Potential role of hybrid positron emission tomography in pre-operative assessment of primary salivary gland carcinomas.

OBJECTIVE: The added value of hybrid positron emission tomography is increasingly recognised in head and neck cancer. However, its potential role in salivary gland carcinomas has been scarcely investigated. METHODS: A consecutive cohort of 45 salivary gland carcinoma patients who underwent pre-therapeutic hybrid positron emission tomography and surgical resection was reviewed. This study investigated whether maximum standardised uptake value correlated with tumour phenotype. RESULTS: Tumours of high-grade disease on histology (salivary duct carcinoma, carcinoma ex pleomorphic adenoma) had higher maximum standardised uptake value (Kruskal-Wallis test, p = 0.011) than low-grade tumours (adenoid cystic carcinoma and acinic cell carcinoma). Patients with pathologically confirmed node-positive disease had significantly higher maximum standardised uptake value of the primary tumour than patients with pathologically confirmed node-negative disease (Kruskal-Wallis test, p = 0.012). CONCLUSION: Maximum standardised uptake value of the primary tumour may guide clinical decision-making in patients with salivary gland carcinomas, as a high maximum standardised uptake value is associated with high-grade tumour histology and the presence of lymph node metastases. Clinicians may consider more aggressive surgery for these patients.

Case series of coronavirus (SARS-CoV-2) in a military recruit school: clinical, sanitary and logistical implications.

INTRODUCTION: A new coronavirus, called Severe Acute Respiratory Syndrome-CoronaVirus-2 (SARS-CoV-2), has emerged from China in late 2019 and has now caused a worldwide pandemic. The impact of COVID-19 has not been described so far in a military setting. We therefore report a case series of infected patients in a recruit school in Switzerland and the herein associated challenges. METHODS: Retrospective review of COVID-19 cases among Swiss Armed Forces recruits in the early weeks of SARS-CoV-2 pandemic in the canton of Ticino, the southernmost canton of Switzerland. Positive cases were defined with two positive PCR testing for SARS-CoV-2 from nasopharyngeal swabs. Serological testing was performed with a commercially available kit according to manufacturers' instructions. RESULTS: The first case was likely contaminated while skiing during weekend permission. He became symptomatic 4 days later, tested positive for SARS-CoV-2 and was put into isolation. He showed complete symptom resolution after 48 hours. Quarantine was ordered for all recruits with close contact in the past 2 days, a total of 55 persons out of 140 in the company. Seven out of nine recruits in one particular quarantine room became mildly symptomatic. SARS-CoV-2 PCR was positive in one of them. Seven days after initial diagnosis, the index patient and the other one from the quarantine retested positive for SARS-CoV-2, although they had been completely asymptomatic for over 96 hours. Serological testing revealed positive for both patients. All others showed negative IgM and IgG. CONCLUSIONS: Young healthy recruits often showed a mild course of COVID-19 with rapid symptom decline but were persistent SARS-CoV-2 carriers. This illustrates how asymptomatic patients may be responsible for covert viral transmission. An early and prolonged establishment of isolation and quarantine for patients and close contacts is essential to slow down the spread of SARS-CoV-2, especially in the confined space of a military environment.

PD-L1 is a positive prognostic factor in squamous cell carcinoma of the nasal vestibule.

BACKGROUND: Aim was to analyse the role of PD-L1 in squamous cell carcinomas of the nasal vestibule. Advanced squamous cell carcinoma of the nasal vestibule is a highly aggressive tumour. The role of PD-L1 expression is unclear in this tumour type. METHODOLOGY: Forty-six patients diagnosed between 1995 and 2014 were analyzed. Baseline characteristics and outcome were correlated to immunohistochemical staining of PD-L1. PD-L1 positivity of tumour cells and tumour infiltrating immune cells (TIIC) was defined by any staining of more than 1% of the tumour cells. RESULTS: PD-L1 expression was interpretable in 31 of 46 patients (67.4%). PD-L1 positivity was present in 14 (45.2%) patients tumour cells and 17 (54.8%) patients TIIC. PD-L1 positivity of tumour cells was associated with a favourable disease free survival (p=0.019). CONCLUSIONS: Positivity for PD-L1 in tumour cells is a prognostic factor in squamous cell carcinoma of the nasal vestibule and might enable a patient-tailored treatment.

Clinicopathological relevance of antithyroglobulin antibodies in low-risk papillary thyroid cancer.

OBJECTIVE: The extent of initial surgical management in papillary thyroid cancer (PTC) is controversial. We examined whether the presence of perioperative antithyroglobulin antibodies (TGA) could predict long-term recurrence and occurrence of adverse features among a homogenous group of patients with PTC. METHODS: The clinical features of patients with PTC treated at a single institution (Jewish General Hospital, McGill University, Montreal, Canada) were obtained from the medical records, and all clinicopathologic information was reviewed. Only low-risk PTC without clinical evidence of nodal disease before surgery and treated with 30 mCi of radioactive iodine was included in the study. RESULTS: The chart review retrieved 361 patients with a median follow-up of 85.0 months (Q25-Q75 73-98). Forty-two (11.6%) patients had presence of perioperative TGA. Perioperative TGAs were associated with present extrathyroidal extension (P=.005), unsuspected nodal disease (P=.001) and autoimmune thyroiditis (P<.0001). Overall, 17 (4.7%) patients experienced locoregional recurrence. Perioperative TGAs were a significant predictor of recurrence in univariable (P=.021) but not in multivariable analysis (P=.13). CONCLUSION: Presence of perioperative TGAs is associated with aggressive histological features and the presence of thyroiditis. Detection of TGA perioperatively may encourage surgeons to consider more extensive initial surgery.

[Percutaneous embolization and ultrasound scissors for removal of a carotid body tumor]. / Behandlung eines Glomus caroticum mit perkutaner Embolisation und Ultraschallschere.

Paragangliomas are highly vascularized usually benign neoplasms originating from the sympathoadrenal and parasympathetic paraganglia of the autonomic nervous system. When resectable, the management of these tumors consists of surgical ablation preceded by transarterial embolization. The aim of this article is to describe a novel treatment strategy combining intralesional percutaneous embolization with dissection using ultrasound scissors. The case of a 74-year-old women presenting with a Shamblin type III carotid body paraganglioma is presented. The combined approach of percutaneous embolization and ultrasound scissors permitted complete resection of the tumor with preservation of both the internal and external carotid artery, without postoperative cranial nerve deficits and with minimal blood loss. Preoperative intralesional embolization with a liquid embolic agent less than 24 h prior to surgical intervention in combination with ultrasound scissors appears to be an excellent strategy for surgical management of carotid body paragangliomas.

Survival and quality of life in oropharyngeal cancer patients treated with primary chemoradiation after salivary gland transfer.

OBJECTIVES: Salivary gland transfer surgery can reduce xerostomia in oropharyngeal squamous cell carcinoma patients undergoing primary chemoradiation. A potential drawback of salivary gland transfer is the treatment delay associated with the surgery, and its complications. This study aimed to determine whether the treatment delay affects patient survival and to evaluate patient quality of life after salivary gland transfer. METHODS: A retrospective analysis of 138 patients (salivary gland transfer group, n = 58; non-salivary gland transfer group, n = 80) was performed. Patient survival was compared between these groups using multivariate analysis. Salivary gland transfer patients were further evaluated for surgical complications and for quality of life using the head and neck module of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. RESULTS: Salivary gland transfer and non-salivary gland transfer patients had comparable baseline clinical characteristics. Salivary gland transfer patients experienced a median treatment delay of 16.5 days before chemoradiation (p = 0.035). Multivariate analysis showed that this did not, however, correspond to a survival disadvantage (p = 0.24 and p = 0.97 for disease-free and disease-specific survival, respectively). A very low complication rate was reported for the salivary gland transfer group (1.7 per cent). Questionnaire scores for the item 'xerostomia' were very low in salivary gland transfer patients. CONCLUSION: The treatment delay associated with salivary gland transfer surgery does not negatively affect patient survival. Oropharyngeal squamous cell patients have an excellent quality of life after salivary gland transfer.

Merkel cell carcinoma of the head and neck: poorer prognosis than non-head and neck sites.

BACKGROUND: Merkel cell carcinoma is a rare, aggressive neurocutaneous malignancy. This study investigated whether patients with Merkel cell carcinoma in the head and neck had poorer outcomes than patients with Merkel cell carcinoma located elsewhere. METHODS: A retrospective study was performed of patients with Merkel cell carcinoma treated at the Jewish General Hospital in Montréal, Canada, from 1993 to 2013. Associations between clinicopathological characteristics and disease-free and disease-specific survival rates were examined according to the Kaplan-Meier method. RESULTS: Twenty-seven patients were identified. Although basic clinicopathological characteristics and treatments were similar between head and neck and non-head and neck Merkel cell carcinoma groups, disease-free and disease-specific survival rates were significantly lower in the head and neck Merkel cell carcinoma group (log-rank test; p = 0.043 and p = 0.001, respectively). Mortality was mainly due to distant metastasis. CONCLUSION: Patients with head and neck Merkel cell carcinoma had poorer survival rates than patients with non-head and neck Merkel cell carcinoma in our study. The tendency to obtain close margins, a less predictable metastatic pattern, and/or intrinsic tumour factors related to the head and neck may explain this discrepancy.

Merkel cell carcinoma of the head and neck: a single institutional experience.

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy occurring mostly in older immunocompromized Caucasian males. A growing incidence of MCC has been reported in epidemiological studies. Treatment of MCC usually consists of surgical excision, pathological lymph node evaluation, and adjuvant radiotherapy. This paper reports the experience of a single tertiary center institution with 17 head and neck Merkel cell carcinoma patients. Median followup for the cohort was 37.5 months. After five years, recurrence-free survival, disease specific survival, and overall survival were 85%, 90%, and 83%, respectively. Our limited data support the use of adjuvant radiotherapy. We also report two cases of MCC located at the vestibule of the nose and two cases of spontaneous regression after diagnostic biopsy. About 40% of our patients were referred to our center for surgical revision and pathological lymph node evaluation. Increased awareness of MCC and an interdisciplinary approach are essential in the management of MCC.

Long-term complications of extraperiosteal plombage.

BACKGROUND: As soon as complications due to migration of extraperiosteal plombage material had been documented, early removal became the rule. Some patients who have escaped this rule may still present with long-term complications. METHODS: Since 1980, 14 patients aged 54 +/- 10 years were admitted 28 +/- 11 years after collapse therapy. Eight presented with signs of infection, 4 with hemoptysis, and 2 with periscapular pain. Vascular erosion, suspected in 3 patients, was demonstrated with angiograms in 1. RESULTS: Ablation of the material was combined with excision of the devitalized ribs in 13 patients. Femorofemoral bypass was used in 2 patients for repair of an aortic erosion. Single ablation of subcutaneously migrated material was performed in a poor-risk patient. Operative bleeding was moderate except in 2 patients; 1 of them died intraoperatively during repair of an aortic erosion. A second patient died postoperatively with a massive pulmonary embolus on day 11. Infection was diagnosed in 8 patients (Mycobacterium tuberculosis, 4; and pyogens, 4). Operative outcome was satisfactory in all 12 operative survivors. A single patient presented with an infected apical space at 1 year and underwent complementary resection of the first rib. CONCLUSIONS: We recommend routine ablation of any residual plombage material whenever operative risk is acceptable because of the high incidence of spontaneous complications.

Does a thoracoscopic approach for surgical treatment of spontaneous pneumothorax represent progress?

OBJECTIVE: Surgical management is indicated in recurrent forms of pneumothorax and for failure of tube drainage. We have for several years performed pleurodesis and apical blebs stapling by axillary thoracotomy. Thoracoscopy has been a well established procedure for 70 years and recently further developed as the result of current technological progress. For 10 years thoracoscopy has been developed as an alternative to thoracotomy in several indications. Spontaneous pneumothorax is ideally suitable for thoracoscopic management. The aim of this retrospective study is to evaluate this new approach. METHODS: We compare our results of axillary thoracotomy management of spontaneous pneumothorax in 237 patients (group 1) with those of thoracoscopic management in 101 patients (group 2). Sex distribution, average age, indications and stapling of apical blebs were comparable in both groups. RESULTS: Etiologies were comparable in both groups. The average operation time was 71 min in group 1 and 57 min in group 2. The average duration of chest tube placement was 8 days in group 1 and 6.5 days in group 2. The mean hospital stay was 14 days in group 1 and 9.5 days in group 2. The overall morbidity was 16 and 11% in groups 1 and 2, respectively. The most frequent complication was early or late failure of pleurodesis which required second drainage or a subsequent operation. Late failure occurred more frequently after thoracoscopy (3 vs. 0.4%) but there was no statistically significant difference between the two groups. CONCLUSIONS: Thoracoscopic management of spontaneous pneumothorax is a safe procedure. Moreover, it offers the benefits of a shorter hospital stay and less postoperative pain.

[Imaging of limbic paraneoplastic encephalitis]. / Imagerie de l'encéphalite limbique paranéoplasique.

Paraneoplastic limbic encephalitis is a rare syndrome mostly associated with small cell lung cancer. We present the case of a 69-year-old man with selective amnesia suggesting limbic encephalitis. A neuroendocrine cell lung cancer was found, confirming the diagnosis of paraneoplastic limbic encephalitis. Contrast-enhanced cerebral CT was normal whether magnetic resonance imaging showed signal abnormalities of the medial part of temporal lobes and hippocampal regions. Because neurologic improvement may follow treatment of the primary tumor, early diagnosis is important.

Blood vessel invasion is a major prognostic factor in resected non-small cell lung cancer.

BACKGROUND: We examined the prognostic value of histologic indices in non-small cell lung cancer with particular interest in major blood vessel invasion. METHODS: We studied 593 patients who had curative resection between November 1983 and December 1988. We determined the histology, T and N status, peritumoral lung tissue invasion, tumor stroma, necrosis, mitotic rate, and blood vessel invasion. RESULTS: The median patient survival of the whole series was 3.2 years, with a 5-year survival of 38.9%. In univariate analysis, a high T stage, a high percentage of necrosis, blood vessel invasion, and N stage significantly worsened the survival. In multivariate analysis, only blood vessel invasion and, less significantly, T stage and lymph node metastasis remained independent prognostic factors. CONCLUSIONS: These results highlight the negative prognostic value of blood vessel invasion in non-small cell lung cancer and suggest that blood vessel invasion, T stage, and node metastasis are three unrelated and distinctive characteristics of resected non-small cell lung cancer.

Pneumonectomy for chronic infection is a high-risk procedure.

BACKGROUND: The purpose of this study was to estimate operative risk, and to identify indicators of adverse prognosis, in patients undergoing pneumonectomy for chronic infection. METHODS: Twenty-five patients aged 41 +/- 15 years underwent pneumonectomy (three completions) for chronic infection: sequelae of tuberculosis, 15; cystic bronchiectasis, 9; and radiation pneumonitis, 1. Eight patients had aspergilloma (7 after tuberculosis, 1 with radiation pneumonitis). RESULTS: Operative mortality was 4%. Operative blood loss was estimated at 1,983 +/- 1,424 mL, ranging from 150 to 5,600 mL. A single patient required reexploration. Eight patients (32%) had empyema, and a further 3 (12%) had bronchopleural fistula; thoracoplasty was required for 10 (40%). Sequelae of tuberculosis heralded increased operative bleeding (t = 2.884; p < 0.005). Incidence of empyema or bronchopleural fistula was increased in patients with sequelae of tuberculosis (chi 2 = 3.896; p < 0.05), patients with aspergilloma (chi 2 = 4.588; p < 0.05), patients in whom the parenchymal cavities were entered (chi 2 = 11.5; p < 0.001), and those in whom blood loss was in excess of 1,000 mL (chi 2 = 4.911; p < 0.05). CONCLUSIONS: We conclude that pneumonectomy is a high-risk procedure, especially in patients with sequelae of tuberculosis.

Tracheobronchial lacerations after intubation and tracheostomy.

BACKGROUND: Although long-term complications of intubation and tracheostomy are well documented, little has been reported on acute complications of airway access techniques. METHODS: Fourteen patients (1 male and 13 female patients) aged 15 to 80 years presented with tracheobronchial lacerations after single-lumen intubation (n = 9), double-lumen intubation (n = 1), or tracheostomy (n = 4). RESULTS: A left bronchial laceration after double-lumen intubation was discovered and repaired intraoperatively. A tracheal laceration after single-lumen intubation was recognized during induction of anesthesia. The remaining 12 were diagnosed within 6 to 126 hours (median, 24 hours) after injury. All patients had mediastinal and subcutaneous emphysema. At endoscopy, 12 injuries were located in the thoracic trachea and 1 in the cervical trachea. Twelve underwent primary repair through a right thoracotomy (n = 11) or left cervicotomy (n = 1), and 1 was treated conservatively. Two patients with tracheostomy injury died postoperatively. All repairs healed well but one. The latter was performed 5 days after the injury; a dehiscence occurred, but healed spontaneously. CONCLUSIONS: We conclude that prognosis of tracheal lacerations depends both on the general health of the patient and on the rapidity of diagnosis and treatment.

Bronchogenic cancer in the elderly: operative risk and long-term prognosis.

Surgery for bronchogenic cancer raises the question of benefit to elderly patients. The present study reviews a cohort of 223 patients aged 70 years and more (range: 70-84), who underwent thoracotomy for pulmonary malignancy over a 10-year period. The aim of the study was to evaluate both operative risk and 5-year survival. Medical history was negative in 29% of the patients; 26% had a history of cardio-vascular disease, and 19% had a history of malignancy in complete remission. Tumor histology was squamous-cell carcinoma for 70.4%, adenocarcinoma for 24.2%, large-cell carcinoma for 3.6%, and small-cell carcinoma for 1.3% of the patients. 48.4% of patients were in stage I, 17.2% in stage II, and 30.3% in stage III. Exploratory thoracotomy was carried out in 5.8% of patients. A resection was achieved in 210 patients (pneumonectomy in 28.5%, lobectomy in 71.5%). Operative mortality was 7.2% for the whole series, 10% after pneumonectomy and 6.6% after lobectomy. Mortality was similar below and above 75 years. Overall 5-year survival was 32.9% (45.7% for stage I, 36.3% for stage II, and 13.8% for stage III). Survival was not influenced by age, symptomatic or asymptomatic presentation, medical history, and in particular not by history of malignant disease. Although operative mortality is slightly increased when compared to younger patients, long-term results legitimize surgery for bronchogenic cancer in the elderly.

Association of bronchial and pharyngo-laryngeal malignancies. A reappraisal.

OBJECTIVE: The purpose of this study was to re-evaluate operative risk and probability for survival patients with a history of upper aerodigestive cancer, who underwent thoracotomy for presumed primary bronchogenic cancer. Our hypothesis was to consider any isolated lung opacity as a primary bronchogenic cancer. METHODS: The cohort under investigation included 114 consecutive patients. Histology of bronchial cancer was squamous cell carcinoma in 98 patients (86%), adenocarcinoma in 14 (12%) and large cell carcinoma in 2 (2%). Exploratory thoracotomy was performed in 5 patients (4%); the remaining 109 patients underwent a potentially curative resection, including 25 pneumonectomies (22%) and 84 conservative resections (74%). Pathological staging was as follows: 66 stage I (58%), 20 II (17.5%), 20 IIIa (17.5%), 6 stage IIIb (5%), and 2 stage IV (2%). RESULTS: Four patients died post-operatively (3.5%). Non-fatal morbidity concerned 32 patients (28.1%) and was dominated by respiratory superinfections. Incidence of respiratory infections was increased after voice-sparing resections (chi 2 = 4.311, P < 0.05), and more particularly after transmaxillary buccopharyngectomy (chi 2 = 12.224; P < 0.01). Estimated 5-year survival was 28.7% (33.3% in stage I, 19.2% in stage II, and 30.2% in stage III). There was no difference in survival with reference to the location of head and neck cancer (chi 2 = 3.412; 0.05 < P < 0.1) or chronology (chi 2 = 0.005; P > 0.9). CONCLUSIONS: We conclude that isolated lung opacities in patients with previous or simultaneous head and neck cancer are most likely primary bronchogenic cancers. The acceptable operative mortality legitimizes surgical treatment despite an impaired 5-year survival; patients with a previous voice-sparing operation are at increased risk for respiratory complications and should be managed carefully.

The dendritic cell lineage: a ubiquitous antigen-presenting organization.

Dendritic cells are specialized antigen-presenting cells with two unique characteristics: the greatest stimulatory potential and the ability to stimulate naive T-lymphocytes. They originate from the bone marrow and reach their destination via hematogenous or lymphatic migration. Their phenotype is characterized by a high expression of major histocompatibility complex class II molecules and a high expression of adhesion molecules (CD25, CD54, CD58, CD72, and CD80). Pulmonary dendritic cells may be investigated by histologic examination, phenotype analysis, and function studies in a mixed lymphocyte reaction. Their isolation requires enzymatic digestion of lung tissue and subsequent steps of cell separation. The complexity of these manipulations makes it difficult to obtain large numbers of viable cells. A close anatomic relationship with alveolar macrophages underlines a functional interconnection: macrophages down-regulate the antigen-presenting function through release of tumor necrosis factor alpha. Dendritic cells most probably play a major role in lung diseases such as histiocytosis, primary and secondary cancers, and both acute and chronic lung graft rejection. Identification of the precise functional pathways might lead to therapeutic use of modulation of dendritic cell function.

[Do pericardial strips (Peri-Strip) facilitate the follow-up after pulmonary surgery in emphysematous patients?]. / Les bandelettes de péricarde (Peri-Strip) facilitent-elles les suites après chirurgie pulmonaire chez le patient emphysémateux?

The aim of this study was to evaluate the contribution of bovine pericardial strips (Peri-Strip) to achieve aerostasis within emphysematous lungs. A preliminary evaluation included 15 patients (13 men and 2 women, mean age 57 years) with severe emphysema (mean FEV-1: 28.6 +/- 10.2% of predicted, mean RV: 18.4 +/- 41.3% of predicted). Two patients were on ventilator owing to acute respiratory failure. Indication for surgery was elective surgery for emphysema in 9 patients, emergency surgery for emphysema in 2, and resection for bronchogenic cancer in 4 patients. The various procedures included single aerostasis in 1, unilateral bullectomy in 6, bilateral volume reduction in 4, thoracoscopic wedge resection for peripheral cancer in 1 and lobectomy for cancer in 3 (2 of which underwent simultaneous bullectomy) Peri-Strip were used to buttress the staple lines at the base of bullae, on parenchymatous transsection lines, and on the borders of fissures. One patient who underwent emergency thoracotomy for single aerostasis died 8 days post-operatively due to multiple organ failure. Another patient developed pneumonia which resolved under treatment. Mean duration of air leaks was 5.6 days (0-21, median 8). Two patients required tube thoracotomy for residual effusions. Mean hospital stay was 17 days (6-53; median 16). We conclude that use of Peri-Strip offered a real benefit to 12 patients; no evidence of benefit was noted in 3 patients.

Decortication is a valuable option for late empyema after collapse therapy.

BACKGROUND: Infection of previous collapse therapy spaces may raise challenging problems. This study evaluated a conservative surgical approach based on decortication. METHODS: Since 1979, 28 patients (mean age, 60 +/- 6 years) have presented at an average of 37 +/- 7 years after artificial pneumothorax for tuberculosis. Diagnosis of empyema was made on follow-up in 12 patients and on symptoms in 16 patients. Mean vital capacity was 66% +/- 16% of normal. Microorganisms were isolated in 13 patients (Aspergillus fumigatus in 5, Mycobacterium tuberculosis in 4, anaerobes in 4). Decortication was made in 24 patients, associated with thoracoplasty in 4, and with partial lung resection in 2 patients. Thoracoplasty alone was performed in 2 patients, and 2 patients underwent an extrapleural pneumonectomy. RESULTS: Both extrapleural pneumonectomies were complicated with empyema requiring thoracoplasty, resulting in one postoperative death. Operative mortality after decortication was nil. Mean intraoperative blood loss during decortication was 1,830 +/- 1,310 mL. All patients were extubated within 24 hours, except 1 patient who was ventilator-dependent preoperatively. Prolonged air leaks were common (mean duration of drainage, 16 +/- 11 days), but ultimately sealed. Existence of symptoms was predictive of prolonged air leaks (p < 0.01). CONCLUSIONS: We conclude that decortication may provide a one-stage cure avoiding the hazards of extrapleural pneumonectomy; the nonfunctioning remaining lung may resolve the space problem.