Sophie Scherl

Subscapular system of flaps: An 8‐year experience with 105 patients

Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps.

Database and registry research in thyroid cancer: Striving for a new and improved national thyroid cancer database

BACKGROUND Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations. SUMMARY In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries. CONCLUSION A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.

Castleman Disease in the Parapharyngeal Space: A Case Report and Review of the Literature

Castleman disease is most commonly found in the mediastinum, while the head and neck is the second most common location. The disease exists in a unicentric and multicentric variety and is usually successfully treated with surgical resection alone. Early identification is important for treatment planning. Castleman disease has been reported to mimic other disease processes, however there has been only one report of the disease mimicking a nerve sheath tumor in the parapharyngeal space. Here we report the second case of Castleman disease mimicking a schwannoma in the parapharyngeal space.

Pathologic Reporting of Lymph Node Metastases in Differentiated Thyroid Cancer: a Call to Action for the College of American Pathologists

Lymph nodes in differentiated thyroid cancer have many different histomorphologic features. The current AJCC staging system does not distinguish between different lymph node characteristics and is based entirely on the presence of metastatic disease to upstage pN0 to pN1. However, clinicians involved in the management of thyroid cancer recognize that there is a difference in the clinical significance of finding macroscopic versus microscopic nodes. There appears to be a difference in disease biology that allows lymph nodes to reach different sizes and to manifest disease extension outside the capsule, which has led clinicians, and even clinical practice guidelines, to stratify nodal metastases on the basis of these features. The inherent presumption is that all lymph node metastases in differentiated thyroid cancer do not have the same clinical significance with respect to the risk of recurrence and the risk of death. However, the College of American Pathology (CAP) has not mandated that pathologists include these findings as part of their standard reporting protocol in thyroid cancer. In order to arm clinicians with the tools to design clinical trials and to make important patient management decisions in the presence of lymph node metastases, it is imperative that the CAP adopt a strategy for more detailed reporting that is similar to the protocol currently utilized in breast cancer pathologic reporting.

Rare Tracheal Tumors and Lesions Initially Diagnosed as Isolated Differentiated Thyroid Cancers

BACKGROUND Thyroid carcinoma with tracheal invasion is uncommon; however, this is significantly more prevalent than primary tracheal tumors. Rare tracheal tumors at the level of the thyroid can be misinterpreted as invasive thyroid cancer upon initial diagnosis. We present a series of tumors within the tracheal wall that were initially misdiagnosed as isolated, but aggressive, thyroid cancer, and later diagnosed to be different histopathologic entities. METHODS The series consisted of four women and five men, all but two age 60 or older, who were initially diagnosed with tracheal invasion from differentiated thyroid carcinoma (DTC). Eight had obstructive airway symptoms and one experienced gagging and choking sensations. Preoperatively, the patients underwent fine-needle aspiration (FNA) and imaging studies. A complete resection of the involved airway in combination with the thyroid gland was performed in all patients. RESULTS In this series of patients, the final diagnosis was tracheal stenosis, recurrent laryngeal nerve schwannoma, papillary thyroid carcinoma (PTC) with benign intratracheal thyroid tissue, adenoid cystic carcinoma, and squamous cell carcinoma, each in one patient. Two patients had a tracheal chondrosarcoma, and two patients had collision tumors (PTC with laryngeal squamous cell carcinoma). All patients were misunderstood preoperatively as having isolated DTC with aggressive involvement of the trachea. An accurate diagnosis in these cases was difficult due to misleading FNA readings, thought due to the FNA needle passing through the thyroid before reaching the trachea or a tumor that abuts both structures on imaging. Primary tracheal tumors and a nontumorous lesion, as well as benign thyroidal masses, mimicked invasive thyroid carcinoma in this preoperative setting. CONCLUSIONS Various entities other than thyroid cancer can masquerade as invasive thyroid cancer. In patients with an FNA showing thyroid tissue or suggesting PTC, but also have obstructive or other airway symptoms, physician awareness is needed to consider the distinct possibility of a primary tracheal lesion. Obtaining the correct preoperative diagnosis is essential for accurate surgical planning for patients with tracheal tumors.

Use of a combined latissimus dorsi scapular free flap revascularized with vein grafting to the internal mammary artery in a vessel‐depleted and previously irradiated neck

For patients who have extensive prior treatment, use of the internal mammary artery/vein (IMA/IMV) or cephalic vein has been shown to be a reliable option. Additionally, for those patients who require vascularized bone and extensive soft tissue reconstruction, the combined latissimus dorsi scapular free flap (mega‐flap) is an excellent option.

Approach to en bloc resection and reconstruction of primary masticator space malignancies

The aim of this study was to present our experience with management of malignant lesions arising within the masticator space, and to describe a technique of en bloc resection and reconstruction.

The differential diagnosis of central compartment radioactive iodine uptake after thyroidectomy: anatomic and surgical considerations.

OBJECTIVE Foci of increased radioactive iodine (RAI) uptake in the thyroid bed following total thyroidectomy (TT) indicate residual thyroid tissue that may be benign or malignant. The use of postoperative RAI therapy in the form of remnant ablation, adjuvant therapy, or therapeutic intervention is often followed by a posttherapy scan. Our objective is to improve the clinicians understanding of the anatomic complexity of this region and to enhance the interpretation of postoperative scans. METHODS We conducted a comprehensive review of the literature evaluating RAI uptake in the central compartment following thyroid cancer treatment and literature related to anatomic nuances associated with this region. Thirty-eight articles were selected. RESULTS Through extensive surgical experience and a literature review, we identified the 5 most important anatomic considerations for clinicians to understand in the interpretation of foci of increased RAI uptake in the thyroid bed on a diagnostic scan: 1) residual benign thyroid tissue at the level of the posterior thyroid ligament, 2) residual benign thyroid tissue at the superior portion of the pyramidal lobe and/or superior poles of the lateral thyroid lobes, 3) residual benign thyroid tissue that was left attached to a parathyroid gland in order to preserve its vascularity, 4) ectopic benign thyroid tissue, and 5) malignant thyroid tissue that has metastasized to central compartment nodes or invaded visceral structures. CONCLUSION By correlating anatomic description, medical illustrations, surgical photos, and scans, we have attempted to clarify the reasons for foci of increased uptake following TT to improve the clinicians understanding of the anatomic complexity of this region.

Total soft palate reconstruction using the palatal island and lateral pharyngeal wall flaps

INTRODUCTION The palatal island flap has been well described for head and neck cancer reconstruction to repair defects in sites such as the soft palate, hard palate, retromolar trigone, cheek, tonsil, and lateral pharyngeal wall. This flap is particularly versatile; however, when used alone for soft palate repair the technique provides only an adynamic reconstruction. In view of this, the lateral pharyngeal wall flap can be used in conjunction with the palatal island to add a dynamic feature that can help to restore the sphincteric function of the velopharynx. We report the use and advantages of employing the palatal island flap in conjunction with the lateral pharyngeal wall flap in a single-staged reconstruction of large soft palate defects. This operation has been highly successful, with low complication rates, due to the high vascularity of the involved flaps, decrease in surgical complexity, and recreation of mucosal lining to the oral and nasal surfaces of the repair. The latter feature helps to add to the predictability of the results through the prevention of granulation tissue formation. We propose that this procedure be considered more often in the surgical reconstruction of large soft palate defects. MATERIALS AND METHODS In select cases, an elective tracheostomy should be considered at the beginning of the operation for airway protection. Once the resection of the soft palate is performed, an oncologic clearance of the tumor is established by frozen section analysis prior to embarking on the reconstruction (Fig 1). Subsequently, restoring the velopharynx can be undertaken. The nasopharyngeal surface of the soft palate is created with two opposing musculomucosal flaps from the lateral pharyngeal wall. The lateral pharyngeal walls are undermined in a submuscular plane starting at the posterior margin of the resection, usually at the level of the posterior tonsillar pillar (Fig. 2). The myomucosal superior and medial pharyngeal constrictors and pharyngeal mucosa are recruited from the lateral pharynx and advanced to the midline to form the nasopharyngeal surface of the neo-soft palate. Creation and closure of the inner myomucosal tube on itself creates a single dynamic chamber from the nasopharynx to the oropharynx (Fig. 3). Once the nasopharyngeal aspect of the soft palate has been created, attention is directed to the palatal island flap. Harvest of the palatal island is initiated by making an incision around the perimeter of the hard palate mucosa within a 5-mm gingival margin medial to the teeth. The incision is extended posteriorly to the hard and soft palate junction bilaterally. Using a freer elevator, the mucoperiosteum is elevated from the bone in an anterior to posterior fashion. One neurovascular pedicle is preserved, whereas the other is ligated with surgical clips. The flap is rotated 180 on its axis, maintaining the mucosal surface oriented toward the oral cavity. The entire palatal island flap is subsequently sutured directly to the margins of the defect with its deep surface apposing the transposed myomucosal pharyngeal flaps to form the oropharyngeal surface of the neo-soft palate. The suture line usually extends laterally along the anterior tonsillar pillar and helps to ensure the posterior positioning of the palatal island flap. The transposed palatal island flap has a tendency to lift away from the palatal bone along its leading edge. This can be overcome by placing boneanchored sutures that are drilled into the palatal bone along the edge and used to appose the palatal flap to the boney surface (Fig. 4). Tension-free closure is imperative on the nasopharyngeal and oropharyngeal side of the neo-soft palate (Fig. 5). From the Albert Einstein College of Medicine (W.E.K.); Thyroid Head and Neck Cancer Foundation (W.E.K., J.B.C., S.S.); and Department of Otolaryngology–Head and Neck Surgery (S.M.A., M.L.U.), Beth Israel Medical Center, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication September 19, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to William E. Karle, 9 Ryan Rd., Troy, NY 12182. E-mail: william.karle@med.einstien.yu.edu

Trismus release in a pediatric patient using a parascapular free flap reconstruction following desmoid tumor resection

INTRODUCTION Desmoid tumors are benign neoplasms composed of fibrous tissue arising from musculoaponeurotic structures throughout the body. These are rare lesions accounting for only 0.03% of all tumors. Alternate names for this tumor include grade I fibrosarcoma and aggressive fibromatosis. The majority of these neoplasms present in the abdomen, with only 12% to 15% presenting in the head and neck. Desmoid tumors require wide excision of the tissues involved. Depending on the extent of the resection and structures involved, the reconstruction can be managed by primary closure, regional flaps, or free tissue transfer. Patients who present with desmoid tumors in the masticator space provide a particular challenge because the surgeon must remove the tumor while preserving oral function. A common consequence of this surgery is trismus, which can arise as a result of fibrosis and scar contracture. The incidence of trismus in the setting of prior treatment for head and neck cancer has been quoted to range between 5% to 38% of patients. Primary risk factors include previous irradiation, multiple treatments with surgery and/or chemoradiation, fibrous or bony ankylosis of the temporomandibular joint, and recurrence of oral cancer. In the case of severe trismus, traditional surgical intervention may include release of scar located at the level of the mucosa or submucosa, myotomy of the pterygomasseteric sling and/or temporalis muscle, and in select advanced cases, a coronoidectomy. In this report, we present a unique case of severe trismus due to extensive, dense scarring and fibrosis following surgical excision of a desmoid tumor in the masticator and parapharyngeal spaces in a pediatric patient. Microvascular free tissue augmentation was undertaken to preserve the increased oral aperture that resulted following release of the trismus. Following multiple unsuccessful attempts to achieve a durable solution to this patient’s condition, it was felt that the introduction of a healthy vascularized tissue barrier to prevent recurrent scar formation represented a viable treatment option. The management of desmoid tumors in the head and neck is also reviewed.