✓ Over a 22-year period, operations were performed on 263 patients for 288 primary benign tumors of major peripheral nerves. The tumors included 85 schwannomas, 197 neurofibromas, and six plexiform neurofibromas. Total removal was achieved in 83 of the 85 schwannomas, and 76 of these patients were available for follow-up evaluation. Motor function either improved or was unchanged in 87% of these patients and 85% of those with pain in the distribution of the involved nerve had either total or partial resolution of their symptoms. Of the neurofibromas, 123 occurred in 121 patients without von Recklinghausen's disease. All tumors within this group were completely excised using a fascicular approach to the tumor. Of the 99 patients available for follow-up evaluation, 90% had either improved or unchanged motor function and 88% had partial or complete resolution of pain syndromes. Fifty-nine patients with von Recklinghausen's disease had 80 tumors removed: 74 fusiform tumors (58 of which were completely removed...

Neural sheath tumors of major nerves

Objectives: To determine prognostic factors for survival in patients with invasive well-differentiated thyroid carcinoma, specifically examining laryngotracheal invasion as an independent prognostic factor, and to compare types of surgical resection to determine treatment efficacy. Design: Retrospective review of patients with papillary invasive well-differentiated thyroid carcinoma surgically treated over 45 years. Setting: Academic tertiary care medical center. Patients: A total of 292 patients with invasive well-differentiated thyroid carcinoma were surgically treated between 1940 and 1995. Informed consent was obtained from all patients. Extent and location of tumor invasion were determined. Invasion of larynx and/or trachea occurred in 124 patients (41%). Patterns of invasion and techniques of surgical resection were evaluated. Intervention: Types of surgical resection performed: complete tumor removal (n=34), "shave" excision (n=75), and incomplete tumor excision (n=15). Main Outcome Measures: Cox regression analysis was used to determine significance of prognostic factors for survival; Kaplan-Meier curves were used to evaluate survival. A P value of less than .05 was statistically significant. Results: Patterns of invasion by thyroid carcinoma included direct spread through laryngeal framework into paraglottic space or spread from involved lymph nodes. Laryngotracheal invasion was a significant, independent, prognostic factor for survival (P Conclusions: Laryngotracheal invasion was a significant independent prognostic factor for survival (P .05). Tumors with minimal invasion may be treated by shaving tumor from the aerodigestive tract. Gross intraluminal involvement should be resected completely to prevent complications. Arch Otolaryngol Head Neck Surg. 1997;123:484-490

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=OTOL&articleId=624138&pdfFileName=archotol_123_5_003.pdf

The Surgical Management of Laryngotracheal Invasion by Well-Differentiated Papillary Thyroid Carcinoma

Segmental laryngotracheal and tracheal resection for invasive thyroid carcinoma.

Background
Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.

Methods
An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus.

Results
After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council. © 2014 Wiley Periodicals, Inc. Head Neck, 36: 1379–1390, 2014

https://onlinelibrary.wiley.com/doi/pdf/10.1002/hed.23619

Management of invasive well-differentiated thyroid cancer: an American Head and Neck Society consensus statement. AHNS consensus statement.

Objectives/Hypothesis: 1) To describe the clinical entity invasive well-differentiated thyroid carcinoma (IWDTC), 2) to determine prognostic factors for survival in patients with IWDTC, 3) to describe and compare types of surgical resection to determine treatment efficacy, 4) to offer a staging system and surgical algorithm for management of patients with IWDTC, 5) to examine alterations in expression of E-cadherin and β-catenin adhesion molecules in three groups of thyroid tissue and propose a cellular mechanism for invasion of the aerodigestive tract.



Study Design: Basic science: quantification of expression of E-cadherin and β-catenin in three groups of thyroid tissue. Clinical: retrospective review of patients with IWDTC surgically treated and followed over a 45-year time period.



Methods: Basic science: immunohistochemical staining was used with antibodies against E-cadherin and β-catenin in three groups of tissue: group 1, normal control thyroid tissue (n = 10); group 2, conventional papillary thyroid carcinoma (n = 20); group 3, IWDTC (n = 12). Intensity scores were given on the basis of protocol. One-way analysis of variance (ANOVA) was used to evaluate differences between groups. Post hoc ANOVA testing was completed. P < .05 was significant. Clinical: patients were divided into three surgical groups within the laryngotracheal subset: group 1, complete resection of gross disease (n = 34); group 2, shave excision (n = 75); group 3, incomplete excision (n = 15). Cox regression analysis was used to determine significance of prognostic factors. Kaplan-Meier plots were used to evaluate survival. P < .05 was significant.



Results: Basic science: a significant difference between the three thyroid tissue groups for E-cadherin expression was demonstrated on one-way ANOVA testing. When controls were compared with either experimental group in post hoc ANOVA testing, differences between all groups were demonstrated (P < .001). For β-catenin, the intensities of the three groups were not different by one-way ANOVA testing. Similar nonsignificant results were found on post hoc ANOVA testing. Clinical: there was a statistically significant difference in survival for patients with and without involvement of any portion of the endolarynx or trachea (P < .01). There was a significant difference among all three surgical groups when compared (P < .001). When complete and shave groups were compared with gross residual group there was a significant decrease in survival in incomplete resection group (P < .01). Cox regression analysis demonstrated invasion of larynx and trachea were significant prognostic factors for poor outcome. The type of initial resection was significant on multivariate analysis. Removal of all gross disease is a major factor for survival.



Conclusions: Basic science: there is a decrease in membrane expression of E-cadherin in IWDTC, and loss of this tumor suppressor adhesion molecule may contribute to the invasive nature of well-differentiated thyroid carcinomas. Clinical: laryngotracheal invasion is a significant independent prognostic factor for survival. Patients undergoing shave excision had similar survival when compared with those undergoing radical tumor resection if gross tumor did not remain. Gross intraluminal tumor should be resected completely. Shave excision is adequate for minimal invasion not involving the intraluminal surfaces of the aerodigestive tract.

Aerodigestive tract invasion by well-differentiated thyroid carcinoma: diagnosis, management, prognosis, and biology.

This study was carried out to ascertain whether the cartilage-shaving procedure is appropriate to control thyroid carcinoma with tracheal cartilage invasion. Of 432 thyroid carcinoma patients treated between 1979 and 1988, 16 had tracheal cartilage invasion only. This patient population was made up of 3 men and 13 women, with a mean age of 55.8 years. Fourteen were diagnosed histologically as having papillary carcinoma and the remaining two as having follicular carcinoma. Cartilage shaving was the primary treatment in all the patients, and subsequent radioactive iodine (131I) or external-beam radiotherapy was administered to control any possible residual disease. Lifelong thyroid hormone replacement was instituted in all patients, and the follow-up period averaged 70.7 months. Only four of the 16 patients remained disease free; the disease was not controlled in the other 12, and seven of this latter group eventually died of their disease. We feel that a more extensive resection procedure than cartilage shaving should be considered, even in patients with superficial tracheal invasion, to increase the disease-free survival rate.

Cartilage-shaving procedure for the control of tracheal cartilage invasion by thyroid carcinoma.

Four patients were seen with neurilemmoma which arose in the cervical vagus nerve. Three tumors arose in the upper third of the lateral neck, and the remaining one in the lower third. Lateral neck mass was a prominent symptom in 3 patients, and parapharyngeal mass in the remaining one. The parapharyngeal mass bulged into the oropharynx in the tonsillar and retrotonsillar region and caused mild swallowing difficulty. Complete surgical extirpation by means of intracapsular enucleation was possible in all 4 patients. All patients remained free of disease for periods ranging from 15 to 75 months following surgery. It would appear that an intracapsular enucleation may be advisable for clearance of this kind of tumor.

Neurilemmomas of the cervical vagus nerve

Nine surgically proven congenital absence of gallbladder (CAGB) cases were reviewed. All of them had one or more kinds of biliary symptom. Tests such as abdominal ultrasonography, intravenous or oral cholecystography and even endoscopic retrograde cholangiography not only failed to predict CAGB but misleadingly indicated other similar conditions. Only the abdominal computed tomography (CT), performed on one patient, enabled the accurate diagnosis of CAGB. All the patients underwent abdominal exploration, and CAGB was confirmed by the meticulous dissection of the entire extrahepatic biliary tree and the operative cholangiography. Five patients had concomitant biliary pathologies responsible for their symptoms, but four patients had isolated CAGB. CAGB is a rarely encountered condition for a clinician, but extensive diagnostic work-ups including abdominal CT should be performed in all situations where CAGB is suspected. Thus unnecessary exploration can be avoided in the isolated CAGB case.

Congenital absence of gallbladder.

100 gastric cancer patients who underwent total gastrectomy and Roux-en-Y, End-to-Side esophagojejunostomy by using stapler were analysed with regard to operative result and complication. In addition, whether a routine use of Levin tube after total gastrectomy is necessary, 20 patients were randomly divided into 2 and were compared by postoperative course; for 10 patients Levin tube was removed at recovery room and for another 10, tube was indwelled until peristalsis returned. Median time for anastomosis was 18 minutes(15 to 45 minutes). 25-mm-cartridges were prefered, 85% of 25 mm vs 15% of 28 mm. In 92 patients, procedures were uneventful. Intraoperative problems happened in 8: 2 misfirings of stapler due to mechanical error, 6 incomplete doughnut tissues. Anastomotic leakage occurred in 2 patients and during follow up period 2 cases of anastomotic stricture were found. They were successfully treated by endoscopic dilatations. There was no operative mortality, nor other complication. Timing of removal of Levin tube did not affect duration of hospital stay and starting day of oral intake.

Roux-en-Y End-to-Side Esophagojejunostomy with Stapler After Total Gastrectomy

To elucidate the precise roles of postoperative radiotherapy, 200 high-risk rectal cancer patients were reviewed. Patients were divided into two groups: 83 patients in group I had undergone curative resection alone and 117 in group II, curative resection followed by radiotherapy. Two groups were compared according to overall rate of recurrence, patterns of recurrence, location of recurrence and the types of treatment of recurrent lesions. Rate of recurrence was 42.2% in group I and 38.5% in group II(p>0.1) but it was significantly lower in group II at stage C2 (85.0% vs 44.8%, p 0.001). Surgical treatment for recurrent lesion was possible in 13 patients (12 of group I, 1 of groupII). The result of this study reassure a logical background of chmoradiation protocols as adjuvant treatment for high risk rectal cancer but revealed that radiotherapy could interfere the surgical plan for the recurrent lesions.

Kwang Wook Suh

Papers

Cartilage-shaving procedure for the control of tracheal cartilage invasion by thyroid carcinoma.

Neurilemmomas of the cervical vagus nerve

Congenital absence of gallbladder.

Roux-en-Y End-to-Side Esophagojejunostomy with Stapler After Total Gastrectomy

Patterns of Recurrence in Rectal Carcinoma Following Curative Resection: What Did the Post-Operative Radiotherapy Do?