Algorithm to predict postoperative complications in oropharyngeal and oral cavity carcinoma.

BACKGROUND: Preoperative data in patients with oral cavity/oropharyngeal cancer may predict postoperative complications that may modify therapeutic choices and improve patient care. METHOD: We reviewed 320 consecutive patients with oral cavity/oropharyngeal cancer, operated on 2003 through 2006 at the European Institute of Oncology. By multivariate analysis of preoperative patient and tumor characteristics, we developed an algorithm to predict postoperative complications. We tested the algorithm on a new series of 307 patients operated on 2007 through 2010. RESULTS: The final algorithm used to produce a nomogram was comprised of: alcohol consumption (p = .01), site of primary (p = .03), interaction of clinical T classification to sex (p = .007), and type of neck dissection (p < .0001). The algorithm had good ability to predict complications (concordance index [c-index] 0.74) in the new series. CONCLUSION: The nomogram accurately predicts presurgical risk of postoperative local/systemic complications in patients with oral cavity/oropharyngeal cancer and can be used to adapt therapy to patient characteristics, optimize ward admissions, and improve care.

Transoral robotic surgery vs transoral laser microsurgery for resection of supraglottic cancer: a pilot surgery.

BACKGROUND: Transoral laser microsurgery (TLM) is a mature approach to supraglottic cancer, while transoral robotic surgery (TORS) is emerging. The present study compared these approaches. METHODS: The first 10 patients (2002-2005) given TLM were compared with the first 10 (2007-2011) given TORS for cT1-3 cN0-cN2c supraglottic cancer. RESULTS: A feeding tube was used in four TLM and seven TORS patients. Margins were more often positive, but operating times shorter, in TORS. All 10 TORS patients are without evidence of disease, but only six TLM patients remain disease-free after much longer follow-up. TORS was considerably less uncomfortable and fatiguing for the surgeon. CONCLUSIONS: TORS seems as safe and effective as TLM. Shorter TORS operating times are probably attributable to prior experience with TLM. For laryngeal exposure, length of tube placement and margin evaluability, TLM was superior; however, this may change as TORS develops and transoral robotic instruments are optimized.

From wide excision to a compartmental approach in tongue tumors: what is going on?

PURPOSE OF REVIEW: Surgical approaches to tongue cancer have not changed substantially over the years. The literature proposes some indications for tumor excision even though type of intervention, resection margins, neck dissection, and 'en bloc' resection versus separate excision of tumor and lymph nodes do not seem to be standardized. The purpose of this review is to describe the evolution of surgical management of tongue carcinoma with particular attention to recent reports focusing on compartmental tongue surgery. RECENT FINDINGS: The current literature usually describes resection of tongue carcinoma within wide disease-free margins, ranging from 1.5 to 2 cm. In case of advanced-stage tumors, performing concomitant neck dissection is recommended; otherwise, a deferred neck dissection is indicated if depth of neoplastic infiltration exceeds 4 mm. In recent years, a new technical approach has been formulated based on anatomy of the tongue, thus, introducing the concept of an anatomy-based, function sparing, compartmental surgery. SUMMARY: Applying such a proposal to clinical practice aims at standardizing a surgical procedure that otherwise might be arbitrary. Compartmental surgery improves overall survival, does not seem to worsen functional outcomes of the residual tongue, and allows comparison of case studies.

Total glossectomy with preservation of the larynx: oncological and functional results.

Our aim was to analyse the overall and disease-free survival (DFS), time to recovery of oral feeding, and morbidity, in a consecutive series of patients who had total glossectomy with preservation of the larynx for advanced cancer of the tongue at the European institute of Oncology (Milan). From June 2002 to April 2011, 37 patients who were treated for advanced cancer of the tongue had total glossectomy, bilateral neck dissection, and preservation of the larynx. Various flaps were used for reconstruction. Overall and disease-free survival were assessed from the day of operation to the latest outpatient examination. Postoperative morbidity and rehabilitation of feeding were also assessed. Six patients had major complications, four of whom had a second operation for necrosis of the flap. Actuarial five-year overall survival (OS) and disease-free survival were 54% and 47%. Twenty-four patients (65%) were operated on as their first treatment, and had 79% five-year overall survival and 61% 5-year disease-free survival. Twenty-six patients were eventually able to feed orally postoperatively. Although this retrospective study include a limited number of patients, the results support the validity of total glossectomy as a safe procedure for advanced cancer of the tongue. Pretreated patient were previously treated with surgery, radiotherapy or chemoradiotherapy with curative purposes. Nevertheless, the long period required for recovery of oral feeding indicates that total glossectomy should be reserved for highly motivated patients.

Compartmental tongue surgery: Long term oncologic results in the treatment of tongue cancer.

Compartmental tongue surgery (CTS) is a surgical technique that removes the compartments (anatomo-functional units) containing the primary tumor, eliminating the disease and potential muscular, vascular, glandular and lymphatic pathways of spread and recurrence. Compartment boundaries are defined as each hemi-tongue bounded by the lingual septum, the stylohyoid ligament and muscle, and the mylohyoid muscle. In this non-randomized retrospective study we evaluated the oncologic efficacy of CTS in patients with squamous cell carcinoma (SCCA) of the tongue treated from 1995 to 2008. We evaluated 193 patients with primary, previously untreated cT2-4a, cN0, cN+, M0 SCCA with no contraindication to anesthesia and able to give informed consent. Fifty patients treated between October 1995 and July 1999 received standard surgery (resection margin >1cm); 143 patients treated between July 1999 and January 2008 received CTS. Study endpoints were: 5-year local disease-free, locoregional disease-free and overall survival. After 5years, local disease control was achieved in 88.4% of CTS patients (16.8% improvement on standard surgery); locoregional disease control in 83.5% (24.4% improvement) and overall survival was 70.7% (27.3% improvement). The markedly improved outcomes in CTS patients, compared to those treated by standard surgery, suggest CTS as an important new approach in the surgical management of tongue cancer.

Laser surgery for early glottic cancer: impact of margin status on local control and organ preservation.

OBJECTIVE: To assess the impact of margin status on disease-free survival, overall survival, and organ preservation in early glottic cancer treated by endoscopic laser surgery. DESIGN: Prospective nonrandomized study. SETTING: Tertiary referral center. PATIENTS: A total of 274 patients with untreated (possibly biopsied) cTis, cT1a/b, cT2, cN0 glottic cancer; adequate exposure of the glottic region; no contraindications to general anesthesia; and the ability to give informed consent. INTERVENTIONS: European Laryngological Society laser cordectomy. Patients with negative margins (>1 mm) were followed, patients with close margins (< or =1 mm) or 1 positive margin (tumor on margin) had another operation, and patients with more than 1 positive margin had postoperative radiotherapy. Median follow-up was 58 months. MAIN OUTCOME MEASURES: Eight-year disease-free survival, 5-year overall survival, and organ preservation rate. RESULTS: Margins were negative in 180 patients, close in 40, and positive in 54. A second laser resection was performed in 36 of 94 patients with close or positive margins. Radiotherapy was administered to 36 patients. Patients with close or positive margins who did not undergo further treatment had a greater recurrence risk (hazard ratio, 2.53; 95% confidence interval, 0.97-6.59, P = .06) than did those with negative margins, mainly owing to relapses in 5 of the 8 protocol breakers with positive margins not treated further. Eight-year relapse-free survival was 88.2%, 5-year overall survival was 90.9%, and the larynx was preserved in 97.1%. CONCLUSIONS: Laser removal of early glottic cancer is oncologically adequate with margins greater than 1 mm from the tumor edge. Positive margins require further treatment; close margins may require further treatment depending on tumor characteristics.