Submandibular gland transfer: a new method of preventing radiation-induced xerostomia.

OBJECTIVE: Radiation-induced xerostomia is a significant morbidity of radiation therapy in the management of patients with head and neck cancers. We have recently reported a method of transfer of one submandibular gland to the submental space in a small pilot series of eligible surgical patients. The submental space was shielded during postoperative radiation therapy. The transferred gland continued to function after the completion of radiation therapy and none of the patients developed xerostomia. The purpose of this article is to present the technique of submandibular gland transfer in detail and to evaluate the postoperative survival and function of the transferred submandibular glands. DESIGN: Prospective clinical trial. METHODS: The submandibular gland was transferred on eligible patients as part of their surgical intervention. The patients were followed clinically, with salivary flow and radioisotope studies. RESULTS: We performed the surgical transfer of the submandibular salivary gland in 24 of 25 patients placed on the protocol. All the glands survived transfer and functioned well postoperatively as demonstrated on the salivary flow and the radioisotope studies. The surgical transfer was relatively simple and added 45 minutes to the surgical procedure. There were no complications attributed to the submandibular gland transfer. CONCLUSIONS: We have successfully demonstrated that the submandibular gland can be surgically transferred to the submental space with its function preserved. The gland seems to continue functioning even after radiation therapy with the appropriate shielding. This surgical transfer procedure has the potential to change the way we currently manage patients with head and neck cancer.

The effect of high dose vitamin A on the morphology and proliferative activity of xenograft lung and head and neck cancer.

In vitro studies have suggested that vitamin A lowers invasive potential of squamous cell carcinoma. Epidemiological data have also indicated that high dose vitamin A may improve survival in patients with previously resected lung carcinoma. To our knowledge, no studies have attempted to test the in vivo effect of vitamin A on the morphology and growth rate of lung and head and neck cancer. Freshly resected tumor cell suspensions were obtained by ex vivo fine needle aspiration and injected subcutaneously in duplicate in athymic male nude mice. Two to six weeks post-engraftment tests and controls were separated for each xenograft. Mice with test xenografts were given water soluble vitamin A (Aquasol ATM, Astra pharmaceutical, Westborough, MA, U.S.A) at a dose of 10,000 U/Kg/day intraperitoneally for 6 to 10 weeks (median 8 weeks). One to two hours prior to sacrifice bromodexouridine (BrdU) was injected intraperitoneally to assess the S-phase fraction in both test and control xenografts. Blood vitamin A levels in test and control animals were measured after sacrifice using high performance liquid chromatography (HPLC). Sections of test and control xenografts were routinely stained to assess morphologic differentiation and mitotic counts. Unstained sections of xenografts were immunostained by the antibody to BrdU to test for BrdU labeling index (BLI) reflecting S-phase fraction (SPF) and also by the MIB-1 antibody to assess proliferative activity. Eighteen tumors were studied. These included 9 squamous cell carcinomas of the lung, 5 squamous cell carcinomas of the head and neck, and 4 adenocarcinomas of the lung. Blood levels of vitamin A in test animals were 7 to 23 times those of the control animals (median 13 times). Neovascularization of the xenografts was seen in all cases. The morphology and mitotic activity of the test and control xenografts showed no significant difference. SPF and proliferative activity measured by BrdU and MIB-1 immunolabelling respectively showed no significant difference between test and control xenografts. Our study suggests that there is no significant in vivo effect of high dose vitamin A on the morphology and growth rate of xenografted non small cell carcinoma of the lung or squamous cell carcinoma of the head and neck.

Liposarcoma of the base of tongue and tonsillar fossa: A possibly underdiagnosed neoplasm.

Liposarcomas of the head and neck are exceedingly rare, and fewer than 90 cases have been reported in the literature. Liposarcoma of the oral cavity is an even less common entity, and to our knowledge only nine cases have been reported to date. We report the clinical and pathologic findings of a case of well-differentiated liposarcoma of the base of tongue and tonsillar fossa. The patient is a 76-year-old white man with a long-standing history of a mass in the oral cavity and hypopharynx. The mass had been resected several times over the span of 23 years, and diagnoses of lipoma, neurofibroma, mesenchymoma, and angiofibrolipoma have been rendered on different occasions. At the last admission, a polypoid mass of the left tonsillar fossa and base of tongue was resected. The tumor was multinodular and measured 2.5 cm in greatest diameter. Histologically the tumor was ill-defined with infiltrating borders and was composed predominantly of mature adipose tissue with occasional lipoblasts. A small proportion of the tumor consisted of clusters of spindle cells and pleomorphic lipoblasts. Mitotic activity was not seen. The pleomorphic cells were positive for S100 protein and negative for muscle-specific markers. Ultrastructural analysis confirmed the nature of the lipoblasts. Our case depicts the typical natural history and histologic features of liposarcoma of the oral cavity. This tumor is usually well differentiated and has a high recurrence rate and almost no tendency for metastasis. Based on our case and review of the literature, it appears that well-differentiated liposarcoma of the oral cavity can occasionally be underdiagnosed because of the low mitotic activity and long latent period between the original diagnosis and first recurrence.

Spindle cell malignant lymphoepithelial lesion of the parotid gland: clinical, light microscopic, ultrastructural, and in situ hybridization findings in one case.

Malignant lymphoepithelial lesions (MLEL) are rare tumors of the salivary glands that show high incidence in Inuit Canadians, Alaskans, and Greenland Eskimos. The tumors are usually anaplastic or poorly differentiated squamous cell carcinomas. Focal spindle cell elements have been rarely reported. The tumors have been epidemiologically linked to Epstein-Barr virus infection. We present a case of malignant lymphoepithelial lesion showing exclusive spindle cell morphology. The patient is a 44-year-old male Inuit Canadian who presented with a long-standing history of a left parotid mass. The mass did not show evidence of rapid growth or facial nerve involvement. Parotidectomy was performed. The tumor was histologically composed of spindle cells nodules in a background of lymphocytes. The spindle cells showed no evidence of cytologic atypia but were mitotically active. Immunohistochemical staining for low-molecular-weight cytokeratin was only focally positive. The differential diagnosis included a mesenchymal neoplasm and malignant lymphoepithelial lesion. Electron microscopic examination confirmed the squamous nature of the neoplasm. Intracytoplasmic viral particles were also identified ultrastructurally. In situ hybridization for Epstein-Barr virus mRNA using a 30-base oligonucleotide probe specific for the EBER-1 gene showed very high level of expression in the tumor cells. No expression was noted in the adjacent parotid gland tissue. Our findings confirm the squamous nature of malignant lymphoepithelial lesions despite the spindle cell morphology occasionally seen in these neoplasms. They also confirm the strong role of Epstein-Barr virus infection in the pathogenesis of these tumors. This may have further diagnostic and therapeutic implications.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical therapy of internal carotid artery lesions of the skull base and temporal bone.

Five cases of carotid artery lesions at the skull base or temporal bone, treated surgically, are presented. These lesions include mycotic aneurysms and carotid stenosis secondary to angiofibroma and a glomus caroticum. One case demonstrated an anomalous carotid anatomic pattern with a persistent stapedial artery. A description is provided of the technique of subtotal petrosectomy with permanent anterior displacement of the facial nerve, and middle ear obliteration, thus achieving a safe exposure of the temporal course of the internal carotid artery. The cases indicate that cooperation between temporal bone surgeons and vascular surgeons is a prerequisite to successful repair of such lesions, as good recovery in all five cases was achieved. The techniques allow maintenance of carotid flow during and after repair, reducing the potential for neurologic complications or mortality.

Recurrent laryngeal nerve dissection: a case report involving return of spastic dysphonia after initial surgery.

This case study describes successful management of spastic dysphonia using a procedure whereby the right recurrent laryngeal nerve was severed. Thirteen months following the surgical treatment, the subject reported a return of the preoperative vocal characteristics of spastic dysphonia. Tests and inspection revealed that the right recurrent nerve was again intact and the right vocal fold was functional. A second surgical procedure was performed, modified to prevent neural reconnection, with a return of the improved voice observed following the initial surgery. The results are discussed in terms of etiological considerations of spastic dysphonia.

Glomus tumors of the temporal region: surgical therapy.

A series of 23 patients with glomus tumors of the temporal region, treated surgically at the ENT Department, University of Zurich, Switzerland from 1970 to 1977, is presented. A system of classification as to tumor size is described with tympanic, tympanomastoid, infralabyrinthine and intracranial tumors categorized as types A, B, C, and D respectively. A majority of tumors, 12 of 19 were infralabyrinthine (type C), and a surgical approach featuring permanent anterior displacement of the facial nerve, an cavity obliteration, has been employed with the aim of total tumor extirpation. There were five males in this series, with a mean age 22 years younger than for the females and all having infralabyrinthine (type C) tumors. The most frequent clinical presentation included pulsatile tinnitus, hearing loss, and observable tumor mass in the ear. Fifteen of 23 patients had significant hearing loss, of varying types on the tumor side, with one presenting as sudden hearing loss, and another as progressive unilateral sensorineural loss over several years, in the absence, initially, of tinnitus. Ten of 23 patients with type B, C, and D tumors had cranial nerve involvement, seven and tenth being the most frequent. Because of slow growth and tendency to multicentric origin, final conclusions cannot be made regarding treatment in such a recent series of cases. However, the impression gained suggests that radiotherapy is less effective than complete surgical excision, and that partial excision is to be avoided.