Head and Neck Potpourri NWAOto Stephen Bayles, MD Joseph Sniezek, MD Jeffrey Houlton, MD

Transcription

1 Head and Neck Potpourri NWAOto 2016 Stephen Bayles, MD Joseph Sniezek, MD Jeffrey Houlton, MD

2 CASE 1 31 yo female long standing mole of forehead that begins to change shape and color during pregnancy 3 years ago Bx- melanoma WLE and SLN bx 0.9mm Clarks level 3 Nonbrisk Lymph response 5mitoses/HPF SLN NEG in tail of parotid

3 Technique Lymphoscintigraphy 1mCi/0.25ml Tc99m Sulfur Colloid injected intradermally T ½ - 6Hrs Isosulfan Blue injected intradermally massaged

4 Sentinel LN Bx

5 Elective Node Dissection CMM - Presence of nodal disease results in a 50% decrease in 5years 4 Large Prospective Randomized Trials Have failed to show a benefit Controversies Balch C. et al: Annals of Surgery 224(3): Intergroup Melanoma Trial

6 Timing of Tx w/sentinel Node WLE should NOT be performed prior to sentinel LN bx lymphatic assessment of the lesion may lead to incorrect sentinel node assignment since you are actually assessing drainage from the peripheral skin and not the lesion

7 Pitfalls -SLN Mapping Sydney Melanoma Unit Disagreement b/w clinically predicted LN and pathway found on lymphoscintigraphy 34% of 97pts studies Multiple SLN 13 pts 1 SLN 32 pts 2 SLN 28 pts 3 SLN 15 pts 4 SLN 5 pts 5 SLN O Brien: AM J Surg 170:461 (1995)

8 Pitfalls -SLN Mapping Sydney Melanoma Unit Difficulty in the operative identification of all SNLN found on Lymphoscintigraphy Regional failure 25% among 16 pts with pn-sn More limited exposure in the parotid bed may place facial nerve and other structures at risk

9 SNLN Localization HN Melanoma (Blue dye &Lymphoscintigraphy) Institute Pts % SLN identified % + SLN % False Neg John Wayne CA Sydney melanoma Unit John Wayne CA Moffet MD Anderson MSK

10 2 nd Pregnancy notices a new parotid lump in 3 rd trimester

11 Total Parotidectomy and CND 2 parotid LN + largest 4.2 cm no ECS 0/57 LNs in levels 1-5 BRAF V600 +

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13 Ipilimumab

14 Adjuvant ipilimumab versus placebo after complete resection of high-risk stage III melanoma (EORTC 18071): a randomised, double-blind, phase 3 trial Alexander M M Eggermont, Vanna Chiarion-Sileni, Jean-Jacques Grob, Reinhard Dummer, Jedd D Wolchok, Henrik Schmidt, Omid Hamid, Caroline Robert, Paolo A Ascierto, Jon M Richards, Céleste Lebbé, Virginia Ferraresi, Michael Smylie, Jeff rey S Weber, Michele Maio, Cyril Konto,

15 Keytruda Th e new england journal o f medicine original article Pembrolizumab versus Ipilimumab in Advanced Melanoma Caroline Robert M.D., Ph.D., Jacob Schachter, M.D., Georgina V.

16 Opdivo MORE TO COME

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18 19 yo Female presents with discomfort and tenderness in her right neck

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20 W/U? Options for therapy?

21 Urine metanephrine Catecholamine negative

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25 6month VC paralysis full return of function No aspiration or need for FT despite sup.laryngeal nerve sacrafice

26 SDHx A,B,C,D negative

27 40 yr old mass in neck with flushing episodes and palpitations, headaches and hypertension uncontrolled on 4 meds

28 Postop nasuea and vomiting VC paralysis Significant dietary alteration but did not need FT 6 months for N/V to subside

29 59 yo with asymptomatic mass

30 10 year follow up at 69yoa NO TX

31 Case 2 73 yo male 1 yr h/o right sided throat pain Was undergoing tx for MI at initial time Stent placement x 2 On Plavix, ASA Tx antibiotics Pain returned and then began bringing up blood from mouth

32 18month CT/PET neg Full oral diet Sprained his shoulder water skiing Now 5yrs NED No Surgery

33 Case 3 61 yo noted a lump while shaving Non-smoker High chol

34 Transoral robotic resection staged after ND Postop Bleed Day 6 Return to OR cauterized

35 Tonsil 4.0 x 2.5 x 2.0 cm Scca nonkeratinizing P16 positive Perineural invasion Present Margins neg 1/23 LN positive 2.5cm with ECS+

36 Case 4 72 yo F nonsmoker Dentures since 19 yoa Sore throat x 9months

37 * Final Diagnosis 1-4. LEFT TONSIL AND TONGUE BASE, TONSILLECTOMY WITH ADDITIONAL DEEP INFERIOR TONGUE, MEDIAL, AND INFERIOR TONGUE BASE MARGINS: Invasive moderately differentiated, predominantly nonkeratinizing, squamous cell carcinoma. A. Tumor size: 1.8 cm. B. Tumor location: Left tonsil and base of tongue. C. Extent of invasion: Tumor invades subepithelial tissue. D. Specimen margins: Uninvolved by tumor. E. Regional lymph nodes: 0/13 (see specimen 5). F. Lymphatic/vascular invasion: Not identified. G. Perineural invasion: Not identified. H. Pathologic stage: pt1 pn0. 5. LEFT NECK CONTENTS, LEVELS II-IV, DISSECTION: Thirteen lymph nodes, no tumor seen (0/13).

38 2 year postop

39 Case 4 50 yo o/w healthy gentleman with 4 month h/o VPI, and nasal regurg No odynophagia No otalagia Does recall scant hemoptysis No weight loss Has noticed some fullness in his neck over the last week Social Hx Buyer for major corporation travels, presentations, and client interaction Avid water skier Married w/3 children Quit smoking 12 yrs ago after 22 pk/yr hx 1-2 EtOH drinks/wk

40 Additional W/U?

41 CT CHEST NEG PET confirmed no Distant uptake

42 Induction CisPlat 5FU Near complete CR at primary 1 cycle Followed by concurrent Chemo/RT 9 years post treatment still water skiing