A novel endoscopic nasopharyngectomy by low-temperature plasma radiofrequency ablation in localized recurrent nasopharyngeal carcinoma.

OBJECTIVE: Endoscopic nasopharyngectomy (ENPG) with en bloc resection has been well accepted in resectable localized recurrent nasopharyngeal carcinoma (rNPC), but it is a difficult technique to master for most otorhinolaryngology head and neck surgeons. Ablation surgery is a new and simplified method to remove tumors. We designed a novel method using low-temperature plasma radiofrequency ablation (LPRA) and evaluated the survival benefit. METHODS: A total of 56 localized rNPC patients were explained in detail and retrospectively analyzed. The surgery method was ablated from the resection margin to the center of the tumor. The postmetastatic overall survival (OS), local relapse-free survival (LRFS) rate, progression-free survival (PFS) and distant metastasis-free survival (DMFS) were analyzed using the Kaplan-Meier method and compared by the log-rank test. RESULTS: All surgeries were successfully performed without any severe postoperative complications or deaths. The median operation time of ablation and harvested NSFF respectively were 29 min (range, 15-100 min) and 101 min (range, 30-180 min). The average number of hospital days postoperation was 3 days (range, 2-5 days). All cases (100.0%) had radical ablation with negative resection margins. The nasopharyngeal defects were completely re-epithelialized in 54 (96.4%) patients. As of the data cutoff (September 3, 2023), the median follow-up time was 44.3 months (range, 17.1-52.7 months, 95% CI: 40.4-48.2). The 3-year OS, LRFS, PFS and DMFS of the entire cohort were 92.9% (95% CI: 0.862-0.996), 89.3% (95% CI: 0.813-0.973), 87.5% (95% CI: 0.789-0.961), and 92.9% (95% CI: 0.862-0.996), respectively. Cycles of radiotherapy were independent risk factors for OS (p = 0.003; HR, 32.041; 95% CI: 3.365-305.064), LRFS (p = 0.002; HR, 10.762; 95% CI: 2.440-47.459), PFS (p = 0.004; HR, 7.457; 95% CI: 1.925-28.877), and DMFS (p = 0.002; HR, 34.776; 95% CI: 3.806-317.799). CONCLUSION: Radical endoscopic nasopharyngectomy by using low-temperature plasma radiofrequency ablation is a novel, safe and simplified method to master and disseminate for treating resectable rNPC. However, further data and longer follow-up time are needed to prove its efficacy.

Postoperative hypoparathyroidism after thyroid operation and exploration of permanent hypoparathyroidism evaluation.

Background: To investigate the risk factors for hypoparathyroidism, discuss the prevention of postoperative hypoparathyroidism, and explore permanent postoperative hypoparathyroidism evaluation (PPHE). Methods: A total of 2,903 patients with thyroid nodules were treated between October 2012 and August 2015. Serum calcium and intact parathyroid hormone (iPTH) levels were measured at 1 day, 1 month, and 6 months postoperatively. The incidence and management of hypoparathyroidism were analyzed. The PPHE was established based on the risk factors and clinical practice. Results: A total of 637 (21.94%) patients developed hypoparathyroidism, and 92.15% of them had malignant nodules. The incidence rates of transient and permanent hypoparathyroidism were 11.47% and 10.47%, respectively. The iPTH level was lower in patients with malignant nodules who underwent total thyroidectomy (TT) and central-compartment neck dissection (CND). These factors were independently associated with the recovery rate of parathyroid function. The formula for PPHE is as follows: {iPTH} + {sCa} + {surgical procedure} + {reoperation} + {pathologic type}. A scoring system was developed, and we scored low, middle, and high risk of permanent postoperative hypoparathyroidism as 4-6, 7-9, and 10-13, respectively. The differences in the recovery rates of parathyroid function in several risk groups were statistically significant (p < 0.001). Conclusion: Simultaneous TT and CND is a risk factor for hypoparathyroidism. The reoperation is not associated with hypoparathyroidism. Identification of parathyroid glands in situ and preservation of their vascular pedicles are key factors in managing hypoparathyroidism. PPHE can forecast the risk of permanent postoperative hypoparathyroidism well.

Efficacy of local therapy to metastatic foci in nasopharyngeal carcinoma: large-cohort strictly-matched retrospective study.

Background: Studies of local therapy (LT) to metastatic foci from nasopharyngeal carcinoma (NPC) are inconsistent and controversial. Here, we aimed to explore the survival benefit of LT directed at metastatic foci from NPC. Methods: A retrospective analysis was conducted in NPC patients with liver, lung, and/or bone metastases. The postmetastatic overall survival (OS) rate was analyzed using the Kaplan-Meier method and compared by the log-rank test. Multivariate analysis was performed using the Cox hazard model. Subgroup analyses evaluating the effect of LT were performed for prespecified covariates. Propensity score matching was applied to homogenize the compared arms. Results: Overall, 2041 of 2962 patients were eligible for analysis. At a median follow-up of 43.4 months, the 5-year OS improved by an absolute difference of 14.6%, from 46.2% in the LT group versus 31.6% in the non-LT group, which led to a hazard ratio of 0.634 for death (p < 0.001). Matched-pair analyses confirmed that LT was associated with improved OS (p = 0.003), and the survival benefits of LT remained consistent in the subcohorts of liver and lung metastasis (p = 0.009 and p = 0.007, respectively) but not of bone metastasis (BoM; p = 0.614). Radiotherapy was predominantly used for BoM and biological effective dose (BED) >60 Gy was found to yield more survival benefit than that of BED ⩽ 60 Gy. Conclusions: The addition of LT directed at metastasis has demonstrated an improvement to OS compared with non-LT group in the present matched-pair study, especially for patients with liver and/or lung metastases.

Transcervical endoscopic retropharyngeal lymph node (RPLN) dissection in nasopharyngeal carcinoma with RPLN recurrence.

BACKGROUND: Surgical access for retropharyngeal lymph node (RPLN) dissection is difficult. We aimed to examine the efficacy of transcervical endoscopic RPLN dissection (TSE-RPLND) for recurrent RPLN in nasopharyngeal carcinoma (NPC). METHODS: From April 2013 to February 2019, a total of 31 patients with NPC diagnosed with RPLN recurrence underwent TSE-RPLND. The clinical characteristics, complications, and survival outcomes were retrospectively analyzed. RESULTS: The mean duration of surgery, quantity of bleeding and postoperative hospitalization stay were 347.9 minutes, 107.7 mL, and 8.7 days, respectively. After a median follow-up of 31.0 months, the 2-year locoregional relapse-free survival, distant metastasis-free survival, progression-free survival, and overall survival rates were 63.9%, 95.2%, 59.9%, and 83.3%, respectively. The long-term incidences of swallowing problems, permanent nutrient tube, tongue atrophy, and shoulder problems were 6 (19.4%), 3 (9.7%), 3 (9.7%), and 3 (9.7%), respectively. CONCLUSIONS: TSE-RPLND is an effective method to treat RPLN recurrence in NPC, but nerve injury-related complications should not be ignored.

A curative-intent endoscopic surgery for postradiation nasopharyngeal necrosis in patients with nasopharyngeal carcinoma.

BACKGROUND: Postradiation nasopharyngeal necrosis (PRNN) is a severe complication after radiotherapy in patients with nasopharyngeal carcinoma (NPC), which can severely affect the quality of life and threaten the patient's life. Only 13.4%-28.6% of patients can be cured by traditional repeated endoscopic debridement. Here, we introduced an innovative curative-intent endoscopic surgery for PRNN patients and evaluated its clinical efficacy. METHODS: Clinical data of 72 PRNN patients who underwent radical endoscopic necrectomy, followed by reconstruction using a posterior pedicle nasal septum and floor mucoperiosteum flap were analyzed to determine the efficacy of this surgery. The endpoints were complete re-epithelialization of the nasopharyngeal defect, relief of headache, and overall survival (OS). RESULTS: All surgeries were successfully performed without any severe postoperative complications or death. The median value of numeric rating scales of pain decreased from 8 before surgery to 0 after surgery (P < 0.001). Fifty-one patients (70.8%) achieved complete re-epithelialization of the nasopharyngeal defect. The number of cycles of radiotherapy (odds ratio [OR], 7.254; 95% confidence interval [CI] 1.035-50.821; P = 0.046), postoperative pathological result (OR, 34.087; 95% CI 3.168-366.746; P = 0.004), and survival status of flap (OR, 261.179; 95% CI 17.176-3971.599; P < 0.001) were independent risk factors of re-epithelialization of the nasopharyngeal defects. Postoperative pathological result (hazard ratio [HR], 5.018; 95% CI 1.970-12.782; P = 0.001) was an independent prognostic factor for OS. The 2-year OS rate of the entire cohort was 77.9%. CONCLUSION: Curative-intent endoscopic necrectomy followed by construction using the posterior pedicle nasal septum and floor mucoperiosteum flap is a novel, safe, and effective treatment of PRNN in patients with NPC.

New surgical staging system for patients with recurrent nasopharyngeal carcinoma based on the AJCC/UICC rTNM classification system.

BACKGROUND: Recurrent tumour, node and metastasis (rTNM) stage system does not have an outstanding prognostic value for survival outcome of patients with recurrent nasopharyngeal carcinoma (rNPC) and it cannot aid the clinicians to choose the most suitable treatment for these patients. METHODS: In total, 894 rNPC patients were consecutively enroled. All recurrent (r) tumour (T) stages (rT) and node (N) stages (rN) were stratified as resectable and unresectable based on the imaging data of the head and neck. These stages were re-subdivided into surgical T stages (sT) and surgical N stages (sN) with similar clinical characteristics and death risks and were re-integrated into a new 'surgical' stage using a Cox proportional hazards model. RESULTS: The 5-year overall survival (OS) was 72.0%, 55.1%, 21.1% and 10.1% in 'surgical' stages I, II, III and IV, respectively (P<0.001). The 'surgical' stage was a significant independent prognostic factor for OS (hazard ratio [HR] 1.78, P<0.001) and exhibited enhanced prognostic value compared with the rTNM staging system (area under receiver operating characteristics 0.68 versus 0.63, P<0.001). Endoscopic nasopharyngectomy and intensity-modulated radiation therapy were significant independent positive prognostic factors for the OS of patients with primary lesions in 'surgical' stage I/II and 'surgical' stage III, respectively (P<0.05). A combination of aggressive treatments for loco-regional lesions exhibited a beneficial trend for OS of patients with 'surgical' stage IV (P>0.05). CONCLUSIONS: Compared with the rTNM stage system, the 'surgical' staging system exhibited enhanced prognostic value for rNPC patient survival and could aid clinicians in choosing the most suitable treatment for rNPC patients.

Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2N0 oral tongue squamous cell carcinoma.

OBJECTIVE: This study aimed to compare the value of sentinel lymph node biopsy (SLNB) with that of elective neck dissection (END) for the prediction of cervical lymph node metastasis in patients with clinically diagnosed T1-2N0 (cT1-2N0) oral tongue squamous cell carcinoma (OTSCC), and it aimed to examine the prognostic value of individualized treatment in sentinel lymph node (SLN)-negative patients. STUDY DESIGN: The study entailed a retrospective review of 82 patients with cT1-2N0 OTSCC. Thirty patients underwent SLNB, and 52 patients underwent END. RESULTS: There was a significant difference between the SLNB and END groups in the incidence of occult cervical lymph node metastasis in initial specimens (30% vs 11.5%; P = .037). However, there were no significant differences between the groups for 10-year overall and cervical recurrence-free survival rates and 10-year overall survival rate. CONCLUSIONS: SLNB is superior to END for the prediction of cervical lymph node metastasis in patients with cT1-2N0 OTSCC. Neck dissection may be reduced for SLN-negative patients, owing to the comparable prognosis of SLNB.

Use of a posterior pedicle nasal septum and floor mucoperiosteum flap to resurface the nasopharynx after endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: Endoscopic nasopharyngectomy is a new salvage treatment for locally recurrent nasopharyngeal carcinoma (NPC). However, how to resurface the nasopharyngeal defects in endoscopic endonasal approaches to avoid persistent postoperative headache, to the best of our knowledge, has not been reported. METHODS: From September 2009 to August 2010, we used a modified posterior pedicle nasal septum and floor mucoperiosteum flap (nasal septum and floor flap, NSFF) after endoscopic nasopharyngectomy in 12 patients with locally recurrent NPC. Most of the nasal septum and floor mucoperiosteum, except for the posterior pedicle, was harvested to cover the nasopharyngeal defects. RESULTS: All NSFFs successfully covered the entire nasopharyngeal defects and relined the nasopharynx with good functional recovery. The nasopharyngeal wounds recovered in 28 days (range, 14 to 56 days), and the donor-site wounds recovered in 46.5 days (range, 24-84 days). No reconstruction-related complications or disease recurrences were observed. CONCLUSION: The NSFF is a safe and promising reconstructive option to resurface the nasopharyngeal defect after endoscopic nasopharyngectomy in patients with locally recurrent NPC.

[Detection and clinical significance of cervical lymph node micrometastases in patients with cN0 tongue squamous cell carcinoma].

BACKGROUND & OBJECTIVE: Postoperative relapse in tongue squamous cell carcinoma patients with pathologically negative cervical lymph node might be related to micrometastases. This study was to detect the lymph node micrometastases in cN0 tongue cancer patients, and explore its clinical significance. METHODS: A total of 523 cervical lymph nodes taken from 49 tongue cancer patients were examined by routine HE staining and immunohistochemistry (IHC) with anti-cytokeratin antibody (CK19) staining. The follow-up period ranged from 9 to 83 (mean 56) months. RESULTS: Metastases were detected in 7 (1.3%) lymph nodes from 5 patients with HE staining, and in 34 (6.5%) lymph nodes from 19 patients with CK19 staining. Micrometastases were detected in 27 (5.2%) lymph nodes from 14 patients. The difference in detecting lymph node metastases between two methods was significant (P=0.001). HE staining upstaged 3 cases from cN0 to pN1, and 2 cases from cN0 to pN2b; IHC staining upstaged 3 cases from cN0 to pN1, and 16 cases from cN0 to pN2b. Lymph node micrometastases showed no correlation to sex, age, T stage, differentiation, and depth of primary tumor invasion (P>0.05). The 5-year survival rates of the patients with and without micrometastases were 78.5% and 86.7%, respectively (P>0.05). CONCLUSIONS: CK19 staining could increase the detection rate of cervical lymph node metastases and the accuracy of pathologic stage in tongue cancer. The results of our study showed that the presence of lymph node micrometastasis has no correlation to the prognosis. A further study is needed.

[Treatment and prognosis of gingival carcinoma: a report of 116 cases].

BACKGROUND & OBJECTIVE: The treatment and prognosis of gingival carcinoma, a common oral carcinoma, have seldom been reported. This study was to explore appropriate therapies and analyze prognostic factors of gingival carcinoma. METHODS: Clinical data of 116 gingival carcinoma patients, treated at Cancer Center of Sun Yat-sen University from 1992 to 2003, were analyzed. Survival analyses were performed for patients who received surgery, radiotherapy, or surgery combined with chemotherapy or/and radiotherapy. The patients had been followed up for more than 3 years. RESULTS: One hundred patients received radical therapy. The overall 3-and 5-year survival rates were 52.7% and 41.8%. The 5-year survival rates were 50.3% in surgery alone group and 49.0% in combined treatment group, without significant difference. The 5-year survival rate of radiotherapy alone group was only 20.0%. For advanced gingival carcinoma, the recurrence rate was much lower in combined treatment group than in surgery alone group. Clinical stage and surgical margin status were predictors of survival. CONCLUSIONS: Surgery alone is appropriate for gingival carcinoma patients at an early stage; surgery combined with chemotherapy or/and radiotherapy is an adequate treatment for patients at advanced stages. Clinical stage and surgical margin status are important prognostic factors.

[Application of helix water jet to parotid surgery].

BACKGROUND & OBJECTIVE: Dissecting the facial nerves safely is an important guarantee for the accomplishment of parotidectomy and reduction of postoperative complications. This study was to explore the application of helix water jet to parotidectomy. METHODS: Clinical data of 43 patients with parotid tumors, who received operation with helix water jet from Feb. 2004 to Feb. 2005 at Cancer Center of Sun Yat-Sen University, were analyzed. Meanwhile, traditional techniques in parotidectomy was performed in 36 patients (control group). Duration of operation, postoperative drainage volume, postoperative hospitalization, and occurrence of postoperative complications, such as facial nerve dysfunction and salivary fistula, of the 2 groups were compared. RESULTS: The postoperative drainage volume was significantly lower in water jet group than in control group [(9.89+/-3.74) mL vs. (12.15+/-2.11) mL, P<0.05]. There were no significant differences in duration of operation [(90.28+/-25.30) min vs. (76.32+/-20.74) min, P>0.05], postoperative hospitalization [(6.39+/-1.38) days vs. (6.45+/-1.05) days, P>0.05] between the two groups. Of the 43 patients in water jet group, 6 (14.0%) had grade II facial nerve dysfunction and 1 (2.3%) had grade III facial nerve dysfunction; of the 36 patients in control group, 5 (13.9%) had grade II facial nerve dysfunction, 2 (5.6%) had grade III facial nerve dysfunction, 1 (2.8%) had grade IV facial nerve dysfunction and 1 (2.8%) had salivary fistula. There was no permanent facial nerve dysfunction occurred in both groups. There was no significant difference in the occurrence of complications between the two groups. Nine patients who retained nervus auricularis magnus suffered from slight numbness symptom of auricular lobule. CONCLUSION: Use of helix water jet in parotid surgery is safe and confers some advantages over conventional methods of parotid dissection.

[Sentinel lymph node radiolocalization in squamous cell carcinoma of the oral tongue].

BACKGROUND & OBJECTIVE: At present, there is no clinical examination that can accurately assess the lymph node metastasis status of oral tongue carcinoma with clinically negative neck lymph node (cN0) before operation. Therefore, the treatment of cN0 neck is still controversial. Sentinel lymph node (SLN) biopsy may be the evidence for individual treatment of cN0 neck. This study was to explore the feasibility of SLN radiolocalization, and to investigate the clinical value of SLN detection in squamous cell carcinoma of the oral tongue. METHODS: Twenty-one oral tongue squamous cell carcinoma patients with cN0 necks were recruited, among which 1 had received primary dissection before. 99mTc-SC, as the tracer, was injected into the submucosa around primary tumor before operation. Lymphoscintigraphy was performed immediately in 5 cases. The gamma probe was used to identify SLNs for all cases before and during operation. All patients received supraomohyoid neck lymph node dissection. The pathologic results were considered as golden standard to evaluate the effectiveness of SLN radiolocalization. SLNs that had been reported as negative by routine pathologic examination were examined by immunohistochemistry. RESULTS: The detection rate of SLNs was 100%. Among the 21 patients, the pathologic results of SLNs for 21 patients accorded with the pathologic results of neck lymph node dissection; the accuracy rate was 95%. In 1 patient, the pathologic result of SLNs was negative, but that of neck lymph node dissection was positive. Micrometastases were found in 3 of 41 detected lymph nodes by immunohistochemstry. CONCLUSIONS: SLN radiolocalization in squamous cell carcinoma of the oral tongue is feasible. SLN biopsy can well predict the cervical lymph node metastasis status of oral tongue carcinoma, but further investigation is necessary to determine its clinical value.

[Surgical management for occult cervical metastasis of oral tongue squamous cell carcinoma].

BACKGROUND & OBJECTIVE: In oral tongue squamous cell carcinoma (SCC), the management for clinically negative (cN0) neck remains controversial. This study was to explore rational neck management for cN0 cases. METHODS: Clinical data of 187 patients with oral tongue SCC of cN0, who received surgery alone, were retrospectively reviewed. Rules of occult nodal metastasis, factors that impact cervical node metastasis, and prognostic factors were analyzed. Neck recurrences of different treatment groups were compared. RESULT: Incidence of occult nodal metastasis in all patients was 23.0% (43/187). The most common site of occult nodal metastases was ipsilateral level II. About 83.0% of occult nodal metastases were found in ipsilateral levels I, II, and III. Pathologic grade was an independent influencing factor for occult neck metastases. Occult neck metastasis was an independent prognostic factor for oral tongue SCC. Supraomohyoid neck dissection (SOHND) was an effective therapeutic method for oral tongue SCC of cN0; the neck recurrence rate after SOHND was only 6.7%. CONCLUSIONS: SOHND is the effective and safe treatment for oral tongue SCC.