Diagnostic utility of microsurgical carbon dioxide laser excision of oral potentially malignant lesions vs incisional biopsy: a retrospective histopathological review.

OBJECTIVE: Complete excision of oral potentially malignant lesions (OPMLs) could result in improved and earlier detection of more severe grades of oral epithelial dysplasia and/or frank malignancy. Transoral microsurgical carbon dioxide laser techniques allow for resection of OPMLs, even those that are extensive. The advantages are improved diagnostic yield, improved viability of the specimen for pathologic evaluation, reduced postoperative morbidity, and easier postoperative clinical surveillance. STUDY DESIGN: Retrospective review of the histopathology slide material and attendant clinical notes of 31 sequential patients with OPMLs demonstrated the following histopathologic diagnoses on conventional incisional biopsy (CIB): verrucous hyperplasia (2 patients); mild dysplasia (11 patients), moderate dysplasia (3 patients) or severe dysplasia (15 patients); and subsequently, these patients went on to have laser excision biopsy (LEB) of their OPMLs. RESULTS: Histologic diagnosis was upgraded after LEB in 14 (45%) patients (P < .001), with unexpected findings of cancer in 9 cases (29%) and more severe dysplasia in 5 cases (16%). CONCLUSIONS: Use of LEB to supplement CIB appears superior in the detection of severe dysplasia and frank malignancy in OPMLs compared with use of CIB alone. Prospective trials are indicated to determine if the superior diagnostic utility of LEB improves patient outcomes with regard to earlier detection of oral squamous cell and/or verrucous carcinoma.

Trans-Frontal Five-Fluorouracil (TraFFF): a novel technique for the application of adjuvant topical chemotherapeutic agents in sinonasal adenocarcinoma.

Sinonasal adenocarcinoma has traditionally been treated with surgery (craniofacial or endoscopic) and adjuvant radiotherapy. Two large series have demonstrated favourable 5-year survival using surgery with adjuvant topical chemotherapy applied repeatedly over several weeks. The authors describe a novel, transnasal application of topical 5-fluorouracil. However, complete coverage of the frontal region of the anterior skull base can be difficult to achieve with a purely transnasal approach in an outpatient setting. We present a novel adjunct method of delivering chemotherapeutic agents into this key area used in a 37-year-old man with T2N0M0 ethmoid adenocarcinoma. The procedure was well tolerated in an outpatient setting and remains disease free at 3 years postoperatively. We suggest that frontal trephination is a useful adjunct to aid accurate placement of adjuvant topical chemotherapeutic agents in the treatment of sinonasal adenocarcinoma.

Minimally invasive surgery versus radiotherapy/chemoradiotherapy for small-volume primary oropharyngeal carcinoma.

BACKGROUND: More than 400,000 cases of oropharyngeal squamous cell carcinoma (OPSCC) are diagnosed each year worldwide and the incidence is rising, partly as a result of human papillomavirus. Human papillomavirus-associated OPSCC affects younger patients and often presents at a higher stage; however, it is associated with a better prognosis.Until recently, first-line management of OPSCC involved chemoradiotherapy, as research had demonstrated comparable survival outcomes when compared with open surgery, with significantly decreased morbidity. However, interventions have now evolved with computerised planning and intensity-modulated radiotherapy, and the advent of endoscopic head and neck surgery, which provide the potential for decreased treatment-associated morbidity.The oropharynx plays an essential role in swallowing, speech and protecting the airway as it is situated at the bifurcation of the respiratory and digestive tracts. Treatment modality recommendations are based on survival outcomes. Given the younger patient demographic, establishing the safety of modalities that potentially have better functional outcome is becoming increasingly important. OBJECTIVES: To assess the efficacy of endoscopic head and neck surgery (transoral robotic surgery or transoral laser microsurgery) for small-volume, primary (T1-2, N0-2) oropharyngeal squamous cell carcinoma (OPSCC) in comparison to radiotherapy/chemoradiotherapy. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 10); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 8 November 2016. SELECTION CRITERIA: Randomised controlled trials in patients with carcinoma in the oropharynx subsite (as defined by the World Health Organization classification C09, C10). Cancers included were primary squamous cell carcinomas arising from the oropharyngeal mucosa. The tumours were classified as T1-T2 with or without nodal disease and with no evidence of distant metastatic spread. The intervention was transoral, minimally invasive surgery with or without adjuvant radiotherapy or adjuvant chemoradiotherapy. The comparator was primary radiotherapy with or without induction or concurrent chemotherapy for the tumour. The treatments received and compared were of curative intent and patients had not undergone prior intervention, other than diagnostic biopsy. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were overall survival (disease-related mortality was to be studied where possible), locoregional control, disease-free survival and progression-free survival or time to recurrence. All outcomes were to be measured at two, three and five years after diagnosis. Our secondary outcomes included quality of life, harms associated with treatment, patient satisfaction and xerostomia score. MAIN RESULTS: No completed studies met the inclusion criteria for the review. Two ongoing trials fulfilled the selection criteria, however neither are complete.'Early-stage squamous cell carcinoma of the oropharynx: radiotherapy versus trans-oral robotic surgery (ORATOR)' is a phase II randomised controlled trial comparing primary radiation therapy with primary transoral robotic surgery for small-volume primary (T1-2, N0-2) OPSCC. It is currently in progress with an estimated completion date of June 2021.'European Organisation for Research and Treatment of Cancer 1420 (EORTC 1420-HNCG-ROG)' is a phase III, randomised study assessing the "best of" radiotherapy compared to transoral robotic surgery/transoral laser microsurgery in patients with T1-T2, N0 squamous cell carcinoma of the oropharynx and base of tongue. It was due to start accrual mid-2016. AUTHORS' CONCLUSIONS: The role of endoscopic head and neck surgery in the management of OPSCC is clearly expanding as evidenced by its more overt incorporation into the current National Comprehensive Cancer Network guidelines. Data are mounting regarding its outcomes both in terms of survival and lower morbidity. As confidence increases, it is being used in the management of more advanced OPSCC.Based on this review, there is currently no high-quality evidence from randomised controlled trials regarding clinical outcomes for patients with oropharyngeal cancer receiving endoscopic head and neck surgery compared with primary chemoradiotherapy.

Swallowing assessment and management pre and post head and neck cancer treatment.

PURPOSE OF REVIEW: Head and neck cancer (HNC) imposes significant structural, functional, and cosmetic burdens upon those affected. Although advances in multimodality organ preservation therapy have assisted in ameliorating a number of previous treatment-related sequelae, dysphagia remains a foremost concern for members of the multidisciplinary team. Given its acute and long-term impact on physical and psychological wellbeing, and subsequent bearing on delivery of treatment, treatment-related morbidity and overall mortality, prompt recognition, and accurate assessment and optimization of management are pivotal. RECENT FINDINGS: Qualitative research has provided greater insight into the psychosocial burdens dysphagia imposes on HNC patients and carers, highlighting the need for holistic strategies of management. There is a growing body of evidence to support dietary alterations and preventive swallowing exercise regimens for maintenance of oral intake throughout and following HNC therapy. The role of prophylactic enteral feeding, however, remains uncertain, with conflicting institutional data and lack of high-quality prospective studies for meaningful systematic literature assessment. Endoscopic surgical techniques hold promise in relieving stricture-related dysphagia; however, multiple treatments are required and recurrence is common. SUMMARY: Swallowing rehabilitation encompassing education, dietary modification, and swallowing exercises comprise the mainstay of current evidence-based dysphagia management in HNC patients.