Salvage surgery after unsuccessful radiotherapy in early glottic cancer.

Surgery is the main therapeutic option to control recurrent laryngeal cancer after radiotherapy (RT) relapse. Most RT-recurred cancer is treated aggressively; although, conservative laryngeal surgery was attempted in selected cases. Here, we report our experiences with salvage laryngeal surgery for early glottic cancers that did not respond to RT. We analyzed files from 1980 to 2006 and selected 173 patients surgically treated for a RT-failed early glottic carcinoma (stage I-II according to 2010 TNM: 114 T1N0, 59 T2N0). Among them, 47 patients (27%) underwent a salvage partial laryngectomy (SPL) and 126 (73%) had a salvage total laryngectomy (STL). When compared with initial T staging, we found 61% of lesions were up-staged, 31% had the same staged lesion, and only 8% were down-staged (according to rTNM). No statistically significant differences were found in terms of disease-free survival and overall survival when SPL and STL patients were compared. Univariate analysis showed that T, rT, and rTNM were prognostic factors for overall survival (p = 0.045, p = 0.028, and p = 0.037, respectively); yet, these significances were lost in multivariate analysis. Our results suggest that salvage surgery is feasible in most cases of RT-recurred early glottic cancer; although, a conservative approach achieves good oncological and functional results only in select RT-recurred patients.

Is elective neck dissection necessary in cases of laryngeal recurrence after previous radiotherapy for early glottic cancer?

OBJECTIVES: To assess the clinical utility of elective neck dissection in node-negative recurrent laryngeal carcinoma after curative radiotherapy for initial early glottic cancer. METHODS: A retrospective review was undertaken of 110 consecutive early glottic cancer patients who developed laryngeal recurrence after radiotherapy (34 recurrent T1, 36 recurrent T2, 29 recurrent T3 and 11 recurrent T4a) and received salvage laryngeal surgery between 1995 and 2005. RESULTS: Six patients presented with laryngeal and neck recurrence and underwent salvage laryngectomy with therapeutic neck dissection, 97 patients with recurrent node-negative tumours underwent salvage laryngeal surgery without neck dissection and only 7 underwent elective neck dissection. No occult positive lymph nodes were documented in neck dissection specimens. During follow up, only three patients with neck failure were recorded, all in the group without neck dissection. There was no significant association between the irradiation field (larynx plus neck vs larynx) and the development of regional failure. A higher rate of post-operative pharyngocutaneous fistula development occurred in the neck dissection group than in the group without neck dissection (57.2 per cent vs. 13.4 per cent, p = 0.01). Multivariate logistic regression analysis showed that early (recurrent tumour-positive, node-positive) or delayed (recurrent tumour-positive, node-negative) neck relapse was not significantly related to the stage of the initial tumour or the recurrent tumour. An age of less than 60 years was significantly associated with early neck failure (recurrent tumour-positive, node-positive). CONCLUSION: Owing to the low occult neck disease rate and high post-operative fistula rate, elective neck dissection is not recommended for recurrent node-negative laryngeal tumours after radiation therapy if the initial tumour was an early glottic cancer.

[Learning of the process of nursing diagnosis by nursing students. An experiment at the San Miniato School]. / Apprendimento del processo diagnostico infermieristico da parte degli studenti infermieri. Una sperimentazione nella Scuola di S. Miniato.

In order to guarantee the quality of health care, it is necessary that the care focus on patients' needs. This requires that care givers possess diagnostic competency skills that allow them to quickly identify the patients' needs, using suitable methods and instruments. In Italy, the development of diagnostic competency skills is generally overlooked in nursing schools; this is due in part to the lack of applied and experimental educational models in teaching and training. During the 1992-1993 year, a didactic teaching intervention to assist students in the acquisition of diagnostic skills was tested. The sample included all students in the third year class of the San Miniato nursing school. The Zanotti's model "Nursing as a stimulus for health-harmony" was used as framework. The purpose of the research was to test: (a) validity and reliability of a new needs' analysis model; (b) the effectiveness of a didactic method for the acquisition of such a model by the students. Students enhanced their skills in data assessment and shifted from the medical perspective to the nursing perspective in using those data to evaluate the patient's status.