Lymph node level ratio: Are we relying too much on numbers?

The lymph node level ratio appears to be a continuation of nodal yield and nodal density, two prognostic metrics already in use. A retrospective analysis conducted in the current study showed that a value of fewer than 4 lymph nodes/level is linked to a lower overall and disease-specific survival. This letter aims to review the reasoning behind the use of node level ratios and nodal yields as quality and prognostic indicators, and to explore possible factors that could affect these.

The Impact and Prognostic Significance of Extra-Nodal Extension in Clinically N0 Oral Cancer: A Prospective Clinical Study.

Oral cavity squamous cell carcinoma (OCSCC) demonstrates a high propensity to metastasize to regional lymph nodes. Despite technological and scientific advances, identification of pathological adverse features preoperatively remains elusive. This study intended to identify the true occurrence of extra-nodal extension (ENE) in clinically and radiologically N0 OCSCC patients and to investigate its impact and prognostic significance. A prospective, single-centre, non-randomized study was conducted at a tertiary cancer centre in South India to include all untreated operable patients of OCSCC without clinical, radiological, or cytological evidence of nodal metastasis (cN0). All the patients underwent tumor resection surgery with neck dissection and received adjuvant therapy when indicated. Patients were followed up and neck dissection specimens were histopathologically analyzed. The primary outcome was to assess the presence of ENE in cN0 OCSCC patients and its extent. The secondary outcomes were 2-year disease-free survival (DFS) and tumor characteristics. A total of 237 patients with operable OCSCC were evaluated. Out of these, 80 patients who were clinically and radiologically N0 were included in the study and they underwent tumor resection surgery and neck dissection. The final histopathological evaluation revealed that 21.25% of patients (n = 17) had metastatic neck disease and 7.5% of patients (n = 6) had ENE, and all were reported as microscopic ENE. Within the node-positive group, the 2-year DFS for patients with and without ENE were 50% and 90.9%, respectively (p = 0.0362). The results suggest that ENE remains a strong predictor of adverse outcomes, recurrence, and survival in oral cancer patients.

Neutrophil Lymphocyte Ratio: A Predictor of Disease Severity in Nasal Polyposis and Allergic Fungal Rhinosinusitis.

To evaluate Neutrophil Lymphocyte ratio (NLR) as a predictor of disease severity in Nasal Polyposis and Allergic Fungal Rhinosinusitis (AFRS). This was a prospective non-randomized interventional study. Disease severity was graded based on endoscopic and CT scoring. Patients were given pre-operative oral steroids for two weeks and taken up for surgery. The pre-treatment neutrophil lymphocyte ratios were calculated from the differential leucocyte counts and compared with the disease severity and post-operative values. In the interventional arms, the disease severity correlated with the NLR. The mean pre-treatment NLR showed a statistically significant change after the intervention at eight weeks. The NLR normalized in patients with nasal polyposis and continued to be higher in patients with AFRS. NLR correlated to the disease severity and showed a linear correlation with the extent of the disease. NLR could be a potential cost-effective marker for disease severity and prognostication. Level of Evidence: Individual Cohort Study (2b).

Cysticercosis Infested Pectoralis Major Myocutaneous Flap Reconstruction: An Ethical Dilemma.

Disseminated cysticercosis is a rare manifestation of cysticercosis, a relatively common tropical disease in Asia, Africa and South America. Here the embryo of pork tapeworm Taenia Solium gets disseminated to multiple organs and tissues via hepatoportal system. we report here a 45 year gentleman with stage IV oral malignancy who was incidentally found to have disseminated cysticercosis on pre-operative work up. Along with the management of primary cancer and new found asymptomatic disseminated cysticercosis, the ethical challenge was to choose an appropriate reconstructive option for the composite oral cavity resection defect, since all the skeletal muscles in body where studded with cysticercosis larvae. We couldn't find any such report in literature to resolve our dilemma. After surgical board discussion, we zeroed down to pedicled pectoralis major myocutaneous flap, the most versatile and workhorse flap for head and neck reconstruction. Eventually the patient underwent surgery and adjuvant radiotherapy without any delay. He was simultaneously treated with oral albendazole under steroid cover and remained complication free at 2 years.

Swallowing: A delayed milestone post-surgery in tongue cancers.

Functional rehabilitation remains an important factor in the post-operative period following tongue cancer surgeries. Patients undergoing surgery for tongue cancers require intense rehabilitation in order to restore their swallowing function, and improve their nutritional status and quality of life. Various swallowing scales like the Functional Oral Intake Scale (FOIS), Performance status scale in head and neck cancer (PSSHNC) and 100 ml water swallow test are used to assess functionality in these patients. These aid in timely assessment and early intervention for better rehabilitation, in turn improving quality of life. Nasogastric tube (NG) or percutaneous endoscopic gastrostomy (PEG) aids in providing adequate nutrition in the immediate post-operative period and during adjuvant therapy to overcome radiation-induced dysphagia.

Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.

BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Residual Thyroid Tissue on Postoperative Diagnostic 131 I Radioactive Whole-Body Scan After Surgery in Differentiated Thyroid Cancer: A Tertiary Referral Centre Experience.

Residual thyroid tissue after total thyroidectomy in differentiated thyroid cancers is considered an independent risk factor for recurrence. Guidelines recommend following up patients after surgery with thyroglobulin (Tg), neck ultrasonography, and occasionally whole-body radioactive scan. However, the results of serum thyroglobulin and whole-body radioiodine scan are often discordant. The present study was undertaken to determine the levels of serum-stimulated thyroglobulin to complement the findings of residual thyroid tissue in the radioactive whole-body scan. One hundred twenty-six patients had undergone a radioiodine (131 I) whole-body scan (WBS) during the study duration, and 121 were available for analysis. The thyroglobulin level (measured by the CLIA method) was recorded at the time of these scans. The data was analysed to determine the level of stimulated thyroglobulin correlating with residual thyroid tissue, locoregional, and distant metastasis as assessed by WBS. The presence of residual thyroid tissue was noted in an overwhelmingly high 94% of cases. Twenty-four of the 28 patients with stimulated Tg < 2 ng/dl had residual thyroid tissue on a WBS. The discordancy rate (positive moderate - large WBS and negative serum thyroglobulin) of 64.28% was seen. Using ROC the serum thyroglobulin cut-offs levels for the loco-regional disease were found to be 27.705 ng/dl and 94.770 ng/dl for distant metastasis. The results highlight the fact that serum Tg levels cannot be used as an accurate predictor of the extent of the remnant thyroid tissue. Irrespective of the quality of surgery, which was analysed based on the centre and surgical specialty, over 90% of cases had residual thyroid tissue on WBS. The use of only stimulated Tg levels for follow-up may be inaccurate. Serum Tg is a useful test along with radioactive whole-body scans to distinguish local disease, loco-regional disease, and distant metastasis.

Remote Access Thyroid Surgery: A Review of Literature.

Since the first description of endoscopic thyroid lobectomy in 1997, a variety of techniques have been developed to avoid the visible cervical scar conventionally been associated with thyroidectomy. These "remote access" approaches, which typically use either endoscopic or robotic instrumentation, have successfully avoided the anterior neck scar, which has a measurable impact on the patient's quality of life (Graves and Suh Surgery 168(5):845-850, 2020; Sakorafas World J Surg 34(8):1793-1804, 2010). The main advantage of these techniques is better cosmesis compared to conventional transcervical approaches (Graves and Suh Surgery 168(5):845-850, 2020) However, these techniques have failed to gain widespread acceptance in the surgical community because of the technical challenges, scepticism about oncological safety and cost factors. This review presents an overview of the various methods of remote access thyroid surgery (RATS) and also evaluates the selection criteria, oncological efficacy, training requirements and key advantages of this technique.

Robotic transoral approach for salvage retropharyngeal node dissection: an analysis of functional and oncological outcomes.

Presence of metastatic tumour in the retropharyngeal node has a negative impact on the prognosis. We present here our 5-year experience and the outcomes of transoral robotic retropharyngeal node dissection (RPND) in salvage settings. Hospital database was accessed to extract details of patients with head and neck cancer who developed retropharyngeal (RP) node metastasis. Patients who underwent transoral robotic surgery (TORS) for RPND in salvage settings were included for the study. Patients were first followed-up after 10 days of discharge and then on a monthly basis after completion of treatment. At each follow-up, swallow functions and disease status were recorded. A total of 10 patients met the inclusion criteria and underwent salvage transoral robotic RPND. The total number of lymph nodes removed from these patients were 11, with all having malignant tumour deposits. The median follow-up was 20 months. Four patients developed distant metastasis. There were no major procedure-related complications. Our experience suggests that TORS as treatment modality is oncologically sound and feasible for salvage RP node dissection.Level of evidence Retrospective Study (3).

The spiral ladder technique of facial nerve trunk identification during parotidectomy: A convenient roadmap for the beginners.

The intricate relationship between the facial nerve and the parotid gland makes the surgeries involving the gland challenging. Though several landmarks have been described to locate the nerve trunk, variations do exist due to the physical and racial characteristics of an individual. The spiral ladder technique described here uses multiple landmarks that appear in a stepwise manner as a beginner proceeds through the surgery as a road map to the nerve trunk. This simple adoption of a cluster of existing landmarks increases the certainty factor. This method may help beginners and in turn, reduce the chances of iatrogenic facial nerve injuries.

Oral cancer in India, a growing problem: Is limiting the exposure to avoidable risk factors the only way to reduce the disease burden?

Cancer represents an uncontrolled growth of cells that invade and cause damage to the adjacent tissues. Globally oral cancer ranks as the sixth most common type of cancer. As compared to the west, the problem of oral cancer is significantly higher in India. The spectrum of oral diseases is formed with oral cancer at one extreme and potentially malignant disorders (PMDs) at the other extreme. Screening programs for the early detection and prevention of oral cancer indicate that visual examination as a part of a population-based screening program reduces the mortality rate of oral cancer in high-risk individuals. Tobacco and alcohol consumption remains the main factors for oral cancer and education of the population about the ill effects of tobacco and alcohol consumption is necessary at a broader scale.

Modified Preauricular Cervico-facial Approach for Oral Cancers: an Analysis of Oncological and Functional Outcomes.

The quest for a more cosmetic and functionally better approach to oral cancer continues unabated. The modified facelift and preauricular approaches have been a common approach in trauma and cosmetic surgery. In the current study, we evaluate the feasibility and functional outcomes of a preauricular cervico-facial approach for compartmental resection of complex gingiva-buccal complex tumours with concurrent neck dissection. This was a prospective single-centre study and recruited patients of biopsy-proven operable advanced oral cavity tumours. These patients underwent compartmental tumour resections with neck dissection using the modified preauricular approach. Patients were followed up and advised adjuvant treatment when mandated. At 3rd month and 6th month follow-up, QoL was assessed using the self-administered University of Washington Quality of Life scale (UW-QOL). A total of 20 patients met the inclusion criteria and were recruited for the approach. All patients had surgically clear margins on histopathological analysis. Oral swallow was initiated on the 10th postoperative day and the average duration of nasogastric tube dependence was 13 days. All patients had reasonably good oral commissure competence and none had drooling of saliva at 6th month follow-up. Modified preauricular cervico-facial approach to locally advanced gingiva-buccal complex tumours is a safe and holds the possibility of a functionally superior approach.

3D Patient-Specific Biomechanical Model of the Tongue for the Management of Tongue Tumors: Conceptualization to Reality.

Objectives: Increasing use of tobacco by the younger generation has resulted in an increase in oral cavity tumors. Surgical treatment is radical and results in severe functional morbidity. Using computer-aided designing technology, surgical and rehabilitative planning can be better. We present here our concept of a patient-specific biomechanical 3D model of the tongue and its clinical utility in the management of tongue tumors. Methods: Using fused deposition modeling, the 3D model of the tongue was printed which easily differentiates the tumor and the uninvolved tongue by printing in two different colors. The 3D tongue model was used by the surgical and rehabilitation teams to frame the treatment and plan the rehabilitation taking into account the patient preferences and needs. The model was used in two patients with operable squamous cell carcinoma (SCC) of the tongue, and the utility of the model in margin planning, surgical defect assessment, and its aid in the reconstruction and rehabilitation was assessed. Results: Two patients with Stage III SCC of the tongue underwent the surgery based on the plan evolved from the 3D model. All the surgical margins assessed by the frozen section analysis were clear. The model helped in addressing the discordance between patient expectations and surgical outcomes. We found that the model aided the reconstructive surgeon in planning the flap harvest based on the pre-operative defect assessment, which, in turn, translated into better rehabilitative outcomes. Conclusion: 3D biomechanical tongue model is a novel concept and aids in improving the overall treatment outcomes. The realistic 3D reconstructed image model helps the oncologist in planning the resection, enables the reconstructive surgery to more precisely predict the defect volume, and lastly the rehabilitative team in developing better rehabilitation strategies.