment of cervical lymph node metastasis from an unknown primary tumor, with a review of the literature.

BACKGROUND: The results of treatment at the Free University Hospital of 44 patients with cervical lymph node metastasis of an unknown primary tumor were reviewed in order to establish an optimal treatment policy and to look for prognostic parameters. These results were compared with results of other treatment policies known from the literature. PATIENTS AND METHOD: Thirty-three out of the 44 patients received a treatment with curative intent; 22 cases received a unilateral neck dissection and postoperative radiotherapy, 7 were irradiated after an excisional biopsy and 4 received radical radiotherapy alone. RESULTS: For the whole group 5- and 10-year overall survival was 50% and 44%, respectively, and for the group treated with curative intent 68% and 56%, respectively. Disease-free survival at 5 and 10 years after treatment for the whole group was 48% and 32%, respectively, and for the group treated with curative intent 63% and 37%, respectively. CONCLUSIONS: Multivariate analysis showed only treatment with intent and histology as significant independent prognostic factors for the whole group. For the patients treated with curative intent no significant influences of variables were found.

The surgical management of recurrent or residual pleomorphic adenomas of the parotid gland. Analysis and results in 40 patients.

From 1974 to 1995, 40 patients were treated surgically at the University Hospital Vrije, Universiteit Amsterdam for recurrent or residual pleomorphic adenomas of the parotid gland after previous surgery. The median interval between the initial procedure and surgery for the recurrence was 122 months. Eleven patients had one or more attempts to resect tumor recurrences prior to referral. During reoperation at this institution it was decided to refrain from tumor resection in three patients. Tumor control in two of these patients was achieved using radiotherapy. In the third patient a "wait-and-see" policy was adopted. The other 37 patients underwent en bloc surgical excisions of their tumor and/or previously incised tissues. Among the 36 patients operated for histopathologically benign disease, 16 received postoperative radiotherapy (to 6500 cGy). None developed a further recurrence, the median follow-up being 106 months. Only one of these patients experienced permanent segmental facial nerve paralysis. Malignant transformation of tumor occurred in two patients. One of these patients died of locoregional disease after surgery and radiotherapy. Radical tumor resection was deferred in the other patient, with tumor control achieved using radiotherapy (7000 cGy). However, since recurrent disease tends to be multifocal in origin, prolonged routine follow-up is required.

Results of the surgical management and histopathological evaluation of 88 parotid gland Warthin's tumours.

With the introduction of parotidectomy after identification of the facial nerve the recurrence rates for benign tumours has declined rapidly. Subsequently, attention was focused on other sequelae of parotid surgery. To reduce the specific surgical morbidity, several modifications of parotidectomy have been implemented. This study compares the results of the different surgical techniques with regard to the histopathological findings and recurrence rate for Warthin's tumour of the parotid gland. Eighty-eight primary surgical parotid procedures were performed on 85 patients for a Warthin's tumour. The surgical procedures included 52 'partial' superficial parotidectomies, 22 'standard' superficial parotidectomies, 12 partial superficial/deep lobe parotidectomies, and two 'selective' deep lobe parotidectomies. No patient developed a recurrence or experienced permanent facial nerve paresis/paralysis, the median follow-up being 93 months. Histopathological examination revealed a multifocal origin in 23% (20/88) of the surgical specimens. Partial parotidectomy is an effective treatment for Warthin's tumour. There is no need for extended follow-up.

[Development and results of surgical treatment of pleomorphic adenoma of the parotid gland in 245 patients, 1974-1994]. / Ontwikkelingen en resultaten van chirurgische behandeling van het pleomorf adenoom van de glandula parotis bij 245 patiënten, 1974-1994.

OBJECTIVE: To describe the results of parotidectomy for pleomorphic adenoma of the parotid gland in 245 patients, 1974-1994. DESIGN: Descriptive. SETTING: Academic Medical Hospital, Free University, Amsterdam, the Netherlands. METHOD: Of all patients follow-up data were obtained by yearly physical diagnostic examination during 10 years, and by a questionnaire (1995) from the general practitioners involved. RESULTS: In the period 1974-1994, 246 primary surgical parotid procedures were performed on 245 patients for pleomorphic adenoma. The surgical procedures included: 131 'partial' and 61 'complete' superficial parotidectomies, 30 partial superficial/ deep lobe parotidectomies, 8 total parotidectomies, and 16 'selective' deep lobe parotidectomies. Eleven patients received postoperative radiotherapy for different reasons. The median follow-up was 95 months. Fourteen patients died without recurrent tumour. Two patients (0.8%) developed a local recurrence, both after total parotidectomy for a deep lobe tumour. None of the patients experienced permanent facial nerve paresis or paralysis. The incidence of auriculotemporal sweating for partial superficial parotidectomy proved to be 6.9% (9/I31) as compared with 13.1% (8/61) for complete superficial parotidectomy. In the later years, in the majority of patients, the posterior branch of the greater auricular nerve was preserved. CONCLUSION: In the hands of the experienced head and neck surgeon partial parotidectomy is an effective treatment for the great majority of pleomorphic adenomas: local recurrence is rare, while in general morbidity is minimal. Rarely there is a need for prolonged follow-up.

Giant keratoacanthoma of the lower lip. Report of a case of spontaneous regression.

The case of a 46-year-old man who refused treatment of a giant keratoacanthoma of the lower lip is presented. Complete regression took place within 10 months. The dilemma of a lesion of the vermilion border of the lower lip being either a (giant) keratoacanthoma or a squamous cell carcinoma is discussed with respect to the management of such lesions.

Partial vertical laryngectomy for recurrent glottic carcinoma.

Partial vertical laryngectomy for recurrent glottic carcinoma was performed in 61 patients according to stringent criteria. The great majority of the recurrent tumours appeared within 2 years of radiotherapy (80%). The mean follow-up after surgery was 79 months. At 5 years 85% of the patients were free of local recurrence. Nine patients (15%) developed a local recurrence; eight of them underwent total laryngectomy; one patient refused the operation and died. Seven patients died of other causes. The actuarial overall survival rate was 88% at 5 years. Post-operative complications were seen in 12 patients (20%); nine of these patients developed airway problems. One patient underwent total laryngectomy for severe aspiration, the others finally were decannulated. The results of this study indicate that partial vertical hemilaryngectomy for irradiation failures is a safe procedure with good results without undue morbidity.

Free vascularized jejunum interposition for pharyngoesophageal reconstruction after total laryngopharyngectomy.

The records of 28 patients who underwent free jejunal graft reconstruction after resection for cancer involving the pharynx were analysed. Seven patients had a T3 carcinoma, 15 patients T4 and six patients recurrence after laryngectomy. Ten patients had received radiotherapy in the past. Post-operatively, 15 patients (54%) had complications and two patients (7%) died. No significant difference was observed in the complication rate between the group that received radiotherapy in the past and those who did not. Nineteen patients received post-operative radiotherapy. Nine patients had no radiotherapy on the basis of complete resection or because of serious complications. For the whole group the 2-year recurrence free period and survival were 42% and 51% respectively. The post-operative radiotherapy group had a significantly better survival (73%) and recurrence free period (63%) than the group without post-operative radiotherapy (0%). Thus, post-operative radiotherapy seems indicated irrespective of resection margins.

Articulation after total glossectomy: a clinical study of speech in six patients.

In this study we investigated the speech of six patients after total glossectomy. After rehabilitation a reasonable function of speech was possible, as a result of compensatory mechanisms. Suggestions to improve the results of speech and language therapy are given.

Castleman's disease as a uncommon cause of a neck mass.

Castleman's disease is an uncommon cause of a neck mass; in only 6% of the cases reported in the literature was the disease located in the neck. We present the case of a 21-year-old woman who developed a swelling in the left side of her neck that was subsequently diagnosed as Castleman's disease. The different forms of the disease and its histopathology are discussed.

Surgery and postoperative radiotherapy and radiotherapy alone in T3-T4 cancers of the pyriform sinus. Treatment results and patterns of failure.

Fifty-four patients with T3-T4 squamous cell carcinomas of the pyriform sinus were treated between 1976 and 1990. Surgery with postoperative radiotherapy (n = 32) was the treatment of choice. Radical radiotherapy was used in patients with contraindications for surgery or with inoperable tumors and in patients who refused surgery. The local control rate was significantly higher in the combined treatment group (31/32; 97%) than in the group treated with radical radiotherapy (14/22; 64%) which consisted of more advanced cases. In patients who received radical radiotherapy, the highest local control rates were recorded with doses of 70 Gy and above and with the use of 2 fractions per day. There was no significant difference in regional control and survival rates between the treatment groups. New approaches are indicated to improve the prognosis of hypopharyngeal cancer.

[Neck lymph node dissection in squamous cell carcinoma originating in the head-and-neck area; the significance for the prognosis]. / Halsklierdissectie bij het plaveiselcelcarcinoom uitgaande van het hoofd-halsgebied; de betekenis voor de prognose.

Neck dissection has a therapeutical as well as a prognostic relevance with respect to regional recurrence and distant metastases. Between January 1973 and July 1986 576 neck dissections in 511 patients (396 men, 115 women, among whom 486 with squamous cell carcinoma of the head and neck, and 14 with neck metastases of an unknown primary tumour) were performed at the department of Otolaryngology-Head and Neck Surgery of the Free University Hospital, Amsterdam. Patients with tumour at the margins were excluded. Recurrence-free curves were calculated according to Kaplan-Meier and the log rank test was used to test the differences. All patients underwent a comprehensive neck dissection and were irradiated postoperatively when three or more tumour-positive nodes or extranodal spread were reported by the pathologist. Endpoint for analysis was occurrence of an ipsilateral neck recurrence or of a distant metastasis. Figures were corrected for a simultaneous recurrence at a higher level. A total of 29 neck recurrences (7.2%; n = 523) and 26 distant metastases (10.7%; n = 281) were demonstrated in the 5-year follow-up period. The number of positive nodes was of prognostic significance for both events (p = 0.039 and p = 0.0027). Extranodal spread was shown only to increase the incidence of distant metastases (p = 0.017), whereas its prognostic value with regard to recurrence in the neck was nullified by the strict institution of postoperative radiotherapy. It is recommended to give radiotherapy to patients with two positive nodes and possibly to every patient with a histopathologically positive neck.(ABSTRACT TRUNCATED AT 250 WORDS)

Atypical leiomyoma of the choana.

Leiomyomas of the nose, nasopharynx and paranasal sinuses are rare. So far only two atypical leiomyomas at these sites have been reported in the English literature. A new case is presented and the literature on the subject is reviewed.

[Masseter muscle flaps and buccal mucosa transposition flaps in the reconstruction of the dorsal oral cavity and the oropharynx]. / M.-masseter-Lappen und Wangenschleimhauttranspositions-lappen zur Rekonstruktion der dorsalen Mundhöhle und des Oropharynx.

The m. masseter crossover flap according to Tiwari combined with a buccal mucosa transposition flap represents an excellent technique for a primary two-layered closure of defects due to surgical removal of T2- and small T3-tumors of the posterior part of the lateral floor of the mouth, the posterior edge of the tongue, the retromolar trigone, the soft palate and the tonsilar region. Especially advantageous are the low postoperative morbidity, the low rate of postoperative complications, and good functional and cosmetic results. The surgical expenditure is little and recommends the use of this technique also in patients with reduced operability.