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Most oropharyngeal squamous cell carcinomas (OPSCCs) are human papillomavirus (HPV)-associated, high-risk (HR) cancers that show a better response to chemoradiotherapy and are associated with improved survival. Nucleophosmin (NPM, also called NPM1/B23) is a nucleolar phosphoprotein that plays different roles within the cell, such as ribosomal synthesis, cell cycle regulation, DNA damage repair and centrosome duplication. NPM is also known as an activator of inflammatory pathways. An increase in NPM expression has been observed in vitro in E6/E7 overexpressing cells and is involved in HPV assembly. In this retrospective study, we investigated the relationship between the immunohistochemical (IHC) expression of NPM and HR-HPV viral load, assayed by RNAScope in situ hybridization (ISH), in ten patients with histologically confirmed p16-positive OPSCC. Our findings show that there is a positive correlation between NPM expression and HR-HPV mRNA (Rs = 0.70, p = 0.03), and a linear regression (r 2 = 0.55; p = 0.01). These data support the hypothesis that NPM IHC, together with HPV RNAScope, could be used as a predictor of transcriptionally active HPV presence and tumor progression, which is useful for therapy decisions. This study includes a small cohort of patients and, cannot report conclusive findings. Further studies with large series of patients are needed to support our hypothesis.

Objectives: To analyze the demographic data, surgical and adjuvant treatment data and the survival outcomes in adult patients affected by acinic cell carcinoma of the parotid gland (AciCC)., Methods: A retrospective multicenter analysis of patients treated for AciCC of the parotid gland from 2000 to 2021 was performed. Exclusion criteria were pediatric (0-18 years) patients, the absence of follow-up and patients with secondary metastatic disease to the parotid gland. Multivariable logistic regression was used to determine factors associated with survival., Results: The study included 81 adult patients with AciCC of the parotid gland. The median age was 46.3 years (SD 15.81, range 19-84 years), with a gender female prevalence (F = 48, M = 33). The mean follow-up was 77.7 months (min 4-max 361, SD 72.46). The 5 years overall survival (OS) was 97.5%. The 5 years disease-free survival (DFS) was 60%. No statistical differences have been found in prognosis for age (< 65 or ≥ 65 years), sex, surgery type (superficial vs profound parotid surgery), radicality (R0 vs R1 + Rclose), neck dissection, early pathologic T and N stages and adjuvant therapy (p > 0.05)., Conclusion: This study did not find prognostic factor for poorest outcome. In contrast with the existing literature, our results showed how also high-grade tumours cannot be considered predictive of recurrence or aggressive behaviour., (© 2022. The Author(s).)

Purpose: Data from literature show a mean incidence of occult metastases of 33% in early OCSCC. The gold standard for most authors is a selective neck dissection and a routine pathological examination. 60-70% of unnecessary neck dissections with associated morbidity, can be avoided by using SNB. The aim of this study is to present the results of one of the major Italian centres for the SNB procedure, reserving neck dissection only for proven positive lymphatic metastases., Methods: From July 2004 to March 2015, 48 patients with transorally resectable cT1-T2N0 oral SCC were submitted to a lymphoscintigraphic examination one-three hours before surgery and a radio-guided SNB (same day protocol). Patients with a negative SNB were checked every 3 months by ultrasound examination. The minimum follow-up was 5 years., Results: Sentinel nodes were found in all cases, with 71% localized in the ipsilateral neck only in levels I-II. Metastases were found in 15 out of 48 cases (31.2%), on levels I, II and III. Further metastatic nodes were found in 6 cases in the neck dissection specimen. In the cohort of 33 patients with SNB negative at 5 years, no-one had a recurrence on the ipsilateral neck., Conclusion: This study confirms the accuracy of SNB in predicting the presence of occult metastases, sparing the need for unnecessary neck dissection in 70% of cases. The same day protocol is designed to detect sentinel nodes, which are almost always on neck level I-II, thereby limiting the number of nodes examined and the extension of the surgical approach.

Background: The eighth international symposium for sentinel node biopsy (SNB) in head and neck cancer was held in 2018. This consensus conference aimed to deliver current multidisciplinary guidelines. This document focuses on the surgical aspects of SNB for oral cancer., Method: Invited expert faculty selected topics requiring guidelines. Topics were reviewed and evidence evaluated where available. Data were presented at the consensus meeting, with live debate from panels comprising expert, nonexpert, and patient representatives followed by voting to assess the level of support for proposed recommendations. Evidence review, debate, and voting results were all considered in constructing these guidelines., Results/conclusion: A range of topics were considered, from patient selection to surgical technique and follow-up schedule. Consensus was not achieved in all areas, highlighting potential issues that would benefit from prospective studies. Nevertheless these guidelines represent an up-to-date pragmatic recommendation based on current evidence and expert opinion., (© 2019 Wiley Periodicals, Inc.)

Purpose: Nuclear imaging plays a crucial role in lymphatic mapping of oral cancer. This evaluation represents a subanalysis of the original multicenter SENT trial data set, involving 434 patients with T1-T2, N0, and M0 oral squamous cell carcinoma. The impact of acquisition techniques, tracer injection timing relative to surgery, and causes of false-negative rate were assessed., Methods: Three to 24 hours before surgery, all patients received a dose of Tc-nanocolloid (10-175 MBq), followed by lymphoscintigraphy. According to institutional protocols, all patients underwent preoperative dynamic/static scan and/or SPECT/CT., Results: Lymphoscintigraphy identified 723 lymphatic basins. 1398 sentinel lymph nodes (SNs) were biopsied (3.2 SN per patient; range, 1-10). Dynamic scan allowed the differentiation of sentinel nodes from second tier lymph nodes. SPECT/CT allowed more accurate anatomical localization and estimated SN depth more efficiently. After pathological examination, 9.9% of the SN excised (138 of 1398 SNs) showed metastases. The first neck level (NL) containing SN+ was NL I in 28.6%, NL IIa in 44.8%, NL IIb in 2.8%, NL III in 17.1%, and NL IV in 6.7% of positive patients. Approximately 96% of positive SNs were localized in the first and second lymphatic basin visualized using lymphoscintigraphy. After neck dissection, the SN+ was the only lymph node containing metastasis in approximately 80% of patients., Conclusions: Best results were observed using a dynamic scan in combination with SPECT/CT. A shorter interval between tracer injection, imaging, and surgery resulted in a lower false-negative rate. At least 2 NLs have to be harvested, as this may increase the detection of lymphatic metastases.

Purpose: Optimum management of the N0 neck is unresolved in oral cancer. Sentinel node biopsy (SNB) can reliably detect microscopic lymph node metastasis. The object of this study was to establish whether the technique was both reliable in staging the N0 neck and a safe oncological procedure in patients with early-stage oral squamous cell carcinoma., Methods: An European Organisation for Research and Treatment of Cancer-approved prospective, observational study commenced in 2005. Fourteen European centres recruited 415 patients with radiologically staged T1-T2N0 squamous cell carcinoma. SNB was undertaken with an average of 3.2 nodes removed per patient. Patients were excluded if the sentinel node (SN) could not be identified. A positive SN led to a neck dissection within 3 weeks. Analysis was performed at 3-year follow-up., Results: An SN was found in 99.5% of cases. Positive SNs were found in 23% (94 in 415). A false-negative result occurred in 14% (15 in 109) of patients, of whom eight were subsequently rescued by salvage therapy. Recurrence after a positive SNB and subsequent neck dissection occurred in 22 patients, of which 16 (73%) were in the neck and just six patients were rescued. Only minor complications (3%) were reported following SNB. Disease-specific survival was 94%. The sensitivity of SNB was 86% and the negative predictive value 95%., Conclusion: These data show that SNB is a reliable and safe oncological technique for staging the clinically N0 neck in patients with T1 and T2 oral cancer. EORTC Protocol 24021: Sentinel Node Biopsy in the Management of Oral and Oropharyngeal Squamous Cell Carcinoma., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Several guidelines on adeno-tonsillar disease have been proposed in recent years and some discrepancies in relation both to clinical manifestations and indications for surgical treatment have emerged. The aim of the study was to verify what influence (adeno)-tonsillectomy guidelines have had on the clinical behaviour of ENT specialists in Italy. Our study is a retrospective and multi-centre case series with chart review., Methods: The survey involved 14,770 children, aged between the ages of 2 and 11, who had undergone adeno-tonsillar surgery between 2002 and 2008 in fourteen Italian tertiary and secondary referral centres. Anova test was used for the statistical analysis, assuming p < 0.05 as the minimum statistical significance value., Results: The frequency of adeno-tonsillar surgeries did not change significantly (p>0.05) during the study period and following the Italian policy document publication. Overall, adeno-tonsillectomy was the most frequent intervention (64.1%), followed by adenoidectomy (31.1%) and tonsillectomy (4.8%). The indications for surgery did not change significantly for each of the operations (p>0.05), with the exception of adeno-tonsillectomy in case of feverish episodes due to acute recurrent tonsillitis ≥ 5 without nasal obstruction (decreased p= 0.010) , even when the feverish episodes due to acute recurrent tonsillitis were < 5 over the last year. Nasal obstruction was associated with feverish episodes due to acute recurrent tonsillitis in 65.2% of operated cases, while otitis media had been diagnosed in 43.3% of the patients studied., Conclusions: The recommendations first developed in Italy in a 2003 policy document and then resumed in guidelines in 2008, were not implemented by ENT units involved in the survey. The study highlights the fact that the indications for adeno-tonsillar operations are based on the overall clinical presentation (comorbidity) rather than on a single symptom. Guidelines are necessary to give coherent recommendations based on both the findings obtained through randomized controlled trials and the data collected from observational studies.

Background: Human papillomaviruses are associated with invasive cancers in the cervical, anogenital, and oropharyngeal areas. Persistent HPV infections, particularly with high-risk HPV such as HPV 16, are involved in the carcinogenesis of a subset of oropharyngeal cancers. The majority of published studies on HPV prevalence in these tumors concentrated on identifying high-risk mucosal types., Objectives: To determine the HPV type specific prevalence in different samples collected from the oral cavity of three groups of patients: (A) healthy (n=25); (B) non-malignant lesions (n=47); and (C) cancers (n=78)., Study Design: To evaluate the prevalence of HPV genotypes in the oral cavity, samples were analyzed by PCR with: MY09/MY11 followed by GP5+/GP6+, CP65/CP70 followed by CP66/CP69, and FAP59/FAP64 primers. The presence of viral transcripts was ascertained by RT-PCR with specific primers for the E7 region., Results: Mucosal HPV types were associated with the presence of cancers. This trend was statistically significant if the analysis was performed for HPV 16 (p=0.04), which is the most prevalent type detected in oropharyngeal cancers. Conversely, cutaneous HPVs were associated with non-malignant lesions (p=0.007). The multiple correspondence analysis confirmed these data. Viral transcripts of only mucosal HPVs were detected in non-malignant lesions and cancers., Conclusions: Different types of HPVs infect the oral epithelium, but only the mucosal types, particularly HPV 16, are clearly associated with tumors. The discovery that cutaneous HPVs are associated with potential malignant oral disorders brings other data to understand the significance of their presence in the oral cavity., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: The role of sentinel node biopsy in head and neck cancer is currently being explored. Patients with positive sentinel nodes were investigated to establish if additional metastases were present in the neck, their distribution, and their impact on outcome., Methods: In all, 109 patients (n = 109) from 15 European centers, with cT1/2,N0 tumors, and a positive sentinel lymph node were identified. Kaplan-Meier and univariate and multivariate logistic regression analysis were used to identify variables that predicted for additional positive nodes and their position within the neck., Results: A total of 122 neck dissections were performed in 109 patients. Additional positive nodes were found in 34.4% of cases (42/122: 18 same, 21 adjacent, and 3 nonadjacent neck level). Additional nodes, especially if outside the sentinel node basin, had an impact on outcome., Conclusions: The results are preliminary but suggest that both the number and the position of positive sentinel nodes may identify different prognostic groups that may allow further tailoring of management plans., (Copyright © 2012 Wiley Periodicals, Inc.)

Although primary tumours of the parapharyngeal space are rare and account for only 0.5% of head and neck neoplasms, they represent a formidable challenge to the surgeon both in the assessment of the preoperative condition and the appropriate surgical approach. This study is a retrospective review of the clinical records of 12 patients (8 male, 4 female, mean age 49 years), treated for parapharyngeal space tumours by the same surgical team from 1992 to 1998 and observed at follow-up for at least 10 years. Of these, 8 (66.6%) were benign and 4 (33.4%) malignant. Magnetic resonance imaging and fine-needle aspiration biopsy were performed as the preoperative evaluation in 8/12 cases. The positive predictive value of our fine-needle aspiration biopsy was 75% for benign tumours (3/4) and 100% (4/4) for malignant tumours. Different surgical approaches were used: transcervical-transmandibular in 5 cases (41.6%); transparotid-transcervical in 4 patients (33.4%); transoral in 2 patients (16.6%) with a small pleomorphic adenoma of the deep lobe of parotid, and in the last case (8.4%), transcervical surgery was performed for papillary thyroid carcinoma metastasis. Post-operative complications occurred in 3/12 patients: two developed Horner's syndrome and one patient presented a temporary marginal mandibular of facial nerve dysfunction. Post-operative radiotherapy was performed in 3/4 patients on account of malignancy. Each patient underwent a follow-up protocol of clinical controls and ultrasonography every 6 months, computed tomography and/or magnetic resonance imaging once a year for 10 years. Eleven patients (91.4%) were still disease free after 10-year follow-up. One patient with a recurrent parotid gland adenocarcinoma died of distant metastasis 4 years after parapharyngeal space surgery. These 12 parapharyngeal space tumours were treated with use of one of the various surgical approaches described in relation to the histopathological diagnosis (benign or malignant), to the side (prestyloid or poststyloid) and to the size (+/-4 cm) of the neoplasia and, moreover, were observed at long-term follow-up. Results of personal experience in the treatment of the tumours of the parapharyngeal space confirm the necessity to follow a careful preoperative diagnostic outline that must be taken advantage of the study for imaging (computed tomography, magnetic resonance imaging) and of cytology, in order to plan surgical treatment with a safe approach and that reduces complications, aesthetic-functional damages and risk of recurrence.

Aim: To evaluate the role of dynamic lymphoscintigraphy with a same-day protocol for sentinel node biopsy in oral cavity cancer., Methods: Twenty-two consecutive patients affected by cT1-2N0 squamous cell carcinoma of the oral cavity were enrolled between September 2001 and November 2005. After a local anaesthetic (10% lidocaine spray), a dose of 30-50 MBq of Tc human serum albumin nanocolloid, in ml saline, was injected superficially (1-2 mm subendothelial injection) into four points around the lesion. Dynamic lymphoscintigraphy was acquired immediately (256x256 matrix, 5 min pre-set time, LEGP collimator) in lateral and anterior projections. The imaging was prolonged until the lymph nodes of at least two neck levels were visualized (time required min). About 3 h later (same-day protocol) the patients had a radioguided sentinel node biopsy. Elective neck dissection was performed in the first 13 patients; whereas the last nine patients had elective neck dissection only if the sentinel node was positive. Sentinel nodes were dissected into 1 mm thick block sections and studied by haematoxylin & eosin staining and immunohistochemistry (anticytokeratin antibody)., Results: The sentinel nodes were found on the 1st neck level in 13 cases, on the 2nd neck level in eight cases, and on the 3rd neck level in one case (100% sensitivity). The average number of sentinel nodes was 2.2 for each patient. The sentinel node was positive in eight patients (36%); with six of them having the sentinel node as the exclusive site of metastasis. No skip metastases were found in the 14 patients with negative sentinel node (100% specificity)., Conclusion: Our preliminary data indicate that superficial injections of radiocolloid and dynamic lymphoscintigraphy provide a high success rate in sentinel node identification in oral cavity cancers. Dynamic lymphoscintigraphy helps in distinguishing sentinel node from second-tier lymph nodes. The same-day protocol is advisable in order to correctly identify the first sentinel node, avoiding multiple and unnecessary node biopsies, without reducing sensitivity.

Aims: To examine the expression of DNA mismatch repair (MMR) proteins and the presence of microsatellite instability (MSI) in seven primary mucosal melanomas of the head and neck (MMHN)., Methods and Results: Haematoxylin and eosin staining and immunohistochemical analysis for routine diagnostic markers and for MMR proteins were performed. Six cases were examined for MSI. Four cases were monomorphous and three cases were pleomorphic type MMHN. Melanocytic markers were positive in all cases. Immunoreactivity for MMR proteins was weak in normal epithelium. The neoplastic tissue in six cases showed positivity for all MMR proteins with different percentages. One case showed weak positivity for hMSH2 and hMSH6 and no immunoreactivity for hMLH1 or hPMS2. Staining intensity was higher in tumour cells than in matched normal mucosa in three cases for hMSH2 and hMLH1 and in two cases for hPMS2. None of the examined cases showed MSI., Conclusions: Expression of hMSH2 and hMLH1 proteins was up-regulated in three cases, whereas in two cases that of hPMS2 was increased. hMSH6 expression was comparable to that of normal cells in all cases. The percentage of positive neoplastic cells and the intensity of staining seemed to be greater in pleomorphic melanomas. Six cases were MMR-proficient and microsatellite stable.

HPV involvement in head and neck (HN) cancer is still under active investigation. Fresh frozen and archival clinical samples from 115 patients affected by HN carcinomas were analysed by PCR-based methods and direct sequencing. HPV types, intra-type variants, physical status, viral load and viral transcript presence were determined. HPV positivity was correlated with the main clinical-pathological features, including smoker and drinker status, and the clinical outcome. Twenty-one tumours were HPV positive (18.3%) with HPV16 being the most frequent type (n=14) followed by HPV6 (n=4), HPV33, HPV35, and HPV58 (n=1, each type). Tonsil carcinomas contained more high-risk HPV types (6/8; 75%) than all other sites (p=0.0004). HPV16 genome was integrated in all analysed tumours, as pure integrated form or mixed with concomitant episomal forms (4 cases). The viral load showed a wide variability (range, 0.7-485 copies per cell) with the highest value detected in a larynx tumour and the lowest one in a case of cancer of the oral cavity. In 9 HPV-positive samples where mRNA was available, transcripts of viral early oncogenes originating by integrated, episomal or mixed forms of the viral genome were found. A statistically significant correlation was evidenced between HPV and tumour differentiation, being the virus more associated with tumour grade G3/G4. Multivariate Cox regression analysis revealed that lymph-node and grade status were significant independent factors for a worse disease-free survival and overall survival, whereas the HPV status was associated with a better overall survival (OR, 0.33; 95% CI, 0.13-0.81; p=0.01). Taken together these results indicate that distinct pathological mechanisms for the malignant transformation in each single HN subsite should be taken in account; HPV molecular analyses should be considered a valid tool to distinguish subsets of oropharyngeal tumours and HPV presence could be useful for the prognostic assessment of HNSCC.

The routine use of a sentinel node biopsy (SNB) protocol in oral cavity squamous cell carcinomas (SCC) has been challenged on the basis of the elevated number of sentinel nodes (SNs) detected (>2.5) and on the multiply neck level involvement reported in several studies. These data limit the practical application of the protocol, because in such cases, it seems easier and safer to perform a selective neck dissection. The aim of our study is to perform radioguided surgery 1-3 h after lymphoscintigraphy (same day protocol) to detect the lymph nodes closest to the tumour site. In our study, 12 patients affected by cT1-2 N0 SCC of the oral cavity were submitted to a same day protocol of a lymphoscintigraphic examination (1-3 h before surgery) and a radioguided SNB. We used a hand-held gamma probe and performed an elective neck dissection on all patients. The SNs were found in all cases with 83% localised in the ipsilateral neck in only levels I-II. The mean number of SN detected was 2.1, with a mean pathological size of 13.8 mm measured on pathological specimen. Metastases were found in 5/12 cases (41.6%), on levels I, II and III and all were identified by step serial sectioning and routine H&E staining. This study confirms the accuracy of SNB in predicting the presence of occult metastases. This protocol is designed to detect SNs, which are almost always on neck level I and II, thereby limiting the number of nodes examined and the extension of the surgical approach.

Background: Inflammatory pseudotumor is a rare lesion of the parotid gland. It usually presents as a mass lesion; thus, the clinical and radiologicfeatures often suggest malignancy. To the best of our knowledge, fine needle aspiration cytologic findings in parotid inflammatory pseudotumor have not been reported previously., Case: A 59-year-old male presented with a palpable right parotid mass. Computed tomography revealed a mass measuring 2.5 cm in diameter. Fine needle aspiration cytology showed inflammatory cells, foamy histiocytes and groups of spindle-shaped cells without cytologic atypia. A diagnosis of inflammatory pseudotumor was suggested and was confirmed on histology., Conclusion: In the presence of a clinically evident mass in the parotid gland and fine needle aspiration cytologic features of inflammatory cells with sheets of spindle cells, the diagnosis of inflammatory pseudotumor should be suspected. The differential diagnosis of this unusual parotid gland lesion principally includes sialadenitis and myoepithelioma.

Neurinoma is a benign capsulate tumor originating from the Schwann cells of all nerve fibers outside the central nervous system, the sole exception being the optic and olfactory nerves. These tumors favor the head and neck district but rarely affect the larynx. This work presents the case of a 73-year-old woman treated in the emergency room for an episode of acute dispnea. The patient's case history indicated that for more than 10 years she had the sensation of a foreign body in the hypopharynx and stomatolalia. Direct hypopharyngo-laryngoscopy with a flexible fiberoptic showed a rounded submucosa neoformation 3.5 cm in diameter at the level of the left aryepiglottic fold, blocking the opening of the laryngeal vestibule. Laryngeal motility was perfectly preserved. The decision was made for prompt exeresis of the neoformation under direct microlaryngoscopy with a CO2 laser. Post-operative follow-up showed that all laryngeal functions were preserved. Three months later, the patient was still symptom-free and direct examination of the larynx showed no signs of recurrence. Histological diagnosis indicated a laryngeal schwannoma. Surgical removal is the treatment of choice and can be performed by endoscopy or through an external approach depending on the site and size of the tumor. Different external approaches have been described such as the median thyrofissure, lateral pharyngotomy and lateral thyrofissure. In the present case, although the neoformation was quite large, the decision was made to perform an endoscopy resection with CO2 laser, without resorting to a tracheotomy, reducing post-operative recovery to a minimum and preserving all laryngeal functions.

Assessment of quality of life (QoL) and satisfaction with care are particularly important in the field of oncology. The definition of QoL and the requirements for its measurement are still a matter of debate, but it is generally accepted that QoL is a multidimensional concept involving three different domains: physical, psychological and social. The aim of this study was to test a simple, inexpensive, multidimensional method of QoL measurement, based both on patients' perception of clinical outcome and the quantitatively evaluated clinical outcome, equally weighted, in patients who underwent three different types of conservative laryngeal surgery: horizontal laryngectomy (HG), supraglottic laryngectomy (SL) and subtotal reconstructive laryngectomy (SRL). The following were carried out for each patient: subjective-objective evaluation of speech [computerized spectrographic analysis of fundamental frequency (FO), percentage of noise and intensity and logopedic evaluation of speech], evaluation of deglutition (videofluoroscopic parameters, and qualitative assessment) and evaluation of physical, social, emotional and functional well-being (Functional Assessment of Cancer Therapy, FACT-G, and modified University of Washington Quality of life Scale, UWQoL). Each assessment was given a score rating from one to three points. The overall evaluation of the qualitative and quantitative score for each field and for each type of laryngeal surgery shows that SL results in the best post-operative QoL. Although HG is less damaging and involves swifter functional recovery times, its slightly lower score is due to the poorer quality of speech. The analysis of the results obtained confirm the need to set up an evaluation protocol combining both the subjective perceptions of the patient, as well as the more objective evaluation of the functions that are impaired following surgery. The protocol described above, although limited by the low number of cases, was easy to carry out, inexpensive and applicable in relation to the various types of surgery that may compromise phonation and deglutition.

Angiolipoma is a histological variation of lipoma. It occurs in 17% of the cases of lipoma and the cervico-facial localization is quite rate. Indeed, in the literature 17 cases of angiolipoma have been presented in the head and neck region and none in the oropharygeal area. The present work reports a case of pedunculate angiolipoma in a 44-year-old male: the red-violaceous growth resting on the upper surface of the tongue--was 13 cm long and 1 cm in diameter. The implantation base corresponded to the left posterior-lateral wall of the oropharnyx, 1 cm below the lower tonsilar pole. A serreneoud loop was used to remove the angiolipoma in direct view, the patients mouth held open with an autostatic gag. Histologically it was a non infiltrating variant for which simple removal is curative and recurrences are rare. Viceversa, removal of the infiltrating type requires expanding there section edges to include surrounding tissues in an attempt to preventre currences which are quite frequent (occurring in approximately 50% of the cases).

In modern multi-disciplinary cancer treatment, rehabilitation and functional results represent utmost intent in reconstructive surgery of the oral cavity. Even in cases where the stage of disease is advanced) and the perspective of survival is limited, it is possible to achieve an acceptable quality of life. The authors report, in this study, the morpho-functional results and the morbidity observed in glossectomies in which the reconstruction was performed using three different methods. In a total of 264 reconstructive flaps of the head and neck regions, the authors considered three groups of 15 patients that had had reconstruction after the demolitive procedure. Respectively these groups were divided by the followed methods: free forearm flap, pectoralis major myocutaneous flap and nasolabial flap. The morbidity showed an extremely low rate of flap loss in all the groups, but "minor" complications, such as fistulas and leakages, were significantly more frequent in the myocutaneous flaps group. Functional evaluation for speech and deglutition showed good results in most patients. Extremely severe postoperative conditions as a permanent NG tube or incomprehensible speech had been observed in less than 15% of the cases. Particularly, the pectoralis major flap, showed its best functional performances in the total or subtotal glossectomies with a sacrifice of the muscles of the oral floor. The free forearm flap is reliable and safe with its low thickness and pliability, especially for partial glossectomies. The nasolabial flap was confirmed to be the first reconstructive choice for selected limited resections of the tongue and of the antero-lateral floor. With this experience it is possible, even in more complex free flaps, to reduce the time consumption and the complication rate. Free flaps do not substitute routinely myocutaneous and conventional flaps, but they represent the "ideal" reconstructive alternatives for specific and selected indications.

The authors analyzed the data obtained from their experiences in extensive head and neck resections, and, reconstructive treatments using myocutaneous and conventional flaps. They tried to evaluate comparatively the reconstructive approach, in terms of morbidity and functional results. The 145 cases of advanced had and neck cancer, treated from January 1990 to January 1994, were considered in this study. The reconstructive procedures consisted of 193 flaps. In this study, 106 were myocutaneous flaps (pectoralis major or trapezius flap); 72 were conventional flaps (fasciocutaneous, cutaneous or muscular only) and the remainder were 15 free flaps. The morbidity related to both flap procedures had been low: 33% in myocutaneous flaps versus 11% in conventional flaps. This report demonstrated the versatility, usefulness, and reliability of both kinds of these reconstructive procedures, especially in intra-oral reconstruction. The expected morphological and functional results were quite encouraging in terms of swallowing and speech.

The purpose of this study was to define MR accuracy in the evaluation of T Stage of tumors in the tonsillar region. Twenty-two patients with a squamous cell carcinoma of the tonsillar region were studied utilizing a superconductive scanner operating at 1.5 T. The study was performed with SE T1 and T2 images before contrast and short SE T1 after Gd-DPTA infusion. MR results were correlated with pathological data on T Stage (TNM classification) and on the relationships between tumors and surrounding structures. A positive correlation between MR and pathological data was obtained in 19/22 cases, with an MR accuracy of 86%. MR did not show the presence of 2 superficial lesions (MR T0, pathological T1), while one lesion was classified T2 with MR, instead of pathology T1. The accuracy of MR was 95% in the evaluation of the relationships between tumors and the base of the tongue and 100% for body of the tongue, retromolar trigone, valleculae, epiglottis, pre-epiglottis, parapharyngeal and masticator space. MR showed high accuracy in the evaluation of T Stage, above all utilizing Gd-DPTA infusion, with short SE T1 sequences. MR did not show the superficial lesions, but in these cases a deep extension of the disease was excluded.

Poor survival rates and the limited palliation afforded by radiotherapy alone, together with progress made in reconstructive surgery in restoring mucosal continuity after large resections, make total glossectomy reasonably indicated for treatment of advanced carcinoma of the tongue. The Authors reviewed 19 cases (17 males, 2 females, mean age 58.4 years) of total and near total glossectomy without laryngectomy treated at National Cancer Institute "Regina Elena" of Rome from 1990 to 1993 in order to evaluate oncological and functional results. All patients were reconstructed immediately, 16 with a pectoralis major flap, 2 with a nasolabial flap and 1 with a radial forearm free flap and were available for follow-up from 6 to 45 months (mean 29 months). There was no operative mortality and no patient needed total laryngectomy for aspiration. The rate of local recurrencies was 52.6%, most of them (75%) in patients who had undergone total/near total glossectomy for recurrence. Survival rate was 61.5% after 1 year and 20% after 2 years. 94% of patients resumed swallowing and independent oral alimentation (48% of them without any dysphagia); 84%; of the patients were decannulated and 48% produced easily intellegible speech. Data from our experience let us conclude that, in the light of the acceptable functional results obtained with reconstructive flaps, total glossectomy should be considered as the primary treatment modality in advanced carcinoma of the tongue (including T2 > 3 cm exceeding midline), and should not be reserved only for salvaging hopeless situations.

Fifty-three patients with oral cavity and tongue tumors were studied with MRI, 18 with CT and 10 with US. MR results were compared with postoperative and clinical results relative to the T variable of the TNM classification of oral cavity tumors. MRI demonstrated 51 of 53 tumors; it was in agreement with surgery, relative to T, in 43 of 48 cases and with clinics in 5 of 5 cases. In 5 patients MRI understaged: two lesions were classified as T0 because the tumors developed on the surface (p T4, for alveolar ridge infiltration). Moreover, MRI staged another lesion as T2 instead of T3 because of its superficial component, while in 2 cases the infiltration of the cortical bone of the jaw was not demonstrated (T1 at MRI, T4 at p; T2 at MRI, T4 at p). MRI was reliable enough to evaluate the relationships between the lesions and the surrounding structures but it was limited in demonstrating superficial lesions and in evaluating the infiltration of the alveolar ridge and of the cortical bone of the jaw in the early stage. The use of gadolinium proved to be especially useful for the exact definition of the size of the lesions and of their relationships with the surrounding structures. CT proved better than MRI to evaluate bone involvement in one case, even though neither technique could identify bone involvement in another patient. US yielded accurate information on the presence of lesions, their size and relationships with midline and floor of the mouth muscles, while its demonstration of the relationships between tumors and bone structures was poor, especially relative to tumor spread outside the oral cavity.

The patients with advanced stages of intraoral cancer, having a limited life expectancy, are often considered non-surgical cases. Radiochemotherapy does not warrant an acceptable quality of life. The authors analysed the data obtained from their experiences in resections that had been extensive, as well as, reconstructive treatment of these kinds of neoplasms. They tried to evaluate the demolitive and reconstructive approach, in terms of morbidity, functional results and survival rate. Thirty-six patients, treated from January 1990 to August 1991 for advanced intraoral cancer, were considered in this study; 58% of the cases had primary tumors and 42% had recurrences. The reconstructive procedure used in all cases, was the pectoralis major myocutaneous flap. Even though the expected oncological results had been poor, the functional ones, had been quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory, respectively in 82% and 89% of cases. The morbidity related to the flap procedure had been low. The quality of the residual life of the patients was good, especially if compared with the life of those patients who had not been treated. In conclusion, the authors maintain that even patients with limited prognosis may be considered as potential candidates for demolitive and reconstructive treatment.

Pleomorphic adenoma (P.A.), the most common tumor of the salivary gland, demonstrates a peculiar clinicopathological behaviour for numerous reasons: the high recurrence rate following primary surgery (up to 50%), the appearance of malignancy (2-9%), the reported number of distant metastases histologically identical to the primary P.A. From among 71 cases of benign parotid tumors treated from Nov. 89 to Nov. 92 in the ENT Department of "Regina Elena", the National Cancer Institute in Rome, six particular cases showed multiple force of P.A. recurring after primary surgery performed from 3 to 32 years previously and are object of discussion in this study. All of these six cases had multiple recurrences, usually manifest as nodular clusters in the parotid area, while in three cases appeared as well a recurrence in the soft tissue of the neck, far removed from the parotid space, with no involvement of neck nodes as was revealed through histological examination following neck dissection. A hypothetical mechanism of diffusion is discussed. The Authors agree with the opinion which holds the surgeon's inability to successfully eradicate primary tumors responsible for the high frequency of recurrences. The surgical technique of "enucleation" is, in fact, inadequate in P.A. excision owing the high risk of mishandling or rupturing the tumor capsule with a consequent seeding of the tumor onto the surgical bed. Lateral lobectomy, with identification of the facial nerve, or total conservative parotidectomy (for deep lobe adenoma) are correct techniques in treating primary P.A.. The Authors also discuss management of recurrent P.A. in relation to facial nerve involvement. Preservation of the seventh nerve with eventual post-operative radiation should be considered an alternative to nerve sacrifice in selected cases of recurrent pleomorphic adenoma.

The rare diagnosis of parotid malignant tumors, the different clinico-biological behavior of each histological type and the lack of agreement concerning surgical procedures to be followed in treating the facial nerve led the Authors to carry out a national survey on malignant parotid tumors and their treatment. A questionnaire concerning problems inherent to facial nerve treatment in malignant tumors of the parotid gland was sent to 69 ENT Departments. Data on 139 patients (69 females and 70 males, mean age--59.9 years) were collected for this study. Facial nerve function deficits occurred in 25.9% of the patients, primarily in cases of adenoid cystic carcinoma, adenocarcinoma and undifferentiated carcinoma. Clinical findings were not a good guide in choosing the best surgical procedure to be used with the VII nerve. In fact, in 17% of the cases with no facial deficit, a neural infiltration was found intraoperatively. Total parotidectomy with facial nerve sacrifice (PTST or PTSP) was performed in 87.6% of the patients with complete facial deficit and in 80% of the patients with partial deficit. A more conservative approach was followed when the facial nerve was compressed but not infiltrated. Only 71.7% of the patients with facial nerve infiltration underwent post-operative radiotherapy, a fact which is probably explained by the few departments of radiotherapy in existence. While the functional results reported in Literature are good, facial nerve repairs were carried out in this study in only 9% of the cases. The present study, which supplies interesting data on the treatment of the facial nerve in parotid gland malignant tumors, confirms the need of a multidisciplinary approach and a more frequent use of neural repair techniques in order to preserve the aesthetic and functional aspects of the facial nerve.