Melanoma of the head and neck

Opinion statement Staging of cutaneous melanoma has changed in recent years with an increased emphasis upon thickness and ulceration on prognosis of early stage disease. Cutaneous melanoma of the head and neck is treated with complete surgical resection in early stage disease. Resection margins are determined by the size, depth, and presence of satellite lesions. Evaluation for regional and distant metastatic disease is necessary in all cases of advanced stage disease. Sentinel lymph node biopsy and possible parotidectomy and neck dissection should be considered in head and neck cutaneous melanomas greater than 1 mm in thickness or with ulceration. Adjuvant therapy may be indicated in advanced primary, nodal, and metastatic disease. Mucosal melanoma of the head and neck remains a difficult disease to treat, with high locoregional recurrence rates and poor prognosis despite aggressive therapy.     

High-risk non-melanoma skin cancer of the head and neck

High-risk non-melanoma skin cancer (NMSC) of the head and neck is difficult to manage, given its propensity for regional metastasis, perineural invasion, direct parotid invasion, and bony destruction. Management of these tumors demands awareness of the characteristics contributing to their recurrence. Recent studies emphasize the importance of treatment of the parotid gland and cervical lymph nodes to improve locoregional control. A multidisciplinary approach to the assessment and treatment of high-risk NMSC is required to provide comprehensive care. This review also covers recent advances in the understanding of NMSC biology and new approaches in chemoprevention.     

Radiation-induced skin cancer and radiodermatitis of the head and neck

From a cohort of 2400 patients who had been irradiated 19 to 48 years previously for benign diseases in the head and neck region a randomly selected group of 605 patients was selected and traced back. From the 360 patients alive, 257 were examined clinically and 49 were examined by questionnaire for radiation-induced skin tumors and radiodermatitis. In 21 patients, a total of 30 skin tumors were diagnosed. In 8 of 21 patients, 10 skin carcinomas were detected at recall. A dose-effect relationship of 40 carcinomas/10(4) persons/Gy for a median follow-up period of 41 years for the area exposed was calculated. The severity of radiodermatitis is associated with a higher prevalence of skin cancer. The number of radiation-induced skin cancers rises with the post-treatment time. Because of these late radiation effects, radiotherapy of benign skin lesions is contraindicated, especially now that other therapy modalities are available.     

Melanoma of the head and neck: current concepts in staging, diagnosis, and management

Major advances in the understanding of the causes and risk factors for melanoma and for the prevention and management of this tumor have taken place since the beginning of the past century, when the diagnosis of melanoma was synonymous with death. As many as 80% of early melanomas can be cured, and a high rate of locoregional control for even far-advanced melanoma is plausible. The major challenge for the years to come lies in curtailing the steady rise in the incidence of melanoma by increasing patient education and adopting measures to prevent the increasing mortality rates associated with this disease. Cure rates can be improved by early diagnosis by physicians and instant referral to experienced oncologists. Finally, new advances in diagnostic and treatment strategies carry the hope for further improvements in locoregional control and survival rates.     

Melanoma of the skin and pregnancy

Out of 2018 patients, skin melanoma occurred in IO2 (5%) cases during pregnancy. Three-, five- and ten year survival was analysed in the latter cases versus term of pregnancy, abortion and the stage of the disease. Also comparison was made between the said group, another 42 females who developed tumors during lactation period and 599 normally-cycling females of reproductive age who were not pregnant when melanoma appeared (controls). Significantly lower 10-year survival was observed in pregnant patients, as compared with those who were not pregnant (p less than 0.05). Five- and ten-year survivals were significantly lower in cases of stage I tumor during the latter half of pregnancy than in skin melanoma patients who were not pregnant (p less than 0.05). Abortion during the first half of pregnancy was found to produce an adverse effect on prognosis in stage I tumor patients while this effect was reversed in stage II tumor. No significant differences were found between 3-, 5- and 10-year survival in melanoma patients who had pregnancies before the disease and those who had not (p greater than 0.05).     

Photodynamic therapy in the treatment of malignant tumours of the skin and head and neck

Photodynamic therapy utilizes a tumour-localizing photosensitive substance which, when activated by light of an appropriate wavelength, releases cytotoxic substances causing destruction of the malignant tumour with preservation of surrounding normal tissues. In this technique the only drug/light combination which has been regularly used to date is that of haematoporphyrin derivative and red light at a wavelength of 630 nm usually produced by a dye or gold vapour laser. A pilot/feasibility study was set up in Southampton in 1983, with ethical permission, to treat tumours of the skin and head and neck which had failed all other treatment modalities or for which there was no practical alternative therapy. Thirty-eight patients were treated in this study and all tumours showed a response; significant palliation was achieved in a number of patients. Basal cell carcinomas and the multiple lesions of Bowen's disease were found to be particularly suitable for this form of therapy and prolonged local control was achieved in a number of patients.     

Head and neck skin involvement by non-cutaneous head and neck cancers: free flap reconstruction.

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.     

头颈部皮肤与粘膜恶性黑色素瘤的临床探讨

目的 :探讨头颈部皮肤恶性黑色素瘤和粘膜恶性黑色素瘤的转移规律及疗效 ,及头颈部粘膜恶性黑色素瘤套用皮肤恶性黑色素瘤临床分期是否合理。方法 :采用回顾性多因素回归分析 ,将 5 5例头颈部恶性黑色素瘤分成皮肤恶性黑色素瘤组 31例 ,黏膜恶性黑色素瘤 2 4例 ,分析转移规律及预后因素。结果 :皮肤恶性黑色素瘤和粘膜恶性黑色素瘤原发灶复发率、淋巴结转移率、血行转移率分别为 4 8 38%、4 5 16 %、2 1 81%和 37 5 0 %、4 1 6 7%、33 33% ;多因素回归分析两组原发灶复发率、淋巴结转移率、血行转移率有显著性差异 (P <0 0 5 ) ,临床分期、原发灶首次手术方式、起源影响复发率和转移率 (P<0 0 5 )。皮肤恶性黑色素瘤组和粘膜恶性黑色素瘤组 1、3、5年生存率分别为 81 15 %、6 6 2 0 %、4 5 0 7%和 81 95 %、4 9 72 %、39 77% ;多因素回归分析两组间生存率无显著性差异 (P >0 0 5 ) ,临床分期、原发灶首次手术方式、血行转移影响头颈部恶性黑色素瘤生存率 (P <0 0 5 )。分组后行多因素回归分析 ,皮肤恶性黑色素瘤组临床分期与生存率有显著性差异 (P<0 0 1) ,黏膜恶性黑色素瘤组临床分期与生存率无显著性差异 (P >0 0 5 )。结论 :①皮肤恶性黑色素瘤原发灶复发率、淋巴结转移率高 ,粘膜恶性黑色     

光敏拮抗剂类皮肤保护剂预防头颈部放射性皮炎疗效观察

目的：观察光敏拮抗剂类皮肤保护剂预防头颈部放射性皮炎的疗效。方法：将66例头颈部肿瘤病人随机分为两组,观察组33例,放疗期间使用光敏拮抗剂类皮肤保护剂;对照组33例,按常规皮肤护理。比较两组放射性皮炎的发生程度。结果：观察组病人发生Ⅰ级、Ⅱ级、Ⅲ级皮炎分别为72.7%、27.3%、0;对照组病人发生Ⅰ级、Ⅱ级、Ⅲ级皮炎分别为24.2%、66.6%、9.1%。观察组病人发生放射性皮炎程度明显轻于对照组（P〈0.05）。结论：光敏拮抗剂类皮肤保护剂能提高皮肤的耐受能力,降低头颈部放射性皮炎的发生程度。     

光敏拮抗剂类皮肤保护剂预防头颈部放射性皮炎疗效观察

目的:观察光敏拮抗剂类皮肤保护剂预防头颈部放射性皮炎的疗效。方法:将66例头颈部肿瘤病人随机分为两组,观察组33例,放疗期间使用光敏拮抗剂类皮肤保护剂;对照组33例,按常规皮肤护理。比较两组放射性皮炎的发生程度。结果:观察组病人发生Ⅰ级、Ⅱ级、Ⅲ级皮炎分别为72.7%、27.3%、0;对照组病人发生Ⅰ级、Ⅱ级、Ⅲ级皮炎分别为24.2%、66.6%、9.1%。观察组病人发生放射性皮炎程度明显轻于对照组(P<0.05)。结论:光敏拮抗剂类皮肤保护剂能提高皮肤的耐受能力,降低头颈部放射性皮炎的发生程度。     

Paragangliomas of the head and neck

Paragangliomas are uncommon vascular tumours of the head and neck. Eighteen such cases were treated during a six year period. Of the five patients having glomus tympanicum tumours, 3 required a tympanotomy, one a transmastoid excision while one needed a modified Fisch’s type A technique. Eight glomus jugulare tumours were excised by a modified Fisch’s type A approach. One of the four cases with carotid body tumours required carotid replacement by a saphenous vein graft. A glomus vagale tumour was excised transcervically by a median mandibulotomy. Three patients had bilateral tumours. Postoperatively lower cranial nerve palsy persisted in three cases. Two patients having residual intracranial disease received postoperative irradiation. Contrast enhanced CT in axial and coronal planes was found to obviate the need for angiography in all but jugulare tumours. There was no recurrence of symptoms in any case during 6 months to 6 years of followup.     

Paragangliomas of the head and neck

Paragangliomas are neuroendocrine tumors derived from the extra-adrenal paraganglia of the autonomic nervous system. Within the head and neck, they are generally defined and named according to their site of origin, and may be found frequently neighboring vascular structures. Physiologic activity is rare in these neoplasms and they may exhibit patterns of inheritance which predispose their occurrence in families, often with multicentricity. These tumors generally exhibit a slow rate of growth, most often presenting asymptomatically as a space occupying mass lesion noted clinically or radiographically. The most common paraganglioma of the head and neck is the carotid body tumor followed by the jugulo-tympanic and vagal varieties. Other rare sites where this tumor may occur include; the larynx, sinonasal chambers and orbit. Diagnosis is generally made through a combination of clinical findings and radiographic studies. Magnetic resonance represents the most important imaging modality for the evaluation and characterization of suspected head and neck paraganglioma. Definitive management for these lesions should be carefully considered in relation to both tumor and patient-oriented factors, especially in regard to the potential morbidity of treatment. Surgery and radiation therapy represent the main treatment modalities for paraganglioma. The selection of treatment depends on the size, location, and biologic activity of the tumor as well as the overall fitness of the patient. Although radiotherapy may be effective in arresting growth of these tumors, rarely is the neoplasm eliminated without surgical resection. Surgery may be associated with significant morbidity, primarily as a consequence of incurring major cranial nerve injury. Patient selection (relative to age and medical condition) should be carefully considered prior to recommending aggressive surgery for paragangliomas of head and neck, especially in those patients at risk for disabling surgical morbidity.     

Sarcomas of the head and neck

Sarcomas of the head and neck are extremely rare, accounting for less than 1% of all neoplasms of the head and neck. These sarcomas arise in both soft tissues and bone and thus cannot be treated by a single approach. The clinical behavior of these tumors varies considerably. Patients with low-grade lesions are prone to local recurrence, whereas those with high-grade lesions develop both local recurrence and disseminated disease. An additional complicating factor is the multiple sites in which sarcomas may arise in the head and neck. All of these factors make it difficult to ascertain the optimal treatment approach for sarcomas. This article reviews the current literature (as well as the author’s own experience) and provides a general treatment guideline for sarcomas of the head and neck.     

Sarcomas of the head and neck

With the exception of pediatric RMS, soft tissue sarcomas only rarely arise in the head and neck region. Soft tissue sarcomas include a diverse array of histologic types because of the variety of mesenchymal tissues from which they originate. The combination of infrequent occurrence, varied pathologic features, and the many potential sites of presentation makes these tumors a challenge for the head and neck oncologist and underscore the need for review by a pathologist experienced with soft tissue tumors. Classification schemes that group sarcomas according to grade have been helpful in providing prognostic information. Although local control of the primary tumor is critical to successful treatment of both high- and low-grade lesions, the high rate of distant metastases in high-grade tumors supports the role of combined modality therapy. Compared with other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumors arising in sites not amenable to resection. Exceptions to this principle include RMSs of the orbit, paranasal sinuses, and masticator space in children; these are usually treated with radiotherapy and combined multiagent chemotherapy, thereby avoiding the functional and cosmetic impact of surgery. Also, extensive angiosarcomas of the scalp should be treated with multimodality therapy combining surgery and wide-field radiation therapy in an attempt to achieve local control. Adjuvant radiotherapy is generally recommended for high-grade sarcomas, large tumors, close or positive surgical margins, and certain histologic variants. Systemic chemotherapy is recommended for those tumors with a significant risk of distant metastases. Increasingly, neoadjuvant chemotherapy is being used to determine responsiveness to chemotherapy, which can help physicians select patients who may benefit from systemic postoperative therapy. Traditional predictors of treatment failure for soft tissue sarcomas include larger tumor size, high-grade histology, and positive surgical margins. The advent of more advanced reconstructive techniques, including free tissue transfer, has made more aggressive surgical resection of these tumors possible. Nevertheless, a considerable number of ancillary support staff are critical to the patient's postoperative rehabilitation and eventual return to a satisfactory level of function and quality of life. In the future, the discovery of the molecular pathogenesis of specific tumor types, such as the cytogenetic findings in synovial sarcoma, will improve physicians' prognostic abilities and selection of patients who are most likely to benefit from emerging adjuvant therapies.