Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction.

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

Feasibility of Use of the 8th Edition of the American Joint Committee on Cancer Staging for Head and Neck Cancers in Indian Scenario: An Evaluative Study.

INTRODUCTION: Inclusion of depth of invasion (DOI) and a separate classification for human papillomavirus (HPV)-associated Oropharyngeal Cancers (OPCs) are two of the many major changes in the 8th edition of the American Joint Committee on Cancer staging system. After more than 2 years of implementation, the authors found the need to evaluate if the Indian clinicians found it feasible to apply the system in their practice and if the same has influenced their decision-making. METHODS: The survey was done in the form of a questionnaire which was distributed personally and via the internet to 100 clinicians. Seventy-two clinicians responded to the questionnaire. The results were analyzed and frequency distribution was computed. RESULTS: Eighty-three percent of the clinicians experienced that palpation of the tumour was not a reliable method to determine the DOI. The common issues stated by the clinicians were difficulty in assessing DOI in certain subsites of the oral cavity (most commonly retromolar trigone-83%), inability to determine DOI in patients with trismus, and inability to correlate pathological and clinical DOI. Thirteen percent of the clinicians did not rely on radiological tools for measuring the DOI. Seventy percent of the clinicians did not perform a P16 assay for patients with oropharyngeal cancers. Fifty percent of the clinicians preferred chemoradiotherapy for early HPV positive oropharyngeal cancers. DISCUSSION: Based on the results of the survey, the authors recommend a need for more interpretative guidelines and methods for determining the DOI. The authors also emphasize the need for determining HPV status for all oropharyngeal carcinomas.

Economic evaluations comparing Tran-oral robotic surgery and radiotherapy in oropharyngeal squamous cell carcinoma: A systematic review.

BACKGROUND: Trans-oral robotic surgery (TORS) and primary radiotherapy are the two modalities used to treat early T stage oropharyngeal squamous cell carcinoma(OPSCC). Prior literature including a recent randomized controlled trial have not shown the superiority of one modality over the other. When the modalities have similar outcomes, cost-effectiveness have an important role in deciding on the appropriate treatment. There are economic evaluations comparing the two modality with contradicting conclusions. The purpose of this review is to synthesise the evidence. METHODS: This is a systematic review of economic evaluations on the treatment modalities for OPSCC, namely TORS versus radiotherapy. The main outcome measures were the Cost-utility results reported as the effectiveness and costs separately and as part of the Incremental Cost-Effectiveness Ratio. RESULTS: Literature search identified five articles reporting cost-utility analysis, eligible for the review. A strategy is considered to be dominant when the effectiveness achieved was more at a lower cost, compared to the comparator. At the willingness to pay (WTP) threshold of 50,000 to 100,000 USD per Quality Adjusted Life-Year (QALY), three studies showed dominance of strategies in the base case analysis (TORS in two and Primary Chemoradiotherapy in one). Two of the articles studied node negative patients, one of them favored TORS. Three articles had node positive patients and two of them favored TORS and one favored chemoradiotherapy in the base case analysis. On sensitivity analysis, adjuvant treatment was found to be the detrimental factor affecting the cost-effectiveness. CONCLUSIONS: TORS can be considered a cost-effective strategy in early T stage OPSCC, if the addition of adjuvant therapy involving radiotherapy can be avoided. Literature have shown that around 70% of the early cancers would require adjuvant treatment. This implies the importance of case selection while considering TORS as the initial treatment modality.

Metabolically Active Subacute Infarct Masquerading as Metastasis: A Finding not to be overlooked in Asymptomatic Oncology Patients.

A 50-year-old man with carcinoma of the right buccal mucosa underwent staging whole-body 18F-fluorodeoxyglucose positron emission tomography-computed tomography, which revealed a hypermetabolic heterogeneously enhancing lobulated primary lesion in the right buccal region and an incidental finding of subacute stroke. The case highlights the importance of discriminating brain neoplasms mimicking stroke from true ischemic stroke, which is crucial for appropriate management of patients in an oncology setting.

Selective Neck Dissection in Oral Cavity Cancer Is Not Without Morbidity.

The objective of this study is to analyze the morbidity of selective neck dissection (SND) in oral cavity squamous cell carcinoma (OCSCC). This is a cross-sectional study of 106 consecutive patients with T1 and T2 (AJCC seventh edition) stage cancers. Morbidity in terms of scar characteristics, cervical lymphedema, sensation, shoulder dysfunction, and smile asymmetry were analyzed. Scar outcomes were inferior in terms of poor complexion in 15 patients (14.2%), poor texture in 25 patients (23.6%), limited skin movement in 9 patients (8.5%), soft tissue deficit in 13 patients (12.3%), and lymphedema in 14 patients (13.2%). Smile asymmetry was seen in 29.2%. Shoulder dysfunction was seen in 7.5%. Patients who received adjuvant treatment had significant scar issues (p = 0.001), lymphedema (p < 0.001), and sensory issues (p = 0.003). SND in OCSCC is not without morbidity. Smile asymmetry was the commonest problem. Patients who got adjuvant treatment had significantly more morbidity.

Sternal metastatectomy in a case of papillary thyroid carcinoma.

Thyroid cancer is the most common among endocrine cancers. Over 90% of all thyroid malignancies are differentiated thyroid carcinomas (DTC). However, only 2%-13% of DTC present with bone metastasis. Radioactive iodine ablation (RAI) is the treatment of choice for metastatic DTC. However, RAI therapy is not as effective in bone metastasis as it is in lung and visceral metastases. Only few cases of surgical management of bone metastasis in DTC have been reported in the literature. Here, we report a case of follicular variant of papillary thyroid carcinoma with sternal and lung metastases, for which sternal metastatectomy was performed.

Tracheal Allotransplantation-Lessons Learned.

Reconstruction of long tracheal defects still proves to be a challenge. Free fasciocutaneous flaps with cartilaginous struts or an allotransplant trachea have been reported but not been widely performed. This article reports with the experience of using a tracheal allotransplant in such a defect. A 43-year-old lady presented with adenoid cystic carcinoma involving the entire trachea from subglottic area up to the carina, leading to a life-threatening airway occlusion. After preliminary stenting, allotransplant trachea obtained from a brain-dead individual was revascularized in the forearm of the patient after mechanical decellularization to reduce the immune load and fulfil the need for immunosuppression in the background of active cancer. Subsequently, the trachea and larynx were resected. The vascularized neotrachea was transferred successfully into the neck. The patient did well initially but succumbed to a fatal hemorrhage due to innominate vein aneurysmal rupture on the 22nd day after the transplant. The technical details of resection, fabrication of the neotrachea, its transfer, and the lessons learnt in this tracheal allotransplant are described.

Squamous Cell Carcinoma of the Oral Tongue in Young Patients: Outcomes and Implications for Treatment.

Squamous cell carcinoma oral tongue (SCCOT) in patients below 45 years is relatively uncommon in literature; however, there have been increasing trends in incidence. Previous studies showed conflicting data, with no conclusive evidence of differences in outcome compared with older patients. The aim of our study was to determine if younger patients with tongue cancer in India had different clinico-pathological characteristics, prognostic determinants or survival than their older counterparts. Retrospective analysis of 425 adult patients of SCCOT, with 114 patients < 45 years of age (younger group) and 311 patients ≥ 45 years of age (older group), treated with surgery and adjuvant as indicated. Clinical and pathological features were described. Survival analysis was performed using Kaplan Meier's method and multivariate analysis was performed for recurrence and survival using Cox proportional hazards ratio. Younger patients had a higher incidence of adverse pathological features (APFs) like lymphovascular invasion (p = 0.01), perineural invasion (p = 0.009), poorer differentiation (p = 0.044), nodal involvement (p = 0.021), extranodal extension (p = 0.003) and local recurrence (p = 0.008). All of these factors were noted to impact survival. However, on multivariate analysis for APFs, age was not an independent predictor of recurrence or survival. Younger patients with squamous cell carcinoma of tongue have an increased risk of APFs and local recurrence. The clinical observation that young patients have a worse outcome is likely due to the association of APFs rather than age being an independent prognostic factor. Further study is required to show if tumour biology in this cohort is distinct.

Transoral robotic narrow field oropharyngectomy for tumours of the parapharyngeal space.

The advent of transoral robotic surgery (TORS) has allowed transoral approaches for parapharyngeal space (PPS) tumours to be re-evaluated. It provides enhanced visualisation and instrument access for appropriate tumours. We describe a specific technique, TORS narrow-field oropharyngectomy, that is ideal for benign PPS tumours which have been violated by intra-oral biopsy or incision and drainage. This allows the contaminated, overlying oropharyngeal mucosa to be resected en-bloc with the PPS tumour, reducing the risk of local recurrence. This technique provides a window into the PPS, improving visualisation of underlying neurovascular structures as well as the tumour. This reduces the risk of tumour spillage and leads to superior vascular access and haemorrhage control. This technique is only applicable to PPS tumours that are appropriate for transoral approaches and is specifically designed for those selected patients that have been placed at risk of seeding or local scarring by intra-oral procedures prior to definitive resection. We present two such cases: a 38-year-old male with a PPS inflammatory cyst and a 66-year-old female with a PSS pre-styloid Schwannoma.

Lymph node staging systems in oral squamous cell carcinoma: A comparative analysis.

OBJECTIVES: The 8th edition of the AJCC has introduced a new nodal staging system for head and neck cancers. Alternate nodal staging systems exist, however they have not been compared to the current AJCC staging system. MATERIALS AND METHODS: A retrospective analysis of 643 patients with oral squamous cell carcinoma (OSCC) treated with surgery ± adjuvant therapy in a single institution between 2004 and 2014 was undertaken. Nodal staging was performed using AJCC 8th edition (AJCC8), number of positive lymph nodes (PN), log odds of positive lymph nodes (LODDS) and lymph node ratio (LNR). Survival analyses for disease free survival (DFS) and overall survival (OS) were performed with the different staging systems and they were compared on the basis of hazard consistency, hazard discrimination, explained variation and likelihood difference. RESULTS: Overall, PN and LNR best predicted OS and DFS in our cohort of patients. AJCC8 had poor discrimination between sub-stages of pN2. CONCLUSION: PN and LNR provided the most accurate prediction of OS and DFS for patients with OSCC.

Predictors of locoregional control in stage I/II oral squamous cell carcinoma classified by AJCC 8th edition.

OBJECTIVES: To study the determinants of locoregional control (LRC) on stage I/II oral squamous cell carcinoma (OSCC) classified by AJCC 8th edition. METHODS: Retrospective analysis from 296 patients of pT1-2N0 oral OSCC treated with surgery (wide local excision and selective neck dissection). Those receiving adjuvant therapy were excluded. Multivariate analysis was performed for impact of adverse pathological features (APFs) on LRC. RESULTS: In stage I, LRC was impacted by perineural invasion (PNI) (HR 7.72, p = 0.010, 95% CI 1.64-36.26) and moderate/poor differentiation (MD/PD) (HR 3.04, p = 0.049, 95% CI 0.99-9.25). In stage II, LRC was impacted by depth of invasion (DOI) (HR 1.59, p = 0.014, 95% CI 1.099-2.32), PNI (HR = 2.86, p = 0.005, 95% CI 1.36-5.98). Combined MD/PD and PNI were associated with worse LRC than either feature individually (HR = 4.12, p < 0.001, 95% CI 2.16-7.85). CONCLUSION: PNI and differentiation accurately predict LRC in AJCC 8th edition classified stage I/II OSCC. PNI was a stronger predictor of locoregional failure than DOI in stage II disease. By incorporating these parameters, we can improve precision in staging of early OSCC and identify potential candidates for treatment escalation to improve outcomes.

Robot-Assisted Surgery Avoids Mandibulotomy in a Case of Adenoid Cystic Carcinoma of Base of the Tongue.

Surgical management is increasingly preferred in human papilloma-related oropharyngeal squamous cell carcinoma. Robotic surgery has a different role to play in oropharyngeal salivary origin tumors, where surgery is the primary essential modality. This modality may be used for better access to the oropharynx, avoiding a lip split approach with mandibulotomy. The organ preservation approach such as in oropharyngeal squamous cell carcinoma, with nonsurgical modalities like chemoradiotherapy, is not preferred in such cancers, as in the present case. In this context, robot-assisted surgery helps in reducing the morbidity by avoiding the mandibulotomy.

Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia.

OBJECTIVES: The clinical variables that are predictive of aspiration pneumonia are not clear in the pediatric population. This study was conducted in order to identify the demographic, clinical, and radiological risk factors for the development of aspiration pneumonia in children referred to the dysphagia clinic. METHODS: A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS). RESULTS: Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88). CONCLUSION: Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies. LEVEL OF EVIDENCE: 3b. Laryngoscope, 129:2614-2618, 2019.

Gastro-omental free flap for reconstruction of tongue defects.

OBJECTIVES: The purpose of this paper is to report the technique and outcomes of the use of gastro-omental free flap reconstruction in glossectomy defects. MATERIALS AND METHODS: This is a prospective case series of 9 patients of tongue squamous cell carcinoma, who underwent either subtotal or partial glossectomy and reconstruction with gastro-omental free flap. The flap anatomy, surgical technique and the outcomes including the swallowing and speech are presented. RESULTS: Five patients underwent partial glossectomy and 4 had sub-total glossectomy. The median age was 43 years; and the median follow up was 11.4 months. Laparoscopic harvest was done in 8 patients. There was one flap loss. Seven patients underwent postoperative radiotherapy. Functional evaluation was done in 5 patients who were disease free. Four could tolerate soft diet orally, one patient was on liquid to pureed diet. Speech was intelligible in 4. None of the patients had any complications related to laparotomy or laparoscopy. CONCLUSION: Gastro-omental flap provided a secretory mucosal surface and was beneficial in the saliva depleted patients post radiotherapy. The laparoscopic harvest of this flap has minimized donor site morbidity. One patient had a flap loss. Two patients reported superficial ulcerations on the surface, one of them had to undergo surgical debulking to correct it while the other healed with conservative measures. Speech and swallowing outcomes of the reconstructed tongue was good, especially in patients with partial glossectomy. The reconstructed gastric mucosal flaps tolerated the adjuvant radiation well.

Adverse pathologic features in T1/2 oral squamous cell carcinoma classified by the American Joint Committee on Cancer eighth edition and implications for treatment.

BACKGROUND: The American Joint Committee on Cancer (AJCC) eighth edition has incorporated depth of invasion into TNM classification of oral cavity squamous cell carcinoma (SCC) due to the prognostic impact on recurrence and survival. After reclassifying our patients with T1 to T2 oral cavity SCC according to these recommendations, we intended to study the effect of adverse pathological features (perineural invasion [PNI], lymphovascular invasion, and differentiation) on overall survival (OS). METHODS: We conducted a retrospective analysis of 442 patients with T1 to T2 oral cavity SCC. Univariate and multivariate analysis was performed for impact of adverse pathological features on OS. RESULTS: For the newly reclassified T1 to T2 oral cavity tumors, on multivariate analysis, the prognostically relevant parameters were PNI (P = .032) and differentiation (P = .009). Increasing adverse pathological features resulted in worse survival (P = .005). CONCLUSION: Incorporation of PNI and differentiation better reflect prognostic outcome in oral cavity tumors classified as T1 to T2 as per the new AJCC eighth edition. Increasing adverse pathological features resulted in worse survival.

ACSNSQIP Risk Calculator in Indian Patients Undergoing Surgery for Head and Neck Cancers: Is It Valid?

Pre-operative assessment is vital to determine patient-specific risks and minimize them in order to optimize surgical outcomes. The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Surgical Risk Calculator is the most comprehensive surgical risk assessment tool available. We performed this study to determine the validity of ACSNSQIP calculator when used to predict surgical complications in a cohort of patients with head and neck cancer treated in an Indian tertiary care center. Retrospective data was collected for 150 patients with head and neck cancer who were operated in the Department of Head and Neck Oncology, Amrita Institute of Medical Sciences, Kochi, in the year 2016. The predicted outcome data was compared with actual documented outcome data for the variables mentioned. Brier's score was used to estimate the predictive value of the risk assessment generated. Pearson's r coefficient was utilized to validate the prediction of length of hospital stay. Brier's score for the entire calculator was 0.32 (not significant). Additionally, when the score was determined for individual parameters (surgical site infection, pneumonia, etc.), none were significant. Pearson's r value for length of stay was also not significant (p = .632). The ACSNSQIP risk assessment tool did not accurately reflect surgical outcomes in our cohort of Indian patients. Although it is the most comprehensive tool available at present, modifications that may improve accuracy are allowing for input of multiple procedure codes, risk stratifying for previous radiation or surgery, and better risk assessment for microvascular flap reconstruction.

Interdisciplinary Telemedicine in the Management of Dysphagia in Head and Neck.

The study considered the feasibility and impact of interdisciplinary telemedicine discussions in the management of post-treatment dysphagia in patients with head and neck tumors. This is a retrospective analysis of patients with persistent dysphagia after treatment for head and neck pathology, at an institute in India. The cases were discussed in the telemedicine meeting conducted between host institute and a second unit in the United States. A monthly meeting was organized, using an internet-based video conference system. The ongoing swallowing problems and management were presented, and through discussions, a plan for further management was formulated and carried out. The Functional Oral Intake Scale (FOIS) was measured before and after the implementation of the plan. Twenty-six patients were discussed, out of which, 22 were head and neck malignancies. The recommendations concurred with that of the host unit in 18, differed for three and additive in five patients. The pre-treatment mean FOIS was 1.46 with a standard deviation of 0.989 and post-treatment mean improved to 3.92 with a standard deviation of 1.809 (p < 0.0001). The present study supports the success of an interdisciplinary telemedicine meeting to manage difficult cases of dysphagia in head and neck. The outcome in terms of the FOIS score improved significantly after implementing them. In addition to the direct patient benefits, the meeting helped to facilitate interdepartmental collaboration between two units treating similar sets of patients across the globe, in specialized clinical areas like dysphagia management.

Cross-Cheek Dumbbell-Shaped Radial Forearm Flap for Simultaneous Correction of Oral Cancer and Submucous Fibrosis.

Simultaneous occurrence of oral submucous fibrosis along with carcinoma of the buccal mucosa is common. We report a novel technique of a single dumbbell-shaped, cross-cheek radial forearm free flap to repair bilateral defects caused by oral cancer resection on one side and the release of fibrosis on the other side in two patients. The dumbbell-shaped flap provided tissue for both the buccal mucosa defects and central released soft palate preventing fibrosis and reapproximation. The interincisor distance improved in both the patients.

Reconstructive Indications of Anterolateral Thigh Free Flaps in Head and Neck Reconstruction.

Anterolateral thigh (ALT) free flap is a common flap with multitude of indications. The purpose of this article is to review the reconstructive indications of the flap in head and neck defects. This is a retrospective study of 194 consecutive ALT flaps. Data including patient characteristics (age, sex, comorbidities), disease characteristics (histology, T stage), and flap characteristics (size of the flap, type of closure of ALT donor site) were collected. The outcome in terms of flap success rate, surgical, and donor site morbidity were studied. A total of 194 flaps were performed in 193 patients over a period of 10 years. Mean age of the patients was 55 years (range 16-80 years). Out of the 193 patients, 91 (47.1%) patients had oromandibular defects, 52 (26.9%) had tongue defects, 15 (7.7%) had pharyngeal defects, 17 (8.8%) had skull base defects, 4 (2%) had scalp defects, and 14 (7.2%) had contour defects of the neck. The overall flap success rate was 95.8% (8 total flap loss out of 194). Hypertrophic scar was the commonest donor site problem seen in 20 (10.3%) patients. This study shows the versatility of free ALT flap in head and neck reconstruction. It is a reliable and safe. Donor site morbidity is minimal.

Site-wise Differences in Adequacy of the Surgical resection Margins in Head and Neck Cancers.

Adequacy of surgical resection decided by the margin status is important in attaining a good local control and better survival in Head and neck Cancers. Conventionally, a measured distance between the tumor edge and the cut edge of the specimen is taken as the margin. A margin more than 5  millimeter (mm) is considered clear, less than 5 mm is close and less than one mm is denoted as involved. The concept of this adequacy varies between the different sites and subsites in head and neck. The purpose of this paper is to review the current evidence that describes the adequacy of surgical margin status and their variability among the sites and sub-sites in the head and neck.