Neil R. McLean

Malignant tumours of the parotid gland: a 12-year review

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.

A review of 120 Becker permanent tissue expanders in reconstruction of the breast

In reconstructive breast surgery, the permanent tissue expander has become popular because it avoids expander-implant exchange and gives the patient some control over the final breast size. It may, however, be associated with a number of complications. We therefore analysed the clinical notes of 111 consecutive recipients of Becker breast expanders with respect to complications and their possible predisposing factors. 120 prostheses were inserted in 111 consecutive patients with a mean age of 42.6 years. Median follow-up was 12 months (range 8 to 22). The commonest indication was postmastectomy breast reconstruction (81%) followed by congenital hypoplasia (14%) and acquired breast asymmetry following repeated biopsies (3%). Overexpansion before size adjustment was achieved after an average of 8 expander inflations. Complications included capsular contracture (9%), local tumour recurrence (8%), wound dehiscence (8%), filling port failure (6%), infected prostheses (4.5%) and ruptured implants (1.6%). The significant predisposing factors to wound dehiscence/infection were heavy smoking and radiotherapy (P < or = 0.05, chi 2 test). Expansion rate was not a factor. 89% of patients expressed satisfaction with the final aesthetic result. Despite the excellent results obtained with this technique, caution must be exercised in heavy smokers and the previously irradiated.

Radiological imaging in primary parotid malignancy

In a retrospective analysis of the preoperative imaging of patients presenting with primary malignant parotid disease, all relevant images were collected and reviewed by two experienced head and neck radiologists, blinded to the diagnosis. Forty-two patients (25 male, 17 female), median age 67.5 years (range 15-86), were included in the study of which 32 had undergone CT scanning, nine MR and three ultrasound. Forty tumours (93%) were correctly diagnosed as malignant when compared with histology. The two false negatives arose in a patient who had received an ultrasound scan only and in a patient with lymphoma, whose CT scan was reported as a pleomorphic adenoma. Neither had undergone prior radiotherapy. A poorly defined tumour boundary was the most consistent observation for both MR and CT images for the malignant tumours examined. Local infiltration was correctly correlated with pathological findings in eight of the nine MR scans, however, CT proved less reliable, correct in 14 of 24 cases (p=0.01). No correlation was identified between any of the imaging features examined and the final histological diagnosis. A poorly defined tumour boundary with evidence of local invasion was the best indicator of malignancy and was reported more frequently from MR scans than from CT. Imaging alone, however, proved unreliable in the prediction of final histological diagnosis or grade of tumour.

The role of MRI scanning in the diagnosis of cervical lymphadenopathy

In a blind, prospective trial, 42 patients undergoing 51 cervical lymph node dissections for head and neck malignancies were investigated by a preoperative MRI scan. Histological examination of the dissection specimens recorded the distribution, size, percentage of neoplastic involvement and any extra-capsular spread of the sampled nodes. The MRI correctly diagnosed all 17 positive nodes (sensitivity 100%). However it could not differentiate between enlarged reactive and malignant nodes, so there was a significant false positive rate (specificity 53%). Routine use of MRI scans will allow an unnecessary neck dissection to be avoided in a patient with a clinically negative neck who also has a negative MRI scan.

Mucous cyst of the alar base: a rare complication following rhinoplasty

Mucous cyst formation following rhinoplasty is a rare complication and typically presents late. Previously reported cases invariably involve the dorsum of the nose or nasal tip. We present a case where this unusual lesion was found to involve the alar base.

How does sepsis promote thrombosis in microvascular anastomoses

This study on 100 rats, divided into five equal groups, has shown that chronic distant sepsis promotes occlusion of microvascular anastomoses to a significantly greater extent than aseptic inflammation, transient bacteraemia and even local infection. This may be related to the significant increase in the number of platelets in the group with distant sepsis.

Malignant peripheral nerve sheath tumour metastasising to the parotid gland

Two rare cases of metastases from malignant peripheral nerve sheath tumours (MPNST) of the head and neck are described. The initial lesions were superficial, but despite early diagnosis and complete excision, they metastasised to the ipsilateral parotid gland. Both underwent further complete excision and neither metastatic lesion showed progression in grade. One patient is alive, however, the other died of widespread metastases. There are no other reported cases of these sarcomas in the head and neck metastasising to the parotid gland.

What is the impact of breast augmentation on the Breast Screening Programme

AIMS To identify the number of women with breast implants in the Newcastle Breast Screening Programme, its additional workload and compare the number of screen detected cancers in the implant and non-implant group. METHODS Retrospective 9 year review of all women with cosmetic breast augmentation who have joined the National Breast Screening Programme in Newcastle. RESULTS The percentage of total screened attendances involving implants has increased from 61 (0.10%) in 1990-93 to 97 (0.14%) in 1993-96 and 135 (0.23%) in 1996-99. Despite this increasing workload, no additional resources have yet been required in the Breast Screening Unit.1209 cancers (0.57%) were found in the screened population, and there were no screen detected cancers in the implant group, and there was no significant difference between the groups. CONCLUSIONS As the number of younger women receiving breast implants continues to rise, when they become eligible for the National Health Service Breast Screening Programme (NHSBSP), departments should be aware that additional personnel and finance will be needed.