Radial forearm free flap following axillary node dissection and radiotherapy: is it safe?

This is the first published case report of a successful radial forearm free flap harvest on the same side in a patient who had undergone a mastectomy, axillary dissection, and radiotherapy 10 years prior to flap harvest.

Epithelial-myoepithelial carcinoma of the maxillofacial and sinonasal region: a systematic review of presenting characteristics, treatment modalities, and associated outcomes.

Epithelial-myoepithelial carcinoma (EMC) is a rare salivary gland malignancy. Controversy exists in the literature regarding the effectiveness of treatment modalities employed in the management of EMC. This systematic review was undertaken to understand the presenting characteristics of EMC and identify the most common treatment modalities and their associated outcomes, in order to help guide an evidenced-based approach to the algorithm of care. The MEDLINE (PubMed) and Embase databases were searched (up to February 23, 2022), and the review was performed in accordance with the PRISMA statement. Fifty-seven studies (51 case reports and six case series) describing 91 cases of EMC were included in this review. In the included studies, a slow-growing painless mass was the most common presenting clinical feature. EMC was most frequently treated with surgery alone (65%). Local disease recurrence occurred in 24% of the cases and metastatic disease in 11%. A positive surgical margin was found to be associated with a higher risk of recurrence (P < 0.001), while adjuvant radiotherapy was associated with a decreased risk of local disease recurrence (P = 0.034). Metastatic disease and multimodal therapy were found to be associated with decreased disease-free and overall survival (all P < 0.05). The current literature supports surgery with clear margins as the mainstay of treatment for EMC of the salivary and seromucous glands of the head and neck. In certain situations, radiotherapy may improve disease-free survival.

Adenoid cystic carcinoma of the palate with isolated cutaneous metastasis: a unique case and review of current and future treatment modalities of metastatic disease.

Adenoid cystic carcinoma (ACC) is an aggressive salivary gland neoplasm characterized by high rates of local recurrence, early metastasis, and a poor long-term prognosis. Approximately 20-50% of cases result in distant metastasis, commonly involving the lung, bone, liver, and brain. Cutaneous metastasis is a rare occurrence, with a small number of cases reported previously in the context of multiple metastatic sites of involvement. We present a unique case of ACC of the hard palate with isolated cutaneous metastasis. A 36-year-old woman underwent a subtotal maxillectomy and skull base resection for the treatment of a T4N0 ACC of the right maxilla. One year postoperatively, the patient presented with multiple rapidly growing painful nodules on the skin of the scalp, neck, and chest. Biopsy confirmed metastatic poorly differentiated ACC, and positron emission tomography demonstrated cutaneous metastatic lesions without evidence of other tissue involvement. This case highlights the possible rare and aggressive pathways of metastasis of ACC. Currently there is no consensus for the treatment of disseminated disease, due to the poor efficacy of current treatment modalities. Where isolated metastasis is present, surgical resection can be attempted to control disease progression; however the benefit of metastasectomy on survival is not substantiated. As such, the role of newer targeted systemic therapies needs to be further investigated in the hope of achieving disease control.

Immunotherapy in the management of squamous cell carcinoma of the head and neck.

Despite many advances in surgery, radiotherapy, and systemic treatments, only modest improvements in survival, function, and quality of life have been achieved after treatment of squamous cell carcinoma (SCC) of the head and neck. With a better understanding of the biology and genetics of tumours, the emergence of a paradigm shift towards the further development of non-surgical treatments may result in less morbidity and better outcomes than are seen currently. SCC of the head and neck is known to be a complex disease that has a sophisticated interaction with the human immune system. At the forefront of emerging treatments is immunotherapy, which has already been established in many other areas of oncology. The rapidly evolving nature of immunotherapeutic agents and, sometimes, their complex mechanisms can make the understanding of these concepts challenging, and could discourage clinicians from engaging in clinical trials. The aim of this paper therefore was to review the current premise for immunotherapeutic approaches, and to provide a contemporary evidence-based rationale for their use.

Radiographic study to assess the reliability of the Gillies approach for biopsy of the superficial temporal artery.

Biopsy of the superficial temporal artery is often used in the diagnosis of giant cell arteritis, but at traditional sites there is a risk of injury to the facial nerve. Recently the Gillies incision has been suggested as an alternative means of access for the biopsy, but the anatomical basis of this has not been fully elucidated. We therefore undertook a radiographic review of 150 patients, and examining 300 vessels, to find out. Our results indicated that there is considerable variability in the position of the bifurcation of the superficial temporal artery, and so a Gillies approach may not be reliable, particularly if access to the bifurcation is required.

Long-term outcomes of craniofacial implants for the restoration of facial defects.

The aim of this study was to evaluate the long-term survival of craniofacial implants and prostheses and to identify factors associated with failure in a cohort of patients. A 25-year retrospective analysis was conducted at Royal Melbourne Hospital. Data included demographic characteristics, age, site and cause of the deformity, and number and survival of implants. Odds ratios were calculated and event-to-time Kaplan-Meier analyses performed. One hundred and ten patients were included (341 implants); their mean age was 46.2 years. The overall implant survival rate was 79.5% (mean follow-up 10.6 years). Temporal implants had the highest success rate (97.0%), followed by nasal implants (87.5%) and orbital implants (63.3%); differences were statistically significant (P<0.0001 and P=0.033, respectively). Kaplan-Meier analyses to determine long-term implant and prosthesis survival found temporal implants had the highest prosthetic (P<0.0001) and implant survival (P<0.0001). Patients with congenital deformities demonstrated the highest success rate. Radiotherapy was found to increase the risk of implant failure (P=0.02). Craniofacial implant-retained prostheses are a reliable and effective option for the restoration of facial defects, with good long-term success rates. Orbital implants and those placed post oncological surgery have a higher failure rate.

Odontogenic myxoma in the paediatric patient: a review of eight cases.

Paediatric odontogenic myxoma (OM) is a rare pathological condition in the oral and maxillofacial region. There has been much debate in the literature regarding the preferred method of treatment; however due to the rare nature of this disease, definitive algorithms of management are yet to be determined. A case series of eight paediatric patients with OM is presented. Six of the lesions were in the maxilla and two were mandibular lesions. The patients were aged between 2 and 18 years. Treatment ranged from excision and the application of Carnoy's solution to segmental resection and reconstruction. From this case series it can be seen that even in situations where treatment was limited to excision and the application of Carnoy's solution, no recurrences occurred. As such the present authors favour an initially more conservative approach to the management of these lesions where possible and reserving conventional resective treatment for recurrences, lesions causing pathological fracture, and those in regions that are difficult to access.

Purification and characterization of cellobiose dehydrogenase from the plant pathogen Sclerotium (Athelia) rolfsii.

Cellobiose dehydrogenase (CDH) is an extracellular hemoflavoenzyme produced by several wood-degrading fungi. In the presence of a suitable electron acceptor, e.g., 2,6-dichloro-indophenol (DCIP), cytochrome c, or metal ions, CDH oxidizes cellobiose to cellobionolactone. The phytopathogenic fungus Sclerotium rolfsii (teleomorph: Athelia rolfsii) strain CBS 191.62 produces remarkably high levels of CDH activity when grown on a cellulose-containing medium. Of the 7,500 U of extracellular enzyme activity formed per liter, less than 10% can be attributed to the proteolytic product cellobiose:quinone oxidoreductase. As with CDH from wood-rotting fungi, the intact, monomeric enzyme from S. rolfsii contains one heme b and one flavin adenine dinucleotide cofactor per molecule. It has a molecular size of 101 kDa, of which 15% is glycosylation, and a pI value of 4.2. The preferred substrates are cellobiose and cellooligosaccharides; additionally, beta-lactose, thiocellobiose, and xylobiose are efficiently oxidized. Cytochrome c (equine) and the azino-di-(3-ethyl-benzthiazolin-6-sulfonic acid) cation radical were the best electron acceptors, while DCIP, 1,4-benzoquinone, phenothiazine dyes such as methylene blue, phenoxazine dyes such as Meldola's blue, and ferricyanide were also excellent acceptors. In addition, electrons can be transferred to oxygen. Limited in vitro proteolysis with papain resulted in the formation of several protein fragments that are active with DCIP but not with cytochrome c. Such a flavin-containing fragment, with a mass of 75 kDa and a pI of 5.1 and lacking the heme domain, was isolated and partially characterized.

Cloning and characterization of a thermostable cellobiose dehydrogenase from Sporotrichum thermophile.

Cellobiose dehydrogenase (CDH) is an extracellular hemoflavoenzyme produced by several wood-degrading fungi. CDH contains one heme b and one FAD per molecule and oxidizes cellobiose to cellobionolactone in the presence of cytochrome c. In this report, a thermostable CDH from the thermophilic ascomycete Sporotrichum thermophile has been purified, cloned, and characterized. The temperature optimum for this CDH reaction was 60 degrees C, and the activation energy for the reaction was 26.3 kJ/mol. The Km and kcat were temperature-dependent and increased as reaction temperature increased. These kinetic properties prove that this CDH is truly thermophilic. A 2.8-kb cDNA was isolated by screening an expression library of S. thermophile with a polyclonal antisera raised against Phanerochaete chrysosporium CDH. The cDNA encoded an 807-amino-acid protein with a predicted mass of 86,332 Da. S. thermophile CDH is organized into three domains, an N-terminal flavin domain, a middle heme domain, and a C-terminal cellulose-binding domain, which shows sequence similarity with the cellulose-binding domains of endoglucanases and cellobiohydrolases from Trichoderma reesei. Comparison with the CDH sequences of P. chrysosporium and Trametes versicolor identified Met 95 and His 143 as potential heme coordinations. EFIG, LGGPM, and VNSTH motifs in the heme domain and the XRXPXTDXPSXDGXRY motif in the flavin domain were identified as CDH-specific motifs. With regard to the amino acid composition, S. thermophile CDH has more disulfide linkages and acidic and basic amino acids compared to CDHs from P. chrysosporium and T. versicolor.

Resonance Raman spectroscopic studies of cellobiose dehydrogenase from Phanerochaete chrysosporium.

Cellobiose dehydrogenase (CDH), an extracellular hemoflavoenzyme produced by cellulose-degrading cultures of Phanerochaete chrysosporium, oxidizes cellobiose to cellobionolactone. The enzyme contains one 6-coordinate, low-spin b-type heme and one FAD cofactor per monomeric protein. In this work, resonance Raman (RR) spectra are reported for the oxidized, reduced, and deflavo forms of CDH as well as the individual flavin and heme domains of the enzyme obtained by peptide proteolysis. The RR spectra of the flavin and heme groups of CDH were assigned by comparison to the spectra of other hemoflavoenzymes and model compounds. Proteolytic cleavage of the CDH domains had only a minimal spectroscopic effect on the vibrational modes of the heme and FAD cofactors. Excitation of the oxidized CDH holoenzyme at 413 or 442 nm resulted in photoreduction of the heme. However, the same excitation wavelength used on the deflavo form of the enzyme or on the heme domain alone did not cause photoreduction, indicating that photoinitiated electron transfer requires the FAD cofactor. These observations suggest an enzymatic mechanism whereby reducing equivalents obtained from the oxidation of cellobiose are transferred from the FAD to the heme. A similar mechanism has been proposed for flavocytochrome b2 of Saccharomyces cerevisiae which oxidizes lactate to pyruvate (A. Desbois et al., 1989, Biochemistry 28, 8011-8022).

Treatment of idiopathic spasmodic torticollis with botulinum toxin A: a double-blind study on twenty-three patients.

In a double-blind, placebo-controlled study, 23 patients suffering from intractable spasmodic torticollis (ST) were given successively either botulinum toxin A (BTA) or normal saline by intramuscular injections in the affected muscles. Evaluation was carried out by three blinded observers, using a clinical and video assessment of the severity of torticollis, employing a scoring system described by Tsui (1). Patients were also asked to subjectively comment on changes in the amount of pain and on changes in the activities of daily living (ADL). BTA was proven to be superior on all forms of assessment to placebo, and these results were statistically significant. Side effects mainly consisted of pain at the injection site. Tiredness occurred at equal frequency with BTA and placebo. No serious or systemic side effects were noted. Botulinum toxin is a safe, effective and relatively simple treatment for spasmodic torticollis.

Treatment of idiopathic spasmodic torticollis with botulinum-A toxin: a pilot study of 19 patients.

Nineteen patients with spasmodic torticollis, unresponsive to standard therapy, were administered local injections of botulinum-A toxin into the affected muscles. During an average follow-up period of 11.5 months, a more than 25% improvement was noted in 14 of 19 patients. All those with purely focal dystonia and 9 of 10 patients with a disease history of less than three years benefited from treatment. Side effects were insignificant and transient. Botulinum toxin is a very effective and safe method of treatment for spasmodic torticollis.