Giuditta Mannelli

Cancer stem cells hypothesis and stem cells in head and neck cancers

There is increasing evidence that the growth and spread of cancer is driven by a small subpopulation of cancer cells, defined as cancer stem cells (CSCs). Recent data indicate that the initiation, growth, recurrence and metastasis of cancers are related to the behavior of a small population of malignant cells with properties of stem cells, and information about them are potentially helpful in identifying the target for the tumors therapeutic elimination. The presence of subpopulation cells with phenotypic and behavioral characteristics corresponding to both normal epithelial stem cells and to cells capable of initiating tumors has been also reported in head and neck squamous cell carcinomas (HNSCCs).

Comparison of piezosurgery and traditional saw in bimaxillary orthognathic surgery

PURPOSE Investigators have hypothesised that piezoelectric surgical device could permanently replace traditional saws in conventional orthognathic surgery. METHODS Twelve consecutive patients who underwent bimaxillary procedures were involved in the study. In six patients the right maxillary and mandible osteotomies were performed using traditional saw, whilst the left osteotomies by piezoosteotomy; in the remaining six patients, the surgical procedures were reversed. Intraoperative blood loss, procedure duration time, incision precision, postoperative swelling and haematoma, and nerve impairment were evaluated to compare the outcomes and costs of these two procedures. RESULTS Compare to traditional mechanical surgery, piezoosteotomy showed a significant intraoperative blood loss reduction of 25% (p = 0.0367), but the mean surgical procedure duration was longer by 35% (p = 0.0018). Moreover, the use of piezoosteotomy for mandible procedure required more time than for the maxillary surgery (p = 0.0003). There was a lower incidence of postoperative haematoma and swelling following piezoosteotomy, and a statistically significant reduction in postoperative nerve impairment (p = 0.003). CONCLUSIONS We believe that piezoelectric device allows surgeons to achieve better results compared to a traditional surgical saw, especially in terms of intraoperative blood loss, postoperative swelling and nerve impairment. This device represents a less aggressive and safer method to perform invasive surgical procedures such as a Le Fort I osteotomy. However, we recommend the use of traditional saw in mandible surgery because it provides more foreseeable outcomes and well-controlled osteotomy. Further studies are needed to analyse whether piezoosteotomy could prevent relapse and promote bony union in larger advancements.

Acupuncture in shoulder pain and functional impairment after neck dissection: A prospective randomized pilot study

The efficacy of conventional physiotherapy and antiinflammatory/analgesic drugs in the management of shoulder pain and functional disability following neck dissection is often disappointing. Acupuncture is a safe and well‐tolerated method. We report the results regarding our pilot trial of acupuncture versus conventional care in the management of postoperative shoulder pain and dysfunction after neck dissection.

Laryngeal preneoplastic lesions and cancer: challenging diagnosis. Qualitative literature review and meta-analysis.

BACKGROUND Multi-step cancerogenesis guides laryngeal cancer onset and it includes a wide variety of pre-cancerous lesions macroscopically challenging to identify and distinguish from initial cancerous foci. OBJECT Different modalities of diagnostic techniques of laryngeal epithelial lesions exist and they do not offer a single system to make a differential diagnosis. Hence, this meta-analysis aimed to synthesize the validity of each single diagnostic tool to improve laryngeal patient management. METHODS A systematic review of literature was led searching for articles mentioning the following terms: larynx, laryngeal precancerous lesions, laryngeal cancer, white light (WL) endoscopy, stroboscopy, contact endoscopy (CE), autofluorescence (AF), ultrasound (US), narrow band imaging (NBI), computed axial tomography (CAT), magnetic resonance imaging (MRI), positron emission tomography (PET), CAT/PET. Then, a quantitative analysis was carried on for paper published after 2005 onward. RESULTS The search identified 7215 publications, of which 3616 published after 2005, with a final results of a total of 214 articles stratified and included by our selection criteria. 42 out of 214 articles were selected for quantitative synthesis. 25 out of 41 studies had a good quality score, 16 were fair. CONCLUSIONS A comprehensive overview of the most recent advances in laryngeal imaging technology combined with all of the information needed to interpret findings and manage patients with voice disorders can be found herein. Our flow-chart allows clinicians in risk-stratify patients and select proper examination modalities to provide appropriate care. Study limitations, together with possible clinical and research implications have been counted.

Detection of putative stem cell markers, CD44/CD133, in primary and lymph node metastases in head and neck squamous cell carcinomas. A preliminary immunohistochemical and in vitro study

Investigators hypothesized that cancer stem cells (CSCs) could play a role in determining cancer progression by metastasizing to cervical lymph node (N+) and then influencing prognosis of head and neck squamous cell carcinomas (HNSCCs) patients.

Impact of low-thermal-injury devices on margin status in laryngeal cancer. An experimental ex vivo study

INTRODUCTION Status of margins significantly affects disease-free survival. This study examines in ex vivo model the effect of thermal-injury on margins status comparing traditional instrument with several low-thermal-injury devices. METHODS We conducted a prospective study on 10 excised larynges from patients affected by advanced laryngeal cancer, to assess the thermal-effect due to surgical incisions made at standard distance by using: scalpel, CO2 Laser, harmonic scalpel and electrocautery. Upon histopathological examination, thermal damage (Surgical Artifact, SA), tissue lost/retraction (Shrinkage, S), and tissue alterations were compared for each instrument. RESULTS Low-thermal-injury devices increased SA mean value from 800.7 to 11447.85 μm (72%), and S mean value from 2.226 to 2.910 mm (68.4%) (p<0.05). CONCLUSIONS The choice of surgical device could influence the histopathological margins status, consequently affecting post operative therapeutic strategies and risk of recurrence.

Is elective neck dissection necessary in cases of laryngeal recurrence after previous radiotherapy for early glottic cancer

OBJECTIVES To assess the clinical utility of elective neck dissection in node-negative recurrent laryngeal carcinoma after curative radiotherapy for initial early glottic cancer. METHODS A retrospective review was undertaken of 110 consecutive early glottic cancer patients who developed laryngeal recurrence after radiotherapy (34 recurrent T1, 36 recurrent T2, 29 recurrent T3 and 11 recurrent T4a) and received salvage laryngeal surgery between 1995 and 2005. RESULTS Six patients presented with laryngeal and neck recurrence and underwent salvage laryngectomy with therapeutic neck dissection, 97 patients with recurrent node-negative tumours underwent salvage laryngeal surgery without neck dissection and only 7 underwent elective neck dissection. No occult positive lymph nodes were documented in neck dissection specimens. During follow up, only three patients with neck failure were recorded, all in the group without neck dissection. There was no significant association between the irradiation field (larynx plus neck vs larynx) and the development of regional failure. A higher rate of post-operative pharyngocutaneous fistula development occurred in the neck dissection group than in the group without neck dissection (57.2 per cent vs. 13.4 per cent, p = 0.01). Multivariate logistic regression analysis showed that early (recurrent tumour-positive, node-positive) or delayed (recurrent tumour-positive, node-negative) neck relapse was not significantly related to the stage of the initial tumour or the recurrent tumour. An age of less than 60 years was significantly associated with early neck failure (recurrent tumour-positive, node-positive). CONCLUSION Owing to the low occult neck disease rate and high post-operative fistula rate, elective neck dissection is not recommended for recurrent node-negative laryngeal tumours after radiation therapy if the initial tumour was an early glottic cancer.

Tobacco exposure and complications in conservative laryngeal surgery.

Smoking is an important risk factor in the development of head and neck cancer. However, little is known about its effects on postoperative complications in head and neck cancer surgery. We performed a retrospective analysis on 535 consecutive laryngeal cancer patients submitted to open partial laryngectomy at the Otolaryngology-Head and Neck Surgery Department of Florence University to evaluate a possible correlation between smoking and surgical complications. Patients were grouped in non smokers and smokers and evaluated for airway, swallowing, local and fistula complications by multivariate analysis: 507 (95%) patients were smokers, 69% presented supraglottic, 30% glottic and 1% transglottic cancer. The most common operation was supraglottic horizontal laryngectomy in 58%, followed by supracricoid partial laryngectomy in 27% and frontolateral hemilaryngectomy in 15% of cases. The incidence of overall complications was 30%, airway complications representing the most frequent (14%), followed by swallowing (7%), local (6%) and fistula complications (3%). Smokers developed more local complications (p = 0.05, univariate, p = 0.04, multivariate analysis) and pharyngocutaneous fistula (p = 0.01, univariate, p = 0.03, multivariate analysis).

Subtotal supracricoid laryngectomy: changing in indications, surgical techniques and use of new surgical devices

PURPOSE The aim of this study is to evaluate the evolution of supracricoid partial laryngectomy (SCPL) in indications, surgical techniques and outcomes through last decades. MATERIALS AND METHODS A retrospective analysis of 146 patients affected by laryngeal cancer treated with SCPL was carried on. We defined: (1) group A, 100 patients treated by cold instruments between 1995 and 2004; (2) group B, 46 patients treated by harmonic scalpel between 2005 and 2010. Complications rate, and functional and oncological results were documented and a comparison between the two groups was made; histopathological analysis of surgical margins was evaluated and correlated with local incidence of recurrence. RESULTS Significant differences in age mean-value (p=0.02), T classification (p=0.007), and in indication for more advanced-staged patients were found in group B (p=0.001). Surgical procedure was shorter in group B (p<0.001), with shorter swallowing recovery (p=0.003). Oncological outcomes did not report any significant differences. Group B showed a higher incidence of post- operative arytenoid edema (p=0.03) associated with a lower rate of pneumonia (p=0.038). Despite a higher rate of close or positive-margins found in group B no higher incidence of local-recurrence was reported (p=0.02) compared to group A. CONCLUSIONS We documented changing in indications and surgical technique for SCPL because of the development of modern diagnostic techniques and the introduction of low-thermal injury device allowing a more challenging tumor excision as well as with a shorter swallowing recovery in our series.

Risk Factors for Multiple Malignancies in the Head and Neck

Objective To define the prognostic role of multiple epidemiological, clinical, and biological factors for the development of multiple malignancies (MM) in patients with head and neck cancer (HNC). Study Design Historical cohort study. p53 gene status, microsatellite instability (MSI) of the index tumor, and inherited chromosome fragility (CF) were studied. Setting Ninety-six consecutive patients affected by primary HNC, between January 1987 and October 1991, who were eligible for curative radiation therapy were followed up. Subjects and Methods p53 gene status, MSI, and CF in 96 curative radiotherapy-treated patients were correlated with the risk for MM. Results Multiple malignancies occurred in 28.9%. Microsatellite instability (P = 0.05), CF (P < 0.01), and smoking after treatment of the index tumor (P = 0.02) were correlated with an increased risk of MM. Conclusion Genetic susceptibility may play a central role for MM development in patients with HNC.