Transaxillary endoscopic thyroid lobectomy: gas insufflation versus gasless technique.

PURPOSE: The objective of this study is to compare the clinical outcomes between gas insufflation and gasless techniques used in transaxillary endoscopic thyroid lobectomy. METHODS: Data of patients who underwent transaxillary endoscopic thyroid lobectomy from June 2011 to August 2019 were reviewed. All surgeries were performed by one experienced surgeon. The patients were divided into two groups according to surgical technique as gas insufflation or gasless technique. The clinical outcomes such as complications, postoperative pain score assessed using VAS, length of hospital stay, and presence of iatrogenic ectopic thyroid tissue were compared between the two groups. RESULTS: During the study period, a total of 60 patients underwent transaxillary endoscopic thyroid lobectomy: 38 patients via gas insufflation and 22 using the gasless technique. The basic characteristic features of the patients and their diseases were not significantly different between the two groups. Gas insufflation yielded significantly better surgical outcomes than the gasless technique: shorter operative time (209.3 ± 63.1 min. vs. 267.6 ± 66.0 min.; P = 0.001), less estimated blood loss [10.0 (5.0, 20.0) mL vs. 30.0 (16.2, 50.0) mL; P < 0.001], less drainage content [10.0 (0.0, 70.0) mL vs. 81.5 (74.2, 104.5) mL; P < 0.001], and shorter hospital stay [1.5 (1.1, 2.0) days vs. 1.8 (1.5, 2.5) days; P = 0.032]. Regarding postoperative pain, there was no statistically significant difference in visual analog scales (VAS) at 24 and 48 h. Finally, no evidence of iatrogenic ectopic thyroid tissue was found in both groups. CONCLUSION: Compared to the gasless technique, the gas insufflation technique provided shorter operative time, less estimated blood loss, less drainage content, and shorter hospital stay. Moreover, there were comparable outcomes regarding postoperative pain, complications and iatrogenic ectopic thyroid tissue.

Correlation between Serum Squamous Cell Carcinoma Antigen Level and Tumor Volume in Head and Neck Cancer.

PURPOSE OF STUDY: An association of squamous cell carcinoma antigen (SCC-Ag) level with cancer prognosis has been reported in many studies. Our investigators conducted the first study determining a correlation between the SCC-Ag level and the tumor volume in head and neck cancer. PROCEDURES: The SCC-Ag level of patients were measured from the serum, whilst the tumor volume was calculated by the ellipsoid formula and verified by logistic software on radiology. The correlation between SCC-Ag level and tumor volume was analyzed. RESULTS: Fifty-two patients were studied, with the mean age of 62.4 years. Tumor types were: oral cavity cancer (11 cases, 21.6%), oropharyngeal cancer (21 cases, 40.38%), hypopharyngeal cancer (8 cases, 15.7%), and laryngeal cancer (12 cases, 23.5%). Mean tumor volume was 20.01 mL (range 0.02-91.46 mL). Mean SCC-Ag level was 2.69 ng/mL (range 0.5-14.6 ng/mL). The critical point of SCC-Ag was 5.8 ng/mL. The Pearson's correlation coefficient between SCC-Ag level and tumor volume was 0.524 (p = 0.0002). CONCLUSIONS: SCC-Ag moderately correlates with tumor volume in head and neck cancer patients, with statistical significance. We suggest that using tumor volume, rather than a one-dimensional measurement such as tumor size, to analyze correlation with SCC-Ag offers a more accurate means of cancer prognosis.

Transaxillary gasless endoscopic thyroidectomy versus conventional open thyroidectomy: a randomized study.

The objective of this study is to compare the outcomes of transaxillary gasless endoscopic thyroidectomy (TGET) and conventional open thyroidectomy (COT). Thirty-three patients with thyroid nodule were enrolled. All patients were randomized into two different groups. Sixteen patients underwent TGET and 17 patients underwent COT. We analyzed the patients' characteristics, wound satisfaction, the intraoperative phase, hospitalization, pain, and costs. The operative time for the TGET group was significantly longer than in the COT group. The estimated blood loss, the hospitalized days, and pain between the two groups were not significantly different. The drainage content was significantly more in the TGET group. The patients' wound satisfaction and mean total cost per case were significantly greater in the TGET group. The TGET provided better cosmetic outcomes and was comparable regarding the estimated blood loss, pain, complication, and hospitalization. However, the TGET required a longer operative time which determines the higher costs.

HPV-Related Oropharyngeal Cancer in Southern Thailand: Proportion Trend and Survival Outcome.

BACKGROUND: Persistent high-risk human papillomavirus (HPV) infection is one of the major etiologies of oropharyngeal squamous cell carcinoma (OPSCC). This study aimed to determine the proportion, temporal trend, and prognostic significance of HPV-related OPSCC in Thai patients. METHODS: The study included patients with OPSCC who were treated at Songklanagarind Hospital (Songkhla, Southern Thailand) from 2009 to 2020. HPV status was screened by p16 expression using immunohistochemistry and confirmed by real-time polymerase chain reaction. Cox regression was used to determine prognostic significance. RESULTS: The overall proportion of HPV+ OPSCC was 15.3% (95% confidence interval [CI]: 12.1-18.5) with a slightly increased proportion from 10.6% in 2009-2010 to 16.5% (2019-2020) (P for trend = 0.166). Among the HPV+ cases, HPV16 was detected in 65.3%, HPV18 in 34.7%, and other high-risk HPV types in 24%. Patients with P16+ or HPV+ OPSCC had significantly better overall survival (hazard ratio [HR]: 0.63, 95% CI: 0.45-0.90 and HR: 0.63, 95% CI: 0.45-0.88, respectively). CONCLUSION: Thai patients in the southern region have a low proportion of HPV-related OPSCC with an increasing trend. Both P16 expression and HPV DNA status are strong independent prognostic factors of OPSCC.

Oncologic and functional outcomes in advanced laryngeal and hypopharyngeal cancer treated with concurrent chemoradiation versus primary surgery followed by adjuvant treatment.

OBJECTIVE: To compare oncologic outcomes in advanced laryngeal and hypopharyngeal cancer (LHC) patients who received either concurrent chemoradiation (CRT) or primary surgery followed by adjuvant treatment and to examine functional outcomes in the patients treated with CRT. MATERIAL AND METHOD: The clinicopathological data of 136 patients, diagnosed as stage III or IV LHC, were retrospectively reviewed. The eligible patients were classified into two groups based on their primary treatment, CRT group and group of surgery followed by the adjuvant treatment. Oncologic outcomes were evaluated and compared at five years. Functional outcomes were recorded as tracheostomy and/or feeding tube dependency. RESULTS: Five-year overall survival rates were 66.9% for the primary surgery group and 34.8% for the CRT group (p = 0.004). Five-year disease-specific survival rates for the same two groups were 66.9% and 39.9%, respectively (p = 0.03). The three-year laryngectomy-free survival rate in the CRT group was 71.9%. At three months post-CRT 62.3% of patients depended on tracheostomy and/or a feeding tube. CONCLUSION: The primary surgery followed by adjunctive treatment among the advanced LHC cases had significantly better oncologic outcomes. Nevertheless, CRT group had a high survival rate with a preserved larynx, but with relatively inferior functional outcomes.

Functional and oncological outcomes of primary versus salvage transoral laser microsurgery for supraglottic carcinoma.

OBJECTIVES: We evaluated the functional and oncological outcomes of transoral laser microsurgery (TLM) in patients with previously untreated supraglottic carcinoma compared with the outcomes in salvage cases after radiation-based treatment. METHODS: We conducted a retrospective case-control study at a single academic tertiary care institution. The functional outcomes were stratified by prior irradiation and were assessed at baseline, less than 1 week after operation, and at last follow-up. RESULTS: Five patients underwent TLM for previously untreated disease, and 5 previously irradiated patients underwent salvage TLM for local failure. No patient required tracheostomy. There was no local recurrence after TLM as primary therapy, and none of those patients required radiotherapy. One salvage patient developed local recurrence. The duration of feeding tube dependence (p = 0.049) and the rates of chronic aspiration (more than 1 month after operation; p = 0.048) were significantly higher in the salvage TLM cases than in the previously untreated cases. The median scores on the PSS-HN Understandability of Speech were 75 ("usually understandable") in the salvage group and 100 ("always understandable") in the previously untreated group. CONCLUSIONS: Both local control and function were better in the previously untreated patients than in the salvage patients. Our findings provide support for the use of TLM as a primary treatment modality for selected supraglottic carcinomas, but also suggest a potential for functional recovery in both previously untreated and salvage cases.

Pediatric parotidectomy outcomes: A 14-year multicenter study.

Objectives: Parotidectomy increases childhood challenges. This study aimed to determine the clinical profiles, investigations, and outcomes of pediatric patients who had undergone parotidectomy. Methods: A multicenter retrospective review of parotidectomy in pediatric patients between 2007 and 2020. Results: In 108 parotidectomies, the final diagnoses were benign (47.22%), malignant (36.11%), and non-neoplastic (16.67%). The incidence of facial palsy was 37.03%, which was significantly lower in the superficial group than that in the total parotidectomy group (p = .021). The incidence of facial nerve palsy was significantly higher in the malignancy group than that in the benign group (p = .035). Magnetic resonance imaging (MRI) detected malignancy with 92.8% overall accuracy, 83.3% sensitivity, and 100% specificity. The sensitivity and specificity of fine-needle aspiration (FNA) were 54.2% and 92.7%, respectively. Conclusions: Parotidectomy is commonly performed for benign and non-neoplastic diseases in pediatric patients. Facial nerve palsy is significantly associated with malignant tumors and total parotidectomy. MRI is the most accurate imaging modality for diagnosing malignant lesions. FNA exhibits moderate agreement with the final pathology. Level of Evidence: Level IV.

Multidisciplinary management of a penetrating cerebellar injury by a fishing speargun: A case study and literature review.

BACKGROUND: Fishing spearguns are a rare cause of nonmissile penetrating brain injuries (PBIs). Discussion of their injury patterns and treatments has been published only sporadically. Here, we report a case of a self-inflicted PBI caused by this type of weapon and present an extensive review of previous case reports to help ascertain the appropriate surgical approach. CASE DESCRIPTION: A 26-year-old man with a preexisting psychiatric illness was transferred to our hospital after a self-inflicted shot with a fishing speargun through his mouth. The ensuing injuries included the impalement of a spear intracranially through the soft palate and posterior oropharyngeal wall. The spear was surgically accessed by the otolaryngology team by splitting the soft palate and was removed by the neurosurgery team in the retrograde direction. Cerebral angiographies were done pre- and postoperatively, and these did not detect any vertebrobasilar arterial system injuries. The patient's postoperative care was uneventful, and he was followed up by a psychiatrist for his long-term care. CONCLUSION: This example of a complicated case of nonmissile PBI caused by an uncommon type of weapon shows how this type of medical emergency can be managed successfully with effective teamwork using a multidisciplinary approach.

The emergence of endoscopic head and neck surgery.

Endoscopic and minimally invasive techniques represent a natural evolution for the discipline of head and neck surgery. Endoscopic head and neck surgery (eHNS) encompasses transoral laser microsurgery, transoral robotic surgery, as well as video-assisted and robotic surgery of the neck and thyroid. In the next 5 years, with robotic surgery and laser technology as a common platform, we foresee the development and widespread use of eHNS procedures, via transoral and transaxillary approaches.

Efficacy of EPA-enriched supplement compared with standard formula on body weight changes in malnourished patients with head and neck cancer undergone surgery: a randomized study.

BACKGROUND: Eicosapentaenoic acid (EPA) containing nutritional supplement can reverse weight loss and increase lean body mass in a perioperative period of patients with head and neck cancer. To study effects of an EPA-enriched supplement compared with a conventional supplement in malnourished patients with head and neck cancer following surgery is primary objective. METHODS: The patients were randomized into EPA-enriched and standard formula group. The supplements were prescribed 7 days preoperative through 14 days postoperative. Body weight and composition including serum parameters were measured from 7 days preoperative until 4 months postoperative. The hospitalized courses were recorded. RESULTS: Thirty-one patients in each group consumed EPA-enriched and standard formula supplements. There was no significant body weight or composition changes perioperative. No significant differences in the hospitalized days and postoperative complications was observed. CONCLUSIONS: Body weight changes in malnourished patients with head and neck cancer following surgery were not influenced by EPA additives to perioperative nutritional supplements.

Epithelial-Mesenchymal Transition Predicts Survival in Oral Squamous Cell Carcinoma.

Synergistic loss of E-cadherin and acquisition of vimentin are characteristic feature of epithelial-mesenchymal transition (EMT) which confers an invasive phenotype of epithelial cancer cells. The aim of the study was to evaluate the prognostic significance of E-cadherin and vimentin expression individually and in combination as a measure of epithelial-mesenchymal transition (EMT) in oral squamous cell carcinoma (OSCC). Expression of E-cadherin and vimentin through immunohistochemical analysis was examined in 200 patients with surgically resected OSCC. Combined E-cadherin and vimentin expression was evaluated to determine the EMT status. Kaplan-Meier curves and log-rank test were used to compare differences in survival. Cox regression analysis was performed to identify independent prognostic factors. E-cadherin expression was negative in 28 (14%) tumors, and vimentin expression was positive in 87 (43.5%) tumors. Moreover, 99 (49.5%), 87 (43.5%), and 14 (7.5%) tumors exhibited no, partial, and complete EMT, respectively. Both individual protein expression were significant prognostic factors [Negative E-cadherin, hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.04-2.93; positive vimentin, HR = 1.64, 95% CI = 1.12-2.41]. For EMT status, the HR increased with EMT progression [partial EMT, HR = 1.64, 95% CI = 1.09-2.49; complete EMT, HR = 2.88, 95% CI = 1.44-5.79], of which, the complete EMT had higher HR than was individual protein expression. Combined E-cadherin and vimentin expression as a measure of EMT showed a superior prognostic significance compared with individual protein expression.

Retropharyngeal lymphadenectomy with transoral robotic surgery for papillary thyroid cancer.

Retropharyngeal metastasis of papillary thyroid carcinoma is a rare but well recognized phenomenon. Traditional open surgical approaches to nodal metastasis located in the retropharyngeal space are particularly morbid considering the relatively indolent nature of some thyroid cancers. Minimally invasive surgical approaches offer a useful alternative that is both low in morbidity and high in levels of patient acceptance. To assess feasibility and safety, we report a case series of robotic lymphadenectomy in two patients with thyroid cancer metastatic to the retropharyngeal space. Two patients, ages 66 and 73, with unilateral recurrent papillary carcinoma of the retropharyngeal lymph nodes had previously undergone thyroidectomy, neck dissection, and radioactive iodine ablation prior to retropharyngeal resection. Retropharyngeal lymphadenectomy via transoral robotic surgery was performed for both patients: for the first, the oropharyngeal wound was left to heal by secondary intention, while for the other patient, simple pharyngeal flap closure was performed. Retropharyngeal lymph node dissections were successfully carried out using a transoral robotic retropharyngotomy with the da Vinci surgical robotic system. Both patients tolerated the procedure well. One patient did developed temporary dysphagia which resolved with conservative measures, not requiring a feeding tube. We report the first two cases of transoral robot-assisted resection of thyroid cancer metastatic to the retropharyngeal lymph nodes. The technique is feasible, minimally invasive, and appears to be as safe as conventional surgical methods in achieving the goals of management of regionally metastatic disease.