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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
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

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↗
PubMed1991

Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck.

A consecutive series of 111 patients treated between 1964 and 1989 with primary cutaneous malignant melanoma of the head and neck and histologically proven regional metastases was reviewed to determine the patterns of nodal metastases. The primary sites were grouped in the following categories: face (34), anterior scalp (25), anterior neck (16), posterior scalp (15), ear (11), and posterior neck (10). All patients underwent radical neck dissection: 80 of the procedures were therapeutic and 31 elective. A total of 106 specimens were positive for metastases. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases (14 of 20 in therapeutic parotidectomies and 19 of 37 in elective parotidectomies). Based on the incidence of involvement of the parotid gland and the patterns of lymph node metastases from levels I through V, three observations are made. Patients undergoing regional lymphadenectomy for primary melanomas on the ear, face, and anterior scalp should be considered for parotidectomy. The use of selective limited neck dissection for elective regional lymphadenectomy appears justified based on the location of the primary site. In patients undergoing therapeutic neck dissection, a complete neck dissection should be performed due to the unpredictable distribution of lymph node metastases to the cervical lymph nodes.

Female↗
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↗
PubMed1991

Ectopic pregnancy after tubal sterilization.

We report 13 cases of ectopic pregnancy following tubal ligation out of 287 ectopic pregnancies seen during a six year period (1984-1989). These findings suggest that tubal sterilization does not invariably confer infertility. Ectopic pregnancy must not be disregarded in women who have undergone tubal ligation, especially if two or more years have elapsed since the sterilization.

Adult↗
PubMed1990

The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity.

A retrospective review of the records of 501 previously untreated patients from January 1, 1965 through December 31, 1986 with squamous cell carcinoma of the oral cavity was undertaken to ascertain the prevalence of ipsilateral neck node metastases (NM) by neck level. The 501 patients underwent 516 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection (ED) in the N0 neck, immediate therapeutic dissection (ITD) in the N+ neck, and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+. Pathologically identified NM occurred 34% of the time in ED, 69% in ITD and 90% in STD. The sensitivity, specificity, and overall accuracy of the clinical exam was 70%, 65%, and 68%, respectively. Detailed analysis was performed for each group based on the primary site. This revealed a prevalence of NM in level IV of 3% (five of 167) for ED versus 17% (49/296) for ITD + STD (P less than 0.001). Tongue, retromolar trigone, and cheek did not have NM in level V in any group. The prevalence of NM in level V for floor of mouth or gum primaries was less than 1% (one of 109) in ED versus 6% (ten of 167) in ITD + STD (P less than 0.03). These data support the trend toward selective limited neck dissection in both N0 and N+ patients. Further, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection.

Adolescent↗
PubMed1990

Patterns of cervical node metastases from squamous carcinoma of the larynx.

We undertook a retrospective review of 247 previously untreated consecutive patients from 1965 to 1986 with primary squamous cell carcinoma of the supraglottic or glottic larynx to ascertain the prevalence of neck node metastases by neck level. The 247 patients underwent a total of 262 radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the NO neck; immediate therapeutic dissection in the N+ neck; and subsequent therapeutic dissection in the NO neck that over time converted clinically to N+. Detailed analysis revealed a predominance of neck node metastases in levels II, III, and IV for all clinical neck groups. Level V was rarely involved, but always in conjunction with neck node metastases in levels II, III, or IV (ie, N2 disease). Level I was rarely involved; involvement occurred with neck node metastases in levels II, III, or IV 75% of the time. Level I involvement correlated with T3 or T4 primary tumors exhibiting histologic extralaryngeal spread. These data support the trend toward selective limited neck dissection in both NO and N1 patients.

Carcinoma, Squamous Cell↗
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

Complications of the pectoralis major myocutaneous flap in head and neck reconstruction.

A retrospective review of the complications in 211 patients undergoing pectoralis major myocutaneous flap reconstruction is presented. The flap was used for mucosal lining of the oral cavity or oropharynx in 109 patients, for pharyngoesophageal reconstruction in 44, for skin coverage in 47, and for other locations in 14 patients. Flap-related complications developed in 63% of the patients. These included flap necrosis, suture line dehiscence, fistula formation, infection, and hematoma. Analysis of risk factors for the development of flap complications showed the following factors to be significant: age over 70; female gender; nomographic overweight; albumin less than 4 g/dL; use of the flap in reconstruction of the oral cavity after major glossectomy; and presence of other systemic diseases. The median length of hospitalization for those developing complications was 33 days compared with 16 days for those who did not develop any complications. Thirty-five (26%) of the 135 patients developing complications required reoperation and only 2 among these required a second flap. Similarly, only 13 of the 61 patients who developed fistulas required surgical closure.

Adolescent↗
PubMed1990

Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract.

A consecutive series of 1,081 previously untreated patients undergoing 1,119 radical neck dissections (RNDs) for squamous carcinoma of the head and neck was reviewed to study the patterns of nodal metastases. Primary tumors were located in the oral cavity in 501 patients, in the oropharynx in 207 patients, in the hypopharynx in 126 patients, and in the larynx in 247 patients. Lymph node metastases were confirmed histologically in 82% of 776 therapeutic neck dissections, and micrometastases were discovered in 33% of 343 elective RNDs. Lymph node groups in the neck were described by levels (I to V). Predominance of certain levels was seen for each primary site. Levels I, II, and III were at highest risk for metastasis from cancer of the oral cavity, and levels II, III, and IV were at highest risk for metastasis from carcinomas of the oropharynx, hypopharynx, and larynx. Supramohyoid neck dissection (clearing levels I, II, and III) for NO patients with primary squamous cell carcinomas of the oral cavity and anterolateral neck dissection (clearing levels II, III, and IV) for NO patients with primary squamous cell carcinomas of the oropharynx, hypopharynx, and larynx are recommended.

Adolescent↗
PubMed1990

Cervical lymph node metastases--diagnostic, therapeutic, and prognostic implications.

Patients with carcinoma of the upper aerodigestive tract presenting with cervical lymph node metastasis carry a poorer prognosis compared to those in whom the regional lymph nodes are uninvolved. Prognosis worsens as the volume of metastatic cancer in the cervical lymph nodes increases. While the classical treatment for these metastases has been a radical neck dissection, this operation produces significant esthetic and functional morbidity. Radiation therapy alone offers poor results when bulky disease in the neck is present. Fortunately, the combination of surgery and radiation therapy offers significant advantages, not only in terms of reduction of morbidity, but improvement of disease control. The author discusses the current debate over the extent of neck dissection and the advantages of pre- and post-operative radiation.

Humans↗
PubMed1979

Carcinoma of the lip.

(1) Carcinoma of the lip occurs predominantly in men in their seventh and eighth decades of life. (2) Epidermoid carcinoma is the most common malignant lip tumor. (3) Metastases to cervical lymph nodes are uncommon. (4) Elective neck dissection is not indicated. (5) Therapeutic radical neck dissection can benefit the patient in the presence of proved suprahyoid lymph node metastases. (6) The five year survival rate for epidermoid carcinoma of the lip is higher than the rate for epidermoid carcinoma of other sites in the oral cavity or pharynx. (7) Local recurrence does not correlate with the size of the primary tumor. (8) Initial treatment failures can frequently be salvaged surgically.

Aged↗
PubMed1978

Benign solitary lung lesions in patients with cancer.

The appearance of a lung opacity on a chest film of a patient with known cancer may present a diagnostic dilemma. From 1940 through 1975, over 800 patients with this problem underwent thoracotomy for confirmation of diagnosis. In some 500 of these patients, the lesion proved to be primary cancer of the lung; in 196 they were solitary metastases and in 11 patients the lesions were benign. There were six additional patients in whom multiple opacities were found which proved to be benign conditions. An approach to the investigation, diagnosis, and surgical management of such solitary pulmonary lesions is presented. It is emphasized that the appearance of a solitary pulmonary shadow in a patient with a history of cancer should not be assumed to be a metastasis. Appropriate investigations should be performed without delay in an effort to define the nature of the lesion by microscopic analysis permitting definitive therapy to be administered and a more accurate prognosis provided.

Cysts↗