Cheek Cutaneous Melanomas: A Review of 98 Cases

BACKGROUND

Most head and neck melanomas occur on the face, with the cheek being the most frequently affected site. So far, small numbers of researches on cheek melanomas have yielded insufficient and controversial results. In this trial, we aimed to define the histopathological and clinical features specific to cheek melanomas and to compare them with other head and neck melanomas by using a large group of patients from a single tertiary center.

PATIENTS AND METHODS

A total of 98 cheek melanomas and 183 other (noncheek) head and neck melanoma cases were analyzed retrospectively.

RESULTS

The median age was 62 years and malar/zygomatic was the mostly affected site (78.6%). The cheek melanomas developed more frequently in females (61.2%) and most of them were associated with lentigo maligna histopathological subtype (49.2%) and early-stage disease (stage 0-II) (77.6%). The cheek melanomas were found more significantly associated with older patients (P = 0.05), females (P = 0.0001), lentigo maligna subtype (P = 0.0001), lower vertical growth phase (P = 0.03), and early-stage of disease (P = 0.0001) compared with other lesions that developed other sites. Furthermore, they were associated with lower relapse rates (18.6% vs 39.5%, P = 0.0001) and the 5-year recurrence-free survival rate of cheek melanomas was 80% (P = 0.002). Moreover, the 5-year overall survival rate of cheek melanomas was 62%, and they were found to be associated with a favorable overall survival (P = 0.004).

CONCLUSIONS

Cheek melanomas are associated with lower relapse rates and favorable outcomes compared with other (noncheek) head and neck melanomas.

[Clinical course of cutaneous melanoma of the head and neck, and the factors affecting patient survival]

It was found that melanomas of the skin of the head and neck, compared to the trunk and limbs, were characterized by a greater proportion of men, an older average age of the patients, high frequency spindle cell tumors, more frequent synchronous distant metastasis and worse survival. Melanomas, which are localized on the skin of the neck and scalp, have similar aggressive clinical course and are characterized by worse overall and disease-free survival than skin melanomas on the trunk and limbs. However, melanomas of the skin on the ear and face proceed more favorably as compared to skin melanomas of the scalp and neck. Multivariate regression analysis using Cox models showed that the melanoma of the head and neck Breslow tumor thickness was the strongest predictor of overall survival. For skin melanomas of the neck and scalp Breslow tumor thickness was the only significant independent factor for overall survival. In melanoma, skin and ear predictors of survival are: sex, age and tumor thickness. In skin melanomas of the face and ear predictors of survival were sex, age and tumor thickness.

High-energy neodymium laser radiation for the treatment of face cutaneous melanoma

This study retrospectively evaluated the curative efficacy of two powerful pulsed Neodymium (Nd) lasers (lambda = 1060 nm, pulse duration 1 and 4.5 msec, maximum pulse energy 700 and 1000 J, respectively) for the treatment of 47 patients with histologically confirmed stage I cutaneous melanoma of the face who were followed-up 5 years and more. The estimated 5-year survival rate was 82.9%. Regional and distant metastases developed in 23.4% of the patients. There were no cases with local recurrences. High-energy pulsed Nd laser radiation is effective in treating flat and / or slightly raised cutaneous stage I facial melanomas, while the therapeutic result is also accompanied by positive cosmetic result.

[Maxillofacial location of Burkitt's lymphoma in children treated at the University Hospital Center in Bamako, Mali: a 24-case series]

Burkitt's lymphoma was first described in Africa where it remains one of the most common malignant tumors in children. To our knowledge there have been no large series describing Burkitt's lymphoma involving the maxillofacial area or any other location in Malian children. The purpose of this retrospective single-center study was to describe clinical, laboratory, and therapeutic findings in children treated for maxillofacial Burkitt's lymphoma in the Oncology Unit of the Gabriel Touré Pediatric Hospital in Bamako, Mali from January to December 2006. A total of 38 cases of Burkitt's lymphoma were diagnosed during the study period. This series includes 24 children (63.2%) under the age of 15 years in whom diagnosis of previously untreated maxillofacial Burkitt's lymphoma was confirmed by cytology. All patients were treated using the GFA 2005 protocol for Burkitt's lymphoma. There were 17 boys and 7 girls (sex ratio of 2.4). In all cases the disease was advanced, i.e. stage III in 87.5% and stage IV in 12.5%. Following three cycles of Endoxan in association with 3 injections of metothrexate and hydrocortisone, complete remission was observed in 37.5% and 16.6% were lost from follow-up. Treatment complications after 6 cycles included hematologic toxicity in 71.5% and alopecia in 100%. Most patients (70.8%.) presented no infectious episode. Follow-up examination at one year showed that 29.2% of patients remained in complete remission. Despite limited resources for treatment and surveillance, the survival rate in our series of patients treated for advanced stage Burkitt's lymphoma was about 30%. It is likely that a strategy based on an information campaign to enhance the awareness and knowledge of parents, training of medical and paramedical staff, and improvement of management facilities could further reduce mortality due to Burkitt's lymphoma in Malian children.

Successful Blood Conservation During Craniosynostotic Correction With Dual Therapy Using Procrit and Cell Saver

Skin tumors comprise the largest group of malignancies of the head. Despite the accessibility of such lesions, the treatment of neglected, far advanced cancers, many of which have extended deeply into the facial bones and skull, is often required. The key to the cure of malignant tumors of the head is an accurate diagnosis and evaluation of the margins of an excised tumor. Reconstructive surgery of the head after resection of tumors requires a complete understanding of the anatomy of this region. From January 1986 to December of 2005, 31 patients underwent reconstructive surgery for nonmelanoma skin tumors involving the craniofacial region. Preoperative evaluation of the patients was performed in all cases. The results were estimated from the oncologic and functional point of view. The reconstruction, which was performed, included local, regional, and free flaps. In our series, the 5-year disease-free survival rate was 87%. The primary goal of surgical treatment of skin tumors with invasion of craniofacial bone structure is three-dimensional tumor resection with histologically clear margins. This goal has to be balanced, however, with an acceptable functional and aesthetic result. Resections are planned according to pathologic considerations rather than according to the anatomy involved.

The impact of disease on the survival and population growth rate of the Tasmanian devil

1. We investigated the impact of a recently emerged disease, Devil Facial Tumour Disease (DFTD), on the survival and population growth rate of a population of Tasmanian devils, Sarcophilus harrisii, on the Freycinet Peninsula in eastern Tasmania. 2. Cormack-Jolly-Seber and multistate mark-recapture models were employed to investigate the impact of DFTD on age- and sex-specific apparent survival and transition rates. Disease impact on population growth rate was investigated using reverse-time mark-recapture models. 3. The arrival of DFTD triggered an immediate and steady decline in apparent survival rates of adults and subadults, the rate of which was predicted well by the increase in disease prevalence in the population over time. 4. Transitions from healthy to diseased state increased with disease prevalence suggesting that the force of infection in the population is increasing and that the epidemic is not subsiding. 5. The arrival of DFTD coincided with a marked, ongoing decline in the population growth rate of the previously stable population, which to date has not been offset by population compensatory responses.

Traitement par curiethérapie interstitielle du mélanome primitif cutané: 4 cas

BACKGROUND

Traditionally melanoma has been considered as a radioresistant tumor. However, recent observations regarding radiobiology and clinical response of melanoma have prompted physicians to re-evaluate the role of radiotherapy in the management of melanoma. Indeed, radiotherapy is frequently used in the treatment of metastatic melanoma but the role of this therapeutic approach in the primary tumor management is unclear. We report 4 cases of thick primary melanoma treated by interstitial brachytherapy.

CASE REPORTS

Four patients (3 men, 1 woman; age: 73, 74, 79, 84 years), three with lentigo maligna melanoma and one with nodular melanoma, were treated exclusively by interstitial brachytherapy. The thickness of the 4 tumors was more than 3 mm. This treatment was chosen either because of the impossibility of conservative surgery or because of a contraindication for general anesthesia. Median follow-up was 48 months [18 to 65 months] and we did not observe any local tumor relapse. The cosmetic and functional results of this therapy were excellent.

DISCUSSION

These four cases illustrate the possibility of obtaining good local control of thick primary melanoma by interstitial brachytherapy where surgery is impossible, although without challenging the standard surgical therapy for primary melanoma. Before our study, this treatment was used only in one study to treat melanoma patients. In this case however, interstitial brachytherapy was accompanied by surgery. Therefore, the findings reported here are the first to demonstrate the efficacy of this treatment when used as the sole treatment for primary melanoma. In conclusion, where surgery is difficult or impossible, interstitial brachytherapy may be used to treat primary melanoma with excellent local tumor control and a good cosmetic outcome.

Adult head and neck soft tissue sarcomas

PURPOSE

To analyze the outcomes of adult patients with head and neck soft tissue sarcomas.

METHODS

Review of 39 patients treated with radiotherapy (RT) alone (6 patients) or combined with surgery (33 patients) with curative intent between December 1966 and February 2003. Follow-up for living patients ranged from 1 to 21 years (median, 8.7 years).

RESULTS

Five-year outcomes were as follows: local control, 78%; distant metastasis-free survival, 85%; cause-specific survival, 69%, and overall survival, 63%. Three of 6 patients (50%) treated with definitive RT were locally controlled compared with 27 of 33 patients (82%) treated with surgery and RT.

CONCLUSIONS

Approximately two thirds of patients with head and neck soft tissue sarcomas are cured with RT alone or combined with surgery. Local recurrence is a significant mode of treatment failure. Outcome is influenced by tumor extent, histologic grade, and resectability.

Craniofacial resections in the elderly: an outcome study

Object. The elderly population is increasing in number and is healthier now than in the past. The purpose of this study was to examine complications and outcomes following craniofacial resection (CFR) in elderly patients and to compare findings with those of a matched younger cohort.

Methods. All patients 70 years of age or older undergoing CFR at the M. D. Anderson Cancer Center (elderly group) between December 1992 and July 2003 were identified by examining the Department of Neurosurgery database. A random cohort of 28 patients younger than 70 years of age (control group) was selected from the overall population of patients who underwent CFR.

There were 28 patients ranging in age from 70 to 84 years (median 74 years). Major local complications occurred in seven elderly patients (25%) and in six control patients (21%) (p = 0.75), and major systemic complications occurred in nine elderly patients (32%) and in three control patients (11%) (p = 0.05). There was one perioperative death in both groups of patients. The median duration of disease-specific survival for the elderly patients was not reached (mean 6.8 years); however, it was 8.3 years for control patients (p = 0.24). Predictors of poorer overall survival from a multivariate analysis of the elderly group included presence of cardiac disease (p = 0.005), a major systemic perioperative complication (p = 0.03), and a preoperative Karnofsky Performance Scale score less than 100 (p = 0.04).

Conclusions. In this study of elderly patients who underwent CFR, there was no difference in disease-specific survival when compared with a matched cohort of younger patients. There was, however, an increased incidence of perioperative major systemic complications in the elderly group.

[Recurrent tumors in the oral and maxillofacial region. Results and treatment strategies in 20 years]

SUBJECT MATTER: Following clinical diagnosis of a recurrent tumor, curative treatment is seldom available. Depending on the size of the recurrent tumor and the patient's general health condition, extensive surgical resections and reconstructions are avoided in favor of nonsurgical treatment modalities with palliative intent. According to the literature, location of the tumor, tumor size and R-1 and R-2 resection rates are the most frequent reasons for the development of recurrent tumors.

PATIENTS AND METHODS

In a retrospective evaluation, a population of 1000 patients who had been treated for primary head and neck cancer during the period from 1979 to 1996 were analyzed descriptively. Survival probabilities of patients with recurrent tumors were calculated according to the Kaplan-Meier product-limit method, and different treatment concepts were compared and analyzed with the log-rank test for significant differences.

RESULTS

The largest proportion of primary tumors involved the floor of the mouth (n=369, 36.9%). A total of 198 patients (19.8%) developed recurrent cancer; 79.8% of patients experienced recurrent cancer within 2 years following primary treatment. Within the group of T1/T2 tumors the incidence of recurrent tumors was 28.9%, whereas the incidence in the T3/T4 group was 44.6%. Tumor infiltration of the resection margins was detected in 12.9%.

CONCLUSIONS

In line with the literature, tumor infiltration of the resection margins is a relevant prognostic factor; therefore, intraoperative frozen section must be recommended. Treatment with curative intention, in particular extensive surgical resections, is seldom possible and always requires a very intensive discussion with the patient.

Prognostische Faktoren und operative Strategien bei Melanomen des Gesichts

BACKGROUND

In treated facial melanomas, the safety margins generally applied in other body sites cannot be achieved for functional and esthetical reasons. To date there are no controlled studies on safety margins for facial melanomas. Clinical parameters and surgical strategies influencing the prognosis of patients with a facial melanoma were evaluated in a retrospective study of melanoma patients in the Department of Dermatology of the University of Tuebingen (1980-1999).

PATIENTS AND METHODS

The 368 melanomas of the face comprised 9.3% of 3960 primary stage I and II melanomas and 63% of the melanomas in the head and neck area.

RESULTS

Multistep procedures, excisional biopsy for histological diagnosis followed by a subsequent resection of a clinical safety margin or re-excision when the tumor extended to the margin, were associated with a higher probability for recurrence-free survival (p = 0.0007), but had no statistical influence on overall survival. In a multivariate analysis, level of invasion (p = 0.0049), ulceration (p = 0.011), 3D-histology (p = 0.027) and defined safety margins (tumor thickness < or = 1.00 mm: 10 mm; > 1.00 mm 20 mm; lentigo maligna melanoma 5 mm with 3D-histology) (p = 0,033) were independent significant risk factors for recurrence-free survival. Level of invasion (p = 0.032), ulceration (p = 0.029), 3D-histology (p = 0.0047) were identified as independent significant risk factors for overall survival. Multivariate analysis did not show that the histological type of melanoma was of prognostic significance.

CONCLUSION

Reduced safety margins can be employed in melanomas of the face. 3D-histology allows further reduction of safety margins, detects subclinical tumor strands and is correlated with an improved prognosis in patients with facial melanomas.

Angiosarcoma treated with radiotherapy: impact of tumor type and size on outcome

PURPOSE

Angiosarcoma is a rare and highly malignant vascular neoplasm. The purpose of this study was to elucidate the tumor characteristics and evaluate the efficacy of radiotherapy (RT) for angiosarcoma.

MATERIALS AND METHODS

Thirty patients with angiosarcoma (20 males and 10 females, age range 4-89 years, median 66) who received RT from 1986 to 1999 were enrolled in the study. Twenty-four patients had angiosarcoma of the face and scalp (AFS), and 6 patients had angiosarcomas at other sites. AFS was classified into two categories (according to the macroscopic features): nodular AFS (14 patients) and endophytic AFS (10 patients). The median prescribed irradiation dose was 68 Gy. Surgery had been previously performed in 9 patients, and adjuvant immunotherapy using recombinant interleukin-2 (rIL-2) was combined during and after RT in 20 patients. Univariate analyses and calculation of survival by Kaplan-Meier methods were performed.

RESULTS

Local tumor control was obtained in 17 patients (57%). However, 7 (47%) of them developed distant metastases. The median survival time for all patients was 8 months (7 months for AFS), and the 13-year overall survival rate was 25% (20% for AFS). Twenty-one patients died of angiosarcoma, with the cause of death local failure in 7 patients, distant failure in 7, and both in 7. Tumor type and size were found to be significant prognostic factors (p = 0.004 and p = 0.007, respectively), and age, total amount of rIL-2, gender, radiation dose, and surgery were not. Six patients (4 with nodular AFS and 2 with angiosarcoma in other parts) survived >2 years. No patient with endophytic AFS survived >2 years. Ten patients (33%) died of respiratory failure secondary to pulmonary metastases. High-dose rIL-2 administration suppressed the occurrence of distant metastases (p = 0.006). Two patients developed radiation dermatitis (Radiation Therapy Oncology Group Grade 4).

CONCLUSION

RT, combined with complete resection or adjuvant rIL-2 immunotherapy, could be a promising treatment strategy, leading to prolonged survival in patients with angiosarcoma.

Head and neck granulocytic sarcoma with acute myeloid leukemia: three rare cases

We conducted a retrospective review of pathology files and hospital records and identified three unusual presentations of granulocytic sarcoma associated with acute myeloid leukemia (AML) of the head and neck. At least one mass was observed on the skin of all three patients. A 17-year-old boy had masses in each temporal region that were accompanied by bilateral facial paralysis. He was administered chemotherapy and radiotherapy, but he died of infection secondary to a second relapse 29 months after the initial diagnosis. A 17-year-old girl had a tumor in the right parotid area. She received chemotherapy, but she died of infection and bleeding 2 months after the initial diagnosis. A 33-year-old man had numerous tumors widely disseminated over his skin. He received chemotherapy and was in remission 12 months after the initial diagnosis, but he eventually relapsed and died. Granulocytic sarcoma can be localized in unexpected regions, including the head and neck. This tumor is very often misdiagnosed as a malignant lymphoma, which leads to delayed treatment and a poor outcome. Therefore, clinical and histopathologic findings should be evaluated before any diagnosis of malignant lymphoma is pronounced. Immunohistochemical stains should also be performed on patients with suspected granulocytic sarcoma, and aggressive chemotherapy or immunotherapy should be administered. We believe that high-dose chemotherapy can improve survival rates in granulocytic sarcoma associated with AML.

[Results of the DOSAK tumor register]

The German-Swiss-Austrian Group on Maxillofacial Tumors (DOSAK) has been performing observational studies in oral cancer. Since 1989, approximately 1600 cases of tumor of the head and neck per years has been collected in a central tumor registry. The database consists of more than 16,000 patients from 71 clinics; almost two-thirds are primary cases of squamous cell carcinoma. The data show great differences in patho-anatomical findings, therapy concepts, and five-year survival rates among the hospitals.

Sarcoma of the oral and maxillofacial soft tissue in adults

AIMS

Sarcoma occurring in oral and maxillofacial soft tissue is rare. This study was carried out to evaluate the prevalence of oral soft tissue sarcoma and to record its natural history and survival.

METHODS

Retrospective analysis of the patients with histologically proven oral and maxillofacial soft tissue sarcoma treated at the Regional Cancer Centre (RCC), Trivandrum, betweeen 1990-1998 was carried out.

RESULTS

During this period, ten cases of oral and maxillofacial sarcomas were registered. Three lesions were located on the cheek mucosa, two on the tongue and two on the mandibular alveolus, while there was one lesion each in the parotid region, maxilla and face (NOS). Mean age at presentation was 31.3+/-14.1 years (range 15-54 years). Seven of the patients (70%) were males. There were three cases of rhabdomyosarcoma (RMS), three cases of spindle cell sarcoma and one case each of angiosarcoma, haemangioendothelioma, malignant schwannoma and malignant fibrous histiocytoma (MFH). All the patients were treated with surgery as a primary modality. Median follow-up time was 30 months (range 5-94 months). An overall srvival of 87.5% at 5 years was observed; however, 5-year disease free survival was 60.0% (95% CI 19.5-85.2).

CONCLUSIONS

Soft tissue sarcomas are of comparatively less frequent occurrence in oral and maxillofacial soft tissue than in other tissues. A good survival rate can be achieved by multimodality treatment.

Prognostic factors and outcome in craniofacial surgery for malignant cutaneous tumors involving the anterior skull base

BACKGROUND

We retrospectively reviewed the medical charts of 57 patients with advanced malignant cutaneous tumors involving the anterior skull base who underwent combined craniofacial resection in our department from January 1, 1981, to December 31, 1994.

METHODS

The data regarding histological results, demographic aspects, clinical presentation, previous treatment, extent of the disease, extent of surgical procedure, type of reconstruction, complications, and follow-up were analyzed using the chi 2 method. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

We found prevalence of the male sex (60%) and white race (86%), with a mean age of 62 years. Thirty-five patients (61%) showed extensive lesions directly invading the anterior skull base (type II); 46 patients (81%) had been treated previously; 10 patients (18%) had dural invasion; 29 patients (51%) could not have the eyeball preserved; 32 patients (56%) underwent microsurgical reconstruction; and 45 patients (79%) underwent pericranial or galeal-pericranial flap reconstruction for the anterior skull base defect. Postoperative complications occurred in 29 patients (51%). The most common complication was postoperative infection (17 patients [59%]). Thirty-two patients (56%) were free of disease, and 4 (7%) were alive with disease at the time of our study.

CONCLUSIONS

The extent of facial disease (P = .005) and the type of facial reconstruction (P = .01) were the most important risk factors in the development of infectious complications. Invasion of the dura and the type of reconstruction of the anterior skull base were the most important factors related to cerebrospinal fluid leakage (P = .003) and meningoencephalitis (P = .06). Invasion of the dura mater significantly affected survival (P = .005).

Refinements in microvascular repair of extended oromaxillofacial defects with radial forearm free flap

The radial forearm free flap (RFFF) is one of the most widely used and versatile fasciocutaneous free flaps in head and neck reconstruction because of its qualities--the consistent vascular anatomy; the thin and pliable nature; the minimal hair presence; and the possibility of harvesting and transferring it as a composite tissue flap, with bone, tendon, and nerve. The RFFF provides a method of single-stage reconstruction of wide residual defects after excision of advanced cancer (T3-T4) in the head and neck region. We present our ten-year experience with RFFF and the good results obtained with some refinements, which allowed us to verify the efficacy of the oral competence using the palmaris gracilis tendon as a sling. We also present the possibility of harvesting long segments of radius (up to 18 cm), and the discovery that use of antithrombotic or anticoagulant therapy is not necessary for the flap survival. This treatment does not guarantee a complete recovery, but it can improve the quality of the patient's life.

[Basaliomas with invasion of bone: problems and prognosis]

The cure rate for basal cell carcinomas with the appropriate surgical management is excellent. However, when bony involvement is present the prognosis is adversely effected. Only 0.5% of orofacial basal cell carcinomas in our series had bony involvement. These 12 cases were analysed for recurrence rate. This revealed rates from 60% with primary tumours to 90% for recurrences. According to Kaplan-Meier the expected recurrence rate within 10 years is about 90%. Surprisingly the crucial factor mitigating against a cure is the presence of tumour bony infiltration, rather than the demonstration of tumour at the resection margins.

[Desmoplastic malignant melanoma. Clinical and histopathologic results of a study in 34 patients]

Clinical and histopathological findings of 34 cases of desmoplastic malignant melanoma (DMM) are summarized and compared to the literature. DMM develop mostly in sun damaged skin of elderly patients, they are rare and often nonpigmented tumors that are difficult to diagnose clinically. In all cases the tumor parameters showed level IV or V melanomas (level IV: 55.9%, level IV-V: 14.7%, level V: 29.4%) and the tumor thickness measured 3.85 mm +/- 2.31 mm (1.0-11.0 mm). In 22 cases, the follow-up time was between 2 and 7 years. Local recurrences were observed in 7 ( = 31.8%) patients, metastases in 4 ( = 18.2%) and tumor-related deaths in 3. The prognosis for our patients seems to be slightly better than that described in the literature. The main reason is an improved histological diagnosis of this special type of melanoma. Using immunohistochemical staining with anti-S100 antibody it is possible to establish the melanocytic nature of these fibrotic spindle cell tumors earlier that is, in small initial biopsies, and tumor margins can be defined more accurately. As a consequence, surgery is done earlier and is more likely to be curative.

[The current therapeutic trends in rhabdomyosarcoma of the cervicofacial area. A review of the topic]

The authors describe the most common clinical characteristics and main parameters of classification of rhabdomyosarcoma in the maxillo-facial area. They draw the most actual therapeutic iter with particular reference to surgical directions, and they examine different prospects of applicability and of prognostic result.

Immunohistochemical demonstration of S100 protein in malignant melanomas of the facial skin and oral cavity

Immunohistochemical demonstration of S100 protein was performed in 56 cases of malignant melanoma of the facial skin and oral cavity. The depth of invasion was measured comparatively in HE sections and in sections stained for S100 protein. Comparison of measured melanoma invasion depth in S100- and HE-stained sections revealed a deeper invasion of the tumor in S100-stained slides than in slides stained routinely with HE according to Breslow's melanoma staging procedure. A reverse relationship between the intensity of immunohistochemical staining for S100 protein and survival rate was found in both melanomas of the facial skin and oral cavity. Although the presence of S100 protein has been demonstrated previously in skin melanomas, no similar investigations concerning the oral mucosa have been performed up to now.

[Oral and maxillofacial multiple primary cancers]

Among 2989 patients with oral and maxillofacial cancers treated in our department from 1953 to 1985, 49 cases (1.63%) had the multiple primary lesions. The double primary cancers occurred in 44 cases (89.8%), three or more in 5 cases (10.2%). The multiple foci in an organ happened in 16 cases, different organ of systems in 23, and two systems in 10 cases. The followup in 49 cases (92.4%) for 3-27 years revealed the survival rates as follow: 76% (3 yrs), 69% (5 yrs), 42% (10 yrs), and 33% (15 yrs). The aggressive surgical intervention should be performed in oral and maxillofacial multiple primary cancers for a good therapeutic result.

Experience with radical surgical treatment of maxillofacial tumours invading the base of the skull. Long term results

A review of patient data of maxillofacial tumours invading the base of the skull shows a relatively high fatality rate as a result of surgical intervention but also an unexpectedly high life expectancy. Surgical intervention seems to be the right choice whenever clinical examination suggest tumour removal is possible even if a tumour cannot be extirpated in one operation and a further operation from a second access is needed.

[Radiation therapy in the extranodal non-Hodgkin's lymphoma of the maxillo-facial region]

An analysis was made on localized extranodal non-Hodgkin's lymphoma in the maxillo-facial region treated with radiation. Histopathological evaluation was reviewed by Rappaport classification and Working Formulation (WF). High grade histology of WF was rather frequent (32%) compared to Waldeyer's (NHL) (7%). Prognosis of the disease was highly influenced by histopathologic grade in WF; five-year survival rate was 100% with low grade, 65.6% with intermediate grade and 33.3% with high grade. Marginal relapse was rare after radiation dose of 30-50 Gy, however, there was a high incidence of bone and/or soft tissue relapses. Bone marrow biopsy and bone scintigram were useful examinations in the staging procedure of extranodal NHL.

Prediction of recurrence in incompletely excised basal cell carcinoma

This 5-year prospective study evaluated histologic criteria as predictors of tumor recurrence for the individual with a "positive-margin" basal cell carcinoma. The results demonstrated that 93 percent of patients with greater than 75 percent of their tumor cords containing irregularities in in the peripheral palisade had tumor recurrence, while no patient with less than 25 percent of their tumor cords containing irregularities in the peripheral palisade developed a recurrence in 5 years of follow-up. After statistical analysis for the other histologic variables, the presence of greater than 75 percent irregularities in the peripheral palisade conferred a 39-fold increased risk of tumor recurrence, significant at the p much less than 0.001 level. For the patient in the intermediate group (25 to 75 percent irregularities in the peripheral palisade), the presence of a weak host response (absent to minimal infiltration of small lymphocytes) increased the risk of tumor recurrence fourfold, with this effect being significant at the p less than 0.05 level. The presence of tumor ulceration conferred a 2.8-fold increased risk for tumor recurrence, significant at the p less than 0.01 level, while the presence of squamous differentiation conferred no increased risk. This study may provide a valid basis for predicting tumor recurrence in the individual with a positive-margin basal cell carcinoma.

Prevention of neoplasms of the oral-maxillo-facial region: operative proposals

The authors, with their experience in the field of dépistage of maxillofacial cancer, propose the establishment of a health education program for prevention and early diagnosis.

Orofacial synovial sarcoma: a clinicopathologic study of 11 new cases and review of the literature

Synovial sarcoma arises most commonly in the lower extremity, particularly in the region of the lower thigh and knee. Yet the occurrence of thus mesenchymal neoplasm in the head and neck area has been convincingly documented, albeit confined almost exclusively to cervical and parapharyngeal sites. Therefore, in view of its rarity in the head and neck, we analyzed a group of 11 synovial sarcomas arising in the orofacial region. The series comprised nine men (82%) and two women (18%). In common with synovial sarcoma at more conventional sites, this is a disease of young adults: ages ranged from 16-49 years (median, 34 years). Topographically, two subsets were delineated, a more common facial group with eight cases (four cheek, two parotid region, one infraorbital, one submental), all arising as gradually enlarging, usually nontender, solitary tumors; and three intraoral ones (two tonsillar, one lingual), two of which were polypoid and one was an exophytic tonsillar mass which presented with hemoptysis and stridor. Follow-up data, obtained for nine patients (range, 1.3-15.0 years), disclosed three (33%) tumor-related deaths, all belonging to the facial group. Treatment, difficult to significantly correlate with survival in this small series, varied from surgical excision alone to a multimodality approach including both irradiation and chemotherapy. Histologically, all the neoplasms revealed characteristic biphasic features, predominantly fibrosarcomatous in one, but, more typically, showing epithelial clefts and/or pseudoacinar spaces in the others. Differential diagnosis, depending on the proportion of the biphasic components, ranged from spindle cell mesenchymal neoplasms to various adenocarcinomas, including those arising in mixed tumors of salivary gland.

Angiosarcoma of skin and soft tissue: a study of forty-four cases

Forty-four cases of skin and soft tissue angiosarcoma seen at M. D. Anderson Hospital before 1976 were reviewed. The cases fell into six different clinical groups: scalp-face, 17 cases; postmastectomy, 14 cases; postradiation, 5 cases; leg with vascular stasis, 2 cases; breast, 2 cases; and miscellaneous, 4 cases. In all cases in the first four groups, the tumors involved primarily the dermis and subcutis and showed similar blends of vasoformative and solid histologic patterns. Two tumors in the miscellaneous group closely resembled those in the larger groups, but the other two in that group (both located in deeper soft tissue sites) and the two breast angiosarcomas had a somewhat different microscopic appearance. Survival was generally poor in all groups, owing to frequent local recurrence and early metastasis; median survival for the entire series was 20 months. Findings of significantly favorable prognostic importance were tumor size less than 5 cm (in the scalp-face group) and a moderate or marked lymphoid infiltrate in and around the tumor. Less significant favorable factors were a distal location ( in the postmastectomy group) and a low degree of pleomorphism. Only nine patients had long-term, disease-free survival.

Angiosarcoma of skin and soft tissue: a study of forty-four cases

Forty-four cases of skin and soft tissue angiosarcoma seen at M. D. Anderson Hospital before 1976 were reviewed. The cases fell into six different clinical groups: scalp-face, 17 cases; postmastectomy, 14 cases; postradiation, 5 cases; leg with vascular stasis, 2 cases; breast, 2 cases; and miscellaneous, 4 cases. In all cases in the first four groups, the tumors involved primarily the dermis and subcutis and showed similar blends of vasoformative and solid histologic patterns. Two tumors in the miscellaneous group closely resembled those in the larger groups, but the other two in that group (both located in deeper soft tissue sites) and the two breast angiosarcomas had a somewhat different microscopic appearance. Survival was generally poor in all groups, owing to frequent local recurrence and early metastasis; median survival for the entire series was 20 months. Findings of significantly favorable prognostic importance were tumor size less than 5 cm (in the scalp-face group) and a moderate or marked lymphoid infiltrate in and around the tumor. Less significant favorable factors were a distal location ( in the postmastectomy group) and a low degree of pleomorphism. Only nine patients had long-term, disease-free survival.

Long-term survival in basal cell carcinoma metastatic to bone: a case report

A total of 97 cases of metastatic basal cell carcinoma have been reported in the literature, 22 of which were metastatic to bone. To date there has been no survival following bone metastasis. A case report of significant long-term survival--over three times the expected--is presented. The treatment described is perhaps a guideline for management of basal cell carcinoma metastatic to bone, though it is presumed the basic biological nature of the tumor determines length and quality of survival.

Factors leading to delay in the diagnosis and affecting survival of children with head and neck rhabdomyosarcoma

Rhabdomyosarcoma of the head and neck often presents with vague symptoms which mimic other disease conditions. These factors lead to undue delay in the establishment of the correct diagnosis and the delivery of acceptable therapy, including surgery, radiation therapy, and chemotherapy. There is, however, evidence of improved results of treatment of these tumors since the addition of multiple drug chemotherapy to surgery and radiotherapy.

Prognosis in malignant melanoma of the skin. Significance of stage of disease, anatomical site, sex, age and period of diagnosis

The prognosis in malignant melanoma of the skin has been studied in relation to stage, anatomical site, sex, age and period of diagnosis. A total of 2,956 cases diagnosed in Norway 1953-1971 were analyzed. The final date of follow-up was December 31, 1973. The disease is amenable to cure for localized as well as nonlocalized cases, the cure rates being about 60% for the former and 15% for the latter group. Even within the group of localized cases large deviations in prognosis were found, the survival rates varying according to anatomical site, sex and age. The interaction between sex and age in prognosis is discussed in detail. A rise in survival was observed from the period of diagnosis 1953-1963 to that of 1964-1971. Detailed analysis points to earlier diagnosis or therapeutic progress in the later study period rather than a lower degree of malignancy of registered cases.

Fibrosarcoma of the head and neck: a clinical analysis of forty cases

This paper is a clinical analysis of 40 patients with fibrosarcoma of the head and neck treated at the Washington University Medical School, St. Louis, Missouri. Follow-up ranged from 6 to 25 years in 31 patients. Treatment consisted of widefield surgical excision, surgery and irradiation, narrowfield surgery, and irradiation alone. Histological classification of the tumors correlates well with the prognosis. In the well differentiated tumor group 12 out of 16 patients treated for a cure were free of tumor. In the poorly differentiated group only one out of five treated for a cure was free of tumor. Widefield surgical excision is the treatment of choice. Prophylactic radical neck dissection is not indicated. Narrowfield surgical excision resulted in a high recurrence rate although the salvage rate was excellent with subsequent widefield resection. Irradiation therapy produced good palliative results in those patients treated by irradiation alone and has a definite role in the management of this disease.