Cervical Dissection Research Articles

57-Year-Old Man With Vertigo

57-Year-Old Man With Vertigo

Near-infrared irradiation of the thyroid area: effects on weight development and thyroid and parathyroid secretory patterns.

This study evaluates possible changes in weight and the secretory patterns of the thyroid and parathyroid glands irradiated with a 780-nm light-emitting diode (LED) source under conditions allowing their identification in an animal model. The use of near-infrared light sources to detect the parathyroid glands has been a subject of research due to the benefit provided to patients undergoing thyroid and parathyroid surgery. However, few studies have explored possible changes in weight and the secretory patterns of the glands when subjected to light stimulation. Thirty-two male Wistar rats were divided into two groups and subjected to cervical dissection and irradiation of the thyroid-parathyroid region under general anesthesia. The animals in group 1 (irradiated) were exposed to a 780-nm LED light beam for 180s (dose 1.37J/cm2), whereas the animals in group 2 (control) were not irradiated. Blood samples were collected pre-exposure, 7min after exposure, and 30 and 60days after exposure to measure calcium, parathyroid hormone (PTH), triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) levels in both groups. Weight variations between the evaluation periods were also analyzed. Parametric statistics were used (Student's t test and ANOVA) after assuming normal distribution of continuous variables with the Shapiro-Wilk test. No significant variation was observed in any of the analyzed parameters pre- and postexposure. A significant increase in the calcium level was observed at 30days in the irradiated group compared with that in the control group (11.156 ± 1.31mg/dl vs 10.300 ± 0.30mg/dl; df = 30 p < 0.03) but this change was no longer observed at 60days (9.925 ± 0.23mg/dl vs 10.014 ± 0.18mg/dl; df = 14 p = 0.21). Irradiated rats gained less weight in the first 30days after surgery (39.647 ± 32.39 vs 55.917 ± 22.61; df = 30 p = 0.146) and at 60days (84.000 ± 27.36 vs 84.571 ± 5.62; df = 14 p = 0.957), no differences were observed between the two groups. No significant variations in weight development or changes in the secretory patterns of the thyroid and parathyroid glands exposed to near-infrared stimulation were observed, confirming the safety of this light source in the identification of the parathyroid glands.

The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature.

Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations. The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates. Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients.Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01). The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant paraclinoid aneurysms.

Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection

Extracranial carotid and vertebral artery dissection is an important cause of stroke, particularly in younger individuals. In some but not all observational studies, it has been associated with a high risk of recurrent stroke. Both antiplatelet agents (APs) and anticoagulants (ACs) are used to reduce stroke risk, but whether 1 treatment strategy is more effective is unknown. To determine whether AP or AC therapy is more effective in preventing stroke in cervical dissection and the risk of recurrent stroke in a randomized clinical trial setting. A secondary outcome was to determine the effect on arterial imaging outcomes. Randomized, prospective, open-label international multicenter parallel design study with central blinded review of both clinical and imaging end points. Recruitment was conducted in 39 stroke and neurology secondary care centers in the United Kingdom and 7 centers in Australia between February 24, 2006, and June 17, 2013. One-year follow-up and analysis was conducted in 2018. Two hundred fifty participants with extracranial carotid and vertebral dissection with symptom onset within the last 7 days were recruited. Follow-up data at 1 year were available for all participants. Randomization to AP or AC (heparin followed by warfarin) for 3 months, after which the choice of AP and AC agents was decided by the local clinician. The primary end point was ipsilateral stroke and death. A planned per protocol (PP) analysis was performed in patients meeting the inclusion criteria following central review of imaging to confirm the diagnosis of dissection. A secondary end point was angiographic recanalization in those with imaging confirmed dissection. Two hundred fifty patients were randomized (118 carotid and 132 vertebral), 126 to AP and 124 to AC. Mean (SD) age was 49 (12) years. Mean (SD) time to randomization was 3.65 (1.91) days. The recurrent stroke rate at 1 year was 6 of 250 (2.4%) on ITT analysis and 5 of 197 (2.5%) on PP analysis. There were no significant differences between treatment groups for any outcome. Of the 181 patients with confirmed dissection and complete imaging at baseline and 3 months, there was no difference in the presence of residual narrowing or occlusion between those receiving AP (n = 56 of 92) vs those receiving AC (n = 53 of 89) (P = .97). During 12 months of follow-up, the number of recurrent strokes was low. There was no difference between treatment groups in outcome events or the rate of recanalization. ISRCTN.com Identifier: CTN44555237.

THE RELATION BETWEEN THE EXCISED THYROID GLAND WEIGHT AND POSTOPERATIVE COMPLICATIONS IN TOTAL THYROIDECTOMY PATIENTS

Aim: The purpose of this study was to determine the postoperative complications in total thyroidectomy patients based on the weight of the thyroid gland with retrospective screening.Material and Methods: A total of 263 adult patients, who underwent total thyroidectomy were included. The data automation system of the hospital and the files of the patients were examined retrospectively.Results: The total complication incidence was 24.3%, and these were determined as hypocalcemia, vocal cord paralyses (VCP), and hemorrhage and seroma at the surgery area. The rate of temporary hypocalcemia and permanent hypocalcemia rate was 20.1% and 1.5% respectively. The temporary VCP rate was 0.3% (n=1), and no permanent VCP was observed in the patients. The median thyroid weight was measured as 50 gr in patients without postoperative hypocalcemia, and as 40 g in the patients with hypocalcemia (p=0.283). There was no significant relation between the variability in the weight of the thyroid and postoperative hypocalcemia. However, the cervical lymph node dissection (LND) (p=0.006) and cervical dissection site (p=0.031) were significant in terms of postoperative complication development. In the multivariate analyses, it was found that female gender and LND were independent risk factors in the development of postoperative complications.Conclusion: It was determined that cervical LND and female gender were independent risk factors. Consistent with the literature findings, no significant results were found in the risk factors like heavy thyroid gland, presence of thyroid operation history, malignant thyroid pathology, retrosternal localization of the thyroid tissue, and hyperthyroidism.Keywords: Complications; hypocalcemia; thyroid weight; total thyroidectomy.

Postoperative Hypoparathyroidism in Patients After Total Thyroidectomy - Experience of a Tertiary Center in Romania.

Background: Post-surgical hypoparathyroidism (PoSH) is a common long-term complication after thyroid surgery. The reported median (range) incidence rates of temporary and permanent PoSH was 27% (19 - 38%) and 1% (0 - 3%) respectively. Material and Methods: We retrospectively analyzed the files of 552 patients who underwent thyroidectomy in our surgery department between 2015- 2017 with the aim to assess the prevalence of PoSH and to identify patient and disease related factors associated with postoperative hypocalcemia. Results: 171 (30.97%) patients developed PoSH, 88.37% transient, 11.63% permanent. The median (IQR) duration of postoperative hypocalcemia was 60 (67.5) days. Preoperative biological parameters were similar in PoSH and the control group, except median (IQR) serum magnesium level that was significantly higher in PoSH group [2.04 (0.17) vs. 1.89 (0.28) mg/dl, p=0.005]. In the subgroup of patients with thyroid carcinoma the surgery duration was longer in PoSH patients compared to the control group [135 (60) vs. 110 (43) minutes, p=0.020]. In patients with PoSH, median post-operative serum calcium was significantly higher in patients with reported difficult surgery [8.2 (0.2) vs. 7.9 (0.6) mg/dl, p=0.043] and the mean serum calcium decrease was higher in patients with cervical neck dissection and lymphadenectomy (1.94 +-0.59 vs. 1.68 +-0.56 mg/dl, p=0.033). Conclusions: Our data show a high prevalence of PoSH that is likely to increase given the rising number of thyroid surgeries being performed. Further research is needed in order to better define this condition, to establish appropriate treatment and preventive measures.

Two Approaches to Conservative Neck Dissection: Anterior and Posterior Approaches to Level V

Abstract Background: Papillary thyroid cancer metastasizes to the neck in ~60% of patients, necessitating lateral cervical neck dissection in cases of clinically evident metastasis.1 The nodal patt...

Functional radical cervical dissection for differentiated thyroid cancer: the experience of a single center

Functional radical cervical dissection for differentiated thyroid cancer: the experience of a single center

P3.13-19 Surgery for cIIIB Lung Adenocarcinoma After Response to Erlotinib, Survival and Management of Postoperative Oligoprogressions

Down-staging of epidermal growth factor receptor (EGFR) activating mutation-positive (EGFR M+) advanced non-small-cell lung cancer (NSCLC) after first-line EGFR tyrosine kinase inhibitor (TKI) therapy may lead to primary tumor resection. Unfortunately, most patients’ disease will progress postoperatively even with the use of adjuvant TKI therapy mainly due to EGFR T790M mutation. Osimertinib, a third-generation inhibitor of EGFR T790M mutation, is with reduced toxicity profile as compared to non-selective EGFR TKI. Our aim is to assess a survival benefit of salvage lung resection in Stage IIIB lung adenocarcinoma after response to TKI and a management of oligoprogressions in the postoperative period. A Caucasian age 56 female lung adenocarcinoma patient (ECOG PS-0) was initially staged as cT2aN3M0 on October 10, 2015. Pretreatment biopsy specimens from ipsilateral scalene lymph node harbored EGFR mutation (exon 19 E746-T751insI deletions). After six months of first-line treatment with erlotinib150 mg/daily, which patient tolerated very well, a FDG-PET scan showed a 21/16 mm formation of the left upper lobe with SUV-2 without other abnormalities, down-staging with cT1cN0M0. Radical left upper lobectomy with 20 negative dissected mediastinal lymph nodes was carried out (May 17, 2016). Postoperative pathomorphological and mutational studies of residual tumor revealed adenocarcinoma and EGFR exon 19 mutation. Adjuvant erlotinib therapy was started for 3 months. Four months after its discontinuation by patient decision a 3 cm left supraclavicular mass (SUV-2.0 on FDG-PET) was diagnosed and totally resected. Adenocarcinoma involvements of 3 lymph nodes, as well as EGFR exon 19 mutation, were confirmed. The patient continued on erlotinib, but after 6 months on FDG-PET scan 2 left cervical lymph nodes (SUV 4.6 and 6.1 on FDG-PET) were diagnosed. Systematic left cervical dissection was performed with resection of four metastatic lymph nodes. Again adenocarcinoma histology was confirmed, but EGFR T790M mutation was identified as well. Three months later, even without signs of residual tumor mass on computerized tomography scan, Osimertinib therapy in dose 80 mg orally once daily was administered. The last follow-up FDG-PET scan revealed no signs of progression (April 30, 2018). The patient is with ECOG PS-0 and perfect quality of life without drug-related adverse events. Radical surgery of oligoprogression following salvage surgery for Stage IIIB (EGFR M+) lung adenocarcinoma after response to TKI, while continuing to use TKIs (specifically osimertinib in EGFR T790M mutation), can result in prolonged overall survival. The pending question is whether the EGFR-TKI therapy can be discontinued in these patients.

Headache secondary to cervical artery dissections: practice pointers.

Cervical artery dissections may present with mild and misleading symptoms such as a headache or cervical pain. In the absence of early diagnosis and therapy, such patients may have a high risk of cerebrovascular events. In order to refine evaluation of cervical artery dissections, we report the experience of a single center, focusing on clinical findings (e.g., headache and pain-related features at onset). From 2012 to 2017, 49 patients with cervical arteries dissections were admitted to our institution; 28 out of 49 patients (57%) presented with a headache or cervical pain, which were evaluated according to the International Classification of Headache Disorders (ICHD-III beta). Item C3a of ICHD-III beta ("pain is severe and continuous for days or longer") was present in all patients symptomatic for a headache. Another common characteristic was the recent onset, with an average (± SD) timing from the onset of a headache to the first neurologic evaluation of 3 (± 2) days (range 1-5). A refined clinical evaluation of patients presenting with a headache at the Emergency Department could improve the early detection and management of patients with cervical artery dissections, in particular when presenting without other associated neurological symptoms.

Ultrasound-guided laser ablation for local control of neck recurrences of medullary thyroid cancer. A feasibility study

Background: Surgery is the standard treatment for cervical metastases of medullary thyroid cancer (MTC) diagnosed after initial surgical treatment. Repeated neck dissections, however, carry an elevated risk of complications, have an adverse impact on the quality of life, and sometimes do not achieve cure of the diseaseClinical case: In a patient who had undergone two cervical neck dissections complicated by accessory nerve injury, an US-guided laser ablation (LA) of a lymph node metastasis of MTC was performed. LA was performed with two treatments during a five month period. The procedure was carried out with one optical fiber and an energy delivery of 3300 and 360 Joules. Treatments were well tolerated and resulted in complete structural and biochemical cure during a 12 month follow-up. No major complication was registered.Conclusions: LA is a promising tool for the management of relapsing cervical metastases that are localized in non- critical areas and are characterized by low progression rate. Advantages of LA are the outpatient setting, the absence of general anesthesia, the tolerability and the safety of the procedure. Thus, LA may be considered as an alternative approach to surgery or active surveillance for the management of local recurrences of MTC in selected patients.

PS01.078: AN UNUSUAL PRESENTATION OF BOERHAAVE SYNDROME

Abstract Background Oesophageal perforations are rare but potentially lethal. Boerhaave syndrome classically results in a longitudinal oesophageal perforation at the left posterolateral distal oesophagus. We present an unusual case with cervical oesophageal mucosal perforation and submucosal dissection. Methods We review our patient—a 53 year old lady, Mdm S, who presented after 4 days of vomiting with sepsis and diabetic ketoacidosis. CT thorax scan showed extensive long segment circumferential mural thickening and oedema of the entire oesophagus, extensive pneumotosis of the proximal half, and a focal mucosal discontinuitiy of the cervical oesophagus. There were also pneumomediastinum, fat stranding in the superior mediastinum, and a right pleural effusion. Results Gastroscopy and surgical exploration of the right hemithorax and neck identified a 2cm linear cervical oesophageal mucosal defect. There was no muscular perforation; an air leak test did not demonstrate a transmural perforation. Copious lavage of the mediastinum and right thoracic cavity were performed and large bore drains were placed in the neck, right thoracic cavity and superior mediastinum. A venting gastrostomy and a feeding jejunostomy were also created. Mdm S’s recovery was complicated by a persistent right pneumothorax. An interval gastroscopy revealed a line of interrupted longitudinal oesphageal mucosal defects starting at 18cm to 31 cm from the incisors. The submucosal space had opened up for the same length, and the scope easily entered the submucosal plane, where a muscle wall defect was detected at 18cm from the incisors. Conclusion Cervical oesophagus is an unusual site of Boerhaave's perforation. While the initial perforation was not transmural, surgical lavage and drainage were essential for sepsis control. Subsequent recovery was achieved by following principles of fistula management- diversion of gastrointestinal contents, drainage of oesophageal leak to control sepsis, optimisation of nutrition via a feeding jejunostomy. Disclosure All authors have declared no conflicts of interest.

Long-term oncologic outcomes of papillary thyroid microcarcinoma according to the presence of clinically apparent lymph node metastasis: a large retrospective analysis of 5,348 patients.

PurposeActive surveillance (AS) of low-risk papillary thyroid microcarcinoma (PTMC) may reduce the risk of overtreatment of clinically insignificant cancer. However, the absence of predictor for the progression of PTMC resulted in treatment delay and potentially compromising cure of aggressive disease. Therefore, to anticipate potential damage of delayed surgery, we investigated the oncologic outcomes of patients with low-risk PTMC initially eligible for AS except clinically apparent lymph node metastasis (LNM), imitating delayed surgery with neck dissection.Materials and methodsA total of 5,348 patients, enrolled between 1987 and 2016, with low-risk PTMC initially eligible for AS were included regardless of LNM. We classified our study patients into two groups: Group I, lobectomy with prophylactic central cervical node dissection; Group II, total thyroidectomy with modified radical neck dissection for LNM. In addition, we investigated the oncological outcomes of patients with second-wave surgery due to lateral lymph node recurrence (Group III, subgroup of Group I).ResultsGroup I showed more favorable clinicopathological characteristics compared with Group II. In Group I, only 29 (0.58%) of 4,927 patients underwent second-wave surgery with neck dissection for lateral lymph node recurrences, whereas in Group II, all 22 (5.23%) of 421 patients underwent second-wave selective node dissection because of nodal recurrence. Disease-free survival rates were significantly different between Groups I and II (P<0.05). Of note, the recurrence rate of Group II was still significantly higher than that of Group III (5.2% vs 0%, respectively; P=0.021). In addition, Kaplan–Mayer survival analysis indicated poor disease-free survival rates in Group II compared with Group III (P<0.05).ConclusionThe long-term treatment outcome of PTMC without LNM was favorable even if the recurrence occurs during follow-up period compared with that of PTMC with LNM. It should be noted that AS might be able to cause poor prognosis due to clinically apparent LNM.

A Rare Case of Synchronous Cervical Lymph Node Metastasis from Renal and Thyroid Cancer

Papillary thyroid cancer (PTC) has a propensity to metastasize to the cervical lymph nodes (LNs). Renal cancer (RC) can also spread to the cervical LNs and is the most common cause of metastatic infiltration of the thyroid gland. We describe here the case of a 71-year-old patient with a previous history of surgically treated RC who underwent evaluation of a large left cervical mass. Initial cytological investigation on fine needle aspiration (FNA) indicated metastatic PTC. Computed tomography (CT) scanning revealed no other suspicious foci. The patient underwent total thyroidectomy and central and left lateral cervical LN dissection, during which a large neck mass along the left jugular vein was also removed. Histology demonstrated metastatic spread of RC to the thyroid gland and lateral cervical LNs and concurrent LN metastases from PTC. One LN showed evidence of synchronous RC and PTC metastasis. Only a small papillary thyroid microcarcinoma with no aggressive histological features was detected in the thyroid, raising the possibility that the primary focus of metastatic PTC was the large left lateral neck mass. The patient was discharged after successful treatment for transient hypoparathyroidism. The synchronous presence of RC and PTC in the thyroid and cervical LNs and the concurrent metastases in one of the LNs renders this case unique. Evaluation of a cervical mass in a patient with a prior history of malignancy can prove vexing, and surgery may be the only option for the establishment of a definitive diagnosis.

Active Reperfusion Hemorrhage during Thrombectomy: Angiographic Findings and Real-Time Correlation with the CT “Spot Sign”

Introduction: Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT “spot sign.” Methods: This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers. Results: Five patients were identified. Median age was 63 (58–71) years, 66% were male. Median NIHSS was 13.5 (9.5–23.0), platelet level 212,000 (142,000–235,000), baseline systolic blood pressure 152 (133–201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5–9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (n = 2), intracranial atherosclerosis (n = 2), and cervical dissection (n = 1). The median time from onset to puncture was 5.5 (3.9–8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250–6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the “spot sign.” The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days. Conclusions: Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT “spot sign” and to be associated with poor outcomes.

Clinicopathologic Predictive Factors of Cervical Lymph Node Metastasis in Differentiated Thyroid Cancer

BackgroundCervical lymph node metastasis (LNM) has been proven to be a predictor for locoregional recurrence in differentiated thyroid carcinoma (DTC). Clinicopathological features could be effective predictive factors for central and lateral LNM of DTC, and provide references to surgeons for cervical neck dissection. MethodsRetrospective analysis of clinicopathological data was performed on 420 patients who underwent initial surgery from 2010 to 2015. ResultsThe incidence of central and lateral LNM was calculated. Of 420 patients, 247 (58.8%) exhibited central LNM, and 185 (44.1%) exhibited lateral LNM. There were 29 (6.9%) cases confirmed to have skip metastasis. Univariate and multivariate analysis revealed that tumour location, tumour size, multifocality, capsular invasion, affected lobes, and age were independent predictors of central LNM. Tumour location, capsular invasion, affected lobes, and tumour size were independent predictors of lateral LNM. ConclusionsOur findings suggest that tumour location, affected lobes, capsular invasion, age, tumour size and multifocality may be taken as predictive factors for cervical LNM of DTC. Meticulous perioperative evaluation of cervical LNM and prophylactic cervical lymph node dissection that aims to remove the occult lymph nodes may be an option for DTC with risk factors.

The importance of costoclavicular space on possible compression of the subclavian artery in the thoracic outlet region: a radio-anatomical study.

The purposes of this study were to identify possible compression points along the transit route of the subclavian artery and to provide a detailed anatomical analysis of areas that are involved in the surgical management of the thoracic outlet syndrome (TOS). The results of the current study are based on measurements from cadavers, computed tomography (CT) scans and dry adult first ribs. The width and length of the interscalene space and the width of the costoclavicular passage were measured on 18 cervical dissections in 9 cadavers, on 50 dry first ribs and on CT angiography sections from 15 patients whose conditions were not related to TOS. The average width and length of the interscalene space in cadavers were 15.28 ± 1.94 mm and 15.98 ± 2.13 mm, respectively. The widths of the costoclavicular passage (12.42 ± 1.43 mm) were significantly narrower than the widths and lengths of the interscalene space in cadavers (P < 0.05). The average width and length of the interscalene space (groove for the subclavian artery) in 50 dry ribs were 15.53 ± 2.12 mm and 16.12 ± 1.95 mm, respectively. In CT images, the widths of the costoclavicular passage were also significantly narrower than those of the interscalene space (P < 0.05). The measurements from cadavers, dry first ribs and CT images were not significantly different (P > 0.05). Our results showed that the costoclavicular width was the narrowest space along the passage route of the subclavian artery. When considering the surgical decompression of the subclavian artery for TOS, this narrowest area should always be kept in mind. Since measurements from CT images and cadavers were significantly similar, CT measurements may be used to evaluate the thoracic outlet region in patients with TOS.

REGγ Is Associated with Lymph Node Metastasis and T-Stage in Papillary Thyroid Carcinoma.

BackgroundThis paper aimed to evaluate the expression of REGγ and characterize its clinical significance in papillary thyroid carcinoma (PTC).Material/MethodsIn total, 54 patients with PTC who underwent partial or total thyroidectomy and cervical node dissection for PTC from February 2009 to September 2011 were retrospectively reviewed. Thyroid specimens and metastatic lymph nodes from 54 patients and normal thyroid tissues obtained from 13 volunteers were collected and analyzed. Tumor size, T-stage, and lymph nodes metastasis were recorded based on surgical pathology. Immunohistochemical (IHC) technology was performed to analyze REGγ protein expression level. Corrections between the expression of REGγ and the clinicopathological factors were analyzed.ResultsAll the normal thyroid tissues were REGγ-negative. REGγ was positive in 75.9% (41/54) of PTC tissues, of which 29 cases (29/42, 69.0%) were in T1–T2 stage and 12 cases (12/12,100%) were in T3–T4 stage. Positive REGγ was found in 21 cases (21/24, 87.5%) in T1–T2 stage with lymph nodes metastasis, while 11 cases were in T3–T4 stage with metastases to lymph nodes (11/11, 100%). High level of REGγ expression was significantly correlated with T-stage (P<0.05) and lymph node metastases (P<0.05). In addition, there was no statistically significant difference between the expression of REGγ and age, sex, tumor size, or tumor multiplicity (P>0.05). Using binary logistic regression model, positive REGγ was identified as a significant independent predictor factor of lymph node metastasis in PTC.ConclusionsHigh expression of REGγ seemed positively correlated with T-stage and lymph node metastasis in PTC tissues.

Large sporadic thyroid medullary carcinomas: predictive factors for lymph node involvement.

Lymph node involvement (LNI) is one of the most important prognostic factors for poor survival in medullary thyroid carcinoma (MTC). At diagnosis, LNI is found in over 50% of sporadic MTCs, and especially in large tumours. Cervical lymph node dissection is therefore mandatory during MTC surgery. However, some large tumours (responsible for high preoperative basal calcitonin levels) are found to lack LNI, and can be cured definitely. Preoperative detection of these particular tumours might spare patients from undergoing extensive cervical dissection. The objective of the present retrospective study of a series of large sporadic MTCs was to identify clinical, biological and pathological factors that were predictive of LNI. Consecutive cases of large, sporadic MTCs (measuring at least 1cm in diameter) were retrieved and reviewed. The levels of several mature microRNAs (miRs) in paraffin-embedded samples were assessed using qPCR. Of the 54 MTCs, 26 had LNI and 28 were pN0. Relative to pN0 patients, patients with LNI had a significant higher preoperative basal calcitonin level (p = 0.0074) and a greater prevalence of infiltrative margins (p < 0.0001), lymphovascular invasion (p = 0.0004), extrathyroidal extension (p < 0.0001), a higher pT stage (p = 0.0003) and more abundant desmoplastic stroma (p = 0.0006). Tumour expression levels of miR-21 (p = 0.0008) and miR-183 (p = 0.0096) were higher in the LNI group. The abundance of desmoplastic stroma (p = 0.007) and the miR-21 expression level (p = 0.0026) were independent prognostic factors for LNI. The abundance of desmoplastic stroma and high levels of miR-21 expression were strong indicators of LNI, and may thus help the surgeon to choose the extent of cervical lymph node dissection for large, sporadic MTCs with no preoperatively obvious LNI.

Anatomical and histological study of the deep neck fasciae: does the alar fascia exist?

The aim of this study was to determine whether the alar fascia is a distinct layer of the deep cervical neck fasciae. The present study also aimed to elucidate the anatomical limits of this fascia. Neck dissections of ten adult cadavers were performed, layer by layer, in the retropharyngeal region, under a powered operating microscope. Detailed dissections revealed the anatomical limits of the deep neck fasciae. Histological descriptions were also performed on large tissue samples collected from three cervical dissections. In the ten dissections, three layers of fascia were identified and dissected in the retropharyngeal region: a visceral fascia, a prevertebral fascia and an alar fascia. The alar fascia appeared like a connecting band derivative of the visceral fascia, between both vascular sheaths. It fused completely with the visceral fascia anteriorly at the level of T2 and with the prevertebral fascia posteriorly at the level of C1. No sagittal connection between the visceral fascia and the prevertebral fascia was identified. The stained histological sections confirmed the presence of the visceral and prevertebral fasciae at the oropharyngeal level, with a third intermediate layer closely connected with the visceral fascia. The alar fascia is a layer of the cervical neck fascia connected with the visceral fascia from C1 to T2 levels. The anatomical limits of this alar fascia and its relationships with the internal carotid artery are important in the surgical management and the prognosis of deep neck infections and retropharyngeal lymph node metastases.