Management of locoregional recurrence (LRR) and distant metastasis (DM) in adenoid cystic carcinoma (ACC) is guided by limited data. We investigated mortality risks in patients diagnosed and treated ...for recurrent ACC.
A retrospective review of ACC patients treated from 1989 to 2016 identified 36 patients with LRR or DM. High-risk disease was defined as skull base involvement (for LRR) or International Registry of Lung Metastases Group III/IV or extrapulmonary site of metastasis (for DM). Kaplan-Meier method, log-rank tests, and Cox proportional hazards were used for time-to-event analysis.
Among 20 LRR and 16 DM patients, the median times to recurrence were 51 and 50 months, respectively. The median follow-up post-recurrence was 37.5 months (interquartile range (IQR)16.5-56.5). Post-recurrence 3-year overall survival (OS) was 78.5%, 73.3% for LRR and 85.1% for DM (p = 0.62). High-risk recurrences were associated with worse 3-year OS (68.8% for high-risk and 92.3% for low-risk, χ2 = 10.4, p = 0.001). Among LRR patients, 90% had surgery as part of their treatment. Multimodality therapy, age, and histopathologic features (size, margins, solid histology, lymphovascular or perineural invasion) were not associated with PFS or OS. High-risk LRR was the only variable associated with OS (χ2 = 5.9, p = 0.01). Among DM patients, six were initially managed with observation and ten received surgery, RT, or systemic therapy. Upfront therapy was not associated with improved PFS or OS. High-risk DM was the only variable associated with OS (χ2 = 4.7, p = 0.03).
High-risk LRR and DM were associated with decreased 3-year OS. More effective therapies are needed for high-risk ACC recurrences.
Background
Currently, no consensus exists on the appropriate control specimen site to utilize in studies evaluating for biomarkers in chronic rhinosinusitis (CRS). Studies thus far have utilized ...tissue from various anatomic sites despite regional heterogeneity.
Objective
We set out to quantify the differences in biomarker levels present in inferior turbinate versus sphenoid sinus mucosa in paired healthy control patients. We hypothesize that statistically significant differences in cytokine/chemokine expression exist between these two distinct sites.
Methods
A 38-plex commercially available cytokine/chemokine Luminex Assay was performed on 54 specimens encompassing paired inferior turbinate and sphenoid sinus mucosa samples from 27 patients undergoing endoscopic anterior skull base surgery. Patients with a history of CRS were excluded. Paired sample t-tests and Fisher’s exact tests were performed.
Results
Twenty-seven patients were included in the study, including 10 male and 17 female patients with an average age of 48 years. The following 8 biomarkers had statistically significant concentration differences between inferior turbinate mucosa and sphenoid mucosa sites: Flt-3L, Fractalkine, IL-12p40, IL-1Ra, IP-10, MCP-1, MIP-1β, and VEGF, with all P-values <0.01.
Conclusion
No consensus exists regarding the optimal choice of control specimen for CRS research. We present statistically significant quantitative differences in biomarker levels between paired inferior turbinate and sphenoid mucosa samples. This confirms the presence of heterogeneity between different subsites of sinonasal mucosa and highlights the need for standardization in future CRS research.
Summary
Systemic dissemination of microbial pathogens permits microbes to spread from the initial site of infection to secondary target tissues and is responsible for most mortality due to bacterial ...infections. Dissemination is a critical stage of disease progression by the Lyme spirochaete, Borrelia burgdorferi. However, many mechanistic features of the process are not yet understood. A key step is adhesion of circulating microbes to vascular surfaces in the face of the shear forces present in flowing blood. Using real‐time microscopic imaging of the Lyme spirochaete in living mice we previously identified the first bacterial protein (B. burgdorferi BBK32) shown to mediate vascular adhesion in vivo. Vascular adhesion is also dependent on host fibronectin (Fn) and glycosaminoglycans (GAGs). In the present study, we investigated the mechanisms of BBK32‐dependent vascular adhesion in vivo. We determined that BBK32–Fn interactions (tethering) function as a molecular braking mechanism that permits the formation of more stable BBK32–GAG interactions (dragging) between circulating bacteria and vascular surfaces. Since BBK32‐like proteins are expressed in a variety of pathogens we believe that the vascular adhesion mechanisms we have deciphered here may be critical for understanding the dissemination mechanisms of other bacterial pathogens.
Abstract
Objective
Quality of life (QoL) outcomes following endoscopic endonasal transphenoidal surgery (EETS) across a variety of reconstructive methods improve by 2 to 6 months. An option for ...sellar reconstruction, in the absence of a significant intraoperative cerebrospinal fluid (CSF) leak, is a free mucosal graft (FMG) from the posterior septum. We analyze sinonasal QoL outcomes in patients undergoing EETS with FMG reconstruction.
Study Design
This study was a retrospective review.
Setting
This study was conducted at tertiary care academic center.
Participants
This study group consisted of patients undergoing EETS for pituitary adenomas from 2013 to 2018.
Main Outcome Measures
Tumor and surgical factors were included, along with postoperative complications. Patients completed Sinonasal Outcome Test-22 (SNOT-22) questionnaires. Pre- and postoperative scores were compared among the entire cohort using linear multilevel regression. A subcohort analysis was performed among patients who completed questionnaires during the preoperative visit and two postoperative visits (within 1 month and between 2 and 3 months, respectively); pre- and postoperative total and individual domain SNOT-22 scores were compared using paired
t
-tests.
Results
A total of 243 patients underwent EETS with FMG reconstruction. Four patients (1.6%) developed a postoperative CSF leak requiring reoperation. Among the entire cohort, SNOT-22 scores increased at the first postoperative visit (
p
< 0.01) but returned to baseline by the second, third, and fourth postoperative visits (
p
= 0.27,
p
= 0.18, and
p
= 0.21). Among 48 patients who completed both preoperative and two postoperative questionnaires, scores increased within the first month (
p
< 0.01) but returned to baseline at 2 to 3 months (
p
= 0.67).
Conclusion
Posterior septum FMG reconstruction of sellar defects is an effective option, demonstrating early recovery of baseline sinonasal QoL by 2 to 3 months.
Abstract
Introduction
Improved evidence-based guidelines on the optimal type and duration of antibiotics for patients undergoing endoscopic endonasal transsphenoidal surgery (EETS) are needed. We ...analyze the infectious complications among a large cohort of EETS patients undergoing a standardized regimen of cefazolin for 24 hours, followed by cephalexin for 7 days after surgery (clindamycin if penicillin/cephalosporin allergic).
Methods
A retrospective review of 132 EETS patients from 2018 to 2020 was conducted. Patient, tumor, and surgical characteristics were collected, along with infection rates. Multivariate logistic regression determined the variable(s) independently associated with infectious outcomes.
Results
Nearly all patients (99%) received postoperative antibiotics with 78% receiving cefazolin, 17% receiving cephalexin, 3% receiving clindamycin, and 2% receiving other antibiotics. Fifty-three patients (40%) had an intraoperative cerebrospinal fluid (CSF) leak, and three patients (2%) developed a postoperative CSF leak requiring surgical repair. Within 30 days, no patients developed meningitis. Five patients (4%) developed sinusitis, two patients (3%) developed pneumonia, and one patient (1%) developed cellulitis at a peripheral intravenous line. Two patients (2%) developed an allergy to cephalexin, requiring conservative management. After adjustment for comorbidities and operative factors, presence of postoperative infectious complications was independently associated with increased LOS (
β
= 3.7 days;
p
= 0.001).
Conclusion
Compared with reported findings in the literature, we report low rates of infectious complications and antibiotic intolerance, despite presence of a heavy burden of comorbidities and high intraoperative CSF leak rates among our cohort. These findings support our standardized 7-day perioperative antibiotic regimen.
Middle turbinate flap reconstruction of sellar defects Wu, Tara J.; Bergsneider, Marvin; Wang, Marilene B.
Interdisciplinary neurosurgery : Advanced techniques and case management,
September 2020, 2020-09-00, 2020-09-01, Letnik:
21
Journal Article
Recenzirano
Odprti dostop
The principles of sellar reconstruction include adequate defect coverage and prevention of postoperative cerebrospinal fluid (CSF) leak. Sellar reconstruction in certain cases, particularly revision ...surgery, remains challenging, due to lack of availability of septal mucosa, precluding use of a septal free mucosal graft (SFMG) or nasoseptal flap (NSF). We report a technique utilizing middle turbinate flaps (MTF), as an adjunctive technique for repair of sellar defects. At our institution, we have performed six MTFs for patients undergoing endoscopic approaches to sellar pathologies. Here we demonstrate our technique in a patient who developed a delayed CSF leak following reconstruction with a SFMG. An incision is made in the middle turbinate, preserving the upper half. The incision is carried posteriorly, preserving the posterior attachment with the vascular supply (middle turbinate artery branch of the sphenopalatine artery). The cut surface of the turbinate flap is expanded using microscissors. The MTF is rotated posteriorly, and the periosteal layer of the flap is laid flush against the periphery of the prior SFMG, covering the defect at the margin of the graft. Bilateral MTFs are performed, given the CSF leak from bilateral margins of the graft, and DuraSeal is applied. In our case series, there were no incidents of delayed CSF leak, pneumocephalus, or meningitis. Postoperative endoscopies showed adequate seal and 100% flap take. In conclusion, MTFs may be added to the armamentarium of reconstruction options for sellar defects. The advantages include readily available tissue, minimal donor site morbidity, and durable flap survival.
Survival for patients with oral cavity squamous cell carcinoma (OCSCC) has remained relatively stagnant despite advances in treatment. Few studies have examined why advanced-stage disease is ...diagnosed in 40% of patients with OCSCC nationally.
To characterize the diagnostic pathway of OCSCC in an integrated health care system.
Retrospective study of patients with OCSCC (2007-2010).
Referral patterns and demographic, clinical, and tumor characteristics associated with time to diagnosis (diagnostic interval).
Of 247 patients, 167 (68%) had early-stage (I/II) disease, 86 (35%) were referred by dentists, and 70 (28%) had a history of premalignancy. The median time (interquartile range) from symptom onset to care sought from a primary care physician (patient interval), from primary care physician to otolaryngologist, and from otolaryngologist to diagnosis was 8.6 (4.0-25.8), 1.0 (0.6-3.1), 0.0 (0.0-3.0) weeks, respectively. These intervals did not differ by demographic characteristics, clinical factors, or tumor stage. Prolonged diagnostic intervals were observed among patients with premalignant lesions.
The patient interval was the largest component of the total diagnostic interval. The subsequent professional workup proceeded relatively efficiently. Prolonged diagnostic interval in patients with premalignant lesions may reflect the natural history of malignant transformation rather than a delay in diagnosis. However, nearly one-fourth of these cases were diagnosed at an advanced stage; closer surveillance may represent an opportunity for diagnosis at an earlier stage. Surveillance for premalignant lesions and facilitating referrals from dentists may expedite the diagnosis and treatment of OCSCC. Further investigation is warranted.
Although it is generally accepted that Ig heavy chains (HC) are selected at the pre-B cell receptor (pre-BCR) checkpoint, the characteristics of a functional HC and the role of pre-BCR assembly in ...their selection have remained elusive. We determined the characteristics of HCs that successfully passed the pre-BCR checkpoint by examining transcripts harboring V(H)81X and J(H)4 gene segments from J(H)(+/-) and lambda5(-/-)mice. V(H)81X-J(H)4-HC transcripts isolated from cells before or in the absence of pre-BCR assembly had no distinguishing complementarity-determining region 3 traits. In contrast, transcripts isolated subsequent to passage through the pre-BCR checkpoint had distinctive complementarity-determining regions 3 of nine amino acids in length (49%) and a histidine at position 1 (73%). Hence, our data define specific structural requirements for a functional HC, which is instrumental in shaping the diverse B cell repertoire.
Purpose of Review
Facial paralysis can lead to lagophthalmos, loss of corneal protection, and devastating ocular consequences like corneal ulcers or even blindness. The purpose of this review is to ...discuss the importance of comprehensive and early eye care.
Recent Findings
Treatment of paralytic lagophthalmos should be individualized to each patient’s situation; depending on the severity of the problem and the prognosis for recovery, treatment modalities are broad and include lubrication, selective chemodenervation, filler injection, fat augmentation, and surgical procedures like canthopexy and tarsorrhaphy.
Summary
This paper serves to highlight the importance of treating paralytic lagophthalmos and provides an overview of the optimal management algorithm of the compromised periocular complex to help improve function and quality of life. Prospective studies and long-term comparisons of surgical techniques for repair of paralytic lagophthalmos will help improve our understanding of this complex problem and perhaps introduce novel treatment strategies.
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