Oliver H. Beahrs

Experience with 1,360 primary parotid tumors.

Experience with 1,360 primary parotid tumors seen at the Mayo Clinic during two fifteen year periods, 1940 through 1954 and 1955 through 1969, is reviewed. A comparison of histopathologic classification, type of treatment indicated, recurrence rates, and survival in the two periods reveals considerably greater understanding of all factors in the later fifteen year period. The relatively high mortality still encountered among patients with high grade malignant tumors of the parotid glands indicate the nature of the challenge still to be met. Based on the data in this study, it is our opinion that superficial or total conservative parotidectomy is best employed primarily for benign tumors and that the shift to more radical operative procedures should continue in the management of malignant tumors, especially those that are less well differentiated. For experienced surgeons, exceptions might be the small superficially located tumors or the tumors in the lower pole of the gland such as Warthins tumors. Local excision with removal of a margin of parotid parenchyma might be justifiable in such cases.

Primary squamous cell carcinoma and adenoacanthoma of the colon

Squamous cell carcinoma and adenoacanthoma rarely occur in the colon or upper rectum and are seen 0.05% as frequently as adenocarcinoma. At the Mavo Clinic, 20 patients with these lesions were seen during a 60‐year period. The most plausible explanation for the occurrence of these lesions is that glandular epithelioma is destroyed by deleterious influences and replaced by proliferation of basal cells which, with repeated destruction, undergo anaplasia and loss of ability to redifferentiate normally. The surgical treatment of these tumors is the same as that for adenocarcinoma. The 5‐year survival rate for patients with adenoacanthoma and squamous cell epithelioma is 30%, compared to 50% for patients with glandular cancers.

Primary malignant lymphoma of the thyroid: Review of forty-six cases☆

Abstract Forty-six cases of primary malignant lymphoma of the thyroid gland diagnosed and treated at the Mayo Clinic through 1964 have been classified into two groups based on the presence or absence of extension beyond the thyroid capsule. In the twenty cases marked by invasive spread or by involvement of local lymph nodes, the treatment was surgical resection (incomplete in eleven) followed by irradiation. Four of these patients survive (three probably cured) and sixteen are dead, of whom fifteen are believed to have died of lymphoma. Ten patients underwent biopsy of invasive inoperable malignant lymphoma and were treated by irradiation. Of these, six are dead of lymphoma and four are living and well twelve to forty-six months after therapy. Sixteen patients whose malignant lymphoma was confined within the capsule of the thyroid were treated by surgical resection (usually complete) with subsequent irradiation in all but one case. Of these, generalized fatal malignant lymphoma is known to have developed in only one. In five cases of Hashimotos thyroiditis, lymphoid variant, the therapy was subtotal resection without subsequent irradiation. Over a long period of observation, malignant lymphoma or recurrence has not developed in any patient. The presence or absence of locally invasive tendencies appears to be of major importance in the prognosis of primary thyroidal lymphoma.

Intraluminal involvement of the larynx and trachea by thyroid cancer.

Abstract Involvement of the larynx and trachea by thyroid cancer extensive enough to cause an intraluminal mass is rare. In a sixty year period at the Mayo Clinic, only eighteen patients (of 2,000 with thyroid cancer) had involvement that required surgical intervention. Of these eighteen, fifteen were forty years old or older. Seven patients had follicular carcinoma; six, papillary carcinoma; four, anaplastic carcinoma; and one, medullary carcinoma. Seven patients had tracheostomy; seven, laryngectomy; three, partial removal of the larynx or trachea; and one, bronchoscopy and partial removal of the tumor for biopsy. Of the eighteen patients, two died during tracheostomy, seven lived three months to three years after operation, one lived five and a half years, and seven are still alive nine months to eight years after operation. One of the patients was lost to follow-up study. Of the ten patients who have died, two died of causes unrelated to the thyroid cancer. Of the seven surviving patients, six had laryngectomy, and one had partial laryngectomy.

Neck dissection: Is it worthwhile?†‡

Data on 1,048 neck dissections in 881 patients were studied to evaluate the effectiveness of treatment in controlling cervical metastasis. Of the 881 patients, 74.5% were treated by surgery alone, and most of the reMaynder had either planned preoperative or postoperative radiation to the primary site and the entire neck. Planned preoperative or postoperative radiation was defined as the delivery of 4,000 rads or more to the entire neck 123 days before (preoperative) or after (postoperative) neck dissection. In these groups, most patients received more than 5,000 rads. Ninety‐six patients received preoperative radiation that did not satisfy these criteria and were grouped separately. The group with neck dissection alone had recurrence rates in the dissected side at 2 years of 7.5, 20.2, and 37.4%, respectively, for No, N1, and N2 staged necks. There were no differences in recurrence rates for the groups with radiated necks in the stage II (N2) necks compared with each other or with the group having surgery alone. Most recurrences, when they occurred in the neck, were manifest by 2 years. Mean follow‐up in the entire study was 3.5 years. Two patients were lost to follow‐up and were presumed to have died from cancer. When compared with pathologic staging, clinical staging was imprecise in one‐third of the cases.

The surgical anatomy and technic of parotidectomy

From the Section of Surgery, Mayo Clinic and Mayo Conversely, authors reporting comprehensive Foundation, Rochester, Minnesota. The Mayo Foundaanatomic studies understandably have avoided tion is a part of the Graduate School of the University of Minnesota . the simplification and practical presentation looked for by the surgeon . ORE than thirty years ago a few surgeons Results of ill planned operations in the described and employed satisfactory parotid region are seen frequently because surgical technics for the management of tumors many surgeons, although competent in other of the parotid gland . However, the observation fields, have little opportunity to acquire conbasic to these technics, namely that the facial fidence in this location, where lesions are relanerve lay in a dissectable cleavage plane within tively uncommon . To this extent, a didactic the gland, at first was ignored and then was description of anatomy and surgical technic contested for many years . The relative rarity appears justified. We have avoided formal and varied pathologic types of parotid tumors review of the literature and discussion of clinbrought confusion to pathologists and cliniicopathologic factors in the interest of brevity . cians, whereas the occurrence of tumors in an The following description of regional anatunfamiliar vascular region penetrated by filaomy includes only those details of structure ments of the nerve of facial expression fostered and variation having surgical significance . It timidity in surgeons . As a result, general is knowledge of the spatial relations of strucacceptance and modification of the basic protures adjacent to and traversing the gland that cedures came about slowly . is of primary importance to the surgeon underGradually, knowledge of the clinical behavior taking parotidectomy . Detailed knowledge of of parotid tumors has been accumulated, the the variable patterns of branching of the facial results of haphazard operative procedures nerve and parotid duct has little practical have been assessed and details of regional application in surgical treatment of the parotid anatomy have been elucidated . At this higher gland. This is particularly true if the trunk of level of understanding the indications for surthe seventh nerve is identified as an initial gical intervention are more clear and several step in the procedure, refinements of the original technics for parotidectomy are used commonly . SURGICAL ANATOMY

Tumors of the Submaxillary Gland

Abstract Study of 128 cases of neoplasms of the submaxillary gland in which operation was performed at the Mayo Clinic from 1936 through 1955 with careful attention to classification of the lesions and comparison of findings in the literature on other salivary tumors yielded the following observations and conclusions. 1. 1. Benign mixed tumor is the most common tumor found in the submaxillary gland. Its predominance, however, is less than in the parotid gland. 2. 2. Cylindroma is the most common malignant tumor in the submaxillary gland and is relatively more common in the submaxillary gland than in the parotid gland. 3. 3. Benign tumors of the submaxillary gland are found in younger patients than are malignant tumors. 4. 4. Benign tumors tend to be smaller, more stationary in size, give less pain and show less tendency to local invasion than do malignant tumors. 5. 5. Both benign and malignant tumors, that later recur, begin at an earlier age than tumors that do not recur. 6. 6. Removal of the entire submaxillary gland with the tumor is the treatment of choice for all benign tumors and well encapsulated malignant tumors. More radical surgical procedures are preferable for locally invasive malignant tumors. 7. 7. Recurrence is rare after surgical treatment of benign tumors of the submaxillary gland. 8. 8. Following adequate surgical treatment, approximately half of the patients with malignant tumors of the submaxillary gland will live five years without evidence of recurrence. 9. 9. Recurrence may develop in patients with cylindroma more than five years postoperatively, but a ten year follow-up without recurrence should be synonomous with cure.

Anal and perianal malignant neoplasms: Pathology and treatment

SummaryThe types of malignant anal and perianal neoplasms are reviewed. Factors affecting the choice of treatment and the survival in these cases include the type of malignant tumor, degree of anaplasia, stage of infiltration (including presence or absence of metastasis), and size and location of the lesion in relationship to the pectinate line. The final result in many cases may depend on the method of surgical treatment — radical or local excision—and, therefore, treatment should be selected with the pathologic findings in mind.

Management of the Facial Nerve in Parotid Gland Surgery

Abstract Sacrifice of the facial nerve leaves a severe cosmetic deformity, but is necessary in the management of some malignant tumors of the parotid gland. Of 1,600 patients with tumors of the parotid gland seen at the Mayo Clinic over a twenty-two year period, 296 had malignant tumors of this gland; part or all of the facial nerve was sacrificed in 102 patients. Removal of the nerve was more often necessary in patients who had had previous operation for tumor of the parotid gland or who had tumors of high degree of malignancy; it also was necessary in some cases of cylindroma. In general, it is concluded that for tumors of a moderate degree of malignancy (mucoepidermoid carcinoma, acinic cell carcinoma, and cylindroma [adenocystic carcinoma]) the nerve may be preserved; the need for partial or total sacrifice of the nerve is determined on a selective basis depending on the anatomic findings in the course of the operation. For more undifferentiated tumors, the nerve almost always should be sacrificed and the gland with the tumor can be removed en bloc. If the nerve has to be removed, a free nerve graft should be considered to bridge the defect; good results can be expected in more than 70 per cent of these cases.

Procidentia: Surgical treatment

SummaryThe surgical experience at the Mayo Clinic with 124 cases of rectal prolapse during the 16 years before December 31, 1967, has been presented. Anterior resection was performed in 28 patients, with one death and one recurrence (3.7 per cent); the Pemberton operation allowed recurrence in 22 of 68 cases (32.4 per cent); recurrence after the Altemeier procedure occurred in five of 13 cases (38.5 per cent). Other operations were of limited application. Combining a review of the surgical literature with our results allowed several conclusions about the efficacy of the various operations for this condition.Anterior resection, with or without suspension procedures, is recommended for good-risk patients of all ages, reserving the Thiersch operation for older, debilitated, poor-risk patients. The Pemberton procedure with suture of rectal stalks to the sacral fascia may be used in intermediate-risk groups. Those procedures reported by Ripstein and Wells deserve consideration.An attempt has been made to evaluate incontinence preoperatively and postoperatively, and to judge the efficacy of various operations in improving or preventing incontinence. This remains an enigma.