Raul Pellini

Supracricoid partial laryngectomy as salvage surgery after radiation failure.

Radiotherapy is often chosen as the definitive treatment for early stage laryngeal carcinoma. Total laryngectomy is the main procedure for failures. Endoscopic treatment of recurrences by CO2 laser has found limited application. Partial laryngectomy through an external approach has been proposed as salvage surgery, and the vertical partial laryngectomy (VPL) is the most mentioned surgical technique in the literature, although there are, to date, very few reports regarding the use of the supracricoid partial laryngectomy (SCPL) as salvage surgery after radiation failure.

Pectoralis major myocutaneous flap for hypopharyngeal reconstruction

&NA; The reconstruction of total or subtotal defects after surgical treatment for hypopharyngeal cancer is a challenging problem in head and neck surgery. The authors discuss reconstructive surgery performed in 37 patients affected by advanced hypopharyngeal cancer using the pectoralis major myocutaneous flap. In 22 cases of total pharyngolaryngectomy, the reconstructive procedure originally proposed by the authors was based on the use of a pectoralis major myocutaneous flap directly sutured to the pharyngeal and esophageal stumps and the prevertebral fascia, which eventually represented the posterior wall of the neohypopharynx. In 15 cases of subtotal pharyngolaryngectomy, the posterior wall of the neohypopharynx consisted of a residual strip of pharyngeal mucosa. In each patient, removal of the tumor and reconstruction were performed during the same operation, with only a few complications. Neither flap necrosis nor strictures were encountered; five patients had pharyngeal fistula and one patient died because of massive pneumonia. Although the use of microvascular free flaps is a reliable procedure, the pectoralis major myocutaneous flap is still applicable for hypopharyngeal reconstruction, thanks to its feasibility and low complication rate. The other reconstructive options require surgical transgression of the abdomen and/or thorax in patients affected by malnutrition and other chronic systemic disorders.

Supracricoid partial laryngectomies after radiation failure: A multi‐institutional series

Radiation therapy (RT) is one of the gold standard treatments for early laryngeal cancer, and total laryngectomy is still the most applied surgical procedure after failure. Selected recurrences can be managed by supracricoid partial laryngectomies (SCPLs).

Elective treatment of the neck in squamous cell carcinoma of the larynx: Clinical experience

In head and neck cancer, the best prophylactic treatment for the N0 neck is a subject of debate. Some authors propose lateral selective lymph node dissection (levels II–IV) on the basis of the probability of finding occult metastases in those lymph nodes. A more extensive procedure including Vth level is considered unnecessary because of the low incidence of metastases in the posterior triangle.

Hypopharyngeal Reconstruction Using Pectoralis Major Myocutaneous Flap and Pre-Vertebral Fascia

INTRODUCTION Unlike other malignant epithelial tumors of the head and neck area, hypopharyngeal cancer shows a significant submucosal and intramural long distance spread, reaching over 2 cm from the macroscopic edge of the tumor. An extended resection to achieve radicality is therefore mandatory. A safe macroscopic margin is considered to be at least 5 cm, and some authors even suggest an esophagectomy. Direct closure of the residual pharynx that respects radicality and preserves an adequate food intake can be achieved only in tumors limited to the medial wall of the pyriform sinus. In more extended lesions, ablation of a large portion of the pharyngeal wall subsequently requires a reconstructive procedure. Many different solutions have been proposed. The most commonly used techniques are those which adopt gastric transposition or microvascularized free flaps. Among them, the tubulized fasciocutaneous forearm flap and free jejunum transposition are preferred by reconstructive surgeons. Pectoralis major myocutaneous flap (PMMCF) can be useful in case of limited hypopharyngeal resection to adequately complete the organ circumference, or, as suggested by Theogaraj et al., for postsurgical stricture repair. Its tubulization for a total pharyngolaryngectomy defect has been proposed, but a drawback of the PMMCF is the significant bulk of the myocutaneous unit and therefore the possible stenosis of the lumen. In 1984, Fabian described the use of the PMMCF for reconstruction of the lateral and anterior walls of the hypopharynx, while a skin graft placed over the prevertebral fascia was used to reconstruct the posterior wall. In this way it was possible to reduce the flap thickness and obtain an adequate lumen caliber. Our procedure is similar to that proposed by Fabian and differs for the direct suture of the pharyngeal stumps and of the PMMCF to the prevertebral fascia, which eventually represents the posterior pharyngeal wall.

Rhabdomyoma of the Parapharyngeal Space Presenting with Dysphagia

Rhabdomyoma is an exceedingly rare soft tissue benign tumor of skeletal muscle origin classified into cardiac and extracardiac types based on location. Extracardiac rhabdomyoma is further classified into adult, genital, and fetal type depending on the degree of differentiation. Adult rhabdomyomas are rare, but morphologically characteristic, benign mesenchymal tumors with mature skeletal muscle differentiation that in 90% of cases arise in the head and neck region, mainly in the mucosa of the oropharynx, nasopharynx, and larynx, from the branchial musculature of third and fourth branchial arches. Most patients are between 40 and 70 years old, with a mean age of 60 years with a male predominance. Usually presenting symptoms include upper airway obstruction, Eustachian tube dysfunction, and mucosal or neck mass, but rarely does it arise as pure dysphagia. This article presents a case of parapharyngeal rhabdomyoma presenting with only progressive dysphagia.

A case of cervical metastases from temporal bone carcinoid

Carcinoids are neuroendocrine tumors that typically occur in the gastrointestinal tract and lung and less frequently in the head and neck region. Whereas the metastatic potential of laryngeal carcinoid is well documented, only one case of metastasis of temporal bone carcinoid to the cervical lymph nodes has been reported. We present the case of a 55‐year‐old woman with cervical metastases almost 3 years after a primary diagnosis of temporal bone carcinoid.

Supracricoid Partial Laryngectomy in the Management of T3 Laryngeal Cancer

Objective To evaluate the oncologic results only in T3 glottic and supraglottic cancers regarding supracricoid partial laryngectomy (SCPL) not requiring total laryngectomy and to assess functional results by self-evaluation by the patient. Study Design Case series with medical record review. Setting Single tertiary care center. Subjects and Methods Thirty-two patients with laryngeal squamous cell carcinoma, previously untreated, who underwent SCPL with cricohyoidopexy or cricohyoidoepiglottopexy were reviewed. Results At 1, 3, and 5 years, the disease-free survival rates were 96.9%, 89.4%, and 78.2%; overall survival rates were 96.9%, 93.2%, and 87.3%; local control and locoregional control rates were 100%, 96.2%, and 96.2%; and distant metastasis–free survival rates were 100%, 100%, and 88.2%, respectively. Aspiration pneumonia was the most common complication observed. The 3 laryngeal functions (speech, swallowing, and breathing) were spared in 83.9% of patients. Conclusion Supracricoid partial laryngectomy for selected glottic and supraglottic T3 tumors has excellent oncologic and functional results.

Planned neck dissection after chemoradiotherapy in advanced oropharyngeal squamous cell cancer: the role of US, MRI and FDG-PET/TC scans to assess residual neck disease.

OBJECTIVE To investigate the ability of neck ultrasounds (US), magnetic resonance imaging (MRI) and positron emission tomography (FDG-PET/TC) in detecting residual nodal disease after chemoradiotherapy in patients with advanced oropharyngeal squamous cell carcinoma (OPSCC). METHODS From 2006 to 2009, 36 consecutive patients affected by OPSCC with bulky nodal disease (>3 cm), treated with primary concurrent chemoradiotherapy, were enrolled prospectively. Nodal response to treatment was assessed by using US, MRI and FDG-PET/CT. Planned neck dissection (ND) was performed in all the patients, and the histopathological node status was compared to the imaging findings in order to establish sensitivity, specificity, accuracy and predictive values of each technique. RESULTS Metastatic disease was assessed in 18/37 (48.6%) hemi-necks, always localized in levels II-IV. US showed greater sensitivity (77.8%) and, combined with FDG-PET/TC, produced the highest negative predictive value (93.3%). US, MRI and FDG-PET/TC scans showed the highest specificity (100%), accuracy (93.8%) and positive predictive values (100%). CONCLUSIONS In the presence of advanced OPSCC with bulky nodal disease, US combined with FDG-PET/TC could be a reliable and cost-effective strategy to identify patients with complete nodal response to chemoradiotherapy that might not require post-treatment ND but only observation. When residual disease in the neck was detected, selective ND was recommended.

Pectoralis major myocutaneous flap for hypopharyngeal reconstruction: long-term results.

Surgical treatment of hypopharyngeal cancer is indicated in advanced stages and recurrent/persistent disease after conservative regimens. As of today, no criterion standard treatment is applicable to all cases. Comparing functional results, complication rates and feasibility of different techniques proposed (free flaps, gastric pull-up, etc), and poor outcome in disease-free survival and in overall survival are more related to the tumor stage rather than the reconstruction technique. The authors discuss reconstructive surgery performed in 52 patients using a pectoralis major myocutaneous flap, according to a technique proposed by Spriano et al in 2001, after total circular partial/total hypopharyngectomy and total laryngectomy from January 1993 to 2008. Primary surgical treatment was performed in 38 patients. Surgery after radiotherapy/chemotherapy failure was performed in 8 patients. Surgery after chemotherapy was performed in 6 patients. Postoperative radiation treatment was administered in 35 patients. Two patients did not receive complementary radiotherapy: 1 patient died perioperatively and 1 had previous radiation treatment in 2002 for oropharyngeal cancer. Follow-up period ranged from a minimum of 7 months to a maximum of 15 years. Overall survival was 19.6%. To date, disease-free survival is 9 (17.3%) of 52 patients. Long-term follow-up shows that late complications are low or absent. For this reason, we consider this procedure to be time-sparing and safe, especially in this category of patients commonly affected by malnutrition and other long-term diseases.