The last document describes a novel endoscopic technique for performing extended

1. 17th January 2012

2. 1:
Annals of Thoracic Surgery
1990
Impact factor: 3.039

3.  Single centre
 Massachusetts General Hospital
 November 1962 to July 1989 (26 years)
 Retrospective analysis

4.  198 patients with
primary tracheal
lesions
 80 (40%) Adenoid
cystic carcinoma
 70 (36%) SCC
 48 (24%) other
primary tumours

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

8.  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)

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%)

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

29. 3: (last)
Americal Journal of Rhinology
& Allergy
(Am J Rhinol)
Nov-Dec 2010 Vol 24, No 6
Impact Factor: 2.252

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