Flow cytometric evaluation of adenoid cystic carcinoma: correlation with histologic subtype and survival

Adenoid cystic carcinoma is an unusual but capricious tumor of salivary gland origin. Characteristically, these tumors follow a relentless clinical course, although some patients experience prolonged disease-free survival. Tumor size, site, and grade have been shown to correlate with tumor behavior. Recent investigation by others has suggested that DNA ploidy as determined by flow cytometry may provide an additional biologic marker of tumor behavior. This study was undertaken to investigate the relationship of DNA ploidy to tumor grade, biologic behavior, and patient outcome. A retrospective comparison of flow cytometric evaluations of paraffin-embedded formalin-fixed tumor specimens with patient outcome and histopathologic grade was undertaken. Follow-up of 4 to 7 years in 26 patients confirmed that the presence of a solid histologic component in the tumor correlated with the presence of recurrent or persistent disease (p = 0.04). Twenty-two of 28 tumors (78%) were found to be aneuploid on at least one section. Comparison of DNA ploidy with either patient outcome or the presence of a solid component did not achieve statistical significance, although a trend was suggested. This study confirms previous studies demonstrating the validity of histopathologic evaluation of tumor grade in the prediction of the biologic behavior of adenoid cystic carcinoma. However, our findings suggest that DNA ploidy has only limited value as an additional marker of tumor behavior in this patient population.

Metabolism in vivo and in vitro of the refrigerant substitute 1,1,1,2-tetrafluoro-2-chloroethane

Ternary mixtures of hydrochlorofluorocarbons and hydrofluorocarbons are being evaluated as refrigerant substitutes for dichlorodifluoromethane, which is to be banned from further production in 2000. A priori consideration of the similarity between 1,1,1,2-tetrafluoro-2-chloroethane (HCFC-124), a primary component of candidate refrigerant blends, and halothane suggests that metabolism of HCFC-124 might proceed via reactive intermediates. Our data show that rats exposed for 2 hr to approximately 10,000 ppm HCFC-124 excreted both inorganic fluoride (F-) and trifluoroacetic acid (TFA), identified by 9F-NMR, in the urine. Likewise, microsomes produced F- and TFA from HCFC-124 in an NADPH-dependent, CO-inhibited, aerobic reaction. Treatment of rats with pyridine caused about a 20-fold increase in aerobic microsomal metabolism (F- release) of HCFC-124, while the rate of defluorination was slightly decreased by phenobarbital administration. An antibody to cytochrome P450 IIE1 inhibited more than 90% of HCFC-124 metabolism in pyridine-induced preparations. Defluorination of HCFC-124 by microsomes also occurred under conditions of greatly reduced oxygen tension, demonstrating that this halocarbon can be reductively metabolized. Moreover, heat-inactivated, NADPH-reduced microsomes liberated F- and a fluorinated organic product, although not TFA, from HCFC-124. Formation of TFA and F- as products of oxidative HCFC-124 metabolism support the hypothesis that trifluoroacetyl fluoride is formed as an intermediate. Trifluoroacetyl halides are known to adduct tissue proteins. The reductive metabolism of HCFC-124, by analogy to halothane, may produce a radical (CHFCF3) capable of biological interactions.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional and phenotypic analysis of lymphocytes in head and neck cancer

We compared the phenotype and antitumor effector function of lymphocytes obtained from tumor tissues, lymph nodes, and the peripheral blood of patients with head and neck cancer. Freshly isolated tumor-infiltrating lymphocytes were deficient in CD4+ T cells in comparison with lymph node lymphocytes (LNL) and peripheral blood lymphocytes. A significantly higher CD4/CD8 ratio observed in LNL vs tumor-infiltrating lymphocytes and peripheral blood lymphocytes was attributable to both a significant enrichment in CD4+ T cells as well as a decrease in CD8+ T cells. The percentage of natural killer cells (CD3-CD56+) was uniformly low in both tumor-infiltrating lymphocytes and LNL. In patients with cervical metastases, LNL contained an increased proportion of CD16+ cells. Tumor-involved lymph nodes were not enriched in the CD8+C11b+ subset of T "suppressor" lymphocytes compared with uninvolved lymph nodes. Also, tumor-involved lymph nodes had significantly fewer CD4+ T cells than did uninvolved lymph nodes. In comparison with peripheral blood lymphocytes, freshly isolated tumor-infiltrating lymphocytes and LNL were depleted of cytotoxic effector cells, as indicated by low or absent cytotoxic activity against tumor cell targets. The ability to generate lymphokine-activated killer cells was significantly reduced in LNL in comparison with peripheral blood lymphocytes. In patients with head and neck cancer, depressed local and regional antitumor responses are associated with a deficiency of functional cytotoxic effector cells rather than an increase in suppressor T lymphocytes.

Enrichment in tumor-reactive CD8+ T-lymphocytes by positive selection from the blood and lymph nodes of patients with head and neck cancer

To study antitumor functions of T-lymphocyte subpopulations in the blood [peripheral blood lymphocytes (PBLs)] and tumor-draining lymph nodes (LNs) of patients (n = 26) with squamous cell carcinoma of the head and neck (SCCHN), antibody-coated devices were used to positively select CD8+ or CD4+ cells. The mean percentage of CD8+ cells captured on antibody-coated flasks from PBLs was 92% and that captured from lymph node lymphocytes (LNLs) was 98%. The initial enrichment in CD4+ T-cells was comparable. CD8+ T-lymphocytes captured from PBLs proliferated as well as unseparated lymphocytes in both patients with SCCHN and normal donors, while captured CD4+ PBLs of the patients showed significantly lower expansion than those of normal volunteers. Unseparated LNLs proliferated as well as PBLs, but captured CD4+ or CD8+ LNLs failed to proliferate in the presence of interleukin 2 (100 units/ml) and phytohemagglutinin (5 micrograms/ml). The addition to captured LNL cultures of irradiated autologous or allogeneic feeder cells significantly improved expansion of CD8+ LNLs but not CD4+ LNLs. During 15-day culture of captured CD8+ PBLs or CD8+ LNLs in the presence of feeder cells, a significant (P less than 0.05) enrichment in CD8+ T-cells was maintained [94 +/- 5% (mean +/- SEM) or 99.5 +/- 0.1%, respectively, on day 15]. Capture of CD8+ LNLs and their expansion resulted in the outgrowth of CD8+CD11b- effectors which had no or little cytotoxicity against Daudi, low cytotoxicity against K562, and very high levels of cytotoxicity against 4 different natural killer cell-resistant SCCHN targets, as measured in 4-h 51Cr release assays. Such significant enrichment in SCCHN-restricted cytotoxicity could be obtained with LNLs from tumor-uninvolved LNs but not from tumor-involved LNs. Captured and cultured CD4+ LNLs had no preferential anti-SCCHN cytotoxicity. The addition of irradiated autologous tumor cells to captured CD8+ PBLs did not result in improved proliferation or antitumor function of the effector cells. Positive selection on antibody-coated flasks of CD8+ T-lymphocytes from tumor-uninvolved LNs of patients with SCCHN led to the enrichment in SCCHN-restricted but the major histocompatibility complex-unrestricted effector cells in 15-day cultures. Thus, CD8+ lymphocytes separated from tumor-draining LNs in patients with head and neck cancer contained cytolytic T-cell precursors capable of developing into effectors with preferential activity against SCCHN targets.

Cefonicid versus clindamycin prophylaxis for head and neck surgery in a randomized, double-blind trial, with pharmacokinetic implications

Perioperative single-dose antibiotic prophylaxis of cefonicid was compared with clindamycin in a prospective, randomized, double-blind trial of patients undergoing oncologic head and neck surgery. Antibiotics were administered intravenously beginning 1 to 2 h preoperatively. Cefonicid, 1 g, was given as a single dose. Clindamycin, 600 mg, was administered every 8 h for a total of four doses. Blood and wound drainage samples were collected for 24 h following the dose of cefonicid and assayed for total and free cefonicid concentrations, using reverse-phase high-performance liquid chromatography. Although total concentrations of cefonicid in both serum and wound drainage exceeded the MIC for 90% of the isolates of common bacterial pathogens for 24 h, free concentrations in serum and wound drainage (11.0 and 14.9% of total concentrations) were subinhibitory within 6 h following administration. Free concentrations of cefonicid in the postoperative wound drainage were subinhibitory for the entire study period, both perioperatively and postoperatively. Postoperative wound infection occurred significantly (P less than 0.05) more frequently in patients receiving cefonicid (24%) as compared with those receiving clindamycin (8.2%). The relatively low free levels of cefonicid achieved in serum and wound drainage were attributed to the high degree of protein binding (89% in serum) and may be related to the poor clinical outcome.

[Antitumor activity of adherent LAK cells (A-LAK) in a model of squamous carcinoma of the head and neck]

Local adoptive immunotherapy employed on a selected population using IL2-activated immune cells (A-LAK cells) and IL2 resulted in complete growth inhibition of a human squamous cell carcinoma of the head and neck implanted three to seven days previously and growing in nude mice. Although the in vitro cytotoxicity of A-LAK cells against the carcinoma cells was not higher than that of the whole population (LAK cells), the in vivo antitumor efficacy was from 4 to 9 times higher for A-LAK cells, as confirmed by the total number of injected cells needed for a complete growth inhibition. In addition, local A-LAK cell administration was characterized by early peritumoral erythema and swelling, not observed during LAK-cell therapy, which disappeared at the end of therapy. Histology of the tumors, during and at the end of therapy, showed an initial granulocytic and plasma cellular infiltration followed by mononuclear infiltration of the stroma of the tumor. The tumors showed a terminal-like differentiation with an increase of the keratinic layer and decrease of basal epithelial cells. These effects were proportional to the number of A-LAK cells injected. With the highest number of A-LAK cells, a complete epithelial disorganization was observed and 4 weeks from therapy termination the tumors were reduced to keratinic areas surrounded by connective tissue. These observations suggest the possibility of a A-LAK cell-dependent process of accelerated tumor differentiation and keratinization leading to tumor regression in nude mice.

Induction of tumor regression in experimental model of human head and neck cancer by human A-LAK cells and IL-2

In a nude mouse model of human squamous-cell carcinoma of the head and neck (SCCHN), locoregional therapy with interleukin 2 and human lymphokine-activated killer (LAK) cells resulted in a significant inhibition of growth of 3-day established tumors. The same model was used for therapy of 7-day established tumors with highly enriched populations of human adherent (A)-LAK (CD3- CD56+) cells and IL-2. Peritumoral transfer of 10 x 10(6) A-LAK cells, whose in vitro cytotoxicity against a SCCHN cell line (PCI-I) was not significantly different from that of LAK cells, resulted in complete regression of all 3-day or 7-day human SCCHN in nude mice. An initial inflammatory-type reaction, which appeared within hours of the first peritumoral cell transfer, was accompanied by infiltration initially by granulocytes and plasma cells, and later by mononuclear cells into the tumor stroma. A-LAK cells labelled with a fluorescent dye prior to injection appeared in the tumor stroma within 24 hr and were localized around or in the basal epithelial tumor layer by 48 hr. Histologic sections revealed an increasing epithelial disorganization and progressively decreasing basal epithelial layer, which were proportional to the increasing number of A-LAK cells transferred. Within 4 weeks, the tumors were reduced to amorphous keratinic remnants surrounded by the connective tissue containing abundant mononuclear cells. Local administration of human A-LAK cells and IL-2 to SCCHN tumors growing in nude mice led to accelerated tumor differentiation, keratinization and regression.

Oxidation of 1,1,1,2-tetrafluoroethane in rat liver microsomes is catalyzed primarily by cytochrome P-450IIE1

1,1,1,2-Tetrafluoroethane (R-134a), a nonozone-depleting alternative air-conditioning refrigerant and propellant for pharmaceutical preparations, is oxidatively defluorinated by rat hepatic microsomes. In this report we show that induction of cytochrome P-450IIE1 in rats, by pyridine administration, resulted in an 8-fold increase in the rate of R-134a metabolism by hepatic microsomes (Vmax 47 vs. 6 nmol F-/mg microsomal protein/15 min). Furthermore, when data were normalized for P-450 content, a 4-fold increase in R-134a metabolism was noted for IIE1-enriched microsome preparations. In contrast, phenobarbital and Aroclor 1254 decreased the specific activity of hepatic microsomes for this function. The microsomal content of P-450IIE1, as evaluated by Western blot, was elevated significantly only in microsomes from pyridine-treated rats. p-Nitrophenol and aniline, which are metabolized at high rates by rat P-450IIE1, decreased the rate of R-134a defluorination by hepatic microsomes; Dixon plot analysis indicated competitive inhibition with a Ki of 36 microM p-nitrophenol or 115 microM aniline. Pyridine also potently induced defluorination of R-134a catalyzed by rabbit liver microsomes. Studies with individual P-450 isozymes purified from rabbit liver showed that the phenobarbital- and polycyclic hydrocarbon-induced isozymes (IIB1 and IA2) defluorinated R-134a at negligible rates (1.9 and 0.4 nmol F-/nmol P-450/60 min, respectively). In contrast, P-450IIE1 catalyzed defluorination of R-134a at a relatively high rate (16.2 nmol F-/nmol P-450/60 min); isozyme IA1, which also is induced by nitrogen-containing heterocycles such as pyridine, was somewhat active (5.3 nmol F-/nmol P-450/60 min).(ABSTRACT TRUNCATED AT 250 WORDS)

Antiproliferative effects of cytokines on squamous cell carcinoma

A panel of 12 squamous cell carcinoma of the head and neck (SCCHN) cell lines has been used to determine sensitivity of tumor cells to cytokines, tumor necrosis factor alpha (TNF-alpha), interferon gamma (IFN-gamma), and interferon alfa (IFN-alpha) in vitro. Antiproliferative activity of these cytokines on squamous cell carcinoma of the head and neck monolayers was measured in a colorimetric MTT [3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl tetrazolium bromide]-based assay. All 12 cell lines tested were sensitive to IFN-gamma, with the 50% inhibitory dose (ID50) ranging from 0.07 +/- 0.001 to 104 +/- 4.6 U/mL. The TNF-alpha showed antiproliferative activity on three cell lines at relatively high doses (ID50 from 55 +/- 4.1 to 847.10 +/- 10 U/mL), and IFN-alpha was growth inhibitory in only one line (ID50 = 1211 +/- 46.2 U/mL). The combination of IFN-gamma and TNF-alpha had a synergistic antiproliferative effect on eight cell lines and an additive effect on two cell lines. In two cell lines, the effect of the combination was equal to that of IFN-gamma alone. A combination of IFN-alpha and TNF-alpha resulted in cell growth inhibition in six of the seven lines tested, and this effect was synergistic. These in vitro studies indicate that combinations of IFN-gamma and TNF-alpha or IFN-alpha and TNF-alpha may be more growth inhibitory against squamous cell carcinoma of the head and neck and at lower doses than each of these cytokines used singly.

Transtracheal delivery of oxygen: efficacy and safety for long-term continuous therapy

Transtracheal (TT) oxygen delivery involves administration of oxygen percutaneously through a catheter inserted in the suprasternal trachea. Transtracheal oxygen delivery has been proposed as a means of overcoming the high visibility, inconvenience, and discomfort associated with nasal cannula use. This report describes our experience using TT delivery in 40 patients with chronic obstructive pulmonary disease (n = 32) and other types of lung disease (n = 8). Overall acceptance of TT catheter use was high and only 5 subjects elected to discontinue use. We believe the TT route is a relatively safe approach for oxygen administration and a promising method of improving patient compliance. It also offers the potential of more adequately oxygenating patients with refractory hypoxemia.

Role of prophylactic antibiotics in uncontaminated neck dissections

The use of perioperative prophylactic antibiotics in uncontaminated head and neck surgery remains controversial. We performed a retrospective analysis of 192 patients undergoing uncontaminated neck dissections from 1976 to 1989. Wound infection developed in 10% (10/99) of patients who did not receive antibiotics, while only three (3.3%) of 93 patients who received antibiotics developed infections. This difference was not statistically significant. We correlated the use of flaps, length of surgery, prior radiation treatment, and postoperative complications with rate of wound infection. The difference was not statistically significant for any of these variables. Our beta error was, however, greater than 0.2. Our data do not demonstrate efficacy of prophylactic antibiotics in uncontaminated neck dissections with statistical significance; however, a trend exists suggesting its possible value.

Stomal recurrence after laryngectomy: interrelated risk factor study

This study was designed to identify pathogenic factors in recurrent carcinoma at the tracheal stoma. The charts of 444 patients with laryngeal cancer who were treated surgically between 1976 and 1988 revealed stomal recurrence in 15 (3.4%). Eighty percent of the patients with stomal recurrence had tumors in the subglottis. In comparison to patients with different sites involved this was significant (p less than 0.001). Other variables examined and analyzed included primary stage, previous treatment, neck pathologic status, neck treatment, age, sex, postoperative adjunctive therapy, and timing of tracheotomy. Tumor involvement of the subglottis is the single most important variable in stomal recurrence of carcinoma. Previous conservation laryngeal surgery and preoperative/emergency tracheotomy are not related to stomal recurrence of carcinoma. Mean length of survival for patients with stomal recurrence of carcinoma in our series was 8.9 months. Two patients were successfully treated with extensive surgical resection. The dismal prognosis of stomal recurrence of carcinoma suggests that management of this condition should focus on prevention. Treatment of patients with tumors of the subglottis should include attention to the paratracheal region and superior mediastinum, in conjunction with laryngectomy immediately after initial diagnosis.

Hemilaryngectomy for salvage of radiation therapy failures

Radiation therapy has been the treatment most frequently used for early vocal cord cancer with surgery usually in the form of total laryngectomy held in reserve as a salvage option. We report our experience in selected patients who, having failed radiation therapy for their early vocal cord cancers, underwent frontolateral hemilaryngectomy as attempted salvage surgery. Between 1977 and 1986, fourteen patients at the University of Pittsburgh Eye and Ear Hospital underwent hemilaryngectomy for salvage of their stage I vocal cord squamous cell carcinoma after full-course radiation therapy had been unsuccessful. Over this same time period, 77 patients underwent total laryngectomy for salvage of radiation therapy failure. Three patients failed hemilaryngectomy, two of whom were ultimately salvaged with total laryngectomy. Thus a 79% salvage rate was achieved with hemilaryngectomy with an average followup of 90 months. The overall cure rate was 93% (13 of 14) with voice preservation in 86% (12 of 14). Decannulation, postoperative infection, and initiation of oral intake were not influenced by age. Such problems occurred more often in patients undergoing radiation therapy compared to those undergoing hemilaryngectomy without previous radiation therapy. These results indicate that hemilaryngectomy may be used for the salvage of radiation therapy failures of stage I vocal cord carcinoma with good success and without undue morbidity.

The absence of lymphoid suppressor cells in tumor-involved lymph nodes of patients with head and neck cancer

Patients with head and neck cancer often have decreased local or regional immunocompetence. Lymphocytes obtained from tumor-involved or -uninvolved lymph nodes (LNL) of these patients showed low or undetectable levels of antitumor cytotoxicity and low proliferative responses in vitro to interleukin 2 (IL2) or mitogens in comparison to peripheral blood lymphocytes (PBL). Lymphokine-activated killer (LAK) cell activity of LNL was lower (P less than 0.05) than that of autologous PBL. Fresh LNL were neither enriched in cells with the CD8+ CD11b+ "suppressor" phenotype nor did they suppress proliferative or cytotoxic responses of autologous PBL in mixing experiments. LNL did not inhibit LAK cell generation from autologous PBL in the presence of IL2. Also, no evidence for the inhibition of autotumor-restricted responses by IL2-activated LNL was obtained. Spontaneous or in vitro-induced production of IL1 beta. TNF alpha, and IFN-tau was low or undetectable in LNL from tumor-involved and -uninvolved lymph nodes in comparison to that in normal or autologous PBL. Mitogen-induced IL2 production was normal in LNL. The depressed ability to produce certain cytokines may be in part responsible for a state of unresponsiveness present in lymph nodes obtained from patients with head and neck cancer. No evidence for the presence of lymphoid suppressor cell in LNL of these patients was obtained.

Hearing loss--risk factor for cisplatin ototoxicity? Observations

Ototoxicity associated with cisplatin chemotherapy is well established, but opinion is split regarding the relative risk associated with preexisting hearing loss. The emerging consensus is that pretreatment loss does not increase the risk of cisplatin ototoxicity. Results from a preliminary study of a small sample from our patient population supports this consensus.

Peritonsillar abscess. Why aggressive management is appropriate

Peritonsillar abscess is the most common deep neck infection in adults. Infections develop from purulent material collecting in the fascial spaces lateral to the capsule of the palatine tonsil. Infections are usually polymicrobial, and a significant number of anaerobes are isolated. The cornerstone of therapy is drainage of the abscess. With cooperative patients, careful permucosal needle aspiration is an accepted method of primary therapy. Large or recurrent abscesses require otolaryngologic consultation for adequate incision and drainage. Tonsillectomy may be necessary to prevent re-formation of abscess in patients with a history of recurrent tonsillitis.

Medical complications in total laryngectomy: incidence and risk factors

The prevention and management of medical complications are important components in the surgical treatment of head and neck malignancies. We retrospectively evaluated the postoperative medical complications in 414 patients who underwent total laryngectomy between 1973 and 1987. The mortality rate was 1.2% (five deaths); while major, nonfatal medical complications occurred in 6.3% (24 of 384 patients)--seven strokes, three myocardial infarctions, two pulmonary emboli, and 12 respiratory failures requiring mechanical ventilation. Elderly patients did not experience more frequent or more severe medical complications, and the overall pattern of complications was different from that of other surgical specialties. Only specific cardiovascular and pulmonary risk factors were associated with these complications. We conclude that medical complications are a significant cause of morbidity in total laryngectomy; a focused preanesthetic risk factor analysis by a medical team familiar with head and neck cancer patients assures prompt identification and management of these complications.

Modulation of glucose metabolism in isolated rat hepatocytes by 1,1,1,2-tetrafluoroethane

The thermodynamic behavior and lack of ozone-depleting potential of 1,1,1,2-tetrafluoroethane (R-134a) suggest it as a likely replacement for dichlorodifluoromethane (R-12), now used as the refrigerant in many air-conditioning systems. To further the presently incomplete toxicological analysis of R-134a, the effects of R-134a on cell viability and functional competence of glucose metabolism were evaluated in suspension cultures of hepatocytes derived from fed or fasted rats. R-134a concentrations up to and including 75% (750,000 ppm) in the gas phase of sealed culture flasks did not produce evidence of cytolethality (LDH leakage) following 2 hr of exposure; in contrast, halothane (1,1,1-trifluoro-2-bromo-2-chloroethane) caused cell death at a gas phase concentration of only 1250 ppm. In hepatocytes isolated from fed rats. R-134a at concentrations of 12.5 to 75% increased glycolysis (production of lactate + pyruvate) in a concentration-dependent manner; no effect was observed at 5%. At 25%, R-12 and 1,1,2,2-tetrafluoro-1,2-dichloroethane (R-114) were of equal potency to R-134a in stimulating glycolysis: 1,1,1,2,2-pentafluoro-2-chloroethane (R-115) depressed glycolysis slightly. Halothane, at concentrations as low as 300 ppm, markedly increased rates of glycolysis. Glucose production by hepatocytes of fed rats was decreased by R-134, R-12, and R-114 only at concentrations of 25% or more. On the other hand, halothane (greater than or equal to 300 ppm) potently decreased glucose production by hepatocytes. In cells isolated from livers of fasted rats, R-134a exposure inhibited gluconeogenesis in a concentration-dependent manner although this effect was not significant until R-134a concentrations reached 12.5%. Comparative potency studies showed that R-134a, R-12, or R-114 (25% gas phase) inhibited gluconeogenesis about equally while as little as 300 ppm halothane was effective and R-115 (25%) was without effect. Considering that the threshold for alteration of the rate of glucose metabolism in this in vitro paradigm is about 12.5% R-134a, we conclude that toxicologically significant alteration of glucose-linked bioenergetics is unlikely at the levels of R-134a exposure anticipated in workplace or environment.

Extramedullary plasmacytoma of the thyroid associated with a serum monoclonal gammopathy

Extramedullary plasmacytoma is a malignant plasma cell dyscrasia that is most commonly found in the head and neck. Progression to disseminated disease in the form of multiple myeloma occurs in 17% to 32% of cases. Herein, we describe a patient with extramedullary plasmacytoma of the thyroid gland in whom a serum monoclonal gammopathy resolved with surgery and irradiation of the primary. Although rare, this diagnosis should be considered in patients presenting with obstructive thyromegaly and autoimmune thyroiditis.

Extramedullary plasmacytoma of the parotid

Primary extramedullary plasmacytoma (PEMP) is a tumor of atypical neoplastic cells that arise outside the bone marrow in patients without clinical evidence of existing multiple myeloma. These rare tumors, which can occur in virtually any part of the body, have shown a clear predilection for the head and neck. Yet despite the fact that nearly 80% of these tumors can be found in the upper respiratory tract or oral cavity, their involvement in the parotid is singularly rare. The clinical behavior of this tumor is not yet well-defined, and local recurrence, distant metastasis, and transformation to multiple myeloma have all been reported. Since the first case of parotid PEMP was reported in 1965, 8 additional cases have been noted in the literature. This is the 9th case of PEMP of the parotid to be described.

Adjuvant methotrexate-5-fluorouracil for extracapsular squamous cell carcinoma in cervical metastasis

A trial of surgery, irradiation, and adjuvant chemotherapy was offered to patients with extracapsular spread of squamous cell carcinoma in cervical metastases. Following surgery and irradiation, methotrexate, 5-fluorouracil, and leucovorin were administered 18 times over 6 months. Fifty patients undertook chemotherapy, while 47 patients declined further therapy. Comparison of the two groups according to stage, site, and Karnofsky performance status demonstrated no significant differences. The number of nodes encountered and the number and percentage of nodes with extracapsular spread were similar in the two groups. The minimum 5-year adjusted survival for patients undergoing adjuvant chemotherapy is 54% (20 of 37 patients), while survival of patients who failed to undertake adjuvant chemotherapy was 17% (5 of 30 patients). These data suggest the efficacy of methotrexate-5-fluorouracil adjuvant chemotherapy and support the need for a prospective randomized clinical trial.

Jejunal interposition for repair of stricture or fistula after laryngectomy

Complications following total laryngectomy may include pharyngocutaneous fistula or pharyngeal stricture. Traditional techniques of repair of fistula and stricture with local or regional flaps lead to a high rate of failure. In this study, we report 18 patients treated by secondary jejunal interposition (JI) to rehabilitate swallowing following recalcitrant postlaryngectomy stricture or fistula. All patients had undergone total laryngectomy with or without partial pharyngectomy for treatment of squamous cell carcinoma of the larynx (8) or hypopharynx (10). Four were stage II; 5, stage III; and 9, stage IV. Thirteen patients (72%) regained swallowing function. Complications of secondary JI included perioperative death (2), flap loss (1), and persistent fistulas (3). Jejunal interposition may be the best modality in the rehabilitation of swallowing in patients with persistent fistula or stricture that fails to respond to traditional management.