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Biomedical subjects

J P Shah

Publications and source records attributed to J P Shah.

At least 19 recordsLinked to original sources
PubMed1997

Current role of the radial forearm free flap in mandibular reconstruction.

The radial forearm free flap was selected as a donor site in only 17 (11 percent) of 155 consecutive free flap mandible reconstructions performed over a 9-year period. It was used either as an osteocutaneous flap (58 percent), as a soft-tissue flap alone for coverage of a reconstruction plate (18 percent), to supplement another free flap (12 percent), or to salvage a previous reconstruction (12 percent). The most common underlying disease was epidermoid carcinoma (82 percent), the average patient age was 55 years, and the average length of follow-up was 13.5 months. Although there was one patient death, there were no anastomotic failures. Postoperatively, two patients experienced fracture at the donor site (12 percent), and three patients (18 percent) had hardware related problems such as exposure, infection, or both. Although early studies advocated using the osteocutaneous radial forearm flap as a preferred method in mandible reconstruction, superior donor site options such as the fibula have now relegated it to a minor role. The best remaining indication for its use today is for a limited posterior bone defect associated with a large adjacent mucosal loss. Osseointegrated implant capability is not important in this setting, and the short bone length needed for this application minimizes the potential for fracture at the donor site, a serious complication. Otherwise, the osteocutaneous radial forearm flap is not recommended for the majority of segmental mandibular defects. The radial forearm flap without bone continues to have an important supportive role in mandibular reconstruction. It is an excellent choice in this regard when used to cover a reconstruction plate, as a second free flap when soft-tissue requirements are exceptionally large, or for salvage of a previous mandible reconstruction.

Adult↗
PubMed1996

Management of the orbit during anterior fossa craniofacial resection.

OBJECTIVE: To determine the postoperative ocular function in patients undergoing anterior fossa craniofacial resection with preservation of the orbit. DESIGN: Retrospective medical chart review of patients treated from January 1, 1973, to July 31, 1994. Median follow-up was 38 months (range, 1-210 months). SETTING: Tertiary referral center. PATIENTS: Fifty-eight consecutive patients undergoing anterior fossa craniofacial resection with orbital preservation for tumors involving the anterior skull base. MAIN OUTCOME MEASURES: Assessment of orbital complications of treatment, need for further surgical intervention to correct these complications, and determination whether functional vision was retained at last follow-up examination, and tumor recurrence within preserved orbits. INTERVENTIONS: Anterior craniofacial resection with orbital preservation. Postoperative radiation therapy was administered to selected patients. RESULTS: Overall, 25 patients (43%) had some ocular sequelae of their treatment. This consisted of epiphora in 21 patients, diplopia in 8, vision loss in 6, and pain and enophthalmos in 2. Twelve patients required revision surgery consisting of dacryocystorhinostomy in 8, ectropion repair in 3, drainage of orbital mucocele in 1, and corneal transplant in 1. Ocular complications were more common and vision loss occurred only in patients treated with postoperative radiation therapy. Functional vision in the ipsilateral eye was retained in 50 of the 58 patients. CONCLUSIONS: When the orbit is preserved during anterior fossa craniofacial resection, ocular sequelae are frequent and may require revision surgery. Functional vision can be preserved in most patients.

Adolescent↗
PubMed1996

Risk group stratification and prognostic factors in papillary carcinoma of thyroid.

BACKGROUND: Our understanding of the natural history of differentiated thyroid carcinoma has improved with the definition of prognostic factors. These prognostic factors have helped us identify patients in various risk groups. METHODS: A retrospective review of a consecutive series of 810 previously untreated patients with papillary carcinoma of the thyroid was undertaken to analyze the prognostic factors and risk groups. There were 403 patients in the low-risk group, 313 in the intermediate group, and 94 classified in the high-risk group. RESULTS: With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 43% survived in the high-risk group. The intermediate-risk group had a 20-year survival of 83%. The favorable prognostic factors included female sex, young age, absence of distant metastases and extrathyroidal extension of the disease, size < 4 cm, and low-grade histology. Focality, presence of lymph node metastasis, and pure papillary or mixed variant had no statistical significance on prognosis. CONCLUSIONS: Based on various prognostic factors, low-, intermediate-, and high-risk groups are identified. Patients in the low-risk group have excellent survival (99%). Appropriate selection of surgical and adjuvant treatment should therefore be used based on prognostic factors and risk group stratification.

Age Factors↗
PubMed1996

The extent of neck disease after regional failure during observation of the N0 neck.

BACKGROUND: The optimum management of the N0 neck remains controversial. When the neck is observed it is hoped that close follow-up will detect regional failure at an early stage. To test this hypothesis we examined patients undergoing therapeutic neck dissection for newly developed neck metastases during observation after treatment of the primary tumor. METHODS: A retrospective chart review of 47 patients undergoing neck dissection for regional failure after surgical treatment of the primary tumor and observation of the neck from 1987 to 1992 was performed. The median time to failure in the neck was 13 months. RESULTS: The clinical neck stage at the time of neck dissection was N1 in 37, N2A in 6, N2B in 1, and N3 in 3. However, pathologic staging revealed stages of N1 in 19, N2A in 5, N2B in 20, and N3 in 3. Extracapsular spread (ECS) was present in 23 patients (49%). Overall 36 patients (77%) had adverse pathologic findings (N greater than 1 or ECS). CONCLUSIONS: These data indicate that when observation is used for the neck at risk for metastasis, patients tend to fail with high stage disease in the neck. This supports the philosophy of elective treatment of the neck but cannot show whether elective treatment will improve survival.

Aged↗
PubMed1996

Conservation surgery for recurrent carcinoma of the glottic larynx.

BACKGROUND: Partial laryngectomy following previous irradiation is an oncologically sound procedure with excellent local control and survival rates. Several reports suggest an increased complication rate in previously irradiated patients. METHODS: To analyze whether previous irradiation affected complications, disease control, or survival we performed a retrospective analysis of all patients who underwent vertical partial laryngectomy (VPL) for squamous cell carcinoma of the glottic larynx between January 1984 and August 1993. RESULTS: Sixty-eight patients had adequate followup. The overall 5-year survival rates were 79% for previously treated patients and 95% for primary VPL patients (P = NS). The local control rates with surgical salvage were 93% and 98%, respectively. No increase in wound complications, time to decannulation, length of hospitalization, or ability to swallow were found. CONCLUSIONS: VPL can be performed safely in selected patients following previous radiotherapy without a significant increase in complications or cost.

Adult↗
PubMed1996

Supraspinal accessory lymph node metastases in supraomohyoid neck dissection.

BACKGROUND: Some patients undergoing surgical resection of primary squamous cell carcinoma of the oral cavity and oropharynx also undergo supraomohyoid neck dissection for staging of the negative (N(o)) neck. Dissection of the supraspinal accessory lymph node pad requires significant traction of the spinal accessory nerve. There are currently no data to indicate the incidence of metastases to this site and thus the necessity of performing dissection of these nodes. METHODS: A prospective analysis of a consecutive series of 44 patients with newly diagnosed squamous carcinoma of the oral cavity or oropharynx undergoing surgical management of the primary lesion with staging neck dissection was performed. Patients underwent unilateral (41) or bilateral (3) supraomohyoid neck dissection with separate submission of the supraspinal accessory lymph node pad for pathologic evaluation to determine the incidence of nodal metastases. RESULTS: A total of 15 patients (32%) had microscopic metastatic squamous cell carcinoma involving the supraomohyoid neck dissection specimen. Only 1 patient had a metastatic deposit involving the supraspinal accessory lymph node pad. This patient also had metastases in additional lymph nodes at level II. There was an equal incidence of metastases for all patients when stratifying by T stage. CONCLUSION: This preliminary report reveals a small incidence of supraspinal accessory lymph node metastases in patients with T + NO squamous cell carcinoma of the oral cavity and oropharynx. We continue to accrue patients to determine if the incidence of supraspinal accessory lymph node metastases varies with an increased number of patients.

Adolescent↗
PubMed1996

Supraomohyoid neck dissection.

BACKGROUND: Supraomohyoid neck dissection (SOHND) has assumed increasing importance as a staging lymphadenectomy in patients with N(o) oral and oropharyngeal squamous cell carcinoma (SCC), as well as a potentially curative procedure in selected patients with limited metastatic disease in the neck. METHODS: Retrospective chart review of 287 patients who had a total of 320 SOHND for SCC between 1986 and 1993 as a follow-up to an earlier report that covered our experience between 1980 and 1985. After excluding 24 patients who also had local recurrence, or a new primary, the remaining 296 SOHND were assessed for the effectiveness of tumor control in the neck. RESULTS: Of 248 elective SOHND, clinically negative nodes proved histologically positive in 60 patients (25%), only 4 of whom failed in the neck (7%). A total of 48 patients (16%) had a therapeutic SOHND for limited N+ disease, confirmed pathologically in 31, with neck recurrence documented in 2 (6%). Nodes proved negative histologically in 205 patients, 10 of whom failed in the neck (5%). Nine of the 16 patients with neck recurrence had received postoperative radiation therapy and 9 recurred within the field of the SOHND. CONCLUSIONS: SOHND is a reliable staging procedure in patients with N(o) oral or oropharyngeal SCC. Therapeutic SOHND, in conjunction with postoperative radiation therapy, was highly effective in controlling neck metastases in carefully selected patients with limited disease in the upper neck.

Adult↗
PubMed1996

Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid.

BACKGROUND: Understanding of differentiated carcinoma of the thyroid has improved in recent years with the definition of prognostic factors and risk group analysis. We intend to review our experience of differentiated thyroid cancer in relation to the risk of nodal and distant metastasis based on various histologic subgroups. METHODS: This is a retrospective review of a consecutive series of 1,038 previously untreated patients with differentiated carcinoma of the thyroid treated over a period of 55 years. Univariate and multivariate analysis of various prognostic factors was performed. The incidence of nodal and distant metastasis was analyzed based on various histologic varieties of differentiated thyroid cancer. RESULTS: There were 337 male and 701 female patients. The various histologic subgroups included papillary (810), follicular (169), and Hurthle cell cancer (59). The cumulative risk of nodal metastasis based on histological group was 61%, 30%, and 21% for papillary, follicular, and Hurthle cell variety, respectively. The risk of distant metastasis for the same histologic varieties was 10%, 22%, and 33%, respectively. The 5- and 20-year survival for these histologic subgroups was papillary (94% and 87%, respectively), follicular (87% and 81%), and Hurthle cell tumors (81% and 65%; P < 0.001). CONCLUSIONS: The incidence of nodal metastasis is highest in the papillary subgroup; however, the incidence of distant metastasis was 33% in the Hurthle cell variety. The risk of nodal and distant metastasis varies considerably based on individual histologic variety.

Adenocarcinoma↗
PubMed1996

Long-term subjective functional outcome of surgery plus postoperative radiotheraphy for advanced stage oral cavity and oropharyngeal carcinoma.

BACKGROUND: Although long-term cures have been achieved for locally advanced squamous cell carcinomas of the head and neck, there is a paucity of information available regarding patients' perspectives of their functional outcome. PATIENTS AND METHODS: Thirty-five long-term survivors free of disease following surgery and postoperative radiotherapy for advanced cancers of the oral cavity and oropharynx were sent questionnaires to evaluate their long-term functional outcome after therapy. The questionnaires included a subjective performance status scale that assessed the patient perceived (1) ability to eat in public, (2) understandability of speech, and (3) normalcy of diet. Twenty-nine of 35 patients participated in this function assessment and are the subjects of this report. RESULTS: The mean function scores for all patients were as follows: 72 for eating in public, 69 for understandability of speech, and 58 for normalcy of diet. Functional results were further analyzed by T stage and anatomic subsite. Inferior results were noted with increasing T stage. A two-way analysis of variance showed that this difference was significant even after adjusting for the effect of anatomic subsite (P = 0.0002, P = 0.018, and P = 0.0018 for the three outcome variables). In addition, patients with base of tongue lesions had a worse functional outcome for both early T state (T1/T2) and advanced T stage (T3/T4) when compared to other subsites. This difference averaged across T stage was statistically significant for understandability of speech (P = 0.0019) and normalcy of diet (P = 0.013), but was not significant for eating in public (P = 0.16). CONCLUSIONS: This performance status scale was found to be a useful tool for functional assessment following definitive therapy for advanced stage head and neck carcinomas. These subjective functional scores deteriorated with increasing T stage. In addition, functional scores for oral tongue, floor of mouth, and tonsillar primaries were superior to those for base of tongue lesions. These functional outcome scores are consistent with the extent of surgery required for the base of tongue subsite and are in direct relation to the patients' T stage in this study population.

Adult↗
PubMed1995

Prevalence and predictors of continued tobacco use after treatment of patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer who continue to smoke after diagnosis and treatment are more likely than patients who quit to experience tumor recurrence and second primary malignancies. Therefore, information about patients' smoking status and the factors associated with continued tobacco use are important considerations in the comprehensive care patients with head and neck cancer. METHODS: Study participants were 144 patients with newly diagnosed squamous cell carcinomas of the upper aerodigestive tract who underwent surgical treatment, with or without postoperative radiotherapy or chemotherapy, 3-15 months before assessment of their postoperative tobacco use. RESULTS: Among the 74 patients who had smoked in the year before diagnosis, 35% reported continued tobacco use after surgery. Compared with patients who abstained from smoking, patients who continued to use tobacco were less likely to have received postoperative radiotherapy, to have had less extensive disease, to have had oral cavity disease, and to have had higher levels of education. Hierarchical regression analysis indicated that most of the explained variance in smoking status could be accounted for on the first step of analysis by disease site. Interest in smoking cessation was high, and most patients made multiple attempts to quit. CONCLUSIONS: Although the diagnosis of a tobacco-related malignancy clearly represents a strong catalyst for smoking cessation, a sizable subgroup of patients continue to smoke. Patients with less severe disease who undergo less extensive treatment are particularly at risk for continued tobacco use. These data highlight the importance of developing smoking cessation interventions designed to meet the demographic, disease, treatment, and tobacco-use characteristics of this patient population.

Carcinoma, Squamous Cell↗
PubMed1995

Impact of clinicopathologic parameters on patient survival in carcinoma of the cervical esophagus.

BACKGROUND: The survival of patients with carcinoma of the cervical esophagus remains poor in spite of multimodality treatment and technical improvements in surgical resection and reconstruction. This study was undertaken to update our experience with cervical esophageal carcinoma and to identify factors that had an impact on patient survival and quality of life. PATIENTS AND METHODS: Clinical data encompassing 132 variables were collected on 67 patients with cervical esophageal carcinoma from 1980 to 1993. Statistical analysis was performed: independent Student's t-tests, Cox regression, Kaplan-Meier curves, and log rank analyses were used in the statistical evaluation. The mean age of the patients was 63 years (range 31 to 88). Dysphagia was the primary symptom in 86% of patients; 80% had received no prior treatment. The most common abnormal finding (21%) on physical examination was a neck mass. RESULTS: Curative resection was performed in 22 patients, 7 had palliative procedures, and 7 were found to be inoperable at exploration and received palliative treatment. Radiation with or without chemotherapy was definitive treatment for 10 patients, whereas 4 patients were treated with chemotherapy alone for cure, and 17 patients received palliative treatment. The mean survival following diagnosis was 17 months (range 1 to 96). Cumulative 5-year survival was 12%. CONCLUSIONS: Persistent disease, chemotherapy prior to presentation, and chemotherapy for cure remained as statistically significant parameters associated with decreased survival by multivariate analysis. There was a trend toward improved survival in patients treated with surgical resection.

Adult↗
PubMed1995

Differentiated carcinoma of the thyroid with extrathyroidal extension.

BACKGROUND: We have analyzed our experience with differentiated thyroid cancer patients with extrathyroidal extension (ETE) to investigate patterns of recurrence and define factors that predict failure. PATIENTS AND METHODS: The records of 1,012 patients treated surgically from 1930 to 1985 were reviewed. A total of 79 patients (8%) had ETE. The median length of follow-up was 10 years. RESULTS: Patients with ETE were more likely to fail treatment and to die of their disease than were patients without ETE (77% versus 34% and 71% versus 13%, respectively; P < 0.0001). Local, regional, and distant failures were more prominent among patients with ETE than among those without ETE (48% versus 9%, 41% versus 16%, and 37% versus 11% respectively; P < 0.0001). Survival of patients with ETE was adversely affected by nonpapillary histology, distant metastasis, age > 45, tumor size > 4 cm, and incomplete excision (P < or = 0.05). After stratification for age, survival in older patients was not affected by tumor size or incomplete excision, while in younger patients tumor size or the presence of distant metastasis did not adversely affect survival. Patients younger than 45 with negative margins had similar survival to patients without ETE (P = 0.46). CONCLUSIONS: Patients with ETE are more likely to die of their disease and to fail at all sites. Survival in older patients was not affected by incomplete excision while it was in younger patients. The presence of distant metastasis did not affect survival in younger patients. Our results suggest that among patients under 45, the presence of ETE does not adversely impact upon survival when the primary tumor is completely resected.

Adenocarcinoma↗
PubMed1995

Prognostic factors and risk group analysis in follicular carcinoma of the thyroid.

BACKGROUND: The understanding of prognostic factors has facilitated stratification of risk groups in differentiated carcinoma of the thyroid. The prognostic factors have clearly identified the risk groups as low, intermediate, and high risk. Risk group categorization has facilitated a selective surgical approach for thyroid carcinoma. METHODS: A retrospective review of 228 patients with follicular carcinoma of the thyroid was undertaken. Various prognostic factors and risk groups were analyzed. Univariate and multivariate analyses were performed, and the survival curves were plotted by the Kaplan-Meier method. Fifty-nine (26%) patients presented with Hürthle cell histology. The risk groups revealed 62 patients in the low, 84 in the intermediate, and 82 in the high risk groups. RESULTS: The 10-year survival for low, intermediate, and high risk groups was 98%, 88%, and 56%, respectively, and the 20-year survival for the same groups was 97%, 87%, and 49%, respectively. Adverse prognostic factors included age older than 45 years (p < 0.001), Hürthle cell variety (p = 0.05), extrathyroidal extension, tumor size exceeding 4 cm, and the presence or absence of distant metastasis (p < 0.001). Gender, focality, and presence of lymph node metastasis had no significant impact on prognosis. CONCLUSIONS: Patients in the low risk group have excellent survival, whereas the high risk group behaves poorly. Appropriate selection of treatment for the primary disease and adjuvant therapy should be considered on the basis of the prognostic factors and risk group analysis.

Adenocarcinoma, Follicular↗