Merkel cell tumour: clinical behaviour and treatmentW e have reviewed 30 reports of Merkel cell tumour and described a further five cases in order to establish a database and from this more clearly dejine the biology of this tumour, prognostic factors that govern outcome, and optimal management. After excision alone of the primary lesion, local recurrence occurred in 39 per cent of patients and regional failure occurred in 46per cent. In contrast, inpatients treated bji excision plus prophylactic treatment (adjuvant node dissection andlor adjuvant radiation), local recurrence occurred in 26per cent and regional failure in 22 per cent. Locoregional recurrence carried an ominous signijkance with 67 per cent of patients subsequently dying of the disease. For patients who either presented with regional disease or later developed regional disease, the best outcome (44 per cent survival with mean follow-up of 40 mont}is~ was obtained following treatment by therapeutic node dissection with or without radiation. In contrast, treatment of' regional disease with radiation alone was associated with only a 20 per cent survival rate. Unfavourable prognostic factors included young age, lesions sited in the head and neck or trunk, male sex, and the presence of locoregional failure andlor systemic disease. W e conclude that Merkel cell tumours behave in a similar manner to the aggressive variants of melanoma and that minimal treatment consists of wide surgical resection of the primar-y lesion (with a margin of 2.5-3 cm) coupled with resection and probably also radiation of regional disease iJ' present. In addition, consideration should be given to prophylactic node dissection in node negative patients, especially in those patients with unfavourable prognostic factors. 138 0007-1323/91/020138-05 ic) 199 1 Butterworth-Helnemann Ltd

Energy and protein metabolism in septic and trauma patients has been extensively studied over the past 30 years. Despite this, a number of inconsistencies are present in the literature and it is difficult to formulate a clear global picture of this complex series of metabolic events. Conclusions from human studies have often been hampered by the utilization of small numbers of patients, and data from animal models of sepsis or trauma are often difficult to interpret. Over the past 5 years, the authors have performed a series of isotopic infusions in normal volunteers, and in patients with either sepsis or trauma, in order to gain a clearer understanding of energy and protein metabolism in severely stressed patients. This review summarizes the findings.

This report comprises a retrospective review of the clinical data on 157 patients seen in the auckland area having a diagnosis of cancer of the tongue, floor of the mouth, inferior alveolus, or buccal mucosa (retromolar area, vestibule of the mouth, and cheek mucosa) during 1970–86. One hundred patients were male, 95% were european, 85% were cigarette smokers, and 58% had a history of high alcohol intake. All primary tumours were squamous cell carcinomas, 50% were located in the tongue, 27% in the floor of the mouth, and 11.5% each in the buccal mucosa and inferior alveolus. The majority (60%) of patients with tongue cancer were clinically stage i at presentation while other intra‐oral tumours were evenly distributed between stages i and iv. Surgical resection of the primary intra‐oral lesion produced local control in 90% of stage i tumours, but this fell to below 70% in stage ii—iv tumours. Most patients (82%) who recurred locally had positive or ‘close’ margins, and this rate of local tumour recurrence as a consequence of narrow margins did not decrease with the addition of adjuvant radiotherapy. Of those patients with stage i disease who received only treatment of the primary lesion, 20% later developed regional nodal disease which was controlled in more than half by neck dissection, but control was achieved only in 11% of patients treated with radiation. The presence of regional disease at presentation was associated with a poor prognosis. It is concluded that local control of inferior oral cavity tumours can be achieved if resection is accomplished with clear margins. Regional control can be obtained in 50% of patients with neck dissection. Considered together, the high rate of regional recurrence with stage i lesions, and the poor results following salvage therapy (12% 2 year survival) indicate that these patients require as aggressive initial therapy (often involving neck dissection) as do those with more advanced disease.

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The case‐notes of 30 patients presenting with primary gastric lymphoma in the auckland area during 1969–87 have been reviewed. The mean age of the study group was 62 years, and 16 were female and 14 were male. There were 22 european, one maori and seven polynesian patients. The most common presenting symptom was abdominal pain and five patients presented acutely with gastrointestinal haemorrhage. The lesions occurred more frequently in the distal stomach and half were polypoid and half were ulcerating. They tended to be of substantial size at presentation, with seven being greater than 10cm in diameter. Nine lesions were confined to the stomach, 12 involved the surrounding lymph nodes and eight were invading adjacent organs. Twenty‐three patients underwent partial or total gastrectomy. Four of these received postoperative radiotherapy, and adjuvant chemotherapy was administered to 13. Chemotherapy, or combination chemo‐and radiotherapy were used as the primary treatment in seven patients. Following surgical treatment, 18 patients remained alive and well. Five of the seven patients treated non‐surgically were dead of disease at the time of study and the other two remained alive with persisting disease. The following factors were found to affect prognosis adversely: weight loss of greater than 5 kg, tumour invasion of adjacent organs, and non‐surgical primary treatment. Involvement of the lymph nodes draining the stomach did not appear to worsen the outlook, and there was little correlation between lesion size and prognosis.