5. Feature Squamous Cell Adenoid Cystic Others
Carcinoma Carcinoma
52: 17 41:39 26:22
Sex (M:F ratio) Similar to lung ca
Risk factor Smoking in all pt Incidental smoking Incidental smoking
hx hx
Age (yr) of highest 50-69 (6-7 decade) 30-59(slight peak at 11-39 (children and
incidence 5th decade) young adults)
Carinal 25% 50%
involvement
6. 66% (147) of the lesions
were resected
132 resection and
reconstruction
7 removal of larynx and
trachea
8 had staged
reconstruction
7. Detailed description on surgical approach
Cervical collar incision
Median sternotomy with transpericardial trap
door incision
Right thoracotomy
Carinal resection
+/- Pneumonectomy
+/- Laryngeal/hilar release
9. 135 out of 147
patients survived
tumour resection
70% are still alive
without tumour
Disease specific
▪ 49% SCC
▪ 75% ACC
▪ 83% others
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
16. 2:
Journal of the Chinese Medical
Association
October 2006
Vol 69, No 10
Impact factor: 0.678
17. 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
18. 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.
19. 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%)
20.
21. 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
22. 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, com
bined treatment of surgery and
radiotherapy, and local recurrence.
23. 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).
24. 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).
25. 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.
26. 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.
27. 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
28. 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
30. 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
31. 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
32. 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
33. Schematic drawing: 2:
Continued dissection opened maxillary sinus;
Characteristic After reinsertion of IT at
Cutting of the anterior slightly lateral along the 3: opened lacrimal sac; 1:
endoscopic appearance the original attachment
attachment of IT attachment, preserving IT sutured at its anterior
of an inverted papilloma site end
posterior part
5: ground lamella
34. 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
35. 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.
36. 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
37. 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
38. 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
39. 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
Editor's Notes
Dr Hermes Grillo, father of tracheal surgery. Even though he has passed away from a car accident in 2006, I had to choose his work as this is the largest series of primary tracheal tumours ever collected with longest long term followup
None of the SCC were secondary to other common primaries in the lungs, bronchus, larynx or esophagusAdenoid cystic radiosensitive hence not all were resectedPapillomas treated with cryo, laserPleomorphic adenoma: had salivary PA 10 years beforeRhabdomyosarcoma: pedunculated isolated tracheal lesion; cervical rhabdomyosarcoma treated with RND and RT 6 years agoPlexiformneurofibroma and paraganglioma: primary trachea
Give a detailed description on patients who had resection and primary reconstruction
HsingHao Su from ENT department in Kaohsiung Veterans GH, not much is known, only has 6 published articles on Research Gate, all of them published in Chinese journals, none internationalDespite decreases in subsidies, VGH-KS, the only public medical center in the southern area, continues to serve the public. We coordinate with the official health authorities to implement policies and serve as a leader of medical service improvement standards throughout the community and the region. The continuance of our role as a veterans hospital to protect and care for our veterans and their families.
25 years ago series by Ellis et al: 10 patients; this series 18 patients
Rainer K. Weber, MD university of Marburg Germany, Karlsruhe ospitalProfessor and Head Division of Paranasal Sinus and Skull Base Surgery