Laterocervical Nodes Research Articles

Central (N1A) and latero-cervical (N1B) lymph nodes metastases in sporadic medullary thyroid carcinoma patients: clinical impact on disease specific and recurrence free survival

Central (N1A) and latero-cervical (N1B) lymph nodes metastases in sporadic medullary thyroid carcinoma patients: clinical impact on disease specific and recurrence free survival

The role of intraoperative neuromonitoring in preventing lesions of the spinal accessory nerve during functional neck dissection.

Intraoperative neuromonitoring (IONM) in thyroid surgery offers a valid aid to the operator in identifying the recurrent laryngeal nerve and preserving its function. Recently, IONM has also been used in other surgeries, such as spinal accessory nerve dissection, during lymphectomy of the II, III, IV, and V laterocervical lymph nodes. The goal is the preservation of the spinal accessory nerve, whose macroscopic integrity does not always indicate its functionality. A further difficulty is the anatomical variability of its course at the cervical level. The aim of our study is to assess whether the use of the IONM helps to reduce the incidence of transient and permanent paralysis of the spinal accessory nerve, compared to "de visu" identification by the surgeon alone. In our case series, the use of the IONM reduced the incidence of transient paralysis, and no permanent paralysis was recorded. In addition, if the IONM registers a reduction in nerve potential, compared to the baseline value during surgery, it could indicate the need for early rehabilitation treatment, increasing the patients' chances of regaining function and reducing the costs of prolonged physiotherapy treatment.

Carcinomatous-like mastitis due to axillary lymphadenopathy in a case of nasopharyngeal carcinoma: A case report.

Nasopharyngeal carcinoma (NPC) is a rare form of malignancy, accounting for 2% of all cancers of the head and neck in Europe. Axillary lymph node metastases are very rare in these cases. This is a case report of a 40-year-old premenopausal woman diagnosed in May 2015 with T1N2M0 stage III NPC, treated with induction chemotherapy, followed by chemo-radiotherapy. Post-therapeutic computed tomography (CT) scan showed partial response (PR) on the primary tumor and complete response (CR) on the latero-cervical lymph nodes. In 2017, our patient developed left carcinomatous-like mastitis with axillary lymphadenopathy. This raised suspicions of a carcinomatous mastitis. The pathology report with immunohistochemistry (IHC) of the third biopsy highlighted axillary metastasis of a non-keratinizing squamous cell carcinoma (NSCC). There are very few references in the literature regarding axillary metastases from squamous cell carcinoma of the head and neck (HNSCC). As far as we know, this is the first case report of mastitis due to NPC. To conclude, treatment consisted of two surgical excisions of axillary lymphadenopathy associated with local radiotherapy and chemotherapy (neo-adjuvant, adjuvant). The second surgery, performed after radiotherapy, required plastic surgery. A psychiatric evaluation was necessary, revealing a reactive anxiety disorder. This case required multidisciplinary management, where oncology, plastic surgery, pathology and psychiatric specialists collaborated in deciding the therapeutic approach.

Semen quality in non-Hodgkin lymphoma survivors: a monocentric retrospective study.

How is semen quality affected by treatment in survivors of non-Hodgkin lymphoma (NHL)? Before cancer treatment, most NHL subjects were normozoospermic and, while standard first-line treatments seemed compatible with post-treatment recovery after 18 months, salvage therapy followed by haematopoietic stem cell transplant caused permanent damage to spermatogenesis in many cases, with 66% azoospermic subjects in the long term. Testicular function has been widely investigated in relation to the most common malignancies in men of reproductive age, such as testicular cancer and Hodgkin lymphoma, but NHL has been somewhat under-investigated. The available reports generally show a post-treatment worsening of semen parameters in NHL survivors, but they involved small caseloads or a subgroup of broader caseloads, and their results are not comparable. We conducted a retrospective analysis of 222 subjects who attended our University Hospital Sperm Bank between 2002 and 2017 for sperm cryopreservation after a diagnosis of NHL. The study included 222 patients with NHL who underwent sperm cryopreservation before any antineoplastic treatment. Subjects with any comorbidity and/or other conditions interfering with sperm parameters were excluded. All patients underwent a careful medical history and physical examination at the time of sperm cryopreservation (T0) and had at least one follow-up visit at 6 (T6), 12 (T12), 18 (T18) and/or 24 months (T24) or more than 24 months (T > 24), with a median follow-up of 47.5 months (range 28-140 months). Fertility information was collected through the administration of a questionnaire. Pre-treatment, more than 80% of NHL patients were normozoospermic and in 15.9% of cases had already fathered a child. Aggressive lymphomas were associated with worse baseline semen volume and total sperm number compared to indolent subtypes (P < 0.05). Post-treatment analyses showed that standard first-line treatments alone had a more favourable outcome than intensified regimens for semen parameters, with total sperm number returning to near-baseline values at 18 months (T0: 195.0 ± 189.8 versus T18: 113.4 ± 103.1, P = 0.278), and a 7.7% prevalence of azoospermia at 2 years. In this subgroup receiving standard first-line treatments, radiotherapy of the pelvis versus other 'high' sites (mediastinum, latero-cervical and axillary lymph nodes, etc.) was associated with an increased risk of developing post-treatment azoospermia (odds ratio 4.29, 95% CI 1.81-10.14; P = 0.001). Two-thirds of subjects who had relapsed or had disease progression after first-line treatment and then underwent salvage treatment ± haematopoietic stem cell transplant became azoospermic. Fertility data were available for 176 patients: 15.9% already had at least one child prior to the NHL diagnosis and 12.5% (22 patients) desired children after treatment. Fourteen patients achieved fatherhood: 12 through natural conception and two following ART. The main limitations of the study are the lack of data on blood hormones for evaluation of testicular function as a whole and the non-compliance of several patients in attending follow-up visits at all time points, resulting in a reduced sample size for the treatment subgroup analyses. Furthermore, despite a good fertility questionnaire response rate (>80%), the low number of NHL survivors actively seeking fatherhood limits the generalization of results. The increased survival of NHL patients of reproductive age makes it essential to focus on the testicular toxicity of the treatment. Sperm cryopreservation must be suggested before any treatment. Two years after first-line treatments, sperm number showed signs of recovery: this finding is of the utmost importance for oncofertility counselling, as it indicates that only a standard first-line chemotherapy in many patients may be compatible with at least a partial spermatogenesis recovery in the long term. Nonetheless, it is expected that up to 30% of subjects will require treatment intensification, which could result in permanent testicular damage; in such cases the use of banked semen might represent the patient's best chance for future fertility. This work was supported by a grant from the Italian Ministry of Education and Research (MIUR-PRIN 2015-2015XSNA83-002) and the 'Sapienza' University of Rome, Faculty of Medicine. The authors report no conflicts of interest. N/A.

Acute cholestasis as uncommon onset of Kawasaki disease: a case report

BackgroundKawasaki disease (KD) or mucocutaneous lymph node syndrome is a vasculitis that mostly occurs in young children. Adult-onset KD (AKD) is rare and often misdiagnosed. Here we report a rare case of KD with cholestasis as principal symptom.Case presentationA 43-year-old caucasian man was admitted to our hospital for high fever, lack of appetite related to nausea and vomiting, headache and significant malaise. Physical examination highlighted fever, increasing jaundice, bilateral laterocervical lymph nodes, erythema of the palms, and strikingly red lips and conjunctiva. The clinical course was complicated by arterial hypotension, tachycardia, decreasing haemoglobin, increasing acute phase reactants tests, and multiorgan failure. Due to cardiovascular instability the patient was admitted to the local Intensive Care Unit. Chest X-ray, abdominal ultrasound, chest and abdominal CT and Colangio Magnetic Resonance were normal. Jaundice was investigated and infections, autoimmune diseases or drugs adverse reactions, were excluded. Also coronary artery computed tomography was carried out excluding coronary artery aneurysms. Broad-spectrum antibiotics were not effective. After exclusion other possible conditions, diagnosis of KD was set. He was treated with high doses of corticosteroids and acetylsalicylic acid and clinical conditions as well as laboratory exams improved.ConclusionsThis report dealing with an adult onset of atypical KD may be of benefit to physicians of various specialties, including primary care doctors, hospital internists, intensivists and gastroenterologists due to its peculiarities. It demonstrates that a case of prolonged fever unresponsive to antibiotics and related to cholestatic jaundice, oedema or erythema of the extremity associated with desquamation of feet and hands, and red eyes, may suggest atypical form of KD.

A New MEN2 Syndrome with Clinical Features of Both MEN2A and MEN2B Associated with a New RET Germline Deletion

Background Multiple endocrine neoplasia type 2 (MEN2) is a hereditary cancer syndrome caused by RET proto-oncogene mutation. Two different clinical variants of MEN2 are known (MEN2A and MEN2B): medullary thyroid carcinoma (MTC) almost always present and associated with pheochromocytoma (Pheo), and primary hyperparathyroidism (HPTH) in MEN2A and with Pheo and other nonendocrine diseases in MEN2B. Case Report. A 7-year-old girl, previously treated for a pelvic plexiform neurofibroma, arrived at our observation with a peculiar MEN2B syndrome and with HPTH. The neck ultrasound showed bilateral thyroid nodules, local lymph node lesions, and a suspicious left hyperplastic parathyroid. The CT scan showed a megacolon and described the persistence of the pelvic tumor. A new RET germline deletion in exon 11 (c.1892_1899delCGAGCT; p.Glu632_Leu633del) was found. She underwent total thyroidectomy, central compartment and latero-cervical lymph node dissection, and neck exploration for primary HPTH. The histology confirmed bilateral MTC, multiple lymph node metastases, a hyperplastic parathyroid, and a parathyroid adenoma. Conclusions This is the first case of a complex syndrome characterized by peculiar features of MEN2B, without Pheo but with a pelvic plexiform neurofibroma and with HPTH, which is typical of MEN2A. A “de novo” new germline RET deletion located in exon 11 was found.

Molecular characterisation and clinical correlation of papillary thyroid microcarcinoma.

Papillary thyroid microcarcinoma (mPTC) is defined as a papillary thyroid cancer sized 10 mm or less. Despite their generally indolent clinical course and good prognosis, a subset of mPTCs shows potentially aggressive behaviour. To search for predictors of clinical outcome of mPTCs, we retrospectively evaluated the genetic tumour profile of 100 patients (23 M/77 F, mean age ± SD 53.8 ± 13.4 years) with histologically confirmed mPTCs through analysis of BRAF, NRAS and TERT promoter mutations as well as RET/PTC translocations. Mean follow-up period was 8.4 ± 3.6 years. In 55 cases, mPTC were detected incidentally after surgery. Capsular invasion, bilateralism and multifocality were found in 11/100, 17/100 and 24/100 cases, respectively, while lymph-nodes metastases were present at diagnosis in 9/100 cases. After 3.5 ± 2.0 years, tumour relapse occurred in 6/100 cases and was locoregional in five (two in the thyroid bed, three in laterocervical lymph-nodes), while lung metastasis occurred in one case. Biochemical persistence of disease was seen in 1/100 case. Mutations occurred in 55/100 cases; BRAFV600E was the most frequently detected (49/100) and was associated with higher tumour size, bilateralism and follicular variant but not with capsular invasion. RET/PTC rearrangements were found in 2/100 cases, NRASQ61R in 4/100, while no mutations of TERT promoter gene were detected. Despite the observed association between BRAFV600E mutation and unfavourable histopathological features, we found no direct association with tumour recurrence, distant metastases and mortality. In our study, the search for the most frequent genetic alterations as prognostic markers in mPTCs would not have changed the therapeutic strategy.

MODERN DIAGNOSTIC AND MINIMALLY INVASIVE TECHNOLOGY IN THYROID SURGERY

Purpose of the study: to evaluate the role of the main instrumental methods of diagnostics and to determine the criteria for selecting patients with surgical diseases of the thyroid gland (TG) for the reasonable implementation of optimal minimally invasive surgical interventions. Materials and methods: the results of the examination and treatment of 340 patients with surgical diseases of the TG, who underwent variety of minimally invasive techniques were analyzed. Results: we compared the sensitivity, specificity, accuracy, positive and negative predictive values of the multiparametric neck ultrasonography, 99mTc-MIBI scintigraphy TG and fine-needle cytology. Minimally invasive video-assisted procedure was performed in 29,4% patients, nonendoscopic - in 38,2%, endoscopic - in 32,4%. Postoperative specific complications were revealed in 4,4% who underwent surgery: transitory recurrent laryngeal nerve palsy - in 1,5%, transient hypoparathyroidism - in 1,6%, hematoma - in 0,8%. It was stated that the main criteria that determine the rationale for minimally invasive interventions on the TG are: the nodule size and the TG volume; hyperfunctioning thyroid and clinical thyroiditis; substernal extension; extrathyroid extension and the necessity of implementation of central neck dissection due to central and laterocervical lymph node metastases. Conclusion: the application of the determined criteria based on the integrated use of modern diagnostic techniques for patients with surgical diseases of the TG can justify the selection of optimal minimally invasive surgical interventions, avoid unreasonable operations, to avoid increasing of the frequency of specific complications, reduces surgical trauma and duration of stay in hospital, improves cosmetic outcome and enhances the quality of life of the patients.

Active Surveillance in Papillary Thyroid Microcarcinomas is Feasible and Safe: Experience at a Single Italian Center.

The dramatic rise in the incidence of thyroid cancer over the last 30 years is largely attributable to the increasing diagnosis of papillary microcarcinomas (mPTCs). Current guidelines endorse an observational management approach in properly selected cases. To evaluate the feasibility of active surveillance in mPTC in Italy, its impact on real life, and to identify risk factors of progression. In 2014 we started a prospective-observational study of active surveillance in mPTC patients. Included patients demonstrated a single Thy4 or Thy5 thyroid nodule, with largest diameter ≤1.3 cm, and no suspicious laterocervical lymph nodes by neck ultrasonography. Of 185 eligible subjects, 50.3% (93/185) enrolled in the observational management protocol while the others opted for surgery and were excluded from this analysis. Enrolled patients were followed with neck ultrasound at 6- to 12-month intervals. Disease progression was defined as the appearance of abnormal lymph nodes or nodule enlargement during follow-up. In these cases, patients were directed to surgery. Three patients (3/93, 3%) showed clinical progression and required surgery. Another 19 patients (19/93, 20%) decided to transition to surgical intervention even though there was no evidence of disease progression. All operated patients had excellent response to initial treatment despite the delayed surgery. Within an Italian medical context, active surveillance appears to be a feasible and safe alternative to immediate surgery in healthy mPTC patients. Only 3% of mPTC demonstrated disease progression during a median follow-up of 19 months (range 6-54) and importantly demonstrated excellent outcomes after surgical intervention in a short-term follow-up.

Comorbidities and medical course in a young patient diagnosed with severe obstructive sleep apnea

Abstract We present the 6-year evolution of a young patient (32 years at diagnosis), smoker (10 pack years), diagnosed in September 2011 by cardiorespiratory polygraphy with severe obstructive sleep apnea syndrome (OSA)-apnea–hypopnea index (AHI) 82/h, mean SaO2 76%, which associate class II obesity (body mass index [BMI] 37.5 kg/m2), dyslipidemia, hypertension, mixed ventilatory dysfunction with hypoxemia and hypercapnia, pulmonary hypertension, and right bundle branch block. It was administered drug treatment, oxygen therapy, and continuous positive airway pressure (CPAP) with favorable evolution. One year later, we notice a significant improvement in the severity of OSA (AHI 13/h) and significant weight loss (about 24 kg). He was diagnosed with thyroid papillary carcinoma and left laterocervical node metastasis. Total thyroidectomy, treatment with radioactive iodine, and Euthirox replacement were done. In 2013, the patient presents moderate OSA (AHI 25/h) and class I obesity (BMI 31.8 kg/m2). Withdrawal of CPAP on its own initiative and weight gain (BMI 43 kg/m2) causes clinical deterioration in 2014, with diurnal drowsiness, dyspnea at rest, peripheral edema, hypoxemia, and hypercapnia, requiring admission. The cardiorespiratory polygraphic evaluation highlights severe OSA with AHI 84/h. Evolution was favorable with medication, oxygen therapy, and CPAP. Over the next 3 years, the patient continues CPAP treatment at home, but variations in body weight help improve or worsen OSA severity.

Rare breast and subcutaneous metastases from pancreatic neuroendocrine tumor: a case report

BackgroundNeuroendocrine tumors are a group of rare neoplasms, and the pancreatic neuroendocrine tumors (PNETs) represent only 1–2% of all pancreatic malignant tumors. The most common sites of these tumors include the gastrointestinal tract, lung, adrenal gland, and thyroid gland. Moreover, the most common sites of PNET metastases are the lymph nodes, liver, spleen, and bone.Case summaryA 40-year-old woman with pT3N1 PNET underwent surgical excision of the lesion (12 cm, at the level of the pancreatic body and tail). Postsurgical treatment included chemotherapy and radiation, both of which the patient showed a good tolerance for. After a 12-month disease-free interval, however, the patient reported the development of a lesion in her left breast and a small lesion in the left posterior region of her neck. The lesions were surgically excised, and the histological findings characterized both as pancreatic neuroendocrine metastatic poorly differentiated neoplasms (G3). A re-staging CT scan showed multiple metastases in the left axillary, clavicular, and latero-cervical lymph nodes, as well as diffuse osteolytic-osteoblastic bone metastases, almost mimicking the behavior of a primitive breast tumor.ConclusionThis case of breast and subcutaneous metastases from PNET should prompt awareness of potential metastatic lesions in unusual locations.

Preoperative ultrasound evaluation of laterocervical lymph nodes: timing and experience modify the treatment of patients with differentiated thyroid cancer.

Since laterocervical lymphadenectomyis never routinely performed, all patients who undergo thyroidectomy for differentiated cancer must have an ultrasound examination (US). The aim of this study is to assess the accuracy of the preoperative US conducted at the time of surgery as a staging US (time 0) compared to the US performed sometime before in a location other than the surgical department as screening/diagnostic US (time - 1), to determine the necessity of always performing a preoperative US before surgery. 4060 patients with cytologic diagnosis (FNAB) of differentiated thyroid neoplasm (Tyr 4 and Tyr 5) were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a screening US prior to admission into our hospital (time - 1) and were rescanned in the operating room before surgery (time 0) by the same team of surgeons experienced in the field of thyroid diseases. The examinations conducted at time 0 revealed a sensitivity of 100% and a specificity of 92.3%, while examinations performed at time - 1 showed a sensitivity of 22.8% and a specificity of 72.7%. The statistical analysis shows how the diagnostic timing and the experience of the examiner can make a difference both in terms of PPV and NPV to not only to assist in identifying all the lymph node lesions that would remain indeterminate if not specifically researched during surgery, but also helps avoid surgical overtreatment. The systematic execution of a staging US (time 0) in addition to a screening/diagnostic US (time - 1) results in forming a more appropriate therapeutic plan.

Less than 2% of the Low- and Intermediate-Risk Differentiated Thyroid Cancers Show Distant Metastases at Post-Ablation Whole-Body Scan

Background: Recently, there has been a trend to reduce the use of radioiodine remnant ablation (RRA) in patients with low-risk (LR) and intermediate-risk (IR) differentiated thyroid cancer (DTC). Objectives: The aim of this paper was to evaluate the diagnostic role of whole-body scan (ptWBS) performed after RRA in LR and IR DTC patients. Methods: We analyzed 545 DTC patients treated with total thyroidectomy and RRA in hypothyroidism followed by a ptWBS. Neck ultrasound (US) and serum thyroglobulin measurement were performed. According to the American Thyroid Association guidelines, patients were classified as LR (n = 345) and IR (n = 200). Results: In addition to the thyroid remnant, the ptWBS showed the presence of further areas of ¹³¹I uptake in 16/545 (2.9%) cases. ptWBS showed laterocervical lymph node metastases in 11/16 patients (10/11 were also detected by US), mediastinal uptake in 1/16, lung metastases in 3/16, and bone metastases in 1/16. Only 6/545 (1.1%) metastases were detected by ptWBS alone. After 7.8 years, 8/16 patients were free of disease, and 8 had persistent disease: 4 “biochemical” and 4 “structural.” Remission was achieved in 3 cases after one single ¹³¹I course, in 1 case after surgery, and in the last 4 cases after several ¹³¹I courses. Conclusions: The ptWBS diagnostic role was clinically relevant for the therapeutic strategies of our patients only in 1.1% of the cases. The cost-effectiveness of performing RRA and ptWBS in all LR and IR patients to find 1–2% of the cases with distant metastases remains controversial.

Unusual metastatic localization to the kidney of basaloid squamous cell carcinoma of the oropharynx

A 55-year-old man with a history of basaloid squamous cell carcinoma of the oropharynx with laterocervical lymph node metastases 6 years before (and treated with chemoradiation) presented with flank pain and hematuria. Computed tomography scan found a renal lesion, with radiological features more suspicious for primitive renal neoplasia. Histopathological and immunohistochemical examination after surgical excision revealed a basaloid squamous cell carcinoma involving renal parenchyma. Basaloid squamous cell carcinoma is a rare tumor but with a high percentage of distant metastasis, and it is mandatory, also for a general pathologist, to know this disease. Moreover, in a patient with renal metastases, any type of cancer should be taken into account, and this case is emblematic of why the previous medical history is crucial for differential diagnosis.

FDG-PET/CT Predicts Outcome in Oropharingeal Carcinoma Patients Undergoing Intensity Modulated Radiation Therapy with Dose Escalation to FDG-avid Tumour Volumes.

To evaluate the predictive value of FDG-PET/CT parameters on outcome of oropharyngeal squamocellular cancer (OSCC) patients undergoing helical tomotherapy (HTT), with dose escalation to FDG-PET/CT positive tumour volumes using the simultaneous integrated boost (SIB) technique. We analysed 41 patients studied by FDG-PET/CT and treated with radical intent between 2005 and 2014 for OSCC. HTT-SIB was delivered in 30 fractions concomitantly: 69 Gy, as SIB, to the PET-positive volume (biological target volume - BTV-PET), both to the primary tumour (T) and lymph nodes (N), 66 Gy to the T and positive N, 54 Gy to the laterocervical nodes at risk. Selected PET parameters were recovered: maximum and mean standardized uptake values (SUVmax and SUVmean, respectively), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) obtained with different thresholds (40-50-60% of the SUVmax) for T and N. The correlation between these parameters and the 3-year overall (OS), cancer specific (CSS), disease free (DFS), local relapse free for T and N (LRFS-T and LRFS-N) and distant metastasis free (DMFS) survivals was investigated. The median follow-up was 37 months (range: 3-125). The 3-year OS, CSS, DFS, LRFST, LRFS-N and DMFS were 86%, 88%, 76%, 83%, 88% and 91%, respectively. BTVT+ N>30.9cc and BTV-T>22.4cc were correlated with CSS (p=0.02) and OS (p=0.006) respectively; TLG-T-60>34.6cc was correlated with CSS (p=0.04) and OS (p=0.01). MTV-T-60>4.4cc could predict a higher risk of relapse/death (CSS: p=0.033; hazard ratio (HR) =10.92; OS: p=0.01; HR=16.4; LRFS-T: p=0.02; HR=13.90; LRFS-T+N: p=0.03; HR=6.50). PET parameters predicted survival outcomes and may be considered in the future in the implementation of more personalized treatment schedules in patients affected by OSCC undergoing radiotherapy. FDG-PET/CT dose escalated HTT-SIB allowed very promising 3-year disease control rates in OSCC patients.

Latero-cervical lymph node metastases (N1b) represent an additional risk factor for papillary thyroid cancer outcome.

Papillary thyroid carcinoma (PTC), the most common thyroid cancer histotype, has a good prognosis even when spread to the neck lymph node (LN). The prognostic role of LN metastases' location is still controversial. The aim of the present study was to evaluate the clinical relevance of the number and location of LN metastases at presentation in PTCs. This retrospective study included a consecutive series of 1653 PTC patients followed for a mean period of 5.9years in a referral thyroid cancer clinic. All patients have undergone thyroidectomy with the dissection of at least six LNs. According to the LN status, patients were subdivided into 569 N0 (34.4%), 644 N1a (39.0%, central compartment) and 440 N1b (26.6%, latero-cervical compartment). Age at diagnosis was significantly lower in N1b (39.8, IQR 30.7-51.6) and N1a (40.1, IQR 31.3-50.1) than in N0 (44.7, IQR 36.6-55.0 yrs). The male gender was more prevalent in N1b than in N1a and N0 (F/M=1.9/1, 4.0/1 and 5.5/1, respectively). Persistent/recurrent disease at last control was significantly more frequent in N1b (29.8%) than in N1a (14.3%), and in N1a than in N0 (4.2%) (p<0.01 for all). Also, distant metastases were significantly (p<0.001) more frequent in N1b (14.1%) than in N1a (4.3%) and N0 (1.6%). LN metastases' number (>5) was a significant risk factor for persistent/recurrent disease only for N1a patients. These data indicate that persistent/recurrent disease and distant metastases are significantly more frequent in patients with latero-cervical LN (N1b) metastases and that the LN location should be used for a better postsurgical risk stratification.

Primary laryngeal localization of multiple myeloma: A case report.

Multiple myeloma is a lymphoproliferative disease that may involve the bone marrow as well as extramedullary soft tissues. However, laryngeal localization of multiple myeloma is extremely rare. We herein present the case of a 68-year-old male patient with a history of dyspnea, dysphonia and dysphagia. Laryngoscopic examination revealed a lesion involving the right glottis and right vestibular (false) vocal fold, with absence of ipsilateral laryngeal motility and constriction of the airway. Computed tomography and magnetic resonance imaging revealed a gross swelling infiltrating the right glottis and right false vocal fold, sized 33×19×33 mm, with sub-centimeter laterocervical lymph nodes bilaterally. Careful integration of the clinical manifestations with the radiological and pathological data led to the diagnosis of multiple myeloma. Given the rarity of this localization, the purpose of this study was to increase knowledge of this disease among ear, nose and throat specialists, in order to enable a more timely diagnosis.

Charcoal suspension tattoo: new tool for the localization of malignant laterocervical lymph nodes.

We present a retrospective study to evaluate safety and effectiveness of ultrasound (US)-guided tattooing with charcoal of suspicious laterocervical lymph nodes. When an open biopsy of a laterocervical lymph node is needed, the choice of the lymph node to excise and examine is fundamental to avoid rebiopsy. Surgeons tend to choose the most surgical approachable enlarged lymph node that does not always correspond to the one with worst echographic aspect. We present 16 cases of patients with laterocervical adenopathy with inconclusive or non-adequate results at fine needle aspiration cytology addressed to open biopsy. Those patients underwent US-guided preoperative injection of a charcoal suspension inside the lymph node to excise to mark it, and then excisional biopsy was performed. Sixteen marked lesions (100%) were detected intraoperatively and dissected. The injected charcoal was detected intraoperatively in all cases. In 14 patients (87, 5%) it was inside the lesion; in two cases (12, 5%), the charcoal suspension was found in the tissues above the lesion. The procedure was well tolerated in all cases. No major procedure-related complications were encountered. US-guided charcoal tattooing is a new, safe, well-tolerated, and easy-to-perform technique for the marking of US suspicious laterocervical lymph nodes. This preliminary study shows a high technical success rate (76%) and high percentage of intraoperative detection of marked lesions (100%) with a low rate of complications.

Head and Neck Extranodal Interdigitating Dendritic Cell Sarcoma: Case Report and Review of the Literature.

Interdigitating dendritic cell sarcoma (IDCS) is an exceedingly rare neoplasm originating from professional antigen presenting cells normally located in the T zone of the lymph node. The purpose of this report was to describe the first case of the IDCS of the submandibular gland and perform a review of the literature of head and neck IDCS. We present a case of an 81-year-old man with a 5 months history of slowly enlarging painless mass in right submandibular region. Fine needle aspiration cytology was suggestive of squamous cell carcinoma. The patient underwent surgical resection of the right submandibular gland and neck dissection. A malignant spindle cell proliferation involving the submandibular gland and colonizing one laterocervical lymph node was found. Morphology and immunophenotype prompted a differential diagnosis of a metastatic spindle cell melanoma versus an IDCS. Transmission electron microscopy was performed and supported a diagnosis of IDCS. The diagnosis of IDCS is a challenging task and may require a large array of techniques.

Tuberculous Lymphadenitis in Southern Italy: Clinical Aspects and Treatment Perspectives

Lymph node tuberculosis (TB) represents the most common form of extrapulmonary TB that affects most often laterocervical lymph nodes. The disease, favored by states of immunosuppression, manifests itself by usually unilateral swelling, which may be associated with skin changes (hyperaemia, infiltration or fistula) and poor systemic symptoms. Our study included 75 patients arrived at the hospital “V. Monaldi” of Naples from 2008 to 2012, in order to evaluate some aspects of clinical, diagnostic and therapeutic characteristics of tuberculous lymphadenopathy. All patients were subjected to clinical, microbiological and radiological findings, surgical biopsy (alternatively, fine needle aspiration cytology, FNAC) of lymph nodes affected by pathology, antituberculosis chemotherapy for six months and subsequent followup. 49% patients were female and 51% male (mean age 44.5 years). 50.7% of patients were immunocompromised (6.7% of HIV-positive cases, 4% with type II diabetes mellitus, 16% of drug users, 6.7% treated with immunosuppressive drugs, 4% affected by malnutrition, 12% homeless). The laterocervical lymphadenopathy was unilateral in 70.7% of cases, smaller than 2 cm in 66.7%, single in 62.7%, with normal overlying skin in 72%. 9.3% of cases showed pulmonary involvement. 68% of cases excisional biopsy was performed for microbiological and histopathological examination and in 32% patients FNAC (integrated with excisional biopsy in more than half of the cases). Lymph node tuberculosis is still a problem of high clinical significance. Diagnosis requires excisional biopsy for differential diagnosis from other forms of adenopathy; treatment utilises a multi-agent chemotherapy scheme that allows a good cure rate, with few side effects. Keywords: Adenopathy, antitubercular polychemotherapy, lymph nodes, Mycobacterium tuberculosis, tuberculosis, tuberculous lymphadenitis.