• Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) constitute the majority of nonmelanoma skin cancers (NMSCs):
  • Which are also referred to as “keratinocyte cancer
• Keratinocyte cancer represents:
  • About 95% of malignant skin tumors estimated at greater than 3.5 million cases annually
• While BCC is four to five times more common than SCC:
  • The incidence of both tumor types continues to rise despite growing awareness of the risk factors for these skin cancers
• The overall incidence increases with age and is known to be higher in men than in women
• Development of NMSC is multifactorial and is related to:
  • Various genotypic, phenotypic, and environmental risk factors
• Ultraviolet (UV) solar radiation:
  • Is considered to be the dominant risk factor for the development of both BCC and SCC:
    • Supported by the fact that most of these tumors tend to present on sun-exposed areas of the body
  • The development of BCC:
    • Is thought to arise from intense intermittent sun exposure leading to burns
  • Whereas the development of SCC:
    • Appears to be linked to the cumulative dose of UV solar radiation over time
  • Sun exposure earlier in life appears to be more influential in skin cancer development than that received later in life
  • Markers of UV sensitivity (e.g., fair skin, light eyes, blond or red hair) and intensity of exposure (i.e., increased incidence for individuals living in proximity to the equator):
    • Are associated with increased NMSC risk:
      • As is additional UV exposure from recreational tanning booths and UV light therapy:
        • One case-controlled study demonstrated that the use of tanning devices was associated with an estimated twofold risk for both SCC (odds ratio = 2.5) and BCC (odds ratio = 1.5)
        • Karagas et al. reported that treatment of psoriasis with oral psoralen in combination with light treatment (PUVA therapy) resulted in an increased adjusted relative risk of 8.6 for SCC while the risk for BCC was much lower
  • UV-induced mutations in the p53 tumor suppressor gene:
    • Is thought to be a common event in NMSC development
• Another important risk factor for both BCC and SCC is immunosuppression:
  • Long-term immunosuppression therapy such as that used for solid organ transplant has been shown to increase the risk of SCC over 100-fold and for BCC about 10-fold
  • SCC in immunosuppressed patients:
    • Tend to be behave more aggressively and are associated with:
      • Greater tumor depth:
      • Higher risk of recurrence
      • More frequently associated with perineural or lymphovascular invasion
  • However, BCCs have not been found to be more aggressive in solid organ transplant recipients than the general population
  • Patients with acquired immunodeficiency syndrome also have an increased incidence of NMSC:
    • And factors such as persistent human papilloma virus (HPV) infection may act synergistically with UV exposure to increase risk:
      • Moreover, HPV infection, especially HPV 16 and 18, has been implicated in the development of anogenital SCC
• Exposure to ionizing radiation:
  • Increases the risk of NMSC threefold and often presents decades after initial exposure
  • This risk has been shown to be dose dependent
• Chemical exposures:
  • Such as arsenic, tar, soot, tobacco, asphalt, and mineral oil:
    • Have all been associated with an increased risk of SCC
• SCC can also arise from areas of chronic inflammation and healing:
  • Such as from scars, burn sites, or ulcers:
    • This type of SCC is also known as a Marjolin ulcer
• Patients with genetic syndromes including:
  • Xeroderma pigmentosum, albinism, Muir–Torre syndrome, dystrophic epidermolysis bullosa, Fanconi anemia, Werner syndrome, nevoid basal cell syndrome, and Li–Fraumeni syndrome:
    • Have an increased incidence of NMSC
  • Xeroderma pigmentosum:
    • Is a rare autosomal recessive disease characterized by:
      • Photophobia
      • Severe sun sensitivity
      • Advanced sun damage
    • Affected individuals have defective DNA excision repair:
      • When exposed to UV radiation:
        • Develop malignancies of the skin and eyes:
          • At a rate 1,000 times that of the general population
    • Aggressive sun protection:
      • In the form of full-body sun suits and regular skin examinations are critical for patients with xeroderma pigmentosum
    • Ideally, these patients should only go outside at night
  • Nevoid basal cell syndrome:
    • Is an autosomal dominant disorder characterized by the development of multiple BCCs
    • BCCs in patients with nevoid basal cell syndrome:
      • Are often quite small but can number in the hundreds on any given skin surface
    • The sonic hedgehog signaling pathway (PTCH1 gene, chromosome 9q) has been recognized as having a significant etiologic role in nevoid BCC syndrome, and is also present in 90% of sporadic BCC
    • These patients are exquisitely sensitive to radiation:
      • Should avoid excessive sun exposure and radiation therapy
    • Regular follow-up is important, as such tumors are difficult to monitor and treat
• Similar to other tumor types, a previous diagnosis of cutaneous carcinoma increases the risk of future NMSCs to as high as:
  • 35% at 3 years and 50% at 5 years
• DIFFERENTIAL DIAGNOSIS
  • Several epidermal tumors common to the skin can resemble or are precursors to NMSC:
    • Recognition of these tumors is important for both tumor surveillance and cancer prevention
  • Seborrheic keratoses:
    • Are benign proliferations of epidermis that can appear on any part of the skin:
      • Except mucous membranes:
        • Usually appear after the age of 30 years
    • They are not related to sun exposure:
      • But are common on the face, neck, and trunk:
        • Often in large numbers
    • They initially appear as:
      • Flat brown macules:
        • Eventually becoming larger, “stuck-on” brown plaques with dull crumbly surfaces
    • Seborrheic keratoses can sometimes be confused with melanoma:
      • Biopsy of these lesions is prudent if any sudden changes in size or color occur

• Actinic keratoses (AKs):
  • • Are premalignant lesions:
      • With the potential to develop into SCCs
    • They are found mainly on sun-exposed areas
    • These lesions most commonly present as:
      • Skin-colored, erythematous, or brown ill-defined patches with adherent scales
    • These lesions are extremely common on the:
      • Face, scalp, ears, and lips and can often be better appreciated by palpation rather than by inspection with the naked eye

• Keratoacanthoma:
  • Is a tumor that often occurs on older, sun-damaged skin:
    • Is most commonly found on the:
      • Neck and face
    • These tumors originate in:
      • The pilosebaceous glands:
        • May grow rapidly as a red- or skin-colored dome-shaped nodule with a central crater:
          • Maximum size may be attained at 6 to 8 weeks with slow regression over a period of months leaving a residual scar
  • These tumors can be confused both clinically and histologically with SCC:
    • There are reports of progression of keratoacanthomas to invasive or metastatic carcinoma
  • Classification of these tumors as a:
    • Well-differentiated variant of invasive SCC has been proposed
  • Surgical excision of keratoacanthomas with 3- to 5-mm margins is recommended, and Mohs surgery may be employed in cosmetically sensitive areas
  • These tumors are radiation sensitive if surgery is not an option
• A cutaneous horn:
  • Is the clinical description for a growth that appears as a dense cone of epithelium resembling a horn
  • They range in size from several millimeters to over a centimeter and are generally white or yellowish in color
  • They also tend to appear on sun-exposed skin of older individuals
  • Histologically, cutaneous horns can develop from:
    • Benign lesions such as:
      • Warts
      • Seborrheic keratoses
    • Premalignant lesions such as:
      • AKs
      • SCCs in situ
    • Malignant lesions such as:
      • SCCs
  • Up to 15% of cutaneous horns demonstrate invasive SCCs at the base:
    • Excision of these tumors is always indicated
• Nevus sebaceous:
  • Is a benign tumor of the scalp:
    • That appears at or soon after birth as a yellowish-orange, well-demarcated plaque
  • Initially, the surface has a:
    • Smooth or waxy appearance that gradually becomes more warty or verrucous during puberty
  • In adulthood, approximately 10% of these lesions develop into BCC:
    • It is therefore recommended that these lesions be excised or closely monitored for the life of the patient.

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👉Standard treatment options for iodine-resistant thyroid cancer include the following:

1. Thyroid-suppression therapy.
2. Targeted therapy.
3. Surgery.
4. External-beam radiation therapy (EBRT).

👉Thyroid-suppression therapy

TSH suppression with thyroxine is effective in many lesions that are not sensitive to 131I

👉Targeted therapy

Sorafenib

Sorafenib is an orally active, multityrosine kinase inhibitor. 

Evidence (sorafenib):

• A phase III randomized, double-blind, placebo-controlled study (DECISION[NCT00984282]) evaluated the activity of sorafenib in patients with progressive, iodine-refractory differentiated thyroid cancer.
  • In the trial, 417 patients with locally advanced or metastatic RAI−refractory thyroid cancer (papillary, follicular [including Hürthle cell], and poorly differentiated, not anaplastic tumors, defined as beyond well-differentiated tumors or those well-differentiated tumors that become resistant to radioiodine treatment) whose disease had progressed within the past 14 months were randomly assigned to receive sorafenib (400 mg twice a day) or placebo.
  • Patients who received previous chemotherapy, thalidomide, or targeted therapy were excluded.
  • The median PFS in the sorafenib group was 10.8 months versus 5.8 months in the placebo group (hazard ratio [HR] 0.59; 95% confidence interval [CI], 0.45–0.76, P < .0001).
  • OS was not significantly improved (HR, 0.80; 95% CI, 0.54–1.19, P = .14, one-sided P-value), but the median OS had not been reached at the time of primary analysis data cutoff, and crossover was allowed.
  • Objective response rate (all partial responses) was 12.2% in the sorafenib group compared with 0.5% in the placebo group.
  • Median time-to-progression was 11.1 months in the sorafenib group compared with 5.7 months in the placebo group (HR, 0.56; 95% CI, 0.43–0.72, P < .001).
  • Adverse events occurred in 98.6% of patients treated with sorafenib and 87.6% of patients treated with placebo.
  • The most common adverse events in the sorafenib group were hand-foot skin reactions (76.3%), diarrhea (68.6%), alopecia (67.1%), and rash or desquamation (50.2%).
  • Most events were grade 1 or 2.
  • Seven squamous cell carcinomas of the skin occurred in the sorafenib group.

👉Lenvatinib

Lenvatinib is an orally active, multitargeted tyrosine kinase inhibitor.

Evidence (lenvatinib):

• A phase III, randomized, double-blind, placebo-controlled study (SELECT[NCT01321554]) evaluated the activity of lenvatinib in patients with progressive, iodine-refractory, differentiated thyroid cancer.
• In this trial, 261 patients were randomly assigned to receive lenvatinib (24 mg every day), and 131 patients were randomly assigned to receive placebo.
• Eligible patients had differentiated thyroid cancer (including papillary, follicular, poorly differentiated, and Hürthle cell carcinomas), RAI-refractory disease, and evidence of radiological progression within the previous 13 months.
• At disease progression, patients in the placebo group could receive open-label lenvatinib.
  • The primary endpoint was PFS, and secondary endpoints were OS, response rate, and safety.
  • The median PFS in the lenvatinib group was 18.3 months versus 3.6 months in the placebo group (HR_{progression or death}, 0.21; 99% CI, 0.14–0.31; P < .001).
  • A PFS difference was observed in patients with all histologic types of thyroid cancer enrolled in this trial.
  • There was no significant difference in OS between the two groups (HR _death, 0.73; 95% CI, 0.50–1.07; P = .10), even with the crossover design of the study.
  • Objective response rate was 64.8% in the lenvatinib group versus 1.5% in the placebo group (odds ratio [OR], 28.87; 95% CI, 12.46–66.86; P < .001).
  • Treatment-related adverse events (all grades) occurred in 97.3% of patients in the lenvatinib group and 59.5% of patients in the placebo group.
    • Grade 3 or higher adverse events were observed in 75.9% of patients receiving lenvatinib and 9.9% of patients receiving placebo.
    • The most common adverse events in the lenvatinib group were hypertension (67.8%), diarrhea (59.4%), fatigue (59%), decreased appetite (50.2%), decreased weight (46.4%), and nausea (41%).
    • Discontinuation of the study drug because of adverse events occurred in 14.2% of patients receiving lenvatinib and 2.3% of patients receiving placebo.
    • In the lenvatinib group, 6 of 20 deaths occurring during the treatment period were considered drug related.

👉Surgery

Resection of limited metastases, especially symptomatic metastases, should be considered when the tumor has no uptake of 131I

👉EBRT

EBRT is considered for patients with localized lesions that are unresponsive to 131I

👉Treatment options under clinical evaluation for metastatic papillary and follicular thyroid cancer

👉Patients unresponsive to 131I should also be considered candidates for clinical trials testing new approaches to this disease.

• Chemotherapy has been reported to produce occasional complete responses of long duration.
• Clinical trials evaluating new treatment approaches to this disease should be considered for patients with radioiodine-refractory papillary or follicular thyroid cancer.
• Oral inhibitors targeting specific activating point mutations are under clinical evaluation, as are new immunotherapy approaches.

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #CancerSurgeon #ThyroidCancer #PapillaryThyroidCancer #PTC #CASO #CenterforAdvancedSurgicalOncology

A. BCC is the most common cancer in the United States.

1. It is estimated that BCCs occur in 2 million Americans annually:

• This exceeds the incidence of all other cancers combined.

1. Due to its prevalence, treatment of non-melanoma skin cancer (NMSC) in the United States costs Medicare more than $400 million per year.
2. Furthermore, the incidence of this common malignancy is rising rapidly.
3. BCCs are at least 2 times more common than squamous cell carcinomas (SCCs):

• The second most common type of skin cancer.

1. Although rarely metastatic, BCC can produce substantial local destruction along with disfigurement and may involve extensive areas of soft tissue, cartilage, and bone.
2. Fortunately BCCs generally have a good prognosis due to low rates of metastasis.

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👉In the past, a thyroid cancer diagnosis all but guaranteed a patient would have their thyroid gland removed (total thyroidectomy). But newer guidelines have called for a less radical, more personalized standard of card

👉There has been a big shift in the pendulum in the way thyroid cancer is managed, especially since 2015

👉While thyroid removal, or a total thyroidectomy, is still the primary treatment for some thyroid cancers, that’s no longer the case for every patient

👉Today patients with low-risk thyroid cancers (up to 4 cm thyroid tumors) may only need to have half of their thyroid gland removed, known as a partial thyroidectomy or hemithyroidectomy.

👉Some patients with very small nodules or so-called micro cancers (less than 1 cm), might even be candidates for active surveillance or watchful waiting

👉This shift in treatment is reflective of how experts see thyroid cancer treatment in 2021: Not every patient is the same, and sometimes less treatment is more

👉The de-escalation of treatment means an individualized approach to treatment, which means not everybody needs the whole thyroid out, and not everybody needs radioactive iodine

👉Radioactive iodine is a common follow-up treatment after surgery for thyroid cancer

👉The thyroid is a butterfly-shaped gland in the neck that makes thyroid hormones. These hormones play a key role in managing essential functions like helping the body use energy, regulate metabolism, and maintain the right temperature

👉Patients who have their entire thyroid gland removed have to take synthetic thyroid hormone medications for the rest of their lives. And though thyroid surgery is generally considered safe, there are still risks.

👉Surgery could damage a patient’s nerve supplying the vocal cords or parathyroid glands and lead to long-term side effects. There’s also the potential for severe bleeding in the immediate hours after the procedure.

👈Surgery to remove just part of the thyroid poses fewer risks. The majority of patients who retain half of their thyroid also don’t need to take thyroid medications or may need only low dose thyroid medication for thyroid cancer treatment. And many of those who do need medication may eventually be able to stop taking the drugs as the remaining part of their thyroid gland eventually regains function.

👉The decision to remove all or half of a patient’s thyroid is highly individualized. The size and location of the cancer (including the presence of other thyroid nodules in the contralateral lobe) and the risk for recurrence are the most important factors, but a patient’s age and personal preferences can also come into play

👉It’s important to discuss all of these considerations with your surgeon and a multidisciplinary care team with experience treating thyroid cancers

👉Head and Neck Surgeons are not just technicians: You want them to be good at removing the thyroid and understanding the nuances of this cancer.

👉 You want someone who has a lot of experience and works as part of a multidisciplinary team, so they can make adjustments as necessary

👉Survival of most thyroid cancers is in excess of 90%

👉Weighing the risks and benefits of different treatment approaches isn’t always easy, of course. But consulting with a panel of dedicated thyroid cancer specialists gives you the chance to explore your options fully—and feel confident that your treatment path will likely be successful

At Center for Advanced Surgical Oncology, we look forward to providing an individualized and evidence-based approach in thyroid cancer care

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #ThyroidCancer #HeadandNeckSurgeon #CancerSurgeon #MultidisciplinaryTeam #CASO #CenterforAdvancedSurgicalOncology

• Papillary thyroid cancer (PTC) tends to have an indolent clinical course with low morbidity and mortality. Nevertheless, this entity has a broad range of biologic and clinical behavior that can result in disease recurrence and death, depending on patient and tumor characteristics and the initial management approach.
• PTC is the most common form of well-differentiated thyroid cancer (WDTC) and based on the most recent statistics, accounts for approximately 89.4% of all thyroid malignancies, and is the predominant histology observed in patients exposed to radiation.
• The average age of diagnosis of PTC is between 30 and 40 years, women are affected more frequently than men at a 2:1 ratio.
• PTC appears as an irregular solid or cystic nodule in a normal thyroid parenchyma.
• Notwithstanding its well-differentiated characteristics, PTC may be blatantly or minimally invasive. In fact, these tumors may spread easily to other organs.
• PTC has the propensity for lymphatic invasion but it is less likely to have hematogenous spread. 
• Roughly 11% of patients with PTC present with distant metastases outside the neck and mediastinum.
• In the past, regional lymph node metastases were thought to be aberrant (supernumerary) thyroids because they contained well-differentiated PTC, but occult regional lymph node metastases are now known to be a very common finding in patients with PTC.

#Arrangoiz #CancerSurgeon #ThyroidSurgeon #HeadandNeckSurgeon #SurgicalOncologist #ThyroidCancer #PapillaryThyroidCancer #PTC #CASO #CenterforAdvancedSurgicalOncology

👉If you have thyroid nodules, there are some things you need to know.

👉By the age of 60, more than half of women will have a thyroid nodule.

👉Recent studies show that most are benign (not cancerous), but 4.0% to 6.5% of end up being cancer.

👉Here is what you need to pay attention to:

1. If you find out you have a thyroid nodule, check your thyroid functions to see if your thyroid functions normally. It is important to have your thyroid functions regularly monitored.
2. Risk factors for developing a thyroid nodule: radiation, smoking, obesity, metabolic syndrome, alcohol consumption and uterine fibroids.
3. Biopsy (an examination of the tissue) is needed if thyroid nodules are larger than 1 cm. If your nodule is larger than 1 cm, you experience any thyroid pain or shortness of breath and you have difficulty swallowing, you should consult with your doctor immediately.
4. If your nodule is smaller than 1 cm, it is important to regularly consult with your doctor to discover any changes in the nodule in time.
5. Zamora EA, Khare S, Cassaro S. Thyroid Nodule. In: StatPearls Publishing. 2020 January.

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #EndocrineSurgery #HeadandNeckSurgery #CancerSurgeon #CASO #CenterforAdvancedSurgicalOncology #PalmettoGeneralHospital

• Obesity has repeatedly been cited as a possible etiologic factor in the pathogenesis of thyroid cancer and has been postulated to be a possible origin of the increase incidence of this disease worldwide.
• Undeniably, being overweight and obesity have been associated with an increased risk of developing numerous malignancies, including thyroid, breast, colorectal, kidney, and endometrial cancers.
• In the United States from 1995 to 2015, one out of every six PTC and two thirds of PTC greater than 4 cm in size have been linked to being overweight or obesity, based on an analysis of data from three large national US databases.
• Kitahara et al projected that the total relative risk for PTC was 1.26 for persons who are overweight (body mass index [BMI] 25 to 29 kg/m2) and 1.30 for those who are obese (BMI ≥ 30  kg/m2), compared with persons with normal-weight BMI (18.5 to 24.9 kg/m2).
• The risk in PTCs greater than 4 cm in size was nearly 3-fold higher (hazard ratio [HR] = 2.93, 95% CI 1.25-6.87) with overweight individuals, and more than 5-fold higher (HR = 5.42, 95% CI 2.24-13.1) in obese individuals compared with normal-weight individuals.
• A study by Leitzmann et al, found that obese adults had a nearly 40% higher risk for developing thyroid cancer when compared with normal-weight individuals.
• More research is needed to define the exact role of obesity in the development of thyroid cancer, particularly as the incidence of obesity continues to climb throughout the world. 

• References:
  • Society, A.C., American Cancer Society: Cancer Facts and Figures 2018., A.C. Society, Editor. 2018: Atlanta, Ga.
  • Brindel, P., et al., Anthropometric factors in differentiated thyroid cancer in French Polynesia: a case-control study.Cancer Causes Control, 2009. 20(5): p. 581-90.
  • Dal Maso, L., et al., A pooled analysis of thyroid cancer studies. V. Anthropometric factors. Cancer Causes Control, 2000. 11(2): p. 137-44.
  • Kitahara CM, P.R., Sosa JA, Shiels MS, Impact of overweight and obesity on U.S. papillary thyroid cancer incidence trends (1995-2015). J Natl Cancer Inst, 2019.
  • Leitzmann, M.F., et al., Prospective study of body mass index, physical activity and thyroid cancer. Int J Cancer, 2010. 126(12): p. 2947-56.
  • Berghofer, A., et al., Obesity prevalence from a European perspective: a systematic review. BMC Public Health, 2008. 8: p. 200.
  • Wang, Y. and M.A. Beydoun, The obesity epidemic in the United States–gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev, 2007. 29: p. 6-28.

#Arrangoiz #CancerSurgeon #ThyroidSurgeon #EndocrineSurgery #HeadandNeckSurgeon #CASO #CenterforAdvancedSurgicalOncology

• The facial artery (external maxillary artery in some texts):
  • Is a branch of the external carotid artery that supplies structures of the superficial face
• The facial artery arises in the carotid triangle:
  • From the external carotid artery:
    • A little above the lingual artery:
      • Sheltered by the ramus of the mandible
    • It passes obliquely up beneath the digastric and stylohyoid muscles:
      • Over which it arches to enter a groove on the posterior surface of the submandibular gland
      • It then curves upward over the body of the mandible at the antero-inferior angle of the masseter:
        • Passes forward and upward across the cheek to the angle of the mouth, then ascends along the side of the nose, and ends at the medial commissure of the eye, under the name of the angular artery
• The facial artery is remarkably tortuous:
  • This is to accommodate itself to neck movements such as those of the pharynx in deglutition; and facial movements such as those of the mandible, lips, and cheeks
• In the neck, its origin is superficial, being covered by the integument, platysma, and fascia:
  • It then passes beneath the digastric and stylohyoid muscles and part of the submandibular gland, but superficial to the hypoglossal nerve

• It lies upon the middle pharyngeal constrictor and the superior pharyngeal constrictor, the latter of which separates it, at the summit of its arch, from the lower and back part of the tonsil
• On the face, where it passes over the body of the mandible, it is comparatively superficial, lying immediately beneath the dilators of the mouth
• In its course over the face, it is covered by the integument, the fat of the cheek, and, near the angle of the mouth, by the platysma, risorius, and zygomaticus major
• It rests on the buccinator and levator anguli oris, and passes either over or under the infraorbital head of the levator labii superioris
• The anterior facial vein lies lateral / posterior to the artery, and takes a more direct course across the face, where it is separated from the artery by a considerable interval. In the neck it lies superficial to the artery
• The branches of the facial nerve cross the artery from behind forward
• The facial artery anastomoses with (among others) the dorsal nasal artery of the internal carotid artery
• The branches of the facial artery are:
  • Cervical:
    • Ascending palatine artery
    • Tonsillar branch
    • Submental artery
    • Glandular branches
  • Facial:
    • Inferior labial artery
    • Superior labial artery
    • Lateral nasal branch to nasalis muscle
    • Angular artery – the terminal branch
• Muscles supplied by the facial artery include:
  • Buccinator
  • Levator anguli oris
  • Levator labii superioris
  • Levator labii superioris alaeque nasi
  • Levator veli palatini
  • Masseter
  • Mentalis
  • Mylohyoid
  • Nasalis
  • Palatoglossus
  • Palatopharyngeus
  • Platysma
  • Procerus
  • Risorius
  • Styloglossus
  • Transverse portion of the nasalis

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• The larynx is an inferior continuation of the oropharynx:It extends from the epiglottis (namely the glossoepiglottic and pharyngoepiglottic folds) to the inferior aspect / border of the cricoid cartilage. Inferiorly:It continues as the cervical trachea. 
• Gross anatomy:The larynx consists of a cartilage “skeleton”, as well as internal structures that are divided into three subsites, mainly for the purposes of laryngeal cancer staging:Supraglottis: Which extends from the tip of the epiglottis to the laryngeal ventricle
  • • • Subsites:Epiglottis:Divided into suprahyoid and infrahyoid portionsPre-epiglottic spaceArytenoid cartilagesAryepiglottic foldsVentriclesFalse vocal cords
        • Paraepiglottic space
    • GlottisTrue vocal cordsAnterior commissurePosterior commissure
    • Subglottis: Extends from the inferior surface of the true vocal cords / 5mm below the free margin of the true vocal cord to the inferior aspect / lower border of the cricoid cartilage
• Relations:Anterior: Strap muscles
  • • Anterior jugular vein
  • Posterior: EsophagusLaryngopharynx
  • Superior: Hyoid boneLaryngopharynx
  • inferior: Trachea
• Arterial supply:Above the vocal cords: Superior laryngeal artery:Branch of the superior thyroid arteryBelow the vocal cords:Inferior laryngeal artery:
  • • • Branch of the inferior thyroid artery
• Venous drainageAbove the vocal cords: Superior laryngeal vein accompanies its artery and drains into the superior thyroid vein:A tributary to the internal jugular veinBelow the vocal cords: Inferior laryngeal vein accompanies its artery and drains into the inferior thyroid vein:A direct tributary to the brachiocephalic vein
• Lymphatic drainage:Supraglottic: The supraglottic lymphatic network follows the superior laryngeal artery:Piercing the thyrohyoid membrane and then draining into the superior deep cervical nodes and the pre-epiglottic nodes. Subglottic: The infraglotttic lymphatic network drains to the inferior deep cervical nodes, following the inferior laryngeal artery, and/or the prelaryngeal (Delphian) nodes via the conus elasticus (aka the lateral cricothyroid ligaments). Both the superior and inferior deep cervical nodes then drain into the right and left jugular trunks:Which subsequently empty into the right lymphatic duct and the thoracic duct on the left. 
• Innervation:Motor: The recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx apart from the cricothyroid muscle:Which is supplied by the external branch of the superior laryngeal nerve.Sensory: Above the vocal cords (supraglottic): Internal branch of the  superior laryngeal nerveBelow the vocal cords (infraglottic): Recurrent laryngeal nerve
• Development:The larynx is formed from the laryngotracheal groove:Which is related to the caudal aspect of the floor of the primordial pharynxThe cartilages of the larynx develop from:The 4^th and 6^th pharyngeal arches

Staging of Laryngeal Cancer

• Rodrigo Arrangoiz MS, MD, FACS es especialista en Cirugía de Tumores de Cabeza y Cuello / Cirugía Endocrina y Cirugía Oncológica compleja:
• Fue egresado como Médico General de la Universidad Anahuac:

• Graduado Suma Cum Laude. Es miembro de Center for Advanced Surgical Oncology
• El Doctor Arrangoiz es experto en el manejo del: Cáncer de Tiroides:Cáncer papilar de tiroides

• • • • Cáncer folicular de tiroides
      • Cáncer medular de tiroides
      • Cáncer anaplásico de tiroides
    • Patología Quirúrgica de Tiroides:Bocio multi nodular no toxico sintomático  Bocio multi nodular toxicoHipertiroidismo
    • Hiperparatiroidismo:Hiperparatiroidismo primarioHiperparatiroidismo secundarioHiperparatiroidismo terciario
    • Tumores de Cabeza y Cuello:Cancer de la cavidad oral
      • Cáncer de faringe:
        • Nasofaringe
        • Orofaringe
        • Hipofaringe
      • Cáncer Laringeo:
        • Cáncer supraglótico
        • Cáncer glótico
        • Cancer subglótico
      • Cáncer de glándulas salivales:
        • Glándula Parótida
        • Glándula submandibular
        • Glándula sublingual
        • Glándulas salivales menores
      • Cáncer de piel de la cabeza y cuello:
        • Melanoma
        • Carcinoma basocelular
        • Carcinoma epidermoide
        • Carcinoma de Merkel
        • Dermatofibrosacroma Protuberans
      • Cáncer de Mama. 
      • Cáncer de piel:
        • Melanoma
        • Carcinoma basocelular
        • Carcinoma epidermoide
        • Carcinoma de Merkel
        • Dermatofibrosacroma Protuberans
  • Fue entrenado en las mejores instituciones académicas de los Estados Unidos.
  • Mantiene certificaciones por los Consejos de Cirugía General y Cirugía Oncológica en México y en los Estados Unidos de América. 
     
• Su entrenamiento incluyó:Cirugía General y Gastrointestinal:Michigan State University (2004 – 2010)

• Cirugía Oncológica / Tumores de Cabeza y Cuello / Cirugía Endocrina:Fox Chase Cancer Center en Filadelfia (2010 al 2012)

• Maestría en Ciencias (Clinical Research for Health Professionals):Drexel University (Filadelfia) (2010 – 2012)

• Cirugía de Tumores de Cabeza y Cuello / Cirugía Endocrina (2014 al 2016):IFHNOS / Memorial Sloan Kettering Cancer Center

• Ha participado en múltiples cursos y congresos como Conferencista y Profesor Invitado, así mismo ha realizado diversas publicaciones y artículos sobre temas relacionados con su especialidad.
• Fue pionero en México de la:
  • Cirugía minimamente invasive radioguida de paratiroides.
• Se encuentra certificado por el Consejo Mexicano de Cirugía General y el Consejo Mexicano de Oncología así como es de los pocos mexicanos certificado por, el AMERICAN BOARD OF SURGERY,  el cuál le faculta como cirujano con licencia en los EU.
• Es miembro de diversas asociaciones médicas como el:American College of Surgeons, American Thyroid Association, American Society of Endocrine Surgeons, American Medical Association, American Society of Clinical Oncology, Association of Academic Surgeons, Society of Surgical Oncology,  The Society of Surgery of the Alimentary Tract, Society of American Gastrointestinal Endoscopic Surgeons, y la American Society of Breast Surgeons, entre otras.
• Gracias a esto el Dr. Rodrigo Arrangoiz es reconocido como uno de los mejores especialistas en Cirugía de Tumores de Cabeza y Cuello / Cirugía Endocrina y Cirugía Oncológica en México, además de ser galardonado como uno de los 50 mejores médicos de México en los Top Doctors Awards 2018.

#Arrangoiz

#Teacher

#Surgeon

#Cirujano

#ThyroidExpert

#ThyroidSurgeon

#CirujanodeTiroides

#ExpertoenTiroides

#ExpertoenParatiroides

#Paratiroides

#Hiperparatiroidismo

#CancerdeTiroides

#ThyroidCancer

#PapillaryThyroidCancer

#SurgicalOncologist

#CirujanoOncologo

#CancerSurgeon

#CirujanodeCancer

#HeadandNeckSurgeon

#CirugiaEndocrina

#CirujanodeTumoresdeCabezayCuello

#OralCavityCancer

#Melanoma

• The scalp refers to the layers of skin and subcutaneous tissue that cover the bones of cranial vault
• Layers of the Scalp:
  • The scalp consists of five layers
  • The first three layers are tightly bound together:
    • Move as a collective structure
  • The mnemonic ‘SCALP’ can be a useful way to remember the layers of the scalp:
    • Skin
    • Dense Connective Tissue
    • Epicranial Aponeurosis (Galea Aponeurotica)
    • Loose Areolar Connective Tissue
    • Periosteum
  • Skin:
    • Contains numerous hair follicles and sebaceous glands:
      • Thus a common site for sebaceous cysts
  • Dense Connective tissue:
    • Connects the skin to the epicranial aponeurosis
    • It is richly vascularized and innervated
    • The blood vessels within the layer are highly adherent to the connective tissue:
      • This renders them unable to constrict fully if lacerated:
        • And so the scalp can be a site of profuse bleeding
  • Epicranial Aponeurosis:
    • A thin, tendon-like structure that:
      • Connects the occipitalis and frontalis muscles
  • Loose Areolar Connective Tissue:
    • A thin connective tissue layer that:
      • Separates the periosteum of the skull from the epicranial aponeurosis
    • It contains numerous blood vessels, including emissary veins:
      • Which connect the veins of the scalp to the diploic veins and intracranial venous sinuses
  • Periosteum:
    • The outer layer of the skull bones
    • It becomes continuous with the endosteum at the suture lines

• Arterial Supply:
  • The scalp receives a rich arterial supply via the:
    • External carotid artery
    • The ophthalmic artery:
      • A branch of the internal carotid
  • There are three branches of the external carotid artery involved:
    • Superficial temporal artery:
      • Supplies the frontal and temporal regions
    • Posterior auricular artery :
      • Supplies the area superiorly and posteriorly to the auricle
    • Occipital artery:
      • Supplies the back of the scalp
  • Anteriorly and superiorly, the scalp receives additional supply from two branches of the ophthalmic artery:
    • The supraorbital and supratrochlear arteries:
      • These vessels accompany the supraorbital and supratrochlear nerves respectively

• Venous drainage:
  • The venous drainage of the scalp can be divided into:
    • Superficial and deep components
  • The superficial drainage follows the arterial supply:
    • Superficial temporal, occipital, posterior auricular, supraorbital and supratrochlear veins
  • The deep (temporal) region of the skull is drained by:
    • The pterygoid venous plexus:
      • This is a large plexus of veins situated between the temporalis and lateral pterygoid muscles:
        • Drains into the maxillary vein
  • Importantly, the veins of the scalp connect to the diploic veins of the skull:
    • Via valveless emissary veins:
      • This establishes a connection between the scalp and the dural venous sinuses

• Innervation:
  • The scalp receives cutaneous innervation from branches of the:
    • Trigeminal nerve or the cervical nerve roots
  • Trigeminal Nerve:
    • Supratrochlear nerve:
      • Branch of the ophthalmic nerve:
        • Which supplies the anteromedial forehead
    • Supraorbital nerve:
      • Branch of the ophthalmic nerve:
        • Which supplies a large portion of the scalp between the anterolateral forehead and the vertex
    • Zygomaticotemporal nerve:
      • Branch of the maxillary nerve:
        • This supplies the temple
    • Auriculotemporal nerve:
      • Branch of the mandibular nerve:
        • Which supplies skin anterosuperior to the auricle
  • Cervical Nerves:
    • Lesser occipital nerve:
      • Derived from the anterior ramus (division) of C2 and supplies the skin posterior to the ear
    • Greater occipital nerve:
      • Derived from the posterior ramus (division) of C2 and supplies the skin of the occipital region
    • Great auricular nerve:
      • Derived from the anterior rami of C2 and C3 and supplies the skin posterior to the ear and over the angle of the mandible.
    • Third occipital nerve:
      • Derived from the posterior ramus of C3 and supplies the skin of the inferior occipital region

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SCALP #ScalpAnatomy #SkinCancer #CASO #CenterforAdvancedSurgicalOncology