Orbital exenteration and reconstruction in a tertiary UK institution: a 5-year experience.

PURPOSE: Orbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach. METHODS: We performed a clinicopathological review of patients referred to Guy's and St Thomas' NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed. RESULTS: 27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects. CONCLUSIONS: A multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.

Palatine tonsil SUVmax on FDG PET-CT as a discriminator between benign and malignant tonsils in patients with and without head and neck squamous cell carcinoma of unknown primary.

AIM: To analyse the maximum standardised uptake value (SUVmax) ratio between tonsils in patients with and without tonsillar carcinoma to determine useful diagnostic thresholds. MATERIALS AND METHODS: Positron-emission tomography (PET)/computed tomography (CT) examinations of patients with suspected head and neck squamous cell carcinoma (SCC) and controls from April 2013 to September 2016 were reviewed retrospectively. Tonsillar SUVmax ratios (ipsilateral/contralateral for malignant tonsils, maximum/minimum for patients without [controls]) were calculated and used to construct a receiver operating characteristic (ROC) curve. RESULTS: Twenty-five patients had tonsillar carcinoma (mean SUVmax ratio of 2, range 0.89-5.4) and 86 patients acted as controls (mean SUVmax ratio of 1.1, range 1-1.5). Using the ROC, the most accurate SUVmax ratio for identifying malignancy was >1.2 (77% sensitivity, 86% specificity). A potentially more clinically useful SUVmax ratio is ≥1.6 with 62% sensitivity and 100% specificity. CONCLUSION: An SUVmax ratio between tonsils of ≥1.6 is highly suspicious for SCC and could be used to direct site of biopsy. Some malignant tonsils had normal FDG uptake; therefore, PET/CT should not be used to exclude tonsillar cancer. Minor asymmetrical uptake is frequently seen in non-malignant tonsils and does not necessarily require further investigation. Due to the single centre nature of this study and the recognised variation in SUV measurements between PET scans, other centres may need to develop their own cut-offs.

Outcomes of intensity-modulated radiotherapy as primary treatment for oropharyngeal squamous cell carcinoma - a European singleinstitution analysis.

OBJECTIVES: To analyse survival and toxicity outcomes in patients treated with primary intensity-modulated radiotherapy (IMRT) for oropharyngeal squamous cell carcinoma (OPSCC) in the era of routine human papilloma virus (HPV) testing. DESIGN: Single-institution case series. SETTING: Tertiary Head and Neck Cancer Unit. PARTICIPANTS: A total of 186 patients received IMRT (+/- chemotherapy) for radical primary treatment of OPSCC between March 2010 and December 2013. HPV status was available for 88% of cases. Median radiation dose was 65 Gy in 30 daily fractions. 90% of stage III/IV patients received concurrent chemotherapy or cetuximab. MAIN OUTCOME MEASURES: Overall, disease-free and disease-specific survival; rates of late xerostomia and dysphagia. RESULTS: A total of 177 patients completed treatment (Stage I/II: 23; Stage III/IV: 154), with median follow-up of 26 months. Estimated 3-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) rates were 77.2% (70.5-83.9), 72.3% (65.4-79.2) and 80.2% (74.1-86.3). Estimated 3-year OS, DFS and DSS for HPV-positive patients were 90.9% (85.2-96.6), 87.9% (81.4-94.4) and 91.8% (86.3-97.3). A previously identified risk stratification method was validated, showing improved OS for low-risk over high-risk patients (HR 0.09, P < 0.001). The 2-year feeding tube retention rate was 6%, and 2-year grade ≥2 xerostomia rate was 38% (23% if mean contralateral parotid dose <24 Gy). CONCLUSIONS: Outcomes with IMRT are favourable, particularly in the HPV-positive patient group. This data further supports the use of a previously described prognostication model that can be used to select patients for escalation/de-escalation clinical trials.

Time interval between primary radiotherapy and salvage laryngectomy: a predictor of pharyngocutaneous fistula formation.

Salvage laryngectomy (SL) is associated with high levels of morbidity. Rates of pharyngocutaneous fistulae (PCF) are as high as 35 % in some series. Patients at highest risk of such complications may be candidates for altered surgical management in terms of additional tissue transfer, or delayed tracheoesophageal puncture. This study investigates the relationship between the time from primary radiotherapy (RT) to salvage surgery and the development of PCF. 26 consecutive patients who underwent SL between 2000 and 2010 were identified from our institutional database. Demographic, staging, treatment and complication data were collected. Subgroup analysis was performed using the Student's t test or Mann-Whitney U test for continuous variables and either Chi-squared test or Fisher's Exact test for categorical variables. 26 patients underwent SL between October 2003 and July 2010. Of these, 15 (58 %) developed a PCF. On analysis of the time between pre-operative RT and surgery, a significant difference was seen, with a mean time of 19.5 months in those who developed a PCF versus 47.0 months in those who did not (p = 0.02). Patient characteristics, treatment, and pathology results were comparable between the two groups. There was no significant difference in distribution of the other covariates between the PCF and non-PCF groups. We reported a high rate of PCF and identified an association between PCF and a short time from primary treatment to salvage surgery. Identifying factors associated with higher rates of post-operative morbidity allows surgeons to adapt surgical planning in an attempt to minimize rates of PCF.

Patterns of neck metastasis and occult neck disease during recurrent laryngeal cancer.

OBJECTIVE: Numerous factors are considered to impact on the rate of complications during salvage total laryngectomy procedures. Neck dissection could be one of these factors. This study analysed the pattern of lymph node metastasis and rate of occult neck disease during salvage total laryngectomy as well as the impact of neck dissection on survival and complication rates. METHOD: This was a retrospective analysis of a prospectively maintained laryngectomy database in two large tertiary teaching hospitals. RESULTS: The rate of occult neck disease was 11.1 per cent. Most cases with occult neck disease had rT4 disease. Patients with complications, advanced tumour stage and positive margins had a significant decrease in overall survival. Patients receiving elective neck dissection did not have any survival benefit. Positron emission tomography-computed tomography showed a very high specificity and negative predictive value. CONCLUSION: According to the low risk of occult neck disease when using contemporary imaging techniques as well as the lack of impact on survival, conservative management of the neck should be considered for crT1-T3 recurrence.

The utility of molecular diagnostics to predict recurrence of head and neck carcinoma.

BACKGROUND: Locoregional recurrence is the major cause of treatment failure after surgery for oral squamous cell carcinoma. Molecular diagnostics have the potential to improve on clinicopathological parameters to predict this recurrence and plan adjuvant treatment. The test most frequently applied is based on detecting TP53 mutations, but alternative methodology is required for cases that harbour the wild-type gene. METHODS: One hundred and two cases with tumour-adjacent margins, considered to be clear margins by microscopy, were examined using carefully optimised molecular diagnostics based on detection of the TP53 and Ly-6D markers. The markers were also combined to provide a dual approach. RESULTS: The dual molecular diagnostic identified cases with a significant increase in the probablility of developing locoregional recurrence when tumour-adjacent positive and clear margins were compared (P=0.0001). These tests were most useful when the clearance at the resection margins was 5 mm or less. The TP53-based diagnostic was a better predictor of locoregional recurrence than established clinicopathological parameters. CONCLUSION: The optimised TP53-based diagnostic rapidly identifies an important subgroup of cases with close margins that will benefit from new treatment modalities to reduce the risk of recurrence.

Establishing and integrating a transoral robotic surgery programme into routine oncological management of head and neck cancer - a UK perspective.

BACKGROUND: The introduction of transoral robotic surgery into routine management of patients is complex. It involves organisational, logistical and clinical challenges. This study presents our experience of implementing such a programme and provides a blueprint for other centres willing to establish similar services. METHODS: Implementation of the robotic surgery programme focused on several key domains: training, logistics, governance, multidisciplinary team awareness, pre-operative imaging, anaesthesia, post-operative care, finance, patient selection and consent. Programme outcomes were evaluated by assessing operative outcomes of the first 117 procedures performed. RESULTS: The success of the transoral robotic surgery programme has been possible because of the scrupulous planning phase before the first procedure, and the time invested on team awareness and training. CONCLUSION: Implementation of a new transoral robotic surgery service has led to: the development of a dedicated transoral robotic surgery patient care protocol, the performance of progressively more complex procedures, the inclusion of transoral robotic surgery training and the establishment of several research projects.

Head and neck cancer surgery during the coronavirus pandemic: a single-institution experience.

OBJECTIVE: The coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas' NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic. METHODS: A head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus. RESULTS: Sixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths. CONCLUSION: Performing major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes.

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience.

OBJECTIVE: The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study. METHOD: Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic. RESULTS: Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis. CONCLUSION: Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Three-dimensional reconstruction of laryngeal cancer with whole organ serial immunohistochemical sections.

Three-dimensional (3D) image reconstruction of tumors based on serial histological sectioning is one of the most powerful methods for accurate high-resolution visualization of tumor structures. However, 3D histological reconstruction of whole tumor has not yet been achieved. We established a high-resolution 3D model of molecular marked whole laryngeal cancer by optimizing the currently available techniques. A series of 5,388 HE stained or immunohistochemically stained whole light microscopic images (200 ×) were acquired (15.61 TB).The data set of block-face images (96.2 GB) was also captured. Direct volume rendering of serial 6.25 × light microscopy images did not demonstrate the major characteristics of the laryngeal cancer as expected. Based on fusion of two datasets, the accurate boundary of laryngeal tumor bulk was visualized in an anatomically realistic context. In the regions of interest, micro tumor structure, budding, cell proliferation and tumor lymph vessels were well represented in 3D after segmentation, which highlighted the advantages of 3D reconstruction of light microscopy images. In conclusion, generating 3D digital histopathological images of a whole solid tumor based on current technology is feasible. However, data mining strategy should be developed for complete utilization of the large amount of data generated.

Radical (chemo)radiotherapy in oropharyngeal squamous cell carcinoma: Comparison of TNM 7th and 8th staging systems.

PURPOSE: To evaluate whether the 8th staging system is a better discriminator of overall survival (OS) than the 7th edition for oropharyngeal cancer patients after definitive (chemo)radiotherapy (CRT). MATERIAL AND METHODS: Data from oropharyngeal cancer patients treated with CRT with curative intent between 2010 and 2016 at Guy's and St Thomas' Hospitals were reviewed. Human papillomavirus (HPV) status was ascertained in all cases. Patients were staged using the 7th edition and the 8th edition TNM staging system. Demographics, tumor characteristics and treatment response data were included in univariate and multivariate analysis for OS. OS and disease-free survival (DFS) were estimated using the Kaplan-Meier method. In addition, a multivariate survival Cox regression analysis of several clinical variables was performed. RESULTS: A total of 273 patients were included. The median follow-up was 4.7 years. Overall 63 patients died. In multivariate analysis, HPV status, complete response at 3 months and ≤21 units/week alcohol were prognostic for OS. For the entire cohort, the 5-year OS and DFS rates were 78.1% (95% confidence interval CI 0.719-0.831) and 73.9% (95% CI 0.677-0.792), respectively. Better stratification of OS and DFS was recorded by 8th edition for the entire cohort. In HPV-positive cases, risk stratification based on tobacco smoking and nodal stage resulted in statistically higher discrimination in OS rates (5-year OS 90.7% in low risk patients and 84.6% in intermediate risk, p = 0.05) and DFS rates (5-year DFS 91.5% in low risk and 76.1% in intermediate risk, p = 0.001). CONCLUSION: The 8th edition TNM staging system provides better OS stratification in oropharyngeal cancer after definitive CRT compared with the 7th edition. Other clinical variables, such as complete response at 3 months, alcohol and tobacco smoking, should also be considered in future classifications as they provide additional risk stratification information in both HPV-positive and HPV-negative disease.

Improving prediction of malignancy of cytologically indeterminate thyroid nodules.

BACKGROUND: Fine-needle aspiration (FNA) is essential in the investigation of thyroid nodules. The British Thyroid Association guidelines recommend clarification of whether follicular nodules are probable follicular neoplasms that require surgical excision. This study assessed the value of the subclassification of cytologically indeterminate thyroid nodules into either follicular neoplasms or other pathology. METHODS: The cytology reports of all thyroid FNAs performed between November 2005 and December 2007 at a single institution reported as Thy 3 (follicular lesions) were reviewed. They were reclassified as Thy 3A (probable follicular neoplasm) or Thy 3B (probable non-neoplastic lesion), and subsequently correlated with final clinical outcome to determine the predictive value of this subclassification. RESULTS: Forty-nine specimens were categorized as Thy 3A and 55 as Thy 3B. Of excised lesions, 14 (29 per cent) of 48 Thy 3A and 4 (10 per cent) of 42 Thy 3B nodules were malignant. If Thy 3A were to predict malignancy and Thy 3B benign disease, the sensitivity of the classification was 88 per cent, with a specificity of 55 per cent and negative predictive value of 91 per cent. CONCLUSION: Subclassification of Thy 3 nodules into Thy 3A and Thy 3B improves the assessment of risk for thyroid malignancy.

Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review.

BACKGROUND: Recurrent laryngeal nerve palsy (RLNP) is a recognised possible complication after thyroid surgery. It may present with a variety of symptoms, such as voice change and respiratory symptoms. However, it may remain undetected and the true incidence may be under-reported. The aim of this study was to determine the reported incidence of temporary and permanent palsy after thyroid surgery using different vocal assessment methods. METHODS: A Medline search was performed. A systematic review was undertaken which included 27 articles and 25,000 patients. RESULTS: The average incidence of temporary RLNP after thyroid operations is 9.8% and the incidence of permanent RLNP is 2.3%. The RLNP rate varied according to the method of examining the larynx and ranged from 26% to 2.3%. Most of the reviewed studies recommend a follow-up period up to 1 year to assess and evaluate RLNP. CONCLUSION: Our study has identified that different methods are used to diagnose RNLP and that a wide variety of reported RLNP rates exist. We propose establishment of a 'gold standard' for assessing the voice after thyroidectomy to reduce reporting bias.

Thyroid lymphoma and airway obstruction - is there a rationale for surgical management?

BACKGROUND: The current management of thyroid lymphomas (TL) includes the combined use of chemotherapy and radiotherapy, with surgery mainly confined to diagnosis through an open biopsy following ultrasound-guided fine-needle aspiration cytology (US-FNAC). AIMS: To analyse the clinical presentation and methods of diagnosis of TL, its pitfalls and the management of these tumours presenting with compression symptoms and airway obstruction. METHODS: A retrospective review of nine patients diagnosed with TL at Guy's and St Thomas Hospital NHS Foundation Trust in London over the past 5 years. RESULTS: Nine consecutive patients were identified with the diagnosis of TL, and seven (78%) of them being women and with a mean age of 65 years. All patients presented with an anterior neck mass while four (44.4%) presented with stridor and vocal cord palsy. Two (22.2%) presented with a hoarse voice, dysphagia, and only one patient had a B symptom of weight loss. FNAC was diagnostic in three patients (33.3%) and a report of multi-nodular goitre in one patient. There was clinical suspicion of TL in three patients (33.3%). Of the three patients presenting with stridor, two had an open biopsy followed by the initiation of dexamethasone therapy and resolution of symptoms within 48 h. One patient had a partial thyroidectomy following a suspected diagnosis of multi-nodular goitre from US-FNAC. One patient required tracheostomy for airway management. CONCLUSION: Diagnosis of TL may be difficult. However, US-FNAC is useful in raising the suspicion of a TL. Open biopsy is still the definitive diagnostic tool of choice. In the emergency setting of airway obstruction, once definitive diagnosis is achieved, dexamethasone therapy and endotracheal intubation for airway management are all that is required for optimal management strategy. Surgical intervention has no role except for providing tissue for diagnosis.

Utility of neck dissection for management of carcinoma of the parotid gland.

To validate the use of neck dissection as part of the management of patients with parotid carcinomas, we retrospectively reviewed pathological and clinical data from the head and neck pathology archive at Guy's and St Thomas' Hospital on all patients who had primary parotid carcinomas resected between 1992 and 2014. The main outcome measure was the incidence of metastatic disease. A total of 54 of the 82 patients identified had neck dissections. Nodal metastases were detected in 10 with high-grade, invasive carcinoma ex-pleomorphic adenomas, two with salivary duct carcinomas, one with a high-grade adenocarcinoma not otherwise specified (NOS), one with an adenoid cystic carcinoma, and one with a high-grade acinic cell carcinoma. No metastases were found in those with a low-grade acinic cell carcinoma, low-grade mucoepidermoid carcinoma, epithelial-myoepithelial carcinoma, or non-invasive carcinoma ex-pleomorphic adenoma. The findings of this study support the use of routine neck dissection for the treatment of high-grade, invasive carcinoma ex-pleomorphic adenoma, salivary duct carcinoma, high-grade adenocarcinoma NOS, adenoid cystic carcinoma, and high-grade acinic cell carcinoma.

Implementing the National Institute of Clinical Excellence improving outcome guidelines for head and neck cancer: developing a business plan with reorganisation of head and neck cancer services.

The implementation of the National Institute of Clinical Excellence improving outcome guidelines (NICE-IOG) manual for head and neck cancer may have a huge potential cost implication. Head and neck cancer is a rare disease which utilises large quantities of resources which can only be provided in a tertiary centre. Head and neck cancer services should be centralised into a single site for each cancer network. A new higher tariff rate for complex head and neck cancer cases is needed which recognises the true cost of this work. Each network should set its own tariff to make head and neck cancer care financially viable.

Penetrating neck injuries.

Penetrating neck injuries are becoming more common because of the increasing prevalence of knife and gun crimes. The immediate and long-term consequences of injury to the neck can be significant because of the close relationship of important anatomical structures in a confined space. Delayed recognition of major injury and inadequate treatment results in high morbidity and mortality. Developing a clear understanding of the underlying anatomy, common mechanisms of injury and principles of management will provide first responders, emergency doctors and trauma surgeons with confidence in appropriate evidence-based management. Early involvement of otolaryngologists or head and neck surgeons is advisable. Two cases of penetrating neck injury from the June 2017 London Bridge terror attack are discussed.