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BackgroundThe incidence of thyroid carcinoma has been increasing worldwide and surgery is the primary treatment. Central compartment dissection of the neck is a very delicate procedure given the risks of recurrent laryngeal nerve injury and hypoparathyroidism.MethodsThis paper gives a detailed description of this surgical technique in a patient affected by papillary carcinoma of the thyroid gland, supported by highly representative iconographic materials from a tertiary department.ResultsA stepwise description is provided, along with high-quality pictures and specific tips and tricks. Although neck dissection is a well-codified procedure, the fine details of this surgical technique are not currently available and are still the prerogative of the expert surgeon.ConclusionThe central neck compartment contains several vulnerable structures; damage to these structures would affect patients’ lives, possibly permanently. Anatomical knowledge and standardisation are needed for all surgeons, particularly new surgeons (such as residents) who cannot rely simply on experience.

Mandibular reconstruction is challenging for most head and neck surgeons. Technological advances have led to the development of a new innovative procedure based on the concepts of computer-assisted design (CAD) and virtual surgical planning (VSP). The main disadvantage of this technique is the lack of flexibility, especially in oncology. A possible solution is the development of a semi-standardized mandible and fibula resection cutting guide: the L1® mandible ReconGuide. We provided a step-by-step description of the operative technique for mandibular reconstruction with the L1® mandible ReconGuide. The L1® mandible ReconGuide is a guiding force toward mandibular reconstruction. Moreover, the tool has been designed to suit the needs of the patients, particularly those with oral cancer, thereby permitting intraoperative planning and increasing time and cost effectiveness. In this pictorial essay, we have presented the operative techniques of using the L1® mandible ReconGuide for reconstruction.

Il cancro del cavo orale: ridefinizione del ruolo delle biopsie nell’era della medicina di precisione. Review della letteratura.Il cancro orale è una malattia eterogenea che origina ed evolve con un processo complesso e multifasico. La medicina di precisione permette di pianificare un trattamento personalizzato sulla base delle caratteristiche biologiche e molecolari delle singole neoplasie. Le informazioni oggi più affidabili sono fornite dalla valutazione post-operatoria dei biomarcatori, ma per pianificare un trattamento personalizzato è necessario valutare questi marcatori sulla biopsia. Per questo abbiamo rivisto la letteratura dell’ultimo quinquennio ed abbiamo identificato 6/184 articoli che valutano i marcatori sulla biopsia confrontandone i valori con quelli misurati sul pezzo operatorio di ciascun paziente o valutandone la predittività per lo sviluppo di metastasi linfonodali. I dati che emergono da questi studi suggeriscono che la valutazione dei marcatori sul campione bioptico potrebbe fornire indicazioni utili per programmare trattamenti personalizzati. Tuttavia, a causa della eterogeneità e del basso livello di evidenza dei lavori considerati, questi risultati devono essere confermati da studi clinici su un’ampia popolazione per standardizzare e validare i biomarcatori e la loro affidabilità in altre procedure mini-invasive, ad esempio radiomica e biopsia liquida.Oral cancer is a heterogeneous disease that develops through a complex, multi-step process. Precision medicine should help to better understand its molecular basis, integrate traditional classifications and have a positive impact on cancer management. To apply this information in clinical practice, we need to define its histology and identify biomarkers expressed by the tumour that provide useful information for planning tailored treatment. The most reliable information currently derives from evaluation of biomarkers on post-operative samples. To plan personalised treatment, oncologists need to assess these markers on biopsy samples. We reviewed the recent literature and identified 6 of 184 publications that compared markers measured on biopsy and post-operative samples or assessed their predictivity for the development of lymph node metastases. Data from these studies suggest that markers measured on biopsy samples can provide useful indications for tailoring treatments. However, due to their heterogeneity and low level of evidence, these results need to be confirmed by clinical studies on a large population to standardise and validate biomarkers in biopsies and to assess their reliability in other diagnostic mini-invasive procedures such as radiomics and liquid biopsy.

Background: The treatment of tongue tumors includes different surgical procedures ranging from a simple mucosal resection to complex combined resection depending on the tumor stage and size. In 2019 we reported an international glossectomy classification with the purpose of standardizing all the different types of surgical procedures adopted for tongue cancer. Methods: The present communication aims at providing further insight into the glossectomy classification. More specifically, it is intended to better specify the indications to glossectomy type IIIA and B in selected tongue cancers, with positive cervical lymph nodes at the diagnosis. Results and Conclusions: Type IIIA glossectomy permits a high function sparing surgery in selected cases, with better postoperative functional outcomes. From an oncological perspective, it permits a radical surgery, avoiding postoperative radiation in the absence of extracapsular spread, multiple nodal metastases or T-N tract involvement.

Tiroidectomia totale versus emitiroidectomia: approccio chirurgico al carcinoma papillare della tiroide T1-T2.Il carcinoma papillare della tiroide rappresenta l’80-90% dei tumori tiroidei e la sua incidenza è attualmente in aumento. Vogliamo valutare i risultati oncologici e funzionali del trattamento chirurgico del cancro della tiroide: tiroidectomia totale versus emitiroidectomia. Abbiamo effettuato uno studio monocentrico di coorte storica in un centro di riferimento terziario. Abbiamo raccolto i dati demografici, clinicopatologici e complicanze post operatorie di 586 pazienti trattati nel nostro istituto per carcinoma papillare della tiroide. Sono stati applicati modelli di rischio proporzionale Cox per valutare le differenze nei risultati, stratificandoli con il propensity score. I nostri dati suggeriscono che l’emitiroidectomia non porta ad un aumento del rischio di ricaduta locoregionale né a distanza rispetto alla tiroidectomia totale nei pazienti affetti da carcinoma in stadio T1-2 N0. La tiroidectomia totale riveste un ruolo importante in termini di miglioramento della prognosi nei casi di metastasi linfonodali del comparto centrale del collo (pN1a) (p = 0,001). Nella nostra casistica la tiroidectomia totale ha un rischio più elevato di complicanze chirurgiche in termini di ipocalcemia post operatoria e paralisi ricorrenziali (p0,001 e p = 0,02 rispettivamente).The incidence of papillary thyroid carcinoma, which accounts for 80-90% of all thyroid cancers, has recently been increasing. The current study aimed to compare the oncological and functional outcomes of total thyroidectomy (TT) and thyroid lobectomy (TL). To this end, a retrospective single-centre cohort study involving a tertiary care institution was conducted. Data regarding demographics, clinicopathology and postoperative complications from 586 patients with papillary thyroid cancer treated in a single institution were collected. Cox proportional-hazards models were utilised to determine differences in outcomes stratified according to propensity score. Our data suggested no significant difference in the risk for locoregional recurrence or distant metastasis between TL and TT among patients with pT1-2 pN0 papillary carcinoma. TT plays an important role in improving prognosis among patients with metastatic lymph nodes in the central neck compartment (pN1a) (p = 0.001). Moreover, TT had significantly higher rates of postoperative hypocalcaemia and recurrent laryngeal nerve paralysis compared to TL (p0.001 and p = 0.02, respectively).

Impatto della presenza di un radiologo dedicato nella gestione multidisciplinare dei pazienti con tumori del distretto testa collo: l’esperienza di un singolo centro.Scopo del lavoro è stato quello di quantificare l’impatto della revisione radiologica condotta da radiologi esperti nell’ambito di un gruppo di lavoro multidisciplinare nella gestione dei tumori del distretto testa collo. È stata condotta un’analisi retrospettiva dei casi discussi nelle riunioni multidisciplinari svoltesi tra i mesi di aprile 2014 e marzo 2017, per i quali è stata richiesta una revisione radiologica. Le modifiche apportate ai referti radiologici originari sono state classificate come segue: 1) variazioni dello stadio tumorale e 2) cambiamenti alla strategia terapeutica, di seguito classificati come “rilevanti” e come “non rilevanti”. La revisione radiologica si è resa necessaria in 540 casi, in 310 (57,4%) si trattava di pazienti in prima diagnosi. La maggior parte dei pazienti (69%) presentava tumori in stadio avanzato (III e IV). In 262 casi (48%) non è stato apportato alcun cambiamento rispetto alla valutazione radiologica iniziale. In 144 casi (27%), le immagini disponibili non sono state considerate sufficienti per una adeguata pianificazione terapeutica e sono state richieste ulteriori indagini diagnostiche. Nei rimanenti 134 casi (25%), la revisione radiologica ha portato a modificare lo stadio della malattia (55%) o la strategia terapeutica (44%). In particolare, variazioni “rilevanti” e “non rilevanti” alla strategia terapeutica sono state applicate rispettivamente in 44 (13%) e in 17 (11%) dei casi considerati. In 118 di tali pazienti erano disponibili i successivi controlli nel tempo. In tutti i casi, tranne uno, è stato possibile confermare che la modifica apportata ai referti originari in sede di discussione multidisciplinare era corretta. I nostri dati confermano l’importanza di includere un radiologo esperto come componente fondamentale dei gruppi di lavoro multidisciplinari per la gestione dei tumori del distretto testa-collo.The aim of this study was to quantify the impact of radiologic image review performed by experienced radiologists in a multidisciplinary team (MDT) for head and neck cancers (HNCs). We performed a retrospective review of cases discussed at MDT meetings from April 2014 to March 2017 for which radiologic review was required. All changes in the former radiologic report were collected and classified as follows: 1) modifications of radiological reports (patients for whom the treatment strategy had not been defined at the moment of MDT meeting) and 2) modifications in treatment strategy (patients for whom treatment strategy had previously been defined and subsequently modified according to the outcome of radiologic revision). The latter subgroup was further categorised as “major changes” and as “minor changes”. A total of 540 cases were retrieved. Imaging review was required at the time of tumour diagnosis in 310 (57.4%) cases. Most patients (69%) had advanced stage tumours (III and IV). In 262 (48%) cases, no change of the initial radiologic report was made. In a total of 144 (27%) cases, the available imaging was not considered sufficient for a final indication to treatment and further imaging was required. In the remaining 134 (25%) cases, radiologic review led to a modification of either tumour staging (55%) or treatment strategy (45%). Specifically, major and minor modifications were applied in 44 (13%) and 17 (11%) of the cases considered, respectively. Among 134 patients for whom the radiologic review led to stage/treatment modification, follow-up was available for 118. In all but one patient, we could confirm the original reports were correctly modified per MDT discussion results. Our data strongly support the importance of including an experienced radiologist as a core member of the MDT for HNCs.

Nowadays surgery remains the gold standard of treatment for tongue cancer. Via a more clear and precise terminology, the glossectomy classification by Ansarin et al. facilitates shared communication between surgeons, allowing comparison between published research and improving surgical practice and patient care. To establish the association of glossectomies, according to their classification by Ansarin et al. with overall survival (OS), disease-free survival (DSF), and cause-specific survival (CSS) in tongue cancer, we conducted a systemic retrospective study on 300 consecutive patients affected by primary oral tongue cancer and treated with surgery at the European Institute of Oncology, IRCCS (IEO).Three hundred patients with tongue squamous cell carcinoma and treated at the Division of Otorhinolaryngology and Head and Neck Surgery of the European Institute of Oncology, IRCCS were cataloged according to the glossectomy classification. OS, DFS, and CSS were compared by surgical treatments.OS-5yrs was 80% for the type I glossectomy group, 75% for type II, 65% for type III, and 35% for type IV-V. DFS-5yrs was 74%, 60%, 55%, and 27%, respectively for I, II, III, and IV-V glossectomy group; CSS-5yrs was 82%, 80%, 72%, and 48%, respectively for I, II, III, and IV-V glossectomy group (p 0.01).This study confirmed that the application of the glossectomy classification was statistically correlated with patients' oncological outcomes.

Objective:To describe the approach and outcomes from two cancer centres in Southern and Northern Europe during the first wave of coronavirus disease 2019 (COVID-19) of patients with head and neck cancer (HNC).Methods:Data collection was performed on a retrospective cohort of patients surgically treated for primary HNC between March and May 2020, using data from two tertiary hospitals: the European Institute of Oncology (Milan) and Guy’s & St Thomas’ NHS Foundation Trust (London).Results:We included 77 patients with HNC. More patients with COVID-19 were taking angiotensin-converting enzyme (ACE) inhibitors and had Clavien-Dindo Classification grade I compared to negative patients, respectively (60% vs 22% [ p = 0.058] and 40% vs 8% [ p = 0.025]). Multivariate logistic regression analyses confirmed our data ( p = 0.05 and 0.03, respectively). Sex and age were statistically significantly different ( p = 0.05 and 63 years: 69.44% vs 29.27%).Conclusions:This study presents a large cohort of patients with HNC with nasopharyngeal swab during the first peak of the COVID-19 pandemic in Europe. Patients with HNC with COVID-19 appeared more likely to develop postsurgical complications and to be taking ACE inhibitors. The preventive measures adopted guaranteed the continuation of therapeutic surgical intervention.

Simple Summary The present study focused on patients affected by stage pT1a papillary thyroid micro-carcinomas that were treated with surgery and central lymph node dissection. In this study, male sex, low age, and sub-capsular carcinoma localization resulted as independent predictive factors for central lymph node metastases. Abstract Papillary thyroid micro-carcinomas are considered relatively indolent carcinomas, often occult and incidental, with good prognosis and favorable outcomes. Despite these findings, central lymph node metastases are common, and are related to a poor prognosis for the patient. We performed a retrospective analysis on patients treated with surgery for stage pT1a papillary thyroid micro-carcinomas. One hundred ninety-five patients were included in the analyses. The presence of central lymph node metastases was identified and studied. A multivariate analysis employing binary logistic regression was used to calculate adjusted odds ratios with 95% confidence intervals of possible central lymph node metastases risk factors. In the performed multivariate analysis, male gender, younger age, and histopathological characteristics, such as a tumor sub-capsular localization, were significantly associated with central lymph node metastases in pT1a patients. Central compartment lymph node metastases are present in a non-negligible number of cases in patients with papillary thyroid micro-carcinoma undergoing surgical resection. Studying these factors could be an effective tool for predicting patients’ central lymph node metastases in papillary thyroid micro-carcinomas, defining a tailored surgical treatment in the future.

Purpose Parapharyngeal space (PPS) tumors are rare, accounting for 0.5% of all head-and-neck masses. Surgery remains the standard treatment for most cases, including different approaches (cervical approach, parotidectomy, mandibulotomy, transoral/robotic). We report our experience in the management of PPS tumors, aiming to create a surgical algorithm on the base of tumor's radiological and clinical characteristics. Materials and methods Critical retrospective analysis of patients with PPS neoplasms who underwent surgery at our Institute. Data were collected on patient age and sex, tumor location and size, preoperative investigations, surgical approaches, histopathology, complications and outcomes. Results Between January 2000 and July 2015, 53 patients were treated at our Institute. Salivary gland tumors were the most common neoplasms followed by neurogenic tumors. CT scan/MRI were the most used preoperative imaging studies. The cervical approach with or without parotidectomy is the most used, providing the best compromise between the need for radicality and low risk of damage to the neurovascular structures. Mandibulotomy is used whenever the mass extends to the cranial base, assuming a higher morbidity, a slower functional recovery and the need for tracheotomy. Recently, TORS has been used for tumors of the PPS with promising outcomes. Conclusions PPS surgery includes a wide spectrum of approaches but it is still a matter of debate which one guarantees better functional and oncological outcomes. We report a surgical algorithm based on surgical invasiveness and tumor characteristics to standardize PPS tumors management. We also highlight the upcoming role of TORS in this field.

Background We investigated the role of the soft tissue tract between the primary tumor and the neck lymph nodes, the "T-N tract," in patients with tongue squamous cell carcinoma at an advanced stage. Methods We performed a compartmental tongue surgery in 233 patients. Cumulative incidence of relapses and overall survival curves were compared by T-N tract involvement. Multivariate Cox proportional hazards models were used to assess the independent role of T-N tract. Results At 4 years of follow-up, patients with disease in the T-N tract experienced a significantly more distant recurrence (40%) than did patients without T-N tract involvement (22%; P = .02). Multivariate Cox models indicate a significant almost triple risk of distant metastases (hazard ratio [HR], 2.70; 95% CI, 1.01-7.19; P = .05) and double risk of death (HR, 2.09; 95%CI, 1.13-3.85; P = .02) in patients with "T-N tract involvement." Conclusions Our data show that the T-N tract plays an important role in prognosis and survival in patients with tongue cancer.

Benign thyroid nodules are a common clinical occurrence and usually do not require treatment unless symptomatic. During the last years, ultrasound-guided minimally invasive treatments (MIT) gained an increasing role in the management of nodules causing local symptoms. In February 2018, the Italian MIT Thyroid Group was founded to create a permanent cooperation between Italian and international physicians dedicated to clinical research and assistance on MIT for thyroid nodules. The group drafted this list of statements based on literature review and consensus opinion of interdisciplinary experts to facilitate the diffusion and the appropriate use of MIT of thyroid nodules in clinical practice. (#1) Predominantly cystic/cystic symptomatic nodules should first undergo US-guided aspiration; ethanol injection should be performed if relapsing (level of evidence [LoE]: ethanol is superior to simple aspiration = 2); (#2) In symptomatic cystic nodules, thermal ablation is an option when symptoms persist after ethanol ablation (LoE = 4); (#3) Double cytological benignity confirmation is needed before thermal ablation (LoE = 2); (#4) Single cytological sample is adequate in ultrasound low risk (EU-TIRADS ≤3) and in autonomously functioning nodules (LoE = 2); (#5) Thermal ablation may be proposed as first-line treatment for solid, symptomatic, nonfunctioning, benign nodules (LoE = 2); (#6) Thermal ablation may be used for dominant lesions in nonfunctioning multinodular goiter in patients refusing/not eligible for surgery (LoE = 5); (#7) Clinical and ultrasound follow-up is appropriate after thermal ablation (LoE = 2); (#8) Nodule re-treatment can be considered when symptoms relapse or partially resolve (LoE = 2); (#9) In case of nodule regrowth, a new cytological assessment is suggested before second ablation (LoE = 5); (#10) Thermal ablation is an option for autonomously functioning nodules in patients refusing/not eligible for radioiodine or surgery (LoE = 2); (#11) Small autonomously functioning nodules can be treated with thermal ablation when thyroid tissue sparing is a priority and ≥80% nodule volume ablation is expected (LoE = 3).

Background Primary hyperparathyroidism is primarily caused by parathyroid adenoma, followed by hyperplasia and parathyroid carcinoma. In the era of minimally invasive, targeted parathyroidectomy, the main challenge remains that of distinguishing intraoperatively pathological parathyroid from normal glands and peri-thyroid fat tissue. The aim of this study is to evaluate the surgical outcomes of a novel minimally invasive technique called ultrasound-guided dye-assisted parathyroidectomy (USDAP). Methods We perform a retrospective analysis of patients affected by parathyroid adenoma, treated with USDAP at our institution between 2014 and 2019. Data were collected on patient age and sex, tumor location and size, preoperative investigations, histopathology, perioperative complications and surgical outcomes. Results Between January 2014 and June 2019, 43 patients underwent parathyroidectomy in our Institute. Each case was discussed by the Institutional Multidisciplinary Board. All patients undergoing thyroidectomy together with USDAP or patients undergoing USDAP under endoscopic control were excluded from the present study. The final cohort, the largest to our knowledge, consisted of 29 patients. All patients were successfully treated with USDAP and remained disease-free during follow up. In all cases, pathological parathyroid was correctly identified and removed. There was no postoperative allergic reaction, nor were there neurotoxicity complications. USDAP permitted a shortening of operative and hospitalization time. Conclusions USDAP is an effective and safe procedure both as first line treatment and as a re-operative procedure after previous surgical failures in selected cases.

Background Surgery of tongue tumors includes different procedures ranging from mucosal resection to complex combined resection. Numerous terms have been used to describe such procedures, but there is no consensus between the terminology and the extent of resection. Methods and Results We searched the medical literature and found a lack of published information. We undertook to describe a new classification of surgical procedures for tongue tumor resection. We based it upon the surgical anatomy of the tongue and the spread of the cancer. We posited that there were five major types of glossectomy embracing all the methods of tongue cancer resection. This classification was reviewed and endorsed by an international team of experts. Conclusion We propose a more precise classification than that currently in practice, thereby bringing clarity and consistency to the terminology, facilitating shared communication between surgeons, comparison between published research, and ultimately improving surgical practice and patient care.

Background Preoperative data in patients with oral cavity/oropharyngeal cancer may predict postoperative complications that may modify therapeutic choices and improve patient care. Method We reviewed 320 consecutive patients with oral cavity/oropharyngeal cancer, operated on 2003 through 2006 at the European Institute of Oncology. By multivariate analysis of preoperative patient and tumor characteristics, we developed an algorithm to predict postoperative complications. We tested the algorithm on a new series of 307 patients operated on 2007 through 2010. Results The final algorithm used to produce a nomogram was comprised of: alcohol consumption (p = .01), site of primary (p = .03), interaction of clinical T classification to sex (p = .007), and type of neck dissection (p

In an era of personalized treatment, there is a great interest in identifying factors which might predict patient response to radiotherapy (RT). The role of epidermal growth factor receptor (EGFR) in head and neck squamous cell carcinoma (HNSCC) remains still controversial. We performed a retrospective analysis on the prognostic value of EGFR in HNSCC patients treated with surgery and postoperative RT through a semiquantitative immunohistochemical analysis of EGFR membrane expression. We retrospectively analyzed 65 HNSCC patients treated in our Institute from 1997 to 2003 who underwent adjuvant RT after surgery. Median follow-up was 43.5 months (range 0.2-173 months). None of these patients were treated with postoperative concomitant chemotherapy. Tumor samples were obtained from surgical specimens. Membrane features (intensity, extension) of EGFR expression were evaluated, and a statistical analysis (univariate and multivariate) was conducted to correlate these parameters with overall survival (OS) and disease-free survival (DFS). Patients with an intense and complete labeling of EGFR presented worse OS and DFS compared with groups obtained by all other possible combination, and the difference was borderline statistically significant (P = 0.08 for OS and P = 0.006 for DFS). Moreover, a stratification of patients was performed considering EGFR expression on the tumor tissue and classifying its distribution as "homogeneous" or "heterogeneous." We found that patients showing an "heterogeneous" EGFR expression distribution had worse OS and DFS compared to the "homogeneous" group of patients. Based on our results, EGFR expression, especially referring to membrane features (semiquantitative analysis), might have a prognostic value for OS and DFS in locally advanced HNSCC treated with surgery and adjuvant RT. Prospective trials could be useful to confirm the prognostic role of EGFR expression and also to assess a predictive role to select that might benefit from more aggressive treatments.

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.

Medullary thyroid carcinoma (MTC) can assume various cytomorphological and architectural forms, mimicking other thyroid and extra-thyroid tumors and rendering the cytological and histological diagnosis challenging. Consequently, measurement of calcitonin (CT) levels is generally considered to be more accurate than cytology in diagnosing MTC. Here, we report on a patient with a multinodular goiter and significantly elevated basal CT levels; based on cytology examination and CT immunocytostains, neither MTC nor C-cell hyperplasia was detected upon final histopathological examination. CT testing has a high false-positive rate and low positive predictive value for detecting clinically relevant MTC. Judicious integration of cytological examination with immunocytochemical stains (when needed) may be useful for selecting the most appropriate therapy and avoiding overtreatment (i.e., central neck lymph node dissection in the present case). This case demonstrates that cytological examination with ancillary techniques is still valuable in patients with thyroid nodules and suspicious MTC.

Background Transoral laser microsurgery (TLM) is a mature approach to supraglottic cancer, while transoral robotic surgery (TORS) is emerging. The present study compared these approaches. Methods The first 10 patients (2002–2005) given TLM were compared with the first 10 (2007–2011) given TORS for cT1-3 cN0-cN2c supraglottic cancer. Results A feeding tube was used in four TLM and seven TORS patients. Margins were more often positive, but operating times shorter, in TORS. All 10 TORS patients are without evidence of disease, but only six TLM patients remain disease-free after much longer follow-up. TORS was considerably less uncomfortable and fatiguing for the surgeon. Conclusions TORS seems as safe and effective as TLM. Shorter TORS operating times are probably attributable to prior experience with TLM. For laryngeal exposure, length of tube placement and margin evaluability, TLM was superior; however, this may change as TORS develops and transoral robotic instruments are optimized. Copyright © 2013 John Wiley & Sons, Ltd.

Mandibular symphyseal resection requires composite reconstructions, often with unsatisfactory morphofunctional results. Seven patients with advanced squamous cell carcinoma of the floor of the mouth underwent block resection with immediate reconstruction, using the removed mandible treated with liquid nitrogen and covered with a free forearm flap. In all cases, the resection was radical and no major postoperative complications occurred. Two patients died in 6 months for distant metastases and regional recurrence. In the other 5 patients, no local recurrence occurred at a mean follow-up of 52 months (36-70). Immediate cosmetic and functional results were good. Of the 5 patients, 4 had late complications requiring further surgery. This technique of bone reimplantation produces no donor site morbidity, perfect immediate morphological result, and is of low cost. The free forearm flap is effective in sealing the oral cavity, though further clinical and experimental studies are necessary to reduce late local complications.

Background : Evaluation of immediate and long-term surgical results in major surgery for the head and neck tumours in elderly patients and identification of tumour and patient related factors that affect the incidence and severity of surgical and medical complications. Methods : Retrospective analysis of a series of 24 consecutive patients aged 70 and over with head and neck tumours undergoing extensive surgical resections with reconstruction with/without osseous and/or soft tissue transfer. Patients' demographics and surgery and tumour related data were extracted from appropriate charts and recorded. Pre-existent comorbid conditions, immediate and long-term surgical and medical complications were analysed. Pre-existing comorbidities were graded and staged using the Comorbidity Data Collection Form. Postoperative surgical and medical complications were scored according to their severity. Results : Overall complication rate in present study was 63% and 54% of patients experienced clinically important surgical and/or medical complications. However, medium admission time remained at 16 days. Presence of advanced comorbidity, longer operative times and advanced stage of disease seemed to influence the development of surgical or medical complications. Conclusions : Major surgery for head and neck tumours is of great value even in elderly patients providing very good surgical results with acceptable complication rates. The choice of treatment modality should be based on all factors affecting the treatment outcomes. In particular, the presence of the co-existent underlying diseases should be assessed meticulously and in cases with clinically important comorbidities the surgical treatment stress should be reduced to minimum.

Background The Chernobyl nuclear accident of 1986 caused a dramatic increase in the incidence of thyroid cancers in exposed children in Belarus. Airborne radioactivity from the reactor spread over northern Italy, where rainout gave rise to low levels of radioactivity at ground level. Patients and methods As the latency between exposure to ionising radiation and development of thyroid cancer is thought to be about 10 years, in 1996/1997 all children born in 1985 and 1986 and attending school in an area of Milan, Italy were examined for thyroid nodules. A total of 3949 children were examined by two physicians blinded to the examination and diagnosis of the other. The children were to be reassessed in 2001/2002. Results In total, 1% had palpable nodules. The nodule diagnoses were: Hurtle cell adenoma (one), thyroglossal duct cyst (one), thyroid cyst (four) and thyroiditis (four). The prevalence of thyroid disease in the cohort was indistinguishable from that of populations not exposed to radioactive pollution. Only 10 children re-presented for examination 5 years later; all were negative. The direct costs of the study were estimated at € 21 200. Conclusion The high cost of the study in relation to reassuring lack of increase in thyroid nodule prevalence suggests that further studies are not justified.

Objectives Translaryngeal tracheotomy (TLT) is a widely accepted procedure in intensive-care units for its simplicity of execution, low morbidity, rapid wound closure after cannula removal, good esthetic results, and lack of long-term sequelae. The aim of this study was to evaluate the feasibility and use of adopting TLT in patients with cancer undergoing major head and neck surgery. Study Design Prospective analysis of learning curve and incidence of complications in 41 patients with cancer who underwent TLT at the Division of Head and Neck Surgery of the European Institute of Oncology from November 1997 to June 1999. Methods Patient characteristics, pathology, anatomic characteristics of the neck, and surgical short-term and long-term complications were noted. The patients were divided into consecutive groups of six or seven patients, and time trends in occurrence of complications and time to execute the procedure were assessed. Results TLT performance time decreased from 50 minutes in the first seven patients to 24 minutes in the last group. The technique was easy to perform and safe, with only two minor complications during surgery. However, minor complications occurred in three and major complications in 17 patients in the days immediately following surgery, almost entirely attributable to lack of counter-cannu1a and stylet. Conclusions In view of the high proportion of major complications, TLT using the presently available kit is unsuitable for major head and neck surgery. However, the considerable advantages of the technique would recommend it as a valid alternative to surgical tracheotomy if the kit included a counter-cannu1a and stylet.

The ability to reliably predict cancer outcome could tailor therapy to the aggressiveness of the tumour to achieve the best results in terms of loco-regional control, overall survival and quality of life. Retrospective and prospective clinical trials involving large series of patients have validated some predictive clinical and pathological factors, whereas the utility of many other prognostic factors has not been established. This has led to some confusion in clinical practice. In order to clarify the significance, role and cost of these prognostic factors we carried out a Medline search of all papers published between 1993 and 1998 concerning the reliability and cost of markers with prognostic significance, in head and neck squamous cell carcinoma, and assessed the results according to a number of criteria relating to reliability and cost. Regarding reliability we classified prognostic factors into: (1) those with a proven significance based on the fact that they were unanimously reported as having an independent statistical correlation with outcome and prognosis; and (2) those for which results were not unanimous, and which significance is still controversial. Cost analysis showed a substantial difference between validated tests which are of low cost and experimental tests which are expensive. Based on these data regarding both the reliability and cost of each prognostic factor, we propose guidelines for their use in clinical practice in the year 2000.

Preoperative data in patients with oral cavity/oropharyngeal cancer may predict postoperative complications that may modify therapeutic choices and improve patient care.We reviewed 320 consecutive patients with oral cavity/oropharyngeal cancer, operated on 2003 through 2006 at the European Institute of Oncology. By multivariate analysis of preoperative patient and tumor characteristics, we developed an algorithm to predict postoperative complications. We tested the algorithm on a new series of 307 patients operated on 2007 through 2010.The final algorithm used to produce a nomogram was comprised of: alcohol consumption (p = .01), site of primary (p = .03), interaction of clinical T classification to sex (p = .007), and type of neck dissection (p .0001). The algorithm had good ability to predict complications (concordance index [c-index] 0.74) in the new series.The nomogram accurately predicts presurgical risk of postoperative local/systemic complications in patients with oral cavity/oropharyngeal cancer and can be used to adapt therapy to patient characteristics, optimize ward admissions, and improve care.

Transoral laser microsurgery (TLM) is a mature approach to supraglottic cancer, while transoral robotic surgery (TORS) is emerging. The present study compared these approaches.The first 10 patients (2002-2005) given TLM were compared with the first 10 (2007-2011) given TORS for cT1-3 cN0-cN2c supraglottic cancer.A feeding tube was used in four TLM and seven TORS patients. Margins were more often positive, but operating times shorter, in TORS. All 10 TORS patients are without evidence of disease, but only six TLM patients remain disease-free after much longer follow-up. TORS was considerably less uncomfortable and fatiguing for the surgeon.TORS seems as safe and effective as TLM. Shorter TORS operating times are probably attributable to prior experience with TLM. For laryngeal exposure, length of tube placement and margin evaluability, TLM was superior; however, this may change as TORS develops and transoral robotic instruments are optimized.

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.

Aims and background Salivary gland malignancies are rare. The aim of our study was to investigate radiotherapy-related toxicity and clinical outcome in patients treated at our division with postoperative radiotherapy (pRT) for parotid tumors. Methods and study design Forty-three consecutive patients (32 with primary parotid tumors, 9 with parotid metastases and 2 with recurrent benign diseases) were retrospectively analyzed. Results The median follow-up was 28 months. Twenty and 5 patients had a follow-up longer than 2 and 5 years, respectively. Thirty-seven patients were alive and most of them (78%) were free from disease. The local and distant control rates were higher in patients with primary parotid tumors (94% and 87.5%) than in patients with parotid metastases (87.5% and 75%). Grade 3 radiotherapy-related acute toxicity of skin and mucosa was recorded in 20.9% and 28% of patients, respectively. Two patients (4.7%) had grade 4 skin toxicity. Late toxicity data were available for 33 (77%) patients. None of the patients developed severe (grade 3 and 4) late toxicity of soft tissues, skin or temporomandibular joints. Conclusions Postoperative radiotherapy is a feasible treatment that was found to be effective mainly in patients with primary parotid tumors. Toxicity was acceptable but could probably be further reduced using more advanced radiotherapy techniques. Longer follow-up is required to achieve definitive results.

To analyze dose distribution in the hearing organ and to evaluate the dose effect on the hearing thresholds in patients treated with post-parotidectomy 3-dimensional conformal radiotherapy (3D-CRT). A total of 17 patients received post-parotidectomy 3D-CRT (median dose: 63 Gy). The audiometric evaluation comprised pure tone audiometry and tympanometry performed before radiotherapy (RT) and 3, 6, and 24 months after RT. The ear structures were delineated on planning computer tomography scans. Mean and maximum doses were calculated and dose–volume histograms were plotted. Before RT, the median baseline audiometric thresholds were normal. At 3 months post-RT, 3 patients were diagnosed as having middle ear underpressure and/or effusion that resolved completely by 6 months. During 2-year follow-up, none of the ears showed perceptive hearing loss at speech frequencies. The mean doses at ipsilateral external auditory canal, mastoids cells, tympanic case, Eustachian tube, semicircular canals, and cochlea were 44.8 Gy, 39.0 Gy, 30.9 Gy, 33.0 Gy, 19.6 Gy, and 19.2 Gy, respectively. The doses to the contralateral ear were negligible, except for the Eustachian tube (up to 28.2 Gy). Post-parotidectomy 3D-CRT is associated with relatively low doses to the ear and the surrounding structures. Post-RT audiometry did not show any permanent (neither conductive nor perceptive) hearing impairment. Only in 3 patients were there signs of transient unilateral dysfunction of the Eustachian tube observed during the first few months after RT. Longer follow-up and larger patient series are warranted to confirm these preliminary findings.

Summary 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 >1 cm); 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 5 years, 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.

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.

Lipofilling is a well-established technique in reconstructive plastic surgery. It is used primarily in recontouring of the body and face to correct post-traumatic and congenital defects. The regenerative properties of adipose tissue have allowed the use of the lipofilling technique for the treatment of burn sequelae and irradiated breast to improve tissue quality and elasticity. We report on the case of a patient treated with radiation therapy for a nasopharyngeal carcinoma who presented with severe postradiation dysphagia. The lipofilling technique was successfully used to improve abnormal swallowing. The technical details and functional outcomes are discussed.

Objective: The aim of this study was to assess the potential of perfusion computed tomography (CTp) for monitoring induction chemotherapy in patients with squamous cell carcinoma (SCCA) of the upper aerodigestive tract. Materials and Methods: Twenty-five patients with advanced SCCA underwent CTp and volumetric CT before and after induction chemotherapy. Perfusion CT parameters were calculated in the tumor, normal tissue, and muscles and correlated with tumor volume. Results: The blood flow (BF), blood volume (BV), and permeability surface were significantly higher, and the mean transit time was significantly lower in the tumor than in the normal tissue. The tumor BF and BV significantly decreased, and the mean transit time significantly increased after the therapy; decrease in BF and BV correlated with tumor volume reduction after chemotherapy. The baseline tumor BV was significantly lower in nonresponders compared with that in responders. Conclusions: In patients with SCCA, CTp showed potential for monitoring induction chemotherapy, reduction in tumor BF and BV correlated with reduction of tumor volume after chemotherapy, and baseline tumor BV may predict response to chemotherapy.

Objective To assess the impact of margin status on disease-free survival, overall survival, and organ preservation in early glottic cancer treated by endoscopic laser surgery. Design Prospective nonrandomized study. Setting Tertiary referral center. Patients A total of 274 patients with untreated (possibly biopsied) cTis, cT1a/b, cT2, cN0 glottic cancer; adequate exposure of the glottic region; no contraindications to general anesthesia; and the ability to give informed consent. Interventions European Laryngological Society laser cordectomy. Patients with negative margins (>1 mm) were followed, patients with close margins (≤1 mm) or 1 positive margin (tumor on margin) had another operation, and patients with more than 1 positive margin had postoperative radiotherapy. Median follow-up was 58 months. Main Outcome Measures Eight-year disease-free survival, 5-year overall survival, and organ preservation rate. Results Margins were negative in 180 patients, close in 40, and positive in 54. A second laser resection was performed in 36 of 94 patients with close or positive margins. Radiotherapy was administered to 36 patients. Patients with close or positive margins who did not undergo further treatment had a greater recurrence risk (hazard ratio, 2.53; 95% confidence interval, 0.97-6.59,P = .06) than did those with negative margins, mainly owing to relapses in 5 of the 8 protocol breakers with positive margins not treated further. Eight-year relapse-free survival was 88.2%, 5-year overall survival was 90.9%, and the larynx was preserved in 97.1%. Conclusions Laser removal of early glottic cancer is oncologically adequate with margins greater than 1 mm from the tumor edge. Positive margins require further treatment; close margins may require further treatment depending on tumor characteristics.

Thyroid cancer is the most common endocrine neoplasm; however, it only accounts for less than 1% of all human malignances. Thyroid cancers are divided into well differentiated and non-well differentiated cancers, according to their histology and behavior. The surgical management options of well-differentiated thyroid cancer include total or near-total thyroidectomy, subtotal thyroidectomy and lobectomy plus isthmusectomy. The extent of surgery for thyroid cancer continues to be an area of controversy. Complications associated with thyroid surgery are directly proportional to the extent of thyroidectomy and inversely proportional to the experience of the operating surgeon. They occur less frequently with good surgical technique and better understanding of surgical anatomy, and include wound healing and infections (seroma, hematoma and wound infection), nerve injury, hypoparathyroidism, hypothyroidism, postoperative hemorrhage and respiratory obstruction.

The aim of this study was to evaluate the biological behaviour of a frozen bone graft in orthotopic and heterotopic sites in the rat. The previous experimental study on this subject was published 25 years ago without sufficient detail about the histology and comparison between the orthotopic and ectopic sites. Therefore, being very important for future clinical application, we decided to evaluate the frozen bone graft using rats. The procedure was performed on two groups of five rats each (Charles River). After wide dissection of the inferior border of the mandible from the surrounding muscle, an inferior segmental resection 4 mm in length was performed, taking care not to fracture the superior part and to maintain mucosal integrity. This segment was placed in liquid nitrogen for two periods of 10 minutes each with a third period to allow it to reach room temperature. In the first group (A), the frozen segment was placed ectopically in a gluteal muscle pocket, and in the second group (B), the frozen bone was fixed in the same position in the same mandible. After 1 month of follow-up, the animals were killed, the bone graft was removed, and histology was performed. Results were consistent in both groups. In group A, the segment was surrounded by strong inflammatory reaction, with no vital cells or bone cells, but some vascular penetration. We concluded that there was no bone deposition and no bone rehabitation. In group B, the initial segment was strongly fixed to the remaining mandible, there was an increase of the macroscopic dimension that paralleled the increase in the dimension of the remaining mandible and the growth of the animal. The cortical part had thinned down, the medullary part presented signs of bone deposition as well as bone resorption and vascular penetration. The periosteum from the adjacent normal mandible was growing and covering the frozen bone graft, offering additional stimulus to the bone deposition. In conclusion, the frozen bone graft acts as a normal bone graft. It needs to be placed in contact with vascularised bone and surrounded by well vascularised soft tissue to allow deposition of new bone. If the frozen graft is placed ectopically, it will be surrounded by chronic inflammatory reaction with no bone deposition.