Transoral non-robotic surgery for oropharyngeal squamous cell carcinoma.

PURPOSE: This retrospective cohort study aims to evaluate the clinical, oncological, and functional outcomes of transoral non-robotic surgery for oropharyngeal squamous cell carcinoma (OPSCC). MATERIALS AND METHODS: Data from 131 patients with surgically treated OPSCC (2010-2022) were analyzed. Patients who underwent exclusively transoral surgery were included in the study. The surgeries were performed under microscopic or endoscopic guidance and either a CO2 laser or an ultrasound/radiofrequency scalpel was used as a cutting instrument, depending on the characteristics and location of the tumor. Functional outcomes were assessed in terms of length of hospital stay, tracheostomy rate, duration of feeding tube dependency and complications. Survival outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS). RESULTS: Of 74 included patients, transoral surgery demonstrated safety with no major complications. Tracheotomy was performed in 51.4 % of cases, and was maintained for a median of 10 days. Complete swallowing recovery was restored in 97.3 % of cases, after a median of 5 days. The median length of hospital stay was 12 days. At 5 years, OS was 68.2 %, PFS was 58.2 % and DSS was 83.6 %. CONCLUSION: The study confirms the safety and efficacy of a transoral approach for OPSCC. Having the capability to utilize and access a variety of tools provides the opportunity to tailor the technique to the individual patient and specific circumstances.

Palatoglossus Muscle and T4 Category in the Eighth Edition of TNM Staging System for OPSCC.

OBJECTIVE: The present study challenges the appropriateness of considering invasion of the palatoglossus muscle (PGM) as a criterion for staging oropharyngeal squamous cell carcinoma (OPSCC) as T4. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary University Hospital. METHODS: This retrospective study included nonmetastatic OPSCC patients treated with curative intent at the University of Trieste, Italy from 2015 to 2021. Patients were categorized into 4 groups: (1) tumors classified as T1-T2 by both International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC)-TNM; (2) T1-T2 tumors upgraded to T4 solely by UICC due to oropharyngeal PGM infiltration; (3) T1-T2 tumors upgraded to T4 by both UICC and AJCC due to oral PGM infiltration; (4) tumors classified as T3-T4 by both UICC and AJCC. Kaplan-Meier analysis estimated overall survival (OS) and disease-free survival (DFS). Multivariable Cox models, adjusted for clinical factors, assessed the impact of palatoglossus invasion on outcomes over 5 years. RESULTS: A total of 121 consecutive patients with primary OPSCC were included (median [interquartile range] age 65 years [58-74]; 63% male). While patients with upgraded T4 category due to infiltration of the oral portion of the PGM exhibited a prognosis superimposable on that of other patients with advanced stage disease, those with upgraded T4 category due to infiltration of the oropharyngeal portion of the PGM displayed OS and DFS comparable to T1-T2 patients. CONCLUSION: Our findings highlight that invasion of the oropharyngeal portion of the PGM may not be a suitable criterion for staging OPSCC as T4. Further research involving larger and independent patient cohorts is strongly encouraged to corroborate these observations.

MRI and frozen section evaluation of mylohyoid muscle in determining surgical approach for T2-T3 floor of the mouth cancer.

PURPOSE: The choice of surgical approach for floor of the mouth (FOM) cancer, particularly for intermediate-stage tumors (cT2-cT3), remains controversial. This study aims to evaluate a method considering mylohyoid muscle (MM) invasion as a determinant for surgical approach selection, utilizing magnetic resonance imaging (MRI) preoperatively and frozen section (FS) analysis intraoperatively. METHODS: This observational retrospective cohort study analyzed patients undergoing surgical resection of cT2 and cT3 FOM squamous cell carcinoma (SCC) between January 2013 and June 2023. MM infiltration assessed by preoperative MRI determined the surgical approach: clear infiltration led to compartmental surgery (CS), while doubtful or absent infiltration led to transoral surgery (TOS). Conversion from TOS to CS occurred intraoperatively based on macroscopic evidence or positive FS. Data collected included demographic, clinical, surgical, and pathological variables. Survival analysis was conducted using Kaplan-Meier method. RESULTS: Among 44 patients included, majority had cT2 tumors (59.1%). MM resection was necessary in 22.7% of cases. Overall survival (OS) and progression-free survival (PFS) did not significantly differ between TOS and CS groups. Radiological depth of invasion (rDOI) < 10 mm is correlated with MM preservation in 89% of cases, while rDOI > 10 mm is correlated with MM resection only in 23.8% of cases. Pathological depth of invasion (pDOI) discrepancies were observed in the two groups: in CS group is shown a higher pDOI (> 10 mm) confirmation (90%). Surgical complications and functional outcomes differed between TOS and CS groups. CONCLUSION: Considering MM invasion for surgical approach selection in cT2-cT3 FOM tumors appears oncologically safe, with better functional outcomes in muscle preservation. Preoperative MRI for MM assessment combined with intraoperative FS analysis provides reliable guidance for surgical decision-making.

Prognostic role of the MRI-based involvement of superior pharyngeal constrictor muscle in oropharyngeal squamous cell carcinoma.

OBJECTIVES: The aim of this study was to determine the impact of the involvement of the superior pharyngeal constrictor muscle (SPCM) evaluated by magnetic resonance imaging (MRI) on outcome in oropharyngeal squamous cell carcinomas (OPSCCs). METHODS: A retrospective study including consecutive patients with OPSCC treated with curative intent. RESULTS: A total of 82 consecutive patients with OPSCC met inclusion criteria. At multivariate analysis, patients with SPCM infiltration were at significantly higher risk of death (HR: 3.37, CI: 1.21-9.38) and progression (HR: 3.39, CI: 1.38-8.32). In a multivariate model conditioned on HPV status, a significantly higher risk of death and progression was observed by combining both SPCM and HPV status with patients harboring an HPV-negative OPSCC with SPCM infiltration showing the poorest outcome. CONCLUSION: MRI evidence of SPCM involvement significantly and independently increases the risk of death and progression in subjects with OPSCC. Considering both MRI-assessed SPCM infiltration and HPV status significantly improved risk stratification in these malignancies.

Otological Planning Software-OTOPLAN: A Narrative Literature Review.

The cochlear implant (CI) is a widely accepted option in patients with severe to profound hearing loss receiving limited benefit from traditional hearing aids. CI surgery uses a default setting for frequency allocation aiming to reproduce tonotopicity, thus mimicking the normal cochlea. One emerging instrument that may substantially help the surgeon before, during, and after the surgery is a surgical planning software product developed in collaboration by CASCINATION AG (Bern, Switzerland) and MED-EL (Innsbruck Austria). The aim of this narrative review is to present an overview of the main features of this otological planning software, called OTOPLAN®. The literature was searched on the PubMed and Web of Science databases. The search terms used were "OTOPLAN", "cochlear planning software" "three-dimensional imaging", "3D segmentation", and "cochlear implant" combined into different queries. This strategy yielded 52 publications, and a total of 31 studies were included. The review of the literature revealed that OTOPLAN is a useful tool for otologists and audiologists as it improves preoperative surgical planning both in adults and in children, guides the intraoperative procedure and allows postoperative evaluation of the CI.

Impact of time-to-surgery on survival and quality of life in oral cancer.

PURPOSE: To investigate the association between time-to-surgery (TTS) and overall survival (OS), disease specific survival (DSS) and quality of life (QoL) in patients with oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS: 116 patients with OSCC candidate to surgery were examined. TTS intervals starting from diagnosis (TTS-clinical-based) and from histological reports (TTS-biopsy-based) were calculated. The effects of TTS intervals and prognostic factors on 5-year OS and DSS were explored. RESULTS: In our cohort advanced T-categories OSCCs with TTS < 30 days showed a trend to have higher DSS rate (p = 0.049). Patients with TTS-clinical-based < 30 days showed better postoperative QoL. Positive surgical margins, nodal involvement (pN+), DOI >10 mm, invasive surgery and extra-capsular extension in pN+ were found to be significantly associated with a poor OS and DSS. CONCLUSIONS: TTS ≥ 30 days can adversely affect DSS, especially in the advanced T categories. Short TTS intervals resulted associated with a better postoperative QoL.

Is there a role for tumor volume in prediction of prognosis for oral cancer?

PURPOSE: New prognostic factors in oral squamous cell carcinoma (OSCC) (tumor-, host-, and environment-related) have been introduced recently to complete those traditionally considered. Among them, tumor volume (TV) could be the most interesting and applicable in clinical practice, considering the routine use of computed tomography in tumor staging. In this retrospective study we aimed to investigate whether a correlation exists among these new prognostic factors and survival outcomes. METERIALS AND METHODS: We collected data about 140 patients affected by OSCC who underwent primary surgery. Prognostic factors were collected and Overall Survival (OS), Disease Specific Survival (DSS) and Disease Free Survival (DFS) were estimated using Kaplan-Meier method; the Log-Rank test (Mantel-Cox) and Cox regression models were applied to investigate predictors of survival. RESULTS: The 5-year OS, DSS and DFS were 73.6 %, 89.2 % and 75.2 % respectively. Nodal metastasis (pN+), relapse and American Society of Anesthesiologists ASA-II were found independent prognostic factors for OS, and significantly associated to worst DSS (p < 0.001). TV significantly correlated with higher relapse occurrence (p = 0.03). CONCLUSIONS: In our experience, lymph-node status, ASA classification and relapse significantly influenced DSS on univariate analysis. TV could represent an interesting additional parameter, since it significantly influenced DFS. However, prospective studies with standardized TV measurements and a greater number of patients are needed to validate this result.

Accuracy of fine-needle aspiration and frozen section for the detection of squamous metastasis in cystic masses of the lateral neck.

Cystic masses of the lateral neck are mostly benign. However, the incidence of metastatic squamous cell carcinoma (SCC) in cervical cystic masses initially diagnosed as benign is quite high in patients older than 40 years. The aim of this study was to compare the diagnostic accuracy of preoperative cytology and intraoperative frozen section (FS) in detecting malignancy in cystic masses of the neck. We reviewed 61 patients who underwent preoperative ultrasound-guided fine-needle aspiration cytology (FNAC) and neck biopsy of a cystic neck mass, and analysed the concordance between FNAC and intraoperative FS with respect to definitive histology. HPV status was also tested. Of 49 eligible cases, the accuracy of preoperative FNAC was 70.5% (weighted kappa 0.53), meaning moderate agreement between cytology and final diagnosis. Intraoperative FS consultations detected 16 cases of SCC metastasis while the remaining 33 cases were negative for SCC, showing perfect agreement with histology. Since FS results were useful in evaluating cystic neck masses, despite a moderate accuracy of cytology, we suggest intraoperative FS analysis for all cystic neck masses. This technique can allow us to switch to therapeutic neck dissection, multiple upper aerodigestive tract biopsies, tongue base mucosectomy, and bilateral tonsillectomy in the same surgical setting.

Prevalence and prognostic impact of retropharyngeal lymph nodes metastases in oropharyngeal squamous cell carcinoma: Meta-analysis of published literature.

BACKGROUND: This systematic review and meta-analysis aims to estimate the prevalence and prognostic impact of retropharyngeal lymph node metastases (RLNMs) in oropharyngeal squamous cell carcinoma (OPSCC). METHODS: This meta-analysis was conducted according to PRISMA guidelines. INCLUSION CRITERIA: studies with more than 20 patients reporting the prevalence or prognostic impact of RLNMs in OPSCC. Whenever available, data on HPV status and subsites were extracted. RESULTS: Twenty-two articles were included. The overall prevalence of RLNMs in OPSCC was 13%, with no significant differences depending on HPV status. The highest prevalence was observed for posterior pharyngeal wall SCC (24%), followed by soft palate (17%), palatine tonsil (15%), and base of tongue (8%). RLNMs were associated with a significantly higher risk of death (HR:2.54;IC95%1.89-3.41) and progression (HR:2.44;IC95%1.80-3.30). CONCLUSIONS: The prevalence of RLNMs in OPSCC was 13%, being higher in tumors of the posterior pharyngeal wall. RLNMs were associated with unfavorable outcomes.

Italian validation of the Neck Dissection Impairment Index questionnaire.

Objective: The Neck Dissection Impairment Index (NDII) questionnaire is a useful and validated Quality of Life (QoL) evaluation instrument in patients undergoing major head-neck surgery. Its English version has been used in several studies in the last years. The aim of this work is to validate the NDII in Italian for both patient assessment and future studies. Materials and methods: Cross-cultural adaptation of the NDII was performed using standard techniques. Items of the original NDII were translated into Italian by a professional translator and two bilingual investigators. A final consensus version was obtained and given to two professional translators to produce a literal translation into English. The two translators and an expert committee synthesised the results of the translations in an English back-translated version that was compared with the original to check that they had the same semantic value. Results: Finally, a total of 42 patients completed both copies of the translated questionnaires. Internal consistency proved to be excellent, with Cronbach's alpha = 0.95. Conclusions: The NDII was successfully translated into Italian and its use was easy for patients. The translation of the NDII can represent a useful tool for individual patient assessment and future research.

Self-reported smell and taste recovery in coronavirus disease 2019 patients: a one-year prospective study.

PURPOSE: The aim of the present study was to estimate the 1 year prevalence and recovery rate of self-reported chemosensory dysfunction in a series of subjects with previous mild-to-moderate symptomatic COVID-19. METHODS: Prospective study based on the SNOT-22, item "sense of smell or taste" and additional outcomes. RESULTS: 268/315 patients (85.1%) completing the survey at baseline also completed the follow-up interview. The 12 months prevalence of self-reported COVID-19 associated chemosensory dysfunction was 21.3% (95% CI 16.5-26.7%). Of the 187 patients who complained of COVID-19 associated chemosensory dysfunction at baseline, 130 (69.5%; 95% CI 62.4-76.0%) reported complete resolution of smell or taste impairment, 41 (21.9%) reported a decrease in the severity, and 16 (8.6%) reported the symptom was unchanged or worse 1 year after onset. The risk of persistence was higher for patients reporting a baseline SNOT-22 score ≥ 4 (OR = 3.32; 95% CI 1.32-8.36) as well as for those requiring ≥ 22 days for a negative swab (OR = 2.18; 95% CI 1.12-4.27). CONCLUSION: A substantial proportion of patients with previous mild-to-moderate symptomatic COVID-19 characterized by new onset of chemosensory dysfunction still complained on altered sense of smell or taste 1 year after the onset.

Relevance of perimarginal nodes for head and neck cancer.

OBJECTIVE: To estimate the prevalence of metastasis in the perimarginal nodes (PMNs) (also known as perifacial, preglandular and retroglandual nodes) in head and neck cancer. METHODS: We recruited 136 patients affected by cancers of the oral cavity, lip, oropharynx, skin and by cáncer of unknown primary (CUP), who were candidates for level IB dissection. PMNs were identified and sent separately for histological analysis. Correlation between metastasis to the PMNs and characteristics of the primary tumour were reported. RESULTS: The incidence of metastasis was 17% from oral cancer, 50% from lip cancer and 12.5% from skin cancer. No metastases were reported for oropharynx cancer or CUP. The only factor that correlated with the incidence of metastases was origin of the tumour from the upper part of oral cavity. CONCLUSION: PMNs represent a frequent site of metastasis in oral and lip cancers. In cancer of the oropharynx, their involvement has not been not reported, while their role in skin cancers remains to be clarified.

The CO2 waveguide laser with flexible fiber in transoral resection of oral and oropharyngeal cancers: a retrospective cohort study on postoperative and quality of life outcomes.

The aim of this study was to evaluate the CO2 waveguide laser (WG CO2 laser) with flexible fiber (Lumenis Ltd., Yokneam, Israel) in the treatment of oral and oropharyngeal cancers, specifically focusing on postoperative outcomes, pain, and quality of life (QoL). Eighty-one patients, 43 women and 38 men, with oral or oropharyngeal cancer who consecutively underwent transoral resection by WG CO2 laser from August 2015 to April 2020 were retrospectively enrolled. Resections were performed in super pulsed mode with a power setting ranging between 3 and 10 W. Data about frozen sections, reconstruction, complication rate, length of hospital stay, tracheostomy rate and time to decannulation, nasogastric feeding tube rate and time to oral feeding, pain, and QoL were reviewed. Continuous variables were presented as mean and standard deviation. Concordance between intraoperative frozen section examination and definitive histology was calculated using Cohen's K test of agreement. The mean length of hospital stay was 13 days. The feeding tube rate was 81%; the tracheostomy rate was 35%; the feeding tube was left in place for 8 days on average, and the time to decannulation was 9 days. The only complication was a postoperative bleeding in 4 patients. The median postoperative pain score measured by the Numeric Pain Rating Scale on postoperative days 1, 3, and 5 was 0 and there was a constant decrease in painkiller use over the days. The overall mean composite QoL score was 77 ± 14, with excellent results in saliva, taste, pain, and speech domains. Frozen section evaluation had a specificity of 99% and a negative predictive value of 98%. WG CO2 laser is a good and safe tool for transoral tailored resection of oral and oropharyngeal cancers. It ensures a good overall QoL and guarantees fast recovery and a very low postoperative pain.

The role of NBI with flexible video-endoscope in the follow-up of head and neck cancer patients: a prospective study.

PURPOSE: Narrow band imaging (NBI) enhances mucosal vasculature and could help in the identification of recurrences. We assessed the effectiveness of NBI with flexible video-endoscope in the early detection of recurrence after treatment of head and neck squamous cell carcinoma, its diagnostic advantage over high-definition white-light (HD WL) endoscopy, also in relation to recurrence site, and the influence of previous radiotherapy (RT) or chemotherapy (CT). Moreover, we investigated the association between index tumor site and the risk of developing recurrence, and the relation between index tumor site and recurrence site. METHODS: From January 2018 to November 2020, 160 patients previously treated with surgery and/or RT ± CT were evaluated using NBI with flexible video-endoscope. Sensitivity, specificity, positive/negative predictive value, and accuracy were calculated for NBI and HD WL, and compared using the McNemar test. The Fisher exact test was used to compare the other associations investigated. RESULTS: The difference between NBI and HD WL sensitivity was statistically significant (p < 0.001). The NBI diagnostic advantage was 62.5%, highest in the hypopharynx (p = 0.05), and was not influenced by previous RT or CT (p = 0.49). Index tumor site statistically related with recurrence site (p < 0.001), but not with the risk of developing recurrence (p = 0.81). CONCLUSION: NBI with flexible video-endoscope could represent a valid option to detect recurrence early during the follow-up, especially in a difficult-to-visualize site such as the hypopharynx.

Is there a role for ultrasonic surgery in transoral laryngeal cancer resections?

INTRODUCTION: Minimally invasive surgery for laryngeal cancer is nowadays the goal of all larynx surgeons. Transoral laser microsurgery is a widespread and standardized technique that has made it possible to reduce surgical morbidities and hospitalization and to spare laryngeal function. Nonetheless, it has some limitations, which may be exceeded by using new optical and cutting devices as in TransOral UltraSonic Surgery. Areas covered: The aim of this paper is to identify current knowledge about ultrasonic scalpel (US) application in transoral laryngeal surgery and to deduce reasonable indications and contraindications of the tool. Expert opinion: Transoral laryngeal surgery with US is feasible and allows for 'angulated' dissections with higher hemostatic capacity than the CO2 laser. When coupled with an endoscope, surgeons have the possibility to angulate the laryngeal exposure from the inside, reducing blind areas. Nonetheless, US blades are quite bulky, thermal damage is higher than that produced by CO2 laser, and its use should be avoided where the functional result is more closely related to the amount of resected tissue. Tumors limited to the suprahyoid larynx are the current indications for US surgery.

Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy.

Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.

Neck abscess: An unusual clinical presentation of immunoglobulin G4 related disease.

Immunoglobulin G4 related disease (IgG4-RD) is a systemic fibroinflammatory disease that can affect almost any organ. Only a few cases of IgG4-RD have been reported to present with cervical lymphadenopathy and none with neck abscesses. We report a case in a patient with bilateral neck mass and bilateral neck abscesses. The patient underwent bilateral neck incision for drainage of the abscesses on two occasions, followed by a neck dissection after a third recurrence. Immunohistochemistry of the specimen revealed IgG4-RD. Although surgery is not the recommended first-line approach for IgG4-RD, only a neck dissection enabled clinical resolution of the lesions in our patient. LEVEL OF EVIDENCE: NA Laryngoscope, 126:1114-1116, 2016.

Charcoal Suspension Tattoo: A New Technique for Intraoperative Detection of Small Tumors of the Parotid Gland.

OBJECTIVE: The current surgical trend in the treatment of pleomorphic adenomas of the parotid gland is to limit the extent of resection. This raises the need to correctly identify the mass within the normal parenchyma so as to avoid dissecting the entire superficial lobe of the gland. We describe ultrasound-guided tattooing as a technique to facilitate identification and excision of parotid pleomorphic adenomas. METHODS: We reviewed 23 consecutive patients with pleomorphic adenoma of the parotid gland. All patients underwent ultrasound-guided tattooing of the lesions with a charcoal suspension. Baseline tumor and patients' characteristics, major and minor complications, and subjective tolerance to the procedure were recorded. We assessed the number of intralesionally marked masses and the percentage of intraoperatively detected marked lesions. RESULTS: The injection was well tolerated. No major complications were recorded. In 2 cases (9%), a transient increase in lesion size was observed. No other minor complications were encountered. Charcoal was found inside the tumor in 19 cases (83%). In 4 cases (17%), it was found in the tissues above the lesion. Twenty-three lesions were intraoperatively detected (100%) and dissected. CONCLUSION: Charcoal suspension tattooing is safe and well tolerated for the detection of small pleomorphic adenomas during parotid surgery.