PubMed Health⌕ Search

Biomedical subjects

R H Spiro

Publications and source records attributed to R H Spiro.

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

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↗
PubMed1991

The importance of clinical staging of minor salivary gland carcinoma.

We reviewed a 45-year experience with 459 patients who had previously untreated minor salivary gland neoplasms, 378 (82%) of which were malignant. Data were adequate for retrospective clinical staging in 353 of the 378 patients with malignant tumors using criteria identical to those for squamous carcinoma in the same sites. Five-, 10-, and 15-year survival rates for the patients with malignant tumors treated after 1966 were 75%, 62%, and 56%, respectively, a significant improvement compared with results reported previously. Multivariate analysis confirms that survival was significantly influenced by the clinical stage and the histologic grade, but the applicability of grading was limited to patients with mucoepidermoid carcinoma or adenocarcinoma. Ten-year overall survival was 83%, 53%, 35%, and 24% for patients with stage I through stage IV, respectively. Results in these patients are similar to those we have recently reported in patients with major salivary gland carcinomas, but we are unable to demonstrate that postoperative radiotherapy improved survival.

Carcinoma↗
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↗
PubMed1990

Malignant tumors of major salivary gland origin. A matched-pair analysis of the role of combined surgery and postoperative radiotherapy.

Between 1966 and 1982, 46 patients with previously untreated malignant tumors of major salivary gland origin received combined surgery and postoperative radiotherapy. They were compared with 46 patients treated with surgery only between 1939 and 1965, who were matched according to prognostic criteria. Radiation doses ranged from 4000 to 7740 cGy (median, 5664 cGy). The 5-year determinate survival rates for patients given combined therapy with stage I and II disease vs patients given surgery only was 81.9% vs 95.8%, while for stages III and IV it was 51.2% vs 9.5%, respectively. Local control for stage III and IV disease in patients given combined therapy vs patients given surgery only at 5 years was 51.3% vs 16.8%. For patients with nodal metastases, 5-year determinate survival for the combined-therapy group vs the surgery-only group was 48.9% vs 18.7%, and the corresponding local-regional control was 69.1% vs 40.2%. The results of this analysis suggest that postoperative radiotherapy significantly improves outcome for patients with stage III and IV disease and for patients with lymph node metastases.

Combined Modality Therapy↗
PubMed1990

Observations on the natural history and treatment of recurrent major salivary gland cancer.

In an attempt to define the natural history and the indications for postoperative radiotherapy (RT) in locally recurrent major salivary gland cancers, we reviewed 78 patients treated between 1965 and 1982. All patients underwent resection of the tumor. Group 1 (N = 38) had complete resection of tumors, with low or intermediate grade histology and without lymph node spread. Group 2 consisted of the remaining 40 patients who had high-risk features (HR) (high grade histology, lymph node metastases, and close or positive margins of resection). Half of the Group 2 patients received radiation therapy. Overall survival was 63% at 5 years, and 35% at 15 years. Survival of Group 1 was 83% at 5 years and 58% at 15 years. Local control for Group 1 was 69% at 5 years, 54% at 15 years, and was size-dependent. Group 2 survival was 40% at 5 years and 29% at 10 years. Local control at 5 and 10 years was 49% and 35%. Our data indicate that surgery alone yielded good local control in patients with small tumors (less than or equal to 3 cm) and no HR features, suggesting that postoperative RT may be unnecessary for these patients. Other patients have suboptimal local control, and although there is a rationale for the use of postoperative radiotherapy, we cannot assess its impact in this retrospective study.

Adolescent↗
PubMed1990

Postoperative radiation therapy for major salivary gland malignancies.

Between 1966 and 1982 there have been 46 patients treated with surgery plus post-operative radiation therapy for malignant tumors of salivary gland origin. The indication(s) for radiotherapy included positive margins (42%), advanced local tumor (37%), positive nodes (33%), or high grade histology (48%). Overall actuarial local control at 5 years was 73%, being 100% for T1, 83% for T2, 80% for T3, and 43% for T4. Actuarial survival at 5 years was 80% for T1, 83% for T2, 60% for T3, and 48% for T4. Patients with positive nodes (N+) did worse than those with negative nodes (No), with locoregional control and survival at 5 years being 58% vs. 83%, (P = 0.025) and 38% vs. 80% (P = less than .01), respectively. We found no need for contralateral neck treatment even for those with positive nodes. Also, to date, none of eight patients with adenoid cystic histology has failed locally, as opposed to three of eight failures in patients treated with surgery alone. We believe that post-operative irradiation provides excellent locoregional control for appropriate patients with malignant tumors of major salivary glands.

Adolescent↗
PubMed1990

Central adenoid cystic carcinoma of the mandible.

A patient with adenoid cystic carcinoma arising centrally within the mandible, a rare location for this malignant salivary gland tumor, is described. Current concepts regarding the etiology, diagnosis, histology, and treatment of central intramandibular salivary gland tumors are discussed and the literature is reviewed.

Adult↗
PubMed1990

Squamous carcinoma of the posterior pharyngeal wall.

We have reviewed a 12-year experience with 295 patients treated for squamous carcinoma of the pharynx in order to focus on 78 patients whose lesions arose in the posterior wall. Surgery was the definitive therapy for the primary tumor in 57 (73%), including 3 treatment groups. Thirty-two patients had limited resections that preserved the larynx, involving local excision (7 patients), anterior pharyngotomy (7 patients), lateral pharyngotomy (6 patients), median labiomandibular glossotomy (6 patients), or median mandibulotomy with paralingual extension (6 patients). The second group consisted of 21 patients with more extensive tumors who required a laryngectomy and complex reconstruction, often with postoperative radiotherapy. Finally, there were four patients who developed metachronous second primaries in the pharynx subsequent to a laryngectomy. All required flap reconstruction. Of the 21 patients whose primary treatment was radiotherapy, 5 had lesions that were implanted after access was provided by a mandibulotomy. Cumulative 5-year survival was 32% and ranged from 44% in those with favorable lesions to 15% in those with extensive tumors. Our experience highlights the variety of treatment approaches available in patients with pharyngeal carcinomas confined to the posterior wall. Surgery in this setting carries acceptable morbidity and yields survival rates that compare favorably with those achieved by external radiation therapy alone. Results in patients with extensive lesions still leave much to be desired, despite radical surgery and aggressive radiotherapy. Innovative brachytherapy techniques using surgery for access deserve further investigation.

Adult↗
PubMed1990

A management plan for tongue base cancer that includes brachytherapy.

For physiologic as well as oncologic reasons, there has been an increasing interest in radiation therapy as the primary treatment of base of tongue carcinoma. At Memorial Sloan-Kettering Cancer Center, we have used such a plan, using external beam conventional therapy in combination with an interstitial boost of iridium 192 to the primary site, plus planned neck dissections in selected patients. Between 1981 and 1986, 17 patients with untreated base of tongue squamous cell carcinoma were treated in this manner. Thirteen of the 17 are disease-free as a result of this therapy. Two patients have failed locally, yielding an actuarial local control of 87% at a median followup of 2 years. These data would suggest that primary radiation that includes interstitial therapy as part of the plan, along with neck dissection in certain situations, is a worthwhile method management of base of tongue carcinoma.

Adult↗
PubMed1990

The management of chyle fistula.

Over a recent 4-year period, 823 neck dissections that included the lower jugular lymph nodes were performed. Of the 823, 14 (1.9%) patients developed chyle fistulas. Two other patients developed fistulas, one after undergoing a gastric transposition, and the other after a scalene node biopsy. All 16 patients were initially managed conservatively with closed-wound drainage and low-fat nutritional support; this was successful in only 4 patients, 3 of whom had peak 24-hour chyle drainage of less than 600 cc. The remaining 10 patients required open-wound management, which included operative ligation in 4 instances. Continued conservative treatment with an open neck wound resulted in significant additional hospitalization. Our experience indicates that closed-wound management of a chyle fistula is likely to fail when peak 24-hour fistula output exceeds 600 cc. Considering the cost and morbidity of conservative treatment, early reoperation may be appropriate in those patients with high fistula output.

Chyle↗
PubMed1989

Carcinoma of major salivary glands. Recent trends.

We have reviewed a 44-year experience with previously untreated carcinomas arising in major salivary glands to compare 319 patients treated before 1966 with 155 who received therapy between 1966 and 1982. Actuarial analysis indicates that five- and ten-year survival of our more recently treated patients was 80% and 65%, compared with 60% and 50% in patients treated before 1966. Explanation for this includes the higher proportion of patients with less aggressive histologic subtypes seen in recent years, as well as the fact that many of our patients treated before 1966 had surgical procedures considered inadequate by current standards. We also believe that adjunctive radiation oncology enhanced survival, but it could not be proved in this retrospective study. Multivariate analysis confirms that the clinical stage was the most important prognostic variable.

Adenocarcinoma↗
PubMed1989

Carcinoma of the tonsillar fossa. An update.

A retrospective analysis of 162 patients with carcinoma of the tonsillar fossa treated between 1969 and 1983 was undertaken. Of these patients, 117 were previously untreated; 11 had stage I, carcinoma, 24 had stage II, 40 had stage III, and 42 had stage IV. Combination therapy was utilized in 29% of patients with stage II disease, 40% of patients with stage III disease, and 67% of patients with stage IV disease. The three-year determinate "cure" rates were 89%, 83%, 58%, and 49% for stages I through IV, respectively. Only 22% of the previously treated patients were salvaged. Complications occurred in 36% of the previously treated patients and 18% of the previously untreated patients. Since our previous report, survival has improved, whereas operative mortality has decreased. We are unable to demonstrate a significant survival advantage when surgery and radiotherapy were used in combination.

Adult↗