Surgical management of parapharyngeal space tumours: results of 10-year follow-up.

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.

DNA mismatch repair protein expression and microsatellite instability in primary mucosal melanomas of the head and neck.

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.

[Laryngeal schwannoma treated with CO2 laser]. / Schwannoma della laringe trattato con laser CO2.

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.

[Oropharyngeal angiolipoma: a case study]. / Un caso di angiolipoma orofaringo-ipofaringeo.

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).

[Free radial forearm flap and myocutaneous flaps in oncological reconstructive surgery of the oral cavity, Comparison of functional results]. / Il lembo libero radiale di avambraccio ed i lembi miocutanei nella chirurgia ricostruttiva oncologica del cavo orale. Implicazioni funzionali a confronto.

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.

[Reconstructive oncologic surgery of the head and neck. Morbidity and comparative results of conventional and myocutaneous flaps]. / Chirurgia ricostruttiva oncologica cervico-facciale. Morbilità e risultati comparativi tra lembi convenzionali e miocutanei.

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.

[Evaluation of the T parameter of TNM classification of tumors of the tonsillar region. Correlation of MR and pathological data]. / Valutazione del parametro T della classificazione TNM dei tumori della regione tonsillare. Correlazione tra RM e dati patologici.

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.

[Total/near-total glossectomy for advanced carcinoma of the tongue]. / La glossectoma totale/subtotale nel trattamento dei tumori avanzati della lingua.

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.

[The magnetic resonance estimation of the T parameter in the staging of tumors of the oral cavity and tongue. A correlation with postoperative data and preliminary echotomographic experience]. / Valutazione con risonanza magnetica del parametro "T" nella stadiazione dei tumori della cavità orale e della lingua. Correlazione con i dati post-operatori e preliminare esperienza con ecotomografia.

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.

[Excisional and reconstructive treatment of stage IV tumors in the oral cavity. Results and limits]. / Trattamento exeretico e ricostruttivo dei tumori del cavo orale al IV stadio. Risultati e limiti.

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.

[The recurrent multifocal pleomorphic adenoma]. / Le recidive multifocali di adenoma pleomorfo.

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.

[Results of a national survey on the treatment of the facial nerve in malignant tumors of the parotid gland]. / Risultati di un'indagine conoscitiva in ambito nazionale sul trattamento del nervo facciale nei tumori maligni della parotide.

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.