Frank P. Gerold

Ameloblastoma of maxilla and mandible

Results of various treatment modalities in 72 patients with ameloblastoma of mandible and 20 patients with ameloblastoma of maxilla are analyzed. Controversial methods of treatment are discussed to arrive at a semblance of rational management. It was found that: 1. Curettage was followed by local recurrence in 90% of mandibular and all maxillary ameloblastomas; 2. Subsequent resection could control 80% of mandibular but only a fraction of maxillary recurrences; 3. Marginal resection, in a few selected cases, might control primary cases of mandibular ameloblastoma but is not a useful procedure for recurrent mandibular ameloblastoma; 4. External radiation therapy was ineffective in controlling ameloblastoma but did not seem to adversely affect prognosis even after subsequent resection; and 5. Distant metastases, although rare, occurred in 7 patients.

Neuroendocrine carcinomas of the larynx. A study of two types, one of which mimics thyroid medullary carcinoma

We studied 13 neuroendocrine carcinomas of the larynx. They constituted 59% of the 22 nonepidermoid carcinomas of the larynx seen at Memorial Hospital during a 45-year period, and for which adequate material was available for review. Four tumors were histologically identical to small cell carcinomas of the lung and were classified as small cell neuroendocrine carcinomas (SCNC). One case represents one of the original descriptions of the laryngeal SCNC. No SCNC was argyrophil, and of the three studied immunohistochemically, all contained neuron-specific enolase, one carcinoembryonic antigen (CEA) and one serotonin. Nine tumors were large cell carcinomas (LCNC). Eight LCNC were argyrophil, and all nine contained neuron-specific enolase, six calcitonin, four CEA, one HCG, two serotonin, and two somatostatin. The laryngeal neuroendocrine carcinomas commonly presented in chronic cigarette smokers with mean ages of 63 (SCNC) and 60 (LCNC), were not associated with other endocrine tumors, and proved highly fatal in spite of radical surgery and radiation therapy. At last follow-up only one patient was alive (after 13 months). Patients dying with SCNC survived a mean of 11 months, and those with LCNC, 36 months. To determine whether the laryngeal LCNC most closely resembles pulmonary neuroendocrine tumors, head and neck paragangliomas, or thyroid medullary carcinoma (TMC), they were histologically, histochemically, and immunohistochemically compared with control cases of each group. Overall, LCNC most closely resembles TMC, and given the frequency with which each presents as a neck mass, misinterpretation of one for the other is very possible. Evidence is provided suggesting that some LCNC have also been mistaken for the laryngeal paraganglioma.

Myxoma of the jaw bones.

Myxoma is a peculiar and rare bone tumor of the jaws. During the last 50 years, 10 such cases were treated in the Memorial‐Sloan Kettering Cancer Center. Six were in the mandible and four in the maxilla. During that period, 8,723 primary bone tumors were treated in this hospital. Although this tumor is histologically benign, it has the potentiality of local invasion of the bone. Excision of the underlying bone whenever involved by the tumor should be done.

Percutaneous endoscopic gastrostomy and jejunostomy for long-term feeding in patients with cancer of the head and neck.

Enteral feeding is often required in patients with cancer of the head and neck. Percutaneous endoscopic gastrostomies (PEGs) and Jejunostomies (PEJs) can facilitate enteral feeding in patients who require this treatment. The endoscopic technique allows for the placement of feeding gastrostomies and Jejunostomies without a surgical procedure and eliminates the need for nasal tubes for long-term enteral feeding. Forty-two patients with head and neck tumors were referred for placement of PEGs because of severe dysphagia induced by tumors, surgery, radiation, or chemotherapy. The procedure was performed in the gastroenterology suite. Patients were sedated with intravenous meperidine and diazepam, and local anesthetic with lidocaine was applied to the area of incision. Average procedure time was approximately 20 minutes. The procedure was successful in 39 patients in whom tubes were placed ranging in diameter from 15F to 22F. PEGs were placed in 36 patients with intact stomachs and PEJs in three patients with previous gastrectomies. The remaining three procedures were unsuccessful because of technical reasons. There were three localized skin infections, and all responded to antibiotic therapy. Neither peritonitis nor any other immediate complication occurred. In 16 nonhospitalized patients, the procedure was performed on an outpatient basis. After a mean followup of 4.5 ± 6 months of enteral feeding in the home, there was only one case of aspiration and subsequent pneumonia, and this case responded to antibiotics. No other long-term complications were noted. Thus feeding gastrostomies and Jejunostomies can be placed safely and easily in patients with cancers of the head and neck by endoscopic methods without abdominal surgery. These tubes can be used for enteral feeding and eliminate the need for nasogastric tubes. They are better tolerated, are of a wider diameter, and have a reduced risk for migration, clogging, and aspiration-related complications.

Mandibulotomy approach to oropharyngeal tumors

We have reviewed our experience with 120 selected patients who had pharyngeal tumors resected through a median mandibulotomy approach with paralingual extension (mandibular swing). Clinical findings, technique, and complications are discussed. Results were gratifying in terms of salvage, patient appearance, and function. We believe that this surgical approach, in combination with postoperative radiotherapy when appropriate, offers an attractive alternative to high dose radiotherapy alone in patients with oropharyngeal carcinoma.

Gastric transposition in head and neck surgery. Indications, complications, and expectations.

From 1973 through 1982 a total of 63 of our patients had their upper alimentary tracts reconstructed after major ablative neck operations by transposition of the mobilized stomach into the neck through the bed of the resected esophagus. This gastric pull-up procedure was performed without thoracotomy using two surgical teams for resection of locally extensive primary tumors arising in the hypopharynx, cervical esophagus, and thyroid gland. Morbidity and mortality were significant but acceptable. Relatively few patients were cured, but excellent palliation was often achieved. In our experience, use of the transposed stomach for restoration of alimentary continuity after cervical esophagectomy or circumferential pharyngectomy offered greater reliability and versatility than other available methods.

The problem of neck relapse in early stage supraglottic larynx cancer

We reviewed the records of 104 patients with Stage T1NO or Stage T2NO epidermoid carcinoma of the supraglottic larynx treated between 1965 and 1979. In 79 patients, surgery was the only type of initial treatment. These 79 patients are the subjects of this report. Forty‐eight (61%) of these patients were treated by total laryngectomy, whereas 31 (39%) had a partial laryngectomy. An elective unilateral radical neck dissection was performed on 31 patients considered at high risk, butt metastatic disease was found in the dissected side of the neck histologically in only 32% (ten of 31) of these patients. The minimum follow‐up period was 5 years and the maximum was 20 years. Twenty‐nine percent of the patients (23 of 79) experienced a neck relapse. The neck relapse rate was the same whether the patients did or did not have an elective radical neck dissection. Among the patients who experienced a neck relapse, 65% (15 of 32) have died of the cancer. Among those who did not experience a neck relapse, none (zero of 56) have died of the cancer (P < 0.01). These results indicate that in surgically treated patients with early stage supraglottic larynx cancer, neck relapse was the major cause of failure associated with death from cancer. Strategies for decreasing the relapse rate are discussed.

Analysis of prognostic variables and results after supraglottic partial laryngectomy

A consecutive series of 78 patients who underwent conservation surgery for squamous cell carcinoma of the supraglottic larynx is analyzed. The majority of the patients were middle-aged men who had early-stage disease, with only 18 patients in stage III and 6 in stage IV. The epiglottis was the most frequent site, followed by the aryepiglottic fold and other sites in the supraglottic larynx. There was no operative mortality and the complication rate was low. Univariate analysis showed no influence of tumor stage, tumor differentiation, or involved surgical margins on survival. Determinate survival rates of 85 percent at 3 years and 72 percent at 5 years were observed. Local recurrences took place in 12 patients, 4 of whom were salvaged by total laryngectomy; neck failure occurred in 13 patients, 7 of whom were salvaged after further treatment; and 1 of the 2 patients with distant metastasis was salvaged after further treatment. We believe that every patient with a favorable lesion of the supraglottic larynx should be considered for conservation surgery, specifically, supraglottic partial laryngectomy, adhering to the criteria mentioned. Initial surgical treatment offers excellent local control and 5 year survival. Adjuvant postoperative radiotherapy may be considered in those patients with bulky primary tumors, positive surgical margins, and histologically confirmed cervical lymph node metastases.

Intraoperative radiotherapy in patients with recurrent head and neck cancer.

Patients with head and neck cancer who have a relapse of the disease above the clavicles can sometimes be salvaged by additional surgery. However, if all gross tumor cannot be removed during surgery or if the resection margins are unsatisfactory, the likelihood of salvage is remote, especially when postoperative radiotherapy is not feasible due to previous radiotherapy. Between 1979 and 1983, we employed intraoperative brachytherapy for 21 such patients. Sixteen patients had a recurrence after previous surgery and radiotherapy, and 5 after radical radiotherapy. All gross tumor could not be removed in 15 patients, whereas satisfactory margins could not be obtained in 6. In 11 patients, we delivered radiotherapy by a temporary implant of iridium-192 (median dose 4,800 rads in 6 days). In 10 patients, radiotherapy was delivered by a permanent implant of iodine-125 (median activity 13 mCi). Three patients (14 percent) had a relapse within the surgical field, whereas six others (28 percent) had a relapse elsewhere or had development of metastases. Complications developed in four patients (19 percent) and were fatal in one patient. The actuarial disease-free survival rate at 2 years was 55 percent, whereas the rate of local disease control was 81 percent. Our experience suggests that intraoperative brachytherapy can salvage certain high-risk patients with head and neck cancer.

A non-looping afterloading technique for base of tongue implants: Results in the first 20 patients

The results of treatment in the first 20 patients treated by a non-looping afterloading technique for base of tongue implant are described. Ten patients had carcinoma recurrent in the base of tongue after previous treatment and they were treated by implant alone. The other 10 patients had previously untreated carcinoma of the base of tongue and they were treated with a combination of interstitial implant, external radiation therapy and surgery. The minimum follow-up is 1 year and maximum 5 years. No local or regional failures have occurred in the previously untreated patients. No local failures have occurred in the previously treated patients who had lesions up to 4 cm in diameter, but three out of four patients with recurrent lesions larger than 4 cm have failed locally. Two patients developed necrosis related to the implant; the factors responsible for this are discussed.