A Qualitative Study of Decision-making (DM) in Surgery and Cancer Care: an Indian Perspective.

Cancer psychology is a vitally important part of cancer management. Qualitative research is a gateway to exploring this. Weighing the treatment options in terms of quality of life and survival is important. Given the globalization of healthcare seen in the last decade, the exploration of the decision-making process in a developing nation was deemed highly appropriate. The aim is to explore the thoughts of surgical colleagues and care providing clinicians about patient decision-making in cancer care in developing countries, with special reference to India. The secondary objective was to identify factors that may have a role to play in decision-making in India. A prospective qualitative study. The exercise was carried out at Kiran Mazumdhar Shah Cancer Center. The hospital is a tertiary referral center for cancer services in the city of Bangalore, India. A qualitative study by methodology, a focus group discussion was undertaken with the members of the head and neck tumor board. The results showed, in India, decision-making is predominantly led by the clinicians and the patient's family members. A number of factors play an important role in the decision-making process. These include as follows: health outcome measures (quality of life, health-related quality of life), clinician factors (knowledge, skill, expertise, judgment), patient factors (socio-economic, education, cultural), nursing factors, translational research, and resource infrastructure. Important themes and outcomes emerged from the qualitative study. As modern healthcare moves towards a patient-centered care approach, evidence-based patient choice and patient decision-making clearly have a greater role to play, and the cultural and practical issues demonstrated in this article must be considered. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01521-x.

Patients' views on a proposed oral cancer screening technology.

Brush cytology and telemedicine platforms are used with proven benefits in remote diagnosis of malignancies like cervical cancer. In low-resource settings access to the current standard of care, biopsy and histopathology grading of oral lesions, can be unfeasible. Risk-stratifying early malignant and oral potentially-malignant lesions can help instigate therapeutic treatment and improve prognosis. Therefore, a telecytology platform enabling remote connectivity to specialist centres may aid early detection of oral cancer. We outline head and neck (H&N) cancer patients' views on an oral brush cytology investigation.

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.

Trends of head and neck cancers in urban and rural India.

BACKGROUND: The sub-site predilection of head and neck squamous cell carcinoma (HNSCC) reflects the risk profile of a community and there are suggestions that these are changing over time. OBJECTIVE: To determine the change in head and neck cancer in rural and urban populations in India. METHODS: Cancer registry data of an urban and a rural population were reviewed over a period of 13 and 11 years, respectively. Age adjusted rates (AAR) and age specific incidence rates were used for data analysis. RESULTS: Oral cancers formed the majority of the head and neck cancers with a predilection for tongue, except in rural males, in whom the pharynx was the predominant sub-site. Overall there was a reduction in the incidence of HNSCC, which was more pronounced in urban females and rural males (p< .001). Among the sub-sites, oral cavity cancers showed a decreasing trend in urban females (p< .01) and rural males (p< .01). However, the trend was towards increase of incidence of tongue cancers. Pharyngeal cancer showed reduction in urban females (p< .01), whereas it increased in rural females. The recent increase in incidence of young adults with HNSCC reported in developed countries was not observed. CONCLUSIONS: Overall, incidence of HNSCC is reducing. This may be attributed to the decreased prevalence of tobacco use. The increase in incidence of tongue cancer may suggest factors other than tobacco and alcohol in its genesis.

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.

A technique for recording the activity of brain-stem neurones in awake, unrestrained cats using microwires and an implantable micromanipulator.

A new technique is described which is suitable for long-term recording of the activity of neurones in the brain of an awake, unrestrained cat. By using telescopic electrodes, neurones up to 39 mm from the cranial surface can be reached with a miniature micromanipulator which is small enough to be left in place between recording sessions. The most stable recordings have been obtained with electrodes made from microwire, with which units have been held for up to 8 h.

Leptospirosis--clinical spectrum and correlation with seven simple laboratory tests for early diagnosis in the Third World.

Twenty-four patients who were clinically suspected of having leptospirosis were subjected to 7 simple commonly available laboratory tests. The 21 patients who had 3 or more positive tests were confirmed serologically to have leptospirosis. The high frequency of acute abdominal pain (71.4%) as a major presenting symptom and the laboratory findings of raised serum amylase levels in a high percentage of patients (84.2%) were especially noteworthy.

A novel approach to laryngeal suspension after partial laryngectomy.

OBJECTIVES: Supraglottic laryngectomy is a well-established surgical therapy for selected carcinomas of the larynx and hypopharynx. Most compromised by this procedure and its variations is the laryngeal mechanism that protects the lower respiratory tract from aspiration. Laryngeal suspension serves to compensate for the loss of the resected laryngeal elevator muscles by pulling the larynx upward and forward beneath the tongue base. In this study we describe a method of laryngeal suspension in supraglottic laryngectomy using a cartilage-anchored suture carrier device. STUDY DESIGN: Report of this novel approach to laryngeal suspension using seven suture anchors in two patients undergoing supraglottic laryngectomy. METHODS: Seven Mitek Micro anchors (Mitek, Westwood, MA) were used to perform laryngeal suspension in two patients undergoing supraglottic laryngectomy. Our technique is compared with traditional methods. Operative data as well as postoperative functional results are reviewed. RESULTS: Laryngeal suspension using suture anchors was successful, with failure of only one anchor. Oral alimentation was quickly reestablished in both patients. There were no perioperative or postoperative complications. CONCLUSIONS: We describe a novel approach to laryngeal suspension that overcomes some of the technical challenges inherent in traditional suturing techniques. This novel approach is technically easier and more efficient than traditional methods and accomplishes distribution of stress forces on the thyroid cartilage remnant.

Surgery versus radiation therapy as single-modality treatment of tonsillar fossa carcinoma: the Roswell Park Cancer Institute experience (1971-1991).

OBJECTIVE: To compare the efficacy and treatment outcomes in patients with tonsillar fossa cancer using surgery or radiation as a single modality therapy. METHODS: From 1971 to 1991 239 patients with oral pharyngeal cancer were treated at Roswell Park Cancer Institute. Of these patients 90 had tonsillar carcinoma. Seventy-six of these patients received either surgery (SA) (n = 56) or radiation therapy (RA) (n = 20) as single-modality therapy and are the subject of this review. All patients in the radiation arm of this review were surgical candidates who declined primary surgical therapy. RESULTS: Sixty-three percent of the SA and 80% of the RA treatment groups presented with either stage III or stage IV disease (P < or = .05). Forty-seven percent of the SA group and 52% of the RA patients had clinically positive regional disease at initial presentation. There was a predictable pattern of nodal presentation, with level II the most frequently involved region. The rate of occult metastasis was 27% and was evenly distributed between T1 and T4 disease. The overall local control rate in the SA group was 75%, compared with 60% in the RA group (P value was not significant). The disease-specific survival (all stages) was 61% in the SA group and 37% in the RA group (P < or = .05). The disease-free survival for stage III and stage IV disease in the SA group was 47% and in the RA group 27% (P < or = .05). Survival measured against clinical response to radiation therapy, in complete responders (all stages) was 83%; by contrast there were no survivors past 24 months in the partial response group (P < or = .001). CONCLUSION: The results from this study suggest that for early disease (stage I/II), surgery or radiation therapy as single-modality treatment is equally effective. For advanced disease radiation therapy is inferior to surgery as a single-modality treatment, as measured by ultimate survival and the local control of disease. There is, however, a subset of patients with advanced disease who respond to radiation therapy and whose survival is equivalent to our surgical cohort of patients.

Motility-related proteins as markers for head and neck squamous cell cancer.

HYPOTHESIS: Increased cell motility is a hallmark of cancer cells. Proteins involved in cell motility may be used as molecular markers to characterize the malignant potential of tumors. METHODS: Molecular biology and immunohistochemistry techniques were used to investigate the expression of a selected panel of motility-related proteins (Rho A, Rac 2, Cdc42, PI3K, 2E4, and Arp2) in normal, premalignant, and squamous cell cancer cell lines of human head and neck origin. To assess the clinical potential of these proteins as molecular markers for cancer, immunohistochemistry was performed on paraffin-fixed head and neck cancer specimens (n = 15). RESULTS: All six motility-associated proteins were overexpressed in the premalignant and squamous cell cancer cell lines relative to normal keratinocytes. Immunohistochemistry with Rho A and Rac 2 showed increased staining in areas of cancer but not in normal tissue. CONCLUSION: Proteins involved in cell motility can be used as markers for head and neck squamous cell carcinoma. The head and neck cell lines used in this study may be used as a model to further investigate cell motility. Molecular markers of motility could have a significant impact on the diagnosis and staging of cancers originating from differentiated non-motile cells.

Adhesion molecules as prognostic factors in nasopharyngeal carcinoma.

OBJECTIVE/HYPOTHESIS: To identify the significance of molecular markers in determining the risk of recurrence and distant metastases in nasopharyngeal carcinoma. STUDY DESIGN: In this retrospective case study, we evaluated archival nasopharyngeal carcinoma specimens for patterns of expression of E-cadherin, beta-catenin, c-erb-B2, and Ki-67, which have been demonstrated to be important in other tumors. METHODS: Fifty-four cases of nasopharyngeal carcinoma were identified, with a maximum follow-up of 13 years. The histopathological sections were stained using an automated immunohistochemical stainer (NexES, Ventana Medical Systems, Tucson, AZ) for E-cadherin (Zymed Laboratories [San Francisco, CA] and Transduction Laboratories [Lexington, KY] clones), beta-catenin (Zymed), c-erb-B2 (Ventana Medical Systems), and Ki-67 (Novocastra, Burlingame, CA). The numbers of positively staining cells were scored as follows: 0%, 1% to 33%, 34% to 66%, or greater than 67%. RESULTS: E-cadherin (Zymed) stained positively in only one case. The Transduction Laboratories clone demonstrated a spectrum of staining in all cases, from complete to disrupted to no identifiable membranous staining. The staining was consistently absent at the advancing tumor border, regardless of stage. The loss of beta-catenin expression did not correlate with that of E-cadherin or with clinical outcomes. No staining was identified for c-erb-B2. Ki-67 staining was variable and did not correlate with clinical outcomes. CONCLUSIONS: Altered expression or loss of E-cadherin, or both, may result in loss of function, particularly at the infiltrating edge, with resultant loss of cell polarity, cell migration, and eventual metastasis. The interpretation of E-cadherin staining depends on antibody source. In contrast to recent studies, beta-catenin expression is not altered and c-erb-B2 expression not identified, suggesting that these markers are not important in the prognosis of nasopharyngeal carcinoma.

Simultaneously presenting head and neck and lung cancer: a diagnostic and treatment dilemma.

OBJECTIVES/HYPOTHESIS: Synchronous tumors are defined as malignancies presenting within 6 months of the index tumors. A significant subset of patients present at initial evaluation with malignant tumors of both the head and neck (head and neck squamous cell carcinoma) and the lung, which are termed simultaneous primaries. The management and treatment outcomes in this cohort of patients have not been clearly defined and are the subject of the present review. STUDY DESIGN: Retrospective chart review of previously untreated patients. METHODS: From January 1974 to December 1997, a total of 2964 patients were treated for mucosal squamous cell carcinoma of the head and neck. Forty-two patients fulfilled the criteria for synchronous head and neck and lung malignancy. Of these, 27 patients had simultaneous tumors of the head and neck and the lung. This cohort of patients (n = 27) was stratified into three treatment groups. Patients in group A (n = 10) had resectable head and neck and lung primaries treated with curative intent. Group B (n = 8) was composed of patients who could have been treated with curative intent but declined and were given only palliative therapy. Patients in group C (n = 9) were candidates for only palliative treatment. RESULTS: The estimated 5-year disease-specific survival in group A was 47%, whereas patients in group B had a 5-year disease-specific survival of only 13% (P =.05). There were no survivors beyond 1 year in group C. The presence of mediastinal adenopathy in patients in group A portended poor clinical outcome. There was an estimated 5-year disease-specific survival of 51% in patients with no preoperative evidence of mediastinal adenopathy (n = 7), whereas 67% of patients with radiological evidence of mediastinal adenopathy died (two of three patients). CONCLUSION: The presence of simultaneous head and neck squamous cell carcinoma and pulmonary malignancies should not be a deterrent to aggressive surgical therapy because a potentially satisfactory outcome can be expected in these patients.

Clinical experience in end-to-side venous anastomoses with a microvascular anastomotic coupling device in head and neck reconstruction.

BACKGROUND: Microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. Despite the availability of various mechanical anastomotic coupling systems for human clinical use during the last 8 years, reported clinical series remain rare. OBJECTIVE: To describe a clinical experience in applying a mechanical microvascular anastomotic coupling device (MACD) to end-to-side anastomotic configurations in head and neck free-flap reconstruction. METHODS: The MACD is a readily available high-density polyethylene ring-stainless steel pin system that has been found to be highly effective in clinical studies of end-to-end arterial and venous anastomosis and in laboratory studies of end-to-side anastomosis of rabbit arteries. RESULTS: Thirty-seven end-to-side venous anastomoses were attempted, of which 33 (89%) were completed. Of these, 9 patients had critical anastomoses (only 1 venous anastomosis per patient). In patients undergoing parallel venous anastomoses, 6 had both anastomoses performed using the MACD; in the remaining 12 patients, 1 of the anastomoses was performed using the MACD. A variety of donor flaps and clinical contexts were encountered. Flap survival in the MACD series was 100%. Four anastomoses were converted to conventional suture technique intraoperatively. CONCLUSIONS: The MACD is well suited to end-to-side venous anastomosis when carefully and selectively used by experienced microvascular surgeons. The most common clinical situation requiring this configuration and technique was the lack of ipsilateral recipient veins for end-to-end anastomosis or a ligated internal jugular vein stump that required this approach for device application. Previous radiation therapy does not appear to be a contraindication to its use.

Sensate radial forearm free flaps in tongue reconstruction.

BACKGROUND: Successful rehabilitation after ablative surgery requires not only the reconstruction of 3-dimensional form but also the restoration of physiologic function. OBJECTIVE: To assess sensory recovery of reinnervated radial forearm flaps used for tongue reconstruction. PATIENTS AND METHODS: Seventeen patients, who underwent reconstruction of glossectomy defects with reinnervated radial forearm free flaps, formed the study group. Recovery of sensation was measured by both subjective and detailed objective tests 8 months after surgery. Sensory function of the flap was compared with that of the normal residual tongue or the adjacent oral mucosa and the contralateral forearm donor site. RESULTS: All patients involved in this study had tongue defects of hemiglossectomy or greater and adjacent floor of the mouth. Sensory recovery was observed in all of the 17 patients within 8 months. Detailed sensory testing showed that median static 2-point discrimination, moving 2-point discrimination, and pressure sensitivity (1.2 cm, 0.8 cm, and 3.7 psi, respectively) were subjectively greater in the innervated forearm flaps than in the contralateral forearm donor site (2.3 cm, 1.7 cm, and 4.6 psi, respectively) (P= .064) and similar to those of the normal tongue (0.9 cm, 0.5 cm, and 3.6 psi). CONCLUSIONS: In all modalities examined, sensate free flaps proved superior in sensory fidelity to the native forearm donor site and closely approached that of the normal tongue. Microsurgical reinnervation of flaps should be considered in tongue reconstruction.

Tissue-specific gene expression of head and neck squamous cell carcinoma in vivo by complementary DNA microarray analysis.

OBJECTIVES: To identify distinct gene expression profiles of human head and neck squamous cell carcinomas (HNSCCAs) using complementary DNA (cDNA) microarray analysis and to create a preliminary, comprehensive database of HNSCCA gene expression. PATIENTS AND METHODS: Nine patients with histologically confirmed HNSCCAs, staged according to the American Joint Committee on Cancer, were enrolled. The HNSCCA tumor tissue and normal mucosal tissue were harvested at the time of surgery. A cDNA library was constructed from the paired fresh-frozen human surgical specimens of HNSCCAs and nonmalignant epithelial tissues. Biotinylated RNA was transcribed from the cDNA library and hybridized to high-density microarrays containing approximately 12 000 human genes. Altered gene expression of HNSCCAs was identified by comparison to corresponding normal mucosal tissues after a bayesian statistical analysis of variance. Results were analyzed using the gene database of the National Institutes of Health. Hierarchical clustering of the genomic data sets was determined by similarity metrics based on Pearson correlation. RESULTS: Hierarchical clustering analysis revealed that the gene expression profiles obtained from the nonselected panel of 12 000 genes could distinguish the tumors from nonmalignant tissues. Gene expression changes were reproducibly observed in 227 genes representing previously identified chemokines, tumor suppressors, differentiation markers, matrix molecules, membrane receptors, and transcription factors that correlated with neoplasia, including 46 previously uncharacterized genes. Moreover, significant expression of the collagen type XI alpha1 gene and a novel gene was reproducibly observed in all 9 tumors, whereas these genes were virtually undetectable in their corresponding, adjacent nonmalignant tissues. CONCLUSIONS: Complementary DNA microarray analysis of human HNSCCAs has produced a preliminary, comprehensive database of tumor-specific gene expression profiles and provided important insights into modeling gene expression changes implicated in carcinogenesis. A large-scale analysis of gene expression carries the future potential of identifying sensitive molecular markers for early tumor detection, prognosis, and novel targets for interceptive therapeutics.

Patterns of nodal metastasis and surgical management of the neck in supraglottic laryngeal carcinoma.

BACKGROUND: Appropriate management of the clinically negative (N0) neck in supraglottic laryngeal cancer continues to be an area of controversy in head and neck surgery. Our treatment policy has been aggressive surgical management even in the clinically N0 neck. METHODS: Between 1971 and 1991, 104 patients had the primary diagnosis of supraglottic laryngeal cancer. Ninety of these patients received their treatment at Roswell Park Cancer Institute and are the subject of this retrospective review. RESULTS: All neoplasms included in this study were squamous cell cancers. The most common subsite involved with tumor in our series was the epiglottis, followed by the aryepiglottic folds and false cords. Supraglottic laryngectomy was performed of 29% of the cases; the remainder received total laryngectomy. Thirty-six percent of the patients had pathologic stage I/II disease, and 64% had stage III/IV. The 5-year survival rates were 100%, 81%, 73%, and 63% for stages I through IV, respectively. Fifty-seven patients had clinically N0 disease at presentation; of these 34 underwent elective neck dissection, and the remaining 23 patients were observed. Of those patients receiving neck dissection, 30% (n = 10) were found to have histologically positive disease, and of the 23 patients observed, 30% (n = 7) had histologically positive regional (neck) disease. Of the 17 clinically N0 and pathologically N+ patients, 82% (14 of 17) had involvement of level I (submandibular triangle), and 100% had involvement of level II. The incidence of bilateral disease in the clinically N0 patient was 44%. There were no local failures. CONCLUSIONS: There is a high incidence of occult regional disease even in early-stage supraglottic squamous cell carcinoma of the larynx. In the surgical management the clinically N0 neck, we presently recommend bilateral neck dissection of levels I through IV to adequately address those regions at highest risk for occult disease.

Titanium mesh in orbital wall reconstruction.

Successful use of titanium mesh sheets in the reconstruction of orbital wall defects of up to 2.5 x 2.5 cm following trauma and followed up for a mean of 24 months is demonstrated. This material is especially useful in orbital floor and medial wall blow-out fractures, and is a valuable additional material for use in maxillofacial reconstruction.

Supraglottic carcinoma: does preoperative radiotherapy reduce the incidence of cervical metastasis?

OBJECTIVE: To compare surgery (S) alone with combined radiotherapy and surgery (R + S) in the management of patients with supraglottic laryngeal cancer. METHODS: Between 1981 and 1994, patients were stratified according to stage and randomised to either surgery (S) or 4000cGy of radiotherapy and surgery. There were 102 patients in the S group and 99 in the R + S group who completed at least 3-year follow-up. RESULTS: Using Kaplan-Meier survival method showed no significant difference between the two groups. When the patients were grouped according to tumour stage, a significant reduction in the regional recurrence was noted in the R + S group for stage I-III disease (Cox multivariate analysis, P < 0.02). They had an increased relative risk of 1.8 (95% confidence 1.1-2.9) for neck recurrence. There was no significant difference in neck recurrence rates in the two groups for stage IV disease. When Cox proportional hazard model was used, only TNM stage (P < 0.02) and histological nodal status (positive lymph nodes, P < 0.01) were found to be independent risk factors for regional control. CONCLUSION: Preoperative radiotherapy can improve regional cervical control of stage I-III supraglottic cancer as compared with surgery alone.

A precision method for contouring bioresorbable implants in craniomaxillofacial surgery.

Bioresorbable implants (meshs and plates) are increasingly used in reconstructive craniofacial and skull base surgery. Usually these implants must be contoured to fit the complex craniofacial anatomy ex vivo; occasionally final contouring is performed in vivo and must be done without damaging surrounding structures (e.g., dura, brain). We report a precision method for in vivo contouring of bioresorbable implants using the Shaw hemostatic thermal scalpel.