Optimal resection margin for head and neck cutaneous melanoma.

OBJECTIVES/HYPOTHESIS: The objective of this study was to examine the difference between a narrow (between 1 and 2 cm) and a wide (>2 cm) margin in the surgical resection of head and neck cutaneous melanoma. STUDY DESIGN: Population-based cohort analysis. METHODS: The Surveillance, Epidemiology, and End Results database was employed to identify patients who had cutaneous melanoma of the head and neck from 2004 to 2014. Outcome measures were overall survival (OS) and disease-specific survival (DSS). RESULTS: Among the total of 3,583 cases of cutaneous melanoma of the head and neck with known resection margins, 2,641 individuals had narrow resection margins, and 942 patients had wide margins. Most of the tumors presented in the skin of the scalp and neck, followed by the face, external ear, and other areas. The 5-year and 10-year Kaplan-Meier OS probabilities for narrow and wide margins were 65% and 66%, respectively, compared with 49% and 48%, respectively. The DSS probabilities exhibited similar trends between the two groups at these time points. In the Cox regression model, the patients who received narrow margins had similar OS (95% confidence interval [CI]: 0.918-1.217) and DSS (95% CI: 0.856-1.352) compared with the wide resection margin group, even when controlled for age, sex, T stage, and histology. CONCLUSIONS: The survival of patients with cutaneous melanoma of the head and neck depends on age, depth of tumor invasion, and histology. Within the head and neck, a wider resection margin of >2 cm does not confer any additional survival benefit compared with a narrower margin. Future studies should examine whether wider surgical margins would confer survival benefit in local or recurrent melanoma. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1386-1394, 2019.

The Gracilis Free Flap.

The gracilis free flap is the ideal modality of emotive and spontaneous facial reanimation in patients with a viable contralateral facial nerve. A 2-stage procedure with a cross-face nerve graft followed by gracilis free flap inset is advocated. In this article, the anatomy of the gracilis muscle, alternative neural sources (including the masseteric nerve), and technical aspects of the procedure are discussed. The literature regarding outcomes and complications is reviewed.

Acute vocal fold dystonic reaction to propofol: a case report.

A 67-year old male underwent uneventful robotic-assisted thoracoscopic resection of a solitary pulmonary fibrous tumor. Immediately following extubation at the completion of the surgical procedure, the patient developed respiratory distress that did not resolve with treatment. Benadryl provided only temporary relief. Midazolam and hydromorphone were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening. The patient was then given diazepam and reintubated. Given the patient's history of difficulty breathing after previous surgery and the lack of vocal cord movement, dystonic reaction to propofol was suspected. The patient remained intubated for two hours in the post-anesthesia care unit before being extubated uneventfully.

Frontoethmoid osteoma with pneumocephalus: options for surgical management.

Pneumocephalus is an exceedingly rare complication associated with neurological deficit in cases of frontoethmoid osteoma. The overarching management strategy for affected patients remains undefined. We describe the case of a 61-year-old female patient presenting with frontoethmoid osteoma manifesting as profound intraparenchymal pneumocephalus and associated neurological deficit, treated through a minimally invasive combined surgical strategy involving image-guided burr hole decompression of the pneumocephalus followed by transnasal endoscopic removal of the tumor. Using this approach, the patient rapidly recovered full neurologic function. We review the existing literature and, given the likely intraparenchymal location of pneumocephalus associated with these lesions with the potential of rapid clinical deterioration, recommend aggressive surgical management. Although these lesions can be removed from a purely endoscopic approach, we recommend burr-hole decompression of the pneumocephalus as an adjunct to ensure prompt resolution of the neurologic symptoms.

Defective DNA double-strand break repair in pediatric systemic lupus erythematosus.

OBJECTIVE: Previous reports of cells from patients with systemic lupus erythematosus (SLE) note that repair of single-strand breaks is delayed, and these lesions may be converted to double-strand breaks (DSBs) at DNA replication forks. We undertook this study to assess the integrity of DSB recognition, signaling, and repair mechanisms in B lymphoblastoid cell lines derived from patients with pediatric SLE. METHODS: Nine assays were used to interrogate DSB repair and recognition in lymphoblastoid cell lines from patients with pediatric SLE, including the neutral comet assay (NCA), colony survival assay (CSA), irradiation-induced foci formation for γ-H2AX and 53BP1 proteins, kinetics of phosphorylation of structural maintenance of chromosomes protein 1 (SMC1), postirradiation bromodeoxyuridine incorporation to evaluate S phase checkpoint integrity, monoubiquitination of Fanconi protein D2, ATM protein expression, and non-homologous DNA end joining protein expression and function. RESULTS: Three of the 9 assays revealed abnormal patterns of response to irradiation-induced DNA damage. The NCA and CSA yielded aberrant results in the majority of SLE lymphoblastoid cell lines. Abnormal prolongation of SMC1 phosphorylation was also noted in 2 of 16 SLE lymphoblastoid cell lines. CONCLUSION: Our data suggest that DSB repair is defective in some lymphoblastoid cell lines from pediatric patients with SLE, especially when assessed by both NCA and CSA. Since these studies are nonspecific, further studies of DNA repair and kinetics are indicated to further delineate the underlying pathogenesis of SLE and possibly identify therapeutic targets.

High-throughput screening identifies two classes of antibiotics as radioprotectors: tetracyclines and fluoroquinolones.

PURPOSE: Discovery of agents that protect or mitigate normal tissue from radiation injury during radiotherapy, accidents, or terrorist attacks is of importance. Specifically, bone marrow insufficiency, with possible infection due to immunosuppression, can occur after total body irradiation (TBI) or regional irradiation and is a major component of the acute radiation syndrome. The purpose of this study was to identify novel radioprotectors and mitigators of the hematopoietic system. EXPERIMENTAL DESIGN: High-throughput screening of small-molecule libraries was done using viability of a murine lymphocyte line as a readout with further validation in human lymphoblastoid cells. The selected compounds were then tested for their ability to counter TBI lethality in mice. RESULTS: All of two major classes of antibiotics, tetracyclines and fluoroquinolones, which share a common planar ring moiety, were radioprotective. Furthermore, tetracycline protected murine hematopoietic stem/progenitor cell populations from radiation damage and allowed 87.5% of mice to survive when given before and 35% when given 24 h after lethal TBI. Interestingly, tetracycline did not alter the radiosensitivity of Lewis lung cancer cells. Tetracycline and ciprofloxacine also protected human lymphoblastoid cells, reducing radiation-induced DNA double-strand breaks by 33% and 21%, respectively. The effects of these agents on radiation lethality are not due to the classic mechanism of free radical scavenging but potentially through activation of the Tip60 histone acetyltransferase and altered chromatin structure. CONCLUSIONS: Tetracyclines and fluoroquinolones can be robust radioprotectors and mitigators of the hematopoietic system with potential utility in anticancer radiotherapy and radiation emergencies.

Vacations to waterside locations result in nevus development in Colorado children.

Nevi are a main risk factor for malignant melanoma, and most nevi develop in childhood. This study examined the relationship between vacations and nevi in 681 White children born in 1998 who were lifetime residents of Colorado. Vacation histories were assessed through telephone interviews of parents, whereas nevus and phenotypic characteristics were assessed through skin exams at age 7. Multiple linear and logistic regression were used to assess the influence of vacations on counts of nevi <2 mm in size and the presence of any nevi > or = 2 mm after controlling for other variables. Each waterside vacation > or = 1 year before the exam at age 7 was found to be associated with a 5% increase in nevi <2 mm. Waterside vacations <1 year before the skin exam were not related to nevus count (<2 mm); regardless of timeframe, waterside vacations were not related to the presence of nevi > or = 2 mm. UV dose received on waterside vacations, number of days spent on waterside vacations, and nonwaterside vacations were not significantly related to nevi <2 or > or = 2 mm. These results suggest that there is a lag of at least 1 year in the development of new nevi after vacation sun exposure. It appears that a threshold dose of UV exposure is received quickly on each waterside vacation. Parents of young children should exercise caution in selection of vacation locations to reduce melanoma risk.