Selenium and glutathione peroxidase levels in patients with epidermoid carcinoma of the oral cavity and oropharynx.

Selenium ingestion may inhibit carcinogenesis. Epidemiologic studies have shown that age-adjusted death rates for cancer at most head and neck sites are lower in states where the soil and forage crops contain higher levels of selenium. The mode of action is incompletely understood, but may be mediated through an increase in the activity of the selenium dependent, antioxidant enzyme glutathione peroxidase (GSH-Px). The authors studied blood selenium levels and blood and tissue GSH-Px activities in 50 patients with untreated cancer of the oral cavity and oropharynx. Mean erythrocyte selenium and glutathione peroxidase were significantly depressed when compared to age-matched controls. Mean plasma selenium, on the other hand, was significantly elevated in the cancer patient group. Data from subsets within the cancer patient group were also discussed. GSH-Px activity did not differ in tumor and adjacent normal tissue. The concept of chemoprevention of carcinogenesis with inhibitory chemical compounds is particularly apropos to head and neck cancer control. Further work is indicated to determine if ingestion of supplemental selenium corrects the abnormalities identified here, and what affect, if any, this would have on the development and behavior of squamous cell cancers in the upper aerodigestive tract.

Hypothalamic, pituitary and thyroid dysfunction after radiotherapy to the head and neck.

One hundred-ten patients who had nasopharyngeal cancer and paranasal sinus tumors and were free of the primary disease were studied one to 26 years following radiotherapy. There were 70 males and 40 females ranging in age from 4 to 75 years, with a mean age of 36.5 years. During therapy both the hypothalamus and the anterior pituitary gland were in the field of irradiation. The radiation dose to the hypothalamus and the anterior pituitary gland was estimated to be 400 to 7500 rad with a median dose of 5618 rad to the anterior pituitary gland and a median dose of 5000 rad to the hypothalamus. We found evidence of endocrine deficiencies in 91 of the 110 patients studied. Seventy-six patients showed evidence of one or more hypothalamic lesions and 43 patients showed evidence of primary pituitary deficiency. Forty of the 66 patients who received radiotherapy to the neck for treatment or prevention of lymph node metastasis showed evidence of primary hypothyroidism. The range of the dose to the thyroid area was 3000 to 8800 rad with a median of 5000 rad. One young adult woman who developed galactorrhea and amenorrhea 2 years following radiotherapy showed a high serum prolactin level, but had normal anterior pituitary function and sella turcica. She regained her menses and had a normal pregnancy and delivery following bromocriptine therapy. These results indicate that endocrine deficiencies after radiotherapy for tumors of the head and neck are common and should be detected early and treated. Long-term follow-up of these patients is indicated since complications may appear after the completion of radiotherapy.

Preservation of the orbital contents in cancer of the maxillary sinus.

Tumor invasion of the periorbita, posterior ethmoid cells, or orbital apex is considered an absolute indication for orbital exenteration. Preservation of the orbital contents in selected cases can be applied safely to the treatment of primary maxillary sinus cancer. Patient complaints relating to the preserved eye were more commonly associated with radiation therapy than the method of reconstruction used. Reconstruction of the orbital floor with a skin graft, even when combined with radiation therapy, gave a functional eye in the majority of cases while not compromising the oncologic safety or the procedure.

Presence of cellular retinol and retinoic acid-binding proteins in epidermoid carcinoma of the oral cavity and oropharynx.

Epidermoid carcinomas of the oral cavity and oropharynx from six patients were examined for the presence and amount of cellular retinol (CRBP) and cellular retinoic acid-binding (CRABP) proteins. In all cases adjacent, grossly normal tissue was similarly examined. For each example CRBP levels were significantly higher in tumor tissue compared to adjacent tissue. In four cases CRABP was significantly higher. This is of interest because retinol, retinoic acid and their analogs have been shown to inhibit the development of various epithelial tumors, and this inhibition is possibly mediated by these binding proteins.

Combined laryngeal conservation surgery and irradiation: can we expand the indications for conservation therapy?

Thirty-nine patients (median age of 60 years) with carcinoma of the supraglottic larynx (N = 16), vocal cord (N = 4), and hypopharyngeal wall and pyriform sinus (N = 19) were treated by combined conservation surgery and radiation therapy. Thirty-three patients had postoperative treatment, and the remaining six were given preoperative irradiation. The plan was chosen because of clinical and pathologic features known to be fraught with a high incidence of recurrence above the clavicles. Long-term complications occurred in six patients, two of whom died of aspiration pneumonia. Thirty-eight patients completed their treatment and have been followed for a median of 48 months (1 1/2 to six years). Survival rates are 56% and 63% for absolute and determinant cases, respectively.

The management of squamous cell carcinoma in cervical lymph nodes in the clinical absence of a primary lesion by combined surgery and irradiation.

Sixty-three patients who had either previously treated primary tumors or unknown primary tumors and developed metastatic cervical adenopathy in their previously untreated necks received the combination of surgery and megavoltage irradiation. Within two years, 12 patients died of intercurrent disease, nine patients died with distant metastases only, and five patients had disease recur at a primary site. The remaining 37 patients were evaluable for control of neck disease; 26 patients had previous treatment to a primary head and neck cancer that was under control at the time cervical adenopathy was treated; and 11 patients had an unknown primary tumor that was believed to be in the head and neck area. The combination of pre- or postoperative irradiation and surgery controlled neck disease in 86% of the evaluable patients. Because of the extent of neck disease, these patients would have been at a high risk of failure in the treated area if only a single modality of treatment were used. Analysis of the data shows an association of extranodal connective tissue involvement with both a decreased rate of control within the treated area and distant metastases.

Prolatin secreting pituitary adenomas.

Prolactin secreting adenomas are the most frequently (50%) occurring pituitary adenoma. They occur more commonly in women than in men (4:1). Impairment of gonadal function accounts for the predominant symptoms in both sexes. Forty females and ten males with prolactin secreting adenomas were treated with selective adenoma removal by transsphenoidal surgery. Duration of symptoms varied from two months to 25 years. Twenty percent of the women and 100% of the men had invasive adenomas, a tumor that is difficult or impossible to eradicate. The chances of surgically correcting hyperprolactinemia in the female patient was 75% if the preoperative basal prolactin was 200 ng/ml or less, or 71% if the adenoma was non-invasive. The men were more difficult to treat because they all had invasive adenoma. In 50% of the men, prolactin was normalized by surgery. Early recognition of these patients before the adenomas become invasive is needed.

Malignant neoplasms of the external auditory canal and temporal bone.

In a review of 136 patients with squamous cell, basal cell, and salivary gland cancers involving the external auditory canal and temporal bone, the majority of patients had received prior treatment and came to us with recurrent tumor. Squamous cell carcinoma of the concha and cartilaginous ear canal behaved aggressively. Five-year survival in 35 patients with deep temporal bone involvement was 29%. The major reason for failure in this group was incomplete resection of disease. Postoperative irradiation was of no benefit when the cancer could not be completely excised. When compared with surgery alone, combined therapy with postoperative irradiation did improve local control in patients with completely resected lesions but did not demonstrate a corresponding increase in five-year survival.

Management of osteosarcoma of the maxilla and mandible.

The treatment protocols of 30 patients with osteosarcoma of the maxilla and mandible presenting to M.D. Anderson Hospital and Tumor Institute over a 30 year period were reviewed. Of the patients who received definitive treatment at this institution, 50 percent of those with maxillary and 71 percent of those with mandibular osteosarcomas survived 5 years. Local recurrences were the major problems, whereas distant metastases occurred less frequently. All patients who died from the cancer did so within 3 years of initial treatment. Primary treatment should consist of aggressive surgical resection. Preoperative radiation therapy is used for mandibular tumors. Postoperative radiation is occasionally used for maxillary cancer. Recurrent disease should be treated by surgery, radiation or chemotherapy as indicated.

Posterolateral neck dissection.

The charts of 17 patients who received postauricular, suboccipital, and posterior triangle neck dissection for primary malignant melanoma or squamous cell carcinoma of the posterior half of the scalp (behind the coronal plane of the tragus) or nape of the neck were reviewed. The regional procedure was applied bilaterally in five of these patients in whom the primary lesion was on or close to the midline. The low recurrence rate in the neck, in the absence of moderate or severe funtional and cosmetic sequelae, makes this regional neck dissection a sound procedure for selected patients.

Malignant melanoma of the scalp.

Malignant melanoma of the scalp has a significantly worse prognosis than cutaneous melanoma arising in other head and neck sites. In this series, 125 patients were treated for Stage I invasive melanoma of the scalp and followed 3 to 19 years. Survival rates for these patients were calculated on the basis of several factors. Survival after treatment was not affected by the age and sex of the patient, size and site of the primary, or treatment of the primary lesion, although local failure was higher among those treated by primary excision and closure. Patients undergoing elective neck dissection with histologically negative nodes had significantly better survival rates than those with histologically positive nodes or patients in whom a neck dissection was not performed.

Surgical treatment of advanced carcinomas of the base of the tongue.

During the decade of 1964 through 1973, thirty-four patients with advanced squamous carcinoma of the base of the tongue (20 with T3 lesions and 14 with T4 lesions) were treated by surgical resection. These patients underwent an operative procedure as the only and definitive form of treatment. Twenty-eight (82.3 per cent) presented with clinically positive cervical nodal metastases (4 staged N1, 13 staged N2, and 11 staged N3). The number of primary lesions controlled, cervical metastasis, and the failures of treatment were analyzed. The patients were followed for a minimum of two years or until death or recurrence. The determinate control at two years was 27 per cent and the final determinate survival 20 per cent. Fifteen patients (44.2 per cent) required laryngectomy as part of the primary surgical treatment. The surgical procedures used and other therapeutic options available are discussed.

Radical or modified neck dissection: a therapeutic dilemma.

Three hundred ten evaluable patients received a classic, functional, or spinal accessory-nerve-sparing neck dissection during 1970 to 1975. The functional procedure was at least equal to the classic procedure in the patients in whom it was employed. The spinal accessory-nerve-sparing operation is offered as an alternative to the classic procedure in all patients in whom the nerve is not directly invaded by cancer. If these guidelines are followed, the patient will rarely experience the pain and shoulder dysfunction that result from the loss of the trapezius muscle, while the chances of control of cancer in the neck remain optimal.

Treatment of laryngeal carcinoma with conservative surgery and postoperative radiation therapy.

Thirteen patients with carcinoma of the supragiottic larynx (N = 10), vocal cord (N = 2), and pyriform sinus (N = 1) were treated with conservative surgery followed by radiation therapy. This plan was chosen because clinically or histologically proven lymph node metastases were present and because the primary cancer had one or more of the following factors that were adverse to patient survival: (1) the tumor extended beyond the limits of safe, conservative laryngeal surgery; (2) it infiltrated surrounding soft tissues, ie, preepiglottic space; (3) it was close to the resected margin; and (4) perineural invasion was present. Laryngeal function has been adequate in all but two patients: one has persistent aspiration one year after treatment, and one has a narrow airway after an extended supraglottic laryngectomy that included the anterior third of both cords and a portion of the subglottis at the anterior commissure with adjacent thyroid cartilage. One patient died in the immediate postoperative period, and this case cannot be evaluted. Twelve patients who completed treatment have been followed up for a median of 30 months (1 1/2 through 3 1/2 years), and all have remained free of recurrent disease.