Squamous cell carcinoma of the parotid gland

Squamous cell carcinoma involving the parotid gland is an aggressive and rapidly advancing lesion which if not recognized and treated early will result in a high morbidity and mortality. We reviewed 30 patients with squamous cell carcinoma involving the parotid gland. Twenty-four patients had had previous epidermoid skin lesions in an area known to drain to the parotid gland and three resulted from direct extension into the gland from an overlying skin carcinoma, whereas only three were primary lesions of the gland. Patients who presented with involvement of the gland more than 4 months after excision of the skin lesion had a poor prognosis. Patients with epidermoid skin cancer in areas with a propensity to secondarily involve the parotid gland must be closely followed after treatment of the primary skin lesion.

Favourable response to conservative surgery for extra-pancreatic gastrinoma with lymph node metastases

Five patients with the Zollinger-Ellison syndrome who had extra-pancreatic (duodenal or paraduodenal) gastrinoma with lymph node metastases responded favourably to simple excision or mere shelling out of macroscopic tumour. Acid studies, serum gastrin and the secretin test became normal in all cases in the immediate postoperative period and remained so in three of the five patients when tested at 57, 33 and 8 months. The tests became abnormal in two patients when tested 8 and 53 months after surgery, but both patients are currently well-controlled on ranitidine 150 mg b.d. 22 and 65 months respectively after surgery. These results suggest that in patients with extra-pancreatic gastrinoma who have lymph node metastases simple excision of all macroscopic tumours may offer the prospect of long-term control. The place of total gastrectomy in such patients is questioned.

Metastatic inguinal nodes from an unknown primary neoplasm. A review of 56 cases

Fifty-six cases of this uncommon neoplastic manifestation are presented. These cases represent 0.065% of 86,589 new cases of malignant disease seen at The Princess Margaret Hospital from 1968 to 1982. There were 29 men and 27 women. The median age at presentation was 58 years. Three major groups were identified: inguinal disease, 24 cases; unilateral inguinal plus iliac disease, 16 cases; local plus systemic disease, 16 cases. Pathologic subtypes were anaplastic, 24; squamous, 11; adenocarcinoma, nine; melanoma, nine; and others, three. Survival at 5 years for all patients was 27%. Among 40 patients who presented with inguinal and inguinal plus iliac disease, survival was 37.5% at 5 years. Initial treatment following biopsy was radiation in 35, lymph node dissection in eight, and chemotherapy in four. Excisional biopsy only was performed in nine cases. There were no treatment-related deaths. The findings observed in this study, in which radiation therapy was employed as initial management in the majority of cases, suggests that radiation therapy is a valid alternative to surgery in the management of this disease.

The metastatic potential of prostate carcinomas composed entirely of single malignant glands

Consecutive staging lymphadenectomies on 1046 patients with prostate carcinoma identified 275 patients with metastases in a total of 1115 regional lymph nodes. No prostate carcinomas composed entirely of single malignant glands metastasized and no patient had metastases composed entirely of single malignant glands. All prostate carcinomas that metastasized had cribriform and/or undifferentiated histological patterns in the prostate and in the metastases. These findings suggest that identification of cribriform and/or undifferentiated histological patterns, through rebiopsy or further examination of the surgical specimen, should be considered prior to subjecting patients with prostate carcinomas composed entirely of single malignant glands to therapy or procedures directed against the possibility of metastatic disease.

Postoperative extended-field irradiation in patients with pelvic and/or common iliac node metastases from cervical carcinoma stages IB to IIB

Radical hysterectomy with pelvic and common iliac lymphadenectomy was done for 207 Stage IB (148), IIA (19), and IIB (40) cervical carcinomas. Pelvic nodal involvement was limited in 30 (14.5%) cases, whereas common iliac nodes were involved in 16 (7.7%) cases. Common iliac node metastases were significantly increased, when the number of positive pelvic nodes increased from 2 to 3 or 4 or more (21.4% to 73.3%, P less than 0.05), when the tumor invaded deeper than 20 mm (3.7% to 22.2%, P less than 0.001), and when the tumor extended into parametrial tissues (4.8% to 14.8%, P less than 0.05). Postoperative extended-field irradiation was administered to 40 patients with nodal metastases. The 3-year disease-free rates were 85% in 24 patients with positive pelvic nodes, and 51% in 16 patients with common iliac node metastases; 70% in total. These results indicate that postoperative extended-field irradiation is essential for those patients with nodal metastases from locally resectable cervical carcinomas.

Lymph node metastasis in early gastric cancer

From 1969 through 1984, 304 case of early gastric cancer (EGC) were resected. Nodal status was studied in 272 cases in which lymph node dissection was performed. The lymph nodes were negative for metastasis in 90% of the cases. In 7%, metastasis was noted in the Group 1 lymph nodes alone and in 3%, as far as the Group 2 nodes. But in no case were the Group 3 involved. The 10-year survival rate was poorer in patients with positive nodes than in those with negative nodes (52.8% vs. 94.1%). Cancer recurred more often in patients who had no lymph node dissection than in those with node dissection (9.4% vs. 1.5%). Lymph node metastasis was more frequent in the following EGC types: macroscopically combined type, over 5 cm, and with submucosal invasion. Dissection as far as the Group 2 nodes should be routinely performed even in EGC, especially in cases with the above-mentioned characteristics.

Surgery as palliative treatment for distant metastases of melanoma

Sixty-five patients with distant metastatic melanoma amenable to surgical treatment had excision of 94 metastatic lesions from the brain, lung, abdomen, distant subcutaneous sites, and distant lymph nodes. Relief of symptoms, if present, was obtained after excision of 77% of brain metastases, 100% of lung metastases, 88% of distant lymph node and subcutaneous metastases, and 100% of abdominal metastases. Median survival after excision of brain metastases was 8 months, lung metastases 9 months, abdominal metastases 8 months, and distant subcutaneous and lymph node metastases 15 months. Sixteen per cent of patients lived for 2 years of longer. These results demonstrated that surgery can achieve an effective local disease control in selected patients with distant melanoma metastases and that a few have a relatively long-term survival.

Occult primary adenocarcinoma with axillary metastases

The medical charts of 20 women with occult primary adenocarcinoma with axillary metastases were reviewed. An extensive radiologic workup in search of the primary lesion had a less than 7 percent positivity rate in the 74 studies carried out. Eleven patients were treated with mastectomy, 5 of whom were found to have carcinoma (49 percent). Four of the 11 patients, all with 14 or more positive axillary lymph nodes, died from breast cancer. Seven patients with no evidence of disease had an average of 4.6 positive axillary lymph nodes. Seven patients did not receive mastectomy, and one died from breast cancer. There was no significant difference in survival between the group treated with mastectomy and the group treated with axillary dissection. We conclude that mastectomy is unnecessary for patients with adenocarcinoma in axillary nodes but no apparent primary tumor.

[Adjuvant chemotherapy in addition to radical surgical treatment of regional lymph node metastases in malignant melanoma]

Thirty-three patients with malignant melanoma and regional lymph node metastases who underwent lymph node dissection were additionally given polychemotherapy with carmustine, hydroxycarbamide and dacarbazine immediately before surgery and up to five times postoperatively. Twenty-nine patients were only treated surgically. These two groups were comparable as regards prognostic criteria, in particular tumour size, ulceration and the number of lymph nodes affected, although the individual follow-up periods varied considerably. The group given chemotherapy showed better results than the control group undergoing surgery alone. The log rank test yielded a significant difference (P less than 0.05) with respect to the probability of relapse-free survival but not as regards probability of survival time. Patients with ulcerated primary melanomas and with a large number of affected lymph nodes had a less favourable prognosis. The major side effects of chemotherapy were transient nausea and bone marrow depression.

Studies on hepatobiliary lymph flow with radioactive colloid--for lymph node metastasis resection of carcinoma of the bifurcation of hepatic duct

Hepatobiliary lymphoscintigraphy by Technetium 99m-rhenium colloid (99mTc-Re colloid) using a fine needle guided by ultrasonography was performed on 12 patients who underwent resection of the hepatoduodenal ligament lymph nodes. Histological examination revealed no lymph node metastasis in 8 patients. In 4 patients in whom 99mTc-Re colloid was injected into the left medial inferior hepatic segment, periarterial lymph nodes showed higher isotope uptake count than periductal nodes, and lymph nodes around the common hepatic artery revealed higher values than superior posterior pancreatoduodenal nodes. On the contrary, in 3 patients in whom the isotope was injected into the right anterior inferior segment, periductal lymph nodes had higher values than periarterial nodes, and superior posterior pancreatoduodenal lymph nodes showed higher values than those around the common hepatic artery. In one patient in whom the isotope was injected into both right and left segments, superior posterior pancreatoduodenal lymph nodes showed similar values to those around the common hepatic artery. Periportal lymph nodes tended to have values between those of periarterial and periductal ones. Lymph node metastases were confirmed in 4 patients in whom the relationships mentioned above was not always observed, and periportal lymph nodes showed the highest values among the three.

Metastasis to the lingual lymph node in carcinoma of the tongue

Lingual lymph nodes are occasionally found along the course of some lymph-vessels of the tongue. However, their existence has received little attention and metastasis of carcinoma of the tongue to them has not previously been reported. Three cases of carcinoma of the tongue with metastasis to the lingual lymph node are described and a discussion of the importance of such metastasis in the treatment of carcinoma of the tongue is presented.

Result of treatment of patients with stage D1 prostatic carcinoma

Between 1972 and 1982, 59 patients who had documented pelvic lymph node metastases, proved by pelvic lymphadenectomy, were available for analysis. Radical retropubic prostatectomy was the primary treatment in 33 patients with or without other therapies, while 23 patients received external beam radiation therapy as their primary treatment. Three patients received hormonal therapy alone. Forty-two of 59 patients are alive for a crude survival of 71 per cent. Sixteen patients have died of metastases. Patients with low-grade tumors, small tumor burden, and limited lymph node metastases had excellent short-term survival after radical prostatectomy.

Chylous ascites complicating genitourinary oncological surgery

Chylous ascites is an uncommon complication of retroperitoneal surgery. We report 2 cases of intraperitoneal chyle fistulas, one following retroperitoneal lymphadenectomy for testis cancer and the other after radical nephrectomy with regional lymphadenectomy for renal cell carcinoma. Both patients were treated successfully with medium chain triglyceride diets. We believe that most patients with chylous ascites will respond to simple dietary manipulation, and do not require complex and potentially morbid treatment regimens.

Melanoma metastatic to cervical and parotid nodes from an unknown primary site

The medical records of 96 patients with melanoma metastatic to cervical and parotid nodes from an unknown primary site have been reviewed. The use of various surgical procedures were correlated with local recurrence and survival rates. The size and number of involved nodes and the extent of nodal disease were compared with the type of treatment, and the age and sex of the patients, incidence of above-clavicle recurrence, and the 2, 5, and 10 year survival rates. The only significant correlations were the adverse affects of patient age over 50 years and multiple, large, pathologically positive nodes on local control and survival. Adjunctive chemotherapy and immunotherapy had no therapeutic value.

[New aspects of the reconstruction of large defects of the oral mucosa with microvascularly anastomosed small intestinal grafts]

Our experience in reconstruction of extensive defects in the oral mucosa with free jejunal grafts in 15 patients is reported. The jejunum provides a well vascularised mucosal lining, which is resistant to mechanical stress and being a thin flap contours well in the mouth. Methods of avoiding technical failure are described. The technique permits radical resection of oral tumours.

The surgical approach to primary malignant melanoma

Surgical excision is the only curative treatment for malignant melanoma. Excisional biopsy of the suspected lesion allows for adequate tissue diagnosis and microstaging and does not alter ten year survival periods. Wide local excision with a resection margin of 3 centimeters is recommended for all but the most superficial (less than 0.76 millimeters) lesions. Nodal and systemic metastases and long term survival are unaffected by the size of the resection margin. The role of prophylactic lymphadenectomy for Stage I melanoma remains controversial. The results of both prospective and retrospective studies have demonstrated an improved survival after prophylactic lymphadenectomy for patients with intermediate thickness (0.76 to 3.9 millimeters or Clark's level III to IV, or both) lesions. Patients with ulcerated lesions and lesions in the BANS distribution, even when superficial, might benefit from elective lymphadenectomy. At least quarterly follow-up examination is recommended for those patients who undergo wide excision alone. Therapeutic lymphadenectomy is indicated for the treatment of Stage II melanoma. The results of ongoing prospective randomized studies will clarify the role of fascia removal, resection margins and prophylactic lymphadenectomy in the treatment of malignant melanoma.