Sudip D. Thakar

Sentinel lymph node biopsy for ocular adnexal melanoma

We sought to update our prior report of findings on sentinel lymph node biopsy (SLNB) and predictors of a positive SLN in patients with conjunctival or eyelid melanoma.

Lymphomas of the Ocular Adnexa

Lymphoid tumors are the most common primary orbital tumors. The majority of ocular adnexal lymphomas (OAL) are low grade. In order of frequency, the most common histologic subtypes of lymphoma in the orbit and ocular adnexa are marginal zone lymphoma (“MALT”), follicular lymphoma, diffuse large B-cell lymphoma, and mantle cell lymphoma. The American Joint Committee on Cancer (AJCC) classification for ocular adnexal lymphoma is more detailed in terms of the extent of involvement of the orbital and ocular structures, while the Ann Arbor staging may be more relevant to systemic staging of lymphoma. The role of positron emission tomography (PET)/computed tomography (CT) scans and bone marrow biopsy in staging of ocular adnexal lymphoma are better defined. Treatment options depend on the stage of lymphoma and the histologic subtype of lymphoma. Treatments that may include very low-dose radiation therapy, monoclonal antibody treatment, radioimmunotherapy, and systemic chemotherapy may be considered depending on the stage and histologic subtype of OAL.

Orbital Cellulitis in Cancer Patients

Cancer patients present with a unique set of anatomic, physiologic, and treatment-related conditions that may result in infections including orbital cellulitis. These patients are more prone for infections due to immunosuppression caused either by the cancer itself or due to the treatments they are undergoing for their cancer. Tumor-induced, surgery-induced, and radiation-induced changes to the orbital and facial tissues can also contribute to the development of orbital cellulitis. In this chapter, we review the etiology and management of orbital cellulitis in cancer patients and review masquerade syndromes and treatment-induced inflammatory conditions that may mimic this condition.

Immunotherapy With Programmed Cell Death 1 Inhibitors for 5 Patients With Conjunctival Melanoma

Importance Conjunctival melanoma has the potential for regional lymphatic and distant metastasis. There is an urgent need for effective treatment for patients with metastatic or locally advanced conjunctival melanoma. Objective To describe the use of immune checkpoint inhibitors for the treatment of conjunctival melanoma in 5 adult patients. Design, Setting, and Participants A retrospective review was conducted of the medical records of 5 patients with conjunctival melanoma who were treated with immune checkpoint inhibitors from March 6, 2013, to July 7, 2017. Main Outcomes and Measures Response to treatment and disease-free survival. Results Of the 5 patients (4 women and 1 man) with metastatic conjunctival melanoma, 4 were treated with a programmed cell death 1 (PD-1) inhibitor, nivolumab, and had a complete response to treatment with no evidence of disease at 1, 7, 9, and 36 months after completing treatment. One patient with metastatic conjunctival melanoma was treated with another PD-1 inhibitor, pembrolizumab, and had stable metastases during the first 6 months of treatment. Later disease progression resulted in treatment cessation after 11 months and switching to another therapy. Two patients treated with nivolumab developed autoimmune colitis that necessitated stopping the immunotherapy; these patients subsequently were managed with systemic corticosteroids or infliximab. Conclusions and Relevance This case series report suggests that anti–PD-1 therapy can be used to treat metastatic conjunctival melanoma. Longer follow-up is needed to determine the long-term disease-free survival. Future studies might assess the potential for immune checkpoint inhibitors to obviate the need for orbital exenteration in selected patients with locally advanced disease.

Ocular preservation with neoadjuvant vismodegib in patients with locally advanced periocular basal cell carcinoma

Background/Aims Locally advanced (T4 per American Joint Committee on Cancer (AJCC) 8th edition) periocular basal cell carcinoma (BCC) can lead to loss of the eye. We report the neoadjuvant use of vismodegib followed by surgery in patients with such lesions with eye preservation as primary goal. Methods This retrospective interventional study includes all patients with a T4 periocular BCC (per 8th edition AJCC for eyelid carcinoma) treated by the senior author between 2013 and 2017 with neoadjuvant vismodegib prior to definitive surgery. Results Eight patients had a T4 tumour. Six patients presented with recurrent disease. Indications for neoadjuvant treatment were an unresectable tumour in one patient, an attempt to avoid an orbital exenteration in six patients and an attempt to avoid disfiguring facial surgery in one patient. Patients were treated for a median of 14 months (range: 4–36 months). All patients underwent an eye-sparing surgery following neoadjuvant vismodegib and all final surgical margins were negative for tumour. Five patients had a complete response to vismodegib with no microscopic residual BCC found during surgery; three patients had a significant partial response with residual tumour found on pathology. At last follow-up, a mean of 18 (range: 6–43) months after surgery, all patients were off-vismodegib and alive without evidence of disease. Conclusions Neoadjuvant vismodegib for locally advanced (T4) periocular BCC enabled an eye-sparing surgery in all patients in our cohort. Prolonged treatment was well tolerated by most patients. Over half of patients achieved a complete response with no residual microscopic disease. Careful long-term follow-up is needed to confirm long-term disease-free survival.

A 60-year-old woman with an asymptomatic left lacrimal gland mass found incidentally

A 60-year-old woman with an asymptomatic left lacrimal gland mass found incidentally Sudip D. Thakar, BS, Oded Sagiv, MD, Michael T. Tetzlaff, MD, PhD, Adel El-Naggar, MD, PhD, J. Matthew Debnam, MD, Thomas J. Kandl, MD, and Bita Esmaeli, MD, FACS Author affiliations: aOrbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery bDepartment of Pathology, The University of Texas MD Anderson Cancer Center, Houston cDepartment of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston dDepartment of Radiology, The University of Texas MD Anderson Cancer Center, Houston

Carotid body paraganglioma a rare tumor with serious anesthetic challenges

<zdoi;10.1097/ALN.0000000000001561> Anesthesiology, V 126 • No 6 1170 June 2017 T carotid angiogram investigating a neck mass shows a 4 × 3 cm tumor splaying the carotid bifurcation (lyre sign), typical of a carotid body paraganglioma. This rare tumor has a reported incidence of 1 to 2 per 100,000.1 Encasing the internal carotid artery (ICA) and the carotid sinus, it receives numerous branches from the external carotid artery (ECA), resulting in a dense tumor blush. A second lesion, an atheromatous plaque, is noted, causing a 70% stenosis of the ICA. From these findings, several perioperative anesthetic implications2 can be anticipated during resection. First, because a carotid body paraganglioma is a neuroendocrine tumor, release of catecholamines or association with a pheochromocytoma should be suspected. Endocrine evaluation will determine if preoperative α-blockade is needed to prevent intraoperative hypertensive crises. The tumor blush from the neoplastic vascular proliferation is indicative of an increased risk of profuse hemorrhage. Consequently, tumor biopsy is contraindicated. Preoperative tumor embolization should be considered3 and the need for rapid blood transfusion anticipated. The ICA plaque may lead to cerebrovascular accidents by obstruction of cerebral blood flow and by embolic stroke from plaque dislodgement during ICA dissection. Finally, tumor invasion may lead to carotid sinus hypersensitivity, and carotid sinus manipulation may precipitate severe bradycardia. Considering the conjunction of risks from the two problems (carotid body paraganglioma and carotid plaque) noted on this image, cardiac output monitoring, electroencephalography, and cerebral oximetry are indicated. As carotid body paraganglioma resection may result in baroreceptor and chemoreceptor dysfunction, postoperative monitoring enables detection of hemodynamic instability and abnormal response to hypoxia.

Orotracheal Intubation Using the Retromolar Space: A Reliable Alternative Intubation Approach to Prevent Dental Injury.

Despite recent advances in airway management, perianesthetic dental injury remains one of the most common anesthesia-related adverse events and cause for malpractice litigation against anesthesia providers. Recommended precautions for prevention of dental damage may not always be effective because these techniques involve contact and pressure exerted on vulnerable teeth. We describe a novel approach using the retromolar space to insert a flexible fiberscope for tracheal tube placement as a reliable method to achieve atraumatic tracheal intubation. Written consent for publication has been obtained from the patient.