Selective attention to real phobic and safety stimuli

BACKGROUND: Improvements in the understanding of intrahepatic anatomy and radiographic technology have facilitated a segment-oriented approach to liver resection. This approach involves the resection of isolated anatomic segments or sectors of the liver as dictated by the extent of the intrahepatic pathology. Segment-oriented resection allows maximal conservation of normal liver parenchyma while clearing tumor. This report describes the technical features and the results of a prospective evaluation of segmental and sectoral resections in the treatment of malignant hepatic neoplasms. STUDY DESIGN: Patients with malignant hepatic neoplasms that were treated with a segment-oriented hepatic resection were identified from a prospective clinical data base. After undergoing segment-oriented liver resection, the patients were followed at regular intervals. Recurrent disease was the end point of the study. Followup is reported at a median of 12 months. This review outlines the technique of resection, intraoperative events, operating time, blood loss, and the ability to obtain negative resection margins. RESULTS: During the 5-year period between July 1992 and July 1997, 400 patients underwent liver resection for metastatic neoplasms and hepatocellular carcinoma (HCC). During this period, 79 patients (20%) were treated with a segment-oriented resection. These patients represent the study group for this report. The overall mortality rate was 2.5%; all postoperative deaths occurred in patients with HCC and cirrhosis. Overall morbidity was 26%. The median hospital stay was 8 days. Mean transfusion requirements were 1.0 +/- 0.3 U of packed red blood cells. Patients with HCC showed a greater transfusion requirement than did patients without HCC: 2.7 +/- 1.2 U versus 0.6 +/- 0.2 U (p < 0.05). Of the patients without HCC, 17% required transfusion. During the 12-month median followup period, the overall disease recurrence rate was 23%. Disease recurred at the hepatic-resection margin in 2.5% of the patients. CONCLUSIONS: Segmental resection is a safe technique that allows complete resection of liver tumors with preservation of normal liver parenchyma. Segmental resection is particularly useful for patients with HCC and patients undergoing repeat liver resections or bilobar resections.     

Surgery for lung metastases

Authors analyse the cases of lung metastasectomy collected during fourteen years in eleven thoracic surgical departments in Hungary. 668 operations were carried out on 620 patients. The primary tumor originated mainly from kidney, testis and colo-rectum. Most of the interventions were performed through median sternotomy. The tumors were removed by tissue sparing lung resections (wedge resection). The prognosis depends basically on tumor free interval, however the number and the size of the metastases and the histology of the primary tumor have also impact on it. When lung lesions appear in a cancer patient, thoracic surgeon should be consulted to consider operability. In certain cases metastasectomies can result in longer survival and better quality of life.     

Partial nephrectomy in cancer of the upper pole of kidney. Anatomical bases

On the basis of their importance for nephron-sparing surgery in tumors of the superior pole of the kidney, we analyzed 3-dimensional endocasts of the intrarenal structures. In 86.6% the superior pole was related to 3 arteries involved in its resection. Management of the superior (apical) segmental artery is in general simple as well as the ligature of the artery related to the anterior surface of the upper infundibulum. Ligature of the branch of the posterior segmental artery, that is related to the upper infundibulum, is critical due to the risk of injuring this segmental artery with loss of a great portion of renal parenchyma. The posterior segmental artery (retropelvic artery) is involved and must be preserved in all cases of superior pole resection. A retropelvic vein with its upper dorsal plexus was present in 69% of the cases. This vein must be previously ligated to provided safe management of the arteries during superior pole resection.     

Flap of the musculus latissimus dorsi to prevent alveolar air leakage from sectional plane of the lung after resection of metastatic pulmonary and chest wall tumor

Alveolar air leakage after pulmonary resection usually heals with adequate pleural drainage, but must be more actively treated if leakage may be severe. If left untreated, the postresection space can lead to empyema. We used a muscle flap to prevent alveolar air leakage from a large sectional plane of the lung resected because of metastases in the lung and chest wall. A 48-year-old man complained of pain and a mass on the right side of his back. He had undergone resection and chemotherapy for clear cell sarcoma that originated on the back of the left hand when 43 years of age, wedge resection of the right lower lobe of the lung for a metastatic pulmonary tumor at 46 years, and lobectomy of the same lobe for a recurrence of the metastatic pulmonary tumor at 47 years. The diagnosis was of a metastatic tumor to the right chest wall with peripheral pulmonary tumors of the right upper and middle lobes. Resection of the chest wall and the lung including the tumors was done. Much air leakage from the extensive sectional plane of the right upper and middle lobes was seen intraoperatively, and this plane was therefore covered with a flap of the musculus latissimus dorsi. Chest tubes were removed on day 7 postoperatively when air leakage was no longer seen. Subcutaneous emphysema, which appeared on day 14 postoperatively, required redrainage of the pleural air space, but pleurodesis was effective. Use of a muscle flap was simple and effective for covering of a sectional plane of the lung, and should be considered when alveolar air leakage may be extensive.     

Surgical therapeutic strategy in non-small-cell bronchial carcinoma

For localized, non-small cell carcinomas (stages I and II) surgery is the treatment of choice because these lesions usually can be excised completely. The choice of the surgical procedure--lobectomy, pneumonectomy, segmental or sleeve resection--depends on the extent of malignant disease and the patients functional status. The procedure of choice is usually that which will encompass all existing disease and provide maximum conservation of normal lung tissue. On occasion, stage III disease may present borderline cases for surgery. Indications are based on existing or imminent complications in advanced locoregional tumor growth. Localized chest-wall or pericardium invasion, superior sulcus tumors, limited mediastinal nodal involvement, and phrenic involvement are not absolute surgical contraindications. Each case must carefully be evaluated and individualised. This kind of tumor management requires sophisticated techniques. The primary aim is to achieve complete tumor resection and to avoid an exploratory thoracotomy or an incomplete surgical resection. The hilar and mediastinal lymph nodes have to be completely resected to ensure a real R0-resection. The presence of distant or extrathoracic metastasis is indicative of inoperability and a surgical procedure is an absolute contraindication. There is no proven place to date for debulking surgical procedures in lung cancer.     

Liver segmentectomy as anatomically precise resections. An experimental study in sheep

OBJECTIVE: To assess a new technique of anatomically precise hepatic segmental resection and to compare the degree of precision and biochemical profiles with results after traditional segmental resection and a sham operation. DESIGN: Experimental study. SETTING: University hospital, Germany. MATERIAL: 50 sheep (10 each had segments II, III, and IV removed by the new technique, and 10 each were studied in the traditional resection and sham operated groups). INTERVENTIONS: Operative ultrasonography and injection of methylene blue to identify segmental boundaries. In traditional operations boundaries were identified only from knowledge of the surface structure of the liver. MAIN OUTCOME MEASURES: Degree of precision, duration of operation, blood loss, mortality, transaminase activities and liver function tests. RESULTS: Anatomically precise segmentectomies were achieved in 6/9 (67%) for segment II, 6/9 (67%) for segment III, and 4/8 (50%) for segment IV. Using the traditional technique (segment III only) there was only 1/10 anatomically precise resections, together with 5 perisegmentectomies and 4 incomplete resections (p < 0.02). The operations for anatomically precise resection lasted significantly longer, but resection time was similar. Blood loss, survival, and transaminase activities were similar for the two groups, but the margin of necrosis at the cut edge was significantly less in anatomically precise resections. CONCLUSION: Anatomically precise hepatic resections are technically feasible with the use of intraoperative ultrasonography and selective staining of the segment(s) to be removed with methylene blue. Although it takes longer, there are no detrimental consequences compared with the considerably less accurate traditional technique.     

Primary tracheal tumors

A 33-year study (from 1963 through 1995) was conducted on 144 patients who underwent surgery for primary tumors of the trachea: 70 females and 65 males aged between 7 and 69 years. In 77 patients the tumor was in the thoracic trachea, in 26 in the cervical trachea, and in 41 at the tracheal bifurcation. The tumor was benign in 24 and malignant in 120. The most frequent malignant tumors were adenoidcystic carcinoma (more than 50%), squamous cell carcinoma, and carcinoid. The main diagnostic methods used were lateral and oblique roentgenography, tracheobronchoscopy and in the last 10 years, CT scans. One hundred forty-six operations were performed (2 patients underwent surgery twice). In 60, sleeve resection with anastomosis was made; in 37, different kinds of carinal resections were performed. Total hospital mortality was 15%. After resection for malignant tumors, 3-year, 5-year and 10-year survival rates were 47.5%, 35.9%, and 27.1%, respectively.     

Tumor recurrence and hypertension persistence after successful pheochromocytoma operation

Pheochromocytoma is a catecholamine-secreting tumor and a rare cause of hypertension that is usually curable. However, pheochromocytoma may recur as a benign or malignant tumor, and hypertension may persist after successful surgical intervention. The frequency of and risk indicators for tumor recurrence and hypertension persistence after successful surgical intervention have not been adequately studied. We determined tumoral and blood pressure outcome in 129 patients followed-up from initial pheochromocytoma resection to death or to 1994 (796 patient-years). We assessed several candidate indicators for their predictive value for the risk of tumor recurrence or hypertension persistence. Recurrence was defined as the reappearance of disease after normalization of biochemical tests. Pheochromocytoma caused death or persistent or recurrent disease in 28 patients. Of the 114 with benign tumors at initial operation, pheochromocytoma recurred as a benign or malignant tumor 17 to 194 months after initial operation in 16 cases. Kaplan-Meier estimates of pheochromocytoma-free survival were 92% and 80% at 5 and 10 years, respectively. In the 98 living patients without recurrence, Kaplan-Meier estimates of hypertension-free survival were 74% and 45% at 5 and 10 years. In the Cox model, familial pheochromocytoma and a low ratio of plasma epinephrine to total catecholamines were independently associated with recurrence. Familial hypertension and age were similarly associated with hypertension persistence. After surgery for pheochromocytoma, patients should be followed-up indefinitely, especially those with familial tumors or a low epinephrine secretion. Pheochromocytoma should not unreservedly be considered a surgically remediable cause of hypertension.     

Central bronchoplastic procedures in Hungary and their outcome (198-1993)

Bronchoplastic procedures involving the main carina are declared as central bronchoplasties. A nation-wide collection of these interventions performed between 1980 and 1993 is analysed. The study is on a total of 154 operations, that were 16 bifurcation resections and 14 stem bronchus resections without parenchyma sacrifice, 61 sleeve or wedge pneumonectomies and 63 tracheal sleeve or wedge right upper lobectomies or carina-plasties. Surgery alone-without multimodality therapy-was the choice of treatment almost exclusively. About 90% of these interventions were performed for highly malignant, histologically peripheral-type, but centrally located bronchial cancers. The hospital mortality and morbidity were found up to 30% (an average of appr. 17%), depending on surgical subsets. Cause of death were surgical at 11% (leakage, anastomotic dehiscence and bleeding) and non surgical at 5.8% respectively. Complications at another 9% were related to surgery. Data of survival suggest, that nodal state is the strongest predictor, but the unfavourable N2 group comprises longer survivors as well. Certain part of this kind of interventions is to be chosen without alternatives (isolated tracheobronchial resections without parenchyma-resection, extended pneumonectomies) while extended lobectomies are alternatives of the extended pneumonectomies in strict conditions. A central bronchoplastic procedure is justified only with hope of complete resection for its high complication rate.     

Functioning muscle transplantation after wide excision of sarcomas in the extremity

Free functioning muscle transplantation was performed after resection of 23 sarcomas in the extremity. There were 21 soft tissue sarcomas and two malignant bone tumors. The tumor resection was performed with a wide margin in all except two patients who had a marginal margin in a limited area. The consequent extensive soft tissue defect received free musculocutaneous flaps, the motor nerve of which was repaired in the recipient site. The most frequent procedure was latissimus dorsi transplantation to replace thigh muscles in 17 cases. The other donors included gracilis, tensor fascia lata, and rectus femoris, which were selected according to the site of defects. Patients were followed up for a mean of 60 months (range, 13-119 months). The grafted muscles showed reinnervation at a mean of 6 months postoperatively in all patients except for a 75-year-old patient. Obtained contraction of the muscles was powerful in 18 patients and fair in four patients. Performance of the salvaged limb significantly improved after recovery of the muscles. Although there were five distant recurrences, local recurrence was seen in one patient with systemic metastases. Because muscle loss could be compensated functionally for by the innervated free muscle transfer, the method encouraged surgeons to perform more radical tumor excisions and this may have contributed to the excellent local tumor control that was achieved. Thus, functioning muscle transplantation was extremely useful in limb salvage surgery from the functional and oncologic viewpoints.     

Comparison of primary and reoperative surgery in patients with Crohns disease

OBJECTIVE: This study was performed to determine the clinical results of patients with Crohns disease who require surgical resection. The outcome of patients undergoing initial surgery was compared with those having reoperation. METHODS: One hundred sixty-four patients undergoing intestinal resection for Crohns disease at The Mount Sinai Hospital from 1976 to 1989 were studied prospectively. The mean duration of follow-up was 72 months. RESULTS: Ninety patients (55%) underwent initial intestinal resection whereas 74 patients (45%) underwent reoperation for recurrent disease. Patients undergoing reoperation were older (33.4 vs. 38.7 years), had longer durations of disease (8.7 vs. 15.2 years), had shorter resections (60 vs. 46 cm), and were more likely to require ileostomy. Forty-seven percent of the patients with multiple previous resections required an ileostomy. This group also received a mean of 2.3 U blood in the perioperative period and showed a trend to increased symptomatic recurrence (49% vs. 71% at 5 years). CONCLUSIONS: Patients with Crohns disease undergoing first and second reoperation have outcomes similar to those in patients undergoing primary resection. Patients requiring multiple reoperations are more likely to require blood transfusions and permanent ileostomy and to show a greater trend to early symptomatic recurrence.     

Pharmacokinetics of tacrolimus (FK506) in primary orthotopic heart transplant patients

STUDY OBJECTIVES: Local recurrence is high when sublobar resection is chosen as primary management of stage I non-small cell lung carcinoma. Postoperative external-beam radiotherapy may reduce this local recurrence problem. A technique of intraoperative brachyradiotherapy following thoracoscopic wedge resection is described as an alternative to adjuvant external-beam radiotherapy for high-risk patients who are not candidates for pulmonary lobectomy. PATIENTS: Fourteen patients with significant impairment in cardiopulmonary function having small peripheral solitary pulmonary nodules underwent video-assisted thoracoscopic (VATS) wedge resection and were found to have non-small cell cancer. Surgical margins were pathologically clear and mediastinal nodes were benign-stage I (T1NO). INTERVENTIONS: A custom polyglyconate mesh (Vicryl) containing 125I seeds was applied to pulmonary resection margins following wedge resection of peripheral lung cancers. A total dose of 100 to 120 Gy at 1 cm was applied to the target area. RESULTS: All patients had histologically clear surgical margins. Postoperative dosimetry confirmed adequate resection margin coverage. There was neither operative mortality nor morbidity related to the VATS wedge resection or the brachytherapy implants. Implants did not migrate, and there were no cases of significant radiation pneumonitis or local recurrence at mean follow-up of 7 months (range, 2 to 12 months). CONCLUSIONS: Intraoperative brachytherapy appears to be a safe and efficient alternative to external-beam radiation therapy when adjuvant radiotherapy is considered following therapeutic wedge resection of stage I (T1NO) lung cancers. The impact on local recurrence, disease-free interval, and survival will require additional follow-up.     

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence?

PURPOSE: This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery. METHODS: During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumor of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence. RESULTS: Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank, P = 0.01 and P = 0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank, P = 0.38). CONCLUSIONS: When mesorectal excision is performed, circumferential margin involvement is more an indicator of advance disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.     

Hereditary persistence of alpha-fetoprotein. Case report and review of the literature

BACKGROUND: The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. METHODS: Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n = 10), benign disease (n = 2) and carcinoid (n = 1). Lung resections included pneumonectomy (n = 3), lobectomy (n = 4), segmentectomy (n = 1) and local excision (n = 5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. RESULTS: There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n = 3), anticoagulant related haemorrhage (n = 1) and broncho-pleural fistula (n = 1). Of the remaining five patients four are alive and disease free 7-23 months post-operatively; one patient has recurrent disease 40 months post-operatively. CONCLUSIONS: Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.     

Gestational hypertension plasma and human umbilical vein endothelial cells: an in vitro study

A case of metastatic dermatofibrosarcoma protuberans (DFSP) in a 47-year-old woman is presented. Dermatofibrosarcoma protuberans occasionally recurs, but rarely metastasizes. The patient underwent local removal of the nuchal tumor by a general practitioner, followed by a rapid recurrence. She underwent total removal of the tumor and a diagnosis of spindle cell sarcoma was made after an incisional biopsy was performed. This lesion had both a typical DFSP-like area and a fibrosarcoma (FS)-like area. After 7 years, an abnormal lung shadow was observed and a segmental lung resection was performed. Histologically, the lung tumor was similar to the FS-like area in the nuchal tumor. Confirming CD34 expression in the tumor cells, this lung tumor was diagnosed as metastatic DFSP. Usually CD34 expression is unique to DFSP but almost negative in FS-like areas. In the present case, the FS-like area in the nuchal tumor showed decreased CD34 reactivity, as previously reported, but the FS-like area in the metastatic tumor still widely preserved CD34 expression. The presented case suggests that the FS-like area in DFSP is histogenetically different from typical FS or malignant fibrous histiocytoma.     

Combination of systemic acetazolamide and topical dorzolamide in reducing intraocular pressure and aqueous humor formation

BACKGROUND: Neuroendocrine tumors commonly metastasize to the liver. Although surgical resection is considered a treatment option for patients with localized metastases confined to the liver, the longterm survival benefit of liver resection has not been clearly demonstrated. We examined the survival of patients undergoing liver resection for this disease. STUDY DESIGN: Between 1984 and 1995, we evaluated 38 patients with liver-only metastases from neuroendocrine tumors, including 21 carcinoid, 13 islet cell, and 4 atypical neuroendocrine neoplasms. Data from a combined prospective and retrospective database and a tumor registry were analyzed. Of these patients, 15 underwent complete resection of all known disease. The remaining 23 patients, who also had disease confined to the liver, had comparable tumor burden but were believed to be unresectable. The longterm survival rates of these two groups were compared. RESULTS: Patients who underwent liver resection did not differ from those who were unresectable with regard to age, pathology, primary tumor site, serum alkaline phosphatase levels, or percentage of the liver involved. All resections were complete, leaving no residual disease, and consisted of lobectomy (n = 3), segmentectomy (n = 1), and wedge resections (n = 11). There were no operative deaths. Patients who underwent hepatic resection had a significantly longer survival than unresected patients. Although median survival had not been reached in resected patients, the median survival in the unresectable group was 27 months. Patients who underwent liver resection had a higher 5-year actuarial survival (73% versus 29%). CONCLUSIONS: Hepatic resection in selected patients with isolated liver metastases from neuroendocrine tumors may prolong survival. This conclusion was reached by comparing our resected group with an unresectable group with similar tumor burden.     

Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer

BACKGROUND: The role of nonanatomic wedge resection in the management of stage I (T1 N0 M0) non-small-cell lung cancer continues to be debated against the present gold standard of care--anatomic lobectomy. METHODS: We analyzed the results of 219 consecutive patients with pathologic stage I (T1 N0 M0) non-small-cell lung cancer who underwent open wedge resection (n = 42), video-assisted wedge resection (n = 60), and lobectomy (n = 117) to assess morbidity, recurrence, and survival differences between these approaches. RESULTS: There were no differences among the three groups with regard to histologic tumor type. Analysis demonstrated the wedge resection groups to be significantly older and to have reduced pulmonary function despite a higher incidence of treatment for chronic obstructive pulmonary disease when compared with patients having lobectomy. The mean hospital stay was significantly less in the wedge resection groups. There were no operative deaths among patients having wedge resection; however, a 3% operative mortality occurred among patients having lobectomy (p = 0.20). Kaplan-Meier survival curves were nearly identical at 1 year (open wedge resection, 94%; video-assisted wedge resection, 95%; lobectomy, 91%). At 5 years survival was 58% for patients having open wedge resection, 65% for those having video-assisted wedge resection, and 70% for those having lobectomy. Log rank testing demonstrated significant differences between the survival curves during the 5-year period of study (p = 0.02). This difference was a result of a significantly greater non-cancer-related death rate by 5 years among patients having wedge resection (38% vs 18% for those having lobectomy; p = 0.014). CONCLUSION: Wedge resection, done by open thoracotomy or video-assisted techniques, appears to be a viable "compromise" surgical treatment of stage I (T1 N0 M0) non-small-cell lung cancer for patients with cardiopulmonary physiologic impairment. Because of the increased risk for local recurrence, anatomic lobectomy remains the surgical treatment of choice for patients with stage I non-small-cell lung cancer who have adequate physiologic reserve.     

Completion right lower lobectomy for recurrence after left pneumonectomy for metastases

Resection of pulmonary recurrences on the residual lung after pneumonectomy for metastases is exceptional. A 37-year-old woman was submitted to left extended pleuro-pneumonectomy after left leg amputation for fibrosarcoma. At 43 months later, a wedge resection on the right lower lobe was performed followed 32 months later by a further wedge resection in the same lobe. A completion right lower lobectomy for a new recurrence was performed 17 months after the last pulmonary resection. The patient did not develop postoperative complications. She is still alive and free of disease 10 years and 9 months after pneumonectomy and 36 months after completion lobectomy on the residual lung. In highly selected patients, aggressive surgery for metastases on the residual lung can be successfully performed and it can improve survival.     

Segmental pericholangial fibrosis: a peculiar benign fibrosing disease at the hepatic hilum

The authors report on a 9-year-old child who underwent surgery to remove a tumor of the hepatic hilum with preoperative radiographic studies suggestive of malignancy, but whose surgical specimens showed a peculiar fibrosing disease. The lesion was localized to the bifurcation of the hepatic duct, where the bile duct wall and the surrounding tissue was markedly fibrotic. No malignant cells or epithelial destruction were seen. The patient's postoperative course was uneventful, and he is without any sign of recurrence 2 years after surgery. Because the histological features of this case do not correspond to any established disease, including primary sclerosing cholangitis, the authors believe it represents a new entity, segmental pericholangial fibrosis. Local resection resulted in a good outcome. A review of the literature disclosed a few similar cases with a benign clinical course.     

Vinorelbine treatment of recurrent salivary gland carcinomas

Twenty patients (13 males, 7 females, median age 61 years, range 27-74) with recurrent adenocarcinoma-like tumors of major (10 patients) and minor (10 patients) salivary gland origin (13 adenoid cystic carcinoma, 5 adenocarcinoma, 1 malignant mixed tumor, 1 undifferentiated carcinoma) were treated with vinorelbine at the dose of 30 mg/m2 i.v. weekly. Sixteen patients had been previously treated with surgery + radiation, 3 with surgery + radiotherapy + Novantrone and 1 with radiotherapy alone. Nine patients had local recurrence, 2 local relapse + metastasis and 9 metastasis alone. Site of metastases are: lung (7), bone (1), lung + bone (2), lung + bone + lymph-node + skin (1). Overall 174 courses were given (median 9, range 6-19). Responses were: PR in 4 patients (20%) with a median duration of 6 months (3-9), 9 NC (45%) with a median duration of 3.5 months and 7 PD (35%). The median survival time was 10 months for PR/NC patients, 4 months for non-responders. Median overall survival was 7 months. Vinorelbine has a moderate activity in these very advanced cases.