Isolated laryngeal tuberculosis complex infection: expect the unexpected.

Laryngeal tuberculosis (LT), a rare but possible manifestation of extrapulmonary tuberculosis (TBC) and the most frequent granulomatous disease of the larynx, is slowly resurfacing due to the worldwide recrudescence of TBC. We present the case of a 59 y-o Caucasian woman, non-smoker, with no history of recent travels in endemic areas, affected by pulmonary sarcoidosis, that presented with a symptomatic vegetating lesion involving the left free margin of the epiglottic and a small, ulcerated lesion over the right arytenoid mucosa. While the patient's profile would not lead to a primary suspect of laryngeal TBC, the diagnostic workup and histological examination confirmed the unusual finding, and the patient was started on standard antitubercular therapy, with a complete laryngeal response. Although isolated laryngeal tuberculosis is still a rare finding, it should be kept into consideration also in non-endemic areas, especially in patients with chronic disease requiring immunosuppressive drugs.

Solitary fibrous tumor: A rare lesion with an unusual paravertebral presentation.

BACKGROUND: Solitary fibrous tumor (SFT) is a rare spindle-cell neoplasm [1]. Although typically originating from pleura, head and neck presentation accounts for about 6-18 % and very few cases have been described in paravertebral and posterior neck spaces [2]. Both computed tomography (CT) scans and magnetic resonance imaging (MRI) help in differential diagnosis of such lesion [3]. However, only histological and immunohistochemical studies give a conclusive diagnosis: CD34, BCL-2, and in particular STAT6 stainings are strongly orientative [4]. Radical surgery with free margin excision is the first treatment option, rarely requiring adjuvant therapy [2]. Prognosis is typically good and strictly related to histological risk assessment [5]. Rare cases of local recurrence and distant metastasis have been described in literature [2]. OBJECTIVE: The purpose of this video is to describe the operative technique of a transcervical removal of a rare case of right paravertebral SFT. We present the diagnostic flowchart, management strategies, surgical technique and we provide anatomical dissection parallelism, which might be of interest to the readers. MATERIALS AND METHODS: A 59-years-old man with a one-year right cervical asymptomatic swelling was referred to our department. A contrasted MRI documented an expansive 6.5 cm capsulated lesion in the deep posterior neck spaces with diffuse contrast enhancement and inhomogeneous appearance. A core needle biopsy was performed, and the results from the initial immunohistochemical panel were not univocal showing positivity for cytokeratins AE1/AE3, PAX8, and no reactivity for CD34. A second immunohistochemical panel was then performed, displaying diffuse nuclear positivity for STAT6, which is a surrogate marker for the NAB2-STAT6 gene fusion, a specific driver mutation of SFT. Therefore, a radical excision was performed via transcervical approach (Video 1). No post-operative complications neither cranio-cervical neurological deficit occurred. RESULTS: In comparison to pre-operative histopathologic study, the definitive histological examination of the whole mass revealed a more classical morphology of SFT. It was classified as an intermediate risk SFT [5]. A complete free margin excision was confirmed. After a multidisciplinary discussion, no adjuvant therapies were suggested. A six- and twelve-months radiological follow-up with MRI showed no evidence of disease. CONCLUSION: SFT may represent a misdiagnosed entity in head and neck spaces and a correct diagnosis through immunohistochemistry is mandatory. Radical excision with free surgical margins should be pursued as adequate goal. Since SFTs show variable risk of metastatic disease, adjuvant radiotherapy should be contemplated in high-risk diseases and a clinico-radiological follow-up with MRI is required.

Outcomes of head and neck cancer management from two cancer centres in Southern and Northern Europe during the first wave of COVID-19.

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 <0.001 respectively), showing more male patients (75% vs 53.66%, respectively) and more elderly patients in Italy than in the United Kingdom (patients aged >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.

Upfront surgical organ-preservation strategy in advanced-stage laryngeal cancer.

PURPOSE: Advanced-stage laryngeal cancer is a challenging disease that needs multimodal treatment. Medical and surgical organ-preservation strategies have been developing in the last decades to spare these functions while granting cancer cure. The current work presents the experience of a tertiary-care center in conservative surgery for advanced-stage laryngeal cancer. MATERIALS AND METHODS: We collected clinical data of patients submitted to open partial horizontal laryngectomies (OPHLs) and any possible adjuvant treatment from 2005 to 2018. Outcomes were also compared to the most recent studies reporting on both medical and surgical organ-preservation strategies. RESULTS: One hundred ten patients were included in the analysis. Adjuvant therapy was employed in 51% of cases. The local control rate was 96.4%, while overall survival (OS) was 67%, and laryngo-esophageal dysfunction free survival (LEDFS) was 66%. Stage IV and vascular invasion were associated with a statistically-significant worse survival. CONCLUSIONS: OPHLs are valid as upfront treatment in fit patients affected by advanced-stage laryngeal cancer. Disease control and function preservation are granted in a significant percentage of cases, even when followed by adjuvant therapy.

A role for the immune system in advanced laryngeal cancer.

To investigate the role of the altered activation of the immune system in the prognosis of patients affected by laryngeal squamous cell carcinoma (LSCC). We analyzed 56 patients with advanced LSCC divided into two groups according to their prognosis: the first group relapsed within 24 months after treatment, the second group had no evidence of disease at 2 years. The presence of stromal tumor infiltrating lymphocytes (TILs) at the tumor-host border was investigated. In 43 patients we evaluated the expression of 395 genes related to immune system activation through a next generation sequencing panel. Priority-LASSO models and clustering analyses were integrated with multivariate Cox proportional hazard modeling to identify independent genes associated with relapse and estimate hazard ratios in relation to gene expression and TILs. TILs and the expression of genes related with immune system activation (FCGR1A, IFNA17, FCRLA, NCR3, KREMEN1, CD14, CD3G, CD19, CD20 and CD79A) were significantly associated with prognostic factors or disease specific survival. In patients with lymph node metastases and advanced T stage (pT4), the expression of other genes was altered. Low TILs count was highly associated with relapse within 2 years (p < 0.001). Low TILs and altered expression of specific genes associated with tumor-immune systems interactions emerged as independent risk factors, associated to poor prognosis and relapse within 2 years in advanced LSCC. Evaluation of patients' immune profile could be useful for prognosis and future therapeutic approaches towards personalized therapy.

Diagnostic accuracy of surface coil MRI in assessing cartilaginous invasion in laryngeal tumours: Do we need contrast-agent administration?

OBJECTIVES: To assess the diagnostic accuracy of MRI performed using surface coils, with and without contrast medium, in predicting thyroid and cricoid cartilage infiltration in laryngeal tumours, and to investigate whether the radiologist's experience influences diagnostic accuracy. METHODS: We retrospectively enrolled patients with biopsy-proven laryngeal cancer who had undergone preoperative staging MRI and open surgery. Two radiologists with different experience (senior vs. junior) reviewed the MR images without (session A1) and with contrast medium (session A2) separately. We calculated the accuracy of MRI with and without contrast medium in detecting infiltration of the thyroid and cricoid cartilages. Interobserver agreement was calculated by Cohen's Kappa (k). RESULTS: Forty-two patients were enrolled, for a total of 62 cartilages. In session A1 the senior and junior radiologists showed an accuracy of 85% and 71%, respectively, with k = 0.53 (0.33-0.72). In session A2 the senior and junior radiologists showed an accuracy of 84% and 77%, respectively, with k = 0.68 (0.49-0.86). CONCLUSIONS: Staging of laryngeal tumours with surface coil MRI showed good diagnostic accuracy in assessing cartilaginous infiltration. We observed similar values of diagnostic accuracy for the analysis performed with and without contrast medium for the senior radiologist. KEY POINTS: • Surface coil MRI demonstrated good accuracy in assessing laryngeal cartilage invasion. • The radiologist's experience can influence the diagnostic accuracy. • Gadolinium administration may increase interobserver concordance.

Retrospective analysis of factors influencing oncologic outcome in 590 patients with early-intermediate glottic cancer treated by transoral laser microsurgery.

BACKGROUND: The purpose of this study was to identify the factors influencing oncologic outcomes for patients with early-intermediate glottic cancer treated by transoral laser microsurgery (TLM). METHODS: This was a retrospective mono-institutional study. A total of 590 patients with cTis-cT3 glottic cancer underwent TLM with curative intent. RESULTS: TLM alone was performed in 538 patients (91.2%) and TLM followed by adjuvant radiotherapy (RT) was done in 52 (8.8%). Five-year recurrence-free survival (RFS) and 10-year overall survival (OS) were 85.3% and 74.7%, respectively. The larynx-preservation ratio was 95.9%. In particular, from our data, we found that occult metastases were rare (1.2%); preventive tracheotomy was not necessary; the local recurrence rate of Tis was similar to that in the T2 and T3 group; and no major or lethal complications were observed. CONCLUSION: Age (>60 vs ≤60), type of cordectomy (≥IV vs ≤III), status of margins, fixed arytenoid, and pathologic T classification, were the variables associated with RFS, OS, and organ-preservation rate. © 2016 Wiley Periodicals, Head Neck 39: 71-81, 2017.

A case of NUT midline carcinoma with no HPV infection, slight EWSR1 rearrangement and strong expression of EGFR.

NUT midline carcinoma (NMC) is a rare neoplasm with a poor prognosis and involving mostly young patients. Here we describe a classic NMC with a BRD4-NUT fusion gene in a middle-aged woman. We also analyzed some biological features that could potentially influence its clinical behavior such as HPV infection, EWSR1 rearrangement, and the status of the EGFR gene.

Transoral CO2 laser microsurgery for Tis-T3 supraglottic squamous cell carcinomas.

Eighty patients affected by supraglottic cancer were treated by transoral carbon dioxide laser surgery between 1989 and 2006 in two Italian institutions. Patient staging was as follows: 2 pTis, 20 pT1, 38 pT2, and 20 pT3. Simultaneous or 1-month delayed neck dissection (ND) was performed on 27 (34%) patients, unilaterally in 10 and bilaterally in 17. The pN category was as follows: 9 pN0, 6 pN1, 8 pN2b, and 4 pN2c. A total of 16 (20%) patients received complementary radiotherapy (RT) and 5 (6%) were subjected to chemo-RT for persistent tumor after re-excision due to positive margins, multiple lymph nodes, and/or extracapsular spread after ND. The last follow-up was in December 2008. The 5-year overall, disease-specific and disease-free survivals, local control with laser alone, and organ preservation rates calculated by Kaplan-Meier analysis were 84.4, 97.4, 88.3, 96, and 97.2%, respectively. Univariate analysis showed a statistically significant impact on disease-free survival, local control with laser alone, and organ preservation of pT category (p = 0.009, p = 0.01, and p = 0.03, respectively), while pN category and tumor stage negatively influenced disease-free survival (p = 0.007 and p = 0.01, respectively). This series confirms the good overall oncologic outcomes obtained by transoral laser surgery for Tis, T1, T2, and selected T3 supraglottic cancer with minimal pre-epiglottic space involvement.

Laser surgery for early glottic cancer: impact of margin status on local control and organ preservation.

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 (< or =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.

Endoscopic carbon dioxide laser surgery for glottic cancer recurrence after radiotherapy: oncological results.

OBJECTIVE: To evaluate local control, organ preservation, and complications after endoscopic laser surgery for early recurrent glottic cancer after radiotherapy. DESIGN: Retrospective study. SETTING: European Institute of Oncology, Milan, Italy. PATIENTS: The study, which was conducted between May 1999 and September 2005, included 37 consecutive patients (33 men and 4 women) with recurrent glottic cancer after radiotherapy. Selection criteria were as follows: rcTis, rcT1, or rcT2 with subglottic or supraglottic involvement of less than 5 mm and no arytenoid invasion; adequate laryngeal exposure; no previous open surgery; no contraindications to general anesthesia; and signed consent. INTERVENTIONS: Endoscopic laser surgery with curative intent using types III to V cordectomies according to the European Laryngological Association. MAIN OUTCOME MEASURES: Five-year actuarial recurrence-free and overall survival, complications, and rate of laryngeal preservation. RESULTS: The clinical classifications of the recurrences were rcTis (n = 4), rcT1a (n = 10), rcT1b (n = 11), and rcT2 (n = 12). The pathologic classifications of the recurrences were rpT0 (n = 2), rpTis (n = 5), rpT1a (n = 9), rpT1b (n = 3), rpT2 (n = 14), and rpT3 (n = 4). The median follow-up was 44 months (range, 18-88 months). New recurrences developed in 13 patients (35%): 11 were treated by total laryngectomy, 1 by supracricoid laryngectomy, and 1 by chemotherapy. Three patients died of laryngeal cancer, 1 is alive with disease, and 1 died of a second cancer. Five-year actuarial recurrence-free and overall survival rates were 58% and 86%, respectively. The larynx was preserved in 26 patients (70%). Laryngeal stenosis was the most common major complication (in 3 of 4 women and 1 of 33 men). CONCLUSIONS: Endoscopic laser surgery is a safe and effective salvage procedure in selected cases involving glottic recurrence after radiotherapy. Oncological results are satisfactory, and organ preservation can be achieved in a high proportion of cases; however, the risk of laryngeal stenosis is high in women.

Salvage surgery after radiotherapy for laryngeal cancer: from endoscopic resections to open-neck partial and total laryngectomies.

OBJECTIVE: To evaluate our experience in management of radiotherapy failure using endoscopic resection (ER) with carbon dioxide laser, open-neck partial laryngectomy (ONPL), and total laryngectomy. DESIGN: Retrospective medical record review. SETTING: Referral university hospital. PATIENTS: Seventy-one patients with laryngeal cancer previously treated with radiotherapy (69 patients) and chemoradiotherapy (2 patients) underwent salvage surgery. INTERVENTIONS: The treatment policy encompassed ER for glottic rT1a, rT1b with limited anterior commissure involvement, and rT2 with normal cord mobility carcinoma. All ONPLs were performed for rT1 and rT2 tumors with suboptimal endoscopic exposure, rT2 tumors with impaired cord mobility or transcommissural extension, and rT3 tumors for limited paraglottic space invasion or involvement of the inner portion of the thyroid cartilage. Total laryngectomy was planned in patients who were not suitable for partial laryngectomy owing to poor general condition, for rT3 carcinoma with massive involvement of the paraglottic space, and for rT4a tumors. MAIN OUTCOME MEASURES: Clinical, radiologic, surgical, and pathologic data. Survival curves were calculated using the Kaplan-Meier method. Comparisons between different variables were performed using the log-rank test. RESULTS: Salvage surgery consisted of ER in 22 patients, ONPL in 15, and total laryngectomy in 34. The pT category after salvage surgery was pT1 in 12 patients, pT2 in 20, pT3 in 20, and pT4a in 19. Five-year disease-specific and disease-free survival and laryngeal preservation for the entire series were 72%, 61%, and 40%, respectively. CONCLUSIONS: Survival rates for the entire series were not different from those previously reported using a more aggressive surgical approach without attempts at organ preservation. The laryngeal preservation rate justifies conservative treatment in the presence of limited recurrent lesions.

Phonosurgery after endoscopic cordectomies. I. Primary intracordal autologous fat injection after transmuscular resection: preliminary results.

Treatment of glottic cancer by CO(2) laser endoscopic cordectomies can be associated with poor vocal outcome when the excision is extended beyond the superficial part of the thyro-arytenoid muscle. Different phonosugical techniques have been described in order to improve postoperative vocal outcome in patients undergoing this type of surgery. We herein present a new device for augmentation of residual vocal cord by video-endoscopic assisted primary intracordal autologous fat injection (PIAFI) performed at the end of transmuscular cordectomy. Twenty-four patients underwent transmuscular cordectomy and PIAFI for Tis and T1a glottic cancer. Eight cc of abdominal fat were obtained during the endoscopic procedure and processed. Infusion of intact parcels of fat tissue was performed to maximally reduce its resorption. PIAFI was performed in the residual vocal cord obtaining its immediate medialization, using a new device that permitted modulated (0.5 cc per click) injection. Fourteen patients were submitted to postoperative voice evaluation including subjective, perceptual, and objective assessment. The results were compared with those of 24 patients treated by transmuscular (Type III) cordectomy without subsequent PIAFI. No complications were observed as a result of PIAFI and the procedure did not significantly prolong overall surgical time. All patients were discharged the day after surgery. Comparison of vocal outcomes according to the Mann-Whitney and Wilcoxon tests showed a positive trend for patients submitted to PIAFI in terms of subjective and objective analysis. By contrast, a statistically significant improvement was reached in terms of perceptual analysis when comparing patients treated by Type III cordectomy alone with those submitted to this kind of procedure followed by PIAFI.

Phonosurgery after endoscopic cordectomies. II. Delayed medialization techniques for major glottic incompetence after total and extended resections.

Major glottic incompetence is often encountered after total (Type IV) and extended (Type V) cordectomies and is responsible for poor vocal outcome. Even though the vast majority of patients do not complain of significant limitations in daily life, a selected number of them eventually require some sort of phonosurgical treatment in order to improve voice quality. Different techniques have been described in the literature to ameliorate long-term vocal outcome. The aim of the present report was to retrospectively describe our experience in this challenging clinical scenario. Between April 1999 and March 2005, 24 patients previously treated by Type IV-V endoscopic cordectomies for T1 and T2 glottic cancer presented unsatisfactory vocal outcome in spite of intensive speech therapy and therefore underwent some form of phonosurgical treatment at our Department after at least 12 months without evidence of local-regional recurrence. Patients were treated by medialization thyroplasty with a Montgomery System Implant (two cases), Gore-Tex strips (16 cases), medialization thyroplasty with Gore-Tex associated with anterior commissure laryngoplasty (three cases), and augmentation with Vox Implant injection (three cases). Nineteen patients had comprehensive evaluation by videolaryngoscopic examination and subjective, perceptual, and objective voice analysis both in the pre-phonosurgical treatment period and after at least 12 months. Comparison of pre- and postoperative videolaryngoscopic findings revealed improved glottic closure in 74% of patients. Comparison between the pre- and postoperative subjective, perceptual, and objective voice analysis by the Wilcoxon matched-pair test showed a statistically significant improvement from a Voice Handicap Index mean value of 46 (preoperative) to 21 (postoperative); an improvement for each parameter of the GRBAS scale with statistically significant differences for G, B, A, and S, while R showed only an improving trend; and statistically significant improvement in the mean values of Jitter, Shimmer, Noise to Harmonic Ratio, and Maximum Phonation Time. In conclusion, the different delayed phonosurgical procedures herein used demonstrate the possibility to improve vocal outcomes after total and extended cordectomies in selected and highly motivated patients that have not achieved satisfactory performance after prolonged and intensive speech therapy.

Comparison of functional outcomes after endoscopic versus open-neck supraglottic laryngectomies.

OBJECTIVES: Endoscopic supraglottic laryngectomy (ESL) by carbon dioxide laser for selected T1-T3 supraglottic squamous cell carcinomas is a sound procedure with oncological results comparable to those obtained by open-neck supraglottic laryngectomy (ONSL). The aim of this study was to retrospectively evaluate functional outcomes after ESL in comparison with ONSL. METHODS: We performed perceptual voice evaluation by GRBAS (grade, roughness, breathiness, asthenicity, strain), subjective analysis by Voice Handicap Index, objective analysis with the Multidimensional Voice Program, swallowing evaluation with the M. D. Anderson Dysphagia Inventory, video nasal endoscopic examination of swallowing, videofluoroscopy, and analysis of hospitalization time, need for and duration of feeding tube and tracheotomy, and complication and aspiration pneumonia rates in a group of 14 patients treated with ESL. These results were compared to those obtained in a historical group of 14 patients matched for T category who were treated with ONSL at the same institution. Statistical analysis was performed with the Mann-Whitney U and Pearson chi(2) tests. RESULTS: Comparison of comprehensive voice analysis, M. D. Anderson Dysphagia Inventory, and complication and aspiration rates showed no statistically significant differences between the two groups. However, significant differences were found for video nasal endoscopic examination of swallowing (p = .03), videofluoroscopy (p = .03), hospitalization (p = .0001), feeding tube duration (p = .0001), and tracheotomy duration (p = .0001). CONCLUSIONS: Endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than ONSL, even though it was not subjectively perceived by patients, and was associated with less morbidity and a shorter hospitalization time.