Patient Selection for Surgery vs Radiotherapy for Early Stage Oropharyngeal Cancer.

Surgery and radiation therapy are both commonly used in the treatment of early stage (AJCC stages T1-T2 N0-M0) oropharyngeal squamous cell carcinoma (OPSCC). Transoral robotic surgery (TORS) and intensity modulated radiation therapy (IMRT) have been reported to result in similar survival and disease control outcomes. However, their side effect profiles widely differ. Nevertheless, patients who experience the worst side effects and quality of life are the ones who receive the combination of TORS and adjuvant radiation or chemoradiation therapy. Thus, appropriate patient selection for surgery to minimize the need for multimodality therapy is key. We propose, in this paper, the use of sentinel lymph node biopsy in the node negative (N0) neck as a means that is worth exploring for selecting patients to either radiation therapy or surgery. Patients with a positive sentinel lymph node (SLN) would be better directed to upfront radiation. On the contrary, patients with a negative SLN biopsy would be more confidently directed towards TORS and neck dissection alone.

HPV-related oropharyngeal cancer prevalence in a middle eastern population using E6/E7 PCR.

BACKGROUND: Given the paucity of data and widely variable rates that have been reported, the main objective of this study was to examine the prevalence of HPV-positivity in oropharyngeal squamous cell carcinoma (OPSCC) in Middle Eastern patients presenting to one of the region's largest tertiary care centers using polymerase chain reaction (PCR) amplification of the HPV E6/E7 oncogenes, a highly sensitive and specific method of detection. METHODS: Medical charts and archived pathological specimens were obtained for patients diagnosed with biopsy proven oropharyngeal cancer who presented to the American University of Beirut Medical Center between 1972 and 2017. DNA was extracted from paraffin-embedded specimens and tested for 30 high-risk and low-risk papilloma viruses using the PCR-based EUROarray HPV kit (EuroImmun). RESULTS: A total of 57 patients with oropharyngeal cancer were initially identified; only 34 met inclusion/exclusion criteria and were included in the present study. Most patients were males (73.5%) from Lebanon (79.4%). The most common primary tumor site was in the base of tongue (50%), followed by the tonsil (41.2%). The majority of patients (85.3%) tested positive for HPV DNA. CONCLUSION: The prevalence of HPV-positivity amongst Middle Eastern OPSCC patients, specifically those from Lebanon, may be far greater than previously thought. The Lebanese population and other neighboring Middle Eastern countries may require a more vigilant approach towards HPV detection and awareness. On an international level, further research is required to better elucidate non-classical mechanisms of HPV exposure and transmission.

A Patient With a Protuberant Fibro-Osseous Lesion of the Temporal Bone.

Protuberant fibro-osseous lesion of the temporal bone, otherwise known as "Bullough's lesion", is a rare, benign exophytic fibro-osseous tumor. In this brief report, we present a case of a 61-year-old woman with a history of a right-sided skull mass that had been increasing in size for approximately 6 years before presentation. Clinical, radiological and histological features are examined and discussed. We achieved excellent results with surgical resection, with no evidence of recurrence.

Nasal Basal Cell Carcinoma with Matrical Differentiation: Risk of Metastasis and Impact on Management.

Basal cell carcinoma (BCC) is the most common type of skin cancer. Microscopically, BCC can be classified into indolent-growth and aggressive-growth subtypes. Additionally, uncommon variants have been described in the literature including adamantinoid, granular, clear cell, and BCC with matrical differentiation (BCCMD). If left untreated, BCC can invade locally causing significant tissue destruction while metastatic BCC is extremely rare. There have only been rare cases of BCCMD previously reported in the literature with none exhibiting metastasis. In this report, a 76 year old male patient presented to our center with a recurrent nasal lesion. He had been diagnosed with BCC at another institution about 8 years prior. He underwent a completion rhinectomy procedure, and on microscopic examination the tumor was diagnosed as BCCMD. In view of the uncommon pathology, a PET scan was ordered, which showed a left submandibular hypermetabolic lymph node with central areas of necrosis. A fine needle aspirate from the node confirmed metastasis, and the patient underwent subsequent neck dissection. In conclusion, we have presented a very rare case of a nasal BCCMD with regional metastasis. To the best of our knowledge, this constitutes the first reported case in the English literature. This might raise the possibility of a probable metastatic potential for this lesion and subsequently a more aggressive behavior. However, it is to be noted that this is a single case report and the affirmation of any metastatic potential would still need to be confirmed through additional future reports.

Old World Leishmaniasis: an ancient disease with nonstandardized microscopic and clinical classifications.

BACKGROUND: Microscopic and clinical classifications of cutaneous leishmania have been set in the 1980s. Since then, they have been used invariably. Lebanon, a nonendemic country, is suffering from a leishmaniasis epidemic because of the massive population influx from endemic Syria. DESIGN: Patients diagnosed and speciated with leishmania (n = 169) using molecular and microscopic analysis were studied. General demographic data, microscopic data [Ridley's pattern (RP), microscopic pattern, Parasitic Index (PI)] and clinical stage were documented. Clinical score was scored as: 1: inflammatory; 2: proliferative/reorganization; 3: healed phases. The three patterns were studied in comparison to the lesion age and PI. RESULTS: At low PI, the clinical score and microscopic pattern showed healing scores (scores 3 and 4, respectively). In contrast, RP showed variable distribution at low PI. The same pattern is noted when correlating the different patterns with high PI. In comparison to lesion age, none of the three patterns showed the predicted linear correlation with lesion progression. CONCLUSION: In the studied population, the previously adopted classifications did not correlate with the disease progression. Such findings may raise the possibility of evolving disease. The proposed clinical and microscopic patterns showed better correlation with the disease progression.

Mandibular melanotic neuroectodermal tumor of infancy: a role for neoadjuvant chemotherapy.

Melanotic Neuroectodermal Tumor of Infancy (MNTI) is a rare, locally aggressive neoplasm with a predilection for the head and neck area, most commonly occurring in the maxilla. The vast majority of treatment modalities for all cases of MNTI to date have involved surgical intervention only, with just 9.6 % involving some sort of chemotherapy, radiotherapy, or a combination of the prior mentioned modalities. There is very limited information available regarding the use of neoadjuvant chemotherapy, due to its rare nature. In this report, a 4 month old girl presented to our clinic with a chief complaint of a large oral mass of about 2.5 months in duration. Intraoral examination showed an oral mass arising from the lingual aspect of inferior alveolar ridge with extensive mandibular invasion. The patient received three cycles of vincristine, Adriamycin, and cyclophosphamide as neodajuvant therapy. Upon completion, the tumor had decreased significantly in size. The patient was then scheduled for surgery and underwent surgical resection of the tumor. We were able to obtain adequate shrinkage of the tumor to allow better resectability, easier surgical access and a more minimally invasive approach with no lip split and a smaller neck incision. In conclusion, we have reported an extremely rare case of MNTI of the mandible that was successfully treated with neoadjuvant chemotherapy and surgical resection. This approach was advantageous to minimize the chance of recurrence and improve resectability in particularly large tumors, while maximizing functional outcomes and minimizing deformity.

Head and neck cutaneous leishmania: clinical characteristics, microscopic features and molecular analysis in a cohort of 168 cases.

Lebanon, an underendemic area for cutaneous leishmania (CL), is suffering from a CL outbreak brought by the massive population influx from endemic Syria. CL affects mainly exposed areas; therefore, the head and neck (HN) region is highly susceptible. Individuals diagnosed and speciated with CL (n = 168) using molecular and microscopic analysis on punch biopsy/scrapings were studied. Clinical data, parasitic index (PI) and Ridley's Pattern (RP) were recorded. The HN was divided into 11 anatomic locations. Of 168 patients, 96 patients (57.1 %) had HN involvement and 72 (42.9 %) had no HN involvement. Lesions from the HN were significantly more common in younger patients and were more prone for ulceration, had larger size, higher PI and more advanced RP (p < 0.05). There was no difference in the anatomic distribution of lesions among age groups and genders in the HN group. The cheek area was the most HN involved location. Lesions were less commonly encountered in the veiled area in women. In the community we studied, HN is commonly involved by CL. Lesions with HN involvement were encountered more in pediatric age group and showed more extensive features.

Cutaneous Leishmaniasis: An Overlooked Etiology of Midfacial Destructive Lesions.

BACKGROUND: Midline destructive lesions of the face (MDL) have a wide range of etiologies. Cutaneous Leishmaniasis (CL) is rarely reported as a possible cause. METHODS: Fifteen patients with solitary nasal lesions caused by CL were studied. The clinical data, biopsies/scrapings and PCR were collected/performed. Ridley's Pattern (RP) and Parasitic Index (PI) were documented. RESULTS: Patients' age ranged from 1 to 60 years including 7 males and 8 females. The duration of the observed lesions ranged from 1 to 18 months. Clinically, the lesions showed 6 patterns varying from dermal erythematous papulonodular with no epidermal changes to destructive erythematous plaque with massive central hemorrhagic crust. The clinical impression ranged from neoplastic to inflammatory processes. RP varied among the cases [RP 3 (n = 6), RP 4 (n = 3), RP 5 (n = 6)]. All cases show low PI [PI 0 (n = 7), PI 1 (n = 6), PI 2 (n = 1), and PI 3 (n = 1)]. Higher PI was noted in the pediatric group [average age 24 years for PI 0-1 vs. 6.5 years for PI 2-3]. Molecular speciation showed Leishmania tropica (n = 13) and Leishmania major (n = 2). All the patients received Meglumine Antimoniate (Glucantine) injections and had initial cure defined as complete scarring and disappearance of inflammatory signs within 3 months. CONCLUSION: Leishmaniasis may cause MDL especially in endemic areas. PCR is instrumental in confirming the diagnosis. MDL caused by CL showed wide spectrum of clinical and microscopic presentation.

Fibroblastic and myofibroblastic tumors of the head and neck: comprehensive imaging-based review with pathologic correlation.

Fibroblastic and myofibroblastic tumors of the head and neck are a heterogeneous group of disorders characterized by the proliferation of fibroblasts, myofibroblasts, or both. These tumors may be further subclassified on the basis of their behavior as benign, intermediate with malignant potential, or malignant. There are different types of fibroblastic and myofibroblastic tumors that can involve the head and neck including desmoid-type fibromatosis, solitary fibrous tumor, myofibroma/myofibromatosis, nodular fasciitis, nasopharyngeal angiofibroma, fibrosarcoma, dermatofibrosarcoma protuberans, fibromatosis coli, inflammatory myofibroblastic tumor, ossifying fibroma, fibrous histiocytoma, nodular fasciitis, fibromyxoma, hyaline fibromatosis and fibrous hamartoma. Although the imaging characteristics of fibroblastic and myofibroblastic tumors of the head and neck are nonspecific, imaging plays a pivotal role in the noninvasive diagnosis and characterization of these tumors, providing information about the constitution of tumors, their extension and invasion of adjacent structures. Correlation with the clinical history may help limit the differential diagnosis and radiologists should be familiar with the imaging appearance of these tumors to reach an accurate diagnosis.

Transglottic basaloid squamous cell carcinoma of the larynx.

OBJECTIVE: To report a rare case of Transglottic Basaloid Squamous cell carcinoma of the larynx and review the pathologic features of these lesions. CASE REPORT: A 64 year old male, heavy smoker and alcohol abuser, presented with a 6 month history of hoarseness. Laryngoscopy revealed a right transglottic lesion involving the epiglottis, aryepiglottic fold, ventricle and true vocal fold. Microscopically, the tumor was characterized by infiltrating solid sheets of basaloid cells showing palisading pattern along the edges. In areas of solid growth, tumor cells displayed scant cytoplasm, and hyperchromatic nuclei. A portion of the tumor abutting the thyroid cartilage showed squamous differentiation. An island of tumor cells with comedonecrosis was also noted. Immunohistochemical staining for a number of markers was performed. CONCLUSION: Basaloid squamous cell carcinoma displays a biphasic histology. The stage of the disease at presentation is invariably advanced with metastatic lymphadenopathy in two thirds of the patients.

A novel tool for the objective measurement of neck fibrosis: validation in clinical practice.

BACKGROUND: Radiotherapy is commonly used to treat neoplasms of the head and neck, and fibrosis is a known side effect. The Cutometer is a device that quantifies properties of the skin. The goal of the study was to validate the Cutometer in normal neck tissues and then quantify fibrosis in radiated necks. METHODS: We performed a prospective study of 251 patients. The elasticity and stiffness parameters were recorded. Control patients were compared to determine the correlation between their left and right sides. Next, the treatment groups were compared using a nonparametric test (Kruskal-Wallis). RESULTS: We found a significant correlation between the left and right sides of the control patients' necks, supporting the view that the Cutometer provides reproducible measurements in the normal neck. Furthermore, the Cutometer demonstrated reduced elasticity in necks treated with radiation, surgery-radiation, and chemoradiation. No significant difference in stiffness was seen. CONCLUSION: The Cutometer may serve as a valuable and valid tool for the measurement of neck skin elasticity. Radiated patients have a quantifiable decrease in their skin elasticity.

Angiofibroma of the nasal septum.

Angiofibromas originate predominantly in the nasopharynx. Extranasopharyngeal sites such as the paranasal sinuses and nasal cavity are less frequent. Angiofibroma of the nasal septum is extremely rare and the site of origin is either anterior, at the bony cartilaginous junction or posterior. Clinically, patients present with recurrent epistaxis and nasal obstruction secondary to a fleshy or polypoidal nasal mass. Computerized tomography of the nasal cavity and bilateral carotid angiography are useful in the pre-operative work-up. The main stay of treatment is surgical resection. A rare case of nasal septal angiofibroma is hereby presented.

The N3 neck: outcomes following primary chemoradiotherapy.

OBJECTIVE: To study the treatment outcomes of N3 neck disease following primary chemoradiotherapy. DESIGN: Retrospective cohort. SETTING: Tertiary care centre. METHODS: A review was conducted of 25 consecutive patients with N3 neck disease treated with primary platinum-based chemoradiotherapy. A neck dissection (ND) was offered in the event of clinical and/or radiologic evidence of residual disease on follow-up. MAIN OUTCOME MEASURES: Recurrence-free, disease-specific, and overall survival and patterns of failure. RESULTS: A regional complete response (CR) was noted in 48% of the patients. ND was performed in 36% of the cases. The median duration between the end of radiation and ND was 71 days. The recurrence-free survival rates at 1 and 2 years were 73% and 64%, respectively. The 2-, 3-, and 5-year overall survival rates were 66.7%, 52%, and 31.2%, respectively. Disease-specific survival rates were 69.6%, 63.3%, and 50.6%, respectively. Nine patients developed distant recurrence, with one having concurrent local and regional recurrence as well. Patients in the CR group remained free of regional recurrence. Among the initial partial responders, 54% eventually developed distant metastasis compared to 17% in the CR group. CONCLUSION: Patients with N3 disease may be managed with chemoradiotherapy, with ND reserved for salvage. Distant metastasis accounts for most recurrences and for the reduction in survival.

Voice-related quality of life (V-RQOL) outcomes in laryngectomees.

BACKGROUND: Laryngeal cancer has a significant impact on patients. This study compared the Voice-Related Quality of Life (V-RQOL) outcomes specific to 3 different postlaryngectomy voice rehabilitation methods. METHODS: We conducted a retrospective review of 75 patients with laryngectomy from our V-RQOL questionnaire database. RESULTS: The database included 18 electrolaryngeal speech (ELS), 15 esophageal speech (ES), and 42 tracheoesophageal speech (TES) patients. Pairwise comparisons of V-RQOL outcomes showed that TES was perceived to be better than ELS (p < .001). ES was perceived as better than ELS, but this was driven by a difference in the total and social-emotional V-RQOL scores (p < .05). There was no difference between TES and ES groups. Only ELS showed a positive correlation with time after surgery and older age. CONCLUSIONS: Patients using TES had similar V-RQOL outcomes compared to ES and both performed significantly better than ELS. For ELS, the total V-RQOL score was better with longer time after surgery and older age.

The scapular free flap: when versatility is needed in head and neck reconstruction.

OBJECTIVE: To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions. DESIGN: Retrospective review. SETTING: Tertiary care centre. METHODS: A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed. MAIN OUTCOME MEASURES: Defect analysis, flap-related complications, and non-flap-related complications. RESULTS: Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality. CONCLUSIONS: Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Neck and shoulder disability following reconstruction with the pectoralis major pedicled flap.

OBJECTIVES/HYPOTHESIS: To conduct a comprehensive assessment of shoulder and neck function following the pectoralis major pedicled flap (PMPF) for head and neck reconstruction. DESIGN: Case-control study. METHODS: The study group consisted of laryngectomized patients who underwent PMPF and a control group of those who underwent standard laryngectomy. Bilateral quantitative measurements of shoulder strength and range of motion (ROM) and neck ROM by a blinded physiotherapist and subjective quality-of-life assessment using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires were collected. Lateral cervical radiographs in the neutral, flexion, and extension positions were evaluated by a blinded neuroradiologist. The main outcome measures were shoulder ROM, strength, and SPADI scores; physical and radiologic measurements of neck ROM; and NDI Score. RESULTS: Shoulder analysis showed a significantly reduced flexion angle (P = .043) and combined internal/external rotation angle on the operated side (P = .027) and a significant strength reduction for the flexion, external rotation, and adduction domains (P < .05). SPADI score analysis showed a significantly higher disability score (P = .017) and total score (P = .009) on the PMPF side. Neck physical analysis showed significant differences in extension (P = .013) and total ROM distances (P = .002) but not flexion (P = .184). The total flexion/extension angular ROM was reduced in the PMPF population (P = .05) due to a reduced neck extension excursion angle from a neutral position (P = .04). CONCLUSIONS: The PMPF for head and neck reconstruction is associated with a limitation in neck ROM attributed to a loss in extension and reduced shoulder strength and ROM.

Tracheal schwannoma: a misleading entity.

Primary tracheal tumors are rare with the majority being malignant. Benign lesions are less frequent with primary tracheal schwannomas accounting for less than 0.5% of tracheal tumors. They are more common in females and their clinical presentation is non-specific. Chronic cough, progressive respiratory distress and even asthma-like conditions prevail as presenting symptoms and signs. Laryngotracheal endoscopy reveals a solitary, well encapsulated mass arising most often from the posterior tracheal wall. The diagnosis of tracheal schwannomas is primarily pathological. Endoscopic excision, sleeve excision or tracheal resection, are all commonly accepted treatment modalities. Proper awareness of these lesions is crucial in the pre-operative work-up of patients presenting with stridor.

Computer-assisted teaching of epistaxis management: a Randomized Controlled Trial.

OBJECTIVES: To determine whether computer-assisted learning (CAL) is an effective tool for the instruction of technical skills. STUDY DESIGN: Prospective blinded randomized-control trial conducted on a cohort of 47 first-year medical students. METHODS: Students were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis, using either a standard text-based article or a novel computer-based learning module. Students were evaluated on proper nasal packing technique using standardized subjective and objective outcome measures by three board-certified otolaryngologists. Blind assessments took place prior to and following instruction, using the assigned learning modality. RESULTS: There were 47 participants enrolled in the study. Both groups demonstrated improvement in performance of both packing procedures following training. A significant post-training difference favoring CAL learners over text-based learners was observed, using the global assessment of skill for both packing techniques (P < .001). Additionally, a significant post-training difference favoring CAL learners over text-based learners was observed for all checklist items for the tampon pack and five of eight items on the formal pack checklist. The vast majority of students (94.6%) indicated that if given the choice, they would prefer to learn using CAL rather than by using text-based learning materials. CONCLUSIONS: CAL learners demonstrated significantly greater improvement across both subjective and objective outcome measures when compared to the text-based group. Additionally, students favored learning via the CAL modality, which further suggests that CAL is a valuable means of imparting procedural knowledge to novice medical trainees.