Christian Meerwein

Airway management in head and neck cancer patients undergoing microvascular free tissue transfer: delayed extubation as an alternative to routine tracheotomy

QUESTIONS UNDER STUDY The aim of this study was to evaluate two practices of airway management in patients undergoing head and neck cancer (HNC) resection and microvascular free tissue transfer (MFTT), and to assess the advantages and disadvantages of the two approaches. METHODS Patients undergoing a delayed extubation approach (NO-TRACH group) and patients undergoing primary tracheotomy (PRIM-TRACH group) were retrospectively evaluated in terms of perioperative and postoperative outcome measures. RESULTS Not performing routine tracheotomy was safe and no perioperative airway complications occurred. NO-TRACH patients were extubated after 1.1 ± 0.9 days (mean ± standard deviation) and secondary tracheotomy was necessary in three patients (13%). NO-TRACH patients revealed decreased duration of surgery (p <0.05) and showed trends to earlier resumption of oral feeding and decreased length of hospitalisation. Flap complication rates were similar in both groups, with an overall flap survival rate of 97.5% (n = 39/40). CONCLUSIONS With appropriate postoperative care, carefully selected patients undergoing major HNC resections with MFTT can be safely managed without routine tracheotomy.

The effect of low-dose continuous erythropoietin receptor activator in an experimental model of acute Cyclosporine A induced renal injury

The use of Cyclosporine A (CsA) as rejection prophylaxis following organ transplantation is limited by its nephrotoxicity. CsA induces renal damage that is associated with tubulo-interstitial injury and parenchymal sequestration of macrophages, perpetuating pro-inflammatory processes. Furthermore, CsA exerts a diabetogenic effect by damaging pancreatic islet cell integrity. Continuous Erythropoietin Receptor Activator (CERA) was shown to mediate tissue-protective and anti-inflammatory effects in various settings of organ injury. Here, we investigated the effect of low dose CERA in a model of CsA-induced renal and pancreatic injury. Rats were exposed to medium-dose CsA for 28 days. Low-dose CERA was given to the treatment group (CERA) (n=6) once per week vs. a CsA-treated control group (CONTROL) (n=6). The effect of CERA on renal and pancreatic injuries was analyzed by organ function, histology, immunohistochemistry (CD68(+)-macrophages, insulin), ELISA (TGF-β1) and RT-PCR (TGF-β1, Osteopontin, IL-10). CsA induced functional kidney damage. Low dose CERA did not lead to improved kidney function in the treatment group. However, low dose CERA showed a trend toward upregulation of osteopontin accompanied by increased renal macrophage-infiltration and enhanced parenchymal TGF-β1 and IL-10 when compared to controls. Moreover, CERA treated animals showed amelioration of pancreatic islet cell injury. In this model of acute CsA-mediated renal injury, low dose CERA administration was associated with anti-inflammatory effects and preservation of pancreatic islet cell viability.

Post-treatment surveillance of head and neck cancer: pitfalls in the interpretation of FDG PET-CT/MRI

QUESTIONS UNDER STUDY We investigated non-malignancy-associated (¹⁸F)fluoro-deoxy-D-glucose (FDG) uptake in the head and neck cancer (HNC) post-treatment follow-up with positron emission tomography - computed tomography / magnetic resonance imaging (PET-CT/MRI). A retrospective study on HNC patients undergoing follow-up or re-staging PET-CT/MRI examinations was performed. Thereby, FDG-positive regions were morphologically correlated to the CT and MRI images and a statement regarding tumour persistence/recurrence. METHODS FDG-positive lesions were assessed according to their anatomical localisation and categorised as true positive, true negative, false positive or false negative findings. The gold standard for verification of an FDG-positive lesion was the cytological or histopathological examination of the region of interest. The most likely aetiology was assessed according to the following categories: (1.) physiological uptake (2.) post-surgical, inflammatory uptake, (3.) post-irradiation, inflammatory uptake and (4.) reactive, not otherwise specified. RESULTS Tumour recurrence / tumour persistence was found in 14/87 patients (16.1%). A total of 159 non-malignancy-associated FDG-positive lesions were found. Every PET-CT/MRI examination revealed 2.1 ± 1.5 FDG-positive lesions in the head and neck. A total of 107 FDG-positive lesions (67.3%) were categorised as physiological, 52 FDG-positive lesions (32.7%) as inflammatory (post-surgical: n = 14, 8.8%; post-irradiation: n = 9, 5.7%; reactive, not otherwise specified: n = 29, 18.2%). Eight patients (11.8%) underwent invasive diagnostic procedures to clarify indistinct findings. CONCLUSIONS Post-treatment follow-up of HNC patients requires interdisciplinary management and familiarity with the patients past medical history. Awareness of common confounders of FDG positivity often allows clarification of indistinct lesions. However, a substantial number of approximately 12% of FDG-positive lesions remain unclear unless invasive diagnostic procedures are performed.

Perineural Invasion in Squamous Cell Carcinoma of the Oral Cavity: Histology, Tumor Stage, and Outcome

To analyze the impact of different types of perineural invasion (PNI) in squamous cell carcinoma (SCC) of the oral cavity on overall survival and recurrence rate, with a special focus on histologic subtypes and tumor stage.

Multi-slice SPECT/CT vs. lymphoscintigraphy and intraoperative gamma ray probe for sentinel node mapping in HNSCC

To assess the diagnostic potential of multi-slice single-photon emission computed tomography/computed tomography (SPECT/CT) for preoperative sentinel node (SN) mapping in early stage head and neck squamous cell carcinoma (HNSCC). Retrospective case–control study including data of consecutive HNSCC patients treated between November 2011 and December 2015. The diagnostic accuracy of multi-slice SPECT/CT was assessed with regard to the gold standard intraoperative gamma ray detection probe, using McNemar’s test and calculating the area under the ROC curve. Additionally, the hot spot yield of SPECT/CT and planar lymphoscintigraphy (LS) was compared. Compared to the intraoperative gold standard, SPECT/CT showed an overall positive predictive value of 60.3% [confidence interval (CI) 46.6–73.0%)], a negative predictive value of 96.3% (CI 93.6–98.1%), and an accuracy of 90.8% (CI 89.1–92.4%). SPECT/CT detected more hot spots than LS and provided detailed anatomical information as well as relevant additional findings with potential impact on further patient management. Sentinel lymph node biopsy proved to be a reliable and safe procedure with an excellent SN excision rate (97%). Multi-slice SPECT/CT is a highly accurate diagnostic test and matches the gold standard intraoperative gamma ray detection probe.

Secondary voice prosthesis insertion in patients without direct access to the upper esophagus

Laryngoscope, 124:469–471, 2014