Biomedical subjects

T R Loree

Publications and source records attributed to T R Loree.

At least 37 records · Page 2Linked to original sources

PubMed1997

Squamous cell carcinoma of the floor of mouth: a 20-year review.

BACKGROUND: This study retrospectively examines our treatment choices and outcomes with patients diagnosed with squamous cell cancer of the floor of mouth. Because of our division's past strong surgical bias in the treatment of this disease, we have assessed the results of a patient population treated largely by surgical extirpation. This clinical information has been used to draw conclusions and formulate treatment paradigms for patients with floor of mouth cancer. METHODS: Four hundred fifty patients with the diagnosis of squamous cell carcinoma of the oral cavity received their primary treatment at Roswell Park Cancer Center (RPCI) from 1971 to 1991. Ninety-nine had disease originating in the floor of mouth and are the basis of this retrospective review. RESULTS: Forty-three percent of the patients had early-stage disease (stage I or II). Five-year survival for stages I through IV was 95%, 86%, 82%, and 52%, respectively. The incidence of occult cervical metastases for clinical stage I patients was 21%. For clinical stage II patients, the incidence was 62%. Local control of patients treated with surgery alone was 81%. The regional control rate for these patients was 71%. In patients where negative margins were achieved (> or = 5 mm), the local recurrence rate was 13%, regardless of T stage. Eleven percent of the patients underwent a course of postoperative radiotherapy; all had stage IV disease. When compared with advanced-stage patients undergoing surgery alone, there was a significantly improved regional control rate and a trend toward enhanced survival in the patients receiving adjuvant radiotherapy. CONCLUSIONS: There is a significantly high incidence of occult metastatic disease (21%) for T1 lesions or greater in floor of mouth cancer to warrant elective treatment of regional lymphatics. In patients treated with surgery alone with negative margins, the local control rate was 90% versus 62% when the margins were close or positive. Adjunctive radiotherapy showed a statistically significant (p = .005) increased regional control in patients with stage IV disease. Adjunctive radiotherapy is warranted for increased regional control of disease; good local control can be achieved in floor of mouth cancer with surgery alone when negative margins are obtained.

Adult↗

PubMed1997

The inferior gluteal flap in the difficult vulvar and perineal reconstruction.

OBJECTIVE: The objective was to study the feasibility and complications of the use of the inferior gluteal flap in the difficult vaginal, perineal, and vulvar reconstruction among women treated for gynecologic cancers. METHODS: A prospective pilot study is reported. Between October 1994 and May 1996, seven patients underwent either unilateral (n = 3) or bilateral (n = 4) inferior gluteal flaps for primary reconstruction of extensive vulvar, perineal, and vaginal defects. RESULTS: The median age of the patients was 59 years (range, 40-70). The indications for the construction of the flaps were radical resection of recurrent vulvar cancer (n = 2), radical resection of stage IV vulvar cancer (n = 2), resection of recurrent Paget's disease of the vulva (n = 1), resection of perineal recurrence of cancer of the cervix (n = 1), and resection of enteroperineal fistula following total pelvic exenteration (n = 1). The median surface area of the vulvar and perineal defect was 113 cm2 (range, 10.5-448 cm2). The median operative time for both the extirpative and the reconstructive procedures was 270 min (95-685 min) and the median estimated blood loss was 200 mL (50-950 mL). The median postoperative hospital stay was 15 days (9-29). None of the patients experienced complete graft loss. Two patients suffered necrosis of the tip of the flap that resulted in minimal wound dehiscence which healed by secondary intention, and one patient suffered graft separation which required graft revision and reconstruction. The patients were followed for a median of 11 months (3-26 months). No late complications of the reconstructive surgery were recorded. CONCLUSIONS: The inferior gluteal flap can be safely used for the reconstruction of the difficult and extensive vulvar, perineal, and vaginal defects with excellent results.

Adult↗

PubMed1997

Low-risk differentiated thyroid cancer: the need for selective treatment.

BACKGROUND: The well recognized prognostic factors in differentiated carcinoma of the thyroid are age, grade, extracapsular extension, distant metastasis, and size of the tumor. Based on these prognostic factors, we have divided patients into low-, intermediate-, and high-risk categories. Clearly, there are significant differences in these three groups. This article analyzes in depth our data on low-risk thyroid cancer patients. METHODS: A retrospective review of 1,038 patients with differentiated carcinoma of the thyroid was undertaken. Various prognostic factors and risk groups were analyzed. Univariate and multivariate analyses were performed, and the survival curves were plotted by the Kaplan-Meier method. The inclusion criteria for the low-risk group were age younger than 45 years, tumors < 4 cm in size, low-grade histology, absence of distant metastasis, and absence of extrathyroidal extension. There were 465 patients in the low-risk group. Four hundred three patients had papillary and 62 patients had follicular thyroid cancer. There were 120 male and 354 female patients. Two hundred seventy-eight patients (60%) presented with clinically apparent lymph node metastasis. RESULTS: With a median follow-up of 20 years, the 10- and 20-year survival in this select group was 99%. The local, regional, and distant recurrence rates were 5, 9, and 2% in this series. The analysis of the data showed statistical difference in local recurrence rate between partial lobectomy and total lobectomy (27 vs. 4%; p = 0.005). There was no statistical difference in local recurrence rate between total lobectomy compared with total thyroidectomy (4 vs. 1%; p = 0.10). The overall failure rate between partial lobectomy and total thyroidectomy (27 vs. 8%) was statistically significant (p = 0.04). There was no statistical difference in the overall failure rate between total lobectomy and total thyroidectomy (13 vs. 8%; p = 0.06). There was no survival difference between various histologies or nodal status. CONCLUSIONS: Patients with low-risk tumors have excellent long-term survival. Nodulectomy or partial lobectomy should be avoided. The intraoperative decisions regarding the extent of thyroidectomy should be based on gross clinical findings and risk group analysis.

Adenocarcinoma, Follicular↗

PubMed1997

Differentiated thyroid cancer presenting initially with distant metastasis.

BACKGROUND: The initial presentation of distant metastases in patients with differentiated thyroid cancer is a rare event. Interestingly, if managed appropriately, the long-term survival in this group of patients is approximately 43%. We intend to review our experience of patients presenting initially with distant metastatic disease in a large series of differentiated thyroid cancer patients. METHODS: In the entire series of 1,038 consecutive patients treated at Memorial Sloan-Kettering Cancer Center from 1930 to 1985, 44 patients presented initially with distant metastases (4%). There were 22 male and 22 female patients ranging in age from 7 to 75 years with a mean age of 51 years. Patients were analyzed for their prognostic factors, and the survival curves were drawn by the Kaplan-Meier method. Univariate and multivariate analyses were performed by the Cox regression model. RESULTS: There were 19 patients presenting with distant metastases in 810 patients presenting with papillary thyroid cancer (2.3%). The incidence was high in patients with follicular thyroid cancer (11%). It is interesting to note that the highest incidence of presentation with distant metastatic disease was in patients above the age of 45 and with follicular thyroid carcinoma. The long-term survival in this group is 43% compared with 86% in patients presenting without distant metastasis (P < 0.001). There was no statistical difference in survival of patients below or above the age of 45. CONCLUSION: Even though the presence of distant metastasis at the time of initial presentation in other cancers is considered to be of grave prognosis, for patients with differentiated thyroid cancer, the long-term survival is still 43%. The incidence of distant metastasis is highest in patients with follicular thyroid cancer. Appropriate initial evaluation and treatment will lead to satisfactory long-term survival.

Adenocarcinoma, Follicular↗

PubMed1997

Diagnostic dilemma involving calcification in the parapharyngeal space: metastatic thyroid carcinoma masquerading as a deep lobe parotid mass.

As the parapharyngeal space is difficult to examine clinically, the radiographic distinction between deep lobe parotid masses and extraparotid tumors is essential in determining the surgical approach. We describe the case of a 53-year-old woman who presented with facial pain consequent to metastatic papillary thyroid carcinoma of the parapharyngeal space. A highly unusual pattern of calcification was present in the mass as observed by panoramic radiography and computed tomography. Parapharyngeal metastasis as the presenting feature of occult thyroid carcinoma has only been described four times previously in the medical literature.

Calcinosis↗

PubMed1997

Papillary carcinoma of the thyroid metastatic to the parapharyngeal space.

The parapharyngeal space is a complex anatomic area which can give rise to a variety of both primary and metastatic neoplasms. Squamous cell carcinoma can also present as a parapharyngeal space mass, either by direct extension or by metastases. Occult thyroid carcinoma presenting as a parapharyngeal space mass is a rare clinical occurrence which has been only sporadically reported in the medical literature. We present a case of occult papillary thyroid cancer with parapharyngeal space metastasis in the form of an isolated tumor, as well as a review of the literature on similar presentations. This rare situation has been previously described only once in the medical literature. Metastatic thyroid cancer should be considered in the differential diagnosis of a parapharyngeal space mass.

Carcinoma, Papillary↗

PubMed1996

Risk group stratification and prognostic factors in papillary carcinoma of thyroid.

BACKGROUND: Our understanding of the natural history of differentiated thyroid carcinoma has improved with the definition of prognostic factors. These prognostic factors have helped us identify patients in various risk groups. METHODS: A retrospective review of a consecutive series of 810 previously untreated patients with papillary carcinoma of the thyroid was undertaken to analyze the prognostic factors and risk groups. There were 403 patients in the low-risk group, 313 in the intermediate group, and 94 classified in the high-risk group. RESULTS: With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 43% survived in the high-risk group. The intermediate-risk group had a 20-year survival of 83%. The favorable prognostic factors included female sex, young age, absence of distant metastases and extrathyroidal extension of the disease, size < 4 cm, and low-grade histology. Focality, presence of lymph node metastasis, and pure papillary or mixed variant had no statistical significance on prognosis. CONCLUSIONS: Based on various prognostic factors, low-, intermediate-, and high-risk groups are identified. Patients in the low-risk group have excellent survival (99%). Appropriate selection of surgical and adjuvant treatment should therefore be used based on prognostic factors and risk group stratification.

Age Factors↗

PubMed1996

Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid.

BACKGROUND: Understanding of differentiated carcinoma of the thyroid has improved in recent years with the definition of prognostic factors and risk group analysis. We intend to review our experience of differentiated thyroid cancer in relation to the risk of nodal and distant metastasis based on various histologic subgroups. METHODS: This is a retrospective review of a consecutive series of 1,038 previously untreated patients with differentiated carcinoma of the thyroid treated over a period of 55 years. Univariate and multivariate analysis of various prognostic factors was performed. The incidence of nodal and distant metastasis was analyzed based on various histologic varieties of differentiated thyroid cancer. RESULTS: There were 337 male and 701 female patients. The various histologic subgroups included papillary (810), follicular (169), and Hurthle cell cancer (59). The cumulative risk of nodal metastasis based on histological group was 61%, 30%, and 21% for papillary, follicular, and Hurthle cell variety, respectively. The risk of distant metastasis for the same histologic varieties was 10%, 22%, and 33%, respectively. The 5- and 20-year survival for these histologic subgroups was papillary (94% and 87%, respectively), follicular (87% and 81%), and Hurthle cell tumors (81% and 65%; P < 0.001). CONCLUSIONS: The incidence of nodal metastasis is highest in the papillary subgroup; however, the incidence of distant metastasis was 33% in the Hurthle cell variety. The risk of nodal and distant metastasis varies considerably based on individual histologic variety.

Adenocarcinoma↗

PubMed1995

Differentiated carcinoma of the thyroid with extrathyroidal extension.

BACKGROUND: We have analyzed our experience with differentiated thyroid cancer patients with extrathyroidal extension (ETE) to investigate patterns of recurrence and define factors that predict failure. PATIENTS AND METHODS: The records of 1,012 patients treated surgically from 1930 to 1985 were reviewed. A total of 79 patients (8%) had ETE. The median length of follow-up was 10 years. RESULTS: Patients with ETE were more likely to fail treatment and to die of their disease than were patients without ETE (77% versus 34% and 71% versus 13%, respectively; P < 0.0001). Local, regional, and distant failures were more prominent among patients with ETE than among those without ETE (48% versus 9%, 41% versus 16%, and 37% versus 11% respectively; P < 0.0001). Survival of patients with ETE was adversely affected by nonpapillary histology, distant metastasis, age > 45, tumor size > 4 cm, and incomplete excision (P < or = 0.05). After stratification for age, survival in older patients was not affected by tumor size or incomplete excision, while in younger patients tumor size or the presence of distant metastasis did not adversely affect survival. Patients younger than 45 with negative margins had similar survival to patients without ETE (P = 0.46). CONCLUSIONS: Patients with ETE are more likely to die of their disease and to fail at all sites. Survival in older patients was not affected by incomplete excision while it was in younger patients. The presence of distant metastasis did not affect survival in younger patients. Our results suggest that among patients under 45, the presence of ETE does not adversely impact upon survival when the primary tumor is completely resected.

Adenocarcinoma↗

PubMed1995

Clinical experience with a microvascular anastomotic device in head and neck reconstruction.

BACKGROUND: Despite numerous refinements in microsurgical technique and instrumentation, the microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. MATERIALS AND METHODS: Concurrent with the development of microsurgical techniques, various anastomotic coupling systems have been introduced in an effort to facilitate the performance and reliability of microvascular anastomoses. The microvascular anastomotic coupling device (MACD) studied here is a high-density, polyethylene ring-stainless steel pin system that has been found to be highly effective in laboratory animal studies. Despite its availability for human clinical use over the last 5 years, reported clinical series remain rare. Our clinical experience with this MACD in 29 head and neck free-tissue transfers is reported herein. RESULTS: Thirty-five of 37 (95%) attempted anastomoses were completed with 100% flap survival with a variety of donor flaps, recipient vessels, and clinical contexts. Two anastomoses were converted to conventional suture technique intraoperatively, and one late postoperative venous thrombosis occurred after fistulization and vessel exposure. CONCLUSIONS: We conclude that the MACD studied here is best suited for the end-to-end anastomosis of soft, pliable, minimally discrepant vessels. Previous radiation therapy does not appear to be a contraindication to its use. Interpositional vein grafts may also be well suited to anastomosis with the device. When carefully and selectively employed by experienced microvascular surgeons, this MACD can be a safe, fast, and reliable adjunct in head and neck free-tissue transfer reconstructions, greatly facilitating the efficiency and ease of application of these techniques.

Adult↗

PubMed1995

Prognostic factors and risk group analysis in follicular carcinoma of the thyroid.

BACKGROUND: The understanding of prognostic factors has facilitated stratification of risk groups in differentiated carcinoma of the thyroid. The prognostic factors have clearly identified the risk groups as low, intermediate, and high risk. Risk group categorization has facilitated a selective surgical approach for thyroid carcinoma. METHODS: A retrospective review of 228 patients with follicular carcinoma of the thyroid was undertaken. Various prognostic factors and risk groups were analyzed. Univariate and multivariate analyses were performed, and the survival curves were plotted by the Kaplan-Meier method. Fifty-nine (26%) patients presented with Hürthle cell histology. The risk groups revealed 62 patients in the low, 84 in the intermediate, and 82 in the high risk groups. RESULTS: The 10-year survival for low, intermediate, and high risk groups was 98%, 88%, and 56%, respectively, and the 20-year survival for the same groups was 97%, 87%, and 49%, respectively. Adverse prognostic factors included age older than 45 years (p < 0.001), Hürthle cell variety (p = 0.05), extrathyroidal extension, tumor size exceeding 4 cm, and the presence or absence of distant metastasis (p < 0.001). Gender, focality, and presence of lymph node metastasis had no significant impact on prognosis. CONCLUSIONS: Patients in the low risk group have excellent survival, whereas the high risk group behaves poorly. Appropriate selection of treatment for the primary disease and adjuvant therapy should be considered on the basis of the prognostic factors and risk group analysis.

Adenocarcinoma, Follicular↗

PubMed1994

Intermediate-risk group for differentiated carcinoma of thyroid.

BACKGROUND: We have previously described prognostic factors in differentiated carcinoma of the thyroid gland relating to age, size and extrathyroid extension of the tumor, histologic grade, gender, and distant metastasis. These factors have identified patients in the low-risk group with excellent prognosis and the high-risk group with significant mortality. However, some patients fall within the intermediate-risk category where due deliberation in decision making is required for selection of appropriate treatment. METHODS: A retrospective review of a consecutive series of 1038 previously untreated patients with differentiated carcinoma of thyroid treated during a period of 55 years was undertaken. Data gathered from review of the charts were subjected to univariate and multivariate analysis to assess prognostic factors. On the basis of the patient's age, presence of distant metastasis, and size, grade, and histologic characteristics of the tumor they could be classified into low-, intermediate-, and high-risk categories. Thus 403 (39%) patients were in the low-risk group, 232 (22%) patients in the high-risk category, and 403 (39%) patients in the intermediate-risk category. RESULTS: With a median follow-up of 20 years, 99% survival was achieved in the low-risk group, whereas only 57% survived in the high-risk group. Interestingly, in the intermediate-risk category of 403 patients, the 20-year survival was only 85%. Our results clearly identify a distinct intermediate-risk category that includes low-risk patients with high-risk tumor or high-risk patients with low-risk tumor. CONCLUSION: Patients in the intermediate-risk category should be considered for an aggressive treatment approach based on individual prognostic factors.

Adult↗

PubMed1993

Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis.

The extent of surgical resection for differentiated carcinoma of the thyroid gland confined to one lobe remains controversial. Although primary tumor size and extrathyroid extension are associated with a poor prognosis, the presence of multifocal lesions is not associated with an adverse prognosis. Therefore, the role of lobectomy versus total thyroidectomy must be studied in a prospective, randomized trial. Due to the need for long-term follow-up, such a trial has not yet been undertaken. As an alternative to such a trial, we have identified 146 patients from a consecutive series of 931 previously untreated patients undergoing surgical treatment at 1 institution between 1930 and 1980. For this study of matched-pair analysis, 73 patients, aged 45 years or older, were matched in each arm for significant prognostic factors. One group underwent lobectomy, and the other group underwent total thyroidectomy. The 20-year survival rate in the lobectomy group was 82% compared with 73% in the total thyroidectomy group (p = not significant). The patterns of failure in these two groups of patients were examined. A comparison of the patients who underwent lobectomy with an unmatched group of patients who underwent lobectomy showed similar survival rates. On the other hand, unmatched patients undergoing total thyroidectomy had a poorer survival rate than the matched group. This signifies a more aggressive nature of disease in the unmatched group of patients undergoing total thyroidectomy. We therefore conclude that low-risk patients undergoing lobectomy are likely to do as well as those undergoing total thyroidectomy and without the increased risk of the morbidity of total thyroidectomy.

Adult↗

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↗

PubMed1991

Major salivary gland lymphoepithelial lesions and the acquired immunodeficiency syndrome.

Presently, there is no consensus regarding the most appropriate diagnostic and therapeutic approach to patients with human immunodeficiency virus (HIV)-associated lymphoepithelial lesions of the major salivary glands. A retrospective review of 60 consecutive patients with lymphoepithelial lesions is presented. Thirty-eight cases were associated with HIV infection. Lesions associated with HIV infection were usually bilateral, multiple, cystic, and associated with lymphadenopathy. In contrast, in those cases without HIV infection, the lesions tended to be solitary and solid. In the HIV-infected group, treatment included surgery, radiotherapy, zidovudine (AZT), and/or cyst aspiration. All therapeutic regimens, other than aspiration alone, were found to be effective. Eighteen of the patients with HIV infection developed the acquired immunodeficiency syndrome (AIDS) during the study period. Surgical treatment is probably not necessary in the majority of HIV-associated cases. Depending upon individual circumstances, treatment with AZT or low-dose radiotherapy is recommended. A diagnostic and therapeutic algorithm is presented as a guide to the management of future cases.

AIDS-Related Complex↗

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

Significance of positive margins in oral cavity squamous carcinoma.

Three hundred ninety-eight consecutive, previously untreated patients undergoing surgery for epidermoid carcinoma of the oral cavity from 1979 to 1983 were reviewed. One hundred twenty-nine patients were classified as having positive surgical margins. Of these, 83 patients had tumor within 0.5 mm of the surgical margin, 9 had premalignant changes at the margin, 9 had in situ carcinoma at the margin, and 28 had invasive cancer at the margin. The remaining 269 patients had uninvolved margins. The significance of positive margins relating to survival, subsequent clinical course, local recurrence, and patterns of treatment failure was examined, along with the impact of adjuvant postoperative radiotherapy on positive margins. The percentage of patients having positive margins progressively increased with increasing T stage: 21% in T1 versus 55% in T4 primary cancer. The overall 5-year survival for patients with negative margins was 60%. For patients with positive margins, 5-year survival was 52%. This difference was statistically significant. The incidence of local recurrence in patients having positive surgical margins was twice as much as in those with negative margins (36% versus 18%). Metastasis rates in the neck and at distant sites were not significantly influenced by the status of the surgical margin. Of the 129 patients with positive margins, 49 received postoperative radiotherapy. In those patients so treated, a trend toward lower recurrence rates was noted. Differences were not statistically significant. This retrospective review confirms the importance of adequate resection of the primary tumor as well as the relative ineffectiveness of adjuvant postoperative radiotherapy in the improvement of local control in patients with positive surgical margins.

Adult↗

PubMed1989

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.

Adolescent↗