Antonino R. Antonelli

Endoscopic Surgery for Juvenile Angiofibroma: When and How†

Objectives/Hypothesis In recent years, the indications for endoscopic surgery of the sinonasal tract, originally introduced for the treatment of inflammatory diseases, have been expanded to include selected cases of benign and malignant neoplastic lesions. The aim of the present study was to establish the efficacy of endoscopic surgery in the management of small and intermediate‐sized juvenile angiofibromas.

Endoscopic CO2 Laser Excision for Tis, T1, and T2 Glottic Carcinomas: Cure Rate and Prognostic Factors:

We present the results of a retrospective study based on a cohort of 140 patients who underwent endoscopic CO2 laser excision for previously untreated early glottic cancer (21 Tis, 96 T1, and 23 T2). This study used univariate analysis to review the impact on disease-free survival of 15 factors related to the host, the tumor, and the treatment. Recurrent cancer developed in 28 patients with an average interval to recurrence of 37.5 months. Retreatment consisted of different procedures, including laser excision, partial or total laryngectomy, and/or radiotherapy. The larynx was definitively preserved in 96% of patients. By the end of the study, 14 patients had died, but only 2 of them had died of the disease. Five-year overall survival and determinate survival were 93% and 98%, respectively. Ultimate local control at 5 years with CO2 laser excision alone was 95% for Tis, 87% for T1, and 91% for T2 lesions. Only involvement of the anterior third of the vocal cord (P = 0.02), involvement of the false vocal cord (P = 0.02), and infiltration of the vocalis muscle (P = 0.004) showed a significant negative impact on disease-free survival.

Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma (JNA).

Nineteen patients with juvenile nasopharyngeal angiofibroma (JNA) were surgically treated with different techniques from January 1968 through December 1985. Two patients had undergone a previous operation at another hospital; all patients were males (mean age 15.4), and the most common symptom was nasal obstruction (84.2%). Lateral extension into the pterygomaxillary fossa occurred in 14 patients (73.6%), and 2 also had intracranial invasion (10.5%).

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.

Oncological results of endoscopic resections of Tis and T1 glottic carcinomas by carbon dioxide laser.

A cohort of 88 patients with glottic cancer (13 Tis, 75 T1) who underwent endoscopic CO2 laser excision between January 1995 and June 1997 was prospectively studied. The mean follow-up was 43 months (range, 30 to 60 months). The depth and extent of the excision (graded according to the European Laryngological Society Classification, which includes 5 types of resection) were based on the results of a preoperative and intraoperative diagnostic test battery. Five patients died of other diseases, and none of glottic cancer. Of the 12 patients who developed a local recurrence, 5 underwent a second endoscopic procedure, 5 a total laryngectomy, and 1 a supracricoid laryngectomy, and 1 was treated with radiotherapy. The 5-year local control rate with endoscopic surgery alone, according to the Kaplan-Meier method, was 91%. None of the variables (8 related to the tumor and 2 to the treatment) tested in a univariate analysis by the log-rank test was found to have a significant impact on disease-free survival rates. The present study confirmed that endoscopic partial cordectomy for Tis and T1 glottic cancers can be regarded as a valid alternative to radiotherapy in terms of oncological results.

The distribution of lymph node metastases in supraglottic squamous cell carcinoma: Therapeutic implications

The treatment of the neck in cancer of the upper aerodigestive tract is still a matter of controversy, even though nowadays there is a trend in the literature toward elective surgery in the N0 neck when the probability of occult lymph node metastasis is greater than 20%. In the elective setup, every effort is made for preservation of uninvolved nonlymphatic structures in positive neck. The aim of this study is to analyze in a large cohort of patients treated for supraglottic carcinoma the prevalence of lymph node metastases and their distribution through various neck levels to redefine our policy of neck treatment.

Preoperative and postoperative voice in Tis-T1 glottic cancer treated by endoscopic cordectomy: an additional issue for patient counseling.

Radiotherapy contends with endoscopic surgery for the role of treatment of choice for Tis-T1 glottic cancer. The amount of vocal cord to be surgically removed logically depends on the surface and deep extension of the neoplasm. Thus, a prerequisite for proper management includes an analysis of the voice changes after each of the progressive types of cordectomy described in the European Laryngological Society Classification. Between January 1998 and December 2000, 89 patients with glottic cancer (8 Tis, 63 T1a, 18 T1b) underwent different types of endoscopic cordectomy. Perceptual analysis (GRBAS scale); objective analyses of jitter, shimmer, and noise-to-harmonics ratio; and subjective (Voice Handicap Index) evaluation of voice were performed in 51 patients. Statistical evaluation of preoperative and postoperative objective results by analysis of covariance, as well as perceptual and subjective data, showed significant voice improvement after type I and II cordectomies, with the voice attaining nearly normal parameters. By contrast, after type III, IV, and V cordectomies, the vocal outcome was not significantly different from the preoperative pattern. It can therefore be concluded that type I and II resections, whenever indicated, are adequate procedures even for professional voice users. By contrast, accurate counseling is mandatory before type III, IV, and V cordectomies.

Endoscopic laser excisional biopsy for selected glottic carcinomas.

From January 1988 to December 1990, 44 previously untreated patients with squamous cell carcinomas (SCCs) of the true vocal cord (33 T1a, 11 Tis) underwent carbon dioxide laser excision. The mean follow‐up was 28 months (range, 12 to 44 months). Endoscopic excisional biopsy was the primary treatment in 38 of the 44 patients, whereas postoperative radiotherapy was added in 6 cases in which the pathology report showed positive margins. Recurrent vocal cord SCC developed in 8 (18%) of the cases, with an average interval of 17.8 months. Re‐treatment consisted of a second laser excision in 4 cases, radiotherapy in 1, hemilaryngectomy in 1, and total laryngectomy in 2. The definitive cure rate with endoscopic excisional biopsy for the patients originally treated with laser excision alone was 94.7% (36/38). Endoscopic laser treatment for selected glottic SCC proves to be an excellent alternative to radiotherapy or open neck surgery.

Audiological findings in elderly patients with chronic renal failure

The audiological results of 46 patients (m/f 27/19, mean age; 57.4 +/- 11.1) with chronic renal failure (CRF) undergoing dialysis were compared with those of an age- and gender-matched control group (n = 25). Mean pure tone average from 0.5 to 8 kHz was about 15 dB higher in CRF patients than in control subjects. The ABR parameters of the test group were then contrasted with those recorded in a second control group (n = 47, m/f 26/21, mean age: 56.1 +/- 11.4) matched by age, gender and degree of hearing loss (HL). After assessing the normality of the groups by the usual criteria, using the data of a sample of normal young adults, the ABR were found to be abnormal in 23.9% of the controls and in the 39.13% of the CRF patients. Wave V, I-III, III-V and I-V delays were significantly shorter in the females of the control group; in the CRF group, only the V and the I-V delays were shorter in females. The only age-dependent effect was found in the CRF sample, in which older patients had significantly longer I-III IPLD. The degree of HL influenced the latency of the waves in both groups but only the I-V IPLD was longer in CRF patients with pronounced high tone loss. The most distinguishing feature between the effects of CRF plus ageing and those of normal ageing was the lengthening of the I-III IPLD in the test group. This finding is likely to reflect a subclinical disorder of the VIII nerve function that is a part of the axonal uremic neuropathy.

Prognostic determinants in supraglottic carcinoma: Univariate and Cox regression analysis

A series of 281 consecutive patients affected by supraglottic cancer and treated with surgery alone or with surgery followed by radiotherapy between 1983 and 1989 was reviewed to identify significant prognostic determinants.