Mario Bilić

A prospective observational study of 363 cases operated with three different harmonic scalpels

The objective of this study is to evaluate the efficacy of the Harmonic ACE™, Harmonic FOCUS™ and harmonic scalpel with 5-mm curved blade in head and neck surgery. During a 15-month period, we performed 295 thyroidectomies, 23 parotidectomies and 45 tonsillectomies using the harmonic scalpel. Control group consisted of 106 thyroidectomies, 9 parotidectomies and 30 tonsillectomies performed with the use of conventional hemostatic techniques. The use of both Harmonic ACE™ and Harmonic FOCUS™ scalpel reduced the time of thyroid and parotid surgery by 20–25%. The use of Harmonic ACE™ reduced the mean time of tonsillectomy, while the use of 5-mm curved blade had no significant effect. Postoperative pain and complication rate were comparable for both the groups. In conclusion, the use of both Harmonic ACE™ and Harmonic FOCUS™ devices significantly reduces operative time in the head and neck procedures and enables a smaller neck skin incision in thyroidectomy.

Videofluoroscopy of the swallowing act after partial supraglottic laryngectomy by CO2 laser

Abstract. The evaluation of functional deglutition in patients after partial supraglottic laryngectomy by CO2 laser was performed by videoflouroscopy of the swallowing act. We studied 20 patients in PA and LL projections, and the swallowing act, at 25 frames per s, was captured on videotape. Aspiration was found in six patients, four of whom had manifest clinical symptoms of aspiration. Four patients had post-deglutitive, one intra-deglutitive and one both intra- and post-deglutitive aspiration. Other swallowing disturbances or structural deformities were not detected. Dynamic radiological studies of swallowing, such as videoflouroscopy of the swallowing act, can provide valuable information regarding functional results after surgical procedures in the upper aerodigestive tract. Our encouraging results prove the validity of partial supraglottic laryngectomy by CO2 laser as a method of treatment for carcinoma of the larynx.

Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement]

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 × 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a ‘computed journey’ through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.

Mucoepidermoid carcinoma of the larynx: report of three cases.

Mucoepidermoid carcinoma of the larynx is very rare, with only a few individual cases or studies in small patient groups reported in the literature. Treatment modalities for this type of carcinoma are not uniform; in addition, errors in the recognition and pathologic diagnosis are not uncommon. During the period 1991-2000, 771 cases of malignant laryngeal tumours were recorded and histologically verified at the University Department of Otorhinolaryngology and Cervicofacial Surgery, Zagreb University Hospital Centre, three of them were mucoepidermoid supraglottic carcinomas. The experience acquired in the treatment of these tumours is presented along with a review of the literature.

Extranotochordal extralaryngeal chordoma : a case report

Chordomas are rare, malignant, slowly growing neoplasms which develop from vestigial remnants of the fetal notochord. Most chordomas arise in the sacrococcygeal and spheno-occipital region. Extranotochordal chordomas are extremely unusual. A case of extranotochordal chordoma with extralaryngeal localization is described. A 73-year-old male presented with swallowing difficulties and hoarseness. Contrast-enhanced magnetic resonance imaging of the neck revealed a well-encapsulated tumor mass that was well enhanced and located in the left retrolaryngeal space at the level of C4, dislocating the larynx to the right. Left radical neck dissection and tumor extirpation were performed. The tumor had not invaded cervical vertebra and the surrounding soft tissue but superficial erosions of the ossificated thyroid and cricoid cartilage were found. High-power pathologic examination and immunohistochemistry defined the lesion as a dedifferentiated type of chordoma. The patient received adjuvant radiotherapy. Four years after the surgery, the patient has been free from tumor recurrence.

Basement membrane protein ladinin-1 and the MIF-CD44-β1 integrin signaling axis are implicated in laryngeal cancer metastasis

Laryngeal squamous cell carcinoma (LSCC) is the most common form of malignant disease in the head and neck region characterized by frequent occurrence of metastases in the neck lymph nodes early in the disease onset. In the presented study, we performed quantitative proteomic profiling of patient-matched primary tumor and adjacent non-tumorous tissues derived from metastatic LSCC as to identify new protein candidates with potential diagnostic and therapeutic significance. Obtained results revealed for the first time involvement of the basement membrane protein ladinin-1 in laryngeal cancer metastases. Alterations in the cellular microenvironment that propel metastatic events in laryngeal cancer include activation of MIF-CD44-β1 integrin signal transduction pathway and induction of downstream signaling mediated by NF-κB and Src tyrosine kinase, which ultimately impinge on cytoskeletal dynamics and architecture resulting in increased cellular motility and invasiveness. In this context, particularly interesting finding is upregulation of several actin-binding proteins novel to laryngeal cancer pathogenesis including coronin-1C and plastin-2, whose functional significance in laryngeal carcinogenesis has yet to be established. We also detected for the first time a complete loss of afamin in metastatic laryngeal cancer tissues, which warrants further studies into its use as a possible marker for monitoring disease progression and/or treatment outcome.

Primary laryngeal manifestation in precursor T-cell acute lymphoblastic leukemia.

Involvement of the larynx by lymphoma is very rare. 1 All cases reported in recent literature refer to isolated laryngeal lymphoma, most of them of the supraglottic region. There are reports of isolated subglottic non-Hodgkin lymphoma that can cause life-threatening airway obstruction. We present a female patient with airway obstruction due to subglottic T-cell lymphoma as the only manifestation of precursor T-cell acute lymphoblastic leukemia (ALL). To our knowledge, this is the first case of T-cell ALL manifesting as laryngeal airway obstruction reported in the English literature. The patient underwent carbon dioxide laser resection of the tumorous subglottic mass, with follow-up during chemotherapy treatment. There was no laryngeal recurrence during the 4-month treatment. The tracheostomy was successfully closed without airway problems; however, the patient died from sepsis due to Pseudomonas aeruginosa infection. A 37-year-old female patient was admitted for dyspnea due to tracheal stenosis with no history of fever, night sweats, or weight loss. CT scan showed a solid subglottic mass, which extended intraluminally to the level of the fifth cervical vertebra. On fiber laryngoscopy, we found a circumferential, soft, pale submucosal subglottic swelling, which caused upper airway obstruction (Fig 1). We performed a tracheotomy and tumorous mass removal by carbon dioxide laser resection. On immunohistochemistry, the tumor was positive for CD3 and CD43, and negative for bcl 6, CD4, CD8, CD20, and CD30. The diagnosis of T-cell non-Hodgkin lymphoma was made. CT scanning of the chest, abdomen, and pelvis revealed a solid mass in the anterior mediastinum. Bone marrow biopsy confirmed the diagnosis and showed that tumor cells were positive for CD45RO and negative for CD20, with 30 percent of the bone marrow containing blasts. Immunophenotype determined by flow cytometry showed that precursor T cells comprised 33 percent of the sample total cell count, verifying a definitive diagnosis of precursor T-cell ALL. The patient underwent the first chemotherapy cycle, to which she failed to respond. The second

Expression of polysialic acid in primary laryngeal squamous cell carcinoma

Aims: Expression of polySia is associated with metastatic dissemination and progression of various malignant diseases. In particular, it may contribute to tumorigenesis by a negative modulatory effect on cellular signaling cascades responsible for cellular migration, differentiation and proliferation. In this study, we investigated the expression of polySia in primary metastatic and non‐metastatic laryngeal squamous cell carcinoma (LSCC) tumor tissues and its potential impact on the LSCC progression. Main methods: The expression of polySia in metastatic and non‐metastatic primary laryngeal squamous cell carcinoma (LSCC) tumor biopsy specimens was investigated by immunohistochemistry, while the expression of polysialyltransferase IV (ST8SiaIV)(), fibroblast growth factor receptor 1 (FGFR1), extracellular signal regulated kinases 1 and 2 (Erk 1/2) and c‐Raf was tested in metastatic and non‐metastatic primary tumor tissues (including the corresponding non‐tumor control tissues) by Western blot analysis. Key findings: The expression of polySia was detected in LSCC biopsies specimens with generally stronger immunoreactivity in non‐metastatic tumor LSCC sections and in histologically undifferentiated tumors. Also, increased polySia expression was observed in adjacent histologically unaltered laryngeal tumor‐associated tissue of the metastatic sections. In addition, we provide an evidence of increased polysialyltransferase IV (ST8SiaIV) expression, involved in polySia synthesis in both metastatic and non‐metastatic primary tumors which is accompanied by decreased levels of FGFR1, Erk 1/2 and c‐Raf. Significance: We present for the first time the evidence for the polySia expression in LSCC biopsies specimens which suggests its potential impact on initial steps of LSCC malignant transformation.

Pathology quiz case 1. Wegener granulomatosis

A 23-YEAR-OLD WHITE WOMAN PRESENTED with a 2-month history of a pyoderma gangrenosum–like ulcer in the right postauricular region. The cutaneous lesion had initially started as a pustule that was associated with local pain, subfebrile temperature, night sweats, and spontaneous perforation with a whitish discharge 2 weeks after the disease onset. Necrectomy was performed, and antibiotics (clindamycin, amoxicillin and clavulanate potassium [co-amoxiclav], and azithromycin) were administered intravenously in an outpatient clinic, without success. Two months after the first symptoms appeared, the patientwasadmitted toourclinic.Shehada4.5-cm-diameter, painful, necrotic area in the right postauricular and subauricular regions. The lesion was covered with granulation tissue and mucous discharge. In the left postauricular region, there was an indurated purple pustule, 2 cm in diameter, that was solid and painful to palpation. A smaller pustule was seen in the medial part of the left scapula. The patient also had painful episcleritis and uveitis of both eyes as well as granulation tissue in the septal and conchal mucousmembranes.Antibiotic therapy(piperacillinandgentamicinsulfate)wasadministeredintravenously,andasecond necrectomyoftherightpostauricularandsubauricularareas was performed on day 5 of admission. A huge ulcer penetrating deeply into the right parotid gland, almost to the facial nerve, was found on removal of the necrotic tissue (Figure 1). The tissue was sent for cytologic, microbiologic, andhistopathologic analysis.Cultureswerenegative for aerobic and anaerobic microorganisms and fungi. Cytologicexaminationshowedgranulomatous inflammation. Thehistopathologyreport revealed fibrinoidnecrosisof the vascular wall; macrophage, lymphocyte, and neutrophilic leukocyteinfiltration;andformationofgranuloma(Figure2 and Figure 3). What is your diagnosis?