Adenoid cystic carcinoma of the tongue--clinicopathological study and survival analysis

Background

To review the demographic data of a series of adenoid cystic carcinoma (ACC) of the tongue, as well as to analyze c-kit expression, histopathologic patterns, prognostic factors, evolution, recurrences and/or persistence and survival.

Methods

Retrospective study from 1986 to 2006, which reviews a database of 68 patients with diagnosis of head and neck ACC.

Results

We found eight cases of ACC of the tongue (11.7% of all head and neck ACCs). There were 7 female (87.5%) and 1 male (12.5%) patients, with an average age of 51 years (range 33 to 67 years). Seven patients were surgically treated, three of which required adjuvant treatment. Only one female patient did not accept treatment. Average follow-up time was 5.3 years. Metastases developed in 37% of cases during the follow-up period. Histopathologically, the cribriform pattern predominated (6/8 cases). All cases presented perineural invasion, and one patient also presented vascular invasion. c-kit positivity was observed in all cases. Global survival in the seven treated cases was 51% and 34% at 5 and 10 years, respectively, while the disease-free period was of 64% at 3 years and 42% at 10 years.

Conclusion

ACC of the tongue is a rare neoplasm, in which early diagnosis is important because these are slowly-growing tumors that produce diffuse invasion. As the role of c-kit could not be assesed in this series, surgery continues to be the cornerstone of treatment and radiotherapy is indicated when surgical margins are compromised. Metastatic disease is still hard to handle because of the lack of adequate therapies for these tumors. Hence, survival has not changed in the last years.

Laser resection of liposarcoma of the hypopharynx

Liposarcomas represent between 15 and 18% of all sarcomas with the most common site being the extremities and retroperitoneum. Liposarcomas of the head and neck are rare, with an estimated incidence representing 3 to 5.6% of all liposarcomas. Liposarcomas most commonly present in the soft tissues of the neck. Primary liposarcoma of the hypopharynx (piriform sinus) is extremely rare. The symptoms presented are principally dysphagia, dyspnea, dysphonia, airway obstruction and sensation of a foreign body. Treatment of choice is surgery, and the literature describes the performance of lateral pharyngotomy, simple excision and even total laryngectomy. We present the case of a 23-year-old patient who was diagnosed 7 years prior with liposarcoma of the piriform sinus. The patient underwent surgery using a cervical approach. The tumor recurred 4 years postoperatively and the patient was again surgically intervened using the same approach. He presented to our Institute with 3 months evolution of dysphonia. Nasofibrolaryngoscopy and imaging studies were performed. Surgical treatment was decided upon with CO2 laser using suspension microlaryngoscopy, obtaining excellent results. Some of the advantages of this approach are low morbidity because of the avoidance of performing a tracheostomy, rapid return to oral feeding without necessity of a feeding tube, and reduction in hospitalization days. Disadvantage includes difficulty in evaluating margins.

[Zenker's diverticulum: laser or stapler treatment]

OBJECTIVE

We undertook this study to report on transoral endoscopic management of Zenker's diverticulum.

METHODS

Four patients with Zenker's diverticulum were treated by transoral microendoscopic surgery, two by stapler and two by laser resection.

RESULTS

All patients were successfully treated, and no complications were noted. Hospital stay was <24 h in all cases. Patients treated by stapler resumed oral feeding 8 h after surgery and those treated by laser required nasogastric tube feeding. Normal oral intake was achieved 5 days later.

CONCLUSIONS

Currently, treatment for Zenker's diverticulum must be done by transoral approach. Technique selection (laser or stapler) depends on surgeon's experience and their access to technology. Both techniques have important advantages when compared to classic open surgery (shorter hospital stay, lower cost, low morbidity and low rate of complications). Open surgery is indicated only when transoral technique is impossible for medical reasons or technical challenges, such as when technological support is not available.

Giant retroperitoneal liposarcoma

Background

Liposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment.

Case presentation

We present the case of a 24-year-old male who was diagnosed with a giant retroperitoneal liposarcoma. The patient received palliative treatment due to non-resectability on the basis of chemotherapy. We decided to perform surgery after no benefit was received with systemic treatment. Complete macroscopic resection of the tumor was performed, without multi-organ resection. The patient is currently alive and disease free at 14 months of evolution.

Conclusion

Retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.

[Malignant neoplasm in burn scar: Marjolin's ulcer. Report of two cases and review of the literature]

BACKGROUND

Marjolin's ulcer forms part of a group of neoplasms that originate in a burn scar, a phenomenon associated with superficial tissue trauma. The frequency of Marjolin's ulcer is low and represents between 2 and 5% of all squamous cell carcinomas of the skin. This condition is found three times more frequently in men than in women and is thought to be more aggressive than conventional squamous cell carcinoma of the skin.

CLINICAL CASES

We present two cases of squamous cell carcinoma that originated on a burn scar. 41 year old woman with gasoline burn on the left foot, 3 months old, in whom an exofitic ulcerated lesion on the right calcaneum region has evolved since she was 32 years old. Left transtibial amputation was decided. Another woman who started its suffering 9 years after a thorax burn with a progressive fungus lesion on the scar area. For its size and as it was a high degree neoplasia, surgical resection and radiotherapy to the zone of the primary with 50 Gy in 25 fractions was decided.

CONCLUSIONS

Marjolin's ulcer usually occurs in old burn sites that were not skin grafted and were left to heal secondarily. Although it is believed that there is a latency period of 25-40 years after burn injury before the occurrence of malignancy, this may occur in a period as short as 3 months. Recurrence after radical surgery is 14.7%. Nonetheless, because of the aggressive behavior of this type of cancer, appropriate radical treatment allows an adequate control of the disease. Early grafting of the burn site can prevent the formation a malignant neoplasm. This condition should be suspected in a non-healing chronic ulcer on a burn scar.

[Supracricoid partial laryngectomy as salvage for recurrent carcinoma of the larynx initially treated by vertical partial hemilaryngectomy. Case report]

OBJECTIVE

We undertook this study to report the possibility of salvage of vertical partial hemilaryngectomy with imbrication laryngoplasty (PVHLIL) to supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP) in a patient with recurrent glottic carcinoma.

CLINICAL CASE

A 68-year-old patient with recurrent glottic squamous cell carcinoma (T1aN0) was treated with imbricated partial laryngectomy. Transoperative histopathological report demonstrated vocal cord free surgical margins anterior at 1 cm and 0.4 cm posterior. The patient was evaluated trimonthly and at 16-month follow-up presented with tumor activity on the posterior third of the left false vocal cord, close to the arytenoids, which still conserved mobility. Biopsy was performed and confirmed recurrence of squamous cell carcinoma. SCPL with CHEP was performed with a satisfactory postoperative evolution with tracheotomy decannulation at day 7. Physiological phonation and retirement of nasogastric tube were accomplished at day 15, as well as reinitiation of oral feeding. Histopathological report showed a moderately differentiated squamous cell carcinoma. Functional evaluation with PVHLIL is a clear voice alteration; however, patients do not require permanent tracheostomy, and a close to normal biopsicosocial integration after SCPL + CHEP is possible.

CONCLUSIONS

PVHLIL is an excellent treatment option for selected glottic tumors staged T1 or T2. Close follow-up must be given to allow the possibility of organ conservation either with radiotherapy or surgery. When recurrence occurs, SCPL + CHEP must be considered according to the established criteria for this procedure. Total laryngectomy must be considered as the last option, with the only purpose being a normal quality of life.

[Reconstruction of the floor of the mouth with double free flap: report of three cases]

BACKGROUND

We undertook this study to describe three cases of reconstruction of the floor of the mouth with two simultaneous free flaps.

METHODS

Three patients with cancer of the anterior floor of the mouth were subjected to segmental resection of the mandible and resection of the floor of the mouth with subsequent reconstruction using two simultaneous osseous and fasciocutaneous free flaps.

RESULTS

All patients had a satisfactory evolution. Two patients underwent adjuvant radiotherapy, one due to the initial clinical stage and the other due to positive surgical margins. The third patient had neoadjuvant postoperative radiotherapy and concomitant chemoradiotherapy.

CONCLUSIONS

If a tumor involves osseous structures of the anterior floor of the mouth, it is best to perform surgery with wide margins with segmental resection of the mandible. Surgical technique is the decision of the surgeon: how many and which types of flaps will be used for reconstruction of the anterior floor of mouth. When there is necrosis of a free flap in the head and neck region, attempt with another free flap is recommended.

[Laryngeal cancer in patients younger than 40 years]

BACKGROUND

We undertook this study to report demographic data of laryngeal cancer patients <40 years old and treatment results.

METHODS

In a retrolective study we reviewed the clinical records of 500 patients with laryngeal cancer in the period from 1989 to 2004 and included those patients<40 years of age.

RESULTS

We found 15 patients, representing 4.4% of the series. Nine (60%) were men and six (40%) were women, with a 1.5:1 ratio. Average group age was 35 years (range 21-40 and median of 37 months). Average time of evolution at the time of diagnosis was 14.4 months (range 0-36 and median of 12 months); 60% of the patients were smokers and 40% admitted to drinking alcohol; dysphonia was the main symptom found in 87% of the patients. The most frequent location was the glottis in 11 (73%) patients. Well-differentiated tumors represented 53% of the cases. Initial treatment was surgery in four (27%) patients; radiotherapy in five (33%) patients receiving an average of 63.44 Gy; concomitant chemoradiotherapy in one patient (7%) using gemcitabine; four (27%) patients were treated with neoadjuvant chemotherapy followed by radiotherapy; and one patient did not receive treatment. The average time in which the patients relapsed after the first treatment was 19.57 months (range 2-63) and four were classified as persistent. Survival time was 32 months (range 2-106 and median 27 months). Finally, organ preservation rate was obtained in 28.5%.

CONCLUSIONS

Squamous cell carcinoma of the larynx is rare in patients<40 years old in our study. Gender relation seems to be equal, although a slight predominance of men does still exist. Classical risk factors were present in 60% of the cases. Prognosis for these patients was determined by the initial clinical stage.

Craniofacial resection for sinunasal tumors

INTRODUCTION

Malignant sinonasal tumors are very rare in Mexico. They ussually present as advanced disease because it is extremely difficult to make an early diagnosis; in addition, its treatment is complicated by a variety of lesions. Surgical resection remains the mainstay of treatment, but its relative therapeutic value compared with alternative treatments is controversial.

OBJECTIVE

We undertook a retrospective analysis in order to evaluate results of craniofacial resections for sinonasal tumors.

MATERIALS AND METHODS

A total of 20 patients, 11 men and 9 women were considered, median age was 49 years (18-74). Eleven had received previous treatment elsewhere. In 13 patients tumor was limited to maxillo-ethmoid complex, but in 6 cases tumor involved anteroinferior aspect of sphenoid sinus, in 7 extended to the orbit, in 3 to dura and two to the brain. One had cervical metastases. Median tumoral size was 5.8 cm (1-10).

RESULTS

Overall complication rate was 50%. Major surgical complications occurred in 4 patients (20%): one patient developed isolated cerebrospinal fluid leakage (CEFL), 1 developed deterioration of mental status, and two developed meningitis associated with CEFL. Late complications occurred in 30% of the patients. There was not any operative death. Eleven patients received postoperative radiotherapy. Fifteen patients recurred. There were 11 local relapses, although one associated with a regional relapse, and another with regional and distant relapse. There were four isolated regional fails and six isolated distant failures. Three year overall survival was 65%, and 3-year disease free survival was 50%. Patients without previous treatment median survival was 28.3 months, meanwhile with previous treatment was 18.2 months.

CONCLUSIONS

Craniofacial resection is a safe and valuable tool in the treatment of advanced sinonasal tumors involving cranial base.

Supracricoid partial laryngectomy as a primary treatment for carcinosarcoma of the larynx

Carcinosarcoma of the larynx is uncommon. When it does occur; its clinical features resemble those of sarcomatoid carcinoma, and its biologic behavior is similar to that of malignant mesenchymal neoplasms. We describe 2 cases of carcinosarcoma of the glottis. The tumors were staged as T3N0M0 and T2N0M0. Both patients were treated with supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Eight months postoperatively, 1 of the 2 patients experienced a recurrence of the sarcomatous component of the tumor, and he underwent a total laryngectomy. The other patient remained free of disease at 12 months of follow-up. We conclude that supracricoid partial laryngectomy may be offered as an organ-preserving measure even in patients with sarcomatous disease; total laryngectomy can be held in reserve as a rescue measure. Patients must be closely monitored for early detection of recurrence. The role of adjuvant therapy for sarcomatous neoplasms in this area has not yet been clearly established.

Supracricoid Partial Laryngectomy as a Primary Treatment for Carcinosarcoma of the Larynx

Carcinosarcoma of the larynx is uncommon. When it does occur, its clinical features resemble those of sarcomatoid carcinoma, and its biologic behavior is similar to that of malignant mesenchymal neoplasms. We describe 2 cases of carcinosarcoma of the glottis. The tumors were staged as T3N0M0 and T2N0M0. Both patients were treated with supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Eight months postoperatively, 1 of the 2 patients experienced a recurrence of the sarcomatous component of the tumor, and he underwent a total laryngectomy. The other patient remained free of disease at 12 months of follow-up. We conclude that supracricoid partial laryngectomy may be offered as an organ-preserving measure even in patients with sarcomatous disease; total laryngectomy can be held in reserve as a rescue measure. Patients must be closely monitored for early detection of recurrence. The role of adjuvant therapy for sarcomatous neoplasms in this area has not yet been clearly established.

Quality of life and functional evaluation after supracricoid partial laryngectomy with cricohyoidoepiglottopexy in Mexican patients

This study assessed the functional results in patients treated primarily through supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP).

Fifteen patients with a diagnosis of epidermoid carcinoma of the glottis region admitted to the Instituto Nacional de Cancerología (México) between June 2001 and September 2002 were studied. Three patients were at stage I, five at stage II, six at stage III, and one at stage IV. Both cricoarytenoid units were preserved in 12 patients, and only one in three. Each case was assessed through the clinical grading postoperative aspiration (CGPA) scale, the performance status scale for head and neck cancer (PSS-HNC), and the Karnofsky Performance Scale (KPS). Likewise, voice quality of the patients was assessed regarding tone and intensity using the SpeechViewer version 1 (IBM) and data were obtained with the Cool Edit 2000 software.

Twelve patients received phoniatric rehabilitation and three were left without rehabilitation. The average time for decannulation was 12 days and 23 days for removal of the nasogastric catheter. The degree of aspiration was 0 in four patients and one in 11. According to PSS-HNC, the mean for normalcy in the diet was 95 and the mean for those eating in public was 91. Intelligibility reached an average of 90. Karnofsky’s assessment was related to the disease and not to the treatment, as it remained at 100 per cent in most patients and was never below 80 percent. The mean intensity of quality of voice was -18 dB below normal; however, the mean frequency was 243.7 Hz.

SCPL and CHEP allows the preservation of the basic function of the larynx; however, a clear alteration in voice occurs after the procedure, although normal frequency is kept when both arytenoids are preserved. Likewise, preservation of both arytenoids shortens the time needed for cannula and feeding catheter removal. PSS-HNC, Karnofsky, and CGPA assessments demonstrated thatpatients can reach an almost normal bio-psycho-social integration. It is recommended that all patients be subjected to phoniatric rehabilitation.

Free osseous and soft tissue surgical margins as prognostic factors in mandibular osteosarcoma

Osteosarcoma is an infrequent, locally aggressive neoplasm in the head and neck region. To date, surgery is the mainstay of treatment. However, patients with mandibular osteosarcomas usually have a locally advanced disease at diagnosis and therefore represent a therapeutic challenge because surgical margins are difficult to obtain due to aesthetic and functional concerns. To evaluate possible prognostic factors implicated in recurrence, persistence or relapse in osteosarcoma of the mandible, with special reference to the soft tissue and bone surgical margins. A series of 20 patients with mandibular osteosarcomas treated at the Instituto Nacional de Cancerología (México) from 1985 to 1999 are reviewed. There were 14 female and 6 male patients. Twelve cases were treated with surgery alone, 3 patients with surgery and adjuvant radiotherapy, 1 had neoadjuvant chemotherapy followed by surgery, 1 had neoadjuvant chemotherapy, surgery and postoperative radiotherapy, 1 with surgery and adjuvant chemotherapy, 1 with surgery followed by adjuvant chemotherapy and radiotherapy and one patient rejected treatment. Between 1985 and 1992 these neoplasms were treated by means of total mandibulectomy, independently of tumor size, but between 1993 and 1999 the policy was to practice smaller resections but long enough to obtain macroscopic surgical free margins. In the first period the relationship between mandibular size resection and tumor size was 1.9, meanwhile in the second period the relation was 1.5. There was not significant difference between both periods in terms of tumor size (6.0 cm vs. 6.02 cm at the time of surgery) nor in local control and survival. Soft tissue involvement as reported by histological study was strongly associated with recurrence (p = 0.0024). Overall 5-year survival was 20%. A policy of total mandibulectomy is not associated with a better local control or survival. Extent of resection must be tailored with tumor size. Extent of margins in soft tissue is the limiting factor for local control.

Does Shamblin's classification predict postoperative morbidity in carotid body tumors? A proposal to modify Shamblin's classification

The objective of this study was to analyze the possible correlation between Shamblin's classification and post-surgical morbidity in the treatment of carotid body tumors (CBTs). Seventy-two patients with carotid body tumors were seen over a 22-year period. Twenty-three patients were excluded as they did not comply with the criteria of the objectives. All patients were grouped according to Shamblin's classification. We propose a modification to this classification and make a comparison by analyzing the surgical time and bleeding, as well as the neurological and vascular damage. We resected 50 CBTs in 49 patients, ranging in age from 18 to 73 years. Three groups were formed: group I with 8 (16%) patients, group II with 17 (34%) and group III with 24 (49%). Post-surgical neurological damage was observed in one patient (12.5%) from group I, in six (35%) from group II and in nine patients (37.5%) from group III. Vascular sacrifice had to be performed in 21% of class II tumors and in 8.7% of class III. None of the class I tumors required vascular sacrifice. No statistically significant difference existed for vascular or neurological risk in relation to Shamblin's classification. However, when analyzed according to the classification proposed herein, there was a correlation between Shamblin's classification and vascular sacrifice (P =0.001). There was a statistically significant correlation between the original Shamblin and the modified Shamblin regarding surgical time and bleeding. Shamblin's classification predicts only vascular morbidity. Neurological morbidity is not reflected in it and only reflects the surgeon's experience with CBT resections. Surgical time and bleeding are directly related to the Shamblin as it reflects the size of tumors in relation to the blood vessels. Shamblin's classification must be modified to be more objective so that the international reports can accurately reflect the morbidity related to it.

Carotid body tumors: review of a 20-year experience

Carotid body tumors (CBT) are a rare entity that should be considered in evaluating every lateral neck mass. The objective of the study was to compare demographic data, complications and evolution of patients treated at our institution. A retrospective study was made of 66 patients with 69 CBT that were treated at our institution between 1982 and 2002. We reviewed the demographic characteristics, clinical features, surgical approach and complications. Women significantly predominated (96.9%) with a female:male ratio of 31.2:1. Ages ranged from 18 to 94 (mean=50.2). Fifty-four per cent of the patients lived at altitudes higher than 2200 m above sea level. The most common chief complaint was a painless neck mass (78.7%). No patient had any malignant tumors or a familial history of CBT. Both sides were similarly affected. There were four tumors grouped in Shamblin's class I, 24 in class II, and 35 in class III. Six tumors were of undetermined Shamblin's class as inferred from their medical records. Fifty-three patients received treatment: 46 (86.8%), surgery; 6 (11.3%), radiotherapy; 1 (1.9%), radiotherapy following surgery. Three patients (6.3%) underwent vascular reconstruction. In 23 (49%) patients neurological deficit was observed after surgery. Minor complications occurred in five (10.6%) patients. Median follow-up was 38 months, one patient died from a cause not related to the CBT, and the rest remain disease-free and asymptomatic. We found an overwhelming predominance of women, which opens the possibility that we are dealing with a different disease in female Latin populations. Most of the tumors were of Shamblin's class III CBT. Early surgical management is recommended to avoid neurological deficit due to a Shamblin's class III tumor.

Delphian lymph node in glottic carcinoma subjected to supracricoid partial laryngectomy with cricohyoidoepiglottopexy

INTRODUCTION

Metastases to Delphian lymph node is rarely present in laryngeal malignancy. This report describes its frequency in patients with glottic cancer undergoing supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP).

MATERIAL AND METHODS

Fourteen patients (13 male and 1 female) with a mean age of 58 years underwent a SCPL with CHEP and functional bilateral neck dissection (levels II-V) searching for the Delphian lymph node. Four patients were in stage I, five in stage II, four in stage III, and one in stage IV. Surgical margins and Delphian lymph nodes were searched for in each partial laryngectomy sample.

RESULTS

The mean follow-up was 9 months. The right-side dissection yielded an average of 18 lymph nodes and the left-side dissection yielded an average of 22 lymph nodes, with no metastatic disease on the ultimate examination. Only one patient (7%) revealed a carcinoma-positive Delphian lymph node, and 6 months later a metastatic lymph node was found on the same side as the primary tumor. The patient underwent standard radiation therapy (66 Gy) targeted to larynx and lymph node areas, as well as to the supraclavicular region (20 Gy).

DISCUSSION

Bilateral functional dissection is indicated in the presence of Delphian lymph node metastatic spread. Post-operative radiation therapy may occasionally be used as an adjuvant treatment in cases with positive Delphian lymph node in spite of a negative functional dissection in partial laryngectomies due to other possible node spread routes. Bilateral functional dissection should be chosen based on tumor site and size.

Lip cancer experience in Mexico. An 11-year retrospective study

Lip cancer is the most frequent malignant neoplasm of the oral cavity; however, there is no information available on the incidence of this type of cancer in Mexico. This study provides information about the clinico-pathological features of lip cancer patients admitted at a cancer hospital in Mexico City during an 11-year period and describes the treatment modalities performed and their results. A total of 113 patients were studied. There were 74 men (65.5%) and 39 women (34.5%), ranging in age from 14 to 106 years (mean 70 years). In 53 cases (46.9%) an association was found between the disease and chronic sun exposure. Additionally, positive smoking antecedents were recorded in 58 cases (51.3%). As 15 patients were followed for less than 1 month, they were excluded for further analysis. There were 82 cases (83.7%) of squamous cell carcinoma, 10 (10.2%) basal cell carcinomas, and one case (1%) each of adenocarcinoma NOS, melanoma, adenoid cystic carcinoma, Merkel cell carcinoma, lymphoepithelioma and angiosarcoma. We observed an incidence of malignant neoplasms in the upper lip of 33.7%, which is higher than most of the published series and may be due to the fact that in this series we included all histological types of lip cancers. Fifty percent of the cases were found in stages III and IV. Cervical lymph node metastases were found in 21% of patients with no previous treatment, and they developed in 5.3% after treatment. Our data suggest that tumoral size is directly related to the possibility of developing node metastases, as none of them occurred in patients T1, whereas 10 (62.5%) of the patients in T4 presented them. Seven deaths were documented (7.1%), five of which corresponded to squamous cell carcinoma, one to Merkel cell carcinoma, and one to adenocarcinoma. Deaths were directly related to the disease in six cases, and one patient died due to surgical complications. Distant metastases were found in only two patients, one of which coursed with an adenocarcinoma and the other with a Merkel cell carcinoma. Based on the present results, we suggest that the differences encountered with respect to other series, particularly the higher incidence found in women, the frequent presentation of this type of neoplasms in the upper lip, the wide variety of histopathological diagnoses and the high frequency of cases with cervical lymph node affection, should lead us to search for multi-modal treatment alternatives in this population.

[Internal carotid artery reconstruction with transposition of external carotid artery in carotid body tumor resection]

The current treatment of Shamblin's class III carotid body tumors includes a variety of reconstructive techniques for the internal carotid artery, ranging from angioplasty to the use of various grafts such as autologous saphenous vein or synthetic shunts. We present the case of a 56-year-old female patient with a carotid body tumor. The diagnosis and therapeutic approach is discussed, as well as the surgical technique and postoperative outcome. In those cases where the carotid body tumor involves the internal carotid artery to the point that its sacrifice is imminent and synthetic grafts are not available, reconstruction of the internal carotid artery with transposition of the external carotid artery is recommended.

[Total glossectomy with larynx preservation and reconstruction with rectus abdominis free flap]

OBJECTIVE

Our objective was to show the complexity and series of events needed to perform the reconstruction with rectus abdominis free flap to achieve an adequate rehabilitation for patients submitted to total glossectomy with larynx preservation due to advanced tongue carcinoma.

METHODS

Two patients with stage IV carcinoma of the tongue were treated with surgery--one as primary treatment, the other for recurrence. Patients underwent total glossectomy, bilateral radical neck dissection, gastrostomy, tracheostomy, and reconstruction with rectus abdominis free flap.

RESULTS

Both patients had an uneventful postoperative evolution and were discharged from the hospital without tracheostomy on the 7th and 8th days, respectively. The patient who received primary treatment is currently receiving adjuvant radiotherapy.

CONCLUSIONS

Patients requiring total glossectomy, either with or without laryngectomy, must undergo a careful and individualized selection of the reconstructive procedure by a highly specialized surgical team. The rectus abdominis flap represents one of the best options for reconstruction in patients treated with total glossectomy. Its main disadvantage is seen in overweight patients, in whom the flap volume taken may be excessive for the oral cavity. Most of these patients are fed by a gastrostomy tube, which may be removed only when aspiration is absent. The type of gastrostomy can even be evaluated before surgery.

[Dysphagia secondary to lingual thyroid]

BACKGROUND

Lingual thyroid is a rare developmental anomaly originating from aberrant embryogenesis during descent of the gland from its site of origin, the foramen caecum, to its eutopic location.

OBJECTIVE

We present the case of a 30-year-old female with a history of dysphagia and pharyngeal foreign body sensation over the past 12 months, associated with hypothyroidism.

METHODS

Diagnostic and therapeutic approaches are discussed.

RESULTS

Diagnosis of lingual thyroid was made and transoral thyroidectomy was performed as procedure-of-choice. Microscopic analysis revealed normal thyroid tissue with abundant colloid. The patient had an uneventful recovery and was discharged 2 days after surgery. Gamma-gram with Tc99m was scheduled for postoperative follow-up.

CONCLUSIONS

Transoral lingual thyroidectomy followed by life-long hormonal therapy is the appropiate approach for patients with severe symptoms due to lingual thyroid hypertrophy associated with hypothyroidism.

Thyroglossal duct cyst with papillary carcinoma: what must be done?

OBJECTIVE

To present a report series of five cases, compare their clinical evolution, and establish the appropriate treatment.

METHODS

A retrospective study was performed with the clinical records from three health institutions in Mexico City, Mexico, in order to search for patients with histologic diagnosis of thyroglossal duct carcinoma and were classified by different risk stratifications to compare their outcome.

RESULTS

We found five patients, three females and two males, mean age 49 years. Four were treated by Sistrunk's procedure, total thyroidectomy, radioiodine ablation, and thyroxine suppression; one patient underwent Sistrunk's procedure only. Four patients were classified in the low- and median-risk group and had good outcome; one patient was in the high-risk group and had poor outcome.

CONCLUSIONS

The thyroglossal duct cyst must be studied in the adult population through fine-needle aspiration biopsy (FNAB) and a frozen section in cases in which FNAB is inconclusive or unavailable. When a diagnosis of a thyroglossal cyst carcinoma is made, an evaluation of the thyroid gland during surgery must be done as well as a careful examination to identify suspicious lymph nodes and neck dissection should be reserved for confirmed adenopathies. When an thyroglossal duct cyst has been excised using Sistrunk's procedure and the definitive histologic analysis reports malignancy, the thyroid gland must be studied. The extension of the surgery must be handled according to the criteria established for differentiated thyroid cancer.