Fabricating Flaps in the Forearm Prior to Tracheal Reconstruction.

Background The process of reconstruction of tracheal defects is complex and still not optimum. Options range from using staged reconstructions, combining flaps with autologous or alloplastic implants, as well as use of tissue-engineered constructs combined with vascularized tissues which are lined with cell cultures. Staged reconstructions using prelaminated epithelium, and prefabricated flaps, help in reconstruction of this complex structure. Prefabricating the flap at a different site allows for integration of the tissues prior to its transfer. Method This article reports two patients planned for tracheal reconstruction for the purpose of advanced papillary carcinoma of the thyroid invading the trachea. Staged reconstruction using a prefabricated radial artery forearm flap (RAFF) and split rib cartilage was performed. In the second patient, a young girl, a similar construct of the RAFF, prelaminated with buccal mucosa, was performed. However, in the latter case, an intraoperative decision by the head and neck team to limit excision of the trachea sparing the mucosa was taken; the reconstruct in the forearm was redundant and needed to be discarded, replacing the defect with a free superficial circumflex iliac artery perforator (SCIP) flap. Result At 3 years follow-up, both the patients are free of disease, with the construct serving its purpose in the older female.

Redefining adequate margins in oral squamous cell carcinoma: outcomes from close and positive margins.

PURPOSE: Adequacy of surgical margins impacts outcomes in oral cancer. We sought to determine whether close and positive margins have different outcomes in patients with oral cancer. METHODS: Retrospective data from 612 patients with oral carcinoma were analyzed for the effect of margin status on locoregional recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS). RESULTS: A total of 90 cases (14.7%) had close margins and 26 patients (4.2%) had positive margins. Recurrences were documented in 173 patients (28%), of which 137 (22% of the study sample) were locoregional, and 164 patients (27%) had died. Among patients with close or positive margins, a cutoff of 1 mm optimally separated LRFS (adjusted p = 0.0190) and OS curves (adjusted p = 0.0168) whereas a cutoff of 2 mm was sufficient to significantly separate DFS curves (adjusted p = 0.0281). CONCLUSIONS: Patients with oral carcinoma with positive margins (< 1 mm) had poorer outcomes compared to those with close margins (1-5 mm) in terms of LRFS, DFS and OS. There is a suggestion that a cutoff of < 2 mm might provide slightly more separation for DFS.

Outcomes of pectoralis major myocutaneous flap in female patients for oral cavity defect reconstruction.

PURPOSE: Although much has been mentioned in the literature worldwide regarding the outcome of pectoralis major myocutaneous flaps (PMMFs), hardly any studies are available that mention the outcome of PMMFs in female patients. It has been presumed that complication rates after PMMF reconstruction in female patients are higher because of the presence of more adipose tissue in the flap. The objective of this study was to analyze our data regarding the outcomes of PMMFs in female patients with oral cancer undergoing reconstruction after tumor ablation. MATERIALS AND METHODS: In this retrospective study from January 2008 to May 2012, performed in a single institution in south India, we have analyzed our data on PMMFs in 140 female patients with oral cancer. The operative technique used was essentially the same as that described originally by Ariyan. However, to preserve the deltopectoral flap area, the incision was appropriately modified in a manner as described by Schuller. RESULTS: The mean age of the patients was 52.36 years, with a range from 30 to 76 years. They presented mostly with ulcers or ulceroproliferative lesions. Most of the patients had a history of tobacco and betel nut chewing. All of them underwent composite resection and reconstruction with PMMF under general anesthesia. Of the patients, 30 (21.4%) had complications, comprising infection (8), superficial flap necrosis (11), combined wound infection and superficial flap necrosis (3), total flap failure (2), and orocutaneous fistula (6). CONCLUSIONS: PMMF reconstruction is a reliable and cosmetically acceptable method of reconstruction in female patients for oral cavity defects after tumor ablation.

Reconstructive indications of simultaneous double free flaps in the head and neck: a case series and literature review.

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo-radiotherapy. Forty-two free flaps were used in these patients. The predominant combination was that of free fibula osteo-cutaneous flap with free anterolateral thigh (ALT) fascio-cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro-mandibular bone and soft tissue defects (n = 13), (b) large oro-mandibular soft tissue defects (n = 4), (c) complex skull-base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow-up period was 11 months. Twelve patients were alive and free of disease at the end of the follow-up. Eighteen of 19 patients with oro-mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro-mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed.

Risk of Hypocalcemia and the Need to Augment Calcium Supplementation After Total Thyroidectomy.

Hypocalcemia is the most common complication after total thyroidectomy. The aim of this study was to determine the predictors of postoperative hypocalcemia requiring augmentation of routine calcium supplementation. Prospectively collected data of 61 patients who underwent total thyroidectomy from December 2018 to June 2019 was considered for the study. All patients received calcium and vitamin D supplementation after the surgery. In the postoperative period, serum calcium and parathormone (PTH) levels were monitored. The need of additional oral or intravenous (i.v.) calcium supplementation was evaluated as an outcome measure. This cohort comprised 61 patients with median age of 46 years (range 16-80 years) and 49 (80%) females. Central compartment clearance (CCC) was done in 32 patients. Escalation to increased oral and intravenous calcium was required in 15 patients (24.6%) and 2 patients (3.3%), respectively. Serum parathormone level of 11.5 pg/ml on postoperative day 1 predicted the requirement of additional calcium with a sensitivity of 82.4% and specificity of 77.3%. On univariate analysis, serum PTH (p < 0.001), CCC (p = 0.018), and intraoperative parathyroid gland congestion (p = 0.021) predicted the need for escalation of calcium supplementation. On multivariate analysis, only serum PTH showed a significant impact on the need for augmentation of calcium supplementation (p = 0.003). The need for calcium dose augmentation after total thyroidectomy was significantly associated with CCC, parathyroid gland congestion, and serum PTH levels. Intraoperative identification of parathyroid gland congestion and postoperative serum PTH levels is effective in predicting postoperative hypocalcemia with implications on time and cost.

Factors predicting contralateral nodal spread in papillary carcinoma of thyroid.

Background: Lymph node metastasis (LNM) is evident in about 20-50% of cases at presentation in papillary carcinoma thyroid (PTC). There are no clear recommendations for the need and extent of lateral and central compartment dissection in PTC. Methods: A total of 83 patients who underwent total thyroidectomy and bilateral selective neck dissection for diagnosed PTC from September 2011 to October 2017 were retrospectively analyzed. Results: Tumor site was bilobar or involving isthmus in 40 patients. Contralateral LNM was seen in 42 patients. Both radiological (median size 2.6 cm, P = 0.051) and pathological (median size 3.65 cm, P = 0.015) size of tumor, tumor involving isthmus or bilateral lobes (P = 0.006), and lymphovascular invasion (LVI) (P = 0.026) had significant correlation with contralateral LNM. Conclusion: Size and site of tumor, ipsilateral lateral compartment nodes involvement, and LVI status of tumor significantly increases the probability of contralateral LNM in patients of PTC.

Radiation-induced hypothyroidism in patients of oral squamous cell carcinoma: A retrospective analysis of 195 patients.

Background: Radiation-induced hypothyroidism (RIH) is common after neck irradiation, and biochemical evaluation of thyroid function is recommended periodically for early diagnosis and treatment. This study aimed to evaluate the predictors of RIH after completion of adjuvant radiotherapy (RT) for primary oral squamous cell carcinoma (OSCC). Methods: This is a retrospective study involving 195 patients who received RT after surgery for OSCC between August 2011 and December 2016. Thyroid function tests were obtained every 6 months and patients were considered to be hypothyroid if thyroid-stimulating hormone level was >5 mIU/mL. Results: The study cohort comprised 130 men with a median age of 52 years (range 21-77 years). About 107 (54.87%) patients developed hypothyroidism, with a median of 21 months (range 2-67 months) for the development of RIH. Women [41 (63.1%) versus 66 (50.8%), p=0.035], addition of chemotherapy [36 (63.2%) versus 71 (51.4%), p= 0.019], and higher cumulative dose to the thyroid gland (median dose 4690 cGy versus 2981 cGy, P < 0.001) resulted in higher incidence of RIH on univariate analysis. On multivariate Cox regression analysis, female sex (P = 0.042), bilateral irradiation (P = 0.046), and cumulative dose to the thyroid (P = 0.001) were factors associated with increased risk of developing RIH. Conclusion: The addition of chemotherapy, high dose of radiation to the thyroid gland, bilateral irradiation, and female sex were at higher risk of developing RIH. However, more studies are required to identify the dose-volume constraints of the thyroid gland.

Outcomes of clinico-radiologically advanced cancer (cT4b) of buccal mucosa: a retrospective analysis of 104 patients.

Although guidelines recommend non-surgical management for cT4b patients, recent studies have shown that upfront surgery in carefully selected patients can be performed with acceptable long-term survival benefit. In this study, we analysed the survival outcome of curative intent treatment on cT4b patients. Data from 104 patients who were staged cT4b and underwent upfront surgery for squamous cell carcinoma of buccal mucosa were retrospectively analysed. Outcome measures were locoregional recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS). The study cohort comprised 104 patients who had a median age of 52.5 years (range 27-81 years) and included 81 males (77.9%). Thirty-six patients had masticator space involvement on final histopathology, designating them as pT4b. Contrast enhanced computed tomography scan demonstrated 91.67% sensitivity in identifying masticator space involvement, albeit with a lower accuracy of 31.7%. Pathologically, clear margins were achieved in 79 (76%) patients. 62 (59.7%) and 20 (19.2%) patients received adjuvant radiotherapy (RT) and adjuvant chemoradiotherapy respectively. 2-year LRFS, DFS and OS were 61.8%, 60% and 68.1%, respectively. On multivariate analyses, involved margins (hazard ratio (HR) 28.766, p = 0.006), pN2b status (HR 4.68, p = 0.027) and perineural invasion (PNI) (HR 3.001, p = 0.027) showed statistically significant impact on LRFS, involved margins (HR 28.859, p = 0.008) and pN2b status (HR 4.018, p = 0.004) affected DFS. Involved margins (HR 14.139, p = 0.023) and pN2b status (HR 3.166, p = 0.025) showed statistically significant impact on OS. In conclusion, upfront surgery is a feasible option for patients with carcinoma of the buccal mucosa with the involvement of the masticator space. Survival outcomes are better in patients where resection is achieved with clear margins, and regional disease is limited to a single cervical lymph node.

Emergence of hybrid states of stem-like cancer cells correlates with poor prognosis in oral cancer.

Cancer cell state transitions emerged as powerful mechanisms responsible for drug tolerance and overall poor prognosis; however, evidences were largely missing in oral cancer. Here, by multiplexing phenotypic markers of stem-like cancer cells (SLCCs); CD44, CD24 and aldehyde dehydrogenase (ALDH), we characterized diversity among multiple oral tumor tissues and cell lines. Two distinct patterns of spontaneous transitions with stochastic bidirectional interconversions on 'ALDH-axis', and unidirectional non-interconvertible transitions on 'CD24-axis' were observed. Interestingly, plastic 'ALDH-axis' was harnessed by cells to adapt to a Cisplatin tolerant state. Furthermore, phenotype-specific RNA sequencing suggested the possible maintenance of intermediate hybrid cell states maintaining stemness within the differentiating subpopulations. Importantly, survival analysis with subpopulation-specific gene sets strongly suggested that cell-state transitions may drive non-genetic heterogeneity, resulting in poor prognosis. Therefore, we have described the phenotypic-composition of heterogeneous subpopulations critical for global tumor behavior in oral cancer; which may provide prerequisite knowledge for treatment strategies.

Lateral arm free flap for oral tongue reconstruction: an analysis of surgical details, morbidity, and functional and aesthetic outcome.

The purpose of this study was to report the effectiveness of the lateral arm free flap (LAFF) in the reconstruction of oral tongue defects, the subsite in which it may have advantage over the other donor sites. This is a retrospective analysis of 48 consecutive cases of LAFF used for the reconstruction of partial glossectomy defects for squamous cell carcinoma of the oral tongue. Primary defect and donor-site morbidity and the functional and aesthetic outcomes were assessed in 37 evaluable patients, with a minimum of 6 months follow-up. Patient-reported Visual Analog Scale score from 0 (minimum satisfaction) to 10 (maximum satisfaction) was used to evaluate the aesthetic outcome. The follow-up was for 6 to 52 months (mean, 24 months). The flap was successful in 45 (93.8%) patients. The commonest observed donor-site morbidity was a broad scar, but it did not cause much patient dissatisfaction because it could be covered with appropriate dressing. Speech was normal or near-normal in all patients. Poor functional outcome was associated with adjuvant postoperative radiotherapy. The visual analog scale score for the aesthetic satisfaction (mean [standard deviation]) was 6.58 (1.82) for primary site and 7.13 (1.99) for the donor site. LAFF is an excellent option for the reconstruction of partial glossectomy defects of oral tongue without significant involvement of the floor of mouth and base of tongue.

Determinants of prognosis in patients with oral squamous cell carcinoma metastasizing to a single cervical lymph node.

OBJECTIVES: Metastasis in a single lymph node without adverse tumour factors and perineural invasion has been assigned to a lower risk category by the ASCO recommendations of 2019. We analyzed patients with a single positive node with a view to identifying high risk features and their impact on prognosis within this subgroup. MATERIALS AND METHODS: The study retrospectively analyzed 707 patients with OSCC. Descriptive statistics were used to compare distribution of clinicopathologic risk features between 323 N0 and 121 single node positive (Ns) patients. The Ns group was further analyzed for the impact of clinicopathologic factors on disease free (DFS) and overall survival (OS) using univariate and multivariate models. RESULTS: The Ns group exhibited greater depth of invasion compared to the N0 group and significantly higher proportion of lymphovascular invasion (LVI), perineural invasion (PNI) and poorly differentiated tumors. Within the Ns group, primary tumor localised to the gingivobuccal subsite (HR 2.55, 1.18-5.52 95%CI, p = 0.02) and PNI (HR 2.55, 1.14-5.62, 95%CI p = 0.02) exhibited poor DFS. PNI also contributed to poor OS (HR 2.86, 1.27-6.47 95%CI, p = 0.01). Uninvolved margins (HR 0.46, 0.22-0.96 95%CI, p = 0.04) and chemoradiation (HR 0.18,0.05-0.68 95% CI, p = 0.01) improved OS. CONCLUSION: Significant differences are noted in the prevalence of pathologic risk factors between the single node positive and node negative groups. Within the single node positive group, tumour factors like the gingivobuccal subsite, PNI and margin positivity impacted survival. Among nodal factors, deposit size of 12 mm or more and presence of ENE are pointers to poor prognosis. These patients would benefit from adjuvant treatment.

Contribution of Weight and Volume of the Extirpated Thyroid Gland on Voice Alterations After Total Thyroidectomy in Patients With Papillary Carcinoma of the Thyroid.

PURPOSE: Voice change after thyroid surgery is common despite preservation of laryngeal nerves. In this study, we sought to find if the change in voice after total thyroidectomy is related to the weight and volume of the removed thyroid gland. METHODS: This is a prospective cohort study of 50 patients of papillary carcinoma of the thyroid treated with total thyroidectomy from December 2016 through May 2018. Both objective and subjective voice parameters were analyzed preoperatively and at 1 and 3 months following surgery. RESULTS: A cohort of 29 patients, with a median age of 31 years (18-64 years), comprising 22 women were eligible for final analysis. Speaking fundamental frequency showed a mean change of 17.21 Hz (SD 34.49) while the mean intensity change was 5.54 dB (SD 18.21). The mean weight and volume of thyroid gland was 18.99 g (SD 8.93) and 15.67 ml (SD 8.70), respectively. On multivariate analysis, both weight and volume affected the range of frequency (P = 0.002 and 0.035, respectively) and range of intensity (P = 0.014 and 0.008, respectively). CONCLUSION: Larger thyroid tumors are more likely to be associated with transient change in voice quality following their surgical removal despite physical preservation of external and recurrent laryngeal nerves, which may persist up to 3 months. This study affirms that perturbations in voice after thyroidectomy can still exist in spite of clinical demonstration of integrity of neuromuscular function.

Feasibility, Safety, Nodal yields and Learning curves in Retroauricular Robot/Endoscope Assisted Neck Dissection in the Management of Head and Neck Cancer.

Head and neck cancer is one of the most common in India. There is an increasing incidence of oral cancer in young patients. Where the primary lesion is amenable to transoral resection for early cancer, young patients are concerned about cosmesis and would prefer a surgical approach that would avoid a visible scar in the neck. Robot/endoscope-assisted neck dissection by retroauricular approach was performed in a total of 28 patients of cN0 patients between June 2016 and December 2019. The duration of surgery, perioperative complications, number of lymph nodes retrieved, and cosmetic outcomes were analyzed. Robot- and endoscope-assisted neck dissections were done in 15 and 13 cases, respectively. The mean age of the cohort was 46.18 ± 9.68 years. Twenty-four patients had tongue cancer. Mean time for skin flap raising, docking, and robotic console use was 48.21 ± 7.48 min, 10 ± 3.16 min, and 176.67 ± 47.27 min, respectively. Mean neck dissection time from skin incision to skin closure was 231.79 ± 54.94 min for completing level I to IV neck dissection. The mean number of retrieved nodes was 33.69 ± 12.81. Majority of the patients were highly satisfied with their cosmetic outcomes. During a median follow-up of 19.5 months, 3 patients developed recurrence. Robot/ endoscope-assisted neck dissection was feasible and safe but took a longer time to perform. Nodal yields were adequate and better cosmetic outcomes were achieved.

Lymph node characteristics and their prognostic significance in oral squamous cell carcinoma.

BACKGROUND: The prognostic significance of various histopathologic lymph node-based biomarkers in oral squamous cell carcinoma (OSCC) needs further evaluation. METHODS: Retrospective analysis of 212 OSCC patients with regional metastasis to determine the association of extranodal extension (ENE), extent of ENE, size of metastatic deposit, lymph node yield (LNY), lymph node ratio (LNR), and topography of involvement with survival outcomes. RESULTS: The presence of ENE, larger nodal deposit, higher pN stage, lymph nodes in the lower levels, and patients who did not receive adjuvant treatment had poor disease-free survival (DFS). In addition, more positive nodes and high LNR showed worse overall survival (OS). ENE beyond 5 mm resulted in poorer outcomes. Larger sizes of metastatic deposit predisposed to ENE. Multivariate analyses showed only lower level of neck involvement to affect both DFS and OS. CONCLUSIONS: Lymph node metastasis to lower levels and other lymph node characteristics affect prognosis and must be considered in the evolution of staging systems for OSCC.

Nodal yield and topography of nodal metastases from oral cavity squamous cell carcinoma - An audit of 1004 cases undergoing primary surgical resection.

OBJECTIVES: Nodal metastasis is an important prognostic factor in oral squamous cell carcinoma (OSCC). Detailed topographic study of metastasis can guide surgical and adjuvant radiation treatment protocols. METHODS: Retrospective analysis of distribution of nodal spread was done by auditing pathology records of 1004 patients who underwent primary surgical management at our center. RESULTS: The median nodal yield was 41 (range of 9-166) nodes, per patient. Metastasis was present in 42.9% patients, of which 52.3% demonstrated extranodal extension. Reclassification by AJCC8 criteria resulted in up-staging in 35.6% patients (pN1, pN2a, pN2b, pN2c, pN3a and pN3b in 13.1%, 3.7%, 6.9%, 0.9%, 0%, 18.1% respectively). Ipsilateral levels Ib and IIa were involved in a quarter of patients each, while IIb, IV and V were involved in < 4%, 3% and 1% of patients, respectively. Contralateral nodal metastasis was present in 5.4%. Skip metastases to level IV were 2.2% and 1.2% for tongue and gingivobuccal primaries. Tongue primaries had a lower likelihood of involving level Ib, but higher of level IIa and III, compared to gingivobuccal primaries, and a lower likelihood of extranodal extension. Primary site did not influence nodal metastasis to levels IIb, IV or V, but other factors like lymphovascular invasion, pT stage and margin status had an influence. CONCLUSION: This large series with high nodal yield, shows low level of metastasis to level IIb, IV and V, which can help modify future guidelines for extent of surgery and avoid targeted adjuvant radiation to specific levels.

Two novel cell culture models of buccal mucosal oral cancer from patients with no risk-habits of tobacco smoking or chewing.

OBJECTIVE: Tobacco consumption is one of the major etiological factors for oral cancer, but it also develops in non-tobacco users, with unknown etiologies. Cellular models for tobacco associated oral cancer are available, however; reports of cellular models for studying non-tobacco associated oral cancer are limiting. We report here the establishment and characterization of two novel buccal mucosal cancer cell lines 'GBC02' and 'GBC035' derived from non-tobacco users. MATERIALS AND METHODS: Short tandem repeats (STR) profiling, Next-generation sequencing for whole-genome, exome and copy number alterations, immunofluorescence, flow-cytometry, proliferation, live-cell chemotaxis, 3D-spheroid formation, chemotherapy response, gene-expression microarray, gene-set enrichment analysis and xenograft development were performed. RESULTS: Sources of the established cultures were matched to their donors through STR profiling. Genome sequence analysis revealed somatic mutations in TP53, CASP8, CDKN2A for GBC02 with deletions and amplifications encompassing CDKN2A, FAT1 and CCND1, PIK3CA, SOX2, EGFR, MYC genes, respectively. GBC035 harbored mutations in FAT1, NOTCH1, HRAS, CDKN2A, HLA-B, HLA-A genes. While GBC035 cells showed higher E-Cadherin positive cell-cell junctions and collective cell migration in chemotaxis; GBC02 cells were vimentin-positive and demonstrated individual cell migration. Further, exhibiting their relevance to preclinical research, GBC02 3D-spheroids demonstrated enrichment of development-related gene-signatures in microarray transcriptome analysis and were resistant to Cisplatin, but showed sensitivity to cancer stem cells-targeting drug, Salinomycin. Additionally, tumorigenic ability of GBC02 was demonstrated. CONCLUSIONS: Altogether, we present here comprehensively characterized unique cell lines established from non-tobacco associated tumors, which may serve as models for preclinical investigations of oral cancers caused independent of tobacco usage.

A simplified technique of free flap pedicle transfer for reconstruction of defects following head and neck cancer ablation.

Free flaps are being widely used for reconstruction of defects following head and neck cancer ablation. The pedicle of the flap is usually tunneled into the neck wound for anastomosis to the neck vessels. This transfer of the pedicle can be technically difficult to execute and associated with difficulties of torsion and kinking. No effective method has been so far reported to make this procedure easy and safe. A very easy and effective method for the pedicle transfer is described in this report, which has been practiced successfully in our head and neck service in more than 175 free flaps.

Novel Technique to Increase the PMMC Flap Pedicle Length by Coplanar Rotation Along the Pedicle Axis.

Pectoralis major myocutaneous flap (PMMC) continues to be a prime tool in the armamentarium for the reconstruction of head and neck malignancies even though free flaps have proved their versatility in functional and cosmetic outcomes. It still holds significance in both primary reconstruction and salvage procedures in head and neck malignancies. Inadequate infrastructure and resources make PMMC a preferred choice in many high-volume centres of developing countries. However, the length of the PMMC flap becomes a limiting factor for the distance that flap can be transferred when extensive reconstructions are being planned (Kudva et al. in J Maxillofac Oral Surg 14:481-483, 2015). We propose a modification in the conventional technique that maximises the length of the pedicle in orofacial reconstruction. Our technique allows the rotation of skin paddle along the longitudinal axis of the pedicle at the distal end along the same plane. This technique provides an easily reproducible and reliable technique that enables the surgeon to enhance the reach of the skin paddle and flexibility considerably.

Unusual loco-regional presentation in papillary carcinoma of thyroid: A case series.

BACKGROUND: Papillary carcinoma of thyroid (PTC) is usually indolent with good prognosis and excellent long-term survival. However, PTC sometimes presents itself in unusual situations, posing diagnostic and therapeutic challenges. Owing to paucity of data, there is lack of consensus as to what treatment should be prescribed in patients with loco-regional spread other than the usual sites. MATERIALS AND METHODS: Six patients of PTC presenting with involvement of the aero-digestive tract, retropharyngeal, and para-pharyngeal lymph nodes and great vessels of the neck are included in this case series. RESULTS AND CONCLUSION: Though rare, unusual loco-regional presentation of PTC poses challenges in diagnosis and treatment. A keen clinical sense is paramount in effectively diagnosing these cases. Aggressive surgical resection and reconstruction results in good functional and aesthetic outcomes. Further studies are required for establishing specific guidelines on the approach to the treatment of these cases.

Clinicopathologic Determinants of Outcome in Pathologic T4a (pT4a) Squamous Cell Carcinoma of the Gingivobuccal Subsite of the Oral Cavity.

Carcinoma of the gingivobuccal complex is one of the most common cancers in India and patients usually present in an advanced stage. There is limited data in literature regarding the factors predicting outcome in pathological T4a patients. In this study, we aimed to study the clinic-pathological factors which may influence treatment outcomes in pT4a patients. This is a retrospective study of 121 patients who underwent surgery for oral squamous cell carcinoma between August 2011 and December 2016, staged pT4a. Overall survival (OS) and disease-free survival (DFS) were analyzed for variables including age, depth of invasion, margin status, differentiation, nodal status, extranodal spread, lymphovascular and perineural spread, and adjuvant treatment. The study cohort comprised 93 males with mean age 60.28 years (S.D. 11.25). Median DFS was 21 months (range 9 to 2374 days) whereas median OS was 24.5 months (range 9 to 2374 days). On univariate analysis, lymphovascular invasion, perineural invasion, cervical nodal metastasis, and extranodal extension had a statistically significant effect on both DFS and OS. On multivariate analysis, age (p = 0.014) and adjuvant radiotherapy (p = 0.010) were the statistically significant factors affecting OS. None of the factors affected DFS on multivariate analysis. Patients staged pT4a with cervical nodal metastasis, extranodal extension, lymphovascular invasion, and perineural invasion have reduced OS and DFS. On multivariate analysis, lower age at presentation and adjuvant radiation improved patient outcome.