How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group

PURPOSE

In clinical practice the assessment of the "vocal cord-arytenoid unit" (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension.

METHODS

In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated.

RESULTS

Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal.

CONCLUSIONS

The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology.

Prognostic Value of Anteroposterior Extension in Oral Tongue and Floor Squamous Cell Carcinoma

Importance

The tongue and oral floor represent the most involved subsite by oral cancer, and there are no reported systems to classify anteroposterior tumor extension with prognostic effect. In other cancers, the anterior vs posterior tumor extension is a relevant prognostic factor.

Objective

To establish whether anterior vs posterior tumor extension may represent a prognostic factor in oral tongue and floor squamous cell carcinoma (OTFSCC).

Design, Setting, and Participants

This was a retrospective cohort study of patients who underwent surgery for OTFSCC from January 1, 2010, to December 31, 2021, at 2 tertiary-level academic institutions in Italy (University of Padua and University of Brescia). Patients eligible for the study had histologically proven primary OTFSCC; underwent surgery-based, curative treatment; and had available preoperative contrast-enhanced imaging.

Exposures

Four anatomical lines were designed to assess tumor extension: (1) chin-palate line (CPL), (2) chin-basion line, (3) Stensen duct line, and (4) lingual septum line. Preoperative imaging was re-evaluated, and tumor extension was classified as either anterior or posterior according to the lines.

Main Outcomes and Measures

Overall survival and time to recurrence (TTR) were evaluated according to tumor extension. These outcomes were reported as 5-year survival rates with 95% CIs.

Results

Of the 133 patients included, 79 (59.4%) were male, and the mean (SD) age was 62.7 (15.4) years. The 5-year TTR difference was higher for posterior vs anterior OTFSCC classified according to CPL (21.0%; 95% CI, 8.3%-33.7%), Stensen duct line (15.5%; 95% CI, 1.0%-30.0%), and lingual septum line (17.2%; 95% CI, 2.2%-32.3%). Overall survival analysis showed similar results. At the multivariable analysis on TTR, N status (adjusted hazard ratio [HR], 3.0; 95% CI, 1.2-7.1) and anteroposterior classification according to CPL (adjusted HR, 7.1; 95% CI, 0.9-54.6) were the variables associated with the highest adjusted HRs.

Conclusions and Relevance

In this cohort study, OTFSCC with a posterior extension to the CPL was associated with a higher risk of recurrence and death. This analysis suggests that the poor prognosis conveyed by the posterior tumor extension is independent of other relevant prognosticators except for the burden of nodal disease. This estimate is not precise and does not allow for definitive clinically important conclusions; therefore, further prospective studies are necessary to confirm these data.

High-resolution US of the facial vessels with new facial vein landmarks for reconstructive surgery and dermal injection

BACKGROUND

Accurate knowledge of vessel anatomy is essential in facial reconstructive surgery. The technological advances of ultrasound (US) equipment with the introduction of new high-resolution probes improved the evaluation of facial anatomical structures. Our study had these objectives: the primary objective was to identify new surgical landmarks for the facial vein and to verify their precision with US, the secondary objective was to evaluate the potential of high-resolution US examination in the study of both the facial artery and vein.

METHODS

Two radiologists examined a prospective series of adult volunteers with a 22-8 MHz hockey-stick probe. Two predictive lines of the facial artery and vein with respective measurement points were defined. The distance between the facial vein and its predictive line (named mandibular-orbital line) was determined at each measurement point. The distance from the skin and the area of the two vessels were assessed at every established measurement point.

RESULTS

Forty-one volunteers were examined. The median distance of the facial vein from its predictive line did not exceed 2 mm. The facial vein was visible at every measurement point in all volunteers on the right side, and in 40 volunteers on the left. The facial artery was visible at every measurement point in all volunteers on the right and in 37 volunteers on the left.

CONCLUSIONS

The facial vein demonstrated a constant course concerning the mandibular-orbital line, which seems a promising clinical and imaging-based method for its identification. High-resolution US is valuable in studying the facial artery and vein.

RELEVANCE STATEMENT

High-resolution US is valuable for examining facial vessels and can be a useful tool for pre-operative assessment, especially when combined with the mandibular-orbital line, a new promising imaging and clinical technique to identify the facial vein.

KEY POINTS

• High-resolution US is valuable in studying the facial artery and vein. • The facial vein demonstrated a constant course concerning its predictive mandibular-orbital line. • The clinical application of the mandibular-orbital line could help reduce facial surgical and cosmetic procedure complications.

Electric Bioimpedance Sensing for the Detection of Head and Neck Squamous Cell Carcinoma

The early detection of head and neck squamous cell carcinoma (HNSCC) is essential to improve patient prognosis and enable organ and function preservation treatments. The objective of this study is to assess the feasibility of using electrical bioimpedance (EBI) sensing technology to detect HNSCC tissue. A prospective study was carried out analyzing tissue from 46 patients undergoing surgery for HNSCC. The goal was the correct identification of pathologic tissue using a novel needle-based EBI sensing device and AI-based classifiers. Considering the data from the overall patient cohort, the system achieved accuracies between 0.67 and 0.93 when tested on tissues from the mucosa, skin, muscle, lymph node, and cartilage. Furthermore, when considering a patient-specific setting, the accuracy range increased to values between 0.82 and 0.95. This indicates that more reliable results may be achieved when considering a tissue-specific and patient-specific tissue assessment approach. Overall, this study shows that EBI sensing may be a reliable technology to distinguish pathologic from healthy tissue in the head and neck region. This observation supports the continuation of this research on the clinical use of EBI-based devices for early detection and margin assessment of HNSCC.

Survival Outcomes in Squamous Cell Carcinoma of the External Auditory Canal: A Systematic Review and Meta-Analysis

Squamous cell carcinomas (SCC) of the external auditory canal (EAC) are rare tumors representing a surgical challenge. Current knowledge is based largely on case series; thus, the level of evidence is weak. This study sought to systematically review the available SCC of the EAC literature and to identify risk factors for overall survival (OS) and disease-specific survival (DSS). A systematic review and meta-analysis of papers searched up to December 2022 through PubMed, Scopus, Web of Science, and Cochrane Library databases was conducted. Quality assessment of the eligible studies was done according to the Newcastle-Ottawa Scale. Pooled univariate and multivariable analyses and meta-analysis using a random-effects or fixed-effects Mantel-Haenszel model were performed. Fifteen articles (282 patients) met the inclusion criteria and were included in the quantitative analysis. The pooled multivariable analysis revealed cT3 and cT4 as independent prognostic factors for OS (p = 0.005, and p < 0.001, respectively) and DSS (p = 0.002, and p < 0.001, respectively). Local recurrence rate was 32.3%. The meta-analysis estimated significantly higher odds ratios for advanced T categories, than cT1-T2 tumors for OS and DSS (OR = 3.55; 95% CI, 1.93–6.52, and OR = 3.73; 95% CI, 2.00–6.97, respectively). In conclusion, locally advanced tumors were associated with poor prognosis. Poor outcomes mostly occurred due to local recurrence.

Cerebrospinal Fluid Leak Repair: Usefulness of Intrathecal Fluorescein for Correct Topographic Identification of the Skull Base Defects

BACKGROUND

In the management of cerebrospinal fluid (CSF) leak, the identification of the exact discharge spot is paramount. This process can represent a challenge for the radiologist and the surgeon. In the present study, we analyzed a series of patients affected by endonasal CSF leak who underwent endoscopic surgical reconstruction aided by the use of ITF. The purpose of this work is to assess the efficacy of intraoperative ITF in addition to computed tomography (CT) and magnetic resonance imaging for correct topographic localization of the CSF leak.

METHODS

Eighty-three patients were enrolled in the study. The main outcome was the concordance between the supposed radiologic defect site and the actual one seen intraoperatively. Recurrence-free survival was evaluated as secondary outcome.

RESULTS

ITF better defined the defect site, allowing a change in the treatment in 21 patients (25.3%), in whom nonconcordance was observed between the suspected radiologic site and the actual surgical site. Good agreement was found between the specific topographic localization (κ = 0.737; P < 0.0001), whereas fair agreement was observed considering the side of the defect (κ = 0.362; P = 0.0009) and correct identification of multiple sites (κ = 0.044; P = 0.666). The 10-year 96% estimate of recurrence-free survival confirmed the correct repair of the fistula site in most cases.

CONCLUSIONS

Our data show the usefulness and safety of intraoperative ITF for management of patients affected by endonasal CSF leak. ITF improved the topographic diagnosis of the leak site, ensuring the best target reconstruction and very low recurrence rate.

Resection of the internal carotid artery in selected patients affected by cancer of the skull base

Invasion of the internal carotid artery (ICA) has been historically considered a criterion of non-resectability of skull base cancer (SBC). Patients affected by SBC who underwent surgery including resection of ICA at two tertiary institutions were included. Demographics, oncologic, and surgical information, complications, and survival outcomes were retrospectively reviewed. Survival outcomes were calculated. Ten patients were included. Three surgical approaches (transnasal endoscopic, transorbital, and transpetrosal) were employed to resect the invaded/abutted tract(s) of the ICA. All patients underwent ICA temporary balloon occlusion test. In two patients, an extracranial-to-intracranial arterial bypass was harvested. Major neuromorbidity was observed in two patients. Perioperative mortality of the series was 10.0%. Mean overall survival was 27.2 months, with 2-year overall and progression-free survival rate of 88.9%. ICA resection is feasible as part of the ablation performed for very advanced SBCs. Survival outcomes are acceptable in adequately selected patients.

Application of a symptoms score questionnaire after conjunctivodacryocystorhinostomy: outcomes

Objective

To evaluate medium/long term outcomes and patient satisfaction through relief of symptoms and improved quality of life (QoL) after Jones tube conjunctivodacryocystorhinostomy (JT-CDCR) using the Naso Lacrimal Duct Obstruction symptom-score (NLDO-SS).

Methods

We conducted a retrospective, non-comparative, multicentric study including patients with complete obstruction of the superior and inferior proximal lacrimal drainage system. All patients underwent JT-CDCR, and the patency of the tube was evaluated with saline irrigation and endoscopic examination. We assessed patient satisfaction and quality of life administering the NLDO-SS.

Results

We enrolled 16 patients, for a total of 21 eyes operated. The success rate for procedures was 81%. The success rate for single parameters was globally 95.9%; if considered separately, ocular symptoms and nasal symptoms were respectively 94.3% and 100%.

Conclusions

JT-CDCR was a reliable procedure, able to solve symptoms in a majority of patients and guaranteed a good quality of life over a long period of time.

Validation of the European Laryngological Society classification of glottic vascular changes as seen by narrow band imaging in the optical biopsy setting

Purpose

In 2016, the European Laryngological Society (ELS) proposed a classification for vascular changes occurring in glottic lesions as visible by narrow band imaging (NBI), based on the dichotomic distinction between longitudinal vessels (not suspicious) and perpendicular ones (suspicious). The aim of our study was to validate this classification assessing the interobserver agreement and diagnostic test performance in detecting the final histopathology.

Methods

A retrospective study was carried out by reviewing clinical charts, preoperative videos, and final pathologic diagnosis of patients submitted to transoral microsurgery for laryngeal lesions in two Italian referral centers. In each institution, two physicians, independently re-assessed each case applying the ELS classification.

Results

The cohort was composed of 707 patients. The pathologic report showed benign lesions in 208 (29.5%) cases, papillomatosis in 34 (4.8%), squamous intraepithelial neoplasia (SIN) up to carcinoma in situ in 200 (28.2%), and squamous cell carcinoma (SCC) in 265 (37.5%). The interobserver agreement was extremely high in both institutions (k = 0.954, p < 0.001 and k = 0.880, p < 0.001). Considering the diagnostic performance for identification of at least SIN or SCC, the sensitivity was 0.804 and 0.902, the specificity 0.793 and 0.581, the positive predictive value 0.882 and 0.564, and the negative predictive value 0.678 and 0.908, respectively.

Conclusion

The ELS classification for NBI vascular changes of glottic lesions is a highly reliable tool whose systematic use allows a better diagnostic evaluation of suspicious laryngeal lesions, reliably distinguishing benign ones from those with a diagnosis of papillomatosis, SIN or SCC, thus paving the way towards confirmation of the optical biopsy concept.

Intraoral ultrasonography in the assessment of DOI in oral cavity squamous cell carcinoma: a comparison with magnetic resonance and histopathology

Objective

The first-line therapeutic approach for oral cavity squamous cell carcinoma (OCSCC) is complete surgical resection. Preoperative assessment of depth of invasion (cDOI) is crucial to plan the surgery. Magnetic resonance (MR) and intraoral ultrasonography (IOUS) have been shown to be useful tools for assessment of DOI. The present analysis investigates the accuracy of MR and IOUS in evaluating DOI in OCSCC compared to histological evaluation (pDOI).

Materials and methods

Forty-nine previously untreated patients with cT1-T3 OCSCC were reviewed. Nine patients were staged with MR alone, 10 with IOUS alone, and 30 with both MR and IOUS.

Results

Mean difference between cDOI_MR and pDOI values of 0.2 mm (95% CI − 1.0–1.3 mm) and between cDOI_IOUS and pDOI of 0.3 mm (95% CI − 1.0–1.6 mm). Spearman R between cDOI_MR and pDOI was R = 0.83 and between cDOI_IOUS and pDOI was R = 0.76. Both radiological techniques showed high performance for the correct identification, with the optimum cut-off of 5 mm, of patients with a pDOI ≥ 4 mm and amenable to a neck dissection, with an AUC of 0.92 and 0.82 for MR and IOUS, respectively.

Conclusion

Both examinations were valid approaches for preoperative determination of DOI in OCSCC, although with different cost-effectiveness profiles and indications.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06421-w) contains supplementary material, which is available to authorized users.

Microsurgical procedures during COVID-19 pandemic: the VITOM® 3D-HD exoscopic system as alternative to the operating microscope to properly use personal protective equipment (PPE)

PURPOSE

In the field of microsurgery, the use of conventional operating microscope, adopted in several disciplines, is not suitable with the full adoption of appropriate personal protective equipment (PPE), as goggles and face shields, needing the eyes to be at close contact with oculars.

METHODS

Herein we present an exoscopic surgical setup, implemented for transoral laser microsurgery, by the VITOM® 3D-HD system.

RESULTS

Our proposed exoscopic setting overcomes safety limits of the conventional operating microscope, being suitable with the adoption of full PPE necessary facing with suspected or confirmed positive SARS-CoV-2 patients needing urgent microsurgical procedures.

CONCLUSION

The use of protocols to reduce the virus spreading is mandatory to safely treat also patients potentially SARS-CoV-2 infected. The described surgical setup is advisable to manage urgent microsurgical procedures along the duration of the COVID-19 pandemic, being applicable PPE necessary to treat potentially or confirmed SARS-CoV-2-infected patients.

SmartProbe: a bioimpedance sensing system for head and neck cancer tissue detection

OBJECTIVES

This study presents SmartProbe, an electrical bioimpedance (EBI) sensing system based on a concentric needle electrode (CNE). The system allows the use of commercial CNEs for accurate EBI measurement, and was specially developed for in-vivo real-time cancer detection.

APPROACH

Considering the uncertainties in EBI measurements due to the CNE manufacturing tolerances, we propose a calibration method based on statistical learning. This is done by extracting the correlation between the measured impedance value |Z|, and the material conductivity σ, for a group of reference materials. By utilizing this correlation, the relationship of σ and |Z| can be described as a function and reconstructed using a single measurement on a reference material of known conductivity.

MAIN RESULTS

This method simplifies the calibration process, and is verified experimentally. Its effectiveness is demonstrate by results that show less than 6% relative error. An additional experiment is conducted for evaluating the system's capability to detect cancerous tissue. Four types of ex-vivo human tissue from the head and neck region, including mucosa, muscle, cartilage and salivary gland, are characterized using SmartProbe. The measurements include both cancer and surrounding healthy tissue excised from 10 different patients operated on for head and neck cancer. The measured data is then processed using dimension reduction and analyzed for tissue classification. The final results show significant differences between pathologic and healthy tissues in muscle, mucosa and cartilage specimens.

SIGNIFICANCE

These results are highly promising and indicate a great potential for SmartProbe to be used in various cancer detection tasks.

Magnetic Resonance vs. Intraoral Ultrasonography in the Preoperative Assessment of Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Background: Preoperative assessment is critical to decide the most adequate surgical strategy for oral squamous cell carcinoma (SCC). Magnetic resonance (MR) and intraoral ultrasonography (US) have been reported to be of great value for preoperative estimation of depth of invasion (DOI) and/or tumor thickness (TT). This review aims to analyze the accuracy of MR and intraoral US in determining DOI/TT in oral SCC, by assuming histological evaluation as the reference method.

Methods: The procedure was conducted following the modified 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We performed a systematic search of papers on PubMed, Scopus, Web of Science, and Cochrane Library databases until July 31st, 2019. For quantitative synthesis, we included nine studies (487 patients) focused on MR, and 12 (520 patients) focused on intraoral US. The Pearson correlation coefficient (r) between DOI/TT evaluated with MR or intraoral US was assumed as effect size. A meta-analysis (MA) for each study group (MR and US) was performed by using the random-effects models with the DerSimonian–Laird estimator and r-to-z transformation.

Results: In the MA for MR studies, a high heterogeneity was found (I² = 94.84%; Q = 154.915, P < 0.001). No significant risk of bias occurred by evaluating funnel plot asymmetry (P = 0.563). The pooled (overall) r of the MR studies was 0.87 (95% CI from 0.82 to 0.92), whereas the pooled r-to-z transformed was 1.44 (95% CI from 1.02 to 1.85). In the MA for US studies a high heterogeneity was found (I² = 93.56%; Q = 170.884, P < 0.001). However, no significant risk of bias occurred (P = 0.779). The pooled r of the US studies was 0.96 (95% CI from 0.94 to 0.97), whereas the pooled r-to-z transformed was 1.76 (95% CI from 1.39 to 2.13). These outputs were confirmed in additional MA performed by enrolling only MR (n = 8) and US (n = 11) studies that evaluated TT.

Conclusions: MR and intraoral US seem to be promising approaches for preoperative assessment of DOI/TT in oral SCC. Remarkably, a higher pooled r and r-to-z transformed were observed in the intraoral US studies, suggesting that this approach could be more closely related to histopathological findings.