Biomedical subjects
R H Spiro
Publications and source records attributed to R H Spiro.
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.
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.
Squamous carcinoma of the nasal cavity and paranasal sinuses.
This study retrospectively analyzed 105 patients with squamous carcinoma of the nasal cavity and paranasal sinuses. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 (10 percent), and the sphenoid sinus in 2 (2 percent). Over half of the patients with antral cancer were treated with surgery and radiotherapy, whereas one-third of the remaining patients received combination therapy. Most procedures were radical, including sacrifice of the orbital contents in half of the surgically treated patients. The 5-year determinate cure rate was 45 percent for patients with nasal cavity tumors, 38 percent for those with maxillary sinus lesions, and 13 percent for those with ethmoid tumors. Local recurrence remains a major problem despite aggressive surgery and increased use of adjunctive radiotherapy.
Cutaneous melanoma of the head and neck.
We have reviewed a 21-year experience with 289 patients who received definitive surgical treatment for cutaneous melanomas arising in the skin of the head and neck. Elective lymphadenectomy was performed in 39 percent of those who presented with no clinical evidence of nodal metastasis. The cumulative 5- and 10-year survival was 56 percent and 45 percent, respectively. Increased tumor thickness, age greater than 55 years, male sex, ulceration, nodular morphology, and scalp site were significant adverse factors. Patients with ear or neck lesions had the best survival. The risk of distant metastasis was almost equivalent to that of nodal metastasis, regardless of thickness. Elective lymphadenectomy appeared to have minimal impact on survival.
Squamous carcinoma of the gums.
We reviewed a 20-year experience with squamous carcinoma of the gums in 347 patients who received definitive therapy. More than three-quarters of the lesions involved the lower gum and all but 37 patients were previously untreated. The proportion of patients with localized tumors (N0) remained the same (64 percent). Surgery continued to be the treatment of choice in 97 percent of patients, but proportionately more patients had a more conservative procedure which preserved lower jaw continuity. The 5-year determinate survival rate was little changed (54 percent). Advanced clinical stage (stages III and IV), prior dental extraction, bone invasion, and involvement of surgical margins were predictive of a lower survival rate on univariate analysis. Clinical stage was the only significant predictor of survival on multivariate analysis. The impact of adjunctive radiotherapy could not be assessed.
Critical assessment of supraomohyoid neck dissection.
During a recent 5-year period, 115 patients had 131 supraomohyoid neck dissections. Eighty-one percent of these procedures were performed for squamous carcinoma. Seventy-nine percent of the primary tumors were located in the oral cavity and 16 percent arose in the oropharynx. Almost 80 percent of the necks dissected for primary squamous carcinoma were clinically N0, and occult nodal disease was discovered in 31 percent of these neck specimens. When the supraomohyoid neck dissection specimen showed no involvement, the overall incidence of treatment failure in the neck at 2-year follow-up was 5 percent. Almost all patients with occult squamous carcinoma in the supraomohyoid neck dissection specimen received postoperative radiotherapy, and the failure rate in the neck was 15 percent. When neck nodes were both clinically and pathologically involved, neck recurrence developed in 29 percent of the patients despite the addition of adequate postoperative radiotherapy. Among those patients with nonsquamous primary tumors and a pathologically negative supraomohyoid neck dissection specimen, there was only one subsequent treatment failure in the neck. Supraomohyoid neck dissection appears to be a valid staging procedure for clinically N0 patients with primary squamous carcinomas located in the oral cavity or oropharynx, with an appropriate yield of occult nodal disease, and infrequent treatment failure in the dissected neck when the supraomohyoid neck dissection specimen is pathologically uninvolved. When nodal disease is clinically obvious, treatment failure is more frequent, even with the addition of postoperative radiotherapy. The role of supraomohyoid neck dissection in this setting deserves further study.
The role of parotidectomy in the treatment of cutaneous head and neck melanoma.
Sixty-five patients with melanoma underwent parotidectomy as part of the initial treatment. Clinical evaluation of the parotid nodal status was inaccurate. Patients with parotid nodal metastases had a significantly decreased survival at 5 years, 22 percent compared with 67 percent in the patients with uninvolved nodes. Distant metastasis was the first indication of treatment failure in most of the patients with parotid involvement.
New strategies for avoiding total laryngectomy in patients with head and neck cancer.
Cisplatin-based chemotherapy has yielded high response rates in patients with head and neck cancer but has failed to improve the survival rates in randomized studies. Thus, its place in the management of head and neck cancer remains unclear. We have been investigating whether the combination of chemotherapy and radical irradiation as an alternative to morbid surgery in selected patients might yield an improved quality of life without compromising survival. Between January 1983 and December 1985, we treated 32 patients with epidermoid carcinoma arising from the larynx, base of the tongue, or hypopharynx, using an interdisciplinary regimen, with the objective of avoiding total laryngectomy. All of these patients had large primary tumors that could not have been removed without total laryngectomy. Patients who could be treated by conservation laryngeal surgery were excluded, as were patients who presented with clearly unresectable disease. The regimen employed cisplatin-based chemotherapy together with brachytherapy and external radiation therapy, with highly individualized treatment planning. Seven patients had T2 lesions, 19 had T3, and 6 had T4. The follow-up periods ranged from 8 to 38 months (median, 18). The actuarial survival rate at 2 years is 85%, and the laryngectomy-free rate at 2 years is also 85%. None of the 11 patients with laryngeal cancer has relapsed, and none has required laryngectomy. None of the 12 patients with base of the tongue cancer treated by brachytherapy has relapsed above the clavicles and none has required laryngectomy, but 1 patient has died of complications of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
A pilot study of cisplatin-vinblastine as the initial treatment of advanced head and neck cancer.
Twenty patients with Stage IV and five patients with Stage III carcinoma of the head and neck were treated with the combination of cisplatin and vinblastine before locoregional therapy. Among 24 patients evaluable for response after chemotherapy, there were four complete responders and 16 partial responders for an overall major response rate of 83%. No complete responses were observed in patients with T4 primary lesions or N3a nodal disease. Toxicity was limited primarily to nausea and vomiting (76%) and myelosuppression (72%). Four patients, all treated at the higher vinblastine dose, required hospitalization for fever associated with neutropenia. Two patients had a transient increase in the serum creatinine clearance to greater than 3 mg/dl. The combination of high-dose cisplatin and frequent vinblastine has significant activity in locally advanced squamous cell carcinoma of the head and neck, has mild and reversible toxicity, and does not require prolonged hospitalizations for continuous intravenous infusions.
Predictive value of tumor thickness in squamous carcinoma confined to the tongue and floor of the mouth.
In this review of 105 consecutive patients who underwent operation for previously untreated, N0 squamous carcinomas arising in the oral tongue or the floor of the mouth, 86 percent of the determinate patients remained alive and well 2 years after treatment. Included were 48 patients, 49 patients, and 8 patients who had T1, T2, and T3 tumors respectively. Elective cervical lymphadenectomy was performed in about a third, but tumor staging did not facilitate selection of those who were most likely to have occult metastases. For this reason, we retrospectively assessed the impact of tumor thickness using an optical micrometer to measure the thickness in millimeters of the excised tumors in routinely prepared paraffin sections. Disease-related death appears to be unusual when oral tumors are thin (2 mm or less), regardless of the tumor stage. Multivariate analysis confirms that increasing tumor thickness, rather than tumor stage, had the best correlation with treatment failure and survival. These findings need to be verified in prospective studies involving a larger patient population and other head and neck sites, but they strongly suggest that measurement of tumor thickness may be a better way to select those oral cancer patients who are most likely to benefit from elective treatment of the N0 neck.
Difficult decisions in parotid surgery.
Six atypical case presentations of parotid tumors are presented along with solutions proposed by two experts on the topic. The differences and similarities of the opinions expressed are summarized and discussed by the editor.
Identical laryngeal cancers in two non-twin sibling pairs: case reports and a review of the literature.
The occurrence of identical laryngeal cancers in two nontwin sibling pairs is reported for the first time. To understand the relative importance of genetic and environmental factors in the etiology of laryngeal cancer, the evidence in the literature for the development of identical cancers in genetically unrelated and related pairs sharing the same environments was examined.
Mandibulotomy approach to oropharyngeal tumors.
We have reviewed our experience with 120 selected patients who had pharyngeal tumors resected through a median mandibulotomy approach with paralingual extension (mandibular swing). Clinical findings, technique, and complications are discussed. Results were gratifying in terms of salvage, patient appearance, and function. We believe that this surgical approach, in combination with postoperative radiotherapy when appropriate, offers an attractive alternative to high dose radiotherapy alone in patients with oropharyngeal carcinoma.
Intraoperative radiotherapy in patients with recurrent head and neck cancer.
Patients with head and neck cancer who have a relapse of the disease above the clavicles can sometimes be salvaged by additional surgery. However, if all gross tumor cannot be removed during surgery or if the resection margins are unsatisfactory, the likelihood of salvage is remote, especially when postoperative radiotherapy is not feasible due to previous radiotherapy. Between 1979 and 1983, we employed intraoperative brachytherapy for 21 such patients. Sixteen patients had a recurrence after previous surgery and radiotherapy, and 5 after radical radiotherapy. All gross tumor could not be removed in 15 patients, whereas satisfactory margins could not be obtained in 6. In 11 patients, we delivered radiotherapy by a temporary implant of iridium-192 (median dose 4,800 rads in 6 days). In 10 patients, radiotherapy was delivered by a permanent implant of iodine-125 (median activity 13 mCi). Three patients (14 percent) had a relapse within the surgical field, whereas six others (28 percent) had a relapse elsewhere or had development of metastases. Complications developed in four patients (19 percent) and were fatal in one patient. The actuarial disease-free survival rate at 2 years was 55 percent, whereas the rate of local disease control was 81 percent. Our experience suggests that intraoperative brachytherapy can salvage certain high-risk patients with head and neck cancer.
The management of salivary neoplasms: an overview.
From 1939 through 1973, 2,807 patients with salivary gland tumors received definitive treatment at the Memorial Sloan Kettering Cancer Center. This included 1,965 patients (70%) with parotid gland lesions, 244 patients (8%) with neoplasms in the submandibular gland, and 607 patients (22%) with tumors which arose in the predominantly mucus secreting glands (minor salivary) which line the upper aerodigestive tract. The proportion with malignant tumors was 25, 43, and 82% in the parotid, submandibular and minor salivary glands, respectively; benign tumors occurred more often in women. Mucoepidermoid, acinic cell and most adenocarcinomas were subdivided according to histologic grade and all patients were retrospectively staged according to criteria established by the American Joint Committee on Cancer Staging. Treatment was almost exclusively surgical and the extent of the operation performed depended on the extent of the tumor rather than its histology. In patients with malignant parotid tumors, the facial nerve was sacrificed only if it was adherent to or directly involved by the tumor. Lymphadenectomy was usually reserved for those patients who had palpable metastases. Prolonged follow-up (10 years minimum in this study) is necessary in order to appreciate the slow growth of some salivary neoplasms. Results depended upon the complex interplay between the site of origin, the clinical stage, and the histologic appearance of the tumors. This study antedates our current interest in postoperative radiation therapy, but other reports suggest that combination therapy enhances local control.
The management of neck nodes in head and neck cancer: a surgeon's view.
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Changing trends in the management of squamous carcinoma of the tongue.
An analysis of 412 patients with primary squamous carcinoma of the tongue seen from 1969 through 1978 reveals that the age and clinical stage of patients with tongue cancer have remained constant when compared with previous reports from our hospital. The proportion of female patients has increased, and we are seeing more patients with tumors located in the base of the tongue. Treatment methods are changing. Mandible-sparing procedures were used more often, and significantly more patients received primary and adjuvant radiotherapy in the early study period. At the same time, there were fewer composite neck, tongue, and jaw resections and fewer laryngectomies, although more patients had elective treatment of the neck. The overall determinate cure rate has not changed since the 1957 through 1963 period. Age, sex, and adjuvant radiotherapy did not seem to affect survival. When patients with oral tongue primary lesions were compared with those with tumors in the base of the tongue, the prognosis seemed to be better in those with oral primary lesions when the patient had stage I or II disease. Finally, patients with tongue cancer have at least a 1 in 5 chance of development of a second aerodigestive tract malignancy and require lifelong scrutiny. Although current therapy results in lower morbidity, the proportions of patients with stage III and IV tumors remain high, and the cure rates remain disappointingly stable.