Transoral robotic surgery for oropharyngeal cancer: a systematic review on the role of margin status.

INTRODUCTION: Nowadays, robotic surgery finds application in the field of head and neck in the treatment of oropharyngeal tumors. The aim of this work is to examine the efficacy of transoral robotic surgery (TORS) in performing safe oncological resections of oropharyngeal squamous cell carcinoma (OPSCC), with particular attention to the status of margins. EVIDENCE ACQUISITION: Literature search of English-language studies focused on TORS through PubMed, the Cochrane Library and EMBASE databases. A total of 431 papers returned to search, but only 24 met the inclusion criteria. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. EVIDENCE SYNTHESIS: Within the selected studies, the overall rate of OPSCC positive margins following TORS is minimal, especially when patient selection is adequate and when TORS is used by high volume centers. CONCLUSIONS: TORS is a very precise and viable therapeutic tool that provides good results in terms of surgical radicality with low positive margin rates and good results in terms of overall survival and disease-free survival; however, there is still a great heterogeneity in margins definition within the available literature. Consequently, even if this surgical approach is very promising, it is still challenging to draw firm conclusions nowadays.

Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas.

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.

Trans oral robotic surgery for oropharyngeal cancer: A multi institutional experience.

OBJECTIVES: Trans Oral Robotic Surgery (TORS) has proved to be a safe and feasible treatment for oropharyngeal squamous cell carcinoma (OPSCC). The aim of this study is to analyse oncological outcomes of OPSCC patients treated with TORS. MATERIALS AND METHODS: This study involved 139 patients with OPSCC, treated with TORS between 2008 and 2020. Clinicopathological characteristics, treatment details and oncological outcomes were evaluated retrospectively. RESULTS: The management strategies included TORS alone in 42.5%, TORS-RT in 25.2% and TORS-CRT in 30.9%. The ENE was noted in 28.8% of neck dissections. In 19 patients clinically classified as unknown primaries, the primary was found in 73.7%. Rates of local, regional relapses and distant metastasis were 8.6%, 7.2%, and 6.5%, respectively. The 5 year- Overall Survival and Disease Free Survival were 69.6% and 71.3%, respectively. CONCLUSION: TORS fits well in the modern management of OPSCC. Although definitive CRT remains a milestone, TORS is proving to be a valid and safe treatment option. The choice of the therapeutic strategy requires evaluation by a multidisciplinary team.

Reconstructive Options after Oncological Rhinectomy: State of the Art.

BACKGROUND: The nose is a central component of the face, and it is fundamental to an individual's recognition and attractiveness. The aim of this study is to present a review of the last twenty years literature on reconstructive techniques after oncological rhinectomy. METHODS: Literature searches were conducted in the databases PubMed, Scopus, Medline and Google Scholar. "Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA)" for scoping review was followed. RESULTS: Seventeen articles regarding total rhinectomy reconstruction were finally identified in the English literature, with a total of 447 cases. The prostheses were the reconstructive choice in 213 (47.7%) patients, followed by local flaps in 172 (38.5%) and free flaps in 62 (13.8%). The forehead flap (FF) and the radial forearm free flap (RFFF) are the most frequently used flaps. CONCLUSIONS: This study shows that both prosthetic and surgical reconstruction are very suitable solutions in terms of surgical and aesthetic outcomes for the patient.

Deciphering the Genomic Landscape and Pharmacological Profile of Uncommon Entities of Adult Rhabdomyosarcomas.

Adult rhabdomyosarcoma (RMS) represents an uncommon entity with an incidence of less than 3% of all soft tissue sarcomas (STS). Consequently, the natural history and the clinical management of this disease are infrequently reported. In order to fill this gap, we investigated the molecular biology of an adult RMS case series. The expression of epithelial mesenchymal transition-related gene and chemoresistance-related gene panels were evaluated. Moreover, taking advantage of our STS translational model combining patient-derived primary culture and 3D-scaffold, the pharmacological profile of an adult head and neck sclerosing RMS was assessed. Furthermore, NGS, microsatellite instability, and in silico analyses were carried out. RT-PCR identified the upregulation of CDH1, SLUG, MMP9, RAB22a, S100P, and LAPTM4b, representing promising biomarkers for this disease. Pharmacological profiling showed the highest sensitivity with anthracycline-based regimen in both 2D and 3D culture systems. NGS analysis detected RAB3IP-HMGA2 in frame gene rearrangement and FGFR4 mutation; microsatellite instability analysis did not detect any alteration. In silico analysis confirmed the mutation of FGFR4 as a promising marker for poor prognosis and a potential therapeutic target. We report for the first time the molecular and pharmacological characterization of rare entities of adult head and neck and posterior trunk RMS. These preliminary data could shed light on this poorly understood disease.

Synchronized "One-Step" Resection and Cranio-Orbital Reconstruction for Spheno-Orbital Lesions With Custom Made Implant.

BACKGROUND: In the last few years, skull base tumors involving the fronto-orbital region have been approached with complex, invasive, and time-consuming cranial reconstruction techniques. On the other hand, recent custom-made implants allow easier and faster procedures, with excellent aesthetic results. The authors propose an easy surgical-planned protocol with a synchronized "one-step" resection and reconstruction of these complex lesions, with a preformed poly-methyilmethacrylate (PMMA) cranioplasty. METHODS: Our technique consists of a 2-phases procedure. In the first one, the so-called "virtual" phase, the authors get a tailored 3D-PMMA model based on high-resolution (HR) CT-scans of the patient's skull. Afterward, the authors perform the planned craniotomy on the 3D-PMMA model with the assistance of intraoperative navigation system. Therefore, a further CT-scan of the resected model is performed to develop the final implant. In the second phase, the "surgical phase," a single procedure consisting in a cranial resection and custom reconstruction is performed with the assistance of stealth-navigation. The authors describe 6 cases of complex fronto-orbital-sphenoidal benign tumors that required skull reconstruction. All patients were examined 3 months after surgery through cosmetic (facial and eyes symmetry and globe position) and ophthalmology tests (visual field, visual impairment, and diplopia). Postsurgical HR CT-scans of the head and MRI-scans of the brain documented a total resection of the tumor and an optimal accuracy of skull reconstruction. RESULTS: In all cases, the authors obtained a highly accurate skull reconstruction following cranio-orbital tumor resection, with a less aggressive and faster procedure compared to autologous bone graft. Final cosmetic and functional results were excellent, with good results in cases of presurgical exophthalmos and orbital asymmetry. None of the patients developed implant-related complications. CONCLUSIONS: The "one-step" resection and reconstruction of benign tumors involving the spheno-orbital region with neuronavigation assistance is a technique that allows an accurate tumor removal and a cranial-bone reconstruction within a single surgical procedure, with fewer complications and excellent cosmetic and functional results.

Accuracy of Fibula Reconstruction Using Patient-Specific Cad/Cam Plates: A Multicenter Study on 47 Patients.

OBJECTIVES: This prospective study evaluated the accuracy of mandibular reconstruction using free fibular flaps (by comparing virtual plans to the three-dimensional postoperative results), and the extent of bone-to-bone contact after computer-assisted surgery. METHODS: We included 65 patients who underwent partial-continuity mandibular resections from February 2013 to January 2017, and evaluated virtual planning, surgical techniques, and accuracy. RESULTS: Forty-seven patients were analysed. A total of 112 fibular segments received 54 implants. We measured 227 distances between landmarks to assess the accuracy of reconstruction. Postoperative reconstruction accuracy ranged from 0.5 to 3 mm. CONCLUSION: Virtual surgical planning very accurately translated simulation into reality, particularly in patients requiring large, complex mandibular reconstructions using multiple fibular segments. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2169-E2175, 2021.

Surgical fenestrated approach to the maxillary sinus like alternative to Caldwell-Luc technique.

INTRODUCTION: In the last few years the surgical treatment of patients with maxillary sinus disease has shifted from more invasive maneuvers to more conservative approaches in order to save intraoral mucosa. Recently, some authors have proposed a modification to the classical Caldwell-Luc's approach (CL) for the removal of dental implants displaced into the maxillary sinus. The modified approach involves a fenestrated approach to the maxillary sinus. The bony pedicled windows of maxillary sinus in some selected cases may limit some of the most common complications and it may reduce healing times. EVIDENCE ACQUISITION: Evaluation of the middle term results of a maxillary fenestrated sinus approach as an alternative technique to CL and review of literature. EVIDENCE SYNTHESIS: From 2013 to 2017 thirty-one patients were treated with the CL modified technique, most of which for foreign bodies, displacement of endodontic material and implants in the maxillary sinus, large mucoceles and odontogenic maxillary sinusitis. All patients were subjected to clinical, and in some cases radiological, from 6 months to 18 months follow-up. Different combinations of Keywords and MeSH term were used for the bibliographic research in the main search engines (PubMed, Cochrane library, Medline). Inclusion criteria - fenestrated approach to the maxillary sinus, postoperative complications, description of the operative case. CONCLUSIONS: No complications occurred in the intraoperative period and during the months of follow-up. There has been no recurrence of the starting problem and all treated patients were free from residual maxillary pathology 18 months after surgery. Four works meeting the inclusion criteria were identified. The surgical fenestrated approach to the maxillary sinus is a valid alternative to the classical Caldwell-Luc techniques that, alone or in combination with endoscopic sinus surgery, allow to treat foreign bodies of maxillary sinus, of mucoceles and other diseases of the maxillary sinus. The proposed technique does not require particular surgical skills, it does not increase the operating time and can also be performed under local anesthesia.

The role of intraoperative nerve monitoring in tracheal surgery: 20-year experience with 110 cases.

PURPOSE: To determine the utility of intraoperative nerve monitoring (IONM) during tracheal resection or slide tracheoplasty to prevent recurrent laryngeal nerve injury. METHODS: 110 patients underwent tracheal resection or tracheoplasty between 1997 and 2016. During the first 10-year period, IONM was not used while during the second 10-year period, IONM was used. 49 patients had surgery without IONM while 61 had surgery with IONM. During the post-operative period, patients with nerve injury were compared to determine if significant difference existed between the two modalities. RESULTS: In patients who had surgery without IONM, 7 (14.2%) patients were found to have compromised nerve function whereas 8 (13.1%) patients in the group with IONM had nerve injury. 3 patients regained function in the first group while four regained function in the second. A Fisher's exact test was run on the entire cohort and the difference in vocal fold injury was not found to be statistically significant (p > 0.05). CONCLUSION: Based on this single surgeon experience, there may be no protective benefit with the use of IONM during tracheal surgery.

Posterior atrophic jaws rehabilitated with prostheses supported by 5 x 5 mm implants with a novel nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. One-year results from a randomised controlled trial.

PURPOSE: To evaluate whether 5 × 5 mm dental implants with a novel nanostructured calciumincorporated titanium surface could be an alternative to implants at least 10 mm long placed in bone augmented with bone substitutes in posterior atrophic jaws. MATERIALS AND METHODS: A total of 40 patients with atrophic posterior (premolar and molar areas) mandibles having 5 to 7 mm of bone height above the mandibular canal and 40 patients with atrophic maxillae having 4 to 6 mm below the maxillary sinus, were randomised according to a parallel group design to receive one to three 5 mm implants or one to three at least 10 mm-long implants in augmented bone at two centres. All implants had a diameter of 5 mm. Mandibles were vertically augmented with interpositional bovine bone blocks and resorbable barriers. Implants were placed after 4 months. Maxillary sinuses were augmented with particulated porcine bone via a lateral window covered with resorbable barriers and implants were placed simultaneously. All implants were submerged and loaded after 4 months with provisional prostheses. Four months later, definitive screw-retained or provisionally cemented metal-ceramic or zirconia prostheses were delivered. Patients were followed up to 1 year post-loading and the outcome measures were prosthesis and implant failures, any complications and peri-implant marginal bone level changes. RESULTS: One maxillary grafted patient dropped out before the 1-year evaluation. In mandibles, 1 grafted patient did not want to go ahead with the treatment because of multiple complications and graft failure, and another grafted patient did not receive his prostheses due the loss of 2 implants. In maxillae, one 5 × 5 mm implant failed with its provisional crown 3 months post-loading. There were no statistically significant differences in prostheses and implant failures. Significantly more complications occurred at both mandibular and maxillary grafted sites: 17 augmented patients were affected by complications versus 8 patients treated with short implants in the mandible (P = 0.0079; difference in proportion = -0.45; 95% CI -0.67 to -0.15), and 5 sinus-lift patients versus none treated with maxillary short implants (P = 0.047; difference in proportion = -0.25; 95% CI -0.44 to -0.06). Patients with mandibular short implants lost on average 0.94 mm of peri-implant bone at 1 year and patients with 10 mm or longer mandibular implants lost 1.03 mm. Patients with maxillary short implants lost on average 0.87 mm of peri-implant bone at 1 year and patients with 10 mm or longer maxillary implants lost 1.15 mm. There were no statistically significant differences in bone level changes up to 1 year between short and longer implants in maxillae (mean difference -0.28 mm, 95% CI -0.56 to 0.01, P = 0.051) and in mandibles (mean difference -0.09 mm, 95% CI -0.26 to 0.08, P = 0.295). CONCLUSIONS: One year after loading, 5 × 5 mm implants achieved similar results compared to longer implants placed in augmented bone. Short implants might be a preferable choice to bone augmentation especially in posterior mandibles since the treatment is faster, cheaper and associated with less morbidity, however 5 to 10 years of post-loading data are necessary before making reliable recommendations. CONFLICT-OF-INTEREST STATEMENT: MegaGen partially supported this trial and donated implants and prosthetic components used in this study, whereas Tecnoss donated the biomaterials. The data belonged to the authors and by no means did the manufacturers interfere with the conduct of the trial or the publication of its results.

Intraoperative biopsy of the major cranial nerves in the surgical strategy for adenoid cystic carcinoma close to the skull base.

OBJECTIVE: Adenoid cystic carcinoma of the salivary glands has a propensity for perineural invasion, which could favor spread along the major cranial nerves, sometimes to the skull base and through the foramina to the brain parenchyma. This study evaluated the relationship between neural spread and relapse in the skull base. STUDY DESIGN: During surgery, we performed multiple biopsies with extemporaneous examination of the major nerves close to the tumor to guide the surgical resection. RESULTS: The percentage of actuarial local control at 5 years for patients with a positive named nerve and skull base infiltration was 12.5%, compared with 90.0% in patients who were named nerve-negative and without infiltration of the skull base (P = .001). CONCLUSIONS: Our study shows that local control of disease for patients who are named nerve-positive with skull base infiltration is significantly more complex compared with patients who are named nerve-negative without infiltration of the skull base.

Treatment of the atrophic edentulous maxilla: short implants versus bone augmentation for placing longer implants. Five-month post-loading results of a pilot randomised controlled trial.

PURPOSE: To evaluate whether short (5 to 8.5 mm) dental implants could be a suitable alternative to longer (>11.5 mm) implants placed in atrophic maxillae augmented with autogenous bone for supporting dental prostheses. MATERIALS AND METHODS: Twenty-eight patients with fully edentulous atrophic maxillae having 5 to 9 mm of residual crestal bone height at least 5 mm thick, as measured on computerised tomography scans, were randomised into two groups either to receive 4 to 8 short (5 to 8.5 mm) implants (15 patients) or autogenous bone from the iliac crest to allow the placement of at least 11.5 mmlong implants (13 patients). Bone blocks and the windows at maxillary sinuses were covered with rigid resorbable barriers. Grafts were left to heal for 4 months before placing implants, which were submerged. After 4 months, provisional reinforced acrylic prostheses or bar-retained overdentures were delivered. Provisional prostheses were replaced, after 4 months, by definitive screw-retained metal-resin cross-arch fixed dental prostheses. Outcome measures were: prosthesis and implant failures, any complications (including prolonged postoperative pain) and patient satisfaction. All patients were followed for 5 months after loading. RESULTS: All patients could be rehabilitated with implant-supported prostheses and none dropped out. One bilateral sinus lift procedure failed due to infection, though short implants could be placed. One implant failed in the augmented group versus 2 short implants in 2 patients. All failures occurred before loading. Significantly more complications occurred in augmented patients: 8 complications occurred in 5 augmented patients (all complained of pain 1 month after bone harvesting from the iliac crest). No complications occurred in the short implant group. All patients were fully satisfied with the treatment and would do it again. CONCLUSIONS: This pilot study suggests that short implants may be a suitable, cheaper and faster alternative to longer implants placed in bone augmented with autogenous bone for rehabilitating edentulous atrophic maxillae. However, these preliminary results need to be confirmed by larger trials with follow-ups of at least 5 years.