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From January 1958 through December 1983, 56 modified radical neck dissections were performed on 47 patients with metastases to the cervical nodes from differentiated carcinomas of the thyroid. In nine patients, a second modified radical neck dissection was performed either simultaneously or at a later date. Lymph node clearance was performed on all but one surgical specimen. The number of nodes in each specimen ranged from 10 to 96, and the number of involved nodes ranged from 1 to 20. Thirty-eight of the 56 neck specimens contained four or more positive nodes. Seventeen patients were followed for 10 to 26 years, 18 patients for 5 to 9 years, and 5 patients for less than 5 years. Seven other patients died, three from other causes and four from lung metastases. There were no recurrences in the neck sides that would have been cleared if standard radical neck dissection had been performed. This reappraisal with long-term follow-up supports our initial impression that a modified radical neck dissection sparing the spinal accessory nerve, the sternocleidomastoid muscle, the internal jugular vein, or any combination thereof is an effective procedure for differentiated cancer of the thyroid, with preservation of good shoulder function and improvement in the cosmetic appearance of the neck.

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A painless lateral neck mass in an otherwise healthy 58-year-old man is a frequent diagnostic problem. We have recently seen such a patient with a cervical neck mass whose preoperative evaluation findings were normal. Excisional biopsy revealed a lymph node exhibiting changes compatible with extramedullary hematopoiesis. This becomes an additional unusual cause of enlarged lateral neck nodes.

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A 62-year-old Caucasian man presented with a slow-growing 3 by 3 cm. mass in the left preauricular region. The pathologist's report on the surgical specimen favored a diagnosis of acinic cell carcinoma but recommended evaluation of the patient for possible metastatic renal cell carcinoma. A subsequent intravenous pyelogram and arteriogram revealed the presence of a mass in the right kidney. The lesion proved to be a renal cell carcinoma which was microscopically indistinguishable from the parotid tumor.

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The surgical oncologist is sometimes confronted with a patient who was surgically treated for cancer of the thyroid gland and now has recurrent disease. In most instances, additional surgical treatment is indicated. The magnitude of surgery is primarily determined by the amount of tissue removed at the original operation. Surgery for recurrent disease may include completion of total thyroidectomy with dissection of lymphatic tissues in the thyroid compartment or/and neck dissection, preferably modified. Several clinical situations are outlined and discussed.

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In clinical practice, small or localized thyroid cancer is often missed at the time of surgery and is diagnosed only later after the pathologist has been able to study multiple sections. Our data suggest that patients with early or localized thyroid cancer can be controlled with less than total thyroidectomy. If the nodule is completely excised without fracture (preferably lobectomy) or not cut into, if there is no evidence of metastatic disease either by palpation or frozen section, and if gross examination of the surgical specimen and frozen sections is negative for carcinoma, it is our policy to place these individuals on a regimen of observation only. Additional surgery is performed only if clinical evidence of recurrent cancer develops. Long-term follow-up of forty-four patients supports this treatment policy. Of these, seven had clinical recurrences: three benign; four (9 per cent) malignant. (The 2 patients with metastatic periglandular lymph nodes in the surgical specimen would not meet our present criteria.) We have in our files several additional patients who seem to support the same conclusions but will be reported on only after longer follow-up.

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We have outlined the clinical manifestations of "localized" malignant lesions of the intraoral cavity, their clinical behavior after intraoral excision, and their control rate employing intraoral excision as primary therapy. We must keep in mind that these small "localized" cancers are potential "killers" and the five year mortality from disease in our series was 25 per cent. This mortality may decrease with (1) more careful selection when patients are included in the "localized" lesion group and (2) earlier use of composite procedures in questionable cases.

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During a period of 23 years, 57 patients who had an initial neck node biopsy elsewhere, with the diagnosis of metastatic squamous cell carcinoma established, underwent curative resection by our department after the site of head and neck primary was found. Ten patients free of disease died of other causes, leaving 47 patients who were eligible for at least 3 years of follow-up. Ninteen patients are alive after 3 or more years. The incidence of recurrence in the neck was 57% (27/47). The 3-year survival in this group of Stage III was 40% (19/47) and 5-year survival was 34% (16/47). Compared with historical data, it appears from the present study that a previous biopsy of a neck node did not adversely affect the incidence either of neck recurrence or survival when appropriate surgery is performed.

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Operations for intraoral carcinoma do produce deformities and loss of function. Historically, surgeons have constantly tried to correct or improve these deficiencies. The tendency on the part of the surgeon is to replace each bit of tissue removed, hoping that if the site appears normal the patient will be normal. The appearance of the patient has as a rule been given more attention than the functional result. Dysfunction is related to the alteration of certain anatomic and physiologic conditions identified as: (1) inability to obliterate the anterior oral cavity, (2) defects in the palate, (3) inability to close off the oropharyngeal space, and (4) disturbance of normal channels to bypass the larynx. Lateral mandibulectomy and radical neck dissection performed for cancer of the retromolar area, lower gum, lateral tongue, or floor of the mouth will in most instances result in very acceptable cosmetic and functional results. These patients look well, speak well, eat and swallow well, and can assume their usual role in society. Further surgical attempts to improve any deficiencies are discouraged. Patients sometimes ask about bone grafting or devices to replace the resected mandible and our recommendations are very emphatic on the negative side.

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Serum antibody titers to Epstein-Barr virus were significantly elevated in a group of twenty-three patients with nasopharyngeal carcinoma as compared with eighty-six patients with cancer of other sites in the head and neck and 222 age-matched controls. Our findings in this group of patients support the suggestion of an association between the Epstein-Barr virus and nasopharyngeal carcinoma.

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1. A well defined group of patients have been studied. 2. Composite operation resulted in a 56 per cent five year disease-free survival rate. 3. Treatment of recurrent disease with irradiation increased the five year survival to 61 per cent. 4. Preoperative irradiation for squamous cell carcinoma of the intraoral cavity, stage III, is unwarranted unless this treatment plan can produce five year end results better than 61 per cent.

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