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Biomedical subjects

I Eliachar

Publications and source records attributed to I Eliachar.

At least 37 records · Page 2Linked to original sources
PubMed1997

Management of the neck in a randomized trial comparing concurrent chemotherapy and radiotherapy with radiotherapy alone in resectable stage III and IV squamous cell head and neck cancer.

BACKGROUND: Treating the neck after organ-preservation treatment with radiotherapy or chemoradiotherapy can be problematic. METHODS: To develop management guidelines, we reviewed the results of a 100-patient phase-3 trial that had compared outcome after radiotherapy alone with outcome after chemoradiotherapy for head and neck cancer. Patients were randomly assigned to receive radiotherapy alone or concurrent chemoradiotherapy. After completing therapy, patients were reassessed, and surgery was recommended for persistent disease at the primary site or neck and for all patients with stage N2-3 neck nodes regardless of clinical response. RESULTS: Of the 47 patients with stage NO-1, 43 had a complete response (CR); of the 18 N1 patients, all but 4 had a CR. One of these 4, as well as 5 others among the NO-1 patients, underwent neck dissection (n = 6). No disease was found on pathologic examination, and no patient had neck recurrence. Of the remaining 41 N0-1 patients, 3 had disease progression and received no further therapy. Of the 38 others, 4 had neck recurrence, with 3 recurring at the primary site. Of the 53 with stage N2-3, 23 had less than a complete response (<CR), and 30 had a CR. In 35 N2-3 patients, neck dissection was performed as planned. Of these 35, 18 had a CR in the neck; 4 had positive nodes on pathologic examination. The other 17 had a <CR in the neck; 8 had positive nodes on pathologic examination. One patient in this group of 17 had regional recurrence after a pathologically negative neck dissection. Of the 18 N2-3 patients who did not undergo planned neck dissection, 6 had tumor progression and had no further therapy. The other 12, all with a CR in the neck, were followed, and 3 had neck recurrence; none successfully salvaged. Despite a CR in 30 N2-3 patients, 7 had persistent disease or eventual neck recurrence. Adding neck dissection minimized neck recurrence (p = .05). In N2-3 patients, disease-specific survival was significantly better in patients with a CR in the neck (p = .002). Disease-specific survival was not affected by neck dissection (p = .40) but was significantly affected by viable tumor in the specimen (p = .03). CONCLUSION: Based on these results and the realization that it is difficult to follow patients for recurrent neck cancer, that salvage is often unsuccessful, and that patients dying from uncontrollable neck disease have an extremely poor quality of life, we recommend neck dissection for all N2-3 patients regardless of the neck response and for N1 patients without a CR.

Antimetabolites, Antineoplastic↗
PubMed1997

A phase III randomized trial comparing concurrent chemotherapy and radiotherapy with radiotherapy alone in resectable stage III and IV squamous cell head and neck cancer: preliminary results.

BACKGROUND: A phase III randomized comparison of radiotherapy alone versus combination chemotherapy and concurrent continuous-course radiotherapy was performed at the Cleveland Clinic Foundation. METHODS: Between March 1990 and June 1995, 100 patients with resectable stage III and IV squamous cell head and neck cancer were randomized to either Arm A: radiotherapy alone, 68-72 Gy at 1.8-2.0 Gy per day; or to Arm B: the identical radiotherapy with concurrent chemotherapy. Chemotherapy consisted of 5-fluorouracil, 1000 mg/m2/day, and cisplatin 20 mg/m2/ day, both given as continuous intravenous infusions over 4 days beginning on day 1 and day 22 of the radiotherapy. At 50-55 Gy, patients were clinically reassessed. If a response was evident, radiotherapy was completed. In non-responding patients, however, radiotherapy was terminated and surgery recommended. After completion of all treatment, salvage surgery was performed, if possible, for any residual primary or nodal disease or for any subsequent locoregional recurrence. RESULTS: Except for an overrepresentation of T1 patients on Arm A, the treatment arms were equivalent. Toxicity was greater in the patients on Arm B with a higher incidence of grade III and IV neutropenia, thrombocytopenia, cutaneous reaction, and mucositis. Feeding tubes were also required more often, and weight loss was greater on the chemotherapy arm. No toxic deaths occurred. With a median follow-up of 36 months, the Kaplan-Meier 3-year projections of relapse-free survival are 52% for Arm A and 67% for Arm B (p = .03), and the likelihood of developing hematogenous metastases is 21% for Arm A and 10% for Arm B (p = .04). Although overall survival is not significantly different, overall survival with successful primary site preservation was 35% for Arm A and 57% for Arm B (p = .02). This difference remains statistically significant in the subsets of patients with laryngeal and hypopharyngeal primaries but not in patients with oropharyngeal primaries. CONCLUSIONS: Continuous-course radiotherapy and concurrent combination chemotherapy is an intensive, toxic but tolerable treatment regimen, which, when compared with radio therapy alone, can produce an improvement in relapse-free survival, a decrease in distant metastases, and an improvement in overall survival with successful primary site preservation.

Antimetabolites, Antineoplastic↗
PubMed1997

Endoscopically introduced expandable stents in laryngotracheal stenosis: the jury is still out.

A new technique using endoscopically introduced, expandable stents for the management of upper airway stenosis is presented. Evaluation of this technique in the canine model forms the basis of this pilot study. Stenosis was surgically induced in a controlled fashion by resection of cartilage from the anterior cricoid arch and tracheal wall to reduce the airway diameter by approximately 50%. A period of 8 weeks was allowed for complete healing and maturation of the surgical stenosis. This was followed by endoscopic introduction of expandable titanium-mesh stents. The stents were then balloon-inflated to dilate the stenotic region. Airway patency was assessed clinically, radiologically, and endoscopically, before expansion and at 4 and 8 weeks after expansion. This assessment was followed by euthanasia of the animals and gross examination of the expanded stenotic segments. In general, the stents were well tolerated with adequate expansion of the airway. In some instances granulation tissue formation was noted around the stents. This was less pronounced when stents coated with Tecoflex (Advanced Surgical Intervention Co., San Clemente, Calif.) were used. This is probably because of their "inert" nature, which induces less tissue reaction. A literature review of the subject is presented. The significance of this endoscopic modality for management of upper airway stenosis is discussed, and the indications, alternatives, potential pitfalls, and complications are depicted.

Animals↗
PubMed1997

Surgical outcome in 87 patients with Zenker's diverticulum.

Surgical treatment of Zenker's diverticulum is controversial because many different procedures exist. We retrospectively reviewed 87 consecutive patients surgically treated for Zenker's diverticulum at a tertiary care institution from 1976 through 1993. Four surgical procedures were performed: cricopharyngeal myotomy alone (n = 16), excision (hand-sewn) plus myotomy (n = 51), excision (stapler) plus myotomy (n = 11), and diverticulopexy plus myotomy (n = 9). There were three surgical mortalities (3.5%) and a complication rate of 24%. Eighty patients (92%) were available for follow up. Sixty-eight patients (78%) reported excellent relief of symptoms, 10 (13%) reported improvement with occasional symptoms, and two (3%) described persistent dysphagia. No statistical difference in complication rate was found among surgical groups (P = 0.15). Myotomy alone patients had worse outcomes (P = 0.04) compared with the other surgical groups. Median follow-up was 7.5 months.

Adult↗
PubMed1997

Concurrent chemoradiotherapy for salvage in relapsed squamous cell head and neck cancer.

The results in 9 patients with unresectable recurrent squamous cell cancer of the head and neck who were treated with aggressive concurrent chemoradiotherapy are reported. Treatment consisted of one or two courses of chemotherapy with 5-fluorouracil 1000 mg/m2/day and cisplatin 20 mg/m2/day, both given as 4-day continuous intravenous infusions, concurrent with radiation therapy. Salvage radiation doses between 30 and 70 Gy were administered. Seven patients had previously undergone an attempt at curative surgery, and 7 had been treated with radiation doses between 52 and 72 Gy. The recurrent disease was locally confined in 3, locoregional in 5, and locoregional with metastases in 1 of the 9 patients. Treatment toxicity was significant and included mucositis, nausea/vomiting, and granulocytopenia, but there were no toxic deaths. Complete tumor clearance was possible in 6 of these 9 patients, and 5 patients remain disease-free at 41+, 43+, 45+, 47+, and 50+ months. Of these 5 patients, 4 had previously been treated with both surgery and radiation, while 1 had only undergone surgery. We conclude that aggressive chemotherapy and concurrent (re)irradiation can be given to patients with unresectable, recurrent, squamous cell cancer of the head and neck. Treatment is tolerable, and disease-free long-term survival is possible. Careful patient selection, however, is required.

Adult↗
PubMed1996

Management of acute laryngeal trauma.

The larynx, by nature, is rightfully a very protected organ, being the bottleneck of the airway and the protective gate to the lungs. Laryngeal trauma although rare, represents a serious threat to critical physiologic functions and too often may end in death. The multiple presentations of these injuries are extremely diverse, to the extent that restricts any generalized guidelines and results in dilemmas and controversies. This manuscript attempts to represent the authors approach to the challenging perplexities of this subject, and provide overall functional guidelines.

Diagnostic Imaging↗
PubMed1996

MR evaluation of epiglottic disruption.

Epiglottic disruption is an uncommon injury usually associated with significant supraglottic trauma. This injury may be overlooked because of the difficulty in examining the larynx or other associated severe injuries. We present two cases of clinically unsuspected epiglottic disruption that were first seen on MR images of the neck.

Accidents, Traffic↗
PubMed1995

Improved nasal septal prosthetic button.

Nasal septal button prostheses are useful alternatives to surgical management of symptomatic nasal septal perforations. The new modified button appears to be superior to the conventional button in several ways. It can be trimmed or ordered with larger or asymmetric disks if needed. The two new features of this button are (1) its flexible hub, giving it plasticity and adaptability; and (2) the tapered dome or umbrella-shaped, flexible disks, which allow for greater conformity to the septum.

Biocompatible Materials↗
PubMed1995

An overview of treatment options for lower airway obstruction.

Effectively treating airway stenosis is a challenging problem for the otolaryngologist-head and neck surgeon. A number of options are available. The most effective management requires an approach that is flexible and individualized for each patient. This article outlines the available options and highlights the indications, techniques, results, and potential complications of each.

Endoscopy↗
PubMed1995

Augmentation techniques in laryngotracheal reconstruction.

The treatment of laryngotracheal stenosis remains challenging. Even with the wide variety of current techniques available, optimal reconstruction is not possible for all patients. However, the future of laryngotracheal reconstruction is promising with ongoing development of innovative techniques for repair, as well as the prospect of laryngeal transplantation.

Humans↗
PubMed1994

Continuous course radiation therapy and concurrent combination chemotherapy for squamous cell head and neck cancer.

Concurrent radiation therapy and chemotherapy is a promising approach to the treatment of squamous cell head and neck cancer. Toxicity, however, has required either scheduled breaks in radiation therapy administration or compromise in chemotherapy dose intensity. We describe the toxicity and results in 19 patients treated at diagnosis with a continuous course of radiation therapy and intensive concurrent combination chemotherapy using 5-fluorouracil and cisplatin. Toxicity among these 19 patients was significant, including mucositis, myelosuppression, and weight loss, and aggressive supportive efforts were required. No toxic deaths occurred, however. At the end of treatment, all patients had achieved complete control of their primary-site tumor. Primary-site resection was not required in any patient for tumor control, but neck dissections were performed in selected individuals with involved nodes at diagnosis. No patient recurred at the primary site and only a single patient recurred in the neck. We conclude that this chemoradiotherapy schedule is very effective, albeit toxic. Toxicity, however, can be managed with appropriate aggressive supportive measures. Confirmation of these encouraging treatment results will require performance of a randomized clinical trial.

Adult↗
PubMed1993

Facial nerve morbidity following parotid surgery for benign disease: the Cleveland Clinic Foundation experience.

Standard surgical management for benign tumors of the parotid gland requires either superficial, subtotal, or total parotidectomy with preservation of the facial nerve. Although this approach is effective in minimizing recurrence, the resultant facial nerve morbidity is seldom addressed. Two hundred fifty-six consecutive patients who underwent parotid surgery for benign neoplasia at this institution in the past 15 years are reviewed, with attention to postoperative facial nerve function. Immediate dysfunction was frequently encountered (46.1%), but permanent dysfunction was uncommon (3.9%). The incidence of long-term dysfunction may be higher in revision cases and when an extended (total or subtotal) parotidectomy is performed.

Facial Nerve↗
PubMed1993

Laser welding of fascial grafts and its potential application in tympanoplasty: an animal model.

This study evaluates the welding effect of argon laser on fascial grafts and its potential application in tympanoplasty. An animal model was designed so that surgically induced perforations of the lumbar fascia of the animals were grafted in an underlay fashion. Each graft was "spot welded" around the circumference of the perforation using a hand-held argon laser. Various lasing parameters were used on different grafts. Control perforations were grafted but not welded. A total of 96 perforations was studied. Weld sites were evaluated both histologically and by tensile strength measurement at the end of surgery, and at 7, 14, and 21 days postoperatively. Comparison with controls showed a higher tensile strength for welded grafts, which was most significant in the early postoperative period (p < 0.001). Histologically, it seems that the basic mechanism of fascial welding involves liquification and denaturation of extravasated proteins at the weld sites. Correlation between the extent of thermal damage on the tissues and the various lasing parameters is described. Based on the well-documented safety of argon laser in otologic surgery, and the successful welding of fascial grafts in this study, argon laser may prove beneficial in welding temporalis fascia grafts in tympanoplasty.

Animals↗
PubMed1993

Concentric tracheal and subglottic stenosis. Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation.

Treatment of tracheal stenosis varies with the type and extent of the disease. Tracheostomy with stents, end-to-end anastomosis, or extensive reconstructive procedures often is required, especially when tracheomalacia is present. High recurrence rate is associated with relatively less invasive endotracheal treatments, such as bougie dilatation or total laser ablation. Mucosal sparing technique using Nd:YAG laser photodissection (LPD) and gentle dilatation (GD) can provide durable successful results in selected patients with benign concentric tracheal stenosis (CTS). In our study of 18 patients with CTS, 12 were successfully treated with Nd:YAG LPD and GD. Of these patients, eight required a single treatment while four required two or more treatments. No patients required new tracheostomy to carry out the procedure. Follow-up periods ranging from 2 to 85 months (mean: 32.6 +/- 1.5 months) for 12 successfully treated patients have revealed no recurrence of their stenosis. Lengthy scars (> 1 cm) and tracheomalacia were the clinical features common to those patients who failed the treatment. We advocate the use of Nd:YAG LPD in conjunction with "gentle" rigid bronchoscopic dilatation as the initial treatment of CTS.

Adult↗