Second malignant neoplasms of the head and neck in survivors of retinoblastoma

Retinoblastoma is a malignant tumor of the embryonic retina. Although it is rare, it is the most common primary eye tumor of childhood. Life expectancy following treatment is now excellent, but survivors who have heritable retinoblastoma face an increased risk of a second malignant head or neck neoplasm. A second neoplasm, which often occurs in the irradiated field of the original tumor, has become the most significant threat to the survival of these patients. We report the case of a young girl who was cured of her retinoblastoma only to later develop a second nonocular tumor that metastasized to the superficial parotid gland. She underwent a superficial parotidectomy and neck dissection, but the malignancy eventually recurred and required further surgery and radiation therapy. In this article, we discuss the etiology, incidence, sites of occurrence, and management options for a second malignant neoplasm in retinoblastoma survivors. The head and neck surgeon must be vigilant in the diagnosis and management of second neoplasms in this patient population because they often occur in irradiated fields; surgical management is important to patient survival.

Molecular cloning, genetic mapping, and developmental expression of bovine POU5F1

We describe isolation and characterization of the bovine ortholog of POU5F1 (bPOU5F1) encoding octamer-binding transcription factor-4 (Oct-4). The organization of bPOU5F1 is similar to its human and murine orthologs, and it shares 90.6% and 81.7% overall identity at the protein level, respectively. Transient transfection of luciferase reporter constructs in murine P19 embryonal carcinoma cells demonstrated that bPOU5F1 has a functional promoter and contains two enhancer elements, of which one is repressed by retinoic acid. bPOU5F1 was mapped to the major histocompatibility complex on chromosome 23. bPOU5F1 mRNA was detected by nested reverse transcription-polymerase chain reaction in immature oocytes and in in vitro-produced preattachment-stage embryos. Oct-4 in oocytes and in vitro-produced preattachment-stage embryos was demonstrated by indirect immunofluorescence. Confocal laser scanning microscopy revealed Oct-4 in both the inner cell mass and trophoblast cells of the blastocyst until Day 10 of development. Immunofluorescence performed on the outgrowths formed at Day 13 postfertilization from in vitro-produced Day 8 blastocysts showed Oct-4 staining in all cells. This expression pattern suggests that bPOU5F1 acts early in bovine embryonic development but that its expression is not restricted to pluripotent cells of the blastocyst.

Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer

BACKGROUND

Radiotherapy is often the primary treatment for advanced head and neck cancer, but the rates of locoregional recurrence are high and survival is poor. We investigated whether hyperfractionated irradiation plus concurrent chemotherapy (combined treatment) is superior to hyperfractionated irradiation alone.

METHODS

Patients with advanced head and neck cancer who were treated only with hyperfractionated irradiation received 125 cGy twice daily, for a total of 7500 cGy. Patients in the combined-treatment group received 125 cGy twice daily, for a total of 7000 cGy, and five days of treatment with 12 mg of cisplatin per square meter of body-surface area per day and 600 mg of fluorouracil per square meter per day during weeks 1 and 6 of irradiation. Two cycles of cisplatin and fluorouracil were given to most patients after the completion of radiotherapy.

RESULTS

Of 122 patients who underwent randomization, 116 were included in the analysis. Most patients in both treatment groups had unresectable disease. The median follow-up was 41 months (range, 19 to 86). At three years the rate of overall survival was 55 percent in the combined-therapy group and 34 percent in the hyperfractionation group (P=0.07). The relapse-free survival rate was higher in the combined-treatment group (61 percent vs. 41 percent, P=0.08). The rate of locoregional control of disease at three years was 70 percent in the combined-treatment group and 44 percent in the hyperfractionation group (P=0.01). Confluent mucositis developed in 77 percent and 75 percent of the two groups, respectively. Severe complications occurred in three patients in the hyperfractionation group and five patients in the combined-treatment group.

CONCLUSIONS

Combined treatment for advanced head and neck cancer is more efficacious and not more toxic than hyperfractionated irradiation alone.

Genetic mapping of five human chromosome 4 orthologues to bovine chromosomes 6 and 17

Five loci that map to human chromosome 4 (HSA4) were selected to expand the bovine comparative linkage map. Loci included b-casein (CSN2), basic fibroblast growth factor (FGF2), immunoglobulin J chain (IGJ), interleukin 2 (IL2) and microsomal triglyceride transfer protein (MTTP). Polymorphisms for each locus were identified by either polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) or single-strand conformational polymorphism (SSCP) analysis. The bovine genes for CSN2, IGJ and MTTP were mapped by linkage analysis to chromosome 6; FGF2 and IL2 mapped to chromosome 17. These data refine a position of chromosomal evolution to a small region between FGF2 and the previously mapped complement I factor (IF).

A male linkage map of the cattle (Bos taurus) genome

A male linkage map of the cattle (Bos taurus) genome was constructed using nine large half-sib families. The map consists of 269 loci, of which 249 are microsatellites and 20 are structural genes. Among the 249 microsatellites, 140 are markers selected from other maps and 98 are new assignments. Chromosome assignment were established for 35 new markers by somatic cell hybrid analysis, of which 26 were confirmed by linkage analysis. Genome coverage is 1975 cM contained within terminal markers on all 29 autosomes. The average distance between adjacent loci is 9.7 cM, with 72.1% of the map intervals < or = 15 cM and 4.9% of the intervals > or = 25 cM. The inclusion of mapped markers permitted integration and comparisons with other maps, facilitating the identification of discrepancies in chromosome assignment, gene order, and map distance. The inclusion of Type I and blood group markers in the map was useful for comparative mapping, revealing possible blood group orthologies between humans and cattle. The map generated will serve as a useful tool for comparative mapping, mapping of quantitative trait loci and marker assisted selection.

Cytomegalovirus sialadenitis in patients with the acquired immunodeficiency syndrome: a potential diagnostic pitfall with fine-needle aspiration cytology

We report three cases of cytomegalovirus (CMV) sialadenitis which presented as parotid gland nodules in patients infected with the human immunodeficiency virus. While CMV is known to widely infect patients with the acquired immunodeficiency syndrome (AIDS), we are aware of only a single report of CMV sialadenitis in a patient with AIDS (Pialoux et al.: Rev Infect Dis 1991;13:338). Utilizing fine-needle aspiration (FNA) cytology as the initial investigative modality, two cases were correctly diagnosed preoperatively while the third case displayed atypical features and was interpreted erroneously as carcinoma leading to surgical intervention. Upon review of these cases of CMV sialadenitis, the characteristic intranuclear inclusions are best identified with Papanicolaou (Pap) staining. CMV sialadenitis should be considered in the differential diagnosis of painless salivary gland enlargement in patients with AIDS. We believe this lesion can be diagnosed preoperatively with FNA and the interpretation is aided by evaluating both Pap- and Giemsa-stained material.

A phase I/II trial of twice daily irradiation and concurrent chemotherapy for locally advanced squamous cell carcinoma of the head and neck

PURPOSE

This study was designed to test the toxicity and efficacy of a regimen of twice daily irradiation and concurrent multiagent chemotherapy for patients with locally advanced squamous cell carcinoma of the head and neck.

METHODS AND MATERIALS

This was a prospective Phase I/II trial. Patients received 125 cGy b.i.d. to 7000 cGy with a 6 hr interfraction interval. Chemotherapy was given during weeks 1 and 6 of irradiation and consisted of a 5 day infusion of 5-fluorouracil at 600 mg/M2/day and 5 daily injections of cisplatin at 12 mg/M2/day. Two additional cycles of chemotherapy were given after the completion of radiotherapy.

RESULTS

Forty-six patients were evaluable: 28 had technically unresectable disease and 18 had resectable tumors. All had Stage III or IV disease: 84% had T3 or T4 primaries while 53% had > or = N2 neck disease. The primary acute toxicity, confluent mucositis, was seen in 74% of patients. Late side effects occurred in four patients. Median follow-up is 36 months (range 25-44 months). Kaplan-Meier estimates of 2-year disease-free survival and overall survival are 65% and 73%, respectively, while 2-year local regional control and distant disease-free survival are 72% and 88%, respectively. Multivariate analysis revealed that resectability and receiving > 2 cycles of chemotherapy significantly influenced local regional control while age < 60 significantly influenced disease-free survival.

CONCLUSION

This form of treatment can be delivered safely. The encouraging results have led to the initiation of a Phase III trial comparing this regimen with b.i.d. radiation alone.

Lentigo maligna melanoma of the head and neck

Historically, lentigo maligna melanoma has been considered a "favorable" histological type of melanoma, and treatment by wide local excision was considered curative. A retrospective multivariate analysis of 143 head and neck patients with stage I lentigo maligna melanoma was performed from a database of 1067 head and neck patients followed at Duke Medical Center. Fifty-six percent of all lentigo maligna melanomas presented with lesions deeper than 0.76 mm, and 8% presented with stage II or III disease. Recurrent disease occurred in 45% of stage I patients, with a 5-year disease-free interval of 6 years and a median survival time of 10 years. Multivariate analysis demonstrated no significant difference in disease-free interval or survival by histological subtype. The data suggest that treatment should be based on tumor thickness and not histologic subtype.

Thin malignant melanomas of the head and neck

Historically, Breslow classified thin melanomas as invasive lesions less than 0.76 mm in depth with rare instances of recurrence and mortality. From 1970 to 1990, 87 patients with thin head and neck melanoma were treated at Duke Medical Center. A computer-aided retrospective analysis was performed. Recurrence occurred in 30% of these patients; however, of the 66 patients seen at this institution prior to recurrence, only 8% recurred. Recurrence significantly shortened survival. Compared to an overall 84% 5-year survival, there was less than a 50% 5-year survival after recurrence. For thin melanomas, thickness did not affect survival. There was no difference in survival between thin melanomas and those ranging from 0.76 to 1.5 mm. A multivariate analysis was performed. The data suggest that thin melanomas of the head and neck may recur at a higher rate than previously reported and in addition, that they can be lethal.

The effect of head and neck radiation therapy on voice quality

Twenty-five patients with squamous cell carcinoma of the head and neck who received radiation therapy as their only form of treatment underwent a computer-assisted voice analysis before, and 6 months following treatment. Those with early laryngeal tumors had a significant improvement in intelligibility (P = .07), percent of sound voiced (P = .04), and sound perturbation. Those with nonlaryngeal tumors had no change in any measured parameters. Head and neck radiation therapy can significantly improve the voice quality of patients with laryngeal tumors, while having a minimal effect on the voice quality of those with nonlaryngeal tumors.

Penile metastasis secondary to supraglottic squamous cell carcinoma: review of the literature

We report an unusual supraglottic carcinoma metastasis to the penis. Review of the literature revealed more than 300 cases of metastatic lesions to the penis, excluding primary neoplasms from skin, urethra and blood. Of these metastatic neoplasms 16 originated above the diaphragm, only 4 of which were from the head and neck region. The most common neoplastic metastases to the penis in order of frequency were from the bladder, prostate, rectum and rectosigmoid areas, and kidney in 32, 30, 13 and 8% of the cases, respectively. The incidence of other primary tumor sites that metastasize to the penis is extremely rare.

Therapeutic and prognostic considerations of head and neck melanoma

Therapeutic considerations are discussed based on recurrence and survival statistics of 900 patients treated at Duke University Medical Center (Durham, NC). Approximately one-third of all patients developed recurrence. Factors affecting recurrence include tumor thickness, presence of positive regional nodes at diagnosis, and advanced Clark level. Patients with more than one adverse index had even higher rates of recurrence than with one alone. The 5-year survival of all patients after recurrence was 32%. Therapeutic decisions should include considerations that relate to patients' recurrence patterns and survival curves.

Closure of tracheocutaneous fistula with perichondrial flap following cricothyroidotomy

A method for closure of large tracheocutaneous fistulas occurring in the cricothyroid membrane is described. Though an infrequent complication, large defects in this area can be successfully repaired with this technique.

Divergence of muscle and liver fructose 2,6-diphosphate in fasted exercising rats

Previous studies demonstrate that nonexercising muscle may serve as a source of lactate for hepatic gluconeogenesis during long-term exercise. The concentration of fructose 2,6-diphosphate (F-2,6-P2), a signal molecule that accelerates glycolysis, was examined in liver and muscles of fed and fasted resting rats and in fasted rats run for 5, 15, or 30 min at 21 m/min (15% grade). Liver F-2,6-P2 decreased in response to fasting and exercise. White quadriceps (composed predominantly of type IIb fibers) F-2,6-P2 increased from 2.2 +/- 0.1 to 4.5 +/- 0.4 pmol/mg in the fasted rats in response to 30 min of treadmill running. No increase was observed in the red region of the quadriceps (composed of type IIa fibers). The fasted rats also exhibited a threefold increase in glucose 1,6-diphosphate (G-1,6-P2) in the white quadriceps after 30 min of exercise, whereas no significant changes were observed in the red quadriceps or in liver. The increases in F-2,6-P2 and G-1,6-P2 may be important in accelerating glycolysis and enhancing lactate production in muscles that are not glycogen depleted during long-term exercise.

Otolaryngologic management of patients with subdural empyema

From 1979 to 1988, 17 patients presented to Duke University Medical Center for treatment of subdural empyema. Empyemas were caused by sinusitis in 53% of the patients and by otitis media in 12%. None of those with otologic causes required mastoid drainage, while all patients with sinus infections required sinus drainage. External frontoethmoidectomies were associated with a lower incidence of frontoethmoid re-exploration (P = 0.048), and antrostomies with a lower incidence of maxillary re-exploration (P = 0.111), than were more limited drainage procedures. Sinus drainage performed simultaneously with neurosurgical drainage reduced the incidence of sinus re-exploration (P = 0.167), neurosurgical reexploration (P = 0.048), and length of hospitalization (P = 0.020).

Free jejunal interposition graft for reconstruction of the esophagus

Forty-seven patients underwent pharyngoesophageal reconstruction using a free jejunal interposition graft (FJIG) at Duke University Medical Center from 1978 through 1987. There were 30 men and 17 women with ages ranging from 38 to 87 years old (mean age, 64 years). Twenty-one patients (group A) had no prior surgical procedures, 20 (group B) were reconstructed following radiation and/or surgical failure, with 6 patients (group C) having benign strictures of the upper alimentary tract. Follow-up ranged up to 122 months (mean, 23 months), with 3 patients lost to follow-up, and 4 perioperative deaths (within 3 months of surgery). There were a total of 9 initial graft failures, 4 patients undergoing successful re-implantation, resulting in an overall success rate of 89% (42 of 47). Excluding patients with graft failures, perioperative deaths, and patients lost to follow-up, 33 of 36 patients with a viable FJIG were able to maintain adequate swallowing function yielding a physiologic success rate of 86%. All of the 21 patients dying of recurrent disease had excellent palliation with the FJIG. Of the 7 patients who are alive, only 1 has dysphagia secondary to stricture. In conclusion, it is felt that the FJIG is a sophisticated method of reconstructing large surgical defects of the pharyngoesophagus with a high technical and physiologic success rate.

Mucosal melanoma of the head and neck

From 1972 to 1988, 15 patients presented to the Duke University Melanoma Clinic, Durham, NC, with malignant melanoma of the mucus membranes of the upper aerodigestive tract. Eleven patients had a nasopharyngeal origin of their melanoma, while 4 patients had oropharyngeal lesions. The average age of the patients was 58.4 years. Median survival for the patients was 1.8 years, with a 5-year survival of approximately 10%. Survival was found to be independent of sex, tumor site, and extent of disease at presentation. Recurrence occurred in 80% of the patients and the median time to recurrence was 10 months. The median survival following recurrence was 13 months and was independent of the site of recurrence. Mucosal melanoma of the head and neck continues to result in a poor prognosis in spite of aggressive treatment.

Cutaneous malignant melanoma of the head and neck

A computer-aided analysis of 5,109 patients with malignant melanoma was performed. Patient population characteristics according to body site (head and neck, extremity, and trunk) were determined for the following parameters: sex, histologic type of melanoma, Clark's level, Breslow thickness, age, clinical status of regional nodes, presence or absence of ulceration, and recurrence. Head and neck melanomas accounted for 17% of the total population (N = 877). A detailed analysis of general population characteristics according to subsites within the head and neck region (ear, face, neck, nose, and scalp) was performed. Survival characteristics were determined for head and neck patients according to lymph node surgery, histologic type of tumor, and tumor thickness. The effect on survival of lymph node dissection (elective for stage I disease and therapeutic for stage II disease) was analyzed by univariate and multivariate methods. Elective lymph node dissection (ELND) was performed on 77 patients and 39 patients underwent therapeutic nodal dissection (TLND). Overall, survival was significantly improved following ELND as compared to TLND; however, multivariate analysis indicated the improved survival was related to variations of age within the population rather than the beneficial effect of lymph node surgery. Elective lymph node dissection did significantly reduce the incidence of recurrence for head and neck patients (p = 0.002). Since recurrence was demonstrated to be directly related to survival, the trend toward improved survival following ELND after 5 years was felt to be important. There was no difference in survival according to the histologic type of melanoma.

Survival following recurrent malignant melanoma of the head and neck

A retrospective analysis of 877 patients who had malignant melanoma of the head and neck identified 366 patients who developed recurrent disease. Sex, race, age, histology, Clark level, thickness, ulceration, lymph node status, lymph node dissection, site of recurrence, and time to recurrence were analyzed to determine their effect on survival following the development of recurrent disease. Survival following the development of recurrence was found to be influenced by the site of first recurrence and the age of the patient at the time of recurrence. For a given age, patients who had initial recurrences at distant sites were three times as likely to die following recurrence than patients with local recurrence. Patients who had initial recurrences at distant sites were twice as likely to die following recurrence than patients with regional sites of recurrence (p less than 0.001).

Juvenile malignant melanoma of the head and neck

Malignant melanoma of the head and neck is a potentially lethal disease and considered rare among juveniles. Treatment patterns have historically been dictated by experience with adults, however a paucity of data is available to determine the natural history and treatment guidelines for juveniles and children with malignant melanoma. Therefore a retrospective computer-aided analysis of patients less than 20 years of age having malignant melanoma were obtained from the records of 4,843 patients with malignant melanoma recorded from 1972 through 1986. Eighty-seven patients were identified from this group with 17 patients having primary malignant melanomas confined to the head and neck. Parameters evaluated were age at diagnosis, sex, type of melanoma, Clark Level, Breslow depth of invasion, pathologic classification, site of primary, nodal status at diagnosis, surgical treatment, recurrence rate and site of recurrence, and follow-up status. Two of 17 patients had stage II disease and were treated with wide local excision and therapeutic radical neck dissection. Fifteen of 17 patients initially presented with stage I disease were treated with wide local excision. Two of these patients underwent elective radical neck dissection both of which proved to have positive occult nodal disease. Both are alive without evidence of disease 2 1/2 to 7 years later. Of the 13 patients who were initially treated with only wide local excision, nine patients developed local (3), regional (3), or systemic (3) disease within 3 months to 9 years from the date of diagnosis. Seven of the nine died of their disease 5 months to 20 years later. When juvenile patients with melanomas of the head and neck are compared to a comparable age group of patients with melanomas at other primary body sites, the head and neck group had a significantly higher frequency of death. Compared to the adult head and neck population, juvenile patients had identical actuarial survival time, but shorter disease-free intervals, even though the adult population had a higher percent of poor prognostic indices (presence of ulceration and thickness of lesions). Failure to control local and regional disease coupled with the overall poor survival rate, indicates that malignant melanoma occurs in the young as a biologically active tumor and suggests an aggressive approach for better control of local and regional disease and, hopefully, survival.

Sleep apnea and vocal cord paralysis secondary to type I Chiari malformation

A previously healthy 13-year-old boy without myelodysplasia who had mild scoliosis was seen with complaints of nasal congestion, noisy nighttime breathing, and difficulty sleeping. Flattening of the inspiratory loop on the flow-volume curve was found on pulmonary function testing, suggesting a variable extrathoracic obstruction due to a laryngeal lesion. Bilateral abductor vocal cord paralysis and sleep apnea developed precipitously following general anesthesia. Further workup demonstrated a type-I Chiari malformation with syringomyelia. Brainstem abnormalities such as Chiari malformation with secondary tenth cranial nerve deficits should be considered in previously healthy children and adolescents with signs and symptoms of upper airway obstruction and apnea.

A prospective study of squamous head and neck carcinoma. Immunologic aberrations in patients who develop recurrent disease

In a prospective study of squamous head and neck cancer, the pretreatment peripheral blood of 125 patients was examined for lymphocyte subclass and in vitro immunologic function. After 4 years of follow-up, 49 recurrences of disease were observed. Lymphocytes from patients with recurrent disease showed elevated interleukin-2 (IL-2) production and a tendency towards increased response to mitogens in comparison to those without recurrence. When disease-free survival is analyzed on the basis of IL-2 levels, patients with high relative IL-2 synthesis (greater than or equal to 1) had a 40% poorer prognosis than patients with low relative IL-2 levels (less than 1). The difference is significant at a P value of 0.02. Since IL-2 synthesis occurs with antigenic stimulation, it is postulated that patients who have a high IL-2 synthesis in their pretreatment lymphocytes may have had prior stimulation by circulating tumor antigen. Such immune response by the host may be successful in destroying the antigenic tumor cells but may leave the undifferentiated, less antigenic tumor cells to grow and metastasize. Thus, elevated IL-2 synthesis in pretreatment lymphocytes predicts a poorer prognosis.

Primary cutaneous lymphoma of the head and neck

One hundred three patients with Stage I and II extranodal primary lymphomas of the head and neck were reviewed. Six patients (5%) presented with cutaneous lesions, five with single site and one with multiple sites of involvement. Histopathology was malignant lymphoma (ML) large cell (3), ML small cleaved cell (1), ML small lymphocytic (1), and ML mixed large and small cell (1). Five of six patients relapsed following initial treatment. Four patients were treated with primary radiation therapy, three of which had relapses outside the treatment area. One patient was treated with intralesional steroid injection and also recurred outside the treated area. One patient was treated with radiation and chemotherapy and recurred outside the treatment area. Three patients are alive without disease, two died of disseminated disease, and one died of unrelated causes. Isolated cutaneous presentation of head and neck lymphoma is uncommon. Radiation therapy appears to have been curative in one patient with localized disease. Four patients recurred outside the radiation portals despite careful staging, suggesting that systemic therapy may be necessary for disease control.

Pharyngoesophageal reconstruction using free jejunal interposition grafts

Forty patients underwent pharyngoesophageal reconstruction with a free jejunal interposition graft (FJIG). Three categories of disease were treated: (1) primary upper aerodigestive tract carcinomas, (2) recurrent carcinomas, and (3) benign pharyngoesophageal stenosis. There were no intraoperative graft failures. Postoperative complications included four perioperative deaths, eight late graft failures, three transient fistulas, eight distal graft strictures, one prolonged ileus, two postoperative hematomas, one abdominal wound dehiscence, one abdominal abscess, and one hypoglossal nerve palsy. Of the eight patients with late graft failures, three underwent successful jejunal reimplantation, yielding an overall success rate of 88% (35/40). The advantages of an FJIG are as follows: (1) a single-stage procedure for large defects, (2) a jejunal segment approximately the size of the pharyngoesophagus, (3) tissue that is able to tolerate radiation therapy, (4) maintenance of near-physiologic swallowing mechanism, (5) denervated small-bowel model, (6) excellent palliative procedure, and (7) shortened hospitalization. Disadvantages include (1) microvascular surgical technique, (2) abdominal procedure, and (3) limited esophageal speech.

Carcinoma of the larynx and hypopharynx: computed tomographic-histopathologic correlations

Twenty consecutive patients underwent computed tomography (CT) prior to total laryngectomy in order to assess the accuracy of CT scanning in the evaluation of carcinoma of the larynx and hypopharynx. CT scans were prospectively interpreted and the extent of tumor was recorded graphically at five major levels of the larynx. The extent of tumor was similarly evaluated on whole-mount histologic sections of the laryngeal specimens prepared in the horizontal plane similar to the CT scans. The results were compared to assess the ability of CT to identify tumor extent accurately. Despite good correlation of gross tumor extent between histologic specimens and CT scanning, specific pitfalls in CT diagnosis were identified. Overestimation of tumor extent was caused by edematous changes in six patients and tumor-associated inflammatory changes in three patients. In seven patients, mass effect from adjacent bulky tumor significantly distorted normal structures, mimicking tumor involvement. Small foci of mucosal tumor in three patients and microscopic cartilage involvement in two patients were not identified on CT scanning, causing underestimation of tumor extent.

Cutaneous melanoma of the head and neck. A review of 399 cases

A retrospective search of the Duke University Melanoma Clinic patients identified 399 cases with primary malignant melanoma located in the head and neck region. Ninety-five percent of the deaths in this series were from metastatic melanoma. Various clinical and pathological data were examined and their effects on survivability and disease-free intervals were evaluated. The characteristics noted included sex, age, depth of the invasion, thickness, site of the lesion, histologic type, and nodal status. A multivariate regression analysis identified the following factors as having a negative effect on survival: nodular histologic type, scalp primary, increasing Clark level, and male sex. In comparing head and neck, extremity, and truncal primary sites, the median survival for patients with head and neck malignant melanomas was notably less. These differences correlated with a higher incidence for male patients, for patients with thicker lesions, and for patients with an increased frequency of nodular histologic type.

Application of posterior neck dissection in treating malignant melanoma of the posterior scalp

Utilization of a posterior neck dissection in the treatment of nine patients with malignant melanoma of the posterior scalp is presented. Seven of nine patients presented with metastatic disease present in the posterior neck after initial treatment elsewhere. Four of the seven patients developed regional disease 4 months to 4 years following initial diagnosis. Variables dictating surgical treatment included the Clark's level, Breslow depth of invasion of original lesion, evidence of metastatic disease, and type of melanoma. The surgical technique of the posterior neck dissection is graphically depicted and the indications outlined. The posterior neck dissection is mandatory to adequately resect the primary lymphatics of the posterior scalp. Controlled studies are urged to determine the efficacy of prophylactic surgical lymphadenectomy in malignant melanoma of the head and neck.

Effect of total laryngectomy on esophageal motility

Total laryngectomy for cancer can result in dysphagia and altered esophageal motility. Manometric changes in the upper esophageal sphincter (UES), and in proximal and distal esophageal function have been reported. However, most studies have failed to take into account radiation therapy and appropriate controls. We selected ten male patients (54.3 +/- 1.9 yr) for longitudinal manometric evaluation prior to laryngectomy then at two weeks and again six months later. No patient received preoperative radiation therapy, had a previous history of esophageal surgery, or developed a postoperative wound infection or fistula. Seven of ten patients had positive nodes and received 6,000-6,600 rads postoperative radiation therapy. Preoperatively 4 of 10 patients complained of dysphagia which did not significantly change following surgery and radiation. Two of three patients who did not complain of dysphagia preoperatively and received radiation postoperatively developed dysphagia. No patient without dysphagia preoperatively who received no radiation therapy developed symptoms. Our studies show that laryngectomy causes alterations in the UES resting and peak pressures but not in the proximal or distal esophagus, or the lower esophageal sphincter. These data also imply radiation therapy may be associated with progressive alterations in motility and symptomatology. Further study regarding the effects of radiation on esophageal motility and function are urged.

Motor function of the esophagus after repair of esophageal atresia and tracheoesophageal fistula

Eleven patients with previous esophageal atresia repair (TEF) underwent esophageal motility studies and were compared to 10 normal patients. The upper sphincters (UES) in the two groups did not differ in resting pressure, contraction pressure, or coordination. UES relaxation, was 100% in normal patients and 83+/-8% in the TEF patients (p less than 0.05). In the proximal esophagus, 100% of the TEF group showed a normal peristaltic wave, coupled with an abnormal nonperistaltic wave. The normal group did not show this type of contraction. In the middle esophagus, the mean peak pressure of 30.5+/-2.0 mm Hg was greater in controls than the 14.6+/-1.0 in the TEF group (p less than 0.001). Coordination was observed in 97+/-1% of the controls, while present in only 27+/-4% of the TEF patients (p less than 0.001). In the distal 10 cm of esophagus, peak contraction pressures were 43.3+/-1.6 in controls and 21.3+/-1.1 in the TEF group (p less than 0.001). Coordination was 94+/-1% in normal subjects and 66+/-4% in the TEF patients (p less than 0.001). The resting pressure in TEF patients was significantly higher at all three esophageal levels (proximal, mid, distal) than in normal patients. In both groups lower esophageal sphincter function did not show any significant difference, except for closing pressure, which was significantly higher in controls (39.9+/-6.8 mm Hg) than in the TEF groups (21.3+/-3.0 mm Hg) (p less than 0.02). These studies suggest that marked motility abnormalities occur in the repaired esophagus after atresia. These abnormalities are distinctly different from other motor disorders of the esophagus.