Robert M. Byers

The prognostic and therapeutic value of frozen section determinations in the surgical treatment of squamous carcinoma of the head and neck.

The records of 216 patients with squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx treated by surgery alone were reviewed. Frozen section control at the time of the surgical procedure was used to evaluate the margins of the excision. Findings at frozen section were correlated with local control and survival. The inability of the surgeon to obtain clear margins by frozen section for whatever reason resulted in a very high incidence of local recurrence and death. The fact that the patients tumor could be removed with free margins at the time of surgery did not guarantee long-term success, although the frozen section technic did prove to be reliable and an effective tool for evaluating the patients prognosis and the efficacy of the surgical procedure.

True malignant mixed tumors (carcinosarcoma) of salivary glands

True malignant mixed tumors (carcinosarcomas) of salivary glands are of a high grade of malignancy and are distinguishable from the more frequently occurring carcinomas ex pleomorphic adenoma. Having a putative origin from a benign pleomorphic adenoma, the true malignant mixed tumor is an aggressive, often rapidly lethal neoplasm in which the sarcomatous element is most often a chondrosarcoma and the epithelial element is most often a ductal carcinoma. The twelve cases in this report represent the largest recorded series to date.

Results of treatment for squamous carcinoma of the lower gum.

The records of 61 patients with a diagnosis of squamous carcinoma of the lower alveolar ridge were reviewed. The overall two‐year survival was 67% with a local or regional failure of 5%. The majority of patients were treated with surgery initially with an excellent local control of 98%, if the patient who died in the postoperative period and the patient lost to follow‐up are excluded. Radiation therapy should be used postoperatively for those patients whose cancer exhibits some of the adverse findings such as extensive nodal metastasis, perineural invasion, or inadequate margins of surgical resection.

The therapeutic and prognostic implications of nerve invasion in cancer of the lower lip

Abstract The incidence of histologically proven perineural invasion in squamous carcinoma of the lower lip is 2%. The 2 year survival in this group of patients is striking low compared to the overall survival with lower lip cancer in general. This may be related to the higher incidence of cervical nodal metastasis in these patients with nerve invasion than those patients without, (80% vs 10%). In addition, no patient survived who presented with a large lesion (greater than 3 cm) nerve invasion and nodal metastasis. In is of interest that 60% of these patient with nerve invasion presented with a history of radiation therapy in the past for a localized lip lesion. Based on the analysis of failures, combined treatment with the judicious use of surgery and radiation in a planned sequential manner hopefully will improved the overall survival in patients with lip cancer and nerve invasion.

Chemotherapy of malignant major salivary gland neoplasms: a 25-year review of M. D. Anderson Hospital experience.

From 1950 through 1975, 671 patients with malignant major salivary gland neoplasms were referred to M. D. Anderson Hospital and Tumor Institute. Thirty‐six patients with advanced local or metastatic disease subsequently underwent 62 evaluable trials with a variety of chemotherapeutic agents, either alone or in combination. Six patients achieved a partial response, with a median duration of 3 months. Ten additional patients had stable disease for 2 or more months. Anthracyclines appeared to be the most effective agents in this study, with three partial responses of six evaluable trials. The longest partial response (10 months) occurred in a patient receiving combination chemotherapy plus BCG immunotherapy. Pulmonary metastases were most commonly responsive to chemotherapy. The median intervals from diagnosis to death or to last follow‐up and from initiation of chemotherapy to death or to last follow‐up were 30 months and 6 months, respectively. Further therapeutic trials are necessary before response rates to single chemotherapeutic agents or combinations can be accurately assessed. In view of the poor prognosis of patients with recurrent disease, postoperative adjuvant studies with chemoimmuno‐therapy in patients with a high risk of recurrence are planned. Cancer 40:619–624, 1977.

Combination chemotherapy of head and neck cancer.

A total of 77 patients with cancer of the head and neck area were treated with five different drug combination regimens. Five of the 77 patients had lymphoepithelioma; four had adenocystic carcinoma, and 68 had squamous‐cell carcinoma of the head and neck (16 from the skin). Of these 77 patients, 16 had no previous treatment, five had surgery, 11 had radiotherapy, and 45 had surgery and radiotherapy. The first regimen consisted of a four‐day Bleomycin infusion followed after a 24‐hour rest, by cyclophosphamide (Cytoxan), Vincristine (Oncovin), methotrexate and 5‐Fluorouracil (5‐FU) (B‐COMF). The next three regimens consisted of a four‐day Bleomycin course, followed by either Cytoxan and methotrexate (B‐CM), Cytoxan and 5‐FU (B‐CF) or Methotrexate and 5‐FU (B‐MF). The fifth regimen consisted of Bleomycin concomitant with Cytoxan, Methotrexate, and 5‐FU (B‐CMF). Of the 49 patients receiving B‐COMF and B‐CMF, 12 showed a complete response and 12 a partial response. Among the 28 patients receiving Bleomycin, followed by any one of the two drug regimens, only six showed a partial response. The severity of the thrombocytopenia, number of drugs, lymphoepithelioma histology and performance status of the patient influenced the rate of response. Drug toxicity consisted mostly in myelosuppression. The B‐CMF combination is highly effective and can be used as an adjuvant to surgery and/or radiotherapy. Cancer 42:1661–1669, 1978.

Combined Therapeutic Approach to Malignant Lacrimal Gland Tumors

The medical records of 13 patients with primary malignant lesions of the lacrimal gland revealed adenoid cystic carcinoma as the most common malignant tumor. The histologic cell type, neural invasion, and bony destruction were correlated with localized control and ultimate survival. Surgical removal of the lacrimal gland was adequate treatment for low-grade mucoepidermoid carcinoma confined to the gland itself. Combining a radical surgical removal of the area in planned sequence with high voltage radiation therapy offered the only reasonable hope for localized control in the more aggressive cell types or in tumors with neural invasion or bony involvement. A 40%-localized control and survival rate was achieved in the adenoid cystic carcinoma group of patients. Radiation therapy administered for cancer that obviously recurs after surgical resection was generally unsuccessful.

Continuous cisplatin (24‐hour) and 5‐fluorouracil (120‐hour) infusion in recurrent head and neck squamous cell carcinoma

Cisplatin and 5‐fluorouracil (5‐FU) has been reported to be one of the most active chemotherapeutic regimens in recurrent head and neck squamous cell carcinoma. In this study, 21 patients with recurrent head and neck squamous cell carcinoma received a combination of cisplatin given as a 100 mg/m2 continous infusion over 24 hours and 5‐FU given as a 1000 mg/m2 24‐hour continuous infusion for 120 hours. Toxicity was evaluated in all patients, and response and survival were evaluated 20 patients. There were two complete remissions (10%) and three partial remissions (15%) for a major response of 25%. Overall survival for the complete responders was 79+ and 61+ weeks, respectively. Median survival for all patients was 36 weeks. Toxicity consisted of moderate to severe nausea and vomiting in 14 patients (66%), mucositis in 14 patients (66%), granulocytopenia of less than 1000/μl in 11 patients (52%), objective peripheral neuropathy in one patient (4.7%), and nephrotoxocity in one patient (4.7%). We conclude that the efficacy of 24‐hour cisplatin infusion and 120‐hour 5‐FU infusion in the treatment of recurrent head and neck squamous carcinoma is not superior to the efficacy of single agent trials reported in the literature.

The place of irradiation in the treatment of malignant tumors of the salivary glands

1. Radiation therapy is not indicated after surgical removal with adequate margins of low-grade tumor. 2. Radiation therapy is indicated with a) Inadequate surgical margins in low-grade tumors b) All high-grade tumors c) All recurrent malignant tumors 3. Irradiation of nerve pathways is indicated with demonstrated nerve and perineural invasion and/or with adenoicystic carcinoma. 4. Irradiation of the entire ipsilateral neck is indicated a) Wtih high-grade tumors unless radical neck dissection shows negative nodes b) In the place of radical neck dissection.

Malignant salivary gland neoplasms of the lip.

The charts of fourteen patients with malignant salivary gland tumors of the lip were reviewed. These patients represented 1 per cent of all patients seen during this same period of time with malignant salivary gland tumors. No specific etiologic factors were implicated except that the tumors occurred predominantly in white males. The overall results of treatment were poor, perhaps secondary to delay in diagnosis, very biologically aggressive tumors, or inadequate or improper treatment. Hopefully, the 20 per cent survival can be improved with planned combined sequential surgery and radiation in those selected high risk patients.