A. Scott Earle

Simultaneous versus sequential combined technique therapy for squamous cell head and neck CANCER

Forty‐eight patients with locally confined (MO) squamous cell head and neck cancer were prospectively randomized to receive either simultaneous (SIM) or sequential (SEQ) combined technique therapy with a 5‐fluorouracil infusion, a cisplatin bolus injection, and radiation therapy. Patients with residual resectable disease underwent surgery after induction therapy, whereas those achieving a complete response to induction did not require surgery. Patients on the two treatment arms were equivalent in all measured variables, including disease extent. Toxicities of the SIM and SEQ arms also were equivalent except for mucositis and the resultant weight loss, which were more severe on the SIM arm (P = 0.002). With a follow‐up time ranging from 9 to 41 months, seven of the 24 SIM patients and 14 of the 24 SEQ patients are considered treatment failures. The relapse‐free survival is significantly better on the SIM arm (P = 0.03), although an overall survival advantage has not yet been demonstrated (P = 0.13). The achievement of a complete response after induction therapy correlates with both the relapse‐free (P = 0.0005) and overall (P = 0.05) survival, and the likelihood of an induction complete response also is significantly better for those treated with the SIM schedule (P = 0.02). Eighteen patients did not require surgery after achieving an induction complete response. Relapse‐free survival does not appear to be compromised in this patient subset.

Avulsion injuries of the thumb

Similar findings in a series of seven avulsions of the thumb suggest that this injury is a well-defined entity. In all cases avulsion was the result of catching the digit in a rotating machine. In most cases a glove was worn. The usual clinical findings included extrinsic tendon avulsion from the forearm, nerve avulsion from the median nerve within the carpal tunnel, extensive arterial damage in the amputated thumb, and partial degloving of soft tissues. Successful replantation was possible in every case. We believe that vein grafts should be used routinely, anastomosed to normal distal vessels. The site of nerve injury should be identified by dissection of the median nerve within the carpal tunnel. Retrograde flaps should not be sutured for wound closure. We believe that replantation should be attempted in all cases of thumb amputation in which the part is available.

Effect of nerve graft polarity on nerve regeneration and function.

To evaluate the effect of the polarity of nerve grafts, a 1.0 cm segment of sciatic nerve of 40 adult male Sprague-Dawley rats was excised. In 20 animals the nerve was sutured, maintaining the original polarity. In the order 20 the graft was reversed and sutured into place. Four to 6 months later, the nerves were exposed and directed conduction velocity and amplitude studies were done across the graft. No difference was found between the two groups. Comparison with the control side showed return of 70% to 75% of conduction velocity and amplitude. Nerve graft function was independent of nerve graft polarity.

Intraoperative Heparin in Replantation Surgery—an Experimental Study

An experimental study to define the usefulness of heparin in microvascular surgery was undertaken. Fifty-four rabbits underwent replantation of an amputated ear. The animals were randomly divided into two groups— “heparin” and “no heparin,” with 27 animals in each group. Arterial patency was recorded based on direct microscopic observation of the anastomosed vessels prior to wound closure and on subsequent viability or necrosis of the ear during the following week. Protection from closure during the surgical procedure was markedly enhanced by the use of intraoperative heparinization. The overall patency rate for the heparin group was 74%, whereas that of the no-heparin group was 44% —a statistically significant difference. This study confirms the value of intraoperative heparin in experimental replantation surgery using a rabbit ear model.

Concurrent radiation therapy, 5‐fluorouracil, and cisplatin for stage II, III, and IV, node‐negative, squamous cell head and neck cancer. Results and surgical implications

Methods. Between 1983 and 1989, 42 patients with Stage II, III, and IV, node‐negative, squamous cell head and neck cancer were treated with concurrent 5‐flUOrO‐uracil, cisplatin, and radiation therapy. Two courses of chemotherapy with 30 Gy of concurrent radiation therapy were to be followed in all patients by definitive surgery and then an additional 30 Gy of radiation therapy and one to two courses of chemotherapy. The patients who achieved a complete response to the initial induction treatment, however, did not undergo surgery.

A palmar cross-finger flap for coverage of thumb defects

We have devised a method of covering tissue defects of the distal thumb using a flap elevated between the two flexion creases on the palmar skin over the proximal phalanx of the long finger. The advantages of this method over the usual dorsally based, distal, cross-finger flap include improved appearance of the donor finger, comfortable positioning, and avoidance of joint contractures. Although sensitivity of the palmar scar, contractures, or other disadvantages of this approach were sought during follow-up, none were found.

Delayed definitive reconstruction of the burned hand: evolution of a program of care.

Experience gained in treating patients with hand burns admitted to an active Regional Burn Center has resulted in the development of a biphasic approach which separates early healing and later reconstructive surgical procedures. This schedule permits late definitive surgery on healed functioning hands and is accomplished in a single operation in most cases. This biphasic approach has led to better results at our institution in terms of hand function and appearance, and to a decrease in total numbers of surgical procedures. Reports of others using alternative methods and schedules, also with satisfactory results, are discussed.

Treatment of oral squamous cell carcinoma with simultaneous chemotherapy and radiation: results and surgical implications

Thirty-seven patients with oral squamous cell carcinoma, many with advanced disease, were treated initially with a protocol using simultaneous intravenous 5-fluorouracil (5-FU) cis-platinum, and radiation. Twenty-two patients (62%) experienced complete remission after one cycle of therapy. Fifteen patients (38%) demonstrated an incomplete response; surgical resection was possible in 14 of these 15 patients. A second cycle of chemoradiotherapy was administered to all 37 patients. After this treatment resection is possible for some patients who are initially inoperable, and surgery is necessary only for those patients (38%) who show an incomplete remission after the first cycle of therapy and for those who present initially with bony invasion. Furthermore, the treatment of cervical nodes and intraoral disease may be divorced and the extent of surgery may be reduced for many patients. A 5-year survival of 76% is predicted for this group of patients. The described protocol shows promise for treatment of oral squamous cell carcinoma.

Reduction mammaplasty and other skin excisions as sources of homograft skin

Abstract Homograft skin is often unavailable when most needed. We wish to call attention to a skin source which can supply fresh, viable grafts from healthy donors: the reduction mammaplasty and other skin excisions.