Head and neck mucoepidermoid carcinoma: does AFIP histological grading correlate with rate of nodal metastases?

OBJECTIVE: The aim of this study is to retrospectively evaluate the presentation of head and neck mucoepidermoid carcinoma at the Royal Melbourne Hospital and identify the significance of AFIP histological grading on the risk of neck metastasis and cancer free survival. MATERIALS AND METHODS: This study is a retrospective cohort analysis of patients treated for head and neck mucoepidermoid carcinoma at the RMH between 2005 and 2022. Patient demographics, treatment, pathology, in particular the AFIP histological grading of the primary tumour, and outcomes were collected and tabulated. Time to recurrence was recorded, and survival outcomes were calculated with Kaplan-Meier method. Comparisons were made on different histological grading and regional metastases. RESULTS: Thirty-three patients were identified and thirty met the inclusion criteria. There was an age range of 18-77 years (median 54 years) with no significant sex difference. Our patients had a 94% 5-year survival and an 86% 10-year survival. Thirteen patients had elective neck dissection and 2 out of 13 (15%) of the patients had positive neck disease. Of the two patients with regional metastasis, the primary tumour was graded as intermediate and low grade. No high-grade MEC patients had regional metastasis. CONCLUSION: Mucoepidermoid carcinoma of the head and neck is associated with a good disease-specific and overall survival despite the presence of regional metastasis. The AFIP histological grading system did not have a statistically significant correlation to the incidence of nodal metastasis.

Does Segmental Mandibulectomy Involving Critical Functional Sites Affect Quality of Life?

PURPOSE: Segmental mandibulectomy (SM) is a morbid procedure, often indicated in the treatment of oral cavity pathology; however, the effect on quality of life resulting from resection of specific mandibular subsites has not previously been investigated. This study's primary aim was to evaluate differences in Health-Related Quality of Life (HRQoL) among patients who underwent segmental mandibulectomy with condylectomy (SMc+) or not (SMc-), and secondarily among patients who underwent SM with symphyseal resection (SMs+) or not (SMs-). METHODS: A single-centre cross-sectional study was performed, identifying adults who had undergone SM over a 5-year period. Patients who had disease recurrence, further major head and neck surgery, or any surgery 3 months prior to participating were excluded. Demographic, disease and treatment data were obtained via chart review. Participants completed the European Organisation for Treatment of Cancer 'General' and 'Head and Neck Specific' HRQoL modules. Condylectomy and midline-crossing resection were the primary and secondary predictor variables, while the primary outcome was HRQoL. Study variables were cross tabulated against predictor and outcome variables to identify potential confounders. The association between condylectomy and symphyseal resection on HRQoL was modelled using linear regression and subsequently with identified confounding factors. RESULTS: Forty-five enrolled participants completed questionnaires, of which 20 had undergone condylectomy and 14 symphyseal resection. Participants were majority male (68.9%) and on average 60.2 ± 18 years old, having undergone surgery 3.8 ± 1.8 years prior to participation. Prior to adjustment, Condylectomy patients reported significantly worse 'Emotional Function' (mean ± standard deviation) (47.7 ± 25.5 vs 68.4 ± 26.6, P = .02), 'Social Function' (46.3 ± 33.6 vs 61.4 ± 28.9, P = .04) and 'Mouth Opening' (61.1 ± 36.7 vs 29.8 ± 38.3, P = .04) compared to the SMC- group. SMs + patients reported significantly worse scores in 'Social Function' (43.9 ± 30.1 vs 48.3 ± 32,1, P = .03), 'Dry Saliva' (65.1 ± 35.3 vs 38.5 ± 33.9, P < .01) and 'Social Eating' (48.5 ± 45.6 vs 30.8 ± 36.4, P < .01) compared to the SMs-group. Following adjustment only 'emotional function' in the SMc comparison retained significance (P = .04). CONCLUSIONS: SM causes anatomical distortion resulting in functional deficit. While the condyle and symphysis are theoretically functionally important, our findings suggest that morbidity associated with their resection may be the result of associated surgical and adjuvant treatment burden.

Challenges With the Jaw in a Day Technique.

PURPOSE: The Jaw in a Day (JIAD) procedure allows for complete primary reconstruction of bone and teeth during the same operation as tumor resection. We reviewed 12 cases, the largest published case series of the JIAD procedure, and discussed both the prosthodontic and surgical considerations. MATERIALS AND METHODS: A multi-institutional retrospective chart review was completed to identify patients undergoing the JIAD procedure. Patients with a minimum of 6 months' follow-up were included. Variables included skeletal relationship, dental Angle classification changes, postoperative diet, prosthesis complications, flap failure, osseointegration of dental implants, hardware complications, infection, intelligible speech, and patients' subjective satisfaction with facial and dental esthetics. RESULTS: The sample included 12 patients (8 male and 4 female patients) with a mean age of 38 years (range, 15 to 75 years) and an average follow-up period of 19 months (range, 7 to 42 months). Patients underwent the JIAD procedure at the same time as resection of an ameloblastoma (mandibular in 9 and maxillary in 1) or odontogenic myxoma (mandibular in 1 and maxillary in 1). Nine patients' Angle classification remained unchanged after the procedure, with 3 patients showing correction from dental Class III to Class I. On average, 4 implants (range, 2 to 6 implants) were placed. Hybrid or splinted crown prostheses replaced, on average, 8 teeth (range, 3 to 12 teeth) with no prosthetic fractures. All patients had viable fibular flaps, absence of infection, and completely intelligible speech. All but 1 patient had subjective satisfaction with facial and dental esthetics. Complications included plate fracture with fibrous union (1), premature contacts requiring occlusal equilibration (2), implant loss (1), delayed wound healing (1), heterotopic bone formation along the pedicle (1), and dissatisfaction with chin symmetry (1). CONCLUSIONS: The JIAD technique predictably reconstructs bone and teeth in a single operation. The tools and services streamlining this protocol are now widely available. However, there are still several challenges with this protocol that surgeons and patients must overcome. Further study and refinements are necessary to address these.

Immunotherapy for Head and Neck Cancer.

The immune system has a vital role in the development, establishment, and progression of head and neck squamous cell carcinoma (HNSCC). Immune evasion of cancer cells leads to progression of HNSCC. An understanding of this mechanism provides the basis for improved therapies and outcomes for patients. Through the tumor's influence on the microenvironment, the immune system can be exploited to promote metastasis, angiogenesis, and growth. This article provides an overview of the interaction between immune infiltrating cells in the tumor microenvironment, and the immunologic principles related to HNSCC. Current immunotherapeutic strategies and emerging results from ongoing clinical trials are presented.

Immunotherapy for Head and Neck Cancer.

The immune system has a vital role in the development, establishment, and progression of head and neck squamous cell carcinoma (HNSCC). Immune evasion of cancer cells leads to progression of HNSCC. An understanding of this mechanism provides the basis for improved therapies and outcomes for patients. Through the tumor's influence on the microenvironment, the immune system can be exploited to promote metastasis, angiogenesis, and growth. This article provides an overview of the interaction between immune infiltrating cells in the tumor microenvironment, and the immunologic principles related to HNSCC. Current immunotherapeutic strategies and emerging results from ongoing clinical trials are presented.

Functional Anatomic Computer Engineered Surgery Protocol for the Management of Self-Inflicted Gunshot Wounds to the Maxillofacial Skeleton.

PURPOSE: Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair. METHODS: A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT. RESULTS: The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2). CONCLUSION: Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.

Margin Analysis: Squamous Cell Carcinoma of the Oropharynx.

Because of the common shared risk factors of smoking and heavy alcohol consumption, literature involving oropharyngeal squamous cell carcinoma (OPSCC) is often combined with oral squamous cell carcinoma. Human papilloma virus is now confirmed to be a major risk factor of OPSCC with its distinct epidemiology and favorable treatment outcome. The impact of adjuvant chemoradiation in the setting of positive surgical margins remains unclear but is likely influenced by tumor biology. This article reviews the tumor biology of OPSCC and summarizes recent findings on outcomes following surgical treatment of OPSCC.

Survival Outcomes of Mucosal Melanoma in the Head and Neck: Case Series and Review of Current Treatment Guidelines.

PURPOSE: Malignant mucosal melanoma of the head and neck (MMHN) is an aggressive and rare neoplasm with poor long-term outcomes. The aim of this study is to evaluate the outcomes of patients treated by a single-institution head and neck multidisciplinary team. MATERIALS AND METHODS: In this retrospective case series, all MMHN cases treated at the Royal Melbourne Hospital from 1990-2015 were retrospectively reviewed. Patient demographic characteristics (eg, age), treatment offered, pathology, and outcomes were collected, tabulated, and correlated with outcomes. Survival outcomes were calculated by the Kaplan-Meier method. Comparison was made between oral and sinonasal melanomas. RESULTS: A total of 16 cases were identified. Two were excluded because of inaccessible data. Of the 14 remaining cases, 8 were sinonasal melanomas and 6 were oral cavity melanomas. Sinonasal tumor patients presented with epistaxis or visual impairment. Oral melanoma patients presented with pigmented lesions or ulceration. Follow-up ranged from 4 months to 11 years. In 2 patients, locoregional recurrences developed that were successfully re-excised. Six patients died of distant metastases despite clear surgical margins. Two patients with sinonasal melanomas died of extensive local disease with intracranial invasion. One patient died 4 years after diagnosis without disease. There were no failures in the neck. The 2- and 5-year overall survival rates were 63.3% and 31.7%, respectively, by the Kaplan-Meier method. The difference in survival between oral and sinonasal melanomas was not statistically significant. CONCLUSIONS: Despite clear surgical margins, MMHN has a poor prognosis and most deaths are due to distant metastases. Systemic therapies such as those used in cutaneous melanoma treatment might be used in the future for MMHN.

Cautery versus scalpel for abdominal skin incisions: a double blind, randomized crossover trial of scar cosmesis.

BACKGROUND: The purpose of this study was to determine whether there is any difference in cosmetic outcome between using cutting diathermy and using a scalpel to make abdominal skin incisions. METHOD: This was a prospective, randomized, double-blind crossover study. The primary end point was wound cosmesis as judged by the patient. In each case, one-half of the skin incision was made using diathermy, and one-half using a scalpel blade. Patients were contacted at 6 months post-operatively, and were asked which half of the wound looked better to them. A panel of 18 surgeons was also shown photographs of the wounds taken after 6 months, and were asked the same question. RESULTS: Of the 31 patients with complete follow-up, 11 (35%) reported no difference between the two halves of the wound. Nine (29%) preferred the half incised with diathermy, and 11 (35%) preferred the half incised with the scalpel (P = 0.82, chi-squared test). Twenty-four patients consented to having their wound photographed. There was no difference in the surgeons' preference between the diathermy and scalpel halves of the incision (P = 0.35, signed-rank test). CONCLUSION: We found the use of cutting diathermy to make abdominal skin incisions to be cosmetically equivalent to cutting with the scalpel. As previous studies have not shown adverse wound outcomes using this technique, and considering the safety concerns for theatre staff when the scalpel is used, the routine use of cutting diathermy for skin incisions in abdominal surgery is justified.