Neck Disease Research Articles

Successful Salvage of Refractory Burkitts Lymphoma Using Maximum Intensity of the DA EPOCH-R Regimen—a Case Report

Burkitt lymphoma (BL) that is refractory to frontline intensive therapy is generally associated with a dismal outcome. We report a case where this prognosis has apparently been overcome with an intensified variation of the DA EPOCH-R schedule. Wilson and coworkers have developed this infusional schedule with dose modification and it has been reported to achieve excellent outcomes in the first line therapy of BL. A 56 year old male presented with rapid onset superior vena cava obstruction that caused an intensive care admission at the time of diagnosis. Staging showed stage 2 with neck disease, near complete SVC obstruction and a 6 x 5 x 5cm superior mediastinal mass. Therapy was commenced with R CODOX-M / R IVAC with an initial symptomatic improvement but by the time of recovery from course 2, the symptoms of respiratory distress were recurring in the left neck where partial acute respiratory obstruction occurred. No significant improvement in the neck mass was seen on repeat CT and urgent radiotherapy (R/T) was given to relieve symptoms. Persistent active disease was then confirmed by CT /PET scanning in the left neck (SUV 10.8), an exemplar image of this scan is shown in Figure. The patient was counselled as to the dire prognosis but was unwilling to accept that further intensive treatment was unlikely be successful and requested further chemotherapy. In the light the intensity of the treatment already delivered a novel strategy was conceived and agreed. Second line treatment was given with the DA EPOCH -R schedule but escalated to dose level 6 from the start of second line therapy. The rationale for this was that the dose intensity needed to be higher than that of the failed front line regimen. Dose limiting mucositis was encountered and the etoposide was reduced to 65% of dose level 6, other drugs remained at dose level 6. By cycle 5, the doxorubicin dose was capped at a total cumulative dose of 450 mg/m2 so as to not exceed a safe cardiac dose. The chemotherapy doses delivered were Etoposide 125 ( 80 from cycle 2) mg/ m2 /day , Vincristine 0.4 mg/ m2/day, Doxorubicin 25 mg/ m2/day (cycle1-4), Cyclophosphamide 1900 mg/ m2 day 5 and rituximab 375 mg/ m2. 5 cycles were delivered in total. The total cumulative hospital inpatient stay during treatment was 58 days. End of treatment PET showed a complete response which has now been maintained for 12 months. Two attempts at stem cell mobilisation failed, despite the use of plerixifor, so a consolidation autologous stem cell transplant was not pursued. End of treatment radiotherapy to sites of initial disease was implemented after end of treatment restaging. This is a single case but we believe a good outcome has been achieved in an otherwise near hopeless situation and may provide a useful insight into improving salvage therapy of BL. We believe the strategy of using DA EPOCH R starting at maximum intensity from the start of therapy has not been previously reported. We also acknowledge the courage and stoicism of our patient whose determination to persist with therapy was exceptional. He remains in remission, has an ECOG status of 0 and has returned to work. Disclosures McMillan: Roche: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees, Other: travel sponsorship. Bishton: Roche: Other: Travel Sponsorship. Fox: Roche: Consultancy, Honoraria, Other: Travel Sponsorship, Research Funding, Speakers Bureau; AbbVie: Consultancy, Honoraria, Other: Travel Sponsorship, Research Funding; Janssen: Consultancy, Honoraria, Other: Travel Sponsorship, Speakers Bureau.

Metastatic lymph node characteristics as predictors of recurrence/persistence in the neck and distant metastases in differentiated thyroid cancer.

The aim of this study was to evaluate the association between this characteristic and outcomes in patients with lymph node metastasis in a Brazilian cohort. This study examined a retrospective cohort of adult patients diagnosed with differentiated thyroid cancer and lymph node metastases from 1998 to 2015 in two referral centers. Number, location, size and extranodal extension (ENE) of metastatic lymph nodes were assessed and correlated with response to initial therapy. A greater number of metastatic nodes, larger size, presence of lateral neck disease and ENE were all associated with a lower probability of achieving an excellent response to initial therapy (p ≤ 0.05 for all these parameters). Local recurrent disease had a significant association with lymph node number (6 in the recurrence/persistence group versus 4 in the non-recurrent group; p = 0.02) and ENE (19.2 versus 75%, p = 0.03). Lateral neck disease was the only characteristic associated with distant metastasis and was present in 52.1% of the group without metastasis and 70.4% of the group with metastasis (p = 0.001). The lymph node characteristics were associated with response to initial therapy and neck recurrence/persistence, confirming the importance of the analysis of these factors in risk stratification in a Brazilian population and its possible use to tailor initial staging and long term follow-up.

How new NICE guidelines will impact service provision in patients treated for early oral cavity squamous cell carcinoma – a ten-year single centre retrospective review

Introduction: Historically, patients with early oral cavity squamous cell carcinoma (oSCC) without evidence of neck disease have not all been treated with cervical node surgery. New NICE guidelines recommends all patients are offered surgical intervention in the neck (elective neck dissection, ND or sentinel lymph node biopsy (SLNB).

Rescue transtracheal jet ventilation during difficult intubation in patients with upper airway cancer

IntroductionThe failure rates of intubation and/or mask ventilation are higher in patients with neck or upper airway disease. To ensure oxygenation, rescue trans-tracheal jet ventilation (RTTJV) may be used. In this critical situation, a high rate of complications has been reported. The aim of this study was to report RTTJV performed by a jet ventilator with an end-expiratory pressure control in an experienced institution. Patients and methodsFrom a computerised database of 63,905 anaesthesia cases, the anaesthetic reports of patients who underwent emergency RTTJV during intubation were studied retrospectively. The following information were analysed: anaesthetic procedures, data from the monitoring: lowest SpO2, duration of SpO2<90%, and complications. Success of emergency RTTJV was defined when SpO2 was>90% under jet ventilation. ResultsRTTJV was used in 31 patients, of whom 26 had upper airway cancer, (pre-treatment, n=9, post-treatment, n=17). Difficult intubation was anticipated in 15 out of 31 cases including six fiber-optic-aided intubations under spontaneous ventilation. RTTJV was effective in all cases with quick restoration of oxygenation (SpO2>90%). During jet ventilation, final airway control was performed either by oral intubation (n=25) or tracheotomy (n=1) in a short delay (mean: 8.1±1.7min). Subcutaneous emphysema was observed in one case without pneumothorax. ConclusionRTTJV with end-expiratory pressure control allowed oxygenation during difficult intubation, with a low rate of complications.

Regional Neck Control in Head and Neck Squamous Cell Carcinoma with Positive Neck Disease Treated with Primary Chemoradiation

The treatment of squamous cell carcinomas of the head and neck (HNSCC) is multidisciplinary. Chemoradiation has become an integral part of the treatment process in managing metastatic neck disease. Randomized controlled trials and meta-analyses have demonstrated major improvements not only in loco-regional tumor control, but also in terms of survival when chemotherapy is added to radiotherapy. In clinical practice, this has translated into a reduction in the number of recurrent neck disease needing salvage surgery. Studies have reported up to 2-year overall survival (OS) of 92% and disease-free survival (DFS) of 95%, in patients with advanced HNSSC treated with CRT. This single institution, retrospective cohort study was conducted to analyze the regional control rates after primary chemo-radiation therapy in a tertiary center.

Clinical Characteristics and Treatment Outcomes of Radiation-Associated and Spontaneous Malignant Peripheral Nerve Sheath Tumor

In an IRB approved protocol, we reviewed the clinical characteristics and outcomes of patients treated for malignant peripheral nerve sheath tumor (MPNST) at our institution and sought to characterize the impact of association with prior radiation, clinicopathologic features and treatment modalities on clinical outcomes. We identified 133 patients with MPNST treated at our institution between 1995 and 2015 and collected the clinical information. Overall survival (OS), local control (LC) and metastasis-free survival (MFS) were estimated using the Kaplan-Meier method. The multivariate Cox proportional hazards regression was used to analyze survival outcomes and risk variables. With a median follow-up of 35.4 mo (range: 0.7-270.1), the median OS was 70.7 mo (95% CI: 37.6-103.9). There were 71 men and 62 women with a median age of 42 y (range: 7-86). Patients were classified as having either radiation-associated MPNST (raMPNST, n=10) or spontaneous MPNST (sMPNST, n=123). The median time to development of raMPNST from prior malignancy was 15 y (range: 7-38). Prior malignancies in patients developing raMPNST included Hodgkin disease (6), testicular cancer (2), ALL (1), and Wilms disease (1) at a median age of 20 y (range: 4-39). Compared with sMPNST, raMPNST was not related with either NF syndrome (0% in raMPNST vs 37.4% in sMPNST, p=0.015), occurred more frequently in trunk (90.0% vs 36.8%, p=0.003) and as intermediate grade (90% G2 and 10% G3 vs 43.9% G2 and 43.1% G3, p=0.047). The rate of metastatic disease on presentation was similar (10% raMPNST vs 12.8% sMPNST). No significant difference was found in treatment (surgery, radiation or chemotherapy) between raMPNST and sMPNST (p=NS). On univariate analysis, raMPNST showed worse OS (median: 24.3 mo vs 79.6 mo, p=0.006), LC (9.3 vs 71.6, p=0.031) and MFS (9.3 vs 73.6, p=0.031) than sMPNST. Compared with NF associated sMPNST, raMPNST still showed poorer OS (p=0.021), LC (p=0.043) and MFS (p=0.035). On multivariate analysis, older age (HR=1.02, 95% CI: 1.01-1.03, p=0.027), raMPNST (HR=3.22, 95% CI:1.35-7.65, p=0.008), trunk (HR=2.39, 95% CI: 1.18-4.84, p=0.015), positive lymph node (HR=6.80, 95% CI: 2.11-21.88, p=0.001), metastatic disease at diagnosis (HR=3.61, 95% CI: 1.84-7.10, p<0.001) were related with worse OS, whereas surgery (HR=0.41, 95% CI: 0.20-0.86, p=0.018) was associated with improved OS. Among the 116 patients without metastatic disease at diagnosis, primary disease in head or neck (HR=0.36, 95% CI: 0.16-0.78, p=0.010) and radiation therapy (HR=0.29, 95% CI: 0.16-0.53, p<0.001) were correlated with improved LC, while primary disease in trunk was correlated with worse MFS (HR=3.22, 95% CI: 1.33-7.79, p=0.009). Radiation associated MPNSTs appear to be more likely to develop in the trunk (an unfavorable site), have poorer prognosis than spontaneous MPNST including NF associated ones, and warrant further characterization to determine optimal treatment.

Pathologic Risk Factors Associated With Contralateral Neck Disease in Patients with Tonsil Cancer: Implications on Patient Selection for Unilateral Neck Radiation Therapy

Pathologic Risk Factors Associated With Contralateral Neck Disease in Patients with Tonsil Cancer: Implications on Patient Selection for Unilateral Neck Radiation Therapy

Clinical Course of Cervical Percutaneous Epidural Neuroplasty in Single-Level Cervical Disc Disease with 12-Month Follow-up

Background: Cervical disc disease is a common and occasionally disabling condition, occurring as a natural consequence of aging in the vast majority of the adult population. Percutaneous epidural neuroplasty (PEN) has been used to deliver highly concentrated drugs for chronic neck pain and to prevent scarring in cases refractory to conventional epidural blocks. However, the clinical course after PEN in cervical disc disease is not well-documented. Objective: The purpose of this study was to evaluate the efficacy of cervical PEN for single-level cervical disc disease. Study Design: A retrospective observational study. Methods: A consecutive series of 100 patients who underwent cervical PEN for single-level disc disease (bulging or protrusion) were included in this study. Preoperatively, all patients underwent magnetic resonance imaging (MRI), and visual analog scale (VAS) scores as well as Odom’s criteria were measured preoperatively and at post-operative follow-up visits (one, 3, 6, and 12 months). Limitations: The results of this study are limited by the lack of a control group that did not undergo treatment with PEN. Results: Additional block therapy was performed in 58 patients (58.0%). Subsequent surgery was performed in 10 patients (10.0%, excluded from data of clinical follow-up). Mean neck pain and VAS arm pain scores for all follow-up patients decreased from 6.82 and 4.74 preoperatively to 2.18 and 1.87 at 12 months after PEN (P &lt; 0.001). More than 80% and 40% of all patients with and without additional block therapy after cervical PEN, respectively, showed good and excellent outcomes according to Odom’s Criteria during 12 months of follow-up. During this follow-up period, no severe complications related to the procedure were observed. Conclusion: Cervical PEN was shown to be a safe and effective treatment for neck and arm pain in single-level disc disease during 12 months of follow-up.

Prognostic Variables Affecting Primary Treatment Outcome for Medullary Thyroid Cancer

Identifying prognostic risk factors and determining the efficacy of common surgical treatments is critical to determine optimal treatment strategies for patients with medullary thyroid carcinoma (MTC). The objective of this study was to review a contemporary institutional experience with MTC primary treatment with 2 goals: to identify prognostic factors that impact survival and to study the effect of neck dissection on those outcomes. This study was a retrospective case series of patients with MTC who underwent at least a total thyroidectomy with curative intent. Clinical parameters including tumor and nodal staging with corresponding pathology findings were identified. Survival endpoints included overall survival, disease-free survival, and biochemical cure. Sixty-seven patients were included. The majority presented with early T-stage disease. Fifty (76%) patients were N0 at presentation. Seventeen (24%) had some evidence of neck disease on clinical examination or imaging. Forty (71%) achieved biochemical cure, and the 5-year biochemical recurrence-free survival for those cases was 86.5%. Among patients who had successful resection of all gross disease, 92% had no evidence of structural disease at 5 years. Overall survival was 91% at 5 years. Increased pre-operative calcitonin (Ct) level, primary tumor size, extrathyroidal extension, and neck metastases decrease the rate of biochemical cure. Larger tumor size increases the risk of structural disease recurrence and biochemical relapse after initial cure. The presence and number of neck metastases correlate with biochemical relapse. The presence of lateral neck nodes (pN1b) does not have different survival implications than centrally confined disease (pN1a). This study shows increasing tumor size, increased Ct level, and cervical metastases are poor prognostic factors. Patients with large tumors, high Ct level, or unfavorable pathologic findings may warrant more aggressive initial treatment, although limitations of the study prevent any conclusion regarding the effect of neck dissection. ATA = American Thyroid Association BRFS = biochemical recurrence-free survival CND = central neck dissection Ct = calcitonin DFS = disease-free survival MTC = medullary thyroid carcinoma OR = odds ratio OS = overall survival pCND = prophylactic CND.

Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography After Concurrent Chemoradiotherapy in Locally Advanced Head-and-Neck Squamous Cell Cancer: The ECLYPS Study

Purpose To assess the standardized implementation and reporting of surveillance [18F]fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scan of the neck in locoregionally advanced head-and-neck squamous cell carcinoma (LAHNSCC) after concurrent chemoradiotherapy (CCRT). Patients and Methods We performed a prospective multicenter study of FDG-PET/CT scanning 12 weeks after CCRT in newly diagnosed patients with LAHNSCC (stage IVa/b) that used standardized reconstruction and Hopkins reporting criteria. The reference standard was histology or > 12 months of clinical follow-up. The primary outcome measure was the negative predictive value (NPV) of FDG-PET/CT scans and other supporting diagnostic test characteristics, including time dependency with increasing follow-up time. Results Of 152 patients, 125 had adequate primary tumor control after CCRT and entered follow-up (median, 20.4 months). Twenty-three (18.4%) had residual neck disease. Overall, NPV was 92.1% (95% CI, 86.9% to 95.3%; null hypothesis: NPV = 85%; P = .012) with sensitivity of 65.2% (95% CI, 44.9% to 81.2%), specificity of 91.2% (95% CI, 84.1% to 95.3%), positive predictive value of 62.5% (95% CI, 45.5% to 76.9%), and accuracy of 86.4% (95% CI, 79.3% to 91.3%). Sensitivity was time dependent and high for residual disease manifesting up to 9 months after imaging but lower (59.7%) for disease detected up to 12 months after imaging. Standardized reporting criteria reduced the number of equivocal reports (95% CI for the difference, 2.6% to 15.0%; P = .003). Test characteristics were not improved with the addition of lymph node CT morphology criteria. Conclusion FDG-PET/CT surveillance using Hopkins criteria 12 weeks after CCRT is reliable in LAHNSCC except for late manifesting residual disease, which may require an additional surveillance scan at 1 year after CCRT to be detected.

Volumetric analysis of olfactory neuroblastoma skull base laterality and implications on neck disease.

To determine if the laterality of primary tumors in patients with olfactory neuroblastoma (ONB) influenced the pattern and development of neck disease. Using a retrospective cohort study design from 1994 to 2015, the primary tumors of patients who either presented with or developed neck disease were volumetrically analyzed using iPlan software (version 3.0.0, BrainLAB, Feldkirchen, Germany) by two independent observers. Agreement of volume-derived sidedness was assessed with a kappa statistic, whereas agreement in volume-derived degree of tumor laterality was evaluated with an intraclass correlation coefficient. A one-sample t test was used to assess the difference in dominant percentage between the two observers. Sixty-one patients with histological diagnosis and treatment of ONB at our institution were identified. Twenty-four patients exhibited neck involvement, 13 of whom could be volumetrically analyzed. Tumors that were greater than 75% eccentric to one side all exhibited contralateral disease, whereas the majority of unilateral neck disease was associated with relatively midline masses. Within the entire cohort, ipsilateral level 2 lymph nodes displayed the highest involvement (83%, 20 of 24), followed by ipsilateral level 1 (54%, 13 of 24), contralateral level 2 (46%, 11 of 24), contralateral level 1 (21%, 5 of 24), and ipsilateral level 3 (21%, 5 of 24). Ipsilateral neck involvement frequently was observed; however, the degree of ONB primary site laterality did not appear to have implications on the development of contralateral neck disease. Therefore, when considering elective therapy to the neck, ONB laterality should not be used to justify unilateral neck treatment. 4. Laryngoscope, 128:864-870, 2018.

Gastrostomy in the era of minimally invasive head and neck cancer surgery.

Minimally invasive transoral robotic surgery (TORS) is less likely to necessitate gastrostomy tube (GT) following resection of head and neck lesions versus conventional open procedures. However, the incidence of and indications for GT after TORS have not been reported in detail. This study defines the incidence of intra- and postoperative gastrostomy following robotic resection of advanced head and neck disease. It seeks to clarify the relevance of GT after TORS. Adult patients undergoing TORS and neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Cooperative System all-payer administrative database. Demographic data and timing of GT in relation to surgery were recorded. Emergency department (ED) visits and inpatient readmissions were compared with multivariable logistic analysis. Of the 441 included patients, immediate, delayed, and total GT incidence within the first postoperative year was 9.5%, 11.6%, and 21.1%, respectively. Gastrostomy tube complications resulted in 4.5% of 30-day ED visits, 3.3% of 30-day readmissions, and 3.5% of 90-day readmissions. Thirty-nine percent of 90-day readmissions were linked to poor postoperative oral intake. Delayed GT status was associated with an increase in 30-day ED visits, and 30- or 90-day readmissions attributable to poor oral intake (P = 0.10, P < 0.0001, 0.002, respectively). Even in the era of minimally invasive TORS, impaired oral intake is a significant postoperative burden to head and neck cancer patients with advanced disease. Attention to patient risk factors combined with a complicated hospital course may identify patients benefiting from early GT. 2c. Laryngoscope, 128:847-851, 2018.

Disease Severity at Presentation in Patients with Disease-Related Mortality from Differentiated Thyroid Cancer: Implications for the 2015 ATA Guidelines.

The current trend of less aggressive treatment of low-risk differentiated thyroid cancer (DTC) patients was recently challenged by a study reporting >10% disease-related mortality (DRM) in low-risk patients ablated with radioiodine activities below 54 mCi. However, this study and others were limited by incomplete data on disease severity at presentation. Whether patients presenting with low-risk disease are at risk for disease-related mortality is crucial for planning current treatment strategies. Patients with documented DRM from DTC were included from the Rabin thyroid cancer registry and the Davidoff Head and Neck cancer service databases. Disease characteristics at presentation, treatments, disease course, and cause of death were analyzed. Of 1374 patients whose charts were reviewed, 56 were confirmed to have died of DTC, and 53 had sufficient data for analysis. Median time from diagnosis to death was 9 years (range 1-36). Cause of death was related to distant metastases in 46 patients and aggressive neck disease in 7 patients. The median age at diagnosis was 62 years (range 22-83, 83% older than 45), and were initially categorized as American Thyroid Association high risk in 89% of cases (in 4 cases due to high thyroglobulin levels), intermediate risk in 6% (3 older patients with N1b disease), misclassification as benign in one case, and none was low risk. Most patients had an advanced disease stage (stage IV, 88%; III, 2%; II, 2%; I, 8%). All patients with stage I disease were <45 years, with aggressive features (1 poorly differentiated, 3 gross extrathyroidal extension). One patient with stage II disease was <45 years and had distant metastases. Detection of distant metastases occurred within the first year in 25 patients and during subsequent follow-up in 25 patients. Overall, aside from one patient who was misdiagnosed as having a benign follicular adenoma at presentation, all patients had aggressive disease features at presentation. None of the patients with DRM had low-risk features at presentation, supporting the current paradigm of less aggressive approach in the low-risk group. Studies analyzing mortality from thyroid cancer should stratify patients into the various risk categories based on full baseline data, including postoperative thyroglobulin levels.

Analysis of the clinical characteristics and efficacy of 20 cases of extranodal Rosai-Dorfman disease in head and neck

Objective: To analyze the clinical characteristics and efficacy of extranodal Rosai-Dorfman disease in head and neck. Methods: Clinical and pathological features and follow-up of patients who were diagnosed as RDD at Beijing Tongren Hospital of Capital Medical University between May 2008 and November 2016 were analyzed retrospectively. Results: There were a total of 20 extranodal RDD patients in head and neck including 14 females and 6 males, aged from 27 to 86 years (mean 52.5 years). Nose (14 cases) and throat (5 cases) were most commonly involved organs and 5 patients had 2 or more organs involved. Diagnosis depends on biopsy. Histopathologically, the lesions of RDD were characterized by the presence of large histiocytes with emperipolesis. The large sinus histiocytes were positive for S-100 and CD68 protein staining. Diagnostic Errors in 13 patients and operations in all patients were happened. More than 1 operation was performed in 9 recurrence patients. Eight patients were treated by Glucocorticoids and immunosuppressive agents. All the patients were alive until Feb 2017. Conclusion: Extranodal RDD in head and neck is known as a rare benign idiopathic proliferative disease. Nose is the most common site involved, and recurrence easily. It is diagnosis depending on histopathological report. Operation is first choice in diagnosis and treatment now. Glucocorticoids and immunosuppressive agents are effective in recurrence patients.

Margin Analysis: Cutaneous Malignancy of the Head and Neck.

This article focuses only on margin analysis of the cutaneous malignancy of the skin. It discusses basal cell carcinoma, squamous cell carcinoma, and cutaneous melanoma. The management of the neck and distant disease are beyond the scope of this article, but it answers what is the appropriate surgical margin when excising these skin tumors, whether frozen sections are accurate for the analysis of these tumors, and treatment algorithm and rationale for a positive resection margin.

Prognostic significance of soft tissue deposits in laryngeal carcinoma.

IntroductionSoft tissue deposits is tumorous islands apart from lymph nodes and occasionally diagnosed in neck dissection specimens. Their importance has begun to be recognized, however, their value has not been investigated in laryngeal cancer as a single tumor site.ObjectiveTo investigate the prognostic value of soft tissue deposits in patients with laryngeal carcinoma.MethodsMedical records of 194 patients with laryngeal carcinoma who were treated primarily by surgery and neck dissection were reviewed. Prognostic significance of soft tissue deposits was assessed along with other clinical and pathological findings. Recurrence rates, overall and disease-specific survival rates were examined.ResultsThe incidence of soft tissue deposits was found to be 7.2% in laryngeal carcinoma. N stage was more advanced in patients who had soft tissue deposits. Regional recurrence rate was higher and disease specific and overall survivals rates were significantly lower in patients with soft tissue deposits in univariate analysis. However, in multivariate analysis, soft tissue deposits were not found as an independent risk factor.ConclusionIn laryngeal carcinoma, soft tissue deposits was diagnosed in patients with more advanced neck disease and their significance was lesser than other factors including extranodal extension.

Airway management in surgical correction of severe kyphoscoliosis associated with tethered cord and multiple malformations: A method of tracheostomaplasty by partial resection of the cricoid cartilage

Abstract In patients with factors leading to potentially difficult tracheostomy placement, including neck stiffness, obesity, cephalad displacement of the brachiocephalic artery, short neck, or thyroid disease, tracheostomaplasty by partial resection of the cricoid cartilage is a safe and effective method. The case of a 13-year-old boy with congenital kyphoscoliosis associated with a tethered cord and multiple malformations is reported herein. Tracheostomy was necessary for him to undergo extensive surgery, but failed to keep his airway secure as the tracheal tube readily dropped out of the tracheal lumen due to the spinal malformation. A tracheostoma was created by suturing the cricothyroid membrane and skin as a tracheostomaplasty by partial resection of the cricoid cartilage. After tracheostomaplasty, the patient successfully underwent detethering of the cord and corrective scoliosis surgery. After discharge, he had successful postoperative management of the tracheostomaplasty.

Safety of differential radiation dosing in lymph node positive necks treated with IMRT

PurposeWhen treating head and neck squamous cell carcinoma (HNSCC) with intensity modulated radiation therapy (IMRT), it is common to use several dose levels for a lymph node positive neck: full dose (66-70 Gy) to gross cancer, intermediate dose (59-63 Gy) to higher risk neck regions, and standard dose (50-54 Gy) to lower risk neck regions. There is no consensus regarding how much of the neck should receive intermediate versus standard dose, however. Methods and materialsHNSCC patients treated with IMRT were identified from 2 academic medical centers between 2004 and 2016. Intermediate dose was restricted to a region of the neck 2 cm above and below the most superior and inferior involved lymph nodes; standard dose was delivered to more distal neck regions. Descriptive statistics were calculated for demographics and clinical characteristics as well as proportions for failures 2 years after treatment. Failure outside the intermediate dose region was determined by calculating confidence intervals from a modification of the Poisson distribution. ResultsOf the 57 necks included in this study, 17.5% experienced disease recurrence in the neck within 2 years of completing treatment. All failures were within the 2-cm margin above or below the most superior and inferior involved nodes; there were no failures outside this 2-cm margin (95% confidence interval, 0-7.7). ConclusionsThe results of this study support the feasibility of treating only the neck adjacent to gross neck disease to an intermediate dose, and treating the remainder of the neck to a lower, standard dose. Although these results are encouraging, additional study of this treatment paradigm is warranted.

Prognostic factors for recurrence of locally advanced differentiated thyroid cancer.

Retrospective review of 70 patients in a single, tertiary referral institution was done. Clinical pathology characteristics were analyzed to investigate prognosticators, based on primary endpoints; locoregional recurrence alone (LRR), total recurrence (LRR or distant metastasis (DM)), and recurrence-free survival. Recurrent laryngeal nerve (n = 31) and trachea (n = 30) were most commonly invaded organs by tumor. At the mean follow-up of 81.7 months, LRR occurred in 15 patients and/or DM was detected in 15 patients (10 developed LRR and DM). By multivariate analysis, R1 resection (positive margin) and pN1b stage increased risk of LRR with a fold of 3.16 [95%CI 1.08-9.24, P = 0.03] and 5.92 [1.61-21.7, P = 0.007], respectively. Also, they increased risk of total recurrence with a fold of 3.04 [95%CI 1.26-7.31, P = 0.01] and 3.42 [95%CI 1.16-10.0, P = 0.02], respectively. Patients with pN1b stage showed better LRR-free survival than pN0/N1a stage (P = 0.03). Conclusions Along with careful preoperative evaluation of the extent of primary and neck disease, obtaining negative resection margin and aggressive neck management is critical to improve oncologic outcomes of locally advanced DTC.

Neck dissection for head and neck malignancies: A Malaysian 13 years review

Introduction and Objective: Neck dissection (ND) is a surgical procedure performed in treating head and neck cancer patients with cervical neck metastasis. The aim of neck dissection is to achieveloco-regional control thus optimizing the cancer’s cure rate. Various complications may potentially occur following this surgery. The main objective of this study is to evaluate the incidence of complications following neck dissection.Materials &amp; Methods: This is a 13 years retrospective descriptive case notes analysis conducted in UKMMC (University Kebangsaan Malaysia Medical Centre), a tertiary centre in Malaysia. Neck dissection surgeries that were performed between January 2000tillDecember 2012 were recruited for data analyses.Results: A total of 233 neck dissections were performed in our centre over 13 years period from January 2000 until December 2012. Of these, 27 cases were excluded due to unavailability of data and therefore a total of 206 cases were recruited for data analyses.The types of neck dissection performed include Extended Radical ND (n=7), Radical ND (n=40), Modified Radical ND (n=88) and Selective ND (n=71). Majority of neck dissection was performed for malignant oral cavity tumours (47.1%). Out of 206 cases, 57 (27.7%) developed wound complications, 48 (23.3%) cases had nerve complications with marginal mandibular nerve was most commonly injured (13%) and 20 (9.7%) cases had vascular and lymphatic complications mainly involving the thoracic duct (5.3%). The incidence of residual or recurrent neck disease was observed in 41 cases (20%). Pre-operative clinical assesment of cervical neck node metastatic status has a high sensivity of 89.7% but low specificity of 47.5%.Conclusion: Various complications may potentially occur following neck dissection. Awareness of these possible complications could minimize the incidence of complication following this surgery. This current study observed a strong association between the type of neck dissection performed with the incidence of wound, nerve and vascularcomplications following neck dissection surgery.Bangladesh Journal of Medical Science Vol.16(3) 2017 p.384-396