A retrospective review of the records of 501 previously untreated patients from January 1,1965 through December 31,1986 with squamous cell carcinoma of the oral cavity was undertaken to ascertain the prevalence of ipsilateral neck node metastases (NM) by neck level. The 501 patients underwent 516 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection (ED) in the NO neck, immediate therapeutic dissection (LTD) in the N+ neck, and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+. Pathologically identified NM occurred 34% of the time in ED, 69% in ITD and 90% in STD. The sensitivity, specificity, and overall accuracy of the clinical exam was 70%, 65%, and 6870, respectively. Detailed analysis was performed for each group based on the primary site. This revealed a prevalence of NM in level IV of 3% (five of 167) for ED versus 17% (49/ 296) for ITD + STD (P < 0.001). Tongue, retromolar trigone, and cheek did not have NM in level V in any group. The prevalence of NM in level V for floor of mouth or gum primaries was < 1% (one of 109) in ED versus 6% (ten of 167) in ITD + STD (P < 0.03). These data support the trend toward selective limited neck dissection in both NO and N+ patients. Further, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection. Cancer 66109-113,1990.HE ROLE OF LIMITED NECK DISSECTION in the man-

Paraneoplastic syndrome affects less than 1% of cancer patients. Diagnosis of paraneoplastic syndrome with neurological presentation requires screening for an underlying malignancy, including a complete history, physical examination and imaging studies. Treatment often results in symptom stability, rather than improvement. Paraneoplastic polymyositis can precede or instantaneously occur at diagnosis or treatment of a primary tumour, while neurological symptoms can persist even following cancer treatment. We report a rare case of metaplastic breast carcinoma with an unusual presentation of paraneoplastic polymyositis. KEYWORDSParaneoplastic syndrome -Metaplastic carcinoma -Diagnosis -Neurology -Breast cancer Paraneoplastic syndrome is a rare condition, affecting less than 1% of cancer patients.1 Diagnosis of paraneoplastic syndrome with neurological presentation requires screening for an underlying malignancy. This process includes a complete history, physical examination and imaging studies. 1Treatment often results in symptom stability, rather than improvement.1 Paraneoplastic polymyositis can precede or instantaneously occur at diagnosis or treatment of a primary tumour. Neurological symptoms can persist even following cancer treatment.2 Polymyositis belongs to a heterogeneous group of autoimmune diseases called inflammatory myopathies, which are characterised by proximal skeletal muscle weakness, cutaneous manifestations, elevated serum creatine kinase activity and inflammatory cells in muscle biopsy. Polymyositis is a cell-mediated autoimmune disorder. 3 The first reported association between malignancy and myositis was made by Stertz G et al in 1916. 4 The reported incidence for inflammatory myositis varies from 0.5 to 0.89 per 100,000 per year. 5We report a rare case of metaplastic breast carcinoma with an unusual presentation of paraneoplastic polymyositis. Case presentationA 66-year-old caucasian female presented with progressive difficulties with walking and climbing stairs, and developed proximal muscle weakness, paresthesia and gait ataxia over a period of 11 months. She became wheelchair-dependent and required hospital admission under the care of a neurologist. The patient had no relevant past medical history.Cerebrospinal fluid oligoclonal bands were negative, and a raised creatine kinase (CPK) level of 825 IU/L was detected on admission. Autoantibodies directed against antiRo, anti-Jo and anti-La, and extractable nuclear antigen antibodies, were detected. The antinuclear antibody test was positive. Electromyography was consistent with myopathy. An open-muscle biopsy of the leg revealed endomysial mononuclear cells and myonecrosis indicative of inflammatory myopathy.Patient was referred for radiological investigations. Computed tomography of the chest, abdomen and pelvis was unremarkable. Magnetic resonance imaging of the lower limbs showed inflammatory changes consistent with myositis and myopathy. As part of the investigations for the neurological presentation of paraneoplastic syndrome wi...

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Tracheal cast formation postlaryngectomy is common in patients with dry, inspissated secretions, more so in dry weather, but is rarely large enough to cause significant respiratory distress. Our patient had significantly large tracheal casts to cause respiratory distress even with a widely patent tracheostoma.