Dawn of Staging for Head and Neck Soft Tissue Sarcoma: Validation of the Novel 8th Edition AJCC T Classification and Proposed Stage Groupings

PURPOSE/OBJECTIVE(S)

After decades of stagnation, the 8th edition TNM (TNM8) introduced a new T classification for head and neck (HN) soft tissue sarcomas (STS). New size cutoffs of 2 and 4 cm define T1-3, and a novel T4 category is defined by local invasion of adjoining structures. These size cutoffs had been chosen arbitrarily to advance data collection in this unique disease site since literature showed approximately 70% of HN STS did not reach the previous size threshold (5 cm) for the existing T1 category. The definition of the TNM8 T categories also align with mucosal HN cancers. No stage grouping for HN STS was defined since this new classification required more data collection to derive stage groups. This study aims to validate the TNM8 T classification and to propose stage groupings.

MATERIALS/METHODS

Clinical data of all adult (>16 years) HN STS patients treated from 1988 - 2019 with curative intent in our tertiary cancer center were retrieved from a prospective database, and supplemented with chart review. As per TNM8, cutaneous angiosarcoma, embryonal and alveolar rhabdomyosarcoma, Kaposi sarcoma, and dermatofibrosarcoma protuberans were excluded due to their different behavior. Multivariate analysis (MVA) identified prognostic factors for overall survival (OS). Adjusted hazard ratios (AHR) and recursive partitioning analysis (RPA) were used to derive stage groupings. Stage grouping performance for OS was assessed and also compared against the existing TNM8 groups for non-HN STS.

RESULTS

A total of 221 patients (N1: 2; M1: 2) were included. Of the 219 M0 patients, 63% were males; median tumor size was 3.0 cm (range: 0.3-14.0); the proportion of TNM8 T1-T4 were 35%, 34%, 26%, and 5%, respectively. Median follow up was 5.9 years. Five-year OS was 79%. MVA confirmed the prognostic value of T category (T4 HR 7.73, 95% CI 3.62-16.5) and grade (G2/3 vs G1 HR 3.7, 95% CI 1.82-7.53), in addition to age (HR 1.03, 95% CI 1.01-1.04) (all p<0.001) for OS. AHR model derived T1-3_Grade 1 as stage 1; T1-3_Grade 2/3 as stage II; and T4_any Grade or any T_N1 as stage III (Table 1); the corresponding 5-year OS was 93%, 73%, and 38%, respectively. Both patients with M1 died within 1.5 years after diagnosis and M1 disease was designated stage IV. The AHR-grouping outperformed the RPA and non-HN TNM8 stage grouping for hazard consistency, hazard discrimination, percent variance explained, hazard difference, and sample size balance.

CONCLUSION

The novel T4 category introduced in TNM8 is associated with a >7 fold increased risk of death. Grade continues to be a critical prognostic factor in HN STS. The TNM8 HN STS T classifications have been validated, and the proposed new stage groupings with TNM8 incorporating grade have excellent performance for OS.

Outcomes of Head and Neck Cutaneous Angiosarcoma Treated in the IMRT Era

PURPOSE/OBJECTIVE(S)

Clinical behavior, natural history, and varied presentations of cutaneous angiosarcomas of the head and neck region (HN), in conjunction with its rarity, have rendered standardization of treatment elusive. We aimed to assess outcomes and patterns of failure for patients treated with surgery and radiation (Sx+RT), and radiation alone (RT).

MATERIALS/METHODS

A retrospective review of all HN angiosarcoma patients amenable for upfront Sx or RT in our institution between 2004-2018 was completed. Generally, treatment included Sx when feasible, and RT for large or extensive/ill-defined tumors. Demographic, tumor characteristics, local (LC), regional (RC), distant control (DC), and overall survival (OS), as well as patterns (in-field, marginal, out-of-field) of local failure at 5-year were estimated. Univariate analysis (UVA) was conducted to assess association with outcomes.

RESULTS

A total of 33 patients were eligible (14 Sx+RT and 19 RT). Tumor locations were: scalp (16, 48%). face (n = 12, 36%), and overlapping (5, 15%). Lesion types were: nodular (n = 23, 70%), flat (n = 4, 12%) and mixed (n = 6, 18%). Tumor size was larger in the RT group (median: 10.00 vs 2.85 cm, p<0.01). RT and Sx+RT patients had otherwise similar baseline characteristics: median age 74.3; male 70%; and ECOG performance status ≤1 85%. RT dose fractionations ranged from 50-70 Gy in 25-35 fractions in the RT group and 50-66 Gy in 25-33 fractions in the Sx+RT group. Four (12%) patients received neoadjuvant chemotherapy. Median follow up was 5.5 years. Five-year LC, RC, DC, and OS for RT vs Sx+RT groups were 68% vs 85% (p = 0.28); 95% vs 86% (p = 0.89); 79% vs 86% (p = 0.39); and 45% vs 55% (p = 0.71), respectively. The in-field/marginal/out-of-field local failure rate at 5 years were 16% vs 7% (p = 0.46), 26% vs 15% (p = 0.41), and 13% vs 0% (p = 0.24) for the RT vs Sx+RT groups, respectively. UVA showed that scalp location and ulceration/bleeding were strong adverse features for OS. Bone invasion was significantly associated with lower DC (Table). Lesion type (nodular/flat/mixed), tumor size, and treatment type (Sx+RT vs RT), were not significantly associated with LC or pattern of local failure.

CONCLUSION

Scalp tumors, as compared to face, portended poorer prognosis, and ulceration/bleeding and bone invasion were associated with increased distant metastases. Sx+RT was the preferred treatment modality when possible and typically used for smaller and better defined tumors. RT was reserved for larger and extensive/ill-defined disease; despite this, in the IMRT era, RT achieves reasonable rates of control, markedly superior to historical series.

Non-operative management for oral cavity carcinoma: Definitive radiation therapy as a potential alternative treatment approach

PURPOSE

To determine the outcomes of oral cavity squamous cell cancer (OSCC) patients treated with non-surgical approach i.e. definitive intensity-modulated radiation therapy (IMRT).

METHODS

All OSCC patients treated radically with IMRT (without primary surgery) between 2005-2014 were reviewed in a prospectively collected database. OSCC patients treated with definitive RT received concurrent chemotherapy except for early stage patients or those who declined or were unfit for chemotherapy. The 5-year local, and regional, distant control rates, disease-free, overall, and cancer-specific survival, and late toxicity were analyzed.

RESULTS

Among 1316 OSCC patients treated with curative-intent; 108 patients (8%) received non-operative management due to: medical inoperability (n = 14, 13%), surgical unresectability (n = 8, 7%), patient declined surgery (n = 15, 14%), attempted preservation of oral structure/function in view of required extensive surgery (n = 53, 49%) or extensive oropharyngeal involvement (n = 18, 17%). Sixty-eight (63%) were cT3-4, 38 (35%) were cN2-3, and 38 (35%) received concurrent chemotherapy. With a median follow-up of 52 months, the 5-year local, regional, distant control rate, disease-free, overall, and cancer-specific survival were 78%, 92%, 90%, 42%, 50%, and 76% respectively. Patients with cN2-3 had higher rate of 5-year distant metastasis (24% vs 3%, p = 0.001), with detrimental impact on DFS (p = 0.03) and OS (p < 0.02) on multivariable analysis. Grade ≥ 3 late toxicity was reported in 9% of patients (most common: grade 3 osteoradionecrosis in 6%).

CONCLUSIONS

Non-operative management of OSCC resulted in a meaningful rate of locoregional control, and could be an alternative curative approach when primary surgery would be declined, unsuitable or unacceptably delayed.

Correlation between clinical and MRI assessment of depth of invasion in oral tongue squamous cell carcinoma

Background

Neck metastasis is the most important prognostic factor in oral cavity squamous cell carcinomas (SCC). Apart from the T- stage, depth of invasion has been used as a highly predictable factor for microscopic neck metastasis, despite the controversy on the exact depth cut off point. Depth of invasion can be determined clinically and radio logically. However, there is no standard tool to determine depth of invasion preoperatively. Although MRI is used widely to stage the head and neck disease, its utility in depth evaluation has not formally been assessed.

Objective

To compare preoperative clinical and radiological depth evaluation in oral tongue SCC using the standard pathological depth.

To compare clinical and radiological accuracy between superficial (<5 mm) vs. deep invaded tumor (≥5 mm)

Methods

This prospective study used consecutive biopsy-proven oral tongue invasive SCC that presented to the University health network (UHN), Toronto. Clinical examination, radiological scan and appropriate staging were determined preoperatively. Standard pathology reports postoperatively were reviewed to determine the depth of invasion from the tumor specimen.

Results

72 tumour samples were available for analysis and 53 patients were included. For all tumors, both clinical depth (r = 0.779; p < 0.001) and radiographic depth (r =0.907; p <0.001) correlated well with pathological depth, with radiographic depth correlating slightly better. Clinical depth also correlated well with radiographic depth (r = 0.731; p < 0.001). By contrast, for superficial tumors (less than 5 mm on pathological measurement) neither clinical (r = 0.333, p = 0.34) nor radiographic examination (r = − 0.211; p = 0.56) correlated with pathological depth of invasion.

Conclusion

This is the first study evaluating the clinical assessment of tumor thickness in comparison to radiographic interpretation in oral cavity cancer. There are strong correlations between pathological, radiological, and clinical measurements in deep tumors (≥5 mm). In superficial tumors (<5 mm), clinical and radiological examination had low correlation with pathological thickness.

Role of endolaryngeal surgery (with or without laser) compared with radiotherapy in the management of early (T1) glottic cancer: a clinical practice guideline

AIMS

To provide evidence-based practice guideline recommendations concerning the role of endolaryngeal surgery (with or without laser) compared with radiation therapy for patients with early (T1) glottic cancer, assessing survival, locoregional control, laryngeal preservation rates, and voice outcomes.

METHODS

The medline, embase, and Cochrane Library databases were searched to identify relevant studies from 1996 to 2011. Recommendations were formulated based on that evidence and on the expert opinion of Cancer Care Ontario's Head and Neck Cancer disease site group. The systematic review and practice guideline were externally reviewed by practitioners in Ontario, Canada.

RESULTS

The available evidence was of a level insufficient to demonstrate a clear difference between treatment options when considering the likelihood of local control or overall survival. Although the evidence was mainly retrospective, there was a suggestion that, compared with surgery, radiotherapy might be associated with less measureable perturbation of voice without a significant difference in patient perception. The likelihood of laryngeal preservation may be higher when surgery can be offered as initial treatment.

CONCLUSIONS

For patients with early (T1) glottic cancer, the evidence is insufficient to demonstrate a difference between endolaryngeal surgery (with or without laser) and external-beam radiation therapy. The choice between treatment modalities has been based on patient and clinician preferences and general medical condition.

Outcome of oral tongue squamous cell carcinoma in patients with and without known risk factors

BACKGROUND

Tobacco smoking and high alcohol consumption are considered major risk factors of oral tongue squamous cell carcinoma. This study compared disease outcome between patients with and without known risk factors.

METHODS

Patients with oral tongue squamous cell carcinoma treated at two major medical centers from 1994 to 2008 were identified by cancer registry search. The medical files were reviewed for background-and-disease-related data, risk factors, and outcome.

RESULTS

The study sample consisted of 291 patients: 175 had a history of heavy tobacco smoking and alcohol abuse and 116 did not. Comparison of the patients without risk factors between the two centers yielded no differences in background features. Men accounted for 74% of the total patients with risk factors and comprised 77% of the risk-factor group. The risk-factor group was characterized by a significantly higher mean tumor grade (p=0.0001) and greater tumor depth of invasion (p=0.022) than the non-risk-factor group. The 5-year local and regional control rates were 85.3% and 74%, respectively, with no significant difference between the groups. The 5-year overall survival rate was 68% in the risk-factor group and 64% in the non-risk-factor group (p=NS). Separate analysis of patients aged <40 years at diagnosis revealed a worse overall (p=0.015) and disease-free survival (p=0.038) in those without risk factors.

CONCLUSIONS

The outcome of oral tongue carcinoma is similar in patients with and without risk factors. The worse prognosis in younger patients (<40 years) without risk factors suggests that the pathogenesis in these cases involves factors other than smoking and alcohol.

Prospective evaluation of eyelid function with gold weight implant and lower eyelid shortening for facial paralysis

OBJECTIVES

To assess which signs and symptoms were relieved by gold weight implantation and which signs and symptoms persisted.

DESIGN

Prospective observational cohort.

SETTING

Tertiary care neurotology and oncology center.

PATIENTS

Sixteen (4 males and 12 females) consecutive patients whose average age was 56 years (age range, 31-76 years). Inclusion criteria were gold weight implant, lagophthalmos of 2 mm or more, and a House-Brackmann score of 3 or less at the completion of follow-up. Mean follow-up was 13 months.

INTERVENTIONS

Each patient received a gold weight implant. Six of these patients underwent a lower eyelid procedure.

MAIN OUTCOME MEASURES

Surgical complications, static and dynamic lagophthalmos, static and dynamic corneal coverage, visual acuity, keratitis, topical treatment, and patient satisfaction.

RESULTS

There were no extrusions. The preoperative mean lagophthalmos was 7.5 mm and the postoperative mean was 0.5 mm, (P<.001). Corneal coverage with eye closure before implantation was 73% and after implantation was 100%, (P<.001). Corneal coverage with normal (reflex) blink was less than 50% in 9 of 14 patients. When wearing correction, no patients had 20/20 visual acuity. The mean patient satisfaction score before the procedure was 3.5 and after was 7.1, (P<.001). Patient satisfaction was most closely related to visual acuity. The relationship was linear and statistically significant (P<.04).

CONCLUSIONS

Gold weight implantation provides significant reduction in lagophthalmos and significant improvement in corneal coverage. But owing to delayed closure time and disrupted tear film, irritation may persist. As a result, some patients require ongoing topical treatment of the eye, which can compromise visual acuity.

Blood flow rate effects in continuous venovenous hemodiafiltration on blood urea nitrogen and creatinine reduction

The effect of blood flow rates (BFRs) in continuous venovenous hemodiafiltration (CVVHDF) on the clearances of blood urea nitrogen (BUN) and creatinine was studied using a retrospective chart review. Fifteen patients, 9 males and 6 females aged 50-85 years, were included in the study. Each patient had a primary cardiovascular diagnosis with acute renal failure (ARF) and was treated with CVVHDF on the Gambro PRISMA continuous renal replacement therapy (CRRT) machine using the COBE AN69 filter. Independent sample t-test, simple linear regression, ANOVA, and multiple comparisons were used. Simple linear regression revealed that BUN, creatinine, and difference in creatinine (DIFFCRTN) were best predicted by the number of hours of treatment. For every hour of treatment the BUN decreased by .08 mg/dl, the creatinine decreased by .01 mg/dl, and the DIFFCRTN increased by .01 mg/dl. The study concluded that patients on CVVHDF for greater than 72 hours had the greatest changes in BUN and creatinine when a BFR between 135-145 cc/min was used.

Anodal block: can this occur during routine nerve conduction studies?

The median nerves of five normal subjects were electrically excited at the wrist with fine-tipped stimulating electrodes in a bipolar fashion. Compound sensory nerve action potentials (CSNAPs) were recorded from the index finger and compound muscle action potentials (CMAPs) from the thenar muscles. Both the cathode and the anode were positioned over the length of the nerve. Recordings were performed with different cathode-to-anode distances of 5, 10, 20, and in some cases, 30 mm. Just supramaximal CSNAPs and CMAPs were obtained initially with the cathode situated distal to the anode and then with the stimulus polarity reversed. There were no significant differences in the amplitude, duration, and morphology of the CSNAPs or CMAPs that were recorded by using different stimulus polarities. There was a consistent increase in the onset latency of the responses when the stimulus polarity was reversed (cathode located proximal to anode). This increase in latency was proportionate to the increase in distance from the cathode to the recording electrode. The effect of anodal block could not be observed from the above experiment.

Comparing treatment outcomes of radiotherapy and surgery in locally advanced carcinoma of the larynx: a comparison limited to patients eligible for surgery

PURPOSE

The use of radical radiotherapy and surgery for salvage (RRSS) in locally advanced squamous cell carcinoma (SCC) of the larynx is controversial. In the absence of randomized studies, it is unclear if RRSS can match the rates of locoregional control and survival reported for primary surgery in this setting. The aim of this study was to compare treatment outcomes of radiotherapy and surgery in comparable patients with CS III-IV SCC of the larynx.

METHODS AND MATERIALS

Eighty-two patients with untreated T2N+M0 or T3T4NM0 SCC of the larynx were treated with a policy RRSS at the Toronto-Sunnybrook Regional Cancer Centre between June 1980 and December 1990. The medical records at presentation were reviewed independently by a panel of three surgical oncologists blinded as to treatment outcome to determine patient suitability for laryngectomy and neck dissection using eligibility criteria adopted by recent clinical trials. Treatment outcomes for surgery-eligible patients were compared to results of comparably staged patients in the surgical literature since 1980.

RESULTS

Sixty-three patients (77%) were eligible for study. With a median follow-up of 3 years, radiotherapy controlled the primary in 8/20 evaluable glottic primaries and 21/41 evaluable supraglottic primaries. Forty-five percent of patients surviving 5 years retained a functional larynx. Sixteen of 29 relapsing patients were salvaged with surgery. Disease above the clavicles was controlled in 65% of T3T4N0N+ glottic primaries (compared to a published range of 53% to 79%) and 82% of T3N0 glottic primaries (compared to a published range of 69% to 84%). The 5-year overall survival of patients with T3T4 glottic cancer was 54% compared to a published range of 50% to 63%. The cause-specific survival (CSS) of patients with T3N0 glottic primaries (86% at 1 year and 73% at 2 years) was identical to the only published report of CSS in the surgical literature.

CONCLUSION

A policy of RRSS offers a good chance of laryngeal conservation without compromising ultimate locoregional control or survival when compared to primary laryngectomy and neck dissection in patients with locally advanced carcinoma of the larynx meeting the surgical eligibility of clinical trials.

Solitary fibrous tumor of the oral cavity: an uncommon location for a ubiquitous neoplasm

Solitary fibrous tumor is an uncommon soft tissue tumor initially reported in the pleura but recently described in other sites of the body. To date, only 5 examples of oral solitary fibrous tumor have been reported. Here, we describe 2 additional cases of this tumor in the oral cavity. The tumors were composed of small to medium-sized spindle cells with bland cytologic features; these cells were haphazardly arranged in highly cellular sheets or ill-formed fascicles as well as in hypocellular areas with hyalinized blood vessels. Both tumors contained blood vessels with a hemangiopericytomalike appearance and expressed vimentin, CD34, and CD99. One case was also strongly positive for bcl-2. The diagnosis of solitary fibrous tumor may be difficult inasmuch as it shares a number of histologic features with other soft tissue tumors. Awareness of its occurrence in the oral cavity is important so that confusion with other spindle cell neoplasms can be avoided.

Predicting postlaryngectomy voice outcome in an era of primary tracheoesophageal fistulization: a retrospective evaluation

OBJECTIVES

Not all laryngectomees appear to have the same potential to develop functional spoken communication. Our goal was to evaluate voice outcome in different functional subgroups of laryngectomees and to identify physical and demographic factors associated with success and failure to achieve functional spoken communication.

DESIGN

Retrospective chart review.

SETTING

Surgery was performed at a tertiary care hospital. Multidisciplinary follow-up was conducted at weekly head and neck clinics held at the associated regional cancer centre. Voice rehabilitation procedures took place in both settings.

PATIENTS

Sixty-four consecutive patients who had undergone total laryngectomy during the era of primary tracheoesophageal fistulization (TEF) at this facility. Patients were subdivided into four groups according to whether they had undergone primary TEF, or whether this had been contraindicated by locoregional factors of TEF candidacy/performance status, or both.

INTERVENTIONS

Primary TEF was performed whenever technically feasible and traditional TEF candidacy criteria were met. Voice rehabilitation procedures were initiated prior to discharge.

OUTCOME MEASURES

A judgement of voice outcome was assigned based on documentation on at least one of three patient treatment records by a physician or speech-language pathologist that a patient had demonstrated functional spoken communication within the clinical setting.

RESULTS

Forty-five of 64 patients (70%) achieved functional spoken communication. Six laryngectomized subgroups were ultimately identified and characterized. Voice outcome varied considerably between these subgroups. Prelaryngectomy communication status and age emerged as predictors of voice outcome.

CONCLUSIONS

Voice outcome is related to several factors present prior to or at laryngectomy. Different combinations of such factors create various postlaryngectomy recovery streams for which voice outcome may be predicted more specifically.

Copper sulfate toxicosis in commercial laying hens

A flock of 51-week-old leghorn hens experienced a 16% drop in egg production in a single week. The layer ration contained 1477 ppm copper from the addition of copper sulfate. Severe oral ulcers were present in the pharynx. Oral ulcers, reduced feed intake, and a drop in egg production occurred when a ration containing 1437 ppm copper was evaluated experimentally.

Free forearm flap in oral reconstruction. Functional outcome

OBJECTIVE

To examine functional outcome associated with free radical forearm flap reconstruction of oral cavity and oropharyngeal defects.

DESIGN AND SETTING

Case series obtained from a head and neck clinic conducted at a regional cancer center. Patients underwent surgery at the associated tertiary care center.

PATIENTS

Thirty consecutive patients treated for oral and oropharyngeal malignant neoplasms staged from T1 to T4 were studied. Subjects were assigned to five groups based on the site and extent of their surgical resections, as specified on a resection template.

INTERVENTION

All patients had undergone free radial forearm flap reconstruction of their surgical defects.

OUTCOME MEASURES

Ten factors reflecting functional properties and processes of the upper aerodigestive tract were evaluated clinically or with videofluoroscopy or both.

RESULTS

Near-normal and fair oral and oropharyngeal function wholly characterized the sample. Patients who underwent reconstruction of unilateral tongue, floor of mouth-ventral tongue, and retromolar trigone-buccal defects functioned well on most measures; the function of patients with anterior tongue-jaw and tongue base-tonsil defects varied.

CONCLUSIONS

Functional outcome with free radial forearm flap reconstruction was favorable for three of five subgroups of oral and oropharyngeal cancer patients. Qualitatively different functional profiles emerged for subgroups based on resection site. Methodologic issues for research on surgical reconstruction and functional outcome include the need for a meaningful, reliable system of classifying oral and oropharyngeal resections, and the development of standardized procedures for evaluating functional outcome.

Primary mandibular reconstruction with the titanium hollow screw reconstruction plate: evaluation of 51 cases

Fifty-one patients undergoing surgical reconstruction of mandibular defects with the titanium hollow screw reconstruction plate over a 4-year period were analyzed. Plate failure was defined as flap necrosis, plate extrusion, or plate fracture necessitating a further surgical procedure and occurred in 12 patients (24 percent). The incidence was highest for patients who had more than three mandibular regions resected. It was not affected by the primary site of the tumor or whether the patient had received radiation therapy. Although the failure rate was the same whether the patient attained full oral function or was fed by gastrostomy, plate fracture was limited to the former group. The overall cause-specific survival rate for this group of patients was 68 and 56 percent at 1 and 2 years, respectively. In addition, 81 percent of patients attained a full oral diet.

Effect of calcium/phosphorus imbalance in the ration on flock performance in two broiler flocks in north Georgia

Five- and six-day-old broilers from two flocks experiencing excessive mortality were submitted for necropsy. Rickets was diagnosed based on clinical signs of lameness and on gross and histopathologic lesions. Because of a confirmed feed mill error, these flocks had been fed a starter ration with a high calcium/phosphorus ratio (either 7.7:1 or 3.5:1). After debate concerning the profitability of salvaging the remaining birds in the affected flocks, the starter feed was replaced at 7 days of age. At processing, the affected flocks had weighted averages of body weight and feed conversion of 1.71 kg and 1.88, respectively; these averages compared favorably with the company averages of 1.72 kg and 1.87. The majority of the mortality in the affected flocks occurred during the first week. This case report demonstrates that it may be advantageous for a producer to salvage chicks that have been affected severely with rickets at less than 1 week of age.

Microvenous grafts to arterial defects. The use of mechanical or suture anastomoses

A mechanical microvascular anastomotic device, the Unilink system, was compared with sutures in terms of patency, anastomotic time, and histologic changes when a microvenous graft is placed in an arterial defect. Twenty rabbits underwent grafting of a 1.0-cm defect in both carotid arteries with a 1.5-cm reversed femoral vein graft. Anastomoses were performed with the Unilink system on one side and sutures on the other. Animals were killed at 2 weeks (10 animals) and 16 weeks (10 animals) with the vein grafts being assessed with clinical patency tests and then fixated for histologic evaluation. All 20 grafts (100%) interposed with the Unilink system were fully patent while 17 (85%) of the 20 grafts interposed with sutures were fully patent. The grafting procedure with the Unilink anastomoses averaged 12.5 minutes while the sutured anastomoses averaged 41.9 minutes. No differences in the histologic appearance of the vein grafts were noted between the two types of anastomoses. All grafts showed endothelialization at 2 weeks with intimal hyperplasia or "arterialization" being a constant finding.

Arterial end-to-side anastomosis with the UNILINK system

A new technique for mechanical end-to-side anastomoses using the UNILINK anastomotic system is presented. The technique, based on the concept of vessel wall eversion over paired ring pins, is described as is a new device for vessel expansion. To evaluate the technique of end-to-side anastomosis, we detached the left renal artery in 18 rabbits and then reanastomosed them end-to-side to the aorta using the UNILINK anastomotic system. Renal blood flow was evaluated before and after anastomoses with a laser Doppler flowmeter. Animals were separated into three groups of 6 and were killed at 24 hours, 2 weeks, and 16 weeks, respectively. To evaluate the acute effects of vessel expansion, 7 additional rabbits underwent expansion of the aorta without subsequent anastomosis. All vessels were evaluated with light and scanning electron microscopy. A patency rate of 100% was achieved in the 18 animals; histological changes at the anastomotic site were comparable to those described previously for this mechanical anastomotic system. The animal model demonstrates that it is both technically possible and efficacious to perform end-to-side anastomoses of arteries with the UNILINK anastomotic system.

Strength of microvascular anastomoses: comparison between the unilink anastomotic system and sutures

The Unilink system, a mechanical anastomotic device, was compared with standard suture techniques in terms of anastomotic strength under conditions of uniaxial loading. Twenty-five rabbits underwent Unilink and suture anastomosis of both carotid arteries and facial veins. Animals were sacrificed at 1 hour (five animals), 2 weeks (10 animals), and 16 weeks (10 animals), and all vessels were tested by constant loading in a material testing machine. The maximum load required to disrupt the anastomosis as well as the site of vessel failure were recorded. All 100 anastomoses were fully patent as evaluated by clinical testing. At 1 hour and 2 weeks, the Unilink arterial anastomoses were consistently and significantly stronger than the sutured anastomoses. At 16 weeks the sutured arterial anastomoses were significantly stronger than Unilink. The Unilink anastomoses, however, remained approximately 50% stronger than unoperated normal vessels. No statistical differences were observed in the strength of venous anastomoses at any of the intervals tested. There were no statistical differences in the sites of failure of the vessels under loading (i.e., at the anastomosis or proximal or distal to it) between the two techniques.

T3N0M0 glottic carcinoma--a failure analysis

There is at present considerable controversy regarding the appropriate management of a patient who presents with a T3N0M0 glottic carcinoma. This paper presents the results for 141 patients presenting clinically with T3N0M0 glottic carcinoma between 1964 and 1981 and treated with primary radiotherapy reserving surgery for residual or recurrent disease. The actuarial survival for the entire group of patients was 50.5% at 5 yr; 28% of the patients died of glottic cancer. The local relapse-free rate achieved with radiotherapy was higher in female patients (68%) than male patients (41%) (P = 0.04); the local relapse-free rate was higher in males 60 yr of age or older (46%) than in males 59 yr of age or younger (31%) (P = 0.02). Involvement of all three laryngeal regions and initial tracheotomy were associated with a high primary failure rate. Fifty-nine per cent of patients alive at 5 yr retained and intact and functioning larynx. The time up until diagnosis of recurrence and the number of endoscopies required to establish recurrent or residual disease were all assessed with respect to their effects on survival and were shown to have no significant impact. Methods of improving the results of treatment for those patients with a high primary failure rate following radiotherapy are discussed.

T3N0M0 glottic carcinoma--a pathologic analysis of 41 patients treated surgically following radiotherapy

Forty-one patients undergoing surgery for recurrent or residual tumour following radical radiotherapy for T3N0M0 glottic carcinoma had their larynges evaluated pathologically by whole organ laryngeal sectioning. All patients had been staged initially as T3N0M0 glottic carcinoma and treated according to a protocol of radical radiotherapy (50-55 Gy in 4-5 weeks) with surgery reserved for radiation failure. Seventeen of the 41 patients died as a result of locoregional or distant recurrence or complications following surgery. Twenty-four patients were either alive or dead with intercurrent disease. Pathologic staging demonstrated 58% of these tumours to be rpT4, 29% rpT3 and the remainder rpT0-2. The incidence of major cartilage invasion, vascular or perineural invasion, and subglottic extension greater than 15 mm was more frequent in patients with locoregional recurrence than in patients without recurrence. The presence of these pathologic features had a positive predictive value of 0.78 in relation to probability of locoregional failure. In addition, there was a significant difference in the frequency of these pathologic features between patients with and without locoregional recurrence (P less than 0.001). The frequency of positive margins (19%) and pattern of involvement are described. The incidence of occult nodes (0%) in patients undergoing neck dissection is presented. The frequency (23%) and pattern of osteo-chondroradionecrosis are also described. The patterns of growth and spread observed were similar to those described previously. The importance of performing wide surgical resections in patients with recurrence following radiotherapy is emphasized.

The anatomy of external rhinoplasty

The results achieved in rhinoplasty are directly related to the surgeon's ability to elucidate how subtle changes in the bony and cartilaginous supports of the nose will alter its appearance. Therefore, any surgeon who performs rhinoplastic procedures requires a sophisticated knowledge and understanding of the anatomy of the nose. This article reviews the anatomy of the nose from the perspective of the external rhinoplasty approach.

Management of patients with long-term tracheotomies and aspiration

The purpose of this study was to develop a management protocol for patients with long-term tracheotomies and aspiration, in order to develop clinical criteria for extubation and reduction of aspiration-related complications. We studied 39 patients with tracheotomies in place for over 3 months, 28 of whom completed management. Patients were classified according to degree of impairment and managed with the aims of avoiding aspiration and performing extubation whenever feasible. Criteria for choosing various management strategies are presented.

Correlation of tumor volume with local control in laryngeal carcinoma treated by radiotherapy

An analysis of 37 patients with laryngeal carcinoma (T2 or greater) treated with radical radiotherapy, with surgery reserved for failure, was performed to determine if tumor volume, alone or in association with other prognostic factors, accurately predicted the probability of local control. Patient records were reviewed retrospectively and the following data extracted: age, sex, laryngeal region and number of sites involved by tumor, T and N categories, and success or failure of radiotherapy. Tumor volume for each patient was calculated from pretreatment computed tomograms by summing the products of the cross-sectional tumor area on each CT cut and the interval in millimeters between sequential CT cuts. The mean tumor volume for patients failing radiotherapy was 21.8 cm3, and the mean volume for patients primarily controlled by radiotherapy was 8.86 cm3. Tumor volume significantly predicted disease-free interval (p = .045) and outcome with radiotherapy (p = .02). The study suggests that tumor volume is a significant factor in determining the outcome of primary radiotherapy in advanced laryngeal carcinoma.

Cryptic otalgia: a case of Munchausen syndrome in a pediatric patient

This paper reports a case of Munchausen syndrome in a pediatric patient. The patient, a 13-year-old boy, presented with a complaint of persistent otalgia. As a result of the patient's deception of his physicians, he underwent numerous unnecessary investigations and two unnecessary operative procedures. The patient's deception included the simulation of a cerebrospinal fluid leak. The literature with respect to Munchausen syndrome in the pediatric patient is reviewed. Emphasis is placed on the fact that physicians, by their investigations and treatments, inflict most of the morbidity on this group of patients. Specific warning signals as well as an approach for management of these patients are also reviewed.

Prognostic significance of thyroid gland involvement in laryngeal carcinoma

We reviewed 173 laryngeal specimens that included thyroid tissue received from patients undergoing laryngectomy between 1966 and 1980 for evidence of thyroid gland invasion. Twenty-three (14%) of the larynges demonstrated thyroid involvement. In 15 specimens, involvement of the thyroid gland was by direct extension, and in eight the thyroid was involved metastatically. The survival in this group of patients was poor, with 18 patients dying of their disease within three years. Subglottic extension of 10 mm or greater was noted in 21 of 23 patients, and local recurrence was noted in 15 of 18 patients dying of their disease. The importance of removing one or both lobes of the thyroid gland in advanced laryngeal cancer is restated, and a surgically aggressive approach to the paratracheal nodes is recommended in patients with extensive subglottic involvement.

Malignant schwannoma in the head and neck

The authors' experience in dealing with three cases of malignant Schwannoma in the head and neck is outlined. The symptomatology of this tumor is discussed with its investigation and management. A correct diagnosis with a CT scan to delineate tumor extent is imperative. A wide surgical resection is the preferred method of treatment with postoperative irradiation of value for residual microscopic disease. The pernicious nature of this tumor often leads to a dismal outcome despite aggressive therapy.

Augmentation in rhinoplasty--a personal view

This paper presents a view on the use of various synthetic materials in rhinoplasty and the authors' preference for autologous bone as an augmentation material. The biology of bone transplantation as it applies to rhinoplasty is reviewed. Specific techniques for augmentation of the major saddle deformity are described, emphasizing the use of the external rhinoplasty approach for exposure as well as the authors' view that the dorsal graft should not extend beyond the cephalic border of the lower lateral cartilage. The senior author's experience with autologous bone as an augmentation material in 60 patients with major saddle deformities is reviewed. There were three patients whose grafts totally resorbed, and two cases of late graft fracture and displacement. The remaining patients had resorption graded as minor or insignificant. There were only two donor site complications--both wound seromas. Patients reviewed had been followed from one to 18 years.

Approach to naso-frontal-ethmoidal complex fractures

Naso-fronto-ethmoidal complex fractures are infrequently encountered. The authors' approach to the management of the patient with this injury is presented emphasizing the importance of the adoption of a systematic approach to the evaluation of the patient with a maxillofacial injury. The frequency of associated injuries is stressed. The open reduction of this fracture and the use of interosseous fixation is recommended. The importance and technique of repair of the medial canthal ligaments is reviewed as well as the authors' preference for the use of the "open sky" exposure in most patients with this injury.

Refinement of the pectoralis major myocutaneous flap

The pectoralis major myocutaneous flap has become the primary reconstructive flap in head and neck surgery. We have reviewed our experience and describe some modifications of incisions for elevation of this flap which will improve cosmetic results in both male and female patients. The technique for elevation of this flap is reviewed as well as some of the problem areas including the female with a large breast and the elevation of vascularized rib with the myocutaneous flap.

An approach to the posterior interosseous nerve

An exposure of the posterior interosseous nerve has been described. We feel this exposure is simple, anatomic, and atraumatic and yet provides excellent visualization of the posterior interosseous nerve. In addition, proximal and distal exposure of the nerve is easily obtained. This exposure has been used in various clinical settings from trauma to compressive lesions. It has proved both effective and superior to any previously described exposures of the posterior interosseous nerve.

Epidural spinal cord compression from metastatic tumor: diagnosis and treatment

The clinical findings in 130 conseucutive cases of spinal cord compression by metastatic extradural tumors were analyzed. These 130 patients were combined with a previous survey of 105 patients to compare the effectiveness of radiation therapy (RT) alone with that of surgical decompression followed by RT. Ambulation after treatment was considered a successful outcome. The most common primary tumors producing spinal cord compression were (in order) breast, lung, prostate, and kidney. In 68% of these tumors the thoracic region was involved. Pain was the primary symptom of 96% of the patients, while motor or sensory deficits (or both) were found in 82% of them. Therapy consisted of surgery and RT in 65 patients and RT alone in 170 patients. There were no differences in outcome between those treated by surgery combined with RT and those managed by RT alone. Patients with radiosensitive tumors and those ambulatory at the onset of treatment benefited whether treated by surgery or by RT. Seventy-five percent of living patients who improved from treatment remained ambulatory at 6 months, and approximately 50% of living patients were ambulatory at 1 year. We conclude that RT without decompressive laminectomy is as effective as decompressive laminectomy in treating epidural spinal cord compression from systemic cancer.

Cellular immunity in rats with primary brain tumors: inhibition of macrophage migration by soluble extracts of avian sarcoma virus-induced tumors

Rats bearing primary tumors of the brain induced by avian sarcoma virus (ASV) were studied with the migration-inhibition factor (MIF) assay for the presence of cell-mediated immunity to tumor-associated antigens. Astrocytomas and sarcomas of the brain were induced in 34 neonatal F344 rats by the intracerebral inoculation of Bratislava-77 ASV. At weekly intervals from 4 to 9 weeks after the inoculation with virus, peritoneal exudate cells (PEC) from rats bearing brain tumors were tested an an MIF assay against soluble and KCl-treated extracts of a syngeneic, ASV-induced sarcoma. Incubation of the PEC with a soluble extract of syngeneic liver or with a KCl extract of a syngeneic, chemically induced tumor served as controls. Of 14 rats tested against the soluble tumor extract, 6 (43%) had statistically significant inhibition of migration (P less than or equal to 0.05). Of 23 animals tested against the KCl extract, 16 (70%) had significant inhibition. Immunity to the KCl extract was significant in most rats at each period. Ten rats were tested against a KCl extract of a hamster ASV-induced tumor; 7 gad significant inhibition of migration. None of 3 tested against a soluble extract of a syngeneic, chemically induced tumor had significant inhibition. Rats bearing ASV-induced brain tumors displayed cell-mediated immunity to tumor-associated antigen or antigens of ASV-induced tumors, which could be solubilized.