376
Comment
We read with interest the paper by Afify and Maynard (Annals, May 1992, vol 74, p186) describing the management of carcinoma of the major salivary glands. As stated by the authors, the total number of patients is small while the numbers in ea l histological group are very small, especially when diviked further into low- and high-grade subgroups. It is therefore difficult to accept the recommendations regarding management based on such limited numbers of patients. The flow diagrams of management depend essentially on
diagnosis using frozen section techniques during operation. Such techniques are open to error and diagnoses may have to be changed once paraffin sections have been examined. Freezing can lead to alterations in cellular morphology; varying thickness of sections can cause difficulty with interpretation; and small samples, although multiple, may not be representative of a whole tumour. Areas of cribriform pattern are typical of adenoid cystic carcinoma but may also be seen in benign pleomorphic adenomas. Obviously, the reliability of diagnosis will depend on the experience of the pathologist involved, but it would seem inadvisable to advocate general dependence on frozen section techniques, especially when they may be the basis for extended radical surgery. Although some types of tumour can be separated into lowand high-grade subgroups on histological grounds, these groupings do not necessarily determine the subsequent natural history. Other factors may have a significant effect on the outcome for individual patients. There is a wide spectrum of behaviour between the different histological types. Stage of a tumour at the time of presentation and treatment has a significant effect. The classical clinical signs of malignant tumours of the major salivary glands are those of disease that is already locally advanced, ie fixity, and nerve palsy, and for which the prognosis will be poor. These factors are reflected in the TNM classification of both the UICC and AJCC. From the figures presented in the paper, it would seem that block dissection of the neck in continuity would have been indicated in 27 of the 52 patients (51.9%). From the experience of the Surgical Salivary Gland Clinic at The Christie Hospital, the incidence of metastatic regional lymphadenopathy has been only 5.4%. Elective block dissection of the No neck is not generally advocated (1). Some of our reservations have been expressed by the assessor's comment from Professor Hobsley. Malignant tumours of the salivary glands are uncommon, an expected incidence of 5.4 per million of the population per year in the North-West of England. In addition to the seven histological types listed by the authors, there are occasional malignant myoepithelial tumours to be added to the list. It would seem that there is great need for a national registry of malignant tumours of the salivary glands in order to pool experience and determine properly the management according to histological type and clinical stage. E N GLEAVE FRCS
Consultant Surgeon N K GUPTA FRCR Consultant Radiotherapist and Oncologist Christie Hospital National Health Service Trust Manchester
Reference I Rice DH, Spiro RH. Current Concepts in Head and Neck Cancer. American Cancer Society, 1989.
Care of road traffic accident victims in a district general hospital I read with interest the paper by Nayeem et al. on the care of road traffic accident victims at a district general hospital (Annals, May 1992, vol 74, p212). Having recently completed a trauma audit at a nearby district general hospital, a similarity arises in the large number of patients admitted with severe head trauma, who account for almost all deaths in both series (5 out of 6 at Luton and Dunstable, and 6 out of 7 in our study). Although many of these deaths are unavoidable due to primary brain damage, the difficulties in managing head-injured patients at district general hospitals are worthy of further discussion. In our series of 136 RTAs, 11 patients with severe head injuries were urgently transferred to the local neurosurgical unit. A 24 h CT scan service was not available at our hospital, and all patients were transferred prior to undergoing computed tomography at the neurosurgical unit. Two patients had the successful evacuation of intracranial haematomas, two had intracranial pressure monitoring, and the remaining seven were returned to the referring hospital. No deaths occurred as a result of the transfer procedure, but the hazards of transferring head-injured patients are well recognised (1). If CT scanning were available to us, some transfers may have been avoided, as it allows improved patient selection (2). However, it can cause delays in transfer, and computed tomography should be performed in the presence of a neurosurgeon or neuroradiologist (3). The policy of selectively transferring patients to a neurosurgical unit prior to CT scanning has been shown to reduce the mortality from intracranial haematomas (4). Until Trauma Centres are established, interhospital transfer will be required for certain head-injured patients. Transfer policies must be carefully drawn up by prior discussion between surgeons at the referring hospital and the neurosurgical unit. ATLS-trained staff should assess these patients in the casualty department, and supervise the transfer procedure if needed. These measures would optimise the selection of patients for transfer, help ensure a safe journey, and avoid fatal delays. G C SINGER FRCS
Orthopaedic Registrar Northwick Park Hospital Harrow, Middlesex
References I Jennett B, Carlin J. Preventable mortality and morbidity after head injury. Injury 1979;10:31-9. 2 Bartlet JR, Neil-Dwyer G. The role of computed tomography in the care of the injured. Injury 1980;11:144-7. 3 Bullock R, Teasdale G. ABC of major trauma. Head injuries (2). Br Med J 1990;300:1576-9. 4 Bryden JS, Jennett B. Neurosurgical resources and transfer policies for head injuries. Br Med Jf 1983;286:1791-3.
Comment
We read with interest the paper by Afify and Maynard (Annals, May 1992, vol 74, p186) describing the management of carcinoma of the major salivary glands. As stated by the authors, the total number of patients is small while the numbers in ea l histological group are very small, especially when diviked further into low- and high-grade subgroups. It is therefore difficult to accept the recommendations regarding management based on such limited numbers of patients. The flow diagrams of management depend essentially on
diagnosis using frozen section techniques during operation. Such techniques are open to error and diagnoses may have to be changed once paraffin sections have been examined. Freezing can lead to alterations in cellular morphology; varying thickness of sections can cause difficulty with interpretation; and small samples, although multiple, may not be representative of a whole tumour. Areas of cribriform pattern are typical of adenoid cystic carcinoma but may also be seen in benign pleomorphic adenomas. Obviously, the reliability of diagnosis will depend on the experience of the pathologist involved, but it would seem inadvisable to advocate general dependence on frozen section techniques, especially when they may be the basis for extended radical surgery. Although some types of tumour can be separated into lowand high-grade subgroups on histological grounds, these groupings do not necessarily determine the subsequent natural history. Other factors may have a significant effect on the outcome for individual patients. There is a wide spectrum of behaviour between the different histological types. Stage of a tumour at the time of presentation and treatment has a significant effect. The classical clinical signs of malignant tumours of the major salivary glands are those of disease that is already locally advanced, ie fixity, and nerve palsy, and for which the prognosis will be poor. These factors are reflected in the TNM classification of both the UICC and AJCC. From the figures presented in the paper, it would seem that block dissection of the neck in continuity would have been indicated in 27 of the 52 patients (51.9%). From the experience of the Surgical Salivary Gland Clinic at The Christie Hospital, the incidence of metastatic regional lymphadenopathy has been only 5.4%. Elective block dissection of the No neck is not generally advocated (1). Some of our reservations have been expressed by the assessor's comment from Professor Hobsley. Malignant tumours of the salivary glands are uncommon, an expected incidence of 5.4 per million of the population per year in the North-West of England. In addition to the seven histological types listed by the authors, there are occasional malignant myoepithelial tumours to be added to the list. It would seem that there is great need for a national registry of malignant tumours of the salivary glands in order to pool experience and determine properly the management according to histological type and clinical stage. E N GLEAVE FRCS
Consultant Surgeon N K GUPTA FRCR Consultant Radiotherapist and Oncologist Christie Hospital National Health Service Trust Manchester
Reference I Rice DH, Spiro RH. Current Concepts in Head and Neck Cancer. American Cancer Society, 1989.
Care of road traffic accident victims in a district general hospital I read with interest the paper by Nayeem et al. on the care of road traffic accident victims at a district general hospital (Annals, May 1992, vol 74, p212). Having recently completed a trauma audit at a nearby district general hospital, a similarity arises in the large number of patients admitted with severe head trauma, who account for almost all deaths in both series (5 out of 6 at Luton and Dunstable, and 6 out of 7 in our study). Although many of these deaths are unavoidable due to primary brain damage, the difficulties in managing head-injured patients at district general hospitals are worthy of further discussion. In our series of 136 RTAs, 11 patients with severe head injuries were urgently transferred to the local neurosurgical unit. A 24 h CT scan service was not available at our hospital, and all patients were transferred prior to undergoing computed tomography at the neurosurgical unit. Two patients had the successful evacuation of intracranial haematomas, two had intracranial pressure monitoring, and the remaining seven were returned to the referring hospital. No deaths occurred as a result of the transfer procedure, but the hazards of transferring head-injured patients are well recognised (1). If CT scanning were available to us, some transfers may have been avoided, as it allows improved patient selection (2). However, it can cause delays in transfer, and computed tomography should be performed in the presence of a neurosurgeon or neuroradiologist (3). The policy of selectively transferring patients to a neurosurgical unit prior to CT scanning has been shown to reduce the mortality from intracranial haematomas (4). Until Trauma Centres are established, interhospital transfer will be required for certain head-injured patients. Transfer policies must be carefully drawn up by prior discussion between surgeons at the referring hospital and the neurosurgical unit. ATLS-trained staff should assess these patients in the casualty department, and supervise the transfer procedure if needed. These measures would optimise the selection of patients for transfer, help ensure a safe journey, and avoid fatal delays. G C SINGER FRCS
Orthopaedic Registrar Northwick Park Hospital Harrow, Middlesex
References I Jennett B, Carlin J. Preventable mortality and morbidity after head injury. Injury 1979;10:31-9. 2 Bartlet JR, Neil-Dwyer G. The role of computed tomography in the care of the injured. Injury 1980;11:144-7. 3 Bullock R, Teasdale G. ABC of major trauma. Head injuries (2). Br Med J 1990;300:1576-9. 4 Bryden JS, Jennett B. Neurosurgical resources and transfer policies for head injuries. Br Med Jf 1983;286:1791-3.
