Enrico Sesenna

Sentinel Node Biopsy in Head and Neck Cancer: Preliminary Results of a Multicenter Trial

Background: The aim was to determine the reliability and reproducibility of sentinel node biopsy (SNB) as a staging tool in head and neck squamous cell carcinoma (HNSCC) for T1/2 clinically N0 patients by means of a standardized technique.Methods: Between June 1998 and June 2002, 227 SNB procedures have been performed in HNSCC cases at six centers. One hundred thirty-four T1/2 tumors of the oral cavity/oropharynx in clinically N0 patients were investigated with preoperative lymphoscintigraphy (LSG), intraoperative use of blue dye/gamma probe, and pathological evaluation with step serial sectioning and immunohistochemistry, with a follow-up of at least 12 months. In 79 cases SNB alone was used to stage the neck carcinoma, and in 55 cases SNB was used in combination with an elective neck dissection (END).Results: In 125/134 cases (93%) a sentinel node was identified. Of 59 positive nodes, 57 were identified with the intraoperative gamma probe and 44 with blue dye. Upstaging of disease occurred in 42/125 cases (34%): with hematoxylin-eosin in 32/125 (26%) and with additional pathological staging in 10/93 (11%). The sensitivity of the technique with a mean follow-up of 24 months was 42/45 (93%). The identification of SNB for floor of mouth (FOM) tumors was 37/43 (86%), compared with 88/91 (97%) for other tumors. The sensitivity for FOM tumors was 12/15 (80%), compared with 30/30 (100%) for other tumor groups.Conclusion: SNB can be successfully applied to early T1/2 tumors of the oral cavity/oropharynx in a standardized fashion by centers worldwide. For the majority of these tumors the SNB technique can be used alone as a staging tool.

Functional disturbances of the inferior alveolar nerve after sagittal osteotomy of the mandibular ramus: Operating technique for prevention

The high frequency of permanent functional disturbance of the inferior alveolar nerve after sagittal osteotomy of the mandibular ramus is a disadvantage to which attention is always drawn in the different operating statistics. The authors, on the basis of previous experimental research, and in order to reduce the incidence of this disadvantage, have carried out sagittal osteotomy of the ramus in a series of patients by performing the splitting of the two cortical plates using a thin cement spatula as a chisel. The results have been extremely encouraging as the authors have observed only one case of permanent functional deficit of the inferior alveolar nerve and they have even noticed a very low incidence of temporary impairment.

Free flaps: Outcomes and complications in head and neck reconstructions

Between 2000 and 2007, 376 free-flap transfers were performed in 352 patients at the Department of Maxillofacial Surgery, University of Parma, Italy. They included 303 reconstructions after cancer surgery (80.6%), 28 secondary reconstructions (7.4%), 32 transfers for facial paralysis (8.5%) and 13 reconstructions for other pathology (3.5%) such as osteonecrosis and ameloblastoma. We determined the rates of major and minor flap, donor-site and systemic complications and analysed their relationships with factors such as aetiology, patient age, smoking history and the presence of comorbid conditions. For the free flaps examined in this study, the overall complication rate was 47%. Major complications occurred in 20.7% of the cases and minor complications in 26.3%. The major flap, donor-site and systemic complication rates were 11.9, 3.2 and 5.6%, respectively. Total flap loss occurred in 15 cases (4%). The minor flap, donor-site and systemic complication rates were 19.1, 4 and 3.2% respectively. Aetiology, patient age, smoking history and the presence of comorbid conditions were related to higher rates of major and minor complications, although these were not statistically significant.

Head and neck mucosal melanoma: experience with 42 patients, with emphasis on the role of postoperative radiotherapy.

Treatment of head and neck mucosal melanoma remains a challenge. Surgery has traditionally been the main therapeutic approach. The role of postoperative radiotherapy has never been clearly established.

Bilateral condylar atrophy after combined osteotomy for correction of mandibular retrusion a case report

Bilateral atrophy of the mandibular condyles after maxillo-mandibular surgery for correction of a Class II open-bite is reported. Although a definite cause could not be ascertained, it is postulated that a biomechanical phenomenon based on increased muscle tension was the most likely causative mechanism.

Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection

INTRODUCTION Free flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications. MATERIALS AND METHODS Between 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University - Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment. RESULTS At the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001). DISCUSSION AND CONCLUSIONS The results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an appropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

Myomucosal cheek flaps: applications in intraoral reconstruction using three different techniques

OBJECTIVE The use of myomucosal flaps harvested from the cheek area for intraoral reconstruction has been recently popularized in the literature. Several surgical techniques have been reported, and each study has described the outcomes and advantages of each method. However, the literature lacks a summary of the various surgical techniques utilizing buccinator myomucosal flaps. This paper examines the use of the 3 most important buccinator myomucosal flaps: the buccinator musculomucosal flap, the facial artery musculomucosal flap, and the buccinator musculomucosal island flap. We clarify the applications of each technique in intraoral reconstruction and discuss the indications for, and advantages and disadvantages of, each flap. STUDY DESIGN Forty-six patients who underwent surgical resection for malignancies of the oral cavity and reconstructions with cheek flaps were retrospectively studied. RESULTS All flaps were harvested and transposed. Complete loss of the flap occurred in only 1 case. In 2 cases, marginal necrosis of the flap took place, with complete spontaneous healing in 2 weeks. CONCLUSION Buccinator musculomucosal flaps are a good option for reconstruction of moderately sized oral cavity defects. A key point in this procedure is flap selection based on not only the size and site of the defect, but also the patients characteristics and type of surgical procedure.

Adenoid cystic carcinoma of intraoral minor salivary glands

We present a retrospective multicentric study of 67 patients with adenoid cystic carcinomas of the intraoral minor salivary glands, who were diagnosed and treated between 1986 and 2004 in the Operative Units of Maxillofacial Surgery of the University of Parma and of the Bellaria Hospital in Bologna. There were 28 males and 39 females with a mean age of 54.5 years (range 28-84 years). The palate was the most common site of involvement, with 71.6% of cases. All the patients were treated with surgery as the primary modality. Neck dissection was performed in 9% of the patients, and more than half (59.7%) were treated with adjuvant radiation therapy. All surviving patients had a minimum of 2 years follow-up, with a range of 2-20 years (median: 12 years). Of the 67 patients examined in this study, 19 were dead at the end of the follow-up, 16 of them due to tumor disease. Distant or loco-regional recurrence was documented in 29 of the 67 patients (43.3%). Disease-free intervals ranged from 1 month to 12 years. Twenty-two percent of patients had loco-regional failure, whereas 29.8% had distant metastases. The disease specific survival rates were 76.1% at 5 years and 74% at 10 and 15 years.The actuarial loco-regional control rates at 5-, 10- and 15-years were 79.7%, 74.8% and 70%, respectively. The actuarial freedom from distant relapse was 76.5% at 5 years, 64.9% at 10 years and 61.1% at 15 years. Stage T, cervical lymph node metastasis and surgical margin status proved to make a statistically significant contribution when describing the outcome.

Is neck dissection needed in squamous-cell carcinoma of the maxillary gingiva, alveolus, and hard palate? A multicentre Italian study of 65 cases and literature review

The occurrence of occult cervical metastases due to squamous-cell carcinoma of the hard palate and maxillary alveolar ridge has not been studied systematically. We have observed that many patients return with a delayed cervical metastasis following resection of a primary cancer at these sites. Some of these patients have died as a result of a regional or distant metastasis, despite control of the primary cancer. The literature contains few recommendations to guide the treatment of maxillary squamous-cell carcinoma; prospective studies are difficult due to the rarity of such tumours. The aim of this study is to define the incidence of cervical metastasis and to investigate whether elective neck dissection is justified. We present a retrospective multicentre study of 65 patients with squamous-cell carcinomas of the maxillary alveolar ridge and hard palate and review of the existing literature. The overall incidence of cervical metastases was 21%. We evaluated the significance of primary-site tumours as indicator of regional disease. The maxillary squamous-cell carcinoma cases in our multicentre study and in the literature review exhibited aggressive regional metastatic behaviour, comparable with that of carcinomas of the tongue, mouth floor, and mandibular gingiva. Based on our findings, we recommend selective neck dissection in clinically negative necks as a primary management strategy for patients with maxillary squamous-cell carcinomas involving the palate, maxillary gingiva, or maxillary alveolus.

Does Tumor Depth Affect Nodal Upstaging in Squamous Cell Carcinoma of the Head and Neck

Purpose: The aim of this study was to determine whether tumor depth affects upstaging of the clinically node‐negative neck, as determined by sentinel lymph node biopsy with full pathologic evaluation of harvested nodes including step‐serial sectioning (SSS) and immunohistochemistry (IHC).