Biomedical subjects
Publications and source records attributed to E M Skolnik.
The clinical presentations of various nonsquamous tumors of the oral cavity are reviewed, along with their gross pathology, histology, and treatment. Survival rates are presented for those neoplasms that occur frequently enough to allow meaningful analysis of various modes of therapy.
The mode of presentation, initial findings, treatment, and survival in differentiated thyroid carcinoma were studied in 155 patients. The classic signs, symptoms, and scan findings were present in approximately 70 per cent of the patients, with the remaining 30 per cent displaying unusual manifestations or findings. The effects of neck metastases, extracapsular invasion, and recurrent laryngeal nerve involvement on long-term survival were studied in detail. Prognosis was dependent more on age at initial appearance than any other factor. Patients with prior exposure to radiation had more extensive disease and required more extensive surgery, but they ultimately had the same prognosis for 10-year cure. Treatment of distant metastatic disease by surgery, radioactive iodine, and external radiation resulted in long-term survival in certain cases.
Five unusual case studies are presented. Each case is followed by solutions proposed by three authorities and a concluding commentary by the editor.
This study compares the neck tumor recurrence rate between patients treated with radical neck dissection and those treated with conservation neck dissection. A standard radical neck dissection modified by sparing at least the internal jugular vein or the spinal accessory nerve is defined as a conservation dissection. Six hundred ninety-one neck dissections performed on 631 patients in the Department of Otolaryngology-Head and Neck Surgery of the University of Illinois College of Medicine at Chicago were reviewed retrospectively. All patients had been followed postoperatively for at least 24 months. Group I consisted of 422 radical neck dissections. Group II contained 269 conservation neck dissections. We found no statistically significant difference in the rate of neck recurrence between the group of patients who underwent radical neck dissection and the group who underwent conservation neck dissection.
Data from 92 patients with stage III or IV squamous cell carcinoma of the head and neck treated with surgery and planned postoperative radiotherapy were analyzed to determine the incidence and patterns of tumor recurrence. Overall, recurrent tumor in the cervical region developed in 19 patients (21%). Of these, eight were in the neck alone and 11 in both the neck and the primary site. All recurrences were in the ipsilateral cervical region and none in the contralateral neck. The presence of two or more metastatic nodes at the time of surgery correlated with tumor recurrence and decreased survival. Extracapsular tumor spread increased the recurrence rate. Our data suggest that postoperative radiotherapy decreases ipsilateral cervical tumor recurrence in only those patients with more than two metastatic lymph nodes, and contralateral neck recurrence in all patients.
Seventy-two patients with a carcinoma of the head and neck, who were treated with surgery and postoperative irradiation, were reviewed to determine the local recurrence rates and survival in patients with inadequate surgical margins. Tumor recurrence rate was 31% for patients with microscopic tumors at resection margins and 50% for those with macroscopic tumor. Actuarial 3-year survival for these patients was 71% and 43%, respectively. All 4 patients who were irradiated later than 6 weeks after surgery developed recurrent malignancy despite the resection margins being free of tumor. Excluding these patients the 3-year survival for R0 patients was similar to that of R1 patients. It is concluded that postoperative irradiation is effective in patients with tumor at the surgical margins. It is suggested that the time interval between surgery and radiation therapy be limited to less than 6 weeks. Radiation dose prescriptions for various clinical situations are discussed.
The authors conducted a multivariate analysis of the prognostic factors in 96 patients with early glottic cancer treated by radiation therapy. Of these, 73 had T1 and 23 had T2 tumor. The primary tumor was controlled in 82% of T1 and 74% of T2 lesions. Actuarial five-year survival rates were 87% for T1 and 74% for T2. Carcinoma of the anterior commissure associated with bilateral vocal cord involvement, subglottic tumor extension, persistent or recurrent laryngeal edema, and impaired cord mobility was found to adversely influence the prognosis. The data suggest that irradiation is the treatment of choice for glottic cancer limited to the vocal cords or with minimal extension to the anterior commissure or supraglottic larynx.
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The complications of planned postoperative irradiation in 60 consecutive patients treated between 1975 and 1979 are compared with those seen in 92 patients treated with preoperative irradiation between 1968 and 1974. The overall rate of complications requiring additional hospitalization was 15% (nine patients) in the postoperative radiotherapy group as compared with 54% (50 patients) in the preoperative radiotherapy group. A statistically significant increase in acute complications was noted in the latter group (46 vs three, 50% vs 5%). Delayed complications occurred with similar frequency in both groups. The three-year survival was comparable between similar patients of each group treated with either of the two modalities. We favor postoperative irradiation because of decreased acute complications and comparable survival. Modifications of the treatment technique are suggested to minimize the overall rate of complications.
Stomal recurrence developed in 5% of the 507 patients who underwent total laryngectomy for a squamous cell carcinoma. The most common site of the primary tumor was the glottis, followed by the supraglottic and pyriform sinus regions. Initial subglottic extension of the tumor and metastatic lymphadenopathy were the most significant risk factors. The primary tumor size, prior emergency tracheostomy, and conservation surgical procedures had no effect on the incidence of stomal recurrence. The median survival in patients with stomal malignant neoplasms was only five months. In high-risk patients, extended dissection or elective postoperative radiotherapy is recommended.
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Differentiated thyroid carcinoma was studied with regard to mode of presentation, initial findings, treatment and survival. The classic signs, symptoms, physical and scan findings were found to be present in approximately 70% of the patients. Thirty percent of the patients had either unusual presentations or findings. Prognosis was found to be dependent on age of presentation more than any other factor. The effects of neck metastasis, extracapsular invasion and recurrent laryngeal nerve involvement on long-term survival are studied in detail. patients with prior exposure to radiation were found to have more extensive disease and require more extensive surgery but ultimately had the same prognosis for 15-year cure. Treatment for distant metastatic disease by surgery, radioactive iodine and external radiation all resulted in long-term survival in certain cases.
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Tumors of the major salivary glands are reviewed according to classification, location, surgical procedure and end results. Our data of the incidence of benign and malignant tumors show that the most commonly involved area is the parotid gland and the most frequent is of the mixed variety. In the parotid region 80 percent are benign and 20 percent are malignant; whereas, in the submandibular gland, the malignant and benign tumors are equally distributed. The need for an extensive surgical attack and inclusion of contiguous structure is dictated by the nature of the malignant disease. The role of postoperative irradiation is discussed as is the indication for neck dissection. Management of the facial nerve, relative to malignant tumors of the parotid gland, is considered in detail.
We evaluate the importance of cancer spread to the lymphatic system in the posterior triangle. The posterior triangle tissues of 51 radical neck specimens were serially sectioned and studied for metastic involvement. The findings were correlated with the findings in the anterior triangle and the primary tumor. Of the 51 neck operations performed, 25 were elective and 26 were therapeutic for carcinoma of the larynx, pharynx, and oral cavity. Metastasis in the anterior triangles was detected in 88.4% of the therapeutic group and in 24.0% of the elective group. However, no metastasis in the posterior triangel was found in either group, regardless of the site of the tumor. We suggest that the posterior triangle can be totally preserved in radical neck surgery, which may make preservation of the spinal accessory nerve a more likely practice.
Lingual thyroid represents the only functioning thyroid tissue in the body in 70-80% of the cases, surgical ablation of which will produce hypothyroidism. Transposition of the lingual ectopic thyroid with its vasculary supply intact as a pedicle graft is presented. This seems to be the most locigal approach in preserving the viability and function of these ectopic tissues.
The challenging restoration of form and function in radical surgery of the head and neck demands sound concepts and proper execution in reconstruction. Flaps are most frequently employed in reconstruction, following major surgery because of their rich blood supply and cosmetic superiority. Of the many types of flaps known, the midline forhead flap, temporoforehead flap, mastoid-occipital flap, tongue flap, and deltopectoral flap have enjoyed most popularity. The design and application of these flaps are discussed. Our techniques in reconstruction of the oral cavity, hypopharynx, esophagus, nose, Andy-Gump deformities (anterior jaw complex resection), pharyngo-orocutaneous fistulas, and radionecrosis of the mandible are presented.