Amelanotic lentigo maligna melanoma of the face: a case report and review of the literature

Neuroleptic medications may result in extrapyramidal symptoms that can affect swallowing. Both oral and pharyngeal phases of swallowing may be affected. Unlike the more common causes of dysphagia, especially in the elderly, drug-induced dysphagia may be reversible. This report describes a case of neuroleptic-induced dysphagia in an elderly male with Alzheimer's disease. When the loxapine was discontinued, the dysphagia improved significantly.     

Management of malignant melanoma of the head and neck

A total of 91 patients with melanoma of the head and neck treated between 1973 and 1991 were studied prospectively with regard to prognostic features, treatment and outcome. Other than Breslow thickness, the only important prognostic feature was the less aggressive nature of lentigo maligna melanoma. A policy of selective excision margins, 1 cm for impalpable and 2 cm for palpable lesions, was found to be safe, although preliminary biopsy should be used if there is diagnostic uncertainty or where the expected extent of surgery entails a mutilating procedure. Local recurrence rates were not affected by the method of wound closure, which should be determined by the best functional and cosmetic outcome. These results support the trend against prophylactic neck dissection. Such dissection, when indicated for lesions of the face, pinna, anterior scalp and parotid area, should routinely include superficial parotidectomy. Uncontrolled symptomatic loco-regional recurrence is an uncommon complication that may occur despite radical primary surgery. The role of preoperative radiotherapy for high-risk melanoma in this situation warrants investigation.     

Value of neck dissection in the treatment of patients with intermediate-thickness cutaneous malignant melanoma of the head and neck

In the present paper we describe a rapid and sensitive method for the simultaneous isolation of total RNA and genomic plus low-molecular-weight DNA from apoptotic cells. Using this method, we were able to detect a DNA ladder from as low as 30,000 apoptotic cells in only 45 min including gel electrophoresis. In addition, RNA can be readily obtained from the same specimen to assess gene expression during apoptosis. This method therefore appears to be advantageous when sensitivity and low amounts of sample material are a limiting factor.     

Malignant mucosal melanoma of the head and neck: review of the literature and report of 14 patients

BACKGROUND: Fortunately, primary malignant mucosal melanoma of the head and neck is a rare entity. A paucity of data elucidating the predictive factors as well as the unpredictable and aggressive biologic behavior of mucosal melanoma compound the vexing clinical situation. This review summarizes what the literature reveals about the epidemiology, patient survival, patterns of local recurrence, and local and distant metastasis of the disease. Over 1000 patients with this disease have been reported. Survivals at 5 and 10 years is 17% and 5%, respectively. Approximately 19% of patients present with lymph node metastasis and another 16% develop lymph node metastases after treatment, whereas 10% present with distant metastasis. Local metastasis does not affect survival; this is in sharp contrast with skin melanoma. Over 50% of patients experience local treatment failure, and salvage treatment is effective in only 25% of these cases. Local failure is the harbinger of distant metastases. Patients with nasal mucosal melanoma have a 31% 5-year survival rate, whereas sinus melanoma patients fare poorly, with a 0% rate of 5-year survival. METHODS: The authors conducted a retrospective review of 14 patients with characteristics similar to those in the literature in terms of outcome. RESULTS: The 5-year survival rate for these patients was 14%. Whole-body positron emission tomography was performed on 3 patients to detect metastatic disease. The patterns of local recurrence, distant metastasis, and survival for these patients were compared with the same data for patients described in the literature. CONCLUSIONS: Surgery appears to have the greatest efficacy in the management of mucosal melanoma, although radiation therapy may play an increasingly important role in the future.     

Merkel cell tumor of the head and neck. Five new cases with literature review

Merkel cell carcinoma (MCC) of the skin is an uncommon, but highly aggressive neoplasm with a marked propensity for local and distant metastasis. Despite the fact that more than half of the 600 cases of MCC reported in the literature involved primary sites in the head and neck, MCC has rarely been discussed in otolaryngology publications. We present five new cases of MCC of the head and neck and summarize 89 additional cases from the literature in which detailed treatment and survival data were given. Our findings again emphasize the difficulty in making the initial histopathologic diagnosis of MCC and demonstrate the necessity of early diagnosis and multimodality treatment.     

Inheritance in idiopathic premature ovarian failure: analysis of 71 cases

Premature ovarian failure is defined as cessation of ovarian function under the age of 40 years and affects approximately 1% of women in the general population. The aetiology of this disorder is still unknown in most cases. Although there have been some reports of familial premature ovarian failure, very little is known about the incidence and inheritance pattern of its idiopathic form. The aims of this study were to investigate the incidence and inheritance pattern of familial premature ovarian failure in a homogeneous group of patients with premature idiopathic menopause and to identify possible clinical differences between patients with the familial and the sporadic form of premature ovarian failure. A total of 71 women were recruited into the study. Clinical assessments and genetic counselling showed that 22 (31%) patients had familial premature ovarian failure, this high incidence strongly suggesting that the disorder is a recognizable heritable entity. There was a statistically significant (P < 0.05) difference in the median age of precocious menopause in patients with sporadic and familial premature ovarian failure (31.0 and 37.5 years of age in the two groups, respectively). Pedigree analysis strongly suggests the existence of a familial pattern of premature ovarian failure with a dominant maternal and/or paternal transmission and incomplete penetrance. In the presence of familial history of premature ovarian failure, reproductive counselling is recommended.     

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.     

Reconstruction of the head and neck

The collaboration of surgeons, radiation oncologists, chemotherapists, dentists, oral surgeons, prosthodontists, and speech therapists has led to major advances in the management of the difficult cancers of the head and neck area. The advent of myocutaneous flaps and the facilitation of microsurgical free flaps have ushered in an era of one-stage reconstructions to shorten the hospital stay and improve the overall therapeutic, functional, and cosmetic results.     

Melanomas of the head and neck

Melanomas of the skin and mucous membranes of the head and neck region are an uncommon problem for most clinicians. The article emphasizes the differences in terms of biological aggressiveness and treatment between lentigo maligna (LM) and lentigo maligna melanoma (LMM), superficial spreading melanoma (SSM), and nodular melanoma de novo. The results of radiotherapy in the treatment of melanoma of the head and neck are reviewed, and indications are suggested for the use of irradiation in the management of patients with this tumor. A brief discussion of the results of treatment of mucosal melanomas is given.     

Plasmacytomas of the head and neck

Plasmacytomas are rare tumors that often appear in the head and neck region and are characterized by a monoclonal proliferation of plasma cells. On both clinical presentation and pathologic examination these tumors may be confused with more common tumors of the head and neck. The purpose of this article is to review our experience with these rare neoplasms, with emphasis on clinical, pathologic, and therapeutic features. On retrospective chart review, we identified 20 patients with the diagnosis of plasmacytoma of the head and neck region at the Cleveland Clinic Foundation between 1976 and 1993. Records were reviewed with regard to initial symptoms, location of the neoplasm, diagnostic evaluation, treatment modalities, and survival. Of the 20 cases we identified, the tumor arose in the sinonasal/nasopharyngeal region in 11 (55%). Two cases (10%) represented medullary plasmacytomas, arising in the clavicle and presenting as supraclavicular masses. The mean follow-up was 60.2 months (range 6 to 131 months). In 15 of the 20 cases, immunohistochemistry staining for immunoglobulin light chain production was conducted. One of the two cases (50%) classified as medullary plasmacytoma demonstrated conversion to multiple myeloma, whereas only 2 of 18 cases of extramedullary plasmacytoma (11%) converted to multiple myeloma. The primary modality of treatment was radiation therapy with typical doses of 4500 to 6000 cGy. Kaplan-Meier survival estimates demonstrated 95% survival at 1 year, 82% survival at 5 years, and 10-year estimated survival of 72%. Plasmacytomas of the head and neck region are rare and on initial evaluation must be distinguished from multiple myeloma. The diagnostic evaluation includes appropriate radiologic and pathologic studies including immunohistochemistry. Despite the typical presentation as a locally destructive tumor, plasmacytomas are highly radiosensitive, and 70% to 80% survival may be obtained with the use of radiotherapy. Patients with plasmacytomas require long-term follow-up to detect conversion to multiple myeloma.     

En bloc resection of the carotid axis in epidermoid carcinoma of the head and neck. Retrospective analysis of 7 cases

En bloc resection of carotid artery involved by squamous cell carcinoma was performed in 7 patients from 1993 to 1997. Cerebral tolerance was tested with qualitative evaluation of cerebral blood flow during preoperative balloon test occlusion of the internal carotid artery. Four patients later underwent permanent carotid occlusion prior to en bloc resection, 2 patients underwent carotid ligation without reconstruction and one patient underwent carotid resection associated with carotid reconstruction. The preliminary neurovascular and carcinologic results are presented. One patient had definitive stoke postoperatively. Follow-up ranged from 3 to 34 months. Two patients died by the 6th and 26th postoperative month respectively. Among the remaining 5 patients, tumoral recurrence occurred in two. Two patients have survived more than 2 years, but one of them had local recurrence and distant metastases. Considering these data and the review of the literature, selection of patients after carcinologic and cerebral tolerance evaluation is important in order to improve survival and quality of life of these patients.     

Oxygenation status of squamous cell carcinoma of the head and neck: comparison of primary tumors, their neck node metastases and normal tissue

AIM: Investigation of the relationship between the pO2-status of primary tumors, their cervical neck node metastases and normal tissues in squamous cell carcinomas of the head and neck. PATIENTS AND METHODS: Pretreatment oxygenation of primary tumors, their neck node metastases and of the contralateral sternocleidomastoid muscle was assessed in 16 patients with histologically proven advanced squamous cell carcinomas of head and neck. Oxygenation was measured with a polarographic microelectrode system (Eppendorf-pO-Histograph). Using CT/MRT additionally the volume of the tumors was estimated. RESULTS: A highly significant correlation existed between the median pO2 of primary tumors and their neck node metastases and between the relative proportion of hypoxic values (< 5 mm Hg) of both anatomic sites (both p = 0.0001) (Figure 1). Primary tumors were not different from their neck node metastases, neither regarding the pO2 median values nor in view of the relative frequency of hypoxic values (Table 1). No correlation was found between the volume of primary tumors and the one of their neck node metastases. For volume of tumors and the oxygenation status no relationship was found as well. Significantly different was the median pO2 in the muscles from the one of the malignant tissues (p = 0.0004). CONCLUSION: The results suggest that for to estimate the oxygenation status of squanious cell carcinomas of the head and neck pO2 measurements of primary tumors and neck node metastases are equally sufficient.     

Four cases of aggressive MRSA wound infection following head and neck surgery

A case of partial trisomy 2(q21q33) detected by cordocentesis at 27 weeks' gestation in a polymalformed fetus is described. This is the second case of a prenatally detected de novo duplication of 2q and the first involving the region referred to above.     

Pilomatrixoma of the head and neck in children: a study of 38 cases and a review of the literature

OBJECTIVES: To describe the clinical presentations and discuss the guidelines for surgical management of pilomatrixoma involving the head and neck in children. DESIGN: Retrospective study. SETTING: A tertiary care center. PATIENTS: Thirty-three patients, with a mean age of 4.5 years, underwent surgical treatment for pilomatrixoma (n = 38) between 1989 and 1997. INTERVENTION: All patients were treated surgically. In 34 cases, a direct approach was used to achieve complete removal of the lesion with (n = 11) or without (n = 23) skin resection. In the remaining 4 cases, an indirect approach via a parotidectomylike incision was used. RESULTS: In 88% of cases, the presenting symptom was a hard, slow-growing, subcutaneous tumor. The lesion was associated with pain and inflammation in 7 cases (18%) and abscess or ulceration in 4 cases (11%). Twenty-nine patients presented with single nodules and 4 presented with multiple occurrences. The lesions were located on the face (cheek, eyelid, or forehead) in 20 cases (53%), on the neck in 8 cases (21%), in the parotid region in 8 cases (21%), and on the scalp in 2 cases (5%). CONCLUSIONS: Pilomatrixoma is a rare, benign skin tumor, but practitioners should be aware of its clinical features. Diagnosis is usually easy based on clinical findings, but computed tomographic scan is helpful, especially in cases involving tumors located in the parotid region. Spontaneous regression is never observed. Complete surgical excision, including the overlying skin, is the treatment of choice.     

Treatment of the neck in melanoma

Three and five times weekly narrow-band TL-01 (311-313 nm) ultraviolet (UV) B phototherapy regimens for chronic plaque psoriasis were compared in a randomized, observer-blinded, half-body, within-patient paired study. Twenty-one patients [13 men, eight women, age range 21-68 years, skin phototypes I (two patients), II (14) and III (five)] entered the study. Sixteen reached clearance or minimal residual activity (MRA) on both sides. Of the other five, three withdrew because they did not reach clearance or MRA on the 5x weekly side by a maximum of 30 treatments, one when he was satisfied with moderate improvement and one because of repeated failure to attend. Those who completed treatment reached clearance or MRA after a median of 35 days with 5x weekly treatment compared with 40 days with 3x weekly treatment (P = 0.007), but required a median of 23.5 compared with 17 UVB exposures (P = 0.001) and 94 minimal erythema dose multiples (MEDs) compared with 64 MEDs (P = 0.01). Fifteen (of 16) developed at least one episode of well-demarcated erythema during 5x weekly treatment compared with just three of 16 treated 3x weekly (P < 0.001). There was no significant difference between regimens in duration of remission. For this skin phototype I-III population, the more rapid clearance of psoriasis with 5x weekly phototherapy is not, for the majority of patients, sufficient to justify the extra exposures and higher UVB dose. We no longer use 5x weekly phototherapy for psoriasis.     

Mucosal melanomas of the head and neck

PURPOSE: To determine the effect of epidural analgesia on biochemical markers of stress, plasma oxytocin concentrations and frequency of uterine contractions during the first stage of labour. METHODS: Nine nulliparous women, in spontaneous labour, with a singleton fetus and cervical dilatation < or = 5 cm were enrolled. Epidural bupivacaine 0.25% (range 10-14 ml) was administered and bilateral sensory blockade to ice (T8-L4) achieved. Blood samples were collected before the epidermal block and every 10 min for one hour after the block was achieved for the measurement of plasma beta-endorphin, cortical, glucose, lactate and oxytocin concentrations. No exogenous oxytocin was given. Intensity of pain was assessed at the time of the blood sampling using a 10 cm visual analogue scale (VAS). The frequency of uterine contractions was recorded for 60 min before and after the epidural block. RESULTS: There was a decrease in plasma beta-endorphin and cortisol concentrations after epidural block (P < 0.01). There were no changes in plasma glucose and lactate concentrations. The mean VAS for pain decreased 10 min after epidural block was achieved and remained < 2 throughout the study period (P < 0.001). Mean plasma oxytocin concentrations did not change. The frequency of uterine contractions before and after the epidural block was similar. CONCLUSIONS: The metabolic stress response to the pain of labour was attenuated by epidural analgesia. In contrast, plasma oxytocin concentration and frequency of uterine contractions were unaffected by the attenuation of metabolic stress response.     

Nonnasopharyngeal lymphoepithelioma of the head and neck

BACKGROUND: Lymphoepithelioma (squamous cell carcinoma with associated lymphoid stroma) commonly occurs in the nasopharynx, rarely at other sites. As a result, the clinical course and optimal treatment of nonnasopharyngeal lymphoepithelioma of the head and neck have not been well described. This retrospective study was undertaken to analyze the clinical course of the disease in patients treated at a single institution and to formulate recommendations for treatment based on that experience as well as results reported in the literature. METHODS: Between 1950 and 1994, 34 patients with nonnasopharyngeal lymphoepithelioma of the head and neck were treated at the University of Texas M. D. Anderson Cancer Center. The patients' medical records were reviewed and their pathologic specimens evaluated. The primary tumor sites were: oropharynx (24 patients), salivary gland (4), laryngohypopharynx (4), and the maxillary sinus/nasal cavity (2). Assessed in accordance with the 1992 American Joint Committee Against Cancer TNM staging system, T classifications were TX-2, T1-7, T2-8, T3-10, and T4-7, and N classifications were N0-8, N1-5, N2-15, and N3-6. Treatment consisted of radiotherapy for 24 patients, excisional biopsy of the primary tumor followed by radiotherapy for 7 patients, and surgery for 3 patients. Of the patients treated with radiotherapy, neck dissections were performed on only two, both of whom had persistent lymph node masses after completing radiotherapy. The median dose delivered to the primary tumor was 65 gray (Gy) (range, 46-78 Gy). The median fraction size was 2.1 Gy (range, 1.6-3.2 Gy). RESULTS: The 5-year actuarial disease specific survival and overall survival rates were 59% and 39%, respectively. The 5-year actuarial local control rate for all patients was 94%. For the irradiated patients, the 5-year regional control rates were 77% overall and 83% within the radiation field. The 5-year actuarial rate of distant metastasis for all patients was 30%. For patients who presented with and without regional adenopathy, the 5-year rates of distant metastasis were 36% and 12%, respectively (P = 0.27). CONCLUSIONS: Nonnasopharygeal lymphoepithelioma is a radiosensitive disease. High rates of locoregional tumor control were achieved with radiotherapy at all head and neck sites. The main cause of treatment failure was distant metastasis, which occurred more frequently in patients with lymph node involvement. Radiotherapy is appropriate initial locoregional therapy for patients with this disease. Surgery should be reserved for patients who have persistent disease after completing radiotherapy. Systemic therapy is a reasonable approach for patients who present with regional adenopathy because they have a relatively high rate of distant metastasis.     

Skin cancer of the head and neck

The incidence of skin cancers is increasing at a rate greater than any other cancer occurring in humans. In this era of managed care, patients with a suspicious skin lesion may first present to their primary care physician for evaluation. Therefore, it is important for the primary care physician to be able to distinguish between benign and malignant pigmented lesions, to know how to evaluate such a patient, and to appreciate the importance of appropriate interdisciplinary management of these patients.