Bilateral Neck Dissection Research Articles

Application of Indocyanine Green Angiography in Bilateral Axillo-Breast Approach Robotic Thyroidectomy for Papillary Thyroid Cancer.

BackgroundIndocyanine green angiography (ICGA) has been used to identify and preserve the parathyroid glands (PGs), and to evaluate PGs viability and function during thyroid surgery. However, evidence on the utilization of IGCA in thyroid cancer and robotic surgery is lacking. The efficacy of IGCA remains to be evaluated in PTC patients undergoing bilateral axillo-breast approach robotic thyroidectomy (BABA RT) and central neck dissection (CND).MethodsFrom March 2020 to August 2021, 81 papillary thyroid cancer (PTC) patients receiving total thyroidectomy and CND were enrolled in this retrospective analysis. An intravenous bolus of 7.5 mg ICG was administrated three times in the ICGA group (n=34). Medical records were reviewed and analyzed, including the baseline characteristics, surgical parameters, PGs-related parameters, and perioperative PTH and calcium levels.ResultsThe mean number of total identified PGs and preserved PGs were significantly more in the ICG group than in the control group (3.74 ± 0.45 vs. 3.15 ± 0.55, P<0.001; 3.12 ± 0.64 vs. 2.74 ± 0.57, P=0.007, respectively), as were PTH and calcium levels on POD 1 (23.16 ± 18.32 vs. 6.06 ± 7.74, P=0.039; 2.13 ± 0.11 vs. 2.08 ± 0.08, P=0.024, respectively). While there were no differences in PTH levels on POD 30. Additionally, patients with at least one well vascularized PG had higher ioPTH 3 and PTH on POD 1, which significantly suggested the absence of postoperative hypocalcemia. Although not statistically significant, ICGA seemed superior to relative ioPTH decline and ioPTH 3 in predicting postoperative hypocalcemia.ConclusionIn PTC patients undergoing BABA RT and CND, ICGA is a simple, safe, effective, and cost-effective tool in better identification and preservation of PGs as well as evaluation of PGs viability and function, with the potential to preserve more PGs, guide more appropriate autotransplantation, and accurately predict postoperative hypocalcemia.

More than two – A cadaveric study on the morphometry and classification of the digastric muscle in a selected kenyan population

This study aims to elucidate anatomical variations of the digastric muscle in the Kenyan population. A total of 41 bilateral neck dissections were performed whereby morphologic observations and morphometric measurements were carried out to characterize and classify the various presentations of the muscle. All cadavers presented with bilateral anterior (ABDM) and posterior (PBDM) bellies of the digastric muscle. Accessory ABDM was observed in 68.3% of cadavers with De-Ary-Pires et al.'s Type II (one accessory belly; 48.8%) and Type III (two accessory bellies; 34.1%) being the most common variations. Unilateral accessory ABDM (43.9%) was more common than bilateral accessory ABDM (24.4%). Two cadavers presented with a mentohyoid muscle. In addition, variations that have not been previously reported, namely fusion of ABDM to the midline and insertion of accessory ABDM into the hyoid bone were observed in one case each. Variation of the PBDM was less prominent, observed at 12.2% of sides dissected. Duplication of PBDM was observed on 4 sides with origin at the mastoid process. The PBDM was longer than the ABDM, but narrower in width. The mean length and width of the ABDM were 4.29±0.72cm and 1.52±1.07cm. The mean length and width of the PBDM were 5.64±1.31cm and 1.07±0.28cm, with the right side being statistically larger than the contralateral side. Variations of the digastric muscle are a common finding, with a high incidence at the ABDM. Two new variants were discovered.

Prevalence and Patterns of Nodal Metastasis Among Oral Cavity Cancer Patients: A Prospective Observational Study.

Lip and oral cavity cancer remains the most common cancer among Indian males and third most common cause of cancer-related deaths in India. Cervical lymph node metastasis is one of the most important prognostic factors in oral cavity cancer. The aim of present study was to estimate the prevalence of nodal involvement and analyse patterns of nodal metastasis in oral cavity cancer patients. This prospective observational study was conducted between January 2019 and June 2020. Patients of oral cavity squamous cell carcinoma undergoing surgery with simultaneous neck dissection were included. Data pertaining to the clinical profile, treatment and histology details were collected and analysed. A total of 63 patients were included in present study. Out of 63 patients, unilateral neck dissection was performed in 47 (75%), while 16 (25%) underwent bilateral neck dissection. Overall clinical and pathological nodal positivity rates were 75% and 52%, respectively. Level I (48%) followed by IIa (20%) were most commonly involved stations. Combined involvement of level IV and V was seen in only 5%, and no skip metastasis was reported in level IV and V. Level I and II are the most commonly involved stations in oral cavity squamous cell carcinoma (SCC). Oral SCC has a predictable nodal spread pattern with no skip metastasis to level IV/V noted in present study. There is a need for good quality randomised control trials to optimise the treatment protocols in clinically node-positive patients with respect to level IIB and V dissection.

Extent of Neck Dissection and Cervical Lymph Node Involvement in Oral Squamous Cell Carcinoma.

IntroductionTumor resection combined with neck dissection (ND) or radiotherapy are established methods for the treatment of patients with oral squamous cell carcinoma (OSCC). However, the extent of ND can lead to postoperative complications. Therefore, for the first time, this study aims to identify lymph node involvement in OSCC performed in a bilateral systematic approach based on oncologic board meetings relying on presurgical magnetic resonance imaging (MRI) and computed tomography (CT).Materials and MethodsIn a retrospective single-center study, patients with primary OSCC resection and systematic ND performed in 4 different manners (MRND III bilateral, MRND III left and SND right, MRND III right, SND left, and SND bilateral) were examined. Lymph node involvement allocated to levels was evaluated depending on primary localization and T-stage.ResultsA total of 177 consecutive patients (mean age 63.64; 92 female, male 85) were enrolled in this study. A total of 38.98% showed cervical lymph node involvement, and metastases were found in levels 1–4. The distribution of positive lymph node metastases (n=190 LNs) was 39.47% in level 1, 38.95% in level 2, 10.53% in level 3, and 11.05% in level 4.DiscussionIn a cohort of OSCC patients with systematic bilateral ND, levels 1 and 2 had positive lymph node involvement, and no lymph node involvement was seen at level 5. Without any clinical or imaging suspicion, ND expanding 5-level MRND should be avoided regardless of the primary tumor localization, T-stage and intraoperative proof of cervical metastases.

Risk Factors Associated With Reoperative Surgery for Thyroid Malignancies: A Retrospective Cohort Study.

To examine various factors associated with an increased risk of reoperation for persistent or recurrent malignant thyroid cancers. Retrospective cohort study. Tertiary academic hospital centers. Patients undergoing surgery for thyroid cancer at 2 tertiary academic institutions from 2006 to 2020 were included. Those who underwent a reoperative procedure were compared with patients only requiring 1 procedure. The Pearson chi-square and independent t test were used to compare group data accordingly. Furthermore, a binomial logistic regression was performed, while machine learning models were used to construct a predictive algorithm. This study included 2266 patients with surgically managed thyroid malignancy, of which 54 (2.4%) necessitated reoperations. Those requiring a second surgical procedure were more likely to be male (40.7% vs 20.9%, P < .001), undergo bilateral (24.1% vs 3.3%, P < .001) and lateral (16.7% vs 1.8%, P < .001) neck dissections, and have a greater number of metastatic lymph nodes (mean, 9.1 vs 3.5; P < .001) and a larger tumor size (mean, 3.0 vs 2.0 cm; P < .001). According to the binomial logistic regression model, lateral neck dissection, greater number of metastatic lymph nodes, and larger tumor size significantly increased the odds of necessitating a second procedure by 7.8 (95% CI, 2.523-24.083), 1.1 (95% CI, 1.032-1.152), and 1.3 (95% CI, 1.064-1.559), respectively. Last, machine learning models could not significantly predict the occurrence of reoperation. This study identified patient- and cancer-related characteristics associated with an increased risk of requiring reoperation for thyroid malignancies.

The Necessity of Lymph Node Dissection Between Sternocleidomastoid and Sternohyoid Muscles in pN1b Papillary Thyroid Carcinoma

BackgroundThis study aimed to evaluate the association between clinicopathologic variables and metastasis of the lymph node (LN) between the sternocleidomastoid and sternohyoid muscles (LNSS) to clarify the necessity of LNSS dissection in papillary thyroid carcinomas (PTCs).MethodsA total of 219 patients undergoing unilateral or bilateral neck dissection for PTCs were prospectively enrolled. The associations between clinicopathologic variables and LNSS metastasis were evaluated by univariate and multivariate analyses.ResultsLNSS was present in 108 (40.1%) neck dissection samples and in 76 (34.7%) patients. Positive LNSS occurred in 40/269 (14.9%) neck dissection samples and in 20/219 (9.1%) patients. Univariate analysis showed that tumor stage, number of positive nodes in level III, and number of positive nodes in level IV were related to LNSS metastasis. Multivariate analysis confirmed that T3/4 stage tumors and >2 positive LNs in level IV independently increased the risk of LNSS metastasis.ConclusionsThe low rate of LNSS metastasis would deem routine dissection unnecessary; however, LNSS would require excision if advanced stage tumors or level IV LN metastasis were present.

Factors Influencing Lymph Node Metastasis From Supraglottic Laryngeal Carcinoma

In patients with supraglottic carcinoma (SGLC), lymphatic metastasis is frequent and can cause a significant reduction in local control rate and survival. Currently, the preferred method of neck treatment in patients with supraglottic cancer is prophylactic bilateral neck dissection that could result in overtreatment in at least two thirds of patients. The purpose of this study is to evaluate factors influencing neck metastasis and to determine whether routine elective neck dissection is necessary for the management of all SGLCs. 66 patients with SGLCs who underwent transoral laser surgery and neck dissection were included in this study. The rate of overall and occult lymphatic involvement was 29% and 20%, respectively. The most common involvement site was level II, and factors such as T category, tumor grade, epilarynx involvement, and extension of tumor to the medial wall of pyriform sinus were significantly related to cervical lymph node metastasis. In conclusion, our results suggest that in selected patients with SGLC (such as small T1 or lateralized tumors), elective neck treatment could be ignored, and instead, close follow-up be considered.

ONLY THE INQUIRING MIND SOLVES PROBLEMS

<h3>Objective</h3> Hyalinizing clear cell carcinoma (HCCC) is a rare low-grade malignancy involving mainly the minor salivary glands of the palate. It usually presents as a painless swelling and follows an indolent behavior. Histologically, it demonstrates nests of monomorphic clear cells and cells with eosinophilic granular cytoplasm. The histologic overlap between different tumor types poses diagnostic challenges, and molecular changes are becoming pivotal for classification. Most HCCCs have a t(12;22)(q13;q12) chromosomal translocation, leading to fusion of the EWSR1 and ATF1 genes. The integration of histology, fluorescence in situ hybridization (FISH), and immunohistochemistry confirms the diagnosis of HCCC, dictating the prognosis and management. Most HCCCs have a good outcome and respond well irrespective of treatment. <h3>Case Summary</h3> A 61-year-old man with a medical history significant for hyperlipidemia and diabetes mellitus presented for virtual (video) evaluation of throat pain when swallowing present for 1 month. Limited evaluation exhibited an oral mass and the patient was evaluated in person the next day. Examination revealed a soft, crater-like mass of 3 cm in diameter involving the soft and hard palate. Incisional biopsy demonstrated an infiltrative tumor composed of nests of monotonous, round to polygonal epithelial cells with variably eosinophilic to clear cytoplasm surrounded by hyalinized stroma and with perineural invasion. Immunohistochemistry demonstrated p40 positivity of neoplastic nonductal cells; FISH analysis was positive for EWSR1 rearrangement in 82% of the nuclei. The integrated pathologic findings confirmed the diagnosis of HCCC. Imaging was negative for involved cervical nodes or distant findings. The patient underwent partial maxillectomy and bilateral neck dissection followed by adjuvant radiation therapy. <h3>Conclusions</h3> HCCC is a rare low-grade salivary gland malignancy with indolent behavior. Morphologic features remain the cornerstone of salivary gland tumor assessment; however, ancillary testing now helps define the diagnosis. FISH for EWSR1 is a paramount marker for several tumors; nonetheless, EWRS1 rearrangement is not specific for 1 entity and FISH interpretation should be intertwined with clinical, morphologic, and immunohistochemical features to confirm the diagnosis, predict good prognosis, and guide subsequent management of HCCC. Although virtual care can be an effective triage tool, there must be a low threshold for subsequent in-person evaluation to provide adequate care.

Feasibility of dpFAMM flap in tongue reconstruction after facial vessel ligation and radiotherapy\u2014case presentation

BackgroundSalvage surgery with reconstruction of the second and next primary tongue cancer remains difficult, especially after earlier neck dissection and radiotherapy. In the current report, we describe the feasibility of the extended, double-pedicled facial artery musculomucosal (dpFAMM) flap in the reconstruction of the patient with second primary tongue squamous cell carcinoma, after facial vessel ligation and radiotherapy.Case presentationAn 81-year-old female patient was operated on due to tongue squamous cell carcinoma (SCC) on the left side T3N1M0 in 2019. Bilateral selective neck dissection with tongue reconstruction was performed by island FAMM flap. The patient also suffered from synchronous mucinous breast carcinoma treated with tamoxifen. The second primary SCC of the tongue on the opposite (right) side was detected in 2020. The patient did not agree to surgical treatment; therefore, radiotherapy was performed. The local recurrence of the tongue cancer of the right side was treated surgically in 2021. Salvage surgery comprised hemiglossectomy and dpFAMM flap reconstruction with uneventful postoperative follow-up.ConclusionsThis case presentation proved that dpFAMM flap can be used in salvage surgery and reconstruction even in patients after ligation of facial vessels, irradiation, and in the course of hormone therapy. The flap is easy to handle, has good vascularity, and comprises a predictable method of reconstruction, especially for patients with severe comorbidities.

Dosimetric Comparison of Intensity Modulated Radiotherapy (IMRT) and Intensity Modulated Proton Therapy (IMPT) for Novel Oral Tongue Avoidance Concept in Low-Risk Squamous Cell Carcinoma of the Oral Tongue

<h3>Purpose/Objective(s)</h3> A subset of favorable oral tongue squamous cell carcinoma patients who undergo adequate surgical resection are at low risk of local recurrence to the primary site. Since irradiation of the primary site is the major cause of treatment morbidity during adjuvant radiotherapy, avoidance of this target while still treating the at-risk lymph nodes including the intervening lymphatics between the tongue and neck is an attractive potential treatment strategy. Prior to initiation of an investigator-initiated trial, we sought to quantify the dosimetric advantage of this strategy, hypothesizing intensity modulated proton therapy (IMPT) may further reduce dose to organs at risk (OAR) when avoiding the oral tongue compared to intensity modulated radiation therapy (IMRT). <h3>Materials/Methods</h3> Five consecutive patients with oral tongue cancer treated with postoperative radiation therapy from 8/2020 to 9/2021 were retrospectively reviewed. Novel Clinical Target Volume (CTV) contours were generated that excluded the oral tongue while maintaining coverage of at-risk lymph nodes. Comparison IMRT (X) and IMPT (PBT) plans were generated using both standard treatment volumes (Control) and oral tongue avoidance volumes (Study) (n=4 plans per patient). Dosimetric variables for critical OARs were compared using the paired t-test. <h3>Results</h3> Patients had T1-2 and N0-N2b disease with complete margin-negative partial or hemiglossectomy and bilateral neck dissections. The prescribed dose was 60 Gy in 30 fractions. D95% CTV coverage was similar between X and PBT plans for both Control and Study target volumes. Comparing Control to Study plans, both X (58.9 Gy vs. 38.3 Gy, p=0.007) and PBT (60.2 Gy vs. 26.1 Gy, p<0.001) decreased the mean dose to the oral cavity (OC). Similar results were demonstrated for mean pharyngeal constrictor dose with X (47.7 Gy vs. 44.6 Gy, p=0.003) and PBT (45.0 Gy vs. 34.9 Gy, p=0.001). There was no difference between Control and Study plans for larynx (p>0.19) or parotid (p>0.11) mean dose, or mandible max dose (p>0.59). Comparing the Study plans alone, PBT resulted in a significant reduction in mean OC dose (38.3 Gy vs. 26.1 Gy, p=0.007) and reduction in mean parotid dose (23.3 Gy vs.19.3 Gy, p=0.03) compared to X. For Control plans, there was no difference in OC dose using PBT compared to X but an improvement in mean parotid dose (26.6 Gy vs 19.7 Gy, p=0.02). <h3>Conclusion</h3> This study quantifies the dosimetric advantage of avoiding the oral tongue while still treating the at-risk intervening lymphatics and the bilateral necks during adjuvant radiotherapy for oral tongue cancer. The dosimetric difference between PBT and X was most prominent with an oral tongue avoidance strategy. Prospective studies are warranted to evaluate the clinical efficacy of oral tongue avoidance for favorable oral tongue cancer patients with indications for elective nodal irradiation.

PET/CT Prediction of Head and Neck Melanoma Nodal Metastases

<h3>Purpose/Objective(s)</h3> Lymph node dissection is an important oncologic treatment for many head and neck melanomas. Over time, surgeons have narrowed the basins covered by neck dissections based on the underlying disease. In melanoma, there is a need for diagnostic modalities that can effectively predict locoregional metastasis to tailor the extent of neck dissection. PET-CT is an imaging modality often employed in oncologic staging, but definitive data are lacking on basin-specific predictive capabilities of PET-CT for head and neck melanoma. The objective of this study is to determine the predictive value of PET-CT for detecting melanoma metastasis to head and neck lymph node basins. <h3>Materials/Methods</h3> This is a retrospective case series of adults who underwent lymphadenectomy for melanoma metastasis to the neck at a single tertiary academic medical center from 2000-2018. Exclusion criteria included: prior head and neck radiation or lymphadenectomy except for sentinel lymph node biopsies, lack of preoperative PET-CT images, incomplete pathology records, or less than one year of follow-up. Demographic data, clinical and pathologic staging, surgical details, and post-operative complications were collected. The eighth edition of the American Joint Committee on Cancer staging system was used. PET-CT was performed according to institutional protocol, and all PET-CT images were re-reviewed by a board-certified nuclear medicine physician blinded to pathology results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for predicting nodal metastasis were calculated by comparing the results of the PET-CT to final pathology, which was considered the gold standard for this study. <h3>Results</h3> 108 subjects were included, 2 of whom had bilateral neck dissections, for a total of 110 neck dissections. Median follow-up was 2.0 years. The average age (SD) was 63 (14), 74% were male, and 93% identified as Caucasian. The most common primary sites were the face (n=30), scalp (n=29), and neck (n=23). The majority of tumors were classified as T2-T4 (77%) and as either cN1 (n=55) or cN0 (n=26) disease. The most frequent surgical complications included seroma (n=7) and hematoma (n=5). There were no reports of gross nerve injury or permanent neuropathies. When compared to final pathology, preoperative PET-CT had a 90% sensitivity (CI 79.5%-95.6%), 92% specificity (CI 80.7 %-97.4%), 93.1% PPV (CI 83.1%-97.8%), and 88.5% NPV (CI 76.7%-95%). In 86.5% of neck dissections, there was concordance on nodal basin metastases between PET-CT and final surgical pathology. <h3>Conclusion</h3> PET-CT demonstrates acceptable predictability of locoregional head and neck melanoma metastases with nodal basin concordance. This information could be incorporated into shared decision making regarding the extent of regional lymph node dissection as treatment paradigms shift.

Elective Neck Dissection during Salvage Total Laryngectomy: Personal Experience.

The role of elective neck dissection during salvage surgery in patients with a clinically negative neck (cN0) is still discussed. The main objective of this work was to estimate the prevalence and predictive factors of occult neck nodes metastasis; we therefore aimed to evaluate the survival rate and the main oncologic outcomes of cN0 patients who underwent salvage total laryngectomy and elective bilateral neck dissection. In this retrospective observational study, we enrolled 80 cN0 patients affected by recurrent laryngeal cancer and who underwent salvage total laryngectomy and bilateral selective elective neck dissection. Several parameters were collected in order to find prognostic factors; finally, postoperative complications were reviewed and survival analysis was performed. Occult lymph node metastases were reported in 18 out of 80 patients (22.5%). Significant statistical correlation between lymphovascular invasion (p = 0.007), perineural invasion (p = 0.025) and occult nodal metastasis was found. Other variables (glottic subsite of recurrence, clinical T, pathological T, previous chemotherapy) were not significantly predictive of occult nodal metastasis. The 5-year OS, DSS, and RFS were 50.4%, 64.7%, and 63.4%, respectively. In conclusion, our single-institution data on a large cohort of patients, suggest performing routinely elective selective bilateral neck dissection during salvage total laryngectomy in cN0 patients due to the biological attitude of the tumor to spread to cervical nodes, considering an acceptable complications rate.

Squamous cell carcinoma around a subperiosteal implant in the maxilla and the association of chronic mechanical irritation and peri-implantitis: a case report

BackgroundAs carcinogenic risk factors, environmental factors can be classified into physical, biological, and chemical factors. Subperiosteal implants (SIs) are associated with complications, such as framework exposure, infection, and fistula formation. A current hypothesis suggests that chronic mechanical irritation could be a co-factor in carcinogenesis, while peri-implantitis might be an initiating or promoting agent in the development of oral mucosal cancer. Herein, we report a case of squamous cell carcinoma (SCC) around a maxillary SI associated with chronic mechanical irritation and peri-implantitis as physical and biological factors, respectively.Case presentationA 74-year-old male patient presented with severe mobility of the SI and an undermined ulcer with induration, accompanied by a palatal fistula and the exposure of the metal framework. The SI had been placed on the maxilla for the occlusal reconstruction of the molar area 20 years ago. An incisional biopsy of the ulcer revealed SCC (cT4aN2cM0). Neoadjuvant chemotherapy was initiated, followed by bilateral neck dissection and partial resection of the maxilla with SI removal. Energy-dispersive X-ray analysis suggested that the SI was fabricated using pure titanium, and titanium was absent in the specimen. Scanning electron microscopy of the SI in contact with the SCC showed a few microcracks, suggesting pitting corrosion.DiscussionChronic mechanical irritation due to the mobility of an improperly designed SI can be a physical factor, and prolonged peri-implantitis without regular maintenance can be a biological factor in carcinogenesis. Improperly designed main struts and a large masticatory force in the molar area resulted in deterioration of the retention and mobility of the SI. The screw and framework frequently moved on mastication and came in direct contact with the ulcer as chronic mechanical irritation. Bacterial invasion into the subperiosteal space expanded by the mobility of the metal framework led to peri-implantitis. The influence of chemical factors was considered relatively small in this case since the patient had no history of smoking or drinking, and titanium was absent in the specimen. Therefore, it is conceivable that SCC can arise owing to persistent inflammation caused by chronic mechanical irritation and peri-implantitis as physical and biological factors, respectively.

Diagnosis and management of intra-operative pulmonary embolism under general anaesthesia in a peripheral tertiary care centre with limited resources.

Sir, It is difficult to detect and diagnose acute pulmonary embolism (APE) in patients under general anaesthesia (GA) as signs and symptoms such as dyspnoea, chest pain, haemoptysis and syncope are not evident.[1] A 64-year-old male, with left sided carcinoma buccal mucosa and American Society of Anesthesiologists physical status II, was listed for left anterior hemi-mandibulectomy with bilateral multinodal neck dissection and left sided pectoral muscle musculocutaneous flap (PMMC) under GA. Preoperative contrast enhanced computed tomography (CECT) thorax was unremarkable. After induction, haemodynamics remained stable during excision of the primary lesion. Approximately, 5 hours into the surgery, while raising the PMMC, the patient developed sudden pronounced hypotension with a mean arterial pressure of 45 mmHg and a decrease in end tidal carbon di-oxide (EtCO2) 38 mmHg to 15 mmHg. This was associated with bradycardia (heart rate 44-48/min) and a gradual fall in oxygen saturation to 86-88%. Peak airway pressures gradually increased from 21 cmH2O to 32 cmH2O with an associated increase in plateau pressures from 19 cmH2O to 29 cmH2O. Central venous pressures were elevated and bilateral breath sounds were marginally reduced with no adventitious sounds. There was no significant acute blood loss, nor any evidence of sepsis. Immediately, the inhalational agent was switched off and the fraction of inspiratory oxygen increased to 100%. Intravenous mephentermine 6 mg (two boluses), hydrocortisone 100 mg and atropine 0.6 mg were administered intravenously. A single intravenous adrenaline bolus of 10 μg was subsequently administered, followed by an infusion at the rate of 0.02 μg/kg/min. Immediate arterial blood gas (ABG) analysis showed hypercarbia as well as hypoxia [Table 1a]. Transthoracic echocardiography (TTE) through subcostal four chamber view showed dilated and strained right heart chambers (McConnell sign) and distended inferior vena cava [Figure 1a and b]. A probable diagnosis of APE was made.Table 1: Arterial blood gas analysisFigure 1: (a) Echo showing dilated IVC and RA (b) Dilated RA and RV. IVC: Inferior vena cava; RA: Right atrium; RV: Right ventricleOur institute is a tertiary cancer care centre in a small town with limited resources. After adequate resuscitation, a joint consensus among operating room team members was made for pharmacological treatment. Unfractionated heparin (UFH) 5000 IU was administered intra-venously. Activated partial thromboplastin time (APTT) was maintained 1.5-2 times of the normal value. We were in the middle of the surgery (with tumour excised and the PMMC flap raised), and the haemodynamics had stabilised. Repeat blood gas analysis came normal [Table 1b]. So, we decided to complete the surgery. Post-surgery, the patient was kept on mechanical ventilation. Vitals in the postoperative period remained stable. A dose of 2500 IU of UFH was repeated as the reported APTT was 38.3 seconds. The patient underwent computed tomographic pulmonary angiography which showed no filling defect [Figure 2] and was shifted onto subcutaneous low molecular weight heparin 60 mg twice a day. On post-operative day (POD) 1, the patient was weaned off the ventilator. He was shifted to the ward on POD 2. He was found haemodynamically stable during follow-up.Figure 2: CT Pulmonary Angiography (Post Surgery)APE leads to significant separation of EtCO2 and PaCO2 values intra-operatively. It causes a sudden decrease in EtCO2 and an increase in PaCO2. This separation in EtCO2 and PaCO2 values is also an important tool to measure thrombolysis under GA.[1] TTE coupled with EtCO2 changes seems to be useful in intra-operative cardio- circulatory failure to exclude other differential diagnoses.[2] The 2019 consensus European Society of Cardiology (ESC) guidelines strongly recommend intravenous UFH as a treatment of choice in haemodynamically unstable APE.[3] Catheter-directed therapy (CDT) had been done for APE.[4] CDT is recommended by the American College of Chest Physicians as second-line therapy for massive pulmonary embolism.[5] Our case is a classic example of APE in head and neck malignancy. The involvement of a multidisciplinary team can also help in preparedness for emergent and unanticipated situations.[6] We emphasise that vigilant monitoring of EtCO2, timely use of TTE and systemic anticoagulation with adequate intraoperative haemodynamic resuscitation can lead to safe completion of surgery with minimal morbidity and mortality. Though UFH is not a recommended modality in the intra-operative period, due to the limitations of our set -up, CDT was beyond our purview. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to concealidentity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A synchronous medullary and papillary thyroid carcinoma

&lt;p&gt;The synchronous occurrence of medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) is rare (&amp;lt;1%). The medullary component determines the prognosis. A 31-year-old female with no relevant personal or family cancer history presented with swelling on the right side of the neck. A fine-needle aspiration biopsy was positive for MTC and PTC. Mass sequencing of 322 genes associated with cancer came back negative. The histopathological examination revealed synchronous MTC and PTC with thymic and bilateral lymph node metastasis. The patient underwent total thyroidectomy with bilateral radical neck dissection (II-V), central dissection, and mediastinal dissection including the thymus. The extent of surgery is determined by MTC and the analysis of RET and BRAF mutations. Post-operative treatment must include monitoring for specific markers (calcitonin and thyroglobulin, respectively, for MTC and PTC). Based on histopathological results and recurrent PTC, TSH suppression and iodine-131 therapy should be considered. Recurrent MTC must be treated with new targeted therapies.&lt;/p&gt;

Isthmectomy is effective and sufficient for selected patients with the isthmus-confined solitary papillary thyroid carcinoma

BackgroundTo retrospectively analyze the outcomes of patients treated with isthmusectomy for a solitary papillary thyroid carcinoma (PTC) confined to the isthmus, and re-assess the role of isthmusectomy in these patients. MethodsThe medical records of 65 patients who underwent isthmusectomy for a solitary PTC confined to the isthmus at the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College between 1985 and 2015 were retrospectively reviewed. Demographic data, surgical procedures, pathological characteristics, stages, and outcomes were analyzed. ResultsPatients’ median age was 39 years (range, 19–63), and the majority were female (86.2% female, 13.8% male). All patients had a solitary PTC confined to the isthmus and were treated with isthmusectomy. Pretracheal lymph node dissection was performed in 34 patients, in which unilateral central neck dissection was performed in 4 patients and bilateral central neck dissection in 2 patients. Microscopic extrathyroidal extension (ETE) was observed in 23 (35.4%) patients, and macroscopic ETE was observed in 3 (4.6%) patients. Thirty-eight (58.5%) patients were stage pT1a, 19 (29.2%) patients were stage pT1b, 5 (7.7%) patients were stage pT2, and 3 (4.6%) patients were stage p3b. Fifteen (23.1%) patients were stage pN1a. Median follow-up time was 78 months (range, 12–274). Two patients experienced a recurrence and both achieved remission after re-operation. The 10-year recurrence-free survival was 92.1%. The 10-year overall survival and disease specific survival were 98.3% and 100%, respectively. ConclusionsIsthmusectomy is effective and sufficient for select patients with a solitary PTC confined to the isthmus.

Non-opioid analgesics and post-operative pain following transoral robotic surgery for oropharyngeal cancer.

To investigate associations between multimodal analgesia and post-operative pain among patients undergoing transoral robotic surgery for oropharyngeal squamous cell carcinoma. Records of patients who underwent surgery from 5 September 2012 to 30 November 2016 were abstracted. Associations were assessed using multivariable analysis. A total of 216 patients (mean age of 59.1 years, 89.4 per cent male) underwent transoral robotic surgery (92.6 per cent were human papilloma virus positive, 87.5 per cent had stage T1-T2 tumours, and 82.9 per cent had stage N0-N1 nodes). Gabapentin (n = 86) was not associated with a reduction in severe pain. Ibuprofen (n = 72) was administered less often in patients with severe pain. Gabapentin was not associated with increased post-operative sedation (p = 0.624) and ibuprofen was not associated with increased bleeding (p = 0.221). Post-operative opioid usage was not associated with surgical duration, pharyngotomy, bilateral neck dissections, tumour stage, tumour size, subsite or gabapentin. Scheduled low-dose gabapentin was not associated with improved pain control or increased respiratory depression. Ibuprofen was not associated with an increased risk of bleeding and may be under-utilised.

A case report of anaplastic thyroid cancer and papillary thyroid cancer lymph node metastasis: an unusual presentation as an invasive hypopharyngeal mass

Anaplastic thyroid carcinoma is a rare undifferentiated tumour of the thyroid follicular epithelium. It almost always develops from a pre-existing well-differentiated thyroid cancer with a co-existent thyroid malignancy varying from 5 to 17% . The co-existence of papillary thyroid cancer (PTC) with anaplastic thyroid cancer is a rare occurrence in metastases outside the primary thyroid lesion. Traditionally, this has been regarded as an aggressive form of cancer associated with a dismal prognosis. Recently, the focus has shifted to the development of novel therapies based on the availability of comprehensive genomic profiling platforms (CGP) with a rapid turn-around to identify molecular aberrations in tumours which acts as potential therapeutic targets. In the United Kingdom, we report the case of a 60-year-old woman with an unusual presentation of (metastatic) anaplastic thyroid carcinoma and concomitant papillary thyroid cancer metastasis within a contralateral lymph node. This was initially perceived as a left pyriform fossa mass involving and compressing her left hemi-larynx on clinical and radiological examination. Following the identification of BRAF V600E mutation on CGP, she was started on targeted therapy with the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib and demonstrated excellent clinical and radiological response following 7 months of treatment. She has subsequently undergone total thyroidectomy alongside with bilateral neck dissection, and is due to start radioactive iodine treatment to reduce the risk of recurrence of disease.

Prophylactic bilateral central neck dissection should be evaluated based on prospective randomized study of 581 PTC patients

BackgroundProphylactic central lymph node dissection (PCND) was a basic consensus for patients with papillary thyroid carcinoma (PTC) in China. However, unilateral or bilateral central lymph node dissection (CND) was still controversial. This study aimed at investigating the safety and long-term benefit for the patients undergone with bilateral central lymph node dissection (BCCD).Methods581 patients were enrolled and divided randomly into the test and control groups according to range of CND. 285 patients were prospectively assigned to undergo thyroid lobectomy plus BCND in the test group, other 296 patients were assigned to undergo thyroid lobectomy plus ipsilateral central lymph node dissection (ICND) in the control group.ResultsWe found that the numbers of total LN and pN1a in the test group were more than that of the control group (p = 0.002,0.004), but there was no difference in the number of metastasized lymph nodes (p = 0.857) and tumor recurrence (p = 0.308). Additionally, in the aspect of postoperative complication (1 day after surgery), the serum levels of parathyroid hormone in the BCND group were lower than that in the ICND group (P = 0.010), and the numbers of transient laryngeal nerve palsy were more than that(p = 0.033). Meanwhile, we further found that pathological tumor size larger than 1 cm and tumor side lymph node metastasis were independent risk factors for contralateral central lymph node metastasis(p = 0.002,0.001).ConclusionBCND may be an alternative for patients with tumor sizes larger than 1 cm, but it would significantly increase the rate of transient vocal cord palsy, parathyroid auto transplantation and decreased PTH, but the risk of permanent complications was similar to the ICND group.

Thyroglossal Duct Cyst Carcinoma in The Pediatric Population: A Case Report and Literature Review

Thyroglossal duct cyst carcinoma (TGDCa) is a rare cause of neck masses in children. Its pathophysiology stems from two main theories. One suggests that the primary carcinoma originated from ectopic thyroid tissue, whilst the other suggest it is a result of metastasis to the thyroglossal duct cyst from the thyroid gland. A case of a 12-year-old girl who presented with a suspicious neck mass and subsequently diagnosed with TGDCa is reported. A literature review was performed and we conclude that aggressive surgical management of a Sistrunk procedure, total thyroidectomy, bilateral tracheoesophageal groove clearance and neck dissection was justified for this child. We found that if the preoperative diagnosis is TGDCa, a more aggressive surgical approach tends to be taken. However, cases of recurrence remain low and a total thyroidectomy does entail a larger morbidity for the pediatric patient. Hence, we do not recommend an aggressive approach routinely. In this review, we extrapolated AJCC data for thyroid malignancies and staged the TGDCa reported in literature in the last 10 years. It showed us that pT3 tumors tend to have a more aggressive surgical course, whilst a pT1 TGDCa tend to receive a more conservative surgical approach.