Evaluation and validation of Physiological and Operative Severity Score for the enumeration of mortality and morbidity and Portsmouth-POSSUM scores in predicting morbidity and mortality in patients undergoing head and neck cancer surgeries.

BACKGROUND: Identification of risk factors for perioperative complications helps in the prognostication. We wanted to determine whether Physiological and Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) can be used in patients undergoing head and neck oncosurgery. METHODS: We conducted a retrospective analysis of 1265 patients after they had major head and neck oncosurgeries. Demographic, surgical and outcome data was collected. We separately analyzed data for patients who had undergone cancer surgery for oral cavity, pharynx, and larynx. We calculated the POSSUM and P-POSSUM scores. RESULTS: POSSUM scoring system had moderate discrimination (AUC = 0.61) and good calibration (P = .36) for the entire study cohort and in the subgroup. Since there were no deaths in the entire cohort, we were not able to check predictive ability of the scores, for mortality. CONCLUSIONS: We found that POSSUM had moderate discrimination and good calibration for morbidity prediction in head and neck cancer surgeries, as well as for the selected subgroup.

Total laryngectomy: Surgical morbidity and outcomes - A case series.

BACKGROUND: Total laryngectomy (TL) is a well-established procedure for laryngeal and hypopharyngeal cancers. There is an increasing number of TLs done after organ preservation strategies. AIM: The aim of this study was to report 30-day morbidity and survival outcomes in patients undergoing TL at a tertiary referral center. SETTING AND DESIGN: This was a retrospective review of a prospective database of TL patients operated during 2012-2013. MATERIALS AND METHODS: Patient demographics and other data were captured from the database. Surgical complications were graded as per Clavien-Dindo grading system and were also divided into major and minor as per predecided criteria. Recurrence and survival data were computed using Kaplan-Meier survival curves. RESULTS: A total of 169 patients underwent TL during the study period. About 34% of the patients had received prior radiation therapy. Around 18% of the patients had major complications with a pharyngocutaneous fistula rate of 22.4%. Ninety percent of these were managed conservatively. Though used in a small subset, microvascular reconstruction had the least complication rates. The 3-year disease-free survival and overall survival were 66% and 72%, respectively. There was no difference in survival between per primum and salvage surgery cohorts. CONCLUSION: TL is a safe and oncologically sound procedure in patients with laryngeal and hypopharyngeal cancers. A large proportion of patients still undergo TL as a de novo procedure. This denotes that patients still present with locally advanced cancers which are not amenable to organ preservation.

Prospective study of 583 neck dissections in oral cancers: implications for clinical practice.

BACKGROUND: Determining the level of nodal metastases may help decrease the extent of neck dissections and reduce morbidity. METHODS: A prospective study of neck dissections in patients with oral cancer was conducted. Each nodal level was delineated, sent for histopathology, and reported level-wise. Incidence of overall and isolated metastatic nodes at different levels was calculated. Logistic regression was used to find factors predicting metastases to levels IIB and V. RESULTS: Five hundred eighty-three neck dissections were prospectively evaluated. A total of 95.7% metastases occurred at levels I to IV. Overall incidence of metastases to levels IIB and V was 3.8% and 3.3%, respectively. Multivariate analysis revealed IIA positivity as an independent predictive factor for metastases to both IIB and V. CONCLUSION: This study of lymph node mapping in patients with oral cancer showed a predictable pattern of lymph node metastasis according to primary site. Selective neck dissection (levels I-IV) in patients with oral cancers may be adequate. Determining status of level IIA is important to guide dissection of levels IIB and V.

Minor salivary gland tumors of the sinonasal region: results of a retrospective analysis with review of literature.

BACKGROUND: Minor salivary gland tumors of the sinonasal region are rare. Minor salivary gland tumors of this region behave differently from other subsites in the head and neck. The objective of our study was to analyze the survival and prognostic factors in patients with minor salivary gland tumors of the sinonasal region. METHODS: We carried out a retrospective review of patients with minor salivary gland tumors of the sinonasal region. All slides were reviewed by an independent pathologist. Survival was analyzed using the Kaplan-Meier method and Cox multivariate regression to identify prognostic factors. RESULTS: In all, 163 patients were identified from our registry. The 5-year disease-free and overall survival rates were 48.3% and 83.3%, respectively. Tumor grade, nodal status, and adjuvant radiotherapy were significant predictors of disease-free survival (DFS), on multivariate analysis. CONCLUSIONS: Minor salivary gland tumors have a good overall survival in spite of high recurrence rates. Tumor grade, nodal status, and adjuvant radiotherapy are independent predictors of DFS.

Elective neck dissection for the management of the N0 neck in early cancer of the oral tongue: need for a randomized controlled trial.

BACKGROUND: The aim of this study is to determine the need for a randomized controlled trial in order to define the role of an elective neck dissection (END) in the treatment of early tongue cancers. METHODS: We present a large retrospective analysis of patients with T1-2 N0 squamous cell cancers of the oral anterior tongue treated at a single institution. A total of 359 eligible patients with early tongue cancers were divided into 2 groups: END and wait and watch (WW). An analysis for survival outcomes and prognostic factors was conducted. RESULTS: The estimated 3- and 5-year disease-free survival for the END group was 76% and 74% versus 71% and 68% for the WW group, respectively (p = .53). The 3- and 5-year overall survival (OS) rate for the END group was 69% and 60% versus 62% and 60% for the WW group, respectively (p = .24). Tumor grade and perineural invasion were independent predictors of recurrence. CONCLUSION: END did not impact disease-free or OS. Current literature still remains divided on this issue emphasizing the need for a randomized controlled trial.

Urinary bladder metastasis--an unusual presentation of distant spread from a primary pyriform sinus cancer: a case report.

Hypopharyngeal cancers have a high propensity to distant metastasis. However, metastasis to the urinary bladder as an initial presentation of distant spread has not been reported in literature. We present a report of a patient with a treated and controlled pyriform sinus cancer who presented with complaints of dysuria, 8 months after completion of treatment. Cystoscopy revealed a bladder mass and biopsy confirmed it to be a metastatic squamous cell carcinoma. On further investigation, the patient was found to have disseminated disease for which chemotherapy was instituted. A relevant review of literature is also presented.

Thoracic duct cyst of the mediastinum.

Thoracic duct cysts of the mediastinum are extremely rare. The etiology may be related to a congenital or degenerative weakness in the wall of the thoracic duct. They are generally asymptomatic but may sometimes cause pressure effects on adjacent structures. Imaging studies are supportive but not diagnostic. Excision of these cysts is required for diagnosis and to prevent complications. We describe a 49-year old man who presented to us with hoarseness and a fixed right vocal cord. Computed tomography (CT) showed a cystic posterior mediastinal mass in the right paratracheal region. We performed a posterolateral thoracotomy and found the cyst arising from the thoracic duct and contained chylous fluid with a high lipid concentration. We dissected the cyst from the surrounding structures and excised it. Histopathology revealed a cyst lined by a single layer of endothelial cells. He is asymptomatic now one year after surgery.

Benign metastasizing meningioma.

Meningiomas represent about one sixth of all primary neoplasms of the central nervous system. They rarely metastasize outside the intracranial compartment. There are no clear criteria to identify the subset of aggressive tumors which recur locally or metastasize. Histological tumor grade is the most important predictor of recurrence or metastases. We report an unusual case of recurrent metastasis in an extrapleural location and review the literature. Our patient developed recurrent thoracic metastases from an intracranial benign meningioma after a disease-free interval of 8 years. She was successfully managed by wide excision of the metastasis and is currently asymptomatic.

Small cell carcinoma of the esophagus: the Tata Memorial Hospital experience.

BACKGROUND: Small cell carcinoma of the esophagus is a rare disease, characterized by aggressive progression. It has a high incidence of metastatic disease at presentation and a poor overall prognosis. Treatment protocols are not well established because of the paucity of cases and a lack of large studies. METHODS: We performed a retrospective review of all patients with small cell carcinoma of the esophagus diagnosed at the Tata Memorial Hospital between 1985 and 2001. We retrieved and analyzed data regarding demographic details, diagnosis, staging, type of treatment, and overall survival. RESULTS: Eighteen patients with a mean age of 62 years (range 48 to 80 years) diagnosed as having small cell carcinoma of the esophagus were analyzed. The group included 13 men and 5 women. Seven of the 18 patients (39%) presented with metastatic disease including 5 patients (28%) with liver metastases. Four patients were treated with surgery, with or without chemotherapy or radiotherapy. Three patients were treated with combination chemoradiotherapy, 2 patients with chemotherapy alone, and 5 patients with radiotherapy alone. Four patients with advanced disease and poor general condition were not offered any treatment. The overall median survival of our patients was 6 months. Patients treated with surgery and chemotherapy had a better overall survival. CONCLUSIONS: Small cell carcinoma of the esophagus should be regarded as a systemic disease with a high distant failure rate. Treatment strategies hence must incorporate systemic chemotherapy along with radical surgery or radiotherapy as part of a multimodality approach.