Patrick Gullane

COMPLICATIONS OF CRANIOFACIAL RESECTION FOR MALIGNANT TUMORS OF THE SKULL BASE: REPORT OF AN INTERNATIONAL COLLABORATIVE STUDY

Advances in imaging, surgical technique, and perioperative care have made craniofacial resection (CFR) an effective and safe option for treating malignant tumors involving the skull base. The procedure does, however, have complications. Because of the relative rarity of these tumors, most existing data on postoperative complications come from individual reports of relatively small series of patients. This international collaborative report examines a large cohort of patients accumulated from multiple institutions with the aim of identifying patient‐related and tumor‐related predictors of postoperative morbidity and mortality and set a benchmark for future studies.

Craniofacial resection for malignant paranasal sinus tumors: Report of an international collaborative study

Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient‐related and tumor‐related predictors of prognosis after craniofacial resection (CFR).

Implications for Clinical Staging of Metastatic Cutaneous Squamous Carcinoma of the Head and Neck Based on a Multicenter Study of Treatment Outcomes

Cutaneous squamous cell carcinoma (SCC) of the head and neck is a common cancer that has the potential to metastasize to lymph nodes in the parotid gland and neck. Previous studies have highlighted limitations with the current TNM staging system for metastatic skin carcinoma. The aim of this study was to test a new staging system that may provide better discrimination between patient groups.

ETHMOID SINUS CANCER: TWENTY-NINE CASES MANAGED WITH PRIMARY RADIATION THERAPY

PURPOSE To describe the outcome of patients with carcinoma of the ethmoid sinus managed with a policy of primary radiation therapy with surgery for salvage of persistent or progressive disease. METHODS AND MATERIALS A retrospective chart review was undertaken of 29 patients with the diagnosis of carcinoma of the ethmoid complex who underwent treatment in the period between January 1976 and December 1994 at the Princess Margaret Hospital. Analysis was confined to those patients with epithelial invasive histology (squamous carcinoma, adenocarcinoma, or undifferentiated carcinoma) managed with curative intent with primary radiation therapy. The median patient age was 62, with a median follow-up time of 4 years. Staging was assigned according to a modification of the UICC 1997 system with 19 (66%) of patients presenting with T4 category tumors. The most common radiation dose regimes were 60 Gy in 30 daily fractions over 6 weeks, or 50 Gy in 20 daily fractions over 4 weeks. Outcome was analyzed with respect to overall survival, cause-specific survival, and local progression-free survival. The influence of a variety of clinical and therapeutic factors on outcome is discussed, the patterns of disease failure are described, and the rationale for this treatment approach is outlined. RESULTS The 5-year rates of overall survival, cause-specific survival, and local progression-free survival were 39%, 58%, and 41%, respectively. A total of 18 of 29 patients died during the period of review. Of these, 12 deaths were due to ethmoid cancer, one was due to a second primary lung cancer, and five were attributed to nononcologic causes. No patients died due to treatment-related toxicity. Increasing T category predicted for worse outcome on univariate analysis. Local progression was the major cause of treatment failure and was documented in 15 of 29 patients treated (52%). Six patients were offered salvage surgery for local progression, of whom two remained disease free at 15 and 17 months follow-up. CONCLUSIONS Outcome of patients with ethmoid cancer managed with primary radiation therapy with surgery for salvage is comparable to that achieved with planned combined modality approaches. Nevertheless, outcome remains poor and is dependent on the local extent of tumor, with 40-50% of patients eventually succumbing to disease.

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases

BACKGROUND AND PURPOSE Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution. MATERIALS AND METHODS A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110). RESULTS The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival. CONCLUSIONS This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

Role of hyperbaric oxygen therapy in the management of mandibular osteoradionecrosis

Hyperbaric oxygen (HBO) has been used as a tool in the management of osteoradionecrosis (ORN). However, it has not been conclusively proven to be of benefit. The precise role and guidelines for its use also have not been clearly defined. This report retrospectively analyzes 41 patients treated at the Hyperbaric Chamber Unit at the Toronto Hospital (Toronto General Division) with proven mandibular ORN from 1980 to 1985. The results show that 83% of the patients had a significant improvement with HBO therapy, judged by at least a 50% decrease in the size of the exposed bone, closing of the fistulous tract, or complete relief of symptoms. Within the group of patients who were significantly improved, 15% showed complete resolution of ORN. Seven (17%) of the patients did not benefit from the HBO. All seven patients had radiological evidence of dead bone. Based on these observations, the following conclusions can be made: 1. HBO is of benefit in the management of ORN. 2. Patients with ORN may be divided into two groups: mild and severe. 3. Cases of mild ORN will heal with HBO alone, but, in severe ORN, surgery is necessary to remove dead bone. 4. All patients with ORN should receive dental evaluation, local wound care, and a strict oral hygiene regimen. Diseased teeth should be removed prior to radiotherapy. Subsequently, any teeth that became abscessed should be extracted in conjunction with prophylactic HBO. Antibiotics play an ancillary role in the management of ORN. For patients who have received radiation to the mandible, the authors propose regular follow-up in order to detect ORN at a time when HBO can arrest the disease.

Cerebrospinal Fluid Fistula Secondary to Ecchordosis Physaliphora

A patient with a large ecchordosis physaliphora extending from the sphenoid sinus into the subarachnoid space of the prepontine cistern and resulting in a cerebrospinal fluid fistula is described. Ecchordoses are most commonly asymptomatic and found only incidently at autopsy. This case report adds to the scant literature on symptomatic ecchordoses. The previously reported cases of symptomatic ecchordoses and intradural chordomas are briefly reviewed. Differentiation of chordoma and symptomatic ecchordosis may be difficult; however, the intradural location and relatively benign behavior of the latter are useful points. A discussion concerning the remnants of the notochord which persist in the adult and their role in the genesis of chordoma and ecchordosis physaliphora is also provided.

Mucoceles of the maxillary sinus

Antral mucoceles are a separate entity that must be distinguished from the common, dome-shaped lesions of the floor of the sinus that are also often, although inaccurately, referred to as mucoceles. The latter lesions are known by a variety of names, including pseudocysts, and are innocuous. True antral mucoceles are potentially destructive lesions that are often secondary to trauma, especially the Caldwell-Luc procedure. This article describes in some detail the clinical, radiologic, and histopathologic features of true antral mucoceles. One type of antral mucocele, commonly seen in Japan, is referred to as a postoperative maxillary cyst and is identical to the surgical ciliated cyst of the maxilla originally reported by Gregory and Shafer.

Liposarcoma: Report of a case and review of the literature

Liposarcoma of the head and neck region is extremely rare. An additional case of pleomorphic liposarcoma of the buccal mucosa is reported, representing an even rarer combination. The importance of combined radiation and radical surgical therapy as a means of improving survival is emphasized.

Percutaneous feeding gastrostomy in patients with head and neck tumors: a 5-year review.

Since the beginning of this decade major advances have taken place in the alimentation of patients with tumors of the head and neck. Gauderer and Ponsky described a percutaneous method of gastrostomy and, in 1983, a number of radiologists, including the senior author, described a percutaneous radiologic method using the Seldinger technique to create a feeding gastrostomy. This method is ideally suited for patients with advanced tumors of the head and neck because it requires neither endoscopy nor general anesthesia. Over the past 5 years, 55 patients with tumors of the head and neck have undergone this procedure. Eighty‐one percent of the patients had advanced disease at initial presentation. One patient (1.8%) had a procedure‐related death and another patient (1.8%) had a complication that required a laparotomy. Three patients (5.4%) had minor complications that required minimal medical attention. None of the patients required general anesthesia and an endoscopy was not required. Patient discomfort during the procedure was minimal.