Publications by authors named "Mark L Urken"

148 Publications

Rare case of anaplastic plasmacytoma in the sinonasal tract.

Head Neck 2021 Jul 17. Epub 2021 Jul 17.

The Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA.

Background: Extramedullary plasmacytomas are tumors that develop from plasma cells and rarely express anaplastic features. To our knowledge, there have only been three reported cases of anaplastic plasmacytomas of the sinonasal tract in the English literature. We detail the fourth case.

Methods: A 70-year-old male was seen with a 4-month history of nasal congestion, bloody mucous, and left sided nasal obstruction. On positron emission tomography/computed tomography, the lesion was FDG-avid with an SUV of 25.1. A biopsy of the lesion and subsequent immunohistochemical staining confirmed the diagnosis of an anaplastic plasmacytoma.

Results: The patient is undergoing a 5-week course of curative-intent radiation therapy.

Conclusion: Extramedullary plasmacytomas with anaplastic features are very rare. We highlight the value of thorough histopathological review and detailed immunostains to arrive at a diagnosis of anaplastic extramedullary plasmacytoma.
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http://dx.doi.org/10.1002/hed.26818DOI Listing
July 2021

Reconstruction of the external auditory canal: The tragal flap revisited and review of contemporary reconstructive techniques.

Am J Otolaryngol 2021 May 31;42(6):103094. Epub 2021 May 31.

Thyroid, Head, and Neck Cancer (THANC) Foundation, 10 Union Square East, Suite 5B, New York, NY 10003, USA; Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY 10003, USA.

Background: Primary malignancies arising in the external auditory canal (EAC) are rare and usually are treated surgically. We review techniques to reconstruct the EAC following ablative surgery, and introduce a rarely utilized tragal skin flap which has particular advantages for reconstruction of limited anterior EAC defects.

Methods: The terms "tragal flap", "external auditory canal", "preauricular tragal flap", "reconstructive techniques" were searched on PubMed and Google Scholar.

Results: Our review identified one description of a tragal flap to reconstruct the EAC following resection of a malignancy. We add an additional case of a preauricular tragal flap to reconstruct the anterior EAC following resection of a recurrent basal cell carcinoma located in the EAC that led to a circumferential defect.

Conclusion: There are several surgical techniques that can be utilized to reconstruct the EAC. We describe a novel tragal flap used to reconstruct the anterior EAC following resection of a recurrent tumor.
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http://dx.doi.org/10.1016/j.amjoto.2021.103094DOI Listing
May 2021

Fine needle aspiration cytology of metastatic myxoid liposarcoma to the thyroid.

Diagn Cytopathol 2021 Jul 12;49(7):899-901. Epub 2021 May 12.

Fine Needle Aspiration Biopsy Clinic, Department of Pathology, Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Downtown Union Square Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1002/dc.24773DOI Listing
July 2021

Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options.

Am J Otolaryngol 2021 Mar 22;42(5):103003. Epub 2021 Mar 22.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America.

Background: Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES.

Methods: The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps.

Results: The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy.

Conclusions: The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.
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http://dx.doi.org/10.1016/j.amjoto.2021.103003DOI Listing
March 2021

First reported PET positive, FDG avid free flap pedicle ossification and review of the literature.

Clin Imaging 2021 Apr 13;79:30-35. Epub 2021 Apr 13.

Thyroid, Head and Neck Cancer (THANC) Foundation, 10 Union Square East, Suite 5B, New York, NY 10003, USA; Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY 10003, USA.

The fibular free flap (FFF) is commonly used for head and neck bony reconstruction. Ossification of the vascular pedicle has been reported but is an uncommon complication of this procedure. Ossification of the pedicle with FDG avidity has not been identified in the literature. Here we present a case of FDG avid free flap ossification seen on PET/CT imaging in a patient who developed trismus after fibular free flap reconstruction of a maxillary defect for a primary squamous cell carcinoma of the palate. The FDG avidity of the free flap ossification and trismus were both concerning for recurrent squamous cell carcinoma.
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http://dx.doi.org/10.1016/j.clinimag.2021.03.034DOI Listing
April 2021

Unusual location of a second branchial cleft cyst presenting in the suprasternal notch.

Head Neck 2021 04 3;43(4):E27-E29. Epub 2021 Feb 3.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New York, New York, USA.

Background: Second branchial cleft cysts (SBCCs) are congenital benign tumors that comprise up to 90% of all branchial cleft anomalies. SBCCs typically present in the lateral neck along the anterior border of the upper third of the sternocleidomastoid muscle. We describe a case of a SBCC presenting in an unusual location in the lower neck close to midline.

Methods: An 18-year-old male presented with a 2-year history of a neck mass in the suprasternal notch. Imaging findings were reviewed with a head and neck radiologist who felt that the findings were highly suggestive of a fourth branchial cleft cyst.

Results: The patient underwent surgical excision of the mass. Final pathologic evaluation confirmed the diagnosis of a second branchial cleft cyst.

Conclusions: Though extremely uncommon, second branchial cleft cysts can extend to the suprasternal notch and should not be excluded from the differential diagnoses of lower neck masses.
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http://dx.doi.org/10.1002/hed.26629DOI Listing
April 2021

Extraskeletal Ewing sarcoma of the buccal space.

Clin Imaging 2021 May 25;73:108-110. Epub 2020 Dec 25.

Thyroid, Head, and Neck Cancer (THANC) Foundation, 10 Union Square East, Suite 5B, New York, NY 10003, USA; Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY 10003, USA.

Extraskeletal Ewing sarcoma (EES) is a rare soft tissue tumor, and EES of the head and neck is particularly rare. Radiographic imaging of these lesions is crucial given their anatomical complexity and infrequent incidence. Conventional EES imaging features include a large, hyperintense, heterogeneously enhancing lesion, with frequent invasion of local structures. In this case report, a 19-year old male presented with left facial swelling and pain. He underwent sclerotherapy and bleomycin treatment for a presumed lymphatic malformation. Initial imaging demonstrated a rim-enhancing lesion within the left buccal space with no muscle invasion or bony erosion present. Two years later, imaging identified an enlarging buccal mass with destruction of the zygomatic arch and inferolateral orbital wall. The patient underwent surgical resection of the mass. Pathology confirmed the mass to be a small round blue cell tumor and FISH testing confirmed the presence of the EWSR1 gene arrangement that is consistent with EES. The patient tolerated the procedure well and underwent chemoradiation therapy. At three years postoperatively, the patient remains disease free. The presented case demonstrates an unusual presentation of a buccal space EES as a rim-enhancing, centrally hypointense mass with no bony erosion or muscular invasion. The location and atypical imaging appearance of this case offer insight for future diagnosis of EES.
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http://dx.doi.org/10.1016/j.clinimag.2020.12.004DOI Listing
May 2021

Metastatic thyroid carcinoma to the parapharyngeal and retropharyngeal spaces: Systematic review with seven newly reported cases describing an uncommon presentation of a common disease.

Head Neck 2021 04 9;43(4):1331-1344. Epub 2020 Dec 9.

Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA.

Background: Metastatic thyroid carcinoma to retropharyngeal and parapharyngeal (RP/PP) lymph nodes is rare. Literature suggests previous lateral neck dissection (LND) may alter patterns of lymphatic drainage in the neck, predisposing to these less common sites of spread.

Methods: PRISMA-guided systematic search for all published cases detailing RP/PP metastases of well-differentiated thyroid carcinoma from 1970 to 2019.

Results: Seventy articles were identified and 44 were included, along with seven cases treated at our institution, totaling 239 cases. Cases represented both retropharyngeal (60.7%) and parapharyngeal (39.3%) metastases identified in the initial (27.6%) and recurrent (72.4%) setting.

Conclusion: RP/PP metastases generally present in the recurrent setting. RP/PP metastases often represent high-risk disease, and surgical treatment is recommended.
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http://dx.doi.org/10.1002/hed.26572DOI Listing
April 2021

Rare case of metastatic liposarcoma to the thyroid gland and a review of the literature of metastatic sarcomas to the thyroid.

Head Neck 2021 03 21;43(3):E20-E26. Epub 2020 Nov 21.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New York, NY, USA.

Background: Liposarcomas are the second most common type of soft tissue sarcomas. Typically, myxoid liposarcomas have a metastatic rate of 10%, usually involving the retroperitoneal space, abdomen, and spine. Metastasis to the thyroid is extremely rare.

Design/method: A 62-year-old male with a history of metastatic myxoid liposarcoma in his right thigh presented to our clinic for evaluation of a thyroid nodule incidentally identified on a CT scan. A subsequent FNA biopsy was suggestive of a metastatic liposarcoma.

Results: The patient underwent a left thyroid lobectomy and final pathology confirmed a grade II/III metastatic myxoid liposarcoma that measured 3.3 cm. The patient tolerated the procedure well.

Conclusions: Our case highlights the role of a patient's medical history when evaluating thyroid nodules to optimize accurate diagnosis, as liposarcomas do not typically metastasize to the thyroid. We also provide an updated review of the literature on all cases of metastatic sarcomas to the thyroid.
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http://dx.doi.org/10.1002/hed.26552DOI Listing
March 2021

Atypical metastasis of nasopharyngeal cancer: noncontiguous spread to the ipsilateral ear.

Clin Imaging 2021 Apr 14;72:70-74. Epub 2020 Nov 14.

THANC (Thyroid, Head and Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY 10003, USA; Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai West, 1000 10th Avenue, New York, NY 10003, USA.

Objectives: Nasopharyngeal carcinoma (NPC) is a rare form of squamous cell carcinoma. Primary NPC is generally treated with radiation and chemotherapy, though recurrence and distant metastases are common. Reports of noncontiguous metastasis to the middle ear and external ear canal (EAC) are rare.

Materials And Methods: Case presentation of a female patient previously treated for NPC, who developed an EAC metastasis. A literature review of all reported cases of metastatic NPC in the middle ear and EAC is also included.

Results: A patient presenting with noncontiguous metastasis of NPC to the EAC was treated with surgical resection followed by chemotherapy and radiation. The patient successfully completed treatment and is currently alive but with suspected distant metastatic disease at 11 months following treatment.

Conclusions: NPC metastasis to the EAC is extremely rare. Treatment options are varied, and prognosis is generally poor. The case presented here shows better outcomes than many previous reports.
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http://dx.doi.org/10.1016/j.clinimag.2020.11.029DOI Listing
April 2021

Reply to "Function preservation for resection of vagal schwannoma of the head and neck: Are we talking about the same technique?"

Head Neck 2020 11 3;42(11):3471. Epub 2020 Sep 3.

Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel Hospital, New York, NY, USA.

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http://dx.doi.org/10.1002/hed.26450DOI Listing
November 2020

Radiation necrosis of the pharyngeal soft tissue: Unique clinical entity reconstructed with a previously unreported composite brachioradialis and flexor digitorum superficialis radial forearm flap.

Head Neck 2020 10 12;42(10):E23-E29. Epub 2020 Aug 12.

Department of Otolaryngology-Head & Neck Surgery, Mount Sinai Beth Israel, New York, New York, USA.

Background: The radial forearm free flap (RFFF) is a versatile flap commonly used in head and neck reconstructive surgery. We describe the use of a composite RFFF that includes muscle for reconstruction of a hostile wound of the posterior pharyngeal wall.

Methods: A 54-year-old male with a history of recurrent right palatine tonsil HPV+ squamous cell carcinoma developed severe soft tissue necrosis of the posterior pharyngeal wall secondary to reirradiation. The defect was reconstructed with a composite RFFF that included the brachioradialis (BR) muscle and the flexor digitorum superficialis (FDS) muscle.

Results: Restoration of this complex defect was successfully accomplished with minimal donor site functional deficits and satisfactory functional outcomes including decannulation and resumption of oral intake.

Conclusion: This composite RFFF can be effectively used to reconstruct a hostile wound of the posterior pharyngeal wall. Incorporation of muscle in the reconstruction of complex wounds with soft tissue necrosis is beneficial.
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http://dx.doi.org/10.1002/hed.26405DOI Listing
October 2020

Oral squamous carcinoma: Aggressive tumor pattern of invasion predicts direct mandible invasion.

Head Neck 2020 11 25;42(11):3171-3178. Epub 2020 Jul 25.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York City, New York, USA.

Background: Aggressive histologic worst pattern of invasion (WPOI) in surrounding soft tissue has been shown to be predictive of higher local recurrence and poorer survival in oral cavity squamous cell carcinoma (OCSCC) patients. This study investigates whether aggressive WPOI can predict the mandibular invasion phenotype.

Methods: Patients consecutively diagnosed with OCSCC undergoing a mandibulectomy (marginal or segmental) between 2013 and 2018 were reviewed. Senior physicians re-reviewed radiologic scans and pathologic slides of 44 cases.

Results: Aggressive WPOI (WPOI-4, 5) is significantly associated with infiltrative bone invasion. Non-aggressive WPOI (WPOI-1, 2, 3) is significantly associated with the absence of bone invasion.

Conclusions: WPOI has become a useful tool that further characterizes the biologic behavior of OCSCC. Potentially, planned surgery may escalate from a marginal to segmental mandibulectomy based on aggressive WPOI for patients with radiographically uncertain cortical status. Further studies are needed to validate the relationship between OCSCC WPOI and mandible status.
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http://dx.doi.org/10.1002/hed.26360DOI Listing
November 2020

Images in cytology: Fine needle aspiration cytology of BRAF positive anaplastic thyroid carcinoma.

Diagn Cytopathol 2021 Jan 18;49(1):150-152. Epub 2020 Jul 18.

Fine Needle Aspiration Biopsy Clinic, Department of Pathology, Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, New York, New York, USA.

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http://dx.doi.org/10.1002/dc.24545DOI Listing
January 2021

Multifocal Parotid Oncocytic Cystadenomatosis: A Rare Process that Can Mimic Malignancy.

Head Neck Pathol 2021 Mar 14;15(1):323-327. Epub 2020 May 14.

THANC (Thyroid, Head and Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA.

Multifocal cystic oncocytosis (MCO) is a rare, benign process accounting for approximately 0.1% of salivary gland lesions. Salivary oncocytosis is characterized by multiple unencapsulated solid nodules of oncocytic cells derived from transformed striated ducts. MCO is a variant of salivary oncocytosis which manifests as cystically dilated striated ducts. It is difficult to obtain a definitive preoperative diagnosis of MCO; therefore, these lesions are commonly treated with surgery. We report the unique case of a 66-year-old male who previously underwent a superficial left parotidectomy for a pleomorphic adenoma. Four years later, he presented with clinical and radiographic suspicion of a multifocal recurrent pleomorphic adenoma. The patient subsequently underwent a revision parotidectomy. However, final pathology confirmed a diagnosis of MCO. Although MCO is commonly treated with surgery due to lack of a definitive preoperative diagnosis, surgery is unnecessary outside of diagnostic, functional or cosmetic considerations. Thus, if a patient with parotid oncocytosis treated by superficial parotidectomy develops disease re-manifestation in the residual deep lobe, further surgery is not indicated. There is no risk of malignant progression in this process. We report on this unusual entity as it may mimic salivary malignancy or, as in this case, recurrence of benign disease.
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http://dx.doi.org/10.1007/s12105-020-01170-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010016PMC
March 2021

Stair-step tracheal repair: Surgical technique.

Head Neck 2020 09 29;42(9):2741-2744. Epub 2020 Apr 29.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York, USA.

Typical surgical treatment for invasive thyroid carcinoma at the level of the cricoid substantially reduces surrounding cartilaginous support and risks damage to the recurrent laryngeal nerve (RLN). We present a novel tracheal reconstructive technique that minimizes this injury risk. A 72-year-old man with recurrent invasive thyroid carcinoma underwent cricotracheal resection and reconstruction using a stair-step approach. Diseased cartilage was removed by a left hemitracheal and hemicricoid resection. A portion of normal trachea was also resected on the contralateral right side, removing the third and fourth hemitracheal rings, to close the defect with a sliding tracheoplasty and avoid dissection near the right cricothyroid joint on the side of the functioning RLN. The trachea was elevated superiorly and reanastomosed to the cut margin of the cricoid. This novel stair-step approach to tracheal reconstruction offers reduced risk of injury to the contralateral RLN while still establishing a patent airway.
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http://dx.doi.org/10.1002/hed.26173DOI Listing
September 2020

The use of negative pressure wound therapy in the primary setting for high-risk head and neck surgery.

Am J Otolaryngol 2020 Jul - Aug;41(4):102470. Epub 2020 Apr 1.

THANC (Thyroid, Head and Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY 10003, USA; Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, 10 Union Square East, Suite 5B, New York, NY 10003, USA.

Background: In head and neck surgery, dead space is typically managed by transferring a secondary pedicled flap or harvesting a larger composite flap with a muscular component. We demonstrate the novel use of prophylactic negative pressure wound therapy (NPWT) to obliterate dead space and reduce possible communication between the upper aerodigestive tract and the contents of the neck.

Methods: We present a single-institutional case series of five patients with high-risk head and neck cancer treated with NPWT after ablative and reconstructive surgery to eliminate dead space following surgical resection.

Results: All patients achieved successful wound closure following NPWT, which was applied in the secondary setting to combat infection in one patient and the primary setting to prophylactically eliminate dead space in four patients.

Conclusion: NPWT can be used to treat unfilled dead space in the primary setting of head and neck ablative and reconstructive surgery and help to avoid wound healing problems as well as the need for secondary flap transfers.
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http://dx.doi.org/10.1016/j.amjoto.2020.102470DOI Listing
October 2020

Harder than just hitting a bulls-eye: treatment for hypothyroidism in children might have more than just one target.

Endocrine 2020 07 11;69(1):230. Epub 2020 Mar 11.

Thyroid, Head and Neck Cancer (THANC) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA.

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http://dx.doi.org/10.1007/s12020-020-02254-zDOI Listing
July 2020

Positive Lymph Node Counts in American Thyroid Association Low-Risk Papillary Thyroid Carcinoma Patients.

World J Surg 2020 06;44(6):1892-1897

THANC (Thyroid, Head and Neck Cancer) Foundation, 10 Union Square East, New York, NY, 10003, USA.

Background: Current American Thyroid Association (ATA) guidelines state that patients with intermediate-risk papillary thyroid cancer (PTC) may benefit from remnant ablation. One criterion for intermediate-risk classification is >5 positive lymph nodes (LNs). We investigate whether performing step-sectioning of LNs increases the metastatic detection rate, thereby influencing ATA risk of recurrence (ROR) classification.

Methods: A retrospective review was conducted of cases in which ≥ 5 LNs were removed during thyroidectomy and ≤5 LNs were found positive for PTC. Step-sectioning was performed on the original tissue blocks. All slides were re-reviewed by a senior pathologist.

Results: Twenty patients met study criteria. Step-sectioning significantly increased LN yield compared to standard sectioning. In total, we found 12 new positive lymph nodes; seven (58%) were in totally new lymph nodes, while five (42%) were in lymph nodes previously read as negative. All newly discovered metastases were classified as micrometastases (≤2 mm). Of the 15 patients originally classified as low-risk, the step-sectioning protocol impacted two patients (13%), increasing ROR stratification.

Conclusion: Intensive step-sectioning reveals additional micrometastases. More detailed analysis did not identify clinically significant nodal disease likely to impact the clinical course of patients in this study. Our study supports current standards of pathology specimen handling related to LN assessment and the impact on ATA ROR classification. Nonetheless, it is important for clinicians to understand their institution's sectioning protocol utilized to report positive and total LN counts, which could impact ATA risk stratification and denote the comprehensive nature of the LN dissection that was performed.
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http://dx.doi.org/10.1007/s00268-020-05399-0DOI Listing
June 2020

Incongruent radiographic indication of calvarial metastatic diploic space invasion with absent histologic findings in a patient with basal cell carcinoma of the scalp.

Head Neck 2020 04 3;42(4):E1-E5. Epub 2020 Feb 3.

Department of Otolaryngology-Head & Neck Surgery, Mount Sinai Beth Israel, New York, New York.

Background: Radiographic imaging is often used to determine basal cell carcinoma (BCC) extension and invasion and to define a surgical plan. However, imaging modalities may overestimate tumor invasion and lead to unnecessarily aggressive treatment.

Methods: A 77-year-old woman was seen with a growing BCC of the scalp with MRI imaging indicative of calvarial diploic space invasion. The patient underwent Mohs surgery followed by a parietal craniectomy.

Results: Contrary to the MRI findings, histological evaluation of the cortical parietal calvarium and the diploic space did not demonstrate BCC.

Conclusions: Surgeons should be wary of diploic space changes in the absence of cortical erosion demonstrated in MRI as it may not explicitly indicate tumor invasion. Biopsy of the diploe is necessary in such cases to determine the surgical course and to avoid morbidity associated with calvarium removal.
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http://dx.doi.org/10.1002/hed.26097DOI Listing
April 2020

Treatment Decisions in Thyroid Microcarcinomas: Identifying Gaps in Knowledge to Empower Our Patients.

Thyroid 2020 03 21;30(3):467-468. Epub 2020 Feb 21.

Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York.

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http://dx.doi.org/10.1089/thy.2019.0451DOI Listing
March 2020

Reconstructive and prosthodontic outcomes after multiple palatomaxillary reconstructions.

Laryngoscope 2020 10 30;130(10):2349-2353. Epub 2019 Dec 30.

THANC (Thyroid, Head and Neck Cancer) Foundation, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York.

Objective: A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population.

Methods: We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016.

Results: Twenty-one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps.

Conclusion: This patient cohort represents unique oncologic and reconstructive challenges. With long-term follow-up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction.

Level Of Evidence: 2B Laryngoscope, 130:2349-2353, 2020.
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http://dx.doi.org/10.1002/lary.28481DOI Listing
October 2020

Management of orbital complications in palatomaxillary reconstruction: A review of preemptive and corrective measures.

Head Neck 2020 03 13;42(3):556-568. Epub 2019 Dec 13.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York.

Background: Reconstruction of orbit-sparing palatomaxillary defects requires consideration of globe dystopia, orbital volume, eyelid position and function, and the nasolacrimal system to preserve and optimize vision, globe protection, and appearance. We describe the fundamentals of orbital and eyelid anatomy, common orbital complications related to palatomaxillary reconstruction, and preemptive and corrective surgical techniques to be utilized during and after globe-sparing palatomaxillary reconstruction.

Methods: We present a review of the literature supplemented by clinical case examples.

Results: We advocate for the use of preemptive and corrective techniques to ensure optimal aesthetic and functional outcomes for patients with orbital defects.

Conclusions: Recognition and anticipation of problems in patients undergoing midface ablative and reconstructive procedures are vital to the implementation of corrective measures. Incision choice, orbital volume restoration, appropriate orbital floor reconstruction, and permanent or temporary lower eyelid suspension during the primary surgery can all significantly impact the development of long-term orbital complications.
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http://dx.doi.org/10.1002/hed.26015DOI Listing
March 2020

Ten patients with high-grade transformation of acinic cell carcinomas: Expression profiling of β-catenin and cyclin D1 is useful.

Pathol Res Pract 2020 Feb 30;216(2):152767. Epub 2019 Nov 30.

THANC (Thyroid, Head and Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA; Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai Hospital, Mount Sinai Beth Israel, 10 Union Square East, Suite 5B, New York, NY, 10003, USA.

Conventional acinic cell carcinoma (CACC) represents a prototypical low-grade salivary malignancy. Rarely, acinic cell carcinoma (ACC) can demonstrate aggressive features (zones of necrosis, apoptosis, varying nuclear atypia) warranting classification as "ACC with high-grade transformation" (HGT-ACC) or "dedifferentiated" ACC. This study reports ten new cases of HGT-ACC. There is potential for subtlety in recognizing high-grade transformation and distinguishing discrete nodules of necrosis from cytology aspiration changes. We compared immunohistochemical (IHC) profiles, specifically β-catenin (bCAT) and cyclin D1 expression, which have been touted as potentially helpful in this context. We quantified morphology (primary axis nucleus, nuclear area and perimeter) in HGT-ACC and CACC. Clinical outcome is known for eight HGT-ACC patients; three patients developed locoregional or distant metastases, five remained disease-free. Nine of ten HGT-ACC expressed strong, diffuse, membranous bCAT. CACC demonstrated lower intensity of membranous bCAT expression. Strong, diffuse nuclear cyclin D1 was seen in five of ten HGT-ACC whereas no CACC demonstrated cyclin D1 with distribution greater than 50 %. The quantified nuclear morphologic features of CACC and HGT-ACC demonstrated overlapping means values. Maximum values for nuclear primary axis, area, and perimeter were greater for HGT-ACC versus CACC, corresponding to a subpopulation of larger tumor cells in HGT-ACC. The poor outcome associated with HGT-ACC justifies its recognition, which should alter surgical approach with respect to elective neck dissection or possible facial nerve sacrifice. With respect to ancillary IHC studies, strong, diffuse membranous bCAT expression, with or without strong nuclear cyclin D1 ≥ 50 % distribution or Ki67 index ≥ 25 % supports this diagnosis.
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http://dx.doi.org/10.1016/j.prp.2019.152767DOI Listing
February 2020

A novel radial forearm free flap design to treat pharyngoesophageal stenosis in combination with the posterior wall of the trachea.

J Surg Oncol 2019 Dec 16;120(8):1446-1449. Epub 2019 Nov 16.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York.

Pharyngoesophageal stenosis (PES) is a common and serious complication of head and neck cancer treatments such as radiation therapy, chemotherapy, tracheoesophageal puncture placement, and total laryngectomy surgery. Dilation-resistant stenosis requires surgical reconstruction, often with a radial forearm free flap (RFFF). With the present technique, the authors refine their previous bipaddled free flap design used to reconstruct a persistent tracheoesophageal fistulae (TEF) in combination with PES. Accordingly, we present a novel bipaddled triangular RFFF design ideally suited to address the shape of the defect in the posterior tracheal wall that results when the TEF is opened and the esophageal and tracheal components are restored.
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http://dx.doi.org/10.1002/jso.25758DOI Listing
December 2019

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study.

Head Neck 2019 11 12;41(11):3806-3817. Epub 2019 Aug 12.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York.

Background: Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation.

Methods: A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively.

Results: Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points.

Conclusions: The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.
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http://dx.doi.org/10.1002/hed.25908DOI Listing
November 2019

A novel approach to neurologic function sparing surgical management of vagal schwannomas: Continuous intraoperative nerve monitoring of the laryngeal adductor reflex.

Head Neck 2019 09 6;41(9):E146-E152. Epub 2019 May 6.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York.

Background: Vagal schwannomas are rare, benign tumors of the head and neck. Nerve damage during surgical resection is associated with significant morbidity. A new technique of continuous intraoperative nerve monitoring (IONM) that allows for real-time intraoperative feedback has recently been used for thyroid and cervical spine surgeries but has not previously been used in vagal schwannoma surgery.

Methods: Case series of three patients who underwent vagal schwannoma excision utilizing this novel IONM technique. The recurrent laryngeal and vagus nerves were monitored via the laryngeal adductor reflex (LAR) using an electromyographic endotracheal tube.

Results: Three patients with suspected vagal schwannomas were treated surgically using the intracapsular enucleation approach with a combination of intermittent IONM and continuous IONM of the LAR.

Conclusion: This combination of continuous and intermittent IONM can be used to preserve vagal laryngeal innervation and function and may represent the future standard of care for vagal schwannoma excision.
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http://dx.doi.org/10.1002/hed.25793DOI Listing
September 2019

Vagal schwannomas of the head and neck: A comprehensive review and a novel approach to preserving vocal cord innervation and function.

Head Neck 2019 07 7;41(7):2450-2466. Epub 2019 Apr 7.

THANC (Thyroid, Head and Neck Cancer) Foundation, New York, New York.

Background: Schwannomas, benign tumors arising from neurolemmocytes, are the most common type of peripheral nerve tumors. Extracranial schwannomas are most often found in the parapharyngeal space, commonly involving the vagus nerve to cervical sympathetic trunk. Vagal schwannomas present several unique clinical and therapeutic challenges.

Methods: A comprehensive literature review was conducted on 197 articles reporting 235 cases of cervical vagal schwannomas. Presenting symptoms, treatment approach, and postoperative outcomes were recorded and analyzed.

Results: Vagal schwannomas commonly present as asymptomatic neck masses. When they become symptomatic, surgical resection is the standard of care. Gross total resection is associated with higher postoperative morbidity compared to subtotal resection. Initial reports using intraoperative nerve monitoring have shown improved nerve preservation. Recurrence rates are low.

Conclusion: The combination of intermittent nerve mapping with novel continuous vagal nerve monitoring techniques may reduce postoperative morbidity and could represent the future standard of care for vagal schwannoma treatment.
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http://dx.doi.org/10.1002/hed.25758DOI Listing
July 2019

A rare invasion route for differentiated thyroid carcinoma: The tracheoesophageal common party wall.

Laryngoscope 2019 12 12;129(12):E455-E459. Epub 2019 Mar 12.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai West, New York, New York, U.S.A.

Thyroid carcinoma can infiltrate the aerodigestive tract. Invasion via the common party wall of the tracheoesophageal groove (TEG) is rare. A review of patients with thyroid cancer invading the aerodigestive tract was performed. We describe three cases of invasive thyroid cancer presenting 4 to 6 years after the initial thyroidectomy. Original pathology showed positive margins near the recurrent laryngeal nerve and TEG. A partial tracheal resection with a stair-step reconstruction was performed in one case; the other cases required total laryngopharyngectomy. Surgeons should be prepared to perform oncologically complete resections at the primary surgery to avoid potentially significant clinical consequences requiring aggressive surgery. Laryngoscope, 129:E455-E459, 2019.
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http://dx.doi.org/10.1002/lary.27915DOI Listing
December 2019
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