Danny Enepekides

Impact of positive frozen section microscopic tumor cut-through revised to negative on oral carcinoma control and survival rates†

The objective of the study was to evaluate the prognostic and therapeutic implications of an initial positive frozen section margin that was revised until negative (microscopic tumor cut‐through), and to analyze the influence of microscopic margin status on oral carcinoma control.

Volumetric changes of the anterolateral thigh free flap following adjuvant radiotherapy in total parotidectomy reconstruction

The aim of this study was to prospectively evaluate volume change in anterolateral thigh free flaps pre‐ and postradiotherapy and to compare computed tomography (CT) volumetric analysis with intraoperative water displacement calculation.

Temporoparietal fascia free flap for pharyngeal coverage after salvage total laryngectomy

The aim of this study was to assess whether the use of the temporoparietal fascia as a free flap for pharyngeal closure reinforcement reduced the incidence of pharyngocutaneous fistula (PCF) in the salvage setting.

Informed consent: do information pamphlets improve post-operative risk-recall in patients undergoing total thyroidectomy: prospective randomized control study.

BackgroundInformed consent consists of basic five elements: voluntarism, capacity, disclosure, understanding, and ultimate decision-making. Physician disclosure, patient understanding, and information retention are all essential in the doctor-patient relationship. This is inclusive of helping patients make and manage their decisions and expectations better and also to deal with any consequences and/or complications that arise. This study investigates whether giving patients procedure-specific handouts pre-operatively as part of the established informed consent process significantly improves overall risk-recall following surgery. These handouts outline the anticipated peri-operative risks and complications associated with total thyroidectomy, as well as the corrective measures to address complications. In addition, the influence of potential confounders affecting risk-recall, such as anxiety and pre-existing memory disturbance, are also examined.MethodsConsecutive adult (≥18 years old) patients undergoing total thyroidectomy at a single academic tertiary care referral centre are included. Participants are randomly assigned into either the experimental group (with pamphlets) or the control group by a computerized randomization system (Clinstat). All participants filled out a Hospital Anxiety and Depression Scale (HADS) and they are tested by the physician for short-term memory loss using the Memory Impairment Screen (MIS) exam. All patients are evaluated at one week post-operatively. The written recall questionnaire test is also administered during this clinical encounter.ResultsForty-nine patients are included - 25 of them receive verbal consent only, while another 24 patients received both verbal consent and patient education information pamphlets. The overall average of correct answers for each group was 83 % and 80 % in the control and intervention groups, respectively, with no statistically significant differences. There are also no statistically significant differences between the two groups, in both interview duration, in time between interviews, and in recall tests. No correlation is also apparent between the pre-op HADS score and the recall questionnaire overall score.ConclusionsA pre-operative thyroid surgical information pamphlet alone might not be sufficient to enhance patient test scores and optimally educate the patient on their expected care pathway in thyroid surgery. Supplementation with alternative means of patient education perhaps using emerging technologies needs to be further investigated.

Magnetic resonance-guided high-intensity focused ultrasound combined with radiotherapy for palliation of head and neck cancer-a pilot study.

BackgroundRadiotherapy is a critical component of the multidisciplinary management of cancers of the head and neck. It may comprise the primary curative treatment modality or is used in an adjuvant setting to improve local control and survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. Although considerable advances have been made recently in the fields of radiotherapy, systemic treatment and surgery for head and neck tumours, locoregional recurrence rates remain high and treatment side effects may have severe impact on patients’ quality of life.Magnetic resonance-guided high-intensity focused ultrasound (MRg-HIFU) is a novel technique in the treatment of cancer that has the potential to improve tumour cure rates and decrease treatment-related toxicity. Clinical applications of HIFU are being used increasingly for the treatment of several tumour sites, for example uterine leiomyomas and prostate cancer.Methods/DesignThe pilot study presented here is an initial step toward utilizing MRg-HIFU for head and neck cancer treatment. The rationale for novel treatment options in head and neck cancer is reviewed as well as emerging evidence that support the increasing clinical utilization of MRg-HIFU.DiscussionThis pilot study aims to assess safety, toxicity and feasibility of MRg-HIFU treatments to the head and neck region and to evaluate changes caused by MRg-HIFU within the treated tumour regions based on post-treatment MRI.

Predicting complications of major head and neck oncological surgery: an evaluation of the ACS NSQIP surgical risk calculator

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) universal surgical risk calculator is an online tool intended to improve the informed consent process and surgical decision-making. The risk calculator uses a database of information from 585 hospitals to predict a patient’s risk of developing specific postoperative outcomes.MethodsPatient records at a major Canadian tertiary care referral center between July 2015 and March 2017 were reviewed for surgical cases including one of six major head and neck oncologic surgeries: total thyroidectomy, total laryngectomy, hemiglossectomy, partial glossectomy, laryngopharyngectomy, and composite resection. Preoperative information for 107 patients was entered into the risk calculator and compared to observed postoperative outcomes. Statistical analysis of the risk calculator was completed for the entire study population, for stratification by procedure, and by utilization of microvascular reconstruction. Accuracy was assessed using the ratio of predicted to observed outcomes, Receiver Operating Characteristics (ROC), Brier score, and the Wilcoxon signed–ranked test.ResultsThe risk calculator accurately predicted the incidences for 11 of 12 outcomes for patients that did not undergo free flap reconstruction (NFF group), but was less accurate for patients that underwent free flap reconstruction (FF group). Length of stay (LOS) analysis showed similar results, with predicted and observed LOS statistically different in the overall population and FF group analyses (p = 0.001 for both), but not for the NFF group analysis (p = 0.764). All outcomes in the NFF group, when analyzed for calibration, met the threshold value (Brier scores < 0.09). Risk predictions for 8 of 12, and 10 of 12 outcomes were adequately calibrated in the FF group and the overall study population, respectively. Analyses by procedure were excellent, with the risk calculator showing adequate calibration for 7 of 8 procedural categories and adequate discrimination for all calculable categories (6 of 6).ConclusionThe NSQIP-RC demonstrated efficacy for predicting postoperative complications in head and neck oncology surgeries that do not require microvascular reconstruction. The predictive value of the metric can be improved by inclusion of several factors important for risk stratification in head and neck oncology.

Motor and sensory morbidity associated with the anterolateral thigh perforator free flap

To quantify changes in motor function, sensation, and lower extremity quality of life following anterior lateral thigh free flap (ALT) resection.

Neoplastic meningitis presenting with dysphagia and bilateral vocal cord paralysis

Neoplastic meningitis is the infiltration of the leptomeninges and subarachnoid space by tumor cells occurring in 3% to 5% of patients with systemic malignancies. Most cases present with multifocal neurological symptoms that vary according to the central nervous system territory involved. Here, we describe the first reported case to our knowledge of neoplastic meningitis causing bilateral vocal cord paralysis. Early diagnosis of this progressive disease process is essential to achieving a better treatment response and improved survival. This report demonstrates that neoplastic meningitis should be considered in the investigation of bilateral vocal cord paralysis, particularly in patients with a history of metastatic disease. Laryngoscope, 124:1912–1914, 2014

Florid Cutaneous and Mucosal Papillomatosis: Mucocutaneous Markers of an Underlying Gastric Malignancy

Case Report An 86-year female patient was referred to us for assessment of lip lesions and numerous cutaneous warty growths of 6-month duration. She had mild dysphagia but no systemic symptoms, including weight loss. Her only medication was risedronate for osteoporosis and she was otherwise healthy. Examination revealed confluent fine papillomatosis across the lip vermillion (Fig 1), which diffusely affected the mucosa of the oral cavity and oropharynx. There were several wartlike papules affecting the skin of her face, neck, and extremities (Fig 2). There was no cutaneous hyperpigmentation or velvety thickening. Histologic examination of cutaneous and mucosal lesions showed hyperkeratosis, acanthosis, and papillomatosis but no viral inclusion or vacuolar degeneration of keratinocytes. There was no evidence of human papillomavirus (HPV) by polymerase chain reaction. Results of complete blood count and serum chemistry were normal but tumor markers showed elevated carcinoembryonic antigen (19.3 ug/L; normal, 0 to 4 ug/L), which was suggestive of a gastrointestinal tract neoplasm. A computed tomography scan showed marked mural thickening of the gastric body and antrum and several enlarged, confluent upper abdominal lymph nodes. Upper gastrointestinal endoscopy revealed gastric mucosal friability and ulceration. Biopsies demonstrated a poorly differentiated carcinoma. Palliative measures were provided when the patient experienced a rapid deterioration in health, and she died after 3 months. The eruption of wart-like papules was suggestive of a viral genesis but, surprisingly, there was no evidence to support the presence of HPV. Florid cutaneous papillomatosis (FCP) is a rare condition characterized by the rapid onset of numerous warty papulonodules that may be widespread and result in facial disfigurement and social exclusion. Lesions are clinically indistinguishable from viral papillomas, yet have no evidence of HPV infection. FCP may occur with other cutaneous markers of malignancy, such as sign of Leser-Trélat and acanthosis nigricans (AN). Mucosal papillomatosis was exuberant in our patient and the appearance was similar to that seen with oral AN, which lacks hyperpigmentation. Though other cutaneous manifestations of AN were not identified, oral mucosal changes may have represented the primary sign, as has been previously reported.

A lateral neck mass

CLINICAL PRESENTATION A 50-year-old man was referred for assessment of a right lateral neck mass. Four months earlier, a right submandibular space infection was managed with antibiotic therapy and extraction of several grossly decayed teeth in the right posterior mandible. A focal painless swelling persisted. He was otherwise healthy and did not take any medication. On examination, there was a subcutaneous swelling affecting the right submandibular region that measured 2 cm in maximum dimension (Figure 1). On bimanual palpation, this was nontender, firm, ovoid, and mobile. The oral soft tissues were normal, and extraction sockets had completely healed. Clear and ample saliva was expressed from the Wharton ducts. Plain films showed no osseous abnormalities or sialolith.