Space Case Series

[Olowookere Devost]

Theinformation in this post may be old news to many of you, but I have been getting a lot of questions from readers asking why both MBA and Musketeer stopped at three books. The posts where I explained this are now a couple years old, so I thought I would revisit the issue. The reasons I stopped writing each series are quite different.

When I first started writing this series, I really thought it might run for a long time. But I also made the decision to write a sci-fi series where space travel was depicted as realistically as possible. My good friend, astronaut Garrett Reisman, who was overseeing the human space flight program at SpaceX, served as my technical advisor. I was very pleased with the world that I created, but it had an unforeseen side effect:

Even worse, the only way to go outside the moon base involved wearing a space suit, which provided its own limitations. An action sequence in a space suit is very different from one where the characters are free to move about in any way they would like.

I would have been happy to write more books in this series if the publisher had supported it. But it made far more sense to write books for a more supportive publisher like Simon & Schuster instead. There is little point in writing a book that you think no one is ever going to read.

I am a huge fan of your books and I always buy your books as soon as they come out. I was just wondering if you are gonna make a movie about any of your books? I know you were creating a spy school movie a few years ago but it got cancelled. Are you gonna still create the spy school movie or are scraping that idea? Thanks, Alec

Please i honestly do not care what its about just make another mba book as long as it

1. Has everyone in it

2. Has the Sjobergs screwing things up

3. Takes place at mba or mbb

4. Is as long as the others

Stuart,

I was reading your FAQ page and was wondering if you could ask your friend who became an ASTRONAUT to respond to this question: Was it hard to become an astronaut and do you enjoy it?

The reason I want to become an astronaut is because of your MBA series.

I know for a fact that Garrett enjoyed being an astronaut very much. The biggest issue was probably that he had to wait long periods of time before going into space and between trips to space, so much of being an astronaut is training.

I know you have said that the MBA series is over but could you possibly make a GN series of MBA and CT I have read all your books so what if you could make the GN of MBA and CT cause both books are awesome and it would be awesome if you could make the GN of both

if the series is about the moon base then just start a new one about bosco in the same canon. and if you choose to end another series could you please start this one again. just dont end spy school. btw this series was more intresting than spy school in some ways but i wont be able to believe that ss is over

Abstract: The buccal space is an often overlooked fascial space in the head and neck region. Presentation of a mass in the buccal space is rare, and patients are usually asymptomatic. There is a paucity of published surgical data on lesions in this space. A case series has been collated retrospectively of eleven patients presenting with a mass in the buccal space. Basic demographic data is recorded as well as cytologic and radiologic work-up prior to surgery. Eleven patients were retrospectively identified. All lesions were successful removed through a trans-oral approach. No complications were identified in this small series. No patient exhibited evidence of recurrence of their lesion during a 2-year follow-up period. Lesions of the buccal space are rare, and show diverse pathologies. The trans-oral approach can be used safely to achieve complete removal of lesions of the buccal space, with an adequate margin and minimal morbidity.

The buccal space was first described by Juvara in 1870 (1), and subsequently by Coller and Yglesias in 1935 (2). Further detail regarding its contents and enclosing fasciae was elucidated by Gaughran in 1957 (3). Tumours of this space, although rare, represent a diverse range of pathologies. This is a consequence of the anatomic features of the space, including its close relationship with a variety of tissue types and communication with other spaces of the head and neck.

The surgical approach to a tumour within the buccal space depends largely on the location of the mass within the space and the index of suspicion of malignancy. As more accurate characterization of buccal space masses has become possible through the use of imaging and fine needle aspiration cytology (FNAC), surgical techniques have evolved to allow adequate surgical margins, while minimizing the risk of cosmetic defects. There are minimal surgical case series on the buccal space, the pathologies it includes and surgical approaches. Furthermore there is controversy regarding the optimal surgical approach to this space. Here, we present eleven cases of buccal space tumour that demonstrate our experience with a trans-oral surgical approach. We also present a review of the differential diagnoses, investigative approach and surgical management options for a buccal space mass.

We access lesions of the buccal space via a trans-oral approach under general anaesthesia, using an oral nasotracheal tube, with the patient supine and neck extended. The use of a Boyle-Davis tonsil gag provides adequate access to the buccal space, and the approach can be further facilitated with the use of a cheek retractor. Lesions are excised with a Colorado monopolar dissection needle. This enables precise excision, with minimal tissue trauma, and haemostasis can be achieved at the same time. Suction tubing is taped to the cheek dissector to evacuate smoke.

The neural anatomy comprises the buccal branches of the facial and mandibular (V3) nerve. The former follows the parotid duct and has pierced the buccinators muscle in its final arborisations and hence is not injured by the dissection. The latter is responsible for internal mucosal sensation.

After appropriate haemostasis a capsular dissection of the lesion is performed taking care to avoid rupture with a blunt peanut dissection technique. The surgical assistant provides gentle external pressure to assist in tumour delivery. The incision is closed with interrupted 5.0 Vicryl Rapide sutures.

Eleven patients with buccal space tumours were identified in our series (Table 1). The mean age was 40.6. There were 4 males and 7 females. All patients with lesions of the buccal space presented above had favourable short- and long-term post-operative outcomes, with no recurrence of original disease at final follow-up two years later. There were no post-operative complications and in particular there were no facial nerve or parotid duct injuries.

A 61-year-old woman presented with a painless mass in the left cheek, noted during a routine dental examination. The mass was thought to be have been present for many years. A non-contrast magnetic resonance imaging (MRI) scan demonstrated a well-circumscribed lesion between the alveolar process of the left maxilla medially, the lateral wall of the left maxillary sinus and anterior surface of the ramus of the mandible posteriorly and the zygomatic process laterally; it showed low intensity signal on T1, and heterogeneous, high intensity signal on T2. FNAC was consistent with a pleomorphic adenoma, and post-operative histopathologic examination of the excised tissue confirmed this diagnosis.

A 13-year-old female presented with a painless 21 mm diameter mass in the left buccal space. A well-circumscribed heterogeneous lesion was seen on a T1-weighted gadolinium-enhanced MRI scan (Figure 1). FNAC and histology confirmed a pleomorphic adenoma, with typical pseudopodia formation.

A 48-year-old male presented with an asymptomatic, firm, mobile mass in the right cheek. MRI with gadolinium demonstrated a well-defined soft tissue mass anterior to the right buccinator, sandwiched between the buccinator, angle of the mandible and the lateral margin of the alveolus. It had a lower signal than parotid tissue and fat on T1, and a higher signal than that of parotid tissue on T2; fat suppression with gadolinium showed uniform, intense enhancement. FNAC yielded only blood. Histopathologic examination of the excised lesion showed a haemangioma characterized by well-demarcated lobules of dilated, thin-walled vascular spaces lined by endothelial cells, with bland cytologic features. There was some intervening fibrosis with chronic inflammation, and hemosiderin-laden macrophages consistent with previous haemorrhage. The post-operative course was uncomplicated.

A 33-year-old female presented with a slow-growing painful 15 mm diameter mass in the left buccal space. A soft compressible mass was palpable on bimanual palpation. A T2-weighted MRI sequences demonstrated a multilocular cystic lesion with high signal intensity. Surgical excision confirmed a microcystic lymphatic malformation.

A 29-year-old female presented with a painful 23 mm diameter mass in the right buccal space. FNAC yielded sheets and cohesive clusters of relatively uniform appearing epithelioid cells with finely vacuolated cytoplasm and monotonous round nuclei with prominent pseudoinclusions. A diagnosis of a low-grade neoplasm, possibly of salivary gland origin was considered. Post-operative histopathologic examination showed an encapsulated, lobulated tumour comprising sheets of relatively uniform cells with interspersed delicate vascular channels. There was infiltration of the capsule, and mitotic activity was seen. An extensive panel of immunohistochemical stains performed on both the cell block as well as the resected lesion demonstrated immunoreactivity with smooth muscle actin (SMA), and were negative for a large number of epithelial, myoepithelial, vascular, melanocytic and lymphoid markers. A diagnosis of a glomus tumour of uncertain malignant potential was made in conjunction with international consultation (see Acknowledgments).

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