Κυριακή 21 Μαρτίου 2021

Molecular analysis of fine-needle aspiration cytology in thyroid disease: where are we?

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imagePurpose of review The prevalence of thyroid nodules in the general population is high but only about 5% are malignant lesions. Cytology is usually appropriate to rule out malignancy in sonographically suspicious nodules but in many cases, reports are indeterminate. Molecular testing is a more recent approach to rule out malignancy and guide subsequent management. Recent findings Although several different molecular testing approaches have proven useful in reducing unnecessary surgery, there are still several remaining issues, such as the possible occurrence of RAS mutations (which are difficult to interpret in clinical management) and the role of molecular analysis in specific histotypes, such as Hürthle cell carcinomas. Furthermore, conclusive evidence is lacking regarding the cost-effectiveness and appropriateness of surgical options following molecular tests. Summary To be useful in clinical practice, molecular tests should be applied to appropriate candidates. In truly uncertain thyroid nodules in which diagnostic surgery may be considered, molecular testing may change the clinical approach and 'save' a number of thyroids.
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Videomics: bringing deep learning to diagnostic endoscopy

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imagePurpose of review Machine learning (ML) algorithms have augmented human judgment in various fields of clinical medicine. However, little progress has been made in applying these tools to video-endoscopy. We reviewed the field of video-analysis (herein termed 'Videomics' for the first time) as applied to diagnostic endoscopy, assessing its preliminary findings, potential, as well as limitations, and consider future developments. Recent findings ML has been applied to diagnostic endoscopy with different aims: blind-spot detection, automatic quality control, lesion detection, classification, and characterization. The early experience in gastrointestinal endoscopy has recently been expanded to the upper aerodigestive tract, demonstrating promising results in both clinical fields. From top to bottom, multispectral imaging (such as Narrow Band Imaging) appeared to provide significant information drawn from endoscopic images. Summary Videomics is an emerging discipline that has the potential to significantly improve human detection and characterization of clinically significant lesions during endoscopy across medical and surgical disciplines. Research teams should focus on the standardization of data collection, identification of common targets, and optimal reporting. With such a collaborative stepwise approach, Videomics is likely to soon augment clinical endoscopy, significantly impacting cancer patient outcomes.
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Indications and limits of postoperative radiotherapy for skin malignancies

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imagePurpose of review To provide a summary of the current evidence, with a focus on recent publications, pertaining to indications for postoperative radiation therapy for cutaneous squamous-cell carcinoma (cSCC), basal-cell carcinoma, Merkel-cell carcinoma and melanoma of the head and neck. Recent findings Meta-analyses in cSCC and Merkel-cell carcinoma have shown an association between postoperative radiation therapy and overall survival. Prospective phase III data in head and neck cSCC has shown excellent locoregional control following surgery and postoperative radiation therapy. The addition of concurrent cytotoxic chemotherapy to postoperative radiation therapy has not improved outcomes in either of these two entities. Postoperative immune checkpoint inhibition or combined BRAF and MEK blockade in stage-III melanoma improves progression-free survival whereas postoperative radiation therapy does not. Summary Further improvement in outcomes with high-risk cSCC and Merkel-cell carcinoma might be achieved with concurrent or sequential immune checkpoint inhibition and postoperative radiation therapy. Postoperative radiation therapy for cutaneous melanoma should be reserved for patients in whom novel systemic therapies are not a treatment option.
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Immediate dental implant placement and restoration in the edentulous mandible in head and neck cancer patients: a systematic review and meta-analysis

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imagePurpose of review Oral rehabilitation with dental implants in head and neck cancer (HNC) patients is challenging. After tooth removal prior to radiotherapy, immediate placement of dental implants during panendoscopy or surgery is thought to reduce the oral rehabilitation time improving patients' quality of life. Recent findings There is lack of consensus on the timing of dental implant placement and loading protocols. The aim of this study was to perform a systematic review of the literature regarding the performance and survival rate of immediately inserted dental implants placed prior to radiotherapy. Of 1003 articles, 10 were finally included comparing immediate vs. delayed placement of implants and comparing the effect of radiotherapy on immediately placed implants. Meta-analysis demonstrated a slightly higher survival of immediately placed implants compared with postponed placed implants [risk ratio: 0.92, 95% confidence interval (95% CI): 0.48–1.78, P = 0.81, I2 = 0%]. The other meta-analysis comparing radiotherapy vs. nonradiotherapy showed a clearly better survival of immediately placed implants not having received radiotherapy (risk ratio: 5.02, 95% CI: 0.92–27.38, P = 0.10, I2  = 56%). Summary Guidelines are recommended for immediate dental implant placement in the edentulous mandible in HNC patients prior to radiotherapy to allow homogeneity regarding the treatment protocols and thus comparison of treatment outcomes.
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Nasal vestibule and columella cancer: a therapeutic and reconstructive conundrum

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imagePurpose of review Nasal vestibular cancers are rare entities among the head and neck cancers. The treatment options are varied. Although surgical treatment plays an important role, postablative defects are difficult to reconstruct. This review aims to discuss the current views in the management of these cancers and issues related to the reconstruction of the complex surgical defects. Recent findings Nasal vestibular cancers are a distinct rare entity of head and neck cancers. These cancers are staged using the AJCC-TNM system for nonmelanoma cutaneous cancers of head and neck or the Wang classification. Early lesions are best treated by either surgery or radiation giving excellent cure rates. Advanced stages tumours need combined treatment with surgery and adjuvant radiation therapy. Primary radiation therapy can be offered by external beam or interstitial brachytherapy. Surgical treatment varies from endonasal resections, Mohs' chemosurgery to open excisions. Summary Even though the Wang system of classification is used by majority of reports due its clinical utility, it has a drawback of not taking into account the tumour size as done by the AJCC system. Brachytherapy has been reported to be offering excellent cure rates with low morbidity in early tumours. Surgical treatment is also effective in early lesions, but its role is more established in advanced lesions. Reconstruction of the surgical defects is often a challenge, to preserve functional integrity and cosmesis. Various techniques, including skin grafts, local flaps, free flaps and prosthetics, form part of the reconstructive armamentarium.
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Treatment of persistent/recurrent nodal disease in nasopharyngeal cancer

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imagePurpose of review Persistent or recurrent disease in the neck lymphatics is an unusual pattern of failure in nasopharyngeal carcinoma (NPC) after definitive radiotherapy or chemoradiotherapy. The purpose of this review is to critically synthesize the current knowledge regarding salvage treatment of this unique form of failure in NPC. Recent findings Surgery in the form of radical neck dissection has been established as the standard salvage treatment with 5-year regional control of 60--86%. Recent shift in paradigm has resulted in the use of modified or selective neck dissection as salvage surgery in some centers. Risk factors for poor survival outcome include recurrent nodal disease, number of involved lymph nodes, extracapsular extension, high lymph node ratio, and positive resection margin. There are no well controlled studies on the role of additional radiotherapy or chemotherapy to improve local control or survival after salvage neck dissection in this group of patients with regional failure. Summary There is limited literature regarding the extent of surgical dissection in treating nodal persistent or recurrent disease. Prospective studies are also needed to determine whether adjuvant therapy improves treatment outcomes.
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Imaging-based navigation technologies in head and neck surgery

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imagePurpose of review Image guided navigation has had significant impact in head and neck surgery, and has been most prolific in endonasal surgeries. Although conventional image guidance involves static computed tomography (CT) images attained in the preoperative setting, the continual evolution of surgical navigation technologies is fast expanding to incorporate both real-time data and bioinformation that allows for improved precision in surgical guidance. With the rapid advances in technologies, this article allows for a timely review of the current and developing techniques in surgical navigation for head and neck surgery. Recent findings Current advances for cross-sectional-based image-guided surgery include fusion of CT with other imaging modalities (e.g., magnetic resonance imaging and positron emission tomography) as well as the uptake in intraoperative real-time 'on the table' imaging (e.g., cone-beam CT). These advances, together with the integration of virtual/augmented reality, enable potential enhancements in surgical navigation. In addition to the advances in radiological imaging, the development of optical modalities such as fluorescence and spectroscopy techniques further allows the assimilation of biological data to improve navigation particularly for head and neck surgery. Summary The steady development of radiological and optical imaging techniques shows great promise in changing the paradigm of head and neck surgery.
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Current indications for adjuvant treatment following transoral laser microsurgery of early intermediate laryngeal cancer

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imagePurpose of review This review summarizes the information in the literature on the indications for adjuvant therapy after transoral laser microsurgery (TLM) for early/intermediate stage laryngeal cancer. Recent findings A high rate of 'nonevaluable' margins after TLM significantly complicates decision-making concerning adjuvant therapy. However, consensus grows that second-look TLM in patients with multiple superficial and deep positive margins is more sensible than sending these patients systematically for adjuvant radiotherapy (RT). Summary The classical adagium: 'Failure to achieve negative margins indicates need for adjuvant RT' does not translate automatically to patients with glottic cancer treated by TLM. Rather, specifically patients with multiple superficial positive margins and positive deep margins after TLM need careful judging what constitutes the best additional adjuvant treatment. Second-look resection is nowadays regarded as the preferred adjuvant treatment for many of these patients whereas RT is reserved for those in whom a second look TLM is judged unlikely to result in 'true negative margins.' Additionally, when the pathology of the re-resection reveals multiple foci of residual disease or suggests again a resection with positive margins, adjuvant postoperative RT is likely to result in a better local control. If this strict selection of patients for adjuvant RT is adhered to carefully, oncological and functional results will be optimal.
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Therapeutic challenges in radiation-induced salivary gland cancers

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imagePurpose of review To give an overview of recent advances in therapeutic approaches of radiation-induced salivary gland cancers (ri-SGCs). Recent findings Reirradiation with protons and carbon ions demonstrated to be feasible, safe and to offer good local control rates, with the possibility of overcoming radioresistance and dosimetric issues in previously irradiated cancer patients. Chromosomal rearrangements, gene fusions and expression profiles are important to identify specific cancer subtypes and can guide tailored systemic therapy. Summary Ri-SGCs are rare and heterogeneous. Patients are often heavily pretreated and at risk of toxicities, and their management remain challenging. A multidisciplinary approach in referral centers is mandatory. Knowledge about SGCs cellular and molecular mechanisms is constantly evolving. In the last years, novel advances in therapeutic approaches, such as carbon ion radiotherapy, are emerging as safe and effective options in active treatment, but further efforts are needed to offer tailored personalized treatments and to improve survival.
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A roadmap of six different pathways to improve survival in laryngeal cancer patients

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imagePurpose of review Laryngeal cancer continues to require improvement in earlier stage diagnosis and better imaging delineation of disease, and hence 'more evidence-based' selection of treatment, as recent evidence suggests that related mortality, in the last decades, has not significantly decreased worldwide. Even though the reasons are not fully understood, there persists an urgency for a review and development of future strategies to embrace such clinical and diagnostic challenges from a political, societal, as well as scientific and clinical points of view. Recent findings This review of the published literature suggests that survival improvement in laryngeal cancer may be achieved by fuelling and combining at least some or all of six targeted agendas: documentation of disease global incidence and national burden monitoring; development and implementation of high-quality cancer registries; education on risk factors and hazardous habits associated with laryngeal cancer for the general population; active modification of proven at-risk population lifestyles; centralization of treatment; and use of machine learning of gathered 'big data' and their integration into approaches for the optimization of prevention and treatments strategies. Summary Laryngeal cancer should be tackled on several fronts, commencing with disease monitoring and prevention, up to treatment optimisation. Available modern resources offer the possibility to generate significant advances in laryngeal cancer management. However, each nation needs to develop a comprehensive approach, which is an essential prerequisite to obtain meaningful improvement on results.
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Oral potentially malignant disorders: new insights for future treatment

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imagePurpose of review The purpose of this review is to define the issues regarding oral potentially malignant disorders (OPMDs) and provide an overview of currently available treatments and ongoing clinical trials for future opportunities. Recent findings Nowadays, the treatment of choice of OPMD is surgery, whose role in preventing malignant transformation is however limited because of the high rate of recurrence and field cancerization. There have been several attempts of combining systemic therapies with surgery to reduce risk of malignant transformation. The identification of biomarkers that could predict malignant transformation is crucial in better tailoring the risk profile and possible therapeutic approaches. Summary Loss of heterozygosity remains the most predictive marker of malignant transformation; however, role of specific microRNA and OPMD immune infiltration are emerging as potential biomarkers. Given the failure of previous trials with various chemopreventive strategies, new strategies should be defined to address the issue of systemic prevention of malignant transformation. Recent updates about immune infiltration and the immune-equilibrium concept for OPMD could shed light into new preventive approaches.
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