Is routine neck dissection warranted at salvage laryngectomy?

BACKGROUND: There is controversy regarding management of the neck at salvage laryngectomy. The aim of this study was to perform an analysis to determine the incidence of occult node positivity in this group and analyse factors affecting it. METHOD: A retrospective analysis of 171 patients who underwent salvage total laryngectomy between 2000 and 2015 for recurrent or residual disease following definitive non-surgical treatment and were clinico-radiologically node negative at the time salvage laryngectomy was carried out. RESULTS: A total of 171 patients with laryngeal or hypopharyngeal cancers underwent concurrent neck dissection at laryngectomy. There were 162 patients (94.7 per cent) who underwent bilateral neck dissection, and 9 patients (5.3 per cent) who underwent ipsilateral neck dissection. The occult lateral nodal metastasis rate was 10.5 per cent. Of various factors, initial node positive disease was the only factor predicting occult metastasis on univariable and multivariable analysis (p = 0.001). CONCLUSION: Risk of occult metastasis is high in patients who have node positive disease before starting radiotherapy. This group should be offered elective neck dissection.

Taxane-based Induction Chemotherapy Plus Concurrent Chemoradiotherapy in Nasopharyngeal Carcinoma: Prospective Results from a Non-endemic Cohort.

AIMS: To report the outcomes of induction chemotherapy (ICT) followed by chemoradiotherapy (CTRT) for a large cohort of locoregionally advanced nasopharyngeal cancer (LA-NPC) from a non-endemic region. MATERIALS AND METHODS: Between January 2008 and July 2015, 201 patients with histologically proven, non-metastatic NPC were treated with ICT followed by CTRT at our institute. All the patients received two to three cycles of a taxane-based ICT regimen. Radiotherapy was delivered using an intensity-modulated radiotherapy (IMRT) technique in all patients. RESULTS: After a median follow-up of 37 months (range: 7-110 months), the 3-year disease-free survival (DFS), locoregional relapse-free survival (LRFS), distant metastasis-free survival (DMFS) and overall survival of the entire cohort was 72, 85, 83 and 87.4%, respectively. On multivariate analysis, histology was an independent predictor of DFS, LRFS and overall survival, with keratinising squamous cell carcinoma histologies predicting a worse outcome. The nodal stage was an independent predictor of DFS, DMFS and overall survival. Age, gender, ethnicity, tumour stage and response to ICT did not significantly affect any of the outcomes. Grade 2 or worse subcutaneous fibrosis was seen in 19% of patients at last follow-up and grade 2 or worse xerostomia was seen in 24% of patients. Thirty-nine per cent of patients developed clinical hypothyroidism at last follow-up. CONCLUSION: ICT followed by concurrent CTRT in the IMRT era provides excellent locoregional control, distant control and overall survival rates in patients with LA-NPC. However, distant failure continues to be a problem and may require further systemic intensification.

Invasion of the mandible in gingivobuccal complex cancers: Histopathological analysis of routes of tumour entry and correlation with preoperative assessment.

OBJECTIVES: To determine the most accurate imaging modality predicting mandibular invasion in gingivobuccal (GB) complex cancers. To determine patterns of invasion and routes of tumour entry into the mandible by detailed histopathologic analysis. MATERIAL AND METHODS: Prospective observational study of GB Complex cancers juxtaposed with the mandible clinically necessitating some form of mandibular resection. Orthopantomogram (OPG), Multi Detector Computed Tomography (MDCT), DENTA scan and Single Photon Emission Computed Tomography scan (SPECT) were performed after which the patient was subjected to surgery. Histopathological assessment was systematically performed with serial cuts of the mandibular segment. RESULTS: Of 70 patients, MDCT was the most accurate with area under curve (AUC) of 0.833. OPG, DENTA and SPECT had AUC of 0.714, 0.786 and 0.738 respectively. Mean calculated difference of involved height was -0.025 cm by MDCT (p value 0.87), -0.2 cm by OPG (p value 0.09) and 0.12 by DENTA scan (p value 0.41). Mean difference of involved length was -0.51 cm (p value 0.08) and -1.02 cm (p value 0.04) for MDCT and OPG respectively. 50% of tumour invasion was through the occlusal route while large tumours demonstrated multiple routes of entry. CONCLUSION: -Gingivobuccal complex cancers are homogenous with respect to mandibular invasion, preferred route of tumour entry being the occlusal surface. -Multidetector CT scan is fairly accurate in detecting mandibular involvement and predicting extent of involvement. -Oncological safety can be achieved by positioning the bone cuts corresponding to the adjacent soft tissue margins in segmental mandibulectomy.

Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy.

OBJECTIVE: This study aimed to assess the utility of onlay pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage total laryngectomy. METHODS: A retrospective analysis was performed of 172 patients who underwent salvage laryngectomy for recurrent carcinoma of the larynx or hypopharynx between 1999 and 2014. One hundred and ten patients underwent primary closure and 62 patients had pectoralis major myofascial flap onlay. RESULTS: The overall pharyngocutaneous fistula rate was 43 per cent, and was similar in both groups (primary closure group, 43.6 per cent; onlay flap group, 41.9 per cent; p = 0.8). Fistulae in the onlay flap group healed faster: the median and mean fistula duration were 37 and 55 days, respectively, in the primary closure group and 20 and 25 days, respectively, in the onlay flap group (p = 0.008). CONCLUSION: Use of an onlay pectoralis major myofascial flap did not decrease the pharyngocutaneous fistula rate, although fistula duration was shortened. A well-designed randomised-controlled trial is needed to establish parameters for its routine use in clinical practice.

Positron emission tomography thyroid incidentaloma: Is it different in Indian subcontinent?

BACKGROUND: Positron emission tomography (PET) forms an integral part in work-up and follow-up of various malignancies. With the increased use of PET in oncology, finding of an incidental focal thyroid uptake (incidentaloma) is not unusual and presents a diagnostic challenge. AIM: The aim of the following study is to evaluate the frequency and radio-pathologic correlation of focal 18-fluoro deoxyglucose uptake (FDG) on PET within the thyroid from a large series. MATERIALS AND METHODS: Retrospective review of 37,000 consecutive patients who underwent FDG-PET at tertiary cancer center in India. Radiological, pathological, PET scan and follow-up details were evaluated. Statistical analyzes were carried out using Mann Whitney test and Pearson correlation. RESULTS: Abnormal thyroid uptake was seen in 78 (0.2%) patients. Nearly 61 (0.16%) scans had focal and 17 (0.04%) had diffuse FDG uptake. A total of 57 patients with focal uptake were available for further evaluation. No further evaluation was done in 24 (42.1%) patients who had advanced index malignancy. Of the remaining 33 patients 26 were benign and seven were a cause for concern (four primary thyroid cancers, one follicular neoplasm with hurthle cell change and two metastatic cancers). There was no significant correlation in Standardized uptake value (SUV) max of benign and malignant lesion (P = 0.5 on Mann Whitney) or size (r = 0.087 Pearson correlation co-efficient P= 0.667). CONCLUSION: Incidence of PET incidentaloma is low in this large cohort of Indian patients. Nearly 27% of focal incidentaloma were malignant. There was no correlation between the SUVmax, size and malignancy.

Clinical significance of aberrant vimentin expression in oral premalignant lesions and carcinomas.

OBJECTIVE: To investigate the clinical significance of vimentin expression at early and late events of tobacco/areca nut-associated oral tumorigenesis. MATERIALS AND METHODS: Immunohistochemistry (IHC) was carried out on paraffin-embedded tissues of oral mucosa normal (n = 10), inflammatory lesions (n = 19), leukoplakia (n = 52), submucous fibrosis (n = 71) and tumours/cut margins (n = 227 each), using anti-vimentin antibody, and the expression profile was correlated with patients' clinical parameters. Immunofluorescence, Western blot and RT-PCR analysis were also carried out wherever adequate and fresh tissues were available. RESULTS: Aberrant vimentin expression was seen in hyperplastic, dysplastic and fibrotic tissues, which showed statistically significant correlation with the histopathological grade of dysplasia (P = 0.001) and fibrosis (P = 0.009). Vimentin expression also showed statistically significant correlation with tumour size (P = 0.048), clinical stage (P = 0.013), regional lymph node metastases (P = 0.001), local recurrence (P = 0.001) and survival (P = 0.021) of patients with oral squamous cell carcinoma (OSCC). Its expression in invasive fronts statistically correlated with development of nodal metastasis and local recurrence. CONCLUSIONS: Our results suggest possible role of vimentin in early events of tobacco/areca nut-associated oral tumorigenesis, which may prove useful to predict the malignant potential of high-risk oral lesions. Further, association between vimentin expression in invasive fronts and aggressive phenotype of tumours may help clinicians to choose the appropriate treatment modality for OSCC management.

Is there a role of induction chemotherapy followed by resection in T4b oral cavity cancers?

OBJECTIVE: The objective of the following study is to investigate the efficacy and impact of induction chemotherapy in T4b oral cavity cancers. MATERIALS AND METHODS: It's a retrospective analysis of prospectively collected data of T4b oral cavity cancer patients who were offered induction chemotherapy and then assessed for resectability at the end of 2 cycles of chemotherapy. Post-induction these patients either underwent surgical or non-surgical local intervention depending upon their response. These patients were then followed-up until either recurrence progression or death whichever was later. Statistical analysis was performed by SPSS version 16. Descriptive analysis was performed. Factors affecting achievement of resectability were sought by univariate and multivariate analysis. The impact of surgery on overall survival (OS) was studied using Kaplan Meier survival analysis with the use of log rank test. RESULTS: A total of 110 patients received chemotherapy. Median age been 41.5 years (range 25-66 years). 21 (20%) of our patient received 3 drug regimen while the rest of our patients received 2 drug regimen. Partial response was achieved in 28 patients, stable disease in 49 patients and progression was noted in 23 patients. Resectability was achieved in 34 (30.9%) of 110 patients. The estimated median OS in patients who underwent surgery was 18.0 months (95% confidence interval [CI]: 13.6-22.46 months) and for those treated with non-surgical treatment was 6.5 months (95% CI: 5.6-7.4 months) (P = 0.0001). CONCLUSION: Use of induction chemotherapy is safe and can achieve resectability in 30.9% of our T4b patients. In those patients undergoing resection have much better OS then those who underwent non-surgical local treatment.

Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: does it make a difference?

BACKGROUND: Locally advanced and unresectable oral cavity cancers have a poor prognosis. Induction might be beneficial in this setting by reducing tumor bulk and allowing definitive surgery. AIM: To analyze the impact of induction chemotherapy on locally advanced, technically unresectable oral cavity cancers. MATERIALS AND METHODS: Retrospective analysis of patients with locally advanced oral cavity cancers, who were treated with neoadjuvant chemotherapy (NACT) during the period between June 2009 and December 2010. Data from a prospectively filled database were analyzed for information on patient characteristics, chemotherapy received, toxicity, response rates, local treatment offered, patterns of failure, and overall survival. The statistical analysis was performed with SPSS version 16. RESULTS: 123 patients, with a median age of 42 years were analyzed. Buccal mucosa was the most common subsite (68.30%). Three drug regimen was utilized in 26 patients (21.10%) and the rest received two drug regimen. Resectability was achieved in 17 patients treated with 3 drug regimen (68.00%) and 36 patients receiving 2 drug regimen. Febrile neutropenia was seen in 3 patients (3.09%) receiving 2 drug regimen and in 9 patients (34.62%) receiving 3 drug regimen. The estimated median OS was not reached in patients who had clinical response and underwent surgery as opposed to 8 months in patients treated with non-surgical modality post NACT (P = 0.0001). CONCLUSION: Induction chemotherapy was effective in converting technically unresectable oral cavity cancers to operable disease in approximately 40% of patients and was associated with significantly improved overall survival in comparison to nonsurgical treatment.

Ectopic thyroid masquerading as submandibular tumour: a case report.

An ectopic thyroid gland may be present in any location along the path of migration from the foramen caecum to the mediastinum. The most common locations for an ectopic thyroid are the lingual thyroid followed by median cervical cysts. An ectopic thyroid in the submandibular region is extremely rare. We present the case of a 44-year-old patient with ectopic thyroid tissue in submandibular space and a review of the literature related to it.

Utility of PET in unknown primary with cervical metastasis: a retrospective study.

BACKGROUND: FDG-PET is recommended as an investigation in unknown primary tumors, but its definitive role and cost effectiveness are yet to be established. AIMS: dditional value of FDG-PET over conventional imaging in unknown primary tumors with cervical metastasis. SETTING AND DESIGN: Retrospective study in a tertiary level oncology centre. MATERIALS AND METHODS: A total of 112 patients were divided into three groups; 53 with conventional modalities (either computed tomography or magnetic resonance imaging) (group I), 59 with FDG-PET (group II), and group III (subgroup of group II) with both (40 patients). STATISTICAL ANALYSIS: Sensitivity and specificity of both conventional modality and PET were calculated. Association between neck nodes and distant metastasis was analysed using multivariate logistic regression analysis. RESULTS: Sensitivity and specificity for conventional modalities was 92.3% and 50% and sensitivity and specificity of FDG-PET was 92.8% and 71.4%, respectively. FDG-PET detected metastasis in 52.54% of patients. Multivariate logistic regression analysis showed statistically significant association between distant metastasis and multiplicity of nodes (N2b, N2c) (P = 0.007). Among all patients with low neck nodes in group II, FDG-PET detected primaries in 12 patients, 9 of which were infraclavicular (75%). FDG-PET added information to conventional imaging in 32.5% of patients and influenced an overall change in management in 38.9% of patients. CONCLUSIONS: FDG-PET is a valuable tool influencing change of management in unknown primary with cervical metastasis. It is recommended especially in the presence of low or multiple neck nodes in view of high incidence of infraclavicular primary and distant metastasis, respectively.

Bisphosphonate induced osteonecrosis of the jaw masquerading as tumor: a word of caution for oral surgeons and oncologists.

AIMS: To highlight the misdiagnosis or delay in the detection of Bisphosphonate induced necrosis of Jaw (BINJ). It is associated with prolonged administration of intravenous bisphosphonates that are routinely used in the management of osteoporosis, Paget's disease, Multiple Myeloma, bone metastases. It improves quality of life, delays the skeletal complication, decreases the pain and hypercalcemia. METHODS: We prospectively collected data of those patients who were receiving bisphosphonates for management of their primary illness and developed BINJ. This pathology being a new entity most oncologists are still ignorant about its existence. RESULTS: Use of intravenous bisphosphanates can lead to BINJ which may mimic malignancy or metastasis. None of our patients were counseled, oncologists did not perform routine oral examinations, dentists went ahead with unwarranted interventions, radiologist raised false alarm and oral surgeons undertook unnecessary biopsies. Misled by clinical presentation and radiological appearance, all patients were initially misdiagnosed and underwent unwarranted interventions. CONCLUSIONS: A careful dental clinical examination and appropriate imaging study is recommended before starting bisphosphonate therapy. The doctors prescribing Bisphosphonates especially intravenous preparations should not only counsel the patients but also routinely examine patient's oral cavity.

Chronic arsenic poisoning: a global health issue -- a report of multiple primary cancers.

Chronic arsenic (As) poisoning is a worldwide public health problem. Effects of prolonged exposure to high levels of As in drinking water have been observed and documented in various epidemiological studies from all over the world. The non-malignant cutaneous effects of chronic exposure to inorganic As are well known. A case presenting with multiple cutaneous cancers as well as an internal lung primary in a patient exposed to toxic levels of As in the drinking water is discussed along with a review of literature.

In vitro chemosensitivity profile of oral squamous cell cancer and its correlation with clinical response to chemotherapy.

CONTEXT: Oral cancers represent a disparate group of tumors with diverse clinical behavior and chemosensitivity profile. Currently, it is difficult to predict whether a tumor will respond to chemotherapy and which drug(s) will achieve the maximum clinical response. AIMS: To study in vitro chemosensitivity profile of oral cancers and to correlate the in vitro chemosensitivity of oral cancer to clinical response to chemotherapy. SETTINGS AND DESIGN: Prospective study in a tertiary cancer care center. METHODS AND MATERIAL: We prospectively studied the chemosensitivity profile of 57 untreated, advanced, unresectable oral cancers to cisplatin, methotrexate, 5-fluorouracil and their combinations by using histoculture drug response assay (HDRA) and correlated them to the clinical response to chemotherapy. STATISTICAL ANALYSIS USED: Chi Square test. RESULTS: Biopsy samples were successfully histocultured in 52/57 (91%) cases. Of these 52 evaluable patients, 47 had primary gingivo-buccal cancers and five had tongue / floor of mouth cancers. Based on the assay, 27 (52%) tumors were sensitive to cisplatin, 27 (52%) to methotrexate, 24 (46%) to 5-fluorouracil, 38 (73%) to combination of cisplatin and methotrexate and 36 (69%) to combination of cisplatin and 5-fluorouracil. Of these, 31 patients with good performance status received two cycles of chemotherapy using one or more of these test drugs. There was a significant correlation (p=0.03) between the in vitro chemosensitivity and the clinical response. Negative predictive value of the test was 80%, positive predictive value-69%, sensitivity-79% and specificity -71%. The overall accuracy of the assay was 74%. CONCLUSIONS: We found HDRA to be a fairly good predictor of chemo-response of oral cancer.

Validation of the University of Washington quality of life questionnaires for head and neck cancer patients in India.

UNLABELLED: Quality of life (QOL) is a multidimensional construct capturing the subjective wellbeing of patients in physical, emotional, functional and social domains. Available work on post treatment QOL have only been made in western literature and less in Indian literature. AIMS: To translate the UW-QOL into both Hindi and Marathi and psychometrically validate the translation in HandN cancer patients in Indian population. SETTINGS AND DESIGN: A prospective study was done at the Tata Memorial Hospital for patients who were treated for H and N cancers. MATERIALS AND METHODS: 147 patients were enrolled from January to April 2005. The study was carried out in two phases. Patients were given translated versions of the UW-QOL and EORTC QOL questionnaires pre-operatively, 15 days post-operatively and then three months post-operatively. RESULTS: Both the Hindi and Marathi translations had strong internal consistency (Cronbach's alpha=0.7971 and 0.7839). UW-QOL composite scores correlated well with the global questions on overall QOL in both the Hindi (r=0.69) and Marathi (r=0.66) translations and also with T-stage. QOL scores were worse three months post-operatively than pre-operatively and for patients undergoing surgery that violated the mucosa. A strong correlations was observed (r>0.50) between all similar domains on the UW-QOL and EORTC HandN35 except the saliva item on the Marathi translation, where r< 0.50, but P-values were significant. CONCLUSIONS: The Marathi and Hindi versions of the UW-QOL appear to be valid and reliable instruments for assessing the QOL in Indian population and will be a vital tool for achieving greater insight into the short- and the long term QOL.

A technique to identify and preserve the spinal accessory nerve during neck dissection.

INTRODUCTION: Preservation of the spinal accessory nerve during neck dissection should be the rule rather than the exception. Despite the presence of many described techniques to locate the nerve, a tedious dissection is often required; as a consequence, it remains vulnerable to damage. METHOD: We describe a novel method, not previously reported, based on identifying a constant vein which crosses the nerve. This aids in the nerve's early identification. CONCLUSION: Our method enables the surgeon to locate the nerve precisely and to avoid damage to it, thereby maximizing post-operative function.

Split therapy: planned neck dissection followed by definitive radiotherapy for a T1, T2 pharyngolaryngeal primary cancer with operable N2, N3 nodal metastases--a prospective study.

BACKGROUND: The management of patients with a small pharyngolaryngeal cancer (T1 and T2) with large nodal metastases is a subject of debate. We present data on the feasibility and outcome of treating these patients with surgery for the nodal metastases followed by definitive radiotherapy. METHODS: Prospective study of 59 patients of small pharyngolaryngeal primary squamous carcinomas with operable (N2/N3) nodal metastasis treated with neck dissection followed by radiotherapy. RESULTS: Complete nodal clearance was achieved in 54 (90%). The mean nodal size was 4 cm and extranodal extension was seen in 88% of patients in the study group. There were no significant postoperative complications. Median interval between surgery and radiotherapy was 23 days. Forty-nine patients (83%) started their RT within 6 weeks of surgery. With a median follow-up of 25 months, the disease free and overall survival was 54% and 60% (5 years). CONCLUSION: The management of patients with a radiocurable pharyngolaryngeal primary with large nodes by this approach is a feasible option with adequate control and survival.

Differentiated thyroid cancer invading the hypopharynx: A case report.

Most thyroid cancers (90-95%) are well differentiated. Well differentiated cancers of the thyroid are usually confined to the thyroid capsule, making them amenable to isolated thyroid resection. Invasion of the upper aerodigestive tract by these cancers is infrequent and hypopharyngeal invasion is still rare. We report a 51 year old man with thyroid cancer invading the hypopharynx, who was successfully managed with complete resection along with a partial pharyngectomy. He is asymptomatic and disease free eighteen months after surgery. We advocate aggressive surgical extirpation of thyroid carcinoma invading the upper aerodigestive tract.

Simultaneous reconstruction of large skin and mucosal defect following head and neck surgery with a single skin paddle pectoralis major myocutaneous flap.

The pectoralis major myocutaneous (PMMC) flap is commonly used for head and neck reconstruction especially in impoverished nations. PMMC is a sturdy pedicled flap with relatively fewer complications, the learning curve is short and no specialized training in microvascular surgery is needed in order to use this flap. In a defect that requires a large skin and mucosal lining the authors routinely use either a bi-paddle PMMC or a combination of PMMC (for the mucosal lining) and a delto-pectoral flap (for the skin defect). It is indisputable that free tissue transfer is a better way of reconstruction for the majority of most such defects. Unfortunately, not all patients can be offered this form of reconstruction due to the cost, time, expertise and infrastructural constraints in high volume centres such as ours. Bi-paddling of PMMC is hazardous in obese males and most female patients. In such patients the skin defect is reconstructed usually by the delto-pectoral (DP) flap but this, for obvious reasons, is less welcomed by the patients. The authors suggest a technique wherein mucosal lining is created by the myofascial lining (inner surface) of the flap and the skin defect is reconstructed by the skin paddle of the single paddle PMMC. It should be considered wherever a DP flap is unacceptable, or bi-paddling or free tissue transfer is not possible.