Clinico-pathological and treatment-related factors influencing survival in parotid cancer.

One hundred and three patients with primary parotid cancer treated surgically at the Christie Hospital, Manchester (1952-1992), were analysed to assess the influence on survival of prognostic and treatment-related factors. Thirty-seven patients were treated by surgery alone (SG), 66 received post-operative radiation (SG+RT). Median follow-up was 12 years, minimum 5 years. The 10-year disease-specific survival rates for stage I, II and III/IV were 96%, 61% and 17% respectively (P < 0.0001). The various histological types segregated into three survival patterns: low-, intermediate-and high-grade with 10-year survival rates of 93%, 41% and 50% respectively (P < 0.0001). On multivariate analysis, the factors influencing risk of cancer death in order of importance were: tumour size > 4 cm (P < 0.001), presence of nodes (P = 0.001), histology of adenoid cystic carcinoma (P = 0.01), high-tumour grade (P = 0.02) and perineural involvement (P = 0.01). Neither the extent of surgery nor the operator influenced outcome. Overall, adjuvant RT significantly reduced locoregional recurrence (SG+RT 15% vs SG 43%; P = 0.002) but not survival, although on subanalysis, there was a trend to improved survival with large cancers and high-grade tumours. Long-term survival is determined primarily by tumour characteristics, namely clinical stage and grade. Post-operative RT contributes significantly to locoregional control and probably confers some survival advantage in high-risk patients.

An analysis of the treatment of 114 patients with recurrent pleomorphic adenomas of the parotid gland.

BACKGROUND: Nerve preserving surgery is widely recommended for recurrent parotid pleomorphic adenomas though the risk of further relapse may be high. Adjuvant radiotherapy may improve control but its exact role requires clarification. METHODS: A series of 114 patients with first recurrences treated between 1952 and 1992 is reviewed. Treatment modality was either surgery alone (SG; n = 63) or surgery with radiotherapy (SG + RT; n = 51). Results were determined with respect to long-term tumor control (K-M life-tables) and facial nerve function. RESULTS: The rate to second recurrence was 15% (17/114), median follow-up 14 years. There were no cases of malignant degeneration. Multinodular recurrences treated by SG were at particular high risk of relapse, but control was significantly improved with adjuvant radiotherapy (SG versus SG = RT; 43% versus 4% at 15 years, P = 0.008). In contrast, no difference was demonstrated in the uninodular tumor group (SG versus SG = RT; 15% versus 13% at 15 years, P = 0.9). The incidence of permanent facial nerve injury was 15%. CONCLUSIONS: This study emphasizes the distinction between multinodular and uninodular recurrences; the former is at high risk of relapse and benefits from adjuvant radiotherapy whereas solitary tumors may be adequately treated by surgery alone.

Clinical significance of the tumour capsule in the treatment of parotid pleomorphic adenomas.

The propensity of pleomorphic adenomas to recur is generally attributed to the biological nature of the tumour, and surgery close to the capsule is perceived as undesirable. At the Christie Hospital, Manchester, between 1947 and 1992, 475 tumours arising within the superficial portion of the parotid gland were treated by two surgical techniques: extracapsular dissection (380 patients) and superficial parotidectomy (95). Recurrence rates were 2 per cent in each group (median follow-up 12.5 years). Contact of the tumour with the facial nerve was recorded in 51 per cent of patients. There was no difference between the treatment groups in the incidence of permanent facial nerve injury (2 versus 1 per cent respectively). This study demonstrates that dissection in close proximity to the tumour is possible without inducing recurrence and that in practice the microinvasion of the capsule by tumour buds has limited clinical significance.

Long-term follow-up of over 1000 patients with salivary gland tumours treated in a single centre.

Between 1947 and 1992, 1403 patients with 1432 salivary gland tumours were treated at the Christie Hospital, Manchester. There were 1194 epithelial neoplasms: parotid, 1082 (91 per cent); submandibular, 47 (4 per cent); minor glands, 65 (5 per cent). The commonest histological diagnoses were pleomorphic adenoma (n = 776) and adenolymphoma (n = 159). A total of 244 carcinomas were seen (adenoid cystic carcinoma, n = 75). Treatment was primarily surgical, conservative where possible, and determined by tumour extent and not histology. Adjuvant radiation therapy was used in over half the definitively treated malignancies. The recurrence rate following the treatment of 551 new parotid pleomorphic adenomas was 1.6 per cent at median follow-up 12.5 (range 1-34) years, increasing to 15 per cent in the secondarily referred group (n = 170). For patients with definitively treated primary salivary carcinomas (n = 148), the disease-free survival rate at 5, 10 and 15 years was 58, 47 and 45 per cent respectively. Using multivariate analysis, clinical stage was the most important predictor of survival; the 10-year survival rate for stages I-IV was 96, 70, 47 and 19 per cent respectively.

Radiotherapy for pleomorphic adenoma of the parotid gland.

A study was made of 187 patients with parotid pleomorphic adenoma treated by radiotherapy. This followed surgery but with incomplete removal or tumor spillage. In the early years of the study radiotherapy was given by radium needle implant done usually at the time of surgery, but from the late 1960s beam-directed external radiotherapy with a head shell was used most commonly. A 3-field technique or wedge pair was the standard technique. The median age was 46 with nearly half the patients (87/187) aged between 40 and 60, and the ratio of women to men was 1.4:1 (110:77). Median follow-up for all patients was 14 years. One hundred fifteen patients had radiotherapy immediately after their first operation with a recurrence rate of 0.9% (1/115). Of the 115 there were 2 cases of radionecrosis (1 major, 1 minor), 1 case of permanent facial nerve palsy, 1 Frey Syndrome (post-gustatory sweating), and 1 salivary fistula. Seventy-two patients had radiotherapy delayed until one or more recurrences had been surgically treated. Nine (12.5%) of these developed yet further recurrence after radiotherapy. There were 2 cases of radionecrosis (1 major), 4 cases of facial nerve palsy (3 of which were complete), 16 cases (22.2%) of Frey Syndrome, and 1 case of malignant change in a parotid tumor. In addition one squamous cell carcinoma developed at the site of a needle implant 25 years later. Recurrences after radiotherapy continued beyond 20 years of follow-up. Patients having unsatisfactory surgery due to spill at operation or residual tumor left behind should have radiotherapy immediately and not delayed until local recurrence occurs because of the increased morbidity and the higher incidence of yet further recurrence.

Salivary tumours--experience over thirty years.

A clinicopathological survey of tumours of salivary glands seen in a special surgical clinic at the Christie Hospital and Holt Radium Institute is reported. Nine hundred and seventy-seven benign and malignant tumours have been seen within the past 30 years. The results of treatment are included with particular attention to those of the parotid glands which present the greatest therapeutic problem. The approach to surgical treatment of pleomorphic adenomas is described in detail and guidelines offered as to the procedure that should be used based on full exploration and assessment of each tumour. The need for adjuvant irradiation depends on the standard of surgery that is done. The relationship between carcinomas and benign adenomas is discussed and the need for surgery in all cases is stressed in order to make a definite histological diagnosis in view of the wide range of pathological abnormality encountered.

Abnormal liver function during nutritional support in postoperative cancer patients.

Patients who receive total intravenous or nasogastric nutritional support after surgery for head and neck cancer show abnormalities of liver function. Twenty such patients were maintained in positive nitrogen balance. Serum alkaline phosphatase and aspartate aminotransferase values were increased in 15 and 18 cases respectively. Possible causes for the abnormalities are discussed and further investigations proposed.

Screening for breast cancer.

The feasibility of mass population screening for breast cancer by clinical examination and x-ray mammography was studied. The results indicate that such a programme could be conducted effectively by non-medical staff and be safe from the dangers of irradiation. The response rate of women invited for screening suggests that such a service is acceptable to the general public. The additional work load produced by screening would not overburden the existing surgical services.