Life-threatening Airway Complication After Radioactive Iodine Treatment: A Case Report and Review of the Literature.

BACKGROUND/AIM: Radioactive iodine (RAI) treatment is a cornerstone of treatment of differentiated thyroid carcinoma. Although serious RAI-related complications are uncommon, there have been reports of airway emergencies. Here, a life-threatening airway complication after RAI treatment is reported and previously reported cases are reviewed. CASE REPORT: A 79-year old man with Hürthle cell carcinoma and a remnant thyroid lobe after surgery developed an edema compromising the airway two days after receiving radioactive iodine treatment. An emergency awake intubation and tracheostomy were performed. He could be successfully de-cannulated 17 days later with no long-term complications. CONCLUSION: Although rare, life-threatening airway complications after radioactive iodine treatment, especially with high dose treatment in patients with remaining thyroid tissue, can occur and these patients should be supervised where these complications can be managed.

Ultrasound-assisted resection of oral tongue cancer.

BACKGROUND: In surgical resection of squamous cell carcinoma of the oral tongue (SCCOT), achieving clear margins is important for prognosis. Insufficient histopathological margins are common, particularly deep margins. AIMS/OBJECTIVES: The aim of the present study was to determine whether ultrasound (US)-assisted resection could decrease the proportion of insufficient histopathological deep margins in SCCOT. MATERIAL AND METHODS: 34 patients with SCCOT undergoing US-assisted resection (study group) were compared to 76 whose resections were performed without US (conventional group). Outcome measures were insufficient deep histopathological resection margins and mean difference in deep margins. RESULTS: Insufficient deep resection margins (<5.0 mm) were seen in 8 of 34 (23.5%) in the study group, compared to 31 of 76 (40.8%) in the conventional group, unadjusted RR 0.58 [95% CI 0.30-1.12; p = .11], adjusted RR 0.82 [95% CI 0.35-1.92; p = .64]. Unadjusted mean difference was 1.4 mm (95% CI 0.1-2.7, p = .04), adjusted mean difference 1.1 mm (95% CI -2.7 to 0.5, p = .19). CONCLUSIONS: Intraoperative US can visualize the deep resection margins in T1/T2 SCCOT. US-assisted resection seems to decrease the number of insufficient histopathological deep margins, though the results are not statistically significant. Comparatively good results in the conventional group is one explanation for the lack of significance. CLINICALTRIALS.GOV ID: NCT04059861.

Ultrasound accurately assesses depth of invasion in T1-T2 oral tongue cancer.

Background: Depth of invasion (DOI) is important for the T-classification of squamous cell carcinoma of the oral tongue (SCCOT) and incorporated in the TNM 8 classification of oral cavity cancer. To determine DOI clinical palpation is performed, but the preferred radiological modality remains controversial. The aim of this study was to investigate the assessment of DOI using ultrasound (US-DOI). Methods: The DOI was assessed in 40 patients with T1-T3 SCCOT by ultrasound, palpation, computed tomography and magnetic resonance imaging (MRI). Histopathological DOI (H-DOI) was gold standard. Bland-Altman analysis was used to compare mean difference and 95% limits of agreement (LOA). Results: The mean difference of US-DOI was -0.5 mm (95% LOA -4.9-4.0) compared to H-DOI and the mean difference for MRI was 3.9 mm (95% LOA -2.3-10.2). In the subgroup analysis of cT1-T2 the US-DOI mean difference was 0.1 mm and the 95% LOA limits -2.5-2.7. Conclusions: Ultrasound seems to be the most accurate method to assess DOI in T1-T2 SCCOT. MRI overestimates DOI and cannot assess a substantial proportion of the tumors. Level of Evidence: 2c.

Detection of Recurrence After Primary Treatment for Oropharyngeal Carcinoma.

BACKGROUND/AIM: Post-treatment surveillance of patients with squamous cell oropharyngeal carcinoma (SCOPC) consists of routine follow-up visits for 5 years. It has been suggested that this program is inefficient for finding recurrences and increasing survival. The primary study objective was to investigate how recurrences after treatment for SCOPC were detected, i.e., at routine follow-up visits, at patient-initiated visits, or incidentally. The secondary objective was to investigate whether 2-year survival after diagnosis of recurrence depended on the manner of detection. PATIENTS AND METHODS: Patients with recurrences from SCOPC between 1988 and 2018 were included. Survival was analysed by the Kaplan-Meier method with log-rank test. RESULTS: A total of 75 patients were included. Almost one-third were alive 2 years after the diagnosis of recurrence. Recurrences were detected at routine follow-up visits in 50.7%, at patient-initiated visits in 42.7% and 6.6% were found incidentally. There was an increased survival in the patient-initiated group, but this was not significant. CONCLUSION: The majority of recurrences in both groups compared were amenable to curative treatment.

Successful electrochemotherapy treatment of a large bleeding lymph node melanoma metastasis.

Despite the progress in immunotherapy and targeted therapy for patients with cutaneous malignant melanoma not all patients with loco-regional recurrences will respond to treatment. Electrochemotherapy is a relatively new treatment modality where the efficacy of a chemotherapeutic drug is enhanced by an electrical field. Here we report a case of a 68-year-old woman with a large therapy resistant inguinal lymph node melanoma metastasis complicated by bleeding that was successfully treated with electrochemotherapy.

The Value of Post-treatment Surveillance for Detection of Loco-regional Recurrences in Oral Tongue Cancer.

BACKGROUND/AIM: Follow-up after treatment for oral tongue cancer consists of routine follow-up visits for five years. It has been suggested that this program is inefficient for finding recurrences. The primary objective of this study was to investigate how recurrences are detected; at routine follow-up visits, at patient-initiated visits, or incidentally. The secondary objective was to investigate whether the two-year survival after diagnosis of recurrence depended on the manner of detection. PATIENTS AND METHODS: Patients with recurrences from oral tongue cancer between 1988 and 2016 were included. Survival was analysed by the Kaplan-Meier method and log-rank test. RESULTS: A total of 75 patients were included. In 67% of patients, recurrences were detected at routine follow-up visits, and in 27% at patient-initiated visits. No significant difference in survival between the groups was found (p=0.56). CONCLUSION: The majority of recurrences were detected at routine follow-up visits. Patient-initiated recurrence detection did not lead to increased survival.

Feasibility of an inexperienced examiner using trans-cervical ultrasound in the diagnosis of peritonsillar abscesses.

BACKGROUND: A peritonsillar abscess (PTA) is a common complication to acute tonsillitis. Needle aspiration (NA) is the gold standard for diagnosis of PTA. NA is usually painful and not risk-free. Ultrasound (US) is a noninvasive, portable radiological modality that could potentially be used in the diagnosis of PTA and selection of patients for NA. The reliability of US is dependent on the experience of the examiner which limits is usefulness. AIM: To evaluate the reliability of US in the diagnosis of PTA by an inexperienced examiner. METHODS: Thirty patients with suspected PTA were included. They were first examined with trans-cervical US by a medical student then clinically examined by a physician that performed a NA if clinically motivated. They were then followed for at least two days. RESULTS: Three patients were excluded from analysis because no NA was performed. In these patients, US correctly classified them as negative for PTA. In the remaining 27 patients, the sensitivity and negative predictive value was 100%. The specificity was 64.3% and the positive-predictive value was 72.2%. CONCLUSION: US can be very useful in the diagnosis of PTA and the selection for NA even with an inexperienced examiner. SIGNIFICANCE: The results highlight the usefulness of ultrasound in otolaryngology.

The Role of Electrochemotherapy in Curative Treatment of Head and Neck Cancer and Advanced Skin Cancer: A Need for New Treatment Protocols?

BACKGROUND/AIM: Electrochemotherapy (ECT) is a cancer treatment modality where the efficacy of a chemotherapeutic agent is enhanced by an electrical field. It is an established palliative treatment for cutaneous metastases but its role in curative treatment remains mostly undetermined. Studies have previously reported that ECT can be a safe curative treatment in both skin cancer and oral cavity cancer. The primary aim of this case study was to report the long-term results of ECT in curative treatment of four patients with skin or oral cavity cancer. The study also compares two different ECT treatment protocols. PATIENTS AND METHODS: Three patients with oral cavity cancer and one patient with skin cancer were included. One patient had a primary oral tongue cancer and the others had persistent/recurrent tumors after previous treatment. They were treated with ECT either as a primary, adjuvant or salvage treatment with curative intent. The median follow-up period was 60 months. RESULTS: There was one case of local recurrence after treatment in the follow-up period. In the other three patients, no recurrence was recorded. There was one serious adverse airway event. There was a significant difference in the bleomycin dose between the two studied protocols, especially for large tumors. CONCLUSION: ECT can be a safe mono-modality and adjuvant curative treatment in advanced skin cancer and primary and recurrent oral cavity cancer.

Radiotherapy as Elective Treatment of the Node-negative Neck in Oral Squamous Cell Cancer.

BACKGROUND/AIM: Previous studies of node-negative oral squamous cell carcinoma have shown a benefit of elective neck dissection compared to observation. Evidence for radiotherapy as single-modality elective treatment of the node-negative neck is so far lacking. PATIENTS AND METHODS: In a retrospective material of 420 early-stage oral cancers from 2000 to 2016, overall survival, disease-free survival, and regional relapse-free survival were calculated with the Kaplan-Meier method. RESULTS: At five years, overall survival was 59.7%, disease-specific survival was 77.2%, and regional relapse-free survival was 83.5%. Among those with adjuvant treatment of the neck after surgery of T1-T2 tumours during 2009-2016, regional relapse-free survival at five years was 85.7% for elective radiotherapy of the neck and 87.4% for elective neck dissection. CONCLUSION: Elective radiotherapy to the neck with a modern technique and adequate dose might be an alternative to neck dissection for patients with early-stage oral squamous cell cancer.

Neurological Complications After Electrochemotherapy Treatment in the Head and Neck Area.

BACKGROUND/AIM: Electrochemotherapy (ECT) is a predominately palliative treatment for cutaneous metastases where an electric field is used to increase the intracellular accumulation of a chemotherapeutic drug (bleomycin or cisplatin). ECT induces a strong anti-vascular effect and endothelial cells seem especially vulnerable. To date, almost no neurological and/or cerebrovascular complications after ECT treatment have been published. In this paper two such cases are reported. CASE REPORT: A seizure in a man treated with ECT for a basal cell carcinoma in the temporal region and a fatal ischemic stroke in a woman treated for cutaneous metastases in the neck are reported. In both cases a causal relationship to ECT treatment was strongly suspected. CONCLUSION: ECT in the head and neck can potentially cause severe neurological complications. Ultrasound is recommended for ECT treatment in the neck.

Pseudotumor of the Larynx: A Previously Unreported Side Effect of Apremilast.

Apremilast (Otezla®) is a relatively novel orally administered non-biologic disease-modifying anti-rheumatic drug (DMARD) extensively used in the management of psoriasis and psoriasis arthritis, lately approved for treating oral ulcerations in Behçets disease. Its advantageous side effect profile together with its uncomplicated follow-up and monitoring when compared to other DMARDs facilitates even a broad off-label prescribing. Here, the first case of laryngeal pseudotumor in a patient treated with apremilast for plaque psoriasis is presented.

Long-term follow-up in patients treated with electrochemotherapy for non-melanoma skin cancer in the head and neck area.

BACKGROUND: Electrochemotherapy (ECT) is a cancer treatment modality where the intracellular accumulation of chemotherapeutic agents is enhanced by an applied electrical field. AIMS/OBJECTIVES: To evaluate the long-term efficacy, safety and functional outcome after ECT treatment in high-risk non-melanoma skin cancer (NMSC) with curative intent. MATERIALS AND METHODS: Seven patients with SCC or BCC in the head and neck area were treated with ECT with intratumoral bleomycin administration. RESULTS: Five patients were cured by ECT as a mono-modality treatment after a median 10-year follow-up period. Two patients had recurrences and/or persisting tumors after treatment that required salvage surgery and radiotherapy. In two patients, the eye was spared with no visual impairment. In another patient, full facial nerve function was spared. CONCLUSIONS: ECT can be a curative as well as an organ and function-sparing mono modality treatment in high-risk NMSC. SIGNIFICANCE: Today ECT is mostly used as a palliative treatment. Its curative potential should be further investigated. Randomized studies comparing ECT with standard treatment is needed. Hopefully, this small study can encourage such studies.

[Electrochemotherapy - a simple and effective treatment of skin metastases]. / Elektrokemoterapi är en enkel och effektiv metod för behandling av hudmetastaser - Sannolikt underutnyttjad i Sverige ­ studier behövs.

Electrochemotherapy is  a simple and effective treatment of skin metastases. Electrochemotherapy is possible after previous surgery, radiotherapy and/or limb perfusion. Electrochemotherapy is most likely an under-used treatment modality in Sweden.

Electrochemotherapy - Evidence for Cell-type Selectivity In Vitro.

AIM: Electrochemotherapy (ECT) is a new cancer treatment modality that uses electroporation to potentiate chemotherapeutic agents, especially bleomycin. ECT causes both a direct toxic effect and an anti-vascular effect. The aim of the present study was to investigate a possible selective effect of ECT on the survival of fibroblasts, endothelial cells (HUVEC) and two squamous cell carcinoma cell lines (CAL-27 and SCC-4). MATERIALS AND METHODS: Cells were electroporated using two bleomycin concentrations. The survival rate was assessed 1, 2, 3 and 4 days after treatment, by two different assays. RESULTS: The survival rate of the fibroblasts was statistically significantly higher than the other cell lines at day 4. The HUVEC survival rate was statistically significantly lower than the other cell types at day 1 after electroporation-alone. CONCLUSION: A selective survival effect after ECT was observed in vitro, supporting the anti-vascular effect seen in vivo.

Long-term follow-up in patients treated with curative electrochemotherapy for cancer in the oral cavity and oropharynx.

CONCLUSION: ECT can be a safe curative mono modality treatment, especially in tongue cancer. The future role for ECT in head and neck cancer needs to be further investigated. INTRODUCTION: Electrochemotherapy (ECT) is a cancer treatment modality that uses electroporation to increase the intracellular accumulation of hydrophilic chemotherapeutic drugs, especially bleomycin. OBJECTIVES: To report the 5-year local tumor control, safety of treatment and survival after ECT, and the 1-year quality-of-life (QoL) data. MATERIALS AND METHODS: Nineteen patients with primary head and neck cancer were included and treated with ECT with curative intent. All except one patient had squamous cell carcinoma (SCC). Radiotherapy (RT) was performed in all patients with SCC and tumor infiltration ≥5 mm. The EORTC H&N 35 questionnaire was used at baseline and 12 months after treatment. The Wilcoxon signed rank test and McNemar's test were used for paired data and Mann Whitney U-test and Fishers exact test were used for independent data (sub-group comparison). RESULTS: There were no local recurrences in the follow-up period. Thirteen patients were treated with adjuvant RT. The six patients that were treated with ECT alone were tumor-free and alive 5 years after treatment. There was one serious adverse event reported; aspiration after treatment of a tongue base tumor. The tumor-specific 5-year survival was 75%. The QoL outcome 1 year after ECT showed a significant increase in problems with senses (taste, smell), speech, mouth opening and xerostomia. The QoL outcome also showed worse outcome in the smoking patients regarding speech, in the patients receiving adjuvant RT regarding mouth dryness and swallowing and in the patients with non-tongue oral cavity cancer regarding need for painkillers.

Electrochemotherapy - possible benefits and limitations to its use in the head and neck region.

CONCLUSION: Electrochemotherapy (ECT) is an efficacious treatment. It should, however, be used with some caution in the treatment of head and neck cancer. OBJECTIVES: To assess local tumor control, safety, survival, and functional outcome after treatment of cancer in the head and neck region with ECT. METHODS: Four patients with primary T2 cancer of the oral cavity or oropharynx and one patient with a metastasis of renal cancer in the masseter muscle were treated with ECT with intratumorally administered bleomycin. Control biopsies were carried out 2 months after treatment. Postoperative radiotherapy was performed based on tumor T-stage and the depth of tumor infiltration. Serious adverse events and treatment malfunctions were recorded. The follow-up time was 24 months for the surviving patients and 20 months overall. The PSS-HN scale was used to assess the functional outcome. RESULTS: No local recurrence was recorded in any patient during the follow-up. However, only one patient was treated with ECT alone. There were four serious adverse events: one nearly lethal bleeding, two cases of osteoradionecrosis, and a fistula. One patient died from distant metastasis. The other patients were tumor-free both locally and overall at 24 months. The median functional outcome in all parameters was worse 1 year after treatment.

Outcome of primary treatment of early laryngeal malignancies using photodynamic therapy.

CONCLUSION: Photodynamic therapy (PDT) is a viable and safe option for early laryngeal cancer that would be less suitably treated with radiation or trans-oral laser surgery (TLS). The cure rates with PDT appear to be comparable to those of conventional therapy, and the voice outcomes are also comparable. In the case of many sarcomas, PDT appears to be an organ- and function-sparing therapy, although it is more costly than other treatments. OBJECTIVES: The aim of this study was to show the results of PDT when it is used as a primary treatment of early laryngeal cancer. METHODS: We studied the results of PDT when used as a primary treatment. We looked at survival, effect on tumor, side effects, voice, and costs. RESULTS: The follow-up period was a median of 59 months. Nine of 10 patients were cured of their laryngeal cancer. PDT alone cured seven patients. All four of the sarcomas were cured using temoporfin. Two of three tumors that involved the anterior commissure were cured using only interstitial illumination with PDT. No serious side effects were noted. The patient's voices were improved after treatment in 5 of 10 cases, and none had a worsened voice.

Electroporation therapy for T1 and T2 oral tongue cancer.

CONCLUSION: Electroporation therapy appears to be a safe treatment achieving excellent local tumor control and very good functional results in our study and it should be further clinically evaluated. OBJECTIVES: The objectives of this study were to assess local tumor control, survival, and effects on speech and eating after treatment of tongue cancer with electroporation therapy, a new local therapeutic modality. In this approach intracellular accumulation of a chemotherapeutic agent is achieved by using a locally applied electrical field. METHODS: Fifteen patients with primary T1 and T2 oral tongue cancer were treated with electroporation therapy with intratumorally administered bleomycin. Postoperative radiotherapy was performed when the tumor infiltration was 5 mm or more. The follow-up time was 24 months for the surviving patients and 20.4 months overall. The effects on eating and speech were assessed using the PSS-HN scale and voice recordings. RESULTS: No local recurrence was recorded in any patient during the follow-up. Three patients died, two from progressive regional disease. Of the 12 surviving patients, 2 patients had regional recurrence and 10 patients including the 5 patients treated with EPT alone were tumor-free both locally and regionally at the last follow-up. The functional outcome for speech and eating were very good.

Electroporation therapy of skin cancer in the head and neck area.

BACKGROUND: Electroporation therapy is a new cancer treatment modality in which a locally applied electrical field enhances cell membrane permeability, allowing greater intracellular accumulation of a chemotherapeutic agent. OBJECTIVE: To evaluate the efficacy of electroporation therapy in treating basal cell and squamous cell carcinomas of the skin. MATERIALS AND METHODS: Six patients with skin cancer of the head and neck were treated using electroporation therapy with intratumorally injected bleomycin. Orbital growth, facial nerve proximity, or proximity to cartilage of the external meatus complicated four of these tumors. The intention was curative. The follow-up period was 24 months and included biopsies after 8 weeks. RESULTS: In four of the six patients, one treatment was enough to eradicate the tumor. In one patient, the tumor persisted even after a second treatment with electroporation therapy. A septal cartilage perforation was the only major complication. The cosmetic results were very satisfactory. One additional recurrence was recorded 6 months after the follow-up period CONCLUSION: Electroporation therapy is a promising new cancer treatment that should be further evaluated as an alternative to surgery, especially in complicated skin cancer.

[Increasing incidence of Chlamydia infections in Sweden. Shortcomings in primary health care management]. / Klamydiaincidensen ökar i Sverige. Brister i primärvårdens omhändertagande.

The incidence of Chlamydia trachomatis infections in Sweden is increasing. The primary health care encounters many of the patients with C trachomatis infections. The aim of this study was firstly to examine if the primary health care met the requirements of the Swedish STD legislation and secondly to find out why the testing was done. A total of 44 case-books of patients tested positive for C trachomatis in Orebro county were studied. Contact tracing was ignored in a fourth of the patients identified as contacts. In four cases partners received treatment without testing. Not even half of the patients were examined after treatment as required. Symptoms were the most common reason for testing. Dysuria was the predominant symptom. Almost half of all the cases in women but none in men were diagnosed by screening or voluntary testing in asymptomatic patients. In to many cases the primary health care did not meet the requirements of the STD Act. This must improve. Generous testing of asymptomatic women is supported by this study. Chlamydia trachomatis infection should be considered in patients with cystitis. Voluntary testing in men should be encouraged.