Synchronous Parotid (Mammary Analog) Secretory Carcinoma and Acinic Cell Carcinoma: Report of a Case.

Mammary analogue secretory carcinoma (MASC) is a recently described low-grade salivary gland malignancy with histologic, immunohistochemical and molecular similarities to secretory carcinoma of the breast, including a specific t(12;15)(p13;q25) resulting in an ETV6-NTRK3 gene fusion. Ultrasound and magnetic resonance imaging frequently document a macrocystic structure. The main differential diagnosis of secretory carcinoma is with low grade acinic cell carcinoma (AciCC). The two can be differentiated with immunohistochemical stains for S100, mammaglobin, carbonic anhydrase VI and DOG-1; the identification of the specific translocation can help to characterize non-typical cases. We report a unique case of synchronous MASC and AciCC presenting in a parotid gland and discuss the implications of the correct identification of the two tumors.

The supraclavicular artery island flap (SCAIF) in head and neck reconstruction: an Italian multi-institutional experience.

The supraclavicular artery island flap (SCAIF) is a thin and pliable pedicled flap that is easy and quick to harvest. Thanks to its particular features and high reliability, it is best indicated for the elderly or most fragile patients. SCAIF is very versatile, as it can be used for reconstruction of oral cavity, oropharynx, hypopharynx, facial and cervical skin and tracheostomal defects. We began using this flap in four Italian tertiary referral centres, with several indications, both as first treatment and as salvage surgery. The aim of the study was to demonstrate the easy reproducibility of the flap among four different centres. A series of 28 patients underwent head and neck reconstructions with SCAIF with no recorded complications during flap harvesting. After the very first cases, harvesting time was approximately 45 minutes; 24 patients had successful flap integration at the recipient site, while the remaining 4 suffered from partial flap necrosis, two of whom needed revision surgery. Other minor complications were reported at the recipient site, always at the most distal and most delicate portion of the flap. Donor site was always closed primarily, with only three cases of partial suture dehiscence. We only selected the most fragile patients for SCAIF reconstruction, such as the elderly or those with one or more comorbidities; for this reason, we reported some serious systemic complications and one intraoperative death. SCAIF is an easy reproducible flap, with multiple possible indications. Its use as an alternative to free flaps in the head and neck region is nowadays under discussion. Its use should be encouraged among head and neck surgeons thanks to its various advantages.

Interventional sialendoscopy for radioiodine-induced sialadenitis: quo vadis?

Salivary gland toxicity is a common adverse effect of radioactive iodine (131I) for the treatment of thyroid cancers with a prevalence ranging from 2% to 67% of the 131I exposed population. Recently, sialendoscopy has been introduced as an attractive diagnostic and therapeutic tool for management of patients with radioiodine-induced sialadenitis that is unresponsive to standard medical treatments. The objective of the current review was to assess the impact of this procedure on outcomes in patients suffering from radioiodine sialadenitis. Overall, eight studies were included and 122 patients underwent 264 sialendoscopic procedures. Duct stenosis and mucous plugs were observed in 85.7% of endoscopic findings, supporting the role of ductal obstruction in the pathophysiology of radioiodine sialadenitis. In total, 89.3% of patients experienced complete or partial resolution of sialadenitis recurrences without any major adverse events, and parotidectomy was advocated in only 1 case. However, outcomes mainly concerned subjective reports and only two clinical experiences evaluated objective measurement with dissimilar results. Limited to few studies, xerostomia and obstructive symptoms responded differently after sialendoscopy. The optimal timing of salivary gland videoendoscopy needs to be further analysed in order to define the best management of radioiodine-induced obstructive sialadenitis.

Modern management of paediatric obstructive salivary disorders: long-term clinical experience.

Recent technological improvements in head and neck field have changed diagnostic and therapeutic strategies for salivary disorders. Diagnosis is now based on colour Doppler ultrasonography (US), magnetic resonance (MR) sialography and cone beam 3D computed tomography (CT), and extra- and intracorporeal lithotripsy, interventional sialendscopy and sialendoscopy-assisted surgery are used as minimally invasive, conservative procedures for functional preservation of the affected gland. We evaluated the results of our long-term experience in the management of paediatric obstructive salivary disorders. The study involved a consecutive series of 66 children (38 females) whose obstructive salivary symptoms caused by juvenile recurrent parotitis (JRP) (n = 32), stones (n = 20), ranula (n = 9) and ductal stenosis (n = 5). 45 patients underwent interventional sialendoscopy for JRP, stones and stenoses, 12 a cycle of extracorporeal shockwave lithotripsy (ESWL), three sialendoscopy-assisted transoral surgery, one drainage, six marsupialisation, and two suturing of a ranula. Three children underwent combined ESWL and interventional sialendoscopy, and seven a secondary procedure. An overall successful result was obtained in 90.9% of cases. None of the patients underwent traditional invasive sialadenectomy notwithstanding persistence of mild obstructive symptoms in six patients. No major complications were observed. Using a diagnostic work-up based on colour Doppler US, MR sialography and cone beam 3D TC, children with obstructive salivary disorders can be effectively treated in a modern minimally-invasive manner by extracorporeal and intracorporeal lithotripsy, interventional sialendoscopy and sialendoscopy-assisted transoral surgery; this approach guarantees a successful result in most patients, thus avoiding the need for invasive sialadenectomy while functionally preserving the gland.

Electrochemotherapy in the treatment of metastatic malignant melanoma: a prospective cohort study by InspECT.

BACKGROUND: (ECT) is an effective local treatment for cutaneous metastasis. Treatment involves the administration of chemotherapeutic drugs followed by delivery of electrical pulses to the tumour. OBJECTIVES: To investigate the effectiveness of ECT in cutaneous metastases of melanoma and to identify factors that affect (beneficially or adversely) the outcome. METHODS: Thirteen cancer centres in the International Network for Sharing Practices on Electrochemotherapy consecutively and prospectively uploaded data to a common database. ECT consisted of intratumoral or intravenous injection of bleomycin, followed by application of electric pulses under local or general anaesthesia. RESULTS: In total, 151 patients with metastatic melanoma were identified from the database, 114 of whom had follow-up data of 60 days or more. Eighty-four of these patients (74%) experienced an overall response (OR = complete response + partial response). Overall, 394 lesions were treated, of which 306 (78%) showed OR, with 229 showing complete response (58%). In multivariate analysis, factors positively associated with overall response were coverage of deep margins, absence of visceral metastases, presence of lymphoedema and treatment of nonirradiated areas. Factors significantly associated with complete response to ECT treatment were coverage of deep margins, previous irradiation of the treated area and tumour size (< 3 cm). One-year overall survival in this cohort of patients was 67% (95% confidence interval 57-77%), while melanoma-specific survival was 74% (95% confidence interval 64-84%). No serious adverse events were reported, and the treatment was in general very well tolerated. CONCLUSIONS: ECT is a highly effective local treatment for melanoma metastases in the skin, with no severe adverse effects noted in this study. In the presence of certain clinical factors, ECT may be considered for local tumour control as an alternative to established local treatments, or as an adjunct to systemic treatments.

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.

The value of electrochemotherapy in the treatment of peristomal tumors.

Electrochemotherapy (ECT) holds promise as a minimally invasive palliative tool for selected patients with peristomal tumors. We present the favorable short-term outcome of three patients (two with head and neck cancer, one with gastric cancer) successfully palliated by ECT. Treatment effectiveness and clinical benefit for patients with unresectable stoma recurrence need to be confirmed in future multicenter studies.

Surgical treatment of hypopharyngeal cancer: a review of the literature and proposal for a decisional flow-chart.

Surgical resection is one of the standard therapeutic choices for the treatment of hypopharyngeal cancer, whether or not combined with postoperative radiotherapy. The type of operation depends on the extension of the lesion and the subsites involved and often requires some form of reconstruction. Reconstructive strategies depend on whether the larynx, or part of it, has been preserved. We believe that the decisional flow-chart of the reconstructive methods after hypopharyngeal cancer resection should be based not only on the extent of resection, but also on the subsites involved. This report presents a literature review on the management of cancer of the hypopharynx and a proposal for a surgical decisional flow-chart.

Advanced carcinoma of the hypopharynx: functional results after circumferential pharyngolaryngectomy with flap reconstruction.

Surgical treatment of advanced cancers of the hypopharynx inevitably impairs swallowing, respiration and phonation. The purpose of this study was to analyze the functional results after circumferential pharyngolaryngectomy (CPL) and flap reconstruction, in order to offer decisional guidelines for the choice of the most effective reconstructive method. We performed a retrospective analysis on the medical records of patients submitted to reconstructive surgery after CPL from July 1991 to November 2011. 75% of the 94 patients underwent reconstruction with a free flap (group A), while 25% underwent reconstruction with a pedicled flap (group B); 80% of patients in group A and none in group B were discharged with a free diet; 14% of patients in group A and 26% in group B were unable to resume oral feeding and were discharged with NG-tube or PEG. None of the patients acquired a satisfactory oesophageal voice; 17% of patients in group A and 7% in group B underwent voice restoration with tracheo-oesophageal voice-prosthesis. In conclusion, free flaps should be considered the first choice for reconstruction of the hypopharynx after CPL because of the better functional results obtained. Pedicled flaps represent a valid alternative in patients with contraindications to microvascular surgery.

Functional outcomes in patients reconstructed with flaps following surgery for hypopharyngeal cancer.

Following oncologic surgery for advanced cancer of the hypopharynx, primary closure of the defect of the upper aerodigestive tract is difficult to achieve. Usually locoregional or free flaps are used, the choice being determined by the extent of the surgical defect, the expertise of the surgeons and the general condition of the patient. Aim of the present study was to evaluate the functional recovery of patients who underwent surgical reconstruction, following hypopharyngeal cancer resection, with pedicled or free flaps. A retrospective analysis was conducted examining hospital records of the patients submitted to surgical treatment for hypopharyngeal cancer and reconstruction with pedicled or free flaps in the period between January 1995 and July 2004. Free flaps showed less severe complications, shorter hospital stay, less time to resume oral feeding compared with pedicled flaps. For this reason, we consider free flaps the gold standard for hypopharyngeal reconstruction, while pedicled flaps as the pectoralis major or other locoregional flaps should be used in those cases in which free flap reconstruction is not feasible or contraindicated.

[Laparoscopic harvest of the jejunal free flap for cervical esophageal reconstruction]. / Il prelievo laparoscopico di un lembo libero di digiuno per la ricostruzione dell' esofago cervicale.

The jejunal free flap is a standard technique in the reconstruction of hypopharyngeal and cervical esophageal defects. Conventional harvesting of the jejunal segment is performed with midline open laparotomy, which is associated with complications including prolonged ileus, abdominal pain, wound infection or dehiscence. Laparoscopic resection of the small intestine is a well documented surgical technique. Two different methods of laparoscopic harvest of a jejunal autografts for their cervical implantation have been already described. In both cases, low complication rate and better postoperative course have been observed in the patients treated. During the last 10 years, we have performed 43 circumferential pharyngoesophageal resection for advanced hypo-pharyngeal cancer followed by reconstruction with a free flap of jejunum. All but one the jejunal segments have been harvested with conventional open laparotomy. In the last patient of this group, laparoscopic harvest of the jejunal segment has been successfully performed. In this paper, we describe the laparoscopic technique used and we compare the postoperative course of this patient with those of the patients treated with conventional technique.

[Preliminary results in the use of polydimethylsiloxane textured elastomers (Bioplastique) in the treatment of leakage around tracheoesophageal voice prosthesis]. / Utilizzo degli elastomeri testurizzati di polidimetilsilossano (Bioplastique) per il trattamento dell'incontinenza perivalvolare nei pazienti portatori di protesi fonatoria tracheo-esofagea.

Leakage around the prosthesis is one of the worst problems afflicting patients fitted with tracheoesophageal (TE) voice prosthesis. Removing the prosthesis for a few days can reduce the size of the fistula, or the leakage may be eliminated simply by replacing the prosthesis. In cases that are refractory to such treatment, the perifistular injection of different types of autologous, heterologous or alloplastic substances has been proposed. A new kind of silicone, previously available abroad, has recently appeared on the Italian market as well; constituted by polydimethylsiloxane textured elastomers (Bioplastique) for soft tissue implants, it appears to guarantee excellent standards of long-term safety and stability. Three patients fitted with Provox2 tracheoesophageal voice protheses who had been experiencing leakage for about 4 months underwent Bioplastique implant procedures. The correction of the fistula size was easy to accomplish and well tolerated by the patients. There was no sign of inflammation, formation of granulomas or other pathological modifications, and the size of the fistula, together with its fluid-tightness, remained stable in time. From our point of view, the Bioplastique implant appears to provide valid and effective treatment of gaping TE fistulas.

Voice restoration after circumferential pharyngolaryngectomy with free jejunum repair.

Speech restoration after circumferential pharyngolaryngectomy with free jejunal repair for advanced tumors of the hypopharyngo-esophageal tract remains a difficult problem to solve. We report here the results of secondary voice restoration in six patients who received a Provox 2 type prosthesis and intensive speech therapy after circumferential pharyngolaryngectomy with free jejunum repair. No patient had operative or post-operative complications due to insertion of the prosthesis. No patient had to have the prosthesis removed during the follow-up (8 to 14 months). Analysis of some acoustic parameters of voice (fundamental frequency, waveform perturbations) and qualitative characteristics of speech (intelligibility, pleasantness and acceptability) demonstrated that all the patients were able to produce satisfactory speech after tracheojejunum puncture and speech therapy and were satisfied with their own ability to communicate. Our results are reassuring and we therefore advise that in patients undergoing free jejunum flap reconstruction of the hypopharyngo-esophageal tract voice restoration should be attempted by placing a voice prosthesis through a secondary tracheo-esophageal puncture and providing intensive speech training.

Reconstruction of intrathoracic oesophagus using tubular lateral thigh free flap.

The gastric pull-up or pharyngogastroplasty is the most widely used technique in reconstructing the digestive tract in cases of distal oesophageal tumours. This operation consists of drawing the stomach or part of it up through the chest and mediastinic region to the neck where a mucosal anastomosis with the residual pharyngeal tract is made. The most feared complication is proximal necrosis of the gastric stump with salivary fistulae usually followed by a mediastinitis. In the presence of such a complication the surgeon must tackle the challenge of reconstructing the missing part of the intrathoracic digestive tract. We describe the case of a patient in whom the missing intrathoracic oesophagus, following complete necrosis of a previously performed pharyngogastroplasty, was reconstructed using a revascularized lateral thigh free flap.

[Revascularized jejunum loop in hypopharyngeal reconstruction: oncological and functional results]. / L'ansa digiunale rivascolarizzata nella ricostruzione dell'ipofaringe: risultati oncologici e funzionali.

The aggressiveness of hypopharyngeal cancer makes broad resectioning of the circular pharyngolaryngoesophageal segments necessary, followed by reconstruction to restore the anatomical gap created as fully as possibly creating a neoesophagus with thin walls that can easily be released. Over the years several procedures have been fine tuned for reconstruction of the upper digestive tract employing transposed viscera, miocutaneous pedunculated flaps, revascularized fascio-cutaneous or visceral free flaps. Currently the revascularized jejunum loop is one of the most commonly used methods in the reconstruction of the hypopharynx. Its popularity is due to some anatomical and physiological advantages: it requires transposition of a brief intestinal tract anatomically well adapted to the reconstruction site, ensuring rapid functional recovery. The authors report the oncological and functional results obtained in 25 patients who underwent circular pharyngolaryngectomy followed by reconstruction with a revascularized jejunum loop. The percentage of transplant survival was 90% and local and general complications were reduced to a minimum. The functional results--both in terms of deglutition and phonation--were satisfactory while patient survival (6-37 months follow-up) was in line with that reported by other authors for the same tumor (47%). Although prognosis for hypopharyngeal-esophageal neoplasms is still quite poor, this experience shows that circular pharyngolaryngectomy followed by reconstruction with autotransplant of the jejunum is an excellent choice since it offers the patient a prompt, acceptable functional recovery and a fair quality for his remaining life.

Integrated treatment in locally advanced carcinoma of the oropharynx.

BACKGROUND AND OBJECTIVES: Oropharyngeal carcinoma tends to be aggressive and deeply infiltrative of nearby sites, with an high incidence of lymph node metastases. The last treatment decision generally depends on the stage of the lesion and the patient's general status. Oropharyngeal tumor is generally treated by integrated treatments. METHODS: We retrospectively studied 115 patients with locally advanced oropharyngeal tumors treated in our institution with combined therapies compare the results in two different groups of patients (surgery plus radiotherapy and chemotherapy plus radiotherapy). RESULTS: The 3-year overall survival rate in patients who underwent surgery plus radiotherapy was 82% and in those who underwent chemotherapy plus radiotherapy was 49%. CONCLUSION: The results suggest that surgery followed by radiotherapy seems to be the best treatment in the case of locally advanced oropharyngeal tumor.

The role of computed tomography in the preoperative assessment and follow-up of oromandibular reconstruction with microvascular osteomyocutaneous free flaps.

OBJECTIVE: To investigate the capacity of helical CT in the pre- and post-operative management of oromandibular reconstruction of patients with oropharyngeal carcinoma using microvascular composite free flaps. MATERIALS/METHODS: Thirty-four patients with oropharyngeal cancer were examined by helical CT and nine (six men and three women) submitted to oromandibular reconstruction. The osteomyocutaneous flaps used for reconstruction were taken from the iliac crest in six cases and from the fibula in three cases. All patients were examined by CT 1 - 4 days postoperatively and then at 6 monthly intervals. Double helical scans were performed in all cases, with slices of 2 - 3 mm for primary lesion studies and 5 mm for lymph node staging, pitch >/=1 and RI=1. Multiplanar (MPR) and 3D reconstructions were obtained from pre- and postoperative CT examinations. RESULTS: Preoperative CT showed massive bone infiltration in six of the nine surgical patients and marginal infiltration in three. These findings were confirmed histologically. There were no false negatives. The immediate postoperative examination showed correct flap positioning in eight of nine cases. The flap underwent ischemic necrosis in two cases; CT showed very early signs of bone ischemia in both. CT detected two cases of recurrence after about 1 year. CONCLUSIONS: Axial CT permitted adequate assessment of the extent of mandibular infiltration and detected early ischemic complications and distant recurrences. Integration with MPR and 3D reconstructions simplified the choice of flap type and size and enabled the postoperative assessment of correct flap positioning. This helped the surgeon plan subsequent rehabilitation with osseo-integrated implants.

Proliferative characteristics of head and neck tumors. In vivo evaluation by bromodeoxyuridine incorporation and flow cytometry.

Cell proliferation of head and neck cancers was studied in 52 patients using in vivo bromodeoxyuridine (BUDR) incorporation. Patients received 250 mg BUDR intravenously several hours prior to biopsy of the tumor tissue. Bivariate flow cytometry was used and enabled us to rapidly obtain DNA ploidy, labelling index (LI), DNA synthesis time (TS) and tumor potential doubling time (Tpot). This method was found to be suitable to obtain complete cytokinetic data in 46/52 (88.5%) patients. The mean BUDR LI was 7.9% (range 2-18%); mean TS was 11.6 h (range 6-28.5 h); mean Tpot was 5.7 days (range 2-30 days). BUDR LI and TS were significantly correlated with histological differentiation grading: G3 tumors showed higher LI values and shorter TS values than G1/G2 tumors. A similar correlation was found between LI or TS and tumor dimensions. Tpot was also significantly lower in larger tumors, such as in those with a higher grading. No significant correlation was found between LI or TS and DNA ploidy (50% of the tumors in our series were DNA aneuploid), while Tpot was found to be 10 days in diploid tumors, compared to only 6.3 days for the aneuploid tumors (p < 0.05). All cases with documented lymph node involvement (N+) showed significantly higher LI, and shorter TS and Tpot values if related to nodal free ones (Tpot = 10 days in N+ patients and 6.3 days in N- patients; p < 0.05). The results of this study suggest that the method employed is clinically feasible and could be a useful aid in defining the prognosis of head and neck cancer patients.(ABSTRACT TRUNCATED AT 250 WORDS)