Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2009
Some medical definitions remain the same for many years, others change due to the progress in the... more Some medical definitions remain the same for many years, others change due to the progress in the diagnostic tools, which are able to distinguish markers and symptoms until then undetectable. Occult thyroid carcinoma is a general term indicating clinically different situations, whereas the incidentally detected papillary thyroid microcarcinoma is the most important from the clinical point of view. It is fundamental, for therapeutic management, to determine biological parameters which would define a small group of papillary thyroid microcarcinomas with aggressive biological behaviour. The most promising genetic and molecular markers for papillary thyroid carcinoma risk stratification are discussed in this review. Preoperative evaluation of these markers, obtained through analysis of ultrasonography-guided fine needle biopsy specimens of papillary thyroid microcarcinoma, could be very valuable in guiding treatment of this type of cancer.
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2014
Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of... more Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of cases. The central compartment (VIupper VII levels) is considered to be the first echelon of nodal metastases in all differentiated thyroid carcinomas. The indication for central neck dissection is still debated especially in patients with cN0 disease. For some authors, central neck dissection is recommended for lymph nodes that are suspect preoperatively (either clinically or with ultrasound) and/or for lymph node metastases detected intra-operatively with a positive frozen section. In need of a better definition, we divided the dissection in four different areas to map localization of metastases. In this study, we present the rationale for central neck dissection in the management of differentiated thyroid carcinoma, providing some anatomical reflections on surgical technique, oncological considerations and analysis of complications. Central neck dissection may be limited to the compa...
Pre-operative data in patients with oral cavity/oropharyngeal cancer may predict postoperative co... more Pre-operative data in patients with oral cavity/oropharyngeal cancer may predict postoperative complications, that may modify therapeutic choices and improve patient care. We reviewed 320 consecutive patients with oral cavity/oropharyngeal cancer, operated on 2003 through 2006 at the European Institute of Oncology. By multivariate analysis of preoperative patient and tumor characteristics we developed an algorithm to predict postoperative complications. We tested the algorithm on new series of 307 patients operated on 2007 through 2010. The final algorithm, used to produce a nomogram, comprised: alcohol consumption (p=0.01), site of primary (p=0.03), interaction clinical T stage-sex (p=0.007) and type of neck dissection (p<0.0001). The algorithm had good ability to predict complications (c-index 0.74) in the new series. CONCLUSIONS The nomogram accurately predicts pre-surgical risk of postoperative local/systemic complications in patients with cavity/oropharyngeal cancer and can be used to adapt therapy to patient characteristics, optimize ward admissions, and improve care. Head Neck, 2014.
To present an overview of surgical management of differentiated thyroid cancer. Evaluation of the... more To present an overview of surgical management of differentiated thyroid cancer. Evaluation of the thyroid nodule, assessment of indications for surgical treatment, analysis of the extent of surgical excision, and recommendations for lymph node dissection are addressed. In a patient with a thyroid nodule, certain historical information (such as prior irradiation to the head and neck or a family history of thyroid carcinoma) and physical findings (for example, a nonfunctioning, solitary thyroid nodule) increase the likelihood of a thyroid malignant lesion. Some indications for surgical intervention are a diagnosis of cancer on fine-needle aspiration biopsy, the presence of a cold nodule, or the presence of a large thyroid lesion, especially one that causes symptoms such as hoarseness or dysphagia. Although the extent of surgical excision is controversial, the presence of metastatic lesions, extrathyroidal extension, and multicentricity all are indications for total thyroidectomy. Grossly enlarged lymph nodes should be surgically excised. Probe-guided surgical resection is a promising advance in the management of persistent or recurrent thyroid carcinoma. Most patients with differentiated thyroid cancer have an excellent prognosis. Appropriate management is the key to minimizing morbidity and recurrences.
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2009
The aim of curative surgical oncology is to remove the primary tumour with a wide margin of norma... more The aim of curative surgical oncology is to remove the primary tumour with a wide margin of normal tissue. What constitutes a sufficiently wide margin particularly in oral cancer is fundamentally unclear. The currently accepted standard is to remove the primary lesion with a 1.5-2 cm circumferential macroscopic margin. In the last ten years, anatomical considerations in the approach to primary, advanced and untreated tumours of the tongue led us to develop and improve a new surgical approach to their demolition and reconstruction. From July 1999 to July 2009, at the European Institute of Oncology in Milano, Italy, 155 patients were treated, while defining and refining the concept of compartmental tongue surgery (CTS) and its main components: 1) anatomical approach to the disease that requires removal of the primary lesion and all of the potential pathways of progression--muscular, lymphatic and vascular; 2) identification of a distinct territory at risk of metastatic representation ...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2009
Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retros... more Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retrospective cohort study, the aim was to assess possible advantages of prophylactic central neck dissection with total thyroidectomy in cN0 papillary thyroid cancer. A total of 244 consecutive patients with papillary thyroid cancer, without clinical and ultrasound nodal metastases (cN0), were evaluated out of 1373 patients operated for a thyroid disease at the Istituto Europeo di Oncologia, Milan, Italy from 1994 to 2006. Of these 244 patients, 126 (Group A) underwent thyroidectomy with central neck dissection, while 118 (Group B) underwent thyroidectomy alone. Demographic, clinical and pathological features were analysed. Overall recurrence rate was 6.3% (8/126) in Group A and 7.7% (9/118) in Group B, with a mean follow-up of 47 (Group A) and 64 (Group B) months. In Group A patients, 47% were pN1a and all patients with recurrence had nodal involvement (p = 0.002). Survival rate did not diff...
Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glo... more Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glottic cancer in elderly patients in terms of feasibility, disease-free survival, overall survival and organ preservation, in a single Institute (European Institute of Oncology). A total of 122 patients (male/female ratio 113/9), over 70s with untreated early stage glottic cancer, were consecutively evaluated and treated at the European Institute of Oncology from 2000 to 2008. None had contraindications to general anaesthesia and all patients signed informed consent to this surgical treatment. The severity of pre-operative comorbidities and the intra-operative risk were evaluated according to the American Society of Anaesthesiologists Grading Classification. All patients underwent laser cordectomies according to the European Laryngological Society classification. Histopathological examination demonstrated no evidence of tumour (pT0) in 19 patients (calculated only in patients with a previo...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2011
The evolution of new techniques for cancer surgery has led to important changes in cancer care in... more The evolution of new techniques for cancer surgery has led to important changes in cancer care in recent years. The endpoint of cancer treatment is now to treat the patient with minimum discomfort while respecting quality of life. New techniques, such as mini-invasive surgery, must respect the correct oncological indications, when technically feasible. The surgery for nodal spread or recurrence of disease, after previous surgery on T or T and N for neck cancer, can represent a diagnostic and therapeutic challenge, especially in the neck, which is characterized by small spaces and noble structures. Often lesions become enveloped in scar tissue and can be difficult to visualize during surgery, representing a genuine problem for the surgeon. Ultrasound dye-assisted surgery is a procedure that combines ultra-sound localization of pathological nodes with the use of methylene blue to mark diseased structures to simplify their visualization (and thus removal) in the surgical field. The tec...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2010
Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glo... more Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glottic cancer in elderly patients in terms of feasibility, disease-free survival, overall survival and organ preservation, in a single Institute (European Institute of Oncology). A total of 122 patients (male/female ratio 113/9), over 70s with untreated early stage glottic cancer, were consecutively evaluated and treated at the European Institute of Oncology from 2000 to 2008. None had contraindications to general anaesthesia and all patients signed informed consent to this surgical treatment. The severity of pre-operative comorbidities and the intra-operative risk were evaluated according to the American Society of Anaesthesiologists Grading classification. All patients underwent laser cordectomies according to the European Laryngological Society classification. Histopathological examination demonstrated no evidence of tumour (pT0) in 19 patients (calculated only in patients with a previo...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2012
Sudden death in a 66-year-old woman with squamous cell carcinoma of the oral cavity and exclusive... more Sudden death in a 66-year-old woman with squamous cell carcinoma of the oral cavity and exclusive metastatic involvement of the right stellate ganglion and right nerve vagus is reported. The patient also suffered from paroxysmal atrial fibrillation treated with quinidine. An autopsy showed exclusive metastases to the right stellate ganglion and vagus nerve, along with decreased nerve fibre density in the ventricular myocardium suggesting that Wallerian axon degeneration of cardiac fibres was responsible for sudden death.
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2011
Hypocalcemia is a major post-operative complication of total thyroidectomy, causing severe sympto... more Hypocalcemia is a major post-operative complication of total thyroidectomy, causing severe symptoms and increasing hospitalization time. The primary cause is secondary hypo-parathyroidism following damage to, or devascularisation of, one or more parathyroid glands during surgery. Aim of the study was to develop a simple and reliable method for predicting post-operative hypocalcemia in total thyroidectomy patients. A retrospective analysis was made of immediate pre-operative and early post-operative calcium levels in 100 patients. It was found that a marked decrease in blood calcium, immediately after surgery, was a sensitive predictor of hypocalcemia. In a subsequent prospective series of 67 patients, the efficacy was assessed of early administration of calcium plus Vitamin D in reducing symptomatic hypocalcemia in patients in whom the difference (Δ) between pre- and post-operative blood calcium was ≥ 1.1 mg/dl. This treatment was part of a protocol in which normo-calcemic patients ...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2014
Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of... more Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of cases. The central compartment (VIupper VII levels) is considered to be the first echelon of nodal metastases in all differentiated thyroid carcinomas. The indication for central neck dissection is still debated especially in patients with cN0 disease. For some authors, central neck dissection is recommended for lymph nodes that are suspect preoperatively (either clinically or with ultrasound) and/or for lymph node metastases detected intra-operatively with a positive frozen section. In need of a better definition, we divided the dissection in four different areas to map localization of metastases. In this study, we present the rationale for central neck dissection in the management of differentiated thyroid carcinoma, providing some anatomical reflections on surgical technique, oncological considerations and analysis of complications. Central neck dissection may be limited to the compa...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2009
Some medical definitions remain the same for many years, others change due to the progress in the... more Some medical definitions remain the same for many years, others change due to the progress in the diagnostic tools, which are able to distinguish markers and symptoms until then undetectable. Occult thyroid carcinoma is a general term indicating clinically different situations, whereas the incidentally detected papillary thyroid microcarcinoma is the most important from the clinical point of view. It is fundamental, for therapeutic management, to determine biological parameters which would define a small group of papillary thyroid microcarcinomas with aggressive biological behaviour. The most promising genetic and molecular markers for papillary thyroid carcinoma risk stratification are discussed in this review. Preoperative evaluation of these markers, obtained through analysis of ultrasonography-guided fine needle biopsy specimens of papillary thyroid microcarcinoma, could be very valuable in guiding treatment of this type of cancer.
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2014
Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of... more Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of cases. The central compartment (VIupper VII levels) is considered to be the first echelon of nodal metastases in all differentiated thyroid carcinomas. The indication for central neck dissection is still debated especially in patients with cN0 disease. For some authors, central neck dissection is recommended for lymph nodes that are suspect preoperatively (either clinically or with ultrasound) and/or for lymph node metastases detected intra-operatively with a positive frozen section. In need of a better definition, we divided the dissection in four different areas to map localization of metastases. In this study, we present the rationale for central neck dissection in the management of differentiated thyroid carcinoma, providing some anatomical reflections on surgical technique, oncological considerations and analysis of complications. Central neck dissection may be limited to the compa...
Pre-operative data in patients with oral cavity/oropharyngeal cancer may predict postoperative co... more Pre-operative data in patients with oral cavity/oropharyngeal cancer may predict postoperative complications, that may modify therapeutic choices and improve patient care. We reviewed 320 consecutive patients with oral cavity/oropharyngeal cancer, operated on 2003 through 2006 at the European Institute of Oncology. By multivariate analysis of preoperative patient and tumor characteristics we developed an algorithm to predict postoperative complications. We tested the algorithm on new series of 307 patients operated on 2007 through 2010. The final algorithm, used to produce a nomogram, comprised: alcohol consumption (p=0.01), site of primary (p=0.03), interaction clinical T stage-sex (p=0.007) and type of neck dissection (p<0.0001). The algorithm had good ability to predict complications (c-index 0.74) in the new series. CONCLUSIONS The nomogram accurately predicts pre-surgical risk of postoperative local/systemic complications in patients with cavity/oropharyngeal cancer and can be used to adapt therapy to patient characteristics, optimize ward admissions, and improve care. Head Neck, 2014.
To present an overview of surgical management of differentiated thyroid cancer. Evaluation of the... more To present an overview of surgical management of differentiated thyroid cancer. Evaluation of the thyroid nodule, assessment of indications for surgical treatment, analysis of the extent of surgical excision, and recommendations for lymph node dissection are addressed. In a patient with a thyroid nodule, certain historical information (such as prior irradiation to the head and neck or a family history of thyroid carcinoma) and physical findings (for example, a nonfunctioning, solitary thyroid nodule) increase the likelihood of a thyroid malignant lesion. Some indications for surgical intervention are a diagnosis of cancer on fine-needle aspiration biopsy, the presence of a cold nodule, or the presence of a large thyroid lesion, especially one that causes symptoms such as hoarseness or dysphagia. Although the extent of surgical excision is controversial, the presence of metastatic lesions, extrathyroidal extension, and multicentricity all are indications for total thyroidectomy. Grossly enlarged lymph nodes should be surgically excised. Probe-guided surgical resection is a promising advance in the management of persistent or recurrent thyroid carcinoma. Most patients with differentiated thyroid cancer have an excellent prognosis. Appropriate management is the key to minimizing morbidity and recurrences.
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2009
The aim of curative surgical oncology is to remove the primary tumour with a wide margin of norma... more The aim of curative surgical oncology is to remove the primary tumour with a wide margin of normal tissue. What constitutes a sufficiently wide margin particularly in oral cancer is fundamentally unclear. The currently accepted standard is to remove the primary lesion with a 1.5-2 cm circumferential macroscopic margin. In the last ten years, anatomical considerations in the approach to primary, advanced and untreated tumours of the tongue led us to develop and improve a new surgical approach to their demolition and reconstruction. From July 1999 to July 2009, at the European Institute of Oncology in Milano, Italy, 155 patients were treated, while defining and refining the concept of compartmental tongue surgery (CTS) and its main components: 1) anatomical approach to the disease that requires removal of the primary lesion and all of the potential pathways of progression--muscular, lymphatic and vascular; 2) identification of a distinct territory at risk of metastatic representation ...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2009
Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retros... more Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retrospective cohort study, the aim was to assess possible advantages of prophylactic central neck dissection with total thyroidectomy in cN0 papillary thyroid cancer. A total of 244 consecutive patients with papillary thyroid cancer, without clinical and ultrasound nodal metastases (cN0), were evaluated out of 1373 patients operated for a thyroid disease at the Istituto Europeo di Oncologia, Milan, Italy from 1994 to 2006. Of these 244 patients, 126 (Group A) underwent thyroidectomy with central neck dissection, while 118 (Group B) underwent thyroidectomy alone. Demographic, clinical and pathological features were analysed. Overall recurrence rate was 6.3% (8/126) in Group A and 7.7% (9/118) in Group B, with a mean follow-up of 47 (Group A) and 64 (Group B) months. In Group A patients, 47% were pN1a and all patients with recurrence had nodal involvement (p = 0.002). Survival rate did not diff...
Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glo... more Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glottic cancer in elderly patients in terms of feasibility, disease-free survival, overall survival and organ preservation, in a single Institute (European Institute of Oncology). A total of 122 patients (male/female ratio 113/9), over 70s with untreated early stage glottic cancer, were consecutively evaluated and treated at the European Institute of Oncology from 2000 to 2008. None had contraindications to general anaesthesia and all patients signed informed consent to this surgical treatment. The severity of pre-operative comorbidities and the intra-operative risk were evaluated according to the American Society of Anaesthesiologists Grading Classification. All patients underwent laser cordectomies according to the European Laryngological Society classification. Histopathological examination demonstrated no evidence of tumour (pT0) in 19 patients (calculated only in patients with a previo...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2011
The evolution of new techniques for cancer surgery has led to important changes in cancer care in... more The evolution of new techniques for cancer surgery has led to important changes in cancer care in recent years. The endpoint of cancer treatment is now to treat the patient with minimum discomfort while respecting quality of life. New techniques, such as mini-invasive surgery, must respect the correct oncological indications, when technically feasible. The surgery for nodal spread or recurrence of disease, after previous surgery on T or T and N for neck cancer, can represent a diagnostic and therapeutic challenge, especially in the neck, which is characterized by small spaces and noble structures. Often lesions become enveloped in scar tissue and can be difficult to visualize during surgery, representing a genuine problem for the surgeon. Ultrasound dye-assisted surgery is a procedure that combines ultra-sound localization of pathological nodes with the use of methylene blue to mark diseased structures to simplify their visualization (and thus removal) in the surgical field. The tec...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2010
Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glo... more Aim of this retrospective study is to evaluate the impact of transoral laser surgery of early glottic cancer in elderly patients in terms of feasibility, disease-free survival, overall survival and organ preservation, in a single Institute (European Institute of Oncology). A total of 122 patients (male/female ratio 113/9), over 70s with untreated early stage glottic cancer, were consecutively evaluated and treated at the European Institute of Oncology from 2000 to 2008. None had contraindications to general anaesthesia and all patients signed informed consent to this surgical treatment. The severity of pre-operative comorbidities and the intra-operative risk were evaluated according to the American Society of Anaesthesiologists Grading classification. All patients underwent laser cordectomies according to the European Laryngological Society classification. Histopathological examination demonstrated no evidence of tumour (pT0) in 19 patients (calculated only in patients with a previo...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2012
Sudden death in a 66-year-old woman with squamous cell carcinoma of the oral cavity and exclusive... more Sudden death in a 66-year-old woman with squamous cell carcinoma of the oral cavity and exclusive metastatic involvement of the right stellate ganglion and right nerve vagus is reported. The patient also suffered from paroxysmal atrial fibrillation treated with quinidine. An autopsy showed exclusive metastases to the right stellate ganglion and vagus nerve, along with decreased nerve fibre density in the ventricular myocardium suggesting that Wallerian axon degeneration of cardiac fibres was responsible for sudden death.
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2011
Hypocalcemia is a major post-operative complication of total thyroidectomy, causing severe sympto... more Hypocalcemia is a major post-operative complication of total thyroidectomy, causing severe symptoms and increasing hospitalization time. The primary cause is secondary hypo-parathyroidism following damage to, or devascularisation of, one or more parathyroid glands during surgery. Aim of the study was to develop a simple and reliable method for predicting post-operative hypocalcemia in total thyroidectomy patients. A retrospective analysis was made of immediate pre-operative and early post-operative calcium levels in 100 patients. It was found that a marked decrease in blood calcium, immediately after surgery, was a sensitive predictor of hypocalcemia. In a subsequent prospective series of 67 patients, the efficacy was assessed of early administration of calcium plus Vitamin D in reducing symptomatic hypocalcemia in patients in whom the difference (Δ) between pre- and post-operative blood calcium was ≥ 1.1 mg/dl. This treatment was part of a protocol in which normo-calcemic patients ...
Acta otorhinolaryngologica Italica : organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale, 2014
Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of... more Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of cases. The central compartment (VIupper VII levels) is considered to be the first echelon of nodal metastases in all differentiated thyroid carcinomas. The indication for central neck dissection is still debated especially in patients with cN0 disease. For some authors, central neck dissection is recommended for lymph nodes that are suspect preoperatively (either clinically or with ultrasound) and/or for lymph node metastases detected intra-operatively with a positive frozen section. In need of a better definition, we divided the dissection in four different areas to map localization of metastases. In this study, we present the rationale for central neck dissection in the management of differentiated thyroid carcinoma, providing some anatomical reflections on surgical technique, oncological considerations and analysis of complications. Central neck dissection may be limited to the compa...
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