Oral melanoma and other pigmentations: when to biopsy?

Oral pigmentations (OPs) are often neglected, although a meticulous examination of the oral cavity is important not only in the diagnosis of oral melanoma, but also for the detection of important clinical findings that may indicate the presence of a systemic disease. OPs may be classified into two major groups on the basis of their clinical appearance: focal and diffuse pigmentations, even though this distinction may not appear so limpid in some cases. The former include amalgam tattoo, melanocytic nevi, melanoacanthoma and melanosis, while the latter include physiological/racial pigmentations, smoker's melanosis, drug-induced hyperpigmentations, postinflammatory hyperpigmentations and OPs associated with systemic diseases. We will discuss the most frequent OPs and the differential diagnosis with oral mucosal melanoma (OMM), underlining the most frequent lesions that need to undergo a bioptic examination and lesions that could be proposed for a sequential follow-up.

Patients' survival after free flap reconstructive surgery of head and neck squamous cell carcinoma: a retrospective multicentre study.

Head and neck squamous cell carcinoma of the (HNSCC) represents approximately 5% of malignant tumours in Italy. HNSCC are commonly treated with surgery or radiotherapy, or a combination of such therapies. The objectives of treatment are maximum cure rate balanced with organ preservation, restoration of form and function, reduction of morbidities and improvement or maintenance of the patient's quality of life. Immediate reconstructive surgery: local, regional or free flaps are now widely advised in the treatment of these patients. Microsurgical transfer requires expertise, is time and resource consuming, and as a whole requires substantial costs. These considerations introduce some concerns about the wide or indiscriminate use of free flap reconstructive surgery. When considering cost-benefit outcomes of such treatment, the main objective is undoubtedly, survival. This data is underreported in the current literature, whereas functional outcomes of free flaps have been largely diffused and accepted. This study collects data from 1178 patients treated with free flap reconstructive surgery following ablation of HNSCC in a group of Italian tertiary hospitals, all members of the Head & Neck Group affiliated with the Italian Society of Microsurgery. According to many authors, free flap surgery for HNSCC seems to be a beneficial option for treatment even in terms of survival.

Recovery of swallowing function following surgery for advanced buccopharyngeal carcinoma.

More than 20 years have passed since the introduction of surgical techniques based on distal myocutaneous flaps or microvascular flaps in the reconstruction after head and neck cancer resections. The experience gained from the beginning of these techniques until today, has improved the possibility to better predict functional impairment of swallowing in patients and its possible recovery. This contributes to a better counselling of the patient and better prediction concerning his/her quality of life. Despite the time passed and good progress in the development of microsurgical techniques, the literature shows that many differences still remain among Authors concerning choice of flap and its inset in relation to the anatomical sites and the extent of resection. Many other variables may condition post-operative swallowing (pre- or post-operative radiotherapy, general conditions of the patient ...) thus contributing to a more difficult comparison of the different series reported in the literature. Personal experience is based upon surgical treatment in >60 patients with advanced bucco-pharyngeal cancer, all of whom evaluated post-operatively by video-endoscopy and video-fluoroscopy. In summary, data collected both from personal experience and the literature show that difficulties still remain in correct evaluation of swallowing in these patients. This is mainly due not only to lack of a commonly accepted scheme of classification to quantify the anatomical defect but also to differences between Authors concerning choice of the type of flap and the mode of inset.

[Non-endoscopic minimally invasive thyroidectomy in papillary carcinoma. Our experience]. / La tiroidectomia mini-invasiva non endoscopica nel carcinoma papillifero. Nostra esperienza.

INTRODUCTION: Minimal access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach in a group of patients with papillary thyroid carcinoma. METHODS: A total of 15 female patients with a thyroid nodule, not exceeding 2 cm, proven to be a papillary thyroid carcinoma at preoperative evaluation, underwent a total thyroidectomy with non endoscopic minimally invasive approach. RESULTS: None of the patients presented intraoperative central lymphnode involvement. The cytologic preoperative diagnosis was confirmed by histology in all cases. One case of transient recurrent nerve palsy was observed immediately after surgery. No permanent nerve lesions were documented at 4 months. The hospital stay ranged from 48 to 72 hours. The iodine 131 uptake ranged from 0 to 2.13%, similar to that obtained with open thyroidectomy. All patients were satisfied for cosmetic result. CONCLUSIONS: The preliminary results of this study showed that non endoscopic minimally invasive thyroidectomy could be proposed in patients with T1 papillary carcinoma. In our experience the results obtained with this technique are similar to that obtained with open thyroidectomy, with the great advantage of a minimal neck wound and shorter hospital stay. However a higher number of cases and a longer follow-up are needed to confirm the safety of this procedure on the management of papillary cancer of the thyroid.

[Atypical partial tracheolaryngectomy associated with circular pharyngectomy followed by flap reconstruction for dedifferentiated papillary carcinoma of the thyroid gland]. / Tracheolaringectomia parziale atipica associata a faringectomia circolare seguita da ricostruzione con lembo alt per carcinoma papillifero dedifferenziato della tiroide.

The management of the extensive malignancy of the hypopharynx generally combines with total laryngectomy. The authors report a case of scanty differentiated papillary thyroid carcinoma, extended to the hypopharynx, with partial involvement of thyroid, cricoid and first tracheal ring cartilage and unilateral vocal fold palsy treated with an "atypical" partial tracheo-laringectomy combined with total circular pharyngectomy. The defect has been replaced with an antero lateral tight free flap suitably modeled to restore the pharyngeal and laryngeal lumen. A modified Montgomery T- tube has been inserted to avoid larynges-tracheal stenosis. This unusual technique allowed to restore a stable airway and satisfying deglutition and an adequate voice. With this case presentation the authors want to subline that when the tumor type is less aggressive than squamous cell carcinoma, it is possible to perform a partial larynx preservation also in the case of circular pharyngectomy. Obviously the residual laryngeal skeleton have to be sufficient to restore laryngeal lumen.

Videofluoroscopy and videoendoscopy in evaluation of swallowing function in 31 patients submitted to surgery for advanced buccopharyngeal carcinoma.

Swallowing function has been evaluated by means of videofluoroscopy and videoendoscopy in 31 patients submitted to surgery for local extended bucco-pharyngeal carcinoma. Aim was to better predict functional deficits and subsequent recovery perspectives of patients as far as concerns swallowing. In 30 patients, surgery was combined with radiotherapy, pre-operative in 6 cases and post-operative in 24. Site and extension of resection were defined using Urken's classification of hard and soft tissue deficits. In 3 cases, resection included half of tongue base and was followed by direct closure of the surgical defect. In 4 cases, the entire hemitongue (hemibody and hemibase) was resected and repair was performed with a free flap. In 5 cases, the whole tongue base was resected (posterior glossectomy). In 2 of these, direct closure of the gap was performed while the other 3 received a free flap. Another 3 cases required resection of the entire mobile tongue with corresponding buccal floor. All were repaired with free flaps. In 6 cases, resection comprised half the tongue base and adjacent tonsillar fossa and was performed using a transmandibular approach (demolitive in 3 cases, reconstructive in 3). Of these patients, 3 received direct closure and 3 reconstruction with a free flap. In 4 patients, resection included the tonsillar fossa and soft palate while in 5 other patients the whole soft palate was resected in addition to the tonsillar fossa. All these 9 patients received repair with free flaps. The remaining patient underwent resection of the entire oro-hypopharyngeal posterior wall, reconstructed with a free flap. During video-endoscopy examination, both liquid and soft meal ("pudding") were given to patients. Diagnostic parameters studied were: grade of pharyngo-laryngeal sensitivity, latency in onset of pharyngeal swallowing reflux, drop of the bolus in pre-swallowing phase, grade of the pharyngeal residual, inhalation and pooling of saliva. Data collected may be usefully employed not only in predicting the type and grade of swallowing deficit related to the extension of resection and repair technique used, but could also be helpful in the choice of the most appropriate behavioural procedure of rehabilitation for the patient.

Clinical outcome of extramedullary plasmacytoma.

BACKGROUND AND OBJECTIVE: The aim of this study was a retrospective analysis of the presenting features of extramedullary plasmacytoma, its response to therapy and its clinical course. DESIGN AND METHODS: Forty-six cases diagnosed between August 1970 and June 1993 were carefully reviewed. The follow-up was continued until June 1998 and the median observation time was 118 months. RESULTS: The disease was most frequently localized in the upper airways (37/46; 80%), with the mass limited to a single site in all but seven patients in whom two contiguous sites were involved. Other localizations were the lymph nodes, thyroid, skin, stomach, and brain. The clinical symptoms were related to the site of presentation, and the median time between appearance and diagnosis was 7.5 months. The median age at diagnosis was 55 years (range 16-80), with 14 patients (30%) being under 50 years old. The disorder was approximately twice as common in males as in females. Ten patients (21%) had a monoclonal component. The therapeutic strategy varied, although the most frequent form of treatment was local radiotherapy. Thirty-nine patients (85%) achieved complete remission (CR), five (11%) a partial remission (PR) and two (4%) did not respond to therapy (NR). Local recurrence (LR) or recurrence at other sites (ROS) occurred in 7.5% and 10%, respectively. Seven patients (15%) developed multiple myeloma (MM), characterized by multiple sites of osteolysis in almost all cases with soft tissue involvement in some of them. The 15 year survival rate was 78%. INTERPRETATION AND CONCLUSIONS: This review of a relatively large series of patients confirms the favorable prognosis of EMP when treated locally by irradiation and/or surgery.

Cell proliferation as an independent predictor of survival for patients with advanced nasopharyngeal carcinoma.

Commonly used clinical and pathologic criteria are often of limited value in predicting the outcome of patients with undifferentiated nasopharyngeal carcinoma, and new parameters related to the biology of growth of neoplastic cells are still required for better definition of the aggressiveness of these tumors. The prognostic significance of DNA ploidy, measured by image cytometry on isolated cells, and of the mitotic index, proliferating cell nuclear antigen, and p53 protein, all measured by image cytometry in histologic sections, were evaluated on archival tumor tissues from 53 patients with Stage III or IV nasopharyngeal carcinomas. Patients were staged according to the criteria of the International Union Against Cancer and were irradiated according to a conventional radiotherapy schedule. No significant associations were found between biologic parameters and clinical features. Only the stage and the mitotic index were related to patient survival, and, when examined in a proportional hazard regression analysis, both provided independent information. When patients with compromised skull and/or cranial nerves (T4 tumors), who had a very short survival, were eliminated from the analysis, only the mitotic index and proliferating cell nuclear antigen allowed discrimination of a subset of patients with poor prognoses. This study shows that the assessment of cell proliferative activity can provide useful information for better predicting the clinical course of high-risk patients with nasopharyngeal carcinomas and improve therapeutic strategies.

[Cytokeratin and vimentin expression in laryngeal squamous cell carcinoma]. / Espressione delle citocheratine e della vimentina nel carcinoma della laringe.

The present study employed immunohistochemical methods to study the cytokeratin (ck) and vimentin expression in 40 cases of laryngeal squamous cell carcinoma. Specific monoclonal isoform antibodies and mixes of antibodies vs. a specific molecule were used in order to determine what cytokeratins were present as accurately as possible. In this sampling two ck patterns were identified based on whether the ck pair 8/18 was present or not. The ck 8/18 positive cases were further broken down into three sub-groups based on the expression of one of the following: the ck 4/13 pair, ck 1/10 pair or vimentin. A statistically significant relationship was found between these sub-groups, the site at which the neoplasm arose and the tendency toward regional metastases. Moreover, it was found that the presence of ck 13 in a squamous cell carcinoma is correlated with the less aggressive forms, as indicated in the literature.

[External radiotherapy in early stage squamous cell carcinoma of the supraglottic larynx. Report of 28 cases]. / Il trattamento radiante nel carcinoma iniziale (T1-T2N0) sopraglottico. Revisione di una casistica di 28 casi.

The Authors reviewed a group of 28 pts with early-stage supraglottic carcinoma (T1-T2N0), classified according to UICC (1987), and treated exclusively with radiotherapy (RT) between 1980 and 1991. Until 1990 RT was employed for such tumors when surgery was refused or controindicated, while since 1991 primary irradiation (with surgery in reserve) has been considered the treatment of choice. The total dose ranged from 66 to 70 Gy on the larynx and up to 50 Gy on neck nodes. RT was applied in a daily fraction of 2 Gy five times a week. No significant early complications were observed. Only 1 pt showed residual cronical oedema in the arytenoid region. In none of the pts was tracheostomy necessary. The local control rate obtained after 30 months was 85.7% (24/28). Salvage surgery (horizontal supraglottic laringectomy, HSL) was performed in 3 out of 4 pts with local failure and achieved complete control of the disease. In the last pt the surgery was controindicated because of poor general health conditions. The actuarial survival rate after 5 years is 86.2%. The present series was compared to a group of 152 pts with T1-T2N0 supraglottic cancer treated surgically (HSL) at the same Istitution. In these pts local control and the actuarial survival rates are 85.6% and 89% respectively. According to recent Literature data, the present findings confirm that RT may be administered for the treatment of selected early stage (T1-T2N0) supraglottic squamous cell carcinoma of the larynx with oncologic results equivalent to those obtained with radical surgery. The importance of imaging techniques (TC, MRI) in the correct staging of the tumor is emphasised.

[Extramedullary plasmocytoma (EMP) of the head and neck: a series of 22 cases]. / Plasmocitoma extramidollare (P.E.M.) della testa e del collo: considerazioni su 22 casi.

Plasmacytoma is a rare neoplastic disorder arising from B-cell series lymphocytes. It can develop in three clinical variants: a) Multiple Myeloma (M.M.); b) Solitary Plasmacytoma of the bone; c) Extramedullary Plasmacytoma (EMP). EMP generally occurs in the submucosal tissue of the upper airways (80% of cases). This paper reports 22 cases of EMP of the head and neck observed in the last 20 years and reviews pertinent Literature. Four of our cases were located in the nasopharynx, four in the oropharynx and five in naso-sinusal sites. More rarely, the lesion occurred in the larynx (2 cases) or in the oral cavity (3 cases). In 4 patients multiple localizations in the upper airways were observed. Full evaluation was carried out in order to exclude disseminated disease. With the exception of 2 cases which were surgically treated, radiotherapy (RT) represented the treatment of choice in all patients, with doses ranging from 36 to 58 Gy. In 9 cases RT was administered after complete surgical resection. Follow-up time ranged from 13 to 167 months (mean 69.6). A partial response after treatment was observed in 4 cases. In only two of these cases neoplastic residue was observed (further RT allowed complete remission of the disease). In the other two cases, residual masses consisted in amyloid deposits. Three patients developed disseminated disease (MM) after a disease-free period ranging from 3 to 6 years. Five-year actuarial disease was 92%. Although surgery is generally considered a diagnostic tool, in our opinion local disease should always be removed surgically when surgery produces low morbidity. Surgical debulking of the lesion can increase the probability or local radiotherapeutic control.

[Radiotherapy of stage T1 carcinoma of the glottis. Analysis of prognostic factors in 154 patients]. / La radioterapia dei carcinomi della glottide nello stadio T1. Analisi dei fattori prognostici in 154 pazienti.

A retrospective study was carried out on a series of 154 patients affected with vocal cord cancer in stage T1 treated with definitive radiotherapy April, 1979, to November, 1991. According to the 1992 TNM classification (UICC), 121 patients were classified as stage T1a and 33 patients as stage T1b. All patients were treated using parallel opposed fields of a 60 cobalt unit. Field size ranged from 16 to 30 square centimeters and the dose from 4400 to 7000 cGy, but only 15 patients received less than 6400 cGy. All patients were treated with once-daily fractionation (200 cGy/day). Follow-up ranges from 25 to 123 months; the median is 63 months. We observed 14 local recurrences (9.0%), all but one within 36 months from the end of treatment. Ten of 14 patients (71.4%) were rescued by surgery (8 patients underwent total laryngectomy and 2 conservative surgery); 13 patients were lost for intercurrent deaths. The incidence of recurrences is 7.4% for T1a patients (9/121) and 15.1% for T1b patients (5/33). The total dose does not seem to be related to relapse rate since recurrences were found in 6.6% of patients after a dose < 6400 cGy and in 9.3% of patients who had received higher doses. In our experience, field size did not affect, treatment results (< 25 cm2: 7.5% recurrences, > 25 cm2: 10.7%). Besides lesion volume, the main prognostic factor was overall treatment time. The incidence of failure was 3 times lower (5.8%) in the patients who completed the treatment within 7 weeks than in the patients whose treatment lasted more than 8 weeks (16.6%).

[Ultrasound staging research of progressive pathology of the base of the tongue]. / L'indagine ecografica nello studio della patologia espansiva della base linguale.

Diagnosis of tongue tumours is often retarded mainly because tumours grow prevalently in deep muscular layers. A correct exploration of the region might be difficult solely employing clinical examination. Therefore, it would be useful to confirm the suspect of a neoplastic lesion at the base of the tongue with a promptly available imaging method. These considerations led us to evaluate ultrasonography (US) as a diagnostic tool for neoplastic lesions of this region. Initially 10 normal patients were studied in order to become familiar with US anatomy of the area. In a second phase our study involved 24 patients with diagnosed carcinoma of the tongue base and 26 patients with clinical suspect of neoplasm in the region. US examination was carried out with real-time equipment provided by a 5 Mhz convex transducer. Patients were examined in supine position with the neck hyperextended. Longitudinal, oblique and transverse scan of the submental region were obtained. The study showed that US gives detailed images of the floor of the mouth and the tongue. Neoplastic infiltration of the base of the tongue is clearly recognizable as a hypoechoic area. It was possible to detect masses ranging from 1.4 to 3.8 cm. In cases of larger lesions, US was useful in evaluating deep infiltration, whereas in other cases the method allowed the diagnosis of small lesions with submucosal growth. US did not proved to be highly reliable in the diagnosis of lesions confined to superficial planes (false negative results).(ABSTRACT TRUNCATED AT 250 WORDS)

A few remarks on the morphogenesis of the larynx.

After having reviewed the principal theories regarding the development of the larynx the authors performed a study on the morphogenesis of the above structure using four horizontally- and sagitally-sectioned human embryos. The conclusion of a study of these sections is that the LC constitutes the primordium of the laryngeal vestibule. From its lateral margin, caudally (Stage 19, Carnegie System), the primitive ventricles begin to form, while in the final stages the EL extends caudally enclosing a small cephalic infraglottic area and therefore completely separating the IG from the LC. Such findings in our opinion would confirm a different embryological derivation of the laryngeal cavity above and below the glottis.

5-fluorouracil + folinic acid with cisplatinum and bleomycin in the treatment of advanced head and neck squamous cell carcinoma.

Thirty-six patients with advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with a regimen including cisplatinum (CP) 30 mg/m2 i.v., 5-fluorouracil (5-FU) 500 mg/m2 i.v. bolus, folinic acid (FA) 200 mg/m2 i.v. in a continuous one-hour infusion, and bleomycin (B) 15 mg i.m. on the first and second days and repeated every 28 days. Thirty-three patients (25 with recurrent disease and 8 untreated) are evaluable for objective response. Of these, 4 (12%) achieved CR and 15 (45%) PR. All of the untreated patients responded. The mean duration of response in the patients with recurrent or metastatic disease was 5.5 months (range 2-10+). Remission of symptoms, such as pain and dysphagia, was obtained in 58% and in 44%, respectively. Subjective remission occurred almost exclusively in objectively responsive patients. The major side effects were leukopenia (55%) and nausea/vomiting (58%). This regimen is active in the treatment of advanced SCCHN. The quality of life may be improved in responsive patients.

Carcinoid tumours of the larynx: report of two cases.

Carcinoid tumour of the larynx is extremely rare. The increasing number of these lesions reported is due to the application of ultrastructural and immunological methods in the diagnosis. Two new cases of this malignant neoplasm are presented and discussed with particular reference to the difficulty in distinguishing carcinoids from other tumours of the larynx. The accurate pathological identification of the tumour is essential for treatment and prognosis.