Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy.

INTRODUCTION: Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol. METHODS: Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent. RESULTS: Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%). CONCLUSION: The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.

Management of loco-regionally advanced squamous laryngeal cancer in elderly patients.

PURPOSE: To describe the management and outcomes of loco-regionally advanced (stages III-IV) laryngeal cancer (LRALC) in elderly patients. METHODS: Clinical records of 88 LRALC patients treated at our Institution from 2002 to 2017 were retrospectively reviewed. Patients were divided in 2 subgroups: age > 65 years (elderly) and age ≤ 65 years (controls). Survivals were estimated with Kaplan-Meier method and compared with log-rank test, multivariate analysis were performed with Cox proportional hazard methods. RESULTS: Eighty-eight LRALC patients were included: 45 elderly and 43 controls. Median follow-up was 55.3 months. Median age was 66 years (range 41-84) in the overall population, 72 years (range 66-84) in the elderly cohort. The majority (98%) of elderly patients had at least one comorbidity (ACE27 1-3), while ACE27 was 0 in 37% of controls (p = 0.0001). ECOG PS was 0 in 42% of elderly vs 79% of controls (p = 0.0029). Clinical stage (TNM eighth edition) was III in 67%, IVA in 22% and IVB in 11%. Treatment consisted in total laryngectomy (TL) in 55%, chemo-radiation in 29%, exclusive radiotherapy in 9%, and conservative surgery in 7%. In elderly patients 2-year disease-free and overall survivals were 58% and 74%, respectively. Multivariate analysis performed on the overall group of 88 patients showed that age (HR 1.07, p = 0.0006) and TNM (for both 7th and 8th Editions HR 0.27 for stage III vs IV, p = 0.0005) maintained an independent statistical significant association with OS. CONCLUSIONS: In this monocentric cohort, age and TNM confirmed their independent prognostic role in LRALC patients. Organ-preservation is still an unmet need in a significant portion of elderly patients.

Postoperative radiotherapy with volumetric modulated arc therapy of lacrimal gland carcinoma: two case reports and literature review.

AIMS: To evaluate technical issues and clinical outcomes after postoperative volumetric-modulated arc therapy (VMAT) in two cases of malignant lacrimal gland cancer. PATIENTS & METHODS: Patients were treated by postoperative VMAT and post-treatment clinical outcomes were followed-up to 18 months. RESULTS: Dosimetric results were acceptable and acute toxicity was manageable in both patients. No evidence of disease was found at latest follow-up. One patient underwent corneal transplant for central corneal ulceration, experiencing reduction of visual acuity. CONCLUSION: Postoperative VMAT for treatment of lacrimal gland tumors offers improved outcome, with manageable side effects. In the context of photon beam radiotherapy, VMAT emerged as a valuable treatment option for these malignant tumors.

Skull base surgery for malignant tumors: The 2nd international collaborative study (1995-2015).

BACKGROUND: The current study presents the effort of a global collaborative group to review the management and outcomes of malignant tumors of the skull base worldwide. PATIENTS AND METHODS: A total of 28 institutions contributed data on 3061 patients. Analysis evaluated clinical variables, survival outcomes, and multivariable factors associated with outcomes. RESULTS: The median age was 56 years (IQR 44-67). The open surgical approach was used in 55% (n = 1680) of cases, endoscopic resection was performed in 36% (n = 1087), and the combined approach in 9.6% (n = 294). With a median follow-up of 7.1 years, the 5-year OS DSS and RFS were 65%, 71.7% and 53%, respectively. On multivariable analysis, older age, comorbidities, histology, dural/intracranial involvement, positive margins, advanced stage, and primary site were independent prognostic factors for OS, DSS, and RFS. Adjuvant RT was a protective prognostic factor. CONCLUSION: The progress across various disciplines may have contributed to improved OS and DSS in this study compared to previous reports.

Compartmental tongue surgery for intermediate-advanced squamous cell carcinoma: A multicentric study.

BACKGROUND: A multicentric study was conducted on technical reproducibility of compartmental tongue surgery (CTS) in advanced tongue cancers (OTSCC) and comparison to standard wide margin surgery (SWMS). METHODS: We studied 551 patients with OTSCC treated by CTS and 50 by SWMS. Oncological outcomes were analyzed. A propensity score was performed to compare survival endpoints for the two cohorts. RESULTS: In the CTS group, survival and prognosis were significantly associated with positive lymph-nodes, extranodal extension, depth of invasion and involvement of the soft tissue connecting the tongue primary tumor to neck lymph nodes (T-N tract), independently from the center performing the surgery. SWMS versus CTS showed a HR Cause-Specific Survival (CSS) of 3.24 (95% CI: 1.71-6.11; p < 0.001); HR Loco-Regional Recurrence Free Survival (LRRFS) of 2.54 (95% CI: 1.47-4.40; p < 0.001); HR Overall Survival (OS) of 0.11 (95% CI: 0.01-0.77; p = 0.03). CONCLUSION: Performing the CTS could provide better CSS and LRRFS than SWMS regardless of the center performing the surgery, in advanced OTSSC.

Oncological outcomes of compartmental surgery and wide local excision in oral tongue and floor of the mouth cancer.

OBJECTIVES: Oral tongue carcinomas represent more than half of the tumors arising in the oral cavity, a site with a high cancer specific mortality and impact on quality of life. Current guidelines are lacking for a standardized surgical approach of these tumors. The aim of this study is to compare two currently adopted surgical strategies, compartmental surgery (CTS) and wide local excision (WLE), with loco-regional control as the main oncological endpoint. MATERIALS AND METHODS: An observational retrospective multicentric study was carried out enrolling a cohort of patients affected by oral tongue or floor of the mouth squamous cell carcinoma and surgically treated in 4 international tertiary referral centers. Survival analysis was performed by propensity-score matching approach and multivariable Cox regression analysis. RESULTS: A cohort of 933 patients was enrolled. CTS was applied in 113 patients (12.1%) and WLE in 820 (87.9%). Analyzing a propensity-score matched cohort (98 CTS vs. 172 WLE) and applying a survival multivariable modeling strategy on the whole cohort, both confirmed that CTS and WLE are comparable and oncologically safe. Parameters such as number of positive lymph nodes, depth of invasion, and lymphovascular invasion still represent the key prognosticators. CONCLUSION: The main goals for surgical resection of oral cancer remain its three-dimensional circumferential clearance with adequate margins and en-bloc removal of the tumor-lymph node tract, independently of the technique adopted (CTS or WLE). Further prospective studies including quality of life evaluation are needed to better understand if one of these approaches can provide superior functional outcomes.

Comparison of Different Staging Systems Applied to a Cohort of Patients With Oral Tongue and Floor of the Mouth Cancer.

Purpose: The present work compares the effects produced by the application of the 7th edition of the tumor node metastasis (TNM) staging system (TNM7), 8th Edition (TNM8) with its two subsequent revisions, and pN-N+ classification on a cohort of patients with oral tongue and floor of the mouth cancer. Methods: A monocentric cohort of 148 patients was retrospectively analyzed. Patients were staged according to the TNM7, TNM8 and revisions, and pN-N+ classification. Stage migration was assessed and overall survival (OS) analyzed with the Kaplan-Meier method. The pT, pN, and stage stratification was evaluated with univariate and multivariate Cox regression and comparing adjacent categories with the log-rank method. Results: pT3-T4a categories showed significant differences in comparison to pT1-T2 for each staging metric employed in both uni- and multivariate analysis. When comparing adjacent pT categories, OS was significantly different only between pT2 and pT3 categories of the TNM8. Disproportionate patient distribution among pN categories was observed in the TNM8, and stratification was scarce. Conversely, in the pN-N+ classification the difference between pN2 and pN3a categories was significant. Only stage IVa reached statistical significance in TNM7, whereas stage III and above were significant in TNM8 and revisions in both uni- and multivariate analysis. However, no significant difference was noted comparing adjacent stages. Conclusion: The TNM8 pT classification differentiated low- from high-risk diseases. Nonetheless, it failed to separate pT1 from pT2 and pT3 from pT4a categories. Conversely, although TNM8 nodal staging was inaccurate, the number of metastatic lymph nodes was more valuable.

Vertical platysma myocutaneous flap reconstruction for T2-staged oral carcinoma.

The surgical resection of tumour-affected oral soft tissue structures often leads to tissue defects. Various techniques can be used for reconstruction. Our experience of using a vertical platysma myocutaneous flap in a group of patients who underwent reconstruction after T2-staged oral cancer surgical resection associated with neck dissection is described. Only one patient required a surgical revision, due to flap detachment, with a pectoralis major myocutaneous flap. No other major complications, such as nerve lesions or orocutaneous fistulas, were observed. Satisfactory swallowing function was achieved within two weeks in all cases. A platysma myocutaneous flap is a versatile, easy-to-perform, one-stage procedure, and the outcome is best in adequately selected patients; it should not be adopted in patients who have undergone previous neck surgery or radiotherapy, or if radical neck dissection is planned. Care is required to preserve the external jugular vein and the submental artery, particularly when level I is dissected.

Does a multidisciplinary team approach in a tertiary referral centre impact on the initial management of head and neck cancer?

OBJECTIVES: A multi-disciplinary team (MDT) is essential in the management of cancer. Head and neck cancer (HNC) is a rare, complex and heterogeneous group of malignancies for which different treatment options are available. However, the potential impact of MDT on the management of HNC has been only poorly evaluated to date. This study evaluates the impact of MDT on the management of HNC in a tertiary centre. METHODS: We retrospectively analysed records of HNC patients referred to a MDT evaluation at the Istituto Nazionale Tumori of Milan, Italy, from May 2007 to January 2012. All cases were reviewed by a MDT consisting of a head and neck surgeon, a radiation oncologist, and a medical oncologist. RESULTS: Data from 781 HNC patients were analysed. Approximately 70% of patients were referred to our Institution for a second opinion consultation. Following MDT evaluation, new staging examinations were requested in 49% of patients, and treatment plan was modified in 10%. CONCLUSIONS: A MDT approach in a tertiary referral hospital leads to staging refinement of disease or changes in treatment plan in about 60% of patients.

Four- and five- level en bloc spondylectomy for malignant spinal tumors.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report results of 4- and 5-level en bloc spondylectomy (EBS) in the treatment of malignant spinal tumors. SUMMARY OF BACKGROUND DATA: EBS is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Four- and 5-level EBS are aggressive procedures associated with complications and morbidity. METHODS: We conducted a retrospective study of all patients treated with minimum 4-level EBS. Patient and surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. Type of excision was classified into intralesional, marginal, and wide margins. Complications were divided into major or minor and were further classified as intraoperative, early, and late postoperative. At the last follow-up, the patients were classified as alive with no evidence of local or systemic disease, alive with evidence of local or systemic disease or both, dead with evidence of local disease, or systemic disease or both, and dead without evidence of local and systemic disease. RESULTS: Nine patients were identified who required a minimum 4-level en bloc resection. Five males and 4 females. Average age was 41.66 years (11-66). There were 8 primary malignant tumors: 3 chordomas, 3 osteosarcomas, 1 chondrosarcoma, 1 primary lung tumor and 1 metastatic alveolar soft part sarcoma. Six were operated with 4-level en bloc and 3 with 5 levels. The mean surgical time was 713 minutes and estimated blood loss was 4.5 L. Mean follow-up was 27.7 months (8-84). At the last follow-up, 6 patients were alive with no evidence of local or systemic disease, 1 alive with evidence of systemic disease, 1 dead with evidence of local disease, or systemic disease or both, and 1 DNLS. Only 1 (11%) patient had a local recurrence. Three patients with Frankel D had full neurological recovery. Histopathological assessment showed marginal margins in 7 patients and wide in 2. There were 9 major and 9 minor complications in 7 patients. Five of 7 patients (71%) with complications, had fully recovered from their complications at the last follow-up. CONCLUSION: Multilevel EBS, can be offered to a patient to prevent local recurrence of disease. Even in experienced hands, the risks of intra- and postoperative complications are high (78%). However, most of the patients with complications, recovered completely (71%). Although the surgery itself may prove beneficial, patients should be well informed regarding the morbidity associated with it. LEVEL OF EVIDENCE: 4.

Open organ preservation surgery of the larynx: Experience of Istituto Nazionale Tumori of Milan.

BACKGROUND: The purpose of the present study was to report the oncological and functional results of our experience in open organ preservation surgery of the larynx. METHODS: Between 1978 and 2006, 140 patients were treated with organ preservation surgery of the larynx. Feeding tube and tracheotomy duration, surgical infection, fistulae, and pneumonia were recorded. RESULTS: Most patients were treated with supraglottic laryngectomies. Thirteen patients (9%) experienced a faringo-cutaneous fistula, 23 (16%) presented with a surgical site infection, and 6 (4%) developed pneumonia. Tracheotomy was maintained for a median period of 47 days in patients who did not receive postoperative radiotherapy (RT) and 140 days in patients who did. Eight (6%) total laryngectomies were performed because of oncological and functional reasons. Tube feeding continued for an average period of 34 days. Patients with squamous cell carcinoma (SCC) had 5-year disease-free survival (DFS) of 83.6%. CONCLUSION: Open organ preservation surgery proved oncologically effective with good functional outcome and acceptable complications.

Bisphosphonate-associated osteonecrosis of the jaws: a therapeutic dilemma.

OBJECTIVE: To describe our experience in prevention and treatment of mandibular and maxillary osteonecrosis, an emerging complication of long-term intravenous administration of bisphosphonates. STUDY DESIGN: Between February 2004 and February 2006, 10 patients who had received zoledronic acid intravenously because of multiple bone myelomas or bone metastases were treated for mandibular and maxillary osteonecrosis in the Departments of Otorhinolaryngology and Maxillofacial Surgery of our institution. RESULTS: All of the patients underwent surgical sequestrectomies. More extensive surgery was necessary in 3 cases. There were no major complications, and the majority of the patients are alive with no signs of infection or bone exposure. CONCLUSIONS: Our experience confirms that bisphosphonate therapy contributes to the pathogenesis of mandibular and maxillary osteonecrosis. Surgery seems to be necessary in the majority of the patients, although the most adequate procedure is far from being standardized and prevention seems to play a pivotal role.

Complicaciones de terapias endodónticas. La micosis de los senos paranasales. Diagnóstico y terapia / Complications of endodontic therapies. The paranasal sinuses mycosis. Diagnosis and therapy

Se conoce la existencia de la aspergillosis desde hace más de un siglo. Su incidencia parece ir aumentado con el paso del tiempo. Si bien una de las razones para este aumento es una mejor documentación de los casos, al parecer existen ciertos factores y enfermedades que contribuyen a la formación de esta infección. Sin embargo, llama la atención el hecho de que principalmente afecta a los individuos por lo demás sanos. Este trabajo abarca una revisión bibliográfica de los diversos tipos de micosis, así como de los tratamientos usados en cada uno de sus casos