Following the canyon to reach and remove olfactory groove meningiomas.

BACKGROUND: Olfactory groove meningiomas (OGMs) represent approximately 10% of all intracranial meningiomas. They arise in the olfactory fossa, a variable depression delimited by the lateral lamella and perpendicular plate. The cribriform plate with the lateral lamella and ethmoidal and orbital roof could be viewed as a 'canyon' with the frontal sinus as the main entrance. METHODS: Between January 2000 and December 2013, 32 consecutive patients underwent removal of OGMs through this 'canyon' at the Department of Neurosurgery of Brescia and Turin. Complete removal was achieved in all patients with this trans-frontal sinus subcranial approach (Simpson grade I; mean lesion volume, 46.6 cm3). RESULTS: Five patients (15.6%) experienced nasal CSF leakage, treated with external lumbar drain positioning for 4 days and resolved in all cases but one, which was re-operated. Two patients (6.2%) during the CSF leakage experienced meningitis at day 7 after surgery, both successfully treated by intravenous antibiotic therapy. After one month, one patient developed hydrocephalus, treated with a ventricular peritoneal shunt. In one patient, traction on the OGM caused bleeding of the callosomarginal artery, which was coagulated with superior frontal gyrus ischemia without neurological consequences. Glasgow Outcome Scale Score at 6 months was V in 29 patients, IV in one patient, and I in two patients. CONCLUSIONS: Advantages with this approach may include easy and early control of blood supply from its insertion in the skull base, minimal frontal lobe retraction, preservation of the frontal veins draining to the sagittal sinus, and a satisfactory aesthetic outcome.

The origin of regional failure in oral cavity squamous cell carcinoma with pathologically negative neck metastases.

IMPORTANCE: Squamous cell carcinoma of the oral cavity (OSCC) is a common malignant tumor worldwide. OBJECTIVE: To determine if regional failure in patients with OSCC and pathologically negative neck nodes (pN-) is due to an incomplete sampling procedure during surgery. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed the medical records of 2258 patients from 11 cancer centers worldwide who underwent neck dissection for OSCC (1990-2011) and who were pN-. Of those, 345 had clinical evidence of nodal metastases (cN+) on radiologic workup. The neck specimens were available for reanalysis in 193 patients. Survival rates were calculated using the Kaplan-Meier graphs and analyzed by multivariable analysis. MAIN OUTCOMES AND MEASURES: Five-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). RESULTS: Resectioning and analysis of the neck dissection specimens in the cN+/pN- subgroup revealed false-negative results in 29 (15%) of 193 patients. The negative predictive value of the initial pathologic examination was 85%. The 5-year OS and DSS in the cN-/pN- group were 77.6% and 87.2%, respectively. The 5-year OS and DSS of the cN+/pN- group were 62.6% and 78.5%, respectively (P < .001). In multivariable analysis, cN+ classification was significantly associated with poor OS (hazard ratio [HR], 1.7; 95% CI, 1.1-3.8; P = .03) and poor DSS (HR, 1.46; 95% CI, 1.1-4.1; P = .04). A cN+ classification was associated with lower DFS (66.3% vs 76.2%; P = .05) and lower regional recurrence-free survival (68.6% vs 78.8%; P = .02) but not with local (P = .20) or distant recurrence (P = .80). CONCLUSIONS AND RELEVANCE: Pathologic staging underestimates the incidence of nodal metastases in cN+ disease. After correction for pathologically missed nodal metastases, radiologic evidence of neck nodes is an independent predictor of outcome, suggesting that traditional sampling during surgery might miss metastases, and this fact might explain the origin of treatment failure in these patients.

Circulating tumour cells in locally advanced head and neck cancer: preliminary report about their possible role in predicting response to non-surgical treatment and survival.

BACKGROUND AND PURPOSE: The mechanism of dissemination of locally advanced head and neck cancer (LAHNC) is far to be resolved. Circulating tumour cells (CTC) have been identified as a prognostic factor in metastatic breast and prostate cancer. This prospective multi-centric analysis studied the possible role of CTC identification in LAHNC. MATERIALS AND METHODS: CTC were searched in 73 patients with LAHNC (oropharynx, n=39; nasopharynx, n=10; larynx, n=10; paranasal sinuses, n=6, of whom 3 with sinonasal undifferentiated carcinoma, SNUC; hypopharynx, n=5; oral cavity, n=3). All of them (apart from SNUC) had squamous cell cancers. The relationship between CTC positivity and other clinical prognostic factors has been investigated. Response to treatment and survival has been related with changes in CTC number during the treatment. RESULTS: CTC were frequently identified in oro- and hypopharyngeal cancer and in SNUC. They were more frequent in stage IV than in stages I-III disease (18% versus 6%, p=NS (not significant)). Partial or complete response (CR) was related with the absence or disappearance of CTC during treatment (p=0.017). A decrease in the CTC number or their absence throughout the treatment seems also related with non-progressive disease, after both complete or incomplete remission and with the proportion of patients alive and NED (no evidence of disease) (p=0.009). CONCLUSIONS: These preliminary data suggest a possible role of CTC determination in head and neck cancer. Additional and longer follow up data need to be collected to confirm these findings.

Prevalence and localization of nodal metastases in squamous cell carcinoma of the oral cavity: role and extension of neck dissection.

Lymph node (LN) metastases represent the most important negative prognostic factor in squamous cell carcinoma (SCC) of the oral cavity, even though controversies still exist regarding their management. The aim of this study was to retrospectively analyze our experience in surgical management of SCC of the oral cavity with particular focus on the prevalence and localization of lymph nodal metastases and recurrences. The clinical records of 89 consecutive patients treated from 1983 to 2002 by concomitant surgery on both the T and N sites, excluding those undergoing salvage surgery, were reviewed. A total of 119 neck dissections (ND) were performed. Survival outcomes were calculated by the Kaplan-Meier method, while univariate comparisons by the log-rank and non-parametric tests were performed between different groups of patients. Five-year overall and determinate survivals were 50 and 57%, respectively. LN metastases were observed in 52% (56% of these showing extracapsular spread) and their presence strongly correlated with determinate survival (p < 0.0001). The prevalence of clinical and occult nodal disease was not related to the pT status. Neck levels II (59%) and I (56%) were most frequently involved. Metastases to level IV accounted for 15% of positive LN, even though 28% of them turned out to be skip metastases. Five neck recurrences were observed, only one of which was salvaged by surgery. The high prevalence of clinical and occult LN metastases in this setting suggests that ND should be performed on a nearly routine basis, even for lesions with a low-T category and a cN0 neck. Moreover, ND should always encompass level IV due to the possibility of skip metastases, particularly in tumors involving the oral tongue. In patients with a cN+ neck, levels from I to V should be addressed, particularly in the presence of metastases at levels III and IV.

Cervical spondylodiscitis: a rare complication after phonatory prosthesis insertion.

BACKGROUND: Tracheoesophageal puncture has excellent voice rehabilitation after total laryngectomy. However, despite its easy insertion and use, severe complications have been reported. METHODS: We report a case of cervical spondylodiscitis, occurring in a 67-year-old woman submitted to phonatory prosthesis insertion. After 1 month, she complained of severe cervicalgia associated with fever. Spondylodiscitis involving C6, C7, and the intervening vertebral disk with medullary compression was detected by means of imaging studies. RESULTS: A right cervicotomy with drainage of necrotic tissue was performed, and a de-epithelialized fasciocutaneous deltopectoral flap was interposed between the neopharynx-esophagus and the prevertebral fascia to protect the neurovascular axis. MR performed 1 month later showed a complete resolution of the infectious process. CONCLUSIONS: Severe neck pain after tracheoesophageal puncture should alert the physician about the possibility of a cervical spondylodiscitis. MR is the most useful imaging technique for preoperative and postoperative evaluation. When neurologic symptoms are detected, surgical exploration of the neck is mandatory.

Penetrating foreign body mimicking supraglottic carcinoma.

Penetrating trauma to the neck is a rare observation. We report the first case of laryngeal myofibroblastic tumor due to a persistent splinter of glass in the preepiglottic space, which presented with recurrent mild hemoptysis and cough, and mimicked supraglottic carcinoma. The clinical and imaging evaluations are herein reported. Finally, medical and surgical options in the management of this unusual observation are discussed.

Endoscopic treatment of cT2 glottic carcinoma: prognostic impact of different pT subcategories.

OBJECTIVES: The cT2 glottic squamous cell carcinomas are a heterogeneous group of lesions in terms of superficial and deep extension. As a consequence, they differ greatly in treatment indications and prognosis. The aim of the present study was to divide cT2 glottic tumors into subcategories according to radiologic and postoperative histopathologic information, in order to identify risk factors connected with determinate survival, local-regional control, and laryngeal preservation rates. METHODS: We retrospectively analyzed 55 cT2 glottic lesions treated at a single institution by carbon dioxide laser with at least 2 years of follow-up. Clinical, radiologic, surgical, and histopathologic data were reviewed, and the tumors were accordingly divided into 5 subcategories: I, or pT2 with lateral supraglottic extension (19 patients); II, or pT2 with lateral subglottic extension (6 patients); III, or pT2 with supracommissural and/or subcommissural extension (10 patients); IV, or pT2 with deep vocal muscle infiltration (14 patients); and V, or pT3, for superior and/or inferior paraglottic space invasion lateral to the thyroarytenoid muscle not detected before operation by computed tomographic scan (6 patients). RESULTS: The disease-free survival, ultimate local control with laser alone, and laryngeal preservation rates were compared for each subcategory. Statistically significant differences were found only for the pT3 subgroup (2-year rates of 16.7%, 16.7%, and 16.7% for pT3 versus 5-year rates of 80.5%, 84.7%, and 93.3% for the entire pT2 group). CONCLUSIONS: Endoscopic treatment of cT2 glottic tumors can be considered effective when the pT2 stage has been confirmed. In cT2/pT3 patients, after the first endoscopic resection that allows the correct pT staging, additional treatment should always be considered.

Benign myoepithelioma of the lacrimal gland: report of a case.

Myoepithelioma of the lacrimal gland is an extremely rare monomorphic adenoma, with only six previously reported cases in the literature. We herein report the radiological, clinical and histopathological evaluation of a 46-year-old patient with a history of right eye proptosis and progressive diplopia. A mass in the right lacrimal fossa was detected at MRI and turned out to be benign myoepithelioma of the lacrimal gland at the histopathological examination. The patient underwent excision of the mass by means of a coronal bitemporal approach and lateral orbitotomy. The lesion was entirely removed "en-bloc" with the lacrimal gland. MRI did not show any evidence of recurrent disease 12 months after surgery. The patient was clinically free of disease after 22 months. Surgery is the treatment of choice for this kind of lesion. The coronal bi-temporal approach herein reported offered good exposure of the entire lesion and a satisfactory aesthetic result. Periodic postoperative radiological evaluations with MRI are mandatory.

Analysis of recurrences in 322 Tis, T1, or T2 glottic carcinomas treated by carbon dioxide laser.

An endoscopic approach to early glottic carcinoma is considered a sound treatment for both previously untreated lesions and selected recurrent lesions. Between January 1988 and December 2000, we treated 322 patients by CO2 laser at a single institution; 37 had Tis, 191 T1a, 55 T1b, and 39 T2 lesions (mean follow-up, 77 months; range, 6 to 180 months). Kaplan-Meier curves showed a 5-year overall survival rate of 88%, a determinate survival rate of 99%, a disease-free survival rate of 81%, a rate of ultimate local control with laser alone of 91%, and a laryngeal preservation rate of 97%. Univariate and multivariate analysis showed that the only factor that statistically affected endoscopic control was lateral extension of the tumor with involvement of the bottom of the ventricle (hazard risk ratio, 4.0; 95% confidence interval, 1.71 to 9.35). The 58 recurrences were classified according to their location compared with the site of the primary tumor as follows: 14 in the same area (group A), 27 in adjacent subsites with superficial spreading or multifocal distribution (group B), and 17 in adjacent sites by submucosal diffusion to the visceral spaces, cartilaginous framework, or extralaryngeal tissues (group C). For each group, we analyzed the rate of patients who underwent salvage by endoscopic or open neck procedures and the rate of laryngeal preservation. Recurrences in groups A and B were endoscopically treated in 86% and 74% of cases, respectively. By contrast, in group C no patient was endoscopically cured, and there was a low laryngeal preservation rate (47%). The pathways of spread in recurrent carcinoma are therefore the single most important factor in predicting its endoscopic curability.

Diagnostic accuracy of magnetic resonance imaging in the assessment of mandibular involvement in oral-oropharyngeal squamous cell carcinoma: a prospective study.

OBJECTIVE: To evaluate the sensitivity, specificity, accuracy, and predictive values of magnetic resonance imaging (MRI) in the assessment of mandibular involvement in oral-oropharyngeal squamous cell carcinoma. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Forty-three patients with oral or oropharyngeal squamous cell carcinoma undergoing marginal or segmental mandibulectomy between January 1, 1994, and January 31, 2003. INTERVENTIONS: Indications for mandibulectomy were MRIs suggestive of bony invasion, tumor involving the retromolar trigone or the alveolar ridge, recurrent or persistent lesion, or intraoperative suspicion of periosteal invasion. Detection of tumor signal replacing the hypointense cortical rim was considered the main radiologic finding for mandibular invasion. MAIN OUTCOME MEASURES: The MRI findings were subsequently compared with histopathologic data of surgical specimens with reference to the presence of cortical and/or medullary mandibular involvement. RESULTS: Sixteen patients had MRI findings suggestive of mandibular involvement. Segmental mandibulectomy was performed in 15 cases and marginal resection in the remaining case. In 14 patients, bony invasion was confirmed. All of the other 27 patients who underwent marginal or segmental mandibulectomy with negative MRI findings had no histopathologic evidence of mandibular involvement, except in 1 patient: on histopathologic examination, despite cortical integrity, neoplastic vascular embolization into the bony lacunae was detected. Sensitivity of MRI in detecting mandibular involvement was 93%; specificity, 93%; accuracy, 93%; and negative and positive predictive values, 96% and 87.5%, respectively. CONCLUSIONS: Magnetic resonance imaging is commonly considered the technique of choice for treatment planning in advanced oral and oropharyngeal squamous cell carcinoma because of its accuracy in depicting soft-tissue involvement. This study demonstrates the additional diagnostic value of MRI in detecting bone invasion.

Thyroid metastasis from rectal adenocarcinoma involving the airway treated by crico-tracheal resection and anastomosis: the role of palliative surgery.

A 59-year-old woman underwent surgical removal of a pT3N3M0 rectal adenocarcinoma (RAC) through an abdominal-perineal approach followed by chemoradiotherapy (CHT-RT) in 1995. She underwent a right inferior lobectomy for a lung metastasis 3 years later, followed in 2000 by an additional intervention for a second metastasis that was treated by a left superior atypical lobectomy and CHT. The patient complained 1 year later of dysphagia and an anterior neck mass was found. US examination detected a multifocal lesion in the thyroid gland with involvement of the strap muscles, which was confirmed by FNAB to be a third RAC metastasis. A palliative course of RT was performed, but no regression of the lesion was observed. Crico-tracheal infiltration was also suspected after CT scan. The patient was in good general condition and strongly favored surgery. In August 2001 she underwent total thyroidectomy, total parathyroidectomy, strap muscles excision, central compartment neck dissection and crico-tracheal resection and anastomosis involving the anterior arch of the cricoid between the crico-thyroid joints and the first three tracheal rings. She was extubated at the end of the surgical procedure with no tracheotomy, started an oral diet the day after, and was discharged without complications 9 days later. She was followed up monthly by endoscopy and has undergone one CT and two MR scans at 6-month intervals. The patient had no RAC recurrence in the neck when last seen 26 months after surgery. During this time, she underwent four further lung metastasectomies followed by CHT.

Inflammatory myofibroblastic tumor of the temporal bone.

Inflammatory myofibroblastic tumors include a diverse group of lesions characterized by inflammatory cell infiltration and variable fibrotic responses. Occurrence in the temporal bone is unusual. We present CT and MR imaging findings of an inflammatory myofibroblastic tumor of the temporal bone in a 26-year-old patient with repeated paroxystic episodes of rotatory vertigo that occurred over a few days. CT and MR imaging revealed a homogeneously enhancing soft-tissue mass of the right mastoid with bone erosion of the tegmen and extensive dural thickening. The mass resembled a malignant tumor, and the patient underwent an extended mastoidectomy through a retroauricular approach. Microscopic examination showed myofibroblastic spindle cells with mixed inflammatory infiltrate, and the pathologic diagnosis was inflammatory myofibroblastic tumor.

Endoscopic management of laryngo-tracheobronchial amyloidosis: a series of 32 patients.

Between June 1983 and December 2002, 32 patients were treated for primary localized laryngo-tracheobronchial amyloidosis (LTBA) at our institution. For enrollment in this retrospective study, at least one positive biopsy with Congo red stain and a diagnostic test battery excluding systemic or secondary amyloidosis were mandatory. The most common presenting symptom was dyspnea, which was observed in 75% of cases. Endoscopic appearance was described as submucosal plaques and nodules with a cobblestone appearance in 44% of patients, tumor-like in 28% and circumferential wall thickening in 28% of cases. Tracheobronchopatia osteochondroplastica was associated with LTBA in 22% of patients, both at the first treatment (four cases) or during follow-up examinations (three). Synchronous or metachronous disease in the larynx and tracheobronchial tree was observed in 47% of cases, while only one patient showed lung involvement with extensive amyloidosis of the trachea and bronchi. All but two patients were endoscopically treated. One of these was affected by a tracheal amyloidoma cured by endoscopic debulking and further tracheal resection-anastomosis. The other patient presented massive laryngo-pharyngeal involvement and was therefore treated by total laryngectomy. A total of 58 endoscopic procedures (range: 1-7; mean: two per patient) were carried out, 11 with CO2 laser (for supraglottic, glottic and selected subglottic lesions) and 47 with Nd:YAG laser (for the most part of subglottic lesions and amyloid deposits located in trachea and bronchi). Four patients required a tracheotomy and three necessitated a T-tube stent during management, which was subsequently removed in all cases. One patient was lost to follow-up, nine were endoscopically controlled elsewhere (Group A) and 22 were followed at our institution (Group B). In Group A, the patient with tracheal amyloidoma is asymptomatic and free of additional LTBA localizations 8 years after surgery. The remaining eight are asymptomatic, but with persistent endoscopic signs of amyloidosis. In Group B, five patients died: one from heart failure and another one from pneumonia 3 and 4 days after surgery, respectively. In one case death was from unrelated causes, and in the two remaining patients it was from respiratory failure due to uncontrolled bilateral bronchial amyloidosis in the subsequent 5 to 6 years. One patient is completely cured 5 years after surgery, and 16 are asymptomatic with persistence of LTBA.

Head and neck intramuscular haemangioma: report of two cases with unusual localization.

Head and neck intramuscular haemangioma (IMH) is a benign, uncommon neoplasm arising most frequently in the masseter and trapezius muscles. It usually appears as an enlarging mass without specific clinical features and is therefore frequently misdiagnosed. We report two cases of IMH at unusual localizations: one involving the pterygoid muscles in a 30-year-old female and another one originating from the thyrohyoid muscles in a 38-year-old male. Preoperative evaluation included routine ENT examination, ultrasound (US) and CT scan. The preoperative clinical diagnoses were lymphangioma of the parapharyngeal space in the first case and atypical thyroid duct cyst in the second. Both patients were treated with open-neck approaches. The histopathologic diagnosis was capillary-type IMH in the first patient and cavernous-type IMH in the second. Postoperative courses were uneventful, and the patients were discharged within a few days. Clinical and US follow-ups were negative at 50 and 20 months, respectively. Preoperative diagnosis of head and neck IMH is rendered difficult by its rarity and non-specific clinical findings. Ample surgical excision is required for an adequate cure due to the frequent microscopically infiltrative pattern of diffusion of such a tumor into skeletal muscles, and long-term follow-up is mandatory to promptly treat any recurrence.