Different inflammatory blood markers correlate with specific outcomes in incident HPV-negative head and neck squamous cell carcinoma: a retrospective cohort study.

BACKGROUND: Inflammatory blood markers have been associated with oncological outcomes in several cancers, but evidence for head and neck squamous cell carcinoma (HNSCC) is scanty. Therefore, this study aims at investigating the association between five different inflammatory blood markers and several oncological outcomes. METHODS: This multi-centre retrospective analysis included 925 consecutive patients with primary HPV-negative HNSCC (median age: 68 years) diagnosed between April 2004 and June 2018, whose pre-treatment blood parameters were available. Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), systemic inflammatory marker (SIM), and systemic immune-inflammation index (SII) were calculated; their associations with local, regional, and distant failure, disease-free survival (DFS), and overall survival (OS) was calculated. RESULTS: The median follow-up was 53 months. All five indexes were significantly associated with OS; the highest accuracy in predicting patients' survival was found for SIM (10-year OS = 53.2% for SIM < 1.40 and 40.9% for SIM ≥ 2.46; c-index = 0.569) and LMR (10-year OS = 60.4% for LMR ≥ 3.76 and 40.5% for LMR < 2.92; c-index = 0.568). While LMR showed the strongest association with local failure (HR = 2.16; 95% CI:1.22-3.84), PLR showed the strongest association with regional (HR = 1.98; 95% CI:1.24-3.15) and distant failure (HR = 1.67; 95% CI:1.08-2.58). CONCLUSION: Different inflammatory blood markers may be useful to identify patients at risk of local, regional, or distant recurrences who may benefit from treatment intensification or intensive surveillance programs.

Feasibility of 3D printed salivary duct models for sialendoscopic skills training: preliminary report.

PURPOSES: To explore the feasibility of 3D printed salivary duct models for the sialendoscopic skills training. METHODS: Healthy volunteers and patients affected by obstructive salivary gland disorders were submitted to 3 Tesla MR sialography. The MR data underwent an image segmentation process to produce the 3D printed salivary duct prototypes. Sialendoscopies were carried out by three groups of investigators with different levels of endoscopic experience. Realism, usefulness of the training process and potential advantages of the 3D printed models in the preoperative surgical planning were evaluated by means of a specific survey. RESULTS: Four cases were included in our study: one healthy parotid, one submandibular gland, one case of lithiasis and one of stenosis involving the parotid gland. In all cases, the three groups of investigators successfully explored the salivary ducts up to the tertiary branches, detected the cause of obstruction and correctly treated it. Seven untoward events occurred during the operative sialendoscopies. Overall, the questionnaire score was about 79.3%, reflecting a positive impression regarding the models on behalf of all the investigators. CONCLUSIONS: 3D printed salivary duct models resulted feasible for the sialendoscopic skills training. The opportunity to reproduce the patient-specific anatomy may add further information useful in the preoperative decision making. These positive results should be verified by further researches and experiences.

Updated standard operating procedures for electrochemotherapy of cutaneous tumours and skin metastases.

Electrochemotherapy is now in routine clinical use to treat cutaneous metastases of any histology, and is listed in national and international guidelines for cutaneous metastases and primary skin cancer. Electrochemotherapy is used by dermatologists, surgeons, and oncologists, and for different degrees and manifestations of metastases to skin and primary skin tumours not amenable to surgery. This treatment utilises electric pulses to permeabilize cell membranes in tumours, thus allowing a dramatic increase of the cytotoxicity of anti-cancer agents. Response rates, often after only one treatment, are very high across all tumour types. The most frequent indications are cutaneous metastases from malignant melanoma and breast cancer. In 2006, standard operating procedures (SOPs) were written for this novel technology, greatly facilitating introduction and dissemination of the therapy. Since then considerable experience has been obtained treating a wider range of tumour histologies and increasing size of tumours which was not originally thought possible. A pan-European expert panel drawn from a range of disciplines from dermatology, general surgery, head and neck surgery, plastic surgery, and oncology met to form a consensus opinion to update the SOPs based on the experience obtained. This paper contains these updated recommendations for indications for electrochemotherapy, pre-treatment information and evaluation, treatment choices, as well as follow-up.

Telomeric Repeat-Containing RNAs (TERRA) Decrease in Squamous Cell Carcinoma of the Head and Neck Is Associated with Worsened Clinical Outcome.

Telomeres are transcribed into noncoding telomeric repeat-containing RNAs (TERRA), which are essential for telomere maintenance. Deregulation of TERRA transcription impairs telomere metabolism and a role in tumorigenesis has been proposed. Head and neck cancer (HNC) is one of the most frequent cancers worldwide, with head and neck squamous cell carcinoma (HNSCC) being the predominant type. Since HNSCC patients are characterized by altered telomere maintenance, a dysfunction in telomere transcription can be hypothesized. In this prospective study, we compared TERRA levels in the tumor and matched normal tissue from 23 HNSCC patients. We then classified patients in two categories according to the level of TERRA expression in the tumor compared to the normal tissue: (1) lower expression in the tumor, (2) higher or similar expression in tumor. A significant proportion of patients in the first group died of the disease within less than 34 months postsurgery, while the majority of patients in the second group were alive and disease-free. Our results highlight a striking correlation between TERRA expression and tumor aggressiveness in HNSCC suggesting that TERRA levels may be proposed as a novel molecular prognostic marker for HNSCC.

Supraclavicular artery island flap (SCAIF): a rising opportunity for head and neck reconstruction.

Over the last 20 years, free flaps have represented the gold standard for moderate to large head and neck reconstruction. However, regional flaps continue to evolve and still play an important role in a reconstructive surgeon's armamentarium, especially for the more delicate patients who would certainly benefit from simpler surgical procedures. The supraclavicular artery island flap (SCAIF) is a pedicled flap that has recently gained great popularity for reconstruction of most head and neck sites, because of its unusual versatility and wide arc of rotation. SCAIF is a fasciocutaneous flap that is very reliable and both easy and quick to harvest. It is pedicled on the supraclavicular artery, which is a branch of the transverse cervical artery. Between October 2012 and July 2015, at Ospedale San Raffaele (Milan, Italy) and Policlinico San Matteo (Pavia, Italy), we used the SCAIF procedure on 14 patients with cervical and facial skin, oral cavity, oropharyngeal, and hypopharyngeal defects after oncologic surgery or as revision surgery after free-flap failure. The presence of the supraclavicular artery was demonstrated preoperatively by computed tomography angiography. Harvesting time never exceeded 50 min. Functional outcomes were excellent, and the donor site was always closed. We reported only one case of tip desquamation, which was treated conservatively, and two cases of partial flap necrosis, which required revision surgery. In our opinion, SCAIF should be considered to be a valid alternative to free-flap reconstruction, especially for facial and cervical skin, floor-of-mouth, and hypopharyngeal defects; oropharyngeal defects may be harder to reconstruct.

CO2 laser cordectomy for T1-T2 glottic cancer: oncological and functional long-term results.

The purpose of this study was to assess the validity of CO2 laser cordectomy in the treatment of early glottic cancer and to determine the impact of margin status on disease-free survival and of the operation on voice quality. This is a retrospective review of 169 patients. Quantitative and qualitative variables were statistically compared. The impact on overall and disease-free survivals of different variables was calculated by univariate and multivariate analyses. Ten-year overall and disease free-survivals were 75 % and 60 %, respectively. Age and clinical stage showed a significant negative impact on overall survival, while margin status both on overall and disease-free survivals. The degree of dysphonia was directly related to the extension of the resection. This series confirms the good oncologic and functional outcomes of laser surgery for Tis, T1 and selected T2 glottic tumors. Patients with positive margins should undergo a further treatment or a very close follow-up.

Recurrent laryngeal nerve monitoring by flexible laryngoscopy during thyroid radiofrequency ablation in the awake patient.

Objective: Although radiofrequency ablation (RFA) is a safe and effective non-surgical treatment for benign thyroid nodules, injury to the recurrent laryngeal nerve (RLN), is a potential and feared complication. Intermittent voice checks have been proposed to monitor vocal cord (VC) function during RFA, but such assessment is highly subjective and effort-dependent. Methods: We are here reporting the methodological use of flexible laryngoscopy (FL) for VC monitoring during bilateral thyroid RFA treatment. The patient, a 35-year-old woman, was referred to the Endocrinology Unit for subclinical hyperthyroidism due to bilateral autonomously functioning thyroid nodules. Results: At the end of the treatment of the first nodule, the FL performed by an otorhinolaryngologist specialist allowed evaluating VC function and ruling out possible paralysis before proceeding with the contralateral RFA treatment. The patient was awake during the entire procedure and well tolerated the laryngoscopic examination. The TSH serum evaluations performed one month and 9 months after the procedure assessed an euthyroid state (TSH 3.2 mIU/L and 2.8 mIU/L, respectively). Conclusion: During bilateral thyroid RFA the use of FL for VC monitoring treatment resulted in a safe, easy-to-perform, and effective strategy to minimize and anticipate RLN injury risk in the awake patient. The prevention of RLN damage is advisable in the case of single RFA treatment, while it should be strongly recommended when RFA is performed on bilateral nodules.

Electrochemotherapy as a new therapeutic strategy in advanced Merkel cell carcinoma of head and neck region.

BACKGROUND: Merkel Cell Carcinoma (MCC) is a rare and aggressive tumour, arising from a cutaneous mechanoceptor cell located in the basal layer of epidermis, with poor prognosis. The treatment of choice for the initial stage of the disease is surgery and/or radiotherapy. The treatment of recurrent or advanced disease is still controversial. CASE REPORT: We report a case of 84 years old woman with a recurrent MCC of the chin treated with electrochemotherapy (ECT). During the period of 20 months, four sessions of ECT were employed, which resulted in an objective response of the tumour and good quality of residual life. CONCLUSIONS: Our case shows the effectiveness of ECT in the treatment of locally advanced MCC of the head and neck region in a patient not suitable for standard therapeutic options.

Transoral robotic surgery with laser for head and neck cancers: a feasibility study.

AIMS: To assess the feasibility of a flexible thulium laser coupled with a novel robotic introducer for head and neck cancers. METHODS: In a prospective nonrandomized clinical trial, 58 patients were evaluated. When indicated, transoral robotic surgery (TORS) with laser was performed using an Intuitive da Vinci S System with the Intuitive Surgical® Endo Wrist Introducer, 5Fr to hold and position thulium surgical laser fibers. RESULTS: Six patients underwent TORS with laser for early supraglottic and oropharyngeal squamous cell carcinomas. All approaches were successfully completed without the need for microscopic/open conversion or positive margins to the final pathological study. No intraoperative adverse events occurred and recovery was relatively quick, with no evidence of disease recurrence at the time of reporting, the short observation time notwithstanding. CONCLUSIONS: In our preliminary experience, TORS with laser showed feasible and promising results. Further studies are mandatory to demonstrate thulium laser benefits in surgical and oncological practice.

A Rare Presentation of Recalcitrant Oropharyngeal Stenosis in a 54-Year-Old Male Patient Following Transoral Robotic Surgery for Obstructive Sleep Apnea.

BACKGROUND Transoral robotic surgery (TORS) is an effective and safe option for obstructive sleep apnea syndrome (OSAS) patients with isolated retrolingual obstruction, as well as part of multilevel surgical approach in case of multilevel obstruction. Stenosis after TORS in OSAS patients is rarely described and no literature review has investigated this dramatic untoward event. CASE REPORT We report on a case of severe recalcitrant oropharyngeal stenosis after multilevel surgery with transoral robotic tongue base resection in an OSAS patient, leading to tracheotomy and gastrostomy dependence. Following the failure of numerous conservative therapeutic attempts, oropharyngeal patency was restored after extensive scar tissue removal through an open-neck approach, followed by a pharyngeal reconstruction with radial forearm free flap (RFFF). CONCLUSIONS Recalcitrant oropharyngeal stenosis is a dramatic complication that must be considered in OSAS patients submitted to TORS in a multilevel strategy and that is rarely described in the literature. A thorough review of the existing literature is presented to assess which factors are involved and the therapeutic strategies invoked in this scenario. The adoption of resection tools suited for robot-assisted surgery and the staging of TORS in case of multilevel surgery could decrease the risk of extensive scar formation. To date there is still no broad consensus on which therapeutic choice is the best for recalcitrant oropharyngeal stenosis. When minimally invasive treatments fail, a wide scar resection with a RFFF oropharyngeal reconstruction could be considered as a valuable option to restore the upper aerodigestive tract patency.

A multinational consensus on dysphagia in Parkinson's disease: screening, diagnosis and prognostic value.

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disorder characterized by a combination of motor and non-motor dysfunction. Dysphagia is a common symptom in PD, though it is still too frequently underdiagnosed. Consensus is lacking on screening, diagnosis, and prognosis of dysphagia in PD. OBJECTIVE: To systematically review the literature and to define consensus statements on the screening and the diagnosis of dysphagia in PD, as well as on the impact of dysphagia on the prognosis and quality of life (QoL) of PD patients. METHODS: A multinational group of experts in the field of neurogenic dysphagia and/or PD conducted a systematic revision of the literature published since January 1990 to February 2021 and reported the results according to PRISMA guidelines. The output of the research was then analyzed and discussed in a consensus conference convened in Pavia, Italy, where the consensus statements were drafted. The final version of statements was subsequently achieved by e-mail consensus. RESULTS: Eighty-five papers were used to inform the Panel's statements even though most of them were of Class IV quality. The statements tackled four main areas: (1) screening of dysphagia: timing and tools; (2) diagnosis of dysphagia: clinical and instrumental detection, severity assessment; (3) dysphagia and QoL: impact and assessment; (4) prognostic value of dysphagia; impact on the outcome and role of associated conditions. CONCLUSIONS: The statements elaborated by the Consensus Panel provide a framework to guide the neurologist in the timely detection and accurate diagnosis of dysphagia in PD.

Dye-Perfused Human Placenta for Vascular Microneurosurgery Training: Preparation Protocol and Validation Testing.

BACKGROUND: Human placenta is recognized as a valuable vascular microneurosurgery training model because of its abundant availability, ethical acceptance, and analogous vasculature with other vessels of the human body; however, human placenta laboratory preparation techniques are not well described in the literature. This study outlines a detailed and standardized laboratory protocol for preparation of a color-perfused human placenta model. Survey-based validation of the model is also reported herein. METHODS: The protocol involved cleaning and cannulation of the umbilical vein and arteries, irrigation with heparin, and storage at 3°C or freezing at -18°C. Before use, arteries were perfused with carmine/cochineal, and veins were perfused with methylthioninium chloride. A questionnaire with 5 questions was administered to 40 participants among attending or resident neurosurgeons, otolaryngologists, and maxillofacial surgeons on 4 consecutive microsurgical courses to assess the reliability of the placenta model. Trainees were divided into 3 groups based on their experience. A χ2 test was used to identify differences between groups. RESULTS: Forty-two placentas were considered appropriate for training and were successfully perfused with dyes. Thirty-three participants completed the questionnaire, of which most, especially advanced and intermediate participants, indicated the placenta as a valuable, accurate, and reproducible model. No differences were observed among the groups. CONCLUSIONS: The human placenta is an excellent tool for vascular microneurosurgery laboratory training. Color perfusion enhances the reliability of this model, which was validated by most surgeons, regardless of their experience.

Case Report: Exceptional Response to Avelumab After Failure of Electrochemotherapy in a Patient With Rapidly Progressive, PD-L1-Negative Merkel Cell Carcinoma.

This case report shows, for the first time, a patient experiencing a complete response after one dose of avelumab following extensive disease progression with prior electrochemotherapy (ECT) treatment. We suggest that ECT may help to establish a tumor microenvironment favorable to immunotherapy. Merkel cell carcinoma (MCC) is a highly aggressive skin cancer with seldom durable chemotherapy responses. ECT has recently emerged as a potential treatment option for several malignancies, including MCC. Avelumab, an anti-programmed cell death-ligand 1 (PD-L1) monoclonal antibody, became the first approved treatment for patients with metastatic MCC. ECT has been shown to activate the immune response, but it is still unknown how ECT may affect patient's response to subsequent immunotherapy. We report a case of a patient with MCC who presented with a rapidly growing skin nodule of the right cheek and experienced extensive disease progression following surgical debulking and ECT treatment. The patient received a flat dose of 800 mg avelumab intravenously every 2 weeks showing complete tumor regression after only one dose. Immunohistochemical analysis of surgical and post-ECT biopsies collected from the primary lesion revealed tumor expression of programmed cell death protein-1 (PD-1), but not PD-L1. Analysis of the tumor samples also revealed no expression of Merkel cell polyomavirus (MCPyV). Comparison of the biopsies showed a decrease in myeloid and T-cell markers after ECT but an increase in major histocompatibility complex (MHC) class I expression on tumor cells. Additionally, the patient experienced an increase in neutrophil-to-lymphocyte ratio and lactate dehydrogenase values post-ECT, which subsequently decreased with avelumab treatment. As of 30 October 2019, the patient was still receiving avelumab treatment and had an ongoing complete response. In this case report, a patient with PD-L1-negative and MCPyV-negative MCC who had disease progression following ECT experienced complete tumor regression with avelumab treatment, suggesting, for the first time to our knowledge, that ECT may help to establish a tumor microenvironment favorable to immunotherapy via a potential abscopal effect. Tumor-intrinsic PD-1 expression and modulation of MHC class I antigens after ECT may contribute to the clinical efficacy of avelumab in this context.

Consensus on the treatment of dysphagia in Parkinson's disease.

BACKGROUND: Dysphagia is common in Parkinson's disease (PD). The effects of antiparkinsonian drugs on dysphagia are controversial. Several treatments for dysphagia are available but there is no consensus on their efficacy in PD. OBJECTIVE: To conduct a systematic review of the literature and to define consensus statements on the treatment of dysphagia in PD and related nutritional management. METHODS: A multinational group of experts in the field of neurogenic dysphagia and/or Parkinson's disease conducted a systematic evaluation of the literature and reported the results according to PRISMA guidelines. The evidence from the retrieved studies was analyzed and discussed in a consensus conference organized in Pavia, Italy, and the consensus statements were drafted. The final version of statements was subsequently achieved by e-mail consensus. RESULTS: The literature review retrieved 64 papers on treatment and nutrition of patients with PD and dysphagia, mainly of Class IV quality. Based on the literature and expert opinion in cases where the evidence was limited or lacking, 26 statements were developed. CONCLUSIONS: The statements developed by the Consensus panel provide a guidance for a multi-disciplinary treatment of dysphagia in patients with PD, involving neurologists, otorhinolaryngologists, gastroenterologists, phoniatricians, speech-language pathologists, dieticians, and clinical nutritionists.

Morphological analysis of ischemia-reperfusion injury in a cold ischemia model of jejunal free flap for hypopharyngeal reconstruction.

BACKGROUND: Jejunal free flap (JFF) reconstruction is a popular treatment option for advanced hypopharyngeal cancer. Several factors including ischemia-reperfusion injury (IRI) can cause mucosal damage and progressive flap necrosis. We investigated the development and time-related progression of morphological and cellular changes in patients with JFF reconstruction including cold preservation of the graft. METHODS: Eleven patients were enrolled. Biopsies were taken during surgery from normally perfused tissue, before loop isolation (T0), at the end of back-table surgery (T1), immediately before reperfusion (T2), 15' after reperfusion (T3), and at the end of the digestive anastomoses (T4) and from the external monitor daily from the 1st to the 5th postoperative day (M1-M5). Histomorphological and immunohistochemical parameters in the intraoperative and postoperative samples were evaluated and compared. RESULTS: Delayed flap necrosis was observed in 2 patients. The cold ischemia phase did not negatively affect mucosal regeneration after reperfusion; morphological and cellular damage parameters returned to normal by the end of surgery or along the early postoperative period. Significant enterocyte replication activity was observed at the end of revascularization, which continued in the postoperative phase, leading to recovery of the epithelial morphological integrity and disappearance of apoptotic cells. An inflammatory infiltrate persisted in the M samples, and in a significant proportion of samples, mucosal fibrosis developed by the end of the postoperative observation. CONCLUSION: Cold perfusion and preservation of the JFF can effectively limit the negative effects of IRI and to prevent short- and medium-term complications that can compromise the final outcome.

Concurrent intra-arterial carboplatin administration and radiation therapy for the treatment of advanced head and neck squamous cell carcinoma: short term results.

BACKGROUND: The aim of the present study was to evaluate the survival, efficacy and safety of a modified RADPLAT-like protocol using carboplatin instead of cisplatin. METHODS: Fifty-six patients with primary head and neck squamous cell carcinoma received 4 cycles of intra-arterial carboplatin (350 mg/m2 per cycle every 2 weeks), with concurrent three-dimensional conformal radiation therapy. RESULTS: Two major and 4 minor complications were observed. Forty-five of the 56 patients (80%) completed the protocol, while 11 (20%) patients had to discontinue the intra-arterial infusions due to the occurrence of severe haematological toxicity, but were able to complete radiotherapy. Forty-four (98%) of the 45 patients who completed the protocol and 10 (91%) of the 11 who did not, were free of disease at the end of the treatment, for a comprehensive 96% of CR overall. After a median 23.55 months (range: 2 to 58 months) of follow-up, 40 patients (71%) are alive and disease-free, 1 (2%) is alive but affected by disease and 15 (27%) have died of the disease or other causes. CONCLUSION: Intra-arterial carboplatin administration with concurrent three-dimensional conformal radiation therapy seems to be a promising alternative to RADPLAT in the treatment of advanced head and neck tumours. Haematological and non-haematological toxicities are virtually similar, but carboplatin has the advantage in that it is not nephrotoxic and can be used at very high doses without any significant increase in the extent of side effects.

Transoral Robot-Assisted Surgery in Supraglottic and Oropharyngeal Squamous Cell Carcinoma: Laser Versus Monopolar Electrocautery.

BACKGROUND: Monopolar electrocautery (EC) is the surgical cutting and haemostatic tool most commonly used for transoral robotic surgery (TORS). The aim of this study was to retrospectively compare EC efficacy in the treatment of patients affected by T1 or T2 oropharyngeal and supraglottic squamous cell carcinomas with the more recently introduced laser fibres. METHODS: We considered all TORS patients admitted to our department from January 2010 to June 2019. The outcomes of patients treated with Thulium: yttrium aluminium garnet (YAG) laser (TY-TORS), CO2 laser (CO2-TORS) and EC (EC-TORS) were analysed in order to assess surgical performances, functional outcomes and postoperative complications. RESULTS: Twenty patients satisfied the enrolling criteria, of which nine underwent laser-TORS, and the remaining 11 underwent EC-TORS. In all candidates, TORS procedures were completed without the need for microscopic/open conversion. Close or positive margins were significantly more frequent in EC-TORS (p = 0.028). A considerable difference was found in overall functional parameters: times of nasogastric tube and tracheostomy removal and time of hospital discharge were significantly shorter in laser-TORS (p = 0.04, p = 0.05, p = 0.04, respectively). CONCLUSIONS: Laser-TORS showed better results in comparison with EC-TORS in term of tumour resection margins and patient functional outcomes. Our findings can be justified with the greater tissue thermal damage caused by EC-TORS, despite prospective randomized trials and increased patient numbers being needed to confirm these preliminary conclusions.

Reconstruction of the hypopharynx after free jejunum flap failure: is a second free jejunum transfer feasible?

Reconstruction after circumferential pharyngolaryngectomy is a challenging problem. Reconstruction methods should ensure an appropriate mucosa lining of the digestive tract, preferably already tubulized, and peristalsis. Despite the high reported success rates, the jejunum flap is still occasionally lost due to thrombosis of the pedicle and/or fistula formation. Five cases of circumferential pharyngolaryngectomy in which failure of the jejunum loop was managed with a second free or pedicle flap are presented. A second free jejunum was reliable in selected patients, depending on time of detection of flap necrosis, on bacterial control of the wound and on the vascular or general conditions. For this reason, careful monitoring of the flap and clinical signs of necrosis in the first 5 post-operative days is crucial to prevent the formation of fistulas and infection and to increase the possibility of using this kind of salvage surgery. Pedicle flaps should be used only in the event of severe complications because of their high risk of post-operative salivary fistulas.

Sternocleidomastoid muscle flap in esophageal perforation repair after cervical spine surgery: concepts, techniques, and personal experience.

STUDY DESIGN: A retrospective report was conducted on clinical and instrumental data of 3 patients treated for esophageal perforation after anterior cervical spine surgery. OBJECTIVE: To define indications and evaluate the safety and effectiveness of surgical repair of esophageal perforations by means of sternocleidomastoid (SCM) muscle flap in the setting of anterior spinal surgery. SUMMARY OF BACKGROUND DATA: Esophageal perforation is an occasional or underreported complication in anterior cervical spine surgery. To prevent its potentially devastating and even life-threatening sequelae, prompt diagnosis and treatment are required. No treatment protocol has yet been standardized. In addition to conservative measures, several surgical approaches have been presented, ranging from primary repair to reconstruction with local, regional, or distant flaps. METHODS: Primary spinal pathology and intervention, esophageal fistulae morphology, diagnostic work-up, clinical course, and surgical techniques for their repair are illustrated in each case. Follow-up data have been gathered by in-person visits. RESULTS: Mean time from discovery of perforation to definitive surgical treatment institution was 44.3 days (range: 34 to 61 d). SCM muscle flap way used as reinforcement and protection of a primary esophageal suture in 2 cases and as a patch to the perforation in 1 case. All the fistulae healed without further complications. Mean time to oral feeding resumption was 17.6 days (range: 10 to 27 d) and mean hospitalization time was 19 days (range: 11 to 28 d). All the patients presented with a free oral diet at the last follow-up check. CONCLUSIONS: Esophageal perforation treatment has to be multidisciplinary and tailored on each individual case. SCM muscle flap, used as reinforcement of a primary suture or as a patch to the lesion, has proved to be effective as definitive treatment for persisting or recurring esophageal fistulae after anterior cervical spine surgery. In this setting, conservative treatments may be inadequate or may actually perpetuate the condition.

Hypopharyngeal squamous cell carcinoma and laryngeal neuroendocrine carcinoma colliding in the aryepiglottic fold: a case report.

PURPOSE: A collision tumor consists of 2 different histologically distinct and topographically independent tumors merging in the same mass. In the head and neck region they are rare, with only 4 cases reported in the larynx. CASE REPORT: A 60-year-old heavy smoker complained of a left submandibular lesion in October 2014. The lesion was excised and showed a poorly differentiated carcinoma, suggestive for adenocarcinoma. After a positron emission tomography-computed tomography scan showed increased metabolic activity in the left laterocervical region and right vocal cord, the patient underwent endoscopic biopsy of the lesion of the left piriform sinus, which was positive for moderately differentiated squamous cell carcinoma (SCC). He was then submitted to circular pharyngolaryngectomy, reconstruction with a radial forearm free flap, and bilateral neck dissection. The histopathologic examination showed an in situ and microinvasive SCC of the left pyriform sinus colliding with a high-grade, non-small-cell neuroendocrine carcinoma of the larynx. CONCLUSIONS: To our knowledge, this is the first case described of laryngeal collision tumor comprising a neuroendocrine component. The choice of treatment of this kind of lesion is difficult because of the presence of 2 different histologies and of the controversial prognostic correlation of non-small-cell neuroendocrine neoplasms of the head and neck region.