Comparison between 2D and 3D computed tomography evaluation of glenoid bone defect in unilateral anterior gleno-humeral instability.

PURPOSE: This study evaluated the agreement between 2D and 3D computed tomography (CT) measurements in identifying the size and type of glenoid-bone defect in anterior glenohumeral instability. MATERIALS AND METHODS: One hundred patients affected by unilateral anterior glenohumeral instability underwent a CT of both shoulders. Images were processed with both 2D [multiplanar reconstruction (MPR)] and 3D [volumerendering (VR)] methods. The area of the missing glenoid was calculated in comparison with the healthy glenoid and expressed as a percentage. Agreement between the two measurements was assessed according to the Bland-Altman method; a 5% mean difference was considered as clinically relevant. RESULTS: Analysis of agreement between MPR and VR measurements of the percentage of missing glenoid showed a mean difference equal to 0.62%±1.96%. Percent agreement between the two measurements in detecting the presence of bone defect was 97% (p<0.0001). Percent agreement between the two measurements in discriminating the type of bone defect was 97% (p<0.0001). CONCLUSIONS: Agreement between 2D (MPR) and 3D (VR) CT measurements to identify the size and type of glenoid-bone defect in anterior glenohumeral instability was so high that the two measurements can be considered interchangeable.

How to identify and calculate glenoid bone deficit.

In recent years, we have seen increased interest in bone lesions of the glenoid rim as acute fractures (Bony-Bankart) and as chronic bone defect in instability. This derives from three main clinical and statistical findings: a significant incidence of bony Bankart lesion after a first dislocation, a high percentage of glenoid bone defects in chronic instability, and, finally, a close relationship between bone defect and incidence of recurrence after arthroscopic stabilization. The authors agree on determining glenoid bone defect that exceeds 15-20% as the main contraindication to arthroscopic stabilization. It is thus necessary to accurately calculate bone defect in order to be able to plan the most suited type of surgery. The authors report their simple, accurate and reproducible CT method known as Pico to quantify and measure bone defect in terms of percentage bone area and in terms of square mm of defect.

One-pot direct conversion of 2,3-epoxy alcohols into enantiomerically pure 4-hydroxy-4,5-dihydroisoxazole 2-oxides.

[structure: see text]. A new methodology for the one-pot direct conversion of 2,3-epoxy alcohols into enantiomerically pure 4-hydroxy-4,5-dihydroisoxazole 2-oxides 1 has been found. The reaction works at room temperature and can be run at the 5-10 g scale. The mixture of 4,5-cis and 4,5-trans isomers obtained can be separated as such or as the bis-TDS ethers. A preliminary example of reductive cleavage of 1 to the corresponding amino polyol is also reported.

Isolated cervical recurrence of squamous cell carcinoma in the previously treated neck.

PURPOSE: Our study goal was to identify clinical factors associated with, and that might predict, treatment outcome for patients with an isolated cervical recurrence of squamous cell carcinoma in the previously treated neck (ICR-PTN). MATERIALS AND METHODS: We reviewed all patients with noncutaneous head and neck squamous cell carcinoma treated at our tertiary care center between 1987 and 1997, and identified 17 patients (2%) who later developed an isolated recurrence in a previously treated neck. These patients made up our study group, and their charts were thoroughly reviewed. Outcome of salvage therapy (surgery, radiation, or combined therapy) for these patients was compared with pooled clinicopathologic data using the Fisher exact test (one tail). RESULTS: Fifteen such ICR-PTN patients consented to salvage therapy. Six patients were without disease at last follow-up, and 3 were successfully palliated. A statistically significant association between the side of ICR-PTN relative to the primary tumor and outcome of salvage therapy (P =.026) was noted, with ipsilateral neck recurrence being a favorable prognostic factor. Trends that did not meet the standard for statistical significance were observed between a better outcome of salvage therapy and the following parameters: age of less than 60, nonsurgical initial treatment of the neck, and lack of a history of a recurrence before they developed the ICR-PTN. CONCLUSIONS: The current study showed that only the side of the ICR-PTN relative to the primary site is associated with outcome of salvage therapy. Based on our findings and a review of the literature, we have developed a summary of factors that might predict which patients with an ICR-PTN are most likely to benefit from aggressive salvage therapy.

Factors related to outcome of salvage therapy for isolated cervical recurrence of squamous cell carcinoma in the previously treated neck: a multi-institutional study.

OBJECTIVE: The goal was to identify factors associated with the outcome of salvage therapy for patients with isolated cervical recurrences of squamous cell carcinoma in the previously treated neck (ICR-PTN). STUDY DESIGN AND SETTINGS: A tumor registry search for ICR-PTN patients was performed at 7 participating institutions, and the charts were reviewed. Kaplan-Meier plots for survival and time until re-recurrence were used to evaluate the significance of associated variables. RESULTS: Median survival and time until re-recurrence were both 11 months. Survival was better in patients with the following characteristics: nonsurgical initial neck treatment, negative initial disease resection margins, no history of prior recurrence, ipsilateral location of the ICR-PTN relative to the primary, and use of surgical salvage. CONCLUSIONS: By pooling the experience of 7 US tertiary care medical centers, we have identified 5 factors that are associated with outcome of salvage therapy for ICR-PTN. SIGNIFICANCE: Consideration of these factors, as well as the reviewed literature, should facilitate patient selection for salvage protocols.

A bicyclo[3.2.0]hept-3-en-6-one approach to prostaglandin intermediates.

[reaction:see text] The substituted cyclopentanic structures, 6-benzyloxymethyl-7-hydroxy-2-oxabicyclo [3.3.0]octan-3-one (1), a Corey lactone derivative, and 6-exo-benzyloxymethyl-2-oxabicyclo[3.3. 0]oct-7-en-3-one (2), have been obtained stereoselectively through the bicyclo[3.2.0]hept-3-en-6-one approach via 5-benzyloxymethyl-3-hydroxy-6-heptenoic acid, easily accessible from the inexpensive monoprotected cis-2-butene-1,4-diol.

Craniofacial resection of a nasoseptal chondrosarcoma: case report and review of the literature.

BACKGROUND: Chondrosarcoma of the nasal septum is a rare, malignant neoplasm. A case is presented that illustrates the evaluation and treatment of this malignancy, reviews the relevant literature, discusses surgical approaches, and assesses adjuvant, nonsurgical therapy. METHODS: A craniofacial approach using an extended, bifrontal craniotomy and lateral rhinotomy with medial maxillectomy resulted in gross total resection at surgery. Because permanent sections of bone margins after decalcification were positive, conformal external beam radiation was used. RESULTS: The patient made a complete recovery, returned to work, and is disease-free 26 months after treatment. CONCLUSIONS: Surgical therapy using an anterior craniofacial resection is the preferred approach. External beam radiation therapy is potentially indicated for the following: positive or close surgical margins on permanent histopathology, extensive tumor with known residual at operation, or local recurrence not amenable to resection. Because of late local recurrence, lifelong follow-up is required.

Zenker's diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy.

OBJECTIVE: To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenker's diverticulum. STUDY DESIGN: Retrospective. MATERIALS AND METHODS: A chart review was conducted of all patients with a Zenker's diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. RESULTS: Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. CONCLUSIONS: Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenker's diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment.

Medium sized lactones with hypolipidaemic and antioxidant activity: synthesis and biological evaluation of promising dual-action anti-atherosclerosis drugs.

Macrocyclic lactones 1a-b have been synthesized and their potential therapeutic value evaluated. The key structural feature of these active 'chimera' compounds is the 12-membered lactone ring that brings together the well-known polysubstituted hydroquinone moiety of antioxidants and the alpha,alpha-dimethyl substituted acyl residue of gemfibrozil. Lactones 1a-b showed better activity than probucol, a classical phenolic antioxidant, in preventing the Cu++-induced oxidative modification of human LDL. The hypolipidaemic activity of the new lactones, evaluated as the inhibition of lipids biosynthesis in Hep-G2 cells, was comparable to that of gemfibrozil. These features, added to the lack of cytotoxicity, make this new class of medium sized lactones promising dual-action drugs useful as anti-atherosclerosis agents.

Radiologic percutaneous gastrostomy: results in 56 patients with head and neck cancer.

OBJECTIVE: The establishment of a direct enteral feeding route is critical in the overall treatment of many patients with head and neck cancer. Use of radiologic percutaneous gastrostomy (RPG), the newest technique for gaining enteral access, has not been studied in such patients extensively. This study evaluated the indications, technique, success rate, and complications associated with RPG in patients with head and neck cancer. STUDY DESIGN: Retrospective. METHODS: A comprehensive chart review was undertaken of 56 patients with head and neck cancer treated at a tertiary care institution who had undergone successful or attempted RPG at some point during their treatment course. RESULTS: Most study patients had advanced oropharyngeal squamous cell carcinoma. The most frequent indications for RPG were dysphagia/aspiration following tumor resection (n = 26) and dysphagia following completion of single- or combined-modality therapy (n = 22). The success rate of attempted RPGs was 98.2%. The overall complication rate for RPG was 12.7% (10.9% minor and 1.8% major). CONCLUSIONS: RPG is a valuable tool for establishing enteral nutrition in patients with head and neck cancer. Advantages of RPG include high success rate despite obstructing lesions, low complication rate, time efficiency and scheduling ease compared with intraoperative percutaneous gastrostomy (PEG) by a second team, no reported tumor seeding of the tube site, and the fact that postoperative RPG allows for more accurate selection of patients who require a gastrostomy tube.

Odontogenic keratocyst of the mandible: an unusual cause of a parotid mass.

Odontogenic keratocyst (OKC) of the mandible refers to an uncommon benign lesion of the jaw that originates from dental primordia. Clinically an OKC is characterized by aggressive, local growth. The likelihood of local recurrence following initial treatment is high. The diagnosis of a mandibular OKC may be suspected based on physical examination and plain film radiographic findings. However, histopathological confirmation is required to make the diagnosis with certainty. Complete surgical removal is the preferred treatment. In the current report, we describe the management of a patient with a large mandibular OKC that produced an apparent mass in the parotid gland. In addition, the diagnosis, management, and long-term results of treatment of mandibular OKCs are reviewed.

The value of ultrasound with ultrasound-guided fine-needle aspiration biopsy compared to computed tomography in the detection of regional metastases in the clinically negative neck.

PURPOSE: Head and neck oncologists have not reached consensus regarding the role of contemporary imaging techniques in the evaluation of the clinically negative neck in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of the present study was to compare the accuracy of ultrasound with guided fine-needle aspiration biopsy (UGFNAB) and computed tomography (CT) in detecting lymph node metastasis in the clinically negative neck. METHODS AND MATERIALS: Sixty-four neck sides of patients with HNSCC were examined preoperatively by ultrasound/UGFNAB and CT at one of five participating tertiary care medical centers. The findings were correlated with the results of histopathologic examination of the neck specimen. RESULTS: Ultrasound with guided fine-needle aspiration biopsy was characterized by a sensitivity of 48%, specificity of 100%, and overall accuracy of 79%. Three cases had nondiagnostic aspirations using UGFNAB and were excluded. CT demonstrated a sensitivity of 54%, specificity of 92%, and overall accuracy of 77%. UGFNAB detected two additional metastases not visualized on CT, whereas CT detected no metastases not seen on UGFNAB. The results of UGFNAB were similar between the participating centers. CONCLUSIONS: Approximately one half of the clinically occult nodal metastases in our patient group were identified by both CT and UGFNAB. Overall, UGFNAB and CT demonstrated comparable accuracy. The sensitivity of CT was slightly better than UGFNAB, but the latter remained characterized by a superior specificity. The results of CT and UGFNAB did not appear to be supplementary. The choice of imaging modality for staging of the clinically negative neck depends on tumor site, T-stage, and experience and preference of the head and neck oncologist. If CT is required for staging of the primary tumor, additional staging of the neck by UGFNAB does not provide significant additional value.

The pectoralis major myofascial flap: clinical applications in head and neck reconstruction.

PURPOSE: The pectoralis major myofascial (PMMF) flap, a simple variant of the pectoralis major myocutaneous (PMMC) flap, has been underemphasized as a reconstructive method in head and neck surgery. MATERIALS AND METHODS: In the present study, we review our experience using 18 PMMF flaps for a variety of reconstructive purposes in 15 head and neck cancer patients treated at a tertiary care hospital. Twelve of the study patients were undergoing surgical salvage of a recurrent cancer, and 10 had received previous radiation. RESULTS: The overall rate of flap complications in our series was 22%, and the incidence of major flap complications requiring surgical revision was 11%. CONCLUSION: In our experience, the use of the PMMF flap for a variety of reconstructive tasks in the head and neck has been associated with a high overall success rate with avoidance of some of the limitations of the PMMC flap.

Metastatic melanoma to retropharyngeal lymph nodes causing pharyngeal obstruction.

The finding of melanoma that has metastasized to regional lymph nodes is prognostically unfavorable. Occasionally, lymph nodes beyond the regional lymph node basin are the site of distant melanoma metastases. We present the case of a patient with melanoma who developed nonregional lymph node metastases to retropharyngeal/parapharyngeal lymph nodes, resulting in symptoms of upper aerodigestive tract obstruction. Physical examination of the head and neck, fiberoptic examination, and CT scan were abnormal. The patient underwent unilateral transcervical lymphadenectomy and resection of the obstructing retropharyngeal tumor mass. A sternocleidomastoid muscle flap was used to augment the posterior pharyngeal wall closure. The patient was able to resume full oral intake without need for a tracheostomy. Surgical intervention can play an important role in the palliation of selected patients with nonregional metastatic melanoma to the head and neck.

Imaging features and clinical significance of perineural spread or extension of head and neck tumors.

Perineural spread of head and neck tumors is a form of metastatic disease in which tumor disseminates to noncontiguous regions along the endoneurium or perineurium. Both computed tomography (CT) and magnetic resonance (MR) imaging can help detect perineural spread, although MR imaging is the modality of choice because of its multiplanar capability, its superior soft-tissue contrast, and the decreased amount of artifact from dental hardware. Perineural spread most commonly occurs in adenoid cystic carcinoma and squamous cell carcinoma. Nerve enlargement may lead to foraminal enlargement and, ultimately, to foraminal destruction, findings that are best seen at CT. Extension through the foramen ovale and involvement of the Meckel cave is best seen on coronal T1-weighted MR images, and nerve enhancement is best seen on fat-suppressed T1-weighted MR images. Other radiologic findings include obliteration of fat planes at foraminal openings, neuropathic atrophy, cavernous sinus enlargement, and replacement of the trigeminal subarachnoid cistern with soft tissue. The pathway of perineural tumor spread is predictable with knowledge of the pertinent cranial nerve anatomy; however, patients with radiologically or pathologically proved perineural spread may have normal nerve function at clinical examination. Therefore, it is imperative that the radiologist be familiar with both normal cranial nerve anatomy and the radiologic appearance and assessment of perineural tumor extension.

Predictive factors for functional recovery after free tissue transfer oromandibular reconstruction.

BACKGROUND: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.

p53 immunostaining of surgical margins as a predictor of local recurrence in squamous cell carcinoma of the oral cavity and oropharynx.

Local and regional recurrence is the principal reason for treatment failure in squamous cell carcinoma (SCC) of the head and neck. The conventional method of evaluating surgical margins for cellular atypia does not always predict risk of local recurrence accurately. Immunostaining of surgical margins for tumor markers may provide a more precise evaluation of risk of local recurrence. Paraffin-embedded tissue blocks of surgical margins from 24 patients with oral cavity and oropharyngeal squamous cell carcinoma were immunostained for p53 protein. Fifty-eight percent of the patients had at least one margin stain positive for p53, including eight of ten patients whose SCC recurred locally. The sample odds ratio test predicted a 5.333 times higher chance of local recurrence with at least one p53 positive surgical margin. The implications of these results for patient management and further investigations will be discussed.

Wound complications associated with brachytherapy for primary or salvage treatment of head and neck cancer.

Brachytherapy can be employed in the primary or salvage treatment of head and neck cancer. The advantage of brachytherapy is the stereotactic limitation of radiation exposure to noninvolved tissues. Wound complications associated with brachytherapy have been discussed only sporadically in the literature. This retrospective study examines 28 patients, 20 for initial treatment and eight for salvage, with varying site and stage head and neck cancer treated with brachytherapy in addition to external beam radiation therapy and/or surgery. The overall complication rate was 50% (14/28), with infection and minor flap breakdown being the most common problems. Tumor site in the primary treatment group was the only significant factor in wound complications. In the salvage group complications were minor and primarily related to flap coverage of brachytherapy catheters.