Recurrence Rates Over 20 Years in the Treatment of Malignant Melanoma: Immediate Versus Delayed Reconstruction.

Wide local excision (WLE) with a safety margin is the standard of treatment for primary head and neck cutaneous malignant melanoma (HNCMM). Studies have demonstrated inconsistency in recurrence rates following immediate versus delayed reconstruction. The objectives of this study were to assess and compare recurrence rates after WLE of HNCMM followed by immediate or delayed reconstruction in determining recurrence-free survival estimates. METHODS: A consecutive, retrospective analysis of 451 patients undergoing WLE of primary HNCMM followed by reconstruction over a period of 20 years was performed. Patients were divided into 2 groups based on timing of reconstruction (immediate versus delayed). Univariate analyses were performed to assess distributions. Kaplan-Meier survival analysis and multivariate Cox proportional hazard analyses were performed to estimate recurrence-free survival. RESULTS: Tumor specimen positive margins were comparable between immediate and delayed reconstruction groups (P = 0.129). Univariate analysis demonstrated comparable local melanoma recurrence after immediate or delayed reconstruction (41.4% versus 53.3%; P = 0.399). After adjusting for prognostic factors, multivariate analysis also failed to demonstrate an association between reconstruction timing and local recurrence-free survival (P = 0.167). CONCLUSIONS: In this long-term study, we were not able to demonstrate an association between reconstruction timing and local recurrence-free survival after excision WLE of HNCMM, rendering immediate reconstruction a reliable approach. In addition, the presence of ulceration and a positive sentinel lymph node were positively associated with the risk of recurrence.

The glomic artery supply of carotid body tumors and implications for embolization.

Carotid body tumors (CBT) are rare neuroendocrine neoplasms that usually present in the third or fourth decades of life and are benign in more than 95% of cases. In the angiographic literature, the arterial supply to carotid body tumors is well documented but is often incomplete, with infrequent mention of the glomic artery, a common arterial feeder described in the anatomic and pathologic literature. Through a review of our neuroendovascular patient database, we identified eight patients with CBT undergoing transarterial embolization followed by resection. Mean patient age was 51.5 years (range 29-82), and all patients were female. Mean tumor size was 91.2 cc (standard deviation [SD] 61.1, median 67.7 cc). After embolization, greater than 90% flow reduction was achieved in 5/8 patients (63%); 60-80% flow reduction was achieved in the remaining patients. Mean operative blood loss was 166 cc (SD 100, median 122 cc) and mean operative time was 252 minutes (SD 134.5, median 155 minutes). Pre-embolization angiography was reviewed to identify a glomic artery, defined as a dominant artery supplying the CBT arising from the region of the carotid bifurcation. In six of eight patients (75%) a glomic artery could be identified, arising from the common carotid artery in 4/6 patients and the external carotid artery in 2/6 patients. Thus, glomic artery to supply to CBT was identified in the majority of patients in this series. Knowledge of its presence and identification as a direct supplier, frequently from the common carotid artery itself, provides an avenue for more thorough preoperative embolization of CBT.

Analysis of the NSQIP database in 676 patients undergoing laryngopharyngectomy: the impact of flap reconstruction.

OBJECTIVE: Assess impact of reconstructive procedures on patients undergoing laryngopharyngectomy and to determine whether 30-day postoperative morbidity and mortality varied between patients who underwent flap reconstruction and those who did not. STUDY DESIGN: Retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. SETTING: Tertiary medical center. SUBJECTS AND METHODS: We reviewed the 2005-2011 ACS-NSQIP database to identify patients undergoing laryngectomy and/or pharyngectomy. Bivariate analysis was done to compare preoperative variables and postoperative outcomes between the flap reconstruction group and non-reconstruction group. Chi-square tests were used for categorical variables and t-tests for continuous variables. Logistic regression analysis was performed to calculate odds ratio to account for potential confounders. To create a valid logistic analysis model, F-test was used to determine whether certain variables should be included in the model. RESULTS: Six hundred seventy-six patients were included in our study; 213 patients received concurrent flap reconstruction whereas 463 did not. After risk adjustment, analyses revealed no statistically significant difference in wound complication, minor morbidity, and mortality between the 2 groups. The flap reconstruction cohort showed significantly longer operative times (8.09 ± 3.36 hours vs 5.63 ± 3.47 hours; P = .001) and higher major morbidity rate (OR = 5.906, 95% CI, 3.131-11.139, P = .001). CONCLUSIONS: This is the first comprehensive analysis of flap reconstruction for laryngopharyngeal defects using the ACS-NSQIP registry. Additional measures involved in flap reconstruction are associated with an increase in major morbidity but not mortality. An understanding of these variables may optimize the decision-making process for patients undergoing laryngectomy and/or pharyngectomy.

Mammary analogue secretory carcinoma: update on a new diagnosis of salivary gland malignancy.

OBJECTIVES/HYPOTHESIS: To review the known histopathologic findings and clinical behavior of mammary analogue secretory carcinoma (MASC). DATA SOURCES: PubMed. REVIEW METHODS: Literature search using the terms "Mammary analogue secretory carcinoma," "Mammary analog secretory carcinoma," and "MASC" to identify all relevant publications. RESULTS: MASC is an unusual and rare malignant salivary gland tumor first described in 2010. It shares histologic, immunohistochemical, and genetic features with secretory carcinoma of the breast. The clinical behavior of MASC ranges from slowly growing tumors that infrequently recur after surgical resection to aggressive tumors that cause widespread metastasis and death. Many cases of MASC were discovered in archived cases previously classified as acinic cell carcinoma, mucoepidermoid carcinoma, and adenocarcinoma not otherwise specified. CONCLUSION: MASC is a newly recognized variant of salivary gland malignancy. Further research is needed to better delineate its overall prevalence and to define an appropriate treatment algorithm for this new clinical entity.

Use of in vivo confocal microscopy in malignant melanoma: an aid in diagnosis and assessment of surgical and nonsurgical therapeutic approaches.

BACKGROUND: Melanomas with poorly defined borders, lack of pigmentation, lentiginous extension, and location in cosmetically sensitive regions represent diagnostic and therapeutic challenges. Repeated surgical reexcisions are frequently required to achieve tumor-free margins. The use of reflectance mode confocal microscopy as an noninvasive method has shown to be a promising tool for diagnosing pigmented lesions in vivo. OBSERVATIONS: We report 3 clinical cases of melanoma: amelanotic melanoma (case 1), locally recurrent melanoma (case 2), and lentigo maligna melanoma (case 3). In case 1, in vivo confocal microscopy was instrumental in making the diagnosis and in monitoring the response to imiquimod therapy for in situ residual disease. It was also used to successfully delineate preoperative surgical margins in cases 2 and 3. CONCLUSION: As new methods for treating melanoma emerge and become more available, confocal microscopy can play a significant role by improving sensitivity in diagnosis, by increasing rates of successful initial excision, and by serving as a noninvasive means of monitoring therapy.

A Phase I/II trial of concurrent docetaxel and radiation after induction chemotherapy in patients with poor prognosis squamous cell carcinoma of the head and neck.

BACKGROUND: The authors conducted a Phase I/II study in patients with a poor prognosis who had locally advanced squamous cell carcinoma of the head and neck (SCCHN) and who were treated initially with induction chemotherapy. Patients were treated with weekly docetaxel and concurrent daily fractionated radiation therapy to determine the maximum tolerated dose (MTD) of docetaxel and the efficacy of the regimen. METHODS: Twenty-two patients were enrolled, and 21 patients were treated. Eight patients had Stage III SCCHN, and 13 patients had Stage IV SCCHN without distant metastases and were treated first with 2-3 cycles of induction chemotherapy, which consisted of cisplatin plus 5-fluorouracil with or without leucovorin. Patients with a poor prognosis were identified as those who achieved a partial response to induction treatment, achieved a complete response with a positive biopsy, or were at high risk for developing recurrent disease. Patients were treated subsequently with concurrent, escalating doses of docetaxel (given weekly x 6) and once daily 200-centigray radiation fractions. RESULTS: Three patients were treated with a weekly docetaxel dose of 20 mg/m(2) without dose-limiting toxicity (DLT). Both patients who were treated at the next dose level of 30 mg/m(2) experienced DLT. A dose of 25 mg/m(2) was studied without DLT in the 16 patients who were treated, establishing this as the MTD. Sixty-seven percent of the patients are alive without disease at a median follow-up of 35 months (range, 12-59 months) after the initiation of chemoradiotherapy. CONCLUSIONS: The MTD of weekly docetaxel with concurrent daily radiation therapy in the postinduction setting was 25 mg/m(2). Disease free survival data from this study were good and indicated that this regimen was effective in the treatment of patients with SCCHN who had a poor prognosis.