Biomedical subjects
Publications and source records attributed to N R McLean.
A case of metastatic facial skin involvement from colonic carcinoma is reported where, despite radiotherapy given preoperatively, the tumour continued to grow. The patient remained disease free for 8 months after excision and reconstruction, but died of pulmonary metastases.
INTRODUCTION: Patients with skin involvement from head and neck cancer have a poor prognosis, with a median survival time of 2 months. METHOD AND RESULTS: During a 9 year period, 31 patients with skin involvement above the clavicle by non-cutaneous malignant tumours of the head and neck were treated. In 19 males and 12 females with a mean age of 62 years, the parotid gland (32%) and the oral cavity (29%) were the commonest sites of primary disease and 77% of the cases were squamous cell carcinomas. Twenty-six had recurrent disease, 20 had received previous radiotherapy and all underwent surgical resection with free flap reconstruction, the commonest being the radial forearm (78%). Complete histological clearance was achieved in 53% of the cases, and adjuvant post-operative irradiation was given to 60%. With this form of management, palliation was extended to a mean survival of 23 months. Six patients are currently alive and disease free at a mean follow up of 4.5 years. CONCLUSIONS: Patients with head and neck skin involvement by non-cutaneous head and neck malignancies have a very poor prognosis, but surgical resection combined with free microvascular flap reconstruction and planned post-operative radiotherapy, can offer good long-term palliation.
Brachytherapy following surgical resection of head and neck malignancy is a useful adjunct if full dose external beam radiotherapy has been performed previously. Percutaneous tube placement has been described but accurate placement can be technically difficult in certain areas of the head and neck. A case report is presented of trans-osseous brachytherapy tube placement through the zygoma bone to allow for optimum surgical bed irradiation without kinking of the tubes. It is proposed that the trans-osseous placement is a useful technique when siting of the tubes is difficult.
Angiosarcoma of the breast following conservation surgery and radiotherapy for carcinoma is rare. We report a case occurring after a latent period of 8 years, which required excision with a 5 cm margin and latissimus dorsi flap repair.
It is well-recognised that recurrent disease can occur following surgery for malignancy in the head and neck region. This is particularly true of basal cell carcinoma in which recurrences may occur over many years and despite the use of different treatment modalities. Reconstruction of large defects may become increasingly difficult and can be optimally managed by free tissue transfer. The authors report a case of basal cell carcinoma that has required treatment for over 20 years, unique in that on five different occasions, free flaps have been used for reconstruction.
The surgical management of an extensive pleomorphic adenoma arising within deep lobe of the parotid gland is presented.
AIMS: To investigate the malignant potential of oral lichen planus (OLP), a common mucocutaneous disease of unknown aetiology. The malignant potential of OLP is still controversial, with studies reporting malignant transformation rates of between 0 and 5.6%. We also aimed to identify factors that might be associated with malignant transformation. METHODS: We retrospectively reviewed the records of 832 patients with histologically confirmed OLP treated at the Dental Hospital, Newcastle upon Tyne during the period 1983-1996. RESULTS: Of these 832 patients, a total of seven (0.8%) developed intra-oral squamous cell carcinoma (SCC), including three cases of carcinoma in situ. It was noted that OLP patients with SCC are more likely to be women, relatively young and have a low tobacco and alcohol intake. However, they had a good long-term prognosis. CONCLUSIONS: We conclude that the risk of malignant transformation in OLP is real but not high. Clinicians should have a higher index of suspicion of the possibility of malignancy developing in OLP, because such patients are different from typical patients who develop oral malignancy. Follow-up for at least 6 years is recommended.
The recurrence rate of spontaneous pneumothorax in patients with underlying lung disease can be as high as 50%. We present a novel method of treatment for recurrent pneumothorax based on the intrathoracic transfer of an extrathoracic muscle flap.
The occurrence of multiple tumours in the salivary glands is an unusual phenomenon and the simultaneous development of tumours different types is extremely rare. Two cases are presented with synchronous tumours of the parotid gland of different histological types. The first was a Warthin tumour in combination with a metastatic lung carcinoma and the second was a pleomorphic adenoma in combination with non-Hodgkin's malignant lymphoma.
Twenty patients (12 men and 8 women, median age 69 years) with metastatic tumours in the parotid gland who presented over a 12-year period were evaluated retrospectively. Preoperative investigations included fine needle aspiration cytology (n = 11) and computed tomography or magnetic resonance imaging (MRI) (n = 14). Most tumours originated from the head and neck region, the two main types being squamous cell carcinoma (n = 10) and malignant melanoma (n = 7). All 20 presented with a parotid mass and 11/20 (55%) had associated lymphadenopathy. Eleven patients (55%) underwent superficial, five total, and four radical, parotidectomy. Neck dissection was required in 16 patients (80%), and all 11 patients with clinically palpable lymph nodes had evidence of tumour in the neck dissection specimens. Half of all patients (n = 10) received adjuvant postoperative radiotherapy. Three-quarters of the patients (n = 15) were alive after a mean follow-up of 31 months and only one developed a marginal recurrence. The cumulative 5-year survival rate was 51%, and there was no significant difference (P = 0.48) in the 3-year survival rates of patients who had radical compared with those who had modified neck dissections. Patients who had superficial parotidectomy had a longer overall survival compared with those who had total or radical parotidectomy (P = 0.04) perhaps reflecting the advanced nature of tumours that required total or radical excision of the gland. We conclude that superficial parotidectomy is usually an adequate treatment for secondary parotid tumours (when disease is clinically limited to the superficial lobe), and we suggest that patients in whom metastatic disease of the parotid gland is suspected do not require neck dissection if they have no palpable lymph nodes and MRI shows no evidence of spread. There seems to be no survival advantage in radical over modified neck dissection.
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Malignant tumours of the submandibular salivary gland are rare, difficult to distinguish clinically from benign disease and often only diagnosed after initial excision of the enlarged gland. In this study of 70 patients (46 male, 24 female) with a mean age of 64 years (range 17-94), and an average duration of symptoms of 3 months, a painless submandibular swelling was the most common presentation. Of the 69 primary tumours, the most frequent histological types were adenoid cystic carcinomas (26 patients, 37%) and carcinoma ex-PSA (18 patients, 26%). One tumour was metastatic in origin, arising from a parotid primary. A total of 65 patients were treated by primary excision of the gland while five patients who presented with advanced disease were treated by radiotherapy alone. Adjuvant postoperative radiotherapy was utilised in 53 (75%) of patients. After a mean follow-up of 5 years, 32 (46%) of patients are still alive. Metastatic disease accounted for 21 deaths (30%). The clinical stage at presentation was the most significant factor predicting survival.
Chronic non-specific sialadenitis of the parotid gland is an insidious inflammatory disorder which is characterised by intermittent, often painful, swelling of the gland. The disease tends to progress and may lead to the formation of a fibrous mass. The purpose of this paper is to review our experience in the surgical management of patients with chronic non-specific parotid sialadenitis. In a consecutive series of 100 patients treated for benign parotid disease, 19 were found to have chronic non-specific sialadenitis; 10 were male and 9 female. Mean age was 46 years and the mean duration of symptoms was 4.6 years. Sialography was performed in two-thirds of the patients and 17 patients were treated by superficial parotidectomy. Thirteen patients developed temporary facial nerve weakness and three Frey's syndrome. Three patients complained of temporary paraesthesia of the cheek, and two developed painful neuroma of the greater auricular nerve. Although there were two cases of infection of the parotid duct remnant, no recurrence of deep lobe sialadenitis or fistula formation was noted. Histologically, 3 lesions showed mild chronic sialadenitis, the rest had widespread involvement of the gland, and prolonged duration of symptoms was associated with extensive and severe involvement of the gland. Superficial parotidectomy has a very high success rate, with minimal long-term complications, and should be offered early in established cases, to reduce unnecessary morbidity.
Over an 18-year period, 147 patients with malignant tumours involving the maxillary complex were treated in a combined head and neck clinic, of whom 50 underwent surgery. There were 33 males and 17 females, the mean age was 57 years (range 11-87 years). The most common clinical presentations were either painful facial swelling, infraorbital anaesthesia, palatal ulceration or nasal obstruction. Preoperative investigations included EUA, biopsy and either CT or MRI scans. Of the 50 tumours, 62% were squamous cell carcinomas. Surgery consisted of either partial or total maxillectomy including craniofacial resection in nine patients. Reconstruction was by either split skin grafting or by free tissue transfer when the cranial contents had been exposed. Adjuvant radiotherapy was given in 82% of the patients. The mean follow-up was 5 years and 59% of patients are alive and disease free. The 5-year local control rate was 67%; it was greatly influenced by histological evidence of nerve invasion, local recurrence being the major cause of death. It was concluded that adequate surgical clearance, followed by planned postoperative radiotherapy, is the most effective treatment for malignant disease of the maxillary complex.
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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.
We present an 8-year experience with the Würzburg noncompression titanium miniplate system for the rigid fixation of the mandible during elective head and neck cancer surgery in a consecutive series of 100 patients. One half of the miniplates were used to fix mandibulotomies undertaken for surgical access. The remaining half were in patients undergoing reconstruction of segmental mandibular defects, the vast majority (92%) with vascularised bone grafts. One to four variously shaped miniplates were used per patient (mean = 1.5), plate size ranging from 4 to 40 holes. Fifteen patients (15%) developed complications which included 3 mandibular osteoradionecrosis, 8 broken, 5 infected, and 4 exposed plates. Three of the eight fractured plates were associated with nonunion. In this study, the main advantages of titanium miniplate fixation, namely case of application, decreased fixation time and malleability, were accompanied by a level of morbidity which, while comparing well with alternatives, may necessitate a reappraisal of this technique of fixation.
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