Biomedical subjects

Jonathan R Clark

Publications and source records attributed to Jonathan R Clark.

10 recordsLinked to original sources

PubMed2007

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube.

BACKGROUND: This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube. METHODS: The charts of 14 patients were reviewed. All patients who had reconstruction of a pharyngoesophageal defect using an anterolateral thigh flap with a salivary bypass tube between 2001 and 2005 were included. RESULTS: There were 10 men and 4 women (mean age, 61 years). There were no fistulae reported, and the stricture rate was 14%. Eleven patients achieved oral diet sufficient to have the gastrostomy or jejunal tube removed. The patients who had tracheoesophageal puncture for voice developed functional speech. There were no flap losses. However, problems with salivary tube migration in the early cases have led to technique refinement. CONCLUSIONS: The low complication rates and the excellent functional outcomes make the anterolateral thigh flap in combination with a salivary bypass tube a viable option for reconstruction of these difficult defects.

Aged↗

PubMed2007

Merkel cell carcinoma of the head and neck: is adjuvant radiotherapy necessary?

BACKGROUND: Controversy exists regarding the optimal management of patients with Merkel cell carcinoma. The primary aim of this study was to determine whether combined treatment with surgery and radiotherapy improves outcome in a multi-institutional cohort of patients with Merkel cell carcinoma of the head and neck. The secondary aims were to determine by stage, which patients derive benefit from combined therapy and to identify predictors for survival on multivariable analysis. METHODS: A retrospective analysis of 110 patients with Merkel cell carcinoma of the head and neck was performed. Data were collected from 3 tertiary care institutions (Westmead Hospital, Sydney, Australia; Princess Margaret Hospital, Toronto, Canada; Royal Prince Alfred Hospital, Sydney). There were 78 males and 32 females, median age was 70 years, and mean follow-up of survivors was 2.3 years. Sixty-six patients underwent combined treatment, and 44 patients had either surgery or radiotherapy alone. Analysis by stage was performed using 2 staging systems. RESULTS: Local and regional control at 5 years was 84% and 69%, respectively. Combined treatment improved both local (p = .009) and regional control (p = .006). Overall and disease-specific survival at 5 years was 49% and 62%, respectively. Combined treatment was associated with significantly better disease-free survival on univariable analysis (p = .013) When analyzed by stage, patients with stage IIb (primary >1 cm, node negative) disease who underwent combined treatment had improved disease-free (p = .005) and disease-specific survival (p = .035). Predictors of survival on multivariable analysis were age >70 years (HR 6.19, p < .001), primary tumor size >1 cm (HR 7.55, p < .001), number of nodal metastases divided into none, 2 (HR 3.71 per stratum, p < .001). When analyzed with age and disease stage, treatment modality trended toward significance as a predictor of disease-specific (p = .081) and overall survival (p = .076). Disease stage was the most powerful independent predictor on Cox regression (HR 5.43 per stratum, p < .001). CONCLUSIONS: Merkel cell carcinoma is an aggressive cutaneous malignancy. Age and disease stage are the most important predictors of survival. Combined surgery and radiotherapy improves both locoregional control and disease-free survival. Patients with stage II disease appear to derive the greatest benefit from adjuvant radiotherapy, including improved disease specific survival.

Adult↗

PubMed2006

Risk of malignancy in Filipinos with thyroid nodules--a matched pair analysis.

BACKGROUND: Ethnicity is an infrequently cited risk factor for thyroid cancer. This study aims to determine whether patients of Filipino origin assessed at a tertiary referral center are at increased risk of thyroid cancer and to quantify that risk. METHODS: This is a retrospective analysis of 72 Filipino patients with thyroid nodules undergoing thyroidectomy individually matched to 72 controls according to demographics, risk factors, and pre-referral investigations. RESULTS: Thyroid cancer was found in 50 (69.4%) Filipino patients compared with 28 (38.9%) controls. Odds ratio for malignancy in Filipinos was 3.57 (95% confidence interval, 1.79-7.12). Pathologic characteristics of thyroid cancer were not significantly different in the two groups. The median follow-up for Filipino patients was 14.1 months (range, 1.4 months-19.7 years). Recurrence occurred in four Filipino patients, and one patient with anaplastic thyroid cancer died of the disease. CONCLUSIONS: Filipino patients with thyroid nodules are at significantly increased risk of thyroid cancer compared with matched controls, and hence the index of suspicion for malignancy should be high when evaluating these patients.

Adult↗

PubMed2006

Primary and salvage (hypo)pharyngectomy: Analysis and outcome.

BACKGROUND: Surgery for squamous cell carcinoma (SCC) arising or extending to the hypopharynx is generally reserved for advanced disease or salvage. The prognosis of patients requiring pharyngectomy is poor, and the perioperative morbidity is significant. The aim of the present study is to describe the disease-related and treatment-related outcomes of patients undergoing primary and salvage pharyngectomy for cancer of the hypopharynx and larynx over a 10-year period from a single institution. METHODS: We retrospectively reviewed 138 partial and circumferential pharyngectomies performed at a tertiary referral center between 1992 and 2002. There were 31 females and 107 males. The median age was 62 years (range, 27-81 years), and mean follow-up was 3.6 years. Salvage pharyngectomy for radiation failure was performed in 72 patients (52%), and in 66 patients (48%) pharyngectomy was performed as the primary treatment. RESULTS: The 5-year overall survival rate after salvage pharyngectomy was 31% and after primary pharyngectomy was 38%. The 5-year disease-specific survival (DSS) for salvage was 40% and after primary surgery was 45%. The 5-year local and regional control rates for salvage pharyngectomy were 71% and 70%, respectively, and for primary pharyngectomy were 79% and 67%, respectively. The perioperative mortality rate was 3.6%, and the combined morbidity rate was 70%. Postoperative hypocalcemia developed in 44% of patients, a pharyngocutaneous fistula developed in 31% of patients, and the long-term stricture rate was 15%. Variables adversely affecting DSS on univariate analysis were nodal metastases (p = .044), extracapsular spread (ECS) (p = .006), poorly differentiated tumors (p = .015), lymphovascular invasion (p = .042), and positive tumor margins (p = .026). ECS (p = .023) was the only independent prognostic variable on multivariable analysis; however, there was a trend toward significance for nodal metastases (p = .064) and tumor differentiation (p = .079). CONCLUSION: This study demonstrates that both salvage pharyngectomy and primary surgery for advanced disease are viable options with high locoregional control. However, this represents a high-risk group in terms of both operative morbidity and survival. Patients with nodal metastases, ECS, and poorly differentiated tumors are likely to succumb to their disease and should be selected for adjuvant therapy when possible.

Adult↗

PubMed2006

Established prognostic variables in N0 oral carcinoma.

OBJECTIVES: To examine the utility of established prognostic variables in patients with oral carcinoma and a clinically negative neck. STUDY DESIGN: Retrospective cohort study. METHODS: The distribution of occult metastases was assessed in 105 oral cancer patients with no clinical or radiological evidence of nodal disease. Predictors for nodal metastases, recurrence, and survival were examined. RESULTS: Occult neck metastases occurred in 34 percent of patients. Tumor thickness was the only independent predictor of occult metastases, with thin (</=5 mm) and thick (>5 mm) tumors having a 10 percent and 46 percent incidence of regional disease, respectively (P = 0.001). Nodal metastases and perineural invasion were significant predictors of survival. CONCLUSION: Patients with thick tumors are at high risk of nodal metastases and are likely to benefit from elective neck dissection. Comprehensive neck dissection should be considered in advanced primary disease. SIGNIFICANCE: Tumor thickness is the most important predictor of occult regional metastases in oral cavity cancer.

Cohort Studies↗

PubMed2006

Morbidity after flap reconstruction of hypopharyngeal defects.

OBJECTIVES: Laryngopharyngeal reconstruction continues to challenge in terms of operative morbidity and optimal functional results. The primary aim of this study is to determine whether complications can be predicted on the basis of reconstruction in patients undergoing pharyngectomy for tumors involving the hypopharynx. In addition, we detail a reconstructive algorithm for management of partial and total laryngopharyngectomy defects. METHOD: A retrospective review was performed of 153 patients undergoing flap reconstruction for 85 partial and 68 circumferential pharyngectomies at a single institution over a 10-year period. There were 118 males and 35 females, the median age was 62 years, and mean follow up was 3.1 years. Pharyngectomy was performed for recurrence after radiotherapy in 80 patients and as primary surgery in 73. Free flap reconstruction was used in 42%, with 30 jejunal, 15 radial forearm, 11 anterolateral thigh, five rectus abdominis, and three gastro-omental flaps. Gastric transposition and pectoralis major pedicle flap was used in 14% and 44% of patients, respectively. Morbidity was analyzed according to extent of defect, regional versus free flap, enteric versus fasciocutaneous free flap reconstruction, and the effect of laparotomy. RESULTS: The total operative morbidity and mortality rate was 71% and 3%, respectively. The most common complications were hypocalcemia in 45%, pharyngocutaneous fistula in 33%, and wound complications in 25%. The late complication and stricture rate was 26% and 15%, respectively. On univariate analysis, circumferential defects were associated with increased total (P=.046) and flap-related morbidity (P=.037), hypocalcemia (P<.001), late complications (P=.003), and stricture (P=.009). Gastric transposition had increased total (P=.007), flap-related (P=.035), late complications (P=.034), and hypocalcemia (P=.001). Pharyngocutaneous fistula was increased in patients undergoing salvage pharyngectomy for radiation failure (P=.048) compared with primary surgery. On multivariate analysis, gastric transposition independently predicted for wound complications (P=.014) and fistula (P=.012). Circumferential defects predicted for flap-related morbidity (P=.030), hypocalcemia (P=.017), and late complications (P=.042). Tracheoesophageal speech was the method of voice restoration in 44% of patients. Oral diet was achieved in 93% of patients; however, 16% required gastrostomy tube feeds for either total or supplemental nutrition. CONCLUSION: The operative morbidity associated with pharyngeal reconstruction is substantial in terms of early and late complications. We were able to predict morbidity by defect extent and reconstruction type and initial treatment modality. Swallowing function is acceptable; however, less than half of the patients undergoing pharyngectomy had tracheoesophageal puncture voice restoration.

Adult↗

PubMed2006

Sublingual gland resection in squamous cell carcinoma of the floor of mouth: is it necessary?

OBJECTIVES: Little evidence exists to guide surgeons in the management of the sublingual glands (SLG) not macroscopically involved by squamous cell carcinoma of the floor of mouth and oral tongue. This study aims to determine the frequency with which the SLG is invaded, to identify variables predicting for SLG invasion and the morbidity associated with it's resection in entirety. STUDY DESIGN: Retrospective cohort study. METHODS: A review of 164 patients treated for oral cavity cancer at a tertiary institution with a large volume of head and neck malignancy was performed. Demographic data, rates of surgical complications and follow up information was recorded. Pathologic review of resected material in this group yielded 134 specimens in the region of the SLG. A detailed analysis of 63 specimens in which the SLG was included was carried out. RESULTS: The median age was 58 years, mean follow up was 2.2 years, and there were 44 males and 19 females. Seventeen cases (27%) demonstrated histopathological SLG invasion. In patients with SLG involvement, this was evident at the time of surgery in 15 patients (88%). Microscopic SLG invasion, without macroscopic evidence at surgery, was present in only 4.2% of patients undergoing SLG resection. Clinical and pathological T stage (p = 0.023 and 0.005) and tumor thickness (p = 0.015) predicted for SLG invasion. Total SLG resection significantly increased the post-operative wound complication rate from 14% in patients without SLG resection to 25% (p = 0.05). CONCLUSION: Total SLG resection in early stage and thin squamous cell carcinoma of the floor of mouth and oral tongue provides minimal oncologic benefit and is associated with increased perioperative morbidity due to neck wound complications.

Adult↗

PubMed2005

Interspecialty and intraspecialty differences in the management of thyroid nodular disease and cancer.

INTRODUCTION: The management of thyroid cancer includes multiple medical specialties. Physicians from different specialties may vary in opinion regarding the optimal investigation and treatment of patients. Little data exist evaluating the differences within or between various specialties treating thyroid disease. This study aims to examine responses from a variety of specialty physicians closely involved in the medical or surgical management of thyroid disease to provide evidence as to whether any difference exists. METHODS: A cross-sectional survey of attendees at the 5(th) Biennial Course on the Management of Thyroid Nodular Disease and Cancer was conducted using an anonymous electronic touch pad system. Touch pads were given to 213 attendees who were asked to respond to 44 questions. This study analyzes the responses obtained from 19 selected questions (43%) and compares the results between endocrinologists (n = 48), general surgeons (n = 41), otolaryngologists (n = 61), and pathologists (n = 20). RESULTS: Responses were obtained from 69% of endocrinologists, 68% of general surgeons, 72% of otolaryngologists, and 65% of pathologists. Statistically significant interspecialty differences were observed in 12 (63%) of 19 questions. Each question and a summary of responses from all touch pads were recorded. CONCLUSIONS: Significant differences in the attitudes toward, and presumably the practice of, managing thyroid nodular disease and cancer exist between specialties. An understanding of these differences is helpful when working as a multidisciplinary team to optimize patient care.

Adult↗

PubMed2005

Variables predicting distant metastases in thyroid cancer.

OBJECTIVES: Distant metastases from thyroid cancer are uncommon and have a variable prognosis. We present a series of patients with distant metastases to determine which patients are at risk of developing distant disease and to examine the significant prognostic variables. STUDY DESIGN: Retrospective chart review of 30 patients with distant metastases compared with 633 controls from the Mount Sinai Thyroid Cancer Database and literature review. METHODS: The prevalence of distant metastases was 4.5%, and median follow-up of survivors was 12.7 years. Histologic type was Hurthle cell carcinoma in 3, follicular in 3, papillary in 19, and 5 patients had focal anaplasia either in the primary site or regional metastases. Predictors for distant metastases, locoregional control, and survival were analyzed. RESULTS: Cumulative survival for patients with distant metastases was 49.5% at 10 years and 12.9% at 20 years. Site of metastases was lung in 26, bone in 11 and brain in 1 patient, with 8 patients having multiple sites. The median time to diagnosis of distant metastases was 3 months. Variables that predicted for development of distant disease were male sex, age, size, extrathyroidal extension, regional metastases, and elevated thyroglobulin. Survival in patients without distant disease was significantly better than those with distant metastases (P < .001). Variables that predicted poor outcome in patients with distant metastases on analysis were age greater than 45 years (P = .003) and histologic type of thyroid cancer (P = .009). CONCLUSION: Although patients with thyroid cancer and distant metastases may live prolonged periods with disease, it does significantly impact on patient survival. Age remains an important variable in both predicting for development of distant metastases and also influences long-term survival in patients with existing distant metastases.

Adenocarcinoma, Follicular↗

PubMed2005

Prognostic variables and calcitonin in medullary thyroid cancer.

OBJECTIVES/HYPOTHESIS: Medullary thyroid cancer (MTC) is a nonepithelial, neuroendocrine tumor with a more aggressive clinical behavior than differentiated thyroid cancer. The purpose of the study was to review a single institution's experience with MCT since 1969. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective review of 30 patients treated for MTC at a tertiary care referral center between 1969 and 2000. There were 17 female and 13 male patients, median age at presentation was 38 years, and median follow-up for survivors was 12.4 years. RESULTS: Seventy percent of patients had sporadic MTC, 6.7% had familial MTC, 16.7% had multiple endocrine neoplasia syndrome type IIA, and 6.7% had multiple endocrine neoplasia syndrome type IIB. The cumulative overall survival rates at 5, 10, and 20 years were 97%, 88%, and 84%, respectively; disease-free survival rates were 97%, 74%, and 29%, respectively. Advanced tumor stage (P = .014) and multiple endocrine neoplasia syndrome type IIB predicted decreased disease-specific survival. Variables affecting disease-free survival were post-thyroidectomy calcitonin level (P = .001), vascular invasion (P = .005), perineural invasion (P = .010), extrathyroidal extension (P < .001), and the presence of nodal metastases (P = .001). Locoregional control rates were 83% at 5 years and 70% at 10 years. Vascular invasion (P = .004), extrathyroidal extension (P = .008), and post-thyroidectomy basal calcitonin level (P = .003) predicted locoregional failure. Many patients in the series experienced prolonged survival despite elevated calcitonin levels. CONCLUSION: Long-term disease-free survival is uncommon in MTC, but the study data indicate that the majority of patients with MTC live for prolonged periods, despite biochemical evidence of persistent disease. Adverse pathological features such as extrathyroidal extension and vascular and perineural invasion were predictors of disease recurrence. The use of serum markers in the follow-up of patients with MTC must be interpreted within the clinical context.

Adolescent↗