Biomedical subjects

E W Strong

Publications and source records attributed to E W Strong.

At least 37 records · Page 2Linked to original sources

PubMed1994

Prognostic factors for recurrence and survival in head and neck soft tissue sarcomas.

BACKGROUND: Soft tissue sarcomas of the head and neck represent uncommon malignant neoplasms. With the exception of orbital and parameningeal sites, the treatment of sarcomas in the head and neck has not been standardized. The authors used a prospectively collected database of adult soft tissue sarcomas to identify prognostic factors for local control and survival. METHODS: A prospectively collected database of adult soft tissue sarcoma from 1982 to 1989 was analyzed for the impact of prognostic factors on local control and survival. Factors examined included histologic type, tumor grade, size, and resection margins. RESULTS: The overall and disease free survival at 5 years was 71 and 60%, respectively. Local control was 70% at 5 years. On univariate analysis, grade and margin status were predictors for local control. Analysis based on the Cox proportional hazard model revealed that margin status was the only significant factor in predicting local control. Grade and margin status were significant prognostic indicators for survival both on univariate analysis and in the Cox proportional hazard model. CONCLUSION: Patients with head and neck sarcomas should undergo wide excision with the removal of all gross disease and the acquisition of negative, microscopic surgical margins. Patients with positive margins should receive adjuvant radiotherapy for local control. High grade lesions place patients at risk for local recurrence and distant dissemination. Investigational regimens designed to prevent metastatic disease should be performed.

Adolescent↗

PubMed1994

Classification of neck dissection: variations on a new theme.

BACKGROUND: Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck dissection. METHODS: We considered a neck dissection as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels. RESULTS: At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient. CONCLUSIONS: The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nonlymphatic structures sacrificed, we allow for the possibility that some procedures may be both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.

Carcinoma, Squamous Cell↗

PubMed1994

Management of unresectable malignant tumors at the skull base using concomitant chemotherapy and radiotherapy with accelerated fractionation.

Between January 1988 and June 1992, 20 patients with unresectable malignant tumors at the skull base were treated. Eleven had T4 lesions of the paranasal sinus/cavity complex, and 9 had T4 nasopharynx cancer. All patients had stage IV disease by the American Joint Committee on Staging Criteria. The histology was squamous cell cancer in 15 patients and other minor salivary gland histologies in 5. There was brain and/or dural invasion in 11 patients and orbital invasion in 9. All patients received radiation therapy with accelerated fractionation to a total of 70 Gy in 6 weeks. Concomitant cisplatin (100 mg/m(2)) was given on days 1 and 22 of radiation. Seven patients received mitomycin C (7.5 mg/m(2)) on days 1 and 22, plus adjuvant chemotherapy with cisplatin and vinblastine. Median follow-up was 11 (range: 1 to 43) months. At 2 years, local progression-free survival was 94%, distant metastases-free survival was 57%, and overall survival was 80%. Complications occurred in 20% and caused the death of 1 patient. Treatment of this group of patients with aggressive chemotherapy and radiation therapy produced excellent local control in our early experience, but longer follow-up is needed. There is a high rate of distant failure. Future strategies are outlined.

Journal Article↗

PubMed1993

Postoperative radiation therapy for squamous cell carcinomas of the oral cavity and oropharynx: impact of therapy on patients with positive surgical margins.

PURPOSE: The presence of a positive or close margin after resection of a squamous cancer of the head and neck is associated with a significant risk of local recurrence. To determine the efficacy of postoperative radiation therapy for patients with advanced oral cavity and oropharyngeal cancers with inadequate margins of resection, the present retrospective analysis was undertaken. METHODS AND MATERIALS: One hundred and two patients were treated with surgery and postoperative radiation therapy for advanced squamous cell carcinomas of the oral cavity and oropharynx. The anatomic subsites treated include oral tongue (n = 29), floor of mouth (n = 22), base of tongue (n = 31) and tonsillar fossa (n = 20). Twenty-five patients (25%) had positive margins, 41 patients (40%) had close margins (< or = 0.5 cm from the surgical margin) and 36 (35%) had negative margins. The median radiation dose was 6000 cGy. RESULTS: With a median follow-up of 7 years, the actuarial control rate for patients with positive, close and negative margins was 79%, 71%, and 79%, respectively. When postoperative doses of > or = 60 Gy were delivered to patients with positive/close margins (excluding patients with oral tongue lesions), the 7-year actuarial control was 92%. In similar patients receiving < 60 Gy, the actuarial control was 44% (p = 0.0007). Compared to other anatomic subsites, inferior control rates were obtained with oral tongue lesions. For this subsite, the control rates for positive, close, and negative margins were 50%, 62% and 69% respectively. CONCLUSION: We conclude that excellent local control can be achieved with postoperative radiation therapy, despite the presence of inadequate margins of resection, when doses of > or = 60 Gy are used. Future strategies must be directed at further improving these results in patients with oral tongue lesions.

Carcinoma, Squamous Cell↗

PubMed1993

Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis.

The extent of surgical resection for differentiated carcinoma of the thyroid gland confined to one lobe remains controversial. Although primary tumor size and extrathyroid extension are associated with a poor prognosis, the presence of multifocal lesions is not associated with an adverse prognosis. Therefore, the role of lobectomy versus total thyroidectomy must be studied in a prospective, randomized trial. Due to the need for long-term follow-up, such a trial has not yet been undertaken. As an alternative to such a trial, we have identified 146 patients from a consecutive series of 931 previously untreated patients undergoing surgical treatment at 1 institution between 1930 and 1980. For this study of matched-pair analysis, 73 patients, aged 45 years or older, were matched in each arm for significant prognostic factors. One group underwent lobectomy, and the other group underwent total thyroidectomy. The 20-year survival rate in the lobectomy group was 82% compared with 73% in the total thyroidectomy group (p = not significant). The patterns of failure in these two groups of patients were examined. A comparison of the patients who underwent lobectomy with an unmatched group of patients who underwent lobectomy showed similar survival rates. On the other hand, unmatched patients undergoing total thyroidectomy had a poorer survival rate than the matched group. This signifies a more aggressive nature of disease in the unmatched group of patients undergoing total thyroidectomy. We therefore conclude that low-risk patients undergoing lobectomy are likely to do as well as those undergoing total thyroidectomy and without the increased risk of the morbidity of total thyroidectomy.

Adult↗

PubMed1993

Estrogen and progesterone receptor content in human thyroid disease.

Recent studies have confirmed the presence of estrogen and progesterone receptors in many benign and malignant thyroid tumors, but their clinical significance is unclear. The estrogen and progesterone receptor content of 135 thyroid lesions was assayed prospectively from 1980 through 1986 using the dextran-coated charcoal method. The cases included 30 papillary, 13 follicular, 6 medullary, and 2 Hürthle cell carcinomas. Thirty-two follicular adenomas, 45 goiters, and 7 cases of thyroiditis also were studied. Estrogen receptor protein was positive (> or = 2 fmol/mg) in 46% of the cases, with no clear statistical predilection related to the type or size of the thyroid lesion, age, or sex. Progesterone receptor protein was positive (> or = 10 fmol/mg) in 51% of the cases, with the highest median values obtained in papillary carcinomas, particularly in male patients and women older than 50 years. Metastases at presentation, noted in 28 of 51 carcinomas, were unrelated to receptor content. Mean follow-up of 55 months in 48 patients with various carcinomas yielded 12 cases with late metastases, which were similarly unrelated to receptor content. Although estrogen receptors are commonly detectable in thyroid lesions, they have no clear relationship to presenting clinical or pathologic features or, in cases of carcinoma, to subsequent metastatic potential. The role of progesterone activity in papillary carcinoma and in goiter merits more investigation.

Carcinoma, Papillary↗

PubMed1992

Carcinosarcoma of the submandibular salivary gland. Immunohistochemical findings.

Carcinosarcomas of the salivary glands are rare lesions that generally have been associated with benign mixed tumors. The authors report a case of a submandibular gland lesion, which occurred in a 64-year-old man, that was composed of intermingled ductal type adenocarcinoma and osteogenic sarcoma with a large component of osteoclast-like giant cells. The local recurrence of the tumor was entirely sarcomatous with no epithelial component observed. There was no histologic evidence of a preexisting or coexisting pleomorphic adenoma. Immunohistochemical studies confirmed two separate populations of tumor cells, corresponding to the histologic growth pattern. The authors review the literature and discuss histogenetic implications of distinction between de novo carcinosarcoma and carcinosarcoma in association with pleomorphic adenoma.

Carcinoma, Intraductal, Noninfiltrating↗

PubMed1992

The indications for elective treatment of the neck in cancer of the major salivary glands.

To define the indications for elective neck treatment, the cases of 474 previously untreated patients were reviewed who had locally confined major salivary gland cancers treated between 1939 and 1982. Clinically positive nodes were present in 14% (67 of 474). Overall, clinically occult, pathologically positive nodes occurred in 12% (47 of 407). By univariate analysis, several factors appeared to predict the risk of occult metastases; however, multivariate analysis revealed that only size and grade were significant risk factors. Tumors 4 cm or more in size had a 20% (32 of 164) risk of occult metastases compared with a 4% (nine of 220) risk for smaller tumors (P less than 0.00001). High-grade tumors (regardless of histologic type) had a 49% (29 of 59) risk of occult metastases compared with a 7% (15 of 221) risk for intermediate-grade or low-grade tumors (P less than 0.00001). In view of the low frequency of occult metastases in the entire group, routine elective treatment of the neck is not recommended. High-grade tumors and larger tumors have a high rate of occult neck metastases, and treatment should be considered in this group.

Analysis of Variance↗

PubMed1992

Prognostic factors in differentiated carcinoma of the thyroid gland.

A retrospective review of a consecutive series of 931 previously untreated patients with differentiated thyroid carcinoma treated over a 50-year period was undertaken to analyze prognostic factors. Data pertaining to demographic status, clinical, operative, and pathologic findings, and survival were analyzed. Univariate statistical analysis was performed based on the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed to assess the independent effect of these variables using the Cox model. There were 630 female and 301 male patients, with an average age of 43 years. A total of 532 patients were younger than 45 years. Seven hundred thirty-one patients had either pure or mixed papillary carcinoma, and 200 had follicular carcinoma. In 153 patients, lesions were larger than 4 cm. Extrathyroidal extension was noted in 71 patients. Multifocal lesions were present in 159 patients. Regional lymph node metastasis was present on admission in 451 patients, and distant metastases were noted on presentation in 45 patients. Determinate survival for all patients was 87% at 10 years. Favorable prognostic factors using univariate analysis included female gender, multifocal primary tumors, and regional lymph node metastases. Adverse prognostic factors included age over 45 years, follicular histology, extrathyroidal extension, tumor size exceeding 4 cm, and the presence of distant metastases. On multivariate analysis, the only factors that affected the prognosis were patient age, histology, tumor size, extrathyroidal extension, and distant metastases. These observations support findings of reports from the Mayo Clinic and Lahey Clinic regarding the significance of prognostic factors for differentiated carcinoma of the thyroid gland.

Adenocarcinoma↗

PubMed1992

Base-of-tongue cancer treated with external beam irradiation plus brachytherapy: oncologic and functional outcome.

Between January 1981 and June 1990, 36 previously untreated patients with squamous cancer of the base of the tongue were treated with radiation therapy. This therapy consisted of a 5,000-5,400-cGy external beam plus a 2,000-3,000-cGy boost to the base of the tongue with an iridium-192 implant. Necks with negative nodes were only irradiated, while necks with positive nodes were treated with irradiation plus neck dissection. Actuarial local control and survival at 2 years were 87.5%. Neck control was achieved in 35 of 36 patients. When implantation was performed with the nonlooping technique, the injury rate was statistically higher than in patients who underwent implantation with the looping technique (P = .02). Thirty patients participated in a function assessment involving a Performance Status Scale for patients with head and neck cancer. The authors concluded that management of base-of-tongue cancer with external beam irradiation plus brachytherapy is both oncologically and functionally successful.

Adult↗

PubMed1992

Craniofacial resection for tumors involving the anterior skull base.

A consecutive series of 71 patients who underwent craniofacial resection between 1974 and 1990 for tumors that involved the anterior cranial base was reviewed. A variety of histologic diagnoses was present in this series. The most prevalent sites of origin included the nasal cavity, ethmoid sinus, and frontal sinus. Gross tumor removal was achieved in all patients, with 29 requiring orbital exenteration. Adjuvant radiation therapy was used in 25 patients. Two patients died of postoperative complications and 26 had complications that increased morbidity and length of the hospitalization. Five-year overall survival was 56%, with a median survival of 4.2 years. Local control was observed in 40 of 56 patients with negative margins and 9 of 15 patients with positive margins. There was no difference in survival between previously treated and untreated patients. Survival varied considerably among the various pathologic diagnoses. Survival was related to the extent of disease. Patients with either dural or brain invasion had significantly decreased survival compared to those with no dural invasion. The operative procedure is safe, with acceptable morbidity and mortality, and offers respectable survival in properly selected patients.

Adolescent↗

PubMed1992

Current status of larynx preservation with multimodality therapy.

Patients with advanced squamous cell carcinoma of the head and neck often require total laryngectomy, but many patients will refuse the procedure despite the prospect of a lower cure rate. Radiation therapy alone can cure selected patients. Chemotherapy has been combined with radiation in a variety of ways, in hopes of improving local control, preserving function, and achieving survival better than that achieved with radiation therapy alone. Several studies have yielded encouraging results, including the only randomized study that has compared chemotherapy/radiation to standard total laryngectomy and postoperative radiation therapy. All function preservation treatment programs require a motivated and compliant patient, careful patient monitoring, and close cooperation among surgical, radiation, and medical oncologists.

Carcinoma, Squamous Cell↗

PubMed1991

The importance of clinical staging of minor salivary gland carcinoma.

We reviewed a 45-year experience with 459 patients who had previously untreated minor salivary gland neoplasms, 378 (82%) of which were malignant. Data were adequate for retrospective clinical staging in 353 of the 378 patients with malignant tumors using criteria identical to those for squamous carcinoma in the same sites. Five-, 10-, and 15-year survival rates for the patients with malignant tumors treated after 1966 were 75%, 62%, and 56%, respectively, a significant improvement compared with results reported previously. Multivariate analysis confirms that survival was significantly influenced by the clinical stage and the histologic grade, but the applicability of grading was limited to patients with mucoepidermoid carcinoma or adenocarcinoma. Ten-year overall survival was 83%, 53%, 35%, and 24% for patients with stage I through stage IV, respectively. Results in these patients are similar to those we have recently reported in patients with major salivary gland carcinomas, but we are unable to demonstrate that postoperative radiotherapy improved survival.

Carcinoma↗

PubMed1991

Gastric transposition for head and neck cancer: a critical update.

We reviewed our experience with 120 patients who had gastrointestinal (GI) continuity restored by gastric transposition after cervical esophagectomy or circumferential pharyngectomy. This included 62 patients with pharyngeal tumors, 43 with esophageal lesions, 7 with parastomal recurrences, and 8 with other primaries (including 4 with thyroid cancer). Operative mortality (11%) for this two-team procedure was significantly higher in patients 60 years of age or older, and there was a trend toward higher mortality in those who had resection of esophageal rather than pharyngeal primaries (14% versus 5%). A total of 105 intraoperative or perioperative complications occurred in 66 patients (55%), 81 of which were directly related to the surgery and 24 of which involved various organ systems. Aside from 15 anastomotic leaks (13%) and 3 instances of partial stomach necrosis (3%), most of the local complications were relatively minor. Our experience indicates that the transposed stomach is highly reliable for restoration of GI continuity, but complications are frequent and the mortality is high. Careful patient selection is essential to minimize morbidity.

Aged↗

PubMed1991

Concomitant chemotherapy-radiation therapy followed by hyperfractionated radiation therapy for advanced unresectable head and neck cancer.

In January 1988, we initiated a prospective study evaluating a new treatment approach with chemotherapy and radiotherapy for unresectable head and neck cancer. Weeks 1-4 were the initial debulking phase. Radiotherapy was delivered using 1.8 Gy/day to large portals including gross disease and all areas at risk. Cisplatinum, 100mg/m2, was given concomitant with radiotherapy on days 1 and 22. Weeks 5 and 6 were the boosting phase. This involved twice-a-day irradiation. The AM fraction of 1.8 Gy was given to the entire area at risk, whereas the PM dose of 1.6 Gy was limited to the gross disease alone. Thus a total of 70 Gy/6 weeks was delivered. A total of 24 patients were treated, 22 of whom have completed this protocol and are evaluable. All patients had massive disease, with 15 having gross involvement of brain, orbit, skull base, or carotid artery. Follow-up ranged from 3-22 months (median 12 months). Major responses were achieved in 96%, with 64% complete responses and 32% partial responses. Two patients with PR were able to undergo complete surgical resection, making the overall rate of complete response, including surgery, 73%. At 1 year, actuarial survival was 69%, and local progression-free survival was 56%. Distant metastases developed in 5 (23%). This approach appears both safe and effective in producing excellent regression and local control for far advanced head and neck cancer. More time is needed to see if these results are sustained. Efforts to build upon this experience appear warranted.

Adenocarcinoma↗

PubMed1990

Malignant tumors of major salivary gland origin. A matched-pair analysis of the role of combined surgery and postoperative radiotherapy.

Between 1966 and 1982, 46 patients with previously untreated malignant tumors of major salivary gland origin received combined surgery and postoperative radiotherapy. They were compared with 46 patients treated with surgery only between 1939 and 1965, who were matched according to prognostic criteria. Radiation doses ranged from 4000 to 7740 cGy (median, 5664 cGy). The 5-year determinate survival rates for patients given combined therapy with stage I and II disease vs patients given surgery only was 81.9% vs 95.8%, while for stages III and IV it was 51.2% vs 9.5%, respectively. Local control for stage III and IV disease in patients given combined therapy vs patients given surgery only at 5 years was 51.3% vs 16.8%. For patients with nodal metastases, 5-year determinate survival for the combined-therapy group vs the surgery-only group was 48.9% vs 18.7%, and the corresponding local-regional control was 69.1% vs 40.2%. The results of this analysis suggest that postoperative radiotherapy significantly improves outcome for patients with stage III and IV disease and for patients with lymph node metastases.

Combined Modality Therapy↗

PubMed1990

Impact of the time interval between surgery and postoperative radiation therapy on locoregional control in advanced head and neck cancer.

Between January 1975 and December 1980, 111 patients with AJCC stages III and IV squamous cell carcinoma of the head and neck were treated with surgery followed by planned postoperative radiation therapy. A previous analysis of a subgroup of these patients showed that, when radiation was delayed more than 6 weeks from surgery, a higher incidence of regional failure occurred compared with the incidence observed when therapy began within a 6 week period. We have looked back at this group of patients plus others in an attempt to determine whether other factors played a role in the results obtained. In the current study, 50 patients had a delay of 6 weeks or more and, of these, 11 (22%) suffered a locoregional recurrence. However, 8 of these 11 patients received suboptimal radiation doses (less than 56 Gy) for permanent control of the disease. In fact, of 17 patients who received at least 60 Gy and had more than a 6 week delay, only 2 (12%) had locoregional failure. This was similar to the incidence of failure in the patients who received at least 60 Gy and who started radiation within the first 6 weeks from surgery (3/20 [15%]). The effect of delay was apparent only in those who received less than 60 Gy (27% vs. 7%, P less than 0.05). Therefore, we cannot validate the previous conclusion that a greater than 6 week delay in the delivery of postoperative radiation therapy in advanced head and neck cancers produces poorer results. The current analysis suggests that a prolonged delay in postoperative radiation therapy in itself does not have a negative impact on locoregional control as long as appropriate tumorcidal doses of more than 60 Gy are employed.

Carcinoma, Squamous Cell↗

PubMed1990

Observations on the natural history and treatment of recurrent major salivary gland cancer.

In an attempt to define the natural history and the indications for postoperative radiotherapy (RT) in locally recurrent major salivary gland cancers, we reviewed 78 patients treated between 1965 and 1982. All patients underwent resection of the tumor. Group 1 (N = 38) had complete resection of tumors, with low or intermediate grade histology and without lymph node spread. Group 2 consisted of the remaining 40 patients who had high-risk features (HR) (high grade histology, lymph node metastases, and close or positive margins of resection). Half of the Group 2 patients received radiation therapy. Overall survival was 63% at 5 years, and 35% at 15 years. Survival of Group 1 was 83% at 5 years and 58% at 15 years. Local control for Group 1 was 69% at 5 years, 54% at 15 years, and was size-dependent. Group 2 survival was 40% at 5 years and 29% at 10 years. Local control at 5 and 10 years was 49% and 35%. Our data indicate that surgery alone yielded good local control in patients with small tumors (less than or equal to 3 cm) and no HR features, suggesting that postoperative RT may be unnecessary for these patients. Other patients have suboptimal local control, and although there is a rationale for the use of postoperative radiotherapy, we cannot assess its impact in this retrospective study.

Adolescent↗