The significance of the presence of extranodal extension in the metastatic node of differentiated thyroid cancer: a proposal for modification in the American Thyroid Association (ATA) risk stratification.

BACKGROUND: Multiple factors contribute to recurrences in differentiated thyroid cancers (DTC). Though the nodal size and number of positive nodes along with the presence of extranodal extension (ENE) have been mentioned in the present ATA risk stratification, the weightage given for ENE seems inadequate compared to the former two. METHODOLOGY: Factors predicting recurrences were analysed in this retrospective study of patients with DTC operated in a tertiary care centre. Based on our findings, we propose a modification in the present risk stratification. We have done so by comparing with existing risk stratification for fit and discrimination of this system. RESULTS: Out of 1428 patients, 859 (60.2%) patients had pathological nodal metastases (pN +) with ENE being present in 26.8% of these. The recurrence rate was 6.4% (92 patients). Recurrence rates in patients with ≤ 5 nodes without ENE, > 5 nodes without ENE, ≤ 5 nodes with ENE and > 5 nodes with ENE were 2.7%, 1.3%, 8.3% and 10.3%, respectively. Recurrence rates in patients with 0.2-3 cm without ENE, 0.2-3 cm with ENE and > 3 cm with/without ENE were 1.8%, 8.5% and 13.4%, respectively. A modified risk stratification incorporating ENE and excluding the number of metastatic nodes was proposed. The modified risk stratification had a better fit than the present system in terms of higher C index and lower AIC. CONCLUSIONS: Extranodal extension in differentiated thyroid cancer had the maximum influence on recurrence risk (recurrence-free survival) in our cohort. The prognostic impact of ENE supersedes the number of positive nodes in the risk of recurrence.

Sentinel lymph node biopsy in early oral cancers: are we ready for it yet? Results from a survey among Indian surgeons treating oral cancers.

OBJECTIVE: Emerging evidence has shown that sentinel node biopsy (SNB) is an oncologically safe option in patients with early oral cancer compared with elective neck dissection (END). However, its use on a routine basis could be associated with many challenges. STUDY DESIGN: This online survey was conducted among the Indian surgeons treating patients with oral cancer to understand and comprehend the incidence and patterns of usage of SNB in their practice, their approach toward the use of SNB, and the possible challenges they face or perceive in its routine use in patients with early oral cancer. RESULTS: We received 352 responses with a response rate of 47.63%. Most of the respondents (82.6%) were managing N-zero necks with END, only 15.1% (n = 53) respondents practiced SNB currently. Most respondents believed that SNB offered the advantage of better shoulder function compared with END (76.4% [n = 269]). The deterrents considered for routine use of SNB in early oral cancer were additional costs (71.9% [n = 253]), the unavailability of necessary expertise and infrastructure (87.2% [n = 307]), SLNB being a more time-consuming treatment (58.8% [n = 207]), a higher false negative rate (74.1% [n = 261]), and the possible need of a second surgery (82.4% [n = 290]). CONCLUSIONS: Though SNB presently could be considered as an alternative treatment option, there seem to be various issues that need to be addressed before it can be adopted as a standard of care across centers.

Impact of Changes in Treatment Paradigms on Survival in Oral Squamous Carcinoma-a Population-Level Study.

There have been notable improvements in the treatment of oral cancers. The objective of this study was to see whether these improvements have translated into survival benefits at the population level from the SEER database. This is a retrospective study using the SEER 19 Custom database which included patients diagnosed with oral cancer between January 1, 1995, and December 31, 2015. The overall stage, age, sex, and treatment modalities were the covariates. For analysis, the patients were divided into four cohorts as per their year of diagnosis-cohort I included patients who were diagnosed between 1995 and 2000 (n = 3873), cohort II between 2001 and 2005 (n = 5881), cohort III between 2006 and 2010 (n = 6233), and cohort IV between 2011 and 2015 (n = 12567). Patients undergoing surgery with adjuvant therapy have increased significantly across cohorts and there is a significant fall in patients undergoing non-surgical treatment. Pairwise comparison by the Mantel-Cox test showed that cohort IV had significantly improved median overall survival (OS) and disease-specific survival (DSS) as compared to other cohorts and there was a significant impact of treatment modality on OS and DSS, especially in cohorts III and IV (p<0.001). Though geographical variations in the presentation and habits limit the generalization of these results, this study demonstrates that the changes and improvements in treatment paradigms incorporating level I evidence and surgical techniques have translated into improved survival outcomes at the population level. We recommend further studies on the local population to lend further credence to our observation. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-023-01790-0.

Regression Derived Staging Model to Predict Overall and Disease Specific Survival in Patients With Major Salivary Gland Carcinomas With Independent External Validation.

PURPOSE: The current American Joint Cancer Committee (AJCC) staging system for salivary gland tumors does not include histology and grade in its classification despite their proven prognostic importance. We planned to analyze if a modified staging system integrating these two factors into the staging improves prognostic performance and then validate it externally. MATERIALS AND METHODS: From SEER database (2000-2018), patients with major salivary gland carcinoma who underwent surgical resection between 2004 and 2015 were analyzed. Histologies were recoded into two groups based on grade and type of histology into "Low Aggression" and "High aggression" groups. Cox proportional hazards model was used to identify predictor variables for overall survival and disease-specific survival and models were generated based on least absolute shrinkage and selection operator regression. Model performance was evaluated by Akaike Information Criterion, concordance index and calibration plot. The best model chosen was externally validated from our hospital database of patients who underwent surgery for salivary gland tumor between January 1, 2012 to December 31, 2019. RESULTS: Six thousand two hundred forty-six patients were analyzed with a median follow up of 58 months. Age > 65 years, male sex, metastatic disease, Histological Stratification, Grade of tumor, AJCC stage and Primary Site were the significant factors influencing overall survival and disease-specific survival. By least absolute shrinkage and selection operator regression method, Correlation analysis and Interaction testing by multiple regression, AJCC stage and Histological Risk stratification were used for generating four models, out of which the best model was selected by Akaike Information Criterion, C index and calibration plot. This model was then externally validated in our hospital database of 269 patients. CONCLUSION: We propose an externally validated modified salivary gland staging system that incorporates histology and grade of tumor for improved hazard discrimination among patient subgroups.

Parotid fistula and/or salivary collection: an underrecognized and underreported preventable complication following surgery for oral cancer.

BACKGROUND: Parotid fistula after surgery for oral cancer is a less commonly recognized and less reported complication. In this study, we aimed to report its incidence and identify factors predisposing patients to it and the management of the patients in our cohort. METHODS: This was a retrospective study of treatment-naive patients with oral cancer who underwent surgery from January 2019 to December 2020 in a single unit of our institute. Patients who were operated for recurrence and second primary were excluded. RESULTS: A total of 434 patients were included in the study. Most were men (n = 352; 81.1%) and presented with an advanced clinical stage (n = 318; 73.2%). The incidence of parotid fistula in our study was 6.9% (n = 30 of 434). Buccal mucosa/gingival buccal sulcus subsite (P = .05; odds ratio [OR] = 3.423; 95% CI, 0.969-12.087) and advanced clinical T stage (P = .003; OR = 6.15; 95% CI, 1.835-20.608) were the 2 most important factors predisposing patients to the development of parotid fistula after surgery for oral cancer. CONCLUSIONS: Parotid fistula is a less common complication after surgery for oral cancer. A conservative treatment approach is usually successful in treating this complication.

Importance of Intraoperative Neuromonitoring Parameters in Predicting Temporary Recurrent Laryngeal Nerve Palsy Following Thyroid Surgery for Malignancy.

Recurrent laryngeal nerve (RLN) palsy is one of the feared complications following thyroid surgery. Intraoperative neuromonitoring (IONM) has been used as an adjunct to reduce this complication. In the present study, we attempted to evaluate the IONM parameters such as latency, current requirement, and baseline amplitude that could predict temporary RLN palsy along with factors that could influence these parameters during thyroid surgery. This was a retrospective study of patients who underwent hemi, total, or completion thyroidectomy for cancer at our institute between June 1, 2017 to May 31, 2019 in whom IONM was used during surgery. The study consisted of 84 consecutive patients with 138 nerves at risk. The RLN palsy rate in our study was 5% (n = 7). Patients with low baseline amplitude and/or requiring higher current to maintain normal baseline amplitude were often associated with temporary RLN palsy. In the multivariate analysis, age > 40 years (p = 0.001, OR = 4.14) influenced the baseline EMG amplitude the most. The intraoperative current management was influenced by advanced pT stage (p = 0.001, OR = 2.87), and structural nerve injury (p = 0.001, OR = 3.15). Patients with low baseline amplitude and/or requiring higher current to maintain normal baseline amplitude were often associated with temporary RLN palsy. Factors such as age, pT stage, and structural nerve injury influenced the IONM stimulation and recording parameters.

Importance and implications of neurovascular bundle involvement and other MRI findings of oral tongue squamous cell carcinoma (OTSCC) on prognosis.

BACKGROUND: The description for T4a oral tongue cancer in the 8th edition AJCC staging can be improved further. In this article we attempted to identify the important radiological (MRI) findings that could possibly be included in the staging eventually. METHODS: We included all oral tongue squamous cell carcinoma patients who underwent surgery at TMH between Jan 2012 to Dec 2018 and whose MRIs were available for review. The relation of the tumor to the neurovascular bundle (NVB) on MRI was classified as Type I to IV. The association of the type of NVB involvement with DFS and the presence of PNI in the final HPR was analyzed. RESULTS: Two-hundred and fifty-nine patients satisfied the eligibility criteria. The majority of them were men (82.6%), with a median age of 49 Yrs. Sixty-nine percent of patients had either abutment (Type III) or encasement (Type IV) of the NVB. The presence of Abutment/encasement of the NVB was significantly associated with the presence of PNI in the final HPR (p < 0.001). This abutment/encasement was seen in clinically advanced T-stage tumors. However, the presence of abutment/encasement of the NVB influenced the DFS in the univariate analysis only. CONCLUSION: Abutment/encasement of the NVB in patients with carcinoma oral tongue is often seen in advanced-stage tumors and is significantly associated with the presence of PNI in the final HPR. Hence, the relation of the tumor with the NVB should be further assessed to understand its importance and its possible inclusion in the AJCC T-staging.

Recurrent angioleiomyoma of the middle turbinate.

We present a case of a middle-aged woman with a history of not only progressive nasal obstruction, facial pain, hyposmia and epistaxis, but also excision of the nasal mass diagnosed as a vascular leiomyoma. On examination, a smooth bulge was seen over the middle turbinate. Surgical excision along with histopathology and immunohistochemistry revealed a diagnosis of recurrent vascular leiomyoma of the middle turbinate.