Robert C. Hoye

The ethmoid sinuses: A re-evaluation of surgical resection*

Summary The combined intracranial transfacial approach to the ethmoid, sphenoid, and frontal sinuses has been satisfactory in performing en bloc resection of cancer arising in or involving these anatomic areas. Fifty-four patients have been treated with this procedure, using the combined expertise of the neurosurgeon and the surgeon interested in the head and neck area. Two postoperative deaths have occurred, both attributed to meningitis. The long range postoperative morbidity is negligible, except as it relates to loss of the palate in all but eight patients and the orbital contents in thirty patients. The cumulative five year survival in this series of patients, forty-two of whom had failure of previous treatment, is 56 per cent. If the procedure is carried out with rigid attention to good surgical technic and the principles of en bloc tumor removal, this combined procedure has the following advantages: (1) allows accurate evaluation of the intracranial tumor extension, (2) protects the brain, (3) avoids cerebrospinal fistulization, (4) provides adequate hemostasis, (5) facilitates en bloc tumor resection, and (6) selectively conserves the orbital contents.

Prognostic significance of histologic host response in cancer of the larynx or hypopharynx

A series of 84 patients with carcinoma of the larynx or hypopharynx was studied with regard to tumor host interaction. Prognostic evaluation of the “tumor” aspects of this interaction included preoperative staging (TNM), histologic grading of the primary tumor, and histologic examination for the presence of metastases confined to regional lymph nodes or extranodal spread. Morphological evidence of host resistance was judged by the presence and degree of lymphoid inflammatory infiltration around the primary tumor and factors suggestive of enhanced immune reactivity in lymph nodes, i.e., sinus histiocytosis, germinal center hyperplasia, plasmacytosis, and the presence of pyroninophilic blast cells. Of the factors evaluated, those which appeared to correlate best with 5‐year survival were stage of disease, presence or absence of positive regional nodes, histologic grade of the primary tumor, lymphoid infiltration in the primary tumor, and extensive germinal center hyperpiasia in the regional nodes. The favorable prognosis attached to the presence of lymphoid infiltration or germinal center hyperpiasia, however, was not uniform for all patients. The presence of lymphoid infiltration was a favorable sign only in the group of patients with positive nodes or in those patients with well‐differentiated (Grade I, II) tumors. The presence of extensive germinal center hyperpiasia was a favorable prognostic sign only in those patients with positive nodes or in those patients who had a poorly differentiated (Grade III, IV) tumor. None of the other morphological structures related to lymph node reactivity showed favorable prognostic significance. The relationship of morphology to host immune mechanisms was discussed.

Complications of intracranial facial resection for tumors of the paranasal sinuses

Abstract This review of the complications which developed in twenty-three of thirty-one patients who underwent a combined intracranial facial approach to the paranasal sinuses indicates that the cribriform plate and ethmoid sinuses can be safely resected. Two deaths (7 per cent) were associated with four instances of meningitis, the most severe of the complications encountered. Complications such as facial edema, cellulitis, wound and bone infection, cerebrospinal fluid leaks, diplopia, postoperative bleeding, and slough of graft were treated without subsequent disability. A greatly increased survival free of disease in this group of patients, 68 per cent of whom had not responded to treatment, indicates that the procedure should continue to be more frequently used to control paranasal sinus malignancy.

Spontaneous carotid artery hemorrhage after head and neck surgery.

Abstract Through a planned program of anticipation and repeated orientation of all surgical personnel to the problems and procedures to be followed, seventeen of nineteen instances of massive spontaneous hemorrhage of the carotid artery have been successfully controlled. The restoration and stabilization of the patients vital signs by point-pressure control of bleeding, maintenance of adequate ventilation, and rapid blood volume restoration, together with the emergency mobilization of hospital facilities, have allowed all but three of these patients to undergo successful ligation. No neurologic defects have resulted, and all have been restored to their prior “blowout” ambulatory status. Removal of a portion of the medial clavicle often facilitated ligation and wound closure. The common etiologic factor in this series of spontaneous hemorrhage of the carotid artery has been the combination of surgery for postirradiation recurrent cancer which was subsequently followed by wound breakdown secondary to tissue necrosis or fistula formation. In addition, tumor either grossly or microscopically has been present in at least seven instances. Three carotid artery hemorrhages in two patients occurred from infection alone after radical surgery. The incidence of spontaneous hemorrhage of the carotid artery has significantly decreased since, at the time of surgery, skin incisions overlying the carotid are avoided, all carotids are routinely covered with muscle flaps, and antibiotic prophylaxis is employed.

High dose methotrexate as a preoperative adjuvant in the treatment of epidermoid carcinoma of the head and neck: A feasibility study and clinical trial☆

Thirty patients with operable epidermoid carcinoma of the head and neck were treated with intravenous high dose methotrexate and leucovorin rescue prior to resection. Their clinical courses were compared with those of thirty randomly selected patients matched for tumors site and clinical stage who were treated by surgery alone. No medical or surgical complications associated with methotrexate were encountered. An objective decrease in tumor size (primary lesion or nodal metastases) was noted prior to resection in twenty-three patients (77 per cent). The number of recurrences in the two groups was similar. However, these was a significantly greater disease-free interval in the methotrexate-treated patients (p less than 0.05). No significant differences in survival have been noted to date between the two groups. In view of the absence of complications, the regressions in tumor size, and the increase in postoperative disease-free interval in this trial, evaluation as preoperative adjuvants of higher doses of methotrexate and of other chemotherapeutic agents in combination with methotrexate appears warranted.

Pelvic exenteration for carcinoma of the uterine cervix. A 15-year experience.

From 1954 to 1969, 162 patients at the National Cancer Institute were treated with pelvic exenterations for carcinoma of the uterine cervix. A total cumulative 5‐year survival of 38% was obtained. Sixty‐eight of these patients presented with large, previously untreated lesions not amenable to lesser curative therapy. Their actuarial 5‐year survival was 48%. The remaining 94 patients were treated for radiation recurrent cancer with a 5‐year actuarial survival of 28%. Positive pelvic lymph nodes did not affect prognosis in patients treated for primary cancer, but survival decreased to 11% in those patients with recurrent disease and positive pelvic nodes. The 30‐day mortality was 7%, and the total intrahospital mortality was 17% (1 to 108 days). This mortality correlated with previous radiotherapy, patient age, preoperative medical status, operative time, and intraoperative transfusion requirements. Operative time and intraoperative transfusion requirements appeared to be related to the relative experience of the 17 surgeons involved in this study. Postoperative complications were similarly related to the above factors and have increased over the years in proportion to the degree that preoperative selection criteria have been liberalized. Over the 15 years encompassed in this study, there has been, however, a steady significant increase in cumulative 5‐year survival. Criteria for patient selection for pelvic exenteration are outlined, and salient suggestions are made for operative and postoperative management.

Delayed intestinal obstruction following treatment for cancer.

A review of 117 patients who have been treated for cancer and subsequently developed 173 episodes of intestinal obstruction has established guidelines for the management of the cancer patient with abdominal distress. Operative intervention is the treatment of choice for intestinal obstruction occurring in a patient previously treated for a malignant neoplasm. Approximately one fourth of such patients will have intestinal obstructions which are not caused by recurrence of, or metastases from, the neoplasm for which they had been previously treated. In these patients, obstruction may be due to a new primary cancer or to nonneoplastic disease. The prognosis for such patients is good, with a long‐term survival of 40%. When intestinal obstruction is due to recurrent or metastatic neoplasm, significant palliation may be expected by surgically relieving the intestinal obstruction even when multiple episodes are experienced. The interval of palliation following each subsequent obstruction is, however, of progressively shorter duration. Nonoperative management of these patients has been uniformly unsuccessful. Repeated exploration and bowel resection is indicated for palliation and, on occasion, may be curative even when intestinal obstruction is due to local recurrence of cancer.

Irradiation twenty-four hours preoperatively☆

Abstract A clinical study of preoperative irradiation was established as a result of experimental studies which indicated that local recurrence and metastases could essentially be eliminated by administering preoperative irradiation. Using a single 2,000 or 1,500 r dose twenty-four hours before surgery, there was a high incidence of complications. Seventy-nine patients were then studied in a carefully controlled double-blind study using 1,000 r preoperatively. All lesions were squamous cell cancers of the oral pharyngolaryngeal area and were excised by standard but aggressive surgical procedures. The postoperative complications were significantly increased in the patients with irradiation. Although there was a definite trend toward the decrease of local recurrence with preoperative irradiation, there was no statistically significant decrease in the local recurrence rate in the operative wound, nor was there any tendency toward the decrease in incidence of metastases; neither was patient survival prolonged. A carefully controlled and double-blind clinical study gave results which again indicated that tumors in human subjects do not necessarily behave as expected on the basis of studies of experimental tumor systems.

Laser Effects on Normal and Tumor Tissue

Early reports of experimental and clinical applications, using the intense, coherent, monochromatic laser energy for selected surgical procedures, were published by McGuff et al. (1963) and Helsper et al. (1964). In some instances these observations suggested that ruby laser energy (694.3 nm) partially destroyed tumor tissue which, later, was followed by a delayed remission of the entire tumor. Permanent tumor cures were obtained on certain strains of transplanted melanoma growing in laboratory animals. A year later, McGuff et al. (1964) reported the successful destruction of subcutaneous human tumor, and Goldman et al. (1964) nevi and melanomas. Enthusiasm in surgical research was sparked by such successes but was constrained by the limited availability of suitable apparatus and qualified technical personnel.

Pulmonary effects of autotransfused blood: A comparison of fresh autologous and stored blood with blood retrieved from the pleural cavity in an in situ lung perfusion model

Abstract An in situ pulmonary lobe perfusion model in dogs was used to examine the pulmonary effects of autotransfused blood as compared with fresh and stored blood. Fresh arterial blood was collected in heparin solution from ten dogs and was drained into and collected from the pleural cavity using a commercially available autotransfusion device for continuous filtration. Results of perfusion with autotransfused blood were compared with results of perfusion of blood stored at 4 °C in ACD solution for twenty-four hours in seven dogs and those of perfusion of blood stored for twenty-one days at 4 °C in ACD solution in seven dogs. The fresh and stored blood samples were passed through a standard recipient set filter prior to perfusion. Perfusion with autotransfused blood resulted in a decreased arteriovenous pO 2 gradient as compared with results in control blood, but there was no concomitant elevation in pulmonary vascular resistance (PVR) or endobronchial pressure (P b ) for the autotransfused blood. Stored blood by comparison showed significantly increased PVR and P b but a progressive decline in A-VpO 2 which was in excess of the level reached by perfusion of autotransfused blood. Fresh blood showed essentially no change in pulmonary functional parameters during perfusion. The great majority of animals whose lungs were perfused with stored blood had microscopic evidence of interstitial pulmonary edema, perivascular hemorrhage, intra-alveolar fluid, and alveolar congestion. Significantly fewer animals showed these changes when lungs were perfused with autotransfused or fresh blood. Wet-dry weight ratios of lung tissue after perfusion indicated significantly higher uptake of water by the lung perfused with stored blood than by those perfused with autotransfused or fresh blood.