Metastasis to ipsilateral medial retropharyngeal and deep cervical lymph nodes in 22 dogs with thyroid carcinoma.

OBJECTIVE: To determine the rate of nodal metastasis to the medial retropharyngeal (MRP) and deep cervical lymph nodes in dogs surgically treated for thyroid carcinoma. STUDY DESIGN: Retrospective study. ANIMALS: Twenty-two client-owned dogs. METHODS: Medical records between July 2015 and October 2019 at the Universities of Missouri and Florida were reviewed. Dogs that underwent thyroidectomy with concurrent elective MRP lymphadenectomy ± deep cervical lymphadenectomy were included. Tumor site, preoperative staging, and histopathological findings were recorded. RESULTS: Twenty-two dogs with 26 total thyroid carcinomas were included. Primary tumors were lateralized in 19 dogs, bilateral in two dogs, and bilateral and midline ectopic in one dog. All dogs underwent ipsilateral MRP resection, including bilateral resection in dogs with bilateral tumors. Three contralateral MRP lymph nodes were excised from dogs with unilateral carcinomas. Four deep cervical lymph nodes and one superficial cervical lymph node were excised. Metastases were identified in 14 lymph nodes in 10 of 22 (45%) dogs. All four excised deep cervical lymph nodes and one contralateral MRP lymph node were identified as metastatic. Size of deposit could be classified in 13 of 14 metastatic lymph nodes. Macrometastasis was detected in seven lymph nodes, micrometastasis was detected in one node, and isolated tumor cells were detected in five lymph nodes. CONCLUSION: Regional metastasis was common within the lymph nodes sampled in this population of dogs with thyroid carcinoma. CLINICAL SIGNIFICANCE: These results provide evidence to justify further exploration of a larger population to verify the rate of regional metastasis and determine the prognostic impact of nodal metastasis.

Parapharyngeal metastasis from papillary thyroid microcarcinoma.

Carcinoma of the thyroid gland is one of the most commonly encountered endocrine malignancies. Papillary carcinoma is the most common histological type and its pattern of metastasis are usually lymphatic. Lymphatic metastasis to parapharyngeal space is rare and have been reported, so we report the case of a 50-year-old male patient who had an occult papillary carcinoma of the thyroid presented as right lateral node of the neck and a nodal involvement of the right parapharyngeal space.

Pharyngeal metastasis following living-donor liver transplantation for hepatocellular carcinoma: a case report and literature review.

BACKGROUND: The most common sites of recurrence after liver transplantation for hepatocellular carcinoma (HCC) have been reported to be the liver, lung, bone, and adrenal glands, but there have also been many reports of cases of multiple recurrence. The prognosis after recurrence is poor, with reported median survival after recurrence of HCC ranging from 9 to 19 months. Here, we report a case of long-term survival after recurrence of pharyngeal metastasis following living-donor liver transplantation (LDLT) for HCC within the Milan criteria, by resection of the metastatic region and cervical lymph node dissection. CASE PRESENTATION: A 47-year-old man with a Model End-stage Liver Disease (MELD) score of 11 underwent LDLT for HCC within the Milan criteria for liver cirrhosis associated with hepatitis B virus infection, with his 48-year-old elder brother as the living donor. One year and 10 months after liver transplantation, he visited a nearby hospital with a chief complaint of discomfort on swallowing. A pedunculated polyp was found in the hypopharynx, and biopsy revealed HCC metastasis. We performed pharyngeal polypectomy. Two years later, cervical lymph node metastasis appeared, and neck lymph node dissection was performed. Although recurrence subsequently occurred three times in the grafted liver, the patient is still alive 12 years and 10 months after recurrence of pharyngeal metastasis. He is now a tumor-free outpatient taking sorafenib. CONCLUSION: It is necessary to recognize that the nasopharyngeal region is a potential site of HCC metastasis. Prognostic improvement can be expected with close follow-up, early detection, and multidisciplinary treatment, including radical resection.

A novel combined transoral and transcervical surgical approach for recurrent metastatic medullary thyroid cancer to the parapharyngeal space.

Medullary thyroid cancer (MTC) represents less than 1% of all thyroid cancers. Complete surgical resection remains the mainstay of treatment for locoregional disease. Unfortunately, patients with recurrence may present with metastasis to challenging anatomic locations. We describe the first case of a recurrent MTC metastatic to the parapharyngeal space (PPS) that was managed using a combined transoral robotic surgery (TORS) and transcervical (TC) approach. We review the presentation, natural history, diagnosis and management of recurrent MTC, and describe a novel combined TORS-TC surgical approach for the treatment of PPS metastasis. A 66-year-old male with history of MTC treated with total thyroidectomy in 2000 and a liver resection in 2011 for metastatic MTC was referred to our Head and Neck Surgery Clinic in October 2016 due to increased calcitonin and CEA levels. Exam was significant for mild right tonsillar/pharyngeal bulging and induration. Imaging with PET-CT and MRI showed an enlarging ovoid mass centered within the right PPS without the presence of another systemic metastasis. FNA was consistent with MTC. The patient was taken to the operating room for a combined TORS-TC approach. Final pathology was consistent with metastatic MTC. Until recently, PPS tumors have been managed using highly morbid and cosmetically disfiguring open surgical approach. TORS provides a safe and effective alternative.

Unusual loco-regional presentation in papillary carcinoma of thyroid: A case series.

BACKGROUND: Papillary carcinoma of thyroid (PTC) is usually indolent with good prognosis and excellent long-term survival. However, PTC sometimes presents itself in unusual situations, posing diagnostic and therapeutic challenges. Owing to paucity of data, there is lack of consensus as to what treatment should be prescribed in patients with loco-regional spread other than the usual sites. MATERIALS AND METHODS: Six patients of PTC presenting with involvement of the aero-digestive tract, retropharyngeal, and para-pharyngeal lymph nodes and great vessels of the neck are included in this case series. RESULTS AND CONCLUSION: Though rare, unusual loco-regional presentation of PTC poses challenges in diagnosis and treatment. A keen clinical sense is paramount in effectively diagnosing these cases. Aggressive surgical resection and reconstruction results in good functional and aesthetic outcomes. Further studies are required for establishing specific guidelines on the approach to the treatment of these cases.

Diagnostic accuracy of contrast-enhanced computed tomography for assessment of mandibular and medial retropharyngeal lymph node metastasis in dogs with oral and nasal cancer.

The diagnostic accuracy of contrast-enhanced CT for detection of cervical lymph node metastasis in dogs is unknown. The purpose of this retrospective, observational, diagnostic accuracy study was to assess the efficacy of CT for detection of mandibular and medial retropharyngeal lymph node metastasis in dogs. Histopathology of dogs with cancer of the head, CT and bilateral mandibular and medial retropharyngeal lymphadenectomy was reviewed. A single radiologist measured lymph nodes to derive short axis width and long-short axis ratios. Two blinded radiologists separately assessed lymph node margins, attenuation and contrast enhancement and each provided a final subjective interpretation of each node site as benign or neoplastic. Where radiologists' opinions differed, a consensus was reached. Sensitivity, specificity and accuracy were calculated for mandibular and medial retropharyngeal sites. Agreement between radiologists was assessed. Fisher's exact test and the Kruskal-Wallis H-test were used to assess associations between variables. Forty-one primary tumours were recorded in 40 dogs. Metastasis to mandibular or retropharyngeal lymph nodes occurred in 16 out of 40 dogs (43/160 nodes). Agreement between radiologists was almost perfect for margination, attenuation and enhancement, strong for interpretation of mandibular lymph node metastasis, and weak for interpretation of medial retropharyngeal lymph node metastasis. Sensitivity of CT was 12.5% and 10.5%, specificity was 91.1% and 96.7%, and accuracy was 67.5% and 76.3% for mandibular and medial retropharyngeal lymph nodes respectively. No individual CT findings were predictive of nodal metastasis. Given the low sensitivity of CT, this modality cannot be relied upon alone for assessment of cervical lymph node metastasis in dogs.

Treatment for retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site: results of a prospective study with irradiation to nasopharyngeal mucosa plus bilateral neck.

Background and Objetive: To evaluate treatment outcomes for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma (SCC) from an unknown primary site. METHODS: From January 2005 to January 2015, patients who presented with enlarged retropharyngeal nodes underwent transoral sonography-guided fine-needle aspiration to confirm histology. Those with metastatic undifferentiated SCC with unknown primary tumors were treated with radical radiotherapy to nasopharyngeal mucosa plus bilateral neck. Chemotherapy was administered for patients staged N2-3. Endpoints included metastatic nodes control, the appearance of primary tumor, overall survival and treatment-related toxicities. RESULTS: A total of 49 patients were recruited into this study. Retropharyngeal and cervical nodal disease was controlled in 96% of all patients. The incidence of occult primary cancer appearance was 8%. No primary cancer other than of the nasopharynx was detected during the course of follow-up. Ten patients developed distant metastases. The 5-year overall survival, progression-free survival, regional relapse free survival, distant metastasis free survival were 79.6%, 61.1%, 83.4%, 73.8%, respectively. Common late adverse effects included xerostomia (57%) and hearing impairment (35%). CONCLUSION: Radical radiotherapy to both the nasopharynx and bilateral neck can achieve excellent outcome with mild toxicities for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site.

Metástasis parafaríngea de carcinoma oculto de tiroides / Parapharyngeal metastasis of an occult thyroid carcinoma

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Unusual sites of metastasis of papillary thyroid cancer: Case series and review of the literature.

Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are found in only 1% of patients with PTC at the time of surgery; the two most common sites are the lung and bone. We report 4 cases of PTC metastasis to unusual sites: (1) the occipital skull and internal jugular vein, (2) the parapharyngeal space, (3) the sternocleidomastoid muscle, and (4) the right atrium of the heart. It has been well documented that aggressive distant metastasis is a characteristic of PTC, and it is known to be an indicator of a poor prognosis. Some of our patients' sites of metastatic disease have not been previously reported. Patients in this series exhibited aggressive histologic findings, including columnar cell and follicular variants of papillary disease. In addition, all 4 patients demonstrated "PET-avid" disease with decreased iodine avidity.

The predictive role of infiltrative growth pattern in early pharyngeal cancers.

CONCLUSION: The infiltrative growth pattern may predict tumor depth and lymph node metastasis. INF-a seems to fall into a low-risk category, and no additional treatment may be required immediately. OBJECTIVES: Tumor depth is a predictor of lymph node metastasis in early pharyngeal cancers. An infiltrative growth pattern is also a prognostic factor in other cancers. This study aimed to elucidate the predictive role of infiltrative growth pattern in early pharyngeal cancers. METHODS: Thirty-eight lesions from 37 patients who had undergone trans-oral resection of pharyngeal cancers were included. According to the Japanese Classification of Esophageal Cancer, infiltrative growth pattern was classified into three groups; INF-a, INF-b, and INF-c. The correlation between infiltrative growth pattern and tumor depth, cervical lymph node metastasis was analyzed. RESULTS: Of the 38 lesions, 25 were INF-a, nine were INF-b, and four were INF-c lesions. Lymph node metastasis was observed in three INF-b and one INF-c lesions. In contrast, no INF-a had lymph node metastasis. All INF-a lesions showed shallow invasion of the sub-epithelium; INF-b and INF-c lesions had significantly greater depth than INF-a.

Parapharyngeal metastases from thyroid cancer: surgical management of two cases with minimally-invasive video-assisted technique.

Metastases to parapharyngeal or retropharyngeal lymph nodes are rare in well-differentiated thyroid cancers. A review of English literature found only 112 cases reported in the last two decades, with an incidence of parapharyngeal lymph nodes metastases ranging from 0.43 to 2.5%. Surgical resection is the most effective treatment for patients with parapharyngeal lymph node metastasis from thyroid carcinoma. We describe two cases of thyroid cancer parapharyngeal lymph node metastases that were surgically removed using a traditional transcervical approach, with the help of a minimally-invasive video-assisted technique. A video-assisted minimally-invasive transcervical approach is a new technique for excision of sizable benign tumours and selected malignant tumours. The endoscopic technique allows clear identification of critical surgical landmarks that guide the dissection through the correct cleavage plane in a nearly bloodless surgical field, thus decreasing the rate of complications. In both patients postoperative follow-up showed no sequelae and recurrence after 20 and 15 months from surgery.

The nodal response to chemoselection predicts the risk of recurrence following definitive chemoradiotherapy for pharyngeal cancer.

CONCLUSIONS: The poor response of neck tumors to induction chemotherapy (ICT) as chemoselection is related to a significantly worse prognosis, including higher risks of local recurrence and/or distant metastasis, after definitive chemoradiotherapy (CRT). OBJECTIVES: Neck dissection is frequently performed to treat residual lymph nodes after CRT for the purpose of locoregional control; however, the prognosis of patients with pathologically proven residual neck tumors is poor, and no methods for predicting unfavorable results before CRT have been established. Therefore, in the present study, we focused on the response of lymph nodes to ICT and its relationship with the prognosis among patients treated with chemoselection. METHODS: We retrospectively reviewed a total of 27 oropharyngeal and 24 hypopharyngeal squamous cell carcinoma stage III/IV consecutive patients with cervical lymph node metastasis who exhibited a response of >50% in the primary tumor to ICT followed by concurrent definitive CRT. RESULTS: The relapse-free survival of the patients who responded (partial response/complete response, PR/CR) to ICT was significantly superior to that of the patients who did not respond (stable disease, SD) to ICT (p = 0.008).

[Malignant acanthosis nigricans: report of a case]. / Acantose nigricante maligna: realato de caso.

The authors present a case of a 44-year-old patient with a disseminated dermatosis diagnosed as acanthosis nigricans. The patient was a smoker and investigation of the cause of her skin lesions resulted in discovery of an asymptomatic metastatic carcinoma in the laryngopharanx, probably of pulmonary origin.

[Surgical management of persisting fistulas after salvage-laryngectomy]. / Chirurgisches Management der persistierenden Speichelfistel nach Salvage-Laryngektomie.

BACKGROUND: The salvage-laryngectomy (SLE) has compared to the laryngectomy a high risk for complications. The salivary fistula is the most frequent complication with an incidence range from 3% to 65% according to the literature. MATERIAL AND METHODS: From 2004-2011 we included in this study 16 patients with a recurrent or secondary T4a-squamous cell carcinoma (HNSCC) of the larynx or pyriform sinus undergoing a SLE. 6 HNSCC were located at the pyriform sinus (44%) and 9 at the larynx (56%). The aim of this retrospective study was to analyze the risk of developing a postoperative fistula after SLE as well as to present our surgical concept of persisting fistula treatment. RESULTS: 6 out of these 16 patients (38%) had a persisting fistula which needed a secondary surgical closure. In all of these cases we used a "sandwich"-concept which included a reconstruction of the pharynx by the pectoralis myofascial flap and another regional rotation flap as the deltopectoral flap or the latissimus dorsi flap for skin reconstruction of the neck. With this concept we were able to successfully close the fistula after the SLE in all 6 cases. CONCLUSION: By using our "sandwich"-concept we provide a multi-layered fistula closure with insertion of vital muscle tissue and a double epithelium. This guarantees a secure barrier to the saliva and prevents effectively a further fistula.

Significant invasion of the pharyngeal constrictor muscle in early squamous cell carcinoma of the tonsil: prediction of multiple regional metastasis.

OBJECTIVE: To determine whether invasion of the pharyngeal constrictor muscle in early squamous cell carcinoma of the tonsil is correlated with lymph node metastasis. DESIGN: Retrospective analysis of medical records and pathology specimens. SETTING: Tertiary care referral center. PATIENTS: Forty-eight patients who were diagnosed as having T2 squamous cell carcinoma of the tonsil and who underwent surgery. They were divided into 2 groups: an invasive group with invasion of the pharyngeal constrictor muscle and a noninvasive group without invasion of the pharyngeal constrictor muscle. MAIN OUTCOME MEASURES: Comparison of regional metastasis, 5-year locoregional recurrence, and 5-year disease-specific survival between the 2 groups. RESULTS: Invasion of the pharyngeal constrictor muscle was found in 36 patients (75%) with T2 squamous cell carcinoma of the tonsil. The rate of lymph node metastasis, the mean (SD) number of positive nodes, and the mean (SD) lymph node density were 81%, 5.47 (9.27), and 0.15 (0.22) in the invasive group, respectively, and 50%, 1.33 (1.72), and 0.04 (0.04) in the noninvasive group, respectively (P = .04, P = .02, and P = .01, respectively). Five-year locoregional recurrence was significantly correlated with invasion of the pharyngeal constrictor muscle (P = .05) and with multiple lymph node metastasis (≥5 nodes) (P = .04) in the univariate analyses. No factor was correlated with 5-year locoregional recurrence in the multivariate analysis. Five-year disease-specific survival was significantly correlated with multiple lymph node metastasis (≥5 nodes) in the univariate analyses (P = .009). Five-year disease-specific survival was not significantly correlated with any clinicopathological factor in the multivariate analysis. CONCLUSION: Higher risk for multiple lymph node metastasis and 5-year locoregional recurrence seems to be predicted in patients with extratonsillar invasion of the pharyngeal constrictor muscle, even in early squamous cell carcinoma of the tonsil.

Neoplastic lymphangiosis of the upper aerodigestive tract simulating field cancerization: histopathological analysis, surgical limits and literature review.

Neoplastic lymphangiosis is defined as extensive embolic spread of cancer cells in the lymphatic vessels often without any evidence of a mass. Instead, field cancerization is defined by the presence of multifocal neoplastic lesions in a mucosal field previously exposed to mutagenic factors. In this case report, this oncological entity was suggested by the wide extent and multifocality of the disease and by the patient's exposure to risk factors. Instead, the pathological slides revealed the integrity of the mucosa and the presence of widespread embolic metastasis to lymphatic vessels. Thus, the diagnosis was changed to neoplastic lymphangiosis. This clinical presentation is a negative prognostic factor, and surgical treatment is ineffective because of the impossibility to obtain adequate free margins. The present case underlines the poor prognosis of such locally advanced cancer and the importance of recognizing it early so that the treatment approach can be adapted.

Metastasis of papillary thyroid cancer to the larynx and pharynx: unusual case report.

Papillary thyroid cancer favors lymphatic spread both within the thyroid gland and to the cervical lymph nodes. Hematogenous spread rarely occurs in the lung, bones and brain. We report a case where metastatic nodules from papillary thyroid cancer were seen in the right aryepiglottic fold (supraglottis) and lateral wall of hypopharynx, an extremely rare event.

The dual role of TLR3 in metastatic cell line.

Toll-like receptors (TLRs) are members of transmembrane proteins that recognize conserved molecular motifs of viral and bacterial origin and initiate innate immune response. As the role of TLRs in tumors cells is still not clear, our aim was to investigate the role of TLR3 in primary tumor and metastatic cells (SW480, SW620, FaDu and Detroit 562). We have reported here on the dual role of TLR3 in pharynx metastatic cell line (Detroit 562); on one hand TLR3 activation drove cells to apoptosis while on the other its stimulation contributed to tumor progression by altering the expression of tumor promoting genes (PLAUR, RORB) and enhancing the cell migration potential. In addition, we have shown TLR3 signaling pathway is functional in another metastatic cancer cell line (SW620) suggesting TLR3 might be important in the process of tumor metastasis. Since TLR3 agonists have been used in tumor therapy with the aim to activate immune system, scientific contribution of this work is drawing attention to the importance of further work on this topic, especially pro-tumor effect of TLR3, in order to avoid possible side-effects.

Pattern of cervical lymph node metastasis in tonsil cancer: predictive factor analysis of contralateral and retropharyngeal lymph node metastasis.

The purpose of this study was to determine the pattern of cervical lymph node metastasis in tonsil cancer including the retropharyngeal (RPLN) nodal metastasis. Seventy-six tonsillar squamous cell carcinoma patients who underwent surgery-based treatment were retrospectively analyzed. Most patients had advanced stage (stages III and IV: 81.6%) tonsil cancer. Sixteen patients were treated with surgery only. Postoperative radiotherapy was performed to 38 patients, and chemoradiation to 22 patients. Seventy-one therapeutic neck dissections and 27 elective neck dissections were performed. Thirty-four patients underwent RPLN dissection based on the preoperative inclusion criteria. There was a statistically significant metastasis in level I or V nodes, when the ipsilateral multilevel, or contralateral nodes were positive. The rate of contralateral occult cases was 28.6%. T3-4 stages, primary lesions close to the midline, or ipsilateral multilevel involvement were significantly associated with contralateral metastasis. Ipsilateral multilevel involvement was the independent factor with multivariate analysis. RPLN metastasis was confirmed in 9 of the 34 (26.5%) subjects. Disease-specific survival rate was significantly different according to RPLN status (82.1% vs. 55.6%; p=0.021). Positive pre-operative image, posterior pharyngeal wall invasion, more than N2 stage, contralateral node metastasis, or ipsilateral multilevel involvement were correlated with RPLN metastasis. Bilateral neck dissection is mandatory for primary lesions close to the midline and advanced ipsilateral nodal disease. Elective RPLN dissection should be considered for patients with advanced neck and primary tumor, particularly for tumors with posterior pharyngeal wall invasion.