Journal Club17th January 2012

1:

Annals of Thoracic Surgery 1990Impact factor: 3.039

Background

Single centre Massachusetts General Hospital November 1962 to July 1989 (26

years) Retrospective analysis

Material and Methods

198 patients with primary tracheal lesions 80 (40%)

Adenoid cystic carcinoma

70 (36%) SCC 48 (24%) other

primary tumours

Material and Methods

Feature Squamous Cell Carcinoma

Adenoid Cystic Carcinoma

Others

Sex (M:F ratio)52: 17 Similar to lung ca

41:39 26:22

Risk factor Smoking in all pt

Incidental smoking hx

Incidental smoking hx

Age (yr) of highest incidence

50-69 (6-7 decade)

30-59(slight peak at 5th decade)

11-39 (children and young adults)

Carinal involvement

25% 50%

Material and Methods

66% (147) of the lesions were resected 132 resection and

reconstruction 7 removal of larynx

and trachea 8 had staged

reconstruction

Detailed description on surgical approach Cervical collar incision Median sternotomy with transpericardial

trap door incision Right thoracotomy Carinal resection +/- Pneumonectomy +/- Laryngeal/hilar release

Results

Morbidity Anastomotic

▪ Stenosis (6)▪ Leak (3)▪ Suture line granuloma (4)

Esophageal fistula (1) CN

▪ VC paralysis (8)▪ Aspiration (6)

Lung▪ Pulmonary edema (2)▪ Empyema (1)▪ Pneumonia (3)▪ Nonfunctioning lung (1)

Mortality Operative (12/147)

▪ Leak, respiratory failure, h’age Staged reconstruction (5/8)

135 out of 147 patients survived tumour resection 70% are still alive

without tumour Disease specific▪ 49% SCC▪ 75% ACC▪ 83% others

Recurrence SCC 1st recurrence noted

after 3 years of resection▪ One patient was resected 3

times, 81, 85, 89▪ All patient who died of SCC

did so within 4 years of resection

Long term outlook less clear with ACC▪ Ist patient had suture line

recurrence 17 years after resection (postop not radiated)

▪ Dis free for many yrs but late recurrence typical

All patients with positive nodes or margins were radiated (4500 to 6500 rads)

Positive nodes and positive margins were frequently found in patients who later died with SCC

ACC, submucosal and perineural invasion was common hence most often resection margins are compromised for safe anastomosis, nodal or margins positive was rampant even in survived subgroup of patients

Irradiation in unresected ACC is uniformly characterized by local recurrence within 3-5 years

Resection vs Irradiation

In both groups of patients with SCC and ACC patients who underwent resection as primary treatment had better survival compared to those who had primary irradiation

Resection combined with irradiation provided tripled survival time for SCC and ACC

Discussion

Largest series, however with least mortality comparatively

Recommendations: Benign and intermediate aggressiveness are

best treated by surgical resection and reconstruction of the airway

Primary SCC and ACC of the trachea are best treated by surgical resection only when primary reconstruction can be safely accomplished▪ High mortality with staged procedure

Appraisal

Title: appropriate,more informative to mention single centre experience of 26 years

Material and Methods Long term follow up with large amount of patients Mean/ median follow up not mentioned, good amounts

>10 years in table No mention of subgroup of patient that did not undergo

surgical resection primarily. ? Anatomical contraindications or extensive disease, hence difficult to intepret results in terms of survival and disease free years

Results Authors mention in detail regarding various types of

surgeries performed and their learning experiences

Appraisal

Result All study questions were addressed by subjective

comparison and no statistical analysis were offered to conclude results.

Effect on survival, adjunct chemo or radio not properly mentioned

Conclusion A good study that address different types of primary

tracheal tumours in terms of clinical features and characteristic clinical progression

Treatment options and survival: biased to surgical resection (single centre experience)

Limitations to study were not mentioned

2:

Journal of the Chinese Medical AssociationOctober 2006Vol 69, No 10Impact factor: 0.678

Introduction

Spindle Cell Carcinoma (SpCC) is also known as sarcomatoid carcinoma, rare

Sites: Larynx (1%) Nasal cavity, hypopharynx, oral cavity, esophagus,

trachea, skin, breast Gender predilection to men SpCC is an unusual form of poorly differentiated

SCC Microscopic feature akin to sarcoma (elongated spindle

cells) Immunohistologic feature: CK, EMA (Epithelial

Membrane Antigen) positive, Vimentin negativity

Methods

Retrospective analysis of patient’s records 1994 to 2005 18 lesions (SpCC oral cavity and oropharynx) in 17

patients Criteria for diagnosis:

Identification of carcinoma with squamoid feature Spindle cells positive for CK and negative for Vimentin Presence of SCC in situ

Statistical analyses The Kaplan–Meier model with log rank test was performed for survival analysis. Fisher’s exact test and Student’s t test were used to determine the relationship

between the variables and recurrent pattern. The Mann–Whitney test was used to compare the relationship between time to

recurrence and salvage operation. A p value< 0.05 was considered statistically significant.

Results

Male preponderance 94% to 6%

Age of onset Median 51 years, range 32-76 years

Mean follow up time 14.2 months Common primary sites:

Tongue (28%) Buccal mucosa (22%)

Results

15 patients underwent WLE of tumour with a safety margin of

about 1–2 cm and neck dissection for possible neck

disease▪ 11 developed local recurrence (73%)▪ 4 with nodal recurrence too▪ 5 with distant mets then subseq died▪ Even so in negative margins and early stage

1 received chemotherapy alone 1 refused treatment

Results

The median overall survival time was 8.9 months. The 1-year overall survival rate was 36.7% 3-year overall survival rate was 27.5%. In the early stage group (stages I and II),

the 3-year survival rate was100%. In the late stage group (stages III and IV),

the 1-year survival rate was only 9%, and the 3-year survival rate was 0%

The following factors did not statistically significantly influence survival: gender, age, tumor site, previous

existence of SCC, cigarette smoking, alcohol drinking, betel nut chewing, positive surgical margin, distance of safe margin, nerve invasion, muscular invasion, tumor necrosis, radiotherapy, chemotherapy, combined treatment of surgery and radiotherapy, and local recurrence.

The median overall recurrence time was 5.2 months. In the early stage group was

10.5 months, versus 4.0 months in the late

stage group (p = 0.03).

The median recurrence time in patients managed with salvage operation was 8 months, whereas it was 2 months in patients who did not receive salvage operation (p = 0.014).

Results

No patient with recurrence had positive margin

The significant factor for local recurrence was alcohol consumption (p = 0.03).

There were no significant factors for regional recurrence, but muscular invasion (p=0.05) was noteworthy.

The significant factors for distant metastasis were age < 50 years (p = 0.03), T stage > T2 (p =0.03), and nerve invasion (p = 0.007).

Discussion

Survival and reaction to treatment of SpCC still controversial Ellis (oral) 36% survival Olsen (larynx) 56% survival This series show lower survival rates compared to SCC of

oral cavity and oropharynx The recurrence rate was very high, even in the early

stage patients. The metastatic rate was high in the advanced-stage patients. More aggressive behaviour

None of the patients with local recurrence had positive margin a much wider safety margin (> 2 cm) for SpCC would be

helpful.

Conclusion

SpCC in the oral cavity and oropharynx is potentially aggressive and seems to recur easily and to metastasize.

Those with early-stage tumors usually have an excellent prognosis.

If local recurrence occurs, salvage operation should be performed and will be beneficial to patients.

Appraisal

Title: appropriate to content,more informative to mention single centre experience of 10 years

Methods No mention of 1 patient with two lesions ?

Synchronous, recurrence; even though 1 patient but this series has small number of patient and statistical analysis might be affected

Statistical analyses well mentioned, appropriately used for given study objectives

Methods Descriptive data well presented,

summarized well in table One data mistakenly represented in

table▪ median recurrence time in patients managed

with salvage operation was 8 months, whereas it was 2 months in patients who did not receive salvage operation (p = 0.014). Table <0.01

Study well concluded and limitations were mentioned

3: (last)

Americal Journal of Rhinology & Allergy(Am J Rhinol)Nov-Dec 2010 Vol 24, No 6Impact Factor: 2.252

Introduction

Endoscopic surgery plays a central role in the treatment of inverted papilloma (IP) of the nose and paranasal sinuses and both its safety and its efficacy have been established

The goal of surgical treatment is complete removal of the lesion under direct visual control with minimal morbidity.

Many authors advocate extended endoscopic medial maxillectomy (include removal of nasolacrimal duct and IT even though not involved)

The IT warms, cleans, moistens inhaled air and regains water during exhalation.

Novel technique for performing EEMM with preservation of IT

Materials and Methods

Retrospective series of patients who underwent EEMM with preservation of IT

15 operated sides 5 with primary IP of the MS 7 with recurrent IP of the MS 2 patients with 3 mucoceles of the MS

12 patients (5 women and 7 men, aged 26-77 years)

Endoscopic follow up 3/12 1st year, 6/12 next yr and then once a year

Operative technique

A 45° endoscope was used for most parts of the operation. Additionally, 0° and 70° telescope was used.

In IP, the tumor is first debulked intranasally and then followed into the MS to look for the attachment.

An uncinectomy is necessary to do this. If the tumor can not be sufficiently removed via a middle meatal antrostomy and the IT is not involved in the tumor, the decision to perform an EEMM with preservation of the IT is made

Operative technique

Characteristic endoscopic appearance

of an inverted papilloma

Cutting of the anterior

attachment of IT

Continued dissection

slightly lateral along the

attachment, preserving

posterior part

After reinsertion of IT at the original attachment

site

Schematic drawing: 2:

opened maxillary sinus;

3: opened lacrimal sac; 1: IT sutured at its

anterior end5: ground lamella

Post operative care

Nose is occluded for 2-4 weeks by taping nose with sticking plaster To prevent dryness, which may cause

impaired healing and increased risk of dehiscence

Gentle after care toileting to prevent mechanical trauma

Results

Postoperative endoscopy revealed no recurrence of the tumor in any of the cases after a follow-up period of 12–80 months (28 months on average)

All ITs survived dissection and reinsertion, showed normal appearance endoscopically

Both patients with mucoceles, the marsupialized cavities were patent 12 month post op.

Complications

No specific additional pain, postoperative bleeding and occlusion was well tolerated

One has persistent crusting but is also a heavy smoker with recurrent infection of the residual MS

Two patients with IP developed mucoceles in the MS but remained asymptomatic

Conclusion

In all cases of EEMM authors recommend attempting to preserve the IT

With permanent occlusion for at least 2 weeks, preservation of the IT is possible in all cases.

Aftercare should focus on not pulling off the healing turbinate

Appraisal

Title: appropriate to content Methods

Small number of patients Limited literature review on clinical

significance of preserving the IT in whole length as opposed to current practise of preserving anterior 1 cm

2 different pathologies were lumped into same group ? Not appropriate

Appraisal

Operative technique Discuss in detail with beautiful pictures

to facilitate understanding Occlusion of the nose not elaborated

much, unclear Results

No mention on additional patient’s benefit on preserving the IT