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.

Depth of Invasion Assessment in Laryngeal Glottic Carcinoma: A Preoperative Imaging Approach for Prognostication

OBJECTIVE

The prognostic value of depth of invasion (DOI) in oral squamous cell cancer carcinoma and cutaneous melanoma is well established, while there is a lack of reports investigating the role of DOI in laryngeal cancer. This study aims to explore the association of glottic cancer DOI with other established pathological risk factors and nodal metastasis and evaluate the feasibility of measuring DOI preoperatively using tomographic imaging.

METHODS

The medical records of glottic cancer patients treated between 2015 and 2020 in a single tertiary referral center were screened retrospectively. Pathologically measured DOI (pDOI) value was also reviewed and registered. Preoperative computer tomography (CT) was used to obtain the radiological DOI (rDOI) measured by two dedicated radiologists. Their inter-rated agreement was assessed and the correlation between pDOI and rDOI was calculated. pDOI association with the main pathology report features was assessed with univariable analysis. Cox univariable and multivariable models were used to explore the role of pDOI on survival.

RESULTS

Ninety-one patients had pDOI data available, of which 59 also had rDOI data. A strong concordance between the two radiologists was found (concordance correlation coefficient = 0.96); rDOI and pDOI were highly and significantly correlated (R = 0.85; p < 0.001). pDOI was significantly higher in patients with perineural invasion (PNI; p < 0.001), lymphovascular invasion (LVI; p < 0.001), and nodal metastasis (p < 0.001). pDOI was associated with disease-free survival at univariable analysis (p = 0.04) while it did not show a significant impact (p = 0.10) at multivariable analysis.

CONCLUSION

Glottic carcinoma DOI correlates with PNI, LVI, and nodal metastasis and it can be reliably assessed in a preoperative setting using CT imaging.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

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.

Can High-Frequency Intraoral Ultrasound Predict Histological Risk Factors in Oral Squamous Cell Carcinoma? A Preliminary Experience

Despite advancements in multidisciplinary care, oncologic outcomes of oral cavity squamous cell carcinoma (OSCC) have not substantially improved: still, one-third of patients affected by stage I and II can develop locoregional recurrences. Imaging plays a pivotal role in preoperative staging of OSCC, providing depth of invasion (DOI) measurements. However, locoregional recurrences have a strong association with adverse histopathological factors not included in the staging system, and any imaging features linked to them have been lacking. In this study, the possibility to predict histological risk factors in OSCC with high-frequency intraoral ultrasonography (IOUS) was evaluated. Thirty-four patients were enrolled. The agreement between ultrasonographic and pathological DOI was evaluated, and ultrasonographic margins' appearance was compared to the Brandwein-Gensler score and the worst pattern of invasion (WPOI). Excellent agreement between ultrasonographic and pathological DOI was found (mean difference: 0.2 mm). A significant relationship was found between ultrasonographic morphology of the front of infiltration and both Brandwein-Gensler score ≥ 3 (p < 0.0001) and WPOI ≥4 (p = 0.0001). Sensitivity, specificity, positive predictive value, and negative predictive value for the IOUS to predict a Brandwein-Gensler score ≥3 were 93.33%, 89.47%, 87.50%, and 94.44%, respectively. The present study demonstrated the promising role of IOUS in aiding risk stratification for OSCC patients.

Does the distal ureteral diameter ratio (UDR) matter in the surgical management of vesicoureteral reflux in children?

PURPOSE

To evaluate UDR reliability, sensitivity, specificity and to identify the best treatment basing on UDR among single or double endoscopic injections and ureteral reimplantation.

METHODS

Data of patients affected by primary VUR and treated by endoscopic injection over a 10 years period were retrospectively analyzed. Two radiologist attributed reflux grade and UDR on voiding cystourethrogram twice and blinded. Follow-up focused on resolution after 1 or 2 endoscopic injections. Relation between UDR, reflux grade and outcomes were analyzed.

RESULTS

Patient enrolled were 198. Low grade VUR was present in 24.8%, grade 3 in 41.6%, grade 4-5 in 33.6%. Resolution after one injection was obtained in 88 patients; among 110 not resolved 104 cases had a second injection. Success after 2 injections was reported in 138 cases. UDR showed a higher reliability compared with reflux grade both in intra than inter-reader measurement (ICC > 90%). Success after 1 or 2 injections was reported for UDR < 0.33 and UDR < 0.47 respectively.

CONCLUSION

UDR shows to be a more reliable measurement that allows for an objective estimation of VUR severity and prognosis. It represents a quantitative parameter that might be useful to identify patients who may benefit endoscopic or surgical treatment, avoiding unnecessary under or over-treatment.

High-Resolution Ultrasound of Facial Muscles: Sonoanatomy, Scanning Technique, and Pathological Cases

The aim of the present work is to review the sonographic appearance of facial muscles with high-frequency transducers and to illustrate a step-by-step scanning technique that enables an effective evaluation of them. In addition, we highlighted the clinical application showing some pathological cases demonstrated with ultrasound (US). The recent technological advances have greatly enlarged the potential of high-resolution US in the evaluation of the face. Furthermore, the clinical indications of this technique are expected to increase in the near future.

High-Frequency Intraoral Ultrasound for Preoperative Assessment of Depth of Invasion for Early Tongue Squamous Cell Carcinoma: Radiological-Pathological Correlations

The eighth edition of the TNM classification officially introduced "depth of invasion" (DOI) as a criterion for determining the T stage in tongue squamous cell carcinoma. The DOI is a well-known independent risk factor for nodal metastases. In fact, several experts strongly suggest elective neck dissection for tongue cancer with a DOI > 4 mm due to the high risk of early and occult nodal metastases. Imaging plays a pivotal role in preoperative assessments of the DOI and, hence, in planning the surgical approach. Intraoral ultrasound (IOUS) has been proposed for early-stage SCC of the oral tongue as an alternative to magnetic resonance imaging (MRI) for local staging. The aim of this work is to investigate the accuracy of IOUS in the assessment of the DOI in early oral SCC (CIS, pT1, and pT2). A total of 41 patients with tongue SCCs (CIS-T2) underwent a preoperative high-frequency IOUS. An IOUS was performed using a small-size, high-frequency hockey-stick linear probe. The ultrasonographic DOI (usDOI) was retrospectively compared to the pathological DOI (pDOI) as the standard reference. In patients who underwent a preoperative MRI, their usDOI, magnetic resonance DOI (mriDOI), and pDOI were compared. Specificity and sensitivity for the IOUS to predict a pDOI > 4 mm and to differentiate invasive and noninvasive tumors were also evaluated. A high correlation was found between the pDOI and usDOI, pDOI and mriDOI, and usDOI and mriDOI (Spearman's ρ = 0.84, p < 0.0001, Spearman's ρ = 0.79, p < 0.0001, and Spearman's ρ = 0.91, p < 0.0001, respectively). A Bland-Altman plot showed a high agreement between the usDOI and pDOI, even though a mean systematic error was found between the usDOI and pDOI (0.7 mm), mriDOI and pDOI (1.6 mm), and usDOI and mriDOI (-0.7 mm). The IOUS was accurate at determining the T stage (p < 0.0001). The sensitivity and specificity for the IOUS to predict a pDOI ≥4 mm were 92.31% and 82.14%, respectively, with an AUC of 0.87 (p < 0.0001). The specificity, sensitivity, negative predictive value (NPV), and positive predictive value (PPV) for the IOUS to predict an invasive cancer were 100%, 94.7%, 60%, and 100%, respectively. The AUC was 0.8 (95% CI 0.646-0.908, p < 0.0001). The IOUS was accurate in a preoperative assessment of a pDOI and T stage, and can be proposed as an alternative to MRI in the preoperative staging of tongue SCC.

Correlation Between Skin and Affected Organs in 52 Sclerodermic Patients Followed in a Diseases Management Team: Development of a Risk Prediction Model of Organ-Specific Complications

Objective

To identify the existence of a correlation among the various organs affected, focusing primarily on immuno-dermatological aspects, and to create a risk prediction model of organ-specific complications.

Material and Methods

Fifty-two patients with stable scleroderma, followed between 2015 and 2019, were investigated through an extensive multidisciplinary evaluation in the last year.

Results

Patients with lung involvement presented a worse degree of skin fibrosis than patients without it (p <0.001). No relationship was observed for the heart, kidney, and esophagus. Patients with pulmonary involvement had a lower pressure of the low esophagus sphincter and a higher Warrick score than patients without it (p <0.05). Age was significantly higher in patients with kidney involvement. Diffuse scleroderma patients had a worse pulmonary impairment than limited scleroderma patients (p <0.05). The manometric "sclerodermic" pattern was observed to be the most frequent (55.6%, p <0.05) in dcSSc patients while the sclerodermic and normal pattern were equally represented (41.2 and 32.4% respectively, p <0.05) in lcSSc patients. When compared to the negative serological groups, anti-Scl-70 positive patients presented a worse lung involvement while anti-centromere patients presented a better lung outcome (p <0.05). PM-Scl 100/75 positive patients presented mostly a pulmonary fibrotic pattern (p <0.05) and, also, heart complications were more likely associated with anti PM-Scl 100/75 positivity (p <0.05). The risk prediction model for organ-specific complications had an accuracy of 84.4% (95%CI 78, 89) in complication-site prediction, AUC of 0.871, 86% of sensitivity, and 83% of specificity, Cohen's Kappa (k) of 0.68.

Conclusions

Out of all the organs studied, the skin is the one that correlates with the lung. Patients with a diffuse form of disease presented more frequently the anti Scl-70 antibody and had a worse lung and esophageal involvement (scleroderma pattern) than the negative group. Conversely, patients with limited disease presented all positive for the anti-centromere antibody with a better lung involvement than the negative group, without any difference among the esophageal manometric pattern. Anti PM-Scl 100/75 antibody patients were associated with pulmonary fibrosis and presented cardiac involvement. The model created has demonstrated excellent values of sensitivity, specificity, and accuracy, but further studies are needed for validation.

Recent Borexino results and perspectives of the SOX measurement

Borexino is a liquid scintillator detector sited underground in the Laboratori Nazionali del Gran Sasso (Italy). Its physics program, until the end of this year, is focussed on the study of solar neutrinos, in particular from the Beryllium, pp, pep and CNO fusion reactions. Knowing the reaction chains in the sun provides insights towards physics disciplines such as astrophysics (star physics, star formation, etc.), astroparticle and particle physics. Phase II started in 2011 and its aim is to improve the phase I results, in particular the measurements of the neutrino fluxes from the pep and CNO processes. By the end of this year, data taking from the sun will be over and a new project is scheduled to launch: Short distance Oscillation with boreXino (SOX), which uses a Cerium source for neutrinos (100÷150 kCi of activity) and aims to confirm or rule out the presence of sterile neutrinos. This particle is hypothesised to justify the reactor, Gallium and LSND anomalies found and can reject extensions to the standard model. The work presented is a summary of the solar neutrino results achieved so far, which lead not only to a precise study of the processes in the sun, but also to more Standard Model oriented measurements (such as the stability of the charge, i.e. the life time of the electron). Furthermore, the perspectives of the SOX program are discussed showing the experiment sensitivity to a fourth neutrino state covering almost entirely 3σ of the preferred region of the anomalous neutrino experiments, and additional applications of the detector such as the study of geo-neutrinos.

Bilateral inflammatory pseudotumour of the trigeminal nerve: a diagnostic challenge

Inflammatory pseudotumour (IPT) is an uncommon disease with undefined pathogenesis. It is often characterized by local aggressiveness with compressive and displacing effects on surrounding structures. It may appear in different regions of the body, rarely involving perineural structures unilaterally. We present a case of a bilateral IPT around trigeminal branches in a patient with a long-term history of periorbital swelling and proptosis.

Virological and Immunological Responses to a Once-a-Day Antiretroviral Regimen with Didanosine, Lamivudine and Efavirenz

Current antiretroviral drugs cannot eradicate HIV infections, and persons living with HIV are often faced with very demanding daily therapeutic schedules that can induce poor adherence. More conveniently dosed and patient-friendly regimens are needed. We investigated, in this 48-week pilot study, a once-a-day highly active antiretroviral therapy regimen of didanosine, lamivudine and efavirenz. Seventy-five consecutive antiretroviral-naive subjects were enrolled. Over the 48-week period, plasma HIV-RNA levels declined sharply, with a median decrease at the end of the observation time >3.4 log copies/ml. The proportion of patients achieving a plasma HIV-RNA level below the limit of detection (50 copies/ml) was 77% (intention to treat analysis) at the end of the study period. The mean CD4 cell count increased steadily over time from 251 to 459 cells/μl. Antiviral efficacy was similar in patients with a baseline HIV-RNA level above or below 100 000 copies/ml. However, patients with a baseline CD4 cell count <200 cells/μl showed a significantly worse virological response than that observed in patients with higher baseline CD4 counts. Overall 15 patients interrupted therapy. In four cases treatment interruption was due to lack of treatment response; three additional patients were lost to follow-up or withdrew informed consent. Eight patients stopped therapy because of adverse events. The once-daily combination of didanosine, lamivudine and efavirenz resulted in sustained viral suppression and was well-accepted by patients. This regimen may offer advantages in selected difficult-to-treat populations, allows directly observed therapy and can be a safe and effective alternative in antiretroviral-naive patients. These encouraging pilot results need to be confirmed in a comparative clinical trial.

Duration of viral suppression in patients on stable therapy for HIV-1 infection is predicted by plasma HIV RNA level after 1 month of treatment

The aim of this study was to assess the predictive value of HIV RNA levels after 1 month of therapy on the long-term virologic outcome in an unselected general population of HIV-infected patients.

DESIGN

Analysis was conducted retrospectively on an ongoing clinical cohort of HIV-positive patients who were receiving antiretroviral treatment. Data on 575 patients were analyzed.

RESULTS

The HIV RNA value at 1 month was significantly correlated with the virologic outcome after 12 and 24 months of therapy (R = 0.258 and R = 0.44, respectively). The predictive value of the 1-month viral load was also statistically significant after stratification for baseline CD4 T-cell counts. Prediction was similar in highly compromised patients (CD4 < or = 100 cells/microl; R = 0.426; p = .001) or in patients with a better immunologic status (R = 0.419; p < .0001). It retained validity in patients who were naive or experienced for antiretroviral therapy.

CONCLUSION

HIV RNA level after 1 month of therapy is a useful prognostic marker in HIV-infected patients. It predicts long-term virologic and immunologic outcome. A cutoff level of 5000 copies/ml identifies patients most likely to fail current therapy. In these patients, a more aggressive strategy or specific diagnostic interventions to clarify the relative influence of viral resistance and/or subtherapeutic regimens is advised.

Teicoplanin versus cefamandole in the prevention of infection in total hip replacement

In a prospective, controlled, single-blind study the efficacy of teicoplanin versus cefamandole in preventing infections in total hip replacement was investigated in 496 consecutive patients. A single intravenous dose of teicoplanin (400 mg) was as effective as two intravenous doses of cefamandole (2 g before and 1 g after surgery). No major complications were observed in either group. Infective wound complications were observed only in the cefamandole group. These infections, although not dangerous for the patients, required supplementary antibiotic treatment in all cases. Teicoplanin is a reasonable choice as a prophylactic agent in orthopaedic surgery when a high risk of infection due to staphylococci is present.