Synchronous appearance of germ cell tumor and papillary carcinoma of the thyroid.

Synchronous appearance of 2 different malignancies in one patient is a rare phenomenon. We describe our experience of 2 patients with synchronous malignancies of the testis and thyroid gland, and of a third patient who developed a thyroid neoplasm unrelated to recent treatment for a germ cell tumor. The medical records of 3 male patients treated for both a germ cell tumor and a thyroid cancer between 1989 and 1994 were reviewed. Two patients with nonseminomatous germ cell tumor received postoperative chemotherapy after orchiectomy and developed a papillary carcinoma of the thyroid during treatment. A third patient, who received radiation therapy for a clinical stage 1 seminoma, recurred with biopsy proven seminoma in the neck in association with a thyroid nodule 2 years later. All 3 patients had their thyroid cancer treated by surgical resection, and one received adjuvant radioactive iodine. Two of the patients are currently alive and disease-free. One patient died of pulmonary complications that stemmed from bleomycin toxicity. Synchronous appearance of germ cell tumor and papillary carcinoma of the thyroid has not been previously described. Genetic predisposition may play a role in the development of such simultaneous neoplasms.

Wound infection in head and neck surgery: implications for perioperative antibiotic treatment.

Perioperative antibiotic treatment significantly reduces the risk of postoperative wound infection and is cost-effective in clean-contaminated head and neck operations. A clear consensus on the most suitable single agent or combination is, however, lacking. Most surgical wound infections involve both gram-positive and gram-negative aerobes and anaerobes; some organisms may exhibit antibiotic resistance through beta-lactamase production. Comparative trials have indicated that combinations with both aerobic and anaerobic activity provide protection superior to that achieved with single agents active against only aerobic pathogens. Recent results suggest that the beta-lactam/beta-lactamase-inhibitor combination ampicillin/sulbactam is cost-effective for perioperative treatment of patients undergoing head and neck surgery.

A model for predicting transfusion requirements in head and neck surgery.

INTRODUCTION: Although allogeneic blood transfusions have allowed surgeons increased latitude in resecting advanced cancers, they can cause significant morbidity or even death in rare instances. Potential side effects may include transmission of infection and immunosuppression leading to an increased risk of cancer recurrence. Because patients have become more reluctant to receive transfusions, they frequently request preoperative autologous blood donation (PABD). In practice, however, only 50% or less of the donated blood is ultimately transfused while the remainder is discarded. PURPOSE: The purpose of this study was to develop a transfusion prediction and risk assessment (TPRA) model for predicting the need for perioperative blood transfusions in patients undergoing major head and neck oncologic surgical procedures. By knowing the probability for blood transfusion, the physician and patient can make an educated decision regarding the need for PABD. PATIENTS AND METHODS: Over a 4-year period, 436 patients underwent major head and neck surgical procedures for neoplasms of the upper aerodigestive tract, the thyroid gland, and the salivary glands. Data obtained prospectively on each patient included age and gender, the TNM stage, primary disease site, type of prior treatment, estimated intraoperative blood loss, duration of surgery, transfusion requirements, preoperative and postoperative hemoglobin and hematocrit levels, type of procedure and method of reconstruction. These variables were examined singly and in combination both for descriptive purposes and to evaluate their interrelationships. In order to develop the TPRA model, only the 12 variables available prior to the surgical procedure were examined. Variables associated with transfusion need were evaluated further in a multivariate analysis. The logistic regression model allowed a linear expression of patient characteristics to be related to a function of the probability of transfusion need. Analyses of association between categorical variables and transfusion status were based on chi-squared, Fisher's Exact, and Mann-Whitney U tests. RESULTS: Overall, 51 (11.7%) patients required blood transfusions. The median number of units transfused was 2.0 (range, 1 to 13 U). Univariate analysis demonstrated a higher probability for blood replacement in patients with oropharyngeal or hypopharyngeal primary tumor sites, a preoperative hemoglobin level below normal, prior chemotherapy, composite resection, flap reconstruction, between 50 and 59 years of age, and T3 or T4 tumor stage. Logistic regression analysis demonstrated that the need for flap reconstruction, a preoperative hemoglobin below the normal level, and T3 or T4 primary stage were the three factors most significantly associated with the need for transfusion (P < .03). Based on eight combinations of these three variables, transfusion risk predictions were obtained. The TPRA model predicted that patients with a normal hemoglobin level who did not require flap reconstruction and did not have either a T3 or T4 primary stage tumor had the lowest probability (.02) for requiring blood transfusion. Patients at highest risk (.65) were those with less than a normal hemoglobin level, who required flap reconstruction, and had T3 or T4 primary tumor stage. Based on the TPRA model, an algorithm was developed which could serve as a guideline for preoperative transfusion planning. CONCLUSION: By using the TPRA model to change guidelines for preoperative transfusion planning, costs can theoretically be reduced by 50% without significantly increasing the risk of exposing patients to allogeneic blood transfusion. If the TPRA model proves accurate in a follow-up study to test its validity, it may have clinical utility for aiding the surgeon in more cost-effective transfusion planning.

Bacteriologic profile of surgical infection after antibiotic prophylaxis.

Wound infections resulting from contamination during major head and neck surgery continue to be a critical issue. In this study, specimens of pus or draining fluids from the wounds of 43 surgical patients who received perioperative administration of ampicillin/sulbactam or clindamycin were cultured for aerobic and anaerobic isolates to species level. Polymicrobial infections were identified in 13 of 43 patients (30%); 82% of isolates were aerobic organisms (45 of 55), and 18% were anaerobic or facultative species (10 of 55). Nine of 43 patients (21%) showed no bacterial isolates from cultured material. Independent of the primary site of malignancy or antibiotics used, nine of 25 isolates (36%) obtained from patients who underwent concomitant dental extractions, but only one of 24 (4%) who did not, developed anaerobic infections, (p < 0.001). The minimum inhibitory concentration of anaerobic isolates suggested sensitivity to the antibiotics used, and minimum bactericidal concentration data suggested that further postoperative doses may be required to adequately treat the heavily contaminated wounds. These data suggest that wound colonization following dental extraction procedures in clean contaminated head and neck surgery increases the risk of anaerobic infections. The use of a therapeutic dose and longer duration of perioperative antibiotics may be warranted.

Comparison of low-dose isotretinoin with beta carotene to prevent oral carcinogenesis.

BACKGROUND: High-dose isotretinoin therapy has been determined to be an effective treatment for leukoplakia. However, a high rate of relapses and toxic reactions led us to conduct a trial of a much lower dose of isotretinoin in the hope of maintaining a response and limiting toxicity. METHODS: In the first phase of the study, 70 patients with leukoplakia underwent induction therapy with a high dose of isotretinoin (1.5 mg per kilogram of body weight per day) for three months; in the second phase, patients with responses or stable lesions were randomly assigned to maintenance therapy with either beta carotene (30 mg per day) or a low dose of isotretinoin (0.5 mg per kilogram per day) for nine months. RESULTS: In the first phase, the rate of response to high-dose induction therapy in the 66 patients who could be evaluated was 55 percent (36 patients). The lesions of seven patients progressed, and therefore they did not participate in the second phase of the trial. Of the 59 patients included in the second phase, 33 were assigned to beta carotene therapy and 26 to low-dose isotretinoin therapy; these two groups did not differ significantly in prognostic factors. Of the 53 patients who could be evaluated, 22 in the low-dose isotretinoin group and 13 in the beta carotene group responded to maintenance therapy or continued to have stable lesions (92 percent vs. 45 percent, P < 0.001). In situ carcinoma developed in one patient in each group, and invasive squamous-cell carcinoma in five patients in the beta carotene group. Toxicity was generally mild, though greater in the group given low-dose isotretinoin therapy. CONCLUSIONS: When preceded by high-dose induction therapy, low-dose isotretinoin therapy was significantly more active against leukoplakia than beta carotene and was easily tolerated.

Clinical restoration of voice function after loss of the vagus nerve.

One hundred eleven patients with unilateral vocal cord paralysis underwent Teflon injection for the rehabilitation of laryngeal function. The most common etiology was vocal cord paralysis after surgical treatment of thoracic abdominal aortic aneurysms, which accounted for 36.9% of patients. Of the 111 patients, 85% had improved voice function after Teflon injection. Two patients developed airway obstruction secondary to edema and required temporary tracheostomy. Twenty-four patients with paralysis after aneurysm surgery were injected acutely with no morbidity and immediate restoration of voice function. We now advocate Teflon injection in patients with vocal cord paralysis after thoracic aneurysm surgery in the immediate convalescent period to restore voice function and lessen pulmonary complications.