Ipsilateral Level Research Articles

Extradural Contralateral Ventral Root Transfer to Treat Lower Limb Motor Dysfunction in Paraplegia.

Eight cadavers were included in this anatomical study. This study aimed to confirm the anatomical feasibility of extradural transfer of the contralateral T11 ventral root (VR) to the ipsilateral L2 level and the contralateral L1 VR to the ipsilateral L3 level to restore lower limb function in cases of paraplegia. Motor dysfunction due to hemiplegia significantly affects the daily life of patients. To date, unlike in cases of upper limb dysfunction, there are few studies on the surgical management of lower limb movement dysfunction. Eight cadavers were included in this study to confirm the feasibility of the nerve transfer. After separating the VR and dorsal root at each level, the VRs at the T11 and L1 levels were anastomosed with the VRs of L2 and L3, respectively. The length of the VRs of donor roots and the distance between the donor and recipient nerves were measured. H&E staining was performed to verify the number of axons and the cross-sectional area of the VRs. Lumbar x-rays of 60 healthy adults were used to measure the distance between the donor and recipient nerves. After exposing the bilateral extradural each root, the VRs could be easily isolated from the whole root. The distance between the VRs of T11 and L2, L1, and L3 was significantly longer than the length of the donor nerve. Therefore, the sural nerve was used for grafting. The measurements performed on the lumbar x-rays of the 60 healthy adults confirmed the results. The number of axons and cross-sectional area of the VRs were measured. Our study confirmed the anatomical feasibility of transferring the VRs of T11 to L2 and that of L1 to L3 to restore lower limb function in cases of hemiplegia. 5.

The Effect of Tumor Characteristics and Location on the Extent of Lymph Node Metastases of Head and Neck Cutaneous Squamous Cell Carcinoma.

BackgroundThe extent of a neck dissection for patients with metastasis of cutaneous squamous cell carcinoma of the head and neck (HNcSCC) is still subject to debate and clear guidelines are lacking. Tumor characteristics like size, differentiation and tumor location are known risk factors for lymph node metastasis (LNM). There is some evidence that, depending on tumor location, LNM follows a specific pattern. This study aims to identify which tumor characteristics can predict the pattern and extent of LNM.MethodIn this cohort study 80 patients were included, who underwent a primary neck dissection for LNM of HNcSCC between 2003 and 2018 at the University Medical Center Groningen, the Netherlands. Retrospective data was collected for primary tumor characteristics and LNM and included surgical and follow-up data. Influence of tumor characteristics on the extent of LNM was analyzed using non-parametric tests. Logistic regression analysis were used to identify a metastasis pattern based on the primary tumor location.ResultsOnly primary tumor location was associated with the pattern of LNM. HNcSCC of the ear metastasized to level II (OR = 2.6) and the parotid gland (OR = 3.6). Cutaneous lip carcinoma metastasized to ipsilateral and contralateral level I (OR = 5.3). Posterior scalp tumors showed a metastasis pattern to level II (OR = 5.6); level III (OR = 11.2), level IV (OR = 4.7) and the parotid gland (OR = 10.8). Ear canal tumors showed a low risk of LNM for all levels. The extent of LNM was not related to age or any tumor characteristics i.e. tumor diameter, infiltration depth, differentiation grade, perineural growth and vascular invasion.ConclusionPrimary tumor location determines the LNM pattern. Whereas known unfavorable tumor characteristics did not relate to the extent of LNM. Location guided limited neck dissection combined with parotidectomy will treat most patients adequately.

Factors influencing outcomes in selective neck dissection in 661 patients with head and neck squamous cell carcinoma

BackgroundSelective neck dissection (SND) is the surgical treatment of choice in squamous cell carcinoma of the head and neck (HNSCC) with suspected or manifest metastases in the cervical lymph nodes. For SND to be successful, treated lymph node levels should be selected according to anatomic considerations and the extent of the disease. Aim of this study was to identify neck dissection levels that had an impact on individual prognosis.MethodsWe conducted a retrospective review of SND as part of primary treatment of HNSCC. Overall survival (OS) and regional control rates (RCR) were calculated for all patients treated at one academic tertiary referral center.Results661 patients with HNSCC were included, 644 underwent ipsilateral and 319 contralateral SND. Average follow-up was 78.9 ± 106.4 months. 67 (10.1%) patients eventually developed nodal recurrence. Tumor sites were oral cavity (135), oropharynx (179), hypopharynx (118) and larynx (229). Tumor categories pT1–pT4a, and all clinical and pathological nodal categories were included. Multivariate analysis indicated improved OS rates for patients undergoing SND in ipsilateral levels I and V as well as level III contralaterally. Analysis for tumor origin showed that SND in ipsilateral level I showed significantly improved OS in HNSCC of the oral cavity.ConclusionThe dissection of ipsilateral level I in oral cavity cancer was of particular relevance in our exploratory, retrospective analysis. To clarify the relevance for the determination of the extent of SND, this should be investigated prospectively in a more homogenous patient cohort.

Relationship between subgroups of central and lateral lymph node metastasis in clinically node-negative papillary thyroid carcinoma.

BACKGROUNDLymph node metastasis (LNM) of papillary thyroid carcinoma (PTC) has a certain regularity and occurs first to the central lymph node and then to the lateral lymph node. The pathway of PTC LNM can guide surgical prophylactic lymph node dissection (LND) for clinical surgeons.AIMTo investigate the relationship between subgroups of central LNM and lateral LNM in unilateral clinically node-negative PTC (cN0-PTC).METHODSData were collected for 1089 PTC patients who underwent surgical treatment at the Department of Endocrine and Breast Surgery of the First Hospital of Chongqing Medical University from January 2016 to December 2017. A total of 388 unilateral cN0-PTC patients met the inclusion criteria and were enrolled in this study. The clinical and pathological data for these 388 patients who underwent total thyroidectomy + central LND + lateral LND were retrospectively analyzed. The relationship between the central LNM and lateral LNM subgroups was investigated.RESULTSThe coincidence rate of cN0-PTC was only 30.0%.Optimal scaling regression analysis showed that sex (57.1% vs 42.9%, P = 0.026), primary tumor size (68.8% vs 31.2%, P = 0.008), tumor location (59.7% vs 40.3%, P = 0.007), extrathyroid extension (ETE) (50.6% vs 49.9%, P = 0.046), and prelaryngeal LNM (57.1% vs 42.9%, P = 0.004) were significantly associated with ipsilateral level-II LNM. Their importance levels were 0.122, 0.213, 0.172, 0.110, and 0.227, respectively. Primary tumor size (74.6% vs 30.2%, P = 0.016), pretracheal LNM (67.5% vs 32.5%, P < 0.001), and paratracheal LNM (71.4% vs 28.6%, P < 0.001) were significantly associated with ipsilateral level-III LNM. Their importance levels were 0.120, 0.408, and 0.351, respectively. Primary tumor size (72.1% vs 27.9%, P = 0.003), ETE (70.4% vs 29.6%, P = 0.016), pretracheal LNM (68.3% vs 31.7%, P=0.001), and paratracheal LNM (80.8% vs 19.2%, P < 0.001) were significantly associated with ipsilateral level-IV LNM. Their importance levels were 0.164, 0.146, 0.216, and 0.472, respectively. CONCLUSIONThe LNM pathway of thyroid cancer has a certain regularity. For unilateral cN0-PTC patients with a tumor diameter > 2 cm and pretracheal or ipsilateral paratracheal LNM, LND at ipsilateral level III and level IV must be considered. When there is a tumor in the upper third of the thyroid with prelaryngeal LNM, LND at level II, level III and level IV must be considered.

\u201cMYH9 mutation and squamous cell cancer of the tongue in a young adult: a novel case report\u201d

BackgroundThe incidence of tongue cancer in young adults is on the rise. This trend is more pronounced in females. Although the aetiology is still unclear, there is mounting evidence that genetic syndromes can play a key role in development of oral cancers in this patient group. We report the first case of oral squamous cell carcinoma (oSCC) in a young adult with an MYH9-related disorder (MYH9-RD).Case presentationA 19-year-old female with a germline MYH9 variant (missense variant in exon 2: c.287C > T, (p.Ser96Leu)) was referred to the head and neck surgery department for investigation of a painful, thick right tongue ulcer. She was diagnosed with Epstein syndrome, an MYH9-RD, at 12 years of age. Her main phenotypic features were profound thrombocytopenia and marked renal impairment. The tongue biopsy confirmed SCC. Preoperative positron emission tomography (PET) revealed avidity in the right tongue and ipsilateral level 2A neck lymph node. With substantial preoperative multidisciplinary input, she underwent cancer ablation and microvascular free flap reconstruction. Her pathology showed a 35 mm diameter, 14 mm thick moderately differentiated SCC with perineural and lymphovascular invasion. Two out of 38 right neck nodes were positive for metastasis with extranodal extension. None of the 34 left neck nodes was involved.She had an uneventful recovery and was discharged home on day 6 postoperative day. On day 15 postoperative day, she had catastrophic bleeding in the neck with a respiratory arrest after a forceful cough. She required an emergency tracheostomy and returned to the theatre for haemostasis. Following a short inpatient stay, she was again discharged home and underwent adjuvant therapy consisting of external beam radiotherapy of 60Gy in 30 fractions. On clinical examination and PET at 6 months after surgery, she had no evidence of disease recurrence.ConclusionsMYH9-RD can present with advanced locoregional oral cavity malignancy at an early age. The combination of profound thrombocytopenia and marked renal impairment can impact heavily on routine major head and neck cancer surgery and adjuvant treatment. This rare and challenging condition underlines the importance of early detection of cancer and multidisciplinary team input.

Detailed patient-individual reporting of lymph node involvement in oropharyngeal squamous cell carcinoma with an online interface

Purpose/ObjectiveWhereas the prevalence of lymph node level (LNL) involvement in head & neck squamous cell carcinomas (HNSCC) has been reported, the details of lymphatic progression patterns are insufficiently quantified. In this study, we investigate how the risk of metastases in each LNL depends on the involvement of upstream LNLs, T-category, HPV status and other risk factors. Materials/MethodsWe retrospectively analyzed patients with newly diagnosed oropharyngeal squamous cell carcinoma (OPSCC) treated at a single institution, resulting in a dataset of 287 patients. For all patients, involvement of LNLs I-VII was recorded individually based on available diagnostic modalities (PET, MRI, CT, FNA) together with clinicopathological factors. To analyze the dataset, a web-based graphical user interface (GUI) was developed, which allows querying the number of patients with a certain combination of co-involved LNLs and tumor characteristics. ResultsThe full dataset and GUI is part of the publication. Selected findings are: Ipsilateral level IV was involved in 27% of patients with level II and III involvement, but only in 2% of patients with level II but not III involvement. Prevalence of involvement of ipsilateral levels II, III, IV, V was 79%, 34%, 7%, 3% for early T-category patients (T1/T2) and 85%, 50%, 17%, 9% for late T-category (T3/T4), quantifying increasing involvement with T-category. Contralateral levels II, III, IV were involved in 41%, 19%, 4% and 12%, 3%, 2% for tumors with and without midline extension, respectively. T-stage dependence of LNL involvement was more pronounced in HPV negative than positive tumors, but overall involvement was similar. Ipsilateral level VII was involved in 14% and 6% of patients with primary tumors in the tonsil and the base of tongue, respectively. ConclusionsDetailed quantification of LNL involvement in HNSCC depending on involvement of upstream LNLs and clinicopathological factors may allow for further personalization of CTV-N definition in the future.

Prevalence and risk factors of retro-styloid lymph node metastasis in oropharyngeal carcinoma

Background Supporting data defining the selection criteria of level VIIb for inclusion in the target volume in radiotherapy (RT) planning are insufficient. We evaluated the prevalence of level VIIb retro-styloid lymph node metastasis (RSLNM) and associated risk factors in patients with oropharyngeal carcinoma (OPC). Materials and methods We retrospectively reviewed pre-treatment [18F]-fluoro-2-deoxy-d-glucose–positron emission tomography/computed tomography (CT) along with contrast-enhanced thin slice CT and magnetic resonance (MR) images of 137 patients pathologically confirmed as having OPC who underwent RT. The location of lymph nodes (LNs) was confirmed on the planning CT images. Fisher’s exact test and logistic regression analyses were made to determine the risk factors of RSLNM. Results RSLNM was confirmed in 18 (13%) patients. All RSLNMs were located within level VIIb on the planning CT images. No patients exhibited LNM in contralateral level VIIb. Furthermore, no patients with negative or single ipsilateral cervical LNM had RSLNM. Fisher’s exact test revealed that smoking status (p=.027), multiple ipsilateral cervical LNM (p=.045) and LN ≥15 mm in the upper limit of ipsilateral level II (p<.001) were significantly associated with RSLNM. Logistic regression analyses revealed that the presence of LNs ≥15 mm in upper limit of ipsilateral level II was significantly associated with RSLNM (odds ratio: 977.297; 95% confidence interval: 57.629–16573.308; p<.001). Conclusions RSLNM is relatively common in patients with OPC with a prevalence rate of approximately 10%. The prevalence of RSLNM in patients with negative or single ipsilateral cervical LNM and contralateral RSLNM is extremely low; therefore, level VIIb can be excluded from the target volume in such patients. LN ≥15 mm in the upper limit of ipsilateral level II is a risk factor for RSLNM. Ipsilateral level VIIb should be included in the target volume for patients with this risk factor. KEY MESSAGE Retro-styloid lymph node metastasis (RSLNM) prevalence is ∼10% in oropharyngeal carcinoma. Lymph node ≥15 mm in ipsilateral level II upper limit is a risk factor for RSLNM.

DEPENDENCE OF THE RESTORATIVE EFFECT OF MACROPOROUS POLY(N-[2-HYDROXYPROPYL]-METHACRYLAMIDE HYDROGEL ON THE SEVERITY OF EXPERIMENTAL LACERATIVE SPINAL CORD INJURY

restoration of the spinal cord function presents a most severe biomedical issue nowadays. The aim of the study was to detect the macroporous poly(N-[2-hydroxypropyl]-methacrylamide hydrogel (PHPMA-hydrogel, HG) restorative effect dependence on the severity of the laceration spinal cord injury in young organisms. The male rats sample (~1-month-old, ~50 g, inbred Wistar line) was represented with 4 experimental groups: 1) spinal cord lateral hemisection at the level of ~Т12–Т13 segments (Sect; n=11); 2) spinal cord lateral hemiexcision ~1 mm long at the similar level (Exc; n=8); 3) spinal cord lateral hemisection at the similar level with immediate implantation of the hydrogel fragment into the trauma region (HGsect; n=11); 4) spinal cord lateral hemiexcision at the similar level with immediate implantation of the hydrogel fragment into the affected region (HGexс; n=6). The motor function and spasticity of the paretic hindlimb was estimated respectively by the technically modified Basso–Beattie–Bresnahan (ВВВ) and Ashworth, conditionally blinded to individual characteristics of all operated animals and previous study results. The observation lasted for ~5 months. The criteria of non-inclusion were as follows: the ipsilateral hindlimb function level in a week after the injury &gt;9 points ВВВ, and the contralateral hindlimb function level during prolonged period ≤14 points ВВВ. The results were interpreted and presented according to the standardized time scale with interpolatory representation of the motor function and spasticity individual level in certain cases. Asymptotic stage differences between the studied groups and subgroups were stated during the first three weeks as well as in 8 weeks and 3 months after the injury. We found out that in a week after injury the motor function level in group Exc made up 0.9±0.5 points ВВВ, in group HGexc — 3.6±1.2 points, in group Sect — 5.9±1.1 points, in group HGsect — 6.0±1.0 points. In 5 months the motor function level in group Sect made up 9.5±1.0 points ВВВ, in group HGsect — 9.5±1.1 points, in group Exc — 0.8±0.3 points, in group HGexc — 4.5±1.8 points. At the same study stage the spasticity level in groups Sect and HGsect was, respectively, 0.8±0.2 and 0.8±0.3 points Ashworth, in group HGexc — 1.8±0.7 points, in group Exc — 3.6±0.3 points. Throughout the study no significant differences in groups Sect and HGsect have been detected, and in groups Exc і HGexc such differences were detected only in 5 weeks after the injury. The considerable difference of spasticity in groups Sect and HGsect was noted in 1 week after the injury, in groups HGexc and Exc — during first 2 months of the experiment. In groups Sect and Exc reliable difference of both motor function and spasticity level was found at all study stages. In groups HGsect and HGexc considerable difference of the motor function level was characteristic at all stages, except for the end of the 1st and 7th weeks, whereas spasticity level differences throughout the study remained insignificant. So, the tested hydrogel in young organisms shows positive effect only with severe trauma stages accompanied with extensive spinal cord defect.

DEPENDENCE OF THE RESTORATIVE EFFECT OF MACROPOROUS POLY(N-[2- HYDROXYPROPYL]-METHACRYLAMIDE HYDROGEL ON THE SEVERITY OF EXPERIMENTAL LACERATIVE SPINAL CORD INJURY

restoration of the spinal cord function presents a most severe biomedical issue nowadays. The aimof the study was to detect the macroporous poly(N-[2-hydroxypropyl]-methacrylamide hydrogel (PHPMA-hydrogel,HG) restorative effect dependence on the severity of the laceration spinal cord injury in young organisms.The male rats sample (~1-month-old, ~50 g, inbred Wistar line) was represented with 4 experimental groups: 1)spinal cord lateral hemisection at the level of ~Т12–Т13 segments (Sect; n=11); 2) spinal cord lateral hemiexcision~1 mm long at the similar level (Exc; n=8); 3) spinal cord lateral hemisection at the similar level with immediateimplantation of the hydrogel fragment into the trauma region (HGsect; n=11); 4) spinal cord lateral hemiexcisionat the similar level with immediate implantation of the hydrogel fragment into the affected region (HGexс; n=6).The motor function and spasticity of the paretic hindlimb was estimated respectively by the technically modifiedBasso–Beattie–Bresnahan (ВВВ) and Ashworth, conditionally blinded to individual characteristics of all operatedanimals and previous study results. The observation lasted for ~5 months. The criteria of non-inclusion wereas follows: the ipsilateral hindlimb function level in a week after the injury &gt;9 points ВВВ, and the contralateralhindlimb function level during prolonged period ≤14 points ВВВ. The results were interpreted and presentedaccording to the standardized time scale with interpolatory representation of the motor function and spasticityindividual level in certain cases. Asymptotic stage differences between the studied groups and subgroups werestated during the first three weeks as well as in 8 weeks and 3 months after the injury. We found out that in aweek after injury the motor function level in group Exc made up 0.9±0.5 points ВВВ, in group HGexc — 3.6±1.2points, in group Sect — 5.9±1.1 points, in group HGsect — 6.0±1.0 points. In 5 months the motor function levelin group Sect made up 9.5±1.0 points ВВВ, in group HGsect — 9.5±1.1 points, in group Exc — 0.8±0.3 points,in group HGexc — 4.5±1.8 points. At the same study stage the spasticity level in groups Sect and HGsect was,respectively, 0.8±0.2 and 0.8±0.3 points Ashworth, in group HGexc — 1.8±0.7 points, in group Exc — 3.6±0.3points. Throughout the study no significant differences in groups Sect and HGsect have been detected, and ingroups Exc і HGexc such differences were detected only in 5 weeks after the injury. The considerable difference ofspasticity in groups Sect and HGsect was noted in 1 week after the injury, in groups HGexc and Exc — during first2 months of the experiment. In groups Sect and Exc reliable difference of both motor function and spasticity levelwas found at all study stages. In groups HGsect and HGexc considerable difference of the motor function levelwas characteristic at all stages, except for the end of the 1st and 7th weeks, whereas spasticity level differences throughout the study remained insignificant. So, the tested hydrogel in young organisms shows positive effect onlywith severe trauma stages accompanied with extensive spinal cord defect.

Adjuvant Radiation Therapy Nodal Target Volumes in Oral Cancer: Do Consensus Guidelines Reflect Patterns of Failure?

Consensus guidelines on nodal target volumes in oral cancer intensity-modulated radiotherapy (IMRT) (Chao 2002, Liu 2015, Merlotti 2015) recommend bilateral and lower neck volumes, even in pN0 and lateralized primaries. However clinical practice is varied. We evaluated the patterns of nodal failure following adjuvant IMRT and its correlation with the treated target volumes in a large single institutional series, with special emphasis on contralateral and lower neck failures.Retrospective data of 421 patients treated between 2011 to 2017 with adjuvant IMRT for oral cancer was evaluated. This included data on the site of primary, the level and side of pathological nodal involvement, radiotherapy target volumes, doses delivered to each volume and site(s) of failure. Nodal target volumes were varied and reflected more conservative practice. Patterns of failure were mapped according to the nodal status and site of the primary, oral tongue or gingivobuccal (GB).Nodal target volumes and failures with a median follow-up of 36 months are depicted in Table 1. In terms of contralateral nodal coverage, ipsilateral lower neck treatment and contralateral lower neck treatment 110/254 (43.7%), 111/280 (39.6%), 165/232 (71.1%) patients were treated more conservatively than published guidelines. For pN0 cancers of either oral tongue or gingivobuccal site, the incidence of any contralateral failure or ipsilateral level IV failure was low (0-4%) and independent of inclusion into target volumes. In pN+ cancers of both sites, contralateral failures were more common (5-23%) and were predominantly in the contralateral Ib and II. Contralateral level III-IV failures were very uncommon even in pN+ cancers, especially in GB primaries (< 2%).Patterns of failure, when correlated with treated volumes, suggest that current recommendations may be generous and not reflective of actual patterns of failure. Consideration should be given to sparing of elective contralateral neck and lower neck treatments in pN0 tongue and GB patients, and contralateral lower neck in node-positive lateralized GB primaries.

Pathological Level VI Lymph Node Metastasis in Clinical N3b Pyriform Sinus Squamous Cell Carcinoma.

The frequency of metastasis to level VI lymph nodes in advanced pyriform sinus squamous cell carcinoma (PSSCC) is unknown. We intended to analyze the clinical features and pathological presence or absence of level VI lymph node metastasis in patients with PSSCC. The data of 270 patients with previously untreated hypopharyngeal squamous cell carcinoma from 2006 to 2016 were obtained. Patients who underwent pharyngolaryngectomy for the pyriform sinus subsite with a curative intent with level VI dissection were included. We retrospectively analyzed the clinical Tumor-Node (TN) status (TNM classification of malignant tumors, eighth edition) and the presence or absence of pathological level VI lymph node metastasis. A total of 34 patients were included. Eight patients (24%) had pathological level VI lymph node metastasis. The rate of pathological level VI lymph node metastasis was directly proportional to the clinical N status (P = .0002, Chi-square test for trend). In all, 5 patients with cN2b- 3 were classified as cN3b. Ipsilateral pathological level VI lymph node metastasis was observed in 1 patient, and bilateral metastasis was observed in 3 patients. There was no association between clinical T status or pyriform sinus apex invasion and pathological level VI metastasis (both P > .99, Fisher's exact test). PSSCC with cN3b is prone to bilateral level VI metastasis. We recommend that patients with PSSCC with cN3b should undergo bilateral level VI lymph node dissection.

Ipsilateral BDNF mRNA expression in the motor cortex positively correlates with motor function of the affected forelimb after intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a subtype of stroke that causes major motor impairments. Brain-derived neurotrophic factor (BDNF) is known to have important roles in neuroplasticity and beneficially contributes to stroke recovery. This study aimed to characterize BDNF expression in the motor cortex after ICH and investigate the relationship between cortical BDNF expression and behavioral outcomes using an ICH rat model. Wistar rats were divided into two groups: a SHAM group (n = 7) and an ICH group (n = 8). ICH was induced by the injection of collagenase into the left striatum near the internal capsule. For behavioral assessments, the cylinder test and open field test were performed before surgery and 3 days, 1 week, 2 weeks, and 4 weeks after surgery. Following the behavioral assessments at 4 weeks, BDNF expression in the ipsilateral and contralateral motor cortex was assayed using RT-PCR and ELISA methods. There was no significant difference in either cortical BDNF mRNA or protein expression levels between the SHAM and ICH groups. However, the asymmetry index of BDNF mRNA expression between the ipsilateral and contralateral hemispheres shifted to the ipsilateral hemisphere after ICH. Furthermore, the ipsilateral cortical BDNF mRNA expression level positively correlated with motor function in the affected forelimb after ICH. This study describes for the first time that cortical BDNF mRNA expression is related to post-ICH motor impairment. These results highlight the importance of assessing the interhemispheric laterality of BDNF expression and could help develop novel treatment strategies for BDNF-dependent recovery after ICH.

Prevalence and distribution of cervical lymph node metastases in HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma

ObjectiveIn oropharyngeal squamous cell carcinoma (OP-SCC), the prevalence and distribution of clinical and pathological lymph node metastasis in the neck have been extensively reported. It served as the basis for consensus recommendations on the selection of the lymph node levels in the neck requiring a treatment. The objective of the study is to compare the prevalence and distribution of neck node metastases in HPV+ and HPV− OP-SCC from a large series of patients with OP-SCC who underwent a cervical lymph-node dissection (LND) as part of their treatment. MethodsThe study concentrated on OP-SCC patients treated by various neck node dissection (LND) procedures from January 2014 to December 2018 in 3 French institutions. Patients with prior head and neck cancer, prior neck surgery, the use of induction chemotherapy, or patients with carcinoma of unknown primary were excluded. HPV-status was assessed by p16 immunohistochemistry. For each patient, the clinical and the pathological nodal status, as well as the distribution of the positive nodes in each neck level (from Ia to V) were reported. ResultsTwo-hundred and sixty-three patients were included (126 p16-negative (p16−), and 137 p16-positive (p16+). The rate of clinical positive node (cN+) reached 54% and 88.3% in the p16− and p16+ groups, respectively (p < 0.001); the corresponding rate of pathological positive node (pN+) reached 61.9% and 91.2%, respectively (p < 0.001). Regarding the clinical lymph node distribution, in p16+ patients, more positive nodes were observed in the ipsilateral level IV (p = 0.003), and less positive nodes were observed in the contralateral levels III and IV (p = 0.003 and p = 0.045, respectively). Regarding the pathologic lymph node distribution in the ipsilateral neck, in the cN0 patients, no significant difference was observed between p16− and p16+ patients (p = 0.33 to 1); in the cN+ patients, the nodes were distributed in levels Ib, II, III, IV and V without differences between the p16− and the p16+ patients. In the contralateral neck of p16− patients, nodes metastases were mainly observed in levels II, III and IV, whereas for the p16+ patients, positive nodes were only observed in level II (p = 0.03). ConclusionThis study demonstrated the higher prevalence of cN+ and pN+ in p16+ OP-SCC patients, but without meaningful difference in the distribution of the lymph node drainage between p16− and p16+ OP-SCC. It indicates that no difference should be made between p16− and p16+ patients regarding the extend of neck treatment.

Is the retropharyngeal lymph node the first echelon node for carcinoma tonsil? Prospective evaluation and literature review.

Tonsil cancer being predominantly treated by non-surgical means, there is a paucity of data on lymph nodal drainage pathways and histo-pathologically confirmed metastatic rates. This study assesses the retropharyngeal lymph node (RPLN) in N0 squamous cell carcinoma tonsil as a possible first echelon node and a site for occult metastasis. Prospective study involving treatment naïve N0 carcinoma tonsil treated by primary surgery and adjuvant treatment from June 2017 to March 2019. In-vivo lymph nodal drainage patterns were assessed by sentinel node mapping by preoperative SPECT-CT and intra-operative hand-held Gamma probe. All patients had a subsequent Level I-III/IV sampling neck dissection supplemented with RPLN dissection. Histological evaluation of sentinel nodes and RPLN involved step-serial sectioning and pan-cytokeratin immunohistochemistry. A comprehensive literature review was performed with keywords "retropharyngeal lymph node", "oropharynx", "tonsil", "squamous cell carcinoma" to determine the incidence of RPLN positivity in previously published series. Sentinel node was successfully identified by SPECT-CT in all 17 patients (ipsilateral level 2a-13/17, 2b-1/17, 3-1/17; bilateral 2a-1/17; isolated contralateral retropharyngeal node-1/17). 8/17 had occult neck metastasis. In no patient was an ipsilateral RPLN identified as the sentinel node. Histological sampling did not indicate metastatic tumor in the RPLN in any patient (0/17). A systematic literature review further confirmed that RPLN metastasis in oropharyngeal cancer is noted only in the presence of pN + disease at other neck levels, and isolated RPLN metastasis is extremely rare (1.2%). The ipsilateral RPLN is not identified either as the first echelon node or as a site of occult metastatic disease in N0 tonsil cancer. CTRI/2019/06/019551.

When Should Elective Neck Dissection Be Performed for Parotid Gland Malignancy?

When Should Elective Neck Dissection Be Performed for Parotid Gland Malignancy?

Ultrasonic features and pathological information of lymphoepithelial carcinomas of the salivary gland with ferroferric oxide nanometer ultrasound contrast agent

This study aimed to investigate and analyze the ultrasonic features and pathological information of lymphoepithelial carcinomas of the salivary gland using ultrasound. The general clinical information of 62 patients with lymphoepithelial carcinomas of the salivary gland and the ultrasonic features and pathological information of 28 patients who underwent surgery were retrospectively analyzed and compared with ferroferric oxide (Fe3O4) nanometer lipid microbubble contrast agent using Minitab software with P &lt; 0.005 to indicate statistical significance. Similarly, inflammatory nodules, lymphomas, and metastatic nasopharyngeal carcinomas were identified using ultrasound. Lymphoepithelial carcinomas were often observed in the parotid glands, with hypoechoic nodules. Network-like or cord-like hyperechoes were often observed in the nodules, with unclear boundaries, irregular morphologies, and significantly less invasion into the surrounding tissues. Differences in the incidence in the right and left glands, blood flow signal, nerve invasion, lymphatic metastasis, and tumor volume were insignificant. Lymphatic metastasis was often noted in ipsilateral neck level II, followed by the periparotid region or ipsilateral neck level I. The diagnoses of inflammatory nodules and lymphomas had a combined pathology, while the diagnosis of nasopharynx cancer was dependent on the result of nasopharyngoscopy. The ultrasonic features of lymphoepithelial carcinomas of the salivary gland are network-like or cord-like hypoechoic nodules that possess the ultrasonic and biological features of malignant tumors.

Extended Level IV Neck Dissection for Limited Prophylactic Clearance of Level V in Node-Positive Papillary Thyroid Carcinoma: a Homogenous Study Population.

There is near consensus that prophylactic lateral neck dissection has no role in the management of differentiated thyroid cancer, but the extent of lateral neck dissection in differentiated thyroid cancer remains controversial, especially whether level V should be addressed or not. There is lot of heterogeneity in reporting of the management of level V in papillary thyroid cancer. We at our Institute address the lateral neck positive papillary thyroid cancer with selective neck dissection involving levels II-IV, performing extended level IV dissection with inclusion of the triangular area delineated by the sternocleidomastoid muscle, the clavicle, and the perpendicular line drawn to the clavicle from the point where the horizontal line at the level of cricoid cuts the posterior border of sternocleidomastoid muscle. Retrospective analysis of the departmental data set related to thyroidectomy with lateral neck dissection from 2013 to mid-2019 for papillary thyroid cancer, was carried out. Patients with recurrent papillary thyroid cancer were excluded as were patients with involvement of level V. Data related to the demography of patients, histological diagnosis, and postoperative complications were compiled and summarized. Note was made of the incidence of ipsilateral neck recurrence and the neck level involved with recurrence noted. Data was analyzed for fifty-two patients of non-recurrent papillary thyroid cancer who had undergone total thyroidectomy and lateral neck dissection involving levels II-IV, with extended dissection at level IV. It should be noted that none of the patients had clinical involvement of level V. Only two patients had lateral neck recurrence, both the recurrences were in level III, one on the ipsilateral side and the other on the contralateral side. Recurrence in the central compartment was noted in two patients, with one of these patients also having ipsilateral level III recurrence. One of the patients had distal metastasis to the lungs. Transient paresis of the unilateral vocal cords was noted in seven patients which got resolved within 2months in all of them. Transient hypocalcemia was noted in four patients. Although our series has a small sample size with limited follow-up, it is one of the few studies in which prophylactic level V dissection has been studied in a homogenous study population of non-recurrent papillary thyroid cancer. Our study has shown that prophylactic dissection of level V may have a limited role, but further large multi-institutional studies need to be carried out to come up with a definite answer.

Scarless endoscopic thyroidectomy (SET) lateral neck dissection for papillary thyroid carcinoma through breast approach: 10years of experience.

Breast approach endoscopic thyroidectomy with lateral neck lymph node metastases dissection has been described. However, in this article, we report on 10years' experience with the breast approach to patients with endoscopic thyroidectomy with level II, III, and IV lateral neck dissection (LND). Patients with papillary thyroid carcinoma (PTC) who received scarless endoscopic thyroidectomy (SET) were included to evaluate its therapeutic effect. Between June 2009 and June 2019, we selected 155 patients with PTC with level II, III, or IV level lymph node metastasis suspected. Ipsilateral level II, III, and IV dissection was performed, accompanied by thyroidectomy and central compartment dissection. In addition, 102 patients received conventional open LND during the same period and were included. Clinicopathological characteristics, outcomes, and tumor prognosis were retrospectively compared in the two groups. During the 10years, the submitted patients' clinicopathological characteristics including tumor size, tumor stage, retrieved lymph nodes number, complication rates, postoperative PTH, and mean postoperative hospital stay were similar between the SET and open group. The mean operating time in the SET group (278.2 ± 38.6min) was longer than in the open group (179.3 ± 25.4min). The recurrent rate was not significantly different (2/155, 2/106) in the SET and conventional open group. The safety and oncological completeness dissection of SET was similar to that of open procedures. SET is an effective treatment approach for patients with PTC having cosmetic results' demand of lateral neck lymph node metastases.

Distribution pattern and prognosis of metastatic lymph nodes in cervical posterior to level V in nasopharyngeal carcinoma patients

BackgroundLymph node metastasis in the cervical region posterior to level V (PLV) can occurs in patients with nasopharyngeal carcinoma (NPC), but the significance of lymph node metastasis in this region and the delineation of the radiotherapy target area have not been reported. We aimed to explore the distribution pattern and prognosis of metastatic lymph nodes in the PLV region in patients with NPC.MethodsWe retrospectively studied 605 cases of NPC diagnosed by pathological detection from December 2011 to November 2017. The nodal distribution at each level was assessed in accordance with the Radiation Therapy Oncology Group (RTOG) guidelines proposed in 2013. The central points of the metastatic lymph nodes of the PLV region in the patients were recreated proportionally on the CT images of a standard patient with N0 NPC in reference to the normal anatomy of the PLV area. The correlation between the PLV region and the other levels, the nodal location, and the characteristics and prognosis of the PLV region were analyzed.ResultsLymph node metastasis occurred in 557 (92.06%) of 605 patients. There were 30 patients (4.95%) with lymph node metastasis in the PLV region. A total of 49 metastatic lymph nodes from the PLV region were counted, and the mean vertical distance of the central point of each lymph node from the anterior surface of the trapezius muscle was 14 mm. Linear regression correlation analysis suggested that lymph node metastasis in the PLV region was associated with ipsilateral level IVa (P = 0.018), level Va, level Vb, and level Vc lymph node metastasis (all P < 0.001). The 5-year OS, PFS, LRFS, and DMFS of 29 patients with lymph node metastasis in the PLV region were 41.6, 27.7, 89.1, and 47.3%, respectively. Multivariate analysis showed that lymph node metastasis in the PLV region was an independent prognostic factor for DMFS (P < 0.05).ConclusionNPC patients with lymph node metastasis in the PLV region had a poor prognosis and a high risk of distant metastasis. We recommend that the margin of the PLV region may be a new cervical lymph node segment for NPC.

Total thyroidectomy with therapeutic level II-IV neck dissection for papillary thyroid carcinoma: level VI recurrence patterns.

Lateral and central compartments cervical lymph nodes metastases are common among patients with papillary thyroid carcinoma (PTC). Elective level VI neck dissection during thyroidectomy and lateral neck dissection (LND) for the treatment of PTC with lateral compartment lymph node metastases is controversial because of the uncertain benefit in clinical outcomes and increased risks of surgical morbidity. We aimed to determine the potential benefit of elective level VI neck dissection in patients with cN1 papillary thyroid carcinoma (PTC) by investigating the rate and pattern of locoregional recurrence in PTC patients who underwent total thyroidectomy and therapeutic lateral node dissection (LND; levels II-IV) without elective level VI dissection. A retrospective cohort study. Data on demographics, clinical presentation and workup, intraoperative and pathological report, postoperative course, adjuvant therapy, recurrence patterns, and overall survival were retrieved from the medical charts of patients who underwent thyroid surgery in our hospital between January 2006 and December 2017. A total of 1415 thyroidectomies were performed during the study period, of which 802 (56.67%) were for PTC. Of those PTC patients, 228 (28.42%) also underwent LND (levels II-VI) during the same thyroidectomy procedure. Thirty-four (14.91%) of those 228 patients, underwent total thyroidectomy with therapeutic lateral ND II-IV without elective level VI ND. During the follow-up period, five (14.7%) of the latter cohort were diagnosed with recurrence in central neck (level VI) lymph nodes, and four of them (11.7%) were diagnosed with ipsilateral recurrence at level VI. Our results revealed 11.7% rate of clinically significant recurrent disease in ipsilateral level VI which, in our opinion, does not justify routine prophylactic level VI ND dissection when the ipsilateral lateral neck is operated for metastases.