Palpable Cervical Nodes Research Articles

Local and distant metastases in patients with surgically treated squamous cell carcinoma of the lip.

There were 18 patients (16%) with metastatic squamous cell carcinoma of the lip in a total material of 114 operatively treated patients. There were initially palpable cervical nodes in 14% of the patients, but only 6 (5%) had histologically proved metastases. Two patients (1.8%) had distant metastases. The primary tumour in the metastatic group was classified as T1 in 3 (17%), T2 in 4 (22%) and T3 in 11 (61%) cases. During 5-year-follow-up of 73 of the patients, local recurrences were found in 10 cases (13.5%), 5 of whom developed subsequent metastases. Of the remaining 63 patients without local recurrences only 3 (5%) had metastases. Totally 8 of 73 patients, who had no metastases initially, developed them during 5-year-follow-up. Metastases appeared within three years after initial treatment. In the metastatic group only 15.5% of the patients are alive after 5 years, and totally 13.5% of the patients died of the carcinoma of the hip within in 5 years.

Oat Cell Carcinoma of the Larynx

Oat cell carcinoma is a well known pulmonary entity. Reports of this disease at extrapulmonary sites, particularly the larynx, have been rare. The natural history of such a tumor in a 64‐year‐old man is documented in this report. This supraglottic tumor (classified as T2N1bM0 was surgically resectable. Because of the large cervical node, preoperative irradiation was performed. After completion of 4000 rads to the primary tumor and regional lymphatics, there was dramatic regression of disease at both sites. Subsequently, the patient underwent supraglottic laryngectomy and neck dissection. The gross specimen revealed microscopic residual tumor at the primary site (with uninvolved margins) and in the palpable cervical node. In spite of adequate surgical excision, the patient was dead of widespread distant metastases within two months of surgery. Review of the literature reveals that oat cell carcinoma at extrapulmonary sites is likely to behave in this manner. The operating laryngologist should be aware of this rare pathological variant because of its propensity for distant metastases in the presence of surgically curable disease in the region of origin. Alternative methods of management (including radiation therapy and chemotherapy) are discussed.

Practical ENT. Incidence of palpable cervical nodes in adults.

Palpable cervical nodes were found in 56% of 561 adult outpatients studied. The incidence decreased with advancing age. Only two patients with palpable nodes had a history of neck cancer.

Die Bewertung der Metastasen in den zervikalen Lymphknoten bei Malignomen im Kopf- und Halsbereich

Metastases in the cervical lymph nodes in cancerous head and neck cases burden both the treatment and the prognosis. On 50 patients suffering from cancer of the head and the neck, there takes place a clinical and histological evaluation of the removed cervical lymph nodes. The palpable mobile cervical lymph nodes do not always indicate a metastasis. The number of stricken lymph nodes as well as the degree of their cancerous infiltration and histological differentiation of the neoplasm are studied and compared with the patients survival rate.

T-cell deficiency in patients with squamous cell cancer of the head and neck

Cellular immunity was assessed in patients with operable squamous cell cancer of the head and neck using in vivo skin tests and in vitro lymphocyte stimulation tests. An expansion of a previous study continued to show that 30 per cent of patients with T 1N 0M 0 lesions were DNCB-negative and that with more advanced lesions there was further impairment. A similar finding was observed in the blastogenic response to phytohemagglutinin and conconavalin A but not pokeweed mitogen. Overall, 40 per cent of patients with resectable cancer had a significant depression of the blastogenic responses to conconavalin A and phytohemagglutinin. This depression ranged from 15 per cent in patients with T 1N 0M 0 lesions to 71 per cent in those with T 3N 0M 0 lesions. Although this depression was more severe in patients with palpable cervical node metastases, it was related more to the size of the primary tumor than to the nodes per se. An exception occurred in patients with large fixed nodes in whom the depression of lymphocyte stimulation was most severe. The absolute T-cell count was also depressed in patients with head and neck cancer. This depression parallelled the lymphocyte stimulation results with phytohemagglutinin and conconavalin A and was progressive with increasing stage of disease. A correlation exists between DNCB negativity and early recurrence and shortened survival. Clinical follow-up study is too short to assess the correlation of in vitro immune function with these clinical prognostic factors.

Epidermoid carcinoma of the supraglottic larynx: Role of neck dissection in initial surgical treatment

Epidermoid carcinoma of the supraglottic larynx is defined as carcinoma that arises on the laryngeal surface of the epiglottis, aryepiglottic folds, arytenoids, ventricular bands, and ventricular cavities. Such tumors may extend inferiorly to involve the vocal cords or subglottic region. More often they spill over the superior margins of the laryngeal box to invade adjacent sites outside the larynx such as the base of the tongue, vallecula, pyriform sinus, and postcricoid region. These tumors may also infiltrate beneath the laryngeal mucosa to involve underlying structures causing fixation of the larynx or even infiltrate deeply to extend outside the larynx. The most common mode of metastases of these tumors is through the lymphatics to cervical lymph nodes. One of the questions that face the clinician is whether lymbhatic metastasis has taken place and, if so, to what extent. On the basis of this information the plan of treatment is formulated. Unfortunately no preoperative tests of any clinical value are available to ascertain the presence of metastases in the absence of palpable cervical lymph nodes, and thus the clinical findings at initial examination must be relied on. It is dbvious that in the presence of clinical cervical metastases there is no controversy as to the type of surgery advocated. However, when the cervical nodes are clinically negative for metastases, the dilemma arises as to whether elective neck dissection should be performed at the time of init,ial surgery of the

Bilateral radical neck dissection

Sixty-three patients underwent bilateral radical neck dissection for control of tumors of the head and neck. Two operative deaths occurred for a mortality of 1.5 per cent per procedure. Complications occurred in 45 per cent and related primarily to the procedure performed in conjunction with radical neck dissection. The high incidence of facial deformity and cerebrovascular complications described in other reports after bilateral radical neck dissection was not seen in this group. The three and five year survival percentages for the group as a whole were 44 and 32 per cent, respectively. Patients without histologic involvement of cervical nodes had three and five year survival rates of 60 and 48 per cent, respectively, whereas in those with nodal involvement three and five year survival fell to 43 and 28 per cent, respectively. The review of our experience has led to the following conclusions: 1. 1. Bilateral radical neck dissection is both an effective and feasible weapon in the control of tumors of the head and neck. 2. 2. A high incidence of relatively minor complications can be expected and relates directly to the procedure performed in conjunction with radical neck dissection. The operative death rate of 3.0 per cent and the low incidence of facial deformity and cerebrovascular complications is well within acceptable limits. 3. 3. The presence of histologic involvement of nonpalpable cervical lymph nodes lends support to those who advocate prophylactic neck dissection. 4. 4. The increased survival seen in the patients who had a second neck dissection during the initial hospitalization period, before palpable cervical nodes developed, lends further evidence that prophylactic neck dissection is of benefit in patients with aggressive lesions of the head and neck. 5. 5. With both the low operative mortality and prolonged survival offered many patients, bilateral radical neck dissection should be employed more frequently in control of tumors of the head and neck.

The surgical treatment of carcinoma of the thyroid

After consideration of the various methods of treatment suggested for the three main histologic types of cancer of the thyroid certain conclusions seem evident: 1. 1. In most patients with follicular carcinoma total lobectomy is adequate treatment for the primary tumor. The incidence of cervical metastases from follicular carcinoma is higher than generally realized and may approach that of papillary carcinoma of the thyroid. 2. 2. In papillary carcinoma the choice between total lobectomy and total thyroidectomy has not been clearly defined. The not infrequent incidence of carcinoma in both lobes would favor total thyroidectomy as the choice of treatment. However, some, who advocate routine radical neck dissection, prefer total lobectomy and radical neck dissection en masse as it affords more complete dissection of the neck; if the opposite lobe is involved, total lobectomy and radical neck dissection are performed on this side at a later date. The incidence of positive lymph nodes in specimens from radical neck dissections is 85 per cent; it is greater than 60 per cent in those patients undergoing routine radical neck dissection in the absence of palpable cervical lymph nodes. This high incidence strongly suggests that routine radical neck dissection should be performed in cases of papillary carcinoma. 3. 3. In undifferentiated carcinoma the possibility of cure rarely comes up, but when it does, total thyroidectomy and radical neck dissection would seem advisable.

Experiences With Nasopharyngeal Carcinoma

It is fortunate that malignant tumors of the nasopharynx are of rare occurrence. Between 1932 and 1942 only 29 patients were admitted to this clinic with a nasopharyngeal cancer. Because the nasopharynx is accessible only to the most careful rhinoscopist, this lesion is frequently missed. Before admission to the clinic, more than half our patients were under the care of a physician and had one or more nasal operations directed toward the relief of symptoms without recognition of the primary lesion. Other writers have recorded a similar experience (1, 2). New (3) reports that 185 operations had been performed on 194 patients before the underlying disease was recognized. Of our 29 cases, 3 are not included in this study, since they received no x-ray therapy. Most of the cases were treated and followed by Dr. Anna Hamann. Symptoms and Signs In 16 of the 26 patients, or 62 per cent, the chief complaint on admission was a cervical mass. Others (4, 5, 6, 7) have reported an incidence of 35 to 77 per cent. Cutler and Buschke (6) regard cervical adenopathy as the most frequent finding and usually the sign which brings the patient to a physician. Pain referable to the temporal area, face, or side of the head was the next most common complaint, occurring in 6 patients. It is this failure of the primary lesion to produce prominent local symptoms that accounts for the difficulty in diagnosing and dealing with nasopharyngeal cancer in an early stage. In all instances the rhinoscopists were able to visualize a nasopharyngeal mass or ulcer. There was great variation in size, and in several cases a small ulcer could be seen behind the cushion of the eustachian tube or in the fossa of Rosenmüller. This made biopsy very difficult. Eighteen of the 26 patients had palpable cervical lymph nodes, which again emphasizes the point that these patients appear for treatment in an advanced stage of the disease. In 4 of these 18 patients, the lymph node enlargement was bilateral. In 4 instances biopsy was done on the nodes and metastatic neoplasm was revealed. Cranial nerve signs were almost as frequent as involvement of cervical lymph nodes. In 15 of the 26 patients one or more cranial nerves was involved—the trigeminal most frequently (10 patients), the sixth next (6 patients). Middle-ear disease was noted in 9 of the cases. Varying degrees of change in the ear drum, from redness to perforation with purulent discharge, were observed. X-ray Signs Films usually showed varying degrees of clouding of one or more of the paranasal sinuses. The lateral skull films were useful in demonstrating a soft-tissue mass but, except in two instances, there was no evidence of bone destruction in the sphenoid. By far the most significant x-ray examination was the stereoscopic verticomental, basal, or what we call axial views of the skull. Twenty-four of our 26 patients had one or more stereo sets of axial films made during the course of their illness.

Surgery as applied to lymph nodes of the neck in cancer of the lip and buccal cavity: A statistical study

1. 1. This study is based upon an analysis of 66 lip cases and 112 cases of carcinoma of the buccal cavity and pharynx in a free cancer hospital. There is included for comparison a similar group of 47 private cases. 2. 2. All cases were treated by bilateral suprahyoid resection of lymph nodes (for lip cases) or unilateral or bilateral anterior and posterior triangle resection of lymph nodes (for mouth cases). 3. 3. Tables for each group are appended to show five-year results of treatment, the pathology of lymph nodes in relation to clinical findings and end-results, the grade in reference to “cure”, and, in the mouth cases, the type of operation followed by death in the hospital. 4. 4. The operative deaths following the suprahyoid resection of lymph nodes is negligible. The unilateral anterior and posterior triangle dissection is more formidable, but while 42 of 112 patients who were thus treated died in the hospital, in only 3 of these 42 was the operation limited to the attack on the lymph nodes. 5. 5. It is impossible to distinguish by palpation between hyperplastic and carcinomatous lymph nodes. 6. 6. Approximately 90 per cent of cases of carcinoma of the mouth have palpable cervical lymph nodes; 70 per cent of the cases (including those with non-palpable nodes) in this study showed carcinoma in the lymph nodes. 7. 7. The grade of the primary lesion either on lip or in the buccal cavity should not influence decision for or against neck dissection. 8. 8. Conclusive evidence that any method other than surgery is effective either in the prevention of or the cure of cervical metastasis is lacking. 9. 9. In the cases herein studied which showed proved carcinoma in the lymph nodes, in 33 per cent of the lip cases and 13.8 per cent of the mouth cases the patients lived five years or more after operation. 10. 10. The resection of lymph nodes as an important part in the routine treatment of carcinoma of the lip and buccal cavity is to be strongly advocated.