Modified Radical Neck Dissection Research Articles

Physiotherapeutic Rehabilitation of a 48-Year Male with Buccal Mucosa Carcinoma of Squamous Cell: A Case Report

Buccal mucosa carcinoma of squamous cell is an uncommon kind of oral cavity cancer that is known to be dangerous. It's also linked to a high probability of local regional recurrence, and it's more likely in persons who chew tobacco and/or smoke, whether or not they drink alcohol. A 48-year patient is an elderly man who works as a farmer, mesomorphic built with right-hand dominance came to the tertiary care hospital with complaints of painful ulcers in upper left Jaw's front portion, which was relatively small initially and further increases to 6 x 4 cm approx., since last 4 months. Patient was complaining of pain, difficulty in mastication and manipulations etc. He has history of kharra chewing and tobacco chewing since last 10 years. With these complaints patient has come to the oral surgery department with buccal mucosa skin involvement and underwent surgery as compartmental resection of lesion, Modified Radical neck dissection and segmental mandibulectomy. Following surgical procedure patient has complaints of discomfort, limitation of movements at the operated site, chest pain, and limited mouth opening. For these complaints, programmed physiotherapy treatment was given to the patient which mainly concentrates on mouth opening and increasing range of motion of affected side.

Serum Calcitonin-Negative Medullary Thyroid Carcinoma: A Case Series of 19 Patients in a Single Center.

IntroductionMedullary thyroid carcinoma (MTC) is a rare cancer that accounts for 5% of thyroid cancers. Serum calcitonin is a good biomarker for MTC, which is used for diagnosis, prognosis, and monitoring of recurrence. Calcitonin-negative MTC (CNMTC) is rare but confounds diagnostic and prognostic directions. This study introduces 19 cases of CNMTC in a single center.MethodFrom 2002 March to 2020 July, more than 76,500 patients had undergone thyroid surgery due to thyroid cancer at the Severance Hospital, and a total of 320 patients were diagnosed with MTC (0.4%). Serum calcitonin levels were obtained from every patient who was suspected with MTC. These patients had undergone either bilateral total thyroidectomy or unilateral thyroidectomy with central compartment lymph node dissection, and additional modified radical lymph node dissection if lateral lymph node metastasis was positive. Postoperative monitoring and out-patient clinic follow-up were performed with obtaining the serum calcitonin levels.ResultNineteen patients tested negative for calcitonin preoperatively (6%). The mean preoperative calcitonin level was 5.1pg/mL if undetectable level is regarded as 0pg/mL. Only two patients were males, and the female bias was significant (p = 0.017). No one except two patients with modified radical neck dissection showed central compartment lymph node metastasis. Every patient’s postoperative calcitonin level remained low. The median follow-up period was 71 months. There was no recurrence and only one fatality, and the overall survival rate was 95%.ConclusionSince incidence of CNMTC is not negligible, MTC should not be ruled out in the diagnostic phase even if serum calcitonin is negative in preoperative examination. We presented 19 cases of CNMTC whose prognosis in general were favorable. Markers of serum and immunohistochemical samples other than calcitonin should be actively examined.

Surgical management of papillary thyroid carcinoma

Background: Papillary thyroid carcinoma (PTC) is the most prevailing thyroid cancer but remains of a favorable prognosis. Thyroidectomy with excision of all positive cervical nodes remains the cornerstone of the management PTC. The role for prophylactic central neck dissection (PCND) remains controversial. Methods: A prospective non randomised open label study of 20 PTC patients, 8 of them underwent total thyroidectomy with PCND and 12 underwent total thyroidectomy with modified radical neck dissection type III in El Zahraa hospital, Azhar university, and Damanhour oncology center, Egypt starting from September 2019 to August 2021. The incidence of central lymph node metastasis in N0 cases underwent PCND were reported, the relationship between lymph node metastasis with lympho-vascular permeation and capsular invasion, were analysed and sensitivity of fine needle aspiration cytology in diagnosis of PTC was reported.Results: Occult central lymph node metastasis was observed in 62.5% of PTC lesions. The FNAC showed a sensitivity of 85%. Lympho-vascular permeation and capsular invasion showed a sensitivity of 94.12% and 58.82%, respectively for lymph nodes metastasis. Thyroiditis is detected in 50% of cases with PTC. Postoperative ablative dose of radioactive iodine 131 (RAI-131) ranged from 80 to 100 millicurie.Conclusions: R0 resection is mandatory to cure PTC. PCND remains a debatable issue, that needs a large multicentre study with large sample of patients with long term follow up to ascertain the efficacy of PCND in reducing rate of local recurrence, morbidity and mortality.

A cutaneous representation of parotid adenocarcinoma not otherwise specified

<p class="abstract">Cutaneous manifestations of adenocarcinoma is a very rare entity. The patient reported to our institute with a complain of swelling on right parotid region that would bleed profusely merely on palpation. The hematological values revealed very low Hemoglobin, RBC and PCV counts indicating severe hemolytic anemia. The patient had palpable lymph nodes of level I and IIA which were enlarged. The patient underwent excision of the lesion along with modified radical neck dissection and reconstruction of the skin defect using pectoralis major myocutaneous flap.</p>

Clinical T4b Squamous Cell Carcinoma Resection With Hemimandibulectomy and Temporomandibular Joint Reconstruction With Bridging Plate and Modified Dautrey Procedure

Clinical T4b oral squamous cell carcinoma is traditionally considered nonoperable. We present a case of right mandibular squamous cell carcinoma (PT4bN0M0, stage IVB). The tumor had extended to the right mandibular condylar head and masticatory space. The patient received right modified radical neck dissection and radical operation with hemimandibulectomy to remove the right mandibular condyle. Then, we reconstructed the resected portion with an anterior lateral thigh free flap and bridging plate, which was bent to form an artificial condyle and fixed using the modified Dautrey procedure. The patient had stable postoperative occlusion and normal hinge movement of the temporomandibular joint. After postoperative concurrent chemotherapy and radiotherapy, the patient is under regular out patient department follow-up with satisfactory jaw function and oral intake.

The Role of IONM in Reducing the Occurrence of Shoulder Syndrome Following Lateral Neck Dissection for Thyroid Cancer.

Lateral neck dissection (LND) leads to a significant morbidity involving accessory nerve injury. Modified radical neck dissection (MRND) aims at preservation of the accessory nerve, but patients often present with negative functional outcomes after surgery. The role of neuromonitoring (IONM) in the prevention of shoulder syndrome has not yet been defined in comparison to nerve visualization only. We retrospectively analyzed 56 thyroid cancer patients who underwent MRND over a period of six years (2015–2020) in a high-volume institution. Demographic variables, type of surgical procedure, removed lymph nodes and the metastatic node ratio, pathology, adoption of IONM and shoulder functional outcome were investigated. The mean number of lymph nodes removed was 15.61, with a metastatic node ratio of 0.2745. IONM was used in 41.07% of patients, with a prevalence of 68% in the period 2017–2020. IONM adoption showed an effect on post-operative shoulder function. There were no effects in 89.29% of cases, and temporary and permanent effects in 8.93% and 1.79%, respectively. Confidence intervals and two-sample tests for equality of proportions were used when applicable. Expertise in high-volume centres and IONM during MRND seem to be correlated with a reduced prevalence of accessory nerve lesions and limited functional impairments. These results need to be confirmed by larger prospective randomized controlled trials.

Recurrent Giant Mucoepidermoid Carcinoma of the Parotid: A Case Report and Review of Literature.

Mucoepidermoid carcinoma is the most common salivary gland malignancy and about one third occurs in the parotid gland. The peak incidence is commonly seen between the third and fifth decades of life. It routinely presents as a fixed, painless mass below the ear. However, its presentation as a giant mass is exceedingly rare. Here, we report a case of a recurrent giant exophytic mucoepidermoid carcinoma in a young male. He underwent Revision Total Parotidectomy with Modified Radical neck dissection with Sural nerve grafting and an Anterolateral thigh flap reconstruction followed by Adjuvant radiotherapy. The rarity of the clinical presentation and the management challenges faced in a young male are being discussed in this case report.

The importance of flaps in reconstruction of locoregionally advanced lateral skull-base cancer defects: a tertiary otorhinolaryngology referral centre experience.

BackgroundThe aim of the study was to identify the value of extensive resection and reconstruction with flaps in the treatment of locoregionally advanced lateral skull-base cancer.Patients and methodsThe retrospective case review of patients with lateral skull-base cancer treated surgically with curative intent between 2011 and 2019 at a tertiary otorhinolaryngology referral centre was made.ResultsTwelve patients with locoregionally advanced cancer were analysed. Lateral temporal bone resection was performed in nine (75.0%), partial parotidectomy in six (50.0%), total parotidectomy in one (8.3%), ipsilateral selective neck dissection in eight (66.7%) and ipsilateral modified radical neck dissection in one patient (8.3%). The defect was reconstructed with anterolateral thigh free flap, radial forearm free flap or pectoralis major myocutaneous flap in two patients (17.0%) each. Mean overall survival was 3.1 years (SD = 2.5) and cancer-free survival rate 100%. At the data collection cut-off, 83% of analysed patients and 100% of patients with flap reconstruction were alive.ConclusionsFavourable local control in lateral skull-base cancer, which mainly involves temporal bone is achieved with an extensive locoregional resection followed by free or regional flap reconstruction. Universal cancer registry should be considered in centres treating this rare disease to alleviate analysis and multicentric research.

P22-9 Intraoperative spinal accessory nerve monitoring during modified radical neck dissections in thyroid cancer patients

P22-9 Intraoperative spinal accessory nerve monitoring during modified radical neck dissections in thyroid cancer patients

P22-10 Modified radical neck dissections in different ages thyroid cancer patients

The aim of this study was to assess the characteristics of thyroid carcinoma (TC) with lymph nodes metastasis in childhood and aged 61 and older. Among 771 patients (134 Male and 637 female; mean age 48 ± 14.7 years) who underwent surgery for thyroid cancer at our institution between 1983 and 2013, we retrospectively enrolled 160 PTC patients with regional metastasis (26 male, 134 female; mean age 15.2 ± 6.4 years) aged from 0-18 years and 135 PTC patients with regional metastasis (24 male, 111 female; mean age 78.6±10.2 years) aged 61 years and older. To identify the risk factors for recurrence, we analyzed age, gender, multiplicity, size, number, extrathyroidal extension (ETE) of the tumors, type of surgery and the dose of radioactive ablation using a Cox regression model to identify hazard rations (HRs). Cox regression analysis demonstrated that tumor size (HR, 2.12; p < 0.001) and LNM (central LNM: HR, 9.08; P=0.004; lateral LNM: HR, 14.71; P=0.002; both central and lateral LNM: HR, 58.41; p < 0.001) significantly increased the recurrence rate. ETE, LNM, and recurrence were significantly less frequent in PTMCs than in non- PTMC (all p < 0.001). PTCs of small size and absent LNM showed significantly better prognoses in patient before 18 and patients 61 years and older.

Thyroid Malignancy a 5year Experience at Our Centre

Objective: To find out the frequency of various types thyroid carcinomas and their management in tertiary care hospital of Bengaluru. Study design: Retrospective study. Place &amp;Duration of study: Department of General Surgery, KIMS Hospital and Research Centre, Bangalore. 2016 -2021. Methodology: All patients with well differentiated thyroid carcinoma and medullary thyroid carcinoma were included in the study. Patients with anaplastic carcinoma were excluded. Written and informed consent were taken from the patients and data was recorded on a pre-designed form. Results: One hundred and twenty four patients were included in this study. Eighty four patients were female and fourty male with female to male ratio of 2:1. Papillary carcinoma was found to be the most frequent thyroid carcinoma encountered (n=78 – 62.90%) followed by follicular and medullary carcinoma, 34 (27.42%) and 12 (9.67%) respectively. Various surgical procedures were done to deal with these malignancies, that included total thyroidectomy (n=68 – 54.84%), total thyroidectomy plus modified radical neck dissection (n=18 – 14.51%) completion thyroidectomy (n=32 – 25.81%), completion thyroidectomy with modified radical neck dissection (n=4 – 3.22%), and modified radical neck dissection (MRND) alone in (n= 2 -1.65%) patients. Conclusions: Papillary carcinoma was the most common thyroid malignancy encountered. Frequency of medullary carcinoma was found almost equal to the follicular carcinoma.

Neck dissection and trans oral robotic surgery for oropharyngeal squamous cell carcinoma

ObjectiveTrans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was planned to determine whether Selective Neck Dissection (SND) is oncological safe procedure even in patients with lymph node metastases. MethodsOPSCC patients were divided into Modified Radical Neck Dissection (MRND) and SND groups. The outcome measures were overall survival (OS), disease-free survival (DFS) and regional recurrence free survival (RRFS). ResultsThirty-seven SNDs and 18 MRNDs were performed. Regional relapse rate was 6.1% in SND group whilst 18.8% in MRND group(p=0.19). The 5-year OS, DFS and RRFS rates’ differences were not statistically significant between SND and MRND groups (p=0.40, p=0.42 and p=0.18, respectively). At multivariate analysis, advanced stage impacted the 5-year OS and DFS(HR=9.39, p<0.01 and HR=11.03, p=0.04). ConclusionsThe SND seems to be effective in a TORS framework. The indication should be accurately discussed by the multidisciplinary tumor board.

Anaplastic Lymphoma Kinase Positive Large B-cell Lymphoma Mimicking Metastatic Carcinoma of the Cervical Lymph Node from an Unknown Primary Lesion

Anaplastic lymphoma kinase positive large B-cell lymphoma (ALK+LBCL) is a rare subtype of B-cell lymphoma with aggressive features and a poor prognosis. The rarity of this disease and similarity of microscopic features with undifferentiated epithelial neoplasm disturb the provision of proper treatment. A 57-year-old male presented with a rapidly growing and painless mass on the left side of the neck. Metastatic carcinoma of an unknown primary (CUP) lesion was initially suspected based on the pathologic results obtained from a core needle biopsy, but it was finally diagnosed as ALK+LBCL after a modified radical neck dissection. We herein report a case of ALK+LBCL mimicking CUP with a literature review.

Lymph Node Yield and Ratio in Selective and Modified Radical Neck Dissection in Head and Neck Cancer-Impact on Oncological Outcome.

Simple SummaryHead and neck cancers metastasize into the neck lymph nodes. The surgical removal of neck lymph nodes (i.e., neck dissection) is commonly performed before or after radiation therapy. The most common types of neck dissection include selective (with removal of nodes at risk) and radical modified (with removal of all neck lymph nodes). Given the variability in surgical techniques, quality and prognostic markers for neck dissection are missing. Lymph node ratio (LNR: number of metastatic nodes/total number of nodes harvested) has been previously suggested as a quality and prognostic marker. Here, we assess the impact of prior irradiation on the lymph node yield (LNY) as well as the role of LNR in both selective and modified radical neck dissection. We found that previous irradiation to the neck leads to a reduced LNY; there is no change in LNR. LNR has a prognostic impact in modified radical neck dissection but not in selective neck dissection.Background: Lymph node metastases are associated with poor prognosis in head and neck squamous cell carcinoma (HNSCC). Neck dissection (ND) is often performed prior to or after (chemo)radiation (CRT) and is an integral part of HNSCC treatment strategies. The impact of CRT delivered prior to ND on lymph node yield (LNY) and lymph node ratio (LNR) has not been comprehensively investigated. Material and methods: A retrospective cohort study was conducted from January 2014 to 30 June 2019 at the University Hospital of Bern, Switzerland. We included 252 patients with primary HNSCC who underwent NDs either before or after CRT. LNY and LNR were compared in patients undergoing ND prior to or after CRT. A total of 137 and 115 patients underwent modified radical ND (levels I to V) and selective ND, respectively. The impact of several features on survival and disease control was assessed. Results: Of the included patients, 170 were male and 82 were females. There were 141 primaries from the oral cavity, 55 from the oropharynx, and 28 from the larynx. ND specimens showed a pN0 stage in 105 patients and pN+ in 147. LNY, but LNR was not significantly higher in patients undergoing upfront ND than in those after CRT (median: 38 vs. 22, p < 0.0001). Cox hazard ratio regression showed that an LNR ≥ 6.5% correlated with poor overall (HR 2.42, CI 1.12-4.89, p = 0.014) and disease-free survival (HR 3.416, CI 1.54-754, p = 0.003) in MRND. Conclusion: ND after CRT leads to significantly reduced LNY. An LNR ≥6.5% is an independent risk factor for decreased overall, disease-free, and distant metastasis-free survival for MRND.

Concurrent Papillary Carcinoma of Thyroglossal Duct Cyst and Thyroid Isthmus, Beyond the Sistrunk Procedure

Introduction/Background: Papillary carcinoma (PC) originating from the thyroglossal cyst is a rare entity. It is even more uncommon to have concurrent thyroglossal duct cyst PC and papillary thyroid carcinomas (PTC). The surgical approach for such patients would involve a combination of a Sistrunk’s procedure and total thyroidectomy. We describe management of a patient found to have multi focal PC originating from a thyroglossal duct cyst and thyroid isthmus with extensive cervical lymph node metastasis. Clinical Case: 30-year-old male presented to PCP with palpable bilateral cervical adenopathy most prominent in the right supraclavicular region. Neck ultrasound confirmed multiple metastatic appearing nodes (largest 4cm) in the central, right and left lateral cervical compartments as well as a hypoechoic, TI-RADS category 5 right thyroid isthmus nodule. FNA of the cervical nodes confirmed metastatic PTC. Neck CT in addition to extensive cervical adenopathy revealed a 2 cm solid mass inferior to the central hyoid bone with infiltrative borders and calcifications suspicious for a primary tumor. Patient underwent total thyroidectomy with central compartment lymph node dissection, excision of thyroglossal cyst and bilateral modified radical neck dissections. Histopathology report revealed a 2.4 cm thyroglossal duct tumor and a 1.1 cm tumor in the thyroid isthmus, confirming two separate tumors both being classical variants of papillary thyroid carcinoma, with no lympho-vascular invasion and 8/53 positive lymph nodes. BRAF V600E mutation was positive. On follow up, the patient is doing well and has deferred adjuvant radioactive iodine treatment for 6 months for personal reasons. Clinical Lesson/ Conclusion: PC of the thyroglossal cyst with synchronous isthmic PTC merits total thyroidectomy and central compartment dissection in addition to the Sistrunk’s procedure, as the likelihood of local metastasis is high. Presence of BRAF V600E mutation has been identified as a predictor of more aggressive behavior in isolated PC of the thyroglossal duct cyst, suggesting a need for more than a Sistrunk’s procedure in such patients. Our patient, who presented with local lymph node metastasis supports this conclusion. Determining BRAF mutation status preoperatively may be a helpful strategy in planning the extent of surgery. Keywords Thyroglossal duct cyst, Papillary thyroid carcinoma, BRAF mutation

Squamous Cell Carcinoma of the Thyroid Gland in an elderly Female

Background: Squamous cell carcinoma of the thyroid gland is a rare tumor. The tumor may arise as a primary tumor within the thyroid gland. Case Presentation: A 62-years-old lady with history a history of a long-standing left neck mass presented with progressive enlargement of the mass for the last 2 months. The mass was associated with dyspnea, dry cough, and difficulty in swallowing but no change of voice. On examination, it was hard and fixed, and other parts of the general examination were unremarkable. Fine needle aspiration revealed malignant cells with squamous cell cancer (BETHESDA VI). On surgical exploration, there was a mixed cystic and solid mass arising from the left thyroid gland locally invading strap muscles, esophagus and trachea. Complete excision was not possible, debulking was done with modified radical neck dissection. The histopathology showed Invasive poorly differentiated squamous cell carcinoma of the thyroid with cystic changes in background of Hashimoto’s thyroiditis. Conclusion: Thyroid squamous cell carcinoma is a rare malignancy with significant management implications. Less than three hundred clear cases of thyroid squamous cell carcinoma have been reported. In this report we describe one additional case of a thyroid squamous cell carcinoma and provide a comprehensive discussion of the clinical significance, and appropriate surgical management.

P2: CONSIDERATIONS IN SURGICAL VERSUS NONSURGICAL MANAGEMENT OF HEAD AND NECK MERKEL CELL CARCINOMA

Abstract Introduction MCC is a rare cutaneous neuroendocrine tumour with a high risk of regional and distant metastasis. Management of this highly aggressive tumour is complex and mandates a multidisciplinary approach for optimal outcomes. Method Over 12 months, three cases of MCC in the cervicofacial region were identified and described. A critical review of the literature is included. Result Tumour staging confirmed 2/3 cases had regional spread. One patient underwent unilateral parotidectomy with modified radical neck dissection and adjuvant radiotherapy. The other case is awaiting radiotherapy following a selective neck dissection. The final case had no further surgery and is currently under surveillance. Conclusion This case series illustrates the diversity in managing cervicofacial MCC's at various stages of their development. Take-home message Merkel cell carcinoma must be managed aggressively with a multidisciplinary approach, regardless of how localised it may appear.

Therapeutic neck dissection in head and neck melanoma patients: Comparing extent of surgery and clinical outcome in two cohorts

BackgroundThe extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach. MethodsSixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I–V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3–4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS). ResultsClinical characteristics of patients were equal in both groups. In the NCI cohort 62.5% (n = 25) of patients recurred versus 65% (n = 13) in the EMC cohort. None of the NCI recurrences affected the parotid gland in contrast to 3 patients in the EMC group. Survival characteristics were not different between the two groups: OS (p = 0.56), MSS (p = 0.98), DFS (p = 0.92). ConclusionThis study does not support to continue the practice of routine elective parotidectomy and MRND in melanoma patients undergoing a lymph node dissection for macroscopic (palpable) nodal disease and justifies (S)SND.

Risk factors for postoperative hypocalcaemia after thyroidectomy: A systematic review and meta-analysis.

ObjectiveA meta-analysis to investigate the risk factors for postoperative hypocalcaemia after thyroidectomy in adult patients.MethodsA systematic search of publications in the electronic databases (PubMed®, The Cochrane Library, Web of Science, OVID and Embase®) from inception to June 2020 was conducted. Screening of titles, abstracts and full texts and data extraction were independently performed by two authors. The OR was selected as the pooled estimate.ResultsThe analysis included 23 studies. Twelve significant risk factors for postoperative hypocalcaemia were identified: hypoparathyroidism, OR 5.58; total thyroidectomy, OR 3.59; hypomagnesaemia, OR 2.85; preoperative vitamin D deficiency, OR 2.32; female sex, OR 1.49; thyroid malignancy, OR 1.85; thyroiditis, OR 1.48; substernal multinodular goitres, OR 1.70; parathyroidectomy, OR 1.58; central compartment neck dissection, OR 1.17; modified radical neck dissection, OR 1.57; and central neck dissection, OR 1.54.ConclusionsThis meta-analysis provides moderate-to-high quality evidence that the 12 risk factors were predictive of postoperative hypocalcaemia, which should be monitored closely before thyroidectomy.

ASO Author Reflections: A New Procedure for Modified Radical Neck Dissection via the Transoral Endoscopic Approach.

ASO Author Reflections: A New Procedure for Modified Radical Neck Dissection via the Transoral Endoscopic Approach.