A Matter of Margins in Oral Cancer-How Close Is Enough?

In patients with oral cancer, the risk factors for local, regional, and distant recurrence according to margin status have not been well established. We aimed to determine the risk factors for recurrence by margin status and to identify a margin cut-off point for improved survival in patients with close margins. We retrospectively reviewed adult patients treated at our centre from 2009 to 2021 for primary oral cancer. Margins were classified as positive (<1 mm), close (1 to 4.9 mm), or clear (>5 mm). Univariate and multivariate analyses were performed. A total of 326 patients (210 men) were included. The mean age was 59.1 years. Margin status was close (n = 168, 51.5%), clear (n = 83, 25.4%), or positive (n = 75, 23.0%). In the univariate analysis, positive surgical margins (HR = 7.53) had the greatest impact on distant failure. Positive surgical margins-without nodal involvement-had the greatest impact on the risk of distant failure. In the close margin group, the optimal cut-off for disease-free survival (AUC = 0.58) and overall survival (AUC = 0.63) was a deep margin > 3 mm, with survival outcomes that were comparable to the clear margin group. These finding suggest that margins < 5 mm may be sufficient in certain well-defined cases. Prospective studies are warranted to confirm these findings.

Artificial intelligence in head and neck surgery: Potential applications and future perspectives.

Artificial intelligence (AI) has the potential to improve the surgical treatment of patients with head and neck cancer. AI algorithms can analyse a wide range of data, including images, voice, molecular expression and raw clinical data. In the field of oncology, there are numerous AI practical applications, including diagnostics and treatment. AI can also develop predictive models to assess prognosis, overall survival, the likelihood of occult metastases, risk of complications and hospital length of stay.

Management of clinically negative neck in salivary gland cancers - elective neck dissection, irradiation, or surveillance?

AIM OF THE STUDY: To retrospectively assess treatment outcomes among patients treated for salivary gland cancers at our institution to determine which of the three most common treatment approaches - elective neck dissection (END), elective neck irradiation (ENI), or observation - provide the best results. MATERIAL AND METHODS: A total of 122 patients were identified who had undergone primary surgery for SGC followed by END, ENI, or observation. The patients were classified into three groups according to the treatment approach used to manage the neck: END, ENI, or observation. The main outcome measures were disease-free survival (DFS) and overall survival (OS). We also sought to identify the risk factors potentially associated with neck metastasis and treatment failure. RESULTS: 106 patients met all inclusion criteria. Of these 106 patients, 27 (25.7%) underwent END, 17 (16.0%) underwent ENI, and 62 (58.5%) observation. There were no statistically significant differences between the three groups in any of the following variables: advanced age (> 70); presence of locally advanced disease (T3 or T4); perineural invasion; lymphovascular invasion; and primary tumour location. Treatment failure was higher (non-significantly) in the END group (25.9%) vs. the observation (21.0%) and ENI (11.8%) groups. No differences (Kaplan-Meir curves) were observed among the three groups in terms of DFS or OS. CONCLUSIONS: Our results show that elective neck dissection does not appear to provide any benefit to patients treated for malignant salivary gland cancer. Importantly, these findings contradict most of the currently available research. However, due to methodological differences among the available studies, our findings cannot be compared directly to other studies.

Robotic surgery (da Vinci Xi system) in head and neck cancer - own experience.

INTRODUCTION: Patients before 50 years of age with HPV-positive oropharyngeal cancer are characterized by significantly better survival than HPV-negative patients. The consequences of oncological treatment directly affect physiological function of the organs of the upper respiratory tract and, in consequence, the quality of life of these individuals. Therefore, the choice of therapy is of great importance. Minimally invasive surgery offers radical oncological treatment, while preserving the quality of life. The principal surgical methods are transoral access using TLM, electrosurgery and TORS. Radiochemotherapy as primary treatment is equally effective in the first and second stages of clinical advancement of cancer. However, occurrence of late complications such as swallowing, breathing, taste and smell disorders led to a recent re-emergence of minimally invasive surgery, particularly transoral robotic surgery, which has been widely used in head and neck surgery in the United States of America, Asia and Western European countries for more than 20 years. After many years, Poland joined the community of countries where the head and neck interventions are performed using the da Vinci Surgical System. OBJECTIVE: The purpose of the work is to present our own experience with the TORS at the Department of the Head and Neck Surgery and Laryngological Oncology of the Poznan University of Medical Sciences and to analyze the latest literature reports on the use of TORS in the treatment of oropharyngeal squamous cell carcinoma.

Patterns of treatment failure in salivary gland cancers.

AIM: The purpose of the study was to publish our experience of salivary gland cancer treatment with large number of patients treated at a single institution. BACKGROUND: Salivary gland cancers are rare tumors of the head and neck representing about 5% of cancers in that region and about 0.5% of all malignancies. Due to the rarity of the disease, most of the studies regarding treatment outcome consist of low number of patients, thus making it difficult to draw conclusions. MATERIAL AND METHODS: 115 patients with primary salivary gland cancer were included in a retrospective study. The subsites of tumor were the parotid gland (58% patients), submandibular gland (19%) and minor salivary glands (23%). All patients underwent primary surgical resection. The following were collected: age, stage of the disease, T status, N status, grade of tumor, perineurial invasion, lymphovascular invasion, extracapsular spread, final histological margin status and postoperative treatment. Details of local, regional or distant recurrence, disease free survival and overall survival were included. RESULTS: The majority (65%) of patients presented in early stage, T1 and T2 tumors. 81% of patients were N0. Free surgical margins were achieved in 18% of patients, close in 28% patients and positive surgical margins in 54% (62) patients. Factors that significantly increased the risk of recurrence: T stage (p = 0.0006); N-positive status (p < 0.0001); advanced stage of the disease (p < 0.0001); high grade of tumor (p = 0.0007); PNI (p = 0.0061); LVI (p = 0.0022); ECS (p = 0.0136); positive surgical margins (p = 0.0022). On multivariate analysis, high grade of tumor and positive surgical margins remained significant independent adverse factors for recurrence formation. CONCLUSIONS: This report shows a single institution results of oncological treatment in patients with malignant salivary gland tumors, where positive surgical margins strongly correlate with patients' worse outcome. Whether to extend the procedure, which very often requires sacrificing the nerve is still a question of debate.

Multivariate analysis as an advantageous approach for prediction of the adverse outcome in head and neck microvascular reconstructive surgery.

BACKGROUND: The use of a free flap has become a mainstay of reconstruction following the ablative surgery in head and neck. The success rates are about 90%, however, several factors have been described to have an adverse effect on free flap survival. METHODS: We have performed a retrospective analysis of the treatment outcome of 93 microvascular flaps and evaluated the factors influencing the risk of flap loss including patients' age, body mass index, smoking, general medical history and previous oncological treatment. RESULTS: Out of 93 flaps the total necrosis have been observed in 15 flaps with gradual improvement in the consecutive years. In individual analysis the patients age, BMI, and comorbidities did not reveal any significant relation. The history of any previous oncological treatment represented a significant adverse factor of success rate (p=0.035), and was even more significant when patients experienced all treatment modalities prior to the reconstructive procedure (p=0.009). Multivariate logistic regression model indicated that only surgery (p=0.0008), chemotherapy (p=0.02), cardiovascular diseases (p=0.05) and patient's age (p=0.02) represented significant factors impairing the success rate. CONCLUSION: Incorporating multivariate analysis represents important statistical approach for better prediction of free flaps survival in head and neck reconstructive surgery. Incorporation of additional collective information could provide more precise approach in the risk of the flap loss assessment.

Photodynamic therapy in palliative treatment of head and neck cancer.

INTRODUCTION: Head and neck cancers account for about 6% of all malignant tumors. Head and neck cancers are responsible for about 650,000 new cases and approximately 260,000 deaths in the world annually. About 50% of patients fail to achieve cure or relapse of cancer occurs despite intensive combined treatment. A small number of patients is eligible for re-treatment, and for most of them symptomatic treatment is used. Photodynamic therapy(PDT) may be an alternative these patients. PDT improves the quality of life in patients who are at the stage of the disease recognized as incurable according to present knowledge. MATERIALS AND METHODS: Study group consisted of three patients treated in the Department of Head and Neck Surgery in Poznan due to recurrence of squamous cell carcinoma of the head and neck. Patients were qualified to the palliative PDT ( Photodynamic therapy)with Foscan. when other possibilities of treatment have been used up. RESULTS: Two patients achieved a partial response (PR) by RECIST criteria. One patient achieved disease stabilization (SD). DISCUSSION: Photodynamic therapy is a therapeutic option in the palliative treatment of patients with squamous cell carcinoma of the head and neck. The careful qualification of the patients for this type of treatment is very important. One should take into account the location of the tumor and its size. Great advantage of photodynamic therapy is that it can be used repeatedly. Treatment with photodynamic therapy should be performed in specialized centers because of the need of adequate technical facilities. PDT may improve the quality of life of selected patients with incurable cancer of the head and neck.

Uncontrolled human papilloma virus infection in a 28-year-old man leading to death - case report and review of literature.

Recurrent respiratory papillomatosis is an increasingly common disease which leads to organic and functional limitations. Clinical symptoms depend on the location and extent of the papillomatosis. They include hoarseness, cough, and, in some cases, significant narrowing of the respiratory and digestive tracts. The present report describes a fatal case of a young man (28 years old) who developed a very dynamic papilloma infection of the larynx, which spread to the trachea, the oesophagus, the soft tissues of the neck, and the mediastinum. Multimodal treatment did not stop the progression of the disease. The papillomatous lesion was removed with a CO2 laser used in a Kleinsasser microlaryngoscopy and under a microscope using a electrocoagulation loop with argon plasma during the gastroscopy. Antiviral treatment with cidofovir was introduced, as well as in further follow-up radiotherapy. Congenital or acquired immunodeficiency was also excluded. Despite multimodal treatment, successful eradication of the infection was not possible. In our case, aggressive progression of the disease was observed. We were unable to confirm malignant transformation. Papillomatosis was the only disease, and its aggressive development led to the patient's death. In the case of aggressive, uncontrolled progression - when the infiltration spreads beyond the larynx and the hypopharynx - there are no alternative treatment methods that would lead to an effective cure.

Correlations between the clinical, histological and neurophysiological examinations in patients before and after parotid gland tumor surgery: verification of facial nerve transmission.

Parotid gland tumor surgery sometimes leads to facial nerve paralysis. Malignant more than benign tumors determine nerve function preoperatively, while postoperative observations based on clinical, histological and neurophysiological studies have not been reported in detail. The aims of this pilot study were evaluation and correlations of histological properties of tumor (its size and location) and clinical and neurophysiological assessment of facial nerve function pre- and post-operatively (1 and 6 months). Comparative studies included 17 patients with benign (n = 13) and malignant (n = 4) tumors. Clinical assessment was based on House-Brackmann scale (H-B), neurophysiological diagnostics included facial electroneurography [ENG, compound muscle action potential (CMAP)], mimetic muscle electromyography (EMG) and blink-reflex examinations (BR). Mainly grade I of H-B was recorded both pre- (n = 13) and post-operatively (n = 12) in patients with small (1.5-2.4 cm) benign tumors located in superficial lobes. Patients with medium size (2.5-3.4 cm) malignant tumors in both lobes were scored at grade I (n = 2) and III (n = 2) pre- and mainly VI (n = 4) post-operatively. CMAP amplitudes after stimulation of mandibular marginal branch were reduced at about 25 % in patients with benign tumors after surgery. In the cases of malignant tumors CMAPs were not recorded following stimulation of any branch. A similar trend was found for BR results. H-B and ENG results revealed positive correlations between the type of tumor and surgery with facial nerve function. Neurophysiological studies detected clinically silent facial nerve neuropathy of mandibular marginal branch in postoperative period. Needle EMG, ENG and BR examinations allow for the evaluation of face muscles reinnervation and facial nerve regeneration.

Oral cavity and oropharyngeal squamous cell carcinoma in young adults: a review of the literature.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is a disease of middle-aged to elderly adults. However, an increased incidence of HNSCC in young people under 45 years of age has been reported recently. In the present review, we focused on the epidemiology and aetiology of HNSCC in adults under 45 years of age. METHODS: We reviewed literature related to HNSCC in adult patients less than 45 years of age and discussed current treatment options and prognosis. RESULTS: HNSCC in young adults is associated with a higher incidence rate in nonsmokers, lower female-to-male ratio, a higher percentage of oral cavity and oropharynx tumours, and fewer second primary tumours. However, aside from traditional risk factors of tobacco and alcohol exposure, the causes of these cancers in young adults remain unclear. Agents that might contribute to risk include infection with high-risk human papillomavirus subtypes as well as genetic factors or immunodeficiency status. The expected increase in incidence and mortality of the young with HNSCC may become a major public health concern if current trends persist, particularly lifestyle habits that may contribute to this disease. CONCLUSIONS: Given the younger age and potential long-term adverse sequelae of traditional HNSCC treatments, young adults should be treated on a case-by-case basis and post-therapy quality of life must be considered in any treatment-decision making process.

The role of colour duplex sonography in preoperative perforator mapping of the anterolateral thigh flap.

The anterolateral thigh (ALT) flap was first described in 1984. It is now widely used in reconstructive surgery following extensive tumour resection in head and neck cancer. Routine preoperative perforator mapping is recommended due to variability of the vascular anatomy of the flap. A wide array of diagnostic tools is available for this purpose, including colour duplex sonography (CDS). In this study, we report our experience with CDS. The number, location, and course (myocutaneous or septocutaneous) of ALT perforators were assessed by CDS prior to reconstructive surgery in 22 patients with head and neck cancer. These data were compared with the intraoperative anatomical findings to assess agreement and reliability. The positive predictive value and sensitivity of CDS in detecting perforator location was 89.4 and 94.4%, respectively, when compared to the surgical report. CDS also identified the perforator course with 100% accuracy. Colour duplex sonography is an effective, non-invasive, and relatively inexpensive technique for assessing the location of skin perforators.

[Early surgical revision as a salvage procedure in the anterolateral thigh flap failure prevention--case report]. / Interwencja chirurgiczna w obrebie szypuly naczyniowej jako wczesna profilaktyka martwicy plata ALT--opis przypadku.

Microsurgical free flaps are considered state of the art in head and neck reconstruction after composite tumor resections. The anterolateral thigh (ALT) flap is frequently used in ablative head and neck surgery, providing superior functional and aesthetic restoration with a minor donor-site morbidity. However, flap failures do occur occasionally, vascular obstruction within first 24 postoperative hours is one of the main reasons of flap compromise. We present a case report of an early surgical exploration as a successful salvage procedure for ALT flap used for reconstruction of the massive scalp excision due to basal cell carcinoma.

[Orbital tumors in material of Department of Head and Neck Surgery and Oncological Laryngology of Greater Poland Cancer Center 2007-2010]. / Guzy oczodolu w materiale Oddzialu Chirurgii Glowy i Szyi i Onkologii Laryngologicznej Wielkopolskiego Centrum Onkologii w Poznaniu w latach 2007-2010.

INTRODUCTION: Tumors of the orbit are diagnosed sporadically. Based on the tumor registry of the American Cancer Society the incidence of tumors of the orbit is assessed at fewer than 1 per 100 000 persons. Tumors of the orbit can be divided into three groups: primary tumors, tumors penetrating the orbit from neighboring structures, and tumors that are metastases of malignant cancers from distant organs. AIM OF THE STUDY: To present the results of treatment of patients with tumors of the orbit treated in the Head and Neck Surgery and Laryngological Oncology Ward of the Greater Poland Cancer Centre in Poznan during 2007-2010. MATERIAL AND METHODS: The study group consisted of 26 patients surgically treated during 2007-2010 in the Head and Neck Surgery and Laryngological Oncology Ward of the Greater Poland Cancer Centre in Poznan. RESULTS: In the postoperative histopathological examination 18 patients (69%) were diagnosed with malignant tumors, 7 patients (27%) with non-malignant tumor and 1 patient (4%) with inflammatory lesion. Among malignant tumors the most frequent was basal cell carcinoma, diagnosed in 7 patients (27%). When removing the tumors of the orbit 4 types of operation were performed: lateral orbitotomy, superior orbitotomy, eye enucleation, and exenteration of the orbit. In 3 patients (12%) cancer recurrences occurred. All patients with recurrences underwent reoperation. In a patient with an extensive recurrence of squamous cell carcinoma the surgery was not radical and the patient died during palliative chemotherapy. CONCLUSIONS: Patients with tumors of the orbit should be treated operatively in appropriately prepared centers. In our material the confirmation of this thesis is the group of patients with recurrences of basal cell carcinoma, operated on many times in the past, who due to the extent of the cancerous process had to have the seeing eye removed. In the case of malignant cancers of the orbit an interdisciplinary approach to the problem and the assurance of psychological care for patients who have lost an orbit are essential.

[Our experience in the use of anterolateral thigh flap for reconstruction of the head and neck neoplasms]. / Doswiadczenia wlasne w zastosowaniu wolnych platów udowych w rekonstrukcji ubytków po rozleglych operacjach nowotworów zlosliwych glowy i szyi.

INTRODUCTION: Free flaps with vascular anastomosis have been widely used in clinical practice for more than 30 years. They are standard in reconstructive surgery following extensive resections caused by neoplasms of the head and neck. The anterolateral thigh flap (ALT) constitutes very good reconstructive material due to the long vascular pedicle, the appropriate diameter of vessels, the large skin island plane, and thickness depending on requirements. MATERIAL: The own material comprises 5 patients who have had extensive neoplastic infiltrations removed at different anatomic locations within the area of healthy tissue. RESULTS: Reconstructions have been conducted using a microvascular thigh flap (ALT). All of the operated patients are under constant supervision. The observation period ranges from 2 to 3 months. No recurrence of the neoplastic process or graft rejection has been observed in any of the patients.

[Intraoperative facial nerve monitoring for parotid gland surgery]. / Sródoperacyjne monitorowanie czynnosci nerwu twarzowego w chirurgii slinianki przyusznej.

INTRODUCTION: The route of the facial nerve in its extracranial part determines the technique of parotid gland surgery. Permanent facial nerve paralysis after parotidectomy is not rare. It is the most devastating complication for the patient and surgeon. Facial nerve monitoring by observing or palpating the face during the surgery is a long-standing practice. Using an EMG device is a standard procedure at present. AIM OF THE STUDY: Evaluation of the effectiveness of intraoperative facial nerve monitoring for parotid gland surgery. MATERIAL AND METHODS: Fifty three patients operated on due to parotid gland tumour in the Head and Neck Surgery and Laryngological Oncology Department of the Greater Poland Cancer Center in 2007-2008. All patients had been provided with EMG and ENG examinations of the facial nerve before the surgery and continuous facial nerve monitoring during the operation. Facial nerve function after surgery was assessed according to the House-Brackmann grading system. RESULTS: Six (12%) patients presented facial nerve dysfunction after surgery. Three (6%) patients had temporary paralysis grade III H-B with complete recovery in 6 weeks. Three (6%) patients with deep lobe tumour had grade V H-B with complete recovery in one patient after 3 months, and two (4%) patients had grade III H-B after one year since the surgery. CONCLUSIONS: Intraoperative facial nerve monitoring should be a standard procedure during parotid gland surgery in most clinical situations.

[Reconstruction of the hypopharynx and cervical esophagus with gastric pull-up technique in the patient with recurrence carcinoma of the hypopharynx]. / Rekonstrukcja czessci szyjnej przelyku technika gastric pull-up w przebiegu wznowy raka gardla dolnego i krtani.

Patient with hypopharyngeal cancer are difficult to treat because they usually present with advanced disease, poor general health status and severe nutritional problems. Because of the poor prognosis, careful consideration has to be given regarding the choice of the correct surgical approach for respirato-digestive tract reconstruction. The authors present a case of recurrent hypopharyngeal cancer with cervical esophagus infiltration successfully treated with total laryngectomy and esophagectomy and gastric pull up reconstruction. Indications for technique, method of reconstruction and complications are, discussed. As most authors we consider the gastric transposition method as the preferred approach to restore digestive continuity after total esophagectomy. As the method is the single stage procedure it provides the best palliation of dysphagia and allows early resumption of an oral diet.