Pathology of advanced buccal mucosa cancer involving masticator space (T4b).

BACKGROUND: Buccal mucosa cancer involving masticator space is classified as very advanced local disease (T4b). The local recurrence rate is very high due to poor understanding of the extent of tumor spread in masticator space and technically difficult surgical clearance. The objective of this study is to understand the extent of tumor spread in masticator space to form basis for appropriate surgical resection. MATERIALS AND METHODS: All consecutive patients with T4b-buccal cancer underwent compartment resection, with complete anatomical removal of involved soft-tissue structures. Specimens were systematically studied to understand the extent of invasion of various structures. The findings of clinical history, imaging and pathologic evaluation were compared and the results were evaluated. RESULTS: A total of 45 patients with advanced buccal cancer (T4b) were included in this study. The skin, mandible and lymph nodes were involved in 30, 24 and 17 cases respectively. The pterygoid muscles were involved in 34 cases (medial-pterygoid in 12 and both pterygoids in 22 cases) and masseter-muscle in 32 cases. Average distance for soft-tissue margins after compartment surgery was 2 cm and the margins were positive in 3 cases. The group with involvement of medial pterygoid muscle had safest margin with compartment surgery while it was also possible to achieve negative margins for group involving lateral pterygoid muscle and plates.The involvement of pterygomaxillary fissure was area of concern and margin was positive in 2 cases with one patient developing local recurrence with intracranial extension. At 21 months median follow-up (13-35 months), 38 patients were alive without disease while two developed local recurrence at the skull base. CONCLUSIONS: T4b buccal cancers have significant soft-tissue involvement in the masticator space. En bloc removal of all soft-tissues in masticator space is advocated to remove tumor contained within space. The compartment surgery provides an opportunity to achieve negative margins for cancers actually contained within masticator space.It is inappropriate to club all patients with masticator space involvement in one group.

Optimizing multimodality treatment for head and neck cancer in rural India.

BACKGROUND: Multimodality treatment of head and neck cancer in rural India is not always feasible due to lack of infrastructure and logistics. AIM: To demonstrate the feasibility of multimodality treatment for head and neck cancer in a community setting in rural India. SETTING AND DESIGN: Community cancer center, retrospective review. MATERIALS AND METHODS: This article focuses on practice environment in a cancer clinic in rural India. We evaluated patient profile, treatment protocols, infrastructure availability, factors impacting treatment decisions, cost estimations, completion of treatment, and major treatment-related complications for the patient population treated in our clinic for a 2-year period. RESULTS: A total of 230 head and neck cancer patients were treated with curative intent. Infrastructure support included basic operating room facility (cautery machine, suction, drill system, microscope, and anesthesia machine without ventilator support), blood bank, histopathology laboratory, and computerized tomography machine. Radiation therapy (RT) facility was available in a nearby city, about 75 km away. One hundred and fifty-four (67%) patients presented at an advanced stage, with 138 (60%) receiving multimodality treatment. One hundred and eighty-four (80%) patients underwent primary surgery and 167 (73%) received radiotherapy. Two hundred and twelve (92%) patients completed the treatment, 60 (26%) were lost to follow-up at 18-month median follow-up (range 12-26 months), with 112 patients (66%) being alive, disease free. Totally 142 were major head neck surgeries with 25 free flap reconstructions and 41 regional flaps. There were 15 (6%) major post-op complications and two perioperative mortalities. Average cost of treatment for single modality treatment was approximately 40,000 INR and for multimodality treatment was 80,000 INR. CONCLUSIONS: This study demonstrates that it is feasible to provide basic multimodality treatment to head and neck cancer patients in the community.

A retrospective evaluation of submandibular gland involvement in oral cavity cancers: a case for gland preservation.

The key factor mitigating against prognosis in head and neck cancer is nodal metastasis and its management. Neck dissection has been known to play an integral part in this type of cancer management. Submandibular gland preservation during neck dissection and post radiotherapy, have been known to improve subjective symptoms of xerostomia. The authors retrospectively surveyed the involvement of submandibular gland involvement in oral cancer with a view to confirm oncologic safety of submandibular gland preservation, as a first step in a quest to manage radiation induced xerostomia by submandibular gland transfer. The medical and pathological records of oral cancer patients who underwent surgical treatment at the authors' centre were reviewed retrospectively. 194 patients were included in the study. 229 submandibular glands were excised from the same number of neck dissections. 3 (1.3%) submandibular glands were involved with malignancies microscopically. The mode of involvement was by direct infiltration. In conclusion, no metastasis to submandibular gland was observed. This may suggest the oncologic safety of submandibular gland preservation and transfer.

Feasibility of organ-preservation strategies in head and neck cancer in developing countries.

BACKGROUND: Chemoradiotherapy is an established strategy for organ preservation in head-neck cancer. These protocols are associated with added toxicity and need support infrastructure. Practice setup and availability of resources vary at the community level in developing countries. AIM: To evaluate the feasibility of organ-preservation strategies in different settings in developing countries. SETTINGS AND DESIGN: Survey. MATERIALS AND METHODS: In a questionnaire-based study, questions were directed to clinicians with varied practice setups to gather information regarding infrastructure, finance, and feasibility of organ-preservation protocols and their current practice trends. STATISTICAL ANALYSIS: Descriptive. RESULTS: Responses from 100 clinicians with focused practice in head-neck oncology were analyzed. Sixty-one percent clinicians were practicing organ preservation for advanced head-neck cancers in their practice. However, 65% centers lacked sufficient infrastructure to support organ-preservation protocols. Forty percent patients were treated on cobalt-radiotherapy machine. Fifty-nine percent of clinicians suggested that less than third of their patients were fit to undergo chemoradiation and 67% believed that adherence to treatment protocol was observed in less than two-thirds of cases. Based on their experience 82% clinicians felt that only one-third patients requiring salvage would actually undergo treatment. The majority of the patients (68%) used personal funds for treatment and less than one-third of the patients could afford complete treatment. CONCLUSIONS: The infrastructure needed to support organ-preservation protocols varies significantly between centers in developing countries. It may not be feasible to perform organ-preservation strategies in certain centers and feasibility guidelines should be made for their judicious use in developing countries.

Head and neck cancer in India: need to formulate uniform national treatment guideline?

BACKGROUND: In a large and diverse country like India, there is a wide variation in the availability of infrastructure and expertise to treat head-neck cancer patients. Lack of consistent adherence to evidence-based management is the biggest problem. AIMS: There is an unmet need to evaluate the existing treatment practices to form the basis for development of effective and uniform treatment policies. SETTINGS AND DESIGNS: Prospective case series. MATERIALS AND METHODS: A group of previously treated, potentially curable patients presenting to our institution (from April 2009 to March 2011) were evaluated for appropriateness of initial treatment based on National Comprehensive Cancer Network or Tata Memorial Hospital guidelines. Data regarding treatment center, protocol and accuracy of delivered treatment and their eventual outcome were analyzed. STATISTICAL ANALYSIS: Descriptive. RESULTS: Amongst 450 newly registered patients, 77(17%) were previously treated with curative intent and 69(89%) of them were inappropriately treated. Seventeen (25%) patients were treated in clinics while 12(17%) in cancer centers and 34(50%) in corporate hospitals. Fourteen (20%) patients received chemotherapy, 22(32%) received radiotherapy and 14(20%) underwent surgery while 19(28%) patients received multimodality treatment. Disease stage changed to more advanced stage in 40(58%) patients and curative intent treatment could be offered only to 33(48%) patients. Amongst 56 patients available for outcome review, 18(32%) patients were alive disease-free, 20(36%) had died and 18(32%) were alive with disease. CONCLUSION: Large numbers of potentially curable patients are inappropriately treated and their outcome is significantly affected. Many initiatives have been taken in the existing National Cancer Control Program but formulation of a uniform national treatment guideline should be prioritized.

Pectoralis major flap for head and neck reconstruction in era of free flaps.

The aim of this study was to evaluate factors affecting the selection of pectoralis major flap in the era of free tissue reconstruction for post ablative head and neck defects and flap associated complications. The records of patients who underwent various reconstructive procedures between July 2009 and December 2010 were retrospectively analysed. 147 reconstructive procedures including 79 free flaps and 58 pectoralis major flaps were performed. Pectoralis major flap was selected for reconstruction in 21 patients (36%) due to resource constrains, in 12 (20%) patients for associated medical comorbidities, in 11 (19%) undergoing extended/salvage neck dissections, and in 5 patients with vessel depleted neck and free flap failure salvage surgery. None of the flaps was lost, 41% of patients had flap related complications. Most complications were self-limiting and were managed conservatively. Data from this study suggest that pectoralis major flap is a reliable option for head and neck reconstruction and has a major role even in this era of free flaps. The selection of pectoralis major flap over free flap was influenced by patient factors in most cases. Resource constraints remain a major deciding factor in a developing country setting.

Safe and simple method for secondary tracheoesophageal puncture using curved forceps.

INTRODUCTION: Secondary tracheoesophageal puncture is sometimes difficult and has a higher complication rate. In the irradiated neck, where neck extension is difficult, the traditional tracheoesophageal puncture method of insertion with a rigid endoscope is not possible. We describe a simple, safe and effective alternative method of tracheoesophageal puncture using curved forceps (Kocher's curved intestinal clamp forceps or Mixter forceps). SURGICAL TECHNIQUE: The procedure is performed under local or general anaesthesia with equal ease. Maximum neck extension is achieved. The curved intestinal forceps are passed through the mouth into the oesophageal lumen. The instrument tip can easily be seen or felt at the posterior wall of the tracheostoma. A small incision is made in the mucosa to allow the forceps tip to emerge, and a guide wire is passed through this incision out of the mouth. The prosthesis can be guided over the guide wire, in retrograde fashion, to fit the puncture hole. RESULTS: Secondary tracheoesophageal puncture was performed in five cases with severe neck fibrosis. In all cases, valve insertion was easily achieved after secondary tracheoesophageal puncture, without any peri-operative complications. CONCLUSION: This is a safe, simple and effective method for secondary tracheoesophageal puncture. It can be performed easily in any setting and is not associated with any complications.

Stomaplasty--anterior advancement flap and lateral splaying of trachea, a simple and effective technique.

BACKGROUND: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. AIM: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. SETTINGS AND DESIGN: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. MATERIALS AND METHODS: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. STATISTICAL ANALYSIS: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. RESULTS: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. CONCLUSIONS: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

Hepatoprotective and antioxidant property of Andrographis paniculata (Nees) in BHC induced liver damage in mice.

Andrographis paniculata (AP) treatment prevents BHC induced increase in the activities of enzymes y-Glutamyl transpeptidase, glutathione-S-transferase and lipid peroxidation. The activities of antioxidant enzymes like superoxide dismutase, catalase, glutathione peroxidase and the levels of glutathione were decreased following BHC effect. Administration of AP showed protective effects in the activity of superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase as well the level of glutathione. The activity of lipid peroxidase was also decreased. The result indicate antioxidant and hepatoprotective action of A. paniculata.

Video endoscopic neurosurgery (VENS) : a prospective study of 55 patients.

Neurosurgery has undergone dramatic innovations in the last few decades. It now allows the use of a microchip camera mounted on to an endoscope, introduced through a key hole in the brain. The image is projected onto a TV monitor located next to theoperating table. The minimally invasive technique is what we call Video Endoscopic Neurosurgery (VENS). Cab's universal rigid endoscope is used in all cases. VENS has a wide spectrum of diagnostic and therapeutic applications but cannot as yet replace open microscopic surgery. A prospective study of 55 patients from January, 1990 to February, 1995 is described. Hydrocephalus was a major indication, where VENS was useful for its diagnostic orientation especially when there were ambiguities on the CT/MRI.It also helped in the proper placement of the shunt, doing a III ventriculostomy and stenting of the aqueduct. VENS was utilised to diagnose, debulk and at times excise III ventricular and various other cystic lesions, visualize vascular loops in trigeminal neuralgia and hemifacial spasm. It is also useful in searching small CP angle lesions and residual tumour after intrassphenoidal excision of pituitary adenoma. Results were satisfactory in 94.5 of patients with an average follow up period of 26.4 months. Laser and CT-guided stereotactic VENS have already arrived which allows precise target localization and excellent visual control of any bleeding.