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Biomedical subjects

R H Spiro

Publications and source records attributed to R H Spiro.

At least 37 records · Page 2Linked to original sources
PubMed1995

Treating tumors of the sublingual glands, including a useful technique for repair of the floor of the mouth after resection.

BACKGROUND: From a 55-year experience with about 4,000 patients treated for salivary gland tumors, we have identified 18 patients (0.5%) who received definitive treatment for neoplasms arising in the sublingual glands. PATIENTS AND METHODS: Patient ages ranged from 35 to 76 years (median 59), and men and women were equally represented. All had malignant tumors, which included adenoid cystic carcinoma (9 patients), mucoepidermoid carcinoma (5 patients), and adenocarcinoma (4 patients). An asymptomatic swelling was the most common complaint (7 patients); the tumor was incidentally discovered by a dentist in 4 others. For all patients, the treatment delay ranged from 3 to 24 months, but only 3 had lesions that extended beyond the confines of the floor of the mouth. All were treated surgically by resections, which were peroral in 4 patients, transcervical in 5, and pull-through type (including the submandibular gland) in 7. The remaining 2 patients had composite procedures. In 3 more recently treated patients, pull-through resections were followed by a floor-of-the-mouth repair involving transmandibular sutures. This technique has proved useful and will be described in detail. RESULTS: Results in this small patient cohort have been most encouraging. Local recurrence occurred in 3 patients who succumbed 11 months, 27 months, and 21 years after initial treatment. Fourteen others remain alive and well 20 months to 20 years (median 74 months) posttreatment, and the remaining patient was recurrence free when he died of unrelated causes 7 years after resection. CONCLUSION: This small experience confirms the rarity of sublingual gland tumors and attests to the good results in terms of function and survival that can be anticipated with adequate surgical treatment when the lesion is relatively small.

Adenocarcinoma↗
PubMed1995

Salvage laryngectomy for unsuccessful larynx preservation therapy.

From 1983 to 1991, 31 patients underwent salvage laryngectomy for persistent or recurrent squamous carcinoma of the larynx (14), hypopharynx (15), or oropharynx (2) as part of a larynx preservation protocol. Laryngectomy was performed as a consequence of poor response to induction chemotherapy in 13 and for recurrent disease after completion of chemotherapy and irradiation in 18. Postoperative pharyngocutaneous fistula occurred in 39%, resulting in prolonged hospitalization. Local control was achieved in 68%, more often in patients with laryngeal as opposed to nonlaryngeal primaries (86% versus 53%; p = .05). The overall actuarial survival and disease-specific survival at 2 years were 32% and 38%, respectively. Disease-specific survival at 2 years was better in patients with laryngeal as compared to nonlaryngeal primaries (56% versus 24%; p = .02). There were no long-term survivors among the nonlaryngeal primary patients. In selected patients in whom larynx preservation failed, salvage laryngectomy was associated with acceptable local control and survival. Palliation was obtained in patients who were not cured by their laryngectomy. Future investigation will focus on identification of factors predicting complications and strategies to reduce the incidence and severity.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

Cervical metastases of occult origin: the impact of combined modality therapy.

BACKGROUND: We have updated our experience with metastatic carcinoma to the neck of occult origin to assess whether increasing use of adjunctive radiation therapy has had a significant impact. METHODS: This retrospective review of 115 patients treated between 1977 and 1990 includes 73 (63%) with squamous cell carcinoma. These 73 patients were analyzed for survival, control of disease in the neck, and incidence of subsequent primary tumors. RESULTS: There has been no change in the proportion of patients with advanced neck disease (N2/N3 = 52; 71%) when compared to our last report. Surgery included comprehensive neck dissection in 59 (81%) and adjunctive radiotherapy was employed in 54 (83% of surgically treated patients). Primary carcinomas within the head and neck were identified subsequently in 9 (12%) patients, including 4 of 11 (36%) who did not have adjunctive radiotherapy and 5 of 54 (9%) who did (P = 0.038). Control of the treated neck (54/73; 74%) has improved significantly (P = 0.005) when compared to our earlier experience (37/74; 50%), and this was most apparent in those with extensive neck disease. However, cumulative survival at 5 years (45%) was not significantly different from that previously reported. CONCLUSION: Our data support the increased use of adjunctive radiation therapy for metastatic squamous cell carcinoma in the neck of occult origin. Control of neck disease has improved and the likelihood that a primary will be identified has been reduced, but there has been no improvement in survival when compared to historical controls.

Adult↗
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

The role of comprehensive neck dissection with preservation of the spinal accessory nerve in the clinically positive neck.

BACKGROUND: The most significant prognostic factor in patients with squamous cell carcinoma of the head and neck is the presence of cervical nodal metastases. Radical neck dissection is the standard by which all cervical lymphadenectomy procedures are judged. In the presence of clinically positive nodal metastasis, the benefit of preserving the spinal accessory nerve (SAN) has to be weighed against the possible risk of increased failure in the neck. We performed this retrospective study to determine if preservation of the SAN in patients with clinically evident nodal metastases was associated with increased risk of failure in the dissected neck. PATIENTS AND METHODS: Between January 1, 1984 and December 31, 1991, 378 comprehensive neck dissections were performed in 366 patients with clinically and pathologically positive nodal metastases from squamous carcinoma of the upper aerodigestive tract. We compared survival, neck control rates, and other factors in patients who had a classic radical neck dissection (RND) to those who had modified radical neck dissection sparing only the SAN (MRND I). RESULTS: Actuarial 5-year survival and neck failure rates for the RND group were 63% and 12%, compared to 71% and 8% for the MRND I group (P = NS). Survival and neck failure were not statistically different between the MRND I and RND groups when the analysis controlled for pathologic N stage, presence of extra capsular spread, and the presence of pathologically demonstrated metastatic nodes along the course of the SAN. Nor were there significantly different patterns of neck failure with RND versus MRND. CONCLUSION: Modification RND to preserve an uninvolved SAN in the clinically positive neck does not adversely affect survival or neck control.

Accessory Nerve↗
PubMed1994

Carcinoma of the oropharynx.

Carcinoma of the oropharynx poses particular challenges and problems to head and neck clinicians. These include relative anatomic inaccessibility, field cancerization and the need to minimize speech and swallowing dysfunction. The aim of this review is to bring together an appreciation of the issues involved in the management of this disease and the more recent results of its treatment.

Carcinoma↗
PubMed1994

Larynx preservation with combined chemotherapy and radiation therapy in advanced hypopharynx cancer.

Twenty-five untreated patients with advanced, resectable squamous cell carcinoma of the hypopharynx, for whom standard treatment would have required total laryngectomy, were treated with one to three cycles of cisplatin-based chemotherapy with larynx preservation as the goal. Patients with a major (complete or partial) response to chemotherapy at the primary site were treated with definitive radiation therapy, with total laryngectomy reserved for salvage; patients with less than a partial response to chemotherapy had total laryngectomy and postoperative radiation therapy recommended. Four patients had a poor response to chemotherapy and thus were not candidates for laryngectomy. Total laryngectomy was required for initial induction chemotherapy failure in five patients and for local recurrence in five others. Three additional patients had unresectable recurrence. Successful larynx preservation was achieved in 32% (8 of 25). With a median follow-up period of 41 months, the actuarial overall and failure-free 2-year survival rates were 44% and 32%, respectively. These preliminary data suggest larynx preservation is feasible in patients with advanced lesions of the hypopharynx. Improved local and regional control must be incorporated into the larynx preservation approach for hypopharyngeal lesions. A prospective, randomized study is necessary for a more valid comparison with conventional therapy, including comparative assessments of survival, morbidity, cost and functional results.

Adult↗
PubMed1993

Wound bleeding after head and neck surgery.

Using our head and neck service database, we reviewed 3,200 surgical procedures performed at our institution over a 7-year period. We identified 54 patients whose surgery was complicated postoperatively by wound bleeding. The procedure most often complicated by wound bleeding was parotidectomy, 1.7% (14 of 510 patients), followed by thyroidectomy, 1.6% (8 of 504 patients), neck dissection combined with other procedures, 1.3% (12 of 885 patients), and neck dissection alone, 1.1% (6 of 534 patients). Bleeding developed in flap donor sites in 2 of 227 patients and followed miscellaneous procedures in 12 others. Thirty-one patients were treated by reexploration in the operating room, 13 had limited exploration on the ward and 10 were observed with no intervention. There was no difference in wound healing between the three treatment groups. However, mean hospital stay was shortest for patients who had wound exploration in the operating room, 6.2 days, for exploration on the ward, 10.8 days, and 18.9 for those that were observed. Drains had no effect on wound healing or mean hospital stay.

Hematoma↗
PubMed1993

Improved survival in the treatment of squamous carcinoma of the oral tongue.

During the past 15 years, newer trends in the management of oral tongue cancer have included increased use of elective neck dissection and mandible-sparing procedures, as well as a commitment to postoperative radiotherapy in patients with stage III and IV tumors. We retrospectively reviewed the records of 297 consecutive patients who underwent primary treatment of a squamous cancer of the oral tongue at our institution between 1978 and 1987 to determine the effects of the aforementioned therapeutic approaches on patients' survival. Determinate 5-year survival was 65% overall (82% for stages I and II, 49% for stages III and IV), which represents a significant improvement when compared with the survival rates we reported for the preceding 10-year period, despite the fact that the distribution of patients according to stage was about the same. Some type of lymphadenectomy was performed in 130 patients, 63 of whom underwent elective node dissection for T1 or T2 lesions. Forty-one percent of the latter had positive nodes, which upstaged the disease in a significant proportion of N0 patients. The number of positive nodes (more than two positive nodes) was a significant predictor of survival (p = 0.03). Postoperative radiotherapy was performed in 70% of patients with stage III or IV tumors. In this group of patients, the incidence of neck recurrence was reduced (13% versus 29% for patients who did not receive radiotherapy). The only long-term survivors among patients with stage IV tumors were those who received postoperative radiotherapy. Our results strongly suggest that the improvement in results is related to a more aggressive and effective treatment of the neck.

Adolescent↗
PubMed1993

Management of occult neck metastases in oral cavity squamous carcinoma.

A large experience with patients who had radical neck dissection for oral squamous carcinoma has been reviewed in order to compare elective lymphadenectomy results with those achieved when neck dissection was delayed until metastases appeared or was performed initially for limited N1 neck disease. No significant difference in survival rates was observed, but neck failure was a more significant problem when treatment was delayed. This was most obvious in patients treated for tongue cancer. Although the impact of elective neck treatment on "cure" rates will require prospective studies, it seems clear that elective lymphadenectomy can enhance regional control of cancer and improve the quality of the patients' survival.

Adult↗
PubMed1993

Surgical management of squamous cell carcinoma of the base of the tongue.

An 11-year experience with 100 patients who had surgery as definitive treatment for squamous cell carcinoma of the base of the tongue between 1979 and 1989 has been retrospectively reviewed. Although 81% of the patients had stage III or stage IV disease, mandible continuity was maintained in 86%, and the larynx was preserved in 80%. Lymphadenectomy was performed in conjunction with the primary resection in a total of 89 patients, including 62 patients who had clinically evident metastases. Postoperative radiation was administered to 63 patients because of positive resection margins (17), positive cervical lymph nodes (34), or high tumor stage (12). Overall and disease-specific 5-year survival rates for the entire group were 55% and 65%, respectively. The 5-year disease-specific survival rates for stages I/II, III, and IV were 77%, 64%, and 59%, respectively. Local control was achieved in all but 18 patients. Our results indicate that surgery remains a viable treatment option for patients with advanced base-of-tongue cancer. Prospective trials are necessary to compare surgery versus definitive radiotherapy with respect to patients' survival and quality of life.

Adult↗
PubMed1993

Selective jugular node dissection in patients with squamous carcinoma of the larynx or pharynx.

We reviewed our experience with 66 patients who had 85 jugular node dissections (JND) between 1984 and 1991. When JND was used as a staging procedure in 56 patients with N0 squamous carcinoma of the larynx or hypopharynx, it identified 15 of 19 patients (79%) who had occult metastases. The pattern of neck failure in six patients after JND strongly suggests that the dissection must be carried posterior to the internal jugular vein in order to achieve adequate sampling. Neck failure was a relatively minor problem in this patient population, and the indications for elective JND may be less than compelling in most patients with N0 class laryngeal or pharyngeal squamous carcinomas. Our very limited experience with JND for resection of N1 disease supports a growing consensus that limited lymphadenectomy and aggressive radiotherapy may yield comparable results in carefully selected patients with palpable metastases. Obviously, these are issues that can only be resolved by prospective, randomized studies.

Adult↗
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

Nasopharyngeal brachytherapy with access via a transpalatal flap.

We used a posteriorly based transpalatal flap for interstitial nasopharyngeal brachytherapy in five patients with nasopharyngeal carcinoma. All of these implants were done with iodine 125 seeds. The disease in three of five patients has been controlled locally for 27, 30, and 40 months, respectively. Two patients experienced local failure and died. There have been no palatal healing problems despite high doses of previous radiation in all of our patients. No palatal incompetence has been seen. This technique appears safe and should be considered for discrete lesions of the high posterior or superior nasopharynx that cannot be approached by less invasive methods.

Adult↗
PubMed1992

Stage means more than grade in adenoid cystic carcinoma.

Our experience with 184 previously untreated patients who had adenoid cystic carcinoma of salivary gland origin is reviewed. Retrospective staging was possible in all but nine patients who had minor salivary gland primary tumors. Sixty-three percent of patients were diagnosed as having stage I or stage II disease (stage I, 64 patients; stage II, 47 patients), whereas 43 and 21 patients had stage III and IV tumors, respectively. Grading was as follows: cribriform pattern only (grade 1, 126 patients; 68%), mixed cribriform and solid features (grade 2, 48 patients; 26%), and solid only (grade 3, 10 patients; 5%). Treatment was predominantly surgical (174 patients), and relatively few patients received adjunctive, postoperative irradiation (27 patients). Cumulative 10-year survival was 75%, 43%, and 15% for stage I, stage II, and stage III and IV patients, respectively, and cause-specific survival at 10 years was as high as 94% in patients with stage I disease. Only the clinical stage had a significant impact on survival. Neither survival, regional metastases (16 patients; 11%), nor distant dissemination (64 patients; 43%) was predictable on the basis of tumor grade alone. The prognosis in patients with early stage lesions may be better than has been appreciated.

Adult↗
PubMed1991

Laryngeal myxoma.

Myxoma is a rare mesenchymal tumor that is especially uncommon in the head and neck. We report a case of a myxoma of the larynx in a 70-year-old man, which, to our knowledge, is the second case reported in the English-language literature. Although benign, myxomas have a propensity for local recurrence due to their tendency to infiltrate surrounding tissues. They commonly appear encapsulated, but simple enucleation is not adequate treatment; excision should include a margin of normal tissue around the tumor.

Aged↗