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To identify the rates and types of postoperative complications in patients with and without Graves' disease undergoing total thyroidectomy using the National Surgical Quality Improvement Program (NSQIP) database.Retrospective cohort study.All hospitals participating in NSQIP from 2007 to 2017.Thyroidectomy data were abstracted from the NSQIP database from 2007 to 2017 using relatedUnmatched data demonstrated that patients with Graves' disease who underwent total thyroidectomy (n = 5495) had a higher rate of readmission (odds ratio [OR], 1.41; 95% CI, 1.16-1.73) and rate of reoperation (OR, 2.29; 95% CI, 1.88-2.79) in comparison to control patients (n = 24,213). They also had a higher rate of postoperative complication (OR, 1.54; 95% CI, 1.23-1.93) especially for wound-related outcomes (OR, 1.88; 95% CI, 1.32-2.69), readmission for postoperative hypocalcemia (OR, 2.12; 95% CI, 1.54-2.92), and reoperation for hematoma or hemorrhage (OR, 1.88; 95% CI, 1.32-2.69). A matched-pair analysis of the data also demonstrated similar significant results.Patients with Graves' disease undergoing total thyroidectomy are at higher risk of complications in comparison to those who do not have Graves' disease, likely due to sequelae of the disease. However, overall rates were low, suggesting that the procedure remains relatively low risk and should continue to be offered to select patients who meet criteria for surgery.

To describe the outcome of patients with poorly differentiated thyroid cancer (PDTC) presenting with gross extrathyroidal extension (ETE). After obtaining Institutional Review Board approval, we performed a retrospective review of a consecutive series of thyroid cancer patients treated by primary surgical resection with or without adjuvant therapy at Memorial Sloan-Kettering Cancer Center from 1986 to 2009. Out of 91 PDTC patients, 27 (30%) had gross ETE (T4a), and they formed the basis of our study. Of 27 patients, 52% were women. The median age was 70 years (range 27-87 years). Ten patients (37%) presented with distant metastases; four to bone, three to lung, and three to both bone and lung. All patients had extended total thyroidectomy, except two who had subtotal thyroidectomy. Twenty patients (74%) had central compartment neck dissection and 11 also had lateral neck dissection. Four patients had pN0, six (30%) pN1a, and 10 (50%) pN1b neck disease. Twenty-one patients (77%) had adjuvant therapy: 15 (55%) radioactive iodine (RAI) only, three (11%) postoperative external beam radiation (EBRT) only, and three (11%) had both RAI and EBRT. Overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS) were calculated by the Kaplan Meier method. The median follow-up time was 57 months (range 1-197 months). The 5 year OS and DSS were 47% and 49%, respectively. This poor outcome was due to distant metastatic disease; 10 patients had distant metastases at presentation and a further six developed distant metastases during follow-up. Locoregional control was good with 5-year LRFS and RRFS of 70% and 62%, respectively. Overall, eight patients (30%) had recurrences: two had distant alone, two regional, two regional and distant, one local and distant, and one had local, regional, and distant recurrence. Aggressive surgery in patients with PDTC showing gross ETE resulted in satisfactory locoregional control. Due to the small proportion of patients who received EBRT (22%), it is not possible to analyze its benefit on locoregional control. Of significance is the observation that the majority of patients (60%) who presented with or subsequently developed distant metastases eventually died of distant disease. New systemic therapies to target distant metastatic disease are required for improvements in outcome

The incidence of thyroid cancer in the United States has been increasing. The biologic behavior of well-differentiated thyroid cancer (WDTC) can vary from indolent tumor to an aggressive disease with invasion of critical structures and/or widespread distant metastasis. Therefore, the risk stratification is crucial in understanding the biology of thyroid cancer, its prognosis and appropriate therapeutic interventions. In fact, understanding the nuances of biological behavior of thyroid carcinomas lays the foundation for the idea of selective surgical management of this disease.

Electrical stimulation has been widely applied in medicine to combat microorganisms,1 enhance wound healing,2 and treat tumors,3 as well as promote strengthening and motor control of skeletal muscles.4,5 Common rehabilitation practice is to place electrodes on the skin to stimulate nerves supplying muscle groups of interest to increase strength.6,7 Neuromuscular electrical stimulation (NMES) has been used for decades on a wide array of muscle groups, but it was investigated for dysphagia rehabilitation in neurologically impaired patients in the late 1990s,8,9 and in 2002, the U.S. Food and Drug Administration (FDA) cleared a device for the treatment of dysphagia. Several meta-analyses have since evaluated the effect of NMES on swallowing rehabilitation and revealed a small but significant summary effect size.10,11 More recently, investigation of NMES has focused on its effects as an adjunct to traditional swallowing therapy in patients receiving treatment for locally advanced head and neck cancer.12 However, the FDA applies a general warning to all NMES devices to avoid stimulating over areas of malignancy.13,14 The concern is that applying electrical stimulation to the anterior neck may stimulate tumor growth if there is residual disease or recurrence following treatment. It is common practice to wait at least several months after radiation and/or surgical treatment before initiating NMES to minimize or resolve dysphagia. A drawback to delaying therapy is that by the time NMES has commenced, the patient typically has chronic dysphagia,15 making the condition more difficult to manage. If NMES in the setting of active malignancy proves not to enhance tumorigenic activity, then perhaps its benefit for dysphagia therapy can be enhanced by starting therapy earlier in the rehabilitation period. To our knowledge, there has never been an animal or human study investigating the effects of skin surface electrical stimulation (as in NMES) on an underlying malignancy, located deep to the skin surface but aligned with the location of electrical stimulation. Based on our review of the literature pertaining to electrodes inserted directly into tumors and resulting in tumor destruction,3, 16–21 we hypothesized that NMES will not increase underlying tumor burden.

We describe a case of benign inverted papilloma with intracranial extension treated with endoscopic resection combined with craniotomy. Intracranial involvement of inverted papilloma, in the absence of malignancy, is uncommon. We present an analysis of the literature identifying the characteristics and outcomes of benign intracranial inverted papilloma. PubMed database was searched using keywords intracranial, inverted or inverting, and papilloma. There are 17 reports of benign inverted papilloma with intracranial extension reported with a mean age of 49.2 years (range, 23 to 92 years), a female predominance, 22% of cases with an associated mucocele, and 60% recurrent disease. The most common sites of invasion are the frontal sinus or cribriform plate. The prognosis for benign intracranial inverted papilloma is dependent on the presence of dural invasion and the achievement of total resection. There are no reported recurrences after craniofacial resection with a mean follow-up of 7.9 years. Adjuvant radiation therapy has demonstrated benefit in cases of residual disease after resection. We expect that endoscopic resection, the standard treatment for sinonasal inverted papilloma, will be increasingly used in the presence of intracranial extension.

Objective The purpose of this study was to demonstrate the efficacy of arterial coupling. Study Design Retrospective data were collected in a consecutive series of 124 patients undergoing surgical resection of head and neck tumors followed by free tissue transfer (FTT). Methods and Measures The Unilink coupling device was used to perform arterial and venous anastomosis. Flap survival and thrombosis of the arterial anastomoses were determined. Results A total of 124 consecutive patients underwent a total of 127 microvascular FTTs. Reconstruction included 90 radial forearm, 26 fibula, 9 rectus abdominis, and 2 iliac crest myocutaneous free flaps. There were four (3.2%) complications related to arterial insufficiency in our series, three of which were salvageable. There were three (2.4%) flap failures, resulting in an overall free flap survival rate of 97.6 percent. Conclusion The flap survival with the Unilink Microvascular Anastomotic System is similar to that of standard suture techniques. Use of a coupler device is the preferred method in performing microvascular FTT at our institution.

Salivary gland carcinomas are relatively rare malignant tumors, accounting for less than 5% of all cancers of the head and neck.1 They encompass a wide spectrum of histologic abnormalities with varied biologic behavior. Initial therapy of localized disease consists of complete surgical excision. The risk of recurrence and metastasis is significantly higher in patients with locally advanced salivary carcinomas. Individuals with high-grade salivary carcinomas have a 5-year survival of roughly 40%; those with low-and intermediate-grade tumors have a 5-year survival of 85% to 90%.2,3 For these patients, complete surgical resection followed by postoperative radiation therapy is recommended.4 Unfortunately, patients with recurrent and/or unresectable disease have few effective treatment options. Clinical trials exploring the role of chemotherapy in the management of salivary gland carcinomas failed to show survival benefit.1 Chemotherapy, therefore, is generally reserved as a palliative measure for patients with symptoms and/or rapid disease progression. Clearly, novel therapies are needed to improve outcomes for patients with salivary carcinomas. Oncolytic viruses have emerged as versatile therapeutic agents that can selectively infect, replicate within, and ultimately lyse a host cancer cell. A variety of viruses have been reported5–7 to possess on-colytic antitumoral activity, including herpes simplex type 1, adenovirus, reovirus, vesicular stomatitis virus, measles virus, poliovirus, West Nile virus, and New-castle disease virus. Vaccinia virus, which is a double-stranded DNA member of the genus Orthopoxvirus, has many unique characteristics that make it an excellent tool in cancer treatment. In addition to its natural tropism for tumor tissues and its abilities for efficient entry, replication, and lysis, vaccinia virus has a remarkable safety record in its historical widespread human application as a vaccine for smallpox. The vaccinia replication cycle occurs exclusively in the cytoplasm, which eliminates the possibility of chromosomal integration.7 Furthermore, there are many Food and Drug Administration–approved antiviral agents available to limit viral spread and control the unlikely possibility of viral toxicity.8 Consequently, several recombinant vaccinia viruses have been constructed and studied in preclinical and clinical phase 1 settings.8,9 Recombinant, replication-competent vaccinia virus (GLV-1h68) has been reported10–16 as effective in breast cancer, thyroid cancer, mesothelioma, pancreatic cancer, prostate cancer, human hepatocellular carcinoma, and head and neck cancer models. The aim of this study was to assess the usefulness of GLV-1h68 as a therapeutic agent against salivary gland carcinoma in vitro and in vivo. Murine flank and orthotopic parotid tumor models were used.

Background Approximately one fourth of bone and soft-tissue sarcomas recur after prior treatment. GLV-1h68 is a recombinant, replication-competent vaccinia virus that has been shown to have oncolytic effects against many human cancer types. We sought to determine whether GLV-1h68 could selectively target and lyse a panel of human bone and soft-tissue sarcoma cell lines in vitro and in vivo . Methods GLV-1h68 was tested in a panel of four cell lines including: fibrosarcoma HT-1080, osteosarcoma U-2OS, fibrohistiocytoma M-805, and rhabdomyosarcoma HTB-82. Gene expression, infectivity, viral proliferation, and cytotoxicity were characterized in vitro . HT-1080 xenograft flank tumors grown in vivo were injected intratumorally with a single dose of GLV-1h68. Results All four cell lines supported robust viral transgene expression in vitro . At a multiplicity of infection (MOI) of five, GLV-1h68 was cytotoxic to three cell lines, resulting in >80% cytotoxicity over 7 d. In vivo , a single injection of GLV-1h68 into HT-1080 xenografts exhibited localized intratumoral luciferase activity peaking at d 2–4, with gradual resolution over 8 d and no evidence of spread to normal tissues. Treated animals exhibited near-complete tumor regression over a 28-d period without observed toxicity. Conclusion GLV-1h68 has potent direct oncolytic effects against human sarcoma in vitro and in vivo . Recombinant vaccinia oncolytic virotherapy could provide a new platform for the treatment of patients with bone and soft tissue sarcomas. Future clinical trials investigating oncolytic vaccinia as a therapy for sarcomas are warranted.

Objective: The purpose of this study is to demonstrate the success rate of using a coupling device for end-to-side venous anastomosis in patients undergoing free-tissue transfer (FTT) in head and neck reconstruction. Methods and Measures: Retrospective data were collected in consecutive series of 134 patients undergoing surgical resection of head and neck tumors followed by FTT. All microvascular FTTs were performed at Yale-New Haven Hospital between November 2001 and August 2007. The Unilink coupling device was used to perform arterial and venous anastomosis in this case series. Flap survival and thrombosis of the venous anastomoses were determined. Results: One hundred thirty-four consecutive patients underwent a total of 137 microvascular FTTs using a coupling device. In our series, a total of 173 end-to-side anastomoses were completed in 96 patients. Of these, 77 patients had both venous anastomoses, 17 underwent one end-to-side and one end-to-end anastomoses, and two patients had one venous anastomosis per patient performed in end-to-side fashion. Reconstruction included 76 radial forearm, 17 fibula, and three rectus abdominis free flaps. There were three vascular insufficiency related complications of which two were salvageable. There was one case of flap failure (1%), resulting in a free flap survival rate of 99%. Conclusion: This largest reported series of end-to-side venous anastomoses with an anastomotic coupling device demonstrates feasibility and efficacy of this technique in head and neck reconstruction.