Kam H. Lam

Efficacy of radical neck dissection for the control of cervical metastasis after radiotherapy for nasopharyngeal carcinoma

Fifty-one patients who had persistent or recurrent neck disease from nasopharyngeal carcinoma after radiotherapy underwent radical neck dissection. The follow-up period ranged from 0.5 to 9 years (median: 2 years). Multiple cervical lymph node involvement was present in 51% of the patients (26 of 51). Malignant cells were detected in 88% of the resected specimens (45 of 51). The clinical sign of fixation of lymph node is the only factor that affects the successful control of neck disease (p = 0.04). Extracapsular extension of the nodal disease was present, and 35% of the lymph nodes were adherent to surrounding structures at operation (18 of 51). There was one hospital mortality and the overall morbidity was minimal. The actuarial survival at 5 years was 38%, and the probability of control of neck disease was 66%. Radical neck dissection is effective in controlling post-irradiation cervical metastasis from nasopharyngeal carcinoma.

Bronchoscopy and carcinoma of the esophagus I: Findings of bronchoscopy in carcinoma of the esophagus

Tracheobronchial involvement frequently occurs in patients with carcinoma of the esophagus. A study of the results of 525 bronchoscopies performed on patients with carcinoma of the esophagus who were evaluated for surgery revealed that abnormalities were found in 33.9 percent. The incidence was highest for those with cervical and upper-third thoracic tumors; however, a significant number of lower-third thoracic and abdominal tumors also showed abnormalities (12.5 and 5 percent, respectively). The incidence was also higher with large tumors, but again, a significant number of apparently small tumors also showed abnormalities. The abnormalities could be broadly classified into two groups: those showing only impingement and those showing actual invasion. Further studies are needed to determine whether the tumors with impingement are resectable.

Bronchoscopy and carcinoma of the esophagus II: carcinoma of the esophagus with tracheobronchial involvement

Involvement of the tracheobronchial tree, as observed through the bronchoscope, was in the form of impingement or invasion. Bronchoscopy was performed on 525 patients with carcinoma of the esophagus. Impingement was found in 91 patients and invasion in 87 patients. Forty-eight of the 63 patients with impingement and 7 of the 51 patients with invasion were found to have resectable tumors. Bypass operations were performed on the rest of the patients. The operative mortality was high for both bypass and resection procedures. The median survival for bypassed patients and resected patients were 4 months and 9 months, respectively. Four resected patients survived 3 years or more, 2 of whom had no evidence of recurrence. Most patients with impingement have resectable tumors and long-term survival is possible if the tumor can be resected.

Immediate Tracheoesophageal puncture for voice restoration in laryngopharyngeal resection

A 2-year prospective study on primary tracheoesophageal puncture was carried out to evaluate the morbidity of the procedure and its success in restoring speech. Fifty-two patients, 36 of whom suffered from carcinoma of the larynx and 16, carcinoma of the hypopharynx, were entered into the study. Thirty-three patients underwent total laryngectomy with primary pharyngeal closure, 14 patients had, in addition, pharyngectomy and pectoralis major myocutaneous flap reconstruction, and 5 patients had pharyngolaryngoesophagectomy and gastric transposition. Tracheoesophageal or tracheogastric speech was successful in 58, 86, and 80 percent, respectively. Manometric studies showed that the neopharyngeal sphincter pressure decreased in all instances, but a correlation between the neopharyngeal pressure and the success of tracheoesophageal speech was not demonstrable. The morbidity rate related to tracheoesophageal puncture was low. Therefore, we believe it to be a safe and feasible procedure that can facilitate early voice restoration.

Mandibular invasion in carcinoma of the lower alveolus

PURPOSE Efforts to conserve the mandible in resection for oral cancer tend to bring the resection margin progressively closer to the tumor front. This study of the manner of mandibular invasion by carcinoma of the lower alveolus provides added information regarding the behavior of the cancer within the bone. MATERIALS AND METHODS Twenty-four resected specimens of squamous carcinoma of the lower alveolus were studied with x-rays and step-serial whole-organ histological sections. RESULTS In 19 of the 21 specimens showing bone invasion, the spread was in the form of a broad front. Insinuation of tumor beyond the tumor front was extensive in 9 of 13 tumors showing deep mandibular invasion. Horizontal subcortical spread took place in 5 of 18 specimens for a distance of up to 1 cm. Perineural spread along the inferior alveolar nerve was found in 4 of 13 specimens in which the tumor extended to the canal; tumor spread along the canal, without neural involvement, was never seen. Preoperative orthopantomogram correctly estimated the extent of mandibular invasion in 16 of 24 patients. CONCLUSIONS The tumor front of mandibular invasion by carcinoma of the lower alveolus is usually broad. In the absence of deep invasion, which is defined by invasion reaching the alveolar canal, there is little or no insinuation of cancer cells beyond the tumor front, and no spread along the alveolar canal. Marginal mandibulectomy can be applied more widely, taking a margin of 1 cm in all directions.

Radial clearance in resection of hypopharyngeal cancer: an independent prognostic factor.

The depth of infiltration of tumor is of particular relevance in hypopharyngeal cancers, because most of them are seen late, and extensive infiltration into the muscle wall and the cartilage are not uncommon.

Reconstruction of hypopharyngeal defects in cancer surgery: Do we have a choice?☆

Abstract Between 1982 and 1985, 83 patients with hypopharyngeal or extensive laryngeal cancers underwent pharyngoesophagectomy (48 patients), circumferential pharyngectomy (8 patients), and partial pharyngectomy (27 patients), depending on the site and extent of tumor involvement. The resultant hypopharyngeal defects were reconstructed with gastric transposition, a tubed pectoralis major myocutaneous flap, and a pectoralis major flap patch, respectively. There were three hospital deaths in the gastric transposition group (6 percent) and none in both pectoralis major flap groups. The leakage rate was 8.3 percent in the gastric transposition group, 25 percent in the tubed pectoralis major flap group, and 3.7 percent in the pectoralis major flap patch group. Stricture was avoided with the interdigitation technique used at the tubed-flap-to-esophagus anastomosis, although the fistula rate was high. The overall complication rate was higher with gastric transposition. Although swallowing was satisfactory in all three groups, 42 percent of the patients with gastric transposition experienced regurgitation. Over a follow-up period of 16 to 50 months the local recurrence rate was 5 percent, and the actuarial survival rate was 55 percent at 24 months.

Healing between cartilage and bone ends: An experimental study☆☆☆

Whether healing or nonunion occurs at the junction between cartilage and bone was studied in an animal experimental model. The costochondral junctions of the floating ribs of rabbits were excised and the cut ends of bone and cartilage reapproximated with wire. The process of healing was then observed. Fibrocartilaginous callus formed in the first week. Beginning in the second week, this was gradually replaced by bony callus, a process which started from the medullary cavity of the bone end. The cut end of the original cartilage showed no activity. The periosteum and perichondrium became continuous at 4 weeks. The site of ossification assumed the appearance of the original costochondral junction. The gap between the original cartilage and the new cartilage disappeared when fusion occurred at 48 weeks. Osteochondral junctions at various periods after operation were subjected to disruption force until the junctions were pulled apart. The average force required to break 16 junctions was 2,738 g, and was not related to the period of healing.