Antonio E. Alfonso

Cervical node metastasis from epidermoid carcinoma of the oral cavity and oropharynx: A critical assessment of current staging☆

Abstract The clinical and histologic status of cervical lymph nodes has been correlated with the results of treatment in 1,069 consecutive patients who underwent radical neck dissection as part of the initial treatment of a primary epidermoid carcinoma arising in either the oral cavity or oropharynx. The influence on “cure” rates of size, number, location, and fixation of involved nodes, correlated with the specific site of origin within the oral cavity, was evaluated in determinate patients with proved nodal metastasis. As the extent of lymph node involvement increased from solitary to multiple ipsilateral and to bilateral enlarged nodes, cure rates dropped progressively. Survival was not invariably decreased in those whose involved nodes were large or considered fixed, and there was considerable variance among examiners when size and fixation were evaluated. These data suggest that the N system of staging presently advocated might be improved. Rather than designating contralateral or bilateral node involvement as N 2 , this category might be reserved for those with multiple ipsilateral cervical node metastases. Those with contralateral and bilateral as well as so-called fixed metastases might better be relegated to the N 3 category. The results of treatment were uniformly poor in the latter group of patients, provided the term “fixed” indicated immobility of involved lymph nodes and not merely the presumption that tumor had extended beyond the capsule of the node.

Warthin's tumor: Multicentricity and increasing incidence in women

Warthins tumors comprised 14 percent of all parotid tumors operated on. The average patient age in our series was 57.2 years. Eighty-seven percent of the tumors occurred in the parotid tail. The rest were in the deep lobe, or in an extraparotid location. Fifteen patients had multifocal tumors. The maximum number of tumor foci in one patient was six. A significant increase in the female incidence was noted with a 1.5:1 male-to-female ratio as compared with the previous male dominant ratio of 8:1. Eighty-two percent of the female patients in our group were smokers. We correlated a very high incidence of cigarette smoking in our series when compared with age-matched groups in both sexes within the general population. Since it is estimated that one of eight patients with Warthins tumor will have multifocal disease, we suggest wider exposure and more meticulous operative exploration to avoid overlooked synchronous tumor foci and subsequent recurrence.

Survival following breast cancer surgery in the elderly

A retrospective analysis was performed on a series of 780 patients with breast cancer who underwent surgery, with emphasis on survival in the 138 patients over 70 years of age (elderly group). Absolute survival rates were determined using life table methods. Relative survival figures were derived from absolute figures by adjusting for expected longevity in each age group. Patients over 70 years of age had overall 5 and 10 year absolute survival rates of 54% and 41%, respectively, which did not differ significantly from survival rates of younger patients. Relative five‐year survival rates for the elderly were actually higher than those of younger patients, being 90% for those with local disease and 65% for those with regional disease. Survival in the elderly was comparable to that of younger patients, irrespective of race, type of surgery, histology or tumor size. These findings support the conclusion that there is little justification for avoiding conventional operative treatment in elderly patients with breast cancer solely on the basis of advanced age.

Goiters and airway problems

Even though thyroid enlargement occurs commonly, the incidence of goiter has decreased in the United States due to the routine use of iodized salt. We continue to see a large number of patients with neglected goiters that cause airway compression. The progressive nature of this disease occasionally results in severe tracheal compression and acute airway distress. We treated 120 patients with airway compression secondary to goiters during a 7-year period. Thirty patients presented initially with acute airway distress requiring either intubation or semiemergent surgery. The decision to operate was based primarily on clinical evaluation and airway films. Ninety patients had substernal goiters. Only one patient required sternal splitting. If one lobe was enlarged causing tracheal deviation, lobectomy was performed; if both lobes were enlarged, subtotal thyroidectomy was performed. Two patients required tracheostomy. There were no operative deaths, and morbidity was limited to minor wound problems. It is important to consider early surgical decompression whenever tracheal compression is caused by goiters, especially if the patients are symptomatic or there is mediastinal extension.

Intraoral papillary squamous cell tumor of the soft palate with features of sialadenoma papilliferum‐? malignant sialadenoma papilliferum

An unusual, recurring, squamous papillary tumor involving and possibly arising from minor salivary gland excretory ducts in the palate is presented. Similarity to sialadenoma papilliferum and upper respiratory tract papillomatosis is noted. A paraglandular cystic mass with some resemblance to the palatal lesion, and a solitary lymph node with papillary squamous epithelial deposits was found in a radical neck dissection. We suggest that the lymph node lesion represents a metastasis which may have arisen from the palatal lesion, and therefore propose the concept of a possible malignant analogue of sialadenoma papilliferum. Cancer 42:1859–1869, 1978.

Survival among chronic renal failure patients requiring major abdominal surgery

BACKGROUND There is limited literature on survival of patients with chronic renal failure (CRF) who require major abdominal surgery. The goal of the present study was to evaluate indications for surgery and survival among dialysis patients undergoing major abdominal operations. STUDY DESIGN Medical records for 26 CRF patients at our institution undergoing major nonvascular abdominal operations from 1990 to 1996 were reviewed. Results were evaluated by chi-square analysis. RESULTS Surgery was performed emergently in 21 patients (81%) and electively in 5 patients (19%). The most common finding among the emergency surgery patients was ischemic colitis, occurring in 9 of 21 patients (43%). Postoperative (30-day) mortality among the emergency surgery patients was 38%. Longterm (1 year) survival was 28%. All 5 patients undergoing elective surgery are alive on followup of 1 to 5 years. The disparity in longterm survival between the emergency surgery versus the elective surgery patients was statistically significant (p = 0.004). CONCLUSIONS Emergency surgery in patients with CRF is associated with poor survival rates. Colonic ischemia is a significant problem among these patients.

Mechanisms of interleukin-22's beneficial effects in acute pancreatitis.

Acute pancreatitis (AP) is a disorder characterized by parenchymal injury of the pancreas controlled by immune cell-mediated inflammation. AP remains a significant challenge in the clinic due to a lack of specific and effective treatment. Knowledge of the complex mechanisms that regulate the inflammatory response in AP is needed for the development of new approaches to treatment, since immune cell-derived inflammatory cytokines have been recognized to play critical roles in the pathogenesis of the disease. Recent studies have shown that interleukin (IL)-22, a cytokine secreted by leukocytes, when applied in the severe animal models of AP, protects against the inflammation-mediated acinar injury. In contrast, in a mild AP model, endogenous IL-22 has been found to be a predominantly anti-inflammatory mediator that inhibits inflammatory cell infiltration via the induction of Reg3 proteins in acinar cells, but does not protect against acinar injury in the early stage of AP. However, constitutively over-expressed IL-22 can prevent the initial acinar injury caused by excessive autophagy through the induction of the anti-autophagic proteins Bcl-2 and Bcl-XL. Thus IL-22 plays different roles in AP depending on the severity of the AP model. This review focuses on these recently reported findings for the purpose of better understanding IL-22s regulatory roles in AP which could help to develop a novel therapeutic strategy.

Determination of the function of the internal branch of the superior laryngeal nerve after thyroidectomy.

Several unique complications of thyroidectomy exist because of its regional anatomy; they are well studied and reported. A majority of thyroidectomy patients report vague upper aerodigestive tract complaints. Despite this, no formal assessment of the integrity of the internal branch of the superior laryngeal nerve after thyroidectomy exists in the literature.

Single-Site Robotic Cholecystectomy at an Inner-City Academic Center.

Introduction: We investigate the safety and efficacy of single-site robotic cholecystectomy compared to laparoscopic cholecystectomy at an inner-city academic medical center. Materials and Methods: Retrospective analysis comparing single-site robotic to laparoscopic cholecystectomies from August 1, 2013, to January 31, 2015, was conducted. Age, gender, race, body mass index (BMI), total operative time (docking and console time for robotic cases), length of stay, comorbidities, and conversion to open procedures were examined. The χ2 and Students t test were used for categorical and continuous data, respectively. A P ≤ 0.05 was considered statistically significant. Results: From August 2013 to January 2015, 70 single-site robotic cholecystectomies and 70 laparoscopic cholecystectomies were performed. Patients were older (mean age, 40.3 years vs 47.6 years; P = .0084), had a higher mean BMI (29.5 vs 32.4 kg/m2; P = .011), and had a higher assigned ASA (American Society of Anesthesiologists) classification (P = .024) in the laparoscopic than in the single-site group. Hypertension was more common in the laparoscopic group (P = .0078). Average docking time was 11.5 (SD 5.7) minutes, and the average console time was 52.8 (SD 22.5) minutes in the single-site group. Total operating time for the laparoscopic and single-site groups was not significantly different (111.5 minutes vs 106.0 minutes; P = .38). There were more conversions to open procedures in the laparoscopic compared to the single-site group (11 vs 1; P = .007). There were no biliary tree injuries and no deaths in either group. Conclusion: Single-site robotic cholecystectomy is safe to perform in an inner-city academic hospital setting. Surgical resident involvement does not adversely affect outcomes.

Primary carcinoma of the duodenum producing a malignant duodenocolic fistula.

SummaryA unique case of primary duodenal carcinoma with a malignant duodenocolic fistula is reported.En-bloc resection of the lesion with pancreatico-duodenectomy and right hemicolectomy resulted in a 15-month disease-free interval.