Long-term results of robotic-assisted nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: We have previously reported our early experience in robotic-assisted nasopharyngectomy. The current case series is a report of our experience in 33 robotic-assisted nasopharyngectomy. METHODS: Prospective series of patients who underwent robotic-assisted nasopharyngectomy for local recurrent nasopharyngeal carcinoma from January 2010 to March 2019. RESULTS: Thirty-one patients underwent robotic-assisted nasopharyngectomy with two additional second procedure for positive margin. Median age is 55 years (29-85). Twenty-five patients had rT1 disease and six patients had tumor invaded sphenoid floor (rT3). Median operative time was 227 min and median blood loss was 200 ml. The median follow-up period for all patients were 38 months. Four patients had local recurrence. Five-year local control rate, overall survival, and disease-free survival are 85.1%, 55.7%, and 69.1%, respectively. CONCLUSION: Robotic-assisted nasopharyngectomy for recurrent nasopharyngectomy was showed to have a high local control rate. The operating time was comparable to open surgery.

Transcervical Transtracheal Resection of Cervical Esophageal Smooth Muscle Tumor.

Cervical esophageal smooth muscle tumors are traditionally resected via lateral transcervical with or without video-assisted thoracoscopic approaches. Exposure is frequently limited, however, with risks of recurrent laryngeal nerve and posterior tracheal wall injury and jeopardization of cervical tracheal and cervical esophageal blood supply. We herein describe an anterior transcervical transtracheal approach to counter some of the aforementioned problems and avoid morbidities associated with thoracoscopic surgery when resecting smooth muscle tumors arising from the cervical esophagus.

Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity.

Multiple anterior surgical approaches are available to obtain access to the nasopharynx, clivus, and craniocervical junction. These include the direct and transoral robotic surgery transpalatal, maxillary swing, and endoscopic endonasal approaches. In this article, we describe the indications for these techniques, surgical steps, and associated morbidities. This article is a PubMed literature review. A review of the literature was conducted to assess the techniques, surgical steps, and associated morbidities with transpalatal approaches to the skull base and nasopharynx. The transpalatal approach has been traditionally utilized to obtain surgical access to the nasopharynx, clivus, and craniocervical junction. Morbidity includes velopalatine insufficiency due to shortening of the soft palate from scar contraction or neuromuscular damage, thus leading to hypernasal speech and dysphagia. Middle ear effusion and oronasal or oronasopharyngeal palatal fistula are additional potential morbidities. The choice of surgical approach depends on a variety of factors including the disease location and extent, surgeon experience, and available resources.

Swallowing disorders following free jejunal flap reconstruction of circumferential pharyngeal defect: Does Botox help?

OBJECTIVES: Free jejunal flap for circumferential pharyngeal reconstruction is associated with late-onset dysphagia, regurgitation and prolonged transit time. This study aims to assess the feasibility and efficacy of Botulinum toxin A (Botox) in alleviating such swallowing dysfunction. MATERIALS AND METHODS: Twenty-six consecutive patients underwent free jejunal flap for circumferential pharyngeal reconstruction between January 2012 and December 2018. Outcomes were compared at 6, 12 and 24 months. RESULTS: In the non-Botox group (n = 13), video-fluoroscopic and manometry studies demonstrated asynchronous contractions and retrograde propulsion. All patients complained of nasal regurgitation on thin fluids at 6, 12 and 24 months. Bolus residue accumulation along jejunal mucosal folds resulted in prolonged transit time. In the Botox group (n = 13), amplitude of asynchronous contractions were lower: 25.4 mmHg vs. 52.1 mmHg (p = 0.037) for thin fluids at 12 months. Three patients complained of nasal regurgitation on thin fluids at 6 months. All 3 were asymptomatic at 12 months. Transit time was shortened overall. Functional Oral Intake Scale was higher. MD Anderson Dysphagia Inventory global (72.5% vs 45.7%, p = 0.003) and functional (62.0% vs 40.6%, p = 0.012) subscales were significantly improved at 24 months. CONCLUSION: Botox safely and effectively alleviates swallowing dysfunction associated with free jejunal flap for circumferential pharyngeal reconstruction.

Management of locally recurrent nasopharyngeal carcinoma.

As a consequence of the current excellent loco-regional control rates attained using the generally accepted treatment paradigms involving intensity-modulated radiotherapy for nasopharyngeal carcinoma (NPC), only 10-20% of patients will suffer from local and/or nodal recurrence after primary treatment. Early detection of recurrence is important as localized recurrent disease is still potentially salvageable, but this treatment often incurs a high risk of major toxicities. Due to the possibility of radio-resistance of tumors which persist or recur despite adequate prior irradiation and the limited tolerance of adjacent normal tissues to sustain further additional treatment, the management of local failures remains one of the greatest challenges in this disease. Both surgical approaches for radical resection and specialized re-irradiation modalities have been explored. Unfortunately, available data are based on retrospective studies, and the majority of them are based on a small number of patients or relatively short follow-up. In this article, we will review the different salvage treatment options and associated prognostic factors for each of them. We will also propose a treatment algorithm based on the latest available evidence and discuss the future directions of treatment for locally recurrent NPC.

Esophagogastric Preservation in the Surgical Management of Proximal Esophageal Cancer.

BACKGROUND: Definitive chemoradiotherapy is offered for most patients with isolated cervical esophageal tumor. Surgery is reserved for locally advanced diseases and salvage for failed chemoradiotherapy. Traditionally, surgery comprises total pharyngolaryngeal esophagectomy and gastric pull-up, which is associated with high morbidity and mortality rates. We hereby propose pharyngo-laryngo-cervico-esophagectomy by a transcervical approach, allowing preservation of the esophagus and stomach below, reducing operative morbidity and mortality. METHODS: A retrospective review of 31 patients who underwent curative pharyngo-laryngo-cervico-esophagectomy for isolated cervical esophageal tumor at the Department of Surgery, The University of Hong Kong, Queen Mary Hospital, between January 1, 2005, and June 30, 2018, was performed. RESULTS: There were 26 male and 5 female patients. Median age was 64.8 years. Seventeen patients underwent definitive surgery. Fourteen patients underwent salvage surgery for failed chemoradiotherapy. Most patients presented with stage III and IV diseases (90.3%). Median length of pharyngoesophageal defect was 14.0 cm (range, 8.0-21.0 cm). Free jejunal flap was used for pharyngoesophageal reconstruction in 77.4%. Eight complications developed in 7 patients (22.6%). There was no in-hospital mortality. Clear radial and longitudinal resection margins were achieved in 96.8%. Median follow-up was 21.5 months. Locoregional recurrence rate was 32.3%. Nine patients died of disease progression (29.0%). Seven died of other causes (22.6%). Median survival was 21.5 months. Overall 2-year survival rate was 36.7%. CONCLUSIONS: Transcervical pharyngo-laryngo-cervico-esophagectomy should be considered in patients with isolated cervical esophageal tumors. Pharyngo-laryngo-cervico-esophagectomy allows adequate tumor resection while preserving the esophagus and stomach below. Operative morbidity and mortality outcomes were improved without compromising oncologic control.

Head and neck cancer in Hong Kong.

Head and neck cancer is a major cause of morbidity and mortality in Hong Kong. HNC is well-known for its heterogeneity in epidemiology, clinical behavior, clinic-pathological features and patient characteristics. Treatment strategies for this heterogeneous disease vary greatly in different parts of the world, depending on availability of resources, local expertise and experience. Extensive research in head and neck cancer, particularly nasopharyngeal carcinoma, has been conducted in Hong Kong in the past few decades. In this article, we will review the available local evidence and summarize common practice in management of head and neck cancer in Hong Kong.

Prevalence, Clinicopathological Characteristics, and Outcome of Human Papillomavirus-Associated Oropharyngeal Cancer in Southern Chinese Patients.

BACKGROUND: Although the global incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is increasing, there is little information on southern Chinese population available. METHODS: We analyzed 207 patients which constituted 63.5% of all newly diagnosed OPSCC in Hong Kong during a 5-year period from 2005 to 2009. RESULTS: We used E6/7 mRNA as a marker of oncogenic involvement and found 20.8% (43/207) of OPSCC and 29.0% (36/124) of tonsillar SCC was associated with HPV. HPV-16 was identified in all cases except one (HPV-18). Patients with HPV-associated OPSCCs were significantly younger than HPV-negative patients (mean age: 59.8 vs. 63.9 years, P = 0.05). Multivariate analysis showed that HPV-associated OPSCC was more likely to occur in nonsmokers (39.5% vs. 15.1%, OR: 2.89, P = 0.05), nondrinkers (52.5% vs. 25.6%, OR: 2.72, P = 0.04), originate from the palatine tonsils (83.7% vs. 53.7%, OR: 3.88, P = 0.01), present with an early primary tumor (T1/2; 79.1% vs. 47.6%, OR: 3.81, P = 0.004), and exhibit basaloid differentiation (33.3% vs. 7.3%, OR: 19.74, P = 0.006). HPV positivity was an independent predictor for better prognosis for both 5-year overall and 5-year disease-specific survivals (DSS; 63.0% vs. 29.7%, HR: 0.33, P < 0.001, and 87.8% vs. 42.6%, HR: 0.16, P < 0.001, respectively). CONCLUSION: The estimated age-standardized incidence of OPSCC in Hong Kong during the period 2005-2009 was 0.12/100,000/year. IMPACT: This study has provided the most comprehensive clinical and pathologic information to date about this newly recognized disease in southern Chinese. In view of the global trend, we should anticipate and prepare for an increase in HPV-related OPSCC in southern China.

Early results of robotic assisted nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: Minimally invasive nasopharyngectomy with the da Vinci surgical robot has been shown to be a feasible operation for salvage of recurrent nasopharyngeal carcinoma. The current case series presents the early results of robotic nasopharyngectomy. METHODS: We conducted a prospective series of patients who underwent robotic nasopharyngectomy for recurrent nasopharyngeal carcinoma in a single institution. RESULTS: Twelve patients underwent robotic nasopharyngectomy. The median operating time was 225 minutes. Median follow-up time was 23.8 months. Nine patients had clear resection margins, 2 patients had close margins, and 1 patient had positive margin. Two patients developed local recurrence and 1 patient had distant metastasis. Two patients in the cohort died of unrelated causes. The 2-year local control rate was 86%. The 2-year overall survival and disease-free survival was 83% and 61%, respectively. CONCLUSION: Early results of robotic nasopharyngectomy showed a high local control rate. The operating time was comparable to open surgery and morbidities were low.

Salvage surgery for recurrent carcinoma of the cervical esophagus postesophagectomy.

BACKGROUND: Management of cervical esophageal tumor postesophagectomy is mainly palliative because of inadequate exposure of tumor in the cervicothoracic region. In this study, we propose a means of cure for these patients. METHODS: Between January 2003 and June 2013, 6 patients underwent curative pharyngolaryngectomy and completion cervical esophagectomy via manubrial resection. Operative outcomes were analyzed and compared with a historical cohort who received palliative therapy. RESULTS: One patient required prolonged hospital stay for pneumonia, resulting in a median hospital stay of 30 days (range, 21-55 days). All patients resumed oral feeding at a mean of 15.2 days (range, 14-19 days). Tracheostoma stenosis was noted in 2 patients. One patient developed nodal recurrence, another with distant metastasis, resulting in a median disease-free survival of 13 months (range, 4-20 months). Median overall survival was significantly longer than the cohort group (19.0 vs 3.0 months; p = .013). CONCLUSION: Salvage surgery in patients with carcinoma of the cervical esophagus postesophagectomy is feasible with significantly prolonged survival.

Whole-organ histopathological study of recurrent nasopharyngeal carcinoma.

OBJECTIVES/HYPOTHESIS: To study the histopathological features of recurrent nasopharyngeal carcinoma and the accuracy of preoperative magnetic resonance imaging (MRI). STUDY DESIGN: Prospective. METHODS: Whole-organ study of nasopharyngectomy specimens. RESULTS: Between 2006 and 2009, 50 specimens were obtained after maxillary swing nasopharyngectomy and sent for whole-organ study. The tumors arose from the fossa of Rosenmüller (68%), posterior wall (18%), or roof of the nasopharynx (14%), and the majority (72%) took the form of an ulcerative tumor. The T-classifications of the recurrent tumors were: T1, 24%; T2, 48%; and T3, 28%. All the tumors appeared as islands of cancer cells separated by lymphoplasmacytic infiltrate and fibrosis. The tumor size measured by MRI correlated closely with that measured histologically, especially for the depth of invasion and parapharyngeal extension. For tumors with parapharyngeal extension, removal of the pharyngobasilar fascia was essential to ensure a clear margin on the surface of the petrosal internal carotid artery. None of the tumors showed invasion of the Eustachian tube. CONCLUSIONS: Contrast MRI is accurate in assessing the local extent of recurrent nasopharyngeal carcinoma. During nasopharyngectomy, a radial resection margin of 15 mm should be taken with the underlying medial pterygoid muscle. For tumors with parapharyngeal extension, the pharyngobasilar fascia should be resected en bloc with the specimen. LEVEL OF EVIDENCE: N/A.

Accuracy of intraoperative frozen section analysis of nasopharyngeal carcinoma resection margins.

BACKGROUND: Frozen section analysis (FSA) is frequently used in salvage surgery for recurrent or residual nasopharyngeal carcinoma (rNPC) after radiotherapy to ensure adequate tumor removal. However, the diagnostic accuracy of FSA in rNPC has never been clearly established. We believe that this is the first study to specifically address these issues. METHODS: Patients with rNPC who underwent nasopharyngectomy in Queen Mary Hospital from 2006 to 2011 were identified. Clinical data, FSA results, and permanent histological results were analyzed. RESULTS: In the tissue-based analysis, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 70.6%, 100%, 100%, 95.2%, and 95.7%, respectively. Only 37% of inconclusive FSA turned out negative on permanent histology. Presence of inconclusive (p = .000) or positive (p = .000) FSA results in the same operation significantly lowered the NPV of FSA. CONCLUSION: FSA is useful in ensuring clear resection margins for rNPC. Further resection is advisable in cases of inconclusive FSA results.

Practice of laryngectomy rehabilitation interventions: a perspective from Hong Kong.

PURPOSE OF REVIEW: To review the current practice of rehabilitation for laryngectomees in Hong Kong. RECENT FINDINGS: Factors affecting the quality of life of laryngectomees include their performance in speech restoration, the presence of complications of treatment, as well as the availability of psycho-social support. In Hong Kong, more than 90% of laryngectomees have speech restoration by various means, the commonest of which being tracheo-oesophageal puncture and electrolaryngeal speech. However, they face special problems in communication using the current alaryngeal speech modalities, as it is difficult to produce variation in tones, which is important to express different meanings in Cantonese. The responsibility of surgeons to follow-up patients after surgery and the practice of management of common complications after laryngectomy are also discussed. The New Voice Club of Hong Kong promotes self-help and mutual help between laryngectomees, with the aim of helping new members to regain normal speech and to re-integrate into society. Quality-of-life study in Hong Kong shows that although the mean global health score is satisfactory, the social functioning domain is most severely affected after surgery. SUMMARY: Cantonese-speaking laryngectomees in Hong Kong are facing unique challenges in speech restoration and re-integration into society after surgery. Surgeons should take the leading role in the multidisciplinary management of these patients.

A modification of technique to cover a large posterior thigh defect using an anterolateral thigh flap.

Anterolateral thigh (ALT) flap is one of the popular flaps for soft-tissue reconstruction. It is a versatile flap which commonly used to resurface external skin defect and internal mucosal lining. In addition if raised as musculocutaneous flap, the muscle portion provides bulk to fill up any potential space. With increase knowledge on the vascular anatomy of this flap, it is possible to harvest 2 skin paddles base on more than one branches of the supplying vessel. This technique is commonly employed to provide coverage of more than one epithelial surfaces such as the complex facial defect after maxillectomy where both the cheek skin and oral mucosa reconstruction are required. Using similar concept, we report a case in which a large external skin defect was successfully covered with an ALT flap and the donor site could be closed primarily without skin grafting.

Clinical implications of anterolateral thigh flap shrinkage.

OBJECTIVE: To evaluate anterolateral thigh flap shrinkage after elevation and to develop a predictive model for flap design. METHOD: A prospective study was conducted in a university teaching hospital. The skin islands from anterolateral thigh flaps were outlined on a transparent sheet before and after the reconstruction procedure. Dimensions of the stretched flaps were also recorded. These three outlines were scanned and the surface areas computed and compared by tracing and use of AutoCAD. Age, sex, flap dimension, and flap thickness were investigated for association with flap shrinkage. RESULTS: Forty-five anterolateral thigh flaps harvested for head and neck soft tissue reconstruction after tumor resection were studied. Flap size ranged from 4 to 14 cm in width and 8 to 22 cm in length; flap area ranged from 30.6 to 151.0 cm. On average, the flaps shrunk by 25.0% (6.2%-52.6%), a highly significant change (P < .01). Flap width and thickness correlated with the reduction in flap size. The average stretched-flap area was 10.1% (0.4%-29.4%) less than the preflap area, a significant reduction (P < .01). The difference between stretched-flap and preflap areas was independent of all variables. We developed a predictive model using a stepwise multiple linear regression method with a coefficient of determination of 0.495. CONCLUSIONS: Anterolateral thigh flaps shrink after harvesting, and flap width and thickness are significant contributing variables. These findings indicate that flap size must take shrinkage into account to ensure sufficient coverage.

Free posterior tibial flap for head and neck reconstruction after tumor expiration.

BACKGROUND: Similar to the radial forearm flap, free tissue transfer of a fasciocutaneous flap is possible if the septocutaneous perforators of the posterior tibial vessels are preserved. OBJECTIVE: The authors report their clinical experience on using the free posterior tibial flap for primary reconstruction of head and neck defects after tumor extirpation. METHODS: Eleven patients were included between October of 2005 and March of 2007. Patients' clinical and demographic data were collected. The flap harvesting results and outcomes were retrospectively reviewed. Representative cases are presented for illustration. RESULT: There were nine men and two women, and their ages ranged from 34 to 83 (mean, 60.3) years. The flaps measured from 6 x 9 cm to 8 x 12 cm. Two cutaneous perforators were included in the majority of cases. The average flap thickness was 0.7 cm, and the average pedicle length was 14 cm. Flap survival was 100%. Skin grafts of all donor sites healed well. All patients were ambulatory early in the postoperative period, and there was no distal limb ischemia or cold intolerance on follow-up. Four patients needed postoperative adjuvant radiotherapy. CONCLUSION: Our study demonstrates that the posterior tibial flap is a safe and reliable flap for reconstruction of head and neck defects after tumor expiration. It has all the comparable properties of a radial forearm flap. In addition, a larger area of skin can be removed, and the graft donor site is less conspicuous.

Clinical use of a pedicled anterolateral thigh flap.

BACKGROUND: Anterolateral thigh flap is a safe and reliable flap for soft tissue reconstruction. It has successfully been used as free flap reconstruction for defects in the head and neck region, the upper extremities and lower extremities. However, there were only a few reports in the literature concerning the clinical application of this flap for regional reconstruction. METHODS: The authors describe their experience of using the pedicled island anterolateral thigh flap for reconstruction of soft tissue defects in neighbouring areas. Representative cases are presented for illustration. RESULT: Between July 2005 and September 2006, seven patients underwent an immediate reconstruction with pedicled anterolateral thigh flap. The patients were between 49 and 69 years old. The size of the flaps measured from 5 x 8 cm to 15 x 15 cm. They were prepared as myocutaneous flaps in three cases and as perforator flaps in four cases. One patient, who had the largest flap harvested, needed skin grafting of the donor site. Primary closure was performed for all other cases. All flaps survived without any vascular compromise and the donor site healed without complication. CONCLUSION: Our study has shown that the pedicled anterolateral thigh flap is a safe and reliable flap for repair of defects at the internal pelvis, lateral thigh, groin, and genitoperineal region. The long vascular pedicle and having no restriction to the arc of rotation are keys to the successful transposition of the flap for immediate reconstruction of soft tissue defects in neighbouring areas.

Surgical reconstruction of attempted suicide charcoal burns.

Burning charcoal in an enclosed space is now the second most-common method of committing suicide in Hong Kong. When the suicide is unsuccessful, the patients can still sustain extensive tissue destruction from both direct and indirect thermal burns. We report a series of three patients who sustained deep injuries that, after débridement, left exposed bones and joints needing acute coverage. Free tissue transfer was required in each case to close the wounds. This short series illustrates the extensive destruction that can occur from both contact burns and radiant heat injury and the reconstructive challenges that can result. Of particular note was that serial débridment was necessary in the radiant heat injury because of the evolving and more extensive nature of the wound.