Surgical resources in advanced thyroid cancer treatment with aerodigestive tract invasion.

BACKGROUND: Despite papillary thyroid cancer (PTC) excellent prognosis, 10-15% of patients may present aggressive local behaviour. We present two cases with different aerodigestive tract invasion partners in which two reconstructions were used, out of all the surgical resources we have planned preoperatively [1-4]. METHODS: Case 1: 57-year-old woman with asymmetric goitre and a 60mm nodule (Bethesda-VI). CT showed suspected involvement of aero-digestive tract. Endobronchial ultrasound (EBUS) showed no tracheal invasion. Per oral endoscopic-US confirmed transmural oesophageal involvement. Surgery included total thyroidectomy(left recurrent laryngeal nerve was sacrificed), bilateral central and left lateral lymph node dissection, oesophageal partial resection and reconstruction with free radial flap. Case 2: 75-year-old male with cervical mass and haemoptysis. US showed a 62 mm nodule (Bethesda-VI). PET-CT showed tracheal invasion(bronchoscopy confirmatory). Per oral endoscopic-US showed no transmural oesophageal involvement. Surgery included total thyroidectomy (right recurrent laryngeal nerve was sacrificed), bilateral central lymph node dissection, tracheal resection and extra-mucosal oesophageal resection. RESULTS: First patient required tracheostomy. She presented a self-limiting salivary fistula. She was discharged after 6 weeks with good oral intake and tracheostomy closed. Pathology report showed multifocal papillary thyroid cancer(tall cells, 70mm),micro-metastatic lymph node involvement. Afterwards, radioiodine ablation was performed. Six months after surgery there was no evidence of structural disease and analysis showed Tg 1 µg/L. Second patient developed nosocomial pneumonia and was discharged after 3 weeks. Pathology report showed papillary thyroid cancer (insular growth, 52 mm), bilateral neck central lymph nodes involvement, transmural tracheal infiltration, free margins. Radioiodine ablation is pending. CONCLUSIONS: Surgical treatment of advanced/invasive PTC offers good results in terms of survival and quality of life. Adequate pre-surgical planning, which includes multiple surgical resources, and a multidisciplinary team approach are required.

Extracranial Course of the Facial Nerve Revisited.

INTRODUCTION: The extrapetrous course of the facial nerve has been a matter of study and debate since XIX century. Two different classifications have been classically proposed and widely accepted by most of the authors. Nevertheless, there are reported cases which do not fit in any of those. The aim of this study is to propose a new and useful classification. MATERIAL AND METHODS: We have used 23 embalmed Caucasian adult cadavers (11 male and 12 female) belonging to the Bodies Donation and Dissecting Rooms Centre of the University Complutense of Madrid. The extra-petrous facial nerve was dissected in the possible specimens resulting in 38 facial nerves. The studied parameters were length, diameter of divisions, terminal branches, and nerve connections. RESULTS: In every specimen two main divisions were found, temporofacial and cervicofacial. They divided into five terminal branches from cranial to caudal: temporal, zygomatic, buccal, marginal or mandibular, and cervical. Based on the comparison with previous proposed classifications, we have unified the patterns in 12 types being the most frequent types the type 3 (eight cases, 21.05%), with connections between temporal, zygomatic and buccal branches and the type 8 (eight cases, 21.05%), a complex network between temporal, zygomatic, buccal, and mandibular branches. The number of terminal branches was so variable. CONCLUSION: We propose a new 12-patterned classification which summarizes the previous ones. However, we consider that a good study of the number of terminal branches, connections between branches or with other cranial nerves are more useful for surgeons to avoid injuries to the facial nerve during surgery than complex classifications. Anat Rec, 302:599-608, 2019. © 2018 Wiley Periodicals, Inc.

First Report of Pyoderma Gangrenosum after Surgery of Breast Cancer-Related Lymphedema with Transfer of Vascularized Free Lymph Nodes of the Groin and Simultaneous DIEP Flap.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare cutaneous ulcerative disease that does not respond to antibiotics and worsens with surgical manipulation. This is the first report in the literature revealing that this disease complicates total microsurgical breast reconstruction associated with the transfer of free lymph nodes. CASE REPORT: We report the case of a female patient who underwent left-breast microsurgical reconstruction with a deep inferior epigastric perforator (DIEP) flap and simultaneous transfer of vascularized free lymph nodes for the surgical treatment of secondary left upper-limb lymphedema, and who developed a severe PG of both the skin of the flap and the donor zone on postoperative day 7. After exclusion of other etiologies, treatment with high-dose corticosteroids and topical zinc sulfate was initiated. The flap was salvaged and breast cancer-related lymphedema (BCRL) surgery was definitively effective despite the PG. CONCLUSIONS: PG should be considered in the differential diagnosis of progressive cutaneous ulcers following surgical interventions, once infectious and ischemic etiologies have been excluded. Early initiation of immunosuppressive treatment can lead to preservation of the initial flap and function of the transferred lymph nodes in the case of microsurgical breast reconstruction with associated lymph node transfer.