PubMed Health⌕ Search

Biomedical subjects

P Gullane

Publications and source records attributed to P Gullane.

At least 19 recordsLinked to original sources
PubMed2003

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton.

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.

Aged↗
PubMed2001

The benefits and pitfalls of ipsilateral radiotherapy in carcinoma of the tonsillar region.

PURPOSE: Ipsilateral techniques designed to restrict treatment to the primary tumor and neck on the same side have been used in selected cases of cases of carcinoma of the tonsillar region at our institution for many years. The primary purpose of this study is to evaluate the risk of failure in the opposite neck in cases selected for unilateral radiotherapy over a 21-year period. METHODS AND MATERIALS: Ipsilateral radiotherapy techniques were used in 228 of 642 patients with carcinoma of the tonsillar region from 1970 to 1991. Local control, regional lymph-node control (including contralateral failure), and survival were calculated for different degrees of tumor extent treated with these techniques. RESULTS: Mean follow-up was 7 years. Cases tended to be T1 and T2, with N0 disease. The 3-year actuarial local control rate was 77% and cause-specific survival was 76%. Opposite neck failure was seen in 8 patients (crude rate of 3.5%). In the earlier period of the study, primary coverage was problematic in a proportion of cases and resulted in higher rates of local failure. CONCLUSION: Appropriately selected cases of carcinoma of the tonsil show minimal risk of failure in the opposite neck with ipsilateral techniques. Patients should undergo computed tomography planning to ensure adequate target coverage.

Adult↗
PubMed2001

High frequency of microsatellite instability in young patients with head-and-neck squamous-cell carcinoma: lack of involvement of the mismatch repair genes hMLH1 AND hMSH2.

The most prevalent risk factors in the development of head-and-neck squamous-cell carcinoma (HNSCC) are excessive tobacco and alcohol consumption. In young patients with HNSCC, these risk factors are often absent. Our purpose was to investigate the risk factors, microsatellite instability (MSI) changes and status of the mismatch repair genes hMLH1 and hMSH2 in a cohort of young patients with HNSCC. Fifty-seven HNSCC tumors were examined for the presence of MSI at 16 microsatellite sites using PCR. In the young patient group (24 cases, < or = 44 years old), 100% of tumors had MSI at 1 site at least and 88% had MSI at 2 or more loci. In older patients (33 cases, > or = 45 years), MSI at 1 or more sites was found in 61% of tumors (young vs. old, p = 0.0003) and instability at 2 or more sites was found in 36% of tumors (young vs. old, p = 0.0001). The involvement of the mismatch repair genes was investigated by examining promoter methylation, exon mutation and gene expression of hMLH1 and hMSH2. All results were negative, indicating that inactivation of these 2 genes does not play a role in the development of MSI in tumors from this patient group. Furthermore, the young patient group had a significantly lower incidence of smoking (46% young, 88% old; p = 0.001) and alcohol consumption (33% young, 67% old; p = 0.0169), emphasizing the probable importance of other environmental and/or genetic factors in the development of their disease.

Adaptor Proteins, Signal Transducing↗
PubMed2001

Abnormalities of the ARF-p53 pathway in oral squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is associated with heavy smoking and drinking, but the molecular pathway of tumorigenesis is not understood. Inactivation of the p53 tumor suppressor gene is likely to play an important role since p53 mutation is frequently found. The p14ARF tumor suppressor gene is functionally linked to p53, because it is activated by oncogenes and causes p53-dependent growth arrest and apoptosis. The relationship between p14ARF and p53 inactivation has not been described for OSCC. We studied 25 cases of OSCC to determine if there is an inverse correlation between p53 mutation and p14ARF inactivation by homozygous deletion or mutation. p53 mutation was found in 16 of 25 cases (64%), including nine missense and seven truncating mutations. While all cases with missense mutations showed abnormal accumulation of p53 protein, there were also five carcinomas which showed increased p53 staining in the absence of mutation. p14ARF deletion or mutation was found in eight cases (32%), six of which also demonstrated p53 mutation. Our findings indicate that OSCC often involves loss of both p14ARF and p53 function and suggest that inactivation of these two tumor suppressor genes are not functionally equivalent during tumorigenesis.

Adult↗
PubMed2001

Outcome of curative management of malignant tumours of the parotid gland.

PURPOSE: The optimal management of malignant parotid gland tumours remains to be defined precisely. Specifically, a further understanding of the tumour features that influence treatment outcome is needed. MATERIALS AND METHODS: A retrospective review was conducted on 184 patients who were registered at the Princess Margaret Hospital with a diagnosis of a primary malignant parotid gland tumour. RESULTS: All patients were initially managed with a parotidectomy, and postoperative x-ray radiation therapy (XRT) was administered to 159 patients. The actuarial 5-year cause-specific survival and locoregional control rates were 76% and 81%, respectively. The survival and locoregional control rates for patients treated with surgery alone versus surgery plus postoperative XRT were not statistically different. A multiple regression analysis identified only age and tumour category to be independently significant prognostic factors for both survival and locoregional control. CONCLUSION: We would recommend that patients with malignant parotid gland tumours be managed with parotidectomy, followed by postoperative XRT for tumours with residual disease, aggressive histology, and/or positive lymph nodes.

Adolescent↗
PubMed2001

Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital.

The pectoralis major myocutaneous pedicled flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps for head and neck reconstruction, and several series of PMMPF procedures have been reported in the literature. Between 1983 and 1997, 244 reconstruction procedures using the PMMPF were carried out on 229 patients by the Otolaryngology-Head and Neck Surgery Department at the Toronto General Hospital. Pectoralis major myocutaneous pedicled flap reconstructions were completed after ablation of cancer in the following sites: oral cavity, 113; oropharynx/hypopharynx, 50; larynx, 59; and other, 21. The locations of reconstruction were oral cavity, 121; pharynx, 74; and neck or face, 50. Of the 244 cases, 202 were carried out as primary reconstructive procedures, whereas 42 flaps were "salvage" procedures (reconstruction after fistula, flap failure, osteoradionecrosis, and internal jugular vein rupture). Eighty-five cases (35%) were affected by complications such as dehiscence, infection, hematoma, seroma, partial flap failure, total flap failure, fistula, and donor site complications. The duration of admission for cases with complications was longer, and higher complication rates were associated with salvage procedures, number of comorbidities, number of pack-years of cigarettes smoked, and oral cavity reconstructions. This series of consecutive PMMPF procedures is the largest reported to date.

Canada↗
PubMed2000

The role of panendoscopy in the management of mucosal head and neck malignancy-a prospective evaluation.

BACKGROUND: It is common practice for a panendoscopy to be included in the evaluation of patients with mucosal head and neck malignancies. Whether this intervention is efficient or cost-effective has not been established in our patient population. METHODS: Two hundred twenty-four patients with squamous cell carcinoma involving the oral cavity, pharynx, larynx, or neck were evaluated prospectively with panendoscopy and chest x-ray with or without barium swallow. One hundred fifty-four patients had newly diagnosed tumors and 70 were previously diagnosed and currently undergoing symptom-directed investigations. RESULTS: The incidence of synchronous primary tumors was 2.6% (4 of 154); pulmonary, 1.3%; head and neck mucosa, 1.3%; and esophageal, 0%. There was no associated morbidity. CONCLUSIONS: Although there was no associated morbidity, our head and neck oncology group is of the opinion that routine panendoscopy is not warranted. Specific indications for this investigation are discussed.

Barium Sulfate↗
PubMed2000

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases.

BACKGROUND AND PURPOSE: Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution. MATERIALS AND METHODS: A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110). RESULTS: The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival. CONCLUSIONS: This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

Adult↗
PubMed1999

Use of alternative medicine among patients with head and neck cancer.

OBJECTIVES: To determine the prevalence of alternative medicine use in the population with head and neck cancer and correlate with demographics and tumor characteristics. DESIGN: Cross-sectional survey study. SETTING: Two tertiary cancer centers. PATIENTS: Two hundred consecutive outpatients with consecutive head and neck cancer. INTERVENTIONS: A 10- to 25-minute patient interview administered by primary investigator. MAIN OUTCOME MEASURES: Demographic markers (sex, age, education, household income, marital status, ethnic background, and geographic location); tumor characteristics (tumor site, pathology, staging, time since diagnosis, and incidence of recurrence); conventional mode of treatment; attitudes regarding alternative medicine, source of exposure to alternative medicine, therapeutic rationale, treatment efficacy, sources of information, and discussions with physicians about alternative medicine. RESULTS: Seventy-seven (38.5%) of 200 patients had used alternative medicine for some purpose, and 45 (22.5%) of 200 did so for head and neck cancer. Increased use of alternative medicine occurred among patients of younger age, having a postsecondary education, higher personal income, and Indo-Asian extraction. Of those patients using alternative anticancer therapy, increased use was noted among patients with tumors of the nasopharynx, nonsquamous cell carcinoma pathology, and recurrent disease. Conventional mode of treatment had no association with alternative medicine use. Physicians were believed to be the most knowledgeable about alternative medicine, while the usual proponents of alternative medicine were identified least frequently. CONCLUSIONS: Alternative cancer therapy use among patients with head and neck cancer was 22.5%, with increased use in younger, affluent, better educated patients, and those of Indo-Asian extraction. Patients view physicians as being knowledgeable about alternative medicine. Otolaryngologists should inform themselves about alternative medicine to counsel patients more effectively.

Adult↗
PubMed1999

The local management of soft tissue sarcoma.

Soft tissue sarcomas (STS) are rare tumors arising from the connective tissues. STS can arise at any anatomic site, can demonstrate varied behavior and prognosis, and therefore present a formidable challenge in management. The local treatment of STS demands technical complexity in the application of diagnostic tools, including pathology and imaging, as well as treatment approaches, including surgical ablation and reconstruction, radiotherapy, and, in defined cases, chemotherapy. The understanding of the management of these lesions is profoundly dependent on the multidisciplinary setting, where experience has been gained and skills are available to increase the likelihood of a successful result. Several proven options are available for optimal local management, and the choice of approach depends on the prevailing practice and resource profile of the treating center. With modern approaches, the local control rate can be expected to be at least 90% for extremity lesions, which constitute the most common STS. The experience in other anatomic sites is less favorable as a result of a combination of late diagnosis, technically difficult access sites, and possibly less familiarity with these less common presentations. The disappointing results make it all the more important for patients to be referred to a multidisciplinary setting with experience in sarcoma management to maximize the chance of successful local outcome.

Amputation, Surgical↗
PubMed1999

Effects of medialization laryngoplasty on airway resistance: a pilot study.

OBJECTIVE: To investigate the effects of medialization laryngoplasty on laryngeal airway resistance at various clinically relevant flow rates. STUDY DESIGN: This study was conducted using a total of 13 laboratory experiments. Two of the experiments were used to validate the cadaveric model employed. Eleven experiments were used to quantify airway resistance relative to increasing medialization laryngoplasty stent size. METHODS: With autopsy consent the authors obtained 13 consecutive and anatomically complete larynges for experimentation. A thyrotomy window measuring 8 x 6 mm was made on the left side of the thyroid cartilage. A #4 laryngeal mask was secured to the pharyngeal airway with sutures. Eleven experiments were conducted at the same flow rates using increasingly larger stents from 1 mm to 11 mm in size. Using the Bernoulli equation, the pressure measured at the proximal end of the laryngeal mask is representative of the pressure drop across the airway. The experimental model was validated in two experiments using flow rates between 5 and 50 L/min and stents measured at 5, 10, 15, and 20 mm. RESULTS: Average results from the 11 experiments indicate that at increasing levels of medialization, from 0 to 11 mm, there is essentially the same pressure drop across the larynx at a given flow rate. CONCLUSION: At physiologic airflow rates in a cadaveric model, medialization laryngoplasty implants of 11 mm or less seem to have no obvious effect on airway resistance.

Aged↗
PubMed1998

Ethmoid sinus cancer: twenty-nine cases managed with primary radiation therapy.

PURPOSE: To describe the outcome of patients with carcinoma of the ethmoid sinus managed with a policy of primary radiation therapy with surgery for salvage of persistent or progressive disease. METHODS AND MATERIALS: A retrospective chart review was undertaken of 29 patients with the diagnosis of carcinoma of the ethmoid complex who underwent treatment in the period between January 1976 and December 1994 at the Princess Margaret Hospital. Analysis was confined to those patients with epithelial invasive histology (squamous carcinoma, adenocarcinoma, or undifferentiated carcinoma) managed with curative intent with primary radiation therapy. The median patient age was 62, with a median follow-up time of 4 years. Staging was assigned according to a modification of the UICC 1997 system with 19 (66%) of patients presenting with T4 category tumors. The most common radiation dose regimes were 60 Gy in 30 daily fractions over 6 weeks, or 50 Gy in 20 daily fractions over 4 weeks. Outcome was analyzed with respect to overall survival, cause-specific survival, and local progression-free survival. The influence of a variety of clinical and therapeutic factors on outcome is discussed, the patterns of disease failure are described, and the rationale for this treatment approach is outlined. RESULTS: The 5-year rates of overall survival, cause-specific survival, and local progression-free survival were 39%, 58%, and 41%, respectively. A total of 18 of 29 patients died during the period of review. Of these, 12 deaths were due to ethmoid cancer, one was due to a second primary lung cancer, and five were attributed to nononcologic causes. No patients died due to treatment-related toxicity. Increasing T category predicted for worse outcome on univariate analysis. Local progression was the major cause of treatment failure and was documented in 15 of 29 patients treated (52%). Six patients were offered salvage surgery for local progression, of whom two remained disease free at 15 and 17 months follow-up. CONCLUSIONS: Outcome of patients with ethmoid cancer managed with primary radiation therapy with surgery for salvage is comparable to that achieved with planned combined modality approaches. Nevertheless, outcome remains poor and is dependent on the local extent of tumor, with 40-50% of patients eventually succumbing to disease.

Adenocarcinoma↗
PubMed1998

Reoperative parathyroidectomy in the era of localization technology.

BACKGROUND: Recurrent and/or persistent hyperparathyroidism (HPT) is an uncommon disease. Relatively few cases are seen by any one center or surgeon. Most of the prior reviews of this problem were done in the era prior to potentially accurate magnetic resonsance imaging (MRI) and sestimibi scan localization and do not reflect current preoperative localization technology. METHODS: All cases of recurrent or persistent parathyroidectomy seen in our institution between 1992 and 1996 were reviewed retrospectively to assess the predictive value of preoperative MRI, selective venous sampling, sestimibi scanning, ultrasound examination, and computerized tomography (CT) scanning. The preoperative localization studies were compared with the findings at operation, the pathology report, and the patient's long-term calcium status. RESULTS: Twenty-eight patients were operated upon at our institution for recurrent or persistent HPT during this time interval. The final pathology turned out to be: adenoma, 24; hyperplasia, 2; carcinoma, 2. The site at which the reoperative pathology was found was in the neck in 22 patients and intrathoracic requiring sternotomy in 6. The long-term outcome, i.e., serum calcium level at > 6 months postoperatively, was normocalcemia in 22 of 28 (85%), persistent hypocalcemia in 2 of 28, and persistent hypercalcemia in 2 of 28. Some combination of MRI, sestimibi, selective venous sampling, ultrasound, and CT scan was performed on all patients preoperatively. Preoperative MRI scans were performed on 26 of 28 patients. They correctly localized the side and site of the pathology in only 12, yielding a sensitivity of 66%. There were, however, no false positives; therefore, the positive predictive value of this test was 100%. Selective venous sampling was carried out on 26 of 28 patients and correctly localized in only 8 (sensitivity, 50%). Again, there were no false positives, yielding a positive predictive value of 100%. Sestimibi scanning was performed in 16 of 28, localizing in 8 (sensitivity, 50%). The positive predictive value of this test was 80%. Ultrasound was performed in 26 of 28 patients and localized in only 3, yielding a sensitivity of 17%, with a positive predictive value of 75%. Computerized tomographic scan was performed preoperatively only when all other investigations turned out to have been nonlocalizing and was therefore done in only four patients, one of whom had a positive CT scan showing an intrathoracic, intrapericardial adenoma. CONCLUSIONS: These data demonstrate that despite the availability of what are putatively accurate preoperative localizing tests for previously unoperated cases, no one localizing test is particularly sensitive in reoperative parathyroid surgery. Magnetic resonance imaging and selective venous sampling, however, are complementary and when positive do accurately predict the site of the persistent/recurrent parathyroid pathology. Use of these preoperative localizing studies resulted in a successful outcome, i.e., normocalcemia or hypocalcemia in 93% of patients operated on.

Adult↗
PubMed1997

Surgical salvage after radiotherapy for advanced laryngopharyngeal carcinoma.

OBJECTIVE: To comment on the use of surgery after the failure of radiotherapy in patients with advanced laryngeal, oropharyngeal, and hypopharyngeal carcinomas. DESIGN: Randomized, controlled, clinical trial, with a mean follow-up period of 3.1 years. SETTING: The Princess Margaret Hospital, Toronto, Ontario. PATIENTS: Patients with advanced laryngopharyngeal carcinoma (T3 or T4 or N+). INTERVENTION: Three hundred thirty-six patients who met the eligibility criteria were enrolled in a randomized, controlled, clinical trial and treated with primary radiotherapy using either the standard fractionation regimen or the hyperfractionation regimen. One hundred eight patients with recurrent disease underwent salvage surgery and were observed prospectively, with careful documentation of surgical and tumor data, complications, recurrences, and survival. MAIN OUTCOME MEASURES: Surgical complication rate and survival. RESULTS: Of the 108 patients who underwent surgery, 29 (27%) had complications. One third of these had multiple complications. There was no statistical difference between the surgical complication rates of the 2 radiotherapy groups (16 patients [28%] in the standard fractionation radiotherapy group and 13 [25%] in the hyperfractionation radiotherapy group). Survival after surgery was statistically correlated with the TNM system for the stage of the recurrent tumor, the pathologic nodal status, and the surgical margin status. The overall 3-year survival rate, which was calculated from the date of surgery, for the group of patients who underwent surgery was 22%. CONCLUSIONS: In this patient population, the hyperfractionation regimen was not associated with a higher surgical complication rate. Using the policy of primary radiotherapy and reserving surgery for the management of failures of radiotherapy, 140 patients (71%) at highest risk (laryngeal and hypopharyngeal primary tumor sites) retained an intact larynx until the end of the study or death. Since it is the stage of the recurrent tumor that correlates with survival rather than the stage of the tumor at initial presentation, we suggest that tumors be restaged at the time of recurrence.

Adult↗
PubMed1997

A central giant cell granuloma influenced by pregnancy.

A case of a 17-year-old patient with exacerbation of a central giant cell granuloma of the mandible during pregnancy is reported. The possible relationship of the giant cell lesion to a pre-existing fibrous dysplasia is considered although there was lack of histological evidence.

Adolescent↗
PubMed1997

Leg morbidity and function following fibular free flap harvest.

Over a period of 3 years, 50 consecutive free fibular flaps for mandibular reconstruction were performed on 47 patients. In 38 patients (81%) a skin paddle was included with the flap to provide either mucosal lining or skin cover; in 9 patients (19%) bone alone was used. Thirty-one patients (66%) required a skin graft to close the donor defect in the leg. Donor leg morbidity and function were determined by patient questionnaire and by physical examination. Forty-one donor sites in 40 patients were available for long-term follow-up. The follow-up ranged from 4 to 39 months with an average of 17 months. Immediate postoperative infection occurred in the donor site of 1 patient (2%) and required additional surgery. There was no other immediate donor site complications when closure required skin grafting. Eleven patients (27%) had late donor site morbidity, consisting of motor weakness of the great toe in 5 patients, ankle instability and/or stiffness in 3 patients, donor site pain in 1 patient, and edema in 2 patients. All complications were graded as mild in severity by the patient and by the examiner. In this series, although most donor site defects required skin grafting, short- and long-term morbidity was minimal. After a short rehabilitation period, all patients were fully able to engage in all daily and recreational activities.

Adult↗
PubMed1997

Outcome and analysis of the surgical management of esthesioneuroblastoma.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of combined radical surgical resection and radiotherapy for the treatment of esthesioneuroblastoma, a rare malignant neoplasm accounting for 1 to 5% of malignant neoplasms of the nasal cavity. METHOD: A 10-year review of 12 patients treated at our institution suggests that primary treatment consisting of a combined otolaryngologic/neurosurgical craniofacial approach results in good local control with relatively low morbidity and complication. Patients tend to present with advanced stage disease because of the nonspecific presenting signs and symptoms. Eighty-three percent of the patients were treated with combined surgery and radiation. RESULTS: Seventy-five percent of the patients are free of disease with an average follow-up time of 54 months. Based on our experience in anterior skull base surgery (zone I), we strongly advocate the pericranial flap for dural reconstruction. Postoperative complications occurred in 25% of the cases with no postoperative deaths. CONCLUSION: Failure analysis suggests that radical surgical resection combined with radiotherapy provides the best chance of disease control.

Adolescent↗