Lymphatic drainage patterns of head and neck cutaneous melanoma: does primary melanoma site correlate with anatomic distribution of pathologically involved lymph nodes?

The aim of this study was to analyse patterns of metastatic spread from cutaneous head and neck melanoma, which are said to be highly variable. The medical records of 145 patients with pathologically proven metastatic melanoma were reviewed retrospectively. The location of pathologically positive lymph nodes was compared with clinically predicted spread, and patients with metastatic disease in areas outside of predicted drainage patterns were considered aberrant. There were 33 curative and 73 elective neck dissections. 21 of 77 patients undergoing parotidectomy had positive results for metastases. Clinical prediction proved to be correct in 33 of 45 cases (73.3%). Two patients with lateralized melanomas were initially seen with contralateral metastases. Six of 45 patients (13.3%) developed contralateral metastases after neck dissection. Patients with clinical involvement of the parotid gland were at high risk of occult neck disease (40%). Patients undergoing neck dissection for primaries originating in face, forehead, coronal scalp, periauricular area, and upper neck should be considered for parotidectomy. Patients with posterior scalp and posterior neck primaries should be considered for selective neck dissection in conjunction with posterior lymphadenectomy. In patients with coronal scalp and periauricular primaries, a complete neck dissection including parotidectomy is the recommended approach

Functional radical cervical dissection for differentiated thyroid cancer: the experience of a single center

There is ongoing debate regarding the role of neck dissection in differentiated thyroid cancer, about its usefulness in elective settings, and the increased costs regarding morbidity and operative time. This retrospective study aimed to determine the rate of metastases in cervical lymph nodes, to examine the morbidity of this surgery, and to assess whether a pattern of distribution of tumor cells concerning neck lymphatic compartments exists. The most frequent type of cancer to metastasize was papillary cancer, the majority of patients were young with a median of 30 years, predominantly females. Differentiated thyroid cancer frequently metastasizes to the central and lateral compartments of the neck. The morbidity is minimal in a high-volume center. Radical neck dissection is safe and feasible in selected patients with confirmed invaded or enlarged lymph nodes due to differentiated thyroid cancer, and postoperative complications are minimal if the anatomy is correctly identified and the cases strictly selected

Is elective neck dissection necessary in cases of laryngeal recurrence after previous radiotherapy for early glottic cancer?

To assess the clinical utility of elective neck dissection in node-negative recurrent laryngeal carcinoma after curative radiotherapy for initial early glottic cancer.A retrospective review was undertaken of 110 consecutive early glottic cancer patients who developed laryngeal recurrence after radiotherapy (34 recurrent T1, 36 recurrent T2, 29 recurrent T3 and 11 recurrent T4a) and received salvage laryngeal surgery between 1995 and 2005.Six patients presented with laryngeal and neck recurrence and underwent salvage laryngectomy with therapeutic neck dissection, 97 patients with recurrent node-negative tumours underwent salvage laryngeal surgery without neck dissection and only 7 underwent elective neck dissection. No occult positive lymph nodes were documented in neck dissection specimens. During follow up, only three patients with neck failure were recorded, all in the group without neck dissection. There was no significant association between the irradiation field (larynx plus neck vs larynx) and the development of regional failure. A higher rate of post-operative pharyngocutaneous fistula development occurred in the neck dissection group than in the group without neck dissection (57.2 per cent vs. 13.4 per cent, p = 0.01). Multivariate logistic regression analysis showed that early (recurrent tumour-positive, node-positive) or delayed (recurrent tumour-positive, node-negative) neck relapse was not significantly related to the stage of the initial tumour or the recurrent tumour. An age of less than 60 years was significantly associated with early neck failure (recurrent tumour-positive, node-positive).Owing to the low occult neck disease rate and high post-operative fistula rate, elective neck dissection is not recommended for recurrent node-negative laryngeal tumours after radiation therapy if the initial tumour was an early glottic cancer

Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment.

BACKGROUND: Surgery is an important part of the management of oral cavity cancer with regard to both the removal of the primary tumour and removal of lymph nodes in the neck. Surgery is less frequently used in oropharyngeal cancer. Surgery alone may be treatment for early stage disease or surgery may be used in combination with radiotherapy, chemotherapy and immunotherapy/biotherapy. There is variation in the recommended timing and extent of surgery in the overall treatment regimens of people with these cancers. OBJECTIVES: To determine which surgical treatment modalities for oral cavity and oropharyngeal cancers result in increased overall survival, disease free survival, progression free survival and reduced recurrence. SEARCH STRATEGY: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 17 February 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 17 February 2011) and EMBASE via OVID (1980 to 17 February 2011). There were no restrictions regarding language or date of publication. SELECTION CRITERIA: Randomised controlled trials where more than 50% of participants had primary tumours of the oral cavity or oropharynx, and which compared two or more surgical treatment modalities or surgery versus other treatment modalities. DATA COLLECTION AND ANALYSIS: Data extraction and assessment of risk of bias was undertaken independently by two or more review authors. Study authors were contacted for additional information as required. Adverse events data were collected from published trials. MAIN RESULTS: Seven trials (n = 669; 667 with cancers of the oral cavity) satisfied the inclusion criteria, but none were assessed as low risk of bias. Trials were grouped into three main comparisons. Four trials compared elective neck dissection (ND) with therapeutic neck dissection in patients with oral cavity cancer and clinically negative neck nodes, but differences in type of surgery and duration of follow-up made meta-analysis inappropriate. Three of these trials reported overall and disease free survival. One trial showed a benefit for elective supraomohyoid neck dissection compared to therapeutic ND in overall and disease free survival. Two trials found no difference between elective radical ND and therapeutic ND for the outcomes of overall survival and disease free survival. All four trials found reduced locoregional recurrence following elective ND.A further two trials compared elective radical ND with elective selective ND and found no difference in overall survival, disease free survival or recurrence. The final trial compared surgery plus radiotherapy to radiotherapy alone but data were unreliable because the trial stopped early and there were multiple protocol violations.None of the trials reported quality of life as an outcome. Two trials, evaluating different comparisons reported adverse effects of treatment. AUTHORS' CONCLUSIONS: Seven included trials evaluated neck dissection surgery in patients with oral cavity cancers. The review found weak evidence that elective neck dissection of clinically negative neck nodes at the time of removal of the primary tumour results in reduced locoregional recurrence, but there is insufficient evidence to conclude that elective neck dissection increases overall survival or disease free survival compared to therapeutic neck dissection. There is very weak evidence from one trial that elective supraomohyoid neck dissection may be associated with increased overall and disease free survival. There is no evidence that radical neck dissection increases overall survival compared to conservative neck dissection surgery. Reporting of adverse events in all trials was poor and it was not possible to compare the quality of life of patients undergoing different surgeries

Head and neck squamous cell carcinoma of unknown primary: Neck dissection and radiotherapy or definitive radiotherapy

Background Management of head and neck carcinoma from unknown primary (HNCUP) remains controversial, with neck dissection and radiotherapy (RT) or definitive RT both commonly used. The purpose of this study was to characterize HNCUP and retrospectively compare outcomes for patients treated with neck dissection + RT versus definitive RT. Methods From 1994 to 2009, 41 patients with HNCUP underwent either neck dissection + RT ( n  = 22) or definitive RT ± concurrent chemotherapy ( n  = 19) at our institution. Treatment outcomes were compared using Kaplan–Meier methods and log‐rank test. Results There were no differences between patients treated with neck dissection + RT and definitive RT in overall survival (OS), progression‐free survival (PFS), locoregional relapse‐free survival (LRFS), freedom from locoregional failure (FFLRG), or freedom from distant failure (FFDF). Among 17 patients who underwent neck dissection + RT for whom human papillomavirus (HPV) status could be determined, HPV(+) patients trended toward improved OS ( p  = .06) and PFS ( p  = .15). Conclusion Neck dissection and postoperative RT resulted in similar outcomes as definitive RT. The prognostic implications of HPV(+) nodes in HNCUP are similar to those in oropharyngeal primary cancers. © 2013 Wiley Periodicals, Inc. Head Neck 36: 1589–1595, 2014Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109313/1/hed23479.pd

NECK DISSECTIONS: MISCONCEPTIONS, MALPRACTICE AND COMMON CONTROVERSIES

B a c k g ro u n d. Neck metastases are the single most important prognostic factor in Head and Neck Squamous Cell Carcinoma. Wise approach to neck treatment is then mandatory to give a chanche for cure. Still, there are some issues about neck dissection that need to be clarified. M e t h o d s. Through a review of the literature and of everyday clinical observations, the following issues are discussed: Functional Neck Dissection, biopsies, nodal levels, Selective Neck Dissections, Spinal Accessory Nerve, neck dissection classification. R e s u l t s. Integration of historical, anatomical, clinical and surgical concepts and up-to-date knowledge can allow to understand how to behave in diverse clinical situations. Conclusions. Standardized guidelines are far to be achieved. Wise behaviour, however, may allow to avoid some mistakes. The aim of this paper is to make the above mentioned issues clear and hopefully give more diffusion to concepts that too often seem to be overlooked

Neck involvement in early carcinoma of tongue. Is elective neck dissection warranted?

Objective: To evaluate need of elective neck dissection in patients with early oral tongue cancer, and to see the pattern of involvement of different lymph node levels. Methods: Ninety four patients with T1-T2, N0 squamous cell carcinoma of the oral tongue were treated with a partial glossectomy and an elective modified radical neck dissection. Results: Thirty two patients had T1 and 62 patients had T2 lesion. In patients with T1 carcinoma, 9 out of 32 had metastases (28%), whereas in patients with T2 carcinoma, 21 out of 62 showed metastases(34%).Thus, the overall rate of occult lymph node metastases was high(32%).In our study skip metastases to level III was seen in only in 2 patients (6%) but there was no skip metastases seen involving level IV or V. Conclusion: The overall micrometastases rate in our patients (32%) warrants elective neck dissection in early cases also. The incidence of metastases to level IV and V from T1-T2 oral tongue cancer is low so these lymph nodes should be removed only when there is intraoperative suspicion of extensive metastases in levels I,II or III.,otherwise supraomohyoid neck dissection is sufficien

The pros and cons of routine central compartment neck dissection for clinically nodal negative (cN0) papillary thyroid cancer

Metastatic disease to regional lymph nodes (LNs) is common in papillary thyroid carcinoma (PTC). LN dissection is increasingly performed as part of the surgical management of PTC. The role of prophylactic central neck dissection (pCND) in PTC is unclear. There is limited evidence to support a routine pCND in clinical setting for nodal negative (cN0) PTC. The aim of this review was to examine the pros and cons of prophylactic neck dissection in cN0 PTC. In summary, the advantages of pCND are: removal of the central LNs that potentially harbor micro-metastases, more accurate staging of disease in order to plan more individualized management, reducing the need for re-operation to remove the metastatic LNs which have developed later and possible improvement in overall survival. The disadvantages are: an extensive surgery but lack of evidence of survival benefit, higher incidence of complications with little impact on local recurrence rate, possibility of over treating in cN0 patients and it does not sound like a cost effective approach in the management of small thyroid cancer. Considering low frequency of permanent morbidity, some authors believe that prophylactic neck dissection is safe in experienced hands even though its prognostic benefit has yet to be demonstrated.published_or_final_versio

Gastric pseudoaneurysm in the setting of Loey’s Dietz Syndrome

Loey’s Dietz syndrome is a disorder of connective tissue caused by a mutation in the genes that encode transforming growth factor (TGF) beta receptor 1 and 2. It is an autosomal dominant disorder similar to Marfan’s syndrome but with a more aggressive clinical course. Patients with Loey’s-Dietz syndrome have progressive dilatation of the aortic root that can lead to aortic dissection and rupture. The location of non-aortic arterial aneurysms may be wide spread but often occur in the head and neck vessels.peer-reviewe

Holmium Laser Enucleation of the Prostate

Introduction: Holmium laser enucleation of the prostate (HoLEP) offers superior voiding outcomes to traditional transurethral resection and less morbidity than open simple prostatectomy. Likewise, HoLEP has been determined to result in excellent outcomes regardless of gland size. We present a step-by-step surgical approach to HoLEP describing both the traditional enucleation technique and a modified “top-down” surgical technique. Materials and Methods: In this video, two techniques are presented that were performed by two (A.E.K., J.E.L.) surgeons at our institution. Results: In the examples of the two enucleation techniques mentioned, outcomes are similar with regard to surgical and functional outcomes. Conclusions: HoLEP as a treatment for BPH with associated lower urinary tract symptoms (LUTS) results in excellent patient outcomes and can be offered to patients regardless of prostate volume