Mohamed S. Razack

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.

Correlation between prognosis and degree of lymph node involvement in carcinoma of the oral cavity.

Abstract Accurate histologic determination of lymph node metastasis is most important in predicting prognosis in patients who undergo radical neck dissection. In this study of 340 determinate patients, the five year survival was 75 per cent when lymph nodes were histologically negative, 49 per cent when one lymph node was positive, 30 per cent when two lymph nodes were positive, and 13 per cent when three or more nodes were positive. Other factors useful in predicting prognosis are, to some extent, the level of lymph node metastasis in the neck, and the presence or absence of capsule penetration and soft tissue involvement. Those patients with metastasis to three or more lymph nodes had a five year survival of 13 per cent and belong to a high risk group. In this high risk group among those who died, the incidence of recurrence in the neck was 72 per cent, and the incidence of distant metastasis was 70 per cent. When autopsy was performed, more still were found to have distant metastasis, 75 to 80 per cent. Most of these high risk patients already have systemic dissemination of cancer at the time of their initial therapy; therefore, the addition of a systemic form of adjuvant therapy, such as chemotherapy and/or immunotherapy, is justified.

Chemotherapy for advanced and recurrent squamous cell carcinoma of the head and neck with high and low dose cis-diamminedichloroplatinum.

Cis-diamminedichloroplatinum (cis-DDP) in both a high dose regimen of 120 mg/M2 every three weeks with pretherapy hydration and mannitol diuresis and a low dose regimen of 20 mg/M2 daily for five days and cycled every three weeks have effective antitumor activity in approximately one third of patients. Its toxicity in both regimens appears to limit the number of cycles of administration and the duration of response. Further trials with dose schedules intermediate between the present high and low dose schedules are needed to provide a suitable and effective one day regimen every three to four weeks that can be given on an outpatient basis and on a long-term basis.

Major head and neck reconstruction using the deltopectoral flap: A 20 year experience☆

Six hundred seventy-eight deltopectoral flaps were raised in 604 patients, 125 of which were delayed and 215 of which were used in previously irradiated beds. The rate of major flap necrosis was 16.9 percent and the overall rate of complications, 51.4 percent. Delay in creating the deltopectoral flap had no influence on the risk of complications and necrosis, whereas the use of the flap in a previously irradiated bed was associated with a significantly increased risk of major flap necrosis. The least flap loss occurred when the deltopectoral flap was used without tubulation for skin coverage only. Complications and flap necrosis occurred most frequently when flaps were tubulated in a reversed manner or used for lining of major portions of or for total oropharyngeal and hypopharyngeal reconstruction. The deltopectoral flap remains a useful, reliable, and versatile regional flap that can be used alone or in combination with other flaps in selected circumstances for major head and neck reconstruction.

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.

Surgical management of squamous cell carcinoma of the floor of the mouth

Treatment failure and survival in 209 patients with squamous cell carcinoma of the floor of the mouth treated with surgery as the single curative modality are reported. Fifty percent of the patients had stage III and IV disease. The primary tumor was excised with 1 to 2 cm margins and the mandible was resected in 73 percent of the patients; 77 percent underwent radical neck dissection. No cures were observed in 11 patients with involved surgical margins on permanent section. For 198 patients with uninvolved margins, determinate survival at 5 years for all stages was 49 percent and 69, 64, 46, and 26 percent for stages I through IV (p less than 0.01). The most common sites of initial and ultimate treatment failure were the neck (42 of 72 patients) and distant metastases (33 of 53 patients), respectively. Treatment of the neck is identified as an unresolved problem in the management of early stage disease. Recent improvements in survival for stage III and IV disease are accounted for, in part, by adequate surgical resection.

Carcinoma of the Hypopharynx: Success and failure

Abstract From January 1957 to December 1971, 141 patients were treated for hypopharyngeal carcinoma. Twenty-one patients who died within three years of treatment with unrelated cause are excluded, leaving 120 patients for the present study with a minimum of five years follow-up. Nine patients were classified stage I, eight stage II, eighty-four stage III, and nineteen stage IV. Eighty-one patients were treated primarily by radical surgery with (27) or without (54) deltopectoral flap reconstruction. Twenty of these eighty-one patients (24 per cent) survived for five years. Four patients had microscopic tumor at margin of resection and received a full course of radiation therapy in the immediate postoperative period. Two of four (50 per cent) survived for five years. Fiftyseven other patients developed recurrences; of these, forty patients could be treated with radiation therapy. Eight of forty patients (20 per cent) with postoperative local recurrences and treated with radiation therapy survived five years. The overall total five year survival by surgery, surgery and immediate postoperative radiation therapy for microscopic residual disease, and surgery and radiation therapy for postsurgical local recurrence is 37.3 per cent (30/81). Eleven patients were seen here with radiation therapy failures elsewhere that were treated with surgery. Five year survival in this group is 27.27 per cent (3/11). Twenty-eight patients were treated here with radiation therapy alone. These patients were in very poor general condition or had far advanced disease (fixed neck masses). Only one of twenty-eight (3.5 per cent) was alive after five years. Total five year survivorship was 34 of 120 (28.3 per cent). Seven patients had stage I, five stage II, twenty-one stage III, and one stage IV disease. From this study it appears that radiation therapy for local postoperative recurrence and in the immediate postoperative period for microscopic residual disease is worthwhile and can significantly increase the five year salvage rate.

Radiotracer Uptake in Medullary Carcinoma of the Thyroid

A patient with pathologically confirmed medullary carcinoma of the thyroid with lymph node metastases was noted to show uptake of radiothallium, radiopertechnetate, and radioiodine. A perchlorate washout test was markedly positive, indicating that the uptake was largely due to trapping.

Immunologic patterns of regional lymph nodes in squamous cell carcinoma of the floor of the mouth: Prognostic significance

Histologic specimens from 43 patients with squamous cell carcinoma of the floor of the mouth treated exclusively by surgery were studied with special attention paid to the reactivity of regional lymph nodes. The lymph nodes were classified into four microscopic patterns of immune response: lymphocyte predominance for sinus histiocytosis, germinal center predominance, unstimulated, and lymphocyte depletion. No nodes of the lymphocyte depletion pattern were found. Correlations were then made between the patterns and survival rate at 5 year follow-up. The results showed that those patients with lymph nodes that demonstrated lymphocyte predominance had a better survival rate than patients with germinal center predominance and the unstimulated patterns. These correlations were independent of stage and metastatic nodal status and the differences were statistically significant (p less than 0.5). Morphologic assessment of immunologic activity in lymph nodes that drain carcinoma of the floor of the mouth appears to be of significant prognostic value.

Suppressive therapy of thyroid nodules in patients with previous radiotherapy to the head and neck

This is a prospective, randomized study of 431 patients with palpable thyroid nodules who had previous radiotherapy for benign disorders of the head and neck area to determine the response of the thyroid nodules to suppressive therapy and the incidence of thyroid cancer in patients who could not be suppressed and had surgery. A complete response was achieved within 6 months in 18.3 percent of the patients, and in an additional 26 percent of patients between 7 and 12 months postoperatively. Twenty percent of the patients showed complete disappearance of nodules after 1 to 2 years of suppressive therapy. Twenty-two percent who underwent surgery showed carcinoma. If suppressive therapy is to be used, a trial of 1 year rather than 3 or 6 months, as often recommended, may be appropriate.