Validation of the 8th edition UICC/AJCC TNM staging system for HPV associated oropharyngeal cancer patients managed with contemporary chemo-radiotherapy.

BACKGROUND: To compare outcomes of high-risk human papilloma virus-related oropharyngeal squamous cell carcinoma (HPV OPSCC) treated with modern radiation treatment (RT) and daily image-guidance, staged with the 7th versus the 8th Edition (Ed) Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) TNM staging systems. METHODS: All eligible patients with HPV OPSCC treated definitively over a 10-year period (2007-2016) at a single institution were included. Protocols consisting of either RT or chemo-radiation (CRT) (weekly cisplatin or cetuximab) +/- neoadjuvant chemotherapy for those with bulky disease were used. All patients were Fluorine-18-deoxyglucose positron emission tomography (FDG-PET) staged at baseline and at intervals for up to 2 years post-treatment. Patients received parotid-sparing intensity modulated or volumetric modulated arc therapy with simultaneous integrated boost to either 70Gy in 35 fractions or 66Gy in 30 fractions. The overall survival (OS) was determined for each stage using the 7th Ed and subsequently with the updated 8th Ed staging system. RESULTS: One hundred fifty-three patients were analysed. Patient stage groupings varied between the 7th and 8th Eds respectively; Stage I (0.7% vs 64.7%), Stage II (8.5% vs 22.2%), stage III (21.6% vs 12.4%) and stage IV (69.3% vs 0.7%). In the 7th Ed, the 5 year probability of OS for stages I to III was 90%, versus stage IV 85.5%. There was no statistically significant difference between the staging groups (p = 0.85). In the 8th Ed there was a statistically significant difference in 5 year OS for stage I and stage II disease (96.9% vs 77.1% respectively; p < 0.0001), but not between stage II and III disease (p = 0.98). CONCLUSIONS: The new 8th Ed UICC/AJCC TNM staging system better discriminates between stage I and Stage II HPV OPSCC with respect to OS compared with the 7th Ed staging system. Further investigation is required for stage III or IV patients.

The training and creativity of professional chefs: Stoking the imagination in global gastronomic discourse.

The sameness of eating out has been criticised in some quarters of food media in recent years. In this paper I demonstrate through the case of three chefs in Hong Kong how this sameness is the product of global gastronomic discourse. I suggest that chefs play a crucial role in providing the content that fuels gastronomic discourses and also in delivering the experiences of the discourse on the plate to diners. The experience of chefs in cuisines such as Thai, Vietnamese and Spanish allows them to prepare dishes that attract plaudits from food media and fuel the imagination of potential diners. This experience includes professional training in a cuisine under a well-known exponent of the cuisine, which allows them to be associated with the image of their mentor. The other route is vocational culinary training, which gives the chefs the ability to create dishes that stoke the imagination of diners.

Pre-operative tracheostomy does not impact on stomal recurrence and overall survival in patients undergoing primary laryngectomy.

Pre-operative tracheostomy (POT) to secure a critical airway up to several weeks before definitive laryngectomy in patients with laryngeal cancer has been proposed as a risk factor for poor oncologic outcome. Few modern papers, however, examine this question. The aim of this study is therefore to determine whether POT affects oncologic outcome with an emphasis on stomal/peristomal recurrence. This is a retrospective case note review of 60 consecutive patients undergoing curative primary total laryngectomy (TL) for advanced laryngeal squamous cell carcinoma (SCC). Demographic, staging, treatment and outcome data were collected. 27/60 (45 %) patients had POT and 33/60 did not. No patient underwent laser debulking. Median age was 62 years (39-90 years) and median follow-up of survivors was 31 months. 5-year overall survival (OS), disease-specific survival (DSS) and local recurrence-free survival (LRFS) of patients undergoing POT versus no POT was 28 versus 39 % (p = 0.947), 55 versus 46 % (p = 0.201) and 96 versus 88 % (p = 0.324) respectively. No statistically significant difference in OS, DSS and LRFS was found between patients undergoing POT and those not. Despite the relatively small case series, this evidence should reassure surgeons without the ability to perform trans-oral debulking that they should not hesitate to perform tracheostomy on a patient with airway obstruction due to laryngeal cancer. Appropriate definitive treatment meant that POT was not a risk factor for poor oncological outcome in our series.

Post-operative wound infection in salvage laryngectomy: does antibiotic prophylaxis have an impact?

Salvage laryngectomy carries a high risk of post-operative infection with reported rates of 40-61%. The purpose of this study was to analyse infections in our own patients and review the potential impact of our current antibiotic prophylaxis (AP). A retrospective analysis of infection in 26 consecutive patients between 2000 and 2010 undergoing salvage total laryngectomy (SL) following recurrent laryngeal cancer after failed radiotherapy or chemo-radiation was undertaken. The antibiotic prophylaxis was intravenous teicoplanin, cefuroxime and metronidazole at induction and for the following 24 h. Infection was defined by Tabet and Johnson's grade 5, categorized as pharyngocutaneous fistula. Fifteen patients (58%) developed a post-operative wound infection, which occurred on average at 12 days after surgery. Univariate analysis demonstrated three risk variables that had a significant correlation with infection: alcohol consumption (p = 0.01), cN stage of tumour (p < 0.01), and pre-operative albumin levels <3.2 g/L (p = 0.012). There was a trend, though not significant, for increased infection in patients with high or low BMIs. The most common organisms isolated from clinical samples from infected patients were methicillin-resistant Staphylococcus aureus MRSA (43%), Pseudomonas aeruginosa (36%), Serratia marcescens, Proteus mirabilis and Enterococcus faecalis (7% each). All these organisms are typical hospital-acquired pathogens. Pseudomonas and Serratia were not covered by the prophylactic regime we used. The current antibiotic regime following SL is inadequate as the rate of infection is high. It would therefore seem logical to trial a separate antibiotic protocol of AP for patients undergoing SL that would include an extended course of antibiotics after the standard prophylaxis. In addition, infection rates may also be reduced by improving the metabolic state of patients pre-operatively by multi-disciplinary action. Steps should also be taken to reduce cross-infection with nosocomial pathogens in these patients. Other aspects of surgical management should be also taken in consideration.

Minimizing complications in salvage head and neck oncological surgery following radiotherapy and chemo-radiotherapy.

PURPOSE OF REVIEW: The term salvage surgery denotes oncological surgery after failed radiotherapy or chemoradiotherapy (CRT). Salvage surgery is a high-risk endeavour as it carries a significant risk of complications. The purpose of this review is to assess the ways in which complications from salvage surgery can be prevented and minimized. This is a complex subject and complications are often multifactorial and interrelated. There are many aspects that can be discussed; however, to address each of them individually would be impossible and beyond the scope of this article. We will, therefore, focus this review on the most relevant aspects to current practice for head and neck surgeons. RECENT FINDINGS: Salvage surgery after failure of radiotherapy and CRT remains controversial and many aspects still lack evidence. Many patients with recurrent cancer are not suitable for salvage surgery due to severe co-morbidities or disease progression. Salvage surgery is best carried out in tertiary centres by experienced multidisciplinary teams. Preoperative assessment and evaluation is critical to success and to minimize complications. Surgical principles include single incisions, delicate tissue handling, use of frozen sections, adopting a critical approach to neck dissections and the use of flaps, secondary surgical voice restoration for laryngectomies and appropriate postoperative care. SUMMARY: This review emphasizes the importance of a multidisciplinary approach by experienced teams, the centralization of resources and teams, a structured and thorough patient assessment, surgical planning and a systematic attention to detail when addressing patients undergoing salvage surgery.

Mastoiditis in a paediatric population: a review of 11 years experience in management.

OBJECTIVE: This study explores the experience at Sydney Children's Hospital (SCH) managing children with acute mastoiditis and establishes a robust treatment algorithm. METHODS: Retrospective review of all patients admitted to SCH with an ICD-10 coding of "Mastoiditis" from 1 January 1996 through 31 December 2006 inclusive. Criteria assessed included demographic characteristics, clinical features, symptom duration and treatment initiated by the general practitioner. The results of investigations at SCH were reviewed including white blood cell count, microbiology and imaging. The presence of complications was determined and the results of medical and surgical treatment were assessed. RESULTS: Seventy-nine episodes of acute mastoiditis were managed in 76 patients. Treatment prior to SCH was commenced by the family practitioner or district hospital doctor in 53/79 patients. The mean duration of community initiated treatment before presentation to SCH was 3.7 days. In 33 episodes a previous history of acute otitis media was noted (42%). In the remaining 46 episodes (58%) mastoiditis was the initial diagnosis. Complications were found in 30 episodes (38%) and 36 episodes (46%) required surgical treatment. CONCLUSIONS: Mastoiditis often develops rapidly but may be treated very effectively. The potential for significant morbidity remains high but excellent outcomes can be expected for those who are managed without delay. Children with acute mastoiditis should be managed in centres where timely and complete medical and surgical treatment is available.

Vertigo - part 2 - management in general practice.

BACKGROUND: Vertigo is a common clinical problem managed by general practitioners. OBJECTIVE: This article focuses on the acute management of a vertigo attack, specific management of conditions causing vertigo, and the long term management issues associated with chronic vertigo. DISCUSSION: Supportive treatment, antiemetic and vestibular blocking agents help relieve an acute vertigo attack, however the prolonged use of such medications is not recommended. Specific treatments for various conditions causing vertigo are available, however, the majority of patients are managed symptomatically. The patient's ability to drive safely should be carefully assessed according to Austroads guidelines and advice from an ear, nose and throat surgeon should be sought when in doubt. There is evidence to support the efficacy of vestibular rehabilitation programs for unilateral peripheral vestibular disorder and these programs should be considered. A simple program including patient education and home based exercises can be sufficient.

Vertigo - part 1 - assessment in general practice.

BACKGROUND: Vertigo is a common and diagnostic challenge faced by clinicians. OBJECTIVE: This article discusses the assessment of patients with vertigo. DISCUSSION: The clinical assessment aims to: establish the presence of true vertigo, differentiate between vertigo of central or peripheral origins, and to evaluate the need for urgent investigations and referrals. Peripheral causes of vertigo are more common, but central causes such as transient ischaemic attack or stroke should always be considered and ruled out appropriately. Presence of syncope excludes the peripheral causes of vertigo. Vertigo in the elderly population is likely to be multifactorial and warrants careful evaluation. Online videos of the head impulse test and the Dix-Hallpike manoeuvre are valuable as these tests are of great diagnostic value. Audiological testing and neuroimaging can provide further information to guide patient management.

Traumatic pulmonary arteriovenous malformation presenting with massive hemoptysis 30 years after penetrating chest injury.

A 39-year-old man presented with massive hemoptysis requiring emergency double lumen endobronchial intubation, bronchial arteriography and embolization, and subsequent right lower lobectomy. He had suffered a shrapnel blast injury to the right chest as a 9-year-old boy. Pathology of the resected specimen revealed lodged metallic foreign body with traumatic arteriovenous malformation. We present this case to alert thoracic surgeons to this extremely rare clinical entity that can present itself many years after the penetrating trauma, which requires urgent surgery.