A cadaveric study of auricular lymphatics and implications for sentinel lymph node biopsy

Malignant cutaneous tumors of the auricle are known to have a high rate of spread to the regional lymph nodes, and, for this reason, removal of the lymph nodes, for diagnostic or therapeutic purposes, is often required. Recent experience with sentinel node biopsy in cutaneous tumors of the head and neck has questioned the traditional lymphatic pathways and prompted a new study. Lymphatic pathways from the auricle were demonstrated by India ink injection of five auricles in three cadavers followed by block dissection and Spalteholz clearing of en bloc specimens. Lymphatics descend adjacent to the mastoid bone periosteum and lie deep to the insertion of the sternocleidomastoid muscle. There are five different locations for sentinel nodes: superficial parotid, anterior mastoid, infra-auricular parotid, deep to sternocleidomastoid, and lateral mastoid. Two of these nodal locations (anterior and lateral mastoid) may be bypassed by anastomotic pathways. We conclude that, first, echelon lymph nodes lie in five different sites, some bypassed by anastomotic lymphatics. Lymphatics from the ear lie close to the mastoid bone and pass deep to the insertion of sternocleidomastoid where they may be difficult to follow. Sentinel lymph node biopsy for cutaneous tumors of the auricle is possible, but the presence of skip metastases should be considered.

Pleomorphic adenomas: post-operative radiotherapy is unnecessary following primary incomplete excision: a retrospective review

BACKGROUND

Current standard treatment of Pleomorphic Salivary Adenoma (PSA) of the Parotid Gland is by surgical excision. The management of incomplete excision remains undecided with post-operative radiotherapy advocated by some and observation by others.

METHODS

190 patients who underwent resection of PSA of the parotid gland within the West of Scotland region from 1981 to 2008 were identified and data collected.

RESULTS

78/190 patients had a primary incomplete excision. 25/78 received post-operative radiotherapy and 53 were observed. Recurrences occurred in 11/53 in those observed and in 1/25 of those who received radiotherapy. 21/25 complained of significant side effects from the radiotherapy. 38 surgeons performed 190 procedures, with a range of experience from 1 to28 procedures.

CONCLUSIONS

Radiotherapy does appear to reduce recurrence with incomplete excision, however it is associated with significant side effects. We therefore feel radiotherapy should not be routinely recommended. Subspecialisation should be adopted to increase the operating surgeon's experience.

Micrometastases and isolated tumour cells in sentinel lymph nodes in oral and oropharyngeal squamous cell carcinoma

BACKGROUND

The occurrence of micrometastases (MMs) and isolated tumour cells (ITCs) in oral sentinel lymph node (SLN) biopsy is poorly known, and the definitions and clinical significance of MMs and ITCs in SLN biopsy are controversial. We compared the UICC/TNM definitions of MMs and ITCs with our previously published sentinel node protocol to assess how the adoption of the UICC/TNM criteria would affect the staging of nodal micrometastatic disease.

METHODS

Of 107 patients who had a SLN biopsy and pathology at 150 microm intervals, 35 with metastatic tumour were included. Eighty-six SLNs were reassessed using the UICC/TNM definitions for MMs and ITCs. Findings were linked to the final pathology in the subsequent neck dissection.

RESULTS

Initial H&E sections showed metastases in 24 patients (in 34 out of 61 SLN), 8 of whom (9 SLNs) had MMs. Additional step serial sections revealed metastatic deposits in a further 11 patients (15 out of 25 SLNs were positive) which were reassessed as MMs (6 patients) or ITCs (5 patients). Subsequent neck dissection revealed additional metastases in 46% of patients with MM, whilst one of the ITC patients had subsequent neck metastases (20%).

CONCLUSION

Despite some limitations, the UICC/TNM classification provides an objective, uniform method of detecting MMs and ITC's. Unlike in cases with ITC, metastases in other non-SLNs were common when a micrometastasis was detected in a SLN, indicating need for further treatment of the neck.

Lymph node metastases from auricular squamous cell carcinoma. A systematic review and meta-analysis

INTRODUCTION

Squamous cell carcinoma arising on the auricle is believed to metastasise to the regional lymph nodes more frequently than comparable tumours at other sites. Metastatic spread of these tumours is associated with a poor outcome but there is no clear consensus of opinion on how to identify patients at risk of metastatic spread and treat them.

MATERIALS AND METHODS

A systematic review database search of Medline and Embase was conducted with cross referencing of articles.

RESULTS

The metastatic rate is 11.2% with spread to the parotid and upper deep cervical chain most common. Eighty-five per cent of metastases develop within 12 months and 98% within 24 months, although follow up was limited to 12 to 36 months in most cases. Death occurs in 6.2% of cases (about half of the patients who develop metastases) usually due to failure of loco-regional control. Depth of invasion, tumour size, degree of cellular differentiation and incomplete primary excision margins may be useful in identifying lesions most at risk of metastasising but there is insufficient evidence at present to allow targeted neck dissections.

The unexpected sites of melanoma regional recurrences

Sentinel node biopsy is a means of identifying nodal involvement in melanoma and lymphoscintigraphy identifies unpredictable sites of melanoma sentinel nodes in up to 25% of cases. Whilst there is a dearth of recent publications in this area, it nevertheless remains an interesting observation that unpredictable sites of sentinel nodes are so common as to be accepted as normal. This study was performed to determine if this high rate of unpredictable lymphatic drainage was reflected in clinical practice, where therapeutic lymph node dissections were performed for pathologically confirmed regional disease.

METHODS

Patients undergoing regional lymph node dissections for histologically proven malignant melanoma were identified from a computer database. Patient details were analysed from case records.

RESULTS

Two hundred and forty-three case records were examined and 237 were suitable for analysis. The site of the primary was the head and neck in 50 (21%), trunk in 73 (31%), upper limb in 27 (11%) and lower limb in 87 (37%). In 15 cases (6%), the first site of regional disease was unpredictable. In these 15 cases, the site of the primary was the head and neck in two, trunk in 11, upper limb in one and lower limb in one. In 37 cases (16%), a subsequent site of nodal recurrence was unpredictable. Clinicians should be aware that patients with melanomas, particularly of the trunk, especially those in whom a therapeutic nodal dissection has been performed, may have nodal disease at unpredictable sites. However, unexpected sites of regional disease are not as common as sentinel node biopsy would suggest. Guidelines for lymph node examination in cutaneous melanoma are suggested based on these findings.

The nodal neck level of sentinel lymph nodes in mucosal head and neck cancer

Sentinel node biopsy is emerging as a successful means of identifying subclinical lymph node disease in mucosal head and neck cancer. Sentinel node studies in melanoma and breast cancer have identified sentinel nodes at unusual sites and the technique is redefining our understanding of dynamic lymphatic flow. In this study, the sentinel nodes in mucosal head and neck malignancies were mapped according to their site within the neck and this was correlated with tumour site within the oral cavity. Fifty-two necks were explored for sentinel nodes from tumours located in the tongue (23 cases), floor of mouth (12 cases), palate (six cases), retromolar trigone (five cases), alveolus (three cases), buccal mucosa (two cases), tonsil (two cases) and lip (one case). In total, 124 sentinel nodes were found in levels I-V. Two hot spots were found in the tonsils and were not excised, two nodes were located in level IIB, four nodes were found in level IV, three in the contralateral neck and one in level V. The sentinel nodes located at unusual sites would not have been excised in a supraomohyoid neck dissection and the study has improved our understanding of dynamic lymph flow from tumours.

Improved Staging of Cervical Metastases in Clinically Node-Negative Patients With Head and Neck Squamous Cell Carcinoma

BACKGROUND

The management of the N0 neck in oral and oropharyngeal cancer is often determined by the risk of metastases related to features of the primary tumor. Where the risk of metastases is >20%, elective neck dissection (END) has been advocated. This study reviewed clinical staging, surgical staging, pathologic staging, and histopathologic parameters to determine the prediction of nodal metastases and micrometastases in patients with head and neck squamous cell carcinoma.

METHODS

A prospective series of 61 clinically neck node-negative patients undergoing surgical resection of a T1/2 intraoral or oropharyngeal invasive squamous cell carcinoma and surgical staging of the neck, with sentinel node biopsy (SNB) alone or SNB-assisted END, between June 1998 and March 2002 were included in this study.

RESULTS

Pathologic upstaging of the clinically N0 neck occurred in 27 (44%) of 61 patients. Routine pathology with hematoxylin and eosin upstaged disease in 22 of 27 patients (sensitivity of 81%). Five patients with micrometastasis were staged pN1mi after stepped serial sectioning and immunohistochemistry. Tumor thickness, a noncohesive invasive front, and perineural and bone invasion were all histological predictors for cervical metastases. Five patients with micrometastases were staged pN1mi.

CONCLUSIONS

Both clinical staging and routine pathologic staging underestimate the presence of nodal metastases. Staging with either SNB alone or SNB-assisted END shows promise in the management of the N0 neck by identifying patients with micrometastases (pN1mi).

Histological changes in radial forearm skin flaps in the oral cavity

We reported previously that skin flaps transplanted to the oral cavity in reconstructive surgery for oral cancer frequently acquired the gross appearance of buccal mucosa. The changes were shown to be reactive in nature. The "changed" flaps generally had a heavier infiltration of leukocytes in the dermis and appeared to have thicker epithelium. The present study quantifies these parameters, as well as the numbers of intraepithelial leukocytes. The flaps that had acquired the gross appearance of oral mucosa had significantly thicker epithelium, larger numbers of dermal leukocytes, and more intraepidermal inflammatory cells per unit length than flaps that retained the gross appearance of thin skin. No correlation was found between these changes and radiotherapy.

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.

The impact of immunohistochemistry on sentinel node biopsy for primary cutaneous malignant melanoma

Sentinel node biopsy (SNB) has emerged as an accurate means of identifying nodal disease in patients with malignant melanoma. Superselection of pathological nodes has allowed improved pathological staging of disease. The aim of this study was to look at the impact of immunohistochemistry on pathological staging of sentinel nodes. The first 100 patients undergoing SNB for primary cutaneous malignant melanoma were included in this study. Sentinel node harvesting was performed with the aid of preoperative lymphoscintigraphy and the intraoperative use of both a gamma probe and blue dye. If the sentinel nodes contained tumour on either routine pathology or immunohistochemistry, patients were offered a therapeutic lymph node dissection (TLND). Patients underwent no other treatment to the primary lymph node basin if the sentinel node was free of metastases. In all, 95 patients had at least one node identified, and 25 were staged SNB positive and offered subsequent TLND. We found that 76% (19/25) of SNB positive patients were staged positive on routine pathology, and 24% (6/25) were staged with immunohistochemistry. Immunohistochemistry upstaged disease in 8% of patients (6/76). In all, 21 of the patients staged positive with SNB underwent TLND; 50% (8/16) of the patients staged sentinel node positive with routine pathology showed no further disease in the TLND, compared with 100% (5/5) of the patients staged sentinel node positive with immunohistochemistry only (P<0.05). Three patients have developed recurrence within the nodal basin following a negative SNB. The sensitivity of the procedure is currently 89% (25/28), with a mean follow-up of 24 months. Immunohistochemistry is an essential part of identifying micrometastasis in sentinel nodes, upstaging 8% of patients in our series. Patients with micrometastatic disease may well have a different prognosis from those with occult disease, and careful delineation of these patients is required to determine the prognostic influence of micrometastasis.

Increasing dietary supervision can reduce weight loss in oral cancer patients

Weight loss after treatment for intraoral malignancy is common and can impair patient recovery and wound healing. We report a reduction in weight loss in patients undergoing combined-modality treatment (surgery + radiotherapy) after an increase in dietary supervision and changes to the patient dietary protocol. Two groups of patients were compared: Group I received treatment before the protocol changes, and Group II received treatment after the changes took effect. After surgery the average weight loss for Group I was 3.67% compared with 2.42% for Group II (P < 0.05), after radiotherapy the average weight loss for Group I was 6.56% compared with 4.83% for Group II (P < 0.05), and after combined-modality treatment the average weight loss for Group I was 9.83% compared with 6.6% for Group II (P < 0.05). The successful protocol changes included increased supervision of patients by the dedicated head-and-neck team dietitian when patients were undergoing radiotherapy, including the period between completion of surgery and commencement of radiotherapy. The period of time spent without specialist dietary supervision was therefore reduced. Specific guidelines were devised to allow for increased dietary input when required, specifically, if patients lost weight for > or = 2 wk or if they were being fed enterally. These changes were made after an audit that demonstrated that severe weight loss in this group of patients was common. We have demonstrated that regular appraisal of weight loss in this group of patients is valuable and that this weight loss can be reduced if appropriate action is taken.

The ability of lymphoscintigraphy to direct sentinel node biopsy in the clinically N0 neck for patients with head and neck squamous cell carcinoma

This study aimed to evaluate the ability of lymphoscintigraphy (LSG) to direct sentinel node biopsy (SNB) in the identification of occult metastases in the clinically N0 neck for patients with head and neck squamous cell carcinoma (HNSCC). 57 clinically N0 neck sides in 48 patients were assessed using the triple diagnostic approach of pre-operative LSG, intra-operative use of a gamma probe and blue dye. SNB was performed after radiocolloid and blue dye injection. Pre-operative LSG and the intra-operative use of a gamma probe identified radioactive sentinel nodes, and visualization of blue stained lymphatics identified blue sentinel nodes. 104 sentinel nodes were harvested from 43 patients. The identification rate was 90% (43 of 48). Of the 104 nodes harvested, 17 of 62 (27%) nodes identified as both radioactive and blue were positive for occult metastases compared with 5 of 42 (12%) nodes identified as hot or blue only (p<0.05). Sentinel nodes were identified in 39 of 48 (81%) patients using LSG. Of 39 patients in whom sentinel nodes were identified using LSG, 37 of 39 (95%) had radioactive sentinel nodes harvested intra-operatively. In patients who had no sentinel nodes identified on LSG, 4 of 9 (44%) had radioactive sentinel nodes harvested intra-operatively. This difference was statistically significant using the t-test (p<0.05). LSG directs SNB and is essential in the identification of occult metastases within the clinically N0 neck for patients with HNSCC.

Treatment of oral cancer: the need for defined protocols and specialist centres. variations in the treatment of oral cancer

The authors of this study aimed to identify treatment philosophies for oral cancer within the west of Scotland and to investigate any survival differences associated with the various treatment options by means of a retrospective review of case notes and cancer registry data. All patients with squamous cancer of the tongue or floor of the mouth were identified from the West of Scotland Cancer Registry for the period 1984-1990. A total of 206 patients were available for study. Five different treatment protocols were identified: 5% of patients underwent biopsy only, 16% biopsy plus radiotherapy, 11% excisional biopsy, 25% radical surgery, and 42% radical surgery plus radiotherapy. Tumour staging by the TNM classification was an important factor that determined outcome. When adjusting for T stage and nodal involvement, there was a significant effect of treatment protocol on both the disease-free period (P < 0.001) and on survival (P < 0.001). The treatment options were used differently by individual clinicians and were related to stage of the disease. One hundred and forty-four (70%) of the patients were treated by a single combined head and neck unit based within the plastic surgery unit at Canniesburn Hospital. The remaining 62 were treated in 13 different units throughout the west of Scotland. For those not treated in the combined head and neck unit, the increased hazard for recurrence was 1.43 (95% confidence interval (CI) 1.01-2.02), and the increased hazard ratio for death was 1.48 (95% CI 1.06-2.06) when adjusting for tumour stage, and nodal involvement. Treatment philosophies for oral cancer have a significant effect on outcome. There is a need to develop clearly defined protocols based on staging and site of disease. We believe that treatment should be carried out within a multidisciplinary setting in a combined head and neck cancer unit.

The learning curve for sentinel node biopsy in malignant melanoma

Sentinel node biopsy (SNB) has emerged as an accurate means of identifying nodal micrometastasis in cutaneous melanoma. In order to assess our learning curve, we compared our first 30 cases with our subsequent 30 cases. A total of 60 patients underwent SNB for cutaneous melanoma, using preoperative lymphoscintigraphy together with the intraoperative use of a Neoprobe and Patent Blue V dye. At least one sentinel node was identified in 93% of patients (90% in our first 30 cases; 97% in our subsequent 30 cases). Sentinel nodes contained tumour in 21% of cases. Of the sentinel nodes that contained tumour in the first 30 cases, 87% were identified by Neoprobe examination and 60% using blue dye. In the second 30 cases, the tumour-containing sentinel nodes were identified in all cases by both the Neoprobe and the blue dye. The sentinel node appeared to be the only involved node in 71% of patients. In the first 30 patients, one patient with a negative sentinel node developed nodal recurrence. These data confirm the feasibility of the sentinel-node technique in cutaneous melanoma. However, there is a learning curve, and the technique should be performed only by limited numbers of people with suitable training.

The First International Conference on Sentinel Node Biopsy in Mucosal Head and Neck Cancer and adoption of a multicenter trial protocol

BACKGROUND

Sentinel node biopsy (SNB) is a new technique in staging the clinically N0 neck. On June 25 and 26, 2001, the First International Conference on Sentinel Node Biopsy in Mucosal Head and Neck Cancer took place in Glasgow, United Kingdom.

METHODS

Twenty-two centers contributed results on the use of SNB as a staging tool in head and neck squamous cell carcinoma. The pathology of the sentinel node was compared with that of the pathologic neck specimen.

RESULTS

Three hundred sixteen clinically N0 necks were included. Sentinel nodes were identified in 301 necks (95%). Of these 301 necks, 76 necks were staged positive with SNB, and 225 were staged negative. The overall sensitivity of the procedure was 90%. Centers who had performed < or = 10 cases had a lower sensitivity (57%), discovering only 4 of 7 metastatic nodes, in comparison with 72 of 77 metastatic nodes discovered for centers that had performed >10 cases (sensitivity, 94%).

CONCLUSIONS

The cumulative results of all those who contributed to the first international conference confirm that there is a role for SNB for staging the clinically N0 neck, and it has a similar sensitivity to that of a staging neck dissection.

The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck

BACKGROUND

Sentinel lymph node (SLN) biopsy originally was described as a means of identifying lymph node metastases in malignant melanoma and breast carcinoma. The use of SLN biopsy in patients with oral and oropharyngeal squamous cell carcinoma and clinically N0 necks was investigated to determine whether the pathology of the SLN reflected that of the neck.

METHODS

Patients undergoing elective neck dissections for head and neck squamous cell carcinoma accessible to injection were enrolled into our study. Sentinel lymph node biopsy was performed after blue dye and radiocolloid injection. Preoperative lymphoscintigraphy and the perioperative use of a gamma probe identified radioactive SLNs; visualization of blue stained lymphatics identified blue SLNs. A neck dissection completed the surgical procedure, and the pathology of the SLN was compared with that of the remaining neck dissection.

RESULTS

Sentinel lymph node biopsy was performed on 40 cases with clinically N0 necks. Twenty were pathologically clear of tumor and 20 contained subclinical metastases. SLNs were found in 17 necks with pathologic disease and contained metastases in 16. The sentinel lymph node was the only lymph node containing tumor in 12 of 16.

CONCLUSIONS

The SLN, in head and neck carcinomas accessible to injection without anesthesia, is an accurate reflector of the status of the regional lymph nodes, when found in patients with early tumors. Sentinel lymph nodes may be found in clinically unpredictable sites, and SLN biopsy may aid in identifying the clinically N0 patient with early lymph node disease. If SLNs cannot be located in the neck, an elective lymph node dissection should be considered.

Behavior of radial forearm skin flaps transplanted into the oral cavity

Radial forearm skin flaps transplanted into the oral cavity in patients undergoing treatment for intra-oral tumors frequently acquire a gross appearance resembling that of buccal mucosa. This article reports studies of biopsies of the flaps in 53 patients, of which 21 showed changes at some stage in the follow-up period. The project aims to determine whether 1) the change in the epithelium to a mucosal form is genuine or reactive, 2) a creeping replacement of epidermis results from the surrounding buccal epithelium, 3) alterations in the epidermis could be associated with changes in the dermis, 4) the change is caused by radiotherapy. Examination of the biopsies by resin histology and transmission electron microscopy shows that the changes may be reversible: it suggests that they are reactive in nature, and related to the degree of dermal inflammation, rather than to the effect of radiotherapy. The dermis persists as such and is not replaced by buccal lamina propria.

Nerve supply of the breast with special reference to the nipple and areola: Sir Astley Cooper revisited

Cooper in 1840 described mammary branches from the 2nd-6th intercostal nerves, and noticed that the nipple was supplied by branches which lay close to the surface of the gland. Eckhard (1850) divided the mammary branches into superficial branches to the skin and nipple, and deep branches to the glandular tissue and nipple, but many later authors ignored those findings. After the second World War, cosmetic surgery of the breast made further research critical, as surgeons strove to design operations which would retain its shape and preserve postoperative sensation. Craig and Sykes (1970) described mainly anterior branches from the 3rd, 4th and 5th intercostal nerves passing through the glandular tissue of the breast and along the line of the ducts to the nipple, while Farina et al. (1980) concluded that the nipple was supplied solely by superficial lateral branches of the 4th nerve. Using improvements in dissecting technique learned from microsurgery, Sarhadi et al. (1996) found that the nipple was innervated by the lateral cutaneous branch of the 4th intercostal nerve, by two branches, one passing superficial to the gland, and the other through the retromammary space, and by variable lateral and medial additional branches from the 2nd-5th nerves. These branches came to lie superficially and formed a subdermal plexus under the areola. This account is uncannily close to Cooper's original description; it is a reassuring, if sobering, conclusion that his early account remains one of the most reliable.

Current role of gene therapy in head and neck cancer

Our increasing knowledge of cancer molecular biology has led to the development of new genetic therapies for the treatment of cancer. Such therapies are advantageous in that they can selectively target tumour tissue leaving normal tissue relatively unaffected. In squamous cell cancer of the head and neck, such therapies may be beneficial in the treatment of loco-regional recurrence, minimal residual disease and in the treatment of distant metastatic disease. This article describes the principles of cancer gene therapy reviews some early clinical trials of gene therapy in head and neck cancer.

Natural history and patterns of recurrence of tongue tumours

This retrospective study comprises 226 patients with squamous cell carcinoma of the tongue treated at Canniesburn Hospital, Glasgow between 1980 and 1996. The male:female ratio was 1.2:1 and the average age was 64 years. The ratio of anterior 2/3 to posterior 1/3 tongue lesions was 1.8:1. A total of 23% of patients were clinically staged as T1, 50% were T2 and 27% were T3/T4. At presentation 156 patients (69%) had a clinically negative neck, while 110 patients (49%) had a neck dissection at the time of treatment of the primary. A comparison between the clinical and pathological T and N stages highlighted the difficulties of clinical TNM staging with upstaging of the primary T stage in 21% of patients and downstaging in 6% and upstaging of neck disease in 36% and downstaging in 7.7%. The incidence of clinically occult disease in the neck was 41% including six patients (4.5%) with occult disease in the contralateral neck.

A phase I study of Onyx-015, an E1B attenuated adenovirus, administered intratumorally to patients with recurrent head and neck cancer

An E1B 55 kDa gene-deleted adenovirus, Onyx-015, which reportedly selectively replicates in and lyses p53-deficient cells, was administered by a single intratumoral injection to a total of 22 patients with recurrent head and neck cancer. The objectives of this Phase I study were to determine the safety, feasibility, and efficacy of this therapy and determine any correlation to p53 status. Six cohorts were investigated with a dose escalation from 10(7)-10(11) plaque-forming units. Toxicity was assessed using NCIC criteria. Tumor response was assessed by clinical and radiological measurement. Blood samples were taken to detect adenovirus DNA and neutralizing antibody to adenovirus. Tumor biopsies were taken to detect adenovirus by in situ hybridization. Treatment was well tolerated, with the main toxicity being grade 1/2 flu-like symptoms. Dose-limiting toxicity was not reached at the highest dose of 10(11) plaque-forming units. Twenty-one of the 22 patients treated showed an increase in neutralizing antibody to adenovirus. In situ hybridization showed viral replication in 4 of 22 patients treated, all of whom had mutant p53 tumors. Using conventional response criteria, no objective responses were observed. However, magnetic resonance imaging scans were suggestive of tumor necrosis at the site of viral injection in five patients, three of whom were classified using nonconventional criteria as partial responders, and two of whom were classified using nonconventional criteria as minor responders. Of these five cases, four had mutant p53 tumors. The response duration for the three partial responders was 4, 8, and 12 weeks. An additional eight patients had stable disease in the injected tumors lasting from 4-8 weeks. These preliminary results show that intratumoral administration of Onyx-015 is feasible, well tolerated, and associated with biological activity. Further investigation of Onyx-015, particularly with a more frequent injection protocol and in combination with systemic chemotherapy, is warranted.

Interstitial iridium-192 implantation for recurrent and/or locally advanced head and neck cancer

We report our experience with the use of interstitial iridium-192 implantation in the management of patients with recurrent and locally advanced squamous cell carcinoma of the head and neck. Between June 1992 and July 1998 this technique was employed in the management of two groups of patients: (1) a primary group, comprising 42 patients who had presented for the first time with advanced head and neck disease, and had therefore not undergone any previous treatment; and (2) a salvage group of 16 patients with recurrent disease previously treated with external beam radiotherapy (four received therapy to the neck, one to the cheek, eight to the tongue and three to the floor of the mouth). The follow-up in each group was short, ranging from 3 to 56 months. The overall response in the primary group was 38/42 (90%). A complete response was achieved in 35/42 (83%). In the salvage group, the overall response was 13/16 (81%); 4/16 (25%) showed a complete response and 9/16 (56%) a partial response. The estimated percentage surviving at 1 year for patients with primary disease is 70% (95% confidence interval (CI) 54-86). For those receiving salvage therapy the estimated percentage surviving at 1 year is 45% (95% CI 19-71).

p53 alterations in recurrent squamous cell cancer of the head and neck refractory to radiotherapy

The aim of the study was to determine the incidence of p53 alterations by mutation, deletion or inactivation by mdm2 or human papillomavirus (HPV) infection in recurrent squamous cell cancer of the head and neck (SCCHN) refractory to radiotherapy. Twenty-two tumours were studied. The p53 status of each tumour was analysed by sequencing of exons 4-9 and by immunohistochemistry. Mdm2 expression was assessed by immunohistochemistry and HPV infection was assessed by polymerase chain reaction of tumour DNA for HPV 16, 18 and 33. Fifteen (68%) of the 22 tumours studied had p53 mutations, while seven had wild-type p53 sequence. p53 immunohistochemistry correlated with the type of mutation. HPV DNA was detected in 8 (36%) tumours and all were of serotype HPV 16. Of these, five were in tumours with mutant p53 and three were in tumours with wild-type p53. Mdm2 overexpression was detected in 11 (50%) tumours. Of these, seven were in tumours with mutant p53 and four were in tumours with wild-type p53. Overall, 21 of the 22 tumours had p53 alterations either by mutation, deletion or inactivation by mdm2 or HPV. In this study, the overall incidence of p53 inactivation in recurrent head and neck cancer was very high at 95%. The main mechanism of inactivation was gene mutation or deletion which occurred in 15 of the 22 tumours studied. In addition, six of the seven tumours with wild-type p53 sequence had either HPV 16 DNA, overexpression of mdm2 or both which suggested that these tumours had p53 inactivation by these mechanisms. This high incidence of p53 dysfunction is one factor which could account for the poor response of these tumours to radiotherapy and chemotherapy. Therefore, new therapies for recurrent SCCHN which either act in a p53 independent pathway, or which restore p53 function may be beneficial in this disease.

A suggested method for sentinel node biopsy in squamous cell carcinoma of the head and neck

BACKGROUND

Debate continues over the management of the N0 neck in head and neck malignancy. Therefore, the possibility of performing sentinel node biopsy in these patients was investigated to formulate a method for the procedure.

METHODS

Patients undergoing prophylactic or therapeutic neck dissections were injected with either Patent Blue V dye alone or with blue dye and 99m-Tc labeled Albures. The latter group underwent preoperative lymphoscintigraphy. During surgery, blue stained lymphatics were followed to blue nodes, and a neoprobe was used to identify radioactive nodes.

RESULTS

In 5 of 13 patients receiving blue dye, a blue node was identified, but none contained tumor. Metastases were identified in other neck nodes in 3 of 5. Sentinel nodes were identified in 15 of 16 patients receiving dye, and Albures. Sentinel node biopsy was accurate in 7 of 7 necks containing impalpable metastases when all nodes had been evaluated after dissection.

DISCUSSION

Sentinel node biopsy using blue dye and radiocolloid may prove to be a reliable technique in the N0 neck and warrants further investigation.

Improved survival for patients with clinically T1/T2, N0 tongue tumors undergoing a prophylactic neck dissection

BACKGROUND

Prophylactic surgical treatment of the neck in "early tongue tumors" is a controversial issue.

METHODS

From a database of 226 patients with squamous cell carcinoma of the tongue treated at Canniesburn Hospital, Glasgow, U.K., between 1980 and 1996, a total of 137 patients with a minimum follow up of 24 months or until death were clinically identified as being T1/T2, N0 (UICC) when first seen. These patients were divided into three groups according to the management of the neck; 53 patients did not have a neck dissection at any time (NKD0), 47 patients underwent a synchronous neck dissection at the time of treatment of the primary (NKDS), and 37 patients subsequently required a metachronous neck dissection when lymph node metastasis became clinically apparent (NKDM). These three groups were compared with respect to age, sex, site, duration of symptoms, previous treatment (if any), initial treatment protocol, resection margin, type of neck dissection (if any), loco-regional recurrence, systemic escape, number of positive lymph nodes, and presence of extracapsular spread. Disease-related survival was calculated using Kaplan-Meier survival curves with logrank test and chi-square statistical analysis.

RESULTS

The pT stage was upgraded to T3/4 in 3/53 patients (6%) of the NKD0 group, 11/47 patients (23%) of the NKDS group, and 2/37 patients (5%) of the NKDM group (p < 0.001). The 5-year determinate survival rates for the three groups were: NKD0 59.7%, NKDS 80.5%, NKDM 44.8%, and (NKD0 + NKDM) 53.6% with a statistically significant improvement in survival for NKDS vs NKDM (logrank 10.58, p = 0.001) and for NKDS vs (NKD0 + NKDM) (logrank 6.06, p = 0.014). The incidences of positive nodes in the NKDS and NKDM groups were 18/47 patients (38%) and 32/37 patients (86%) respectively. Neck positive patients in the NKDM group had a significantly greater number of positive nodes in comparison with N positive patients in the NKDS group (chi trend, p = 0.001), a higher incidence of extracapsular spread, 30/32 vs 9/18 (chi test, p < 0. 0001), and decreased survival. The incidence of occult cervical metastasis for the whole group was 41%.

CONCLUSION

Patients with clinical T1/2, N0 tongue tumors who underwent a synchronous neck dissection had an improved survival outcome even though as a group they had a higher incidence of occult metastasis, relatively more T2 lesions, a worse pT stage, and had more posterior third lesions requiring more difficult initial surgery. Tongue tumors have a high incidence of subclinical nodal disease, which is less curable when it presents clinically. The information gleaned from the nodal status allows a more informed plan of adjuvant therapy.

Early closure of a randomized trial: surgery and postoperative radiotherapy versus radiotherapy in the management of intra-oral tumours

Tumours of the oral cavity/oropharynx occur relatively infrequently in the UK. The management of such lesions, especially the squamous cell carcinomas, is still a little controversial. Some centres advocate radiotherapy while others adopt surgery and radiotherapy. In an attempt to resolve the question of which approach gives the better results, a multicentre randomized trial was established to compare surgery plus postoperative radiotherapy with radical radiotherapy alone. It was anticipated that 350 patients would be required to give a statistically significant result, but, after 35 patients had been entered, the trial was closed prematurely with a marked difference in overall survival in favour of the combination arm (P = 0.0006). At this analysis, carried out 23 months after trial closure, the survival difference between the two arms remains statistically significant for all causes of mortality (P = 0.001; relative death rate = 0.24; 95% CI 0.10-0.59).

Tumour seeding following percutaneous endoscopic gastrostomy placement in head and neck cancer

We report the case of a patient with advanced squamous carcinoma of the supraglottic larynx and hypopharynx who developed metastatic gastric deposits occurring at the site of a percutaneous endoscopic gastrostomy tube, inserted 10 months previously by the pull technique. We review seven previous reports of tumour deposits occurring at the site of placement of a percutaneous endoscopic gastrostomy in patients with head and neck cancer, and consider alternative methods of enteral feeding in such patients.

Recovery of sensation in the radial forearm free flap in oral reconstruction

The purpose of this study was to find out to what extent sensory function recovers in a free radial forearm flap used for intraoral reconstruction after surgery for oral cancer. In 40 free radial forearm flaps we investigated the perception of light touch, two-point discrimination, pain, directional sensation, and temperature between 6 months and 11 years after flap transfer to the oral cavity. Four flaps (10 percent) were anesthetic, 21 flaps (52.5 percent) recovered partly, and 15 flaps (37.5 percent) had perception of all sensory modalities tested in at least two-thirds of the flap area. All patients with positive sensation in the surrounding area subsequently had good sensory recovery in the flap. This suggests that recovery of sensation in a nonreinnervated free flap is due to nerve ingrowth from the surrounding mucosa. The present results suggest that sensory function in intraoral free radial forearm flaps returns again. Further study is necessary to define the use of neurofasciocutaneous radial forearm flaps in reconstruction of the oral cavity.

An anatomical study of the nerve supply of the breast, including the nipple and areola

There are widely differing accounts in the literature of the origin, course, and distribution of the nerves to the breast and especially to the nipple and areola. This, together with our own findings at operation, led us to investigate whether the accounts are inaccurate or the nerve supply is very variable or both. 15 breast specimens from dissecting room cadavers, 12 female and 3 male, were dissected to study the nerve supply of the breast in detail. In the female, the breast received its innervation from the lateral and anterior cutaneous branches of the second to the sixth intercostal nerves and from the supraclavicular nerves. On the lateral side in the 12 females, branches from the third (9/12), fourth (12/12) and fifth (4/12), and on the medial side branches from the second (3/12), the third (6/12), the fourth (4/12) and the fifth (2/12) intercostal nerves were traced to a plexus under the areola. Branches from the sixth intercostal nerve supplied the lower part of the breast but there was no direct branch to the nipple. The nerves to the nipple lay in the superficial fascia and passed through the subdermal tissue of the areola to form a plexus under it. The extent of the contribution by each nerve was variable, and it differed even on the left and right of the same cadaver. The nerve often described as passing through the inferolateral part of the breast to reach the nipple is a deep branch from the anterior division of the fourth lateral cutaneous nerve. This was present in 11/12 of the female breasts but it is not the only nerve to reach the plexus under the areola as sometimes claimed. The male breast had a similar nerve supply but the nerves were lying close together, whereas in a female breast they are spread out more widely.

Intraoral reconstruction using a second free flap for recurrent or metachronous carcinoma

A retrospective review of clinical records at Canniesburn Hospital has identified 6 patients in whom intraoral squamous carcinomas were excised and reconstruction performed by free tissue transfer on two separate occasions. The interval between procedures ranged from 8 months to 8 years. One dorsalis pedis flap was used and the other tissue transfers were radial forearm free flaps, two of which were osteocutaneous. One flap completely failed and the rest survived. There was no evidence of greater risk in carrying out a second microsurgical intraoral reconstruction in this series. 4 out of 6 patients remain alive following their second procedure, one after 9 years. The results suggest that in selected cases it may be worthwhile to carry out a major intraoral reconstruction on more than one occasion.

An unusual presentation of gas gangrene complicated by penicillin allergy

A case is reported of non-clostridial gas gangrene that presented in a similar way to deep venous thrombosis and then developed into septic shock. Management was complicated by penicillin allergy.

Flow cytometric analysis of DNA content in squamous carcinoma of the tongue: the relationship to host and tumour factors and survival

Cellular DNA content has been found to be an important prognostic factor in many human tumours, yet within the head and neck region few studies have examined its effect on survival and in those that have, findings differ. Eighty-one consecutive patients with squamous carcinoma of the tongue mainly treated by surgery and post-operative radiotherapy were studied. The DNA content of archival paraffin embedded tumours was measured by flow cytometry. Fifty-seven tumours were diploid and 24 were aneuploid. There was no association between ploidy status and age, sex, tumour size or nodal status. Ploidy status was not related to survival. These findings indicate that analysis of tumour DNA content in squamous carcinoma of the tongue does not provide any additional prognostic information for the individual patient.

Relative effect of surgery and radiotherapy on the internal jugular vein following functional neck dissection

We examined the internal jugular veins in three groups of patients who had undergone (1) a functional neck dissection and radiotherapy, (2) a functional neck dissection alone, or (3) radiotherapy alone, using a noninvasive color Doppler ultrasound scan. The internal jugular veins were ultrasonically bilaterally normal in 18% of patients who had undergone a functional neck dissection and radiotherapy, in 88% of patients who had undergone a functional neck dissection alone, and in 57% of patients who had undergone radiotherapy alone. The combination of a functional neck dissection and radiotherapy significantly affected the internal jugular vein when compared with a functional neck dissection alone.

Refinements in the axial frontonasal flap

The frontonasal flap is a useful flap for medial and lateral tip defects of the nose. It can be used as a random rotation flap or as an axial flap. This paper describes modifications to the original designs of these flaps, with improvements in the final scar.

Recurrence of intraoral squamous cell carcinoma at the base of nasolabial flaps used for intraoral reconstruction: a report of two cases

The nasolabial flap has proved useful in facial and intraoral reconstruction. Two cases are presented where nasolabial flaps used for intraoral reconstruction were associated with tumour recurrence in the base of the nasolabial flap.

The management of tumours arising in the maxillary antrum

Eighty-eight cases of tumours arising in the maxillary antrum undergoing treatment between 1967 and 1989 are reported. The series comprised 34 females and 54 males. Sixty-two patients had squamous cell carcinoma (SCC). Forty of those with SCC were treated by XRT only, four cases by surgery only, while the remaining 18 patients had surgery and post-operative XRT as a combined modality treatment. Early SCC (T2N0) was adequately controlled by radical radiotherapy alone with a 5-year survival of 69.1%. In more advanced SCC (T3N0 and (T4N0) radical radiotherapy alone was less successful with the 5-year survival falling to 19%. Combined modality treatment comprising radical surgery followed by radical postoperative radiotherapy improved 5-year survival in advanced SCC to 61%. It is therefore recommended that if patients are treated for cure, major surgery followed by radical postoperative radiotherapy is preferable in advanced squamous tumours ((T3/T4) of the maxillary antrum.

An evaluation of functional outcome after surgery and radiotherapy for intraoral cancer

Two hundred and fifty five patients undergoing treatment for oral cancer were studied. Tumour site, classification and treatment modality were recorded and an assessment of their ability to swallow was made postoperatively. Patients were graded into one of three groups depending on dietary consistency. Pre- and postoperative dental examinations were made and patients were weighted pre- and postoperatively. Postoperative functional problems are outlined. The results indicated that 21% of the sample reported difficulty with swallowing solid foods and 46% were limited to semi-solid or liquid diets postoperatively; 16% were unable to wear upper or lower dentures postoperatively and 15% of edentulous patients were able to wear an upper denture only; 65% of the patients who had surgery and radiotherapy were unable to regain their preoperative weight after 6 months. Patients with T1 tumours who did not progress to radiotherapy faired much better postoperatively and were more likely to return to normal diet and regain their preoperative weight.

Buccal mucosal flaps in nasal reconstruction

Buccal mucosal flaps provide a simple and effective method of replacing nasal mucosal lining. This technique has been used in 15 patients requiring reconstruction of full thickness defects of the lateral nasal wall and tip of nose, in combination with a variety of local flaps for skin cover. The buccal mucosal flap is of particular value in reconstructing the common defect of the lower lateral nasal wall and alar rim where more bulky reconstructions often distort the airway.

Reducing morbidity in the radial forearm flap donor site

The radial forearm flap, although widely used, has been criticized for the poor quality of its donor site. To investigate the causes of morbidity, 100 radial artery free-flap donor sites have been reviewed. Sixty-seven patients required skin grafting (group 1), and the remaining 33 patients were closed directly (group 2). Seventeen patients in the series had compound osteocutaneous flaps (group 3). Wound healing proved to be a significant problem in groups 1 and 3, and fracture of the radius occurred in 4 of the 17 patients in group 3 and was the most significant cause of morbidity. The radial artery was reconstructed in 12 patients, but only 6 of the arteries (50 percent) were patent at the time of review. Subjective assessment on a scale of 0 to 10 demonstrated a relatively pain-free donor site with low pain scores (2.5 of 10). The cosmetic result was acceptable in men (1.5 of 10) but was less so in women (4 of 10). Angulated fracture of the radius produced an unacceptable cosmetic result (7 of 10). In light of this experience, we no longer reconstruct the radial artery as a matter of routine. The donor defect is closed directly wherever possible using an ulnar artery-based transposition flap when required. A "boat shaped" osteotomy is used in preference to right-angled bone cuts when harvesting a segment of radius to avoid the complications and sequelae of fracture. These changes in surgical technique have improved the acceptability and minimized the problems associated with this donor site.

Comparative study of technetium-99m bone scans and orthopantomography in determining mandible invasion in intraoral squamous cell carcinoma

The accuracy of preoperative assessment in determining invasion of the mandible by intraoral squamous cell carcinoma was analyzed in 48 patients who underwent mandibulectomy, and the results correlated with the histopathological reports of the resected specimens. Only 50% of the patients underwent the "ideal" surgery based primarily on clinical judgement, whereas 10 patients in the series were significantly undertreated. Clinical judgement and routine preoperative x-rays are accurate in cases where there is gross involvement of the mandible (17 of 19) but are significantly less successful in determining early bone invasion, invasion of the periosteum, or periosteal new bone formation. In such cases (26 of 48), a technetium-99m bone scan provides additional information. A grading system for reporting orthopantomographics (OPTs) and bone scans has been developed and utilized to form a reference grid to determine the optimum extent of mandibular surgery. The results show that using this protocol, unnecessary mandibular surgery may be reduced and inadequate surgical excision avoided.

Unexpected lymph node pathology in neck dissection for head and neck cancer

The pathological findings in 62 patients with head and neck cancers who underwent neck dissection during a 12-month period are presented. Histological confirmation of metastatic disease was obtained in 46 cases (74%). In the remaining 16 cases (26%), there was no evidence of metastasis from the primary tumor. In 7 cases (11%), there was unexpected pathology in the cervical lymph nodes which was not related to the primary tumor. Accurate clinical staging of head and neck tumors is made increasingly more difficult in such cases where unrelated or dual lymph node pathology exists.