Donald P. Shedd

Metastatic Patterns in Squamous Cell Cancer of the Head and Neck

This retrospective study on 832 head and neck cancer patients who died between 1961 and 1985 was carried out to determine the incidence and sites of distant metastases. All patients were staged prior to definitive treatment and were autopsied. The overall incidence of distant metastases was 47 percent. The hypopharynx had the highest incidence of distant metastases (60 percent), followed by the base of the tongue (53 percent) and the anterior tongue (50 percent). Of the 387 patients with distant metastases, 91 percent died with uncontrolled tumor either at the primary site or in the neck. The lung was the most common site of distant metastases (80 percent), followed by the mediastinal nodes (34 percent), the liver (31 percent), and bone (31 percent). Overall, 6 percent of the patients had stage I disease, 20 percent had stage II disease, 32 percent had stage III disease, and 43 percent had stage IV disease. The highest incidence of distant metastases was found in those patients with stage IV disease (193 of 350 patients, 55 percent). We believe that the initial stage of disease does appear to be related to the ultimate development of the distant metastases.

Surgical Variables Affecting Speech in Treated Patients With Oral and Oropharyngeal Cancer

Postoperative speech function may be influenced by a number of treatment variables. The objective of this study was to examine the relationships among various treatment factors to determine the impact of these measures on speech function. Speech function was tested prospectively in 142 patients with surgically treated oral and oropharyngeal cancer 3 months after treatment. Each patients speech was recorded during a 6‐ to 7‐minute conversation and while performing a standard articulation test, producing speech outcome measures of percent correct consonant phonemes and percent conversational understandability. Correlational analyses were used to determine the relationships among the speech outcome measures and 14 treatment parameters. Speech function was mildly to moderately negatively correlated with most surgical resection variables, indicating that larger amounts of tissue resected were associated with worse speech function. Overall measures of conversational understandability and percent correct consonant phonemes were related to extent of oral tongue resection, floor of mouth resection, soft palate resection, and total volume of tissue resected. These relationships varied depending on the method of surgical closure. Method of surgical reconstruction had a profound impact on postoperative speech function 3 months after treatment and was an important factor in determining how oral tongue resection influenced articulation and intelligibility. The combination of closure type, percent oral tongue resected, and percent soft palate resected had the strongest relationship with overall speech function for patients with surgically treated oral and oropharyngeal cancer 3 months after treatment.

Surgical variables affecting postoperative swallowing efficiency in oral cancer patients: A pilot study

This study examined the correlation between swallow function at 3 months postoperatively and surgical variables including volume resected, flap volume, ratio of flap volume to volume resected, percentage of oral tongue, tongue base, and anterior and lateral floor of mouth resected, and whether or not the mandible was preserved in 30 surgically treated oral cancer patients. Swallows of measured amounts of liquid and paste (pudding) materials were examined videofluoroscopically. Nine measures of swallow function were completed for each swallow. A factor analysis of all swallow variables was done for liquid and for paste consistencies to determine whether one measure was statistically representative of all swallow measures. This analysis indicated that oral pharyngeal swallow efficiency (OPSE) represented all measures for both liquid and paste consistencies. Then the correlation between OPSE and surgical variables was defined. Only percentage of oral tongue and percentage of tongue base resected were significantly negatively correlated with OPSE. That is, OPSE decreased for both liquid and paste as percentage of oral tongue or percentage of tongue base resected increased. Results are discussed in terms of diet choices and surgical management.

Adenoid cystic carcinoma of major and minor salivary glands.

Abstract The records of eighty-one patients with adenoid cystic carcinoma of major and minor salivary glands at Roswell Park Memorial Institute have been reviewed. Survival data on sixty-five patients followed five years or more reveals an average survival of 7.4 years. Sixty-five per cent (forty-two of sixty-five patients) lived for five years, 31 per cent (twenty of sixty-five) for ten years, and 15 per cent (ten of sixty-five) for fifteen years or longer. The patients were divided into four anatomic groups which regionally involve similar problems in treatment and often result in similar cosmetic and functional deformities. Similarities are seen but there are also some notable differences in recurrences and total survival depending on the anatomic location of the primary lesion. Aggressive surgical resection and reconstruction is the preferred method of therapy for both primary and locally recurrent disease whenever possible. Local recurrences and systemic metastases are common, but are often delayed for several years. Locally recurrent tumor can be controlled in many instances by surgical resection or radiotherapy, but careful lifetime follow-up study of the patient is required to discover recurrent disease at its earliest stage.

Squamous cell carcinoma of the floor of mouth: A 20‐year review

This study retrospectively examines our treatment choices and outcomes with patients diagnosed with squamous cell cancer of the floor of mouth. Because of our divisions 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.

Results of surgical resection of pulmonary metastases of squamous cell carcinoma of the head and neck

In this retrospective review of 58 patients (12 females and 46 males) with pulmonary metastases of squamous cell carcinoma of the head and neck treated between January 1, 1970, and December 31, 1989, we evaluated their clinical courses and analyzed the outcomes of those who underwent pulmonary resection. For the entire group of patients, factors predictive of survival in those patients with a diagnosis of pulmonary metastases included pulmonary resection of metastases (p = 0.0001), locoregional control of the head and neck primary tumor at the time of diagnosis of pulmonary metastases (p = 0.007), TNM stage of the head and neck primary tumor (p = 0.02), a single nodule seen on the chest radiograph (p = 0.02), and disease-free interval (DFI) from the primary tumor of the head and neck of 2 years or more (p = 0.05). Twenty-four of 58 patients underwent thoracotomy for resection of metastases. Four (17%) were found to have a second primary tumor of the lung. Of the 20 remaining patients who underwent explorative surgery for possible pulmonary resection, 18 (90%) underwent complete resection of all malignant disease with an estimated 5-year survival of 29%. In these patients, a DFI of less than 1 year was associated with a 5-year survival rate of 0%, whereas a DFI of 1 to 2 years was associated with a 5-year survival rate of 43% and a DFI of 2 years or longer had a 5-year survival rate of 33%. The number of malignant pulmonary nodules that were resected ranged from one to five and was not significant in predicting survival (p = 0.19). Of eight patients who underwent the resection of more than one malignant pulmonary nodule, 50% survived 2 years, but none survived 5 years. Resection of a solitary pulmonary metastasis from squamous cell carcinoma of the head and neck resulted in long-term survival in selected patients. Important prognostic factors included locoregional control of the head and neck primary tumor, the number of nodules seen on chest radiograph, the TNM stage of the primary tumor, and the DFI from the head and neck primary tumor. The value of resection in patients with more than one malignant pulmonary nodule remains to be defined for this group of patients.

Surgery as a single modality therapy for squamous cell carcinoma of the oral tongue

PURPOSE The treatment of squamous cell cancer of the oral tongue remains a challenging clinical problem. The efficacy of primary treatment with surgery versus radiation therapy for early stage disease and an adequate treatment paradigm for the clinically negative neck continues to be the subject of clinical debate. We have reviewed our experience in the treatment of oral tongue cancer with surgery as a single definitive treatment modality. PATIENTS AND METHODS From 1971 to 1993, 79 patients with squamous cell carcinoma of the oral tongue were treated with surgery alone at Roswell Park Cancer Institute. RESULTS Clinically, 69% of the patients presented with stage I/II disease and 31% presented with stage III/IV. Survival by pathological stage I to IV was 89%, 95%, 76%, and 65%, respectively. Surgical therapy ranged from partial to total glossectomy. There were no patients with positive margins. Local recurrence was observed in 15% of patients with close margins (< 1 cm) and 9% of patients with adequate margins (> or = 1 cm). The incidence of pathological node positive (N+) disease was 6%, 36%, 50%, and 67% for T1, T2, T3, and T4 tumors, respectively. Twenty-five percent of patients undergoing elective neck dissection were pathological N+. All pathological confirmed nodal disease was at level I or II. Of the 43 patients with clinical N0 disease, 16% subsequently developed regional recurrence, all of which were surgically salvaged. CONCLUSION Locoregional control in patients with squamous cell carcinoma of the oral tongue can be achieved with primary surgical therapy. Adequate margins are crucial to local control. Salvage neck dissection may result in long-term survival for patients with regional relapse. Because of the high rate of occult disease (41%), we currently recommend prophylactic treatment of regional lymphatics for primary clinical disease of T2 or greater.

In vivo staining properties of oral cancer

Abstract Studies were carried out on the in vivo staining properties of fifty patients with proved or suspected oral neoplasia. Toluidine blue, a nuclear stain, was employed, and acetic acid 1 per cent was used for decolorization. Normal oral mucosa, with certain exceptions, does not stain. Our studies indicate that in vivo staining with toluidine blue is useful for: (1) the detection of areas of carcinoma in situ ; (2) the recognition of small, early invasive carcinoma; (3) delineation of the margins of larger epithelial neoplasms; (4) the recognition of postsurgical marginal recurrence; (5) The recognition of recurrence or new lesions postirradiation; and (6) the delineation of areas of field cancerization.

Rehabilitation of deglutition problems in patients with head and neck cancer

Patients who have undergone major resections for cancer in the oral cavity, oropharynx, hypopharynx, and larynx may experience varying degrees of swallowing difficulty. Such difficulty may result from (1) actual loss or alteration of structure; (2) loss or disturbance of motility and sphincteric function; (3) incoordination of peristaltic and sphincteric functions; (4) loss of motor or sensory nerve supply, or both; and (5) scar formation, fibrosis, fistula formation, or persisting edema in the upper alimentary tract. In addition, other factors such as pain and xerostomia may influence the swallowing function. Psychologic and emotional problems specifically consequent to the swallowing disability are not uncommon. The rehabilitation of swallowing disability is a major challenge in head and neck oncology. Clinical insight and a rational basis for the rehabilitation and management of swallowing impairment may be obtained from (1) an understanding of the mechanism of normal swallowing, (2) an understanding of the clinical correlation of the dysphagia with the nature and extent of surgical resection, and (3) direct observation of the adaptive and compensatory mechanisms developed by patients.

Management of advanced glottic carcinomas

One hundred twenty-eight patients with T3 or T4 glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent (12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.