Alando J. Ballantyne

Radical or modified neck dissection: A therapeutic dilemma

Three hundred ten evaluable patients received a classic, functional, or spinal accessory-nerve-sparing neck dissection during 1970 to 1975. The functional procedure was at least equal to the classic procedure in the patients in whom it was employed. The spinal accessory-nerve-sparing operation is offered as an alternative to the classic procedure in all patients in whom the nerve is not directly invaded by cancer. If these guidelines are followed, the patient will rarely experience the pain and shoulder dysfunction that result from the loss of the trapezius muscle, while the chances of control of cancer in the neck remain optimal.

Role of parotidectomy for skin cancer of the head and neck

Involvement of the parotid gland or periparotid nodes by direct extension from a skin cancer or metastasis from a present or previously treated skin cancer is an uncommon but potentially disastrous event. Aggressive surgery with sacrifice of necessary structures but preservation of the facial nerve and surrounding structures when feasible results in satisfactory local and regional control. The overall local or regional control rate was 70.9 percent. Isolated metastases to the parotid gland in patients with successfully treated nonbasal cell skin cancers are controlled locally or regionally in 84.2 percent of the 57 patients reviewed. The addition of radiotherapy should be considered in patients when warranted by the pathologic findings and clinical condition of the patient, however, it is not without complications.

Resections of the upper aerodigestive tract for locally invasive thyroid cancer

BACKGROUND In view of the indolent nature of most cancers of the thyroid, particularly of the papillary and follicular variety, the decision to remove a segment of the upper aerodigestive tract when the cancer is either close to or invading this area is a difficult one. It was felt relevant to review the experience at the M.D. Anderson Hospital to see when such resections were necessary, how they were repaired, and the survival rates. PATIENTS AND METHODS Of the 1,098 patients with cancers of the thyroid treated surgically at M.D. Anderson Cancer Center from 1954 to 1993, 46 underwent resections of some portion of the upper aerodigestive tract for invasive cancer. These included 35 patients who had histories of prior surgical treatment with or without radiation or radioactive iodine therapy. The operations included 27 total and 5 partial laryngectomies, 1 circumferential and 13 partial resections of the trachea, and 5 circumferential and 10 partial esophagectomies. Several patients had combinations of these procedures. Details of the repairs are provided. Postoperative radiation or radioactive iodine treatment was administered when indicated. RESULTS Local recurrence was infrequent. Most deaths occurred from either pulmonary metastasis or causes other than the cancer. The 5-year survival rate for all patients exceeded 50%. More than 70% of patients with papillary and follicular cancers survived for 5 years, and some for up to 30 years. CONCLUSIONS Although it cannot be stated with any degree of certainty if a resection of a portion of the upper aerodigestive tract should be done at the time of the initial surgical procedure, it is apparent that there are some situations in which the resection should be done because of severe local problems A variety of methods of repair are available, and the survival rate is greater than 50% for all such procedures, with those having the papillary and follicular variety surviving for 5 years in more than 70% of cases. Patients can exist with severe local problems for a number of years and it is sometimes the patient who decides when the resection should be done.

Analysis of survival and disease control in stage I melanoma of the head and neck.

From 1958 through 1969, 357 patients were treated for melanoma of the head and neck. Of these, 166 had invasive, clinical stage I disease. All patients had wide local excision of the primary. Elective regional node dissection was performed in sixty-nine patients and in the remaining ninety-seven observation only was elected. Retrospective analysis of these 166 patients considered (1) survival and disease control, (2) sites and timing of failures, and (3) the effect of sex, site, type of biopsy, skin grafting, and regional node dissection on disease control and survival. More than 80 per cent of the local recurrences developed within the first twenty-four months. Similarly, in the patients not undergoing initial neck dissection, 80 per cent of those who subsequently had clinically positive regional nodes did so within twenty-four months. In the sixty-nine patients undergoing elective regional node dissection, the survival rate was 33.5 per cent at five and ten years in those with histologically positive nodes. Those patients with elective neck dissections having histologically negative nodes had a survival rate of 75.8 and 67.1 per cent at five and ten years, respectively.

Malignant melanoma of the scalp.

Malignant melanoma of the scalp has a significantly worse prognosis than cutaneous melanoma arising in other head and neck sites. In this series, 125 patients were treated for Stage I invasive melanoma of the scalp and followed 3 to 19 years. Survival rates for these patients were calculated on the basis of several factors. Survival after treatment was not affected by the age and sex of the patient, size and site of the primary, or treatment of the primary lesion, although local failure was higher among those treated by primary excision and closure. Patients undergoing elective neck dissection with histologically negative nodes had significantly better survival rates than those with histologically positive nodes or patients in whom a neck dissection was not performed.

The infrahyoid musculocutaneous flap in head and neck reconstruction

The infrahyoid musculocutaneous flap (IHMF), as first described by Wang in 1986, is mainly nourished by the superior thyroid vessels through the perforators of the infrahyoid muscles (i.e., sternohyoid muscle, sternothyroid muscle, superior belly of the omohyoid muscle). This thin flap, usually extending from the hyoid bone to the sternal notch at the central part of the anterior neck, provides a skin island of about 4 by 8 cm. After these muscles have been divided from their origins, the flap can be freely transferred on its pedicle of superior thyroid artery to cover the soft tissue defect created after surgical ablation of cancer of the midface, parotid region, oral cavity, oropharnyx, or hypopharynx. From April 1987 to October 1990, our department successfully performed this flap procedure in 22 patients (cancer of the buccal mucosa 8, lower gum 5, floor of mouth 2, tongue 2, lower lip 2, parotid gland 1, skin 1, hemangioma of buccal mucosa 1). Two were treatment failures, three had partial dermal necrosis (distal third of flap surface), and the remainder had no major complications. The donor sites were closed either primarily or by means of a small, local skin flap. Contraindications to the flap are previous thyroid surgery, radical neck dissection, irradiation to the anterior neck, and hairy neck skin. We believe our results indicate that the IHMF is a versatile, reliable flap that may be used in combination with other regional flaps, such as the pectoralis major flap. It obviates the need for a microvascular free flap in many cases.

Synchronous bilateral neck dissection

The type of treatment used to control evident or possible metastatic cancer in the cervical region remains in dispute. When clinically positive lymph nodes are present in both sides of the neck, treatment to both sides is mandatory. If surgery is elected as the primary treatment, the neck dissection can be done bilaterally, either in one or two stages. Synchronous bilateral radical neck dissection has been associated with a high morbidity rate. It was the purpose of this paper to report the indications, complications, and results in a series of 179 synchronous bilateral neck dissections done between 1967 and 1979. In all except one instance, the internal jugular vein was saved on one or both sides. The mortality rate was 3.4 percent. Patients with histologically positive lymph nodes that were present bilaterally were found to have a reasonable prospect for cure. The rate of recurrence was related more to the inability to control the primary cancer than to treatment failure in the neck.

Reflections of a cancer observer

I am deeply honored to have been asked to present the Hayes Martin Memorial Lecture. My contacts with Dr. Martin were relatively brief and occurred in the 1950s when I started attending the meetings of this Society. He was an awe-inspiring figure, not only because of his commanding presence, but because of his many contributions to the art of head and neck surgery. I was fortunate, though, to work under Dr. William S. McComb, who was a colleague of Dr. Martins at Memorial Hospital, and so I learned from him much of the philosophy of Dr. Martin. The topic of this presentation caused much pondering, but I finally decided to select a topic that gave me great latitude for subject material. I would like to present some of my reflections gained by observing and treating patients with cancer of the head and neck over a 38-year period. The time spent by my observations is very brief when one considers that the Egyptian physicians of 5,000 years ago knew about and described cancer. Had observers been around 50 to 100 million years ago, they might have found that dinosaurs also had cancer--they certainly had bone tumors. The study of Egyptian skeletal remains has disclosed what seem to be osteogenic sarcomas in three instances and probably cancers of the nasopharynx in an additional three specimens [I]. Probable cancers have also been found in the skeletal remains of some Precolumbian Indians [2]. Cancer is indeed a very ancient disease, but its relative frequency seems to have changed now that individuals are living longer and diagnosis is more accurate. Undoubtedly, there also has been a real change in the incidence because of exposure to a multitude of carcinogenic agents and to changes in lifestyle and dietary habits. Cancer was apparently rare among Eskimos prior to the adoption of the white mans style of food consumption. It apparently was also uncommon among the early American Indians and the African natives [3]. Recently, doubt has been cast on the reported freedom from cancer, the fabled longevity, general strength, and happiness of the Hunzas living in their splendid isolation in the Karakoram Mountains [4]. During most of the 5,000-year time period of recorded history, cancer was only observed, for the means of treatment were few and consisted principally of surgery, ointments, purges, bloodletting, and incantations. We now have a far greater variety of treatments, but we seem to have forgotten incantations, which might be better than