Dakshika A. Gunaratne

Sentinel lymph node biopsy in Merkel cell carcinoma: a 15-year institutional experience and statistical analysis of 721 reported cases

Merkel cell carcinoma (MCC) is a rare aggressive cutaneous neuroendocrine malignancy that frequently metastasizes to the regional lymphatic basin. Pathological assessment of regional lymph nodes with sentinel lymph node biopsy (SLNB) in patients without clinical involvement has permitted more accurate staging and more appropriate management. Nonetheless, concerns have been raised regarding the accuracy of this technique and its prognostic implications. We conducted a review of previously published data analysing the positive and false negative rates of SLNB in MCC. A search of the Medline and Embase databases to April 2015 identified 36 published studies between 1997 and 2015 comprising 692 patients. With the addition of 29 patients treated at our own institution, we conducted an analysis of 721 patients. Among this cumulative cohort, SLNBs were performed from 736 regional sites with 29·6% recorded as positive. Regional metastasis occurred in 45 cases following a negative SLNB, for a false negative rate of 17·1%. Adjuvant regional radiotherapy in the setting of a negative SLNB did not affect regional recurrence (P = 0·31), providing credence to emerging evidence that regional therapy can be safely omitted in the setting of a negative SLNB. Distant relapse was noted far more frequently following a positive rather than negative SLNB (17·6% vs. 7·3%, P < 0·001).

Definitive radiotherapy for Merkel cell carcinoma confers clinically meaningful in-field locoregional control: A review and analysis of the literature

Background Merkel cell carcinoma (MCC) is an uncommon radiosensitive, neuroendocrine malignancy. Treatment often involves surgery; however, older, sicker patients may not be candidates for an operation. Institutions have published data favoring the role of definitive radiotherapy for macroscopic locoregional disease. Objective Our objective was to report the outcome of patients treated with definitive radiotherapy. Methods We performed a systematic review of Medline, PubMed, and Embase databases for reported cases or series of definitive radiotherapy for macroscopic locoregional MCC. Results The mean radiation dose did not significantly differ between primary and regional sites (48.7 ± 13.2 vs 49.4 ± 10.1 Gy, P = .74). The rate of recurrence was calculated on the basis of the site of disease (11.7%) and per patient (14.3%). Recurrence was significantly more likely to occur at regional than at primary irradiated sites (16.3% vs 7.6%, P = .02). There was no association between radiotherapy dose and incidence of recurrence or nonrecurrence; primary (42.7 ± 23 vs 49.3 ± 11.8 Gy, P = .197) and regional (48.6 ± 10 vs 49.5 ± 10.3 Gy, P = .77). Limitations A limitation of this report is that most publications were retrospective; heterogeneity was present in the size of MCC and in radiotherapy details. Conclusions Definitive radiotherapy for locoregional macroscopic MCC was found to confer clinically meaningful local and regional in‐field control. Abbreviations used: Gy: Gray; MCC: Merkel cell carcinoma; NCCN: National Comprehensive Cancer Network.

Merkel cell carcinoma: A case of palliative upper limb amputation in a patient with refractory in-transit metastases.

We report an unusual case of Merkel cell carcinoma in a 70‐year‐old woman with the rapid development of left upper limb in‐transit and hepatic metastases. The patient had a preceding history of left‐sided breast cancer. Palliative chemotherapy with carboplatin and etoposide produced a minimal response. The in‐transit metastases rapidly progressed and were refractory to chemotherapy and a single fraction of palliative radiotherapy, leading to a marked impact on her quality of life, secondary to sepsis and bleeding. After lengthy discussion, she consented to an above‐elbow amputation resulting in a marked improvement in her well‐being. In this case, we believe that palliative amputation of the involved arm was justified and beneficial to the patient.

Swallowing assessment and management pre and post head and neck cancer treatment.

Purpose of reviewHead and neck cancer (HNC) imposes significant structural, functional, and cosmetic burdens upon those affected. Although advances in multimodality organ preservation therapy have assisted in ameliorating a number of previous treatment-related sequelae, dysphagia remains a foremost concern for members of the multidisciplinary team. Given its acute and long-term impact on physical and psychological wellbeing, and subsequent bearing on delivery of treatment, treatment-related morbidity and overall mortality, prompt recognition, and accurate assessment and optimization of management are pivotal. Recent findingsQualitative research has provided greater insight into the psychosocial burdens dysphagia imposes on HNC patients and carers, highlighting the need for holistic strategies of management. There is a growing body of evidence to support dietary alterations and preventive swallowing exercise regimens for maintenance of oral intake throughout and following HNC therapy. The role of prophylactic enteral feeding, however, remains uncertain, with conflicting institutional data and lack of high-quality prospective studies for meaningful systematic literature assessment. Endoscopic surgical techniques hold promise in relieving stricture-related dysphagia; however, multiple treatments are required and recurrence is common. SummarySwallowing rehabilitation encompassing education, dietary modification, and swallowing exercises comprise the mainstay of current evidence-based dysphagia management in HNC patients.

Neuroendocrine Adenoma of the Middle Ear: A Rare Histopathological Diagnosis.

Neuroendocrine tumours occur throughout the body but are rare in the head and neck region and particularly rare in the middle ear. Clinical findings are often nonspecific and therefore pose a diagnostic challenge. Furthermore, the nomenclature of neuroendocrine tumours of the middle ear is historically controversial. Herein a case is presented of a middle ear adenoma in a 33-year-old patient who presented with otalgia, hearing loss, and facial nerve palsy. A brief discussion is included regarding the histopathological features of middle ear adenomas and seeks to clarify the correct nomenclature for these tumours.

Efficacy of hypofractionated radiotherapy in patients with non-melanoma skin cancer: Results of a systematic review

Radiation oncologists are increasingly tasked with the management of elderly patients with non‐melanoma skin cancer, unsuitable for surgical intervention due to inoperable lesions and/or poor performance status. In this cohort, hypofractionated radiotherapy, delivered either daily, alternative daily or once weekly is highly effective. A systematic literature search was conducted of PUBMED, MEDLINE and EMBASE databases using the algorithm (‘radiotherapy’ OR ‘radiation therapy’ OR ‘brachytherapy’) AND (‘hypofraction’ OR ‘hypofractionated’ OR ‘hypofractionation’) AND (‘skin neoplasms’ OR ‘carcinoma’ OR ‘malignancy’) AND (‘skin’ OR ‘epidermis’ OR ‘epidermal’ OR ‘cutaneous’). Forty relevant publications (1983–2017) encompassing 12,337 irradiated lesions were retrieved. Studies documented a mean age of 71.73 years and male predilection (54.5%). Both external beam radiotherapy and brachytherapy were utilized. Tumour subtype was squamous cell carcinoma (23.5%), basal cell carcinoma (75.2%) or others (1.3%). Irradiated lesions were primary (or denovo) (92.6%), located on the head and neck (95.7%) and received definitive therapy (96.5%). Analysis demonstrated a mean weighted total radiotherapy dose (38.15 Gy), dose per fraction (7.95 Gy) and treatments per week (2.98). Despite significant heterogeneity in the study population, the radiotherapy delivered and follow‐up, local recurrence rate (crude or Kaplan–Meier analysis) did not exceed 7.9% in all but three of the 36 publications providing these data. Twenty‐nine publications documented local control exceeding 90%. There is a body of evidence documenting the efficacy of hypofractionated radiotherapy as an option that confers no obvious disadvantage in local control when compared to traditional more protracted radiotherapy schedules.

Wide anterior neck dissection for management of recurrent thyroglossal duct cysts in adults.

OBJECTIVE Thyroglossal duct cyst recurrence following resection is attributed to anatomical variability and residual thyroglossal ducts. In adults, thyroglossal duct cyst recurrence is extremely rare and a surgical solution is yet to be well explored. This paper describes our approach to the management of recurrent thyroglossal duct cysts and sinuses in adults using a wide anterior neck dissection. METHOD A retrospective review was performed to identify adults who underwent a wide anterior neck dissection for recurrent thyroglossal duct cyst management between 1 January 2009 and 1 January 2015. RESULTS Six males and one female were included in the series (mean age, 26.4 ± 10.9 years). Recurrence occurred at a mean of 18 ± 9.8 months following primary surgical management (3 patients underwent cystectomy and 4 had a Sistrunk procedure). All patients subsequently underwent wide anterior neck dissection; there was no further recurrence over the 12-month average follow-up period. CONCLUSION This paper describes a wide anterior neck dissection technique for the management of recurrent thyroglossal duct cysts or sinuses in adults; this approach addresses the variable anatomy of the thyroglossal duct and is associated with minimal morbidity.

Bilateral stage I chronic maxillary atelectasis: A case report.

Highlights • A rare case of bilateral chronic maxillary atelectasis is described.• There is a poor correlate between symptoms and severity of chronic maxillary atelectasis.• As seen in this case, the term ‘chronic’ maxillary atelectasis can be misleading, and rapid disease progression may occur.• Re-ventilation of the affected sinuses alleviates symptoms, halts disease progression and facilitates antral re-expansion.

Endoscopic pedicled nasoseptal flap repair of spontaneous sphenoid sinus cerebrospinal fluid leaks

Spontaneous cerebrospinal fluid (CSF) leaks in the sphenoid sinus are an uncommon but potentially significant condition associated with thin pneumatised bone, obesity and raised intracranial pressure. Despite advances in endoscopic sinus surgery, successful repair remains problematic due to limitations in visualisation, access and management of underlying aetiological factors. Utilisation of vascularised tissue in the primary repair process of sphenoid CSF leaks is yet to be well explored in the literature. In this series, we describe our surgical approach and explore related clinical, pathological and operative factors in three cases of spontaneous sphenoid sinus CSF leaks, successfully repaired on first attempt with the use of a vascularised nasoseptal flap.

Cervical necrotizing fasciitis: Systematic review and analysis of 1235 reported cases from the literature

Cervical necrotizing fasciitis is a progressive soft tissue infection with significant morbidity and mortality.