Axillary nodal metastasis at primary presentation of an oropharyngeal primary carcinoma: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Axillary nodal metastasis is very rare in head and neck squamous cell carcinoma. The few cases reported in the literature all involve patients who have previously undergone either neck dissection alone, or neck dissection and radiotherapy to the neck, and subsequently develop delayed recurrences of disease, with axillary nodal involvement.</p> <p>Case presentation</p> <p>We present the case of a 62-year-old man of Cape Malay ethnicity, who presented with an oropharyngeal squamous cell carcinoma, and cervical and axillary nodal metastasis at primary presentation.</p> <p>Conclusion</p> <p>Whilst previous reports in the literature suggest routine examination of the axilla is advisable in patients with previously treated neck cancer and recurrence of head and neck cancer, we propose that the axilla should be routinely examined in new cases, particularly when there is involvement of the level 5 nodes.</p

Diagnosis and staging of laryngopharyngeal tumours with flexible endoscopy: A prospective study

Background: Many suspected laryngopharyngeal neoplasms are examination under general anaesthesia (EUA). Office-based endoscopy is already routinely performed on all patients presenting with a suspected laryngopharyngeal neoplasm. Accurate clinical staging and tissue sampling using flexible endoscopy may eliminate the need for EUA. Aim: To compare the use of flexible endoscopy to EUA as primary diagnostic tool of laryngopharyngeal lesions to EUA, using accuracy of tissue samples obtained and clinical staging as primary outcome measures. Duration, patient tolerance and cost implications were also assessed. Setting: The study was performed in the outpatient department and surgical theatres of Tygerberg Hospital, Cape Town, South Africa. Methods: A prospective study compared staging and tissue sampling accuracy with flexible endoscopy to EUA in 54 patients. Duration, tolerance and cost implications were also assessed. Results: Flexible endoscopic biopsy had a 77.1% sensitivity, 100% specificity and 82.2% diagnostic accuracy. Liquid-based cytology had 97.3% sensitivity, 100% specificity and 97.9% diagnostic accuracy in differentiating high-grade lesions from low-grade lesions. Local staging agreement occurred in 88.6% (n = 31/35) of malignant cases. The mean duration was 15 ± 7 min; 86% of patients perceived the procedure as tolerable. Flexible endoscopy as a primary diagnostic tool would have avoided EUA in 68.6% (n = 24/35) of squamous cell carcinoma cases, with a R128 232 cost savings. Conclusion: Office-based endoscopy is an accurate, well-tolerated, time- and cost-effective primary diagnostic tool of laryngopharyngeal lesions. It reduces the number of patients requiring EUA. Further evaluation is empirical when the histopathology does not confirm the clinical suspicion of malignancy

Interactive Simulation of Surgical Needle Insertion and Steering

We present algorithms for simulating and visualizing the insertion and steering of needles through deformable tissues for surgical training and planning. Needle insertion is an essential component of many clinical procedures such as biopsies, injections, neurosurgery, and brachytherapy cancer treatment. The success of these procedures depends on accurate guidance of the needle tip to a clinical target while avoiding vital tissues. Needle insertion deforms body tissues, making accurate placement difficult. Our interactive needle insertion simulator models the coupling between a steerable needle and deformable tissue. We introduce (1) a novel algorithm for local remeshing that quickly enforces the conformity of a tetrahedral mesh to a curvilinear needle path, enabling accurate computation of contact forces, (2) an efficient method for coupling a 3D finite element simulation with a 1D inextensible rod with stick-slip friction, and (3) optimizations that reduce the computation time for physically based simulations. We can realistically and interactively simulate needle insertion into a prostate mesh of 13,375 tetrahedra and 2,763 vertices at a 25 Hz frame rate on an 8-core 3.0 GHz Intel Xeon PC. The simulation models prostate brachytherapy with needles of varying stiffness, steering needles around obstacles, and supports motion planning for robotic needle insertion. We evaluate the accuracy of the simulation by comparing against real-world experiments in which flexible, steerable needles were inserted into gel tissue phantoms

Aromatic Amino Acid Metabolism during Liver Failure

Liver failure is associated with hepatic encephalopathy (HE). An imbalance in plasma levels of aromatic amino acids (AAA) phenylalanine, tyrosine, and tryptophan and branched chain amino acids (BCAA) and their BCAA/AAA ratio has been suggested to play a causal role in HE by enhanced brain AAA uptake and subsequently disturbed neurotransmission. Until recently, data on this subject and the role of the liver and splanchnic bed were scarce, particularly in humans, due to inaccessibility of portal and hepatic veins. Here, we discuss, against a background of relevant literature, data obtained in patients undergoing liver resection or with a transjugular intrahepatic portasystemic stent shunt (TIPSS), where these veins are accessible. The BCAA/AAA ratio remained unchanged after major liver resection, but plasma AAA levels were inversely correlated (P < 0.001) with residual liver volume, in keeping with the observed hepatic AAA uptake. In patients with stable cirrhosis and a TIPSS, the plasma BCAA/AAA ratio was lower than in controls (1.19 +/- 0.09 vs. controls: 3.63 +/- 0.34). Gastrointestinal bleeding in cirrhotics with a TIPSS induced disturbances in BCAA levels and the BCAA/AAA ratio and induced catabolism, which could partly be corrected by isoleucine administration. AAA may be important in the pathogenesis of HE, but it is unlikely that they are the sole factors. HE most likely is a syndrome with multifactorial pathogenesis, where hyperammonemia, AAA/BCAA imbalances, inflammation, brain edema, and neurotransmitter changes interact. Novel therapies to normalize AAA levels in patients with liver failure (such as the molecular adsorbent recirculating system dialysis device) should probably be combined with supplementation of e.g. isoleucine and enhancing ammonia excretion by the kidneys