Daniel J. Archer

Tumour thickness predicts cervical nodal metastases and survival in early oral tongue cancer

Squamous cell carcinoma (SCC) of the oral tongue is characterized by a high propensity for cervical nodal metastasis, which affects the probability of regional control and survival. Until now, elective treatment of the clinically negative neck in early lesions (T(1-2)) of the oral tongue cancer remains controversial. This study attempted to identify predictive factor(s) for cervical nodal metastasis and treatment outcomes in patients with early stage SCC of the oral tongue treated primarily by surgery. Fifty patients with previously untreated Stage I/II primary tongue carcinomas with available archival specimens treated at the Royal Marsden Hospital between 1981 and 1998 were reviewed. Clinico-pathological features including age, gender, alcohol and tobacco consumption, tumour location, histological grade, tumour-stromal border, growth pattern, tumour thickness, and clinical stage were evaluated and the correlations with cervical metastases and outcome analysis were determined. The overall occult nodal metastatic rate was 40% (20/50). Tumour thickness exceeding 5 mm was statistically significantly correlated with cervical metastases (P = 0.003; relative risk = 2.429). No statistical correlation was observed between other clinico-pathological parameters and nodal metastasis. With a median follow-up of 98 months, 5-year actuarial overall, disease-specific (DSS), and relapse-free survival were 65.71, 67.77, and 68.18%, respectively. Univariate analysis for DSS showed poorer outcomes for patients with age > 60 years (P = 0.0423) and tumour thickness > 5 mm (P = 0.0067). The effect of tumour thickness was maintained (P = 0.005) on multivariate analysis. The present study indicates that the thickness of primary tumour has a strong predictive value for occult cervical metastasis and poor outcomes in patients with Stage I/II oral tongue SCC. Thus, elective neck treatment (surgery or irradiation) is indicated for tumours exceeding 5 mm thickness.

Head and neck sarcomas: prognostic factors and implications for treatment.

One hundred and thirty patients with soft tissue sarcoma of the head and neck were treated at the Royal Marsden Hospital between 1944 and 1988. Pathological review was possible in 103 of these cases; only pathologically reviewed cases have been analysed. The median age at presentation was 36 years, and 53% were male. Four had neurofibromatosis type I, and one previous bilateral retinoblastoma. Six had undergone previous radiotherapy, 12 to 45 years prior to developing sarcoma. The tumours were < or = 5 cm in 78% of cases and high grade in 48%. Only one patient presented with lymph node metastases and only one with distant metastases (to lung). Malignant fibrous histiocytoma was the commonest histological type, occurring in 30 cases. The overall 5 year survival was 50% (95% CI 39-60). Local tumour was the cause of death in 63% of cases and 5 year local control was only 47% (95% CI 36-58) with local recurrence occurring as late as 15 years after treatment. The only favourable independent prognostic factor for survival was the ability to perform surgery (other than biopsy), with or without radiotherapy, as opposed to radiotherapy alone (hazard ratio 0.39; P = 0.003). Only one patient had a biopsy with no further treatment. Favourable independent prognostic factors for local control at 5 years were site (tumours of the head as opposed to the neck, hazard ratio 0.42; P = 0.02) and modality of treatment (combined surgery and radiotherapy compared to either alone, hazard ratio 0.31; P = 0.002). Patients in the combined modality and single treatment modality groups were well balanced for T stage, grade and tumour site. The patients in the combined treatment group had less extensive surgery, yet their local recurrence-free survival was longer. Unlike soft tissue sarcomas at other sites, those in the head and neck region more often cause death by local recurrence. The addition of radiotherapy to surgery may result in longer local recurrence-free survival.

Radiation induced sarcoma of the head and neck.

Radiation‐induced sarcoma of the head and neck (RISHN) is a long‐term complication of treatment. The rarity of this tumour is reflected in the very few series reported in the English language medical literature. The incidence of RISHN is, however, likely to increase due to progressive aging of the population combined with improved survival in head and neck cancer patients resulting from better treatment regimes. Diagnosis and management of this problem can be extremely challenging and the overall outlook has been reported to be very bleak. As survival data from isolated case reports cannot be expected to provide reliable information on outcome, we have reviewed 69 cases reported in the English medical literature since 1966 and pooled this information with our experience in treatment of RISHN.

Cisplatin and 5-fluorouracil for symptom control in advanced salivary adenoid cystic carcinoma

Adenoid cystic carcinoma is a relatively rare tumour which arises in the parotid and submandibular salivary glands. Initial management is surgical, often with post-operative radiotherapy, but local relapse is common and distant metastasis not infrequent. Chemotherapy is generally reserved for cases where symptoms are not controlled by other means, since the tumour is slow growing and the response rate frequently disappointing. Cisplatin and 5-fluorouracil (5-FU) both show single agent activity in this disease but had not been previously investigated in combination. All patients referred for palliative chemotherapy of metastatic, symptomatic, histologically confirmed adenoid cystic carcinoma between November 1990 and February 1994 were considered for this study. The drugs were administered as follows: cisplatin 100 mg/m2 with appropriate pre- and post-hydration and 5-FU on a 4-day schedule of 1 g/m2/day. A total of 11 patients (7 male, 4 female) with median age 53 years (range 34-69) received 46 courses of chemotherapy (median four, range one to six). All patients had prior surgery and 8 had previously received radiotherapy. There were no objective responses of > 50% reduction in tumour size. 3 patients had a minor response and two progressed on treatment. The symptomatic response rate, however, was 64%, which compares favourably with other previously reported regimens. Toxicity was manageable. The median time to tumour progression was 9 months (range 0-38) and median survival was 12 months (range 1-65). This cisplatin/5-FU regimen would appear to produce a low rate of objective response but useful palliative benefits in advanced symptomatic adenoid cystic carcinoma. Prior series suggest that a higher objective response rate may be possible with a platinum/anthracycline/fluorouracil combination, and investigation of such a regimen is warranted.

Improved Access to Lesions of the Central Skull Base by Mobilization of the Zygoma: Experience with 54 Cases

Improved access to lesions at the medial end of the sphenoid wing or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study describes the operative technique we have adopted and records our experience with 55 operations in 54 patients who underwent the procedure in the past 3 years. Seven patients had vascular lesions, 44 had tumors, and 3 had miscellaneous lesions. The majority of the tumors were medial meningiomas, and particular note is made of those arising from the cavernous sinus with respect to their resectability. Sixteen of these tumors were encountered, and total excision was possible in 11 cases. Access to the infratemporal fossa is facilitated, and in 2 cases we were able to excise completely trigeminal neuromas that had extended there. The extra maneuver adds little to the overall operating time, and complications relating to it are uncommon, mild in degree, and usually self-limiting. We conclude that the operation is extremely valuable in appropriate circumstances.

Chondrosarcoma of the skull base: a series of eight cases.

Chondrosarcomas of the skull base are indolent, locally invasive tumors with a marked tendency to recur. Surgery is the mainstay of treatment because these tumors are generally resistant to other forms of treatment. A surgical approach with wide access to the skull base and one that is easily repeatable is required, because recurrence is common. We have used the LeFort I maxillotomy or mobilization of the zygoma at the time of craniotomy to obtain wide access to the skull base in eight cases of chondrosarcoma. Three patients have undergone subsequent procedures by us for recurrent disease. One patient died 30 days after the operation, and one has required an open repair of a cerebrospinal fluid leak. Good palliation of symptoms has been achieved in all survivors. These approaches fulfill the criteria for the surgical management of these difficult tumors by allowing excellent exposure, safe repetition if required, satisfactory palliation, and acceptable morbidity.

The role of genetic factors in predisposition to squamous cell cancer of the head and neck

© 1999 Cancer Research Campaign

Imaging after titanium cranioplasty

Titanium cranioplasty has been used in our unit for reconstruction of cranial defects following trauma, tumour resection and bone loss due to postcraniotomy infection. It has previously been assumed that imaging to assess recurrence of disease progression after cranioplasty would be severely compromised in the presence of metallic material. Titanium is a non-ferrous metal of low atomic number, which is relatively radiolucent and allows exceptionally clear images to be obtained without significant degradation of image quality, on CT and magnetic resonance (MR) imaging. Cases are presented that demonstrate the use of CT contrast cisternography and MR imaging after titanium cranioplasty. On the basis of its strength, biocompatibility and excellent handling characteristics, allied to its suitability for all post-operative imaging techniques, we conclude that titanium plate is the material of choice for cranioplasty.

Giant cell tumors of the sphenoid bone.

Giant cell tumors of the sphenoid are rare; there are 36 previously reported cases. We report two cases of these tumors in women in their thirties, both associated with pregnancy. In the first patient, the tumor was removed via a transnasal transsphenoidal approach. In the second patient, a Le Fort maxillotomy was required. In these cases, an interoperative diagnosis was made, and in both, this diagnosis directed surgical tactics towards a more radical excision. Reported experience with the outcome of giant cell tumors in other sites suggest that total removal by curettage is the ideal treatment; the main principle is to prevent local recurrence because the metastatic potential of this tumor is low. A combination of surgery and radiotherapy is essential for giant cell tumors occurring in sites where access is difficult, such as the sphenoid bone. Previous objections to radiotherapy have included poor response rate and malignant change. Recent studies suggest that neither of these problems is significant when modern therapeutic techniques are employed.

Chondrosarcoma of the Skull BaseA Series of Eight Cases

: Chondrosarcomas of the skull base are indolent, locally invasive tumors with a marked tendency to recur. Surgery is the mainstay of treatment because these tumors are generally resistant to other forms of treatment. A surgical approach with wide access to the skull base and one that is easily repeatable is required, because recurrence is common. We have used the LeFort I maxillotomy or mobilization of the zygoma at the time of craniotomy to obtain wide access to the skull base in eight cases of chondrosarcoma. Three patients have undergone subsequent procedures by us for recurrent disease. One patient died 30 days after the operation, and one has required an open repair of a cerebrospinal fluid leak. Good palliation of symptoms has been achieved in all survivors. These approaches fulfill the criteria for the surgical management of these difficult tumors by allowing excellent exposure, safe repetition if required, satisfactory palliation, and acceptable morbidity.