Multidisciplinary approach to anaplastic and metastatic meningioma: A case report and review of the literature.

Background: Meningiomas are slow-growing neoplasms, accounting for 20% of all primary intracranial neoplasms and 25% of all intraspinal tumors. Atypical and anaplastic meningiomas are infrequent, representing fewer than 5% of all meningiomas. Unusually, they can show aggressive behavior, and extracranial metastases are extremely rare, representing approximately 0.1% of all reported cases. Case Description: Fifty-six-year-old male patient diagnosed with atypical basal frontal meningioma with multiple resections, both endoscopic endonasal and transcranial. After hypofractionated radiosurgery, the patient showed new tumor recurrence associated to right cervical level II ganglionic metastasis. We opted for complete resection of the meningioma and reconstruction with anterior rectus abdominis muscle flap, as well as selective cervical ganglionectomy. Anatomical pathology showed neoplastic proliferation of meningothelial cells in syncytial cytoplasm, oval or spherical nuclei with slight anisocariosis and hyperchromasia, and intranuclear vacuoles, all compatible with anaplastic meningioma. Conclusion: Due to a lack of consensus on how to treat a metastatic malignant meningioma, this pathology requires a multidisciplinary approach, and treatment needs to be adapted to each particular case. Complete resection of the lesion is the primary goal, and this requires complex procedures involving endocranial as well as extracranial surgeries, which result in composite defects difficult to resolve. Microvascular free flaps are considered the gold standard in reconstructions of large skull base defects, with high success rates and few complications.

Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications / Utilización de colgajos libres microvasculares para la reconstrucción de la base del cráneo secundaria a resecciones tumorales: técnicas disponibles y complicaciones

Introduction: Resection of malignant tumors located in the anterior and middle fossae of the skull base requires thorough anatomical knowledge, as well as experience regarding the possible reconstructive options to resolve the resulting defects. The anatomical and functional relevance of the region, the complexity of the defects requiring reconstruction and the potential complications that can occur, represent a true challenge for the surgical team. The goal of this study is to describe the microsurgical reconstructive techniques available, their usefulness and postoperative complications, in patients with malignant tumors involving the skull base. Materials and method: This observational, retrospective study, included all patients who underwent surgery for malignant craniofacial tumors from January 1st, 2009 to January 1st, 2019 at a University Hospital in Argentina. Only patients who required reconstruction of the resulting defect with a free flap were included. Results: Twenty-four patients required reconstruction with FF; 14 were male (58.3%) and mean age was 54.9 years. Sarcoma was the most frequent tumor histology. Free flaps used were the following: anterolateral thigh, rectus abdominis, radial, latissimus dorsi, iliac crest and fibular. Complications occurred in 6 cases and no deaths were reported in the study group. Conclusion: Free flaps are considered one of the preferable choices of treatment for large skull base defects. In spite of the complexity of the technique and the learning curve required, free flaps have shown to be safe, with a low rate of serious complications. For these patients, the surgical resolution should be performed by a multidisciplinary team. (AU)

Introducción: La resección de los tumores malignos de la base de cráneo anterior y media requieren no solo un amplio conocimiento anatómico, sino también experiencia en las posibles opciones reconstructivas factibles para resolver el defecto generado. La importancia anatómica y funcional de la región, la complejidad de los defectos a reconstruir y las posibles complicaciones que pueden desarrollar representan un verdadero desafío para el equipo quirúrgico. El objetivo del presente trabajo es exponer las posibles opciones reconstructivas microquirúrgicas, su utilidad y las complicaciones postoperatorias en pacientes con tumores malignos que comprometen la base de cráneo. Materiales y método: Se realizó un estudio observacional retrospectivo de todos los pacientes operados de tumores malignos craneofaciales en el período comprendido entre el primero de enero de 2009 al primero de enero de 2019 en un hospital universitario de Argentina. Se incluyeron solo aquellos pacientes en los que fue necesario reconstruir el defecto a través de un colgajo libre (CL). Resultados: Veinticuatro pacientes requirieron reconstrucción con CL. Catorce fueron varones (n = 14 [58,3%]) y la media de edad fue de 54,9 años. La variedad tumoral histológica más frecuente fue el sarcoma. Los tipos de CL utilizados fueron los siguientes: anterolateral de muslo, recto anterior del abdomen, radial, dorsal ancho, cresta iliaca y fibular fueron los CL utilizados. Se reportó una tasa global de complicaciones del n = 6 (25%). Un solo paciente presentó isquemia del colgajo. No hubo mortalidad asociada. Conclusión: Los CL representan una de las primeras opciones en el tratamiento en defectos grandes de la base de cráneo. A pesar de la complejidad de la técnica y la curva de aprendizaje necesaria, los CL han demostrado ser seguros con bajas tasas de complicaciones graves. La resolución quirúrgica de estos pacientes se debe realizar por un equipo multidisciplinario. (AU)

Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications.

INTRODUCTION: Resection of malignant tumors located in the anterior and middle fossae of the skull base requires thorough anatomical knowledge, as well as experience regarding the possible reconstructive options to resolve the resulting defects. The anatomical and functional relevance of the region, the complexity of the defects requiring reconstruction and the potential complications that can occur, represent a true challenge for the surgical team. The goal of this study is to describe the microsurgical reconstructive techniques available, their usefulness and postoperative complications, in patients with malignant tumors involving the skull base. MATERIALS AND METHOD: This observational, retrospective study, included all patients who underwent surgery for malignant craniofacial tumors from January 1st, 2009 to January 1st, 2019 at a University Hospital in Argentina. Only patients who required reconstruction of the resulting defect with a free flap were included. RESULTS: Twenty-four patients required reconstruction with FF; 14 were male (58.3%) and mean age was 54.9 years. Sarcoma was the most frequent tumor histology. Free flaps used were the following: anterolateral thigh, rectus abdominis, radial, latissimus dorsi, iliac crest and fibular. Complications occurred in 6 cases and no deaths were reported in the study group. CONCLUSION: Free flaps are considered one of the preferable choices of treatment for large skull base defects. In spite of the complexity of the technique and the learning curve required, free flaps have shown to be safe, with a low rate of serious complications. For these patients, the surgical resolution should be performed by a multidisciplinary team.

Giant Cell Tumor of the Carotid Body: A Rare Tumor with Malignant Potential.

Introduction: Carotid body tumors (CBTs) are certainly unusual. They are vascular lesions originating from paraganglionic cells, located at the common carotid artery (CCA) bifurcation. They represent less than 0.5% of head and neck tumors, approximately 1-3 cases per million. Malignant CBTs are extremely rare; in the literature, published rates on average are < 10%. The diagnostic criteria for malignancy should be based on the finding of distant metastasis. Due to its unpredictable nature and its malignant potential, diagnosis before metastasis and complete surgical resection are the keys to a favorable prognosis. Case Report: Given little experience in CBTs, its biology and treatment remain uncertain. We present the case of a 48-years-old patient, with a mass on the left side of the neck that was found to be a vast CBT with suspicious histopathology. Its size, rare location, pathologic findings, and management strategy applied for its treatment, illustrate an unusual case that highlights the importance of its publication. Conclusions: CBT is rare, but subject to cure lesion if resected without metastatic or residual disease. This is why surgery should be performed whenever possible and why it is so necessary to study this pathology thoroughly and to take it into account in the differential diagnosis.

Recommendations regarding emergency head and neck procedures during coronavirus disease-2019.

The coronavirus disease-2019 (COVID-19) has spread globally and is considered a world health emergency. Healthcare professionals represent an important percentage of the infected population, with otolaryngologists and head and neck surgeons at particular risk. Elective procedures have been strongly discouraged, but urgent disorders still entail a hazardous setting. We performed a non-systematic review of the publications and guidelines regarding Head and Neck surgical emergencies management in the context of the COVID-19 pandemic. The literature describing management of the disease was also reviewed to adapt conventional treatment to the present circumstances. A concise and specific compilation of practical recommendations was made with the aim of improving management of emergencies involving the head and neck region, while offering a safe alternative for patients and healthcare providers. In addition, we have made a brief summary of how these recommendations were adapted based on our socio-economic background and available health resources.

La enfermedad del coronavirus-2019 (COVID-19) se ha extendido a nivel mundial y se considera una emergencia sanitaria mundial. Los profesionales sanitarios representan un porcentaje importante de la población infectada, y los otorrinolaringólogos y cirujanos de cabeza y cuello corren un riesgo especial. Se han desaconsejado enérgicamente los procedimientos electivos, pero los trastornos urgentes aún implican un entorno peligroso. Realizamos una revisión no sistemática de las publicaciones y guías sobre el manejo de emergencias quirúrgicas de cabeza y cuello en el contexto de la pandemia de COVID-19. También se revisó la literatura que describe el manejo de la enfermedad con el fin de adaptar el tratamiento convencional a las circunstancias actuales. Se realizó una recopilación concisa y específica de recomendaciones prácticas con el objetivo de mejorar el manejo de las emergencias que involucran la región de la cabeza y el cuello, al tiempo que ofrece una alternativa segura para los pacientes y los proveedores de atención médica. Además, hemos hecho un breve resumen de cómo se adaptaron estas recomendaciones en función de nuestros antecedentes socioeconómicos y los recursos de salud disponibles.

Tongue squamous cell carcinoma and bilateral kidney metastases / [Carcinoma escamoso de lengua y metástasis renales bilaterales]

Squamous cell carcinoma of the tongue is the most common malignant tumor of the oral cavity. The finding of metastases, in this type of cancer, is considered the main factor of poor prognosis with a marked effect on the overall survival. The normal progression tends to be locoregional, at the surgical site or regional lymph nodes, and systemic involvement is usually uncommon. We present the case of a male patient, 40 years old, with tongue cancer and bilateral kidney metastases, eleven months after initial diagnosis. The aggressive biology, the extremely rare metastases location and a grim prognosis, illustrate an unusual case, which highlights the importance of its publication.

El carcinoma escamoso de lengua es la lesión maligna más frecuente de la cavidad oral. El hallazgo de metástasis en este tipo de neoplasias se considera el principal factor de mal pronóstico con efecto marcado en la sobrevida global del paciente. La progresión habitual suele ser locorregional, en el lecho quirúrgico o a nivel ganglionar, siendo poco frecuente el hallazgo de afectación sistémica.  Se presenta el caso de un paciente masculino de 40 años de edad con diagnóstico de cáncer de lengua y metástasis renales bilaterales, a los 11 meses del diagnóstico inicial. La biología agresiva, la localización extremadamente rara de las metástasis y el pronóstico sombrío ilustran un caso inusual que resalta la importancia de su publicación.

Head and neck sarcomas: treatment outcomes in a tertiary referral center in Argentina.

PURPOSE: To analyze the clinical findings, management, and results of oncological treatments and to identify prognostic factors in patients diagnosed with head and neck sarcoma. METHODS: We performed a retrospective analysis including 48 adult patients with primary head and neck sarcomas, treated between 2006 and 2018 in a referral center of Argentina. RESULTS: The median follow-up time was 44 months (range: 4-146 months). Five-year overall survival was 68%. On univariate analysis, radiation-induced sarcomas (p=0.038) had worse survival. Five-year disease-free survival was 58% and local recurrence at 2 years was 22.7%. On multivariate analysis, positive/close resection margins (p=0.031), radiation-induced sarcomas (p=0.037), and mandibular and oral cavity location (p=0.002) were independent prognostic factors associated to local recurrence and shorter disease-free survival. CONCLUSION: Head and neck sarcomas are a rare entity. Surgery is feasible in more than 80% of patients, with an acceptable overall and disease-free survival. Radiation-induced sarcomas, location in the mandible and oral cavity, and close margins were significant prognostic factors in our population.

Clear cell odontogenic carcinoma: a rare pathology with an innovative resolution.

Clear cell odontogenic carcinoma (CCOC) is an uncommon condition that has been considered malignant since 2005. The clinical presentation usually involves an asymptomatic swelling, which typically affects the anterior mandible in middle-aged women; it has neither clinical nor radiological defining features. Immunohistochemical analysis usually aids diagnosis, as clear cells are also associated with other clear cell carcinomas and benign tumors. Radical surgery is the gold standard of treatment and usually needs microsurgical reconstruction with bone transference for restoration of facial anatomy and adequate function.  We present the case of a young woman with CCOC whose tumor removal and reconstructive surgery were planned virtually and assisted by intraoperative navigation. The novelty of the reconstructive procedure was the replacement of the fibula cutting guides for intraoperative navigation of the osteotomies. We present a brief review of CCOC and the benefits of using computer-assisted surgery (CAS) in high-complexity cases like this one.

Treatment for postchemoradiotherapy hypopharyngeal stenosis: Pharyngoesophageal bypass using an anterolateral thigh flap-A case report.

Radiation-induced pharyngoesophageal stenosis is a frequent and unwanted consequence of nonsurgical treatment of hypopharyngeal carcinomas. Current treatment mainly includes endoscopic dilatations, but a poor response to this modality and/or a severe stenosis may lead to a radical resection (pharyngolaryngectomy) and reconstruction with tubed flaps, which allow oral feeding but fail to preserve speech. In this report, we present a case of radiation-induced hypopharyngeal stenosis treated with a pharyngoesophageal bypass using an anterolateral thigh (ALT) flap with the intention of preserving the larynx. We describe the case of a 59-year-old male with severe pharyngoesophageal stenosis after chemoradiotherapy due to a squamous cell carcinoma, where conventional dilatation treatment failed to restore pharyngoesophageal passage of solids or liquids. Since the patient rejected a pharyngolaryngectomy due the loss of speech entailed, a pharyngoesophageal bypass was performed using an ALT flap. The flap measured 13 × 20 cm, which ensured a 4-cm-diameter tube and enough length to communicate the lateral pharyngeal wall with the cervical esophagus. Endoscopy did not reveal flap failure, and during the immediate postoperative period, the patient had a small cervical leak detected only by imaging that did not affect the skin and resolved with antibiotic treatment. The patient also required a tracheostomy on day 4 and initially had no passage of saliva through the bypass; we attributed this to edema that resolved spontaneously after 1 month with complete liquid and solid passage and laryngeal competence that led to tracheal decannulation. Good functional results were achieved both for speech and swallowing at 5-year follow-up. We believe that this procedure may be considered before performing a pharyngolaryngectomy for the treatment of a persistent benign stenosis in patients with a functional larynx.

Reconstruction of Hind and Mid-Foot Defects after Melanoma Resection Using the Reverse Sural Flap: A Case Series.

Background Melanoma resection creates important soft tissues defects, which are difficult to manage when located on the weight-bearing heel and mid foot. There is little evidence on the use of the reverse-flow sural flap for this type of reconstruction. Objective This study reports our case series on the reconstructive management of the hind and mid-foot defects after melanoma resection using the reverse sural artery flap. Materials and Methods This is a retrospective study of four consecutive patients treated with resection of melanoma of the feet and reconstruction with reverse sural artery flap from 2006 to 2009. Results The mean age of the patients was 54 years, three were females, and one was male. Three of the defects were located on the weight-bearing heel, the other on the mid-foot dorsum. The melanomas were fully resected with wide margins. Three patients were reconstructed primarily, whereas one patient was reconstructed 4 weeks after the resective surgery. This series revealed 100% flap survival and there was no partial necrosis. Major complications were not observed. The four patients completely recovered the function of the affected limb. Conclusion The reverse sural flap is a viable option for the reconstruction of foot defects after melanoma resection.

Carcinoma espinocelular del oído externo con extensión parotídea: a propósito de un caso / Squamous cell carcinoma of the external ear with parotid extension: case report

El pabellón auricular y el conducto auditivo externo constituyen una región anatómica que puede ser asiento de múltiples patologías, entre ellas procesos inflamatorios, infecciosos y neoplásicos, tanto benignos como malignos. Con respecto a los tumores, los diversos tipos suelen presentarse con síntomas y signos similares y en general es difícil inferir la variedad histológica del tumor a través del examen físico, por lo cual es necesario el estudio histopatológico para determinar el diagnóstico. La mayoría de los tumores del oído externo son carcinomas; entre ellos se destacan el carcinoma basocelular, el más frecuente, y el carcinoma espinocelular. Menos frecuentemente se encuentran otros tipos de tumores como los melanomas, adenocarcinomas, carcinomas de glándulas ceruminosas, carcinomas mucoepidermoides, sarcomas, procesos linfoproliferativos, etc. Suelen ocurrir en la edad media y avanzada (50-70 años) y con mayor periodicidad en el sexo masculino. En el presente trabajo se describe un caso clínico de carcinoma espinocelular del oído externo, tratado exitosamente mediante cirugía y radioterapia, así como también se describen las características clínicas de esta enfermedad, con especial atención al compromiso del oído externo por ella.

The pinna and the ear canal are an anatomical region that can be affected by many diseases, including inflammatory, infectious and benign and malignant neoplastic processes. With regard to tumors, various types usually present with similar symptoms and usually is very difficult to know the histological type through physical examination, so histopathological examination is necessary in order to determine the diagnosis. Most tumors are carcinomas; they can be basal cell carcinoma (more frequently), or squamous carcinoma. Less frequently are other types of tumors such as melanomas, adenocarcinomas, ceruminous glands carcinomas, mucoepidermoid carcinomas, sarcomas, lymphoproliferative disorders, etc. They usually present in middle and advanced age people (50-70 years) and are more frequently in men. In this article we present a case of squamous cell carcinoma of the external ear with extention to parotid gland, successfully treated with surgery and radiotherapy, as well as we describe the clinical characteristics of this disease, with special attention to the compromise of the external ear. (AU)

Management Issues in the Treatment of an Ameloblastoma with an Atypical Presentation.

Benign ameloblastoma (BA) is the most common tumor arising from the odontogenic epithelium. Surgical resection with adequate margins is the mainstay of treatment due to the high index of tumor recurrence when not completely excised. Although locoregional spread has been described in the literature, it is very uncommon. We describe the treatment and follow-up of a 22-year-old woman with multiple recurrences and locoregional spread of a mandibular ameloblastoma who was referred to our center after several tumor resections with subsequent reconstructions. After a complete macroscopical removal of a new recurrence, the mandible was primarily reconstructed. A local homolateral recurrence and a second lesion in the contralateral maxilla were detected after 1-year follow-up and accordingly treated. After 4 years the patient showed a new tumor in the temporal fossa and was reoperated. The histopathology was consistent with a BA in all cases. Even though it is rare, locoregional spread of BA has been reported previously. Recurrences discovered during follow-up may require further resections. A close follow-up is mandatory, and treatment of these cases may result demanding requiring a multiple team approach, including oncologists and radiotherapists.

Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review.

The aim of the study is to analyze the effectiveness of rigid internal fixation (RIF) for treating edentulous mandibular fractures. Because of the low incidence of fractures in edentulous mandible, there is no consensus of the optimal treatment for it. This study included all edentulous patients with mandibular fracture diagnosis, who were treated with internal fixation at the Hospital Italiano de Buenos Aires from November 1991 to July 2011. Data such as age, gender, etiology and location of fracture, surgical approach, type of osteosynthesis used, and postoperative complications were analyzed. A total of 18 patients, 76.2 years mean age, 12 females (66.6%), presented a total of 35 mandibular fractures. The mandibular body was the most common localization of the fractures. Twenty-five fractures received surgical treatment with RIF, mainly approached extraorally. Reconstruction plates were the most common type of fixation used. Fracture reduction was considered satisfactory in 96.5%, with 22.2% of complications and 11.1% of reoperations needed. Open reduction and RIF demonstrated to be a reliable method for treating edentulous mandibular fractures. Nevertheless, there is lack of high-level recommendation publication to support this.

Pasado, presente y futuro del trasplante facial en el mundo y en la Argentina / Past, present and future of facial transplant in the world and in Argentina

El año 2005 marcó un cambio de paradigma en la reconstrucción facial. En Amiens, Francia, se llevó a cabo con éxito el primer trasplante de cara. Desde entonces, se han planteado varios interrogantes; entre ellos el desafío técnico, el manejo inmunológico y el dilema ético. El presente trabajo es una revisión de la literatura publicada hasta la actualidad. Se analiza la historia, implicaciones, resultados hasta hoy y su futuro. Asimismo, se evalúa la situación actual y factibilidad en la Argentina.

Pasado, presente y futuro del trasplante facial en el mundo y en la Argentina / Past, present and future of facial transplant in the world and in Argentina

El año 2005 marcó un cambio de paradigma en la reconstrucción facial. En Amiens, Francia, se llevó a cabo con éxito el primer trasplante de cara. Desde entonces, se han planteado varios interrogantes; entre ellos el desafío técnico, el manejo inmunológico y el dilema ético. El presente trabajo es una revisión de la literatura publicada hasta la actualidad. Se analiza la historia, implicaciones, resultados hasta hoy y su futuro. Asimismo, se evalúa la situación actual y factibilidad en la Argentina.(AU)

Free flap reconstruction for complex scalp and forehead defects with associated full-thickness calvarial bone resections.

Extensive defects of the scalp and forehead associated with calvarial bone resections demand complex reconstructions. Free flaps offer vascularized tissue of excellent quality and quantity. We report six patients with extensive scalp and forehead defects associated with calvarial bone resections reconstructed with free flaps. Five patients also required a cranioplasty. The flaps used were two anterolateral thigh flaps, one vastus lateralis flap, one myocutaneous latissimus dorsi flap, one latissimus dorsi flap, and one radial forearm flap. All flaps survived with no partial necrosis. There were no donor site complications. One patient presented an exposure of the alloplastic material used for cranioplasty. We strongly recommend the use of free flaps for this kind of reconstruction.