The differential diagnosis of central compartment radioactive iodine uptake after thyroidectomy: anatomic and surgical considerations.

OBJECTIVE: Foci of increased radioactive iodine (RAI) uptake in the thyroid bed following total thyroidectomy (TT) indicate residual thyroid tissue that may be benign or malignant. The use of postoperative RAI therapy in the form of remnant ablation, adjuvant therapy, or therapeutic intervention is often followed by a posttherapy scan. Our objective is to improve the clinician's understanding of the anatomic complexity of this region and to enhance the interpretation of postoperative scans. METHODS: We conducted a comprehensive review of the literature evaluating RAI uptake in the central compartment following thyroid cancer treatment and literature related to anatomic nuances associated with this region. Thirty-eight articles were selected. RESULTS: Through extensive surgical experience and a literature review, we identified the 5 most important anatomic considerations for clinicians to understand in the interpretation of foci of increased RAI uptake in the thyroid bed on a diagnostic scan: 1) residual benign thyroid tissue at the level of the posterior thyroid ligament, 2) residual benign thyroid tissue at the superior portion of the pyramidal lobe and/or superior poles of the lateral thyroid lobes, 3) residual benign thyroid tissue that was left attached to a parathyroid gland in order to preserve its vascularity, 4) ectopic benign thyroid tissue, and 5) malignant thyroid tissue that has metastasized to central compartment nodes or invaded visceral structures. CONCLUSION: By correlating anatomic description, medical illustrations, surgical photos, and scans, we have attempted to clarify the reasons for foci of increased uptake following TT to improve the clinician's understanding of the anatomic complexity of this region.

Locoregional Flap Closure for High-risk Multilevel Spine Surgery.

BACKGROUND: Postoperative wound complications pose a challenge to patients undergoing complex spine surgery. Long-term sequelae can be devastating including decreased quality of life, meningitis, prolonged hospital stay, and need for reoperation. Among high-risk patients, postoperative wound complications have been shown to approach 40% in the literature. The aim of this study was to identify predictive factors for postoperative complications following soft-tissue reconstruction after high-risk spine surgery with the hypothesis that it would result in significantly fewer postoperative wound complications. METHODS: A retrospective review of 67 consecutive spine operations at an academic, tertiary care center was performed, evaluating outcomes with a single plastic surgeon in conjunction with the spine surgery team. Data regarding patient demographics, perioperative risk variables, flap type, location of defect, and postoperative outcomes were obtained through retrospective chart review. Complications included soft-tissue complications and a number of reoperations. A bivariate analysis was used to identify predictors of postoperative complication. These data were compared to literature-reported averages. RESULTS: A total of 67 consecutive spinal reconstructive operations were included with a mean follow-up of 11.8 months. Thirty-seven patients (55.2%) underwent immediate reconstruction at the time of the index operation, and 30 (44.8%) underwent delayed reconstruction for secondary wound healing problems following the index operation (in which plastic surgery was not involved). The majority of both immediate (95%, n = 35) and delayed (100%, n = 30) patients was defined as high risk based on literature standards. Patients in this series demonstrated a 7.5% complication rate, compared to 18.7% complication rate in the literature. We did not find a difference between major wound complications in the immediate (8.1%) or delayed (6.7%) reconstructive setting (P > 0.99). There were no specific variables identified that predicted postoperative complications. CONCLUSION: This study illustrates a postoperative complication rate of 7.5% among patients undergoing paraspinous or locoregional muscle flap closure by plastic surgery, which is significantly lower than that reported in contemporary literature for these high-risk patients.

Clinical Outcomes of Limited Open Intramedullary Headless Screw Fixation of Metacarpal Fractures in 91 Consecutive Patients.

Background: The objective of the study is to evaluate clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw (IMHS) fixation for metacarpal neck and shaft fractures. Methods: Retrospective review of 91 consecutive patients (79 men; 12 women), mean age 28 (range =15-69) years, treated with IMHS fixation for acute displaced metacarpal neck (N = 56) and shaft (N = 35) fractures at a single institution. Mean follow-up was 10 (range = 1-71, median = 3) months. Preoperative mean magnitude of metacarpal neck angulation was 48° (range = 0°-90°), and mean shaft angulation was 42° (range = 0°-70°). Active motion was initiated within 5 days postoperatively. Clinical outcomes were assessed with digital goniometry, grip strength, and return to full activity. The time to radiographic union and radiographic arthrosis was assessed. Results: All 91 patients achieved full functional arc of metacarpophalangeal (MCP) motion, and all achieved full active MCP extension or hyperextension. At mean follow-up of 10 months, postoperative mean MCP joint flexion-extension arc was 88° (range = 55°-110°). Grip strength was available for 52 patients and measured 104.1% of the contralateral hand (range = 58%-230%). Radiographic union data were available for 86 patients. Seventy-six percent (65/86) achieved radiographic union by the end of week 6 (range = 2-10 weeks). Early arthrosis was noted in 1 patient at the MCP. There were 3 cases of shaft refracture after recurrent blunt trauma, following prior evidence of full osseous union. Conclusions: The IMHS fixation is safe, reliable, and durable for metacarpal neck/subcapital, axially stable shaft fractures, and select delayed unions or malunions. It allows for early postoperative motion without affecting union rates and obviates immobilization. This technique offers distinct advantages over formal open reduction and percutaneous Kirschner wire techniques.

Ulnar Nerve Complications After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review.

BACKGROUND: While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. PURPOSE: The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. UCLR case series that contained complications data were included. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Meta-analysis of the pooled data was completed. RESULTS: Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. There were no cases of intraoperative ulnar nerve injury reported. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). CONCLUSION: Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature.

Approach to en bloc resection and reconstruction of primary masticator space malignancies.

OBJECTIVES/HYPOTHESIS: The aim of this study was to present our experience with management of malignant lesions arising within the masticator space, and to describe a technique of en bloc resection and reconstruction. STUDY DESIGN: Case series and case report. METHODS: Eight cases of masticator space malignancies treated surgically with en bloc resection and free flap reconstruction were retrospectively reviewed. RESULTS: Tumor extirpation was carried out through a parotidectomy approach with mobilization and protection of the facial nerve. Primary reconstruction was accomplished with vascularized bone containing free flaps, fibula (n = 4), scapula (n = 2), and scapula with latissimus dorsi muscle (n = 2). Mean follow-up was 62.5 months (range, 18-132 months). CONCLUSIONS: En bloc resection of masticator space malignancies can be consistently accomplished through an extended parotidectomy approach. The defect is best reconstructed with a vascularized bone and soft tissue free flap. Favorable functional and aesthetic outcomes can be successfully achieved using the techniques described in this series. LEVEL OF EVIDENCE: 4.

Staged laryngeal reconstruction with a prefabricated flap for radiation recurrent glottic carcinoma.

OBJECTIVES/HYPOTHESIS: Although salvage total laryngectomy remains the definitive approach to recurrent/persistent glottic cancer following failed radiation therapy for favorable early-stage disease, it comes at the price of a permanent laryngostome and an impact on quality of life. We describe a three-stage method of laryngeal reconstruction for salvage partial laryngectomy to address the unique challenges of operating on radiation recurrent/persistent cancer. STUDY DESIGN: This was a single-surgeon retrospective case series of patients who underwent a three-stage laryngeal reconstruction for salvage partial laryngectomy. METHODS: We performed a comprehensive review of the clinical, pathologic, and radiologic files of all patients who underwent a three-stage laryngeal reconstruction for salvage partial laryngectomy. RESULTS: Seven male patients underwent a three-stage laryngeal reconstruction following open partial salvage laryngectomy. The average follow-up time since salvage surgery was 55 months. All patients were without evidence of recurrence and demonstrated satisfactory functional outcomes. CONCLUSION: Staged reconstruction provides a more controlled assessment of wound healing and valuable pathologic information regarding the specific disease virulence and adequacy of the margins. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1061-1070, 2016.

Subscapular system of flaps: An 8-year experience with 105 patients.

BACKGROUND: Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps. METHODS: A retrospective medical chart review was conducted on all patients who underwent the subscapular system of free flaps for head and neck reconstruction. RESULTS: Ninety-eight reconstructions were performed for mandibular defects, 4 for maxillary defects alone and 3 for combined mandible-maxilla defects. The overall success rate was 98%. CONCLUSION: The subscapular system of free flaps is an excellent option in patients for whom the alternative donor sites are either not usable or lack the associated soft tissue elements required for a successful reconstruction. This flap should also be considered as a first choice for patients with complex/extensive surgical defects requiring multiple, independently mobile, soft tissue components; in patients who will benefit from a large muscle flap placed over the vital structures in the neck; patients of advanced age; and patients in whom early mobilization is critical.

Database and registry research in thyroid cancer: striving for a new and improved national thyroid cancer database.

BACKGROUND: Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations. SUMMARY: In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries. CONCLUSION: A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.

Management of recurrent and persistent metastatic lymph nodes in well-differentiated thyroid cancer: a multifactorial decision-making guide for the Thyroid Cancer Care Collaborative.

BACKGROUND: Well-differentiated thyroid cancer (WDTC) recurs in up to 30% of patients. Guidelines from the American Thyroid Association (ATA) and the National Comprehensive Cancer Network (NCCN) provide valuable parameters for the management of recurrent disease, but fail to guide the clinician as to the multitude of factors that should be taken into account. The Thyroid Cancer Care Collaborative (TCCC) is a web-based repository of a patient's clinical information. Ten clinical decision-making modules (CDMMs) process this information and display individualized treatment recommendations. METHODS: We conducted a review of the literature and analysis of the management of patients with recurrent/persistent WDTC. RESULTS: Surgery remains the most common treatment in recurrent/persistent WDTC and can be performed with limited morbidity in experienced hands. However, careful observation may be the recommended course in select patients. Reoperation yields biochemical remission rates between 21% and 66%. There is a reported 1.2% incidence of permanent unexpected nerve paralysis and a 3.5% incidence of permanent hypoparathyroidism. External beam radiotherapy and percutaneous ethanol ablation have been reported as therapeutic alternatives. Radioactive iodine as a primary therapy has been reported previously for metastatic lymph nodes, but is currently advocated by the ATA as an adjuvant to surgery. CONCLUSION: The management of recurrent lymph nodes is a multifactorial decision and is best determined by a multidisciplinary team. The CDMMs allow for easy adoption of contemporary knowledge, making this information accessible to both patient and clinician.

Noninvasive anaplastic thyroid carcinoma: report of a case and literature review.

Anaplastic thyroid carcinoma (ATC) is an uncommon thyroid malignancy. Noninvasive ATC is a rare, surgically resectable variant with only four reported cases. We report a case of an 81-year-old man who presented with a 3.1 cm right thyroid lobe mass that on fine-needle aspiration biopsy was diagnosed as an ATC. Preoperative imaging revealed an encapsulated thyroid tumor without evidence of invasion of surrounding structures and no locoregional and distant metastases. A total thyroidectomy was performed that by histologic and immunohistochemical evaluation was diagnostic for a noninvasive ATC. Given the diagnosis of noninvasive ATC, adjuvant therapy was not administered. At 14 months following diagnosis, the patient remains disease free based on positron emission tomography/computed tomography imaging. A review of the outcomes of similar cases reported in the literature, as well as observations from our case, suggest a favorable prognosis for patients with noninvasive ATC. Noninvasive ATC may represent a distinct subset of resectable ATCs with an improved prognosis. The recently published American Thyroid Association (ATA) Guidelines for Management of Patients with ATC do not include this specific form of ATC. We encourage other authors to report similar cases in order to determine whether noninvasive ATC should be considered as a separate disease entity from the traditional highly lethal form of ATC.

Intrathyroidal tumors presenting with extranodal extension: what are we missing?

Extranodal extension (ENE) is an indicator of poor prognosis in well-differentiated thyroid cancer (WDTC). We have demonstrated that extrathyroidal extension (ETE) predicts ENE in patients with positive lymph nodes, indicating concordance between primary tumor and lymph node biology. In an effort to determine if there were other histologic features of the primary tumors that indicated an aggressive biology, we examined a subset of patients with intrathyroidal (T1/T2) disease whose lymph nodes had ENE. A review was conducted from January 2004 to March 2013. The histologic features of ETE-negative/ENE-positive tumors (group A, 12 cases) were compared with a random sample of ETE-negative/ENE-negative node-positive patients (group B, 27 cases). Cases were reviewed for size, capsule presence, infiltration, sclerosis, lymphocytic thyroiditis (LT), psammoma bodies, lymphovascular invasion (LVI), perineural invasion (PNI), architecture/cytomorphology, and focality. Size was compared using the Mann-Whitney test, while the remaining features were compared using a Fischer exact test. The breakdown of pathologic features of groups A/B were as follows: 2.28 cm/1.46 cm mean tumor size, 90 %/67 % unencapsulated, 100 %/89 % infiltrative, 100 %/89 % sclerotic, 60 %/52 % LT, 30 %/59 % positive psammoma bodies, 0 %/11 % LVI, 0 %/4 % PNI, 90 %/96 % classic architecture, 50 %/44 % multifocal. Neither size (p = 0.072) nor the other nine histologic features examined reached statistical significance. None of the histologic features appeared to significantly predict ENE. Further examination of intrathyroidal tumors at a molecular level is necessary to determine if there are any identifiable features of intrathyroidal tumors that predict ENE and thus a more aggressive phenotype.

The effect of surgeon experience on the detection of metastatic lymph nodes in the central compartment and the pathologic features of clinically unapparent metastatic lymph nodes: what are we missing when we don't perform a prophylactic dissection of central compartment lymph nodes in papillary thyroid cancer?

BACKGROUND: Prophylactic central neck dissection (PCND) for papillary thyroid cancer (PTC) is controversial. Recent publications suggest that the number and size of nodes and the presence of extranodal extension (ENE) are important features for risk stratification of lymph node metastases. We analyzed these features in clinically unapparent nodes that would not otherwise be removed. We also investigated the impact of surgeon experience on the ability to detect metastatic lymph nodes intraoperatively. METHODS: Forty-seven patients with well-differentiated PTC, with no preoperative evidence of central metastases, were included in this study. Intraoperatively, clinically apparent disease was determined by inspection and palpation by the senior surgeon and a fellow/senior resident, and recorded in a blinded fashion. Rate of occult metastases based on intraoperative evaluation were tabulated for each group of surgeons. Histopathologic features of occult nodes were analyzed to determine what clinicians would be missing by foregoing a PCND, and how that would have impacted the patient management. RESULTS: The rate of occult metastases, based on senior surgeon assessment, was 26%, and did not differ significantly from fellow/senior resident assessment. The level of agreement between these two surgeon groups was moderate (k=0.665). Analysis of the false negative cases revealed that the size of the largest undetected node ranged from 0.1 to 1.3 cm; 36% of patients with occult metastases demonstrated five or more positive nodes, and 27% showed ENE. DISCUSSION: Clinical assessment based on intraoperative inspection and palpation had poor sensitivity and specificity in identifying metastatic central nodes, regardless of the level of experience of the surgeon. There was moderate agreement between surgeons of different experience levels. Sensitivity improved significantly with larger size of positive nodes, but not with the presence of multiple positive nodes or presence of ENE. In foregoing PCND in this patient population, our results suggest that treating clinicians miss potentially virulent disease with a large number of occult positive central nodes and occult nodes with ENE. This is the first report to address the pathologic features of clinically nonevident central nodes showing a high incidence of clinically relevant, adverse histologic features, as well as the impact of surgeon experience in performing the important intraoperative determination of whether there are clinically evident nodes that require removal.

Extrathyroidal extension predicts extranodal extension in patients with positive lymph nodes: an important association that may affect clinical management.

BACKGROUND: While there is consensus that significant extrathyroidal extension (ETE) (T4) should upstage a patient with well-differentiated thyroid cancer, the importance of minimal ETE (T3) remains controversial. Additionally, the importance of nodal metastases on prognosis has come under scrutiny. Recent publications highlight the importance of size, number of positive nodes, and, in particular, the presence of extranodal extension (ENE) as measures of disease aggressiveness. In this study, we examined whether ETE is a predictor of ENE. METHODS: A retrospective review was conducted from January 2004 to March 2013. All node-positive patients who underwent total or completion thyroidectomy were included. Histologic features defined by the College of American Pathologists (CAP) protocol for thyroid carcinoma were recorded. RESULTS: A total of 193 patients qualified for review. Patients who were found to have ETE were 12 times more likely to have lymph nodes in the primary setting with ENE than patients with intrathyroidal primary tumors (p<0.000). After exclusion of all T4 cases (n=6), patients with minimal ETE were 13 times more likely to have ENE than those with no ETE (p<0.000). Twenty percent of microcarcinomas with ETE demonstrated ENE. CONCLUSION: We have found that the biology of the primary tumor is conferred to the lymph node in that the presence of ETE leads to a significantly higher incidence of ENE. Awareness of this relationship should be accounted for in the management of primary and recurrent lymph nodes. This study shows that minimal ETE is a significant predictor of ENE. Although long-term survival and recurrence follow-up is not available for the majority of patients in this series, the presence of ENE as a surrogate for more aggressive disease biology and its strong association with minimal ETE supports the upstaging of patients with minimal ETE.

Improving the quality of thyroid cancer care: how does the Thyroid Cancer Care Collaborative cross the Institute of Medicine's Quality Chasm?

BACKGROUND: The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled "Crossing the Quality Chasm," the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery. SUMMARY: The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, "ask the expert," and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management. CONCLUSION: The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.

What is the gold standard for comprehensive interinstitutional communication of perioperative information for thyroid cancer patients? A comparison of existing electronic health records with the current American Thyroid Association recommendations.

BACKGROUND: Appropriate management of well-differentiated thyroid cancer requires treating clinicians to have access to critical elements of the patient's presentation, surgical management, postoperative course, and pathologic assessment. Electronic health records (EHRs) provide an effective method for the storage and transmission of patient information, although most commercially available EHRs are not intended to be disease-specific. In addition, there are significant challenges for the sharing of relevant clinical information when providers involved in the care of a patient with thyroid cancer are not connected by a common EHR. In 2012, the American Thyroid Association (ATA) defined the critical elements for optimal interclinician communication in a position paper entitled, "The Essential Elements of Interdisciplinary Communication of Perioperative Information for Patients Undergoing Thyroid Cancer Surgery." SUMMARY: We present a field-by-field comparison of the ATA's essential elements as applied to three contemporary electronic reporting systems: the Thyroid Surgery e-Form from Memorial Sloan-Kettering Cancer Center (MSKCC), the Alberta WebSMR from the University of Calgary, and the Thyroid Cancer Care Collaborative (TCCC). The MSKCC e-form fulfills 21 of 32 intraoperative fields and includes an additional 14 fields not specifically mentioned in the ATA's report. The Alberta WebSMR fulfills 45 of 82 preoperative and intraoperative fields outlined by the ATA and includes 13 additional fields. The TCCC fulfills 117 of 120 fields outlined by the ATA and includes 23 additional fields. CONCLUSIONS: Effective management of thyroid cancer is a highly collaborative, multidisciplinary effort. The patient information that factors into clinical decisions about thyroid cancer is complex. For these reasons, EHRs are particularly favorable for the management of patients with thyroid cancer. The MSKCC Thyroid Surgery e-Form, the Alberta WebSMR, and the TCCC each meet all of the general recommendations for effective reporting of the specific domains that they cover in the management of thyroid cancer, as recommended by the ATA. However, the TCCC format is the most comprehensive. The TCCC is a new Web-based disease-specific database to enhance communication of patient information between clinicians in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner. We believe the easy-to-use TCCC format will enhance clinician communication while providing portability of thyroid cancer information for patients.

Use of a combined latissimus dorsi scapular free flap revascularized with vein grafting to the internal mammary artery in a vessel-depleted and previously irradiated neck.

BACKGROUND: For patients who have extensive prior treatment, use of the internal mammary artery/vein (IMA/IMV) or cephalic vein has been shown to be a reliable option. Additionally, for those patients who require vascularized bone and extensive soft tissue reconstruction, the combined latissimus dorsi scapular free flap (mega-flap) is an excellent option. METHODS: We reviewed 3 cases in which extensive prior surgery and radiation precluded the use of traditional recipient vessels in the neck. RESULTS: Three patients with major jaw deformities were reconstructed using a mega-flap. In all cases, saphenous vein grafting succeeded in achieving arterial inflow from the IMA to the subscapular artery. Venous egress was achieved using a vein graft to the IMV in 1 patient and a transposed cephalic vein in the remaining 2 patients. CONCLUSIONS: This approach of restoring large oral cavity defects for patients with extensive prior therapy and comorbid conditions has proven to be reliable and reproducible.

Rare tracheal tumors and lesions initially diagnosed as isolated differentiated thyroid cancers.

BACKGROUND: Thyroid carcinoma with tracheal invasion is uncommon; however, this is significantly more prevalent than primary tracheal tumors. Rare tracheal tumors at the level of the thyroid can be misinterpreted as invasive thyroid cancer upon initial diagnosis. We present a series of tumors within the tracheal wall that were initially misdiagnosed as isolated, but aggressive, thyroid cancer, and later diagnosed to be different histopathologic entities. METHODS: The series consisted of four women and five men, all but two age 60 or older, who were initially diagnosed with tracheal invasion from differentiated thyroid carcinoma (DTC). Eight had obstructive airway symptoms and one experienced gagging and choking sensations. Preoperatively, the patients underwent fine-needle aspiration (FNA) and imaging studies. A complete resection of the involved airway in combination with the thyroid gland was performed in all patients. RESULTS: In this series of patients, the final diagnosis was tracheal stenosis, recurrent laryngeal nerve schwannoma, papillary thyroid carcinoma (PTC) with benign intratracheal thyroid tissue, adenoid cystic carcinoma, and squamous cell carcinoma, each in one patient. Two patients had a tracheal chondrosarcoma, and two patients had collision tumors (PTC with laryngeal squamous cell carcinoma). All patients were misunderstood preoperatively as having isolated DTC with aggressive involvement of the trachea. An accurate diagnosis in these cases was difficult due to misleading FNA readings, thought due to the FNA needle passing through the thyroid before reaching the trachea or a tumor that abuts both structures on imaging. Primary tracheal tumors and a nontumorous lesion, as well as benign thyroidal masses, mimicked invasive thyroid carcinoma in this preoperative setting. CONCLUSIONS: Various entities other than thyroid cancer can masquerade as invasive thyroid cancer. In patients with an FNA showing thyroid tissue or suggesting PTC, but also have obstructive or other airway symptoms, physician awareness is needed to consider the distinct possibility of a primary tracheal lesion. Obtaining the correct preoperative diagnosis is essential for accurate surgical planning for patients with tracheal tumors.

Castleman disease in the parapharyngeal space: a case report and review of the literature.

Castleman disease is most commonly found in the mediastinum, while the head and neck is the second most common location. The disease exists in a unicentric and multicentric variety and is usually successfully treated with surgical resection alone. Early identification is important for treatment planning. Castleman disease has been reported to mimic other disease processes, however there has been only one report of the disease mimicking a nerve sheath tumor in the parapharyngeal space. Here we report the second case of Castleman disease mimicking a schwannoma in the parapharyngeal space.