Recurrent Laryngeal Research Articles

Using a CT-based scale to evaluate disease extension and the resectability of locally advanced thyroid cancer.

To establish a computed tomography (CT)-based scale to evaluate the resectability of locally advanced thyroid cancer. This twin-centre retrospective study included 95 locally advanced thyroid cancer patients from the 1st centre as the training cohort and 31 patients from the 2nd centre as the testing cohort, who were categorised into the resectable and unresectable groups. Three radiologists scored the CT scans of each patient by evaluating the extension to the recurrent laryngeal nerve (RLN), trachea, oesophagus, artery, vein, soft tissue, and larynx. A 14-score scale (including all comprised structures) and a 12-score scale (excluding larynx) were developed. Receiver-operating characteristic (ROC) analysis was used to evaluate the performance of the scales. Stratified fivefold cross-validation and external verification were used to validate the scale. In the training cohort, compromised RLN (p < 0.001), trachea (p = 0.001), oesophagus (p = 0.002), artery (p < 0.001), vein (p = 0.005), and soft tissue (p < 0.001) were predictors for unresectability, while compromised larynx (p = 0.283) was not. The 12-score scale (AUC = 0.882, 95%CI: 0.812-0.952) was not inferior to the 14-score scale (AUC = 0.891, 95%CI: 0.823-0.960). In subgroup analysis, the AUCs of the 12-score scale were 0.826 for treatment-naïve patients and 0.976 for patients with prior surgery. The 12-score scale was further validated with a fivefold cross-validation analysis, with an overall accuracy of 78.9-89.4%. Finally, external validation using the testing cohort showed an AUC of 0.875. The researchers built a CT-based 12-score scale to evaluate the resectability of locally advanced thyroid cancer. Validation with a larger sample size is required to confirm the efficacy of the scale. This 12-score CT scale would help clinicians evaluate the resectability of locally advanced thyroid cancer. • The researchers built a 12-score CT scale (including recurrent laryngeal nerve, trachea, oesophagus, artery, vein, and soft tissue) to evaluate the resectability of locally advanced thyroid cancer. • This scale has the potential to help clinicians make treatment plans for locally advanced thyroid cancer.

Hoarseness of Voice Due to Ipsilateral Recurrent Laryngeal Nerve Palsy in Ultrasound Guided Right Sided Supraclavicular Brachial Plexus Block: A Case Report

Supraclavicular brachial plexus block is well established regional anaesthesia technique for upper limb surgeries. USG guided supraclavicular brachial plexus block provides many advantages but is also associated with the rare complication of recurrent laryngeal nerve palsy, seen in 1.3% of cases. Recurrent laryngeal nerve palsy is mostly documented in right sided supraclavicular blocks than left sided supraclavicular blocks. Here, we report a case of 28 years old male undergoing right upper arm surgery under supraclavicular block who developed hoarseness of voice due to ipsilateral recurrent laryngeal nerve involvement which was followed up properly and managed successfully.

Intra Operative Recurrent Laryngeal Nerve Monitering During Thyroid Surgery - Is It Worth?

The basic principle of head and neck surgery is based on the identification and preservation of important structures, rather than avoidance. Thyroid surgeries are the most frequently performed endocrine procedures worldwide. Recurrent laryngeal nerve (RLN) palsy after thyroid surgery is a serious postoperative complication that can diminish the quality of life. While it is generally accepted that direct visualisation of the nerve is the gold standard, intraoperative nerve monitoring (IONM) is being used increasingly as an adjuvant to help identify the nerve. This study was carried out in Mahatma Gandhi medical college and hospital, Jaipur, Rajasthan from June 2018 to March 2020. 100 patients were enrolled in the study. RLN is identified & visualized in Beahr's triangle or in Lore's triangle. We have randomly selected the patient and use IONM as an adjunct to standard visual identification of the recurrent laryngeal nerve (RLN) to prevent nerve lesion. 8 out of 108 nerves which were at risk during thyroid surgery were found injured. 2 of 50 (4%) nerves at risk were injured with IONM that caused temporary paresis. Without IONM, 5 of 58 (8.6%) nerves at risk suffered temporary paresis and 1of 58(1.72%) had paralysis. Visual nerve identification alone remains the gold standard of recurrent laryngeal nerve management in thyroid surgery and one can use operating microscope for magnification. Neuromonitoring helps to identify the RLN particularly in difficult cases, but it does not decrease the injury to RLN as compared to visualization alone.

Two-rope method for dissecting esophagus in McKeown MIE.

Minimally invasive McKeown esophagectomy (McKeown MIE) is performed at many hospitals in esophageal cancer(EC) treatment. However, secure and quick methods for dissecting the esophagus and dissecting lymph nodes in this surgery are lacking. This study introduces a simple, secure and feasible esophagus dissecting technique named two-rope method. Two mobile traction ropes are placed around the esophagus and we tow these ropes to free the esophagus, dissect the lymph nodes, and decrease the operative trauma. Retrospective analysis was performed on 112 patients who underwent McKeown MIE in our center from January 2019 to September 2021. They were assigned into two groups based on the method of dissecting the esophagus: Group A (two-rope method, 45 cases) and Group B (regular method, 67 cases). Operation time, thoracic operation time, the number of dissected thoracic lymph nodes, and postoperative complications were compared between the two groups after propensity score matching. Using 1:1 nearest neighbor matching, we successfully matched 41 pairs of patients. Operation time, thoracic operation time, and the duration (ac to as) was significantly shorter and the size of the abdominal incision was significantly smaller in the Group A than Group B (p < 0.05). There was no statistically significant difference in the number of dissected thoracic lymph nodes, pulmonary infection, anastomotic leak, recurrent laryngeal (RLN) injury, and chylothorax between the two groups (p > 0.05). Two-rope method to free the esophagus and dissect thoracic lymph nodes in McKeown MIE has significant advantages compared with the regular method. The technique is, therefore suitable for widespread adoption by surgeons.

Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy

Controversy exists regarding management of the clinically node-negative neck in patients with recurrent larynx or hypopharynx cancers who received total laryngectomy after definitive radiation with or without chemotherapy. To explore clinical and oncologic outcomes after elective neck dissection vs observation in patients who received clinically node-negative salvage total laryngectomy. This cohort study was performed from January 2009 to June 2021 at a single, high-volume tertiary care center. Follow-up was conducted through June 2021 for all patients. Survival outcomes were based on at least 2 years of follow-up. Patients aged 18 years or older with recurrent, clinically node-negative larynx or hypopharynx tumors after definitive nonsurgical treatment who were treated with a salvage total laryngectomy were included. Data were analyzed from October 2021 through September 2022. Elective neck dissection. Presence and location of occult nodal metastasis in electively dissected necks, along with differences in fistula rates and overall and disease-free survival between patients receiving elective neck dissection vs observation. Among 107 patients receiving clinically node-negative salvage total laryngectomy (median [IQR] age, 65.0 [57.8-71.3] years; 91 [85.0%] men), 81 patients underwent elective neck dissection (75.7%) and 26 patients underwent observation (24.3%). Among patients with elective neck dissection, 13 patients had occult nodal positivity (16.0%). Recurrent supraglottic (4 of 20 patients [20.0%]) or advanced T classification (ie, T3-T4; 12 of 61 patients [19.7%]) had an occult nodal positivity rate of 20% or more, and positive nodes were most likely to occur in levels II and III (II: 6 of 67 patients [9.0%]; III: 6 of 65 patients [9.2%]; VI: 3 of 44 patients [6.8%]; IV: 3 of 62 patients [4.8%]; V: 0 of 4 patients; I: 0 of 18 patients). There was a large difference in fistula rate between elective neck dissection (12 patients [14.8%]) and observed (8 patients [30.8%]) groups (difference, 16.0 percentage points; 95% CI, -3.4 to 35.3 percentage points), while the difference in fistula rate was negligible between 50 patients undergoing regional or free flap reconstruction (10 patients [20.0%]) vs 57 patients undergoing primary closure (10 patients [17.5%]) (difference, 2.5 percentage points; 95% CI, -12.4 to 17.3 percentage points). Undergoing elective neck dissection was not associated with a clinically meaningful improvement in overall or disease-free survival compared with observation. Recurrent hypopharynx subsite was associated with an increased risk of death (hazard ratio, 4.28; 95% CI, 1.81 to 10.09) and distant recurrence (hazard ratio, 7.94; 95% CI, 2.07 to 30.48) compared with glottic subsite. In this cohort study, patients with recurrent supraglottic or advanced T classification tumors had an increased occult nodal positivity rate, elective neck dissection was not associated with survival, and patients with recurrent hypopharynx subsite were more likely to have a distant recurrence and die of their disease. These findings suggest that underlying disease pathology rather than surgical management may be associated with survival outcomes in this population.

Novel Enhancement of Checkpoint Inhibition Using Pulsing Radiotherapy with Concurrent and Adjuvant CPI for LAHNSCC in Elderly Patients Considered Ineligible for Curative Intent Therapy

<h3>Purpose/Objective(s)</h3> Elderly patients with NON-METASTATIC HNSCC represent an unmet and growing need population that would benefit for more novel, less toxic approaches. With the success of immunotherapy in metastatic LAHNSCC, understanding how to best utilize palliative radiotherapy (RT) with immunotherapy remains a challenge. We sought to combine a pulsing RT strategy (QUAD shot x 3) directed only to gross LAHNSCC non-metastatic, to enhance response to immunotherapy. <h3>Materials/Methods</h3> 25 pts (16 males/9 females), median age of 82, were seen in our HN-MDC and determined to be ineligible for curative intent treatment. 23 were evaluable for this analysis. Pts were treated with the QUAD shot regimen (3,7 Gy x 4 BID) x 3 (TD 44.4 Gy) spaced 3 weeks apart with inclusion of an approved CPI at the discretion of the Medical Oncologist. ERT was directed to ONLY Gross disease, determined by clinical and diagnostic PET/CT scan. CPI was administered in the majority of patients AFTER the 1^st QUAD shot within the 1^st five days. CPI continued until assessment of response, or AE/tolerance or POD. Sites treated included oropharynx (43%), LA/or recurrent cutaneous SCC (30%), Nasopharynx (8%), OC (8%) and Larynx (4%). AJCC 8^th edition stage included Stage 1 (4%), stage II (8%), stage III (8%) and stage IVa-c (56%). The median cycles of CPI were 5 (range: 2-24). <h3>Results</h3> The median Follow-up time was 5 months, (range 3-36). 16/23pts (70%) achieved a cCR at the completion of their QUAD regimen +CPI, while 1 pt achieved a cCR after 2 Quad shots. 2 pts were not evaluable due to death from intercurrent disease or covid after completion of the QUAD regimen. The overall infield LRC control rate was 65%. The infield LC and RC rates were 65% and 71% respectively. The regional failure rate in the untreated elective neck was only 8% (2/21). 2 patients died immediately after completing radiation from Covid and FTT. Of the patients treated for LA-cSCC, the infield and out of field LRC was 100% and 100% respectively. 3 pts developed distant failure. 2/3 experienced Local and/or regional failure as well. QUAD regimen was well tolerated when combined with CPI, with only 1/23 pts requiring treatment interruption and admission for FTT, but completed therapy. Gr 3 mucositis occurred in 1 patient on the lower lip that resolved. Gr 1 fatigue, xerostomia, and anorexia were noted in 1 patient. Gr 3/ 4 IMAR's were observed in 3 patients and included infusion reaction, colitis, and fatigue/FTT and were discontinued. 4 pts (23%) required post QUAD PEG's unrelated to radiation toxicity and due to POD or intercurrent illness. <h3>Conclusion</h3> This represents the first reported experience utilizing a pulsing radiotherapy approach in elderly patients with LAHNSCC combined with a CPI unable to undergo conventional radiotherapy. The regimen was well tolerated with surprisingly low local/regional toxicity and very encouraging response rates. The low failure rate observed in the untreated neck was encouraging and reduces toxicity.

Chemoradiation therapy alters the PD-L1 score in locoregional recurrent squamous cell carcinomas of the head and neck

PD-L1 testing guides therapeutic decision-making for head and neck squamous cell carcinoma (HNSCC). We sought to understand whether chemoradiation therapy (CRT) influences the PD-L1 combined positive score (CPS) and other biomarkers of response to immunotherapy. PD-L1 expression was assessed using immunohistochemistry, and bulk RNA sequencing was performed on 146 HNSCC patients (65 primary sites, 50 paired local recurrences, and 31 paired regional recurrences). PD-L1 was scored using the CPS of ≥1, ≥20, and ≥50. Overall, 98 %, 54 %, and 17 % of HNSCCs had a CPS ≥1, ≥20, and ≥50, respectively. When using a cut-off of ≥1, CRT did not significantly change CPS at the locoregional recurrent site. However, there were significant changes when using CPS ≥20 or ≥50. The CPS changed for 32 % of patients when using a CPS ≥20 (p < 0.001). When using a CPS ≥50, there was a 20–23 % (p = 0.0058–0.00067) discordance rate at the site of locoregional recurrence. Oral cavity cancers had a significantly higher discordant rate than other primary sites for CPS ≥50, 44 % (8/18, p = 0.0058) and 58 % (7/12, p = 0.00067) discordance at the site of local and regional recurrence, respectively. When evaluating the 18 gene IFN-ɣ signature predictive of response to anti-PD-1 blockade, there was a statistically significant increase in the IFN-ɣ signature in recurrent larynx cancer (p = 0.02). Our study demonstrates that when using a higher cut-off of CPS ≥20 and ≥50, a repeat biopsy may be warranted after CRT for local and regional recurrent HNSCCs.

Generation, breakdown and responses of ATP in the carotid body

Purinergic signaling involving adenosine triphosphate (ATP) acting on P2X2/3 receptors modulates physiological carotid body (CB) afferent discharge and chemoreflex activation however, the upregulation of P2X3 receptors on petrosal sensory neurons is partly responsible for aberrant CB tonicity and hyperreflexia, and the increase in blood pressure in the Spontaneously Hypertensive rat (SHR). The enhanced chemoreflex occurs prior to the onset of hypertension and elevated CB activity is thought to contribute to the underlying pathophysiology of the disease but the exact mechanisms remain unclear. We hypothesize that there is greater release of ATP and/or decreased ATP breakdown in the pre‐hypertensive SHR CB compared with that in the Wistar rat, and this evokes an increase in the chemoreflex response and subsequent activation of the sympathetic nervous system. We performed three studies. (i) Using digital droplet PCR (ddPCR), we measured mRNA expression levels of enzymes involved in the breakdown of ATP in CBs extracted from male 4‐week‐old prehypertensive SHR and Wistar rats; these included: ectonucleotide pyrophosphatase/phosphodiesterase 1‐3 (Enpp1‐3), ectonucleoside triphosphate diphosphohydrolase 2‐3 (Entpd2‐3), and ecto‐5’‐nucleotidase (Nt5e). (ii) We quantified ATP release from CBs in vitro during baseline conditions and during cyanide‐evoked ATP release using a colorimetric assay (213‐579‐1 ‐ Millipore), comparing between male 4‐week‐old pre‐hypertensive SHR and Wistar rats. (iii) In an in situ working heart‐brainstem preparation of 4‐week‐old Wistar rats, simultaneous recordings were made from phrenic (PN), hypoglossal (HN), recurrent laryngeal (RLN), abdominal (ABN), and thoracic sympathetic nerves (tSNA). The peripheral chemoreceptors were stimulated with either potassium cyanide (KCN 20‐100 μL, 0.04%) or ATP at varying concentrations (10‐100 µL, 50 µM ‐ 2 mM) delivered via the internal carotid artery. In whole CB extracts, ddPCR revealed increased Enpp2‐3 and Nt5e expression (p&lt;0.05) in pre‐hypertensive SHRs relative to Wistar rats suggesting greater capacity to break down ATP in the pre‐hypertensive SHR CB. There were no differences in the expressions of Enpp1 or Entpd2‐3 between rat strains. However, the amount of ATP released from the CB in both baseline and during cyanide stimulation was two‐fold greater in the pre‐hypertensive SHR (P&lt;0.05). Stimulation of the CB with KCN evoked hyperpnoea, bradycardia and sympathoexcitation at all doses. In contrast, CB injection of low dose ATP increased PN rate with little effect on tSNA, whereas higher doses induced apnea accompanied by repetitive burst discharge of post‐inspiratory activity in the RLN with tonic elevations in the discharge of both ABN and tSNA. In sum, despite the upregulation of several ATP degrading enzymes in the CBs of the SHR, CB release of ATP is higher in this species. We hypothesize that the increase in ATP release in the SHR CB drives the CB hyperexcitability and that the shift towards an upregulation of ATP degrading enzymes even prior to the development of hypertension is compensatory to oppose the increase in ATP signaling. The dose‐dependent effect of exogenous ATP at supraphysiological levels evoking greater CB‐mediated expiratory and sympathetic outflow in the Wistar rat mimics aspects of pathophysiological CB chemoreflex signaling in the SHR.

Patterns of cardio-respiratory motor outputs during acute and subacute exposure to chlorpyrifos in an ex-vivo in situ preparation in rats

While a considerable body of literature has characterized the clinical features induced by organophosphate pesticides, the field lacks scrutiny into cardio-respiratory changes in different phases of poisoning. Herein, we evaluated the impact of chlorpyrifos (CPF) and its active metabolite chlorpyrifos-oxon (CPO) on the cardiorespiratory system during acute and subacute phases of poisoning using an in situ experimental rodent model. CPF (30 mg/kg) was injected intraperitoneally to rats beforehand (24 h) whereas CPO (15 mg/kg) was added into the perfusate reservoir to evaluate the effects on the motor outputs throughout the three phases of the respiratory cycle: inspiration, post-inspiration and late expiration. Phrenic, recurrent laryngeal (RLN) and thoracic sympathetic nerve activity (tSNA) were recorded. Heart rate was derived from the electrocardiogram (ECG) and the baro- and chemo-reflexes tested. CPF and CPO led to a time-dependent change in cardiorespiratory motor outputs. In the acute phase, the CPO induced bradypnea, transiently reduced the inspiratory time (TI), and increased the amplitude of phrenic. Post-inspiratory (PI) discharge recorded from the RLN was progressively reduced while tSNA was increased. CPO significantly depressed the chemoreflex but had no effect on baroreflex. During subacute phase, CPF prolongated TI with no effect on respiratory rate. Both the RLN PI discharge, the chemoreflex and the baroreflex sympathetic gain were reduced. In addition, both CPF and CPO shifted the cardiac sympatho-vagal balance towards sympathetic dominance. Our data show that different phases of poisoning are associated with specific changes in the cardio-respiratory system and might therefore demand distinct approaches by health care providers.

Diagnostic accuracy of MRI and PET/CT for neck staging prior to salvage total laryngectomy

Aim: Lymph node (LN) metastases are associated with poor outcomes in patients with recurrent larynx squamous cell carcinoma (LSCC). Neck dissection (ND) is therefore commonly performed along with salvage total laryngectomy (STL). Here, we assess the rate of occult LN metastases and the diagnostic value of MRI and PET/CT for detecting them in recurrent LSCC. Methods: This retrospective study included patients with recurrent LSCC after primary (chemo)radiotherapy [(C)RT] who were re-staged by MRI and/or PET/CT and treated with STL and ND between 2004 and 2019. The histopathology of ND samples was used as the reference standard. Results: Forty-one patients were included. The prevalence of occult metastases in MRI-negative and PET/CT-negative neck nodes was between 3.2% and 6.1%. Negative predictive values of neck node re-staging were 93.9% for MRI, 96.8% for PET/CT, and 96.2% for MRI and PET/CT combined. Conclusion: Both MRI and PET/CT afforded good negative predictive values for nodal staging in patients with recurrent LSCC after (C)RT prior to STL. In selected patients, these radiological modalities, particularly PET/CT, could help to avoid unnecessary surgery to the neck and its associated morbidity.

Salvage surgery for recurrent larynx cancer.

Despite advances in treatment, the recurrence rates for laryngeal cancer range from 16% to 40%. Patients with recurrent laryngeal cancer treated at Memorial Sloan Kettering (MSK) from 1999 to 2016 were reviewed. Survival outcomes were analyzed. Of 241 patients, 88% were male; the median age was 67 years; 71% had primary glottic tumors. At initial treatment, 72% of patients were seen with early stage disease; primary treatment was radiation (68%), chemoradiation (29%), and surgery (3%). The most common salvage surgery was total laryngectomy (74%). Forty-seven percentage were upstaged at salvage surgery. The 2- and 5-year disease-specific survival (DSS) was 74% and 57%, respectively. Patients with cT4 disease treated with nonsurgical primary management had a 0% 5-year DSS. Independent predictors of DSS were tumor location, perineural invasion, margin, and stage. Salvage surgery results in acceptable oncologic outcomes. Stage, disease site, perineural invasion, and margins are associated with inferior DSS.

Unilateral recurrent laryngeal nerve palsy post-thyroidectomy: Looking for hyperventilation syndrome

AimsUnilateral Recurrent Laryngeal Nerve (RLN) palsy is responsible for dysphonia and difficulties in swallowing. The role of unilateral RLN palsy on dyspnea is not fully elucidated. Our hypothesis is that air leak could be responsible for development of hyperventilation syndrome (HVS). ObjectiveThe objective of this study was to determine in patients with unilateral RLN palsy if dyspnea could be associated with HVS. Material and methodsOver a 12-month period, all patients with permanent unilateral RLN palsy after thyroidectomy complaining from the onset of unexplained dyspnea were tested. Measurement of Nijmegen score, an hyperventilation test, an arterial blood gas, lung function and cardiac tests were performed. The diagnosis of HVS was defined if at least two criteria were present among: Nijmegen score>23; reproduction of at least 2 usual symptoms during hyperventilation test; an expirated pressure of CO2 (EpCO2)<30mmHg or<90% of the initial EpCO2 after a 5minutes recovery period following a 3minutes voluntary hyperventilation. ResultsTen out of 366 patients with thyroidectomy for benign disease had permanent unilateral RLN palsy and dyspnea. Among 10 patients included, 8 were diagnosed having HVS on the hyperventilation test without cardiac/lung dysfunction. ConclusionIn summary, this study is a proof of concept that HVS might be involved in dyspnea associated with unilateral RLN palsy.

Surgical management of locally advanced thyroid cancer (narrative review)

A review of the literature on the problem of surgical treatment of local invasive thyroid cancer with damage to surrounding structures is presented. The comparative characteristics of various surgical tactics for the invasion of highly differentiated thyroid cancer into recurrent guttural nerves, larynx and trachea, esophagus have been performed. The advantage of intraoperative neuromonitoring was shown when deciding whether to retain the recurrent laryngeal nerve in the presence of invasion. The systems of staging of laryngotracheal invasion depending on the degree of its spread and surgical tactics used for each degree of laryngotracheal invasion are considered.

Laryngeal Nerves Monitoring Versus Non-monitoring in Thyroid Surgery

Background and objectives: Thyroid surgery is the most common cause of recurrent nerve (RLN) injury. Deliberate identification of the RLN minimizes the risk of injury. When the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0-2.1%. Continuous intra-operative nerve monitoring during surgery remains a controversial issue. The basic technique involves a skin surface electrode or muscle electrode used to make electromyography (EMG) recordings, which have an audible alarm to alert the surgeon if passive (e.g.stretch during traction) or active nerve stimulation has occurred. We aim to evaluate the use of intra-operative nerve monitoring (IONM) to preserve the laryngeal nerves that may be at risk for injury during thyroid surgery and show the merits of using electrophysiologic laryngeal nerve monitoring during thyroid surgery. Patients and methods: This study was conducted as a prospective study on 28 patients whom are thyroidectomy candidates; we elected 14 thyroidectomy candidates in whom we don’t use NIM during surgery (Control group_A). These patients were chosen to be evenly matched with another 14 thyroidectomy candidates to monitor the recurrent laryngeal (RLN) and external branch of superior laryngeal (EBSLN) throughout thyroidectomy procedures (NIM group_ B) to compare the laryngeal nerves risk of injury with and without the use of nerve monitor. Results: Four patients (2 patients in-group A and 2 patients in-group B) were dysphonic after operation. Laryngoscopy revealed unilateral recurrent laryngeal nerve palsy in all except one bilateral in group A. There were no significant differences in RLN paralysis, paresis, or total injury rates between both groups. The number of patients in the presented study was limited to draw a statistical conclusion for significance. Conclusions: The routine application of IONM cannot prevent or reduce recurrent laryngeal nerve injury. However the study signifies the trend towards the use of INOM in expectedly difficult cases and in revision surgery with distorted anatomical relationships and fibrous adhesions.

Recurrent Larynx and Hypopharyngeal Liposarcoma with Systemic Progression

Introduction: Liposarcomas are infrequent tumors. Only 5.6% of these tumors occur in the head and neck. Primary liposarcomas of the larynx comprise ∼10% to 15% of head and neck liposarcomas. Multiple surgeries and recurrences history are common. Case summary: We present the case of a 33-year-old male whose illness started at 16 years of age, and who underwent multiple surgeries due to multiple recurrence (six) by a liposarcoma in the neck, all treated with organ preservation. In 2014 patient arrived with a big recurrence a total pharyngolaryngectomy with a jejunal are flap was performed. after 18 month of the follow up the patient comes to the visits and refered developed headache, ataxia and shortness of breath, that is why a MRI of the brain and CT of the torax shown intraxial lesions in the brain and multiple bilateral pulmonary nodules compatible with metastatic disease, We propose palliative treatment with radiotherapy but the patient refuse treatment so he was sent to palliative care. Discussion: The mainstay of treatment is surgical resection. Multiple recurrence is the rule but metastasis to the brain was not reported before. The role of radiotherapy is not well know. Chemotherapy until now showed no sustancial benefit.

Operative management of locally advanced, differentiated thyroid cancer

The majority of differentiated thyroid cancer tends to present with limited locoregional disease, leading to excellent long-term survival after operative treatment. Even patients with advanced local disease may survive for long periods with appropriate treatment. The aim of this study is to present our institutional experience of the management of locally advanced differentiated thyroid cancer and to analyze factors predictive of outcome. We reviewed our institutional database of 3,664 previously untreated patients with differentiated thyroid cancer operated between 1986 and 2010. A total of 153 patients had tumor extension beyond the thyroid capsule that invaded the subcutaneous soft tissues, recurrent laryngeal nerve, larynx, trachea, or esophagus. Details on extent of operation and adjuvant therapy were recorded. Disease-specific survival and locoregional recurrence-free probability were determined by the Kaplan-Meier method. Factors predictive of outcome were determined by multivariate analysis. The median age of the 153 patients with tumor extension beyond the thyroid capsule was 55years (range 11-91years). Eighty-nine patients (58.2%) were female. Twenty-three patients (15.0%) were staged as M1 at presentation, and 122 (79.7%) had pathologically involved lymph nodes. The most common site of extrathyroidal extension was the recurrent laryngeal nerve (51.0%) followed by the trachea (46.4%) and esophagus (39.2%). Sixty-three patients (41%) required resection of the recurrent laryngeal nerve due to tumor involvement. After surgery, 20 patients (13.0%) had gross residual disease (R2), 63 (41.2%) had a positive margin of resection (R1), and 70 (45.8%) had complete resection with negative margins (R0). With a median follow-up of 63.9months, 5-year, disease-specific survival, when stratified by R0/R1/R2 resection, was 94.4%, 87.6%, and 67.9%, respectively (P=.030). The data do not demonstrate a statistical difference in survival between R0 versus R1 (P=.222). The 5-year distant recurrence-free probability for M0 patients was 90.8%, 90.3%, and 70.7% (P=.410). The locoregional recurrence-free probability was 85.8% for R0 patients and 85.5% for R1 patients (P=.593). With an appropriate operative strategy, patients with locally advanced thyroid cancer with an R0 or R1 resection have excellent survival outcome.

Treatment Outcomes and Risk Factors for Recurrence After Definitive Surgery of Locally Invasive Well-Differentiated Papillary Thyroid Carcinoma

Papillary thyroid carcinoma (PTC) is generally an indolent tumor that has a favorable prognosis. However, locally invasive PTC can recur after treatment, and its optimal treatment is still controversial. This study aimed to evaluate treatment outcomes and identify risk factors for recurrence and survival in patients with locally invasive PTC. All consecutive patients who underwent definitive surgery and radioactive iodine therapy for non-distant metastatic invasive PTC were included. Clinical factors, operative and pathological findings, surgical morbidity, and recurrences were recorded. Univariate and multivariate Cox proportional hazard models served to identify factors associated with recurrence-free survival (RFS) and overall survival. Of the 96 patients, 74 (77%), 52 (55%), 4 (4%), and 14 (15%) had invasion to the recurrent laryngeal nerve (RLN), trachea, larynx, and esophagus, respectively; 39 (41%) had preoperative vocal cord paresis or paralysis; and 24 (25%) developed recurrence during follow-up (median 77 months). The patients with single and multiple organ invasion did not differ significantly in terms of recurrence-free or overall survival (p > 0.05). The patients with and without recurrences did not differ in terms of surgical extent and involving nerve preservation. Multivariate analysis showed that high (≥1 ng/mL) post-ablation stimulated serum thyroglobulin concentration was an independent predictor of poor RFS (p = 0.013). Disease extent, surgical extent, and involving nerve preservation did not associate with recurrence or overall survival outcomes. The post-ablation stimulated thyroglobulin level may be an independent predictor for recurrence. Careful follow-up of patients with this risk factor is recommended.

The Overwhelming Majority but not All Motor Fibers of the Bifid Recurrent Laryngeal Nerve are Located in the Anterior Extralaryngeal Branch.

BackgroundFew small studies reported that motor fibers are located exclusively in the anterior branch of the bifid recurrent laryngeal nerve (RLN). The aim of this study was to investigate the location of the motor fibers to the intrinsic muscles of the larynx among the bifid RLNs, and assess the prevalence of RLN injury with respect to nerve branching in a pragmatic trial.MethodsThis was a prospective cohort study of 1250 patients who underwent total thyroidectomy with intraoperative neural monitoring. The primary outcome was the position of the motor fibers in the bifid nerves. Adduction of the vocal folds was detected by the endotracheal tube electromyography and abduction by finger palpation of muscle contraction in the posterior cricoarytenoid. The secondary outcomes were the prevalence of the RLN branching and the prevalence of RLN injury in bifid versus non-bifid nerves.ResultsThe bifid RLNs were identified in 613/2500 (24.5 %) nerves at risk, including 92 (7.4 %) patients with bilateral bifurcations. The motor fibers were present exclusively in the anterior branch in 605/613 (98.7 %) bifid nerves, and in both the RLN branches in 8/613 (1.3 %) bifid nerves. Prevalence of RLN injury was 5.2 versus 1.6 % for the bifid versus non-bifid nerves (p < 0.001), odds ratio 2.98 (95 % confidence interval 1.79–4.95; p < 0.001).ConclusionsThe motor fibers of the RLN are located in the anterior extralaryngeal branch in the vast majority of but not in all patients. In rare cases, the motor fibers for adduction or abduction are located in the posterior branch of the RLN. As the bifid nerves are more prone to injury than non-branched nerves, meticulous dissection is recommended to assure preservation of all the branches of the RLN during thyroidectomy.

Prevention and treatment of emergencies in thyroid patients

Aim To evaluate the surgical treatment outcomes for patients with acute complications of thyroid disease (compression syndrome, early postoperative complications - like bilateral recurrent laryngeal nerve injure, bleeding (PB) in thyroid bed and others) performed in the single medical center. Material and methods Anaplastic Thyroid Cancer (243 patients), multiglandular retrosternal goiter (25 cases), and purulent acute thyroiditis (9 observations) made heavy compression of neck and mediastinal aerodigestive organs and were the reason for emergent thyroid surgery. Were estimated intraoperative recurrent nerve (RLN) injures consequences and postoperative bleeding, made necessary for reoperations after 25663 thyroid surgeries during 36 years of the Center practice. Results Surgical intervention for Anaplastic Thyroid Cancer in all of patients has got palliative character only. Postop. lethality rate made 21,0% after emergency interventions, and 2,5% - after routine procedure. Combinations of it with radiochemotherapy has prolonged survival rate up to 13 month in 25% of cases. Follow up results of thyroid surgery in 23777 patients has found unexpected and relevant unilateral RLN injures in 251 (1.0%) and bilateral – in 91 (0.38%) cases. Recurrent laryngeal nerves and larynges reconstruction surgery allow us to decanulate more that 75% those patients. Postoperative bleeding (PB) and thyroid bad hematomas were found in 138 больных (0.58%) patients. The most often PB happened in initial and recurrent DTG (1.07%, 0.94%), TC (0.82%) patients. In most (65.5%) of cases PB began during the first 6 hours. In case of PB we parted wound edges anywhere, intubated repeatedly trachea, inspected wound; performed hemostasis and drained wound. Main sources of PB were inferior (40.38%) or superior (17.30%) thyroid artery. Source was not found in 13.35%. PB prevention included: careful hemostasis with control lavage of the wound; fascia covering of the thyroid bed and high pressure test, ligation of inferior thyroid artery in doubtful cases. Conclusion Thyroid Surgery needs precise knowledge of skull base, neck and mediastinum anatomy, safety resection of thyroid, parathyroid, under RLN visual control, thorough hemostasis and closely postoperative watching for patients.

Pinch, Burn, Cut Parathyroid-sparing Thyroidectomy Saves Recurrent and Superior Laryngeal Nerves (Conventional, PBC and Harmonic Scalpel Techniques Compared)

ABSTRACT Introduction Recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN) have been and continue to be the Achilles tendon of thyroidectomy. Many anatomical landmarks described and taught. How to cite this article Prasad RG, Rao JVS, Hameed MAR. Pinch, Burn, Cut Parathyroid-sparing Thyroidectomy Saves Recurrent and Superior Laryngeal Nerves (Conventional, PBC and Harmonic Scalpel Techniques Compared). Int J Phonosurg Laryngol 2015;5(2):48-52.