Deepak M. Parikh

Osteosarcoma of the craniofacial bones: A Clinico-Pathological study

Thirty-four cases of osteosarcoma involving the craniofacial bones over a period of 19 years were reviewed. They formed 6.2% of osteosarcomas occurring in the skeleton during the same period at the Tata Memorial Hospital. Mean age of occurrence was 30.9% years, with a range of 7 to 61 years. Male preponderance was noted in maxillary tumours (M:F = 2.6:1), while the mandibular tumours occurred with equal frequency in both sexes. The mandible was the bone of origin in 56%, maxilla in 32% and other craniofacial bones in 12% of patients. Histological sub-type did not affect the prognosis. Radical surgery with resection of adequate disease-free margins is the most effective mode of treatment. Morbidity and mortality is due to extensive local recurrence of disease, particularly with maxillary tumours. Metastasis to other organs occurs rarely. No statistically significant difference in survival was observed between tumours of the mandible and maxilla, or between patients above and below 20 years of age.

Histologic trends in thyroid cancer 1969-1993: a clinico-pathologic analysis of the relative proportion of anaplastic carcinoma of the thyroid.

It was observed that new presentations of anaplastic carcinoma of the thyroid had become infrequent in the last two decades.

Lateral thyrotomy for neurilemmoma of the larynx

We present a rare case of neurilemmoma of the larynx, which was excised through a lateral thyrotomy approach with resulting restoration of laryngeal function. The advantage of the lateral thyrotomy approach for submucous tumours of the larynx is discussed.

Prognostic factors in follicular carcinoma of the thyroid: a study of 198 cases.

Prognostic parameters for papillary carcinoma of the thyroid have been defined by several groups. However, no such study has been reported for follicular carcinoma.

Phase II Study of High-Dose Ifosfamide as a Single Agent and in Combination with Cisplatin in the Treatment of Advanced and/or Recurrent Squamous Cell Carcinoma of Head and Neck

152 patients with histologically proven squamous cell carcinoma of the head and neck (advanced and/or recurrent) were treated with a single drug therapy of ifosfamide 1.5 g/m2 by intravenous drip for half an hour in 125 ml of dextrose saline for 5 days and mesna 20% of the total ifosfamide dose in 3 doses for 5 days, or in combination with cisplatin 10 mg/m2 by intravenous infusion for 5 days following the ifosfamide drip. The courses of treatment were repeated at the interval of every 4 weeks, and a total of 3 cycles was given. Out of 152 patients 64 received ifosfamide alone, and 88 received ifosfamide with cisplatin. 6 complete and 25 partial remissions (total response 53%) were observed in 58 evaluable patients of the ifosfamide group, and 10 complete and 40 partial remissions (total response 65.7%) were observed in 76 evaluable patients of the combination group. Nausea, vomiting, alopecia and leucopenia were experienced by all patients.

Perioperative chemotherapy in patients with oral cancer

In the final report of a prospective, randomized controlled clinical trial, we report the results of using adjuvant perioperative chemotherapy in patients with oral cancer. Our study is based on the hypothesis of Goldie and Coldman. A total of 135 patients with alveolobuccal carcinoma, classified as clinically stage III and IV, were entered on the protocol. After a curative resection, they were randomized. The patients in the test arm of the study received methotrexate 50 mg/m2 on the 3rd, 10th, and 17th postoperative days. The patients in the control arm underwent observation. This analysis at 24 months showed a disease-free survival rate of 61% in the test arm versus 37% in the control arm, which is statistically highly significant (P < 0.01). Analysis of the recurrence pattern showed that recurrence at the primary site was dramatically reduced during the first 6 postoperative months (P = 0.002). Our study provided further clinical evidence in support of the concepts of Goldie and Coldman that the timing of chemotherapeutic drugs is critical for a successful end result.

Neoadjuvant chemotherapy with ifosfamide and cisplatin combination in advanced head and neck cancer: a retrospective analysis of 519 patients: a single institution experience.

Advanced head and neck cancer is a major therapeutic problem in India. Ifosfamide has shown significant activity as a single agent in head and neck squamous carcinoma. In this study, we present our experience with two cycles of ifosfamide and cisplatin in the neoadjuvant setting given to a total of 519 patients. The complete response rate was 20% and the overall response rate was 80%. The treatment was well tolerated, there was no need for dose reduction, and there were no life-threatening side effects. We feel that this high response rate is sufficient to warrant more studies using ifosfamide-based combinations in a neoadjuvant setting for squamous carcinoma of the head and neck.

Prognosticators of survival in differentiated thyroid carcinoma.

Differentiated carcinoma of the thyroid has good prognosis, even in patients presenting in the late stage and with distant metastasis. In India, the incidence of papillary carcinoma and follicular carcinoma are in the ratio of 60∶40. A retrospective study was carried out to determine the impact of patient and tumor factors on survival, and to develop a simple rish group staging system to predict survival in patients with differentiated thyroid carcinomas. Four hundred and seventeen (417) patients undergoing primary treatment at our hospital between 197–1985, were entered to the study. There were 198 follicular carcinomas and 219 papillary carcinomas. Impact of patient and tumor variables were studied by drawing Kaplan Meier curves and comparing them by the Chi Sq Test. Age<=40 years (p=0.00001), tumor size <5cms (p=0.01), extrrathyroidal spread (p=0.001) and distant metastasis (p=0.00001) had significant impact on survival. These finding were true for a subset analysis follicular and papillary carcinomas separately. A Cox Regression Analysis was also performed and this showed the above factors to impact significantly on survival. Basing on the regression analysis we devised a simple risk group system and classified the patients as high and low risk. Low risk group patients had a significant survival advantage. Our findings show that the incidence of follicular carcinoma is significantly high in india (48%) and that 65% of our patients are in the high risk group. Incidence of contralateral lobe disease on completion thyroidectomy is as high as 53%. Hence, a more aggressive treatment policy is warranted and total thyroidectomy is the appropriate treatment of choice in our patients.

Evidence-based protocols for the management of well-differentiated carcinomas of the thyroid.

OBJECTIVES In recent years, well-differentiated carcinomas of the thyroid have been stratified into low-risk and high-risk groups. The pattern of thyroid cancer in India is different from that seen in the West. Moreover, patients present with more advanced stages of the disease. Our aim was to develop protocols for the management of well-differentiated thyroid cancer, based on the analysis of our data and our experience. METHODS Cases of thyroid carcinoma, which were surgically treated at the Tata Memorial Hospital during 1970-5, were studied. The survival curves were plotted according to the Kaplan-Meier method. Univariate analysis was done using the log rank test. The prognostic factors analyzed were age, sex, tumour size, extra-thyroid extension, distant metastases and lymph node metastases. Multivariate analysis using the Cox regression model was performed. Analyses were separate for follicular and papillary carcinomas. RESULTS Four hundred and seventeen cases were entered in the study, of which 198 were follicular and 219 were papillary. Based on the evidence derived from this study, we stratified our cases into low- and high-risk groups. The low-risk group consisted of patients below 40 years of age, nodules smaller than 5 cm, absence of extra-thyroidal spread and absence of distant metastases. For follicular carcinoma, the low-risk group had 100% survival at 15 years, compared with 40% for the high-risk group. (p < 0.001). For papillary carcinomas, the survival at 15 years was 95% for the low-risk group and 40% for the high-risk group (p < 0.001). CONCLUSIONS We recommend lobectomy for the low-risk group, and total thyroidectomy for the high-risk group and for cases with lymph node metastases. In the latter, total thyroidectomy facilitates the use of 131I.

Pharyngoesophageal segment manometry : Its role in determining post-laryngectomy speech

Pharyngoesphageal (P. E) segment manometry was performed in 15 patients to determine the significance of the tone of the neoglottis in post-laryngectomy speech. The time interval following laryngectomy ranged from 3 months to 19 years. Peak pressures and graphic records during esophageal and tracheoesophageal speech were obtained, using a Swan-Ganz catheter, arterial pressure transducer and monitor with recorder. Peak pressures below 22mm Hg. and above 30mm Hg. were associated with fluent (7 patients) and nonfluent (8 patients) speech respectively. All 5 patients with primary pharyngeal myotomy demonstrated low pressures with fluent speech. P. E. manometry accurately reflected the type of speech developed and identified abnormal tone of the neoglottis as the cause of speech failure. Pharyngeal myotomy should be performed in those who demonstrate high P. E. pressures with poor speech development after laryngectomy.