Marc A. Cohen

Increase in primary surgical treatment of T1 and T2 oropharyngeal squamous cell carcinoma and rates of adverse pathologic features: National Cancer Data Base

There has been increasing interest in the primary surgical treatment of patients with early T classification (T1‐T2) oropharyngeal squamous cell carcinoma (OPSCC), with the stated goal of de‐escalating or avoiding adjuvant treatment. Herein, the authors sought to determine the degree to which this interest has translated into changes in practice patterns, and the rates of adverse postoperative pathologic features.

Parathyroid Localization and Preservation during Transcervical Resection of Substernal Thyroid Glands

Objective The feasibility of parathyroid preservation during thyroidectomy has not been well documented for cases in which the thyroid gland extends into the mediastinum. Study Design Retrospective chart review. Setting Tertiary academic referral center. Subjects and Methods In this retrospective cohort study, 70 consecutive patients who had substernal thyroid glands treated with a transcervical thyroidectomy between 1993 and 2013 were compared with 286 thyroidectomies that did not entail substernal extension within that same time period. All localized parathyroid glands were confirmed histologically. Results Of 160 possible parathyroid glands in the substernal cases, 119 (74%) were histologically confirmed intraoperatively (67 superior and 52 inferior). In nonsubsternal cases, 725 (89%) were histologically confirmed (372 superior and 353 inferior). There was a statistically significant difference between the substernal and nonsubsternal cases in the total number of glands found (P < .0001) and the number of superior and inferior glands that were identified (P = .009 and < 0.0001). Conclusions Even when the thyroid gland extends into the mediastinum, it is often possible, although with reduced efficiency, to identify and preserve the parathyroid glands.

Is Intraoperative Parathyroid Hormone Monitoring Warranted in Cases of 4D-CT/Ultrasound Localized Single Adenomas?

Objective To analyze the utility of intraoperative parathyroid hormone (IOPTH) monitoring for patients with primary hyperparathyroidism who had evidence of single-gland disease on preoperative imaging with modified 4-dimensional computed tomography that was done in conjunction with ultrasonography (Mod 4D-CT/US). Study Design Case series with chart review. Setting Tertiary care university medical center. Subjects and Methods Patients were drawn from consecutive directed parathyroidectomies performed between December 2001 and June 2013 by the senior authors. All patients had primary hyperparathyroidism and underwent a Mod 4D-CT/US study that showed findings on both studies that were consistent with a single adenoma. The modified Miami criteria were used for IOPTH monitoring (parathyroid hormone decrease by >50% and into the normal range). Results Of 356 patients who underwent parathyroid surgery, 206 had a single gland localized on the Mod 4D-CT and the US studies. IOPTH monitoring was used in 172 cases, of which 169 had adequate clinical follow-up to assess the surgical outcome. Twenty-one patients (12.4%) had IOPTH values that did not meet modified Miami criteria after removal of one gland, of which 7 were found to have multigland disease (4.1%). Three patients (1.8%) had persistent primary hyperparathyroidism despite an IOPTH that met modified Miami criteria. Conclusions Although IOPTH monitoring correctly identifies a small percentage of patients with multigland disease, some patients will be subjected to unnecessary neck explorations that can result in difficult intraoperative decisions, such as whether to remove normal or equivocal-sized glands when they are encountered.

In Silico Analysis of RET Variants in Medullary Thyroid Cancer From the Computer to the Bedside

Objective The American Thyroid Association (ATA) medullary thyroid cancer (MTC) guidelines group RET variants, in the setting of familial medullary thyroid cancer and multiple endocrine neoplasia type 2, into 4 classes of severity based on epidemiological data. The aim of this study was to determine if genotype correlates with phenotype in RET missense mutations. Study Design In silico mutational tolerance prediction. Setting Academic research hospital. Subjects and Methods We analyzed all RET variants currently listed in the ATA guidelines for the management of MTC using 2 computer-based (in silico) mutation tolerance prediction approaches: PolyPhen-2 HumVar and PolyPhen-2 HumDiv. Our analysis also included 27 different RET single-nucleotide polymorphisms resulting in missense variants. Results There was a statistically significant difference in the overall HumDiv score between ATA groups A and B (P = .025) and a statistically significant different HumVar score between benign polymorphisms and ATA group A (P = .023). Overall, RET variants associated with a less aggressive clinical phenotype generally had a lower Hum Div/Var score. Conclusions Polyphen-2 Hum Div/Var may provide additional clinical data to help distinguish benign from MEN2/familial medullary thyroid carcinoma–causing RET variants as well as less aggressive phenotypes (ATA A) from more aggressive ones (ATA B-C). In silico genetic analyses, with proper validation, may predict the phenotypic severity of RET variants, providing clinicians with a tool to aid clinical decision making in cases in which the RET variant is currently unknown or little epidemiological data are available.

Quality of neck dissection operative reports

PURPOSE The operative report is the official documentation of an operation and a key form of surgical communication. The objective of this study is to assess completeness of operative reports for neck dissections. METHODS This is a retrospective review of narrative operative reports for neck dissections for head and neck squamous cell carcinoma. Forty-nine operative reports were provided by ten surgeons from seven academic institutions. Operative report completeness was expressed as a percentage of variables from a standardized checklist created by an expert panel. RESULTS For level 1 dissections, most reports identified critical structures, such as the marginal mandibular nerve (84%) and the submandibular gland (84%). Of the cases that involved submandibular gland excision, reports were deficient in identification of the lingual nerve (74%), hypoglossal nerve (58%) and submandibular duct (22%). For neck dissections involving levels 2, 3 and 4, most described identifying spinal accessory nerve (92%) and internal jugular vein (98%), whereas fewer described identification of carotid artery or vagus nerve (67%), ansa cervicalis (31%), or cervical rootlets (48%). For level 5 dissections, only 75% of reports reported identification of spinal accessory nerve. Sixty percent of reports provided some description of the removed lymph nodes, but there was no consistency in terminology or definitions. Overall completeness of all NORs was 64% (40%-79%, SD 9%). CONCLUSIONS There is heterogeneity and incompleteness in neck dissection operative reports across surgeons and institutions, despite being a crucial record of head and neck cancer treatment.

Neither high-dose nor low-dose brachytherapy increases flap morbidity in salvage treatment of recurrent head and neck cancer.

Purpose While brachytherapy is often used concurrently with flap reconstruction following surgical ablation for head and neck cancer, it remains unclear whether it increases morbidity in the particularly high risk subset of patients undergoing salvage treatment for recurrent head and neck cancer (RH&NC). Material and methods A retrospective chart review was undertaken that evaluated patients with RH&NC who underwent flap coverage after surgical re-resection and concomitant brachytherapy. The primary endpoint was flap viability, and the secondary endpoints were flap and recipient site complications. Results In the 23 subjects included in series, flap viability and skin graft take was 100%. Overall recipient site complication rate was 34.8%, high-dose radiation (HDR) group 50%, and low-dose radiation (LDR) group 29.4%. There was no statistically significant difference between these groups. Conclusions In patients who undergo flap reconstruction and immediate postoperative radiotherapy following salvage procedures for RH&NC, flap coverage of defects in combination with brachytherapy remains a safe and effective means of providing stable soft tissue coverage.

Multiple endocrine neoplasia type 2 kindred with novel tandem RET mutations: Case report with an applied in silico mutational tolerance analysis

The American Thyroid Association (ATA) has established guidelines for prophylactic thyroidectomy in multiple endocrine neoplasia type 2A (MEN2A) based on rearranged during transfection (RET) mutations. In silico analysis, which uses computer modeling to predict alterations in protein structure, is a new method for studying these mutations.

Left Parotid Gland Swelling in an Infant

An infant girlpresented to thepediatric otolaryngology clinicwith a 2-monthhistory of an enlarging left preauricularmass. Theparents first noticed apea-sizednodule in front of her left ear thatwas now3 cm, soft, mobile, and nontender, without overlying skin changes or facial nerve impairment. The infant was otherwise well without fevers, feeding well, and growing appropriately. Hermother had a full-term vaginal delivery without complications and a medical history that was notable only for gastroesophageal reflux disease treated with ranitidine. Ultrasonography showed a 2.2 × 3.0-cm solid nodule. The patient was then referred for magnetic resonance imaging (MRI) with contrast, which showed a 2.9 × 1.6 × 2.3-cm mass with a welldefined capsule arising fromwithin the superficial left parotid gland. Themasswas largely of fat signal intensity on both T1-weighted (Figure, A) and T2-weighted sequences with heterogeneous soft-tissueenhancementonT1post-contrast (Figure,B). Themassalso suppressed relativelyuniformlyon short T1 inversion recovery (STIR) sequence (Figure, C). The Figure, D, shows themass in situ during surgical excision with facial nerve monitoring. T1-Weighted sequence A T1-Weighted sequence postcontrast with fat suppression B

Unusual Presentation of a Laryngeal Mass

Awomaninher50swithahistoryofhypertensionandchronicback painpresented to theemergencydepartment. Shehadbeendiscoveredunresponsive inbed,wasapneic, andwas intubated in the field. Shehadexperiencedmultiple episodesof emesis. Atpresentation, a computed tomographic (CT) scan demonstrated diffuse subarachnoidhemorrhage, intraventricular hemorrhage, andcommunicating hydrocephaluswithtonsillarandcentralherniation.Shereceivedmannitolandanemergentextraventriculardrain.Duringherhospital stay, a cerebral aneurysm was successfully treated by an endovascular route. She required a tracheostomy and percutaneous gastrostomy tube placement. Twenty-eight days after her tracheostomy, a flexible endoscopic evaluation of swallowing with sensory testing (FEESST) revealed a submucosal mass. The mass did not fully obstruct the airway, and the patient tolerated a Passy-Muir valve with no respiratory distress. The primary teamadministered dexamethasonesodiumphosphateandconsultedtheotolaryngologyservice.On examination, her vital signs werewithin normal limits, shewas nonverbalbut innoacutedistress,herbreathingunlaboredandsilent,with no stridor or stertor. Passing a flexible fiber-optic laryngoscope confirmedthepresenceofanapparentsubmucosalmassthateitheroriginated from the epiglottis or deep to a severely edematous right aryepiglottic (AE) fold or arytenoid, or completely obstructed the vocal cords from view. Themass did not respond to steroids. A CT scan of the neck with intravenous contrast was performed (Figure, A). The mass was nonenhancing. Subsequently, a retrospective review of a magnetic resonance imaging (MRI) examination demonstrated the mass compressed by the endotracheal catheter (Figure, B). What is your diagnosis? A