A multicenter validation of the revised version of the Milan system for reporting salivary gland cytology (MSRSGC).

INTRODUCTION: Fine-needle aspiration cytology (FNAC) is a basic step in the diagnosis of salivary gland tumors that have a wide variety of histological types. The recent Milan system for reporting salivary gland cytopathology (MSRSGC) can correlate the risk of malignancy with precise cytological features. A revised version was recently proposed to improve the surgical relevance and facilitate uniform management. MATERIAL AND METHODS: A multicenter study retrospectively used the original and revised MSRSGC criteria to classify a series of patients who received surgery after FNAC. RESULTS: We enrolled 503 patients from three tertiary centers. The risk of malignancy for the MSRSGC resulted 19.5% in cat. I, 14.3% in cat. II, 17.6% in cat. III, 3.6% in cat. IVa, 24.6% in cat. IVb, 66.7% in cat. V, and 96.8% in cat. VI. The results from the revised MSRSGC were consistent with the original values. CONCLUSION: The MSRSGC is a promising classification system. In our opinion, the revised version of the MSRSGC supplements FNAC with some crucial clinical information and can better identify the appropriate treatment in each category.

Electrochemotherapy: a well-accepted palliative treatment by patients with head and neck tumours.

SUMMARY: Electrochemotherapy (ECT) is a well established treatment strategy for skin tumuors. The aim of this study was to evaluate the feasibility and efficacy of electrochemotherapy in the palliative setting in patients with head and neck malignancies, in terms of improvement of quality of life and in control of pain and bleeding. Twenty-four patients with a loco-regional M0/M1 relapse not suitable for cure with radical intent by surgery or radiotherapy (RT) and not suitable for systemic therapy and/or already treated with it, were admitted to ECT protocol treatment. Clinical features, treatment response, and adverse effects were evaluated. An overall response of 100% was observed. Overall survival probability at 24 months was 46.5% (median OS: 9 months). The multiple application of ECT was associated with improved survival (p = 0.02). Pain, need for medical assistance or dressing and bleeding events was significantly reduced at 1 month after ECT (p #x003C; 0.001). ECT is effective as palliative treatment of non-resectable head and neck malignancies. Its main advantages are improved quality of life, local tumour control and limited side effects.

Cytology and direct human papillomavirus testing on fine needle aspirates from cervical lymph node metastases of patients with oropharyngeal squamous cell carcinoma or occult primary.

OBJECTIVE: Cervical lymph node fine needle aspirates (FNAs) may represent the only specimens available for an initial characterisation of patients with lymphadenopathy. Morphology and human papillomavirus (HPV) DNA presence were evaluated in FNAs collected from patients with oropharyngeal squamous cell carcinoma (OPSCC) or cancer of unknown primary (CUP). FNA HPV results were compared with those of the respective formalin-fixed paraffin-embedded (FFPE) primary cancer. METHODS: Liquid-based cytology was performed on FNAs collected in PreservCyt. HPV-DNA was analysed by the INNO-LiPA HPV genotyping Extra II on both cytological and FFPE samples. The CINtec® Histology Kit was used to assess p16 expression in cancer tissues. RESULTS: Forty-seven FNAs were collected from OPSCC and 16 from CUP patients. Cancer cells were found in 35/47 cases (74.5%), while 11 (23.4%) showed only necrosis and one (2.1%) was negative for malignancy. HPV-DNA was detected in 30/47 FNAs (63.8%), mostly harbouring HPV16 (90.0%). An excellent agreement was observed between the FNA and corresponding FFPE HPV status (raw agreement: 97.5%; Cohen κ: 0.94). The HPV test result on the necrotic FNAs completely matched that of the respective primary cancer. FNA HPV testing correctly identified 26/27 HPV-driven OPSCCs (96.3%). HPV was detected in nine of 16 FNAs (56.2%) from CUP patients. CONCLUSIONS: HPV status of metastatic cervical lymph node FNAs reflects that of the corresponding primary OPSCCs even when cell integrity in the FNA is not preserved and only necrotic debris are present. In patients with initial CUP, HPV-positivity on the FNA may guide the diagnostic workup and therapeutic management, since it suggests an oropharyngeal origin.

Vastus lateralis myofascial free flap in tongue reconstruction.

In the last decade, the antero-lateral thigh free flap (ALT) has become the most popular free flap for tongue reconstruction because of less donor site morbidity and better cosmetic outcomes. However, fascio-cutaneous ALT may be insufficient to reconstruct major tongue defects, while its muscular-cutaneous variant (using the vastus lateralis muscle) may be too bulky. The present study describes our preliminary experience of tongue reconstruction with vastus lateralis myofascial flap, which could potentially offer unique advantages in head and neck reconstruction including adequate bulk when needed, optimal functional results and obliteration of dead space thus preventing fistulas and infections with minimal morbidity.

Predictive factors for postoperative wound complications after neck dissection.

The objective of this retrospective study was to evaluate risk factors for wound complications after neck dissection. One hundred and nineteen patients were treated with neck dissection for squamous-cell carcinoma of the upper aerodigestive tract at the National Cancer Institute in Rome between 2006 and 2009. Postoperative wound complications were divided into major or minor and were related to different variables to identify risk factors. Postoperative wound complications were found in 20.2% of patients with an individual patient probability for different risk factors ranging from 2% to 34.1%. Preoperative chemoradiation therapy (CRT) and the type of neck dissection were associated with a higher risk of major complications (p ≤ 0.05). Previous CRT and radical neck dissection/modified radical neck dissection are risk factors for major wound complications in patients with head and neck squamous cell carcinoma undergoing neck dissection. Patients requiring neck dissection after CRT should be informed about the increased risk of the procedure, and selective neck dissection, if oncologically appropriate, should be considered to reduce complications.

Italian cross-cultural adaptation and validation of three different scales for the evaluation of shoulder pain and dysfunction after neck dissection: University of California - Los Angeles (UCLA) Shoulder Scale, Shoulder Pain and Disability Index (SPADI) and Simple Shoulder Test (SST).

Shoulder syndrome after neck dissection is a well known entity, but its incidence and prognostic factors influencing recovery have not been clearly assessed due to the heterogeneity of possible evaluations. The University of California - Los Angeles (UCLA) Shoulder Scale, the Shoulder Pain and Disability Index (SPADI) and the Simple Shoulder Test (SST) are three English-language questionnaires commonly used to test shoulder impairment. An Italian version of these scales is not available. The aim of the present study was to translate, culturally adapt and validate an Italian version of UCLA Shoulder Scale, SPADI and SST. Translation and cross-cultural adaptation of the SPADI, the UCLA shoulder scale and the SST was performed according to the international guidelines. Sixty-six patients treated with neck dissection for head and neck cancer were called to draw up these scales. Forty patients completed the same questionnaires a second time one week after the first to test the reproducibility of the Italian versions. All the English-speaking Italian patients (n = 11) were asked to complete both the English and the Italian versions of the three questionnaires to validate the scales. No major problems regarding the content or the language were found during the translation of the 3 questionnaires. For all three scales, Cronbach's α was > 0.89. The Pearson correlation coefficient was r > 0.91. With respect to validity, there was a significant correlation between the Italian and the English versions of all three scales. This study shows that the Italian versions of UCLA Shoulder Scale, SPADI and SST are valid instruments for the evaluation of shoulder dysfunction after neck dissection in Italian patients.

Oral cavity and base of the tongue tumors. Correlation between clinical, MRI and pathological staging of primary tumor.

The diagnosis of oral cavity and oropharyngeal tumors can be obtained through clinical examination and biopsy. CT and MRI can then be used to define the extension of the disease. The aim of this study was to define the accuracy of clinical and MRI T staging of oral cavity and base of the tongue tumors and correlate the results with pathological data. Mandibular involvement, in a subgroup of patients, was determined and sensitivity, specificity, accuracy and positive and negative predictive values were evaluated. Fifty-nine patients affected by squamous cell carcinoma and 1 case of adenoido-cystic carcinoma were examined by means of a superconductive MR unit, using SE T1, and fat-suppressed T2 weighted sequences before contrast medium infusion. SE T1 and T1 fat-suppressed sequences after gadolinium-DTPA infusion were used. T stage accuracy of both clinical examination and MRI were found to be respectively 62% (k 0.459) and 82% (k 0.775). The sensitivity, specificity and accuracy of MRI in the detection of mandibular involvement were 94.1%, 60% and 81.5%, while the positive and negative predictive values were 80% and 85.7%, respectively. The sensitivity, specificity and accuracy of clinical examination in the detection of mandibular involvement were 100%, 30% and 74.1%, while the positive and negative predictive values were 70.8% and 100%. In the present study, MRI was seen to be an adequate technique for the assessment of oral cavity malignancies, in the evaluation of depth invasion, presence and extension of mandibular involvement.

External monitor for buried free flaps in head and neck reconstructions.

Head and neck defects following oncological surgery must often be repaired with soft tissue and/or bone from other areas of the body. Significant loss of soft tissue requires flaps of sufficient bulk to adequately reconstruct the defect. Microvascular free tissue transfer is a good method for reconstructing even large defects following oncological surgery for head and neck cancer. Continuous post-operative monitoring of the perfusion of a free flap is vitally important to achieve not only a favourable outcome but also to decrease morbidity. Microvascular thrombosis occurs in 4% of the flaps and the best chance for flap salvage is offered by the earliest possible revision of the microanastomosis. Use of buried flaps in head and neck reconstruction makes monitoring particularly difficult and exteriorization of a segment of the flap permits a direct visualization. An original technique is presented for harvesting forearm free flaps with a secondary monitor skin paddle to externally check the status of the paddle and, when modified, can also be used for fibula and rectus abdominis flap.

Video-based system for intraoperative facial nerve monitoring: comparison with electromyography.

OBJECTIVE: To validate a recently developed intraoperative facial nerve monitoring system that is based on video control of facial movements. STUDY DESIGN: In a single-subject design study, involving 15 otoneurosurgical patients, the relationship between intensity of neural stimulation, facial movements, and electrophysiologic voltage were measured. The analysis was performed by measuring the ipsilateral oral commissure displacement in relation to different levels of current administered to the nerve during surgical procedures. SETTING: Electromyography and video system intraoperative facial nerve monitoring. PATIENTS: 15 patients (9 men, 6 women; mean age, 61 yr) undergoing a translabyrinthine approach for removal of acoustic neuroma. RESULTS: Electromyography showed slightly greater sensitivity. With regard to the stimulation-response ratio, facial movement and electromyographic amplitude showed very similar responses. CONCLUSIONS: The video system was considered useful in terms of validity and reliability. Furthermore, the authors' surgical experience showed some limitations of electromyography, especially in terms of electrical artifact during cauterization, totally masking the electrophysiologic monitoring.