Roberto Bruschini

Lymphatic mapping to tailor selective lymphadenectomy in cN0 tongue carcinoma: beyond the sentinel node concept.

PurposeCervical lymph node status is the most important pathological determinant of prognosis and decision making in head and neck squamous cell carcinoma (SCC). The aim of this study was to demonstrate that lymphoscintigraphy (LS) can supply a complete map of the lymphatic drainage before surgery, allowing planning of the type of intervention and serving to guide lymphadenectomy.MethodsThe study population comprised 14 patients with T2–4 SCCs of the tongue and clinically negative lymph nodes in the neck (cN0) who were scheduled to undergo tumour resection and selective level I–IV neck dissection extended to level V. LS was performed in all patients following the injection of 99mTc-colloidal sulphide in three aliquots around the primary lesion. Dynamic, static and tomographic images of the head and neck were acquired. The operative specimens were subjected to lymphoscintigraphic evaluation. Preoperative and postoperative imaging results were compared with the pathological findings. All nodes were examined using haematoxylin-eosin staining.ResultsPreoperative LS was successful in all patients. Preferential pathways of lymphatic drainage were identified: level II of the neck was the most common lymphatic drainage pattern, followed by levels IV and III. Contralateral drainage occurred in 11 patients and in two of them metastatic nodes were found on the contralateral side. Metastases were observed only in radioactive lymph nodes.ConclusionLS is able to supply a complete map of the lymphatic drainage before surgery, making it possible to tailor selective neck dissection to each individual patient based on the results of preoperative mapping, thereby sparing healthy lymphatic tissue and reducing surgery-related morbidity.

Relationship between histologic thickness of tongue carcinoma and thickness estimated from preoperative MRI

Several studies have shown that the thickness of tongue carcinoma is related to prognosis and to the likelihood of cervical node metastases. We investigated whether preoperative estimates of tumor thickness and volume, as determined from magnetic resonance imaging (MRI), correlated with histologic thickness and might therefore predict the presence of neck metastases. We assessed relationships between histologic tumor thickness and MRI tumor thickness and volume in a retrospective series of 33 patients with squamous cell carcinoma of the tongue. Thicknesses were determined by direct measurement and by considering corrections for ulceration or tumor vegetation (reconstructed thickness). Relationships between MRI thickness and the presence or absence of homolateral and contralateral nodal metastases were also investigated. We found that MRI thicknesses correlated strongly and directly with histologic tumor thicknesses, although mean MRI thicknesses were significantly greater than histologic thicknesses. MRI thicknesses were significantly greater in patients with contralateral neck involvement than in those with no neck involvement. We conclude that MRI provides an accurate and reproducible means of estimating the thickness of tongue carcinomas, paving the way for further studies on more extensive series of patients to determine whether preoperatively determined MRI thickness can reliably predict homolateral and bilateral neck involvement.

Cystic lymphangioma of the neck in adults: a report of three cases

ZusammenfassungLymphangiome sind seltene Läsionen der lymphatischen Kanäle, die oft bereits bei der Geburt bestehen und zumeist (in 90% der Fälle) vor dem 2. Lebensjahr diagnostiziert werden. Nur wenige Fälle eines Auftretens im Erwachsenenalter wurden bisher in der Literatur beschrieben. Die Therapie der Wahl ist die komplette operative Entfernung. Manchmal ist dies allerdings nicht möglich, da der Tumor dazu tendiert, sich entlang lebensnotwendiger Strukturen auszubreiten. Wir beschreiben die klinischen und pathologischen Eigenschaften von zystischen Lymphangiomen bei 3 Erwachsenen: Die Tumoren traten alle im lateralen Halsbereich auf. Es wurden eine klinische Untersuchung, Ultraschall, MR sowie FNAC durchgeführt. Wir diskutieren die Schwierigkeiten bei der korrekten Diagnose dieser seltenen Läsion, die in vielen Fällen erst bei der histopathologischen Untersuchung möglich ist Die therapeutischen Optionen werden ebenfalls kurz beschrieben. Unsere Fälle zeigen, dass bei der Differentialdiagnose lateraler Halstumoren zystische Lymphangiome berücksichtigt werden sollten. Außerdem betonen sie die Notwendigkeit für eine adäquate Bildgebung und Zytologie, um die präoperative Verdachtsdiagnose zu erhärten.SummaryLymphangiomas are uncommon lesions of lymphatic channels that are often present at birth and diagnosed mostly (90%) before the age of two years. Lymphangiomas occur exceedingly rarely in adults and few cases are described in the literature. The treatment of choice is complete surgical removal; however, the tumor tends to spread along vital structures therefore sometimes inductive complete surgical removal is impossible. We describe the clinical and pathological features of cystic lymphangioma diagnosed in three adults with lateral neck mass. Clinical examination, ultrasonography, MRI and fine-needle aspiration cytology were performed. We discuss the diagnostic difficulties of this uncommon lesion where in many cases the correct diagnosis is reached only after histopathological investigation of the surgical specimen. Therapeutic options are briefly described. Our cases suggest the need to consider cystic lymphangioma in the differential diagnosis of lateral neck masses in adults, together with adequate imaging and cytological studies to corroborate the preoperative diagnosis.

Total glossectomy with preservation of the larynx: oncological and functional results.

Our aim was to analyse the overall and disease-free survival (DFS), time to recovery of oral feeding, and morbidity, in a consecutive series of patients who had total glossectomy with preservation of the larynx for advanced cancer of the tongue at the European institute of Oncology (Milan). From June 2002 to April 2011, 37 patients who were treated for advanced cancer of the tongue had total glossectomy, bilateral neck dissection, and preservation of the larynx. Various flaps were used for reconstruction. Overall and disease-free survival were assessed from the day of operation to the latest outpatient examination. Postoperative morbidity and rehabilitation of feeding were also assessed. Six patients had major complications, four of whom had a second operation for necrosis of the flap. Actuarial five-year overall survival (OS) and disease-free survival were 54% and 47%. Twenty-four patients (65%) were operated on as their first treatment, and had 79% five-year overall survival and 61% 5-year disease-free survival. Twenty-six patients were eventually able to feed orally postoperatively. Although this retrospective study include a limited number of patients, the results support the validity of total glossectomy as a safe procedure for advanced cancer of the tongue. Pretreated patient were previously treated with surgery, radiotherapy or chemoradiotherapy with curative purposes. Nevertheless, the long period required for recovery of oral feeding indicates that total glossectomy should be reserved for highly motivated patients.

Compartmental tongue surgery: Long term oncologic results in the treatment of tongue cancer.

Compartmental tongue surgery (CTS) is a surgical technique that removes the compartments (anatomo-functional units) containing the primary tumor, eliminating the disease and potential muscular, vascular, glandular and lymphatic pathways of spread and recurrence. Compartment boundaries are defined as each hemi-tongue bounded by the lingual septum, the stylohyoid ligament and muscle, and the mylohyoid muscle. In this non-randomized retrospective study we evaluated the oncologic efficacy of CTS in patients with squamous cell carcinoma (SCCA) of the tongue treated from 1995 to 2008. We evaluated 193 patients with primary, previously untreated cT2-4a, cN0, cN+, M0 SCCA with no contraindication to anesthesia and able to give informed consent. Fifty patients treated between October 1995 and July 1999 received standard surgery (resection margin >1cm); 143 patients treated between July 1999 and January 2008 received CTS. Study endpoints were: 5-year local disease-free, locoregional disease-free and overall survival. After 5years, local disease control was achieved in 88.4% of CTS patients (16.8% improvement on standard surgery); locoregional disease control in 83.5% (24.4% improvement) and overall survival was 70.7% (27.3% improvement). The markedly improved outcomes in CTS patients, compared to those treated by standard surgery, suggest CTS as an important new approach in the surgical management of tongue cancer.

Ultrasound-guided transcutaneous Tru-Cut biopsy to diagnose laryngopharyngeal masses: a pilot study.

Patients with bulky laryngopharyngeal masses and a relative or absolute contraindication to general anesthesia present diagnostic difficulties. In the current study, the authors assessed the utility of transcutaneous ultrasound‐guided Tru‐Cut biopsy (USGTCB) under local anesthesia in such individuals.

Hyperfractionated Radiotherapy in Locally Advanced Nasopharyngeal Cancer

Background:Despite numerous randomized trials suggesting a benefit of unconventional fractionation in locally advanced head and neck cancer, the role of this approach in nasopharyngeal carcinoma is debatable. Based on the current clinical experience, the authors introduced hyperfractionated irradiation in the treatment of locally advanced head and neck cancer, including nasopharyngeal tumors. The preliminary results of this treatment approach in nasopharyngeal cancer patients are presented, with special focus on the pattern of failure and toxicity.Patients and Methods:43 patients with nasopharyngeal cancer (stage II–IV, TNM 1997) underwent hyperfractionated irradiation. In 34 cases, radiotherapy was preceded by a median of three cycles of cisplatin-based induction chemotherapy. Irradiation was delivered using a shrinking-field technique up to a total dose of 74.4 Gy in 62 fractions of 1.2 Gy twice daily (minimum 6-h interval)/5 days/week.Results:Acute toxicity of hyperfractionated radiotherapy was significant but tolerable. Mucositis proved the most common side effect (grade 3: 24 patients, grade 4: three patients). Severe late toxicity was not observed. 30 of 34 patients (88%) responded to induction chemotherapy. At 6 weeks after completion of radiotherapy, complete response was seen in 35 patients (81%), partial response in five (12%), stable disease in one, and progressive disease in two. After a median follow-up of 32 months, 18 patients (41%) developed progressive disease. Primary tumor progression was observed in three patients, and seven patients each showed regional lymph node progression and distant metastases. In one case both regional lymph node progression and distant metastases were diagnosed. The 2-year progression-free survival and overall survival rates were 58% and 84%, respectively.Conclusion:Hyperfractionated radiotherapy seems a feasible and active regimen in locally advanced nasopharyngeal carcinoma. Accompanying acute and late toxicity is acceptable and does not compromise delivery of the planned irradiation dose. This regimen is associated with a high local control rate; relatively high nodal and distant failure, however, call for further treatment modifications, e. g., optimization of irradiation technique and/or dose escalation as well as improved systemic therapies.Hintergrund:Obwohl zahlreiche randomisierte Studien zugunsten unkonventioneller Fraktionierungsschemata bei lokal fortgeschrittenenen Kopf-Hals-Tumoren sprechen, ist der Stellenwert dieses Vorgehens beim Nasopharynxkarzinom umstritten. Auf der Basis gängiger klinischer Erfahrung führten die Autoren die hyperfraktionierte Bestrahlung in die Therapie lokal fortgeschrittener Kopf-Hals-Tumoren, einschließlich Nasopharynxkarzinome, ein. Erste Ergebnisse dieses Therapieansatzes bei Patienten mit Nasopharynxkarzinom werden vorgestellt und insbesondere Grenzen des Verfahrens und seine Toxizität diskutiert.Patienten und Methodik:43 Patienten mit Nasopharynxkarzinom (Stadium II–IV, TNM 1997) erhielten eine hyperfraktionierte Strahlentherapie. In 34 Fällen gingen der Bestrahlung im Mittel drei Zyklen einer Cisplatin-basierten Induktionschemotherapie voraus. Die Strahlentherapie wurde im Rahmen einer „Shrinking-Field-Technik“ bis zu einer Gesamtdosis von 74,4 Gy in 62 Fraktionen mit 2× täglich 1,2 Gy (Minimum 6-h-Interval) an 5 Tagen pro Woche durchgeführt.Ergebnisse:Die Akuttoxizität der hyperfraktionierten Strahlentherapie war bedeutend, aber tolerabel. Häufigste Nebenwirkung war die Mukositis (Grad 3: 24 Patienten, Grad 4: drei Patienten). Schwerwiegende Spättoxizitäten wurden nicht festgestellt. 30 von 34 Patienten (88%) sprachen auf die Induktionschemotherapie an. 6 Wochen nach Abschluss der Strahlentherapie, wurde eine komplette Remission bei 35 Patienten (81%) beobachtet, partielles Ansprechen bei fünf (12%), Krankheitsstillstand bei einem und Fortschreiten der Erkrankung bei zwei Patienten. Nach im Median 32 Monaten Follow-up zeigte sich bei 18 Patienten (41%) eine Progression der Erkrankung. Fortschreiten des Primärtumors wurde bei drei Patienten beobachtet, und sieben Patienten wiesen entweder Befall der regionalen Lymphknoten oder Fernmetastasen auf. In einem Fall wurden sowohl Befall der regionalen Lymphknoten als auch Fernmetastasen diagnostiziert. Das progressionsfreie Überleben und Gesamtüberleben nach 2 Jahren waren 58% bzw. 84%.Schlussfolgerung:Die hyperfraktionierte Strahlentherapie scheint bei lokal fortgeschrittenem Nasopharynxarzinom praktikabel und wirksam zu sein. Die auftretende Akut- und Spättoxizität ist akzeptabel und gefährdet die Verabreichung der geplanten Strahlungsdosis nicht. Dieses Vorgehen führt zu einer hohen lokalen Kontrolle; allerdings verlangt das relativ hohe regionale und systemische Therapieversagen weitere Modifikationen, z. B. die Optimierung der Bestrahlungstechnik und/oder Dosisekalation sowie verbesserte systemische Therapien.

Tongue reconstruction with the gracilis myocutaneous free flap

We describe our experience in tongue reconstruction using the transverse gracilis myocutaneous (TMG) free flap after major demolitive surgery for advanced cancer. This technique was used in 10 patients: seven underwent total glossectomy and three partial glossectomy. In eight patients we performed motor reinnervation attempting to maintain muscular trophism and gain long‐term volumetric stability. The follow‐up period ranged from 6 to 28 months. The overall flap survival was 100%. Nine out of 10 patients resumed oral intake. Our preliminary experience shows that this flap is a good reconstructive option for total glossectomy patients, whereas it is less suited for reconstruction of hemiglossectomy defects. Functional and objective evaluation of the tongue reconstructed with TMG free flap requires further and standardized evaluation.

Future challenges in head and neck cancer: from the bench to the bedside?

HNC is the 11th most frequent carcinoma with a world-wide yearly incidence exceeding over half a million cases [1], a 10:1 male gender predilection and country specific variability [2]. The principal risk factors are tobacco and alcohol use and, in a growing population without these exposures, HPV infection. While much progress has been made in understanding the molecular basis of cancer, the 5-year mortality of head and neck cancer has remained approximately 50%. To this date we have not been able to translate as much of our basic science knowledge into significant disease altering therapeutic strategies in terms of local, loco-regional, functional and overall survival. Challenges remain in all aspects of head and neck cancer management: prevention, diagnosis, surgical and non-surgical treatment.

Hyperfractionated radiotherapy in locally advanced nasopharyngeal cancer: An analysis of 43 consecutive patients

Background:Despite numerous randomized trials suggesting a benefit of unconventional fractionation in locally advanced head and neck cancer, the role of this approach in nasopharyngeal carcinoma is debatable. Based on the current clinical experience, the authors introduced hyperfractionated irradiation in the treatment of locally advanced head and neck cancer, including nasopharyngeal tumors. The preliminary results of this treatment approach in nasopharyngeal cancer patients are presented, with special focus on the pattern of failure and toxicity.Patients and Methods:43 patients with nasopharyngeal cancer (stage II–IV, TNM 1997) underwent hyperfractionated irradiation. In 34 cases, radiotherapy was preceded by a median of three cycles of cisplatin-based induction chemotherapy. Irradiation was delivered using a shrinking-field technique up to a total dose of 74.4 Gy in 62 fractions of 1.2 Gy twice daily (minimum 6-h interval)/5 days/week.Results:Acute toxicity of hyperfractionated radiotherapy was significant but tolerable. Mucositis proved the most common side effect (grade 3: 24 patients, grade 4: three patients). Severe late toxicity was not observed. 30 of 34 patients (88%) responded to induction chemotherapy. At 6 weeks after completion of radiotherapy, complete response was seen in 35 patients (81%), partial response in five (12%), stable disease in one, and progressive disease in two. After a median follow-up of 32 months, 18 patients (41%) developed progressive disease. Primary tumor progression was observed in three patients, and seven patients each showed regional lymph node progression and distant metastases. In one case both regional lymph node progression and distant metastases were diagnosed. The 2-year progression-free survival and overall survival rates were 58% and 84%, respectively.Conclusion:Hyperfractionated radiotherapy seems a feasible and active regimen in locally advanced nasopharyngeal carcinoma. Accompanying acute and late toxicity is acceptable and does not compromise delivery of the planned irradiation dose. This regimen is associated with a high local control rate; relatively high nodal and distant failure, however, call for further treatment modifications, e. g., optimization of irradiation technique and/or dose escalation as well as improved systemic therapies.Hintergrund:Obwohl zahlreiche randomisierte Studien zugunsten unkonventioneller Fraktionierungsschemata bei lokal fortgeschrittenenen Kopf-Hals-Tumoren sprechen, ist der Stellenwert dieses Vorgehens beim Nasopharynxkarzinom umstritten. Auf der Basis gängiger klinischer Erfahrung führten die Autoren die hyperfraktionierte Bestrahlung in die Therapie lokal fortgeschrittener Kopf-Hals-Tumoren, einschließlich Nasopharynxkarzinome, ein. Erste Ergebnisse dieses Therapieansatzes bei Patienten mit Nasopharynxkarzinom werden vorgestellt und insbesondere Grenzen des Verfahrens und seine Toxizität diskutiert.Patienten und Methodik:43 Patienten mit Nasopharynxkarzinom (Stadium II–IV, TNM 1997) erhielten eine hyperfraktionierte Strahlentherapie. In 34 Fällen gingen der Bestrahlung im Mittel drei Zyklen einer Cisplatin-basierten Induktionschemotherapie voraus. Die Strahlentherapie wurde im Rahmen einer „Shrinking-Field-Technik“ bis zu einer Gesamtdosis von 74,4 Gy in 62 Fraktionen mit 2× täglich 1,2 Gy (Minimum 6-h-Interval) an 5 Tagen pro Woche durchgeführt.Ergebnisse:Die Akuttoxizität der hyperfraktionierten Strahlentherapie war bedeutend, aber tolerabel. Häufigste Nebenwirkung war die Mukositis (Grad 3: 24 Patienten, Grad 4: drei Patienten). Schwerwiegende Spättoxizitäten wurden nicht festgestellt. 30 von 34 Patienten (88%) sprachen auf die Induktionschemotherapie an. 6 Wochen nach Abschluss der Strahlentherapie, wurde eine komplette Remission bei 35 Patienten (81%) beobachtet, partielles Ansprechen bei fünf (12%), Krankheitsstillstand bei einem und Fortschreiten der Erkrankung bei zwei Patienten. Nach im Median 32 Monaten Follow-up zeigte sich bei 18 Patienten (41%) eine Progression der Erkrankung. Fortschreiten des Primärtumors wurde bei drei Patienten beobachtet, und sieben Patienten wiesen entweder Befall der regionalen Lymphknoten oder Fernmetastasen auf. In einem Fall wurden sowohl Befall der regionalen Lymphknoten als auch Fernmetastasen diagnostiziert. Das progressionsfreie Überleben und Gesamtüberleben nach 2 Jahren waren 58% bzw. 84%.Schlussfolgerung:Die hyperfraktionierte Strahlentherapie scheint bei lokal fortgeschrittenem Nasopharynxarzinom praktikabel und wirksam zu sein. Die auftretende Akut- und Spättoxizität ist akzeptabel und gefährdet die Verabreichung der geplanten Strahlungsdosis nicht. Dieses Vorgehen führt zu einer hohen lokalen Kontrolle; allerdings verlangt das relativ hohe regionale und systemische Therapieversagen weitere Modifikationen, z. B. die Optimierung der Bestrahlungstechnik und/oder Dosisekalation sowie verbesserte systemische Therapien.