Efficacy of fibrinolytic enhancement with stanozolol in the treatment of venous insufficiency.

Pericapillary fibrin cuffs have been shown in patients with chronic venous insufficiency. It has been suggested that this fibrin deposition is responsible for an oxygen diffusion block, leading to local hypoxia and resulting in ulceration. Fibrinolysis is depressed in patients with venous insufficiency and therefore pharmacological enhancement of this factor might be expected to produce clinical improvement in this condition. Sixty patients with lipodermatoscelerosis were entered into a prospective, double-blind, placebo-controlled, randomized trial. Stanozolol 5 mg or a placebo tablet was given twice daily for 6 months. All patients were supplied with below knee German/Swiss specification class 2 graduated compression stockings. The area of lipodermatosclerosis was measured at monthly intervals and transcutaneous oxygen tension within the liposclerotic area was measured at 3-monthly intervals. The control group showed a mean reduction in area of lipodermatosclerosis of 14% (95% c.i.: -2.6-31%) compared with a 28% reduction in area in the active treatment group (95% c.i.: 5.3-46%). Transcutaneous oxygen measurements showed no change in either group. Side effects were significantly more common in the active treatment group (P less than 0.02, Chi-squared). Although fibrinolytic enhancement caused a reduction in area of lipodermatosclerosis, no evidence of any effect on a possible oxygen diffusion block was indicated.

Unremarkable parotid tumours that prove to be malignant.

Of 539 patients with clinically unremarkable lumps treated by formal parotidectomy, subsequent histological examination indicated that 20 of these lesions were malignant. After a follow-up of 1-18 years, only one patient has suffered a recurrent tumour and none has died from disease related causes. The results indicate that formal parotidectomy is an acceptable means of treating the small number of malignant tumours presenting in this way, and strengthen the argument that attempts to obtain a histological diagnosis before treatment are contraindicated.

Natural history of patients with recurrent parotitis and punctate sialectasis.

The clinical features of 68 patients (26 children and 42 adults) who suffered recurrent attacks of parotitis and in whom sialography had revealed punctate sialectasis of the affected gland is described. The sex incidence was equal in those patients in whom symptoms commenced during childhood (younger than 15). When symptoms commenced later in life, however, there was a marked preponderance of females (female:male = 7.5:1). Bilateral sialography in 16 patients with unilateral symptoms revealed punctate sialectasis in the asymptomatic gland in 11 (69 per cent) of patients. Neither the presence of the sicca syndrome nor auto-antibodies had a significant predictive value as to the outcome of the disease. Five-year follow-up of 52 patients revealed that 56 per cent of adults and 64 per cent of children had shown spontaneous improvement of symptoms with symptomatic treatment alone. In 40 per cent of adults and 4 per cent of children, however, the persistence or worsening of symptoms necessitated parotidectomy. We believe that these results of conservative management indicate that, at least in the first instance and particularly in children, conservative management is justified and that the use of radiotherapy or steroids (with their attendant morbidity) is unnecessary.

Influence of local surgery and radiotherapy on the natural history of pleomorphic adenomas.

We have analysed the interval between first treatment and tumour recurrence in 65 patients with parotid pleomorphic adenomas which had recurred following local excision. Our results indicate that 5 years is an inadequate period of follow-up and that 10-20 years may be more realistic. Radiotherapy given to 17 patients after local excision of their tumours was found to have had no significant advantageous effect in terms of recurrence-free interval either before or following formal parotidectomy or in limiting the ultimate surgery required. Major complications directly attributable to radiotherapy developed in at least 3 of these 17 patients. Malignant transformation of the pleomorphic adenoma has occurred in three patients, two of whom had been subjected to radiotherapy. We advise that caution is exercised in the interpretation of results of local excision and radiotherapy in this disease. In view of the fact that an alternative and apparently superior treatment is available in the form of formal parotidectomy, we urge that this should be universally adopted for the management of both primary and recurrent pleomorphic adenomas.

Lymphomas presenting as lumps in the parotid region.

The clinical and pathological features of 17 patients who had lymphomas of the parotid region are discussed. Although it is in general impossible on clinical grounds to make a pathological diagnosis on clinical examination of a lump in the parotid region, features which are not typically seen in the majority of patients with parotid lumps, but which were present in 11 (65 per cent) of those patients, are emphasized. Multiple ipsilateral and bilateral lumps were seen in 30 per cent of our patients with lymphomas of the parotid region. However, these are statistically more likely to indicate the benign adenolymphoma. Palpable lymph nodes were seen in association with the parotid mass in 53 per cent of our patients. Whereas a clinical diagnosis cannot be established simply by the presence of an enlarged lymph node in association with the parotid lump, we suggest that the probability of the lump being a lymphoma is sufficient to justify biopsy of the lymph node as a first line of treatment. Biopsy of associated palpable lymph nodes enabled the diagnosis to be made in seven out of eight patients subjected to biopsy, and avoided the necessity for parotidectomy in these patients.