Hypoglossal nerve monitoring, a potential application of intraoperative nerve monitoring in head and neck surgery.

BACKGROUND: Intraoperative nerve monitoring (IONM) has many applications in different surgical fields. In head and neck surgery, IONM has been used to perform surgery of the parotid, thyroid and parathyroid glands, preserving the facial and recurrent nerves. However, hypoglossal nerve neuromonitoring has not been addressed with such relevance. MATERIAL AND METHODS: A retrospective review of surgeries performed on patients with special tongue and floor of mouth conditions was undertaken to examine the indications that prompted its use. Particular attention was given to the pathology, intraoperative findings and the final outcome of each patient. RESULTS: Four patients, aged between 6 years and 68 years, with complex oral tongue and floor of mouth lesions were reviewed. Three patients were male, aged 22 years and younger, and two of these patients had oral tongue cancers with previous surgery. Oral tongue and neck conditions are challenging since the functions of the hypoglossal nerve are put at risk. The use of IONM technology allowed us to preserve nerve functions, speech and swallowing. CONCLUSIONS: Although IONM of the hypoglossal nerve is not a common indication in tongue and floor of mouth lesions, under special conditions its application can be extrapolated to challenging surgical cases, like the ones described.

Understanding the Role of Human Papillomavirus in Head and Neck Cancer of Unknown Primary: A Systematic Review.

This systematic review aims to provide a comprehensive understanding of the role of human papillomavirus (HPV) in head and neck cancer of unknown primary (HNCUP). HNCUP is a rare type of cancer with an unknown primary site, which makes it difficult to diagnose and treat. The review includes articles published between 2013 and 2023 that investigated the prevalence of HPV in HNCUP, its association with clinical outcomes, and its potential implications for diagnosis and treatment. The search was conducted in 11 electronic databases, and the gray literature: Cochrane, Cumed, IBECS, JAMA Network, LILACS, MEDLINE Ovid, MEDLINE-EBSCO, PubMed, Scopus, SciELO, and Taylor & Francis Online; a total of 23 studies met the inclusion criteria. The review found that HPV is present in a significant proportion of HNCUP cases, ranging from 15.5% to 100%. HNCUP incidence is increasing, and the presence of HPV was associated with improved clinical outcomes in some studies, such as overall survival and disease-free survival; but was found to have no association with outcomes in others. This may have implications for diagnostic and treatment strategies. The findings of this review suggest that further research is needed to better understand the role of HPV in HNCUP and to develop targeted therapies for this disease.

Facial nerve monitoring in parotid gland surgery: Design and feasibility assessment of a potential standardized technique.

Background: Even though the use of nerve monitoring during parotid gland surgery is not the gold standard to prevent damage to the nerve, it surely offers some advantages over the traditional approach. Different from thyroid surgery, where a series of steps in intraoperative nerve monitoring have been described to confirm not only the integrity but-most importantly-the function of the recurrent laryngeal nerve, in parotid gland surgery, a formal guideline to follow while dissecting the facial nerve has yet to be described. Methods: A five-year retrospective study was done reviewing the intraoperative records of patients who underwent parotid gland surgery under neural monitoring. The operative findings regarding the neuromonitoring process, particularly in regard to the amplitude of two main branches, were revised. A literature search was done to search for guidelines to follow when a facial nerve loss of signal is encountered. Results: Fifty-five patients were operated on using the Nim 3 Nerve Monitoring System (Medtronic); 31 were female patients, and 47 patients had benign lesions. Minimum changes were observed in the amplitude records after a comparison was made between the first and the last stimulation. There were only three articles discussing the term loss of signal during parotid gland surgery. Conclusion: Today, no sufficient attention has been given to the facial nerve monitoring process during parotidectomy. This study proposes a formal guideline to follow during this procedure as well as an instruction to consider when a loss of signal is observed to develop a uniform technique of facial nerve stimulation.

Molecular profiling of papillary thyroid carcinomas in healthcare workers exposed to low dose radiation at the workplace.

PURPOSE: Exposure to ionizing radiation, especially during childhood, is a well-established risk factor for thyroid cancer. The vast majority of radiation-induced cancers are papillary carcinomas (PTCs). These tumors typically have gene fusions in contrast to point mutations prevalent in sporadic PTCs. The aim of this study was to investigate the molecular profiles of PTC patients with workplace exposure to ionizing radiation. METHODS: A retrospective review of 543 patients who underwent surgery with diagnosis of PTC was performed. A cohort of nine healthcare specialists previously exposed to radiation sources during their professional practice was selected and analyzed using the ThyroSeq mutation panel for point mutations and gene fusions associated with thyroid cancer. RESULTS: The molecular analysis of surgical samples of PTCs was informative and revealed genetic alterations in five patients. BRAF V600E was found in four (67%) cases whereas RET/PTC1 fusion in one (17%) and one sample (17%) was wild type for point mutations and fusions. One sample completely failed molecular analysis while two others were negative for genes fusions but failed DNA analysis; these three samples were excluded. CONCLUSIONS: In this limited cohort of healthcare workers exposed to low dose of ionizing radiation at the workplace and developed PTC, the molecular profiling determined BRAF V600E point mutation as the most common event, arguing against the role of workplace radiation exposure in the etiology of these tumors.

BRAF and TERT mutations in papillary thyroid cancer patients of Latino ancestry.

Papillary thyroid cancer (PTC) is the second most commonly diagnosed malignancy in U.S. Latinas and in Colombian women. Studies in non-Latinos indicate that BRAF and TERT mutations are PTC prognostic markers. This study aimed to determine the prevalence and clinical associations of BRAF and TERT mutations in PTC Latino patients from Colombia. We analyzed mutations of BRAF (V600E) and TERT promoter (C228T, C250T) in tumor DNA from 141 patients (75 with classical variant PTC, CVPTC; 66 with follicular variant PTC, FVPTC) recruited through a multi-center study. Associations between mutations and clinical variables were evaluated with Fisher exact tests. Survival was evaluated with Kaplan-Meier plots. Double-mutant tumors (BRAF+/TERT+, n = 14 patients) were more common in CVPTC (P = 0.02). Relative to patients without mutations (n = 48), double mutations were more common in patients with large tumors (P = 0.03), lymph node metastasis (P = 0.01), extra-thyroid extension (P = 0.03), and advanced stage (P = 6.0 × 10-5). In older patients, TERT mutations were more frequent (mean age 51 years vs 45 years for wild type TERT, P = 0.04) and survival was lower (HR = 1.20; P = 0.017); however, given the small sample size, the decrease in survival was not statically significant between genotypes. Comparisons with published data in US whites revealed that Colombian patients had a higher prevalence of severe pathological features and of double-mutant tumors (10 vs 6%, P = 0.001). Mutations in both oncogenes show prognostic associations in Latinos from Colombia. Our study is important to advance Latino PTC precision medicine and replicates previous prognostic associations between BRAF and TERT in this population.

Use of intraoperative ultrasound for localizing difficult parapharyngeal space abscesses in children.

While treatment of parapharyngeal and deep-space neck abscesses has progressed rapidly due to improvements in diagnostic imaging and medical therapy, surgical drainage remains the mainstay of treatment for larger and medically unresponsive abscesses. In many cases the intricate and delicate anatomy in children represents a challenging situation for the surgeon, particularly if he or she is not experienced in the care of the pediatric population. We present a novel idea used in the surgical management of parapharyngeal space abscesses in three children less that 6 years of age, in whom intraoperative ultrasound was used as an additional tool to locate and successfully drain the abscess.

Chyle fistula in advanced and metastatic thyroid cancer.

BACKGROUND: Chyle fistula (CF) is a rare but challenging condition for the surgeon and the patient's health. METHODS: A retrospective review of single surgeon's case load in a 12-year period is presented, reviewing the case of those patients presenting with a CF. RESULTS: Three patients were found during this study period from more than 1,050 surgeries performed due to thyroid cancer. Patients underwent extensive lymph node dissection for advanced, metastatic and infiltrative disease. In all patients, a long hospital stay and surgical re-interventions were required. CONCLUSIONS: A description of the management of CF is presented along with a review of current Literature.

Phrenic nerve stimulation during neck dissection for advanced thyroid cancer involving level IV: is it worth doing it?

During thyroidectomy and neck dissection surgery for advanced or recurrent metastatic thyroid cancer under intraoperative monitoring, we used the available technology to assess the feasibility of such an intervention to monitor those patients with phrenic nerves at risk. A retrospective review of patients operated on from January 2009 to December 2015 by a single surgeon (CSD) was conducted. Patients who had neck and mediastinal dissection, with or without total thyroidectomy, due to advanced or recurrent metastatic disease to the neck were selected. The procedures were done under intraoperative nerve monitoring using nerve monitoring systems (NIM 2.0 or 3.0; Medtronic, Jacksonville, FL, USA). A total of 19 patients were included in the study, with a mean age of 57.6 years ± 16.3 and a male/female ratio of 10:9. Overall, all patients had an intact phrenic nerve at the conclusion of the surgery. One patient had an aggressive tumor that precluded sacrifice of the left recurrent laryngeal nerve and ipsilateral thoracic duct. The procedure was complicated by a temporary impairment of the diaphragm contraction with intraoperative nerve monitoring as well as a chyle fistula. This was due to the manipulation of the tissue surrounding the phrenic nerve. Intraoperative nerve monitoring of the phrenic nerve offers the surgeon a "potential" method of ensuring phrenic nerve integrity in cases of advanced thyroid cancers with gross level IV metastatic disease. Further prospective studies are needed to assess the risks of this intervention and evaluate the method of recording diaphragm contraction movement.

The HABP2 G534E polymorphism does not increase nonmedullary thyroid cancer risk in Hispanics.

Familial nonmedullary thyroid cancer (NMTC) has not been clearly linked to causal germline variants, despite the large role that genetic factors play in risk. Recently, HABP2 G534E (rs7080536A) has been implicated as a causal variant in NMTC. We have previously shown that the HABP2 G534E variant is not associated with TC risk in patients from the British Isles. Hispanics are the largest and the youngest minority in the United States and NMTC is now the second most common malignancy in women from this population. In order to determine if the HABP2 G534E variant played a role in NMTC risk among Hispanic populations, we analyzed 281 cases and 1105 population-matched controls from a multicenter study in Colombia, evaluating the association through logistic regression. We found that the HABP2 G534E variant was not significantly associated with NMTC risk (P=0.843) in this Hispanic group. We also stratified available clinical data by multiple available clinicopathological variables and further analyzed the effect of HABP2 on NMTC presentation. However, we failed to detect associations between HABP2 G534E and NMTC risk, regardless of disease presentation (P≥0.273 for all cases). Therefore, without any significant associations between the HABP2 G534E variant and NMTC risk, we conclude that the variant is not causal of NMTC in this Hispanic population.

Clinical features of Hispanic thyroid cancer cases and the role of known genetic variants on disease risk.

Thyroid cancer (TC) is the second most common cancer among Hispanic women. Recent genome-wide association (GWA) and candidate studies identified 6 single nucleotide polymorphisms (SNPs; rs966423, rs2439302, rs965513, rs6983267, rs944289, and rs116909374), associated with increased TC risk in Europeans but their effects on disease risk have not been comprehensively tested in Hispanics. In this study, we aimed to describe the main clinicopathological manifestations and to evaluate the effects of known SNPs on TC risk and on clinicopathological manifestations in a Hispanic population.We analyzed 281 nonmedullary TC cases and 1146 cancer-free controls recruited in a multicenter population-based study in Colombia. SNPs were genotyped by Kompetitive allele specific polymerase chain reaction (KASP) technique. Association between genetic variants and TC risk was assessed by computing odds ratios (OR) and confidence intervals (CIs).Consistent with published data in U.S. Hispanics, our cases had a high prevalence of large tumors (>2 cm, 43%) and a high female/male ratio (5:1). We detected significant associations between TC risk and rs965513A (OR = 1.41), rs944289T (OR = 1.26), rs116909374A (OR = 1.96), rs2439302G (OR = 1.19), and rs6983267G (OR = 1.18). Cases carried more risk alleles than controls (5.16 vs. 4.78, P = 4.8 × 10). Individuals with ≥6 risk alleles had >6-fold increased TC risk (OR = 6.33, P = 4.0 × 10) compared to individuals with ≤2 risk alleles. rs944289T and rs116909374A were strongly associated with follicular histology (ORs = 1.61 and 3.33, respectively); rs2439302G with large tumors (OR = 1.50); and rs965513A with regional disease (OR = 1.92).To our knowledge, this is the first study of known TC risk variants in South American Hispanics and suggests that they increase TC susceptibility in this population and can identify patients at higher risk of severe disease.

Efficacy of perioperative thromboprophylactic agents in the maintenance of anastamotic patency and survival of rat microvascular free groin flaps.

OBJECTIVES: We sought to determine the thromboprophylactic effects of low-molecular-weight heparin (LMWH) and pentoxifylline. DESIGN: Randomized blinded study. Materials and methods Sixty Sprague-Dawley rats were assigned to 1 of 4 treatment groups: (1) control group (n = 15), (2) pentoxifylline group (n = 15), (3) LMWH group (n = 15), and (4) combined therapy group (n = 15). A groin/abdominal free flap was elevated in each, with division of the artery and microvascular repair The animals received therapy for 4 days preoperatively and 6 days postoperatively. Flaps were monitored visually, and on the seventh postoperative day, the flap was elevated, and the microvascular anastomosis was assessed for patency. RESULTS: There was a statistically significant improvement in arterial patency in both pentoxifylline and LMWH groups compared with controls (P < 0.01) but no significant improvement with combined therapy (P > 0.05). CONCLUSIONS: In this animal model, LMWH and pentoxifylline have significant thrombroprophylactic effects when used individually but not in combination.

Melanoma metastásico a la glándula tiroides: reporte de dos casos / Metastatic thyroid melanoma: report of two cases

Las metástasis por melanoma a la glándula tiroides son raras, su presentación representa para elpaciente un pésimo pronóstico, dado que indica enfermedad diseminada terminal. El proceso de diagnóstico no difiere al usual para toda masa tiroidea y su tratamiento final depende del estado del paciente y de lo avanzado de la enfermedad. En el presente artículo presentamos dos casos de melanomametastásico a la tiroides.

Metastatic melanoma to the thyroid gland are rare, their presence on a patient represents bad prognosisas it indicates disseminated terminal disease. The diagnostic process is similar to all thyroid masses and its final treatment depends on the patient´s status and how disseminated the disease is. In the present article we describe two cases of metastatic thyroid melanoma.