Biomedical subjects

D Sessions

Publications and source records attributed to D Sessions.

11 recordsLinked to original sources

PubMed2001

Free flap reconstruction of the head and neck: analysis of 241 cases.

OBJECTIVE: We undertook this study of free flap reconstruction of the head and neck to stratify patients and procedures, to determine how donor site preference changed over time, to assess medical and surgical outcomes, and to identify variables associated with complications. METHODS: We analyzed computerized medical records from 236 patients who underwent a total of 241 reconstructions at a tertiary academic medical center in St. Louis between 1989 and 1998. We created a more detailed retrospective database of 141 of those patients by using 48 perioperative variables and 7 adverse outcome measures. Multivariate statistical models were used to analyze associations between variables and outcomes. RESULTS: The fibula became the preferred donor site for mandibular reconstruction, and the radial forearm became the preferred donor site for pharyngoesophageal reconstruction. For the 241 procedures, the mortality rate was 2.1%, the median length of stay was 11 days, and the flap survival rate was 95%. Administration of more than 7 L of crystalloid during surgery and age over 55 were associated with major medical complications. Blood transfusion, prognostic comorbidity, and number of surgeons correlated with length of stay. Cigarette smoking and receipt of more than 7 L of crystalloid during surgery were associated with overall flap complications, and weight loss of more than 10% before surgery, more than one operating surgeon, and cigarette smoking were associated with major flap complications. CONCLUSIONS: Risk to patients and transferred tissue is low in free flap head and neck reconstruction. Age, smoking history, and weight loss should be considered during patient selection. Fluid balance should be considered during and after surgery. Division of labor for patient care should be carefully delineated among surgeons in a teaching setting.

Adolescent↗

PubMed1998

Carcinoma of the tonsillar fossa: prognostic factors and long-term therapy outcome.

PURPOSE: To identify prognostic parameters and evaluate the therapeutic outcomes for patients with carcinoma of the tonsillar fossa treated with three treatment modalities. METHODS AND MATERIALS: The results of therapy are reported in 384 patients with histologically proven epidermoid carcinoma of the tonsillar fossa; 154 were treated with irradiation alone (55-70 Gy), 144 with preoperative radiation therapy (20-40 Gy), and 86 with postoperative irradiation (50-60 Gy). The operation in all but four patients in the last two groups consisted of an en bloc radical tonsillectomy with ipsilateral lymph node dissection. RESULTS: Treatment modality and total irradiation doses had no impact on survival. Actuarial 10-year disease-free survival rates were 65% for patients with T1 tumors, 60% for T2, 60% for T3, and 30% for T4 disease. Patients with no cervical lymphadenopathy or with a small metastatic lymph node (N1) had better disease-free survival (60% and 70%, respectively) at 5 years than those with large or fixed lymph nodes (30%). Primary tumor recurrence (local, marginal) rates in the T1, T2, and T3 groups were 20-25% in patients treated with irradiation and surgery and 31% for those treated with irradiation alone (difference not statistically significant). In patients with T4 disease treated with surgery and postoperative irradiation, the local failure rate was 32% compared with 86% with low-dose preoperative irradiation and 47% with irradiation alone (p = 0.03). The overall recurrence rates in the neck were 10% for N0 patients, 25% for N1 and N2, and 35-40% for patients with N3 cervical lymph nodes, without significant differences among the various treatment groups. The incidence of contralateral neck recurrences was 8% with the various treatment modalities. On multivariate analysis the only significant factors for local tumor control and disease-free survival were T and N stage (p = 0.04-0.001). Fatal complications were noted in 7 of 144 (5%) patients treated with preoperative irradiation and surgery, 2 of 86 (2%) of those receiving postoperative irradiation, and 2 of 154 (1.3%) patients treated with radiation therapy alone. Other moderate or severe nonfatal sequelae were noted in 30% of the patients treated with preoperative irradiation and surgery, in 53% treated with postoperative irradiation, and in 19% receiving radiation therapy alone. CONCLUSION: Primary tumor and neck node stage are the only significant prognostic factors influencing locoregional tumor control and disease-free survival. Treatment modality had no significant impact on outcome. Radiation therapy remains the treatment of choice for patients with stage T1-T2 carcinoma of the tonsillar fossa. In patients with T3-T4 tumors and good general condition, combination surgery and postoperative irradiation offers better tumor control than single-modality and preoperative irradiation procedures, but with greater morbidity.

Analysis of Variance↗

PubMed1997

Primary intrathyroidal paraganglioma with metachronous carotid body tumor: report of a case and review of the literature.

A case of primary intrathyroidal paraganglioma is reported, and the light microscopic and immunohistochemical findings are described. Primary paragangliomas of the thyroid region are extremely uncommon and are therefore often confused clinically and histopathologically with more common intrathyroidal mass lesions. The diagnostic difficulties are underscored by the present case, which was misdiagnosed twice, firstly as a medullary thyroid carcinoma and secondly as a follicular thyroid carcinoma. Immunohistochemistry may be very helpful in arriving at the correct diagnosis. The case was further complicated by a second neck mass contralateral to the original thyroid nodule, which was interpreted as consistent with metastasis. The second lesions was proved angiographically and histologically to be a carotid body paraganglioma.

Adult↗

PubMed1996

The impact of surgical margin status and use of an interstitial implant on T1, T2 oral tongue cancers after surgery.

PURPOSE: In patients with T1,T2 oral tongue carcinoma treated with surgical resection, postoperative radiation therapy (RT) is required especially when surgical margins contain tumors. Irradiation techniques include external beam, interstitial implants, or a combination of the two modalities. We investigated whether positive surgical margin remains a poor prognostic factor after radiation therapy, and the contribution of interstitial implants to disease control. METHODS AND MATERIALS: Between 1972 and 1989, 55 patients were treated postoperatively at the Mallinckrodt Institute of Radiology for T1,T2 squamous cell carcinomas of the oral tongue. Surgeries included 26 wide excisions or excisional biopsies and 29 composite resections or hemiglossectomies. Thirty-nine patients received external radiation therapy alone and 16 patients had an interstitial implant (ISI) as part of the treatment. The minimum follow-up is 4 years. RESULTS: At 2 and 5 years, the overall survivals for all patients were 82 and 68%. The disease-free survivals (DFS) were 82 and 70%, respectively. There was no significant difference in the pattern of failure and DFS when stratified by the status of surgical margins and the type of the surgical procedure. Local control was achieved in 15 of 18 patients when surgical margins were involved by tumor and in 29 of 37 patients without tumor involving margins (p > 0.05). Ten of 18 (56%) patients with tumor involving resection margins were treated with ISI, whereas only 3 of 33 (9%) of those with negative margins received ISI. Local control was achieved in 32 of 39 patients treated with external beam RT alone, and 13 of 16 patients who received interstitial implant (p > 0.05). Four patients treated with ISI developed persistent soft tissue ulceration and mandibular bone exposures. CONCLUSIONS: Postoperative radiation therapy converted the ominous outcome of patients with tumor involving surgical margins. Patients with positive surgical margins were often selected to be treated with interstitial implants. We found that the local control was as good as in those with a more favorable pathology (negative margins) and treated with external RT alone. Further investigation is needed to optimize the implant treatment to minimize the complications.

Adult↗

PubMed1991

Supraglottic carcinoma: impact of radiation therapy on outcome of patients with positive margins and extracapsular nodal disease.

Seventy-nine patients with supraglottic carcinoma treated between 1966 and 1985 are reviewed. All patients were treated with surgery and postoperative radiation therapy. Thirty-five percent of the patients had positive margins at the site of resection of the primary tumor. Of the 25 patients who had positive nodal disease, 13 patients (52%) had either extracapsular extension or soft-tissue or adjacent organ invasion, referred to in composite as "grave signs." The median follow-up of the patients was 4.9 years and all patients were followed for a minimum of 3 years. The disease-free survival for all patients was 76% at 2 years and 71% at 3 years. The locoregional control rate for all patients was 70%. This study demonstrates that there is no difference in local recurrence or disease-free survival, or time to recurrence relative to the status of the surgical margins, which may be a benefit of the postoperative radiation therapy. This study also demonstrates that there is an increase in the number of patients with grave signs with increasing nodal stage. The rate of neck recurrence in patients with grave signs was substantially higher (54%) than in patients without grave signs (8%), even though these patients also had positive lymph nodes. Interestingly, there was also a higher rate of local recurrence among patients who had grave signs. Patients receiving doses higher than 6000 cGy to the primary site had fewer local failures, although within each group of patients with positive or negative surgical margins the differences in survival were minimal.

Adult↗

PubMed1989

Clinical and histopathological considerations for the diagnosis and treatment of verrucous carcinoma of the larynx.

Verrucous carcinoma of the larynx is quite distinct from well-differentiated squamous cell carcinoma has a characteristic morphology and specific clinical behavior. It accounts for approximately 1%-2% of all laryngeal carcinomas. However, difficulties are encountered clinically in separating verrucous carcinomas from keratoses, verruca vulgaris and squamous cell carcinomas with a verrucous appearance. Between 1962 and 1982, 1504 patients with squamous cell carcinomas of the larynx were diagnosed and treated by staff physicians in the Department of Otolaryngology--Head and Neck Surgery, Washington University in St. Louis. Fifteen of these patients (1%) had verrucous carcinomas. These cases were studied in order to clarify any diagnostic problems, trace the biologic behavior of the tumors and report the results of the treatment used. Of these 15 patients, we were able to follow up 8. The latter had been treated only with surgery and none of them had received radiotherapy. One death occurred, but the patient died of other causes and remained free of cancer. Reports in the literature describe a high rate of recurrence of verrucous carcinomas following radiotherapy with occasional anaplastic transformation of tumors. No patients in our series developed a metastasis in the neck, indicating that neck dissection is not justified for patients with these neoplasms even though clinically enlarged neck nodes may be present.

Adult↗

PubMed1984

The neck after vertical hemilaryngectomy: computed tomographic study.

Computed tomographic scans in 22 postoperative vertical hemilaryngectomy patients were analyzed retrospectively to determine the normal postoperative appearance and to evaluate the role of CT in assessing recurrent neoplasm. Twelve patients without clinical evidence of recurrence illustrated the normal postoperative changes: loss of the preepiglottic space fat and the aryepiglottic fold on the operated side, convexity of the residual true vocal cord, and regeneration of the resected thyroid cartilage ala. In the six patients with recurrent neoplasm, the CT manifestations included increased width of the remaining true vocal cord, convexity of the surgically formed pseudocord at glottic level, subglottic tumor, and extralaryngeal neck masses. Recurrence was mimicked in four patients by bulky soft tissue at the endolaryngeal operative site at both CT and laryngoscopy; this was due to hyperkeratosis or granulation tissue in three cases and an inclusion cyst in one case. CT supplemented the physical examination and indirect laryngoscopy, providing information regarding the presence and extent of tumor that was useful in planning the mode or scope of subsequent therapy.

Humans↗

PubMed1984

The neck after total laryngectomy: CT study.

Computed tomographic scans in 23 patients who had undergone total laryngectomy were analyzed retrospectively to determine normal postoperative appearance and to evaluate the role of CT in assessing recurrent neoplasm. Nine patients without clinical evidence of recurrence illustrated the normal postoperative changes: a round or ovoid neopharynx connecting the base of the tongue with the cervical esophagus and intact fat planes surrounding the neopharynx, neurovascular bundles, and sternocleidomastoid muscles. In the 12 patients with recurrent neoplasm, the CT manifestations included masses involving the internal jugular lymph node chain (adjacent to the neopharynx, neurovascular bundles, or sternocleidomastoid muscles), tracheostomy site, or paratracheal region. Recurrence was mimicked on CT in two patients, one with an abscess and one with metastases from an adenocarcinoma of unknown primary site. In eight patients, a distended neopharyngeal lumen correlated with benign or malignant stricture. CT supplemented physical examination and indirect mirror examination, providing data regarding presence and extent of recurrent tumor and aiding in planning the mode and scope of therapy.

Aged↗

PubMedDate not supplied

Development of surgical quality-control mechanisms in large-scale prospective trials: head and neck intergroup report.

One of the current national prospective clinical trials of the Head and Neck Intergroup explores the usage of chemotherapy in advanced operable head and neck cancer patients. The experimental arm consists of the addition of 3 courses of cisplatin-containing chemotherapy to standard treatment defined as surgery followed by postoperative radiotherapy. In the design of the study it is necessary to define not only the extent of the surgery performed for each eligible lesion, but also to insure uniformity of surgery performed between surgeons and institutions. This will hopefully insure that any variation between the 2 arms of the study represent the effect of the chemotherapy. The procedure to obtain and confirm uniformity of surgery is multifaceted. It is, however, fundamentally based upon the current TNM staging system and therefore has intrinsic limitations.

Antineoplastic Combined Chemotherapy Protocols↗

PubMedDate not supplied

Carcinoma of the tonsillar fossa: a nonrandomized comparison of irradiation alone or combined with surgery: long-term results.

The results of therapy are reported in 296 patients with histologically proven epidermoid carcinoma of the tonsillar fossa; 127 were treated with irradiation alone (5,500 to 7,000 cGy), 133 with preoperative radiotherapy (2,000 to 3,000 cGy) or were initially planned for preoperative irradiation but treated with radiotherapy alone, and 36 with postoperative irradiation (5,000 to 6,000 cGy). The operation in all but 4 patients consisted of an en bloc radical tonsillectomy with ipsilateral lymph node dissection. Actuarial 5-year no evidence of disease (NED) was as follows: survival rates for patients with T1 tumors, 76%; T2, 54%; T3, 45%; and T4, 20%. Patients with no cervical lymphadenopathy or with a small metastatic lymph node (N1) had better relapse-free survival (60% to 70% at 5 years) than those with large or fixed lymph nodes (30% to 40%). Primary tumor recurrence rate in the T1-T2 groups was about 20% in patients treated with irradiation and surgery and 30% for those treated with irradiation alone (difference not statistically significant), 30% in patients with stage T3 lesions in all treatment groups, and 33% in patients with T4 disease treated with surgery and postoperative irradiation compared to 52% with irradiation alone (p = 0.03). The overall recurrence rate in the neck was about 20% for the N0 patients, 25% for N1, and 30% for those with N2 and N3 cervical lymph nodes in the 4 treatment groups. The incidence of contralateral neck recurrences was about 8% with the various treatment modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma, Squamous Cell↗

PubMedDate not supplied

The transformation of laryngeal keratosis into invasive carcinoma.

Although 93.0% to 97.0% of all laryngeal carcinomas are diagnosed on the first biopsy, 3.0% to 6.7% of them occur in patients who have what is initially diagnosed as "laryngeal keratosis." To study this phenomenon, we examined data from 1,019 patients with laryngeal keratosis seen between 1962 and 1981. Eleven patients with keratosis and initially undetected cancer at different laryngeal sites were excluded, as were 87 outside referrals for whom no records were available beyond the histologic report. The remaining 921 patients were classified on the basis of the initial histologic findings into groups comprising 604 patients with keratosis without atypia (group 1), 204 patients with mild atypia (group 2), 23 patients with moderate atypia (group 3), and 90 patients with severe atypia (group 4). All 921 were followed for from 5 to 25 years. Invasive carcinoma of the larynx developed in 18 patients from group 1 (3.0%), 15 from group 2 (7.4%), four from group 3 (17.4%), and 25 from group 4 (27.8%). Fifty-seven patients (91.9%) developed invasive carcinoma after less than 10 years but only five (8.1%) did so after 10 years or more.

Adolescent↗