Local Flap Reconstructions in Oral Cavity Defects: An Insight from 104 Cases.

BACKGROUND: Resection of oral cavity carcinoma often leads to complex defects causing functional and aesthetic morbidity. Providing optimum reconstruction with free flaps becomes challenging in a high-volume center setting with constrained resources. Hence, understanding the local flap technique for reconstructing oral cancer defects is prudent. MATERIALS AND METHODS: This study is a retrospective analysis of prospectively operated cases of oral cavity resections which were subsequently reconstructed using local flaps from 2019 to 2022. Patients who underwent reconstruction with either melolabial flap, islanded facial artery myomucosal (FAMM) flap, submental flap, supraclavicular artery island flap, infrahyoid flap, or platysma myocutaneous flap (PMF) were included in this analysis. Eligible patients were followed up to evaluate functional outcomes like oral feeding and to analyze the Performance Status Scale for Head and Neck Cancer. RESULTS: The study included 104 patients. The tongue was the most common subsite, resulting in most hemiglossectomy defects, which were reconstructed using the melolabial flap procedure. Buccal mucosa defects in our series were reconstructed using the supraclavicular flap, whereas the submental flap procedure was the choice for lower lip-commissure defects. Complications such as partial and total flap loss, deep neck infection, and donor site complications like infection and gaping, oral cutaneous fistula, parotid fistula, and seroma were analyzed; the supraclavicular flap presented with a majority of complications. CONCLUSION: Local flaps are an alternative to free flap reconstruction in select cases with optimum functional outcomes and minimal donor site morbidity. This article comprehensively reviews the surgical steps for various local flap procedures in oral cancer defects.

The Trans-facial Approach for Simultaneous Resection and Reconstruction of Retromolar Trigone Tumors: A Pilot Study.

Introduction: Early retromolar trigone (RMT) lesions are difficult to access and free tissue transfer is often an overkill for such small lesions. The aim was to devise a novel surgical approach that would aid the resection without raising a cheek flap and simultaneously provide a local reconstructive option for small lesions in the RMT. Methodology: This study was to demonstrate the outcomes of the "trans-facial" approach used to simultaneously access and reconstruct small RMT tumors through an islanded nasolabial flap. Patients with histologically proven squamous cell carcinoma of RMT requiring surgery were included from January 2021 to September 2022. Case selection was done based on the location of the disease and its size (cT1/T2). All needed bone and soft tissue resection via per oral trans-facial approach, along with an ipsilateral neck dissection. The technique is described along with their post-operative and pathologic outcomes. Results: Out of the eight patients included in this study, six underwent a bi-alveolar marginal resection and reconstructed using the trans-facial approach. No major complications were noted in the post-operative period. 50% were pT1 tumors and 75% were pN0 status. One patient had a close margin; while, the others had adequate resection margins. All patients were followed up for a median of 18 months with a locoregionally controlled status. Conclusion: The trans-facial approach can be a suitable option with a reasonable oncologic outcome to address small RMT lesions.

Surgical management of patients with distant metastasized adenoid cystic carcinoma of the head and neck.

BACKGROUND: Adenoid cystic carcinoma (ACC) is a rare and malignant tumor of the salivary glands. Despite its slow-growing nature, this clinical entity is notorious for presenting with distant metastasis (DM) which significantly worsens patient outcomes. The role of surgery in patients with ACC and distant metastasis (DM) remains controversial. METHODS: We conducted a retrospective analysis of 47 patients with ACC who underwent surgery for the primary tumor and presented with DM at baseline or developed DM during follow-up. We compared survival outcomes between patients with DM at baseline (Group A) and those who developed DM during follow-up (Group B). RESULTS: The median overall survival (OS) for the entire cohort was 88%. Patients with DM at baseline (Group A) had significantly worse OS (51%) compared to those without DM at baseline (Group B) (91%; P = .04). Local recurrence (LR) was associated with poor survival in both groups. However, salvage surgery for LR+DM was associated with improved OS compared to palliative treatment (100% vs 77%; P = .79). CONCLUSION: Our findings suggest that surgery for the primary tumor of ACC may provide survival benefits in patients with DM. Salvage surgery should be considered particularly for patients who develop local recurrence and distant metastasis during follow-up.

A prospective health economic evaluation to determine the productivity loss due to premature mortality from oral cancer in India.

INTRODUCTION: India contributes two-thirds of the global mortality due to oral cancer and has a younger population at risk. The societal costs of this premature mortality are barely discussed. METHODS: Using the human capital approach, we aimed to estimate the productivity lost due to premature mortality, valued using individual socioeconomic data, related to oral cancer in India. A bottom-up approach was used to prospectively collect data of 100 consecutive patients with oral cancer treated between 2019 and 2020, with a follow-up of 36 months. RESULTS: The disease-specific survival for early and advanced stage was 85% and 70%, with a median age of 47 years. With 671 years lost prematurely, the loss of productivity was $41 900/early and $96 044/advanced stage. Based on population level rates, the total cost of premature mortality was $5.6 billion, representing 0.18% of GDP. CONCLUSION: India needs to implement tailored strategies to reduce the economic burden from premature mortality.

Outcomes of Cancer Surgery During the COVID-19 Pandemic: Preparedness to Practising Continuous Cancer Care.

The COVID-19 pandemic has placed unprecedented pressure on healthcare services. Deprioritisation of nonemergency clinical services and growing concerns of adverse outcomes of COVID-19 in cancer patients is having a deleterious impact across oncologic practice. We report cancer surgery outcomes taking into account the acuity of the COVID-19 situation. A prospectively maintained database of the Department of Surgical Oncology was analysed from 1st May to 30th June, 2020, to evaluate the perioperative outcomes, morbidity and mortality following major surgical procedures. A total of 359, preoperatively, tested negative for COVID-19 underwent surgery. Median age was 52 years with 26.7% (n = 96) above the age of 60 years. Sixty-one percent (n = 219) patients were American Society of Anaesthesiology grades II-III. As per surgical complexity grading, 36.8% (n = 132) cases were lower grades (I-III) and 63.2% (n = 227) were complex surgeries (IV-VI). 5.3% (n = 19) had ≥ grade III Clavien-Dindo complication, and the postoperative mortality rate was 0.27% (n = 1). Major complication rates in patients > 60 years were 9.3% in comparison to 4.1% in < 60 years (p = 0·63). The median hospital stay was 1-10 days across subspecialties. Postoperatively, repeat COVID 19 testing in 2 suspected patients were negative. Our study showed that after screening, triaging and prioritisation, asymptomatic cases may undergo cancer surgeries without increased morbidity during COVID-19 pandemic.

The impact of peritumoral depapillation in cancers of the tongue.

OBJECTIVES: We observed that a prominent strip of depapillated mucosa surrounded tongue carcinomas. This study evaluates its correlation with other prognosticating factors. STUDY DESIGN: This prospective study included treatment naïve squamous carcinomas of tongue operated between January and December 2018. Patients with any disorder that could possibly influence the presence of depapillation were excluded, and stratified based on the presence (Group A) and absence (Group B) of depapillation surrounding the tumor. Data sets included biochemical test, clinical variables, and postoperative histologic features. A multivariate logistic regression was performed to identify the association of these factors. RESULTS: Group A comprised 62.8% (n = 76/121) of the entire cohort, which was reasonably distributed for tumor and host factors. A greater number of inadequate margins were found in Group A. Clinical factors significantly associated with depapillation included higher preoperative platelet count (>250.5), infection rates, and Clavien-Dindo scores. Perineural invasion and lymphocytic infiltrate were significantly associated with Group A, particularly in early tumors (P = .040). CONCLUSIONS: Local invasion and inflammation results in papilla dysfunction clinically appearing as depapillation, leading to accumulation of neurotransmitters and a favorable environment for neural infiltration. We suggest peritumoral depapillation to be a clinical surrogate for perineural invasion, especially in early tongue cancers.

Comparison of the seventh and eighth editions American Joint Committee Cancer classification system in oral cavity squamous cell cancers.

The aim of our study was to evaluate the predictive ability of the American Joint Committee Cancer (AJCC) eighth edition (AJCC8) staging system for oral cavity cancers and validate these changes rendering the hypothesis of improving prognostication. We conducted a retrospective study including all oral cavity squamous cell carcinoma patients visiting our tertiary center from 2012 to 2015, staged as per the AJCC seventh edition (AJCC7) and AJCC8 systems. Stage-specific disease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Concordance index (CI) and Akaike information criterion (AIC) were used to calculate the predictive accuracy of the both systems. The study sample consisted of 863 subjects followed up for a median of 24 months. Buccal mucosa complex (BMC) was the most common site (n = 496). We observed a 25.8% (n = 222) overall upstaging in the eighth edition, significantly seen in early tongue cancers (TCs) (Stage I) and advanced BMC cancers (Stage III). An increase in CI and reduction in AIC scores were indicative of a superior predictive accuracy for the eighth edition in assessing DFS (confidence interval [CI*] = 0.650-0.654; AIC = 3,022-3,014) and OS (CI* = 0.643-0.648; AIC = 2089-2086) across all stages. The accuracy was higher for TCs as compared to BMC. Although not statistically significant, we observed an increase in soft risk factors at higher stages in the eighth edition as compared to its predecessor. We concluded that the AJCC8 has a higher predictive accuracy than the AJCC7 edition, making it a reliable prognosticative tool.

Depth of invasion, size and number of metastatic nodes predicts extracapsular spread in early oral cancers with occult metastases.

OBJECTIVE: Presence of extracapsular spread (ECS) significantly decreases survival in oral cancer patients. Considering its prognostic impact, we have studied the incidence and factors predicting ECS in clinically node negative early oral cancers. MATERIALS AND METHODS: We performed a retrospective chart review of 354 treatment naïve clinically node negative early oral cancer patients operated between 2012 and 2014. Chi-square test and logistic regression were used for identifying predictors of ECS, while cox-regression test was used for survival analysis. RESULTS: The incidence of occult nodal metastasis was 28.5% (101/354). Among them, ECS was seen in 15.3%(54/354) patients. The incidence of ECS in T1 and T2 lesion was 13.4% (21/157) and 16.8% (33/197), respectively. The overall incidence of ECS was 48% and 29% in lymph nodes smaller than 10 mm and 5 mm respectively. We found that tumor depth of invasion (>5 mm; p-0.027) and node (metastatic) size >15 mm (p-0.018) were significant predictors of ECS. p N2b disease was seen in 41/354 (11.6%) of which 31/354 (8.7%) had ECS, i.e. 75.6% of pN2b patients been ECS positive (p-0.000). The 3-year OS of patients without nodal metastasis, nodal metastasis without ECS and nodal metastasis with ECS was 88.4%, 66.9% and 59.2% (p-0.000) respectively. CONCLUSION: A significant number of patients with metastatic nodal size less than 1 cm have ECS which suggests aggressive behavior of the primary tumor. Thus, elective neck dissection is the only way of detecting ECS in these patients which may warrant treatment intensification.

Significance of Serum L-fucose Glycoprotein as Cancer Biomarker in Head and Neck Malignancies without Distant Metastasis.

BACKGROUND: Head and neck neoplasia is a major form of cancer in India, accounting for 30% of all cancers which occur in males and 11% of cancers which occur in females. Elevated serum L-fucose glycoprotein levels have been reported to be associated with neoplastic conditions involving various sites. Therefore, monitoring serum/tissue L-fucose glycoprotein levels could be a promising approach for the early diagnosis and prognosis of head neck cancers. AIM: This study was carried out to determine the significance of serum L-fucose levels in head and neck malignancies. SETTINGS AND DESIGN: This comparative study was carried out at a tertiary care hospital in South India. MATERIAL AND METHODS: Serum L-fucose glycoprotein levels were estimated in 50 patients with histopathologically confirmed head and neck malignancies and they were compared with those of 50 age- and sex-matched healthy controls. STATISTICAL ANALYSIS USED: Student's t-test was used to compare L-fucose glycoprotein levels in study and control groups. RESULTS: Most common site of the primary tumour in the current study was oral cavity, followed by larynx, hypopharynx and oropharynx respectively. Comparison of glycoprotein L-fucose in two groups showed more than a two-fold rise in serum fucose levels in cases as compared to the those in controls, with mean values of 11.33±7.39 and 4.74±1.55 mg% in cases and controls respectively. There was no relationship between serum fucose levels and age, sex and tumour differentiation. CONCLUSION: Serum glycoprotein L-fucose levels can be used as an effective biochemical indicator in conjunction with clinical diagnostic procedures in head and neck neoplasia and they may be useful for monitoring recurrences.