Andrea Bolzoni

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.

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.

Cervical spondylodiscitis: A rare complication after phonatory prosthesis insertion

Tracheoesophageal puncture has excellent voice rehabilitation after total laryngectomy. However, despite its easy insertion and use, severe complications have been reported.

Renal cell carcinoma metastatic to the larynx.

u F s i e 54-year-old Caucasian male presented to the Deartment of Otolaryngology Service at the University f Brescia Hospital in December 2002 for a foreign ody sensation in his throat and slight dysphagia lasting or 2 weeks. In June 1999, he had been submitted to ight nephrectomy for renal cell carcinoma (RCC) taged as pT1N0M0G3. Between July 1999 and Noember 2000, he had undergone multiple bilateral lung etastasectomies and mediastinal lymphadenectomies or pulmonary metastases of RCC. When first seen in ur department, he was still under palliative chemotherpy for multiple hepatic and lung metastases. However, is general status was satisfactory and the rest of the linical history unremarkable for systemic diseases. Direct laryngoscopy under local anesthesia showed hypervascularized, pedicled, berry-like neoformation rising from the infrahyoid epiglottis, projecting into he laryngeal vestibule, in contact laterally with the left ryepiglottic fold and the false vocal cord below (Fig ). Due to the concern of further RCC metastases with high risk of bleeding from biopsy under local aneshesia, an “en bloc” excisional biopsy under direct icrolaryngoscopy by CO2 laser (Sharplan 1055 S) ith an Acuspot 712 micromanipulator (Sharplan, Tel viv, Israel) was performed after a full supraglottic xposure by the Lindholm laryngoscope. The resection as accomplished using the laser beam set on the uperpulse mode (3.5 watts, 270-micron spot size). The ostoperative course was uneventful and the patient as discharged the day after surgery with complete emission of symptoms. Histopathologic examination was suggestive for a etastasis of RCC: the mucosa appeared infiltrated by heets of polygonal and oval clear cells, forming a solid attern interrupted only by fibrous septae and thinalled vessels. There were scanty nuclear atypia and are mitoses.

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.

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.

Endonasal and Open Surgery: Key Concepts

Surgery plays a role of paramount importance in the management of both infl ammatory and neoplastic lesions of the sinonasal tract. During the last two decades a clear tendency to limit the indications of external approaches in favor of endonasal procedures with the help of endoscopes and/or the microscope has been observed. However, external approaches have still a role in the management of some selected cases of infl ammatory diseases and benign tumors and they must be considered the gold standard for malignant tumors. The aim of this chapter will not be to review all the numerous surgical techniques which have been reported along the years in the literature, but instead to focus on those which are nowadays more commonly used and which should be necessarily included in the armamentarium of any otorhinolaryngologist or maxillo-facial surgeon with special interest in sinonasal diseases. 5.2 Microendoscopic Surgery: Knowledge of the Basic Principles