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Magnetic resonance imaging (MR) has already gained wide acceptance in the evaluation of intracranial and spinal canal abnormalities. MR also provides excellent resolution of certain tumors of the head and neck and is particularly useful for the evaluation of neoplasms in the vicinity of the skull base. The absence of a bone signal prevents the streaking artifact so troublesome with computerized axial tomography (CT) and allows better definition of tumor. MR does not use ionizing radiation and appears to be an innocuous imaging mode--thus multiple examinations in young patients are not objectionable with MR. The ability to obtain images in multiple planes by control of the magnetic gradients allows for axial, sagittal, and coronal imaging, without changing the supine position of the patient. Multiple projections are helpful in providing better preoperative assessment of the extent and size of certain neoplasms of the neck.

Standard methods of managing large or recurrent cutaneous nasal malignant neoplasms are often inadequate, leaving extensions of the tumor that are clinically invisible. Conventional methods may also allow considerable amounts of normal tissue to be sacrificed in an attempt to ensure the removal of all carcinoma. Through partnership of the dermatologic surgeon and the reconstructive surgeon, a more effective method of curing and rehabilitating patients with nasal skin cancer can be achieved. The dermatologic Mohs' surgeon can perform microscopically controlled excision of malignant neoplasms, providing the highest cure rates obtained by any method. This method is particularly suited for basal cell carcinomas that are recurrent, larger than 1 cm in size, or are of the morpheaform histologic subtype. Total microscopic excision allows nasal reconstruction to proceed with the highest degree of confidence of tumor control. The location and extent of the malignancy dictate the surgical approach for nasal reconstruction.

Tumors of the skull base with intracranial and extracranial components pose special access problems. Traditional craniotomy and extensive external incisions produce morbidity that can be avoided in properly selected cases. Current surgical techniques extend previously described operations to allow good visualization and safe resection through the face for certain intracranial tumors. Meticulous attention to surgical techniques and wide exposure for complete tumor visualization are essential to ensure the safety of these procedures.

Intra-arterial chemotherapy for the treatment of localized malignant neoplasms in the head and neck is an appealing approach for several reasons. Perhaps the most important is the possibility of obtaining a regional advantage such that an increased drug concentration is delivered systemically. The patient may, therefore, be spared systemic toxicity. We report our accumulated experience using a totally implantable infusion pump in 37 patients. A total of 42 pumps were implanted: 28 single-catheter pumps and 14 dual-catheter pumps. Radionuclide imaging demonstrated total perfusion of the tumor in all patients. A combination of cisplatin (50 to 100 mg/m2) and floxuridine (0.01 to 0.045 mg/kg/d) was used to treat 26 patients. For these heavily pretreated patients, we observed a 43% complete and partial response rate in the subgroup of patients with squamous cell carcinoma. These results are comparable with those reported for these drugs administered systemically and for other drug combinations tested in the treatment of recurrence disease.

A multi-institutional National Cancer Institute trial of preoperative cisplatin (100 mg/sq m, day 1) and intravenous bleomycin sulfate (15-mg/sq m bolus, day 3, followed by 15 mg/sq m/day, 24-hour infusion, days 3 to 7) was carried out in patients with previously untreated, resectable stage III and IV squamous cell carcinoma of the oral cavity or larynx and hypopharynx. Of the first 113 patients who received a single course of induction chemotherapy, eight complete responses and 47 partial responses at the primary site were observed (49%). Of 76 patients who had clinically positive regional adenopathy, 11 complete responses and 31 partial responses of neck nodes were observed (55%). The response rates of the primary tumor and the regional nodes to induction chemotherapy were assessed with respect to several pretreatment patient and tumor characteristics and to reported toxic effects after chemotherapy. Of the factors examined, no prognostic indicators were highly useful to predict the response of the primary tumor. However, the response of regional adenopathy was associated with the initial N class, the site of primary tumor, and the response of the primary tumor to induction chemotherapy.

Periosteal osteosarcoma, a variant of juxtacortical osteosarcoma, is seldom seen in the jaws. The clinical, radiographic, and histopathologic features of a rare mandibular periosteal osteosarcoma presenting as a deep mass in the area of the parotid are reported. The clinicopathologic features that distinguish this lesion from the more common parosteal osteosarcoma are also discussed.

Despite almost 3 decades of experience, the use of intraarterial (IA) chemotherapy for the treatment of head and neck cancer is not universally accepted. The overall reported response rates are not substantially different from the therapeutic results obtained with systemic therapy. The additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. It is clear that considerable improvement in the techniques and efficacy of IA chemotherapy is necessary. This second and last part of this article considers the past and present clinical experience with IA therapy in the treatment of head and neck cancer and explores future developments.

Serum antibody reactivity to squamous cell carcinoma of the head and neck (SCCHN) was evaluated in 41 autologous serum-tumor cell line combinations using the protein A hemadsorption assay. Autologous antibody reactivity (median titer of 1:4) was detected in sera from 24 of the patients tested. In 10 cases autologous antibody reactivity could be detected only in undiluted serum precluding further analysis. Analysis of higher titer sera from one patient revealed antibodies that define an antigen expressed on autologous tumor cells cultured from both the primary tumor (UM-SCC-17A) and from a metastasis (UM-SCC-17B). Absorption analysis showed that this antigen was also expressed on 6 of 10 allogeneic SCCHN cell lines but not on autologous fibroblasts or on allogeneic melanoma cell lines. Due to the low titer of autologous antibody reactivity in most sera, we sought to determine if dissociation of immune complexes through acidification and ultrafiltration of serum might enhance detectable antibody reactivity as has been done in previous studies in melanoma. Twelve serum samples from eight patients were subjected to acid dissociation and ultrafiltration (AD-U). Only six of the untreated sera had detectable antibody reactivity against the autologous SCCHN cell line whereas following AD-U all 12 sera had enhanced IgG reactivity against autologous SCCHN. Specificity analysis of one serum sample after dissociation revealed that the antibody detected an antigen common to SCCHN cell lines as well as melanoma, glioma, renal, and colon carcinoma cell lines. Circulating immune complexes may provide a reservoir of antibody with potential diagnostic and therapeutic applications.

The treatment of advanced cancer of the maxillary sinus often requires extensive ablation and orbital exenteration that results in large full-thickness defects of the upper cheek and orbital regions. Reconstruction of such defects with local flaps is usually difficult because of the need for a large flap. Several regional flaps such as the deltopectoral flap, the temporal flap, and the shoulder flap may be used, but these techniques frequently require surgery in stages and result in severe deformity of the donor site. The island pedicled, pectoralis major myocutaneous flap may be rotated up to the orbital region; however, the uncertain blood supply to the skin in the distal area of the pectoralis may cause unexpected marginal necrosis of the flap. Reconstruction of large orbital-maxillary defects can readily be accomplished in one stage using microsurgical free transfer of latissimus dorsi myocutaneous flaps. The thoracodorsal artery and vein that form the nutrient pedicle of the flap approaches 2 mm in external diameter and up to 10 cm in length, allowing greater versatility in head and neck reconstruction. The muscle may be used to fill the orbital and maxillary cavities and will accept a skin graft on its deep surface. The donor defect is closed primarily and the resulting scar is well concealed beneath the arm. If necessary, extremely large flaps may be transferred by harvesting the entire latissimus dorsi muscle and the overlying skin based on the thoracodorsal system.

The membrane glycoproteins from control (BHK21/C13) and Rous sarcoma virus-transformed (C13/B4) baby hamster kidney cells grown in medium containing [14C]- or D-[3H]glucosamine have been separated into two distinct classes: a phenol-soluble fraction and an aqueous fraction. The membrane glycoproteins from both BHK21/C13 and C13/B4 partitioned similarly into these two fractions. The phenol and aquesous-soluble glycoproteins differed in their sodium dodecyl sulfate-polyacrylamide gel profiles, polyacrylamide isoelectric focusing profiles, and glycopeptide distribution on Sephadex G-50. A number of aqueous and phenol-soluble glycoproteins from BHK21/C13 and C13/B4 cells were purified to near homogeneity by means of polyacrylamide electrophoresis and gel electrofocusing. These glycoproteins range in molecular weight from 179,000 to 31,000 and have isoelectric points of 7.5 to 3.0. Our results show that the pronase glycopeptides of 20 out of 24 homologous membrane glycoproteins of equivalent molecular weight and isoelectric point from BHK21/C13 and C13/B4 cells are dissimilar as measured by Sephadex G-50 gel filtration.

In 22 patients with advanced squamous cell carcinoma of the head and neck we evaluated the efficacy and toxicity of 200 mg/m2 cisplatin administered in 3% NaCl with vigorous hydration. Six patients had previously untreated stage IV disease and 16 patients had recurrent disease, including eight with prior chemotherapy including low-dose cisplatin and carboplatin. Cisplatin was administered as a brief infusion, either 40 mg/m2/day X 5 or 50 mg/m2/day X4, every 28 days. Objective responses were observed in 16 of 22 (73%) patients, including 5 of 6 (83%) previously untreated patients and 11 of 16 (69%) patients with recurrent disease. This included two complete responses, one confirmed pathologically. Fifty-seven courses of drug were administered and toxicity was monitored with serial creatinine clearance determinations, audiograms, and sensorimotor exams. Neuropathy and ototoxicity were dose-limiting and led to the stopping of treatment in 12 of the 16 responders after one to four courses (median three courses). Only two responding patients continued treatment until disease progression occurred at 3 and 4 months after achieving maximum response. Acute, transient nephrotoxicity occurred in four patients; two were retreated. Moderate myelosuppression occurred in all patients but was not treatment-limiting. For most patients the maximally tolerated number of courses was three. The median survival time was 33.5 weeks for recurrent disease patients, 108 weeks for newly diagnosed patients. This regimen is not recommended for the palliation of recurrent disease. However, the very high response rate suggests that high-dose cisplatin may have a useful role in induction or adjuvant chemotherapy regimens.

In recent years, the successful grafting of human tumors into immune deprived animals has spurred the hopes of developing a reliable in vivo model for evaluation of human cancer. The nude mouse has created new perspectives in many different areas of cancer research, and has proved to be the most useful recipient of any animal system for tumor heterotransplantation. This study determined which of several squamous cell carcinoma (SCC) cell lines would reproducibly grow as heterotransplants in nude mice, and allowed an opportunity to determine whether characteristics of the tumor changed as a result of propagation in tissue culture. Sixteen (76%) of the 21 SCC lines heterotransplanted in nude mice remained as viable tumor nodules. Nine (43%) of these lines reproducibly produced progressively enlarging tumor masses. Five (24%) SCC lines failed to grow as heterotransplants. The average lag phase between implantation and the beginning of growth for all SCC lines tested was approximately 7 weeks and emphasizes the need for prolonged observation of nude mice following SCC heterotransplantation. The rate and pattern of growth of SCC in nude mice appears to be related specifically to the tumorigenic factors of a given cell line. The concurrent presence of other SCC or non-SCC tumors in a given mouse do not appear to influence the growth of a specific cell line. In addition, specific host factors that might vary from one mouse to another did not alter the growth patterns of SCC. Histological examination of the SCC lines successfully heterotransplanted in nude mice showed similar histological appearances to the original tumor in the human host.

We have evaluated the use of the completely implantable infusaid pump in 22 patients with advanced cancer confined to the head and neck. Unilateral head lesions are treated with a single-catheter pump infusing the external carotid artery. A dual-catheter pump is used for midline or bilateral head lesions (both external carotid arteries infused) or unilateral head and neck disease (the second catheter positioned in the thyrocervical trunk). The infused volume of each catheter is determined by nuclear tomography after slow intra-arterial injection of 99mTc-labeled macroaggregated albumin through the pump's auxiliary port. The injection port/infusion chamber configuration of the pump permits long-term, multiple-course, combination-drug intra-arterial therapy on an outpatient basis. To date, 15 patients have been treated longer than 6 months and five longer than 1 year with no bleeding or neurologic complications. Eight of 10 patients treated with cisplatin and fluorodeoxyuridine (FUdR) have responded. The Infusaid pump permits long-term, practical, cost-effective, intra-arterial therapy to the entire tumor volume of ambulatory head and neck cancer patients with a high rate of tumor response.

A totally implantable infusion pump (infusaid) has been developed to achieve continuous drug delivery for long periods of time. The recent availability of a dual-catheter totally implantable infusion pump permits the infusion of both external carotid arteries simultaneously. This has obvious advantages for the treatment of extensive tumors of the head and neck that extend across the midline. Likewise, for the first time, unilateral local-regional disease that extends inferiorly beyond the nutrient field of the external carotid artery may be treated with intra-arterial infusion chemotherapy without the need to infuse the common carotid or innominate arteries. Unilateral infusion of the entire head and neck is accomplished by using the dual-catheter pump to infuse both the thyrocervical trunk and the external carotid artery.

Developments in microvascular surgery have overcome much of the problem of inadequate vascularity encountered by more conventional methods of mandibular reconstruction. The advantage of the osteocutaneous scapular flap compared with earlier described revascularized bone grafts or composite flaps is its greater versatility in reconstruction of soft-tissue defects of the oral cavity concomitant with mandibular reconstruction. This is primarily related to the independent vascular pedicles of the cutaneous and osseous portions of the flap. This flap is our preferred method of reconstructing mandibular defects.

We report two cases of portal vein wall calcification demonstrated by CT. The clinical features of such patients are reviewed, and proposed etiologic mechanisms are discussed.

A case of gallbladder empyema is presented, which opacified initially on excretory urography and then on nephrotomography, mimicking a renal mass. Correct diagnosis was accomplished by angiography and ultrasound examination. With normal renal function gallbladder visualization on urography is indicative of a gallbladder abnormality.

Squamous cell carcinoma of the nasopharynx is an uncommon disease in childhood. Ten patients under the age of 18 years with nasopharyngeal carcinoma are reviewed. The average patient age was 13 years and the average duration of symptoms was 18 weeks. Cervical mass (8/10) and hearing loss (4/10) were the most frequently encountered complaints. Three- and five-year determinate survival was 50% and 44% respectively. Bilateral cervical metastases or cranial nerve impairment from neoplasm offered a poor prognosis.

A case of fluctuating sensorineural hearing loss from acute carbon monoxide (CO) poisoning with presentation of a U-shaped audiogram is reported. Acute CO intoxication seems to involve vestibular function more frequently than auditory function. Hearing loss is uncommon, but when present, may often display a U-shaped audiometric curve. Decrease in hearing sensitivity probably results from hypoxia to the cochlea, VIII nerve and brain stem nuclei. Fluctuation in hearing sensitivity may be an early manifestation of acute CO exposure, and requires periodic audiometric examination until the hearing has stabilized.

Cancer of the ethmoid sinus is a rare tumor in the head and neck, accounting for less than 1 per cent of all such malignancies. This paper examines squamous cell carcinoma arising in the ethmoid sinus, the most common form of ethmoidal malignancy in a series reviewed at the University of Michigan. Sixteen cases diagnosed between 1964 and 1974 (inclusive) were included in this study. Peak incidence of the disease occurred in the seventh decade of life. All patients had a minimum follow-up of at least five years. The patients had relatively common nasal complaints that unfortunately represented an unusual and frequently fatal disease. The symptoms of ethmoid sinus cancer are reviewed, and the many modalities of treatment that can be used are discussed. The problems of staging ethmoid sinus cancer are elucidated, and difficulties with the suggested classification systems are discussed. Ultimately, only 29 per cent of the patients survived five years.

Two cases of giant vascular malformation of the kidney demonstrated by computed tomography and angiography are presented. The vascular malformations form completely outside the kidney. They arise from the renal parenchyma, simulating renal cyst, and present as a renal pelvic mass causing hydronephrosis. The finding of a renal mass with a markedly and uniformly contrast enhancement demonstrated by computed tomography should suggest the possibility of a vascular malformation.

Since there has been no significant increase in cancer cure rates in recent years that can be attributed to the treatment method alone, new and more radical procedures have been introduced in an effort to improve the results. In radiation therapy this has taken the form of supervoltage generators and in the use of high energy sources of radiation such as Cobalt 60 and Cesium 137. As this trend gains momentum, the place and future of orthovoltage therapeutic radiation (250 to 400 kilovolts) must be considered. General agreement is that supervoltage radiation offers an increase in depth dose and fewer local and systemic reactions, but it is too early to assess any change in cure rate. Measured against this is the danger of deep tissue damage, less relative biological efficiency and increased costs. In view of our ignorance regarding cancer, abandoning proved procedures prematurely is unjustified. The most promising trend lies in improved training and in the skillful use of what we have. While it may be that radiation of higher voltages will improve the morbidity and mortality rates, it would be better to concentrate these new modalities in centers where large numbers of cases are available.