Michael E. Johns

Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative radiotherapy.

From 1975 to 1987, 87 patients with carcinomas of the major salivary glands (70 parotid and 17 submandibular) were treated at our institution by either surgery or surgery followed by postoperative radiotherapy (RT). Surgical procedures included superficial (24%) or total (56%) parotidectomies and submandibular gland resection (20%). Postoperative RT usually began 2 to 4 weeks following surgery. Using 4 MV photons or, infrequently, 60Co, the majority of patients received 6000 cGy in 6 weeks to the parotid region (ranged from 4500 to 7000 cGy). Determinant actuarial survival was 74% at 5 years and 71% at 10 years. For patients with previously untreated disease, 5 of 19 (26%) treated by surgery alone experienced local recurrence, whereas only 2 of 50 (4%) recurred locally following surgery plus postoperative RT (p = 0.01). For patients presenting with recurrent disease, 4/4 (100%) failed locally following surgery as opposed to 3/14 (21%) following surgery plus postoperative RT (p = 0.01). The determinant 5-year actuarial survival for patients receiving postoperative RT was 75% versus 59% for surgery alone. Results were analyzed by multivariate methods using determinant survival or recurrence as endpoints. Five important prognostic factors were identified. (a) Facial nerve paresis was predictive of poor outcome (p less than 0.001) with 3-year relapse free survival of 13%. (b) Undifferentiated histology was associated with decreased survival (p = 0.002). (c) Male sex was associated with poor outcome (p = 0.008). (d) Skin invasion resulted in decreased survival (p = 0.012). (e) Radiotherapy was associated with improved survival (p = 0.014). In addition, postoperative RT was effective in preventing local recurrence (p less than 0.001). The data demonstrate the efficacy of postoperative RT in improving survival and local control for patients with carcinomas of the major salivary glands.

Platysma myocutaneous flap for intraoral reconstruction

Fourteen patients were treated for intraoral epidermoid carcinoma with a single stage reconstructive technic employing a myocutaneous flap based upon the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The flap has proved to be highly reliable and has significant benefits over many other technics commonly employed for head and neck reconstruction.

Aspergillosis of the nose and paranasal sinuses

Aspergillosis of the nose and paranasal sinuses should not be considered an innocuous disease. In a review of 103 cases, other than in the Sudan, the mortality rate was 16 per cent. Intracranial extension of the fungus from the nose and sinuses carries a grave prognosis. Although aspergillosis occurs frequently in patients debilitated from other diseases, this is not always the case, and most deaths in the review series occurred in otherwise healthy individuals. The authors present eight cases of their own.

Warthin's tumor: a 40-year experience at The Johns Hopkins Hospital.

Warthins tumor previously has been thought to occur much more commonly in men than in women and rarely in African Americans. One hundred thirty‐two cases of Warthins tumor treated at The Johns Hopkins Hospital from 1952 to 1992 were retrospectively reviewed. There were 90 (68%) men and 42 (32%) women, with an overall man‐to‐woman ratio of 2.2:1. The number and percentage of women with Warthins tumor increased over each consecutive decade: 1952 to 1962, 5 (21%); 1963 to 1972, 6 (29%); 1973 to 1982, 11 (31%); and 1983 to 1992, 20 (39%). A positive smoking history was found in 88% of the men and in 89% of the women with a Warthins tumor. Eleven (8%) African Americans and 1 (0.75%) Asian American were diagnosed to have a Warthins tumor. Also, the incidence of African Americans with a Warthins tumor increased over each decade: 0 (0%), 1 (4.8%), 2 (5.5%), and 8 (16%). This studys results indicate a progressive increase in the occurrence of this tumor in women and in African Americans and a higher overall incidence in African Americans than previously reported.

The versatile midface degloving approach

The exposure obtained using the degloving approach is superb and the absence of resultant facial scar or deformity provides a dramatic new addition to the otolaryngologists surgical repertoire. The advantages of the degloving technique in exposure of the midface, nasal cavities, paranasal sinuses, nasopharynx, skull base, and clivus have led to its increasing importance in the otolaryngology literature. Within 2 years of the techniques introduction in our department, it had been used 48 times for a wide variety of problems, including inverting papilloma, juvenile angiofibroma, chordoma and selected cases of fungal disease of the sinuses.

The pericranial flap for reconstruction of anterior skull base defects

In 1981, the senior author first reported the use of the pericranial flap for support of the brain following resection of the anterior skull base. Since the initial report, considerable experience has been gained with this flap. It is currently deployed via a bifrontal craniotomy and is placed primarily as a support beneath the frontal lobes. The pericranial flap may also be used to repair dural laceration and defects. The sinonasal surface is routinely grafted with split‐thickness skin or dermis.

Oncocytic and oncocytoid tumors of the salivary glands

Histochemistry and electron microscopy have now enabled investigators to define precisely the oncocyte of salivary tissue. By these techniques, all oncocytes are characterized by a rich complement of mitochondria and most often by high oxidative enzyme activity.

Response of esthesioneuroblastoma to chemotherapy report of five cases and review of the literature

Five patients with advanced stage or metastatic esthesioneuroblastoma treated with chemotherapy are reported, and another eight cases found in the literature are reviewed. In this collective experience with chemotherapy in this disease, the authors found that 8 of 13 patients (62%) had an objective response to chemotherapy. The agents which may be active in this disease and the role of chemotherapy, particularly adjuvant therapy for patients presenting with advanced disease, are discussed. Cancer 53:1036‐1041, 1984.

Chemotherapy for salivary gland cancer.

Because of the scarcity of such lesions, little is known about the efficacy of chemotherapy for advanced salivary gland cancers. Although surgery and irradiation are the mainstays of treatment, patients with recurrent tumors and those with unresectable or metastatic cancer are not candidates for this usual approach. Ten patients with recurrent, metastatic, or unresectable salivary gland tumors were treated with combination chemotherapy, primarily with cisplatin, doxorubicin hydrochloride (Adriamycin), and cyclophosphamide, or cisplatin with 5-fluorouracil. In patients whose tumors exhibited no response, second-line drugs were used. The overall response rate was 50%—with one complete response—but the duration of response was short. This report contributes to the growing data base that demonstrates definite chemosensitivity of these tumors. To date, 116 patients have been reviewed. Adenocarcinoma-like cancers respond best to cisplatin, doxorubicin hydrochloride, and 5-fluorouracil. Highgrade mucoepidermoid carcinoma may show a sensitivity similar to that of squamous cell carcinoma. Multi-institutional protocols need to be developed to assess the roles of adjuvant and palliative chemotherapy in the treatment of salivary gland cancer.

Small cell undifferentiated carcinoma of the larynx. Report of two patients and review of 13 additional cases.

Two patients with small cell undifferentiated carcinoma of the larynx (SCUCL) are described and 13 additional well‐documented cases are reviewed. SCUCL affects middle‐aged and elderly smokers and has a 2:1 male predominance. Half the patients presented with cervical metastases, an additional 43% developed regional metastases, and 71% ultimately had distant metastases. Thyroid gland involvement occurred in 29% of cases. Ten of fourteen patients had died of their neoplasms (mean survival, 7.8 months). One was living with unresectable tumor. Three were clinically disease‐free, 30, 15, and six months, respectively, after diagnosis. Following initial therapy, six patients had recurrent or persistent local tumor or regional metastases. None of them received both total laryngectomy and ipsilateral cervical lymphadenectomy. Four of the six patients had radiation, suggesting that radiotherapy was not always effective in the control of local or regional disease when used in lieu of more extensive surgery. Three patients received chemotherapy, in addition to other modes of treatment, and their mean survival compared favorably with the overall group. The tumor from one of the patients contained a squamous component, and, ultrastructurally, both neoplasms had squamous and neuroendocrine features.