Long-Term Outcome of Differentiated Thyroid Cancer Patients-Fifty Years of Croatian Thyroid Disease Referral Centre Experience.

Background: Indolent nature but a high incidence of differentiated thyroid cancer (DTC) remains a challenge for optimizing patient care. Therefore, prognostic factors present valuable information for determining an adequate clinical approach. Methods: This study assessed prognostic features of 1167 papillary (PTC) and 215 follicular (FTC) thyroid cancer patients that had undergone surgery between 1962 and 2012, and were followed-up up to 50 years in a single institution, till April 2020. Age, gender, tumor size, presence of local and distant metastases at presentation, extrathyroidal extension, disease recurrence, and cancer-specific survival were evaluated. Results: In multivariate analysis, factors affecting the worse outcome were age (p = 0.005), tumor size (p = 0.006), and distant metastases (p = 0.001) in PTC, while extrathyroidal extension (p < 0.001), neck recurrence (p = 0.002), and distant metastases (p < 0.001) in FTC patients. Loco-regional recurrence rate was 6% for PTC and 4.7% for FTC patients, while distant metastases were detected in 4.2% PTC and 14.4% of FTC patients. The 10-year cancer-specific survival rates for PTC and FTC were 98.6% and 89.8%, respectively (p < 0.001). Conclusions: Negative prognostic factors, besides distant metastases, were older age and greater tumor size in PTC, and extrathyroidal extension and neck recurrence in FTC patients. The recurrence and mortality rates were very low.

Systemic Inflammatory Markers as Predictors of Postoperative Complications and Survival in Patients With Advanced Head and Neck Squamous Cell Carcinoma Undergoing Free-Flap Reconstruction.

PURPOSE: The aim of this study was to determine the prognostic value of systemic inflammatory indices as factors for postoperative complications and survival in patients with advanced stages of p16-negative head and neck squamous cell carcinoma undergoing free-flap reconstruction. METHODS: This was a retrospective cohort study. The primary predictor variables were inflammatory markers such as neutrophil, lymphocyte, monocyte, and platelet count, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio, lymphocyte-monocyte ratio, derived NLR, systemic immune-inflammatory index, and systemic inflammatory marker index (SIM). Multivariate regression analyses were used to measure the associations between systemic inflammatory indices and overall and disease-free survival as a primary outcome and occurrence of postoperative complications as a secondary outcome measure. RESULTS: The sample was composed of 69 male (76.67%) and 21 female (23.33%) patients, with an average age of 61.15 ± 9.79 years. The median follow-up time was 24 months, and 73 of 91 (66.43%) patients were alive during the median follow-up. Overall disease survival correlated with systemic immune-inflammation (P = .022, cutoff >1,005.3, sensitivity 67.1%, and specificity 70.6%) and SIM (P = .0001, cutoff >4.05, sensitivity 90.4%, and specificity 41.2%), preoperative platelets (P = .036, cutoff <194, sensitivity 28.8%, and specificity 94.1%), and postoperative lymphocytes (P = .012, cutoff <0.6, sensitivity 38%, and specificity 76.5%), whereas increased SIM (P = .042, cutoff >4.05, sensitivity 91.3%, and specificity 38.1%), NLR (P = .031, cutoff >13.2, sensitivity 56.9%, and specificity 60%), and preoperative platelets (P = .006, cutoff <244, sensitivity 52.3%, and specificity 76%) were associated with adverse disease-free survival. The cumulative postoperative complication rate was 34.5%, of which 13.3% accounted for major complications, whereas derived NLR (P = .013, degrees of freedom 1, χ2 test 6.161, cutoff >2.3) and postoperative lymphocytes (P = .009, DF 1, χ2 test 6.756, cutoff <1) correlated with occurrence of complications. CONCLUSIONS: Inflammatory indices as measures of inflammation-related systemic dysfunction may be associated with adverse survival in patients with head and neck squamous cell carcinoma and occurrence of postoperative complications and with specific cutoff values.

The Role of Folded Multi-Island Vertical Rectus Abdominis Myocutaneous Flap in Reconstruction of Complex Maxillectomy and Midfacial Defects.

ABSTRACT: The rationale and outcomes for reconstruction of complex maxillectomy and midfacial defects using a folded multi-island vertical rectus abdominis myocutaneous free flap (MI-VRAM) are analyzed in this study.A retrospective review of prospectively collected database was conducted on all VRAM free flaps used in head and neck reconstruction from 2013 to 2019. A total of 39 cases were identified, of which 21 patients underwent immediate VRAM flap reconstruction for complex maxillectomy and midfacial defects. Variables including age, sex, pathologic subtypes, tumor staging, type of resection, defect classification, adjuvant therapy, complications, follow-up time, and reconstructive details were collected.Single skin-island VRAM was used in 10 (47.6%) patients. Eleven (52.4%) patients required the use of folded MI-VRAM flap. In 6 (28.6%) patients a triple skin-island VRAM was used and 5 (23.8%) received a double skin-island VRAM. The average size of harvested skin paddle was 15 × 7.2 cm. Secondary flap contouring was required in 6 (28.6%) patients. There were no cases of total flap loss and no major donor site complications recorded.Folded MI-VRAM flap is a reliable method for reconstruction of complex maxillectomy and midfacial defects. It provides multiple independent skin islands with excellent plasticity and abundant volume of tissue for restoration of facial contours.

Identifying early postoperative serum parathyroid hormone levels as predictors of hypocalcaemia after total thyroidectomy: A prospective non-randomized study.

OBJECTIVE: There is no clear cut-off value of serum parathyroid hormone (PTH) or calcium in which patients are at risk for hypocalcemia after total thyroidectomy. We evaluated the usefulness of serum calcium and PTH concentration measurements after total thyroidectomy in predicting late-occurring hypocalcemia. DESIGN: A prospective, single-center, non-randomized longitudinal cohort study of 143 patients undergoing thyroidectomy between August 2019 and December 2019 with serum calcium and PTH levels sampled 1 h after surgery and on the first and fifth postoperative day. Hypocalcemia was defined as serum calcium levels < 2.14 mmol/L regardless of clinical symptoms. Normal PTH range was 1.6-6.9 pmol/L. MEASUREMENTS: The primary outcome measure was presence of hypocalcemia on the first and fifth postoperative day, analyzed by a logistic regression model. The PTH cut-off value for prediction of hypocalcemia was identified using a ROC curve comparing all three time points using the Youden J index. RESULTS: Out of 143 patients, 52 (36.4%) had hypocalcemia on the fifth postoperative day. Advanced age, concomitant neck dissection and serum PTH levels < 2.9 pmol/L 1 h after surgery and on the first postoperative surgery day were associated with a high risk of hypocalcemia on the first and fifth postoperative day and need for higher doses of calcium supplements (P < 0.0001, AUC 0.748, 95% CI 0.669-0.817, with 76.92% sensitivity and 71.43% specificity). CONCLUSION: Serum PTH level measured immediately postoperatively and on the first postoperative day is a reliable predictor of postoperative hypocalcemia with important clinical implications.

Significance of Anthropometric and Nutritive Factors in Oral and Oropharyngeal Cancer Patients Undergoing Free Flap Reconstruction.

PURPOSE: This study analyzed associations between preoperative nutritional status and the incidence of early postoperative complications as a primary outcome in patients with oral and oropharyngeal cancer undergoing free flap reconstruction. We hypothesized that preoperative nutritional status may be linked with specific complications, allowing for better preoperative risk assessment. PATIENTS AND METHODS: This longitudinal, retrospective cohort study encompassed 113 patients, all treated surgically for oral and oropharyngeal cancer in the period from March 2013 up to March 2018 in a tertiary referral center. Variables considered were preoperative and postoperative serum albumin and protein values; body mass index; waist-to-hip ratio; circumference of the neck, waist, hip, and thigh; number of cigarettes smoked per day during the 10-year period before surgery; average alcohol consumption; operative time; and postoperative albumin administration. RESULTS: Our study identified preoperative protein serum concentration (≤62 g/L), postoperative albumin administration (≥200 mL), number of cigarettes smoked per day (>20), and prolonged operative time (≥450 minutes) to be associated with postoperative complications. CONCLUSIONS: This is the first study reporting cutoff values of clinical significance in assessing patient preoperative nutritional status in light of reducing postoperative complications after free flap reconstruction.

An internal carotid artery pseudoaneurysm with neck hematoma: A rare cause of a life-threatening neck mass mimicking an abscess.

A neck mass has a broad and complex differential diagnosis, generally divided into neoplastic, congenital and inflammatory categories. An internal carotid artery hemorrhage with pseudoaneurysm formation is a very rare entity that may resemble other common conditions in the differential diagnosis. Large, expanding or symptomatic pseudoaneurysm is critical to efficiently diagnose and manage, due to risk of life-threatening hemorrhage. We present a case of an adult male patient with clinical and laboratory signs of severe neck cellulitis and a large gradually increasing neck mass, primarily suggestive of an abscess. Neck CT and MRI imaging revealed the presence of a disruption of the internal carotid artery resulting in a large hematoma and formation of pseudoaneurysm. A multidisciplinary team of interventional radiologists and ENT surgeons successfully treated the patient by endovascular placement of stents and subsequent surgical drainage. Awareness of such a rare, life-threatening condition and efficient multidisciplinary teamwork are essential for patient management.

TYPE II HYPOPHARYNGEAL DEFECT RECONSTRUCTION - A SINGLE INSTITUTION EXPERIENCE.

- There are several options for hypopharyngeal reconstruction depending on defect size. Reconstructive options include primary closure, local flaps, regional axial flaps or regional intestinal flaps, and free flap transfer with skin or intestinal free flaps. The preferred method of reconstruction should minimize early postoperative complications that prolong hospital stay and/or become life threatening, ensure early restoration of function and decrease donor site morbidity. The purpose of this study was to evaluate functional outcomes of different flap reconstruction methods in type II hypopharyngeal defects. In this non-randomized retrospective cohort study, data on 31 (27 male and four female) patients were collected over a 10-year period of single institution type II hypopharyngeal defect reconstructions. The following measures of functional outcome were extracted from patient medical histories: postoperative complications (flap failure, fistula formation, donor site related complications), hospital stay in days and swallowing function after 14 days, 1 month and 6 months. There were nine patients in the radial forearm free flap (RFFF) reconstruction group, seven in the jejunum reconstruction group, and 15 in the gastric tube reconstruction group. In the RFFF group, three patients experienced flap failure; in the jejunal transfer group, no donor site morbidity was observed; whereas three patients from the gastric tube reconstruction group had minor abdominal skin wound dehiscence. Out of the 3 different reconstructive methods, RFFF was most likely to fail. The mean duration of hospital stay was 22.6 days, being shortest in the RFFF group. There were no significant differences in early postoperative swallowing function among the groups. The choice of flap used for hypopharynx reconstruction should be driven by donor site factors and functional outcomes. When assessing type II hypopharyngeal defect reconstruction results, the findings of this study suggest that free jejunal flaps and gastric tubes offer superior functional results in comparison with RFFFs.

Cystic Shape Cemento-Ossifying Fibroma of Ethmoid Sinus.

Cemento-ossifying fibromas are a group of rarely occurring benign tumours, developing from the periodontal membrane and varying considerably in appearance and in the progress of the disease. Their common feature is higher or lower production of cemental tissue. In most cases the tumours are small because their cementoma mature quickly and become inactive, which causes the tumour to stop growing. They develop most frequently in the mandible and also in the maxilla. Other sites, such as paranasal cavities, soft tissues and bones of the head, are extremely rare. The case of a cemento-fibrosing tumour with psammoma infiltrations, developing from the ethmoid sinus in a nine-year-old girl is reported. Due to frontal headaches and sight defects as well as impaired vision on the right side, NMR was done, which showed a mucocele of the front and rear ethmoid with destruction of the orbital wall and a breakthrough into the orbit. The right maxillary sinus showed a visible retention and a thickened mucous membrane. A rhinoscopy revealed a ball-shaped spherical mass in the medial nasal meatus, which was defined as concha bullosa. An endoscopic examination showed that the tumour protruded in front of the medium nasal concha into the right nasal cavity, softened the ethmoid roof, penetrated toward the base of the skull, adhered and pushed the orbit. It was removed by FESS technique, and PHD revealed subsequently that it was not a mucocele but a cemento-ossifying fibroma.

Radiotherapy-induced hearing loss in patients with laryngeal and hypopharyngeal carcinomas.

The purpose of this study was to investigate a hypothesized correlation of development of a sensorineural hearing loss and radiotherapy in patients with laryngeal and hypopharyngeal carcinoma. This prospective study included a total of 50 patients, which after strict exclusion critera (audiologic problems before RT primary tumors of the auditory system, spread of the primary tumor to any part of the auditory system) resulted in 23 analyzed patients, ranging between 50 and 76 years of age, with a mean age of 60. Audiometry measuring frequency-specific thresholds was performed in three time points: one month before radiotherapy, one and six months after radiotherapy. A significant statistical difference in hearing tresholds after radiotherapy was found in 6 out of 23 patients. An obvious tendency towards hearing loss without statistical significance at 250 and 4000 Hz was found for a whole tested population (p < or = 0.3 with Bonferroni correction). Observed tendency towards hearing loss after radiotherapy of laryngeal carcinoma was related to side of the tumor and less severe when chemotherapy was not added as adjuvant therapy. These results should help to decrease a rate of hearing loss by careful planing of ear protection, by using observed frequencies as relevant markers of hearing loss and by reconsidering adjuvant chemoterapy during radiotherapy of laryngeal carcinoma.

Local IgE and inflammation in chronic rhinosinusitis of asthmatics and non-asthmatics.

The aim of the study was to show the difference in the pattern of inflammation, and Th1/Th2 polarization between asthmatic and non-asthmatic patients with CRS, specifically eosinophil activation, local IgE levels in the sinus fluid and tissue, and the severity of inflammation were measured. The maxillary sinus lavages, mucosal biopsies and bacteriological swabs were taken in 17 asthmatic and 36 non-asthmatic adult patients with CRS. The concentrations of IgE, eosinophil cationic protein (ECP), myeloperoxidase (MPO), and tryptase were analyzed and IgE+ cells, eosinophils, lymphocytes and plasma cells were counted. The granulocyte activation markers and IgE in sinus lavages, and the inflammatory and IgE+ cells counts were significantly higher in the asthmatics with the greatest difference in ECP and IgE concentrations. The tryptase concentrations did not differ, but only in the asthmatics they correlated significantly with the IgE concentrations and IgE+ cells count. Asthmatic patients present a distinct subgroup among the patients with chronic rhinosinusitis (CRS). The levels of the cellular markers and IgE in the sinus fluid differ from those of non-asthmatic patients with CRS. The activation of granulocytes (especially eosinophils), local IgE concentrations and the inflammatory cells infiltration are significantly higher in the asthmatics.

Histopathologic parameters as predictors of response to endoscopic sinus surgery in nonallergic patients with chronic rhinosinusitis.

OBJECTIVE: To estimate the predictable value of histopathologic parameters in chronic rhinosinusitis (CRS) for response to endoscopic sinus surgery (ESS). STUDY DESIGN: Symptomatology was rated in 100 patients prior to as well as 12 and 24 months after surgery. Specimens taken during the procedure were examined and scored for goblet cells, subepithelial thickening, mast cells, and eosinophils. Multiple regression analysis was performed to predict the total score of subjective symptoms before treatment by histopathologic parameters. The correlation between histopathologic parameters and postoperative symptoms was then evaluated. RESULTS: Goblet cells were the best predictor correlating with 5 symptoms. Subepithelial thickening correlated with 4 symptoms. Mast cell infiltration correlated with 3 symptoms. Eosinophilic infiltration correlated with only one symptom (P<0.05). CONCLUSION: Certain histopathologic parameters in CRS are predictive of favorable response to ESS. SIGNIFICANCE: Pathologic evaluation may help the ENT surgeon to predict the persistence of certain CRS symptoms after ESS, even in patients at low risk for surgical failure. EBM RATING: C-4.