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Case 1:

A 30 old male patient presented with ulcer on the right lateral border tongue x 3 months.

On examination: 3x3 cm ulcer right lateral border tongue with induration and abutting the gingivolabial sulcus, neck showed enlarged left submandibular lymphnodes level 1B

CECT: Lesion in tongue with infiltration into right mandibular cortex with nodes in neck

Plan: Biopsy 1ST – Sqamous cell carcinoma, well differentiated

Treatment: right adequate (hemi glossectomy) with right henimadibulectomy with right modified radical neck dissection level 1-5 and right pectoralis myocutaneous flap

Post Op Recovery: RT feeds for 1 week, orally from day 8, neck drain and stitches out on POD 12

HPR: 4x3 cm lesion T2N1Mx with all margins clear, well differentiated with 2/12 lymphnodes positive

Post Op Management: Adjuvant CT + RT for 5 weeks, completed treatment

Pet scan 6 months: Negative for any metabolically active disease in body

Follow up 1 year: Patient working normally and no evidence of recurrence

Discussion:Since the patient has come late, stage 3, the case needed massive operation. If, it was a small lesion T1, CT/RT or a small non-morbid surgery would be enough. So, it is important to diagnose cases, early.

Case 2:

55 year old male with hoarseness of voice x 1.5 years, diagnosed case of Ca larynx, biopsy proven well differentiated squamous cell carcinoma, taken many doctors treatment(ayurvedic) for 6 months , had 3 CT scan reports every 3 months done by patient. Every scan showed increase in the lesion over 1 year

Recent CT on examination had 4x2 cm mass lesion in right vocal codes with extension to left cord with anterior commissure involvement with thyroid cartilage involvement, post cricoids normal and had bilateral multiple lymphnodes. The mass was extending to parapharyngeal spaces and reaching to tonsillar bed.

Management: After a direct laryngoscopy under GA and clinical examination, the patient appeared to have a locally advanced disease as he had come very late to us.

A modified method of management was planned for him. We gave him 3 cycles of Neo-adjuvant chemotherapy with paclitaxel, Cisplatin and 5 Fu every 21 days and respected Ct, Found > 70% response, reduction of tumour size to 3 cms and reduction in lymphnodal mets, later staged total radical laryngectomy with bilateral neck dissection with permanent Tracheostomy with voice prosthesis and patch pmmc (Pectoral muscle flap to reconstruct the anterior wall of upper Esophagus) was done.

Post op management – recovered in 15 days, small anastomotic leak, healed with conservative management, taken adjuvant CT RT after surgery within 2 months, completed treatment in 3 months of surgery. Follow up 8 months, PET negative and patient today is vocalising normally and is working in bhilad.

Case 3:

A 26 year old female patient with left maxillary mass for last 6 months. Slowly growing tumour in a tobacco chewer.

O/E- Oral cavity showed left upper hard palate ulcer proliferative lesion not crossing midline. Biopsy- sqamous cell carcinoma.

CECT: Showed a huge mass infiltering the medical and lateral walls of maxilla extending to zygomaand mandible, not involving the infratemnporal fossa.

Plan: Radical left mexilectomy with left hemimandibulectomy with neck dissection with pmmc flap.

POST OPERATIVELY- adjuvant RT taken, follow up 4 months, patient is normally taking orals and working.

Case 4:

A 26 year old male patient has a left adrenal mass on routine health check up USG finding. Worker in a factory in vapi.

CECT reported in vapi as 8x10 cm large cystic lesion with solid component in left adrenal gland with infiltration into left kidney, spleen and tail of pancreas. malignant adrenal mass.

The catch in this case- normal asymptomatic young patient, incidentaloma under evaluation.

Now adrenal masses can be secretory or non secretory, so its important to do some blood tests to rule out pheochromocytoma, or cortisol secreting tumours, all tests like urinary VMA, 24 hrs samples, 4,8 am cortisol levels, etc all levels were normal.

2nd catch- the CT report showing inoperability.

The ability of the surgeon to read a CT image is a very important. Myself, I felt the CT was wrongly reported. On the scans, with whatever minimal experience I have, I thought the mass was a well circumscribed cystic lesion and I thought it is benign. I did not do a pre operative FNAC as it would lead to loss of planes intra op. Also my gut feeling said, this is operable and this young patient has to be given a good chance of survival. Seeing the CT report, Ahmedabad surgeons had doomed him for palliative care already.

On table- huge vascular lesion, multiple blood vessels direct branches from aorta and IVC. Using a multiclip applicator and stand by 3 bottles blood with 2 anaesthetists around, dared to open the case. To my surprise it was a 8x10x9 cms mass cystic well circumscribed with lots of vessels around, abutting the spleen or kidney or pancreas.

The patient is cured of the disease and reported HPR is NON FUNCTIONALADENOMA.