Timothy Lian

Pharmacodynamic evaluation of temsirolimus in patients with newly diagnosed advanced-stage head and neck squamous cell carcinoma

Activation of the mammalian target of rapamycin (mTOR) pathway in surgical margins of head and neck squamous cell carcinoma (HNSCC) is a predictor of recurrence and patients with minimal residual disease may benefit from adjuvant therapy with temsirolimus, an mTOR inhibitor.

Predictive Factors for Posterior Triangle Metastasis in HNSCC

Objective: Surgical modifications sparing uninvolved structures such as the spinal accessory nerve have been implemented since the advent of the radical neck dissection in 1906. The increased morbidity to the spinal accessory nerve involved with the dissection of level V lymph nodes has led to much controversy. In this study, we examine the incidence of nodal metastasis to all nodal levels involved with upper aerodigestive squamous cell carcinoma and attempt to determine when level V dissection is indicated.

Sinonasal teratocarcinosarcoma with yolk sac elements: a neoplasm of somatic or germ cell origin?

Sinonasal teratocarcinosarcoma is an uncommon, aggressive, morphologically heterogenous tumor composed of cells derived from the 3 somatic layers. A histogenetic origin from a multipotential adult somatic stem cell with divergent differentiation has been favored over a germ cell origin. This assumption has been based on the lack of germ cell elements and, until recently, the absence of demonstrable amplification of 12p. We report a case that exhibited foci of yolk sac elements with papillary structures and intracytoplasmic periodic acid-Schiff-positive, diastase-resistant, α-fetoprotein-positive, hyaline globules. An expanded area of undifferentiated cells, likely precursor cells, in the basal layer of the overlying mucosal epithelium transitions into and merges with the immature epithelial, neuroepithelial, and mesenchymal components. These previously unreported histomorphological features support the hypothesis that this tumor is a teratomatous tumor arising from pluripotent embryonic stem cells in the basal layer of the sinonasal epithelium. That notion is further supported by fluorescence in situ hybridization cytogenetic analysis, which showed a distinct subpopulation of the tumor cells with an extra copy of chromosome 12p13.

Extracranial Infrasellar Ectopic Craniopharyngioma: A Case Report and Review of the Literature

We present a case of a purely infrasellar craniopharyngioma that initially presented as a sphenoid sinus mass. Craniopharyngiomas are usually located within the sella. Purely infrasellar craniopharyngiomas have only rarely been reported in the literature. A 25-year-old woman presented with 6-month history of progressive headaches. Initial neuroimaging revealed the presence of a sphenoid sinus mass. Initially, she underwent an endoscopic biopsy of the mass by our ENT service. Pathology was consistent with craniopharyngioma and she was referred to neurosurgery for further surgical management. She then underwent an endoscopic transsphenoidal approach for complete resection of the purely extracranial, infrasellar craniopharyngioma. The Rathke pouch arises from the roof of the primitive mouth and grows toward the brain at the fourth week of gestation. Normally, it loses its attachment with the stomadeum completely by the eighth week of gestation. The craniopharyngeal canal (CPC) extends from the floor of the sella to the vomer and may rarely give rise to ectopic craniopharyngiomas. This case shows that such ectopic tumors may arise anywhere along the CPC. Endoscopic endonasal approach provides an excellent route for the resection of these tumors.

What is the role of flap reconstruction in salvage total laryngectomy

BACKGROUND Given the results of the Department of Veterans Affairs Laryngeal Cancer Study Group investigations in the 1990s and the subsequent publication of the Radiation Therapy Oncology Group 91-11 (RTOG 91-11) study in 2003, treatment for advanced staged laryngeal carcinoma has focused on organ preservation strategies involving chemotherapy and radiation. Analysis of these studies reveals that pharyngocutaneous fistula occurred in at least 30% percent of patients undergoing salvage laryngectomy, and other series have reported even higher fistula rates after organ preservation treatment. Development of a postoperative fistula is a multifactorial process, and the surgeon’s assessment of the patient’s clinical situation could help select those patients who are at a higher risk for fistula development. Fistula development results in increased hospitalization, time before initiation of an oral diet, and use of healthcare resources. Investigators have reported decreased fistula rates following salvage laryngectomy when using flap reconstruction. In addition, patients with primary flap reconstructions that did develop fistulas healed at a faster rate than those without primary flap reconstruction. Reconstructions in these salvage laryngectomy surgeries have involved free flaps or pedicled myocutaneous flaps. This review will seek to answer the question of best practice with regard to flap reconstruction of laryngectomy defects for salvage laryngectomy following failed organ preservation treatment.

Intracerebral metastasis of a sinonasal teratocarcinosarcoma: a case report.

Sinonasal teratocarcinosarcoma (SNTCS) is a rare, malignant neoplasm that contains both mesenchymal and epithelial components. The mortality rate for this tumor is ∼60% within 3 years, with the average survival rate being 1.7 years. Usually, this neoplasm presents with symptoms of nasal obstruction and epistaxis. Neurological symptoms from intracranial extension and dural invasion are rare presentations for this neoplasm. We present the first known case of an intracerebral metastasis of a previously resected SNTCS.

The ABCs of rhinophyma management

Background Rhinophyma is a benign inflammatory growth of the nose. It usually involves the caudal one-third of the nose in men. It not only affects the patients appearance, but also can have profound functional implications. Many difficult treatment methods have been advocated, often with acceptable success. Because there appears to be no distinct advantages in the different therapeutic modalities, no one modality is universally endorsed. Methods We performed a retrospective review of patients from 1990–2001 who underwent treatment of their rhinophyma at Louisiana State University, Health Science Center and Overton Brooks Veterans Hospital in Shreveport, LA. The tumescent anesthesia, Weck blade excision and argon beam coagulator technique (TWA) was used on 51 patients. Results Patients undergoing this technique have operating times no greater than ten minutes. The average blood loss was less than 5cc. No surgical complications were noted. Conclusion The TWA technique yields good cosmetic results and is cost-effective.

Management of severe bilateral nasal wall collapse

Objective The aim of this study was to examine and analyze the pathology contributing to severe bilateral nasal wall collapse seen in certain revision rhinoplasty patients and identify those surgical maneuvers in the previous nasal surgery, which may have contributed to this complication; suggest alternatives or modifying steps in nasal surgery to prevent lateral wall collapse; analyze consecutive revision rhinoplasties and identify those patients who have complete bilateral nasal collapse at the internal nasal valve; and analyze the results achieved after surgical reconstruction of complete bilateral nasal collapse. Patients We identified 49 patients, who presented from 1990 to 2000 for revision surgery, who had bilateral collapse of the upper lateral cartilage. All patients had at least one previous rhinoplasty and all but 14 patients had undergone two or more procedures. The patients were reconstructed with a conchal cartilage graft placed through an external rhinoplasty approach. Results All patients complained of nasal obstruction with forced nasal inspiration. The collapse was visualized on inspiration and when prevented with intranasal positioning of a bayonet, all patients experienced an immediate improvement in nasal breathing. Postoperatively, all patients experienced this same improvement in their nasal airway. Collapse was not identified in any of the patients after surgery. Two patients underwent revision because of cosmetic asymmetries. Conclusion We strongly recommend a cartilage overlay to reconstitute the rigid midline continuity of the upper lateral cartilages. Unfortunately, with any significant hump removal, this structural interruption is, to varying degrees, inevitable in most rhinoplasty techniques. The upper lateral cartilages can be sutured to circumvent some of the inferior drift, but this will not reconstitute the rigid lateral cantilever effect of the intact cartilage.

Dynamics of early stem cell recruitment in skin flaps subjected to ischemia reperfusion injury

OBJECTIVE Bone marrow-derived stromal cell (BMSCs) therapy improves survival of skin flaps subject to ischemia/reperfusion (I/R) injury. However, very little is known about the trafficking and distribution of BMSCs in post-ischemic skin tissue following intravenous administration. The aim of this study was to assess the behavior of BMSCs in post-ischemic skin flaps and to compare the magnitude and kinetics of accumulation of BMSCs and leukocytes following I/R. METHODS Cutaneous flaps perfused by the inferior epigastric vessels were created in C57Bl6 mice. The flaps were subjected to 3.5h of ischemia followed by reperfusion. Wound healing and vascular perfusion were assessed in 3 groups of mice (sham, I/R, and I/R+BMSCs treatment) on days 3, 5, 7 and 14 post-reperfusion. The kinetics and magnitude of BMSCs and leukocyte recruitment were quantified in additional 2 groups (Sham and I/R) after I/R using intravital fluorescence microscopy at 2 and 4h after the intravenous injection of fluorescently labeled BMSCs. RESULTS Wound healing after I/R was significantly enhanced in skin flaps of mice treated with BMSCs, compared to controls. The rolling velocity of BMSCs was higher compared to leukocytes both in control mice (32.4±3.7μm/s vs 24.0±2.2μm/s, p<0.05) and in I/R mice (34.6±3.8μm/s vs 20.2±2.3μm/s, p<0.005). However, the rolling velocity of both cell populations was not altered by I/R. The firm adhesion and transendothelial migration of BMSCs did not differ from the values detected for leukocytes for both control and I/R mice. CONCLUSIONS The magnitude and kinetics of BMSCs recruitment in skin flaps subjected to I/R are not significantly different from the responses noted for leukocytes, suggesting that similar mechanisms may be involved in the recruitment of both cell populations following I/R.

Improved wound healing of postischemic cutaneous flaps with the use of bone marrow‐derived stem cells

To determine if the intravascular delivery of mesenchymal stem cells improves wound healing and blood perfusion to postischemic cutaneous flap tissues.