Search

It is well known that malignant laryngeal tumours can extend from their site of origin into tributary lymph nodes, depending on their location and size. Management protocols almost always include concomitant surgical treatment of both the tumour and cervical nodes. When palpable lymph nodes are present, dissection is mandatory but there is no general agreement on the option of choice in clinically N0 patients. Elective neck dissection, following the current indications, is necessary in most cases of N0 laryngeal cancer, but the number of bilateral dissections may be limited. In tumours of only one hemilarynx or extending slightly beyond it, metastatic involvement is more likely to be on the same side as the lesion although there is no absolute certainty that it will be. In these cases, and especially in supraglottic tumours, occult metastatic spread may also penetrate into the contralateral lymph nodes of the neck. The present report deals with the results of a surgical strategy to limit bilateral elective dissection, based on the following criteria. In supraglottic tumours of only one hemilarynx or extending slightly beyond it, the presence of ipsilateral node metastases is highly predictive of a concomitant involvement of the contralateral nodes. In these supraglottic tumours, only in cases with post-operative serial positive histology of the uni-ipsilateral dissected cervical lymph nodes, has contralateral elective neck dissection (“conditional dissection”) been performed. “Conditional dissections” led to a reduction of approximately 70% of elective bilateral neck dissections.

Today clinical evaluation of the presence and extent of dysphonia is still essentially based on subjective-perceptive criteria. The lack of objectivity and the one-sidedness of such an approach reinforces the desire for a quantitative, objective determination of dysphonia which could aid in making an modern, unequivocal evaluation of the presence, extent and variations in time of this disorder both upon onset and after treatment. The purpose of the present research was to determine the reliability, possibilities and limitations of an objective, parametric procedure to evaluate both the normal and pathological voice. This procedure is based on the detection of the relationship between the noise and harmonic portions in the voice (the Yumoto H/N ratio). The study involved a group of 208 subjects (148 with dysphonia and 60 normal) and the procedure was applied using computerized digital sonography and dedicated algorithms. The results of this research showed that the vocal analysis procedure developed by Yumoto is not only simple but also highly sensitive, providing an objective study of dysphonia. In fact, the comparison between the average H/N ratio recorded in our patients (1.697 dB) is significantly different from that recorded in the normal subjects (11.169 dB) (p0.001). This also showed a clear discrimination between the two groups with no borderline or overlapping data found. The initial evaluation does not appear to establish a relationship between abnormal H/N ratio values and the type of pathology although greater morphological destruction of the vocal cords corresponds to worse vocal quality and therefore increased noise. For the data obtained to be valid, a necessary condition is the application of a strict, precise, correct sampling and analysis method following well-defined rules. Finally, the values obtained can serve as a basis for the construction of an objective instrumental voice measurement protocol that can be used in forensic evaluation of dysphonia. Standardization of the regulations is essential to such a project.

A series of 564 patients who underwent conservative or radical surgery for laryngeal carcinoma were studied in a postoperative follow-up. In particular the onset of local recurrences was studied in relation to the histopathological typing of the resection margin. Histology was performed both on the surgical sample and performing an additional biopsy on the surgical margin. The incidence of local recurrences--in relation to the positive or negative tumor infiltration at the resection margins of the surgical sample--was analogous throughout the entire case study (11.1% vs. 11.7%). Only as light increase in the incidence of recurrence was found in those patients with partial laryngectomy (12% vs. 8.9%) although this was not statistically significant. On the contrary, when the marginal biopsy tested positive for neoplasm, it was clearly and significantly related to a higher incidence of T recurrences. This held true for all cases as a whole (36.4% vs. 10.1%, p0.04) and, in particular for those treated with partial laryngectomy (46.2% vs. 3%, p0.02). On the basis of these observations it can be concluded that, where possible, additional biopsy should be performed to integrate the traditional evaluation of the margins of the surgical piece in order to gain greater prognostic reliability, particularly in cases of partial surgery. From the therapeutic point of view, the authors assert that scheduling supplementary radiation therapy and shorter intervals between follow-up examinations is timely if the resection margin tests positive.

An a series of 1.053 treated surgically for laryngeal cancer, a noteworthy incidence of secondary tumors (S.T.) was observed. This occurrence was correlated to various oncological parameters of primitive laryngeal tumors in order to reveal any eventual predictive factors. A S.T. occurred in 80 patients (7.6%): in 22 cases (27.5%) in the upper aero-digestive tract; in 23 (28,8%) in the lungs; in 15 (18.7%) in the gastro-intestinal tract (stomach, intestines, liver, esophagus); in 9 (11.2%) in the genitourinary tract (bladder, prostate); in 4 (5%) on the skin; in 3 (3.8%) in the thyroid; in 2 (2.5%) in the skeletal system; in one case each in the nervous system and in the mediastinum (1.2% respectively). On slightly more than one half of the cases (56.3%) diagnosis was made in the first 5 years following laryngeal surgery; in 26.2% in the following 6-10 years; in 26.2% in the 17.5% after 10 years. Only in two cases (stomach and thyroid) a S.T. appear within 6 months (simultaneous S.T.). No predictive correlation was revealed with regard to site or laryngeal tumor extension; to the presence of lymph node metastases or capsular rupture. However, in patients that had undergone functional surgery, S.T. incidence was double that of those who had been treated with total laryngectomy. Furthermore, in comparing the incidence of pulmonary metastases with that of a pulmonary S.T., it appeared that these is a higher probability of occurrence of the former in cases of supraglottic carcinomas, of laterocervical lymph node metastases or of capsular rupture. This findings clearly demonstrate that during pre-operative staging and post-operative follow-up an extremely accurate clinical and instrumental examination, aimed furthermore at revealing any eventual second neoplasms which, on the basis of our observations, may strike anywhere in the body, is absolutely indispensable.

This paper reports a study of microscopic infiltration of the cartilage of the cricoid carried out in 335 patients with T2-T3 carcinomas of the larynx who had undergone total laryngectomy. The results of the investigation revealed microscopic infiltration of the cricoid cartilage in 12% (14/335) of the cases examined. The incidence, however, was much higher in those cases of extension to the hypoglottis (28% vs 5%, p0.0001) or in cases of an even greater extension of the tumor (13% vs 7%). In the 161 patients with neoplasias situated in the glottis, there was cricoid invasion in 30 cases regardless of the tumor class. However, with regard to cases with extension to the hypoglottis, a higher incidence of cricoid infiltration (20% vs 8%, p0.002) for all T classes was observed. As for as those cases with neoplasias in the supraglottis are concerned, there were no patients classified T2 (0/50) with cricoid infiltration against 8% in T3 subjects (10/124). In these subjects extension to the hypoglottis led to microscopic invasion of the cricoid cartilage in a greater number of patients (31% vs 3%, p0.0001). These observations confirm that microscopic infiltration of the cartilagenous skeleton of the larynx, especially of the cricoid, is relatively frequent. Factor of even higher risk are occurrence in the glottis and, in all the situations examined, extension to the hypoglottis. In addition, except in cases of vestibular T2, there is a 5 to 8% possibility of microscopic infiltration of cricoid cartilage even in the absence of clinical signs of hypoglottic invasion.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of microscopic infiltration of the laryngeal framework, with or without extra-laryngeal extension, was studied retrospectively in a series of 63 patients treated surgically for glottic T3 carcinomas in order to establish prognostic values. The results of histopathological examination revealed neoplastic invasion of the fibro-cartilaginous skeleton in 46 of the patients examined and in half of these microscopic diffusion in peri-laryngeal tissue. As far as prognosis is concerned, there was a clear-cut correlation between a decrease in survival rates and a contemporaneous increase in the real extension of the neoplasia, even if microscopic. In fact the NED survival rate of confirmed T3 patients was 85% while in cases reclassified as pT4, it was 64% and 47% on the basis on the absence or presence of extra-laryngeal extension. With these observations it is possible to affirm that the major staging is also attributable to cases with initial infiltration of the "laryngeal framework" without an extensive extension toward peri-laryngeal tissue. As far as T recurrences are concerned, a high incidence of relapse of the neoplasia was observed principally in the cases with extra-cartilaginous diffusion. This observation may have a predictive role and therefore direct post-surgery follow-up as well as eventual complementary treatment.

Grading evaluation is becoming increasingly more important in establishing a valid prognosis and in the choice of therapeutical strategies in dealing with squamous laryngeal cancer. It follows, therefore, that grading of bioptic tissue, made before therapy planning, must offer reliable data and correspond to data gathered through grading of the entire neoplasm. Thus the aim of our study carried out on 267 cases was to verify if grading of bioptic tissue corresponds to that of the operatory specimen. In 7% of the cases (19 in 267) bioptic grading overestimated the neoplasm in that post-operatory grading revealed a less differentiated form. On the contrary, in 16% of the cases (43 in 267) bioptic grading underestimated the form since as post-operatory grading showed a more highly differentiated form. It appears clear that these values depend on the clinical extension of the neoplasm in that the difference was inferior in the case of limited neoplasms and greater in that more largely extended ones. Generally speaking then, the less extended the neoplasm (the most frequently observed clinical form), the more coinciding the bioptic evaluation indicating good differentiation with the post-operatory evaluation. On the other hand, bioptic evaluation indicating moderate or poor differentiation is less reliable since it does not coincide with findings in approximately 16% of the neoplasms, above all those most limited (12%). This means that any reductive adoption of therapy planning made on the basis of the degree of differentiation revealed upon bioptic examination is possible only in the case of those forms more advanced with regard to extension.(ABSTRACT TRUNCATED AT 250 WORDS)

In laryngeal oncology histological evidence of neoplastic invasion of the latero-cervical lymph nodes (N+) is considered extremely serious in terms of prognosis. To find evidence of metastasis in more than one latero-cervical lymph node is, in fact, not unusual. The purpose of the present work has been to evaluate the clinical and prognostic aspects of multiple latero-cervical metastases in a group of 440 patients suffering from laryngeal carcinoma and who had undergone either total or partial laryngectomy with mono or bilateral lymph node dissection and who had been followed up for at least three years. Of the 440 patients examined 128 (29%) proved histologically N positive and of these 71 (71/128, 55%) showed multiple lymph node metastases, even in those cases of NO. On the average, from a prognostic point of view, the presence of multiple lymph node metastases halved the NED survival rate at three years (38% vs. 65%), clinical staging being equal. In conclusion, in agreement with the literature, the present observations indicate that the number of latero-cervical lymph nodes invaded must be taken into consideration along with the common prognostic factors used in cases of laryngeal carcinoma. In fact, the presence of multiple metastases has a broad, negative affect on survival. Nonetheless, it is not yet possible and is still risky to translate multiple metastases into a preoperative prognosis.

Invasion of the thyro-hyoid-epiglottic (TIE) space in supraglottic carcinoma is a frequent occurrence which, in most cases, only reveals itself upon post-surgical histology. In order to verify the current feeling that subclinical invasion does not in any way worsen prognosis the authors performed a retrospective study on the oncological results of 98 patients with T1-T2 supraglottic carcinoma. Of these 67 were treated by supraglottic laryngectomy while 31, taken as controls, had undergone total laryngectomy because of contraindications of a general nature. Histological examination of the surgical samples showed signs of space invasion in 60% of the cases. In these cases, there was a higher percentage of poor results (greater than 20%; mainly T recurrence) no matter what type of surgery had been performed. Therefore, subclinical invasion of the space must be considered as having an effect on prognosis and the authors feel that, whenever the pre-operative semiological criteria are insufficient to optimize surgical results, the patients presenting subclinical invasion of the space should be subjected to complementary radiotherapy.

The incidence of controlateral metastatic adenopathy appearing in time was studied in a group of 117 patients. These patients were all affected by carcinoma either basically found in or solely limited to one hemilarynx. All had been treated at least three years before by either total laryngectomy or horizontal supraglottic laryngectomy with either functional or radical monolateral ipsilateral neck dissection. Controlateral metastatic adenopathy appeared in 12% of the cases and was more frequently found in vestibular carcinoma (15.3%), in patients with N1 and N3 (20%) and in cases of histologically invasive ipsilateral lymph nodes (31.8%). The following had markedly lower incidence: glottic neoplasm (3%), N0 patients (11.1%) as well as unaffected ipsilateral lymph nodes (9.5%). These observations would suggest a more limited use of bilateral laterocervical lymph node dissection in lateralized N0 laryngeal carcinoma.

A group of 117 subjects suffering from vasomotor rhinopathy (33 with nasal polyposis) were studied with the nasal provocation test with carbacholine in order to evaluate aspecific nasal reactivity. The results obtained by quantifying the variations in nasal secretions and rhinomanometric resistance after application of the test substance indicate the following: a marked hypersecretory response and obstruction in 80% of the vasomotor rhinitis cases; a more marked aspecific reactivity in perennial allergic rhinitis sufferers than in those with seasonal atopic rhinopathy; a lack of statistical significance between the group of those with atopic polyposis and those with a negative skin test. The authors conclude by confirming the usefulness of the test for aspecific reactivity in the diagnosis of vasomotor rhinopathy and propose its use for better screening those patients to undergo specific hyposensitivity therapy.